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acrac_3195150_2

Endometriosis

MRI Pelvis Without and With IV Contrast MRI pelvis is an excellent imaging modality for the preoperative diagnosis of endometriosis [37-39] and has been shown to correspond well with surgical staging systems and histopathologic findings [40-43]. Variability in the literature surrounding accuracy of MRI compared to other modalities for detection of endometriosis may be attributed to differences in imaging techniques used [40]. The performance of MRI for detection of endometriosis varies by lesion location. MRI is excellent for identification of DE but has shown poorer diagnostic accuracy for detection of superficial peritoneal disease [44-46]. Image acquisition is more automated for MRI than US [47]. The large field-of-view afforded by MRI can decrease the need for multiple additional imaging studies that are sometimes required to supplement US pelvis studies, which do not include the entire urinary or gastrointestinal tracts [48]. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is helpful for the diagnosis of DE as described in the preceding paragraph. Although much of the literature surrounding MRI of the pelvis for detection of DE describes using IV contrast agents, a study that specifically compared MRI without IV contrast to MRI with IV contrast found no benefit of IV contrast media [50]. Endometriosis US Pelvis Transabdominal Although it is possible that larger ovarian endometriomas could be detected by transabdominal pelvic US, many of the structures involved by superficial and DE are not well seen by transabdominal technique alone. US Pelvis Transabdominal and US Pelvis Transvaginal Transabdominal pelvic US imaging is described in some endometriosis protocols as an adjunct to TVUS imaging to evaluate the urinary tract or gastrointestinal tract [51]. Transabdominal US can serve as an important adjunct to TVUS studies because it widens the field-of-view beyond what is possible by TVUS imaging. Transabdominal US imaging is useful for detection of urinary tract endometriosis.

Endometriosis. MRI Pelvis Without and With IV Contrast MRI pelvis is an excellent imaging modality for the preoperative diagnosis of endometriosis [37-39] and has been shown to correspond well with surgical staging systems and histopathologic findings [40-43]. Variability in the literature surrounding accuracy of MRI compared to other modalities for detection of endometriosis may be attributed to differences in imaging techniques used [40]. The performance of MRI for detection of endometriosis varies by lesion location. MRI is excellent for identification of DE but has shown poorer diagnostic accuracy for detection of superficial peritoneal disease [44-46]. Image acquisition is more automated for MRI than US [47]. The large field-of-view afforded by MRI can decrease the need for multiple additional imaging studies that are sometimes required to supplement US pelvis studies, which do not include the entire urinary or gastrointestinal tracts [48]. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is helpful for the diagnosis of DE as described in the preceding paragraph. Although much of the literature surrounding MRI of the pelvis for detection of DE describes using IV contrast agents, a study that specifically compared MRI without IV contrast to MRI with IV contrast found no benefit of IV contrast media [50]. Endometriosis US Pelvis Transabdominal Although it is possible that larger ovarian endometriomas could be detected by transabdominal pelvic US, many of the structures involved by superficial and DE are not well seen by transabdominal technique alone. US Pelvis Transabdominal and US Pelvis Transvaginal Transabdominal pelvic US imaging is described in some endometriosis protocols as an adjunct to TVUS imaging to evaluate the urinary tract or gastrointestinal tract [51]. Transabdominal US can serve as an important adjunct to TVUS studies because it widens the field-of-view beyond what is possible by TVUS imaging. Transabdominal US imaging is useful for detection of urinary tract endometriosis.

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Endometriosis

Urinary obstruction caused by involvement of the ureters or bladder can be silent and associated with loss of renal function [51]. Transabdominal US imaging can also help identify sites of bowel involvement beyond the pelvis, including the appendix, terminal ileum, cecum, and sigmoid [14]. DE TVUS supplemented by transabdominal US imaging was found to accurately predict intraoperative endometriosis staging at a multi-institutional study performed at centers of endometriosis excellence [52]. Variant 2: Adult. Clinically suspected pelvic endometriosis. Indeterminate or negative ultrasound. Next imaging study for characterization or treatment planning. CT Pelvis With IV Contrast There is no relevant literature to support the use of routine pelvic CT with IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of routine pelvic CT without and with IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis. CT Pelvis Without IV Contrast There is no relevant literature to support the use of routine pelvic CT without IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis. MRI Pelvis Without and With IV Contrast A study that evaluated patients who underwent routine pelvic US and pelvic MRI with IV contrast and later went on to surgery for endometriosis found 51% of patients with a negative US went on to have disease identified on MRI. The same study showed that 78% of patients with endometriosis identified by US were found to have additional sites of disease by MRI [73]. MRI is known to correspond well with surgical staging systems and histopathologic findings [40-43]. Some pelvic MRI classification systems can predict surgical time, length of hospital stay, and postoperative complications [74].

Endometriosis. Urinary obstruction caused by involvement of the ureters or bladder can be silent and associated with loss of renal function [51]. Transabdominal US imaging can also help identify sites of bowel involvement beyond the pelvis, including the appendix, terminal ileum, cecum, and sigmoid [14]. DE TVUS supplemented by transabdominal US imaging was found to accurately predict intraoperative endometriosis staging at a multi-institutional study performed at centers of endometriosis excellence [52]. Variant 2: Adult. Clinically suspected pelvic endometriosis. Indeterminate or negative ultrasound. Next imaging study for characterization or treatment planning. CT Pelvis With IV Contrast There is no relevant literature to support the use of routine pelvic CT with IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of routine pelvic CT without and with IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis. CT Pelvis Without IV Contrast There is no relevant literature to support the use of routine pelvic CT without IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis. MRI Pelvis Without and With IV Contrast A study that evaluated patients who underwent routine pelvic US and pelvic MRI with IV contrast and later went on to surgery for endometriosis found 51% of patients with a negative US went on to have disease identified on MRI. The same study showed that 78% of patients with endometriosis identified by US were found to have additional sites of disease by MRI [73]. MRI is known to correspond well with surgical staging systems and histopathologic findings [40-43]. Some pelvic MRI classification systems can predict surgical time, length of hospital stay, and postoperative complications [74].

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Endometriosis

Structured reporting of pelvic MRI studies can improve sensitivity compared to routine read studies and are preferred by referring physicians [75,76]. MRI pelvis allows imaging with a large field-of-view to include anatomy that is generally beyond the field-of-view for TVUS. Structures that are not well seen by US, such as pelvic nerves, can be depicted by MRI [77,78]. MRI pelvis can be used for surgical planning for bladder endometriosis because it can accurately predict lesion size and Endometriosis involvement of the ureter orifices [46,79]. These studies are also helpful for surgical planning when bowel disease is present as described under Variant 3. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is helpful for the diagnosis of DE, for further characterization of indeterminate findings on US, and for treatment planning as described in the preceding paragraph. Assessment of ovarian lesions is limited without IV contrast. Variant 3: Adult. Clinically suspected rectosigmoid endometriosis. Initial imaging. The intestinal tract is the most common site of nongynecologic endometriosis. Endometriosis can infiltrate the muscular bowel wall leading to gastrointestinal symptoms. The anterior wall of the rectosigmoid colon is the most common location for bowel endometriosis, followed by the sigmoid colon, cecum and ileocecal valve, appendix. and small bowel [80]. Rectosigmoid bowel lesions can be removed by surgical shaving, discoid resection, or segmental resection. Information from imaging studies is used to predict which of these surgical approaches will be needed. CT Pelvis With IV Contrast There is no relevant literature to support the use of standard pelvic CT without a water enema as an initial imaging modality for clinically suspected rectosigmoid endometriosis.

Endometriosis. Structured reporting of pelvic MRI studies can improve sensitivity compared to routine read studies and are preferred by referring physicians [75,76]. MRI pelvis allows imaging with a large field-of-view to include anatomy that is generally beyond the field-of-view for TVUS. Structures that are not well seen by US, such as pelvic nerves, can be depicted by MRI [77,78]. MRI pelvis can be used for surgical planning for bladder endometriosis because it can accurately predict lesion size and Endometriosis involvement of the ureter orifices [46,79]. These studies are also helpful for surgical planning when bowel disease is present as described under Variant 3. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is helpful for the diagnosis of DE, for further characterization of indeterminate findings on US, and for treatment planning as described in the preceding paragraph. Assessment of ovarian lesions is limited without IV contrast. Variant 3: Adult. Clinically suspected rectosigmoid endometriosis. Initial imaging. The intestinal tract is the most common site of nongynecologic endometriosis. Endometriosis can infiltrate the muscular bowel wall leading to gastrointestinal symptoms. The anterior wall of the rectosigmoid colon is the most common location for bowel endometriosis, followed by the sigmoid colon, cecum and ileocecal valve, appendix. and small bowel [80]. Rectosigmoid bowel lesions can be removed by surgical shaving, discoid resection, or segmental resection. Information from imaging studies is used to predict which of these surgical approaches will be needed. CT Pelvis With IV Contrast There is no relevant literature to support the use of standard pelvic CT without a water enema as an initial imaging modality for clinically suspected rectosigmoid endometriosis.

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Endometriosis

Studies looking into specialized CT techniques that are not widely available, such as CT with colonic distention by water enema or CT colonography have found these methods to be accurate for identifying and characterizing gastrointestinal tract endometriotic lesions for surgical planning. Both of these techniques allow for detection of multifocal lesions and lesions proximal to the rectosigmoid beyond the field-of-view of TVUS [81-89]. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of standard CT pelvis without and with IV contrast in the evaluation of clinically suspected rectosigmoid endometriosis. CT Pelvis Without IV Contrast There is no relevant literature to support the use of CT pelvis without IV contrast for clinically suspected rectosigmoid endometriosis. Fluoroscopy Contrast Enema Fluoroscopic enema studies allow for evaluation of the entire colon, allowing for diagnosis of cecal lesions. These studies are less specific than other imaging modalities because the cause of the mass effect on the bowel wall is not directly visualized and cannot be characterized. A study comparing double-contrast barium enema to TVUS performed with rectal water contrast shows similar accuracy for both studies with slightly better tolerance of TVUS with bowel preparation compared to barium enema [90]. MRI Pelvis Without and With IV Contrast MR pelvis is an excellent modality to detect and classify rectosigmoid bowel endometriosis for surgical planning [42,91,92]. Surgical approach can be predicted based on morphologic characteristics of lesions and quantitative assessment of lesion length, thickness, and circumferential involvement of the bowel lumen [93,94]. This information can be used to predict the type of resection that will be needed, aiding in informed decision making and treatment planning [42,91,92,94-96]. The field-of-view for pelvic MRI includes the entire rectum and sigmoid colon. The cecum and terminal ileum are often included within the field-of-view.

Endometriosis. Studies looking into specialized CT techniques that are not widely available, such as CT with colonic distention by water enema or CT colonography have found these methods to be accurate for identifying and characterizing gastrointestinal tract endometriotic lesions for surgical planning. Both of these techniques allow for detection of multifocal lesions and lesions proximal to the rectosigmoid beyond the field-of-view of TVUS [81-89]. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of standard CT pelvis without and with IV contrast in the evaluation of clinically suspected rectosigmoid endometriosis. CT Pelvis Without IV Contrast There is no relevant literature to support the use of CT pelvis without IV contrast for clinically suspected rectosigmoid endometriosis. Fluoroscopy Contrast Enema Fluoroscopic enema studies allow for evaluation of the entire colon, allowing for diagnosis of cecal lesions. These studies are less specific than other imaging modalities because the cause of the mass effect on the bowel wall is not directly visualized and cannot be characterized. A study comparing double-contrast barium enema to TVUS performed with rectal water contrast shows similar accuracy for both studies with slightly better tolerance of TVUS with bowel preparation compared to barium enema [90]. MRI Pelvis Without and With IV Contrast MR pelvis is an excellent modality to detect and classify rectosigmoid bowel endometriosis for surgical planning [42,91,92]. Surgical approach can be predicted based on morphologic characteristics of lesions and quantitative assessment of lesion length, thickness, and circumferential involvement of the bowel lumen [93,94]. This information can be used to predict the type of resection that will be needed, aiding in informed decision making and treatment planning [42,91,92,94-96]. The field-of-view for pelvic MRI includes the entire rectum and sigmoid colon. The cecum and terminal ileum are often included within the field-of-view.

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Endometriosis

A small percentage of small bowel loops are also included within the field- of-view. Added MR cine sequences have been suggested to evaluate immobility from pelvic adhesions like the US sliding sign [97]. MR colonography has also been described as an accurate tool for evaluation of bowel lesions before surgery [98]. Endometriosis MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is excellent for diagnosis of rectosigmoid endometriosis and for treatment planning as described in the preceding paragraph. Assessment of ovarian lesions, or other pelvic pathology, is a finding that is often seen in association with rectosigmoid endometriosis and is limited without IV contrast. US Pelvis Transabdominal Transabdominal US imaging cannot be used to evaluate rectosigmoid lesions but can be used as an adjunct to identify sites of bowel involvement beyond the pelvis including the appendix, terminal ileum, cecum, and sigmoid [14]. US Pelvis Transabdominal and US Pelvis Transvaginal A study evaluating a combined transabdominal US and TVUS protocol found excellent sensitivity and specificity for rectosigmoid lesions and slightly decreased sensitivity for sigmoid lesions. The study did not report data on more proximal lesions [80]. As described in the previous paragraph, other studies have shown that transabdominal pelvis US can be used to evaluate the appendix, terminal ileum, cecum, and sigmoid colon, and therefore the addition of transabdominal imaging is likely to be of benefit in evaluating lesions proximal to the rectosigmoid. US Pelvis Transrectal Transrectal pelvic US allows for evaluation of the bowel wall layers involved by an endometriotic lesion, which can help with surgical planning, as rectosigmoid endometriotic lesions involving the muscular layer may require discoid or segmental resection, whereas more superficial lesions can be treated with rectal shaving.

Endometriosis. A small percentage of small bowel loops are also included within the field- of-view. Added MR cine sequences have been suggested to evaluate immobility from pelvic adhesions like the US sliding sign [97]. MR colonography has also been described as an accurate tool for evaluation of bowel lesions before surgery [98]. Endometriosis MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is excellent for diagnosis of rectosigmoid endometriosis and for treatment planning as described in the preceding paragraph. Assessment of ovarian lesions, or other pelvic pathology, is a finding that is often seen in association with rectosigmoid endometriosis and is limited without IV contrast. US Pelvis Transabdominal Transabdominal US imaging cannot be used to evaluate rectosigmoid lesions but can be used as an adjunct to identify sites of bowel involvement beyond the pelvis including the appendix, terminal ileum, cecum, and sigmoid [14]. US Pelvis Transabdominal and US Pelvis Transvaginal A study evaluating a combined transabdominal US and TVUS protocol found excellent sensitivity and specificity for rectosigmoid lesions and slightly decreased sensitivity for sigmoid lesions. The study did not report data on more proximal lesions [80]. As described in the previous paragraph, other studies have shown that transabdominal pelvis US can be used to evaluate the appendix, terminal ileum, cecum, and sigmoid colon, and therefore the addition of transabdominal imaging is likely to be of benefit in evaluating lesions proximal to the rectosigmoid. US Pelvis Transrectal Transrectal pelvic US allows for evaluation of the bowel wall layers involved by an endometriotic lesion, which can help with surgical planning, as rectosigmoid endometriotic lesions involving the muscular layer may require discoid or segmental resection, whereas more superficial lesions can be treated with rectal shaving.

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Endometriosis

Transrectal pelvic US also allows for accurate measurements from the caudal margin of an endometriotic lesion to the anal verge, which is important for surgical planning in the setting of low-lying lesions that may require a diverting ostomy. These studies are limited by a narrow field-of-view that allows for evaluation of the rectosigmoid colon but cannot evaluate more proximal structures [40,99,100]. US Pelvis Transvaginal TVUS can be used to evaluate rectosigmoid endometriosis but cannot be used to evaluate for lesions proximal to the rectosigmoid junction, which is beyond the field-of-view for a transvaginal probe. Literature surrounding the use of TVUS for the evaluation of rectosigmoid endometriosis has exclusively evaluated protocols that include scanning maneuvers beyond what is included in a routine TVUS as defined by the ACR Practice Parameters. TVUS performed with added maneuvers including scanning with probe in the posterior vaginal fornix and the sliding sign has been shown to be a reliable predictor of bowel endometriosis [101-104]. These protocols can also be used for surgical planning when the lesion length, circumferential extent, distance to the anal verge, and muscular involvement are reported [105-107]. When specialist-performed DE TVUS is used, the accuracy of surgical planning measurements is similar to MRI [108]. A study comparing DE TVUS performed by a trained versus untrained operator showed the modality predicted bowel endometriosis when performed by the trained operator but not by the untrained operator [109]. Variant 4: Adult. Established postoperative endometriosis diagnosis. New or ongoing symptoms of endometriosis. Follow-up imaging. CT Pelvis With IV Contrast There is no relevant literature to support the use of pelvic CT for patients with an endometriosis diagnosis established by surgery with new or ongoing symptoms. CT with IV contrast could help identify and characterize other etiologies of pelvic pain.

Endometriosis. Transrectal pelvic US also allows for accurate measurements from the caudal margin of an endometriotic lesion to the anal verge, which is important for surgical planning in the setting of low-lying lesions that may require a diverting ostomy. These studies are limited by a narrow field-of-view that allows for evaluation of the rectosigmoid colon but cannot evaluate more proximal structures [40,99,100]. US Pelvis Transvaginal TVUS can be used to evaluate rectosigmoid endometriosis but cannot be used to evaluate for lesions proximal to the rectosigmoid junction, which is beyond the field-of-view for a transvaginal probe. Literature surrounding the use of TVUS for the evaluation of rectosigmoid endometriosis has exclusively evaluated protocols that include scanning maneuvers beyond what is included in a routine TVUS as defined by the ACR Practice Parameters. TVUS performed with added maneuvers including scanning with probe in the posterior vaginal fornix and the sliding sign has been shown to be a reliable predictor of bowel endometriosis [101-104]. These protocols can also be used for surgical planning when the lesion length, circumferential extent, distance to the anal verge, and muscular involvement are reported [105-107]. When specialist-performed DE TVUS is used, the accuracy of surgical planning measurements is similar to MRI [108]. A study comparing DE TVUS performed by a trained versus untrained operator showed the modality predicted bowel endometriosis when performed by the trained operator but not by the untrained operator [109]. Variant 4: Adult. Established postoperative endometriosis diagnosis. New or ongoing symptoms of endometriosis. Follow-up imaging. CT Pelvis With IV Contrast There is no relevant literature to support the use of pelvic CT for patients with an endometriosis diagnosis established by surgery with new or ongoing symptoms. CT with IV contrast could help identify and characterize other etiologies of pelvic pain.

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acrac_3195150_8

Endometriosis

CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of pelvic CT without and with IV contrast for patients with endometriosis diagnosis established by surgery and new or ongoing symptoms. CT Pelvis Without IV Contrast There is no relevant literature to support the use of pelvic CT without IV contrast for patients with endometriosis diagnosis established by surgery and new or ongoing symptoms. MRI Pelvis Without and With IV Contrast MRI pelvis is known to be an excellent modality for detecting endometriosis. An imaging review paper describes findings that may be seen postoperatively, including susceptibility artifacts related to surgical material and fibrotic adhesions that appear as linear hypointense bands on T2-weighted images with signal intensity lower than that is seen with endometriosis [110]. Semicircular suture may be seen along the anterior rectosigmoid wall in patients Endometriosis who have undergone discoid resection. Bladder volumes may be decreased, and the bladder contour may be irregular following partial cystectomy for endometriosis lesion resection [110]. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is known to be an excellent modality for detecting and mapping endometriosis as summarized in the preceding paragraph; however, there are little data on the use of MRI without IV contrast to evaluate patients with ongoing or new symptoms following laparoscopy. IV contrast can be helpful in diagnosing other causes for recurrent symptoms in the postoperative time period. US Pelvis Transabdominal There are no data describing the use of transabdominal pelvic US to evaluate for endometriosis in patients with ongoing or new symptoms following surgery. As in the preoperative setting, it is possible that larger ovarian endometriomas could be detected by transabdominal US, but many of the structures involved by superficial and DE are not well seen by transabdominal US technique alone.

Endometriosis. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of pelvic CT without and with IV contrast for patients with endometriosis diagnosis established by surgery and new or ongoing symptoms. CT Pelvis Without IV Contrast There is no relevant literature to support the use of pelvic CT without IV contrast for patients with endometriosis diagnosis established by surgery and new or ongoing symptoms. MRI Pelvis Without and With IV Contrast MRI pelvis is known to be an excellent modality for detecting endometriosis. An imaging review paper describes findings that may be seen postoperatively, including susceptibility artifacts related to surgical material and fibrotic adhesions that appear as linear hypointense bands on T2-weighted images with signal intensity lower than that is seen with endometriosis [110]. Semicircular suture may be seen along the anterior rectosigmoid wall in patients Endometriosis who have undergone discoid resection. Bladder volumes may be decreased, and the bladder contour may be irregular following partial cystectomy for endometriosis lesion resection [110]. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is known to be an excellent modality for detecting and mapping endometriosis as summarized in the preceding paragraph; however, there are little data on the use of MRI without IV contrast to evaluate patients with ongoing or new symptoms following laparoscopy. IV contrast can be helpful in diagnosing other causes for recurrent symptoms in the postoperative time period. US Pelvis Transabdominal There are no data describing the use of transabdominal pelvic US to evaluate for endometriosis in patients with ongoing or new symptoms following surgery. As in the preoperative setting, it is possible that larger ovarian endometriomas could be detected by transabdominal US, but many of the structures involved by superficial and DE are not well seen by transabdominal US technique alone.

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acrac_3158176_0

Nontraumatic Chest Wall Pain

Introduction/Background Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings. Of the many causes for undifferentiated chest pain, acute cardiovascular processes (eg, myocardial infarction or aortic dissection) are the most important to distinguish from less life-threatening etiologies. Distinguishing visceral (eg, angina) from musculoskeletal (ie, chest wall) pain is an essential step in the diagnostic approach. An estimated 20% to 40% of the general population may be affected by chest pain in their lifetime [1], and almost half of patients presenting to primary care settings with chest pain were diagnosed with musculoskeletal causes. Patients presenting to ambulatory care settings more often are found to have noncardiovascular causes of chest pain (musculoskeletal, gastrointestinal, and psychopathologic) than those presenting to emergency departments [1,2]. One large series of ambulatory patients described their chest wall symptoms as stinging (53.0%) or pressing (35.1%), retrosternal (52.0%) or left-sided (69.2%), occurring more than once daily (62.9%), with more than half (55.4%) having chronic symptoms lasting >6 months [1]. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Discussion of Procedures by Variant Variant 1: Nontraumatic chest wall pain. No history of malignancy. Initial imaging.

Nontraumatic Chest Wall Pain. Introduction/Background Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings. Of the many causes for undifferentiated chest pain, acute cardiovascular processes (eg, myocardial infarction or aortic dissection) are the most important to distinguish from less life-threatening etiologies. Distinguishing visceral (eg, angina) from musculoskeletal (ie, chest wall) pain is an essential step in the diagnostic approach. An estimated 20% to 40% of the general population may be affected by chest pain in their lifetime [1], and almost half of patients presenting to primary care settings with chest pain were diagnosed with musculoskeletal causes. Patients presenting to ambulatory care settings more often are found to have noncardiovascular causes of chest pain (musculoskeletal, gastrointestinal, and psychopathologic) than those presenting to emergency departments [1,2]. One large series of ambulatory patients described their chest wall symptoms as stinging (53.0%) or pressing (35.1%), retrosternal (52.0%) or left-sided (69.2%), occurring more than once daily (62.9%), with more than half (55.4%) having chronic symptoms lasting >6 months [1]. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Discussion of Procedures by Variant Variant 1: Nontraumatic chest wall pain. No history of malignancy. Initial imaging.

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acrac_3158176_1

Nontraumatic Chest Wall Pain

Bone Scan Whole Body Bone scintigraphy using diphosphonate radiotracer has been used to detect a variety of bone diseases that may cause chest wall pain, including fractures, metastases, arthritis, osteomyelitis, osteonecrosis, and costochondritis [9], but is usually not useful as an initial imaging modality. In a retrospective study of 225 patients with atypical chest pain considered to be of low to intermediate Framingham coronary risk, Tc-99m methylene diphosphonate bone scintigraphy showed a focal abnormality in nearly half (49.4%), with most (42.7%) being posttraumatic lesions of the rib, sternum, vertebral bodies, or clavicle; 4.9% costochondritis; and 1.8% neoplastic lesions [9]. Bone scintigraphy was positive in 5/7 (71.4%) patients diagnosed with costochondritis [9]. Overall, bone scintigraphy helped determine a cause for chest pain in 94/225 (41.8%) of patients, but in 15.3% of patients with abnormalities on bone scintigraphy, the true cause for chest pain was considered irrelevant to those findings [9]. CT Chest Despite its superior sensitivity for detection and characterization of chest wall abnormalities, in the absence of other clinical risk factors like trauma, infection, or malignancy, CT may not be useful as a first-line modality for evaluation of chest wall pain [10]. For diagnosis of cough-induced rib fractures, some authors suggest that chest CT be reserved for patients who require evaluation of other pulmonary diseases [11]. Although not validated in nontraumatic settings, diagnostic accuracy for rib fractures may be improved and reading time decreased when the radiologist incorporates unfolded rib reformatted images [12,13]. Chest CT might also diagnose other causes of chest wall pain, such as mediastinal fat necrosis (also variably referred to in the literature as pericardial, epicardial, and epipericardial fat necrosis) [14].

Nontraumatic Chest Wall Pain. Bone Scan Whole Body Bone scintigraphy using diphosphonate radiotracer has been used to detect a variety of bone diseases that may cause chest wall pain, including fractures, metastases, arthritis, osteomyelitis, osteonecrosis, and costochondritis [9], but is usually not useful as an initial imaging modality. In a retrospective study of 225 patients with atypical chest pain considered to be of low to intermediate Framingham coronary risk, Tc-99m methylene diphosphonate bone scintigraphy showed a focal abnormality in nearly half (49.4%), with most (42.7%) being posttraumatic lesions of the rib, sternum, vertebral bodies, or clavicle; 4.9% costochondritis; and 1.8% neoplastic lesions [9]. Bone scintigraphy was positive in 5/7 (71.4%) patients diagnosed with costochondritis [9]. Overall, bone scintigraphy helped determine a cause for chest pain in 94/225 (41.8%) of patients, but in 15.3% of patients with abnormalities on bone scintigraphy, the true cause for chest pain was considered irrelevant to those findings [9]. CT Chest Despite its superior sensitivity for detection and characterization of chest wall abnormalities, in the absence of other clinical risk factors like trauma, infection, or malignancy, CT may not be useful as a first-line modality for evaluation of chest wall pain [10]. For diagnosis of cough-induced rib fractures, some authors suggest that chest CT be reserved for patients who require evaluation of other pulmonary diseases [11]. Although not validated in nontraumatic settings, diagnostic accuracy for rib fractures may be improved and reading time decreased when the radiologist incorporates unfolded rib reformatted images [12,13]. Chest CT might also diagnose other causes of chest wall pain, such as mediastinal fat necrosis (also variably referred to in the literature as pericardial, epicardial, and epipericardial fat necrosis) [14].

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acrac_3158176_2

Nontraumatic Chest Wall Pain

FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT as initial imaging in the evaluation of chest wall pain in patients with no history of malignancy. MRI Chest MRI may be complementary to other modalities in characterization of various processes and to delineate the extent of chest wall or osseous involvement on a case-by-case basis [15]. Radiography Chest After a thorough history and physical examination, chest radiography may be a useful initial imaging test to evaluate for specific etiologies of chest wall pain (eg, rib fracture, infection, or neoplasm) and to evaluate for other conditions that may simulate chest wall pain, such as spontaneous pneumothorax [16]. However, chest radiographs may be insensitive to detect abnormalities of the rib cartilages, costochondral junctions, costovertebral joints, and chest wall soft tissues. In a series of 183 stable adult outpatients presenting with nontraumatic chest pain imaging with both chest radiography and rib series, rib fractures were detected in only 4.9% of cases [17]. In another study of 1,089 patients presenting to the emergency department who underwent chest radiography for evaluation of nontraumatic chest pain, only 70 (6.4%) were deemed to have findings clinically relevant to emergency department care [18]. In one series of patients with rupture of the costal margin associated with severe coughing fits, all patients had widening of the rib spaces on chest radiographs, whereas 4/9 patients had associated rib fractures [19]. Nontraumatic Chest Wall Pain US Chest Although diagnostic ultrasound (US) of the chest is not typically utilized for the evaluation of chest wall pain, point- of-care US has been shown to be feasible for detection of rib fractures in the setting of minor trauma in emergency settings, with 27/94 (29%) detecting rib fractures after negative chest radiography [22].

Nontraumatic Chest Wall Pain. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT as initial imaging in the evaluation of chest wall pain in patients with no history of malignancy. MRI Chest MRI may be complementary to other modalities in characterization of various processes and to delineate the extent of chest wall or osseous involvement on a case-by-case basis [15]. Radiography Chest After a thorough history and physical examination, chest radiography may be a useful initial imaging test to evaluate for specific etiologies of chest wall pain (eg, rib fracture, infection, or neoplasm) and to evaluate for other conditions that may simulate chest wall pain, such as spontaneous pneumothorax [16]. However, chest radiographs may be insensitive to detect abnormalities of the rib cartilages, costochondral junctions, costovertebral joints, and chest wall soft tissues. In a series of 183 stable adult outpatients presenting with nontraumatic chest pain imaging with both chest radiography and rib series, rib fractures were detected in only 4.9% of cases [17]. In another study of 1,089 patients presenting to the emergency department who underwent chest radiography for evaluation of nontraumatic chest pain, only 70 (6.4%) were deemed to have findings clinically relevant to emergency department care [18]. In one series of patients with rupture of the costal margin associated with severe coughing fits, all patients had widening of the rib spaces on chest radiographs, whereas 4/9 patients had associated rib fractures [19]. Nontraumatic Chest Wall Pain US Chest Although diagnostic ultrasound (US) of the chest is not typically utilized for the evaluation of chest wall pain, point- of-care US has been shown to be feasible for detection of rib fractures in the setting of minor trauma in emergency settings, with 27/94 (29%) detecting rib fractures after negative chest radiography [22].

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acrac_3158176_3

Nontraumatic Chest Wall Pain

Another study showed US to detect costochondral fractures in 68.8% of radiographically occult cases [23]. US of the chest has several diagnostic limitations, including technical difficulties related to posterior location of fractures, and soft-tissue penetration in patients with large breasts [22]. Patient-reported pain during the US examination limited evaluation in only 14% of cases but may be helpful in targeting the examination to the focal abnormality. US has added benefits of dynamic imaging capabilities as well as relative ease [15,24]. Dynamic US detected slipping rib syndrome in 32/36 (89%) and ruled it out in 10/10 (100%) [25]. WBC Scan Chest There is no relevant literature to support the use of nuclear medicine white blood cell (WBC) chest scans as initial imaging in the evaluation of chest wall pain in patients with no history of malignancy. Variant 2: Nontraumatic chest wall pain. Known or suspected malignancy. Secondary evaluation after normal chest radiograph. Next imaging study. Bone Scan Whole Body Bone scintigraphy has been shown to have 95% sensitivity for detection of skeletal metastases and defines extent of involvement across the entire skeleton [26]. It may have a role in characterization of primary chest wall neoplasms, especially those that may contain chondroid or osteoid components [26]. Limitations of bone scintigraphy occur in the setting of nonosteoblastic processes such as multiple myeloma that may not be detected by this modality. Although uncommon, chest wall metastases usually indicate advanced disease. Osseous metastases may manifest as sclerotic (eg, prostate cancer), mixed lytic and sclerotic (eg, breast cancer), or purely lytic (eg, renal cell carcinoma) and are best characterized at CT [27]. Soft-tissue metastases may be readily detected at CT if they involve the skin or subcutaneous fat.

Nontraumatic Chest Wall Pain. Another study showed US to detect costochondral fractures in 68.8% of radiographically occult cases [23]. US of the chest has several diagnostic limitations, including technical difficulties related to posterior location of fractures, and soft-tissue penetration in patients with large breasts [22]. Patient-reported pain during the US examination limited evaluation in only 14% of cases but may be helpful in targeting the examination to the focal abnormality. US has added benefits of dynamic imaging capabilities as well as relative ease [15,24]. Dynamic US detected slipping rib syndrome in 32/36 (89%) and ruled it out in 10/10 (100%) [25]. WBC Scan Chest There is no relevant literature to support the use of nuclear medicine white blood cell (WBC) chest scans as initial imaging in the evaluation of chest wall pain in patients with no history of malignancy. Variant 2: Nontraumatic chest wall pain. Known or suspected malignancy. Secondary evaluation after normal chest radiograph. Next imaging study. Bone Scan Whole Body Bone scintigraphy has been shown to have 95% sensitivity for detection of skeletal metastases and defines extent of involvement across the entire skeleton [26]. It may have a role in characterization of primary chest wall neoplasms, especially those that may contain chondroid or osteoid components [26]. Limitations of bone scintigraphy occur in the setting of nonosteoblastic processes such as multiple myeloma that may not be detected by this modality. Although uncommon, chest wall metastases usually indicate advanced disease. Osseous metastases may manifest as sclerotic (eg, prostate cancer), mixed lytic and sclerotic (eg, breast cancer), or purely lytic (eg, renal cell carcinoma) and are best characterized at CT [27]. Soft-tissue metastases may be readily detected at CT if they involve the skin or subcutaneous fat.

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acrac_3158176_4

Nontraumatic Chest Wall Pain

However, intramuscular lesions may have similar attenuation as the skeletal muscle and may be missed, unless there is muscle expansion, invasion of adjacent osseous structures, or enhancement after administration of intravenous (IV) contrast material. CT is also useful for image-guided biopsy of lesions [32]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is valuable in the staging (presurgical planning, detection of distant metastases) and follow-up of patients with primary soft-tissue sarcomas, with maximum standardized uptake value (SUVmax) measurements being correlated with greater glucose transporter protein expression and histologic aggressiveness [33]. In one study, FDG-PET/CT was shown to have prognostic value, with greater event-free survival in patients whose tumors measured less than SUVmax 10.2 [33]. In addition, FDG-PET/CT may be helpful in directing image-guided needle biopsy to areas of metabolic activity to improve diagnostic accuracy in heterogeneous tumors [32]. Although FDG- PET/CT is sensitive for the detection of FDG-avid tumors, false-positives may result from misinterpretation of various normal physiologic states, including skeletal muscle uptake, brown fat uptake, and some benign lesions, such as infection, inflammation, healing fractures, and fibrous dysplasia. In one large retrospective series, benign nonphysiologic FDG uptake was present in >25% of oncologic FDG-PET/CT, with 55.7% of lesions showing moderate or marked FDG uptake relative to background [34]. Choi et al [35] determined that FDG-PET/CT had poor performance (accuracy 57.2%) in differentiating between benign and metastatic rib lesions, with the best SUVmax cutoff to differentiate being low at 2.4. However, predictive value for metastases was improved when FDG- PET activity was combined with CT findings of correlative osteolytic and osteoblastic lesions [35]. FDG-PET/CT may identify CT occult bone metastases, which demonstrate focal FDG uptake without a corresponding lesion on

Nontraumatic Chest Wall Pain. However, intramuscular lesions may have similar attenuation as the skeletal muscle and may be missed, unless there is muscle expansion, invasion of adjacent osseous structures, or enhancement after administration of intravenous (IV) contrast material. CT is also useful for image-guided biopsy of lesions [32]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is valuable in the staging (presurgical planning, detection of distant metastases) and follow-up of patients with primary soft-tissue sarcomas, with maximum standardized uptake value (SUVmax) measurements being correlated with greater glucose transporter protein expression and histologic aggressiveness [33]. In one study, FDG-PET/CT was shown to have prognostic value, with greater event-free survival in patients whose tumors measured less than SUVmax 10.2 [33]. In addition, FDG-PET/CT may be helpful in directing image-guided needle biopsy to areas of metabolic activity to improve diagnostic accuracy in heterogeneous tumors [32]. Although FDG- PET/CT is sensitive for the detection of FDG-avid tumors, false-positives may result from misinterpretation of various normal physiologic states, including skeletal muscle uptake, brown fat uptake, and some benign lesions, such as infection, inflammation, healing fractures, and fibrous dysplasia. In one large retrospective series, benign nonphysiologic FDG uptake was present in >25% of oncologic FDG-PET/CT, with 55.7% of lesions showing moderate or marked FDG uptake relative to background [34]. Choi et al [35] determined that FDG-PET/CT had poor performance (accuracy 57.2%) in differentiating between benign and metastatic rib lesions, with the best SUVmax cutoff to differentiate being low at 2.4. However, predictive value for metastases was improved when FDG- PET activity was combined with CT findings of correlative osteolytic and osteoblastic lesions [35]. FDG-PET/CT may identify CT occult bone metastases, which demonstrate focal FDG uptake without a corresponding lesion on

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acrac_3158176_5

Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain MRI Chest Chest MRI is often complementary to CT in comprehensive tissue characterization of chest wall neoplasms, defining their extent, and for planning of therapeutic interventions [15,27-30,38]. The soft-tissue contrast afforded by MRI may allow for tissue characterization of lesions, including differentiation of neoplastic processes from nonneoplastic mimics (eg, infection) [27,30,39]. Chest MRI also has been utilized for determining neurovascular involvement [40]. Some studies have shown added value of respiratory dynamic chest MRI in determination of chest wall invasion, defined as restricted movement of a tumor by the chest wall during breathing maneuvers [41,42]. One study of 61 patients whose static CT or MRI were equivocal for invasion showed respiratory dynamic chest MRI to have 100% sensitivity, 82.9% specificity, and 88.5% accuracy for predicting chest wall invasion with positive and negative predictive values of 74.1% and 100%, respectively [41]. False-positives occurred in the setting of pleural adhesions that restricted movement, but in most cases, they could be differentiated from true invasion at surgery [41]. Radiography Rib Views For focal chest wall pain in patients with suspected malignancy, a radiographic rib series may be helpful to assess for a rib lesion [16]. However, as for chest radiography, further characterization with CT, MRI, or nuclear medicine studies may be beneficial to detect radiographically occult lesions. US Chest Generally, US serves a limited role in the primary evaluation of suspected primary chest wall neoplasms but may serve a role in determining secondary invasion of the chest wall by intrathoracic tumors.

Nontraumatic Chest Wall Pain. Nontraumatic Chest Wall Pain MRI Chest Chest MRI is often complementary to CT in comprehensive tissue characterization of chest wall neoplasms, defining their extent, and for planning of therapeutic interventions [15,27-30,38]. The soft-tissue contrast afforded by MRI may allow for tissue characterization of lesions, including differentiation of neoplastic processes from nonneoplastic mimics (eg, infection) [27,30,39]. Chest MRI also has been utilized for determining neurovascular involvement [40]. Some studies have shown added value of respiratory dynamic chest MRI in determination of chest wall invasion, defined as restricted movement of a tumor by the chest wall during breathing maneuvers [41,42]. One study of 61 patients whose static CT or MRI were equivocal for invasion showed respiratory dynamic chest MRI to have 100% sensitivity, 82.9% specificity, and 88.5% accuracy for predicting chest wall invasion with positive and negative predictive values of 74.1% and 100%, respectively [41]. False-positives occurred in the setting of pleural adhesions that restricted movement, but in most cases, they could be differentiated from true invasion at surgery [41]. Radiography Rib Views For focal chest wall pain in patients with suspected malignancy, a radiographic rib series may be helpful to assess for a rib lesion [16]. However, as for chest radiography, further characterization with CT, MRI, or nuclear medicine studies may be beneficial to detect radiographically occult lesions. US Chest Generally, US serves a limited role in the primary evaluation of suspected primary chest wall neoplasms but may serve a role in determining secondary invasion of the chest wall by intrathoracic tumors.

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acrac_3158176_6

Nontraumatic Chest Wall Pain

In a study of 23 patients who had a chest CT that showed findings suspicious for chest wall invasion by intrathoracic tumors or lung invasion by chest wall tumors, the sensitivity and specificity for chest wall invasion (using absence of a sliding pleura sign) were 88.9% and 100%, respectively, with 100% and 93.3% positive and negative predictive values, respectively [43]. Surgeon-performed US outperformed CT in diagnosis of chest wall invasion, with 90.9% sensitivity and 85.7% specificity versus 61.5% sensitivity and 84.6% specificity for CT [44]. Respective positive and negative predictive values in the same study of 28 patients were 83.3% and 92.3% for US compared with 80% and 68.8% for CT [44]. Another study showed US to have a higher sensitivity than CT for determining chest wall invasion by lung cancer (89% versus 42%, respectively) but had a lower specificity (95% versus 100%, respectively) [45]. However, a study of 131 patients with thoracic masses showed overlap in performance of US and CT for diagnosing chest wall invasion [46]. US may be helpful for image-guided biopsy of superficial lesions [27,32,39,46]. WBC Scan Chest There is no relevant literature to support the use of nuclear medicine WBC scans as initial imaging in the evaluation of chest wall pain in patients with known or suspected malignancy. Variant 3: Nontraumatic chest wall pain. Suspected infectious or inflammatory condition. Secondary evaluation after normal chest radiograph. Next imaging study. Bone Scan Whole Body Nuclear medicine studies, including bone scans and radiolabeled WBC scans, are especially helpful in localization of infectious or inflammatory conditions of the bones, joints, and costal cartilages, especially in the setting of negative radiographs and CT and in patients with metallic implants [47,48]. Bone scintigraphy is useful in screening the entire body for occult infectious or inflammatory disease, especially for patients with fever of unknown origin [26]. Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. In a study of 23 patients who had a chest CT that showed findings suspicious for chest wall invasion by intrathoracic tumors or lung invasion by chest wall tumors, the sensitivity and specificity for chest wall invasion (using absence of a sliding pleura sign) were 88.9% and 100%, respectively, with 100% and 93.3% positive and negative predictive values, respectively [43]. Surgeon-performed US outperformed CT in diagnosis of chest wall invasion, with 90.9% sensitivity and 85.7% specificity versus 61.5% sensitivity and 84.6% specificity for CT [44]. Respective positive and negative predictive values in the same study of 28 patients were 83.3% and 92.3% for US compared with 80% and 68.8% for CT [44]. Another study showed US to have a higher sensitivity than CT for determining chest wall invasion by lung cancer (89% versus 42%, respectively) but had a lower specificity (95% versus 100%, respectively) [45]. However, a study of 131 patients with thoracic masses showed overlap in performance of US and CT for diagnosing chest wall invasion [46]. US may be helpful for image-guided biopsy of superficial lesions [27,32,39,46]. WBC Scan Chest There is no relevant literature to support the use of nuclear medicine WBC scans as initial imaging in the evaluation of chest wall pain in patients with known or suspected malignancy. Variant 3: Nontraumatic chest wall pain. Suspected infectious or inflammatory condition. Secondary evaluation after normal chest radiograph. Next imaging study. Bone Scan Whole Body Nuclear medicine studies, including bone scans and radiolabeled WBC scans, are especially helpful in localization of infectious or inflammatory conditions of the bones, joints, and costal cartilages, especially in the setting of negative radiographs and CT and in patients with metallic implants [47,48]. Bone scintigraphy is useful in screening the entire body for occult infectious or inflammatory disease, especially for patients with fever of unknown origin [26]. Nontraumatic Chest Wall Pain

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acrac_3158176_7

Nontraumatic Chest Wall Pain

CT Chest CT is superior to US and radiography in determination of disease extent, including characterization of deep compartments and intrathoracic involvement. Osseous involvement, including cortical erosion, fragmentation, and sequestra, are readily depicted on CT. Gas formation within necrotic tissues or in the setting of serious infections, such as necrotizing fasciitis, is easily depicted on CT [48,52]. Chronic chest wall infections (eg, empyema necessitans, actinomycosis, Aspergillus) are well characterized with CT [52]. Administration of IV contrast may help to characterize and define fluid collections and soft-tissue sinus tract formation. Advantages of CT include rapid image acquisition, isotropic data, and high spatial resolution. Limitations include decreased sensitivity related to streak artifacts around metallic hardware. CT may be utilized for image-guided drainage procedures or during percutaneous biopsy. MRI Chest MRI is highly effective at detecting and characterizing infectious and inflammatory disorders of the chest wall soft tissues and osseous structures, maintaining a high negative predictive value in excluding disease in the setting of normal imaging findings [48,58]. Fluid-sensitive sequences, especially those with applied fat signal suppression, detect early edema and readily define extent of soft tissue and osseous involvement that may not be apparent on CT [52]. Administration of gadolinium-based contrast material further characterizes areas of hyperemia and defines fluid collections and soft-tissue sinus tract formation. Unlike CT, gas formation is not as well appreciated on MRI but may be seen as signal void, especially on gradient-echo sequences [48]. MRI may be useful for defining infectious involvement of skin and fascial layers, muscle, bursae, and tendons.

Nontraumatic Chest Wall Pain. CT Chest CT is superior to US and radiography in determination of disease extent, including characterization of deep compartments and intrathoracic involvement. Osseous involvement, including cortical erosion, fragmentation, and sequestra, are readily depicted on CT. Gas formation within necrotic tissues or in the setting of serious infections, such as necrotizing fasciitis, is easily depicted on CT [48,52]. Chronic chest wall infections (eg, empyema necessitans, actinomycosis, Aspergillus) are well characterized with CT [52]. Administration of IV contrast may help to characterize and define fluid collections and soft-tissue sinus tract formation. Advantages of CT include rapid image acquisition, isotropic data, and high spatial resolution. Limitations include decreased sensitivity related to streak artifacts around metallic hardware. CT may be utilized for image-guided drainage procedures or during percutaneous biopsy. MRI Chest MRI is highly effective at detecting and characterizing infectious and inflammatory disorders of the chest wall soft tissues and osseous structures, maintaining a high negative predictive value in excluding disease in the setting of normal imaging findings [48,58]. Fluid-sensitive sequences, especially those with applied fat signal suppression, detect early edema and readily define extent of soft tissue and osseous involvement that may not be apparent on CT [52]. Administration of gadolinium-based contrast material further characterizes areas of hyperemia and defines fluid collections and soft-tissue sinus tract formation. Unlike CT, gas formation is not as well appreciated on MRI but may be seen as signal void, especially on gradient-echo sequences [48]. MRI may be useful for defining infectious involvement of skin and fascial layers, muscle, bursae, and tendons.

3158176

acrac_3158176_8

Nontraumatic Chest Wall Pain

If clinical suspicion for potentially life-threatening necrotizing fasciitis is high, detection of hyperintense signal within chest wall deep fascial compartments on fluid-sensitive MRI sequences is highly suggestive of the disease, and the absence of these findings essentially exclude the disease [48,58]. MRI also serves a role in surgical planning prior to debridement procedures, distinguishing viable from nonviable tissue based on tissue signal and enhancement characteristics [48]. MRI may be helpful in the differentiation of chest wall infection from tumor. Anterior chest wall pain is a common complaint among patients who have underlying spondyloarthritis, but the diagnosis may be delayed for many years [53]. MRI was 62.5% sensitive in determining sternoclavicular and sternocostal involvement by inflammatory spondyloarthritis in patients who presented with anterior chest wall pain as an early manifestation of their disease and was able to provide specific information regarding disease activity and severity beyond that provided by bone scintigraphy [49]. Another study showed higher sensitivity of MRI for detection of disease activity (bone marrow edema, erosions, and fat infiltration) than other serologic and clinical Nontraumatic Chest Wall Pain parameters, and especially involvement of the manubriosternal joint [59]. Other systemic inflammatory conditions can also be suggested by MRI with abnormal signal intensity of skeletal muscle (whether from edema or fatty atrophy), such as immune-mediated myositis and other neurodegenerative diseases [48]. Radiography Rib Views There is no relevant literature to support the use of radiography rib views beyond chest radiography in the primary evaluation of chest wall pain in patients with suspected chest wall infectious or inflammatory conditions.

Nontraumatic Chest Wall Pain. If clinical suspicion for potentially life-threatening necrotizing fasciitis is high, detection of hyperintense signal within chest wall deep fascial compartments on fluid-sensitive MRI sequences is highly suggestive of the disease, and the absence of these findings essentially exclude the disease [48,58]. MRI also serves a role in surgical planning prior to debridement procedures, distinguishing viable from nonviable tissue based on tissue signal and enhancement characteristics [48]. MRI may be helpful in the differentiation of chest wall infection from tumor. Anterior chest wall pain is a common complaint among patients who have underlying spondyloarthritis, but the diagnosis may be delayed for many years [53]. MRI was 62.5% sensitive in determining sternoclavicular and sternocostal involvement by inflammatory spondyloarthritis in patients who presented with anterior chest wall pain as an early manifestation of their disease and was able to provide specific information regarding disease activity and severity beyond that provided by bone scintigraphy [49]. Another study showed higher sensitivity of MRI for detection of disease activity (bone marrow edema, erosions, and fat infiltration) than other serologic and clinical Nontraumatic Chest Wall Pain parameters, and especially involvement of the manubriosternal joint [59]. Other systemic inflammatory conditions can also be suggested by MRI with abnormal signal intensity of skeletal muscle (whether from edema or fatty atrophy), such as immune-mediated myositis and other neurodegenerative diseases [48]. Radiography Rib Views There is no relevant literature to support the use of radiography rib views beyond chest radiography in the primary evaluation of chest wall pain in patients with suspected chest wall infectious or inflammatory conditions.

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acrac_3158176_9

Nontraumatic Chest Wall Pain

US Chest US is a useful modality for targeted evaluation of soft tissue, osseous, and joints of the chest wall and for characterization and potential drainage of abscesses and joint effusions but has limited capability of determining extent of disease [48]. Variant 4: Nontraumatic chest wall pain. History of prior chest intervention. Secondary evaluation after normal chest radiograph. Next imaging study. Bone Scan Whole Body A single case report described bone scan findings of heterogeneous radiotracer uptake in ribs that were within the areas of the chest wall that received >30 Gy after a chest CT revealed no abnormality [62]. In a case report of a patient with chest pain 11 months after chest wall radiation for breast cancer, a bone scan showed evidence of costochondritis but no metastases after initial negative CT and were both later positive after the patient developed rib fractures [63]. Bone scan or radiolabeled WBC scan plays a role in the evaluation of sternal osteomyelitis, especially in patients who have equivocal CT findings, maintaining a high negative predictive value for osteomyelitis [64]. CT has variable performance in the diagnosis of sternal wound infections after cardiac surgery. Most patients may present with clinical signs and symptoms of sternal infection, precluding the need for imaging. However, CT may be useful for diagnosis in patients in whom the diagnosis is suspected but who lack overt clinical signs and symptoms [64,67]. In a study of 40 patients, the sensitivity and specificity of CT for diagnosis of mediastinitis was best beyond 17 days after surgery (100% and 90%, respectively), with 100% sensitivity and only 33% specificity in the first 17 postoperative days [68,69]. Noninfectious poststernotomy chest pain may affect more than half of patients after sternotomy and was inversely correlated with the degree of osseous healing (complete versus incomplete) [8].

Nontraumatic Chest Wall Pain. US Chest US is a useful modality for targeted evaluation of soft tissue, osseous, and joints of the chest wall and for characterization and potential drainage of abscesses and joint effusions but has limited capability of determining extent of disease [48]. Variant 4: Nontraumatic chest wall pain. History of prior chest intervention. Secondary evaluation after normal chest radiograph. Next imaging study. Bone Scan Whole Body A single case report described bone scan findings of heterogeneous radiotracer uptake in ribs that were within the areas of the chest wall that received >30 Gy after a chest CT revealed no abnormality [62]. In a case report of a patient with chest pain 11 months after chest wall radiation for breast cancer, a bone scan showed evidence of costochondritis but no metastases after initial negative CT and were both later positive after the patient developed rib fractures [63]. Bone scan or radiolabeled WBC scan plays a role in the evaluation of sternal osteomyelitis, especially in patients who have equivocal CT findings, maintaining a high negative predictive value for osteomyelitis [64]. CT has variable performance in the diagnosis of sternal wound infections after cardiac surgery. Most patients may present with clinical signs and symptoms of sternal infection, precluding the need for imaging. However, CT may be useful for diagnosis in patients in whom the diagnosis is suspected but who lack overt clinical signs and symptoms [64,67]. In a study of 40 patients, the sensitivity and specificity of CT for diagnosis of mediastinitis was best beyond 17 days after surgery (100% and 90%, respectively), with 100% sensitivity and only 33% specificity in the first 17 postoperative days [68,69]. Noninfectious poststernotomy chest pain may affect more than half of patients after sternotomy and was inversely correlated with the degree of osseous healing (complete versus incomplete) [8].

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acrac_3158176_10

Nontraumatic Chest Wall Pain

Sternal nonunion and sternal dehiscence may be characterized at CT, with sternal gap >3 mm correlating with significantly higher chest pain intensity compared with those with minor dehiscence and those with normal sternal healing, as determined by chest CT [8,64,70]. Chest CT with 3-D reconstructions was useful in assessing the degree of healing and residual chest wall deformities in 46 patients randomized to either operative or nonoperative management of flail chest [71]. CT is commonly used in the pre- and postoperative evaluation of patients who underwent chest wall reconstruction for rib fractures and chest wall tumors [72,73]. Rarely, desmoid-type fibromatosis can occur at prior thoracotomy sites Nontraumatic Chest Wall Pain and may mimic chest wall recurrence. CT in combination with FDG-PET/CT is useful for detecting and characterizing these lesions and for image-guided biopsy [74]. FDG-PET/CT Skull Base to Mid-Thigh Investigators have shown a positive dose-dependent relationship in chest wall FDG-PET/CT uptake predictive of patients who later developed chest wall complications (pain and rib fractures) after stereotactic body radiation therapy for lung cancer [75]. False-positive diagnoses can occur in cases in which there is myositis-related FDG uptake in the chest wall musculature in patients who have undergone prior radiation [76]. Furthermore, FDG- PET/CT is valuable in determining depth of infection, involvement of costal cartilages, and for preoperative planning of debridement procedures in patients with deep sternal wound infections after sternotomy procedures [77]. The sensitivity and specificity of FDG-PET/CT for sternal wound infections was 91% and 97%, respectively, with SUVmax showing value in patients who are imaged >6 months after surgery [78].

Nontraumatic Chest Wall Pain. Sternal nonunion and sternal dehiscence may be characterized at CT, with sternal gap >3 mm correlating with significantly higher chest pain intensity compared with those with minor dehiscence and those with normal sternal healing, as determined by chest CT [8,64,70]. Chest CT with 3-D reconstructions was useful in assessing the degree of healing and residual chest wall deformities in 46 patients randomized to either operative or nonoperative management of flail chest [71]. CT is commonly used in the pre- and postoperative evaluation of patients who underwent chest wall reconstruction for rib fractures and chest wall tumors [72,73]. Rarely, desmoid-type fibromatosis can occur at prior thoracotomy sites Nontraumatic Chest Wall Pain and may mimic chest wall recurrence. CT in combination with FDG-PET/CT is useful for detecting and characterizing these lesions and for image-guided biopsy [74]. FDG-PET/CT Skull Base to Mid-Thigh Investigators have shown a positive dose-dependent relationship in chest wall FDG-PET/CT uptake predictive of patients who later developed chest wall complications (pain and rib fractures) after stereotactic body radiation therapy for lung cancer [75]. False-positive diagnoses can occur in cases in which there is myositis-related FDG uptake in the chest wall musculature in patients who have undergone prior radiation [76]. Furthermore, FDG- PET/CT is valuable in determining depth of infection, involvement of costal cartilages, and for preoperative planning of debridement procedures in patients with deep sternal wound infections after sternotomy procedures [77]. The sensitivity and specificity of FDG-PET/CT for sternal wound infections was 91% and 97%, respectively, with SUVmax showing value in patients who are imaged >6 months after surgery [78].

3158176

acrac_3158176_11

Nontraumatic Chest Wall Pain

MRI Chest Chest MRI is valuable in the evaluation of patients after treatment of chest wall neoplasms and is superior to chest CT for detection of sites of residual or recurrent tumor after chest radiation or resection, especially using T1- weighted fat-suppressed sequences after administration of gadolinium-based contrast material [27]. MRI may also be used to determine the etiology of rib fractures in patients with known malignancy [63]. MRI has been also used in follow-up and response evaluation of patients with chest wall and breast desmoid tumors that developed after mastectomy and silicone implant augmentation [79]. Chest MRI may be a valuable tool in the early detection of sternal wound infections, given its high spatial resolution and soft-tissue contrast, but is limited by susceptibility artifacts related to sternotomy wires and other cardiac implants [69]. Radiography Rib Views There is no relevant literature to support the use of radiography rib views beyond chest radiography in the primary evaluation of chest wall pain in patients with prior chest wall intervention. US Chest Apart from targeted evaluation of the chest wall soft tissues for hematoma or abscess evaluation or treatment after chest wall surgery, US has a limited role. One study utilized sternal US to assess for sternal nonunion with dynamic compression and cortical sliding as a cause for poststernotomy chest pain [70]. WBC Scan Chest There is sparse literature to support the use of WBC scans in the primary evaluation of patients who present with chest wall pain after previous intervention. Quirce et al [80,81] compared the diagnostic performance of planar and SPECT WBC scans among 41 patients with suspected sternal infections after sternotomy, showing superior performance of SPECT over planar imaging for detection of infections at both 4 and 20 hours after injection and for differentiating superficial from deeper infections.

Nontraumatic Chest Wall Pain. MRI Chest Chest MRI is valuable in the evaluation of patients after treatment of chest wall neoplasms and is superior to chest CT for detection of sites of residual or recurrent tumor after chest radiation or resection, especially using T1- weighted fat-suppressed sequences after administration of gadolinium-based contrast material [27]. MRI may also be used to determine the etiology of rib fractures in patients with known malignancy [63]. MRI has been also used in follow-up and response evaluation of patients with chest wall and breast desmoid tumors that developed after mastectomy and silicone implant augmentation [79]. Chest MRI may be a valuable tool in the early detection of sternal wound infections, given its high spatial resolution and soft-tissue contrast, but is limited by susceptibility artifacts related to sternotomy wires and other cardiac implants [69]. Radiography Rib Views There is no relevant literature to support the use of radiography rib views beyond chest radiography in the primary evaluation of chest wall pain in patients with prior chest wall intervention. US Chest Apart from targeted evaluation of the chest wall soft tissues for hematoma or abscess evaluation or treatment after chest wall surgery, US has a limited role. One study utilized sternal US to assess for sternal nonunion with dynamic compression and cortical sliding as a cause for poststernotomy chest pain [70]. WBC Scan Chest There is sparse literature to support the use of WBC scans in the primary evaluation of patients who present with chest wall pain after previous intervention. Quirce et al [80,81] compared the diagnostic performance of planar and SPECT WBC scans among 41 patients with suspected sternal infections after sternotomy, showing superior performance of SPECT over planar imaging for detection of infections at both 4 and 20 hours after injection and for differentiating superficial from deeper infections.

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acrac_3113019_0

Postpartum Hemorrhage

Introduction/Background Postpartum hemorrhage (PPH) is among the top three causes of maternal death in the United States and accounts for 27% of all maternal deaths worldwide [1,2]. PPH affects 1% to 5% of all deliveries and may be life-threatening. PPH in the first 24 hours after delivery is termed primary or early PPH, whereas after 24 hours to 6 weeks it is termed secondary, late, or delayed PPH. Although classically, PPH has referred to pregnancies delivered beyond 20 weeks of gestation, the definition may be expanded to include hemorrhage post terminations or early pregnancy loss [3]. PPH is defined as any hemorrhage associated with signs or symptoms of hypovolemia within 24 hours of delivery, regardless of the type of delivery [4]. Conservative measures such as uterine tamponade with either packing or balloon catheter and massage, uterotonic medications, and correction of coagulopathies are the first line of treatment. Once a specific diagnosis has been identified, tailored intervention such as curettage for RPOC, embolization for VUA, antibiotics for infection, evacuation of large bladder hematoma, or surgical repair for uterine rupture can be performed. Uterine artery embolization, surgical ligation of uterine/internal iliac arteries, or hysterectomy may be necessary if these measures fail. Of special note is the evolving diagnosis and management of VUA. Myometrial VUA are believed to represent subinvolution of the placental bed, may be associated with RPOC, and will resolve either with removal of RPOC or expectant management in most patients. Timmerman et al [7] has reported an increased risk of significant PPH in those areas of intense myometrial vascularity with peak systolic velocity >83 cm/s. A subsequent report by the same group indicated surgical removal of RPOC would also result in almost immediate resolution of these areas of intense myometrial vascularity [8,9].

Postpartum Hemorrhage. Introduction/Background Postpartum hemorrhage (PPH) is among the top three causes of maternal death in the United States and accounts for 27% of all maternal deaths worldwide [1,2]. PPH affects 1% to 5% of all deliveries and may be life-threatening. PPH in the first 24 hours after delivery is termed primary or early PPH, whereas after 24 hours to 6 weeks it is termed secondary, late, or delayed PPH. Although classically, PPH has referred to pregnancies delivered beyond 20 weeks of gestation, the definition may be expanded to include hemorrhage post terminations or early pregnancy loss [3]. PPH is defined as any hemorrhage associated with signs or symptoms of hypovolemia within 24 hours of delivery, regardless of the type of delivery [4]. Conservative measures such as uterine tamponade with either packing or balloon catheter and massage, uterotonic medications, and correction of coagulopathies are the first line of treatment. Once a specific diagnosis has been identified, tailored intervention such as curettage for RPOC, embolization for VUA, antibiotics for infection, evacuation of large bladder hematoma, or surgical repair for uterine rupture can be performed. Uterine artery embolization, surgical ligation of uterine/internal iliac arteries, or hysterectomy may be necessary if these measures fail. Of special note is the evolving diagnosis and management of VUA. Myometrial VUA are believed to represent subinvolution of the placental bed, may be associated with RPOC, and will resolve either with removal of RPOC or expectant management in most patients. Timmerman et al [7] has reported an increased risk of significant PPH in those areas of intense myometrial vascularity with peak systolic velocity >83 cm/s. A subsequent report by the same group indicated surgical removal of RPOC would also result in almost immediate resolution of these areas of intense myometrial vascularity [8,9].

3113019

acrac_3113019_1

Postpartum Hemorrhage

Multidisciplinary consultation may aid in optimal management protocols in this group of patients with VUAs, RPOC, and PPH. 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] 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 the CMS has applied to the Current Procedural Terminology codes. Pelvic angiography has not been included in this document because the clinical utility of pelvic angiography has a very limited role as an isolated diagnostic imaging study. Pelvic angiography in the setting of PPH is primarily used to perform therapeutic interventions, which is not within the scope of this document. OR Discussion of Procedures by Variant Variant 1: Postpartum hemorrhage. Early (within first 24 hours) after cesarean delivery. Initial imaging. The most common cause of early PPH is related to uterine atony or lack of effective uterine contraction after delivery and is typically a clinical diagnosis in >75% of patients. It is initially treated by uterine massage and uterotonic drugs such as oxytocin, and the majority of patients respond well to these treatments. In the setting of cesarean section, because the abdomen is already open, surgical procedures to control intraoperative and immediate hemorrhage such as uterine or ovarian artery ligation or uterine compression sutures may be utilized.

Postpartum Hemorrhage. Multidisciplinary consultation may aid in optimal management protocols in this group of patients with VUAs, RPOC, and PPH. 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] 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 the CMS has applied to the Current Procedural Terminology codes. Pelvic angiography has not been included in this document because the clinical utility of pelvic angiography has a very limited role as an isolated diagnostic imaging study. Pelvic angiography in the setting of PPH is primarily used to perform therapeutic interventions, which is not within the scope of this document. OR Discussion of Procedures by Variant Variant 1: Postpartum hemorrhage. Early (within first 24 hours) after cesarean delivery. Initial imaging. The most common cause of early PPH is related to uterine atony or lack of effective uterine contraction after delivery and is typically a clinical diagnosis in >75% of patients. It is initially treated by uterine massage and uterotonic drugs such as oxytocin, and the majority of patients respond well to these treatments. In the setting of cesarean section, because the abdomen is already open, surgical procedures to control intraoperative and immediate hemorrhage such as uterine or ovarian artery ligation or uterine compression sutures may be utilized.

3113019

acrac_3113019_2

Postpartum Hemorrhage

If there is no response, additional considerations would include associated RPOC, adherent placentation, or even uterine inversion, and in these situations, imaging may be helpful. About 1% of third trimester deliveries are complicated by RPOC [11] and is the second most common etiology for PPH after uterine atony; although, this is typically seen in the delayed PPH population. The diagnosis of RPOC is helpful to the clinician in determining whether surgical intervention is warranted. Trauma-related hemorrhage may be due to lacerations, uterine rupture, or incision extensions. Imaging may be helpful to delineate the extent of intra-abdominal hemorrhage, whereas infralevator or perineal hemorrhage may be evaluated on visual inspection. Coagulopathy, either inherited or acute related to amniotic fluid embolism, placental abruption, severe pre-eclampsia or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, is less common but potentially life threatening. There is a long list of risk factors associated with uterine atony, which is not within the scope of this document. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with intravenous (IV) contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage. In hemodynamically stable patients when conventional medical treatment has been unsuccessful in terminating hemorrhage, further evaluation with CT can be considered, particularly in suspected intra-abdominal hemorrhage or postsurgical complications [12]. CT has a role in identifying surgical causes of PPH, which will not benefit from empiric embolization such as uterine rupture and genital tract laceration.

Postpartum Hemorrhage. If there is no response, additional considerations would include associated RPOC, adherent placentation, or even uterine inversion, and in these situations, imaging may be helpful. About 1% of third trimester deliveries are complicated by RPOC [11] and is the second most common etiology for PPH after uterine atony; although, this is typically seen in the delayed PPH population. The diagnosis of RPOC is helpful to the clinician in determining whether surgical intervention is warranted. Trauma-related hemorrhage may be due to lacerations, uterine rupture, or incision extensions. Imaging may be helpful to delineate the extent of intra-abdominal hemorrhage, whereas infralevator or perineal hemorrhage may be evaluated on visual inspection. Coagulopathy, either inherited or acute related to amniotic fluid embolism, placental abruption, severe pre-eclampsia or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, is less common but potentially life threatening. There is a long list of risk factors associated with uterine atony, which is not within the scope of this document. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with intravenous (IV) contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage. In hemodynamically stable patients when conventional medical treatment has been unsuccessful in terminating hemorrhage, further evaluation with CT can be considered, particularly in suspected intra-abdominal hemorrhage or postsurgical complications [12]. CT has a role in identifying surgical causes of PPH, which will not benefit from empiric embolization such as uterine rupture and genital tract laceration.

3113019

acrac_3113019_3

Postpartum Hemorrhage

Although uterine atony is a clinical diagnosis, CT can be helpful by detecting a hematoma within the cavity of an enlarged uterus [13] and excluding other causes of PPH. However, it can be difficult to differentiate blood products from RPOC [12]. CT can detect vascular complications such as bladder flap, subfascial, or perivaginal space hematoma and delineate relationship to adjacent organs (supralevator versus infralevator location in the perivaginal space) [14,15]. Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant [15]. A >5 cm bladder flap Postpartum Hemorrhage hematoma should raise suspicion for uterine dehiscence, characterized by disruption of the endometrial and myometrial layers with an intact serosal layer [15,16]. Low correlation between clinical and radiologic findings of dehiscence have been noted, and it is important not to interpret hypodense edema at the cesarean incision site as dehiscence in the first postpartum week [15]. Presence of gas in the myometrial defect extending from the endometrium to the parametrial tissue along with hemoperitoneum are findings suggestive of uterine rupture [15]. CTA Abdomen and Pelvis Persistent hemorrhage after empiric embolization is an indication for CTA [12]. Active extravasation is seen in 41% to 74% cases of PPH on CTA [17] and multiphasic CT, including a noncontrast arterial and portal venous phases, has excellent accuracy of 97% [18] for detection of the site of active extravasation, similar to that of gastrointestinal hemorrhage [17,18]. CTA can be falsely positive because of dilated tortuous hypertrophic uterine arteries mimicking extravasation and be falsely negative in atony because of slow intermittent hemorrhage [12,18]. CTA also enables comprehensive evaluation of abdominopelvic vasculature, including vessels not often evaluated on routine angiography such as the ovarian and inferior epigastric arteries [18].

Postpartum Hemorrhage. Although uterine atony is a clinical diagnosis, CT can be helpful by detecting a hematoma within the cavity of an enlarged uterus [13] and excluding other causes of PPH. However, it can be difficult to differentiate blood products from RPOC [12]. CT can detect vascular complications such as bladder flap, subfascial, or perivaginal space hematoma and delineate relationship to adjacent organs (supralevator versus infralevator location in the perivaginal space) [14,15]. Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant [15]. A >5 cm bladder flap Postpartum Hemorrhage hematoma should raise suspicion for uterine dehiscence, characterized by disruption of the endometrial and myometrial layers with an intact serosal layer [15,16]. Low correlation between clinical and radiologic findings of dehiscence have been noted, and it is important not to interpret hypodense edema at the cesarean incision site as dehiscence in the first postpartum week [15]. Presence of gas in the myometrial defect extending from the endometrium to the parametrial tissue along with hemoperitoneum are findings suggestive of uterine rupture [15]. CTA Abdomen and Pelvis Persistent hemorrhage after empiric embolization is an indication for CTA [12]. Active extravasation is seen in 41% to 74% cases of PPH on CTA [17] and multiphasic CT, including a noncontrast arterial and portal venous phases, has excellent accuracy of 97% [18] for detection of the site of active extravasation, similar to that of gastrointestinal hemorrhage [17,18]. CTA can be falsely positive because of dilated tortuous hypertrophic uterine arteries mimicking extravasation and be falsely negative in atony because of slow intermittent hemorrhage [12,18]. CTA also enables comprehensive evaluation of abdominopelvic vasculature, including vessels not often evaluated on routine angiography such as the ovarian and inferior epigastric arteries [18].

3113019

acrac_3113019_4

Postpartum Hemorrhage

Serpiginous myometrial vessels and prominent parametrial vessels can be a sign of VUA [19], whereas the presence of a pseudoaneurysmal sac is a more specific finding [14,20,21]. CTA can also identify and localize the feeding arteries of arteriovenous malformation (AVM) for treatment planning [14]. However, CTA cannot reliably distinguish acquired VUA from failure of obliteration/subinvolution of the placental bed vessels, assess its severity, or need for intervention [19]. MRI Pelvis MRI is not commonly used in significant life-threatening early PPH as CT, in part related to access and time required to perform the study in an acute setting. MRI has an important role to play in distinguishing and/or confirming uterine dehiscence versus rupture, in particular when it is confusing on ultrasound (US) or CT. Although RPOC can be seen as an intracavitary mass with variable signal characteristics, distinction from blood products is limited in the absence of contrast administration. MRI is better than CT and US in detecting the myometrial defect with intact serosal layer in uterine dehiscence because of superior soft-tissue contrast [14,15]. However, in the immediate postpartum period, the cesarean section incision can be T1 and T2 hyperintense and may mimic a dehiscence [22]. Noncontrast MRI can be used to identify bladder flap, subfascial, and deep-seated pelvic hematomas, which depending on the time since delivery may demonstrate variable T1 and T2 signal characteristics [14,23]. The superior spatial resolution of MRI compared to US enables localization of the hematoma (eg, supralevator versus infralevator location in the perivaginal space) for potential targeted intervention [23]. On MRI fast-spin echo sequences, AVM demonstrates serpiginous signal voids with prominent parametrial vessels and focal disruption of the junctional zone [14].

Postpartum Hemorrhage. Serpiginous myometrial vessels and prominent parametrial vessels can be a sign of VUA [19], whereas the presence of a pseudoaneurysmal sac is a more specific finding [14,20,21]. CTA can also identify and localize the feeding arteries of arteriovenous malformation (AVM) for treatment planning [14]. However, CTA cannot reliably distinguish acquired VUA from failure of obliteration/subinvolution of the placental bed vessels, assess its severity, or need for intervention [19]. MRI Pelvis MRI is not commonly used in significant life-threatening early PPH as CT, in part related to access and time required to perform the study in an acute setting. MRI has an important role to play in distinguishing and/or confirming uterine dehiscence versus rupture, in particular when it is confusing on ultrasound (US) or CT. Although RPOC can be seen as an intracavitary mass with variable signal characteristics, distinction from blood products is limited in the absence of contrast administration. MRI is better than CT and US in detecting the myometrial defect with intact serosal layer in uterine dehiscence because of superior soft-tissue contrast [14,15]. However, in the immediate postpartum period, the cesarean section incision can be T1 and T2 hyperintense and may mimic a dehiscence [22]. Noncontrast MRI can be used to identify bladder flap, subfascial, and deep-seated pelvic hematomas, which depending on the time since delivery may demonstrate variable T1 and T2 signal characteristics [14,23]. The superior spatial resolution of MRI compared to US enables localization of the hematoma (eg, supralevator versus infralevator location in the perivaginal space) for potential targeted intervention [23]. On MRI fast-spin echo sequences, AVM demonstrates serpiginous signal voids with prominent parametrial vessels and focal disruption of the junctional zone [14].

3113019

acrac_3113019_5

Postpartum Hemorrhage

VUA can also be seen on MRI fast-spin echo sequence as serpiginous signal voids with prominent parametrial vessels, whereas the presence of a pseudoaneurysm sac is more specific [14,20]. Failure of obliteration of the placental bed vessels after pregnancy cannot be reliably distinguished from acquired VUA on MRI [19]. US Duplex Doppler Pelvis Transabdominal US is often performed in conjunction with transvaginal US and color or power Doppler and should be considered a single examination. Color and spectral Doppler are commonly employed in pelvic sonography to detect the presence of vascular flow in normal anatomic structures as well as various pathologic lesions. In women with PPH, Doppler improves the specificity and negative predictive value of detecting RPOC by detecting vascularity within a thickened endometrial echo complex [24]. When a pseudoaneurysm is suspected, color and spectral Doppler can detect swirling or yin-yang pattern of blood flow within a hypoanechoic structure [14,20]. Pitfalls in assessment include that absence of vascularity could represent an avascular RPOC [12] and marked vascularity can mimic a pseudoaneurysm, although RPOC generally extends to the endometrium, whereas pseudoaneurysm is restricted to the myometrium [25]. However, it can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. Although high peak systolic velocities have been used to predict need for intervention, there is considerable overlap [7]. Postpartum Hemorrhage US Pelvis Transvaginal A combined transabdominal and transvaginal approach is the primary modality of choice for the investigation of early PPH not responsive to initial conservative measures. Although transvaginal US detection of an echogenic endometrial mass has the highest sensitivity for the detection of RPOC, this is a nonspecific finding that overlaps with the normal postpartum appearance [14].

Postpartum Hemorrhage. VUA can also be seen on MRI fast-spin echo sequence as serpiginous signal voids with prominent parametrial vessels, whereas the presence of a pseudoaneurysm sac is more specific [14,20]. Failure of obliteration of the placental bed vessels after pregnancy cannot be reliably distinguished from acquired VUA on MRI [19]. US Duplex Doppler Pelvis Transabdominal US is often performed in conjunction with transvaginal US and color or power Doppler and should be considered a single examination. Color and spectral Doppler are commonly employed in pelvic sonography to detect the presence of vascular flow in normal anatomic structures as well as various pathologic lesions. In women with PPH, Doppler improves the specificity and negative predictive value of detecting RPOC by detecting vascularity within a thickened endometrial echo complex [24]. When a pseudoaneurysm is suspected, color and spectral Doppler can detect swirling or yin-yang pattern of blood flow within a hypoanechoic structure [14,20]. Pitfalls in assessment include that absence of vascularity could represent an avascular RPOC [12] and marked vascularity can mimic a pseudoaneurysm, although RPOC generally extends to the endometrium, whereas pseudoaneurysm is restricted to the myometrium [25]. However, it can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. Although high peak systolic velocities have been used to predict need for intervention, there is considerable overlap [7]. Postpartum Hemorrhage US Pelvis Transvaginal A combined transabdominal and transvaginal approach is the primary modality of choice for the investigation of early PPH not responsive to initial conservative measures. Although transvaginal US detection of an echogenic endometrial mass has the highest sensitivity for the detection of RPOC, this is a nonspecific finding that overlaps with the normal postpartum appearance [14].

3113019

acrac_3113019_6

Postpartum Hemorrhage

The most diagnostic combination of US findings is an echogenic endometrial mass that is vascular [27]. The presence of debris and gas is relatively common in the early postpartum period, in as much as 20% to 25%. Thickened endometrial echo complex, up to 2 to 2.5 cm in diameter, is nonspecific in this early postpartum period [28]. US can be used in this setting to assess for coexisting pathology and complications, such as RPOC or hematoma. US can detect most pelvic hematomas [13], including bladder flap hematomas [14,15]. Although uterine scar dehiscence may be seen on US as an irregular thinned uterine wall or a myometrial defect [14], differentiation from the normal appearance of the cesarean section scar can be difficult. VUA, including uterine artery pseudoaneurysm, are a relatively rare cause of early PPH, occurring particularly in the traumatic setting [19,20], and most commonly arise from the uterine artery. VUA appear as hypoechoic tortuous channels or masses in the myometrium with characteristic Doppler findings [14,19] with turbulent flow on color Doppler and high-velocity and low-resistance flow on spectral analysis and may be associated with a peripheral echogenic hematoma [20]. It can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. A dilated vessel in the myometrium may suggest the diagnosis of pseudoaneurysm. Variant 2: Postpartum hemorrhage. Early (within first 24 hours) after vaginal delivery. Initial imaging. The most common cause of early PPH is related to uterine atony or lack of effective uterine contraction after delivery and is typically a clinical diagnosis in >75% of patients. It is initially treated by uterine massage and uterotonic drugs such as oxytocin, and the majority of patients respond well to these treatments.

Postpartum Hemorrhage. The most diagnostic combination of US findings is an echogenic endometrial mass that is vascular [27]. The presence of debris and gas is relatively common in the early postpartum period, in as much as 20% to 25%. Thickened endometrial echo complex, up to 2 to 2.5 cm in diameter, is nonspecific in this early postpartum period [28]. US can be used in this setting to assess for coexisting pathology and complications, such as RPOC or hematoma. US can detect most pelvic hematomas [13], including bladder flap hematomas [14,15]. Although uterine scar dehiscence may be seen on US as an irregular thinned uterine wall or a myometrial defect [14], differentiation from the normal appearance of the cesarean section scar can be difficult. VUA, including uterine artery pseudoaneurysm, are a relatively rare cause of early PPH, occurring particularly in the traumatic setting [19,20], and most commonly arise from the uterine artery. VUA appear as hypoechoic tortuous channels or masses in the myometrium with characteristic Doppler findings [14,19] with turbulent flow on color Doppler and high-velocity and low-resistance flow on spectral analysis and may be associated with a peripheral echogenic hematoma [20]. It can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. A dilated vessel in the myometrium may suggest the diagnosis of pseudoaneurysm. Variant 2: Postpartum hemorrhage. Early (within first 24 hours) after vaginal delivery. Initial imaging. The most common cause of early PPH is related to uterine atony or lack of effective uterine contraction after delivery and is typically a clinical diagnosis in >75% of patients. It is initially treated by uterine massage and uterotonic drugs such as oxytocin, and the majority of patients respond well to these treatments.

3113019

acrac_3113019_7

Postpartum Hemorrhage

If there is no response, additional considerations would include associated RPOC, adherent placentation, or even uterine inversion, and in these situations, imaging may be helpful. About 1% of third trimester deliveries are complicated by RPOC [11] and is the second most common etiology for PPH after uterine atony; although, this is typically seen in the delayed PPH population. The diagnosis of RPOC is helpful to the clinician in determining whether surgical intervention is warranted. Trauma-related hemorrhage may be due to lacerations, uterine rupture, or incision extensions. Imaging may be helpful to delineate the extent of intra-abdominal hemorrhage, whereas infralevator or perineal hemorrhage may be evaluated on visual inspection. Coagulopathy, either inherited or acute related to amniotic fluid embolism, placental abruption, severe pre-eclampsia or HELLP syndrome, is less common but potentially life threatening. There is a long list of risk factors associated with uterine atony, which is not within the scope of this document. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with IV contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage. In hemodynamically stable patients, when conventional medical treatment has been unsuccessful in terminating hemorrhage, multiphasic CT can be useful in localizing the source of extravasation for targeted therapy [12,29], particularly in suspected intra-abdominal hemorrhage [12]. Although uterine atony is a clinical diagnosis, CT can be helpful by detecting focal or diffuse arterial or venous oozing and/or hematoma within the cavity of an enlarged uterus [13]. RPOC can be difficult to differentiate from blood products even on multiphase CT [12].

Postpartum Hemorrhage. If there is no response, additional considerations would include associated RPOC, adherent placentation, or even uterine inversion, and in these situations, imaging may be helpful. About 1% of third trimester deliveries are complicated by RPOC [11] and is the second most common etiology for PPH after uterine atony; although, this is typically seen in the delayed PPH population. The diagnosis of RPOC is helpful to the clinician in determining whether surgical intervention is warranted. Trauma-related hemorrhage may be due to lacerations, uterine rupture, or incision extensions. Imaging may be helpful to delineate the extent of intra-abdominal hemorrhage, whereas infralevator or perineal hemorrhage may be evaluated on visual inspection. Coagulopathy, either inherited or acute related to amniotic fluid embolism, placental abruption, severe pre-eclampsia or HELLP syndrome, is less common but potentially life threatening. There is a long list of risk factors associated with uterine atony, which is not within the scope of this document. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with IV contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage. In hemodynamically stable patients, when conventional medical treatment has been unsuccessful in terminating hemorrhage, multiphasic CT can be useful in localizing the source of extravasation for targeted therapy [12,29], particularly in suspected intra-abdominal hemorrhage [12]. Although uterine atony is a clinical diagnosis, CT can be helpful by detecting focal or diffuse arterial or venous oozing and/or hematoma within the cavity of an enlarged uterus [13]. RPOC can be difficult to differentiate from blood products even on multiphase CT [12].

3113019

acrac_3113019_8

Postpartum Hemorrhage

Endometritis is a clinical diagnosis with a nonspecific CT appearance of a thickened heterogeneous endometrium with fluid, gas, and debris within the cavity [15]. Postpartum Hemorrhage CT can detect vascular complications such as supraumbilical and perivaginal space hematoma and delineate the relationship to adjacent organs (supralevator versus infralevator location in the perivaginal space) for targeted intervention [12,14,15,30]. CTA Abdomen and Pelvis Persistent hemorrhage after empiric embolization is an indication for CTA [12]. Active extravasation is seen in 41% to 74% cases of PPH on CTA [17] and multiphasic CT, including a noncontrast, arterial, and portal venous phases, has excellent accuracy of 97% [18] for detection of the site of active extravasation, similar to that of gastrointestinal hemorrhage [17,18]. CTA can be falsely positive because of dilated tortuous hypertrophic uterine arteries mimicking extravasation and be falsely negative in atony because of slow intermittent hemorrhage [12,18]. Serpiginous myometrial vessels and prominent parametrial vessels can be a sign of VUA [19], whereas the presence of a pseudoaneurysmal sac is a more specific finding [14,20,21]. CTA can also identify and localize the feeding arteries of AVM for treatment planning [14]. However, CTA cannot reliably distinguish acquired VUA from failure of obliteration or subinvolution of the placental bed vessels, assess its severity, or need for intervention [19]. MRI Pelvis MRI is not as commonly used in significant life-threatening early PPH as CT, in part related to access and to time required to perform the study in an acute setting. MRI has an important role to play in distinguishing and/or confirming uterine dehiscence versus rupture, in particular when it is confusing on US or CT. RPOC can be seen as a variably enhancing intracavitory mass with variable degree of myometrial thinning [13,14].

Postpartum Hemorrhage. Endometritis is a clinical diagnosis with a nonspecific CT appearance of a thickened heterogeneous endometrium with fluid, gas, and debris within the cavity [15]. Postpartum Hemorrhage CT can detect vascular complications such as supraumbilical and perivaginal space hematoma and delineate the relationship to adjacent organs (supralevator versus infralevator location in the perivaginal space) for targeted intervention [12,14,15,30]. CTA Abdomen and Pelvis Persistent hemorrhage after empiric embolization is an indication for CTA [12]. Active extravasation is seen in 41% to 74% cases of PPH on CTA [17] and multiphasic CT, including a noncontrast, arterial, and portal venous phases, has excellent accuracy of 97% [18] for detection of the site of active extravasation, similar to that of gastrointestinal hemorrhage [17,18]. CTA can be falsely positive because of dilated tortuous hypertrophic uterine arteries mimicking extravasation and be falsely negative in atony because of slow intermittent hemorrhage [12,18]. Serpiginous myometrial vessels and prominent parametrial vessels can be a sign of VUA [19], whereas the presence of a pseudoaneurysmal sac is a more specific finding [14,20,21]. CTA can also identify and localize the feeding arteries of AVM for treatment planning [14]. However, CTA cannot reliably distinguish acquired VUA from failure of obliteration or subinvolution of the placental bed vessels, assess its severity, or need for intervention [19]. MRI Pelvis MRI is not as commonly used in significant life-threatening early PPH as CT, in part related to access and to time required to perform the study in an acute setting. MRI has an important role to play in distinguishing and/or confirming uterine dehiscence versus rupture, in particular when it is confusing on US or CT. RPOC can be seen as a variably enhancing intracavitory mass with variable degree of myometrial thinning [13,14].

3113019

acrac_3113019_9

Postpartum Hemorrhage

Patients with difficult vaginal deliveries without large palpable hematomas may benefit from noncontrast MRI to identify deep-seated pelvic hematomas, which, depending on the time since delivery, may demonstrate variable T1 and T2 signal characteristics [14,23]. The superior spatial resolution of MRI compared to US enables localization of hematomas (eg, supralevator versus infralevator location in perivaginal space) for potential targeted intervention [23]. VUA can be seen on MRI fast-spin echo sequence as serpiginous signal voids with prominent parametrial vessels, whereas the presence of a pseudoaneurysm sac is more specific [14,20]. Failure of obliteration of the placental bed vessels after pregnancy cannot be reliably distinguished from acquired VUA on MRI [19]. US Duplex Doppler Pelvis Transabdominal US is often performed in conjunction with transvaginal US and color or power Doppler and should be considered a single examination. Color and spectral Doppler are commonly employed in pelvic sonography to detect the presence of vascular flow in normal anatomic structures as well as various pathologic lesions. In women with PPH, Doppler improves the specificity and negative predictive value of detecting RPOC by detecting vascularity within a thickened endometrial echo complex [24]. When a pseudoaneurysm is suspected, color and spectral Doppler can detect swirling or yin-yang pattern of blood flow within a hypoanechoic structure [14,20]. Pitfalls in assessment include that absence of vascularity could represent an avascular RPOC [12] and marked vascularity can mimic a pseudoaneurysm, although RPOC generally extends to the endometrium, whereas pseudoaneurysm is restricted to the myometrium [25]. However, it can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. Although high peak systolic velocities have been used to predict need for intervention, there is considerable overlap [7].

Postpartum Hemorrhage. Patients with difficult vaginal deliveries without large palpable hematomas may benefit from noncontrast MRI to identify deep-seated pelvic hematomas, which, depending on the time since delivery, may demonstrate variable T1 and T2 signal characteristics [14,23]. The superior spatial resolution of MRI compared to US enables localization of hematomas (eg, supralevator versus infralevator location in perivaginal space) for potential targeted intervention [23]. VUA can be seen on MRI fast-spin echo sequence as serpiginous signal voids with prominent parametrial vessels, whereas the presence of a pseudoaneurysm sac is more specific [14,20]. Failure of obliteration of the placental bed vessels after pregnancy cannot be reliably distinguished from acquired VUA on MRI [19]. US Duplex Doppler Pelvis Transabdominal US is often performed in conjunction with transvaginal US and color or power Doppler and should be considered a single examination. Color and spectral Doppler are commonly employed in pelvic sonography to detect the presence of vascular flow in normal anatomic structures as well as various pathologic lesions. In women with PPH, Doppler improves the specificity and negative predictive value of detecting RPOC by detecting vascularity within a thickened endometrial echo complex [24]. When a pseudoaneurysm is suspected, color and spectral Doppler can detect swirling or yin-yang pattern of blood flow within a hypoanechoic structure [14,20]. Pitfalls in assessment include that absence of vascularity could represent an avascular RPOC [12] and marked vascularity can mimic a pseudoaneurysm, although RPOC generally extends to the endometrium, whereas pseudoaneurysm is restricted to the myometrium [25]. However, it can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. Although high peak systolic velocities have been used to predict need for intervention, there is considerable overlap [7].

3113019

acrac_3113019_10

Postpartum Hemorrhage

US Pelvis Transvaginal A combined transabdominal and transvaginal approach is the primary modality of choice for the investigation of early PPH not responsive to initial conservative measures. Although transvaginal US detection of an echogenic endometrial mass has the highest sensitivity for the detection of RPOC, this is a nonspecific finding that overlaps with the normal postpartum appearance [14]. The most diagnostic combination of US findings is an echogenic endometrial mass that is vascular [27]. The presence of debris and gas is relatively common in the early postpartum period, in as much as 20% to 25%. Thickened endometrial echo complex, up to 2 to 2.5 cm in diameter, is nonspecific in this early postpartum period [28]. Postpartum Hemorrhage US can detect most pelvic hematomas [13-15]. Rarely, US may demonstrate ovarian vein thrombosis as an echogenic mass within an enlarged ovarian vein [14]. Variant 3: Postpartum hemorrhage. Late (greater than 24 hours to 6 weeks) after caesarian delivery. Initial imaging. Secondary or late PPH is typically defined as any significant uterine hemorrhage occurring between 24 hours to 6 weeks postpartum. The most common etiologies are RPOC, subinvolution of the placental bed, or infection. RPOCs are more likely after vaginal delivery, whereas postpartum endometritis is more common after cesarean. Less common causes include, but are not limited to, coagulopathy, pseudoaneurysm or AVMs, dehiscent cesarean scar, or gestational trophoblast disease (GTD). Primary PPH is considered a risk factor for secondary PPH. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with IV contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage.

Postpartum Hemorrhage. US Pelvis Transvaginal A combined transabdominal and transvaginal approach is the primary modality of choice for the investigation of early PPH not responsive to initial conservative measures. Although transvaginal US detection of an echogenic endometrial mass has the highest sensitivity for the detection of RPOC, this is a nonspecific finding that overlaps with the normal postpartum appearance [14]. The most diagnostic combination of US findings is an echogenic endometrial mass that is vascular [27]. The presence of debris and gas is relatively common in the early postpartum period, in as much as 20% to 25%. Thickened endometrial echo complex, up to 2 to 2.5 cm in diameter, is nonspecific in this early postpartum period [28]. Postpartum Hemorrhage US can detect most pelvic hematomas [13-15]. Rarely, US may demonstrate ovarian vein thrombosis as an echogenic mass within an enlarged ovarian vein [14]. Variant 3: Postpartum hemorrhage. Late (greater than 24 hours to 6 weeks) after caesarian delivery. Initial imaging. Secondary or late PPH is typically defined as any significant uterine hemorrhage occurring between 24 hours to 6 weeks postpartum. The most common etiologies are RPOC, subinvolution of the placental bed, or infection. RPOCs are more likely after vaginal delivery, whereas postpartum endometritis is more common after cesarean. Less common causes include, but are not limited to, coagulopathy, pseudoaneurysm or AVMs, dehiscent cesarean scar, or gestational trophoblast disease (GTD). Primary PPH is considered a risk factor for secondary PPH. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with IV contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage.

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acrac_3113019_11

Postpartum Hemorrhage

In hemodynamically stable patients, when conventional medical treatment has been unsuccessful in terminating hemorrhage, multiphasic CT can be useful in localizing the source of extravasation for targeted therapy [12,29], particularly in suspected intra-abdominal hemorrhage [12]. CT can detect vascular complications such as bladder flap, subfascial, or perivaginal space hematoma and delineate relationship to adjacent organs (supralevator versus infralevator location in the perivaginal space) [14,15]. Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant [15]. A >5 cm bladder flap hematoma should raise suspicion for uterine dehiscence, characterized by disruption of the endometrial and myometrial layers with an intact serosal layer [15,16]. Low correlation between clinical and radiologic findings of dehiscence have been noted, and it is important not to interpret hypodense edema at the cesarean incision site as dehiscence in the first postpartum week [15]. Presence of gas in the myometrial defect extending from the endometrium to the parametrial tissue along with hemoperitoneum are findings suggestive of uterine rupture [15]. RPOC can be difficult to differentiate from blood products even on multiphase CT [12]. Endometritis is a clinical diagnosis with a nonspecific CT appearance of a thickened heterogeneous endometrium with fluid, gas, and debris within the cavity [15]. Superimposed parametrial abscess or infected hematoma and other complications such as ovarian vein thrombosis [14,15] can be detected on CT. GTD (most commonly choriocarcinoma after third trimester delivery) is a rare cause of delayed PPH and appears as a heterogeneous hypervascular intrauterine mass, often with central necrosis, indistinguishable from RPOC, except in cases of invasion of adjacent organs or distant metastasis [14]. CTA Abdomen and Pelvis Persistent hemorrhage after empiric embolization is an indication for CTA [12].

Postpartum Hemorrhage. In hemodynamically stable patients, when conventional medical treatment has been unsuccessful in terminating hemorrhage, multiphasic CT can be useful in localizing the source of extravasation for targeted therapy [12,29], particularly in suspected intra-abdominal hemorrhage [12]. CT can detect vascular complications such as bladder flap, subfascial, or perivaginal space hematoma and delineate relationship to adjacent organs (supralevator versus infralevator location in the perivaginal space) [14,15]. Small (<4 cm) subfascial and bladder flap hematomas may not be clinically significant [15]. A >5 cm bladder flap hematoma should raise suspicion for uterine dehiscence, characterized by disruption of the endometrial and myometrial layers with an intact serosal layer [15,16]. Low correlation between clinical and radiologic findings of dehiscence have been noted, and it is important not to interpret hypodense edema at the cesarean incision site as dehiscence in the first postpartum week [15]. Presence of gas in the myometrial defect extending from the endometrium to the parametrial tissue along with hemoperitoneum are findings suggestive of uterine rupture [15]. RPOC can be difficult to differentiate from blood products even on multiphase CT [12]. Endometritis is a clinical diagnosis with a nonspecific CT appearance of a thickened heterogeneous endometrium with fluid, gas, and debris within the cavity [15]. Superimposed parametrial abscess or infected hematoma and other complications such as ovarian vein thrombosis [14,15] can be detected on CT. GTD (most commonly choriocarcinoma after third trimester delivery) is a rare cause of delayed PPH and appears as a heterogeneous hypervascular intrauterine mass, often with central necrosis, indistinguishable from RPOC, except in cases of invasion of adjacent organs or distant metastasis [14]. CTA Abdomen and Pelvis Persistent hemorrhage after empiric embolization is an indication for CTA [12].

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acrac_3113019_12

Postpartum Hemorrhage

Active extravasation is seen in 41% to 74% cases of PPH on CTA [17] and multiphasic CT, including a noncontrast, arterial, and portal venous phases, has excellent accuracy of 97% [18] for detection of the site of active extravasation, similar to that of gastrointestinal hemorrhage [17,18]. CTA can be falsely positive because of dilated tortuous hypertrophic uterine arteries mimicking extravasation and be falsely negative in atony because of slow intermittent hemorrhage [12,18]. Serpiginous myometrial vessels and prominent parametrial vessels can be a sign of VUA [19], whereas the presence of a pseudoaneurysmal sac is a more specific finding [14,20,21]. CTA can also identify and localize the feeding arteries of AVM for treatment planning [14]. However, CTA cannot reliably distinguish acquired VUA from failure of obliteration/subinvolution of the placental bed vessels, assess its severity, or need for intervention [19]. MRI Pelvis In clinically suspected endometritis, MRI can identify associated findings such as abscess or infected hematoma that may require drainage and other complications such as ovarian vein thrombosis [14]. RPOC can be seen as a variably enhancing intracavitory mass with variable degree of myometrial thinning [13,14]. MRI is superior to CT and US in detecting the myometrial defect with intact serosal layer in uterine dehiscence because of superior soft- tissue contrast [14,15]. However, in the immediate postpartum period, the cesarean section incision can be T1 and T2 hyperintense and may mimic a dehiscence [22]. Noncontrast MRI can be used to identify bladder flap, subfascial, and deep-seated pelvic hematomas, which depending on the time since delivery, may demonstrate variable T1 and T2 signal characteristics [14,23] and a low T2 signal rim after >2 weeks due to hemosiderin deposition. The superior spatial resolution of MRI compared to Postpartum Hemorrhage

Postpartum Hemorrhage. Active extravasation is seen in 41% to 74% cases of PPH on CTA [17] and multiphasic CT, including a noncontrast, arterial, and portal venous phases, has excellent accuracy of 97% [18] for detection of the site of active extravasation, similar to that of gastrointestinal hemorrhage [17,18]. CTA can be falsely positive because of dilated tortuous hypertrophic uterine arteries mimicking extravasation and be falsely negative in atony because of slow intermittent hemorrhage [12,18]. Serpiginous myometrial vessels and prominent parametrial vessels can be a sign of VUA [19], whereas the presence of a pseudoaneurysmal sac is a more specific finding [14,20,21]. CTA can also identify and localize the feeding arteries of AVM for treatment planning [14]. However, CTA cannot reliably distinguish acquired VUA from failure of obliteration/subinvolution of the placental bed vessels, assess its severity, or need for intervention [19]. MRI Pelvis In clinically suspected endometritis, MRI can identify associated findings such as abscess or infected hematoma that may require drainage and other complications such as ovarian vein thrombosis [14]. RPOC can be seen as a variably enhancing intracavitory mass with variable degree of myometrial thinning [13,14]. MRI is superior to CT and US in detecting the myometrial defect with intact serosal layer in uterine dehiscence because of superior soft- tissue contrast [14,15]. However, in the immediate postpartum period, the cesarean section incision can be T1 and T2 hyperintense and may mimic a dehiscence [22]. Noncontrast MRI can be used to identify bladder flap, subfascial, and deep-seated pelvic hematomas, which depending on the time since delivery, may demonstrate variable T1 and T2 signal characteristics [14,23] and a low T2 signal rim after >2 weeks due to hemosiderin deposition. The superior spatial resolution of MRI compared to Postpartum Hemorrhage

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Postpartum Hemorrhage

US enables localization of hematoma (eg, supralevator versus infralevator location in perivaginal space) for potential targeted intervention [23]. VUA can be seen on MRI fast-spin echo sequence as serpiginous signal voids with prominent parametrial vessels, whereas the presence of a pseudoaneurysm sac is more specific [14,20]. Failure of obliteration of the placental bed vessels after pregnancy cannot be reliably distinguished from acquired VUA on MRI [19]. GTD is a rare cause of delayed PPH and appears as a heterogeneous hypervascular intrauterine mass, often with central necrosis, indistinguishable from RPOC, except in cases of invasion of adjacent organs or distant metastasis [14]. US Duplex Doppler Pelvis Transabdominal US is often performed in conjunction with transvaginal US and color or power Doppler and should be considered a single examination. Color and spectral Doppler are commonly employed in pelvic sonography to detect the presence of vascular flow in normal anatomic structures as well as various pathologic lesions. In women with PPH, Doppler improves the specificity and negative predictive value of detecting RPOC by detecting vascularity within a thickened endometrial echo complex [24]. When a pseudoaneurysm is suspected, color and spectral Doppler can detect swirling or yin-yang pattern of blood flow within a hypoanechoic structure [14,20]. Pitfalls in assessment include that absence of vascularity could represent an avascular RPOC [12] and marked vascularity can mimic a pseudoaneurysm, although RPOC generally extends to the endometrium, whereas pseudoaneurysm is restricted to the myometrium [25]. However, it can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. Although high peak systolic velocities have been used to predict need for intervention, there is considerable overlap [7].

Postpartum Hemorrhage. US enables localization of hematoma (eg, supralevator versus infralevator location in perivaginal space) for potential targeted intervention [23]. VUA can be seen on MRI fast-spin echo sequence as serpiginous signal voids with prominent parametrial vessels, whereas the presence of a pseudoaneurysm sac is more specific [14,20]. Failure of obliteration of the placental bed vessels after pregnancy cannot be reliably distinguished from acquired VUA on MRI [19]. GTD is a rare cause of delayed PPH and appears as a heterogeneous hypervascular intrauterine mass, often with central necrosis, indistinguishable from RPOC, except in cases of invasion of adjacent organs or distant metastasis [14]. US Duplex Doppler Pelvis Transabdominal US is often performed in conjunction with transvaginal US and color or power Doppler and should be considered a single examination. Color and spectral Doppler are commonly employed in pelvic sonography to detect the presence of vascular flow in normal anatomic structures as well as various pathologic lesions. In women with PPH, Doppler improves the specificity and negative predictive value of detecting RPOC by detecting vascularity within a thickened endometrial echo complex [24]. When a pseudoaneurysm is suspected, color and spectral Doppler can detect swirling or yin-yang pattern of blood flow within a hypoanechoic structure [14,20]. Pitfalls in assessment include that absence of vascularity could represent an avascular RPOC [12] and marked vascularity can mimic a pseudoaneurysm, although RPOC generally extends to the endometrium, whereas pseudoaneurysm is restricted to the myometrium [25]. However, it can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. Although high peak systolic velocities have been used to predict need for intervention, there is considerable overlap [7].

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acrac_3113019_14

Postpartum Hemorrhage

US Pelvis Transvaginal Pelvic US using a combined transvaginal and transabdominal approach is the primary modality of choice for the investigation of late PPH as RPOC with or without endometritis is one of the major causes of secondary or late PPH. Although detection of an echogenic or mixed-echo pattern endometrial mass has the highest sensitivity for the detection of RPOC, this is a nonspecific finding that overlaps with the normal postpartum appearance [14,31]. The most specific finding is a vascular echogenic mass, although flow may not be identified in all RPOC. Another US finding in RPOC is a thickened endometrial echo complex with a variable cutoff of 8 to 13 mm [25,32]. US can be used in this setting to assess for coexisting pathology and complications, such as RPOC, hematoma, or abscess. US can detect most pelvic hematomas [13], including bladder flap hematomas [14,15] with superimposed echogenic foci of air suggesting infection [15]. Although uterine scar dehiscence may be seen on US as an irregular thinned uterine wall or a myometrial defect [14], differentiation from the normal appearance of the cesarean section scar can be difficult. VUA, including uterine artery pseudoaneurysms, are a relatively rare cause of PPH [19,20] and most commonly arise from the uterine artery. VUA appear as hypoechoic tortuous channels or masses in the myometrium with turbulent flow on color Doppler and high-velocity and low-resistance flow on spectral analysis. It can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. A dilated vessel in the myometrium may suggest the diagnosis of pseudoaneurysm. Postpartum Hemorrhage Variant 4: Postpartum hemorrhage. Late (greater than 24 hours to 6 weeks) after vaginal delivery. Initial imaging. Secondary or late PPH is typically defined as any significant uterine hemorrhage occurring between 24 hours to 6 weeks postpartum.

Postpartum Hemorrhage. US Pelvis Transvaginal Pelvic US using a combined transvaginal and transabdominal approach is the primary modality of choice for the investigation of late PPH as RPOC with or without endometritis is one of the major causes of secondary or late PPH. Although detection of an echogenic or mixed-echo pattern endometrial mass has the highest sensitivity for the detection of RPOC, this is a nonspecific finding that overlaps with the normal postpartum appearance [14,31]. The most specific finding is a vascular echogenic mass, although flow may not be identified in all RPOC. Another US finding in RPOC is a thickened endometrial echo complex with a variable cutoff of 8 to 13 mm [25,32]. US can be used in this setting to assess for coexisting pathology and complications, such as RPOC, hematoma, or abscess. US can detect most pelvic hematomas [13], including bladder flap hematomas [14,15] with superimposed echogenic foci of air suggesting infection [15]. Although uterine scar dehiscence may be seen on US as an irregular thinned uterine wall or a myometrial defect [14], differentiation from the normal appearance of the cesarean section scar can be difficult. VUA, including uterine artery pseudoaneurysms, are a relatively rare cause of PPH [19,20] and most commonly arise from the uterine artery. VUA appear as hypoechoic tortuous channels or masses in the myometrium with turbulent flow on color Doppler and high-velocity and low-resistance flow on spectral analysis. It can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. A dilated vessel in the myometrium may suggest the diagnosis of pseudoaneurysm. Postpartum Hemorrhage Variant 4: Postpartum hemorrhage. Late (greater than 24 hours to 6 weeks) after vaginal delivery. Initial imaging. Secondary or late PPH is typically defined as any significant uterine hemorrhage occurring between 24 hours to 6 weeks postpartum.

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acrac_3113019_15

Postpartum Hemorrhage

The most common etiologies are RPOC, subinvolution of the placental bed, or infection. RPOC are more likely after vaginal delivery, whereas postpartum endometritis is more common after cesarean. Less common causes include, but are not limited to, coagulopathy, pseudoaneurysm or AVMs, dehiscent cesarean scar, or GTD. Primary PPH is considered a risk factor for secondary PPH. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with IV contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage. In hemodynamically stable patients with delayed PPH, multiphasic CTA can be useful in localizing the source of extravasation for targeted therapy [12,29], particularly in suspected intra-abdominal hemorrhage [12]. CT can detect vascular complications such as supraumbilical and perivaginal space hematoma and delineate the relationship to adjacent organs (supralevator versus infralevator location in the perivaginal space) [12,14,15]. Although the diagnosis of complete uterine inversion is made clinically, subacute partial uterine inversions may be detected as a concavity of the uterine fundus in CT [12]. RPOC can be difficult to differentiate from blood products even on multiphase CT [12]. Endometritis is a clinical diagnosis with a nonspecific CT appearance of a thickened heterogeneous endometrium with fluid, gas, and debris within the cavity [15]. Superimposed parametrial abscess or infected hematoma and other complications such as ovarian vein thrombosis [14,15] can be detected on CT.

Postpartum Hemorrhage. The most common etiologies are RPOC, subinvolution of the placental bed, or infection. RPOC are more likely after vaginal delivery, whereas postpartum endometritis is more common after cesarean. Less common causes include, but are not limited to, coagulopathy, pseudoaneurysm or AVMs, dehiscent cesarean scar, or GTD. Primary PPH is considered a risk factor for secondary PPH. CT Abdomen and Pelvis In the setting of hemorrhage, the primary role of CT is to determine whether active ongoing hemorrhage is present, to localize the bleeding, and to identify the source, which is best accomplished with a CT with IV contrast. There is little clinical utility in a noncontrast CT or CT with and without IV contrast in the setting of active ongoing hemorrhage. In hemodynamically stable patients with delayed PPH, multiphasic CTA can be useful in localizing the source of extravasation for targeted therapy [12,29], particularly in suspected intra-abdominal hemorrhage [12]. CT can detect vascular complications such as supraumbilical and perivaginal space hematoma and delineate the relationship to adjacent organs (supralevator versus infralevator location in the perivaginal space) [12,14,15]. Although the diagnosis of complete uterine inversion is made clinically, subacute partial uterine inversions may be detected as a concavity of the uterine fundus in CT [12]. RPOC can be difficult to differentiate from blood products even on multiphase CT [12]. Endometritis is a clinical diagnosis with a nonspecific CT appearance of a thickened heterogeneous endometrium with fluid, gas, and debris within the cavity [15]. Superimposed parametrial abscess or infected hematoma and other complications such as ovarian vein thrombosis [14,15] can be detected on CT.

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acrac_3113019_16

Postpartum Hemorrhage

GTD (most commonly choriocarcinoma after third trimester delivery) is a rare cause of delayed PPH and appears as a heterogeneous hypervascular intrauterine mass, often with central necrosis, indistinguishable from RPOC, except in cases of invasion of adjacent organs or distant metastasis [14]. CTA Abdomen and Pelvis Persistent hemorrhage after empiric embolization is an indication for CTA [12]. Active extravasation is seen in 41% to 74% cases of PPH on CTA [17] and multiphasic CT, including a noncontrast, arterial, and portal venous phases, has excellent accuracy of 97% [18] for detection of the site of active extravasation, similar to that of gastrointestinal hemorrhage [17,18]. CTA can be falsely positive because of dilated tortuous hypertrophic uterine arteries mimicking extravasation and be falsely negative in atony because of slow intermittent hemorrhage [12,18]. Serpiginous myometrial vessels and prominent parametrial vessels can be a sign of VUA [19], whereas the presence of a pseudoaneurysmal sac is a more specific finding [14,20,21]. CTA can also identify and localize the feeding arteries of AVM for treatment planning [14]. However, CTA cannot reliably distinguish acquired VUA from failure of obliteration/subinvolution of the placental bed vessels, assess its severity, or need for intervention [19]. MRI Pelvis In clinically suspected endometritis, MRI can identify associated findings such as abscess or infected hematoma that may require drainage and other complications such as ovarian vein thrombosis [14]. RPOC can be seen as a variably enhancing intracavitory mass with variable degree of myometrial thinning [13,14]. Patients with difficult vaginal delivery without large palpable hematoma may benefit from noncontrast MRI to identify deep-seated pelvic hematomas, which depending on the time since delivery may demonstrate variable T1 and T2 signal characteristics [14,23] and a low T2 signal rim after >2 weeks because of hemosiderin deposition.

Postpartum Hemorrhage. GTD (most commonly choriocarcinoma after third trimester delivery) is a rare cause of delayed PPH and appears as a heterogeneous hypervascular intrauterine mass, often with central necrosis, indistinguishable from RPOC, except in cases of invasion of adjacent organs or distant metastasis [14]. CTA Abdomen and Pelvis Persistent hemorrhage after empiric embolization is an indication for CTA [12]. Active extravasation is seen in 41% to 74% cases of PPH on CTA [17] and multiphasic CT, including a noncontrast, arterial, and portal venous phases, has excellent accuracy of 97% [18] for detection of the site of active extravasation, similar to that of gastrointestinal hemorrhage [17,18]. CTA can be falsely positive because of dilated tortuous hypertrophic uterine arteries mimicking extravasation and be falsely negative in atony because of slow intermittent hemorrhage [12,18]. Serpiginous myometrial vessels and prominent parametrial vessels can be a sign of VUA [19], whereas the presence of a pseudoaneurysmal sac is a more specific finding [14,20,21]. CTA can also identify and localize the feeding arteries of AVM for treatment planning [14]. However, CTA cannot reliably distinguish acquired VUA from failure of obliteration/subinvolution of the placental bed vessels, assess its severity, or need for intervention [19]. MRI Pelvis In clinically suspected endometritis, MRI can identify associated findings such as abscess or infected hematoma that may require drainage and other complications such as ovarian vein thrombosis [14]. RPOC can be seen as a variably enhancing intracavitory mass with variable degree of myometrial thinning [13,14]. Patients with difficult vaginal delivery without large palpable hematoma may benefit from noncontrast MRI to identify deep-seated pelvic hematomas, which depending on the time since delivery may demonstrate variable T1 and T2 signal characteristics [14,23] and a low T2 signal rim after >2 weeks because of hemosiderin deposition.

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acrac_3113019_17

Postpartum Hemorrhage

The superior spatial resolution of MRI compared to US enables localization of hematoma (eg, supralevator versus infralevator location in perivaginal space) for potential targeted intervention [23]. VUA can be seen on MRI fast-spin echo sequence as serpiginous signal voids with prominent parametrial vessels, whereas the presence of a pseudoaneurysm sac is more specific [14,20]. Failure of obliteration of the placental bed vessels after pregnancy cannot be reliably distinguished from acquired VUA on MRI [19]. GTD is a rare cause of delayed PPH and appears as a heterogeneous hypervascular intrauterine mass, often with central necrosis, indistinguishable from RPOC, except in cases of invasion of adjacent organs or distant metastasis [14]. Postpartum Hemorrhage US Duplex Doppler Pelvis Transabdominal US is often performed in conjunction with transvaginal US and color or power Doppler and should be considered a single examination. Color and spectral Doppler are commonly employed in pelvic sonography to detect the presence of vascular flow in normal anatomic structures as well as various pathologic lesions. In women with PPH, Doppler improves the specificity and negative predictive value of detecting RPOC by detecting vascularity within a thickened endometrial echo complex [24]. When a pseudoaneurysm is suspected, color and spectral Doppler can detect swirling or yin-yang pattern of blood flow within a hypoanechoic structure [14,20]. Pitfalls in assessment include that absence of vascularity could represent an avascular RPOC [12], and marked vascularity can mimic a pseudoaneurysm, although RPOC generally extends to the endometrium, whereas pseudoaneurysm is restricted to the myometrium [25]. However, it can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. Although high peak systolic velocities have been used to predict need for intervention, there is considerable overlap [7].

Postpartum Hemorrhage. The superior spatial resolution of MRI compared to US enables localization of hematoma (eg, supralevator versus infralevator location in perivaginal space) for potential targeted intervention [23]. VUA can be seen on MRI fast-spin echo sequence as serpiginous signal voids with prominent parametrial vessels, whereas the presence of a pseudoaneurysm sac is more specific [14,20]. Failure of obliteration of the placental bed vessels after pregnancy cannot be reliably distinguished from acquired VUA on MRI [19]. GTD is a rare cause of delayed PPH and appears as a heterogeneous hypervascular intrauterine mass, often with central necrosis, indistinguishable from RPOC, except in cases of invasion of adjacent organs or distant metastasis [14]. Postpartum Hemorrhage US Duplex Doppler Pelvis Transabdominal US is often performed in conjunction with transvaginal US and color or power Doppler and should be considered a single examination. Color and spectral Doppler are commonly employed in pelvic sonography to detect the presence of vascular flow in normal anatomic structures as well as various pathologic lesions. In women with PPH, Doppler improves the specificity and negative predictive value of detecting RPOC by detecting vascularity within a thickened endometrial echo complex [24]. When a pseudoaneurysm is suspected, color and spectral Doppler can detect swirling or yin-yang pattern of blood flow within a hypoanechoic structure [14,20]. Pitfalls in assessment include that absence of vascularity could represent an avascular RPOC [12], and marked vascularity can mimic a pseudoaneurysm, although RPOC generally extends to the endometrium, whereas pseudoaneurysm is restricted to the myometrium [25]. However, it can be difficult to distinguish acquired VUA from subinvolution of the placental bed [19,26] or to assess its severity or need for intervention on US [19]. Although high peak systolic velocities have been used to predict need for intervention, there is considerable overlap [7].

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acrac_69365_0

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Introduction/Background According to the American Cancer Society, approximately 73,750 new cases of kidney and renal pelvis cancer will be diagnosed in the United States in 2020, and approximately 14,830 people will die of this disease [1]. Renal cell carcinoma (RCC) accounts for 85% of all malignant renal tumors and represents approximately 2% to 3% of all malignancies in adults [2]. RCC is also considered the most lethal of all urologic cancers. Surgical resection with curative intent, including radical nephrectomy (RN) or partial nephrectomy (PN), continues to be the standard of care for clinically localized RCC [2]. Ablative therapies such as radiofrequency ablation, microwave ablation, and cryoablation have been shown to be effective and safe alternatives for the treatment of small localized RCCs [3-7]. In some patients with small localized RCCs, treatment may also be deferred, with management instead consisting of active surveillance protocols [8]. For follow-up of patients with treated or untreated RCC and those with neoplasms suspected to represent RCC, radiologic imaging is the most useful component of surveillance, because most relapses and cases of disease progression are identified when patients are asymptomatic [9,10]. There is currently no consensus regarding surveillance protocols; however, various guidelines and strategies have been developed by international oncologic and urologic societies, such as the National Comprehensive Cancer Network, the American Urological Association, and the European Association of Urology, using both patient- and tumor-specific characteristics [2,9,11,12]. Although imaging is the centerpiece in all of these guidelines, the recommendations vary regarding the timing, frequency, and duration of follow-up, as well as the selection of imaging modalities for follow-up [12,13].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Introduction/Background According to the American Cancer Society, approximately 73,750 new cases of kidney and renal pelvis cancer will be diagnosed in the United States in 2020, and approximately 14,830 people will die of this disease [1]. Renal cell carcinoma (RCC) accounts for 85% of all malignant renal tumors and represents approximately 2% to 3% of all malignancies in adults [2]. RCC is also considered the most lethal of all urologic cancers. Surgical resection with curative intent, including radical nephrectomy (RN) or partial nephrectomy (PN), continues to be the standard of care for clinically localized RCC [2]. Ablative therapies such as radiofrequency ablation, microwave ablation, and cryoablation have been shown to be effective and safe alternatives for the treatment of small localized RCCs [3-7]. In some patients with small localized RCCs, treatment may also be deferred, with management instead consisting of active surveillance protocols [8]. For follow-up of patients with treated or untreated RCC and those with neoplasms suspected to represent RCC, radiologic imaging is the most useful component of surveillance, because most relapses and cases of disease progression are identified when patients are asymptomatic [9,10]. There is currently no consensus regarding surveillance protocols; however, various guidelines and strategies have been developed by international oncologic and urologic societies, such as the National Comprehensive Cancer Network, the American Urological Association, and the European Association of Urology, using both patient- and tumor-specific characteristics [2,9,11,12]. Although imaging is the centerpiece in all of these guidelines, the recommendations vary regarding the timing, frequency, and duration of follow-up, as well as the selection of imaging modalities for follow-up [12,13].

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acrac_69365_1

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Understanding the strengths and limitations of the various imaging modalities for the detection of disease recurrence or progression is important when planning follow-up regimens. In this document, we provide an update on the appropriate use of imaging examinations for asymptomatic patients who have been treated for RCC with RN, PN, or ablative therapies. We also address the appropriate imaging examinations for asymptomatic patients with localized biopsy-proven or suspected RCC who are undergoing active surveillance. As in the previous version, this document does not address the imaging of complications from treatment and does not discuss the follow-up of patients with known residual or recurrent cancer. Special Imaging Considerations CT urography (CTU) is an imaging study that is tailored to improve visualization of both the upper and lower urinary tracts. There is variability in the specific parameters, but it usually involves unenhanced images followed by intravenous (IV) contrast-enhanced images, including nephrographic and excretory phases acquired at least 5 minutes after contrast injection. Alternatively, a split-bolus technique uses an initial loading dose of IV contrast and then obtains a combined nephrographic-excretory phase after a second IV contrast dose; some sites include arterial phase. CTU should use thin-slice acquisition. Reconstruction methods commonly include maximum intensity projection or 3-D volume rendering. For the purposes of this document, we make a distinction between CTU and CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is Reprint requests to: [email protected] Post-treatment Follow-up of Renal Cell Carcinoma defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases. MR urography (MRU) is also tailored to improve imaging of the urinary system.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Understanding the strengths and limitations of the various imaging modalities for the detection of disease recurrence or progression is important when planning follow-up regimens. In this document, we provide an update on the appropriate use of imaging examinations for asymptomatic patients who have been treated for RCC with RN, PN, or ablative therapies. We also address the appropriate imaging examinations for asymptomatic patients with localized biopsy-proven or suspected RCC who are undergoing active surveillance. As in the previous version, this document does not address the imaging of complications from treatment and does not discuss the follow-up of patients with known residual or recurrent cancer. Special Imaging Considerations CT urography (CTU) is an imaging study that is tailored to improve visualization of both the upper and lower urinary tracts. There is variability in the specific parameters, but it usually involves unenhanced images followed by intravenous (IV) contrast-enhanced images, including nephrographic and excretory phases acquired at least 5 minutes after contrast injection. Alternatively, a split-bolus technique uses an initial loading dose of IV contrast and then obtains a combined nephrographic-excretory phase after a second IV contrast dose; some sites include arterial phase. CTU should use thin-slice acquisition. Reconstruction methods commonly include maximum intensity projection or 3-D volume rendering. For the purposes of this document, we make a distinction between CTU and CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is Reprint requests to: [email protected] Post-treatment Follow-up of Renal Cell Carcinoma defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases. MR urography (MRU) is also tailored to improve imaging of the urinary system.

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Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic high signal intensity from urine for evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include a corticomedullary, nephrographic, and excretory phase. Thin-slice acquisition and multiplanar imaging should be obtained. For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and without heavily T2- weighted images of the urinary tract. Discussion of Procedures by Variant Variant 1: Follow-up for clinically localized renal cell carcinoma; post radical or partial nephrectomy. Many tumor- and patient-specific characteristics have been shown to be predictive of local recurrence or distant metastasis of RCC after treatment [2,14-19]. In addition to these characteristics, the timing and location of tumor recurrence and the type of treatment (ie, RN versus PN) are considered in the development of imaging surveillance strategies that aim to identify asymptomatic solitary or oligometastatic disease that may benefit from early potentially curative or life-prolonging salvage treatment [10,16,20]. Among the tumor characteristics predictive of tumor recurrence, the tumor, node, and metastases staging system has been the most extensively researched; associations between pathologic T stage and both the risk and patterns of tumor recurrence have been demonstrated in many studies [14,15,17,21].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic high signal intensity from urine for evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include a corticomedullary, nephrographic, and excretory phase. Thin-slice acquisition and multiplanar imaging should be obtained. For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and without heavily T2- weighted images of the urinary tract. Discussion of Procedures by Variant Variant 1: Follow-up for clinically localized renal cell carcinoma; post radical or partial nephrectomy. Many tumor- and patient-specific characteristics have been shown to be predictive of local recurrence or distant metastasis of RCC after treatment [2,14-19]. In addition to these characteristics, the timing and location of tumor recurrence and the type of treatment (ie, RN versus PN) are considered in the development of imaging surveillance strategies that aim to identify asymptomatic solitary or oligometastatic disease that may benefit from early potentially curative or life-prolonging salvage treatment [10,16,20]. Among the tumor characteristics predictive of tumor recurrence, the tumor, node, and metastases staging system has been the most extensively researched; associations between pathologic T stage and both the risk and patterns of tumor recurrence have been demonstrated in many studies [14,15,17,21].

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Patient symptoms, tumor size, tumor necrosis, and microvascular invasion are some of the other factors that have been evaluated and integrated into risk stratification models that separate patients into low-, intermediate-, or high-risk groups according to the probability of local recurrence or distant metastases [11,14,18,19]. Most recurrences occur within 3 years after treatment, with a median time to relapse of 1 to 2 years; thus, most surveillance guidelines address follow-up for up to 5 years after treatment [2,9,11,22]. In patients with high-risk tumors (ie, pT2 and pT3 tumors), especially those patients without a significant competing risk for non-RCC death, follow-up beyond 5 years may also be considered because of a nonnegligible incidence of late recurrence [14,18]. Patients who have undergone PN have a similar or slightly higher incidence of local recurrence compared with those who have undergone RN [11,23]. In some guidelines, a more rigorous follow-up protocol is recommended to assess for local recurrence in those who have undergone PN [2,9]. However, more commonly, recurrence manifests as distant metastases [10,20,24,25]. The lungs are the most common site affected by metastases, followed by the lymph nodes, bones, liver, adrenal glands, and brain. Other less common sites include the spleen, pancreas, diaphragm, heart, skin, and connective tissues. Apart from bone and brain metastases, most metastases and local recurrences are identified in asymptomatic patients [10,15,18,26]. Post-treatment Follow-up of Renal Cell Carcinoma Radiography Chest A chest radiograph is a low-yield diagnostic tool for detecting pulmonary metastasis in patients after surgical excision of RCC, particularly in those with low-risk tumors, irrespective of the treatment modality (RN, PN, or ablation) [27,28].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Patient symptoms, tumor size, tumor necrosis, and microvascular invasion are some of the other factors that have been evaluated and integrated into risk stratification models that separate patients into low-, intermediate-, or high-risk groups according to the probability of local recurrence or distant metastases [11,14,18,19]. Most recurrences occur within 3 years after treatment, with a median time to relapse of 1 to 2 years; thus, most surveillance guidelines address follow-up for up to 5 years after treatment [2,9,11,22]. In patients with high-risk tumors (ie, pT2 and pT3 tumors), especially those patients without a significant competing risk for non-RCC death, follow-up beyond 5 years may also be considered because of a nonnegligible incidence of late recurrence [14,18]. Patients who have undergone PN have a similar or slightly higher incidence of local recurrence compared with those who have undergone RN [11,23]. In some guidelines, a more rigorous follow-up protocol is recommended to assess for local recurrence in those who have undergone PN [2,9]. However, more commonly, recurrence manifests as distant metastases [10,20,24,25]. The lungs are the most common site affected by metastases, followed by the lymph nodes, bones, liver, adrenal glands, and brain. Other less common sites include the spleen, pancreas, diaphragm, heart, skin, and connective tissues. Apart from bone and brain metastases, most metastases and local recurrences are identified in asymptomatic patients [10,15,18,26]. Post-treatment Follow-up of Renal Cell Carcinoma Radiography Chest A chest radiograph is a low-yield diagnostic tool for detecting pulmonary metastasis in patients after surgical excision of RCC, particularly in those with low-risk tumors, irrespective of the treatment modality (RN, PN, or ablation) [27,28].

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In a retrospective analysis of 221 patients with pT1-3N0M0 RCC, only 0.85% of the follow-up chest radiographs detected pulmonary metastases in asymptomatic patients [28]. The yield of a chest radiograph increased to 1.9% when used in patients with intermediate-risk (T2) or high-risk (T3) tumors. In more than half of the patients, pulmonary metastases were detected when patients became symptomatic outside of the routine follow- up. In a second retrospective analysis of 258 patients who had undergone resection or ablation for low-risk (T1a) RCC, pulmonary metastases developed in 3 patients (1.2%), but in only 1 patient (0.4%) was this metastasis diagnosed with surveillance chest radiographs [27]. In a more recent study, only 2 of 384 patients (0.005%) with T1a RCC were found to have pulmonary metastases after surgical therapy, and in both cases, the pulmonary metastases were not detected by surveillance chest radiographs [24]. In the same study, 10 of 184 patients (5.4%) with T1b RCC had suspicious pulmonary lesions found on surveillance radiography of the chest; only 2 of these patients had biopsy-confirmed pulmonary metastasis. However, according to guidelines from urologic and oncologic societies, a chest radiograph is still the recommended technique for the surveillance of patients with T1a tumors, and this technique is also recommended as an alternative to chest CT for the surveillance of patients with T2 and T3 tumors after an initial negative follow-up chest CT examination [9,11]. This is in part because of concerns about potential false-positive findings with chest CT (ie, intrapulmonary lymph nodes and granulomas) that can lead to further unnecessary and potentially invasive investigations [9,12]. Radiography Abdomen There is no relevant literature regarding the use of abdominal radiographs in the follow-up of patients after surgical excision of RCC, and this method is not recommended by the guidelines [2,9,11].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. In a retrospective analysis of 221 patients with pT1-3N0M0 RCC, only 0.85% of the follow-up chest radiographs detected pulmonary metastases in asymptomatic patients [28]. The yield of a chest radiograph increased to 1.9% when used in patients with intermediate-risk (T2) or high-risk (T3) tumors. In more than half of the patients, pulmonary metastases were detected when patients became symptomatic outside of the routine follow- up. In a second retrospective analysis of 258 patients who had undergone resection or ablation for low-risk (T1a) RCC, pulmonary metastases developed in 3 patients (1.2%), but in only 1 patient (0.4%) was this metastasis diagnosed with surveillance chest radiographs [27]. In a more recent study, only 2 of 384 patients (0.005%) with T1a RCC were found to have pulmonary metastases after surgical therapy, and in both cases, the pulmonary metastases were not detected by surveillance chest radiographs [24]. In the same study, 10 of 184 patients (5.4%) with T1b RCC had suspicious pulmonary lesions found on surveillance radiography of the chest; only 2 of these patients had biopsy-confirmed pulmonary metastasis. However, according to guidelines from urologic and oncologic societies, a chest radiograph is still the recommended technique for the surveillance of patients with T1a tumors, and this technique is also recommended as an alternative to chest CT for the surveillance of patients with T2 and T3 tumors after an initial negative follow-up chest CT examination [9,11]. This is in part because of concerns about potential false-positive findings with chest CT (ie, intrapulmonary lymph nodes and granulomas) that can lead to further unnecessary and potentially invasive investigations [9,12]. Radiography Abdomen There is no relevant literature regarding the use of abdominal radiographs in the follow-up of patients after surgical excision of RCC, and this method is not recommended by the guidelines [2,9,11].

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Radiography Skeletal Survey There is no relevant literature regarding the use of a radiographic survey of the whole body in the follow-up of patients after surgical excision of RCC, and this method is not included in the guidelines [2,9,11]. Radiography Intravenous Urography There is no relevant literature regarding the use of IV urography in the follow-up of patients after surgical excision of RCC, and this method is not recommended by the guidelines [2,9,11]. CT Abdomen CT of the abdomen is the most commonly used method for surveillance after surgical excision of RCC [29]. CT is a sensitive method for the detection of recurrences in the resection bed and in other more common sites of metastases in the abdomen, such as the contralateral kidney, adrenal glands, liver, and lymph nodes, and in the visualized bones [16,17,20,22,30]. Although several studies have advised against routine imaging of the abdomen after resection of low-risk (T1) tumors because of the low frequency of abdominal recurrences [15,17,21,30], CT of the abdomen is commonly performed in this group, particularly after PN, to serve as a baseline for future comparisons and to evaluate postoperative complications [9]. Although CT of the abdomen performed without and with IV contrast may be considered beneficial in cases in which postoperative changes need to be distinguished from residual or recurrent tumors, in general, surveillance protocols in oncology often use a single-phase examination in the portal- venous phase. Because RCC metastases tend to be hypervascular, some authors have also suggested that arterial phase imaging can be used to complement portal-venous imaging for the detection of RCC metastases to the liver, pancreas, and contralateral kidney.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Radiography Skeletal Survey There is no relevant literature regarding the use of a radiographic survey of the whole body in the follow-up of patients after surgical excision of RCC, and this method is not included in the guidelines [2,9,11]. Radiography Intravenous Urography There is no relevant literature regarding the use of IV urography in the follow-up of patients after surgical excision of RCC, and this method is not recommended by the guidelines [2,9,11]. CT Abdomen CT of the abdomen is the most commonly used method for surveillance after surgical excision of RCC [29]. CT is a sensitive method for the detection of recurrences in the resection bed and in other more common sites of metastases in the abdomen, such as the contralateral kidney, adrenal glands, liver, and lymph nodes, and in the visualized bones [16,17,20,22,30]. Although several studies have advised against routine imaging of the abdomen after resection of low-risk (T1) tumors because of the low frequency of abdominal recurrences [15,17,21,30], CT of the abdomen is commonly performed in this group, particularly after PN, to serve as a baseline for future comparisons and to evaluate postoperative complications [9]. Although CT of the abdomen performed without and with IV contrast may be considered beneficial in cases in which postoperative changes need to be distinguished from residual or recurrent tumors, in general, surveillance protocols in oncology often use a single-phase examination in the portal- venous phase. Because RCC metastases tend to be hypervascular, some authors have also suggested that arterial phase imaging can be used to complement portal-venous imaging for the detection of RCC metastases to the liver, pancreas, and contralateral kidney.

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In a retrospective study including 100 patients, 9 patients had metastases in the liver, pancreas, or contralateral kidney detected only in the arterial phase, and these findings led to a change in management for 2 patients [31]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), CT of the abdomen without IV contrast may be considered appropriate. CT Abdomen and Pelvis CT of the abdomen is the most commonly used method for surveillance after surgical excision of RCC [29]. CT is a sensitive method for the detection of recurrences in the resection bed and in other more common sites of metastases in the abdomen, such as the contralateral kidney, adrenal glands, liver, and lymph nodes, and in the visualized bones [16,17,20,22,30]. Although several studies have advised against routine imaging of the abdomen after resection of 6 Post-treatment Follow-up of Renal Cell Carcinoma low-risk (T1) tumors because of the low frequency of abdominal recurrences [15,17,21,30], CT of the abdomen is commonly performed in this group, particularly after PN, to serve as a baseline for future comparisons and to evaluate postoperative complications [9]. Although CT of the abdomen performed without and with IV contrast may be considered beneficial in cases in which postoperative changes need to be distinguished from residual or recurrent tumors, in general, surveillance protocols in oncology often use a single-phase examination in the portal- venous phase. Because RCC metastases tend to be hypervascular, some authors have also suggested that arterial phase imaging can be used to complement portal-venous imaging for the detection of RCC metastases to the liver, pancreas, and contralateral kidney. In a retrospective study including 100 patients, 9 patients had metastases in the liver, pancreas, or contralateral kidney detected only in the arterial phase, and these findings led to a change in management for 2 patients [31].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. In a retrospective study including 100 patients, 9 patients had metastases in the liver, pancreas, or contralateral kidney detected only in the arterial phase, and these findings led to a change in management for 2 patients [31]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), CT of the abdomen without IV contrast may be considered appropriate. CT Abdomen and Pelvis CT of the abdomen is the most commonly used method for surveillance after surgical excision of RCC [29]. CT is a sensitive method for the detection of recurrences in the resection bed and in other more common sites of metastases in the abdomen, such as the contralateral kidney, adrenal glands, liver, and lymph nodes, and in the visualized bones [16,17,20,22,30]. Although several studies have advised against routine imaging of the abdomen after resection of 6 Post-treatment Follow-up of Renal Cell Carcinoma low-risk (T1) tumors because of the low frequency of abdominal recurrences [15,17,21,30], CT of the abdomen is commonly performed in this group, particularly after PN, to serve as a baseline for future comparisons and to evaluate postoperative complications [9]. Although CT of the abdomen performed without and with IV contrast may be considered beneficial in cases in which postoperative changes need to be distinguished from residual or recurrent tumors, in general, surveillance protocols in oncology often use a single-phase examination in the portal- venous phase. Because RCC metastases tend to be hypervascular, some authors have also suggested that arterial phase imaging can be used to complement portal-venous imaging for the detection of RCC metastases to the liver, pancreas, and contralateral kidney. In a retrospective study including 100 patients, 9 patients had metastases in the liver, pancreas, or contralateral kidney detected only in the arterial phase, and these findings led to a change in management for 2 patients [31].

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For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), CT of the abdomen without IV contrast may be considered appropriate. CTU There is no relevant literature suggesting that CTU offers any additional benefit over conventional CT of the abdomen in the surveillance of patients after treatment of localized RCC, and this method is not included in the guidelines [2,9,11]. In a retrospective analysis of 23 tumors that progressed locally after ablation, CT or MRIs obtained in the corticomedullary phase were found to be sufficient for diagnosis of recurrence in 100% of the cases; noncontrast, nephrographic, and excretory-phase images, which are typically obtained in a CTU or MRU protocol, were able to detect recurrence in only 11%, 81%, and 44% of cases, respectively [35]. CT Chest Limited data suggest that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging [27]. Although no direct comparison between the 2 methods has been reported in the posttreatment surveillance setting, one study demonstrated that the overwhelming majority of chest recurrences in asymptomatic cases are detected by chest CT examinations (92.3%) rather than by radiography (7.7%) [36]. In addition to a high sensitivity for the detection of pulmonary metastases, chest CT has a high sensitivity for the detection of intrathoracic nodal metastases from RCC; this finding has prognostic implications and may affect surgical planning for metastases resection [37]. The use of IV contrast is optional for chest CT, but it may be beneficial for the detection and characterization of hilar lymph nodes. In patients undergoing surveillance with CT of the abdomen with IV contrast, chest CT should also be performed after IV contrast administration.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), CT of the abdomen without IV contrast may be considered appropriate. CTU There is no relevant literature suggesting that CTU offers any additional benefit over conventional CT of the abdomen in the surveillance of patients after treatment of localized RCC, and this method is not included in the guidelines [2,9,11]. In a retrospective analysis of 23 tumors that progressed locally after ablation, CT or MRIs obtained in the corticomedullary phase were found to be sufficient for diagnosis of recurrence in 100% of the cases; noncontrast, nephrographic, and excretory-phase images, which are typically obtained in a CTU or MRU protocol, were able to detect recurrence in only 11%, 81%, and 44% of cases, respectively [35]. CT Chest Limited data suggest that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging [27]. Although no direct comparison between the 2 methods has been reported in the posttreatment surveillance setting, one study demonstrated that the overwhelming majority of chest recurrences in asymptomatic cases are detected by chest CT examinations (92.3%) rather than by radiography (7.7%) [36]. In addition to a high sensitivity for the detection of pulmonary metastases, chest CT has a high sensitivity for the detection of intrathoracic nodal metastases from RCC; this finding has prognostic implications and may affect surgical planning for metastases resection [37]. The use of IV contrast is optional for chest CT, but it may be beneficial for the detection and characterization of hilar lymph nodes. In patients undergoing surveillance with CT of the abdomen with IV contrast, chest CT should also be performed after IV contrast administration.

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Unlike CT of the abdomen, in which images obtained without and with IV contrast may be appropriate in some circumstances, CT of the chest without and with IV contrast does not provide additional information in these patients and is considered inappropriate. Although some consider CT to be the standard chest imaging technique for surveillance after RCC resection [11], there are concerns regarding the risk of false-positive findings (ie, intrapulmonary lymph nodes and granulomas), particularly in patients with T1a RCC, which can lead to further unnecessary and potentially invasive investigations [9]. It is worth noting that in a recent pilot study, the authors suggested that CT of the chest may not be necessary to identify most cases of pulmonary recurrence when a CT examination of the abdomen with coverage of the lung bases to the T7 thoracic level is performed [26]. CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, surveillance protocols after surgical excision of RCC have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. Post-treatment Follow-up of Renal Cell Carcinoma MRI Abdomen MRI of the abdomen without and with IV contrast is considered in all major guidelines as an adequate method for surveillance of the abdomen after surgical excision of RCC [2,9,11]. MRI has a high soft-tissue contrast resolution and is an accurate method for detecting metastases in the common sites of RCC recurrences (ie, liver, adrenal glands, lymph nodes, contralateral kidney, and bones) [38]. MRI can also assist in the distinction between residual/recurrent disease and postoperative changes after PN [39]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Unlike CT of the abdomen, in which images obtained without and with IV contrast may be appropriate in some circumstances, CT of the chest without and with IV contrast does not provide additional information in these patients and is considered inappropriate. Although some consider CT to be the standard chest imaging technique for surveillance after RCC resection [11], there are concerns regarding the risk of false-positive findings (ie, intrapulmonary lymph nodes and granulomas), particularly in patients with T1a RCC, which can lead to further unnecessary and potentially invasive investigations [9]. It is worth noting that in a recent pilot study, the authors suggested that CT of the chest may not be necessary to identify most cases of pulmonary recurrence when a CT examination of the abdomen with coverage of the lung bases to the T7 thoracic level is performed [26]. CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, surveillance protocols after surgical excision of RCC have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. Post-treatment Follow-up of Renal Cell Carcinoma MRI Abdomen MRI of the abdomen without and with IV contrast is considered in all major guidelines as an adequate method for surveillance of the abdomen after surgical excision of RCC [2,9,11]. MRI has a high soft-tissue contrast resolution and is an accurate method for detecting metastases in the common sites of RCC recurrences (ie, liver, adrenal glands, lymph nodes, contralateral kidney, and bones) [38]. MRI can also assist in the distinction between residual/recurrent disease and postoperative changes after PN [39]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate.

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MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is considered in all major guidelines as an adequate method for surveillance of the abdomen after surgical excision of RCC [2,9,11]. MRI has a high soft-tissue contrast resolution and is an accurate method for detecting metastases in the common sites of RCC recurrences (ie, liver, adrenal glands, lymph nodes, contralateral kidney, and bones) [38]. MRI can also assist in the distinction between residual/recurrent disease and postoperative changes after PN [39]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate. Although MRI of the abdomen with IV contrast is considered in all major guidelines as an adequate method for surveillance of the abdomen after surgical excision of RCC, imaging the pelvis during surveillance after RCC treatment is considered optional in the guidelines [2,9,11]. There is no relevant literature regarding the use of MRI of the pelvis in the follow-up of patients after surgical excision of RCC, although data from 2 retrospective studies suggested that imaging of the pelvis with CT had minimal benefit for the detection of metastases in patients after RN or PN for RCC [25,32-34]. Therefore, MRI of the abdomen alone may be preferred over MRI of the abdomen and pelvis in this setting. MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the surveillance of patients after treatment of localized RCC, and this method is not included in the guidelines [2,9,11].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is considered in all major guidelines as an adequate method for surveillance of the abdomen after surgical excision of RCC [2,9,11]. MRI has a high soft-tissue contrast resolution and is an accurate method for detecting metastases in the common sites of RCC recurrences (ie, liver, adrenal glands, lymph nodes, contralateral kidney, and bones) [38]. MRI can also assist in the distinction between residual/recurrent disease and postoperative changes after PN [39]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate. Although MRI of the abdomen with IV contrast is considered in all major guidelines as an adequate method for surveillance of the abdomen after surgical excision of RCC, imaging the pelvis during surveillance after RCC treatment is considered optional in the guidelines [2,9,11]. There is no relevant literature regarding the use of MRI of the pelvis in the follow-up of patients after surgical excision of RCC, although data from 2 retrospective studies suggested that imaging of the pelvis with CT had minimal benefit for the detection of metastases in patients after RN or PN for RCC [25,32-34]. Therefore, MRI of the abdomen alone may be preferred over MRI of the abdomen and pelvis in this setting. MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the surveillance of patients after treatment of localized RCC, and this method is not included in the guidelines [2,9,11].

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In a retrospective analysis of 23 tumors that progressed locally after ablation, CT or MRIs obtained in the corticomedullary phase were found to be sufficient for diagnosis of recurrence in 100% of the cases; noncontrast, nephrographic, and excretory-phase images, which are typically obtained in a CTU or MRU protocol, were able to detect recurrence in only 11%, 81%, and 44% of cases, respectively [35]. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, surveillance protocols for RCC have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. US Kidney Retroperitoneal The major guidelines include US as another option for imaging surveillance of the abdomen after surgical resection of localized RCC [2,9,11]. Although US may be considered an appropriate alternative for patients with contraindications to CT or MRI, one important consideration is that US is likely to be less sensitive than CT or MRI for the detection of small recurrences or distant visceral and nodal metastases in the abdomen. In one study, among 14 patients who were found to have recurrence after RN or PN for T1-3 RCC, US correctly identified only 1 case of recurrence, whereas CT detected all cases of recurrence [40]. US failed to detect 4 out of 5 recurrences in the kidney after PN [40]. In another study investigating outcomes after PN for T1-2 RCC, CT/MRI detected 96.6% of recurrences in the abdomen, whereas US detected only 3.4% of abdominal recurrences [36]. US Abdomen with IV Contrast There is no relevant literature regarding the use of contrast-enhanced US (CEUS) in the follow-up of patients after surgical excision of RCC, and this method is not included in the guidelines [2,9,11].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. In a retrospective analysis of 23 tumors that progressed locally after ablation, CT or MRIs obtained in the corticomedullary phase were found to be sufficient for diagnosis of recurrence in 100% of the cases; noncontrast, nephrographic, and excretory-phase images, which are typically obtained in a CTU or MRU protocol, were able to detect recurrence in only 11%, 81%, and 44% of cases, respectively [35]. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, surveillance protocols for RCC have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. US Kidney Retroperitoneal The major guidelines include US as another option for imaging surveillance of the abdomen after surgical resection of localized RCC [2,9,11]. Although US may be considered an appropriate alternative for patients with contraindications to CT or MRI, one important consideration is that US is likely to be less sensitive than CT or MRI for the detection of small recurrences or distant visceral and nodal metastases in the abdomen. In one study, among 14 patients who were found to have recurrence after RN or PN for T1-3 RCC, US correctly identified only 1 case of recurrence, whereas CT detected all cases of recurrence [40]. US failed to detect 4 out of 5 recurrences in the kidney after PN [40]. In another study investigating outcomes after PN for T1-2 RCC, CT/MRI detected 96.6% of recurrences in the abdomen, whereas US detected only 3.4% of abdominal recurrences [36]. US Abdomen with IV Contrast There is no relevant literature regarding the use of contrast-enhanced US (CEUS) in the follow-up of patients after surgical excision of RCC, and this method is not included in the guidelines [2,9,11].

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Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Studies evaluating the performance of CEUS after ablative treatment of renal masses have shown that CEUS has an excellent concordance with CT or MRI with regard to the presence or absence of residual or recurrent tumor after ablation, both immediately after treatment and through long-term follow-up [41-49]. One important consideration is that CEUS would still be less sensitive than CT or MRI for the detection of distant visceral and nodal metastases because the contrast-enhanced portion of the study would be limited to the surgical bed. Nevertheless, in patients at low risk for recurrence, CEUS may be considered an appropriate alternative to CT and MRI. Post-treatment Follow-up of Renal Cell Carcinoma Bone Scan Whole Body The prevalence of osseous metastases after treatment for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [50,51]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines do not support its routine use in surveillance after treatment for localized RCC [2,9,11]. Preliminary results for other PET tracers are also becoming available. For instance, in a prospective study of 28 patients with RCC undergoing initial staging or restaging, 11C-choline PET/CT was significantly more accurate than FDG-PET/CT (85.7% versus 57.1%). Among 120 lesions detected, 11C-choline PET/CT detected 75 lesions (62.5%), whereas FDG-PET/CT detected 47 lesions (39.2%) [54].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Studies evaluating the performance of CEUS after ablative treatment of renal masses have shown that CEUS has an excellent concordance with CT or MRI with regard to the presence or absence of residual or recurrent tumor after ablation, both immediately after treatment and through long-term follow-up [41-49]. One important consideration is that CEUS would still be less sensitive than CT or MRI for the detection of distant visceral and nodal metastases because the contrast-enhanced portion of the study would be limited to the surgical bed. Nevertheless, in patients at low risk for recurrence, CEUS may be considered an appropriate alternative to CT and MRI. Post-treatment Follow-up of Renal Cell Carcinoma Bone Scan Whole Body The prevalence of osseous metastases after treatment for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [50,51]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines do not support its routine use in surveillance after treatment for localized RCC [2,9,11]. Preliminary results for other PET tracers are also becoming available. For instance, in a prospective study of 28 patients with RCC undergoing initial staging or restaging, 11C-choline PET/CT was significantly more accurate than FDG-PET/CT (85.7% versus 57.1%). Among 120 lesions detected, 11C-choline PET/CT detected 75 lesions (62.5%), whereas FDG-PET/CT detected 47 lesions (39.2%) [54].

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acrac_69365_12

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

In another prospective study of 10 patients with metastatic RCC, 18F-sodium fluoride (NaF) PET/CT was found to be significantly more sensitive for the detection of RCC skeletal metastases than Tc-99m bone scintigraphy or CT, with sensitivities of 100%, 29%, and 46%, respectively. CT and Tc-99m bone scintigraphy in this study identified only 65% of the metastases detected by NaF-PET/CT [55]. A small series has also shown that 68Ga-labeled prostate-specific membrane antigen PET/CT can help to detect metastatic lesions in patients with the clear cell subtype of RCC [56]. Variant 2: Follow-up for clinically localized renal cell carcinoma; post ablation. Among several techniques available for the ablation of localized RCC, thermal ablation techniques using radiofrequency ablation, microwave ablation, or cryoablation are the most commonly used; these procedures can be performed percutaneously or laparoscopically [57-59]. Ablation therapy is currently considered a less invasive alternative to RN or PN for renal masses measuring <4 cm (ie, T1a tumors) [2,9,11]. There is growing evidence suggesting that ablation of small renal masses produces oncologic outcomes that approach those of surgical excision but with a significantly lower overall complication rate and a significantly lower decline in renal function [5- 7,57,60-67]. Because of the higher rate of local recurrence seen with ablation than with surgical excision, ablation requires more frequent use of imaging to monitor tumor involution over time [3,29,65]. Early detection of treatment failure or recurrence is important to maximize retreatment potential [65,68]. Because the risk of local recurrence is greater than the risk of distant metastases in this patient population, surveillance strategies should prioritize evaluation of the treatment bed. Guidelines recommend performing CT or MRI of the abdomen at 3 and 6 months after ablation and yearly thereafter for 5 years [2,9,11].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. In another prospective study of 10 patients with metastatic RCC, 18F-sodium fluoride (NaF) PET/CT was found to be significantly more sensitive for the detection of RCC skeletal metastases than Tc-99m bone scintigraphy or CT, with sensitivities of 100%, 29%, and 46%, respectively. CT and Tc-99m bone scintigraphy in this study identified only 65% of the metastases detected by NaF-PET/CT [55]. A small series has also shown that 68Ga-labeled prostate-specific membrane antigen PET/CT can help to detect metastatic lesions in patients with the clear cell subtype of RCC [56]. Variant 2: Follow-up for clinically localized renal cell carcinoma; post ablation. Among several techniques available for the ablation of localized RCC, thermal ablation techniques using radiofrequency ablation, microwave ablation, or cryoablation are the most commonly used; these procedures can be performed percutaneously or laparoscopically [57-59]. Ablation therapy is currently considered a less invasive alternative to RN or PN for renal masses measuring <4 cm (ie, T1a tumors) [2,9,11]. There is growing evidence suggesting that ablation of small renal masses produces oncologic outcomes that approach those of surgical excision but with a significantly lower overall complication rate and a significantly lower decline in renal function [5- 7,57,60-67]. Because of the higher rate of local recurrence seen with ablation than with surgical excision, ablation requires more frequent use of imaging to monitor tumor involution over time [3,29,65]. Early detection of treatment failure or recurrence is important to maximize retreatment potential [65,68]. Because the risk of local recurrence is greater than the risk of distant metastases in this patient population, surveillance strategies should prioritize evaluation of the treatment bed. Guidelines recommend performing CT or MRI of the abdomen at 3 and 6 months after ablation and yearly thereafter for 5 years [2,9,11].

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acrac_69365_13

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Guidelines also recommend the use of imaging surveillance with chest radiography or CT annually for up to 5 years after ablation of RCC [2,9,11]. Imaging-guided biopsy of renal masses is encouraged in patients considering ablative therapies [2,9,11,60]. Pretreatment biopsy can help confirm the malignant nature and aggressiveness of the tumors, which in turn can influence the frequency and duration of follow-up. After treatment, biopsy is also indicated for masses that fail to regress or that display findings suggestive of recurrence. Radiography Chest Chest radiography is a low-yield diagnostic tool for detecting pulmonary metastasis in patients treated for RCC, particularly in those with low-risk tumors, irrespective of the treatment modality (RN, PN, or ablation) [27,28]. In a retrospective analysis of 258 patients who had undergone resection or ablation of low-risk (T1a) RCC, pulmonary metastases developed in 3 patients (1.2%), but in only 1 patient (0.4%) was this metastasis diagnosed by surveillance chest radiographs [27]. However, according to guidelines from urologic and oncologic societies, chest radiography Post-treatment Follow-up of Renal Cell Carcinoma is the recommended technique for surveillance of patients after ablation of T1a tumors [2,9,11]. This is in part because of concerns about potential false-positive findings with chest CT (ie, intrapulmonary lymph nodes and granulomas) that can lead to further unnecessary and potentially invasive investigations [9,12]. Radiography Abdomen There is no relevant literature regarding the use of abdominal radiographs in the follow-up of patients after localized RCC ablation, and this method is not recommended by the guidelines [2,9,11]. Radiography Skeletal Survey There is no relevant literature regarding the use of a radiographic survey of the whole body in the follow-up of patients after localized RCC ablation, and this method is not recommended by the guidelines [2,9,11].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Guidelines also recommend the use of imaging surveillance with chest radiography or CT annually for up to 5 years after ablation of RCC [2,9,11]. Imaging-guided biopsy of renal masses is encouraged in patients considering ablative therapies [2,9,11,60]. Pretreatment biopsy can help confirm the malignant nature and aggressiveness of the tumors, which in turn can influence the frequency and duration of follow-up. After treatment, biopsy is also indicated for masses that fail to regress or that display findings suggestive of recurrence. Radiography Chest Chest radiography is a low-yield diagnostic tool for detecting pulmonary metastasis in patients treated for RCC, particularly in those with low-risk tumors, irrespective of the treatment modality (RN, PN, or ablation) [27,28]. In a retrospective analysis of 258 patients who had undergone resection or ablation of low-risk (T1a) RCC, pulmonary metastases developed in 3 patients (1.2%), but in only 1 patient (0.4%) was this metastasis diagnosed by surveillance chest radiographs [27]. However, according to guidelines from urologic and oncologic societies, chest radiography Post-treatment Follow-up of Renal Cell Carcinoma is the recommended technique for surveillance of patients after ablation of T1a tumors [2,9,11]. This is in part because of concerns about potential false-positive findings with chest CT (ie, intrapulmonary lymph nodes and granulomas) that can lead to further unnecessary and potentially invasive investigations [9,12]. Radiography Abdomen There is no relevant literature regarding the use of abdominal radiographs in the follow-up of patients after localized RCC ablation, and this method is not recommended by the guidelines [2,9,11]. Radiography Skeletal Survey There is no relevant literature regarding the use of a radiographic survey of the whole body in the follow-up of patients after localized RCC ablation, and this method is not recommended by the guidelines [2,9,11].

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acrac_69365_14

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Radiography Intravenous Urography There is no relevant literature regarding the use of IV urography in the follow-up of patients after localized RCC ablation, and this method is not recommended by the guidelines [2,9,11]. Imaging of the pelvis with CT has been found to have limited benefit for the detection of metastases in initial staging and after RN or PN for RCC [25,32-34] and is considered optional in the surveillance guidelines [2,9,11]. Because the risk of distant metastases is significantly lower in patients with localized RCC after ablation, CT of the abdomen is preferred over CT of the abdomen and pelvis. Post-treatment Follow-up of Renal Cell Carcinoma CT Chest Limited data suggest that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging [27]. Although no direct comparison between the 2 methods has been reported in the posttreatment surveillance setting, one study demonstrated that the overwhelming majority of chest recurrences in asymptomatic cases are detected by chest CT examinations (92.3%) rather than by radiography (7.7%) [36]. In addition to a high sensitivity for the detection of pulmonary metastases, chest CT has a high sensitivity for the detection of intrathoracic nodal metastases from RCC; this finding has prognostic implications and may affect surgical planning for metastases resection [37]. The use of IV contrast is optional for chest CT, but it may be beneficial for the detection and characterization of hilar lymph nodes. In patients undergoing surveillance with CT of the abdomen with IV contrast, chest CT should also be performed after IV contrast administration. Unlike CT of the abdomen, in which images without and with IV contrast are appropriate, CT of the chest without and with IV contrast does not provide additional information in these patients and is considered inappropriate.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Radiography Intravenous Urography There is no relevant literature regarding the use of IV urography in the follow-up of patients after localized RCC ablation, and this method is not recommended by the guidelines [2,9,11]. Imaging of the pelvis with CT has been found to have limited benefit for the detection of metastases in initial staging and after RN or PN for RCC [25,32-34] and is considered optional in the surveillance guidelines [2,9,11]. Because the risk of distant metastases is significantly lower in patients with localized RCC after ablation, CT of the abdomen is preferred over CT of the abdomen and pelvis. Post-treatment Follow-up of Renal Cell Carcinoma CT Chest Limited data suggest that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging [27]. Although no direct comparison between the 2 methods has been reported in the posttreatment surveillance setting, one study demonstrated that the overwhelming majority of chest recurrences in asymptomatic cases are detected by chest CT examinations (92.3%) rather than by radiography (7.7%) [36]. In addition to a high sensitivity for the detection of pulmonary metastases, chest CT has a high sensitivity for the detection of intrathoracic nodal metastases from RCC; this finding has prognostic implications and may affect surgical planning for metastases resection [37]. The use of IV contrast is optional for chest CT, but it may be beneficial for the detection and characterization of hilar lymph nodes. In patients undergoing surveillance with CT of the abdomen with IV contrast, chest CT should also be performed after IV contrast administration. Unlike CT of the abdomen, in which images without and with IV contrast are appropriate, CT of the chest without and with IV contrast does not provide additional information in these patients and is considered inappropriate.

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acrac_69365_15

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Although some consider CT the standard chest imaging technique for surveillance after RCC resection [11], there are concerns about the risk of false-positive findings (ie, intrapulmonary lymph nodes and granulomas), particularly in patients with T1a RCC, which can lead to further unnecessary and potentially invasive investigations [9]. Additionally, some authors suggest that CT of the chest may not be necessary to identify most patients with pulmonary recurrence when CT of the abdomen with coverage of the lung bases at the T7 thoracic level is performed [26]. CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, surveillance protocols after localized RCC ablation have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. CTU There is no relevant literature suggesting that CTU offers any additional benefit over conventional CT of the abdomen in the surveillance of patients after treatment of localized RCC, and this method is not included in the guidelines [2,9,11]. In a retrospective analysis of 23 tumors that progressed locally after ablation, CT or MR images in the corticomedullary phase were found to be sufficient for diagnosis of recurrence in 100% of the cases; noncontrast, nephrographic, and excretory-phase images, which are typically obtained in a CTU or MRU protocol, were able to detect recurrence in only 11%, 81%, and 44% of cases, respectively [35]. MRI Abdomen MRI of the abdomen is commonly used for follow-up after ablation of localized RCC [29]. MRI should be performed without and with IV contrast to assess tumor enhancement.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Although some consider CT the standard chest imaging technique for surveillance after RCC resection [11], there are concerns about the risk of false-positive findings (ie, intrapulmonary lymph nodes and granulomas), particularly in patients with T1a RCC, which can lead to further unnecessary and potentially invasive investigations [9]. Additionally, some authors suggest that CT of the chest may not be necessary to identify most patients with pulmonary recurrence when CT of the abdomen with coverage of the lung bases at the T7 thoracic level is performed [26]. CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, surveillance protocols after localized RCC ablation have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. CTU There is no relevant literature suggesting that CTU offers any additional benefit over conventional CT of the abdomen in the surveillance of patients after treatment of localized RCC, and this method is not included in the guidelines [2,9,11]. In a retrospective analysis of 23 tumors that progressed locally after ablation, CT or MR images in the corticomedullary phase were found to be sufficient for diagnosis of recurrence in 100% of the cases; noncontrast, nephrographic, and excretory-phase images, which are typically obtained in a CTU or MRU protocol, were able to detect recurrence in only 11%, 81%, and 44% of cases, respectively [35]. MRI Abdomen MRI of the abdomen is commonly used for follow-up after ablation of localized RCC [29]. MRI should be performed without and with IV contrast to assess tumor enhancement.

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acrac_69365_16

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Image data sets generated from subtraction of the precontrast from the postcontrast images can assist with evaluation of residual or recurrent tumor enhancement, especially during the first year of follow-up, because of the high signal intensity background of the ablated tumor on T1-weighted images [72]. However, as with CT, persistent tumor enhancement is common after successful ablation, particularly in patients with clear-cell RCC [73], and this enhancement can last for days to months after treatment [72-74]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate. MRI Abdomen and Pelvis MRI of the abdomen is commonly used for follow-up after ablation of localized RCC [29]. MRI should be performed without and with IV contrast to assess tumor enhancement. Image data sets generated from subtraction of the precontrast from the postcontrast images can assist with evaluation of residual or recurrent tumor enhancement, especially during the first year of follow-up, because of the high signal intensity background of the ablated tumor on T1-weighted images [72]. However, as with CT, persistent tumor enhancement is common after successful ablation, particularly in patients with clear-cell RCC [73], and this enhancement can last for days to months after treatment [72-74]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reactions), MRI of the abdomen without IV contrast may be considered appropriate. There is no relevant literature regarding the use of MRI of the pelvis in the follow-up of patients after RCC ablation. Imaging of the pelvis with CT has been found to provide minimal benefit for the detection of metastases in the initial staging and after RN or PN for RCC [25,32-34] and is considered optional in the surveillance guidelines [2,9,11].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Image data sets generated from subtraction of the precontrast from the postcontrast images can assist with evaluation of residual or recurrent tumor enhancement, especially during the first year of follow-up, because of the high signal intensity background of the ablated tumor on T1-weighted images [72]. However, as with CT, persistent tumor enhancement is common after successful ablation, particularly in patients with clear-cell RCC [73], and this enhancement can last for days to months after treatment [72-74]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate. MRI Abdomen and Pelvis MRI of the abdomen is commonly used for follow-up after ablation of localized RCC [29]. MRI should be performed without and with IV contrast to assess tumor enhancement. Image data sets generated from subtraction of the precontrast from the postcontrast images can assist with evaluation of residual or recurrent tumor enhancement, especially during the first year of follow-up, because of the high signal intensity background of the ablated tumor on T1-weighted images [72]. However, as with CT, persistent tumor enhancement is common after successful ablation, particularly in patients with clear-cell RCC [73], and this enhancement can last for days to months after treatment [72-74]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reactions), MRI of the abdomen without IV contrast may be considered appropriate. There is no relevant literature regarding the use of MRI of the pelvis in the follow-up of patients after RCC ablation. Imaging of the pelvis with CT has been found to provide minimal benefit for the detection of metastases in the initial staging and after RN or PN for RCC [25,32-34] and is considered optional in the surveillance guidelines [2,9,11].

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acrac_69365_17

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Because the risk of distant metastases is significantly lower in patients with localized RCC after ablation, MRI of the abdomen is preferred over MRI of the abdomen and pelvis. Post-treatment Follow-up of Renal Cell Carcinoma MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the surveillance of patients after treatment of localized RCC, and this method is not included in the guidelines [2,9,11]. In a retrospective analysis of 23 tumors that progressed locally after ablation, CT or MR images obtained in the corticomedullary phase were found to be sufficient for diagnosis of recurrence in 100% of the cases; noncontrast, nephrographic, and excretory-phase images, which are typically obtained in a CTU or MRU protocol, were able to detect recurrence in only 11%, 81%, and 44% of cases, respectively [35]. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, surveillance protocols for RCC have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. US Kidney Retroperitoneal There is no relevant literature regarding the use of conventional US of the kidney in follow-up of patients after localized RCC ablation, and the guidelines offer different recommendations. The National Comprehensive Cancer Network considers US an alternative for annual surveillance after negative evaluation with CT or MRI in the first 6 months [2]; the European Association of Urology recommends US only for surveillance after the treatment of RCC with a low-risk profile [11]; and the American Urological Association does not include US in their recommendations regarding follow-up after ablation [9].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Because the risk of distant metastases is significantly lower in patients with localized RCC after ablation, MRI of the abdomen is preferred over MRI of the abdomen and pelvis. Post-treatment Follow-up of Renal Cell Carcinoma MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the surveillance of patients after treatment of localized RCC, and this method is not included in the guidelines [2,9,11]. In a retrospective analysis of 23 tumors that progressed locally after ablation, CT or MR images obtained in the corticomedullary phase were found to be sufficient for diagnosis of recurrence in 100% of the cases; noncontrast, nephrographic, and excretory-phase images, which are typically obtained in a CTU or MRU protocol, were able to detect recurrence in only 11%, 81%, and 44% of cases, respectively [35]. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, surveillance protocols for RCC have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. US Kidney Retroperitoneal There is no relevant literature regarding the use of conventional US of the kidney in follow-up of patients after localized RCC ablation, and the guidelines offer different recommendations. The National Comprehensive Cancer Network considers US an alternative for annual surveillance after negative evaluation with CT or MRI in the first 6 months [2]; the European Association of Urology recommends US only for surveillance after the treatment of RCC with a low-risk profile [11]; and the American Urological Association does not include US in their recommendations regarding follow-up after ablation [9].

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acrac_69365_18

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Bone Scan Whole Body The prevalence of osseous metastases has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [50,51]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, although Tc-99m bone scanning can be helpful in confirming clinically or radiographically suspected metastatic disease, current guidelines do not support its routine use in surveillance after treatment for localized RCC [2,9,11]. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature regarding the use of FDG-PET or PET/CT for the follow-up of patients after localized RCC ablation. At present, the guidelines do not recommend FDG-PET/CT for the surveillance of patients after RCC ablation [2,9,11]. Variant 3: Follow-up for clinically localized renal cell carcinoma; active surveillance. Active surveillance has been increasingly used for the management of small localized renal masses in a selected group of patients with comorbidities or reduced life expectancy in whom the risks associated with surgical excision or ablative therapies surpass the risk of significant disease progression and cancer-specific mortality [2,9,11,75-80]. Post-treatment Follow-up of Renal Cell Carcinoma Current guidelines recommend biopsy of the renal masses to define the surveillance strategy [2,9,11]. Researchers have found that biopsy is being increasingly used for T1a tumors and that patients who undergo biopsy are significantly more likely to be treated with nonsurgical management (36.8%) than those who do not undergo biopsy (11.4%) [85]. Of note, small renal mass growth kinetics can vary greatly, especially during the initial 6 to 12 months of active surveillance [82,84].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Bone Scan Whole Body The prevalence of osseous metastases has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [50,51]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, although Tc-99m bone scanning can be helpful in confirming clinically or radiographically suspected metastatic disease, current guidelines do not support its routine use in surveillance after treatment for localized RCC [2,9,11]. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature regarding the use of FDG-PET or PET/CT for the follow-up of patients after localized RCC ablation. At present, the guidelines do not recommend FDG-PET/CT for the surveillance of patients after RCC ablation [2,9,11]. Variant 3: Follow-up for clinically localized renal cell carcinoma; active surveillance. Active surveillance has been increasingly used for the management of small localized renal masses in a selected group of patients with comorbidities or reduced life expectancy in whom the risks associated with surgical excision or ablative therapies surpass the risk of significant disease progression and cancer-specific mortality [2,9,11,75-80]. Post-treatment Follow-up of Renal Cell Carcinoma Current guidelines recommend biopsy of the renal masses to define the surveillance strategy [2,9,11]. Researchers have found that biopsy is being increasingly used for T1a tumors and that patients who undergo biopsy are significantly more likely to be treated with nonsurgical management (36.8%) than those who do not undergo biopsy (11.4%) [85]. Of note, small renal mass growth kinetics can vary greatly, especially during the initial 6 to 12 months of active surveillance [82,84].

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acrac_69365_19

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

In a systematic review of the literature, researchers found no significant difference between the growth rates of benign masses (0.3 cm/y) and those of malignant masses (0.35 cm/y) [82]. Furthermore, studies have shown that even masses without growth may be malignant [8,76,77,81]. In spite of this, growth rates are generally accepted as surrogates for aggressive behavior and metastatic potential in small renal masses [76,81]. Therefore, the guidelines recommend defining the growth rate of renal masses with serial imaging of the abdomen with CT or MRI within 6 months of the initiation of active surveillance for masses that are shown to be RCCs or oncocytic neoplasms and for those with indeterminate histology features [2,9]. Imaging should be performed at least annually thereafter with CT, MRI, or US. Imaging surveillance of the chest on a yearly basis (or more frequently depending on clinical behavior) is recommended only in those patients with RCC or tumors with oncocytic features [2,9]. Radiography Chest Metastatic progression occurs infrequently in patients with T1a renal masses on active surveillance [76,77,81]. Nevertheless, it has been reported that 20% to 30% of T1a tumors have potentially aggressive histologic features, thus requiring surveillance of the chest [9]. No studies have compared chest radiography and chest CT in the setting of active surveillance; however, chest radiography is the most commonly used method for surveillance [2,9]. This is in part because of concerns about potential false-positive findings with chest CT (ie, intrapulmonary lymph nodes and granulomas) that can lead to further unnecessary and potentially invasive investigations [9,12]. Radiography Abdomen There is no relevant literature regarding the use of abdominal radiographs in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. In a systematic review of the literature, researchers found no significant difference between the growth rates of benign masses (0.3 cm/y) and those of malignant masses (0.35 cm/y) [82]. Furthermore, studies have shown that even masses without growth may be malignant [8,76,77,81]. In spite of this, growth rates are generally accepted as surrogates for aggressive behavior and metastatic potential in small renal masses [76,81]. Therefore, the guidelines recommend defining the growth rate of renal masses with serial imaging of the abdomen with CT or MRI within 6 months of the initiation of active surveillance for masses that are shown to be RCCs or oncocytic neoplasms and for those with indeterminate histology features [2,9]. Imaging should be performed at least annually thereafter with CT, MRI, or US. Imaging surveillance of the chest on a yearly basis (or more frequently depending on clinical behavior) is recommended only in those patients with RCC or tumors with oncocytic features [2,9]. Radiography Chest Metastatic progression occurs infrequently in patients with T1a renal masses on active surveillance [76,77,81]. Nevertheless, it has been reported that 20% to 30% of T1a tumors have potentially aggressive histologic features, thus requiring surveillance of the chest [9]. No studies have compared chest radiography and chest CT in the setting of active surveillance; however, chest radiography is the most commonly used method for surveillance [2,9]. This is in part because of concerns about potential false-positive findings with chest CT (ie, intrapulmonary lymph nodes and granulomas) that can lead to further unnecessary and potentially invasive investigations [9,12]. Radiography Abdomen There is no relevant literature regarding the use of abdominal radiographs in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11].

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acrac_69365_20

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Radiography Skeletal Survey There is no relevant literature regarding the use of a radiographic survey of the whole body in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11]. Radiography Intravenous Urography There is no relevant literature regarding the use of IV urography in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11]. CT Abdomen and Pelvis CT of the abdomen is the most common method by which small renal masses are detected and is also the most commonly used method for surveillance of small localized renal masses. CT of the abdomen performed without Post-treatment Follow-up of Renal Cell Carcinoma Although CT of the abdomen is the most commonly used method for surveillance of small localized renal masses, the benefit of imaging the pelvis during surveillance has not yet been defined and is considered optional in the guidelines [2,9,11]. Data from 2 retrospective studies evaluating RCC staging with CT suggested that imaging of the pelvis had limited benefit for the detection of metastases [33,34]. Because metastatic progression occurs infrequently in patients on active surveillance with T1a renal masses [8,75-78,81-84], CT of the abdomen is preferred over CT of the abdomen and pelvis. CTU There is no relevant literature regarding the use of CTU in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11]. CT Chest Chest CT is listed as an alternative to radiography for surveillance of small localized renal masses by the National Comprehensive Cancer Network guidelines [2]. Limited data have demonstrated that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging [27]. However, no comparison between radiography and CT has been reported in the active surveillance setting.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Radiography Skeletal Survey There is no relevant literature regarding the use of a radiographic survey of the whole body in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11]. Radiography Intravenous Urography There is no relevant literature regarding the use of IV urography in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11]. CT Abdomen and Pelvis CT of the abdomen is the most common method by which small renal masses are detected and is also the most commonly used method for surveillance of small localized renal masses. CT of the abdomen performed without Post-treatment Follow-up of Renal Cell Carcinoma Although CT of the abdomen is the most commonly used method for surveillance of small localized renal masses, the benefit of imaging the pelvis during surveillance has not yet been defined and is considered optional in the guidelines [2,9,11]. Data from 2 retrospective studies evaluating RCC staging with CT suggested that imaging of the pelvis had limited benefit for the detection of metastases [33,34]. Because metastatic progression occurs infrequently in patients on active surveillance with T1a renal masses [8,75-78,81-84], CT of the abdomen is preferred over CT of the abdomen and pelvis. CTU There is no relevant literature regarding the use of CTU in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11]. CT Chest Chest CT is listed as an alternative to radiography for surveillance of small localized renal masses by the National Comprehensive Cancer Network guidelines [2]. Limited data have demonstrated that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging [27]. However, no comparison between radiography and CT has been reported in the active surveillance setting.

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acrac_69365_21

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Despite the higher sensitivity of CT, there are some concerns about the risk of false-positive findings (ie, intrapulmonary lymph nodes and granulomas), particularly in patients with T1a RCC, which can lead to further unnecessary and potentially invasive investigations [9]. Additionally, some authors suggest that CT of the chest may not be necessary to identify most cases of pulmonary recurrence after nephrectomy for RCC when CT of the abdomen with coverage of the lung bases at the T7 thoracic level is performed [26]. The use of IV contrast is optional for CT of the chest but it may be beneficial for detection and characterization of the hilar lymph nodes. In patients undergoing active surveillance with CT of the abdomen who are receiving IV contrast, chest CT can also be performed after IV contrast administration. Unlike CT of the abdomen, in which images without and with IV contrast may be appropriate in some circumstances, CT of the chest without and with IV contrast does not provide additional information in these patients and is considered inappropriate. CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, active surveillance protocols for small localized renal masses have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. MRI Abdomen MRI of the abdomen without and with IV contrast is an accurate method for the detection and characterization of small localized renal masses. Different sequences, including T2-weighted, chemical shift T1-weighted, contrast- enhanced T1-weighted, and diffusion-weighted images, can help distinguish RCC from other benign and malignant lesions and distinguish the clear-cell subtype from other subtypes of RCC.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Despite the higher sensitivity of CT, there are some concerns about the risk of false-positive findings (ie, intrapulmonary lymph nodes and granulomas), particularly in patients with T1a RCC, which can lead to further unnecessary and potentially invasive investigations [9]. Additionally, some authors suggest that CT of the chest may not be necessary to identify most cases of pulmonary recurrence after nephrectomy for RCC when CT of the abdomen with coverage of the lung bases at the T7 thoracic level is performed [26]. The use of IV contrast is optional for CT of the chest but it may be beneficial for detection and characterization of the hilar lymph nodes. In patients undergoing active surveillance with CT of the abdomen who are receiving IV contrast, chest CT can also be performed after IV contrast administration. Unlike CT of the abdomen, in which images without and with IV contrast may be appropriate in some circumstances, CT of the chest without and with IV contrast does not provide additional information in these patients and is considered inappropriate. CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, active surveillance protocols for small localized renal masses have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. MRI Abdomen MRI of the abdomen without and with IV contrast is an accurate method for the detection and characterization of small localized renal masses. Different sequences, including T2-weighted, chemical shift T1-weighted, contrast- enhanced T1-weighted, and diffusion-weighted images, can help distinguish RCC from other benign and malignant lesions and distinguish the clear-cell subtype from other subtypes of RCC.

69365

acrac_69365_22

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Some MRI features of renal masses beyond size and growth rates can also be used to determine tumor aggressiveness and risk of metastatic potential [87]. This may be particularly useful for the characterization of small renal masses that have indeterminate findings on CT and US or when biopsy of these masses is not feasible or is inconclusive. Active surveillance guidelines include MRI and CT as appropriate imaging modalities for the initial evaluation of growth patterns and for subsequent follow-up [2,9,11]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate. Post-treatment Follow-up of Renal Cell Carcinoma MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is an accurate method for the detection and characterization of small localized renal masses. Different sequences, including T2-weighted, chemical shift T1-weighted, contrast- enhanced T1-weighted, and diffusion-weighted images, can help distinguish RCC from other benign and malignant lesions and distinguish the clear-cell subtype from other subtypes of RCC. Some MRI features of renal masses beyond size and growth rates can also be used to determine tumor aggressiveness and risk of metastatic potential [87]. This may be particularly useful for the characterization of small renal masses that have indeterminate findings on CT and US or when biopsy of these masses is not feasible or is inconclusive. Active surveillance guidelines include MRI and CT as appropriate imaging modalities for the initial evaluation of growth patterns and for subsequent follow-up [2,9,11]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate.

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Some MRI features of renal masses beyond size and growth rates can also be used to determine tumor aggressiveness and risk of metastatic potential [87]. This may be particularly useful for the characterization of small renal masses that have indeterminate findings on CT and US or when biopsy of these masses is not feasible or is inconclusive. Active surveillance guidelines include MRI and CT as appropriate imaging modalities for the initial evaluation of growth patterns and for subsequent follow-up [2,9,11]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate. Post-treatment Follow-up of Renal Cell Carcinoma MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is an accurate method for the detection and characterization of small localized renal masses. Different sequences, including T2-weighted, chemical shift T1-weighted, contrast- enhanced T1-weighted, and diffusion-weighted images, can help distinguish RCC from other benign and malignant lesions and distinguish the clear-cell subtype from other subtypes of RCC. Some MRI features of renal masses beyond size and growth rates can also be used to determine tumor aggressiveness and risk of metastatic potential [87]. This may be particularly useful for the characterization of small renal masses that have indeterminate findings on CT and US or when biopsy of these masses is not feasible or is inconclusive. Active surveillance guidelines include MRI and CT as appropriate imaging modalities for the initial evaluation of growth patterns and for subsequent follow-up [2,9,11]. For patients in whom contrast is contraindicated (eg, previous anaphylactic reaction), MRI of the abdomen without IV contrast may be considered appropriate.

69365

acrac_69365_23

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma

Although MRI of the abdomen can be useful for characterization and follow-up of small localized renal masses undergoing active surveillance, the benefit of imaging the pelvis during surveillance has not yet been defined and is considered optional in the guidelines [2,9,11]. There is no relevant literature regarding the use of MRI of the pelvis in the follow-up of patients on active surveillance, although data from 2 retrospective studies evaluating RCC staging with CT suggested that imaging of the pelvis had limited benefit for the detection of metastases [33,34]. Furthermore, metastatic progression occurs infrequently in patients on active surveillance with T1a renal masses [8,75-78,81,82]; therefore, MRI of the abdomen is preferred over MRI of the abdomen and pelvis. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, active surveillance protocols for small localized renal masses have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. MRU There is no relevant literature regarding the use of MRU in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11]. US Kidney Retroperitoneal US of the kidney is an acceptable imaging modality for follow-up of small localized renal masses on active surveillance, especially once the growth rate of the renal mass has been established with CT or MRI [2,9,11,78]. US is an excellent method for characterizing cystic lesions and often provides supplementary information to the other imaging modalities. However, unenhanced US has an overall diagnostic accuracy for characterizing renal masses of only 30% [88].

Post Treatment Follow up and Active Surveillance of Renal Cell Carcinoma. Although MRI of the abdomen can be useful for characterization and follow-up of small localized renal masses undergoing active surveillance, the benefit of imaging the pelvis during surveillance has not yet been defined and is considered optional in the guidelines [2,9,11]. There is no relevant literature regarding the use of MRI of the pelvis in the follow-up of patients on active surveillance, although data from 2 retrospective studies evaluating RCC staging with CT suggested that imaging of the pelvis had limited benefit for the detection of metastases [33,34]. Furthermore, metastatic progression occurs infrequently in patients on active surveillance with T1a renal masses [8,75-78,81,82]; therefore, MRI of the abdomen is preferred over MRI of the abdomen and pelvis. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, active surveillance protocols for small localized renal masses have not supported routine imaging of the brain to search for metastases in asymptomatic patients. Brain imaging should be performed only in cases with suggestive signs or symptoms [2,9,11]. MRU There is no relevant literature regarding the use of MRU in the surveillance of small localized renal masses, and this method is not recommended by the guidelines [2,9,11]. US Kidney Retroperitoneal US of the kidney is an acceptable imaging modality for follow-up of small localized renal masses on active surveillance, especially once the growth rate of the renal mass has been established with CT or MRI [2,9,11,78]. US is an excellent method for characterizing cystic lesions and often provides supplementary information to the other imaging modalities. However, unenhanced US has an overall diagnostic accuracy for characterizing renal masses of only 30% [88].

69365

acrac_69452_0

Intensive Care Unit Patients

In a prospective study of 253 LUS examinations performed for unexplained deterioration of arterial blood gases, the management was changed directly as a result of information provided by the LUS in 119 out of 253 cases (47%) [3]. In a study by Phillips and Manning [4], a total of 102 chest radiographs and pocket US examinations were performed in 66 patients in the coronary care unit. The pocket US demonstrated overall good concordance with chest radiographs ranging from 77% for pleural effusion to 92% for pneumonia. Additionally, the pocket US examination appeared to anticipate resolution of pulmonary edema prior to the chest radiographs. Compared with transthoracic echocardiography, pocket US had excellent sensitivity for cardiac findings with values ranging from 85% for left atrial enlargement to 100% for cardiomegaly but had limited specificity of cardiomegaly at just 51% [4]. A meta-analysis that included 10 full-text studies that included 543 patients in evaluating the diagnostic accuracy of chest radiographs, and when concomitantly studied LUS, in comparison with CT as the reference standard, for Intensive Care Unit Patients OR Discussion of Procedures by Variant Variant 1: Admission or transfer to intensive care unit. Initial imaging. Radiography Chest Portable The strategy of ordering daily routine chest radiographs for critically ill and mechanically ventilated patients is slowly changing from daily chest radiographs to on-demand radiographs only. In a study evaluating the practice of chest radiographs in a Dutch ICU by Tolsma et al [6], 61% of the responding ICUs were said to never perform chest radiographs on a routine basis and that only 7% of responding ICUs were currently performing daily routine chest radiographs for all patients.

Intensive Care Unit Patients. In a prospective study of 253 LUS examinations performed for unexplained deterioration of arterial blood gases, the management was changed directly as a result of information provided by the LUS in 119 out of 253 cases (47%) [3]. In a study by Phillips and Manning [4], a total of 102 chest radiographs and pocket US examinations were performed in 66 patients in the coronary care unit. The pocket US demonstrated overall good concordance with chest radiographs ranging from 77% for pleural effusion to 92% for pneumonia. Additionally, the pocket US examination appeared to anticipate resolution of pulmonary edema prior to the chest radiographs. Compared with transthoracic echocardiography, pocket US had excellent sensitivity for cardiac findings with values ranging from 85% for left atrial enlargement to 100% for cardiomegaly but had limited specificity of cardiomegaly at just 51% [4]. A meta-analysis that included 10 full-text studies that included 543 patients in evaluating the diagnostic accuracy of chest radiographs, and when concomitantly studied LUS, in comparison with CT as the reference standard, for Intensive Care Unit Patients OR Discussion of Procedures by Variant Variant 1: Admission or transfer to intensive care unit. Initial imaging. Radiography Chest Portable The strategy of ordering daily routine chest radiographs for critically ill and mechanically ventilated patients is slowly changing from daily chest radiographs to on-demand radiographs only. In a study evaluating the practice of chest radiographs in a Dutch ICU by Tolsma et al [6], 61% of the responding ICUs were said to never perform chest radiographs on a routine basis and that only 7% of responding ICUs were currently performing daily routine chest radiographs for all patients.

69452

acrac_69452_1

Intensive Care Unit Patients

In this study, they asked the intensivists to judge the clinical value (therapeutic efficacy) of routine and on-demand chest radiographs and to judge the value of an established radiologic evaluation with a radiologist and asked them to state some indications for routine chest radiographs. The therapeutic efficacy of routine chest radiographs was between 10% and 20% compared with that between 10% and 60% for on-demand chest radiographs. In a prospective study by Mets et al [7] and a meta-analysis by Ganapathy et al [8], elimination of daily routine chest radiographs and a restrictive approach with chest radiographs performed to investigate clinical changes among critically ill patients led to a decrease in the total number of chest radiographs obtained per patient per day in the ICU, and, without negative influence on length of stay in the ICU and hospital, a decrease in the readmission rate. A study from a university hospital in British Columbia, Canada, evaluated their quality improvement initiative to reduce daily chest radiographs in the ICU. The authors observed that education, reminders of appropriate indications, and computerized decision support were effective in decreasing the number of routine chest radiographs in an ICU by 26%. There were no differences between the periods in age, sex, or severity of illness (Acute Physiology and Chronic Health Evaluation [APACHE] II score) of the patients, number of chest CTs, mechanical ventilator days, length of ICU stay, and ICU or hospital mortality [9]. Another study by Tolsma et al [10] with a total of 1,102 consecutive cardiac surgery patients showed that the diagnostic efficacy of chest radiographs for major abnormalities was higher for the postoperative on-demand chest radiographs (n = 301; 27%) than for the routine chest radiographs taken the morning after surgery (n = 801; 73%) Intensive Care Unit Patients (6.6% versus 2.7%, P = . 004).

Intensive Care Unit Patients. In this study, they asked the intensivists to judge the clinical value (therapeutic efficacy) of routine and on-demand chest radiographs and to judge the value of an established radiologic evaluation with a radiologist and asked them to state some indications for routine chest radiographs. The therapeutic efficacy of routine chest radiographs was between 10% and 20% compared with that between 10% and 60% for on-demand chest radiographs. In a prospective study by Mets et al [7] and a meta-analysis by Ganapathy et al [8], elimination of daily routine chest radiographs and a restrictive approach with chest radiographs performed to investigate clinical changes among critically ill patients led to a decrease in the total number of chest radiographs obtained per patient per day in the ICU, and, without negative influence on length of stay in the ICU and hospital, a decrease in the readmission rate. A study from a university hospital in British Columbia, Canada, evaluated their quality improvement initiative to reduce daily chest radiographs in the ICU. The authors observed that education, reminders of appropriate indications, and computerized decision support were effective in decreasing the number of routine chest radiographs in an ICU by 26%. There were no differences between the periods in age, sex, or severity of illness (Acute Physiology and Chronic Health Evaluation [APACHE] II score) of the patients, number of chest CTs, mechanical ventilator days, length of ICU stay, and ICU or hospital mortality [9]. Another study by Tolsma et al [10] with a total of 1,102 consecutive cardiac surgery patients showed that the diagnostic efficacy of chest radiographs for major abnormalities was higher for the postoperative on-demand chest radiographs (n = 301; 27%) than for the routine chest radiographs taken the morning after surgery (n = 801; 73%) Intensive Care Unit Patients (6.6% versus 2.7%, P = . 004).

69452

acrac_69452_2

Intensive Care Unit Patients

They concluded that defining clear indications for selective chest radiographs after cardiac surgery is effective and seems to be safe. This approach can significantly reduce the total number of chest radiographs performed and increase their efficacy. Current evidence shows that chest radiographs could be forgone after lung resection because on-demand chest radiographs based on clinical monitoring have a better impact on management and have not proved to negatively affect patient outcomes [11]. The authors, however, noted that their results question the current use of chest radiograph as the first-line diagnostic modality for critically ill patients with respiratory symptoms as LUS seems to be a good alternative. Larger trials that compare chest radiograph with LUS not only for accuracy but also for effects on outcome, clinical utility, and ease of implementation are needed [5,12]. In another study of 253 LUS examinations, patient management was changed directly as a result of information provided by the LUS in 119 out of 253 cases (47%) [3]. In 81 cases, the change in patient management involved invasive interventions (chest tube, bronchoscopy, diagnostic thoracentesis/fluid drainage, continuous venous- venous hemofiltration, abdominal decompression, tracheotomy), and in 38 cases, noninvasive interventions (PEEP in bed position, antibiotics change/titration, recruitment maneuver, diuretics, physiotherapy, change initiation/change). In 21%, the LUS revealed findings not suspected by the primary physician (7 cases of pneumothorax, 9 cases of significant pleural effusion, 9 cases of pneumonia, 16 cases of unilateral atelectasis, and 12 cases of diffuse interstitial syndrome). It was concluded that, thoracic US has similar diagnostic accuracy to CT in pleural effusion, consolidation, and pneumothorax [3]. Variant 2: Stable intensive care unit patient. No change in clinical status. Initial imaging.

Intensive Care Unit Patients. They concluded that defining clear indications for selective chest radiographs after cardiac surgery is effective and seems to be safe. This approach can significantly reduce the total number of chest radiographs performed and increase their efficacy. Current evidence shows that chest radiographs could be forgone after lung resection because on-demand chest radiographs based on clinical monitoring have a better impact on management and have not proved to negatively affect patient outcomes [11]. The authors, however, noted that their results question the current use of chest radiograph as the first-line diagnostic modality for critically ill patients with respiratory symptoms as LUS seems to be a good alternative. Larger trials that compare chest radiograph with LUS not only for accuracy but also for effects on outcome, clinical utility, and ease of implementation are needed [5,12]. In another study of 253 LUS examinations, patient management was changed directly as a result of information provided by the LUS in 119 out of 253 cases (47%) [3]. In 81 cases, the change in patient management involved invasive interventions (chest tube, bronchoscopy, diagnostic thoracentesis/fluid drainage, continuous venous- venous hemofiltration, abdominal decompression, tracheotomy), and in 38 cases, noninvasive interventions (PEEP in bed position, antibiotics change/titration, recruitment maneuver, diuretics, physiotherapy, change initiation/change). In 21%, the LUS revealed findings not suspected by the primary physician (7 cases of pneumothorax, 9 cases of significant pleural effusion, 9 cases of pneumonia, 16 cases of unilateral atelectasis, and 12 cases of diffuse interstitial syndrome). It was concluded that, thoracic US has similar diagnostic accuracy to CT in pleural effusion, consolidation, and pneumothorax [3]. Variant 2: Stable intensive care unit patient. No change in clinical status. Initial imaging.

69452

acrac_69452_3

Intensive Care Unit Patients

Radiography Chest Portable Unexpected findings on chest radiographs were noted in <6% of the 2,457 daily routine radiographs that were ordered in 754 consecutive ICU patients in a mixed medical-surgical ICU [13]. In a cross-sectional study of ICUs in hospitals in Saudi Arabia, the daily routine chest radiograph was performed in almost 96.8% of ICU patients. However, a majority of the clinical staff members (73%) thought that this current daily routine chest radiographs protocol in the ICUs should be replaced with the on-demand chest radiographs policy. They observed that intensivists support the change of the current practice of daily chest radiographs and recommend an on-demand chest radiographs policy likely to be followed in intensive care management [14]. In a survey of Dutch intensivists on the current practice of chest radiography in their departments, only 7% of responding ICUs to the survey were currently performing daily routine chest radiographs for all patients, and 61% of the responding ICUs reported never performing chest radiographs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine chest radiographs was assumed by intensivists to be between 10% and 20% compared with 10% and 60% for on-demand chest radiographs. Therapeutic efficacy was defined as the percentage of chest radiograph findings that resulted in a subsequent change in patient management. There was a consensus between intensivists to perform a routine chest radiograph after endotracheal intubation, chest tube placement, or central venous catheterization, and for diagnostic workups for pneumonia, acute respiratory distress

Intensive Care Unit Patients. Radiography Chest Portable Unexpected findings on chest radiographs were noted in <6% of the 2,457 daily routine radiographs that were ordered in 754 consecutive ICU patients in a mixed medical-surgical ICU [13]. In a cross-sectional study of ICUs in hospitals in Saudi Arabia, the daily routine chest radiograph was performed in almost 96.8% of ICU patients. However, a majority of the clinical staff members (73%) thought that this current daily routine chest radiographs protocol in the ICUs should be replaced with the on-demand chest radiographs policy. They observed that intensivists support the change of the current practice of daily chest radiographs and recommend an on-demand chest radiographs policy likely to be followed in intensive care management [14]. In a survey of Dutch intensivists on the current practice of chest radiography in their departments, only 7% of responding ICUs to the survey were currently performing daily routine chest radiographs for all patients, and 61% of the responding ICUs reported never performing chest radiographs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine chest radiographs was assumed by intensivists to be between 10% and 20% compared with 10% and 60% for on-demand chest radiographs. Therapeutic efficacy was defined as the percentage of chest radiograph findings that resulted in a subsequent change in patient management. There was a consensus between intensivists to perform a routine chest radiograph after endotracheal intubation, chest tube placement, or central venous catheterization, and for diagnostic workups for pneumonia, acute respiratory distress

69452

acrac_69452_4

Intensive Care Unit Patients

In a systematic review and meta-analysis by Ganapathy et al [8] and Mets et al [7] in cardiothoracic surgery patients in the ICU and the post-ICU did not observe any negative influence of on-demand chest radiographs on length of stay in the ICU and hospital, and readmission rate. However, Ganapathy et al [8] observed that CIs were wide and harm was not rigorously assessed. Therefore, they concluded that the safety of abandoning routine chest radiographs in patients admitted to the ICU remains uncertain and mandates further investigation. Current evidence shows that routine daily chest radiographs are not necessary after lung resection because daily imaging in nonhypoxic patients is unlikely to lead to clinically impactful changes in care [15] and because on- demand chest radiographs based on clinical monitoring have a better impact on management without negatively affecting patient outcomes [11]. In another study of 253 LUS examinations, the management was changed directly as a result of information provided by the LUS in 119 out of 253 cases (47%) [3]. In 81 cases, the change in patient management involved invasive interventions, and in 21% of cases, the LUS revealed findings not suspected by the primary physician such as pneumothorax, significant pleural effusion, pneumonia, unilateral atelectasis, and diffuse interstitial syndrome. It was concluded that thoracic US has similar diagnostic accuracy to CT in pleural effusion, consolidation, and pneumothorax [3]. Variant 3: Intensive care unit patient with clinically worsening condition. Initial imaging. Radiography Chest Portable In a survey of Dutch intensivists, there was a consensus between intensivists to perform a routine chest radiograph after endotracheal intubation, chest tube placement, or CVC as well as for diagnostic workups for pneumonia, ARDS, or pneumothorax [6].

Intensive Care Unit Patients. In a systematic review and meta-analysis by Ganapathy et al [8] and Mets et al [7] in cardiothoracic surgery patients in the ICU and the post-ICU did not observe any negative influence of on-demand chest radiographs on length of stay in the ICU and hospital, and readmission rate. However, Ganapathy et al [8] observed that CIs were wide and harm was not rigorously assessed. Therefore, they concluded that the safety of abandoning routine chest radiographs in patients admitted to the ICU remains uncertain and mandates further investigation. Current evidence shows that routine daily chest radiographs are not necessary after lung resection because daily imaging in nonhypoxic patients is unlikely to lead to clinically impactful changes in care [15] and because on- demand chest radiographs based on clinical monitoring have a better impact on management without negatively affecting patient outcomes [11]. In another study of 253 LUS examinations, the management was changed directly as a result of information provided by the LUS in 119 out of 253 cases (47%) [3]. In 81 cases, the change in patient management involved invasive interventions, and in 21% of cases, the LUS revealed findings not suspected by the primary physician such as pneumothorax, significant pleural effusion, pneumonia, unilateral atelectasis, and diffuse interstitial syndrome. It was concluded that thoracic US has similar diagnostic accuracy to CT in pleural effusion, consolidation, and pneumothorax [3]. Variant 3: Intensive care unit patient with clinically worsening condition. Initial imaging. Radiography Chest Portable In a survey of Dutch intensivists, there was a consensus between intensivists to perform a routine chest radiograph after endotracheal intubation, chest tube placement, or CVC as well as for diagnostic workups for pneumonia, ARDS, or pneumothorax [6].

69452

acrac_69452_5

Intensive Care Unit Patients

In a prospective, single-blind study of 192 critically ill patients, each patient received a LUS examination, a bedside chest radiograph, followed by a thoracic CT scan searching for pneumothorax, CT of the chest confirmed the diagnosis of pneumothorax in 36 (18.75%) patients of which 31 were diagnosed by thoracic US and chest radiograph detected only 19 cases. Overall, LUS showed a considerably higher sensitivity than bedside chest radiograph (86.1% versus 52.7%). LUS also showed higher negative predictive values and diagnostic accuracy compared with chest radiograph (96.8% versus 90.1% and 95.3% versus 90.6%, respectively). Chest radiographs had a slightly higher specificity than LUS (99.4% versus 97.4%) as well as higher positive predictive values (95.0% versus 88.6%) [16]. Intensive Care Unit Patients A meta-analysis showed that the diagnostic accuracy of chest US was higher than supine chest radiographs for detection of pneumothorax. It seems that chest US is superior to chest radiographs in detection of pneumothorax, even after adjusting for possible sources of heterogeneity [5,12,16,17]. LUS is also a valid tool in excluding pneumothoraces after lung biopsy in postlung transplant patients [18]. In a multicenter prospective study of 99 patients with suspected ventilator-associated pneumonia, the diagnostic performance of LUS findings of infection with direct microbiologic examination of endotracheal aspirates showed that LUS had a positive predictive value of 86% to 94% [19,20]. LUS showed better sensitivity and specificity than chest radiography for the diagnosis of pleural effusion and also helped distinguish between different forms of effusions, guide thoracentesis, and insertion of chest tubes [21]. LUS could also monitor the volume of effusion drained to help decide removal of the drainage [21].

Intensive Care Unit Patients. In a prospective, single-blind study of 192 critically ill patients, each patient received a LUS examination, a bedside chest radiograph, followed by a thoracic CT scan searching for pneumothorax, CT of the chest confirmed the diagnosis of pneumothorax in 36 (18.75%) patients of which 31 were diagnosed by thoracic US and chest radiograph detected only 19 cases. Overall, LUS showed a considerably higher sensitivity than bedside chest radiograph (86.1% versus 52.7%). LUS also showed higher negative predictive values and diagnostic accuracy compared with chest radiograph (96.8% versus 90.1% and 95.3% versus 90.6%, respectively). Chest radiographs had a slightly higher specificity than LUS (99.4% versus 97.4%) as well as higher positive predictive values (95.0% versus 88.6%) [16]. Intensive Care Unit Patients A meta-analysis showed that the diagnostic accuracy of chest US was higher than supine chest radiographs for detection of pneumothorax. It seems that chest US is superior to chest radiographs in detection of pneumothorax, even after adjusting for possible sources of heterogeneity [5,12,16,17]. LUS is also a valid tool in excluding pneumothoraces after lung biopsy in postlung transplant patients [18]. In a multicenter prospective study of 99 patients with suspected ventilator-associated pneumonia, the diagnostic performance of LUS findings of infection with direct microbiologic examination of endotracheal aspirates showed that LUS had a positive predictive value of 86% to 94% [19,20]. LUS showed better sensitivity and specificity than chest radiography for the diagnosis of pleural effusion and also helped distinguish between different forms of effusions, guide thoracentesis, and insertion of chest tubes [21]. LUS could also monitor the volume of effusion drained to help decide removal of the drainage [21].

69452

acrac_69452_6

Intensive Care Unit Patients

Evaluation of the performance of a rapid cardiothoracic US protocol, which combines echocardiographically derived E/e' and LUS, for diagnosing acute heart failure in patients with undifferentiated dyspnea in an emergency department showed that the rapid cardiothoracic US protocol provided excellent accuracy for diagnosing acute heart failure [22]. In a prospective, single-center study in the ICU, pulse oximetry and pulmonary US were found to be useful tools to screen for, or rule out, impaired oxygenation or lung abnormalities consistent with ARDS in underresourced settings in which arterial blood gas testing and chest radiography are not readily available [23]. In a prospective, single-center study, combining SpO2/FiO2 with US was found to be a useful tools in screening for, or ruling out, impaired oxygenation or lung abnormalities consistent with ARDS criteria in underresourced settings where arterial blood gas testing and chest radiography are not readily available [23]. Variant 4: Intensive care unit patient following support device placement. Initial imaging. Radiography Chest Portable Endotracheal Tube Placement Since 1980, there have been only 9 studies present in the literature [24-32] that evaluate the significance of chest radiography in assessing endotracheal tube placement following insertion. In 5 studies, between 12% and 15% of patients had malpositioned endotracheal tubes, many of which required repositioning. Two studies found 28% and 46% of tubes malpositioned upon insertion, and the single dissenting paper found that only 2% were malpositioned. Two studies compared radiographs with physical examination [24,33]. In both studies, physical examination predicted malpositioned tubes in 3% of patients, whereas the radiographs showed malpositioning in 14% of patients in one study and 28% in the other [24,33]. Kollef et al [34] found that the vast majority of malpositioned tubes were discovered in the first 3 days.

Intensive Care Unit Patients. Evaluation of the performance of a rapid cardiothoracic US protocol, which combines echocardiographically derived E/e' and LUS, for diagnosing acute heart failure in patients with undifferentiated dyspnea in an emergency department showed that the rapid cardiothoracic US protocol provided excellent accuracy for diagnosing acute heart failure [22]. In a prospective, single-center study in the ICU, pulse oximetry and pulmonary US were found to be useful tools to screen for, or rule out, impaired oxygenation or lung abnormalities consistent with ARDS in underresourced settings in which arterial blood gas testing and chest radiography are not readily available [23]. In a prospective, single-center study, combining SpO2/FiO2 with US was found to be a useful tools in screening for, or ruling out, impaired oxygenation or lung abnormalities consistent with ARDS criteria in underresourced settings where arterial blood gas testing and chest radiography are not readily available [23]. Variant 4: Intensive care unit patient following support device placement. Initial imaging. Radiography Chest Portable Endotracheal Tube Placement Since 1980, there have been only 9 studies present in the literature [24-32] that evaluate the significance of chest radiography in assessing endotracheal tube placement following insertion. In 5 studies, between 12% and 15% of patients had malpositioned endotracheal tubes, many of which required repositioning. Two studies found 28% and 46% of tubes malpositioned upon insertion, and the single dissenting paper found that only 2% were malpositioned. Two studies compared radiographs with physical examination [24,33]. In both studies, physical examination predicted malpositioned tubes in 3% of patients, whereas the radiographs showed malpositioning in 14% of patients in one study and 28% in the other [24,33]. Kollef et al [34] found that the vast majority of malpositioned tubes were discovered in the first 3 days.

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acrac_69452_7

Intensive Care Unit Patients

Endotracheal tube repositioning based on measurement at the incisors is inaccurate and the magnitude of the intervention does not correlate with the degree of error. Repositioning of endotracheal tubes based on measurements at the incisors should be abandoned; if not abandoned, follow-up chest radiograph images are recommended [35]. Routine daily imaging of patients with tracheostomy in an ICU provides little clinical utility, and chest radiographs in this population should be performed selectively based on the patient's clinical status. In one study of 761 chest radiographs, only 18 (2.3%) radiographs revealed new complications [36]. All complications were clinically suspected prior to imaging. Only 5 (0.7%) complications resulted in a management change. The most common management changes were a change in antibiotic regimen (0.3%) and ordering of diuretics (0.3%) [36]. Studies evaluating the efficacy of deep learning systems with deep convolutional neural networks were accurate to detect presence versus absence of an endotracheal tube, but deep convolutional neural networks did not perform as well and achieved only reasonable accuracy for differentiating low versus normal positioning of the endotracheal tube [37]. Central Venous Catheter Eight studies were reviewed regarding CVC [24-26,28-30,32,34]. The majority came to the same conclusion: chest radiographs following catheter insertion are useful, with approximately 10% of the chest radiographs demonstrating Intensive Care Unit Patients malpositioned catheters. Pneumothoraces were present in only a small percentage of patients. Gray et al [24] separated jugular and subclavian catheters. Complications were twice as common with subclavian catheters (17% versus 8%), although unsuspected complications were infrequent.

Intensive Care Unit Patients. Endotracheal tube repositioning based on measurement at the incisors is inaccurate and the magnitude of the intervention does not correlate with the degree of error. Repositioning of endotracheal tubes based on measurements at the incisors should be abandoned; if not abandoned, follow-up chest radiograph images are recommended [35]. Routine daily imaging of patients with tracheostomy in an ICU provides little clinical utility, and chest radiographs in this population should be performed selectively based on the patient's clinical status. In one study of 761 chest radiographs, only 18 (2.3%) radiographs revealed new complications [36]. All complications were clinically suspected prior to imaging. Only 5 (0.7%) complications resulted in a management change. The most common management changes were a change in antibiotic regimen (0.3%) and ordering of diuretics (0.3%) [36]. Studies evaluating the efficacy of deep learning systems with deep convolutional neural networks were accurate to detect presence versus absence of an endotracheal tube, but deep convolutional neural networks did not perform as well and achieved only reasonable accuracy for differentiating low versus normal positioning of the endotracheal tube [37]. Central Venous Catheter Eight studies were reviewed regarding CVC [24-26,28-30,32,34]. The majority came to the same conclusion: chest radiographs following catheter insertion are useful, with approximately 10% of the chest radiographs demonstrating Intensive Care Unit Patients malpositioned catheters. Pneumothoraces were present in only a small percentage of patients. Gray et al [24] separated jugular and subclavian catheters. Complications were twice as common with subclavian catheters (17% versus 8%), although unsuspected complications were infrequent.

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Intensive Care Unit Patients

In a retrospective chart review in a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following US-guided right internal jugular vein catheterization is exceedingly low. A routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients [38]. In 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian [39]. No cases of pneumothorax or hemothorax were identified, and 15.3% of CVCs were improperly positioned. Only one (0.5%) of these was deemed clinically significant and repositioned after the chest radiograph was performed. They concluded that routine chest radiographs consume valuable time and resources and rarely affect management. Selection should be guided by clinical factors [39]. Swan-Ganz Catheter Previously mentioned studies incorporated the position and potential complications of Swan-Ganz catheter placements shown on chest radiographs obtained immediately postprocedure. The majority of complications, which occur in approximately 10% of catheter insertions, are minor and require catheter repositioning [24,26,29,40]. The pneumothorax rate was approximately 2% [26,40]. Central Venous Catheter In a prospective, blinded, observational study of 210 consecutive patients undergoing emergency central venous catheterization, US was compared with chest radiography to verify the correct CVC placement and to identify mechanical complications; there was a high correlation between these two modalities in identifying possible malpositioning of the catheter. However, the less time required to perform US allows earlier use of the catheter for the administration of acute therapies that can be lifesaving for critically ill patients [45]. Several studies demonstrated that LUS can reduce CVC insertion-to-use time and improve patient safety [46-48].

Intensive Care Unit Patients. In a retrospective chart review in a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following US-guided right internal jugular vein catheterization is exceedingly low. A routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients [38]. In 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian [39]. No cases of pneumothorax or hemothorax were identified, and 15.3% of CVCs were improperly positioned. Only one (0.5%) of these was deemed clinically significant and repositioned after the chest radiograph was performed. They concluded that routine chest radiographs consume valuable time and resources and rarely affect management. Selection should be guided by clinical factors [39]. Swan-Ganz Catheter Previously mentioned studies incorporated the position and potential complications of Swan-Ganz catheter placements shown on chest radiographs obtained immediately postprocedure. The majority of complications, which occur in approximately 10% of catheter insertions, are minor and require catheter repositioning [24,26,29,40]. The pneumothorax rate was approximately 2% [26,40]. Central Venous Catheter In a prospective, blinded, observational study of 210 consecutive patients undergoing emergency central venous catheterization, US was compared with chest radiography to verify the correct CVC placement and to identify mechanical complications; there was a high correlation between these two modalities in identifying possible malpositioning of the catheter. However, the less time required to perform US allows earlier use of the catheter for the administration of acute therapies that can be lifesaving for critically ill patients [45]. Several studies demonstrated that LUS can reduce CVC insertion-to-use time and improve patient safety [46-48].

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Intensive Care Unit Patients

Intensive Care Unit Patients However, in another study, contrast-enhanced US detected 11 of the 16 true catheter malpositionings. Contrast- enhanced US showed 2 false right atrium misplacements and 5 falsely correct CVC positions. They concluded that contrast-enhanced US is not a suitable alternative for standard chest radiography in detecting CVC location; however, considering its high sensitivity and acceptable specificity in our study, its usefulness as a triage method for detecting CVC location on a real-time basis in the operating room cannot be ignored [50]. A systematic review and meta-analysis to examine the accuracy of bedside US for confirmation of CVC position and exclusion of pneumothorax compared with chest radiography concluded that LUS is faster than radiography at identifying pneumothorax after CVC insertion. When a CVC malposition exists, bedside US will identify 4 out of every 5 earlier than chest radiography [51]. Swan-Ganz Catheter There is insufficient data evaluating the placement of pulmonary artery catheter. US may be used to guide insertion of a Swan-Ganz catheter. Nasogastric Tubes A pilot study confirmed the high sensitivity of US in the correct positioning of gastric tube in the adult ICU patient. The US examination seems to be easy and faster when performed by an intensivist with a sonographic training of only 40 hours [52]. A study designed to compare the effectiveness of using auscultation, pH measurements of gastric aspirates, and US as physical examination methods to verify nasogastric tube placement in emergency department patients with low consciousness in 47 patients concluded that US is useful for confirming the results of auscultation after nasogastric tube insertion among patients with low consciousness. When US findings suggest that the nasogastric tube placement is not gastric, additional chest radiographs should be performed [53]. Variant 5: Intensive care unit patient. Post chest tube or mediastinal tube removal. Initial imaging.

Intensive Care Unit Patients. Intensive Care Unit Patients However, in another study, contrast-enhanced US detected 11 of the 16 true catheter malpositionings. Contrast- enhanced US showed 2 false right atrium misplacements and 5 falsely correct CVC positions. They concluded that contrast-enhanced US is not a suitable alternative for standard chest radiography in detecting CVC location; however, considering its high sensitivity and acceptable specificity in our study, its usefulness as a triage method for detecting CVC location on a real-time basis in the operating room cannot be ignored [50]. A systematic review and meta-analysis to examine the accuracy of bedside US for confirmation of CVC position and exclusion of pneumothorax compared with chest radiography concluded that LUS is faster than radiography at identifying pneumothorax after CVC insertion. When a CVC malposition exists, bedside US will identify 4 out of every 5 earlier than chest radiography [51]. Swan-Ganz Catheter There is insufficient data evaluating the placement of pulmonary artery catheter. US may be used to guide insertion of a Swan-Ganz catheter. Nasogastric Tubes A pilot study confirmed the high sensitivity of US in the correct positioning of gastric tube in the adult ICU patient. The US examination seems to be easy and faster when performed by an intensivist with a sonographic training of only 40 hours [52]. A study designed to compare the effectiveness of using auscultation, pH measurements of gastric aspirates, and US as physical examination methods to verify nasogastric tube placement in emergency department patients with low consciousness in 47 patients concluded that US is useful for confirming the results of auscultation after nasogastric tube insertion among patients with low consciousness. When US findings suggest that the nasogastric tube placement is not gastric, additional chest radiographs should be performed [53]. Variant 5: Intensive care unit patient. Post chest tube or mediastinal tube removal. Initial imaging.

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Management of Vertebral Compression Fractures PCAs

Introduction/Background Vertebral compression fractures (VCFs) can be caused by benign clinical conditions such as osteoporosis, metabolic disorders, congenital disorders, infections, and acute trauma or neoplasms. Neoplasms may incorporate primary/secondary bone tumors and myeloma. Painful VCFs may cause a marked decline in physical activity and quality of life, leading to general physical deconditioning with increased psychological distress. This physical deconditioning, in turn, may prompt further complications related to poor inspiratory effort (ie, atelectasis and pneumonia) [1] and venous stasis (ie, deep venous thrombosis and pulmonary embolism) [2]. Successful and timely management of painful VCFs can improve quality of life, increase the likelihood of an independent and productive life, and prevent superimposed medical complications. This document addresses the management of both osteoporotic and pathologic VCFs. Neoplasms causing VCFs include 1) primary benign bone neoplasms, such as hemangioma (aggressive type) or giant cell tumors [11], and tumor-like conditions causing bony and cellular remodeling, such as aneurysmal bone cysts, or Paget disease (osteitis deformans); 2) primary malignant neoplasms including but not limited to multiple myeloma and lymphoma; and 3) metastatic neoplasms [2,12,13]. Because the literature has focused predominantly aThomas Jefferson University Hospital, Philadelphia, Pennsylvania. bResearch Author, Washington University, Saint Louis, Missouri. cMallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri. dFroedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin. ePanel Chair, University of Utah, Salt Lake City, Utah. fPanel Chair, University of Wisconsin, Madison, Wisconsin. gPanel Chair, Mayo Clinic, Jacksonville, Florida. hPanel Vice-Chair, Duke University Medical Center, Durham, North Carolina.

Management of Vertebral Compression Fractures PCAs. Introduction/Background Vertebral compression fractures (VCFs) can be caused by benign clinical conditions such as osteoporosis, metabolic disorders, congenital disorders, infections, and acute trauma or neoplasms. Neoplasms may incorporate primary/secondary bone tumors and myeloma. Painful VCFs may cause a marked decline in physical activity and quality of life, leading to general physical deconditioning with increased psychological distress. This physical deconditioning, in turn, may prompt further complications related to poor inspiratory effort (ie, atelectasis and pneumonia) [1] and venous stasis (ie, deep venous thrombosis and pulmonary embolism) [2]. Successful and timely management of painful VCFs can improve quality of life, increase the likelihood of an independent and productive life, and prevent superimposed medical complications. This document addresses the management of both osteoporotic and pathologic VCFs. Neoplasms causing VCFs include 1) primary benign bone neoplasms, such as hemangioma (aggressive type) or giant cell tumors [11], and tumor-like conditions causing bony and cellular remodeling, such as aneurysmal bone cysts, or Paget disease (osteitis deformans); 2) primary malignant neoplasms including but not limited to multiple myeloma and lymphoma; and 3) metastatic neoplasms [2,12,13]. Because the literature has focused predominantly aThomas Jefferson University Hospital, Philadelphia, Pennsylvania. bResearch Author, Washington University, Saint Louis, Missouri. cMallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri. dFroedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin. ePanel Chair, University of Utah, Salt Lake City, Utah. fPanel Chair, University of Wisconsin, Madison, Wisconsin. gPanel Chair, Mayo Clinic, Jacksonville, Florida. hPanel Vice-Chair, Duke University Medical Center, Durham, North Carolina.

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Management of Vertebral Compression Fractures PCAs

iPanel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina. jPanel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri. kDeaconess Hospital, Evansville, Indiana; American College of Emergency Physicians. lUniversity of Washington School of Medicine, Seattle, Washington; Commission on Radiation Oncology. mBrigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts; American Association of Neurological Surgeons/Congress of Neurological Surgeons. nBrigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER. oMedical University of South Carolina, Charleston, South Carolina; North American Spine Society. pSunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Commission on Radiation Oncology. qMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. rMallinckrodt Institute of Radiology, Saint Louis, Missouri, Primary care physician. sSpecialty Chair, University of Kentucky, Lexington, Kentucky. tSpecialty Chair, University of Michigan, Ann Arbor, Michigan. uSpecialty Chair, Montefiore Medical Center, Bronx, New York. 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] Vertebral Compression Fractures on VCFs due to metastatic disease, this document focuses on the management of pathological VCFs secondary to metastatic disease. However, it should be noted that treatment can vary depending on tumor type. Special Treatment Considerations VA is a generic term that includes percutaneous VP, balloon-assisted kyphoplasty (BK) [2], and other implantable methods of VA [17-20].

Management of Vertebral Compression Fractures PCAs. iPanel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina. jPanel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri. kDeaconess Hospital, Evansville, Indiana; American College of Emergency Physicians. lUniversity of Washington School of Medicine, Seattle, Washington; Commission on Radiation Oncology. mBrigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts; American Association of Neurological Surgeons/Congress of Neurological Surgeons. nBrigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER. oMedical University of South Carolina, Charleston, South Carolina; North American Spine Society. pSunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Commission on Radiation Oncology. qMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. rMallinckrodt Institute of Radiology, Saint Louis, Missouri, Primary care physician. sSpecialty Chair, University of Kentucky, Lexington, Kentucky. tSpecialty Chair, University of Michigan, Ann Arbor, Michigan. uSpecialty Chair, Montefiore Medical Center, Bronx, New York. 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] Vertebral Compression Fractures on VCFs due to metastatic disease, this document focuses on the management of pathological VCFs secondary to metastatic disease. However, it should be noted that treatment can vary depending on tumor type. Special Treatment Considerations VA is a generic term that includes percutaneous VP, balloon-assisted kyphoplasty (BK) [2], and other implantable methods of VA [17-20].

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Management of Vertebral Compression Fractures PCAs

These procedures, the majority of which are described in the lumbar and thoracic spine, are used for the palliation of pain related to VCFs and have been shown to be effective compared to medical management [13,21-23]. Minimally invasive percutaneous image-guided techniques for treating spine tumors include newer technologies, such as radiofrequency ablation (RFA) [37], cryoablation, microwave ablation, alcohol ablation, and laser photocoagulation. These modalities provide an alternative or adjunct therapeutic option for treating spinal tumors beyond medical pain management, surgery, radiation therapy (RT), and standard VA. Curative ablation can be applied to treat specific benign or selected cases of malignant oligometastatic spinal tumors. Pain palliation of primary and secondary bone tumors is also possible with ablation (chemical, thermal, mechanical), cavitation (radiofrequency ionization), and consolidation (VP, BK) techniques performed separately or in combination. Discussion of Procedures by Variant Variant 1: New symptomatic vertebral compression fracture (VCF) identified on radiographs. No known malignancy. Next imaging study. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. For some authors, focal tenderness upon palpation in correlation with radiographs of the vertebral column is a satisfactory indication for intervention. However, spine radiographs are often nonspecific with respect to the acuity or cause of the vertebral fracture [38]. CT Spine Area of Interest CT provides osseous details of axial spine fractures before VA [12,39].

Management of Vertebral Compression Fractures PCAs. These procedures, the majority of which are described in the lumbar and thoracic spine, are used for the palliation of pain related to VCFs and have been shown to be effective compared to medical management [13,21-23]. Minimally invasive percutaneous image-guided techniques for treating spine tumors include newer technologies, such as radiofrequency ablation (RFA) [37], cryoablation, microwave ablation, alcohol ablation, and laser photocoagulation. These modalities provide an alternative or adjunct therapeutic option for treating spinal tumors beyond medical pain management, surgery, radiation therapy (RT), and standard VA. Curative ablation can be applied to treat specific benign or selected cases of malignant oligometastatic spinal tumors. Pain palliation of primary and secondary bone tumors is also possible with ablation (chemical, thermal, mechanical), cavitation (radiofrequency ionization), and consolidation (VP, BK) techniques performed separately or in combination. Discussion of Procedures by Variant Variant 1: New symptomatic vertebral compression fracture (VCF) identified on radiographs. No known malignancy. Next imaging study. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information, including prior imaging. For some authors, focal tenderness upon palpation in correlation with radiographs of the vertebral column is a satisfactory indication for intervention. However, spine radiographs are often nonspecific with respect to the acuity or cause of the vertebral fracture [38]. CT Spine Area of Interest CT provides osseous details of axial spine fractures before VA [12,39].

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Management of Vertebral Compression Fractures PCAs

CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with cortical disruption, posterior cortex osseous retropulsion, and spinal canal compression. Comparison to prior imaging is helpful to determine acuity. Dual-energy CT may show bone marrow edema with reasonably high sensitivity and specificity [40,41] and good concordance to MRI in thoracolumbar VCFs [42]. Intravenous (IV) contrast does not provide additional value in this clinical scenario. Vertebral Compression Fractures CT Myelography Spine Area of Interest CT myelography is not routinely used for evaluating benign VCFs unless the patient has a neurologic deficit with suspected spinal canal compression. MRI Spine Area of Interest MRI may provide valuable information to determine the need for intervention and procedural guidance. The benefits of MRI for preprocedural planning have been reported [43-45]. Minimally deforming fractures that may not be well seen on conventional radiographs may be better detected on preprocedure MRI, mainly if the imaging evaluation is >3 months since the suspected injury or if there is a change in symptoms from the initial workup [43,46]. Fluid- sensitive MRI sequences (short tau inversion recovery or fat-saturated T2-weighted imaging) help detect and differentiate acute/subacute versus chronic fractures, identifying fracture clefts, and differentiating synchronous fractures [46,47]. MRI is also valuable for distinguishing recent from chronic vertebral fractures in patients with multiple vertebral fractures and diffuse back pain, which can at times confound the clinical examination [48,49]. However, vertebral body edema is not a precise measure of compression fracture age because the duration after an osteoporotic compression fracture is often not known with certainty. Bone marrow edema typically resolves within 1 to 3 months [50,51].

Management of Vertebral Compression Fractures PCAs. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with cortical disruption, posterior cortex osseous retropulsion, and spinal canal compression. Comparison to prior imaging is helpful to determine acuity. Dual-energy CT may show bone marrow edema with reasonably high sensitivity and specificity [40,41] and good concordance to MRI in thoracolumbar VCFs [42]. Intravenous (IV) contrast does not provide additional value in this clinical scenario. Vertebral Compression Fractures CT Myelography Spine Area of Interest CT myelography is not routinely used for evaluating benign VCFs unless the patient has a neurologic deficit with suspected spinal canal compression. MRI Spine Area of Interest MRI may provide valuable information to determine the need for intervention and procedural guidance. The benefits of MRI for preprocedural planning have been reported [43-45]. Minimally deforming fractures that may not be well seen on conventional radiographs may be better detected on preprocedure MRI, mainly if the imaging evaluation is >3 months since the suspected injury or if there is a change in symptoms from the initial workup [43,46]. Fluid- sensitive MRI sequences (short tau inversion recovery or fat-saturated T2-weighted imaging) help detect and differentiate acute/subacute versus chronic fractures, identifying fracture clefts, and differentiating synchronous fractures [46,47]. MRI is also valuable for distinguishing recent from chronic vertebral fractures in patients with multiple vertebral fractures and diffuse back pain, which can at times confound the clinical examination [48,49]. However, vertebral body edema is not a precise measure of compression fracture age because the duration after an osteoporotic compression fracture is often not known with certainty. Bone marrow edema typically resolves within 1 to 3 months [50,51].

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Management of Vertebral Compression Fractures PCAs

IV contrast is not useful because it does not add information in the setting of recent osteoporotic VCF. Bone Scan Whole Body Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae [52], particularly the causative level [53,54]. Bone scan and MRI have higher concordance with single-level fractures compared with multiple level involvements [55]. When more than one area of increased activity is detected, bone scans may overestimate the number of acute fractures. As such, multiple regions of radiotracer accumulation should be interpreted cautiously [56]. The utilization of bone scans may be based on institutional preference. SPECT or SPECT/CT Spine Area of Interest Single-photon emission computed tomography (SPECT) coupled with CT provides complementary information because sites of abnormal radiopharmaceutical uptake on the spine are of interest. SPECT images can be anatomically localized on the CT, and anatomic abnormalities on CT images can draw attention to subtle areas of SPECT tracer uptake. SPECT/CT has been shown to localize abnormalities in the vertebra more precisely compared with SPECT imaging alone, particularly in complicated cases, such as multiple collapsed vertebrae of different ages [57]. Studies have demonstrated a 63% to 80% agreement between SPECT/CT and MRI in detecting acute VCF [58,59]. Li et al [60] found that SPECT/CT is useful for imaging diagnosis of acute fractures in their study of 46 patients. FDG-PET/CT Skull Base to Mid-Thigh PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG) combined with morphologic CT imaging can noninvasively localize metabolic activity in areas of spinal infection [61-63]. Vertebral osteomyelitis may present as a compression fracture [64] and may be difficult to distinguish from noninfectious, osteoporotic VCF.

Management of Vertebral Compression Fractures PCAs. IV contrast is not useful because it does not add information in the setting of recent osteoporotic VCF. Bone Scan Whole Body Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae [52], particularly the causative level [53,54]. Bone scan and MRI have higher concordance with single-level fractures compared with multiple level involvements [55]. When more than one area of increased activity is detected, bone scans may overestimate the number of acute fractures. As such, multiple regions of radiotracer accumulation should be interpreted cautiously [56]. The utilization of bone scans may be based on institutional preference. SPECT or SPECT/CT Spine Area of Interest Single-photon emission computed tomography (SPECT) coupled with CT provides complementary information because sites of abnormal radiopharmaceutical uptake on the spine are of interest. SPECT images can be anatomically localized on the CT, and anatomic abnormalities on CT images can draw attention to subtle areas of SPECT tracer uptake. SPECT/CT has been shown to localize abnormalities in the vertebra more precisely compared with SPECT imaging alone, particularly in complicated cases, such as multiple collapsed vertebrae of different ages [57]. Studies have demonstrated a 63% to 80% agreement between SPECT/CT and MRI in detecting acute VCF [58,59]. Li et al [60] found that SPECT/CT is useful for imaging diagnosis of acute fractures in their study of 46 patients. FDG-PET/CT Skull Base to Mid-Thigh PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG) combined with morphologic CT imaging can noninvasively localize metabolic activity in areas of spinal infection [61-63]. Vertebral osteomyelitis may present as a compression fracture [64] and may be difficult to distinguish from noninfectious, osteoporotic VCF.

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Management of Vertebral Compression Fractures PCAs

Vertebral osteomyelitis may be considered in the setting of severe back pain, persistent unexplained fever, elevated inflammatory markers (ie, erythrocyte sedimentation rate), or bacteremia without a known extravertebral focus of infection, particularly if the patient is immunocompromised. Importantly, acute benign VCFs can be a source of false positive findings due to increased FDG uptake in the acute phase; however, the increased activity should return to normal in 3 months from the fracture date. If there is a failure of increased PET FDG activity in a VCF to return to normal by 3 months, clinical suspicion for malignancy or infection should remain high [65]. Variant 2: New symptomatic VCF identified on radiographs. History of malignancy. Next imaging study. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination, guided by physical examination findings, patient history, and other available information, including prior imaging. For some authors, focal tenderness upon palpation in correlation with radiographs of the vertebral column is a satisfactory indication for intervention. However, spine radiographs are often nonspecific with respect to the acuity or cause of the vertebral fracture [38]. CT Spine Area of Interest CT provides osseous details of axial spine fractures before VA [12,39]. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with Vertebral Compression Fractures cortical disruption, posterior cortex osseous retropulsion, epidural extension, and spinal canal compression. Comparison to prior imaging is helpful to determine acuity. The presence of lobulated paraspinal masses with involvement of both vertebral body and posterior elements at the same time favors malignant involvement [66].

Management of Vertebral Compression Fractures PCAs. Vertebral osteomyelitis may be considered in the setting of severe back pain, persistent unexplained fever, elevated inflammatory markers (ie, erythrocyte sedimentation rate), or bacteremia without a known extravertebral focus of infection, particularly if the patient is immunocompromised. Importantly, acute benign VCFs can be a source of false positive findings due to increased FDG uptake in the acute phase; however, the increased activity should return to normal in 3 months from the fracture date. If there is a failure of increased PET FDG activity in a VCF to return to normal by 3 months, clinical suspicion for malignancy or infection should remain high [65]. Variant 2: New symptomatic VCF identified on radiographs. History of malignancy. Next imaging study. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination, guided by physical examination findings, patient history, and other available information, including prior imaging. For some authors, focal tenderness upon palpation in correlation with radiographs of the vertebral column is a satisfactory indication for intervention. However, spine radiographs are often nonspecific with respect to the acuity or cause of the vertebral fracture [38]. CT Spine Area of Interest CT provides osseous details of axial spine fractures before VA [12,39]. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with Vertebral Compression Fractures cortical disruption, posterior cortex osseous retropulsion, epidural extension, and spinal canal compression. Comparison to prior imaging is helpful to determine acuity. The presence of lobulated paraspinal masses with involvement of both vertebral body and posterior elements at the same time favors malignant involvement [66].

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Management of Vertebral Compression Fractures PCAs

Dual-energy CT may show bone marrow edema with reasonably high sensitivity and specificity [40,41] and good concordance to MRI in thoracolumbar VCFs [42]. The presence of intravertebral vacuum phenomenon favors a benign etiology [67]. IV contrast does not provide additional value in this clinical scenario. CT Myelography Spine Area of Interest CT myelography of the spine may be useful in patients in this clinical scenario because it can delineate the degree of thecal sac compression. Myelography is also obtained in patients with previous metal hardware to evaluate epidural disease and to accurately delineate the spinal cord for preirradiation treatment planning. MRI Spine Area of Interest MRI may provide valuable information to differentiate malignant from benign VCFs. Neoplastic VCFs often have a total replacement of the normally high T1 bone marrow signal intensity, resulting in diffuse homogeneous low signal intensity. In osteoporosis, the underlying mechanism leading to fracture is the loss of bone mineral density with preservation of the marrow [68]. Abnormal marrow signal involving the pedicles or other posterior elements is a strong indicator of malignancy in VCFs because tumor spread to the posterior elements typically occurs before tumor-associated structural instability leads to fracture within the vertebral body [65,69]. Although osteoporotic fractures can also have edema in the pedicles related to stress reaction, they infrequently have signal change in the posterior elements [65,69]. Abnormal epidural or paravertebral soft tissue is another imaging finding suggesting a pathologic VCF with convex retropulsion of the posterior cortex [70]. A bilobed appearance in the ventral extradural space is more commonly seen in neoplastic disease, as opposed to nonneoplastic disease, in which there is preservation of the strong attachment of the central sagittal septum [71].

Management of Vertebral Compression Fractures PCAs. Dual-energy CT may show bone marrow edema with reasonably high sensitivity and specificity [40,41] and good concordance to MRI in thoracolumbar VCFs [42]. The presence of intravertebral vacuum phenomenon favors a benign etiology [67]. IV contrast does not provide additional value in this clinical scenario. CT Myelography Spine Area of Interest CT myelography of the spine may be useful in patients in this clinical scenario because it can delineate the degree of thecal sac compression. Myelography is also obtained in patients with previous metal hardware to evaluate epidural disease and to accurately delineate the spinal cord for preirradiation treatment planning. MRI Spine Area of Interest MRI may provide valuable information to differentiate malignant from benign VCFs. Neoplastic VCFs often have a total replacement of the normally high T1 bone marrow signal intensity, resulting in diffuse homogeneous low signal intensity. In osteoporosis, the underlying mechanism leading to fracture is the loss of bone mineral density with preservation of the marrow [68]. Abnormal marrow signal involving the pedicles or other posterior elements is a strong indicator of malignancy in VCFs because tumor spread to the posterior elements typically occurs before tumor-associated structural instability leads to fracture within the vertebral body [65,69]. Although osteoporotic fractures can also have edema in the pedicles related to stress reaction, they infrequently have signal change in the posterior elements [65,69]. Abnormal epidural or paravertebral soft tissue is another imaging finding suggesting a pathologic VCF with convex retropulsion of the posterior cortex [70]. A bilobed appearance in the ventral extradural space is more commonly seen in neoplastic disease, as opposed to nonneoplastic disease, in which there is preservation of the strong attachment of the central sagittal septum [71].

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Management of Vertebral Compression Fractures PCAs

Fluid-sensitive MRI sequences (short tau inversion recovery or fat-saturated T2-weighted imaging) can help detect fracture clefts and identify synchronous fractures [46,47]. IV contrast may yield beneficial information with increased homogenous and heterogenous enhancement patterns seen more in neoplastic fractures with or without associated enhancing paraspinal soft tissues. Enhancement involving the posterior elements raises the suspicion for malignancy further [66]. Diffusion and perfusion imaging are also used to help differentiate benign from malignant compression fractures with low apparent diffusion coefficient values and increased perfusion parameters, suggesting neoplastic over benign involvement [66]. Bone Scan Whole Body Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae [52] and also to evaluate other areas of metastases because of complete skeletal coverage, especially in a patient with a history of malignancy [53,54,58]. Bone scan and MRI have higher concordance with single-level fractures compared with multiple-level involvement [55]. When more than one area of increased activity is detected, bone scans may overestimate the number of acute fractures. As such, multiple regions of radiotracer accumulation should be interpreted cautiously [56]. Osteosclerotic bone metastases can be detected on bone scintigraphy up to 18 months earlier than on radiographs [72]. The utilization of bone scans may be based on institutional preference. SPECT or SPECT/CT Spine Area of Interest SPECT coupled with CT provides complementary information because sites of abnormal radiopharmaceutical uptake on the spine are of interest. SPECT images can be anatomically localized on the CT, and anatomic abnormalities on CT images can draw attention to subtle areas of SPECT tracer uptake.

Management of Vertebral Compression Fractures PCAs. Fluid-sensitive MRI sequences (short tau inversion recovery or fat-saturated T2-weighted imaging) can help detect fracture clefts and identify synchronous fractures [46,47]. IV contrast may yield beneficial information with increased homogenous and heterogenous enhancement patterns seen more in neoplastic fractures with or without associated enhancing paraspinal soft tissues. Enhancement involving the posterior elements raises the suspicion for malignancy further [66]. Diffusion and perfusion imaging are also used to help differentiate benign from malignant compression fractures with low apparent diffusion coefficient values and increased perfusion parameters, suggesting neoplastic over benign involvement [66]. Bone Scan Whole Body Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae [52] and also to evaluate other areas of metastases because of complete skeletal coverage, especially in a patient with a history of malignancy [53,54,58]. Bone scan and MRI have higher concordance with single-level fractures compared with multiple-level involvement [55]. When more than one area of increased activity is detected, bone scans may overestimate the number of acute fractures. As such, multiple regions of radiotracer accumulation should be interpreted cautiously [56]. Osteosclerotic bone metastases can be detected on bone scintigraphy up to 18 months earlier than on radiographs [72]. The utilization of bone scans may be based on institutional preference. SPECT or SPECT/CT Spine Area of Interest SPECT coupled with CT provides complementary information because sites of abnormal radiopharmaceutical uptake on the spine are of interest. SPECT images can be anatomically localized on the CT, and anatomic abnormalities on CT images can draw attention to subtle areas of SPECT tracer uptake.

70545

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Management of Vertebral Compression Fractures PCAs

SPECT/CT has been shown to localize abnormalities in the vertebra more precisely compared to SPECT imaging alone, particularly in complicated cases, such as multiple collapsed vertebrae of different ages [57]. Studies have demonstrated a 63% to 80% agreement between SPECT/CT and MRI in detecting acute VCF [58,59]. Bone SPECT/CT can also gauge successful treatment response after VA and adds valuable information for the cause of back pain. [59]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET combined with morphologic CT imaging can noninvasively localize metabolic activity in areas of spinal neoplastic involvement and can differentiate between benign and malignant VCFs, with the caveat that acute osteoporotic fractures can also have a high standardized uptake value on PET/CT imaging. A meta-analysis by Kim et al [73] showed high sensitivity and moderate specificity for the use of FDG-PET/CT to differentiate benign from malignant compression fractures. In a patient with a history of malignancy, PET/CT is routinely included in the paradigm of metastatic disease evaluation workup [61]. Vertebral osteomyelitis may present as a compression fracture [64] and may be difficult to distinguish from noninfectious, osteoporotic VCF. Other potential radiotracers Vertebral Compression Fractures have been described for the early detection of marrow-based metastases, such as 18F-NaF PET/CT, which indicates areas of increased bone turnover and is generally used in the assessment of primary and secondary osseous malignancies, the evaluation of response to treatment, and the clarification of abnormalities on other imaging modalities or clinical data. However, 18F-NaF PET/CT is a highly sensitive method in evaluating bone metastases (eg, prostate cancer). Still, it can be problematic because of low specificity because the tracer accumulates in degenerative and inflammatory bone diseases.

Management of Vertebral Compression Fractures PCAs. SPECT/CT has been shown to localize abnormalities in the vertebra more precisely compared to SPECT imaging alone, particularly in complicated cases, such as multiple collapsed vertebrae of different ages [57]. Studies have demonstrated a 63% to 80% agreement between SPECT/CT and MRI in detecting acute VCF [58,59]. Bone SPECT/CT can also gauge successful treatment response after VA and adds valuable information for the cause of back pain. [59]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET combined with morphologic CT imaging can noninvasively localize metabolic activity in areas of spinal neoplastic involvement and can differentiate between benign and malignant VCFs, with the caveat that acute osteoporotic fractures can also have a high standardized uptake value on PET/CT imaging. A meta-analysis by Kim et al [73] showed high sensitivity and moderate specificity for the use of FDG-PET/CT to differentiate benign from malignant compression fractures. In a patient with a history of malignancy, PET/CT is routinely included in the paradigm of metastatic disease evaluation workup [61]. Vertebral osteomyelitis may present as a compression fracture [64] and may be difficult to distinguish from noninfectious, osteoporotic VCF. Other potential radiotracers Vertebral Compression Fractures have been described for the early detection of marrow-based metastases, such as 18F-NaF PET/CT, which indicates areas of increased bone turnover and is generally used in the assessment of primary and secondary osseous malignancies, the evaluation of response to treatment, and the clarification of abnormalities on other imaging modalities or clinical data. However, 18F-NaF PET/CT is a highly sensitive method in evaluating bone metastases (eg, prostate cancer). Still, it can be problematic because of low specificity because the tracer accumulates in degenerative and inflammatory bone diseases.

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Management of Vertebral Compression Fractures PCAs

18F-fluorocholine may be able to differentiate between degenerative and malignant osseous abnormalities because degenerative changes are not choline-avid [74]. Prostate-specific membrane antigen (PSMA)-PET imaging has been approved by the FDA in patients with prostate cancer with radioactive agent binding to prostatic cancer cells. Image-Guided Biopsy Spine Area of Interest Percutaneous biopsy is performed to verify the etiology of VCF, especially if imaging findings are equivocal or the fractured vertebra is the only site of involvement in a patient with known malignancy. Biopsy has been shown to confirm clinical suspicion of neoplastic involvement and also aids in directing future treatment planning [75]. Variant 3: New back pain. Previously treated VCF or multiple VCFs. Initial Imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination, guided by physical examination findings, patient history, and other available information, including prior imaging. CT Spine Area of Interest CT provides osseous details of axial spine fractures prior to VA [12,39]. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with cortical disruption, posterior cortex osseous retropulsion, epidural extension, and spinal canal compression. CT is also the optimal modality to identify cement leakage in paraspinal, epidural, intravascular, or adjacent discal regions [76,77]. CT also depicts the development of adjacent level fracture in a patient with recent augmentation and new back pain [78]. CT is also useful to evaluate the cause of new pain in patients with surgical intervention with hardware placement. This modality can evaluate a patient with new back pain after undergoing treatment of single- or multiple-level VCFs.

Management of Vertebral Compression Fractures PCAs. 18F-fluorocholine may be able to differentiate between degenerative and malignant osseous abnormalities because degenerative changes are not choline-avid [74]. Prostate-specific membrane antigen (PSMA)-PET imaging has been approved by the FDA in patients with prostate cancer with radioactive agent binding to prostatic cancer cells. Image-Guided Biopsy Spine Area of Interest Percutaneous biopsy is performed to verify the etiology of VCF, especially if imaging findings are equivocal or the fractured vertebra is the only site of involvement in a patient with known malignancy. Biopsy has been shown to confirm clinical suspicion of neoplastic involvement and also aids in directing future treatment planning [75]. Variant 3: New back pain. Previously treated VCF or multiple VCFs. Initial Imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination, guided by physical examination findings, patient history, and other available information, including prior imaging. CT Spine Area of Interest CT provides osseous details of axial spine fractures prior to VA [12,39]. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with cortical disruption, posterior cortex osseous retropulsion, epidural extension, and spinal canal compression. CT is also the optimal modality to identify cement leakage in paraspinal, epidural, intravascular, or adjacent discal regions [76,77]. CT also depicts the development of adjacent level fracture in a patient with recent augmentation and new back pain [78]. CT is also useful to evaluate the cause of new pain in patients with surgical intervention with hardware placement. This modality can evaluate a patient with new back pain after undergoing treatment of single- or multiple-level VCFs.

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Management of Vertebral Compression Fractures PCAs

CT Myelography Spine Area of Interest CT myelography is not routinely used for evaluating benign VCFs unless the patient has a neurologic deficit with suspected spinal canal compression. This modality can also be helpful in patients who have surgical hardware from prior spinal surgical intervention to evaluate the spinal canal at the involved level. MRI Spine Area of Interest Fluid-sensitive MRI sequences (short tau inversion recovery or fat-saturated T2-weighted imaging) help detect new acute adjacent level fractures after VCF treatment. MRI can also show the presence of procedure-related complications that can result in new pain in a treated patient, including epidural or paraspinal hematomas, infection in or around the treated level(s), spinal canal compression, and cord injury/ischemia [79]. A cerebrospinal fluid leak or pseudomeningocele formation is also well depicted with MRI [80]. IV contrast can add information in a posttreatment scan, especially to evaluate for any infection/inflammation in or adjacent to the spinal canal but it should be noted that sometimes a rind of enhancement maybe seen around the bone cement in treated vertebra due to reactionary changes and mild inflammatory response induced by polymethylmethacrylate. Bone Scan Whole Body Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae [52], particularly the causative level [53,54]. Bone scan and MRI have higher concordance with single-level fractures compared with multiple-level involvement [55]. When more than one area of increased activity is detected, bone scans may overestimate the number of acute fractures. As such, multiple regions of radiotracer accumulation should be interpreted cautiously [56]. The utilization of bone scans may be based on institutional preference.

Management of Vertebral Compression Fractures PCAs. CT Myelography Spine Area of Interest CT myelography is not routinely used for evaluating benign VCFs unless the patient has a neurologic deficit with suspected spinal canal compression. This modality can also be helpful in patients who have surgical hardware from prior spinal surgical intervention to evaluate the spinal canal at the involved level. MRI Spine Area of Interest Fluid-sensitive MRI sequences (short tau inversion recovery or fat-saturated T2-weighted imaging) help detect new acute adjacent level fractures after VCF treatment. MRI can also show the presence of procedure-related complications that can result in new pain in a treated patient, including epidural or paraspinal hematomas, infection in or around the treated level(s), spinal canal compression, and cord injury/ischemia [79]. A cerebrospinal fluid leak or pseudomeningocele formation is also well depicted with MRI [80]. IV contrast can add information in a posttreatment scan, especially to evaluate for any infection/inflammation in or adjacent to the spinal canal but it should be noted that sometimes a rind of enhancement maybe seen around the bone cement in treated vertebra due to reactionary changes and mild inflammatory response induced by polymethylmethacrylate. Bone Scan Whole Body Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae [52], particularly the causative level [53,54]. Bone scan and MRI have higher concordance with single-level fractures compared with multiple-level involvement [55]. When more than one area of increased activity is detected, bone scans may overestimate the number of acute fractures. As such, multiple regions of radiotracer accumulation should be interpreted cautiously [56]. The utilization of bone scans may be based on institutional preference.

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acrac_70545_11

Management of Vertebral Compression Fractures PCAs

SPECT or SPECT/CT Spine Area of Interest SPECT coupled with CT provides complementary information because sites of abnormal radiopharmaceutical uptake on the spine are of interest. SPECT images can be anatomically localized on the CT, and anatomic abnormalities on CT images can draw attention to subtle areas of SPECT tracer uptake. SPECT/CT has been shown to localize abnormalities in the vertebra more precisely compared with SPECT imaging alone, particularly in complicated cases, such as multiple collapsed vertebrae of different ages [57]. Studies have demonstrated a 63% to Vertebral Compression Fractures 80% agreement between SPECT/CT and MRI in detecting acute VCF [58,59]. SPECT/CT may be useful for imaging diagnosis of acute fractures [60]. FDG-PET/CT Skull Base to Mid-Thigh In the postprocedure setting, new pain may be due to infection. FDG-PET combined with morphologic CT imaging can noninvasively localize metabolic activity in areas of spinal infection. Studies on the diagnosis of vertebral osteomyelitis reported a sensitivity and specificity of 83% and 88% for FDG-PET/CT [61-63]. Vertebral osteomyelitis may present as a compression fracture [64] and may be difficult to distinguish from noninfectious, osteoporotic VCF. Vertebral osteomyelitis may be considered in the setting of severe back pain, persistent unexplained fever, elevated inflammatory markers (ie, erythrocyte sedimentation rate), or bacteremia without a known extravertebral focus of infection, particularly if the patient is immunocompromised. Variant 4: Asymptomatic VCF identified on radiographs. History of malignancy. Next imaging study. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination, guided by physical examination findings, patient history, and other available information, including prior imaging.

Management of Vertebral Compression Fractures PCAs. SPECT or SPECT/CT Spine Area of Interest SPECT coupled with CT provides complementary information because sites of abnormal radiopharmaceutical uptake on the spine are of interest. SPECT images can be anatomically localized on the CT, and anatomic abnormalities on CT images can draw attention to subtle areas of SPECT tracer uptake. SPECT/CT has been shown to localize abnormalities in the vertebra more precisely compared with SPECT imaging alone, particularly in complicated cases, such as multiple collapsed vertebrae of different ages [57]. Studies have demonstrated a 63% to Vertebral Compression Fractures 80% agreement between SPECT/CT and MRI in detecting acute VCF [58,59]. SPECT/CT may be useful for imaging diagnosis of acute fractures [60]. FDG-PET/CT Skull Base to Mid-Thigh In the postprocedure setting, new pain may be due to infection. FDG-PET combined with morphologic CT imaging can noninvasively localize metabolic activity in areas of spinal infection. Studies on the diagnosis of vertebral osteomyelitis reported a sensitivity and specificity of 83% and 88% for FDG-PET/CT [61-63]. Vertebral osteomyelitis may present as a compression fracture [64] and may be difficult to distinguish from noninfectious, osteoporotic VCF. Vertebral osteomyelitis may be considered in the setting of severe back pain, persistent unexplained fever, elevated inflammatory markers (ie, erythrocyte sedimentation rate), or bacteremia without a known extravertebral focus of infection, particularly if the patient is immunocompromised. Variant 4: Asymptomatic VCF identified on radiographs. History of malignancy. Next imaging study. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination, guided by physical examination findings, patient history, and other available information, including prior imaging.

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acrac_70545_12

Management of Vertebral Compression Fractures PCAs

Algorithms for patient selection and VCF management have been proposed by multidisciplinary groups that include oncology, surgery, and interventional radiology, based on evidence and expert opinion for managing metastatic spinal disease [81]. Medical therapy, including bisphosphonates for osteoclast inhibition [82-84] and osteoclast regulating agents [85-87], can be used to prevent skeletal-related events. CT Spine Area of Interest CT provides osseous details of axial spine fractures before VA [12,39]. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with cortical disruption, posterior cortex osseous retropulsion, epidural extension, and spinal canal compression [12,39]. Comparison to prior imaging is helpful to determine acuity. The presence of lobulated paraspinal masses with involvement of both vertebral body and posterior elements at the same time favors malignant involvement [66]. CT is fast and can be used to evaluate a patient with new back pain after undergoing single- or multiple-level VCFs. Dual-energy CT may show bone marrow edema with reasonably high sensitivity and specificity [40,41] and good concordance to MRI in thoracolumbar VCFs [42]. Performing contrast-enhanced CT does not add much to the information already available. MRI Spine Area of Interest MRI can provide valuable information in the assessment of VCFs in patients with a history of malignancy or atypical clinical features. In addition to detecting metastases localized entirely in the bone marrow cavity, MRI can be used to differentiate benign from malignant fractures, because osteoporotic VCFs can occur in patients with malignancy [66,67,70,88,89]. MRI allows assessment of the degree of thecal sac or spinal cord compression, epidural tumor extension [16], paraspinal tumor extension, presence of other lesions, and lesion vascularity.

Management of Vertebral Compression Fractures PCAs. Algorithms for patient selection and VCF management have been proposed by multidisciplinary groups that include oncology, surgery, and interventional radiology, based on evidence and expert opinion for managing metastatic spinal disease [81]. Medical therapy, including bisphosphonates for osteoclast inhibition [82-84] and osteoclast regulating agents [85-87], can be used to prevent skeletal-related events. CT Spine Area of Interest CT provides osseous details of axial spine fractures before VA [12,39]. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with cortical disruption, posterior cortex osseous retropulsion, epidural extension, and spinal canal compression [12,39]. Comparison to prior imaging is helpful to determine acuity. The presence of lobulated paraspinal masses with involvement of both vertebral body and posterior elements at the same time favors malignant involvement [66]. CT is fast and can be used to evaluate a patient with new back pain after undergoing single- or multiple-level VCFs. Dual-energy CT may show bone marrow edema with reasonably high sensitivity and specificity [40,41] and good concordance to MRI in thoracolumbar VCFs [42]. Performing contrast-enhanced CT does not add much to the information already available. MRI Spine Area of Interest MRI can provide valuable information in the assessment of VCFs in patients with a history of malignancy or atypical clinical features. In addition to detecting metastases localized entirely in the bone marrow cavity, MRI can be used to differentiate benign from malignant fractures, because osteoporotic VCFs can occur in patients with malignancy [66,67,70,88,89]. MRI allows assessment of the degree of thecal sac or spinal cord compression, epidural tumor extension [16], paraspinal tumor extension, presence of other lesions, and lesion vascularity.

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Management of Vertebral Compression Fractures PCAs

Intraosseous disease is best delineated on noncontrast MRI sequences (T1-weighted and short tau inversion recovery). Contrast- enhanced MRI is helpful to delineate epidural, foraminal, paraspinal, and intrathecal disease extension, including intramedullary disease, compared to sequences without contrast. It is most beneficial to compare precontrast and postcontrast MRI sequences. With tumor involvement, marrow edema may be difficult to detect on conventional MRI sequences [90]. Diffusion-weighted [88] and MR perfusion techniques [91] may be helpful tools to differentiate benign from pathological fractures and new metastasis from previously treated lesions despite a similar appearance on conventional MRI [92]. MRI is also important for further treatment planning, such as VA, percutaneous ablation, RT (stereotactic body RT [SBRT] or conventional palliative radiation), or systemic chemotherapy [93-96]. Vertebral Compression Fractures CT Myelography Spine Area of Interest Myelography of the spine may be obtained especially to detect epidural tumor extension and spinal cord compression. This modality can also be helpful in patients who have surgical hardware from prior spinal surgical intervention to evaluate the spinal canal at the involved level. Bone Scan Whole Body Tc-99m bone scan (bone scintigraphy) of the whole body is often used for initial detection of metastases as well as the staging of patients with cancer. Hot uptake on a bone scan can persist for 2 years after the fracture [97] and hence is hard to differentiate a subacute from chronic fracture. In patients with osteoporosis, bone scan can show additional fractures in the skeleton and also can be helpful in distinguishing the cause of back pain among fracture, facet joint arthritis, and disc degenerative lesions and can be of help to triage appropriate treatment [98]. Bone scans may be performed based on institutional preference.

Management of Vertebral Compression Fractures PCAs. Intraosseous disease is best delineated on noncontrast MRI sequences (T1-weighted and short tau inversion recovery). Contrast- enhanced MRI is helpful to delineate epidural, foraminal, paraspinal, and intrathecal disease extension, including intramedullary disease, compared to sequences without contrast. It is most beneficial to compare precontrast and postcontrast MRI sequences. With tumor involvement, marrow edema may be difficult to detect on conventional MRI sequences [90]. Diffusion-weighted [88] and MR perfusion techniques [91] may be helpful tools to differentiate benign from pathological fractures and new metastasis from previously treated lesions despite a similar appearance on conventional MRI [92]. MRI is also important for further treatment planning, such as VA, percutaneous ablation, RT (stereotactic body RT [SBRT] or conventional palliative radiation), or systemic chemotherapy [93-96]. Vertebral Compression Fractures CT Myelography Spine Area of Interest Myelography of the spine may be obtained especially to detect epidural tumor extension and spinal cord compression. This modality can also be helpful in patients who have surgical hardware from prior spinal surgical intervention to evaluate the spinal canal at the involved level. Bone Scan Whole Body Tc-99m bone scan (bone scintigraphy) of the whole body is often used for initial detection of metastases as well as the staging of patients with cancer. Hot uptake on a bone scan can persist for 2 years after the fracture [97] and hence is hard to differentiate a subacute from chronic fracture. In patients with osteoporosis, bone scan can show additional fractures in the skeleton and also can be helpful in distinguishing the cause of back pain among fracture, facet joint arthritis, and disc degenerative lesions and can be of help to triage appropriate treatment [98]. Bone scans may be performed based on institutional preference.

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Management of Vertebral Compression Fractures PCAs

SPECT or SPECT/CT Spine Area of Interest SPECT/CT has been shown to precisely localize abnormalities in the vertebra, particularly in complicated cases, such as multiple collapsed vertebrae of different ages [57]. However, MRI has a greater sensitivity and specificity for metastasis in specific spine locations [99] and for certain primaries, such as prostate cancer [100]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT may demonstrate localized metabolic activity in a neoplastic VCF and in areas of spinal infection [61-63]. MRI features coupled with clinical symptoms may help discern the etiology of a VCF with increased FDG uptake [101]. A meta-analysis study showed high sensitivity and moderate specificity for FDG-PET/CT to differentiate malignant versus benign VCFs [73]. Other potential radiotracers have been described for the early detection of marrow-based metastases, such as 18F-NaF PET/CT, which indicates areas of increased bone turnover and is generally used in the assessment of primary and secondary osseous malignancies, the evaluation of response to treatment, and the clarification of abnormalities on other imaging modalities or clinical data. However, 18F-NaF PET/CT is a highly sensitive method in evaluating bone metastases (eg, prostate cancer). Still, it can be problematic because of low specificity because the tracer accumulates in degenerative and inflammatory bone diseases. 18F- fluorocholine may be able to differentiate between degenerative and malignant osseous abnormalities because degenerative changes are not choline-avid [74]. Image-Guided Biopsy Spine Area of Interest If the imaging features are ambiguous and not definitely in keeping with a pathologic VCF, a biopsy can be performed to verify the etiology. A biopsy of the spine region of interest may be important for staging when isolated spine involvement is the first presentation of metastatic disease.

Management of Vertebral Compression Fractures PCAs. SPECT or SPECT/CT Spine Area of Interest SPECT/CT has been shown to precisely localize abnormalities in the vertebra, particularly in complicated cases, such as multiple collapsed vertebrae of different ages [57]. However, MRI has a greater sensitivity and specificity for metastasis in specific spine locations [99] and for certain primaries, such as prostate cancer [100]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT may demonstrate localized metabolic activity in a neoplastic VCF and in areas of spinal infection [61-63]. MRI features coupled with clinical symptoms may help discern the etiology of a VCF with increased FDG uptake [101]. A meta-analysis study showed high sensitivity and moderate specificity for FDG-PET/CT to differentiate malignant versus benign VCFs [73]. Other potential radiotracers have been described for the early detection of marrow-based metastases, such as 18F-NaF PET/CT, which indicates areas of increased bone turnover and is generally used in the assessment of primary and secondary osseous malignancies, the evaluation of response to treatment, and the clarification of abnormalities on other imaging modalities or clinical data. However, 18F-NaF PET/CT is a highly sensitive method in evaluating bone metastases (eg, prostate cancer). Still, it can be problematic because of low specificity because the tracer accumulates in degenerative and inflammatory bone diseases. 18F- fluorocholine may be able to differentiate between degenerative and malignant osseous abnormalities because degenerative changes are not choline-avid [74]. Image-Guided Biopsy Spine Area of Interest If the imaging features are ambiguous and not definitely in keeping with a pathologic VCF, a biopsy can be performed to verify the etiology. A biopsy of the spine region of interest may be important for staging when isolated spine involvement is the first presentation of metastatic disease.

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acrac_70545_15

Management of Vertebral Compression Fractures PCAs

Both fluoroscopy- and CT-guided spine biopsies can be performed with high diagnostic accuracy and few complications [102]. Variant 5: Asymptomatic, osteoporotic VCF. Initial treatment. Most patients with VCFs have a gradual improvement in pain over 2 to 12 weeks, with a variable return of function [103,104]. Bone marrow edema associated with acute fractures on MRI typically resolves within 1 to 3 months [50,51]. Patients may not be candidates for percutaneous or surgical intervention because of factors related to performance status, pregnancy, infection, or coagulation disorders, among others. Clinical decision-making must account for the overall risk and benefit to the patient. Medical Management Only Medical management is complementary to other therapies and should be offered in all clinical scenarios. The natural history of most healing VCFs is that of gradual improvement in pain over 2 to 12 weeks, with a variable return of function [103,104]. Conservative management includes medical management with or without methods of immobility and is the initial treatment of painful VCFs [36,107,108]. Vertebral Compression Fractures Asymptomatic osteoporotic VCFs do not require active management if not associated with focal mechanical pain and if there is no restriction of physical activity due to the fracture. Patients should return for a follow-up evaluation after 2 to 4 weeks of nonsurgical management, and, after a satisfactory result, continued follow-up may be unnecessary. Additional imaging and clinical assessment may be obtained for patients who have recurrence or persistence of symptoms to determine the source of their discomfort. There should be continuous evaluation and treatment for the underlying disorder of osteoporosis to prevent future fractures. Concerning follow-up, most currently available guidelines are restricted to recommendations on pharmacologic treatment for osteoporosis [109].

Management of Vertebral Compression Fractures PCAs. Both fluoroscopy- and CT-guided spine biopsies can be performed with high diagnostic accuracy and few complications [102]. Variant 5: Asymptomatic, osteoporotic VCF. Initial treatment. Most patients with VCFs have a gradual improvement in pain over 2 to 12 weeks, with a variable return of function [103,104]. Bone marrow edema associated with acute fractures on MRI typically resolves within 1 to 3 months [50,51]. Patients may not be candidates for percutaneous or surgical intervention because of factors related to performance status, pregnancy, infection, or coagulation disorders, among others. Clinical decision-making must account for the overall risk and benefit to the patient. Medical Management Only Medical management is complementary to other therapies and should be offered in all clinical scenarios. The natural history of most healing VCFs is that of gradual improvement in pain over 2 to 12 weeks, with a variable return of function [103,104]. Conservative management includes medical management with or without methods of immobility and is the initial treatment of painful VCFs [36,107,108]. Vertebral Compression Fractures Asymptomatic osteoporotic VCFs do not require active management if not associated with focal mechanical pain and if there is no restriction of physical activity due to the fracture. Patients should return for a follow-up evaluation after 2 to 4 weeks of nonsurgical management, and, after a satisfactory result, continued follow-up may be unnecessary. Additional imaging and clinical assessment may be obtained for patients who have recurrence or persistence of symptoms to determine the source of their discomfort. There should be continuous evaluation and treatment for the underlying disorder of osteoporosis to prevent future fractures. Concerning follow-up, most currently available guidelines are restricted to recommendations on pharmacologic treatment for osteoporosis [109].

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Management of Vertebral Compression Fractures PCAs

Physical therapy is likely to be useful in patients with VCFs and osteoporosis. Home exercise programs have a more limited evidence base, with some small trials demonstrating pain reduction, improved balance, and improved quality of life. Back extensor strengthening can improve strength and bone density and reduce the risk of future VCFs. Exercise is beneficial for all patients with osteoporosis [110,111]. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgical intervention is reserved for patients with neurologic deficits, spinal deformity (eg, junctional kyphosis, retropulsion), or spinal instability. Surgical consultation can assist in prescribing and supervising immobilization devices. Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF. If cancer is thought to be the cause of a VCF, a biopsy is needed to confirm a cancer diagnosis. RT is reserved for metastatic spinal disease and typically for those spinal metastases causing pain, neurologic compromise, or those asymptomatic lesions with radiologic features suggesting a risk of neurologic compromise or VCF. Variant 6: Symptomatic osteoporotic VCF with bone marrow edema or intravertebral cleft. Initial treatment. Medical Management Only The traditional first-line treatment of painful VCFs has been nonoperative or conservative management [107,108]. Conservative management includes a short period of bed rest followed by gradual mobilization with external orthoses. Because VCFs are flexion-compression injuries, a hyperextension brace is used. These braces may be beneficial for the first few months until the pain resolves [101]. Although younger patients may tolerate bracing well, elderly patients generally do not because of increased pain with bracing, leading to limited activity with more bed rest.

Management of Vertebral Compression Fractures PCAs. Physical therapy is likely to be useful in patients with VCFs and osteoporosis. Home exercise programs have a more limited evidence base, with some small trials demonstrating pain reduction, improved balance, and improved quality of life. Back extensor strengthening can improve strength and bone density and reduce the risk of future VCFs. Exercise is beneficial for all patients with osteoporosis [110,111]. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgical intervention is reserved for patients with neurologic deficits, spinal deformity (eg, junctional kyphosis, retropulsion), or spinal instability. Surgical consultation can assist in prescribing and supervising immobilization devices. Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF. If cancer is thought to be the cause of a VCF, a biopsy is needed to confirm a cancer diagnosis. RT is reserved for metastatic spinal disease and typically for those spinal metastases causing pain, neurologic compromise, or those asymptomatic lesions with radiologic features suggesting a risk of neurologic compromise or VCF. Variant 6: Symptomatic osteoporotic VCF with bone marrow edema or intravertebral cleft. Initial treatment. Medical Management Only The traditional first-line treatment of painful VCFs has been nonoperative or conservative management [107,108]. Conservative management includes a short period of bed rest followed by gradual mobilization with external orthoses. Because VCFs are flexion-compression injuries, a hyperextension brace is used. These braces may be beneficial for the first few months until the pain resolves [101]. Although younger patients may tolerate bracing well, elderly patients generally do not because of increased pain with bracing, leading to limited activity with more bed rest.

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Management of Vertebral Compression Fractures PCAs

Immobility predisposes patients to venous thrombosis and life-threatening complications such as pulmonary embolism [101]. It can also lead to pressure ulcers, pulmonary complications, urinary tract infections, and progressive deconditioning. Medical management is often complementary to other treatment strategies. To reduce pain and thus promote early mobilization with conservative management, appropriate analgesics should be prescribed. Narcotics should be reserved for patients who receive inadequate relief from regular analgesics and have to be used with caution given the associated effects of sedation, nausea, further decrease in physical conditioning, and fall risks. Most patients with osteoporotic VCF have spontaneous resolution of pain, even without medication, in 6 to 8 weeks [103,104,108,113]. Prevention and treatment of osteoporosis are one of the first steps in managing VCFs. Cigarette smoking should be discouraged, and alcohol should only be consumed in moderation. A daily weight-bearing exercise program should be recommended [101]. Patients may not be candidates for percutaneous or surgical intervention because of factors related to performance status, pregnancy, infection, or coagulation disorders, among others. Clinical decision-making must account for the overall risk and benefit to the patient. Vertebral Compression Fractures Percutaneous Vertebral Augmentation VA, in the form of VP and BK, may be offered to patients who have failed conservative therapy for 3 months [34]. However, recent studies have found VA superior to placebo intervention for pain reduction in patients with acute osteoporotic VCF of <6 weeks duration [22]. Two randomized controlled trials that reported no statistically significant advantage for VA versus sham therapy raised discussions and controversial editorials, particularly regarding the inclusion criteria and other methodological issues [113,114].

Management of Vertebral Compression Fractures PCAs. Immobility predisposes patients to venous thrombosis and life-threatening complications such as pulmonary embolism [101]. It can also lead to pressure ulcers, pulmonary complications, urinary tract infections, and progressive deconditioning. Medical management is often complementary to other treatment strategies. To reduce pain and thus promote early mobilization with conservative management, appropriate analgesics should be prescribed. Narcotics should be reserved for patients who receive inadequate relief from regular analgesics and have to be used with caution given the associated effects of sedation, nausea, further decrease in physical conditioning, and fall risks. Most patients with osteoporotic VCF have spontaneous resolution of pain, even without medication, in 6 to 8 weeks [103,104,108,113]. Prevention and treatment of osteoporosis are one of the first steps in managing VCFs. Cigarette smoking should be discouraged, and alcohol should only be consumed in moderation. A daily weight-bearing exercise program should be recommended [101]. Patients may not be candidates for percutaneous or surgical intervention because of factors related to performance status, pregnancy, infection, or coagulation disorders, among others. Clinical decision-making must account for the overall risk and benefit to the patient. Vertebral Compression Fractures Percutaneous Vertebral Augmentation VA, in the form of VP and BK, may be offered to patients who have failed conservative therapy for 3 months [34]. However, recent studies have found VA superior to placebo intervention for pain reduction in patients with acute osteoporotic VCF of <6 weeks duration [22]. Two randomized controlled trials that reported no statistically significant advantage for VA versus sham therapy raised discussions and controversial editorials, particularly regarding the inclusion criteria and other methodological issues [113,114].

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Several studies have shown the benefit of VA versus conservative treatment in acute osteoporotic VCF [23,108,115-117], with benefits persisting through 1 year after intervention. However, others demonstrated that VA procedures might not affect global spinal alignment [118]. A meta-analysis found improvements in pain intensity, vertebral height, sagittal alignment, functional capacity, and quality of life with BK compared with conventional medical management [119]. Multiple other studies demonstrated the benefit of VA for alignment with improvement in pain relief [22,120-122] and respiratory function [89,123,124]. In a multisociety position statement, it was concluded that the VA of osteoporotic VCF is clearly beneficial in the short term and is likely beneficial in the long term [36]. Given the evidence that VA is more effective than prolonged medical treatment in achieving analgesia, improving function in patients with painful VCFs [117,125], and avoiding the complications of narcotic use, the threshold for performing VA has declined. Farrokhi et al [23] showed in a randomized control trial of percutaneous augmentation versus medical management for relief of pain and disability that the VA group had statistically significant improvements in pain and disability scores maintained over 24 months, improved vertebral body height restoration maintained over 36 months, and fewer adjacent level fractures compared to the medical management group. The timing of when VA is useful has been debated. Studies found VA to be superior to placebo intervention for pain reduction in patients with acute osteoporotic VCF of <6 weeks duration [22]. In a study by Syed et al [33], patients with VCFs >12 weeks compared to those patients with VCFs <12 weeks had equivalent benefit, suggesting that the age of the fracture does not independently affect the outcomes of VA.

Management of Vertebral Compression Fractures PCAs. Several studies have shown the benefit of VA versus conservative treatment in acute osteoporotic VCF [23,108,115-117], with benefits persisting through 1 year after intervention. However, others demonstrated that VA procedures might not affect global spinal alignment [118]. A meta-analysis found improvements in pain intensity, vertebral height, sagittal alignment, functional capacity, and quality of life with BK compared with conventional medical management [119]. Multiple other studies demonstrated the benefit of VA for alignment with improvement in pain relief [22,120-122] and respiratory function [89,123,124]. In a multisociety position statement, it was concluded that the VA of osteoporotic VCF is clearly beneficial in the short term and is likely beneficial in the long term [36]. Given the evidence that VA is more effective than prolonged medical treatment in achieving analgesia, improving function in patients with painful VCFs [117,125], and avoiding the complications of narcotic use, the threshold for performing VA has declined. Farrokhi et al [23] showed in a randomized control trial of percutaneous augmentation versus medical management for relief of pain and disability that the VA group had statistically significant improvements in pain and disability scores maintained over 24 months, improved vertebral body height restoration maintained over 36 months, and fewer adjacent level fractures compared to the medical management group. The timing of when VA is useful has been debated. Studies found VA to be superior to placebo intervention for pain reduction in patients with acute osteoporotic VCF of <6 weeks duration [22]. In a study by Syed et al [33], patients with VCFs >12 weeks compared to those patients with VCFs <12 weeks had equivalent benefit, suggesting that the age of the fracture does not independently affect the outcomes of VA.

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Management of Vertebral Compression Fractures PCAs

However, Chen et al [21] showed improved pain relief in chronic fractures >3 months treated with VA compared to conservative management at 1 year follow-up. Implant kyphoplasty is being performed more after the Sakos Trial findings supported the use of titanium implantable VA devices as an early treatment option for painful, acute VCFs with excellent risk/benefit profile [126]. Tutton et al [20] in the KAST study (The Kiva safety and effectiveness Trial), a multicentered randomized control trial successfully established that the Kiva system is noninferior to BK based on a composite primary endpoint assessment incorporating pain-, function-, and device-related serious adverse events for the treatment of osteoporotic VCFs. Cianfoni et al [127] demonstrated the use of stent-assisted internal fixation as a minimally invasive option to obtain VA and restore axial load capability in severe osteoporotic fractures, potentially obviating more invasive surgical interventions in situations that would pose significant challenges to standard VA. When the etiology of the VCF is questionable, biopsy may be necessary and can be performed as a part of the VA procedure [128,129]. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgical intervention is reserved for patients with neurologic deficits, spinal deformity (eg, junctional kyphosis, retropulsion), or spinal instability. Several surgical techniques have been developed to treat osteoporosis-related deformities, including posterior instrumentation with fusion. However, achieving fixation and fusion in these patients can be difficult secondary to insufficient bone integrity. Augmentation methods to improve pedicle screw fixation have evolved, including instrumentation at multiple levels, bioactive cement augmentation, and fenestrated or expandable pedicle screws, but their impact on clinical outcomes remains unknown.

Management of Vertebral Compression Fractures PCAs. However, Chen et al [21] showed improved pain relief in chronic fractures >3 months treated with VA compared to conservative management at 1 year follow-up. Implant kyphoplasty is being performed more after the Sakos Trial findings supported the use of titanium implantable VA devices as an early treatment option for painful, acute VCFs with excellent risk/benefit profile [126]. Tutton et al [20] in the KAST study (The Kiva safety and effectiveness Trial), a multicentered randomized control trial successfully established that the Kiva system is noninferior to BK based on a composite primary endpoint assessment incorporating pain-, function-, and device-related serious adverse events for the treatment of osteoporotic VCFs. Cianfoni et al [127] demonstrated the use of stent-assisted internal fixation as a minimally invasive option to obtain VA and restore axial load capability in severe osteoporotic fractures, potentially obviating more invasive surgical interventions in situations that would pose significant challenges to standard VA. When the etiology of the VCF is questionable, biopsy may be necessary and can be performed as a part of the VA procedure [128,129]. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgical intervention is reserved for patients with neurologic deficits, spinal deformity (eg, junctional kyphosis, retropulsion), or spinal instability. Several surgical techniques have been developed to treat osteoporosis-related deformities, including posterior instrumentation with fusion. However, achieving fixation and fusion in these patients can be difficult secondary to insufficient bone integrity. Augmentation methods to improve pedicle screw fixation have evolved, including instrumentation at multiple levels, bioactive cement augmentation, and fenestrated or expandable pedicle screws, but their impact on clinical outcomes remains unknown.

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Management of Vertebral Compression Fractures PCAs

Management of osteoporosis in patients undergoing spine surgery is challenging. Still, with appropriate patient selection, medical optimization, and surgical techniques, these patients can experience pain relief, deformity correction, and improved function [130]. Surgical consultation can assist in prescribing and supervising immobilization devices. When the etiology of the VCF is questionable and not amenable to percutaneous biopsy, an open biopsy may be necessary. Vertebral Compression Fractures Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF. If cancer is thought to be the cause of a VCF, a biopsy is needed to confirm a cancer diagnosis. RT is reserved for metastatic spinal disease and typically for those spinal metastases causing pain, neurologic compromise, or those asymptomatic lesions with radiologic features suggesting a risk of neurologic compromise or VCF. Systemic Radionuclide Therapy This procedure is not useful for benign osteoporosis-related compressions fractures. Medical Management Only Medical management is complementary to other therapies and should be offered in all clinical scenarios. Conservative management includes medical management with or without methods of immobility [36,107,108]. If there is failure of medical management with worsening of symptoms to medications or in the setting of spinal deformity or pulmonary dysfunction, other management alternatives should be considered. Patients complaining of significant pain after undergoing a VA must be re-evaluated with radiographs, CT, and MRI scans because the increased pain maybe due to progression of fracture at the same level or development of adjacent level fracture. Percutaneous Vertebral Augmentation A recent meta-analysis from 2017 comprising 1,328 patients found no increased risk for adjacent or remote level vertebral body fracture following augmentation using VP or BK compared with nonsurgical management.

Management of Vertebral Compression Fractures PCAs. Management of osteoporosis in patients undergoing spine surgery is challenging. Still, with appropriate patient selection, medical optimization, and surgical techniques, these patients can experience pain relief, deformity correction, and improved function [130]. Surgical consultation can assist in prescribing and supervising immobilization devices. When the etiology of the VCF is questionable and not amenable to percutaneous biopsy, an open biopsy may be necessary. Vertebral Compression Fractures Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF. If cancer is thought to be the cause of a VCF, a biopsy is needed to confirm a cancer diagnosis. RT is reserved for metastatic spinal disease and typically for those spinal metastases causing pain, neurologic compromise, or those asymptomatic lesions with radiologic features suggesting a risk of neurologic compromise or VCF. Systemic Radionuclide Therapy This procedure is not useful for benign osteoporosis-related compressions fractures. Medical Management Only Medical management is complementary to other therapies and should be offered in all clinical scenarios. Conservative management includes medical management with or without methods of immobility [36,107,108]. If there is failure of medical management with worsening of symptoms to medications or in the setting of spinal deformity or pulmonary dysfunction, other management alternatives should be considered. Patients complaining of significant pain after undergoing a VA must be re-evaluated with radiographs, CT, and MRI scans because the increased pain maybe due to progression of fracture at the same level or development of adjacent level fracture. Percutaneous Vertebral Augmentation A recent meta-analysis from 2017 comprising 1,328 patients found no increased risk for adjacent or remote level vertebral body fracture following augmentation using VP or BK compared with nonsurgical management.

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Management of Vertebral Compression Fractures PCAs

Of the randomized control trials discussed in this document, only 2 studies showed a statistically significant difference in the rate of adjacent vertebral fractures in follow-up between the VA and control groups, one favoring VA and the other nonsurgical management. In addition, VP and BK may be protective against further height loss of a fractured vertebra. In the VERTOS IV trial, the risk of further height loss was almost 10 times higher after the sham procedure compared with VA treatment [133,134]. Patients with ongoing compression at a previously treated level can undergo a second augmentation, especially if the initial fluid-filled cleft did not completely fill or the cleft enlarges afterward. In several large studies, intravertebral clefts were identified in between 90% and 100% of cases of recurrent fractures in a previously treated level [135,136]. The goal is more uniform filling of the vertebra to decrease the micromotion at the fractured vertebral endplates, which helps in pain palliation. After initial augmentation, the development of a new adjacent level fracture can also be addressed by repeating the procedure for the new fracture level. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgery is typically reserved for patients who have developed new neurologic compromise, new spinal instability, or leakage of cement into the spinal epidural space with canal compression and the development of new radicular symptoms. Observational studies suggest that surgical decompression and stabilization improve neurological status from nonambulatory to ambulatory as well as pain relief [137]. Surgical consultation can be performed concurrently with other procedures. Vertebral Compression Fractures Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF.

Management of Vertebral Compression Fractures PCAs. Of the randomized control trials discussed in this document, only 2 studies showed a statistically significant difference in the rate of adjacent vertebral fractures in follow-up between the VA and control groups, one favoring VA and the other nonsurgical management. In addition, VP and BK may be protective against further height loss of a fractured vertebra. In the VERTOS IV trial, the risk of further height loss was almost 10 times higher after the sham procedure compared with VA treatment [133,134]. Patients with ongoing compression at a previously treated level can undergo a second augmentation, especially if the initial fluid-filled cleft did not completely fill or the cleft enlarges afterward. In several large studies, intravertebral clefts were identified in between 90% and 100% of cases of recurrent fractures in a previously treated level [135,136]. The goal is more uniform filling of the vertebra to decrease the micromotion at the fractured vertebral endplates, which helps in pain palliation. After initial augmentation, the development of a new adjacent level fracture can also be addressed by repeating the procedure for the new fracture level. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgery is typically reserved for patients who have developed new neurologic compromise, new spinal instability, or leakage of cement into the spinal epidural space with canal compression and the development of new radicular symptoms. Observational studies suggest that surgical decompression and stabilization improve neurological status from nonambulatory to ambulatory as well as pain relief [137]. Surgical consultation can be performed concurrently with other procedures. Vertebral Compression Fractures Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF.

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Management of Vertebral Compression Fractures PCAs

If cancer is thought to be the cause of a VCF, a biopsy is needed to confirm a cancer diagnosis. RT is reserved for metastatic spinal disease and typically for those spinal metastases causing pain, neurologic compromise, or those asymptomatic lesions with radiologic features suggesting a risk of neurologic compromise or VCF. Systemic Radionuclide Therapy This procedure is not useful for this clinical scenario. Variant 8: Benign VCF with worsening pain, deformity, or pulmonary dysfunction. Initial treatment. Most VCFs show a gradual improvement in pain over 2 to 12 weeks, with a variable return of function [103,104]. Bone marrow edema associated with acute fractures on MRI typically resolves within 1 to 3 months [50,51]. Medical Management Only Medical management is complementary to other therapies and should be offered in all clinical scenarios. Conservative management includes medical management with or without methods of immobility and is the initial treatment of painful VCFs [36,107,108]. Patients may not be candidates for percutaneous or surgical intervention because of factors related to performance status, pregnancy, infection, or coagulation disorders, among others. Clinical decision-making must account for the overall risk and benefit to the patient. Percutaneous Vertebral Augmentation VA may be a treatment option [36,107] for osteoporotic VCFs because there is evidence that VA is associated with better pain relief and improved functional outcomes compared to conservative therapy [21,23,32,34]. VA has shown immediate and considerable improvement in pain and patient mobility. This supports consideration of VA to abate the secondary sequelae of VCFs, such as decreased bone mineral density and muscle strength with immobility [138,139], increased risk of deep venous thrombosis [138], and deconditioning of cardiovascular and respiratory muscles [1,139].

Management of Vertebral Compression Fractures PCAs. If cancer is thought to be the cause of a VCF, a biopsy is needed to confirm a cancer diagnosis. RT is reserved for metastatic spinal disease and typically for those spinal metastases causing pain, neurologic compromise, or those asymptomatic lesions with radiologic features suggesting a risk of neurologic compromise or VCF. Systemic Radionuclide Therapy This procedure is not useful for this clinical scenario. Variant 8: Benign VCF with worsening pain, deformity, or pulmonary dysfunction. Initial treatment. Most VCFs show a gradual improvement in pain over 2 to 12 weeks, with a variable return of function [103,104]. Bone marrow edema associated with acute fractures on MRI typically resolves within 1 to 3 months [50,51]. Medical Management Only Medical management is complementary to other therapies and should be offered in all clinical scenarios. Conservative management includes medical management with or without methods of immobility and is the initial treatment of painful VCFs [36,107,108]. Patients may not be candidates for percutaneous or surgical intervention because of factors related to performance status, pregnancy, infection, or coagulation disorders, among others. Clinical decision-making must account for the overall risk and benefit to the patient. Percutaneous Vertebral Augmentation VA may be a treatment option [36,107] for osteoporotic VCFs because there is evidence that VA is associated with better pain relief and improved functional outcomes compared to conservative therapy [21,23,32,34]. VA has shown immediate and considerable improvement in pain and patient mobility. This supports consideration of VA to abate the secondary sequelae of VCFs, such as decreased bone mineral density and muscle strength with immobility [138,139], increased risk of deep venous thrombosis [138], and deconditioning of cardiovascular and respiratory muscles [1,139].

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Management of Vertebral Compression Fractures PCAs

Because of improved alignment and decreased pain, VA has been shown to improve pulmonary function in patients with VCF [89,123,124,140]. Certain newer variants of VA are shown to be comparable to standard methods, such as BK, for decreased pain score, functional improvement, and height restoration [17,141]. The timing of when VA is useful has been debated. In the VERTOS II trial, of the patients who had significant pain relief on medical management, the majority achieved this level by 3 months; this study suggested that patients who had not received sufficient pain relief by 3 months with conservative treatment may be candidates for VA [34]. Studies have found VA to be superior to placebo intervention for pain reduction in patients with acute osteoporotic VCF of <6 weeks duration [22]. As noted in Variant 1 in the study by Syed et al [33], patients with VCF >12 weeks compared with VCF <12 weeks had equivalent benefit suggesting that the age of the fracture does not independently affect the outcomes of VA, although there is evidence for treatment of subacute and chronic, painful compression fractures [21,23,31,32]. Vertebral Compression Fractures position that BK or VP may be considered to be useful and generally interchangeable techniques for the performance of VA [36]. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgical intervention is reserved for patients with neurologic deficits or spinal instability. When the etiology of the VCF is questionable and percutaneous biopsy is not feasible, an open biopsy may be necessary. Surgical consultation can assist in prescribing and supervising immobilization devices. Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF. If cancer is thought to be the cause of a VCF, then a biopsy is needed to confirm a cancer diagnosis.

Management of Vertebral Compression Fractures PCAs. Because of improved alignment and decreased pain, VA has been shown to improve pulmonary function in patients with VCF [89,123,124,140]. Certain newer variants of VA are shown to be comparable to standard methods, such as BK, for decreased pain score, functional improvement, and height restoration [17,141]. The timing of when VA is useful has been debated. In the VERTOS II trial, of the patients who had significant pain relief on medical management, the majority achieved this level by 3 months; this study suggested that patients who had not received sufficient pain relief by 3 months with conservative treatment may be candidates for VA [34]. Studies have found VA to be superior to placebo intervention for pain reduction in patients with acute osteoporotic VCF of <6 weeks duration [22]. As noted in Variant 1 in the study by Syed et al [33], patients with VCF >12 weeks compared with VCF <12 weeks had equivalent benefit suggesting that the age of the fracture does not independently affect the outcomes of VA, although there is evidence for treatment of subacute and chronic, painful compression fractures [21,23,31,32]. Vertebral Compression Fractures position that BK or VP may be considered to be useful and generally interchangeable techniques for the performance of VA [36]. Percutaneous Ablation Spine Percutaneous thermal ablation procedures are reserved for symptomatic spinal metastatic disease [112]. Surgical Consultation Surgical intervention is reserved for patients with neurologic deficits or spinal instability. When the etiology of the VCF is questionable and percutaneous biopsy is not feasible, an open biopsy may be necessary. Surgical consultation can assist in prescribing and supervising immobilization devices. Radiation Oncology Consultation There is no role for RT in a patient without a cancer diagnosis and a nonpathologic VCF. If cancer is thought to be the cause of a VCF, then a biopsy is needed to confirm a cancer diagnosis.

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Management of Vertebral Compression Fractures PCAs

RT is reserved for metastatic spinal disease and typically for those spinal metastases causing pain, neurologic compromise, or those asymptomatic lesions with radiologic features suggesting a risk of neurologic compromise or VCF. Systemic Radionuclide Therapy This procedure is not useful for this clinical scenario but this therapy maybe an option for pain palliation in patients with multifocal osteoblastic metastases, particularly hormone-resistant prostate and breast cancers. The radionuclides are incorporated into the bony matrix and emit radioactive alpha or beta particles that reduce tumor volume and decrease the production of pain sensitive cytokines Variant 9: Pathological VCF with ongoing or increasing mechanical pain. Initial treatment. Medical Management Only Medical management is complementary to other therapies and should be offered in all clinical scenarios. Upon presentation with neurological deficits, the patient should be treated with corticosteroid therapy, and treatment should be initiated as soon as possible to prevent further neurological deterioration [142]. Percutaneous Ablation Spine Image-guided ablative therapies demonstrate potential advantages, including reduced morbidity, lower procedural suitability for real-time imaging guidance, the ability to perform therapy in an outpatient setting, synergy with other cancer treatments, repeatability, and short procedural time [143]. Percutaneous thermal ablation of vertebral metastases is a valid therapeutic option for the following patient subgroups: patients with a life expectancy of more than 6 months, good performance status, and few visceral metastases; uncomplicated (lack of metastatic epidural spinal cord compression), painful spinal metastases; and stable pathologic VCF. Percutaneous thermal ablation has been demonstrated to be an effective treatment option for the management of vertebral metastases with an excellent safety profile.

Management of Vertebral Compression Fractures PCAs. RT is reserved for metastatic spinal disease and typically for those spinal metastases causing pain, neurologic compromise, or those asymptomatic lesions with radiologic features suggesting a risk of neurologic compromise or VCF. Systemic Radionuclide Therapy This procedure is not useful for this clinical scenario but this therapy maybe an option for pain palliation in patients with multifocal osteoblastic metastases, particularly hormone-resistant prostate and breast cancers. The radionuclides are incorporated into the bony matrix and emit radioactive alpha or beta particles that reduce tumor volume and decrease the production of pain sensitive cytokines Variant 9: Pathological VCF with ongoing or increasing mechanical pain. Initial treatment. Medical Management Only Medical management is complementary to other therapies and should be offered in all clinical scenarios. Upon presentation with neurological deficits, the patient should be treated with corticosteroid therapy, and treatment should be initiated as soon as possible to prevent further neurological deterioration [142]. Percutaneous Ablation Spine Image-guided ablative therapies demonstrate potential advantages, including reduced morbidity, lower procedural suitability for real-time imaging guidance, the ability to perform therapy in an outpatient setting, synergy with other cancer treatments, repeatability, and short procedural time [143]. Percutaneous thermal ablation of vertebral metastases is a valid therapeutic option for the following patient subgroups: patients with a life expectancy of more than 6 months, good performance status, and few visceral metastases; uncomplicated (lack of metastatic epidural spinal cord compression), painful spinal metastases; and stable pathologic VCF. Percutaneous thermal ablation has been demonstrated to be an effective treatment option for the management of vertebral metastases with an excellent safety profile.

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Management of Vertebral Compression Fractures PCAs

The local tumor control rates of percutaneous thermal ablation of spinal osseous metastatic disease have been reported at 70% to 96% in several case series [144-146]. Implementation of appropriate patient selection guidelines, the optimal choice of ablation modality, and the use of thermal protection when necessary are major contributors to improved treatment outcomes. RFA is typically used to treat osteolytic or mixed osteolytic-osteoblastic vertebral (body and/or posterior elements) tumors without soft tissue components. RFA is often ineffective in treating primarily osteoblastic lesions because of the high impedance of densely sclerotic bone [145]. Microwave ablation uses electromagnetic waves to agitate water molecules, producing friction and heat that induces cellular death via coagulation necrosis. Microwave ablation is more effective in high-impedance tissues like bone because poor thermal conduction in bone may be at times a limiting factor in RFA. Osseous relative permeability and low conduction help microwaves penetrate deeper and are more effective in thermal ablation than RFA. Microwave ablation is a promising, safe, and effective treatment for osseous tumors, resulting in both a reduction in pain and a degree of locoregional control of the disease process [143]. Cryoablation results in the formation of a hypoattenuating ice ball, which is readily identified by CT, beyond which tissues are safe from thermal injury. Additional advantages of cryoablation are decreased intraprocedural and postprocedural pain, the ability to use multiple probes in various orientations to achieve additive overlapping ablation zones, and efficiency in treating osteoblastic metastases [147]. Typically followed VA procedure patients should still be considered for radiation. Vertebral Compression Fractures Percutaneous Vertebral Augmentation VA is a safe and effective treatment for vertebrae weakened by neoplasia [148].

Management of Vertebral Compression Fractures PCAs. The local tumor control rates of percutaneous thermal ablation of spinal osseous metastatic disease have been reported at 70% to 96% in several case series [144-146]. Implementation of appropriate patient selection guidelines, the optimal choice of ablation modality, and the use of thermal protection when necessary are major contributors to improved treatment outcomes. RFA is typically used to treat osteolytic or mixed osteolytic-osteoblastic vertebral (body and/or posterior elements) tumors without soft tissue components. RFA is often ineffective in treating primarily osteoblastic lesions because of the high impedance of densely sclerotic bone [145]. Microwave ablation uses electromagnetic waves to agitate water molecules, producing friction and heat that induces cellular death via coagulation necrosis. Microwave ablation is more effective in high-impedance tissues like bone because poor thermal conduction in bone may be at times a limiting factor in RFA. Osseous relative permeability and low conduction help microwaves penetrate deeper and are more effective in thermal ablation than RFA. Microwave ablation is a promising, safe, and effective treatment for osseous tumors, resulting in both a reduction in pain and a degree of locoregional control of the disease process [143]. Cryoablation results in the formation of a hypoattenuating ice ball, which is readily identified by CT, beyond which tissues are safe from thermal injury. Additional advantages of cryoablation are decreased intraprocedural and postprocedural pain, the ability to use multiple probes in various orientations to achieve additive overlapping ablation zones, and efficiency in treating osteoblastic metastases [147]. Typically followed VA procedure patients should still be considered for radiation. Vertebral Compression Fractures Percutaneous Vertebral Augmentation VA is a safe and effective treatment for vertebrae weakened by neoplasia [148].

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VA provides analgesia and structural reinforcement more rapidly than other treatment measures [149]. Certain newer variants of VA have been shown to be comparable to standard methods, such as BK, in decreasing pain scores and functional improvement [17]. VCFs following SBRT are also amenable to VA. Typically followed VA procedure patients should still be considered for radiation. Surgical Consultation Surgery is the standard of care for pathologic VCF complicated by frank spinal instability and/or neurologic deficits. The SINS can be used to categorize the metastatic spinal segment as stable, potentially unstable, or unstable based on anatomic and clinical factors [150] and can guide surgical referral [14,150]. In the setting of metastatic spinal cord compression, mainly because of osseous compression, surgery is more likely to allow recovery compared to RT alone [151]. Observational studies suggest that surgical decompression, tumor excision, and stabilization improve neurological status from nonambulatory to ambulatory and provide pain relief [137]. Decompressive surgery followed by RT may benefit symptomatic spinal cord compression in patients who are <65 years of age, in the setting of a single level of compression, in patients with neurologic deficits for <48 hours, and in those patients with a predicted survival of at least 3 months [152]. The combination of a spine stabilization procedure and RT may also help manage axial pain and aid in neurologic recovery [153]. A large prospective randomized trial shows that patients with metastatic epidural spinal cord compression treated with direct decompressive surgery plus postoperative radiotherapy retain the ability to walk for longer and regain the ability more often than patients treated with radiotherapy alone. Surgery allows most patients to remain ambulatory for the remainder of their lives, whereas patients treated with radiation alone spend a substantial proportion of their remaining time paraplegic.

Management of Vertebral Compression Fractures PCAs. VA provides analgesia and structural reinforcement more rapidly than other treatment measures [149]. Certain newer variants of VA have been shown to be comparable to standard methods, such as BK, in decreasing pain scores and functional improvement [17]. VCFs following SBRT are also amenable to VA. Typically followed VA procedure patients should still be considered for radiation. Surgical Consultation Surgery is the standard of care for pathologic VCF complicated by frank spinal instability and/or neurologic deficits. The SINS can be used to categorize the metastatic spinal segment as stable, potentially unstable, or unstable based on anatomic and clinical factors [150] and can guide surgical referral [14,150]. In the setting of metastatic spinal cord compression, mainly because of osseous compression, surgery is more likely to allow recovery compared to RT alone [151]. Observational studies suggest that surgical decompression, tumor excision, and stabilization improve neurological status from nonambulatory to ambulatory and provide pain relief [137]. Decompressive surgery followed by RT may benefit symptomatic spinal cord compression in patients who are <65 years of age, in the setting of a single level of compression, in patients with neurologic deficits for <48 hours, and in those patients with a predicted survival of at least 3 months [152]. The combination of a spine stabilization procedure and RT may also help manage axial pain and aid in neurologic recovery [153]. A large prospective randomized trial shows that patients with metastatic epidural spinal cord compression treated with direct decompressive surgery plus postoperative radiotherapy retain the ability to walk for longer and regain the ability more often than patients treated with radiotherapy alone. Surgery allows most patients to remain ambulatory for the remainder of their lives, whereas patients treated with radiation alone spend a substantial proportion of their remaining time paraplegic.

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Management of Vertebral Compression Fractures PCAs

Surgical treatment also results in increased survival time. The better survival time in the surgical group was probably because a greater proportion of patients in this group were ambulatory and remained so for longer than those in the radiation group. Therefore, patients in the surgery group were less susceptible to infections, blood clots, and other problems that result in the death of paraplegic patients. Surgical treatment also reduces the need for corticosteroids and opioid pain relief [154]. Palliative surgery using posterior decompression and fixation combined with intraoperative VA to treat spinal metastases with osseous and epidural disease can improve neurological function, alleviate pain effectively, and allow low cement leakage and timely disposal of leakage if it happens [155]. Radiation Oncology Consultation The current standard of care for the management of diffuse painful osseous metastases is external beam RT [156] for at least partial pain palliation [157]. A short course, such as 8 Gy in 1 fraction (as opposed to 20 Gy in 5 fractions or 30 Gy in 10 fractions), is best for patients who have radiosensitive tumors (hematologic primary, seminoma, small-cell lung cancer) or have a poor survival prognosis (<3 months). Some studies have demonstrated benefit in up to 70% of patients treated with respect to neurologic improvement for patients with symptomatic spinal cord compression [158,159]. Advancements in radiotherapy have allowed for the delivery of high precision dose- escalated treatment, known as SBRT, to targets throughout the body with excellent local control rates. Recently, the first phase II randomized trial comparing conventional radiotherapy to comprehensive SBRT of oligometastatic disease demonstrated an overall survival and progression-free survival advantage [160].

Management of Vertebral Compression Fractures PCAs. Surgical treatment also results in increased survival time. The better survival time in the surgical group was probably because a greater proportion of patients in this group were ambulatory and remained so for longer than those in the radiation group. Therefore, patients in the surgery group were less susceptible to infections, blood clots, and other problems that result in the death of paraplegic patients. Surgical treatment also reduces the need for corticosteroids and opioid pain relief [154]. Palliative surgery using posterior decompression and fixation combined with intraoperative VA to treat spinal metastases with osseous and epidural disease can improve neurological function, alleviate pain effectively, and allow low cement leakage and timely disposal of leakage if it happens [155]. Radiation Oncology Consultation The current standard of care for the management of diffuse painful osseous metastases is external beam RT [156] for at least partial pain palliation [157]. A short course, such as 8 Gy in 1 fraction (as opposed to 20 Gy in 5 fractions or 30 Gy in 10 fractions), is best for patients who have radiosensitive tumors (hematologic primary, seminoma, small-cell lung cancer) or have a poor survival prognosis (<3 months). Some studies have demonstrated benefit in up to 70% of patients treated with respect to neurologic improvement for patients with symptomatic spinal cord compression [158,159]. Advancements in radiotherapy have allowed for the delivery of high precision dose- escalated treatment, known as SBRT, to targets throughout the body with excellent local control rates. Recently, the first phase II randomized trial comparing conventional radiotherapy to comprehensive SBRT of oligometastatic disease demonstrated an overall survival and progression-free survival advantage [160].

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Management of Vertebral Compression Fractures PCAs

The spine is a common site of metastasis and a complex site for SBRT given the adjacent spinal cord and the tumor embedded within the bone tissue putting the patient at risk of fracture [161]. SBRT delivers precise, high-dose radiation to the target region while sparing the spinal cord and provides satisfactory efficacy and an acceptable safety profile for spinal metastases. A recent landmark randomized phase 3 trial led by Sahgal et al [162] showed that SBRT delivering 24 Gy in 2 fractions was superior to conventional radiotherapy delivering 20 Gy in 5 fractions for patients with limited painful spinal metastases. They reported an 11% risk of VCF in the SBRT arm and superior complete response rates for pain at 3 and 6 months posttreatment with SBRT [162]. No comparative randomized trials have been performed to establish optimal dosing of spine SBRT. Single-fraction SBRT may result in a higher local control rate than those of the other fractionations, particularly with 24 Gy in 1 fraction. However, high-dose single fraction SBRT comes at the expense of a greater rate of vertebral fracture, which can even approximate 40% [96]. At present, the dose of spine SBRT varies from 18 to 24 Gy in 1 fraction, 24 Gy in 2 fractions, and 24 to 40 Gy in 3 to 5 fractions [95]. A study by Chen et al [163] using normal tissue complication probability modeling suggests that the larger volume of the vertebral segment receiving lower doses is more closely associated with post-SBRT VCF than high dose regions, and technical developments in spine SBRT Vertebral Compression Fractures continue to evolve with respect to mitigating the risk of iatrogenic fracture. Typically VCF secondary to radiation can be managed with a cement augmentation procedure, and there is increasing use of cement augmentation procedures prophylactically to mitigate the risk of iatrogenic VCF [15,164].

Management of Vertebral Compression Fractures PCAs. The spine is a common site of metastasis and a complex site for SBRT given the adjacent spinal cord and the tumor embedded within the bone tissue putting the patient at risk of fracture [161]. SBRT delivers precise, high-dose radiation to the target region while sparing the spinal cord and provides satisfactory efficacy and an acceptable safety profile for spinal metastases. A recent landmark randomized phase 3 trial led by Sahgal et al [162] showed that SBRT delivering 24 Gy in 2 fractions was superior to conventional radiotherapy delivering 20 Gy in 5 fractions for patients with limited painful spinal metastases. They reported an 11% risk of VCF in the SBRT arm and superior complete response rates for pain at 3 and 6 months posttreatment with SBRT [162]. No comparative randomized trials have been performed to establish optimal dosing of spine SBRT. Single-fraction SBRT may result in a higher local control rate than those of the other fractionations, particularly with 24 Gy in 1 fraction. However, high-dose single fraction SBRT comes at the expense of a greater rate of vertebral fracture, which can even approximate 40% [96]. At present, the dose of spine SBRT varies from 18 to 24 Gy in 1 fraction, 24 Gy in 2 fractions, and 24 to 40 Gy in 3 to 5 fractions [95]. A study by Chen et al [163] using normal tissue complication probability modeling suggests that the larger volume of the vertebral segment receiving lower doses is more closely associated with post-SBRT VCF than high dose regions, and technical developments in spine SBRT Vertebral Compression Fractures continue to evolve with respect to mitigating the risk of iatrogenic fracture. Typically VCF secondary to radiation can be managed with a cement augmentation procedure, and there is increasing use of cement augmentation procedures prophylactically to mitigate the risk of iatrogenic VCF [15,164].

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