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acrac_69361_3
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Acutely Limping Child Up To Age 5 PCAs
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Radiography Lower Extremity Targeted radiographs of the areas of concern have a role in evaluating for possible fracture [12,26-29]. Negative radiographs do not completely exclude the possibility of a nondisplaced fracture. Dunbar et al [30] first described Acutely Limping Child Up To Age 5 Other causes of limp or pain, such as osteochondritis, apophysitis, osteonecrosis, or tumor, may be diagnosed with radiographs, though MRI has better sensitivity for such pathologies [31,32]. US Hips or Lower Extremity US has a limited field of view and has lower accuracy in detection of fractures as compared with radiographs. Weinberg et al [33] showed that clinician-performed US had a sensitivity and specificity of 73% and 92%, respectively, for the evaluation of fractures in children and young adults, with radiography or CT as the reference standard. 3-Phase Bone Scan Pelvis and Lower Extremity There is no relevant literature regarding the use of bone scan in the initial evaluation of acute limp with localized symptoms and no concern for infection. CT Lower Extremity There is no relevant literature regarding the use of CT in the initial evaluation of acute limp with localized symptoms and no concern for infection. CT without IV contrast can be useful in a few selected cases for preoperative planning after radiographs demonstrate a complex or intra-articular fracture [18]. MRI Lower Extremity There is no relevant literature regarding the use of MRI in the initial evaluation of acute limp with localized symptoms and no concern for infection. In children with persistent limp and negative radiographs, MRI is highly sensitive in detection of stress reaction/fractures [6]. When there are clinical signs of nonseptic arthritis, MRI is superior to both US and radiography in detecting inflammatory changes, early erosions, and cartilage thinning [34-37]. MRI should be performed when a tumor is suspected as it is sensitive for evaluation of bone marrow and soft-tissue extension [38].
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Acutely Limping Child Up To Age 5 PCAs. Radiography Lower Extremity Targeted radiographs of the areas of concern have a role in evaluating for possible fracture [12,26-29]. Negative radiographs do not completely exclude the possibility of a nondisplaced fracture. Dunbar et al [30] first described Acutely Limping Child Up To Age 5 Other causes of limp or pain, such as osteochondritis, apophysitis, osteonecrosis, or tumor, may be diagnosed with radiographs, though MRI has better sensitivity for such pathologies [31,32]. US Hips or Lower Extremity US has a limited field of view and has lower accuracy in detection of fractures as compared with radiographs. Weinberg et al [33] showed that clinician-performed US had a sensitivity and specificity of 73% and 92%, respectively, for the evaluation of fractures in children and young adults, with radiography or CT as the reference standard. 3-Phase Bone Scan Pelvis and Lower Extremity There is no relevant literature regarding the use of bone scan in the initial evaluation of acute limp with localized symptoms and no concern for infection. CT Lower Extremity There is no relevant literature regarding the use of CT in the initial evaluation of acute limp with localized symptoms and no concern for infection. CT without IV contrast can be useful in a few selected cases for preoperative planning after radiographs demonstrate a complex or intra-articular fracture [18]. MRI Lower Extremity There is no relevant literature regarding the use of MRI in the initial evaluation of acute limp with localized symptoms and no concern for infection. In children with persistent limp and negative radiographs, MRI is highly sensitive in detection of stress reaction/fractures [6]. When there are clinical signs of nonseptic arthritis, MRI is superior to both US and radiography in detecting inflammatory changes, early erosions, and cartilage thinning [34-37]. MRI should be performed when a tumor is suspected as it is sensitive for evaluation of bone marrow and soft-tissue extension [38].
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69361
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acrac_69361_4
|
Acutely Limping Child Up To Age 5 PCAs
|
Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging. Limping in the presence of one or more of the following clinical and laboratory signs should suggest the possibility of infection: fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, or elevated C-reactive protein. The differential diagnoses in this scenario most commonly include septic arthritis, osteomyelitis, discitis, pyomyositis, Langerhans cell histiocytosis, and tumor (eg, leukemia, osteosarcoma, Ewing sarcoma, and metastatic disease). When there are signs and symptoms suggestive of an infectious process, imaging has a role in substantiating the diagnosis, localizing the site of infection, evaluating for complications that require surgical intervention, and excluding other pathologies that mimic infection. Radiography Lower Extremities Radiographs have low yield in detecting infection when symptoms and signs are not localized [39,40]. US Hips or Lower Extremity A small field of view limits the role of US when symptoms and clinical evaluation cannot localize the site of pathology [14]. Because pain that is due to hip pathology can be referred elsewhere in the lower extremity, such as the thigh, knee, or buttock [15], US of the hip could be considered even when symptoms cannot be well localized. 3-Phase Bone Scan Pelvis and Lower Extremity Bone scan is reported to have a high sensitivity for the diagnosis of osteomyelitis [17]. Advantages of bone scan in the evaluation of infection include whole-body imaging for site localization, with the main disadvantage being the lack of soft-tissue evaluation and anatomic detail, particularly for the detection of small abscesses [16]. Bone scan may be particularly helpful in cases with implanted hardware and postoperative patients already with Acutely Limping Child Up To Age 5 extensive edema and tissue alternations.
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Acutely Limping Child Up To Age 5 PCAs. Variant 3: Child up to age 5. Acute limp. Nonlocalized symptoms. Concern for infection. Initial imaging. Limping in the presence of one or more of the following clinical and laboratory signs should suggest the possibility of infection: fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, or elevated C-reactive protein. The differential diagnoses in this scenario most commonly include septic arthritis, osteomyelitis, discitis, pyomyositis, Langerhans cell histiocytosis, and tumor (eg, leukemia, osteosarcoma, Ewing sarcoma, and metastatic disease). When there are signs and symptoms suggestive of an infectious process, imaging has a role in substantiating the diagnosis, localizing the site of infection, evaluating for complications that require surgical intervention, and excluding other pathologies that mimic infection. Radiography Lower Extremities Radiographs have low yield in detecting infection when symptoms and signs are not localized [39,40]. US Hips or Lower Extremity A small field of view limits the role of US when symptoms and clinical evaluation cannot localize the site of pathology [14]. Because pain that is due to hip pathology can be referred elsewhere in the lower extremity, such as the thigh, knee, or buttock [15], US of the hip could be considered even when symptoms cannot be well localized. 3-Phase Bone Scan Pelvis and Lower Extremity Bone scan is reported to have a high sensitivity for the diagnosis of osteomyelitis [17]. Advantages of bone scan in the evaluation of infection include whole-body imaging for site localization, with the main disadvantage being the lack of soft-tissue evaluation and anatomic detail, particularly for the detection of small abscesses [16]. Bone scan may be particularly helpful in cases with implanted hardware and postoperative patients already with Acutely Limping Child Up To Age 5 extensive edema and tissue alternations.
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69361
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acrac_69361_5
|
Acutely Limping Child Up To Age 5 PCAs
|
A few case series suggest that bone scan has a lower sensitivity in the detection of source of infection relative to MRI [39-41]. MRI Lower Extremity MRI, given its sensitivity to soft-tissue and bone marrow pathology, has high accuracy in diagnosing infection, including septic arthritis, osteomyelitis, pyomyositis, and discitis [42,43], and could be considered as the initial imaging study [44]. Large field-of-view coronal T1-weighted and fluid-sensitive sequences covering from the pelvis and hips to the ankles may be performed to identify any abnormality. Inclusion of the lower thoracic spine and lumbar spine should be considered if lower extremity or hip pathology is not found and symptoms persist, as some patients with discitis may not have localized symptoms to the back [45-48]. Once localized, additional MRI sequences with smaller fields of view can be performed for further characterization [49]. Contrast administration in the MRI evaluation of suspected soft-tissue or osseous infection does not increase sensitivity or specificity but may increase reader confidence and better delineate abscesses [50,51]. Contrast administration during MRI should be considered in specific cases to improve detection of an abscess when there is significant soft-tissue edema [50,51]. An exception to this may be infants, in whom infection of the epiphyses can be occult on unenhanced MRI sequences [52]. Given these considerations, the use of IV contrast may vary with institutional protocol. While no prospective study of MRI versus bone scan has been performed, there are retrospective studies suggesting superiority of MRI over bone scan in detecting the source of infection, with sensitivity of 99% to 100% for MRI compared to 53% to 71% for bone scan [39,40]. Because of low bone scan sensitivity for soft- tissue pathology, MRI is often obtained after a positive bone scan for further evaluation of soft-tissues, primarily to detect abscess formation that requires drainage [41].
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Acutely Limping Child Up To Age 5 PCAs. A few case series suggest that bone scan has a lower sensitivity in the detection of source of infection relative to MRI [39-41]. MRI Lower Extremity MRI, given its sensitivity to soft-tissue and bone marrow pathology, has high accuracy in diagnosing infection, including septic arthritis, osteomyelitis, pyomyositis, and discitis [42,43], and could be considered as the initial imaging study [44]. Large field-of-view coronal T1-weighted and fluid-sensitive sequences covering from the pelvis and hips to the ankles may be performed to identify any abnormality. Inclusion of the lower thoracic spine and lumbar spine should be considered if lower extremity or hip pathology is not found and symptoms persist, as some patients with discitis may not have localized symptoms to the back [45-48]. Once localized, additional MRI sequences with smaller fields of view can be performed for further characterization [49]. Contrast administration in the MRI evaluation of suspected soft-tissue or osseous infection does not increase sensitivity or specificity but may increase reader confidence and better delineate abscesses [50,51]. Contrast administration during MRI should be considered in specific cases to improve detection of an abscess when there is significant soft-tissue edema [50,51]. An exception to this may be infants, in whom infection of the epiphyses can be occult on unenhanced MRI sequences [52]. Given these considerations, the use of IV contrast may vary with institutional protocol. While no prospective study of MRI versus bone scan has been performed, there are retrospective studies suggesting superiority of MRI over bone scan in detecting the source of infection, with sensitivity of 99% to 100% for MRI compared to 53% to 71% for bone scan [39,40]. Because of low bone scan sensitivity for soft- tissue pathology, MRI is often obtained after a positive bone scan for further evaluation of soft-tissues, primarily to detect abscess formation that requires drainage [41].
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69361
|
acrac_69361_6
|
Acutely Limping Child Up To Age 5 PCAs
|
MRI Whole-Body MRI, given its sensitivity to soft-tissue and bone marrow pathology, has high accuracy in diagnosing infection, including septic arthritis, osteomyelitis, pyomyositis, and discitis [42,43]. Like bone scan, whole-body MRI provides a total-body screen and is sensitive in detecting osseous abnormalities. As such, whole-body MRI may be an appropriate choice when there is suspicion for multifocal osteomyelitis [22,53,54]. While there is no single protocol for whole-body MRI, sequences may include the use of fluid-sensitive, T1-weighted, diffusion-weighted imaging, or chemical shift imaging, with or without the use of IV contrast [53,55]. CT Lower Extremity There is no relevant literature regarding the use of CT in the initial evaluation of acute limp with nonlocalized symptoms and concern for infection. Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging. If pain or physical examination appears localized to the hip, the diagnosis is septic arthritis until proven otherwise. Septic arthritis is the most common cause of acute severe monoarticular pain in children. It typically results from hematogenous and subsequent intra-articular spread of Staphylococcus aureus, with the hip being the most common site of involvement. In some cases, septic arthritis of the hip may be secondary to adjacent osteomyelitis [56]. Septic arthritis requires rapid diagnosis and intervention to prevent permanent damage to the joint [57]. In children with signs of infection and absence of a hip effusion, a diagnosis of pelvic osteomyelitis or pyomyositis should be considered [40]. Radiography Pelvis or Lumbar Spine There are limited data to support the use of radiographs in the initial evaluation of possible septic hip. The sensitivity and specificity of radiographs for the diagnosis of septic hip are low [58]. US Hips US of the hip allows quick and accurate diagnosis of a joint effusion and can be used to guide aspiration [59,60].
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Acutely Limping Child Up To Age 5 PCAs. MRI Whole-Body MRI, given its sensitivity to soft-tissue and bone marrow pathology, has high accuracy in diagnosing infection, including septic arthritis, osteomyelitis, pyomyositis, and discitis [42,43]. Like bone scan, whole-body MRI provides a total-body screen and is sensitive in detecting osseous abnormalities. As such, whole-body MRI may be an appropriate choice when there is suspicion for multifocal osteomyelitis [22,53,54]. While there is no single protocol for whole-body MRI, sequences may include the use of fluid-sensitive, T1-weighted, diffusion-weighted imaging, or chemical shift imaging, with or without the use of IV contrast [53,55]. CT Lower Extremity There is no relevant literature regarding the use of CT in the initial evaluation of acute limp with nonlocalized symptoms and concern for infection. Variant 4: Child up to age 5. Acute limp. Symptoms localized to the hip. Concern for infection. Initial imaging. If pain or physical examination appears localized to the hip, the diagnosis is septic arthritis until proven otherwise. Septic arthritis is the most common cause of acute severe monoarticular pain in children. It typically results from hematogenous and subsequent intra-articular spread of Staphylococcus aureus, with the hip being the most common site of involvement. In some cases, septic arthritis of the hip may be secondary to adjacent osteomyelitis [56]. Septic arthritis requires rapid diagnosis and intervention to prevent permanent damage to the joint [57]. In children with signs of infection and absence of a hip effusion, a diagnosis of pelvic osteomyelitis or pyomyositis should be considered [40]. Radiography Pelvis or Lumbar Spine There are limited data to support the use of radiographs in the initial evaluation of possible septic hip. The sensitivity and specificity of radiographs for the diagnosis of septic hip are low [58]. US Hips US of the hip allows quick and accurate diagnosis of a joint effusion and can be used to guide aspiration [59,60].
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69361
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acrac_69361_7
|
Acutely Limping Child Up To Age 5 PCAs
|
Various investigators have had differing results in differentiating septic arthritis from transient synovitis of the hip when using US in combination with laboratory and clinical data [57,61]. A false-negative US is uncommon and could occur when sonography is performed within 24 hours of onset of symptoms [62]. It is important to be aware that there may be other etiologies to a hip effusion, including fractures, osteonecrosis, and juvenile idiopathic arthritis. Acutely Limping Child Up To Age 5 3-Phase Bone Scan Pelvis and Lower Extremity Bone scan was found to have only 70% sensitivity, as compared to MRI, in a series of 33 patients in detecting source of infection in children presented with acute hip pain who did not have septic hip [40]. CT Pelvis CT has decreased sensitivity in the detection of bone marrow pathology and decreased soft-tissue contrast compared to MRI [63-65]. CT with IV contrast could be considered in children with contraindications to MRI [66]. MRI Pelvis MRI has high sensitivity and specificity for musculoskeletal infection, such as septic arthritis, osteomyelitis, and pyomyositis [67]. MRI detected osteomyelitis in about half of children with clinically suspected septic arthritis [56], and septic arthritis was found to be associated with osteomyelitis in MRI in about 70% of patients. Some also have soft-tissue abscesses [67]. For this reason, some advocate using MRI in the initial evaluation of suspected septic arthritis of the hips. In children with signs of infection and acute hip pain with no evidence of septic arthritis, MRI was shown to have better sensitivity than bone scan in detection of the source of infection [40,41]. In addition, osteomyelitis of the pelvis is commonly (28%) associated with soft-tissue abscesses [68], which are easily detected by MRI. Some advocate performing MRI of the pelvis even in children with known septic arthritis because of the possibility of associated osteomyelitis and soft-tissue abscess [69].
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Acutely Limping Child Up To Age 5 PCAs. Various investigators have had differing results in differentiating septic arthritis from transient synovitis of the hip when using US in combination with laboratory and clinical data [57,61]. A false-negative US is uncommon and could occur when sonography is performed within 24 hours of onset of symptoms [62]. It is important to be aware that there may be other etiologies to a hip effusion, including fractures, osteonecrosis, and juvenile idiopathic arthritis. Acutely Limping Child Up To Age 5 3-Phase Bone Scan Pelvis and Lower Extremity Bone scan was found to have only 70% sensitivity, as compared to MRI, in a series of 33 patients in detecting source of infection in children presented with acute hip pain who did not have septic hip [40]. CT Pelvis CT has decreased sensitivity in the detection of bone marrow pathology and decreased soft-tissue contrast compared to MRI [63-65]. CT with IV contrast could be considered in children with contraindications to MRI [66]. MRI Pelvis MRI has high sensitivity and specificity for musculoskeletal infection, such as septic arthritis, osteomyelitis, and pyomyositis [67]. MRI detected osteomyelitis in about half of children with clinically suspected septic arthritis [56], and septic arthritis was found to be associated with osteomyelitis in MRI in about 70% of patients. Some also have soft-tissue abscesses [67]. For this reason, some advocate using MRI in the initial evaluation of suspected septic arthritis of the hips. In children with signs of infection and acute hip pain with no evidence of septic arthritis, MRI was shown to have better sensitivity than bone scan in detection of the source of infection [40,41]. In addition, osteomyelitis of the pelvis is commonly (28%) associated with soft-tissue abscesses [68], which are easily detected by MRI. Some advocate performing MRI of the pelvis even in children with known septic arthritis because of the possibility of associated osteomyelitis and soft-tissue abscess [69].
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69361
|
acrac_69361_8
|
Acutely Limping Child Up To Age 5 PCAs
|
Findings of hip effusion associated with bone marrow edema or decreased enhancement of the femoral head should raise the possibility of septic arthritis [70,71]; although, definite diagnosis of septic arthritis requires joint aspiration and fluid analysis. Contrast administration in the MRI evaluation of suspected soft-tissue or osseous infection does not increase sensitivity or specificity but increases reader confidence and better delineates abscesses [50,51]. An exception to this may be in infants and younger children with an abundance of nonossified cartilage, in whom infection limited to the intrinsically hyperintense cartilaginous growth plate and epiphyses/apophyses can be occult on unenhanced MRI sequences. Given these considerations, the use of IV contrast may vary with institutional protocol. Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging. The body regions covered in this clinical scenario are: femur, knee, tibia/fibula, ankle, and foot. Radiography Lower Extremity There are limited evidence to support the use of radiographs for the acute evaluation of localized infection. The sensitivity of radiographs in detecting early osteomyelitis or soft-tissue infection is low [39,40]. While soft-tissue signs of swelling and edema may be detected early by radiographs and nonspecific signs, such as periosteal reaction and osteopenia, detection of bone destruction may take up to 3 weeks after onset of symptoms [54,64,72]. US Lower Extremity US may play a role in diagnosing pyomyositis, in which inflammatory change may lead to an altered sonographic appearance in affected muscle [73,74]. Because US will not penetrate cortex, it is unable to evaluate bone marrow and is not sensitive for osteomyelitis. US is sensitive to subperiosteal collections, which can be seen with osteomyelitis [54,75].
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Acutely Limping Child Up To Age 5 PCAs. Findings of hip effusion associated with bone marrow edema or decreased enhancement of the femoral head should raise the possibility of septic arthritis [70,71]; although, definite diagnosis of septic arthritis requires joint aspiration and fluid analysis. Contrast administration in the MRI evaluation of suspected soft-tissue or osseous infection does not increase sensitivity or specificity but increases reader confidence and better delineates abscesses [50,51]. An exception to this may be in infants and younger children with an abundance of nonossified cartilage, in whom infection limited to the intrinsically hyperintense cartilaginous growth plate and epiphyses/apophyses can be occult on unenhanced MRI sequences. Given these considerations, the use of IV contrast may vary with institutional protocol. Variant 5: Child up to age 5. Acute limp. Symptoms localized to lower extremity (not pelvis or hips). Concern for infection. Initial imaging. The body regions covered in this clinical scenario are: femur, knee, tibia/fibula, ankle, and foot. Radiography Lower Extremity There are limited evidence to support the use of radiographs for the acute evaluation of localized infection. The sensitivity of radiographs in detecting early osteomyelitis or soft-tissue infection is low [39,40]. While soft-tissue signs of swelling and edema may be detected early by radiographs and nonspecific signs, such as periosteal reaction and osteopenia, detection of bone destruction may take up to 3 weeks after onset of symptoms [54,64,72]. US Lower Extremity US may play a role in diagnosing pyomyositis, in which inflammatory change may lead to an altered sonographic appearance in affected muscle [73,74]. Because US will not penetrate cortex, it is unable to evaluate bone marrow and is not sensitive for osteomyelitis. US is sensitive to subperiosteal collections, which can be seen with osteomyelitis [54,75].
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69361
|
acrac_69361_9
|
Acutely Limping Child Up To Age 5 PCAs
|
3-Phase Bone Scan Pelvis and Lower Extremity Bone scan has been reported to have a high sensitivity for the diagnosis of osteomyelitis, albeit with lower reported specificity. However, its utility is greatest when symptoms cannot be localized. The main limitation of bone scan with a localized examination is in the detection of soft-tissue abscess [39,41]. CT Lower Extremity CT has decreased sensitivity in the detection of bone marrow pathology and decreased soft-tissue contrast compared to MRI [63-65]. CT with IV contrast can be considered when soft-tissue infection is of concern or in children with contraindications to MRI [66]. Acutely Limping Child Up To Age 5 MRI Lower Extremity MRI, given its sensitivity to musculoskeletal injury and inflammation, has high accuracy in diagnosing infection, specifically osteomyelitis and pyomyositis [43,76]. Contrast administration improves detection of soft-tissue abscesses in selected patients with soft-tissue edema [50,51]. Because of low bone scan sensitivity for soft-tissue pathology, MRI may sometimes need to be obtained after a positive bone scan for further evaluation of soft- tissues pathology mainly to detect any abscess formation that requires drainage [41]. Contrast administration in the MRI evaluation of suspected soft-tissue or osseous infection does not increase sensitivity or specificity but may increase reader confidence and better delineate abscesses [50,51]. Contrast administration during MRI should be considered in specific cases to improve detection of small abscesses when there is significant soft-tissue edema [50,51]. The need for sedation in young patients undergoing MRI is a consideration. MRI Whole-Body There is no relevant literature regarding the use of whole-body MRI in the initial evaluation of acute limp with localized symptoms to the lower extremity and concern for infection. Whole-body MRI may be very sensitive for osteomyelitis.
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Acutely Limping Child Up To Age 5 PCAs. 3-Phase Bone Scan Pelvis and Lower Extremity Bone scan has been reported to have a high sensitivity for the diagnosis of osteomyelitis, albeit with lower reported specificity. However, its utility is greatest when symptoms cannot be localized. The main limitation of bone scan with a localized examination is in the detection of soft-tissue abscess [39,41]. CT Lower Extremity CT has decreased sensitivity in the detection of bone marrow pathology and decreased soft-tissue contrast compared to MRI [63-65]. CT with IV contrast can be considered when soft-tissue infection is of concern or in children with contraindications to MRI [66]. Acutely Limping Child Up To Age 5 MRI Lower Extremity MRI, given its sensitivity to musculoskeletal injury and inflammation, has high accuracy in diagnosing infection, specifically osteomyelitis and pyomyositis [43,76]. Contrast administration improves detection of soft-tissue abscesses in selected patients with soft-tissue edema [50,51]. Because of low bone scan sensitivity for soft-tissue pathology, MRI may sometimes need to be obtained after a positive bone scan for further evaluation of soft- tissues pathology mainly to detect any abscess formation that requires drainage [41]. Contrast administration in the MRI evaluation of suspected soft-tissue or osseous infection does not increase sensitivity or specificity but may increase reader confidence and better delineate abscesses [50,51]. Contrast administration during MRI should be considered in specific cases to improve detection of small abscesses when there is significant soft-tissue edema [50,51]. The need for sedation in young patients undergoing MRI is a consideration. MRI Whole-Body There is no relevant literature regarding the use of whole-body MRI in the initial evaluation of acute limp with localized symptoms to the lower extremity and concern for infection. Whole-body MRI may be very sensitive for osteomyelitis.
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69361
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acrac_3102384_0
|
Anorectal Disease
|
Introduction/Background Inflammatory and infectious disorders of the anorectum are commonly encountered in clinical practice, but their exact incidence is unknown. They encompass a variety of anorectal disorders in a diverse population of patients who may present to the emergency department, urgent care clinic, primary care physician, or subspecialty physician such as a gastroenterologist or colorectal surgeon. Patients with inflammatory and infectious disorders of the anorectum may come in need of medical attention with acute symptoms such as pain, tenesmus, discharge, bleeding, and/or findings of sepsis. Other patients may have chronic symptoms, or their complaints may relate to a prior surgical procedure or underlying disease. Depending upon the condition and presentation, a variety of imaging modalities may be used for the initial evaluation of an anorectal complaint. Imaging may also be helpful for planning the management of rectovaginal fistulas that are the consequence of obstetric trauma from childbirth, iatrogenic anorectal or rectovaginal fistulas that are caused by radiation or surgical complications, and fistulas that result from other forms of trauma. The initial imaging in 4 anorectal disease categories is covered in this document: suspected perianal disease (perianal fistula and abscess); suspected rectal fistula (rectovescicular or rectovaginal); suspected proctitis or pouchitis; and suspected complication after proctectomy, coloproctectomy, or colectomy with pouch or other anastomosis. Special Imaging Considerations Anorectal Fistulae and Malignancy Though the focus of this topic is on inflammatory and infectious disorders of the anorectum, it is important to recognize that inflammatory disease of the anorectum may be a complication of malignancy or associated with malignancy. For example, approximately 11% of colovesical and colovaginal fistulae are caused by malignancy [1].
|
Anorectal Disease. Introduction/Background Inflammatory and infectious disorders of the anorectum are commonly encountered in clinical practice, but their exact incidence is unknown. They encompass a variety of anorectal disorders in a diverse population of patients who may present to the emergency department, urgent care clinic, primary care physician, or subspecialty physician such as a gastroenterologist or colorectal surgeon. Patients with inflammatory and infectious disorders of the anorectum may come in need of medical attention with acute symptoms such as pain, tenesmus, discharge, bleeding, and/or findings of sepsis. Other patients may have chronic symptoms, or their complaints may relate to a prior surgical procedure or underlying disease. Depending upon the condition and presentation, a variety of imaging modalities may be used for the initial evaluation of an anorectal complaint. Imaging may also be helpful for planning the management of rectovaginal fistulas that are the consequence of obstetric trauma from childbirth, iatrogenic anorectal or rectovaginal fistulas that are caused by radiation or surgical complications, and fistulas that result from other forms of trauma. The initial imaging in 4 anorectal disease categories is covered in this document: suspected perianal disease (perianal fistula and abscess); suspected rectal fistula (rectovescicular or rectovaginal); suspected proctitis or pouchitis; and suspected complication after proctectomy, coloproctectomy, or colectomy with pouch or other anastomosis. Special Imaging Considerations Anorectal Fistulae and Malignancy Though the focus of this topic is on inflammatory and infectious disorders of the anorectum, it is important to recognize that inflammatory disease of the anorectum may be a complication of malignancy or associated with malignancy. For example, approximately 11% of colovesical and colovaginal fistulae are caused by malignancy [1].
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3102384
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acrac_3102384_1
|
Anorectal Disease
|
Recently, carcinoma has been reported in association with anal fistulae in Crohn disease (CD), and carcinomas may rarely arise in chronic fistula in the anorectum [2,3]. Consequently, the concern for malignancy should be raised when the imaging findings of a soft mass, mass-like thickening of the wall of the anorectum, or malignant- appearing lymphadenopathy are present during evaluation of the anorectum for suspected benign inflammatory disease. OR aMedstar Georgetown University Hospital, Washington, District of Columbia. bCleveland Clinic, Cleveland, Ohio. cPanel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin. dPanel Vice-Chair, University of California San Diego, San Diego, California. eMayo Clinic, Rochester, Minnesota, American Gastroenterological Association. fBoston University Medical Center, Boston, Massachusetts. gMedstar Georgetown University Hospital, Washington, District of Columbia, Primary care physician. hH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. iVirginia Tech Carilion School of Medicine, Roanoke, Virginia. jMassachusetts General Hospital, Boston, Massachusetts. kOregon Health and Science University, Portland, Oregon. lDuke University Medical Center, Durham, North Carolina. mEmory University, Atlanta, Georgia. nUniversity of Alabama at Birmingham, Birmingham, Alabama. oUniversity of California San Diego, San Diego, California. pUniversity of California San Francisco, San Francisco, California. qCleveland Clinic Florida, Weston, Florida, American College of Surgeons. rSpecialty 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.
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Anorectal Disease. Recently, carcinoma has been reported in association with anal fistulae in Crohn disease (CD), and carcinomas may rarely arise in chronic fistula in the anorectum [2,3]. Consequently, the concern for malignancy should be raised when the imaging findings of a soft mass, mass-like thickening of the wall of the anorectum, or malignant- appearing lymphadenopathy are present during evaluation of the anorectum for suspected benign inflammatory disease. OR aMedstar Georgetown University Hospital, Washington, District of Columbia. bCleveland Clinic, Cleveland, Ohio. cPanel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin. dPanel Vice-Chair, University of California San Diego, San Diego, California. eMayo Clinic, Rochester, Minnesota, American Gastroenterological Association. fBoston University Medical Center, Boston, Massachusetts. gMedstar Georgetown University Hospital, Washington, District of Columbia, Primary care physician. hH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. iVirginia Tech Carilion School of Medicine, Roanoke, Virginia. jMassachusetts General Hospital, Boston, Massachusetts. kOregon Health and Science University, Portland, Oregon. lDuke University Medical Center, Durham, North Carolina. mEmory University, Atlanta, Georgia. nUniversity of Alabama at Birmingham, Birmingham, Alabama. oUniversity of California San Diego, San Diego, California. pUniversity of California San Francisco, San Francisco, California. qCleveland Clinic Florida, Weston, Florida, American College of Surgeons. rSpecialty 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.
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3102384
|
acrac_3102384_2
|
Anorectal Disease
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Reprint requests to: [email protected] Anorectal Disease Discussion of Procedures by Variant Variant 1: Suspected perianal disease. Abscess or fistula. Initial imaging. Anorectal abscesses result from infection of the intersphincteric anal glands. Obstruction of the draining duct may produce an intersphincteric abscess or the infection may rupture through the external sphincter to form an abscess in the ischiorectal or ischioanal spaces. Cephalad extension results in a high intramuscular or perirectal abscess, or a supralevator abscess if it extends above the levator muscles. Posterior extension may result in a horseshoe abscess in the intersphincteric plane or ischiorectal fossa [4]. Patients with anorectal abscess may present with pain that is typically throbbing, visible redness and swelling of the anus, and/or sepsis. On physical examination, there is often tenderness to palpation and an area of fluctuance. In some cases, the abscess may be occult on physical examination. The majority of anal fistulae (fistula-in-ano) arise from a preexisting abscess and as such are believed to represent a spectrum of the same disease. Clinically, patients with fistula-in-ano present with drainage of blood, pus, or fecal material from an external opening in the perianal region, intermittent pain, and perianal itching. The majority of patients with fistula-in-ano are male (2:1) and have a mean age at presentation of 40 years [5]. Other diseases that may cause anal fistula include CD, radiation proctitis, foreign body, prior anal surgery, infections (such as human immunodeficiency virus [HIV], tuberculosis, actinomycosis), and malignancy [6]. Perianal fistulae are a very common component of CD, occurring in 13% to 27% of these patients [7,8]. Perianal fistulae may be the initial manifestation of CD in up to 81% of patients who develop perianal disease, and in a small number of patients, it is the only manifestation of their disease [9]. Complex and multifocal fistulae are more common in CD.
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Anorectal Disease. Reprint requests to: [email protected] Anorectal Disease Discussion of Procedures by Variant Variant 1: Suspected perianal disease. Abscess or fistula. Initial imaging. Anorectal abscesses result from infection of the intersphincteric anal glands. Obstruction of the draining duct may produce an intersphincteric abscess or the infection may rupture through the external sphincter to form an abscess in the ischiorectal or ischioanal spaces. Cephalad extension results in a high intramuscular or perirectal abscess, or a supralevator abscess if it extends above the levator muscles. Posterior extension may result in a horseshoe abscess in the intersphincteric plane or ischiorectal fossa [4]. Patients with anorectal abscess may present with pain that is typically throbbing, visible redness and swelling of the anus, and/or sepsis. On physical examination, there is often tenderness to palpation and an area of fluctuance. In some cases, the abscess may be occult on physical examination. The majority of anal fistulae (fistula-in-ano) arise from a preexisting abscess and as such are believed to represent a spectrum of the same disease. Clinically, patients with fistula-in-ano present with drainage of blood, pus, or fecal material from an external opening in the perianal region, intermittent pain, and perianal itching. The majority of patients with fistula-in-ano are male (2:1) and have a mean age at presentation of 40 years [5]. Other diseases that may cause anal fistula include CD, radiation proctitis, foreign body, prior anal surgery, infections (such as human immunodeficiency virus [HIV], tuberculosis, actinomycosis), and malignancy [6]. Perianal fistulae are a very common component of CD, occurring in 13% to 27% of these patients [7,8]. Perianal fistulae may be the initial manifestation of CD in up to 81% of patients who develop perianal disease, and in a small number of patients, it is the only manifestation of their disease [9]. Complex and multifocal fistulae are more common in CD.
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Anorectal Disease
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Imaging is used in suspected cases of anorectal abscess and/or fistula to confirm the diagnosis, assist in surgical planning, predict surgical outcome, assess for recurrent or residual disease, and monitor medical therapy in patients with CD [10]. CT Pelvis The appropriate CT protocol for imaging a patient with an anorectal complaint depends upon the presentation and differential diagnosis. Intravenous (IV) contrast is preferred to a noncontrast examination to help visualize and characterize fluid collections, abscesses, and fistulous tracts. Water-soluble rectal contrast is generally not necessary to diagnose a rectal abscess and may be challenging to administer depending on symptom severity. However, rectal contrast may help delineate perforation or leak in a patient with a history of trauma or recent surgery. Water-soluble rectal contrast is preferred over barium to avoid the possibility of barium spilling into the peritoneal cavity or spaces of the extraperitoneal pelvis. Water-soluble rectal contrast is also preferred in a patient who could potentially be undergoing surgery. CT is commonly used in the acute setting to evaluate for anorectal abscess. The inherent lack of contrast resolution of CT limits the differentiation of subtle attenuation changes to differentiate small abscesses and fistulae from the anal sphincter complex and the soft tissue of the pelvic floor. To our knowledge, there is no recent literature evaluating the accuracy of modern CT technology for the detection of anorectal abscesses and there are no studies comparing IV contrast-enhanced scans to scans obtained without IV contrast. CT with and without IV contrast would only be useful when there is benefit from dual-phase imaging (eg, gastrointestinal bleeding). However, IV contrast is important to delineate rim-enhancement of fluid collections to aid in the diagnosis of abscess. The reported sensitivity of CT for anorectal abscess is 77% [11].
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Anorectal Disease. Imaging is used in suspected cases of anorectal abscess and/or fistula to confirm the diagnosis, assist in surgical planning, predict surgical outcome, assess for recurrent or residual disease, and monitor medical therapy in patients with CD [10]. CT Pelvis The appropriate CT protocol for imaging a patient with an anorectal complaint depends upon the presentation and differential diagnosis. Intravenous (IV) contrast is preferred to a noncontrast examination to help visualize and characterize fluid collections, abscesses, and fistulous tracts. Water-soluble rectal contrast is generally not necessary to diagnose a rectal abscess and may be challenging to administer depending on symptom severity. However, rectal contrast may help delineate perforation or leak in a patient with a history of trauma or recent surgery. Water-soluble rectal contrast is preferred over barium to avoid the possibility of barium spilling into the peritoneal cavity or spaces of the extraperitoneal pelvis. Water-soluble rectal contrast is also preferred in a patient who could potentially be undergoing surgery. CT is commonly used in the acute setting to evaluate for anorectal abscess. The inherent lack of contrast resolution of CT limits the differentiation of subtle attenuation changes to differentiate small abscesses and fistulae from the anal sphincter complex and the soft tissue of the pelvic floor. To our knowledge, there is no recent literature evaluating the accuracy of modern CT technology for the detection of anorectal abscesses and there are no studies comparing IV contrast-enhanced scans to scans obtained without IV contrast. CT with and without IV contrast would only be useful when there is benefit from dual-phase imaging (eg, gastrointestinal bleeding). However, IV contrast is important to delineate rim-enhancement of fluid collections to aid in the diagnosis of abscess. The reported sensitivity of CT for anorectal abscess is 77% [11].
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Anorectal Disease
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Comparing CT with endoanal ultrasound (US) and surgical findings, only 24% of perianal fistulae were correctly classified on CT, as compared with 82% by endoanal US in a small series of 25 patients reported by Schratter-Sehn et al [12]. Fluoroscopy Contrast Enema Fluoroscopic contrast enema is not useful in this clinical scenario because it cannot assess the presence or absence of an abscess or fistula tract. There is no relevant literature regarding the use of contrast enema in the evaluation of perianal disease. Fluoroscopy Fistulography Fluoroscopic fistulography is performed by cannulating the external opening of a fistula with a small-gauge catheter, such as an IV catheter, pediatric feeding tube, or lacrimal cannula. Scout radiographs are obtained prior to careful injection of water-soluble contrast material into the fistula tract while obtaining spot radiographs [13]. Care Anorectal Disease should be taken not to inadvertently obscure a distal fistula with the enema or catheter tip or the balloon of a catheter. Fistulography may also be performed with CT by injecting a dilute water-soluble contrast material into an external opening of a fistula; however, there is limited published experience with this technique [14,15]. Fluoroscopic fistulography is rarely performed for perianal disease and has been replaced by modern cross-sectional imaging in this setting. Data on the accuracy of fluoroscopic fistulography are available from small series reported in older medical literature. Weisman et al [13] reported the highest sensitivity (89%) for identification of the primary tract in a retrospective review of 27 patients. In contrast, Kuijpers and Schulpen [16] found fistulography was accurate in only 16% of patients in a retrospective review of 25 patients [16]. The limitations of fistulography include lack of filling of the entire tract or extensions of the tract because inflammatory debris in the tract may prevent contrast filling. In these cases, the internal opening may not be defined.
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Anorectal Disease. Comparing CT with endoanal ultrasound (US) and surgical findings, only 24% of perianal fistulae were correctly classified on CT, as compared with 82% by endoanal US in a small series of 25 patients reported by Schratter-Sehn et al [12]. Fluoroscopy Contrast Enema Fluoroscopic contrast enema is not useful in this clinical scenario because it cannot assess the presence or absence of an abscess or fistula tract. There is no relevant literature regarding the use of contrast enema in the evaluation of perianal disease. Fluoroscopy Fistulography Fluoroscopic fistulography is performed by cannulating the external opening of a fistula with a small-gauge catheter, such as an IV catheter, pediatric feeding tube, or lacrimal cannula. Scout radiographs are obtained prior to careful injection of water-soluble contrast material into the fistula tract while obtaining spot radiographs [13]. Care Anorectal Disease should be taken not to inadvertently obscure a distal fistula with the enema or catheter tip or the balloon of a catheter. Fistulography may also be performed with CT by injecting a dilute water-soluble contrast material into an external opening of a fistula; however, there is limited published experience with this technique [14,15]. Fluoroscopic fistulography is rarely performed for perianal disease and has been replaced by modern cross-sectional imaging in this setting. Data on the accuracy of fluoroscopic fistulography are available from small series reported in older medical literature. Weisman et al [13] reported the highest sensitivity (89%) for identification of the primary tract in a retrospective review of 27 patients. In contrast, Kuijpers and Schulpen [16] found fistulography was accurate in only 16% of patients in a retrospective review of 25 patients [16]. The limitations of fistulography include lack of filling of the entire tract or extensions of the tract because inflammatory debris in the tract may prevent contrast filling. In these cases, the internal opening may not be defined.
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Anorectal Disease
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Furthermore, the anal sphincter complex and levator ani are not visualized fluoroscopically; as such, the relationship of the fistula to these structures cannot be defined. Pelvic MRI with a multichannel phased array body coil has become the standard for imaging perianal fistula, especially those associated with CD, because they are more frequently complex with clinically occult tracts. Imaging with a body coil is better tolerated and is not limited by the field of view compared with MRI with an endoanal coil. The surgical concordance with fistula detection has been shown to be better with a body coil (96%) compared with an endoanal coil (68%) [20]. In multiple studies, MRI has been shown to have high sensitivity and specificity for the evaluation of perianal fistula. The meta-analysis by Zbar and Armitage [21] showed MRI had a sensitivity ranging from 81% to 100% and specificity from 67% to 100%, with accuracy for identification of the internal opening of 74% to 97%, and delineation of horseshoe fistula of 97% to 100% [21]. Sahni et al [22] showed that, for diagnosis of the primary fistula in CD patients, MRI had an accuracy of 64% to 100%. Comparing MRI to examination under anesthesia with or without endoanal US, the sensitivity and specificity for discriminating complex from simple perianal fistula was 97% and 96%, 92% and 85% for MRI, and 75% and 64% for endoanal US. Though fistula can be readily identified on MRI without IV contrast as hyperintense tracts on FSE T2-weighted sequences and short-tau inversion recovery sequences, the use of IV contrast facilitates visualization because tracts with active inflammation will avidly enhance and small associated abscesses will show ring enhancement around a central fluid collection. IV contrast enables the differentiation of inactive tracts containing granulation tissue, which diffusely enhance from active tracts that have ring or rim-like enhancement [18].
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Anorectal Disease. Furthermore, the anal sphincter complex and levator ani are not visualized fluoroscopically; as such, the relationship of the fistula to these structures cannot be defined. Pelvic MRI with a multichannel phased array body coil has become the standard for imaging perianal fistula, especially those associated with CD, because they are more frequently complex with clinically occult tracts. Imaging with a body coil is better tolerated and is not limited by the field of view compared with MRI with an endoanal coil. The surgical concordance with fistula detection has been shown to be better with a body coil (96%) compared with an endoanal coil (68%) [20]. In multiple studies, MRI has been shown to have high sensitivity and specificity for the evaluation of perianal fistula. The meta-analysis by Zbar and Armitage [21] showed MRI had a sensitivity ranging from 81% to 100% and specificity from 67% to 100%, with accuracy for identification of the internal opening of 74% to 97%, and delineation of horseshoe fistula of 97% to 100% [21]. Sahni et al [22] showed that, for diagnosis of the primary fistula in CD patients, MRI had an accuracy of 64% to 100%. Comparing MRI to examination under anesthesia with or without endoanal US, the sensitivity and specificity for discriminating complex from simple perianal fistula was 97% and 96%, 92% and 85% for MRI, and 75% and 64% for endoanal US. Though fistula can be readily identified on MRI without IV contrast as hyperintense tracts on FSE T2-weighted sequences and short-tau inversion recovery sequences, the use of IV contrast facilitates visualization because tracts with active inflammation will avidly enhance and small associated abscesses will show ring enhancement around a central fluid collection. IV contrast enables the differentiation of inactive tracts containing granulation tissue, which diffusely enhance from active tracts that have ring or rim-like enhancement [18].
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Anorectal Disease
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Lo Re et al [23] retrospectively evaluated MRI in 31 patients with CD suspected of having perianal fistula and a surgical examination under anesthesia showing that short-tau inversion recovery sequences were equivalent to IV contrast-enhanced fat-suppressed T1-weighted sequences in detection and classification of anal fistula with sensitivity of 96%, specificity of 75%, positive predictive value (PPV) of 93%, and negative predictive value (NPV) of 86% for both sequences [23]. However, their study did not evaluate tract activity. In another retrospective study of 17 patients that underwent MRI prior to surgery, the contribution of MRI sequences to fistula classification was evaluated. All 3 readers showed statistically significant concordance between fistula classification and surgery with IV contrast-enhanced fat-suppressed T1-weighted sequences. The highest concordance for all 3 readers was reached Anorectal Disease with the combination of T2-weighted sequences and IV contrast-enhanced fat-suppressed T1-weighted sequences [24]. Finally, Dohan et al [19] evaluated the addition of diffusion imaging in a retrospective study of 24 patients with perianal fistula that went to surgery. The sensitivity for anal fistula detection for fat-suppressed FSE T2-weighted sequences was 91.2% and for diffusion imaging was 100%, with statistically significant greater fistula conspicuity on diffusion imaging than fat-suppressed FSE T2-weighted sequences. Radiography Pelvis Radiography is not useful in this clinical scenario because it cannot assess the presence or absence of an abscess or fistula tract. There is no relevant literature to support the use of radiography in the evaluation of perianal fistula. In a recent study of 122 patients by Sun et al [27], the reported sensitivity, specificity, and accuracy for the diagnosis of perianal fistula compared with surgery was 92%, 100%, and 93%, respectively. This study reported an accuracy of identification of the internal opening of the fistula of 95%.
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Anorectal Disease. Lo Re et al [23] retrospectively evaluated MRI in 31 patients with CD suspected of having perianal fistula and a surgical examination under anesthesia showing that short-tau inversion recovery sequences were equivalent to IV contrast-enhanced fat-suppressed T1-weighted sequences in detection and classification of anal fistula with sensitivity of 96%, specificity of 75%, positive predictive value (PPV) of 93%, and negative predictive value (NPV) of 86% for both sequences [23]. However, their study did not evaluate tract activity. In another retrospective study of 17 patients that underwent MRI prior to surgery, the contribution of MRI sequences to fistula classification was evaluated. All 3 readers showed statistically significant concordance between fistula classification and surgery with IV contrast-enhanced fat-suppressed T1-weighted sequences. The highest concordance for all 3 readers was reached Anorectal Disease with the combination of T2-weighted sequences and IV contrast-enhanced fat-suppressed T1-weighted sequences [24]. Finally, Dohan et al [19] evaluated the addition of diffusion imaging in a retrospective study of 24 patients with perianal fistula that went to surgery. The sensitivity for anal fistula detection for fat-suppressed FSE T2-weighted sequences was 91.2% and for diffusion imaging was 100%, with statistically significant greater fistula conspicuity on diffusion imaging than fat-suppressed FSE T2-weighted sequences. Radiography Pelvis Radiography is not useful in this clinical scenario because it cannot assess the presence or absence of an abscess or fistula tract. There is no relevant literature to support the use of radiography in the evaluation of perianal fistula. In a recent study of 122 patients by Sun et al [27], the reported sensitivity, specificity, and accuracy for the diagnosis of perianal fistula compared with surgery was 92%, 100%, and 93%, respectively. This study reported an accuracy of identification of the internal opening of the fistula of 95%.
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Anorectal Disease
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In an earlier study of 104 patients by Buchanan et al [28], comparing endoanal US with MRI, endoanal US correctly classified 81% of perianal fistulae compared with 90% by MRI. Their accuracy for detection of the internal opening was 91% by endoanal US and 97% by MRI. Endoanal US is limited by the field of view and depth of penetration. Accuracy for identification of extrasphincteric and suprasphincteric tracts (50% and 67%, respectively) is lower compared with transsphincteric and intersphincteric tracts (93% and 88%, respectively) [27]. Other limitations include obscuration of the tract or secondary extensions by gas in the tract or gas in an associated abscess. In patients with recurrent disease, it may be impossible to distinguish tracts with active inflammation from those with fibrosis and granulation tissue, which is often a clinical question in patients with CD. Hydrogen peroxide may be injected into the external opening of the fistula during endoanal US to enhance visualization of fistula tracts [29]. A tract filled with hydrogen peroxide is brightly hyperechoic on endoanal US, improving its visualization and connection to abscess cavities as well as differentiating it from scar tissue [25]. Variant 2: Suspected rectal fistula. Rectovesicular or rectovaginal. Initial imaging. Rectovaginal and rectovesicular fistulae are uncommon. The most common cause of a rectovaginal fistula is obstetric or vaginal trauma (88% of cases) [32], followed by CD, which accounts for approximately 9% of cases [33]. Other causes include radiation; pelvic infections (diverticulitis, tuberculosis, lymphogranuloma venereum, human papilloma virus, HIV, cytomegalovirus, and schistosomiasis); malignancies of the anorectum, perineum, and gynecologic organs; and iatrogenic injury and postoperative complications. Upon initial imaging, the organ of origin may be unknown. Rectovaginal fistulae are subclassified as high or low fistulae.
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Anorectal Disease. In an earlier study of 104 patients by Buchanan et al [28], comparing endoanal US with MRI, endoanal US correctly classified 81% of perianal fistulae compared with 90% by MRI. Their accuracy for detection of the internal opening was 91% by endoanal US and 97% by MRI. Endoanal US is limited by the field of view and depth of penetration. Accuracy for identification of extrasphincteric and suprasphincteric tracts (50% and 67%, respectively) is lower compared with transsphincteric and intersphincteric tracts (93% and 88%, respectively) [27]. Other limitations include obscuration of the tract or secondary extensions by gas in the tract or gas in an associated abscess. In patients with recurrent disease, it may be impossible to distinguish tracts with active inflammation from those with fibrosis and granulation tissue, which is often a clinical question in patients with CD. Hydrogen peroxide may be injected into the external opening of the fistula during endoanal US to enhance visualization of fistula tracts [29]. A tract filled with hydrogen peroxide is brightly hyperechoic on endoanal US, improving its visualization and connection to abscess cavities as well as differentiating it from scar tissue [25]. Variant 2: Suspected rectal fistula. Rectovesicular or rectovaginal. Initial imaging. Rectovaginal and rectovesicular fistulae are uncommon. The most common cause of a rectovaginal fistula is obstetric or vaginal trauma (88% of cases) [32], followed by CD, which accounts for approximately 9% of cases [33]. Other causes include radiation; pelvic infections (diverticulitis, tuberculosis, lymphogranuloma venereum, human papilloma virus, HIV, cytomegalovirus, and schistosomiasis); malignancies of the anorectum, perineum, and gynecologic organs; and iatrogenic injury and postoperative complications. Upon initial imaging, the organ of origin may be unknown. Rectovaginal fistulae are subclassified as high or low fistulae.
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Anorectal Disease
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High fistula, referred to as rectovaginal fistula, are communications to the rectum, proximal to the anal sphincter. These often involve the posterior vaginal fornix. Low fistula are anovaginal, which are communications from the anal sphincter complex to the lower half of the vagina [34]. Women with rectovaginal or anovaginal fistulae present with stool, gas, or odorous Anorectal Disease mucopurulent discharge from the vagina. These symptoms may be confused for incontinence. Other symptoms include dyspareunia, perineal pain, and recurrent vaginal infections. Rectovesicular fistulae are characterized by the clinical presentation of pneumaturia or fecaluria, which are pathognomonic [1]. Recurrent urinary tract infection may also be a presenting manifestation. Diverticulitis, CD, colorectal or pelvic malignancies, radiation, iatrogenic injury, and postoperative complications are the most common causes. CT Pelvis The appropriate CT protocol for imaging a patient with an anorectal complaint depends upon the presentation and differential diagnosis. IV contrast is preferred to a noncontrast examination to help visualize and characterize fluid collections, abscesses, and fistulous tracts. CT without contrast is not useful in this clinical scenario. CT with and without IV contrast would only be useful when there is benefit from dual-phase imaging, but is not typically performed in this scenario. Water-soluble rectal contrast is generally not necessary to diagnose a rectal abscess and may be challenging to administer, depending on symptom severity. However, rectal contrast may help delineate perforation or leak in a patient with a history of trauma or recent surgery. Water-soluble rectal contrast is preferred over barium to avoid the possibility of barium spilling into the peritoneal cavity or spaces of the extraperitoneal pelvis. Water-soluble rectal contrast is also preferred in a patient who could potentially be undergoing surgery.
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Anorectal Disease. High fistula, referred to as rectovaginal fistula, are communications to the rectum, proximal to the anal sphincter. These often involve the posterior vaginal fornix. Low fistula are anovaginal, which are communications from the anal sphincter complex to the lower half of the vagina [34]. Women with rectovaginal or anovaginal fistulae present with stool, gas, or odorous Anorectal Disease mucopurulent discharge from the vagina. These symptoms may be confused for incontinence. Other symptoms include dyspareunia, perineal pain, and recurrent vaginal infections. Rectovesicular fistulae are characterized by the clinical presentation of pneumaturia or fecaluria, which are pathognomonic [1]. Recurrent urinary tract infection may also be a presenting manifestation. Diverticulitis, CD, colorectal or pelvic malignancies, radiation, iatrogenic injury, and postoperative complications are the most common causes. CT Pelvis The appropriate CT protocol for imaging a patient with an anorectal complaint depends upon the presentation and differential diagnosis. IV contrast is preferred to a noncontrast examination to help visualize and characterize fluid collections, abscesses, and fistulous tracts. CT without contrast is not useful in this clinical scenario. CT with and without IV contrast would only be useful when there is benefit from dual-phase imaging, but is not typically performed in this scenario. Water-soluble rectal contrast is generally not necessary to diagnose a rectal abscess and may be challenging to administer, depending on symptom severity. However, rectal contrast may help delineate perforation or leak in a patient with a history of trauma or recent surgery. Water-soluble rectal contrast is preferred over barium to avoid the possibility of barium spilling into the peritoneal cavity or spaces of the extraperitoneal pelvis. Water-soluble rectal contrast is also preferred in a patient who could potentially be undergoing surgery.
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3102384
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acrac_3102384_9
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Anorectal Disease
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CT provides important information in the diagnosis of the underlying etiology of the fistula, as well as detecting the course and locations of fistulae. To our knowledge, there are no data in the literature regarding the use of IV contrast in the detection of rectovaginal or rectovesicular fistula. Water-soluble contrast should be placed in the bowel or bladder to try to opacify fistulous tracts, depending upon the clinically suspected location of the tract. The bladder can be opacified retrograde (CT cystogram) or antegrade with delayed imaging after IV contrast administration. Kuhlman et al [35] reported an accuracy of 60% for the CT detection of enterovaginal or vesicovaginal fistula by the identification of contrast material in the vagina from the bowel or bladder. In a study of 37 patients with colovaginal and colovesicular fistulae, CT had a diagnostic sensitivity of 76.5% for fistula detection and 94.1% for defining the etiology of the fistula [1]. However, this study does not report how the diagnosis of fistula was made and what type of contrast material was used. Fluoroscopy Contrast Enema Fluoroscopic contrast enemas performed for the diagnosis of perforation or leak, rectovaginal or rectovesicular fistula, pouchitis, or proctitis can be performed with water-soluble contrast or barium. Though this procedure is reported to have low sensitivity and specificity as detailed in the following paragraph, it may be useful for observing subtle fistulas. In general, water-soluble contrast is preferred if a leak or perforation are suspected to avoid barium spillage into the peritoneal cavity or extraperitoneal pelvis. Using barium may also interfere with a subsequent CT scan because of the streak artifact that it causes on CT. Care should be taken not to inadvertently obscure a distal fistula with the enema or catheter tip or the balloon of a catheter. The performance of contrast enema for the detection of rectovaginal fistulas is reported in small series from older published literature.
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Anorectal Disease. CT provides important information in the diagnosis of the underlying etiology of the fistula, as well as detecting the course and locations of fistulae. To our knowledge, there are no data in the literature regarding the use of IV contrast in the detection of rectovaginal or rectovesicular fistula. Water-soluble contrast should be placed in the bowel or bladder to try to opacify fistulous tracts, depending upon the clinically suspected location of the tract. The bladder can be opacified retrograde (CT cystogram) or antegrade with delayed imaging after IV contrast administration. Kuhlman et al [35] reported an accuracy of 60% for the CT detection of enterovaginal or vesicovaginal fistula by the identification of contrast material in the vagina from the bowel or bladder. In a study of 37 patients with colovaginal and colovesicular fistulae, CT had a diagnostic sensitivity of 76.5% for fistula detection and 94.1% for defining the etiology of the fistula [1]. However, this study does not report how the diagnosis of fistula was made and what type of contrast material was used. Fluoroscopy Contrast Enema Fluoroscopic contrast enemas performed for the diagnosis of perforation or leak, rectovaginal or rectovesicular fistula, pouchitis, or proctitis can be performed with water-soluble contrast or barium. Though this procedure is reported to have low sensitivity and specificity as detailed in the following paragraph, it may be useful for observing subtle fistulas. In general, water-soluble contrast is preferred if a leak or perforation are suspected to avoid barium spillage into the peritoneal cavity or extraperitoneal pelvis. Using barium may also interfere with a subsequent CT scan because of the streak artifact that it causes on CT. Care should be taken not to inadvertently obscure a distal fistula with the enema or catheter tip or the balloon of a catheter. The performance of contrast enema for the detection of rectovaginal fistulas is reported in small series from older published literature.
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Anorectal Disease
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In 13 enemas performed by Giordano et al [36], the overall sensitivity was 7.7% for all fistula and 9% for those that involved the colon only. In a previous series of sigmoid vaginal fistulae, contrast enema detected the fistulae in 34% of cases [37]. For fistula to the urinary tract, Amendola et al compared contrast enema and cystography, which showed 50% and 30% of fistula, respectively, in 28 patients with surgically proven colovesicular fistula [38]. Fluoroscopy Cystography The data on diagnosis of rectovesicular fistula by cystography is limited to small series in older medical literature. In series of 30 patients with enterovesicular fistula, Hsieh et al [39] reported 90% were detected by cystography and 75% by contrast enema. Fluoroscopy Vaginography Fluoroscopic vaginography is performed after obtaining anterolateral and lateral scout radiographs or spot films. A large-gauge Foley catheter, such as a 26-guage with a 30-mL balloon, is placed in the vaginal lumen. The balloon is inflated to prevent the spillage of contrast material out of the vagina. Water-soluble contrast is injected under fluoroscopic guidance, and spot radiographs are obtained in the anteroposterior, right and left, oblique, and lateral views. Water-soluble contrast is preferred over barium because the endometrial cavity may fill in normal patients, and contrast may thus spill into the peritoneal cavity. Vaginography may also be performed with CT [40]. An unenhanced scan is obtained prior to vaginal opacification. The vagina is opacified in the same manner as in Anorectal Disease fluoroscopy; however, the water-soluble contrast is diluted with sterile water or normal saline (1/10, V/V) [40]. A second CT is obtained after vaginal filling. It may be acquired with or without IV contrast, depending upon the clinical indication. Giordano et al [36] reported a sensitivity of 79% and PPV of 100% for fluoroscopic vaginography for identification of fistulous tracts in 27 patients with suspected fistulae.
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Anorectal Disease. In 13 enemas performed by Giordano et al [36], the overall sensitivity was 7.7% for all fistula and 9% for those that involved the colon only. In a previous series of sigmoid vaginal fistulae, contrast enema detected the fistulae in 34% of cases [37]. For fistula to the urinary tract, Amendola et al compared contrast enema and cystography, which showed 50% and 30% of fistula, respectively, in 28 patients with surgically proven colovesicular fistula [38]. Fluoroscopy Cystography The data on diagnosis of rectovesicular fistula by cystography is limited to small series in older medical literature. In series of 30 patients with enterovesicular fistula, Hsieh et al [39] reported 90% were detected by cystography and 75% by contrast enema. Fluoroscopy Vaginography Fluoroscopic vaginography is performed after obtaining anterolateral and lateral scout radiographs or spot films. A large-gauge Foley catheter, such as a 26-guage with a 30-mL balloon, is placed in the vaginal lumen. The balloon is inflated to prevent the spillage of contrast material out of the vagina. Water-soluble contrast is injected under fluoroscopic guidance, and spot radiographs are obtained in the anteroposterior, right and left, oblique, and lateral views. Water-soluble contrast is preferred over barium because the endometrial cavity may fill in normal patients, and contrast may thus spill into the peritoneal cavity. Vaginography may also be performed with CT [40]. An unenhanced scan is obtained prior to vaginal opacification. The vagina is opacified in the same manner as in Anorectal Disease fluoroscopy; however, the water-soluble contrast is diluted with sterile water or normal saline (1/10, V/V) [40]. A second CT is obtained after vaginal filling. It may be acquired with or without IV contrast, depending upon the clinical indication. Giordano et al [36] reported a sensitivity of 79% and PPV of 100% for fluoroscopic vaginography for identification of fistulous tracts in 27 patients with suspected fistulae.
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Anorectal Disease
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Earlier series in a smaller number of patients reported sensitivities of 100% [41,42]. Limitations of vaginography include occlusion of low fistula by the Foley catheter balloon and completely filling complex fistulous tracts that may have several branches. The high sensitivity and PPV supports the use of this procedure in certain clinical scenarios. MRI Pelvis Rectovaginal and anovaginal fistula may be visualized on MRI performed with a phased array body coil, but to our knowledge, there are no published studies reporting the accuracy of fistula detection. As such, the advantages of scanning with or without IV contrast have not been studied. Based on our knowledge of anorectal fistula, there is a clear advantage to using IV contrast to visualize collapsed tracts that do not contain fluid and would be difficult to see on T2-weighted sequences. MRI pelvis without IV contrast may be helpful in certain clinical situations but is not as good as one performed with IV contrast. Stoker et al [43] compared endoluminal coil MRI with and without IV contrast to endoluminal US, reporting a PPV for detection of fistula tracts of 92% and 100%, respectively. Radiography Pelvis Radiography is not useful in this clinical scenario because it cannot assess the presence or absence of an abscess or fistula tract. US Pelvis Transrectal Yee et al [44] reported that endoluminal US detected only 28% of rectovaginal fistula in 25 patients prior to surgical repair. However, more recent reports show improved detection; consequently, this procedure can be useful in certain clinical situations for fistula detection. In 28 patients, Yin et al [45] had a PPV of 100% for the identification of the anorectal opening of the fistula and 93% for the identification of the vaginal opening, and an overall PPV of the fistula of 90%. The limitation of endoluminal US is identification of complex fistulas with secondary branches, visualization of occluded branches, and visualization of fistula that extend beyond the field of view.
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Anorectal Disease. Earlier series in a smaller number of patients reported sensitivities of 100% [41,42]. Limitations of vaginography include occlusion of low fistula by the Foley catheter balloon and completely filling complex fistulous tracts that may have several branches. The high sensitivity and PPV supports the use of this procedure in certain clinical scenarios. MRI Pelvis Rectovaginal and anovaginal fistula may be visualized on MRI performed with a phased array body coil, but to our knowledge, there are no published studies reporting the accuracy of fistula detection. As such, the advantages of scanning with or without IV contrast have not been studied. Based on our knowledge of anorectal fistula, there is a clear advantage to using IV contrast to visualize collapsed tracts that do not contain fluid and would be difficult to see on T2-weighted sequences. MRI pelvis without IV contrast may be helpful in certain clinical situations but is not as good as one performed with IV contrast. Stoker et al [43] compared endoluminal coil MRI with and without IV contrast to endoluminal US, reporting a PPV for detection of fistula tracts of 92% and 100%, respectively. Radiography Pelvis Radiography is not useful in this clinical scenario because it cannot assess the presence or absence of an abscess or fistula tract. US Pelvis Transrectal Yee et al [44] reported that endoluminal US detected only 28% of rectovaginal fistula in 25 patients prior to surgical repair. However, more recent reports show improved detection; consequently, this procedure can be useful in certain clinical situations for fistula detection. In 28 patients, Yin et al [45] had a PPV of 100% for the identification of the anorectal opening of the fistula and 93% for the identification of the vaginal opening, and an overall PPV of the fistula of 90%. The limitation of endoluminal US is identification of complex fistulas with secondary branches, visualization of occluded branches, and visualization of fistula that extend beyond the field of view.
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acrac_3102384_12
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Anorectal Disease
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Variant 3: Suspected proctitis or pouchitis. Initial imaging. Proctitis, inflammation of the rectum, is a common manifestation of inflammatory bowel disease (ulcerative colitis and CD). Other causes include infections (gonorrhea, chlamydia, herpes simplex virus, HIV/acquired immunodeficiency syndrome), radiation, and ischemia. Patients present with rectal pain, discomfort, tenesmus, purulent discharge, abdominal pain, and urgency. In most patients, imaging is not required. However, if a more complex disease is clinically suspected, imaging may be indicated to define the extent of disease and/or complications. An ileal pouch anal anastomosis (IPAA), also known as a J-pouch, is the most common surgical approach for creating a continent reservoir following total proctocolectomy. This is typically performed in a two-stage procedure in patients with ulcerative colitis or familial adenomatous polyposis. Pouchitis is a common complication of IPAA, occurring in approximately 20% of patients within 1 year of surgery and 50% of patients within 10 years of surgery [46]. Pouchitis may be caused by primary infection or an immune response to an altered microbiome in the pouch lumen or mucosa. Patients may present with increased stool frequency and fluidity, tenesmus, incontinence, pain, malaise, fever, or bleeding. The symptoms of pouchitis overlap with other postoperative complications, such as dehiscence and abscess, as well as occult CD such as in patients that have presumed ulcerative colitis with undiagnosed CD or subsequently developed CD [47]. Imaging is an important complementary technique to endoscopy with biopsy to accurately diagnose and manage inflammation in the pouch. CT Enterography CT enterography techniques provide better visualization of the small bowel compared with routine CT.
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Anorectal Disease. Variant 3: Suspected proctitis or pouchitis. Initial imaging. Proctitis, inflammation of the rectum, is a common manifestation of inflammatory bowel disease (ulcerative colitis and CD). Other causes include infections (gonorrhea, chlamydia, herpes simplex virus, HIV/acquired immunodeficiency syndrome), radiation, and ischemia. Patients present with rectal pain, discomfort, tenesmus, purulent discharge, abdominal pain, and urgency. In most patients, imaging is not required. However, if a more complex disease is clinically suspected, imaging may be indicated to define the extent of disease and/or complications. An ileal pouch anal anastomosis (IPAA), also known as a J-pouch, is the most common surgical approach for creating a continent reservoir following total proctocolectomy. This is typically performed in a two-stage procedure in patients with ulcerative colitis or familial adenomatous polyposis. Pouchitis is a common complication of IPAA, occurring in approximately 20% of patients within 1 year of surgery and 50% of patients within 10 years of surgery [46]. Pouchitis may be caused by primary infection or an immune response to an altered microbiome in the pouch lumen or mucosa. Patients may present with increased stool frequency and fluidity, tenesmus, incontinence, pain, malaise, fever, or bleeding. The symptoms of pouchitis overlap with other postoperative complications, such as dehiscence and abscess, as well as occult CD such as in patients that have presumed ulcerative colitis with undiagnosed CD or subsequently developed CD [47]. Imaging is an important complementary technique to endoscopy with biopsy to accurately diagnose and manage inflammation in the pouch. CT Enterography CT enterography techniques provide better visualization of the small bowel compared with routine CT.
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acrac_3102384_13
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Anorectal Disease
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To optimize small-bowel distention and visualization of the mucosa, patients ingest a large volume (1,000 to 2,000 cc) of neutral contrast material (such as low w/v barium solutions, water, polyethylene glycol, or methylcellulose suspensions) prior to the examination. IV contrast enhances the small-bowel wall such that it is well seen adjacent to the neutral intraluminal contrast. Single- or dual-phase (arterial and portal venous, respectively) acquisitions may be obtained. Using CT findings of inflammation (wall thickening, mucosal hyperenhancement, mural stratification, peripouch stranding, peripouch hyperemia, and peripouch abscess, fistula, or sinus tract), Liszewski et al [48] showed that IV Anorectal Disease contrast-enhanced CT enterography had a 90% sensitivity, 67% specificity, 90% PPV, 67% NPV, and 85% accuracy for diagnosis of pouchitis when more than 2 signs of inflammation were present. CT Pelvis The appropriate CT protocol for imaging a patient with an anorectal complaint depends upon the presentation and differential diagnosis. IV contrast is preferred to a noncontrast examination to help visualize and characterize fluid collections, abscesses, and fistulous tracts. CT without contrast is not useful in this clinical scenario. CT with and without IV contrast would only be useful when there is benefit from dual-phase imaging, but it is not typically performed in this scenario. Water-soluble rectal contrast is generally not necessary to diagnose a rectal abscess and may be challenging to administer, depending on symptom severity. However, rectal contrast may help delineate perforation or leak in a patient with a history of trauma or recent surgery. Water-soluble rectal contrast is preferred over barium to avoid the possibility of barium spilling into the peritoneal cavity or spaces of the extraperitoneal pelvis. Water-soluble rectal contrast is also preferred in patients who could potentially be undergoing surgery.
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Anorectal Disease. To optimize small-bowel distention and visualization of the mucosa, patients ingest a large volume (1,000 to 2,000 cc) of neutral contrast material (such as low w/v barium solutions, water, polyethylene glycol, or methylcellulose suspensions) prior to the examination. IV contrast enhances the small-bowel wall such that it is well seen adjacent to the neutral intraluminal contrast. Single- or dual-phase (arterial and portal venous, respectively) acquisitions may be obtained. Using CT findings of inflammation (wall thickening, mucosal hyperenhancement, mural stratification, peripouch stranding, peripouch hyperemia, and peripouch abscess, fistula, or sinus tract), Liszewski et al [48] showed that IV Anorectal Disease contrast-enhanced CT enterography had a 90% sensitivity, 67% specificity, 90% PPV, 67% NPV, and 85% accuracy for diagnosis of pouchitis when more than 2 signs of inflammation were present. CT Pelvis The appropriate CT protocol for imaging a patient with an anorectal complaint depends upon the presentation and differential diagnosis. IV contrast is preferred to a noncontrast examination to help visualize and characterize fluid collections, abscesses, and fistulous tracts. CT without contrast is not useful in this clinical scenario. CT with and without IV contrast would only be useful when there is benefit from dual-phase imaging, but it is not typically performed in this scenario. Water-soluble rectal contrast is generally not necessary to diagnose a rectal abscess and may be challenging to administer, depending on symptom severity. However, rectal contrast may help delineate perforation or leak in a patient with a history of trauma or recent surgery. Water-soluble rectal contrast is preferred over barium to avoid the possibility of barium spilling into the peritoneal cavity or spaces of the extraperitoneal pelvis. Water-soluble rectal contrast is also preferred in patients who could potentially be undergoing surgery.
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3102384
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acrac_3102384_14
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Anorectal Disease
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CT is often the initial examination for patients with clinical findings of proctitis or pouchitis because of its ability to evaluate inflammatory thickening of the rectal or pouch wall, associated abscess, possible fistula, or anastomotic leak in an IPAA. IV contrast-enhanced CT is preferred over a noncontrast CT because the presence of IV contrast will allow detection of abnormal enhancement of the bowel wall as well as the presence of rim-enhancement that would suggest abscess in any associated fluid collection. To our knowledge, there are no studies in the literature using modern CT technology that evaluate the accuracy of routine pelvic CT with or without IV contrast for the diagnosis of proctitis or pouchitis. FDG-PET/CT Skull Base to Mid-Thigh Fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT has been reported to be a useful tool in assessing the degree of inflammatory activity in patients with ulcerative colitis and CD [49,50]. Shyn et al [51] compared FDG- PET/CT enterography to conventional CT enterography in evaluating patients with CD. In this study, FDG-PET/CT enterography showed sites of active inflammation in 3 of 13 cases (23.1%) that were not seen on CT enterography, though these areas were not in the rectum or a surgical pouch. To our knowledge, there is no relevant recent literature regarding the use of FDG-PET/CT in the evaluation of suspected proctitis or pouchitis. Fluoroscopy Contrast Enema Fluoroscopic contrast enemas performed for the diagnosis of perforation or leak, rectovaginal or rectovesicular fistula, pouchitis, or proctitis can be performed with water-soluble contrast or barium. In general, water-soluble contrast is preferred if a leak or perforation is suspected in order to avoid barium spillage into the peritoneal cavity or extraperitoneal pelvis. Using barium may also interfere with a subsequent CT scan because of the streak artifact that it causes on CT.
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Anorectal Disease. CT is often the initial examination for patients with clinical findings of proctitis or pouchitis because of its ability to evaluate inflammatory thickening of the rectal or pouch wall, associated abscess, possible fistula, or anastomotic leak in an IPAA. IV contrast-enhanced CT is preferred over a noncontrast CT because the presence of IV contrast will allow detection of abnormal enhancement of the bowel wall as well as the presence of rim-enhancement that would suggest abscess in any associated fluid collection. To our knowledge, there are no studies in the literature using modern CT technology that evaluate the accuracy of routine pelvic CT with or without IV contrast for the diagnosis of proctitis or pouchitis. FDG-PET/CT Skull Base to Mid-Thigh Fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT has been reported to be a useful tool in assessing the degree of inflammatory activity in patients with ulcerative colitis and CD [49,50]. Shyn et al [51] compared FDG- PET/CT enterography to conventional CT enterography in evaluating patients with CD. In this study, FDG-PET/CT enterography showed sites of active inflammation in 3 of 13 cases (23.1%) that were not seen on CT enterography, though these areas were not in the rectum or a surgical pouch. To our knowledge, there is no relevant recent literature regarding the use of FDG-PET/CT in the evaluation of suspected proctitis or pouchitis. Fluoroscopy Contrast Enema Fluoroscopic contrast enemas performed for the diagnosis of perforation or leak, rectovaginal or rectovesicular fistula, pouchitis, or proctitis can be performed with water-soluble contrast or barium. In general, water-soluble contrast is preferred if a leak or perforation is suspected in order to avoid barium spillage into the peritoneal cavity or extraperitoneal pelvis. Using barium may also interfere with a subsequent CT scan because of the streak artifact that it causes on CT.
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3102384
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acrac_3102384_15
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Anorectal Disease
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A retrospective review by Brown et al [52] published in 1990 compared CT to fluoroscopic examination of patients with IPAA. Some of the fluoroscopic examinations were performed antegrade through the distal limb of the loop ileostomy, whereas others were performed retrograde. In these 18 patients, 10 had infectious symptoms and 8 did not. CT more clearly delineated the site and extent of abscess in 9 patients with infectious symptoms compared with the fluoroscopic studies [52]. However, this study did not evaluate the sensitivity or specificity of each examination, neither did it directly address pouchitis. To our knowledge, there is no recent literature evaluating fluoroscopic contrast enema for the diagnosis of proctitis or pouchitis. MR Enterography Pouchitis can also be evaluated as part of MR enterography. MR enterography is commonly performed with biphasic oral contrast agents that produce low signal intensity on T1-weighted sequences and high signal intensity on T2-weighted sequences because they allow excellent characterization of bowel wall enhancement on IV contrast- enhanced T1-weigheted sequences. These agents include low weight/volume barium solutions, water, polyethylene glycol, and methylcellulose. Patients ingest a large volume of the oral contrast prior to the examination. Administering an antispasmodic drug such as glucagon is useful for reducing motion artifact caused by bowel peristalsis. Both FSE T2-weighted and steady-state free precession T2-weighted sequences are generally performed to compensate for limitations of each in addition to dynamic IV contrast-enhanced sequences. In 28 patients who underwent colectomy with IPAA, Sahi et al [53] compared MR enterography, pouch endoscopy, and biopsy. They found that the presence of 4 or more MR enterography features of inflammation had the best correlation with endoscopic findings (86% sensitivity, 79% specificity, 80% PPV, 85% NPV, and 82% accuracy). Anorectal Disease
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Anorectal Disease. A retrospective review by Brown et al [52] published in 1990 compared CT to fluoroscopic examination of patients with IPAA. Some of the fluoroscopic examinations were performed antegrade through the distal limb of the loop ileostomy, whereas others were performed retrograde. In these 18 patients, 10 had infectious symptoms and 8 did not. CT more clearly delineated the site and extent of abscess in 9 patients with infectious symptoms compared with the fluoroscopic studies [52]. However, this study did not evaluate the sensitivity or specificity of each examination, neither did it directly address pouchitis. To our knowledge, there is no recent literature evaluating fluoroscopic contrast enema for the diagnosis of proctitis or pouchitis. MR Enterography Pouchitis can also be evaluated as part of MR enterography. MR enterography is commonly performed with biphasic oral contrast agents that produce low signal intensity on T1-weighted sequences and high signal intensity on T2-weighted sequences because they allow excellent characterization of bowel wall enhancement on IV contrast- enhanced T1-weigheted sequences. These agents include low weight/volume barium solutions, water, polyethylene glycol, and methylcellulose. Patients ingest a large volume of the oral contrast prior to the examination. Administering an antispasmodic drug such as glucagon is useful for reducing motion artifact caused by bowel peristalsis. Both FSE T2-weighted and steady-state free precession T2-weighted sequences are generally performed to compensate for limitations of each in addition to dynamic IV contrast-enhanced sequences. In 28 patients who underwent colectomy with IPAA, Sahi et al [53] compared MR enterography, pouch endoscopy, and biopsy. They found that the presence of 4 or more MR enterography features of inflammation had the best correlation with endoscopic findings (86% sensitivity, 79% specificity, 80% PPV, 85% NPV, and 82% accuracy). Anorectal Disease
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3102384
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acrac_3102384_16
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Anorectal Disease
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MRI is an excellent imaging modality for the evaluation of inflammatory disease of the rectum or IPAA. Using IV contrast material enhances the ability to diagnose inflammation, adding the findings of mucosal hyperenhancement to other findings such as wall thickening, submucosal edema seen on T2-weighted sequences, and mucosal ulceration. Additional findings, such as perirectal and perianal fistula and abscess, can also be seen. In a study of 58 patients with CD who had MRI and colonoscopy, several MRI features correlated with endoscopic diagnosis of proctitis, including wall thickness, submucosal fat, increased perimural signal intensity on T2-weighted sequences, increased perimural enhancement, creeping fat, and mesorectal lymph node size [54]. In another study of 9 patients, MRI had sensitivity and specificity of 100% for pouchitis as validated by pathology, using the criteria of increased wall thickness and enhancement [55]. Radiography Pelvis Radiography is not useful in this clinical scenario because it cannot assess inflammation of the rectum or ileoanal pouch. There is no relevant literature to support the use of radiography in the evaluation of suspected proctitis or pouchitis. US Pelvis Various US techniques (transabdominal, transperineal, transvaginal, and endorectal) can be used to assess the rectum or IPAA. In one study using endorectal US to evaluate radiation proctitis as compared with colonoscopy, endorectal US had sensitivity of 86.4%, specificity of 66.7%, PPV of 76.0%, NPV of 80.0%, and overall accuracy of 77.5% in differentiating mild from severe radiation proctitis by using blurred rectal wall stratification and wall vascularity [56]. There is no relevant recent literature regarding the use of US in the evaluation of suspected pouchitis. WBC Scan Abdomen and Pelvis In 1990, Thoeni et al [57] published a retrospective study of 55 patients who underwent total colectomy and IPAA.
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Anorectal Disease. MRI is an excellent imaging modality for the evaluation of inflammatory disease of the rectum or IPAA. Using IV contrast material enhances the ability to diagnose inflammation, adding the findings of mucosal hyperenhancement to other findings such as wall thickening, submucosal edema seen on T2-weighted sequences, and mucosal ulceration. Additional findings, such as perirectal and perianal fistula and abscess, can also be seen. In a study of 58 patients with CD who had MRI and colonoscopy, several MRI features correlated with endoscopic diagnosis of proctitis, including wall thickness, submucosal fat, increased perimural signal intensity on T2-weighted sequences, increased perimural enhancement, creeping fat, and mesorectal lymph node size [54]. In another study of 9 patients, MRI had sensitivity and specificity of 100% for pouchitis as validated by pathology, using the criteria of increased wall thickness and enhancement [55]. Radiography Pelvis Radiography is not useful in this clinical scenario because it cannot assess inflammation of the rectum or ileoanal pouch. There is no relevant literature to support the use of radiography in the evaluation of suspected proctitis or pouchitis. US Pelvis Various US techniques (transabdominal, transperineal, transvaginal, and endorectal) can be used to assess the rectum or IPAA. In one study using endorectal US to evaluate radiation proctitis as compared with colonoscopy, endorectal US had sensitivity of 86.4%, specificity of 66.7%, PPV of 76.0%, NPV of 80.0%, and overall accuracy of 77.5% in differentiating mild from severe radiation proctitis by using blurred rectal wall stratification and wall vascularity [56]. There is no relevant recent literature regarding the use of US in the evaluation of suspected pouchitis. WBC Scan Abdomen and Pelvis In 1990, Thoeni et al [57] published a retrospective study of 55 patients who underwent total colectomy and IPAA.
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acrac_3102384_17
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Anorectal Disease
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They compared CT, indium-11 (In-111) scintigraphy, and fluoroscopic pouchography for the detection of pouchitis, abscess, and fistula. For pouchitis, the sensitivity of CT, In-111 scintigraphy, and pouchography was 71%, 80%, and 53%, respectively. To our knowledge, there is no recent literature evaluating and comparing scintigraphy for the diagnosis of proctitis or pouchitis. There is no relevant recent literature regarding the use of Tc-99m white blood cell (WBC) scan in the evaluation of suspected proctitis or pouchitis. Anorectal Disease prolapse in the case of IPAA. A meta-analysis of complications after total proctocolectomy with IPAA performed by Hueting et al [59] showed a pooled incidence of 9.5% for pelvic sepsis, 5.5% for pouch-related anal or vaginal fistula, 9.2% for strictures, and 13.1% for small-bowel obstruction. The initial imaging modality for patients with a suspected postoperative complication may vary based upon the suspected complication. CT is often the first imaging modality used for patients who return following surgery with acute pain, sepsis, or signs of bowel obstruction. CT Abdomen and Pelvis CT abdomen and pelvis may be preferred over CT pelvis alone, depending upon the clinical scenario or specific type of operation performed. To our knowledge, there are no studies comparing noncontrast CT to IV contrast- enhanced CT for the detection of postoperative complications. However, IV contrast does improve the detection of abscesses and is important for the evaluation of the integrity of the bowel wall when ischemia or anastomotic dehiscence is suspected. CT with and without contrast would only be indicated when there is benefit from dual- phase imaging. When anastomotic leak is suspected, rectally administered contrast material is important to demonstrate extraluminal extravasation of contrast to confirm the leak, adding an additional finding to other findings of leak: perianastomotic gas, fluid collection, and staple line integrity.
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Anorectal Disease. They compared CT, indium-11 (In-111) scintigraphy, and fluoroscopic pouchography for the detection of pouchitis, abscess, and fistula. For pouchitis, the sensitivity of CT, In-111 scintigraphy, and pouchography was 71%, 80%, and 53%, respectively. To our knowledge, there is no recent literature evaluating and comparing scintigraphy for the diagnosis of proctitis or pouchitis. There is no relevant recent literature regarding the use of Tc-99m white blood cell (WBC) scan in the evaluation of suspected proctitis or pouchitis. Anorectal Disease prolapse in the case of IPAA. A meta-analysis of complications after total proctocolectomy with IPAA performed by Hueting et al [59] showed a pooled incidence of 9.5% for pelvic sepsis, 5.5% for pouch-related anal or vaginal fistula, 9.2% for strictures, and 13.1% for small-bowel obstruction. The initial imaging modality for patients with a suspected postoperative complication may vary based upon the suspected complication. CT is often the first imaging modality used for patients who return following surgery with acute pain, sepsis, or signs of bowel obstruction. CT Abdomen and Pelvis CT abdomen and pelvis may be preferred over CT pelvis alone, depending upon the clinical scenario or specific type of operation performed. To our knowledge, there are no studies comparing noncontrast CT to IV contrast- enhanced CT for the detection of postoperative complications. However, IV contrast does improve the detection of abscesses and is important for the evaluation of the integrity of the bowel wall when ischemia or anastomotic dehiscence is suspected. CT with and without contrast would only be indicated when there is benefit from dual- phase imaging. When anastomotic leak is suspected, rectally administered contrast material is important to demonstrate extraluminal extravasation of contrast to confirm the leak, adding an additional finding to other findings of leak: perianastomotic gas, fluid collection, and staple line integrity.
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3102384
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acrac_3102384_18
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Anorectal Disease
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Hyman et al [60] reported that CT was superior to fluoroscopic contrast enema at detecting leaks, with a PPV of 89.5% for CT and 40% for contrast enema in 33 patients who developed leaks. Kaur et al [61] showed a 91% sensitivity, 100% specificity, 100% PPV, and 95% NPV for CT in detecting postoperative anastomotic leaks in a retrospective study 170 patients who had undergone a low anterior resection, emphasizing the importance of rectal contrast material to improve confidence in diagnosis. CT Pelvis CT pelvis may be preferred over CT abdomen and pelvis in specific clinical scenarios when the pelvis alone is the area of clinical concern. To our knowledge there are no studies comparing noncontrast CT with IV contrast- enhanced CT for the detection of postoperative complications. However, IV contrast does improve the detection of abscesses and is important for the evaluation of the integrity of the bowel wall when ischemia or anastomotic dehiscence is suspected. CT with and without IV contrast would only be useful when there is benefit from dual- phase imaging. When anastomotic leak is suspected, rectally administered contrast material is important to demonstrate extraluminal extravasation of contrast to confirm the leak, adding an additional finding to other findings of leak: perianastomotic gas, fluid collection, and staple line integrity. Hyman et al [60] reported that CT was superior to fluoroscopic contrast enema at detecting leaks, with a PPV of 89.5% for CT and 40% for contrast enema in 33 patients who developed leaks. Kaur et al [61] showed a 91% sensitivity, 100% specificity, 100% PPV, and 95% NPV for CT in detecting postoperative anastomotic leaks in a retrospective study of 170 patients who had undergone a low anterior resection, emphasizing the importance of rectal contrast material to improve confidence in diagnosis.
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Anorectal Disease. Hyman et al [60] reported that CT was superior to fluoroscopic contrast enema at detecting leaks, with a PPV of 89.5% for CT and 40% for contrast enema in 33 patients who developed leaks. Kaur et al [61] showed a 91% sensitivity, 100% specificity, 100% PPV, and 95% NPV for CT in detecting postoperative anastomotic leaks in a retrospective study 170 patients who had undergone a low anterior resection, emphasizing the importance of rectal contrast material to improve confidence in diagnosis. CT Pelvis CT pelvis may be preferred over CT abdomen and pelvis in specific clinical scenarios when the pelvis alone is the area of clinical concern. To our knowledge there are no studies comparing noncontrast CT with IV contrast- enhanced CT for the detection of postoperative complications. However, IV contrast does improve the detection of abscesses and is important for the evaluation of the integrity of the bowel wall when ischemia or anastomotic dehiscence is suspected. CT with and without IV contrast would only be useful when there is benefit from dual- phase imaging. When anastomotic leak is suspected, rectally administered contrast material is important to demonstrate extraluminal extravasation of contrast to confirm the leak, adding an additional finding to other findings of leak: perianastomotic gas, fluid collection, and staple line integrity. Hyman et al [60] reported that CT was superior to fluoroscopic contrast enema at detecting leaks, with a PPV of 89.5% for CT and 40% for contrast enema in 33 patients who developed leaks. Kaur et al [61] showed a 91% sensitivity, 100% specificity, 100% PPV, and 95% NPV for CT in detecting postoperative anastomotic leaks in a retrospective study of 170 patients who had undergone a low anterior resection, emphasizing the importance of rectal contrast material to improve confidence in diagnosis.
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3102384
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acrac_3102384_19
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Anorectal Disease
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Fluoroscopy Contrast Enema Fluoroscopic contrast enemas performed for the diagnosis of perforation or leak, rectovaginal or rectovesicular fistula, pouchitis, or proctitis can be performed with water-soluble contrast or barium. In general, water-soluble contrast is preferred if a leak or perforation are suspected in order to avoid barium spillage into the peritoneal cavity or extraperitoneal pelvis. Using barium may also interfere with a subsequent CT scan because of the streak artifact that it causes on CT. Fluoroscopic water-soluble contrast enema is routinely used to evaluate clinically suspected leaks, anastomotic stenoses, fistulas, and sinus tracts. It may be complementary to CT or performed in conjunction with CT. In the study by Tang et al [62], water-soluble contrast enema was performed in 33 of the 66 patients evaluated for pouch disorders and compared with a composite clinical diagnosis. The sensitivity and specificity for the diagnosis of small-bowel and inlet strictures was 80% and 95.7%, and pouch outlet strictures was 0% and 93.5%, respectively. They also found the sensitivity and specificity for the diagnosis of fistula was 33.3% and 96.3%, sinus tract 50% and 100%, pouch leak 50% and 96.8%, respectively [62]. In some institutions, routine water-soluble contrast enema is performed prior to ileostomy takedown. In a study of 42 patients who underwent total proctocolectomy with IPAA, Dolinsky et al [63] showed that 14% of patients had clinically significant occult strictures detected by water- soluble contrast enema prior to ileostomy takedown. On the other hand, others report that routine use of fluoroscopic water-soluble contrast enema in patients with low pelvic anastomoses (ultralow colorectal, coloanal, and IPAA) does not impact ileostomy takedown compared with digital rectal examination and colonoscopy or sigmoidoscopy.
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Anorectal Disease. Fluoroscopy Contrast Enema Fluoroscopic contrast enemas performed for the diagnosis of perforation or leak, rectovaginal or rectovesicular fistula, pouchitis, or proctitis can be performed with water-soluble contrast or barium. In general, water-soluble contrast is preferred if a leak or perforation are suspected in order to avoid barium spillage into the peritoneal cavity or extraperitoneal pelvis. Using barium may also interfere with a subsequent CT scan because of the streak artifact that it causes on CT. Fluoroscopic water-soluble contrast enema is routinely used to evaluate clinically suspected leaks, anastomotic stenoses, fistulas, and sinus tracts. It may be complementary to CT or performed in conjunction with CT. In the study by Tang et al [62], water-soluble contrast enema was performed in 33 of the 66 patients evaluated for pouch disorders and compared with a composite clinical diagnosis. The sensitivity and specificity for the diagnosis of small-bowel and inlet strictures was 80% and 95.7%, and pouch outlet strictures was 0% and 93.5%, respectively. They also found the sensitivity and specificity for the diagnosis of fistula was 33.3% and 96.3%, sinus tract 50% and 100%, pouch leak 50% and 96.8%, respectively [62]. In some institutions, routine water-soluble contrast enema is performed prior to ileostomy takedown. In a study of 42 patients who underwent total proctocolectomy with IPAA, Dolinsky et al [63] showed that 14% of patients had clinically significant occult strictures detected by water- soluble contrast enema prior to ileostomy takedown. On the other hand, others report that routine use of fluoroscopic water-soluble contrast enema in patients with low pelvic anastomoses (ultralow colorectal, coloanal, and IPAA) does not impact ileostomy takedown compared with digital rectal examination and colonoscopy or sigmoidoscopy.
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3102384
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acrac_3102384_20
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Anorectal Disease
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In the study by Karsten et al [64], 38 patients were evaluated with fluoroscopic water-soluble contrast enema, which was 100% sensitive and 69% specific for detection of significant pathology, but that pathology was equally detected Anorectal Disease on digital rectal examination and endoscopic examinations such that fluoroscopic water-soluble contrast enema could be used selectively on patients with abnormal clinical findings. The superior contrast resolution of MRI compared with CT makes it an ideal modality for the evaluation of clinically suspected anastomotic or IPAA-related fistulas or sinus tracts. In a study of 44 patients with ulcerative colitis and IPAA with pelvic symptoms, MRI with and without IV gadolinium contrast material detected 23 of 26 fistula for a sensitivity of 88%, specificity of 100%, PPV of 100%, and NPV of 85% [65]. The authors reported that high diagnostic confidence was obtained with the IV gadolinium-enhanced sequence compared with the T2-weighted fat-saturated sequence. MRI was obtained in 23 of the 66 postoperative patients reported by Tang et al [62]. MRI had a sensitivity and specificity for the diagnosis of small-bowel and inlet strictures of 33.3% and 100%, pouch outlet strictures of 0% and 92%, fistula of 57.1% and 88.9%, sinus of 0% and 70.8%, and pouch leak of 0% and 91.7%, respectively. Radiography Abdomen and Pelvis Radiographs may be helpful in evaluating postoperative patients when there is a suspected bowel obstruction by confirming or excluding small-bowel obstruction. Radiographs may also show free air if there is a suspected postoperative perforation or ectopic air, or bubbly lucencies in the case of abscess, fistula, or sinus tracts that contain air. However, radiographs will frequently be inconclusive and additional imaging will be needed for those patients with abnormal radiographs; additional imaging is often necessary to confirm the suspected diagnosis and to add more specificity to the findings.
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Anorectal Disease. In the study by Karsten et al [64], 38 patients were evaluated with fluoroscopic water-soluble contrast enema, which was 100% sensitive and 69% specific for detection of significant pathology, but that pathology was equally detected Anorectal Disease on digital rectal examination and endoscopic examinations such that fluoroscopic water-soluble contrast enema could be used selectively on patients with abnormal clinical findings. The superior contrast resolution of MRI compared with CT makes it an ideal modality for the evaluation of clinically suspected anastomotic or IPAA-related fistulas or sinus tracts. In a study of 44 patients with ulcerative colitis and IPAA with pelvic symptoms, MRI with and without IV gadolinium contrast material detected 23 of 26 fistula for a sensitivity of 88%, specificity of 100%, PPV of 100%, and NPV of 85% [65]. The authors reported that high diagnostic confidence was obtained with the IV gadolinium-enhanced sequence compared with the T2-weighted fat-saturated sequence. MRI was obtained in 23 of the 66 postoperative patients reported by Tang et al [62]. MRI had a sensitivity and specificity for the diagnosis of small-bowel and inlet strictures of 33.3% and 100%, pouch outlet strictures of 0% and 92%, fistula of 57.1% and 88.9%, sinus of 0% and 70.8%, and pouch leak of 0% and 91.7%, respectively. Radiography Abdomen and Pelvis Radiographs may be helpful in evaluating postoperative patients when there is a suspected bowel obstruction by confirming or excluding small-bowel obstruction. Radiographs may also show free air if there is a suspected postoperative perforation or ectopic air, or bubbly lucencies in the case of abscess, fistula, or sinus tracts that contain air. However, radiographs will frequently be inconclusive and additional imaging will be needed for those patients with abnormal radiographs; additional imaging is often necessary to confirm the suspected diagnosis and to add more specificity to the findings.
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Anorectal Disease
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To our knowledge, there is no recent literature on the use of radiographs in the evaluation of suspected complications after proctectomy with coloanal or colorectal anastomosis and coloproctectomy with IPAA. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Anorectal Disease Anorectal Disease 20. Halligan S, Bartram CI. MR imaging of fistula in ano: are endoanal coils the gold standard? AJR Am J Roentgenol 1998;171:407-12. 21. Zbar AP, Armitage NC. Complex perirectal sepsis: clinical classification and imaging. Tech Coloproctol 2006;10:83-93. 22. Sahni VA, Ahmad R, Burling D. Which method is best for imaging of perianal fistula? Abdom Imaging 2008;33:26-30. 23. Lo Re G, Tudisca C, Vernuccio F, et al. MR imaging of perianal fistulas in Crohn's disease: sensitivity and specificity of STIR sequences. Radiol Med 2016;121:243-51. 24. Yildirim N, Gokalp G, Ozturk E, et al. Ideal combination of MRI sequences for perianal fistula classification and the evaluation of additional findings for readers with varying levels of experience. Diagn Interv Radiol 2012;18:11-9. 25. Visscher AP, Felt-Bersma RJ. Endoanal ultrasound in perianal fistulae and abscesses. Ultrasound Q 2015;31:130-7. 26. Buchanan GN, Bartram CI, Williams AB, Halligan S, Cohen CR. Value of hydrogen peroxide enhancement of three-dimensional endoanal ultrasound in fistula-in-ano. Dis Colon Rectum 2005;48:141-7. 27. Sun Y, Cui LG, Liu JB, Wang JR, Ping H, Chen ZW. Utility of 360 degrees Real-time Endoanal Sonography for Evaluation of Perianal Fistulas. J Ultrasound Med 2018;37:93-98. 28. Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR.
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Anorectal Disease. To our knowledge, there is no recent literature on the use of radiographs in the evaluation of suspected complications after proctectomy with coloanal or colorectal anastomosis and coloproctectomy with IPAA. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Anorectal Disease Anorectal Disease 20. Halligan S, Bartram CI. MR imaging of fistula in ano: are endoanal coils the gold standard? AJR Am J Roentgenol 1998;171:407-12. 21. Zbar AP, Armitage NC. Complex perirectal sepsis: clinical classification and imaging. Tech Coloproctol 2006;10:83-93. 22. Sahni VA, Ahmad R, Burling D. Which method is best for imaging of perianal fistula? Abdom Imaging 2008;33:26-30. 23. Lo Re G, Tudisca C, Vernuccio F, et al. MR imaging of perianal fistulas in Crohn's disease: sensitivity and specificity of STIR sequences. Radiol Med 2016;121:243-51. 24. Yildirim N, Gokalp G, Ozturk E, et al. Ideal combination of MRI sequences for perianal fistula classification and the evaluation of additional findings for readers with varying levels of experience. Diagn Interv Radiol 2012;18:11-9. 25. Visscher AP, Felt-Bersma RJ. Endoanal ultrasound in perianal fistulae and abscesses. Ultrasound Q 2015;31:130-7. 26. Buchanan GN, Bartram CI, Williams AB, Halligan S, Cohen CR. Value of hydrogen peroxide enhancement of three-dimensional endoanal ultrasound in fistula-in-ano. Dis Colon Rectum 2005;48:141-7. 27. Sun Y, Cui LG, Liu JB, Wang JR, Ping H, Chen ZW. Utility of 360 degrees Real-time Endoanal Sonography for Evaluation of Perianal Fistulas. J Ultrasound Med 2018;37:93-98. 28. Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR.
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Anorectal Disease
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Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 2004;233:674-81. 29. Cheong DM, Nogueras JJ, Wexner SD, Jagelman DG. Anal endosonography for recurrent anal fistulas: image enhancement with hydrogen peroxide. Dis Colon Rectum 1993;36:1158-60. 30. West RL, Zimmerman DD, Dwarkasing S, et al. Prospective comparison of hydrogen peroxide-enhanced three- dimensional endoanal ultrasonography and endoanal magnetic resonance imaging of perianal fistulas. Dis Colon Rectum 2003;46:1407-15. 31. Brillantino A, Iacobellis F, Reginelli A, et al. Preoperative assessment of simple and complex anorectal fistulas: Tridimensional endoanal ultrasound? Magnetic resonance? Both? Radiol Med 2019;124:339-49. 32. Senatore PJ, Jr. Anovaginal fistulae. Surg Clin North Am 1994;74:1361-75. 33. Andreani SM, Dang HH, Grondona P, Khan AZ, Edwards DP. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum 2007;50:2215-22. 34. Champagne BJ, McGee MF. Rectovaginal fistula. Surg Clin North Am 2010;90:69-82, Table of Contents. 35. Kuhlman JE, Fishman EK. CT evaluation of enterovaginal and vesicovaginal fistulas. J Comput Assist Tomogr 1990;14:390-4. 36. Giordano P, Drew PJ, Taylor D, Duthie G, Lee PW, Monson JR. Vaginography--investigation of choice for clinically suspected vaginal fistulas. Dis Colon Rectum 1996;39:568-72. 37. Wychulis AR, Pratt JH. Sigmoidovaginal fistulas. A study of 37 cases. Arch Surg 1966;92:520-4. 38. Amendola MA, Agha FP, Dent TL, Amendola BE, Shirazi KK. Detection of occult colovesical fistula by the Bourne test. AJR Am J Roentgenol 1984;142:715-8. 39. Hsieh JH, Chen WS, Jiang JK, Lin TC, Lin JK, Hsu H. Enterovesical fistula: 10 years experience. Zhonghua Yi Xue Za Zhi (Taipei) 1997;59:283-8. 40. Botsikas D, Pluchino N, Kalovidouri A, et al. CT vaginography: a new CT technique for imaging of upper and middle vaginal fistulas. Br J Radiol 2017;90:20160947. 41. Coe FO. Vaginography.
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Anorectal Disease. Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 2004;233:674-81. 29. Cheong DM, Nogueras JJ, Wexner SD, Jagelman DG. Anal endosonography for recurrent anal fistulas: image enhancement with hydrogen peroxide. Dis Colon Rectum 1993;36:1158-60. 30. West RL, Zimmerman DD, Dwarkasing S, et al. Prospective comparison of hydrogen peroxide-enhanced three- dimensional endoanal ultrasonography and endoanal magnetic resonance imaging of perianal fistulas. Dis Colon Rectum 2003;46:1407-15. 31. Brillantino A, Iacobellis F, Reginelli A, et al. Preoperative assessment of simple and complex anorectal fistulas: Tridimensional endoanal ultrasound? Magnetic resonance? Both? Radiol Med 2019;124:339-49. 32. Senatore PJ, Jr. Anovaginal fistulae. Surg Clin North Am 1994;74:1361-75. 33. Andreani SM, Dang HH, Grondona P, Khan AZ, Edwards DP. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum 2007;50:2215-22. 34. Champagne BJ, McGee MF. Rectovaginal fistula. Surg Clin North Am 2010;90:69-82, Table of Contents. 35. Kuhlman JE, Fishman EK. CT evaluation of enterovaginal and vesicovaginal fistulas. J Comput Assist Tomogr 1990;14:390-4. 36. Giordano P, Drew PJ, Taylor D, Duthie G, Lee PW, Monson JR. Vaginography--investigation of choice for clinically suspected vaginal fistulas. Dis Colon Rectum 1996;39:568-72. 37. Wychulis AR, Pratt JH. Sigmoidovaginal fistulas. A study of 37 cases. Arch Surg 1966;92:520-4. 38. Amendola MA, Agha FP, Dent TL, Amendola BE, Shirazi KK. Detection of occult colovesical fistula by the Bourne test. AJR Am J Roentgenol 1984;142:715-8. 39. Hsieh JH, Chen WS, Jiang JK, Lin TC, Lin JK, Hsu H. Enterovesical fistula: 10 years experience. Zhonghua Yi Xue Za Zhi (Taipei) 1997;59:283-8. 40. Botsikas D, Pluchino N, Kalovidouri A, et al. CT vaginography: a new CT technique for imaging of upper and middle vaginal fistulas. Br J Radiol 2017;90:20160947. 41. Coe FO. Vaginography.
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Recurrent Lower Urinary Tract Infections in Females
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Introduction/Background A urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response. A UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis. Less commonly, this infection ascends to the kidney to cause bacterial pyelonephritis [1]. The overall lifetime risk of UTI for women is >50% [2]. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities. It should be noted that although uncomplicated UTI includes both lower tract infection (cystitis) and upper tract infection (pyelonephritis), repeated pyelonephritis should prompt consideration of a complicated etiology [1]. Complicated UTIs are those occurring in patients with underlying structural or medical problems [3,4]. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy [2,5]. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI [6]. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months [3]. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence [1-3].
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Recurrent Lower Urinary Tract Infections in Females. Introduction/Background A urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response. A UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis. Less commonly, this infection ascends to the kidney to cause bacterial pyelonephritis [1]. The overall lifetime risk of UTI for women is >50% [2]. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities. It should be noted that although uncomplicated UTI includes both lower tract infection (cystitis) and upper tract infection (pyelonephritis), repeated pyelonephritis should prompt consideration of a complicated etiology [1]. Complicated UTIs are those occurring in patients with underlying structural or medical problems [3,4]. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy [2,5]. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI [6]. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months [3]. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence [1-3].
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Recurrent Lower Urinary Tract Infections in Females
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In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) [3,7]. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects. It therefore should be approached judiciously. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate [8,9]. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine. E. coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by E. faecalis, Proteus mirabilis, Klebsiella, or S. saprophyticus particularly in patients with risk factors for complicated UTIs [6,10-12]. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine [13,14]. Women who have three or more symptomatic infections over a 12-month period may benefit from prophylaxis [3,4,7]. Imaging is of low yield in patients without underlying risk factors, less than two episodes per year on average, and who respond promptly to appropriate therapy (see Appendix 1) [1,7,15,16]. Current clinical guidelines indicate that imaging should not be routinely obtained in the index patient presenting with recurrent UTIs because aThe University of Texas MD Anderson Cancer Center, Houston, Texas. bPanel Chair, University of Chicago, Chicago, Illinois.
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Recurrent Lower Urinary Tract Infections in Females. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) [3,7]. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects. It therefore should be approached judiciously. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate [8,9]. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine. E. coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by E. faecalis, Proteus mirabilis, Klebsiella, or S. saprophyticus particularly in patients with risk factors for complicated UTIs [6,10-12]. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine [13,14]. Women who have three or more symptomatic infections over a 12-month period may benefit from prophylaxis [3,4,7]. Imaging is of low yield in patients without underlying risk factors, less than two episodes per year on average, and who respond promptly to appropriate therapy (see Appendix 1) [1,7,15,16]. Current clinical guidelines indicate that imaging should not be routinely obtained in the index patient presenting with recurrent UTIs because aThe University of Texas MD Anderson Cancer Center, Houston, Texas. bPanel Chair, University of Chicago, Chicago, Illinois.
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Recurrent Lower Urinary Tract Infections in Females
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cPanel Vice-Chair, Duke University Medical Center, Durham, North Carolina. dMemorial Sloan Kettering Cancer Center, New York, New York. eMayo Clinic, Jacksonville, Florida. fMcGill University, Montreal, Quebec, Canada. gMayo Clinic, Rochester, Minnesota. hUrology Clinics of North Texas, Dallas, Texas; American Urological Association. iUniversity of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; American Society of Nephrology. jUniversity of Wisconsin, Madison, Wisconsin. kUPMC, Pittsburgh, Pennsylvania; American Urological Association. lStanford University Medical Center, Stanford, California. mOttawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada. nEmory University Hospital, Atlanta, Georgia. oNational Institutes of Health, Bethesda, Maryland. pSpecialty Chair, University of Alabama at Birmingham, Birmingham, Alabama. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through 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] Special Imaging Considerations CTU CT urography (CTU) is an imaging study that is tailored to improve visualization of both the upper and lower urinary tracts. There is variability in the specific parameters, but it usually involves unenhanced images followed by intravenous (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.
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Recurrent Lower Urinary Tract Infections in Females. cPanel Vice-Chair, Duke University Medical Center, Durham, North Carolina. dMemorial Sloan Kettering Cancer Center, New York, New York. eMayo Clinic, Jacksonville, Florida. fMcGill University, Montreal, Quebec, Canada. gMayo Clinic, Rochester, Minnesota. hUrology Clinics of North Texas, Dallas, Texas; American Urological Association. iUniversity of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; American Society of Nephrology. jUniversity of Wisconsin, Madison, Wisconsin. kUPMC, Pittsburgh, Pennsylvania; American Urological Association. lStanford University Medical Center, Stanford, California. mOttawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada. nEmory University Hospital, Atlanta, Georgia. oNational Institutes of Health, Bethesda, Maryland. pSpecialty Chair, University of Alabama at Birmingham, Birmingham, Alabama. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through 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] Special Imaging Considerations CTU CT urography (CTU) is an imaging study that is tailored to improve visualization of both the upper and lower urinary tracts. There is variability in the specific parameters, but it usually involves unenhanced images followed by intravenous (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.
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acrac_69491_3
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Recurrent Lower Urinary Tract Infections in Females
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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, as is the case for CTU. CT Pelvis with Bladder Contrast (CT Cystography) CT cystography is an imaging study that is tailored to visualize traumatic bladder lesions. This technique involves retrograde drip infusion of diluted iodinated contrast into the urinary bladder followed by pelvic CT imaging at maximal bladder distension. IV contrast may be administered, particularly if evaluating for underlying neoplastic or inflammatory processes [19]. For the purposes of this document, we distinguish CT cystography from CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is also defined as any protocol not specifically tailored for evaluation of the integrity of the urinary bladder wall and without retrograde instillation of contrast into the urinary bladder, as is the case for CT cystography. MRU 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 phase. 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.
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Recurrent Lower Urinary Tract Infections in Females. 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, as is the case for CTU. CT Pelvis with Bladder Contrast (CT Cystography) CT cystography is an imaging study that is tailored to visualize traumatic bladder lesions. This technique involves retrograde drip infusion of diluted iodinated contrast into the urinary bladder followed by pelvic CT imaging at maximal bladder distension. IV contrast may be administered, particularly if evaluating for underlying neoplastic or inflammatory processes [19]. For the purposes of this document, we distinguish CT cystography from CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is also defined as any protocol not specifically tailored for evaluation of the integrity of the urinary bladder wall and without retrograde instillation of contrast into the urinary bladder, as is the case for CT cystography. MRU 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 phase. 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.
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Recurrent Lower Urinary Tract Infections in Females
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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, as is the case for MRU. US Abdomen with IV Contrast Prior studies show promise regarding the potential role of contrast-enhanced ultrasound (US) for the initial diagnosis and follow-up of patients with complicated acute pyelonephritis [20-22]. Using CT as a reference standard, Mitterberger et al [22] demonstrated a sensitivity of 98% and a specificity of 100% for contrast-enhanced US in the diagnosis of acute pyelonephritis in 100 patients. Its use in current mainstream practice remains limited, however, with only recent FDA approval for abdominal imaging applications. Recurrent Lower Urinary Tract Infections in Females Discussion of Procedures by Variant Variant 1: Recurrent lower urinary tract infections in a female. Uncomplicated with no underlying risk factors. In women with recurrent uncomplicated UTIs, cystoscopy and imaging are not routinely used [1]. Lawrentschuk et al [23] showed that women with no risk factors for UTI had a negative predictive value of 93% for normal cystoscopy. Prior series have demonstrated a low yield of nonincidental findings in those patients with a low pretest probability of complicated UTI [1,24]. CT Abdomen and Pelvis There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,25]. As such, CT is not generally performed for evaluation of uncomplicated UTI. CT Pelvis with Bladder Contrast (CT Cystography) There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,20]. As such, CT cystography is not generally performed for evaluation of uncomplicated UTI.
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Recurrent Lower Urinary Tract Infections in Females. 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, as is the case for MRU. US Abdomen with IV Contrast Prior studies show promise regarding the potential role of contrast-enhanced ultrasound (US) for the initial diagnosis and follow-up of patients with complicated acute pyelonephritis [20-22]. Using CT as a reference standard, Mitterberger et al [22] demonstrated a sensitivity of 98% and a specificity of 100% for contrast-enhanced US in the diagnosis of acute pyelonephritis in 100 patients. Its use in current mainstream practice remains limited, however, with only recent FDA approval for abdominal imaging applications. Recurrent Lower Urinary Tract Infections in Females Discussion of Procedures by Variant Variant 1: Recurrent lower urinary tract infections in a female. Uncomplicated with no underlying risk factors. In women with recurrent uncomplicated UTIs, cystoscopy and imaging are not routinely used [1]. Lawrentschuk et al [23] showed that women with no risk factors for UTI had a negative predictive value of 93% for normal cystoscopy. Prior series have demonstrated a low yield of nonincidental findings in those patients with a low pretest probability of complicated UTI [1,24]. CT Abdomen and Pelvis There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,25]. As such, CT is not generally performed for evaluation of uncomplicated UTI. CT Pelvis with Bladder Contrast (CT Cystography) There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,20]. As such, CT cystography is not generally performed for evaluation of uncomplicated UTI.
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acrac_69491_5
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Recurrent Lower Urinary Tract Infections in Females
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CTU There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,20]. As such, CTU is not generally performed for evaluation of uncomplicated UTI. Fluoroscopy Contrast Enema Although fluoroscopic contrast enema may be useful in the setting of suspected vesicoenteric fistula, it is not used for imaging in women with recurrent uncomplicated UTIs in the absence of risk factors. Fluoroscopy Cystography A prior prospective study of findings with excretory urography, cystography, and cystoscopy in women with symptomatic UTI revealed only rare instances of abnormalities important in the treatment of UTI in this group of patients, primarily urethral diverticula [26]. Most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with fluoroscopic cystography. Fluoroscopy Voiding Cystourethrography As most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts, they do not routinely require imaging with voiding cystourethrography. A prior prospective study including findings of excretory urography in women with symptomatic UTI revealed only rare instances of structural abnormalities important in the treatment of UTI in this group of patients [26]. MRI Abdomen and Pelvis CT and MRU have supplanted the use of IV urography (IVU) at most institutions for most types of urinary applications [27]. However, most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with MRI. MRU CT and MRU have supplanted the use of IVU at most institutions for most types of urinary applications [27]. However, most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with MRI.
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Recurrent Lower Urinary Tract Infections in Females. CTU There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,20]. As such, CTU is not generally performed for evaluation of uncomplicated UTI. Fluoroscopy Contrast Enema Although fluoroscopic contrast enema may be useful in the setting of suspected vesicoenteric fistula, it is not used for imaging in women with recurrent uncomplicated UTIs in the absence of risk factors. Fluoroscopy Cystography A prior prospective study of findings with excretory urography, cystography, and cystoscopy in women with symptomatic UTI revealed only rare instances of abnormalities important in the treatment of UTI in this group of patients, primarily urethral diverticula [26]. Most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with fluoroscopic cystography. Fluoroscopy Voiding Cystourethrography As most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts, they do not routinely require imaging with voiding cystourethrography. A prior prospective study including findings of excretory urography in women with symptomatic UTI revealed only rare instances of structural abnormalities important in the treatment of UTI in this group of patients [26]. MRI Abdomen and Pelvis CT and MRU have supplanted the use of IV urography (IVU) at most institutions for most types of urinary applications [27]. However, most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with MRI. MRU CT and MRU have supplanted the use of IVU at most institutions for most types of urinary applications [27]. However, most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with MRI.
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69491
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acrac_69491_6
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Recurrent Lower Urinary Tract Infections in Females
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Radiography Abdomen As most women with recurrent symptomatic UTI have normal urinary tracts, they do not routinely require imaging with radiography of the abdomen. Radiography Intravenous Urography Historically, intravenous urography (IVU) was the imaging study of choice to evaluate the urinary tract, but it is no longer used at most institutions [13]. IVU is not used for evaluation of uncomplicated UTI. US Kidneys and Bladder Retroperitoneal As most women with recurrent symptomatic UTI have normal urinary tracts, they do not routinely require imaging with US of the kidneys, bladder, and retroperitoneum. Recurrent Lower Urinary Tract Infections in Females Variant 2: Recurrent lower urinary tract infections in a female. Complicated, or patients who are nonresponders to conventional therapy, develop frequent reinfections or relapses, or have known underlying risk factors. Complicated causes of UTI can be evaluated by history and physical examination. In women suspected of having a recurrent complicated UTI, cystoscopy and imaging should be considered [24]. CT Abdomen and Pelvis Historically, unenhanced CT has been used predominantly for the emergency patient with renal colic and/or hematuria. It has also been used to define the severity and extent of upper tract calculi, which are occasionally associated with recurrent complicated UTIs. The lack of additional contrast-enhanced CT imaging and the lack of dedicated imaging of the collecting systems, kidneys, and bladder limits further evaluation of underlying anatomical or pathophysiologic processes. Contrast-enhanced CT has been used effectively to evaluate a range of urinary tract abnormalities, including renal masses, genitourinary trauma, and specific aspects of renal infection, including the presence of pyelonephritis, renal abscesses, and obstruction.
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Recurrent Lower Urinary Tract Infections in Females. Radiography Abdomen As most women with recurrent symptomatic UTI have normal urinary tracts, they do not routinely require imaging with radiography of the abdomen. Radiography Intravenous Urography Historically, intravenous urography (IVU) was the imaging study of choice to evaluate the urinary tract, but it is no longer used at most institutions [13]. IVU is not used for evaluation of uncomplicated UTI. US Kidneys and Bladder Retroperitoneal As most women with recurrent symptomatic UTI have normal urinary tracts, they do not routinely require imaging with US of the kidneys, bladder, and retroperitoneum. Recurrent Lower Urinary Tract Infections in Females Variant 2: Recurrent lower urinary tract infections in a female. Complicated, or patients who are nonresponders to conventional therapy, develop frequent reinfections or relapses, or have known underlying risk factors. Complicated causes of UTI can be evaluated by history and physical examination. In women suspected of having a recurrent complicated UTI, cystoscopy and imaging should be considered [24]. CT Abdomen and Pelvis Historically, unenhanced CT has been used predominantly for the emergency patient with renal colic and/or hematuria. It has also been used to define the severity and extent of upper tract calculi, which are occasionally associated with recurrent complicated UTIs. The lack of additional contrast-enhanced CT imaging and the lack of dedicated imaging of the collecting systems, kidneys, and bladder limits further evaluation of underlying anatomical or pathophysiologic processes. Contrast-enhanced CT has been used effectively to evaluate a range of urinary tract abnormalities, including renal masses, genitourinary trauma, and specific aspects of renal infection, including the presence of pyelonephritis, renal abscesses, and obstruction.
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69491
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acrac_69491_7
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Recurrent Lower Urinary Tract Infections in Females
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However, a contrast-enhanced CT of the abdomen and pelvis remains a study that is not tailored for evaluation of the urothelium and therefore does not optimally evaluate the collecting systems, ureters, and bladder. Moreover, lacking an unenhanced CT component, a contrast-enhanced CT of the abdomen and pelvis can limit the detection of calculi and the characterization of enhancement within masses [24]. The addition of rectal contrast or oral contrast with delayed scanning of an enhanced CT of the abdomen and pelvis is useful to detect enterovesical fistulas and infected fistulous tracts [28]. CT Pelvis with Bladder Contrast (CT Cystography) CT cystography has supplanted fluoroscopic cystogram for the evaluation of traumatic bladder injuries, including intraperitoneal, extraperitoneal, or combined rupture and bladder contusions [29]. It is also useful for diagnosing bladder fistulas and leaks, particularly colovesical fistulas occurring as a result of sigmoid diverticular disease, which can remain undiagnosed despite evaluation with cystoscopy and contrast-enhanced CT [19]. CTU CTU CTU is a primary test for the evaluation of recurrent complicated UTIs. It includes unenhanced, nephrographic phase, and excretory phase images, with the latter providing a detailed anatomic depiction of each of the major portions of the urinary tract including the kidneys, intrarenal collecting systems, ureters, and bladder [30]. Diuretic administration prior to the excretory phase can augment both urinary tract distention and opacification [30]. CTU has excellent sensitivity and specificity for the identification of renal and urothelial lesions [31]. This allows patients with hematuria to be evaluated comprehensively and can identify abnormalities of the collecting systems [27]. It is also useful for detecting or excluding congenital anomalies or obstruction of the urinary tract in patients with complicated recurrent UTIs.
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Recurrent Lower Urinary Tract Infections in Females. However, a contrast-enhanced CT of the abdomen and pelvis remains a study that is not tailored for evaluation of the urothelium and therefore does not optimally evaluate the collecting systems, ureters, and bladder. Moreover, lacking an unenhanced CT component, a contrast-enhanced CT of the abdomen and pelvis can limit the detection of calculi and the characterization of enhancement within masses [24]. The addition of rectal contrast or oral contrast with delayed scanning of an enhanced CT of the abdomen and pelvis is useful to detect enterovesical fistulas and infected fistulous tracts [28]. CT Pelvis with Bladder Contrast (CT Cystography) CT cystography has supplanted fluoroscopic cystogram for the evaluation of traumatic bladder injuries, including intraperitoneal, extraperitoneal, or combined rupture and bladder contusions [29]. It is also useful for diagnosing bladder fistulas and leaks, particularly colovesical fistulas occurring as a result of sigmoid diverticular disease, which can remain undiagnosed despite evaluation with cystoscopy and contrast-enhanced CT [19]. CTU CTU CTU is a primary test for the evaluation of recurrent complicated UTIs. It includes unenhanced, nephrographic phase, and excretory phase images, with the latter providing a detailed anatomic depiction of each of the major portions of the urinary tract including the kidneys, intrarenal collecting systems, ureters, and bladder [30]. Diuretic administration prior to the excretory phase can augment both urinary tract distention and opacification [30]. CTU has excellent sensitivity and specificity for the identification of renal and urothelial lesions [31]. This allows patients with hematuria to be evaluated comprehensively and can identify abnormalities of the collecting systems [27]. It is also useful for detecting or excluding congenital anomalies or obstruction of the urinary tract in patients with complicated recurrent UTIs.
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69491
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acrac_69491_8
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Recurrent Lower Urinary Tract Infections in Females
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Given the low yield of CTU screening for asymptomatic hematuria in patients <30 years of age, or without risk factors for urinary tract malignancy, US or noncontrast CT may be the first-line imaging examinations in these patients. When there are risk factors present for urinary tract malignancy and the patient is >50 years of age, CTU is the preferred examination [31]. Fluoroscopy Contrast Enema Contrast enema is generally not useful for women with recurrent complicated UTIs. Although it may be utilized for imaging of vesicoenteric fistulas, CT is the primary imaging modality for suspected cases of enterovesical fistulas and has been found to have a higher rate of detection and also capable of identifying the underlying etiology [32,33]. If an enema is performed, water-soluble contrast should be selected rather than barium. Fluoroscopy Cystography Fluoroscopic cystography is generally not useful for women with recurrent complicated UTIs. Although it can delineate bladder diverticuli and vesicoenteric fistulas, CT has supplanted fluoroscopic cystography at most institutions. Fluoroscopy Urethrography Double Balloon Double-balloon urethrography can be useful for demonstration of urethral diverticula, although MRI best assesses the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning. MRI to evaluate for urethral diverticulum has replaced double-balloon urethrography at most institutions. Double- balloon urethrography can be technically difficult and may be uncomfortable for the patient. For this document, it is assumed the procedure is performed and interpreted by an expert. Recurrent Lower Urinary Tract Infections in Females Fluoroscopy Voiding Cystourethrography When a bladder diverticulum is at or near a ureteral orifice, voiding cystourethrography can be considered to evaluate the possibility of vesicoureteral reflux [34].
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Recurrent Lower Urinary Tract Infections in Females. Given the low yield of CTU screening for asymptomatic hematuria in patients <30 years of age, or without risk factors for urinary tract malignancy, US or noncontrast CT may be the first-line imaging examinations in these patients. When there are risk factors present for urinary tract malignancy and the patient is >50 years of age, CTU is the preferred examination [31]. Fluoroscopy Contrast Enema Contrast enema is generally not useful for women with recurrent complicated UTIs. Although it may be utilized for imaging of vesicoenteric fistulas, CT is the primary imaging modality for suspected cases of enterovesical fistulas and has been found to have a higher rate of detection and also capable of identifying the underlying etiology [32,33]. If an enema is performed, water-soluble contrast should be selected rather than barium. Fluoroscopy Cystography Fluoroscopic cystography is generally not useful for women with recurrent complicated UTIs. Although it can delineate bladder diverticuli and vesicoenteric fistulas, CT has supplanted fluoroscopic cystography at most institutions. Fluoroscopy Urethrography Double Balloon Double-balloon urethrography can be useful for demonstration of urethral diverticula, although MRI best assesses the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning. MRI to evaluate for urethral diverticulum has replaced double-balloon urethrography at most institutions. Double- balloon urethrography can be technically difficult and may be uncomfortable for the patient. For this document, it is assumed the procedure is performed and interpreted by an expert. Recurrent Lower Urinary Tract Infections in Females Fluoroscopy Voiding Cystourethrography When a bladder diverticulum is at or near a ureteral orifice, voiding cystourethrography can be considered to evaluate the possibility of vesicoureteral reflux [34].
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69491
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acrac_69491_9
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Recurrent Lower Urinary Tract Infections in Females
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It can also be employed for imaging of suspected bladder or urethral fistula, urethral diverticulum, or bladder prolapse. MRI Abdomen and Pelvis Both MRI of the abdomen and pelvis and MRU can be used to evaluate the urinary tract and have the advantage to provide more functional information than CT. MRI has been shown to be useful in the diagnosis and follow-up of UTI and acute pyelonephritis [27,35,36]. MRI is effective at diagnosing pelvic-organ prolapse. The resultant cystoceles and urinary incontinence associated with pelvic-organ prolapse are significant risk factors for recurrent UTIs in postmenopausal women [13,37,38]. MRI is the optimum imaging modality for assessment of the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning [39]. Given the excellent soft-tissue contrast on MRI, this modality is equally sensitive to CT for evaluating vesicovaginal and enterovesicular fistulae [40,41]. In at least one study, MRI altered the surgical management in 15% of patients [39]. A history of recurrent UTI is seen in 30% to 50% of patients with urethral diverticula. Diverticula of the urethra can be evaluated with high sensitivity and specificity by double-balloon urethrography, voiding CT urethrography, and MRI [42-44]. MRI best assesses the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning. Patients with suspected bladder diverticula may be imaged with cystography, US, or CT [45]. Bladder diverticula are unusual in women and are associated with a neurogenic or postoperative bladder; they are rarely congenital. MRI has also been shown to be accurate in the diagnosis of colovesical fistula. The multiplanar imaging capability and high soft-tissue resolution inherent to MRI also makes this modality suitable for imaging suspected fistulae, particularly when repeat imaging is an issue [40,41].
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Recurrent Lower Urinary Tract Infections in Females. It can also be employed for imaging of suspected bladder or urethral fistula, urethral diverticulum, or bladder prolapse. MRI Abdomen and Pelvis Both MRI of the abdomen and pelvis and MRU can be used to evaluate the urinary tract and have the advantage to provide more functional information than CT. MRI has been shown to be useful in the diagnosis and follow-up of UTI and acute pyelonephritis [27,35,36]. MRI is effective at diagnosing pelvic-organ prolapse. The resultant cystoceles and urinary incontinence associated with pelvic-organ prolapse are significant risk factors for recurrent UTIs in postmenopausal women [13,37,38]. MRI is the optimum imaging modality for assessment of the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning [39]. Given the excellent soft-tissue contrast on MRI, this modality is equally sensitive to CT for evaluating vesicovaginal and enterovesicular fistulae [40,41]. In at least one study, MRI altered the surgical management in 15% of patients [39]. A history of recurrent UTI is seen in 30% to 50% of patients with urethral diverticula. Diverticula of the urethra can be evaluated with high sensitivity and specificity by double-balloon urethrography, voiding CT urethrography, and MRI [42-44]. MRI best assesses the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning. Patients with suspected bladder diverticula may be imaged with cystography, US, or CT [45]. Bladder diverticula are unusual in women and are associated with a neurogenic or postoperative bladder; they are rarely congenital. MRI has also been shown to be accurate in the diagnosis of colovesical fistula. The multiplanar imaging capability and high soft-tissue resolution inherent to MRI also makes this modality suitable for imaging suspected fistulae, particularly when repeat imaging is an issue [40,41].
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69491
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acrac_69491_10
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Recurrent Lower Urinary Tract Infections in Females
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IVU, US, and upper gastrointestinal or small-bowel follow-through have very low yields for fistula [46,47]. MRU MRU is useful to evaluate suspected urinary tract obstruction, hematuria, and congenital anomalies, as well as postoperative anatomy. The most common MRU techniques for displaying the urinary tract can be divided into two categories: static-fluid MRU and excretory MRU. Static-fluid MRU makes use of heavily T2-weighted sequences to image the urinary tract as a static collection of fluid, can be repeated sequentially (cine MRU) to better demonstrate the ureters in their entirety and to confirm the presence of fixed stenoses, and is most successful in patients with dilated or obstructed collecting systems. Excretory MRU is performed during the excretory phase of enhancement after the IV administration of gadolinium-based contrast material. Diuretic administration is integral to excretory MRU to better demonstrate nondilated systems. Static-fluid and excretory MRU can be combined with conventional MRI for comprehensive evaluation of the urinary tract [48]. MRU can be used to evaluate the urinary tract and provides more functional information than CT provides. However, MRU is less established and less reliable and thus results in lesser diagnostic image quality relative to CTU [23]. In comparison to CTU, it necessitates a longer examination time and is less sensitive than CT for detecting urinary tract calculi. In a study of 149 patients, MRU demonstrated 69% sensitivity for detecting calculi versus 100% for CT [49]. However, MRU has shown increased sensitivity for perirenal fluid and ureteric dilatation in comparison with CT in the setting of acute obstruction [50]. Multiplanar reconstruction images in the coronal and sagittal planes are commonly included in MRU images to improve visualization of urinary tract abnormalities [27,48].
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Recurrent Lower Urinary Tract Infections in Females. IVU, US, and upper gastrointestinal or small-bowel follow-through have very low yields for fistula [46,47]. MRU MRU is useful to evaluate suspected urinary tract obstruction, hematuria, and congenital anomalies, as well as postoperative anatomy. The most common MRU techniques for displaying the urinary tract can be divided into two categories: static-fluid MRU and excretory MRU. Static-fluid MRU makes use of heavily T2-weighted sequences to image the urinary tract as a static collection of fluid, can be repeated sequentially (cine MRU) to better demonstrate the ureters in their entirety and to confirm the presence of fixed stenoses, and is most successful in patients with dilated or obstructed collecting systems. Excretory MRU is performed during the excretory phase of enhancement after the IV administration of gadolinium-based contrast material. Diuretic administration is integral to excretory MRU to better demonstrate nondilated systems. Static-fluid and excretory MRU can be combined with conventional MRI for comprehensive evaluation of the urinary tract [48]. MRU can be used to evaluate the urinary tract and provides more functional information than CT provides. However, MRU is less established and less reliable and thus results in lesser diagnostic image quality relative to CTU [23]. In comparison to CTU, it necessitates a longer examination time and is less sensitive than CT for detecting urinary tract calculi. In a study of 149 patients, MRU demonstrated 69% sensitivity for detecting calculi versus 100% for CT [49]. However, MRU has shown increased sensitivity for perirenal fluid and ureteric dilatation in comparison with CT in the setting of acute obstruction [50]. Multiplanar reconstruction images in the coronal and sagittal planes are commonly included in MRU images to improve visualization of urinary tract abnormalities [27,48].
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acrac_69491_11
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Recurrent Lower Urinary Tract Infections in Females
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Additional benefits for MRU are in documenting active upper-tract infection versus scar formation to determine whether therapy has been effective in the high-risk patient. Radiography Abdomen Radiography of the abdomen has long been employed for the detection of calculi, intramural bladder wall calcification, gas in the wall or lumen of the urinary bladder, and/or foreign bodies that may be the etiology of a UTI. Use of digital tomosynthesis of the abdomen results in improved detection of urinary stones in general over digital radiography [51]. Bladder-wall calcification, when present, is typically due to prior infection with Schistosoma (uncommon in the United States, but very common in other parts of the world), tuberculosis, Cytoxan cystitis, or radiation cystitis [52]. For women with recurrent UTIs, however, abdominal radiography is generally not a useful diagnostic tool as other imaging modalities have higher sensitivity and specificity in this setting. Recurrent Lower Urinary Tract Infections in Females Radiography Intravenous Urography CT and MRU have supplanted the use of IVU for evaluation of urinary abnormalities at most institutions [27], and it is generally not useful for women with recurrent complicated UTIs. US Kidneys and Bladder Retroperitoneal US may be useful in women with recurrent UTIs, particularly prior to pregnancy, to evaluate for hydronephrosis and risk factors for recurrent infection. Hydronephrosis can be demonstrated as an indication of obstruction, although US may not yield a specific etiology [53-55]. US is a useful initial screening tool for obstructive uropathy and for postvoid residual volume determination to detect incomplete bladder emptying [56]. It should be noted, although US can detect renal stones, it is generally less sensitive than CT [57-59]. Renal abscess or perinephric collections can also be detected sonographically, and US of the bladder can be employed to evaluate for bladder diverticula detection [45].
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Recurrent Lower Urinary Tract Infections in Females. Additional benefits for MRU are in documenting active upper-tract infection versus scar formation to determine whether therapy has been effective in the high-risk patient. Radiography Abdomen Radiography of the abdomen has long been employed for the detection of calculi, intramural bladder wall calcification, gas in the wall or lumen of the urinary bladder, and/or foreign bodies that may be the etiology of a UTI. Use of digital tomosynthesis of the abdomen results in improved detection of urinary stones in general over digital radiography [51]. Bladder-wall calcification, when present, is typically due to prior infection with Schistosoma (uncommon in the United States, but very common in other parts of the world), tuberculosis, Cytoxan cystitis, or radiation cystitis [52]. For women with recurrent UTIs, however, abdominal radiography is generally not a useful diagnostic tool as other imaging modalities have higher sensitivity and specificity in this setting. Recurrent Lower Urinary Tract Infections in Females Radiography Intravenous Urography CT and MRU have supplanted the use of IVU for evaluation of urinary abnormalities at most institutions [27], and it is generally not useful for women with recurrent complicated UTIs. US Kidneys and Bladder Retroperitoneal US may be useful in women with recurrent UTIs, particularly prior to pregnancy, to evaluate for hydronephrosis and risk factors for recurrent infection. Hydronephrosis can be demonstrated as an indication of obstruction, although US may not yield a specific etiology [53-55]. US is a useful initial screening tool for obstructive uropathy and for postvoid residual volume determination to detect incomplete bladder emptying [56]. It should be noted, although US can detect renal stones, it is generally less sensitive than CT [57-59]. Renal abscess or perinephric collections can also be detected sonographically, and US of the bladder can be employed to evaluate for bladder diverticula detection [45].
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69491
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acrac_3195154_0
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Acute Elbow and Forearm Pain
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Diagnostic imaging plays a key role in the assessment of acute elbow pain. A thorough understanding of diagnostic imaging modalities is essential to expeditiously identify the damaged structures and assist in treatment/surgical planning, thus allowing for rapid return to play/activity. In a more recent study, the same authors tested joint widening on cadaveric human elbows at various stages of ligamentous transection. The 5 sequential stages, evaluated with varus stress, included 1) intact, 2) transection of the lateral ulnar collateral ligament (UCL), 3) complete transection of the lateral collateral ligament complex, 4) transection of the anterior aspect of the capsule, and 5) transection of the medial collateral ligament. The 5 sequential stages, evaluated by valgus stress, included 1) intact, 2) transection of the anteromedial collateral ligament, 3) complete transection of the medial collateral ligament, 4) transection of the anterior capsule, and 5) transection of Reprint requests to: [email protected] Acute Elbow and Forearm Pain the lateral collateral ligamentous complex. The authors concluded that dynamic fluoroscopy makes it possible to distinguish among different stages of collateral ligament injury of the elbow [5]. OR Discussion of Procedures by Variant Variant 1: Adult. Acute elbow or forearm pain. Initial imaging. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan as the initial imaging study for the evaluation of acute elbow and forearm pain. CT Area of Interest With IV Contrast There is no evidence to support the use of contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. CT Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain.
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Acute Elbow and Forearm Pain. Diagnostic imaging plays a key role in the assessment of acute elbow pain. A thorough understanding of diagnostic imaging modalities is essential to expeditiously identify the damaged structures and assist in treatment/surgical planning, thus allowing for rapid return to play/activity. In a more recent study, the same authors tested joint widening on cadaveric human elbows at various stages of ligamentous transection. The 5 sequential stages, evaluated with varus stress, included 1) intact, 2) transection of the lateral ulnar collateral ligament (UCL), 3) complete transection of the lateral collateral ligament complex, 4) transection of the anterior aspect of the capsule, and 5) transection of the medial collateral ligament. The 5 sequential stages, evaluated by valgus stress, included 1) intact, 2) transection of the anteromedial collateral ligament, 3) complete transection of the medial collateral ligament, 4) transection of the anterior capsule, and 5) transection of Reprint requests to: [email protected] Acute Elbow and Forearm Pain the lateral collateral ligamentous complex. The authors concluded that dynamic fluoroscopy makes it possible to distinguish among different stages of collateral ligament injury of the elbow [5]. OR Discussion of Procedures by Variant Variant 1: Adult. Acute elbow or forearm pain. Initial imaging. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan as the initial imaging study for the evaluation of acute elbow and forearm pain. CT Area of Interest With IV Contrast There is no evidence to support the use of contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. CT Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain.
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3195154
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acrac_3195154_1
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Acute Elbow and Forearm Pain
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CT Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. MRI Area of Interest Without IV Contrast There is no evidence to support the use of contrast-enhanced MRI of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. Radiography Area of Interest Radiographs are beneficial as the initial imaging assessment for acute elbow and proximal forearm pain. Conventional radiographs are often the first-imaging modality used to exclude a fracture or dislocation. In adults, the most frequent fracture involves the radial head or neck and accounts for 50% of cases [1]. An elbow joint effusion can be identified on conventional radiography with the presence of posterior and anterior fat pad elevation. In combination with the clinical context of acute trauma, the presence of a joint effusion can imply an occult elbow fracture. Avulsion fractures can also be identified at the attachment sites of tendons and ligaments. Occasionally, triceps tendon tears may result in avulsion fractures of the olecranon or an olecranon enthesophyte. Injuries to the coronoid process are sequela of prior elbow dislocation, which is typically associated with soft tissue injury. As such, coronoid process fractures should prompt the referring provider to assess for associated tendon or ligament injury because these are commonly associated with elbow dislocation. US Area of Interest There is limited evidence to support the use of ultrasound (US) of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. Acute Elbow and Forearm Pain
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Acute Elbow and Forearm Pain. CT Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. MRI Area of Interest Without IV Contrast There is no evidence to support the use of contrast-enhanced MRI of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. Radiography Area of Interest Radiographs are beneficial as the initial imaging assessment for acute elbow and proximal forearm pain. Conventional radiographs are often the first-imaging modality used to exclude a fracture or dislocation. In adults, the most frequent fracture involves the radial head or neck and accounts for 50% of cases [1]. An elbow joint effusion can be identified on conventional radiography with the presence of posterior and anterior fat pad elevation. In combination with the clinical context of acute trauma, the presence of a joint effusion can imply an occult elbow fracture. Avulsion fractures can also be identified at the attachment sites of tendons and ligaments. Occasionally, triceps tendon tears may result in avulsion fractures of the olecranon or an olecranon enthesophyte. Injuries to the coronoid process are sequela of prior elbow dislocation, which is typically associated with soft tissue injury. As such, coronoid process fractures should prompt the referring provider to assess for associated tendon or ligament injury because these are commonly associated with elbow dislocation. US Area of Interest There is limited evidence to support the use of ultrasound (US) of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. Acute Elbow and Forearm Pain
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3195154
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acrac_3195154_2
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Acute Elbow and Forearm Pain
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Variant 2: Adult. Acute elbow or forearm pain. Suspect fracture. Radiographs normal or indeterminate. Next imaging study. This variant is associated with osseous injury only. Please refer to Variant 3 for recommendations for the evaluation of soft tissue injury. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan as the initial imaging study for the evaluation of acute elbow and forearm pain. CT Area of Interest With IV Contrast There is no evidence to support the use of contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. CT Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. In the elbow, the additional knowledge gleaned from CT includes size of fracture fragments and amount of displacement or angulation, which may affect the surgical treatment options. Isolated radial head fractures, Essex- Lopresti injuries, and Monteggia fractures with dislocation of the elbow can be diagnosed. Traumatic elbow injuries are categorized into radial head fracture with posterior dislocation, terrible triad injury, posterior and anterior fracture-dislocation, trans-olecranon (anterior) fracture-dislocation, and varus posteromedial rotational instability. Fracture mapping and quantitative 3-D CT analysis of coronoid and olecranon fractures have identified specific shapes, sizes, and orientations of fracture fragments according to a pattern of traumatic elbow instability.
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Acute Elbow and Forearm Pain. Variant 2: Adult. Acute elbow or forearm pain. Suspect fracture. Radiographs normal or indeterminate. Next imaging study. This variant is associated with osseous injury only. Please refer to Variant 3 for recommendations for the evaluation of soft tissue injury. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan as the initial imaging study for the evaluation of acute elbow and forearm pain. CT Area of Interest With IV Contrast There is no evidence to support the use of contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. CT Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain. In the elbow, the additional knowledge gleaned from CT includes size of fracture fragments and amount of displacement or angulation, which may affect the surgical treatment options. Isolated radial head fractures, Essex- Lopresti injuries, and Monteggia fractures with dislocation of the elbow can be diagnosed. Traumatic elbow injuries are categorized into radial head fracture with posterior dislocation, terrible triad injury, posterior and anterior fracture-dislocation, trans-olecranon (anterior) fracture-dislocation, and varus posteromedial rotational instability. Fracture mapping and quantitative 3-D CT analysis of coronoid and olecranon fractures have identified specific shapes, sizes, and orientations of fracture fragments according to a pattern of traumatic elbow instability.
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3195154
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acrac_3195154_3
|
Acute Elbow and Forearm Pain
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Specifically, with regards to proximal olecranon fractures, plate and screw constructs tend to have only a few short proximal screws, and further stabilization with a supplementary wire or suture fixation incorporating the triceps attachment has been found to be helpful and knowledge of the fracture morphology is helpful for this surgical planning. Furthermore, CT can assess the degree of ulnohumeral incongruity, which is inversely proportional to the proximal olecranon fracture size [8]. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the next imaging study for the evaluation of occult fracture of the elbow and/or proximal forearm. MRI Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast MRI of the elbow/proximal forearm as the next imaging study for the evaluation of occult fracture of the elbow and/or proximal forearm. In the setting of the Osborne- Cotterill lesion, occasionally the impaction, avulsion, and shear fracture of the posterolateral capitellum during elbow fracture-dislocation could be nondisplaced on CT; however, MRI is able to demonstrate the injury with marrow edema at the fracture site [9]. Radiography Area of Interest Repeat in 10-14 Days Pavic et al [10] evaluated 193 patients with acute elbow trauma with no acute fracture identified at the time of initial radiographic evaluation. Of note, these patients all had elbow joint effusions. Follow-up conventional radiographs were performed in 184 patients (95%) and showed fractures of the radial neck in 58% and nondisplaced fractures of the radial head in 37% of cases. Five percent of patients continued to have normal radiographs and were further evaluated with MRI and found to have intraarticular joint effusions, bone contusion, and radial and UCL ruptures.
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Acute Elbow and Forearm Pain. Specifically, with regards to proximal olecranon fractures, plate and screw constructs tend to have only a few short proximal screws, and further stabilization with a supplementary wire or suture fixation incorporating the triceps attachment has been found to be helpful and knowledge of the fracture morphology is helpful for this surgical planning. Furthermore, CT can assess the degree of ulnohumeral incongruity, which is inversely proportional to the proximal olecranon fracture size [8]. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the next imaging study for the evaluation of occult fracture of the elbow and/or proximal forearm. MRI Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast MRI of the elbow/proximal forearm as the next imaging study for the evaluation of occult fracture of the elbow and/or proximal forearm. In the setting of the Osborne- Cotterill lesion, occasionally the impaction, avulsion, and shear fracture of the posterolateral capitellum during elbow fracture-dislocation could be nondisplaced on CT; however, MRI is able to demonstrate the injury with marrow edema at the fracture site [9]. Radiography Area of Interest Repeat in 10-14 Days Pavic et al [10] evaluated 193 patients with acute elbow trauma with no acute fracture identified at the time of initial radiographic evaluation. Of note, these patients all had elbow joint effusions. Follow-up conventional radiographs were performed in 184 patients (95%) and showed fractures of the radial neck in 58% and nondisplaced fractures of the radial head in 37% of cases. Five percent of patients continued to have normal radiographs and were further evaluated with MRI and found to have intraarticular joint effusions, bone contusion, and radial and UCL ruptures.
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3195154
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acrac_3195154_4
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Acute Elbow and Forearm Pain
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Acute Elbow and Forearm Pain US Area of Interest There is no evidence to support the use of diagnostic US of the elbow/proximal forearm as the imaging study for the evaluation of acute elbow and forearm pain. There are 2 studies discussing point-of-care US that are too small to support use in this setting [11,12]. Variant 3: Adult. Acute elbow or forearm pain. Suspect tendon or ligament or muscle injury. Radiographs normal or indeterminate. Next imaging study. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan for the assessment of tendon, ligamentous, or muscle injury. CT Area of Interest With IV Contrast There is no evidence to support the use of contrast-enhanced CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury. CT Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury. CT Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the for the assessment of tendon, ligamentous, or muscle injury. MRI Area of Interest Without IV Contrast Several studies have evaluated the use of noncontrast MRI in the assessment for ligamentous and tendinous injury [13]. Tarallo et al showed the best interobserver agreement in the assessment of lateral collateral complex injuries and the worst interobserver reliability for the UCL [7,14-18]. Athletes are prone to both acute and chronic overuse injuries of the elbow [13]. In a study of elbow injuries incurred during participation of the Rio de Janeiro 2016 Summer Olympic Games, Alizai et al [20] showed a predominance of UCL injury.
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Acute Elbow and Forearm Pain. Acute Elbow and Forearm Pain US Area of Interest There is no evidence to support the use of diagnostic US of the elbow/proximal forearm as the imaging study for the evaluation of acute elbow and forearm pain. There are 2 studies discussing point-of-care US that are too small to support use in this setting [11,12]. Variant 3: Adult. Acute elbow or forearm pain. Suspect tendon or ligament or muscle injury. Radiographs normal or indeterminate. Next imaging study. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan for the assessment of tendon, ligamentous, or muscle injury. CT Area of Interest With IV Contrast There is no evidence to support the use of contrast-enhanced CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury. CT Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury. CT Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the for the assessment of tendon, ligamentous, or muscle injury. MRI Area of Interest Without IV Contrast Several studies have evaluated the use of noncontrast MRI in the assessment for ligamentous and tendinous injury [13]. Tarallo et al showed the best interobserver agreement in the assessment of lateral collateral complex injuries and the worst interobserver reliability for the UCL [7,14-18]. Athletes are prone to both acute and chronic overuse injuries of the elbow [13]. In a study of elbow injuries incurred during participation of the Rio de Janeiro 2016 Summer Olympic Games, Alizai et al [20] showed a predominance of UCL injury.
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3195154
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acrac_3195154_5
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Acute Elbow and Forearm Pain
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For the purposes of this document, it is difficult to ascertain the acuity of the injuries from this report. Furthermore, MRI is particularly useful in the assessment of biceps tears [21-24]. MRI has an improved sensitivity for the detection of partial tears of the biceps and triceps tendons. In a study of 77 patients, Nicolay et al [24] showed partial rupture of the long head of the biceps with an intact short head of the biceps to be the most common injury. On the other hand, isolated complete ruptures of the long head represented the least common injury pattern. Traumatic ruptures had a significantly higher association with ruptures of the short head of the biceps tendon, whereas ruptures of the long head of the biceps tendon accounted for 89% of atraumatic ruptures. Acute Elbow and Forearm Pain diagnosis of partial distal biceps tendon tears. However, the interrater reliability was better for FABS view and significantly more accurate than surgical findings in grading the extent of pathology. MRI is also useful in the assessment of rare triceps tears [21-24]. Lee et al [23] evaluated a small subset of patients and found 2 major causes for acute traumatic rupture of the triceps tendon at the elbow. A fall on an outstretched hand was categorized as an indirect injury, whereas a direct blow to the triceps by an object was considered a direct injury. The authors found that the indirect injury was most likely to result in injury of the lateral and long heads of the distal triceps tendon with an intact medial head tendon. Direct injuries were more likely to have a full-thickness rupture with an odds ratio of 1.75 (95% confidence interval, 0.92-3.32; P = . 02). In addition, they found that the indirect injuries had associated ligamentous injuries with an odds ratio of 0.13 (95% confidence interval, 0.02-0.78; P < . 001). However, one paper noted the overestimation of triceps tear severity compared with surgical assessment [28].
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Acute Elbow and Forearm Pain. For the purposes of this document, it is difficult to ascertain the acuity of the injuries from this report. Furthermore, MRI is particularly useful in the assessment of biceps tears [21-24]. MRI has an improved sensitivity for the detection of partial tears of the biceps and triceps tendons. In a study of 77 patients, Nicolay et al [24] showed partial rupture of the long head of the biceps with an intact short head of the biceps to be the most common injury. On the other hand, isolated complete ruptures of the long head represented the least common injury pattern. Traumatic ruptures had a significantly higher association with ruptures of the short head of the biceps tendon, whereas ruptures of the long head of the biceps tendon accounted for 89% of atraumatic ruptures. Acute Elbow and Forearm Pain diagnosis of partial distal biceps tendon tears. However, the interrater reliability was better for FABS view and significantly more accurate than surgical findings in grading the extent of pathology. MRI is also useful in the assessment of rare triceps tears [21-24]. Lee et al [23] evaluated a small subset of patients and found 2 major causes for acute traumatic rupture of the triceps tendon at the elbow. A fall on an outstretched hand was categorized as an indirect injury, whereas a direct blow to the triceps by an object was considered a direct injury. The authors found that the indirect injury was most likely to result in injury of the lateral and long heads of the distal triceps tendon with an intact medial head tendon. Direct injuries were more likely to have a full-thickness rupture with an odds ratio of 1.75 (95% confidence interval, 0.92-3.32; P = . 02). In addition, they found that the indirect injuries had associated ligamentous injuries with an odds ratio of 0.13 (95% confidence interval, 0.02-0.78; P < . 001). However, one paper noted the overestimation of triceps tear severity compared with surgical assessment [28].
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3195154
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acrac_3195154_6
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Acute Elbow and Forearm Pain
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US Area of Interest The use of US to evaluate the distal biceps tendon is well described in the literature [21,29,30]. A study by de la Fuente et al [30] investigated the sensitivity of US in detecting injuries of the distal biceps brachii tendon. The authors compared US examinations with MRI and surgery and found a slight statistical advantage of US over MRI. However, US is at a disadvantage with regard to the detection of partial tearing and tendinopathy. Lynch et al [31] showed the accuracy of US in the diagnosis of complete distal biceps tendon rupture was inferior to MRI, 45.5% compared with 86.4%. The accuracy rate of US to detect partial tears of the biceps was the same as MRI at 66.7%. The sensitivity and specificity of US for the detection of biceps tendon tears were 62.5% and 20.0%, respectively, inferior to MRI at 76% and 50%. The authors concluded that MRI is a more accurate imaging modality at correctly identifying the type of distal biceps tendon tear, thus enabling the orthopedic surgeon to provide a more precise treatment plan. Deschrijver et al [32] conducted an extensive literature search and meta-analysis to assess the usefulness of clinical examination testing as well as the usefulness of US. They further investigated whether supplementary sonographic views/maneuvers (eg, posterior approach Cobra technique, lateral approach supinator view, and medial approach pronator view) added benefit to the standard US examination. Their conclusion was that US can be considered an alternative to MRI in the evaluation of the distal biceps tendon ruptures. In a recent study by Miller et al, it was shown that radiologists preferred the medial imaging approach. Furthermore, this particular imaging approach demonstrated substantial interreader agreement [33]. Triceps tendon ruptures are rare, and a handful of studies have shown that US can identify both complete and isolated partial tears of the triceps brachii tendon [34,35].
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Acute Elbow and Forearm Pain. US Area of Interest The use of US to evaluate the distal biceps tendon is well described in the literature [21,29,30]. A study by de la Fuente et al [30] investigated the sensitivity of US in detecting injuries of the distal biceps brachii tendon. The authors compared US examinations with MRI and surgery and found a slight statistical advantage of US over MRI. However, US is at a disadvantage with regard to the detection of partial tearing and tendinopathy. Lynch et al [31] showed the accuracy of US in the diagnosis of complete distal biceps tendon rupture was inferior to MRI, 45.5% compared with 86.4%. The accuracy rate of US to detect partial tears of the biceps was the same as MRI at 66.7%. The sensitivity and specificity of US for the detection of biceps tendon tears were 62.5% and 20.0%, respectively, inferior to MRI at 76% and 50%. The authors concluded that MRI is a more accurate imaging modality at correctly identifying the type of distal biceps tendon tear, thus enabling the orthopedic surgeon to provide a more precise treatment plan. Deschrijver et al [32] conducted an extensive literature search and meta-analysis to assess the usefulness of clinical examination testing as well as the usefulness of US. They further investigated whether supplementary sonographic views/maneuvers (eg, posterior approach Cobra technique, lateral approach supinator view, and medial approach pronator view) added benefit to the standard US examination. Their conclusion was that US can be considered an alternative to MRI in the evaluation of the distal biceps tendon ruptures. In a recent study by Miller et al, it was shown that radiologists preferred the medial imaging approach. Furthermore, this particular imaging approach demonstrated substantial interreader agreement [33]. Triceps tendon ruptures are rare, and a handful of studies have shown that US can identify both complete and isolated partial tears of the triceps brachii tendon [34,35].
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3195154
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acrac_3195154_7
|
Acute Elbow and Forearm Pain
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In addition, in a feasibility study, Barret et al [12] showed that traumatic ligamentous lesions could be detected on US examination with the identified pathology matching the clinical symptomatology. Of note, no traumatic ruptures of the flexor or extensor tendon origins were detected on this study; however, this was a small study with only 9 patients. Assessment of the anterior bundle of the UCL in athletes is well documented and thus could be useful in the setting of acute trauma as well [20,36-38]. The ability of US to visualize tendinous and ligamentous structures in cadaveric and normal volunteers of the medial and lateral elbow is well accepted; however, there are few articles evaluating its usefulness in the acute setting. A case report by van Duijn and Felton [39] described a case of an 18-year-old collegiate baseball pitcher with preinjury and postinjury US with MR arthrographic correlation. This patient was already participating in a research study evaluating the reliability of UCL thickness measurements using US imaging. In this study, the preinjury US image showed a normal hyperechoic appearance of the anterior band of the UCL. Postinjury images showed disruption of the ligamentous fibers of the anterior band of the UCL, with a large hypoechoic gap separating the 2 torn ends of the UCL, which was confirmed at the time of MR arthrography. A single study by Bilger et al [40] evaluated the use of US in the acute phase of closed elbow injuries and found a strong interrater reliability for injuries of the radial collateral, annular, and anterior bundle of the medial collateral ligaments. They further showed 100% US-surgical correlation in a subset of patients who had surgery. In a cadaveric study, Arrigoni et al [41] evaluated the lateral compartment of the elbow after release of the anterior half of the common extensor origin and after complete radial collateral ligament release. They concluded that US evaluation can detect changes related to tendon tears or
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Acute Elbow and Forearm Pain. In addition, in a feasibility study, Barret et al [12] showed that traumatic ligamentous lesions could be detected on US examination with the identified pathology matching the clinical symptomatology. Of note, no traumatic ruptures of the flexor or extensor tendon origins were detected on this study; however, this was a small study with only 9 patients. Assessment of the anterior bundle of the UCL in athletes is well documented and thus could be useful in the setting of acute trauma as well [20,36-38]. The ability of US to visualize tendinous and ligamentous structures in cadaveric and normal volunteers of the medial and lateral elbow is well accepted; however, there are few articles evaluating its usefulness in the acute setting. A case report by van Duijn and Felton [39] described a case of an 18-year-old collegiate baseball pitcher with preinjury and postinjury US with MR arthrographic correlation. This patient was already participating in a research study evaluating the reliability of UCL thickness measurements using US imaging. In this study, the preinjury US image showed a normal hyperechoic appearance of the anterior band of the UCL. Postinjury images showed disruption of the ligamentous fibers of the anterior band of the UCL, with a large hypoechoic gap separating the 2 torn ends of the UCL, which was confirmed at the time of MR arthrography. A single study by Bilger et al [40] evaluated the use of US in the acute phase of closed elbow injuries and found a strong interrater reliability for injuries of the radial collateral, annular, and anterior bundle of the medial collateral ligaments. They further showed 100% US-surgical correlation in a subset of patients who had surgery. In a cadaveric study, Arrigoni et al [41] evaluated the lateral compartment of the elbow after release of the anterior half of the common extensor origin and after complete radial collateral ligament release. They concluded that US evaluation can detect changes related to tendon tears or
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3195154
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acrac_3195154_8
|
Acute Elbow and Forearm Pain
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Acute Elbow and Forearm Pain muscular avulsions of the common extensor origin and can depict lateral elbow compartmental pathologic laxity as evidence by widening of the articular joint space under dynamic stress maneuvers. Unfortunately, accurate identification of injuries to the lateral collateral ligament was not reliable. The majority of literature using US for the diagnosis of tendinous injuries is found in the setting of chronic elbow pain, particularly in the athlete. US of the elbow has moderate agreement with MRI of the elbow for the diagnosis and grading of common extensor tendon tears, with the sensitivity, specificity, and accuracy reported at 64.52%, 85.19%, and 72.73%, respectively [42]. Sonoelastography has shown promise for the detection of medial epicondylalgia with a sensitivity, specificity, accuracy, and positive predictive value, and negative predictive value of 95.2%, 92%, 93.5%, 90.0%, and 95.8%, respectively [43]. Conventional US has a sensitivity and specificity of 81% and 91%, respectively, in the detection of full-thickness UCL tears [44]. The sensitivity and specificity of dynamic stress US for the detection of UCL injury are 96% and 81%, respectively [44]. In a review of the literature, Sutterer et al [45] found that stress US can aid in the diagnosis of medial UCL tears, with an injured elbow stress delta (change in ulnohumeral joint space with valgus stress) of 2.4 mm and a stress delta difference (side-side difference in stress delta) of 1 mm, compatible with abnormal ulnohumeral joint laxity as a result of medial UCL injury. Given the scarcity of literature with regards to lateral and medial supporting structures, more rigorous studies evaluating the usefulness of US in the acute setting are needed; however, given US accuracy in the evaluation of chronic injuries, it will likely provide clinical usefulness for assessment of acute injury.
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Acute Elbow and Forearm Pain. Acute Elbow and Forearm Pain muscular avulsions of the common extensor origin and can depict lateral elbow compartmental pathologic laxity as evidence by widening of the articular joint space under dynamic stress maneuvers. Unfortunately, accurate identification of injuries to the lateral collateral ligament was not reliable. The majority of literature using US for the diagnosis of tendinous injuries is found in the setting of chronic elbow pain, particularly in the athlete. US of the elbow has moderate agreement with MRI of the elbow for the diagnosis and grading of common extensor tendon tears, with the sensitivity, specificity, and accuracy reported at 64.52%, 85.19%, and 72.73%, respectively [42]. Sonoelastography has shown promise for the detection of medial epicondylalgia with a sensitivity, specificity, accuracy, and positive predictive value, and negative predictive value of 95.2%, 92%, 93.5%, 90.0%, and 95.8%, respectively [43]. Conventional US has a sensitivity and specificity of 81% and 91%, respectively, in the detection of full-thickness UCL tears [44]. The sensitivity and specificity of dynamic stress US for the detection of UCL injury are 96% and 81%, respectively [44]. In a review of the literature, Sutterer et al [45] found that stress US can aid in the diagnosis of medial UCL tears, with an injured elbow stress delta (change in ulnohumeral joint space with valgus stress) of 2.4 mm and a stress delta difference (side-side difference in stress delta) of 1 mm, compatible with abnormal ulnohumeral joint laxity as a result of medial UCL injury. Given the scarcity of literature with regards to lateral and medial supporting structures, more rigorous studies evaluating the usefulness of US in the acute setting are needed; however, given US accuracy in the evaluation of chronic injuries, it will likely provide clinical usefulness for assessment of acute injury.
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3195154
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acrac_69434_0
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Soft Tissue Masses
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Introduction/Background A variety of benign and malignant processes may present clinically as a soft tissue mass. The behavior of a mass, whether nonaggressive, indeterminant, or aggressive, can often be discerned based on history and physical examination. However, when a benign clinical diagnosis cannot be confidently provided, further characterization of a soft tissue mass with imaging is warranted [1]. Urgent imaging requests should be sought for masses that are >5 cm in diameter, deep in location, or have shown rapid growth [2]. Modern imaging techniques allow for a detailed analysis of the morphology of a soft tissue mass as well as further insight into its biologic activity, which informs the interpreter on diagnosis and appropriate next steps in management [3,4]. The purpose of this document is to identify the most appropriate imaging study(ies) to order for the assessment of a soft tissue mass based on the most frequently encountered clinical scenarios in medical practice. The rationale for the level of appropriateness granted to each study option is also described in accordance with the current literature and the consensus opinion of the members of the ACR Appropriateness Criteria Expert Panel on Musculoskeletal Imaging. This document does not address follow-up recommendations for patients with previously diagnosed masses or the appropriate approach or techniques for the imaging-guided biopsy of known masses. The former is covered by a separate ACR Appropriateness Criteria document [4], whereas the latter requires direct communication with the clinician or orthopedic oncologist supervising and coordinating patient care. OR aMayo Clinic Florida, Jacksonville, Florida. bPanel Chair, Mayo Clinic, Jacksonville, Florida. cPanel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina. dJohns Hopkins University School of Medicine, Baltimore, Maryland. eMallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri.
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Soft Tissue Masses. Introduction/Background A variety of benign and malignant processes may present clinically as a soft tissue mass. The behavior of a mass, whether nonaggressive, indeterminant, or aggressive, can often be discerned based on history and physical examination. However, when a benign clinical diagnosis cannot be confidently provided, further characterization of a soft tissue mass with imaging is warranted [1]. Urgent imaging requests should be sought for masses that are >5 cm in diameter, deep in location, or have shown rapid growth [2]. Modern imaging techniques allow for a detailed analysis of the morphology of a soft tissue mass as well as further insight into its biologic activity, which informs the interpreter on diagnosis and appropriate next steps in management [3,4]. The purpose of this document is to identify the most appropriate imaging study(ies) to order for the assessment of a soft tissue mass based on the most frequently encountered clinical scenarios in medical practice. The rationale for the level of appropriateness granted to each study option is also described in accordance with the current literature and the consensus opinion of the members of the ACR Appropriateness Criteria Expert Panel on Musculoskeletal Imaging. This document does not address follow-up recommendations for patients with previously diagnosed masses or the appropriate approach or techniques for the imaging-guided biopsy of known masses. The former is covered by a separate ACR Appropriateness Criteria document [4], whereas the latter requires direct communication with the clinician or orthopedic oncologist supervising and coordinating patient care. OR aMayo Clinic Florida, Jacksonville, Florida. bPanel Chair, Mayo Clinic, Jacksonville, Florida. cPanel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina. dJohns Hopkins University School of Medicine, Baltimore, Maryland. eMallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri.
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69434
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acrac_69434_1
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Soft Tissue Masses
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fNova Southeastern University, Fort Lauderdale, Florida. gDiagnostic Imaging Associates, Chesterfield, Missouri. hThe University of Texas MD Anderson Cancer Center, Houston, Texas; American Academy of Orthopaedic Surgeons. iUniversity of Virginia, Charlottesville, Virginia. jSUNY Downstate Health Sciences University, Brooklyn, New York. kDuke University School of Medicine, Durham, North Carolina; American Geriatrics Society. lThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. mBillings Clinic, Billings, Montana; American Academy of Family Physicians. nSpecialty 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] Soft Tissue Masses Discussion of Procedures by Variant Variant 1: Superficial soft tissue mass. Initial imaging. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot. US Area of Interest Ultrasound (US) has become increasingly recognized as an excellent triage tool for evaluation of superficial soft tissue masses [12-15]. This recognition has been further supported by a recent prospective study of 219 histologically proven masses that showed US had a sensitivity, specificity, positive predictive value, and negative predictive value of 93.3%, 97.9%, 45.2%, and 99.9%, respectively, for discriminating benign from malignant tumors in the superficial soft tissues [16].
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Soft Tissue Masses. fNova Southeastern University, Fort Lauderdale, Florida. gDiagnostic Imaging Associates, Chesterfield, Missouri. hThe University of Texas MD Anderson Cancer Center, Houston, Texas; American Academy of Orthopaedic Surgeons. iUniversity of Virginia, Charlottesville, Virginia. jSUNY Downstate Health Sciences University, Brooklyn, New York. kDuke University School of Medicine, Durham, North Carolina; American Geriatrics Society. lThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. mBillings Clinic, Billings, Montana; American Academy of Family Physicians. nSpecialty 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] Soft Tissue Masses Discussion of Procedures by Variant Variant 1: Superficial soft tissue mass. Initial imaging. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot. US Area of Interest Ultrasound (US) has become increasingly recognized as an excellent triage tool for evaluation of superficial soft tissue masses [12-15]. This recognition has been further supported by a recent prospective study of 219 histologically proven masses that showed US had a sensitivity, specificity, positive predictive value, and negative predictive value of 93.3%, 97.9%, 45.2%, and 99.9%, respectively, for discriminating benign from malignant tumors in the superficial soft tissues [16].
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69434
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acrac_69434_2
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Soft Tissue Masses
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The same group of researchers had similar results in an earlier separate retrospective analysis of 247 histologically proven masses [17]. However, although these results highlight the benefits of US in the initial assessment of superficial masses, the overall number of malignancies in both the prospective [16] and retrospective [17] studies was very small (12 patients and 11 patients, respectively). Another recent study of 42 histologically proven masses concluded that MRI performed after US does not frequently change the working diagnosis or add diagnostic value, but again, this study only included a small number of malignancies and the value of MRI for these malignancies was not separately addressed in the study [18]. Therefore, we emphasize that these studies do not have sufficient power for showing high accuracy of US in the diagnosis of malignancy. Ultimately, US is most beneficial for triage, and when US features are not clearly benign or when history and physical examination findings are otherwise concerning, further imaging is required [9,19]. US Area of Interest With IV Contrast The use of intravenous (IV) contrast during US evaluation of soft tissue tumors may add further confidence in discriminating benign from indeterminate or malignant masses [20-22]. However, there is no literature showing that the addition of contrast provides a gain in diagnostic accuracy over standard grayscale and Doppler US features in the assessment of a soft tissue mass. Therefore, the literature does not support the use of US contrast in the initial examination of a superficial soft tissue mass. MRI Area of Interest Without and With IV Contrast There is insufficient literature to support the routine use of MRI without or with IV contrast as the initial examination for a soft tissue mass. The inherent limitations of this modality, most notably in the identification of mineralization, limit its use in isolation.
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Soft Tissue Masses. The same group of researchers had similar results in an earlier separate retrospective analysis of 247 histologically proven masses [17]. However, although these results highlight the benefits of US in the initial assessment of superficial masses, the overall number of malignancies in both the prospective [16] and retrospective [17] studies was very small (12 patients and 11 patients, respectively). Another recent study of 42 histologically proven masses concluded that MRI performed after US does not frequently change the working diagnosis or add diagnostic value, but again, this study only included a small number of malignancies and the value of MRI for these malignancies was not separately addressed in the study [18]. Therefore, we emphasize that these studies do not have sufficient power for showing high accuracy of US in the diagnosis of malignancy. Ultimately, US is most beneficial for triage, and when US features are not clearly benign or when history and physical examination findings are otherwise concerning, further imaging is required [9,19]. US Area of Interest With IV Contrast The use of intravenous (IV) contrast during US evaluation of soft tissue tumors may add further confidence in discriminating benign from indeterminate or malignant masses [20-22]. However, there is no literature showing that the addition of contrast provides a gain in diagnostic accuracy over standard grayscale and Doppler US features in the assessment of a soft tissue mass. Therefore, the literature does not support the use of US contrast in the initial examination of a superficial soft tissue mass. MRI Area of Interest Without and With IV Contrast There is insufficient literature to support the routine use of MRI without or with IV contrast as the initial examination for a soft tissue mass. The inherent limitations of this modality, most notably in the identification of mineralization, limit its use in isolation.
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acrac_69434_3
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Soft Tissue Masses
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MRI Area of Interest Without IV Contrast There is insufficient literature to support the routine use of MRI without IV contrast as the initial examination for a soft tissue mass. The inherent limitations of this modality, most notably in the identification of mineralization, limit its use in isolation. CT Area of Interest With IV Contrast CT with IV contrast does not typically play a role in the initial evaluation of a superficial soft tissue mass. Soft Tissue Masses CT Area of Interest Without and With IV Contrast CT does not typically play a role in the initial evaluation of a superficial soft tissue mass. CT Area of Interest Without IV Contrast CT does not typically play a role in the initial evaluation of a superficial soft tissue mass. FDG-PET/CT Area of Interest There is insufficient literature to support the routine use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT for the initial evaluation of a soft tissue mass. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24]. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant fine needle aspiration.
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Soft Tissue Masses. MRI Area of Interest Without IV Contrast There is insufficient literature to support the routine use of MRI without IV contrast as the initial examination for a soft tissue mass. The inherent limitations of this modality, most notably in the identification of mineralization, limit its use in isolation. CT Area of Interest With IV Contrast CT with IV contrast does not typically play a role in the initial evaluation of a superficial soft tissue mass. Soft Tissue Masses CT Area of Interest Without and With IV Contrast CT does not typically play a role in the initial evaluation of a superficial soft tissue mass. CT Area of Interest Without IV Contrast CT does not typically play a role in the initial evaluation of a superficial soft tissue mass. FDG-PET/CT Area of Interest There is insufficient literature to support the routine use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT for the initial evaluation of a soft tissue mass. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24]. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant fine needle aspiration.
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69434
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acrac_69434_4
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Soft Tissue Masses
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Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy or fine needle aspiration should be performed only after adequate imaging [24]. Variant 2: Nonsuperficial (deep) soft tissue mass. Initial imaging. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot. Radiography Area of Interest Initial imaging assessment of a suspected musculoskeletal soft tissue mass should almost invariably begin with radiographic evaluation and is advocated by ESMO-EURACAN [9]. Radiographs remain the modality best suited for the initial assessment of a suspected soft tissue mass and are the initial study of choice for orthopedic oncologists [25,26]. However, radiographs have limitations and may not reveal an abnormality when a mass is small, deep- seated, nonmineralized, or in an area with complex anatomy such as the flank, paraspinal region, groin, or deep soft tissues of the hands and feet [11]. US Area of Interest The diagnostic accuracy of US is considerably less when lesions outside the subcutaneous tissue are included. It is also less reliable for defining deep masses in large anatomical areas [27]. Although a recent prospective study of US accuracy in the characterization of 134 histologically proven deep soft tissue masses showed promising results, there were only a small number of malignancies in the study cohort, and the investigators had a high level of US expertise [28]. Therefore, US is most appropriate for superficial masses that are small (<5 cm) in size [13] but may be appropriate for deep soft tissue masses in specific settings, such as a deep mass in a thin patient.
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Soft Tissue Masses. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy or fine needle aspiration should be performed only after adequate imaging [24]. Variant 2: Nonsuperficial (deep) soft tissue mass. Initial imaging. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot. Radiography Area of Interest Initial imaging assessment of a suspected musculoskeletal soft tissue mass should almost invariably begin with radiographic evaluation and is advocated by ESMO-EURACAN [9]. Radiographs remain the modality best suited for the initial assessment of a suspected soft tissue mass and are the initial study of choice for orthopedic oncologists [25,26]. However, radiographs have limitations and may not reveal an abnormality when a mass is small, deep- seated, nonmineralized, or in an area with complex anatomy such as the flank, paraspinal region, groin, or deep soft tissues of the hands and feet [11]. US Area of Interest The diagnostic accuracy of US is considerably less when lesions outside the subcutaneous tissue are included. It is also less reliable for defining deep masses in large anatomical areas [27]. Although a recent prospective study of US accuracy in the characterization of 134 histologically proven deep soft tissue masses showed promising results, there were only a small number of malignancies in the study cohort, and the investigators had a high level of US expertise [28]. Therefore, US is most appropriate for superficial masses that are small (<5 cm) in size [13] but may be appropriate for deep soft tissue masses in specific settings, such as a deep mass in a thin patient.
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acrac_69434_5
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Soft Tissue Masses
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US Area of Interest With IV Contrast The diagnostic accuracy of US is considerably less when lesions outside the subcutaneous tissue are included. It is also less reliable for defining deep masses in large anatomical areas [27]. Although an assessment of diagnostic accuracy of US with IV contrast in the setting of a deep soft tissue mass is not available in the current literature, there is presumably no added benefit over standard grayscale and Doppler US. Therefore, the US with IV contrast is not useful for the initial assessment of deep soft tissue masses. MRI Area of Interest Without and With IV Contrast The current radiology, orthopedic oncology, and surgical oncology literature does not support the use of MRI without and with IV as the initial examination for a soft tissue mass. MRI Area of Interest Without IV Contrast The current radiology, orthopedic oncology, and surgical oncology literature does not support the use of MRI without IV contrast as the initial examination for a soft tissue mass. Soft Tissue Masses CT Area of Interest With IV Contrast CT with IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. For myositis ossificans, CT is superior to radiography in detecting the zonal pattern of mineralization, which is essential for early diagnosis [11].
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Soft Tissue Masses. US Area of Interest With IV Contrast The diagnostic accuracy of US is considerably less when lesions outside the subcutaneous tissue are included. It is also less reliable for defining deep masses in large anatomical areas [27]. Although an assessment of diagnostic accuracy of US with IV contrast in the setting of a deep soft tissue mass is not available in the current literature, there is presumably no added benefit over standard grayscale and Doppler US. Therefore, the US with IV contrast is not useful for the initial assessment of deep soft tissue masses. MRI Area of Interest Without and With IV Contrast The current radiology, orthopedic oncology, and surgical oncology literature does not support the use of MRI without and with IV as the initial examination for a soft tissue mass. MRI Area of Interest Without IV Contrast The current radiology, orthopedic oncology, and surgical oncology literature does not support the use of MRI without IV contrast as the initial examination for a soft tissue mass. Soft Tissue Masses CT Area of Interest With IV Contrast CT with IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. For myositis ossificans, CT is superior to radiography in detecting the zonal pattern of mineralization, which is essential for early diagnosis [11].
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69434
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acrac_69434_6
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Soft Tissue Masses
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In addition, CT allows for differentiation of soft tissue masses based on lesion density and can delineate vascular and bone involvement [29,30]. This differentiation may be better defined by immediately repeating the scan after contrast administration. During the assessment of cortical remodeling or invasion, the character of the interface between a soft tissue mass and the adjacent osseous cortex can usually be visualized to better advantage with CT compared to radiographs. CT Area of Interest Without and With IV Contrast CT without and with IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual- source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. For myositis ossificans, CT is superior to radiography in detecting the zonal pattern of mineralization, which is essential for early diagnosis [11]. In addition, CT allows for differentiation of soft tissue masses based on lesion density and can delineate vascular and bone involvement [29,30]. This differentiation may be better defined by immediately repeating the scan after contrast administration. During the assessment of cortical remodeling or invasion, the character of the interface between a soft tissue mass and the adjacent osseous cortex can usually be visualized to better advantage with CT compared to radiographs.
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Soft Tissue Masses. In addition, CT allows for differentiation of soft tissue masses based on lesion density and can delineate vascular and bone involvement [29,30]. This differentiation may be better defined by immediately repeating the scan after contrast administration. During the assessment of cortical remodeling or invasion, the character of the interface between a soft tissue mass and the adjacent osseous cortex can usually be visualized to better advantage with CT compared to radiographs. CT Area of Interest Without and With IV Contrast CT without and with IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual- source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. For myositis ossificans, CT is superior to radiography in detecting the zonal pattern of mineralization, which is essential for early diagnosis [11]. In addition, CT allows for differentiation of soft tissue masses based on lesion density and can delineate vascular and bone involvement [29,30]. This differentiation may be better defined by immediately repeating the scan after contrast administration. During the assessment of cortical remodeling or invasion, the character of the interface between a soft tissue mass and the adjacent osseous cortex can usually be visualized to better advantage with CT compared to radiographs.
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69434
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acrac_69434_7
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Soft Tissue Masses
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CT Area of Interest Without IV Contrast CT without IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. For myositis ossificans, CT is superior to radiography in detecting the zonal pattern of mineralization, which is essential for early diagnosis [11]. In addition, CT allows for differentiation of soft tissue masses based on lesion density and can delineate vascular and bone involvement [29,30]. This differentiation may be better defined by immediately repeating the scan after contrast administration. During the assessment of cortical remodeling or invasion, the character of the interface between a soft tissue mass and the adjacent osseous cortex can usually be visualized to better advantage with CT compared to radiographs. FDG-PET/CT Area of Interest FDG PET/CT does not typically play a role in the initial evaluation of a soft tissue mass. The CT component associated with PET/CT is of lower resolution compared with conventional CT and is not optimal for accurate characterization of soft tissue mineralization. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the initial examination for a soft tissue mass.
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Soft Tissue Masses. CT Area of Interest Without IV Contrast CT without IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. For myositis ossificans, CT is superior to radiography in detecting the zonal pattern of mineralization, which is essential for early diagnosis [11]. In addition, CT allows for differentiation of soft tissue masses based on lesion density and can delineate vascular and bone involvement [29,30]. This differentiation may be better defined by immediately repeating the scan after contrast administration. During the assessment of cortical remodeling or invasion, the character of the interface between a soft tissue mass and the adjacent osseous cortex can usually be visualized to better advantage with CT compared to radiographs. FDG-PET/CT Area of Interest FDG PET/CT does not typically play a role in the initial evaluation of a soft tissue mass. The CT component associated with PET/CT is of lower resolution compared with conventional CT and is not optimal for accurate characterization of soft tissue mineralization. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the initial examination for a soft tissue mass.
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69434
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acrac_69434_8
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Soft Tissue Masses
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At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the Soft Tissue Masses National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24]. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant fine needle aspiration. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy or fine needle aspiration should be performed only after adequate imaging [24]. Variant 3: Soft tissue mass. Nondiagnostic radiograph and noncontrast-enhanced ultrasound. Next imaging study. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot. Of note, this variant addresses the scenario in which radiographs and/or noncontrast US have been performed but did not sufficiently characterize a soft tissue mass. In addition, this variant presumes there are no contraindications to any imaging modality. Variant 4 specifically addresses the situation of a contraindication to MRI.
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Soft Tissue Masses. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the Soft Tissue Masses National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24]. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant fine needle aspiration. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy or fine needle aspiration should be performed only after adequate imaging [24]. Variant 3: Soft tissue mass. Nondiagnostic radiograph and noncontrast-enhanced ultrasound. Next imaging study. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot. Of note, this variant addresses the scenario in which radiographs and/or noncontrast US have been performed but did not sufficiently characterize a soft tissue mass. In addition, this variant presumes there are no contraindications to any imaging modality. Variant 4 specifically addresses the situation of a contraindication to MRI.
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69434
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acrac_69434_9
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Soft Tissue Masses
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CT Area of Interest With IV Contrast Although CT with IV contrast lacks the specificity afforded by MRI in many cases, it does provide useful staging data [32]. In a multi-institutional study of 133 patients with primary soft tissue malignancies, Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures. Therefore, CT with IV contrast remains an important adjunct in the evaluation of a soft tissue mass. The advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. Similar to CT without IV contrast [21, 22], virtual noncontrast imaging allows distinction of ossification from calcification and identification of characteristic patterns of mineralization [29,30] and is particularly useful in assessment of mass mineralization in areas where the osseous anatomy is complex or obscured and radiographs would be less sensitive. CT Area of Interest Without and With IV Contrast The advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. However, a traditional CT without and with IV contrast may be appropriate for characterization of mineralization in an anatomically complex area. Although a multi-institutional study of 133 patients with primary soft tissue malignancies by Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures, this study did not specifically endorse the usefulness of dual-phase CT without and with IV contrast.
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Soft Tissue Masses. CT Area of Interest With IV Contrast Although CT with IV contrast lacks the specificity afforded by MRI in many cases, it does provide useful staging data [32]. In a multi-institutional study of 133 patients with primary soft tissue malignancies, Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures. Therefore, CT with IV contrast remains an important adjunct in the evaluation of a soft tissue mass. The advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. Similar to CT without IV contrast [21, 22], virtual noncontrast imaging allows distinction of ossification from calcification and identification of characteristic patterns of mineralization [29,30] and is particularly useful in assessment of mass mineralization in areas where the osseous anatomy is complex or obscured and radiographs would be less sensitive. CT Area of Interest Without and With IV Contrast The advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. However, a traditional CT without and with IV contrast may be appropriate for characterization of mineralization in an anatomically complex area. Although a multi-institutional study of 133 patients with primary soft tissue malignancies by Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures, this study did not specifically endorse the usefulness of dual-phase CT without and with IV contrast.
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acrac_69434_10
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Soft Tissue Masses
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CT with IV contrast remains an important adjunct in the evaluation of a soft tissue mass. CT Area of Interest Without IV Contrast The literature does not support the use of single-phase CT without IV contrast as the next imaging study for the evaluation of a soft tissue mass. Although a multi-institutional study of 133 patients with primary soft tissue malignancies by Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures, this study did not endorse the usefulness of single-phase CT without IV contrast. MRI Area of Interest Without and With IV Contrast MRI without and with IV contrast is the technique of choice as the next imaging study for the evaluation of soft tissue masses. Its improved soft tissue contrast and multiplanar capability have provided significant advantages for lesion conspicuity, intrinsic tumor characterization, and local staging [3,11]. Vascular structures and neurovascular involvement are more easily defined when compared with CT. Soft Tissue Masses The use of MR contrast agents improves the differentiation of benign from malignant soft tissue masses [33]. The contrast allows for better demarcation between viable tumor and muscle, edema-like reactive change, hemorrhage, and tumor necrosis, as well as providing information on tumor vascularity. In addition to static MR contrast imaging, there are several additional modern MR techniques that provide greater insight into the character and behavior of soft tissue masses and can assist with differentiation of benign from malignant tumors. These include diffusion-weighted imaging [34-37], dynamic contrast-enhanced perfusion imaging [38,39], and MR spectroscopy [38,39]. Of note, chemical-shift imaging has not shown utility in differentiating benign from malignant soft tissue masses [40].
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Soft Tissue Masses. CT with IV contrast remains an important adjunct in the evaluation of a soft tissue mass. CT Area of Interest Without IV Contrast The literature does not support the use of single-phase CT without IV contrast as the next imaging study for the evaluation of a soft tissue mass. Although a multi-institutional study of 133 patients with primary soft tissue malignancies by Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures, this study did not endorse the usefulness of single-phase CT without IV contrast. MRI Area of Interest Without and With IV Contrast MRI without and with IV contrast is the technique of choice as the next imaging study for the evaluation of soft tissue masses. Its improved soft tissue contrast and multiplanar capability have provided significant advantages for lesion conspicuity, intrinsic tumor characterization, and local staging [3,11]. Vascular structures and neurovascular involvement are more easily defined when compared with CT. Soft Tissue Masses The use of MR contrast agents improves the differentiation of benign from malignant soft tissue masses [33]. The contrast allows for better demarcation between viable tumor and muscle, edema-like reactive change, hemorrhage, and tumor necrosis, as well as providing information on tumor vascularity. In addition to static MR contrast imaging, there are several additional modern MR techniques that provide greater insight into the character and behavior of soft tissue masses and can assist with differentiation of benign from malignant tumors. These include diffusion-weighted imaging [34-37], dynamic contrast-enhanced perfusion imaging [38,39], and MR spectroscopy [38,39]. Of note, chemical-shift imaging has not shown utility in differentiating benign from malignant soft tissue masses [40].
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69434
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acrac_69434_11
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Soft Tissue Masses
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However, the Dixon technique will likely be increasingly recognized as beneficial for soft tissue tumor imaging through its potential to provide more homogenous fat suppression when compared to traditional T2-fat saturated imaging and better resolution than inversion recovery imaging. Furthermore, it may help decrease imaging time because the Dixon water-only and fat- only images are acquired simultaneously [41,42]. MRI Area of Interest Without IV Contrast MRI without IV contrast may be beneficial as the next imaging study for the evaluation of soft tissue masses. Its improved soft tissue contrast and multiplanar capability have provided significant advantages for lesion conspicuity, intrinsic tumor characterization, and local staging [3,11]. Vascular structures and neurovascular involvement are more easily defined when compared with CT. The use of MR contrast agents improves the differentiation of benign from malignant soft tissue masses [33]. The contrast allows for better demarcation between viable tumor and muscle, edema-like reactive change, hemorrhage, and tumor necrosis, as well as providing information on tumor vascularity. In addition to static MR contrast imaging, there are several additional modern MR techniques that provide greater insight into the character and behavior of soft tissue masses and can assist with differentiation of benign from malignant tumors. These include diffusion-weighted imaging [34-37], dynamic contrast-enhanced perfusion imaging [38,39], and MR spectroscopy [38,39]. Of note, chemical-shift imaging has not shown utility in differentiating benign from malignant soft tissue masses [40]. However, the Dixon technique will likely be increasingly recognized as beneficial for soft tissue tumor imaging through its potential to provide more homogenous fat suppression when compared to traditional T2-fat saturated imaging and better resolution than inversion recovery imaging.
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Soft Tissue Masses. However, the Dixon technique will likely be increasingly recognized as beneficial for soft tissue tumor imaging through its potential to provide more homogenous fat suppression when compared to traditional T2-fat saturated imaging and better resolution than inversion recovery imaging. Furthermore, it may help decrease imaging time because the Dixon water-only and fat- only images are acquired simultaneously [41,42]. MRI Area of Interest Without IV Contrast MRI without IV contrast may be beneficial as the next imaging study for the evaluation of soft tissue masses. Its improved soft tissue contrast and multiplanar capability have provided significant advantages for lesion conspicuity, intrinsic tumor characterization, and local staging [3,11]. Vascular structures and neurovascular involvement are more easily defined when compared with CT. The use of MR contrast agents improves the differentiation of benign from malignant soft tissue masses [33]. The contrast allows for better demarcation between viable tumor and muscle, edema-like reactive change, hemorrhage, and tumor necrosis, as well as providing information on tumor vascularity. In addition to static MR contrast imaging, there are several additional modern MR techniques that provide greater insight into the character and behavior of soft tissue masses and can assist with differentiation of benign from malignant tumors. These include diffusion-weighted imaging [34-37], dynamic contrast-enhanced perfusion imaging [38,39], and MR spectroscopy [38,39]. Of note, chemical-shift imaging has not shown utility in differentiating benign from malignant soft tissue masses [40]. However, the Dixon technique will likely be increasingly recognized as beneficial for soft tissue tumor imaging through its potential to provide more homogenous fat suppression when compared to traditional T2-fat saturated imaging and better resolution than inversion recovery imaging.
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69434
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acrac_69434_12
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Soft Tissue Masses
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Furthermore, it may help decrease imaging time because the Dixon water-only and fat- only images are acquired simultaneously [41,42]. FDG-PET/CT Area of Interest As a general rule, PET/CT imaging maximum standard uptake value can be useful for differentiating between benign and malignant musculoskeletal masses. When combined with anatomic data provided by CT, FDG-PET/CT can be useful in distinguishing aggressive soft tissue tumors from benign lesions [43-45]. Benz et al [46] showed that FDG-PET can be used to determine a tumor glycolytic phenotype in sarcomas, which correlates significantly with histologic grade. Fused FDG-PET/CT images can be used to plan biopsy, targeting areas with more metabolic activity that may give higher diagnostic yield. Furthermore, a meta-analysis found that FDG-PET can be a helpful tool for predicting outcome in patients with soft tissue sarcoma [47]. Lastly, FDG-PET/CT is an excellent modality to detect metastatic disease and assess treatment response [48]. Despite these benefits, FDG-PET/CT does not usually play a role as the next imaging study for the characterization of a soft tissue mass when initial radiographs or US are nondiagnostic. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24].
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Soft Tissue Masses. Furthermore, it may help decrease imaging time because the Dixon water-only and fat- only images are acquired simultaneously [41,42]. FDG-PET/CT Area of Interest As a general rule, PET/CT imaging maximum standard uptake value can be useful for differentiating between benign and malignant musculoskeletal masses. When combined with anatomic data provided by CT, FDG-PET/CT can be useful in distinguishing aggressive soft tissue tumors from benign lesions [43-45]. Benz et al [46] showed that FDG-PET can be used to determine a tumor glycolytic phenotype in sarcomas, which correlates significantly with histologic grade. Fused FDG-PET/CT images can be used to plan biopsy, targeting areas with more metabolic activity that may give higher diagnostic yield. Furthermore, a meta-analysis found that FDG-PET can be a helpful tool for predicting outcome in patients with soft tissue sarcoma [47]. Lastly, FDG-PET/CT is an excellent modality to detect metastatic disease and assess treatment response [48]. Despite these benefits, FDG-PET/CT does not usually play a role as the next imaging study for the characterization of a soft tissue mass when initial radiographs or US are nondiagnostic. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24].
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Soft Tissue Masses
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Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and Soft Tissue Masses thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24]. US Area of Interest With IV Contrast Although prospective studies have emerged suggesting that US is accurate in the discrimination of benign from malignant soft tissue masses, the number of malignancies in these studies was limited [16,28]. Therefore, the use of US for the final evaluation and staging of a deep soft tissue mass is not recommended. Variant 4: Soft tissue mass. Nondiagnostic radiograph and noncontrast-enhanced ultrasound. MRI contraindicated. Next imaging study. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot. CT Area of Interest With IV Contrast CT has become a useful technique for the evaluation of patients who cannot undergo MRI and is the modality of choice in this scenario [29]. In the evaluation of suspected tumors, contrast imaging is especially useful in distinguishing vascularized from potentially necrotic regions of the tumor. With modern CT technology, calcification can usually be distinguished from vascular enhancement. Of note, dual-energy CT is a relatively newer technology that has shown utility in evaluation of soft tissue masses.
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Soft Tissue Masses. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and Soft Tissue Masses thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24]. US Area of Interest With IV Contrast Although prospective studies have emerged suggesting that US is accurate in the discrimination of benign from malignant soft tissue masses, the number of malignancies in these studies was limited [16,28]. Therefore, the use of US for the final evaluation and staging of a deep soft tissue mass is not recommended. Variant 4: Soft tissue mass. Nondiagnostic radiograph and noncontrast-enhanced ultrasound. MRI contraindicated. Next imaging study. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot. CT Area of Interest With IV Contrast CT has become a useful technique for the evaluation of patients who cannot undergo MRI and is the modality of choice in this scenario [29]. In the evaluation of suspected tumors, contrast imaging is especially useful in distinguishing vascularized from potentially necrotic regions of the tumor. With modern CT technology, calcification can usually be distinguished from vascular enhancement. Of note, dual-energy CT is a relatively newer technology that has shown utility in evaluation of soft tissue masses.
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acrac_69434_14
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Soft Tissue Masses
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Using the differences in energy attenuation of soft tissue at 80 kVp and 140 kVp, this technique can allow reconstruction of virtual noncontrast CT images as well as significantly reduce metal artifact in the assessment of metal implants, improving the diagnostic value of imaging in the surrounding soft tissues [49,50]. It has also shown application in the assessment of marrow edema [51,52] and has been investigated in the distinction of marrow edema from intramedullary tumor invasion [53]. Furthermore, spectral CT is emerging as a useful tool for distinguishing benign from malignant soft tissue masses [54]. CT Area of Interest Without and With IV Contrast Dual-phase CT without and with IV contrast as the next imaging study for the evaluation of a soft tissue mass may be appropriate when MRI is contraindicated. Although single-phase CT with IV contrast is considered most appropriate in this clinical scenario given the advent of virtual noncontrast reconstruction with modern dual-source CT scanners [31], a traditional CT without and with IV contrast can be helpful for characterization of mineralization in an anatomically complex area. CT Area of Interest Without IV Contrast The literature does not support the use of a single-phase CT without IV contrast as the next imaging study for the evaluation of a soft tissue mass when MRI is contraindicated. However, single-phase CT with IV contrast is a useful technique for the evaluation of patients who cannot undergo MRI and is the modality of choice in this scenario [29]. In the evaluation of suspected tumors, contrast imaging is especially useful in distinguishing vascularized from potentially necrotic regions of the tumor. With modern CT technology, calcification can usually be distinguished from vascular enhancement. Therefore, CT without IV contrast is usually not beneficial.
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Soft Tissue Masses. Using the differences in energy attenuation of soft tissue at 80 kVp and 140 kVp, this technique can allow reconstruction of virtual noncontrast CT images as well as significantly reduce metal artifact in the assessment of metal implants, improving the diagnostic value of imaging in the surrounding soft tissues [49,50]. It has also shown application in the assessment of marrow edema [51,52] and has been investigated in the distinction of marrow edema from intramedullary tumor invasion [53]. Furthermore, spectral CT is emerging as a useful tool for distinguishing benign from malignant soft tissue masses [54]. CT Area of Interest Without and With IV Contrast Dual-phase CT without and with IV contrast as the next imaging study for the evaluation of a soft tissue mass may be appropriate when MRI is contraindicated. Although single-phase CT with IV contrast is considered most appropriate in this clinical scenario given the advent of virtual noncontrast reconstruction with modern dual-source CT scanners [31], a traditional CT without and with IV contrast can be helpful for characterization of mineralization in an anatomically complex area. CT Area of Interest Without IV Contrast The literature does not support the use of a single-phase CT without IV contrast as the next imaging study for the evaluation of a soft tissue mass when MRI is contraindicated. However, single-phase CT with IV contrast is a useful technique for the evaluation of patients who cannot undergo MRI and is the modality of choice in this scenario [29]. In the evaluation of suspected tumors, contrast imaging is especially useful in distinguishing vascularized from potentially necrotic regions of the tumor. With modern CT technology, calcification can usually be distinguished from vascular enhancement. Therefore, CT without IV contrast is usually not beneficial.
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69434
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acrac_69434_15
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Soft Tissue Masses
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FDG-PET/CT Area of Interest Although FDG-PET/CT is not typically used as the next imaging study for the characterization of a soft tissue mass, PET/CT imaging maximum standard uptake value can be useful for differentiating between benign and malignant musculoskeletal masses. When combined with anatomic data provided by CT, FDG-PET/CT can be useful in distinguishing aggressive soft tissue tumors from benign lesions [43-45]. Benz et al [46] showed that FDG-PET can be used to determine a tumor glycolytic phenotype in sarcomas, which correlates significantly with histologic grade. Fused FDG-PET/CT images can be used to plan biopsy, targeting areas with more metabolic activity that may give higher diagnostic yield. Furthermore, a meta-analysis found that FDG-PET can be a helpful tool for predicting outcome in patients with soft tissue sarcoma [47]. Lastly, FDG-PET/CT is an excellent modality to detect metastatic disease and assess treatment response [48]. Despite these benefits, FDG-PET/CT does not usually play a role in the initial assessment of a soft tissue mass. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. If MRI is contraindicated, characterization of the mass using Soft Tissue Masses CT with IV contrast should routinely be performed before biopsy [29]. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24]. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. If MRI is contraindicated, characterization of the mass using CT with IV contrast should routinely be performed before biopsy [29].
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Soft Tissue Masses. FDG-PET/CT Area of Interest Although FDG-PET/CT is not typically used as the next imaging study for the characterization of a soft tissue mass, PET/CT imaging maximum standard uptake value can be useful for differentiating between benign and malignant musculoskeletal masses. When combined with anatomic data provided by CT, FDG-PET/CT can be useful in distinguishing aggressive soft tissue tumors from benign lesions [43-45]. Benz et al [46] showed that FDG-PET can be used to determine a tumor glycolytic phenotype in sarcomas, which correlates significantly with histologic grade. Fused FDG-PET/CT images can be used to plan biopsy, targeting areas with more metabolic activity that may give higher diagnostic yield. Furthermore, a meta-analysis found that FDG-PET can be a helpful tool for predicting outcome in patients with soft tissue sarcoma [47]. Lastly, FDG-PET/CT is an excellent modality to detect metastatic disease and assess treatment response [48]. Despite these benefits, FDG-PET/CT does not usually play a role in the initial assessment of a soft tissue mass. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. If MRI is contraindicated, characterization of the mass using Soft Tissue Masses CT with IV contrast should routinely be performed before biopsy [29]. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24]. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. If MRI is contraindicated, characterization of the mass using CT with IV contrast should routinely be performed before biopsy [29].
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69434
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acrac_3163055_0
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Staging and Follow up of Esophageal Cancer
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Introduction/Background Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer death worldwide. The American Cancer Society estimates there will be 19,260 new cases of and 15,530 deaths from esophageal cancer in the United States in 2021 [1]. Squamous cell carcinoma and adenocarcinoma comprise 98% of malignant tumors of the esophagus. Worldwide, squamous cell carcinoma is still more common, but in Western countries, adenocarcinoma now predominates and accounts for more than 60% of cases. In general, squamous cell carcinoma usually occurs in the upper and middle esophagus, whereas adenocarcinoma predominates in the lower esophagus [2]. For esophageal cancers, initial clinical staging uses a combination of imaging modalities with biopsies used to confirm suspected sites of disease. Specific strategies for the evaluation of the patient with esophageal cancer vary by institution not only in terms of the modalities used but in the order in which they are used. One common strategy is initial esophagogastroduodenoscopy and esophageal ultrasound (US) to determine cell type, grade, local extent, and locoregional nodal involvement followed by fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT to provide additional information on nodal disease and to evaluate for distant metastases. Another common strategy involves using CT or FDG-PET/CT first to evaluate for findings of metastatic disease. If metastatic disease is found, further evaluation with esophagogastroduodenoscopy and esophageal US may not be warranted [3]. The identification of distant metastatic disease is critical in the evaluation of the patient with newly diagnosed esophageal cancer because it will direct them to a treatment pathway centered on palliative chemoradiation rather than surgery. A secondary concern is the confirmation of locoregional spread because this is often an important determinant in whether neoadjuvant chemoradiation is used.
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Staging and Follow up of Esophageal Cancer. Introduction/Background Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer death worldwide. The American Cancer Society estimates there will be 19,260 new cases of and 15,530 deaths from esophageal cancer in the United States in 2021 [1]. Squamous cell carcinoma and adenocarcinoma comprise 98% of malignant tumors of the esophagus. Worldwide, squamous cell carcinoma is still more common, but in Western countries, adenocarcinoma now predominates and accounts for more than 60% of cases. In general, squamous cell carcinoma usually occurs in the upper and middle esophagus, whereas adenocarcinoma predominates in the lower esophagus [2]. For esophageal cancers, initial clinical staging uses a combination of imaging modalities with biopsies used to confirm suspected sites of disease. Specific strategies for the evaluation of the patient with esophageal cancer vary by institution not only in terms of the modalities used but in the order in which they are used. One common strategy is initial esophagogastroduodenoscopy and esophageal ultrasound (US) to determine cell type, grade, local extent, and locoregional nodal involvement followed by fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT to provide additional information on nodal disease and to evaluate for distant metastases. Another common strategy involves using CT or FDG-PET/CT first to evaluate for findings of metastatic disease. If metastatic disease is found, further evaluation with esophagogastroduodenoscopy and esophageal US may not be warranted [3]. The identification of distant metastatic disease is critical in the evaluation of the patient with newly diagnosed esophageal cancer because it will direct them to a treatment pathway centered on palliative chemoradiation rather than surgery. A secondary concern is the confirmation of locoregional spread because this is often an important determinant in whether neoadjuvant chemoradiation is used.
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3163055
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acrac_3163055_1
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Staging and Follow up of Esophageal Cancer
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If neoadjuvant chemoradiation is employed, follow- up imaging before definitive surgical treatment is necessary. Although the utility of follow-up imaging, particularly FDG-PET/CT, is of debate during and after neoadjuvant therapy to predict response, it does have a critical role in evaluating for the interval development of distant metastases and is commonly used for this purpose. OR aMallinckrodt Institute of Radiology, Saint Louis, Missouri. bUMass Medical School, Worcester, Massachusetts. cPanel Chair, Duke University, Durham, North Carolina. dPanel Chair, University of Alabama Medical Center, Birmingham, Alabama. eThe University of Chicago, Chicago, Illinois; American Society of Clinical Oncology. fEmory University Hospital, Atlanta, Georgia. gHampton VA Medical Center, Hampton, Virginia. hUniversity of California San Francisco, San Francisco, California, Hospitalist. iUniversity of Michigan Health System, Ann Arbor, Michigan. jUniversity of North Carolina Hospital, Chapel Hill, North Carolina; The Society of Thoracic Surgeons. kUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. lUniversity of Arizona College of Medicine, Phoenix, Arizona. mVanderbilt University Medical Center, Nashville, Tennessee. nNational Institutes of Health, Bethesda, Maryland. oThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. pDavid Grant Medical Center, Travis AFB, California. qSpecialty Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. rSpecialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio. 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.
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Staging and Follow up of Esophageal Cancer. If neoadjuvant chemoradiation is employed, follow- up imaging before definitive surgical treatment is necessary. Although the utility of follow-up imaging, particularly FDG-PET/CT, is of debate during and after neoadjuvant therapy to predict response, it does have a critical role in evaluating for the interval development of distant metastases and is commonly used for this purpose. OR aMallinckrodt Institute of Radiology, Saint Louis, Missouri. bUMass Medical School, Worcester, Massachusetts. cPanel Chair, Duke University, Durham, North Carolina. dPanel Chair, University of Alabama Medical Center, Birmingham, Alabama. eThe University of Chicago, Chicago, Illinois; American Society of Clinical Oncology. fEmory University Hospital, Atlanta, Georgia. gHampton VA Medical Center, Hampton, Virginia. hUniversity of California San Francisco, San Francisco, California, Hospitalist. iUniversity of Michigan Health System, Ann Arbor, Michigan. jUniversity of North Carolina Hospital, Chapel Hill, North Carolina; The Society of Thoracic Surgeons. kUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. lUniversity of Arizona College of Medicine, Phoenix, Arizona. mVanderbilt University Medical Center, Nashville, Tennessee. nNational Institutes of Health, Bethesda, Maryland. oThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. pDavid Grant Medical Center, Travis AFB, California. qSpecialty Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. rSpecialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio. 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.
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3163055
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acrac_3163055_2
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Staging and Follow up of Esophageal Cancer
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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] Staging and Follow-up of Esophageal Cancer Discussion of Procedures by Variant Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with intravenous (IV) contrast. There is no relevant literature supporting the use of CT for evaluation of the extent of tumor extension into the esophageal wall in T1 to T3 tumors. There are, however, older studies that investigated the use of CT for the evaluation of extension into adjacent structures. Picus et al [4] reviewed CT examinations in 52 patients with esophageal carcinoma, 30 of whom had surgery or autopsy, and found that CT appearance correctly determined aortic involvement in 24 of 25 cases, with 5 indeterminate. Takashima et al [5] prospectively reviewed CT examinations on 35 patients and the reported sensitivity, specificity, and accuracy for resectability (defined as absence of evidence of invasion of adjacent structures) to be 100%, 80%, and 84%, respectively. A meta-analysis by Puli et al [6] reviewed data from 49 studies and 2,558 patients and reported pooled sensitivity and specificity of 92.4% and 97.4%, respectively, in the diagnosis of T4 disease. Unlike CT, esophageal US can also evaluate wall involvement of lower T stage tumors, with the meta-analysis by Puli et al [6] reporting sensitivity and specificity for T1 tumors of 81.6% and 99.4%, T2 tumors of 81% and 96%, and T3 tumors of 91.4% and 94.4%, respectively. There is no relevant literature supporting the use of CT for nodal staging.
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Staging and Follow up of Esophageal Cancer. 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] Staging and Follow-up of Esophageal Cancer Discussion of Procedures by Variant Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with intravenous (IV) contrast. There is no relevant literature supporting the use of CT for evaluation of the extent of tumor extension into the esophageal wall in T1 to T3 tumors. There are, however, older studies that investigated the use of CT for the evaluation of extension into adjacent structures. Picus et al [4] reviewed CT examinations in 52 patients with esophageal carcinoma, 30 of whom had surgery or autopsy, and found that CT appearance correctly determined aortic involvement in 24 of 25 cases, with 5 indeterminate. Takashima et al [5] prospectively reviewed CT examinations on 35 patients and the reported sensitivity, specificity, and accuracy for resectability (defined as absence of evidence of invasion of adjacent structures) to be 100%, 80%, and 84%, respectively. A meta-analysis by Puli et al [6] reviewed data from 49 studies and 2,558 patients and reported pooled sensitivity and specificity of 92.4% and 97.4%, respectively, in the diagnosis of T4 disease. Unlike CT, esophageal US can also evaluate wall involvement of lower T stage tumors, with the meta-analysis by Puli et al [6] reporting sensitivity and specificity for T1 tumors of 81.6% and 99.4%, T2 tumors of 81% and 96%, and T3 tumors of 91.4% and 94.4%, respectively. There is no relevant literature supporting the use of CT for nodal staging.
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3163055
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acrac_3163055_3
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Staging and Follow up of Esophageal Cancer
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A study by Choi et al [7], which prospectively evaluated 109 patients with esophageal cancer, used a short-axis diameter of 8 mm for the determination of positive nodes and reported a sensitivity of 35% and specificity of 93% for CT. CT is limited in the evaluation of nodal metastatic disease because multiple studies have shown that nodal metastases often occur in small lymph nodes in patients with esophageal cancer. Foley et al [8] evaluated 112 patients with multiple modalities and reported an accuracy of 54.5%, a sensitivity of 55.4%, a sensitivity of 39.7%, and a specificity of 77.4% for CT. Foley et al [8] also reported that 82% of positive lymph nodes measured <6 mm. Similarly, Kajiyama et al [9] reported that two-thirds of 320 metastatic lymph nodes assessed by surgery were <5 mm, further reinforcing that preoperative anatomic imaging evaluation will have a limited role in the detection of nodal metastatic disease. In terms of clinical relevance, Bunting et al [10] prospectively studied 133 patients undergoing surgery and reported an N stage accuracy of 75.6%. Their conclusion was that staging accuracy of locoregional disease with respect to the neoadjuvant threshold was poor with all modalities, including CT, and could potentially lead to over- and undertreatment. The principle use of CT in the initial evaluation of patients with esophageal cancer is in detecting metastatic disease. CT has been compared with PET and FDG-PET/CT by several authors. Heeren et al [11] compared combined CT/esophageal US with PET and reported that sensitivity for distant nodal and systemic metastatic disease increased from 37% with CT/esophageal US to 78% with PET. Similarly, Hocazade et al [12] prospectively evaluated 91 patients with PET/CT and CT and reported that 47.3% of patients had metastases detected on PET/CT that were not detected by CT.
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Staging and Follow up of Esophageal Cancer. A study by Choi et al [7], which prospectively evaluated 109 patients with esophageal cancer, used a short-axis diameter of 8 mm for the determination of positive nodes and reported a sensitivity of 35% and specificity of 93% for CT. CT is limited in the evaluation of nodal metastatic disease because multiple studies have shown that nodal metastases often occur in small lymph nodes in patients with esophageal cancer. Foley et al [8] evaluated 112 patients with multiple modalities and reported an accuracy of 54.5%, a sensitivity of 55.4%, a sensitivity of 39.7%, and a specificity of 77.4% for CT. Foley et al [8] also reported that 82% of positive lymph nodes measured <6 mm. Similarly, Kajiyama et al [9] reported that two-thirds of 320 metastatic lymph nodes assessed by surgery were <5 mm, further reinforcing that preoperative anatomic imaging evaluation will have a limited role in the detection of nodal metastatic disease. In terms of clinical relevance, Bunting et al [10] prospectively studied 133 patients undergoing surgery and reported an N stage accuracy of 75.6%. Their conclusion was that staging accuracy of locoregional disease with respect to the neoadjuvant threshold was poor with all modalities, including CT, and could potentially lead to over- and undertreatment. The principle use of CT in the initial evaluation of patients with esophageal cancer is in detecting metastatic disease. CT has been compared with PET and FDG-PET/CT by several authors. Heeren et al [11] compared combined CT/esophageal US with PET and reported that sensitivity for distant nodal and systemic metastatic disease increased from 37% with CT/esophageal US to 78% with PET. Similarly, Hocazade et al [12] prospectively evaluated 91 patients with PET/CT and CT and reported that 47.3% of patients had metastases detected on PET/CT that were not detected by CT.
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3163055
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acrac_3163055_4
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Staging and Follow up of Esophageal Cancer
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Thus, although CT can detect metastases in the setting of esophageal cancer, it has been found to be less sensitive than PET and FDG-PET/CT even when combined with esophageal US. The described literature presented here is based on contrast-enhanced CT. There are no reliable studies reporting the use of CT without IV contrast. When CT is used in the initial staging of esophageal cancer, contrast is recommended for optimal performance. CT Chest, Abdomen, and Pelvis For the purposes of this document, CT examinations are considered as being performed with IV contrast. Including the pelvis in CT for esophageal cancer would not affect the performance of CT for locoregional staging. The studies presented above by Heeren et al [11] and Hocazade et al [12] for the evaluation of systemic metastatic disease used CT of the chest and abdomen only. There are no studies that directly compare CT of the chest and abdomen with CT of the chest, abdomen, and pelvis; thus, the utility or added value of including the pelvis for the initial staging of esophageal cancer is not known. FDG-PET/CT Skull Base to Mid-Thigh Although there have been many studies evaluating the use of FDG-PET/CT in the evaluation of the primary tumor for prognosis, data supporting its use for T and N staging are limited. Walker et al [13] prospectively evaluated 81 patients with esophageal cancer with FDG-PET/CT and esophageal US and determined that esophageal US was superior to FDG-PET/CT for T staging and identifying locoregional lymph nodes. Hsu et al [14] investigated the use of PET/CT in 45 patients undergoing surgical resection for esophageal cancer and found that the maximum standardized uptake value (SUV)max showed potential in differentiating T1 from higher T stage tumors. In the same Staging and Follow-up of Esophageal Cancer study, however, the sensitivity, specificity, and accuracy of PET/CT for nodal involvement were 57.1%, 83.3%, and 71.1%, respectively.
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Staging and Follow up of Esophageal Cancer. Thus, although CT can detect metastases in the setting of esophageal cancer, it has been found to be less sensitive than PET and FDG-PET/CT even when combined with esophageal US. The described literature presented here is based on contrast-enhanced CT. There are no reliable studies reporting the use of CT without IV contrast. When CT is used in the initial staging of esophageal cancer, contrast is recommended for optimal performance. CT Chest, Abdomen, and Pelvis For the purposes of this document, CT examinations are considered as being performed with IV contrast. Including the pelvis in CT for esophageal cancer would not affect the performance of CT for locoregional staging. The studies presented above by Heeren et al [11] and Hocazade et al [12] for the evaluation of systemic metastatic disease used CT of the chest and abdomen only. There are no studies that directly compare CT of the chest and abdomen with CT of the chest, abdomen, and pelvis; thus, the utility or added value of including the pelvis for the initial staging of esophageal cancer is not known. FDG-PET/CT Skull Base to Mid-Thigh Although there have been many studies evaluating the use of FDG-PET/CT in the evaluation of the primary tumor for prognosis, data supporting its use for T and N staging are limited. Walker et al [13] prospectively evaluated 81 patients with esophageal cancer with FDG-PET/CT and esophageal US and determined that esophageal US was superior to FDG-PET/CT for T staging and identifying locoregional lymph nodes. Hsu et al [14] investigated the use of PET/CT in 45 patients undergoing surgical resection for esophageal cancer and found that the maximum standardized uptake value (SUV)max showed potential in differentiating T1 from higher T stage tumors. In the same Staging and Follow-up of Esophageal Cancer study, however, the sensitivity, specificity, and accuracy of PET/CT for nodal involvement were 57.1%, 83.3%, and 71.1%, respectively.
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3163055
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acrac_3163055_5
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Staging and Follow up of Esophageal Cancer
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Foley et al [8] also reported sensitivity, specificity, and accuracy of FDG-PET/CT of 77.3%, 75%, and 90.9%, respectively, for nodal involvement in a prospective study of 112 patients with esophageal cancer. Given that 82% of lymph node metastases were <6 mm in this study, the authors concluded that imaging staging for N disease was poor. Bunting et al [10] prospectively evaluated 133 patients with esophageal cancer undergoing surgery and reported an N stage accuracy of 78.6% for FDG-PET/CT. Bunting et al [10] also concluded that staging accuracy with respect to the threshold for treatment for neoadjuvant chemoradiation was poor and could lead to over- and undertreatment. A meta-analysis by van Westreenen et al [15] reported pooled sensitivity of 51% and specificity of 84% for FDG-PET/CT for locoregional metastases. Limited performance of FDG-PET/CT in locoregional staging is likely due to poor spatial resolution of PET and the reality that metastatic lymph nodes in esophageal cancer are often small. Even some primary tumors may not be detected with FDG-PET/CT either because of small size or in histologic subtypes with low FDG uptake [2]. There are many studies that have evaluated the use of FDG-PET/CT in detecting M disease in initial staging. Heeren et al [11] investigated 74 patients with FDG-PET/CT and found that FDG-PET/CT increased detection of M1 disease from 37% to 78% in comparison with CT/esophageal US. Vyas et al [16] prospectively investigated 114 patients with biopsy-proven esophageal adenocarcinoma and reported a sensitivity of 57.14% and specificity of 84.53% in detecting metastatic disease. A larger meta-analysis by van Westreenen et al [15] reported a pooled sensitivity and specificity for FDG-PET/CT of 67% and 97%, respectively, in the detection of M1 disease in esophageal cancer.
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Staging and Follow up of Esophageal Cancer. Foley et al [8] also reported sensitivity, specificity, and accuracy of FDG-PET/CT of 77.3%, 75%, and 90.9%, respectively, for nodal involvement in a prospective study of 112 patients with esophageal cancer. Given that 82% of lymph node metastases were <6 mm in this study, the authors concluded that imaging staging for N disease was poor. Bunting et al [10] prospectively evaluated 133 patients with esophageal cancer undergoing surgery and reported an N stage accuracy of 78.6% for FDG-PET/CT. Bunting et al [10] also concluded that staging accuracy with respect to the threshold for treatment for neoadjuvant chemoradiation was poor and could lead to over- and undertreatment. A meta-analysis by van Westreenen et al [15] reported pooled sensitivity of 51% and specificity of 84% for FDG-PET/CT for locoregional metastases. Limited performance of FDG-PET/CT in locoregional staging is likely due to poor spatial resolution of PET and the reality that metastatic lymph nodes in esophageal cancer are often small. Even some primary tumors may not be detected with FDG-PET/CT either because of small size or in histologic subtypes with low FDG uptake [2]. There are many studies that have evaluated the use of FDG-PET/CT in detecting M disease in initial staging. Heeren et al [11] investigated 74 patients with FDG-PET/CT and found that FDG-PET/CT increased detection of M1 disease from 37% to 78% in comparison with CT/esophageal US. Vyas et al [16] prospectively investigated 114 patients with biopsy-proven esophageal adenocarcinoma and reported a sensitivity of 57.14% and specificity of 84.53% in detecting metastatic disease. A larger meta-analysis by van Westreenen et al [15] reported a pooled sensitivity and specificity for FDG-PET/CT of 67% and 97%, respectively, in the detection of M1 disease in esophageal cancer.
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3163055
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acrac_3163055_6
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Staging and Follow up of Esophageal Cancer
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In terms of effects on clinical staging, You et al [17] prospectively evaluated 491 patients with esophageal cancer with FDG-PET/CT and reported clinically important stage changes in 188 (24%) patients. In a smaller cohort, Williams et al [18] reported the use of FDG-PET/CT changing initial staging in 10 of 38 (26%) patients with esophageal cancer, with 7 of 38 (18%) patients having a concomitant management change. FDG-PET/MRI Skull Base to Mid-Thigh There are no substantial data supporting the use of FDG-PET/MRI in the staging of esophageal cancer. In a small study evaluating 19 patients with esophageal cancer who underwent esophageal US, CT, FDG-PET/CT, and FDG- PET/MRI, Lee et al [19] reported acceptable T staging compared with esophageal US and statistically nonsignificant but higher accuracy than esophageal US and FDG-PET/CT for N staging. Impact on M staging was not reported. Given available data on the performance of FDG-PET/CT in the evaluation of M disease, it would be expected that FDG-PET/MRI may have similar potential, but data supporting its use are not yet available. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper gastrointestinal (GI) series in the staging of esophageal cancer. MRI Chest and Abdomen There is only limited evidence supporting the use of MRI chest and abdomen in the evaluation of patients with esophageal cancer. Giganti et al [20] compared MRI, CT, esophageal US, and FDG-PET/CT in 27 patients with esophageal cancer. In this small study, contrast-enhanced MRI with diffusion-weighted imaging showed higher specificity (92%) and accuracy (82%) for T staging, but esophageal US was the most sensitive modality. MRI showed the highest reported accuracy for N stage (66%) in this study, although this would be in line with values previously determined for other imaging modalities.
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Staging and Follow up of Esophageal Cancer. In terms of effects on clinical staging, You et al [17] prospectively evaluated 491 patients with esophageal cancer with FDG-PET/CT and reported clinically important stage changes in 188 (24%) patients. In a smaller cohort, Williams et al [18] reported the use of FDG-PET/CT changing initial staging in 10 of 38 (26%) patients with esophageal cancer, with 7 of 38 (18%) patients having a concomitant management change. FDG-PET/MRI Skull Base to Mid-Thigh There are no substantial data supporting the use of FDG-PET/MRI in the staging of esophageal cancer. In a small study evaluating 19 patients with esophageal cancer who underwent esophageal US, CT, FDG-PET/CT, and FDG- PET/MRI, Lee et al [19] reported acceptable T staging compared with esophageal US and statistically nonsignificant but higher accuracy than esophageal US and FDG-PET/CT for N staging. Impact on M staging was not reported. Given available data on the performance of FDG-PET/CT in the evaluation of M disease, it would be expected that FDG-PET/MRI may have similar potential, but data supporting its use are not yet available. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper gastrointestinal (GI) series in the staging of esophageal cancer. MRI Chest and Abdomen There is only limited evidence supporting the use of MRI chest and abdomen in the evaluation of patients with esophageal cancer. Giganti et al [20] compared MRI, CT, esophageal US, and FDG-PET/CT in 27 patients with esophageal cancer. In this small study, contrast-enhanced MRI with diffusion-weighted imaging showed higher specificity (92%) and accuracy (82%) for T staging, but esophageal US was the most sensitive modality. MRI showed the highest reported accuracy for N stage (66%) in this study, although this would be in line with values previously determined for other imaging modalities.
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3163055
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acrac_3163055_7
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Staging and Follow up of Esophageal Cancer
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Qu et al [21] prospectively evaluated the use of contrast- enhanced radial VIBE sequences in the T staging of 43 patients with esophageal cancer and determined higher accuracy with MRI for T3 and T4 tumors. Malik et al [22] compared FDG-PET/CT and whole-body MRI in 49 patients, reporting similar performance for locoregional staging. Both modalities identified distant metastases that were present in 2 of the patients. Radiography Chest There is no relevant literature to support the use of chest radiography in the initial staging of patients with esophageal cancer. Variant 2: Esophageal cancer. Imaging during treatment. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. There is no relevant literature supporting the use of CT in patients who have undergone neoadjuvant chemoradiation. There Staging and Follow-up of Esophageal Cancer are 2 studies that discourage its use for the evaluation of tumor response. In a study investigating 39 patients, van Heijl et al [23] reported that tumor volume changes identified on CT at 14 days were not associated with histopathologic tumor response. In a study evaluating the use of CT before and after neoadjuvant therapy in 35 patients with esophageal cancer, Konieczny et al [24] determined that CT accurately predicted complete histopathologic response in 20% and overstaged in 80%. An older systematic review by Westerterp et al [25] that reviewed 4 studies with CT showed the maximum joint value for sensitivity and specificity for CT in predicting response to neoadjuvant therapy was 54%. It should be noted that another important purpose of imaging patients after neoadjuvant therapy is to evaluate for the interval development of metastases. Although there are no studies evaluating CT specifically for this purpose, it would be expected to perform similarly to initial staging.
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Staging and Follow up of Esophageal Cancer. Qu et al [21] prospectively evaluated the use of contrast- enhanced radial VIBE sequences in the T staging of 43 patients with esophageal cancer and determined higher accuracy with MRI for T3 and T4 tumors. Malik et al [22] compared FDG-PET/CT and whole-body MRI in 49 patients, reporting similar performance for locoregional staging. Both modalities identified distant metastases that were present in 2 of the patients. Radiography Chest There is no relevant literature to support the use of chest radiography in the initial staging of patients with esophageal cancer. Variant 2: Esophageal cancer. Imaging during treatment. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. There is no relevant literature supporting the use of CT in patients who have undergone neoadjuvant chemoradiation. There Staging and Follow-up of Esophageal Cancer are 2 studies that discourage its use for the evaluation of tumor response. In a study investigating 39 patients, van Heijl et al [23] reported that tumor volume changes identified on CT at 14 days were not associated with histopathologic tumor response. In a study evaluating the use of CT before and after neoadjuvant therapy in 35 patients with esophageal cancer, Konieczny et al [24] determined that CT accurately predicted complete histopathologic response in 20% and overstaged in 80%. An older systematic review by Westerterp et al [25] that reviewed 4 studies with CT showed the maximum joint value for sensitivity and specificity for CT in predicting response to neoadjuvant therapy was 54%. It should be noted that another important purpose of imaging patients after neoadjuvant therapy is to evaluate for the interval development of metastases. Although there are no studies evaluating CT specifically for this purpose, it would be expected to perform similarly to initial staging.
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3163055
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acrac_3163055_8
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Staging and Follow up of Esophageal Cancer
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CT Chest, Abdomen, and Pelvis There is no relevant literature to support the inclusion of the pelvis in CT examinations during treatment. FDG-PET/CT Skull Base to Mid-Thigh There are conflicting data on the use of FDG-PET/CT for the evaluation of patients undergoing neoadjuvant chemotherapy. A systematic review of the literature in 2004 by Westerterp et al [25] assessed 7 studies using FDG- PET for the assessment of response to neoadjuvant chemotherapy in esophageal cancer. The maximum joint sensitivity and specificity for FDG-PET for in detecting response was 85%, with an accuracy similar to esophageal US and superior to CT. Subsequent studies showed promising results for FDG-PET/CT. Gabrielson et al [26] prospectively evaluated 51 patients undergoing neoadjuvant chemotherapy for esophageal cancer and found that SUVs could be used to differentiate responders from nonresponders but were not found to demonstrate statistical significance in patients with complete versus subtotal response. Beukinga et al [27] prospectively evaluated 74 patients using a radiomics-based quantitative assessment of postneoadjuvant chemoradiation FDG-PET/CT examinations and concluded that posttreatment FDG-PET/CT orderliness combined with clinical T staging resulted in high discriminatory accuracy in predicting complete histopathologic response. Thurau et al [28] conducted a retrospective review of 83 patients with esophageal cancer who had FDG-PET/CT performed at 6 weeks after induction of neoadjuvant therapy. The authors reported that an SUV reduction of >50% correlated with major histomorphologic response and that patients with this reduction also showed significantly increased survival. Other authors, however, found fewer promising results when evaluating FDG-PET/CT for the assessment of response to neoadjuvant therapy.
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Staging and Follow up of Esophageal Cancer. CT Chest, Abdomen, and Pelvis There is no relevant literature to support the inclusion of the pelvis in CT examinations during treatment. FDG-PET/CT Skull Base to Mid-Thigh There are conflicting data on the use of FDG-PET/CT for the evaluation of patients undergoing neoadjuvant chemotherapy. A systematic review of the literature in 2004 by Westerterp et al [25] assessed 7 studies using FDG- PET for the assessment of response to neoadjuvant chemotherapy in esophageal cancer. The maximum joint sensitivity and specificity for FDG-PET for in detecting response was 85%, with an accuracy similar to esophageal US and superior to CT. Subsequent studies showed promising results for FDG-PET/CT. Gabrielson et al [26] prospectively evaluated 51 patients undergoing neoadjuvant chemotherapy for esophageal cancer and found that SUVs could be used to differentiate responders from nonresponders but were not found to demonstrate statistical significance in patients with complete versus subtotal response. Beukinga et al [27] prospectively evaluated 74 patients using a radiomics-based quantitative assessment of postneoadjuvant chemoradiation FDG-PET/CT examinations and concluded that posttreatment FDG-PET/CT orderliness combined with clinical T staging resulted in high discriminatory accuracy in predicting complete histopathologic response. Thurau et al [28] conducted a retrospective review of 83 patients with esophageal cancer who had FDG-PET/CT performed at 6 weeks after induction of neoadjuvant therapy. The authors reported that an SUV reduction of >50% correlated with major histomorphologic response and that patients with this reduction also showed significantly increased survival. Other authors, however, found fewer promising results when evaluating FDG-PET/CT for the assessment of response to neoadjuvant therapy.
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3163055
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acrac_3163055_9
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Staging and Follow up of Esophageal Cancer
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Vallbohmer et al [29] prospectively evaluated 119 patients with FDG-PET/CT 2 to 3 weeks after induction of neoadjuvant chemotherapy and found no significant association between major responders and FDG-PET/CT results; receiver operating characteristic analysis could not identify an SUV threshold to predict histomorphologic response, and there was no association between metabolic imaging and prognosis. Elliot et al [30] prospectively evaluated 100 patients with esophageal cancer who underwent FDG-PET/CT at 2 to 4 weeks after completion of neoadjuvant therapy and concluded FDG-PET/CT had poor prognostic value and clinical application for determining responders. Piessen et al [31] prospectively evaluated 46 patients with esophageal cancer who had FDG-PET/CT performed 4 to 6 weeks after completion of neoadjuvant therapy and concluded that FDG-PET/CT did not correlate with pathological response and long-term survival in patients with locally advanced esophageal cancer. Van Heijl et al [32] prospectively studied patients with esophageal cancer who had FDG- PET/CT at 2 weeks after the induction of chemotherapy and found FDG-PET/CT showed a statistically significant decrease in SUV in responders and correctly identified 58 of 64 responders and 18 of 36 nonresponders. The authors concluded that the low accuracy in detecting nonresponders did not justify using FDG-PET/CT for early discontinuation of neoadjuvant chemotherapy. FDG-PET/CT also has the potential to detect metastases that have developed in the interval after the induction of neoadjuvant therapy. A systematic review and meta-analysis performed by Kroese et al [33] evaluated 14 studies (1,110 patients) and found a pooled proportion of 8% of patients having interval metastases detected by FDG- PET/CT. The authors also reported an additional pooled proportion of 5% of patients who had false-positive concerning distant findings.
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Staging and Follow up of Esophageal Cancer. Vallbohmer et al [29] prospectively evaluated 119 patients with FDG-PET/CT 2 to 3 weeks after induction of neoadjuvant chemotherapy and found no significant association between major responders and FDG-PET/CT results; receiver operating characteristic analysis could not identify an SUV threshold to predict histomorphologic response, and there was no association between metabolic imaging and prognosis. Elliot et al [30] prospectively evaluated 100 patients with esophageal cancer who underwent FDG-PET/CT at 2 to 4 weeks after completion of neoadjuvant therapy and concluded FDG-PET/CT had poor prognostic value and clinical application for determining responders. Piessen et al [31] prospectively evaluated 46 patients with esophageal cancer who had FDG-PET/CT performed 4 to 6 weeks after completion of neoadjuvant therapy and concluded that FDG-PET/CT did not correlate with pathological response and long-term survival in patients with locally advanced esophageal cancer. Van Heijl et al [32] prospectively studied patients with esophageal cancer who had FDG- PET/CT at 2 weeks after the induction of chemotherapy and found FDG-PET/CT showed a statistically significant decrease in SUV in responders and correctly identified 58 of 64 responders and 18 of 36 nonresponders. The authors concluded that the low accuracy in detecting nonresponders did not justify using FDG-PET/CT for early discontinuation of neoadjuvant chemotherapy. FDG-PET/CT also has the potential to detect metastases that have developed in the interval after the induction of neoadjuvant therapy. A systematic review and meta-analysis performed by Kroese et al [33] evaluated 14 studies (1,110 patients) and found a pooled proportion of 8% of patients having interval metastases detected by FDG- PET/CT. The authors also reported an additional pooled proportion of 5% of patients who had false-positive concerning distant findings.
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3163055
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acrac_3163055_10
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Staging and Follow up of Esophageal Cancer
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Kroese et al [33] concluded that the detection of distant metastases on restaging FDG- PET/CT after induction of neoadjuvant therapy can considerably impact decision making but that suspicious imaging findings required pathologic confirmation. FDG-PET/MRI Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/MRI during treatment. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper GI series during treatment. Staging and Follow-up of Esophageal Cancer MRI Chest and Abdomen There are limited data from small series investigating the use of MRI for the evaluation of patients undergoing treatment. A prospective study of 26 patients undergoing neoadjuvant therapy for esophageal cancer who underwent dynamic contrast-enhanced MRI by Heethuis et al [34] demonstrated that the area under the curve could predict good responders and poor responders with a sensitivity of 92% and a specificity of 77%. Sun et al [35] used dynamic contrast-enhanced MRI to evaluate patients with advanced squamous cell cancer of the esophagus and reported that the change in Ktrans was a parameter that could be potentially used to assess treatment response. Wang et al [36] studied 38 patients with squamous cell cancer of the esophagus undergoing chemoradiotherapy with weekly MRI including diffusion-weighted imaging. The authors reported that treatment-induced change in apparent diffusion coefficient during the first 2 to 3 weeks could be used to assess response to therapy. Wang et al [37] prospectively studied 79 patients with esophageal cancer who had 3T MRI before and after neoadjuvant therapy and reported a sensitivity, specificity, and accuracy of more than 90% for several sequences in T staging after neoadjuvant therapy. No studies are available that investigate the performance of MRI for detecting interval metastases in patients undergoing neoadjuvant therapy.
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Staging and Follow up of Esophageal Cancer. Kroese et al [33] concluded that the detection of distant metastases on restaging FDG- PET/CT after induction of neoadjuvant therapy can considerably impact decision making but that suspicious imaging findings required pathologic confirmation. FDG-PET/MRI Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/MRI during treatment. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper GI series during treatment. Staging and Follow-up of Esophageal Cancer MRI Chest and Abdomen There are limited data from small series investigating the use of MRI for the evaluation of patients undergoing treatment. A prospective study of 26 patients undergoing neoadjuvant therapy for esophageal cancer who underwent dynamic contrast-enhanced MRI by Heethuis et al [34] demonstrated that the area under the curve could predict good responders and poor responders with a sensitivity of 92% and a specificity of 77%. Sun et al [35] used dynamic contrast-enhanced MRI to evaluate patients with advanced squamous cell cancer of the esophagus and reported that the change in Ktrans was a parameter that could be potentially used to assess treatment response. Wang et al [36] studied 38 patients with squamous cell cancer of the esophagus undergoing chemoradiotherapy with weekly MRI including diffusion-weighted imaging. The authors reported that treatment-induced change in apparent diffusion coefficient during the first 2 to 3 weeks could be used to assess response to therapy. Wang et al [37] prospectively studied 79 patients with esophageal cancer who had 3T MRI before and after neoadjuvant therapy and reported a sensitivity, specificity, and accuracy of more than 90% for several sequences in T staging after neoadjuvant therapy. No studies are available that investigate the performance of MRI for detecting interval metastases in patients undergoing neoadjuvant therapy.
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3163055
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acrac_3163055_11
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Staging and Follow up of Esophageal Cancer
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Radiography Chest There is no relevant literature to support the use of chest radiography during treatment. Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. CT has been studied in the evaluation of patients who have completed treatment. Recent data exist from studies comparing FDG-PET and FDG-PET/CT with contrast-enhanced CT in the detection of recurrence. Kato et al [38] studied 55 patients and reported 89% sensitivity, 79% specificity, and 84% accuracy for CT in detecting recurrent disease in comparison with 96% sensitivity, 68% specificity, and 82% accuracy for FDG-PET. The authors did note that CT was more sensitive than FDG-PET for the detection of lung metastases. Teyton et al [39] prospectively studied 41 patients postsurgery for esophageal cancer and reported 65% sensitivity and 91% specificity for chest and abdomen CT versus 100% sensitivity and 85% specificity for FDG-PET. Of note, in a retrospective review by Antonowicz et al [40], 169 patients who underwent esophagectomy and were followed with annual CT had no change in management or survival. CT Chest, Abdomen, and Pelvis There are no specific studies comparing body CT scans that include the pelvis with those that do not in asymptomatic patients undergoing CT to evaluate for recurrent disease. FDG-PET/CT Skull Base to Mid-Thigh Several studies have evaluated FDG-PET/CT in the evaluation of asymptomatic patients who have had definitive treatment for esophageal cancer. Betancourt et al [41] studied 162 asymptomatic patients who underwent surgery for esophageal cancer and were followed with FDG-PET/CT. They reported a sensitivity of 77% and specificity of 76% for recurrence at the anastomosis, sensitivity of 88% and specificity of 85% for regional node recurrence, and sensitivity of 97% and specificity of 96% for distant metastases.
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Staging and Follow up of Esophageal Cancer. Radiography Chest There is no relevant literature to support the use of chest radiography during treatment. Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. CT has been studied in the evaluation of patients who have completed treatment. Recent data exist from studies comparing FDG-PET and FDG-PET/CT with contrast-enhanced CT in the detection of recurrence. Kato et al [38] studied 55 patients and reported 89% sensitivity, 79% specificity, and 84% accuracy for CT in detecting recurrent disease in comparison with 96% sensitivity, 68% specificity, and 82% accuracy for FDG-PET. The authors did note that CT was more sensitive than FDG-PET for the detection of lung metastases. Teyton et al [39] prospectively studied 41 patients postsurgery for esophageal cancer and reported 65% sensitivity and 91% specificity for chest and abdomen CT versus 100% sensitivity and 85% specificity for FDG-PET. Of note, in a retrospective review by Antonowicz et al [40], 169 patients who underwent esophagectomy and were followed with annual CT had no change in management or survival. CT Chest, Abdomen, and Pelvis There are no specific studies comparing body CT scans that include the pelvis with those that do not in asymptomatic patients undergoing CT to evaluate for recurrent disease. FDG-PET/CT Skull Base to Mid-Thigh Several studies have evaluated FDG-PET/CT in the evaluation of asymptomatic patients who have had definitive treatment for esophageal cancer. Betancourt et al [41] studied 162 asymptomatic patients who underwent surgery for esophageal cancer and were followed with FDG-PET/CT. They reported a sensitivity of 77% and specificity of 76% for recurrence at the anastomosis, sensitivity of 88% and specificity of 85% for regional node recurrence, and sensitivity of 97% and specificity of 96% for distant metastases.
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3163055
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acrac_3163055_12
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Staging and Follow up of Esophageal Cancer
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A systematic review of the literature by Goense et al [42] evaluating 486 patients across 8 studies reported a pooled sensitivity of 96% and a specificity of 78% in detecting recurrent disease. There was no statistically significant difference in the performance of FDG-PET/CT in patients who were asymptomatic or had a clinical indication for the examination. FDG-PET/MRI Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/MRI to follow asymptomatic patients after treatment. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper GI series to follow asymptomatic patients after treatment. MRI Chest and Abdomen There is no relevant literature to support the use of MRI chest and abdomen to follow asymptomatic patients after treatment. Staging and Follow-up of Esophageal Cancer Radiography Chest There is no relevant literature to support the use of chest radiography to follow asymptomatic patients after treatment. Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. Sharma et al [43] studied 227 patients with suspected esophageal cancer who had suspected metastasis. All patients underwent FDG-PET/CT, whereas 109 patients also underwent contrast-enhanced CT. The authors reported a sensitivity of 96% and a specificity of 81% for FDG-PET/CT compared with a 97% sensitivity and a 21% specificity for contrast-enhanced CT. CT Chest, Abdomen, and Pelvis There are no specific studies comparing body CT scans that include the pelvis with those that do not in patients undergoing CT to evaluate for clinically suspected recurrent disease. FDG-PET/CT Skull Base to Mid-Thigh As above, Sharma et a [43] studied 227 patients with suspected esophageal cancer who had suspected metastasis.
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Staging and Follow up of Esophageal Cancer. A systematic review of the literature by Goense et al [42] evaluating 486 patients across 8 studies reported a pooled sensitivity of 96% and a specificity of 78% in detecting recurrent disease. There was no statistically significant difference in the performance of FDG-PET/CT in patients who were asymptomatic or had a clinical indication for the examination. FDG-PET/MRI Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/MRI to follow asymptomatic patients after treatment. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper GI series to follow asymptomatic patients after treatment. MRI Chest and Abdomen There is no relevant literature to support the use of MRI chest and abdomen to follow asymptomatic patients after treatment. Staging and Follow-up of Esophageal Cancer Radiography Chest There is no relevant literature to support the use of chest radiography to follow asymptomatic patients after treatment. Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. Sharma et al [43] studied 227 patients with suspected esophageal cancer who had suspected metastasis. All patients underwent FDG-PET/CT, whereas 109 patients also underwent contrast-enhanced CT. The authors reported a sensitivity of 96% and a specificity of 81% for FDG-PET/CT compared with a 97% sensitivity and a 21% specificity for contrast-enhanced CT. CT Chest, Abdomen, and Pelvis There are no specific studies comparing body CT scans that include the pelvis with those that do not in patients undergoing CT to evaluate for clinically suspected recurrent disease. FDG-PET/CT Skull Base to Mid-Thigh As above, Sharma et a [43] studied 227 patients with suspected esophageal cancer who had suspected metastasis.
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3163055
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acrac_3094113_0
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Pulmonary Arteriovenous Malformation PAVM
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About 70% to 90% of the patients with PAVMs have hereditary hemorrhagic telangiectasia (HHT) [2]. HHT is an autosomal dominant disorder associated with mutations in genes coding for endoglin and activin receptor-like kinase 1ALK1. The former leads to a phenotypical presentation with cerebral and PAVMs described as HHT type 1 [3]. The later presents with pulmonary hypertension and hepatic AVMs and is described as HHT type 2 [4]. Of patients with HHT, 1% to 2% have a SMAD4 mutation and a clinical phenotype associated with juvenile polyposis syndrome [5]. The clinical diagnosis of HHT is based on the Curacao criteria [6]. The prevalence of PAVM occurs in 1 in 5,000 individuals in the general population but can vary depending on the geographical distribution of HHT. In areas where HHT is more prevalent, PAVM prevalence can reach between 26 and 56 per 100,000 individuals. In general, there is a 1.5 to 2 times higher incidence of PAVMs in women compared to men but a male-predominance is noted in newborns [7]. Other causes of PAVMs are rare and include trauma, chest surgery, schistosomiasis, actinomycosis, mitral valve stenosis, Fanconi syndrome, cirrhosis with hepatopulmonary syndrome, and metastatic cancer [7]. Clinical manifestations of PAVMs depend on the size, number, type (complex versus simple), and flow through the malformations. Most patients are asymptomatic (25%-58%). Hypoxemia (27%-71%) at rest or exercise, especially orthodeoxia (worsening hypoxemia when upright) and platypnea (worsening dyspnea when upright), are classical presentations as 65% to 83% of PAVMs are in the lower lobes of the lungs [8]. Transient ischemic attacks and cerebral strokes (3.2%-55%), systemic infections, and abscesses including cerebral abscesses (0%-25%) and rarely massive hemoptysis and hemothorax (0%-2%) are other manifestations [1].
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Pulmonary Arteriovenous Malformation PAVM . About 70% to 90% of the patients with PAVMs have hereditary hemorrhagic telangiectasia (HHT) [2]. HHT is an autosomal dominant disorder associated with mutations in genes coding for endoglin and activin receptor-like kinase 1ALK1. The former leads to a phenotypical presentation with cerebral and PAVMs described as HHT type 1 [3]. The later presents with pulmonary hypertension and hepatic AVMs and is described as HHT type 2 [4]. Of patients with HHT, 1% to 2% have a SMAD4 mutation and a clinical phenotype associated with juvenile polyposis syndrome [5]. The clinical diagnosis of HHT is based on the Curacao criteria [6]. The prevalence of PAVM occurs in 1 in 5,000 individuals in the general population but can vary depending on the geographical distribution of HHT. In areas where HHT is more prevalent, PAVM prevalence can reach between 26 and 56 per 100,000 individuals. In general, there is a 1.5 to 2 times higher incidence of PAVMs in women compared to men but a male-predominance is noted in newborns [7]. Other causes of PAVMs are rare and include trauma, chest surgery, schistosomiasis, actinomycosis, mitral valve stenosis, Fanconi syndrome, cirrhosis with hepatopulmonary syndrome, and metastatic cancer [7]. Clinical manifestations of PAVMs depend on the size, number, type (complex versus simple), and flow through the malformations. Most patients are asymptomatic (25%-58%). Hypoxemia (27%-71%) at rest or exercise, especially orthodeoxia (worsening hypoxemia when upright) and platypnea (worsening dyspnea when upright), are classical presentations as 65% to 83% of PAVMs are in the lower lobes of the lungs [8]. Transient ischemic attacks and cerebral strokes (3.2%-55%), systemic infections, and abscesses including cerebral abscesses (0%-25%) and rarely massive hemoptysis and hemothorax (0%-2%) are other manifestations [1].
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3094113
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acrac_3094113_1
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Pulmonary Arteriovenous Malformation PAVM
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Pregnancy is associated with the rapid growth of PAVMs due to hormonal and hemodynamic consequences with a higher risk of complications from lack of filtration and rupture [9]. Treatment of PAVMs involves endovascular occlusion of the feeding artery and in rare instances surgical resection. Percutaneous transcatheter embolization is typically performed for the treatment of PAVMs. The feeding artery is occluded by an embolic device obliterating the arteriovenous shunt. Regardless of the size of the feeding artery, any PAVM detected by CT or catheter angiography should be considered for treatment due to the risk of paradoxical embolism [10,11]. Embolization is performed by deploying coils or plugs in the feeding artery as close to the aUT Southwestern Medical Center, Dallas, Texas. bPanel Chair, Brigham & Women's Hospital, Boston, Massachusetts. cPanel Vice-Chair, Brigham & Women's Hospital, Boston, Massachusetts. dUniversity of Toronto, Toronto, Ontario, Canada; American College of Physicians. eKnight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography. fUT Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging. gOchsner Hospital, Baton Rouge, Louisiana. hUniversity of California San Francisco, San Francisco, California. iUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. jWilmington Health, Wilmington, North Carolina; American College of Chest Physicians. kCleveland Clinic, Cleveland, Ohio. lUCLA Medical Center, Los Angeles, California; The Society of Thoracic Surgeons. mVA Puget Sound Health Care System and University of Washington, Seattle, Washington. nThe Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; Nuclear cardiology expert. oSouth Texas Radiology Group, P.A., San Antonio, Texas. pMercyhealth, Rockford, Illinois. qLahey Hospital and Medical Center, Burlington, Massachusetts.
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Pulmonary Arteriovenous Malformation PAVM . Pregnancy is associated with the rapid growth of PAVMs due to hormonal and hemodynamic consequences with a higher risk of complications from lack of filtration and rupture [9]. Treatment of PAVMs involves endovascular occlusion of the feeding artery and in rare instances surgical resection. Percutaneous transcatheter embolization is typically performed for the treatment of PAVMs. The feeding artery is occluded by an embolic device obliterating the arteriovenous shunt. Regardless of the size of the feeding artery, any PAVM detected by CT or catheter angiography should be considered for treatment due to the risk of paradoxical embolism [10,11]. Embolization is performed by deploying coils or plugs in the feeding artery as close to the aUT Southwestern Medical Center, Dallas, Texas. bPanel Chair, Brigham & Women's Hospital, Boston, Massachusetts. cPanel Vice-Chair, Brigham & Women's Hospital, Boston, Massachusetts. dUniversity of Toronto, Toronto, Ontario, Canada; American College of Physicians. eKnight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography. fUT Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging. gOchsner Hospital, Baton Rouge, Louisiana. hUniversity of California San Francisco, San Francisco, California. iUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. jWilmington Health, Wilmington, North Carolina; American College of Chest Physicians. kCleveland Clinic, Cleveland, Ohio. lUCLA Medical Center, Los Angeles, California; The Society of Thoracic Surgeons. mVA Puget Sound Health Care System and University of Washington, Seattle, Washington. nThe Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; Nuclear cardiology expert. oSouth Texas Radiology Group, P.A., San Antonio, Texas. pMercyhealth, Rockford, Illinois. qLahey Hospital and Medical Center, Burlington, Massachusetts.
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3094113
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acrac_3094113_2
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Pulmonary Arteriovenous Malformation PAVM
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rEmory University, Atlanta, Georgia; American Society of Echocardiography. sBrigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER. tSpecialty Chair, Massachusetts General Hospital, Boston, Massachusetts. 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] Pulmonary Arteriovenous Malformation (PAVM) arteriovenous communication as possible. Follow-up CT angiography (CTA) to detect persistence/new lesions within 6 to 12 months followed by every 3 to 5 years is recommended by the international guidelines for the diagnosis and management of HHT [10]. Persistent perfusion of PAVMs following embolization carries the continued risk of paradoxical embolism and is a vexing problem to re-treat with success rates up to 44% to 85% [12]. The persistence rates vary with the embolic material and are primarily due to arterial recanalization. Other causes include pulmonary to pulmonary and systemic to pulmonary perfusion of the venous sac. Persistent sac perfusion following embolization with different embolic materials vary from 5% to 21% for coils alone, 4% to 6% for nitinol vascular plugs, and 0% to 2% for microvascular plugs [13,14]. Use of maximum intensity projection postprocessing has shown to increase the detection rates and reduce reporting times for small PAVMs both in children and adults. Maximum intensity projection also detects the anatomy and size of the feeding artery with higher accuracy compared to thin-section conventional CT images [18-20]. Postembolization scans for PAVMs are prone to artifacts that interfere with the evaluation of persistent flow.
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Pulmonary Arteriovenous Malformation PAVM . rEmory University, Atlanta, Georgia; American Society of Echocardiography. sBrigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER. tSpecialty Chair, Massachusetts General Hospital, Boston, Massachusetts. 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] Pulmonary Arteriovenous Malformation (PAVM) arteriovenous communication as possible. Follow-up CT angiography (CTA) to detect persistence/new lesions within 6 to 12 months followed by every 3 to 5 years is recommended by the international guidelines for the diagnosis and management of HHT [10]. Persistent perfusion of PAVMs following embolization carries the continued risk of paradoxical embolism and is a vexing problem to re-treat with success rates up to 44% to 85% [12]. The persistence rates vary with the embolic material and are primarily due to arterial recanalization. Other causes include pulmonary to pulmonary and systemic to pulmonary perfusion of the venous sac. Persistent sac perfusion following embolization with different embolic materials vary from 5% to 21% for coils alone, 4% to 6% for nitinol vascular plugs, and 0% to 2% for microvascular plugs [13,14]. Use of maximum intensity projection postprocessing has shown to increase the detection rates and reduce reporting times for small PAVMs both in children and adults. Maximum intensity projection also detects the anatomy and size of the feeding artery with higher accuracy compared to thin-section conventional CT images [18-20]. Postembolization scans for PAVMs are prone to artifacts that interfere with the evaluation of persistent flow.
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3094113
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acrac_3094113_3
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Pulmonary Arteriovenous Malformation PAVM
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Spectral and dual-energy CT have been studied in other anatomical locations in reducing the coil and other metallic artifacts [21,22]. There are no studies evaluating their role in PAVM, but these techniques may improve posttreatment image interpretation by reducing artifacts. For the purposes of distinguishing between CT and CT angiography (CTA), ACR Appropriateness Criteria topics use the definition in the ACR-NASCI-SIR-SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA) [23]: All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. OR Discussion of Procedures by Variant Variant 1: Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study. Arteriography Pulmonary The real-time nature of pulmonary arteriography allows for high accuracy in delineating the angioarchitecture and detection of flow characteristics such as the early draining vein. In a study comparing the specificity of pulmonary arteriography and CTA, pulmonary arteriography was noted to have a higher specificity for detecting the angioarchitecture compared to CTA (100% versus 78%) [24]. Pulmonary angiography is performed as a part of the Pulmonary Arteriovenous Malformation (PAVM) treatment procedure and does not have a standalone diagnostic role in detecting PAVM. An exception where pulmonary angiogram would be helpful as an initial diagnostic imaging tool is in a patient who is hemodynamically unstable with clinical suspicion of pulmonary hemorrhage from a PAVM [25].
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Pulmonary Arteriovenous Malformation PAVM . Spectral and dual-energy CT have been studied in other anatomical locations in reducing the coil and other metallic artifacts [21,22]. There are no studies evaluating their role in PAVM, but these techniques may improve posttreatment image interpretation by reducing artifacts. For the purposes of distinguishing between CT and CT angiography (CTA), ACR Appropriateness Criteria topics use the definition in the ACR-NASCI-SIR-SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA) [23]: All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. OR Discussion of Procedures by Variant Variant 1: Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study. Arteriography Pulmonary The real-time nature of pulmonary arteriography allows for high accuracy in delineating the angioarchitecture and detection of flow characteristics such as the early draining vein. In a study comparing the specificity of pulmonary arteriography and CTA, pulmonary arteriography was noted to have a higher specificity for detecting the angioarchitecture compared to CTA (100% versus 78%) [24]. Pulmonary angiography is performed as a part of the Pulmonary Arteriovenous Malformation (PAVM) treatment procedure and does not have a standalone diagnostic role in detecting PAVM. An exception where pulmonary angiogram would be helpful as an initial diagnostic imaging tool is in a patient who is hemodynamically unstable with clinical suspicion of pulmonary hemorrhage from a PAVM [25].
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3094113
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acrac_3094113_4
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Pulmonary Arteriovenous Malformation PAVM
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CT Chest With IV Contrast Chest CT with IV contrast offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Contrast-enhanced CT provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism [10,26]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CT Chest Without and With IV Contrast There is limited data to support obtaining a CT chest with and without IV contrast in the setting of suspected PAVM. A study by Nawaz et al [24] compared CT with and without IV contrast to digital subtraction angiography (DSA) for assessment of PAVMs. Their study showed superior sensitivity of CT compared to DSA for detection of PAVM; however, the specificity for CT was inferior to that of DSA. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. The benefit of using CT chest without and with IV contrast for assessing PAVM compared to stand-alone CT without IV contrast or CT with IV contrast is unclear [24]. CT Chest Without IV Contrast Noncontrast chest CT scan is helpful in confirming the diagnosis of PAVM. Like CT chest with IV contrast, Noncontrast CT offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Remy et al [28] were able to predict angioarchitecture of the PAVMs in 95% of cases using noncontrast CT and 3-D reconstruction. Cross-sectional anatomy displayed on CT chest without IV contrast is useful in treatment planning [10,27]. CTA Chest With IV Contrast CTA chest provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM.
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Pulmonary Arteriovenous Malformation PAVM . CT Chest With IV Contrast Chest CT with IV contrast offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Contrast-enhanced CT provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism [10,26]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CT Chest Without and With IV Contrast There is limited data to support obtaining a CT chest with and without IV contrast in the setting of suspected PAVM. A study by Nawaz et al [24] compared CT with and without IV contrast to digital subtraction angiography (DSA) for assessment of PAVMs. Their study showed superior sensitivity of CT compared to DSA for detection of PAVM; however, the specificity for CT was inferior to that of DSA. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. The benefit of using CT chest without and with IV contrast for assessing PAVM compared to stand-alone CT without IV contrast or CT with IV contrast is unclear [24]. CT Chest Without IV Contrast Noncontrast chest CT scan is helpful in confirming the diagnosis of PAVM. Like CT chest with IV contrast, Noncontrast CT offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Remy et al [28] were able to predict angioarchitecture of the PAVMs in 95% of cases using noncontrast CT and 3-D reconstruction. Cross-sectional anatomy displayed on CT chest without IV contrast is useful in treatment planning [10,27]. CTA Chest With IV Contrast CTA chest provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM.
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3094113
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acrac_3094113_5
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Pulmonary Arteriovenous Malformation PAVM
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Adequate precaution should be taken to prevent air embolism. Unlike CTA pulmonary arteries (CTPA), the vascular enhancement during CTA is timed for the aorta and its branches and, thus, it may help identify systemic supply to PAVMs via the systemic arteries [10,29,30]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CTA Pulmonary Arteries With IV Contrast CTPA specifically assesses the pulmonary vasculature. IV contrast material is timed for optimum evaluation of the pulmonary arteries. Use of CTPA for evaluation of PAVM is used in clinical practice when considering a contrast- enhanced CT scan for evaluating PAVM. Like other CT techniques, CTPA offers high special resolution and can detect the number, size, and distribution of PAVMs accurately. CTPA provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air [27]. Correlating the PAVM grade with contrast-enhanced echo has been shown to be more sensitive with CTPA compared to noncontrast CT [31]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. MRA Chest Without and With IV Contrast There is no role for the routine use of MR angiography (MRA) chest without and with IV contrast in the workup of a patient suspected of a PAVM. Similar to chest CTA, MRA chest may identify systemic arterial supply to PAVM. MRA Chest Without IV Contrast There is no role for the routine use of MRA chest without IV contrast in the workup of a patient suspected of a PAVM.
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Pulmonary Arteriovenous Malformation PAVM . Adequate precaution should be taken to prevent air embolism. Unlike CTA pulmonary arteries (CTPA), the vascular enhancement during CTA is timed for the aorta and its branches and, thus, it may help identify systemic supply to PAVMs via the systemic arteries [10,29,30]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CTA Pulmonary Arteries With IV Contrast CTPA specifically assesses the pulmonary vasculature. IV contrast material is timed for optimum evaluation of the pulmonary arteries. Use of CTPA for evaluation of PAVM is used in clinical practice when considering a contrast- enhanced CT scan for evaluating PAVM. Like other CT techniques, CTPA offers high special resolution and can detect the number, size, and distribution of PAVMs accurately. CTPA provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air [27]. Correlating the PAVM grade with contrast-enhanced echo has been shown to be more sensitive with CTPA compared to noncontrast CT [31]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. MRA Chest Without and With IV Contrast There is no role for the routine use of MR angiography (MRA) chest without and with IV contrast in the workup of a patient suspected of a PAVM. Similar to chest CTA, MRA chest may identify systemic arterial supply to PAVM. MRA Chest Without IV Contrast There is no role for the routine use of MRA chest without IV contrast in the workup of a patient suspected of a PAVM.
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3094113
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acrac_3094113_6
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Pulmonary Arteriovenous Malformation PAVM
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MRA Pulmonary Arteries Without and With IV Contrast Contrast-enhanced MRA pulmonary arteries provides anatomical information about the presence, number, size, and location of PAVMs. Schneider et al [32] evaluated 203 patients with HHT or first-degree relatives with HHT using contrast-enhanced MRA. Patients with definite and uncertain diagnosis of PAVM on MRA underwent pulmonary angiogram. Pulmonary angiogram detected only 77% to 80% of the PAVMs that were seen on MRA. In their study, the majority of the PAVMs not detected by pulmonary angiogram were <5 mm in size. The size criterion was Pulmonary Arteriovenous Malformation (PAVM) defined as the size of the PAVM itself and not of the feeding artery. A more recent study by Van den Heuvel et al [33] investigated the sensitivity of contrast-enhanced MRA for detection of PAVMs with a feeding artery >2 cm in children and young adults. They enrolled 53 patients who had a TTCE grade 2 or 3 who underwent chest CT and were found to have the PAVM with a feeding artery >2 cm to receive a contrast-enhanced MRA. The sensitivity of contrast-enhanced MRA to detect PAVMs with a feeding artery size of >2cm was 92%, and the specificity ranged from 67% to 96%. MRA Pulmonary Arteries Without IV Contrast There is no role for the routine use of MRA pulmonary angiography without IV contrast in the workup of a patient suspected of a PAVM. Pertechnetate Albumin Pulmonary Scan There is no role for pertechnetate albumin pulmonary scan in a modern day practice. Historically, this technique was used to detect and quantify right to left shunting before and after treatment of a PAVM [34,35]. Radiography Chest The radiographic appearance of a lower lobe pulmonary nodule with a branching afferent artery and dilated efferent vein defines the classical appearance of PAVM on chest radiography. The sensitivity of chest radiography is 60% to 70% with a 98% specificity when the classical findings are present [36].
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Pulmonary Arteriovenous Malformation PAVM . MRA Pulmonary Arteries Without and With IV Contrast Contrast-enhanced MRA pulmonary arteries provides anatomical information about the presence, number, size, and location of PAVMs. Schneider et al [32] evaluated 203 patients with HHT or first-degree relatives with HHT using contrast-enhanced MRA. Patients with definite and uncertain diagnosis of PAVM on MRA underwent pulmonary angiogram. Pulmonary angiogram detected only 77% to 80% of the PAVMs that were seen on MRA. In their study, the majority of the PAVMs not detected by pulmonary angiogram were <5 mm in size. The size criterion was Pulmonary Arteriovenous Malformation (PAVM) defined as the size of the PAVM itself and not of the feeding artery. A more recent study by Van den Heuvel et al [33] investigated the sensitivity of contrast-enhanced MRA for detection of PAVMs with a feeding artery >2 cm in children and young adults. They enrolled 53 patients who had a TTCE grade 2 or 3 who underwent chest CT and were found to have the PAVM with a feeding artery >2 cm to receive a contrast-enhanced MRA. The sensitivity of contrast-enhanced MRA to detect PAVMs with a feeding artery size of >2cm was 92%, and the specificity ranged from 67% to 96%. MRA Pulmonary Arteries Without IV Contrast There is no role for the routine use of MRA pulmonary angiography without IV contrast in the workup of a patient suspected of a PAVM. Pertechnetate Albumin Pulmonary Scan There is no role for pertechnetate albumin pulmonary scan in a modern day practice. Historically, this technique was used to detect and quantify right to left shunting before and after treatment of a PAVM [34,35]. Radiography Chest The radiographic appearance of a lower lobe pulmonary nodule with a branching afferent artery and dilated efferent vein defines the classical appearance of PAVM on chest radiography. The sensitivity of chest radiography is 60% to 70% with a 98% specificity when the classical findings are present [36].
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3094113
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acrac_3094113_7
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Pulmonary Arteriovenous Malformation PAVM
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The afferent and efferent vasculature and smaller PAVMs may be difficult to see on a single-view chest radiograph. Best diagnostic results are obtained when a 2-view chest radiograph, posteroanterior view, and lateral view, is performed [37]. The role of chest radiography in the diagnosis of a suspected PAVM is limited due to its poor sensitivity. US Echocardiography Transesophageal There is no role for ultrasound (US) transesophageal echocardiography (TEE) as a standalone diagnostic tool in the evaluation of PAVMs. The usefulness of TEE in the context of PAVM is to rule out intracardiac shunts [38]. Its ability to demonstrate the interatrial septum and the insertion of the pulmonary veins into the left atrium is useful to evaluate the anatomical variations [39]. US Echocardiography Transesophageal With IV Contrast TEE with IV agitated saline contrast material is not routinely used to diagnose PAVM. Contrast-enhanced TEE may be helpful to locate a PAVM based on the excellent visualization of the 4 pulmonary venous ostia as veins drain into the left atrium. Based on the visualization of contrast material emanating from a particular pulmonary vein, the location of the PAVM in that venous territory can be confirmed [38,40]. In the presence of multiple PAVMs, the usefulness of this imaging modality in identifying the location of the PAVMs is limited. US Echocardiography Transthoracic Resting There is no role for transthoracic echocardiography (TTE) in the resting phase for the evaluation of PAVM. It does allow evaluation of intracardiac shunts and assessment of cardiac function [38]. US Echocardiography Transthoracic With IV Contrast TTCE is an essential diagnostic test for patients suspected of having a PAVM. TTCE with agitated saline has a 98% to 99% sensitivity and a 67% to 91% specificity for detecting PAVMs [41].
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Pulmonary Arteriovenous Malformation PAVM . The afferent and efferent vasculature and smaller PAVMs may be difficult to see on a single-view chest radiograph. Best diagnostic results are obtained when a 2-view chest radiograph, posteroanterior view, and lateral view, is performed [37]. The role of chest radiography in the diagnosis of a suspected PAVM is limited due to its poor sensitivity. US Echocardiography Transesophageal There is no role for ultrasound (US) transesophageal echocardiography (TEE) as a standalone diagnostic tool in the evaluation of PAVMs. The usefulness of TEE in the context of PAVM is to rule out intracardiac shunts [38]. Its ability to demonstrate the interatrial septum and the insertion of the pulmonary veins into the left atrium is useful to evaluate the anatomical variations [39]. US Echocardiography Transesophageal With IV Contrast TEE with IV agitated saline contrast material is not routinely used to diagnose PAVM. Contrast-enhanced TEE may be helpful to locate a PAVM based on the excellent visualization of the 4 pulmonary venous ostia as veins drain into the left atrium. Based on the visualization of contrast material emanating from a particular pulmonary vein, the location of the PAVM in that venous territory can be confirmed [38,40]. In the presence of multiple PAVMs, the usefulness of this imaging modality in identifying the location of the PAVMs is limited. US Echocardiography Transthoracic Resting There is no role for transthoracic echocardiography (TTE) in the resting phase for the evaluation of PAVM. It does allow evaluation of intracardiac shunts and assessment of cardiac function [38]. US Echocardiography Transthoracic With IV Contrast TTCE is an essential diagnostic test for patients suspected of having a PAVM. TTCE with agitated saline has a 98% to 99% sensitivity and a 67% to 91% specificity for detecting PAVMs [41].
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3094113
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acrac_3094113_8
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Pulmonary Arteriovenous Malformation PAVM
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The microbubbles are visualized after 3 to 8 cardiac cycles in the left atrium after initial opacification of the right chambers in patients with an intrapulmonary shunt [1]. TTCE does not provide any information regarding the size and location of the PAVM. Based on the appearance of the bubbles in the left atrium a semiquantitative grading system has been developed [42,43]. The grades are defined as 0 with no opacification, grade 1 with <30 bubbles, grade 2 with moderate filling, and grade 3 with complete opacification of the left atrium. The grading system correlates well with the diagnosis of PAVM, with higher grades associated with larger shunts and cerebral complications [41,44,45]. Usefulness of the grading system to predict treatment of PAVM demonstrates that grades 2 and 3 have a positive predictive value of 0.21 (95% confidence interval [CI], 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively [44]. Adverse events including air embolism are rare with TTCE occurring in <1% [46]. Variant 2: Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging. Arteriography Pulmonary The real-time nature of pulmonary arteriography allows for high accuracy in delineating the angioarchitecture and detection of flow characteristics such as the early draining vein. In a study comparing the specificity of pulmonary arteriography and CTA, pulmonary arteriography was noted to have a higher specificity for detecting the angioarchitecture compared to CTA (100% versus 78%) [24]. Pulmonary angiography is performed as a part of the treatment procedure and does not have a standalone diagnostic role in detecting PAVM. An exception in which pulmonary angiogram would be helpful as an initial diagnostic imaging tool is in a patient who is hemodynamically unstable with clinical suspicion of pulmonary hemorrhage from a PAVM [25].
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Pulmonary Arteriovenous Malformation PAVM . The microbubbles are visualized after 3 to 8 cardiac cycles in the left atrium after initial opacification of the right chambers in patients with an intrapulmonary shunt [1]. TTCE does not provide any information regarding the size and location of the PAVM. Based on the appearance of the bubbles in the left atrium a semiquantitative grading system has been developed [42,43]. The grades are defined as 0 with no opacification, grade 1 with <30 bubbles, grade 2 with moderate filling, and grade 3 with complete opacification of the left atrium. The grading system correlates well with the diagnosis of PAVM, with higher grades associated with larger shunts and cerebral complications [41,44,45]. Usefulness of the grading system to predict treatment of PAVM demonstrates that grades 2 and 3 have a positive predictive value of 0.21 (95% confidence interval [CI], 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively [44]. Adverse events including air embolism are rare with TTCE occurring in <1% [46]. Variant 2: Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging. Arteriography Pulmonary The real-time nature of pulmonary arteriography allows for high accuracy in delineating the angioarchitecture and detection of flow characteristics such as the early draining vein. In a study comparing the specificity of pulmonary arteriography and CTA, pulmonary arteriography was noted to have a higher specificity for detecting the angioarchitecture compared to CTA (100% versus 78%) [24]. Pulmonary angiography is performed as a part of the treatment procedure and does not have a standalone diagnostic role in detecting PAVM. An exception in which pulmonary angiogram would be helpful as an initial diagnostic imaging tool is in a patient who is hemodynamically unstable with clinical suspicion of pulmonary hemorrhage from a PAVM [25].
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3094113
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acrac_3094113_9
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Pulmonary Arteriovenous Malformation PAVM
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CT Chest With IV Contrast Contrast-enhanced CT chest offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Contrast-enhanced CT provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism [10,26]. Cross- sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CT Chest Without and With IV Contrast There is limited data to support obtaining a CT chest with and without IV contrast in the setting of suspected PAVM. A study by Nawaz et al [24] compared CT with and without IV contrast to digital subtraction angiography (DSA) for assessment of PAVMs. Their study showed superior sensitivity of CT compared to DSA for detection of PAVM; however, the specificity for CT was inferior to that of DSA. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. The benefit of using CT chest without and with IV contrast for assessing PAVM compared to stand-alone CT without IV contrast or CT with IV contrast is unclear [24]. CT Chest Without IV Contrast Noncontrast chest CT scan is helpful in confirming the diagnosis of PAVM. Like CT chest with IV contrast, Noncontrast CT offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Remy et al [28] were able to predict angioarchitecture of the PAVMs in 95% of cases using noncontrast CT and 3-D reconstruction. Cross-sectional anatomy displayed on CT chest without IV contrast is useful in treatment planning [10,27]. CTA Chest With IV Contrast CTA chest provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM.
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Pulmonary Arteriovenous Malformation PAVM . CT Chest With IV Contrast Contrast-enhanced CT chest offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Contrast-enhanced CT provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism [10,26]. Cross- sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CT Chest Without and With IV Contrast There is limited data to support obtaining a CT chest with and without IV contrast in the setting of suspected PAVM. A study by Nawaz et al [24] compared CT with and without IV contrast to digital subtraction angiography (DSA) for assessment of PAVMs. Their study showed superior sensitivity of CT compared to DSA for detection of PAVM; however, the specificity for CT was inferior to that of DSA. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. The benefit of using CT chest without and with IV contrast for assessing PAVM compared to stand-alone CT without IV contrast or CT with IV contrast is unclear [24]. CT Chest Without IV Contrast Noncontrast chest CT scan is helpful in confirming the diagnosis of PAVM. Like CT chest with IV contrast, Noncontrast CT offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Remy et al [28] were able to predict angioarchitecture of the PAVMs in 95% of cases using noncontrast CT and 3-D reconstruction. Cross-sectional anatomy displayed on CT chest without IV contrast is useful in treatment planning [10,27]. CTA Chest With IV Contrast CTA chest provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM.
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3094113
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acrac_3094113_10
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Pulmonary Arteriovenous Malformation PAVM
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Adequate precaution should be taken to prevent air embolism. Unlike CTPA, the vascular enhancement during CTA is timed for the aorta and its branches and, thus, it may help identify systemic supply to PAVMs via the systemic arteries [10,29,30]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CTA Pulmonary Arteries With IV Contrast CTPA specifically assesses the pulmonary vasculature. IV contrast material is timed for optimum evaluation of the pulmonary arteries. Use of CTPA for evaluation of PAVM is used in clinical practice when considering a contrast- enhanced CT scan for evaluating PAVM. Like other CT techniques, CTPA offers high special resolution and can detect the number, size, and distribution of PAVMs accurately. CTPA provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air [27]. Correlating the PAVM grade with contrast-enhanced echo has been shown to be more sensitive with CTPA compared to noncontrast CT [31]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. MRA Chest Without and With IV Contrast There is no role for the routine use of MRA chest without and with IV contrast in the workup of a patient suspected of a PAVM. MRA Chest Without IV Contrast There is no role for the routine use of MRA chest without IV contrast in the workup of a patient suspected of a PAVM. MRA Pulmonary Arteries Without and With IV Contrast Contrast-enhanced MRA pulmonary arteries provides anatomical information about the presence, number, size, and location of PAVMs. Schneider et al [32] evaluated 203 patients with HHT or first-degree relatives with HHT using contrast-enhanced MRA. Patients with definite and uncertain diagnosis of PAVM on MRA underwent pulmonary angiogram.
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Pulmonary Arteriovenous Malformation PAVM . Adequate precaution should be taken to prevent air embolism. Unlike CTPA, the vascular enhancement during CTA is timed for the aorta and its branches and, thus, it may help identify systemic supply to PAVMs via the systemic arteries [10,29,30]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CTA Pulmonary Arteries With IV Contrast CTPA specifically assesses the pulmonary vasculature. IV contrast material is timed for optimum evaluation of the pulmonary arteries. Use of CTPA for evaluation of PAVM is used in clinical practice when considering a contrast- enhanced CT scan for evaluating PAVM. Like other CT techniques, CTPA offers high special resolution and can detect the number, size, and distribution of PAVMs accurately. CTPA provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air [27]. Correlating the PAVM grade with contrast-enhanced echo has been shown to be more sensitive with CTPA compared to noncontrast CT [31]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. MRA Chest Without and With IV Contrast There is no role for the routine use of MRA chest without and with IV contrast in the workup of a patient suspected of a PAVM. MRA Chest Without IV Contrast There is no role for the routine use of MRA chest without IV contrast in the workup of a patient suspected of a PAVM. MRA Pulmonary Arteries Without and With IV Contrast Contrast-enhanced MRA pulmonary arteries provides anatomical information about the presence, number, size, and location of PAVMs. Schneider et al [32] evaluated 203 patients with HHT or first-degree relatives with HHT using contrast-enhanced MRA. Patients with definite and uncertain diagnosis of PAVM on MRA underwent pulmonary angiogram.
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3094113
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acrac_3094113_11
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Pulmonary Arteriovenous Malformation PAVM
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Pulmonary angiogram detected only 77% to 80% of the PAVMs that were seen on MRA. In their study, Pulmonary Arteriovenous Malformation (PAVM) the majority of the PAVMs not detected by pulmonary angiogram were <5 mm in size. The size criterion was defined as the size of the PAVM itself and not of the feeding artery. A more recent study by Van den Heuvel et al [33] investigated the sensitivity of contrast-enhanced MRA for detection of PAVMs with a feeding artery >2 cm in children and young adults. They enrolled 53 patients who had a TTCE grade 2 or 3 who underwent chest CT and were found to have the PAVM with a feeding artery >2 cm to receive a contrast-enhanced MRA. The sensitivity of contrast-enhanced MRA to detect PAVMs with a feeding artery size of >2cm was 92%, and the specificity ranged from 67% to 96%. MRA Pulmonary Arteries Without IV Contrast There is no role for the routine use of MRA pulmonary angiography without IV contrast in the workup of a patient suspected of a PAVM. Pertechnetate Albumin Pulmonary Scan There is no role for pertechnetate albumin pulmonary scan in a modern day practice. Historically, this technique was used to detect and quantify right to left shunting before and after treatment of a PAVM [34,35]. Radiography Chest The radiographic appearance of a lower lobe pulmonary nodule with a branching afferent artery and dilated efferent vein defines the classical appearance of PAVM on chest radiography. The sensitivity of chest radiography is 60% to 70% with a 98% specificity when the classical findings are present [36]. The afferent and efferent vasculature and smaller PAVMs may be difficult to see on a single-view chest radiograph. Best diagnostic results are obtained when a 2-view chest radiograph, posteroanterior view, and lateral view is performed [37]. The role of chest radiography in the diagnosis of a suspected PAVM is limited due to its poor sensitivity.
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Pulmonary Arteriovenous Malformation PAVM . Pulmonary angiogram detected only 77% to 80% of the PAVMs that were seen on MRA. In their study, Pulmonary Arteriovenous Malformation (PAVM) the majority of the PAVMs not detected by pulmonary angiogram were <5 mm in size. The size criterion was defined as the size of the PAVM itself and not of the feeding artery. A more recent study by Van den Heuvel et al [33] investigated the sensitivity of contrast-enhanced MRA for detection of PAVMs with a feeding artery >2 cm in children and young adults. They enrolled 53 patients who had a TTCE grade 2 or 3 who underwent chest CT and were found to have the PAVM with a feeding artery >2 cm to receive a contrast-enhanced MRA. The sensitivity of contrast-enhanced MRA to detect PAVMs with a feeding artery size of >2cm was 92%, and the specificity ranged from 67% to 96%. MRA Pulmonary Arteries Without IV Contrast There is no role for the routine use of MRA pulmonary angiography without IV contrast in the workup of a patient suspected of a PAVM. Pertechnetate Albumin Pulmonary Scan There is no role for pertechnetate albumin pulmonary scan in a modern day practice. Historically, this technique was used to detect and quantify right to left shunting before and after treatment of a PAVM [34,35]. Radiography Chest The radiographic appearance of a lower lobe pulmonary nodule with a branching afferent artery and dilated efferent vein defines the classical appearance of PAVM on chest radiography. The sensitivity of chest radiography is 60% to 70% with a 98% specificity when the classical findings are present [36]. The afferent and efferent vasculature and smaller PAVMs may be difficult to see on a single-view chest radiograph. Best diagnostic results are obtained when a 2-view chest radiograph, posteroanterior view, and lateral view is performed [37]. The role of chest radiography in the diagnosis of a suspected PAVM is limited due to its poor sensitivity.
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3094113
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acrac_3094113_12
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Pulmonary Arteriovenous Malformation PAVM
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US Echocardiography Transesophageal There is no role for TEE as a standalone diagnostic tool in the evaluation of PAVMs. The usefulness of TEE in the context of PAVM is to rule out intracardiac shunts [38]. Its ability to demonstrate the interatrial septum and the insertion of the pulmonary veins into the left atrium is useful to evaluate the anatomical variations [39]. US Echocardiography Transesophageal With IV Contrast TEE with IV agitated saline contrast material is not routinely used to diagnose PAVM. Contrast-enhanced TEE maybe helpful to locate a PAVM based on the excellent visualization of the 4 pulmonary venous ostia as veins drain into the left atrium. Based on the visualization of contrast material emanating from a particular pulmonary vein, the location of the PAVM in that venous territory can be confirmed [38,40]. In the presence of multiple PAVMs, the usefulness of this imaging modality in identifying the location of the PAVMs is limited. US Echocardiography Transthoracic Resting There is no role for TTE in the resting phase for evaluation of PAVM. It does allow evaluation of intracardiac shunts and assessment of cardiac function [38]. US Echocardiography Transthoracic With IV Contrast TTCE is an essential diagnostic test for patients suspected of having a PAVM. TTCE with agitated saline has a 98% to 99% sensitivity and a 67% to 91% specificity for detecting PAVMs [41]. The microbubbles are visualized after 3 to 8 cardiac cycles in the left atrium after initial opacification of the right chambers in patients with an intrapulmonary shunt [1]. TTCE does not provide any information regarding the size and location of the PAVM. Based on the appearance of the bubbles in the left atrium a semiquantitative grading system has been developed [42,43]. The grades are defined as 0, with no opacification, grade 1 with <30 bubbles, grade 2 with moderate filling, and grade 3 with complete opacification of the left atrium.
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Pulmonary Arteriovenous Malformation PAVM . US Echocardiography Transesophageal There is no role for TEE as a standalone diagnostic tool in the evaluation of PAVMs. The usefulness of TEE in the context of PAVM is to rule out intracardiac shunts [38]. Its ability to demonstrate the interatrial septum and the insertion of the pulmonary veins into the left atrium is useful to evaluate the anatomical variations [39]. US Echocardiography Transesophageal With IV Contrast TEE with IV agitated saline contrast material is not routinely used to diagnose PAVM. Contrast-enhanced TEE maybe helpful to locate a PAVM based on the excellent visualization of the 4 pulmonary venous ostia as veins drain into the left atrium. Based on the visualization of contrast material emanating from a particular pulmonary vein, the location of the PAVM in that venous territory can be confirmed [38,40]. In the presence of multiple PAVMs, the usefulness of this imaging modality in identifying the location of the PAVMs is limited. US Echocardiography Transthoracic Resting There is no role for TTE in the resting phase for evaluation of PAVM. It does allow evaluation of intracardiac shunts and assessment of cardiac function [38]. US Echocardiography Transthoracic With IV Contrast TTCE is an essential diagnostic test for patients suspected of having a PAVM. TTCE with agitated saline has a 98% to 99% sensitivity and a 67% to 91% specificity for detecting PAVMs [41]. The microbubbles are visualized after 3 to 8 cardiac cycles in the left atrium after initial opacification of the right chambers in patients with an intrapulmonary shunt [1]. TTCE does not provide any information regarding the size and location of the PAVM. Based on the appearance of the bubbles in the left atrium a semiquantitative grading system has been developed [42,43]. The grades are defined as 0, with no opacification, grade 1 with <30 bubbles, grade 2 with moderate filling, and grade 3 with complete opacification of the left atrium.
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3094113
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acrac_3094113_13
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Pulmonary Arteriovenous Malformation PAVM
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The grading system correlates well with the diagnosis of PAVM, with higher grades associated with larger shunts and cerebral complications [41,44,45]. Usefulness of the grading system to predict treatment of PAVM demonstrates that grades 2 and 3 have a positive predictive value of 0.21 (95% CI, 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively [44]. Adverse events including air embolism are rare with TTCE occurring in <1% [46]. Variant 3: Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging. Arteriography Pulmonary The real-time nature of pulmonary arteriography allows for high accuracy in delineating the angioarchitecture and detection of flow characteristics such as the early draining vein. In a study comparing the specificity of pulmonary arteriography and CTA, pulmonary arteriography was noted to have a higher specificity for detecting the Pulmonary Arteriovenous Malformation (PAVM) angioarchitecture compared to CTA (100% versus 78%) [24]. Pulmonary angiography is performed as a part of the treatment procedure and does not have a standalone diagnostic role in detecting PAVM. CT Chest With IV Contrast Contrast-enhanced CT chest offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Contrast-enhanced CT provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism [10,26]. Cross- sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CT Chest Without and With IV Contrast There is limited data to support obtaining a CT chest with and without IV contrast in the setting of suspected PAVM.
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Pulmonary Arteriovenous Malformation PAVM . The grading system correlates well with the diagnosis of PAVM, with higher grades associated with larger shunts and cerebral complications [41,44,45]. Usefulness of the grading system to predict treatment of PAVM demonstrates that grades 2 and 3 have a positive predictive value of 0.21 (95% CI, 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively [44]. Adverse events including air embolism are rare with TTCE occurring in <1% [46]. Variant 3: Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging. Arteriography Pulmonary The real-time nature of pulmonary arteriography allows for high accuracy in delineating the angioarchitecture and detection of flow characteristics such as the early draining vein. In a study comparing the specificity of pulmonary arteriography and CTA, pulmonary arteriography was noted to have a higher specificity for detecting the Pulmonary Arteriovenous Malformation (PAVM) angioarchitecture compared to CTA (100% versus 78%) [24]. Pulmonary angiography is performed as a part of the treatment procedure and does not have a standalone diagnostic role in detecting PAVM. CT Chest With IV Contrast Contrast-enhanced CT chest offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Contrast-enhanced CT provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism [10,26]. Cross- sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CT Chest Without and With IV Contrast There is limited data to support obtaining a CT chest with and without IV contrast in the setting of suspected PAVM.
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3094113
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acrac_3094113_14
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Pulmonary Arteriovenous Malformation PAVM
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A study by Nawaz et al [24] compared CT with and without IV contrast to DSA for assessment of PAVMs. Their study showed superior sensitivity of CT compared to DSA for detection of PAVM; however, the specificity for CT was inferior to that of DSA. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. The benefit of using CT chest without and with IV contrast for assessing PAVM compared to stand-alone CT without IV contrast or CT with IV contrast is unclear [24]. CT Chest Without IV Contrast Noncontrast chest CT scan is helpful in confirming the diagnosis of PAVM. Like CT chest with IV contrast, noncontrast CT offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Remy et al [28] were able to predict angioarchitecture of the PAVMs in 95% of cases using noncontrast CT and 3- D reconstruction. Cross-sectional anatomy displayed on CT chest without IV contrast is useful in treatment planning [10,27]. CTA Chest With IV Contrast CTA chest provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism. Unlike CTPA, the vascular enhancement during CTA is timed for the aorta and its branches and, thus, it may help identify systemic supply to PAVMs via the systemic arteries [10,29,30]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CTA Pulmonary Arteries With IV Contrast CTPA specifically assesses the pulmonary vasculature. IV contrast material is timed for optimum evaluation of the pulmonary arteries. Use of CTPA for evaluation of PAVM is used in clinical practice when considering a contrast- enhanced CT scan for evaluating PAVM.
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Pulmonary Arteriovenous Malformation PAVM . A study by Nawaz et al [24] compared CT with and without IV contrast to DSA for assessment of PAVMs. Their study showed superior sensitivity of CT compared to DSA for detection of PAVM; however, the specificity for CT was inferior to that of DSA. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. The benefit of using CT chest without and with IV contrast for assessing PAVM compared to stand-alone CT without IV contrast or CT with IV contrast is unclear [24]. CT Chest Without IV Contrast Noncontrast chest CT scan is helpful in confirming the diagnosis of PAVM. Like CT chest with IV contrast, noncontrast CT offers high spatial resolution and can detect the number, size, and distribution of PAVMs accurately. Remy et al [28] were able to predict angioarchitecture of the PAVMs in 95% of cases using noncontrast CT and 3- D reconstruction. Cross-sectional anatomy displayed on CT chest without IV contrast is useful in treatment planning [10,27]. CTA Chest With IV Contrast CTA chest provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism. Unlike CTPA, the vascular enhancement during CTA is timed for the aorta and its branches and, thus, it may help identify systemic supply to PAVMs via the systemic arteries [10,29,30]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. CTA Pulmonary Arteries With IV Contrast CTPA specifically assesses the pulmonary vasculature. IV contrast material is timed for optimum evaluation of the pulmonary arteries. Use of CTPA for evaluation of PAVM is used in clinical practice when considering a contrast- enhanced CT scan for evaluating PAVM.
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3094113
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acrac_3094113_15
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Pulmonary Arteriovenous Malformation PAVM
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Like other CT techniques, CTPA offers high special resolution and can detect the number, size, and distribution of PAVMs accurately. CTPA provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air [27]. Correlating the PAVM grade with contrast-enhanced echo has been shown to be more sensitive with CTPA compared to noncontrast CT [31]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. MRA Chest Without and With IV Contrast There is no role for the routine use of MRA chest without and with IV contrast in the workup of a patient suspected of a PAVM. MRA Chest Without IV Contrast There is no role for the routine use of MRA chest without IV contrast in the workup of a patient suspected of a PAVM. MRA Pulmonary Arteries Without and With IV Contrast Contrast-enhanced MRA pulmonary arteries provides anatomical information about the presence, number, size, and location of PAVMs. Schneider et al [32] evaluated 203 patients with HHT or first-degree relatives with HHT using contrast-enhanced MRA. Patients with definite and uncertain diagnosis of PAVM on MRA underwent pulmonary angiogram. Pulmonary angiogram detected only 77% to 80% of the PAVMs that were seen on MRA. In their study, the majority of the PAVMs not detected by pulmonary angiogram were <5 mm in size. The size criterion was defined as the size of the PAVM itself and not of the feeding artery. A more recent study by Van den Heuvel et al Pulmonary Arteriovenous Malformation (PAVM) [33] investigated the sensitivity of contrast-enhanced MRA for detection of PAVMs with a feeding artery >2 cm in children and young adults.
|
Pulmonary Arteriovenous Malformation PAVM . Like other CT techniques, CTPA offers high special resolution and can detect the number, size, and distribution of PAVMs accurately. CTPA provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. IV contrast material administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air [27]. Correlating the PAVM grade with contrast-enhanced echo has been shown to be more sensitive with CTPA compared to noncontrast CT [31]. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in treatment planning [10,27]. MRA Chest Without and With IV Contrast There is no role for the routine use of MRA chest without and with IV contrast in the workup of a patient suspected of a PAVM. MRA Chest Without IV Contrast There is no role for the routine use of MRA chest without IV contrast in the workup of a patient suspected of a PAVM. MRA Pulmonary Arteries Without and With IV Contrast Contrast-enhanced MRA pulmonary arteries provides anatomical information about the presence, number, size, and location of PAVMs. Schneider et al [32] evaluated 203 patients with HHT or first-degree relatives with HHT using contrast-enhanced MRA. Patients with definite and uncertain diagnosis of PAVM on MRA underwent pulmonary angiogram. Pulmonary angiogram detected only 77% to 80% of the PAVMs that were seen on MRA. In their study, the majority of the PAVMs not detected by pulmonary angiogram were <5 mm in size. The size criterion was defined as the size of the PAVM itself and not of the feeding artery. A more recent study by Van den Heuvel et al Pulmonary Arteriovenous Malformation (PAVM) [33] investigated the sensitivity of contrast-enhanced MRA for detection of PAVMs with a feeding artery >2 cm in children and young adults.
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3094113
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acrac_3094113_16
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Pulmonary Arteriovenous Malformation PAVM
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They enrolled 53 patients who had a TTCE grade 2 or 3 who underwent chest CT and were found to have the PAVM with a feeding artery >2 cm to receive a contrast-enhanced MRA. The sensitivity of contrast-enhanced MRA to detect PAVMs with a feeding artery size of >2cm was 92%, and the specificity ranged from 67% to 96%. MRA Pulmonary Arteries Without IV Contrast There is no role for the routine use of MRA pulmonary angiography without IV contrast in the workup of a patient suspected of a PAVM. Pertechnetate Albumin Pulmonary Scan There is no role for pertechnetate albumin pulmonary scan in a modern day practice. Historically, this technique was used to detect and quantify right to left shunting before and after treatment of a PAVM [34,35]. Radiography Chest The radiographic appearance of a lower lobe pulmonary nodule with a branching afferent artery and dilated efferent vein defines the classical appearance of PAVM on chest radiography. The sensitivity of chest radiography is 60% to 70% with a 98% specificity when the classical findings are present [36]. The afferent and efferent vasculature and smaller PAVMs may be difficult to see on a single-view chest radiograph. Best diagnostic results are obtained when a 2-view chest radiograph, posteroanterior view, and lateral view is performed [37]. US Echocardiography Transesophageal There is no role for TEE as a standalone diagnostic tool in the evaluation of PAVMs. The usefulness of TEE in the context of PAVM is to rule out intracardiac shunts [38]. Its ability to demonstrate the interatrial septum and the insertion of the pulmonary veins into the left atrium is useful to evaluate the anatomical variations [39]. US Echocardiography Transesophageal With IV Contrast TEE with IV agitated saline contrast material is not routinely used to diagnose PAVM. Contrast-enhanced TEE may be helpful to locate a PAVM based on the excellent visualization of the 4 pulmonary venous ostia as veins drain into the left atrium.
|
Pulmonary Arteriovenous Malformation PAVM . They enrolled 53 patients who had a TTCE grade 2 or 3 who underwent chest CT and were found to have the PAVM with a feeding artery >2 cm to receive a contrast-enhanced MRA. The sensitivity of contrast-enhanced MRA to detect PAVMs with a feeding artery size of >2cm was 92%, and the specificity ranged from 67% to 96%. MRA Pulmonary Arteries Without IV Contrast There is no role for the routine use of MRA pulmonary angiography without IV contrast in the workup of a patient suspected of a PAVM. Pertechnetate Albumin Pulmonary Scan There is no role for pertechnetate albumin pulmonary scan in a modern day practice. Historically, this technique was used to detect and quantify right to left shunting before and after treatment of a PAVM [34,35]. Radiography Chest The radiographic appearance of a lower lobe pulmonary nodule with a branching afferent artery and dilated efferent vein defines the classical appearance of PAVM on chest radiography. The sensitivity of chest radiography is 60% to 70% with a 98% specificity when the classical findings are present [36]. The afferent and efferent vasculature and smaller PAVMs may be difficult to see on a single-view chest radiograph. Best diagnostic results are obtained when a 2-view chest radiograph, posteroanterior view, and lateral view is performed [37]. US Echocardiography Transesophageal There is no role for TEE as a standalone diagnostic tool in the evaluation of PAVMs. The usefulness of TEE in the context of PAVM is to rule out intracardiac shunts [38]. Its ability to demonstrate the interatrial septum and the insertion of the pulmonary veins into the left atrium is useful to evaluate the anatomical variations [39]. US Echocardiography Transesophageal With IV Contrast TEE with IV agitated saline contrast material is not routinely used to diagnose PAVM. Contrast-enhanced TEE may be helpful to locate a PAVM based on the excellent visualization of the 4 pulmonary venous ostia as veins drain into the left atrium.
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3094113
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acrac_3094113_17
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Pulmonary Arteriovenous Malformation PAVM
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Based on the visualization of contrast material emanating from a particular pulmonary vein, the location of the PAVM in that venous territory can be confirmed [38,40]. In the presence of multiple PAVMs, the usefulness of this imaging modality in identifying the location of the PAVMs is limited. US Echocardiography Transthoracic Resting There is no role for TTE in the resting phase for the evaluation of PAVM. It does allow evaluation of intracardiac shunts and assessment of cardiac function [38]. US Echocardiography Transthoracic With IV Contrast TTCE is an essential diagnostic test for patients suspected of having a PAVM. TTCE with agitated saline has a 98% to 99% sensitivity and a 67% to 91% specificity for detecting PAVMs [41]. The microbubbles are visualized after 3 to 8 cardiac cycles in the left atrium after initial opacification of the right chambers in patients with an intrapulmonary shunt [1]. TTCE does not provide any information regarding the size and location of the PAVM. Based on the appearance of the bubbles in the left atrium a semiquantitative grading system has been developed [42,43]. The grades are defined as 0 with no opacification, grade 1 with <30 bubbles, grade 2 with moderate filling, and grade 3 with complete opacification of the left atrium. The grading system correlates well with the diagnosis of PAVM, with higher grades associated with larger shunts and cerebral complications [41,44,45]. Usefulness of the grading system to predict treatment of PAVM demonstrates that grades 2 and 3 have a positive predictive value of 0.21 (95% CI, 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively [44]. Adverse events including air embolism are rare with TTCE occurring in <1% [46]. Variant 4: Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
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Pulmonary Arteriovenous Malformation PAVM . Based on the visualization of contrast material emanating from a particular pulmonary vein, the location of the PAVM in that venous territory can be confirmed [38,40]. In the presence of multiple PAVMs, the usefulness of this imaging modality in identifying the location of the PAVMs is limited. US Echocardiography Transthoracic Resting There is no role for TTE in the resting phase for the evaluation of PAVM. It does allow evaluation of intracardiac shunts and assessment of cardiac function [38]. US Echocardiography Transthoracic With IV Contrast TTCE is an essential diagnostic test for patients suspected of having a PAVM. TTCE with agitated saline has a 98% to 99% sensitivity and a 67% to 91% specificity for detecting PAVMs [41]. The microbubbles are visualized after 3 to 8 cardiac cycles in the left atrium after initial opacification of the right chambers in patients with an intrapulmonary shunt [1]. TTCE does not provide any information regarding the size and location of the PAVM. Based on the appearance of the bubbles in the left atrium a semiquantitative grading system has been developed [42,43]. The grades are defined as 0 with no opacification, grade 1 with <30 bubbles, grade 2 with moderate filling, and grade 3 with complete opacification of the left atrium. The grading system correlates well with the diagnosis of PAVM, with higher grades associated with larger shunts and cerebral complications [41,44,45]. Usefulness of the grading system to predict treatment of PAVM demonstrates that grades 2 and 3 have a positive predictive value of 0.21 (95% CI, 0.05-0.36) and 0.87 (95% CI, 0.79-0.99), respectively [44]. Adverse events including air embolism are rare with TTCE occurring in <1% [46]. Variant 4: Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
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3094113
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acrac_3094113_18
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Pulmonary Arteriovenous Malformation PAVM
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Arteriography Pulmonary The real-time nature of pulmonary arteriography allows for high accuracy for delineating the angioarchitecture and detection of flow characteristics such as the early draining vein. Pulmonary angiogram is the reference standard to detect reperfusion of a treated AVM, but the angiogram is performed as a part of the treatment protocol and not done as a diagnostic test [10]. In patients who have inconclusive findings on CT, pulmonary angiography can assess recanalized PAVMs. Pulmonary Arteriovenous Malformation (PAVM) CT Chest With IV Contrast The high natural contrast inherent to pulmonary anatomy on noncontrast CT and the small risk of air embolism while administering IV medications renders CT chest with IV contrast unnecessary in the diagnosis of PAVM [10]. Artifacts from the embolic material limits the usefulness of contrast enhancement as a tool to evaluate reperfusion [47]. The role of contrast-enhanced CT has been studied after embolotherapy for PAVM in the context of detecting systemic collaterals by Brillet et al [29] in 32 patients. They found systemic collaterals in 13 patients that would otherwise have been missed on noncontrast CT. The role of contrast-enhanced CT scan after PAVM embolization is unclear. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in further treatment planning if new or recanalized PAVMs are detected [10,27]. CT Chest Without and With IV Contrast The high natural contrast inherent to pulmonary anatomy on noncontrast CT and the small risk of air embolism while administering IV medications renders CT chest with IV contrast unnecessary in the diagnosis of PAVM [10]. Artifacts from the embolic material limits the usefulness of contrast enhancement as a tool to evaluate reperfusion [47]. The role of contrast-enhanced CT has been studied after embolotherapy for PAVM in the context of detecting systemic collaterals by Brillet et al [29] in 32 patients.
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Pulmonary Arteriovenous Malformation PAVM . Arteriography Pulmonary The real-time nature of pulmonary arteriography allows for high accuracy for delineating the angioarchitecture and detection of flow characteristics such as the early draining vein. Pulmonary angiogram is the reference standard to detect reperfusion of a treated AVM, but the angiogram is performed as a part of the treatment protocol and not done as a diagnostic test [10]. In patients who have inconclusive findings on CT, pulmonary angiography can assess recanalized PAVMs. Pulmonary Arteriovenous Malformation (PAVM) CT Chest With IV Contrast The high natural contrast inherent to pulmonary anatomy on noncontrast CT and the small risk of air embolism while administering IV medications renders CT chest with IV contrast unnecessary in the diagnosis of PAVM [10]. Artifacts from the embolic material limits the usefulness of contrast enhancement as a tool to evaluate reperfusion [47]. The role of contrast-enhanced CT has been studied after embolotherapy for PAVM in the context of detecting systemic collaterals by Brillet et al [29] in 32 patients. They found systemic collaterals in 13 patients that would otherwise have been missed on noncontrast CT. The role of contrast-enhanced CT scan after PAVM embolization is unclear. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in further treatment planning if new or recanalized PAVMs are detected [10,27]. CT Chest Without and With IV Contrast The high natural contrast inherent to pulmonary anatomy on noncontrast CT and the small risk of air embolism while administering IV medications renders CT chest with IV contrast unnecessary in the diagnosis of PAVM [10]. Artifacts from the embolic material limits the usefulness of contrast enhancement as a tool to evaluate reperfusion [47]. The role of contrast-enhanced CT has been studied after embolotherapy for PAVM in the context of detecting systemic collaterals by Brillet et al [29] in 32 patients.
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acrac_3094113_19
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Pulmonary Arteriovenous Malformation PAVM
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They found systemic collaterals in 13 patients that would otherwise have been missed on noncontrast CT. The role of contrast-enhanced CT scan after PAVM embolization is unclear. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in further treatment planning if new or recanalized PAVMs are detected [10,27]. CTA Chest With IV Contrast CTA also provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. Contrast administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism. CTA may help identify systemic supply to large PAVMs via the systemic arteries [10,29,30]. Artifacts from the embolic material limit the usefulness of contrast enhancement as a tool to evaluate the reperfusion [47]. The role of contrast-enhanced CT has been studied after embolotherapy for PAVM in the context of detecting systemic collaterals by Brillet et al [29] in 32 patients. They found systemic collaterals in 13 patients that would otherwise have been missed on noncontrast CT. Another study by Remy-Jardin et at [30] showed that long-term CTA follow-up of initially successfully treated PAVMs revealed successful embolotherapy of 75% and partially or completely failed embolotherapy of 25% of PAVMs. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in further treatment planning if new or recanalized PAVMs are detected [10,27]. CTA Pulmonary Arteries With IV Contrast CTPA specifically assesses the pulmonary vasculature. IV contrast is timed for optimum evaluation of the pulmonary arteries. Although, there is limited literature specific to CTA of pulmonary arteries for evaluation of PAVM. This protocol is used in clinical practice when considering contrast-enhanced CT scan for evaluating PAVM. Like other CT techniques, CTPA offers high special resolution and can detect the number, size, and distribution of PAVMs accurately.
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Pulmonary Arteriovenous Malformation PAVM . They found systemic collaterals in 13 patients that would otherwise have been missed on noncontrast CT. The role of contrast-enhanced CT scan after PAVM embolization is unclear. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in further treatment planning if new or recanalized PAVMs are detected [10,27]. CTA Chest With IV Contrast CTA also provides similar diagnostic accuracy as noncontrast CT due to the high natural contrast inherent to pulmonary anatomy. Contrast administration adds a small risk of air embolism in patients with PAVM. Adequate precaution should be taken to prevent air embolism. CTA may help identify systemic supply to large PAVMs via the systemic arteries [10,29,30]. Artifacts from the embolic material limit the usefulness of contrast enhancement as a tool to evaluate the reperfusion [47]. The role of contrast-enhanced CT has been studied after embolotherapy for PAVM in the context of detecting systemic collaterals by Brillet et al [29] in 32 patients. They found systemic collaterals in 13 patients that would otherwise have been missed on noncontrast CT. Another study by Remy-Jardin et at [30] showed that long-term CTA follow-up of initially successfully treated PAVMs revealed successful embolotherapy of 75% and partially or completely failed embolotherapy of 25% of PAVMs. Cross-sectional anatomy displayed on CT chest with IV contrast is useful in further treatment planning if new or recanalized PAVMs are detected [10,27]. CTA Pulmonary Arteries With IV Contrast CTPA specifically assesses the pulmonary vasculature. IV contrast is timed for optimum evaluation of the pulmonary arteries. Although, there is limited literature specific to CTA of pulmonary arteries for evaluation of PAVM. This protocol is used in clinical practice when considering contrast-enhanced CT scan for evaluating PAVM. Like other CT techniques, CTPA offers high special resolution and can detect the number, size, and distribution of PAVMs accurately.
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3094113
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