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acrac_3158165_5 | Imaging of the Axilla | In a meta-analysis of 9 retrospective studies, MRI detected an occult breast cancer in more than two-thirds of patients [39]. MRI can also help further characterize the axillary mass(es) by determining involvement of adjacent vessels, the chest wall, and other axillary structures. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI as the initial imaging of patients presenting with bilateral palpable axillary masses. Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT. Regional nodal staging is an important prognostic factor in guiding the treatment of breast cancer, which has undergone significant change over the last decade [42,43]. Historically, ALND was the standard of care for staging the nodal region and providing local control of breast cancer that has metastasized to regional nodes. The result of the Z0011 trial changed the approach to axillary disease management [5]. The Z0011 trial recruited 891 women with T1 or T2 invasive primary breast cancer and no palpable axillary adenopathy [5]. These women were randomized to SLNB versus ALND. The 10-year overall survival for Z0011 patients treated with SLNB alone was noninferior to those treated with ALND [4]. Therefore, SLNB became a safe alternative to ALND for clinically node-negative breast cancer patients, with a less invasive approach and less morbidity. In 2014, the American Society of Breast Surgeons published consensus guideline on the management of the axilla in which SLNB has replaced ALND for clinically node-negative invasive breast cancer patients [6]. It is desirable to identify those patients who can safely receive SLNB and those who we can potentially omit SLNB. However, there is no standard radiologic imaging test for this purpose and this remains an area of controversy. | Imaging of the Axilla. In a meta-analysis of 9 retrospective studies, MRI detected an occult breast cancer in more than two-thirds of patients [39]. MRI can also help further characterize the axillary mass(es) by determining involvement of adjacent vessels, the chest wall, and other axillary structures. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI as the initial imaging of patients presenting with bilateral palpable axillary masses. Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT. Regional nodal staging is an important prognostic factor in guiding the treatment of breast cancer, which has undergone significant change over the last decade [42,43]. Historically, ALND was the standard of care for staging the nodal region and providing local control of breast cancer that has metastasized to regional nodes. The result of the Z0011 trial changed the approach to axillary disease management [5]. The Z0011 trial recruited 891 women with T1 or T2 invasive primary breast cancer and no palpable axillary adenopathy [5]. These women were randomized to SLNB versus ALND. The 10-year overall survival for Z0011 patients treated with SLNB alone was noninferior to those treated with ALND [4]. Therefore, SLNB became a safe alternative to ALND for clinically node-negative breast cancer patients, with a less invasive approach and less morbidity. In 2014, the American Society of Breast Surgeons published consensus guideline on the management of the axilla in which SLNB has replaced ALND for clinically node-negative invasive breast cancer patients [6]. It is desirable to identify those patients who can safely receive SLNB and those who we can potentially omit SLNB. However, there is no standard radiologic imaging test for this purpose and this remains an area of controversy. | 3158165 |
acrac_3158165_6 | Imaging of the Axilla | CT Chest, Abdomen, and Pelvis Studies have shown that the use of advanced imaging modalities such as CT and FDG-PET/CT for staging asymptomatic women with early stage breast cancer has low yield for occult disease [44-46]. The 2020 NCCN Guidelines for Invasive Breast Cancer also suggest the use of CT with IV contrast only when there is elevated liver function tests, pulmonary or abdominal symptoms, or abnormal physical examination [7]. CT chest can visualize and assess the level I, II, and III regions of the axilla. The predictive accuracy of CT is not high enough to replace Imaging of the Axilla Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for staging of the axilla in breast cancer patients. US Axilla Axillary US is often performed in early-stage breast cancer patients since the Z0011 trial showed that early-stage cancer and low nodal burden minimizes surgical morbidity because patients can undergo SLNB rather than ALND without compromising survival [5]. The other point of view supporting preoperative axillary US argues that the finding of an abnormal axillary node on axillary US followed by percutaneous biopsy confirmation would help to identify those patients with higher tumor burden [54,55], who would benefit from proceeding directly to ALND. This approach avoids the need for a Imaging of the Axilla second surgery. One study supporting the utilization of preoperative axillary US from a single center reported that only 3% to 5% of patients had an abnormal axillary US yet met the Z0011 criteria (ie, ALND was not necessary in these patients with preoperative abnormal axillary US). Other studies also supporting the use of preoperative axillary US even in patients who meet Z0011 criteria argue that axillary US can help identify patients with unsuspected extensive nodal disease, thereby removing them from consideration for unindicated SLNB [56-58]. | Imaging of the Axilla. CT Chest, Abdomen, and Pelvis Studies have shown that the use of advanced imaging modalities such as CT and FDG-PET/CT for staging asymptomatic women with early stage breast cancer has low yield for occult disease [44-46]. The 2020 NCCN Guidelines for Invasive Breast Cancer also suggest the use of CT with IV contrast only when there is elevated liver function tests, pulmonary or abdominal symptoms, or abnormal physical examination [7]. CT chest can visualize and assess the level I, II, and III regions of the axilla. The predictive accuracy of CT is not high enough to replace Imaging of the Axilla Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for staging of the axilla in breast cancer patients. US Axilla Axillary US is often performed in early-stage breast cancer patients since the Z0011 trial showed that early-stage cancer and low nodal burden minimizes surgical morbidity because patients can undergo SLNB rather than ALND without compromising survival [5]. The other point of view supporting preoperative axillary US argues that the finding of an abnormal axillary node on axillary US followed by percutaneous biopsy confirmation would help to identify those patients with higher tumor burden [54,55], who would benefit from proceeding directly to ALND. This approach avoids the need for a Imaging of the Axilla second surgery. One study supporting the utilization of preoperative axillary US from a single center reported that only 3% to 5% of patients had an abnormal axillary US yet met the Z0011 criteria (ie, ALND was not necessary in these patients with preoperative abnormal axillary US). Other studies also supporting the use of preoperative axillary US even in patients who meet Z0011 criteria argue that axillary US can help identify patients with unsuspected extensive nodal disease, thereby removing them from consideration for unindicated SLNB [56-58]. | 3158165 |
acrac_3158165_7 | Imaging of the Axilla | Patients with negative preoperative axillary US and SLNB had fewer positive nodes, smaller nodal metastases, and lower extranodal extension on final pathology [58]. US-guided biopsy of any suspicious axillary node either via fine-needle aspiration (FNA) or core biopsy is commonly performed when preoperative axillary US is done. The sensitivity of US-guided biopsy is variable with a wide range of 52% to 90%, whereas the specificity is higher, ranging from 98% to 100% [59-63]. CT Chest, Abdomen, and Pelvis Even in women with clinical node-positive disease, contrast-enhanced CT is not routinely performed and is not a part of the initial staging assessment if the patient does not have any signs or symptoms of disease outside the breast. When adenopathy is seen on CT, the Hounsfield unit of the metastatic lymph node is likely higher than nonmetastatic nodes. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is a valuable modality with potential to impact clinical management of patients with newly diagnosed locally advanced disease, monitoring treatment response in patients with known metastatic breast cancer, and for detection of recurrent disease. FDG-PET/CT is not suggested for routine systemic staging in T0 to T3, N0 to 1, M0 breast cancer patients without signs or symptoms of metastatic disease. A meta-analysis of 25 studies demonstrates the inferiority of FDG-PET/CT to SLNB for evaluation of the axilla [49]. MRI Breast Dynamic contrast-enhanced MRI is useful for staging prior to systemic therapy and for restaging of the axilla after systemic therapy if the preoperative axillary staging was positive [7,48]. However, most of the data focuses on the tumor within the breast and not the axillary nodes. | Imaging of the Axilla. Patients with negative preoperative axillary US and SLNB had fewer positive nodes, smaller nodal metastases, and lower extranodal extension on final pathology [58]. US-guided biopsy of any suspicious axillary node either via fine-needle aspiration (FNA) or core biopsy is commonly performed when preoperative axillary US is done. The sensitivity of US-guided biopsy is variable with a wide range of 52% to 90%, whereas the specificity is higher, ranging from 98% to 100% [59-63]. CT Chest, Abdomen, and Pelvis Even in women with clinical node-positive disease, contrast-enhanced CT is not routinely performed and is not a part of the initial staging assessment if the patient does not have any signs or symptoms of disease outside the breast. When adenopathy is seen on CT, the Hounsfield unit of the metastatic lymph node is likely higher than nonmetastatic nodes. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is a valuable modality with potential to impact clinical management of patients with newly diagnosed locally advanced disease, monitoring treatment response in patients with known metastatic breast cancer, and for detection of recurrent disease. FDG-PET/CT is not suggested for routine systemic staging in T0 to T3, N0 to 1, M0 breast cancer patients without signs or symptoms of metastatic disease. A meta-analysis of 25 studies demonstrates the inferiority of FDG-PET/CT to SLNB for evaluation of the axilla [49]. MRI Breast Dynamic contrast-enhanced MRI is useful for staging prior to systemic therapy and for restaging of the axilla after systemic therapy if the preoperative axillary staging was positive [7,48]. However, most of the data focuses on the tumor within the breast and not the axillary nodes. | 3158165 |
acrac_3158165_8 | Imaging of the Axilla | Current standard MRI of the breast has some technical challenges that do not allow simultaneous optimal imaging of both the breast and axilla, with approximately 30% of the MRI examination excluding the axilla because of technical challenges or incomplete axillary visualization in a retrospective study of 803 newly diagnosed breast cancer patients [79]. When comparing contrast-enhanced breast MRI with noncontrast breast MRI, contrast-enhanced breast MRI is more accurate than noncontrast MRI, based on Imaging of the Axilla a summary of 6 studies evaluating the accuracy of MRI in detecting pathologically proven positive axillary nodes [52]. In a meta-analysis of 21 eligible studies evaluating the efficacy of MRI versus FDG-PET/CT, the pooled sensitivity of MRI was significantly better (82% versus 64%, respectively), and the pooled specificity of MRI was similar (93%) [69]. A negative MRI does not exclude metastatic nodal disease on final histopathology, but a positive MRI finding suggests high tumor burden (>3 abnormal nodes) [15,69,79]. Based on the review of the literature, there was disagreement for the role of breast MRI in this clinical scenario. Diffusion-weighted imaging (DWI) is a noninvasive imaging technique that does not require contrast injection, measuring the mobility of water molecules and may complement contrast-enhanced MRI. In a meta-analysis of 13 studies from a literature search of 159 articles, the apparent diffusion coefficient value of metastatic nodes are lower than nonmetastatic nodes with pooled sensitivity of 86% and specificity of 86% using a b-value of 800 [80]. Sestamibi MBI There is no relevant literature supporting the routine use of Tc-99m sestamibi MBI for staging of the axilla in breast cancer patients. US Axilla US is the most established noninvasive imaging test for assessing the axilla. | Imaging of the Axilla. Current standard MRI of the breast has some technical challenges that do not allow simultaneous optimal imaging of both the breast and axilla, with approximately 30% of the MRI examination excluding the axilla because of technical challenges or incomplete axillary visualization in a retrospective study of 803 newly diagnosed breast cancer patients [79]. When comparing contrast-enhanced breast MRI with noncontrast breast MRI, contrast-enhanced breast MRI is more accurate than noncontrast MRI, based on Imaging of the Axilla a summary of 6 studies evaluating the accuracy of MRI in detecting pathologically proven positive axillary nodes [52]. In a meta-analysis of 21 eligible studies evaluating the efficacy of MRI versus FDG-PET/CT, the pooled sensitivity of MRI was significantly better (82% versus 64%, respectively), and the pooled specificity of MRI was similar (93%) [69]. A negative MRI does not exclude metastatic nodal disease on final histopathology, but a positive MRI finding suggests high tumor burden (>3 abnormal nodes) [15,69,79]. Based on the review of the literature, there was disagreement for the role of breast MRI in this clinical scenario. Diffusion-weighted imaging (DWI) is a noninvasive imaging technique that does not require contrast injection, measuring the mobility of water molecules and may complement contrast-enhanced MRI. In a meta-analysis of 13 studies from a literature search of 159 articles, the apparent diffusion coefficient value of metastatic nodes are lower than nonmetastatic nodes with pooled sensitivity of 86% and specificity of 86% using a b-value of 800 [80]. Sestamibi MBI There is no relevant literature supporting the routine use of Tc-99m sestamibi MBI for staging of the axilla in breast cancer patients. US Axilla US is the most established noninvasive imaging test for assessing the axilla. | 3158165 |
acrac_3158165_9 | Imaging of the Axilla | Benign lymph nodes can often be differentiated from malignant nodes based on size, morphology, and vascularity, although there is a wide range of reported sensitivity and specificity for axillary US. The reported sensitivity can range from 26.4% to 94% and specificity from 53% to 98% [58,81,82]. Axillary US alone has a relatively low NPV and sensitivity to be useful as a predictor of axillary nodal burden [83,84]. When combined with needle biopsy, however, the sensitivity improves from 61% to 79% in a meta-analysis of 21 studies [54,62,85]. US-guided core needle biopsy was superior to US- guided FNA in a meta-analysis of 1,353 patients with newly diagnosed invasive breast carcinoma, with a reported sensitivity of 88% for core biopsy and 74% for FNA [86]. US features associated with a higher likelihood of malignancy include short-axis lymph node size >1 cm, cortical thickness of >0.3cm, and absence of a fatty hilum [87-90]. However, these imaging features are not specific enough to avoid the need for histologic sampling. Since the Z0011 trial, there continues to be variability in incorporating axillary US into practice. Those in favor of performing axillary US routinely argue that >3 abnormal nodes or a positive axillary lymph node on needle biopsy warrant ALND rather than SLNB because these patients tend to have a high nodal tumor burden [58,91]. Those not in favor of performing axillary US recommend proceeding with SLNB, even if the preoperative US identify malignant-appearing lymph node(s) because the specificity of US is relatively low. Variant 5: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT. Lymph node staging is crucial in the management of breast cancer, and several multicenter trials have impacted the approach to axillary lymph node treatment in breast cancer patients. | Imaging of the Axilla. Benign lymph nodes can often be differentiated from malignant nodes based on size, morphology, and vascularity, although there is a wide range of reported sensitivity and specificity for axillary US. The reported sensitivity can range from 26.4% to 94% and specificity from 53% to 98% [58,81,82]. Axillary US alone has a relatively low NPV and sensitivity to be useful as a predictor of axillary nodal burden [83,84]. When combined with needle biopsy, however, the sensitivity improves from 61% to 79% in a meta-analysis of 21 studies [54,62,85]. US-guided core needle biopsy was superior to US- guided FNA in a meta-analysis of 1,353 patients with newly diagnosed invasive breast carcinoma, with a reported sensitivity of 88% for core biopsy and 74% for FNA [86]. US features associated with a higher likelihood of malignancy include short-axis lymph node size >1 cm, cortical thickness of >0.3cm, and absence of a fatty hilum [87-90]. However, these imaging features are not specific enough to avoid the need for histologic sampling. Since the Z0011 trial, there continues to be variability in incorporating axillary US into practice. Those in favor of performing axillary US routinely argue that >3 abnormal nodes or a positive axillary lymph node on needle biopsy warrant ALND rather than SLNB because these patients tend to have a high nodal tumor burden [58,91]. Those not in favor of performing axillary US recommend proceeding with SLNB, even if the preoperative US identify malignant-appearing lymph node(s) because the specificity of US is relatively low. Variant 5: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT. Lymph node staging is crucial in the management of breast cancer, and several multicenter trials have impacted the approach to axillary lymph node treatment in breast cancer patients. | 3158165 |
acrac_3158165_10 | Imaging of the Axilla | For patients with clinically node-negative disease, SLNB is an oncologically safe approach with less morbidity than ALND. The prospective IBCSG 23-01 trial of 934 patients randomized to completion of ALND (n = 465) or no ALND (n = 469), with median follow-up of 9.7 years, revealed that omitting ALND was safe, even if the sentinel nodes contained micrometastases [64]. The NSABP B-32 trial of 5,611 women randomized to SLNB alone versus axillary lymph node biopsy and ALND with follow-up of 8 years reported no statistical differences in overall survival, disease-free survival, and regional control with less postoperative morbidity in the SLNB alone group [2,3]. The Z0011 trial recruited 891 women with T1 or T2 invasive primary breast cancer and no palpable axillary adenopathy [5]. These women were randomized to SLNB versus ALND. The 10-year overall survival for patients treated with SLNB alone was noninferior to those treated with ALND. The Z0011 trial, with median follow-up of 9.3 years, also demonstrated no differences in survival between those who received ALND versus no ALND [5]. The After Mapping of the Axilla: Radiotherapy Or Surgery trial from the European Organization for Research and Treatment of Cancer with median follow-up of 10 years also showed no significant differences at 10 years for axillary recurrence or overall survival between the 2 groups [66]. CT Chest, Abdomen, and Pelvis Contrast-enhanced and noncontrast-enhanced CT studies are not typically performed for early-stage breast cancer in asymptomatic patients because asymptomatic distant disease is rare. Contrast-enhanced CT can be used if the primary breast cancer is >2 cm, there is clinical node-positive disease, the tumor demonstrates biologically Imaging of the Axilla aggressive features on histopathology, or patients present with clinical symptoms such as elevated liver function tests [7,92]. | Imaging of the Axilla. For patients with clinically node-negative disease, SLNB is an oncologically safe approach with less morbidity than ALND. The prospective IBCSG 23-01 trial of 934 patients randomized to completion of ALND (n = 465) or no ALND (n = 469), with median follow-up of 9.7 years, revealed that omitting ALND was safe, even if the sentinel nodes contained micrometastases [64]. The NSABP B-32 trial of 5,611 women randomized to SLNB alone versus axillary lymph node biopsy and ALND with follow-up of 8 years reported no statistical differences in overall survival, disease-free survival, and regional control with less postoperative morbidity in the SLNB alone group [2,3]. The Z0011 trial recruited 891 women with T1 or T2 invasive primary breast cancer and no palpable axillary adenopathy [5]. These women were randomized to SLNB versus ALND. The 10-year overall survival for patients treated with SLNB alone was noninferior to those treated with ALND. The Z0011 trial, with median follow-up of 9.3 years, also demonstrated no differences in survival between those who received ALND versus no ALND [5]. The After Mapping of the Axilla: Radiotherapy Or Surgery trial from the European Organization for Research and Treatment of Cancer with median follow-up of 10 years also showed no significant differences at 10 years for axillary recurrence or overall survival between the 2 groups [66]. CT Chest, Abdomen, and Pelvis Contrast-enhanced and noncontrast-enhanced CT studies are not typically performed for early-stage breast cancer in asymptomatic patients because asymptomatic distant disease is rare. Contrast-enhanced CT can be used if the primary breast cancer is >2 cm, there is clinical node-positive disease, the tumor demonstrates biologically Imaging of the Axilla aggressive features on histopathology, or patients present with clinical symptoms such as elevated liver function tests [7,92]. | 3158165 |
acrac_3158165_11 | Imaging of the Axilla | However, findings on CT do not influence the approach for axillary surgery, reduce the number of axillary surgeries, or reduce the reoperation rate [14,47]. MRI Breast Dynamic contrast-enhanced MRI is not routinely performed [7,92] for staging prior to systemic therapy and for restaging of the axilla after systemic therapy if preoperative axillary staging was negative [7,48]. Current breast MRI protocols do not adequately image the breast and entire axilla in up to 30% of cases based on a retrospective study of 803 newly diagnosed breast cancer patients [79]. However, contrast-enhanced breast MRI is more accurate than noncontrast imaging with a FNR of 12% to 19% and NPV of 97% to 99% based on 6 studies designed to evaluate the accuracy of MRI in patients with histologically positive nodes [52]. In a meta-analysis of 21 eligible studies evaluating the efficacy of MRI versus FDG-PET/CT, the pooled sensitivity of MRI was significantly better (82% versus 64%, respectively), and the pooled specificity was similar (93%) [69]. A negative MRI does not exclude metastatic nodal disease on final histopathology, but a positive MRI finding suggests high tumor burden (>3 abnormal nodes) [15,69,79]. DWI is a noninvasive imaging technique that does not require contrast injection, measures the mobility of water molecules, and may complement contrast-enhanced MRI. In a meta-analysis of 13 studies from a literature search of 159 articles, the apparent diffusion coefficient value of metastatic nodes is lower than nonmetastatic nodes with pooled sensitivity of 86% and specificity of 86% using a b-value of 800 [80]. Sestamibi MBI There is no relevant literature supporting the routine use of sestamibi MBI for staging of the axilla in breast cancer patients. | Imaging of the Axilla. However, findings on CT do not influence the approach for axillary surgery, reduce the number of axillary surgeries, or reduce the reoperation rate [14,47]. MRI Breast Dynamic contrast-enhanced MRI is not routinely performed [7,92] for staging prior to systemic therapy and for restaging of the axilla after systemic therapy if preoperative axillary staging was negative [7,48]. Current breast MRI protocols do not adequately image the breast and entire axilla in up to 30% of cases based on a retrospective study of 803 newly diagnosed breast cancer patients [79]. However, contrast-enhanced breast MRI is more accurate than noncontrast imaging with a FNR of 12% to 19% and NPV of 97% to 99% based on 6 studies designed to evaluate the accuracy of MRI in patients with histologically positive nodes [52]. In a meta-analysis of 21 eligible studies evaluating the efficacy of MRI versus FDG-PET/CT, the pooled sensitivity of MRI was significantly better (82% versus 64%, respectively), and the pooled specificity was similar (93%) [69]. A negative MRI does not exclude metastatic nodal disease on final histopathology, but a positive MRI finding suggests high tumor burden (>3 abnormal nodes) [15,69,79]. DWI is a noninvasive imaging technique that does not require contrast injection, measures the mobility of water molecules, and may complement contrast-enhanced MRI. In a meta-analysis of 13 studies from a literature search of 159 articles, the apparent diffusion coefficient value of metastatic nodes is lower than nonmetastatic nodes with pooled sensitivity of 86% and specificity of 86% using a b-value of 800 [80]. Sestamibi MBI There is no relevant literature supporting the routine use of sestamibi MBI for staging of the axilla in breast cancer patients. | 3158165 |
acrac_3158165_12 | Imaging of the Axilla | The other point of view supporting preoperative axillary US argues that the finding of an abnormal axillary node on axillary US followed by percutaneous biopsy confirmation would help to identify those patients with higher tumor burden [54,55], and these patients would benefit from proceeding directly to ALND. This approach avoids the need for a second surgery. One study, supporting the utilization of preoperative axillary US from a single center, reported that only 3% to 5% of patients had an abnormal axillary US and met the Z0011 criteria (ie, ALND was not necessary in these patients with preoperative abnormal axillary US). Other studies also supporting the addition of preoperative axillary US to the management of patients who met Z0011 criteria argue that axillary US can help identify patients with more extensive nodal disease who meet the Z0011 criteria [56-58]. Patients with negative preoperative axillary US and SLN had fewer positive nodes, smaller nodal metastases, and lower extranodal extension on final pathology [58]. Imaging of the Axilla US-guided biopsy of any suspicious axillary node either via FNA or core biopsy is commonly performed when preoperative axillary US is done. The sensitivity of US-guided biopsy is variable with a wide range of 52% to 90%, whereas the specificity is higher, ranging from 98% to 100% [59-63]. CT Chest, Abdomen, and Pelvis Contrast-enhanced CT is not routinely used to stage the axilla, even in patients with clinically positive axillary findings. While CT chest can visualize and assess the level I, II, and III regions of the axilla, the predictive accuracy of CT is not high enough to replace SLNB [50,51,95]. When adenopathy is seen on CT, the Hounsfield unit of the metastatic lymph node is likely higher than nonmetastatic nodes. | Imaging of the Axilla. The other point of view supporting preoperative axillary US argues that the finding of an abnormal axillary node on axillary US followed by percutaneous biopsy confirmation would help to identify those patients with higher tumor burden [54,55], and these patients would benefit from proceeding directly to ALND. This approach avoids the need for a second surgery. One study, supporting the utilization of preoperative axillary US from a single center, reported that only 3% to 5% of patients had an abnormal axillary US and met the Z0011 criteria (ie, ALND was not necessary in these patients with preoperative abnormal axillary US). Other studies also supporting the addition of preoperative axillary US to the management of patients who met Z0011 criteria argue that axillary US can help identify patients with more extensive nodal disease who meet the Z0011 criteria [56-58]. Patients with negative preoperative axillary US and SLN had fewer positive nodes, smaller nodal metastases, and lower extranodal extension on final pathology [58]. Imaging of the Axilla US-guided biopsy of any suspicious axillary node either via FNA or core biopsy is commonly performed when preoperative axillary US is done. The sensitivity of US-guided biopsy is variable with a wide range of 52% to 90%, whereas the specificity is higher, ranging from 98% to 100% [59-63]. CT Chest, Abdomen, and Pelvis Contrast-enhanced CT is not routinely used to stage the axilla, even in patients with clinically positive axillary findings. While CT chest can visualize and assess the level I, II, and III regions of the axilla, the predictive accuracy of CT is not high enough to replace SLNB [50,51,95]. When adenopathy is seen on CT, the Hounsfield unit of the metastatic lymph node is likely higher than nonmetastatic nodes. | 3158165 |
acrac_3158165_13 | Imaging of the Axilla | Contrast-enhanced CT may be used if the primary breast cancer is >2 cm, there is clinical node-positive disease, the tumor demonstrates biologically aggressive features on histopathology, or patients present with clinical symptoms such as elevated liver function tests [7,92]. However, findings on CT do not influence the approach for axillary surgery, reduce the number of axillary surgeries, or reduce the reoperation rate [14,47]. For locally advanced breast cancer (>5 cm in size, involving skin or underlying chest wall) and local recurrence, CT may be helpful [7]. For inflammatory breast cancer, the incidence of nodal metastases at presentation is high, up to 79.8% in a SEER registry of 761 patients and 5-year survival is worse for lymph node-positive patients (49%) than node-negative patients (66%) [98]. If there is clinical suspicion of inflammatory breast cancer, contrast-enhanced CT may be helpful for staging [7]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT may be useful in the staging of newly diagnosed advanced breast cancer given a higher likelihood of extra-axillary metastatic disease or distant disease [94,95]. It has been proposed that if a primary breast tumor is >2 cm and has a high SUVmax, there is a higher probability of axillary nodal metastases [73,99]. In addition to assisting in the staging of advanced breast cancer, FDG-PET/CT may be beneficial in staging patients with T1 stage breast cancer, particularly those with triple negative or human epidermal growth factor receptor 2 (HER2) positive breast cancer with clinical node positive disease because there is a higher prevalence of nodal disease and distant metastases [71]. In order to assess response to neoadjuvant therapy, comparing pretreatment nodal FDG uptake to subsequent midtreatment or post-treatment FDG uptake is essential and also can be used to identify those at a higher risk of recurrence [100-102]. | Imaging of the Axilla. Contrast-enhanced CT may be used if the primary breast cancer is >2 cm, there is clinical node-positive disease, the tumor demonstrates biologically aggressive features on histopathology, or patients present with clinical symptoms such as elevated liver function tests [7,92]. However, findings on CT do not influence the approach for axillary surgery, reduce the number of axillary surgeries, or reduce the reoperation rate [14,47]. For locally advanced breast cancer (>5 cm in size, involving skin or underlying chest wall) and local recurrence, CT may be helpful [7]. For inflammatory breast cancer, the incidence of nodal metastases at presentation is high, up to 79.8% in a SEER registry of 761 patients and 5-year survival is worse for lymph node-positive patients (49%) than node-negative patients (66%) [98]. If there is clinical suspicion of inflammatory breast cancer, contrast-enhanced CT may be helpful for staging [7]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT may be useful in the staging of newly diagnosed advanced breast cancer given a higher likelihood of extra-axillary metastatic disease or distant disease [94,95]. It has been proposed that if a primary breast tumor is >2 cm and has a high SUVmax, there is a higher probability of axillary nodal metastases [73,99]. In addition to assisting in the staging of advanced breast cancer, FDG-PET/CT may be beneficial in staging patients with T1 stage breast cancer, particularly those with triple negative or human epidermal growth factor receptor 2 (HER2) positive breast cancer with clinical node positive disease because there is a higher prevalence of nodal disease and distant metastases [71]. In order to assess response to neoadjuvant therapy, comparing pretreatment nodal FDG uptake to subsequent midtreatment or post-treatment FDG uptake is essential and also can be used to identify those at a higher risk of recurrence [100-102]. | 3158165 |
acrac_3158165_14 | Imaging of the Axilla | MRI Breast Dynamic contrast-enhanced MRI may be useful for staging prior to systemic therapy and for restaging of the axilla after systemic therapy if the preoperative axillary staging was positive [7,48]. However, most of the data focuses on the tumor within the breast and not of the axillary nodes. Current breast MRI protocols do not adequately image the entire axilla (level I, II, III) in up to 30% of cases based on a retrospective study of 803 newly diagnosed breast cancer patients [79]. However, contrast-enhanced breast MRI is more accurate than noncontrast imaging with a FNR of 12% to 19% and NPV of 97% to 99% based on 6 studies designed to evaluate the accuracy of MRI in patients with histologically positive nodes [52]. In a meta-analysis of 21 eligible studies evaluating the efficacy of MRI versus FDG-PET/CT, the pooled sensitivity of MRI was significantly better (82% versus 64%, respectively), and the pooled specificity of MRI was similar (93%) [69]. A negative MRI does not exclude metastatic nodal disease on final histopathology, but a positive MRI finding suggests high tumor burden (>3 abnormal nodes) [15,69,79]. DWI is a noninvasive imaging technique that does not require contrast injection, measures the mobility of water molecules, and may complement contrast-enhanced MRI. In a meta-analysis of 13 studies from a literature search of 159 articles, apparent diffusion coefficient value of metastatic nodes are lower than nonmetastatic nodes with Imaging of the Axilla pooled sensitivity of 86% and specificity of 86% using a b-value of 800 [80]. There is insufficient data to support the use of DWI for detecting metastatic disease in axillary nodes at this time. In summary, although current breast MRI protocols do not consistently image the entire axilla in patients with newly diagnosed breast cancer over 2 cm in size and clinical node-positive, breast MRI can be beneficial for evaluation of tumor within the breast and may be helpful for the axilla in some circumstances. | Imaging of the Axilla. MRI Breast Dynamic contrast-enhanced MRI may be useful for staging prior to systemic therapy and for restaging of the axilla after systemic therapy if the preoperative axillary staging was positive [7,48]. However, most of the data focuses on the tumor within the breast and not of the axillary nodes. Current breast MRI protocols do not adequately image the entire axilla (level I, II, III) in up to 30% of cases based on a retrospective study of 803 newly diagnosed breast cancer patients [79]. However, contrast-enhanced breast MRI is more accurate than noncontrast imaging with a FNR of 12% to 19% and NPV of 97% to 99% based on 6 studies designed to evaluate the accuracy of MRI in patients with histologically positive nodes [52]. In a meta-analysis of 21 eligible studies evaluating the efficacy of MRI versus FDG-PET/CT, the pooled sensitivity of MRI was significantly better (82% versus 64%, respectively), and the pooled specificity of MRI was similar (93%) [69]. A negative MRI does not exclude metastatic nodal disease on final histopathology, but a positive MRI finding suggests high tumor burden (>3 abnormal nodes) [15,69,79]. DWI is a noninvasive imaging technique that does not require contrast injection, measures the mobility of water molecules, and may complement contrast-enhanced MRI. In a meta-analysis of 13 studies from a literature search of 159 articles, apparent diffusion coefficient value of metastatic nodes are lower than nonmetastatic nodes with Imaging of the Axilla pooled sensitivity of 86% and specificity of 86% using a b-value of 800 [80]. There is insufficient data to support the use of DWI for detecting metastatic disease in axillary nodes at this time. In summary, although current breast MRI protocols do not consistently image the entire axilla in patients with newly diagnosed breast cancer over 2 cm in size and clinical node-positive, breast MRI can be beneficial for evaluation of tumor within the breast and may be helpful for the axilla in some circumstances. | 3158165 |
acrac_3158165_15 | Imaging of the Axilla | Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for staging of the axilla in clinically node-positive breast cancer patients. US Axilla Axillary US is typically performed for assessing nodal disease in patients with newly diagnosed breast carcinoma and palpable adenopathy [7,92]. In a retrospective series of 1,287 breast cancer patients who had preoperative axillary US-FNA followed by SLNB or ALND, the group with axillary US-FNA had a higher number of metastatic axillary lymph nodes than those with micro- or macrometastatic nodal disease on SLNB. This suggests that patients with US visible nodal disease, confirmed by axillary US-FNA, have more extensive nodal involvement [60]. Positive axillary US, confirmed with biopsy, helps to identify patients with higher tumor burden [54,55], and as such, these patients can proceed directly to ALND. However, axillary US is not able to detect all metastatic nodes and therefore cannot replace SLNB or ALND [58]. It is well known that negative axillary US with or without biopsy does not rule out nodal disease [58]. The sensitivity of US-guided biopsy also has variable sensitivity ranging from 52% to 90%, whereas the specificity is higher, ranging from 98% to 100% [59-63]. For many cases, axillary US can differentiate patients with high lymph node tumor burden from patients with low lymph node tumor burden, suggesting that those with positive axillary nodes on percutaneous biopsy should have ALND rather than SLNB, especially because the Z0011 criteria do not apply to patients with clinically palpable adenopathy. Axillary US features favoring nodal metastases include cortical thickness of >0.3 cm and absence of a fatty hilum, a finding with a high positive predictive value (PPV) of 90% to 93% [103-105]. CT Chest, Abdomen, and Pelvis CT allows assessment of the axillary level II and III nodal regions that are not always well visualized on US. | Imaging of the Axilla. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for staging of the axilla in clinically node-positive breast cancer patients. US Axilla Axillary US is typically performed for assessing nodal disease in patients with newly diagnosed breast carcinoma and palpable adenopathy [7,92]. In a retrospective series of 1,287 breast cancer patients who had preoperative axillary US-FNA followed by SLNB or ALND, the group with axillary US-FNA had a higher number of metastatic axillary lymph nodes than those with micro- or macrometastatic nodal disease on SLNB. This suggests that patients with US visible nodal disease, confirmed by axillary US-FNA, have more extensive nodal involvement [60]. Positive axillary US, confirmed with biopsy, helps to identify patients with higher tumor burden [54,55], and as such, these patients can proceed directly to ALND. However, axillary US is not able to detect all metastatic nodes and therefore cannot replace SLNB or ALND [58]. It is well known that negative axillary US with or without biopsy does not rule out nodal disease [58]. The sensitivity of US-guided biopsy also has variable sensitivity ranging from 52% to 90%, whereas the specificity is higher, ranging from 98% to 100% [59-63]. For many cases, axillary US can differentiate patients with high lymph node tumor burden from patients with low lymph node tumor burden, suggesting that those with positive axillary nodes on percutaneous biopsy should have ALND rather than SLNB, especially because the Z0011 criteria do not apply to patients with clinically palpable adenopathy. Axillary US features favoring nodal metastases include cortical thickness of >0.3 cm and absence of a fatty hilum, a finding with a high positive predictive value (PPV) of 90% to 93% [103-105]. CT Chest, Abdomen, and Pelvis CT allows assessment of the axillary level II and III nodal regions that are not always well visualized on US. | 3158165 |
acrac_3158165_16 | Imaging of the Axilla | However, there are no data to support the routine use of CT for assessing a new palpable axillary lump in breast cancer patients at midtreatment of NAC and very limited data on the use of CT for assessing nodal response. One retrospective study reviewed the pretreatment breast MRI, FDG-PET/CT, and CT imaging on 348 breast cancer patients who received NAC followed by surgery and reported that patients with higher radiological nodal stage on imaging were more likely to have node-positivity upon surgery, larger nodal metastases, and more frequent extranodal extension [108]. Digital Breast Tomosynthesis Diagnostic DBT allows visualization of axillary level I nodal regions but does not fully assess the axilla. Although not typically used for axillary evaluation, DBT may be helpful in evaluating for progression of the primary breast malignancy. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for assessing a new palpable axillary mass during midtreatment of NAC. Mammography Diagnostic Similar to DBT, mammography does not visualize the entire axilla and is not useful for assessing an axillary lump. Mammography may be performed to determine if there is also progression of the primary breast carcinoma. Imaging of the Axilla MRI Breast There is no evidence to support the use of breast MRI as the initial imaging test for assessing a new palpable axillary lump during NAC treatment. However, breast MRI may be helpful in assessing response of the primary breast tumor and associated axillary adenopathy. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for assessing a new palpable axillary lump during midtreatment of NAC. US Axilla Despite the limited literature addressing the use of axillary US for assessing a new palpable axillary lump during midtreatment, axillary US may be useful in this scenario because of its noninvasive nature. If the axillary US finding is uncertain, biopsy can be performed [86]. | Imaging of the Axilla. However, there are no data to support the routine use of CT for assessing a new palpable axillary lump in breast cancer patients at midtreatment of NAC and very limited data on the use of CT for assessing nodal response. One retrospective study reviewed the pretreatment breast MRI, FDG-PET/CT, and CT imaging on 348 breast cancer patients who received NAC followed by surgery and reported that patients with higher radiological nodal stage on imaging were more likely to have node-positivity upon surgery, larger nodal metastases, and more frequent extranodal extension [108]. Digital Breast Tomosynthesis Diagnostic DBT allows visualization of axillary level I nodal regions but does not fully assess the axilla. Although not typically used for axillary evaluation, DBT may be helpful in evaluating for progression of the primary breast malignancy. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for assessing a new palpable axillary mass during midtreatment of NAC. Mammography Diagnostic Similar to DBT, mammography does not visualize the entire axilla and is not useful for assessing an axillary lump. Mammography may be performed to determine if there is also progression of the primary breast carcinoma. Imaging of the Axilla MRI Breast There is no evidence to support the use of breast MRI as the initial imaging test for assessing a new palpable axillary lump during NAC treatment. However, breast MRI may be helpful in assessing response of the primary breast tumor and associated axillary adenopathy. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for assessing a new palpable axillary lump during midtreatment of NAC. US Axilla Despite the limited literature addressing the use of axillary US for assessing a new palpable axillary lump during midtreatment, axillary US may be useful in this scenario because of its noninvasive nature. If the axillary US finding is uncertain, biopsy can be performed [86]. | 3158165 |
acrac_3158165_17 | Imaging of the Axilla | A small single-center study looking at the role of midtreatment axillary US in 159 patients of mixed breast cancer subtypes observed that US performed better for residual axillary nodal tumor burden than for residual index breast cancer and provided more consistent results across different cancer subtypes [109]. Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy. NAC is used to treat operable large tumors, nonoperable locally advanced tumors, and inflammatory breast cancers prior to definitive surgical management. If there is pathological response to NAC and the patient is clinically node- negative, SLNB is preferred over ALND in order to minimize morbidity. In a study of 925 patients treated with NAC, 5-year overall survival was superior for patients with pathologic complete remission of cytological proven axillary lymph node metastases (93%) compared with those without complete response (72%) [110]. The prognostic significance of response to NAC can vary between the primary breast tumor and the axilla and based on tumor receptor subtypes (eg, triple negative versus HER2 positive cancers) [112]. Those patients with initial node-positive breast cancer who achieve complete pathological response after NAC have similar prognoses as to those with clinical node-negativity [112]. Even though no imaging will replace SLNB or ALND for staging, the ability to assess response during or after NAC helps to predict outcomes and aids with treatment planning. CT Chest, Abdomen, and Pelvis There is no relevant literature to support the use of contrast-enhanced or noncontrast-enhanced CT to image the axilla after completion of NAC. Digital Breast Tomosynthesis Diagnostic There are no data to support the use of DBT to image the axilla after completion of NAC in patients with initial clinical node-negative disease and no new clinical concern or palpable axillary lump. | Imaging of the Axilla. A small single-center study looking at the role of midtreatment axillary US in 159 patients of mixed breast cancer subtypes observed that US performed better for residual axillary nodal tumor burden than for residual index breast cancer and provided more consistent results across different cancer subtypes [109]. Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy. NAC is used to treat operable large tumors, nonoperable locally advanced tumors, and inflammatory breast cancers prior to definitive surgical management. If there is pathological response to NAC and the patient is clinically node- negative, SLNB is preferred over ALND in order to minimize morbidity. In a study of 925 patients treated with NAC, 5-year overall survival was superior for patients with pathologic complete remission of cytological proven axillary lymph node metastases (93%) compared with those without complete response (72%) [110]. The prognostic significance of response to NAC can vary between the primary breast tumor and the axilla and based on tumor receptor subtypes (eg, triple negative versus HER2 positive cancers) [112]. Those patients with initial node-positive breast cancer who achieve complete pathological response after NAC have similar prognoses as to those with clinical node-negativity [112]. Even though no imaging will replace SLNB or ALND for staging, the ability to assess response during or after NAC helps to predict outcomes and aids with treatment planning. CT Chest, Abdomen, and Pelvis There is no relevant literature to support the use of contrast-enhanced or noncontrast-enhanced CT to image the axilla after completion of NAC. Digital Breast Tomosynthesis Diagnostic There are no data to support the use of DBT to image the axilla after completion of NAC in patients with initial clinical node-negative disease and no new clinical concern or palpable axillary lump. | 3158165 |
acrac_3158165_18 | Imaging of the Axilla | For assessment of the primary breast tumor, one prospective study of 51 stage II and III breast cancer patients reported that MRI and DBT outperformed mammography and whole-breast US in the prediction of pathologic complete response [113]. However, this study cannot be extrapolated to axillary nodal disease. FDG-PET/CT Skull Base to Mid-Thigh There are limited data to support the use of FDG-PET/CT for assessing response of nodal disease from breast cancer following completion of NAC. Most studies report changes in size and SUV measurements of the index breast carcinoma or distant metastases. Four meta-analyses of FDG-PET/CT in detecting residual breast disease reported a pooled sensitivity of 81% to 84% and a specificity of 66% to 79% [114-118]. FDG-PET/CT is limited by the lack of consensus for standard criteria to measure response of the index tumor or nodal disease, and SUV measurements underestimating the amount of residual disease when the residual tumor size is small. In one meta-analysis, 4 of 19 studies reported a pooled sensitivity of 92% and an NPV of 88% in predicting regional lymph node response but the specificity was inconclusive [118]. Even though there is suggestion that the early changes in SUV may correlate Imaging of the Axilla with NAC response, a negative FDG-PET/CT does not guarantee that the final pathology is also negative, especially if the residual tumor is of low to moderate grade [119,120]. A recent report from the National Cancer Database of 33,162 patients concluded that a breast-only response from a node-only response or both breast and nodal response had different prognoses, which also varied with tumor subtypes [112]. Given the limited data, FDG-PET/CT is not currently performed post-NAC to restage the axilla. Mammography Diagnostic Mammography can reliably be used to assess response of a primary breast malignancy to NAC. However, it is less useful in assessing axillary nodal response to therapy given that the axilla is incompletely visualized. | Imaging of the Axilla. For assessment of the primary breast tumor, one prospective study of 51 stage II and III breast cancer patients reported that MRI and DBT outperformed mammography and whole-breast US in the prediction of pathologic complete response [113]. However, this study cannot be extrapolated to axillary nodal disease. FDG-PET/CT Skull Base to Mid-Thigh There are limited data to support the use of FDG-PET/CT for assessing response of nodal disease from breast cancer following completion of NAC. Most studies report changes in size and SUV measurements of the index breast carcinoma or distant metastases. Four meta-analyses of FDG-PET/CT in detecting residual breast disease reported a pooled sensitivity of 81% to 84% and a specificity of 66% to 79% [114-118]. FDG-PET/CT is limited by the lack of consensus for standard criteria to measure response of the index tumor or nodal disease, and SUV measurements underestimating the amount of residual disease when the residual tumor size is small. In one meta-analysis, 4 of 19 studies reported a pooled sensitivity of 92% and an NPV of 88% in predicting regional lymph node response but the specificity was inconclusive [118]. Even though there is suggestion that the early changes in SUV may correlate Imaging of the Axilla with NAC response, a negative FDG-PET/CT does not guarantee that the final pathology is also negative, especially if the residual tumor is of low to moderate grade [119,120]. A recent report from the National Cancer Database of 33,162 patients concluded that a breast-only response from a node-only response or both breast and nodal response had different prognoses, which also varied with tumor subtypes [112]. Given the limited data, FDG-PET/CT is not currently performed post-NAC to restage the axilla. Mammography Diagnostic Mammography can reliably be used to assess response of a primary breast malignancy to NAC. However, it is less useful in assessing axillary nodal response to therapy given that the axilla is incompletely visualized. | 3158165 |
acrac_3158165_19 | Imaging of the Axilla | MRI Breast The role of breast MRI in detecting residual tumor within the axillary lymph nodes remains questionable [121]. Based on a 26-study meta-analysis, MRI has moderate sensitivity (77%) and specificity (90%) for detecting residual disease after NAC [122,123]. Most of the literature confirms the superiority of MRI in detecting residual tumor within the breast after NAC compared with mammography, US, and physical examination [124]. However, it is not proven that preoperative MRI is associated with improved surgical outcomes or lower recurrence rates [125]. A meta-analysis of 44 studies reported MRI sensitivity for detecting residual disease in the breast was 92% and a specificity of 90% [124]. MRI also demonstrates higher accuracy in triple negative tumors and HER2-positive tumors [126-128]. The performance of MRI for the primary breast lesion cannot be extrapolated into MRI performance of the axillary nodal disease [112]. Therefore, MRI is not used routinely for predicting response of axillary nodal disease. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for assessing response after treatment with NAC. US Axilla The role of axillary US to assess the axilla after NAC remains controversial [7]. Most of the data from multicenter trials involve patients with initial clinical node-positive disease [129,130]. These studies, evaluating SLNB after NAC, report that the accuracy rates of SLNB are acceptable. With the variable sensitivity and specificity of axillary US, even in combination with percutaneous biopsy, axillary US is not able to replace SLNB. Therefore, axillary US may not assess axillary response after chemotherapy. Variant 9: Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery. NAC is used to treat operable large tumors, nonoperable locally advanced tumors, and inflammatory breast cancers prior to definitive surgical management. | Imaging of the Axilla. MRI Breast The role of breast MRI in detecting residual tumor within the axillary lymph nodes remains questionable [121]. Based on a 26-study meta-analysis, MRI has moderate sensitivity (77%) and specificity (90%) for detecting residual disease after NAC [122,123]. Most of the literature confirms the superiority of MRI in detecting residual tumor within the breast after NAC compared with mammography, US, and physical examination [124]. However, it is not proven that preoperative MRI is associated with improved surgical outcomes or lower recurrence rates [125]. A meta-analysis of 44 studies reported MRI sensitivity for detecting residual disease in the breast was 92% and a specificity of 90% [124]. MRI also demonstrates higher accuracy in triple negative tumors and HER2-positive tumors [126-128]. The performance of MRI for the primary breast lesion cannot be extrapolated into MRI performance of the axillary nodal disease [112]. Therefore, MRI is not used routinely for predicting response of axillary nodal disease. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for assessing response after treatment with NAC. US Axilla The role of axillary US to assess the axilla after NAC remains controversial [7]. Most of the data from multicenter trials involve patients with initial clinical node-positive disease [129,130]. These studies, evaluating SLNB after NAC, report that the accuracy rates of SLNB are acceptable. With the variable sensitivity and specificity of axillary US, even in combination with percutaneous biopsy, axillary US is not able to replace SLNB. Therefore, axillary US may not assess axillary response after chemotherapy. Variant 9: Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery. NAC is used to treat operable large tumors, nonoperable locally advanced tumors, and inflammatory breast cancers prior to definitive surgical management. | 3158165 |
acrac_3158165_20 | Imaging of the Axilla | Information on the residual disease or positive axillary nodes after NAC is beneficial for the determination of the axillary surgical management and for the need of radiation therapy [7]. The guidelines define low tumor burden in the axilla as nodal disease that is image-detected disease not apparent on clinical examination; however, the imaging test is not specified in the guidelines. If there is pathological response to NAC and the patient is clinically node-negative, SLNB is preferred over ALND in order to minimize morbidity. In a study of 925 patients treated with NAC, 5-year overall survival was superior for patients with pathologic complete remission of the cytological proven axillary lymph node metastases (93%) compared with those without complete response (72%) [110]. Imaging of the Axilla CT Chest, Abdomen, and Pelvis There are no relevant data to support the use of contrast-enhanced or noncontrast-enhanced CT to image the axilla after completion of NAC. Digital Breast Tomosynthesis Diagnostic There are no data to support the use of DBT to image the axilla after completion of NAC in patients with initial clinical node-positive disease pre-NAC and who have no clinical suspicion of disease progression or new axillary nodal disease. When comparing mammography to DBT, one prospective study of 51 stage II and III breast cancer patients reported that MRI and DBT outperformed mammography and whole-breast US in the prediction of pathologic complete response [113]. Unfortunately, this cannot be extrapolated to axillary nodal disease because DBT does not completely visualize the entire axilla. DBT may be useful in selected cases after NAC because it may identify response within a clipped node and provide a means for image guided localization [131]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is widely used to assess response to therapy, despite the lack of consensus on the criteria for determining response. | Imaging of the Axilla. Information on the residual disease or positive axillary nodes after NAC is beneficial for the determination of the axillary surgical management and for the need of radiation therapy [7]. The guidelines define low tumor burden in the axilla as nodal disease that is image-detected disease not apparent on clinical examination; however, the imaging test is not specified in the guidelines. If there is pathological response to NAC and the patient is clinically node-negative, SLNB is preferred over ALND in order to minimize morbidity. In a study of 925 patients treated with NAC, 5-year overall survival was superior for patients with pathologic complete remission of the cytological proven axillary lymph node metastases (93%) compared with those without complete response (72%) [110]. Imaging of the Axilla CT Chest, Abdomen, and Pelvis There are no relevant data to support the use of contrast-enhanced or noncontrast-enhanced CT to image the axilla after completion of NAC. Digital Breast Tomosynthesis Diagnostic There are no data to support the use of DBT to image the axilla after completion of NAC in patients with initial clinical node-positive disease pre-NAC and who have no clinical suspicion of disease progression or new axillary nodal disease. When comparing mammography to DBT, one prospective study of 51 stage II and III breast cancer patients reported that MRI and DBT outperformed mammography and whole-breast US in the prediction of pathologic complete response [113]. Unfortunately, this cannot be extrapolated to axillary nodal disease because DBT does not completely visualize the entire axilla. DBT may be useful in selected cases after NAC because it may identify response within a clipped node and provide a means for image guided localization [131]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is widely used to assess response to therapy, despite the lack of consensus on the criteria for determining response. | 3158165 |
acrac_3158165_21 | Imaging of the Axilla | The reported pooled sensitivity for FDG-PET/CT is 71% to 88% and specificity is 69% to 79.3% [117,120,132,133]. Most of the studies do not specifically report on response of the regional lymph nodes. In one meta-analysis of four studies involving 920 patients, the sensitivity of FDG-PET/CT for regional lymph node response assessment is 92% [118]. In another meta-analysis of 987 abstracts, only four were eligible for analysis, yielding a PPV between 40% and 100% [134]. The timing of FDG-PET/CT is critical and varies between studies, with some investigators demonstrating FDG- PET/CT has more accuracy during NAC (after first or second cycles of chemotherapy) than after NAC, whereas MRI performed better at the end of NAC [118,133]. MRI had higher sensitivity in predicting the pathologic response after NAC in 13 studies involving 575 patients, and FDG-PET/CT had a higher specificity in these same 13 studies involving 618 patients [132]. Currently, there is lack of consensus that early response detected by imaging tests translates into improved overall outcomes. A negative FDG-PET/CT during or after NAC does not necessarily correlate with final pathological node-negative disease, as demonstrated in one series of 206 patients [119]. SUV values may underestimate or overestimate response when the residual tumor is small. Some investigators have reported SUVmax <2.5 as negative [120], whereas others demonstrated that the change in SUV before and after NAC or change between the pre-NAC FDG-PET/CT examination and the examination performed after the first or second cycle of NAC were better predictors of response [134-136]. Despite the research, there is no accurate noninvasive test to replace SLNB or ALND at this time. However, one benefit of using FDG-PET/CT is that this examination can also evaluate other sites of metastases in a single study [102]. A search for a noninvasive restaging technique for identifying patients with axillary complete response is ongoing. | Imaging of the Axilla. The reported pooled sensitivity for FDG-PET/CT is 71% to 88% and specificity is 69% to 79.3% [117,120,132,133]. Most of the studies do not specifically report on response of the regional lymph nodes. In one meta-analysis of four studies involving 920 patients, the sensitivity of FDG-PET/CT for regional lymph node response assessment is 92% [118]. In another meta-analysis of 987 abstracts, only four were eligible for analysis, yielding a PPV between 40% and 100% [134]. The timing of FDG-PET/CT is critical and varies between studies, with some investigators demonstrating FDG- PET/CT has more accuracy during NAC (after first or second cycles of chemotherapy) than after NAC, whereas MRI performed better at the end of NAC [118,133]. MRI had higher sensitivity in predicting the pathologic response after NAC in 13 studies involving 575 patients, and FDG-PET/CT had a higher specificity in these same 13 studies involving 618 patients [132]. Currently, there is lack of consensus that early response detected by imaging tests translates into improved overall outcomes. A negative FDG-PET/CT during or after NAC does not necessarily correlate with final pathological node-negative disease, as demonstrated in one series of 206 patients [119]. SUV values may underestimate or overestimate response when the residual tumor is small. Some investigators have reported SUVmax <2.5 as negative [120], whereas others demonstrated that the change in SUV before and after NAC or change between the pre-NAC FDG-PET/CT examination and the examination performed after the first or second cycle of NAC were better predictors of response [134-136]. Despite the research, there is no accurate noninvasive test to replace SLNB or ALND at this time. However, one benefit of using FDG-PET/CT is that this examination can also evaluate other sites of metastases in a single study [102]. A search for a noninvasive restaging technique for identifying patients with axillary complete response is ongoing. | 3158165 |
acrac_3158165_22 | Imaging of the Axilla | Mammography Diagnostic Mammography can reliably be used to assess response of a primary breast malignancy to NAC. However, it is less useful in assessing axillary nodal response to therapy given that the axilla is incompletely visualized. MRI Breast In patients who have had axillary nodal metastatic disease diagnosed prior to NAC for breast cancer, there is little consensus on how to image the axilla subsequently. MRI has some limitations in evaluating the axilla and is unlikely to be the sole imaging test for estimating residual tumor burden preoperatively [121]. However, a combination of tests with axillary US, MRI, or FDG-PET/CT may be the future direction for clinical trials trying to answer such questions (https://clinicaltrials.gov/ct2/show/NCT03188393). At least one study suggests that measurements at 360 seconds after contrast administration provides the most accurate measurements of size, compared with the earlier phase or the later phase of the dynamic series [137]. Imaging of the Axilla Most of the literature focuses on the evaluation of response of the primary breast tumor after NAC and MRI superiority to mammogram, US, and physical examination in this setting [124]. The performance of MRI for the primary breast lesion cannot be extrapolated to MRI performance of the axillary nodal disease [112]. Therefore, MRI is not used routinely for predicting response of axillary nodal disease. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for assessing response after treatment with NAC. US Axilla Because of its noninvasive nature, axillary US may evaluate for residual axillary nodal disease despite its PPV of 60% to 81%, NPV of 43% to 74%, and specificity of 37% to 92% [138]. However, the sensitivity of US (71%) for prediction of residual nodal metastatic disease was higher than that of clinical examination and MRI/PET in most studies [139]. | Imaging of the Axilla. Mammography Diagnostic Mammography can reliably be used to assess response of a primary breast malignancy to NAC. However, it is less useful in assessing axillary nodal response to therapy given that the axilla is incompletely visualized. MRI Breast In patients who have had axillary nodal metastatic disease diagnosed prior to NAC for breast cancer, there is little consensus on how to image the axilla subsequently. MRI has some limitations in evaluating the axilla and is unlikely to be the sole imaging test for estimating residual tumor burden preoperatively [121]. However, a combination of tests with axillary US, MRI, or FDG-PET/CT may be the future direction for clinical trials trying to answer such questions (https://clinicaltrials.gov/ct2/show/NCT03188393). At least one study suggests that measurements at 360 seconds after contrast administration provides the most accurate measurements of size, compared with the earlier phase or the later phase of the dynamic series [137]. Imaging of the Axilla Most of the literature focuses on the evaluation of response of the primary breast tumor after NAC and MRI superiority to mammogram, US, and physical examination in this setting [124]. The performance of MRI for the primary breast lesion cannot be extrapolated to MRI performance of the axillary nodal disease [112]. Therefore, MRI is not used routinely for predicting response of axillary nodal disease. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for assessing response after treatment with NAC. US Axilla Because of its noninvasive nature, axillary US may evaluate for residual axillary nodal disease despite its PPV of 60% to 81%, NPV of 43% to 74%, and specificity of 37% to 92% [138]. However, the sensitivity of US (71%) for prediction of residual nodal metastatic disease was higher than that of clinical examination and MRI/PET in most studies [139]. | 3158165 |
acrac_3158165_23 | Imaging of the Axilla | Limited data have suggested that the sensitivity of axillary US is higher for some subtypes such as triple negative breast cancer (69%) and HER2 positive breast cancer (71%) [140,141]. This discussion is based on the understanding that patients post-BCS or postmastectomy with reconstruction have likely already undergone a diagnostic mammogram or DBT to evaluate for or rule out in-breast recurrent disease. Therefore, the possible next imaging test or initial imaging test for the axilla are discussed below for each modality. Imaging of the Axilla CT Chest, Abdomen, and Pelvis There are no data to support the utilization of CT for axillary node assessment in the setting of newly diagnosed in- breast recurrent disease or as the initial imaging test for the axilla. However, CT can be performed concurrently at the time of the locally recurrent breast cancer diagnosis to rule out distant metastatic disease and for pretreatment planning. CT allows visualization of any chest wall involvement as well as the relationship of the recurrent disease to regional vital structures such as axillary artery and vein [7,92,154]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT may be ordered concurrently at the time of the locally recurrent breast cancer diagnosis to rule out distant metastatic disease and for pretreatment planning. PET/CT is helpful in identifying unsuspected regional nodal disease or distant metastases in certain situations such as in patients with locally advanced breast cancer and inflammatory breast cancer [7]. In a meta-analysis of 26 studies involving 1,752 patients with suspected recurrent breast cancer, the pooled sensitivity for FDG-PET/CT was 90% and specificity was 81%; FDG-PET/CT is more accurate than PET alone [155]. The authors noted that the studies were heterogeneous, and therefore the analysis had limitations. In-breast recurrent disease versus chest wall or nodal recurrent disease was not specified [155]. | Imaging of the Axilla. Limited data have suggested that the sensitivity of axillary US is higher for some subtypes such as triple negative breast cancer (69%) and HER2 positive breast cancer (71%) [140,141]. This discussion is based on the understanding that patients post-BCS or postmastectomy with reconstruction have likely already undergone a diagnostic mammogram or DBT to evaluate for or rule out in-breast recurrent disease. Therefore, the possible next imaging test or initial imaging test for the axilla are discussed below for each modality. Imaging of the Axilla CT Chest, Abdomen, and Pelvis There are no data to support the utilization of CT for axillary node assessment in the setting of newly diagnosed in- breast recurrent disease or as the initial imaging test for the axilla. However, CT can be performed concurrently at the time of the locally recurrent breast cancer diagnosis to rule out distant metastatic disease and for pretreatment planning. CT allows visualization of any chest wall involvement as well as the relationship of the recurrent disease to regional vital structures such as axillary artery and vein [7,92,154]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT may be ordered concurrently at the time of the locally recurrent breast cancer diagnosis to rule out distant metastatic disease and for pretreatment planning. PET/CT is helpful in identifying unsuspected regional nodal disease or distant metastases in certain situations such as in patients with locally advanced breast cancer and inflammatory breast cancer [7]. In a meta-analysis of 26 studies involving 1,752 patients with suspected recurrent breast cancer, the pooled sensitivity for FDG-PET/CT was 90% and specificity was 81%; FDG-PET/CT is more accurate than PET alone [155]. The authors noted that the studies were heterogeneous, and therefore the analysis had limitations. In-breast recurrent disease versus chest wall or nodal recurrent disease was not specified [155]. | 3158165 |
acrac_3158165_24 | Imaging of the Axilla | MRI Breast Breast MRI is a highly sensitive imaging modality for assessing disease within the breast [156,157]. There are no data to support breast MRI as the initial imaging test of the axilla in patients with newly diagnosed locally recurrent breast cancer to evaluate for additional nodal disease. The MRI may be ordered after the mammogram or DBT to evaluate additional recurrent disease or disease extent within the breast not completely seen on mammogram or DBT [158]. An observational cohort study of 13,266 women and a single-center study of 1,521 women reported higher cancer detection rate with MRI compared with mammography [156,157]. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for imaging the axilla in patients with newly diagnosed recurrent disease. US Axilla US can be used to evaluate the axilla in patients with newly diagnosed recurrent breast cancer after BCS, after mastectomy, or with suspicion of recurrent nodal disease in the axilla. Diagnostic mammogram and/or DBT to evaluate for in-breast recurrent disease has also been shown to be helpful [154]. Axillary US can also provide guidance for percutaneous biopsy of any suspicious nodes because it influences potential surgical approach (SLNB versus full ALND). Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study. CT Chest, Abdomen, and Pelvis CT is not frequently used to assess abnormal axillary nodes detected on US or mammography; however, it is often used to evaluate a biopsy-proven nonbreast malignant axillary node. One study with 297 patients from two centers found no change in the number of second axillary surgeries between patients who received a CT scan of their axilla versus those who did not [47]. There are little data to support the use of contrast- or noncontrast-enhanced CT for this indication if there is no clinical suspicion of additional systemic disease. | Imaging of the Axilla. MRI Breast Breast MRI is a highly sensitive imaging modality for assessing disease within the breast [156,157]. There are no data to support breast MRI as the initial imaging test of the axilla in patients with newly diagnosed locally recurrent breast cancer to evaluate for additional nodal disease. The MRI may be ordered after the mammogram or DBT to evaluate additional recurrent disease or disease extent within the breast not completely seen on mammogram or DBT [158]. An observational cohort study of 13,266 women and a single-center study of 1,521 women reported higher cancer detection rate with MRI compared with mammography [156,157]. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for imaging the axilla in patients with newly diagnosed recurrent disease. US Axilla US can be used to evaluate the axilla in patients with newly diagnosed recurrent breast cancer after BCS, after mastectomy, or with suspicion of recurrent nodal disease in the axilla. Diagnostic mammogram and/or DBT to evaluate for in-breast recurrent disease has also been shown to be helpful [154]. Axillary US can also provide guidance for percutaneous biopsy of any suspicious nodes because it influences potential surgical approach (SLNB versus full ALND). Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study. CT Chest, Abdomen, and Pelvis CT is not frequently used to assess abnormal axillary nodes detected on US or mammography; however, it is often used to evaluate a biopsy-proven nonbreast malignant axillary node. One study with 297 patients from two centers found no change in the number of second axillary surgeries between patients who received a CT scan of their axilla versus those who did not [47]. There are little data to support the use of contrast- or noncontrast-enhanced CT for this indication if there is no clinical suspicion of additional systemic disease. | 3158165 |
acrac_3158165_25 | Imaging of the Axilla | FDG-PET/CT Skull Base to Mid-Thigh Less than 1% of breast cancers initially present as axillary adenopathy [32,33]. Historically, mammography, US, and breast MRI have helped to identify the primary malignancy in patients with pathologic axillary adenopathy from unknown primary. However, mammography and US have relatively low sensitivity for detecting the primary breast lesion [31,159]. The addition of breast MRI has improved sensitivity [160] because MRI is able to detect the primary breast lesion in 36% to 86% of cases [39]. Although PET/CT can be helpful in identifying the site of an unknown primary, for breast cancer, there are little data to support its routine use. MRI Breast Once the suspicious axillary node has been documented as metastatic nodal disease, then breast MRI can detect a mammographic or sonographic occult breast lesion with high sensitivity for detecting an in-breast lesion or confirm no breast primary [34,35]. In a meta-analysis of 8 retrospective studies involving 220 patients, MRI detects an occult breast cancer in 72% of cases with a pooled sensitivity of 90% and a specificity of 31% [39]. MRI can also help further characterize the axillary mass by evaluating its relationship to adjacent vessels, the chest wall, and other axillary structures. In a meta-analysis of 26 studies looking at the diagnostic performance of MRI in detecting Imaging of the Axilla metastatic nodal disease, the pooled sensitivity and specificity in patients with breast cancer is 77% and 90%, respectively [123]. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for imaging the axilla in patients with suspicious axillary nodes detected on mammography and US. US-Guided Core Biopsy Axillary Node US-guided biopsy (either core needle biopsy or FNA) may provide a diagnosis for morphologically abnormal lymph nodes detected on imaging. | Imaging of the Axilla. FDG-PET/CT Skull Base to Mid-Thigh Less than 1% of breast cancers initially present as axillary adenopathy [32,33]. Historically, mammography, US, and breast MRI have helped to identify the primary malignancy in patients with pathologic axillary adenopathy from unknown primary. However, mammography and US have relatively low sensitivity for detecting the primary breast lesion [31,159]. The addition of breast MRI has improved sensitivity [160] because MRI is able to detect the primary breast lesion in 36% to 86% of cases [39]. Although PET/CT can be helpful in identifying the site of an unknown primary, for breast cancer, there are little data to support its routine use. MRI Breast Once the suspicious axillary node has been documented as metastatic nodal disease, then breast MRI can detect a mammographic or sonographic occult breast lesion with high sensitivity for detecting an in-breast lesion or confirm no breast primary [34,35]. In a meta-analysis of 8 retrospective studies involving 220 patients, MRI detects an occult breast cancer in 72% of cases with a pooled sensitivity of 90% and a specificity of 31% [39]. MRI can also help further characterize the axillary mass by evaluating its relationship to adjacent vessels, the chest wall, and other axillary structures. In a meta-analysis of 26 studies looking at the diagnostic performance of MRI in detecting Imaging of the Axilla metastatic nodal disease, the pooled sensitivity and specificity in patients with breast cancer is 77% and 90%, respectively [123]. Sestamibi MBI There is no relevant literature supporting the use of Tc-99m sestamibi MBI for imaging the axilla in patients with suspicious axillary nodes detected on mammography and US. US-Guided Core Biopsy Axillary Node US-guided biopsy (either core needle biopsy or FNA) may provide a diagnosis for morphologically abnormal lymph nodes detected on imaging. | 3158165 |
acrac_3158165_26 | Imaging of the Axilla | In a meta-analysis of 1,353 patients from 6 studies, US-guided core needle biopsy was superior to US-guided FNA in diagnosing axillary nodal metastases with reported pooled sensitivity of 88% versus 74%, respectively. Both US-guided core needle biopsy and FNA had a high specificity of 100% [86]. Complications such as pain, hematoma, and bruising were higher with core needle biopsy than FNA. US-Guided Fine Needle Aspiration Biopsy Axillary Node US-guided FNA biopsy is a reliable procedure associated with minimal complications. In a meta-analysis of 31 studies, US-guided FNA improved the median sensitivity of US from 61% to 79% and specificity from 82.0% to 100% [62]. In another publication of 3,781 breast cancer patients, the sensitivity and specificity of axillary US alone were 59% and 89%, respectively. The specificity improved to 100% when axillary US was combined with FNA. FNA resulted in sensitivity, specificity, PPV, NPV, and accuracy of 52%, 100%, 100%, 74.8%, and 80%, respectively [63]. The decision to perform FNA or core biopsy of a suspicious axillary node is not standardized and depends on provider choice and patient factors. Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study. Digital Breast Tomosynthesis Diagnostic When a suspicious lymph node is identified on imaging, correlation with clinical history and physical examination is essential to guide management. If a breast primary is of concern, mammography and DBT can assist in identifying the breast primary. At least one study has shown that DBT is superior to full-field digital mammography for detection of subtle architectural distortion [161]. Mammography Diagnostic When a suspicious lymph node is identified on imaging, other than mammography or DBT, correlation with clinical history and physical examination is essential to guide further imaging. | Imaging of the Axilla. In a meta-analysis of 1,353 patients from 6 studies, US-guided core needle biopsy was superior to US-guided FNA in diagnosing axillary nodal metastases with reported pooled sensitivity of 88% versus 74%, respectively. Both US-guided core needle biopsy and FNA had a high specificity of 100% [86]. Complications such as pain, hematoma, and bruising were higher with core needle biopsy than FNA. US-Guided Fine Needle Aspiration Biopsy Axillary Node US-guided FNA biopsy is a reliable procedure associated with minimal complications. In a meta-analysis of 31 studies, US-guided FNA improved the median sensitivity of US from 61% to 79% and specificity from 82.0% to 100% [62]. In another publication of 3,781 breast cancer patients, the sensitivity and specificity of axillary US alone were 59% and 89%, respectively. The specificity improved to 100% when axillary US was combined with FNA. FNA resulted in sensitivity, specificity, PPV, NPV, and accuracy of 52%, 100%, 100%, 74.8%, and 80%, respectively [63]. The decision to perform FNA or core biopsy of a suspicious axillary node is not standardized and depends on provider choice and patient factors. Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study. Digital Breast Tomosynthesis Diagnostic When a suspicious lymph node is identified on imaging, correlation with clinical history and physical examination is essential to guide management. If a breast primary is of concern, mammography and DBT can assist in identifying the breast primary. At least one study has shown that DBT is superior to full-field digital mammography for detection of subtle architectural distortion [161]. Mammography Diagnostic When a suspicious lymph node is identified on imaging, other than mammography or DBT, correlation with clinical history and physical examination is essential to guide further imaging. | 3158165 |
acrac_3158165_27 | Imaging of the Axilla | If a breast primary is of concern, mammography and/or DBT may assist in identifying a primary breast malignancy. Mammography is not optimal for evaluating the axilla. Valente et al [162] found that mammography has a high FNR in the detection of axillary metastatic lymphadenopathy. US Axilla If mammogram or DBT identifies a primary breast malignancy, then axillary US after mammogram and/or DBT may evaluate the nodal size, nodal cortical, and hilar morphology. The sensitivity and specificity for axillary US for differentiating benign from malignant nodes is variable, with reported sensitivity ranging from 26% to 94% and specificity from 53% to 98% [58]. Axillary US alone has relatively low NPV and sensitivity and therefore is not a reliable predictor of axillary nodal burden [83,84]. When combined with needle biopsy, however, the sensitivity improves from 61% to 79% in a meta-analysis of 21 studies [54,62,85]. Some US features that are more likely to be associated with malignancy include short-axis diameter >1 cm, cortical thickness >0.3 cm, and absence of a fatty hilum [87-90]. The absence of a fatty hilum has the highest PPV (90% to 93%) for malignancy [103,104]. A suspicious node on US warrants percutaneous biopsy because a positive axillary US helps to identify those patients at risk for higher tumor burden [54,55]. However, a negative axillary US with or without biopsy does not rule out nodal disease [58]. US-Guided Core Biopsy Axillary Node Based on a meta-analysis of 1,353 patients with newly diagnosed breast cancer, US-guided core needle biopsy is superior to US-guided FNA with a reported sensitivity of 88% for core biopsy and 74% for FNA [86]. The overall sensitivity of US-guided biopsy ranges from 52% to 90%, whereas the specificity ranges from 98% to 100% [59- 63]. Imaging of the Axilla | Imaging of the Axilla. If a breast primary is of concern, mammography and/or DBT may assist in identifying a primary breast malignancy. Mammography is not optimal for evaluating the axilla. Valente et al [162] found that mammography has a high FNR in the detection of axillary metastatic lymphadenopathy. US Axilla If mammogram or DBT identifies a primary breast malignancy, then axillary US after mammogram and/or DBT may evaluate the nodal size, nodal cortical, and hilar morphology. The sensitivity and specificity for axillary US for differentiating benign from malignant nodes is variable, with reported sensitivity ranging from 26% to 94% and specificity from 53% to 98% [58]. Axillary US alone has relatively low NPV and sensitivity and therefore is not a reliable predictor of axillary nodal burden [83,84]. When combined with needle biopsy, however, the sensitivity improves from 61% to 79% in a meta-analysis of 21 studies [54,62,85]. Some US features that are more likely to be associated with malignancy include short-axis diameter >1 cm, cortical thickness >0.3 cm, and absence of a fatty hilum [87-90]. The absence of a fatty hilum has the highest PPV (90% to 93%) for malignancy [103,104]. A suspicious node on US warrants percutaneous biopsy because a positive axillary US helps to identify those patients at risk for higher tumor burden [54,55]. However, a negative axillary US with or without biopsy does not rule out nodal disease [58]. US-Guided Core Biopsy Axillary Node Based on a meta-analysis of 1,353 patients with newly diagnosed breast cancer, US-guided core needle biopsy is superior to US-guided FNA with a reported sensitivity of 88% for core biopsy and 74% for FNA [86]. The overall sensitivity of US-guided biopsy ranges from 52% to 90%, whereas the specificity ranges from 98% to 100% [59- 63]. Imaging of the Axilla | 3158165 |
acrac_3102394_0 | Nonatherosclerotic Peripheral Arterial Disease | Introduction/Background Lower-extremity vascular diseases span a diverse range of etiologies and may be autoimmune, congenital, degenerative, inflammatory, infectious, metabolic, neoplastic, or traumatic in nature. Examples of such conditions include, but are not limited to, aneurysm formation, atherosclerosis, Buerger disease, cystic adventitial disease, dissection/transection, deep vein thrombosis, external iliac artery endofibrosis (EIAE), fibromuscular dysplasia (FMD), popliteal arterial entrapment syndrome (PAES), segmental arterial mediolysis (SAM), and genetic syndromes such as Marfan syndrome (MS), Loeys-Dietz syndrome (LDS), and vascular Ehlers-Danlos syndrome (EDS). Because of the plethora of potential underlying disease processes, imaging is often employed to secure a diagnosis and assist in guiding clinical management. Accurate vascular imaging relies upon visualization of the vessel lumen, vessel wall, and surrounding soft-tissue structures, with some modalities also offering the ability to characterize blood flow direction and velocity. Furthermore, nonvascular findings are often paramount in supporting a suspected clinical syndrome [1-4] or guiding surgical management [5-8]. Guidelines proposed in this document focus on nonatherosclerotic, arterial lower-extremity vascular disease. PAES is the most common cause of surgically correctable lower-extremity vascular insufficiency in young adults and consists of anatomic and functional subtypes. Patients with PAES present with calf claudication, paresthesia, and swelling during exercise. In anatomic PAES (Types I, II, III, and V), the extravascular structures within the popliteal fossa compress the popliteal artery and/or the popliteal vein, which results in compression and stenosis or occlusion during plantar flexion. Functional PAES (Type IV) results in compression of the popliteal artery despite the presence of an anatomically normal popliteal fossa; its etiology remains unclear. | Nonatherosclerotic Peripheral Arterial Disease. Introduction/Background Lower-extremity vascular diseases span a diverse range of etiologies and may be autoimmune, congenital, degenerative, inflammatory, infectious, metabolic, neoplastic, or traumatic in nature. Examples of such conditions include, but are not limited to, aneurysm formation, atherosclerosis, Buerger disease, cystic adventitial disease, dissection/transection, deep vein thrombosis, external iliac artery endofibrosis (EIAE), fibromuscular dysplasia (FMD), popliteal arterial entrapment syndrome (PAES), segmental arterial mediolysis (SAM), and genetic syndromes such as Marfan syndrome (MS), Loeys-Dietz syndrome (LDS), and vascular Ehlers-Danlos syndrome (EDS). Because of the plethora of potential underlying disease processes, imaging is often employed to secure a diagnosis and assist in guiding clinical management. Accurate vascular imaging relies upon visualization of the vessel lumen, vessel wall, and surrounding soft-tissue structures, with some modalities also offering the ability to characterize blood flow direction and velocity. Furthermore, nonvascular findings are often paramount in supporting a suspected clinical syndrome [1-4] or guiding surgical management [5-8]. Guidelines proposed in this document focus on nonatherosclerotic, arterial lower-extremity vascular disease. PAES is the most common cause of surgically correctable lower-extremity vascular insufficiency in young adults and consists of anatomic and functional subtypes. Patients with PAES present with calf claudication, paresthesia, and swelling during exercise. In anatomic PAES (Types I, II, III, and V), the extravascular structures within the popliteal fossa compress the popliteal artery and/or the popliteal vein, which results in compression and stenosis or occlusion during plantar flexion. Functional PAES (Type IV) results in compression of the popliteal artery despite the presence of an anatomically normal popliteal fossa; its etiology remains unclear. | 3102394 |
acrac_3102394_1 | Nonatherosclerotic Peripheral Arterial Disease | Either subtype may lead to aneurysm or pseudoaneurysm formation, thrombosis or distal thromboembolism [5-8,15-19]. EIAE is a rare cause of performance-limiting claudication that occurs primarily in endurance athletes. Although EIAE typically occurs in cyclists, it has been described in other groups of elite endurance athletes. Symptoms include lower-extremity weakness, thigh pain, and symptom resolution after cessation of exercise [20]. Its etiology is poorly understood and may be multifactorial. Suggested mechanisms include repeated mechanical Reprint requests to: [email protected] Nonatherosclerotic Peripheral Arterial Disease trauma upon the external iliac artery by a hypertrophied psoas muscle during hip flexion with subsequent arterial kinking [21] and vasospasm [22]. Arterial-brachial pressure indexes typically decrease following exercise [20]. Connective tissue diseases are multisystem disorders, several of which profoundly involve the vascular system. MS is an autosomal-dominant (AD) connective tissue disorder caused by a mutation in the FBN1 gene that codes for fibrillin-1 and occurs in 1 in 20,000 individuals. The systems typically affected by MS are cardiovascular, ocular, and skeletal. MS is classically associated with aortic root aneurysms and dissection; however, the dissection flap may extend into the iliac arteries resulting in pain, pallor, paresthesias, and pulselessness [1,24]. LDS results from an AD heterozygous mutation in either of the genes that encode transforming growth factor beta. LDS has a much more aggressive clinical course than MS, with a mean survival of 26 years. Like MS, LDS is associated with aortic root aneurysm and dissection [3]. Vascular EDS, formerly known as EDS type IV, is an AD disease caused by a heterozygous mutation in the COL3A1 gene that encodes type III collagen. Vascular EDS can affect any vessel and carries a poor prognosis that is due to risk of life-threatening arterial rupture [4]. | Nonatherosclerotic Peripheral Arterial Disease. Either subtype may lead to aneurysm or pseudoaneurysm formation, thrombosis or distal thromboembolism [5-8,15-19]. EIAE is a rare cause of performance-limiting claudication that occurs primarily in endurance athletes. Although EIAE typically occurs in cyclists, it has been described in other groups of elite endurance athletes. Symptoms include lower-extremity weakness, thigh pain, and symptom resolution after cessation of exercise [20]. Its etiology is poorly understood and may be multifactorial. Suggested mechanisms include repeated mechanical Reprint requests to: [email protected] Nonatherosclerotic Peripheral Arterial Disease trauma upon the external iliac artery by a hypertrophied psoas muscle during hip flexion with subsequent arterial kinking [21] and vasospasm [22]. Arterial-brachial pressure indexes typically decrease following exercise [20]. Connective tissue diseases are multisystem disorders, several of which profoundly involve the vascular system. MS is an autosomal-dominant (AD) connective tissue disorder caused by a mutation in the FBN1 gene that codes for fibrillin-1 and occurs in 1 in 20,000 individuals. The systems typically affected by MS are cardiovascular, ocular, and skeletal. MS is classically associated with aortic root aneurysms and dissection; however, the dissection flap may extend into the iliac arteries resulting in pain, pallor, paresthesias, and pulselessness [1,24]. LDS results from an AD heterozygous mutation in either of the genes that encode transforming growth factor beta. LDS has a much more aggressive clinical course than MS, with a mean survival of 26 years. Like MS, LDS is associated with aortic root aneurysm and dissection [3]. Vascular EDS, formerly known as EDS type IV, is an AD disease caused by a heterozygous mutation in the COL3A1 gene that encodes type III collagen. Vascular EDS can affect any vessel and carries a poor prognosis that is due to risk of life-threatening arterial rupture [4]. | 3102394 |
acrac_3102394_2 | Nonatherosclerotic Peripheral Arterial Disease | SAM is a nonatherosclerotic, noninflammatory vascular disease that most commonly affects the visceral abdominal vessels, although involvement of the iliac arteries has been reported [27]. Lysis of the medial layer of the arterial wall in SAM results in dissection, stenosis, occlusion, or aneurysm formation; it commonly presents with catastrophic hemorrhages within the abdominal cavity or retroperitoneum as a result of spontaneous aneurysm rupture [28-30]. Cystic adventitial disease is a rare vascular disease predominantly affecting healthy young men with no cardiovascular risk factors. Arterial involvement is more common than venous involvement, with most cases seen involving the popliteal artery. Cystic adventitial disease affecting the lower extremity typically results in claudication or pain of sudden onset, while imaging demonstrates adventitial cysts localized to the site of symptomatology. Surgical resection is usually curative thereby obviating follow-up [31]. Injury to the lower-extremity vasculature is not an uncommon occurrence in the setting of penetrating or blunt trauma. Rapid diagnostic imaging is paramount to exclude or confirm vascular injury in these potentially unstable individuals. Discussion of Procedures by Variant Variant 1: Suspected popliteal entrapment syndrome. Initial imaging. CTA Lower Extremity CT angiography (CTA), including multiplanar reformation and 3-D volume-rendered reconstructions, is helpful in depicting popliteal vascular changes (vessel deviation, stenosis, occlusion, aneurysm formation) and abnormal musculotendinous structures in the setting of PAES [5,19]. Following revascularization for PAES, CTA is recommended to assess graft patency after an abnormal ultrasound (US) [17]. The use of dynamic CTA has also been proposed for the initial workup of PAES, as images of both lower extremities can be obtained at both rest and plantar flexion in a single examination requiring only one contrast bolus [15]. | Nonatherosclerotic Peripheral Arterial Disease. SAM is a nonatherosclerotic, noninflammatory vascular disease that most commonly affects the visceral abdominal vessels, although involvement of the iliac arteries has been reported [27]. Lysis of the medial layer of the arterial wall in SAM results in dissection, stenosis, occlusion, or aneurysm formation; it commonly presents with catastrophic hemorrhages within the abdominal cavity or retroperitoneum as a result of spontaneous aneurysm rupture [28-30]. Cystic adventitial disease is a rare vascular disease predominantly affecting healthy young men with no cardiovascular risk factors. Arterial involvement is more common than venous involvement, with most cases seen involving the popliteal artery. Cystic adventitial disease affecting the lower extremity typically results in claudication or pain of sudden onset, while imaging demonstrates adventitial cysts localized to the site of symptomatology. Surgical resection is usually curative thereby obviating follow-up [31]. Injury to the lower-extremity vasculature is not an uncommon occurrence in the setting of penetrating or blunt trauma. Rapid diagnostic imaging is paramount to exclude or confirm vascular injury in these potentially unstable individuals. Discussion of Procedures by Variant Variant 1: Suspected popliteal entrapment syndrome. Initial imaging. CTA Lower Extremity CT angiography (CTA), including multiplanar reformation and 3-D volume-rendered reconstructions, is helpful in depicting popliteal vascular changes (vessel deviation, stenosis, occlusion, aneurysm formation) and abnormal musculotendinous structures in the setting of PAES [5,19]. Following revascularization for PAES, CTA is recommended to assess graft patency after an abnormal ultrasound (US) [17]. The use of dynamic CTA has also been proposed for the initial workup of PAES, as images of both lower extremities can be obtained at both rest and plantar flexion in a single examination requiring only one contrast bolus [15]. | 3102394 |
acrac_3102394_3 | Nonatherosclerotic Peripheral Arterial Disease | However, MRA and US duplex Doppler are typically preferred because they do not require ionizing radiation. MRA Lower Extremity MR angiography (MRA) can be used to evaluate vascular abnormalities and the dynamic changes in the popliteal artery during plantar flexion [16]. MRA is typically performed as a confirmatory test after US duplex Doppler. However, many patients are unable to maintain steady forced plantar flexion throughout the duration of lengthy MR sequences, resulting in excessive motion and degradation of image quality [7,8,15]. Despite this, a recent Nonatherosclerotic Peripheral Arterial Disease study demonstrated superiority of MRA over digital subtraction angiography (DSA) in confirming PAES [6]. MRA can be particularly helpful in defining abnormal musculotendinous structures. Furthermore, the T1- weighted and T2-weighted sequences done as part of the MRA study are currently the gold standard for defining the complete anatomy of the popliteal fossa and are therefore most appropriate for determining the anatomic abnormality in suspected PAES [7,15]. MRA without intravenous (IV) contrast is typically not used because the long acquisition times required cause challenges for their performance during stress maneuvers. However, the anatomic imaging used to determine the etiology of PAES can be done without IV contrast. Arteriography Lower Extremity Selective arteriography is regarded as the gold standard in identifying dynamic arterial deviation and/or occlusion during plantar flexion in addition to identifying vascular occlusion/stenosis, aneurysm, and thrombosis. [5,7,15]. In addition to being an invasive modality, arteriography is limited by its inability to depict extravascular anatomy. One study comparing the use of DSA and MRI in the evaluation of PAES found DSA to be nonspecific and unable to determine the etiology of patient symptoms [6], thereby obviating the need for cross-sectional imaging. | Nonatherosclerotic Peripheral Arterial Disease. However, MRA and US duplex Doppler are typically preferred because they do not require ionizing radiation. MRA Lower Extremity MR angiography (MRA) can be used to evaluate vascular abnormalities and the dynamic changes in the popliteal artery during plantar flexion [16]. MRA is typically performed as a confirmatory test after US duplex Doppler. However, many patients are unable to maintain steady forced plantar flexion throughout the duration of lengthy MR sequences, resulting in excessive motion and degradation of image quality [7,8,15]. Despite this, a recent Nonatherosclerotic Peripheral Arterial Disease study demonstrated superiority of MRA over digital subtraction angiography (DSA) in confirming PAES [6]. MRA can be particularly helpful in defining abnormal musculotendinous structures. Furthermore, the T1- weighted and T2-weighted sequences done as part of the MRA study are currently the gold standard for defining the complete anatomy of the popliteal fossa and are therefore most appropriate for determining the anatomic abnormality in suspected PAES [7,15]. MRA without intravenous (IV) contrast is typically not used because the long acquisition times required cause challenges for their performance during stress maneuvers. However, the anatomic imaging used to determine the etiology of PAES can be done without IV contrast. Arteriography Lower Extremity Selective arteriography is regarded as the gold standard in identifying dynamic arterial deviation and/or occlusion during plantar flexion in addition to identifying vascular occlusion/stenosis, aneurysm, and thrombosis. [5,7,15]. In addition to being an invasive modality, arteriography is limited by its inability to depict extravascular anatomy. One study comparing the use of DSA and MRI in the evaluation of PAES found DSA to be nonspecific and unable to determine the etiology of patient symptoms [6], thereby obviating the need for cross-sectional imaging. | 3102394 |
acrac_3102394_4 | Nonatherosclerotic Peripheral Arterial Disease | Selective arteriography is therefore often used as a confirmatory modality when PAES is suspected on cross- sectional imaging or US [7,16]. US Duplex Doppler Lower Extremity US duplex Doppler is heavily relied upon in the initial workup of PAES, where real-time visualization of flow occlusion and changes in segmental Doppler pressures upon provocative plantar flexion is crucial in confirming a suspected diagnosis [16,18]. This is extremely beneficial in the setting of functional PAES, where lack of an anatomic abnormality limits the sensitivity of cross-sectional modalities like CTA and MRA [18]. In PAES patients treated with popliteal bypass, US duplex Doppler is the first-line modality of choice in assessing graft patency; CTA, MRA, and selective arteriography are reserved for postoperative patients with abnormal US duplex Doppler examinations [17]. Several studies have found the use of US in the diagnosis of PAES to be potentially problematic, as the necessary use of transducer pressure applied during the examination may result in velocity changes that are difficult to interpret [7]. Provocative maneuvers may also shift the popliteal artery out of the Doppler region of interest, giving the artifactual appearance of occlusion [7,8]. US duplex Doppler has been found to have a particularly high false-positive rate in the workup of PAES, especially in athletes [5]. MRA is recommended to confirm the etiology of PAES in patients with a positive US duplex Doppler study and in patients with a negative US duplex Doppler study with a high index of clinical suspicion. US Intravascular Lower Extremity The use of intravascular US (IVUS) has been reportedly beneficial in confirming and assessing extent of popliteal artery compression in PAES. IVUS is often used as a confirmatory modality when PAES is suspected on cross- sectional imaging. | Nonatherosclerotic Peripheral Arterial Disease. Selective arteriography is therefore often used as a confirmatory modality when PAES is suspected on cross- sectional imaging or US [7,16]. US Duplex Doppler Lower Extremity US duplex Doppler is heavily relied upon in the initial workup of PAES, where real-time visualization of flow occlusion and changes in segmental Doppler pressures upon provocative plantar flexion is crucial in confirming a suspected diagnosis [16,18]. This is extremely beneficial in the setting of functional PAES, where lack of an anatomic abnormality limits the sensitivity of cross-sectional modalities like CTA and MRA [18]. In PAES patients treated with popliteal bypass, US duplex Doppler is the first-line modality of choice in assessing graft patency; CTA, MRA, and selective arteriography are reserved for postoperative patients with abnormal US duplex Doppler examinations [17]. Several studies have found the use of US in the diagnosis of PAES to be potentially problematic, as the necessary use of transducer pressure applied during the examination may result in velocity changes that are difficult to interpret [7]. Provocative maneuvers may also shift the popliteal artery out of the Doppler region of interest, giving the artifactual appearance of occlusion [7,8]. US duplex Doppler has been found to have a particularly high false-positive rate in the workup of PAES, especially in athletes [5]. MRA is recommended to confirm the etiology of PAES in patients with a positive US duplex Doppler study and in patients with a negative US duplex Doppler study with a high index of clinical suspicion. US Intravascular Lower Extremity The use of intravascular US (IVUS) has been reportedly beneficial in confirming and assessing extent of popliteal artery compression in PAES. IVUS is often used as a confirmatory modality when PAES is suspected on cross- sectional imaging. | 3102394 |
acrac_3102394_5 | Nonatherosclerotic Peripheral Arterial Disease | One study lauded IVUS for its ability to evaluate the arterial lumen for intimal change and potential irreparable mural damage that may be missed with conventional US [16]. In functional PAES, IVUS is beneficial in determining the magnitude of extrinsic muscular compression [16]. Variant 2: Suspected external iliac artery endofibrosis. Initial imaging. CTA Lower Extremity CTA is uncommonly used in the diagnosis of EIAE and has not demonstrated diagnostic superiority to MRA combined with US [21]. CTA allows assessment of arterial kinking, arterial wall thickening, stenosis, and extent of involved arterial segment. MRA Lower Extremity The superior contrast resolution inherent to MRA allows for optimal visualization of extravascular anatomy in suspected EIAE. Like CTA, MRA allows assessment of arterial length and kinking, albeit with improved soft- tissue characterization. MRA is less sensitive than US for detecting intravascular lesions. MRA has proven useful in diagnosing EIAE when used in conjunction with US, a combination that was found to be superior or equal to CTA alone [21]. US Duplex Doppler Lower Extremity The ability to visualize changes in both flow dynamics and vessel caliber in real time has been paramount in diagnosing EIAE in endurance athletes [21,22]. Dynamic use of US duplex Doppler and segmental Doppler pressures in both hip flexion and extension can accurately depict flow disturbance [21], while its use pre- and Nonatherosclerotic Peripheral Arterial Disease postexercise may demonstrate associated exercise-induced vasospasm [20,22]. US duplex Doppler has been found to be superior to MRA in detecting intravascular lesions; however, its sensitivity may be limited in patients with only mildly symptomatic disease [21]. US Intravascular Lower Extremity There is no relevant literature regarding the use of IVUS in the evaluation of EIAE. Arteriography Lower Extremity The role of DSA in the evaluation of EIAE is not as well established. | Nonatherosclerotic Peripheral Arterial Disease. One study lauded IVUS for its ability to evaluate the arterial lumen for intimal change and potential irreparable mural damage that may be missed with conventional US [16]. In functional PAES, IVUS is beneficial in determining the magnitude of extrinsic muscular compression [16]. Variant 2: Suspected external iliac artery endofibrosis. Initial imaging. CTA Lower Extremity CTA is uncommonly used in the diagnosis of EIAE and has not demonstrated diagnostic superiority to MRA combined with US [21]. CTA allows assessment of arterial kinking, arterial wall thickening, stenosis, and extent of involved arterial segment. MRA Lower Extremity The superior contrast resolution inherent to MRA allows for optimal visualization of extravascular anatomy in suspected EIAE. Like CTA, MRA allows assessment of arterial length and kinking, albeit with improved soft- tissue characterization. MRA is less sensitive than US for detecting intravascular lesions. MRA has proven useful in diagnosing EIAE when used in conjunction with US, a combination that was found to be superior or equal to CTA alone [21]. US Duplex Doppler Lower Extremity The ability to visualize changes in both flow dynamics and vessel caliber in real time has been paramount in diagnosing EIAE in endurance athletes [21,22]. Dynamic use of US duplex Doppler and segmental Doppler pressures in both hip flexion and extension can accurately depict flow disturbance [21], while its use pre- and Nonatherosclerotic Peripheral Arterial Disease postexercise may demonstrate associated exercise-induced vasospasm [20,22]. US duplex Doppler has been found to be superior to MRA in detecting intravascular lesions; however, its sensitivity may be limited in patients with only mildly symptomatic disease [21]. US Intravascular Lower Extremity There is no relevant literature regarding the use of IVUS in the evaluation of EIAE. Arteriography Lower Extremity The role of DSA in the evaluation of EIAE is not as well established. | 3102394 |
acrac_3102394_6 | Nonatherosclerotic Peripheral Arterial Disease | The most frequent finding of EIAE at DSA is smooth, long, and eccentric stenosis, with thrombosis and dissection present less frequently [1]. Although the external iliac artery is most frequently affected, the common iliac artery can be involved in approximately 15% of patients [32]. A benefit of arteriography, relative to other modalities, is that the pressure gradient across the narrowing can be measured at baseline as well as during various maneuvers, including following the administration of vasodilators [33]. Acquiring images during hip flexion frequently reveals a kink in the iliac arteries at the site of stenosis [32]. Variant 3: Suspected or known lower-extremity inflammatory vasculitides. Initial imaging. CTA Lower Extremity While the spatial resolution of CTA is relatively high, some authors have suggested that it may not be sensitive enough to resolve the fine collateral vessels seen in thromboangiitis obliterans and other small-vessel pathologies [2]. Evaluation of subtle vascular findings may also be limited by beam hardening artifact related to adjacent bone or metal [34]. CTA is helpful in identifying vessel wall thickening, stenosis, occlusion and collaterals when large- or medium-sized vessels of the lower extremities are involved. MRA Lower Extremity MRA has lower spatial resolution than CTA, a factor that makes it less than ideal in adequately characterizing distal small vessels. Despite this, additional sequences acquired during an MRA examination may be helpful in evaluating for associated nonvascular findings, such as osteomyelitis or septic arthritis [2]. The sensitivity for detecting these soft-tissue abnormalities is greater with contrast-enhanced MRA than noncontrast-enhanced MRA. Arteriography Lower Extremity Because of its high inherent spatial resolution, selective arteriography with DSA is considered the gold standard in the diagnosis of thromboangiitis obliterans [2]. | Nonatherosclerotic Peripheral Arterial Disease. The most frequent finding of EIAE at DSA is smooth, long, and eccentric stenosis, with thrombosis and dissection present less frequently [1]. Although the external iliac artery is most frequently affected, the common iliac artery can be involved in approximately 15% of patients [32]. A benefit of arteriography, relative to other modalities, is that the pressure gradient across the narrowing can be measured at baseline as well as during various maneuvers, including following the administration of vasodilators [33]. Acquiring images during hip flexion frequently reveals a kink in the iliac arteries at the site of stenosis [32]. Variant 3: Suspected or known lower-extremity inflammatory vasculitides. Initial imaging. CTA Lower Extremity While the spatial resolution of CTA is relatively high, some authors have suggested that it may not be sensitive enough to resolve the fine collateral vessels seen in thromboangiitis obliterans and other small-vessel pathologies [2]. Evaluation of subtle vascular findings may also be limited by beam hardening artifact related to adjacent bone or metal [34]. CTA is helpful in identifying vessel wall thickening, stenosis, occlusion and collaterals when large- or medium-sized vessels of the lower extremities are involved. MRA Lower Extremity MRA has lower spatial resolution than CTA, a factor that makes it less than ideal in adequately characterizing distal small vessels. Despite this, additional sequences acquired during an MRA examination may be helpful in evaluating for associated nonvascular findings, such as osteomyelitis or septic arthritis [2]. The sensitivity for detecting these soft-tissue abnormalities is greater with contrast-enhanced MRA than noncontrast-enhanced MRA. Arteriography Lower Extremity Because of its high inherent spatial resolution, selective arteriography with DSA is considered the gold standard in the diagnosis of thromboangiitis obliterans [2]. | 3102394 |
acrac_3102394_7 | Nonatherosclerotic Peripheral Arterial Disease | US Duplex Doppler Lower Extremity US duplex Doppler can identify the typical corkscrew collateral vessels in the walls of the lower-extremity vessels in patients with thromboangiitis obliterans [35]. US Intravascular Lower Extremity There is no relevant literature regarding the use of IVUS in the evaluation of lower-extremity inflammatory vasculitides. Variant 4: Suspected or known dissection or connective tissue lower-extremity vascular diseases. Initial imaging. CTA Lower Extremity CTA is highly recommended in the workup of MS, LDS, and vascular EDS, as it offers comprehensive whole- body imaging and high spatial resolution in a single study. This allows for evaluation of the entire vascular system and identification of typical musculoskeletal malformations that may assist in the initial diagnosis of a heritable connective tissue disease [1,3,4]. CTA is valuable for defining the true and false lumen and can be used for longitudinal follow-up. Although the initial diagnosis of these diseases is most commonly made in the pediatric population, this document addresses imaging in adults (18 years of age and older) only. Because of the high risk of vascular complications inherent to LDS and MS, CTA surveillance is recommended at least every 1 year [3] and 2 years [1], respectively. MRA Lower Extremity MRA has been suggested for evaluation of the lower extremities in patients with connective tissue disorders, such as MS, LDS, and vascular EDS. However, the lower spatial resolution inherent to MRA limits the evaluation of small arterial branches [1,2,36] compared to CTA. Nonatherosclerotic Peripheral Arterial Disease Arteriography Lower Extremity Given its invasive nature, the use of selective arteriography should be avoided in patients with congenitally weakened vessels (eg, collagen vascular diseases, such as vascular EDS) where the risk of catastrophic vascular perforation is high [1,4]. | Nonatherosclerotic Peripheral Arterial Disease. US Duplex Doppler Lower Extremity US duplex Doppler can identify the typical corkscrew collateral vessels in the walls of the lower-extremity vessels in patients with thromboangiitis obliterans [35]. US Intravascular Lower Extremity There is no relevant literature regarding the use of IVUS in the evaluation of lower-extremity inflammatory vasculitides. Variant 4: Suspected or known dissection or connective tissue lower-extremity vascular diseases. Initial imaging. CTA Lower Extremity CTA is highly recommended in the workup of MS, LDS, and vascular EDS, as it offers comprehensive whole- body imaging and high spatial resolution in a single study. This allows for evaluation of the entire vascular system and identification of typical musculoskeletal malformations that may assist in the initial diagnosis of a heritable connective tissue disease [1,3,4]. CTA is valuable for defining the true and false lumen and can be used for longitudinal follow-up. Although the initial diagnosis of these diseases is most commonly made in the pediatric population, this document addresses imaging in adults (18 years of age and older) only. Because of the high risk of vascular complications inherent to LDS and MS, CTA surveillance is recommended at least every 1 year [3] and 2 years [1], respectively. MRA Lower Extremity MRA has been suggested for evaluation of the lower extremities in patients with connective tissue disorders, such as MS, LDS, and vascular EDS. However, the lower spatial resolution inherent to MRA limits the evaluation of small arterial branches [1,2,36] compared to CTA. Nonatherosclerotic Peripheral Arterial Disease Arteriography Lower Extremity Given its invasive nature, the use of selective arteriography should be avoided in patients with congenitally weakened vessels (eg, collagen vascular diseases, such as vascular EDS) where the risk of catastrophic vascular perforation is high [1,4]. | 3102394 |
acrac_3102394_8 | Nonatherosclerotic Peripheral Arterial Disease | In such patients, it has been suggested that this modality only be performed if it is part of a planned interventional procedure (eg, coil embolization of remote bleeding arteries, etc) [4]. US Duplex Doppler Lower Extremity There is no relevant literature regarding the use of US duplex Doppler in the evaluation of lower-extremity connective disease. US Intravascular Lower Extremity There is no relevant literature regarding the use of IVUS in the evaluation of lower-extremity connective disease, but the same concerns regarding arterial puncture would apply. Variant 5: Suspected or known other noninflammatory lower-extremity vascular diseases (such as fibromuscular dysplasia, segmental arterial mediolysis). Initial imaging. CTA Lower Extremity While selective arteriography is considered the gold standard in diagnosing FMD, CTA has proven helpful in the initial diagnosis and follow-up of FMD within the lower extremities [25,37]. Because of its high spatial resolution, several studies have demonstrated the superiority of CTA over MRA in visualizing vascular lesions in FMD [4,36]. Despite this, one study found CTA to have limited sensitivity in the evaluation of small vessels in patients with mild FMD [36]. CTA may be helpful in the workup of cystic adventitial disease [31]. It has also been advocated as a first-line imaging study in the diagnosis of SAM [28,29] with follow-up recommended at 1- year intervals [27]. MRA Lower Extremity The improved contrast resolution inherent to MRA renders superior characterization of the extravascular soft tissues. This is of particular importance in the workup of cystic adventitial disease, where T1-weighted and T2- weighted sequences may demonstrate connections between adventitial cysts and the adjacent joint capsule. It has been recommended as the modality of choice in preoperative planning for cystic adventitial disease [31]. MRA has also been found useful for annual follow-up in SAM [27]. | Nonatherosclerotic Peripheral Arterial Disease. In such patients, it has been suggested that this modality only be performed if it is part of a planned interventional procedure (eg, coil embolization of remote bleeding arteries, etc) [4]. US Duplex Doppler Lower Extremity There is no relevant literature regarding the use of US duplex Doppler in the evaluation of lower-extremity connective disease. US Intravascular Lower Extremity There is no relevant literature regarding the use of IVUS in the evaluation of lower-extremity connective disease, but the same concerns regarding arterial puncture would apply. Variant 5: Suspected or known other noninflammatory lower-extremity vascular diseases (such as fibromuscular dysplasia, segmental arterial mediolysis). Initial imaging. CTA Lower Extremity While selective arteriography is considered the gold standard in diagnosing FMD, CTA has proven helpful in the initial diagnosis and follow-up of FMD within the lower extremities [25,37]. Because of its high spatial resolution, several studies have demonstrated the superiority of CTA over MRA in visualizing vascular lesions in FMD [4,36]. Despite this, one study found CTA to have limited sensitivity in the evaluation of small vessels in patients with mild FMD [36]. CTA may be helpful in the workup of cystic adventitial disease [31]. It has also been advocated as a first-line imaging study in the diagnosis of SAM [28,29] with follow-up recommended at 1- year intervals [27]. MRA Lower Extremity The improved contrast resolution inherent to MRA renders superior characterization of the extravascular soft tissues. This is of particular importance in the workup of cystic adventitial disease, where T1-weighted and T2- weighted sequences may demonstrate connections between adventitial cysts and the adjacent joint capsule. It has been recommended as the modality of choice in preoperative planning for cystic adventitial disease [31]. MRA has also been found useful for annual follow-up in SAM [27]. | 3102394 |
acrac_3102394_9 | Nonatherosclerotic Peripheral Arterial Disease | Arteriography Lower Extremity Because of its high inherent spatial resolution, selective arteriography with DSA is considered the gold standard in the diagnosis of FMD [25,26,36,38-40], with many authors claiming that CTA and MRA may lack the spatial resolution necessary to detect small-artery pathology [36]. Arteriography is susceptible to standing waves. Therefore, caution must be exercised to accurately distinguish standing waves from true arterial beading characteristic of FMD [15]. This modality may simultaneously be therapeutic in FMD, as angioplasty is currently the preferred treatment of choice [25,38,39]. Selective arteriography is considered the reference standard in the diagnosis of SAM while also having therapeutic potential [28]. US Duplex Doppler Lower Extremity A recent study found US duplex Doppler to be helpful in diagnosing cystic adventitial disease, where numerous anechoic cysts are seen scattered throughout the adventitia at a site of vessel stenosis [31]. While much has been published about the use of US duplex Doppler in renal artery FMD, no literature is currently present to support its use in the diagnosis of FMD affecting the lower-extremity arteries. US Intravascular Lower Extremity IVUS has been reported to be useful in diagnosing cystic adventitial disease [31]. In FMD, other authors have concluded that IVUS is likely more accurate than other modalities in characterizing the hemodynamic severity of encountered stenosis [39,41]. Variant 6: Lower-extremity vascular trauma. Initial imaging. CTA Lower Extremity CTA is considered especially important in the setting of trauma to the lower extremities. Several studies recognize its use as a first-line investigation in all patients with suspected vascular injury [42], demonstrating a sensitivity of 95% to 100% and a specificity of 87% to 100% [34,43]. Sensitivity for vascular injury in equivocal cases can be increased by using reconstructed images. | Nonatherosclerotic Peripheral Arterial Disease. Arteriography Lower Extremity Because of its high inherent spatial resolution, selective arteriography with DSA is considered the gold standard in the diagnosis of FMD [25,26,36,38-40], with many authors claiming that CTA and MRA may lack the spatial resolution necessary to detect small-artery pathology [36]. Arteriography is susceptible to standing waves. Therefore, caution must be exercised to accurately distinguish standing waves from true arterial beading characteristic of FMD [15]. This modality may simultaneously be therapeutic in FMD, as angioplasty is currently the preferred treatment of choice [25,38,39]. Selective arteriography is considered the reference standard in the diagnosis of SAM while also having therapeutic potential [28]. US Duplex Doppler Lower Extremity A recent study found US duplex Doppler to be helpful in diagnosing cystic adventitial disease, where numerous anechoic cysts are seen scattered throughout the adventitia at a site of vessel stenosis [31]. While much has been published about the use of US duplex Doppler in renal artery FMD, no literature is currently present to support its use in the diagnosis of FMD affecting the lower-extremity arteries. US Intravascular Lower Extremity IVUS has been reported to be useful in diagnosing cystic adventitial disease [31]. In FMD, other authors have concluded that IVUS is likely more accurate than other modalities in characterizing the hemodynamic severity of encountered stenosis [39,41]. Variant 6: Lower-extremity vascular trauma. Initial imaging. CTA Lower Extremity CTA is considered especially important in the setting of trauma to the lower extremities. Several studies recognize its use as a first-line investigation in all patients with suspected vascular injury [42], demonstrating a sensitivity of 95% to 100% and a specificity of 87% to 100% [34,43]. Sensitivity for vascular injury in equivocal cases can be increased by using reconstructed images. | 3102394 |
acrac_3102394_10 | Nonatherosclerotic Peripheral Arterial Disease | The use of CTA is associated with lower morbidity than that of selective arteriography and has resulted in a precipitous decrease in negative surgical exploration rates in the post-traumatic Nonatherosclerotic Peripheral Arterial Disease patient [43]. One study has suggested that the critical time saved by CTA in diagnosing lower-extremity vascular injury translates to decreased morbidity, thereby reducing hospital costs while improving outcomes [34]. MRA Lower Extremity MRA is not indicated after trauma, as long requisite imaging times are precarious in a potentially unstable patient. Underlying shrapnel or bullet fragments pose significant safety concerns within the confines of the magnetic field, in addition to degrading image quality [43]. Arteriography Lower Extremity Arteriography is recommended for vascular evaluation in patients with hard signs of vascular injury requiring immediate repair [44,45]. This can be done in the operating room with a C-arm or in a hybrid suite [44,45]. Selective arteriography is invasive and unable to depict extravascular anatomy [34]. In addition, it is time- consuming and could delay treatment of other traumatic injuries. However, it accurately detects active bleeding, pseudoaneurysms, arteriovenous fistula, and vascular thrombosis. A recent retrospective review advocates the use of arteriography if CTA is equivocal [43]. US Duplex Doppler Lower Extremity While portability and lack of nephrogenic contrast administration make US duplex Doppler an attractive option for evaluating the lower-extremity vessels after trauma, significant injury to the superficial soft tissues may limit its accuracy in assessing vascular integrity [43]. A recent meta-analysis reported that the post-test probability of arterial injury was 89% with a positive US and 5% with a negative US [46]. US Intravascular Lower Extremity There is no relevant literature regarding the use of IVUS in the evaluation of lower-extremity vascular trauma. | Nonatherosclerotic Peripheral Arterial Disease. The use of CTA is associated with lower morbidity than that of selective arteriography and has resulted in a precipitous decrease in negative surgical exploration rates in the post-traumatic Nonatherosclerotic Peripheral Arterial Disease patient [43]. One study has suggested that the critical time saved by CTA in diagnosing lower-extremity vascular injury translates to decreased morbidity, thereby reducing hospital costs while improving outcomes [34]. MRA Lower Extremity MRA is not indicated after trauma, as long requisite imaging times are precarious in a potentially unstable patient. Underlying shrapnel or bullet fragments pose significant safety concerns within the confines of the magnetic field, in addition to degrading image quality [43]. Arteriography Lower Extremity Arteriography is recommended for vascular evaluation in patients with hard signs of vascular injury requiring immediate repair [44,45]. This can be done in the operating room with a C-arm or in a hybrid suite [44,45]. Selective arteriography is invasive and unable to depict extravascular anatomy [34]. In addition, it is time- consuming and could delay treatment of other traumatic injuries. However, it accurately detects active bleeding, pseudoaneurysms, arteriovenous fistula, and vascular thrombosis. A recent retrospective review advocates the use of arteriography if CTA is equivocal [43]. US Duplex Doppler Lower Extremity While portability and lack of nephrogenic contrast administration make US duplex Doppler an attractive option for evaluating the lower-extremity vessels after trauma, significant injury to the superficial soft tissues may limit its accuracy in assessing vascular integrity [43]. A recent meta-analysis reported that the post-test probability of arterial injury was 89% with a positive US and 5% with a negative US [46]. US Intravascular Lower Extremity There is no relevant literature regarding the use of IVUS in the evaluation of lower-extremity vascular trauma. | 3102394 |
acrac_69367_0 | Indeterminate Renal Mass | Introduction/Background Renal masses are increasingly detected in asymptomatic individuals as incidental findings. Many of these are small renal tumors that vary widely in biological aggressiveness, ranging from benign tumors to high-grade renal cell carcinomas (RCCs). An indeterminate renal mass cannot be diagnosed confidently as benign or malignant at the time it is discovered. Masses that can be definitively characterized on the first imaging test will not be discussed in this review. Special Imaging Considerations Dual-energy CT and contrast-enhanced ultrasound (CEUS) are gaining traction in the characterization of indeterminate renal masses. Several studies have demonstrated that dual-energy CT can improve the differentiation between nonenhancing cysts and low-level-enhancing tumors [8-11]. Dual-energy CT with reconstruction of virtual monochromatic images has been shown to decrease or overcome renal cyst pseudoenhancement [12]. Other studies have shown that dual-energy CT can differentiate between solid tumors and hyperdense cysts incidentally detected on a single-phase postcontrast CT [13-15] and can be useful when a comprehensive multiphase renal protocol CT is not available. CEUS with microbubble agents is a useful alternative for characterizing renal masses, especially for patients in whom iodinated CT contrast or gadolinium-based MRI contrast is contraindicated. The microbubble agents are not excreted by the kidneys and therefore do not affect renal function. CEUS allows real-time evaluation of microvasculature and has been shown to be valuable for differentiating between cystic and solid renal lesions and for characterizing complex renal cystic lesions and indeterminate renal masses [16-18]. CEUS may result in assignment of a higher Bosniak classification compared to contrast-enhanced CT [19,20]. However, a typical CEUS examination does not result in a complete evaluation of both kidneys for additional renal masses. | Indeterminate Renal Mass. Introduction/Background Renal masses are increasingly detected in asymptomatic individuals as incidental findings. Many of these are small renal tumors that vary widely in biological aggressiveness, ranging from benign tumors to high-grade renal cell carcinomas (RCCs). An indeterminate renal mass cannot be diagnosed confidently as benign or malignant at the time it is discovered. Masses that can be definitively characterized on the first imaging test will not be discussed in this review. Special Imaging Considerations Dual-energy CT and contrast-enhanced ultrasound (CEUS) are gaining traction in the characterization of indeterminate renal masses. Several studies have demonstrated that dual-energy CT can improve the differentiation between nonenhancing cysts and low-level-enhancing tumors [8-11]. Dual-energy CT with reconstruction of virtual monochromatic images has been shown to decrease or overcome renal cyst pseudoenhancement [12]. Other studies have shown that dual-energy CT can differentiate between solid tumors and hyperdense cysts incidentally detected on a single-phase postcontrast CT [13-15] and can be useful when a comprehensive multiphase renal protocol CT is not available. CEUS with microbubble agents is a useful alternative for characterizing renal masses, especially for patients in whom iodinated CT contrast or gadolinium-based MRI contrast is contraindicated. The microbubble agents are not excreted by the kidneys and therefore do not affect renal function. CEUS allows real-time evaluation of microvasculature and has been shown to be valuable for differentiating between cystic and solid renal lesions and for characterizing complex renal cystic lesions and indeterminate renal masses [16-18]. CEUS may result in assignment of a higher Bosniak classification compared to contrast-enhanced CT [19,20]. However, a typical CEUS examination does not result in a complete evaluation of both kidneys for additional renal masses. | 69367 |
acrac_69367_1 | Indeterminate Renal Mass | Tc-99m sestamibi single-photon emission computed tomography (SPECT)/CT has been shown in several studies to be helpful when the diagnosis of a renal oncocytoma is suspected [21-23]. For example, in a study of 31 renal masses imaged with Tc-99m sestamibi SPECT/CT, 91.6% (11 of 12) of oncocytomas had radiotracer uptake above aUniversity of California San Francisco School of Medicine, San Francisco, California. bPanel Chair, Northwestern University, Chicago, Illinois. cPanel Vice- Chair, UT Southwestern Medical Center, Dallas, Texas. dUniversity of Rochester Medical Center, Rochester, New York. eThe University of Texas MD Anderson Cancer Center, Houston, Texas. fUniversity of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; American Society of Nephrology. gUniversity of Washington, Seattle, Washington; American Urological Association. hDuke University Medical Center, Durham, North Carolina. iMayo Clinic, Rochester, Minnesota. jEmory University School of Medicine, Atlanta, Georgia. kThomas Jefferson University Hospital, Philadelphia, Pennsylvania. lCleveland Clinic, Cleveland, Ohio. mMedical University of South Carolina, Charleston, South Carolina; American Urological Association. nUniversity of Alabama at Birmingham, Birmingham, Alabama. oJohns Hopkins University School of Medicine, Washington, District of Columbia. pUniversity of Maryland School of Medicine, Baltimore, Maryland. qSpecialty Chair, University of Alabama at Birmingham, Birmingham, Alabama. Reprint requests to: [email protected] Indeterminate Renal Mass adjacent normal renal parenchyma, three hybrid tumors (mixed-type oncocytoma and chromophobe renal cancer) showed tracer uptake, one papillary RCC had a slight tracer uptake, and the remaining 11 RCC were sestamibi negative [23]. CT urography (CTU) is an imaging study that is tailored to improve visualization of both the upper and lower urinary tracts. | Indeterminate Renal Mass. Tc-99m sestamibi single-photon emission computed tomography (SPECT)/CT has been shown in several studies to be helpful when the diagnosis of a renal oncocytoma is suspected [21-23]. For example, in a study of 31 renal masses imaged with Tc-99m sestamibi SPECT/CT, 91.6% (11 of 12) of oncocytomas had radiotracer uptake above aUniversity of California San Francisco School of Medicine, San Francisco, California. bPanel Chair, Northwestern University, Chicago, Illinois. cPanel Vice- Chair, UT Southwestern Medical Center, Dallas, Texas. dUniversity of Rochester Medical Center, Rochester, New York. eThe University of Texas MD Anderson Cancer Center, Houston, Texas. fUniversity of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; American Society of Nephrology. gUniversity of Washington, Seattle, Washington; American Urological Association. hDuke University Medical Center, Durham, North Carolina. iMayo Clinic, Rochester, Minnesota. jEmory University School of Medicine, Atlanta, Georgia. kThomas Jefferson University Hospital, Philadelphia, Pennsylvania. lCleveland Clinic, Cleveland, Ohio. mMedical University of South Carolina, Charleston, South Carolina; American Urological Association. nUniversity of Alabama at Birmingham, Birmingham, Alabama. oJohns Hopkins University School of Medicine, Washington, District of Columbia. pUniversity of Maryland School of Medicine, Baltimore, Maryland. qSpecialty Chair, University of Alabama at Birmingham, Birmingham, Alabama. Reprint requests to: [email protected] Indeterminate Renal Mass adjacent normal renal parenchyma, three hybrid tumors (mixed-type oncocytoma and chromophobe renal cancer) showed tracer uptake, one papillary RCC had a slight tracer uptake, and the remaining 11 RCC were sestamibi negative [23]. CT urography (CTU) is an imaging study that is tailored to improve visualization of both the upper and lower urinary tracts. | 69367 |
acrac_69367_2 | Indeterminate Renal Mass | There is variability in the specific parameters, but it usually involves unenhanced images followed by IV contrast-enhanced images, including nephrographic and excretory phases acquired at least 5 minutes after contrast injection. Alternatively, a split-bolus technique uses an initial loading dose of IV contrast and then obtains a combined nephrographic-excretory phase after a second IV contrast dose; some sites include arterial phase. CTU should use thin-slice acquisition. Reconstruction methods commonly include maximum intensity projection or 3-D volume rendering. For the purposes of this document, we make a distinction between CTU and CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases. MR urography (MRU) is also tailored to improve imaging of the urinary system. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic high signal intensity from urine for evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory phases. Thin-slice acquisition and multiplanar imaging should be obtained. For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and without heavily T2-weighted images of the urinary tract. OR Discussion of Procedures by Variant Variant 1: Indeterminate renal mass. No contraindication to either iodinated CT contrast or gadolinium- based MR intravenous contrast. | Indeterminate Renal Mass. There is variability in the specific parameters, but it usually involves unenhanced images followed by IV contrast-enhanced images, including nephrographic and excretory phases acquired at least 5 minutes after contrast injection. Alternatively, a split-bolus technique uses an initial loading dose of IV contrast and then obtains a combined nephrographic-excretory phase after a second IV contrast dose; some sites include arterial phase. CTU should use thin-slice acquisition. Reconstruction methods commonly include maximum intensity projection or 3-D volume rendering. For the purposes of this document, we make a distinction between CTU and CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases. MR urography (MRU) is also tailored to improve imaging of the urinary system. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic high signal intensity from urine for evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory phases. Thin-slice acquisition and multiplanar imaging should be obtained. For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and without heavily T2-weighted images of the urinary tract. OR Discussion of Procedures by Variant Variant 1: Indeterminate renal mass. No contraindication to either iodinated CT contrast or gadolinium- based MR intravenous contrast. | 69367 |
acrac_69367_3 | Indeterminate Renal Mass | Initial imaging. Arteriography Kidney Cross-sectional imaging has replaced arteriography for the evaluation of indeterminate renal masses. There is no relevant literature regarding the use of arteriography in the evaluation of an indeterminate renal mass. Although CT with and without IV contrast is optimal for evaluation of indeterminate renal masses, CT without IV contrast can provide some information. For example, homogenous renal masses measuring <20 HU or >70 HU [1,2] or lesions containing macroscopic fat can be characterized as benign lesions on noncontrast CT. Other studies have also shown that dual-energy CT can differentiate between solid tumors and hyperdense cysts incidentally detected on a single-phase postcontrast CT [13-15] and can be useful when a comprehensive multiphase renal protocol CT is not available. Indeterminate Renal Mass Cystic Renal Masses The Bosniak CT classification system for cystic renal masses encompasses the spectrum from simple renal cyst to cystic RCC, with the likelihood of malignancy increasing with the complexity of the mass [28,29]. Because the presence of any enhancing nodules, walls, or thick septa within a cystic mass is key to determining the probability of malignancy using the Bosniak classification, CT without and with IV contrast is usually necessary for evaluating these lesions. One retrospective study of 156 Bosniak IIF lesions showed that 10.9% of the lesions progressed to malignancy between 6 months and 3.2 years [30]. Another retrospective study of 69 Bosniak IIF lesions and 144 Bosniak III lesions showed malignancy rates of 25% and 54%, respectively [31]. In one study of 312 prospectively classified Bosniak lesions, the malignancy rate at pathology was 38% for Bosniak IIF, 40% for Bosniak III, and 90% for Bosniak IV renal lesions [32]. Oncocytoma is another benign tumor that mimics RCC, and to date there are no specific CT features to reliably differentiate between the two [37]. | Indeterminate Renal Mass. Initial imaging. Arteriography Kidney Cross-sectional imaging has replaced arteriography for the evaluation of indeterminate renal masses. There is no relevant literature regarding the use of arteriography in the evaluation of an indeterminate renal mass. Although CT with and without IV contrast is optimal for evaluation of indeterminate renal masses, CT without IV contrast can provide some information. For example, homogenous renal masses measuring <20 HU or >70 HU [1,2] or lesions containing macroscopic fat can be characterized as benign lesions on noncontrast CT. Other studies have also shown that dual-energy CT can differentiate between solid tumors and hyperdense cysts incidentally detected on a single-phase postcontrast CT [13-15] and can be useful when a comprehensive multiphase renal protocol CT is not available. Indeterminate Renal Mass Cystic Renal Masses The Bosniak CT classification system for cystic renal masses encompasses the spectrum from simple renal cyst to cystic RCC, with the likelihood of malignancy increasing with the complexity of the mass [28,29]. Because the presence of any enhancing nodules, walls, or thick septa within a cystic mass is key to determining the probability of malignancy using the Bosniak classification, CT without and with IV contrast is usually necessary for evaluating these lesions. One retrospective study of 156 Bosniak IIF lesions showed that 10.9% of the lesions progressed to malignancy between 6 months and 3.2 years [30]. Another retrospective study of 69 Bosniak IIF lesions and 144 Bosniak III lesions showed malignancy rates of 25% and 54%, respectively [31]. In one study of 312 prospectively classified Bosniak lesions, the malignancy rate at pathology was 38% for Bosniak IIF, 40% for Bosniak III, and 90% for Bosniak IV renal lesions [32]. Oncocytoma is another benign tumor that mimics RCC, and to date there are no specific CT features to reliably differentiate between the two [37]. | 69367 |
acrac_69367_4 | Indeterminate Renal Mass | Enhancement pattern on multiphasic CT has been used to subtype RCC. In a retrospective study of 298 cases of RCC and oncocytoma evaluated with 4-phase CT, multiphasic enhancement threshold helped to discriminate clear-cell RCC from oncocytoma with an accuracy of 77%, clear-cell RCC from papillary RCC with an accuracy of 85%, and clear-cell RCC from chromophobe RCC with an accuracy of 84% [38]. However, no prospective studies have validated the reported enhancement threshold, and accuracies of 77% to 85% may not be sufficient to change clinical management. CTU While there is no literature specifically evaluating the performance of CTU for indeterminate renal masses, CTU may be useful in this context. CTU that includes the acquisition of both unenhanced and nephrographic phase images would be expected to provide the same information as CT abdomen without and with IV contrast. The excretory phase images from CTU may provide additional information for differentiating between intrarenal urothelial carcinoma from centrally located RCC [39]. MRI Abdomen MRI is frequently used to characterize renal lesions. In one retrospective study of 120 patients, the specificity of MRI was significantly higher than that of CT in diagnosing RCC (68.1% versus 27.7%), whereas their sensitivities Indeterminate Renal Mass Ho et al [51] showed that the optimal percentage of enhancement threshold for distinguishing cysts from solid tumors on MRI was 15%. Hecht et al [52] reported that both quantitative and qualitative methods are sensitive in the detection of enhancement in a renal lesion on MRI and that subtracted images enable accurate assessment of tumor enhancement for intrinsically hyperintense lesions using qualitative methods. Although MRI without and with IV contrast is optimal for renal lesion characterization, MRI without IV contrast can also provide diagnostic information. | Indeterminate Renal Mass. Enhancement pattern on multiphasic CT has been used to subtype RCC. In a retrospective study of 298 cases of RCC and oncocytoma evaluated with 4-phase CT, multiphasic enhancement threshold helped to discriminate clear-cell RCC from oncocytoma with an accuracy of 77%, clear-cell RCC from papillary RCC with an accuracy of 85%, and clear-cell RCC from chromophobe RCC with an accuracy of 84% [38]. However, no prospective studies have validated the reported enhancement threshold, and accuracies of 77% to 85% may not be sufficient to change clinical management. CTU While there is no literature specifically evaluating the performance of CTU for indeterminate renal masses, CTU may be useful in this context. CTU that includes the acquisition of both unenhanced and nephrographic phase images would be expected to provide the same information as CT abdomen without and with IV contrast. The excretory phase images from CTU may provide additional information for differentiating between intrarenal urothelial carcinoma from centrally located RCC [39]. MRI Abdomen MRI is frequently used to characterize renal lesions. In one retrospective study of 120 patients, the specificity of MRI was significantly higher than that of CT in diagnosing RCC (68.1% versus 27.7%), whereas their sensitivities Indeterminate Renal Mass Ho et al [51] showed that the optimal percentage of enhancement threshold for distinguishing cysts from solid tumors on MRI was 15%. Hecht et al [52] reported that both quantitative and qualitative methods are sensitive in the detection of enhancement in a renal lesion on MRI and that subtracted images enable accurate assessment of tumor enhancement for intrinsically hyperintense lesions using qualitative methods. Although MRI without and with IV contrast is optimal for renal lesion characterization, MRI without IV contrast can also provide diagnostic information. | 69367 |
acrac_69367_5 | Indeterminate Renal Mass | For example, simple cystic lesions, or even those with thin septations, can often be characterized on noncontrast T2-weighted imaging based on their homogeneous and very high T2 signal intensity. To differentiate between hemorrhagic or proteinaceous cyst and RCC, a retrospective study shows that homogenous high T1 signal intensity lesions with smooth borders and lesion to renal parenchyma signal intensity ratio of >1.6 predicted the lesion as a benign cyst [53]. Another study of 144 T1-hyperintense lesions demonstrated that diffuse and marked T1-hyperintensity achieved accuracies of 73.6% to 79.9% for the diagnosis of T1- hyperintense cysts [54]. An angular interface with the renal parenchyma on T2-weighted imaging has been shown to be 78% sensitive and 100% specific for differentiating benign exophytic renal masses from malignant masses [55]. Diffusion-weighted imaging, although less accurate than contrast-enhanced MRI, may have some ability to differentiate solid RCC from oncocytomas and characterize the histologic subtypes of RCC [56]. New and specialized MRI sequences have been proposed for the purposes of characterizing the vascularity of renal lesions in patients with renal dysfunction. For example, one small study of 17 renal lesions used arterial spin labeling to detect blood flow in renal masses, which correlated with malignancy [57]. Cystic Renal Masses In a study of 69 cystic renal masses evaluated using the Bosniak classification with CT and MRI, there was CT and MRI agreement in 56 of 69 lesions (81%) and disagreement in 13 of 69 lesions (19%) [29]. CT and MRI were felt to be similar in evaluation of most renal cystic mass lesions. However, MRI may depict additional findings, such as an increase in number of septa, septal or wall thickness, and enhancement. Such findings would result in MRI upgrading cystic lesions and thus might alter patient management [29]. | Indeterminate Renal Mass. For example, simple cystic lesions, or even those with thin septations, can often be characterized on noncontrast T2-weighted imaging based on their homogeneous and very high T2 signal intensity. To differentiate between hemorrhagic or proteinaceous cyst and RCC, a retrospective study shows that homogenous high T1 signal intensity lesions with smooth borders and lesion to renal parenchyma signal intensity ratio of >1.6 predicted the lesion as a benign cyst [53]. Another study of 144 T1-hyperintense lesions demonstrated that diffuse and marked T1-hyperintensity achieved accuracies of 73.6% to 79.9% for the diagnosis of T1- hyperintense cysts [54]. An angular interface with the renal parenchyma on T2-weighted imaging has been shown to be 78% sensitive and 100% specific for differentiating benign exophytic renal masses from malignant masses [55]. Diffusion-weighted imaging, although less accurate than contrast-enhanced MRI, may have some ability to differentiate solid RCC from oncocytomas and characterize the histologic subtypes of RCC [56]. New and specialized MRI sequences have been proposed for the purposes of characterizing the vascularity of renal lesions in patients with renal dysfunction. For example, one small study of 17 renal lesions used arterial spin labeling to detect blood flow in renal masses, which correlated with malignancy [57]. Cystic Renal Masses In a study of 69 cystic renal masses evaluated using the Bosniak classification with CT and MRI, there was CT and MRI agreement in 56 of 69 lesions (81%) and disagreement in 13 of 69 lesions (19%) [29]. CT and MRI were felt to be similar in evaluation of most renal cystic mass lesions. However, MRI may depict additional findings, such as an increase in number of septa, septal or wall thickness, and enhancement. Such findings would result in MRI upgrading cystic lesions and thus might alter patient management [29]. | 69367 |
acrac_69367_6 | Indeterminate Renal Mass | Another study of 33 cystic lesions imaged with both 1.5T and 3.0T MRI showed that there is a greater tendency to upgrade cyst complexity and Bosniak cyst category at 3.0T than at 1.5T and thus suggested that serial follow-up of cystic renal lesions be performed at constant field strength [58]. Solid Renal Masses Other than AMLs with macroscopic fat, MRI cannot yet reliably differentiate benign from malignant renal tumors. However, several MRI features have been reported to be useful for suggesting types of solid renal tumors. In one multiparametric MRI study, lipid-poor AMLs were characterized by higher T1 signal intensity and lower T2 signal intensity compared to normal renal cortex and by greater arterial-to-delayed enhancement ratio than RCC [59]. Another study showed that the combination of low T2 signal and signal drop on chemical-shift imaging is specific for lipid-poor AMLs but lacks sensitivity, and the combination of low T2 signal intensity and high area under the contrast-enhanced MRI curve is sensitive and specific for lipid-poor AMLs [60]. Although both papillary RCC and lipid-poor AMLs can have low signal intensity on T2-weighted images, the presence of intratumoral hemorrhage seen on T1-weighted images was suggested to be a specific feature of papillary RCC [61]. Nonetheless, MRI findings of lipid-poor AMLs overlap with various RCC subtypes and remain difficult to prospectively diagnose [60]. Indeterminate Renal Mass diagnostic algorithm had diagnostic accuracy of 81% (88 of 109) and 91% (99 of 109) in the diagnosis of clear-cell RCC and papillary RCC, respectively, while achieving moderate to substantial inter-reader agreement among 7 radiologists [64]. MRU There is no relevant literature regarding the use of MRU in the evaluation of indeterminate renal masses. Radiography Intravenous Urography There is no relevant literature regarding the use of IV urography (IVU) in the evaluation of indeterminate renal masses. | Indeterminate Renal Mass. Another study of 33 cystic lesions imaged with both 1.5T and 3.0T MRI showed that there is a greater tendency to upgrade cyst complexity and Bosniak cyst category at 3.0T than at 1.5T and thus suggested that serial follow-up of cystic renal lesions be performed at constant field strength [58]. Solid Renal Masses Other than AMLs with macroscopic fat, MRI cannot yet reliably differentiate benign from malignant renal tumors. However, several MRI features have been reported to be useful for suggesting types of solid renal tumors. In one multiparametric MRI study, lipid-poor AMLs were characterized by higher T1 signal intensity and lower T2 signal intensity compared to normal renal cortex and by greater arterial-to-delayed enhancement ratio than RCC [59]. Another study showed that the combination of low T2 signal and signal drop on chemical-shift imaging is specific for lipid-poor AMLs but lacks sensitivity, and the combination of low T2 signal intensity and high area under the contrast-enhanced MRI curve is sensitive and specific for lipid-poor AMLs [60]. Although both papillary RCC and lipid-poor AMLs can have low signal intensity on T2-weighted images, the presence of intratumoral hemorrhage seen on T1-weighted images was suggested to be a specific feature of papillary RCC [61]. Nonetheless, MRI findings of lipid-poor AMLs overlap with various RCC subtypes and remain difficult to prospectively diagnose [60]. Indeterminate Renal Mass diagnostic algorithm had diagnostic accuracy of 81% (88 of 109) and 91% (99 of 109) in the diagnosis of clear-cell RCC and papillary RCC, respectively, while achieving moderate to substantial inter-reader agreement among 7 radiologists [64]. MRU There is no relevant literature regarding the use of MRU in the evaluation of indeterminate renal masses. Radiography Intravenous Urography There is no relevant literature regarding the use of IV urography (IVU) in the evaluation of indeterminate renal masses. | 69367 |
acrac_69367_7 | Indeterminate Renal Mass | US Abdomen with IV Contrast CEUS using microbubble agents is emerging as a useful way to characterize previously indeterminate renal lesions [16-18]. In a study of 1,018 indeterminate renal lesions, CEUS had a per patient sensitivity of 100% (126 of 126 patients), specificity of 95% (132 of 139 patients), positive predictive value of 94.7% (126 of 133 patients), and negative predictive value of 100% (132 of 132 patients) for classifying benign versus malignant renal masses [16]. In that study, any echogenic masses with enhancement equal to or greater than normal renal cortex and wash-out, and any masses with blood flow, were considered malignant. In another study, CEUS successfully classified 95.7% (90 of 94) previously indeterminate lesions and has an accuracy of 90.2% (37 of 41 lesions) when compared with the reference standard, including histopathology and follow-up [18]. In the subgroup analysis, CEUS was definitive for 94.4% (17 of 18) of cases referred because of equivocal enhancement at CT [18]. In that same study, CEUS was able to classify lesions in 100% (10 of 10) of the cases in which the lesions were indeterminate on prior MRI [18]. Another study of CEUS in 83 CT indeterminate renal masses reported that the accuracy of characterization by CEUS was 95.2% compared with 42.2% using unenhanced US [17]. Studies have shown CEUS to be more sensitive than contrast-enhanced CT in characterizing cystic renal masses [19,65]. In a study of 31 cystic renal masses evaluated by both CT and CEUS using the Bosniak classification, 26% of the lesions were upgraded by CEUS [19]. In a prospective CEUS study of 94 solid renal lesions excluding lipid- rich AML, hypovascularity of small solid renal masses relative to the cortex in the arterial phase has 100% specificity for detecting malignancy, especially for detecting papillary RCC [66]. Quantitative analysis of CEUS has also been reported to be useful to stratify RCC and benign renal tumors [67,68]. Variant 2: Indeterminate renal mass. | Indeterminate Renal Mass. US Abdomen with IV Contrast CEUS using microbubble agents is emerging as a useful way to characterize previously indeterminate renal lesions [16-18]. In a study of 1,018 indeterminate renal lesions, CEUS had a per patient sensitivity of 100% (126 of 126 patients), specificity of 95% (132 of 139 patients), positive predictive value of 94.7% (126 of 133 patients), and negative predictive value of 100% (132 of 132 patients) for classifying benign versus malignant renal masses [16]. In that study, any echogenic masses with enhancement equal to or greater than normal renal cortex and wash-out, and any masses with blood flow, were considered malignant. In another study, CEUS successfully classified 95.7% (90 of 94) previously indeterminate lesions and has an accuracy of 90.2% (37 of 41 lesions) when compared with the reference standard, including histopathology and follow-up [18]. In the subgroup analysis, CEUS was definitive for 94.4% (17 of 18) of cases referred because of equivocal enhancement at CT [18]. In that same study, CEUS was able to classify lesions in 100% (10 of 10) of the cases in which the lesions were indeterminate on prior MRI [18]. Another study of CEUS in 83 CT indeterminate renal masses reported that the accuracy of characterization by CEUS was 95.2% compared with 42.2% using unenhanced US [17]. Studies have shown CEUS to be more sensitive than contrast-enhanced CT in characterizing cystic renal masses [19,65]. In a study of 31 cystic renal masses evaluated by both CT and CEUS using the Bosniak classification, 26% of the lesions were upgraded by CEUS [19]. In a prospective CEUS study of 94 solid renal lesions excluding lipid- rich AML, hypovascularity of small solid renal masses relative to the cortex in the arterial phase has 100% specificity for detecting malignancy, especially for detecting papillary RCC [66]. Quantitative analysis of CEUS has also been reported to be useful to stratify RCC and benign renal tumors [67,68]. Variant 2: Indeterminate renal mass. | 69367 |
acrac_69367_8 | Indeterminate Renal Mass | Contraindication to both iodinated CT and gadolinium-based MR intravenous contrast. Initial imaging. Arteriography Kidney Cross-sectional imaging has replaced arteriography for the evaluation of indeterminate renal masses. There is no relevant literature regarding the use of arteriography in the evaluation of indeterminate renal masses. Arteriography typically requires IV administration of iodinated contrast. CT Abdomen Iodinated CT contrast is contraindicated in some patients with severe allergy to the CT contrast or patients who are at high risk for contrast-induced nephropathy. For more details, please refer to the ACR Manual on Contrast Media [71]. The inability to utilize IV contrast to evaluate a renal mass markedly limits whether it can be classified as benign or malignant on CT, but it does provide some information if calcifications, nodules, or septations are visible. Homogenous renal masses measuring <20 HU or >70 HU [1,2] or lesions containing macroscopic fat can be characterized as benign lesions, but all other small lesions cannot be characterized using CT without IV contrast. Large lesions with calcifications and necrosis may not need further characterization, but detection of venous invasion and metastases is also limited. Indeterminate Renal Mass CTU There is no relevant literature regarding the use of CTU in the evaluation of indeterminate renal masses. MRI Abdomen Because of the risk for nephrogenic systemic fibrosis [72], certain gadolinium-based contrast agents may be contraindicated in patients with renal failure. Another contraindication is severe allergy to gadolinium agents. For more details, please refer to the ACR Manual on Contrast Media [71]. In the absence of contrast, unenhanced MRI has some advantages over unenhanced CT in the characterization of renal masses. Simple cystic lesions or even those with thin septations can often be characterized on noncontrast T2-weighted imaging based on their homogeneous and very high T2 signal intensity. | Indeterminate Renal Mass. Contraindication to both iodinated CT and gadolinium-based MR intravenous contrast. Initial imaging. Arteriography Kidney Cross-sectional imaging has replaced arteriography for the evaluation of indeterminate renal masses. There is no relevant literature regarding the use of arteriography in the evaluation of indeterminate renal masses. Arteriography typically requires IV administration of iodinated contrast. CT Abdomen Iodinated CT contrast is contraindicated in some patients with severe allergy to the CT contrast or patients who are at high risk for contrast-induced nephropathy. For more details, please refer to the ACR Manual on Contrast Media [71]. The inability to utilize IV contrast to evaluate a renal mass markedly limits whether it can be classified as benign or malignant on CT, but it does provide some information if calcifications, nodules, or septations are visible. Homogenous renal masses measuring <20 HU or >70 HU [1,2] or lesions containing macroscopic fat can be characterized as benign lesions, but all other small lesions cannot be characterized using CT without IV contrast. Large lesions with calcifications and necrosis may not need further characterization, but detection of venous invasion and metastases is also limited. Indeterminate Renal Mass CTU There is no relevant literature regarding the use of CTU in the evaluation of indeterminate renal masses. MRI Abdomen Because of the risk for nephrogenic systemic fibrosis [72], certain gadolinium-based contrast agents may be contraindicated in patients with renal failure. Another contraindication is severe allergy to gadolinium agents. For more details, please refer to the ACR Manual on Contrast Media [71]. In the absence of contrast, unenhanced MRI has some advantages over unenhanced CT in the characterization of renal masses. Simple cystic lesions or even those with thin septations can often be characterized on noncontrast T2-weighted imaging based on their homogeneous and very high T2 signal intensity. | 69367 |
acrac_69367_9 | Indeterminate Renal Mass | To differentiate between hemorrhagic or proteinaceous cysts and RCC, a retrospective study shows that homogenous high T1 signal intensity lesions with smooth borders and lesion to renal parenchyma signal intensity ratio of >1.6 predicted the lesion as a benign cyst [53]. Another study of 144 T1-hyperintense lesions demonstrated that diffuse and marked T1-hyperintensity achieved accuracies of 73.6% to 79.9% for the diagnosis of T1-hyperintense cysts [54]. An angular interface with the renal parenchyma on T2- weighted imaging has been shown to be 78% sensitive and 100% specific for differentiating benign exophytic renal masses from malignant masses [55]. Diffusion-weighted imaging, although less accurate than contrast-enhanced MRI, may have some ability to differentiate solid RCC from oncocytomas and characterize the histologic subtypes of RCC [56]. New and specialized MRI sequences have been proposed for the purposes of characterizing the vascularity of renal lesions in patients with renal dysfunction. For example, one small study of 17 renal lesions used arterial spin labeling to detect blood flow in renal masses, which correlated with malignancy [57]. A drawback of MRI compared with CT is the limited ability of MRI for detection of calcifications. MRU There is no relevant literature regarding the use of MRU in the evaluation of indeterminate renal masses. Radiography Intravenous Urography There is no relevant literature regarding the use of IVU for the evaluation of indeterminate renal masses. IVU requires IV administration of iodinated contrast. US Abdomen with IV Contrast CEUS using microbubble agents is emerging as a useful way to characterize previously indeterminate renal lesions [16-18]. It is not limited by renal or hepatic failure. | Indeterminate Renal Mass. To differentiate between hemorrhagic or proteinaceous cysts and RCC, a retrospective study shows that homogenous high T1 signal intensity lesions with smooth borders and lesion to renal parenchyma signal intensity ratio of >1.6 predicted the lesion as a benign cyst [53]. Another study of 144 T1-hyperintense lesions demonstrated that diffuse and marked T1-hyperintensity achieved accuracies of 73.6% to 79.9% for the diagnosis of T1-hyperintense cysts [54]. An angular interface with the renal parenchyma on T2- weighted imaging has been shown to be 78% sensitive and 100% specific for differentiating benign exophytic renal masses from malignant masses [55]. Diffusion-weighted imaging, although less accurate than contrast-enhanced MRI, may have some ability to differentiate solid RCC from oncocytomas and characterize the histologic subtypes of RCC [56]. New and specialized MRI sequences have been proposed for the purposes of characterizing the vascularity of renal lesions in patients with renal dysfunction. For example, one small study of 17 renal lesions used arterial spin labeling to detect blood flow in renal masses, which correlated with malignancy [57]. A drawback of MRI compared with CT is the limited ability of MRI for detection of calcifications. MRU There is no relevant literature regarding the use of MRU in the evaluation of indeterminate renal masses. Radiography Intravenous Urography There is no relevant literature regarding the use of IVU for the evaluation of indeterminate renal masses. IVU requires IV administration of iodinated contrast. US Abdomen with IV Contrast CEUS using microbubble agents is emerging as a useful way to characterize previously indeterminate renal lesions [16-18]. It is not limited by renal or hepatic failure. | 69367 |
acrac_69367_10 | Indeterminate Renal Mass | In one study of 1,018 indeterminate renal lesions, CEUS had a per patient sensitivity of 100% (126 of 126 patients), specificity of 95% (132 of 139 patients), positive predictive value of 94.7% (126 of 133 patients), and negative predictive value of 100% (132 of 132 patients) for classifying benign versus malignant renal masses [16]. In that study, any echogenic masses with enhancement at least of normal renal cortex and wash-out as well as any masses with blood flow were considered malignant. In another study, CEUS successfully classified 95.7% (90 of 94) of previously indeterminate lesions and has an accuracy of 90.2% (37 of 41 lesions) when compared with the reference standard, including histopathology and follow-up [18]. In the subgroup analysis, CEUS was definitive for 94.4% (17 of 18) of cases referred because of equivocal enhancement Indeterminate Renal Mass at CT [18]. In that same study, CEUS was able to classify lesions in 100% (10 of 10) of the cases in which the lesions were indeterminate on prior MRI [18]. Another study of CEUS in 83 CT indeterminate renal masses reported that the accuracy of characterization by CEUS was 95.2% compared with 42.2% using unenhanced US [17]. Studies have shown CEUS to be more sensitive than contrast-enhanced CT in characterizing cystic renal masses [19,65]. In a study of 31 cystic renal masses evaluated by both CT and CEUS using the Bosniak classification, 26% of the lesions were upgraded by CEUS [19]. In a prospective CEUS study of 94 solid renal lesions excluding lipid- rich AMLs, hypovascularity of small solid renal masses relative to the cortex in the arterial phase has 100% specificity for detecting malignancy, especially for detecting papillary RCC [66]. Quantitative analysis of CEUS has also been reported to be useful to stratify RCC and benign renal tumors [67,68]. Variant 3: Indeterminate renal mass. Contraindication only to iodinated CT intravenous contrast. Initial imaging. | Indeterminate Renal Mass. In one study of 1,018 indeterminate renal lesions, CEUS had a per patient sensitivity of 100% (126 of 126 patients), specificity of 95% (132 of 139 patients), positive predictive value of 94.7% (126 of 133 patients), and negative predictive value of 100% (132 of 132 patients) for classifying benign versus malignant renal masses [16]. In that study, any echogenic masses with enhancement at least of normal renal cortex and wash-out as well as any masses with blood flow were considered malignant. In another study, CEUS successfully classified 95.7% (90 of 94) of previously indeterminate lesions and has an accuracy of 90.2% (37 of 41 lesions) when compared with the reference standard, including histopathology and follow-up [18]. In the subgroup analysis, CEUS was definitive for 94.4% (17 of 18) of cases referred because of equivocal enhancement Indeterminate Renal Mass at CT [18]. In that same study, CEUS was able to classify lesions in 100% (10 of 10) of the cases in which the lesions were indeterminate on prior MRI [18]. Another study of CEUS in 83 CT indeterminate renal masses reported that the accuracy of characterization by CEUS was 95.2% compared with 42.2% using unenhanced US [17]. Studies have shown CEUS to be more sensitive than contrast-enhanced CT in characterizing cystic renal masses [19,65]. In a study of 31 cystic renal masses evaluated by both CT and CEUS using the Bosniak classification, 26% of the lesions were upgraded by CEUS [19]. In a prospective CEUS study of 94 solid renal lesions excluding lipid- rich AMLs, hypovascularity of small solid renal masses relative to the cortex in the arterial phase has 100% specificity for detecting malignancy, especially for detecting papillary RCC [66]. Quantitative analysis of CEUS has also been reported to be useful to stratify RCC and benign renal tumors [67,68]. Variant 3: Indeterminate renal mass. Contraindication only to iodinated CT intravenous contrast. Initial imaging. | 69367 |
acrac_69367_11 | Indeterminate Renal Mass | Arteriography Kidney Cross-sectional imaging has replaced arteriography for the evaluation of indeterminate renal masses. There is no relevant literature regarding the use of arteriography in the evaluation of indeterminate renal masses. CT Abdomen Iodinated CT contrast is contraindicated in some patients with severe allergy to the CT contrast or in patients who are at high risk for contrast-induced nephropathy. For more details, please refer to the ACR Manual on Contrast Media [71]. The inability to utilize IV contrast to evaluate a renal mass markedly limits whether it can be classified as benign or malignant on CT, but it can provide some information. Homogenous renal masses measuring <20 HU or >70 HU [1,2] or lesions containing macroscopic fat can be characterized as benign lesions, but all other small lesions cannot be characterized using CT without IV contrast. Large lesions with calcifications and necrosis may not need further characterization, but detection of venous invasion and metastases is also limited. CTU There is no relevant literature regarding the use of CTU in the evaluation of indeterminate renal masses. Indeterminate Renal Mass Ho et al [51] showed that the optimal percentage of enhancement threshold for distinguishing cysts from solid tumors on MRI was 15%. Hecht et al [52] reported that both quantitative and qualitative methods are sensitive in the detection of enhancement in a renal lesion on MRI and that subtracted images enables accurate assessment of tumor enhancement for intrinsically hyperintense lesions using qualitative methods. Although MRI without and with IV contrast is optimal for renal lesion characterization, MRI without IV contrast can also provide diagnostic information. For example, simple cystic lesions or even those with thin septations can often be characterized on noncontrast T2-weighted imaging based on their homogeneous and very high T2 signal intensity. | Indeterminate Renal Mass. Arteriography Kidney Cross-sectional imaging has replaced arteriography for the evaluation of indeterminate renal masses. There is no relevant literature regarding the use of arteriography in the evaluation of indeterminate renal masses. CT Abdomen Iodinated CT contrast is contraindicated in some patients with severe allergy to the CT contrast or in patients who are at high risk for contrast-induced nephropathy. For more details, please refer to the ACR Manual on Contrast Media [71]. The inability to utilize IV contrast to evaluate a renal mass markedly limits whether it can be classified as benign or malignant on CT, but it can provide some information. Homogenous renal masses measuring <20 HU or >70 HU [1,2] or lesions containing macroscopic fat can be characterized as benign lesions, but all other small lesions cannot be characterized using CT without IV contrast. Large lesions with calcifications and necrosis may not need further characterization, but detection of venous invasion and metastases is also limited. CTU There is no relevant literature regarding the use of CTU in the evaluation of indeterminate renal masses. Indeterminate Renal Mass Ho et al [51] showed that the optimal percentage of enhancement threshold for distinguishing cysts from solid tumors on MRI was 15%. Hecht et al [52] reported that both quantitative and qualitative methods are sensitive in the detection of enhancement in a renal lesion on MRI and that subtracted images enables accurate assessment of tumor enhancement for intrinsically hyperintense lesions using qualitative methods. Although MRI without and with IV contrast is optimal for renal lesion characterization, MRI without IV contrast can also provide diagnostic information. For example, simple cystic lesions or even those with thin septations can often be characterized on noncontrast T2-weighted imaging based on their homogeneous and very high T2 signal intensity. | 69367 |
acrac_69367_12 | Indeterminate Renal Mass | To differentiate between hemorrhagic or proteinaceous cysts and RCC, a retrospective study shows that homogenous high T1 signal intensity lesions with smooth borders and lesion to renal parenchyma signal intensity ratio of >1.6 predicted the lesion as a benign cyst [53]. Another study of 144 T1-hyperintense lesions demonstrated that diffuse and marked T1 hyperintensity achieved accuracies of 73.6% to 79.9% for the diagnosis of T1- hyperintense cysts [54]. An angular interface with the renal parenchyma on T2-weighted imaging has been shown to be 78% sensitive and 100% specific for differentiating benign exophytic renal masses from malignant masses [55]. Diffusion-weighted imaging, although less accurate than contrast-enhanced MRI, may have some ability to differentiate solid RCC from oncocytomas and characterize the histologic subtypes of RCC [56]. New and specialized MRI sequences have been proposed for the purposes of characterizing the vascularity of renal lesions in patients with renal dysfunction. For example, one small study of 17 renal lesions used arterial spin labeling to detect blood flow in renal masses, which correlated with malignancy [57]. Cystic Renal Masses In a patient who cannot receive iodinated contrast, MRI without and with IV contrast is a good alternative. MRI may depict findings like an increase in number of septa, septal or wall thickness, and enhancement; these may result in MRI upgrading cystic lesions and thus might alter patient management [29]. Another study of 33 cystic lesions imaged with both 1.5T and 3.0T MRI showed that there is a greater tendency to upgrade cyst complexity and Bosniak cyst category at 3.0T than at 1.5T and thus suggested that serial follow-up of cystic renal lesions be performed at constant field strength [58]. MRU There is no relevant literature regarding the use of MRU in the evaluation of indeterminate renal masses. Indeterminate Renal Mass | Indeterminate Renal Mass. To differentiate between hemorrhagic or proteinaceous cysts and RCC, a retrospective study shows that homogenous high T1 signal intensity lesions with smooth borders and lesion to renal parenchyma signal intensity ratio of >1.6 predicted the lesion as a benign cyst [53]. Another study of 144 T1-hyperintense lesions demonstrated that diffuse and marked T1 hyperintensity achieved accuracies of 73.6% to 79.9% for the diagnosis of T1- hyperintense cysts [54]. An angular interface with the renal parenchyma on T2-weighted imaging has been shown to be 78% sensitive and 100% specific for differentiating benign exophytic renal masses from malignant masses [55]. Diffusion-weighted imaging, although less accurate than contrast-enhanced MRI, may have some ability to differentiate solid RCC from oncocytomas and characterize the histologic subtypes of RCC [56]. New and specialized MRI sequences have been proposed for the purposes of characterizing the vascularity of renal lesions in patients with renal dysfunction. For example, one small study of 17 renal lesions used arterial spin labeling to detect blood flow in renal masses, which correlated with malignancy [57]. Cystic Renal Masses In a patient who cannot receive iodinated contrast, MRI without and with IV contrast is a good alternative. MRI may depict findings like an increase in number of septa, septal or wall thickness, and enhancement; these may result in MRI upgrading cystic lesions and thus might alter patient management [29]. Another study of 33 cystic lesions imaged with both 1.5T and 3.0T MRI showed that there is a greater tendency to upgrade cyst complexity and Bosniak cyst category at 3.0T than at 1.5T and thus suggested that serial follow-up of cystic renal lesions be performed at constant field strength [58]. MRU There is no relevant literature regarding the use of MRU in the evaluation of indeterminate renal masses. Indeterminate Renal Mass | 69367 |
acrac_69367_13 | Indeterminate Renal Mass | Radiography Intravenous Urography There is no relevant literature regarding the use of IVU for the evaluation of indeterminate renal masses. US Abdomen with IV Contrast CEUS using microbubble agents is emerging as a useful way to characterize previously indeterminate renal lesions [16-18]. In one study of 1,018 indeterminate renal lesions, CEUS had a per patient sensitivity of 100% (126 of 126 patients), specificity of 95% (132 of 139 patients), positive predictive value of 94.7% (126 of 133 patients), and negative predictive value of 100% (132 of 132 patients) for classifying benign versus malignant renal masses [16]. In that study, any echogenic masses with enhancement at least of normal renal cortex and wash-out, as well as any masses with blood flow, were considered malignant. In another study, CEUS successfully classified 95.7% (90 of 94) previously indeterminate lesions, and had an accuracy of 90.2% (37 of 41 lesions) when compared with the reference standard, including histopathology and follow-up [18]. In the subgroup analysis, CEUS was definitive for 94.4% (17 of 18) of cases referred because of equivocal enhancement at CT [18]. In that same study, CEUS was able to classify lesions in 100% (10 of 10) of the cases in which the lesions were indeterminate on prior MRI [18]. Another study of CEUS in 83 CT indeterminate renal masses reported that the accuracy of characterization by CEUS was 95.2% compared with 42.2% using unenhanced US [17]. In a prospective CEUS study of 94 solid renal lesions, excluding lipid-rich AML, hypovascularity of small solid renal masses relative to the cortex in the arterial phase has 100% specificity for detecting malignancy, especially for detecting papillary RCC [66]. Quantitative analysis of CEUS has also been reported to be useful to stratify RCC and benign renal tumors [67,68]. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. | Indeterminate Renal Mass. Radiography Intravenous Urography There is no relevant literature regarding the use of IVU for the evaluation of indeterminate renal masses. US Abdomen with IV Contrast CEUS using microbubble agents is emerging as a useful way to characterize previously indeterminate renal lesions [16-18]. In one study of 1,018 indeterminate renal lesions, CEUS had a per patient sensitivity of 100% (126 of 126 patients), specificity of 95% (132 of 139 patients), positive predictive value of 94.7% (126 of 133 patients), and negative predictive value of 100% (132 of 132 patients) for classifying benign versus malignant renal masses [16]. In that study, any echogenic masses with enhancement at least of normal renal cortex and wash-out, as well as any masses with blood flow, were considered malignant. In another study, CEUS successfully classified 95.7% (90 of 94) previously indeterminate lesions, and had an accuracy of 90.2% (37 of 41 lesions) when compared with the reference standard, including histopathology and follow-up [18]. In the subgroup analysis, CEUS was definitive for 94.4% (17 of 18) of cases referred because of equivocal enhancement at CT [18]. In that same study, CEUS was able to classify lesions in 100% (10 of 10) of the cases in which the lesions were indeterminate on prior MRI [18]. Another study of CEUS in 83 CT indeterminate renal masses reported that the accuracy of characterization by CEUS was 95.2% compared with 42.2% using unenhanced US [17]. In a prospective CEUS study of 94 solid renal lesions, excluding lipid-rich AML, hypovascularity of small solid renal masses relative to the cortex in the arterial phase has 100% specificity for detecting malignancy, especially for detecting papillary RCC [66]. Quantitative analysis of CEUS has also been reported to be useful to stratify RCC and benign renal tumors [67,68]. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. | 69367 |
acrac_69427_0 | Chronic Hand and Wrist Pain | OR aUniversity of Missouri Health Care, Columbia, Missouri. bPanel Chair, Mayo Clinic Arizona, Phoenix, Arizona. cPanel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia. dUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. eMayo Clinic, Rochester, Minnesota. fHospital for Special Surgery, New York, New York. gThe 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. hDuke University Medical Center, Durham, North Carolina. iUniversity of Missouri School of Medicine, Columbia, Missouri, Primary care physician. jCleveland Clinic, Cleveland, Ohio. kPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. lThe Ohio State University Wexner Medical Center, Columbus, Ohio; Commission on Nuclear Medicine and Molecular Imaging. mSpecialty Chair, VA San Diego Healthcare System, San Diego, California. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Hand and Wrist Pain Discussion of Procedures by Variant Variant 1: Adult. Chronic hand or wrist pain. Initial imaging. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan as the first imaging study in the evaluation of chronic hand or wrist pain. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. | Chronic Hand and Wrist Pain. OR aUniversity of Missouri Health Care, Columbia, Missouri. bPanel Chair, Mayo Clinic Arizona, Phoenix, Arizona. cPanel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia. dUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. eMayo Clinic, Rochester, Minnesota. fHospital for Special Surgery, New York, New York. gThe 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. hDuke University Medical Center, Durham, North Carolina. iUniversity of Missouri School of Medicine, Columbia, Missouri, Primary care physician. jCleveland Clinic, Cleveland, Ohio. kPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. lThe Ohio State University Wexner Medical Center, Columbus, Ohio; Commission on Nuclear Medicine and Molecular Imaging. mSpecialty Chair, VA San Diego Healthcare System, San Diego, California. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Hand and Wrist Pain Discussion of Procedures by Variant Variant 1: Adult. Chronic hand or wrist pain. Initial imaging. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan as the first imaging study in the evaluation of chronic hand or wrist pain. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. | 69427 |
acrac_69427_1 | Chronic Hand and Wrist Pain | CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography as the first imaging study in the evaluation of chronic hand or wrist pain. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography as the first imaging study in the evaluation of chronic hand or wrist pain. MRI Area of Interest Without and With IV Contrast There is no relevant literature to support the use of MRI without and with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. MRI Area of Interest Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of radiographic arthrography contrast as the first imaging study in the evaluation of chronic hand or wrist pain. Radiography Area of Interest The imaging evaluation of chronic hand or wrist pain should begin with radiographs [6-12]. In many cases, radiographs may be the only imaging examination needed to establish a diagnosis or confirm a clinically expected diagnosis. The standard radiographic evaluation of both the hand and wrist includes 3 views: posteroanterior, lateral, and oblique [9]. The standard projections allow assessment of alignment including ulnar variance, joint spaces, impaction syndromes, static instability, chronic healed and nonunited fractures, soft tissue mineralization, erosions, and soft tissue swelling. | Chronic Hand and Wrist Pain. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography as the first imaging study in the evaluation of chronic hand or wrist pain. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography as the first imaging study in the evaluation of chronic hand or wrist pain. MRI Area of Interest Without and With IV Contrast There is no relevant literature to support the use of MRI without and with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. MRI Area of Interest Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of radiographic arthrography contrast as the first imaging study in the evaluation of chronic hand or wrist pain. Radiography Area of Interest The imaging evaluation of chronic hand or wrist pain should begin with radiographs [6-12]. In many cases, radiographs may be the only imaging examination needed to establish a diagnosis or confirm a clinically expected diagnosis. The standard radiographic evaluation of both the hand and wrist includes 3 views: posteroanterior, lateral, and oblique [9]. The standard projections allow assessment of alignment including ulnar variance, joint spaces, impaction syndromes, static instability, chronic healed and nonunited fractures, soft tissue mineralization, erosions, and soft tissue swelling. | 69427 |
acrac_69427_2 | Chronic Hand and Wrist Pain | US Area of Interest Given the superficial location of the joints, ligaments, muscles, tendons, and nerves of the hand and wrists, US is a useful tool in the assessment of chronic hand and wrist pain bolstered by the ability to readily perform and dynamic examination and evaluate the contralateral side [9,13]. US is optimally performed using high-frequency (10-15 MHz) linear transducers [11,13]. US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, pulley injury, carpal tunnel syndrome (CTS), and retained foreign body [6,13-16]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the wrist, metacarpophalangeal, and interphalangeal joints; US is reasonable to evaluate tendon and soft tissue pathology of the hand and wrist and to assess for entrapment of the median or ulnar nerves [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan in 76% of all patients and 67% of patient who presented without a history Chronic Hand and Wrist Pain of trauma [17]. Although there are many advantages to US evaluation for chronic hand and wrist pain, an interdisciplinary group of hand surgeons and radiologists recommended against the inclusion of US in the standard evaluation of scapholunate instability [18]. Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study. This variant is a guide on appropriate imaging use early in the assessment of chronic wrist pain, when standard radiographic projections are normal or show nonspecific arthritis. | Chronic Hand and Wrist Pain. US Area of Interest Given the superficial location of the joints, ligaments, muscles, tendons, and nerves of the hand and wrists, US is a useful tool in the assessment of chronic hand and wrist pain bolstered by the ability to readily perform and dynamic examination and evaluate the contralateral side [9,13]. US is optimally performed using high-frequency (10-15 MHz) linear transducers [11,13]. US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, pulley injury, carpal tunnel syndrome (CTS), and retained foreign body [6,13-16]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the wrist, metacarpophalangeal, and interphalangeal joints; US is reasonable to evaluate tendon and soft tissue pathology of the hand and wrist and to assess for entrapment of the median or ulnar nerves [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan in 76% of all patients and 67% of patient who presented without a history Chronic Hand and Wrist Pain of trauma [17]. Although there are many advantages to US evaluation for chronic hand and wrist pain, an interdisciplinary group of hand surgeons and radiologists recommended against the inclusion of US in the standard evaluation of scapholunate instability [18]. Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study. This variant is a guide on appropriate imaging use early in the assessment of chronic wrist pain, when standard radiographic projections are normal or show nonspecific arthritis. | 69427 |
acrac_69427_3 | Chronic Hand and Wrist Pain | For purposes of this variant, a nonspecific arthritis is defined as articular changes at a single joint and/or a pattern of arthritis throughout the hand and wrist that, when combined with the appropriate clinical history, does not allow distinction between degenerative or post-traumatic osteoarthritis, inflammatory arthritis, and crystalline arthritis. Bone Scan Wrist There is no relevant literature discussing routine use of bone scan in the assessment of nonspecific chronic wrist pain. Bone scans offer the ability to differentiate metabolically active abnormalities, which may be the cause of pain, from those that are inactive [19]. Bone scans can reliably detect chronic or occult scaphoid fracture with a sensitivity and specificity of 97% and 89%, respectively [20]. Although bone scans are sensitive for the detection of bone abnormalities, the findings may be nonspecific [19]. There are established imaging patterns for fracture, osteonecrosis, nonunited fracture, arthritis, and complex regional pain syndrome [19]. Bone scan of the wrist offers improved specificity when single-photon emission CT is performed [19]. CT Arthrography Wrist Performing arthrography before a CT scan of the wrist aids in the detection of ligament injuries and cartilage abnormalities. CT arthrography allows direct visualization of full thickness ligament tears and visualization of partial thickness tears of the appropriate compartment [6,21]. An interdisciplinary group of hand surgeons and radiologists supports the use of CT arthrography for the assessment of clinically suspected scapholunate instability and cartilage defects [18]. CT arthrography has demonstrated a sensitivity, specificity, and accuracy between 92% and 94% for triangular fibrocartilage (TFC) complex tears, between 80% and 100% for intrinsic ligament tears located within the proximal carpal compartment, and between 94% and 100% for articular cartilage abnormalities [22]. | Chronic Hand and Wrist Pain. For purposes of this variant, a nonspecific arthritis is defined as articular changes at a single joint and/or a pattern of arthritis throughout the hand and wrist that, when combined with the appropriate clinical history, does not allow distinction between degenerative or post-traumatic osteoarthritis, inflammatory arthritis, and crystalline arthritis. Bone Scan Wrist There is no relevant literature discussing routine use of bone scan in the assessment of nonspecific chronic wrist pain. Bone scans offer the ability to differentiate metabolically active abnormalities, which may be the cause of pain, from those that are inactive [19]. Bone scans can reliably detect chronic or occult scaphoid fracture with a sensitivity and specificity of 97% and 89%, respectively [20]. Although bone scans are sensitive for the detection of bone abnormalities, the findings may be nonspecific [19]. There are established imaging patterns for fracture, osteonecrosis, nonunited fracture, arthritis, and complex regional pain syndrome [19]. Bone scan of the wrist offers improved specificity when single-photon emission CT is performed [19]. CT Arthrography Wrist Performing arthrography before a CT scan of the wrist aids in the detection of ligament injuries and cartilage abnormalities. CT arthrography allows direct visualization of full thickness ligament tears and visualization of partial thickness tears of the appropriate compartment [6,21]. An interdisciplinary group of hand surgeons and radiologists supports the use of CT arthrography for the assessment of clinically suspected scapholunate instability and cartilage defects [18]. CT arthrography has demonstrated a sensitivity, specificity, and accuracy between 92% and 94% for triangular fibrocartilage (TFC) complex tears, between 80% and 100% for intrinsic ligament tears located within the proximal carpal compartment, and between 94% and 100% for articular cartilage abnormalities [22]. | 69427 |
acrac_69427_4 | Chronic Hand and Wrist Pain | In a study assessing the diagnostic performance of CT arthrography in cadavers, CT arthrography was more sensitive for the diagnosis of scapholunate and lunotriquetral tears when compared with MRI at 1.5T and performed particularly well in assessment of the dorsal segment of the scapholunate ligament [23]. CT Wrist With IV Contrast There is no relevant literature to support the use of CT wrist with IV contrast in the setting of chronic wrist pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Wrist Without and With IV Contrast There is no relevant literature to support the use of CT wrist without and with IV contrast in the setting of chronic wrist pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Wrist Without IV Contrast CT of the wrist provides a detailed assessment of the cortical and trabecular bone with a high spatial resolution. CT is the ideal modality to assess fracture healing, malunion, and articular surface incongruity [6,24]. CT is particularly useful in assessment of the DRUJ. When there is clinical concern for DRUJ instability, CT can be used to image the symptomatic and contralateral wrist simultaneously in the neutral, supinated, and pronated positions to assess for instability [24-26]. CT without IV contrast has been shown to be beneficial in operative planning for scaphoid fracture [27,28]. A disadvantage of CT compared with both MRI and US is its decreased contrast resolution and lower sensitivity in the detection of soft tissue abnormalities. MR Arthrography Wrist Direct MR arthrography is performed following the intra-articular injection of gadolinium and improves the detection and interobserver agreement for abnormalities of the wrist. MR arthrography is a minimally invasive imaging examination that may be appropriate for cases of suspected intrinsic ligament injury, TFC complex injury, cartilage abnormality, or surgical planning. | Chronic Hand and Wrist Pain. In a study assessing the diagnostic performance of CT arthrography in cadavers, CT arthrography was more sensitive for the diagnosis of scapholunate and lunotriquetral tears when compared with MRI at 1.5T and performed particularly well in assessment of the dorsal segment of the scapholunate ligament [23]. CT Wrist With IV Contrast There is no relevant literature to support the use of CT wrist with IV contrast in the setting of chronic wrist pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Wrist Without and With IV Contrast There is no relevant literature to support the use of CT wrist without and with IV contrast in the setting of chronic wrist pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Wrist Without IV Contrast CT of the wrist provides a detailed assessment of the cortical and trabecular bone with a high spatial resolution. CT is the ideal modality to assess fracture healing, malunion, and articular surface incongruity [6,24]. CT is particularly useful in assessment of the DRUJ. When there is clinical concern for DRUJ instability, CT can be used to image the symptomatic and contralateral wrist simultaneously in the neutral, supinated, and pronated positions to assess for instability [24-26]. CT without IV contrast has been shown to be beneficial in operative planning for scaphoid fracture [27,28]. A disadvantage of CT compared with both MRI and US is its decreased contrast resolution and lower sensitivity in the detection of soft tissue abnormalities. MR Arthrography Wrist Direct MR arthrography is performed following the intra-articular injection of gadolinium and improves the detection and interobserver agreement for abnormalities of the wrist. MR arthrography is a minimally invasive imaging examination that may be appropriate for cases of suspected intrinsic ligament injury, TFC complex injury, cartilage abnormality, or surgical planning. | 69427 |
acrac_69427_5 | Chronic Hand and Wrist Pain | Injection of any combination of the 3 compartments (DRUJ, radiocarpal, midcarpal) can be performed depending on the clinical question [13]. If the injection is performed with fluoroscopy, Chronic Hand and Wrist Pain comparison of the MR images with the fluoroscopic images is an essential step in image interpretation [13]. In most cases, a radiocarpal injection is performed; however, if there is concern for an ulnar sided detachment of the TFC, an additional DRUJ injection should be considered [7]. With single, radiocarpal injection, the sensitivity for TFC tears, intrinsic ligament injury, and cartilage lesions of the radiocarpal joint ranged from 63% to 100%, with specificity ranging from 89% to 97% [29]. MRI Wrist Without and With IV Contrast There is no relevant literature discussing the routine use of MRI wrist without and with IV contrast for the evaluation of chronic wrist pain and normal or nonspecific radiographs. The addition of postcontrast imaging to wrist MRI aids in distinguishing synovitis from joint effusion and ganglion cysts [9,35]. Similarly, postcontrast MRI aids in the detection of tenosynovitis [35]. For these reasons, MRI without and with IV contrast is usually appropriate in the evaluation of chronic joint pain with clinical suspicion of rheumatoid arthritis or seronegative spondyloarthropathy [2] and in cases of suspected septic arthritis or soft tissue infection [3]. MRI Wrist Without IV Contrast MRI without IV contrast is useful in the assessment of wrist pain. MRI is useful in assessing abnormalities of the bones, including bone marrow, and soft tissues, including the ligaments, TFC, tendons, and nerves. When using arthroscopy as the reference standard, the sensitivity and specificity of 3.0T MRI in the evaluation of scapholunate tear range from 70% to 87% and 90% to 97%, respectively, for lunotriquetral tear range from 50% to 63% and 94% to 97% respectively, and for TFC tear range from 63% to 100% and 42% to 100%, respectively [32,36-40]. | Chronic Hand and Wrist Pain. Injection of any combination of the 3 compartments (DRUJ, radiocarpal, midcarpal) can be performed depending on the clinical question [13]. If the injection is performed with fluoroscopy, Chronic Hand and Wrist Pain comparison of the MR images with the fluoroscopic images is an essential step in image interpretation [13]. In most cases, a radiocarpal injection is performed; however, if there is concern for an ulnar sided detachment of the TFC, an additional DRUJ injection should be considered [7]. With single, radiocarpal injection, the sensitivity for TFC tears, intrinsic ligament injury, and cartilage lesions of the radiocarpal joint ranged from 63% to 100%, with specificity ranging from 89% to 97% [29]. MRI Wrist Without and With IV Contrast There is no relevant literature discussing the routine use of MRI wrist without and with IV contrast for the evaluation of chronic wrist pain and normal or nonspecific radiographs. The addition of postcontrast imaging to wrist MRI aids in distinguishing synovitis from joint effusion and ganglion cysts [9,35]. Similarly, postcontrast MRI aids in the detection of tenosynovitis [35]. For these reasons, MRI without and with IV contrast is usually appropriate in the evaluation of chronic joint pain with clinical suspicion of rheumatoid arthritis or seronegative spondyloarthropathy [2] and in cases of suspected septic arthritis or soft tissue infection [3]. MRI Wrist Without IV Contrast MRI without IV contrast is useful in the assessment of wrist pain. MRI is useful in assessing abnormalities of the bones, including bone marrow, and soft tissues, including the ligaments, TFC, tendons, and nerves. When using arthroscopy as the reference standard, the sensitivity and specificity of 3.0T MRI in the evaluation of scapholunate tear range from 70% to 87% and 90% to 97%, respectively, for lunotriquetral tear range from 50% to 63% and 94% to 97% respectively, and for TFC tear range from 63% to 100% and 42% to 100%, respectively [32,36-40]. | 69427 |
acrac_69427_6 | Chronic Hand and Wrist Pain | A study of 18 patients demonstrated good correlation between cartilage lesions at 3.0T MRI and arthroscopy [37]. If a study is specifically performed to assess the intrinsic ligaments or TFC, MR arthrography has been demonstrated to be superior to MRI without IV contrast [30-32,41]. MRI is helpful in the diagnosis of tendon abnormalities including tendinopathy, tenosynovitis, and intersection syndromes [12,13,42,43]. In a retrospective review of 316 consecutive patients referred to a hand surgeon with MRI of the hand or wrist, MRI changed clinical management in 69.5% of cases [44]. MRI was particularly useful in reassuring patients that no further follow-up was necessary in 70% of cases [44]. Radiographic Arthrography Wrist There is no relevant literature to support the use of radiographic arthrography of the wrist in the setting of chronic wrist pain and normal or nonspecific radiographs. Although a meta-analysis has demonstrated a pooled sensitivity of 76.2% and a specificity of 92.5% for the detection of complete TFC complex tear, radiographic arthrography is not routinely performed in isolation [45]. In current practice it is infrequently performed as a standalone imaging examination; rather, it is typically performed in conjunction with CT or MR arthrography. Radiography Wrist Additional Views A variety of additional radiographic projections of the wrist may be obtained to supplement the standard 3-view series depending on the specific clinical indication. However, there is no recent literature to support obtaining additional views in the setting of chronic wrist pain and normal or nonspecific radiographs. An interdisciplinary group of hand surgeons and radiologists consensus statements concluded stress views are indicated for the diagnosis of scapholunate instability [18]. | Chronic Hand and Wrist Pain. A study of 18 patients demonstrated good correlation between cartilage lesions at 3.0T MRI and arthroscopy [37]. If a study is specifically performed to assess the intrinsic ligaments or TFC, MR arthrography has been demonstrated to be superior to MRI without IV contrast [30-32,41]. MRI is helpful in the diagnosis of tendon abnormalities including tendinopathy, tenosynovitis, and intersection syndromes [12,13,42,43]. In a retrospective review of 316 consecutive patients referred to a hand surgeon with MRI of the hand or wrist, MRI changed clinical management in 69.5% of cases [44]. MRI was particularly useful in reassuring patients that no further follow-up was necessary in 70% of cases [44]. Radiographic Arthrography Wrist There is no relevant literature to support the use of radiographic arthrography of the wrist in the setting of chronic wrist pain and normal or nonspecific radiographs. Although a meta-analysis has demonstrated a pooled sensitivity of 76.2% and a specificity of 92.5% for the detection of complete TFC complex tear, radiographic arthrography is not routinely performed in isolation [45]. In current practice it is infrequently performed as a standalone imaging examination; rather, it is typically performed in conjunction with CT or MR arthrography. Radiography Wrist Additional Views A variety of additional radiographic projections of the wrist may be obtained to supplement the standard 3-view series depending on the specific clinical indication. However, there is no recent literature to support obtaining additional views in the setting of chronic wrist pain and normal or nonspecific radiographs. An interdisciplinary group of hand surgeons and radiologists consensus statements concluded stress views are indicated for the diagnosis of scapholunate instability [18]. | 69427 |
acrac_69427_7 | Chronic Hand and Wrist Pain | US Wrist US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, CTS, metacarpophalangeal joint collateral ligament injury, extensor hood injury, and retained foreign body [6,13,14,16,46]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the wrist; US is reasonable to evaluate tendon and soft tissue pathology of the wrist and to assess for entrapment of the median or ulnar nerves [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan, in 76% of all patients and 67% of patients who presented without a history of trauma Chronic Hand and Wrist Pain [17]. Although there are many advantages to US evaluation for chronic hand and wrist pain, an interdisciplinary group of hand surgeons and radiologists recommended against the inclusion of US in the standard evaluation of scapholunate instability [18]. Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study. Bone Scan Hand There is no relevant literature to support the use of bone scan in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Arthrography Hand There is no relevant literature to support the use of CT arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Hand With IV Contrast There is no relevant literature to support the use of CT hand with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. | Chronic Hand and Wrist Pain. US Wrist US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, CTS, metacarpophalangeal joint collateral ligament injury, extensor hood injury, and retained foreign body [6,13,14,16,46]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the wrist; US is reasonable to evaluate tendon and soft tissue pathology of the wrist and to assess for entrapment of the median or ulnar nerves [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan, in 76% of all patients and 67% of patients who presented without a history of trauma Chronic Hand and Wrist Pain [17]. Although there are many advantages to US evaluation for chronic hand and wrist pain, an interdisciplinary group of hand surgeons and radiologists recommended against the inclusion of US in the standard evaluation of scapholunate instability [18]. Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study. Bone Scan Hand There is no relevant literature to support the use of bone scan in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Arthrography Hand There is no relevant literature to support the use of CT arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Hand With IV Contrast There is no relevant literature to support the use of CT hand with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. | 69427 |
acrac_69427_8 | Chronic Hand and Wrist Pain | CT Hand Without and With IV Contrast There is no relevant literature to support the use of CT hand with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Hand Without IV Contrast There is no relevant literature to support the use of CT hand without IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. MR Arthrography Hand There is no relevant literature to support the use of MR arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. MRI Hand Without and With IV Contrast There is no relevant literature discussing routine use of MRI hand without and with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. In the research setting, contrast-enhanced MRI can identify synovitis, periarticular bone marrow edema, and tenosynovitis, which correlates with patient pain in the setting of hand osteoarthritis [47,48]. MRI Hand Without IV Contrast MRI hand without IV contrast is of limited benefit in the setting of nonspecific pain. A study evaluating hand MRI in the setting of erosive osteoarthritis showed no difference in the assessment of joint space narrowing, bone erosion, and malalignment compared with radiographs [49]. MRI can demonstrate many abnormalities that result in chronic pain including arthritis, carpal boss, tendinopathy, tenosynovitis, pulley injury, extensor hood injury, sagittal band injury, volar plate injury, chondral injury, and ligament injury [13,50-54]. In a retrospective review of 316 consecutive patients referred to a hand surgeon with MRI of the hand or wrist, MRI changed clinical management in 69.5% of cases [44]. MRI was particularly useful in reassuring patients that no further follow-up was necessary in 70% of cases [44]. | Chronic Hand and Wrist Pain. CT Hand Without and With IV Contrast There is no relevant literature to support the use of CT hand with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. CT Hand Without IV Contrast There is no relevant literature to support the use of CT hand without IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. MR Arthrography Hand There is no relevant literature to support the use of MR arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. MRI Hand Without and With IV Contrast There is no relevant literature discussing routine use of MRI hand without and with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. In the research setting, contrast-enhanced MRI can identify synovitis, periarticular bone marrow edema, and tenosynovitis, which correlates with patient pain in the setting of hand osteoarthritis [47,48]. MRI Hand Without IV Contrast MRI hand without IV contrast is of limited benefit in the setting of nonspecific pain. A study evaluating hand MRI in the setting of erosive osteoarthritis showed no difference in the assessment of joint space narrowing, bone erosion, and malalignment compared with radiographs [49]. MRI can demonstrate many abnormalities that result in chronic pain including arthritis, carpal boss, tendinopathy, tenosynovitis, pulley injury, extensor hood injury, sagittal band injury, volar plate injury, chondral injury, and ligament injury [13,50-54]. In a retrospective review of 316 consecutive patients referred to a hand surgeon with MRI of the hand or wrist, MRI changed clinical management in 69.5% of cases [44]. MRI was particularly useful in reassuring patients that no further follow-up was necessary in 70% of cases [44]. | 69427 |
acrac_69427_9 | Chronic Hand and Wrist Pain | Radiographic Arthrography Hand There is no relevant literature to support the use of radiographic arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. US Hand US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, pulley injury, CTS, and retained foreign body [6,13-16]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the metacarpophalangeal and interphalangeal joints, and US is reasonable to evaluate tendon and soft tissue pathology of the hand [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan, in 76% of all patients and 67% of patient who presented without a history of trauma [17]. Chronic Hand and Wrist Pain Variant 4: Adult. Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next imaging study. Bone Scan Wrist There is no relevant literature to support the use of bone scan in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. CT Arthrography Wrist There is no relevant literature to support the use of CT arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, or osteonecrosis. If the specific clinical concern requires assessment of the articular cartilage in post-traumatic osteoarthritis, the spatial resolution of CT when combined with intra-articular contrast makes CT arthrography an ideal study. | Chronic Hand and Wrist Pain. Radiographic Arthrography Hand There is no relevant literature to support the use of radiographic arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. US Hand US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, pulley injury, CTS, and retained foreign body [6,13-16]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the metacarpophalangeal and interphalangeal joints, and US is reasonable to evaluate tendon and soft tissue pathology of the hand [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan, in 76% of all patients and 67% of patient who presented without a history of trauma [17]. Chronic Hand and Wrist Pain Variant 4: Adult. Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next imaging study. Bone Scan Wrist There is no relevant literature to support the use of bone scan in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. CT Arthrography Wrist There is no relevant literature to support the use of CT arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, or osteonecrosis. If the specific clinical concern requires assessment of the articular cartilage in post-traumatic osteoarthritis, the spatial resolution of CT when combined with intra-articular contrast makes CT arthrography an ideal study. | 69427 |
acrac_69427_10 | Chronic Hand and Wrist Pain | CT arthrography has demonstrated a sensitivity, specificity, and accuracy between 94% and 100% for articular cartilage injury [22]. CT Wrist With IV Contrast CT wrist with IV contrast is not routinely performed in clinical practice, although there is an isolated report of dual- energy CT with IV contrast used to assess scaphoid osteonecrosis. In addition to the benefits afforded by the high spatial resolution of CT in the assessment of scaphoid fracture, the addition of contrast has been shown to be beneficial in the determination of proximal pole viability. A study of 19 wrists in 18 patients with dual-energy contrast-enhanced CT showed promising results in the assessment of proximal pole osteonecrosis in the setting of scaphoid fracture [55]. When compared with intraoperative assessment or histologic analysis, in a series of 18 patients who underwent dual-energy contrast-enhanced CT of the wrist there was a sensitivity of 100% and a specificity of 94% for the assessment of osteonecrosis of the proximal pole of the scaphoid following fracture [55]. CT Wrist Without and With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. CT Wrist Without IV Contrast The spatial resolution obtained with CT makes it well suited to assess for any trabecular bridging at the fracture site, nonunion, malunion, and the sclerosis and fragmentation of avascular necrosis. The isotropic acquisition and the ability to create 3-D models assists in surgical planning [27,28]. MR Arthrography Wrist There is no relevant literature to support the use of MR arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, or osteonecrosis. | Chronic Hand and Wrist Pain. CT arthrography has demonstrated a sensitivity, specificity, and accuracy between 94% and 100% for articular cartilage injury [22]. CT Wrist With IV Contrast CT wrist with IV contrast is not routinely performed in clinical practice, although there is an isolated report of dual- energy CT with IV contrast used to assess scaphoid osteonecrosis. In addition to the benefits afforded by the high spatial resolution of CT in the assessment of scaphoid fracture, the addition of contrast has been shown to be beneficial in the determination of proximal pole viability. A study of 19 wrists in 18 patients with dual-energy contrast-enhanced CT showed promising results in the assessment of proximal pole osteonecrosis in the setting of scaphoid fracture [55]. When compared with intraoperative assessment or histologic analysis, in a series of 18 patients who underwent dual-energy contrast-enhanced CT of the wrist there was a sensitivity of 100% and a specificity of 94% for the assessment of osteonecrosis of the proximal pole of the scaphoid following fracture [55]. CT Wrist Without and With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. CT Wrist Without IV Contrast The spatial resolution obtained with CT makes it well suited to assess for any trabecular bridging at the fracture site, nonunion, malunion, and the sclerosis and fragmentation of avascular necrosis. The isotropic acquisition and the ability to create 3-D models assists in surgical planning [27,28]. MR Arthrography Wrist There is no relevant literature to support the use of MR arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, or osteonecrosis. | 69427 |
acrac_69427_11 | Chronic Hand and Wrist Pain | If the specific clinical concern requires assessment of the articular cartilage in post-traumatic osteoarthritis, the addition of arthrography to MRI improves the assessment of the articular cartilage [31]. However, CT arthrography has a higher sensitivity and specificity for articular cartilage defect compared with MR arthrography [31,56]. MRI Wrist Without and With IV Contrast MRI wrist without and with IV contrast can demonstrate both nonunited and malunited scaphoid fractures. Although 3.0T MRI without IV contrast falls behind MR and CT arthrography in the assessment of the articular cartilage, it has demonstrated a modest sensitivity of 48% to 52% and a good specificity of 82% compared with visual inspection in a cadaver study [57]. The added benefit of MRI comes in the assessment for osteonecrosis in the proximal pole scaphoid following scaphoid fracture. Whether contrast-enhanced MRI is superior to noncontrast MRI for assessment of scaphoid osteonecrosis is controversial. In a study comparing the addition of postcontrast images with the unenhanced MRI in 30 patients, the addition of contrast increased the sensitivity (66% versus 36%), specificity (88% versus 78%), and accuracy (83% versus 68%) when compared with the noncontrast images alone [58]. MRI Wrist Without IV Contrast MRI wrist without IV contrast can demonstrate both nonunited and malunited scaphoid fractures. Although 3.0T MRI without IV contrast falls behind MR and CT arthrography in the assessment of the articular cartilage, it has demonstrated a modest sensitivity of 48% to 52% and a good specificity of 82% compared with visual inspection in a cadaver study [57]. The added benefit of MRI comes in the assessment for osteonecrosis in the proximal pole scaphoid following scaphoid fracture. Whether contrast-enhanced MRI is superior to noncontrast MRI for assessment of scaphoid osteonecrosis is controversial. A study of noncontrast MRI in 29 patients with scaphoid Chronic Hand and Wrist Pain | Chronic Hand and Wrist Pain. If the specific clinical concern requires assessment of the articular cartilage in post-traumatic osteoarthritis, the addition of arthrography to MRI improves the assessment of the articular cartilage [31]. However, CT arthrography has a higher sensitivity and specificity for articular cartilage defect compared with MR arthrography [31,56]. MRI Wrist Without and With IV Contrast MRI wrist without and with IV contrast can demonstrate both nonunited and malunited scaphoid fractures. Although 3.0T MRI without IV contrast falls behind MR and CT arthrography in the assessment of the articular cartilage, it has demonstrated a modest sensitivity of 48% to 52% and a good specificity of 82% compared with visual inspection in a cadaver study [57]. The added benefit of MRI comes in the assessment for osteonecrosis in the proximal pole scaphoid following scaphoid fracture. Whether contrast-enhanced MRI is superior to noncontrast MRI for assessment of scaphoid osteonecrosis is controversial. In a study comparing the addition of postcontrast images with the unenhanced MRI in 30 patients, the addition of contrast increased the sensitivity (66% versus 36%), specificity (88% versus 78%), and accuracy (83% versus 68%) when compared with the noncontrast images alone [58]. MRI Wrist Without IV Contrast MRI wrist without IV contrast can demonstrate both nonunited and malunited scaphoid fractures. Although 3.0T MRI without IV contrast falls behind MR and CT arthrography in the assessment of the articular cartilage, it has demonstrated a modest sensitivity of 48% to 52% and a good specificity of 82% compared with visual inspection in a cadaver study [57]. The added benefit of MRI comes in the assessment for osteonecrosis in the proximal pole scaphoid following scaphoid fracture. Whether contrast-enhanced MRI is superior to noncontrast MRI for assessment of scaphoid osteonecrosis is controversial. A study of noncontrast MRI in 29 patients with scaphoid Chronic Hand and Wrist Pain | 69427 |
acrac_69427_12 | Chronic Hand and Wrist Pain | nonunion demonstrated a sensitivity of 55%, a specificity of 94%, and an accuracy of 79% for the diagnosis of osteonecrosis compared with intraoperative assessment [59]. Radiographic Arthrography Wrist There is no relevant literature to support the use of radiographic arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. US Wrist There is no relevant literature to support the use of US in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan in the setting of chronic hand and wrist pain with clinical concern for CTS. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS. CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS. | Chronic Hand and Wrist Pain. nonunion demonstrated a sensitivity of 55%, a specificity of 94%, and an accuracy of 79% for the diagnosis of osteonecrosis compared with intraoperative assessment [59]. Radiographic Arthrography Wrist There is no relevant literature to support the use of radiographic arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. US Wrist There is no relevant literature to support the use of US in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan in the setting of chronic hand and wrist pain with clinical concern for CTS. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS. CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS. | 69427 |
acrac_69427_13 | Chronic Hand and Wrist Pain | MRI Area of Interest Without and With IV Contrast There is no relevant literature to support the use of MR without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS. MRI Area of Interest Without IV Contrast MRI can identify enlargement and flattening of the median nerve, bowing of the flexor retinaculum, space occupying lesions, anatomic variants including bifid median nerve and persistent median artery, and tendon pathology in the carpal tunnel [60-62]. When compared with clinical assessment and nerve conduction studies, MRI can diagnose CTS with a high accuracy and stage severity with moderate accuracy [62,63]. There is good correlation between the cross-sectional area of the median nerve as assessed by both US and MRI [63,64]. However, MRI of the wrist is typically not indicated in the setting of suspected CTS [60-62]. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of radiographic arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS. Radiography Wrist Additional Views There is no relevant literature to support the use of additional radiographic views in the setting of chronic hand and wrist pain with clinical concern for CTS. US Area of Interest When compared with clinical assessment and electrophysiologic studies, multiple systematic reviews and meta- analyses have demonstrated US to be highly sensitive and specific for the diagnosis of CTS [65-69]. The measurements and calculations used in the literature for US evaluation of the median nerve are heterogeneous; Chronic Hand and Wrist Pain cross-sectional area measurements of the median nerve at multiple locations in the forearm and wrist and ratios or differences in cross-sectional area comparing the various measurements have been reported. | Chronic Hand and Wrist Pain. MRI Area of Interest Without and With IV Contrast There is no relevant literature to support the use of MR without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS. MRI Area of Interest Without IV Contrast MRI can identify enlargement and flattening of the median nerve, bowing of the flexor retinaculum, space occupying lesions, anatomic variants including bifid median nerve and persistent median artery, and tendon pathology in the carpal tunnel [60-62]. When compared with clinical assessment and nerve conduction studies, MRI can diagnose CTS with a high accuracy and stage severity with moderate accuracy [62,63]. There is good correlation between the cross-sectional area of the median nerve as assessed by both US and MRI [63,64]. However, MRI of the wrist is typically not indicated in the setting of suspected CTS [60-62]. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of radiographic arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS. Radiography Wrist Additional Views There is no relevant literature to support the use of additional radiographic views in the setting of chronic hand and wrist pain with clinical concern for CTS. US Area of Interest When compared with clinical assessment and electrophysiologic studies, multiple systematic reviews and meta- analyses have demonstrated US to be highly sensitive and specific for the diagnosis of CTS [65-69]. The measurements and calculations used in the literature for US evaluation of the median nerve are heterogeneous; Chronic Hand and Wrist Pain cross-sectional area measurements of the median nerve at multiple locations in the forearm and wrist and ratios or differences in cross-sectional area comparing the various measurements have been reported. | 69427 |
acrac_69427_14 | Chronic Hand and Wrist Pain | Some authors have advocated for the use of US as the confirmatory test of choice or as a complementary test for the suspected diagnosis of CTS due to the ability to identify space occupying lesions, anatomic variants including bifid median nerve and persistent median artery, and tendon pathology in the carpal tunnel and the false-positive rate of electrodiagnostic studies [70-73]. Despite evidence supporting the diagnostic capabilities of US in the setting of CTS, there is disagreement among hand surgeons regarding the necessity of diagnostic tests [73,74]. The 2016 American Academy of Orthopedic Surgeons guidelines reports limited evidence supports not routinely using US for the diagnosis of CTS [60]. Variant 6: Adult. Chronic hand or wrist pain. Radiographs normal or show nonspecific arthritis. Suspect tendon injury, tenosynovitis, or tendon pathology. Next imaging study. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. | Chronic Hand and Wrist Pain. Some authors have advocated for the use of US as the confirmatory test of choice or as a complementary test for the suspected diagnosis of CTS due to the ability to identify space occupying lesions, anatomic variants including bifid median nerve and persistent median artery, and tendon pathology in the carpal tunnel and the false-positive rate of electrodiagnostic studies [70-73]. Despite evidence supporting the diagnostic capabilities of US in the setting of CTS, there is disagreement among hand surgeons regarding the necessity of diagnostic tests [73,74]. The 2016 American Academy of Orthopedic Surgeons guidelines reports limited evidence supports not routinely using US for the diagnosis of CTS [60]. Variant 6: Adult. Chronic hand or wrist pain. Radiographs normal or show nonspecific arthritis. Suspect tendon injury, tenosynovitis, or tendon pathology. Next imaging study. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. | 69427 |
acrac_69427_15 | Chronic Hand and Wrist Pain | CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. MRI Area of Interest Without and With IV Contrast The inclusion of postcontrast images to MRI of the wrist improves detection of tenosynovitis [43,75]. MRI Area of Interest Without IV Contrast The contrast resolution of MRI makes it ideal to assess soft tissue abnormalities in the hand and wrist. MRI of the hand or wrist without IV contrast can diagnose or confirm a multitude of tendon abnormalities including tendinopathy, tendon tear, intersection syndrome, tenosynovitis, stenosing tenosynovitis, pulley injuries, sagittal band, and palmar fibromatosis [13,43,76,77]. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. US Area of Interest Tendon injuries of the hand and wrist are well suited to US evaluation due to their superficial location and the ability to dynamically assess the tendons. US of the hand or wrist can diagnose or confirm a multitude of tendon abnormalities including tendinopathy, tendon tear, intersection syndrome, tenosynovitis, stenosing tenosynovitis, pulley injuries, sagittal band, and palmar fibromatosis [6,13,46,77,78]. US assists in operative and injection planning in patients with De Quervain tenosynovitis with accurate identification of an intracompartmental septum [79]. | Chronic Hand and Wrist Pain. CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. MRI Area of Interest Without and With IV Contrast The inclusion of postcontrast images to MRI of the wrist improves detection of tenosynovitis [43,75]. MRI Area of Interest Without IV Contrast The contrast resolution of MRI makes it ideal to assess soft tissue abnormalities in the hand and wrist. MRI of the hand or wrist without IV contrast can diagnose or confirm a multitude of tendon abnormalities including tendinopathy, tendon tear, intersection syndrome, tenosynovitis, stenosing tenosynovitis, pulley injuries, sagittal band, and palmar fibromatosis [13,43,76,77]. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology. US Area of Interest Tendon injuries of the hand and wrist are well suited to US evaluation due to their superficial location and the ability to dynamically assess the tendons. US of the hand or wrist can diagnose or confirm a multitude of tendon abnormalities including tendinopathy, tendon tear, intersection syndrome, tenosynovitis, stenosing tenosynovitis, pulley injuries, sagittal band, and palmar fibromatosis [6,13,46,77,78]. US assists in operative and injection planning in patients with De Quervain tenosynovitis with accurate identification of an intracompartmental septum [79]. | 69427 |
acrac_69428_0 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | This document is specific to malignant or aggressive primary tumors of bone or soft tissue origin. This document specifically does not pertain to 1) metastatic disease to bone or soft tissues, 2) primary tumors of spine or neuroaxis origin, 3) primary tumors of head or neck origin, 4) intraabdominal or retroperitoneal tumors, 5) primary tumors of skin origin, and 6) plasma cell or other hematologic disorders that involve bone (ie, multiple myeloma). The variants in this document assume a diagnosis of a primary malignant or aggressive bone or soft tissue tumor has already been established. This document does not address the evaluation of chemotherapy or radiation therapy effectiveness or issues of cost-effectiveness and radiation dose. Special Imaging Considerations Hardware reconstruction is often needed following limb-sparing surgery for the management of bone tumors and occasionally for soft tissue tumors. This hardware creates artifact and limits evaluation of the adjacent structures with traditional CT, PET/CT, and MRI sequences and techniques. Although metal artifact can negatively impact CT, PET/CT, and/or MRI image quality, this document assumes metal artifact can be minimized with current metal artifact reduction protocols. There may still be instances where metal artifact cannot be sufficiently suppressed, and CT, PET/CT, and/or MRI become of limited benefit. In these cases, deviations from the variant recommendations may be necessary and should be informed by the clinical experience and expertise of the treatment team. aResearch Author, Mayo Clinic Florida, Jacksonville, Florida. bDiagnostic Imaging Associates, Chesterfield, Missouri. cPanel Chair, Mayo Clinic, Jacksonville, Florida. dPanel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina. eThe Johns Hopkins University School of Medicine, Baltimore, Maryland. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. This document is specific to malignant or aggressive primary tumors of bone or soft tissue origin. This document specifically does not pertain to 1) metastatic disease to bone or soft tissues, 2) primary tumors of spine or neuroaxis origin, 3) primary tumors of head or neck origin, 4) intraabdominal or retroperitoneal tumors, 5) primary tumors of skin origin, and 6) plasma cell or other hematologic disorders that involve bone (ie, multiple myeloma). The variants in this document assume a diagnosis of a primary malignant or aggressive bone or soft tissue tumor has already been established. This document does not address the evaluation of chemotherapy or radiation therapy effectiveness or issues of cost-effectiveness and radiation dose. Special Imaging Considerations Hardware reconstruction is often needed following limb-sparing surgery for the management of bone tumors and occasionally for soft tissue tumors. This hardware creates artifact and limits evaluation of the adjacent structures with traditional CT, PET/CT, and MRI sequences and techniques. Although metal artifact can negatively impact CT, PET/CT, and/or MRI image quality, this document assumes metal artifact can be minimized with current metal artifact reduction protocols. There may still be instances where metal artifact cannot be sufficiently suppressed, and CT, PET/CT, and/or MRI become of limited benefit. In these cases, deviations from the variant recommendations may be necessary and should be informed by the clinical experience and expertise of the treatment team. aResearch Author, Mayo Clinic Florida, Jacksonville, Florida. bDiagnostic Imaging Associates, Chesterfield, Missouri. cPanel Chair, Mayo Clinic, Jacksonville, Florida. dPanel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina. eThe Johns Hopkins University School of Medicine, Baltimore, Maryland. | 69428 |
acrac_69428_1 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | fMallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri. gNova Southeastern University, Fort Lauderdale, Florida. hMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. iMayo Clinic Florida, Jacksonville, Florida. jStritch School of Medicine Loyola University Chicago, Maywood, Illinois; Commission on Radiation Oncology. kUniversity of Texas Health Science Center, Houston, Texas; American Academy of Orthopaedic Surgeons. lBrigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts; American Association of Neurological Surgeons/Congress of Neurological Surgeons. mMayo Clinic Florida, Jacksonville, Florida, Primary care physician. nUniversity of Virginia, Charlottesville, Virginia. oSUNY Downstate Health Sciences University, Brooklyn, New York. pMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. qSpecialty Chair, University of Kentucky, Lexington, Kentucky. 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] Discussion of Procedures by Variant Variant 1: Malignant or aggressive primary musculoskeletal tumor. Initial staging. Evaluation for pulmonary metastasis. Approximately 20% of patients with primary extremity sarcomas will have or develop distant metastatic disease. Pulmonary metastases account for approximately 75% of all sarcoma metastases, with variations of incidence depending on tumor histology and grade [4,5]. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. fMallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri. gNova Southeastern University, Fort Lauderdale, Florida. hMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. iMayo Clinic Florida, Jacksonville, Florida. jStritch School of Medicine Loyola University Chicago, Maywood, Illinois; Commission on Radiation Oncology. kUniversity of Texas Health Science Center, Houston, Texas; American Academy of Orthopaedic Surgeons. lBrigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts; American Association of Neurological Surgeons/Congress of Neurological Surgeons. mMayo Clinic Florida, Jacksonville, Florida, Primary care physician. nUniversity of Virginia, Charlottesville, Virginia. oSUNY Downstate Health Sciences University, Brooklyn, New York. pMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. qSpecialty Chair, University of Kentucky, Lexington, Kentucky. 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] Discussion of Procedures by Variant Variant 1: Malignant or aggressive primary musculoskeletal tumor. Initial staging. Evaluation for pulmonary metastasis. Approximately 20% of patients with primary extremity sarcomas will have or develop distant metastatic disease. Pulmonary metastases account for approximately 75% of all sarcoma metastases, with variations of incidence depending on tumor histology and grade [4,5]. | 69428 |
acrac_69428_2 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Metastatic disease decreases survival, with pulmonary metastases as the primary cause of death in patients with osteosarcoma [6,7]. Metastasectomy improves survival, and thermal ablation and radiation therapy are emerging as promising alternative treatment options [8-10]. Therefore, evaluation for pulmonary metastases is an essential part of primary musculoskeletal tumor initial staging. CT Chest With IV Contrast There is no relevant literature regarding the specific use of CT chest with intravenous (IV) contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared with CT chest without IV contrast in this setting. CT Chest Without and With IV Contrast There is no relevant literature regarding the specific use of CT chest without and with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared with CT chest without IV contrast in this setting. CT Chest Without IV Contrast CT chest is the most sensitive imaging modality for identifying pulmonary nodules compared with radiography, fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT, or FDG-PET/MRI. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Metastatic disease decreases survival, with pulmonary metastases as the primary cause of death in patients with osteosarcoma [6,7]. Metastasectomy improves survival, and thermal ablation and radiation therapy are emerging as promising alternative treatment options [8-10]. Therefore, evaluation for pulmonary metastases is an essential part of primary musculoskeletal tumor initial staging. CT Chest With IV Contrast There is no relevant literature regarding the specific use of CT chest with intravenous (IV) contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared with CT chest without IV contrast in this setting. CT Chest Without and With IV Contrast There is no relevant literature regarding the specific use of CT chest without and with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared with CT chest without IV contrast in this setting. CT Chest Without IV Contrast CT chest is the most sensitive imaging modality for identifying pulmonary nodules compared with radiography, fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT, or FDG-PET/MRI. | 69428 |
acrac_69428_3 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | However, studies have shown that even CT underestimates the number of pulmonary metastases compared with lung palpation during thoracotomy. Specific to osteosarcoma pulmonary metastases, CT missed approximately 10% of palpable lung lesions, of which nearly half were confirmed metastases in a series of 118 patients with osteosarcoma [9]. A smaller series of 28 patients with osteosarcoma also showed that CT missed 26% of viable metastases compared with palpation [11]. However, as CT technology improves and slice thickness decreases, more and smaller pulmonary nodules can be identified resulting in the dilemma of increased false-positive rates. A study of 283 lung nodules in patients with osteosarcoma found a statistically significant cutoff of 6 mm to differentiate benign and malignant pulmonary nodules (specificity 89.8%) [9]. A study of 311 subcentimeter pulmonary nodules in 195 patients with soft tissue sarcoma found combining morphologic criteria, in addition to size criteria, helped differentiate benign and malignant pulmonary nodules, with round solid nodules >5 mm more likely to be malignant (76% P = . 002) and complex ground-glass nodules <5 mm more likely to be benign (84%, P < . 0001) [12]. Given the survival benefit of treating pulmonary metastases, if pulmonary nodules are identified on any other modality in patients with primary musculoskeletal sarcoma, CT chest is then often indicated for biopsy and/or pretreatment planning. FDG-PET/CT Whole Body A meta-analysis of FDG-PET/CT for the staging of patients with osteosarcoma demonstrated 81% combined sensitivity and 94% specificity for detection of lung metastases [6]. The superiority of PET when combined with CT has been established [13]. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. However, studies have shown that even CT underestimates the number of pulmonary metastases compared with lung palpation during thoracotomy. Specific to osteosarcoma pulmonary metastases, CT missed approximately 10% of palpable lung lesions, of which nearly half were confirmed metastases in a series of 118 patients with osteosarcoma [9]. A smaller series of 28 patients with osteosarcoma also showed that CT missed 26% of viable metastases compared with palpation [11]. However, as CT technology improves and slice thickness decreases, more and smaller pulmonary nodules can be identified resulting in the dilemma of increased false-positive rates. A study of 283 lung nodules in patients with osteosarcoma found a statistically significant cutoff of 6 mm to differentiate benign and malignant pulmonary nodules (specificity 89.8%) [9]. A study of 311 subcentimeter pulmonary nodules in 195 patients with soft tissue sarcoma found combining morphologic criteria, in addition to size criteria, helped differentiate benign and malignant pulmonary nodules, with round solid nodules >5 mm more likely to be malignant (76% P = . 002) and complex ground-glass nodules <5 mm more likely to be benign (84%, P < . 0001) [12]. Given the survival benefit of treating pulmonary metastases, if pulmonary nodules are identified on any other modality in patients with primary musculoskeletal sarcoma, CT chest is then often indicated for biopsy and/or pretreatment planning. FDG-PET/CT Whole Body A meta-analysis of FDG-PET/CT for the staging of patients with osteosarcoma demonstrated 81% combined sensitivity and 94% specificity for detection of lung metastases [6]. The superiority of PET when combined with CT has been established [13]. | 69428 |
acrac_69428_4 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Comparison studies between PET imaging alone versus CT acquired during FDG- PET/CT have been reported, although the CT acquired for attenuation correction and anatomic registration is not regarded as equivalent to dedicated diagnostic CT chest imaging [13]. Roberge et al [14] compared FDG-PET/CT with conventional imaging in a cohort of 109 patients during staging of extremity and body wall soft tissue sarcomas. In this cohort, 16 of the 109 patients had lung metastases, 10 of which were only identified on CT chest. Only 1 of the 16 patients with lung metastases was identified with FDG-PET/CT imaging but not CT chest. The authors concluded that FDG-PET/CT added little benefit over CT chest alone in evaluating for pulmonary metastasis [14]. A study comparing staging and follow-up imaging studies in 41 children with primary bone sarcomas showed greater sensitivity of CT chest (93%) versus FDG-PET/CT (80%) in detecting pulmonary metastases (although 4 Malignant or Aggressive Primary Musculoskeletal Tumor specificity was higher with FDG-PET/CT at 96% compared with 87% for CT chest). Of the false-negative FDG- PET/CT results in that study, half were pulmonary nodules <10 mm [15]. Evaluation of subcentimeter pulmonary nodules is a known limitation of FDG-PET/CT because of the inherent resolution constraints of PET/CT technology and respiratory motion artifact. However, a study of 63 lung nodules in 18 pediatric patients with bone sarcoma did demonstrate the value of using an FDG-PET standardized uptake value (SUV) cutoff in evaluating small pulmonary nodules; using an SUVmax >1 cutoff value and a nodule diameter cutoff of 6 mm can differentiate benign and malignant nodules with an accuracy of 92.1% compared with an accuracy of 88.9% with FDG-PET/CT visual analysis alone [16]. FDG-PET/MRI Whole Body Literature specific to sarcoma staging with FDG-PET/MRI is scarce. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Comparison studies between PET imaging alone versus CT acquired during FDG- PET/CT have been reported, although the CT acquired for attenuation correction and anatomic registration is not regarded as equivalent to dedicated diagnostic CT chest imaging [13]. Roberge et al [14] compared FDG-PET/CT with conventional imaging in a cohort of 109 patients during staging of extremity and body wall soft tissue sarcomas. In this cohort, 16 of the 109 patients had lung metastases, 10 of which were only identified on CT chest. Only 1 of the 16 patients with lung metastases was identified with FDG-PET/CT imaging but not CT chest. The authors concluded that FDG-PET/CT added little benefit over CT chest alone in evaluating for pulmonary metastasis [14]. A study comparing staging and follow-up imaging studies in 41 children with primary bone sarcomas showed greater sensitivity of CT chest (93%) versus FDG-PET/CT (80%) in detecting pulmonary metastases (although 4 Malignant or Aggressive Primary Musculoskeletal Tumor specificity was higher with FDG-PET/CT at 96% compared with 87% for CT chest). Of the false-negative FDG- PET/CT results in that study, half were pulmonary nodules <10 mm [15]. Evaluation of subcentimeter pulmonary nodules is a known limitation of FDG-PET/CT because of the inherent resolution constraints of PET/CT technology and respiratory motion artifact. However, a study of 63 lung nodules in 18 pediatric patients with bone sarcoma did demonstrate the value of using an FDG-PET standardized uptake value (SUV) cutoff in evaluating small pulmonary nodules; using an SUVmax >1 cutoff value and a nodule diameter cutoff of 6 mm can differentiate benign and malignant nodules with an accuracy of 92.1% compared with an accuracy of 88.9% with FDG-PET/CT visual analysis alone [16]. FDG-PET/MRI Whole Body Literature specific to sarcoma staging with FDG-PET/MRI is scarce. | 69428 |
acrac_69428_5 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | A single study by Platzek et al [17] in 2017 evaluated FDG-PET/MRI in sarcoma staging in 29 patients and compared results with conventional CT or MRI studies. Eight of the 29 patients had lung metastases, which were identified on both the FDG-PET/MRI and conventional imaging. However, the small sample size precludes application of this data to larger populations. The inherent decreased spatial resolution of MRI compared to CT raises doubts about the ability to identify small pulmonary metastases with FDG-PET/MRI as accurately as CT. MRI of the lungs relies heavily on the ability to minimize respiratory motion. Radiography Chest There is no relevant literature to support the use of chest radiography in the evaluation of pulmonary metastases in the initial staging of malignant or aggressive primary musculoskeletal tumors. Variant 2: Malignant or aggressive primary musculoskeletal tumor. Initial staging. Evaluation for extrapulmonary metastasis. The body regions covered in this clinical scenario are ankle, chest, shoulder, elbow, femur, foot, forearm, hand, humerus, knee, pelvis, tibia/fibula, and wrist. Bone Scan Whole Body Although historically Tc-99m bone scan has been used to detect bone metastasis, more recent studies have shown Tc-99m bone scan is inferior to FDG-PET/CT in the detection of bone metastases in general oncologic populations [23]. This conclusion has also been supported in patients with bone sarcoma. A study of 206 patients with stage IV osteosarcoma who underwent both Tc-99m bone scan and FDG-PET/CT calculated a 95% sensitivity and 98% accuracy for FDG-PET/CT versus 76% and 96%, respectively, for Tc-99m bone scan [24]. A smaller study of 64 pediatric patients with bone sarcoma also showed greater accuracy of FDG-PET/CT (84%) versus Tc-99m bone scan (70%) in detecting bone metastases during initial staging [22]. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. A single study by Platzek et al [17] in 2017 evaluated FDG-PET/MRI in sarcoma staging in 29 patients and compared results with conventional CT or MRI studies. Eight of the 29 patients had lung metastases, which were identified on both the FDG-PET/MRI and conventional imaging. However, the small sample size precludes application of this data to larger populations. The inherent decreased spatial resolution of MRI compared to CT raises doubts about the ability to identify small pulmonary metastases with FDG-PET/MRI as accurately as CT. MRI of the lungs relies heavily on the ability to minimize respiratory motion. Radiography Chest There is no relevant literature to support the use of chest radiography in the evaluation of pulmonary metastases in the initial staging of malignant or aggressive primary musculoskeletal tumors. Variant 2: Malignant or aggressive primary musculoskeletal tumor. Initial staging. Evaluation for extrapulmonary metastasis. The body regions covered in this clinical scenario are ankle, chest, shoulder, elbow, femur, foot, forearm, hand, humerus, knee, pelvis, tibia/fibula, and wrist. Bone Scan Whole Body Although historically Tc-99m bone scan has been used to detect bone metastasis, more recent studies have shown Tc-99m bone scan is inferior to FDG-PET/CT in the detection of bone metastases in general oncologic populations [23]. This conclusion has also been supported in patients with bone sarcoma. A study of 206 patients with stage IV osteosarcoma who underwent both Tc-99m bone scan and FDG-PET/CT calculated a 95% sensitivity and 98% accuracy for FDG-PET/CT versus 76% and 96%, respectively, for Tc-99m bone scan [24]. A smaller study of 64 pediatric patients with bone sarcoma also showed greater accuracy of FDG-PET/CT (84%) versus Tc-99m bone scan (70%) in detecting bone metastases during initial staging [22]. | 69428 |
acrac_69428_6 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Other studies have suggested that this FDG- PET/CT superiority may be specific only to osteolytic metastases but not osteoblastic metastases [25-27]. The ability to detect extraosseous metastases that are usually occult on Tc-99m bone scan is an additional benefit of FDG-PET/CT [28]. Similarly, studies have demonstrated MRI whole body is superior to Tc-99m bone scan in detecting bone metastases in general populations. A study specific to patients with Ewing sarcoma of bone that had both MRI whole body and Tc-99m bone scan showed not only more bone metastases were identified with MRI, but 4 of the 71 patients had bone metastases only detected on MRI which changed the tumor stage for these patients [29]. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The addition of single-photon emission computed tomography (SPECT) and SPECT/CT to Tc-99m bone scans can increase diagnostic confidence. A study of 2,954 Tc-99m bone scans in a general oncologic population increased diagnostic confidence by 75% and reduced equivocal findings by 27% [30]. However, there is no relevant literature 5 Malignant or Aggressive Primary Musculoskeletal Tumor to support the specific use of SPECT or SPECT/CT with bone scans in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. CT Area of Interest With IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended. CT Area of Interest Without and With IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Other studies have suggested that this FDG- PET/CT superiority may be specific only to osteolytic metastases but not osteoblastic metastases [25-27]. The ability to detect extraosseous metastases that are usually occult on Tc-99m bone scan is an additional benefit of FDG-PET/CT [28]. Similarly, studies have demonstrated MRI whole body is superior to Tc-99m bone scan in detecting bone metastases in general populations. A study specific to patients with Ewing sarcoma of bone that had both MRI whole body and Tc-99m bone scan showed not only more bone metastases were identified with MRI, but 4 of the 71 patients had bone metastases only detected on MRI which changed the tumor stage for these patients [29]. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The addition of single-photon emission computed tomography (SPECT) and SPECT/CT to Tc-99m bone scans can increase diagnostic confidence. A study of 2,954 Tc-99m bone scans in a general oncologic population increased diagnostic confidence by 75% and reduced equivocal findings by 27% [30]. However, there is no relevant literature 5 Malignant or Aggressive Primary Musculoskeletal Tumor to support the specific use of SPECT or SPECT/CT with bone scans in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. CT Area of Interest With IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended. CT Area of Interest Without and With IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. | 69428 |
acrac_69428_7 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended. CT Area of Interest Without IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended. FDG-PET/CT Whole Body A meta-analysis of FDG-PET/CT for the staging of patients with osteosarcoma demonstrated an overall sensitivity of 93% and a specificity of 97% for detection of bone metastases [6]. Coverage of a whole body FDG-PET/CT varies and usually extends either from skull base to thighs or skull vertex to feet. A study of FDG-PET/CT in patients with sarcoma and melanoma showed inclusion of the entire lower extremities does not add additional benefit in identifying metastases [31]. FDG-PET/CT is considered superior to Tc-99m bone scan in the detection of osseous metastases. Literature has concluded this in both general oncologic and bone sarcoma populations [30]. FDG-PET/CT is also superior to CT imaging in this regard. Quartuccio et al [22] studied 64 pediatric patients with bone sarcoma and found greater accuracy of FDG-PET/CT (85% accuracy) versus CT (44% accuracy) in detecting bone metastases during initial staging of patients with Ewing sarcoma. There are mixed conclusions when comparing FDG-PET/CT versus MRI whole body in detecting osseous metastases in general oncology populations [32-34]. In a small study of 20 patients with Ewing sarcoma comparing FDG-PET/CT with MRI whole body, a single patient had a false-positive bone finding on FDG-PET/CT. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended. CT Area of Interest Without IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended. FDG-PET/CT Whole Body A meta-analysis of FDG-PET/CT for the staging of patients with osteosarcoma demonstrated an overall sensitivity of 93% and a specificity of 97% for detection of bone metastases [6]. Coverage of a whole body FDG-PET/CT varies and usually extends either from skull base to thighs or skull vertex to feet. A study of FDG-PET/CT in patients with sarcoma and melanoma showed inclusion of the entire lower extremities does not add additional benefit in identifying metastases [31]. FDG-PET/CT is considered superior to Tc-99m bone scan in the detection of osseous metastases. Literature has concluded this in both general oncologic and bone sarcoma populations [30]. FDG-PET/CT is also superior to CT imaging in this regard. Quartuccio et al [22] studied 64 pediatric patients with bone sarcoma and found greater accuracy of FDG-PET/CT (85% accuracy) versus CT (44% accuracy) in detecting bone metastases during initial staging of patients with Ewing sarcoma. There are mixed conclusions when comparing FDG-PET/CT versus MRI whole body in detecting osseous metastases in general oncology populations [32-34]. In a small study of 20 patients with Ewing sarcoma comparing FDG-PET/CT with MRI whole body, a single patient had a false-positive bone finding on FDG-PET/CT. | 69428 |
acrac_69428_8 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Overall, 39% more bone lesions in this study were identified with MRI whole body versus FDG-PET/CT [35]. In the Quartuccio et al [22] study of 64 pediatric patients with bone sarcoma, when FDG- PET/CT was compared with MRI for the detection of bone metastases, accuracy was similar (85% versus 89%). MRI better discriminates bone metastases from hematopoietic marrow, both of which can have increased metabolic activity on PET imaging. An advantage of PET over MRI is the ability to quantify tumor metabolic activity, which can serve as a prognostic indicator [15]. FDG-PET/CT can also be useful to detect nonskeletal metastases, more frequently in the lung, but also lymph nodes and other organs. FDG-PET/CT can detect a greater number of nodal metastases in soft tissue sarcoma versus conventional imaging alone [36,37]. The incidence of nodal metastases is dependent on tumor histology. FDG-PET/MRI Whole Body Literature specific to sarcoma staging with FDG-PET/MRI is scarce. A study of 29 patients with sarcoma who underwent FDG-PET/MRI and conventional imaging (CT chest/abdomen and/or local MRI) showed no significant difference in accuracy for detecting metastases with sensitivities and specificities of 97.8% and 100% for FDG- PET/MRI compared with 94.4% and 100% for conventional imaging. Of the 10 patients in this study with metastases, 6 had extrapulmonary metastases [17]. Another study of 98 bone lesions in a general oncologic population undergoing simultaneous FDG-PET/CT and FDG-PET/MRI showed these modalities to be equivalent for the detection and characterization of bone lesions [38]. Although FDG-PET/MRI whole body scans may prove to be useful in this setting, additional evidence is needed to compare its utility with existing modalities. Fluoride PET/CT Whole Body Fluoride PET/CT can increase diagnostic confidence when detecting bone metastases in general oncologic populations when compared with planar Tc-99m bone scans [39]. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Overall, 39% more bone lesions in this study were identified with MRI whole body versus FDG-PET/CT [35]. In the Quartuccio et al [22] study of 64 pediatric patients with bone sarcoma, when FDG- PET/CT was compared with MRI for the detection of bone metastases, accuracy was similar (85% versus 89%). MRI better discriminates bone metastases from hematopoietic marrow, both of which can have increased metabolic activity on PET imaging. An advantage of PET over MRI is the ability to quantify tumor metabolic activity, which can serve as a prognostic indicator [15]. FDG-PET/CT can also be useful to detect nonskeletal metastases, more frequently in the lung, but also lymph nodes and other organs. FDG-PET/CT can detect a greater number of nodal metastases in soft tissue sarcoma versus conventional imaging alone [36,37]. The incidence of nodal metastases is dependent on tumor histology. FDG-PET/MRI Whole Body Literature specific to sarcoma staging with FDG-PET/MRI is scarce. A study of 29 patients with sarcoma who underwent FDG-PET/MRI and conventional imaging (CT chest/abdomen and/or local MRI) showed no significant difference in accuracy for detecting metastases with sensitivities and specificities of 97.8% and 100% for FDG- PET/MRI compared with 94.4% and 100% for conventional imaging. Of the 10 patients in this study with metastases, 6 had extrapulmonary metastases [17]. Another study of 98 bone lesions in a general oncologic population undergoing simultaneous FDG-PET/CT and FDG-PET/MRI showed these modalities to be equivalent for the detection and characterization of bone lesions [38]. Although FDG-PET/MRI whole body scans may prove to be useful in this setting, additional evidence is needed to compare its utility with existing modalities. Fluoride PET/CT Whole Body Fluoride PET/CT can increase diagnostic confidence when detecting bone metastases in general oncologic populations when compared with planar Tc-99m bone scans [39]. | 69428 |
acrac_69428_9 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | There is no relevant literature to specifically 6 Malignant or Aggressive Primary Musculoskeletal Tumor support the use of fluoride PET/CT in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. Specifically, extraosseous extrapulmonary metastases will usually be occult on fluoride PET/CT whole body scans. MRI Whole Body Without and With IV Contrast There is no relevant literature to support the use of MRI whole body without and with IV contrast in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. However, the addition of IV contrast can be helpful for assessing soft tissue masses and therefore could be beneficial in this setting. MRI Whole Body Without IV Contrast The ability of MRI to characterize soft tissue and bone marrow make it ideal for identifying extrapulmonary metastases. MRI is particularly useful in identifying and accurately characterizing bone marrow abnormalities as metastases versus nonmalignant processes. Hematopoietic marrow, or red marrow, is a frequently encountered nonmalignant marrow abnormality that can be mistaken for a metastasis on other modalities, particularly on PET imaging, when there is relatively increased metabolic activity. Hematopoietic marrow is abundant in the pediatric and young adult populations making it problematic for the staging of bone sarcomas in these populations. Multiple medications and other systemic illnesses can activate hematopoietic marrow in the adult population. Specific to myxoid liposarcoma, a sarcoma subtype known to metastasize preferentially to extrapulmonary locations, multiple studies have found MRI to be more accurate than FDG-PET, FDG-PET/CT, CT, radiography, and bone scintigraphy imaging to detect extrapulmonary metastases [40-44]. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. There is no relevant literature to specifically 6 Malignant or Aggressive Primary Musculoskeletal Tumor support the use of fluoride PET/CT in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. Specifically, extraosseous extrapulmonary metastases will usually be occult on fluoride PET/CT whole body scans. MRI Whole Body Without and With IV Contrast There is no relevant literature to support the use of MRI whole body without and with IV contrast in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. However, the addition of IV contrast can be helpful for assessing soft tissue masses and therefore could be beneficial in this setting. MRI Whole Body Without IV Contrast The ability of MRI to characterize soft tissue and bone marrow make it ideal for identifying extrapulmonary metastases. MRI is particularly useful in identifying and accurately characterizing bone marrow abnormalities as metastases versus nonmalignant processes. Hematopoietic marrow, or red marrow, is a frequently encountered nonmalignant marrow abnormality that can be mistaken for a metastasis on other modalities, particularly on PET imaging, when there is relatively increased metabolic activity. Hematopoietic marrow is abundant in the pediatric and young adult populations making it problematic for the staging of bone sarcomas in these populations. Multiple medications and other systemic illnesses can activate hematopoietic marrow in the adult population. Specific to myxoid liposarcoma, a sarcoma subtype known to metastasize preferentially to extrapulmonary locations, multiple studies have found MRI to be more accurate than FDG-PET, FDG-PET/CT, CT, radiography, and bone scintigraphy imaging to detect extrapulmonary metastases [40-44]. | 69428 |
acrac_69428_10 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | A small study in patients with Ewing sarcoma showed more bone lesions were more accurately identified on MRI whole body when compared with FDG-PET/CT [35]. There are mixed conclusions when comparing FDG-PET/CT versus MRI whole body in detecting osseous metastases in general oncology populations [32-34]. MRI whole body is more sensitive than Tc-99m bone scan for detecting osseous metastasis in a variety of tumors known to metastasize to bone. Sensitivity was also higher specifically in patients with Ewing sarcoma [29]. Radiography Area of Interest Radiographs could be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of radiography at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. US Area of Interest There is no relevant literature to support the use of ultrasound (US) area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. US could be used to evaluate an area of interest identified clinically or from another imaging modality. US is more useful to evaluate superficial soft tissue masses as opposed to bone lesions, which are usually occult if there is no cortical breakthrough. Variant 3: Malignant or aggressive primary musculoskeletal tumor with no suspected or known recurrence. Surveillance for pulmonary metastasis. Pulmonary metastases account for the majority of distant metastatic disease in patients with primary extremity sarcoma as a whole. Risk of pulmonary metastasis varies with tumor histology and grade. Although patients with high-grade soft tissue sarcomas develop lung metastasis at a rate of ~60%, those with low-grade sarcomas have lung metastasis rates <10% [45,46]. Therefore, guidance regarding modality for lung screening often differ between low-risk and high-risk patients. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. A small study in patients with Ewing sarcoma showed more bone lesions were more accurately identified on MRI whole body when compared with FDG-PET/CT [35]. There are mixed conclusions when comparing FDG-PET/CT versus MRI whole body in detecting osseous metastases in general oncology populations [32-34]. MRI whole body is more sensitive than Tc-99m bone scan for detecting osseous metastasis in a variety of tumors known to metastasize to bone. Sensitivity was also higher specifically in patients with Ewing sarcoma [29]. Radiography Area of Interest Radiographs could be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of radiography at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. US Area of Interest There is no relevant literature to support the use of ultrasound (US) area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. US could be used to evaluate an area of interest identified clinically or from another imaging modality. US is more useful to evaluate superficial soft tissue masses as opposed to bone lesions, which are usually occult if there is no cortical breakthrough. Variant 3: Malignant or aggressive primary musculoskeletal tumor with no suspected or known recurrence. Surveillance for pulmonary metastasis. Pulmonary metastases account for the majority of distant metastatic disease in patients with primary extremity sarcoma as a whole. Risk of pulmonary metastasis varies with tumor histology and grade. Although patients with high-grade soft tissue sarcomas develop lung metastasis at a rate of ~60%, those with low-grade sarcomas have lung metastasis rates <10% [45,46]. Therefore, guidance regarding modality for lung screening often differ between low-risk and high-risk patients. | 69428 |
acrac_69428_11 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | There is also debate concerning the frequency of lung surveillance. Given most pulmonary metastases will occur within 2 years of primary resection [47], many experts support more frequent surveillance initially in the first few years after diagnosis. Surveillance regimens usually de-escalate to annual follow-up after 5 years postresection [48-52]. Although these dynamic protocols are often used, a prospective randomized trial of 500 patients with resected extremity sarcomas and no baseline metastatic disease found no difference in overall survival or recurrence-free survival between groups whether surveilled at 3 month or 6-month consistent intervals [53,54]. Pulmonary metastases are associated with a worse prognosis [45], and treatment of these pulmonary metastases can improve survival [8,10]. Identification of pulmonary metastases is an essential part of primary musculoskeletal tumor screening. There is little to no variation in the ability of a certain modality to detect pulmonary metastasis whether performed at initial staging (see Variant 1), surveillance, or restaging in the setting of recurrence. 7 Malignant or Aggressive Primary Musculoskeletal Tumor CT Chest With IV Contrast There is no relevant literature regarding the specific use of CT chest with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared to CT chest without IV contrast in this setting. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. There is also debate concerning the frequency of lung surveillance. Given most pulmonary metastases will occur within 2 years of primary resection [47], many experts support more frequent surveillance initially in the first few years after diagnosis. Surveillance regimens usually de-escalate to annual follow-up after 5 years postresection [48-52]. Although these dynamic protocols are often used, a prospective randomized trial of 500 patients with resected extremity sarcomas and no baseline metastatic disease found no difference in overall survival or recurrence-free survival between groups whether surveilled at 3 month or 6-month consistent intervals [53,54]. Pulmonary metastases are associated with a worse prognosis [45], and treatment of these pulmonary metastases can improve survival [8,10]. Identification of pulmonary metastases is an essential part of primary musculoskeletal tumor screening. There is little to no variation in the ability of a certain modality to detect pulmonary metastasis whether performed at initial staging (see Variant 1), surveillance, or restaging in the setting of recurrence. 7 Malignant or Aggressive Primary Musculoskeletal Tumor CT Chest With IV Contrast There is no relevant literature regarding the specific use of CT chest with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared to CT chest without IV contrast in this setting. | 69428 |
acrac_69428_12 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | CT Chest Without and With IV Contrast There is no relevant literature regarding the specific use of CT chest without and with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared to CT chest without IV contrast in this setting. CT Chest Without IV Contrast CT chest is the most sensitive imaging modality for the detection of pulmonary metastases. CT imaging for lung metastases has been criticized by some as being too sensitive. Several studies have attempted to find size and morphologic criteria to help discriminate between malignant and benign pulmonary nodules [9,12]. Rissing et al [55] showed that those only with pulmonary lesions <5 mm were associated with equivalent survival to those with normal scans. Often when a pulmonary metastasis is identified on a different imaging modality, CT is then required for biopsy or treatment planning. Guidance varies regarding whether to use CT chest versus chest radiography as surveillance for lung metastases in patients with sarcoma. Much of the debate also takes cost-analysis and radiation exposure into consideration. A retrospective study by Cho et al [56] of 176 patients with stage II or stage III high-grade extremity sarcomas calculated similar 5-year survival rates whether surveilled with chest radiography or CT chest. However, when stratifying survival rates by stage, they found a survival benefit for stage III patients when monitored with CT chest likely related to the increased rates of lung metastasis with high-grade sarcoma. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Chest Without and With IV Contrast There is no relevant literature regarding the specific use of CT chest without and with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared to CT chest without IV contrast in this setting. CT Chest Without IV Contrast CT chest is the most sensitive imaging modality for the detection of pulmonary metastases. CT imaging for lung metastases has been criticized by some as being too sensitive. Several studies have attempted to find size and morphologic criteria to help discriminate between malignant and benign pulmonary nodules [9,12]. Rissing et al [55] showed that those only with pulmonary lesions <5 mm were associated with equivalent survival to those with normal scans. Often when a pulmonary metastasis is identified on a different imaging modality, CT is then required for biopsy or treatment planning. Guidance varies regarding whether to use CT chest versus chest radiography as surveillance for lung metastases in patients with sarcoma. Much of the debate also takes cost-analysis and radiation exposure into consideration. A retrospective study by Cho et al [56] of 176 patients with stage II or stage III high-grade extremity sarcomas calculated similar 5-year survival rates whether surveilled with chest radiography or CT chest. However, when stratifying survival rates by stage, they found a survival benefit for stage III patients when monitored with CT chest likely related to the increased rates of lung metastasis with high-grade sarcoma. | 69428 |
acrac_69428_13 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Other studies have differing conclusions. A large multicenter retrospective study by Gamboa et al [45] comparing lung surveillance in 909 patients with extremity, truncal, or retroperitoneal high-grade soft tissue sarcomas found the 5-year survival rate was noninferior for patients followed with chest radiography versus CT chest (71% versus 60%). This study also found there was no difference in the rate or type of intervention for these lung metastases when detected. Selection bias was a limitation of both of these retrospective studies because the rationale of which modality used to screen was not known or reported. Additionally, the Gamboa et al [45] study included 151 patients with retroperitoneal sarcoma, which has a high rate of local recurrence; this group was overrepresented in the CT imaging group, which had the worse survival rate. A prospective randomized trial of 500 patients with resected extremity bone and soft tissue sarcomas without baseline metastases showed noninferiority of chest radiography compared with CT chest with similar overall survival (56% versus 53% respectively) and recurrence-free survival (59% versus 54% respectively) when used for lung surveillance [53,54]. FDG-PET/CT Whole Body Although FDG-PET/CT is not as sensitive for detecting pulmonary metastases as CT chest imaging, it has been shown to be more specific and therefore may be useful as a problem-solving tool when an indeterminate pulmonary nodule is detected on diagnostic chest CT. A study comparing staging and follow-up imaging studies in 41 children with primary bone sarcomas showed greater sensitivity of CT chest (93%) versus FDG-PET/CT (80%) in detecting pulmonary metastases (although specificity was higher with FDG-PET/CT at 96% compared with 87% for CT chest). Of the false-negative FDG-PET/CT results in that study, half were pulmonary nodules <10 mm [15]. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Other studies have differing conclusions. A large multicenter retrospective study by Gamboa et al [45] comparing lung surveillance in 909 patients with extremity, truncal, or retroperitoneal high-grade soft tissue sarcomas found the 5-year survival rate was noninferior for patients followed with chest radiography versus CT chest (71% versus 60%). This study also found there was no difference in the rate or type of intervention for these lung metastases when detected. Selection bias was a limitation of both of these retrospective studies because the rationale of which modality used to screen was not known or reported. Additionally, the Gamboa et al [45] study included 151 patients with retroperitoneal sarcoma, which has a high rate of local recurrence; this group was overrepresented in the CT imaging group, which had the worse survival rate. A prospective randomized trial of 500 patients with resected extremity bone and soft tissue sarcomas without baseline metastases showed noninferiority of chest radiography compared with CT chest with similar overall survival (56% versus 53% respectively) and recurrence-free survival (59% versus 54% respectively) when used for lung surveillance [53,54]. FDG-PET/CT Whole Body Although FDG-PET/CT is not as sensitive for detecting pulmonary metastases as CT chest imaging, it has been shown to be more specific and therefore may be useful as a problem-solving tool when an indeterminate pulmonary nodule is detected on diagnostic chest CT. A study comparing staging and follow-up imaging studies in 41 children with primary bone sarcomas showed greater sensitivity of CT chest (93%) versus FDG-PET/CT (80%) in detecting pulmonary metastases (although specificity was higher with FDG-PET/CT at 96% compared with 87% for CT chest). Of the false-negative FDG-PET/CT results in that study, half were pulmonary nodules <10 mm [15]. | 69428 |
acrac_69428_14 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Evaluation of subcentimeter pulmonary nodules is a known limitation of FDG-PET/CT because of the inherent resolution constraints of PET/CT technology and respiratory motion artifact. However, a study of 63 lung nodules in 18 pediatric patients with bone sarcoma did demonstrate the benefit of using an FDG-PET SUV cutoff in evaluating small pulmonary nodules; using an SUVmax >1 cutoff value and a nodule diameter cutoff of 6 mm can differentiate benign and malignant nodules with an accuracy of 92.1% compared with an accuracy of 88.9% with FDG-PET/CT visual analysis alone [16]. 8 Malignant or Aggressive Primary Musculoskeletal Tumor FDG-PET/MRI Whole Body There is no relevant literature to support the use of FDG-PET/MRI in the evaluation of pulmonary metastases during surveillance of malignant or aggressive primary musculoskeletal tumors. The inherent decreased spatial resolution of MRI compared with CT raises doubts about the ability to identify small pulmonary metastases with FDG- PET/MRI as accurately as CT. MRI of the lungs relies heavily on the ability to minimize respiratory motion. Radiography Chest Chest radiography is less sensitive than CT chest imaging for the detection of pulmonary nodules. Whooley et al [57] found that 83% of asymptomatic metastases were detected radiographically with a positive predictive value of 92% and a negative predictive value of 97%. However, the detection of more and smaller pulmonary metastases with CT versus radiography has definitely not improved survival rates. Although radiography is less sensitive for detection of lung metastases, how that correlates with clinically significant metastases is less certain. Variant 4: Malignant or aggressive primary bone tumor. Surveillance for local recurrence. The body regions covered in this clinical scenario are ankle, chest, elbow, shoulder, femur, foot, forearm, hand, humerus, knee, pelvis, tibia/fibula, and wrist. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Evaluation of subcentimeter pulmonary nodules is a known limitation of FDG-PET/CT because of the inherent resolution constraints of PET/CT technology and respiratory motion artifact. However, a study of 63 lung nodules in 18 pediatric patients with bone sarcoma did demonstrate the benefit of using an FDG-PET SUV cutoff in evaluating small pulmonary nodules; using an SUVmax >1 cutoff value and a nodule diameter cutoff of 6 mm can differentiate benign and malignant nodules with an accuracy of 92.1% compared with an accuracy of 88.9% with FDG-PET/CT visual analysis alone [16]. 8 Malignant or Aggressive Primary Musculoskeletal Tumor FDG-PET/MRI Whole Body There is no relevant literature to support the use of FDG-PET/MRI in the evaluation of pulmonary metastases during surveillance of malignant or aggressive primary musculoskeletal tumors. The inherent decreased spatial resolution of MRI compared with CT raises doubts about the ability to identify small pulmonary metastases with FDG- PET/MRI as accurately as CT. MRI of the lungs relies heavily on the ability to minimize respiratory motion. Radiography Chest Chest radiography is less sensitive than CT chest imaging for the detection of pulmonary nodules. Whooley et al [57] found that 83% of asymptomatic metastases were detected radiographically with a positive predictive value of 92% and a negative predictive value of 97%. However, the detection of more and smaller pulmonary metastases with CT versus radiography has definitely not improved survival rates. Although radiography is less sensitive for detection of lung metastases, how that correlates with clinically significant metastases is less certain. Variant 4: Malignant or aggressive primary bone tumor. Surveillance for local recurrence. The body regions covered in this clinical scenario are ankle, chest, elbow, shoulder, femur, foot, forearm, hand, humerus, knee, pelvis, tibia/fibula, and wrist. | 69428 |
acrac_69428_15 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Local recurrence rates following primary resection of a malignant or aggressive bone tumor vary and depend on tumor grade and histology. Local recurrence rates of bone sarcomas are reported to be approximately 10% to 15% in patients with osteosarcoma and Ewing sarcoma [58-61]. Prognosis is poor for locally recurrent malignant or aggressive bone tumors, with postrecurrence 5-year survival rates reported approximately 15% to 30% in patients with osteosarcoma and 5% in patients with Ewing sarcoma [60,62]. Factors associated with poorer prognosis in patients with osteosarcoma were size of local recurrence (>5 cm) and presence of distant metastasis [60]. Recommendations for local recurrence surveillance imaging vary amongst expert guidelines, although all acknowledge the benefit of clinical evaluation. Locally recurrent bone tumors can often present as a soft tissue mass, and in a study of osteosarcoma local recurrences, the majority (approximately 75%) were soft tissue masses rather than bone lesions [60]. Some guidelines recommend clinical examination to be performed solely, whereas others recommend in combination with imaging [49,51,52,63]. Time to recurrence also varies with tumor histology. Most osteosarcoma local recurrences have been shown to occur within 5 years of resection. However, late recurrence of both osteosarcoma and Ewing sarcoma have been reported [60,61]. In a study of locally recurrent osteosarcoma, survival rates decreased from 30% at 5 years to 13% at 10 years, suggesting long-term follow-up beyond 5 years is beneficial. Tumor histology, grade, and clinical scenario remain paramount when deciding how to surveil for local recurrence. Bone Scan Whole Body Historically, bone scans have been used for the surveillance of local recurrence. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Local recurrence rates following primary resection of a malignant or aggressive bone tumor vary and depend on tumor grade and histology. Local recurrence rates of bone sarcomas are reported to be approximately 10% to 15% in patients with osteosarcoma and Ewing sarcoma [58-61]. Prognosis is poor for locally recurrent malignant or aggressive bone tumors, with postrecurrence 5-year survival rates reported approximately 15% to 30% in patients with osteosarcoma and 5% in patients with Ewing sarcoma [60,62]. Factors associated with poorer prognosis in patients with osteosarcoma were size of local recurrence (>5 cm) and presence of distant metastasis [60]. Recommendations for local recurrence surveillance imaging vary amongst expert guidelines, although all acknowledge the benefit of clinical evaluation. Locally recurrent bone tumors can often present as a soft tissue mass, and in a study of osteosarcoma local recurrences, the majority (approximately 75%) were soft tissue masses rather than bone lesions [60]. Some guidelines recommend clinical examination to be performed solely, whereas others recommend in combination with imaging [49,51,52,63]. Time to recurrence also varies with tumor histology. Most osteosarcoma local recurrences have been shown to occur within 5 years of resection. However, late recurrence of both osteosarcoma and Ewing sarcoma have been reported [60,61]. In a study of locally recurrent osteosarcoma, survival rates decreased from 30% at 5 years to 13% at 10 years, suggesting long-term follow-up beyond 5 years is beneficial. Tumor histology, grade, and clinical scenario remain paramount when deciding how to surveil for local recurrence. Bone Scan Whole Body Historically, bone scans have been used for the surveillance of local recurrence. | 69428 |
acrac_69428_16 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Increased bone uptake at the primary resection site is nonspecific and can occur for many reasons, including stress changes from adjacent hardware, fractures, and possibly recurrence. With advances in MRI, CT, and PET imaging, the use of bone scan for local recurrence surveillance has decreased. Studies have shown superiority of FDG-PET/CT and MRI versus bone scan for assessment of bone metastases (see Variant 2). Although historically, Tc-99m bone scan has been used to detect bone metastasis, more recent studies have shown Tc-99m bone scan is inferior to FDG-PET/CT in the detection of bone metastases in general oncologic populations [23]. A smaller study of 64 pediatric patients with bone sarcoma also showed greater accuracy of FDG-PET/CT (84%) versus Tc-99m bone scan (70%) in detecting bone metastases during initial staging [22]. There is no relevant literature to support the use of bone scan whole body for surveillance of local recurrence of malignant or aggressive primary bone tumors. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest There is no relevant literature to support the use of bone scan whole body with SPECT or SPECT/CT area of interest for surveillance of local recurrence of malignant or aggressive primary bone tumors. CT Area of Interest With IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors. 9 Malignant or Aggressive Primary Musculoskeletal Tumor | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Increased bone uptake at the primary resection site is nonspecific and can occur for many reasons, including stress changes from adjacent hardware, fractures, and possibly recurrence. With advances in MRI, CT, and PET imaging, the use of bone scan for local recurrence surveillance has decreased. Studies have shown superiority of FDG-PET/CT and MRI versus bone scan for assessment of bone metastases (see Variant 2). Although historically, Tc-99m bone scan has been used to detect bone metastasis, more recent studies have shown Tc-99m bone scan is inferior to FDG-PET/CT in the detection of bone metastases in general oncologic populations [23]. A smaller study of 64 pediatric patients with bone sarcoma also showed greater accuracy of FDG-PET/CT (84%) versus Tc-99m bone scan (70%) in detecting bone metastases during initial staging [22]. There is no relevant literature to support the use of bone scan whole body for surveillance of local recurrence of malignant or aggressive primary bone tumors. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest There is no relevant literature to support the use of bone scan whole body with SPECT or SPECT/CT area of interest for surveillance of local recurrence of malignant or aggressive primary bone tumors. CT Area of Interest With IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors. 9 Malignant or Aggressive Primary Musculoskeletal Tumor | 69428 |
acrac_69428_17 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | CT Area of Interest Without and With IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors. However, given increased radiation dose without clinical benefit, CT without and with IV contrast is usually not recommended over CT with IV contrast alone. CT Area of Interest Without IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors and is usually recommended in this setting. FDG-PET/MRI Whole Body There is no relevant literature to support the use of FDG-PET/MRI whole body as surveillance of local recurrence of malignant or aggressive primary bone tumors. Fluoride PET/CT Whole Body There is no relevant literature to support the use of fluoride PET/CT whole body as surveillance of local recurrence of malignant or aggressive primary bone tumors. MRI Area of Interest Without and With IV Contrast MRI of the primary tumor resection site has further asserted its usefulness for surveillance of local recurrence with improvements in metal artifact reduction. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest Without and With IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors. However, given increased radiation dose without clinical benefit, CT without and with IV contrast is usually not recommended over CT with IV contrast alone. CT Area of Interest Without IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors and is usually recommended in this setting. FDG-PET/MRI Whole Body There is no relevant literature to support the use of FDG-PET/MRI whole body as surveillance of local recurrence of malignant or aggressive primary bone tumors. Fluoride PET/CT Whole Body There is no relevant literature to support the use of fluoride PET/CT whole body as surveillance of local recurrence of malignant or aggressive primary bone tumors. MRI Area of Interest Without and With IV Contrast MRI of the primary tumor resection site has further asserted its usefulness for surveillance of local recurrence with improvements in metal artifact reduction. | 69428 |
acrac_69428_18 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | Given the preference for limb-sparing surgeries, many bone tumor resections require the implantation of hardware which creates local artifact that can obscure the adjacent tissues. Few studies comparing the use of MRI for local recurrence of bone tumors compared with other modalities have been published in recent years likely given its widespread adoption clinically. MRI is often requested before surgery and radiation when local recurrence is established. Given many local recurrences are soft tissue masses, the use of IV contrast remains beneficial to help characterize masses as malignant or benign and can also increase reader confidence [67,68]. MRI Area of Interest Without IV Contrast MRI of the primary tumor resection site has further asserted its usefulness for surveillance of local recurrence with improvements in metal artifact reduction. Given the preference for limb-sparing surgeries, many bone tumor resections require the implantation of hardware, which creates local artifact that can obscure the adjacent tissues. Few studies comparing the use of MRI for local recurrence of bone tumors compared with other modalities have been published in recent years likely given its widespread adoption clinically. MRI is often requested before surgery and radiation when local recurrence is established. Given many local recurrences are soft tissue masses, the use of IV contrast remains beneficial to help characterize masses as malignant or benign and can also increase reader confidence. However, the inherent contrast resolution of MRI, even in the absence of IV contrast, makes this a useful modality to assess for local recurrence of malignant or aggressive primary bone tumors [67,68]. 10 Malignant or Aggressive Primary Musculoskeletal Tumor Radiography Area of Interest Not only is radiography useful to evaluate for bone tumor recurrence, but it is also an invaluable adjunct to MRI interpretation. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Given the preference for limb-sparing surgeries, many bone tumor resections require the implantation of hardware which creates local artifact that can obscure the adjacent tissues. Few studies comparing the use of MRI for local recurrence of bone tumors compared with other modalities have been published in recent years likely given its widespread adoption clinically. MRI is often requested before surgery and radiation when local recurrence is established. Given many local recurrences are soft tissue masses, the use of IV contrast remains beneficial to help characterize masses as malignant or benign and can also increase reader confidence [67,68]. MRI Area of Interest Without IV Contrast MRI of the primary tumor resection site has further asserted its usefulness for surveillance of local recurrence with improvements in metal artifact reduction. Given the preference for limb-sparing surgeries, many bone tumor resections require the implantation of hardware, which creates local artifact that can obscure the adjacent tissues. Few studies comparing the use of MRI for local recurrence of bone tumors compared with other modalities have been published in recent years likely given its widespread adoption clinically. MRI is often requested before surgery and radiation when local recurrence is established. Given many local recurrences are soft tissue masses, the use of IV contrast remains beneficial to help characterize masses as malignant or benign and can also increase reader confidence. However, the inherent contrast resolution of MRI, even in the absence of IV contrast, makes this a useful modality to assess for local recurrence of malignant or aggressive primary bone tumors [67,68]. 10 Malignant or Aggressive Primary Musculoskeletal Tumor Radiography Area of Interest Not only is radiography useful to evaluate for bone tumor recurrence, but it is also an invaluable adjunct to MRI interpretation. | 69428 |
acrac_69428_19 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | When hardware is present, even with modern metal-artifact reduction techniques, radiography can visualize the bone-metal or bone-cement interface, which can be critical to evaluate for tumor recurrence. Radiographs are recommended for the surveillance of local recurrence of malignant or aggressive primary bone tumors. US Area of Interest US is not useful for evaluating bone lesions when there is no extraosseous tumor extension. However, US may be beneficial if a mass is identified clinically. There is no relevant literature to support the use of US as surveillance for asymptomatic local recurrence of malignant or aggressive primary bone tumors. Variant 5: Malignant or aggressive primary soft tissue tumor. Surveillance for local recurrence. The body regions covered in this clinical scenario are abdomen, ankle, chest, elbow, shoulder, thigh, foot, forearm, hand, arm, knee, pelvis, leg, and wrist. Local recurrence rates of soft tissue sarcomas have been reported to occur at rates of 5% to 25% in larger historic studies [69-72]. Although rates of local recurrence following primary resection depend on tumor histology and grade, several other factors have been identified that increase risk. Tumor location is associated with local recurrence, with those tumors located deep to fascia or in the upper extremities/trunk as more likely to recur [73]. Positive or close resection margins have also been associated with increased likelihood of local recurrence [70,73,74]. Local recurrence is associated with metastatic disease and increased mortality [70], and if the recurrence can be treated before developing metastatic disease there is a survival benefit [73]. Size of the recurrence has also been linked with not only survival [75] but also morbidity, because larger tumors often require more extensive surgery [48]. Therefore, surveillance for local recurrence is important to reduce both mortality and morbidity. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. When hardware is present, even with modern metal-artifact reduction techniques, radiography can visualize the bone-metal or bone-cement interface, which can be critical to evaluate for tumor recurrence. Radiographs are recommended for the surveillance of local recurrence of malignant or aggressive primary bone tumors. US Area of Interest US is not useful for evaluating bone lesions when there is no extraosseous tumor extension. However, US may be beneficial if a mass is identified clinically. There is no relevant literature to support the use of US as surveillance for asymptomatic local recurrence of malignant or aggressive primary bone tumors. Variant 5: Malignant or aggressive primary soft tissue tumor. Surveillance for local recurrence. The body regions covered in this clinical scenario are abdomen, ankle, chest, elbow, shoulder, thigh, foot, forearm, hand, arm, knee, pelvis, leg, and wrist. Local recurrence rates of soft tissue sarcomas have been reported to occur at rates of 5% to 25% in larger historic studies [69-72]. Although rates of local recurrence following primary resection depend on tumor histology and grade, several other factors have been identified that increase risk. Tumor location is associated with local recurrence, with those tumors located deep to fascia or in the upper extremities/trunk as more likely to recur [73]. Positive or close resection margins have also been associated with increased likelihood of local recurrence [70,73,74]. Local recurrence is associated with metastatic disease and increased mortality [70], and if the recurrence can be treated before developing metastatic disease there is a survival benefit [73]. Size of the recurrence has also been linked with not only survival [75] but also morbidity, because larger tumors often require more extensive surgery [48]. Therefore, surveillance for local recurrence is important to reduce both mortality and morbidity. | 69428 |
acrac_69428_20 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | There remains some controversy not only on how to surveil resected soft tissue sarcomas but also if imaging surveillance is even necessary. The primary dispute against the need for imaging surveillance is the argument that recurrences are usually clinically detectable [54,76]. The literature also has some conflicting evidence on this topic. For example, a prospective study of 500 patients with sarcoma found 90% of local recurrences were clinically detected [54]. Conversely, a large recent study of 325 patients with soft tissue sarcomas found a rate of 60% of the local recurrences were not detected clinically [77]. Expert guidelines vary on recommendations for local recurrence imaging, although all acknowledge the benefit of clinical evaluation; some guidelines recommend clinical examination to be performed solely, whereas others recommend in combination with imaging [49,51,52,63]. Clinical evaluation of deep soft tissue local recurrence remains a limitation of this approach. Most local recurrences of soft tissue sarcomas occur within 5 years of primary resection [78]. Therefore, those guidelines that recommend imaging usually advocate for more aggressive imaging in the first 5 years that taper off to annual imaging. Tumor histology, grade, and clinical scenario remain paramount when deciding how to surveil for local recurrence. CT Area of Interest With IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. There remains some controversy not only on how to surveil resected soft tissue sarcomas but also if imaging surveillance is even necessary. The primary dispute against the need for imaging surveillance is the argument that recurrences are usually clinically detectable [54,76]. The literature also has some conflicting evidence on this topic. For example, a prospective study of 500 patients with sarcoma found 90% of local recurrences were clinically detected [54]. Conversely, a large recent study of 325 patients with soft tissue sarcomas found a rate of 60% of the local recurrences were not detected clinically [77]. Expert guidelines vary on recommendations for local recurrence imaging, although all acknowledge the benefit of clinical evaluation; some guidelines recommend clinical examination to be performed solely, whereas others recommend in combination with imaging [49,51,52,63]. Clinical evaluation of deep soft tissue local recurrence remains a limitation of this approach. Most local recurrences of soft tissue sarcomas occur within 5 years of primary resection [78]. Therefore, those guidelines that recommend imaging usually advocate for more aggressive imaging in the first 5 years that taper off to annual imaging. Tumor histology, grade, and clinical scenario remain paramount when deciding how to surveil for local recurrence. CT Area of Interest With IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment. | 69428 |
acrac_69428_21 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | CT Area of Interest Without and With IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment. However, CT without and with IV contrast is usually not recommended over CT with IV contrast alone. CT Area of Interest Without IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the 11 Malignant or Aggressive Primary Musculoskeletal Tumor conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment. FDG-PET/CT Whole Body FDG-PET/CT has the added benefit of not only thin-slice CT imaging but also the ability to detect metabolically active disease. FDG-PET/CT is highly accurate in detecting recurrent soft tissue and bone sarcomas, and may be useful as a problem-solving tool when other imaging of the area of interest is equivocal. A retrospective single- institution study of 43 patients with bone or soft tissue sarcomas found better sensitivity and specificity of FDG- PET/CT follow-up versus contrast-enhanced CT imaging (94% and 92% versus 78% and 67%, respectively) [79]. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest Without and With IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment. However, CT without and with IV contrast is usually not recommended over CT with IV contrast alone. CT Area of Interest Without IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the 11 Malignant or Aggressive Primary Musculoskeletal Tumor conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment. FDG-PET/CT Whole Body FDG-PET/CT has the added benefit of not only thin-slice CT imaging but also the ability to detect metabolically active disease. FDG-PET/CT is highly accurate in detecting recurrent soft tissue and bone sarcomas, and may be useful as a problem-solving tool when other imaging of the area of interest is equivocal. A retrospective single- institution study of 43 patients with bone or soft tissue sarcomas found better sensitivity and specificity of FDG- PET/CT follow-up versus contrast-enhanced CT imaging (94% and 92% versus 78% and 67%, respectively) [79]. | 69428 |
acrac_69428_22 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | A retrospective single-institution study of 152 patients with soft tissue sarcomas comparing whole body FDG- PET/CT with MRI at the primary treatment site did not detect a significant difference in performance for detecting local recurrence (MRI sensitivity of 90% and specificity of 98%, compared with FDG-PET/CT sensitivity of 95% and specificity of 96%) [80]. FDG-PET/MRI Whole Body A retrospective single-institution study of 41 patients with resected soft tissue sarcomas and with clinically suspicious recurrence underwent FDG-PET/MRI, either whole body if a truncal primary or localized to the primary tumor site if an extremity sarcoma. The MRI portion and then FDG-PET/MRI portions were interpreted independently. With the addition of FDG-PET imaging to the MRI, sensitivity increased from 82% to 96%, although specificity mildly decreased from 85% to 79%. Diagnostic confidence increased for the readers [81]. FDG- PET/MRI whole body may be useful as a problem-solving tool when other imaging of the area of interest is equivocal. MRI Area of Interest Without and With IV Contrast MRI used as surveillance of the primary soft tissue tumor site is the mainstay for evaluating local recurrence. Few studies regarding the diagnostic utility of MRI for local recurrence of soft tissue sarcomas have been published in recent years, likely given its widespread adoption clinically. MRI is useful not only for asymptomatic surveillance but also if a clinical area of concern at the resection site develops. MRI is often requested before surgery and radiation when local recurrence is established. A retrospective single-institution study by Park et al [77] of 325 patients with extremity sarcoma with a local recurrence rate of 11% found MRI detected 60% of those patients with recurrence not identified clinically or with US. Those with MRI detected local recurrence trended towards better survival, but this did not reach statistical significance. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. A retrospective single-institution study of 152 patients with soft tissue sarcomas comparing whole body FDG- PET/CT with MRI at the primary treatment site did not detect a significant difference in performance for detecting local recurrence (MRI sensitivity of 90% and specificity of 98%, compared with FDG-PET/CT sensitivity of 95% and specificity of 96%) [80]. FDG-PET/MRI Whole Body A retrospective single-institution study of 41 patients with resected soft tissue sarcomas and with clinically suspicious recurrence underwent FDG-PET/MRI, either whole body if a truncal primary or localized to the primary tumor site if an extremity sarcoma. The MRI portion and then FDG-PET/MRI portions were interpreted independently. With the addition of FDG-PET imaging to the MRI, sensitivity increased from 82% to 96%, although specificity mildly decreased from 85% to 79%. Diagnostic confidence increased for the readers [81]. FDG- PET/MRI whole body may be useful as a problem-solving tool when other imaging of the area of interest is equivocal. MRI Area of Interest Without and With IV Contrast MRI used as surveillance of the primary soft tissue tumor site is the mainstay for evaluating local recurrence. Few studies regarding the diagnostic utility of MRI for local recurrence of soft tissue sarcomas have been published in recent years, likely given its widespread adoption clinically. MRI is useful not only for asymptomatic surveillance but also if a clinical area of concern at the resection site develops. MRI is often requested before surgery and radiation when local recurrence is established. A retrospective single-institution study by Park et al [77] of 325 patients with extremity sarcoma with a local recurrence rate of 11% found MRI detected 60% of those patients with recurrence not identified clinically or with US. Those with MRI detected local recurrence trended towards better survival, but this did not reach statistical significance. | 69428 |
acrac_69428_23 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | MRI has been criticized as having many false-positive results, leading to unnecessary procedures and emotional distress [82]. A retrospective single-institution study of 11 local recurrences in 124 patients with soft tissue sarcoma found MRI had a positive predictive value of only 42% with 11 false-positive examinations in this cohort and advocated for clinical surveillance only [83]. However, the Park et al [77] larger single-institution studies found a positive predictive value of 93%. Postcontrast imaging has been shown to add benefit in evaluation of soft tissue tumors to differentiate benign versus malignant lesions [68]. A more recent retrospective study assessing the added value of postcontrast MRI showed contrast improved reader confidence even for experienced readers and improved accuracy of a more inexperienced reader from 65% to 72% [67]. MRI Area of Interest Without IV Contrast MRI used as surveillance of the primary soft tissue tumor site is the mainstay for evaluating local recurrence. Few studies regarding the diagnostic utility of MRI for local recurrence of soft tissue sarcomas have been published in recent years, likely given its widespread adoption clinically. MRI is useful not only for asymptomatic surveillance but also if a clinical area of concern at the resection site develops. MRI is often requested before surgery and radiation when local recurrence is established. A retrospective single-institution study by Park et al [77] of 325 patients with extremity sarcoma with a local recurrence rate of 11% found MRI detected 60% of those patients with recurrence not identified clinically or with US. Those with MRI detected local recurrence trended towards better survival but this did not reach statistical significance. MRI has been criticized as having many false-positive results leading to unnecessary procedures and emotional distress [82]. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. MRI has been criticized as having many false-positive results, leading to unnecessary procedures and emotional distress [82]. A retrospective single-institution study of 11 local recurrences in 124 patients with soft tissue sarcoma found MRI had a positive predictive value of only 42% with 11 false-positive examinations in this cohort and advocated for clinical surveillance only [83]. However, the Park et al [77] larger single-institution studies found a positive predictive value of 93%. Postcontrast imaging has been shown to add benefit in evaluation of soft tissue tumors to differentiate benign versus malignant lesions [68]. A more recent retrospective study assessing the added value of postcontrast MRI showed contrast improved reader confidence even for experienced readers and improved accuracy of a more inexperienced reader from 65% to 72% [67]. MRI Area of Interest Without IV Contrast MRI used as surveillance of the primary soft tissue tumor site is the mainstay for evaluating local recurrence. Few studies regarding the diagnostic utility of MRI for local recurrence of soft tissue sarcomas have been published in recent years, likely given its widespread adoption clinically. MRI is useful not only for asymptomatic surveillance but also if a clinical area of concern at the resection site develops. MRI is often requested before surgery and radiation when local recurrence is established. A retrospective single-institution study by Park et al [77] of 325 patients with extremity sarcoma with a local recurrence rate of 11% found MRI detected 60% of those patients with recurrence not identified clinically or with US. Those with MRI detected local recurrence trended towards better survival but this did not reach statistical significance. MRI has been criticized as having many false-positive results leading to unnecessary procedures and emotional distress [82]. | 69428 |
acrac_69428_24 | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs | A retrospective single-institution study of 11 local recurrences in 124 patients with soft tissue sarcoma found MRI had a positive predictive value of only 42% with 11 false-positive examinations in this cohort and advocated for clinical surveillance only [83]. However, the Park et al [77] larger single-institution studies found a positive predictive value of 93%. 12 Malignant or Aggressive Primary Musculoskeletal Tumor Postcontrast imaging has been shown to add benefit in evaluation of soft tissue tumors to differentiate benign versus malignant lesions [68]. A more recent retrospective study assessing the added value of postcontrast MRI showed contrast improved reader confidence even for experienced readers and improved accuracy of a more inexperienced reader from 65% to 72% [67]. However, MRI without IV contrast is still highly sensitive in detecting local recurrence of soft tissue tumor because of an inherent soft tissue contrast of MRI and therefore is still of benefit. Radiography Area of Interest In rare instances of a primary soft tissue tumor that produces osseous or chondroid matrix, there may be limited benefit of radiography area of interest for detecting local recurrence, but in general this modality is usually not helpful for most patients. There is no relevant literature to support the use of radiography alone as surveillance for local recurrence of malignant or aggressive primary soft tissue tumors. US Area of Interest Local recurrence of a soft tissue tumor can be detected with US. Note that most studies comparing US with MRI are outdated because both US and MRI technology have advanced significantly. | Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. A retrospective single-institution study of 11 local recurrences in 124 patients with soft tissue sarcoma found MRI had a positive predictive value of only 42% with 11 false-positive examinations in this cohort and advocated for clinical surveillance only [83]. However, the Park et al [77] larger single-institution studies found a positive predictive value of 93%. 12 Malignant or Aggressive Primary Musculoskeletal Tumor Postcontrast imaging has been shown to add benefit in evaluation of soft tissue tumors to differentiate benign versus malignant lesions [68]. A more recent retrospective study assessing the added value of postcontrast MRI showed contrast improved reader confidence even for experienced readers and improved accuracy of a more inexperienced reader from 65% to 72% [67]. However, MRI without IV contrast is still highly sensitive in detecting local recurrence of soft tissue tumor because of an inherent soft tissue contrast of MRI and therefore is still of benefit. Radiography Area of Interest In rare instances of a primary soft tissue tumor that produces osseous or chondroid matrix, there may be limited benefit of radiography area of interest for detecting local recurrence, but in general this modality is usually not helpful for most patients. There is no relevant literature to support the use of radiography alone as surveillance for local recurrence of malignant or aggressive primary soft tissue tumors. US Area of Interest Local recurrence of a soft tissue tumor can be detected with US. Note that most studies comparing US with MRI are outdated because both US and MRI technology have advanced significantly. | 69428 |
acrac_3101564_0 | Scoliosis Child | It should be noted that the diagnosis of idiopathic scoliosis is of exclusion. This includes exclusion of a variety of neuromuscular disorders commonly associated with scoliosis, such as cerebral palsy and muscular dystrophy. Intramedullary, extramedullary, and vertebral tumors can be associated with scoliosis, with osteoid osteoma of the posterior elements perhaps being the most well-known. Vertebral infections, such as tuberculosis, may also result in kyphoscoliosis [1,2]. Conditions with dysplastic skeletal development should also be clinically excluded, including osteogenesis imperfecta, neurofibromatosis type I, Marfan syndrome, Ehlers-Danlos syndrome, and achondroplasia. Clinical presentation and physical examination in idiopathic scoliosis are negative for cutaneous stigmata that suggest underlying spinal dysraphism (hemangioma, hairy patches, nevi, dermal appendages, or sinus tracts) [10]. When radiographs reveal anomalies of vertebral formation or segmentation, the scoliosis is termed congenital, accounting for up to 10% of surgical patients [2]. Neural axis anomalies, such as hydrosyringomyelia, Chiari malformation, and cord tethering, have been reported to occur in more than 20% of such patients who thus may benefit from routine preoperative MRI [11]. 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] MRI MRI of the spine, with its superior soft-tissue contrast is selectively used in the setting of scoliosis to detect and characterize suspected intraspinal abnormalities. | Scoliosis Child. It should be noted that the diagnosis of idiopathic scoliosis is of exclusion. This includes exclusion of a variety of neuromuscular disorders commonly associated with scoliosis, such as cerebral palsy and muscular dystrophy. Intramedullary, extramedullary, and vertebral tumors can be associated with scoliosis, with osteoid osteoma of the posterior elements perhaps being the most well-known. Vertebral infections, such as tuberculosis, may also result in kyphoscoliosis [1,2]. Conditions with dysplastic skeletal development should also be clinically excluded, including osteogenesis imperfecta, neurofibromatosis type I, Marfan syndrome, Ehlers-Danlos syndrome, and achondroplasia. Clinical presentation and physical examination in idiopathic scoliosis are negative for cutaneous stigmata that suggest underlying spinal dysraphism (hemangioma, hairy patches, nevi, dermal appendages, or sinus tracts) [10]. When radiographs reveal anomalies of vertebral formation or segmentation, the scoliosis is termed congenital, accounting for up to 10% of surgical patients [2]. Neural axis anomalies, such as hydrosyringomyelia, Chiari malformation, and cord tethering, have been reported to occur in more than 20% of such patients who thus may benefit from routine preoperative MRI [11]. 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] MRI MRI of the spine, with its superior soft-tissue contrast is selectively used in the setting of scoliosis to detect and characterize suspected intraspinal abnormalities. | 3101564 |
acrac_3101564_1 | Scoliosis Child | Intravenous (IV) gadolinium-based contrast agents are not routinely used in the setting of scoliosis, except in those instances when tumor or infection is a consideration. CT Multiplanar and 3-D reconstruction CT of the bony spine can help in selected cases for presurgical planning. In addition, the volumetric CT data can be used for surgical navigation [16,17]. CT may also be used to characterize and define the extent of the lesion, such as with the nidus of an osteoid osteoma. CT can be rapidly acquired, and low-dose protocols have been developed and implemented [18]. IV iodine-based contrast is almost never warranted in the perioperative setting, the exception being when tumor or infection is suspected and MRI with contrast cannot be obtained because of a contraindication. Bone Scan Tc-99m methyl diphosphonate (MDP) bone scintigraphy has been advocated in the specific setting of painful scoliosis and is particularly sensitive in cases with primary bone tumors, such as osteoid osteoma or osteoblastoma, spondylolysis, and infection. However, generalized pain is common in scoliosis, occurring in up to a third of idiopathic cases, and radiography often demonstrates the etiology in those individuals with an underlying bone abnormality [19]. Bone scintigraphy findings are usually not specific. Therefore, after initial evaluation with radiography, MRI is generally the second-line imaging modality even in the setting where a primary bone tumor, such as osteoid osteoma, is a consideration [20]. Discussion of Procedures by Variant Variant 1: Child. Congenital scoliosis. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. | Scoliosis Child. Intravenous (IV) gadolinium-based contrast agents are not routinely used in the setting of scoliosis, except in those instances when tumor or infection is a consideration. CT Multiplanar and 3-D reconstruction CT of the bony spine can help in selected cases for presurgical planning. In addition, the volumetric CT data can be used for surgical navigation [16,17]. CT may also be used to characterize and define the extent of the lesion, such as with the nidus of an osteoid osteoma. CT can be rapidly acquired, and low-dose protocols have been developed and implemented [18]. IV iodine-based contrast is almost never warranted in the perioperative setting, the exception being when tumor or infection is suspected and MRI with contrast cannot be obtained because of a contraindication. Bone Scan Tc-99m methyl diphosphonate (MDP) bone scintigraphy has been advocated in the specific setting of painful scoliosis and is particularly sensitive in cases with primary bone tumors, such as osteoid osteoma or osteoblastoma, spondylolysis, and infection. However, generalized pain is common in scoliosis, occurring in up to a third of idiopathic cases, and radiography often demonstrates the etiology in those individuals with an underlying bone abnormality [19]. Bone scintigraphy findings are usually not specific. Therefore, after initial evaluation with radiography, MRI is generally the second-line imaging modality even in the setting where a primary bone tumor, such as osteoid osteoma, is a consideration [20]. Discussion of Procedures by Variant Variant 1: Child. Congenital scoliosis. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. | 3101564 |
acrac_3101564_2 | Scoliosis Child | MRI Complete Spine Congenital scoliosis as a result of abnormal vertebral formation and segmentation has been shown to be associated with a high incidence of intraspinal anomalies, with a reported prevalence ranging from 20% to 58% [11]. Underlying anomalies include tethered cord, filar lipoma, syringohydromyelia, and diastematomyelia [11]. In a study of 76 patients, Belmont et al [11] noted a prevalence of intraspinal anomalies in 28% of patients with isolated hemivertebra and 21% of patients with more complex vertebral anomalies. Interestingly, history and physical examination only demonstrated an accuracy of 62% for diagnosing an intraspinal anomaly with a hemivertebra. Shen et al [24], in a study of 226 Chinese surgical cases for congenital scoliosis, found a 43% incidence of intraspinal anomalies, the most common being diastematomyelia. Again, similar to the study by Belmont et al, a negative neurologic examination did not predict a normal MRI examination. MRI was suggested in both of these studies for the complete evaluation of congenital scoliosis. CT Spine CT may play a role in the initial imaging evaluation of congenital scoliosis. Multiplanar and 3-D volume rendered reformatted images derived from the axially acquired data set provide multiple views of the spine, allowing a perspective not readily available with conventional radiographs [25,26]. CT may specifically aid in the visualization and characterization of the osseous septum in type I split cord malformations [27]. CT is also helpful in presurgical planning for congenital scoliosis, facilitating visualization of the bony malformations and reducing instrumentation-related complications. Wu et al [26] reported a reduction in the rate of screw misplacement using CT-assisted planning, 6.5% as compared to 15.3% when using C-arm alone. Bone Scan Complete Spine Tc-99m MDP is not a primary imaging modality in the setting of congenital scoliosis as it provides no intraspinal information. Variant 2: Child (0 to 9 years of age). | Scoliosis Child. MRI Complete Spine Congenital scoliosis as a result of abnormal vertebral formation and segmentation has been shown to be associated with a high incidence of intraspinal anomalies, with a reported prevalence ranging from 20% to 58% [11]. Underlying anomalies include tethered cord, filar lipoma, syringohydromyelia, and diastematomyelia [11]. In a study of 76 patients, Belmont et al [11] noted a prevalence of intraspinal anomalies in 28% of patients with isolated hemivertebra and 21% of patients with more complex vertebral anomalies. Interestingly, history and physical examination only demonstrated an accuracy of 62% for diagnosing an intraspinal anomaly with a hemivertebra. Shen et al [24], in a study of 226 Chinese surgical cases for congenital scoliosis, found a 43% incidence of intraspinal anomalies, the most common being diastematomyelia. Again, similar to the study by Belmont et al, a negative neurologic examination did not predict a normal MRI examination. MRI was suggested in both of these studies for the complete evaluation of congenital scoliosis. CT Spine CT may play a role in the initial imaging evaluation of congenital scoliosis. Multiplanar and 3-D volume rendered reformatted images derived from the axially acquired data set provide multiple views of the spine, allowing a perspective not readily available with conventional radiographs [25,26]. CT may specifically aid in the visualization and characterization of the osseous septum in type I split cord malformations [27]. CT is also helpful in presurgical planning for congenital scoliosis, facilitating visualization of the bony malformations and reducing instrumentation-related complications. Wu et al [26] reported a reduction in the rate of screw misplacement using CT-assisted planning, 6.5% as compared to 15.3% when using C-arm alone. Bone Scan Complete Spine Tc-99m MDP is not a primary imaging modality in the setting of congenital scoliosis as it provides no intraspinal information. Variant 2: Child (0 to 9 years of age). | 3101564 |
acrac_3101564_3 | Scoliosis Child | Early onset idiopathic scoliosis. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. MRI Complete Spine Juvenile idiopathic scoliosis carries higher risk for intraspinal anomalies as compared with adolescent idiopathic scoliosis with a range of 13% to 27% [28-30]. Some suggest selective MRI for curve progression, neurologic status change, or routinely when surgical intervention is planned [30], or presurgically when there is back pain [9]. Other authors recommend total spine MRI for all patients with juvenile idiopathic scoliosis [28]. CT Spine CT does not play a significant role in the initial diagnostic assessment of early onset idiopathic scoliosis as it is limited with respect to intraspinal assessment. Bone Scan Complete Spine Tc-99m MDP is not a primary imaging modality in the setting of early onset idiopathic scoliosis as it provides no intraspinal information. Variant 3: Adolescent (10 to 17 years of age). Adolescent idiopathic scoliosis. No risk factors. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. Surgical decision making and planning is also influenced by the flexibility of the curves, which can be assessed using a variety of radiographic techniques, such as side bending, push prone, fulcrum bending, and traction radiographs [33-37]. Cheh et al [38] found that a single supine spine radiograph can predict curve type, flexibility, and structurality. | Scoliosis Child. Early onset idiopathic scoliosis. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. MRI Complete Spine Juvenile idiopathic scoliosis carries higher risk for intraspinal anomalies as compared with adolescent idiopathic scoliosis with a range of 13% to 27% [28-30]. Some suggest selective MRI for curve progression, neurologic status change, or routinely when surgical intervention is planned [30], or presurgically when there is back pain [9]. Other authors recommend total spine MRI for all patients with juvenile idiopathic scoliosis [28]. CT Spine CT does not play a significant role in the initial diagnostic assessment of early onset idiopathic scoliosis as it is limited with respect to intraspinal assessment. Bone Scan Complete Spine Tc-99m MDP is not a primary imaging modality in the setting of early onset idiopathic scoliosis as it provides no intraspinal information. Variant 3: Adolescent (10 to 17 years of age). Adolescent idiopathic scoliosis. No risk factors. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. Surgical decision making and planning is also influenced by the flexibility of the curves, which can be assessed using a variety of radiographic techniques, such as side bending, push prone, fulcrum bending, and traction radiographs [33-37]. Cheh et al [38] found that a single supine spine radiograph can predict curve type, flexibility, and structurality. | 3101564 |
acrac_3101564_4 | Scoliosis Child | SOSORT suggests limiting spine radiographs to once every 12 months for adolescent patients at Risser stages 0 to 3 and every 18 months for patients at Risser stages 4 to 5 unless there are objective clinical changes in the appearance of the scoliosis [39]. CT Spine CT of the spine in adolescent idiopathic scoliosis is not routinely used in initial diagnostic assessment. Rather, some orthopedists use perioperative CT for presurgical planning and intraoperative navigation to optimize screw placement [16,17,40,41]. Bone Scan Complete Spine Tc-99m MDP is not a primary imaging modality in the setting of adolescent idiopathic scoliosis as it provides no intraspinal information. Variant 4: Adolescent (10 to 17 years of age). Adolescent idiopathic scoliosis. Risk factors. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. Surgical decision making and planning is also influenced by the flexibility of the curves, which can be assessed using a variety of radiographic techniques, such as side bending, push prone, fulcrum bending, and traction radiographs [33-37]. Cheh et al [38] noted that a single supine spine radiograph can predict nonstructural minor curves as well. SOSORT suggests limiting spine radiographs to once every 12 months for those adolescent patients at Risser stages 0 to 3 and every 18 months for patients at Risser stages 4 to 5, unless there are objective clinical changes in the appearance of the scoliosis [39]. MRI Complete Spine Up to 2% to 4% of adolescents with scoliosis have an intrinsic anomaly of their spinal cord or spinal contents that can only be identified with MRI [4,5]. The most common abnormalities revealed by MRI include Chiari I malformation, cord syrinx, cord tethering, and, more rarely, intrinsic spinal cord tumor [4,6]. | Scoliosis Child. SOSORT suggests limiting spine radiographs to once every 12 months for adolescent patients at Risser stages 0 to 3 and every 18 months for patients at Risser stages 4 to 5 unless there are objective clinical changes in the appearance of the scoliosis [39]. CT Spine CT of the spine in adolescent idiopathic scoliosis is not routinely used in initial diagnostic assessment. Rather, some orthopedists use perioperative CT for presurgical planning and intraoperative navigation to optimize screw placement [16,17,40,41]. Bone Scan Complete Spine Tc-99m MDP is not a primary imaging modality in the setting of adolescent idiopathic scoliosis as it provides no intraspinal information. Variant 4: Adolescent (10 to 17 years of age). Adolescent idiopathic scoliosis. Risk factors. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. Surgical decision making and planning is also influenced by the flexibility of the curves, which can be assessed using a variety of radiographic techniques, such as side bending, push prone, fulcrum bending, and traction radiographs [33-37]. Cheh et al [38] noted that a single supine spine radiograph can predict nonstructural minor curves as well. SOSORT suggests limiting spine radiographs to once every 12 months for those adolescent patients at Risser stages 0 to 3 and every 18 months for patients at Risser stages 4 to 5, unless there are objective clinical changes in the appearance of the scoliosis [39]. MRI Complete Spine Up to 2% to 4% of adolescents with scoliosis have an intrinsic anomaly of their spinal cord or spinal contents that can only be identified with MRI [4,5]. The most common abnormalities revealed by MRI include Chiari I malformation, cord syrinx, cord tethering, and, more rarely, intrinsic spinal cord tumor [4,6]. | 3101564 |
acrac_69473_0 | Palpable Abdominal Mass Suspected Neoplasm | Discussion of Procedures by Variant Variant 1: Palpable abdominal mass. Suspected intra-abdominal neoplasm. Initial imaging. Little has been written about the use of imaging in evaluating palpable abdominal masses since the 1980s. Newer reviews and case reports have focused on evaluation of specific masses using CT, ultrasound (US), and MRI. Radiography of the abdomen and fluoroscopy play a limited role in the diagnosis and workup of a palpable intra-abdominal mass. CT Abdomen There have been no recent studies on the diagnostic yield of CT for abdominal masses; however, it is widely used and assumed to be accurate in patients presenting with varying pathologies that may cause an abdominal mass [4- 7]. Most data on diagnostic accuracy stem from studies that are >30 years old. In a controlled trial from 1981 by Dixon et al [8], CT established diagnosis more quickly and reduced inpatient workup times in patients with abdominal masses when compared against conventional radiography and workup. In another study from 1984 by Williams et al [9], CT demonstrated high positive predictive value (99%) and negative predictive value (97%) for determining the presence or absence of a mass and correctly identified the organ of origin in 93% of patients with palpable abnormalities on clinical examination. The Dixon et al [8] study demonstrated that, compared with strategies not using CT, the use of CT can result in savings in time for diagnosis. Accordingly, when US findings are indeterminate, CT imaging should be obtained in a timely manner. Organomegaly (ie, enlargement of the liver, spleen, or kidneys), may present with a palpable mass. The differential diagnosis is lengthy, including lymphoma, primary organ disease, metastatic disease, extramedullary hematopoiesis, granulomatous disease, and infections. CT can provide clues to help narrow the differential aPanel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri. | Palpable Abdominal Mass Suspected Neoplasm. Discussion of Procedures by Variant Variant 1: Palpable abdominal mass. Suspected intra-abdominal neoplasm. Initial imaging. Little has been written about the use of imaging in evaluating palpable abdominal masses since the 1980s. Newer reviews and case reports have focused on evaluation of specific masses using CT, ultrasound (US), and MRI. Radiography of the abdomen and fluoroscopy play a limited role in the diagnosis and workup of a palpable intra-abdominal mass. CT Abdomen There have been no recent studies on the diagnostic yield of CT for abdominal masses; however, it is widely used and assumed to be accurate in patients presenting with varying pathologies that may cause an abdominal mass [4- 7]. Most data on diagnostic accuracy stem from studies that are >30 years old. In a controlled trial from 1981 by Dixon et al [8], CT established diagnosis more quickly and reduced inpatient workup times in patients with abdominal masses when compared against conventional radiography and workup. In another study from 1984 by Williams et al [9], CT demonstrated high positive predictive value (99%) and negative predictive value (97%) for determining the presence or absence of a mass and correctly identified the organ of origin in 93% of patients with palpable abnormalities on clinical examination. The Dixon et al [8] study demonstrated that, compared with strategies not using CT, the use of CT can result in savings in time for diagnosis. Accordingly, when US findings are indeterminate, CT imaging should be obtained in a timely manner. Organomegaly (ie, enlargement of the liver, spleen, or kidneys), may present with a palpable mass. The differential diagnosis is lengthy, including lymphoma, primary organ disease, metastatic disease, extramedullary hematopoiesis, granulomatous disease, and infections. CT can provide clues to help narrow the differential aPanel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri. | 69473 |
acrac_69473_1 | Palpable Abdominal Mass Suspected Neoplasm | bVirginia Tech Carilion School of Medicine, Roanoke, Virginia. cPanel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin. dUniversity of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association. eNewton-Wellesley Hospital, Newton, Massachusetts. fThe University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons. gH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. hMassachusetts General Hospital, Boston, Massachusetts. iMedstar Georgetown University Hospital, Washington, District of Columbia. jCleveland Clinic, Cleveland, Ohio. kDuke University Medical Center, Durham, North Carolina. lEmory University, Atlanta, Georgia. mPenn State Health, Hershey, Pennsylvania. nUniversity of Alabama at Birmingham, Birmingham, Alabama. oBeth Israel Deaconess Medical Center, Boston, Massachusetts. pSpecialty 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] Palpable Abdominal Mass-Suspected Neoplasm diagnosis, although biopsy is often warranted [6,10]. CT is considered safe and effective for guiding percutaneous biopsies if the pathology can be visualized and the operator has knowledge of technical parameters, such as the need for breath holding, triangulation methods, gantry angling, and appropriate patient positioning [11-13]. There are no recent studies that specifically address the question of whether CT should be performed with or without intravenous (IV) contrast for a palpable mass. | Palpable Abdominal Mass Suspected Neoplasm. bVirginia Tech Carilion School of Medicine, Roanoke, Virginia. cPanel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin. dUniversity of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association. eNewton-Wellesley Hospital, Newton, Massachusetts. fThe University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons. gH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. hMassachusetts General Hospital, Boston, Massachusetts. iMedstar Georgetown University Hospital, Washington, District of Columbia. jCleveland Clinic, Cleveland, Ohio. kDuke University Medical Center, Durham, North Carolina. lEmory University, Atlanta, Georgia. mPenn State Health, Hershey, Pennsylvania. nUniversity of Alabama at Birmingham, Birmingham, Alabama. oBeth Israel Deaconess Medical Center, Boston, Massachusetts. pSpecialty 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] Palpable Abdominal Mass-Suspected Neoplasm diagnosis, although biopsy is often warranted [6,10]. CT is considered safe and effective for guiding percutaneous biopsies if the pathology can be visualized and the operator has knowledge of technical parameters, such as the need for breath holding, triangulation methods, gantry angling, and appropriate patient positioning [11-13]. There are no recent studies that specifically address the question of whether CT should be performed with or without intravenous (IV) contrast for a palpable mass. | 69473 |
acrac_69473_2 | Palpable Abdominal Mass Suspected Neoplasm | Acquisition of CT both with and without contrast does not generally add diagnostic value. Although available evidence and experience generally supports the appropriateness of CT with IV contrast over that of noncontrast CT for evaluation of intra-abdominal organs and pathology [12,14,15], the use of noncontrast CT may be of value in some circumstances. US Abdomen US has many positive attributes and is a useful tool for detecting and diagnosing potential intra-abdominal masses [4-6,16-19]. In a retrospective study including 104 patients with palpable masses referred for US evaluation, 69 had a correlative mass and US correctly identified the organ of origin in 88% of patients [17]. The 3 cases where the organ of origin was not positively identified were all masses arising in the pelvis (endometriosis, uterine fibroids, and ovarian tumor), which were later defined on CT. Despite the failure in these cases, the positive predictive value was 99% and negative predictive value 97% for identifying or excluding a mass. The one false- negative case was a patient with palpable mass on examination who had a negative US but subsequently positive CT demonstrating transverse colon cancer. The accuracy for identifying the organ of origin ranges from 88% to 91%, and 77% to 81% for correctly suggesting the underlying pathology [16,17,20,21]. Although highly accurate, US visibility of the abdominal cavity may be limited because of bowel gas and body habitus. On the other hand, US has the benefit of real-time imaging. This can be very advantageous in the setting of palpable abnormality, providing additional information, such as tenderness, direct correlation, and dynamic changes like Valsalva maneuvers, when assessing for hernias. Studies have suggested that portable US units may improve diagnostic accuracy for detecting organomegaly [22] and may help to determine the need for additional diagnostic testing with a sensitivity of 91% and specificity of 83% [23]. | Palpable Abdominal Mass Suspected Neoplasm. Acquisition of CT both with and without contrast does not generally add diagnostic value. Although available evidence and experience generally supports the appropriateness of CT with IV contrast over that of noncontrast CT for evaluation of intra-abdominal organs and pathology [12,14,15], the use of noncontrast CT may be of value in some circumstances. US Abdomen US has many positive attributes and is a useful tool for detecting and diagnosing potential intra-abdominal masses [4-6,16-19]. In a retrospective study including 104 patients with palpable masses referred for US evaluation, 69 had a correlative mass and US correctly identified the organ of origin in 88% of patients [17]. The 3 cases where the organ of origin was not positively identified were all masses arising in the pelvis (endometriosis, uterine fibroids, and ovarian tumor), which were later defined on CT. Despite the failure in these cases, the positive predictive value was 99% and negative predictive value 97% for identifying or excluding a mass. The one false- negative case was a patient with palpable mass on examination who had a negative US but subsequently positive CT demonstrating transverse colon cancer. The accuracy for identifying the organ of origin ranges from 88% to 91%, and 77% to 81% for correctly suggesting the underlying pathology [16,17,20,21]. Although highly accurate, US visibility of the abdominal cavity may be limited because of bowel gas and body habitus. On the other hand, US has the benefit of real-time imaging. This can be very advantageous in the setting of palpable abnormality, providing additional information, such as tenderness, direct correlation, and dynamic changes like Valsalva maneuvers, when assessing for hernias. Studies have suggested that portable US units may improve diagnostic accuracy for detecting organomegaly [22] and may help to determine the need for additional diagnostic testing with a sensitivity of 91% and specificity of 83% [23]. | 69473 |
acrac_69473_3 | Palpable Abdominal Mass Suspected Neoplasm | US is considered highly useful for real- time guidance for biopsy and establishing definitive diagnosis [11,12]. MRI Abdomen No comparative studies are available in the literature; however, there are several potential advantages to MRI that may advocate for its use in some instances. MRI possesses very high soft-tissue contrast, allowing depiction and differentiation of cystic structures, soft-tissue components, fat, and blood products [10]. This can be especially useful for defining benign from malignant lesions in organs such as the adrenal glands, kidneys, ovaries, and liver. Although MRI offers potential advantages, its exact performance in evaluating palpable masses relative to US and CT remains unclear given the absence of data; however, it is likely at least comparable. Although not always a first-line option, MRI can be very useful as a second-line imaging modality to further evaluate indeterminate masses detected on CT or US. Similar to CT, there is no evidence evaluating the utility and added benefit of IV contrast versus noncontrast MRI in the setting of a palpable intra-abdominal mass. Experience and evidence related to solid organ evaluation (liver, pancreas, and kidneys) suggests that IV contrast improves visualization of normal organs and pathology. However, there is some value in noncontrast MRI as it may still depict soft-tissue structures and delineate a mass. Radiography Abdomen Radiography is often not sufficient as a first step in evaluation of a palpable mass and hence the acquisition of cross-sectional imaging would likely be required for diagnosis regardless of the results of the radiograph [24,25]. Radiography may also be considered as a first step in rare situations. If the patient reports constipation, a radiograph could be used to confirm that diagnosis or to offer alternative diagnosis, such as bowel obstruction [26,27]. | Palpable Abdominal Mass Suspected Neoplasm. US is considered highly useful for real- time guidance for biopsy and establishing definitive diagnosis [11,12]. MRI Abdomen No comparative studies are available in the literature; however, there are several potential advantages to MRI that may advocate for its use in some instances. MRI possesses very high soft-tissue contrast, allowing depiction and differentiation of cystic structures, soft-tissue components, fat, and blood products [10]. This can be especially useful for defining benign from malignant lesions in organs such as the adrenal glands, kidneys, ovaries, and liver. Although MRI offers potential advantages, its exact performance in evaluating palpable masses relative to US and CT remains unclear given the absence of data; however, it is likely at least comparable. Although not always a first-line option, MRI can be very useful as a second-line imaging modality to further evaluate indeterminate masses detected on CT or US. Similar to CT, there is no evidence evaluating the utility and added benefit of IV contrast versus noncontrast MRI in the setting of a palpable intra-abdominal mass. Experience and evidence related to solid organ evaluation (liver, pancreas, and kidneys) suggests that IV contrast improves visualization of normal organs and pathology. However, there is some value in noncontrast MRI as it may still depict soft-tissue structures and delineate a mass. Radiography Abdomen Radiography is often not sufficient as a first step in evaluation of a palpable mass and hence the acquisition of cross-sectional imaging would likely be required for diagnosis regardless of the results of the radiograph [24,25]. Radiography may also be considered as a first step in rare situations. If the patient reports constipation, a radiograph could be used to confirm that diagnosis or to offer alternative diagnosis, such as bowel obstruction [26,27]. | 69473 |
acrac_69473_4 | Palpable Abdominal Mass Suspected Neoplasm | Fluoroscopy Procedures (Contrast Enema, Upper GI Series, Small-Bowel Follow-Through) Fluoroscopy studies, such as contrast enema, upper gastrointestinal (GI) series, and small-bowel follow-through (SBFT), are usually not first-line imaging studies for palpable masses in adults. However, they may be used to further characterize associated degree of obstruction or abnormalities in GI function or transit [28]. As extraluminal findings are commonly not evaluated by contrast enema or upper GI series, additional imaging may be required even if an intraluminal mass is detected. Palpable Abdominal Mass-Suspected Neoplasm FDG-PET/CT Skull Base to Mid-Thigh In the absence of a known diagnosis, there is a very limited role for fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT in patients with palpable abnormalities. There is no literature to support its use as an initial imaging modality. The main role of FDG-PET/CT would be to stage a known neoplasm, potentially presenting with a new palpable abnormality. Variant 2: Palpable abdominal mass. Suspected abdominal wall mass. Initial imaging. The annual incidence of benign soft-tissue masses is approximately 3,000 per million population [29]. The rate of malignancy ranges from 5% to 42% in large series [30,31]. Clinical evaluation and history are important for developing a differential diagnosis, with features of large size, location within the abdominal cavity, growth, and recurrence at an excision site in a patient with a history of malignancy all raising suspicion of malignancy [31]. Imaging often plays a central role in further narrowing the differential diagnosis and guiding management. However, similar to Variant 1, there are few recent studies, and the overall quality of the literature is poor and primarily focused on specific disease processes rather than a diagnostic approach to palpable masses [32-36]. | Palpable Abdominal Mass Suspected Neoplasm. Fluoroscopy Procedures (Contrast Enema, Upper GI Series, Small-Bowel Follow-Through) Fluoroscopy studies, such as contrast enema, upper gastrointestinal (GI) series, and small-bowel follow-through (SBFT), are usually not first-line imaging studies for palpable masses in adults. However, they may be used to further characterize associated degree of obstruction or abnormalities in GI function or transit [28]. As extraluminal findings are commonly not evaluated by contrast enema or upper GI series, additional imaging may be required even if an intraluminal mass is detected. Palpable Abdominal Mass-Suspected Neoplasm FDG-PET/CT Skull Base to Mid-Thigh In the absence of a known diagnosis, there is a very limited role for fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT in patients with palpable abnormalities. There is no literature to support its use as an initial imaging modality. The main role of FDG-PET/CT would be to stage a known neoplasm, potentially presenting with a new palpable abnormality. Variant 2: Palpable abdominal mass. Suspected abdominal wall mass. Initial imaging. The annual incidence of benign soft-tissue masses is approximately 3,000 per million population [29]. The rate of malignancy ranges from 5% to 42% in large series [30,31]. Clinical evaluation and history are important for developing a differential diagnosis, with features of large size, location within the abdominal cavity, growth, and recurrence at an excision site in a patient with a history of malignancy all raising suspicion of malignancy [31]. Imaging often plays a central role in further narrowing the differential diagnosis and guiding management. However, similar to Variant 1, there are few recent studies, and the overall quality of the literature is poor and primarily focused on specific disease processes rather than a diagnostic approach to palpable masses [32-36]. | 69473 |
acrac_69473_5 | Palpable Abdominal Mass Suspected Neoplasm | The differential diagnosis related to the abdominal wall includes soft-tissue neoplasms of the skin, muscle, fat, bone, and vasculature. Additionally, hernias, congenital abnormalities, hematomas, and infections may present as abdominal wall masses. Differentiation of tissue components, such as blood products, fat, and vascularity, is important for narrowing the differential diagnosis and defining the relationship of the mass to tissue planes and structures is imperative in guiding management. US Abdomen Although no recent studies have evaluated the diagnostic accuracy of US specifically for abdominal wall masses, it is typically considered a first-line imaging modality [29,30,32]. This is due to the many advantages of US, such as capability of real-time imaging, Doppler evaluation of blood flow, and ability to assess for clinical features, such as tenderness. US can sometimes depict classic features of benign lesions, such as lipomas, desmoid tumors, vascular malformations, rectus sheath hematomas, infections, pseudoaneurysms, and endometriosis [30,32-34,36- 38]. However, in the setting of solid lesions, further workup and potentially tissue sampling is often needed. Although perhaps not widely used as a first-line imaging option, US can also confirm the presence of malignant masses, such as metastatic disease, sarcomas, and lymphomas. In a prospective study of 358 patients presenting with soft-tissue masses, US was performed as an initial imaging modality, yielding effective triage results with 100% specificity in referring indeterminate or potentially malignant masses on to more definitive imaging (MRI) and subsequent workup [31]. In patients with suspected abdominal wall endometriosis, which presents as a mass in many instances, US correctly detected disease in approximately 97% of cases in a retrospective series of 151 patients evaluated surgically [36]. | Palpable Abdominal Mass Suspected Neoplasm. The differential diagnosis related to the abdominal wall includes soft-tissue neoplasms of the skin, muscle, fat, bone, and vasculature. Additionally, hernias, congenital abnormalities, hematomas, and infections may present as abdominal wall masses. Differentiation of tissue components, such as blood products, fat, and vascularity, is important for narrowing the differential diagnosis and defining the relationship of the mass to tissue planes and structures is imperative in guiding management. US Abdomen Although no recent studies have evaluated the diagnostic accuracy of US specifically for abdominal wall masses, it is typically considered a first-line imaging modality [29,30,32]. This is due to the many advantages of US, such as capability of real-time imaging, Doppler evaluation of blood flow, and ability to assess for clinical features, such as tenderness. US can sometimes depict classic features of benign lesions, such as lipomas, desmoid tumors, vascular malformations, rectus sheath hematomas, infections, pseudoaneurysms, and endometriosis [30,32-34,36- 38]. However, in the setting of solid lesions, further workup and potentially tissue sampling is often needed. Although perhaps not widely used as a first-line imaging option, US can also confirm the presence of malignant masses, such as metastatic disease, sarcomas, and lymphomas. In a prospective study of 358 patients presenting with soft-tissue masses, US was performed as an initial imaging modality, yielding effective triage results with 100% specificity in referring indeterminate or potentially malignant masses on to more definitive imaging (MRI) and subsequent workup [31]. In patients with suspected abdominal wall endometriosis, which presents as a mass in many instances, US correctly detected disease in approximately 97% of cases in a retrospective series of 151 patients evaluated surgically [36]. | 69473 |
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