Vomiting in Infants

Vomiting in Infants. Nuclear Medicine Gastroesophageal Reflux Scan Reflux scintigraphy can be performed using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA mixed in a feeding. Seibert et al [35] noted reflux scintigraphy to be 79% sensitive when compared to a 24-hour pH esophageal probe as a standard. Methodology and interpretation criteria for reflux scintigraphy are not uniform from center to center [36,37]. Several studies have tried to standardize the methodology of the examination. A 1-hour scintigraphic study formatted in 60-second frames provides a quantitative representation of postprandial GER for children, particularly in the absence of rapid gastric emptying [38]. False-negative examinations can be associated with delayed gastric emptying, and in this patient group, prolongation of the study beyond 60 minutes or confirmatory pH probe evaluation may be advisable. Othman [39] proposes that placing the patient in multiple positions during the scan results in a percentage yield of a positive study that is 3-fold that of the conventional supine position technique.


Vomiting in Infants

Vomiting in Infants. In a series of symptomatic and asymptomatic preterm infants who had reached 32 to 34 weeks postconceptual age, reflux scintigraphy demonstrated a high incidence of reflux in both groups that did not correlate with symptoms [40]. Use of this examination thus may be limited to patients older than 3 months of age in which other modalities have excluded an anatomic cause for feeding disorders [35,41,42].


Vomiting in Infants

Vomiting in Infants. US Abdomen (UGI Tract) There is no relevant literature to support the use of US in the diagnosis of reflux, and inconsistent results are reported with sensitivity ranging from 38% to 100% [43-47]. US diagnosis of reflux is made by visualizing water placed into the stomach refluxing into the distal esophagus. However, there is no standardization of the study, and the amount of water and duration of observation varies.


Vomiting in Infants

Vomiting in Infants. Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging. Fluoroscopy Contrast Enema There is no relevant literature to support the use of contrast enema for evaluation of HPS.


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Upper GI Series Though the UGI series is excellent for diagnosing obstructive causes of vomiting in this age group, it is less ideal than US as an initial imaging test if HPS is a strong consideration [48,49].


Vomiting in Infants

Vomiting in Infants. Nuclear Medicine Gastroesophageal Reflux Scan If all other causes of vomiting have been excluded, reflux scintigraphy using Tc-99m sulfur colloid may be useful for functional evaluation of gastric emptying, although such patients are typically older than 3 months of age when scintigraphy is requested.


Vomiting in Infants

Vomiting in Infants

Vomiting in Infants. Vomiting in Infants


Vomiting in Infants

Vomiting in Infants. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Vomiting in Infants

Vomiting in Infants. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Vomiting in Infants

Vomiting in Infants


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


Evaluation of the Symptomatic Male Breast. If the differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings, or if the clinical presentation is suspicious, imaging is indicated [1,2].


Evaluation of the Symptomatic Male Breast. Discussion of Procedures by Variant Variant 1: Male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia. Initial imaging. Most men with breast symptoms can be diagnosed on the basis of clinical findings without imaging [1,2]. Gynecomastia is the most common cause of a palpable mass, breast enlargement, or pain [1-3]. Gynecomastia is bilateral in approximately half of patients. On physical examination, gynecomastia often presents as a soft, rubbery, or firm mobile mass directly under the nipple [3,4]. In addition, gynecomastia is more likely to be painful than cancer [3], especially gynecomastia that has been present for <6 months [3,4].


Evaluation of the Symptomatic Male Breast. Mammography In men with clinical findings consistent with gynecomastia or pseudogynecomastia, mammography is not routinely indicated. When performed, 3 patterns of gynecomastia have been described on mammography: (1) nodular (subareolar nodule), (2) dendritic (subareolar flame-shaped tissue), and (3) diffuse glandular (much like a heterogeneously dense female breast) [11]. When pseudogynecomastia is identified as the sole imaging finding,


Evaluation of the Symptomatic Male Breast. aH. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. bAlpert Medical School of Brown University, Providence, Rhode Island. cPanel Vice- Chair, NYU Clinical Cancer Center, New York, New York. dRoper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons. eNorthwestern University Feinberg School of Medicine, Chicago, Illinois; American College of Physicians. fDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. gNew York University School of Medicine, New York, New York. hEmory University Hospital, Atlanta, Georgia. iThe University of Texas MD Anderson Cancer Center, Houston, Texas. jNew York University School of Medicine, New York, New York. kBeth Israel Deaconess Medical Center, Boston, Massachusetts. lBeth Israel Deaconess Medical Center, Boston, Massachusetts. mWomen and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists. nMecklenburg Radiology Associates, Charlotte, North Carolina. oMemorial Sloan Kettering Cancer Center, New York, New York. pDonald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York. qPerelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania. rPanel Chair, Emory University Hospital, Atlanta, Georgia.


Evaluation of the Symptomatic Male Breast. 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.


Evaluation of the Symptomatic Male Breast. Reprint requests to: publications@acr.org


Evaluation of the Symptomatic Male Breast. Evaluation of the Symptomatic Male Breast mammography may obviate further unnecessary interventions for falsely presumed gynecomastia (eg, altering medications) [12].


Evaluation of the Symptomatic Male Breast. Gynecomastia may be incidentally identified on chest CT [13]. Men with characteristic imaging findings of gynecomastia on CT do not benefit from further evaluation with mammography unless there is a suspicious clinical finding (eg, eccentric breast mass, nipple discharge, or axillary adenopathy) [13].


Evaluation of the Symptomatic Male Breast. DBT In men with clinical findings consistent with gynecomastia or pseudogynecomastia, digital breast tomosynthesis (DBT) is not routinely indicated. When performed, gynecomastia demonstrates similar imaging characteristics on DBT compared to mammography [14,15].


Evaluation of the Symptomatic Male Breast. US Breast In men with clinical findings consistent with gynecomastia or pseudogynecomastia, ultrasound (US) is not routinely indicated. When US is performed, gynecomastia may appear mass-like and demonstrate vascularity on color Doppler [16-18]. Comparison with the contralateral side may be helpful on real-time imaging, as synchronous bilateral breast carcinoma in males is rare. Chen et al [19] evaluated the incremental clinical value of US in 327 symptomatic male patients where mammography was negative or revealed only gynecomastia and found no additional malignancies. However, in that series, US did lead to additional unnecessary benign biopsies. Tangerud et al [20], in a study of 350 men with mammographic findings diagnostic of gynecomastia, did not identify any patients with male breast cancer when US, fine needle aspiration, or core biopsy was performed in conjunction with mammography.


Evaluation of the Symptomatic Male Breast. When performed for suspected gynecomastia, US may demonstrate a lack of breast tissue in men with pseudogynecomastia and obviate further unnecessary interventions for falsely presumed gynecomastia (eg, altering medications) [12,21-23].


Evaluation of the Symptomatic Male Breast. MRI Breast In men with clinical findings consistent with gynecomastia or pseudogynecomastia, breast MRI is not indicated as the initial imaging study. There is no relevant literature regarding the use of breast MRI as the initial imaging evaluation of suspected gynecomastia.


Evaluation of the Symptomatic Male Breast. Variant 2: Male younger than 25 years of age with indeterminate palpable breast mass. Initial imaging. Only 6% of male breast cancers occur in men <40 years of age and 1% in men <30 years of age [24]. Given the relationship between breast cancer incidence and increasing age, age-based protocols in younger men have been developed [3,25]. If clinical breast examination is indeterminate, imaging is recommended prior to biopsy recommendation.


Evaluation of the Symptomatic Male Breast. Mammography The extremely low incidence of breast cancer in young men reduces the utility of mammography as the initial imaging study. However, if there are suspicious or indeterminate features on US, mammography or DBT should be performed before a biopsy recommendation is made because diagnostic mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2].


Evaluation of the Symptomatic Male Breast. DBT There is no relevant literature regarding the use of DBT in the evaluation of men <25 years of age with an indeterminate palpable breast mass. However, if there are suspicious or indeterminate features on US, mammography or DBT should be performed before a biopsy recommendation is made because mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2]. DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as mammography [14,15,26].


Evaluation of the Symptomatic Male Breast. US Breast Some authors suggest that using US is useful as the initial imaging modality in the young male who is unlikely to have breast cancer and who presents with an indeterminate physical symptom [3]. However, gynecomastia and oil cysts can have a suspicious appearance on US but can typically be diagnosed as benign on mammography or DBT. Therefore, if there are suspicious features on US, mammography or DBT should be performed before a biopsy recommendation is made.


Evaluation of the Symptomatic Male Breast. Evaluation of the Symptomatic Male Breast MRI Breast There is no relevant literature regarding the use of MRI as the initial imaging study in the evaluation of men <25 years of age with an indeterminate palpable breast mass.


Evaluation of the Symptomatic Male Breast. Variant 3: Male 25 years of age or older with indeterminate palpable breast mass. Initial imaging. Breast cancer is a disease of older men and typically presents at a later age than in women at a median age of 63 years [5]. If clinical breast examination is indeterminate, imaging is recommended prior to biopsy recommendation.


Evaluation of the Symptomatic Male Breast. Mammography For men with an equivocal physical examination and of an age at which breast cancer is more likely, mammography or DBT is recommended as the initial imaging modality. Diagnostic mammography is useful in distinguishing malignancy from benign breast conditions in symptomatic males [1,2]. A bilateral mammogram is routinely performed in symptomatic males [27], although there is no literature comparing the efficacy of bilateral versus unilateral imaging. A bilateral examination may be useful to assess for symmetry [28] and may detect asymptomatic contralateral gynecomastia or the rare nonpalpable contralateral carcinoma [3]. Although not routinely performed, pectoralis-displaced mammographic views can be acquired if the breast tissue is obscured by overlying well-developed pectoralis musculature [29].


Evaluation of the Symptomatic Male Breast. Mammography is highly sensitive and specific in distinguishing benign from malignant disease and is likely more sensitive than US at detecting breast cancer because microcalcifications may be optimally visualized on this modality [3,6]. Studies demonstrate sensitivities ranging from 92% to 100%, specificities ranging from 90% to 96%, and negative predictive values (NPV) of 99% to 100% [3,9,12,28]. Thus, mammography is useful both in identifying breast cancer and for obviating the need for US or biopsy in patients for whom the benign mammographic appearance confirms the clinical impression.


Evaluation of the Symptomatic Male Breast. DBT For men with an equivocal physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16]. Data on the incremental utility of DBT compared to mammography alone in the evaluation of the male breast are limited. However, DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as that of mammography [14,15,26].


Evaluation of the Symptomatic Male Breast. US Breast If the mammogram is indeterminate or suspicious, US can assist in clinical management and guide biopsy [3].


Evaluation of the Symptomatic Male Breast. Variant 4: Male 25 years of age or older with indeterminate palpable breast mass. Mammography or digital breast tomosynthesis indeterminate or suspicious. US Breast If the mammogram is indeterminate or suspicious, US is usually appropriate as the next imaging modality because US can assist in lesion characterization and guide biopsy [3]. Performance of breast US in men may be more variable than mammography. Carrasco et al [3], in their series of 638 patients, reported a lower sensitivity of US for distinguishing benign from malignant disease (88.9% compared to 95% for mammography) but a similar, high specificity of 95%. However, Patterson et al [28], in a series of 166 patients, reported US to have the same sensitivity as mammography (100%) but lower specificity (74%).


Evaluation of the Symptomatic Male Breast. MRI Breast Breast MRI is generally not indicated for the evaluation of indeterminate palpable breast masses in men.


Evaluation of the Symptomatic Male Breast. Variant 5: Male of any age with physical examination suspicious for breast cancer (suspicious palpable breast mass, axillary adenopathy, nipple discharge, or nipple retraction). Initial imaging. Breast cancer is a disease of older men and typically presents at a later age (median age of 63 years) than in women [5]. Male breast cancer is rarely bilateral and typically presents with a painless, hard mass, which may be subareolar or, unlike gynecomastia, eccentric to the nipple. With breast cancer, there may be secondary signs of malignancy, such as nipple or skin retraction, nipple discharge, or axillary lymphadenopathy [6]. Breast cancers in


Evaluation of the Symptomatic Male Breast. Evaluation of the Symptomatic Male Breast men often present at a more advanced stage than breast cancers in women, with up to 47% of men having axillary nodal involvement at the time of diagnosis [6]. In addition, nipple discharge is suspicious for breast cancer in men, with 2 studies showing carcinoma in 23% to 57% of men presenting with this symptom [7,8].


Evaluation of the Symptomatic Male Breast. Mammography For men with a suspicious physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16]. Breast cancer in men typically presents with an irregular mass but may present as a focal asymmetry, asymmetry, or in association with calcifications [3,11,12,24]. Because lobular development does not typically occur in men and men do not have the same background of benign proliferative changes as do women, relatively benign imaging findings, such as a circumscribed mass or round calcifications, should be considered suspicious in male patients [3,6,27].


Evaluation of the Symptomatic Male Breast. Mammography is highly sensitive and specific in distinguishing benign from malignant disease and is likely more sensitive than US at detecting breast cancer because microcalcifications may be optimally visualized on this modality [3,6]. Studies demonstrate sensitivities ranging from 92% to 100%, specificities ranging from 90% to 96%, and NPVs of 99% to 100% [3,9,12,28]. Thus, mammography is useful both in identifying breast cancer and for obviating the need for US or biopsy in patients for whom the benign mammographic appearance confirms the clinical impression.


Evaluation of the Symptomatic Male Breast. DBT For men with a suspicious physical examination finding, mammography or DBT is recommended as the initial imaging study because mammography has high sensitivity, specificity, and NPV [3,9,12,16]. Data on the incremental utility of DBT compared to mammography alone in the evaluation of male breast cancer are limited. However, DBT can be performed in men and demonstrates similar imaging appearances for benign and malignant male breast disorders as mammography [14,15,26]. No documented case of male breast cancer identified solely on DBT has been reported [15].


Evaluation of the Symptomatic Male Breast. US Breast Mammography is recommended as the initial imaging study because of its high sensitivity, specificity, and NPV, and the performance of breast US in men may be more variable than mammography [3,9,12,16]. Carrasco et al [3], in their series of 638 patients, reported a lower sensitivity of US for distinguishing benign from malignant disease (88.9% compared to 95% for mammography) but a similar, high specificity of 95.3%. However, Patterson et al [28] in a series of 166 patients reported US to have the same sensitivity as mammography (100%) but lower specificity (74%). In conjunction with mammography or DBT, US is often useful in assisting with management decisions and to facilitate US core biopsy [3].


Evaluation of the Symptomatic Male Breast. Male breast cancers typically manifest as hypoechoic solid masses with irregular borders; however, cystic or circumscribed masses in men should also be viewed with suspicion unless definitely correlative benign findings (eg, oil cyst) are identified on mammography [3,11,24,30,31]. Lapid et al [32] in a series of 557 male patients demonstrated that mammography and/or US imaging in combination had an NPV of 99.8%, and a complex cystic and solid mass on US was the only false-negative examination.


Evaluation of the Symptomatic Male Breast. Summary of Recommendations Variant 1: Imaging is not recommended for the initial imaging of a male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia. Variant 2: US breast is usually appropriate for the initial imaging of a male patient younger than 25 years of age with an indeterminate palpable breast mass. Variant 3: Diagnostic mammography or DBT is usually appropriate for the initial imaging of a male patient 25 years of age or older with an indeterminate palpable breast mass. These procedures are equivalent alternatives.


Evaluation of the Symptomatic Male Breast. 6 Variant 4: US breast is usually appropriate for the imaging of a male patient 25 years of age or older with a breast mass deemed indeterminate or suspicious on diagnostic mammography or DBT. Variant 5: Diagnostic mammography or DBT and US breast are usually appropriate for the initial imaging of a male patient of any age with physical examination suspicious for breast cancer (suspicious palpable breast mass, axillary adenopathy, nipple discharge, or nipple retraction). Diagnostic mammography and DBT are equivalent alternatives as the initial imaging modality. US breast is usually appropriate as a complementary imaging modality.


Evaluation of the Symptomatic Male Breast. Although there are references that report on studies with design limitations, 3 good-quality studies provide good evidence.


Evaluation of the Symptomatic Male Breast. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Sinusitis Child

Sinusitis Child. Introduction/Background Acute sinusitis is defined as an acute inflammatory process involving the paranasal sinuses. Acute sinusitis is common in children and usually resolves spontaneously, although it can result in serious complications [1-9]. Acute sinusitis may be viral, bacterial, or fungal. Viral upper respiratory tract infections occur with an incidence of six episodes per patient year, and 8% of these viral infections are complicated by acute viral sinusitis [2]. Inflammation of the mucosal lining of the nose and paranasal sinuses secondary to viral infection sets the stage for bacterial superinfection [10], thus making viral infections the most common predisposing factor for acute bacterial sinusitis, followed by allergic rhinitis [1,3-5]. Other noninfectious factors that may lead to sinusitis in children include nasal airway obstruction, immunodeficiency, ciliary dysfunction, cystic fibrosis, and odontogenic infections [1,3-9,11-13].


Sinusitis Child

Sinusitis Child. Imaging abnormalities alone are not sufficient for the diagnosis of acute sinusitis because paranasal sinus opacification is often present in healthy children or in children having a CT scan for other reasons. CT performed on young adults recovering from a cold illustrated that 87% had significant maxillary sinus abnormalities. One study showed that >50% of children with viral upper respiratory tract infection had abnormal maxillary sinus radiographs [2]. Further research showed that 68% of symptomatic children with upper respiratory tract infection and 42% of healthy children had significant sinus abnormalities on MRI [2]. This incidence is even higher in very young patient populations and reached 97% in a study of infants who had a cold in the 2 weeks preceding a head CT done for other reasons [15].


Sinusitis Child

Sinusitis Child. The AAP defines subacute bacterial sinusitis as a sinusitis that lasts between 30 and 90 days and whose symptoms resolve completely. Recurrent acute bacterial sinusitis is defined by episodes lasting <30 days each and separated by intervals of at least 10 asymptomatic days. Chronic sinusitis lasts >90 days, and is defined by persistent residual respiratory symptoms, such as cough, rhinorrhea, or nasal obstruction [1]. In patients with recurrent or chronic sinusitis, one must consider other underlying causes such as asthma, gastroesophageal reflux, cystic


Sinusitis Child

Sinusitis Child. 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.


Sinusitis Child

Sinusitis Child. Reprint requests to: publications@acr.org


Sinusitis Child

Sinusitis Child. Intracranial complications most commonly result from spread of primary infection within the frontal sinuses [19- 23,25]. This typically occurs via progression of septic thrombi through the valveless diploic veins of the skull that penetrate the dura, or, less commonly, through direct intracranial extension of osteomyelitis [21]. Symptoms that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Ethmoid sinusitis can lead to spread of infection through the lamina papyracea, a thin bone that separates the medial orbital wall from the ethmoid sinuses [26]. Manifestations of orbital involvement include medial orbital wall subperiosteal abscess, periorbital cellulitis, and ocular findings (eg, abnormal visual examination, ophthalmoplegia, or proptosis) [21,22,26-32]. Cavernous sinus thrombosis is another rare but potentially fatal intracranial complication that can arise from infection of either the sphenoid or ethmoid sinuses [33].


Sinusitis Child

Sinusitis Child. Although rare, increasing frequency of fungal sinusitis has been reported in children within the past 3 decades [34]. Fungal sinusitis can be invasive and noninvasive and has 5 subtypes. Invasive subtypes include acute invasive fungal sinusitis, chronic invasive fungal sinusitis, and chronic granulomatous invasive fungal sinusitis; noninvasive subtypes include allergic fungal sinusitis and fungus ball (fungal mycetoma). The treatment strategies for the subtypes are different, as are their prognoses [35].


Sinusitis Child

Sinusitis Child. Acute invasive fungal sinusitis is the most lethal subtype with mortality rates reaching 50% to 80%; therefore, a high level of clinical suspicion is critical [36]. It is typically seen in immunocompromised children, often times with hematological malignancies with low neutrophil counts. Painless nasal septal necrosis is the classical clinical presentation [34,35,37].


Sinusitis Child

Sinusitis Child. Allergic fungal sinusitis occurs in atopic children with refractory sinus disease, which requires a high index of suspicion for evaluation and aggressive treatment [38]. Allergic fungal sinusitis is more aggressive in children with increased fungal load and higher incidence of proptosis when compared with adults [39]. Allergic fungal sinusitis in children is also less responsive to treatment with increased recurrence rates [40].


Sinusitis Child

Sinusitis Child. Discussion of Procedures by Variant Variant 1: Child. Uncomplicated acute sinusitis. Initial imaging. CT Paranasal Sinuses CT of the paranasal sinuses without or with contrast is not recommended in children as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone.


Sinusitis Child

Sinusitis Child. MRI Paranasal Sinuses MRI of paranasal sinuses without or with intravenous (IV) contrast is not recommended in children, as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone.


Sinusitis Child

Sinusitis Child. Radiography Paranasal Sinuses Radiographs are not recommended in uncomplicated acute sinusitis in children as the diagnosis of uncomplicated acute sinusitis is based on clinical criteria alone.


Sinusitis Child

Sinusitis Child. Variant 2: Child. Persistent sinusitis (worsening course or severe presentation, or not responding to treatment), or recurrent sinusitis, or chronic sinusitis, or define paranasal sinus anatomy before functional endoscopic sinus surgery. Initial imaging. CT Paranasal Sinuses CT is considered the gold standard for the imaging evaluation of sinusitis because it allows for the accurate depiction of sinus anatomy, soft-tissue changes, and potential associated complications [1,9,19,20,23,41-52]. With the advent of multidetector CT volume isometric imaging, it is possible to obtain images in the axial plane and reconstruct them into the coronal and sagittal planes [17,53,54]. CT volume isometric imaging is especially advantageous in young children who may not be able to cooperate for direct coronal plane image acquisition and avoids direct radiation to the orbits [55]. Low-dose CT of the paranasal sinuses has a radiation dose similar to two radiographic views of the paranasal sinuses [56]. CT is the study of choice in children with recurrent or chronic sinusitis before functional endoscopic sinus surgery as it provides a road map for surgery [49,57]. CT of the sinuses was not found to be superior to a clinical symptom score questionnaire in diagnosing chronic sinusitis [58], highlighting the importance of clinical presentation and physical examination findings in diagnoses. When CT of the paranasal sinuses is primarily performed for defining sinus anatomy or confirming clinically suspected recurrent or chronic sinusitis, contrast administration is not recommended.


Sinusitis Child

Sinusitis Child. MRI Paranasal Sinuses MRI of the paranasal sinuses is a radiation-free, high-resolution imaging modality. It has the advantage of being able to differentiate mucosal thickening from sinus secretions [59,60]. However, MRI may require sedation or general anesthesia in order to be performed in young children [61]. Furthermore, MRI does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions, making it less well suited than CT to evaluate for underlying anatomic abnormalities that may predispose to and from chronic sinusitis.


Sinusitis Child

Sinusitis Child. Radiography Paranasal Sinuses Radiography is limited in the evaluation of persistent sinusitis because the views traditionally used in the evaluation of the paranasal sinuses are difficult to perform in young children and have low sensitivity and specificity for sinus disease as compared to CT because of a lack of anatomical detail [45-47,61-63]. The Water projection is the single best view for the evaluation of the maxillary antra. In patients with chronic sinusitis, the Water view reveals a sensitivity of 84.2% and specificity of 76.6% for the detection of sinus disease as compared to the gold standard of nasal endoscopy [16,17]. However, the Water view has also been shown to have a 32% false-negative rate and a 49.2% false-positive rate as compared to CT. In addition, most of the abnormalities in the ethmoid and sphenoid sinuses are not detected on the Water view [64]. The Caldwell and Water projections have also been shown to be limited in the detection of ethmoid disease [54].


Sinusitis Child

Sinusitis Child. Variant 3: Child. Sinusitis with clinical concern of orbital or intracranial complications. Initial imaging. Symptoms at presentation that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Complications include meningitis, encephalitis, epidural and subdural suppuration, orbital abscess, and, less commonly, brain abscess and dural sinus thrombophlebitis [19-23]. Cross-sectional imaging should therefore include the paranasal sinuses and head.


Sinusitis Child

Sinusitis Child. CT Head and Paranasal Sinuses Noncontrast CT examination utilizing the routine head CT or paranasal sinus CT protocol alone may not provide sufficient anatomical coverage for evaluation for complications. In addition, potential complications such as orbital or preseptal/periorbital cellulitis, subperiosteal abscess, or subdural/epidural collections are inadequately visualized and may be missed in the absence of IV contrast administration. Therefore CT with IV contrast of the sinuses to include the orbits and brain is recommended [23,65]. A reported benefit of contrast-enhanced CT for detection of sinusitis-related complications versus MRI is its significantly shorter scan time, decreasing the need for sedation or general anesthesia in very young children.


Sinusitis Child

Sinusitis Child. CT Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis such as venous thrombosis, CT venography (CTV) can be performed, either as a follow-up study or as part of the initial CT imaging protocol [22,23,25]. CTV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed if CTV alone is used.


Sinusitis Child

Sinusitis Child. CTA Head When clinical or imaging findings point to potential vascular complications of sinusitis, such as mycotic aneurysm, CT angiography (CTA) can be performed, either as a follow-up study or as part of the initial CT imaging protocol [66]. CTA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTA is used.


Sinusitis Child

Sinusitis Child. MR Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis such as venous thrombosis, MR venography (MRV) can be performed, either as a follow-up study or as part of the initial MRI protocol. Noncontrast MRV techniques should be reserved for patients with contraindication to IV contrast or those patients who otherwise did not need IV contrast for the cross-sectional part of the examination. MRV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed with when only MRV is used.


Sinusitis Child

Sinusitis Child. Symptoms at presentation that suggest intracranial complications include Pott puffy tumor, altered consciousness, seizures, hemiparesis, and cranial nerve palsy [19-23]. Complications include meningitis, encephalitis, epidural and subdural suppuration, orbital abscess, and, less commonly, brain abscess and dural sinus thrombophlebitis [19-23].


Sinusitis Child

Sinusitis Child. MRA Head When clinical or imaging findings point to potential vascular complications of sinusitis such as mycotic aneurysm, MR angiography (MRA) can be performed, either as a follow-up study or as part of the initial MRI protocol [66]. MRA for the brain can be performed without IV contrast administration. MRA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRA is used.


Sinusitis Child

Sinusitis Child. MRI Head and Paranasal Sinuses MRI of the paranasal sinuses and head with IV contrast are complementary imaging studies that should be performed to evaluate for complications of sinusitis. MRI is a radiation-free, high-contrast resolution imaging modality. The primary role of MRI in the clinical setting of sinusitis is to detect intracranial and orbital complications. It is more sensitive than CT with IV contrast (93% versus 63%) for detecting intracranial complications of sinusitis [21,25]. Studies have shown that MRI is significantly more accurate than CT (97% versus 87%) and clinical findings (82%) in diagnosing meningitis [25]. Diffusion-weighted imaging (DWI) can localize or confirm presence of purulent material as it typically presents with restricted diffusion. Although MRI is also more sensitive than CT in diagnosing the presence of osteomyelitis, it does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions. MRI may require sedation or general anesthesia in order to be performed in young children [61].


Sinusitis Child

Sinusitis Child. Radiography Paranasal Sinuses Radiography is not sensitive for the relatively subtle soft-tissue changes or vascular complications related to the intraorbital or intracranial extension of sinusitis.


Sinusitis Child

Sinusitis Child. Variant 4: Child. Suspected invasive fungal sinusitis. Initial imaging. CT Paranasal Sinuses Immunocompromised children, particularly to development of acute invasive sinusitis, and paranasal sinus CT is more frequently used in this population to rule out the source of infection. If clinical suspicion for complicated sinusitis exists, CT with IV contrast of the sinuses to include the orbits and brain is indicated [23,65]. A reported benefit of contrast-enhanced CT for detection of sinusitis-related complications is its significantly shorter scan time, decreasing the need for sedation or general anesthesia in young children. CT of the paranasal sinuses without and with contrast is not recommended as it doubles the radiation exposure without additional significant diagnostic yield. Fungal sinusitis can be correctly diagnosed on CT with high accuracy [67,68]. Obliteration of the normal fat density within the periantral regions, osseous erosion, orbital, cavernous sinus, or brain involvement in an immunocompromised individual should raise the possibility of acute invasive fungal sinusitis [69].


Sinusitis Child

Sinusitis Child. CT Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm, venous thrombosis), CTV can be performed, either as follow-up studies or as part of the initial CT imaging


Sinusitis Child

Sinusitis Child. protocol. CTV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTV is used.


Sinusitis Child

Sinusitis Child. CTA Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm, venous thrombosis), CTA can be performed, either as a follow-up study or as part of the initial CT imaging protocol. CTA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus CT because other potential complications may be missed when only CTA is used.


Sinusitis Child

Sinusitis Child. MR Venography Head When clinical or imaging findings point to potential vascular complications of sinusitis (venous thrombosis), MRV can be performed either as a follow-up study or as part of the initial CT imaging protocol. One relevant downside in the pediatric population is that this may increase imaging time of already lengthy MRI protocols, slightly increasing the need for or the duration of sedation. MRV is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRV is used.


Sinusitis Child

Sinusitis Child. MRA Head When clinical or imaging findings point to potential vascular complications of sinusitis (mycotic aneurysm), MRA can be performed either as a follow-up study or as part of the initial MRI protocol. One relevant downside in the pediatric population is that this may slightly increase imaging time of already lengthy MRI protocols, increasing the need for or the duration of sedation. MRA is not recommended as a stand-alone study but rather a complementary examination to standard head and sinus MRI because other potential complications may be missed when only MRA is used.


Sinusitis Child

Sinusitis Child. MRI Paranasal Sinuses MRI of the paranasal sinuses is a radiation-free, high-resolution imaging modality. MRI is more sensitive than IV contrast-enhanced CT (93% versus 63%) for detecting intracranial complications of sinusitis [21,25]. Studies have shown that MRI is significantly more accurate than CT (97% versus 87%) and clinical findings (82%) in diagnosing meningitis [25]. Although MRI is also more sensitive than CT in diagnosing the presence of osteomyelitis, it does not demonstrate the bony detail of the osteomeatal complex well and is less sensitive to bony erosions. MRI may require sedation or general anesthesia in order to be performed in young children [61]. Contrast-enhanced MRI evaluation can be helpful in delineating the presence and extent of suspected complications of sinusitis.


Sinusitis Child

Sinusitis Child. The initial stages of fungal infection may not be apparent by imaging. MRI is more sensitive for detecting early changes of fungal sinusitis than CT. Perisinus invasion detected by MRI was found to be the most sensitive and specific single finding indicating invasive fungal sinusitis [70].


Sinusitis Child

Sinusitis Child. Radiography Paranasal Sinuses Radiography is not sensitive for the soft-tissue changes or intracranial complications related to invasive fungal sinusitis.


Sinusitis Child

Sinusitis Child. Summary of Recommendations Variant 1: Child. Uncomplicated acute sinusitis: imaging studies are not recommended. Variant 2: Child. Persistent sinusitis (worsening course or severe presentation, or not responding to treatment), or recurrent sinusitis, or chronic sinusitis, or define paranasal sinus anatomy before functional endoscopic sinus surgery: CT of the paranasal sinuses without IV contrast is recommended. Variant 3: Child. Sinusitis with clinical concern of orbital or intracranial complications: CT or MRI of the head and paranasal sinuses with IV contrast is recommended. CTA or MRA/MRV may be complementary in cases with suspected vascular complications. Variant 4: Child. Suspected invasive fungal sinusitis: CT or MRI of the head and paranasal sinuses with IV contrast is recommended. CTA or MRA/MRV may be complementary in cases with suspected vascular complications.


Sinusitis Child

Sinusitis Child. Although there are references that report on studies with design limitations, 15 well-designed or good-quality studies provide good evidence.


Sinusitis Child

Sinusitis Child. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Staging and Follow up of Ovarian Cancer

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


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. CA-125 Levels The preoperative evaluation of patients with suspected ovarian carcinoma usually includes a serum (cancer antigen) CA-125 determination. Only about 50% of all patients with stage I ovarian cancer have a true-positive result [4,15-17]. Thus, this test alone is inadequate when used in isolation as a screening tool. This is especially true in menstruating females, since false-positive results have been reported with endometriosis, benign ovarian cysts, pregnancy, and pelvic inflammatory disease. Pancreatic cancer and cirrhosis may also result in elevated CA-125 levels [18]. However, with stage II or greater ovarian cancer, the true-positive rate is as high as 80% [16]. There is a very high correlation between CA-125 levels and the clinical course of the patient during chemotherapy. CA-125 levels also can be used to predict tumor recurrence in patients who are clinically tumor free [19]. Oftentimes, other epithelial and nonepithelial tumor markers are ordered to differentiate tumor histology preoperatively. CA19-9 and carcinoembryogenic antigen (CEA) can also be elevated with epithelial ovarian neoplasms, but have limited specificity individually, and a high CA125-to-CEA ratio has been shown to optimize specificity for ovarian versus gastrointestinal primary neoplasms [20,21].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. 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.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Reprint requests to: publications@acr.org


Staging and Follow up of Ovarian Cancer

Staging and Follow-up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Staging and Follow-up of Ovarian Cancer


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. The decision regarding initial treatment for ovarian cancer depends on accurate staging. CT, FDG-PET/CT, and MRI have been used to assess the resectability of tumors, the candidacy of patients for effective cytoreductive surgery, the need for postoperative chemotherapy if debulking is suboptimal, and the need for referral to a gynecologic oncologist [5,34-36,39-45]. Referral to a gynecologic oncologist for optimal staging and debulking is the second most important determinant for survival after tumor stage in patients with ovarian carcinoma. The International Federation of Gynecologists and Obstetricians revised the criteria for ovarian cancer staging in 2014 [46]. The updated system recognizes the morphologic and molecular similarities between fallopian tube, primary peritoneal carcinomas, and ovarian malignancy [47]. Stage I disease includes tumor limited to 1 or both ovaries or fallopian tubes, stage II disease has spread to the surface of other pelvic organs, stage III indicates spread to retroperitoneal lymph nodes (IIIA1) or abdominal peritoneal surfaces (IIIA2 if microscopic disease, IIIB or C with macroscopic nodules), and stage IV is advanced disease with distant metastases to solid organs or a malignant pleural effusion [5,6,46]. When there is a contraindication to administration of iodinated contrast, CT without intravenous contrast offers limited evaluation of extent of disease in initial evaluation or follow-up; for more information on the imaging of patients with end-stage renal failure, please see the ACR Manual on Contrast Media [48].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Discussion of Procedures by Variant Variant 1: Initial staging of pretreatment ovarian cancer. CT Abdomen and Pelvis Contrast-enhanced CT (with oral contrast) is the current imaging modality of choice in the preoperative evaluation of ovarian cancer and is an accurate method for identifying sites of abdominopelvic disease that predict successful surgical cytoreduction [57]. CT has been useful to detect local tumor involvement of the pelvic ureter and uterine serosa (although uterine serosal involvement is less important in ovarian cancer than it is for endometrial cancer), as well as metastases to the peritoneum, omentum, mesentery, liver, spleen, lymph nodes, and lung parenchyma [5,39,40,52]. CT has a reported accuracy for ovarian cancer staging of up to 94% [14]. The sensitivity varies by anatomic site, however, and the most important limitation of CT in staging ovarian cancer is its inability to reliably detect bowel surface, mesenteric, or peritoneal tumor implants <5 mm, especially in the absence of ascites [5,43,58,59]. CT is also useful for guiding biopsy of the omentum, or other abdominal tumor, a procedure that can increase the accuracy of preoperative diagnosis, if indicated [60-63].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. For assessment of the resectability of ovarian cancer, cross-sectional imaging (CT or MRI) plays a critically important role in finding significant lesions (>2 cm) at the root of the mesentery, gastrosplenic ligament, omentum of the lesser sac, porta hepatis, intersegmental fissure of the liver, diaphragm, liver dome, and lung parenchyma, and also in detecting lymphadenopathy at or above the celiac axis, presacral extraperitoneal disease, and pelvic sidewall invasion [5,14,40,52,64-68]. Incomplete resection (residual tumor >1 cm) of primary tumor


Staging and Follow up of Ovarian Cancer

Staging and Follow-up of Ovarian Cancer


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. yields little survival benefit while subjecting patients to substantial perioperative morbidity. To date, imaging and prediction models that are based on imaging, demographic characteristics, and tumor markers have not been shown to provide sufficiently high accuracy for prediction of suboptimal debulking to guide the decision regarding surgery [55,69]. Unresectable disease can be managed by needle or laparoscopic biopsy, followed by chemotherapy, and possibly by a later attempt at interval debulking, resulting in improved survival by virtue of response to chemotherapy and optimal resection [9,34,60-63].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Noncontrast-enhanced CT of the abdomen and pelvis offers limited ability to differentiate small peritoneal or mesenteric implants, or lymphadenopathy, from bowel or other adjacent organs.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. CT Chest CT of the chest is useful for detecting pleural and pulmonary metastases during primary staging. Although CT is not sensitive for detecting pleural metastases, these can be verified by video-assisted thoracoscopy, if needed [70]. Preoperative detection by CT of a moderate-to-large pleural effusion helps predict poor post-treatment outcome [71]. For postsurgical surveillance, the yield of chest CT is low if the chest radiograph shows no abnormalities, CT shows no abdominal or pelvic disease, and there is no rising serum CA-125 [72,73]. If PET using tracer FDG is used and includes chest, abdomen, and pelvis, the added value of diagnostic-quality chest CT is probably even lower.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. MRI MRI is an excellent problem-solving technique by virtue of its ability to define common conditions such as fibroids, dermoid cysts, endometriomas, and other benign lesions [6-8,31,44]. A multivariable analysis showed that the accuracy of MRI with gadolinium enhancement in separating ovarian malignancy from other types of adnexal masses was 93% [74]. Gadolinium enhancement and diffusion-weighted imaging offer improved diagnostic confidence and tissue characterization [31,74]. In staging, MRI has been shown to provide equivalent accuracy to CT and to predict peritoneal tumor volume comparable with surgery, with sensitivity of 0.88, specificity of 0.74, and accuracy of 0.84 [75,76]. However, the role of MRI in staging has been limited because 1) the use of intraluminal gastrointestinal contrast agents with MRI is not routine as it is with CT, and 2) patient motion is a greater problem for MRI than for CT. Although CT is currently the modality of choice for staging ovarian cancer, MRI is recommended for patients with borderline tumors or ovarian cancers that have been previously staged with fertility preservation (to minimize ionizing radiation exposure), or for some patients whose CT findings are inconclusive [68,77]. Higher-field MRI scans may improve the accuracy of MRI for staging ovarian cancer pending further investigation [78].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Intravenous contrast is preferable for detection and characterization of lesions suspected to represent tumor deposits. MRI without contrast may be considered for staging if contrast cannot be given and may offer improved soft-tissue contrast than noncontrast CT for staging in the pelvis; however, to our knowledge, there are no known studies on the comparative performance of MRI without contrast and CT without contrast for staging.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. FDG-PET/CT The use of FDG-PET imaging in the primary diagnosis and tissue characterization of ovarian cancer is unsupported to date. Specificity has been reported to be as low as 54%, while sensitivity has been as high as 86% [33,79,80]. Also, false-negative results have been reported with borderline tumors, mucinous tumors, early carcinomas, and other low-grade types of tumors [81,82]. False-positive results have been reported with fibromas, dermoid cysts, hydrosalpinges, and endometriosis [68,80].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. However, FDG-PET, especially when combined with CT, is a valuable tool for diagnosing and staging advanced disease [32,34-37,79]. For staging, fusion FDG-PET/CT has higher reported accuracy than either CT or FDG- PET alone in multiple studies [32,35,36,79,83]. Improved detection of peritoneal disease may stem from metabolic activity in small deposits or lymph nodes that may be difficult to identify and characterize with CT alone. Thus, although CT with contrast is the modality of choice for initial staging, PET or FDG-PET/CT may be a useful adjunct test, particularly when CT is indeterminate.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Contrast Enema Contrast enema is not routinely used for pretreatment staging of ovarian cancer. An exception may occur when there is concern about the possibility of a colonic primary versus ovarian primary malignancy based on preoperative CT findings, signs, symptoms, and CA-125 and CEA tumor marker ratio.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Staging and Follow-up of Ovarian Cancer IVU Intravenous urography (IVU) is not routinely used for pretreatment staging of ovarian cancer.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. US There is no evidence to support a role for US in initial staging evaluation of ovarian cancer. Transvaginal US is mainly useful for determining the site of origin of a pelvic mass and to characterize the lesion [30].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Variant 2: Extent of disease in suspected or known recurrence of ovarian cancer. Imaging of the chest, abdomen, and pelvis plays a key role in evaluation for recurrence and the extent of disease. Rising CA-125, symptoms, or other clinical suspicion for relapse after treatment prompts imaging evaluation for recurrence. If imaging or clinical examination confirms a recurrent tumor, the extent of disease and timing of disease recurrence then determines the choice(s) of treatments, including surgery, chemotherapy, and radiation therapy. The choices for treatment depend upon the time that has passed since chemotherapy was completed. In general, surgical resection of the recurrent tumor is an option when chemotherapy was completed more than 6 months before recurrence and with the option for additional radiation therapy or chemotherapy after surgery.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. The role for routine surveillance with imaging is unclear in patients considered to be in clinical remission. Imaging has been shown to have limited sensitivity for detection of small tumor deposits in the abdomen and pelvis, with or without monitoring of CA-125 [3,84]. Furthermore, the MRC OV05/EORTC trial did not show a difference in overall survival when patients were treated based on elevated CA-125 versus clinical evidence of recurrence (including imaging findings) [85], despite recognition that CA-125 is generally elevated in cases of recurrence before clinical or imaging signs become evident. The National Comprehensive Cancer Network guidelines for follow-up of primary chemotherapy with complete response include imaging tests as needed, using CT, FDG-PET, FDG-PET/CT, MRI, or chest radiographs [11].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. CT Contrast-enhanced CT (also using oral contrast) is the modality of choice for detecting recurrence in the chest, abdomen, or pelvis. Contrast-enhanced CT has a reported sensitivity ranging from 58% to 84% and specificity in the range of 59% to 100% in identifying tumor recurrence [52,86,87]. Recurrent disease usually manifests as peritoneal implants; within the peritoneal cavity and on the surface of the visceral organs. CT is used to identify tumor deposits in the root of the mesentery, gastrosplenic ligament, omentum of the lesser sac, porta hepatis, intersegmental fissure of the liver, diaphragm, liver dome, and lung parenchyma, and also in detecting lymphadenopathy. However, identification of small (<5 mm) tumor deposits in the mesentery, on bowel wall, or along the peritoneum may be limited [5,43,58,59].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Noncontrast-enhanced CT of the abdomen and pelvis offers limited ability to identify small peritoneal or mesenteric implants, or lymphadenopathy among bowel loops and other adjacent organs.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. MRI The reported accuracy of MRI for detecting lesions >2 cm in recurrent disease is comparable to that of CT at 93% to 95% [14]. However, MRI demonstrated a significantly lower area under the receiver operator characteristic curve than CT, FDG-PET, FDG-PET/CT, or CA-125 for overall detection of recurrent ovarian cancer in a meta- analysis [88]. CT remains the most widely used imaging method for detecting recurrence, and, despite some advantages, the role of MRI in follow-up imaging has been limited because 1) the use of intraluminal gastrointestinal contrast agents with MRI is not routine as it is with CT and 2) patient motion is a greater problem for MRI than for CT. Although CT is currently the modality of choice for suspected recurrence of ovarian cancer, MRI is recommended for borderline tumors or ovarian cancers that have been previously staged with fertility preservation (to minimize ionizing radiation exposure), or for some patients whose CT findings are inconclusive.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Intravenous contrast is preferable for detection and characterization of lesions suspected to represent tumor deposits. MRI without contrast may be considered for staging if contrast cannot be given and may offer improved soft-tissue contrast than noncontrast CT for staging in the pelvis. However, to our knowledge, there are no known studies on the comparative performance of MRI without contrast and CT without contrast for staging.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. FDG-PET/CT For suspected recurrent ovarian cancer, FDG-PET/CT has recently shown similar or higher accuracy for tumor detection than contrast-enhanced CT or PET alone [10,19,34,89,90], with a sensitivity of 95% to 97% and specificity of 80% to 100% [86,89,91]. The spatial resolution of PET limits sensitivity for subcentimeter metastases, and metabolic activity on or between bowel loops, particularly after surgery when adhesions or


Staging and Follow up of Ovarian Cancer

Staging and Follow-up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Staging and Follow-up of Ovarian Cancer


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. inflammation are present, may be difficult to assess. For such reasons, PET or FDG-PET/CT has not uniformly shown improved sensitivity or specificity of recurrence compared with CT alone [88]. Still, the combined metabolic activity and anatomic localization of FDG-PET/CT have been shown to improve disease detection in small lymph nodes and unresectable sites, which can alter management [87,91]. Notably, the performance of FDG-PET/CT in the literature reflects a predominance of serous papillary carcinomas, and false-negative results have been reported with mucinous adenocarcinomas, and cystic, necrotic, low-grade or small-volume (<7 mm) deposits [82]. Thus, either CT or FDG-PET/CT may be used to evaluate suspected recurrence, and FDG-PET/CT may also be a useful adjunct when CT is indeterminate with persistent clinical concern [92].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Contrast Enema Contrast enema is not routinely used for detecting recurrence of ovarian cancer.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. IVU IVU is not routinely used for detecting recurrence of ovarian cancer.


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Laparotomy Second-look laparotomy is no longer routinely performed because the noninvasive diagnosis of recurrence obviates the need for unnecessary surgery, and generally may be reserved for patients in which the second-look findings might change treatment planning or clinical trial protocols [93]. The decision for secondary debulking surgery is guided by a chemotherapy-free interval, patient performance status, and extent and resectability of disease at time of recurrence. Imaging therefore plays a critical role in the decision-making process for secondary debulking [94].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. US US is not routinely used for detection of recurrent ovarian cancer after surgery. In cases of borderline ovarian tumors (or invasive malignancies) in which fertility-sparing surgery has been performed, transvaginal US has been used in surveillance of the adnexa for recurrent lesions [95].


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Although there are references that report on studies with design limitations, 30 well-designed or good-quality studies provide good evidence.


Staging and Follow up of Ovarian Cancer

Staging and Follow-up of Ovarian Cancer


Staging and Follow up of Ovarian Cancer

Staging and Follow up of Ovarian Cancer. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Introduction/Background Patients who present with acute chest pain in the setting of nonspecific signs and symptoms, and a low pretest probability for coronary disease, remain an important clinical management dilemma. This is largely related to the competing imperatives of the medical and legal implications of an undiagnosed acute cardiac event as well as the impact on patient flow and hospital use of efficaciously triaging such low-risk cardiac patients, especially in the emergency room [1]. In the current era, there is great imperative to bring to bear a range of advances, including improved clinical algorithms such as the HEART (history electrocardiogram age risk factors troponin) scoring system [2-5], newer biochemical tests, such as high sensitivity troponins [6-11], and newer advanced imaging modalities, such as coronary artery CT [12-14]. Patient management approaches are exploring integration of these procedure advances in the context of clinical decision units/observational units [15,16]. This publication will focus on the evidence for use of individual imaging approaches, in the context of an integrated decision-making setting.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that CMS has applied to the Current Procedural Terminology codes.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Reprint requests to: publications@acr.org


Acute Nonspecific Chest Pain

Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Acute Nonspecific Chest Pain


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. OR Discussion of Procedures by Variant Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging. Radiography Chest Radiographs of the chest remain an important imaging tool in the workup of patients presenting with acute, nonspecific, low cardiac probability of chest pain, albeit as an indirect indicator of an acute cardiac event, such as the documentation of heart failure. Although there is no relevant literature to support the use of chest radiographs for the evaluation of the coronaries or the heart in the setting of acute nonspecific chest pain with low probability of CAD, this is still a helpful examination.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. US Echocardiography Transthoracic Stress In a national study of 24,000 patients evaluated in chest pain units, two-thirds of patients, mostly those experiencing acute chest pain, underwent echocardiography (not specified whether resting or stress), with high reliability in guiding further invasive management [15]. This is in keeping with the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association guidelines [22]. A single-center study of 250 patients specifically addressing stress imaging with low-risk presentation documented prognostic significance for major adverse cardiovascular events (MACE) at 1-year follow-up [23]. A single-center randomized control study of 400 consecutive participants comparing coronary artery CT with stress echocardiography for early emergency room discharge of low- to intermediate-risk patients documented a smaller percentage of patients being hospitalized, the primary endpoint, and shorter duration of emergency room observation or hospitalization for stress echocardiography. Major adverse cardiac events at 24 months were comparable for the modalities [24].


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. SPECT or SPECT/CT MPI Rest and Stress Although stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has comparable utility to stress echocardiography for the overall detection of ischemia in the emergency room setting [25], there is no relevant literature supporting its use in the setting of acute nonspecific chest pain with low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. US Echocardiography Transthoracic Resting Resting transthoracic echocardiography is of utility to document anatomic abnormalities that may be the cause of nonischemic cardiac pains in the acute setting, such as diseases of the myocardium or pericardium or cardiac masses, to improve diagnostic accuracy and efficiency [22]. Resting transthoracic echocardiography has the ability to characterize wall contractile function, and because of its ability to be deployed at the bedside, this consensus report by the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association supports its use to triage patients with acute chest pain [22].


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. US Echocardiography Transesophageal Transesophageal echocardiography is typically reserved for instances when nonischemic causes of acute chest pain, such as thoracic dissection, are under clinical consideration. It may be used as a follow-up to a nondiagnostic transthoracic study but is sometimes chosen initially when transthoracic echocardiography is anticipated to be nondiagnostic, such as related to patient body habitus or inability to comply with breathing instructions [22]. There is no relevant literature supporting its use in the setting of acute nonspecific chest pain with low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Acute Nonspecific Chest Pain There is no relevant literature to support the use of CTA chest with intravenous (IV) contrast in the evaluation of acute nonspecific chest pain of suspected cardiac etiology as an initial imaging test.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. V/Q Scan Lung Tc-99m ventilation-perfusion (V/Q) lung scan may be performed to detect a pulmonary embolism. There is no relevant literature to support the use of V/Q scanning in the evaluation of acute nonspecific chest pain of a cardiac etiology as an initial imaging test.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Alternatively, evaluating CCTA versus stress MPI, a randomized controlled single-center study of 400 patients, validated against invasive angiography, documented a comparable length of stay (CCTA 28.9 hours versus MPI 30.1 hours) as well as no differences in major cardiovascular events at 40 months [28]. Another randomized controlled study comparing CCTA with SPECT MPI in 598 participants with low to intermediate risk documented time to diagnosis (CCTA 8.1 hours versus MPI 9.4 hours) and length of stay (CCTA 19.7 hours versus MPI 23.5 hours) (both P = .002) [29]. The CATCH (CArdiac cT in the treatment of acute CHest pain) trial examined long- term outcomes of CCTA versus standard care in the setting of low-risk acute chest pains in a randomized cohort of 600 participants, with the outcome being MACE at 19 months. Overall occurrence of a primary endpoint was CCTA (n = 16) versus standard care (n = 47) (P = .04) [30]. A meta-analysis of 37 trials (involving 7,800 patients), compared CCTA, stress echocardiography, and MPI SPECT validated against invasive angiography, or late MACE, in the acute chest pain setting. Weighted mean sensitivity, specificity, positive predictive value, negative predictive value, and total diagnostic accuracy were as follows: CCTA 95%, 99%, 84%, 100%, 99%, respectively; stress echocardiography 84%, 94%, 73%, 96%, 96%, respectively; and SPECT 85%, 86%, 57%, 95%, 88%, respectively. The investigators concluded there was no difference in negative predictive value but that CCTA had superior performance over stress echocardiography and MPI for the other indexes [31]. A meta-analysis of randomized controlled trials evaluating CCTA versus usual care for triaging patients in the emergency room setting documented efficiencies of CCTA for discharge disposition but increased downstream invasive coronary angiography and revascularization [32].


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Hemodynamic assessment using flow indexes, derived from biophysical modeling of CTA-derived data, is a recent development. A small, single-center study was validated in animals (with CT-documented flow correlated with microsphere-determined flow; R-squared = 0.90, P < .001) and also explored in 39 human participants with acute chest pain and normal coronaries, documenting excellent interobserver correlation (R = 0.96, P < .0001) and agreement [33]. Although a report on the initial 1,000 participants in the international, multicenter, prospective, real-world registry, ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care), has documented that CTA stenosis severity had an increased likelihood of an abnormal fractional flow reserve-CT, the utility of this measure was limited in practice, given that mild lesions could result in ischemia whereas intermediate to severe lesions could be nonflow limiting [34]. In addition, in common with the preponderant focus of other leading existing clinical trials exploring the utility of fractional flow reserve-CT, these studies were evaluated in stable chest pain cohorts, as opposed to the acute chest pain setting of the present discussion. Alternate approaches use concurrent CT perfusion (CTP) assessment to augment the anatomic data with functional characterization. In a subanalysis of 183 ROMICAT I (Rule Out Myocardial Infarction by Computer Assisted Tomography) participants, rest CTP predicted ACS independently of obstructive anatomic assessment, and sensitivity for detection of


Acute Nonspecific Chest Pain


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. One specialized protocol of coronary CTA is the triple rule out examination, which uses a specific contrast acquisition scanning protocol to enable assessment of the pulmonary arteries, the aorta and the coronary arteries [37]. For the purpose of this document, the triple rule out is considered part of the CTA coronary arteries.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. CT Chest Without IV Contrast Noncontrast chest CT can assess for the presence of a pericardial effusion, epipericardial fat necrosis, and other noncardiac causes of chest pain. There is no relevant literature to support the use of CT chest without IV contrast in the evaluation of acute nonspecific chest pain with low probability of CAD as an initial imaging test.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. CT Chest With IV Contrast Noncontrast chest CT can assess for the presence of a pericarditis, epipericardial fat necrosis, and other noncardiac causes of chest pain. There is no relevant literature to support the use of CT chest with IV contrast in the evaluation of acute nonspecific chest pain with low probability of CAD as an initial imaging test.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. CT Chest Without and With IV Contrast Chest CT without and with IV contrast as a follow-up to a suspicious finding suggested by radiographs of the chest is typically not used [20,38]. There is no relevant literature to support the use of CT chest without and with IV contrast in the initial imaging evaluation of acute nonspecific chest pain with low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. CT Heart Function and Morphology With IV Contrast In a single-center retrospective analysis of 225 patients, heart morphology and function indexes, as a derivative of a CCTA study, have been shown to correlate with MACE at 13 months [39]. There is no relevant literature to support use of this test as an initial imaging strategy. See the CTA coronary arteries section above for coronary artery assessment.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRA Chest Without and With IV Contrast MR angiography (MRA) has potential uses in the nonischemic setting if acute thoracic aorta conditions, including dissection or intramural hematoma, or aneurysm or pulmonary embolism are being considered [40]. There is no relevant literature to support the use of MRA chest without and with IV contrast for the evaluation of the coronaries or the heart structures in the setting of acute nonspecific chest pain with low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRA Chest Without IV Contrast MRA has potential uses in the nonischemic setting if acute thoracic aorta conditions, including dissection or intramural hematoma, or aneurysm or pulmonary embolism are being considered [40]. There is no relevant literature to support the use of MRA chest without IV contrast for the evaluation of the coronaries or the heart structures in the setting of acute nonspecific chest pain with low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRI Heart Function and Morphology Without IV Contrast Pericarditis, as a cause of chest pain, can be potentially excluded by direct assessment of pericardial thickness on noncontrast MRI heart function and morphology images [41]. Characterization of other myocardial and pericardial conditions would optimally require administration of a gadolinium contrast agent. There is no relevant literature to support the use of MRI as an initial imaging test in the patient with acute nonspecific chest pain with a low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRI Heart Function and Morphology Without and With IV Contrast Although there has been increasing use of MRI with a contrast agent to document clinically suspected myocarditis in patients who have been ruled out for acute myocardial infarction, these are typically patients who have had elevated troponins and thus would not fall in the low probability category [42,43]. A recent review article has reported on the utility of MRI heart function and morphology without and with IV contrast as a prognosticator of myocardial damage and its complications in the clinical setting of acute coronary syndrome; however, such patients


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Acute Nonspecific Chest Pain typically present with signs or symptoms of myocardial ischemia, unlike the nonspecific signs and symptoms of the cohort of the present topic [41]. There is no relevant literature to support the use of MRI as an initial imaging test in the patient with acute nonspecific chest pain with a low probability of CAD. In this clinical scenario, the presentation and etiology, although not common, can be occasionally useful in the appropriate setting.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRI Heart With Function and Vasodilator Stress Perfusion Without and With IV Contrast Vasodilator stress challenge with first-pass perfusion imaging, rather than inotropic stress, can be used to assess for the evaluation of myocardial ischemia [31]. There is no relevant literature to support the use of MRI as an initial imaging test in the patient with acute nonspecific chest pain with a low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRI Heart With Function and Inotropic Stress Without IV Contrast An inotropic stress challenge with assessment of wall contractile function, rather than vasodilator stress, can be used to assess for the evaluation of myocardial ischemia [31]. There is no relevant literature to support the use of MRI as an initial imaging test in the patient with acute nonspecific chest pain with a low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRI Heart With Function and Inotropic Stress Without and With IV Contrast There is no relevant literature to support the use of MRI as an initial imaging test in the patient with acute nonspecific chest pain with a low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRA Coronary Arteries Without and With IV Contrast There is no relevant literature to support the use of MRA coronary arteries without and with IV contrast in the initial imaging evaluation of acute nonspecific chest pain with low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. MRA Coronary Arteries Without IV Contrast There is no relevant literature to support the use of MRA coronary arteries without IV contrast in the initial imaging evaluation of acute nonspecific chest pain with low probability of CAD.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Arteriography Coronary In the acute chest pain setting, invasive coronary angiography is typically undertaken in patients with elevated troponins when there is concern for an acute myocardial infarction/ischemia. There are limited data on its use in the low pretest probability setting of CAD without signs of myocardial ischemia or infarction. Recent studies have proposed triaging of patients for invasive coronary angiography using ischemia stress testing or, alternatively, CCTA coronary anatomy characterization prior to invasive angiography to increase the diagnostic yield [44].


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Radiography Ribs and Thoracic Spine Musculoskeletal conditions such as rib fractures can be identified using radiographs, ideally justified by localized pain symptoms. Conditions that may cause thoracic pain such as scoliosis or diffuse idiopathic skeletal hyperostosis are findings that may be detected incidentally on such an examination. There is no relevant literature to support the use of radiographs of the ribs or thoracic spine in the evaluation of acute nonspecific chest pain with low probability of CAD as an initial imaging test.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Nuclear Medicine Scan Gallbladder History, physical examination, and subsequent laboratory markers may implicate upper abdomen solid organs as a potential source of nonspecific chest pain. Abdominal ultrasonography is an efficient means of excluding acute cholecystitis as a source of chest pain in the acute setting. As a functional assessment of the biliary system, Tc-99m cholescintigraphy may be performed. There is no relevant literature to support the use of Tc-99m cholescintigraphy in the evaluation of acute nonspecific chest pain with low probability of CAD as an initial imaging test.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Acute Nonspecific Chest Pain echocardiography must be acknowledged as a widely deployed imaging modality in the general acute chest pain setting, the panel opined that for the initial imaging of a patient with acute nonspecific chest pain and low probability of CAD, ultrasound resting echocardiography transthoracic resting may be appropriate (but with disagreement, related to insufficient medical literature).


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Acute Nonspecific Chest Pain

Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease PCAs. Acute Nonspecific Chest Pain


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. CT Abdomen and Pelvis With IV Contrast As mentioned from the CT angiography (CTA) abdomen and pelvis without and with intravenous (IV) contrast section below, contrast-enhanced CT scans have not been generally accepted as a first-line screening tool for AAA [13]. Increasing number of abdominal CT scans in most hospitals results in diagnosis of many incidental AAAs. Retrospective review studies of abdominal CT scans done for a variety of reasons showed a prevalence of 2.2% to 5.8% for AAA [14,15].


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. 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.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. Reprint requests to: publications@acr.org


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. Screening for Abdominal Aortic Aneurysm CT Abdomen and Pelvis Without and With IV Contrast Again, as mentioned from the CTA abdomen and pelvis without and with IV contrast section below, contrast- enhanced CT scans have not been generally accepted as a first-line screening tool for AAA [13].


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. CT Abdomen and Pelvis Without IV Contrast Noncontrast CT can be considered as a screening examination for AAA, which can be especially beneficial in the setting of obesity or poor sonographic window. One study reported that noncontrast CT was superior to ultrasound (US) concerning sensitivity ranging from 83% to 89% depending on the measured plane when compared to US with 57% to 70%, although specificity was high for both studies measuring 98% and 99%, respectively [13]. With modern CT imaging technology, noncontrast CT has been proposed as an alternative screening method to offer more reliable examinations with additional information, including aortic wall calcifications, as well as thoracic and iliac aortic abnormality [13]. When compared to CTA, a study reported that the low-dose noncontrast CT exhibited similar accuracy and reproducibility of measurements in AAA [16].


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. CTA Abdomen and Pelvis With IV Contrast Contrast-enhanced CT scans are known to be more precise when compared to US, with near 100% sensitivity and specificity, and are more reliable than US at determining size and extent and demonstrating adjacent structures, and are not degraded by bowel gas or obesity. Although contrast-enhanced CTA is an effective diagnostic tool, it has not been generally accepted as a screening tool due to its use of IV contrast [12,13].


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. CTA imaging of AAA is now well-established and is a popular imaging choice for diagnostic and presurgical/intervention study and sometimes surveillance of AAA, with particular strength in demonstrating the size, extent, and other characteristics of an aneurysm and associated aortic branch disease.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. The difference between US and CTA measurements of AAA were reported, with general accusation that US underestimates AAA diameter and that CT demonstrates a closer reflection of the actual diameter, with parallel debate over the ideal measuring method without complete consensus [17,18]. Recent updates from the 2018 The Society for Vascular Surgery guidelines for the care of AAA patient now recommends using the outer wall to outer wall for measurement of the maximum aneurysm diameter [6], moving away from the inner wall to inner wall measurements.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. CTA Abdomen and Pelvis Without and With IV Contrast Noncontrast CT scans were not commonly used as a primary screening tool for AAA in the past, but recent studies have explored their potential as an alternative method [13,19]. One such study of 533 patients reported a higher sensitivity (83%-89% versus 57%-70%) with high specificity over 98% when compared to US [12]. The added benefit of the noncontrast CT when performed in addition to the CTA is that it allows for a more accurate detection of aneurysm calcification and thoracic and iliac lesions compared to US.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. MRA Abdomen and Pelvis With IV Contrast Similar to the CT, MR angiography (MRA) is also highly accurate in detecting AAA and shows excellent reproducibility in between MRI examinations but has not been accepted as a screening tool [13]. MRA can serve as an alternative tool for CT or US. MRA has the potential to provide further information on AAA beyond its morphology, for example, AAA wall strain and stiffness, which may contribute to better understanding of AAA pathophysiology, biomechanics, and risk for rupture [20].


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. MRA Abdomen and Pelvis Without and With IV Contrast There is insufficient evidence to support noncontrast MRA as a screening examination for AAA. However, a prospective study of nonenhanced MRA compared with contrast-enhanced CTA demonstrated equivalent accuracy of measurements in preoperative planning for endovascular aortic repair (EVAR) of AAA [21]. Noncontrast MRA sequences such as 3-D noncontrast black-blood cardiovascular MR technique has been studied with compressed sensing to decrease its long scan time [22].


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. MRA Abdomen and Pelvis Without IV Contrast There is insufficient evidence to support the use of a noncontrast MRA as a screening examination for AAA.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. MRI Abdomen and Pelvis With IV Contrast There is insufficient evidence to support the use of MRI that lacks MRA sequences as a screening examination for AAA.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. Screening for Abdominal Aortic Aneurysm MRI Abdomen and Pelvis Without and With IV Contrast There is insufficient evidence to support the addition of a noncontrast MRI as a screening examination for AAA.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. MRI Abdomen and Pelvis Without IV Contrast There is insufficient evidence to support a noncontrast MRI as a screening examination for AAA.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. Radiography Abdomen and Pelvis There is no relevant literature to support the use of abdomen and pelvis radiograph for routine screening of AAA, although calcified aneurysmal walls may be visualized by abdomen and pelvis radiograph.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. US Aorta Abdomen US is the most widely used screening and surveillance imaging method for the evaluation of AAA, which is implemented in screening programs in several countries [13,23-26]. The U.S. Preventive Services Task Force recommends one-time screening for AAA with US in men 65 to 75 years of age, who have ever smoked, with reported screening rates ranging 13% to 26% [27-29]. US is safe, portable, easy to operate, and proven beneficial for screening of AAA, with sensitivity and specificity close to 100% and a high accuracy comparable to CT, MRI, or MRA [13]. However, US was reported to show significant interobserver variability [13,30,31] and does not fully reflect other aneurysm characteristics such as intraluminal thrombus, plaque ulceration, or surrounding inflammation, which CT shows strength in [32]. Recent studies on specifying local wall strain information attempt to further stratify the risk of rupture using noninvasive imaging such as real-time 3-D US speckle tracking imaging [33,34].


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. US examination can measure the dimensions of the suprarenal, juxtarenal, pararenal, and infrarenal aorta. Imaging of the iliac arteries should also be included given close correlation. In 1% to 2 % of cases, the aorta cannot be well evaluated due to bowel gas or anatomical challenges regarding aortic depth [32,35].


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm

Screening for Abdominal Aortic Aneurysm. Screening for Abdominal Aortic Aneurysm


Incidentally Detected Indeterminate Pulmonary Nodule PCAs. Introduction/Background A pulmonary nodule is defined as a well or poorly defined rounded opacity measuring <3 cm in diameter [1-5]. Nodules are classified as solid, part-solid, and ground-glass on CT, based on their attenuation, allowing for a more accurate assessment of malignancy risk. Ground-glass nodules are areas of increased attenuation through which underlying structures such as vessels remain visible [3]. Incidental pulmonary nodules are common, with reported frequencies ranging from 5.6% to 51% on CT and 0.1% to 7% on chest radiographs [5-7]. While it is estimated that 70% to 97% of incidental pulmonary nodules are benign [8], most are indeterminate for malignancy when first encountered making their management challenging.


Incidentally Detected Indeterminate Pulmonary Nodule PCAs. Additional methods that can enhance the detection and characterization of lung nodules include computer-aided detection systems [18-20], pulmonary vessel subtraction [21,22], deep convolutional neural networks [23], and other artificial intelligence algorithms [24]. While some practices use these methods, a detailed discussion falls outside of the scope of this document.


Incidentally Detected Indeterminate Pulmonary Nodule PCAs. aUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. bPanel Chair, Duke University, Durham, North Carolina. cStanford University Medical Center, Stanford, California; The Society of Thoracic Surgeons. dMayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging. eEmory University Hospital, Atlanta, Georgia. fNew York University Langone Health, New York, New York; IF Committee. gHampton VA Medical Center, Hampton, Virginia. hUniversity of Michigan Health System, Ann Arbor, Michigan. iVanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians. jUniversity of Arizona College of Medicine, Phoenix, Arizona. kMedical University of South Carolina, Charleston, South Carolina; IF Committee. lMallinckrodt Institute of Radiology, Saint Louis, Missouri. mJohn H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois; American College of Physicians. nNational Institutes of Health, Bethesda, Maryland. oLoyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, Illinois; Commission on Radiation Oncology. pDuke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons. qThe University of Texas MD Anderson Cancer Center, Houston, Texas. rSpecialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio.


Incidentally Detected Indeterminate Pulmonary Nodule PCAs. 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.


Incidentally Detected Indeterminate Pulmonary Nodule PCAs. Reprint requests to: publications@acr.org


Incidentally Detected Indeterminate Pulmonary Nodule PCAs. Incidentally Detected Indeterminate Pulmonary Nodule Discussion of Procedures by Variant Variant 1: Adult greater than or equal to 35 years of age. Incidentally detected indeterminate pulmonary nodule on chest radiograph. Next imaging study. CT Chest Without IV Contrast For individuals with an indeterminate pulmonary nodule detected on chest radiograph, ACCP guidelines recommend reviewing prior studies to determine stability. If the nodule has been stable for at least 2 years, no further workup is advised. If stability cannot be determined, guidelines recommend performing a chest CT to better characterize the nodule [2].