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acrac_69468_16

Acute Pancreatitis

However, clinical suspicion and fine-needle aspiration with fluid analysis remain the gold standard for treatment determination. Hemorrhagic fluid collections may be more easily recognized on MRI than CT because of the presence of T1 hyperintense methemoglobin, low-signal-intensity hemosiderin rim on T2-weighted images, and signal abnormalities related to hemorrhage that persist longer on MRI than CT. However, in the setting of an abrupt decrease in hemoglobin or hematocrit, an acute bleeding episode would be suspected, and MRI without and with IV contrast with MRCP is currently limited by longer acquisition times. In these patients, who may be unstable in the setting of an acute bleeding episode, a more rapid CT examination is preferred. US Abdomen Gas bubbles within necrotic collections and pancreatic and peripancreatic fluid collections may be seen on transabdominal US; however, CT is more commonly used for the imaging diagnosis of infection, particularly because it may be challenging to differentiate gas in overlying stomach/bowel from gas in a collection by US. US Abdomen with IV Contrast Although CEUS can be used to evaluate complications of pancreatitis, such as splenic artery aneurysm [28], in the setting of an abrupt decrease in hemoglobin or hematocrit, CT angiography is the preferred imaging modality given its rapid acquisition and vascular mapping for interventional or surgical treatment planning. Acute Pancreatitis US Duplex Doppler Abdomen Color Doppler US may be used with traditional grayscale US for evaluation of vascular complications, such as arterial pseudoaneurysms or thrombosis of the portal venous system. Pseudoaneurysms, which most frequently involve the splenic, gastroduodenal, and pancreaticoduodenal arteries, may be identified on a Doppler US examination; however, in the setting of an abrupt decrease in hemoglobin or hematocrit, CT angiography is the preferred imaging modality for assessment of suspected pseudoaneurysm rupture. Variant 6: Acute pancreatitis.

Acute Pancreatitis. However, clinical suspicion and fine-needle aspiration with fluid analysis remain the gold standard for treatment determination. Hemorrhagic fluid collections may be more easily recognized on MRI than CT because of the presence of T1 hyperintense methemoglobin, low-signal-intensity hemosiderin rim on T2-weighted images, and signal abnormalities related to hemorrhage that persist longer on MRI than CT. However, in the setting of an abrupt decrease in hemoglobin or hematocrit, an acute bleeding episode would be suspected, and MRI without and with IV contrast with MRCP is currently limited by longer acquisition times. In these patients, who may be unstable in the setting of an acute bleeding episode, a more rapid CT examination is preferred. US Abdomen Gas bubbles within necrotic collections and pancreatic and peripancreatic fluid collections may be seen on transabdominal US; however, CT is more commonly used for the imaging diagnosis of infection, particularly because it may be challenging to differentiate gas in overlying stomach/bowel from gas in a collection by US. US Abdomen with IV Contrast Although CEUS can be used to evaluate complications of pancreatitis, such as splenic artery aneurysm [28], in the setting of an abrupt decrease in hemoglobin or hematocrit, CT angiography is the preferred imaging modality given its rapid acquisition and vascular mapping for interventional or surgical treatment planning. Acute Pancreatitis US Duplex Doppler Abdomen Color Doppler US may be used with traditional grayscale US for evaluation of vascular complications, such as arterial pseudoaneurysms or thrombosis of the portal venous system. Pseudoaneurysms, which most frequently involve the splenic, gastroduodenal, and pancreaticoduodenal arteries, may be identified on a Doppler US examination; however, in the setting of an abrupt decrease in hemoglobin or hematocrit, CT angiography is the preferred imaging modality for assessment of suspected pseudoaneurysm rupture. Variant 6: Acute pancreatitis.

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Acute Pancreatitis

Known pancreatic or peripancreatic fluid collections with continued abdominal pain, early satiety, nausea, vomiting, or signs of infection. Greater than 4 weeks after symptom onset. Local complications in AP include pancreatic or peripancreatic fluid collections. The classification of these fluid collections depends on timing and the presence of necrosis. Acute peripancreatic fluid collections usually develop in the early phase of interstitial edematous pancreatitis and may turn into a pancreatic pseudocyst as a delayed (>4 weeks) complication. A pseudocyst has a well-defined wall and does not contain solid material. In necrotizing pancreatitis, a collection in the early phase is an acute necrotic collection and develops into walled-off necrosis, which is surrounded by a detectible capsule, after 4 weeks [3]. Differentiating walled-off necrosis from pseudocysts that do not contain debris has important implications for management, as residual necrotic debris after drainage may lead to secondary infection. Pseudocysts can be drained by simple percutaneous or endoscopic techniques, as they are composed almost exclusively of fluid. Conversely, walled-off necrosis requires surgical debridement, direct endoscopic necrosectomy, insertion of larger caliber metallic cystgastrostomy stents, or ongoing percutaneous irrigation and drainage of necrotic debris [30]. Although increased clinical severity, particularly persistent organ failure, may suggest that collections likely intervention planning/selection are best represent walled-off necrosis, definitive characterization and accomplished with imaging. CT Abdomen and Pelvis CT of the abdomen and pelvis with IV contrast is historically the most commonly obtained initial test to evaluate the presence of pancreatic or peripancreatic fluid collections. It is also often used to follow-up symptomatic collections and for intervention planning. However, CT is limited in the quantification of debris and differentiation of pseudocysts from walled-off necrosis.

Acute Pancreatitis. Known pancreatic or peripancreatic fluid collections with continued abdominal pain, early satiety, nausea, vomiting, or signs of infection. Greater than 4 weeks after symptom onset. Local complications in AP include pancreatic or peripancreatic fluid collections. The classification of these fluid collections depends on timing and the presence of necrosis. Acute peripancreatic fluid collections usually develop in the early phase of interstitial edematous pancreatitis and may turn into a pancreatic pseudocyst as a delayed (>4 weeks) complication. A pseudocyst has a well-defined wall and does not contain solid material. In necrotizing pancreatitis, a collection in the early phase is an acute necrotic collection and develops into walled-off necrosis, which is surrounded by a detectible capsule, after 4 weeks [3]. Differentiating walled-off necrosis from pseudocysts that do not contain debris has important implications for management, as residual necrotic debris after drainage may lead to secondary infection. Pseudocysts can be drained by simple percutaneous or endoscopic techniques, as they are composed almost exclusively of fluid. Conversely, walled-off necrosis requires surgical debridement, direct endoscopic necrosectomy, insertion of larger caliber metallic cystgastrostomy stents, or ongoing percutaneous irrigation and drainage of necrotic debris [30]. Although increased clinical severity, particularly persistent organ failure, may suggest that collections likely intervention planning/selection are best represent walled-off necrosis, definitive characterization and accomplished with imaging. CT Abdomen and Pelvis CT of the abdomen and pelvis with IV contrast is historically the most commonly obtained initial test to evaluate the presence of pancreatic or peripancreatic fluid collections. It is also often used to follow-up symptomatic collections and for intervention planning. However, CT is limited in the quantification of debris and differentiation of pseudocysts from walled-off necrosis.

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Acute Pancreatitis

The best indication of debris containing collections on CT is increased frequency of fat density globules within the collections. The absence of fat globules within a collection does not exclude the possibility of necrosis; however, the presence of fat globules suggests a debris- containing, necrotic collection [26]. CT abdomen and pelvis with IV contrast is useful for detection of an infected collection, which has the imaging features of an enhancing wall and gas bubbles within the collection. However, air bubbles may not be seen with an infected collection, and the diagnosis is ultimately made by fine-needle aspiration and fluid analysis. CT abdomen and pelvis with IV contrast may also be helpful in the detection of a fistulous communication between a fluid collection and an adjacent bowel loop. CT abdomen and pelvis without IV contrast can help diagnose the presence of large fluid collections that may be symptomatic and may help in preprocedural planning if percutaneous drainage or cyst gastrostomy is contemplated. Smaller fluid collections may sometimes be difficult to discern between fluid-filled bowel loops on an examination performed without IV contrast. Fluid collections are identifiable on a CT abdomen and pelvis examination performed with IV contrast and adding a noncontrast phase by performing CT abdomen and pelvis without and with IV contrast does not add additional diagnostic information. MRI Abdomen The contents of pancreatic and peripancreatic collections can be most accurately assessed by fluid sensitive MRI sequences on MRI abdomen without IV contrast with MRCP. T2-weighted imaging provides superior soft-tissue differentiation when compared with CT and allows for more consistent quantification of debris. As such, MRI is more useful for predicting whether these collections can be drained by endoscopic, percutaneous, or surgical drainage procedures.

Acute Pancreatitis. The best indication of debris containing collections on CT is increased frequency of fat density globules within the collections. The absence of fat globules within a collection does not exclude the possibility of necrosis; however, the presence of fat globules suggests a debris- containing, necrotic collection [26]. CT abdomen and pelvis with IV contrast is useful for detection of an infected collection, which has the imaging features of an enhancing wall and gas bubbles within the collection. However, air bubbles may not be seen with an infected collection, and the diagnosis is ultimately made by fine-needle aspiration and fluid analysis. CT abdomen and pelvis with IV contrast may also be helpful in the detection of a fistulous communication between a fluid collection and an adjacent bowel loop. CT abdomen and pelvis without IV contrast can help diagnose the presence of large fluid collections that may be symptomatic and may help in preprocedural planning if percutaneous drainage or cyst gastrostomy is contemplated. Smaller fluid collections may sometimes be difficult to discern between fluid-filled bowel loops on an examination performed without IV contrast. Fluid collections are identifiable on a CT abdomen and pelvis examination performed with IV contrast and adding a noncontrast phase by performing CT abdomen and pelvis without and with IV contrast does not add additional diagnostic information. MRI Abdomen The contents of pancreatic and peripancreatic collections can be most accurately assessed by fluid sensitive MRI sequences on MRI abdomen without IV contrast with MRCP. T2-weighted imaging provides superior soft-tissue differentiation when compared with CT and allows for more consistent quantification of debris. As such, MRI is more useful for predicting whether these collections can be drained by endoscopic, percutaneous, or surgical drainage procedures.

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Acute Pancreatitis

Therefore, when imaging is considered for evaluation of symptomatic organized pancreatic or peripancreatic fluid collections, particularly when intervention is contemplated, MRI should be considered in place or as a follow-up to a contrast-enhanced CT [31]. MRI abdomen without and with IV contrast with MRCP is also well suited for evaluation of pancreatic duct disruption, which most commonly occurs as a complication of necrotizing pancreatitis [22]. Necrosis (typically of the central gland) may lead to an isolated, functional, upstream pancreatic segment that is not connected to the Acute Pancreatitis downstream pancreatic duct. Conservative treatment strategies or drainage will most likely fail in the setting of a disconnected pancreatic duct or lead to persistent pancreatic fistula formation; therefore, early diagnosis of this condition leads to reduced morbidity and may mitigate unnecessary drainage procedures. MRI with MRCP provides more definitive evaluation of pancreatic ductal integrity when compared with CT. Visualization of the pancreatic duct may be improved by using a synthetic analog of the hormone secretin, which is sometimes administered to augment the MRCP. Furthermore, although ERCP is considered the gold standard for detection of pancreatic ductal disruption, MRI abdomen without and with IV contrast with MRCP has the advantage of being able to evaluate both the main pancreatic duct and the pancreatic parenchyma simultaneously, as compared with combining CT abdomen and pelvis without and with IV contrast with ERCP. MRI abdomen without and with IV contrast with MRCP also avoids the potential complications associated with ERCP, such as post-ERCP pancreatitis [26,32].

Acute Pancreatitis. Therefore, when imaging is considered for evaluation of symptomatic organized pancreatic or peripancreatic fluid collections, particularly when intervention is contemplated, MRI should be considered in place or as a follow-up to a contrast-enhanced CT [31]. MRI abdomen without and with IV contrast with MRCP is also well suited for evaluation of pancreatic duct disruption, which most commonly occurs as a complication of necrotizing pancreatitis [22]. Necrosis (typically of the central gland) may lead to an isolated, functional, upstream pancreatic segment that is not connected to the Acute Pancreatitis downstream pancreatic duct. Conservative treatment strategies or drainage will most likely fail in the setting of a disconnected pancreatic duct or lead to persistent pancreatic fistula formation; therefore, early diagnosis of this condition leads to reduced morbidity and may mitigate unnecessary drainage procedures. MRI with MRCP provides more definitive evaluation of pancreatic ductal integrity when compared with CT. Visualization of the pancreatic duct may be improved by using a synthetic analog of the hormone secretin, which is sometimes administered to augment the MRCP. Furthermore, although ERCP is considered the gold standard for detection of pancreatic ductal disruption, MRI abdomen without and with IV contrast with MRCP has the advantage of being able to evaluate both the main pancreatic duct and the pancreatic parenchyma simultaneously, as compared with combining CT abdomen and pelvis without and with IV contrast with ERCP. MRI abdomen without and with IV contrast with MRCP also avoids the potential complications associated with ERCP, such as post-ERCP pancreatitis [26,32].

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acrac_3102382_0

Breast Imaging of Pregnant and Lactating Women

Introduction/Background Pregnancy-associated breast cancer (PABC) is defined as breast cancer diagnosed during pregnancy, throughout the first postpartum year, or during lactation [1-4]. With a reported incidence of 1 in 3,000 to 10,000 pregnancies, breast cancer is the most common invasive cancer diagnosed during pregnancy [5-10]. Representing up to 3% of all breast cancer diagnoses, PABC is increasing as more women delay child bearing into the fourth decade of life when the incidence of breast cancer is higher [7,10,11]. Breast imaging during pregnancy and lactation is challenging because of the unique physiologic and structural breast changes that increase the difficulty of clinical and radiological evaluation and the need to balance both maternal and fetal well-being. Throughout pregnancy, there is an increase in the size and number of breast ducts and lobules, an increase in the fluid content of the breast, and involution of stromal adipose tissue [9,12]. After delivery, prolactin stimulates secretory changes and the lobular acini become distended with milk [9,13-15]. These physiologic changes lead to increased breast volume, firmness, and nodularity, thereby making the detection of palpable abnormalities on clinical examination more difficult. As a result, there is often a delay in the diagnosis of PABC, and women typically present with more advanced disease exhibiting larger tumors and a higher likelihood of axillary nodal disease compared to nonpregnant women of the same age [8,16]. There is ongoing controversy as to whether delayed diagnosis and young patient age account for the poor prognosis of PABC, or if there may be additional factors causing increased biologic aggressiveness of gestational breast cancer when matched for age and stage [17-19].

Breast Imaging of Pregnant and Lactating Women. Introduction/Background Pregnancy-associated breast cancer (PABC) is defined as breast cancer diagnosed during pregnancy, throughout the first postpartum year, or during lactation [1-4]. With a reported incidence of 1 in 3,000 to 10,000 pregnancies, breast cancer is the most common invasive cancer diagnosed during pregnancy [5-10]. Representing up to 3% of all breast cancer diagnoses, PABC is increasing as more women delay child bearing into the fourth decade of life when the incidence of breast cancer is higher [7,10,11]. Breast imaging during pregnancy and lactation is challenging because of the unique physiologic and structural breast changes that increase the difficulty of clinical and radiological evaluation and the need to balance both maternal and fetal well-being. Throughout pregnancy, there is an increase in the size and number of breast ducts and lobules, an increase in the fluid content of the breast, and involution of stromal adipose tissue [9,12]. After delivery, prolactin stimulates secretory changes and the lobular acini become distended with milk [9,13-15]. These physiologic changes lead to increased breast volume, firmness, and nodularity, thereby making the detection of palpable abnormalities on clinical examination more difficult. As a result, there is often a delay in the diagnosis of PABC, and women typically present with more advanced disease exhibiting larger tumors and a higher likelihood of axillary nodal disease compared to nonpregnant women of the same age [8,16]. There is ongoing controversy as to whether delayed diagnosis and young patient age account for the poor prognosis of PABC, or if there may be additional factors causing increased biologic aggressiveness of gestational breast cancer when matched for age and stage [17-19].

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acrac_3102382_1

Breast Imaging of Pregnant and Lactating Women

Significant vascular and stromal remodeling is necessary to support the expanded epithelium of pregnancy and lactation, and these changes in the breast microenvironment could potentially be leveraged by breast cancer cells, leading to an increase in biologic aggressiveness [2,18,20]. Despite the long-term decreased risk of breast cancer with pregnancy, there are some data to suggest that there may be a transient increased risk for breast cancer during pregnancy and lactation [6]. Some studies show that women with BRCA gene mutations are overrepresented in PABC, and pregnant and lactating women are more likely to have hormone-negative breast cancer than age-matched controls [7,18,21,22]. Although the underlying cause for these observations is not clear, they support the possibility that the tumor biology of PABC is more aggressive than non-PABC breast cancer in young women with equivalent stage and prognostic factors. The most common presentation of PABC is a palpable mass. Therefore, imaging evaluation of a palpable lesion in a pregnant or lactating woman should not be delayed [7,20,23,24]. Less common presenting complaints include focal pain, diffuse breast enlargement, nipple discharge, and, rarely, unilateral milk rejection in which the infant rejects milk from the breast harboring cancer [7,24]. The imaging appearance of PABC is similar to breast cancer in nonpregnant patients. Because of the young age of these women and higher likelihood of triple negative breast cancer, PABC is more likely to demonstrate areas of necrosis[13,25]. In addition, PABC may have a falsely benign appearance presenting as a mass with relatively circumscribed margins, parallel orientation, and posterior acoustic enhancement [1,7]. aDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. bBeth Israel Deaconess Medical Center, Boston, Massachusetts. cPanel Vice-Chair, NYU Clinical Cancer Center, New York, New York.

Breast Imaging of Pregnant and Lactating Women. Significant vascular and stromal remodeling is necessary to support the expanded epithelium of pregnancy and lactation, and these changes in the breast microenvironment could potentially be leveraged by breast cancer cells, leading to an increase in biologic aggressiveness [2,18,20]. Despite the long-term decreased risk of breast cancer with pregnancy, there are some data to suggest that there may be a transient increased risk for breast cancer during pregnancy and lactation [6]. Some studies show that women with BRCA gene mutations are overrepresented in PABC, and pregnant and lactating women are more likely to have hormone-negative breast cancer than age-matched controls [7,18,21,22]. Although the underlying cause for these observations is not clear, they support the possibility that the tumor biology of PABC is more aggressive than non-PABC breast cancer in young women with equivalent stage and prognostic factors. The most common presentation of PABC is a palpable mass. Therefore, imaging evaluation of a palpable lesion in a pregnant or lactating woman should not be delayed [7,20,23,24]. Less common presenting complaints include focal pain, diffuse breast enlargement, nipple discharge, and, rarely, unilateral milk rejection in which the infant rejects milk from the breast harboring cancer [7,24]. The imaging appearance of PABC is similar to breast cancer in nonpregnant patients. Because of the young age of these women and higher likelihood of triple negative breast cancer, PABC is more likely to demonstrate areas of necrosis[13,25]. In addition, PABC may have a falsely benign appearance presenting as a mass with relatively circumscribed margins, parallel orientation, and posterior acoustic enhancement [1,7]. aDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. bBeth Israel Deaconess Medical Center, Boston, Massachusetts. cPanel Vice-Chair, NYU Clinical Cancer Center, New York, New York.

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Breast Imaging of Pregnant and Lactating Women

dRoper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons. eNorthwestern University Feinberg School of Medicine, Chicago, Illinois; American College of Physicians. fNew York University School of Medicine, New York, New York. gEmory University Hospital, Atlanta, Georgia. hNew York University School of Medicine, New York, New York. iAlpert Medical School of Brown University, Providence, Rhode Island. jBeth Israel Deaconess Medical Center, Boston, Massachusetts. kH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. lWomen and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists. mMecklenburg Radiology Associates, Charlotte, North Carolina. nDonald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York. oPerelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania. pPanel Chair, Emory University Hospital, Atlanta, Georgia. 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] Breast Imaging of Pregnant and Lactating Women Although PABC most commonly presents as a palpable mass, greater than 80% of palpable masses that are biopsied in pregnant and breastfeeding women are benign [10,25]. Benign palpable masses may be due to enlargement of pre-existing benign masses, such as fibroadenomas and hamartomas, or they may represent masses unique to pregnancy and lactation, such as lactating adenomas and galactoceles [9,13].

Breast Imaging of Pregnant and Lactating Women. dRoper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons. eNorthwestern University Feinberg School of Medicine, Chicago, Illinois; American College of Physicians. fNew York University School of Medicine, New York, New York. gEmory University Hospital, Atlanta, Georgia. hNew York University School of Medicine, New York, New York. iAlpert Medical School of Brown University, Providence, Rhode Island. jBeth Israel Deaconess Medical Center, Boston, Massachusetts. kH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. lWomen and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists. mMecklenburg Radiology Associates, Charlotte, North Carolina. nDonald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York. oPerelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania. pPanel Chair, Emory University Hospital, Atlanta, Georgia. 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] Breast Imaging of Pregnant and Lactating Women Although PABC most commonly presents as a palpable mass, greater than 80% of palpable masses that are biopsied in pregnant and breastfeeding women are benign [10,25]. Benign palpable masses may be due to enlargement of pre-existing benign masses, such as fibroadenomas and hamartomas, or they may represent masses unique to pregnancy and lactation, such as lactating adenomas and galactoceles [9,13].

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acrac_3102382_3

Breast Imaging of Pregnant and Lactating Women

When pre-existing lesions enlarge because of hormonal stimulation, they may appear atypical secondary to infarction or proliferative and lactational changes within the lesion [9,10,13]. These changes may lead to concerning imaging features and warrant further evaluation with biopsy. Some benign palpable masses are definitively benign on imaging evaluation (ie, cysts), whereas other masses may have benign imaging characteristics that allow for close follow- up. Given the challenge of clinical examination in pregnant and lactating patients, diagnostic breast imaging, particularly breast ultrasound (US), plays a crucial role in characterizing the features of palpable lesions and in determining appropriate management. US has the highest sensitivity for the diagnosis of PABC [24-28]. Furthermore, because of the predominantly young patient age and the decreased sensitivity of mammography in the setting of dense breast tissue, breast US is the first-line imaging examination in pregnant and lactating patients. If breast US is negative, or if there are suspicious sonographic findings, additional imaging with mammography or digital breast tomosynthesis (DBT) may be indicated. There is a limited role for advanced breast imaging techniques in pregnant women. The ACR does not recommend the intravenous (IV) administration of gadolinium during pregnancy [33]. The physiologic increased breast vascularity of pregnancy and lactation may limit the sensitivity of dynamic contrast-enhanced (DCE) breast MRI [12,33-35]. Biopsy should be recommended for any suspicious imaging findings, and patients should be informed regarding the possibility of milk fistula and increased risk of bleeding. Discussion of Procedures by Variant Variant 1: Breast cancer screening during lactation. Initial imaging. There is limited evidence on breast cancer screening in lactating women.

Breast Imaging of Pregnant and Lactating Women. When pre-existing lesions enlarge because of hormonal stimulation, they may appear atypical secondary to infarction or proliferative and lactational changes within the lesion [9,10,13]. These changes may lead to concerning imaging features and warrant further evaluation with biopsy. Some benign palpable masses are definitively benign on imaging evaluation (ie, cysts), whereas other masses may have benign imaging characteristics that allow for close follow- up. Given the challenge of clinical examination in pregnant and lactating patients, diagnostic breast imaging, particularly breast ultrasound (US), plays a crucial role in characterizing the features of palpable lesions and in determining appropriate management. US has the highest sensitivity for the diagnosis of PABC [24-28]. Furthermore, because of the predominantly young patient age and the decreased sensitivity of mammography in the setting of dense breast tissue, breast US is the first-line imaging examination in pregnant and lactating patients. If breast US is negative, or if there are suspicious sonographic findings, additional imaging with mammography or digital breast tomosynthesis (DBT) may be indicated. There is a limited role for advanced breast imaging techniques in pregnant women. The ACR does not recommend the intravenous (IV) administration of gadolinium during pregnancy [33]. The physiologic increased breast vascularity of pregnancy and lactation may limit the sensitivity of dynamic contrast-enhanced (DCE) breast MRI [12,33-35]. Biopsy should be recommended for any suspicious imaging findings, and patients should be informed regarding the possibility of milk fistula and increased risk of bleeding. Discussion of Procedures by Variant Variant 1: Breast cancer screening during lactation. Initial imaging. There is limited evidence on breast cancer screening in lactating women.

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acrac_3102382_4

Breast Imaging of Pregnant and Lactating Women

Because of the potential increased risk of breast cancer in this population, consider continued screening during lactation dependent upon the level of underlying risk and the expected duration of lactation. Breast Imaging of Pregnant and Lactating Women There are no studies specifically evaluating DBT in this patient population. The increased breast density seen in younger women and in the hormonally altered breasts of lactating women is more likely to mask small lesions. Therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue. US Breast There are no studies specifically evaluating hand-held or automated whole-breast US screening in women who are breastfeeding. Given the increased mammographic density during lactation, screening US could be considered as a supplemental screening option in lactating women at intermediate and high risk for breast cancer. It is, however, important to keep in mind that screening US may increase the false-positive rate and prompt additional biopsies with small additional risk of milk fistula in lactating women [39,40]. MRI Breast The physiologic increased vascularity of lactation causes a marked increase in background parenchymal enhancement on breast DCE-MRI. Although this may limit the sensitivity for detecting small enhancing masses and nonmass enhancement, studies have shown that breast DCE-MRI can differentiate enhancing breast cancer from background parenchymal enhancement based on kinetics and morphology [19,34,35,38,41]. A study of 53 patients with known PABC demonstrated moderate or marked background parenchymal enhancement in 58% of patients. Despite increased background parenchymal enhancement, there was 98% sensitivity for detection of known PABC; however, it is unknown how many women were lactating at the time of the MRI [19]. There are scant data on MRI screening in lactating women.

Breast Imaging of Pregnant and Lactating Women. Because of the potential increased risk of breast cancer in this population, consider continued screening during lactation dependent upon the level of underlying risk and the expected duration of lactation. Breast Imaging of Pregnant and Lactating Women There are no studies specifically evaluating DBT in this patient population. The increased breast density seen in younger women and in the hormonally altered breasts of lactating women is more likely to mask small lesions. Therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue. US Breast There are no studies specifically evaluating hand-held or automated whole-breast US screening in women who are breastfeeding. Given the increased mammographic density during lactation, screening US could be considered as a supplemental screening option in lactating women at intermediate and high risk for breast cancer. It is, however, important to keep in mind that screening US may increase the false-positive rate and prompt additional biopsies with small additional risk of milk fistula in lactating women [39,40]. MRI Breast The physiologic increased vascularity of lactation causes a marked increase in background parenchymal enhancement on breast DCE-MRI. Although this may limit the sensitivity for detecting small enhancing masses and nonmass enhancement, studies have shown that breast DCE-MRI can differentiate enhancing breast cancer from background parenchymal enhancement based on kinetics and morphology [19,34,35,38,41]. A study of 53 patients with known PABC demonstrated moderate or marked background parenchymal enhancement in 58% of patients. Despite increased background parenchymal enhancement, there was 98% sensitivity for detection of known PABC; however, it is unknown how many women were lactating at the time of the MRI [19]. There are scant data on MRI screening in lactating women.

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Breast Imaging of Pregnant and Lactating Women

In one study, 4 breast cancers in 3 patients were detected on high-risk screening MRI [7]. It may be helpful to wait until 3 months after cessation of breastfeeding. However, if a woman plans to nurse for a long period, or is at very high risk for breast cancer, screening breast MRI during lactation may be considered [10]. The amount of gadolinium excreted in human breast milk over the first 24 hours after IV contrast administration is <1% of the permitted dose for neonates [42]. Up-to-date recommendations with regard to breastfeeding following IV administration of gadolinium are outlined in detail in the ACR Manual on Contrast Media [33]. Therefore, although not the initial imaging tool of choice, screening breast MRI is not contraindicated during lactation and may be considered in lactating women with a high lifetime risk of breast cancer. An informed decision should be made by the mother regarding continuation of breastfeeding after the examination [3,33,42]. Sestamibi MBI There is no role for molecular breast imaging (MBI) in breast cancer screening during lactation. Mammography and DBT Screening mammography can be performed in pregnant women at high risk. Mammography is not contraindicated during pregnancy, and the dose to the fetus is negligible. The fetal radiation dose from a 4-view mammogram is <0.03 mGy. No teratogenic effects have been demonstrated below 50 mGy [43]. Screening mammography is not recommended for pregnant women who are at average or intermediate risk for breast cancer. However, in women who have a high risk of breast cancer, mammographic screening should be considered. There are no studies specifically evaluating DBT in this patient population. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small lesions. Therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue.

Breast Imaging of Pregnant and Lactating Women. In one study, 4 breast cancers in 3 patients were detected on high-risk screening MRI [7]. It may be helpful to wait until 3 months after cessation of breastfeeding. However, if a woman plans to nurse for a long period, or is at very high risk for breast cancer, screening breast MRI during lactation may be considered [10]. The amount of gadolinium excreted in human breast milk over the first 24 hours after IV contrast administration is <1% of the permitted dose for neonates [42]. Up-to-date recommendations with regard to breastfeeding following IV administration of gadolinium are outlined in detail in the ACR Manual on Contrast Media [33]. Therefore, although not the initial imaging tool of choice, screening breast MRI is not contraindicated during lactation and may be considered in lactating women with a high lifetime risk of breast cancer. An informed decision should be made by the mother regarding continuation of breastfeeding after the examination [3,33,42]. Sestamibi MBI There is no role for molecular breast imaging (MBI) in breast cancer screening during lactation. Mammography and DBT Screening mammography can be performed in pregnant women at high risk. Mammography is not contraindicated during pregnancy, and the dose to the fetus is negligible. The fetal radiation dose from a 4-view mammogram is <0.03 mGy. No teratogenic effects have been demonstrated below 50 mGy [43]. Screening mammography is not recommended for pregnant women who are at average or intermediate risk for breast cancer. However, in women who have a high risk of breast cancer, mammographic screening should be considered. There are no studies specifically evaluating DBT in this patient population. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small lesions. Therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue.

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acrac_3102382_6

Breast Imaging of Pregnant and Lactating Women

Ductal and lobular hyperplasia, combined with increased water content and decreased stromal fat, may increase mammographic density throughout pregnancy. A small study has shown that the anticipated changes in breast density are less pronounced during pregnancy than during lactation, and that most pregnant patients had scattered or heterogeneously dense fibroglandular tissue [44]. Many studies have shown that mammograms may be diagnostic in 74% to 100% of gravid pregnant women [7,24-28]. With current digital techniques and increased Breast Imaging of Pregnant and Lactating Women use of DBT, the ability to detect breast cancer with mammography in pregnant patients may improve. There are several studies that report screen-detected PABC in a small number of patients [7,24]. US Breast Throughout pregnancy, there is progressive ductal and lobular hyperplasia as well as increased duct ectasia. These changes lead to prominent hypoechoic ducts and lobules with diffuse decreased breast echogenicity [9,10]. There are no studies available at this time evaluating the use of screening whole-breast US during pregnancy. Despite the physiologic changes that alter the sonographic appearance of the breasts during pregnancy, screening whole- breast US may be used as a supplemental screening modality in pregnant women younger than 30 at high risk for breast cancer. It is, however, important to keep in mind that screening US may increase the false-positive rate and prompt additional biopsies. MRI Breast It is well-established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33].

Breast Imaging of Pregnant and Lactating Women. Ductal and lobular hyperplasia, combined with increased water content and decreased stromal fat, may increase mammographic density throughout pregnancy. A small study has shown that the anticipated changes in breast density are less pronounced during pregnancy than during lactation, and that most pregnant patients had scattered or heterogeneously dense fibroglandular tissue [44]. Many studies have shown that mammograms may be diagnostic in 74% to 100% of gravid pregnant women [7,24-28]. With current digital techniques and increased Breast Imaging of Pregnant and Lactating Women use of DBT, the ability to detect breast cancer with mammography in pregnant patients may improve. There are several studies that report screen-detected PABC in a small number of patients [7,24]. US Breast Throughout pregnancy, there is progressive ductal and lobular hyperplasia as well as increased duct ectasia. These changes lead to prominent hypoechoic ducts and lobules with diffuse decreased breast echogenicity [9,10]. There are no studies available at this time evaluating the use of screening whole-breast US during pregnancy. Despite the physiologic changes that alter the sonographic appearance of the breasts during pregnancy, screening whole- breast US may be used as a supplemental screening modality in pregnant women younger than 30 at high risk for breast cancer. It is, however, important to keep in mind that screening US may increase the false-positive rate and prompt additional biopsies. MRI Breast It is well-established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33].

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Breast Imaging of Pregnant and Lactating Women

Because of the concerns regarding gadolinium crossing the placenta and limited data regarding its safety in this setting, screening breast DCE-MRI is not recommended in pregnant women with any breast cancer risk profile. Sestamibi MBI There is no role for MBI in breast cancer screening during pregnancy. Mammography and DBT Mammography is not contraindicated during pregnancy. The fetal radiation dose from a 4-view mammogram is <0.03 mGy. No teratogenic effects have been demonstrated below 50 mGy [43]. There are no studies specifically evaluating DBT in this patient population. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small lesions. Therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue. Ductal and lobular hyperplasia, combined with increased water content and decreased stromal fat, may increase mammographic density throughout pregnancy. A small study has shown that the anticipated changes in breast density are less pronounced during pregnancy than during lactation, and that most pregnant patients had scattered or heterogeneously dense fibroglandular tissue [44]. Many studies have shown that mammograms may be diagnostic in 74% to 100% of pregnant women [7,24-28]. With current digital techniques and increased use of DBT, the ability to detect breast cancer with mammography in pregnant patients may improve. There are several studies that report screen-detected PABC in a small number of patients [7,24]. US Breast Throughout pregnancy, there is progressive ductal and lobular hyperplasia as well as increased duct ectasia. These changes lead to prominent hypoechoic ducts and lobules with diffuse decreased breast echogenicity [9,10]. There are no studies available at this time evaluating the use of screening whole-breast US during pregnancy.

Breast Imaging of Pregnant and Lactating Women. Because of the concerns regarding gadolinium crossing the placenta and limited data regarding its safety in this setting, screening breast DCE-MRI is not recommended in pregnant women with any breast cancer risk profile. Sestamibi MBI There is no role for MBI in breast cancer screening during pregnancy. Mammography and DBT Mammography is not contraindicated during pregnancy. The fetal radiation dose from a 4-view mammogram is <0.03 mGy. No teratogenic effects have been demonstrated below 50 mGy [43]. There are no studies specifically evaluating DBT in this patient population. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small lesions. Therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue. Ductal and lobular hyperplasia, combined with increased water content and decreased stromal fat, may increase mammographic density throughout pregnancy. A small study has shown that the anticipated changes in breast density are less pronounced during pregnancy than during lactation, and that most pregnant patients had scattered or heterogeneously dense fibroglandular tissue [44]. Many studies have shown that mammograms may be diagnostic in 74% to 100% of pregnant women [7,24-28]. With current digital techniques and increased use of DBT, the ability to detect breast cancer with mammography in pregnant patients may improve. There are several studies that report screen-detected PABC in a small number of patients [7,24]. US Breast Throughout pregnancy, there is progressive ductal and lobular hyperplasia as well as increased duct ectasia. These changes lead to prominent hypoechoic ducts and lobules with diffuse decreased breast echogenicity [9,10]. There are no studies available at this time evaluating the use of screening whole-breast US during pregnancy.

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Breast Imaging of Pregnant and Lactating Women

Despite the physiologic changes that alter the sonographic appearance of the breasts during pregnancy, screening whole- breast US may be used as a supplemental screening modality in pregnant women between 30 and 39 years of age with a high risk of breast cancer. It is, however, important to keep in mind that screening US may increase the false-positive rate and prompt additional biopsies. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the Breast Imaging of Pregnant and Lactating Women dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33]. Because of the concerns regarding gadolinium crossing the placenta and limited data regarding its safety in this setting, screening breast DCE-MRI is not recommended in pregnant women with any breast cancer risk profile. Sestamibi MBI There is no role for MBI in breast cancer screening during pregnancy. Mammography and DBT Mammography is not contraindicated during pregnancy. The fetal radiation dose from a 4-view mammogram is <0.03 mGy. No teratogenic effects have been demonstrated below 50 mGy [43]. There are no studies specifically evaluating DBT in this patient population. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small lesions. Therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue. Ductal and lobular hyperplasia, combined with increased water content and decreased stromal fat, may increase mammographic density throughout pregnancy.

Breast Imaging of Pregnant and Lactating Women. Despite the physiologic changes that alter the sonographic appearance of the breasts during pregnancy, screening whole- breast US may be used as a supplemental screening modality in pregnant women between 30 and 39 years of age with a high risk of breast cancer. It is, however, important to keep in mind that screening US may increase the false-positive rate and prompt additional biopsies. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the Breast Imaging of Pregnant and Lactating Women dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33]. Because of the concerns regarding gadolinium crossing the placenta and limited data regarding its safety in this setting, screening breast DCE-MRI is not recommended in pregnant women with any breast cancer risk profile. Sestamibi MBI There is no role for MBI in breast cancer screening during pregnancy. Mammography and DBT Mammography is not contraindicated during pregnancy. The fetal radiation dose from a 4-view mammogram is <0.03 mGy. No teratogenic effects have been demonstrated below 50 mGy [43]. There are no studies specifically evaluating DBT in this patient population. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small lesions. Therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue. Ductal and lobular hyperplasia, combined with increased water content and decreased stromal fat, may increase mammographic density throughout pregnancy.

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Breast Imaging of Pregnant and Lactating Women

A small study has shown that the anticipated changes in breast density are less pronounced during pregnancy than during lactation, and that most pregnant patients had scattered or heterogeneously dense fibroglandular tissue [44]. Many studies have shown that mammograms may be diagnostic in 74% to 100% of pregnant women [7,24-28]. With current digital techniques and increased use of DBT, the ability to detect breast cancer with mammography in pregnant patients may improve. There are several studies that report screen-detected PABC in a small number of patients [7,24]. US Breast Throughout pregnancy, there is progressive ductal and lobular hyperplasia as well as increased duct ectasia. These changes lead to prominent hypoechoic ducts and lobules with diffuse decreased breast echogenicity [9,10]. There are no studies available at this time evaluating the use of screening whole-breast US during pregnancy. Despite physiologic changes that alter the sonographic appearance of the breasts during pregnancy, screening whole- breast US may be used as a supplemental screening modality in pregnant women 40 and older, especially those at elevated risk. It is, however, important to keep in mind that screening US may increase the false-positive rate and prompt additional biopsies. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33]. Because of the concerns regarding gadolinium crossing the placenta and limited data regarding its safety in this setting, screening breast DCE-MRI is not recommended in pregnant women with any breast cancer risk profile.

Breast Imaging of Pregnant and Lactating Women. A small study has shown that the anticipated changes in breast density are less pronounced during pregnancy than during lactation, and that most pregnant patients had scattered or heterogeneously dense fibroglandular tissue [44]. Many studies have shown that mammograms may be diagnostic in 74% to 100% of pregnant women [7,24-28]. With current digital techniques and increased use of DBT, the ability to detect breast cancer with mammography in pregnant patients may improve. There are several studies that report screen-detected PABC in a small number of patients [7,24]. US Breast Throughout pregnancy, there is progressive ductal and lobular hyperplasia as well as increased duct ectasia. These changes lead to prominent hypoechoic ducts and lobules with diffuse decreased breast echogenicity [9,10]. There are no studies available at this time evaluating the use of screening whole-breast US during pregnancy. Despite physiologic changes that alter the sonographic appearance of the breasts during pregnancy, screening whole- breast US may be used as a supplemental screening modality in pregnant women 40 and older, especially those at elevated risk. It is, however, important to keep in mind that screening US may increase the false-positive rate and prompt additional biopsies. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33]. Because of the concerns regarding gadolinium crossing the placenta and limited data regarding its safety in this setting, screening breast DCE-MRI is not recommended in pregnant women with any breast cancer risk profile.

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Breast Imaging of Pregnant and Lactating Women

Sestamibi MBI There is no role for MBI in breast cancer screening during pregnancy. Variant 5: Pregnant women with a palpable breast mass. Initial imaging. The most common presentation of PABC is a palpable mass. Therefore imaging evaluation of a palpable lesion in a pregnant or lactating woman should not be delayed [7,20,23,24]. Given the challenge of clinical examination in pregnant and lactating patients, diagnostic breast imaging, particularly breast US, plays a crucial role in characterizing the features of palpable lesions and in determining appropriate management. US has the highest sensitivity for the diagnosis of PABC [24-28]. Furthermore, due to the predominantly young patient age and the decreased sensitivity of mammography in the setting of dense breast tissue, breast US is the first-line imaging examination in pregnant and lactating patients. If breast US is negative, or if there are suspicious sonographic findings, additional imaging with mammography or DBT may be indicated. Breast Imaging of Pregnant and Lactating Women Mammography and DBT Mammography has slightly decreased sensitivity compared to breast sonography in this clinical setting, ranging from 74% to 90% [7,24-27] in most studies. One recent study has reported 100% sensitivity of mammography that may in part be explained by use of full-field digital technique rather than film screen mammography [28]. The advanced stage of PABC may also contribute to the moderate sensitivity of diagnostic mammography given the physiologic increased breast density in these patients that may compromise mammography. Therefore, although diagnostic mammography is not recommended as the initial examination in patients with a palpable mass, there is a role for diagnostic mammography as an adjunct to US. If US does not show an etiology for the palpable mass, diagnostic mammography should be done to look for malignant calcifications or architectural distortion.

Breast Imaging of Pregnant and Lactating Women. Sestamibi MBI There is no role for MBI in breast cancer screening during pregnancy. Variant 5: Pregnant women with a palpable breast mass. Initial imaging. The most common presentation of PABC is a palpable mass. Therefore imaging evaluation of a palpable lesion in a pregnant or lactating woman should not be delayed [7,20,23,24]. Given the challenge of clinical examination in pregnant and lactating patients, diagnostic breast imaging, particularly breast US, plays a crucial role in characterizing the features of palpable lesions and in determining appropriate management. US has the highest sensitivity for the diagnosis of PABC [24-28]. Furthermore, due to the predominantly young patient age and the decreased sensitivity of mammography in the setting of dense breast tissue, breast US is the first-line imaging examination in pregnant and lactating patients. If breast US is negative, or if there are suspicious sonographic findings, additional imaging with mammography or DBT may be indicated. Breast Imaging of Pregnant and Lactating Women Mammography and DBT Mammography has slightly decreased sensitivity compared to breast sonography in this clinical setting, ranging from 74% to 90% [7,24-27] in most studies. One recent study has reported 100% sensitivity of mammography that may in part be explained by use of full-field digital technique rather than film screen mammography [28]. The advanced stage of PABC may also contribute to the moderate sensitivity of diagnostic mammography given the physiologic increased breast density in these patients that may compromise mammography. Therefore, although diagnostic mammography is not recommended as the initial examination in patients with a palpable mass, there is a role for diagnostic mammography as an adjunct to US. If US does not show an etiology for the palpable mass, diagnostic mammography should be done to look for malignant calcifications or architectural distortion.

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Breast Imaging of Pregnant and Lactating Women

If a suspicious finding is seen by US, mammography is also recommended to evaluate for additional suspicious findings, particularly microcalcifications that may be occult by US. Mammography is not contraindicated during pregnancy, and the dose to the fetus is negligible. The fetal radiation dose from a 4-view mammogram is <0.03 mGy, and no teratogenic effects have been demonstrated below 50 mGy [43]. There are no studies specifically evaluating DBT in this patient population. DBT may improve visualization of breast masses in pregnant women. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small lesions; therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue. US Breast PABC most commonly presents as a palpable mass, and breast US is recommended as the first-line imaging modality in pregnant and lactating women regardless of age [9,10,23,25,26,36]. Breast US can define benign etiologies for palpable masses that require no further evaluation, such as simple cysts or galactoceles. Breast US has the highest sensitivity for diagnosis of PABC in the setting of a palpable mass with 100% sensitivity reported in many studies [24-28,45,46]. Several authors have cautioned that PABC may have benign features, including parallel orientation, circumscribed margins, and posterior acoustic enhancement [7,24,26]. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33].

Breast Imaging of Pregnant and Lactating Women. If a suspicious finding is seen by US, mammography is also recommended to evaluate for additional suspicious findings, particularly microcalcifications that may be occult by US. Mammography is not contraindicated during pregnancy, and the dose to the fetus is negligible. The fetal radiation dose from a 4-view mammogram is <0.03 mGy, and no teratogenic effects have been demonstrated below 50 mGy [43]. There are no studies specifically evaluating DBT in this patient population. DBT may improve visualization of breast masses in pregnant women. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small lesions; therefore, this population may benefit from the ability of 3-D mammography to decrease the masking effect of dense breast tissue. US Breast PABC most commonly presents as a palpable mass, and breast US is recommended as the first-line imaging modality in pregnant and lactating women regardless of age [9,10,23,25,26,36]. Breast US can define benign etiologies for palpable masses that require no further evaluation, such as simple cysts or galactoceles. Breast US has the highest sensitivity for diagnosis of PABC in the setting of a palpable mass with 100% sensitivity reported in many studies [24-28,45,46]. Several authors have cautioned that PABC may have benign features, including parallel orientation, circumscribed margins, and posterior acoustic enhancement [7,24,26]. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33].

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Breast Imaging of Pregnant and Lactating Women

There is no role for MRI as the initial imaging evaluation in the diagnostic workup of palpable lumps in pregnant patients. Sestamibi MBI There is no role for MBI as the initial imaging evaluation in the diagnostic workup of palpable lumps in pregnant patients. Variant 6: Clinically suspicious nipple discharge during pregnancy. Initial imaging. Isolated bloody nipple discharge without associated palpable mass may occur in up to 20% of pregnant women and is most commonly due to benign causes. The proliferative epithelial changes and associated increased breast Breast Imaging of Pregnant and Lactating Women Mammography and DBT There is wide variation in degree of mammographic density during pregnancy, and many studies have shown that mammograms have a sensitivity of 74% to 100% in the diagnostic setting [25,28]. This is particularly true for the detection of suspicious calcifications that may be detected despite mammographically dense breast tissue and that may be sonographically occult [7,24]. Mammography is not contraindicated during pregnancy, and the dose to the fetus is negligible. The fetal radiation dose from a 4-view mammogram is <0.03 mGy, and no teratogenic effects have been demonstrated below 50 mGy [43]. Diagnostic mammograms with retroareolar magnification views may be of benefit as the initial examination in pregnant women with persistent nipple discharge or as an adjunct to diagnostic breast US. US Breast Although there are no studies specifically evaluating diagnostic US for nipple discharge in pregnant women, retroareolar sonographic evaluation should be the first-line imaging examination to look for papilloma or other breast masses as the cause of pathologic nipple discharge regardless of patient age. The peripheral compression technique, 2-handed compression technique, and the rolled nipple technique described by Stavros may increase the ability of breast US to detect the cause for bloody nipple discharge [47].

Breast Imaging of Pregnant and Lactating Women. There is no role for MRI as the initial imaging evaluation in the diagnostic workup of palpable lumps in pregnant patients. Sestamibi MBI There is no role for MBI as the initial imaging evaluation in the diagnostic workup of palpable lumps in pregnant patients. Variant 6: Clinically suspicious nipple discharge during pregnancy. Initial imaging. Isolated bloody nipple discharge without associated palpable mass may occur in up to 20% of pregnant women and is most commonly due to benign causes. The proliferative epithelial changes and associated increased breast Breast Imaging of Pregnant and Lactating Women Mammography and DBT There is wide variation in degree of mammographic density during pregnancy, and many studies have shown that mammograms have a sensitivity of 74% to 100% in the diagnostic setting [25,28]. This is particularly true for the detection of suspicious calcifications that may be detected despite mammographically dense breast tissue and that may be sonographically occult [7,24]. Mammography is not contraindicated during pregnancy, and the dose to the fetus is negligible. The fetal radiation dose from a 4-view mammogram is <0.03 mGy, and no teratogenic effects have been demonstrated below 50 mGy [43]. Diagnostic mammograms with retroareolar magnification views may be of benefit as the initial examination in pregnant women with persistent nipple discharge or as an adjunct to diagnostic breast US. US Breast Although there are no studies specifically evaluating diagnostic US for nipple discharge in pregnant women, retroareolar sonographic evaluation should be the first-line imaging examination to look for papilloma or other breast masses as the cause of pathologic nipple discharge regardless of patient age. The peripheral compression technique, 2-handed compression technique, and the rolled nipple technique described by Stavros may increase the ability of breast US to detect the cause for bloody nipple discharge [47].

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Breast Imaging of Pregnant and Lactating Women

MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33]. There is no role for MRI as the initial imaging evaluation in nipple discharge during pregnancy. Sestamibi MBI There is no role for MBI as the initial imaging evaluation in nipple discharge during pregnancy. Variant 7: Locoregional staging of newly diagnosed breast cancer during pregnancy. Initial imaging. Chemotherapy may be used to treat breast cancer after the first trimester of pregnancy [21,48]. Accurate staging is therefore important in order to determine optimal therapy while limiting harm to the fetus. The risk-to-benefit ratio will vary from patient to patient depending on many factors, including gestational age at the time of diagnosis and personal perspectives regarding pregnancy interruption. Locoregional staging is obtained to identify primary tumor size, regional node status, extent of disease, and additional foci of malignancy in the ipsilateral or contralateral breast. This information optimizes definitive local treatment and is used to determine the need for systemic staging to evaluate for distant metastases. Locoregional staging in pregnant patients is discussed below. However, decisions regarding systemic breast cancer staging in pregnant women are best addressed via patient- centered multidisciplinary tumor boards in order to provide specialized care in this complex clinical scenario [11,49]. Mammography and DBT Mammography is not contraindicated during pregnancy, and the dose to the fetus is negligible.

Breast Imaging of Pregnant and Lactating Women. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33]. There is no role for MRI as the initial imaging evaluation in nipple discharge during pregnancy. Sestamibi MBI There is no role for MBI as the initial imaging evaluation in nipple discharge during pregnancy. Variant 7: Locoregional staging of newly diagnosed breast cancer during pregnancy. Initial imaging. Chemotherapy may be used to treat breast cancer after the first trimester of pregnancy [21,48]. Accurate staging is therefore important in order to determine optimal therapy while limiting harm to the fetus. The risk-to-benefit ratio will vary from patient to patient depending on many factors, including gestational age at the time of diagnosis and personal perspectives regarding pregnancy interruption. Locoregional staging is obtained to identify primary tumor size, regional node status, extent of disease, and additional foci of malignancy in the ipsilateral or contralateral breast. This information optimizes definitive local treatment and is used to determine the need for systemic staging to evaluate for distant metastases. Locoregional staging in pregnant patients is discussed below. However, decisions regarding systemic breast cancer staging in pregnant women are best addressed via patient- centered multidisciplinary tumor boards in order to provide specialized care in this complex clinical scenario [11,49]. Mammography and DBT Mammography is not contraindicated during pregnancy, and the dose to the fetus is negligible.

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Breast Imaging of Pregnant and Lactating Women

The fetal radiation dose from a 4-view mammogram is <0.03 mGy, and no teratogenic effects have been demonstrated below 50 mGy [43]. Complete mammographic evaluation is recommended as a component of locoregional staging in pregnant women with newly diagnosed breast cancer. Microcalcifications due to ductal carcinoma in situ adjacent to the index cancer may not be seen by US. Therefore, mammography is recommended for evaluating extent of disease. Multifocal or multicentric disease presenting as microcalcifications due to sonographically occult ductal carcinoma in situ may similarly be identified with adjunctive mammographic breast cancer staging. These findings would affect surgical management and aid in obtaining clear margins and improved patient outcomes. Breast Imaging of Pregnant and Lactating Women There are no studies specifically evaluating DBT during pregnancy. DBT may improve visualization of breast masses in pregnant women. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small masses because of the masking effect of dense breast tissue. US Breast Whole-breast US, including US of the nodal basins, is a staging modality with no known adverse effects on the fetus. In a single study by Yang et al [50], preoperative breast US was performed in 23 pregnant patients for the purpose of evaluating response to neoadjuvant chemotherapy during pregnancy. In this small study, 15 of 18 axillary metastases were correctly diagnosed with sonographic staging of the axilla, and all breast masses were identified by breast US. Whole-breast US staging has been evaluated in nonpregnant patients with reported incremental cancer detection rates similar to those of staging breast MRI [51]. Several additional studies in nonpregnant women support the use of whole-breast US staging [25,52,53].

Breast Imaging of Pregnant and Lactating Women. The fetal radiation dose from a 4-view mammogram is <0.03 mGy, and no teratogenic effects have been demonstrated below 50 mGy [43]. Complete mammographic evaluation is recommended as a component of locoregional staging in pregnant women with newly diagnosed breast cancer. Microcalcifications due to ductal carcinoma in situ adjacent to the index cancer may not be seen by US. Therefore, mammography is recommended for evaluating extent of disease. Multifocal or multicentric disease presenting as microcalcifications due to sonographically occult ductal carcinoma in situ may similarly be identified with adjunctive mammographic breast cancer staging. These findings would affect surgical management and aid in obtaining clear margins and improved patient outcomes. Breast Imaging of Pregnant and Lactating Women There are no studies specifically evaluating DBT during pregnancy. DBT may improve visualization of breast masses in pregnant women. The increased breast density seen in younger women and in the hormonally altered breast of pregnant women is more likely to conceal small masses because of the masking effect of dense breast tissue. US Breast Whole-breast US, including US of the nodal basins, is a staging modality with no known adverse effects on the fetus. In a single study by Yang et al [50], preoperative breast US was performed in 23 pregnant patients for the purpose of evaluating response to neoadjuvant chemotherapy during pregnancy. In this small study, 15 of 18 axillary metastases were correctly diagnosed with sonographic staging of the axilla, and all breast masses were identified by breast US. Whole-breast US staging has been evaluated in nonpregnant patients with reported incremental cancer detection rates similar to those of staging breast MRI [51]. Several additional studies in nonpregnant women support the use of whole-breast US staging [25,52,53].

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Breast Imaging of Pregnant and Lactating Women

However, these studies were performed by breast radiologists with extensive experience in sonographic locoregional staging of breast cancer, and it is not clear to what degree these results would be reproducible in other centers. Therefore, although staging of the axilla via US is recommended, there is no evidence to support whole-breast US for locoregional staging in pregnant patients at this time. US Axilla Sonographic evaluation of the axilla is often performed to stage pregnant patients who are diagnosed with breast cancer. In a study of 23 pregnant patients undergoing neoadjuvant chemotherapy for newly diagnosed breast cancer, 15 of 18 axillary metastases were correctly diagnosed by sonographic evaluation of the axilla [50]. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33]. Because of the concerns regarding gadolinium crossing the placenta and limited data regarding its safety in this setting, breast DCE-MRI is therefore not recommended in pregnant women. However, immediately following delivery or pregnancy termination, breast MRI is recommended for locoregional staging. A small series evaluating PABC on breast MRI showed that 23% of patients had pathologically proven greater extent of disease than was identified with mammography and breast US. This study showed variable background parenchymal enhancement with 58% of patients demonstrating moderate or marked enhancement. Despite increased background parenchymal enhancement, this study showed 98% sensitivity for PABC [19].

Breast Imaging of Pregnant and Lactating Women. However, these studies were performed by breast radiologists with extensive experience in sonographic locoregional staging of breast cancer, and it is not clear to what degree these results would be reproducible in other centers. Therefore, although staging of the axilla via US is recommended, there is no evidence to support whole-breast US for locoregional staging in pregnant patients at this time. US Axilla Sonographic evaluation of the axilla is often performed to stage pregnant patients who are diagnosed with breast cancer. In a study of 23 pregnant patients undergoing neoadjuvant chemotherapy for newly diagnosed breast cancer, 15 of 18 axillary metastases were correctly diagnosed by sonographic evaluation of the axilla [50]. MRI Breast It is well established that IV gadolinium chelates cross the placenta and enter the fetal circulation. Although there are no reported adverse fetal effects due to IV gadolinium in the pregnant mother, there is the potential for the dissociation of free toxic gadolinium ion with limited data in this patient population. Guidelines regarding gadolinium administration during pregnancy are outlined in detail in the ACR Manual on Contrast Media [33]. Because of the concerns regarding gadolinium crossing the placenta and limited data regarding its safety in this setting, breast DCE-MRI is therefore not recommended in pregnant women. However, immediately following delivery or pregnancy termination, breast MRI is recommended for locoregional staging. A small series evaluating PABC on breast MRI showed that 23% of patients had pathologically proven greater extent of disease than was identified with mammography and breast US. This study showed variable background parenchymal enhancement with 58% of patients demonstrating moderate or marked enhancement. Despite increased background parenchymal enhancement, this study showed 98% sensitivity for PABC [19].

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acrac_3155692_0

Transgender Breast Cancer Screening

Introduction/Background Transgender is an umbrella term for any individual whose gender identity, or internal sense of self related to gender, differs from the sex assigned at birth. A nonbinary individual may have been assigned female or male at birth but does not strictly identify with either sex. A transfeminine person identifies with the female side of the gender spectrum but was assigned male at birth. These individuals may include transgender women, historically referred to as male-to-female transsexuals. A transmasculine person identifies with the male side of the gender spectrum but was assigned female at birth. These individuals may include transgender men, historically referred to as female-to- male individuals, breast cancer screening transgender and gender-nonconforming recommendations are based on the sex assigned at birth, risk factors, and use of exogenous hormones. A detailed discussion of the continuously evolving terminology in the context of caring for a great diversity of transgender people is beyond the scope of this document. As of the writing of this document, the terminology is derived from the University of California San Francisco (UCSF) Center of Excellence for Transgender Health (https://transcare. ucsf.edu/guidelines/terminology). The incidence of breast cancer in the transgender community is largely unknown because of inadequate epidemiological information and a lack of longitudinal studies. Current evidence consists primarily of case reports and several cohort studies, all of which are retrospective. However, a younger age at the time of breast cancer diagnosis has been reported in transgender people [1-5]. The same breast pathology that occurs in cisgender women can be found in transgender women treated with gender- affirming hormone therapy. Mammary development includes the formation of ducts, lobules, and acini, which is histologically identical to cisgender females and should not be referred to as gynecomastia [4,9,10]. There are

Transgender Breast Cancer Screening. Introduction/Background Transgender is an umbrella term for any individual whose gender identity, or internal sense of self related to gender, differs from the sex assigned at birth. A nonbinary individual may have been assigned female or male at birth but does not strictly identify with either sex. A transfeminine person identifies with the female side of the gender spectrum but was assigned male at birth. These individuals may include transgender women, historically referred to as male-to-female transsexuals. A transmasculine person identifies with the male side of the gender spectrum but was assigned female at birth. These individuals may include transgender men, historically referred to as female-to- male individuals, breast cancer screening transgender and gender-nonconforming recommendations are based on the sex assigned at birth, risk factors, and use of exogenous hormones. A detailed discussion of the continuously evolving terminology in the context of caring for a great diversity of transgender people is beyond the scope of this document. As of the writing of this document, the terminology is derived from the University of California San Francisco (UCSF) Center of Excellence for Transgender Health (https://transcare. ucsf.edu/guidelines/terminology). The incidence of breast cancer in the transgender community is largely unknown because of inadequate epidemiological information and a lack of longitudinal studies. Current evidence consists primarily of case reports and several cohort studies, all of which are retrospective. However, a younger age at the time of breast cancer diagnosis has been reported in transgender people [1-5]. The same breast pathology that occurs in cisgender women can be found in transgender women treated with gender- affirming hormone therapy. Mammary development includes the formation of ducts, lobules, and acini, which is histologically identical to cisgender females and should not be referred to as gynecomastia [4,9,10]. There are

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Transgender Breast Cancer Screening

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] Transgender Breast Cancer Screening published reports of benign breast entities, such as fibroadenomas, cysts, and lipomas [3,11], as well as breast malignancies that include ductal and lobular carcinomas and malignant phyllodes tumor [3,12]. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving cancer detection rates (CDRs) in breast cancer screening. Transgender Breast Cancer Screening was increased in transgender women who received hormone treatment (31.4 per 100,000 person-years compared with 1.2 per 100,000 person-years for cisgender men and 170 per 100,000 person-years for cisgender women) [1]. Any conclusions drawn from the existing literature are significantly limited by inconsistent dose and length of exposure to hormones as well as small sample size and relatively short duration of follow-up. Large prospective cisgender studies have shown that exogenous hormones, in particular estrogen and progestin, increase breast cancer risk in cisgender postmenopausal females [18-20], which could support a role for screening in this clinical setting. Additionally, in cisgender males, high estrogen levels associated with certain conditions, such as Klinefelter syndrome, liver disease, testicular dysfunction, and obesity, are recognized risk factors for developing breast cancer [21].

Transgender Breast Cancer Screening. 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] Transgender Breast Cancer Screening published reports of benign breast entities, such as fibroadenomas, cysts, and lipomas [3,11], as well as breast malignancies that include ductal and lobular carcinomas and malignant phyllodes tumor [3,12]. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving cancer detection rates (CDRs) in breast cancer screening. Transgender Breast Cancer Screening was increased in transgender women who received hormone treatment (31.4 per 100,000 person-years compared with 1.2 per 100,000 person-years for cisgender men and 170 per 100,000 person-years for cisgender women) [1]. Any conclusions drawn from the existing literature are significantly limited by inconsistent dose and length of exposure to hormones as well as small sample size and relatively short duration of follow-up. Large prospective cisgender studies have shown that exogenous hormones, in particular estrogen and progestin, increase breast cancer risk in cisgender postmenopausal females [18-20], which could support a role for screening in this clinical setting. Additionally, in cisgender males, high estrogen levels associated with certain conditions, such as Klinefelter syndrome, liver disease, testicular dysfunction, and obesity, are recognized risk factors for developing breast cancer [21].

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Transgender Breast Cancer Screening

MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI breast without and with intravenous (IV) contrast to screen for breast cancer in this clinical setting. However, MRI screening may have limited use in patients who have undergone direct injection of particles such as silicone, mineral oil, liquid paraffin, or petroleum jelly to augment the breasts because fibrosis and injection granulomas can obscure the breast tissue on mammography and ultrasound (US). Hence, contrast-enhanced breast MRI is the preferred modality for breast cancer detection in patients who have undergone breast augmentation with free-particle injections [4,10]. US Breast There is insufficient evidence to support screening with US breast in this clinical setting. A small study of screening whole-breast US in 50 transgender women found no cancers [11]. The majority of patients were on estrogen therapy (94%) and had no family history of breast cancer (88%). However, the lack of incremental cancer detection may be secondary to the small sample size. Transgender Breast Cancer Screening to hormones as well as small sample size and relatively short duration of follow-up. Large prospective cisgender studies have shown that exogenous hormones, in particular estrogen and progestin, increase breast cancer risk in cisgender postmenopausal females [18-20], which could support a role for screening in this clinical setting. In the absence of definitive data, some transgender health experts and professional societies recommend digital mammography or DBT to screen for breast cancer in transgender women with higher-than-average risk of breast cancer (https://transcare. ucsf.edu/guidelines/breast-cancer-women). There is no consensus on the age at which to initiate screening in this clinical setting. The Endocrine Society recommends screening transgender women with the same frequency as cisgender women [10].

Transgender Breast Cancer Screening. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI breast without and with intravenous (IV) contrast to screen for breast cancer in this clinical setting. However, MRI screening may have limited use in patients who have undergone direct injection of particles such as silicone, mineral oil, liquid paraffin, or petroleum jelly to augment the breasts because fibrosis and injection granulomas can obscure the breast tissue on mammography and ultrasound (US). Hence, contrast-enhanced breast MRI is the preferred modality for breast cancer detection in patients who have undergone breast augmentation with free-particle injections [4,10]. US Breast There is insufficient evidence to support screening with US breast in this clinical setting. A small study of screening whole-breast US in 50 transgender women found no cancers [11]. The majority of patients were on estrogen therapy (94%) and had no family history of breast cancer (88%). However, the lack of incremental cancer detection may be secondary to the small sample size. Transgender Breast Cancer Screening to hormones as well as small sample size and relatively short duration of follow-up. Large prospective cisgender studies have shown that exogenous hormones, in particular estrogen and progestin, increase breast cancer risk in cisgender postmenopausal females [18-20], which could support a role for screening in this clinical setting. In the absence of definitive data, some transgender health experts and professional societies recommend digital mammography or DBT to screen for breast cancer in transgender women with higher-than-average risk of breast cancer (https://transcare. ucsf.edu/guidelines/breast-cancer-women). There is no consensus on the age at which to initiate screening in this clinical setting. The Endocrine Society recommends screening transgender women with the same frequency as cisgender women [10].

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Transgender Breast Cancer Screening

The ACR screening recommendation for high-risk cisgender women is annual screening mammography beginning 10 years earlier than an affected relative at the age of diagnosis (but not before age 30) or 8 years after radiation therapy (but not before age 25) [25]. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving CDR in breast cancer screening. Transgender Breast Cancer Screening In the absence of definitive data, some transgender health experts and professional societies recommend digital mammography or DBT to screen for breast cancer in transgender women with higher-than-average risk of breast cancer (https://transcare. ucsf.edu/guidelines/breast-cancer-women). There is no consensus on the age at which to initiate screening in this clinical setting. The Endocrine Society recommends screening transgender women with the same frequency as cisgender women [10]. The ACR screening recommendation for high-risk cisgender women is annual screening mammography beginning 10 years earlier than an affected relative at the age of diagnosis (but not before age 30) or 8 years after radiation therapy (but not before age 25) [25]. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI breast without and with IV contrast to screen for breast cancer in this clinical setting. However, MRI screening may have limited use in patients who have undergone direct injection of particles, such as silicone, mineral oil, liquid paraffin, or petroleum jelly, to augment the breasts because fibrosis and injection granulomas can obscure the breast tissue on mammography and US. Hence, contrast-enhanced breast MRI is the preferred modality for breast cancer detection in patients who have undergone breast augmentation with free-particle injections [4,10].

Transgender Breast Cancer Screening. The ACR screening recommendation for high-risk cisgender women is annual screening mammography beginning 10 years earlier than an affected relative at the age of diagnosis (but not before age 30) or 8 years after radiation therapy (but not before age 25) [25]. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving CDR in breast cancer screening. Transgender Breast Cancer Screening In the absence of definitive data, some transgender health experts and professional societies recommend digital mammography or DBT to screen for breast cancer in transgender women with higher-than-average risk of breast cancer (https://transcare. ucsf.edu/guidelines/breast-cancer-women). There is no consensus on the age at which to initiate screening in this clinical setting. The Endocrine Society recommends screening transgender women with the same frequency as cisgender women [10]. The ACR screening recommendation for high-risk cisgender women is annual screening mammography beginning 10 years earlier than an affected relative at the age of diagnosis (but not before age 30) or 8 years after radiation therapy (but not before age 25) [25]. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI breast without and with IV contrast to screen for breast cancer in this clinical setting. However, MRI screening may have limited use in patients who have undergone direct injection of particles, such as silicone, mineral oil, liquid paraffin, or petroleum jelly, to augment the breasts because fibrosis and injection granulomas can obscure the breast tissue on mammography and US. Hence, contrast-enhanced breast MRI is the preferred modality for breast cancer detection in patients who have undergone breast augmentation with free-particle injections [4,10].

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Transgender Breast Cancer Screening

US Breast There is no relevant literature to support the use of US for breast cancer screening in this clinical setting. Variant 3: Breast cancer screening. Transfeminine (male-to-female) patient with no hormone use (or hormone use less than 5 years) at any age. Average-risk patient. Recommendations for breast cancer screening in transfeminine patients are typically based on the male sex assigned at birth, the number of years of feminizing hormone exposure, breast development, and any significant risk factors for breast cancer. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting. In the absence of identifiable risk factors for breast cancer, general screening has no role because of an overall low prevalence of disease. The lifetime risk of breast cancer in transfeminine patients with no hormone use and no significant risk factors is considered to be equivalent to the average risk in cisgender men, which is 0.1% (compared with 12.4% in the average-risk cisgender female) [1,26]. Mammography Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting. In the absence of identifiable risk factors for breast cancer, general screening has no role because of an overall low prevalence of disease. The lifetime risk of breast cancer in transfeminine patients with no hormone use and no significant risk factors is considered to be equivalent to the average risk in cisgender men, which is 0.1% (compared with 12.4% in the average-risk cisgender female) [1,26]. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI breast without and with IV contrast to screen for breast cancer in this clinical setting. US Breast There is no relevant literature to support the use of US for breast cancer screening in this clinical setting.

Transgender Breast Cancer Screening. US Breast There is no relevant literature to support the use of US for breast cancer screening in this clinical setting. Variant 3: Breast cancer screening. Transfeminine (male-to-female) patient with no hormone use (or hormone use less than 5 years) at any age. Average-risk patient. Recommendations for breast cancer screening in transfeminine patients are typically based on the male sex assigned at birth, the number of years of feminizing hormone exposure, breast development, and any significant risk factors for breast cancer. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting. In the absence of identifiable risk factors for breast cancer, general screening has no role because of an overall low prevalence of disease. The lifetime risk of breast cancer in transfeminine patients with no hormone use and no significant risk factors is considered to be equivalent to the average risk in cisgender men, which is 0.1% (compared with 12.4% in the average-risk cisgender female) [1,26]. Mammography Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting. In the absence of identifiable risk factors for breast cancer, general screening has no role because of an overall low prevalence of disease. The lifetime risk of breast cancer in transfeminine patients with no hormone use and no significant risk factors is considered to be equivalent to the average risk in cisgender men, which is 0.1% (compared with 12.4% in the average-risk cisgender female) [1,26]. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI breast without and with IV contrast to screen for breast cancer in this clinical setting. US Breast There is no relevant literature to support the use of US for breast cancer screening in this clinical setting.

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Transgender Breast Cancer Screening

In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving CDR in breast cancer screening. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI breast without and with IV contrast to screen for breast cancer in this clinical setting. However, MRI screening may have limited use in patients who have undergone direct injection of particles, such as silicone, mineral oil, liquid paraffin, or petroleum jelly, to augment the breasts because fibrosis and injection granulomas can obscure the breast tissue on mammography and US. Hence, contrast-enhanced breast MRI is the preferred modality for breast cancer detection in patients who have undergone breast augmentation with free-particle injections [4,10]. US Breast There is no relevant literature to support the use of US for breast cancer screening in this clinical setting. Transgender Breast Cancer Screening Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting. Mammography Screening There is no relevant literature to support the use of digital mammography for breast cancer screening in this clinical setting. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI breast without and with IV contrast for breast cancer screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for breast cancer screening in this clinical setting. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving CDR in breast cancer screening.

Transgender Breast Cancer Screening. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving CDR in breast cancer screening. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI breast without and with IV contrast to screen for breast cancer in this clinical setting. However, MRI screening may have limited use in patients who have undergone direct injection of particles, such as silicone, mineral oil, liquid paraffin, or petroleum jelly, to augment the breasts because fibrosis and injection granulomas can obscure the breast tissue on mammography and US. Hence, contrast-enhanced breast MRI is the preferred modality for breast cancer detection in patients who have undergone breast augmentation with free-particle injections [4,10]. US Breast There is no relevant literature to support the use of US for breast cancer screening in this clinical setting. Transgender Breast Cancer Screening Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting. Mammography Screening There is no relevant literature to support the use of digital mammography for breast cancer screening in this clinical setting. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI breast without and with IV contrast for breast cancer screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for breast cancer screening in this clinical setting. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving CDR in breast cancer screening.

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Transgender Breast Cancer Screening

MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI breast without and with IV contrast for breast cancer screening in this clinical setting. Transgender Breast Cancer Screening MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for breast cancer screening in this clinical setting. US Breast There is insufficient evidence to support the use of US for breast cancer screening of average-risk patients with nondense breast tissue [25,29]. Dense breast tissue lowers the sensitivity of mammography and increases breast cancer risk when compared with fatty breasts [25,30]. In patients with dense breasts and no additional risk factors, breast US may be useful as an adjunct to mammography for incremental cancer detection [25,31]; however, the increased risk of a false-positive examination should be considered in the decision [25,32-34]. Digital Breast Tomosynthesis Screening Annual screening with digital mammography or DBT is recommended in this clinical setting as it is for risk- comparable cisgender women with high-risk lesions, such as lobular neoplasia or atypical ductal hyperplasia, beginning at diagnosis but not before 30 years of age [25,35]. Transmasculine patients with a personal history of breast cancer are recommended to have mammography every 12 months because their breast cancer risk is similar to cisgender women [25,35]. Mammography Screening Annual screening with digital mammography or DBT is recommended in this clinical setting as it is for risk- comparable cisgender women with high-risk lesions, such as lobular neoplasia or atypical ductal hyperplasia, beginning at diagnosis but not before 30 years of age [25,35]. Transmasculine patients with a personal history of breast cancer are recommended to have mammography every 12 months because their breast cancer risk is similar to cisgender women [25,35].

Transgender Breast Cancer Screening. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI breast without and with IV contrast for breast cancer screening in this clinical setting. Transgender Breast Cancer Screening MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for breast cancer screening in this clinical setting. US Breast There is insufficient evidence to support the use of US for breast cancer screening of average-risk patients with nondense breast tissue [25,29]. Dense breast tissue lowers the sensitivity of mammography and increases breast cancer risk when compared with fatty breasts [25,30]. In patients with dense breasts and no additional risk factors, breast US may be useful as an adjunct to mammography for incremental cancer detection [25,31]; however, the increased risk of a false-positive examination should be considered in the decision [25,32-34]. Digital Breast Tomosynthesis Screening Annual screening with digital mammography or DBT is recommended in this clinical setting as it is for risk- comparable cisgender women with high-risk lesions, such as lobular neoplasia or atypical ductal hyperplasia, beginning at diagnosis but not before 30 years of age [25,35]. Transmasculine patients with a personal history of breast cancer are recommended to have mammography every 12 months because their breast cancer risk is similar to cisgender women [25,35]. Mammography Screening Annual screening with digital mammography or DBT is recommended in this clinical setting as it is for risk- comparable cisgender women with high-risk lesions, such as lobular neoplasia or atypical ductal hyperplasia, beginning at diagnosis but not before 30 years of age [25,35]. Transmasculine patients with a personal history of breast cancer are recommended to have mammography every 12 months because their breast cancer risk is similar to cisgender women [25,35].

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Cervical Neck Pain or Cervical Radiculopathy PCAs

Introduction/Background The physical, psychological, and socioeconomic impact of cervical or neck pain is extensive. In 2010, 16.3 million health care visits to hospitals and physician offices were related primarily to neck pain [1]. The Global Burden of Disease 2010 Study identified neck pain as the fourth leading cause of years lost to disability [2], with most epidemiological studies reporting an annual prevalence ranging between 15% and 50% [3-8]. Although most episodes resolve, nearly 50% of individuals continue to experience ongoing or recurrent pain [9]. 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] Cervical Neck Pain or Cervical Radiculopathy vertebral body. Additional proposed red flags include congenital findings, concomitant vascular disease in patients >50 years of age, abnormal labs (erythrocyte sedimentation rate, C-reactive protein level, white blood cell), and neurological deficits [10]. CT Cervical Spine CT offers superior depiction of cortical bone and is more sensitive than radiographs in assessing facet degenerative disease, osteophyte formation, vacuum phenomenon, and joint capsular calcification [24]. Ultra-low- dose techniques are proposed for CT in other regions of the body [25]; however, currently this has not been directly compared to radiographs for evaluation of the neck and cervical spine. CT Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test.

Cervical Neck Pain or Cervical Radiculopathy PCAs. Introduction/Background The physical, psychological, and socioeconomic impact of cervical or neck pain is extensive. In 2010, 16.3 million health care visits to hospitals and physician offices were related primarily to neck pain [1]. The Global Burden of Disease 2010 Study identified neck pain as the fourth leading cause of years lost to disability [2], with most epidemiological studies reporting an annual prevalence ranging between 15% and 50% [3-8]. Although most episodes resolve, nearly 50% of individuals continue to experience ongoing or recurrent pain [9]. 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] Cervical Neck Pain or Cervical Radiculopathy vertebral body. Additional proposed red flags include congenital findings, concomitant vascular disease in patients >50 years of age, abnormal labs (erythrocyte sedimentation rate, C-reactive protein level, white blood cell), and neurological deficits [10]. CT Cervical Spine CT offers superior depiction of cortical bone and is more sensitive than radiographs in assessing facet degenerative disease, osteophyte formation, vacuum phenomenon, and joint capsular calcification [24]. Ultra-low- dose techniques are proposed for CT in other regions of the body [25]; however, currently this has not been directly compared to radiographs for evaluation of the neck and cervical spine. CT Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test.

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Cervical Neck Pain or Cervical Radiculopathy PCAs

CTA Neck The literature search did not identify any studies regarding the use of CT angiography (CTA) in the evaluation of this clinical presentation. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MR angiography (MRA) in the evaluation of this clinical presentation. MRI Cervical Spine MRI is the most sensitive test for detecting soft abnormalities associated with neck pain; however, this is characterized by a high rate of abnormalities in asymptomatic individuals [22,23]. As such, MRI is not considered a first-line imaging modality in the setting of acute or worsening uncomplicated neck pain. Cervical Neck Pain or Cervical Radiculopathy Bone Scan Whole Body with SPECT or SPECT/CT Neck There is no current role for nuclear medicine studies as the initial examination in this scenario. Tc-99m bone scan lacks both resolution and specificity in detecting pathology related to acute or worsening neck pain in the absence of red flag symptoms; most commonly, these will be associated with degenerative spondylosis. A recent retrospective study of patients with nonconclusive MRI or CT findings demonstrated that hybrid single-photon emission computed tomography (SPECT)/CT imaging identified potential pain generators in 92% of cervical spine scans [26]; however, this is not a first-line examination. Radiography Cervical Spine Radiographs are widely accessible and useful to diagnose spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis. Flexion/extension radiographs have limited value in degenerative disease [27]. In the absence of red flag symptoms, therapy is rarely altered by radiographic findings [27-29].

Cervical Neck Pain or Cervical Radiculopathy PCAs. CTA Neck The literature search did not identify any studies regarding the use of CT angiography (CTA) in the evaluation of this clinical presentation. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MR angiography (MRA) in the evaluation of this clinical presentation. MRI Cervical Spine MRI is the most sensitive test for detecting soft abnormalities associated with neck pain; however, this is characterized by a high rate of abnormalities in asymptomatic individuals [22,23]. As such, MRI is not considered a first-line imaging modality in the setting of acute or worsening uncomplicated neck pain. Cervical Neck Pain or Cervical Radiculopathy Bone Scan Whole Body with SPECT or SPECT/CT Neck There is no current role for nuclear medicine studies as the initial examination in this scenario. Tc-99m bone scan lacks both resolution and specificity in detecting pathology related to acute or worsening neck pain in the absence of red flag symptoms; most commonly, these will be associated with degenerative spondylosis. A recent retrospective study of patients with nonconclusive MRI or CT findings demonstrated that hybrid single-photon emission computed tomography (SPECT)/CT imaging identified potential pain generators in 92% of cervical spine scans [26]; however, this is not a first-line examination. Radiography Cervical Spine Radiographs are widely accessible and useful to diagnose spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis. Flexion/extension radiographs have limited value in degenerative disease [27]. In the absence of red flag symptoms, therapy is rarely altered by radiographic findings [27-29].

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acrac_69426_2

Cervical Neck Pain or Cervical Radiculopathy PCAs

Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test. CT Cervical Spine CT provides good definition of bony elements and is helpful in the assessment of neuroforaminal stenosis secondary to uncovertebral or facet hypertrophy and is helpful when C6 and C7 are not clearly seen on traditional lateral radiographic views. However, CT is shown to be less sensitive than MRI for evaluation of nerve root compression [35,36]. CT Myelography Cervical Spine MRI has mostly supplanted CT myelography as a first-line imaging modality for complex cervical radiculopathy [37]. However, studies have shown that CT myelography may prove useful in diagnosing foraminal stenosis, bony lesions, and nerve root compression [38] and can be considered in patients with clinically apparent radiculopathy and contraindication to MRI, or in the setting of equivocal MRI findings. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Cervical Neck Pain or Cervical Radiculopathy Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine MRI has become the preferred method to evaluate the cervical spine in the setting of suspected nerve root impingement [39] because of its superior intrinsic soft-tissue contrast and good spatial resolution.

Cervical Neck Pain or Cervical Radiculopathy PCAs. Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test. CT Cervical Spine CT provides good definition of bony elements and is helpful in the assessment of neuroforaminal stenosis secondary to uncovertebral or facet hypertrophy and is helpful when C6 and C7 are not clearly seen on traditional lateral radiographic views. However, CT is shown to be less sensitive than MRI for evaluation of nerve root compression [35,36]. CT Myelography Cervical Spine MRI has mostly supplanted CT myelography as a first-line imaging modality for complex cervical radiculopathy [37]. However, studies have shown that CT myelography may prove useful in diagnosing foraminal stenosis, bony lesions, and nerve root compression [38] and can be considered in patients with clinically apparent radiculopathy and contraindication to MRI, or in the setting of equivocal MRI findings. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Cervical Neck Pain or Cervical Radiculopathy Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine MRI has become the preferred method to evaluate the cervical spine in the setting of suspected nerve root impingement [39] because of its superior intrinsic soft-tissue contrast and good spatial resolution.

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Cervical Neck Pain or Cervical Radiculopathy PCAs

Brown et al [35] in a blinded, retrospective review studied 34 patients with clinically diagnosed cervical radiculopathy who underwent MRI prior to surgery and reported that MRI correctly predicted 88% of the lesions as opposed to 81% for CT myelography, 57% for plain myelography, and 50% for CT. However, as noted previously, degenerative findings on MRI are commonly observed in asymptomatic patients [21,23,40,41]. A prospective study evaluating MRI cervical spine in recent onset cervical radiculopathy found a high rate of both false-positive and false- negative findings [33]. Bone Scan Whole Body with SPECT or SPECT/CT Neck Tc-99m bone scan lacks both resolution and specificity to detect pathology related to suspected nerve root compression. Radiography Cervical Spine Approximately 65% of asymptomatic patients 50 to 59 years of age will have radiographic evidence of significant cervical spine degeneration, regardless of radiculopathy symptoms [42]. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17]. CT Cervical Spine Multidetector CT scanning with high-quality multiplanar reformatted images have enhanced the efficacy of CT assessment and imaging findings, particularly around hardware. CT is the most sensitive and specific modality to assess spinal fusion [48-50] and can aid in detecting adjacent segment degeneration [51].

Cervical Neck Pain or Cervical Radiculopathy PCAs. Brown et al [35] in a blinded, retrospective review studied 34 patients with clinically diagnosed cervical radiculopathy who underwent MRI prior to surgery and reported that MRI correctly predicted 88% of the lesions as opposed to 81% for CT myelography, 57% for plain myelography, and 50% for CT. However, as noted previously, degenerative findings on MRI are commonly observed in asymptomatic patients [21,23,40,41]. A prospective study evaluating MRI cervical spine in recent onset cervical radiculopathy found a high rate of both false-positive and false- negative findings [33]. Bone Scan Whole Body with SPECT or SPECT/CT Neck Tc-99m bone scan lacks both resolution and specificity to detect pathology related to suspected nerve root compression. Radiography Cervical Spine Approximately 65% of asymptomatic patients 50 to 59 years of age will have radiographic evidence of significant cervical spine degeneration, regardless of radiculopathy symptoms [42]. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17]. CT Cervical Spine Multidetector CT scanning with high-quality multiplanar reformatted images have enhanced the efficacy of CT assessment and imaging findings, particularly around hardware. CT is the most sensitive and specific modality to assess spinal fusion [48-50] and can aid in detecting adjacent segment degeneration [51].

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Cervical Neck Pain or Cervical Radiculopathy PCAs

A recent review of 690 patients who underwent ACDF concluded that CT altered the treatment plan in 39% of patients who had persistent symptoms and altered the treatment plan for 60% of patients with persistent symptoms and abnormal radiographs or MRI. Furthermore, recent advances in dual-energy CT has shown promise to reduce beam- hardening metal artifact, which may improve the evaluation of hardware complications and adjacent segment degeneration in postoperative patients with new or worsening neck pain [52]. Whether imaging is informative for changes to improve outcome remains to be established. In one study, half of the symptomatic cohort did not have postoperative CT, and the majority recovered with 2 years of conservative therapy [53]. CT Myelography Cervical Spine CT myelography is not the first-line test of choice for complex cervical radiculopathy [37]. However, it can be considered in patients with radiculopathy, particularly if MRI is nondiagnostic related to hardware artifact. Cervical Neck Pain or Cervical Radiculopathy CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine Metal artifact may limit assessment of the cervical hardware and complications related to position or integrity. There continues to be emerging techniques for metal artifact reduction, which is beyond the scope of this document [54]. MRI is the most sensitive imaging test for detecting soft-tissue abnormalities associated with neck pain but is characterized by a high rate of abnormalities in asymptomatic individuals [22,23].

Cervical Neck Pain or Cervical Radiculopathy PCAs. A recent review of 690 patients who underwent ACDF concluded that CT altered the treatment plan in 39% of patients who had persistent symptoms and altered the treatment plan for 60% of patients with persistent symptoms and abnormal radiographs or MRI. Furthermore, recent advances in dual-energy CT has shown promise to reduce beam- hardening metal artifact, which may improve the evaluation of hardware complications and adjacent segment degeneration in postoperative patients with new or worsening neck pain [52]. Whether imaging is informative for changes to improve outcome remains to be established. In one study, half of the symptomatic cohort did not have postoperative CT, and the majority recovered with 2 years of conservative therapy [53]. CT Myelography Cervical Spine CT myelography is not the first-line test of choice for complex cervical radiculopathy [37]. However, it can be considered in patients with radiculopathy, particularly if MRI is nondiagnostic related to hardware artifact. Cervical Neck Pain or Cervical Radiculopathy CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine Metal artifact may limit assessment of the cervical hardware and complications related to position or integrity. There continues to be emerging techniques for metal artifact reduction, which is beyond the scope of this document [54]. MRI is the most sensitive imaging test for detecting soft-tissue abnormalities associated with neck pain but is characterized by a high rate of abnormalities in asymptomatic individuals [22,23].

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Cervical Neck Pain or Cervical Radiculopathy PCAs

Most cervical discectomies are performed by an anterior approach without transgression of the epidural space; therefore, epidural scar or granulation tissue formation is minimal, and contrast-enhanced imaging is not routinely used after ACDF [55]. Gadolinium-enhanced MRI may have a role in the setting of neck pain and prior posterior-approach cervical fusion/decompressive procedures, although the majority of the literature to date evaluates the use of gadolinium-based contrast in the differentiation of recurrent disc herniations (a potentially actionable finding) from epidural scar in the setting of lumbar spine surgery [56,57]. Bone Scan Whole Body with SPECT or SPECT/CT Neck There is no current role for nuclear medicine studies as the initial examination in this scenario. The role of Tc- 99m bone scan in the setting of new or worsening neck pain in the postsurgical patient is limited, as radionuclide scans may remain positive for a year or more in the region of the operative bed [58]. SPECT/CT may offer diagnostic information in the setting of suspected pseudoarthrosis or equivocal CT or MRI findings [59]. Radiography Cervical Spine Initial radiographic evaluation, including anteroposterior and lateral views, is useful to assess hardware integrity and detect adjacent segment disease, which may contribute to symptoms [60,61]. The addition of flexion/extension radiographs may be considered to improve detection of vertebral body nonunion or pseudoarthrosis [62] and may supplement conventional views following ACDF [63], cervical disc implantation, or posterior cervical fixation [64-66]. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging.

Cervical Neck Pain or Cervical Radiculopathy PCAs. Most cervical discectomies are performed by an anterior approach without transgression of the epidural space; therefore, epidural scar or granulation tissue formation is minimal, and contrast-enhanced imaging is not routinely used after ACDF [55]. Gadolinium-enhanced MRI may have a role in the setting of neck pain and prior posterior-approach cervical fusion/decompressive procedures, although the majority of the literature to date evaluates the use of gadolinium-based contrast in the differentiation of recurrent disc herniations (a potentially actionable finding) from epidural scar in the setting of lumbar spine surgery [56,57]. Bone Scan Whole Body with SPECT or SPECT/CT Neck There is no current role for nuclear medicine studies as the initial examination in this scenario. The role of Tc- 99m bone scan in the setting of new or worsening neck pain in the postsurgical patient is limited, as radionuclide scans may remain positive for a year or more in the region of the operative bed [58]. SPECT/CT may offer diagnostic information in the setting of suspected pseudoarthrosis or equivocal CT or MRI findings [59]. Radiography Cervical Spine Initial radiographic evaluation, including anteroposterior and lateral views, is useful to assess hardware integrity and detect adjacent segment disease, which may contribute to symptoms [60,61]. The addition of flexion/extension radiographs may be considered to improve detection of vertebral body nonunion or pseudoarthrosis [62] and may supplement conventional views following ACDF [63], cervical disc implantation, or posterior cervical fixation [64-66]. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging.

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Cervical Neck Pain or Cervical Radiculopathy PCAs

The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17]. Cervical Neck Pain or Cervical Radiculopathy CT Cervical Spine CT with and without contrast is superior to radiography for the detection of erosive changes, loss of fat planes, and paraspinal edema and fluid collections [69]. CT scanning also offers potential advantages in identifying the presence of gas within an abscess, the lack of gas within the disc space, or a sequestrum within the spinal canal [70]. CT with contrast is complementary to MRI. CT Myelography Cervical Spine The literature search did not identify any studies regarding the use of CT myelography in the evaluation of this clinical presentation. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. FDG-PET/CT Skull Base to Mid-Thigh PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)/CT is the scintigraphic procedure of choice for spinal osteomyelitis [71-73]. Gallium-67 Scan Whole Body Specificity may be increased by combining Tc-99m methylene diphosphonate (MDP) with gallium-67 citrate [74], and higher sensitivity and resolution can be further achieved with SPECT/CT [75]. Indium-111 WBC Scan Whole Body Indium-labeled leucocytes have a low sensitivity in spinal infections (osteomyelitis and discitis). In these clinical scenarios, leucocytes are generally not used because of a reported 40% false-negative rate, which is manifested as normal uptake or photopenia.

Cervical Neck Pain or Cervical Radiculopathy PCAs. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17]. Cervical Neck Pain or Cervical Radiculopathy CT Cervical Spine CT with and without contrast is superior to radiography for the detection of erosive changes, loss of fat planes, and paraspinal edema and fluid collections [69]. CT scanning also offers potential advantages in identifying the presence of gas within an abscess, the lack of gas within the disc space, or a sequestrum within the spinal canal [70]. CT with contrast is complementary to MRI. CT Myelography Cervical Spine The literature search did not identify any studies regarding the use of CT myelography in the evaluation of this clinical presentation. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. FDG-PET/CT Skull Base to Mid-Thigh PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)/CT is the scintigraphic procedure of choice for spinal osteomyelitis [71-73]. Gallium-67 Scan Whole Body Specificity may be increased by combining Tc-99m methylene diphosphonate (MDP) with gallium-67 citrate [74], and higher sensitivity and resolution can be further achieved with SPECT/CT [75]. Indium-111 WBC Scan Whole Body Indium-labeled leucocytes have a low sensitivity in spinal infections (osteomyelitis and discitis). In these clinical scenarios, leucocytes are generally not used because of a reported 40% false-negative rate, which is manifested as normal uptake or photopenia.

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Cervical Neck Pain or Cervical Radiculopathy PCAs

In the past, the preferred radionuclide imaging for spinal osteomyelitis was a combination of bone and gallium scans. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine MRI with and without contrast is considered the best modality for demonstrating spinal infections, with a sensitivity of 96%, specificity of 92%, and accuracy of 94% [68,69,76]. While bone marrow edema can be detected on noncontrast examinations [68,77-79], the addition of contrast improves detection and characterization of leptomeningeal involvement or the development of an epidural or paraspinal abscess [79,80]. Bone Scan Whole Body with SPECT or SPECT/CT Neck Three-phase Tc-99m MDP scintigraphy is sensitive (90%) but not specific (78%) [76] for the identification of suspect cervical spine osteomyelitis. Radiography Cervical Spine Radiographs lack sensitivity and specificity in the setting of discitis or osteomyelitis, as 30% to 40% of the vertebral bone must be destroyed before lytic changes can be identified [81,82]. Because of the low sensitivity and specificity, particularly in early phases of spine infection, a negative cervical spine radiograph should not be considered comprehensive imaging in this scenario. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17]. Cervical Neck Pain or Cervical Radiculopathy Variant 5: Known malignancy. New or increasing nontraumatic cervical or neck pain or radiculopathy. Initial imaging.

Cervical Neck Pain or Cervical Radiculopathy PCAs. In the past, the preferred radionuclide imaging for spinal osteomyelitis was a combination of bone and gallium scans. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine MRI with and without contrast is considered the best modality for demonstrating spinal infections, with a sensitivity of 96%, specificity of 92%, and accuracy of 94% [68,69,76]. While bone marrow edema can be detected on noncontrast examinations [68,77-79], the addition of contrast improves detection and characterization of leptomeningeal involvement or the development of an epidural or paraspinal abscess [79,80]. Bone Scan Whole Body with SPECT or SPECT/CT Neck Three-phase Tc-99m MDP scintigraphy is sensitive (90%) but not specific (78%) [76] for the identification of suspect cervical spine osteomyelitis. Radiography Cervical Spine Radiographs lack sensitivity and specificity in the setting of discitis or osteomyelitis, as 30% to 40% of the vertebral bone must be destroyed before lytic changes can be identified [81,82]. Because of the low sensitivity and specificity, particularly in early phases of spine infection, a negative cervical spine radiograph should not be considered comprehensive imaging in this scenario. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17]. Cervical Neck Pain or Cervical Radiculopathy Variant 5: Known malignancy. New or increasing nontraumatic cervical or neck pain or radiculopathy. Initial imaging.

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Cervical Neck Pain or Cervical Radiculopathy PCAs

Although primary tumors of the spine are uncommon [83], an estimated 10% of cancer patients develop symptomatic spinal metastases during the course of their disease [84], making the spine the most common site of osseous metastatic disease [85]. Suspected spinal metastases are typically diagnosed using cross-sectional imaging with the dual goal of identifying potential metastases and characterizing the extent of malignancy. As such, the choice of imaging modality is often based on both the type of malignancy and the presenting clinical features, especially if referable to pathological fracture, cord compression, or nerve root impingement. CT Cervical Spine Because of its high spatial resolution, CT is more sensitive than conventional radiography for the detection of bone metastases and has shown good correlation with nuclear bone scans, particularly if coupled with concurrent CT examinations of the thorax, abdomen, and/or pelvis [86]. CT can help characterize lesions as lytic or blastic and may successfully assess paravertebral or intraspinal extension if intravenous contrast is used [87]. CT is also useful to obtain better structural definition of abnormal findings identified on scintigraphy or MRI [88], such as in the setting of suspected pathologic fracture. However, given that CT is relatively insensitive for tumors restricted to the marrow space, the sensitivity of CT is relatively low in early malignant bone involvement [87,89], and as such, MRI is favored as an initial diagnostic modality. CT Myelography Cervical Spine The literature search did not identify any studies regarding the use of CT myelography in the evaluation of this clinical presentation. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation.

Cervical Neck Pain or Cervical Radiculopathy PCAs. Although primary tumors of the spine are uncommon [83], an estimated 10% of cancer patients develop symptomatic spinal metastases during the course of their disease [84], making the spine the most common site of osseous metastatic disease [85]. Suspected spinal metastases are typically diagnosed using cross-sectional imaging with the dual goal of identifying potential metastases and characterizing the extent of malignancy. As such, the choice of imaging modality is often based on both the type of malignancy and the presenting clinical features, especially if referable to pathological fracture, cord compression, or nerve root impingement. CT Cervical Spine Because of its high spatial resolution, CT is more sensitive than conventional radiography for the detection of bone metastases and has shown good correlation with nuclear bone scans, particularly if coupled with concurrent CT examinations of the thorax, abdomen, and/or pelvis [86]. CT can help characterize lesions as lytic or blastic and may successfully assess paravertebral or intraspinal extension if intravenous contrast is used [87]. CT is also useful to obtain better structural definition of abnormal findings identified on scintigraphy or MRI [88], such as in the setting of suspected pathologic fracture. However, given that CT is relatively insensitive for tumors restricted to the marrow space, the sensitivity of CT is relatively low in early malignant bone involvement [87,89], and as such, MRI is favored as an initial diagnostic modality. CT Myelography Cervical Spine The literature search did not identify any studies regarding the use of CT myelography in the evaluation of this clinical presentation. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation.

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Cervical Neck Pain or Cervical Radiculopathy PCAs

Fluoride PET/CT whole body F-18-sodium fluoride (NaF) PET/CT has become an important tool for detecting and evaluating metastatic bone cancer [90,91] and may be a preferable modality for detecting metastatic bone disease in morbidly obese patients; however, there is currently no evidence supporting the validity of F-18 NaF PET/CT as a first-line test evaluating acute neck pain or radicular symptoms in patients with malignancy. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. FDG-PET/CT Whole Body FDG-PET/CT is sensitive for detection of metastatic disease and has been compared to detection rates of bone scans [92,93]. However, resolution of PET scans is limited for assessment of involvement of the spinal cord/meninges and exiting nerve roots, and as such, there is currently no evidence supporting the validity of FDG- PET/CT as a first-line test evaluating acute neck pain or radicular symptoms in patients with malignancy. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine MRI has high sensitivity and specificity for the detection and discrimination of malignant bone lesions [88], with the addition of contrast to delineate the extent of marrow leptomeningeal, epidural, neuroforminal, and paraspinal involvement. Furthermore, local spread of bone metastases and extension into the spinal canal is better assessed on MRI, particularly in the setting of clinical suspicion for nerve root or cord compression [94].

Cervical Neck Pain or Cervical Radiculopathy PCAs. Fluoride PET/CT whole body F-18-sodium fluoride (NaF) PET/CT has become an important tool for detecting and evaluating metastatic bone cancer [90,91] and may be a preferable modality for detecting metastatic bone disease in morbidly obese patients; however, there is currently no evidence supporting the validity of F-18 NaF PET/CT as a first-line test evaluating acute neck pain or radicular symptoms in patients with malignancy. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. FDG-PET/CT Whole Body FDG-PET/CT is sensitive for detection of metastatic disease and has been compared to detection rates of bone scans [92,93]. However, resolution of PET scans is limited for assessment of involvement of the spinal cord/meninges and exiting nerve roots, and as such, there is currently no evidence supporting the validity of FDG- PET/CT as a first-line test evaluating acute neck pain or radicular symptoms in patients with malignancy. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine MRI has high sensitivity and specificity for the detection and discrimination of malignant bone lesions [88], with the addition of contrast to delineate the extent of marrow leptomeningeal, epidural, neuroforminal, and paraspinal involvement. Furthermore, local spread of bone metastases and extension into the spinal canal is better assessed on MRI, particularly in the setting of clinical suspicion for nerve root or cord compression [94].

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Cervical Neck Pain or Cervical Radiculopathy PCAs

Bone Scan Whole Body with SPECT or SPECT/CT Neck Although Tc-99m bone scan is the most commonly used technique for detecting suspected osseous metastasis, it has a high false-positive rate secondary to benign processes with increased bone turnover, such as degenerative osteoarthrosis [95]. The addition of SPECT to the acquisition protocol of bone scintigraphy improves image contrast resolution [96] and, thus, diagnostic accuracy. Furthermore, adding a CT acquisition can increase this diagnostic accuracy with anatomic localization to the SPECT images resulting in SPECT/CT [36]. Cervical Neck Pain or Cervical Radiculopathy Radiography Cervical Spine Conventional radiography still plays an important role in the diagnostic evaluation of bone metastases as pathological changes in cortical bone are detectable by plain radiograph even if they are only a few millimeters wide [97]. Radiographs can also reveal osteolytic lesions at risk for superimposed pathological fracture. However, given that these osteolytic changes may only be detectable after 50% of the bone substance has been destroyed [87], and lesions up to 1 cm may not be detectable, radiographs alone are not sufficient to exclude metastases in the setting of neck pain in a patient with known malignancy. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17]. CT Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103].

Cervical Neck Pain or Cervical Radiculopathy PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Neck Although Tc-99m bone scan is the most commonly used technique for detecting suspected osseous metastasis, it has a high false-positive rate secondary to benign processes with increased bone turnover, such as degenerative osteoarthrosis [95]. The addition of SPECT to the acquisition protocol of bone scintigraphy improves image contrast resolution [96] and, thus, diagnostic accuracy. Furthermore, adding a CT acquisition can increase this diagnostic accuracy with anatomic localization to the SPECT images resulting in SPECT/CT [36]. Cervical Neck Pain or Cervical Radiculopathy Radiography Cervical Spine Conventional radiography still plays an important role in the diagnostic evaluation of bone metastases as pathological changes in cortical bone are detectable by plain radiograph even if they are only a few millimeters wide [97]. Radiographs can also reveal osteolytic lesions at risk for superimposed pathological fracture. However, given that these osteolytic changes may only be detectable after 50% of the bone substance has been destroyed [87], and lesions up to 1 cm may not be detectable, radiographs alone are not sufficient to exclude metastases in the setting of neck pain in a patient with known malignancy. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17]. CT Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103].

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Cervical Neck Pain or Cervical Radiculopathy PCAs

For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104]. CT Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, CT myelography is not an appropriate first-line imaging test. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103]. For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104]. Cervical Neck Pain or Cervical Radiculopathy Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited. The addition of SPECT to the acquisition protocol of bone scintigraphy improves image contrast resolution [105], and thus diagnostic accuracy. Some authors have advocated the use of SPECT imaging in identifying the pain source (ie, facet disease) [106]. Furthermore, adding a CT acquisition can increase this diagnostic accuracy with anatomic localization to the SPECT images resulting in SPECT/CT [36]. Radiography Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103].

Cervical Neck Pain or Cervical Radiculopathy PCAs. For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104]. CT Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, CT myelography is not an appropriate first-line imaging test. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103]. For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104]. Cervical Neck Pain or Cervical Radiculopathy Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited. The addition of SPECT to the acquisition protocol of bone scintigraphy improves image contrast resolution [105], and thus diagnostic accuracy. Some authors have advocated the use of SPECT imaging in identifying the pain source (ie, facet disease) [106]. Furthermore, adding a CT acquisition can increase this diagnostic accuracy with anatomic localization to the SPECT images resulting in SPECT/CT [36]. Radiography Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103].

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Cervical Neck Pain or Cervical Radiculopathy PCAs

For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104]. Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test. CT Cervical Spine CT is not currently recommended as a first-line examination for chronic neck pain in the absence of red flags or neurological symptoms. CT Myelography Cervical Spine CT myelography is not an appropriate test for chronic neck pain in the absence of radicular or myelopathic symptoms. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine MRI is the most sensitive test for detecting soft abnormalities associated with neck pain; however, it is characterized by a high rate of abnormalities in asymptomatic individuals [22,23]. As such, MRI is not considered appropriate as a first-line imaging modality in the setting of chronic, uncomplicated neck pain. Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited, though SPECT likely offers benefit over conventional planar imaging. Some authors have advocated SPECT imaging in identifying the pain source (ie, facet disease) [106]; however, is not considered appropriate as a first imaging modality in the setting of chronic, uncomplicated neck pain.

Cervical Neck Pain or Cervical Radiculopathy PCAs. For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104]. Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test. CT Cervical Spine CT is not currently recommended as a first-line examination for chronic neck pain in the absence of red flags or neurological symptoms. CT Myelography Cervical Spine CT myelography is not an appropriate test for chronic neck pain in the absence of radicular or myelopathic symptoms. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine MRI is the most sensitive test for detecting soft abnormalities associated with neck pain; however, it is characterized by a high rate of abnormalities in asymptomatic individuals [22,23]. As such, MRI is not considered appropriate as a first-line imaging modality in the setting of chronic, uncomplicated neck pain. Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited, though SPECT likely offers benefit over conventional planar imaging. Some authors have advocated SPECT imaging in identifying the pain source (ie, facet disease) [106]; however, is not considered appropriate as a first imaging modality in the setting of chronic, uncomplicated neck pain.

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acrac_69426_13

Cervical Neck Pain or Cervical Radiculopathy PCAs

Radiography Cervical Spine Radiographs may be helpful in clarifying the clinical diagnosis of cervical spondylosis from mechanical, inflammatory, or metabolic processes in patients who otherwise have no red flag symptoms [107]. Radiographically visible degenerative changes, such as disc space narrowing, osteophyte formation, facet, and uncovertebral hypertrophy, are common [108] and may not correlate with symptoms or impact treatment. CT Cervical Spine Multidetector CT scans with high-quality multiplanar reformatted images have enhanced the efficacy of CT, which offers superior depiction of cortical bone and is more sensitive than radiographs in the assessment of facet degenerative disease, osteophyte formation, vacuum phenomenon, and joint capsular calcification [24]. CT Myelography Cervical Spine CT myelography is not an appropriate test for chronic neck pain in the absence of radicular or myelopathic symptoms. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Percutaneous Interventions The use of provocative injections in the cervical spine to identify a pain source is controversial. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders concluded there was no evidence to support using cervical provocative discography or anesthetic facet or nerve blocks [1]. The use of facet injection as a diagnostic maneuver is limited by frequent anesthetic leakage into adjacent spaces, resulting in false-positive results [109,110]. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine In patients with neck pain without neurologic symptoms, the relevance of specific MRI findings in the cervical spine should be considered in light of expected changes associated with aging. MRI is more sensitive than CT in identifying degenerative cervical disorders [111,112].

Cervical Neck Pain or Cervical Radiculopathy PCAs. Radiography Cervical Spine Radiographs may be helpful in clarifying the clinical diagnosis of cervical spondylosis from mechanical, inflammatory, or metabolic processes in patients who otherwise have no red flag symptoms [107]. Radiographically visible degenerative changes, such as disc space narrowing, osteophyte formation, facet, and uncovertebral hypertrophy, are common [108] and may not correlate with symptoms or impact treatment. CT Cervical Spine Multidetector CT scans with high-quality multiplanar reformatted images have enhanced the efficacy of CT, which offers superior depiction of cortical bone and is more sensitive than radiographs in the assessment of facet degenerative disease, osteophyte formation, vacuum phenomenon, and joint capsular calcification [24]. CT Myelography Cervical Spine CT myelography is not an appropriate test for chronic neck pain in the absence of radicular or myelopathic symptoms. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation. Percutaneous Interventions The use of provocative injections in the cervical spine to identify a pain source is controversial. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders concluded there was no evidence to support using cervical provocative discography or anesthetic facet or nerve blocks [1]. The use of facet injection as a diagnostic maneuver is limited by frequent anesthetic leakage into adjacent spaces, resulting in false-positive results [109,110]. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation. MRI Cervical Spine In patients with neck pain without neurologic symptoms, the relevance of specific MRI findings in the cervical spine should be considered in light of expected changes associated with aging. MRI is more sensitive than CT in identifying degenerative cervical disorders [111,112].

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acrac_69426_14

Cervical Neck Pain or Cervical Radiculopathy PCAs

However, the presence of degenerative changes should be interpreted with caution. In a small series, Fryer et al [113] found little correlation between the presence of facet arthropathy and the side or level of symptoms in patients with acute, unilateral neck pain. Spondylotic changes on radiographs and MRI are common in patients over 30 years of age and have been shown to correlate poorly with the presence of neck pain [20-23,114,115]. Okada et al [112], in a 10-year longitudinal MRI study, showed that cervical disc degeneration progressed in 85% of patients, though symptoms developed in only 34% of patients. Most significantly, patients developing symptoms showed more frequent progression of disc degeneration on MRI, including anterior compression of the dura and spinal cord, posterior disc protrusion, disc space narrowing, and foraminal stenosis. Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited, though SPECT likely offers benefit over conventional planar imaging. Some authors have advocated the use of SPECT imaging in identifying the pain source (ie, facet disease) [106]. A recent retrospective study of 25 patients with chronic cervical spine pain demonstrated that hybrid SPECT/CT imaging identified potential pain generators in 92% of patients [26], and as such may have a role in secondary workup. Myelography Cervical Spine Myelography is not an appropriate test for chronic neck pain in the absence of radicular or myelopathic symptoms. Similar to more recent literature on MRI, asymptomatic degenerative changes have been described on myelograms [116]. Cervical Neck Pain or Cervical Radiculopathy Variant 9: Chronic cervical or neck pain without or with radiculopathy. Radiographs show ossification in the posterior longitudinal ligament (OPLL). Next imaging study.

Cervical Neck Pain or Cervical Radiculopathy PCAs. However, the presence of degenerative changes should be interpreted with caution. In a small series, Fryer et al [113] found little correlation between the presence of facet arthropathy and the side or level of symptoms in patients with acute, unilateral neck pain. Spondylotic changes on radiographs and MRI are common in patients over 30 years of age and have been shown to correlate poorly with the presence of neck pain [20-23,114,115]. Okada et al [112], in a 10-year longitudinal MRI study, showed that cervical disc degeneration progressed in 85% of patients, though symptoms developed in only 34% of patients. Most significantly, patients developing symptoms showed more frequent progression of disc degeneration on MRI, including anterior compression of the dura and spinal cord, posterior disc protrusion, disc space narrowing, and foraminal stenosis. Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited, though SPECT likely offers benefit over conventional planar imaging. Some authors have advocated the use of SPECT imaging in identifying the pain source (ie, facet disease) [106]. A recent retrospective study of 25 patients with chronic cervical spine pain demonstrated that hybrid SPECT/CT imaging identified potential pain generators in 92% of patients [26], and as such may have a role in secondary workup. Myelography Cervical Spine Myelography is not an appropriate test for chronic neck pain in the absence of radicular or myelopathic symptoms. Similar to more recent literature on MRI, asymptomatic degenerative changes have been described on myelograms [116]. Cervical Neck Pain or Cervical Radiculopathy Variant 9: Chronic cervical or neck pain without or with radiculopathy. Radiographs show ossification in the posterior longitudinal ligament (OPLL). Next imaging study.

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acrac_69426_15

Cervical Neck Pain or Cervical Radiculopathy PCAs

Heterotopic ossification in the posterior longitudinal ligament (OPLL) predisposes the patient to progressive narrowing of the spinal canal and/or abutment of the spinal cord. OPLL commonly presents in the fifth or sixth decade of life with a 2:1 male-to-female ratio. OPLL of the cervical spine is more common than thoracic OPLL, which was confirmed in a survey of 1,058 patients with OPLL, of whom 3.2% demonstrated involvement of the cervical spine and 0.8%, the thoracic spine [117]. Although original estimates of OPLL prevalence were based on lateral radiographs of the spine, more recently reported prevalence rates based on CT report prevalence rates of cervical OPLL between 1.7% in the white United States population and 4.6% in the Korean population [118,119]. CT Cervical Spine Although radiographs are helpful in the diagnosis of OPLL, particularly in the cervical region, CT is more reliable both in the identification of OPLL and in the evaluation of sequelae related to its diagnosis [120]. CT evaluation can show OPLL type, thickness, length of involved segments, and associated systemic diseases, such as diffuse idiopathic skeletal hyperostosis. The superior spatial resolution of CT helps identify regions of neuroforaminal and spinal canal narrowing and should be considered in any patient presenting with new or worsening radiculopathy in the setting of suspected OPLL. CT Myelography Cervical Spine CT myelography performed in flexion and extension has been described to help identify regions of position- dependent cord compression related to cervical spinal stenosis from OPLL [121], although it is not routinely used in clinical practice. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation.

Cervical Neck Pain or Cervical Radiculopathy PCAs. Heterotopic ossification in the posterior longitudinal ligament (OPLL) predisposes the patient to progressive narrowing of the spinal canal and/or abutment of the spinal cord. OPLL commonly presents in the fifth or sixth decade of life with a 2:1 male-to-female ratio. OPLL of the cervical spine is more common than thoracic OPLL, which was confirmed in a survey of 1,058 patients with OPLL, of whom 3.2% demonstrated involvement of the cervical spine and 0.8%, the thoracic spine [117]. Although original estimates of OPLL prevalence were based on lateral radiographs of the spine, more recently reported prevalence rates based on CT report prevalence rates of cervical OPLL between 1.7% in the white United States population and 4.6% in the Korean population [118,119]. CT Cervical Spine Although radiographs are helpful in the diagnosis of OPLL, particularly in the cervical region, CT is more reliable both in the identification of OPLL and in the evaluation of sequelae related to its diagnosis [120]. CT evaluation can show OPLL type, thickness, length of involved segments, and associated systemic diseases, such as diffuse idiopathic skeletal hyperostosis. The superior spatial resolution of CT helps identify regions of neuroforaminal and spinal canal narrowing and should be considered in any patient presenting with new or worsening radiculopathy in the setting of suspected OPLL. CT Myelography Cervical Spine CT myelography performed in flexion and extension has been described to help identify regions of position- dependent cord compression related to cervical spinal stenosis from OPLL [121], although it is not routinely used in clinical practice. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation.

69426

acrac_69421_0

Primary Bone Tumors

Primary bone tumors are conventionally classified by the World Health Organization as benign, intermediate (locally aggressive or rarely metastasizing), or malignant [1]. Benign tumors include a wide variety of developmental abnormalities and true neoplasms. Because most benign bone tumors are asymptomatic, the true incidence of these tumors is unknown, although they are not uncommon. Intermediate tumors include lesions such as giant cell tumor, osteoblastoma, and desmoplastic fibroma. Primary malignant bone tumors may also arise from malignant mesenchymal cells (sarcomas). Primary malignant bone tumors are quite rare, with an estimated incidence of 1 case per 100,000 persons per year [2]. Diagnosis of benign and malignant primary bone tumors relies on a coordinated evaluation of both clinical and radiologic information. Many primary bone tumors can be effectively stratified with respect to typical age of presentation as well as lesion size, location, and number. Classically, radiographs have played a substantial role in the characterization of primary bone tumors. An assortment of radiographic features, including tumor margin, periosteal reaction, and matrix mineralization, may be used to assess the biological activity of a bone lesion [3-6]. An asymptomatic nonaggressive-appearing lesion incidentally found on radiographs may, in many cases, require no further evaluation. In cases in which clinical or radiographic features are indeterminate or additional anatomic information is required, advanced imaging modalities, such as CT, MRI, or nuclear medicine, may provide a complementary role in the diagnosis and treatment stratification of primary bone tumors. Because primary bone sarcomas are rare, there is sparse level 1 evidence in the literature specifically addressing their imaging evaluation.

Primary Bone Tumors. Primary bone tumors are conventionally classified by the World Health Organization as benign, intermediate (locally aggressive or rarely metastasizing), or malignant [1]. Benign tumors include a wide variety of developmental abnormalities and true neoplasms. Because most benign bone tumors are asymptomatic, the true incidence of these tumors is unknown, although they are not uncommon. Intermediate tumors include lesions such as giant cell tumor, osteoblastoma, and desmoplastic fibroma. Primary malignant bone tumors may also arise from malignant mesenchymal cells (sarcomas). Primary malignant bone tumors are quite rare, with an estimated incidence of 1 case per 100,000 persons per year [2]. Diagnosis of benign and malignant primary bone tumors relies on a coordinated evaluation of both clinical and radiologic information. Many primary bone tumors can be effectively stratified with respect to typical age of presentation as well as lesion size, location, and number. Classically, radiographs have played a substantial role in the characterization of primary bone tumors. An assortment of radiographic features, including tumor margin, periosteal reaction, and matrix mineralization, may be used to assess the biological activity of a bone lesion [3-6]. An asymptomatic nonaggressive-appearing lesion incidentally found on radiographs may, in many cases, require no further evaluation. In cases in which clinical or radiographic features are indeterminate or additional anatomic information is required, advanced imaging modalities, such as CT, MRI, or nuclear medicine, may provide a complementary role in the diagnosis and treatment stratification of primary bone tumors. Because primary bone sarcomas are rare, there is sparse level 1 evidence in the literature specifically addressing their imaging evaluation.

69421

acrac_69421_1

Primary Bone Tumors

The recommendations contained herein are based on assessment of the available literature and on the experience of the members of the ACR Appropriateness Criteria Expert Panel on Musculoskeletal Imaging. This document applies to the evaluation of osseous lesions throughout the entire body. Generally, bone tumors are most common in the long bones [1], and consequently, recommendations for imaging are for the most part based on this. When lesions occur in locations with complex osseous anatomy, such as the skull, spine, pelvis, or small bones of the hand or foot, CT may be a more suitable initial imaging modality. Similarly, when a lesion occurs in a rib or area in which respiratory motion can be an issue, MRI may not be a suitable imaging modality. As noted within the document, the following recommendations must be adapted by the user, based on lesion size, location, and suspected biological aggressiveness. aResearch Author, Mayo Clinic, Jacksonville, Florida. bPanel Vice-Chair, Mayo Clinic, Jacksonville, Florida. cPanel Chair, University of Kentucky, Lexington, Kentucky. dUK Healthcare Spine and Total Joint Service, Lexington, Kentucky; American Academy of Orthopaedic Surgeons. eRadiology Imaging Associates, Denver, Colorado. fDiagnostic Imaging Associates, Chesterfield, Missouri. gWake Forest University School of Medicine, Winston Salem, North Carolina. hDavid Geffen School of Medicine at UCLA, Los Angeles, California. iUniversity of Virginia, Charlottesville, Virginia. jMayo Clinic Florida, Jacksonville, Florida. kUniversity Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio; Neurosurgery Expert. lOregon Health & Science University, Portland, Oregon; Neurosurgery Expert. mPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. nNuclear Radiologist, Weston, Connecticut. oSpecialty Chair, Mayo Clinic, Phoenix, Arizona.

Primary Bone Tumors. The recommendations contained herein are based on assessment of the available literature and on the experience of the members of the ACR Appropriateness Criteria Expert Panel on Musculoskeletal Imaging. This document applies to the evaluation of osseous lesions throughout the entire body. Generally, bone tumors are most common in the long bones [1], and consequently, recommendations for imaging are for the most part based on this. When lesions occur in locations with complex osseous anatomy, such as the skull, spine, pelvis, or small bones of the hand or foot, CT may be a more suitable initial imaging modality. Similarly, when a lesion occurs in a rib or area in which respiratory motion can be an issue, MRI may not be a suitable imaging modality. As noted within the document, the following recommendations must be adapted by the user, based on lesion size, location, and suspected biological aggressiveness. aResearch Author, Mayo Clinic, Jacksonville, Florida. bPanel Vice-Chair, Mayo Clinic, Jacksonville, Florida. cPanel Chair, University of Kentucky, Lexington, Kentucky. dUK Healthcare Spine and Total Joint Service, Lexington, Kentucky; American Academy of Orthopaedic Surgeons. eRadiology Imaging Associates, Denver, Colorado. fDiagnostic Imaging Associates, Chesterfield, Missouri. gWake Forest University School of Medicine, Winston Salem, North Carolina. hDavid Geffen School of Medicine at UCLA, Los Angeles, California. iUniversity of Virginia, Charlottesville, Virginia. jMayo Clinic Florida, Jacksonville, Florida. kUniversity Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio; Neurosurgery Expert. lOregon Health & Science University, Portland, Oregon; Neurosurgery Expert. mPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. nNuclear Radiologist, Weston, Connecticut. oSpecialty Chair, Mayo Clinic, Phoenix, Arizona.

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acrac_69421_2

Primary Bone Tumors

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] Primary Bone Tumors The recommendations for all variants in this document apply to the following body regions: lower extremity, upper extremity, ribs, pelvis, skull, and spine. Discussion of Procedures by Variant Variant 1: Suspect primary bone tumor. Initial imaging. CT Area of Interest CT is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of CT in the initial imaging of primary bone tumors. FDG-PET/CT Whole Body PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)/CT is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of FDG-PET/CT in the initial imaging of primary bone tumors. MRI Area of Interest MRI is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of MRI in the initial imaging of primary bone tumors. Radiography Area of Interest Radiographs remain the most appropriate imaging modality for screening and initial characterization of primary bone tumors. Radiographs provide an accurate means by which to evaluate primary bone tumors. Radiographs effectively provide information in regard to tumor location, size, and shape, as well as evidence of tumor biological activity [3]. Tumor margin and periosteal reaction provide a reliable index of biological potential of the tumor, whereas matrix, if identified, is a key to the underlying histology [3-6].

Primary Bone Tumors. 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] Primary Bone Tumors The recommendations for all variants in this document apply to the following body regions: lower extremity, upper extremity, ribs, pelvis, skull, and spine. Discussion of Procedures by Variant Variant 1: Suspect primary bone tumor. Initial imaging. CT Area of Interest CT is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of CT in the initial imaging of primary bone tumors. FDG-PET/CT Whole Body PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)/CT is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of FDG-PET/CT in the initial imaging of primary bone tumors. MRI Area of Interest MRI is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of MRI in the initial imaging of primary bone tumors. Radiography Area of Interest Radiographs remain the most appropriate imaging modality for screening and initial characterization of primary bone tumors. Radiographs provide an accurate means by which to evaluate primary bone tumors. Radiographs effectively provide information in regard to tumor location, size, and shape, as well as evidence of tumor biological activity [3]. Tumor margin and periosteal reaction provide a reliable index of biological potential of the tumor, whereas matrix, if identified, is a key to the underlying histology [3-6].

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acrac_69421_3

Primary Bone Tumors

Although the utility of radiographs in stratifying bone lesions by biological activity is well established, there is sparse literature documenting concrete values on accuracy. A prospective study evaluating 200 consecutive bone tumors of the hand showed that subjective grading of tumors based on radiographic features provided a correct categorization of tumor grade (benign versus malignant) in 82.5% of cases [7]. In a retrospective study applying a modified Lodwick-Madewell grading system to categorize 183 bone tumors, Caracciolo et al [8] found that a low radiographic grade assignment correlates with benignity and that increasing grade correlates with an increasing risk of malignancy. It should be noted that accurate radiographic characterization of some primary bone tumors (such as low-grade cartilage lesions) is inherently difficult because of overlapping radiographic features of some benign and malignant chondroid lesions. Crim et al [9] performed a retrospective review of 53 cases of low-grade cartilage lesions (enchondroma and grade 1 chondrosarcoma) and found that radiographs suggested the correct diagnosis of enchondroma in 67.2% of cases and the correct diagnosis of chondrosarcoma in only 20.8% of cases. In a retrospective analysis of 35 enchondromas and 43 central grade 1 chondrosarcomas, Geirnaerdt et al [10] found that morphologic features seen on radiographs in combination with clinical symptoms did not improve the ability to differentiate between enchondromas and central grade 1 chondrosarcomas. Bone Scan Whole Body Bone scan is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of Tc-99m bone scan in the initial imaging of primary bone tumors. US Area of Interest Ultrasound (US) is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of US in the initial imaging of primary bone tumors. Variant 2: Suspect primary bone tumor.

Primary Bone Tumors. Although the utility of radiographs in stratifying bone lesions by biological activity is well established, there is sparse literature documenting concrete values on accuracy. A prospective study evaluating 200 consecutive bone tumors of the hand showed that subjective grading of tumors based on radiographic features provided a correct categorization of tumor grade (benign versus malignant) in 82.5% of cases [7]. In a retrospective study applying a modified Lodwick-Madewell grading system to categorize 183 bone tumors, Caracciolo et al [8] found that a low radiographic grade assignment correlates with benignity and that increasing grade correlates with an increasing risk of malignancy. It should be noted that accurate radiographic characterization of some primary bone tumors (such as low-grade cartilage lesions) is inherently difficult because of overlapping radiographic features of some benign and malignant chondroid lesions. Crim et al [9] performed a retrospective review of 53 cases of low-grade cartilage lesions (enchondroma and grade 1 chondrosarcoma) and found that radiographs suggested the correct diagnosis of enchondroma in 67.2% of cases and the correct diagnosis of chondrosarcoma in only 20.8% of cases. In a retrospective analysis of 35 enchondromas and 43 central grade 1 chondrosarcomas, Geirnaerdt et al [10] found that morphologic features seen on radiographs in combination with clinical symptoms did not improve the ability to differentiate between enchondromas and central grade 1 chondrosarcomas. Bone Scan Whole Body Bone scan is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of Tc-99m bone scan in the initial imaging of primary bone tumors. US Area of Interest Ultrasound (US) is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of US in the initial imaging of primary bone tumors. Variant 2: Suspect primary bone tumor.

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acrac_69421_4

Primary Bone Tumors

Radiographs negative or do not explain symptoms. Next imaging study. In cases in which radiographs are negative or radiographic findings do not adequately explain the symptoms, further evaluation with advanced imaging (such as MRI or CT) should be contemplated based on history and level of clinical concern. CT Area of Interest In cases in which radiographs are negative or fail to adequately explain symptoms, CT can be a helpful tool in facilitating detection of bony abnormalities, such as nondisplaced fractures, subtle periosteal reaction, or occult bone tumors. CT can be especially helpful in evaluating regions of complex or overlapping osseous anatomy, in which radiographic evaluation can be limited. In a retrospective study of 47 patients with negative radiographic Primary Bone Tumors findings and positive bone scintigraphy findings specifically involving the ribs, CT was effective in detecting rib fractures and avoiding further unnecessary examinations [11]. CT is also a viable imaging alternative for patients who cannot receive an MRI. Some cases may benefit from both MRI and CT because these modalities provide complementary information regarding soft-tissue (often better evaluated on MRI) and matrix mineralization (often better evaluated on CT). There is no relevant literature specifically regarding the use of CT with intravenous (IV) contrast or CT without and with IV contrast in the evaluation of suspected primary bone tumor with negative or equivocal radiographs or radiographs that do not explain symptoms. Contrast may be helpful if a soft-tissue component is suspected. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used for the evaluation of primary bone tumors in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms.

Primary Bone Tumors. Radiographs negative or do not explain symptoms. Next imaging study. In cases in which radiographs are negative or radiographic findings do not adequately explain the symptoms, further evaluation with advanced imaging (such as MRI or CT) should be contemplated based on history and level of clinical concern. CT Area of Interest In cases in which radiographs are negative or fail to adequately explain symptoms, CT can be a helpful tool in facilitating detection of bony abnormalities, such as nondisplaced fractures, subtle periosteal reaction, or occult bone tumors. CT can be especially helpful in evaluating regions of complex or overlapping osseous anatomy, in which radiographic evaluation can be limited. In a retrospective study of 47 patients with negative radiographic Primary Bone Tumors findings and positive bone scintigraphy findings specifically involving the ribs, CT was effective in detecting rib fractures and avoiding further unnecessary examinations [11]. CT is also a viable imaging alternative for patients who cannot receive an MRI. Some cases may benefit from both MRI and CT because these modalities provide complementary information regarding soft-tissue (often better evaluated on MRI) and matrix mineralization (often better evaluated on CT). There is no relevant literature specifically regarding the use of CT with intravenous (IV) contrast or CT without and with IV contrast in the evaluation of suspected primary bone tumor with negative or equivocal radiographs or radiographs that do not explain symptoms. Contrast may be helpful if a soft-tissue component is suspected. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used for the evaluation of primary bone tumors in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms.

69421

acrac_69421_5

Primary Bone Tumors

Although FDG- PET/CT can detect metabolically active tumors, there is no relevant literature regarding the use of FDG-PET/CT in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms. Bone Scan Whole Body Despite its historical utility in detecting radiographically occult bone abnormalities, studies that are more recent have shown that MRI is superior in this role. A retrospective analysis comparing the sensitivity of MRI and scintigraphy in the detection of malignant bone tumors in 106 patients showed that MRI revealed a focal abnormality compatible with tumor that was occult on scintigraphy in 28% of cases [12]. Although not typically the next imaging study, bone scan remains a viable imaging option in select cases in which MRI is not clinically feasible as well as in cases that require evaluation of the full extent and distribution of disease because it can provide a comprehensive evaluation of the entire skeleton. US Area of Interest Although US may be helpful in detecting regional soft-tissue abnormalities that could explain symptoms, US is quite limited in its ability to evaluate bone. There is no relevant literature regarding the use of US for the evaluation of primary bone tumors in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms. Variant 3: Suspect primary bone tumor. Benign radiographic features. Not osteoid osteoma. Next imaging study. An asymptomatic benign-appearing lesion on radiographs is usually an incidental finding and typically requires no further imaging evaluation. If the lesion is symptomatic, please consult Variant 2. CT Area of Interest CT is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of CT in the evaluation of definitely benign primary bone tumors.

Primary Bone Tumors. Although FDG- PET/CT can detect metabolically active tumors, there is no relevant literature regarding the use of FDG-PET/CT in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms. Bone Scan Whole Body Despite its historical utility in detecting radiographically occult bone abnormalities, studies that are more recent have shown that MRI is superior in this role. A retrospective analysis comparing the sensitivity of MRI and scintigraphy in the detection of malignant bone tumors in 106 patients showed that MRI revealed a focal abnormality compatible with tumor that was occult on scintigraphy in 28% of cases [12]. Although not typically the next imaging study, bone scan remains a viable imaging option in select cases in which MRI is not clinically feasible as well as in cases that require evaluation of the full extent and distribution of disease because it can provide a comprehensive evaluation of the entire skeleton. US Area of Interest Although US may be helpful in detecting regional soft-tissue abnormalities that could explain symptoms, US is quite limited in its ability to evaluate bone. There is no relevant literature regarding the use of US for the evaluation of primary bone tumors in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms. Variant 3: Suspect primary bone tumor. Benign radiographic features. Not osteoid osteoma. Next imaging study. An asymptomatic benign-appearing lesion on radiographs is usually an incidental finding and typically requires no further imaging evaluation. If the lesion is symptomatic, please consult Variant 2. CT Area of Interest CT is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of CT in the evaluation of definitely benign primary bone tumors.

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acrac_69421_6

Primary Bone Tumors

However, if such lesions are symptomatic, CT imaging without IV contrast may be useful to identify complications or for surgical planning. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of FDG-PET/CT in the evaluation of definitely benign primary bone tumors. Primary Bone Tumors MRI Area of Interest MRI is not routinely used in the evaluation of lesions that are definitely benign on radiographs. If such lesions are symptomatic, MRI may be useful to identify unusual complications, such as stress fracture, secondary aneurysmal bone cyst formation, or malignant transformation [13]. Bone Scan Whole Body Bone scan is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of Tc-99m bone scan in the evaluation of definitely benign primary bone tumors. US Area of Interest US is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of US in the evaluation of definitely benign primary bone tumors. Variant 4: Suspect primary bone tumor. Radiographs or clinical presentation suggest osteoid osteoma. Next imaging study. CT Area of Interest CT is considered the optimal imaging modality in patients with suspected osteoid osteoma. CT is preferred over MRI when osteoid osteoma is strongly suspected because it is extremely sensitive for detection and precise delineation of the nidus [14], which is important both for diagnosis and treatment. In a study including 19 patients with histologically proven osteoid osteoma who underwent CT and MRI before excision of the lesion, Assoun et al [15] found that CT was more accurate than MRI in detection of the osteoid osteoma nidus in 63% of cases.

Primary Bone Tumors. However, if such lesions are symptomatic, CT imaging without IV contrast may be useful to identify complications or for surgical planning. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of FDG-PET/CT in the evaluation of definitely benign primary bone tumors. Primary Bone Tumors MRI Area of Interest MRI is not routinely used in the evaluation of lesions that are definitely benign on radiographs. If such lesions are symptomatic, MRI may be useful to identify unusual complications, such as stress fracture, secondary aneurysmal bone cyst formation, or malignant transformation [13]. Bone Scan Whole Body Bone scan is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of Tc-99m bone scan in the evaluation of definitely benign primary bone tumors. US Area of Interest US is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of US in the evaluation of definitely benign primary bone tumors. Variant 4: Suspect primary bone tumor. Radiographs or clinical presentation suggest osteoid osteoma. Next imaging study. CT Area of Interest CT is considered the optimal imaging modality in patients with suspected osteoid osteoma. CT is preferred over MRI when osteoid osteoma is strongly suspected because it is extremely sensitive for detection and precise delineation of the nidus [14], which is important both for diagnosis and treatment. In a study including 19 patients with histologically proven osteoid osteoma who underwent CT and MRI before excision of the lesion, Assoun et al [15] found that CT was more accurate than MRI in detection of the osteoid osteoma nidus in 63% of cases.

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acrac_69421_7

Primary Bone Tumors

There is no relevant literature specifically regarding the use of CT without and with IV contrast in the evaluation of suspected primary bone tumor with negative or equivocal radiographs or radiographs that do not explain symptoms. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. CT perfusion is a dynamic without and with IV contrast CT examination, which facilitates further characterization in the setting of suspected osteoid osteoma. A comparative study looking at CT perfusion parameters of 15 patients with a final diagnosis of osteoid osteoma, 15 patients with lesions that mimic osteoid osteomas, and 26 patients with other bone lytic lesions showed that enhancement curve morphology of the osteoid osteomas was significantly different from its mimickers. All osteoid osteomas had early enhancement with a delay between nidus and arterial peak below 30 seconds. Eighty percent of the mimickers demonstrated a slow and progressive pattern of enhancement. The perfusion parameters of the other lytic bone lesions were similar to those of the osteoid osteomas in 46.1% of the patients, indicating that early enhancement is suggestive but not pathognomonic of osteoid osteomas [16]. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used in the evaluation of suspected osteoid osteoma. There is no relevant literature regarding the use of FDG-PET/CT in the evaluation of suspected osteoid osteoma. MRI Area of Interest MRI is generally considered inferior to CT in the evaluation of suspected osteoid osteoma because it may fail to demonstrate the typical nidus and can present a confounding imaging appearance. Davies et al [17] performed a retrospective review of the MRI findings of 43 patients with osteoid osteoma and then compared the results with those of other imaging modalities. The authors found that the potential for a missed diagnosis of osteoid osteoma on MRI was 35%.

Primary Bone Tumors. There is no relevant literature specifically regarding the use of CT without and with IV contrast in the evaluation of suspected primary bone tumor with negative or equivocal radiographs or radiographs that do not explain symptoms. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. CT perfusion is a dynamic without and with IV contrast CT examination, which facilitates further characterization in the setting of suspected osteoid osteoma. A comparative study looking at CT perfusion parameters of 15 patients with a final diagnosis of osteoid osteoma, 15 patients with lesions that mimic osteoid osteomas, and 26 patients with other bone lytic lesions showed that enhancement curve morphology of the osteoid osteomas was significantly different from its mimickers. All osteoid osteomas had early enhancement with a delay between nidus and arterial peak below 30 seconds. Eighty percent of the mimickers demonstrated a slow and progressive pattern of enhancement. The perfusion parameters of the other lytic bone lesions were similar to those of the osteoid osteomas in 46.1% of the patients, indicating that early enhancement is suggestive but not pathognomonic of osteoid osteomas [16]. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used in the evaluation of suspected osteoid osteoma. There is no relevant literature regarding the use of FDG-PET/CT in the evaluation of suspected osteoid osteoma. MRI Area of Interest MRI is generally considered inferior to CT in the evaluation of suspected osteoid osteoma because it may fail to demonstrate the typical nidus and can present a confounding imaging appearance. Davies et al [17] performed a retrospective review of the MRI findings of 43 patients with osteoid osteoma and then compared the results with those of other imaging modalities. The authors found that the potential for a missed diagnosis of osteoid osteoma on MRI was 35%.

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acrac_69421_8

Primary Bone Tumors

They cautioned that osteoid osteoma may be difficult to identify on MRI and the imaging features may be easily misinterpreted. In a study including 19 patients with histologically proven osteoid osteoma who underwent CT and MRI before excision of the lesion, Assoun et al [15] found that MRI was better than CT in showing intramedullary and soft-tissue changes in all cases. However, the authors cautioned that such findings on MRI may produce a misleading aggressive appearance. Liu et al [18] performed a retrospective study including 11 patients with pathologically proven osteoid osteomas who underwent nonenhanced MRI, dynamic gadolinium-enhanced MRI, and CT. They showed that compared with CT, dynamic gadolinium-enhanced MRI demonstrated the osteoid osteoma equally well in 8 of 11 patients and with better conspicuity in 3 of 11 patients, although this difference was not statistically significant (P = . 69). Furthermore, the dynamic gadolinium-enhanced MRIs demonstrated the osteoid osteomas significantly better than the nonenhanced T1-weighted (P < . 001) and T2-weighted (P < . 001) MRIs. In the majority of cases, peak enhancement of the osteoid osteoma occurred in the Primary Bone Tumors arterial phase with early partial washout. However, MRI without IV contrast or MRI without and with IV contrast may be useful in some cases to identify alternative diagnoses such as osteomyelitis. Bone Scan Whole Body Bone scan is sensitive for the detection of osteoid osteoma but lacks specificity [19]. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest Bone scan is sensitive for the detection of osteoid osteoma but lacks specificity. Single-photon emission computed tomography (SPECT) or SPECT/CT may help improve specificity [19]. US Area of Interest US is not routinely used in the evaluation of suspected osteoid osteoma. There is no relevant literature regarding the use of US in the evaluation of suspected osteoid osteoma. Variant 5: Suspect primary bone tumor. Lesion on radiographs.

Primary Bone Tumors. They cautioned that osteoid osteoma may be difficult to identify on MRI and the imaging features may be easily misinterpreted. In a study including 19 patients with histologically proven osteoid osteoma who underwent CT and MRI before excision of the lesion, Assoun et al [15] found that MRI was better than CT in showing intramedullary and soft-tissue changes in all cases. However, the authors cautioned that such findings on MRI may produce a misleading aggressive appearance. Liu et al [18] performed a retrospective study including 11 patients with pathologically proven osteoid osteomas who underwent nonenhanced MRI, dynamic gadolinium-enhanced MRI, and CT. They showed that compared with CT, dynamic gadolinium-enhanced MRI demonstrated the osteoid osteoma equally well in 8 of 11 patients and with better conspicuity in 3 of 11 patients, although this difference was not statistically significant (P = . 69). Furthermore, the dynamic gadolinium-enhanced MRIs demonstrated the osteoid osteomas significantly better than the nonenhanced T1-weighted (P < . 001) and T2-weighted (P < . 001) MRIs. In the majority of cases, peak enhancement of the osteoid osteoma occurred in the Primary Bone Tumors arterial phase with early partial washout. However, MRI without IV contrast or MRI without and with IV contrast may be useful in some cases to identify alternative diagnoses such as osteomyelitis. Bone Scan Whole Body Bone scan is sensitive for the detection of osteoid osteoma but lacks specificity [19]. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest Bone scan is sensitive for the detection of osteoid osteoma but lacks specificity. Single-photon emission computed tomography (SPECT) or SPECT/CT may help improve specificity [19]. US Area of Interest US is not routinely used in the evaluation of suspected osteoid osteoma. There is no relevant literature regarding the use of US in the evaluation of suspected osteoid osteoma. Variant 5: Suspect primary bone tumor. Lesion on radiographs.

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acrac_69421_9

Primary Bone Tumors

Indeterminate or aggressive appearance for malignancy. Next imaging study. Lesions seen on radiographs that are not definitely benign often require additional characterization using advanced imaging studies such as MRI or CT. The next best imaging examination is not always clearly defined because the choice will be influenced by the radiographic appearance of the lesion, location, number of lesions, availability of imaging equipment, plan for biopsy/treatment, as well as underlying patient-specific clinical parameters. CT Area of Interest CT continues to play a role in the evaluation of indeterminate bone lesions discovered on radiographs, particularly in lesions with mineralized matrix or in suspected cases of osteoid osteoma (see Variant 4). Both MRI and CT have been used to evaluate the degree of cortical involvement in chondroid lesions [20]. In comparison with radiographs and MRI, CT has been shown to better delineate the presence of cortical destruction and the character of matrix mineralization patterns in patients with clear cell chondrosarcoma [21]. In a retrospective review of 40 pathologically confirmed telangiectatic osteosarcomas, Murphey et al [22] noted that CT was the optimal imaging modality for demonstration of subtle matrix mineralization seen in 85% of cases in the intraosseous or soft-tissue components of the lesion. Not all studies conclude that one modality, CT or MRI, is better than the other. A multi- institutional collaborative study assessing the relative accuracy of CT and MRI in the local staging of primary malignant musculoskeletal neoplasms showed no statistically significant difference between CT and MRI in determining tumor involvement of muscle, bone, joints, or neurovascular structures. Furthermore, the combined interpretation of CT and MRI did not significantly improve accuracy [23].

Primary Bone Tumors. Indeterminate or aggressive appearance for malignancy. Next imaging study. Lesions seen on radiographs that are not definitely benign often require additional characterization using advanced imaging studies such as MRI or CT. The next best imaging examination is not always clearly defined because the choice will be influenced by the radiographic appearance of the lesion, location, number of lesions, availability of imaging equipment, plan for biopsy/treatment, as well as underlying patient-specific clinical parameters. CT Area of Interest CT continues to play a role in the evaluation of indeterminate bone lesions discovered on radiographs, particularly in lesions with mineralized matrix or in suspected cases of osteoid osteoma (see Variant 4). Both MRI and CT have been used to evaluate the degree of cortical involvement in chondroid lesions [20]. In comparison with radiographs and MRI, CT has been shown to better delineate the presence of cortical destruction and the character of matrix mineralization patterns in patients with clear cell chondrosarcoma [21]. In a retrospective review of 40 pathologically confirmed telangiectatic osteosarcomas, Murphey et al [22] noted that CT was the optimal imaging modality for demonstration of subtle matrix mineralization seen in 85% of cases in the intraosseous or soft-tissue components of the lesion. Not all studies conclude that one modality, CT or MRI, is better than the other. A multi- institutional collaborative study assessing the relative accuracy of CT and MRI in the local staging of primary malignant musculoskeletal neoplasms showed no statistically significant difference between CT and MRI in determining tumor involvement of muscle, bone, joints, or neurovascular structures. Furthermore, the combined interpretation of CT and MRI did not significantly improve accuracy [23].

69421

acrac_69421_10

Primary Bone Tumors

Advanced CT techniques, such as dual- energy CT, have shown promise in differentiating malignant from nonmalignant tumors, although further research in this area is needed [24]. MRI is generally considered the preferred imaging modality for staging of bone tumors. Some cases may benefit from both MRI and CT because these modalities provide complementary information regarding soft-tissue (often better evaluated on MRI) and matrix mineralization (often better evaluated on CT). There is no relevant literature regarding the specific use of CT with IV contrast or CT without and with IV contrast in the evaluation of suspected primary bone tumor with radiographs indeterminate for malignancy. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. FDG-PET/CT Whole Body FDG-PET has proven useful for further characterizing indeterminate bone tumors identified on radiographs. PET information can be co-registered with CT or MRI, taking advantage of the inherent benefits of these modalities. A number of studies have shown FDG-PET and FDG-PET/CT to be a valuable adjunct to conventional imaging in the diagnosis, staging, restaging, and surveillance of primary bone tumors [25-31]. Shin et al [32] evaluated the efficacy of FDG-PET/CT in differentiating benign from malignant pathologic fractures in a series of 34 patients. With a standardized uptake value max cut-off set at 4.7, they found the sensitivity, specificity, and diagnostic accuracy of FDG-PET/CT to be 89.5%, 86.7%, and 88.2%, respectively. However, it was noted that there may be significant overlap in the metabolic activity of benign and malignant lesions, such as those containing myxoid or necrotic components with inherent low metabolic activity.

Primary Bone Tumors. Advanced CT techniques, such as dual- energy CT, have shown promise in differentiating malignant from nonmalignant tumors, although further research in this area is needed [24]. MRI is generally considered the preferred imaging modality for staging of bone tumors. Some cases may benefit from both MRI and CT because these modalities provide complementary information regarding soft-tissue (often better evaluated on MRI) and matrix mineralization (often better evaluated on CT). There is no relevant literature regarding the specific use of CT with IV contrast or CT without and with IV contrast in the evaluation of suspected primary bone tumor with radiographs indeterminate for malignancy. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. FDG-PET/CT Whole Body FDG-PET has proven useful for further characterizing indeterminate bone tumors identified on radiographs. PET information can be co-registered with CT or MRI, taking advantage of the inherent benefits of these modalities. A number of studies have shown FDG-PET and FDG-PET/CT to be a valuable adjunct to conventional imaging in the diagnosis, staging, restaging, and surveillance of primary bone tumors [25-31]. Shin et al [32] evaluated the efficacy of FDG-PET/CT in differentiating benign from malignant pathologic fractures in a series of 34 patients. With a standardized uptake value max cut-off set at 4.7, they found the sensitivity, specificity, and diagnostic accuracy of FDG-PET/CT to be 89.5%, 86.7%, and 88.2%, respectively. However, it was noted that there may be significant overlap in the metabolic activity of benign and malignant lesions, such as those containing myxoid or necrotic components with inherent low metabolic activity.

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acrac_69421_11

Primary Bone Tumors

In a study of 29 patients assessing the value of PET in appropriately characterizing cartilage neoplasms, the overall sensitivity of PET in differentiating benign from malignant lesions was 90.9%, with a specificity of 100% and accuracy of 96.6% [33]. Bredella et al [26] found Primary Bone Tumors that FDG-PET can help differentiate benign from malignant spinal compression fractures with a sensitivity of 86% and specificity of 83%; however, there was overlap in the range of standardized uptake value in the benign and malignant groups. MRI Area of Interest MRI is a robust tool that can further characterize an indeterminate bone lesion detected on radiographs. Despite its widespread use in this role, there are few controlled studies in the literature over the last 10 years specifically evaluating the role of MRI in further characterizing lesions detected on radiographs. Several studies do exist that serve to highlight the role of MRI in further characterizing the tissue composition (such as fat, hemorrhage, fluid levels) and anatomic extent of a variety of bone tumors [20-22,34,35]. MRI has also been shown to be useful in predicting the grade (benign versus malignant) of known primary bone tumors. A prospective study evaluating 200 consecutive bone tumors of the hand showed that MRI improved grading in comparison with radiography alone by correctly upgrading malignant tumors and downgrading benign tumors in 8% and 12% of cases, respectively [7]. Crim et al [9] performed a retrospective review of 53 cases of low-grade cartilage lesions (enchondroma and grade 1 chondrosarcoma) and found that MRI suggested the correct diagnosis of enchondroma in 57.8% of cases (radiographs correctly diagnosed 67.2% of cases) and the correct diagnosis of chondrosarcoma in 57.8% of cases (radiographs correctly diagnosed 20.8% of cases).

Primary Bone Tumors. In a study of 29 patients assessing the value of PET in appropriately characterizing cartilage neoplasms, the overall sensitivity of PET in differentiating benign from malignant lesions was 90.9%, with a specificity of 100% and accuracy of 96.6% [33]. Bredella et al [26] found Primary Bone Tumors that FDG-PET can help differentiate benign from malignant spinal compression fractures with a sensitivity of 86% and specificity of 83%; however, there was overlap in the range of standardized uptake value in the benign and malignant groups. MRI Area of Interest MRI is a robust tool that can further characterize an indeterminate bone lesion detected on radiographs. Despite its widespread use in this role, there are few controlled studies in the literature over the last 10 years specifically evaluating the role of MRI in further characterizing lesions detected on radiographs. Several studies do exist that serve to highlight the role of MRI in further characterizing the tissue composition (such as fat, hemorrhage, fluid levels) and anatomic extent of a variety of bone tumors [20-22,34,35]. MRI has also been shown to be useful in predicting the grade (benign versus malignant) of known primary bone tumors. A prospective study evaluating 200 consecutive bone tumors of the hand showed that MRI improved grading in comparison with radiography alone by correctly upgrading malignant tumors and downgrading benign tumors in 8% and 12% of cases, respectively [7]. Crim et al [9] performed a retrospective review of 53 cases of low-grade cartilage lesions (enchondroma and grade 1 chondrosarcoma) and found that MRI suggested the correct diagnosis of enchondroma in 57.8% of cases (radiographs correctly diagnosed 67.2% of cases) and the correct diagnosis of chondrosarcoma in 57.8% of cases (radiographs correctly diagnosed 20.8% of cases).

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acrac_69421_12

Primary Bone Tumors

Overall, MRI had an increased rate of both true-positive and radiographic characterization, the characterization of low-grade chondroid lesions on MRI is challenging because of overlapping features of benign and malignant lesions. MRI is generally considered the preferred imaging modality for staging of bone tumors [14]. Hogeboom et al [36] compared the value of MRI to CT in the evaluation of bone tumors in a prospective study of 25 patients. They found that MRI has better soft-tissue contrast than CT, making it possible to study the relationship of the bone tumor to the soft tissues, bone marrow, and joints more accurately. They found that CT better defines destruction of cortical bone. Specifically, MRI was superior to CT in detecting cortical bone destruction in 4.5% of patients studied and better at evaluating marrow involvement in 25%, soft-tissue involvement in 31%, joint involvement in 36.4%, and invasion of neurovascular structures in 15.3% of patients. MRI and CT were judged equivalent in these categories the majority of the time (ranging from 63% to 82% of the time for the various categories). CT was superior to MRI for some patients in two categories: detecting cortical bone destruction (13.6%) and neurovascular involvement (7.7%). If both modalities are available, the authors suggest that MRI is preferable to CT. A prospective study comparing the staging of primary bone sarcoma with CT, MRI, bone scintigraphy, and angiography in 56 patients showed that MRI was superior in defining tumor length, demonstrating involvement of muscle compartments, and delineating the relationship between tumor and major neurovascular bundles [37]. In the same study, MRI was shown to be comparable to CT in demonstrating cortical bone and joint involvement [37].

Primary Bone Tumors. Overall, MRI had an increased rate of both true-positive and radiographic characterization, the characterization of low-grade chondroid lesions on MRI is challenging because of overlapping features of benign and malignant lesions. MRI is generally considered the preferred imaging modality for staging of bone tumors [14]. Hogeboom et al [36] compared the value of MRI to CT in the evaluation of bone tumors in a prospective study of 25 patients. They found that MRI has better soft-tissue contrast than CT, making it possible to study the relationship of the bone tumor to the soft tissues, bone marrow, and joints more accurately. They found that CT better defines destruction of cortical bone. Specifically, MRI was superior to CT in detecting cortical bone destruction in 4.5% of patients studied and better at evaluating marrow involvement in 25%, soft-tissue involvement in 31%, joint involvement in 36.4%, and invasion of neurovascular structures in 15.3% of patients. MRI and CT were judged equivalent in these categories the majority of the time (ranging from 63% to 82% of the time for the various categories). CT was superior to MRI for some patients in two categories: detecting cortical bone destruction (13.6%) and neurovascular involvement (7.7%). If both modalities are available, the authors suggest that MRI is preferable to CT. A prospective study comparing the staging of primary bone sarcoma with CT, MRI, bone scintigraphy, and angiography in 56 patients showed that MRI was superior in defining tumor length, demonstrating involvement of muscle compartments, and delineating the relationship between tumor and major neurovascular bundles [37]. In the same study, MRI was shown to be comparable to CT in demonstrating cortical bone and joint involvement [37].

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acrac_69421_13

Primary Bone Tumors

In contrast, results of a multi-institutional collaborative study assessing the relative accuracy of CT and MRI in the local staging of primary malignant musculoskeletal neoplasms showed no statistically significant difference between CT and MRI in determining tumor involvement of muscle, bone, joints, or neurovascular structures [23]. Furthermore, the combined interpretation of CT and MRI did not significantly improve accuracy [23]. However, a more recent retrospective study comparing the diagnostic accuracy of radiographs, CT, MRI, bone scintigraphy, and FDG-PET/CT versus pathology reports in 409 biopsy-proven tumors showed that the sensitivity of MRI and FDG-PET/CT was better than that of CT, bone scintigraphy, and radiographs. In spine lesions, MRI was the most sensitive modality for detection of tumors, followed by FDG-PET/CT and CT [38]. Several studies have shown that contrast-enhanced MRI and MR angiography can provide additional information (eg, more accurate characterization, evaluation of viability, and biopsy planning) for the preoperative evaluation of primary bone tumors [39-41]. In a study of 37 patients with cartilaginous tumors, Geirnaerdt et al [42] evaluated the utility of fast contrast-enhanced MRI in differentiating benign from malignant tumors. They found that differentiation of malignancy from benignity was possible with this technique, with a sensitivity of 61% and specificity of 95%. The usefulness of MRI with dynamic contrast enhancement in characterizing lesions as benign or malignant has been evaluated in several additional studies with mixed results [43,44]. Other imaging techniques, such as diffusion-weighted and chemical shift MRI, have been shown to be useful in differentiating benign from malignant bone tumors [45-47]. MRI with dynamic contrast enhancement [43], as well as diffusion and chemical shift MRI [47], can help differentiate benign from malignant spinal compression fractures.

Primary Bone Tumors. In contrast, results of a multi-institutional collaborative study assessing the relative accuracy of CT and MRI in the local staging of primary malignant musculoskeletal neoplasms showed no statistically significant difference between CT and MRI in determining tumor involvement of muscle, bone, joints, or neurovascular structures [23]. Furthermore, the combined interpretation of CT and MRI did not significantly improve accuracy [23]. However, a more recent retrospective study comparing the diagnostic accuracy of radiographs, CT, MRI, bone scintigraphy, and FDG-PET/CT versus pathology reports in 409 biopsy-proven tumors showed that the sensitivity of MRI and FDG-PET/CT was better than that of CT, bone scintigraphy, and radiographs. In spine lesions, MRI was the most sensitive modality for detection of tumors, followed by FDG-PET/CT and CT [38]. Several studies have shown that contrast-enhanced MRI and MR angiography can provide additional information (eg, more accurate characterization, evaluation of viability, and biopsy planning) for the preoperative evaluation of primary bone tumors [39-41]. In a study of 37 patients with cartilaginous tumors, Geirnaerdt et al [42] evaluated the utility of fast contrast-enhanced MRI in differentiating benign from malignant tumors. They found that differentiation of malignancy from benignity was possible with this technique, with a sensitivity of 61% and specificity of 95%. The usefulness of MRI with dynamic contrast enhancement in characterizing lesions as benign or malignant has been evaluated in several additional studies with mixed results [43,44]. Other imaging techniques, such as diffusion-weighted and chemical shift MRI, have been shown to be useful in differentiating benign from malignant bone tumors [45-47]. MRI with dynamic contrast enhancement [43], as well as diffusion and chemical shift MRI [47], can help differentiate benign from malignant spinal compression fractures.

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acrac_69421_14

Primary Bone Tumors

Characterization of bone tumors as benign or malignant with MR spectroscopy has shown promise in two small observational studies, although further research is needed [48,49]. Primary Bone Tumors Radiography Skeletal Survey Radiographic survey of the whole body is of limited utility in the evaluation of a suspected primary bone tumor with an indeterminate or aggressive appearance detected on radiographs. The primary utility of radiographic skeletal survey is in evaluating the appearance and distribution of polyostotic bone lesions, which are most commonly multiple myeloma or metastases rather than primary bone lesions. Bone Scan Whole Body Despite its historical utility in further characterizing lesions detected on radiographs, there are no controlled studies in the literature over the last 10 years specifically evaluating the efficacy of bone scan in this role. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest Despite its historical utility in further characterizing lesions detected on radiographs, there are no controlled studies in the literature over the last 10 years specifically evaluating the efficacy of bone scan in this role. However, recent advances in technology, such as SPECT/CT, may provide a useful tool in the evaluation of primary bone tumors. A retrospective review of 99 patients with 108 vertebral lesions showed that SPECT/CT was superior to planar scintigraphy and SPECT alone, but not CT alone, in the characterization of indeterminate vertebral lesions found on bone scintigraphy [50]. US Area of Interest US is not routinely used in the evaluation of indeterminate or aggressive bone lesions seen on radiographs. There is no relevant literature regarding the use of US in the evaluation of an indeterminate or aggressive lesion detected on radiographs. CT Area of Interest There is no relevant literature regarding the use of CT in the evaluation of bone lesions incidentally found on MRI.

Primary Bone Tumors. Characterization of bone tumors as benign or malignant with MR spectroscopy has shown promise in two small observational studies, although further research is needed [48,49]. Primary Bone Tumors Radiography Skeletal Survey Radiographic survey of the whole body is of limited utility in the evaluation of a suspected primary bone tumor with an indeterminate or aggressive appearance detected on radiographs. The primary utility of radiographic skeletal survey is in evaluating the appearance and distribution of polyostotic bone lesions, which are most commonly multiple myeloma or metastases rather than primary bone lesions. Bone Scan Whole Body Despite its historical utility in further characterizing lesions detected on radiographs, there are no controlled studies in the literature over the last 10 years specifically evaluating the efficacy of bone scan in this role. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest Despite its historical utility in further characterizing lesions detected on radiographs, there are no controlled studies in the literature over the last 10 years specifically evaluating the efficacy of bone scan in this role. However, recent advances in technology, such as SPECT/CT, may provide a useful tool in the evaluation of primary bone tumors. A retrospective review of 99 patients with 108 vertebral lesions showed that SPECT/CT was superior to planar scintigraphy and SPECT alone, but not CT alone, in the characterization of indeterminate vertebral lesions found on bone scintigraphy [50]. US Area of Interest US is not routinely used in the evaluation of indeterminate or aggressive bone lesions seen on radiographs. There is no relevant literature regarding the use of US in the evaluation of an indeterminate or aggressive lesion detected on radiographs. CT Area of Interest There is no relevant literature regarding the use of CT in the evaluation of bone lesions incidentally found on MRI.

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acrac_69421_15

Primary Bone Tumors

However, CT, be it without IV contrast, with IV contrast, or without and with IV contrast, may provide complementary information, particularly in respect to assessing matrix mineralization, cortical destruction, or in suspected cases of osteoid osteoma. If contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. However, radiographic evaluation is generally recommended as the next best imaging modality. FDG-PET/CT Whole Body Radiographic evaluation is generally recommended as the next best imaging modality to evaluate bone lesions incidentally found on MRI and CT. FDG-PET/CT may play a limited role in the evaluation of bone lesions incidentally found on MRI and CT. MRI Area of Interest If the initial MRI is not of sufficient quality (eg, limited coverage, limited sequences, etc) or was performed using a nonmusculoskeletal protocol (eg, an incidentally discovered bone lesion on a prostate MRI), then a repeat MRI examination may be warranted. However, this should typically follow radiographic imaging, which can be used to better plan the repeat MRI. Supplementation of an MRI initially performed without IV contrast with contrast- enhanced sequences may provide additional information about lesion vascularity and relationship to regional vascular structures. MRI evaluation of the area of interest may provide complementary information facilitating further assessment of the lesion and can be helpful in preoperative planning. Although there is no relevant literature regarding the use of MRI in the evaluation of bone lesions incidentally found on CT, MRI may provide complementary information, particularly with regard to evaluating soft-tissue components. However, radiographic evaluation is generally the next best imaging modality.

Primary Bone Tumors. However, CT, be it without IV contrast, with IV contrast, or without and with IV contrast, may provide complementary information, particularly in respect to assessing matrix mineralization, cortical destruction, or in suspected cases of osteoid osteoma. If contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. However, radiographic evaluation is generally recommended as the next best imaging modality. FDG-PET/CT Whole Body Radiographic evaluation is generally recommended as the next best imaging modality to evaluate bone lesions incidentally found on MRI and CT. FDG-PET/CT may play a limited role in the evaluation of bone lesions incidentally found on MRI and CT. MRI Area of Interest If the initial MRI is not of sufficient quality (eg, limited coverage, limited sequences, etc) or was performed using a nonmusculoskeletal protocol (eg, an incidentally discovered bone lesion on a prostate MRI), then a repeat MRI examination may be warranted. However, this should typically follow radiographic imaging, which can be used to better plan the repeat MRI. Supplementation of an MRI initially performed without IV contrast with contrast- enhanced sequences may provide additional information about lesion vascularity and relationship to regional vascular structures. MRI evaluation of the area of interest may provide complementary information facilitating further assessment of the lesion and can be helpful in preoperative planning. Although there is no relevant literature regarding the use of MRI in the evaluation of bone lesions incidentally found on CT, MRI may provide complementary information, particularly with regard to evaluating soft-tissue components. However, radiographic evaluation is generally the next best imaging modality.

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acrac_69421_16

Primary Bone Tumors

Radiography Area of Interest Although there is no relevant literature specifically regarding recommendations for follow-up of bone lesions incidentally found on MRI, radiographic evaluation of the area of interest is generally considered the initial study of choice in this situation. Initial radiographs not only provide an accurate means by which to evaluate primary Primary Bone Tumors bone tumors but also provide a baseline study for a bone lesion that may be followed radiographically. Radiographs provide information regarding tumor location, size, and shape as well as evidence of tumor biological activity [3]. Tumor margin and periosteal reaction provide a reliable index of biological potential of the tumor, whereas matrix, if identified, is a key to the underlying histology [3-6]. Although the utility of radiographs in stratifying bone lesions into aggressive and nonaggressive categories is well established, there is sparse literature documenting concrete values on accuracy. A prospective study evaluating 200 consecutive bone tumors of the hand showed that subjective grading of tumors based on radiographic features provided a correct categorization of tumor grade (benign versus malignant) in 82.5% of cases [7]. In a retrospective study applying a modified Lodwick-Madewell grading system to categorize 183 bone tumors, Caracciolo et al [8] found that a low radiographic grade assignment correlates with benignity and that increasing grade correlates with an increasing risk of malignancy. In the case of an incidental lesion on CT, radiographic evaluation of the area of interest may be helpful in allowing for assessment of the lesion based on well-established radiographic criteria. However, radiographs are unlikely to add any additional information specifically about matrix mineralization or cortical involvement that is not readily evident on CT. This is especially true if a high-quality CT with multiplanar reformatting in the coronal and sagittal planes was obtained.

Primary Bone Tumors. Radiography Area of Interest Although there is no relevant literature specifically regarding recommendations for follow-up of bone lesions incidentally found on MRI, radiographic evaluation of the area of interest is generally considered the initial study of choice in this situation. Initial radiographs not only provide an accurate means by which to evaluate primary Primary Bone Tumors bone tumors but also provide a baseline study for a bone lesion that may be followed radiographically. Radiographs provide information regarding tumor location, size, and shape as well as evidence of tumor biological activity [3]. Tumor margin and periosteal reaction provide a reliable index of biological potential of the tumor, whereas matrix, if identified, is a key to the underlying histology [3-6]. Although the utility of radiographs in stratifying bone lesions into aggressive and nonaggressive categories is well established, there is sparse literature documenting concrete values on accuracy. A prospective study evaluating 200 consecutive bone tumors of the hand showed that subjective grading of tumors based on radiographic features provided a correct categorization of tumor grade (benign versus malignant) in 82.5% of cases [7]. In a retrospective study applying a modified Lodwick-Madewell grading system to categorize 183 bone tumors, Caracciolo et al [8] found that a low radiographic grade assignment correlates with benignity and that increasing grade correlates with an increasing risk of malignancy. In the case of an incidental lesion on CT, radiographic evaluation of the area of interest may be helpful in allowing for assessment of the lesion based on well-established radiographic criteria. However, radiographs are unlikely to add any additional information specifically about matrix mineralization or cortical involvement that is not readily evident on CT. This is especially true if a high-quality CT with multiplanar reformatting in the coronal and sagittal planes was obtained.

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acrac_69445_0

Vomiting in Infants

Introduction/Background Vomiting is common in infants, and in the majority of cases is benign. However, vomiting can be a sign of underlying pathology, which could be related to obstruction along the course of the gastrointestinal (GI) tract and may be secondary to infectious etiologies, neurologic diseases, mechanical, or metabolic causes [1,2]. This topic will be limited to the role of imaging in evaluation of complete or partial GI obstruction. Clinically, vomiting is categorized as being nonbilious or bilious; the latter suggests the point of obstruction is distal to the ampulla of Vater. Most commonly, nonbilious vomiting is actually regurgitation, known as gastroesophageal reflux (GER). The clinical differentiation between vomiting and regurgitation may be challenging. Vomiting, secondary to GER, is normal in infants, with decreased incidence with age and resolves in time. It usually has no definitive pathologic cause and is unrelated to a functional defect. Rarely, regurgitation may be due to displacement of a portion of the stomach into the chest (ie, hiatal hernia). In other cases, lower esophageal sphincter pressures or delays in gastric emptying have been implicated as causative and typically resolve in time [1]. Parental complaints of vomiting or regurgitation in infants are common. The cause is usually GER, particularly in the first weeks of life and in part because of overfeeding. Infants with normal weight gain and no other symptoms tend not to have obstruction as the cause of their vomiting [3]. Bilious emesis or repeated forceful vomiting should be evaluated for underlying obstruction. When evaluating a neonate who presents in the first week of life with vomiting, a congenital GI tract abnormality is a primary consideration.

Vomiting in Infants. Introduction/Background Vomiting is common in infants, and in the majority of cases is benign. However, vomiting can be a sign of underlying pathology, which could be related to obstruction along the course of the gastrointestinal (GI) tract and may be secondary to infectious etiologies, neurologic diseases, mechanical, or metabolic causes [1,2]. This topic will be limited to the role of imaging in evaluation of complete or partial GI obstruction. Clinically, vomiting is categorized as being nonbilious or bilious; the latter suggests the point of obstruction is distal to the ampulla of Vater. Most commonly, nonbilious vomiting is actually regurgitation, known as gastroesophageal reflux (GER). The clinical differentiation between vomiting and regurgitation may be challenging. Vomiting, secondary to GER, is normal in infants, with decreased incidence with age and resolves in time. It usually has no definitive pathologic cause and is unrelated to a functional defect. Rarely, regurgitation may be due to displacement of a portion of the stomach into the chest (ie, hiatal hernia). In other cases, lower esophageal sphincter pressures or delays in gastric emptying have been implicated as causative and typically resolve in time [1]. Parental complaints of vomiting or regurgitation in infants are common. The cause is usually GER, particularly in the first weeks of life and in part because of overfeeding. Infants with normal weight gain and no other symptoms tend not to have obstruction as the cause of their vomiting [3]. Bilious emesis or repeated forceful vomiting should be evaluated for underlying obstruction. When evaluating a neonate who presents in the first week of life with vomiting, a congenital GI tract abnormality is a primary consideration.

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Upper or lower tract abnormalities can cause vomiting with possible etiologies including malrotation with or without volvulus, atresia of the antropyloric region, annular pancreas, atresia/stenosis of the small bowel or colon, functional obstructions caused by Hirschsprung disease, functional immaturity of the colon, and meconium ileus. Importantly, although malrotation most commonly presents in newborns, it can present at any time during life with decreasing frequency with age. Several GI pathologies to consider in a vomiting infant outside of the newborn period include hypertrophic pyloric stenosis (HPS), pylorospasm, formula intolerance, and gastroenteritis. In a young infant, less common GI etiologies include neonatal appendicitis, intussusception, gastric ulcer disease, gastric volvulus, trauma, and foreign body including lactobezoar. Medical causes to consider include sepsis, enteritis, pneumonia, otitis media, meningitis, raised trauma, or hydrocephalus), kernicterus, metabolic disorders (phenylketonuria, hyperammonemia, maple syrup urine disease, galactosemia, diabetes, adrenocortical hyperplasia, and methylmalonic acidemia), diencephalic syndrome, and rarely drugs or toxic agents [3-5]. 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] Vomiting in Infants Intussusception, which is unusual in the first 3 months of life, may be diagnosed clinically by crampy, intermittent abdominal pain sometimes progressing to bloody stools and lethargy. Patients with increased intracranial pressure may have an enlarging head circumference, bulging fontanelle, and/or neurologic signs [3,5].

Vomiting in Infants. Upper or lower tract abnormalities can cause vomiting with possible etiologies including malrotation with or without volvulus, atresia of the antropyloric region, annular pancreas, atresia/stenosis of the small bowel or colon, functional obstructions caused by Hirschsprung disease, functional immaturity of the colon, and meconium ileus. Importantly, although malrotation most commonly presents in newborns, it can present at any time during life with decreasing frequency with age. Several GI pathologies to consider in a vomiting infant outside of the newborn period include hypertrophic pyloric stenosis (HPS), pylorospasm, formula intolerance, and gastroenteritis. In a young infant, less common GI etiologies include neonatal appendicitis, intussusception, gastric ulcer disease, gastric volvulus, trauma, and foreign body including lactobezoar. Medical causes to consider include sepsis, enteritis, pneumonia, otitis media, meningitis, raised trauma, or hydrocephalus), kernicterus, metabolic disorders (phenylketonuria, hyperammonemia, maple syrup urine disease, galactosemia, diabetes, adrenocortical hyperplasia, and methylmalonic acidemia), diencephalic syndrome, and rarely drugs or toxic agents [3-5]. 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] Vomiting in Infants Intussusception, which is unusual in the first 3 months of life, may be diagnosed clinically by crampy, intermittent abdominal pain sometimes progressing to bloody stools and lethargy. Patients with increased intracranial pressure may have an enlarging head circumference, bulging fontanelle, and/or neurologic signs [3,5].

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When the clinical and laboratory assessment provides a definitive diagnosis and treatment plan, radiologic imaging is not required. Clinical diagnostic uncertainty may require use of imaging. Often the initial imaging helps in determining whether the patient has bowel obstruction and may provide insight into whether it is proximal or distal obstruction. In some cases, other imaging is necessary to provide diagnosis that is more definitive, help with surgical approach, and diagnose cases that require urgent surgery. OR Discussion of Procedures by Variant Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging. Bilious vomiting in the first days after birth is an ominous sign that suggests the possibility of bowel obstruction and in some cases the need for urgent surgery. In a study of 45 patients with bilious vomiting in the first 72 hours of life, 20% had midgut volvulus and 11% had a lower GI cause (meconium plug syndrome or left-sided microcolon) [6]. Vomiting usually begins in the first 2 days after birth in children with intestinal atresia and is usually bilious. Bilious vomiting and gastric distension suggest proximal bowel obstruction. About 15% of children with proximal bowel obstruction will have nonbilious vomiting [7]. No passage of meconium and yellow colostrum or vomitus with meconium is typical for distal bowel obstruction. Imaging has a role for definitive diagnosis of bowel obstruction as a cause of the vomiting; it can differentiate between proximal and distal obstruction and exclude midgut volvulus that requires urgent surgery. Radiography Abdomen When evaluating a newborn with vomiting after birth, especially when there is bilious vomiting, the initial concern is to identify diseases that require emergent surgical management, specifically, malrotation with midgut volvulus and intestinal atresias.

Vomiting in Infants. When the clinical and laboratory assessment provides a definitive diagnosis and treatment plan, radiologic imaging is not required. Clinical diagnostic uncertainty may require use of imaging. Often the initial imaging helps in determining whether the patient has bowel obstruction and may provide insight into whether it is proximal or distal obstruction. In some cases, other imaging is necessary to provide diagnosis that is more definitive, help with surgical approach, and diagnose cases that require urgent surgery. OR Discussion of Procedures by Variant Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging. Bilious vomiting in the first days after birth is an ominous sign that suggests the possibility of bowel obstruction and in some cases the need for urgent surgery. In a study of 45 patients with bilious vomiting in the first 72 hours of life, 20% had midgut volvulus and 11% had a lower GI cause (meconium plug syndrome or left-sided microcolon) [6]. Vomiting usually begins in the first 2 days after birth in children with intestinal atresia and is usually bilious. Bilious vomiting and gastric distension suggest proximal bowel obstruction. About 15% of children with proximal bowel obstruction will have nonbilious vomiting [7]. No passage of meconium and yellow colostrum or vomitus with meconium is typical for distal bowel obstruction. Imaging has a role for definitive diagnosis of bowel obstruction as a cause of the vomiting; it can differentiate between proximal and distal obstruction and exclude midgut volvulus that requires urgent surgery. Radiography Abdomen When evaluating a newborn with vomiting after birth, especially when there is bilious vomiting, the initial concern is to identify diseases that require emergent surgical management, specifically, malrotation with midgut volvulus and intestinal atresias.

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There are some bowel gas patterns that can guide management; double bubble with no distal gas (classic double bubble) or triple bubble with no distal gas, double bubble with distal gas (nonclassic double bubble), and multiple distended bowel loops with no or decreased distal gas (see Variants 2 and 4) [8]. Fluoroscopy Contrast Enema Although beginning the workup with a contrast enema may lead to a diagnosis, there is no relevant literature to support the use of performing a contrast enema as the initial imaging study prior to an abdominal radiograph. Fluoroscopy Upper GI Series Although beginning the workup with an upper GI (UGI) series may lead to a diagnosis, there is no relevant literature to support the use of performing a UGI series as the initial imaging study prior to an abdominal radiograph. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m diethylenetriamine pentaacetic acid (DTPA) or Tc-99m microaggregated albumin (MAA) in the initial imaging evaluation of the neonate with acute bilious vomiting. Vomiting in Infants US Abdomen (UGI Tract) There is no relevant literature to support the use of ultrasound (US) as the initial imaging examination prior to an abdominal radiograph for the neonate with acute bilious vomiting. Fluoroscopy Contrast Enema In the setting of a suspected proximal atresia with absent distal bowel gas, there is no relevant literature to support the use of a contrast enema for diagnosis. Atresias can be multiple in approximately 15% of patients. Most of these can be diagnosed at the initial surgical exploration [11]. Fluoroscopy Upper GI Series In the setting of a classic double bubble or triple bubble with no gas distally, a UGI series is usually not necessary, because the positive contrast used in fluoroscopy does not typically provide more anatomic details.

Vomiting in Infants. There are some bowel gas patterns that can guide management; double bubble with no distal gas (classic double bubble) or triple bubble with no distal gas, double bubble with distal gas (nonclassic double bubble), and multiple distended bowel loops with no or decreased distal gas (see Variants 2 and 4) [8]. Fluoroscopy Contrast Enema Although beginning the workup with a contrast enema may lead to a diagnosis, there is no relevant literature to support the use of performing a contrast enema as the initial imaging study prior to an abdominal radiograph. Fluoroscopy Upper GI Series Although beginning the workup with an upper GI (UGI) series may lead to a diagnosis, there is no relevant literature to support the use of performing a UGI series as the initial imaging study prior to an abdominal radiograph. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m diethylenetriamine pentaacetic acid (DTPA) or Tc-99m microaggregated albumin (MAA) in the initial imaging evaluation of the neonate with acute bilious vomiting. Vomiting in Infants US Abdomen (UGI Tract) There is no relevant literature to support the use of ultrasound (US) as the initial imaging examination prior to an abdominal radiograph for the neonate with acute bilious vomiting. Fluoroscopy Contrast Enema In the setting of a suspected proximal atresia with absent distal bowel gas, there is no relevant literature to support the use of a contrast enema for diagnosis. Atresias can be multiple in approximately 15% of patients. Most of these can be diagnosed at the initial surgical exploration [11]. Fluoroscopy Upper GI Series In the setting of a classic double bubble or triple bubble with no gas distally, a UGI series is usually not necessary, because the positive contrast used in fluoroscopy does not typically provide more anatomic details.

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In some cases in which there is inadequate gastric or duodenal distention, air can be injected to the stomach through the feeding tube to better delineate the gas pattern and confirm no gas distally. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in evaluating the neonate with acute vomiting and classic double bubble or triple bubble with no gas distally. US Abdomen (UGI Tract) There is a growing acceptance for the role of US, especially in prenatal diagnosis of duodenal atresia. In the postnatal diagnosis of duodenal atresia, there is no relevant literature to support the use of US in evaluating the neonate with acute vomiting and classic double bubble or triple bubble with no gas distally. Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study. The role of imaging in children with multiple distended bowel loops with no or decreased gas distally is to differentiate between temporary functional abnormalities that only need observation (eg, meconium plug), pathologies that require surgery (eg, ileal atresia), therapeutic enema (eg, meconium ileus), or rectal biopsy (eg, Hirschsprung disease) [12]. Fluoroscopy Contrast Enema Contrast enema is the diagnostic imaging procedure of choice when there is a suspected distal obstruction. Congenital distal obstruction can be structural or functional, in which both will give the same appearance on abdominal radiographs that show numerous dilated bowel loops with an absence or paucity of distal gas. In the setting of congenital atresia, most commonly ileal, but also distal jejunal or colonic, the lack of contents moving through the bowel results in a microcolon [12]. Fluoroscopy Upper GI Series There is no relevant literature to support the use of a UGI series in the evaluation of the neonate with suspected distal obstruction.

Vomiting in Infants. In some cases in which there is inadequate gastric or duodenal distention, air can be injected to the stomach through the feeding tube to better delineate the gas pattern and confirm no gas distally. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in evaluating the neonate with acute vomiting and classic double bubble or triple bubble with no gas distally. US Abdomen (UGI Tract) There is a growing acceptance for the role of US, especially in prenatal diagnosis of duodenal atresia. In the postnatal diagnosis of duodenal atresia, there is no relevant literature to support the use of US in evaluating the neonate with acute vomiting and classic double bubble or triple bubble with no gas distally. Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study. The role of imaging in children with multiple distended bowel loops with no or decreased gas distally is to differentiate between temporary functional abnormalities that only need observation (eg, meconium plug), pathologies that require surgery (eg, ileal atresia), therapeutic enema (eg, meconium ileus), or rectal biopsy (eg, Hirschsprung disease) [12]. Fluoroscopy Contrast Enema Contrast enema is the diagnostic imaging procedure of choice when there is a suspected distal obstruction. Congenital distal obstruction can be structural or functional, in which both will give the same appearance on abdominal radiographs that show numerous dilated bowel loops with an absence or paucity of distal gas. In the setting of congenital atresia, most commonly ileal, but also distal jejunal or colonic, the lack of contents moving through the bowel results in a microcolon [12]. Fluoroscopy Upper GI Series There is no relevant literature to support the use of a UGI series in the evaluation of the neonate with suspected distal obstruction.

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Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with suspected distal obstruction. US Abdomen (UGI Tract) There is no relevant literature to support the use of US in the evaluation of the neonate with suspected distal obstruction. Vomiting in Infants Variant 4: Bilious vomiting within the first 2 days after birth. Radiographs show a nonclassic double bubble with gas in the distal small bowel, or few distended bowel loops, or a normal bowel gas pattern. Next imaging study. The role of imaging in a child with bilious vomiting in the first 2 days of life with nonclassic double bubble or few distended bowel loops is to differentiate between congenital intestinal atresia and stenosis and midgut volvulus, which requires urgent surgery. Malrotation or midgut volvulus with incomplete obstruction may have a normal bowel gas pattern [5,6,11]. Fluoroscopy Contrast Enema Abnormalities of the lower GI tract that cause bilious vomiting may be demonstrated by contrast enema [4,13]. The use of a barium enema for analyzing malrotation is less direct than analysis of a UGI series. Approximately 20% of barium enemas may be falsely negative, whereas up to 15% of infants have a high mobile cecum that may cause false-positive interpretations of the study [14]. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with acute bilious vomiting. Although US has limitation for the diagnosis of malrotation, there are a few studies showing high sensitivity and specificity for midgut volvulus. The US finding of the whirlpool sign (a clockwise wrapping of the SMV and mesentery around the SMA as the fixed axis) is specific for volvulus [15,26-28].

Vomiting in Infants. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with suspected distal obstruction. US Abdomen (UGI Tract) There is no relevant literature to support the use of US in the evaluation of the neonate with suspected distal obstruction. Vomiting in Infants Variant 4: Bilious vomiting within the first 2 days after birth. Radiographs show a nonclassic double bubble with gas in the distal small bowel, or few distended bowel loops, or a normal bowel gas pattern. Next imaging study. The role of imaging in a child with bilious vomiting in the first 2 days of life with nonclassic double bubble or few distended bowel loops is to differentiate between congenital intestinal atresia and stenosis and midgut volvulus, which requires urgent surgery. Malrotation or midgut volvulus with incomplete obstruction may have a normal bowel gas pattern [5,6,11]. Fluoroscopy Contrast Enema Abnormalities of the lower GI tract that cause bilious vomiting may be demonstrated by contrast enema [4,13]. The use of a barium enema for analyzing malrotation is less direct than analysis of a UGI series. Approximately 20% of barium enemas may be falsely negative, whereas up to 15% of infants have a high mobile cecum that may cause false-positive interpretations of the study [14]. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with acute bilious vomiting. Although US has limitation for the diagnosis of malrotation, there are a few studies showing high sensitivity and specificity for midgut volvulus. The US finding of the whirlpool sign (a clockwise wrapping of the SMV and mesentery around the SMA as the fixed axis) is specific for volvulus [15,26-28].

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It is important to recognize sonographic features of midgut volvulus because they can help to substantiate the diagnosis in an equivocal UGI study or when US is performed for other indications (eg, evaluation for HPS). Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging. Most congenital intestinal atresia and stenosis will present in the first 2 days of life. Midgut volvulus is the most important diagnosis in older infants presenting with bilious vomiting because this is a medical emergency [15]. Fluoroscopy Contrast Enema There is no relevant literature to support the use of a contrast enema as the initial imaging study for suspected malrotation. In suspected malrotation with midgut volvulus, if the UGI fails to show the etiology or is equivocal, a contrast enema may be performed as a follow-up study in the workup of bilious vomiting. However, up to 15% of individuals may have a normal mobile cecum [29]. More commonly, if the UGI is equivocal, small bowel follow through to the cecum may be pursued. Vomiting in Infants Fluoroscopy Upper GI Series The barium UGI series evaluates the esophagus, stomach, pylorus, and the duodenum to the duodenal jejunal junction, indicating the location of the ligament of Treitz [5,6,15]. Although the UGI series is considered the reference standard for evaluating malrotation, false-positive and false-negative interpretations may occur. In a retrospective review of 229 cases by Sizemore et al [16], UGI had a sensitivity of 96% with two false-positives (abnormal jejunal position with no malrotation) and seven false-negatives (normal jejunal position with malrotation). Retrospective reviews by Hsiao et al [17] and another such study by Long et al [18] noted false- positive rates of 10% and 15%, respectively. The studies concluded that redundant duodenum, bowel distension, and jejunal position can lead to inaccurate UGI interpretation; thus meticulous technique is warranted [16-18].

Vomiting in Infants. It is important to recognize sonographic features of midgut volvulus because they can help to substantiate the diagnosis in an equivocal UGI study or when US is performed for other indications (eg, evaluation for HPS). Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging. Most congenital intestinal atresia and stenosis will present in the first 2 days of life. Midgut volvulus is the most important diagnosis in older infants presenting with bilious vomiting because this is a medical emergency [15]. Fluoroscopy Contrast Enema There is no relevant literature to support the use of a contrast enema as the initial imaging study for suspected malrotation. In suspected malrotation with midgut volvulus, if the UGI fails to show the etiology or is equivocal, a contrast enema may be performed as a follow-up study in the workup of bilious vomiting. However, up to 15% of individuals may have a normal mobile cecum [29]. More commonly, if the UGI is equivocal, small bowel follow through to the cecum may be pursued. Vomiting in Infants Fluoroscopy Upper GI Series The barium UGI series evaluates the esophagus, stomach, pylorus, and the duodenum to the duodenal jejunal junction, indicating the location of the ligament of Treitz [5,6,15]. Although the UGI series is considered the reference standard for evaluating malrotation, false-positive and false-negative interpretations may occur. In a retrospective review of 229 cases by Sizemore et al [16], UGI had a sensitivity of 96% with two false-positives (abnormal jejunal position with no malrotation) and seven false-negatives (normal jejunal position with malrotation). Retrospective reviews by Hsiao et al [17] and another such study by Long et al [18] noted false- positive rates of 10% and 15%, respectively. The studies concluded that redundant duodenum, bowel distension, and jejunal position can lead to inaccurate UGI interpretation; thus meticulous technique is warranted [16-18].

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Radiography Abdomen Abdominal radiographs have a limited role in determining subsequent imaging workup, keeping in mind that normal abdominal radiographs do not exclude the diagnosis of malrotation. In a group studied by Lilien et al [6], only 44% of patients who required surgery for bilious vomiting had definitively positive radiograph readings. If the radiographs do show signs of obstruction, the pattern of bowel distension can help direct further evaluation with an UGI series or contrast enema, respectively. Thus, although the plain radiograph may not be able to make the diagnosis of malrotation without supportive imaging, it may serve a complementary role to guide further imaging. Nuclear Medicine Gastroesophageal Reflux Scan Reflux scintigraphy can be highly effective in analyzing gastric emptying and GER, but there is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with acute bilious vomiting. Although US has limitation for the diagnosis of malrotation, there are few studies showing high sensitivity and specificity for midgut volvulus. The US finding of the whirlpool sign is specific for volvulus [15,26-28]. It is important to recognize sonographic features of midgut volvulus because they can help to substantiate the diagnosis in an equivocal UGI study or when US is performed for other indications (eg, evaluation for HPS). Fluoroscopy Contrast Enema There is no relevant literature to support the use of contrast enema in the evaluation for GER. Fluoroscopy Upper GI Series Clinical practice guidelines on GER from 2001 [2] state that the sensitivity, specificity, and positive predictive values of a UGI series range from 31% to 86%, 21% to 83%, and 80% to 82%, respectively, when compared to esophageal pH monitoring. The recent clinical practice guidelines from the North American and European Societies Vomiting in Infants

Vomiting in Infants. Radiography Abdomen Abdominal radiographs have a limited role in determining subsequent imaging workup, keeping in mind that normal abdominal radiographs do not exclude the diagnosis of malrotation. In a group studied by Lilien et al [6], only 44% of patients who required surgery for bilious vomiting had definitively positive radiograph readings. If the radiographs do show signs of obstruction, the pattern of bowel distension can help direct further evaluation with an UGI series or contrast enema, respectively. Thus, although the plain radiograph may not be able to make the diagnosis of malrotation without supportive imaging, it may serve a complementary role to guide further imaging. Nuclear Medicine Gastroesophageal Reflux Scan Reflux scintigraphy can be highly effective in analyzing gastric emptying and GER, but there is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with acute bilious vomiting. Although US has limitation for the diagnosis of malrotation, there are few studies showing high sensitivity and specificity for midgut volvulus. The US finding of the whirlpool sign is specific for volvulus [15,26-28]. It is important to recognize sonographic features of midgut volvulus because they can help to substantiate the diagnosis in an equivocal UGI study or when US is performed for other indications (eg, evaluation for HPS). Fluoroscopy Contrast Enema There is no relevant literature to support the use of contrast enema in the evaluation for GER. Fluoroscopy Upper GI Series Clinical practice guidelines on GER from 2001 [2] state that the sensitivity, specificity, and positive predictive values of a UGI series range from 31% to 86%, 21% to 83%, and 80% to 82%, respectively, when compared to esophageal pH monitoring. The recent clinical practice guidelines from the North American and European Societies Vomiting in Infants

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for Pediatric Gastroenterology, Hepatology, and Nutrition state that UGI is not useful for diagnosing GER but can help exclude or confirm anatomic abnormalities that cause symptoms similar to GER [34]. The brief duration of the UGI series results in false-negative results for GER, whereas the frequent occurrence of nonpathological reflux results in false-positive results. Thus, the UGI series is not a useful test to reliably determine the presence or absence of GER. In patients with severe or complicated GERD who will be managed with gastrostomy tube placement and Nissen fundoplication or with gastrojejunostomy tube, the UGI is useful to exclude anatomic abnormalities, such as esophageal stricture or malrotation, that would need to be addressed at the time of surgery. Radiography Abdomen There is no relevant literature to support the use of radiographs in the evaluation for GER. Nuclear Medicine Gastroesophageal Reflux Scan Reflux scintigraphy can be performed using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA mixed in a feeding. Seibert et al [35] noted reflux scintigraphy to be 79% sensitive when compared to a 24-hour pH esophageal probe as a standard. Methodology and interpretation criteria for reflux scintigraphy are not uniform from center to center [36,37]. Several studies have tried to standardize the methodology of the examination. A 1-hour scintigraphic study formatted in 60-second frames provides a quantitative representation of postprandial GER for children, particularly in the absence of rapid gastric emptying [38]. False-negative examinations can be associated with delayed gastric emptying, and in this patient group, prolongation of the study beyond 60 minutes or confirmatory pH probe evaluation may be advisable. Othman [39] proposes that placing the patient in multiple positions during the scan results in a percentage yield of a positive study that is 3-fold that of the conventional supine position technique.

Vomiting in Infants. for Pediatric Gastroenterology, Hepatology, and Nutrition state that UGI is not useful for diagnosing GER but can help exclude or confirm anatomic abnormalities that cause symptoms similar to GER [34]. The brief duration of the UGI series results in false-negative results for GER, whereas the frequent occurrence of nonpathological reflux results in false-positive results. Thus, the UGI series is not a useful test to reliably determine the presence or absence of GER. In patients with severe or complicated GERD who will be managed with gastrostomy tube placement and Nissen fundoplication or with gastrojejunostomy tube, the UGI is useful to exclude anatomic abnormalities, such as esophageal stricture or malrotation, that would need to be addressed at the time of surgery. Radiography Abdomen There is no relevant literature to support the use of radiographs in the evaluation for GER. Nuclear Medicine Gastroesophageal Reflux Scan Reflux scintigraphy can be performed using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA mixed in a feeding. Seibert et al [35] noted reflux scintigraphy to be 79% sensitive when compared to a 24-hour pH esophageal probe as a standard. Methodology and interpretation criteria for reflux scintigraphy are not uniform from center to center [36,37]. Several studies have tried to standardize the methodology of the examination. A 1-hour scintigraphic study formatted in 60-second frames provides a quantitative representation of postprandial GER for children, particularly in the absence of rapid gastric emptying [38]. False-negative examinations can be associated with delayed gastric emptying, and in this patient group, prolongation of the study beyond 60 minutes or confirmatory pH probe evaluation may be advisable. Othman [39] proposes that placing the patient in multiple positions during the scan results in a percentage yield of a positive study that is 3-fold that of the conventional supine position technique.

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Vomiting in Infants

In a series of symptomatic and asymptomatic preterm infants who had reached 32 to 34 weeks postconceptual age, reflux scintigraphy demonstrated a high incidence of reflux in both groups that did not correlate with symptoms [40]. Use of this examination thus may be limited to patients older than 3 months of age in which other modalities have excluded an anatomic cause for feeding disorders [35,41,42]. US Abdomen (UGI Tract) There is no relevant literature to support the use of US in the diagnosis of reflux, and inconsistent results are reported with sensitivity ranging from 38% to 100% [43-47]. US diagnosis of reflux is made by visualizing water placed into the stomach refluxing into the distal esophagus. However, there is no standardization of the study, and the amount of water and duration of observation varies. Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging. Fluoroscopy Contrast Enema There is no relevant literature to support the use of contrast enema for evaluation of HPS. Fluoroscopy Upper GI Series Though the UGI series is excellent for diagnosing obstructive causes of vomiting in this age group, it is less ideal than US as an initial imaging test if HPS is a strong consideration [48,49]. Nuclear Medicine Gastroesophageal Reflux Scan If all other causes of vomiting have been excluded, reflux scintigraphy using Tc-99m sulfur colloid may be useful for functional evaluation of gastric emptying, although such patients are typically older than 3 months of age when scintigraphy is requested. Vomiting in Infants 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.

Vomiting in Infants. In a series of symptomatic and asymptomatic preterm infants who had reached 32 to 34 weeks postconceptual age, reflux scintigraphy demonstrated a high incidence of reflux in both groups that did not correlate with symptoms [40]. Use of this examination thus may be limited to patients older than 3 months of age in which other modalities have excluded an anatomic cause for feeding disorders [35,41,42]. US Abdomen (UGI Tract) There is no relevant literature to support the use of US in the diagnosis of reflux, and inconsistent results are reported with sensitivity ranging from 38% to 100% [43-47]. US diagnosis of reflux is made by visualizing water placed into the stomach refluxing into the distal esophagus. However, there is no standardization of the study, and the amount of water and duration of observation varies. Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging. Fluoroscopy Contrast Enema There is no relevant literature to support the use of contrast enema for evaluation of HPS. Fluoroscopy Upper GI Series Though the UGI series is excellent for diagnosing obstructive causes of vomiting in this age group, it is less ideal than US as an initial imaging test if HPS is a strong consideration [48,49]. Nuclear Medicine Gastroesophageal Reflux Scan If all other causes of vomiting have been excluded, reflux scintigraphy using Tc-99m sulfur colloid may be useful for functional evaluation of gastric emptying, although such patients are typically older than 3 months of age when scintigraphy is requested. Vomiting in Infants 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.

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Evaluation of the Symptomatic Male Breast

Introduction/Background Men with breast symptoms are typically concerned about the cause of their problem and whether or not it is due to breast cancer. The majority of male breast problems are benign, with gynecomastia as the most common cause of a palpable mass, breast enlargement, or pain [1-3]. Gynecomastia occurs physiologically in neonates and adolescents and with aging but can occur at any age as a side effect of many medications and recreational drugs, as a result of hormonal changes, and in the setting of chronic liver disease [4]. Although gynecomastia may present at any age, breast cancers usually occur in older men (median age of 63 years) [3,5]. Breast cancer in males accounts for <1% of all breast cancers. Although rare, breast cancer in men frequently presents with associated symptoms (eg, palpable lump, skin or nipple retraction, nipple discharge) and at an advanced stage (larger tumor size and a higher probability of nodal metastases) [6-8]. Because gynecomastia is a common entity, approximately 50% of men with breast cancer may have coexisting gynecomastia [9]. However, gynecomastia is not believed to be a risk factor for male breast cancer [10]. Although gynecomastia and breast cancer are the main considerations in most men with a palpable mass, other masses arising from the skin and subcutaneous tissues, such as lipomas, epidermal inclusion cysts, and oil cysts, are also commonly encountered. Pseudogynecomastia, which is due to excess fatty tissue deposition in the breasts, is also common, especially in patients with an elevated body mass index. If the differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings, or if the clinical presentation is suspicious, imaging is indicated [1,2]. Discussion of Procedures by Variant Variant 1: Male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia. Initial imaging.

Evaluation of the Symptomatic Male Breast. Introduction/Background Men with breast symptoms are typically concerned about the cause of their problem and whether or not it is due to breast cancer. The majority of male breast problems are benign, with gynecomastia as the most common cause of a palpable mass, breast enlargement, or pain [1-3]. Gynecomastia occurs physiologically in neonates and adolescents and with aging but can occur at any age as a side effect of many medications and recreational drugs, as a result of hormonal changes, and in the setting of chronic liver disease [4]. Although gynecomastia may present at any age, breast cancers usually occur in older men (median age of 63 years) [3,5]. Breast cancer in males accounts for <1% of all breast cancers. Although rare, breast cancer in men frequently presents with associated symptoms (eg, palpable lump, skin or nipple retraction, nipple discharge) and at an advanced stage (larger tumor size and a higher probability of nodal metastases) [6-8]. Because gynecomastia is a common entity, approximately 50% of men with breast cancer may have coexisting gynecomastia [9]. However, gynecomastia is not believed to be a risk factor for male breast cancer [10]. Although gynecomastia and breast cancer are the main considerations in most men with a palpable mass, other masses arising from the skin and subcutaneous tissues, such as lipomas, epidermal inclusion cysts, and oil cysts, are also commonly encountered. Pseudogynecomastia, which is due to excess fatty tissue deposition in the breasts, is also common, especially in patients with an elevated body mass index. If the differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings, or if the clinical presentation is suspicious, imaging is indicated [1,2]. Discussion of Procedures by Variant Variant 1: Male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia. Initial imaging.

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Evaluation of the Symptomatic Male Breast

Most men with breast symptoms can be diagnosed on the basis of clinical findings without imaging [1,2]. Gynecomastia is the most common cause of a palpable mass, breast enlargement, or pain [1-3]. Gynecomastia is bilateral in approximately half of patients. On physical examination, gynecomastia often presents as a soft, rubbery, or firm mobile mass directly under the nipple [3,4]. In addition, gynecomastia is more likely to be painful than cancer [3], especially gynecomastia that has been present for <6 months [3,4]. Mammography In men with clinical findings consistent with gynecomastia or pseudogynecomastia, mammography is not routinely indicated. When performed, 3 patterns of gynecomastia have been described on mammography: (1) nodular (subareolar nodule), (2) dendritic (subareolar flame-shaped tissue), and (3) diffuse glandular (much like a heterogeneously dense female breast) [11]. When pseudogynecomastia is identified as the sole imaging finding, aH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. bAlpert Medical School of Brown University, Providence, Rhode Island. cPanel Vice- Chair, NYU Clinical Cancer Center, New York, New York. dRoper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons. eNorthwestern University Feinberg School of Medicine, Chicago, Illinois; American College of Physicians. fDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. gNew York University School of Medicine, New York, New York. hEmory University Hospital, Atlanta, Georgia. iThe University of Texas MD Anderson Cancer Center, Houston, Texas. jNew York University School of Medicine, New York, New York. kBeth Israel Deaconess Medical Center, Boston, Massachusetts. lBeth Israel Deaconess Medical Center, Boston, Massachusetts. mWomen and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists. nMecklenburg Radiology Associates, Charlotte, North Carolina.

Evaluation of the Symptomatic Male Breast. Most men with breast symptoms can be diagnosed on the basis of clinical findings without imaging [1,2]. Gynecomastia is the most common cause of a palpable mass, breast enlargement, or pain [1-3]. Gynecomastia is bilateral in approximately half of patients. On physical examination, gynecomastia often presents as a soft, rubbery, or firm mobile mass directly under the nipple [3,4]. In addition, gynecomastia is more likely to be painful than cancer [3], especially gynecomastia that has been present for <6 months [3,4]. Mammography In men with clinical findings consistent with gynecomastia or pseudogynecomastia, mammography is not routinely indicated. When performed, 3 patterns of gynecomastia have been described on mammography: (1) nodular (subareolar nodule), (2) dendritic (subareolar flame-shaped tissue), and (3) diffuse glandular (much like a heterogeneously dense female breast) [11]. When pseudogynecomastia is identified as the sole imaging finding, aH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. bAlpert Medical School of Brown University, Providence, Rhode Island. cPanel Vice- Chair, NYU Clinical Cancer Center, New York, New York. dRoper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons. eNorthwestern University Feinberg School of Medicine, Chicago, Illinois; American College of Physicians. fDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. gNew York University School of Medicine, New York, New York. hEmory University Hospital, Atlanta, Georgia. iThe University of Texas MD Anderson Cancer Center, Houston, Texas. jNew York University School of Medicine, New York, New York. kBeth Israel Deaconess Medical Center, Boston, Massachusetts. lBeth Israel Deaconess Medical Center, Boston, Massachusetts. mWomen and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists. nMecklenburg Radiology Associates, Charlotte, North Carolina.

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oMemorial Sloan Kettering Cancer Center, New York, New York. pDonald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York. qPerelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania. rPanel Chair, Emory University Hospital, Atlanta, Georgia. 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] Evaluation of the Symptomatic Male Breast mammography may obviate further unnecessary interventions for falsely presumed gynecomastia (eg, altering medications) [12]. Gynecomastia may be incidentally identified on chest CT [13]. Men with characteristic imaging findings of gynecomastia on CT do not benefit from further evaluation with mammography unless there is a suspicious clinical finding (eg, eccentric breast mass, nipple discharge, or axillary adenopathy) [13]. DBT In men with clinical findings consistent with gynecomastia or pseudogynecomastia, digital breast tomosynthesis (DBT) is not routinely indicated. When performed, gynecomastia demonstrates similar imaging characteristics on DBT compared to mammography [14,15]. US Breast In men with clinical findings consistent with gynecomastia or pseudogynecomastia, ultrasound (US) is not routinely indicated. When US is performed, gynecomastia may appear mass-like and demonstrate vascularity on color Doppler [16-18]. Comparison with the contralateral side may be helpful on real-time imaging, as synchronous bilateral breast carcinoma in males is rare.

Evaluation of the Symptomatic Male Breast. oMemorial Sloan Kettering Cancer Center, New York, New York. pDonald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York. qPerelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania. rPanel Chair, Emory University Hospital, Atlanta, Georgia. 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] Evaluation of the Symptomatic Male Breast mammography may obviate further unnecessary interventions for falsely presumed gynecomastia (eg, altering medications) [12]. Gynecomastia may be incidentally identified on chest CT [13]. Men with characteristic imaging findings of gynecomastia on CT do not benefit from further evaluation with mammography unless there is a suspicious clinical finding (eg, eccentric breast mass, nipple discharge, or axillary adenopathy) [13]. DBT In men with clinical findings consistent with gynecomastia or pseudogynecomastia, digital breast tomosynthesis (DBT) is not routinely indicated. When performed, gynecomastia demonstrates similar imaging characteristics on DBT compared to mammography [14,15]. US Breast In men with clinical findings consistent with gynecomastia or pseudogynecomastia, ultrasound (US) is not routinely indicated. When US is performed, gynecomastia may appear mass-like and demonstrate vascularity on color Doppler [16-18]. Comparison with the contralateral side may be helpful on real-time imaging, as synchronous bilateral breast carcinoma in males is rare.

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Evaluation of the Symptomatic Male Breast

Chen et al [19] evaluated the incremental clinical value of US in 327 symptomatic male patients where mammography was negative or revealed only gynecomastia and found no additional malignancies. However, in that series, US did lead to additional unnecessary benign biopsies. Tangerud et al [20], in a study of 350 men with mammographic findings diagnostic of gynecomastia, did not identify any patients with male breast cancer when US, fine needle aspiration, or core biopsy was performed in conjunction with mammography. When performed for suspected gynecomastia, US may demonstrate a lack of breast tissue in men with pseudogynecomastia and obviate further unnecessary interventions for falsely presumed gynecomastia (eg, altering medications) [12,21-23]. MRI Breast In men with clinical findings consistent with gynecomastia or pseudogynecomastia, breast MRI is not indicated as the initial imaging study. There is no relevant literature regarding the use of breast MRI as the initial imaging evaluation of suspected gynecomastia. Variant 2: Male younger than 25 years of age with indeterminate palpable breast mass. Initial imaging. Only 6% of male breast cancers occur in men <40 years of age and 1% in men <30 years of age [24]. Given the relationship between breast cancer incidence and increasing age, age-based protocols in younger men have been developed [3,25]. If clinical breast examination is indeterminate, imaging is recommended prior to biopsy recommendation. Mammography The extremely low incidence of breast cancer in young men reduces the utility of mammography as the initial imaging study. However, if there are suspicious or indeterminate features on US, mammography or DBT should be performed before a biopsy recommendation is made because diagnostic mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2].

Evaluation of the Symptomatic Male Breast. Chen et al [19] evaluated the incremental clinical value of US in 327 symptomatic male patients where mammography was negative or revealed only gynecomastia and found no additional malignancies. However, in that series, US did lead to additional unnecessary benign biopsies. Tangerud et al [20], in a study of 350 men with mammographic findings diagnostic of gynecomastia, did not identify any patients with male breast cancer when US, fine needle aspiration, or core biopsy was performed in conjunction with mammography. When performed for suspected gynecomastia, US may demonstrate a lack of breast tissue in men with pseudogynecomastia and obviate further unnecessary interventions for falsely presumed gynecomastia (eg, altering medications) [12,21-23]. MRI Breast In men with clinical findings consistent with gynecomastia or pseudogynecomastia, breast MRI is not indicated as the initial imaging study. There is no relevant literature regarding the use of breast MRI as the initial imaging evaluation of suspected gynecomastia. Variant 2: Male younger than 25 years of age with indeterminate palpable breast mass. Initial imaging. Only 6% of male breast cancers occur in men <40 years of age and 1% in men <30 years of age [24]. Given the relationship between breast cancer incidence and increasing age, age-based protocols in younger men have been developed [3,25]. If clinical breast examination is indeterminate, imaging is recommended prior to biopsy recommendation. Mammography The extremely low incidence of breast cancer in young men reduces the utility of mammography as the initial imaging study. However, if there are suspicious or indeterminate features on US, mammography or DBT should be performed before a biopsy recommendation is made because diagnostic mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2].

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Evaluation of the Symptomatic Male Breast

DBT There is no relevant literature regarding the use of DBT in the evaluation of men <25 years of age with an indeterminate palpable breast mass. However, if there are suspicious or indeterminate features on US, mammography or DBT should be performed before a biopsy recommendation is made because mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2]. DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as mammography [14,15,26]. US Breast Some authors suggest that using US is useful as the initial imaging modality in the young male who is unlikely to have breast cancer and who presents with an indeterminate physical symptom [3]. However, gynecomastia and oil cysts can have a suspicious appearance on US but can typically be diagnosed as benign on mammography or DBT. Therefore, if there are suspicious features on US, mammography or DBT should be performed before a biopsy recommendation is made. Evaluation of the Symptomatic Male Breast MRI Breast There is no relevant literature regarding the use of MRI as the initial imaging study in the evaluation of men <25 years of age with an indeterminate palpable breast mass. Variant 3: Male 25 years of age or older with indeterminate palpable breast mass. Initial imaging. Breast cancer is a disease of older men and typically presents at a later age than in women at a median age of 63 years [5]. If clinical breast examination is indeterminate, imaging is recommended prior to biopsy recommendation. Mammography For men with an equivocal physical examination and of an age at which breast cancer is more likely, mammography or DBT is recommended as the initial imaging modality. Diagnostic mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2].

Evaluation of the Symptomatic Male Breast. DBT There is no relevant literature regarding the use of DBT in the evaluation of men <25 years of age with an indeterminate palpable breast mass. However, if there are suspicious or indeterminate features on US, mammography or DBT should be performed before a biopsy recommendation is made because mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2]. DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as mammography [14,15,26]. US Breast Some authors suggest that using US is useful as the initial imaging modality in the young male who is unlikely to have breast cancer and who presents with an indeterminate physical symptom [3]. However, gynecomastia and oil cysts can have a suspicious appearance on US but can typically be diagnosed as benign on mammography or DBT. Therefore, if there are suspicious features on US, mammography or DBT should be performed before a biopsy recommendation is made. Evaluation of the Symptomatic Male Breast MRI Breast There is no relevant literature regarding the use of MRI as the initial imaging study in the evaluation of men <25 years of age with an indeterminate palpable breast mass. Variant 3: Male 25 years of age or older with indeterminate palpable breast mass. Initial imaging. Breast cancer is a disease of older men and typically presents at a later age than in women at a median age of 63 years [5]. If clinical breast examination is indeterminate, imaging is recommended prior to biopsy recommendation. Mammography For men with an equivocal physical examination and of an age at which breast cancer is more likely, mammography or DBT is recommended as the initial imaging modality. Diagnostic mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2].

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acrac_3091547_5

Evaluation of the Symptomatic Male Breast

A bilateral mammogram is routinely performed in symptomatic males [27], although there is no literature comparing the efficacy of bilateral versus unilateral imaging. A bilateral examination may be useful to assess for symmetry [28] and may detect asymptomatic contralateral gynecomastia or the rare nonpalpable contralateral carcinoma [3]. Although not routinely performed, pectoralis-displaced mammographic views can be acquired if the breast tissue is obscured by overlying well-developed pectoralis musculature [29]. Mammography is highly sensitive and specific in distinguishing benign from malignant disease and is likely more sensitive than US at detecting breast cancer because microcalcifications may be optimally visualized on this modality [3,6]. Studies demonstrate sensitivities ranging from 92% to 100%, specificities ranging from 90% to 96%, and negative predictive values (NPV) of 99% to 100% [3,9,12,28]. Thus, mammography is useful both in identifying breast cancer and for obviating the need for US or biopsy in patients for whom the benign mammographic appearance confirms the clinical impression. DBT For men with an equivocal physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16]. Data on the incremental utility of DBT compared to mammography alone in the evaluation of the male breast are limited. However, DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as that of mammography [14,15,26]. US Breast If the mammogram is indeterminate or suspicious, US can assist in clinical management and guide biopsy [3]. Variant 4: Male 25 years of age or older with indeterminate palpable breast mass. Mammography or digital breast tomosynthesis indeterminate or suspicious.

Evaluation of the Symptomatic Male Breast. A bilateral mammogram is routinely performed in symptomatic males [27], although there is no literature comparing the efficacy of bilateral versus unilateral imaging. A bilateral examination may be useful to assess for symmetry [28] and may detect asymptomatic contralateral gynecomastia or the rare nonpalpable contralateral carcinoma [3]. Although not routinely performed, pectoralis-displaced mammographic views can be acquired if the breast tissue is obscured by overlying well-developed pectoralis musculature [29]. Mammography is highly sensitive and specific in distinguishing benign from malignant disease and is likely more sensitive than US at detecting breast cancer because microcalcifications may be optimally visualized on this modality [3,6]. Studies demonstrate sensitivities ranging from 92% to 100%, specificities ranging from 90% to 96%, and negative predictive values (NPV) of 99% to 100% [3,9,12,28]. Thus, mammography is useful both in identifying breast cancer and for obviating the need for US or biopsy in patients for whom the benign mammographic appearance confirms the clinical impression. DBT For men with an equivocal physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16]. Data on the incremental utility of DBT compared to mammography alone in the evaluation of the male breast are limited. However, DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as that of mammography [14,15,26]. US Breast If the mammogram is indeterminate or suspicious, US can assist in clinical management and guide biopsy [3]. Variant 4: Male 25 years of age or older with indeterminate palpable breast mass. Mammography or digital breast tomosynthesis indeterminate or suspicious.

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Evaluation of the Symptomatic Male Breast

US Breast If the mammogram is indeterminate or suspicious, US is usually appropriate as the next imaging modality because US can assist in lesion characterization and guide biopsy [3]. Performance of breast US in men may be more variable than mammography. Carrasco et al [3], in their series of 638 patients, reported a lower sensitivity of US for distinguishing benign from malignant disease (88.9% compared to 95% for mammography) but a similar, high specificity of 95%. However, Patterson et al [28], in a series of 166 patients, reported US to have the same sensitivity as mammography (100%) but lower specificity (74%). MRI Breast Breast MRI is generally not indicated for the evaluation of indeterminate palpable breast masses in men. Variant 5: Male of any age with physical examination suspicious for breast cancer (suspicious palpable breast mass, axillary adenopathy, nipple discharge, or nipple retraction). Initial imaging. Breast cancer is a disease of older men and typically presents at a later age (median age of 63 years) than in women [5]. Male breast cancer is rarely bilateral and typically presents with a painless, hard mass, which may be subareolar or, unlike gynecomastia, eccentric to the nipple. With breast cancer, there may be secondary signs of malignancy, such as nipple or skin retraction, nipple discharge, or axillary lymphadenopathy [6]. Breast cancers in Evaluation of the Symptomatic Male Breast men often present at a more advanced stage than breast cancers in women, with up to 47% of men having axillary nodal involvement at the time of diagnosis [6]. In addition, nipple discharge is suspicious for breast cancer in men, with 2 studies showing carcinoma in 23% to 57% of men presenting with this symptom [7,8]. Mammography For men with a suspicious physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16].

Evaluation of the Symptomatic Male Breast. US Breast If the mammogram is indeterminate or suspicious, US is usually appropriate as the next imaging modality because US can assist in lesion characterization and guide biopsy [3]. Performance of breast US in men may be more variable than mammography. Carrasco et al [3], in their series of 638 patients, reported a lower sensitivity of US for distinguishing benign from malignant disease (88.9% compared to 95% for mammography) but a similar, high specificity of 95%. However, Patterson et al [28], in a series of 166 patients, reported US to have the same sensitivity as mammography (100%) but lower specificity (74%). MRI Breast Breast MRI is generally not indicated for the evaluation of indeterminate palpable breast masses in men. Variant 5: Male of any age with physical examination suspicious for breast cancer (suspicious palpable breast mass, axillary adenopathy, nipple discharge, or nipple retraction). Initial imaging. Breast cancer is a disease of older men and typically presents at a later age (median age of 63 years) than in women [5]. Male breast cancer is rarely bilateral and typically presents with a painless, hard mass, which may be subareolar or, unlike gynecomastia, eccentric to the nipple. With breast cancer, there may be secondary signs of malignancy, such as nipple or skin retraction, nipple discharge, or axillary lymphadenopathy [6]. Breast cancers in Evaluation of the Symptomatic Male Breast men often present at a more advanced stage than breast cancers in women, with up to 47% of men having axillary nodal involvement at the time of diagnosis [6]. In addition, nipple discharge is suspicious for breast cancer in men, with 2 studies showing carcinoma in 23% to 57% of men presenting with this symptom [7,8]. Mammography For men with a suspicious physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16].

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Evaluation of the Symptomatic Male Breast

Breast cancer in men typically presents with an irregular mass but may present as a focal asymmetry, asymmetry, or in association with calcifications [3,11,12,24]. Because lobular development does not typically occur in men and men do not have the same background of benign proliferative changes as do women, relatively benign imaging findings, such as a circumscribed mass or round calcifications, should be considered suspicious in male patients [3,6,27]. Mammography is highly sensitive and specific in distinguishing benign from malignant disease and is likely more sensitive than US at detecting breast cancer because microcalcifications may be optimally visualized on this modality [3,6]. Studies demonstrate sensitivities ranging from 92% to 100%, specificities ranging from 90% to 96%, and NPVs of 99% to 100% [3,9,12,28]. Thus, mammography is useful both in identifying breast cancer and for obviating the need for US or biopsy in patients for whom the benign mammographic appearance confirms the clinical impression. DBT For men with a suspicious physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16]. Data on the incremental utility of DBT compared to mammography alone in the evaluation of male breast cancer are limited. However, DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as mammography [14,15,26]. No documented case of male breast cancer identified solely on DBT has been reported [15]. US Breast Mammography is recommended as the initial imaging study because of its high sensitivity, specificity, and NPV, and the performance of breast US in men may be more variable than mammography [3,9,12,16].

Evaluation of the Symptomatic Male Breast. Breast cancer in men typically presents with an irregular mass but may present as a focal asymmetry, asymmetry, or in association with calcifications [3,11,12,24]. Because lobular development does not typically occur in men and men do not have the same background of benign proliferative changes as do women, relatively benign imaging findings, such as a circumscribed mass or round calcifications, should be considered suspicious in male patients [3,6,27]. Mammography is highly sensitive and specific in distinguishing benign from malignant disease and is likely more sensitive than US at detecting breast cancer because microcalcifications may be optimally visualized on this modality [3,6]. Studies demonstrate sensitivities ranging from 92% to 100%, specificities ranging from 90% to 96%, and NPVs of 99% to 100% [3,9,12,28]. Thus, mammography is useful both in identifying breast cancer and for obviating the need for US or biopsy in patients for whom the benign mammographic appearance confirms the clinical impression. DBT For men with a suspicious physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16]. Data on the incremental utility of DBT compared to mammography alone in the evaluation of male breast cancer are limited. However, DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as mammography [14,15,26]. No documented case of male breast cancer identified solely on DBT has been reported [15]. US Breast Mammography is recommended as the initial imaging study because of its high sensitivity, specificity, and NPV, and the performance of breast US in men may be more variable than mammography [3,9,12,16].

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Evaluation of the Symptomatic Male Breast

Carrasco et al [3], in their series of 638 patients, reported a lower sensitivity of US for distinguishing benign from malignant disease (88.9% compared to 95% for mammography) but a similar, high specificity of 95.3%. However, Patterson et al [28] in a series of 166 patients reported US to have the same sensitivity as mammography (100%) but lower specificity (74%). In conjunction with mammography or DBT, US is often useful in assisting with management decisions and to facilitate US core biopsy [3]. Male breast cancers typically manifest as hypoechoic solid masses with irregular borders; however, cystic or circumscribed masses in men should also be viewed with suspicion unless definitely correlative benign findings (eg, oil cyst) are identified on mammography [3,11,24,30,31]. Lapid et al [32] in a series of 557 male patients demonstrated that mammography and/or US imaging in combination had an NPV of 99.8%, and a complex cystic and solid mass on US was the only false-negative examination. Summary of Recommendations Variant 1: Imaging is not recommended for the initial imaging of a male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia. Variant 2: US breast is usually appropriate for the initial imaging of a male patient younger than 25 years of age with an indeterminate palpable breast mass. Variant 3: Diagnostic mammography or DBT is usually appropriate for the initial imaging of a male patient 25 years of age or older with an indeterminate palpable breast mass. These procedures are equivalent alternatives. 6 Variant 4: US breast is usually appropriate for the imaging of a male patient 25 years of age or older with a breast mass deemed indeterminate or suspicious on diagnostic mammography or DBT.

Evaluation of the Symptomatic Male Breast. Carrasco et al [3], in their series of 638 patients, reported a lower sensitivity of US for distinguishing benign from malignant disease (88.9% compared to 95% for mammography) but a similar, high specificity of 95.3%. However, Patterson et al [28] in a series of 166 patients reported US to have the same sensitivity as mammography (100%) but lower specificity (74%). In conjunction with mammography or DBT, US is often useful in assisting with management decisions and to facilitate US core biopsy [3]. Male breast cancers typically manifest as hypoechoic solid masses with irregular borders; however, cystic or circumscribed masses in men should also be viewed with suspicion unless definitely correlative benign findings (eg, oil cyst) are identified on mammography [3,11,24,30,31]. Lapid et al [32] in a series of 557 male patients demonstrated that mammography and/or US imaging in combination had an NPV of 99.8%, and a complex cystic and solid mass on US was the only false-negative examination. Summary of Recommendations Variant 1: Imaging is not recommended for the initial imaging of a male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia. Variant 2: US breast is usually appropriate for the initial imaging of a male patient younger than 25 years of age with an indeterminate palpable breast mass. Variant 3: Diagnostic mammography or DBT is usually appropriate for the initial imaging of a male patient 25 years of age or older with an indeterminate palpable breast mass. These procedures are equivalent alternatives. 6 Variant 4: US breast is usually appropriate for the imaging of a male patient 25 years of age or older with a breast mass deemed indeterminate or suspicious on diagnostic mammography or DBT.

3091547

acrac_69442_0

Sinusitis Child

Introduction/Background Acute sinusitis is defined as an acute inflammatory process involving the paranasal sinuses. Acute sinusitis is common in children and usually resolves spontaneously, although it can result in serious complications [1-9]. Acute sinusitis may be viral, bacterial, or fungal. Viral upper respiratory tract infections occur with an incidence of six episodes per patient year, and 8% of these viral infections are complicated by acute viral sinusitis [2]. Inflammation of the mucosal lining of the nose and paranasal sinuses secondary to viral infection sets the stage for bacterial superinfection [10], thus making viral infections the most common predisposing factor for acute bacterial sinusitis, followed by allergic rhinitis [1,3-5]. Other noninfectious factors that may lead to sinusitis in children include nasal airway obstruction, immunodeficiency, ciliary dysfunction, cystic fibrosis, and odontogenic infections [1,3-9,11-13]. Imaging abnormalities alone are not sufficient for the diagnosis of acute sinusitis because paranasal sinus opacification is often present in healthy children or in children having a CT scan for other reasons. CT performed on young adults recovering from a cold illustrated that 87% had significant maxillary sinus abnormalities. One study showed that >50% of children with viral upper respiratory tract infection had abnormal maxillary sinus radiographs [2]. Further research showed that 68% of symptomatic children with upper respiratory tract infection and 42% of healthy children had significant sinus abnormalities on MRI [2]. This incidence is even higher in very young patient populations and reached 97% in a study of infants who had a cold in the 2 weeks preceding a head CT done for other reasons [15]. The AAP defines subacute bacterial sinusitis as a sinusitis that lasts between 30 and 90 days and whose symptoms resolve completely.

Sinusitis Child. Introduction/Background Acute sinusitis is defined as an acute inflammatory process involving the paranasal sinuses. Acute sinusitis is common in children and usually resolves spontaneously, although it can result in serious complications [1-9]. Acute sinusitis may be viral, bacterial, or fungal. Viral upper respiratory tract infections occur with an incidence of six episodes per patient year, and 8% of these viral infections are complicated by acute viral sinusitis [2]. Inflammation of the mucosal lining of the nose and paranasal sinuses secondary to viral infection sets the stage for bacterial superinfection [10], thus making viral infections the most common predisposing factor for acute bacterial sinusitis, followed by allergic rhinitis [1,3-5]. Other noninfectious factors that may lead to sinusitis in children include nasal airway obstruction, immunodeficiency, ciliary dysfunction, cystic fibrosis, and odontogenic infections [1,3-9,11-13]. Imaging abnormalities alone are not sufficient for the diagnosis of acute sinusitis because paranasal sinus opacification is often present in healthy children or in children having a CT scan for other reasons. CT performed on young adults recovering from a cold illustrated that 87% had significant maxillary sinus abnormalities. One study showed that >50% of children with viral upper respiratory tract infection had abnormal maxillary sinus radiographs [2]. Further research showed that 68% of symptomatic children with upper respiratory tract infection and 42% of healthy children had significant sinus abnormalities on MRI [2]. This incidence is even higher in very young patient populations and reached 97% in a study of infants who had a cold in the 2 weeks preceding a head CT done for other reasons [15]. The AAP defines subacute bacterial sinusitis as a sinusitis that lasts between 30 and 90 days and whose symptoms resolve completely.

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acrac_69442_1

Sinusitis Child

Recurrent acute bacterial sinusitis is defined by episodes lasting <30 days each and separated by intervals of at least 10 asymptomatic days. Chronic sinusitis lasts >90 days, and is defined by persistent residual respiratory symptoms, such as cough, rhinorrhea, or nasal obstruction [1]. In patients with recurrent or chronic sinusitis, one must consider other underlying causes such as asthma, gastroesophageal reflux, cystic 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] Intracranial complications most commonly result from spread of primary infection within the frontal sinuses [19- 23,25]. This typically occurs via progression of septic thrombi through the valveless diploic veins of the skull that penetrate the dura, or, less commonly, through direct intracranial extension of osteomyelitis [21]. Symptoms that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Ethmoid sinusitis can lead to spread of infection through the lamina papyracea, a thin bone that separates the medial orbital wall from the ethmoid sinuses [26]. Manifestations of orbital involvement include medial orbital wall subperiosteal abscess, periorbital cellulitis, and ocular findings (eg, abnormal visual examination, ophthalmoplegia, or proptosis) [21,22,26-32]. Cavernous sinus thrombosis is another rare but potentially fatal intracranial complication that can arise from infection of either the sphenoid or ethmoid sinuses [33]. Although rare, increasing frequency of fungal sinusitis has been reported in children within the past 3 decades [34].

Sinusitis Child. Recurrent acute bacterial sinusitis is defined by episodes lasting <30 days each and separated by intervals of at least 10 asymptomatic days. Chronic sinusitis lasts >90 days, and is defined by persistent residual respiratory symptoms, such as cough, rhinorrhea, or nasal obstruction [1]. In patients with recurrent or chronic sinusitis, one must consider other underlying causes such as asthma, gastroesophageal reflux, cystic 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] Intracranial complications most commonly result from spread of primary infection within the frontal sinuses [19- 23,25]. This typically occurs via progression of septic thrombi through the valveless diploic veins of the skull that penetrate the dura, or, less commonly, through direct intracranial extension of osteomyelitis [21]. Symptoms that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Ethmoid sinusitis can lead to spread of infection through the lamina papyracea, a thin bone that separates the medial orbital wall from the ethmoid sinuses [26]. Manifestations of orbital involvement include medial orbital wall subperiosteal abscess, periorbital cellulitis, and ocular findings (eg, abnormal visual examination, ophthalmoplegia, or proptosis) [21,22,26-32]. Cavernous sinus thrombosis is another rare but potentially fatal intracranial complication that can arise from infection of either the sphenoid or ethmoid sinuses [33]. Although rare, increasing frequency of fungal sinusitis has been reported in children within the past 3 decades [34].

69442

acrac_69442_2

Sinusitis Child

Fungal sinusitis can be invasive and noninvasive and has 5 subtypes. Invasive subtypes include acute invasive fungal sinusitis, chronic invasive fungal sinusitis, and chronic granulomatous invasive fungal sinusitis; noninvasive subtypes include allergic fungal sinusitis and fungus ball (fungal mycetoma). The treatment strategies for the subtypes are different, as are their prognoses [35]. Acute invasive fungal sinusitis is the most lethal subtype with mortality rates reaching 50% to 80%; therefore, a high level of clinical suspicion is critical [36]. It is typically seen in immunocompromised children, often times with hematological malignancies with low neutrophil counts. Painless nasal septal necrosis is the classical clinical presentation [34,35,37]. Allergic fungal sinusitis occurs in atopic children with refractory sinus disease, which requires a high index of suspicion for evaluation and aggressive treatment [38]. Allergic fungal sinusitis is more aggressive in children with increased fungal load and higher incidence of proptosis when compared with adults [39]. Allergic fungal sinusitis in children is also less responsive to treatment with increased recurrence rates [40]. Discussion of Procedures by Variant Variant 1: Child. Uncomplicated acute sinusitis. Initial imaging. CT Paranasal Sinuses CT of the paranasal sinuses without or with contrast is not recommended in children as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone. MRI Paranasal Sinuses MRI of paranasal sinuses without or with intravenous (IV) contrast is not recommended in children, as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone. Radiography Paranasal Sinuses Radiographs are not recommended in uncomplicated acute sinusitis in children as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone. Variant 2: Child.

Sinusitis Child. Fungal sinusitis can be invasive and noninvasive and has 5 subtypes. Invasive subtypes include acute invasive fungal sinusitis, chronic invasive fungal sinusitis, and chronic granulomatous invasive fungal sinusitis; noninvasive subtypes include allergic fungal sinusitis and fungus ball (fungal mycetoma). The treatment strategies for the subtypes are different, as are their prognoses [35]. Acute invasive fungal sinusitis is the most lethal subtype with mortality rates reaching 50% to 80%; therefore, a high level of clinical suspicion is critical [36]. It is typically seen in immunocompromised children, often times with hematological malignancies with low neutrophil counts. Painless nasal septal necrosis is the classical clinical presentation [34,35,37]. Allergic fungal sinusitis occurs in atopic children with refractory sinus disease, which requires a high index of suspicion for evaluation and aggressive treatment [38]. Allergic fungal sinusitis is more aggressive in children with increased fungal load and higher incidence of proptosis when compared with adults [39]. Allergic fungal sinusitis in children is also less responsive to treatment with increased recurrence rates [40]. Discussion of Procedures by Variant Variant 1: Child. Uncomplicated acute sinusitis. Initial imaging. CT Paranasal Sinuses CT of the paranasal sinuses without or with contrast is not recommended in children as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone. MRI Paranasal Sinuses MRI of paranasal sinuses without or with intravenous (IV) contrast is not recommended in children, as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone. Radiography Paranasal Sinuses Radiographs are not recommended in uncomplicated acute sinusitis in children as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone. Variant 2: Child.

69442

acrac_69442_3

Sinusitis Child

Persistent sinusitis (worsening course or severe presentation, or not responding to treatment), or recurrent sinusitis, or chronic sinusitis, or define paranasal sinus anatomy before functional endoscopic sinus surgery. Initial imaging. CT Paranasal Sinuses CT is considered the gold standard for the imaging evaluation of sinusitis because it allows for the accurate depiction of sinus anatomy, soft-tissue changes, and potential associated complications [1,9,19,20,23,41-52]. With the advent of multidetector CT volume isometric imaging, it is possible to obtain images in the axial plane and reconstruct them into the coronal and sagittal planes [17,53,54]. CT volume isometric imaging is especially advantageous in young children who may not be able to cooperate for direct coronal plane image acquisition and avoids direct radiation to the orbits [55]. Low-dose CT of the paranasal sinuses has a radiation dose similar to two radiographic views of the paranasal sinuses [56]. CT is the study of choice in children with recurrent or chronic sinusitis before functional endoscopic sinus surgery as it provides a road map for surgery [49,57]. CT of the sinuses was not found to be superior to a clinical symptom score questionnaire in diagnosing chronic sinusitis [58], highlighting the importance of clinical presentation and physical examination findings in diagnoses. When CT of the paranasal sinuses is primarily performed for defining sinus anatomy or confirming clinically suspected recurrent or chronic sinusitis, contrast administration is not recommended. MRI Paranasal Sinuses MRI of the paranasal sinuses is a radiation-free, high-resolution imaging modality. It has the advantage of being able to differentiate mucosal thickening from sinus secretions [59,60]. However, MRI may require sedation or general anesthesia in order to be performed in young children [61].

Sinusitis Child. Persistent sinusitis (worsening course or severe presentation, or not responding to treatment), or recurrent sinusitis, or chronic sinusitis, or define paranasal sinus anatomy before functional endoscopic sinus surgery. Initial imaging. CT Paranasal Sinuses CT is considered the gold standard for the imaging evaluation of sinusitis because it allows for the accurate depiction of sinus anatomy, soft-tissue changes, and potential associated complications [1,9,19,20,23,41-52]. With the advent of multidetector CT volume isometric imaging, it is possible to obtain images in the axial plane and reconstruct them into the coronal and sagittal planes [17,53,54]. CT volume isometric imaging is especially advantageous in young children who may not be able to cooperate for direct coronal plane image acquisition and avoids direct radiation to the orbits [55]. Low-dose CT of the paranasal sinuses has a radiation dose similar to two radiographic views of the paranasal sinuses [56]. CT is the study of choice in children with recurrent or chronic sinusitis before functional endoscopic sinus surgery as it provides a road map for surgery [49,57]. CT of the sinuses was not found to be superior to a clinical symptom score questionnaire in diagnosing chronic sinusitis [58], highlighting the importance of clinical presentation and physical examination findings in diagnoses. When CT of the paranasal sinuses is primarily performed for defining sinus anatomy or confirming clinically suspected recurrent or chronic sinusitis, contrast administration is not recommended. MRI Paranasal Sinuses MRI of the paranasal sinuses is a radiation-free, high-resolution imaging modality. It has the advantage of being able to differentiate mucosal thickening from sinus secretions [59,60]. However, MRI may require sedation or general anesthesia in order to be performed in young children [61].

69442

acrac_69442_4

Sinusitis Child

Furthermore, MRI does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions, making it less well suited than CT to evaluate for underlying anatomic abnormalities that may predispose to and from chronic sinusitis. Radiography Paranasal Sinuses Radiography is limited in the evaluation of persistent sinusitis because the views traditionally used in the evaluation of the paranasal sinuses are difficult to perform in young children and have low sensitivity and specificity for sinus disease as compared to CT because of a lack of anatomical detail [45-47,61-63]. The Water projection is the single best view for the evaluation of the maxillary antra. In patients with chronic sinusitis, the Water view reveals a sensitivity of 84.2% and specificity of 76.6% for the detection of sinus disease as compared to the gold standard of nasal endoscopy [16,17]. However, the Water view has also been shown to have a 32% false-negative rate and a 49.2% false-positive rate as compared to CT. In addition, most of the abnormalities in the ethmoid and sphenoid sinuses are not detected on the Water view [64]. The Caldwell and Water projections have also been shown to be limited in the detection of ethmoid disease [54]. Variant 3: Child. Sinusitis with clinical concern of orbital or intracranial complications. Initial imaging. Symptoms at presentation that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Complications include meningitis, encephalitis, epidural and subdural suppuration, orbital abscess, and, less commonly, brain abscess and dural sinus thrombophlebitis [19-23]. Cross-sectional imaging should therefore include the paranasal sinuses and head. CT Head and Paranasal Sinuses Noncontrast CT examination utilizing the routine head CT or paranasal sinus CT protocol alone may not provide sufficient anatomical coverage for evaluation for complications.

Sinusitis Child. Furthermore, MRI does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions, making it less well suited than CT to evaluate for underlying anatomic abnormalities that may predispose to and from chronic sinusitis. Radiography Paranasal Sinuses Radiography is limited in the evaluation of persistent sinusitis because the views traditionally used in the evaluation of the paranasal sinuses are difficult to perform in young children and have low sensitivity and specificity for sinus disease as compared to CT because of a lack of anatomical detail [45-47,61-63]. The Water projection is the single best view for the evaluation of the maxillary antra. In patients with chronic sinusitis, the Water view reveals a sensitivity of 84.2% and specificity of 76.6% for the detection of sinus disease as compared to the gold standard of nasal endoscopy [16,17]. However, the Water view has also been shown to have a 32% false-negative rate and a 49.2% false-positive rate as compared to CT. In addition, most of the abnormalities in the ethmoid and sphenoid sinuses are not detected on the Water view [64]. The Caldwell and Water projections have also been shown to be limited in the detection of ethmoid disease [54]. Variant 3: Child. Sinusitis with clinical concern of orbital or intracranial complications. Initial imaging. Symptoms at presentation that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Complications include meningitis, encephalitis, epidural and subdural suppuration, orbital abscess, and, less commonly, brain abscess and dural sinus thrombophlebitis [19-23]. Cross-sectional imaging should therefore include the paranasal sinuses and head. CT Head and Paranasal Sinuses Noncontrast CT examination utilizing the routine head CT or paranasal sinus CT protocol alone may not provide sufficient anatomical coverage for evaluation for complications.

69442

acrac_69442_5

Sinusitis Child

In addition, potential complications such as orbital or preseptal/periorbital cellulitis, subperiosteal abscess, or subdural/epidural collections are inadequately visualized and may be missed in the absence of IV contrast administration. Therefore CT with IV contrast of the sinuses to include the orbits and brain is recommended [23,65]. A reported benefit of contrast-enhanced CT for detection of sinusitis-related complications versus MRI is its significantly shorter scan time, decreasing the need for sedation or general anesthesia in very young children. CT Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis such as venous thrombosis, CT venography (CTV) can be performed, either as a follow-up study or as part of the initial CT imaging protocol [22,23,25]. CTV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed if CTV alone is used. CTA Head When clinical or imaging findings point to potential vascular complications of sinusitis, such as mycotic aneurysm, CT angiography (CTA) can be performed, either as a follow-up study or as part of the initial CT imaging protocol [66]. CTA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTA is used. MR Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis such as venous thrombosis, MR venography (MRV) can be performed, either as a follow-up study or as part of the initial MRI protocol. Noncontrast MRV techniques should be reserved for patients with contraindication to IV contrast or those patients who otherwise did not need IV contrast for the cross-sectional part of the examination.

Sinusitis Child. In addition, potential complications such as orbital or preseptal/periorbital cellulitis, subperiosteal abscess, or subdural/epidural collections are inadequately visualized and may be missed in the absence of IV contrast administration. Therefore CT with IV contrast of the sinuses to include the orbits and brain is recommended [23,65]. A reported benefit of contrast-enhanced CT for detection of sinusitis-related complications versus MRI is its significantly shorter scan time, decreasing the need for sedation or general anesthesia in very young children. CT Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis such as venous thrombosis, CT venography (CTV) can be performed, either as a follow-up study or as part of the initial CT imaging protocol [22,23,25]. CTV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed if CTV alone is used. CTA Head When clinical or imaging findings point to potential vascular complications of sinusitis, such as mycotic aneurysm, CT angiography (CTA) can be performed, either as a follow-up study or as part of the initial CT imaging protocol [66]. CTA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTA is used. MR Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis such as venous thrombosis, MR venography (MRV) can be performed, either as a follow-up study or as part of the initial MRI protocol. Noncontrast MRV techniques should be reserved for patients with contraindication to IV contrast or those patients who otherwise did not need IV contrast for the cross-sectional part of the examination.

69442

acrac_69442_6

Sinusitis Child

MRV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed with when only MRV is used. Symptoms at presentation that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Complications include meningitis, encephalitis, epidural and subdural suppuration, orbital abscess, and, less commonly, brain abscess and dural sinus thrombophlebitis [19-23]. MRA Head When clinical or imaging findings point to potential vascular complications of sinusitis such as mycotic aneurysm, MR angiography (MRA) can be performed, either as a follow-up study or as part of the initial MRI protocol [66]. MRA for the brain can be performed without IV contrast administration. MRA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRA is used. MRI Head and Paranasal Sinuses MRI of the paranasal sinuses and head with IV contrast are complementary imaging studies that should be performed to evaluate for complications of sinusitis. MRI is a radiation-free, high-contrast resolution imaging modality. The primary role of MRI in the clinical setting of sinusitis is to detect intracranial and orbital complications. It is more sensitive than CT with IV contrast (93% versus 63%) for detecting intracranial complications of sinusitis [21,25]. Studies have shown that MRI is significantly more accurate than CT (97% versus 87%) and clinical findings (82%) in diagnosing meningitis [25]. Diffusion-weighted imaging (DWI) can localize or confirm presence of purulent material as it typically presents with restricted diffusion. Although MRI is also more sensitive than CT in diagnosing the presence of osteomyelitis, it does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions.

Sinusitis Child. MRV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed with when only MRV is used. Symptoms at presentation that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Complications include meningitis, encephalitis, epidural and subdural suppuration, orbital abscess, and, less commonly, brain abscess and dural sinus thrombophlebitis [19-23]. MRA Head When clinical or imaging findings point to potential vascular complications of sinusitis such as mycotic aneurysm, MR angiography (MRA) can be performed, either as a follow-up study or as part of the initial MRI protocol [66]. MRA for the brain can be performed without IV contrast administration. MRA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRA is used. MRI Head and Paranasal Sinuses MRI of the paranasal sinuses and head with IV contrast are complementary imaging studies that should be performed to evaluate for complications of sinusitis. MRI is a radiation-free, high-contrast resolution imaging modality. The primary role of MRI in the clinical setting of sinusitis is to detect intracranial and orbital complications. It is more sensitive than CT with IV contrast (93% versus 63%) for detecting intracranial complications of sinusitis [21,25]. Studies have shown that MRI is significantly more accurate than CT (97% versus 87%) and clinical findings (82%) in diagnosing meningitis [25]. Diffusion-weighted imaging (DWI) can localize or confirm presence of purulent material as it typically presents with restricted diffusion. Although MRI is also more sensitive than CT in diagnosing the presence of osteomyelitis, it does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions.

69442

acrac_69442_7

Sinusitis Child

MRI may require sedation or general anesthesia in order to be performed in young children [61]. Radiography Paranasal Sinuses Radiography is not sensitive for the relatively subtle soft-tissue changes or vascular complications related to the intraorbital or intracranial extension of sinusitis. Variant 4: Child. Suspected invasive fungal sinusitis. Initial imaging. CT Paranasal Sinuses Immunocompromised children, particularly to development of acute invasive sinusitis, and paranasal sinus CT is more frequently used in this population to rule out the source of infection. If clinical suspicion for complicated sinusitis exists, CT with IV contrast of the sinuses to include the orbits and brain is indicated [23,65]. A reported benefit of contrast-enhanced CT for detection of sinusitis-related complications is its significantly shorter scan time, decreasing the need for sedation or general anesthesia in young children. CT of the paranasal sinuses without and with contrast is not recommended as it doubles the radiation exposure without additional significant diagnostic yield. Fungal sinusitis can be correctly diagnosed on CT with high accuracy [67,68]. Obliteration of the normal fat density within the periantral regions, osseous erosion, orbital, cavernous sinus, or brain involvement in an immunocompromised individual should raise the possibility of acute invasive fungal sinusitis [69]. CT Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm, venous thrombosis), CTV can be performed, either as follow-up studies or as part of the initial CT imaging protocol. CTV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTV is used.

Sinusitis Child. MRI may require sedation or general anesthesia in order to be performed in young children [61]. Radiography Paranasal Sinuses Radiography is not sensitive for the relatively subtle soft-tissue changes or vascular complications related to the intraorbital or intracranial extension of sinusitis. Variant 4: Child. Suspected invasive fungal sinusitis. Initial imaging. CT Paranasal Sinuses Immunocompromised children, particularly to development of acute invasive sinusitis, and paranasal sinus CT is more frequently used in this population to rule out the source of infection. If clinical suspicion for complicated sinusitis exists, CT with IV contrast of the sinuses to include the orbits and brain is indicated [23,65]. A reported benefit of contrast-enhanced CT for detection of sinusitis-related complications is its significantly shorter scan time, decreasing the need for sedation or general anesthesia in young children. CT of the paranasal sinuses without and with contrast is not recommended as it doubles the radiation exposure without additional significant diagnostic yield. Fungal sinusitis can be correctly diagnosed on CT with high accuracy [67,68]. Obliteration of the normal fat density within the periantral regions, osseous erosion, orbital, cavernous sinus, or brain involvement in an immunocompromised individual should raise the possibility of acute invasive fungal sinusitis [69]. CT Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm, venous thrombosis), CTV can be performed, either as follow-up studies or as part of the initial CT imaging protocol. CTV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTV is used.

69442

acrac_69442_8

Sinusitis Child

CTA Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm, venous thrombosis), CTA can be performed, either as a follow-up study or as part of the initial CT imaging protocol. CTA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTA is used. MR Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis (venous thrombosis), MRV can be performed either as a follow-up study or as part of the initial CT imaging protocol. One relevant downside in the pediatric population is that this may increase imaging time of already lengthy MRI protocols, slightly increasing the need for or the duration of sedation. MRV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRV is used. MRA Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm), MRA can be performed either as a follow-up study or as part of the initial MRI protocol. One relevant downside in the pediatric population is that this may slightly increase imaging time of already lengthy MRI protocols, increasing the need for or the duration of sedation. MRA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRA is used. MRI Paranasal Sinuses MRI of the paranasal sinuses is a radiation-free, high-resolution imaging modality. MRI is more sensitive than IV contrast-enhanced CT (93% versus 63%) for detecting intracranial complications of sinusitis [21,25]. Studies have shown that MRI is significantly more accurate than CT (97% versus 87%) and clinical findings (82%) in diagnosing meningitis [25].

Sinusitis Child. CTA Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm, venous thrombosis), CTA can be performed, either as a follow-up study or as part of the initial CT imaging protocol. CTA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTA is used. MR Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis (venous thrombosis), MRV can be performed either as a follow-up study or as part of the initial CT imaging protocol. One relevant downside in the pediatric population is that this may increase imaging time of already lengthy MRI protocols, slightly increasing the need for or the duration of sedation. MRV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRV is used. MRA Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm), MRA can be performed either as a follow-up study or as part of the initial MRI protocol. One relevant downside in the pediatric population is that this may slightly increase imaging time of already lengthy MRI protocols, increasing the need for or the duration of sedation. MRA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRA is used. MRI Paranasal Sinuses MRI of the paranasal sinuses is a radiation-free, high-resolution imaging modality. MRI is more sensitive than IV contrast-enhanced CT (93% versus 63%) for detecting intracranial complications of sinusitis [21,25]. Studies have shown that MRI is significantly more accurate than CT (97% versus 87%) and clinical findings (82%) in diagnosing meningitis [25].

69442

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Sinusitis Child

Although MRI is also more sensitive than CT in diagnosing the presence of osteomyelitis, it does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions. MRI may require sedation or general anesthesia in order to be performed in young children [61]. Contrast-enhanced MRI evaluation can be helpful in delineating the presence and extent of suspected complications of sinusitis. The initial stages of fungal infection may not be apparent by imaging. MRI is more sensitive for detecting early changes of fungal sinusitis than CT. Perisinus invasion detected by MRI was found to be the most sensitive and specific single finding indicating invasive fungal sinusitis [70]. Radiography Paranasal Sinuses Radiography is not sensitive for the soft-tissue changes or intracranial complications related to invasive fungal sinusitis. Summary of Recommendations Variant 1: Child. Uncomplicated acute sinusitis: imaging studies are not recommended. Variant 2: Child. Persistent sinusitis (worsening course or severe presentation, or not responding to treatment), or recurrent sinusitis, or chronic sinusitis, or define paranasal sinus anatomy before functional endoscopic sinus surgery: CT of the paranasal sinuses without IV contrast is recommended. Variant 3: Child. Sinusitis with clinical concern of orbital or intracranial complications: CT or MRI of the head and paranasal sinuses with IV contrast is recommended. CTA or MRA/MRV may be complementary in cases with suspected vascular complications. Variant 4: Child. Suspected invasive fungal sinusitis: CT or MRI of the head and paranasal sinuses with IV contrast is recommended. CTA or MRA/MRV may be complementary in cases with suspected vascular complications. Although there are references that report on studies with design limitations, 15 well-designed or good-quality studies provide good evidence. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.

Sinusitis Child. Although MRI is also more sensitive than CT in diagnosing the presence of osteomyelitis, it does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions. MRI may require sedation or general anesthesia in order to be performed in young children [61]. Contrast-enhanced MRI evaluation can be helpful in delineating the presence and extent of suspected complications of sinusitis. The initial stages of fungal infection may not be apparent by imaging. MRI is more sensitive for detecting early changes of fungal sinusitis than CT. Perisinus invasion detected by MRI was found to be the most sensitive and specific single finding indicating invasive fungal sinusitis [70]. Radiography Paranasal Sinuses Radiography is not sensitive for the soft-tissue changes or intracranial complications related to invasive fungal sinusitis. Summary of Recommendations Variant 1: Child. Uncomplicated acute sinusitis: imaging studies are not recommended. Variant 2: Child. Persistent sinusitis (worsening course or severe presentation, or not responding to treatment), or recurrent sinusitis, or chronic sinusitis, or define paranasal sinus anatomy before functional endoscopic sinus surgery: CT of the paranasal sinuses without IV contrast is recommended. Variant 3: Child. Sinusitis with clinical concern of orbital or intracranial complications: CT or MRI of the head and paranasal sinuses with IV contrast is recommended. CTA or MRA/MRV may be complementary in cases with suspected vascular complications. Variant 4: Child. Suspected invasive fungal sinusitis: CT or MRI of the head and paranasal sinuses with IV contrast is recommended. CTA or MRA/MRV may be complementary in cases with suspected vascular complications. Although there are references that report on studies with design limitations, 15 well-designed or good-quality studies provide good evidence. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.

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Staging and Follow up of Ovarian Cancer

Introduction/Background Ovarian cancer is the fifth most common cause of cancer death in women in the United States behind lung, breast, colorectal, and pancreatic cancers, accounting for more than 3% of all cancers in women and causing more deaths than any other gynecologic malignancy [1]. Most of the information in this narrative regarding imaging use for staging and evaluation of recurrence applies to epithelial ovarian cancers. Two major subtypes of epithelial ovarian cancers are distinguished by molecular, genetic, and morphologic characteristics: type 1 being the relatively indolent low-grade serous, low-grade endometrioid, mucinous tumors, transitional (Brenner), and clear cell carcinomas; and type 2 being aggressive neoplasms, including high-grade serous or endometrioid, and undifferentiated cancer [2]. The aggressive (type 2) ovarian cancers most often present in advanced stages, stage III-IV, after the disease has spread widely out of the pelvis [3,4]. This document is mostly reflective of staging and follow-up for type 2 ovarian cancers. The major roles of diagnostic imaging have been to characterize the ovarian mass, determine the extent of preoperative disease, predict tumor resectability, and evaluate response to chemotherapy [4-11]. Surgical staging is both diagnostic and therapeutic, and an experienced gynecologic surgeon (a gynecologic oncologist, specifically) is critical in optimum debulking of this tumor [9,12,13]. However, up to 40% of patients may be understaged at laparotomy [14], and prognosis is tied to the presence of residual tumor after surgery. CA-125 Levels The preoperative evaluation of patients with suspected ovarian carcinoma usually includes a serum (cancer antigen) CA-125 determination. Only about 50% of all patients with stage I ovarian cancer have a true-positive result [4,15-17]. Thus, this test alone is inadequate when used in isolation as a screening tool.

Staging and Follow up of Ovarian Cancer. Introduction/Background Ovarian cancer is the fifth most common cause of cancer death in women in the United States behind lung, breast, colorectal, and pancreatic cancers, accounting for more than 3% of all cancers in women and causing more deaths than any other gynecologic malignancy [1]. Most of the information in this narrative regarding imaging use for staging and evaluation of recurrence applies to epithelial ovarian cancers. Two major subtypes of epithelial ovarian cancers are distinguished by molecular, genetic, and morphologic characteristics: type 1 being the relatively indolent low-grade serous, low-grade endometrioid, mucinous tumors, transitional (Brenner), and clear cell carcinomas; and type 2 being aggressive neoplasms, including high-grade serous or endometrioid, and undifferentiated cancer [2]. The aggressive (type 2) ovarian cancers most often present in advanced stages, stage III-IV, after the disease has spread widely out of the pelvis [3,4]. This document is mostly reflective of staging and follow-up for type 2 ovarian cancers. The major roles of diagnostic imaging have been to characterize the ovarian mass, determine the extent of preoperative disease, predict tumor resectability, and evaluate response to chemotherapy [4-11]. Surgical staging is both diagnostic and therapeutic, and an experienced gynecologic surgeon (a gynecologic oncologist, specifically) is critical in optimum debulking of this tumor [9,12,13]. However, up to 40% of patients may be understaged at laparotomy [14], and prognosis is tied to the presence of residual tumor after surgery. CA-125 Levels The preoperative evaluation of patients with suspected ovarian carcinoma usually includes a serum (cancer antigen) CA-125 determination. Only about 50% of all patients with stage I ovarian cancer have a true-positive result [4,15-17]. Thus, this test alone is inadequate when used in isolation as a screening tool.

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Staging and Follow up of Ovarian Cancer

This is especially true in menstruating females, since false-positive results have been reported with endometriosis, benign ovarian cysts, pregnancy, and pelvic inflammatory disease. Pancreatic cancer and cirrhosis may also result in elevated CA-125 levels [18]. However, with stage II or greater ovarian cancer, the true-positive rate is as high as 80% [16]. There is a very high correlation between CA-125 levels and the clinical course of the patient during chemotherapy. CA-125 levels also can be used to predict tumor recurrence in patients who are clinically tumor free [19]. Oftentimes, other epithelial and nonepithelial tumor markers are ordered to differentiate tumor histology preoperatively. CA19-9 and carcinoembryogenic antigen (CEA) can also be elevated with epithelial ovarian neoplasms, but have limited specificity individually, and a high CA125-to-CEA ratio has been shown to optimize specificity for ovarian versus gastrointestinal primary neoplasms [20,21]. 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] Staging and Follow-up of Ovarian Cancer The decision regarding initial treatment for ovarian cancer depends on accurate staging. CT, FDG-PET/CT, and MRI have been used to assess the resectability of tumors, the candidacy of patients for effective cytoreductive surgery, the need for postoperative chemotherapy if debulking is suboptimal, and the need for referral to a gynecologic oncologist [5,34-36,39-45]. Referral to a gynecologic oncologist for optimal staging and debulking is the second most important determinant for survival after tumor stage in patients with ovarian carcinoma.

Staging and Follow up of Ovarian Cancer. This is especially true in menstruating females, since false-positive results have been reported with endometriosis, benign ovarian cysts, pregnancy, and pelvic inflammatory disease. Pancreatic cancer and cirrhosis may also result in elevated CA-125 levels [18]. However, with stage II or greater ovarian cancer, the true-positive rate is as high as 80% [16]. There is a very high correlation between CA-125 levels and the clinical course of the patient during chemotherapy. CA-125 levels also can be used to predict tumor recurrence in patients who are clinically tumor free [19]. Oftentimes, other epithelial and nonepithelial tumor markers are ordered to differentiate tumor histology preoperatively. CA19-9 and carcinoembryogenic antigen (CEA) can also be elevated with epithelial ovarian neoplasms, but have limited specificity individually, and a high CA125-to-CEA ratio has been shown to optimize specificity for ovarian versus gastrointestinal primary neoplasms [20,21]. 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] Staging and Follow-up of Ovarian Cancer The decision regarding initial treatment for ovarian cancer depends on accurate staging. CT, FDG-PET/CT, and MRI have been used to assess the resectability of tumors, the candidacy of patients for effective cytoreductive surgery, the need for postoperative chemotherapy if debulking is suboptimal, and the need for referral to a gynecologic oncologist [5,34-36,39-45]. Referral to a gynecologic oncologist for optimal staging and debulking is the second most important determinant for survival after tumor stage in patients with ovarian carcinoma.

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Staging and Follow up of Ovarian Cancer

The International Federation of Gynecologists and Obstetricians revised the criteria for ovarian cancer staging in 2014 [46]. The updated system recognizes the morphologic and molecular similarities between fallopian tube, primary peritoneal carcinomas, and ovarian malignancy [47]. Stage I disease includes tumor limited to 1 or both ovaries or fallopian tubes, stage II disease has spread to the surface of other pelvic organs, stage III indicates spread to retroperitoneal lymph nodes (IIIA1) or abdominal peritoneal surfaces (IIIA2 if microscopic disease, IIIB or C with macroscopic nodules), and stage IV is advanced disease with distant metastases to solid organs or a malignant pleural effusion [5,6,46]. When there is a contraindication to administration of iodinated contrast, CT without intravenous contrast offers limited evaluation of extent of disease in initial evaluation or follow-up; for more information on the imaging of patients with end-stage renal failure, please see the ACR Manual on Contrast Media [48]. Discussion of Procedures by Variant Variant 1: Initial staging of pretreatment ovarian cancer. CT Abdomen and Pelvis Contrast-enhanced CT (with oral contrast) is the current imaging modality of choice in the preoperative evaluation of ovarian cancer and is an accurate method for identifying sites of abdominopelvic disease that predict successful surgical cytoreduction [57]. CT has been useful to detect local tumor involvement of the pelvic ureter and uterine serosa (although uterine serosal involvement is less important in ovarian cancer than it is for endometrial cancer), as well as metastases to the peritoneum, omentum, mesentery, liver, spleen, lymph nodes, and lung parenchyma [5,39,40,52]. CT has a reported accuracy for ovarian cancer staging of up to 94% [14].

Staging and Follow up of Ovarian Cancer. The International Federation of Gynecologists and Obstetricians revised the criteria for ovarian cancer staging in 2014 [46]. The updated system recognizes the morphologic and molecular similarities between fallopian tube, primary peritoneal carcinomas, and ovarian malignancy [47]. Stage I disease includes tumor limited to 1 or both ovaries or fallopian tubes, stage II disease has spread to the surface of other pelvic organs, stage III indicates spread to retroperitoneal lymph nodes (IIIA1) or abdominal peritoneal surfaces (IIIA2 if microscopic disease, IIIB or C with macroscopic nodules), and stage IV is advanced disease with distant metastases to solid organs or a malignant pleural effusion [5,6,46]. When there is a contraindication to administration of iodinated contrast, CT without intravenous contrast offers limited evaluation of extent of disease in initial evaluation or follow-up; for more information on the imaging of patients with end-stage renal failure, please see the ACR Manual on Contrast Media [48]. Discussion of Procedures by Variant Variant 1: Initial staging of pretreatment ovarian cancer. CT Abdomen and Pelvis Contrast-enhanced CT (with oral contrast) is the current imaging modality of choice in the preoperative evaluation of ovarian cancer and is an accurate method for identifying sites of abdominopelvic disease that predict successful surgical cytoreduction [57]. CT has been useful to detect local tumor involvement of the pelvic ureter and uterine serosa (although uterine serosal involvement is less important in ovarian cancer than it is for endometrial cancer), as well as metastases to the peritoneum, omentum, mesentery, liver, spleen, lymph nodes, and lung parenchyma [5,39,40,52]. CT has a reported accuracy for ovarian cancer staging of up to 94% [14].

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Staging and Follow up of Ovarian Cancer

The sensitivity varies by anatomic site, however, and the most important limitation of CT in staging ovarian cancer is its inability to reliably detect bowel surface, mesenteric, or peritoneal tumor implants <5 mm, especially in the absence of ascites [5,43,58,59]. CT is also useful for guiding biopsy of the omentum, or other abdominal tumor, a procedure that can increase the accuracy of preoperative diagnosis, if indicated [60-63]. For assessment of the resectability of ovarian cancer, cross-sectional imaging (CT or MRI) plays a critically important role in finding significant lesions (>2 cm) at the root of the mesentery, gastrosplenic ligament, omentum of the lesser sac, porta hepatis, intersegmental fissure of the liver, diaphragm, liver dome, and lung parenchyma, and also in detecting lymphadenopathy at or above the celiac axis, presacral extraperitoneal disease, and pelvic sidewall invasion [5,14,40,52,64-68]. Incomplete resection (residual tumor >1 cm) of primary tumor Staging and Follow-up of Ovarian Cancer yields little survival benefit while subjecting patients to substantial perioperative morbidity. To date, imaging and prediction models that are based on imaging, demographic characteristics, and tumor markers have not been shown to provide sufficiently high accuracy for prediction of suboptimal debulking to guide the decision regarding surgery [55,69]. Unresectable disease can be managed by needle or laparoscopic biopsy, followed by chemotherapy, and possibly by a later attempt at interval debulking, resulting in improved survival by virtue of response to chemotherapy and optimal resection [9,34,60-63]. Noncontrast-enhanced CT of the abdomen and pelvis offers limited ability to differentiate small peritoneal or mesenteric implants, or lymphadenopathy, from bowel or other adjacent organs. CT Chest CT of the chest is useful for detecting pleural and pulmonary metastases during primary staging.

Staging and Follow up of Ovarian Cancer. The sensitivity varies by anatomic site, however, and the most important limitation of CT in staging ovarian cancer is its inability to reliably detect bowel surface, mesenteric, or peritoneal tumor implants <5 mm, especially in the absence of ascites [5,43,58,59]. CT is also useful for guiding biopsy of the omentum, or other abdominal tumor, a procedure that can increase the accuracy of preoperative diagnosis, if indicated [60-63]. For assessment of the resectability of ovarian cancer, cross-sectional imaging (CT or MRI) plays a critically important role in finding significant lesions (>2 cm) at the root of the mesentery, gastrosplenic ligament, omentum of the lesser sac, porta hepatis, intersegmental fissure of the liver, diaphragm, liver dome, and lung parenchyma, and also in detecting lymphadenopathy at or above the celiac axis, presacral extraperitoneal disease, and pelvic sidewall invasion [5,14,40,52,64-68]. Incomplete resection (residual tumor >1 cm) of primary tumor Staging and Follow-up of Ovarian Cancer yields little survival benefit while subjecting patients to substantial perioperative morbidity. To date, imaging and prediction models that are based on imaging, demographic characteristics, and tumor markers have not been shown to provide sufficiently high accuracy for prediction of suboptimal debulking to guide the decision regarding surgery [55,69]. Unresectable disease can be managed by needle or laparoscopic biopsy, followed by chemotherapy, and possibly by a later attempt at interval debulking, resulting in improved survival by virtue of response to chemotherapy and optimal resection [9,34,60-63]. Noncontrast-enhanced CT of the abdomen and pelvis offers limited ability to differentiate small peritoneal or mesenteric implants, or lymphadenopathy, from bowel or other adjacent organs. CT Chest CT of the chest is useful for detecting pleural and pulmonary metastases during primary staging.

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Staging and Follow up of Ovarian Cancer

Although CT is not sensitive for detecting pleural metastases, these can be verified by video-assisted thoracoscopy, if needed [70]. Preoperative detection by CT of a moderate-to-large pleural effusion helps predict poor post-treatment outcome [71]. For postsurgical surveillance, the yield of chest CT is low if the chest radiograph shows no abnormalities, CT shows no abdominal or pelvic disease, and there is no rising serum CA-125 [72,73]. If PET using tracer FDG is used and includes chest, abdomen, and pelvis, the added value of diagnostic-quality chest CT is probably even lower. MRI MRI is an excellent problem-solving technique by virtue of its ability to define common conditions such as fibroids, dermoid cysts, endometriomas, and other benign lesions [6-8,31,44]. A multivariable analysis showed that the accuracy of MRI with gadolinium enhancement in separating ovarian malignancy from other types of adnexal masses was 93% [74]. Gadolinium enhancement and diffusion-weighted imaging offer improved diagnostic confidence and tissue characterization [31,74]. In staging, MRI has been shown to provide equivalent accuracy to CT and to predict peritoneal tumor volume comparable with surgery, with sensitivity of 0.88, specificity of 0.74, and accuracy of 0.84 [75,76]. However, the role of MRI in staging has been limited because 1) the use of intraluminal gastrointestinal contrast agents with MRI is not routine as it is with CT, and 2) patient motion is a greater problem for MRI than for CT. Although CT is currently the modality of choice for staging ovarian cancer, MRI is recommended for patients with borderline tumors or ovarian cancers that have been previously staged with fertility preservation (to minimize ionizing radiation exposure), or for some patients whose CT findings are inconclusive [68,77]. Higher-field MRI scans may improve the accuracy of MRI for staging ovarian cancer pending further investigation [78].

Staging and Follow up of Ovarian Cancer. Although CT is not sensitive for detecting pleural metastases, these can be verified by video-assisted thoracoscopy, if needed [70]. Preoperative detection by CT of a moderate-to-large pleural effusion helps predict poor post-treatment outcome [71]. For postsurgical surveillance, the yield of chest CT is low if the chest radiograph shows no abnormalities, CT shows no abdominal or pelvic disease, and there is no rising serum CA-125 [72,73]. If PET using tracer FDG is used and includes chest, abdomen, and pelvis, the added value of diagnostic-quality chest CT is probably even lower. MRI MRI is an excellent problem-solving technique by virtue of its ability to define common conditions such as fibroids, dermoid cysts, endometriomas, and other benign lesions [6-8,31,44]. A multivariable analysis showed that the accuracy of MRI with gadolinium enhancement in separating ovarian malignancy from other types of adnexal masses was 93% [74]. Gadolinium enhancement and diffusion-weighted imaging offer improved diagnostic confidence and tissue characterization [31,74]. In staging, MRI has been shown to provide equivalent accuracy to CT and to predict peritoneal tumor volume comparable with surgery, with sensitivity of 0.88, specificity of 0.74, and accuracy of 0.84 [75,76]. However, the role of MRI in staging has been limited because 1) the use of intraluminal gastrointestinal contrast agents with MRI is not routine as it is with CT, and 2) patient motion is a greater problem for MRI than for CT. Although CT is currently the modality of choice for staging ovarian cancer, MRI is recommended for patients with borderline tumors or ovarian cancers that have been previously staged with fertility preservation (to minimize ionizing radiation exposure), or for some patients whose CT findings are inconclusive [68,77]. Higher-field MRI scans may improve the accuracy of MRI for staging ovarian cancer pending further investigation [78].

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Staging and Follow up of Ovarian Cancer

Intravenous contrast is preferable for detection and characterization of lesions suspected to represent tumor deposits. MRI without contrast may be considered for staging if contrast cannot be given and may offer improved soft-tissue contrast than noncontrast CT for staging in the pelvis; however, to our knowledge, there are no known studies on the comparative performance of MRI without contrast and CT without contrast for staging. FDG-PET/CT The use of FDG-PET imaging in the primary diagnosis and tissue characterization of ovarian cancer is unsupported to date. Specificity has been reported to be as low as 54%, while sensitivity has been as high as 86% [33,79,80]. Also, false-negative results have been reported with borderline tumors, mucinous tumors, early carcinomas, and other low-grade types of tumors [81,82]. False-positive results have been reported with fibromas, dermoid cysts, hydrosalpinges, and endometriosis [68,80]. However, FDG-PET, especially when combined with CT, is a valuable tool for diagnosing and staging advanced disease [32,34-37,79]. For staging, fusion FDG-PET/CT has higher reported accuracy than either CT or FDG- PET alone in multiple studies [32,35,36,79,83]. Improved detection of peritoneal disease may stem from metabolic activity in small deposits or lymph nodes that may be difficult to identify and characterize with CT alone. Thus, although CT with contrast is the modality of choice for initial staging, PET or FDG-PET/CT may be a useful adjunct test, particularly when CT is indeterminate. Contrast Enema Contrast enema is not routinely used for pretreatment staging of ovarian cancer. An exception may occur when there is concern about the possibility of a colonic primary versus ovarian primary malignancy based on preoperative CT findings, signs, symptoms, and CA-125 and CEA tumor marker ratio. Staging and Follow-up of Ovarian Cancer IVU Intravenous urography (IVU) is not routinely used for pretreatment staging of ovarian cancer.

Staging and Follow up of Ovarian Cancer. Intravenous contrast is preferable for detection and characterization of lesions suspected to represent tumor deposits. MRI without contrast may be considered for staging if contrast cannot be given and may offer improved soft-tissue contrast than noncontrast CT for staging in the pelvis; however, to our knowledge, there are no known studies on the comparative performance of MRI without contrast and CT without contrast for staging. FDG-PET/CT The use of FDG-PET imaging in the primary diagnosis and tissue characterization of ovarian cancer is unsupported to date. Specificity has been reported to be as low as 54%, while sensitivity has been as high as 86% [33,79,80]. Also, false-negative results have been reported with borderline tumors, mucinous tumors, early carcinomas, and other low-grade types of tumors [81,82]. False-positive results have been reported with fibromas, dermoid cysts, hydrosalpinges, and endometriosis [68,80]. However, FDG-PET, especially when combined with CT, is a valuable tool for diagnosing and staging advanced disease [32,34-37,79]. For staging, fusion FDG-PET/CT has higher reported accuracy than either CT or FDG- PET alone in multiple studies [32,35,36,79,83]. Improved detection of peritoneal disease may stem from metabolic activity in small deposits or lymph nodes that may be difficult to identify and characterize with CT alone. Thus, although CT with contrast is the modality of choice for initial staging, PET or FDG-PET/CT may be a useful adjunct test, particularly when CT is indeterminate. Contrast Enema Contrast enema is not routinely used for pretreatment staging of ovarian cancer. An exception may occur when there is concern about the possibility of a colonic primary versus ovarian primary malignancy based on preoperative CT findings, signs, symptoms, and CA-125 and CEA tumor marker ratio. Staging and Follow-up of Ovarian Cancer IVU Intravenous urography (IVU) is not routinely used for pretreatment staging of ovarian cancer.

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Staging and Follow up of Ovarian Cancer

US There is no evidence to support a role for US in initial staging evaluation of ovarian cancer. Transvaginal US is mainly useful for determining the site of origin of a pelvic mass and to characterize the lesion [30]. Variant 2: Extent of disease in suspected or known recurrence of ovarian cancer. Imaging of the chest, abdomen, and pelvis plays a key role in evaluation for recurrence and the extent of disease. Rising CA-125, symptoms, or other clinical suspicion for relapse after treatment prompts imaging evaluation for recurrence. If imaging or clinical examination confirms a recurrent tumor, the extent of disease and timing of disease recurrence then determines the choice(s) of treatments, including surgery, chemotherapy, and radiation therapy. The choices for treatment depend upon the time that has passed since chemotherapy was completed. In general, surgical resection of the recurrent tumor is an option when chemotherapy was completed more than 6 months before recurrence and with the option for additional radiation therapy or chemotherapy after surgery. The role for routine surveillance with imaging is unclear in patients considered to be in clinical remission. Imaging has been shown to have limited sensitivity for detection of small tumor deposits in the abdomen and pelvis, with or without monitoring of CA-125 [3,84]. Furthermore, the MRC OV05/EORTC trial did not show a difference in overall survival when patients were treated based on elevated CA-125 versus clinical evidence of recurrence (including imaging findings) [85], despite recognition that CA-125 is generally elevated in cases of recurrence before clinical or imaging signs become evident. The National Comprehensive Cancer Network guidelines for follow-up of primary chemotherapy with complete response include imaging tests as needed, using CT, FDG-PET, FDG-PET/CT, MRI, or chest radiographs [11].

Staging and Follow up of Ovarian Cancer. US There is no evidence to support a role for US in initial staging evaluation of ovarian cancer. Transvaginal US is mainly useful for determining the site of origin of a pelvic mass and to characterize the lesion [30]. Variant 2: Extent of disease in suspected or known recurrence of ovarian cancer. Imaging of the chest, abdomen, and pelvis plays a key role in evaluation for recurrence and the extent of disease. Rising CA-125, symptoms, or other clinical suspicion for relapse after treatment prompts imaging evaluation for recurrence. If imaging or clinical examination confirms a recurrent tumor, the extent of disease and timing of disease recurrence then determines the choice(s) of treatments, including surgery, chemotherapy, and radiation therapy. The choices for treatment depend upon the time that has passed since chemotherapy was completed. In general, surgical resection of the recurrent tumor is an option when chemotherapy was completed more than 6 months before recurrence and with the option for additional radiation therapy or chemotherapy after surgery. The role for routine surveillance with imaging is unclear in patients considered to be in clinical remission. Imaging has been shown to have limited sensitivity for detection of small tumor deposits in the abdomen and pelvis, with or without monitoring of CA-125 [3,84]. Furthermore, the MRC OV05/EORTC trial did not show a difference in overall survival when patients were treated based on elevated CA-125 versus clinical evidence of recurrence (including imaging findings) [85], despite recognition that CA-125 is generally elevated in cases of recurrence before clinical or imaging signs become evident. The National Comprehensive Cancer Network guidelines for follow-up of primary chemotherapy with complete response include imaging tests as needed, using CT, FDG-PET, FDG-PET/CT, MRI, or chest radiographs [11].

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Staging and Follow up of Ovarian Cancer

CT Contrast-enhanced CT (also using oral contrast) is the modality of choice for detecting recurrence in the chest, abdomen, or pelvis. Contrast-enhanced CT has a reported sensitivity ranging from 58% to 84% and specificity in the range of 59% to 100% in identifying tumor recurrence [52,86,87]. Recurrent disease usually manifests as peritoneal implants; within the peritoneal cavity and on the surface of the visceral organs. CT is used to identify tumor deposits in the root of the mesentery, gastrosplenic ligament, omentum of the lesser sac, porta hepatis, intersegmental fissure of the liver, diaphragm, liver dome, and lung parenchyma, and also in detecting lymphadenopathy. However, identification of small (<5 mm) tumor deposits in the mesentery, on bowel wall, or along the peritoneum may be limited [5,43,58,59]. Noncontrast-enhanced CT of the abdomen and pelvis offers limited ability to identify small peritoneal or mesenteric implants, or lymphadenopathy among bowel loops and other adjacent organs. MRI The reported accuracy of MRI for detecting lesions >2 cm in recurrent disease is comparable to that of CT at 93% to 95% [14]. However, MRI demonstrated a significantly lower area under the receiver operator characteristic curve than CT, FDG-PET, FDG-PET/CT, or CA-125 for overall detection of recurrent ovarian cancer in a meta- analysis [88]. CT remains the most widely used imaging method for detecting recurrence, and, despite some advantages, the role of MRI in follow-up imaging has been limited because 1) the use of intraluminal gastrointestinal contrast agents with MRI is not routine as it is with CT and 2) patient motion is a greater problem for MRI than for CT. Although CT is currently the modality of choice for suspected recurrence of ovarian cancer, MRI is recommended for borderline tumors or ovarian cancers that have been previously staged with fertility preservation (to minimize ionizing radiation exposure), or for some patients whose CT findings are inconclusive.

Staging and Follow up of Ovarian Cancer. CT Contrast-enhanced CT (also using oral contrast) is the modality of choice for detecting recurrence in the chest, abdomen, or pelvis. Contrast-enhanced CT has a reported sensitivity ranging from 58% to 84% and specificity in the range of 59% to 100% in identifying tumor recurrence [52,86,87]. Recurrent disease usually manifests as peritoneal implants; within the peritoneal cavity and on the surface of the visceral organs. CT is used to identify tumor deposits in the root of the mesentery, gastrosplenic ligament, omentum of the lesser sac, porta hepatis, intersegmental fissure of the liver, diaphragm, liver dome, and lung parenchyma, and also in detecting lymphadenopathy. However, identification of small (<5 mm) tumor deposits in the mesentery, on bowel wall, or along the peritoneum may be limited [5,43,58,59]. Noncontrast-enhanced CT of the abdomen and pelvis offers limited ability to identify small peritoneal or mesenteric implants, or lymphadenopathy among bowel loops and other adjacent organs. MRI The reported accuracy of MRI for detecting lesions >2 cm in recurrent disease is comparable to that of CT at 93% to 95% [14]. However, MRI demonstrated a significantly lower area under the receiver operator characteristic curve than CT, FDG-PET, FDG-PET/CT, or CA-125 for overall detection of recurrent ovarian cancer in a meta- analysis [88]. CT remains the most widely used imaging method for detecting recurrence, and, despite some advantages, the role of MRI in follow-up imaging has been limited because 1) the use of intraluminal gastrointestinal contrast agents with MRI is not routine as it is with CT and 2) patient motion is a greater problem for MRI than for CT. Although CT is currently the modality of choice for suspected recurrence of ovarian cancer, MRI is recommended for borderline tumors or ovarian cancers that have been previously staged with fertility preservation (to minimize ionizing radiation exposure), or for some patients whose CT findings are inconclusive.

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Staging and Follow up of Ovarian Cancer

Intravenous contrast is preferable for detection and characterization of lesions suspected to represent tumor deposits. MRI without contrast may be considered for staging if contrast cannot be given and may offer improved soft-tissue contrast than noncontrast CT for staging in the pelvis. However, to our knowledge, there are no known studies on the comparative performance of MRI without contrast and CT without contrast for staging. FDG-PET/CT For suspected recurrent ovarian cancer, FDG-PET/CT has recently shown similar or higher accuracy for tumor detection than contrast-enhanced CT or PET alone [10,19,34,89,90], with a sensitivity of 95% to 97% and specificity of 80% to 100% [86,89,91]. The spatial resolution of PET limits sensitivity for subcentimeter metastases, and metabolic activity on or between bowel loops, particularly after surgery when adhesions or Staging and Follow-up of Ovarian Cancer inflammation are present, may be difficult to assess. For such reasons, PET or FDG-PET/CT has not uniformly shown improved sensitivity or specificity of recurrence compared with CT alone [88]. Still, the combined metabolic activity and anatomic localization of FDG-PET/CT have been shown to improve disease detection in small lymph nodes and unresectable sites, which can alter management [87,91]. Notably, the performance of FDG-PET/CT in the literature reflects a predominance of serous papillary carcinomas, and false-negative results have been reported with mucinous adenocarcinomas, and cystic, necrotic, low-grade or small-volume (<7 mm) deposits [82]. Thus, either CT or FDG-PET/CT may be used to evaluate suspected recurrence, and FDG-PET/CT may also be a useful adjunct when CT is indeterminate with persistent clinical concern [92]. Contrast Enema Contrast enema is not routinely used for detecting recurrence of ovarian cancer. IVU IVU is not routinely used for detecting recurrence of ovarian cancer.

Staging and Follow up of Ovarian Cancer. Intravenous contrast is preferable for detection and characterization of lesions suspected to represent tumor deposits. MRI without contrast may be considered for staging if contrast cannot be given and may offer improved soft-tissue contrast than noncontrast CT for staging in the pelvis. However, to our knowledge, there are no known studies on the comparative performance of MRI without contrast and CT without contrast for staging. FDG-PET/CT For suspected recurrent ovarian cancer, FDG-PET/CT has recently shown similar or higher accuracy for tumor detection than contrast-enhanced CT or PET alone [10,19,34,89,90], with a sensitivity of 95% to 97% and specificity of 80% to 100% [86,89,91]. The spatial resolution of PET limits sensitivity for subcentimeter metastases, and metabolic activity on or between bowel loops, particularly after surgery when adhesions or Staging and Follow-up of Ovarian Cancer inflammation are present, may be difficult to assess. For such reasons, PET or FDG-PET/CT has not uniformly shown improved sensitivity or specificity of recurrence compared with CT alone [88]. Still, the combined metabolic activity and anatomic localization of FDG-PET/CT have been shown to improve disease detection in small lymph nodes and unresectable sites, which can alter management [87,91]. Notably, the performance of FDG-PET/CT in the literature reflects a predominance of serous papillary carcinomas, and false-negative results have been reported with mucinous adenocarcinomas, and cystic, necrotic, low-grade or small-volume (<7 mm) deposits [82]. Thus, either CT or FDG-PET/CT may be used to evaluate suspected recurrence, and FDG-PET/CT may also be a useful adjunct when CT is indeterminate with persistent clinical concern [92]. Contrast Enema Contrast enema is not routinely used for detecting recurrence of ovarian cancer. IVU IVU is not routinely used for detecting recurrence of ovarian cancer.

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Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs

Introduction/Background Patients who present with acute chest pain in the setting of nonspecific signs and symptoms, and a low pretest probability for coronary disease, remain an important clinical management dilemma. This is largely related to the competing imperatives of the medical and legal implications of an undiagnosed acute cardiac event as well as the impact on patient flow and hospital use of efficaciously triaging such low-risk cardiac patients, especially in the emergency room [1]. In the current era, there is great imperative to bring to bear a range of advances, including improved clinical algorithms such as the HEART (history electrocardiogram age risk factors troponin) scoring system [2-5], newer biochemical tests, such as high sensitivity troponins [6-11], and newer advanced imaging modalities, such as coronary artery CT [12-14]. Patient management approaches are exploring integration of these procedure advances in the context of clinical decision units/observational units [15,16]. This publication will focus on the evidence for use of individual imaging approaches, in the context of an integrated decision-making setting. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that CMS has applied to the Current Procedural Terminology codes. Reprint requests to: [email protected] Acute Nonspecific Chest Pain OR Discussion of Procedures by Variant Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.

Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Introduction/Background Patients who present with acute chest pain in the setting of nonspecific signs and symptoms, and a low pretest probability for coronary disease, remain an important clinical management dilemma. This is largely related to the competing imperatives of the medical and legal implications of an undiagnosed acute cardiac event as well as the impact on patient flow and hospital use of efficaciously triaging such low-risk cardiac patients, especially in the emergency room [1]. In the current era, there is great imperative to bring to bear a range of advances, including improved clinical algorithms such as the HEART (history electrocardiogram age risk factors troponin) scoring system [2-5], newer biochemical tests, such as high sensitivity troponins [6-11], and newer advanced imaging modalities, such as coronary artery CT [12-14]. Patient management approaches are exploring integration of these procedure advances in the context of clinical decision units/observational units [15,16]. This publication will focus on the evidence for use of individual imaging approaches, in the context of an integrated decision-making setting. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that CMS has applied to the Current Procedural Terminology codes. Reprint requests to: [email protected] Acute Nonspecific Chest Pain OR Discussion of Procedures by Variant Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.

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Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs

Radiography Chest Radiographs of the chest remain an important imaging tool in the workup of patients presenting with acute, nonspecific, low cardiac probability of chest pain, albeit as an indirect indicator of an acute cardiac event, such as the documentation of heart failure. Although there is no relevant literature to support the use of chest radiographs for the evaluation of the coronaries or the heart in the setting of acute nonspecific chest pain with low probability of CAD, this is still a helpful examination. US Echocardiography Transthoracic Stress In a national study of 24,000 patients evaluated in chest pain units, two-thirds of patients, mostly those experiencing acute chest pain, underwent echocardiography (not specified whether resting or stress), with high reliability in guiding further invasive management [15]. This is in keeping with the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association guidelines [22]. A single-center study of 250 patients specifically addressing stress imaging with low-risk presentation documented prognostic significance for major adverse cardiovascular events (MACE) at 1-year follow-up [23]. A single-center randomized control study of 400 consecutive participants comparing coronary artery CT with stress echocardiography for early emergency room discharge of low- to intermediate-risk patients documented a smaller percentage of patients being hospitalized, the primary endpoint, and shorter duration of emergency room observation or hospitalization for stress echocardiography. Major adverse cardiac events at 24 months were comparable for the modalities [24].

Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Radiography Chest Radiographs of the chest remain an important imaging tool in the workup of patients presenting with acute, nonspecific, low cardiac probability of chest pain, albeit as an indirect indicator of an acute cardiac event, such as the documentation of heart failure. Although there is no relevant literature to support the use of chest radiographs for the evaluation of the coronaries or the heart in the setting of acute nonspecific chest pain with low probability of CAD, this is still a helpful examination. US Echocardiography Transthoracic Stress In a national study of 24,000 patients evaluated in chest pain units, two-thirds of patients, mostly those experiencing acute chest pain, underwent echocardiography (not specified whether resting or stress), with high reliability in guiding further invasive management [15]. This is in keeping with the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association guidelines [22]. A single-center study of 250 patients specifically addressing stress imaging with low-risk presentation documented prognostic significance for major adverse cardiovascular events (MACE) at 1-year follow-up [23]. A single-center randomized control study of 400 consecutive participants comparing coronary artery CT with stress echocardiography for early emergency room discharge of low- to intermediate-risk patients documented a smaller percentage of patients being hospitalized, the primary endpoint, and shorter duration of emergency room observation or hospitalization for stress echocardiography. Major adverse cardiac events at 24 months were comparable for the modalities [24].

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