Suspected New Onset and Known Nonacute Heart Failure. MRI Heart In addition to the evaluation of cardiac structure and function by rest-only MRI, myocardial perfusion, viability, and fibrosis imaging can assist in identification of etiology and assess prognosis [41,58]. There is no evidence to support the use of rest and stress MRI.


Suspected New Onset and Known Nonacute Heart Failure. CTA Coronary Arteries There is limited evidence to support the use of cardiac CTA as initial imaging for the evaluation of patients with newly suspected or potential HF.


Suspected New Onset and Known Nonacute Heart Failure. Arteriography Coronary The invasive nature of coronary angiography limits its use for the assessment of patients with newly suspected or potential HF.


Suspected New Onset and Known Nonacute Heart Failure. Suspected New-Onset and Known Nonacute Heart Failure is confounded by the following [1]: (1) in most symptomatic HF patients, variable balances of systolic and diastolic dysfunction coexist; and (2) derived LVEF values are dependent on the imaging modality used, method of analysis, and operator performance.


Suspected New Onset and Known Nonacute Heart Failure. Radiography Chest While radiography may play a role in diagnosing HF, there is no evidence to support the use of chest radiographs for differentiating HFrEF from HFpEF.


Suspected New Onset and Known Nonacute Heart Failure. US Echocardiography Transthoracic Resting and Stress At the time of presentation of patients to the ED with new-onset symptomatic HF, the differentiation between HFpEF and HFrEF using TTE has prognostic significance, with HFpEF having higher noncardiovascular mortality but lower cardiovascular mortality compared to HFrEF [62].


Suspected New Onset and Known Nonacute Heart Failure. Beyond conventional 2-D TTE or TEE evaluations, the use of new more sensitive and more specific technologies, such as tissue Doppler imaging (TDI), strain rate, speckle tracking, or 3-D imaging, has facilitated the identification of other high-risk parameters associated with adverse outcomes, which are useful in guiding therapy and follow-up management of HFrEF patients [63]. In outpatients with new-onset HF examined with TTE, including conventional Doppler and TDI, LA strain rate is significantly reduced in both HFrEF and HFpEF groups (without differences between them) compared with the non-HF group, with LA strain rate and indexed volume showing significant accuracy for HF diagnosis in receiver operating characteristic curves; however, LV strain rate shows no differences between non-HF and HFpEF groups, while both differed from the HFrEF group [64].


Suspected New Onset and Known Nonacute Heart Failure. In patients with suddenly decompensated HF and presenting to the ED, point-of-care TTE has diagnostic sensitivity of 74% and specificity of 74% for HFrEF, changing to 36% and 100%, respectively, when combined with inferior vena cava collapsibility index and pleural sampling for B-lines; sensitivity and specificity of NT- proBNP >500 are 75% and 83%, respectively [65]. With the determination of HFrEF using TTE, LV filling pressure can be estimated well by LA expansion index, which predicts subsequent adverse events [66]. While early mitral inflow velocity to early diastolic mitral annular velocity on TTE with TDI is significantly higher in the elderly, compared to nonelderly, patients presenting with newly diagnosed suddenly decompensated HFrEF, there are no significant differences in in-hospital mortality, rehospitalization, and cardiovascular mortality during the following 45 months [53]. However, right ventricular (RV) systolic dysfunction, assessed using TTE with TDI of peak systolic velocity at the lateral tricuspid annulus, has prognostic significance in newly diagnosed HFrEF patients [67].


Suspected New Onset and Known Nonacute Heart Failure. Diastolic dysfunction is widely considered a key pathophysiologic mediator of HFpEF. It is implicated as a major cause of shortness of breath on exertion in elderly primary-care patients who often are suffering from unrecognized HF (16%), more often from HFpEF (12%) than from either HFrEF (3%) or isolated right-sided HF (1%) as determined on TTE evaluation [68]. In dyspneic patients presenting to an ED, a basic bedside TTE diastolic evaluation performed by an emergency physician-sonographer with limited diastology-specific training (3 hours of didactic and hands-on training by a cardiologist) can accurately identify clinically significant diastolic dysfunction, although correct grading of dysfunction may be only moderately accurate [69].


Suspected New Onset and Known Nonacute Heart Failure. Several TTE parameters, including ratio of early mitral inflow velocity to TDI velocity at lateral mitral annulus, LA volume index, and the difference between duration of reversed pulmonary vein LA systole flow and duration of mitral A wave flow, have the greatest value in diagnosing HFpEF (sensitivity of 77% and specificity of 81%) [70]. However, for the initial diagnosis of HFpEF, the association of NT-proBNP measurement and TTE with TDI is superior to the use of either one alone [61].


Suspected New Onset and Known Nonacute Heart Failure. Certainly, echocardiography technologies have provided greater understanding of the complex pathophysiology related to HFpEF. From the application of TTE with speckle tracking [71], it is now known that HFpEF patients (1) demonstrate significantly lower longitudinal and circumferential strains compared to both normal patients and hypertensive heart disease patients, indicating the presence of underlying impaired LV systolic function [72]; (2) have significantly lower myocardial systolic and diastolic LV performance compared to patients with asymptomatic LV diastolic dysfunction, and this combined dysfunction is associated with increased LV filling


Suspected New Onset and Known Nonacute Heart Failure. Suspected New-Onset and Known Nonacute Heart Failure


Suspected New Onset and Known Nonacute Heart Failure. pressures, decreased cardiac output, and worse New York Heart Association functional class [73]; (3) showing LV mechanical dyssynchrony have significantly higher rates of LV longitudinal systolic (64%) and diastolic (70%) dysfunction than those without dyssynchrony, suggesting that restoration of asynchronous contractions could improve systolic and diastolic longitudinal LV dysfunction, as well as associated symptoms [74]; (4) have significantly more impaired RV longitudinal diastolic (RV global longitudinal early-diastolic strain rate) and systolic (RV global longitudinal systolic strain) function than matched asymptomatic patients with LV diastolic dysfunction, suggesting that RV longitudinal systolic and diastolic dysfunction could contribute to symptoms [75]; and (5) demonstrate significantly reduced LA longitudinal systolic (LA late diastolic strain rate) and diastolic (LA systolic strain and strain rate) function compared to matched asymptomatic patients with LV diastolic dysfunction, suggesting that LA longitudinal systolic and diastolic dysfunction could be related to reduced functional capacity during effort [76]; accordingly, resting global peak LA longitudinal strain during LV systole has significant incremental diagnostic value over clinical and conventional TTE parameters (early diastolic mitral annular velocity ratio, LV mass index, and maximum LA volume index), and diagnostic value is further improved by adding leg-lifting during global peak LA longitudinal strain measurements (global chi-square = 72.2 versus 49.6; P < .0001) [77].


Suspected New Onset and Known Nonacute Heart Failure. Peak mitral annular systolic velocity on TEE with TDI is a significant independent predictor of HFpEF, and when used in combination with exercise, it may increase the diagnostic value of models using the variables recommended by the European Society of Cardiology guidelines [78]. In addition, the assessment of longitudinal systolic and diastolic LV and RV function during a submaximal exercise stress TTE can confirm LV dysfunction related to HFpEF and might be used as a diagnostic test for difficult clinical situations [79]. In addition, it is known that within individual HFpEF cases, TTE with Doppler indexes of LV filling pressures (ie, early diastolic mitral annular velocity and E/Vp) do not reliably track directly measured filling pressures as these pressures vary, precluding the use of these techniques in the titration of medical therapy for HFpEF [80,81].


Suspected New Onset and Known Nonacute Heart Failure. In HFpEF patients, global LV longitudinal strain measured using TTE with speckle tracking can help predict readmission within 30 days [51]. While global longitudinal strain is abnormal in HFpEF and is associated with a worse prognosis, it is not a powerful independent predictor of outcome [82]. However, exercise TTE may contribute to the identification of HFpEF patients, especially high-risk ones [83], and abnormal indices of LA mechanics, especially LA reservoir strain, are powerful clinical and prognostic factors in HFpEF [84].


Suspected New Onset and Known Nonacute Heart Failure. Nuclear Medicine Ventriculography Because RNV can be performed to assess LVEF and volumes [41], it has potential in differentiating between HFrEF and HFpEF.


Suspected New Onset and Known Nonacute Heart Failure. SPECT or SPECT/CT MPI Rest and Stress While there is no evidence to support the use of rest and stress SPECT/CT specifically for differentiating between HFrEF and HFpEF, gated SPECT/CT has potential in differentiating between these forms of HF.


Suspected New Onset and Known Nonacute Heart Failure. FDG-PET/CT Heart and Rb-82 PET/CT Heart While there is no evidence to support the use of PET/CT specifically for differentiating between HFrEF and HFpEF, cardiac gated PET/CT has potential in differentiating between these forms of HF.


Suspected New Onset and Known Nonacute Heart Failure. MRI In addition to the evaluation of cardiac structure and function using rest-only MRI, myocardial focal fibrosis quantified by late gadolinium enhanced (LGE)-MRI in patients with HFpEF is an independent predictor of future events after the adjustment for prognostic factors (ie, age, diabetes mellitus, New York Heart Association classification, history of HF hospitalization, and LVEF) previously identified in the Irbesartan in Heart Failure with Preserved Ejection Fraction study [85].


Suspected New Onset and Known Nonacute Heart Failure. CTA Coronary Arteries There is limited evidence to support the use of cardiac CTA for the differentiating patients with HFrEF from HFpEF.


Suspected New Onset and Known Nonacute Heart Failure. Arteriography Coronary While echocardiography is commonly used to diagnose and stage diastolic dysfunction, uncertainty in characterizing borderline cases may persist, and direct hemodynamic measurements may still be needed to establish a definitive diagnosis of HFpEF [86-88]. However, such invasive hemodynamic assessment is made without the need for concurrent coronary angiography or contrast LV ventriculography.


Suspected New Onset and Known Nonacute Heart Failure. Suspected New-Onset and Known Nonacute Heart Failure Variant 3: Confirmed new-onset heart failure with reduced ejection fraction of uncertain etiology: ischemic versus nonischemic. Because of reversible or irreversible ischemic injury to the LV myocardium, CAD with or without a history of antecedent myocardial infarction remains a major source of HFrEF nationally [1]. Prompt differentiation of ischemic HFrEF from nonischemic HFrEF is important because patients with ischemic cardiomyopathy can potentially have dramatic improvement with specific therapy, including revascularization [14,89]. Thus, in the setting of new-onset nonacute HFrEF, it is important to distinguish between ischemic and nonischemic (eg, remote diffuse myocarditis, alcoholic cardiomyopathy) etiologies in order to guide further evaluation and treatment [15].


Suspected New Onset and Known Nonacute Heart Failure. Radiography Chest While radiography may play a role in diagnosing HF, there is no evidence to support the use of chest radiography for differentiating ischemic versus nonischemic etiology of HF.


Suspected New Onset and Known Nonacute Heart Failure. US Echocardiography Transthoracic Resting and Stress Several studies have demonstrated the utility of stress echocardiography to identify both resting and poststress systolic wall motion abnormalities [90-92]. Additionally, these findings correlate to clinical outcomes.


Suspected New Onset and Known Nonacute Heart Failure. SPECT or SPECT/CT MPI Rest and Stress With SPECT/CT MPI, sensitivity and negative predictive value are both excellent for detecting CAD in patients with HF with either reduced or preserved LVEF; however, the distinction between ischemic and nonischemic etiologies is more characteristic of the evaluation of HFrEF [93,94]. In dyspneic patients with HFrEF without concomitant chest pain, the nonglobal resting LV dysfunction and high-summed stress MPI-deficiency score on gated rest and stress SPECT serve as independent predictors of an ischemic etiology; although low in sensitivity, specificity is acceptable [95].


Suspected New Onset and Known Nonacute Heart Failure. While standard MPI (more often performed with SPECT than PET) is often deficient in making that distinction because a nonischemic cardiomyopathy can have focal defects in tracer uptake and CAD with global balanced ischemia can result in a normal-appearing perfusion pattern, new developments in measuring quantitative blood flow have potential to provide a more accurate determination of HFrEF etiology [94].


Suspected New Onset and Known Nonacute Heart Failure. Nuclear Medicine Ventriculography RNV is used for the evaluation of cardiac function [41].


Suspected New Onset and Known Nonacute Heart Failure. FDG-PET/CT Heart and Rb-82 PET/CT Heart An advantage of the use of stress MPI with PET is its improved accuracy for the detection of severe, multivessel CAD when compared to SPECT alone. Additionally, PET markers of absolute peak stress LVEF measurements and myocardial perfusion reserve may improve detection of patients with CAD [41,96,97].


Suspected New Onset and Known Nonacute Heart Failure. CTA Coronary Arteries For the differentiation between ischemic and nonischemic etiologies in new-onset nonacute HFrEF, CT coronary calcium score = 0 alone may be used to exclude CAD, but this technique is typically used to determine the need for further evaluation with coronary CTA [101-104].


Suspected New Onset and Known Nonacute Heart Failure. A CT algorithm, including coronary CTA when the initial CT coronary calcium score >0, has sensitivity of 100%, specificity of 95%, positive predictive value of 67%, and negative predictive value of 100% for detecting an


Suspected New Onset and Known Nonacute Heart Failure. Arteriography Coronary The role of coronary angiography in evaluating HFrEF is not always clear [99]. In patients presenting with new- onset HFrEF with only risk factors (without angina) suggesting CAD, coronary angiography is not beneficial in the process of differentiation between ischemic and nonischemic etiologies [105]. In patients in whom CAD has been excluded as the cause of HFrEF, coronary angiography is generally not indicated unless a change in clinical status suggests interim development of ischemic disease [1].


Suspected New Onset and Known Nonacute Heart Failure. Although there are references that report on studies with design limitations, 38 well-designed or good-quality studies provide good evidence. 11 Suspected New-Onset and Known Nonacute Heart Failure


Suspected New Onset and Known Nonacute Heart Failure. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Introduction/Background Lung cancer remains the leading cause of cancer-related mortality for men and women in the United States [1]. Screening for lung cancer with annual low-dose CT (LDCT) is saving lives, and the continued implementation of lung cancer screening in clinical practice can save many more [2]. Since the publication of the National Lung Screening Trial (NLST) in 2011, which demonstrated a 20% reduction in lung cancer mortality with annual lung cancer screening [3], multiple clinical trials have demonstrated similar if not superior results [4-10]. Although there are known potential harms of lung cancer screening, including overdiagnosis and false positive results, the growing evidence has shown that correct implementation of lung cancer screening can provide substantial benefit at low clinical risk [2]. Retrospective analysis of the NLST data using updated standardized reporting specifically has been shown to substantially reduce false-positive rates of this screening test [11].


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. In 2015, the CMS began covering annual lung cancer screening for those who qualified based on the original United States Preventive Services Task Force (USPSTF) lung cancer screening criteria, which included patients 55 to 77 years of age with a 30 pack-year history of smoking, who were either currently using tobacco or who had smoked within the previous 15 years. In 2021, the USPSTF issued new screening guidelines, decreasing the age of eligibility to 50 years and pack years to 20 [12,13]. The recommendation was made following a systematic review of the lung cancer screening literature comprised of 223 publications that included 7 randomized clinical trials [14]. New guidelines are estimated to have doubled the population eligible for lung cancer screening in the United States and, importantly, will increase the number of women, underrepresented minorities, and those of lower socioeconomic status who qualify for this life-saving examination [15,16]. Although there has been some variation in eligibility for screening trials, studies have consistently excluded participants over 80 years of age.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Special Imaging Considerations Acceptable low-dose lung cancer screening guidelines are available in the ACR-STR Practice Parameter for the Performance and Reporting of Lung Cancer Screening Thoracic Computed Tomography (CT) [17].


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. OR aVanderbilt University Medical Center, Nashville, Tennessee. bPanel Chair, Duke University, Durham, North Carolina. cCity of Hope National Medical Center, Duarte, California; Commission on Radiation Oncology. dMedical University of South Carolina, Charleston, South Carolina; Commission on Nuclear Medicine and Molecular Imaging. eEmory University Hospital, Atlanta, Georgia. fHampton VA Medical Center, Hampton, Virginia. gUniversity of Michigan Health System, Ann Arbor, Michigan. hUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. iUniversity of Arizona College of Medicine, Phoenix, Arizona. jDivision of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, Primary care physician. kMallinckrodt Institute of Radiology, Saint Louis, Missouri. lMedical University of South Carolina, Charleston, South Carolina; American College of Chest Physicians. mNational Institutes of Health, Bethesda, Maryland. nDuke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons. oBoston University School of Medicine and Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts; American College of Chest Physicians. pUniversity of California San Francisco, San Francisco, California; American Geriatrics Society. qSpecialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Reprint requests to: publications@acr.org


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Lung Cancer Screening Discussion of Procedures by Variant Variant 1: Lung cancer screening. Patient 50 to 80 years of age and 20 or more packs per year smoking history and currently smoke or have quit within the past 15 years. Initial imaging. CT Chest With IV Contrast There is no relevant literature regarding the use of CT with intravenous (IV) contrast for lung cancer screening.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. CT Chest Without and With IV Contrast There is no relevant literature regarding the use of CT without and with IV contrast for lung cancer screening.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. CT Chest Without IV Contrast Screening The population described in this variant exactly matches the updated USPSTF eligibility guidelines for lung cancer screening [12]. These guidelines were expanded from the original eligibility criteria studied in the NLST. The NLST enrolled 53,454 participants 55 to 74 years of age with a 30 pack-year history of smoking, who were either currently using tobacco or had tobacco use in the previous 15 years. This randomized controlled study demonstrated a 20% reduction lung cancer mortality with annual CT imaging [3].


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Screening for lung cancer at an earlier age and with less tobacco exposure than suggested with the original guidelines may help to improve racial and gender disparities in lung cancer screening eligibility [15]. In fact, the original guidelines may have exacerbated disparities in lung cancer morbidity and mortality for women, underrepresented minorities, and vulnerable patients of low socioeconomic status [22-24]. A retrospective examination of lung cancer incidence among the predominantly Black population in the Southern Community Cohort Study demonstrated a much smaller percentage of Black patients with lung cancer met screening eligibility criteria (32%) compared with White patients (56%). The lower percentage of eligibility was primarily associated with lower pack years [25]. Additionally, the expansion of lung cancer screening guidelines will improve eligibility of women for lung cancer screening compared with men [15].


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. FDG-PET/CT Skull Base to Mid-Thigh The role of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT skull base to mid-thigh as a lung cancer screening modality has not been adequately studied. The body of evidence for this modality is growing but remains limited [26,27].


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. MRI Chest Without and With IV Contrast The role of MRI, chest without or with IV contrast, as a lung cancer screening modality has not been adequately studied.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. MRI Chest Without IV Contrast The role of MRI chest without IV contrast as a lung cancer screening modality has not been adequately studied. There is a growing body of evidence suggesting MRI without IV contrast may have a role in screening for lung cancer [28-30].


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Radiography Chest Chest radiography screening does not reduce lung cancer mortality in this population [3].


Lung Cancer Screening PCAs

Lung Cancer Screening

Lung Cancer Screening PCAs. Lung Cancer Screening


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Variant 2: Lung cancer screening. Patient younger than 50 years of age and 20 or more packs per year history of smoking and one additional risk factor (ie, radon exposure or occupational exposure or cancer history or family history of lung cancer or history of COPD or history of pulmonary fibrosis). Initial imaging. CT Chest With IV Contrast There is no evidence to support screening in this population with chest CT with IV contrast.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. CT Chest Without and With IV Contrast There is no evidence to support screening in this population with chest CT without and with IV contrast.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. CT Chest Without IV Contrast Screening Smoking is the leading cause of lung cancer, accounting for approximately 90% of lung cancer cases in the United States [12]. Increased age is also associated with an increased risk for lung cancer, with most patients diagnosed after age 50 [1]. Currently screening for lung cancer is not recommended for those <50 years of age. Additional data are needed to determine if screening younger patients with additional risk factors such as radon exposure, occupational exposure, cancer history, family history of lung cancer, chronic obstructive pulmonary disease (COPD), or emphysema is of appropriate benefit. These criteria have been included in previous evaluation of eligibility in multiple models and in the National Comprehensive Cancer Network Guidelines (High-Risk Group 2) [31].


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Patients with a history of cancer are at increased risk for developing a second primary cancer, and the most common second primary cancer is lung cancer. Within the NLST, 1,071 study participants had a prior history of cancer. These patients were found to have a higher age-adjusted cancer-detection rate on baseline LDCT than those without a cancer history [32]. A retrospective study within a clinical lung cancer screening program has shown that those eligible for screening with a previous cancer history have a higher risk for cancer than those without a cancer history who are screening eligible [33]. A retrospective cohort study of 276 patients with a history of hepato-gastrointestinal cancer and second primary lung cancer suggests that screening for lung cancer in this patient population may improve mortality [34]. Although these results suggest a possible benefit for screening for lung cancer in those with a history of cancer, this is not recommended for cancer survivors without tobacco exposure of at least 20 pack years.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. A real-world cohort study in China evaluated 15,996 participants with LDCT and found 142 cases of lung cancer. In this study, only 9.2% of individuals met the 2021 USPSTF lung cancer screening eligibility criteria. Among male patients with lung cancer, 23.2% were <50 years of age. In female patients with lung cancer, 33.3% were <50 years of age [35]. This study suggests that further evaluation of screening may be warranted in younger individuals, although more research is needed to assess the utility of screening in this population.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Several studies have evaluated LDCT in patients with occupational exposures. In a cohort of 2,433 men exposed to asbestos, both lung cancer-related mortality and all-cause mortality was reduced amongst participants who underwent lung cancer screening [36]. A separate cohort study of LDCT among 7,189 nuclear weapons workers also demonstrated favorable results, detecting 80 lung cancers, of which 59% were stage I and an additional 10% were stage II [37]. As with the populations above, additional investigation is needed to assess screening in individuals with occupational exposures.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. FDG-PET/CT Skull Base to Mid-Thigh There is no evidence to support screening in this population with FDG-PET/CT.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. MRI Chest Without and With IV Contrast There is no evidence to support screening in this population with MRI chest without and with IV contrast.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. MRI Chest Without IV Contrast There is no evidence to support screening in this population with MRI chest without IV contrast.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Radiography Chest There is no evidence to support screening in this population with chest radiography.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Variant 3: Lung cancer screening. Patient of any age with less than 20 packs per year history of smoking, and no additional risk factor (ie, radon exposure or occupational exposure or cancer history or family history of lung cancer or history of COPD or history of pulmonary fibrosis). Initial imaging. CT Chest With IV Contrast There is no evidence to support screening in this population with chest CT with IV contrast.


Lung Cancer Screening PCAs

Lung Cancer Screening


Lung Cancer Screening PCAs


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. CT Chest Without IV Contrast Screening Screening for lung cancer is routinely performed with noncontrast LDCT in individuals who are eligible based on age and smoking history. LDCT for lung cancer screening is not currently useful for those without a significant smoking history.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. A retrospective study of 28,807 patients that included 12,176 who had not smoked; however, showed that LDCT helped to detect a significant number of lung cancers suggesting that more study is needed to evaluate screening in this population [38]. This study and others are part of a growing body of literature evaluating the use of lung cancer screening in patients without a history of smoking. In South Korea, 37,436 asymptomatic adults (17,968 without a smoking history and 19,468 with a smoking history) were screened for lung cancer using LDCT. The lung cancer rate was lower in those who had not smoked; however, no significant differences were seen in the number of false positives or the complication rates between the 2 groups [39].


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. There is particular interest in evaluating lung cancer in women, because the incidence of lung cancer in women without a significant smoking history is greater than in men [40,41]. In a retrospective study of 2,170 patients in the UK with lung cancer, the annual frequency of lung cancer development in those without a smoking history increased from 13% to 28%. Of those patients with lung cancer who had not smoked, 67% were women [42]. In a real-world cohort study of lung cancer screening in China, a total of 15,996 participants underwent LDCT. Among male patients with lung cancer in this study, 75% had a history of tobacco use. Among female patients with lung cancer in this cohort, only 5.8% reported a history of smoking [35]. Additional studies of women without histories of smoking have advocated for screening based on risk prediction that incorporates genetic markers [43,44]. A retrospective study of LDCT in women without a smoking history suggests that although screening may be effective, the optimal screening interval may be up to 5 years rather than annual [45]. Although these results suggest a possible role for screening in those without a significant smoking history, more research is needed to assess the benefit of screening in this population. Future efforts should focus on combining imaging, clinical history, and biomarkers when determining the ideal population for lung cancer screening.


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. MRI Chest Without and With IV Contrast There is no evidence to support screening in this population with MRI chest without or with IV contrast.


Lung Cancer Screening PCAs

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


Lung Cancer Screening PCAs

Lung Cancer Screening

Lung Cancer Screening PCAs. Lung Cancer Screening


Lung Cancer Screening PCAs

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


Lung Cancer Screening PCAs

Lung Cancer Screening PCAs. Relative Radiation Level Designations 30-100 mSv


Lung Cancer Screening PCAs

10-30 mSv

Lung Cancer Screening PCAs. 10-30 mSv


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Discussion of Procedures by Variant Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion. Imaging is recommended for staging evaluation in any person with a clinically visible tumor or a microscopic tumor that is found to have >5 mm of invasion on biopsy, corresponding to stage 1B or greater disease [2]. Accurate determination of the size and local extent of the tumor is critical because this determines the treatment strategy used.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Definitive surgery with radical hysterectomy with lymph node sampling is the treatment of choice for smaller (<4 cm), locally confined invasive cervical cancers (within the cervix or invading only the upper two-thirds of the vagina): stages IA2, IB1, IB2, and IIA1 [2]. Alternatively, trachelectomy can be considered for patients with stage IA2 or IB1 tumors who wish to maintain fertility. In this procedure, the cervix, parametrium, and vaginal cuff are removed with pelvic sentinel node biopsy or lymphadenectomy, and a cerclage suture is placed around the uterine isthmus to preserve uterine competency. Tumor size and location are critical factors in the assessment of trachelectomy candidacy, with cervix-confined tumors <2 cm in size and located >1 cm from the internal cervical os considered ideal features. Some centers will consider trachelectomy for patients with tumors <4 cm or as close to 0.5 cm from the internal os [7,8].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Reprint requests to: publications@acr.org


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix In contrast, primary chemoradiotherapy is the treatment of choice for larger invasive cervical cancers (>4 cm) given their high likelihood of occult nodal metastases, locally advanced tumors invading the parametrium, lower one- third of the vagina, or adjacent pelvic organs, or those with known nodal or distant metastases (stages IB3, IIA2, IIB, III, and IVA, respectively) [2]. In this population, pretreatment imaging plays a critical role in radiation therapy treatment planning, specifically for contouring of the radiation field.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Pelvis With IV Contrast Compared to MRI, CT provides very poor soft tissue characterization in the pelvis and therefore demonstrates a lower accuracy for the determination of local extent of invasive cervical cancer [9]. One multicenter study found that invasive cervical cancers, which appeared hypodense to the normal cervical stroma, were only well delineated in 35% to 73% of contrast-enhanced CT examinations [10]. Considering individual features, meta-analyses have shown CT with intravenous (IV) contrast to have 43% to 55% sensitivity and 71% specificity for parametrial invasion, and 41% sensitivity and 92% specificity for bladder invasion [11,12]. In comparison, MRI demonstrated 71% specificity (95% confidence interval [CI], 62%-79%) and 91% sensitivity (95% CI, 88%-93%) for parametrial invasion, and 84% sensitivity (95% CI, 57%-95%) and 95% specificity (95% CI, 87%-98%) for bladder invasion [12].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Pelvis Without and With IV Contrast CT pelvis without IV contrast provides very poor soft tissue characterization in the pelvis [13] and therefore is not useful for the evaluation of the local extent of invasive cervical cancer. The addition of noncontrast CT images would not appreciably add information to the contrast-enhanced CT evaluation.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Pelvis Without IV Contrast CT without IV contrast provides very poor soft tissue characterization in the pelvis [13] and therefore is not useful for the evaluation of local extent of invasive cervical cancer.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. FDG-PET/CT Skull Base to Mid-Thigh Fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT is most commonly used in addition to pelvic MRI for nodal and metastatic disease assessment (as described in Variant 2), although it can also contribute to the evaluation of local disease extent. Physiologic excreted radiotracer in the bladder may obscure FDG uptake in the region of the cervix in some patients [9]. However, a meta-analysis showed similar overall diagnostic performance for PET/CT and MRI for local extent of disease assessment, with an overall sensitivity of 73% (95% CI, 56%-85%) and specificity of 91% (95% CI, 83%-96%) for PET/CT compared to a sensitivity of 71% (95% CI, 62%-79%) and specificity of 91% (88%-93%) for MRI [12].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. FDG-PET/MRI Skull Base to Mid-Thigh Although still not in widespread clinical use, research has shown PET/MRI to be a promising new modality for comprehensive examination of cervical cancer disease extent. The MRI examination offers ideal imaging of the primary tumor for local extent evaluation, whereas the PET component offers superior sensitivity for the detection of nodal and hematogenous metastases. This is supported by a prospective study of 53 patients with cervical cancer that showed whole body PET/MRI performed comparably to MRI alone for local disease assessment with 85% accuracy versus 87% but better for the detection of lymph node metastases demonstrating 83% sensitivity, 90% specificity, and 87% accuracy compared to 71%, 83%, and 77%, respectively for MRI alone [14]. Considering local invasion, a study of 33 patients who underwent pretreatment PET/MRI showed a higher area under the curve than MRI alone for the detection of parametrial invasion (0.89 versus 0.73), vaginal invasion (85% versus 74%), and deep cervical stromal invasion (96% versus 74%) [15]. In addition to the staging evaluation, PET/MRI offers prognostic information with a higher maximum standardized uptake value (SUVmax) associated with poorer prognosis [16,17] and was found to be an independent predictor of progression-free survival (hazard radio [HR] = 4.57).


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without and With IV Contrast MRI is used to determine invasive cervical cancer tumor size and the extent of local invasion. Its superior soft tissue characterization allows for a more accurate staging assessment than can be obtained by CT or ultrasound (US) [11,18-20]. T2-weighted noncontrast sequences in the sagittal plane, axial oblique plane through the axis of the cervix, and coronal oblique planes though the axis of the cervix are the foundations of the anatomic assessment [21,22].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. One prospective study of 100 patients with prehysterectomy MRIs showed 86% agreement between MRI and surgical pathologic findings for tumor size and local extent evaluation (95% CI, 76.3%-90.9%) [23]. Another meta-


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without IV Contrast Although IV contrast administration is preferred, MRI pelvis without IV contrast may improve the conspicuity of small lesions compared with other imaging modalities [27,28] and may help to distinguish between cervical and endometrial primaries when the tumor involves both anatomic regions [29]. The T2-weighted noncontrast sequences in the sagittal plane, axial oblique plane through the axis of the cervix, and coronal oblique planes though the axis of the cervix are the foundations of the anatomic assessment [21,22], and the DWI/ADC images may help to detect small lesions. Because of its inherent superior soft tissue contrast, a noncontrast MRI is strongly preferred to a noncontrast CT.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transabdominal Transabdominal US of the pelvis plays a limited role in local staging of cervical cancers because of poorer evaluation of the gynecologic organs. For pelvic imaging, transvaginal US (TVUS) is preferred.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transvaginal TVUS of the pelvis has been evaluated as an alternative to MRI for the assessment of local disease extent. One meta-analysis, which compared the performance of US and MRI for local extent of disease assessment, showed similar performance between the 2 modalities, with US demonstrating a pooled sensitivity of 78% (95% CI, 48%- 93%) and specificity of 96% (95% CI, 84%-99%) for parametrial involvement, compared to 68% sensitivity (95% CI, 54%-80%) and 91% specificity (95% CI, 94%-95%) for MRI [30]. Contrast-enhanced US also shows similar diagnostic performance to MRI, with a study of 108 women with invasive cervical cancer who underwent both contrast-enhanced US and MRI demonstrating strong correlation between the 2 modalities for tumor size (r = 0.84- 0.88) and moderate concordance for vaginal and parametrial invasion [31]. Weaknesses of TVUS compared to MRI include the assessment of bulky tumors >4 cm [32].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging). As of 2018, the FIGO staging system incorporates radiologic and pathologic data in the assessment [2]. A new stage was created as a result of this, corresponding to radiologically suspected or pathologically confirmed nodal disease in the pelvis (IIIC1) and para-aortic (IIIC2) stations. When unsuspected nodal disease is found at surgical pathology, adjuvant radiation is necessary, with high morbidity. Therefore, the identification of nodal disease on preoperative imaging is paramount for the selection of the appropriate treatment strategy.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis With IV Contrast CT abdomen and pelvis with IV contrast may be used for the assessment of nodal and distant metastatic disease. Reported rates of unsuspected metastatic disease at a diagnosis range from 6.2% in a study of 1,158 consecutively evaluated cervical cancer patients to 13.7% in a study of patients with stage IB2 or greater disease on local


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix assessment. The other most common sites of metastatic disease are in the lung, peritoneum, supraclavicular lymph nodes, liver, and bone [33-35].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. With regards to nodal disease assessment, a meta-analysis of 115 studies published from 2000 to 2019 showed contrast-enhanced CT demonstrated good, although slightly inferior performance, compared to MRI and PET, with a pooled sensitivity and specificity of 51% (95% CI, 36%-67%) and 87% (95% CI, 81%-92%), compared to 57% (95% CI, 49%-64%) and 93% (95% CI, 89%-95%) for MRI, and 57% (95% CI, 48%-65%) and 95% (95% CI, 93%-97%) for PET [12]. Another meta-analysis of 72 studies found similar results with CT demonstrating a pooled sensitivity of 58% and a specificity of 92%, compared to 56% and 93% for MRI and 75% and 98% for PET [36]. These differences in performance are likely accounted for by difficulty in detecting disease in nodes <1 cm in size, for which MRI or PET are more sensitive.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis Without and With IV Contrast The addition of noncontrast CT abdomen and pelvis images would not appreciably add to the contrast-enhanced CT evaluation.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis Without IV Contrast CT abdomen and pelvis without IV contrast provides very poor soft tissue characterization in the pelvis [13] and therefore is not useful for the evaluation of invasive cervical cancer. Nodal metastases may be detected on a noncontrast-enhanced examination based on an abnormal size of >0.8 cm in axial short axis in the pelvis or >1 cm in axial short axis in the abdomen, an abnormally rounded shape, or loss of the normal fatty hilum. However, sensitivity may be decreased because of the difficulties distinguishing lymph nodes from adjacent vessels and/or small bowel loops.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest With IV Contrast Evaluation of the chest for metastatic disease is critical for patients with stage IB2 or greater disease because the rate of occult metastases is as high as 38% in this population [33]. Given its superior diagnostic performance for the detection of small pulmonary nodules, chest CT is preferred to chest radiography for this purpose. Although IV contrast is not necessary for the evaluation of the lung parenchyma and pleural spaces, it is strongly preferred for the detection of abdominopelvic metastases. Therefore, CT chest with IV contrast is commonly performed along with the abdomen and pelvis examination.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest Without and With IV Contrast The addition of noncontrast CT chest images would not appreciably add to the contrast-enhanced CT evaluation.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest Without IV Contrast Evaluation of the chest for metastatic disease is critical for patients with stage IB2 or greater disease because the rate of occult metastases is as high as 38% in this population [33]. Given its superior diagnostic performance for the detection of small pulmonary nodules, chest CT is preferred to chest radiography for this purpose.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. FDG-PET/CT Skull Base to Mid-Thigh PET/CT is the current modality of choice for assessment for nodal and distant metastatic disease. The National Comprehensive Cancer Network (NCCN) guidelines recommend a PET/CT be performed at the time of initial staging for all patients with stage IB2 disease or greater, given a rate of unsuspected distant metastatic disease of 13.7% in this population [33,37]. A multicenter study of 153 cervical cancer patients showed PET/CT had an overall sensitivity, specificity, PPV, and NPV of 54.8%, 97.7%, 79.3%, and 93.1%, respectively, for the detection of distant cervical cancer metastases. The most common sites of distant metastatic disease are the lung, peritoneum, supraclavicular lymph nodes, liver, and bone [33-35].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. With regards to lymph node assessment, a meta-analysis of 72 studies showed PET to have superior performance to MRI and CT, with a pooled sensitivity of 75% and a specificity of 98%, compared to 56% and 93% for MRI and 58% and 92% for CT [36]. Another meta-analysis of 115 studies published from 2000 to 2019 also showed PET had superior performance, with a pooled sensitivity and specificity of 57% (95% CI, 48%-65%) and 95% (95% CI, 93%-97%) compared to 57% (95% CI, 49%-64%) and 93% (95% CI,89%-95%) for MRI and 51% (95% CI, 36%- 67%) and 87% (95% CI, 81%-92%) for CT [12]. The high specificity of PET/CT for nodal assessment allows for a high NPV of 93.1% [38]. This prospective study in 153 patients also showed that the addition of PET to diagnostic CT was associated with a mild but statistically significant increase in sensitivity to detect abdominal nodal metastases in advanced cervical cancer [38].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix FDG-PET/MRI Skull Base to Mid-Thigh Although still not in widespread clinical use, research has shown PET/MRI to be a promising new modality for comprehensive examination of cervical cancer disease extent. The MRI examination offers ideal imaging of the primary tumor for local extent evaluation, whereas the PET component offers superior sensitivity for the detection of nodal and hematogenous metastases. This is supported by a prospective study of 53 patients with cervical cancer that showed whole body PET/MRI performed comparably to MRI alone of the local disease extent with 85% accuracy versus 87% but was better for the detection of lymph node metastases demonstrating 83% sensitivity, 90% specificity, and 87% accuracy compared to 71%, 83%, and 77%, respectively, for MRI alone [14]. Higher SUVmax is associated with poorer prognosis [16,17]. In addition to the staging evaluation, PET/MRI offers prognostic information with a higher SUVmax associated with poorer prognosis [16,17], and in 1 study was found to be an independent predictor of progression-free survival (HR = 4.57).


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Abdomen Without and With IV Contrast MRI abdomen without and with IV contrast may be used for the assessment of nodal and distant metastatic disease, preferably with IV contrast. It may be obtained along with the pelvic MRI performed for local disease extent assessment. If these examinations are obtained simultaneously, dynamic contrast-enhanced (DCE) imaging should be obtained of the pelvis to prioritize the local extent of disease assessment, with only delayed contrast-enhanced imaging obtained of the abdomen.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. With regards to nodal disease assessment, nodes are considered abnormal on MRI if their axial short axis is >1 cm in the abdomen or if they display abnormal morphologic characteristics such as rounded shape, loss of the normal fatty hilum, heterogenous signal, or more pronounced diffusion restriction than uninvolved lymph nodes. Using these criteria, a meta-analysis of 115 studies published from 2000 to 2019 showed MRI performed comparably to PET for nodal metastatic disease assessment, with a pooled sensitivity and specificity of 57% (95% CI, 49%-64%) and 93% (95% CI, 89%-95%), compared to 57% (95% CI, 48%-65%) and 95% (95% CI, 93%-97%) for PET. In this study, MRI performed better than CT, which had a pooled sensitivity and specificity of 51% (95% CI, 36%- 67%) and 87% (95% CI, 81%-92%), respectively [12]. Another meta-analysis of 72 studies showed MRI had comparable performance to CT and inferior performance to PET, with a sensitivity of 58% and a specificity of 93% compared to 75% and 98% for PET and 58% and 92% for CT [36].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Abdomen Without IV Contrast MRI abdomen without IV contrast may be employed for the assessment of nodal and distant metastatic disease and may be obtained along with the pelvic MRI performed for local disease extent assessment. Although IV contrast administration is preferred because it may increase the conspicuity of small lesions, it still demonstrates inherent superior soft tissue contrast compared to CT, and the DWI/ADC images may help to detect small metastatic foci.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without and With IV Contrast Evaluation for pelvic and lower para-aortic lymph node metastases can be performed at the time of local disease assessment, preferably with IV contrast. Nodes are considered abnormal on MRI if their axial short axis is >0.8 cm in the pelvis or if they display abnormal morphologic characteristics such as rounded shape, loss of the normal fatty hilum, heterogenous signal, or more pronounced diffusion restriction than uninvolved lymph nodes. Using these criteria, a meta-analysis of 115 studies published from 2000 to 2019 showed MRI performed comparably with PET with a pooled sensitivity and specificity of 57% (95% CI, 49%-64%) and 93% (95% CI, 89%-95%), compared to 57% (95% CI, 48%-65%) and 95% (95% CI, 93%-97%) for PET. In this study, MRI performed better than CT, which had a pooled sensitivity and specificity of 51% 57% (95% CI, 49%-64%) and 93% (95% CI, 89%-95%), compared to 57% (95% CI, 48%-65%) and 95% (95% CI, 93%-97%), respectively [12]. Another meta-analysis of 72 studies showed MRI had a comparable performance to CT and an inferior performance to PET, with a sensitivity of 58% and a specificity of 93% compared to 75% and 98% for PET and 58% and 92% for CT [36].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without IV Contrast Evaluation for pelvic and lower para-aortic lymph node metastases can be performed at the time of local disease assessment. Nodes are considered abnormal on MRI if their axial short axis is >1 cm or if they display abnormal morphologic characteristics such as rounded shape, loss of the normal fatty hilum, heterogenous signal, or more pronounced diffusion restriction than uninvolved lymph nodes. Although IV contrast administration is preferred because it may increase the conspicuity of small lesions, it still demonstrates inherent superior soft tissue contrast compared to nonenhanced CT, and MRI may help detect even subcentimeter-sized disease foci [39]. In a study of 53 patients, MRI was able to detect tumors as small as 0.6 cm but missed a 0.3 cm sized lesion [40].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix Radiography Chest Chest radiographs are recommended by the Society of Gynecologic Oncology for the detection of pulmonary metastases (in the form of pulmonary nodules or pleural effusions). However, chest radiographs have a low rate of detection of thoracic metastases (ranging from 0%-20%) compared to 80% to 95% reported by chest CT [41,42]. Therefore, chest CT is preferred.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Abdomen Abdominal US can be used to detect hydronephrosis, which may indicate parametrial invasion and ureteral obstruction corresponding to stage IIIb disease. Although abdominal US may also show metastatic disease in other organs such as the liver or upper abdominal lymph nodes, its narrow field of view makes it a poor modality for a complete nodal and metastatic disease assessment. Cross-sectional imaging with CT or MRI is preferred for this evaluation.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transabdominal Transabdominal US of the pelvis plays a limited role in the staging of cervical cancers because of its incomplete evaluation of the gynecologic organs. For pelvic imaging, TVUS is preferred.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transvaginal Although TVUS of the pelvis plays an important role in local disease assessment, its limited depth of penetration makes it a poor choice of modality for a complete nodal and metastatic disease assessment. Cross-sectional imaging is preferred.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation. This variant primarily applies to response assessment of the locally advanced primary tumor after chemoradiation. Literature on assessment of initial treatment response of cervical cancer after chemoradiation is evolving, with emphasis on the use of MRI or PET/CT, which can help in both response assessment and detection of complete response versus residual disease. This information is critical for the management because patients with refractory disease (presence of residual tumor after 6 months of completion of treatment) in the pelvis without distant metastases may be considered for pelvic exenteration. There is also a growing body of literature exploring the use of the functional parameters such as DWI or ADC images on MRI or metabolic parameters on PET/CT as prognostic biomarkers.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis With IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis with IV contrast for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation. CT may be used for response assessment of nodal and distant metastatic disease [37]. Use of IV contrast material is generally preferred. If there is distant metastatic disease, imaging of the chest, abdomen, and pelvis is concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis Without and With IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis without and with IV contrast for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation. CT may be used for response assessment of nodal and distant metastatic disease [37]; however, a dual-phase study without and with IV contrast is unnecessary.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis Without IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis without IV contrast for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation. CT may be used for response assessment of nodal and distant metastatic disease [37]. Although the use of IV contrast material is preferred, the assessment may be performed without IV contrast. If there is distant metastatic disease, imaging of the chest, abdomen, and pelvis is concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest With IV Contrast CT chest with IV contrast is not useful for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation; however, it may be used for response assessment of distant metastatic disease [37]. Use of IV contrast material is generally preferred. If there is distant metastatic disease, imaging of the chest, abdomen, and pelvis is concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix CT Chest Without and With IV Contrast CT chest without and with IV contrast is not useful for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation; however, it may be used for response assessment of distant metastatic disease [37]. Dual-phase study without and with IV contrast is unnecessary.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest Without IV Contrast CT chest without IV contrast is not useful for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation; however, it may be used for response assessment of distant metastatic disease [37]. Although the use of IV contrast material is preferred, the assessment may be performed without IV contrast. If there is distant metastatic disease, imaging of the chest, abdomen, and pelvis is concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. FDG-PET/CT Skull Base to Mid-Thigh Multiple studies have shown that FDG-PET/CT is useful in assessing metabolic response of cervical cancer to chemoradiation [43-47]. In a prospective study with 88 patients, changes in FDG-PET/CT metabolic parameters such as SUVmax and total lesion glycolysis (TLG) helped predict histopathological response to chemoradiation [48]. In a retrospective study involving 82 patients, metabolic tumor volume (MTV), TLG, and nodal involvement on PET/CT were the significant predictors of response [45]. Higher tumor SUVmax and TLG are also shown to be significantly associated with poor response to chemoradiation [49], whereas MTV has been shown to adversely affect prognosis [50]. A meta-analysis including 12 studies with 1,104 patients demonstrated that response on FDG- PET/CT was a significant prognostic factor and suggested that PET/CT has a role in follow-up assessment of patients with cervical cancer [51]. PET/CT reportedly has better performance than MRI for the detection of active disease after chemoradiation. In a study that included 55 patients, sensitivity, specificity, and accuracy of PET/CT for detection of residual disease was 60%, 100%, and 89%, whereas that of MRI was 27%, 100%, and 80%, respectively [52].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. FDG-PET/MRI Skull Base to Mid-Thigh The literature on the use of FDG-PET/MRI for response assessment of cervical cancer is limited. FDG-PET/MRI likely has a role in assessment of response after chemoradiation. In a prospective case control study with 45 patients, SUVmax was an independent predictor of progression-free survival [53]. In addition, MTV and minimum ADC helped predict progression-free survival in stage I and II disease. Although both FDG-PET and MRI are shown to have utility in response assessment of patients with cervical cancer, additional research is needed to assess the utility of FDG-PET/MRI in these patients.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Abdomen Without and With IV Contrast MRI abdomen without and with IV contrast is not useful for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation; however, it may be used for response assessment of distant metastatic disease [37]. If there is distant metastatic disease, imaging of the chest, abdomen, and pelvis is concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Abdomen Without IV Contrast MRI abdomen without IV contrast is not useful for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation; however, it may be used for response assessment of distant metastatic disease [37]. If there is distant metastatic disease, imaging of the chest, abdomen, and pelvis is concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without and With IV Contrast MRI pelvis without and with IV contrast has a role in assessment of response of cervical cancer after chemoradiation. Given its excellent soft tissue contrast, MRI allows excellent visualization of tumor and allows serial volume measurements as well as early assessment of therapy failure by demonstrating increase in size [54]. Response to treatment results in fibrotic change, and reconstitution of normal low T2 signal of the cervical stroma is the most reliable indicator of complete response to radiation therapy [54,55]. Residual or refractory disease has intermediate T2 signal and restricted diffusion. MRI also has a likely role in patients with early-stage cervical cancer following conization. A retrospective study of 55 patients found that MRI had overall 73% accuracy in detection of pathologically proved residual tumor [56].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. In a small retrospective study of 32 patients, T2-weighted images were useful in assessing change in the tumor volume [57]. In a study of 185 patients, MRI was able to demonstrate the change in size of primary tumor after radiation. Initial tumor size and the rate of decrease of tumor size were significantly associated with local recurrence-free survival and overall survival rates [58]. A meta-analysis including 4 studies and 147 patients


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix demonstrated that MRI had 83.5% sensitivity, 88.5% specificity, and 84.3% accuracy for detection of residual tumor after brachytherapy [59]. In other studies, the sensitivity, specificity, and accuracy of MRI was 27% to 69%, 71% to 100%, and 71% to 80%, with 1 of these studies concluding that MRI had an overall lower performance than PET/CT [52,60]. In another study, there was a relatively low agreement between posttreatment MRI and pathology for assessment of tumor size [23]. A small retrospective study of 51 patients also demonstrated that MRI had high sensitivity and low specificity in identifying persistent parametrial invasion after neoadjuvant chemotherapy [14].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. DWI and DCE MRI likely have a role in assessment of these patients. In a retrospective study of 52 patients using DWI and DCE MRI, an initial increase in tumor signal intensity on DCE MRI, higher than myometrium, as well as low signal on ADC images were significantly associated with incomplete response [61]. In this study, there was excellent agreement between the 3 readers. In a meta-analysis, pretreatment ADC values alone were not reliable in assessing treatment response [62]; however, other studies have indicated that multiparametric MRI with DWI and DCE images together may help predict response to chemoradiation [63,64]. Patients with disease recurrence also had a lower ADC both pre- and posttreatment, as well as had a smaller interval change in ADC values [65]. In a retrospective study with 102 patients, tumors with infiltrative growth pattern on MRI were associated with a lower overall and locoregional recurrence-free survival rates after chemoradiation [66]. Finally, MRI is also helpful for assessment of posttreatment complications [54].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast may have a role in assessment of response of cervical cancer after chemoradiation; however, use of IV contrast may add value. In a study of 185 patients, MRI was able to demonstrate the change in the size of the primary tumor after radiation, and initial tumor size and the rate of decrease of tumor size were significantly associated with local recurrence-free and overall survival rates [58]. A meta-analysis including 4 studies and 147 patients, MRI had 83.5% sensitivity, 88.5% specificity, and 84.3% accuracy for detection of residual tumor after brachytherapy; however, it remains unclear if these results also translate to MRI without IV contrast [59]. MRI parameters on DWI and DCE images also likely have a role in assessment of these patients. In a meta- analysis, pretreatment ADC values on MRI alone were not reliable in assessing treatment response [62]; however, other studies have indicated that multiparametric MRI with DWI and DCE images together may help predict response to chemoradiation [63,64]. In another small retrospective study in 32 patients, T2-weighted images were shown to be useful in assessing changes in the tumor volume [57]. In a retrospective study with 102 patients, tumors with infiltrative growth pattern on MRI were associated with a lower overall and locoregional recurrence-free survival rates after chemoradiation [66].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Radiography Chest Chest radiography is not useful for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation; however, it may be used for detection of distant metastatic disease [37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Abdomen Abdominal US is not useful for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transabdominal There is no relevant literature to support the use of transabdominal pelvic US for the evaluation of initial treatment response assessment of primary cervical cancer after chemoradiation.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transvaginal In a prospective study of 128 women, TVUS showed an overall 92% accuracy in predicting response to chemotherapy, with decreased tumor volume being the most important association of response [67]. In another retrospective study of 51 patients, TVUS had a high sensitivity and specificity in identifying persistent parametrial invasion after neoadjuvant chemotherapy [68]. Another prospective study with 88 patients showed that after 2 weeks of neoadjuvant treatment, TVUS was able to demonstrate higher tumor volume in patients with partial response compared to those with complete response [69]. In the same study, additional color Doppler and contrast features was also significantly different in the partial- and complete-response groups, both before and after 2 weeks of treatment; however, the sensitivity (48%-77%) and specificity (58%-84%) of various US parameters were not high enough for accurate prospective prediction of treatment response [69].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix Variant 4: Surveillance of treated cervical cancer in asymptomatic patients. Recurrent cervical cancer is defined as local regrowth of tumor, presence of distant metastases, or a combination of both 6 months after the completion of treatment. The recurrence rates are in the range of 10% to 20%, and the majority of recurrences occur within 2 to 3 years after the initial treatment [5]. Cervix, parametrium, vaginal vault, pelvic sidewall, or retroperitoneal lymph nodes are the most common sites of recurrence. Patients with recurrent disease are often symptomatic. As a result, the Society of Gynecologic Oncology recommends against routine imaging surveillance of posttreatment cervical cancer patients [5].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis With IV Contrast For stage I patients who undergo nonfertility sparing treatment, use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and degree of clinical concern such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. For stage II to IV patients, CT of the abdomen and pelvis may be used within 3 to 6 months after completion of therapy; however, NCCN guidelines indicate a preference for PET/CT for this purpose [37]. Use of IV contrast is generally preferred. Imaging of the chest, abdomen, and pelvis is often concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis Without and With IV Contrast For stage I patients who undergo nonfertility sparing treatment, use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and the degree of clinical concern such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. For stage II to IV patients, CT of the abdomen and pelvis may be used within 3 to 6 months after completion of therapy; however, NCCN guidelines indicate a preference for PET/CT for this purpose [37]. Dual-phase study without and with IV contrast is unnecessary.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis Without IV Contrast For stage I patients who undergo nonfertility sparing treatment, use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and the degree of clinical concern such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. For stage II to IV patients, CT of the abdomen and pelvis may be used within 3 to 6 months after completion of therapy; however, NCCN guidelines indicate a preference for PET/CT for this purpose [37]. Although the use of IV contrast material is preferred, the assessment may be performed without IV contrast. Imaging of the chest, abdomen, and pelvis is often concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest With IV Contrast For stage I patients who undergo nonfertility sparing treatment, the use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and the degree of clinical concern such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. For stage II to IV patients, CT of the chest may be used within 3 to 6 months after completion of therapy; however, NCCN guidelines indicate a preference for PET/CT for this purpose [37]. Use of IV contrast is generally preferred. Imaging of the chest, abdomen, and pelvis is often concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest Without and With IV Contrast For stage I patients who undergo nonfertility sparing treatment, the use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and the degree of clinical concern such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. For stage II to IV patients, CT of the chest may be used within 3 to 6 months after completion of therapy; however, NCCN guidelines indicate a preference for PET/CT for this purpose [37]. Dual-phase study without and with IV contrast is unnecessary.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest Without IV Contrast For stage I patients who undergo nonfertility sparing treatment, the use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and the degree of clinical concern such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. For stage II to IV patients, CT of the chest may be used within 3 to 6 months after completion of therapy; however, NCCN guidelines indicate preference for PET/CT for this purpose [37]. Although the use of IV contrast material is preferred, the assessment may be performed without IV contrast. Imaging of the chest, abdomen, and pelvis is often concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix FDG-PET/CT Skull Base to Mid-Thigh FDG PET/CT is useful in the evaluation of local and distant recurrence even in asymptomatic patients, as well as in excluding metastatic disease in patients with pelvic recurrence amenable to radical surgery [5,37,54]. A meta- analysis including 18 studies and 762 patients showed that PET/CT had a pooled sensitivity and specificity of 92% (95% CI, 91%-94%) and 84% (95% CI, 74%-91%) and an area under the curve of 0.95 [70]. In another meta- analysis, the pooled sensitivity and specificity of PET/CT to detect local recurrence was 82% (95% CI, 72%-90%) and 98% (95% CI, 96%-99%), whereas that for distant metastasis was 87% (95% CI, 80%-92%) and 97% (95% CI, 96%-98%) [71]. In a retrospective study with 84 patients, higher MTV was associated with a higher rate of recurrence in patients with stage IIB to IVA cervical cancer [72]. Additional studies have indicated that metabolic parameters including SUVmax, MTV, and TLG may help predict outcomes including overall survival and therefore can influence the follow-up imaging strategy [43,46,73,74].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Per NCCN guidelines, for stage I patients who undergo nonfertility sparing treatment, the use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and the degree of clinical concern, such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. Stage IB3 patients of those with risk factors such as positive nodes, parametrial extension. or positive margins may undergo PET/CT at 3 to 6 months after completion of treatment [37]. Generally, NCCN guidelines recommend the use of PET/CT over CT for the evaluation of metastatic disease [37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. FDG-PET/MRI Skull Base to Mid-Thigh In a prospective study of 45 patients with newly diagnosed cervical cancer, an SUVmax was an independent predictor of progression-free survival (HR = 4.57, P < .05). Minimum ADC was an independent predictor of overall survival [53]. Additional studies have indicated that metabolic parameters including SUVmax, MTV, and TLG may help predict outcomes including overall survival [49,73,74]. A retrospective study on 31 patients found PET/MRI to be useful in assessment of recurrent and metastatic disease and also found that that was a significant inverse correlation between SUVmax and ADC values [75]. Another small prospective study showed that PET/MRI was able to detect both local and distant recurrence of cervical cancer and found a similar significant inverse correlation between SUVmax and ADC values [76].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Abdomen Without and With IV Contrast At present there is no relevant literature to support the use of MRI abdomen without and with IV contrast for surveillance of patients with asymptomatic cervical cancer [37]. For stage II to IV patients, NCCN guidelines recommend PET/CT (preferred) or CT of the chest, abdomen, and pelvis [37]. Imaging of the chest, abdomen, and pelvis is often concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Abdomen Without IV Contrast At present there is no relevant literature to support the use of MRI abdomen without IV contrast for surveillance of patients with asymptomatic cervical cancer [37]. For stage II through IV patients, NCCN guidelines recommend PET/CT (preferred) or CT of chest, abdomen and pelvis [37]. If MRI is performed, IV contrast should be used unless contraindicated. Imaging of the chest, abdomen, and pelvis is often concurrently performed.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without and With IV Contrast MRI pelvis has a role in the surveillance imaging after initial treatment; however, at present there is no consensus on the time interval of follow-up imaging after the initial treatment or the optimal frequency of follow-up imaging [54]. Treatment-related changes in T2 signal can limit early detection of recurrent tumor, which is seen as heterogeneous intermediate to high T2 signal, diffusion-restricting tissue on the background of established low- signal radiation-induced fibrosis [54]. In a meta-analysis including 4 studies and 147 patients, MRI had 83.5% sensitivity, 88.5% specificity, and 84.3% accuracy for detection of residual tumor after brachytherapy [59]. In another retrospective study, MRI had an 81.8% PPV and an 87.5% NPV in detecting histologically confirmed recurrent disease in patients who did not have complete response on posttreatment PET/CT [44]. MRI parameters are also shown to predict recurrence-free interval and therefore may influence the imaging surveillance strategy. In a retrospective study of 103 patients with stage IB to IVA cervical cancer, the smaller increase in ADC values and the smaller decrease in tumor volume during chemoradiation or radiation treatment were predictors of tumor recurrence over a median follow-up period of 2.7 years [77]. In a retrospective study with 102 patients, tumors with infiltrative growth pattern on MRI were associated with a lower overall and locoregional recurrence-free survival rates after chemoradiation [66]. Additional studies and a meta-analysis have also indicated that MRI features, including ADC value and tumor volume, of primary cervical cancer as well as nodal disease can help predict


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix metastasis-free and overall survival rates [77-81]. These findings may influence the surveillance strategy of patients with cervical cancer.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Per NCCN guidelines, for stage I patients who undergo nonfertility sparing treatment, the use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and degree of clinical concern, such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. For stage I patients who undergo fertility sparing treatment, MRI with IV contrast may be performed at 3 to 6 months and then yearly for 2 to 3 years [37]. For stage II through IV patients, pelvic MRI with IV contrast should be considered 3 to 6 months after completion of therapy [37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without IV Contrast MRI pelvis with IV contrast is the preferred study, but without IV contrast may also be useful. In a retrospective study of 103 patients with stage IB-IVA cervical cancer, the smaller increase in ADC values and the smaller decrease in tumor volume during chemoradiation or radiation treatment were predictors of tumor recurrence over a median follow-up period of 2.7 years [77]. Additional studies have also indicated that MRI features, including ADC value and tumor volume, of primary cervical cancer as well as nodal disease can help predict metastasis-free and overall survival rates [77-80]. These findings may influence the surveillance strategy of patients with cervical cancer.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Per NCCN guidelines, for stage I patients who undergo nonfertility sparing treatment, the use of imaging for surveillance of cervical cancer in asymptomatic patients should be based on symptomatology and the degree of clinical concern, such as clinical examination findings or pelvic, abdominal, or pulmonary symptoms [37]. For stage I patients who undergo fertility sparing treatment, MRI may be performed at 3 to 6 months and then yearly for 2 to 3 years [37]. For stage II through IV patients, pelvic MRI should be considered at 3 to 6 months after completion of therapy [37]. IV contrast should be used unless contraindicated [37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Radiography Chest There is no relevant literature to support the use of chest radiography in the surveillance of patients with cervical cancer [5,37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Abdomen There is no relevant literature to support the use of US abdomen in the surveillance of patients with cervical cancer [5,37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transabdominal There is no relevant literature to support the use of pelvic transabdominal US in the surveillance of patients with cervical cancer [5,37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transvaginal There is no relevant literature to support the use of pelvic TVUS in the surveillance of patients with cervical cancer [5,37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging. The majority of patients with recurrent cervical cancer are symptomatic, with the symptoms ranging from abdominal and pelvic pain, leg symptoms such as pain or lymphedema, vaginal bleeding or discharge, urinary symptoms, cough, and weight loss [5]. CT, MRI, and PET/CT all have a role in detection of local or distant recurrence in symptomatic patients, as well as in the response assessment after chemotherapy.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis With IV Contrast CT may be used for the assessment of known distant recurrence, preferably with use of IV contrast [37]. In a meta- analysis that included 4 studies that evaluated use of CT for this purpose, the summary estimate of the sensitivity of CT was 90% (95% CI, 82%-94%), and the specificity was 76% (95% CI, 44%-93%) [82]. Imaging of the chest, abdomen, and pelvis is often concurrently performed for evaluation of distant metastatic disease.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Abdomen and Pelvis Without and With IV Contrast CT may be used for assessment of known distant recurrence, preferably with use of IV contrast [37]. In a meta- analysis that included 4 studies that evaluated use of CT for this purpose, the summary estimate of the sensitivity of CT was 90% (95% CI, 82%-94%), and the specificity was 76% (95% CI, 44%-93%) [82]. Dual-phase study without and with IV contrast is unnecessary.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix CT Abdomen and Pelvis Without IV Contrast CT may be used for the assessment of known distant recurrence, preferably with the use of IV contrast [37]. In a meta-analysis that included 4 studies that evaluated the use of CT for this purpose, the summary estimate of the sensitivity of CT was 90% (95% CI, 82%-94%), and the specificity was 76% (95% CI, 44%-93%) [82]. Imaging of the chest, abdomen, and pelvis is often concurrently performed for evaluation of distant metastatic disease.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest With IV Contrast CT may be used for the assessment of known distant recurrence, preferably with the use of IV contrast [37]. In a meta-analysis that included 4 studies that evaluated the use of CT for this purpose, the summary estimate of the sensitivity of CT was 90% (95% CI, 82%-94%), and the specificity was 76% (95% CI, 44%-93%) [82]. Imaging of the chest, abdomen, and pelvis is often concurrently performed for evaluation of distant metastatic disease.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest Without and With IV Contrast CT may be used for the assessment of known distant recurrence, preferably with the use of IV contrast [37]. In a meta-analysis that included 4 studies that evaluated use of CT for this purpose, the summary estimate of the sensitivity of CT was 90% (95% CI, 82%-94%), and the specificity was 76% (95% CI, 44%-93%) [82]. Dual-phase study without and with IV contrast is unnecessary.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. CT Chest Without IV Contrast CT may be used for the assessment of known distant recurrence, preferably with the use of IV contrast [37]. In a meta-analysis that included 4 studies that evaluated use of CT for this purpose, the summary estimate of the sensitivity of CT was 90% (95% CI, 82%-94%), and the specificity was 76% (95% CI, 44%-93%) [82]. Imaging of the chest, abdomen, and pelvis is often concurrently performed for evaluation of distant metastatic disease.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. FDG-PET/CT Skull Base to Mid-Thigh NCCN guidelines support the use of PET/CT over CT for the evaluation of metastatic disease [37]. In patients with suspected recurrence, FDG-PET/CT is useful in detection of local and distant disease, as well as in excluding metastatic disease in patients with pelvic recurrence who are amenable to radical surgery [37,54]. A meta-analysis of 9 PET/CT studies in mostly symptomatic women found an overall sensitivity of 95% (95% CI, 91%-97%) and a specificity of 87% (95% CI, 82%-91%) for detection of recurrent disease [82]. PET/CT is also helpful in assessment of metabolic response and has been shown to correlate well with radiologic response [47].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. FDG-PET/MRI Skull Base to Mid-Thigh There is limited literature on use of PET/MRI for the evaluation of known or suspected recurrent disease; however, a retrospective study on 31 patients found PET/MRI to be useful in the assessment of recurrent and metastatic disease and also found that there was a significant inverse correlation between SUVmax and ADC values [75]. Another small prospective study showed that PET/MRI was able to detect both local and distant recurrence of cervical cancer and found a similar significant inverse correlation between SUVmax and ADC values [76]. These studies indicate a potential of PET/MRI for concurrent assessment of both PET- and MRI-based functional biomarkers.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Abdomen Without and With IV Contrast MRI may be useful for the assessment of distant disease and for the assessment of response, preferably with the use of IV contrast [37]. Imaging of the chest, abdomen, and pelvis is often concurrently performed for evaluation of distant metastatic disease.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Abdomen Without IV Contrast MRI may be used for the assessment of distant disease and for the assessment of response, preferably with the use of IV contrast [37]. Imaging of the chest, abdomen, and pelvis is often concurrently performed for evaluation of distant metastatic disease.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without and With IV contrast Per NCCN guidelines, pelvic MRI is useful for patients with suspected recurrence, preferably with IV contrast [37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. MRI Pelvis Without IV contrast Per NCCN guidelines, pelvic MRI is useful for patients with suspected recurrence, preferably with IV contrast [37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Radiography Chest There is no relevant literature to support the use of chest radiography in the surveillance of patients with cervical cancer [5,37]. The rate of detection of thoracic disease on chest radiograph is reportedly 20% to 47% [5].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix US Abdomen There is no relevant literature to support the use of US abdomen in the surveillance of patients with cervical cancer [5,37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. US Pelvis Transabdominal There is no relevant literature to support the use of pelvic transabdominal US in the surveillance of patients with cervical cancer [5,37].


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix 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.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Pretreatment Evaluation and Follow up of Invasive Cancer of the Cervix. Follow-up of Invasive Cancer of the Cervix


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. Diagnosis of PE is challenging because of the nonspecific nature of the clinical presentation, with associated symptoms such as chest pain, shortness of breath, and tachycardia that may mimic other pulmonary or cardiac conditions. The diagnostic challenge of PE is most commonly addressed with clinical scoring algorithms such as the Wells criteria and the Geneva score [6-8], D-dimer testing, and specialized CT angiography (CTA) [9], during which the images are acquired with a timing of the iodinated contrast bolus to best opacify the pulmonary arteries.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. In hemodynamically stable patients with a low or intermediate clinical likelihood of PE, normal results on D-dimer testing obviates the need for PE imaging. When patients do not fall into these categories, CT pulmonary angiography (CTPA) is commonly performed. There are 3 additional variants covered in this document: patients with a positive D-dimer without a high-risk clinical score (Variant 2), patients with a high pretest probability for PE (Variant 3), and pregnant patients (Variant 4). This document draws on the findings of the joint American College of Cardiology/ACR guideline on chest pain in the emergency room [9] and the American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline: Evaluation of Suspected Pulmonary Embolism In Pregnancy [3].


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. Special Imaging Considerations Chest radiography is very limited in the assessment for PE, but it may diagnose a pneumothorax, pneumonia, or other condition. A chest radiograph is typically used in the interpretation of a ventilation and perfusion (V/Q) lung scan [10]. Because chest radiography is typically performed before advanced imaging is considered, it is not included in the ratings for Variants 1 through 3.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. aCleveland Clinic, Weston, Florida. bThe University of Texas MD Anderson Cancer Center, Houston, Texas. cPanel Chair, Cleveland Clinic, Cleveland, Ohio. dPanel Chair, Duke University, Durham, North Carolina. ePanel Vice-Chair, Mayo Clinic, Rochester, Minnesota. fUniversity of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging. gUniversity of Iowa Hospitals and Clinics, Iowa City, Iowa. hUniversity of Michigan Health System, Ann Arbor, Michigan. iMetroHealth Medical Center, Cleveland, Ohio, Primary care physician. jMallinckrodt Institute of Radiology, Saint Louis, Missouri. kUniversity of Cincinnati, Cincinnati, Ohio. lRhode Island Hospital, Providence, Rhode Island. mJohns Hopkins University School of Medicine, Baltimore, Maryland. nUniversity of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. oDenver Health, Denver, Colorado; American College of Emergency Physicians. pVA Medical Center, University of California-Irvine, Irvine, California; Society for Cardiovascular Magnetic Resonance. qSpecialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio. rSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. Reprint requests to: publications@acr.org


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism

Suspected Pulmonary Embolism PCAs. Suspected Pulmonary Embolism


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. In addition, CTPA is a named CT angiogram with intravenous (IV) contrast. CTPA follows the definition of a CTA above, with the addition that the timing of the scan is tailored so that contrast enhances the pulmonary arterial system to identify potential filling defects.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. OR Discussion of Procedures by Variant Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial imaging. Because this scenario is clinically important, it is presented in Variant 1 despite the fact that the literature does not support advanced imaging [12-16].


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. Radiographs are typically performed because the differential diagnosis is broad in this patient population.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. CTPA The literature does not support the use of CTPA for the evaluation of suspected PE. This is in keeping with the fact that no advanced imaging is supported for patients included in this clinical scenario [8,12-16].


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. CT Chest With IV Contrast The literature does not support the use of CT chest with IV contrast for the evaluation of suspected PE for patients with low to intermediate probability and negative D-dimer [8,12-16]. The use of CT for alternate diagnoses is beyond the scope of this document.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. CT Chest Without and With IV Contrast The literature does not support the use of CT chest without and with IV contrast for the evaluation of suspected PE for patients with low to intermediate probability and negative D-dimer [8,12-16]. The use of CT for alternate diagnoses is beyond the scope of this document.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. CT Chest Without IV Contrast The literature does not support the use of CT chest without IV contrast for the evaluation of suspected PE for patients with low to intermediate probability and negative D-dimer [8,12-16]. The use of CT for alternate diagnoses is beyond the scope of this document.


Suspected Pulmonary Embolism PCAs

Suspected Pulmonary Embolism PCAs. CTA Chest With IV Contrast with CTV Lower Extremities The literature does not support the use of CTA chest with IV contrast with CT venography (CTV) lower extremities for the evaluation of suspected PE for patients with low to intermediate probability and negative D-dimer [8,12- 16]. The use of CTA for alternate diagnoses is beyond the scope of this document.