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acrac_69509_37 | Cranial Neuropathy | Lesions affecting the medulla oblongata, the subarachnoid space, or the posterior skull base, including the jugular foramen and hypoglossal canal, can lead to multiple CN palsies affecting CN IX through CN XII in variable patterns. Patients with medullary lesions will typically have additional neurologic findings such as long tract signs, nystagmus, vertigo, ataxia, nausea, and vomiting. A thorough neurologic examination evaluating for these associated signs can localize a process to the brainstem [18,135]. Imaging protocols can then be tailored to evaluate the suspected region of anatomy affected. Most brainstem syndromes are due to brainstem infarctions and hemorrhages [132]. Wallenberg syndrome or lateral medullary syndrome is typically due to occlusion of the posterior inferior cerebellar artery. Additional disorders that may affect the brainstem include demyelinating disease, primary brainstem tumors, metastasis, encephalitis, Arnold-Chiari malformations, and syringobulbia [18,132]. Multiple different jugular foramen syndromes are described based on variable patterns of CN palsies affecting CN IX through CN XII and include Vernet syndrome (IX, X, XI), Collet-Sicard syndrome (IX, X, XI, XII), and Villaret syndrome (IX, X, XI, XII and cervical sympathetic trunk). Lesions affecting the jugular foramen leading to jugular foramen syndromes include jugular foramen tumors (paragangliomas, schwannomas, and meningiomas), infection, leptomeningeal processes, metastasis, trauma, cholesteatoma, and vascular lesions [147,148,193]. Dissection of the internal carotid artery can result in isolated acute CN XII palsy or less commonly multiple variable patterns of CN palsies including involvement of CN IX through CN XII [185-187]. Leptomeningeal processes can lead to variable patterns of cranial neuropathy [18,132]. CT Head There is no relevant literature to support the use of routine head CT in the initial evaluation of multiple lower CN palsies. | Cranial Neuropathy. Lesions affecting the medulla oblongata, the subarachnoid space, or the posterior skull base, including the jugular foramen and hypoglossal canal, can lead to multiple CN palsies affecting CN IX through CN XII in variable patterns. Patients with medullary lesions will typically have additional neurologic findings such as long tract signs, nystagmus, vertigo, ataxia, nausea, and vomiting. A thorough neurologic examination evaluating for these associated signs can localize a process to the brainstem [18,135]. Imaging protocols can then be tailored to evaluate the suspected region of anatomy affected. Most brainstem syndromes are due to brainstem infarctions and hemorrhages [132]. Wallenberg syndrome or lateral medullary syndrome is typically due to occlusion of the posterior inferior cerebellar artery. Additional disorders that may affect the brainstem include demyelinating disease, primary brainstem tumors, metastasis, encephalitis, Arnold-Chiari malformations, and syringobulbia [18,132]. Multiple different jugular foramen syndromes are described based on variable patterns of CN palsies affecting CN IX through CN XII and include Vernet syndrome (IX, X, XI), Collet-Sicard syndrome (IX, X, XI, XII), and Villaret syndrome (IX, X, XI, XII and cervical sympathetic trunk). Lesions affecting the jugular foramen leading to jugular foramen syndromes include jugular foramen tumors (paragangliomas, schwannomas, and meningiomas), infection, leptomeningeal processes, metastasis, trauma, cholesteatoma, and vascular lesions [147,148,193]. Dissection of the internal carotid artery can result in isolated acute CN XII palsy or less commonly multiple variable patterns of CN palsies including involvement of CN IX through CN XII [185-187]. Leptomeningeal processes can lead to variable patterns of cranial neuropathy [18,132]. CT Head There is no relevant literature to support the use of routine head CT in the initial evaluation of multiple lower CN palsies. | 69509 |
acrac_69509_38 | Cranial Neuropathy | CT Maxillofacial There is no relevant literature to support the use of maxillofacial CT in the initial evaluation of multiple lower CN palsies. CT Temporal Bone There is no relevant literature to support the use of temporal bone CT in the initial evaluation of multiple lower CN palsies. CT Neck Multiple different jugular foramen syndromes can result in variable patterns of CN palsies affecting CN IX through CN XII. Lesions involving the jugular foramen can extend caudally in the neck to involve the carotid space. CT is complementary to MRI in assessing jugular foramen lesions or for evaluating for carotid space lesions. Thin-cut high-resolution bone algorithm windows are useful to delineate skull base fractures, hyperostosis, skull base erosion, intratumoral calcification, and the bony margins of the jugular foramen and nearby skull base foramina [144-148]. Contrast should be administered. There is no relevant literature to support the use of combined pre- and postcontrast imaging. CTA Head and Neck Most brainstem syndromes are due to brainstem infarctions and hemorrhages, which are best imaged with MRI [132]. CTA may be complementary to CT or MRI to characterize the vasculature in these clinical scenarios. Cranial Neuropathy When dissection of the internal carotid artery is clinically suspected as a cause of multiple lower CN palsies, CTA may be useful to evaluate for dissection, particularly in the emergent setting. In a study comparing CTA with conventional angiography, CTA had a sensitivity of 66% when evaluating for blunt carotid vascular injury, with most false-negatives representing low grade injuries [190]. In a comparative study, multidetector CT/CTA demonstrated more features of cervical artery (internal carotid and vertebral arteries) dissection compared with MRI/MRA. There was no significant reader preference for MRI/MRA compared with CT/CTA when evaluating for internal carotid artery dissection. MRI/MRA provided additional characterization of ischemic complications [191]. | Cranial Neuropathy. CT Maxillofacial There is no relevant literature to support the use of maxillofacial CT in the initial evaluation of multiple lower CN palsies. CT Temporal Bone There is no relevant literature to support the use of temporal bone CT in the initial evaluation of multiple lower CN palsies. CT Neck Multiple different jugular foramen syndromes can result in variable patterns of CN palsies affecting CN IX through CN XII. Lesions involving the jugular foramen can extend caudally in the neck to involve the carotid space. CT is complementary to MRI in assessing jugular foramen lesions or for evaluating for carotid space lesions. Thin-cut high-resolution bone algorithm windows are useful to delineate skull base fractures, hyperostosis, skull base erosion, intratumoral calcification, and the bony margins of the jugular foramen and nearby skull base foramina [144-148]. Contrast should be administered. There is no relevant literature to support the use of combined pre- and postcontrast imaging. CTA Head and Neck Most brainstem syndromes are due to brainstem infarctions and hemorrhages, which are best imaged with MRI [132]. CTA may be complementary to CT or MRI to characterize the vasculature in these clinical scenarios. Cranial Neuropathy When dissection of the internal carotid artery is clinically suspected as a cause of multiple lower CN palsies, CTA may be useful to evaluate for dissection, particularly in the emergent setting. In a study comparing CTA with conventional angiography, CTA had a sensitivity of 66% when evaluating for blunt carotid vascular injury, with most false-negatives representing low grade injuries [190]. In a comparative study, multidetector CT/CTA demonstrated more features of cervical artery (internal carotid and vertebral arteries) dissection compared with MRI/MRA. There was no significant reader preference for MRI/MRA compared with CT/CTA when evaluating for internal carotid artery dissection. MRI/MRA provided additional characterization of ischemic complications [191]. | 69509 |
acrac_69509_39 | Cranial Neuropathy | In a retrospective review of the literature comparing test performance of MRI/MRA with CTA in the assessment of cervicocephalic arterial dissection with a reference standard of catheter angiography, the authors report MRI sensitivities and specificities of 50% to 79% and 67% to 99%, respectively, and CTA sensitivities and specificities of 51% to 98% and 67% to 100%, respectively (based on prospective studies) [192]. The authors concluded that the test characteristics of MRI/MRA and CTA for diagnosis of cervicocephalic arterial dissection were similar and study selection should be based on individual factors including urgency of imaging. Limitations of the literature assessing MRA and CTA for dissection include most studies evaluate test performance in the clinical setting of traumatic dissection rather than spontaneous dissection. CTA is often used as a primary screening tool when carotid dissection is suspected in the emergent setting [190]. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT skull base to mid-thigh in the initial evaluation of multiple lower CN palsies. MRA Head and Neck Most brainstem syndromes are due to brainstem infarctions and hemorrhages [132]. MRA may be complementary to MRI to characterize the vasculature in these clinical scenarios. When dissection of the internal carotid artery is clinically suspected as a cause of multiple lower CN palsies clinically, MRA may be useful to evaluate for dissection although it is less accessible emergently compared with CTA. In a comparative study, multidetector CT/CTA demonstrated more features of cervical artery (internal carotid and vertebral arteries) dissection compared with MRI/MRA. There was no significant reader preference for MRI/MRA compared with CT/CTA when evaluating for internal carotid artery dissection. MRI/MRA provided additional characterization of ischemic complications [187]. | Cranial Neuropathy. In a retrospective review of the literature comparing test performance of MRI/MRA with CTA in the assessment of cervicocephalic arterial dissection with a reference standard of catheter angiography, the authors report MRI sensitivities and specificities of 50% to 79% and 67% to 99%, respectively, and CTA sensitivities and specificities of 51% to 98% and 67% to 100%, respectively (based on prospective studies) [192]. The authors concluded that the test characteristics of MRI/MRA and CTA for diagnosis of cervicocephalic arterial dissection were similar and study selection should be based on individual factors including urgency of imaging. Limitations of the literature assessing MRA and CTA for dissection include most studies evaluate test performance in the clinical setting of traumatic dissection rather than spontaneous dissection. CTA is often used as a primary screening tool when carotid dissection is suspected in the emergent setting [190]. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT skull base to mid-thigh in the initial evaluation of multiple lower CN palsies. MRA Head and Neck Most brainstem syndromes are due to brainstem infarctions and hemorrhages [132]. MRA may be complementary to MRI to characterize the vasculature in these clinical scenarios. When dissection of the internal carotid artery is clinically suspected as a cause of multiple lower CN palsies clinically, MRA may be useful to evaluate for dissection although it is less accessible emergently compared with CTA. In a comparative study, multidetector CT/CTA demonstrated more features of cervical artery (internal carotid and vertebral arteries) dissection compared with MRI/MRA. There was no significant reader preference for MRI/MRA compared with CT/CTA when evaluating for internal carotid artery dissection. MRI/MRA provided additional characterization of ischemic complications [187]. | 69509 |
acrac_69509_40 | Cranial Neuropathy | In a retrospective review of the literature comparing test performance of MRI/MRA with CTA in the assessment of cervicocephalic arterial dissection with a reference standard of catheter angiography, the authors report MRI sensitivities and specificities of 50% to 79% and 67% to 99%, respectively, and CTA sensitivities and specificities of 51% to 98% and 67% to 100%, respectively (based on prospective studies) [188]. The authors concluded that the test characteristics of MRI/MRA and CTA for diagnosis of cervicocephalic arterial dissection were similar and study selection should be based on individual factors including urgency of imaging. Limitations of the literature assessing MRA and CTA for dissection include most studies evaluate test performance in the clinical setting of traumatic dissection rather than spontaneous dissection. CTA is often used as a primary screening tool when carotid dissection is suspected in the emergent setting [186]. Thin-cut heavily T2-weighted contrast-enhanced modified balanced SSFP sequences and contrast-enhanced MRA focused on the posterior skull provide detailed imaging of the lower nerves within the jugular foramen, and their relationship to the hypoglossal nerve as they exit the skull base, with 90% to 100% of imaged CN IX, CN X, and CN XII visible [24]. There is variable direct visualization of CN XI with the cranial segment identified in 88% of the sides and the spinal segment identified in 93% of the sides in one study [149]. Another study reported lower rates with the spinal root of CN XI visualized in only 51% of subjects using heavily T2-weighted contrast-enhanced modified balanced SSFP sequences [24]. Cranial Neuropathy DWI can be used to assess for acute brainstem infarction, cholesteatoma, and for characterizing tumor cellularity. False-negative DWI can occur in the setting of very small ischemic brainstem infarcts [137,138]. | Cranial Neuropathy. In a retrospective review of the literature comparing test performance of MRI/MRA with CTA in the assessment of cervicocephalic arterial dissection with a reference standard of catheter angiography, the authors report MRI sensitivities and specificities of 50% to 79% and 67% to 99%, respectively, and CTA sensitivities and specificities of 51% to 98% and 67% to 100%, respectively (based on prospective studies) [188]. The authors concluded that the test characteristics of MRI/MRA and CTA for diagnosis of cervicocephalic arterial dissection were similar and study selection should be based on individual factors including urgency of imaging. Limitations of the literature assessing MRA and CTA for dissection include most studies evaluate test performance in the clinical setting of traumatic dissection rather than spontaneous dissection. CTA is often used as a primary screening tool when carotid dissection is suspected in the emergent setting [186]. Thin-cut heavily T2-weighted contrast-enhanced modified balanced SSFP sequences and contrast-enhanced MRA focused on the posterior skull provide detailed imaging of the lower nerves within the jugular foramen, and their relationship to the hypoglossal nerve as they exit the skull base, with 90% to 100% of imaged CN IX, CN X, and CN XII visible [24]. There is variable direct visualization of CN XI with the cranial segment identified in 88% of the sides and the spinal segment identified in 93% of the sides in one study [149]. Another study reported lower rates with the spinal root of CN XI visualized in only 51% of subjects using heavily T2-weighted contrast-enhanced modified balanced SSFP sequences [24]. Cranial Neuropathy DWI can be used to assess for acute brainstem infarction, cholesteatoma, and for characterizing tumor cellularity. False-negative DWI can occur in the setting of very small ischemic brainstem infarcts [137,138]. | 69509 |
acrac_69509_41 | Cranial Neuropathy | Thinner slice axial DWI or thin-section coronal DWI may improve sensitivity for detecting small acute brainstem infarction, with nearly 25% of acute brainstem infarcts more easily seen on thin-cut coronal DWI compared with standard axial DWI in one study [138,194]. Thin-cut heavily T2-weighted contrast-enhanced modified balanced SSFP sequences and contrast-enhanced MRA focused on the posterior skull provide detailed imaging of the lower nerves within the jugular foramen, and their relationship to the hypoglossal nerve as they exit the skull base, with 90% to 100% of imaged CN IX, CN X, and CN XII visible [24]. There is variable direct visualization of CN XI with the cranial segment identified in 88% of the sides and the spinal segment identified in 93% of the sides in one study [149]. Another study reported lower rates with the spinal root of CN XI visualized in only 51% of subjects using heavily T2-weighted contrast-enhanced modified balanced SSFP sequences [24]. DWI can be used to assess for acute brainstem infarction, cholesteatoma, and for characterizing tumor cellularity. False-negative DWI can occur in the setting of very small ischemic brainstem infarcts [137,138]. Thinner slice axial DWI or thin-section coronal DWI may improve sensitivity for detecting acute brainstem infarction, with nearly 25% of acute brainstem infarcts more easily seen on thin-cut coronal DWI compared with standard axial DWI in one study [138,194]. US Neck There is no relevant literature to support the use of US neck in the initial evaluation of multiple lower CN palsies. Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging. The compact anatomy of the brainstem results in close proximity of multiple CN nuclei, and the complex anatomy of the head and neck results in close proximity and interconnection of multiple CNs, which can lead to multiple cranial neuropathies. Multiple middle and lower CN palsies are discussed in Variant 4 and 9, respectively. | Cranial Neuropathy. Thinner slice axial DWI or thin-section coronal DWI may improve sensitivity for detecting small acute brainstem infarction, with nearly 25% of acute brainstem infarcts more easily seen on thin-cut coronal DWI compared with standard axial DWI in one study [138,194]. Thin-cut heavily T2-weighted contrast-enhanced modified balanced SSFP sequences and contrast-enhanced MRA focused on the posterior skull provide detailed imaging of the lower nerves within the jugular foramen, and their relationship to the hypoglossal nerve as they exit the skull base, with 90% to 100% of imaged CN IX, CN X, and CN XII visible [24]. There is variable direct visualization of CN XI with the cranial segment identified in 88% of the sides and the spinal segment identified in 93% of the sides in one study [149]. Another study reported lower rates with the spinal root of CN XI visualized in only 51% of subjects using heavily T2-weighted contrast-enhanced modified balanced SSFP sequences [24]. DWI can be used to assess for acute brainstem infarction, cholesteatoma, and for characterizing tumor cellularity. False-negative DWI can occur in the setting of very small ischemic brainstem infarcts [137,138]. Thinner slice axial DWI or thin-section coronal DWI may improve sensitivity for detecting acute brainstem infarction, with nearly 25% of acute brainstem infarcts more easily seen on thin-cut coronal DWI compared with standard axial DWI in one study [138,194]. US Neck There is no relevant literature to support the use of US neck in the initial evaluation of multiple lower CN palsies. Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging. The compact anatomy of the brainstem results in close proximity of multiple CN nuclei, and the complex anatomy of the head and neck results in close proximity and interconnection of multiple CNs, which can lead to multiple cranial neuropathies. Multiple middle and lower CN palsies are discussed in Variant 4 and 9, respectively. | 69509 |
acrac_69509_42 | Cranial Neuropathy | Perineural tumor spread can lead to isolated or multiple CN palsies and is the macroscopic spread of tumor along the course of a nerve distant from the site of the primary tumor as detected on imaging. It should be distinguished from perineural invasion, which is local invasion detected on histopathologic diagnosis at the primary tumor site [66,124]. Perineural tumor spread on imaging is associated with a worse prognosis [195]. The trigeminal (CN V) and facial (CN VII) nerves are most commonly affected by perineural tumor spread, although any nerve traveling in the vicinity of a malignancy may become involved. A multitude of tumors can result in perineural tumor spread, with squamous cell carcinoma (cutaneous and mucosal), adenoid cystic carcinoma, melanoma, lymphoma, basal cell carcinoma, and mucoepidermoid carcinoma most commonly occurring in the head and neck. Clues to perineural tumor spread include effacement of perineural and juxtaforaminal fat; asymmetric nerve enlargement or enhancement; osseous foraminal enlargement or erosion; and imaging features of denervation injury [65,66,104,123,124,196]. CT Head There is no relevant literature to support the use of routine head CT in the initial evaluation of perineural spread of tumor. CT Maxillofacial There is no relevant literature to support the use of routine maxillofacial CT in the initial evaluation of perineural spread of tumor. Contrast-enhanced maxillofacial CT may be complementary to MRI and is useful for characterizing osseous changes of skull base and neural foramina; however, contrast-enhanced neck CT with thin- cut high-resolution bone algorithm windows through the skull base can provide similar information while Cranial Neuropathy simultaneously staging the neck [64,66]. There is no relevant literature to support the use of combined pre- and postcontrast imaging. CT Temporal Bone There is no relevant literature to support the use of routine temporal bone CT in the initial evaluation of perineural spread of tumor. | Cranial Neuropathy. Perineural tumor spread can lead to isolated or multiple CN palsies and is the macroscopic spread of tumor along the course of a nerve distant from the site of the primary tumor as detected on imaging. It should be distinguished from perineural invasion, which is local invasion detected on histopathologic diagnosis at the primary tumor site [66,124]. Perineural tumor spread on imaging is associated with a worse prognosis [195]. The trigeminal (CN V) and facial (CN VII) nerves are most commonly affected by perineural tumor spread, although any nerve traveling in the vicinity of a malignancy may become involved. A multitude of tumors can result in perineural tumor spread, with squamous cell carcinoma (cutaneous and mucosal), adenoid cystic carcinoma, melanoma, lymphoma, basal cell carcinoma, and mucoepidermoid carcinoma most commonly occurring in the head and neck. Clues to perineural tumor spread include effacement of perineural and juxtaforaminal fat; asymmetric nerve enlargement or enhancement; osseous foraminal enlargement or erosion; and imaging features of denervation injury [65,66,104,123,124,196]. CT Head There is no relevant literature to support the use of routine head CT in the initial evaluation of perineural spread of tumor. CT Maxillofacial There is no relevant literature to support the use of routine maxillofacial CT in the initial evaluation of perineural spread of tumor. Contrast-enhanced maxillofacial CT may be complementary to MRI and is useful for characterizing osseous changes of skull base and neural foramina; however, contrast-enhanced neck CT with thin- cut high-resolution bone algorithm windows through the skull base can provide similar information while Cranial Neuropathy simultaneously staging the neck [64,66]. There is no relevant literature to support the use of combined pre- and postcontrast imaging. CT Temporal Bone There is no relevant literature to support the use of routine temporal bone CT in the initial evaluation of perineural spread of tumor. | 69509 |
acrac_69509_43 | Cranial Neuropathy | Temporal bone CT with IV contrast may be complementary to MRI and is useful for characterizing osseous changes of the skull base and neural foramina and may be useful to characterize perineural fat planes; however, contrast-enhanced neck CT with thin-cut high-resolution bone algorithm windows through the skull base can provide similar information while simultaneously staging the neck [64,66]. There is no relevant literature to support the use of combined pre- and postcontrast imaging. CT Neck MRI has better sensitivity for detection of perineural spread of tumor compared with CT and is the preferred study for initial assessment of perineural spread of tumor [65]. The trigeminal (CN V) and facial (CN VII) nerves are most commonly affected by perineural tumor spread and have branches extending into the face and neck. Neck CT may be complementary to MRI and is useful for characterizing osseous changes of the skull base and neural foramina and may be useful to characterize perineural fat planes while simultaneously staging the neck [64,66]. Contrast should be administered. There is no relevant literature to support the use of combined pre- and postcontrast imaging. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of perineural spread of tumor. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is not routinely used in the initial evaluation of the perineural spread of tumor, although perineural tumor spread may be detected on metabolic imaging. FDG-PET/CT may be useful for staging and response assessment in patients with a known primary malignancy [195,197]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164]. MRA Head and Neck There is no relevant literature to support the use of MRA in the initial evaluation of perineural spread of tumor. | Cranial Neuropathy. Temporal bone CT with IV contrast may be complementary to MRI and is useful for characterizing osseous changes of the skull base and neural foramina and may be useful to characterize perineural fat planes; however, contrast-enhanced neck CT with thin-cut high-resolution bone algorithm windows through the skull base can provide similar information while simultaneously staging the neck [64,66]. There is no relevant literature to support the use of combined pre- and postcontrast imaging. CT Neck MRI has better sensitivity for detection of perineural spread of tumor compared with CT and is the preferred study for initial assessment of perineural spread of tumor [65]. The trigeminal (CN V) and facial (CN VII) nerves are most commonly affected by perineural tumor spread and have branches extending into the face and neck. Neck CT may be complementary to MRI and is useful for characterizing osseous changes of the skull base and neural foramina and may be useful to characterize perineural fat planes while simultaneously staging the neck [64,66]. Contrast should be administered. There is no relevant literature to support the use of combined pre- and postcontrast imaging. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of perineural spread of tumor. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is not routinely used in the initial evaluation of the perineural spread of tumor, although perineural tumor spread may be detected on metabolic imaging. FDG-PET/CT may be useful for staging and response assessment in patients with a known primary malignancy [195,197]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164]. MRA Head and Neck There is no relevant literature to support the use of MRA in the initial evaluation of perineural spread of tumor. | 69509 |
acrac_69509_44 | Cranial Neuropathy | Sensitivities for MRI detection of perineural spread of tumor range from 73% to 100% and vary according to the nerve evaluated and timing of imaging relative to tissue sampling [65,104,123-125]. MRI may underestimate microscopic perineural spread of a tumor [123-125]. Advanced imaging techniques such as tractography may be useful to detect perineural tumor spread but require further investigation [130]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164]. Cranial Neuropathy Sensitivities for MRI detection of perineural spread of a tumor range from 73% to 100% and vary according to the nerve evaluated and timing of imaging relative to tissue sampling [65,104,123-125]. MRI may underestimate microscopic perineural spread of a tumor [123-125]. Advanced imaging techniques such as tractography may be useful to detect perineural tumor spread but require further investigation [130]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164]. Cranial Neuropathy Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. | Cranial Neuropathy. Sensitivities for MRI detection of perineural spread of tumor range from 73% to 100% and vary according to the nerve evaluated and timing of imaging relative to tissue sampling [65,104,123-125]. MRI may underestimate microscopic perineural spread of a tumor [123-125]. Advanced imaging techniques such as tractography may be useful to detect perineural tumor spread but require further investigation [130]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164]. Cranial Neuropathy Sensitivities for MRI detection of perineural spread of a tumor range from 73% to 100% and vary according to the nerve evaluated and timing of imaging relative to tissue sampling [65,104,123-125]. MRI may underestimate microscopic perineural spread of a tumor [123-125]. Advanced imaging techniques such as tractography may be useful to detect perineural tumor spread but require further investigation [130]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164]. Cranial Neuropathy Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. | 69509 |
acrac_69495_0 | Palpable Breast Masses | Imaging evaluation is necessary to adequately characterize a palpable breast mass. After thorough clinical breast examination, usually by the referring clinician or by a specialist breast clinician, the radiologist must be able to establish concordance between the clinically detected mass and the imaging features at that location [2]. The negative predictive value of mammography with ultrasound (US) in the context of a palpable mass ranges from 97.4% to 100% [7-10]. Nevertheless, negative imaging evaluation should not deter biopsy when a strongly suspicious finding is present on physical examination. OR aUniversity of Michigan, Ann Arbor, Michigan. bResearch Author, Duke University Medical Center, Durham, North Carolina. cPanel Chair, Alpert Medical School of Brown University, Providence, Rhode Island. dPanel Vice-Chair, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. eWashington University School of Medicine, Saint Louis, Missouri. fPenn State Health Hershey Medical Center, Hershey, Pennsylvania. gUniversity of Utah, Salt Lake City, Utah. hKaiser Permanente, Atlanta, Georgia. iMemorial Sloan Kettering Cancer Center, New York, New York. jUniversity of Washington, Seattle, Washington; American College of Obstetricians and Gynecologists. kSt. Bernards Healthcare, Jonesboro, Arkansas. lDuke Signature Care, Durham, North Carolina; American College of Physicians. mUMass Memorial Medical Center/UMass Chan Medical School, Worcester, Massachusetts. nProMedica Breast Care, Toledo, Ohio. oFox Chase Cancer Center, Philadelphia, Pennsylvania; American College of Surgeons. pHoag Family Cancer Institute, Newport Beach, California and University of Southern California, Los Angeles, California; Commission on Nuclear Medicine and Molecular Imaging. qSpecialty Chair, NYU Clinical Cancer Center, New York, New York. | Palpable Breast Masses. Imaging evaluation is necessary to adequately characterize a palpable breast mass. After thorough clinical breast examination, usually by the referring clinician or by a specialist breast clinician, the radiologist must be able to establish concordance between the clinically detected mass and the imaging features at that location [2]. The negative predictive value of mammography with ultrasound (US) in the context of a palpable mass ranges from 97.4% to 100% [7-10]. Nevertheless, negative imaging evaluation should not deter biopsy when a strongly suspicious finding is present on physical examination. OR aUniversity of Michigan, Ann Arbor, Michigan. bResearch Author, Duke University Medical Center, Durham, North Carolina. cPanel Chair, Alpert Medical School of Brown University, Providence, Rhode Island. dPanel Vice-Chair, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. eWashington University School of Medicine, Saint Louis, Missouri. fPenn State Health Hershey Medical Center, Hershey, Pennsylvania. gUniversity of Utah, Salt Lake City, Utah. hKaiser Permanente, Atlanta, Georgia. iMemorial Sloan Kettering Cancer Center, New York, New York. jUniversity of Washington, Seattle, Washington; American College of Obstetricians and Gynecologists. kSt. Bernards Healthcare, Jonesboro, Arkansas. lDuke Signature Care, Durham, North Carolina; American College of Physicians. mUMass Memorial Medical Center/UMass Chan Medical School, Worcester, Massachusetts. nProMedica Breast Care, Toledo, Ohio. oFox Chase Cancer Center, Philadelphia, Pennsylvania; American College of Surgeons. pHoag Family Cancer Institute, Newport Beach, California and University of Southern California, Los Angeles, California; Commission on Nuclear Medicine and Molecular Imaging. qSpecialty Chair, NYU Clinical Cancer Center, New York, New York. | 69495 |
acrac_69495_1 | Palpable Breast Masses | 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] Palpable Breast Masses Discussion of Procedures by Variant Variant 1: Adult female, 40 years of age or older. Palpable breast mass. Initial imaging. Digital Breast Tomosynthesis Diagnostic Diagnostic digital breast tomosynthesis (DBT) should be used for initial imaging evaluation. A small radio-opaque marker is placed on the skin over the palpable finding to identify its location. Several prior studies have shown the diagnostic accuracy of DBT is equivalent to or better than supplemental diagnostic mammographic views in the workup of women with clinical signs and symptoms and in women recalled from screening [11-14]. The added features of planar imaging and thin-section reconstructions allow further assessment of potential false-positive findings. In a recent study, DBT provided similarly accurate diagnostic results as compared with digital mammography (DM) in women with palpable breast masses for detecting breast cancer using either combination DM with DBT (DM/DBT) or DM alone [15]. Several small studies, which specifically included women presenting with clinical symptoms including palpable lumps, demonstrated increased accuracy on combination DM/DBT compared with DM alone [13,16,17]. Additionally, it was demonstrated that DBT may improve lesion detection and characterization with higher conspicuity scores as compared with conventional DM imaging, particularly for cancers presenting as spiculated masses and distortions [17]. | Palpable Breast Masses. 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] Palpable Breast Masses Discussion of Procedures by Variant Variant 1: Adult female, 40 years of age or older. Palpable breast mass. Initial imaging. Digital Breast Tomosynthesis Diagnostic Diagnostic digital breast tomosynthesis (DBT) should be used for initial imaging evaluation. A small radio-opaque marker is placed on the skin over the palpable finding to identify its location. Several prior studies have shown the diagnostic accuracy of DBT is equivalent to or better than supplemental diagnostic mammographic views in the workup of women with clinical signs and symptoms and in women recalled from screening [11-14]. The added features of planar imaging and thin-section reconstructions allow further assessment of potential false-positive findings. In a recent study, DBT provided similarly accurate diagnostic results as compared with digital mammography (DM) in women with palpable breast masses for detecting breast cancer using either combination DM with DBT (DM/DBT) or DM alone [15]. Several small studies, which specifically included women presenting with clinical symptoms including palpable lumps, demonstrated increased accuracy on combination DM/DBT compared with DM alone [13,16,17]. Additionally, it was demonstrated that DBT may improve lesion detection and characterization with higher conspicuity scores as compared with conventional DM imaging, particularly for cancers presenting as spiculated masses and distortions [17]. | 69495 |
acrac_69495_2 | Palpable Breast Masses | Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET breast dedicated in the initial evaluation of a woman presenting with a palpable mass [2]. In several series evaluating palpable breast abnormalities [18-20], the sensitivity of mammography alone was 86% to 91%. Mammography likely does not need to be repeated if it was performed within the past 6 months [21]. This Palpable Breast Masses modality may be particularly useful in women with almost entirely fatty breasts, in which mammography alone was shown to have a high sensitivity (96%) and specificity (93%) in the evaluation of palpable breast masses [22]. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of MRI breast with or without intravenous (IV) contrast in the initial evaluation of a woman presenting with a palpable mass [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi molecular breast imaging (MBI) in the initial evaluation of a woman presenting with a palpable mass. US Breast US may be considered as an initial means of imaging if the patient has had a recent negative mammogram within the past 6 months. In a study of women presenting with a palpable breast mass with a negative mammogram within the previous 6 to 12 months, US detected a finding in 50.3% of 311 cases, whereas repeat mammography detected a change in 12.9% of cases [21]. | Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET breast dedicated in the initial evaluation of a woman presenting with a palpable mass [2]. In several series evaluating palpable breast abnormalities [18-20], the sensitivity of mammography alone was 86% to 91%. Mammography likely does not need to be repeated if it was performed within the past 6 months [21]. This Palpable Breast Masses modality may be particularly useful in women with almost entirely fatty breasts, in which mammography alone was shown to have a high sensitivity (96%) and specificity (93%) in the evaluation of palpable breast masses [22]. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of MRI breast with or without intravenous (IV) contrast in the initial evaluation of a woman presenting with a palpable mass [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi molecular breast imaging (MBI) in the initial evaluation of a woman presenting with a palpable mass. US Breast US may be considered as an initial means of imaging if the patient has had a recent negative mammogram within the past 6 months. In a study of women presenting with a palpable breast mass with a negative mammogram within the previous 6 to 12 months, US detected a finding in 50.3% of 311 cases, whereas repeat mammography detected a change in 12.9% of cases [21]. | 69495 |
acrac_69495_3 | Palpable Breast Masses | US is more frequently used following DBT/mammography in this age group [2,26] (see Variants 2, 3, and 5). The negative predictive value of mammography with US in the context of a palpable mass ranges from 97.4% to 100% [7-9]. Variant 2: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding [2]. Image-Guided Core Biopsy Breast It is preferable for imaging to occur before biopsy because changes related to the biopsy may confuse, alter, obscure, and/or limit image interpretation. If a mammographically suspicious lesion is identified that correlates with the palpable mass, US is recommended as the next step in evaluation before image-guided core biopsy is pursued. However, the lack of sonographic correlate should not deter biopsy of a suspicious mammographic or DBT abnormality in this setting. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. When a mammographically or DBT-detected suspicious lesion is identified that correlates with a palpable mass, biopsy is warranted. If a lesion is only identified on mammography or DBT, mammographically or DBT- guided core biopsy may be pursued [28,29]. If the lesion can be seen with US, US-guided biopsy may be pursued [30]. At image-guided biopsy, a marker clip is placed, and a postbiopsy diagnostic mammogram confirms that the US and mammographic findings correlate. Similarly, a postbiopsy DBT confirms that the US and DBT findings correlate. | Palpable Breast Masses. US is more frequently used following DBT/mammography in this age group [2,26] (see Variants 2, 3, and 5). The negative predictive value of mammography with US in the context of a palpable mass ranges from 97.4% to 100% [7-9]. Variant 2: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding [2]. Image-Guided Core Biopsy Breast It is preferable for imaging to occur before biopsy because changes related to the biopsy may confuse, alter, obscure, and/or limit image interpretation. If a mammographically suspicious lesion is identified that correlates with the palpable mass, US is recommended as the next step in evaluation before image-guided core biopsy is pursued. However, the lack of sonographic correlate should not deter biopsy of a suspicious mammographic or DBT abnormality in this setting. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. When a mammographically or DBT-detected suspicious lesion is identified that correlates with a palpable mass, biopsy is warranted. If a lesion is only identified on mammography or DBT, mammographically or DBT- guided core biopsy may be pursued [28,29]. If the lesion can be seen with US, US-guided biopsy may be pursued [30]. At image-guided biopsy, a marker clip is placed, and a postbiopsy diagnostic mammogram confirms that the US and mammographic findings correlate. Similarly, a postbiopsy DBT confirms that the US and DBT findings correlate. | 69495 |
acrac_69495_4 | Palpable Breast Masses | US-guided core biopsy is also usually more easily tolerated because of a lack of breast compression and may allow biopsy of lesions difficult to access stereotactically (eg, far posterior lesions or axillary lesions) [30]. Image-Guided Fine Needle Aspiration Breast It is preferable for imaging to occur before biopsy because changes related to the biopsy may confuse, alter, obscure, and/or limit image interpretation. If a mammographically suspicious lesion is identified that correlates with the palpable mass, US is recommended as the next step in evaluation before image-guided FNA is pursued. However, the lack of sonographic correlate should not deter biopsy of a suspicious mammographic or DBT abnormality in this setting. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. An additional consideration of FNAB over a core biopsy may be the faster turnover time for a pathology diagnosis without a difference in time to treatment [31]. At US-guided FNA, a marker clip is placed and a postprocedure mammogram confirms that the US and mammographic findings correlate. Similarly, a postprocedure DBT confirms that the US and DBT findings correlate. Palpable Breast Masses MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding [2,23-25]. If malignancy is subsequently established by biopsy, MRI may be useful in delineating extent of disease in certain circumstances [32]. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding. US Breast US may be helpful in characterizing a suspicious mammographic finding [33]. | Palpable Breast Masses. US-guided core biopsy is also usually more easily tolerated because of a lack of breast compression and may allow biopsy of lesions difficult to access stereotactically (eg, far posterior lesions or axillary lesions) [30]. Image-Guided Fine Needle Aspiration Breast It is preferable for imaging to occur before biopsy because changes related to the biopsy may confuse, alter, obscure, and/or limit image interpretation. If a mammographically suspicious lesion is identified that correlates with the palpable mass, US is recommended as the next step in evaluation before image-guided FNA is pursued. However, the lack of sonographic correlate should not deter biopsy of a suspicious mammographic or DBT abnormality in this setting. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. An additional consideration of FNAB over a core biopsy may be the faster turnover time for a pathology diagnosis without a difference in time to treatment [31]. At US-guided FNA, a marker clip is placed and a postprocedure mammogram confirms that the US and mammographic findings correlate. Similarly, a postprocedure DBT confirms that the US and DBT findings correlate. Palpable Breast Masses MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding [2,23-25]. If malignancy is subsequently established by biopsy, MRI may be useful in delineating extent of disease in certain circumstances [32]. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding. US Breast US may be helpful in characterizing a suspicious mammographic finding [33]. | 69495 |
acrac_69495_5 | Palpable Breast Masses | In a study of women presenting with palpable breast thickening, the sensitivity of diagnostic mammography for invasive cancer detection was 60%, whereas the sensitivity of US alone was 100% [34]. Breast US should be performed using a high-resolution, real-time linear array scanner with an adjustable focal zone and a transducer with a minimum center frequency of 12 MHz [35]. Some mammographers also perform screening US of the remainder of the ipsilateral breast and the contralateral breast in the setting of a suspicious finding [33]. If there is no sonographic correlate for a suspicious mammographic finding, tissue sampling (stereotactic biopsy) should be guided by the suspicious mammographic finding. If there is no sonographic correlate for a suspicious DBT finding, tissue sampling (tomosynthesis-guided biopsy) should be guided by the suspicious DBT finding. Image-Guided Core Biopsy Breast If a palpable mass has probably benign features as identified on mammogram and/or US, imaging follow-up may be appropriate. However, if a mass is new on imaging or increasing by >20% in volume or >20% in each diameter in a 6-month period, the mass is considered suspicious, and image-guided biopsy is recommended [36]. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, there are certain cases in which biopsy may be performed even on probably benign lesions. For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling [30,37]. If an image-guided biopsy is pursued, a marker clip is placed and a postbiopsy mammogram/DBT confirms that the clip placement and mammographic/DBT findings correlate. | Palpable Breast Masses. In a study of women presenting with palpable breast thickening, the sensitivity of diagnostic mammography for invasive cancer detection was 60%, whereas the sensitivity of US alone was 100% [34]. Breast US should be performed using a high-resolution, real-time linear array scanner with an adjustable focal zone and a transducer with a minimum center frequency of 12 MHz [35]. Some mammographers also perform screening US of the remainder of the ipsilateral breast and the contralateral breast in the setting of a suspicious finding [33]. If there is no sonographic correlate for a suspicious mammographic finding, tissue sampling (stereotactic biopsy) should be guided by the suspicious mammographic finding. If there is no sonographic correlate for a suspicious DBT finding, tissue sampling (tomosynthesis-guided biopsy) should be guided by the suspicious DBT finding. Image-Guided Core Biopsy Breast If a palpable mass has probably benign features as identified on mammogram and/or US, imaging follow-up may be appropriate. However, if a mass is new on imaging or increasing by >20% in volume or >20% in each diameter in a 6-month period, the mass is considered suspicious, and image-guided biopsy is recommended [36]. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, there are certain cases in which biopsy may be performed even on probably benign lesions. For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling [30,37]. If an image-guided biopsy is pursued, a marker clip is placed and a postbiopsy mammogram/DBT confirms that the clip placement and mammographic/DBT findings correlate. | 69495 |
acrac_69495_6 | Palpable Breast Masses | Image-Guided Fine Needle Aspiration Breast If a palpable mass has probably benign features as identified on mammogram and/or US, imaging follow-up may be appropriate. However, if a mass is new on imaging or increasing by >20% in volume or >20% in each diameter in a 6-month period, image-guided biopsy is recommended [36]. In addition, there are certain cases in which biopsy may be performed even on probably benign lesions. For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling [30,37]. Large series have demonstrated core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. FNAB; however, may allow a faster turnover time as compared with core biopsy for a pathology diagnosis without a difference in time to treatment [31]. At image-guided FNA, a marker clip is placed and a postprocedure mammogram/DBT confirms that the marker clip and mammographic/DBT findings correlate. Palpable Breast Masses Variant 4: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are benign (BI-RADS 2) at the site of palpable mass. Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass in the context of a benign mammographic finding [2]. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy breast as the next step in evaluating a palpable mass in the context of a benign mammographic finding. | Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast If a palpable mass has probably benign features as identified on mammogram and/or US, imaging follow-up may be appropriate. However, if a mass is new on imaging or increasing by >20% in volume or >20% in each diameter in a 6-month period, image-guided biopsy is recommended [36]. In addition, there are certain cases in which biopsy may be performed even on probably benign lesions. For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling [30,37]. Large series have demonstrated core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. FNAB; however, may allow a faster turnover time as compared with core biopsy for a pathology diagnosis without a difference in time to treatment [31]. At image-guided FNA, a marker clip is placed and a postprocedure mammogram/DBT confirms that the marker clip and mammographic/DBT findings correlate. Palpable Breast Masses Variant 4: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are benign (BI-RADS 2) at the site of palpable mass. Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass in the context of a benign mammographic finding [2]. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy breast as the next step in evaluating a palpable mass in the context of a benign mammographic finding. | 69495 |
acrac_69495_7 | Palpable Breast Masses | Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the next step in evaluating a palpable mass in the context of a benign mammographic finding. However, image-guided aspiration can be considered for symptomatic relief of a palpable simple cyst. MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast of the breast as the next step in evaluating a palpable mass in the context of a benign mammographic finding. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass in the context of a benign mammographic finding. US Breast When the mammogram shows a definite benign mass (eg, lymph node, hamartoma, lipoma, calcified fibroadenoma, or oil cyst), US is not necessary as long as the benign mass identified on mammography is a definitive correlate of the clinical finding. If correlation between the mammographic finding and the palpable lesion is uncertain, US is useful. US is preferably targeted specifically to the palpable finding [33]. When both mammography and US are negative or benign in the evaluation of a palpable breast mass, the negative predictive value exceeds 97% [8,9,38]. Together, these imaging modalities can be reassuring when the physical examination is not highly suspicious and clinical follow-up is planned. However, a suspicious physical examination should prompt biopsy regardless of benign imaging findings [38]. Variant 5: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are negative (BI-RADS 1). Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass [2]. | Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the next step in evaluating a palpable mass in the context of a benign mammographic finding. However, image-guided aspiration can be considered for symptomatic relief of a palpable simple cyst. MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast of the breast as the next step in evaluating a palpable mass in the context of a benign mammographic finding. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass in the context of a benign mammographic finding. US Breast When the mammogram shows a definite benign mass (eg, lymph node, hamartoma, lipoma, calcified fibroadenoma, or oil cyst), US is not necessary as long as the benign mass identified on mammography is a definitive correlate of the clinical finding. If correlation between the mammographic finding and the palpable lesion is uncertain, US is useful. US is preferably targeted specifically to the palpable finding [33]. When both mammography and US are negative or benign in the evaluation of a palpable breast mass, the negative predictive value exceeds 97% [8,9,38]. Together, these imaging modalities can be reassuring when the physical examination is not highly suspicious and clinical follow-up is planned. However, a suspicious physical examination should prompt biopsy regardless of benign imaging findings [38]. Variant 5: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are negative (BI-RADS 1). Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass [2]. | 69495 |
acrac_69495_8 | Palpable Breast Masses | Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass. US should be performed, and if a suspicious correlate is identified, then US-guided core biopsy is recommended. However, a suspicious physical examination should prompt biopsy guided by palpation, regardless of negative imaging findings [38]. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass. US should be performed, and if a suspicious correlate is identified, then US-guided core biopsy is recommended. However, a suspicious physical examination should prompt biopsy guided by palpation, regardless of negative imaging findings [38]. MRI Breast MRI of the breast with or without IV contrast for women with a palpable mass and negative mammography is not recommended as the next imaging study [2,23-25]. US should be performed next [8,9,19]. Palpable Breast Masses Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass. US Breast A major advantage of US is the ability to directly correlate the clinical and imaging findings. The use of multiple modalities in diagnosing palpable masses has been advocated as a measure to increase the true-positive rate. In 3 series evaluating palpable breast abnormalities [18-20], the sensitivity of mammography was 86% to 91%. The addition of US detects 93% to 100% of cancers [8,9,19]. The addition of US to mammography may also improve detection of a benign etiology for a palpable finding and may also identify lesions that are mammographically occult [26]. In a series, 40% of benign palpable masses were identified only on US [20]. | Palpable Breast Masses. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass. US should be performed, and if a suspicious correlate is identified, then US-guided core biopsy is recommended. However, a suspicious physical examination should prompt biopsy guided by palpation, regardless of negative imaging findings [38]. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass. US should be performed, and if a suspicious correlate is identified, then US-guided core biopsy is recommended. However, a suspicious physical examination should prompt biopsy guided by palpation, regardless of negative imaging findings [38]. MRI Breast MRI of the breast with or without IV contrast for women with a palpable mass and negative mammography is not recommended as the next imaging study [2,23-25]. US should be performed next [8,9,19]. Palpable Breast Masses Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass. US Breast A major advantage of US is the ability to directly correlate the clinical and imaging findings. The use of multiple modalities in diagnosing palpable masses has been advocated as a measure to increase the true-positive rate. In 3 series evaluating palpable breast abnormalities [18-20], the sensitivity of mammography was 86% to 91%. The addition of US detects 93% to 100% of cancers [8,9,19]. The addition of US to mammography may also improve detection of a benign etiology for a palpable finding and may also identify lesions that are mammographically occult [26]. In a series, 40% of benign palpable masses were identified only on US [20]. | 69495 |
acrac_69495_9 | Palpable Breast Masses | In another study of 375 palpable masses in 320 women, 68.8% of the masses (n = 258) were only identified with US and were typically oval (n = 275, 73.3%) and hypoechoic (n = 336 in 372 US examinations, 90.3%) [39]. When both mammography and US are negative or benign in the evaluation of a palpable breast mass, the negative predictive value is very high, more than 97% [8,9,38,40]. Together, these imaging modalities can be reassuring when the physical examination is not highly suspicious and clinical follow-up is planned. If almost entirely fatty tissue is identified in the palpable region of concern, US may not be necessary [2]. In a study that included 323 palpable masses in 271 women with almost entirely fatty tissue on diagnostic mammography, mammography alone yielded a negative predictive value of 99.6% [22]. Of the 294 (91%) of women with almost entirely fatty breasts who also underwent targeted US for the evaluation of palpable symptoms, US yielded 11 false- positives and 8 benign correlates at sites with no mammographic findings [22]. Variant 6: Adult female, younger than 30 years of age. Palpable breast mass. Initial imaging. Digital Breast Tomosynthesis Diagnostic Because of the low incidence of breast cancer (<1%) in younger women, the recommended initial imaging differs from older patients [41-44]. Younger women tend to have relatively denser breast tissue [45], which is associated with decreased mammographic/DBT sensitivity [46]. DBT is not useful as the initial imaging modality in younger women. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the initial imaging workup in women <30 years of age with a palpable mass [2]. | Palpable Breast Masses. In another study of 375 palpable masses in 320 women, 68.8% of the masses (n = 258) were only identified with US and were typically oval (n = 275, 73.3%) and hypoechoic (n = 336 in 372 US examinations, 90.3%) [39]. When both mammography and US are negative or benign in the evaluation of a palpable breast mass, the negative predictive value is very high, more than 97% [8,9,38,40]. Together, these imaging modalities can be reassuring when the physical examination is not highly suspicious and clinical follow-up is planned. If almost entirely fatty tissue is identified in the palpable region of concern, US may not be necessary [2]. In a study that included 323 palpable masses in 271 women with almost entirely fatty tissue on diagnostic mammography, mammography alone yielded a negative predictive value of 99.6% [22]. Of the 294 (91%) of women with almost entirely fatty breasts who also underwent targeted US for the evaluation of palpable symptoms, US yielded 11 false- positives and 8 benign correlates at sites with no mammographic findings [22]. Variant 6: Adult female, younger than 30 years of age. Palpable breast mass. Initial imaging. Digital Breast Tomosynthesis Diagnostic Because of the low incidence of breast cancer (<1%) in younger women, the recommended initial imaging differs from older patients [41-44]. Younger women tend to have relatively denser breast tissue [45], which is associated with decreased mammographic/DBT sensitivity [46]. DBT is not useful as the initial imaging modality in younger women. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the initial imaging workup in women <30 years of age with a palpable mass [2]. | 69495 |
acrac_69495_10 | Palpable Breast Masses | Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy as the initial imaging workup in women <30 years of age with a palpable mass. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the initial imaging workup in women <30 years of age with a palpable mass. Mammography Diagnostic Because of the low incidence of breast cancer (<1%) in younger women, the recommended initial imaging differs from older patients [41-44]. Younger women tend to have relatively denser breast tissue [45], which is associated with decreased mammographic/DBT sensitivity [46]. Most benign lesions in young women are not visualized on mammography [41,43]. Diagnostic mammography is not useful as the initial imaging modality in younger women. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. Palpable Breast Masses MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast as the initial imaging workup in women <30 years of age with a palpable mass [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the initial imaging workup in women <30 years of age with a palpable mass. Variant 7: Adult female, younger than 30 years of age. Palpable breast mass. US findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study. Digital Breast Tomosynthesis Diagnostic DBT may be useful in a woman <30 years of age with a suspicious sonographic finding that correlates to a palpable mass. | Palpable Breast Masses. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy as the initial imaging workup in women <30 years of age with a palpable mass. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the initial imaging workup in women <30 years of age with a palpable mass. Mammography Diagnostic Because of the low incidence of breast cancer (<1%) in younger women, the recommended initial imaging differs from older patients [41-44]. Younger women tend to have relatively denser breast tissue [45], which is associated with decreased mammographic/DBT sensitivity [46]. Most benign lesions in young women are not visualized on mammography [41,43]. Diagnostic mammography is not useful as the initial imaging modality in younger women. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. Palpable Breast Masses MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast as the initial imaging workup in women <30 years of age with a palpable mass [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the initial imaging workup in women <30 years of age with a palpable mass. Variant 7: Adult female, younger than 30 years of age. Palpable breast mass. US findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study. Digital Breast Tomosynthesis Diagnostic DBT may be useful in a woman <30 years of age with a suspicious sonographic finding that correlates to a palpable mass. | 69495 |
acrac_69495_11 | Palpable Breast Masses | DBT may demonstrate findings not readily detected at US (calcifications or subtle architectural distortion); this may provide a more accurate assessment of the extent of disease in the ipsilateral breast and can identify contralateral lesions as well. In addition, DBT may have relatively high diagnostic accuracy in dense breast tissue, often encountered in younger patients [48,49]. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age [2]. Image-Guided Core Biopsy Breast If a suspicious mass has been identified on US, tissue sampling (US guided) is warranted. It may be appropriate to proceed directly to image-guided biopsy if a palpable lesion has suspicious features on US followed by placement of a biopsy clip. If US findings are particularly worrisome for malignancy, diagnostic mammography or DBT may be performed prior to tissue sampling to delineate disease extent (eg, calcifications extending beyond the margins of the US-identified solid mass) and identify any additional suspicious findings in the ipsilateral or contralateral breast. Core-needle biopsy has been shown in large series to be superior to FNA in terms of sensitivity, specificity, and correct histological grading [27]. Some practices have had good results using FNAB, but this may be facility specific, and a lower threshold for radiologic-pathologic discordance may need to be applied [50,51]. Image-Guided Fine Needle Aspiration Breast If a suspicious mass has been identified on US, tissue sampling (US guided) is warranted. | Palpable Breast Masses. DBT may demonstrate findings not readily detected at US (calcifications or subtle architectural distortion); this may provide a more accurate assessment of the extent of disease in the ipsilateral breast and can identify contralateral lesions as well. In addition, DBT may have relatively high diagnostic accuracy in dense breast tissue, often encountered in younger patients [48,49]. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age [2]. Image-Guided Core Biopsy Breast If a suspicious mass has been identified on US, tissue sampling (US guided) is warranted. It may be appropriate to proceed directly to image-guided biopsy if a palpable lesion has suspicious features on US followed by placement of a biopsy clip. If US findings are particularly worrisome for malignancy, diagnostic mammography or DBT may be performed prior to tissue sampling to delineate disease extent (eg, calcifications extending beyond the margins of the US-identified solid mass) and identify any additional suspicious findings in the ipsilateral or contralateral breast. Core-needle biopsy has been shown in large series to be superior to FNA in terms of sensitivity, specificity, and correct histological grading [27]. Some practices have had good results using FNAB, but this may be facility specific, and a lower threshold for radiologic-pathologic discordance may need to be applied [50,51]. Image-Guided Fine Needle Aspiration Breast If a suspicious mass has been identified on US, tissue sampling (US guided) is warranted. | 69495 |
acrac_69495_12 | Palpable Breast Masses | It may be appropriate to proceed directly to image-guided biopsy if a palpable lesion has suspicious features on US. If US findings are particularly worrisome for malignancy, diagnostic mammography or DBT may be performed before tissue sampling to delineate disease extent (eg, calcifications extending beyond the margins of the US-identified solid mass) and identify any additional suspicious findings in the ipsilateral or contralateral breast. Core-needle biopsy has been shown in large series to be superior to FNA in terms of sensitivity, specificity, and correct histological grading [27]. Some practices have had good results using FNAB, but this may be facility specific, and a lower threshold for radiologic-pathologic discordance may need to be applied [50,51]. US-guided FNAB may be preferred over core biopsy in rare situations but should be used judiciously. Palpable Breast Masses Mammography Diagnostic Mammography may be useful in a woman <30 years of age with a suspicious sonographic finding that correlates to a palpable mass. If US findings are particularly worrisome for malignancy, mammography diagnostic or diagnostic DBT would usually be performed before tissue sampling to identify any additional suspicious findings and/or delineate the extent of disease (eg, calcifications extending beyond the margins of the US-identified solid mass) in the ipsilateral breast. Mammography diagnostic is recommended as a prebiopsy assessment in cases in which cancer is strongly suspected clinically [41]. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age [2,23-25]. | Palpable Breast Masses. It may be appropriate to proceed directly to image-guided biopsy if a palpable lesion has suspicious features on US. If US findings are particularly worrisome for malignancy, diagnostic mammography or DBT may be performed before tissue sampling to delineate disease extent (eg, calcifications extending beyond the margins of the US-identified solid mass) and identify any additional suspicious findings in the ipsilateral or contralateral breast. Core-needle biopsy has been shown in large series to be superior to FNA in terms of sensitivity, specificity, and correct histological grading [27]. Some practices have had good results using FNAB, but this may be facility specific, and a lower threshold for radiologic-pathologic discordance may need to be applied [50,51]. US-guided FNAB may be preferred over core biopsy in rare situations but should be used judiciously. Palpable Breast Masses Mammography Diagnostic Mammography may be useful in a woman <30 years of age with a suspicious sonographic finding that correlates to a palpable mass. If US findings are particularly worrisome for malignancy, mammography diagnostic or diagnostic DBT would usually be performed before tissue sampling to identify any additional suspicious findings and/or delineate the extent of disease (eg, calcifications extending beyond the margins of the US-identified solid mass) in the ipsilateral breast. Mammography diagnostic is recommended as a prebiopsy assessment in cases in which cancer is strongly suspected clinically [41]. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age [2,23-25]. | 69495 |
acrac_69495_13 | Palpable Breast Masses | Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age. Variant 8: Adult female, younger than 30 years of age. Palpable breast mass. US findings probably benign (BI-RADS 3). Next imaging study. Digital Breast Tomosynthesis Diagnostic If a correlate for a palpable mass has been identified on US and is probably benign, there is no indication for DBT to further evaluate the palpable mass in women <30 years of age. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is unnecessary for imaging surveillance. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass [2]. Image-Guided Core Biopsy Breast If a palpable mass has probably benign features as identified on US, US follow-up is recommended. However, image-guided core biopsy may be performed after complete imaging assessment in some cases. For example, BI- RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for biopsy instead of imaging follow-up. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling and a biopsy marker clip should be placed [30]. Image-Guided Fine Needle Aspiration Breast If a palpable mass has probably benign features as identified on US, US follow-up is recommended. Image-guided FNAB may be performed after complete imaging assessment in some cases. | Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age. Variant 8: Adult female, younger than 30 years of age. Palpable breast mass. US findings probably benign (BI-RADS 3). Next imaging study. Digital Breast Tomosynthesis Diagnostic If a correlate for a palpable mass has been identified on US and is probably benign, there is no indication for DBT to further evaluate the palpable mass in women <30 years of age. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is unnecessary for imaging surveillance. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass [2]. Image-Guided Core Biopsy Breast If a palpable mass has probably benign features as identified on US, US follow-up is recommended. However, image-guided core biopsy may be performed after complete imaging assessment in some cases. For example, BI- RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for biopsy instead of imaging follow-up. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling and a biopsy marker clip should be placed [30]. Image-Guided Fine Needle Aspiration Breast If a palpable mass has probably benign features as identified on US, US follow-up is recommended. Image-guided FNAB may be performed after complete imaging assessment in some cases. | 69495 |
acrac_69495_14 | Palpable Breast Masses | For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling, and a biopsy marker clip should be placed [30]. However, large series demonstrate that core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. US-guided FNAB may be preferred in rare situations (lesion abuts an implant). Mammography Diagnostic If a correlate for a palpable mass has been identified on US and is probably benign, there is no indication for diagnostic mammography to further evaluate the palpable mass in women <30 years of age. Palpable Breast Masses Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is unnecessary for imaging surveillance. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass. Variant 9: Adult female, younger than 30 years of age. Palpable breast mass. US findings benign (BI-RADS 2). Next imaging study. Digital Breast Tomosynthesis Diagnostic If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for further evaluation with diagnostic DBT in women <30 years of age. | Palpable Breast Masses. For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling, and a biopsy marker clip should be placed [30]. However, large series demonstrate that core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. US-guided FNAB may be preferred in rare situations (lesion abuts an implant). Mammography Diagnostic If a correlate for a palpable mass has been identified on US and is probably benign, there is no indication for diagnostic mammography to further evaluate the palpable mass in women <30 years of age. Palpable Breast Masses Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is unnecessary for imaging surveillance. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass. Variant 9: Adult female, younger than 30 years of age. Palpable breast mass. US findings benign (BI-RADS 2). Next imaging study. Digital Breast Tomosynthesis Diagnostic If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for further evaluation with diagnostic DBT in women <30 years of age. | 69495 |
acrac_69495_15 | Palpable Breast Masses | Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is unnecessary for confirmation of benignity. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for FDG- PET breast dedicated in women <30 years of age [2]. Image-Guided Core Biopsy Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for tissue sampling. The likelihood of a palpable mass in a young woman that is benign on both clinical examination and US resulting in a cancer is extremely low; one study prospectively evaluating US-guided core biopsy in 248 young women <25 years of age with clinically benign masses and predominantly benign findings found no cancers in this group [52]. Image-Guided Fine Needle Aspiration Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for image- guided FNAB in women <30 years of age. Mammography Diagnostic If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for further evaluation with diagnostic mammography in women <30 years of age. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is unnecessary for confirmation of benignity. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for MRI of the breast with or without IV contrast in women <30 years of age [2,23-25]. | Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is unnecessary for confirmation of benignity. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for FDG- PET breast dedicated in women <30 years of age [2]. Image-Guided Core Biopsy Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for tissue sampling. The likelihood of a palpable mass in a young woman that is benign on both clinical examination and US resulting in a cancer is extremely low; one study prospectively evaluating US-guided core biopsy in 248 young women <25 years of age with clinically benign masses and predominantly benign findings found no cancers in this group [52]. Image-Guided Fine Needle Aspiration Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for image- guided FNAB in women <30 years of age. Mammography Diagnostic If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for further evaluation with diagnostic mammography in women <30 years of age. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is unnecessary for confirmation of benignity. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for MRI of the breast with or without IV contrast in women <30 years of age [2,23-25]. | 69495 |
acrac_69495_16 | Palpable Breast Masses | Sestamibi MBI If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no evidence for Tc-99m sestamibi MBI in women <30 years of age. Palpable Breast Masses age, if physical examination is highly suspicious and DBT and US are negative, tissue sampling with core biopsy or surgical biopsy is warranted. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of the use of FDG-PET breast dedicated in women <30 years of age with negative US findings [2]. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of the use of image-guided core biopsy in women <30 years of age with negative US findings. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of the use of image-guided FNAB in women <30 years of age with negative US findings. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast in women in women <30 years of age with negative US findings [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI in women <30 years of age with negative US findings. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. | Palpable Breast Masses. Sestamibi MBI If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no evidence for Tc-99m sestamibi MBI in women <30 years of age. Palpable Breast Masses age, if physical examination is highly suspicious and DBT and US are negative, tissue sampling with core biopsy or surgical biopsy is warranted. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. FDG-PET Breast Dedicated There is no relevant literature to support the use of the use of FDG-PET breast dedicated in women <30 years of age with negative US findings [2]. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of the use of image-guided core biopsy in women <30 years of age with negative US findings. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of the use of image-guided FNAB in women <30 years of age with negative US findings. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast in women in women <30 years of age with negative US findings [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI in women <30 years of age with negative US findings. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. | 69495 |
acrac_69495_17 | Palpable Breast Masses | Screening mammography is provided to women without signs or symptoms of breast disease. Palpable Breast Masses FDG-PET Breast Dedicated There is no relevant literature to support the use of the use of FDG-PET breast dedicated in the initial evaluation of women 30 to 39 years of age with a palpable mass [2]. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of the use of image-guided core biopsy in the initial evaluation of women 30 to 39 years of age with a palpable mass. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of the use of image-guided FNAB in the initial evaluation of women 30 to 39 years of age with a palpable mass. One study of 1,208 women 30 to 39 years of age presenting with focal breast symptoms found a higher sensitivity for US compared with mammography (95.7% versus 60.9%) but with a similar specificity (89.2% and 94.4%, respectively), negative predictive value (99.9% and 99.2%, respectively), and positive predictive value (13.2% and 18.4%, respectively) [40]. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast in the initial evaluation of women 30 to 39 years of age with palpable mass [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in the initial evaluation of women 30 to 39 years of age with palpable mass. 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. | Palpable Breast Masses. Screening mammography is provided to women without signs or symptoms of breast disease. Palpable Breast Masses FDG-PET Breast Dedicated There is no relevant literature to support the use of the use of FDG-PET breast dedicated in the initial evaluation of women 30 to 39 years of age with a palpable mass [2]. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of the use of image-guided core biopsy in the initial evaluation of women 30 to 39 years of age with a palpable mass. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of the use of image-guided FNAB in the initial evaluation of women 30 to 39 years of age with a palpable mass. One study of 1,208 women 30 to 39 years of age presenting with focal breast symptoms found a higher sensitivity for US compared with mammography (95.7% versus 60.9%) but with a similar specificity (89.2% and 94.4%, respectively), negative predictive value (99.9% and 99.2%, respectively), and positive predictive value (13.2% and 18.4%, respectively) [40]. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease. MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast in the initial evaluation of women 30 to 39 years of age with palpable mass [2,23-25]. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in the initial evaluation of women 30 to 39 years of age with palpable mass. 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. | 69495 |
acrac_69363_0 | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass | Introduction/Background The acute scrotum is a medical emergency defined as scrotal pain, swelling and redness of acute onset, from minutes to 1 to 2 days [1] and comprises at least 0.5% of all emergency department visits [2]. Etiologies of acute scrotum are numerous, and rapid accurate diagnosis is essential to appropriately triage potentially surgical and irreversible conditions from patients for whom conservative management is sufficient. Diagnostic considerations include testicular torsion, torsion of testicular appendage, epididymoorchitis, epididymitis, idiopathic scrotal edema, hydrocele, inflammation of the tunica vaginalis, trauma, testicular tumors, epididymal cysts, Fournier gangrene, scrotal abscess, and strangulated inguinal hernia [3-6]. Torsion of a testicular appendage, epididymitis, and testicular torsion are the three most common causes of acute scrotal pain and account for approximately 85% to 90% of cases [7]. Large differential diagnoses and overlapping clinical presentation make the acute scrotum a diagnostic challenge. Acute epididymoorchitis or epididymitis is the most common cause of acute scrotum in adolescent boys and adults [8,9]. In 2002, epididymitis or epididymoorchitis accounted for 1 in 44 outpatient visits in men 18 to 50 years of age [9,10]. Although uncommon in pediatric populations, it can be associated with urinary tract infections and/or structural and functional abnormalities of the urinary tract [11,12]. Epididymitis has a more insidious and gradual onset than testicular torsion. As inflammation and edema progress, a reactive hydrocele may develop making it difficult to differentiate from testicular torsion. Clinically, scrotal pain associated with epididymitis is usually relieved when the testes are elevated over the symphysis pubis (the Prehn sign) [8,13]. | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Introduction/Background The acute scrotum is a medical emergency defined as scrotal pain, swelling and redness of acute onset, from minutes to 1 to 2 days [1] and comprises at least 0.5% of all emergency department visits [2]. Etiologies of acute scrotum are numerous, and rapid accurate diagnosis is essential to appropriately triage potentially surgical and irreversible conditions from patients for whom conservative management is sufficient. Diagnostic considerations include testicular torsion, torsion of testicular appendage, epididymoorchitis, epididymitis, idiopathic scrotal edema, hydrocele, inflammation of the tunica vaginalis, trauma, testicular tumors, epididymal cysts, Fournier gangrene, scrotal abscess, and strangulated inguinal hernia [3-6]. Torsion of a testicular appendage, epididymitis, and testicular torsion are the three most common causes of acute scrotal pain and account for approximately 85% to 90% of cases [7]. Large differential diagnoses and overlapping clinical presentation make the acute scrotum a diagnostic challenge. Acute epididymoorchitis or epididymitis is the most common cause of acute scrotum in adolescent boys and adults [8,9]. In 2002, epididymitis or epididymoorchitis accounted for 1 in 44 outpatient visits in men 18 to 50 years of age [9,10]. Although uncommon in pediatric populations, it can be associated with urinary tract infections and/or structural and functional abnormalities of the urinary tract [11,12]. Epididymitis has a more insidious and gradual onset than testicular torsion. As inflammation and edema progress, a reactive hydrocele may develop making it difficult to differentiate from testicular torsion. Clinically, scrotal pain associated with epididymitis is usually relieved when the testes are elevated over the symphysis pubis (the Prehn sign) [8,13]. | 69363 |
acrac_69363_1 | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass | This sign may help clinically differentiate between epididymitis and torsion of the spermatic cord, in which scrotal pain is not lessened with this maneuver [14]. Testicular torsion is defined as twisting of the spermatic cord, compromising blood flow to and from the testes [2]. It is a surgical emergency with a bimodal distribution presenting more frequently in neonates and postpubertal boys than in adults, although it can occur at any age [19]. It has an estimated reported yearly incidence ranging from 2.9 to 3.8 in 100,000 boys <18 years of age [20,21]. Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss [22]. A validated [23-26], clinical risk scoring system, Testicular Workup for Ischemia and Suspected Torsion Score, has shown high positive predictive value; however, it has not been widely adopted [20]. Special Imaging Considerations Contrast-enhanced ultrasound (US) has expanded considerably in the last few decades and has proved to be a useful tool in determining the presence or absence of organ perfusion by improving the signal-to-noise ratio of tissue Reprint requests to: [email protected] Acute Onset of Scrotal Pain Microvascular imaging US is a new Doppler module that better differentiates slow flow via mathematical algorithms based on signal amplitude width [33], by separating low frequency of static tissue artifacts from low frequencies of very weak flow. Microvascular imaging obtains a higher resolution by separating the Doppler components of the 2 different sources [34]. Shear wave elastography (SWE) is a recently developed technique capable of quantitatively evaluating soft tissue stiffness [35,36]. This serves as a surrogate marker for tissue composition. | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. This sign may help clinically differentiate between epididymitis and torsion of the spermatic cord, in which scrotal pain is not lessened with this maneuver [14]. Testicular torsion is defined as twisting of the spermatic cord, compromising blood flow to and from the testes [2]. It is a surgical emergency with a bimodal distribution presenting more frequently in neonates and postpubertal boys than in adults, although it can occur at any age [19]. It has an estimated reported yearly incidence ranging from 2.9 to 3.8 in 100,000 boys <18 years of age [20,21]. Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss [22]. A validated [23-26], clinical risk scoring system, Testicular Workup for Ischemia and Suspected Torsion Score, has shown high positive predictive value; however, it has not been widely adopted [20]. Special Imaging Considerations Contrast-enhanced ultrasound (US) has expanded considerably in the last few decades and has proved to be a useful tool in determining the presence or absence of organ perfusion by improving the signal-to-noise ratio of tissue Reprint requests to: [email protected] Acute Onset of Scrotal Pain Microvascular imaging US is a new Doppler module that better differentiates slow flow via mathematical algorithms based on signal amplitude width [33], by separating low frequency of static tissue artifacts from low frequencies of very weak flow. Microvascular imaging obtains a higher resolution by separating the Doppler components of the 2 different sources [34]. Shear wave elastography (SWE) is a recently developed technique capable of quantitatively evaluating soft tissue stiffness [35,36]. This serves as a surrogate marker for tissue composition. | 69363 |
acrac_69363_2 | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass | Studies have shown that SWE values of testicular parenchyma increase during testicular torsion; however, there are limited studies showing whether these changes can be distinguished from other pathologies such as acute inflammation [36]. OR Discussion of Procedures by Variant Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging. This discussion will be limited to patients with acute pain, without history of trauma, and no history of antecedent or known scrotal or testicular mass because these scenarios are discussed elsewhere [37,38]. CT Pelvis With IV Contrast CT of the pelvis with intravenous (IV) contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients. However, in the setting of Fourniers gangrene, CT can lead to early diagnosis with accurate assessment of disease extent [3]. CT Pelvis Without and With IV Contrast CT of the pelvis without and with IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients. CT Pelvis Without IV Contrast CT of the pelvis without IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients. MRI Pelvis (Scrotum) Without and With IV Contrast MRI of the pelvis without and with IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Studies have shown that SWE values of testicular parenchyma increase during testicular torsion; however, there are limited studies showing whether these changes can be distinguished from other pathologies such as acute inflammation [36]. OR Discussion of Procedures by Variant Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging. This discussion will be limited to patients with acute pain, without history of trauma, and no history of antecedent or known scrotal or testicular mass because these scenarios are discussed elsewhere [37,38]. CT Pelvis With IV Contrast CT of the pelvis with intravenous (IV) contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients. However, in the setting of Fourniers gangrene, CT can lead to early diagnosis with accurate assessment of disease extent [3]. CT Pelvis Without and With IV Contrast CT of the pelvis without and with IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients. CT Pelvis Without IV Contrast CT of the pelvis without IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients. MRI Pelvis (Scrotum) Without and With IV Contrast MRI of the pelvis without and with IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. | 69363 |
acrac_69363_3 | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass | However, it may be used as a problem solving second-line modality when findings on US are indeterminate [39,40]. Diagnoses such as minor tunica albuginea tears and blunt scrotal trauma, chronic epididymoorchitis, and partial or intermittent torsion may sometimes be missed on US [39,41,42]. Due to its larger field of view and multiplanar capabilities, MRI of the scrotum provides excellent anatomical detail of all scrotal contents and inguinal region. In addition, MRI provides high soft-tissue contrast, high sensitivity for contrast enhancement, and functional information. These features contribute to a more precise treatment strategy, reducing unwarranted surgical exploration [39,40,43-47]. Limitations of MRI in the Acute Onset of Scrotal Pain evaluation of acute scrotum include long scan time, potentially delaying surgical exploration, and possible need for anesthesia in pediatric patients [39,40,48] and patients with claustrophobia or anxiety. MRI has high accuracy in establishing the diagnosis of segmental testicular infarction [39,49-51]. Segmental testicular infarction is an uncommon entity that can mimic a small hypovascular tumor on US [50,52-55]. MRI findings include a T2 hypointense, avascular lesion with marked rim enhancement. Intralesional hyperintense T1 signal may coexist due to hemorrhagic products [39,44,50,55-57]. Diffusion-weighted imaging and apparent diffusion coefficient (ADC) provide qualitative and quantitative analysis by adding functional information about molecular activity and cellular function, in addition to the morphological information provided by other MRI sequences, like dynamic contrast-enhanced and T2- and T2*-weighted images [60,61]. Diffusion-weighted imaging and ADC images demonstrate lower ADC values of the torsed testicle compared to the normal contralateral testicle [62]. | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. However, it may be used as a problem solving second-line modality when findings on US are indeterminate [39,40]. Diagnoses such as minor tunica albuginea tears and blunt scrotal trauma, chronic epididymoorchitis, and partial or intermittent torsion may sometimes be missed on US [39,41,42]. Due to its larger field of view and multiplanar capabilities, MRI of the scrotum provides excellent anatomical detail of all scrotal contents and inguinal region. In addition, MRI provides high soft-tissue contrast, high sensitivity for contrast enhancement, and functional information. These features contribute to a more precise treatment strategy, reducing unwarranted surgical exploration [39,40,43-47]. Limitations of MRI in the Acute Onset of Scrotal Pain evaluation of acute scrotum include long scan time, potentially delaying surgical exploration, and possible need for anesthesia in pediatric patients [39,40,48] and patients with claustrophobia or anxiety. MRI has high accuracy in establishing the diagnosis of segmental testicular infarction [39,49-51]. Segmental testicular infarction is an uncommon entity that can mimic a small hypovascular tumor on US [50,52-55]. MRI findings include a T2 hypointense, avascular lesion with marked rim enhancement. Intralesional hyperintense T1 signal may coexist due to hemorrhagic products [39,44,50,55-57]. Diffusion-weighted imaging and apparent diffusion coefficient (ADC) provide qualitative and quantitative analysis by adding functional information about molecular activity and cellular function, in addition to the morphological information provided by other MRI sequences, like dynamic contrast-enhanced and T2- and T2*-weighted images [60,61]. Diffusion-weighted imaging and ADC images demonstrate lower ADC values of the torsed testicle compared to the normal contralateral testicle [62]. | 69363 |
acrac_69363_4 | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass | MRI Pelvis (Scrotum) Without IV Contrast MRI of the pelvis without IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of MRI of the pelvis without IV contrast in these patients. Nuclear Medicine Scan Scrotum Radionuclide scrotal imaging (RNSI) has been replaced by Doppler US as the primary imaging modality for evaluation of the acute scrotum. RSNI has a reported sensitivity and specificity for differentiation between testicular torsion and epididymoorchitis from 89% to 98% and 90% to 100%, respectively [68,69]. RSNI is limited by technical challenges in children whose small genitalia are difficult to image with radiotracers. RNSI also can have photon-deficient areas secondary to hydrocele, spermatocele, and inguinal hernias, which can be erroneously diagnosed as avascular testis [70]. US Duplex Doppler Scrotum Spectral analysis of the Doppler waveform allows a quantitative assessment of organ perfusion. Acute Onset of Scrotal Pain contralateral testicle or a different region within the same testicle. Variability of the amplitude was the most common abnormality, followed by reversal of diastolic flow [6]. Additional characteristic spectral Doppler waveforms seen in partial testicular torsion include monophasic waveform, tardus-parvus morphology, and spectral Doppler waveform variations within the same testis, all worrisome for underlying ischemia. Spectral Doppler analysis should be performed in the upper, mid, and lower poles of each testicle [6,72,74]. US Scrotum US is the established first-line imaging modality for acute scrotal disease [75] and can be used to diagnose most scrotal disorders when combined with clinical history and physical examination. US is generally well tolerated and widely available, making it ideal for scrotal evaluation. | Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. MRI Pelvis (Scrotum) Without IV Contrast MRI of the pelvis without IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of MRI of the pelvis without IV contrast in these patients. Nuclear Medicine Scan Scrotum Radionuclide scrotal imaging (RNSI) has been replaced by Doppler US as the primary imaging modality for evaluation of the acute scrotum. RSNI has a reported sensitivity and specificity for differentiation between testicular torsion and epididymoorchitis from 89% to 98% and 90% to 100%, respectively [68,69]. RSNI is limited by technical challenges in children whose small genitalia are difficult to image with radiotracers. RNSI also can have photon-deficient areas secondary to hydrocele, spermatocele, and inguinal hernias, which can be erroneously diagnosed as avascular testis [70]. US Duplex Doppler Scrotum Spectral analysis of the Doppler waveform allows a quantitative assessment of organ perfusion. Acute Onset of Scrotal Pain contralateral testicle or a different region within the same testicle. Variability of the amplitude was the most common abnormality, followed by reversal of diastolic flow [6]. Additional characteristic spectral Doppler waveforms seen in partial testicular torsion include monophasic waveform, tardus-parvus morphology, and spectral Doppler waveform variations within the same testis, all worrisome for underlying ischemia. Spectral Doppler analysis should be performed in the upper, mid, and lower poles of each testicle [6,72,74]. US Scrotum US is the established first-line imaging modality for acute scrotal disease [75] and can be used to diagnose most scrotal disorders when combined with clinical history and physical examination. US is generally well tolerated and widely available, making it ideal for scrotal evaluation. | 69363 |
acrac_3195161_0 | Tracheobronchial Disease | Bronchiectasis is defined as irreversible abnormal bronchial dilatation, with patients most commonly presenting with chronic productive cough. Although a wide range of congenital and acquired conditions can be associated with bronchiectasis, a common etiologic pathway is thought to be impairment of normal bronchial clearance and airway immune mechanisms, resulting in recurrent infections and chronic bronchial inflammation that cause bronchial injury and dilatation [9,10]. The prevalence of bronchiectasis has increased worldwide over the last few decades; in the United States, prevalence has been estimated as approximately 139 per 100,000 individuals [9]. Treatment includes preventive airway clearance therapies, anti-inflammatory agents, prophylactic or therapeutic antibiotics, and, in severe cases, surgical resection or lung transplantation. Special Imaging Considerations In cases of tracheal stenosis and central airway lesions in general, special CT reformatting techniques such as 2-D multiplanar, 3-D volume-rendered, and virtual bronchoscopic images may be helpful for illustration of findings and preprocedural planning [11-13]. For example, coronal and sagittal 2-D reformatted images and 3-D volume reformatted images can depict the craniocaudal extent of lesions and distance from landmarks such as the vocal cords and carina, and virtual bronchoscopic images can illustrate the expected endoluminal appearance of lesions and provide guidance for bronchoscopy and procedures by demonstrating local airway anatomy. Minimum intensity projection reformatted images can also display central airway abnormalities and bronchiectasis [10]. Modern multidetector CT can be used to image the entire trachea at end expiration or during forced expiration (dynamic expiratory imaging). More recently, 320-row multidetector CT scanners have enabled cinematic 4-D volumetric images of the trachea, allowing time-resolved coverage of the entire trachea throughout an inspiratory/expiratory cycle [14,15]. | Tracheobronchial Disease. Bronchiectasis is defined as irreversible abnormal bronchial dilatation, with patients most commonly presenting with chronic productive cough. Although a wide range of congenital and acquired conditions can be associated with bronchiectasis, a common etiologic pathway is thought to be impairment of normal bronchial clearance and airway immune mechanisms, resulting in recurrent infections and chronic bronchial inflammation that cause bronchial injury and dilatation [9,10]. The prevalence of bronchiectasis has increased worldwide over the last few decades; in the United States, prevalence has been estimated as approximately 139 per 100,000 individuals [9]. Treatment includes preventive airway clearance therapies, anti-inflammatory agents, prophylactic or therapeutic antibiotics, and, in severe cases, surgical resection or lung transplantation. Special Imaging Considerations In cases of tracheal stenosis and central airway lesions in general, special CT reformatting techniques such as 2-D multiplanar, 3-D volume-rendered, and virtual bronchoscopic images may be helpful for illustration of findings and preprocedural planning [11-13]. For example, coronal and sagittal 2-D reformatted images and 3-D volume reformatted images can depict the craniocaudal extent of lesions and distance from landmarks such as the vocal cords and carina, and virtual bronchoscopic images can illustrate the expected endoluminal appearance of lesions and provide guidance for bronchoscopy and procedures by demonstrating local airway anatomy. Minimum intensity projection reformatted images can also display central airway abnormalities and bronchiectasis [10]. Modern multidetector CT can be used to image the entire trachea at end expiration or during forced expiration (dynamic expiratory imaging). More recently, 320-row multidetector CT scanners have enabled cinematic 4-D volumetric images of the trachea, allowing time-resolved coverage of the entire trachea throughout an inspiratory/expiratory cycle [14,15]. | 3195161 |
acrac_3195161_1 | Tracheobronchial Disease | Low-dose volumetric CT using 40 to 80 mA is comparable to standard higher- Reprint requests to: [email protected] Tracheobronchial Disease dose techniques in demonstrating degree of trachea collapse [16], and low-dose techniques have been widely adopted for dynamic expiratory imaging assessment of ECAC [17,18]. Optimal evaluation of the airways requires thin-section imaging with a slice thickness of 1.5 mm or thinner. Larger slice thicknesses cause partial volume averaging that can obscure airway anatomy and airway lesions. Adequate breath holding at inspiration is also important, because respiratory motion can also obscure airway lesions and can also cause an erroneous impression of bronchiectasis caused by volume averaging and image blurring. OR Discussion of Procedures by Variant Variant 1: Adult. Clinically suspected tracheal or bronchial stenosis. Initial imaging. CT Chest With IV Contrast Chest CT is widely used for first-line imaging evaluation of central airway pathology such as masses, thickening, and stenosis. CT with intravenous (IV) contrast provides the advantage of evaluation of enhancement characteristics and optimal evaluation of hilar and mediastinal adenopathy [19], however, relevant studies comparing contrast- enhanced CT with unenhanced CT are lacking. CT has shown a high correlation with findings at bronchoscopy and offers additional advantages by depicting degree of stenosis, extraluminal involvement of lesions, and extension to adjacent structures [19-21]. CT allows assessment of the location, shape, dimensions, mural extent, and attenuation characteristics of tumors of the large airways and detection of intrathoracic disease in cases of malignancy [19,20]. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast in the initial evaluation of suspected tracheal stenosis. | Tracheobronchial Disease. Low-dose volumetric CT using 40 to 80 mA is comparable to standard higher- Reprint requests to: [email protected] Tracheobronchial Disease dose techniques in demonstrating degree of trachea collapse [16], and low-dose techniques have been widely adopted for dynamic expiratory imaging assessment of ECAC [17,18]. Optimal evaluation of the airways requires thin-section imaging with a slice thickness of 1.5 mm or thinner. Larger slice thicknesses cause partial volume averaging that can obscure airway anatomy and airway lesions. Adequate breath holding at inspiration is also important, because respiratory motion can also obscure airway lesions and can also cause an erroneous impression of bronchiectasis caused by volume averaging and image blurring. OR Discussion of Procedures by Variant Variant 1: Adult. Clinically suspected tracheal or bronchial stenosis. Initial imaging. CT Chest With IV Contrast Chest CT is widely used for first-line imaging evaluation of central airway pathology such as masses, thickening, and stenosis. CT with intravenous (IV) contrast provides the advantage of evaluation of enhancement characteristics and optimal evaluation of hilar and mediastinal adenopathy [19], however, relevant studies comparing contrast- enhanced CT with unenhanced CT are lacking. CT has shown a high correlation with findings at bronchoscopy and offers additional advantages by depicting degree of stenosis, extraluminal involvement of lesions, and extension to adjacent structures [19-21]. CT allows assessment of the location, shape, dimensions, mural extent, and attenuation characteristics of tumors of the large airways and detection of intrathoracic disease in cases of malignancy [19,20]. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast in the initial evaluation of suspected tracheal stenosis. | 3195161 |
acrac_3195161_2 | Tracheobronchial Disease | CT Chest Without IV Contrast Chest CT is widely used for first-line imaging evaluation of central airway pathology such as masses, thickening, and stenosis. CT without IV contrast readily depicts central airway lesions, thickening, and stenosis. CT has shown high correlation with findings at bronchoscopy and offers additional advantages by depicting degree of stenosis, extraluminal involvement of lesions, and extension to adjacent structures [20,21]. CT allows assessment of the location, shape, dimensions, mural extent, and attenuation characteristics of tumors of the large airways and detection of intrathoracic disease in cases of malignancy [19,20]. CT Neck and Chest With IV Contrast There is no relevant literature to support the use of neck and chest CT with IV contrast in the initial evaluation of suspected tracheal stenosis. However, combined neck and chest CT with IV contrast can be performed for Tracheobronchial Disease assessment of suspected tracheal lesions and stenosis, especially for diseases that can involve the subglottic trachea, such as diffuse tracheal diseases and suspected or known malignancies of the neck. Chest CT protocols to evaluate tracheal stenosis often prescribe z-axis coverage through the lower neck. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast in the initial evaluation of suspected tracheal stenosis. CT Neck and Chest Without IV Contrast There is no relevant literature to support the use of neck and chest CT without IV contrast in the initial evaluation of suspected tracheal stenosis. However, combined neck and chest CT without IV contrast may be performed for assessment of suspected tracheal lesions and stenosis, especially for diseases that can involve the subglottic trachea, such as diffuse tracheal diseases and suspected or known malignancies of the neck. | Tracheobronchial Disease. CT Chest Without IV Contrast Chest CT is widely used for first-line imaging evaluation of central airway pathology such as masses, thickening, and stenosis. CT without IV contrast readily depicts central airway lesions, thickening, and stenosis. CT has shown high correlation with findings at bronchoscopy and offers additional advantages by depicting degree of stenosis, extraluminal involvement of lesions, and extension to adjacent structures [20,21]. CT allows assessment of the location, shape, dimensions, mural extent, and attenuation characteristics of tumors of the large airways and detection of intrathoracic disease in cases of malignancy [19,20]. CT Neck and Chest With IV Contrast There is no relevant literature to support the use of neck and chest CT with IV contrast in the initial evaluation of suspected tracheal stenosis. However, combined neck and chest CT with IV contrast can be performed for Tracheobronchial Disease assessment of suspected tracheal lesions and stenosis, especially for diseases that can involve the subglottic trachea, such as diffuse tracheal diseases and suspected or known malignancies of the neck. Chest CT protocols to evaluate tracheal stenosis often prescribe z-axis coverage through the lower neck. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast in the initial evaluation of suspected tracheal stenosis. CT Neck and Chest Without IV Contrast There is no relevant literature to support the use of neck and chest CT without IV contrast in the initial evaluation of suspected tracheal stenosis. However, combined neck and chest CT without IV contrast may be performed for assessment of suspected tracheal lesions and stenosis, especially for diseases that can involve the subglottic trachea, such as diffuse tracheal diseases and suspected or known malignancies of the neck. | 3195161 |
acrac_3195161_3 | Tracheobronchial Disease | Chest CT protocols to evaluate tracheal stenosis often prescribe z-axis coverage through the lower neck. CT Neck With IV Contrast Neck CT with IV contrast may occasionally be performed as a targeted assessment of known lesions within the superior trachea, including primary neck malignancies with tracheal involvement. However, the limited z-axis coverage of neck CT risks exclusion of the full extent of tracheal disease. More commonly, neck CT may be performed as part of a combined neck and chest CT for assessment of suspected tracheal lesions and stenosis. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast in the initial evaluation of suspected tracheal stenosis. CT Neck Without IV Contrast Neck CT without IV contrast may occasionally be performed as a targeted assessment of known lesions within the superior trachea, including primary neck malignancies with tracheal involvement. However, the limited z-axis coverage of neck CT risks exclusion of the full extent of tracheal disease. More commonly, neck CT may be performed as part of a combined neck and chest CT for assessment of suspected tracheal lesions and stenosis. CTA Chest With IV Contrast Chest CT angiography (CTA) with IV contrast may be used in evaluation of suspected tracheal stenosis in the setting of extrinsic compression due to a vascular cause, such as aberrant vessel or aneurysm. However, there is no relevant evidence comparing chest CTA and standard chest CT with or without IV contrast in initial evaluation of suspected tracheal stenosis. FDG-PET/CT Skull Base To Mid-Thigh Fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT is often used in the initial staging and follow-up of known thoracic malignancies, including tracheal tumors. However, FDG-PET/CT is not usually obtained as the initial imaging assessment of suspected tracheal stenosis. | Tracheobronchial Disease. Chest CT protocols to evaluate tracheal stenosis often prescribe z-axis coverage through the lower neck. CT Neck With IV Contrast Neck CT with IV contrast may occasionally be performed as a targeted assessment of known lesions within the superior trachea, including primary neck malignancies with tracheal involvement. However, the limited z-axis coverage of neck CT risks exclusion of the full extent of tracheal disease. More commonly, neck CT may be performed as part of a combined neck and chest CT for assessment of suspected tracheal lesions and stenosis. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast in the initial evaluation of suspected tracheal stenosis. CT Neck Without IV Contrast Neck CT without IV contrast may occasionally be performed as a targeted assessment of known lesions within the superior trachea, including primary neck malignancies with tracheal involvement. However, the limited z-axis coverage of neck CT risks exclusion of the full extent of tracheal disease. More commonly, neck CT may be performed as part of a combined neck and chest CT for assessment of suspected tracheal lesions and stenosis. CTA Chest With IV Contrast Chest CT angiography (CTA) with IV contrast may be used in evaluation of suspected tracheal stenosis in the setting of extrinsic compression due to a vascular cause, such as aberrant vessel or aneurysm. However, there is no relevant evidence comparing chest CTA and standard chest CT with or without IV contrast in initial evaluation of suspected tracheal stenosis. FDG-PET/CT Skull Base To Mid-Thigh Fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT is often used in the initial staging and follow-up of known thoracic malignancies, including tracheal tumors. However, FDG-PET/CT is not usually obtained as the initial imaging assessment of suspected tracheal stenosis. | 3195161 |
acrac_3195161_4 | Tracheobronchial Disease | MRI Chest Without and With IV Contrast Although tracheal imaging can be performed with MRI, including dynamic imaging, this tool has been used mainly as a research tool. MRI Chest Without IV Contrast Although tracheal imaging can be performed with MRI, including dynamic imaging, this tool has been used mainly as a research tool. Radiography Chest Radiography is often performed as initial imaging in patients with respiratory symptoms. Although tracheal stenosis and masses are occasionally incidental findings at chest radiography, the modality is much less sensitive for detection of central airway pathology than cross-sectional imaging. In a study of 41 patients with tumors and nonneoplastic stenosis of the central airways, radiography performed poorly compared to CT in depicting and characterizing lesions [22]. Radiography may be useful as an evaluation of possible complications of central airway disease, such as postobstructive atelectasis or pneumonia. Tracheobronchial Disease Radiography Neck There is no relevant literature to support the use of neck radiography in the initial evaluation of suspected tracheal stenosis. Radiography of the neck may be obtained in patients with suspected upper airway obstruction due to certain infections or foreign bodies. However, it is not routinely used for evaluation of tracheal stenosis. Variant 2: Adult. Tracheal or bronchial stenosis. Pre- or posttreatment assessment. CT Chest With IV Contrast CT of the chest with IV contrast can be used for pretreatment assessment of lesions and stenosis of the large airways and can help determine suitability and type of surgical or nonsurgical treatment approach [24]. However, studies comparing performance of chest CT with IV contrast to chest CT without IV contrast for evaluation of tracheal stenosis and associated lesions are lacking. | Tracheobronchial Disease. MRI Chest Without and With IV Contrast Although tracheal imaging can be performed with MRI, including dynamic imaging, this tool has been used mainly as a research tool. MRI Chest Without IV Contrast Although tracheal imaging can be performed with MRI, including dynamic imaging, this tool has been used mainly as a research tool. Radiography Chest Radiography is often performed as initial imaging in patients with respiratory symptoms. Although tracheal stenosis and masses are occasionally incidental findings at chest radiography, the modality is much less sensitive for detection of central airway pathology than cross-sectional imaging. In a study of 41 patients with tumors and nonneoplastic stenosis of the central airways, radiography performed poorly compared to CT in depicting and characterizing lesions [22]. Radiography may be useful as an evaluation of possible complications of central airway disease, such as postobstructive atelectasis or pneumonia. Tracheobronchial Disease Radiography Neck There is no relevant literature to support the use of neck radiography in the initial evaluation of suspected tracheal stenosis. Radiography of the neck may be obtained in patients with suspected upper airway obstruction due to certain infections or foreign bodies. However, it is not routinely used for evaluation of tracheal stenosis. Variant 2: Adult. Tracheal or bronchial stenosis. Pre- or posttreatment assessment. CT Chest With IV Contrast CT of the chest with IV contrast can be used for pretreatment assessment of lesions and stenosis of the large airways and can help determine suitability and type of surgical or nonsurgical treatment approach [24]. However, studies comparing performance of chest CT with IV contrast to chest CT without IV contrast for evaluation of tracheal stenosis and associated lesions are lacking. | 3195161 |
acrac_3195161_5 | Tracheobronchial Disease | A few small studies have documented additional incremental benefits of review of 2-D multiplanar, 3-D reformatted, and VB images, including changes in surgical approach or identification of associated findings such as small fistulae [11]. Chest CT is also used for evaluation of suspected posttreatment complications of tracheal interventions. CT is commonly used for planning for tracheal stent implantation; a study of 69 patients with stenosis due to malignancy used CT to select stent diameter by measuring proximal and distal landing zone diameters and to determine desired stent length by measuring length of the involved segment [25]. A small study of 17 stenoses in 14 patients with postintubation stenosis confirmed at surgery found a detection rate of stenosis of 94% (16 of 17 lesions) of CT with VB and 88% (15 of 17) by rigid bronchoscopy; assessment of length was accurate for 87% of stenotic segments by CT and VB and 73% of segments by rigid bronchoscopy [13]. In a study of contrast-enhanced CT of 46 adenoid cystic carcinomas of the trachea and 36 other tracheal tumors, several imaging characteristics were predictive of poor disease-free survival, including longitudinal length >34 mm, transmural growth, and transverse length >20 mm, although only the latter remained significant in multivariate analysis [19]. A retrospective study of 31 tumors of the trachea or main bronchi compared a combination of pre- and postcontrast CT axial images, volume-rendered, and VB postprocessing techniques with surgical and pathology findings, finding good correlations for tumor locations, morphologies, longitudinal involvement, extent and morphology of stenosis, extramural invasion, and distance from the carina [12]. In a study of 52 patients comparing VB with bronchoscopy, VB had a high sensitivity and accuracy (both 93%) for detection of central airway tumors and had a high sensitivity (90%) and accuracy (96%) for characterization of airway stenosis [26]. | Tracheobronchial Disease. A few small studies have documented additional incremental benefits of review of 2-D multiplanar, 3-D reformatted, and VB images, including changes in surgical approach or identification of associated findings such as small fistulae [11]. Chest CT is also used for evaluation of suspected posttreatment complications of tracheal interventions. CT is commonly used for planning for tracheal stent implantation; a study of 69 patients with stenosis due to malignancy used CT to select stent diameter by measuring proximal and distal landing zone diameters and to determine desired stent length by measuring length of the involved segment [25]. A small study of 17 stenoses in 14 patients with postintubation stenosis confirmed at surgery found a detection rate of stenosis of 94% (16 of 17 lesions) of CT with VB and 88% (15 of 17) by rigid bronchoscopy; assessment of length was accurate for 87% of stenotic segments by CT and VB and 73% of segments by rigid bronchoscopy [13]. In a study of contrast-enhanced CT of 46 adenoid cystic carcinomas of the trachea and 36 other tracheal tumors, several imaging characteristics were predictive of poor disease-free survival, including longitudinal length >34 mm, transmural growth, and transverse length >20 mm, although only the latter remained significant in multivariate analysis [19]. A retrospective study of 31 tumors of the trachea or main bronchi compared a combination of pre- and postcontrast CT axial images, volume-rendered, and VB postprocessing techniques with surgical and pathology findings, finding good correlations for tumor locations, morphologies, longitudinal involvement, extent and morphology of stenosis, extramural invasion, and distance from the carina [12]. In a study of 52 patients comparing VB with bronchoscopy, VB had a high sensitivity and accuracy (both 93%) for detection of central airway tumors and had a high sensitivity (90%) and accuracy (96%) for characterization of airway stenosis [26]. | 3195161 |
acrac_3195161_6 | Tracheobronchial Disease | However, there is no relevant literature specifically comparing chest CT with IV contrast to chest CT without IV contrast. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast for pre- or posttreatment evaluation of tracheal stenosis. CT Chest Without IV Contrast CT of the chest without IV contrast is widely used for pretreatment assessment of lesions and stenosis of the large airways and can help determine suitability and type of surgical or nonsurgical treatment approach [24]. A few small studies have documented additional incremental benefits of review of 2-D multiplanar, 3-D reformatted, and VB images, including changes in surgical approach or identification of associated findings such as small fistulae [11]. Chest CT is also used for evaluation of suspected posttreatment complications of tracheal interventions. CT is commonly used for planning for tracheal stent implantation; a study of 69 patients with stenosis due to malignancy used CT to select stent diameter by measuring proximal and distal landing zone diameters and to determine desired stent length by measuring length of the involved segment [25]. A small study of 17 stenoses in 14 patients with postintubation stenosis confirmed at surgery found a detection rate of stenosis of 94% (16 of 17 lesions) of CT with VB and 88% (15 of 17) by rigid bronchoscopy; assessment of length was accurate for 87% of stenotic segments by CT and VB and 73% of segments by rigid bronchoscopy [13]. A retrospective study of 31 tumors of the trachea or main bronchi compared a combination of pre- and postcontrast CT axial images, volume-rendered, and VB postprocessing techniques with surgical and pathology findings, finding good correlations for tumor locations, morphologies, longitudinal involvement, extent and morphology of stenosis, extramural invasion, and distance from the carina [12]. In a study of 52 patients comparing VB with bronchoscopy, Tracheobronchial Disease | Tracheobronchial Disease. However, there is no relevant literature specifically comparing chest CT with IV contrast to chest CT without IV contrast. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast for pre- or posttreatment evaluation of tracheal stenosis. CT Chest Without IV Contrast CT of the chest without IV contrast is widely used for pretreatment assessment of lesions and stenosis of the large airways and can help determine suitability and type of surgical or nonsurgical treatment approach [24]. A few small studies have documented additional incremental benefits of review of 2-D multiplanar, 3-D reformatted, and VB images, including changes in surgical approach or identification of associated findings such as small fistulae [11]. Chest CT is also used for evaluation of suspected posttreatment complications of tracheal interventions. CT is commonly used for planning for tracheal stent implantation; a study of 69 patients with stenosis due to malignancy used CT to select stent diameter by measuring proximal and distal landing zone diameters and to determine desired stent length by measuring length of the involved segment [25]. A small study of 17 stenoses in 14 patients with postintubation stenosis confirmed at surgery found a detection rate of stenosis of 94% (16 of 17 lesions) of CT with VB and 88% (15 of 17) by rigid bronchoscopy; assessment of length was accurate for 87% of stenotic segments by CT and VB and 73% of segments by rigid bronchoscopy [13]. A retrospective study of 31 tumors of the trachea or main bronchi compared a combination of pre- and postcontrast CT axial images, volume-rendered, and VB postprocessing techniques with surgical and pathology findings, finding good correlations for tumor locations, morphologies, longitudinal involvement, extent and morphology of stenosis, extramural invasion, and distance from the carina [12]. In a study of 52 patients comparing VB with bronchoscopy, Tracheobronchial Disease | 3195161 |
acrac_3195161_7 | Tracheobronchial Disease | VB had a high sensitivity and accuracy (both 93%) for detection of central airway tumors and had a high sensitivity (90%) and accuracy (96%) for characterization of airway stenosis [26]. CT Neck and Chest With IV Contrast Combined neck and chest CT with IV contrast can be performed for pre- or posttreatment evaluation of tracheal stenosis, especially for diseases that can involve the subglottic trachea, such as diffuse tracheal diseases and suspected or known malignancies of the neck. Chest CT protocols to evaluate tracheal stenosis often prescribe z- axis coverage through the lower neck. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast for pre- or posttreatment evaluation of tracheal stenosis. CT Neck and Chest Without IV Contrast Combined neck and chest CT without IV contrast can be performed for pre- or posttreatment evaluation of tracheal stenosis, especially for diseases that can involve the subglottic trachea, such as diffuse tracheal diseases and suspected or known malignancies of the neck. Chest CT protocols to evaluate tracheal stenosis often prescribe z- axis coverage through the lower neck. CT Neck With IV Contrast Neck CT with IV contrast may occasionally be performed as a targeted assessment of known lesions within the superior trachea, including primary neck malignancies with tracheal involvement. However, the limited z-axis coverage of neck CT risks exclusion of the full extent of tracheal disease. More commonly, neck CT may be performed as part of a combined neck and chest CT for pre- or posttreatment assessment of tracheal lesions and stenosis. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast for pre- or posttreatment evaluation of tracheal stenosis. | Tracheobronchial Disease. VB had a high sensitivity and accuracy (both 93%) for detection of central airway tumors and had a high sensitivity (90%) and accuracy (96%) for characterization of airway stenosis [26]. CT Neck and Chest With IV Contrast Combined neck and chest CT with IV contrast can be performed for pre- or posttreatment evaluation of tracheal stenosis, especially for diseases that can involve the subglottic trachea, such as diffuse tracheal diseases and suspected or known malignancies of the neck. Chest CT protocols to evaluate tracheal stenosis often prescribe z- axis coverage through the lower neck. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast for pre- or posttreatment evaluation of tracheal stenosis. CT Neck and Chest Without IV Contrast Combined neck and chest CT without IV contrast can be performed for pre- or posttreatment evaluation of tracheal stenosis, especially for diseases that can involve the subglottic trachea, such as diffuse tracheal diseases and suspected or known malignancies of the neck. Chest CT protocols to evaluate tracheal stenosis often prescribe z- axis coverage through the lower neck. CT Neck With IV Contrast Neck CT with IV contrast may occasionally be performed as a targeted assessment of known lesions within the superior trachea, including primary neck malignancies with tracheal involvement. However, the limited z-axis coverage of neck CT risks exclusion of the full extent of tracheal disease. More commonly, neck CT may be performed as part of a combined neck and chest CT for pre- or posttreatment assessment of tracheal lesions and stenosis. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast for pre- or posttreatment evaluation of tracheal stenosis. | 3195161 |
acrac_3195161_8 | Tracheobronchial Disease | CT Neck Without IV Contrast Neck CT without IV contrast may occasionally be performed as a targeted assessment of known lesions within the superior trachea, including primary neck malignancies with tracheal involvement. However, the limited z-axis coverage of neck CT risks exclusion of the full extent of tracheal disease. More commonly, neck CT may be performed as part of a combined neck and chest CT for pre- or posttreatment assessment of tracheal lesions and stenosis. CTA Chest With IV Contrast Chest CTA with IV contrast may be used in preoperative evaluation of tracheal stenosis in the setting of extrinsic compression due to a vascular cause, such as aberrant vessel or aneurysm. Chest CTA with aortic contrast phase timing may be used in selected cases to evaluate suspected bleeding as a complication of tracheal interventions. MRI Chest Without and With IV Contrast Although tracheal imaging can be performed with MRI, including dynamic imaging, this tool has been used mainly as a research tool. MRI Chest Without IV Contrast Although tracheal imaging can be performed with MRI, including dynamic imaging, this tool has been used mainly as a research tool. Tracheobronchial Disease Radiography Chest There is no relevant literature to support the use of chest radiography for pretreatment evaluation of tracheal stenosis. Although there is no relevant literature to support the routine use of chest radiographs after procedures designed to treat tracheal stenosis, in practice chest radiographs may be obtained to evaluate possible complications such as pneumothorax, excessive pneumomediastinum, or aspiration. Radiography Neck There is no relevant literature to support the use of neck radiography for pre- or posttreatment evaluation of tracheal stenosis. Variant 3: Adult. Clinically suspected tracheomalacia or bronchomalacia. Initial imaging. | Tracheobronchial Disease. CT Neck Without IV Contrast Neck CT without IV contrast may occasionally be performed as a targeted assessment of known lesions within the superior trachea, including primary neck malignancies with tracheal involvement. However, the limited z-axis coverage of neck CT risks exclusion of the full extent of tracheal disease. More commonly, neck CT may be performed as part of a combined neck and chest CT for pre- or posttreatment assessment of tracheal lesions and stenosis. CTA Chest With IV Contrast Chest CTA with IV contrast may be used in preoperative evaluation of tracheal stenosis in the setting of extrinsic compression due to a vascular cause, such as aberrant vessel or aneurysm. Chest CTA with aortic contrast phase timing may be used in selected cases to evaluate suspected bleeding as a complication of tracheal interventions. MRI Chest Without and With IV Contrast Although tracheal imaging can be performed with MRI, including dynamic imaging, this tool has been used mainly as a research tool. MRI Chest Without IV Contrast Although tracheal imaging can be performed with MRI, including dynamic imaging, this tool has been used mainly as a research tool. Tracheobronchial Disease Radiography Chest There is no relevant literature to support the use of chest radiography for pretreatment evaluation of tracheal stenosis. Although there is no relevant literature to support the routine use of chest radiographs after procedures designed to treat tracheal stenosis, in practice chest radiographs may be obtained to evaluate possible complications such as pneumothorax, excessive pneumomediastinum, or aspiration. Radiography Neck There is no relevant literature to support the use of neck radiography for pre- or posttreatment evaluation of tracheal stenosis. Variant 3: Adult. Clinically suspected tracheomalacia or bronchomalacia. Initial imaging. | 3195161 |
acrac_3195161_9 | Tracheobronchial Disease | CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Chest Without IV Contrast Chest CT without IV contrast is useful for noninvasive imaging of ECAC, including tracheobronchomalacia and excessive dynamic airway collapse. Chest CT during forced expiration has been widely adopted as the primary imaging protocol because it is more sensitive for detection of ECAC, eliciting greater degrees of expiratory collapse than CT obtained at end expiration [29-31]. In a study of 29 patients with suspected ECAC, forced expiratory dynamic cine imaging showed tracheal collapse >50% at 38% of assessed levels compared to 13% at end-expiratory CT [32]; a study of 67 patients with chronic obstructive pulmonary disease (COPD) showed a mean tracheal collapse of 62% at forced expiratory CT and only 17% at end expiratory CT [31]. Fifty percent area narrowing of the lumen of the trachea on CT at expiration had originally been considered suggestive of ECAC, but a threshold of 70% collapse is now proposed following a study by Boiselle et al [17], finding >50% collapse in 40 of 51 (78%) healthy volunteers. CT Neck and Chest With IV Contrast There is no relevant literature to support the use of neck and chest CT with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. | Tracheobronchial Disease. CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Chest Without IV Contrast Chest CT without IV contrast is useful for noninvasive imaging of ECAC, including tracheobronchomalacia and excessive dynamic airway collapse. Chest CT during forced expiration has been widely adopted as the primary imaging protocol because it is more sensitive for detection of ECAC, eliciting greater degrees of expiratory collapse than CT obtained at end expiration [29-31]. In a study of 29 patients with suspected ECAC, forced expiratory dynamic cine imaging showed tracheal collapse >50% at 38% of assessed levels compared to 13% at end-expiratory CT [32]; a study of 67 patients with chronic obstructive pulmonary disease (COPD) showed a mean tracheal collapse of 62% at forced expiratory CT and only 17% at end expiratory CT [31]. Fifty percent area narrowing of the lumen of the trachea on CT at expiration had originally been considered suggestive of ECAC, but a threshold of 70% collapse is now proposed following a study by Boiselle et al [17], finding >50% collapse in 40 of 51 (78%) healthy volunteers. CT Neck and Chest With IV Contrast There is no relevant literature to support the use of neck and chest CT with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. | 3195161 |
acrac_3195161_10 | Tracheobronchial Disease | CT Neck and Chest Without IV Contrast There is no relevant literature to support performing a full neck CT in this setting, however, z-axis coverage through the lower neck is often prescribed as part of a standard chest CT without IV contrast for evaluation of suspected tracheomalacia or bronchomalacia. CT Neck With IV Contrast There is no relevant literature to support the use of neck CT with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Neck Without IV Contrast There is no relevant literature to support the use of neck CT without IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CTA Chest With IV Contrast There is no relevant literature to support the use of chest CTA for initial evaluation of suspected tracheomalacia or bronchomalacia. Tracheobronchial Disease FDG-PET/CT Skull Base To Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for initial evaluation of suspected tracheomalacia or bronchomalacia. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. Radiography Chest Dynamic chest radiography has been proposed for evaluating ECAC but use has been limited to small preliminary research investigations [34]. Chest radiography may be used in the initial evaluation of other pulmonary diseases that may manifest with respiratory symptoms also seen in ECAC. Radiography Neck There is no relevant literature to support the use of neck radiography for initial evaluation of suspected tracheomalacia or bronchomalacia. Variant 4: Adult. Tracheomalacia or bronchomalacia. Pre- or posttreatment assessment. | Tracheobronchial Disease. CT Neck and Chest Without IV Contrast There is no relevant literature to support performing a full neck CT in this setting, however, z-axis coverage through the lower neck is often prescribed as part of a standard chest CT without IV contrast for evaluation of suspected tracheomalacia or bronchomalacia. CT Neck With IV Contrast There is no relevant literature to support the use of neck CT with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CT Neck Without IV Contrast There is no relevant literature to support the use of neck CT without IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. CTA Chest With IV Contrast There is no relevant literature to support the use of chest CTA for initial evaluation of suspected tracheomalacia or bronchomalacia. Tracheobronchial Disease FDG-PET/CT Skull Base To Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for initial evaluation of suspected tracheomalacia or bronchomalacia. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for initial evaluation of suspected tracheomalacia or bronchomalacia. Radiography Chest Dynamic chest radiography has been proposed for evaluating ECAC but use has been limited to small preliminary research investigations [34]. Chest radiography may be used in the initial evaluation of other pulmonary diseases that may manifest with respiratory symptoms also seen in ECAC. Radiography Neck There is no relevant literature to support the use of neck radiography for initial evaluation of suspected tracheomalacia or bronchomalacia. Variant 4: Adult. Tracheomalacia or bronchomalacia. Pre- or posttreatment assessment. | 3195161 |
acrac_3195161_11 | Tracheobronchial Disease | CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. In practice, chest CT may be performed with IV contrast in evaluation of postsurgical complications of procedures used to treat tracheomalacia or bronchomalacia. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. CT Chest Without IV Contrast Evaluation of ECAC with dynamic expiratory CT can change treatment approach in some patients compared with evaluation with bronchoscopy alone and is standardly performed without IV contrast. In one study, a change in planned treatment was performed in 12 of 29 patients with tracheomalacia or bronchomalacia who had previously undergone bronchoscopy, including changes in surgical approach [30]. A small study using inspiratory and dynamic expiratory CT to evaluate 5 patients with tracheomalacia before and after tracheobronchoplasty found a decrease in degree of tracheal collapse after surgery in all participants [35]. Other studies of 18 patients [8] and 16 patients [36] with tracheobronchomalacia using end inspiratory and dynamic expiratory CT showed significant average decreases trachea after tracheobronchoplasty. However, there are no guidelines for performing routine follow up of patients after treatment for ECAC. CT Neck and Chest With IV Contrast Z-axis coverage through the lower neck is often prescribed as part of a standard chest CT with IV contrast for evaluation of suspected tracheomalacia or bronchomalacia, but there is no relevant evidence to support performing a full neck CT in this setting. In clinical practice, neck CT may be performed in conjunction with chest CT to evaluate suspected complications of tracheal interventions. | Tracheobronchial Disease. CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. In practice, chest CT may be performed with IV contrast in evaluation of postsurgical complications of procedures used to treat tracheomalacia or bronchomalacia. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. CT Chest Without IV Contrast Evaluation of ECAC with dynamic expiratory CT can change treatment approach in some patients compared with evaluation with bronchoscopy alone and is standardly performed without IV contrast. In one study, a change in planned treatment was performed in 12 of 29 patients with tracheomalacia or bronchomalacia who had previously undergone bronchoscopy, including changes in surgical approach [30]. A small study using inspiratory and dynamic expiratory CT to evaluate 5 patients with tracheomalacia before and after tracheobronchoplasty found a decrease in degree of tracheal collapse after surgery in all participants [35]. Other studies of 18 patients [8] and 16 patients [36] with tracheobronchomalacia using end inspiratory and dynamic expiratory CT showed significant average decreases trachea after tracheobronchoplasty. However, there are no guidelines for performing routine follow up of patients after treatment for ECAC. CT Neck and Chest With IV Contrast Z-axis coverage through the lower neck is often prescribed as part of a standard chest CT with IV contrast for evaluation of suspected tracheomalacia or bronchomalacia, but there is no relevant evidence to support performing a full neck CT in this setting. In clinical practice, neck CT may be performed in conjunction with chest CT to evaluate suspected complications of tracheal interventions. | 3195161 |
acrac_3195161_12 | Tracheobronchial Disease | CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. Tracheobronchial Disease CT Neck and Chest Without IV Contrast Z-axis coverage through the lower neck is often prescribed as part of a standard chest CT without IV contrast for evaluation of suspected tracheomalacia or bronchomalacia, but there is no relevant evidence to support performing a full neck CT in this setting. In clinical practice, neck CT may be performed in conjunction with chest CT to evaluate suspected complications of tracheal interventions. CT Neck With IV Contrast There is no relevant literature to support the use of neck CT with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. CT Neck Without IV Contrast There is no relevant literature to support the use of neck CT without IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. CTA Chest With IV Contrast There is no relevant literature to support the use of chest CTA for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. However, chest CTA timed for an aortic phase of contrast may be used in selected cases to evaluate suspected bleeding as a complication of tracheal interventions. FDG-PET/CT Skull Base To Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. | Tracheobronchial Disease. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. Tracheobronchial Disease CT Neck and Chest Without IV Contrast Z-axis coverage through the lower neck is often prescribed as part of a standard chest CT without IV contrast for evaluation of suspected tracheomalacia or bronchomalacia, but there is no relevant evidence to support performing a full neck CT in this setting. In clinical practice, neck CT may be performed in conjunction with chest CT to evaluate suspected complications of tracheal interventions. CT Neck With IV Contrast There is no relevant literature to support the use of neck CT with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. CT Neck Without IV Contrast There is no relevant literature to support the use of neck CT without IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. CTA Chest With IV Contrast There is no relevant literature to support the use of chest CTA for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. However, chest CTA timed for an aortic phase of contrast may be used in selected cases to evaluate suspected bleeding as a complication of tracheal interventions. FDG-PET/CT Skull Base To Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. | 3195161 |
acrac_3195161_13 | Tracheobronchial Disease | Radiography Chest Although there is no relevant literature to support the routine use of chest radiographs after procedures designed to treat tracheomalacia or bronchomalacia, in practice, chest radiographs may be obtained to evaluate possible complications such as pneumothorax, excessive pneumomediastinum, or aspiration. Radiography Neck There is no relevant literature to support the use of neck radiography for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. Variant 5: Adult. Clinically suspected bronchiectasis. Initial imaging. CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with IV contrast for initial evaluation of suspected bronchiectasis. However, bronchiectasis can be detected incidentally on chest CT with IV contrast performed for other indications. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast for initial evaluation of suspected bronchiectasis. Tracheobronchial Disease The 2010 British Thoracic Society guidelines for non-cystic fibrosis (non-CF) bronchiectasis recommend thin- section CT, either conventional high-resolution CT or volumetric thin-slice CT, as the preferred examination for evaluation of suspected bronchiectasis. The guidelines acknowledge that, although certain CT distributions and appearances of bronchiectasis may suggest a particular etiology, in many cases, findings are not pathognomonic, as confirmed by the relatively low reader diagnostic performance in several retrospective CT studies [38-41]. However, CT can play a role in suggesting further clinical evaluation of causes of bronchiectasis and associated findings, such as in prompting testing for nontuberculous mycobacterial infection (NTMB) in the appropriate clinical setting [42]. CT can be used to quantify the extent and severity of bronchiectasis using a variety of techniques and software. | Tracheobronchial Disease. Radiography Chest Although there is no relevant literature to support the routine use of chest radiographs after procedures designed to treat tracheomalacia or bronchomalacia, in practice, chest radiographs may be obtained to evaluate possible complications such as pneumothorax, excessive pneumomediastinum, or aspiration. Radiography Neck There is no relevant literature to support the use of neck radiography for pre- or posttreatment evaluation of tracheomalacia or bronchomalacia. Variant 5: Adult. Clinically suspected bronchiectasis. Initial imaging. CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with IV contrast for initial evaluation of suspected bronchiectasis. However, bronchiectasis can be detected incidentally on chest CT with IV contrast performed for other indications. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast for initial evaluation of suspected bronchiectasis. Tracheobronchial Disease The 2010 British Thoracic Society guidelines for non-cystic fibrosis (non-CF) bronchiectasis recommend thin- section CT, either conventional high-resolution CT or volumetric thin-slice CT, as the preferred examination for evaluation of suspected bronchiectasis. The guidelines acknowledge that, although certain CT distributions and appearances of bronchiectasis may suggest a particular etiology, in many cases, findings are not pathognomonic, as confirmed by the relatively low reader diagnostic performance in several retrospective CT studies [38-41]. However, CT can play a role in suggesting further clinical evaluation of causes of bronchiectasis and associated findings, such as in prompting testing for nontuberculous mycobacterial infection (NTMB) in the appropriate clinical setting [42]. CT can be used to quantify the extent and severity of bronchiectasis using a variety of techniques and software. | 3195161 |
acrac_3195161_14 | Tracheobronchial Disease | A systematic review of 122 studies found 42 quantitative CT scoring methods in the research literature, including calculation of bronchial-arterial ratios, bronchial diameters, or bronchial surface area [43]. Severity of bronchiectasis at CT correlates with measures of airflow obstruction [40]. A relatively large prospective cohort study of 608 patients with bronchiectasis examined the association between a variety of clinical, laboratory, and CT findings and clinical outcomes; a CT finding of bronchiectasis in at least 3 lobes was associated with poorer outcomes and was incorporated along with several clinical variables into a bronchiectasis severity score with relatively high predictive value for exacerbations, hospitalizations, and mortality in patients with bronchiectasis [44]. A prospective multicenter study of 261 patients with non-CF bronchiectasis found weak but statistically significant correlations between severity and extent of bronchiectasis at CT and forced expiratory volume in one second and forced vital capacity [45]. A study of 277 patients with NTMB found correlations between bronchiectasis (as assessed by semiquantitative scores) and clinical variables such as more frequent exacerbations and lower blood oxygenation [46]. CT Neck and Chest With IV Contrast There is no relevant literature to support the use of neck and chest CT with IV contrast for initial evaluation of suspected bronchiectasis. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast for initial evaluation of suspected bronchiectasis. CT Neck and Chest Without IV Contrast There is no relevant literature to support the use of neck and chest CT without IV contrast for initial evaluation of suspected bronchiectasis. CT Neck With IV Contrast There is no relevant literature to support the use of neck CT with IV contrast for initial evaluation of suspected bronchiectasis. | Tracheobronchial Disease. A systematic review of 122 studies found 42 quantitative CT scoring methods in the research literature, including calculation of bronchial-arterial ratios, bronchial diameters, or bronchial surface area [43]. Severity of bronchiectasis at CT correlates with measures of airflow obstruction [40]. A relatively large prospective cohort study of 608 patients with bronchiectasis examined the association between a variety of clinical, laboratory, and CT findings and clinical outcomes; a CT finding of bronchiectasis in at least 3 lobes was associated with poorer outcomes and was incorporated along with several clinical variables into a bronchiectasis severity score with relatively high predictive value for exacerbations, hospitalizations, and mortality in patients with bronchiectasis [44]. A prospective multicenter study of 261 patients with non-CF bronchiectasis found weak but statistically significant correlations between severity and extent of bronchiectasis at CT and forced expiratory volume in one second and forced vital capacity [45]. A study of 277 patients with NTMB found correlations between bronchiectasis (as assessed by semiquantitative scores) and clinical variables such as more frequent exacerbations and lower blood oxygenation [46]. CT Neck and Chest With IV Contrast There is no relevant literature to support the use of neck and chest CT with IV contrast for initial evaluation of suspected bronchiectasis. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast for initial evaluation of suspected bronchiectasis. CT Neck and Chest Without IV Contrast There is no relevant literature to support the use of neck and chest CT without IV contrast for initial evaluation of suspected bronchiectasis. CT Neck With IV Contrast There is no relevant literature to support the use of neck CT with IV contrast for initial evaluation of suspected bronchiectasis. | 3195161 |
acrac_3195161_15 | Tracheobronchial Disease | CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast for initial evaluation of suspected bronchiectasis. CT Neck Without IV Contrast There is no relevant literature to support the use of neck CT without IV contrast for initial evaluation of suspected bronchiectasis. CTA Chest With IV Contrast There is no relevant literature to support the use of chest CTA for initial evaluation of suspected bronchiectasis. However, bronchiectasis can be detected incidentally on chest CTA with IV contrast performed for other indications. Tracheobronchial Disease FDG-PET/CT Skull Base To Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for initial evaluation of suspected bronchiectasis. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for initial evaluation of suspected bronchiectasis. MRI Chest Without IV Contrast Limited data exist on the use of MRI without IV contrast in characterization of bronchiectasis. A small study of 23 adults with primary immunodeficiency found MRI inferior to CT in characterizing extent of bronchiectasis but found similar performance of MRI and CT in assessing severity of bronchiectasis, mucous plugging, bronchial wall thickening, and other associated parenchymal findings [47]. An exploratory study of 25 patients showed moderate agreement between MRI and CT scores for imaging findings in mycobacterium avium complex pneumonia, including for bronchiectasis [48]. However, the use of MRI for assessment of bronchiectasis is currently limited mainly to research settings or use in young patients such as those with cystic fibrosis. Radiography Chest Chest radiography is relatively insensitive for detection of bronchiectasis but is often performed as initial imaging in patients with respiratory symptoms that are common in patients with bronchiectasis [9,10]. | Tracheobronchial Disease. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast for initial evaluation of suspected bronchiectasis. CT Neck Without IV Contrast There is no relevant literature to support the use of neck CT without IV contrast for initial evaluation of suspected bronchiectasis. CTA Chest With IV Contrast There is no relevant literature to support the use of chest CTA for initial evaluation of suspected bronchiectasis. However, bronchiectasis can be detected incidentally on chest CTA with IV contrast performed for other indications. Tracheobronchial Disease FDG-PET/CT Skull Base To Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for initial evaluation of suspected bronchiectasis. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for initial evaluation of suspected bronchiectasis. MRI Chest Without IV Contrast Limited data exist on the use of MRI without IV contrast in characterization of bronchiectasis. A small study of 23 adults with primary immunodeficiency found MRI inferior to CT in characterizing extent of bronchiectasis but found similar performance of MRI and CT in assessing severity of bronchiectasis, mucous plugging, bronchial wall thickening, and other associated parenchymal findings [47]. An exploratory study of 25 patients showed moderate agreement between MRI and CT scores for imaging findings in mycobacterium avium complex pneumonia, including for bronchiectasis [48]. However, the use of MRI for assessment of bronchiectasis is currently limited mainly to research settings or use in young patients such as those with cystic fibrosis. Radiography Chest Chest radiography is relatively insensitive for detection of bronchiectasis but is often performed as initial imaging in patients with respiratory symptoms that are common in patients with bronchiectasis [9,10]. | 3195161 |
acrac_3195161_16 | Tracheobronchial Disease | Chest radiography may be useful for the initial evaluation of the lung parenchyma in conditions associated with bronchiectasis, but it provides limited characterization of severity and morphology of bronchiectasis. The 2010 British Thoracic Society guidelines for non-CF bronchiectasis recommend a baseline chest radiograph in all patients with suspected bronchiectasis but recommend repeat radiographs only if clinically warranted [40]. Radiography Neck There is no relevant literature to support the use of neck radiography for initial evaluation of suspected bronchiectasis. Variant 6: Adult. Bronchiectasis. Assessment of complications or treatment response. CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT chest with IV contrast may also be appropriate in the setting of suspected acute infection and associated complications such as abscess or necrosis. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Chest Without IV Contrast Chest CT without IV contrast may be used to evaluate complications associated with bronchiectasis, including pneumonia and hemoptysis, and is often used in follow-up of conditions associated with bronchiectasis, such as chronic infections or interstitial lung diseases. Chest CT without IV contrast may be appropriate for assessing patients with known bronchiectasis and a change in clinical status to exclude pulmonary causes [40]. Chest CT without IV contrast can be used to quantify extent and severity of bronchiectasis with special software. A systematic review of 122 studies found 42 quantitative CT scoring methods in the research literature, including calculation of bronchial-arterial ratios, bronchial diameters, or bronchial surface area [43]. | Tracheobronchial Disease. Chest radiography may be useful for the initial evaluation of the lung parenchyma in conditions associated with bronchiectasis, but it provides limited characterization of severity and morphology of bronchiectasis. The 2010 British Thoracic Society guidelines for non-CF bronchiectasis recommend a baseline chest radiograph in all patients with suspected bronchiectasis but recommend repeat radiographs only if clinically warranted [40]. Radiography Neck There is no relevant literature to support the use of neck radiography for initial evaluation of suspected bronchiectasis. Variant 6: Adult. Bronchiectasis. Assessment of complications or treatment response. CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT chest with IV contrast may also be appropriate in the setting of suspected acute infection and associated complications such as abscess or necrosis. CT Chest Without and With IV Contrast There is no relevant literature to support the use of chest CT without and with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Chest Without IV Contrast Chest CT without IV contrast may be used to evaluate complications associated with bronchiectasis, including pneumonia and hemoptysis, and is often used in follow-up of conditions associated with bronchiectasis, such as chronic infections or interstitial lung diseases. Chest CT without IV contrast may be appropriate for assessing patients with known bronchiectasis and a change in clinical status to exclude pulmonary causes [40]. Chest CT without IV contrast can be used to quantify extent and severity of bronchiectasis with special software. A systematic review of 122 studies found 42 quantitative CT scoring methods in the research literature, including calculation of bronchial-arterial ratios, bronchial diameters, or bronchial surface area [43]. | 3195161 |
acrac_3195161_17 | Tracheobronchial Disease | Severity of bronchiectasis at CT correlates with measures of airflow obstruction [40]. Although well-established guidelines on imaging follow-up of bronchiectasis are lacking, in practice, patients with diseases associated with bronchiectasis may be assessed with CT to help guide therapy and to provide prognostic information. Patients with NTMB may be followed with chest CT to assess response to therapy or worsening of disease. A study of 210 patients with NTMB found that higher CT severity scores (a combined assessment of nodules, bronchiectasis, cavities, and consolidation) were associated with higher organism sputum counts and worse prognosis [49]; higher sputum organism count was also associated with CT findings of small nodules, consolidation, bronchiectasis, and pleural thickening in another study of 50 patients with NTMB [50]. In a study of 488 patients with NTMB, patients with predominantly fibrocavitary disease were more likely to experience clinical deterioration than those with primarily noncavitary manifestations [51]. In a study of 40 patients with NTMB lung disease not undergoing antimycobacterial treatment, 39 (98%) showed worsening on chest CT findings over the course of Tracheobronchial Disease several years [52], although another study of 475 patients with NTMB pulmonary disease showed improvement in CT scores with antibiotic treatment [53]. In a study of 67 patients with NTMB, more extensive total lung involvement and higher cavitary volume were independently associated with worse pulmonary function [54]. CT may be useful for follow-up of patients with bronchiectasis who may be at risk of developing NTMB. | Tracheobronchial Disease. Severity of bronchiectasis at CT correlates with measures of airflow obstruction [40]. Although well-established guidelines on imaging follow-up of bronchiectasis are lacking, in practice, patients with diseases associated with bronchiectasis may be assessed with CT to help guide therapy and to provide prognostic information. Patients with NTMB may be followed with chest CT to assess response to therapy or worsening of disease. A study of 210 patients with NTMB found that higher CT severity scores (a combined assessment of nodules, bronchiectasis, cavities, and consolidation) were associated with higher organism sputum counts and worse prognosis [49]; higher sputum organism count was also associated with CT findings of small nodules, consolidation, bronchiectasis, and pleural thickening in another study of 50 patients with NTMB [50]. In a study of 488 patients with NTMB, patients with predominantly fibrocavitary disease were more likely to experience clinical deterioration than those with primarily noncavitary manifestations [51]. In a study of 40 patients with NTMB lung disease not undergoing antimycobacterial treatment, 39 (98%) showed worsening on chest CT findings over the course of Tracheobronchial Disease several years [52], although another study of 475 patients with NTMB pulmonary disease showed improvement in CT scores with antibiotic treatment [53]. In a study of 67 patients with NTMB, more extensive total lung involvement and higher cavitary volume were independently associated with worse pulmonary function [54]. CT may be useful for follow-up of patients with bronchiectasis who may be at risk of developing NTMB. | 3195161 |
acrac_3195161_18 | Tracheobronchial Disease | A study of 221 patients with bronchiectasis found new-onset NTMB pulmonary disease in 31 (14%) patients, which was associated with worsening of bronchiectasis, bronchiolitis, and other nodules on CT [55], and another study of 84 patients showed that more severe bronchiectasis and presence of cavities were more likely in NTMB pulmonary disease than in asymptomatic colonization [42]. Some studies have also found an association of CT severity scores and likelihood of NTMB treatment failure [56]. CT Neck and Chest With IV Contrast There is no relevant literature to support the use of neck and chest CT with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck and Chest Without IV Contrast There is no relevant literature to support the use of neck and chest CT without IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck With IV Contrast There is no relevant literature to support the use of neck CT with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck Without IV Contrast There is no relevant literature to support the use of neck CT without IV contrast in the evaluation of bronchiectasis complications or treatment response. CTA Chest With IV Contrast There is no relevant literature to support the use of chest CTA for assessment of other bronchiectasis complications or treatment response. | Tracheobronchial Disease. A study of 221 patients with bronchiectasis found new-onset NTMB pulmonary disease in 31 (14%) patients, which was associated with worsening of bronchiectasis, bronchiolitis, and other nodules on CT [55], and another study of 84 patients showed that more severe bronchiectasis and presence of cavities were more likely in NTMB pulmonary disease than in asymptomatic colonization [42]. Some studies have also found an association of CT severity scores and likelihood of NTMB treatment failure [56]. CT Neck and Chest With IV Contrast There is no relevant literature to support the use of neck and chest CT with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck and Chest Without and With IV Contrast There is no relevant literature to support the use of neck and chest CT without and with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck and Chest Without IV Contrast There is no relevant literature to support the use of neck and chest CT without IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck With IV Contrast There is no relevant literature to support the use of neck CT with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck Without and With IV Contrast There is no relevant literature to support the use of neck CT without and with IV contrast in the evaluation of bronchiectasis complications or treatment response. CT Neck Without IV Contrast There is no relevant literature to support the use of neck CT without IV contrast in the evaluation of bronchiectasis complications or treatment response. CTA Chest With IV Contrast There is no relevant literature to support the use of chest CTA for assessment of other bronchiectasis complications or treatment response. | 3195161 |
acrac_3102386_0 | Thyroid Disease | Introduction/Background There are a wide variety of diseases that affect the thyroid gland and range from hyperplastic to neoplastic, autoimmune, or inflammatory. They can present with functional abnormality or a palpable structural change. Imaging has a key role in diagnosing and characterizing the thyroid finding for management. Imaging is also essential in the management of thyroid cancer. When biopsy reveals the diagnosis of thyroid cancer, imaging has several roles, depending on the type of cancer. Papillary and follicular carcinomas arise from the follicular epithelial cells are known as differentiated thyroid carcinomas (DTC), representing 84% and 11% of all thyroid malignancies, respectively [2]. DTC have an excellent prognosis, with a 10-year survival rate of 99% for papillary carcinoma and 95% for follicular type [2]. DTCs are treated primarily with surgery and may have radioiodine ablation depending on the stage of disease. Medullary thyroid carcinoma (MTC) arises from parafollicular cells and is more aggressive, with a survival rate of 82% at 10 years [2]. MTC is also treated with surgery. Anaplastic carcinoma is an aggressive undifferentiated tumor typically occurring in the elderly with a 10-year survival of 8% [9]. Treatment of anaplastic carcinoma does not significantly impact survival. Other malignancies, such as thyroid lymphoma, sarcoma, and metastases, are rare. Imaging is used in operative planning, routine tumor surveillance, and further evaluation of suspected recurrence. 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. *The views expressed in this manuscript are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, | Thyroid Disease. Introduction/Background There are a wide variety of diseases that affect the thyroid gland and range from hyperplastic to neoplastic, autoimmune, or inflammatory. They can present with functional abnormality or a palpable structural change. Imaging has a key role in diagnosing and characterizing the thyroid finding for management. Imaging is also essential in the management of thyroid cancer. When biopsy reveals the diagnosis of thyroid cancer, imaging has several roles, depending on the type of cancer. Papillary and follicular carcinomas arise from the follicular epithelial cells are known as differentiated thyroid carcinomas (DTC), representing 84% and 11% of all thyroid malignancies, respectively [2]. DTC have an excellent prognosis, with a 10-year survival rate of 99% for papillary carcinoma and 95% for follicular type [2]. DTCs are treated primarily with surgery and may have radioiodine ablation depending on the stage of disease. Medullary thyroid carcinoma (MTC) arises from parafollicular cells and is more aggressive, with a survival rate of 82% at 10 years [2]. MTC is also treated with surgery. Anaplastic carcinoma is an aggressive undifferentiated tumor typically occurring in the elderly with a 10-year survival of 8% [9]. Treatment of anaplastic carcinoma does not significantly impact survival. Other malignancies, such as thyroid lymphoma, sarcoma, and metastases, are rare. Imaging is used in operative planning, routine tumor surveillance, and further evaluation of suspected recurrence. 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. *The views expressed in this manuscript are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, | 3102386 |
acrac_3102386_1 | Thyroid Disease | Department of Defense, or United States Government. Reprint requests to: [email protected] Thyroid Disease Special Imaging Considerations Use of iodinated intravenous (IV) contrast for CT helps to delineate invasive tumor and morphological abnormalities in small nodal metastases. In the past, there were concerns about iodinated contrast agents delaying subsequent whole-body scans or radioiodine ablation; however, this has now been shown to be unfounded. Recent studies show that water-soluble iodinated contrast agents are generally cleared within 4 to 8 weeks in most patients; therefore, post-thyroidectomy patients requiring radioiodine therapy can be scanned with radioactive iodine (RAI) within 1 month of the contrast-enhanced CT [11,12]. Discussion of Procedures by Variant Variant 1: Palpable thyroid nodule. Not goiter. Euthyroid. Initial imaging. Screening for thyroid cancer by palpation is not recommended by the U.S. Preventive Task Force [15]. However, if a patient presents with a palpable neck nodule, the goal of imaging is to determine if the palpable abnormality corresponds to a thyroid nodule and to characterize the nodule for malignancy risk. Thyroid function tests should be performed first. If the serum thyroid-stimulating hormone (TSH) is subnormal, then the patient has thyrotoxicosis (Variant 3). This variant refers to a palpable thyroid nodule in the setting of a euthyroid patient. US Thyroid US provides high-resolution imaging to show that the palpable abnormality is within the thyroid and is the best study to characterize the nodule for the risk of malignancy. Certain sonographic features are more prevalent in malignancies. The combination of these features and the nodule size guide the decision to biopsy under the ACR TI-RADS and other risk stratification criteria [8,16]. CT Neck There is no evidence that CT can differentiate between malignant and benign nodules unless there is gross invasion or metastatic disease [7]. | Thyroid Disease. Department of Defense, or United States Government. Reprint requests to: [email protected] Thyroid Disease Special Imaging Considerations Use of iodinated intravenous (IV) contrast for CT helps to delineate invasive tumor and morphological abnormalities in small nodal metastases. In the past, there were concerns about iodinated contrast agents delaying subsequent whole-body scans or radioiodine ablation; however, this has now been shown to be unfounded. Recent studies show that water-soluble iodinated contrast agents are generally cleared within 4 to 8 weeks in most patients; therefore, post-thyroidectomy patients requiring radioiodine therapy can be scanned with radioactive iodine (RAI) within 1 month of the contrast-enhanced CT [11,12]. Discussion of Procedures by Variant Variant 1: Palpable thyroid nodule. Not goiter. Euthyroid. Initial imaging. Screening for thyroid cancer by palpation is not recommended by the U.S. Preventive Task Force [15]. However, if a patient presents with a palpable neck nodule, the goal of imaging is to determine if the palpable abnormality corresponds to a thyroid nodule and to characterize the nodule for malignancy risk. Thyroid function tests should be performed first. If the serum thyroid-stimulating hormone (TSH) is subnormal, then the patient has thyrotoxicosis (Variant 3). This variant refers to a palpable thyroid nodule in the setting of a euthyroid patient. US Thyroid US provides high-resolution imaging to show that the palpable abnormality is within the thyroid and is the best study to characterize the nodule for the risk of malignancy. Certain sonographic features are more prevalent in malignancies. The combination of these features and the nodule size guide the decision to biopsy under the ACR TI-RADS and other risk stratification criteria [8,16]. CT Neck There is no evidence that CT can differentiate between malignant and benign nodules unless there is gross invasion or metastatic disease [7]. | 3102386 |
acrac_3102386_2 | Thyroid Disease | There may be a role for this cross-sectional imaging modality if the nodule is part of a goiter that is suspected to extend substernally or there is a suspicion of invasive thyroid cancer. Dual- phase CT imaging with and without IV contrast does not provide any additional information. MRI Neck There is no evidence that MRI can differentiate between malignant and benign nodules unless there is gross invasion or metastatic disease. There may be a role for this cross-sectional imaging modality if the nodule is part of a goiter that is suspected to extend substernally or there is a suspicion of invasive thyroid cancer. CT is preferred since there is less respiratory motion artifact. FDG-PET/CT Whole Body There is no evidence to support the use of PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)/CT in the setting of palpable thyroid nodule. Radionuclide Uptake and Scan In euthyroid patients, radioisotope scanning is not helpful in determining malignancy and decision to biopsy. Although cold nodules are more likely to be malignant, the majority of nodules are cold, and the majority of cold nodules are benign, resulting in a low positive predictive value. Variant 2: Suspected goiter. Initial imaging. A goiter is suspected based on a diffuse palpable abnormality or obstructive symptoms, such as dyspnea, orthopnea, obstructive sleep apnea, dysphagia, and dysphonia. These symptoms are related to mass effect on the trachea or esophagus. Thyroid Disease The role of imaging is to confirm the diagnosis of goiter and document the size and extent of the goiter. If obstructive symptoms are present, imaging can quantify the degree of compression on the trachea. This information is valuable in deciding if surgery will improve obstructive symptoms and planning operative approach. US Thyroid US is the preferred first-line imaging modality for suspected goiter. It confirms that the neck mass is arising from the thyroid and characterizes the size and morphology of the goiter. | Thyroid Disease. There may be a role for this cross-sectional imaging modality if the nodule is part of a goiter that is suspected to extend substernally or there is a suspicion of invasive thyroid cancer. Dual- phase CT imaging with and without IV contrast does not provide any additional information. MRI Neck There is no evidence that MRI can differentiate between malignant and benign nodules unless there is gross invasion or metastatic disease. There may be a role for this cross-sectional imaging modality if the nodule is part of a goiter that is suspected to extend substernally or there is a suspicion of invasive thyroid cancer. CT is preferred since there is less respiratory motion artifact. FDG-PET/CT Whole Body There is no evidence to support the use of PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)/CT in the setting of palpable thyroid nodule. Radionuclide Uptake and Scan In euthyroid patients, radioisotope scanning is not helpful in determining malignancy and decision to biopsy. Although cold nodules are more likely to be malignant, the majority of nodules are cold, and the majority of cold nodules are benign, resulting in a low positive predictive value. Variant 2: Suspected goiter. Initial imaging. A goiter is suspected based on a diffuse palpable abnormality or obstructive symptoms, such as dyspnea, orthopnea, obstructive sleep apnea, dysphagia, and dysphonia. These symptoms are related to mass effect on the trachea or esophagus. Thyroid Disease The role of imaging is to confirm the diagnosis of goiter and document the size and extent of the goiter. If obstructive symptoms are present, imaging can quantify the degree of compression on the trachea. This information is valuable in deciding if surgery will improve obstructive symptoms and planning operative approach. US Thyroid US is the preferred first-line imaging modality for suspected goiter. It confirms that the neck mass is arising from the thyroid and characterizes the size and morphology of the goiter. | 3102386 |
acrac_3102386_3 | Thyroid Disease | If the goiter is nodular, US can also evaluate for suspicious features in nodules (see Variant 1). CT Neck CT is superior to US for evaluating substernal extension and deep extension to the retropharyngeal space [17]. CT can also define the degree of tracheal compression more effectively than US. Performing a CT with iodinated contrast is not necessary for goiter evaluation unless there is concern for an infiltrative neoplasm. Dual-phase CT imaging with and without IV contrast does not provide any additional information. MRI Neck MRI is an alternative to CT for characterizing the goiter, but CT is preferred because there is less respiratory motion artifact. Performing an MRI with IV contrast is not necessary for goiter evaluation unless there is concern for an infiltrative neoplasm. FDG-PET/CT Whole Body FDG-PET/CT imaging is not recommended as the initial imaging for the evaluation of suspected goiter. Radionuclide Uptake and Scan Radionuclide uptake may have a role if the goiter is associated with thyrotoxicosis. The radionuclide uptake and scan confirms that the entire goiter consists of thyroid tissue. Iodine-123 (I-123) is preferred over iodine-131 (I- 131) because of its superior imaging quality [18]. In addition to confirming the entire goiter is made of thyroid tissue, in a multinodular goiter the scan should be compared to an US to identify hypofunctioning or isofunctioning nodules to be targeted for biopsy [16]. Variant 3: Thyrotoxicosis. Initial imaging. Thyrotoxicosis may present with symptoms of hyperthyroidism, such as heat intolerance, tachycardia, anxiety, and weight loss, or be subclinical and found as an incidental laboratory abnormality (low TSH). The most common causes of thyrotoxicosis are Graves disease, toxic adenoma, toxic multinodular goiter, and subacute thyroiditis. Rare causes include trophoblastic disease, thyroid hormone resistance, amiodarone-induced thyroiditis, iatrogenic thyrotoxicosis, factitious ingestion of thyroid hormone, and struma ovarii [19]. | Thyroid Disease. If the goiter is nodular, US can also evaluate for suspicious features in nodules (see Variant 1). CT Neck CT is superior to US for evaluating substernal extension and deep extension to the retropharyngeal space [17]. CT can also define the degree of tracheal compression more effectively than US. Performing a CT with iodinated contrast is not necessary for goiter evaluation unless there is concern for an infiltrative neoplasm. Dual-phase CT imaging with and without IV contrast does not provide any additional information. MRI Neck MRI is an alternative to CT for characterizing the goiter, but CT is preferred because there is less respiratory motion artifact. Performing an MRI with IV contrast is not necessary for goiter evaluation unless there is concern for an infiltrative neoplasm. FDG-PET/CT Whole Body FDG-PET/CT imaging is not recommended as the initial imaging for the evaluation of suspected goiter. Radionuclide Uptake and Scan Radionuclide uptake may have a role if the goiter is associated with thyrotoxicosis. The radionuclide uptake and scan confirms that the entire goiter consists of thyroid tissue. Iodine-123 (I-123) is preferred over iodine-131 (I- 131) because of its superior imaging quality [18]. In addition to confirming the entire goiter is made of thyroid tissue, in a multinodular goiter the scan should be compared to an US to identify hypofunctioning or isofunctioning nodules to be targeted for biopsy [16]. Variant 3: Thyrotoxicosis. Initial imaging. Thyrotoxicosis may present with symptoms of hyperthyroidism, such as heat intolerance, tachycardia, anxiety, and weight loss, or be subclinical and found as an incidental laboratory abnormality (low TSH). The most common causes of thyrotoxicosis are Graves disease, toxic adenoma, toxic multinodular goiter, and subacute thyroiditis. Rare causes include trophoblastic disease, thyroid hormone resistance, amiodarone-induced thyroiditis, iatrogenic thyrotoxicosis, factitious ingestion of thyroid hormone, and struma ovarii [19]. | 3102386 |
acrac_3102386_4 | Thyroid Disease | Graves disease is diagnosed by laboratory tests, including measurement of TSH receptor antibodies [20], but in ambiguous cases or where toxic adenoma or multinodular goiter is suspected [19], imaging with an iodine uptake and scan can help confirm the cause for thyrotoxicosis. Imaging also has a role in planning therapy with RAI. US Thyroid US is the best imaging study to evaluate thyroid morphology and can be a helpful adjunct study to a radioiodine uptake. When a radioactive uptake scan shows nodules from toxic multinodular goiter or toxic adenoma, US can confirm presence of nodules and also evaluate for suspicious features of malignancy (see Variant 1). US also provides thyroid dimensions for planning RAI treatment [19]. Doppler US may be an alternative to nuclear medicine for separating thyrotoxicosis that is due to an overactive thyroid, such as Graves disease and toxic adenoma, from thyrotoxicosis, which is due to destructive causes such as subacute or lymphocytic thyroiditis. On Doppler US, these two causes of thyrotoxicosis have increased and decreased thyroid blood flow, respectively [21,22]. Although one study found similar sensitivity and specificity for Doppler US (95% and 90%) and radionuclide uptake studies (90% and 100%) [23], a radionuclide uptake study is still preferred because it directly measures thyroid activity rather than inferring it based on blood flow [24]. Among rarer causes of thyrotoxicosis, US can also distinguish between the two types of amiodarone-induced thyrotoxicosis. Type I (iodine-induced hyperthyroidism) has an enlarged or nodular thyroid gland, whereas type II (destructive) has a normal or small diffuse goiter with decreased blood flow [24]. Other causes also have characteristic features. Postpartum destructive thyroiditis has decreased blood flow. Findings of acute thyroiditis Thyroid Disease on US are hypoechoic lesions in and near the thyroid, tissue destruction, and abscesses. | Thyroid Disease. Graves disease is diagnosed by laboratory tests, including measurement of TSH receptor antibodies [20], but in ambiguous cases or where toxic adenoma or multinodular goiter is suspected [19], imaging with an iodine uptake and scan can help confirm the cause for thyrotoxicosis. Imaging also has a role in planning therapy with RAI. US Thyroid US is the best imaging study to evaluate thyroid morphology and can be a helpful adjunct study to a radioiodine uptake. When a radioactive uptake scan shows nodules from toxic multinodular goiter or toxic adenoma, US can confirm presence of nodules and also evaluate for suspicious features of malignancy (see Variant 1). US also provides thyroid dimensions for planning RAI treatment [19]. Doppler US may be an alternative to nuclear medicine for separating thyrotoxicosis that is due to an overactive thyroid, such as Graves disease and toxic adenoma, from thyrotoxicosis, which is due to destructive causes such as subacute or lymphocytic thyroiditis. On Doppler US, these two causes of thyrotoxicosis have increased and decreased thyroid blood flow, respectively [21,22]. Although one study found similar sensitivity and specificity for Doppler US (95% and 90%) and radionuclide uptake studies (90% and 100%) [23], a radionuclide uptake study is still preferred because it directly measures thyroid activity rather than inferring it based on blood flow [24]. Among rarer causes of thyrotoxicosis, US can also distinguish between the two types of amiodarone-induced thyrotoxicosis. Type I (iodine-induced hyperthyroidism) has an enlarged or nodular thyroid gland, whereas type II (destructive) has a normal or small diffuse goiter with decreased blood flow [24]. Other causes also have characteristic features. Postpartum destructive thyroiditis has decreased blood flow. Findings of acute thyroiditis Thyroid Disease on US are hypoechoic lesions in and near the thyroid, tissue destruction, and abscesses. | 3102386 |
acrac_3102386_5 | Thyroid Disease | Painless thyroiditis has inhomogeneous hypoechogenic texture with decreased blood flow [19]. CT Neck CT is usually not used in the workup of thyrotoxicosis. MRI Neck MRI is usually not used in the workup of thyrotoxicosis. FDG-PET/CT Whole Body FDG-PET/CT imaging is not recommended as the initial imaging for the evaluation of a palpable thyroid nodule. Radionuclide Uptake and Scan Radioiodine uptake and scan can distinguish between high-uptake causes of thyrotoxicosis, such as Graves disease, toxic adenoma, and toxic multinodular goiter, and low-uptake causes, such as subacute thyroiditis and exogenous thyroid hormone [19,25]. The scan component is also helpful in differentiating between high-uptake causes, such as toxic adenoma, toxic multinodular goiter, and Graves disease (diffuse uptake) [19], as well as rarer causes, such as Marine-Lenhart syndrome (toxic nodule plus Graves) [26]. If radioiodine therapy is planned, the uptake component of the scan can then help determine the dose. Either I-123 or I-131 plus pertechnetate can be used [19]. If nodularity is present, I-123 is preferred so as to identify any hypofunctioning or isofunctioning nodules to target for biopsy [16]. In postpartum thyrotoxicosis, I-131 should be avoided [19]. Variant 4: Primary hypothyroidism. Initial imaging. Hypothyroidism is a condition of low thyroid hormone that is due to an underactive gland. Hypothyroidism can present with symptoms such as weight gain, cold intolerance, constipation, weakness, and fatigue, or be diagnosed as a laboratory abnormality. The treatment of hypothyroidism is thyroid hormone replacement. The most common etiology in the developed world (where dietary iodine supply is adequate) is Hashimoto thyroiditis, also known as chronic lymphocytic thyroiditis. Other etiologies include thyroidectomy, radioiodine therapy, external neck irradiation, iodine deficiency or excess, and drugs. There is no role for imaging in the workup of hypothyroidism in adults. | Thyroid Disease. Painless thyroiditis has inhomogeneous hypoechogenic texture with decreased blood flow [19]. CT Neck CT is usually not used in the workup of thyrotoxicosis. MRI Neck MRI is usually not used in the workup of thyrotoxicosis. FDG-PET/CT Whole Body FDG-PET/CT imaging is not recommended as the initial imaging for the evaluation of a palpable thyroid nodule. Radionuclide Uptake and Scan Radioiodine uptake and scan can distinguish between high-uptake causes of thyrotoxicosis, such as Graves disease, toxic adenoma, and toxic multinodular goiter, and low-uptake causes, such as subacute thyroiditis and exogenous thyroid hormone [19,25]. The scan component is also helpful in differentiating between high-uptake causes, such as toxic adenoma, toxic multinodular goiter, and Graves disease (diffuse uptake) [19], as well as rarer causes, such as Marine-Lenhart syndrome (toxic nodule plus Graves) [26]. If radioiodine therapy is planned, the uptake component of the scan can then help determine the dose. Either I-123 or I-131 plus pertechnetate can be used [19]. If nodularity is present, I-123 is preferred so as to identify any hypofunctioning or isofunctioning nodules to target for biopsy [16]. In postpartum thyrotoxicosis, I-131 should be avoided [19]. Variant 4: Primary hypothyroidism. Initial imaging. Hypothyroidism is a condition of low thyroid hormone that is due to an underactive gland. Hypothyroidism can present with symptoms such as weight gain, cold intolerance, constipation, weakness, and fatigue, or be diagnosed as a laboratory abnormality. The treatment of hypothyroidism is thyroid hormone replacement. The most common etiology in the developed world (where dietary iodine supply is adequate) is Hashimoto thyroiditis, also known as chronic lymphocytic thyroiditis. Other etiologies include thyroidectomy, radioiodine therapy, external neck irradiation, iodine deficiency or excess, and drugs. There is no role for imaging in the workup of hypothyroidism in adults. | 3102386 |
acrac_3102386_6 | Thyroid Disease | Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism, and all causes of hypothyroidism will have decreased radioiodine uptake. US Thyroid There is no role for US imaging in the workup of hypothyroidism in adults. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism. CT Neck There is no role for CT imaging in the workup of hypothyroidism in adults. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism. MRI Neck There is no role for MRI in the workup of hypothyroidism in adults. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism. FDG-PET/CT Whole Body There is no role for FDG-PET/CT imaging in the workup of hypothyroidism in adults. Radionuclide Uptake and Scan There is no role for radioiodine uptake and scan in the workup of hypothyroidism in adults. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism, and all causes of hypothyroidism will have decreased radioiodine uptake. Variant 5: Preoperative evaluation of differentiated thyroid cancer. Surgery for DTC involves resection of the primary tumor and clinically significant lymph nodes. The goals of preoperative imaging are to evaluate for extrathyroidal invasion into surrounding structures (airway, esophagus, muscles) and for vascular encasement, and to identify lymph nodes in the lateral compartment >8 to 10 mm. Of note, the resection of larger nodal metastases, not micrometastases, is associated with improved survival, especially in patients <45 years of age [27]. Thyroid Disease In addition to the American Joint Committee on Cancer staging, which provides prognosis for survival, thyroid cancers are categorized by the American Thyroid Association into low, intermediate, and high risk, which provides risk for recurrence [16]. | Thyroid Disease. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism, and all causes of hypothyroidism will have decreased radioiodine uptake. US Thyroid There is no role for US imaging in the workup of hypothyroidism in adults. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism. CT Neck There is no role for CT imaging in the workup of hypothyroidism in adults. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism. MRI Neck There is no role for MRI in the workup of hypothyroidism in adults. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism. FDG-PET/CT Whole Body There is no role for FDG-PET/CT imaging in the workup of hypothyroidism in adults. Radionuclide Uptake and Scan There is no role for radioiodine uptake and scan in the workup of hypothyroidism in adults. Imaging for thyroid morphology does not help differentiate among causes of hypothyroidism, and all causes of hypothyroidism will have decreased radioiodine uptake. Variant 5: Preoperative evaluation of differentiated thyroid cancer. Surgery for DTC involves resection of the primary tumor and clinically significant lymph nodes. The goals of preoperative imaging are to evaluate for extrathyroidal invasion into surrounding structures (airway, esophagus, muscles) and for vascular encasement, and to identify lymph nodes in the lateral compartment >8 to 10 mm. Of note, the resection of larger nodal metastases, not micrometastases, is associated with improved survival, especially in patients <45 years of age [27]. Thyroid Disease In addition to the American Joint Committee on Cancer staging, which provides prognosis for survival, thyroid cancers are categorized by the American Thyroid Association into low, intermediate, and high risk, which provides risk for recurrence [16]. | 3102386 |
acrac_3102386_7 | Thyroid Disease | Preoperative staging and risk of recurrence both determine the need for RAI therapy after surgery and the protocol for tumor surveillance (Variant 6). US Thyroid US is a routine preoperative study in all patients with thyroid cancer. The role of US is to stage the primary tumor and cervical lymph nodes. In a retrospective study of patients who had primary surgery for thyroid cancer, US detected additional sites of metastatic disease not appreciated on physical examination in 20% of patients [28]. Compared to CT, US is more accurate in predicting early extrathyroidal tumor extension and multifocal bilobar disease [29]. US has excellent resolution for lymph node morphology. Most studies find US has higher diagnostic accuracy compared to CT for preoperative evaluation of nodal disease, especially for lateral compartment nodes [29-33]. Some centers use US for routine preoperative lymph node mapping and fine-needle aspiration of suspicious lymph nodes >8 to 10 mm [31]. CT Neck Preoperative CT with IV contrast is recommended as an adjunct to US for patients with clinical suspicion for advanced disease, including invasive primary tumor or clinically apparent multiple or bulky lymph node involvement [16]. CT is a better modality than US for delineating the extent of laryngeal, tracheal, esophageal, or vascular involvement [30,33]. CT is useful in defining the inferior border of disease and in determining the extent to which mediastinal structures are involved in cases with significant caudal spread. These inferior sites cannot be visualized on US. CT can also delineate bulky nodal disease and extranodal extension that involves muscle and blood vessels [34]. In particular, CT has higher sensitivity than US in detecting lymph node metastases in the central compartment and retropharyngeal space [32]. CT should be performed with iodinated contrast in order to better assess for tumor vascular encasement and small nodal metastases with hyperenhancement and necrosis. | Thyroid Disease. Preoperative staging and risk of recurrence both determine the need for RAI therapy after surgery and the protocol for tumor surveillance (Variant 6). US Thyroid US is a routine preoperative study in all patients with thyroid cancer. The role of US is to stage the primary tumor and cervical lymph nodes. In a retrospective study of patients who had primary surgery for thyroid cancer, US detected additional sites of metastatic disease not appreciated on physical examination in 20% of patients [28]. Compared to CT, US is more accurate in predicting early extrathyroidal tumor extension and multifocal bilobar disease [29]. US has excellent resolution for lymph node morphology. Most studies find US has higher diagnostic accuracy compared to CT for preoperative evaluation of nodal disease, especially for lateral compartment nodes [29-33]. Some centers use US for routine preoperative lymph node mapping and fine-needle aspiration of suspicious lymph nodes >8 to 10 mm [31]. CT Neck Preoperative CT with IV contrast is recommended as an adjunct to US for patients with clinical suspicion for advanced disease, including invasive primary tumor or clinically apparent multiple or bulky lymph node involvement [16]. CT is a better modality than US for delineating the extent of laryngeal, tracheal, esophageal, or vascular involvement [30,33]. CT is useful in defining the inferior border of disease and in determining the extent to which mediastinal structures are involved in cases with significant caudal spread. These inferior sites cannot be visualized on US. CT can also delineate bulky nodal disease and extranodal extension that involves muscle and blood vessels [34]. In particular, CT has higher sensitivity than US in detecting lymph node metastases in the central compartment and retropharyngeal space [32]. CT should be performed with iodinated contrast in order to better assess for tumor vascular encasement and small nodal metastases with hyperenhancement and necrosis. | 3102386 |
acrac_3102386_8 | Thyroid Disease | Contrast is not contraindicated for DTC based on new studies on iodine retention [11,12] (see Special Imaging Considerations section above). Dual-phase CT imaging with and without IV contrast does not provide any additional information. MRI Neck MRI of the neck and mediastinum has the same role as CT in evaluating sites that are limited on US. The performance of MRI for imaging the neck and mediastinum has not been directly compared with CT on large numbers of thyroid cancer patients. Contrast is valuable for local staging and assessing suspicious lymph nodes. MRI has disadvantages of motion artifact in the lower neck from respiration and swallowing and is less sensitive than CT scan for the detection of small pulmonary nodules. FDG-PET/CT Whole Body A small prospective study compared diagnostic accuracy of FDG-PET/CT with US and contrast-enhanced CT. The sensitivity of PET for the detection of cervical lymph node metastases at all nodal levels is lowest for PET (30% versus 41% for US and 35% for CT) [35]. In general, because of the low avidity of well-differentiated thyroid cancers, FDG-PET/CT is not useful. Sensitivity of FDG-PET/CT scanning for malignancy may be slightly increased with TSH stimulation with recombinant human TSH but not enough to change management in most patients [36]. Whole-Body Scintigraphy Whole-body scintigraphy (WBS) has no role in the preoperative staging for DTC since the normal thyroid has very high iodine uptake and will take up most of the tracer. Octreotide Scan with SPECT or SPECT/CT Chest and Abdomen There is no role for indium-111 (In-111) somatostatin receptor scintigraphy at any stage of evaluation of DTC. Variant 6: Early imaging after treatment of thyroid cancer. After surgery, an early postoperative US within 6 to 12 months should be performed on all patients. Additional imaging depends on the extent of disease and surgery. | Thyroid Disease. Contrast is not contraindicated for DTC based on new studies on iodine retention [11,12] (see Special Imaging Considerations section above). Dual-phase CT imaging with and without IV contrast does not provide any additional information. MRI Neck MRI of the neck and mediastinum has the same role as CT in evaluating sites that are limited on US. The performance of MRI for imaging the neck and mediastinum has not been directly compared with CT on large numbers of thyroid cancer patients. Contrast is valuable for local staging and assessing suspicious lymph nodes. MRI has disadvantages of motion artifact in the lower neck from respiration and swallowing and is less sensitive than CT scan for the detection of small pulmonary nodules. FDG-PET/CT Whole Body A small prospective study compared diagnostic accuracy of FDG-PET/CT with US and contrast-enhanced CT. The sensitivity of PET for the detection of cervical lymph node metastases at all nodal levels is lowest for PET (30% versus 41% for US and 35% for CT) [35]. In general, because of the low avidity of well-differentiated thyroid cancers, FDG-PET/CT is not useful. Sensitivity of FDG-PET/CT scanning for malignancy may be slightly increased with TSH stimulation with recombinant human TSH but not enough to change management in most patients [36]. Whole-Body Scintigraphy Whole-body scintigraphy (WBS) has no role in the preoperative staging for DTC since the normal thyroid has very high iodine uptake and will take up most of the tracer. Octreotide Scan with SPECT or SPECT/CT Chest and Abdomen There is no role for indium-111 (In-111) somatostatin receptor scintigraphy at any stage of evaluation of DTC. Variant 6: Early imaging after treatment of thyroid cancer. After surgery, an early postoperative US within 6 to 12 months should be performed on all patients. Additional imaging depends on the extent of disease and surgery. | 3102386 |
acrac_3102386_9 | Thyroid Disease | In patients with total thyroidectomy, extent of residual disease cannot be determined at surgery or on US, so WBS helps to decide if and how much RAI the patient should receive. WBS is also performed after RAI therapy. Thyroid Disease Imaging combined with serum thyroglobulin and thyroglobulin antibodies helps to categorize patients into risk groups according to response to therapy. Thyroglobulin testing with different cutoffs can be used to define response to therapy in patients after thyroidectomy with or without RAI and in those with lobectomy alone [37]. The choice of further imaging depends on the response to therapy based upon results from serum thyroglobulin testing and US performed in the first year after definitive treatment [15]. An excellent response to therapy is associated with a low recurrence risk (<5%) in patients with low- or intermediate-risk tumors. For these patients, if the serum thyroglobulin remains low, additional imaging is not indicated. For patients with thyroidectomy and ng/mL on thyroid hormone therapy in a RAI ablation, a low serum thyroglobulin is defined as a level of <0.2 sensitive assay or <1 ng/mL after TSH stimulation in patients who have undergone thyroidectomy and radioiodine ablation [16]. For patients with thyroidectomy or lobectomy but no RAI therapy, a low serum thyroglobulin is defined as a level of <0.2 ng/mL or <30 ng/mL, respectively [37]. However, if the serum thyroglobulin is elevated above the appropriate cutoff or if thyroglobulin antibodies are present and especially if they are rising, additional surveillance imaging is performed (see Variant 7 if there is concern for residual/recurrent disease on this basis). CT Neck CT is not recommended as the initial imaging study after treatment. See Variant 7 if there is concern for residual/recurrent disease. MRI Neck MRI is not recommended as the initial imaging study after treatment. See Variant 7 if there is concern for residual/recurrent disease. | Thyroid Disease. In patients with total thyroidectomy, extent of residual disease cannot be determined at surgery or on US, so WBS helps to decide if and how much RAI the patient should receive. WBS is also performed after RAI therapy. Thyroid Disease Imaging combined with serum thyroglobulin and thyroglobulin antibodies helps to categorize patients into risk groups according to response to therapy. Thyroglobulin testing with different cutoffs can be used to define response to therapy in patients after thyroidectomy with or without RAI and in those with lobectomy alone [37]. The choice of further imaging depends on the response to therapy based upon results from serum thyroglobulin testing and US performed in the first year after definitive treatment [15]. An excellent response to therapy is associated with a low recurrence risk (<5%) in patients with low- or intermediate-risk tumors. For these patients, if the serum thyroglobulin remains low, additional imaging is not indicated. For patients with thyroidectomy and ng/mL on thyroid hormone therapy in a RAI ablation, a low serum thyroglobulin is defined as a level of <0.2 sensitive assay or <1 ng/mL after TSH stimulation in patients who have undergone thyroidectomy and radioiodine ablation [16]. For patients with thyroidectomy or lobectomy but no RAI therapy, a low serum thyroglobulin is defined as a level of <0.2 ng/mL or <30 ng/mL, respectively [37]. However, if the serum thyroglobulin is elevated above the appropriate cutoff or if thyroglobulin antibodies are present and especially if they are rising, additional surveillance imaging is performed (see Variant 7 if there is concern for residual/recurrent disease on this basis). CT Neck CT is not recommended as the initial imaging study after treatment. See Variant 7 if there is concern for residual/recurrent disease. MRI Neck MRI is not recommended as the initial imaging study after treatment. See Variant 7 if there is concern for residual/recurrent disease. | 3102386 |
acrac_3102386_10 | Thyroid Disease | FDG-PET/CT Whole Body FDG-PET/CT scanning is not recommended for routine surveillance if there is no residual disease. Whole-Body Scintigraphy If the patient receives RAI therapy, a post-therapy WBS should be performed to evaluate for residual disease. WBS is not utilized in low-risk patients without suspicion for recurrence and normal thyroid US [16]. It has no role in low-risk patients who have had a lobectomy. In intermediate- and high-risk patients, WBS has a role in evaluating initial response to radioiodine ablation. If there has been excellent response to therapy, WBS is usually not performed for ongoing surveillance. An uptake in the thyroid bed is sometimes performed to aid in detection of local recurrence and guide therapy. Either I-123 or I-131 can be used if a pretherapy scan is desired [16], as rates of successful remnant ablation are similar after I- 123 and I-131 [38,39]. If the choice exists, I-123 has better image quality [40,41]. Note that a post-therapy scan after radioiodine ablation using the radioactivity from the radioiodine ablation is recommended, as it upstages disease in 6% to 13% of cases [42-44]. Octreotide Scan with SPECT or SPECT/CT Chest and Abdomen There is no role for Octreotide scan with SPECT or SPECT/CT chest and abdomen at any stage of evaluation of DTC. Variant 7: Suspected recurrence of differentiated thyroid cancer. Suspected recurrence of DTC may present with a palpable neck abnormality or symptoms related to the organ of distant metastasis. More commonly, there may be no symptoms, but the patient may have a persistently elevated or rising thyroglobulin or rising thyroglobulin antibodies. After imaging, these patients can be categorized as elevated thyroglobulin with structural disease or elevated thyroglobulin with no detectable abnormality on imaging. The latter is thought to be due to small nodal metastases and can remain untreated for years. The 3 American Thyroid Association risk categories of recurrence help to guide imaging. | Thyroid Disease. FDG-PET/CT Whole Body FDG-PET/CT scanning is not recommended for routine surveillance if there is no residual disease. Whole-Body Scintigraphy If the patient receives RAI therapy, a post-therapy WBS should be performed to evaluate for residual disease. WBS is not utilized in low-risk patients without suspicion for recurrence and normal thyroid US [16]. It has no role in low-risk patients who have had a lobectomy. In intermediate- and high-risk patients, WBS has a role in evaluating initial response to radioiodine ablation. If there has been excellent response to therapy, WBS is usually not performed for ongoing surveillance. An uptake in the thyroid bed is sometimes performed to aid in detection of local recurrence and guide therapy. Either I-123 or I-131 can be used if a pretherapy scan is desired [16], as rates of successful remnant ablation are similar after I- 123 and I-131 [38,39]. If the choice exists, I-123 has better image quality [40,41]. Note that a post-therapy scan after radioiodine ablation using the radioactivity from the radioiodine ablation is recommended, as it upstages disease in 6% to 13% of cases [42-44]. Octreotide Scan with SPECT or SPECT/CT Chest and Abdomen There is no role for Octreotide scan with SPECT or SPECT/CT chest and abdomen at any stage of evaluation of DTC. Variant 7: Suspected recurrence of differentiated thyroid cancer. Suspected recurrence of DTC may present with a palpable neck abnormality or symptoms related to the organ of distant metastasis. More commonly, there may be no symptoms, but the patient may have a persistently elevated or rising thyroglobulin or rising thyroglobulin antibodies. After imaging, these patients can be categorized as elevated thyroglobulin with structural disease or elevated thyroglobulin with no detectable abnormality on imaging. The latter is thought to be due to small nodal metastases and can remain untreated for years. The 3 American Thyroid Association risk categories of recurrence help to guide imaging. | 3102386 |
acrac_3102386_11 | Thyroid Disease | After initial excellent response, the risk for recurrence is 1% to 2% in low-risk patients, 2% to 4% in intermediate-risk patients, and 14% in high-risk patients [45-47]. In general, more imaging modalities are used to pursue recurrence in high-risk Thyroid Disease patients because distant metastases are more likely in these patients and negatively impacts on survival. Recurrence with a structural abnormality can be treated with neck dissection, repeat RAI therapy, external beam radiotherapy, and systemic therapy [16]. US Thyroid US of the neck is the first imaging investigation for suspected DTC recurrence and includes evaluation of the thyroid bed and cervical nodes. It can characterize palpable abnormalities in the neck and detect deeper neck masses that are not palpable [28]. CT Neck CT of the neck complements US of the neck for detection of additional metastases in the central compartment, in the mediastinum, and behind the trachea [29,33,48] or for assessment for invasive recurrent disease into the aerodigestive tract. CT should be performed with iodinated contrast in order to better assess for tumor vascular encasement and small nodal metastases with hyperenhancement and necrosis. Contrast is not contraindicated for DTC based on new studies on iodine retention [11,12] (see Special Imaging Considerations section above). Dual-phase CT imaging with and without IV contrast does not provide any additional information. CT Chest CT imaging of the chest should be considered in high-risk DTC patients with elevated serum thyroglobulin (>10 ng/mL) or rising thyroglobulin antibodies with negative imaging studies in the neck. CT chest is favored over MRI chest because it is able to detect small pulmonary metastases [16]. Contrast CT is not necessary for pulmonary metastases but adds to evaluation of metastatic nodes and the thyroid bed. MRI Neck MRI of the neck and mediastinum has the same role as CT. | Thyroid Disease. After initial excellent response, the risk for recurrence is 1% to 2% in low-risk patients, 2% to 4% in intermediate-risk patients, and 14% in high-risk patients [45-47]. In general, more imaging modalities are used to pursue recurrence in high-risk Thyroid Disease patients because distant metastases are more likely in these patients and negatively impacts on survival. Recurrence with a structural abnormality can be treated with neck dissection, repeat RAI therapy, external beam radiotherapy, and systemic therapy [16]. US Thyroid US of the neck is the first imaging investigation for suspected DTC recurrence and includes evaluation of the thyroid bed and cervical nodes. It can characterize palpable abnormalities in the neck and detect deeper neck masses that are not palpable [28]. CT Neck CT of the neck complements US of the neck for detection of additional metastases in the central compartment, in the mediastinum, and behind the trachea [29,33,48] or for assessment for invasive recurrent disease into the aerodigestive tract. CT should be performed with iodinated contrast in order to better assess for tumor vascular encasement and small nodal metastases with hyperenhancement and necrosis. Contrast is not contraindicated for DTC based on new studies on iodine retention [11,12] (see Special Imaging Considerations section above). Dual-phase CT imaging with and without IV contrast does not provide any additional information. CT Chest CT imaging of the chest should be considered in high-risk DTC patients with elevated serum thyroglobulin (>10 ng/mL) or rising thyroglobulin antibodies with negative imaging studies in the neck. CT chest is favored over MRI chest because it is able to detect small pulmonary metastases [16]. Contrast CT is not necessary for pulmonary metastases but adds to evaluation of metastatic nodes and the thyroid bed. MRI Neck MRI of the neck and mediastinum has the same role as CT. | 3102386 |
acrac_3102386_12 | Thyroid Disease | The performance of MRI for imaging the neck and mediastinum has not been directly compared with CT on large numbers of thyroid cancer patients. MRI has disadvantages of motion artifact in the lower neck from respiration and swallowing and is less sensitive than CT scan for the detection of small pulmonary nodules. Using IV contrast is valuable for detecting recurrence in the surgical bed and assessing suspicious lymph nodes. Octreotide Scan with SPECT or SPECT/CT Chest and Abdomen There is no role for Octreotide scan with SPECT or SPECT/CT chest and abdomen at any stage of evaluation of DTC. Whole-Body Scintigraphy If the US is negative, radioiodine WBS can be performed for suspected recurrence of DTC. WBS may be performed as a first-line investigation in high-risk DTC patients, such as those who initially had macroscopic invasion, gross residual disease, or iodine avid distant metastases. An uptake is sometimes performed to aid in detection of local recurrence and guide dosage of local therapy. I-123 is preferred over I-131 if possible [16], as image quality is higher [40,41]. Variant 8: Suspected recurrence of medullary thyroid cancers. Surveillance for MTC involves monitoring tumor markers, calcitonin, and carcinoembryonic antigen. Imaging of the neck is the preferred initial study. If there is suspicion of recurrence in a body site because of localizing signs or symptoms and elevated tumor markers, the specific body site is imaged. If the patient is asymptomatic, imaging depends on the calcitonin level. Thyroid Disease US Thyroid US of the neck is the first imaging investigation for suspected MTC recurrence and includes evaluation of the thyroid bed and cervical nodes. It can characterize palpable abnormalities in the neck and detect deeper neck masses that are not palpable. Imaging with US of the neck alone is generally adequate with calcitonin levels <150 pg/mL, as disease is usually limited to the neck [51]. | Thyroid Disease. The performance of MRI for imaging the neck and mediastinum has not been directly compared with CT on large numbers of thyroid cancer patients. MRI has disadvantages of motion artifact in the lower neck from respiration and swallowing and is less sensitive than CT scan for the detection of small pulmonary nodules. Using IV contrast is valuable for detecting recurrence in the surgical bed and assessing suspicious lymph nodes. Octreotide Scan with SPECT or SPECT/CT Chest and Abdomen There is no role for Octreotide scan with SPECT or SPECT/CT chest and abdomen at any stage of evaluation of DTC. Whole-Body Scintigraphy If the US is negative, radioiodine WBS can be performed for suspected recurrence of DTC. WBS may be performed as a first-line investigation in high-risk DTC patients, such as those who initially had macroscopic invasion, gross residual disease, or iodine avid distant metastases. An uptake is sometimes performed to aid in detection of local recurrence and guide dosage of local therapy. I-123 is preferred over I-131 if possible [16], as image quality is higher [40,41]. Variant 8: Suspected recurrence of medullary thyroid cancers. Surveillance for MTC involves monitoring tumor markers, calcitonin, and carcinoembryonic antigen. Imaging of the neck is the preferred initial study. If there is suspicion of recurrence in a body site because of localizing signs or symptoms and elevated tumor markers, the specific body site is imaged. If the patient is asymptomatic, imaging depends on the calcitonin level. Thyroid Disease US Thyroid US of the neck is the first imaging investigation for suspected MTC recurrence and includes evaluation of the thyroid bed and cervical nodes. It can characterize palpable abnormalities in the neck and detect deeper neck masses that are not palpable. Imaging with US of the neck alone is generally adequate with calcitonin levels <150 pg/mL, as disease is usually limited to the neck [51]. | 3102386 |
acrac_3102386_13 | Thyroid Disease | Overall, per-person sensitivity is similar to CT with much greater specificity for cervical nodes (sensitivity 75% and specificity 92% for US versus sensitivity 80% and specificity 25% for CT) [52], and detection rate is greater than PET (US finds nodes in 56% of patients versus 32% for PET) [53]. CT Neck CT has greater specificity than US for evaluation of cervical nodes (sensitivity 75% and specificity 92% for US versus sensitivity 80% and specificity 25% for CT) [52]. For calcitonin levels >150 pg/mL, the risk of metastases outside the neck is higher. In these patients, imaging is appropriate, starting with neck and chest CT [54]. Dual- phase CT imaging with and without IV contrast does not provide any additional information. CT Chest For calcitonin levels >150 pg/mL, the risk of metastases outside the neck is higher. CT chest is more sensitive than PET alone for lung nodules (detection rate, 35% for CT versus 20% for PET) and mediastinal nodes (detection rate, 31% for CT versus 20% for PET) [53]. CT should be performed with iodinated contrast in order to better assess for tumor in the surgical bed, vascular encasement, and morphology of small nodal metastases. CT Abdomen For calcitonin levels >150 pg/mL, the risk of metastases outside the neck is higher. Three-phase contrast CT of the liver is an alternative to MRI [54]. MRI Neck MRI has the same role as CT in evaluating sites that are limited on US. The performance of MRI for imaging the neck and mediastinum has not been directly compared with CT on large numbers of thyroid cancer patients. MRI has disadvantages of motion artifact in the lower neck from respiration and swallowing and is less sensitive than CT scan for the detection of small pulmonary nodules. Using IV contrast is valuable for detecting recurrence in the surgical bed and assessing suspicious lymph nodes. | Thyroid Disease. Overall, per-person sensitivity is similar to CT with much greater specificity for cervical nodes (sensitivity 75% and specificity 92% for US versus sensitivity 80% and specificity 25% for CT) [52], and detection rate is greater than PET (US finds nodes in 56% of patients versus 32% for PET) [53]. CT Neck CT has greater specificity than US for evaluation of cervical nodes (sensitivity 75% and specificity 92% for US versus sensitivity 80% and specificity 25% for CT) [52]. For calcitonin levels >150 pg/mL, the risk of metastases outside the neck is higher. In these patients, imaging is appropriate, starting with neck and chest CT [54]. Dual- phase CT imaging with and without IV contrast does not provide any additional information. CT Chest For calcitonin levels >150 pg/mL, the risk of metastases outside the neck is higher. CT chest is more sensitive than PET alone for lung nodules (detection rate, 35% for CT versus 20% for PET) and mediastinal nodes (detection rate, 31% for CT versus 20% for PET) [53]. CT should be performed with iodinated contrast in order to better assess for tumor in the surgical bed, vascular encasement, and morphology of small nodal metastases. CT Abdomen For calcitonin levels >150 pg/mL, the risk of metastases outside the neck is higher. Three-phase contrast CT of the liver is an alternative to MRI [54]. MRI Neck MRI has the same role as CT in evaluating sites that are limited on US. The performance of MRI for imaging the neck and mediastinum has not been directly compared with CT on large numbers of thyroid cancer patients. MRI has disadvantages of motion artifact in the lower neck from respiration and swallowing and is less sensitive than CT scan for the detection of small pulmonary nodules. Using IV contrast is valuable for detecting recurrence in the surgical bed and assessing suspicious lymph nodes. | 3102386 |
acrac_3102386_14 | Thyroid Disease | MRI Abdomen MRI of the abdomen is performed for evaluation of liver metastases, and one study reports that it is more sensitive than CT, US, or PET (with a detection rate of 49% versus 44% for CT, 41% for US, and 27% for PET) [53]. A meta-analysis of CT versus MRI for liver metastases of various origins (not MTC) suggests MRI with liver-specific agents is more sensitive than CT [55]. If MRI is used, diffusion-weighted imaging sequences should be included [56]. MRI Complete Spine MRI of the complete spine may be more sensitive than bone scan for bone metastases (100% versus 72% in one study of patients on immunotherapy) [57]. However, another study concluded they were complementary, with equal overall detection rates but bone scintigraphy having the advantage of detecting additional lesions in the extremities (and MRI in the axial skeleton) [53]. Using IV contrast is valuable for detecting bone lesions in this case. FDG-PET/CT Whole Body Medullary cancer is challenging to image with nuclear medicine because it lacks the iodine avidity of DTC while still not being aggressive enough to take up FDG in many cases. FDG-PET/CT has suboptimal detection for MTC in most patients, with 59% sensitivity according to a meta-analysis of 25 studies [58]. However, the sensitivity increases to 75% in patients with more aggressive disease, as indicated by calcitonin levels >1,000 pg/mL and with a calcitonin doubling time <12 months [58-60]. In these patients, FDG-PET/CT may be a first-line study or performed after other imaging studies are negative [61,62]. In countries where the tracer FDOPA (3,4-dihydroxy- 6-18F-fluoro-L-phenylalanine) is available, it should be used in place of FDG as it is more sensitive for MTC [63- 65]. Thyroid Disease Bone Scan Whole Body Bone scan has a role in imaging for patients with symptoms of bone pain with elevated tumor markers and in asymptomatic patients with calcitonin levels >150 pg/mL [16]. | Thyroid Disease. MRI Abdomen MRI of the abdomen is performed for evaluation of liver metastases, and one study reports that it is more sensitive than CT, US, or PET (with a detection rate of 49% versus 44% for CT, 41% for US, and 27% for PET) [53]. A meta-analysis of CT versus MRI for liver metastases of various origins (not MTC) suggests MRI with liver-specific agents is more sensitive than CT [55]. If MRI is used, diffusion-weighted imaging sequences should be included [56]. MRI Complete Spine MRI of the complete spine may be more sensitive than bone scan for bone metastases (100% versus 72% in one study of patients on immunotherapy) [57]. However, another study concluded they were complementary, with equal overall detection rates but bone scintigraphy having the advantage of detecting additional lesions in the extremities (and MRI in the axial skeleton) [53]. Using IV contrast is valuable for detecting bone lesions in this case. FDG-PET/CT Whole Body Medullary cancer is challenging to image with nuclear medicine because it lacks the iodine avidity of DTC while still not being aggressive enough to take up FDG in many cases. FDG-PET/CT has suboptimal detection for MTC in most patients, with 59% sensitivity according to a meta-analysis of 25 studies [58]. However, the sensitivity increases to 75% in patients with more aggressive disease, as indicated by calcitonin levels >1,000 pg/mL and with a calcitonin doubling time <12 months [58-60]. In these patients, FDG-PET/CT may be a first-line study or performed after other imaging studies are negative [61,62]. In countries where the tracer FDOPA (3,4-dihydroxy- 6-18F-fluoro-L-phenylalanine) is available, it should be used in place of FDG as it is more sensitive for MTC [63- 65]. Thyroid Disease Bone Scan Whole Body Bone scan has a role in imaging for patients with symptoms of bone pain with elevated tumor markers and in asymptomatic patients with calcitonin levels >150 pg/mL [16]. | 3102386 |
acrac_3105874_0 | Suspected Appendicitis Child | Introduction/Background Acute abdominal pain is one of the most common presenting complaints to the emergency department for the pediatric population. While the differential diagnosis for acute abdominal pain in children is broad and includes infectious, inflammatory, musculoskeletal, traumatic, gynecologic, and other etiologies, acute appendicitis is an important differential diagnostic consideration because of the potential need for surgical intervention. Acute appendicitis represents in children [1,2]. Approximately 70,000 children per year in the United States are diagnosed with acute appendicitis, accounting for close to 30% of the total cost of all pediatric general surgical conditions combined [1]. The incidence of appendicitis peaks during adolescence and is uncommon in infants and preschool children and rare in newborns [3]. In spite of its high incidence, the diagnosis of acute appendicitis often presents a challenge, as the classic presenting symptoms of periumbilical pain, anorexia, nausea, vomiting, guarding, and migration of pain to the right lower quadrant (RLQ) are not always elicited and are only moderately reproducible between clinicians [4]. Furthermore, these symptoms are less reliable in the pediatric population, particularly those <5 years of age, who more frequently present with atypical symptoms [1]. As a result, presentation and diagnosis may be delayed, which may contribute to a higher rate of perforated appendicitis in the youngest children [5]. While perforated appendicitis tends to be more common in children than adults [6], morbidity is similar to or lower in children than in adults. The most common treatment of appendicitis is appendectomy. In complicated cases of perforated appendicitis with abscess formation, surgery may follow percutaneous abscess drainage and treatment with broad-spectrum antibiotics [2]. | Suspected Appendicitis Child. Introduction/Background Acute abdominal pain is one of the most common presenting complaints to the emergency department for the pediatric population. While the differential diagnosis for acute abdominal pain in children is broad and includes infectious, inflammatory, musculoskeletal, traumatic, gynecologic, and other etiologies, acute appendicitis is an important differential diagnostic consideration because of the potential need for surgical intervention. Acute appendicitis represents in children [1,2]. Approximately 70,000 children per year in the United States are diagnosed with acute appendicitis, accounting for close to 30% of the total cost of all pediatric general surgical conditions combined [1]. The incidence of appendicitis peaks during adolescence and is uncommon in infants and preschool children and rare in newborns [3]. In spite of its high incidence, the diagnosis of acute appendicitis often presents a challenge, as the classic presenting symptoms of periumbilical pain, anorexia, nausea, vomiting, guarding, and migration of pain to the right lower quadrant (RLQ) are not always elicited and are only moderately reproducible between clinicians [4]. Furthermore, these symptoms are less reliable in the pediatric population, particularly those <5 years of age, who more frequently present with atypical symptoms [1]. As a result, presentation and diagnosis may be delayed, which may contribute to a higher rate of perforated appendicitis in the youngest children [5]. While perforated appendicitis tends to be more common in children than adults [6], morbidity is similar to or lower in children than in adults. The most common treatment of appendicitis is appendectomy. In complicated cases of perforated appendicitis with abscess formation, surgery may follow percutaneous abscess drainage and treatment with broad-spectrum antibiotics [2]. | 3105874 |
acrac_3105874_1 | Suspected Appendicitis Child | Nonoperative treatment of early, uncomplicated appendicitis is increasingly being explored, and imaging plays a role in identifying candidates for nonoperative management [2]. Imaging has been shown to facilitate management and decrease the rate of negative appendectomies in children with suspected acute appendicitis [7-10] and remains a central tool in the diagnosis of pediatric acute appendicitis. Special Imaging Considerations This document aims to provide guidance related to the imaging technique(s) best suited for the diagnosis of acute appendicitis. Importantly, this document does not encompass the appropriate imaging of all potential causes of RLQ quadrant pain. While this guideline emphasizes the role of imaging in the diagnosis of acute appendicitis in children, the initial consideration for imaging is based on clinical assessment. Clinical scoring systems and clinical pathways based upon history, symptoms, physical examination, and laboratory findings have been developed to risk stratify regarding the diagnosis of acute appendicitis and to guide imaging, clinical management, and surgery [11-14]. Two of the more widely used scoring systems are the Alvarado Score and Pediatric Appendicitis Score [13,15]. As primary diagnostic tools, clinical scoring systems have been shown to 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] perform variably well depending on the population and often perform less well than imaging or a combination of scoring and imaging [13,15]. | Suspected Appendicitis Child. Nonoperative treatment of early, uncomplicated appendicitis is increasingly being explored, and imaging plays a role in identifying candidates for nonoperative management [2]. Imaging has been shown to facilitate management and decrease the rate of negative appendectomies in children with suspected acute appendicitis [7-10] and remains a central tool in the diagnosis of pediatric acute appendicitis. Special Imaging Considerations This document aims to provide guidance related to the imaging technique(s) best suited for the diagnosis of acute appendicitis. Importantly, this document does not encompass the appropriate imaging of all potential causes of RLQ quadrant pain. While this guideline emphasizes the role of imaging in the diagnosis of acute appendicitis in children, the initial consideration for imaging is based on clinical assessment. Clinical scoring systems and clinical pathways based upon history, symptoms, physical examination, and laboratory findings have been developed to risk stratify regarding the diagnosis of acute appendicitis and to guide imaging, clinical management, and surgery [11-14]. Two of the more widely used scoring systems are the Alvarado Score and Pediatric Appendicitis Score [13,15]. As primary diagnostic tools, clinical scoring systems have been shown to 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] perform variably well depending on the population and often perform less well than imaging or a combination of scoring and imaging [13,15]. | 3105874 |
acrac_3105874_2 | Suspected Appendicitis Child | The greatest benefit of clinical scoring systems has been to differentiate low-risk patients who do not need surgery and generally do not require imaging from high-risk patients who can be triaged to surgical management, potentially without imaging [16-18]. Imaging should still be considered in cases where clinical judgement is at odds with the high or low risk stratification based on a scoring system. The major role for imaging in the context of clinical scoring systems is in the further evaluation of patients considered to have an intermediate risk of appendicitis [11]. While the specific cut-off values for intermediate risk vary based on the clinical score being used and the desired sensitivity and specificity, the intermediate-risk population is the subgroup that has historical, physical examination, or laboratory findings that do not qualify for either the low- or high-risk groups [13]. US Appendix ultrasound (US) is performed in all potential locations of the appendix with gradual increasing pressure to displace overlying bowel gas and content, which is known as the graded compression technique. Graded compression also serves to bring the appendix closer to the transducer. Appendiceal US can be performed as either a focused examination of the RLQ or as a complete abdominal US. For the purpose of this topic, US abdomen includes dedicated appendiceal study. Accuracy of appendix US varies widely, is operator dependent [19], and may be dependent on patient-specific factors, including obesity [20,21]. The sensitivity and specificity of US for the diagnosis of pediatric acute appendicitis and percentage of equivocal cases varies. US accuracy is optimized in experienced hands and can approach that of CT [22-25]. For this document, it is assumed all procedures are performed and interpreted by an expert. | Suspected Appendicitis Child. The greatest benefit of clinical scoring systems has been to differentiate low-risk patients who do not need surgery and generally do not require imaging from high-risk patients who can be triaged to surgical management, potentially without imaging [16-18]. Imaging should still be considered in cases where clinical judgement is at odds with the high or low risk stratification based on a scoring system. The major role for imaging in the context of clinical scoring systems is in the further evaluation of patients considered to have an intermediate risk of appendicitis [11]. While the specific cut-off values for intermediate risk vary based on the clinical score being used and the desired sensitivity and specificity, the intermediate-risk population is the subgroup that has historical, physical examination, or laboratory findings that do not qualify for either the low- or high-risk groups [13]. US Appendix ultrasound (US) is performed in all potential locations of the appendix with gradual increasing pressure to displace overlying bowel gas and content, which is known as the graded compression technique. Graded compression also serves to bring the appendix closer to the transducer. Appendiceal US can be performed as either a focused examination of the RLQ or as a complete abdominal US. For the purpose of this topic, US abdomen includes dedicated appendiceal study. Accuracy of appendix US varies widely, is operator dependent [19], and may be dependent on patient-specific factors, including obesity [20,21]. The sensitivity and specificity of US for the diagnosis of pediatric acute appendicitis and percentage of equivocal cases varies. US accuracy is optimized in experienced hands and can approach that of CT [22-25]. For this document, it is assumed all procedures are performed and interpreted by an expert. | 3105874 |
acrac_3105874_3 | Suspected Appendicitis Child | In a large series of 3,799 patients with suspected acute appendicitis, Cundy et al [26] showed 92% visualization of the appendix with 95.5% accuracy, 97% sensitivity, and 95% specificity for the diagnosis of acute appendicitis. As an initial imaging modality for suspected acute appendicitis, US has been shown to have high diagnostic accuracy and to reduce or obviate the need for further imaging without increased complications or unacceptable increases in length of stay [22,26-28]. An important limitation of US is its low sensitivity in the diagnosis of perforated appendicitis [2]. This should be taken in consideration if nonoperative management is considered. CT CT has high sensitivity (~94%) and specificity (~95%) for the diagnosis of acute appendicitis [29]. If the appendix is not visualized, the negative predictive value is similar to a CT with normal visualized appendix [51]. Studies in both children and adults have allowed optimization of CT technique for the diagnosis of acute appendicitis. There is debate about the usefulness of oral contrast because some studies showed no significant increased accuracy, longer time to examination completion, and increased rates of patient emesis [30-32]. Rectal contrast does not increase accuracy compared to CT with intravenous (IV) contrast only [33]. Most CT examinations for appendicitis are performed with standard technique and coverage for imaging the abdomen and pelvis. Some centers have had success decreasing CT exposure parameters without compromising diagnostic performance [34,35] for acute appendicitis. Other retrospective studies in both adult and pediatric populations have shown that a focused CT from L2 or L3 or based on height-adjusted distance from the umbilicus through the pubis symphysis is sufficient to diagnose acute appendicitis and identify most alternative diagnoses [36,37]. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis. | Suspected Appendicitis Child. In a large series of 3,799 patients with suspected acute appendicitis, Cundy et al [26] showed 92% visualization of the appendix with 95.5% accuracy, 97% sensitivity, and 95% specificity for the diagnosis of acute appendicitis. As an initial imaging modality for suspected acute appendicitis, US has been shown to have high diagnostic accuracy and to reduce or obviate the need for further imaging without increased complications or unacceptable increases in length of stay [22,26-28]. An important limitation of US is its low sensitivity in the diagnosis of perforated appendicitis [2]. This should be taken in consideration if nonoperative management is considered. CT CT has high sensitivity (~94%) and specificity (~95%) for the diagnosis of acute appendicitis [29]. If the appendix is not visualized, the negative predictive value is similar to a CT with normal visualized appendix [51]. Studies in both children and adults have allowed optimization of CT technique for the diagnosis of acute appendicitis. There is debate about the usefulness of oral contrast because some studies showed no significant increased accuracy, longer time to examination completion, and increased rates of patient emesis [30-32]. Rectal contrast does not increase accuracy compared to CT with intravenous (IV) contrast only [33]. Most CT examinations for appendicitis are performed with standard technique and coverage for imaging the abdomen and pelvis. Some centers have had success decreasing CT exposure parameters without compromising diagnostic performance [34,35] for acute appendicitis. Other retrospective studies in both adult and pediatric populations have shown that a focused CT from L2 or L3 or based on height-adjusted distance from the umbilicus through the pubis symphysis is sufficient to diagnose acute appendicitis and identify most alternative diagnoses [36,37]. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis. | 3105874 |
acrac_3105874_4 | Suspected Appendicitis Child | A limited number of retrospective studies of pediatric cohorts imaged without IV contrast have shown rates of visualization of the appendix similar to CT performed with IV contrast as well as high sensitivity and specificity for the diagnosis of appendicitis [1,2]. Potential limitations of unenhanced CT include decreased sensitivity and incomplete characterization of complicated appendicitis (eg, perforation and abscess formation) and possibly lower sensitivity for alternative diagnoses [38,39]. There are no data to suggest that CT with and without IV contrast has better diagnostic performance for acute appendicitis or alternative diagnoses than a single phase (CT with or CT without IV contrast) examination. Furthermore, CT with and without IV contrast approximately doubles radiation exposure to the patient. Radiography Abdomen Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. Radiographs may identify alternative causes of pain, such as constipation or lower lobe pneumonia [51]. US Abdomen RLQ Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. US Abdomen Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. US Pelvis Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. | Suspected Appendicitis Child. A limited number of retrospective studies of pediatric cohorts imaged without IV contrast have shown rates of visualization of the appendix similar to CT performed with IV contrast as well as high sensitivity and specificity for the diagnosis of appendicitis [1,2]. Potential limitations of unenhanced CT include decreased sensitivity and incomplete characterization of complicated appendicitis (eg, perforation and abscess formation) and possibly lower sensitivity for alternative diagnoses [38,39]. There are no data to suggest that CT with and without IV contrast has better diagnostic performance for acute appendicitis or alternative diagnoses than a single phase (CT with or CT without IV contrast) examination. Furthermore, CT with and without IV contrast approximately doubles radiation exposure to the patient. Radiography Abdomen Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. Radiographs may identify alternative causes of pain, such as constipation or lower lobe pneumonia [51]. US Abdomen RLQ Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. US Abdomen Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. US Pelvis Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. | 3105874 |
acrac_3105874_5 | Suspected Appendicitis Child | Pelvic US may identify other causes of pain in girls but there are no data regarding its performance as a first-line imaging modality for acute appendicitis [52]. CT Abdomen and Pelvis In a retrospective study of children who underwent CT of the abdomen and pelvis for suspected acute appendicitis, Kim et al [50] found that no patient categorized as low risk by the Pediatric Appendicitis Score had a positive CT. Similarly, based on retrospective study of a mixed population of children and adults who underwent CT, McKay and Shepard [53] showed that the Alvarado score could rule out appendicitis in low-risk patients with 96% sensitivity. Alternative causes of abdominopelvic pain, which have been described to occur at rates between 7% and 25%, may be identified by CT [54,55]. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis [38,39]. MRI Abdomen and Pelvis Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. Alternative causes of abdominopelvic pain, which occurred at a rate of 20% in a study of MRI as the primary imaging modality for suspected acute appendicitis, may be identified by MRI [55]. Radiography Abdomen Radiographs are neither sensitive nor specific for the diagnosis of acute appendicitis but may identify alternative causes of pain [51]. US Abdomen There are no specific data regarding the relative performance of a focused RLQ US versus a complete abdominal US in intermediate-risk patients. US Pelvis There are no data specific to the use of pelvic US only in children with intermediate clinical risk for acute appendicitis. Pelvic US may be part of a complete evaluation for abdominopelvic pain in peri- or postmenarchal girls [52]. | Suspected Appendicitis Child. Pelvic US may identify other causes of pain in girls but there are no data regarding its performance as a first-line imaging modality for acute appendicitis [52]. CT Abdomen and Pelvis In a retrospective study of children who underwent CT of the abdomen and pelvis for suspected acute appendicitis, Kim et al [50] found that no patient categorized as low risk by the Pediatric Appendicitis Score had a positive CT. Similarly, based on retrospective study of a mixed population of children and adults who underwent CT, McKay and Shepard [53] showed that the Alvarado score could rule out appendicitis in low-risk patients with 96% sensitivity. Alternative causes of abdominopelvic pain, which have been described to occur at rates between 7% and 25%, may be identified by CT [54,55]. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis [38,39]. MRI Abdomen and Pelvis Most studies have shown that in patients stratified as low risk (which varies per study and is based on the system used), imaging for acute appendicitis is not required, and other causes of abdominopelvic pain should be sought [13,16,17,48-50]. Alternative causes of abdominopelvic pain, which occurred at a rate of 20% in a study of MRI as the primary imaging modality for suspected acute appendicitis, may be identified by MRI [55]. Radiography Abdomen Radiographs are neither sensitive nor specific for the diagnosis of acute appendicitis but may identify alternative causes of pain [51]. US Abdomen There are no specific data regarding the relative performance of a focused RLQ US versus a complete abdominal US in intermediate-risk patients. US Pelvis There are no data specific to the use of pelvic US only in children with intermediate clinical risk for acute appendicitis. Pelvic US may be part of a complete evaluation for abdominopelvic pain in peri- or postmenarchal girls [52]. | 3105874 |
acrac_3105874_6 | Suspected Appendicitis Child | CT Abdomen and Pelvis CT of the abdomen and pelvis has been shown to provide diagnostic benefit in a mixed population of children and adults with intermediate clinical risk for acute appendicitis where the examination had 90% sensitivity and 95% specificity for acute appendicitis [53]. Because CT covers more anatomic territory than a limited RLQ US, it may identify alternative causes of abdominopelvic pain [54,55]. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis [38,39]. MRI Abdomen and Pelvis Given its high sensitivity and specificity for acute appendicitis, MRI may be indicated in children with an intermediate clinical risk for acute appendicitis [40,41,43]. Similar to CT, the greater anatomic coverage of MRI (versus US) may identify alternative causes of abdominopelvic pain [54,55]. Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging. Risk stratification for acute appendicitis can be achieved based on overall subjective assessment or use of published scoring systems. The patient-specific likelihood of acute appendicitis among patients classified as high risk varies across the range of high-risk scores and varies between published studies [56]. Approaches to high-risk patients vary in the literature, with some studies using imaging to confirm the diagnosis of appendicitis [49] and other studies advocating surgical intervention without imaging based on a demonstrated high accuracy of the scoring system in their practice [13,17,18,48,57]. Radiography Abdomen Radiographs are neither sensitive nor specific for a diagnosis of acute appendicitis but may aid in terms of excluding complications of acute appendicitis, such as bowel obstruction or gross perforation [51]. US Abdomen RLQ There is no evidence to support routine US in all patients considered high risk for acute appendicitis. | Suspected Appendicitis Child. CT Abdomen and Pelvis CT of the abdomen and pelvis has been shown to provide diagnostic benefit in a mixed population of children and adults with intermediate clinical risk for acute appendicitis where the examination had 90% sensitivity and 95% specificity for acute appendicitis [53]. Because CT covers more anatomic territory than a limited RLQ US, it may identify alternative causes of abdominopelvic pain [54,55]. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis [38,39]. MRI Abdomen and Pelvis Given its high sensitivity and specificity for acute appendicitis, MRI may be indicated in children with an intermediate clinical risk for acute appendicitis [40,41,43]. Similar to CT, the greater anatomic coverage of MRI (versus US) may identify alternative causes of abdominopelvic pain [54,55]. Variant 3: Child. Suspected acute appendicitis, high clinical risk. Initial imaging. Risk stratification for acute appendicitis can be achieved based on overall subjective assessment or use of published scoring systems. The patient-specific likelihood of acute appendicitis among patients classified as high risk varies across the range of high-risk scores and varies between published studies [56]. Approaches to high-risk patients vary in the literature, with some studies using imaging to confirm the diagnosis of appendicitis [49] and other studies advocating surgical intervention without imaging based on a demonstrated high accuracy of the scoring system in their practice [13,17,18,48,57]. Radiography Abdomen Radiographs are neither sensitive nor specific for a diagnosis of acute appendicitis but may aid in terms of excluding complications of acute appendicitis, such as bowel obstruction or gross perforation [51]. US Abdomen RLQ There is no evidence to support routine US in all patients considered high risk for acute appendicitis. | 3105874 |
acrac_3105874_7 | Suspected Appendicitis Child | However, US could be used to confirm the diagnosis of acute appendicitis in this population and to exclude other processes US Abdomen US may be performed in selected high-risk patients to confirm the diagnosis of appendicitis, but US is likely not needed in all high-risk patients, and false-negative results are more common in this population [58]. US Pelvis There are no data regarding the performance of pelvic US as a first-line imaging modality for acute appendicitis. In peri- or postmenarchal girls, a pelvic US may identify alternative causes of pelvic pain [52]. CT Abdomen and Pelvis There is no evidence to support routine use of CT of the abdomen and pelvis or of focused CT in high-risk patients. Based on high sensitivity and specificity, CT could be used to confirm the diagnosis of acute appendicitis in these patients and to exclude other processes that clinically mimic appendicitis. Tan et al [14] showed that in a population of adult and adolescent patients, the positive likelihood ratio for CT was no different from clinical scoring in patients with a high-risk clinical score, suggesting no diagnostic benefit of CT in this context. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis [38,39]. MRI Abdomen and Pelvis There is no evidence to support routine use of MRI in high-risk patients. Based on high sensitivity and specificity that is similar to CT, MRI could be used to confirm the diagnosis of acute appendicitis in high-risk patients and to exclude other processes that clinically mimic appendicitis. However, the diagnostic benefit of MRI in this context has not been demonstrated. Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study. The definition of an equivocal or nondiagnostic US for acute appendicitis varies widely in the literature, and careful definition of this category has major implications on imaging utilization [22,59,60]. | Suspected Appendicitis Child. However, US could be used to confirm the diagnosis of acute appendicitis in this population and to exclude other processes US Abdomen US may be performed in selected high-risk patients to confirm the diagnosis of appendicitis, but US is likely not needed in all high-risk patients, and false-negative results are more common in this population [58]. US Pelvis There are no data regarding the performance of pelvic US as a first-line imaging modality for acute appendicitis. In peri- or postmenarchal girls, a pelvic US may identify alternative causes of pelvic pain [52]. CT Abdomen and Pelvis There is no evidence to support routine use of CT of the abdomen and pelvis or of focused CT in high-risk patients. Based on high sensitivity and specificity, CT could be used to confirm the diagnosis of acute appendicitis in these patients and to exclude other processes that clinically mimic appendicitis. Tan et al [14] showed that in a population of adult and adolescent patients, the positive likelihood ratio for CT was no different from clinical scoring in patients with a high-risk clinical score, suggesting no diagnostic benefit of CT in this context. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis [38,39]. MRI Abdomen and Pelvis There is no evidence to support routine use of MRI in high-risk patients. Based on high sensitivity and specificity that is similar to CT, MRI could be used to confirm the diagnosis of acute appendicitis in high-risk patients and to exclude other processes that clinically mimic appendicitis. However, the diagnostic benefit of MRI in this context has not been demonstrated. Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study. The definition of an equivocal or nondiagnostic US for acute appendicitis varies widely in the literature, and careful definition of this category has major implications on imaging utilization [22,59,60]. | 3105874 |
acrac_3105874_8 | Suspected Appendicitis Child | Some consider nonvisualization of the appendix as an equivocal result [40,61]. However, in several retrospective studies, an appendiceal US in which the appendix is not visualized and no inflammatory findings are present in the RLQ has high negative predictive value [3,62-64]. In this context, further imaging is unlikely to be contributory unless there is discordance between the clinical picture and the negative US result [65]. Further imaging, however, is contributory after equivocal US examinations in which the appendix is either visualized or not visualized, and there are findings that could reflect appendicitis. In one study, appendicitis was present in 26% of patients who met this criteria [3]. While there is good evidence regarding secondary imaging modalities following an equivocal US, there is also evidence of the benefit of repeat clinical assessment in these cases, which can obviate further imaging at the expense of delay in diagnosis and the risk associated with extending the hospital visit [10,66]. Schuh et al [67] in a prospective study found that of 123 patients with an initially equivocal US, acute appendicitis could be correctly ruled out clinically in 59% based on reassessment without further imaging. Radiography Abdomen Given the limited sensitivity and specificity, a radiograph is unlikely to diagnose acute appendicitis in patients with an initial equivocal or nondiagnostic appendiceal US [51]. Radiographs may identify an alternative cause of pain. US Abdomen RLQ Repeating a US examination after an initially equivocal result increases sensitivity for acute appendicitis. Schuh et al [67] showed that repeat US could make a diagnosis in 55% of cases with persistent clinical concern for acute appendicitis after an initially equivocal US. This final diagnosis rate, however, is lower than what has been reported with both CT and MRI. | Suspected Appendicitis Child. Some consider nonvisualization of the appendix as an equivocal result [40,61]. However, in several retrospective studies, an appendiceal US in which the appendix is not visualized and no inflammatory findings are present in the RLQ has high negative predictive value [3,62-64]. In this context, further imaging is unlikely to be contributory unless there is discordance between the clinical picture and the negative US result [65]. Further imaging, however, is contributory after equivocal US examinations in which the appendix is either visualized or not visualized, and there are findings that could reflect appendicitis. In one study, appendicitis was present in 26% of patients who met this criteria [3]. While there is good evidence regarding secondary imaging modalities following an equivocal US, there is also evidence of the benefit of repeat clinical assessment in these cases, which can obviate further imaging at the expense of delay in diagnosis and the risk associated with extending the hospital visit [10,66]. Schuh et al [67] in a prospective study found that of 123 patients with an initially equivocal US, acute appendicitis could be correctly ruled out clinically in 59% based on reassessment without further imaging. Radiography Abdomen Given the limited sensitivity and specificity, a radiograph is unlikely to diagnose acute appendicitis in patients with an initial equivocal or nondiagnostic appendiceal US [51]. Radiographs may identify an alternative cause of pain. US Abdomen RLQ Repeating a US examination after an initially equivocal result increases sensitivity for acute appendicitis. Schuh et al [67] showed that repeat US could make a diagnosis in 55% of cases with persistent clinical concern for acute appendicitis after an initially equivocal US. This final diagnosis rate, however, is lower than what has been reported with both CT and MRI. | 3105874 |
acrac_3105874_9 | Suspected Appendicitis Child | US Abdomen There are no specific data related to whether a repeat focused RLQ US or a completed abdominal US is more effective in the setting of an initial equivocal US. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis [38,39]. MRI Abdomen and Pelvis MRI performed following equivocal or nondiagnostic appendix US has similar sensitivity and specificity to CT with 100% sensitivity and 96% specificity demonstrated by Herliczek et al [41,71]. In a clinical pathway with US as the initial modality and MRI for problem solving, Epifanio et al [48] demonstrated MRI to add diagnostic benefit in the small subset of cases that remained indeterminate after US. The overall sensitivity and specificity of the described pathway were 96% and 100%, respectively. Importantly, Aspelund et al [72] showed no difference in clinical outcomes following a shift from CT as the primary imaging modality for acute appendicitis to US with MRI for equivocal cases. Regarding perforated appendicitis, Dillman et al [40] showed subsequent MRI to have similar sensitivity and specificity to CT for diagnosis of perforation in patients with an initially equivocal or nondiagnostic RLQ US. It should be noted, however, that the total number of cases of perforation in this study was small (10 in the MR group and 4 in the CT group). Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study. Complicated appendicitis, generally a result of perforation, occurs at a frequency of approximately 30% in the pediatric population and has implications for clinical care [73]. There is debate in the literature regarding optimal care for patients with perforated appendicitis, which can range from antibiotic therapy with delayed appendectomy to interventional drainage to surgical intervention. | Suspected Appendicitis Child. US Abdomen There are no specific data related to whether a repeat focused RLQ US or a completed abdominal US is more effective in the setting of an initial equivocal US. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis [38,39]. MRI Abdomen and Pelvis MRI performed following equivocal or nondiagnostic appendix US has similar sensitivity and specificity to CT with 100% sensitivity and 96% specificity demonstrated by Herliczek et al [41,71]. In a clinical pathway with US as the initial modality and MRI for problem solving, Epifanio et al [48] demonstrated MRI to add diagnostic benefit in the small subset of cases that remained indeterminate after US. The overall sensitivity and specificity of the described pathway were 96% and 100%, respectively. Importantly, Aspelund et al [72] showed no difference in clinical outcomes following a shift from CT as the primary imaging modality for acute appendicitis to US with MRI for equivocal cases. Regarding perforated appendicitis, Dillman et al [40] showed subsequent MRI to have similar sensitivity and specificity to CT for diagnosis of perforation in patients with an initially equivocal or nondiagnostic RLQ US. It should be noted, however, that the total number of cases of perforation in this study was small (10 in the MR group and 4 in the CT group). Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study. Complicated appendicitis, generally a result of perforation, occurs at a frequency of approximately 30% in the pediatric population and has implications for clinical care [73]. There is debate in the literature regarding optimal care for patients with perforated appendicitis, which can range from antibiotic therapy with delayed appendectomy to interventional drainage to surgical intervention. | 3105874 |
acrac_3105874_10 | Suspected Appendicitis Child | Radiography Abdomen Radiographs may identify possible complications of acute appendicitis by identifying bowel obstruction or gross perforation. Radiographs, however, have limited sensitivity and specificity for the diagnosis of acute appendicitis as a cause of the complication [51]. US Abdomen RLQ In general, US has been shown to have limited accuracy in the distinction of perforated from nonperforated acute appendicitis [2]. While US can identify RLQ fluid collections/abscesses and dilated bowel loops, the limited field of view may be inadequate to fully assess complications of appendiceal perforation and thereby guide clinical management. US Abdomen The greater anatomic coverage of a full abdominal US (versus an RLQ US) may identify additional findings of complicated acute appendicitis outside of the RLQ, but the small image field of view is still limiting in terms of overall assessment of complications. US Pelvis Focused US of the pelvis is limited in terms of overall assessment of complicated acute appendicitis secondary to its small scope of imaging and field of view. CT Abdomen and Pelvis CT of the abdomen and pelvis with IV contrast, with or without oral contrast, provides a broad field of view for assessment of complications of acute appendicitis, including perforation, abscess, and bowel obstruction. Focused CT will likely be sufficient to characterize complicated appendicitis in the lower abdomen and pelvis; however, the limited coverage may not permit characterization of complications if they extend into the upper abdomen (eg, perisplenic or perihepatic collections). However, this has not been specifically studied. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis. Unenhanced CT may be limited in its ability to characterize complicated appendicitis (eg, perforation and abscess formation) [38,39]. | Suspected Appendicitis Child. Radiography Abdomen Radiographs may identify possible complications of acute appendicitis by identifying bowel obstruction or gross perforation. Radiographs, however, have limited sensitivity and specificity for the diagnosis of acute appendicitis as a cause of the complication [51]. US Abdomen RLQ In general, US has been shown to have limited accuracy in the distinction of perforated from nonperforated acute appendicitis [2]. While US can identify RLQ fluid collections/abscesses and dilated bowel loops, the limited field of view may be inadequate to fully assess complications of appendiceal perforation and thereby guide clinical management. US Abdomen The greater anatomic coverage of a full abdominal US (versus an RLQ US) may identify additional findings of complicated acute appendicitis outside of the RLQ, but the small image field of view is still limiting in terms of overall assessment of complications. US Pelvis Focused US of the pelvis is limited in terms of overall assessment of complicated acute appendicitis secondary to its small scope of imaging and field of view. CT Abdomen and Pelvis CT of the abdomen and pelvis with IV contrast, with or without oral contrast, provides a broad field of view for assessment of complications of acute appendicitis, including perforation, abscess, and bowel obstruction. Focused CT will likely be sufficient to characterize complicated appendicitis in the lower abdomen and pelvis; however, the limited coverage may not permit characterization of complications if they extend into the upper abdomen (eg, perisplenic or perihepatic collections). However, this has not been specifically studied. There are no studies that compare unenhanced and contrast-enhanced CT for diagnosis of acute appendicitis. Unenhanced CT may be limited in its ability to characterize complicated appendicitis (eg, perforation and abscess formation) [38,39]. | 3105874 |
acrac_3179912_0 | Imaging of Facial Trauma Following Primary Survey | aMallinckrodt Institute of Radiology, Saint Louis, Missouri. bPanel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa. cPanel Vice-Chair, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts. dFroedtert Memorial Lutheran Hospital Medical College of Wisconsin, Milwaukee, Wisconsin. eEmory University, Atlanta, Georgia; American Association for the Surgery of Trauma. fMontefiore Medical Center, Bronx, New York. gUniversity of Rochester Medical Center, Rochester, New York; American Academy of Otolaryngology-Head and Neck Surgery. hHouston Methodist Hospital, Houston, Texas. iUniversity of Texas Health Science Center, Houston, Texas. jThe University of Texas MD Anderson Cancer Center, Houston, Texas. kUniversity of Illinois at Chicago, Chicago, Illinois; University of Chicago, Chicago, Illinois; American Society of Plastic Surgeons. lNew York University Langone Health, New York, New York. mMetroHealth Medical Center, Cleveland, Ohio. nMayo Clinic Arizona, Phoenix, Arizona. oUniversity of Iowa Carver College of Medicine, Iowa City, Iowa, Primary care physician. pThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. qGeorge Washington University Hospital, Washington, District of Columbia. rUniversity of Colorado Denver, Denver, Colorado. sSpecialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia. 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] OR Discussion of Procedures by Variant Variant 1: Tenderness to palpation or contusion or edema over frontal bone. | Imaging of Facial Trauma Following Primary Survey. aMallinckrodt Institute of Radiology, Saint Louis, Missouri. bPanel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa. cPanel Vice-Chair, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts. dFroedtert Memorial Lutheran Hospital Medical College of Wisconsin, Milwaukee, Wisconsin. eEmory University, Atlanta, Georgia; American Association for the Surgery of Trauma. fMontefiore Medical Center, Bronx, New York. gUniversity of Rochester Medical Center, Rochester, New York; American Academy of Otolaryngology-Head and Neck Surgery. hHouston Methodist Hospital, Houston, Texas. iUniversity of Texas Health Science Center, Houston, Texas. jThe University of Texas MD Anderson Cancer Center, Houston, Texas. kUniversity of Illinois at Chicago, Chicago, Illinois; University of Chicago, Chicago, Illinois; American Society of Plastic Surgeons. lNew York University Langone Health, New York, New York. mMetroHealth Medical Center, Cleveland, Ohio. nMayo Clinic Arizona, Phoenix, Arizona. oUniversity of Iowa Carver College of Medicine, Iowa City, Iowa, Primary care physician. pThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. qGeorge Washington University Hospital, Washington, District of Columbia. rUniversity of Colorado Denver, Denver, Colorado. sSpecialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia. 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] OR Discussion of Procedures by Variant Variant 1: Tenderness to palpation or contusion or edema over frontal bone. | 3179912 |
acrac_3179912_1 | Imaging of Facial Trauma Following Primary Survey | Suspect frontal bone injury. Initial imaging following primary survey. Representing 5% to 15% of all facial fractures, frontal bone fractures are often the result of high-energy blunt trauma, such as motor vehicle collisions, assaults, and significant falls [30]. Thick cortical bone comprises the anterior table of the frontal sinus, allowing it to withstand up to 1,000 kg of force before fracturing, rendering it the sturdiest bone in the face [31]. In contrast, the posterior table of the frontal sinus, separating the sinus from the anterior cranial fossa, is relatively easily fractured secondary to its thin, delicate nature. One-third of injuries are isolated to the anterior table, whereas two-thirds involve both anterior and posterior tables [31]. Injuries along the inferomedial aspect of the frontal sinus and anterior ethmoids may cause occlusion of the nasofrontal duct leading to potential mucocele formation and possibly osteomyelitis [9,15,22,31-33]. Likewise, fractures through the medial aspect of the frontal sinus floor typically involve the cribriform plate and fovea ethmoidalis and may result in cerebrospinal fluid (CSF) leak or chronic sinusitis. Fractures through the lateral part of the frontal sinus floor may involve the orbital roof. Imaging of Facial Trauma Following Primary Survey CT Maxillofacial Multidetector CT (MDCT) is useful in diagnosing maxillofacial injuries [2,30,31,37-43]. MDCT offers superb delineation of osseous and soft-tissue structures. CT provides high image resolution with thin-section acquisitions allowing for the detection of subtle nondisplaced fractures of the facial skeleton. Also, CT offers multiplanar and 3-D image reconstructions, allowing for better characterization of complex fractures. In particular, many surgeons find the 3-D reformations to be critical in their preoperative planning [13,15,21,39,41,44-46]. CT allows for a faster acquisition time than other modalities such as radiography and MRI. | Imaging of Facial Trauma Following Primary Survey. Suspect frontal bone injury. Initial imaging following primary survey. Representing 5% to 15% of all facial fractures, frontal bone fractures are often the result of high-energy blunt trauma, such as motor vehicle collisions, assaults, and significant falls [30]. Thick cortical bone comprises the anterior table of the frontal sinus, allowing it to withstand up to 1,000 kg of force before fracturing, rendering it the sturdiest bone in the face [31]. In contrast, the posterior table of the frontal sinus, separating the sinus from the anterior cranial fossa, is relatively easily fractured secondary to its thin, delicate nature. One-third of injuries are isolated to the anterior table, whereas two-thirds involve both anterior and posterior tables [31]. Injuries along the inferomedial aspect of the frontal sinus and anterior ethmoids may cause occlusion of the nasofrontal duct leading to potential mucocele formation and possibly osteomyelitis [9,15,22,31-33]. Likewise, fractures through the medial aspect of the frontal sinus floor typically involve the cribriform plate and fovea ethmoidalis and may result in cerebrospinal fluid (CSF) leak or chronic sinusitis. Fractures through the lateral part of the frontal sinus floor may involve the orbital roof. Imaging of Facial Trauma Following Primary Survey CT Maxillofacial Multidetector CT (MDCT) is useful in diagnosing maxillofacial injuries [2,30,31,37-43]. MDCT offers superb delineation of osseous and soft-tissue structures. CT provides high image resolution with thin-section acquisitions allowing for the detection of subtle nondisplaced fractures of the facial skeleton. Also, CT offers multiplanar and 3-D image reconstructions, allowing for better characterization of complex fractures. In particular, many surgeons find the 3-D reformations to be critical in their preoperative planning [13,15,21,39,41,44-46]. CT allows for a faster acquisition time than other modalities such as radiography and MRI. | 3179912 |
acrac_3179912_2 | Imaging of Facial Trauma Following Primary Survey | Also, it is less reliant on patient positioning than radiography. CT is typically the first-line of imaging to identify penetrating foreign bodies and the subsequent determination of their trajectory and extent of the injury [47,48]. A novel volume visualization tool, cinematic rendering, is a promising technique to illustrate maxillofacial fractures [41]. CT with IV contrast does not aid in detection of osseous facial injury. associated cervical spine injuries [19]. Imaging of Facial Trauma Following Primary Survey Radiography Skull CT has replaced radiographs for the initial imaging evaluation of suspected frontal bone injury because radiographs cannot characterize the full extent of fractures, detect nasofrontal duct involvement, and ascertain intracranial pathology [30,59]. Approximately 3% of radiographs that did not detect skull fracture had fractures visible on CT in one study. In the group in which radiographs failed to detect a skull fracture, half of the group eventually developed an epidural hematoma [60]. Radiographs may be useful in identifying and determining the location of foreign bodies in the maxillofacial region [50]. High-velocity maxillofacial trauma and penetrating neck trauma are the most common causes of traumatic vascular injuries. Identification and treatment of these injuries should be swift because irreversible neurologic damage or death may occur. Although blunt cerebrovascular injuries (BCVI) are uncommon in maxillofacial trauma, exclusion of these injuries is necessary when clinical suspicion is present [21]. The excellent negative predictive value and high sensitivity of the revised Denver criteria make them an excellent screening tool for BCVI [61]. Using these criteria, blunt trauma patients with particular signs and symptoms of BCVI or risk factors for BCVI should undergo cerebrovascular imaging. Complex skull fractures or scalp degloving are both risk factors for BCVI, which may occur in frontal injuries. | Imaging of Facial Trauma Following Primary Survey. Also, it is less reliant on patient positioning than radiography. CT is typically the first-line of imaging to identify penetrating foreign bodies and the subsequent determination of their trajectory and extent of the injury [47,48]. A novel volume visualization tool, cinematic rendering, is a promising technique to illustrate maxillofacial fractures [41]. CT with IV contrast does not aid in detection of osseous facial injury. associated cervical spine injuries [19]. Imaging of Facial Trauma Following Primary Survey Radiography Skull CT has replaced radiographs for the initial imaging evaluation of suspected frontal bone injury because radiographs cannot characterize the full extent of fractures, detect nasofrontal duct involvement, and ascertain intracranial pathology [30,59]. Approximately 3% of radiographs that did not detect skull fracture had fractures visible on CT in one study. In the group in which radiographs failed to detect a skull fracture, half of the group eventually developed an epidural hematoma [60]. Radiographs may be useful in identifying and determining the location of foreign bodies in the maxillofacial region [50]. High-velocity maxillofacial trauma and penetrating neck trauma are the most common causes of traumatic vascular injuries. Identification and treatment of these injuries should be swift because irreversible neurologic damage or death may occur. Although blunt cerebrovascular injuries (BCVI) are uncommon in maxillofacial trauma, exclusion of these injuries is necessary when clinical suspicion is present [21]. The excellent negative predictive value and high sensitivity of the revised Denver criteria make them an excellent screening tool for BCVI [61]. Using these criteria, blunt trauma patients with particular signs and symptoms of BCVI or risk factors for BCVI should undergo cerebrovascular imaging. Complex skull fractures or scalp degloving are both risk factors for BCVI, which may occur in frontal injuries. | 3179912 |
acrac_3179912_3 | Imaging of Facial Trauma Following Primary Survey | Occult neurovascular injury, carotid-cavernous fistula, or carotid transection can occur with severe facial fractures [62,63]. A penetration trajectory, vessel wall hematoma, infiltration of perivascular fat, or foreign bodies <5 mm from a vessel wall should raise suspicion of vascular injury requiring vascular imaging [64,65]. CT angiography (CTA) has been recommended over digital subtraction angiography for initial vascular evaluation because of its short acquisition time and low complication rate [21,29]. CTA detects almost all clinically relevant blunt cervical arterial injuries [29,66]. As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Although MR angiography (MRA) is inferior to conventional arteriography, it is considered equivalent to CTA in BCVI. Similar to CTA, MRA does distinguish almost all clinically significant cervical arterial injuries [29,66]. However, MRA without IV contrast in the neck may be limited because of artifacts and limited resolution. Subtle vascular injuries such as wall irregularity and thickening and mild luminal irregularity can be difficult to detect [67]. Also, MRA with or without IV contrast is time-consuming, making it challenging to use in an acute trauma setting. Some debate exists as to whether CTA is superior to MRA in BCVI. One study found CTA to be superior [68], whereas another found them to be equivalent [29,69]. Virtual arteriograms can be created without IV contrast using time-of-flight or phase-contrast sequences. Nevertheless, pseudoaneurysms or subtle stenoses are more easily detected by administering contrast intravenously using 3-D time-of-flight imaging. | Imaging of Facial Trauma Following Primary Survey. Occult neurovascular injury, carotid-cavernous fistula, or carotid transection can occur with severe facial fractures [62,63]. A penetration trajectory, vessel wall hematoma, infiltration of perivascular fat, or foreign bodies <5 mm from a vessel wall should raise suspicion of vascular injury requiring vascular imaging [64,65]. CT angiography (CTA) has been recommended over digital subtraction angiography for initial vascular evaluation because of its short acquisition time and low complication rate [21,29]. CTA detects almost all clinically relevant blunt cervical arterial injuries [29,66]. As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Although MR angiography (MRA) is inferior to conventional arteriography, it is considered equivalent to CTA in BCVI. Similar to CTA, MRA does distinguish almost all clinically significant cervical arterial injuries [29,66]. However, MRA without IV contrast in the neck may be limited because of artifacts and limited resolution. Subtle vascular injuries such as wall irregularity and thickening and mild luminal irregularity can be difficult to detect [67]. Also, MRA with or without IV contrast is time-consuming, making it challenging to use in an acute trauma setting. Some debate exists as to whether CTA is superior to MRA in BCVI. One study found CTA to be superior [68], whereas another found them to be equivalent [29,69]. Virtual arteriograms can be created without IV contrast using time-of-flight or phase-contrast sequences. Nevertheless, pseudoaneurysms or subtle stenoses are more easily detected by administering contrast intravenously using 3-D time-of-flight imaging. | 3179912 |
acrac_3179912_4 | Imaging of Facial Trauma Following Primary Survey | Arteriography Cervicocerebral Angiography of the head and neck may logically follow identification of specific bony or soft tissue injuries but is not useful as the initial imaging modality to identify frontal bone injury. Angiography is used as a problem-solving Imaging of Facial Trauma Following Primary Survey As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Despite improvements in CTA and MRA, the reference standard for identifying cervical arterial injury remains arteriography because of its ability to detect low-grade injuries missed on other modalities [29,70-72]. However, CTA or MRA is generally utilized over arteriography currently, secondary to the 1% to 2% risk of meaningful complications such as stroke and dissection [29]. addresses the role of imaging in the setting of head trauma. CT with IV contrast does not aid in detection of head injury. MRI Maxillofacial There is no relevant literature to support the use of MRI of the face in the initial imaging evaluation of suspected midface injury. However, in patients with cranial nerve deficits not explained or incompletely characterized by CT, MRI can be a useful supplement [31]. In particular, some Le Fort II injuries can disrupt the infraorbital nerve (V2), leading to anesthesia of the upper teeth, gingiva, upper lip, and lateral aspects of the nose [15,32,80]. Zygomatic maxillary complex fractures are often associated with infraorbital nerve (V2) deficits as well [4,79]. In naso-orbital- ethmoid fractures, olfactory nerve injury often occurs. Because of its superior soft-tissue contrast and multiplanar capabilities, MRI may be helpful in the detection of CSF leak from a skull base fracture. High resolution heavily T2-weighted images are useful in the evaluation of the olfactory nerve and for potential CSF leaks. | Imaging of Facial Trauma Following Primary Survey. Arteriography Cervicocerebral Angiography of the head and neck may logically follow identification of specific bony or soft tissue injuries but is not useful as the initial imaging modality to identify frontal bone injury. Angiography is used as a problem-solving Imaging of Facial Trauma Following Primary Survey As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Despite improvements in CTA and MRA, the reference standard for identifying cervical arterial injury remains arteriography because of its ability to detect low-grade injuries missed on other modalities [29,70-72]. However, CTA or MRA is generally utilized over arteriography currently, secondary to the 1% to 2% risk of meaningful complications such as stroke and dissection [29]. addresses the role of imaging in the setting of head trauma. CT with IV contrast does not aid in detection of head injury. MRI Maxillofacial There is no relevant literature to support the use of MRI of the face in the initial imaging evaluation of suspected midface injury. However, in patients with cranial nerve deficits not explained or incompletely characterized by CT, MRI can be a useful supplement [31]. In particular, some Le Fort II injuries can disrupt the infraorbital nerve (V2), leading to anesthesia of the upper teeth, gingiva, upper lip, and lateral aspects of the nose [15,32,80]. Zygomatic maxillary complex fractures are often associated with infraorbital nerve (V2) deficits as well [4,79]. In naso-orbital- ethmoid fractures, olfactory nerve injury often occurs. Because of its superior soft-tissue contrast and multiplanar capabilities, MRI may be helpful in the detection of CSF leak from a skull base fracture. High resolution heavily T2-weighted images are useful in the evaluation of the olfactory nerve and for potential CSF leaks. | 3179912 |
acrac_3179912_5 | Imaging of Facial Trauma Following Primary Survey | MRI aids in diagnosing the contents that have herniated through a defect in skull base injuries [49]. These skull base injuries can occur in naso-orbital-ethmoid fractures [31]. Also, MRI is superior to CT for detecting small pieces of asphalt, which could occur as facial foreign bodies [50]. MRI with IV contrast is not useful in detection of facial injury. Imaging of Facial Trauma Following Primary Survey associated cervical spine injuries [19]. Radiography Paranasal Sinuses For injuries of the midface, CT has largely replaced radiographs [15,30]. The limitations with radiographs are primarily related to inaccuracies, especially with small or fine structures, associated with the superimposition of adjacent anatomic structures and the lack of technical skill resulting from disuse and a lack of training [2]. In one study, radiologists missed 12% of maxillofacial fractures on radiographs compared with CT [81]. When combined with an appropriate physical examination, the Waters, Caldwell, and submentovertex views can provide sufficient information to verify the clinical diagnosis of a zygomaticomaxillary complex fracture. Still, both patient positioning and technological experience are essential [15]. Radiographs may be useful in identifying and determining the location of foreign bodies in the maxillofacial region [50]. High-velocity maxillofacial trauma and penetrating neck trauma are the most common causes of traumatic vascular injuries. Identification and treatment of these injuries should be swift because irreversible neurologic damage or death may occur. Occult neurovascular injury, carotid-cavernous fistula, or carotid transection can occur with severe facial fractures [62,63]. Although BCVI are uncommon in maxillofacial trauma, exclusion of these injuries is necessary when clinical suspicion is present [21]. The excellent negative predictive value and high sensitivity of the revised Denver criteria make them an excellent screening tool for BCVI [61]. | Imaging of Facial Trauma Following Primary Survey. MRI aids in diagnosing the contents that have herniated through a defect in skull base injuries [49]. These skull base injuries can occur in naso-orbital-ethmoid fractures [31]. Also, MRI is superior to CT for detecting small pieces of asphalt, which could occur as facial foreign bodies [50]. MRI with IV contrast is not useful in detection of facial injury. Imaging of Facial Trauma Following Primary Survey associated cervical spine injuries [19]. Radiography Paranasal Sinuses For injuries of the midface, CT has largely replaced radiographs [15,30]. The limitations with radiographs are primarily related to inaccuracies, especially with small or fine structures, associated with the superimposition of adjacent anatomic structures and the lack of technical skill resulting from disuse and a lack of training [2]. In one study, radiologists missed 12% of maxillofacial fractures on radiographs compared with CT [81]. When combined with an appropriate physical examination, the Waters, Caldwell, and submentovertex views can provide sufficient information to verify the clinical diagnosis of a zygomaticomaxillary complex fracture. Still, both patient positioning and technological experience are essential [15]. Radiographs may be useful in identifying and determining the location of foreign bodies in the maxillofacial region [50]. High-velocity maxillofacial trauma and penetrating neck trauma are the most common causes of traumatic vascular injuries. Identification and treatment of these injuries should be swift because irreversible neurologic damage or death may occur. Occult neurovascular injury, carotid-cavernous fistula, or carotid transection can occur with severe facial fractures [62,63]. Although BCVI are uncommon in maxillofacial trauma, exclusion of these injuries is necessary when clinical suspicion is present [21]. The excellent negative predictive value and high sensitivity of the revised Denver criteria make them an excellent screening tool for BCVI [61]. | 3179912 |
acrac_3179912_6 | Imaging of Facial Trauma Following Primary Survey | Using these criteria, blunt trauma patients with particular signs and symptoms of BCVI or risk factors for BCVI should undergo cerebrovascular imaging. Le Fort II and Le Fort III fractures are both risk factors for BCVI. Also, the Eastern Association for the Surgery of Trauma currently recommends screening all patients with Le Fort II or III facial fractures for the presence of BCVI [82]. One study based on an analysis of 4,398 patients recommended screening for BCVI in Le Fort I facial fractures [17]. A penetration trajectory, vessel wall hematoma, infiltration of perivascular fat, or foreign bodies <5 mm from a vessel wall should raise suspicion of vascular injury requiring vascular imaging [64,65]. CTA has been recommended over digital subtraction angiography for initial vascular evaluation because of its short acquisition time and low complication rate [21,29]. CTA detects almost all clinically relevant blunt cervical arterial injuries [29,66]. MRA Head and Neck MRA of the head and neck may logically follow identification of specific bony or soft-tissue injuries but is not useful as the initial imaging modality to identify midface injury. Guidance on the imaging of vascular injuries in Imaging of Facial Trauma Following Primary Survey As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Although MRA is inferior to conventional arteriography, it is considered equivalent to CTA in BCVI. Similar to CTA, MRA does distinguish almost all clinically significant cervical arterial injuries [29,66]. However, MRA without IV contrast in the neck may be limited because of artifacts and limited resolution. Subtle vascular injuries such as wall irregularity and thickening and mild luminal irregularity can be difficult to detect [67]. | Imaging of Facial Trauma Following Primary Survey. Using these criteria, blunt trauma patients with particular signs and symptoms of BCVI or risk factors for BCVI should undergo cerebrovascular imaging. Le Fort II and Le Fort III fractures are both risk factors for BCVI. Also, the Eastern Association for the Surgery of Trauma currently recommends screening all patients with Le Fort II or III facial fractures for the presence of BCVI [82]. One study based on an analysis of 4,398 patients recommended screening for BCVI in Le Fort I facial fractures [17]. A penetration trajectory, vessel wall hematoma, infiltration of perivascular fat, or foreign bodies <5 mm from a vessel wall should raise suspicion of vascular injury requiring vascular imaging [64,65]. CTA has been recommended over digital subtraction angiography for initial vascular evaluation because of its short acquisition time and low complication rate [21,29]. CTA detects almost all clinically relevant blunt cervical arterial injuries [29,66]. MRA Head and Neck MRA of the head and neck may logically follow identification of specific bony or soft-tissue injuries but is not useful as the initial imaging modality to identify midface injury. Guidance on the imaging of vascular injuries in Imaging of Facial Trauma Following Primary Survey As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Although MRA is inferior to conventional arteriography, it is considered equivalent to CTA in BCVI. Similar to CTA, MRA does distinguish almost all clinically significant cervical arterial injuries [29,66]. However, MRA without IV contrast in the neck may be limited because of artifacts and limited resolution. Subtle vascular injuries such as wall irregularity and thickening and mild luminal irregularity can be difficult to detect [67]. | 3179912 |
acrac_3179912_7 | Imaging of Facial Trauma Following Primary Survey | Also, MRA with or without IV contrast is time-consuming, making it challenging to use in an acute trauma setting. Some debate exists as to whether CTA is superior to MRA in BCVI. One study found CTA to be superior [68], whereas another found them to be equivalent [29,69]. Virtual arteriograms can be created without IV contrast using time-of-flight or phase-contrast sequences. Nevertheless, pseudoaneurysms or subtle stenoses are more easily detected by administering contrast intravenously using 3-D time-of-flight imaging. As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Despite improvements in CTA and MRA, the reference standard for identifying cervical arterial injury remains arteriography because of its ability to detect low-grade injuries missed on other modalities [29,70-72]. However, CTA or MRA is generally utilized over arteriography currently, secondary to the 1% to 2% risk of meaningful complications such as stroke and dissection [29]. Radiography Chest There is no relevant literature to support the use of chest radiography in the initial imaging evaluation of suspected midface injury. However, a chest radiograph may be warranted to exclude tooth aspiration if there is a tooth that is absent [46,83]. A physician or surgeon should remove an avulsed tooth in the airway because of the risk of developing obstructive pneumonia [9]. Imaging of Facial Trauma Following Primary Survey cosmetic deformity and nasal obstruction [32]. In particular, a fracture involving the nasal cartilage may cause a septal hematoma leading to cartilage necrosis or resorption, and if untreated, a subsequent saddle nose deformity. US Maxillofacial Ultrasound (US) is typically not the first-line imaging test for evaluation of nasal injuries. | Imaging of Facial Trauma Following Primary Survey. Also, MRA with or without IV contrast is time-consuming, making it challenging to use in an acute trauma setting. Some debate exists as to whether CTA is superior to MRA in BCVI. One study found CTA to be superior [68], whereas another found them to be equivalent [29,69]. Virtual arteriograms can be created without IV contrast using time-of-flight or phase-contrast sequences. Nevertheless, pseudoaneurysms or subtle stenoses are more easily detected by administering contrast intravenously using 3-D time-of-flight imaging. As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Despite improvements in CTA and MRA, the reference standard for identifying cervical arterial injury remains arteriography because of its ability to detect low-grade injuries missed on other modalities [29,70-72]. However, CTA or MRA is generally utilized over arteriography currently, secondary to the 1% to 2% risk of meaningful complications such as stroke and dissection [29]. Radiography Chest There is no relevant literature to support the use of chest radiography in the initial imaging evaluation of suspected midface injury. However, a chest radiograph may be warranted to exclude tooth aspiration if there is a tooth that is absent [46,83]. A physician or surgeon should remove an avulsed tooth in the airway because of the risk of developing obstructive pneumonia [9]. Imaging of Facial Trauma Following Primary Survey cosmetic deformity and nasal obstruction [32]. In particular, a fracture involving the nasal cartilage may cause a septal hematoma leading to cartilage necrosis or resorption, and if untreated, a subsequent saddle nose deformity. US Maxillofacial Ultrasound (US) is typically not the first-line imaging test for evaluation of nasal injuries. | 3179912 |
acrac_3179912_8 | Imaging of Facial Trauma Following Primary Survey | However, researchers have investigated whether US might be useful in this scenario. Research using US has revealed a very high accuracy with sensitivity ranging from 90% to 100%, a specificity of 98% to 100%, and high predictive values [38,85,86]. This is particularly true of isolated nasal bone fractures [87,88]. According to two reports, US better detects nondepressed fractures of the nasal bridge and anterior septal cartilage deviation than CT [85,86]. A conductor- assisted nasal US technique detected nasal fractures, with 100% sensitivity and 89% specificity, 96% positive predictive value, and 100% negative predictive value [89]. Another study revealed that US is a reliable diagnostic tool for estimating the time of nasal bone fracture [90]. Radiography Paranasal Sinuses Nasal radiographs have limited diagnostic value in the evaluation of nasal trauma. According to several studies, the diagnostic accuracy for radiographs to detect nasal bone fractures ranges from 53% to 82% [91-93]. Radiographs do not considerably alter the diagnosis or management of nasal fractures [94]. CT Head There is no relevant literature to support the use of CT of the head in the initial imaging evaluation of suspected nasal bone injury. CT Maxillofacial MDCT is useful in diagnosing maxillofacial injuries [2,30,31,37-43]. MDCT offers superb delineation of osseous and soft-tissue structures. CT provides high image resolution with thin-section acquisitions allowing for the detection of subtle nondisplaced fractures of the facial skeleton. Also, CT offers multiplanar and 3-D image reconstructions, allowing for better characterization of complex fractures. In particular, many surgeons find the 3- D reformations afforded by CT to be critical in their preoperative planning [13,15,21,39,41,44-46]. In complex nasal injuries and other associated facial fractures, CT can fully characterize the extent of injuries and detect any additional facial injuries [30]. | Imaging of Facial Trauma Following Primary Survey. However, researchers have investigated whether US might be useful in this scenario. Research using US has revealed a very high accuracy with sensitivity ranging from 90% to 100%, a specificity of 98% to 100%, and high predictive values [38,85,86]. This is particularly true of isolated nasal bone fractures [87,88]. According to two reports, US better detects nondepressed fractures of the nasal bridge and anterior septal cartilage deviation than CT [85,86]. A conductor- assisted nasal US technique detected nasal fractures, with 100% sensitivity and 89% specificity, 96% positive predictive value, and 100% negative predictive value [89]. Another study revealed that US is a reliable diagnostic tool for estimating the time of nasal bone fracture [90]. Radiography Paranasal Sinuses Nasal radiographs have limited diagnostic value in the evaluation of nasal trauma. According to several studies, the diagnostic accuracy for radiographs to detect nasal bone fractures ranges from 53% to 82% [91-93]. Radiographs do not considerably alter the diagnosis or management of nasal fractures [94]. CT Head There is no relevant literature to support the use of CT of the head in the initial imaging evaluation of suspected nasal bone injury. CT Maxillofacial MDCT is useful in diagnosing maxillofacial injuries [2,30,31,37-43]. MDCT offers superb delineation of osseous and soft-tissue structures. CT provides high image resolution with thin-section acquisitions allowing for the detection of subtle nondisplaced fractures of the facial skeleton. Also, CT offers multiplanar and 3-D image reconstructions, allowing for better characterization of complex fractures. In particular, many surgeons find the 3- D reformations afforded by CT to be critical in their preoperative planning [13,15,21,39,41,44-46]. In complex nasal injuries and other associated facial fractures, CT can fully characterize the extent of injuries and detect any additional facial injuries [30]. | 3179912 |
acrac_3179912_9 | Imaging of Facial Trauma Following Primary Survey | When compared with radiographs, CT is more sensitive in confirming the clinical suspicion of nasal bone fracture [93]. Several classification systems exist for nasal bone fractures, and one classification system created by Rhee et al [95] relies solely on CT to determine the degree of septal deviation. CT allows for a quicker acquisition time compared with other modalities such as radiography and MRI. Also, it is less reliant on patient positioning than radiography. CT is useful as the first-line of imaging to identify penetrating foreign bodies and the subsequent determination of their trajectory and extent of the injury [47,48]. A novel volume visualization tool, cinematic rendering, is a promising technique to illustrate maxillofacial fractures [41]. CT with IV contrast does not aid in detection of facial injury. MRI Maxillofacial There is no relevant literature to support the use of MRI of the face in the initial imaging evaluation of suspected nasal bone injury. Variant 4: Trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth. Suspect mandibular injury. Initial imaging following primary survey. Fractures of the mandible comprise a large proportion of facial fractures because it is vulnerable to low-energy forces. In the setting of assaults and ballistic trauma, the mandible is the most common maxillofacial fracture site [6,96]. Mandibular fractures are classified according to the degree of comminution, location, and the presence of displaced fragments [22]. The mandible is a U-shaped bone forming an incomplete ring that articulates with the calvaria via the temporomandibular joints. Secondary to this ring-like configuration, two separate fractures occur in the mandible in approximately 67% of cases [22,31]. Thus, a second fracture must be sought and excluded after the first fracture is detected. | Imaging of Facial Trauma Following Primary Survey. When compared with radiographs, CT is more sensitive in confirming the clinical suspicion of nasal bone fracture [93]. Several classification systems exist for nasal bone fractures, and one classification system created by Rhee et al [95] relies solely on CT to determine the degree of septal deviation. CT allows for a quicker acquisition time compared with other modalities such as radiography and MRI. Also, it is less reliant on patient positioning than radiography. CT is useful as the first-line of imaging to identify penetrating foreign bodies and the subsequent determination of their trajectory and extent of the injury [47,48]. A novel volume visualization tool, cinematic rendering, is a promising technique to illustrate maxillofacial fractures [41]. CT with IV contrast does not aid in detection of facial injury. MRI Maxillofacial There is no relevant literature to support the use of MRI of the face in the initial imaging evaluation of suspected nasal bone injury. Variant 4: Trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth. Suspect mandibular injury. Initial imaging following primary survey. Fractures of the mandible comprise a large proportion of facial fractures because it is vulnerable to low-energy forces. In the setting of assaults and ballistic trauma, the mandible is the most common maxillofacial fracture site [6,96]. Mandibular fractures are classified according to the degree of comminution, location, and the presence of displaced fragments [22]. The mandible is a U-shaped bone forming an incomplete ring that articulates with the calvaria via the temporomandibular joints. Secondary to this ring-like configuration, two separate fractures occur in the mandible in approximately 67% of cases [22,31]. Thus, a second fracture must be sought and excluded after the first fracture is detected. | 3179912 |
acrac_3179912_10 | Imaging of Facial Trauma Following Primary Survey | A frequent pattern with two distinct fractures is a mandibular angle or subcondylar fracture with a contralateral parasymphyseal fracture. Another critical pattern, a flail mandible, consists of bilateral subcondylar fractures with a symphyseal fracture. In addition to these osseous injuries, fractures of the mandible may damage the inferior alveolar nerve because they extend through the mandibular canal. Beyond the mandible, approximately 20% to 40% of patients with mandibular fractures have further injuries [97]. CT Maxillofacial MDCT is useful in diagnosing maxillofacial injuries [2,30,31,37-43]. MDCT offers superb delineation of osseous and soft-tissue structures. CT provides high image resolution with thin-section acquisitions allowing for the detection of subtle nondisplaced fractures of the facial skeleton. CT is superior to radiography for the evaluation of mandibular fractures [96]. Nearly 100% sensitive with an improved interobserver agreement, CT with multiplanar reformations is proficient in detecting fractures of the mandible [31,99]. This is especially true of posterior mandibular fractures [3,100]. According to one study, more fractures are identified on CT when there is no fracture visible on orthopantomogram (OPG) [99]. CT is beneficial when evaluating ramus or condyle fractures, because the degree of displacement in these areas can be subtle [101]. CT is especially useful in identifying comminution and displacement of mandibular fractures. These are critical findings because they result in a change in surgical management [100,102,103]. Also, CT offers both multiplanar and 3-D image reconstructions, which allow for better characterization of complex fractures. In particular, many surgeons find the 3-D reformations afforded by CT to be critical in their preoperative planning [13,15,21,39,41,44-46]. CT allows for a faster acquisition time than other modalities such as radiography and MRI. | Imaging of Facial Trauma Following Primary Survey. A frequent pattern with two distinct fractures is a mandibular angle or subcondylar fracture with a contralateral parasymphyseal fracture. Another critical pattern, a flail mandible, consists of bilateral subcondylar fractures with a symphyseal fracture. In addition to these osseous injuries, fractures of the mandible may damage the inferior alveolar nerve because they extend through the mandibular canal. Beyond the mandible, approximately 20% to 40% of patients with mandibular fractures have further injuries [97]. CT Maxillofacial MDCT is useful in diagnosing maxillofacial injuries [2,30,31,37-43]. MDCT offers superb delineation of osseous and soft-tissue structures. CT provides high image resolution with thin-section acquisitions allowing for the detection of subtle nondisplaced fractures of the facial skeleton. CT is superior to radiography for the evaluation of mandibular fractures [96]. Nearly 100% sensitive with an improved interobserver agreement, CT with multiplanar reformations is proficient in detecting fractures of the mandible [31,99]. This is especially true of posterior mandibular fractures [3,100]. According to one study, more fractures are identified on CT when there is no fracture visible on orthopantomogram (OPG) [99]. CT is beneficial when evaluating ramus or condyle fractures, because the degree of displacement in these areas can be subtle [101]. CT is especially useful in identifying comminution and displacement of mandibular fractures. These are critical findings because they result in a change in surgical management [100,102,103]. Also, CT offers both multiplanar and 3-D image reconstructions, which allow for better characterization of complex fractures. In particular, many surgeons find the 3-D reformations afforded by CT to be critical in their preoperative planning [13,15,21,39,41,44-46]. CT allows for a faster acquisition time than other modalities such as radiography and MRI. | 3179912 |
acrac_3179912_11 | Imaging of Facial Trauma Following Primary Survey | Also, it is less reliant on patient positioning than radiography. CT is typically the first-line of imaging to identify penetrating foreign bodies and the subsequent determination of their trajectory and extent of the injury [47,48]. A novel volume visualization tool, cinematic rendering, is a promising technique to illustrate mandibular fractures [41]. CT with IV contrast does not aid in detection of facial injury. MRI Maxillofacial In rare instances, some reports have advocated for MRI in the acute setting to diagnose temporomandibular joint disc morphology and position in certain condylar fractures [2,104,105]. Also, in patients with cranial nerve deficits not explained or incompletely characterized by CT, MRI can be a useful supplement [31]. In particular, fractures through the mandibular canal may damage the inferior alveolar nerve as it travels through the mandibular canal. Damage to the inferior alveolar nerve may result in anesthesia of the ipsilateral lower lip, chin, anterior tongue, and mandibular teeth. Also, MRI is superior to CT for detecting small pieces of asphalt, which could occur as facial foreign bodies [50]. MRI with IV contrast is not useful in detection of facial injury. Radiography Mandible In patients with a low clinical suspicion of injury, an OPG (panoramic radiograph) or mandibular series consisting of Towne, bilateral lateral oblique, and lateral views may be obtained to evaluate for mandibular fractures. With a sensitivity of 86% to 92%, OPG has better sensitivity for detecting simple mandibular fractures than a standard 4- view mandibular imaging series [31,101,102,106]. Specifically, an OPG demonstrated a sensitivity of 92% in detecting a mandibular fracture in contrast with 66% with a mandibular series [106]. | Imaging of Facial Trauma Following Primary Survey. Also, it is less reliant on patient positioning than radiography. CT is typically the first-line of imaging to identify penetrating foreign bodies and the subsequent determination of their trajectory and extent of the injury [47,48]. A novel volume visualization tool, cinematic rendering, is a promising technique to illustrate mandibular fractures [41]. CT with IV contrast does not aid in detection of facial injury. MRI Maxillofacial In rare instances, some reports have advocated for MRI in the acute setting to diagnose temporomandibular joint disc morphology and position in certain condylar fractures [2,104,105]. Also, in patients with cranial nerve deficits not explained or incompletely characterized by CT, MRI can be a useful supplement [31]. In particular, fractures through the mandibular canal may damage the inferior alveolar nerve as it travels through the mandibular canal. Damage to the inferior alveolar nerve may result in anesthesia of the ipsilateral lower lip, chin, anterior tongue, and mandibular teeth. Also, MRI is superior to CT for detecting small pieces of asphalt, which could occur as facial foreign bodies [50]. MRI with IV contrast is not useful in detection of facial injury. Radiography Mandible In patients with a low clinical suspicion of injury, an OPG (panoramic radiograph) or mandibular series consisting of Towne, bilateral lateral oblique, and lateral views may be obtained to evaluate for mandibular fractures. With a sensitivity of 86% to 92%, OPG has better sensitivity for detecting simple mandibular fractures than a standard 4- view mandibular imaging series [31,101,102,106]. Specifically, an OPG demonstrated a sensitivity of 92% in detecting a mandibular fracture in contrast with 66% with a mandibular series [106]. | 3179912 |
acrac_3179912_12 | Imaging of Facial Trauma Following Primary Survey | A mandibular series possess several disadvantages compared with an OPG such as superimposition of osseous structures, difficulty in placing the film perpendicular to the fracture, and presence of confusing spatial relationships. A mandibular series does not require the patient to be upright, remain motionless for an extend period, or cervical spine clearance like an OPG [31]. Although isolated mandibular fractures have often been accurately diagnosed using radiography techniques, notable limitations include fractures of the mandible condyle and subcondylar fractures having anterior 14 Imaging of Facial Trauma Following Primary Survey displacement, both of which are more easily demonstrated on CT [107,108]. In addition, an OPG can miss both nondisplaced and minimally displaced anterior fractures when there is overlap with the cervical spine [99,109]. A complex fracture may be mistaken for an isolated fracture if OPG is used initially [42]. An OPG can better visualize dental root fractures compared with CT, particularly when the fracture is located at an angle [31]. The use of OPG and mandibular series radiographs has become less favorable in emergency and trauma care settings [110]. Despite this fact, some authors have used radiographs for creating scoring systems for mandibular fractures for an objective and standardized assessment for the degree of severity of mandibular fractures [111]. associated cervical spine injuries [19]. Imaging of Facial Trauma Following Primary Survey High-velocity maxillofacial trauma and penetrating neck trauma are the most common causes of traumatic vascular injuries. Identification and treatment of these injuries should be swift because irreversible neurologic damage or death may occur. Occult neurovascular injury, carotid-cavernous fistula, or carotid transection can occur with severe facial fractures [62,63]. | Imaging of Facial Trauma Following Primary Survey. A mandibular series possess several disadvantages compared with an OPG such as superimposition of osseous structures, difficulty in placing the film perpendicular to the fracture, and presence of confusing spatial relationships. A mandibular series does not require the patient to be upright, remain motionless for an extend period, or cervical spine clearance like an OPG [31]. Although isolated mandibular fractures have often been accurately diagnosed using radiography techniques, notable limitations include fractures of the mandible condyle and subcondylar fractures having anterior 14 Imaging of Facial Trauma Following Primary Survey displacement, both of which are more easily demonstrated on CT [107,108]. In addition, an OPG can miss both nondisplaced and minimally displaced anterior fractures when there is overlap with the cervical spine [99,109]. A complex fracture may be mistaken for an isolated fracture if OPG is used initially [42]. An OPG can better visualize dental root fractures compared with CT, particularly when the fracture is located at an angle [31]. The use of OPG and mandibular series radiographs has become less favorable in emergency and trauma care settings [110]. Despite this fact, some authors have used radiographs for creating scoring systems for mandibular fractures for an objective and standardized assessment for the degree of severity of mandibular fractures [111]. associated cervical spine injuries [19]. Imaging of Facial Trauma Following Primary Survey High-velocity maxillofacial trauma and penetrating neck trauma are the most common causes of traumatic vascular injuries. Identification and treatment of these injuries should be swift because irreversible neurologic damage or death may occur. Occult neurovascular injury, carotid-cavernous fistula, or carotid transection can occur with severe facial fractures [62,63]. | 3179912 |
acrac_3179912_13 | Imaging of Facial Trauma Following Primary Survey | Although BCVI are uncommon in maxillofacial trauma, exclusion of these injuries is necessary when clinical suspicion is present [21]. The excellent negative predictive value and high sensitivity of the revised Denver criteria make them an excellent screening tool for BCVI [61]. As a risk factor for BCVI, condylar and extracapsular subcondylar fractures should heighten suspicion for concomitant BCVI [9,112]. The data support a force transmission mechanism of injury in addition to direct damage from bony fragments [72,105]. A penetration trajectory, vessel wall hematoma, infiltration of perivascular fat, or foreign bodies <5 mm from a vessel wall should raise suspicion of vascular injury requiring vascular imaging [64,65]. CTA has been recommended over digital subtraction angiography for initial vascular evaluation because of its short acquisition time and low complication rate [21,29]. CTA detects almost all clinically relevant blunt cervical arterial injuries [29,66]. As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Regarding mandibular injuries, condylar and extracapsular subcondylar fractures should heighten suspicion for concomitant BCVI [9,112]. The data support a force transmission mechanism of injury in addition to direct damage from bony fragments [72,105]. Although MRA is inferior to conventional arteriography, it is considered equivalent to CTA in the setting of BCVI. Similar to CTA, MRA does distinguish almost all clinically significant cervical arterial injuries [29,66]. However, MRA without IV contrast in the neck may be limited because of artifacts and limited resolution. Subtle vascular injuries such as wall irregularity and thickening and mild luminal irregularity can be difficult to detect [67]. | Imaging of Facial Trauma Following Primary Survey. Although BCVI are uncommon in maxillofacial trauma, exclusion of these injuries is necessary when clinical suspicion is present [21]. The excellent negative predictive value and high sensitivity of the revised Denver criteria make them an excellent screening tool for BCVI [61]. As a risk factor for BCVI, condylar and extracapsular subcondylar fractures should heighten suspicion for concomitant BCVI [9,112]. The data support a force transmission mechanism of injury in addition to direct damage from bony fragments [72,105]. A penetration trajectory, vessel wall hematoma, infiltration of perivascular fat, or foreign bodies <5 mm from a vessel wall should raise suspicion of vascular injury requiring vascular imaging [64,65]. CTA has been recommended over digital subtraction angiography for initial vascular evaluation because of its short acquisition time and low complication rate [21,29]. CTA detects almost all clinically relevant blunt cervical arterial injuries [29,66]. As stated above, BCVI, although uncommon in maxillofacial trauma, carries significant morbidity and mortality if not identified and treated early. Therefore, the exclusion of these injuries is necessary in the correct clinical context. Regarding mandibular injuries, condylar and extracapsular subcondylar fractures should heighten suspicion for concomitant BCVI [9,112]. The data support a force transmission mechanism of injury in addition to direct damage from bony fragments [72,105]. Although MRA is inferior to conventional arteriography, it is considered equivalent to CTA in the setting of BCVI. Similar to CTA, MRA does distinguish almost all clinically significant cervical arterial injuries [29,66]. However, MRA without IV contrast in the neck may be limited because of artifacts and limited resolution. Subtle vascular injuries such as wall irregularity and thickening and mild luminal irregularity can be difficult to detect [67]. | 3179912 |
acrac_69504_0 | Neck Mass Adenopathy | The American Academy of Otolaryngology-Head and Neck Surgery recently created clinical guidelines for the evaluation of a neck mass in adults [14], emphasizing the importance of timely diagnosis. They issued a strong recommendation for contrast-enhanced neck CT or contrast-enhanced neck MRI for patients with a neck mass deemed at risk for malignancy. In their treatment flow chart, imaging was considered in parallel with fine-needle aspiration of the palpable mass or node for timing of diagnostic evaluation. Ultrasound (US) was considered an option for initial imaging in suspected thyroid or salivary masses or as an adjunct to expedite sampling. Discussion of Procedures by Variant Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging. Cross-sectional imaging with CT or MRI allows for precise localization of the palpable finding. Both CT and MRI can accurately assess tumors and inflammation, and CT and MRI are considered equally effective studies for clinical oncologic evaluation [14,19]. Intravenous (IV) contrast is essential for detecting neck abscesses, especially those that are intramuscular [20-22]. Contrast-enhanced imaging is helpful for identifying nodal necrosis and can help guide the search for primary tumor [23,24]. Contrast also helps to clarify primary tumor within the upper aerodigestive tract and the relationship of neck masses to the major vessels of the neck. 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] Neck Mass/Adenopathy | Neck Mass Adenopathy. The American Academy of Otolaryngology-Head and Neck Surgery recently created clinical guidelines for the evaluation of a neck mass in adults [14], emphasizing the importance of timely diagnosis. They issued a strong recommendation for contrast-enhanced neck CT or contrast-enhanced neck MRI for patients with a neck mass deemed at risk for malignancy. In their treatment flow chart, imaging was considered in parallel with fine-needle aspiration of the palpable mass or node for timing of diagnostic evaluation. Ultrasound (US) was considered an option for initial imaging in suspected thyroid or salivary masses or as an adjunct to expedite sampling. Discussion of Procedures by Variant Variant 1: Nonpulsatile neck mass(es). Not parotid region or thyroid. Initial imaging. Cross-sectional imaging with CT or MRI allows for precise localization of the palpable finding. Both CT and MRI can accurately assess tumors and inflammation, and CT and MRI are considered equally effective studies for clinical oncologic evaluation [14,19]. Intravenous (IV) contrast is essential for detecting neck abscesses, especially those that are intramuscular [20-22]. Contrast-enhanced imaging is helpful for identifying nodal necrosis and can help guide the search for primary tumor [23,24]. Contrast also helps to clarify primary tumor within the upper aerodigestive tract and the relationship of neck masses to the major vessels of the neck. 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] Neck Mass/Adenopathy | 69504 |
acrac_69504_1 | Neck Mass Adenopathy | CT Neck Contrast-enhanced CT has the advantage of superior spatial resolution and is the preferred initial imaging modality for a palpable nonpulsatile neck mass in an adult, particularly considering the risk of head and neck cancer [14,19,25,26]. The presence and distribution of abnormal lymph nodes may be helpful when refining the differential as a reactive or malignant process and in guiding the search for an unknown primary malignancy [19,27,28]. Dual-phase CT imaging (without and with IV contrast) is not usually necessary. CT performed only without IV contrast may be helpful in some cases. CTA Neck There is no evidence to support the use of CT angiography (CTA) for evaluation of a nonpulsatile neck mass. MRI Neck The primary advantage of MRI is improved soft-tissue intrinsic contrast. Intrinsic T1-hyperintensity and fat suppression techniques can confirm fat-containing lesions in the neck [28]. Diffusion-weighted imaging can identify soft-tissue abscess [34]. Apparent diffusion coefficient values also have been proposed as a discriminator between benign and malignant nodal disease in the neck [34-36] and with intravoxel incoherent motion features for both primary and nodal disease [37]; however, histology is needed to confirm any suspected malignancy [13,14,19]. Motion artifact may be a significant issue, particularly for patients who have difficulty managing secretions that are due to neck disease. MRI performed without IV contrast may be helpful in some cases. MRA Neck There is no evidence to support the use of MR angiography (MRA) for evaluation of a nonpulsatile neck mass. US Neck The overall use of neck US in the United States has lagged behind the use of US in Europe and Southeast Asia, which is due, in part, to greater accessibility of CT and MRI in the United States [38-40]. For discrete cystic lesions of the neck, US may suffice to characterize a lesion prior to definitive management. | Neck Mass Adenopathy. CT Neck Contrast-enhanced CT has the advantage of superior spatial resolution and is the preferred initial imaging modality for a palpable nonpulsatile neck mass in an adult, particularly considering the risk of head and neck cancer [14,19,25,26]. The presence and distribution of abnormal lymph nodes may be helpful when refining the differential as a reactive or malignant process and in guiding the search for an unknown primary malignancy [19,27,28]. Dual-phase CT imaging (without and with IV contrast) is not usually necessary. CT performed only without IV contrast may be helpful in some cases. CTA Neck There is no evidence to support the use of CT angiography (CTA) for evaluation of a nonpulsatile neck mass. MRI Neck The primary advantage of MRI is improved soft-tissue intrinsic contrast. Intrinsic T1-hyperintensity and fat suppression techniques can confirm fat-containing lesions in the neck [28]. Diffusion-weighted imaging can identify soft-tissue abscess [34]. Apparent diffusion coefficient values also have been proposed as a discriminator between benign and malignant nodal disease in the neck [34-36] and with intravoxel incoherent motion features for both primary and nodal disease [37]; however, histology is needed to confirm any suspected malignancy [13,14,19]. Motion artifact may be a significant issue, particularly for patients who have difficulty managing secretions that are due to neck disease. MRI performed without IV contrast may be helpful in some cases. MRA Neck There is no evidence to support the use of MR angiography (MRA) for evaluation of a nonpulsatile neck mass. US Neck The overall use of neck US in the United States has lagged behind the use of US in Europe and Southeast Asia, which is due, in part, to greater accessibility of CT and MRI in the United States [38-40]. For discrete cystic lesions of the neck, US may suffice to characterize a lesion prior to definitive management. | 69504 |
acrac_69504_2 | Neck Mass Adenopathy | A few studies suggested that US can distinguish between metastatic and inflammatory neck nodes [41-47]. Although these results are promising, scans are user dependent. US serves as a powerful tool for image-guided sampling [48], which is beyond the scope of this document. Advantages of US include the ability to be performed at the point of care and to expedite sampling [14]; however, US is limited for comprehensive evaluation of the deep spaces of the neck, and for larger, multispatial, and malignant lesions. US may play a future rule in identifying unknown primary mucosal tumors, notably in the oropharynx [49]. Techniques such as US elastography and contrast-enhanced US are being explored for possible future clinical applications [44,45,50-58]. FDG-PET/CT Skull Base to Mid-Thigh While there is established literature regarding the use of PET using the tracer fluorine-18-2-fluoro-2-deoxy-D- glucose (FDG)/CT for staging and surveillance of head or neck malignancy, FDG-PET/CT is not an initial imaging study for evaluation of a nonpulsatile neck mass. FDG-PET/MRI Skull Base to Mid-Thigh While there is growing literature regarding the use of FDG-PET/MRI for staging and surveillance of head or neck malignancy, FDG-PET/MRI is not an initial imaging study for evaluation of a nonpulsatile neck mass. Arteriography Cervicocerebral There is no evidence to support the use of catheter angiography for evaluation of a nonpulsatile neck mass. Neck Mass/Adenopathy CT Neck Neck CT should be performed with IV contrast. Dual-phase CT imaging (without and with IV contrast) is not usually necessary. CT performed only without IV contrast may be helpful in a small minority of cases. Contrast is useful for distinguishing vessels from lymph nodes and confirming whether a mass is hypervascular as many pulsatile neck masses (especially those in level II or III) are lymph nodes overlying the carotid artery rather than true vascular masses. | Neck Mass Adenopathy. A few studies suggested that US can distinguish between metastatic and inflammatory neck nodes [41-47]. Although these results are promising, scans are user dependent. US serves as a powerful tool for image-guided sampling [48], which is beyond the scope of this document. Advantages of US include the ability to be performed at the point of care and to expedite sampling [14]; however, US is limited for comprehensive evaluation of the deep spaces of the neck, and for larger, multispatial, and malignant lesions. US may play a future rule in identifying unknown primary mucosal tumors, notably in the oropharynx [49]. Techniques such as US elastography and contrast-enhanced US are being explored for possible future clinical applications [44,45,50-58]. FDG-PET/CT Skull Base to Mid-Thigh While there is established literature regarding the use of PET using the tracer fluorine-18-2-fluoro-2-deoxy-D- glucose (FDG)/CT for staging and surveillance of head or neck malignancy, FDG-PET/CT is not an initial imaging study for evaluation of a nonpulsatile neck mass. FDG-PET/MRI Skull Base to Mid-Thigh While there is growing literature regarding the use of FDG-PET/MRI for staging and surveillance of head or neck malignancy, FDG-PET/MRI is not an initial imaging study for evaluation of a nonpulsatile neck mass. Arteriography Cervicocerebral There is no evidence to support the use of catheter angiography for evaluation of a nonpulsatile neck mass. Neck Mass/Adenopathy CT Neck Neck CT should be performed with IV contrast. Dual-phase CT imaging (without and with IV contrast) is not usually necessary. CT performed only without IV contrast may be helpful in a small minority of cases. Contrast is useful for distinguishing vessels from lymph nodes and confirming whether a mass is hypervascular as many pulsatile neck masses (especially those in level II or III) are lymph nodes overlying the carotid artery rather than true vascular masses. | 69504 |
acrac_69504_3 | Neck Mass Adenopathy | There is no current literature comparing the efficacy of contrast-enhanced CT to CTA or MRI and MRA for the evaluation of a pulsatile neck mass. Advances in lower dose protocols and reconstruction vary among vendors [32], and all imaging should reflect ALARA practices [33]. CTA Neck Although CTA is optimized to visualize the cervical arteries, the soft tissues are usually well characterized. There is no current literature comparing efficacy of contrast-enhanced CT to CTA or MRI and MRA for the evaluation of a pulsatile neck mass. MRI Neck The primary advantage of MRI is improved soft-tissue intrinsic contrast. A noncontrast MRI also serves a role for anatomic definition of a pulsatile neck mass in patients who cannot receive contrast. There is no current literature comparing efficacy of contrast-enhanced CT to CTA or MRI and MRA for the evaluation of a pulsatile neck mass. Arterial phase, time-resolved (4-D) MRI may be useful for evaluation of possible paragangliomas in the head and neck [59-61], but it is not an initial imaging study of a new palpable neck mass. MRA Neck MRA is complementary to MRI in the evaluation of a pulsatile neck mass to achieve anatomic and vascular detail. Time resolved (4-D) contrast-enhanced MRA technique may be useful for characterization of head and neck arteriovenous malformations [62]. There is no current literature comparing efficacy of contrast-enhanced CT to CTA or MRI and MRA for the evaluation of a pulsatile neck mass. The use of contrast for MRA is institution dependent but generally preferred. US Neck US may identify a distinct mass overlying or adjacent to an artery, may confirm vascularity of a lesion, or may be useful to confirm a clinical suspicion of a tortuous artery. The characteristic US appearance of phleboliths may aid in the diagnosis of low-flow vascular malformations [59]. | Neck Mass Adenopathy. There is no current literature comparing the efficacy of contrast-enhanced CT to CTA or MRI and MRA for the evaluation of a pulsatile neck mass. Advances in lower dose protocols and reconstruction vary among vendors [32], and all imaging should reflect ALARA practices [33]. CTA Neck Although CTA is optimized to visualize the cervical arteries, the soft tissues are usually well characterized. There is no current literature comparing efficacy of contrast-enhanced CT to CTA or MRI and MRA for the evaluation of a pulsatile neck mass. MRI Neck The primary advantage of MRI is improved soft-tissue intrinsic contrast. A noncontrast MRI also serves a role for anatomic definition of a pulsatile neck mass in patients who cannot receive contrast. There is no current literature comparing efficacy of contrast-enhanced CT to CTA or MRI and MRA for the evaluation of a pulsatile neck mass. Arterial phase, time-resolved (4-D) MRI may be useful for evaluation of possible paragangliomas in the head and neck [59-61], but it is not an initial imaging study of a new palpable neck mass. MRA Neck MRA is complementary to MRI in the evaluation of a pulsatile neck mass to achieve anatomic and vascular detail. Time resolved (4-D) contrast-enhanced MRA technique may be useful for characterization of head and neck arteriovenous malformations [62]. There is no current literature comparing efficacy of contrast-enhanced CT to CTA or MRI and MRA for the evaluation of a pulsatile neck mass. The use of contrast for MRA is institution dependent but generally preferred. US Neck US may identify a distinct mass overlying or adjacent to an artery, may confirm vascularity of a lesion, or may be useful to confirm a clinical suspicion of a tortuous artery. The characteristic US appearance of phleboliths may aid in the diagnosis of low-flow vascular malformations [59]. | 69504 |
acrac_69504_4 | Neck Mass Adenopathy | FDG-PET/CT Skull Base to Mid-Thigh Patients with suspected recurrent paraganglioma may benefit from additional types of PET imaging beyond the scope of this document [63-65]; however, PET/CT is not an initial imaging study for evaluation of a pulsatile neck mass. FDG-PET/MRI Skull Base to Mid-Thigh Patients with suspected recurrent paraganglioma may benefit from additional types of PET imaging beyond the scope of this document [63-65]; however, PET/MRI is not an initial imaging study for evaluation of a pulsatile neck mass. Arteriography Cervicocerebral Catheter angiography may be used for surgical planning and endovascular treatment or for further characterization of vascular neck lesions identified on US or cross-sectional imaging; however, it is not an initial imaging study for evaluation of a pulsatile neck mass. Variant 3: Parotid region mass(es). Initial imaging. Imaging generally cannot determine if a newly symptomatic or palpable parotid lesion is benign or malignant. However, imaging may help determine whether the mass is arising from within or outside the parotid gland, the characteristics of the mass, and whether additional masses are present [66]. An extraparotid mass usually reflects a lymph node. For an intraparotid lesion, differential considerations include lymph nodes, benign, malignant, inflammatory, and congenital etiologies. Although certain imaging findings often suggest a specific diagnosis for a parotid mass, histologic diagnosis is usually needed to exclude malignancy [26,67-72]. Clinical history and Neck Mass/Adenopathy physical examination also influences the workup as numbness, trismus, fixation, and facial weakness may suggest a malignant etiology. Radiologist consultation is essential to achieve appropriate anatomic coverage. CT Neck CT face and/or neck with IV contrast is commonly used to evaluate palpable parotid region abnormalities, usually in the setting of suspected parotid acute inflammation [73]. | Neck Mass Adenopathy. FDG-PET/CT Skull Base to Mid-Thigh Patients with suspected recurrent paraganglioma may benefit from additional types of PET imaging beyond the scope of this document [63-65]; however, PET/CT is not an initial imaging study for evaluation of a pulsatile neck mass. FDG-PET/MRI Skull Base to Mid-Thigh Patients with suspected recurrent paraganglioma may benefit from additional types of PET imaging beyond the scope of this document [63-65]; however, PET/MRI is not an initial imaging study for evaluation of a pulsatile neck mass. Arteriography Cervicocerebral Catheter angiography may be used for surgical planning and endovascular treatment or for further characterization of vascular neck lesions identified on US or cross-sectional imaging; however, it is not an initial imaging study for evaluation of a pulsatile neck mass. Variant 3: Parotid region mass(es). Initial imaging. Imaging generally cannot determine if a newly symptomatic or palpable parotid lesion is benign or malignant. However, imaging may help determine whether the mass is arising from within or outside the parotid gland, the characteristics of the mass, and whether additional masses are present [66]. An extraparotid mass usually reflects a lymph node. For an intraparotid lesion, differential considerations include lymph nodes, benign, malignant, inflammatory, and congenital etiologies. Although certain imaging findings often suggest a specific diagnosis for a parotid mass, histologic diagnosis is usually needed to exclude malignancy [26,67-72]. Clinical history and Neck Mass/Adenopathy physical examination also influences the workup as numbness, trismus, fixation, and facial weakness may suggest a malignant etiology. Radiologist consultation is essential to achieve appropriate anatomic coverage. CT Neck CT face and/or neck with IV contrast is commonly used to evaluate palpable parotid region abnormalities, usually in the setting of suspected parotid acute inflammation [73]. | 69504 |
acrac_69504_5 | Neck Mass Adenopathy | CT performed only without IV contrast may be helpful in a small number of cases. Bony details (landmarks, erosion, remodeling) and sialoliths are better delineated by CT compared with MRI [74]. Dual phase (without and with IV contrast) is not usually necessary as most sialoliths are not obscured by contrast. A noncontrast CT study is usually not indicated in patients presenting with a neck mass suspected of being a swollen major salivary gland that is due to obstructing sialolith [20]. CT imaging coverage of the entire neck should be considered if full assessment of regional nodes is required. Advances in lower dose protocols and reconstruction vary among vendors [32], and all imaging should reflect ALARA practices [33]. CT perfusion imaging is still a research tool for evaluation of parotid pathology [75,76]. CT Neck Parotid Sialography In the absence of acute infection, CT sialography may provide detailed assessment of the parotid ducts if there is a clinical concern for duct obstruction. CTA Neck There is no evidence to support the use of CTA for evaluation of a parotid region mass. MRI Neck Parotid Sialography Noninvasive MRI sialography may provide assessment of the parotid ducts [88] complementary to anatomic MRI of the face or neck, if there is a clinical concern for acute parotitis in the setting of duct obstruction. MRA Neck There is no evidence to support the use of MRA for evaluation of a parotid region mass. US Neck US is adept at localization of parotid versus extraparotid masses [77,89], and identifying features suspicious for malignancy [90]. Deep lobe lesions are generally not as well delineated with US as in the superficial lobe. Much of the published literature focuses on US-guided fine-needle aspiration, and not the diagnostic utility of US. Contrast-enhanced US and US elastography are newer techniques currently being explored for evaluation of salivary pathology [71,91-94]. | Neck Mass Adenopathy. CT performed only without IV contrast may be helpful in a small number of cases. Bony details (landmarks, erosion, remodeling) and sialoliths are better delineated by CT compared with MRI [74]. Dual phase (without and with IV contrast) is not usually necessary as most sialoliths are not obscured by contrast. A noncontrast CT study is usually not indicated in patients presenting with a neck mass suspected of being a swollen major salivary gland that is due to obstructing sialolith [20]. CT imaging coverage of the entire neck should be considered if full assessment of regional nodes is required. Advances in lower dose protocols and reconstruction vary among vendors [32], and all imaging should reflect ALARA practices [33]. CT perfusion imaging is still a research tool for evaluation of parotid pathology [75,76]. CT Neck Parotid Sialography In the absence of acute infection, CT sialography may provide detailed assessment of the parotid ducts if there is a clinical concern for duct obstruction. CTA Neck There is no evidence to support the use of CTA for evaluation of a parotid region mass. MRI Neck Parotid Sialography Noninvasive MRI sialography may provide assessment of the parotid ducts [88] complementary to anatomic MRI of the face or neck, if there is a clinical concern for acute parotitis in the setting of duct obstruction. MRA Neck There is no evidence to support the use of MRA for evaluation of a parotid region mass. US Neck US is adept at localization of parotid versus extraparotid masses [77,89], and identifying features suspicious for malignancy [90]. Deep lobe lesions are generally not as well delineated with US as in the superficial lobe. Much of the published literature focuses on US-guided fine-needle aspiration, and not the diagnostic utility of US. Contrast-enhanced US and US elastography are newer techniques currently being explored for evaluation of salivary pathology [71,91-94]. | 69504 |
acrac_69504_6 | Neck Mass Adenopathy | FDG-PET/CT Skull Base to Mid-Thigh While there is established literature regarding the use of FDG-PET/CT for staging and surveillance of parotid malignancy, FDG-PET/CT is not an initial imaging study for evaluation. FDG-PET/MRI Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/MRI for evaluation of a new parotid mass. Arteriography Cervicocerebral There is no evidence to support the use of catheter angiography for evaluation of a new parotid mass. Fluoroscopy Sialography Parotid In the absence of acute infection, conventional fluoroscopic parotid sialography may provide detailed assessment of the parotid ducts if there is a clinical concern for duct obstruction. Neck Mass/Adenopathy Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging. In children who present with neck masses, congenital etiologies should be added to differential diagnostic considerations [6,95] in addition to infectious and malignant etiologies. Clinical examination features and correlation with onset, change in mass size, fluctuance, fever, overlying skin erythema, or recent trauma are important to guiding imaging. CT Neck CT with IV contrast can be performed in children suspected of a having a malignancy or a deep neck infection that may require surgery [21,29,96]. CT has reduced or absent sedation requirements given the shorter examination time. Dual phase (without and with IV contrast) is not usually necessary, as most sialoliths are not obscured by contrast. [20]. CT performed only without IV contrast may be useful in some cases. Advances in lower dose protocols and reconstruction vary among vendors [32], and all imaging should reflect ALARA practices [33]. CTA Neck There is no evidence to support the use of CTA for evaluation of a palpable neck mass in a child. MRI Neck MRI of the neck can be performed in children suspected of having a malignancy or a deep neck abscess that may require surgical drainage [21,29,96]. | Neck Mass Adenopathy. FDG-PET/CT Skull Base to Mid-Thigh While there is established literature regarding the use of FDG-PET/CT for staging and surveillance of parotid malignancy, FDG-PET/CT is not an initial imaging study for evaluation. FDG-PET/MRI Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/MRI for evaluation of a new parotid mass. Arteriography Cervicocerebral There is no evidence to support the use of catheter angiography for evaluation of a new parotid mass. Fluoroscopy Sialography Parotid In the absence of acute infection, conventional fluoroscopic parotid sialography may provide detailed assessment of the parotid ducts if there is a clinical concern for duct obstruction. Neck Mass/Adenopathy Variant 4: Child. Neck mass(es). Not parotid region or thyroid. Initial imaging. In children who present with neck masses, congenital etiologies should be added to differential diagnostic considerations [6,95] in addition to infectious and malignant etiologies. Clinical examination features and correlation with onset, change in mass size, fluctuance, fever, overlying skin erythema, or recent trauma are important to guiding imaging. CT Neck CT with IV contrast can be performed in children suspected of a having a malignancy or a deep neck infection that may require surgery [21,29,96]. CT has reduced or absent sedation requirements given the shorter examination time. Dual phase (without and with IV contrast) is not usually necessary, as most sialoliths are not obscured by contrast. [20]. CT performed only without IV contrast may be useful in some cases. Advances in lower dose protocols and reconstruction vary among vendors [32], and all imaging should reflect ALARA practices [33]. CTA Neck There is no evidence to support the use of CTA for evaluation of a palpable neck mass in a child. MRI Neck MRI of the neck can be performed in children suspected of having a malignancy or a deep neck abscess that may require surgical drainage [21,29,96]. | 69504 |
acrac_69504_7 | Neck Mass Adenopathy | Additionally, in suspected vascular malformation, MRI provides detail of trans-spatial extent and adjacent neurovascular structures [97,98]. The addition of contrast is usually helpful for evaluation of suspected vascular lesions [99]; however, it should be considered on a case-by-case basis as it is not always necessary to achieve diagnosis [100]. MRA Neck There is no evidence to support the use of MRA for evaluation of a palpable neck mass in a child, though time- resolved postcontrast MRA could be useful for evaluating venous malformations and other pathology [59]. Contrast may not be necessary for defining arterial anatomy. US Neck In children suspected of having a congenital abnormality, US is useful in differentiating solid from cystic neck lesions and in discriminating high-flow from low-flow vascular malformations [59,101-103]. Color-flow Doppler US is also helpful for characterizing vascular flow in solid lesions [41,104]. US may suffice for evaluation of superficial infection [105]. FDG-PET/CT Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/CT for evaluation of a palpable neck mass in a child. FDG-PET/MRI Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/MRI for evaluation of a palpable neck mass in a child. Arteriography Cervicocerebral There is no evidence to support the use of catheter angiography for evaluation of a palpable neck mass in a child. Summary of Recommendations Variant 1: CT neck with IV contrast or MRI neck without and with IV contrast is usually appropriate for the initial imaging of nonpulsatile neck masses, not parotid region or thyroid. These procedures are equivalent alternatives. Variant 2: CT neck with IV contrast, CTA neck with IV contrast, MRI neck without and with IV contrast, or MRA neck is usually appropriate for the initial imaging of pulsatile neck masses, not parotid region or thyroid. These procedures are equivalent alternatives, although CTA or MRA may be complementary to CT and MRI. | Neck Mass Adenopathy. Additionally, in suspected vascular malformation, MRI provides detail of trans-spatial extent and adjacent neurovascular structures [97,98]. The addition of contrast is usually helpful for evaluation of suspected vascular lesions [99]; however, it should be considered on a case-by-case basis as it is not always necessary to achieve diagnosis [100]. MRA Neck There is no evidence to support the use of MRA for evaluation of a palpable neck mass in a child, though time- resolved postcontrast MRA could be useful for evaluating venous malformations and other pathology [59]. Contrast may not be necessary for defining arterial anatomy. US Neck In children suspected of having a congenital abnormality, US is useful in differentiating solid from cystic neck lesions and in discriminating high-flow from low-flow vascular malformations [59,101-103]. Color-flow Doppler US is also helpful for characterizing vascular flow in solid lesions [41,104]. US may suffice for evaluation of superficial infection [105]. FDG-PET/CT Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/CT for evaluation of a palpable neck mass in a child. FDG-PET/MRI Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/MRI for evaluation of a palpable neck mass in a child. Arteriography Cervicocerebral There is no evidence to support the use of catheter angiography for evaluation of a palpable neck mass in a child. Summary of Recommendations Variant 1: CT neck with IV contrast or MRI neck without and with IV contrast is usually appropriate for the initial imaging of nonpulsatile neck masses, not parotid region or thyroid. These procedures are equivalent alternatives. Variant 2: CT neck with IV contrast, CTA neck with IV contrast, MRI neck without and with IV contrast, or MRA neck is usually appropriate for the initial imaging of pulsatile neck masses, not parotid region or thyroid. These procedures are equivalent alternatives, although CTA or MRA may be complementary to CT and MRI. | 69504 |
acrac_69472_0 | Liver Lesion Initial Characterization | Introduction/Background Incidental liver masses are commonly discovered on imaging performed for other indications. Because the prevalence of benign focal liver lesions in adults is high, with at least one lesion seen in up to 15% of patients, accurate characterization of incidentally detected lesions is an important objective of diagnostic imaging [1]. Benign lesions are very common in the liver, and even in patients with primary malignancy, benign lesions unrelated to the known malignancy can be found in nearly 30% of patients [2]. Common benign liver masses include cysts, hemangiomas, and focal nodular hyperplasia (FNH). Common malignant tumors include metastases and hepatocellular carcinomas (HCCs). Less common liver masses include hepatocellular adenoma, intrahepatic cholangiocarcinoma, fibrolamellar HCC, biliary cystadenoma and cystadenocarcinoma, lymphoma, stromal tumors, and a variety of sarcomas. On occasion, benign lesions and pseudolesions may mimic liver tumors. These mimics include focal fat deposition or sparing, intrahepatic vascular shunts, transient hepatic attenuation/intensity difference, abscess, hematoma, and peliosis hepatis. Patients with cirrhosis are a special patient population in whom certain benign (regenerating nodules), premalignant (dysplastic nodules), malignant (HCC), and nontumorous (confluent hepatic fibrosis) masses as well as pseudolesions (vascular shunts) are more prevalent than in the general population [3]. For each of the variants in this document, it is assumed that an imaging study has identified a lesion that was not fully characterized by the study that detected it. Prior imaging studies may include ultrasonography (US) with color- flow evaluation, noncontrast or contrast-enhanced multidetector helical CT, or noncontrast or contrast-enhanced MRI. | Liver Lesion Initial Characterization. Introduction/Background Incidental liver masses are commonly discovered on imaging performed for other indications. Because the prevalence of benign focal liver lesions in adults is high, with at least one lesion seen in up to 15% of patients, accurate characterization of incidentally detected lesions is an important objective of diagnostic imaging [1]. Benign lesions are very common in the liver, and even in patients with primary malignancy, benign lesions unrelated to the known malignancy can be found in nearly 30% of patients [2]. Common benign liver masses include cysts, hemangiomas, and focal nodular hyperplasia (FNH). Common malignant tumors include metastases and hepatocellular carcinomas (HCCs). Less common liver masses include hepatocellular adenoma, intrahepatic cholangiocarcinoma, fibrolamellar HCC, biliary cystadenoma and cystadenocarcinoma, lymphoma, stromal tumors, and a variety of sarcomas. On occasion, benign lesions and pseudolesions may mimic liver tumors. These mimics include focal fat deposition or sparing, intrahepatic vascular shunts, transient hepatic attenuation/intensity difference, abscess, hematoma, and peliosis hepatis. Patients with cirrhosis are a special patient population in whom certain benign (regenerating nodules), premalignant (dysplastic nodules), malignant (HCC), and nontumorous (confluent hepatic fibrosis) masses as well as pseudolesions (vascular shunts) are more prevalent than in the general population [3]. For each of the variants in this document, it is assumed that an imaging study has identified a lesion that was not fully characterized by the study that detected it. Prior imaging studies may include ultrasonography (US) with color- flow evaluation, noncontrast or contrast-enhanced multidetector helical CT, or noncontrast or contrast-enhanced MRI. | 69472 |
acrac_69472_1 | Liver Lesion Initial Characterization | Management recommendations of incidental liver lesions were addressed in a recent white paper by the ACR Incidental Findings Committee (Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee) [4]. The document addressed management guidance for incidental liver lesions detected on CT only. In contrast, this document addresses approaches to characterization of hepatic lesions detected with various modalities and in various clinical scenarios. For purposes of increased clarity in this document, we combined the low-risk and average-risk individual into one category using the definitions as stated in the white paper (any age with no known malignancies, hepatic dysfunction, risk factors for HCC, or symptoms attributable to the liver). The definition of a high-risk individual in this document differs from that in the white paper in that we separate those individuals with pre-existing liver disease (cirrhosis and chronic hepatitis B without cirrhosis) from those with a known primary malignancy. Special Imaging Considerations When considering a definitive diagnosis of liver lesions, the dynamic pattern of lesion enhancement can guide the final diagnosis. Therefore, at least two dynamic imaging phases (ie, dual-phase) are required for characterization of most liver lesions. These phases include hepatic arterial phase and portal venous phase and are applicable to CT, aMontefiore Medical Center, Bronx, New York. bPanel Vice-Chair, Northwestern University, Chicago, Illinois. cPanel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. dUniversity of Arizona, Banner University Medical Center, Tucson, Arizona. eDuke University Medical Center, Durham, North Carolina. fUniversity of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association. gInterventional Endoscopy and Pancreatic Diseases, New Haven, Connecticut; American Gastroenterological Association. | Liver Lesion Initial Characterization. Management recommendations of incidental liver lesions were addressed in a recent white paper by the ACR Incidental Findings Committee (Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee) [4]. The document addressed management guidance for incidental liver lesions detected on CT only. In contrast, this document addresses approaches to characterization of hepatic lesions detected with various modalities and in various clinical scenarios. For purposes of increased clarity in this document, we combined the low-risk and average-risk individual into one category using the definitions as stated in the white paper (any age with no known malignancies, hepatic dysfunction, risk factors for HCC, or symptoms attributable to the liver). The definition of a high-risk individual in this document differs from that in the white paper in that we separate those individuals with pre-existing liver disease (cirrhosis and chronic hepatitis B without cirrhosis) from those with a known primary malignancy. Special Imaging Considerations When considering a definitive diagnosis of liver lesions, the dynamic pattern of lesion enhancement can guide the final diagnosis. Therefore, at least two dynamic imaging phases (ie, dual-phase) are required for characterization of most liver lesions. These phases include hepatic arterial phase and portal venous phase and are applicable to CT, aMontefiore Medical Center, Bronx, New York. bPanel Vice-Chair, Northwestern University, Chicago, Illinois. cPanel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. dUniversity of Arizona, Banner University Medical Center, Tucson, Arizona. eDuke University Medical Center, Durham, North Carolina. fUniversity of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association. gInterventional Endoscopy and Pancreatic Diseases, New Haven, Connecticut; American Gastroenterological Association. | 69472 |
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