Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. was increased in transgender women who received hormone treatment (31.4 per 100,000 person-years compared with 1.2 per 100,000 person-years for cisgender men and 170 per 100,000 person-years for cisgender women) [1]. Any conclusions drawn from the existing literature are significantly limited by inconsistent dose and length of exposure to hormones as well as small sample size and relatively short duration of follow-up. Large prospective cisgender studies have shown that exogenous hormones, in particular estrogen and progestin, increase breast cancer risk in cisgender postmenopausal females [18-20], which could support a role for screening in this clinical setting. Additionally, in cisgender males, high estrogen levels associated with certain conditions, such as Klinefelter syndrome, liver disease, testicular dysfunction, and obesity, are recognized risk factors for developing breast cancer [21].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI breast without and with intravenous (IV) contrast to screen for breast cancer in this clinical setting. However, MRI screening may have limited use in patients who have undergone direct injection of particles such as silicone, mineral oil, liquid paraffin, or petroleum jelly to augment the breasts because fibrosis and injection granulomas can obscure the breast tissue on mammography and ultrasound (US). Hence, contrast-enhanced breast MRI is the preferred modality for breast cancer detection in patients who have undergone breast augmentation with free-particle injections [4,10].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. US Breast There is insufficient evidence to support screening with US breast in this clinical setting. A small study of screening whole-breast US in 50 transgender women found no cancers [11]. The majority of patients were on estrogen therapy (94%) and had no family history of breast cancer (88%). However, the lack of incremental cancer detection may be secondary to the small sample size.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Transgender Breast Cancer Screening


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. to hormones as well as small sample size and relatively short duration of follow-up. Large prospective cisgender studies have shown that exogenous hormones, in particular estrogen and progestin, increase breast cancer risk in cisgender postmenopausal females [18-20], which could support a role for screening in this clinical setting.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. In the absence of definitive data, some transgender health experts and professional societies recommend digital mammography or DBT to screen for breast cancer in transgender women with higher-than-average risk of breast cancer (https://transcare.ucsf.edu/guidelines/breast-cancer-women). There is no consensus on the age at which to initiate screening in this clinical setting. The Endocrine Society recommends screening transgender women with the same frequency as cisgender women [10]. The ACR screening recommendation for high-risk cisgender women is annual screening mammography beginning 10 years earlier than an affected relative at the age of diagnosis (but not before age 30) or 8 years after radiation therapy (but not before age 25) [25].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. In addition to planar images, DBT allows for creation and viewing of thin-section reconstructed images that decrease the lesion-masking effect of overlapping normal tissue, thereby decreasing false-positive recalls as well as improving CDR in breast cancer screening.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Transgender Breast Cancer Screening In the absence of definitive data, some transgender health experts and professional societies recommend digital mammography or DBT to screen for breast cancer in transgender women with higher-than-average risk of breast cancer (https://transcare.ucsf.edu/guidelines/breast-cancer-women). There is no consensus on the age at which to initiate screening in this clinical setting. The Endocrine Society recommends screening transgender women with the same frequency as cisgender women [10]. The ACR screening recommendation for high-risk cisgender women is annual screening mammography beginning 10 years earlier than an affected relative at the age of diagnosis (but not before age 30) or 8 years after radiation therapy (but not before age 25) [25].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI breast without and with IV contrast to screen for breast cancer in this clinical setting. However, MRI screening may have limited use in patients who have undergone direct injection of particles, such as silicone, mineral oil, liquid paraffin, or petroleum jelly, to augment the breasts because fibrosis and injection granulomas can obscure the breast tissue on mammography and US. Hence, contrast-enhanced breast MRI is the preferred modality for breast cancer detection in patients who have undergone breast augmentation with free-particle injections [4,10].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. US Breast There is no relevant literature to support the use of US for breast cancer screening in this clinical setting.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Variant 3: Breast cancer screening. Transfeminine (male-to-female) patient with no hormone use (or hormone use less than 5 years) at any age. Average-risk patient. Recommendations for breast cancer screening in transfeminine patients are typically based on the male sex assigned at birth, the number of years of feminizing hormone exposure, breast development, and any significant risk factors for breast cancer. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting. In the absence of identifiable risk factors for breast cancer, general screening has no role because of an overall low prevalence of disease. The lifetime risk of breast cancer in transfeminine patients with no hormone use and no significant risk factors is considered to be equivalent to the average risk in cisgender men, which is 0.1% (compared with 12.4% in the average-risk cisgender female) [1,26].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Mammography Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting. In the absence of identifiable risk factors for breast cancer, general screening has no role because of an overall low prevalence of disease. The lifetime risk of breast cancer in transfeminine patients with no hormone use and no significant risk factors is considered to be equivalent to the average risk in cisgender men, which is 0.1% (compared with 12.4% in the average-risk cisgender female) [1,26].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI breast without and with IV contrast to screen for breast cancer in this clinical setting.


Transgender Breast Cancer Screening


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for breast cancer screening in this clinical setting.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Mammography Screening There is no relevant literature to support the use of digital mammography for breast cancer screening in this clinical setting.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI breast without and with IV contrast for breast cancer screening in this clinical setting.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for breast cancer screening in this clinical setting.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. US Breast There is insufficient evidence to support the use of US for breast cancer screening of average-risk patients with nondense breast tissue [25,29].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Dense breast tissue lowers the sensitivity of mammography and increases breast cancer risk when compared with fatty breasts [25,30]. In patients with dense breasts and no additional risk factors, breast US may be useful as an adjunct to mammography for incremental cancer detection [25,31]; however, the increased risk of a false-positive examination should be considered in the decision [25,32-34].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Digital Breast Tomosynthesis Screening Annual screening with digital mammography or DBT is recommended in this clinical setting as it is for risk- comparable cisgender women with high-risk lesions, such as lobular neoplasia or atypical ductal hyperplasia, beginning at diagnosis but not before 30 years of age [25,35]. Transmasculine patients with a personal history of breast cancer are recommended to have mammography every 12 months because their breast cancer risk is similar to cisgender women [25,35].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Mammography Screening Annual screening with digital mammography or DBT is recommended in this clinical setting as it is for risk- comparable cisgender women with high-risk lesions, such as lobular neoplasia or atypical ductal hyperplasia, beginning at diagnosis but not before 30 years of age [25,35]. Transmasculine patients with a personal history of breast cancer are recommended to have mammography every 12 months because their breast cancer risk is similar to cisgender women [25,35].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. MRI Breast Without IV Contrast There is insufficient evidence to support the use of MRI breast without IV contrast for breast cancer screening in this clinical setting.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. US Breast In patients with dense breasts and increased risk of breast cancer, supplementing screening mammography with breast US increases cancer detection [25,40,41], although false-positives are also increased [25,40,41].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. US Breast Screening breast US may be helpful in this clinical setting because transmasculine patients have breast cancer risk similar to cisgender women. Mammography alone does not perform as well as mammography plus supplemental screening in high-risk patients, especially those with a genetic predisposition [25,40,41].


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. Transgender Breast Cancer Screening


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. 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.


Transgender Breast Cancer Screening

Transgender Breast Cancer Screening. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Introduction/Background The physical, psychological, and socioeconomic impact of cervical or neck pain is extensive. In 2010, 16.3 million health care visits to hospitals and physician offices were related primarily to neck pain [1]. The Global Burden of Disease 2010 Study identified neck pain as the fourth leading cause of years lost to disability [2], with most epidemiological studies reporting an annual prevalence ranging between 15% and 50% [3-8]. Although most episodes resolve, nearly 50% of individuals continue to experience ongoing or recurrent pain [9].


Cervical Neck Pain or Cervical Radiculopathy PCAs. 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.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Reprint requests to: publications@acr.org


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy vertebral body. Additional proposed red flags include congenital findings, concomitant vascular disease in patients >50 years of age, abnormal labs (erythrocyte sedimentation rate, C-reactive protein level, white blood cell), and neurological deficits [10].


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Cervical Spine CT offers superior depiction of cortical bone and is more sensitive than radiographs in assessing facet degenerative disease, osteophyte formation, vacuum phenomenon, and joint capsular calcification [24]. Ultra-low- dose techniques are proposed for CT in other regions of the body [25]; however, currently this has not been directly compared to radiographs for evaluation of the neck and cervical spine.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CTA Neck The literature search did not identify any studies regarding the use of CT angiography (CTA) in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRA Neck The literature search did not identify any studies regarding the use of MR angiography (MRA) in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine MRI is the most sensitive test for detecting soft abnormalities associated with neck pain; however, this is characterized by a high rate of abnormalities in asymptomatic individuals [22,23]. As such, MRI is not considered a first-line imaging modality in the setting of acute or worsening uncomplicated neck pain.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy Bone Scan Whole Body with SPECT or SPECT/CT Neck There is no current role for nuclear medicine studies as the initial examination in this scenario. Tc-99m bone scan lacks both resolution and specificity in detecting pathology related to acute or worsening neck pain in the absence of red flag symptoms; most commonly, these will be associated with degenerative spondylosis. A recent retrospective study of patients with nonconclusive MRI or CT findings demonstrated that hybrid single-photon emission computed tomography (SPECT)/CT imaging identified potential pain generators in 92% of cervical spine scans [26]; however, this is not a first-line examination.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Radiography Cervical Spine Radiographs are widely accessible and useful to diagnose spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis. Flexion/extension radiographs have limited value in degenerative disease [27]. In the absence of red flag symptoms, therapy is rarely altered by radiographic findings [27-29].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Cervical Spine CT provides good definition of bony elements and is helpful in the assessment of neuroforaminal stenosis secondary to uncovertebral or facet hypertrophy and is helpful when C6 and C7 are not clearly seen on traditional lateral radiographic views. However, CT is shown to be less sensitive than MRI for evaluation of nerve root compression [35,36].


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Myelography Cervical Spine MRI has mostly supplanted CT myelography as a first-line imaging modality for complex cervical radiculopathy [37]. However, studies have shown that CT myelography may prove useful in diagnosing foraminal stenosis, bony lesions, and nerve root compression [38] and can be considered in patients with clinically apparent radiculopathy and contraindication to MRI, or in the setting of equivocal MRI findings.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine MRI has become the preferred method to evaluate the cervical spine in the setting of suspected nerve root impingement [39] because of its superior intrinsic soft-tissue contrast and good spatial resolution. Brown et al [35] in a blinded, retrospective review studied 34 patients with clinically diagnosed cervical radiculopathy who underwent MRI prior to surgery and reported that MRI correctly predicted 88% of the lesions as opposed to 81% for CT myelography, 57% for plain myelography, and 50% for CT. However, as noted previously, degenerative findings on MRI are commonly observed in asymptomatic patients [21,23,40,41]. A prospective study evaluating MRI cervical spine in recent onset cervical radiculopathy found a high rate of both false-positive and false- negative findings [33].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Neck Tc-99m bone scan lacks both resolution and specificity to detect pathology related to suspected nerve root compression.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Radiography Cervical Spine Approximately 65% of asymptomatic patients 50 to 59 years of age will have radiographic evidence of significant cervical spine degeneration, regardless of radiculopathy symptoms [42].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17].


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Cervical Spine Multidetector CT scanning with high-quality multiplanar reformatted images have enhanced the efficacy of CT assessment and imaging findings, particularly around hardware. CT is the most sensitive and specific modality to assess spinal fusion [48-50] and can aid in detecting adjacent segment degeneration [51]. A recent review of 690 patients who underwent ACDF concluded that CT altered the treatment plan in 39% of patients who had persistent symptoms and altered the treatment plan for 60% of patients with persistent symptoms and abnormal radiographs or MRI. Furthermore, recent advances in dual-energy CT has shown promise to reduce beam- hardening metal artifact, which may improve the evaluation of hardware complications and adjacent segment degeneration in postoperative patients with new or worsening neck pain [52]. Whether imaging is informative for changes to improve outcome remains to be established. In one study, half of the symptomatic cohort did not have postoperative CT, and the majority recovered with 2 years of conservative therapy [53].


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Myelography Cervical Spine CT myelography is not the first-line test of choice for complex cervical radiculopathy [37]. However, it can be considered in patients with radiculopathy, particularly if MRI is nondiagnostic related to hardware artifact.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine Metal artifact may limit assessment of the cervical hardware and complications related to position or integrity. There continues to be emerging techniques for metal artifact reduction, which is beyond the scope of this document [54]. MRI is the most sensitive imaging test for detecting soft-tissue abnormalities associated with neck pain but is characterized by a high rate of abnormalities in asymptomatic individuals [22,23]. Most cervical discectomies are performed by an anterior approach without transgression of the epidural space; therefore, epidural scar or granulation tissue formation is minimal, and contrast-enhanced imaging is not routinely used after ACDF [55]. Gadolinium-enhanced MRI may have a role in the setting of neck pain and prior posterior-approach cervical fusion/decompressive procedures, although the majority of the literature to date evaluates the use of gadolinium-based contrast in the differentiation of recurrent disc herniations (a potentially actionable finding) from epidural scar in the setting of lumbar spine surgery [56,57].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Neck There is no current role for nuclear medicine studies as the initial examination in this scenario. The role of Tc- 99m bone scan in the setting of new or worsening neck pain in the postsurgical patient is limited, as radionuclide scans may remain positive for a year or more in the region of the operative bed [58]. SPECT/CT may offer diagnostic information in the setting of suspected pseudoarthrosis or equivocal CT or MRI findings [59].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Radiography Cervical Spine Initial radiographic evaluation, including anteroposterior and lateral views, is useful to assess hardware integrity and detect adjacent segment disease, which may contribute to symptoms [60,61]. The addition of flexion/extension radiographs may be considered to improve detection of vertebral body nonunion or pseudoarthrosis [62] and may supplement conventional views following ACDF [63], cervical disc implantation, or posterior cervical fixation [64-66].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy CT Cervical Spine CT with and without contrast is superior to radiography for the detection of erosive changes, loss of fat planes, and paraspinal edema and fluid collections [69]. CT scanning also offers potential advantages in identifying the presence of gas within an abscess, the lack of gas within the disc space, or a sequestrum within the spinal canal [70]. CT with contrast is complementary to MRI.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Myelography Cervical Spine The literature search did not identify any studies regarding the use of CT myelography in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. FDG-PET/CT Skull Base to Mid-Thigh PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)/CT is the scintigraphic procedure of choice for spinal osteomyelitis [71-73].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Gallium-67 Scan Whole Body Specificity may be increased by combining Tc-99m methylene diphosphonate (MDP) with gallium-67 citrate [74], and higher sensitivity and resolution can be further achieved with SPECT/CT [75].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Indium-111 WBC Scan Whole Body Indium-labeled leucocytes have a low sensitivity in spinal infections (osteomyelitis and discitis). In these clinical scenarios, leucocytes are generally not used because of a reported 40% false-negative rate, which is manifested as normal uptake or photopenia. In the past, the preferred radionuclide imaging for spinal osteomyelitis was a combination of bone and gallium scans.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine MRI with and without contrast is considered the best modality for demonstrating spinal infections, with a sensitivity of 96%, specificity of 92%, and accuracy of 94% [68,69,76]. While bone marrow edema can be detected on noncontrast examinations [68,77-79], the addition of contrast improves detection and characterization of leptomeningeal involvement or the development of an epidural or paraspinal abscess [79,80].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Neck Three-phase Tc-99m MDP scintigraphy is sensitive (90%) but not specific (78%) [76] for the identification of suspect cervical spine osteomyelitis.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Radiography Cervical Spine Radiographs lack sensitivity and specificity in the setting of discitis or osteomyelitis, as 30% to 40% of the vertebral bone must be destroyed before lytic changes can be identified [81,82]. Because of the low sensitivity and specificity, particularly in early phases of spine infection, a negative cervical spine radiograph should not be considered comprehensive imaging in this scenario.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Myelography Cervical Spine CT myelography has supplanted fluoroscopic myelography in most circumstances; however, there may be times when fluoroscopic myelography is also performed prior to CT imaging. The ultimate judgment regarding the appropriateness of any specific procedure, lumbar versus cervical puncture route, amount of contrast, and the extent and modality of imaging coverage must be made by the radiologist, with appropriate documentation and coding [17].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy Variant 5: Known malignancy. New or increasing nontraumatic cervical or neck pain or radiculopathy. Initial imaging. Although primary tumors of the spine are uncommon [83], an estimated 10% of cancer patients develop symptomatic spinal metastases during the course of their disease [84], making the spine the most common site of osseous metastatic disease [85]. Suspected spinal metastases are typically diagnosed using cross-sectional imaging with the dual goal of identifying potential metastases and characterizing the extent of malignancy. As such, the choice of imaging modality is often based on both the type of malignancy and the presenting clinical features, especially if referable to pathological fracture, cord compression, or nerve root impingement.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Cervical Spine Because of its high spatial resolution, CT is more sensitive than conventional radiography for the detection of bone metastases and has shown good correlation with nuclear bone scans, particularly if coupled with concurrent CT examinations of the thorax, abdomen, and/or pelvis [86]. CT can help characterize lesions as lytic or blastic and may successfully assess paravertebral or intraspinal extension if intravenous contrast is used [87]. CT is also useful to obtain better structural definition of abnormal findings identified on scintigraphy or MRI [88], such as in the setting of suspected pathologic fracture. However, given that CT is relatively insensitive for tumors restricted to the marrow space, the sensitivity of CT is relatively low in early malignant bone involvement [87,89], and as such, MRI is favored as an initial diagnostic modality.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Fluoride PET/CT whole body F-18-sodium fluoride (NaF) PET/CT has become an important tool for detecting and evaluating metastatic bone cancer [90,91] and may be a preferable modality for detecting metastatic bone disease in morbidly obese patients; however, there is currently no evidence supporting the validity of F-18 NaF PET/CT as a first-line test evaluating acute neck pain or radicular symptoms in patients with malignancy.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. FDG-PET/CT Whole Body FDG-PET/CT is sensitive for detection of metastatic disease and has been compared to detection rates of bone scans [92,93]. However, resolution of PET scans is limited for assessment of involvement of the spinal cord/meninges and exiting nerve roots, and as such, there is currently no evidence supporting the validity of FDG- PET/CT as a first-line test evaluating acute neck pain or radicular symptoms in patients with malignancy.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine MRI has high sensitivity and specificity for the detection and discrimination of malignant bone lesions [88], with the addition of contrast to delineate the extent of marrow leptomeningeal, epidural, neuroforminal, and paraspinal involvement. Furthermore, local spread of bone metastases and extension into the spinal canal is better assessed on MRI, particularly in the setting of clinical suspicion for nerve root or cord compression [94].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Neck Although Tc-99m bone scan is the most commonly used technique for detecting suspected osseous metastasis, it has a high false-positive rate secondary to benign processes with increased bone turnover, such as degenerative osteoarthrosis [95]. The addition of SPECT to the acquisition protocol of bone scintigraphy improves image contrast resolution [96] and, thus, diagnostic accuracy. Furthermore, adding a CT acquisition can increase this diagnostic accuracy with anatomic localization to the SPECT images resulting in SPECT/CT [36].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy Radiography Cervical Spine Conventional radiography still plays an important role in the diagnostic evaluation of bone metastases as pathological changes in cortical bone are detectable by plain radiograph even if they are only a few millimeters wide [97]. Radiographs can also reveal osteolytic lesions at risk for superimposed pathological fracture. However, given that these osteolytic changes may only be detectable after 50% of the bone substance has been destroyed [87], and lesions up to 1 cm may not be detectable, radiographs alone are not sufficient to exclude metastases in the setting of neck pain in a patient with known malignancy.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103]. For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104].


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, CT myelography is not an appropriate first-line imaging test.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103]. For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited. The addition of SPECT to the acquisition protocol of bone scintigraphy improves image contrast resolution [105], and thus diagnostic accuracy. Some authors have advocated the use of SPECT imaging in identifying the pain source (ie, facet disease) [106]. Furthermore, adding a CT acquisition can increase this diagnostic accuracy with anatomic localization to the SPECT images resulting in SPECT/CT [36].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Radiography Cervical Spine There is no evidence that medical imaging is diagnostic for the etiologies of cervicogenic headache; however, imaging may lend support to its diagnosis [103]. For example, in a study of 22 symptomatic and 20 control patients, there was no difference in the number of patients with cervical disc bulges or in the distribution of degenerative disc disease within the cervical spine [104].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Myelography Cervical Spine In the absence of radiographic abnormalities or neurological symptoms, myelography is not an appropriate first- line imaging test.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Cervical Spine CT is not currently recommended as a first-line examination for chronic neck pain in the absence of red flags or neurological symptoms.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Myelography Cervical Spine CT myelography is not an appropriate test for chronic neck pain in the absence of radicular or myelopathic symptoms.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRA Neck The literature search did not identify any studies regarding the use of MRA in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine MRI is the most sensitive test for detecting soft abnormalities associated with neck pain; however, it is characterized by a high rate of abnormalities in asymptomatic individuals [22,23]. As such, MRI is not considered appropriate as a first-line imaging modality in the setting of chronic, uncomplicated neck pain.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited, though SPECT likely offers benefit over conventional planar imaging. Some authors have advocated SPECT imaging in identifying the pain source (ie, facet disease) [106]; however, is not considered appropriate as a first imaging modality in the setting of chronic, uncomplicated neck pain.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Radiography Cervical Spine Radiographs may be helpful in clarifying the clinical diagnosis of cervical spondylosis from mechanical, inflammatory, or metabolic processes in patients who otherwise have no red flag symptoms [107]. Radiographically visible degenerative changes, such as disc space narrowing, osteophyte formation, facet, and uncovertebral hypertrophy, are common [108] and may not correlate with symptoms or impact treatment.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Cervical Spine Multidetector CT scans with high-quality multiplanar reformatted images have enhanced the efficacy of CT, which offers superior depiction of cortical bone and is more sensitive than radiographs in the assessment of facet degenerative disease, osteophyte formation, vacuum phenomenon, and joint capsular calcification [24].


Cervical Neck Pain or Cervical Radiculopathy PCAs. CTA Neck The literature search did not identify any studies regarding the use of CTA in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Percutaneous Interventions The use of provocative injections in the cervical spine to identify a pain source is controversial. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders concluded there was no evidence to support using cervical provocative discography or anesthetic facet or nerve blocks [1]. The use of facet injection as a diagnostic maneuver is limited by frequent anesthetic leakage into adjacent spaces, resulting in false-positive results [109,110].


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine In patients with neck pain without neurologic symptoms, the relevance of specific MRI findings in the cervical spine should be considered in light of expected changes associated with aging. MRI is more sensitive than CT in identifying degenerative cervical disorders [111,112]. However, the presence of degenerative changes should be interpreted with caution. In a small series, Fryer et al [113] found little correlation between the presence of facet arthropathy and the side or level of symptoms in patients with acute, unilateral neck pain. Spondylotic changes on radiographs and MRI are common in patients over 30 years of age and have been shown to correlate poorly with the presence of neck pain [20-23,114,115]. Okada et al [112], in a 10-year longitudinal MRI study, showed that cervical disc degeneration progressed in 85% of patients, though symptoms developed in only 34% of patients. Most significantly, patients developing symptoms showed more frequent progression of disc degeneration on MRI, including anterior compression of the dura and spinal cord, posterior disc protrusion, disc space narrowing, and foraminal stenosis.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Neck The role of Tc-99m bone scan in the setting of chronic neck pain is limited, though SPECT likely offers benefit over conventional planar imaging. Some authors have advocated the use of SPECT imaging in identifying the pain source (ie, facet disease) [106]. A recent retrospective study of 25 patients with chronic cervical spine pain demonstrated that hybrid SPECT/CT imaging identified potential pain generators in 92% of patients [26], and as such may have a role in secondary workup.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Myelography Cervical Spine Myelography is not an appropriate test for chronic neck pain in the absence of radicular or myelopathic symptoms. Similar to more recent literature on MRI, asymptomatic degenerative changes have been described on myelograms [116].


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy Variant 9: Chronic cervical or neck pain without or with radiculopathy. Radiographs show ossification in the posterior longitudinal ligament (OPLL). Next imaging study. Heterotopic ossification in the posterior longitudinal ligament (OPLL) predisposes the patient to progressive narrowing of the spinal canal and/or abutment of the spinal cord. OPLL commonly presents in the fifth or sixth decade of life with a 2:1 male-to-female ratio. OPLL of the cervical spine is more common than thoracic OPLL, which was confirmed in a survey of 1,058 patients with OPLL, of whom 3.2% demonstrated involvement of the cervical spine and 0.8%, the thoracic spine [117]. Although original estimates of OPLL prevalence were based on lateral radiographs of the spine, more recently reported prevalence rates based on CT report prevalence rates of cervical OPLL between 1.7% in the white United States population and 4.6% in the Korean population [118,119].


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Cervical Spine Although radiographs are helpful in the diagnosis of OPLL, particularly in the cervical region, CT is more reliable both in the identification of OPLL and in the evaluation of sequelae related to its diagnosis [120]. CT evaluation can show OPLL type, thickness, length of involved segments, and associated systemic diseases, such as diffuse idiopathic skeletal hyperostosis. The superior spatial resolution of CT helps identify regions of neuroforaminal and spinal canal narrowing and should be considered in any patient presenting with new or worsening radiculopathy in the setting of suspected OPLL.


Cervical Neck Pain or Cervical Radiculopathy PCAs. CT Myelography Cervical Spine CT myelography performed in flexion and extension has been described to help identify regions of position- dependent cord compression related to cervical spinal stenosis from OPLL [121], although it is not routinely used in clinical practice.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Percutaneous Interventions The literature search did not identify any studies regarding the use of cervical facet joint, medial branch blocks, or discography as a first-line test in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. MRI Cervical Spine Detection of OPLL on MRI is limited, with reported sensitivity of 32% to 44.3% [122]. Therefore, the primary utility of MRI in the setting of OPLL is in the assessment of cord abutment/signal changes secondary to spinal canal narrowing. MRI also affords the ability to evaluate the exiting nerve roots in the setting of radiculopathy.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Neck The literature search did not identify any studies regarding the use of bone scan as a first-line test in the evaluation of this clinical presentation.


Cervical Neck Pain or Cervical Radiculopathy PCAs. Cervical Neck Pain or Cervical Radiculopathy 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.


Cervical Neck Pain or Cervical Radiculopathy PCAs. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Primary Bone Tumors

Primary Bone Tumors. Primary bone tumors are conventionally classified by the World Health Organization as benign, intermediate (locally aggressive or rarely metastasizing), or malignant [1]. Benign tumors include a wide variety of developmental abnormalities and true neoplasms. Because most benign bone tumors are asymptomatic, the true incidence of these tumors is unknown, although they are not uncommon. Intermediate tumors include lesions such as giant cell tumor, osteoblastoma, and desmoplastic fibroma. Primary malignant bone tumors may also arise from malignant mesenchymal cells (sarcomas). Primary malignant bone tumors are quite rare, with an estimated incidence of 1 case per 100,000 persons per year [2].


Primary Bone Tumors

Primary Bone Tumors. Diagnosis of benign and malignant primary bone tumors relies on a coordinated evaluation of both clinical and radiologic information. Many primary bone tumors can be effectively stratified with respect to typical age of presentation as well as lesion size, location, and number. Classically, radiographs have played a substantial role in the characterization of primary bone tumors. An assortment of radiographic features, including tumor margin, periosteal reaction, and matrix mineralization, may be used to assess the biological activity of a bone lesion [3-6]. An asymptomatic nonaggressive-appearing lesion incidentally found on radiographs may, in many cases, require no further evaluation. In cases in which clinical or radiographic features are indeterminate or additional anatomic information is required, advanced imaging modalities, such as CT, MRI, or nuclear medicine, may provide a complementary role in the diagnosis and treatment stratification of primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors. Because primary bone sarcomas are rare, there is sparse level 1 evidence in the literature specifically addressing their imaging evaluation. The recommendations contained herein are based on assessment of the available literature and on the experience of the members of the ACR Appropriateness Criteria Expert Panel on Musculoskeletal Imaging.


Primary Bone Tumors

Primary Bone Tumors. This document applies to the evaluation of osseous lesions throughout the entire body. Generally, bone tumors are most common in the long bones [1], and consequently, recommendations for imaging are for the most part based on this. When lesions occur in locations with complex osseous anatomy, such as the skull, spine, pelvis, or small bones of the hand or foot, CT may be a more suitable initial imaging modality. Similarly, when a lesion occurs in a rib or area in which respiratory motion can be an issue, MRI may not be a suitable imaging modality. As noted within the document, the following recommendations must be adapted by the user, based on lesion size, location, and suspected biological aggressiveness.


Primary Bone Tumors

Primary Bone Tumors. aResearch Author, Mayo Clinic, Jacksonville, Florida. bPanel Vice-Chair, Mayo Clinic, Jacksonville, Florida. cPanel Chair, University of Kentucky, Lexington, Kentucky. dUK Healthcare Spine and Total Joint Service, Lexington, Kentucky; American Academy of Orthopaedic Surgeons. eRadiology Imaging Associates, Denver, Colorado. fDiagnostic Imaging Associates, Chesterfield, Missouri. gWake Forest University School of Medicine, Winston Salem, North Carolina. hDavid Geffen School of Medicine at UCLA, Los Angeles, California. iUniversity of Virginia, Charlottesville, Virginia. jMayo Clinic Florida, Jacksonville, Florida. kUniversity Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio; Neurosurgery Expert. lOregon Health & Science University, Portland, Oregon; Neurosurgery Expert. mPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. nNuclear Radiologist, Weston, Connecticut. oSpecialty Chair, Mayo Clinic, Phoenix, Arizona.


Primary Bone Tumors

Primary Bone Tumors. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Primary Bone Tumors

Primary Bone Tumors. Reprint requests to: publications@acr.org


Primary Bone Tumors

Primary Bone Tumors

Primary Bone Tumors. Primary Bone Tumors


Primary Bone Tumors

Primary Bone Tumors. The recommendations for all variants in this document apply to the following body regions: lower extremity, upper extremity, ribs, pelvis, skull, and spine.


Primary Bone Tumors

Primary Bone Tumors. Discussion of Procedures by Variant Variant 1: Suspect primary bone tumor. Initial imaging. CT Area of Interest CT is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of CT in the initial imaging of primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors. FDG-PET/CT Whole Body PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)/CT is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of FDG-PET/CT in the initial imaging of primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors. MRI Area of Interest MRI is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of MRI in the initial imaging of primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors. Radiography Area of Interest Radiographs remain the most appropriate imaging modality for screening and initial characterization of primary bone tumors. Radiographs provide an accurate means by which to evaluate primary bone tumors. Radiographs effectively provide information in regard to tumor location, size, and shape, as well as evidence of tumor biological activity [3]. Tumor margin and periosteal reaction provide a reliable index of biological potential of the tumor, whereas matrix, if identified, is a key to the underlying histology [3-6]. Although the utility of radiographs in stratifying bone lesions by biological activity is well established, there is sparse literature documenting concrete values on accuracy. A prospective study evaluating 200 consecutive bone tumors of the hand showed that subjective grading of tumors based on radiographic features provided a correct categorization of tumor grade (benign versus malignant) in 82.5% of cases [7]. In a retrospective study applying a modified Lodwick-Madewell grading system to categorize 183 bone tumors, Caracciolo et al [8] found that a low radiographic grade assignment correlates with benignity and that increasing grade correlates with an increasing risk of malignancy. It should be noted that accurate radiographic characterization of some primary bone tumors (such as low-grade cartilage lesions) is inherently difficult because of overlapping radiographic features of some benign and malignant chondroid lesions. Crim et al [9] performed a retrospective review of 53 cases of low-grade cartilage lesions (enchondroma and grade 1 chondrosarcoma) and found that radiographs suggested the correct diagnosis of enchondroma in 67.2% of cases and the correct diagnosis of chondrosarcoma in only 20.8% of cases. In a retrospective analysis of 35 enchondromas and 43 central grade 1 chondrosarcomas, Geirnaerdt et al [10] found that morphologic features seen on radiographs in combination with clinical symptoms did not improve the ability to differentiate between enchondromas and central grade 1 chondrosarcomas.


Primary Bone Tumors

Primary Bone Tumors. Bone Scan Whole Body Bone scan is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of Tc-99m bone scan in the initial imaging of primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors. US Area of Interest Ultrasound (US) is not routinely used in the initial evaluation of primary bone tumors. There is no relevant literature regarding the use of US in the initial imaging of primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors. Variant 2: Suspect primary bone tumor. Radiographs negative or do not explain symptoms. Next imaging study. In cases in which radiographs are negative or radiographic findings do not adequately explain the symptoms, further evaluation with advanced imaging (such as MRI or CT) should be contemplated based on history and level of clinical concern.


Primary Bone Tumors

Primary Bone Tumors. CT Area of Interest In cases in which radiographs are negative or fail to adequately explain symptoms, CT can be a helpful tool in facilitating detection of bony abnormalities, such as nondisplaced fractures, subtle periosteal reaction, or occult bone tumors. CT can be especially helpful in evaluating regions of complex or overlapping osseous anatomy, in which radiographic evaluation can be limited. In a retrospective study of 47 patients with negative radiographic


Primary Bone Tumors

Primary Bone Tumors


Primary Bone Tumors

Primary Bone Tumors. findings and positive bone scintigraphy findings specifically involving the ribs, CT was effective in detecting rib fractures and avoiding further unnecessary examinations [11]. CT is also a viable imaging alternative for patients who cannot receive an MRI. Some cases may benefit from both MRI and CT because these modalities provide complementary information regarding soft-tissue (often better evaluated on MRI) and matrix mineralization (often better evaluated on CT).


Primary Bone Tumors

Primary Bone Tumors. There is no relevant literature specifically regarding the use of CT with intravenous (IV) contrast or CT without and with IV contrast in the evaluation of suspected primary bone tumor with negative or equivocal radiographs or radiographs that do not explain symptoms. Contrast may be helpful if a soft-tissue component is suspected. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production.


Primary Bone Tumors

Primary Bone Tumors. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used for the evaluation of primary bone tumors in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms. Although FDG- PET/CT can detect metabolically active tumors, there is no relevant literature regarding the use of FDG-PET/CT in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms.


Primary Bone Tumors

Primary Bone Tumors. Bone Scan Whole Body Despite its historical utility in detecting radiographically occult bone abnormalities, studies that are more recent have shown that MRI is superior in this role. A retrospective analysis comparing the sensitivity of MRI and scintigraphy in the detection of malignant bone tumors in 106 patients showed that MRI revealed a focal abnormality compatible with tumor that was occult on scintigraphy in 28% of cases [12]. Although not typically the next imaging study, bone scan remains a viable imaging option in select cases in which MRI is not clinically feasible as well as in cases that require evaluation of the full extent and distribution of disease because it can provide a comprehensive evaluation of the entire skeleton.


Primary Bone Tumors

Primary Bone Tumors. US Area of Interest Although US may be helpful in detecting regional soft-tissue abnormalities that could explain symptoms, US is quite limited in its ability to evaluate bone. There is no relevant literature regarding the use of US for the evaluation of primary bone tumors in patients with positive localized or regional symptoms and negative radiographs or findings that do not explain symptoms.


Primary Bone Tumors

Primary Bone Tumors. Variant 3: Suspect primary bone tumor. Benign radiographic features. Not osteoid osteoma. Next imaging study. An asymptomatic benign-appearing lesion on radiographs is usually an incidental finding and typically requires no further imaging evaluation. If the lesion is symptomatic, please consult Variant 2.


Primary Bone Tumors

Primary Bone Tumors. CT Area of Interest CT is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of CT in the evaluation of definitely benign primary bone tumors. However, if such lesions are symptomatic, CT imaging without IV contrast may be useful to identify complications or for surgical planning.


Primary Bone Tumors

Primary Bone Tumors. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of FDG-PET/CT in the evaluation of definitely benign primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors

Primary Bone Tumors. Primary Bone Tumors


Primary Bone Tumors

Primary Bone Tumors. MRI Area of Interest MRI is not routinely used in the evaluation of lesions that are definitely benign on radiographs. If such lesions are symptomatic, MRI may be useful to identify unusual complications, such as stress fracture, secondary aneurysmal bone cyst formation, or malignant transformation [13].


Primary Bone Tumors

Primary Bone Tumors. Bone Scan Whole Body Bone scan is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of Tc-99m bone scan in the evaluation of definitely benign primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors. US Area of Interest US is not routinely used in the evaluation of lesions that are definitely benign on radiographs. There is no relevant literature regarding the use of US in the evaluation of definitely benign primary bone tumors.


Primary Bone Tumors

Primary Bone Tumors. Variant 4: Suspect primary bone tumor. Radiographs or clinical presentation suggest osteoid osteoma. Next imaging study. CT Area of Interest CT is considered the optimal imaging modality in patients with suspected osteoid osteoma. CT is preferred over MRI when osteoid osteoma is strongly suspected because it is extremely sensitive for detection and precise delineation of the nidus [14], which is important both for diagnosis and treatment. In a study including 19 patients with histologically proven osteoid osteoma who underwent CT and MRI before excision of the lesion, Assoun et al [15] found that CT was more accurate than MRI in detection of the osteoid osteoma nidus in 63% of cases.


Primary Bone Tumors

Primary Bone Tumors. There is no relevant literature specifically regarding the use of CT without and with IV contrast in the evaluation of suspected primary bone tumor with negative or equivocal radiographs or radiographs that do not explain symptoms. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production.


Primary Bone Tumors

Primary Bone Tumors. CT perfusion is a dynamic without and with IV contrast CT examination, which facilitates further characterization in the setting of suspected osteoid osteoma. A comparative study looking at CT perfusion parameters of 15 patients with a final diagnosis of osteoid osteoma, 15 patients with lesions that mimic osteoid osteomas, and 26 patients with other bone lytic lesions showed that enhancement curve morphology of the osteoid osteomas was significantly different from its mimickers. All osteoid osteomas had early enhancement with a delay between nidus and arterial peak below 30 seconds. Eighty percent of the mimickers demonstrated a slow and progressive pattern of enhancement. The perfusion parameters of the other lytic bone lesions were similar to those of the osteoid osteomas in 46.1% of the patients, indicating that early enhancement is suggestive but not pathognomonic of osteoid osteomas [16].


Primary Bone Tumors

Primary Bone Tumors. FDG-PET/CT Whole Body FDG-PET/CT is not routinely used in the evaluation of suspected osteoid osteoma. There is no relevant literature regarding the use of FDG-PET/CT in the evaluation of suspected osteoid osteoma.


Primary Bone Tumors

Primary Bone Tumors. MRI Area of Interest MRI is generally considered inferior to CT in the evaluation of suspected osteoid osteoma because it may fail to demonstrate the typical nidus and can present a confounding imaging appearance. Davies et al [17] performed a retrospective review of the MRI findings of 43 patients with osteoid osteoma and then compared the results with those of other imaging modalities. The authors found that the potential for a missed diagnosis of osteoid osteoma on MRI was 35%. They cautioned that osteoid osteoma may be difficult to identify on MRI and the imaging features may be easily misinterpreted. In a study including 19 patients with histologically proven osteoid osteoma who underwent CT and MRI before excision of the lesion, Assoun et al [15] found that MRI was better than CT in showing intramedullary and soft-tissue changes in all cases. However, the authors cautioned that such findings on MRI may produce a misleading aggressive appearance. Liu et al [18] performed a retrospective study including 11 patients with pathologically proven osteoid osteomas who underwent nonenhanced MRI, dynamic gadolinium-enhanced MRI, and CT. They showed that compared with CT, dynamic gadolinium-enhanced MRI demonstrated the osteoid osteoma equally well in 8 of 11 patients and with better conspicuity in 3 of 11 patients, although this difference was not statistically significant (P = .69). Furthermore, the dynamic gadolinium-enhanced MRIs demonstrated the osteoid osteomas significantly better than the nonenhanced T1-weighted (P < .001) and T2-weighted (P < .001) MRIs. In the majority of cases, peak enhancement of the osteoid osteoma occurred in the


Primary Bone Tumors

Primary Bone Tumors


Primary Bone Tumors

Primary Bone Tumors. arterial phase with early partial washout. However, MRI without IV contrast or MRI without and with IV contrast may be useful in some cases to identify alternative diagnoses such as osteomyelitis.


Primary Bone Tumors

Primary Bone Tumors. Bone Scan Whole Body Bone scan is sensitive for the detection of osteoid osteoma but lacks specificity [19].


Primary Bone Tumors

Primary Bone Tumors. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest Bone scan is sensitive for the detection of osteoid osteoma but lacks specificity. Single-photon emission computed tomography (SPECT) or SPECT/CT may help improve specificity [19].


Primary Bone Tumors

Primary Bone Tumors. US Area of Interest US is not routinely used in the evaluation of suspected osteoid osteoma. There is no relevant literature regarding the use of US in the evaluation of suspected osteoid osteoma.


Primary Bone Tumors

Primary Bone Tumors. Variant 5: Suspect primary bone tumor. Lesion on radiographs. Indeterminate or aggressive appearance for malignancy. Next imaging study. Lesions seen on radiographs that are not definitely benign often require additional characterization using advanced imaging studies such as MRI or CT. The next best imaging examination is not always clearly defined because the choice will be influenced by the radiographic appearance of the lesion, location, number of lesions, availability of imaging equipment, plan for biopsy/treatment, as well as underlying patient-specific clinical parameters.


Primary Bone Tumors

Primary Bone Tumors. CT Area of Interest CT continues to play a role in the evaluation of indeterminate bone lesions discovered on radiographs, particularly in lesions with mineralized matrix or in suspected cases of osteoid osteoma (see Variant 4). Both MRI and CT have been used to evaluate the degree of cortical involvement in chondroid lesions [20]. In comparison with radiographs and MRI, CT has been shown to better delineate the presence of cortical destruction and the character of matrix mineralization patterns in patients with clear cell chondrosarcoma [21]. In a retrospective review of 40 pathologically confirmed telangiectatic osteosarcomas, Murphey et al [22] noted that CT was the optimal imaging modality for demonstration of subtle matrix mineralization seen in 85% of cases in the intraosseous or soft-tissue components of the lesion. Not all studies conclude that one modality, CT or MRI, is better than the other. A multi- institutional collaborative study assessing the relative accuracy of CT and MRI in the local staging of primary malignant musculoskeletal neoplasms showed no statistically significant difference between CT and MRI in determining tumor involvement of muscle, bone, joints, or neurovascular structures. Furthermore, the combined interpretation of CT and MRI did not significantly improve accuracy [23]. Advanced CT techniques, such as dual- energy CT, have shown promise in differentiating malignant from nonmalignant tumors, although further research in this area is needed [24]. MRI is generally considered the preferred imaging modality for staging of bone tumors. Some cases may benefit from both MRI and CT because these modalities provide complementary information regarding soft-tissue (often better evaluated on MRI) and matrix mineralization (often better evaluated on CT).


Primary Bone Tumors

Primary Bone Tumors. There is no relevant literature regarding the specific use of CT with IV contrast or CT without and with IV contrast in the evaluation of suspected primary bone tumor with radiographs indeterminate for malignancy. However, if contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production.


Primary Bone Tumors

Primary Bone Tumors. FDG-PET/CT Whole Body FDG-PET has proven useful for further characterizing indeterminate bone tumors identified on radiographs. PET information can be co-registered with CT or MRI, taking advantage of the inherent benefits of these modalities. A number of studies have shown FDG-PET and FDG-PET/CT to be a valuable adjunct to conventional imaging in the diagnosis, staging, restaging, and surveillance of primary bone tumors [25-31]. Shin et al [32] evaluated the efficacy of FDG-PET/CT in differentiating benign from malignant pathologic fractures in a series of 34 patients. With a standardized uptake value max cut-off set at 4.7, they found the sensitivity, specificity, and diagnostic accuracy of FDG-PET/CT to be 89.5%, 86.7%, and 88.2%, respectively. However, it was noted that there may be significant overlap in the metabolic activity of benign and malignant lesions, such as those containing myxoid or necrotic components with inherent low metabolic activity. In a study of 29 patients assessing the value of PET in appropriately characterizing cartilage neoplasms, the overall sensitivity of PET in differentiating benign from malignant lesions was 90.9%, with a specificity of 100% and accuracy of 96.6% [33]. Bredella et al [26] found


Primary Bone Tumors

Primary Bone Tumors

Primary Bone Tumors. Primary Bone Tumors


Primary Bone Tumors

Primary Bone Tumors. that FDG-PET can help differentiate benign from malignant spinal compression fractures with a sensitivity of 86% and specificity of 83%; however, there was overlap in the range of standardized uptake value in the benign and malignant groups.


Primary Bone Tumors

Primary Bone Tumors. MRI Area of Interest MRI is a robust tool that can further characterize an indeterminate bone lesion detected on radiographs. Despite its widespread use in this role, there are few controlled studies in the literature over the last 10 years specifically evaluating the role of MRI in further characterizing lesions detected on radiographs. Several studies do exist that serve to highlight the role of MRI in further characterizing the tissue composition (such as fat, hemorrhage, fluid levels) and anatomic extent of a variety of bone tumors [20-22,34,35]. MRI has also been shown to be useful in predicting the grade (benign versus malignant) of known primary bone tumors. A prospective study evaluating 200 consecutive bone tumors of the hand showed that MRI improved grading in comparison with radiography alone by correctly upgrading malignant tumors and downgrading benign tumors in 8% and 12% of cases, respectively [7]. Crim et al [9] performed a retrospective review of 53 cases of low-grade cartilage lesions (enchondroma and grade 1 chondrosarcoma) and found that MRI suggested the correct diagnosis of enchondroma in 57.8% of cases (radiographs correctly diagnosed 67.2% of cases) and the correct diagnosis of chondrosarcoma in 57.8% of cases (radiographs correctly diagnosed 20.8% of cases). Overall, MRI had an increased rate of both true-positive and radiographic characterization, the characterization of low-grade chondroid lesions on MRI is challenging because of overlapping features of benign and malignant lesions.


Primary Bone Tumors

Primary Bone Tumors. MRI is generally considered the preferred imaging modality for staging of bone tumors [14]. Hogeboom et al [36] compared the value of MRI to CT in the evaluation of bone tumors in a prospective study of 25 patients. They found that MRI has better soft-tissue contrast than CT, making it possible to study the relationship of the bone tumor to the soft tissues, bone marrow, and joints more accurately. They found that CT better defines destruction of cortical bone. Specifically, MRI was superior to CT in detecting cortical bone destruction in 4.5% of patients studied and better at evaluating marrow involvement in 25%, soft-tissue involvement in 31%, joint involvement in 36.4%, and invasion of neurovascular structures in 15.3% of patients. MRI and CT were judged equivalent in these categories the majority of the time (ranging from 63% to 82% of the time for the various categories). CT was superior to MRI for some patients in two categories: detecting cortical bone destruction (13.6%) and neurovascular involvement (7.7%). If both modalities are available, the authors suggest that MRI is preferable to CT. A prospective study comparing the staging of primary bone sarcoma with CT, MRI, bone scintigraphy, and angiography in 56 patients showed that MRI was superior in defining tumor length, demonstrating involvement of muscle compartments, and delineating the relationship between tumor and major neurovascular bundles [37]. In the same study, MRI was shown to be comparable to CT in demonstrating cortical bone and joint involvement [37]. In contrast, results of a multi-institutional collaborative study assessing the relative accuracy of CT and MRI in the local staging of primary malignant musculoskeletal neoplasms showed no statistically significant difference between CT and MRI in determining tumor involvement of muscle, bone, joints, or neurovascular structures [23]. Furthermore, the combined interpretation of CT and MRI did not significantly improve accuracy [23]. However, a more recent retrospective study comparing the diagnostic accuracy of radiographs, CT, MRI, bone scintigraphy, and FDG-PET/CT versus pathology reports in 409 biopsy-proven tumors showed that the sensitivity of MRI and FDG-PET/CT was better than that of CT, bone scintigraphy, and radiographs. In spine lesions, MRI was the most sensitive modality for detection of tumors, followed by FDG-PET/CT and CT [38].


Primary Bone Tumors

Primary Bone Tumors. Several studies have shown that contrast-enhanced MRI and MR angiography can provide additional information (eg, more accurate characterization, evaluation of viability, and biopsy planning) for the preoperative evaluation of primary bone tumors [39-41]. In a study of 37 patients with cartilaginous tumors, Geirnaerdt et al [42] evaluated the utility of fast contrast-enhanced MRI in differentiating benign from malignant tumors. They found that differentiation of malignancy from benignity was possible with this technique, with a sensitivity of 61% and specificity of 95%. The usefulness of MRI with dynamic contrast enhancement in characterizing lesions as benign or malignant has been evaluated in several additional studies with mixed results [43,44]. Other imaging techniques, such as diffusion-weighted and chemical shift MRI, have been shown to be useful in differentiating benign from malignant bone tumors [45-47]. MRI with dynamic contrast enhancement [43], as well as diffusion and chemical shift MRI [47], can help differentiate benign from malignant spinal compression fractures. Characterization of bone tumors as benign or malignant with MR spectroscopy has shown promise in two small observational studies, although further research is needed [48,49].


Primary Bone Tumors

Primary Bone Tumors. Radiography Skeletal Survey Radiographic survey of the whole body is of limited utility in the evaluation of a suspected primary bone tumor with an indeterminate or aggressive appearance detected on radiographs. The primary utility of radiographic skeletal survey is in evaluating the appearance and distribution of polyostotic bone lesions, which are most commonly multiple myeloma or metastases rather than primary bone lesions.


Primary Bone Tumors

Primary Bone Tumors. Bone Scan Whole Body Despite its historical utility in further characterizing lesions detected on radiographs, there are no controlled studies in the literature over the last 10 years specifically evaluating the efficacy of bone scan in this role.


Primary Bone Tumors

Primary Bone Tumors. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest Despite its historical utility in further characterizing lesions detected on radiographs, there are no controlled studies in the literature over the last 10 years specifically evaluating the efficacy of bone scan in this role. However, recent advances in technology, such as SPECT/CT, may provide a useful tool in the evaluation of primary bone tumors. A retrospective review of 99 patients with 108 vertebral lesions showed that SPECT/CT was superior to planar scintigraphy and SPECT alone, but not CT alone, in the characterization of indeterminate vertebral lesions found on bone scintigraphy [50].


Primary Bone Tumors

Primary Bone Tumors. US Area of Interest US is not routinely used in the evaluation of indeterminate or aggressive bone lesions seen on radiographs. There is no relevant literature regarding the use of US in the evaluation of an indeterminate or aggressive lesion detected on radiographs.


Primary Bone Tumors

Primary Bone Tumors. CT Area of Interest There is no relevant literature regarding the use of CT in the evaluation of bone lesions incidentally found on MRI. However, CT, be it without IV contrast, with IV contrast, or without and with IV contrast, may provide complementary information, particularly in respect to assessing matrix mineralization, cortical destruction, or in suspected cases of osteoid osteoma. If contrast is given, CT without and with IV contrast is preferred because it allows differentiation of areas of contrast enhancement from areas of osseous matrix production. However, radiographic evaluation is generally recommended as the next best imaging modality.


Primary Bone Tumors

Primary Bone Tumors. FDG-PET/CT Whole Body Radiographic evaluation is generally recommended as the next best imaging modality to evaluate bone lesions incidentally found on MRI and CT. FDG-PET/CT may play a limited role in the evaluation of bone lesions incidentally found on MRI and CT.


Primary Bone Tumors

Primary Bone Tumors. MRI Area of Interest If the initial MRI is not of sufficient quality (eg, limited coverage, limited sequences, etc) or was performed using a nonmusculoskeletal protocol (eg, an incidentally discovered bone lesion on a prostate MRI), then a repeat MRI examination may be warranted. However, this should typically follow radiographic imaging, which can be used to better plan the repeat MRI. Supplementation of an MRI initially performed without IV contrast with contrast- enhanced sequences may provide additional information about lesion vascularity and relationship to regional vascular structures. MRI evaluation of the area of interest may provide complementary information facilitating further assessment of the lesion and can be helpful in preoperative planning.


Primary Bone Tumors

Primary Bone Tumors. Although there is no relevant literature regarding the use of MRI in the evaluation of bone lesions incidentally found on CT, MRI may provide complementary information, particularly with regard to evaluating soft-tissue components. However, radiographic evaluation is generally the next best imaging modality.


Primary Bone Tumors

Primary Bone Tumors. Radiography Area of Interest Although there is no relevant literature specifically regarding recommendations for follow-up of bone lesions incidentally found on MRI, radiographic evaluation of the area of interest is generally considered the initial study of choice in this situation. Initial radiographs not only provide an accurate means by which to evaluate primary


Primary Bone Tumors

Primary Bone Tumors


Primary Bone Tumors

Primary Bone Tumors. bone tumors but also provide a baseline study for a bone lesion that may be followed radiographically. Radiographs provide information regarding tumor location, size, and shape as well as evidence of tumor biological activity [3]. Tumor margin and periosteal reaction provide a reliable index of biological potential of the tumor, whereas matrix, if identified, is a key to the underlying histology [3-6]. Although the utility of radiographs in stratifying bone lesions into aggressive and nonaggressive categories is well established, there is sparse literature documenting concrete values on accuracy. A prospective study evaluating 200 consecutive bone tumors of the hand showed that subjective grading of tumors based on radiographic features provided a correct categorization of tumor grade (benign versus malignant) in 82.5% of cases [7]. In a retrospective study applying a modified Lodwick-Madewell grading system to categorize 183 bone tumors, Caracciolo et al [8] found that a low radiographic grade assignment correlates with benignity and that increasing grade correlates with an increasing risk of malignancy. In the case of an incidental lesion on CT, radiographic evaluation of the area of interest may be helpful in allowing for assessment of the lesion based on well-established radiographic criteria. However, radiographs are unlikely to add any additional information specifically about matrix mineralization or cortical involvement that is not readily evident on CT. This is especially true if a high-quality CT with multiplanar reformatting in the coronal and sagittal planes was obtained.


Primary Bone Tumors

Primary Bone Tumors. Bone Scan Whole Body Radiographic evaluation is generally recommended as the next best imaging modality to evaluate bone lesions incidentally found on MRI and CT. Bone scan may play a limited role in the evaluation of bone lesions incidentally found on MRI and CT.


Primary Bone Tumors

Primary Bone Tumors. US Area of Interest There is no relevant literature regarding the use of US in the evaluation of bone lesions incidentally found on MRI or CT.


Primary Bone Tumors

Primary Bone Tumors

Primary Bone Tumors. Primary Bone Tumors


Primary Bone Tumors

Primary Bone Tumors. 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.


Primary Bone Tumors

Primary Bone Tumors. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Vomiting in Infants

Vomiting in Infants. Introduction/Background Vomiting is common in infants, and in the majority of cases is benign. However, vomiting can be a sign of underlying pathology, which could be related to obstruction along the course of the gastrointestinal (GI) tract and may be secondary to infectious etiologies, neurologic diseases, mechanical, or metabolic causes [1,2]. This topic will be limited to the role of imaging in evaluation of complete or partial GI obstruction.


Vomiting in Infants

Vomiting in Infants. Clinically, vomiting is categorized as being nonbilious or bilious; the latter suggests the point of obstruction is distal to the ampulla of Vater. Most commonly, nonbilious vomiting is actually regurgitation, known as gastroesophageal reflux (GER). The clinical differentiation between vomiting and regurgitation may be challenging.


Vomiting in Infants

Vomiting in Infants. Vomiting, secondary to GER, is normal in infants, with decreased incidence with age and resolves in time. It usually has no definitive pathologic cause and is unrelated to a functional defect. Rarely, regurgitation may be due to displacement of a portion of the stomach into the chest (ie, hiatal hernia). In other cases, lower esophageal sphincter pressures or delays in gastric emptying have been implicated as causative and typically resolve in time [1]. Parental complaints of vomiting or regurgitation in infants are common. The cause is usually GER, particularly in the first weeks of life and in part because of overfeeding. Infants with normal weight gain and no other symptoms tend not to have obstruction as the cause of their vomiting [3].


Vomiting in Infants

Vomiting in Infants. Bilious emesis or repeated forceful vomiting should be evaluated for underlying obstruction. When evaluating a neonate who presents in the first week of life with vomiting, a congenital GI tract abnormality is a primary consideration. Upper or lower tract abnormalities can cause vomiting with possible etiologies including malrotation with or without volvulus, atresia of the antropyloric region, annular pancreas, atresia/stenosis of the small bowel or colon, functional obstructions caused by Hirschsprung disease, functional immaturity of the colon, and meconium ileus. Importantly, although malrotation most commonly presents in newborns, it can present at any time during life with decreasing frequency with age.


Vomiting in Infants

Vomiting in Infants. Several GI pathologies to consider in a vomiting infant outside of the newborn period include hypertrophic pyloric stenosis (HPS), pylorospasm, formula intolerance, and gastroenteritis. In a young infant, less common GI etiologies include neonatal appendicitis, intussusception, gastric ulcer disease, gastric volvulus, trauma, and foreign body including lactobezoar. Medical causes to consider include sepsis, enteritis, pneumonia, otitis media, meningitis, raised trauma, or hydrocephalus), kernicterus, metabolic disorders (phenylketonuria, hyperammonemia, maple syrup urine disease, galactosemia, diabetes, adrenocortical hyperplasia, and methylmalonic acidemia), diencephalic syndrome, and rarely drugs or toxic agents [3-5].


Vomiting in Infants

Vomiting in Infants. 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.


Vomiting in Infants

Vomiting in Infants. Reprint requests to: publications@acr.org


Vomiting in Infants

Vomiting in Infants. Vomiting in Infants Intussusception, which is unusual in the first 3 months of life, may be diagnosed clinically by crampy, intermittent abdominal pain sometimes progressing to bloody stools and lethargy. Patients with increased intracranial pressure may have an enlarging head circumference, bulging fontanelle, and/or neurologic signs [3,5].


Vomiting in Infants

Vomiting in Infants. When the clinical and laboratory assessment provides a definitive diagnosis and treatment plan, radiologic imaging is not required. Clinical diagnostic uncertainty may require use of imaging.


Vomiting in Infants

Vomiting in Infants. Often the initial imaging helps in determining whether the patient has bowel obstruction and may provide insight into whether it is proximal or distal obstruction. In some cases, other imaging is necessary to provide diagnosis that is more definitive, help with surgical approach, and diagnose cases that require urgent surgery.


Vomiting in Infants

Vomiting in Infants. OR Discussion of Procedures by Variant Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging. Bilious vomiting in the first days after birth is an ominous sign that suggests the possibility of bowel obstruction and in some cases the need for urgent surgery. In a study of 45 patients with bilious vomiting in the first 72 hours of life, 20% had midgut volvulus and 11% had a lower GI cause (meconium plug syndrome or left-sided microcolon) [6].


Vomiting in Infants

Vomiting in Infants. Vomiting usually begins in the first 2 days after birth in children with intestinal atresia and is usually bilious. Bilious vomiting and gastric distension suggest proximal bowel obstruction. About 15% of children with proximal bowel obstruction will have nonbilious vomiting [7]. No passage of meconium and yellow colostrum or vomitus with meconium is typical for distal bowel obstruction. Imaging has a role for definitive diagnosis of bowel obstruction as a cause of the vomiting; it can differentiate between proximal and distal obstruction and exclude midgut volvulus that requires urgent surgery.


Vomiting in Infants

Vomiting in Infants. Radiography Abdomen When evaluating a newborn with vomiting after birth, especially when there is bilious vomiting, the initial concern is to identify diseases that require emergent surgical management, specifically, malrotation with midgut volvulus and intestinal atresias. There are some bowel gas patterns that can guide management; double bubble with no distal gas (classic double bubble) or triple bubble with no distal gas, double bubble with distal gas (nonclassic double bubble), and multiple distended bowel loops with no or decreased distal gas (see Variants 2 and 4) [8].


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Contrast Enema Although beginning the workup with a contrast enema may lead to a diagnosis, there is no relevant literature to support the use of performing a contrast enema as the initial imaging study prior to an abdominal radiograph.


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Upper GI Series Although beginning the workup with an upper GI (UGI) series may lead to a diagnosis, there is no relevant literature to support the use of performing a UGI series as the initial imaging study prior to an abdominal radiograph.


Vomiting in Infants

Vomiting in Infants. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m diethylenetriamine pentaacetic acid (DTPA) or Tc-99m microaggregated albumin (MAA) in the initial imaging evaluation of the neonate with acute bilious vomiting.


Vomiting in Infants

Vomiting in Infants

Vomiting in Infants. Vomiting in Infants


Vomiting in Infants

Vomiting in Infants. US Abdomen (UGI Tract) There is no relevant literature to support the use of ultrasound (US) as the initial imaging examination prior to an abdominal radiograph for the neonate with acute bilious vomiting.


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Contrast Enema In the setting of a suspected proximal atresia with absent distal bowel gas, there is no relevant literature to support the use of a contrast enema for diagnosis. Atresias can be multiple in approximately 15% of patients. Most of these can be diagnosed at the initial surgical exploration [11].


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Upper GI Series In the setting of a classic double bubble or triple bubble with no gas distally, a UGI series is usually not necessary, because the positive contrast used in fluoroscopy does not typically provide more anatomic details. In some cases in which there is inadequate gastric or duodenal distention, air can be injected to the stomach through the feeding tube to better delineate the gas pattern and confirm no gas distally.


Vomiting in Infants

Vomiting in Infants. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in evaluating the neonate with acute vomiting and classic double bubble or triple bubble with no gas distally.


Vomiting in Infants

Vomiting in Infants. US Abdomen (UGI Tract) There is a growing acceptance for the role of US, especially in prenatal diagnosis of duodenal atresia. In the postnatal diagnosis of duodenal atresia, there is no relevant literature to support the use of US in evaluating the neonate with acute vomiting and classic double bubble or triple bubble with no gas distally.


Vomiting in Infants

Vomiting in Infants. Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study. The role of imaging in children with multiple distended bowel loops with no or decreased gas distally is to differentiate between temporary functional abnormalities that only need observation (eg, meconium plug), pathologies that require surgery (eg, ileal atresia), therapeutic enema (eg, meconium ileus), or rectal biopsy (eg, Hirschsprung disease) [12].


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Contrast Enema Contrast enema is the diagnostic imaging procedure of choice when there is a suspected distal obstruction. Congenital distal obstruction can be structural or functional, in which both will give the same appearance on abdominal radiographs that show numerous dilated bowel loops with an absence or paucity of distal gas. In the setting of congenital atresia, most commonly ileal, but also distal jejunal or colonic, the lack of contents moving through the bowel results in a microcolon [12].


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Upper GI Series There is no relevant literature to support the use of a UGI series in the evaluation of the neonate with suspected distal obstruction.


Vomiting in Infants

Vomiting in Infants. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with suspected distal obstruction.


Vomiting in Infants

Vomiting in Infants. US Abdomen (UGI Tract) There is no relevant literature to support the use of US in the evaluation of the neonate with suspected distal obstruction.


Vomiting in Infants

Vomiting in Infants


Vomiting in Infants

Vomiting in Infants. Variant 4: Bilious vomiting within the first 2 days after birth. Radiographs show a nonclassic double bubble with gas in the distal small bowel, or few distended bowel loops, or a normal bowel gas pattern. Next imaging study. The role of imaging in a child with bilious vomiting in the first 2 days of life with nonclassic double bubble or few distended bowel loops is to differentiate between congenital intestinal atresia and stenosis and midgut volvulus, which requires urgent surgery. Malrotation or midgut volvulus with incomplete obstruction may have a normal bowel gas pattern [5,6,11]. Fluoroscopy Contrast Enema Abnormalities of the lower GI tract that cause bilious vomiting may be demonstrated by contrast enema [4,13]. The use of a barium enema for analyzing malrotation is less direct than analysis of a UGI series. Approximately 20% of barium enemas may be falsely negative, whereas up to 15% of infants have a high mobile cecum that may cause false-positive interpretations of the study [14].


Vomiting in Infants

Vomiting in Infants. Nuclear Medicine Gastroesophageal Reflux Scan There is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with acute bilious vomiting.


Vomiting in Infants

Vomiting in Infants. Although US has limitation for the diagnosis of malrotation, there are a few studies showing high sensitivity and specificity for midgut volvulus. The US finding of the whirlpool sign (a clockwise wrapping of the SMV and mesentery around the SMA as the fixed axis) is specific for volvulus [15,26-28]. It is important to recognize sonographic features of midgut volvulus because they can help to substantiate the diagnosis in an equivocal UGI study or when US is performed for other indications (eg, evaluation for HPS).


Vomiting in Infants

Vomiting in Infants. Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging. Most congenital intestinal atresia and stenosis will present in the first 2 days of life. Midgut volvulus is the most important diagnosis in older infants presenting with bilious vomiting because this is a medical emergency [15].


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Contrast Enema There is no relevant literature to support the use of a contrast enema as the initial imaging study for suspected malrotation. In suspected malrotation with midgut volvulus, if the UGI fails to show the etiology or is equivocal, a contrast enema may be performed as a follow-up study in the workup of bilious vomiting. However, up to 15% of individuals may have a normal mobile cecum [29]. More commonly, if the UGI is equivocal, small bowel follow through to the cecum may be pursued.


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Upper GI Series The barium UGI series evaluates the esophagus, stomach, pylorus, and the duodenum to the duodenal jejunal junction, indicating the location of the ligament of Treitz [5,6,15]. Although the UGI series is considered the reference standard for evaluating malrotation, false-positive and false-negative interpretations may occur. In a retrospective review of 229 cases by Sizemore et al [16], UGI had a sensitivity of 96% with two false-positives (abnormal jejunal position with no malrotation) and seven false-negatives (normal jejunal position with malrotation). Retrospective reviews by Hsiao et al [17] and another such study by Long et al [18] noted false- positive rates of 10% and 15%, respectively. The studies concluded that redundant duodenum, bowel distension, and jejunal position can lead to inaccurate UGI interpretation; thus meticulous technique is warranted [16-18].


Vomiting in Infants

Vomiting in Infants. Radiography Abdomen Abdominal radiographs have a limited role in determining subsequent imaging workup, keeping in mind that normal abdominal radiographs do not exclude the diagnosis of malrotation. In a group studied by Lilien et al [6], only 44% of patients who required surgery for bilious vomiting had definitively positive radiograph readings. If the radiographs do show signs of obstruction, the pattern of bowel distension can help direct further evaluation with an UGI series or contrast enema, respectively. Thus, although the plain radiograph may not be able to make the diagnosis of malrotation without supportive imaging, it may serve a complementary role to guide further imaging.


Vomiting in Infants

Vomiting in Infants. Nuclear Medicine Gastroesophageal Reflux Scan Reflux scintigraphy can be highly effective in analyzing gastric emptying and GER, but there is no relevant literature to support the use of reflux scintigraphy using Tc-99m sulfur colloid or Tc-99m DTPA or Tc-99m MAA in the evaluation of the neonate with acute bilious vomiting.


Vomiting in Infants

Vomiting in Infants. Although US has limitation for the diagnosis of malrotation, there are few studies showing high sensitivity and specificity for midgut volvulus. The US finding of the whirlpool sign is specific for volvulus [15,26-28]. It is important to recognize sonographic features of midgut volvulus because they can help to substantiate the diagnosis in an equivocal UGI study or when US is performed for other indications (eg, evaluation for HPS).


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Contrast Enema There is no relevant literature to support the use of contrast enema in the evaluation for GER.


Vomiting in Infants

Vomiting in Infants. Fluoroscopy Upper GI Series Clinical practice guidelines on GER from 2001 [2] state that the sensitivity, specificity, and positive predictive values of a UGI series range from 31% to 86%, 21% to 83%, and 80% to 82%, respectively, when compared to esophageal pH monitoring. The recent clinical practice guidelines from the North American and European Societies


Vomiting in Infants

Vomiting in Infants

Vomiting in Infants. Vomiting in Infants


Vomiting in Infants

Vomiting in Infants. for Pediatric Gastroenterology, Hepatology, and Nutrition state that UGI is not useful for diagnosing GER but can help exclude or confirm anatomic abnormalities that cause symptoms similar to GER [34]. The brief duration of the UGI series results in false-negative results for GER, whereas the frequent occurrence of nonpathological reflux results in false-positive results. Thus, the UGI series is not a useful test to reliably determine the presence or absence of GER. In patients with severe or complicated GERD who will be managed with gastrostomy tube placement and Nissen fundoplication or with gastrojejunostomy tube, the UGI is useful to exclude anatomic abnormalities, such as esophageal stricture or malrotation, that would need to be addressed at the time of surgery.


Vomiting in Infants

Vomiting in Infants. Radiography Abdomen There is no relevant literature to support the use of radiographs in the evaluation for GER.