Cranial Neuropathy

Cranial Neuropathy. DWI can be used to assess for acute brainstem infarction, cholesteatoma, and for characterizing tumor cellularity. False-negative DWI can occur in the setting of very small ischemic brainstem infarcts [137,138]. Thin-section coronal DWI or thinner axial DWI may improve sensitivity for detecting acute brainstem infarction, with nearly 25% of acute brainstem infarcts more easily seen on thin-cut coronal DWI compared with standard axial DWI in one study [138].


Cranial Neuropathy

Cranial Neuropathy. The combination of ipsilateral CN V and CN VII palsies raises concern for perineural spread of a tumor, which is discussed in Variant 10.


Cranial Neuropathy


Cranial Neuropathy

Cranial Neuropathy. US Neck There is no relevant literature to support the use of US neck in the initial evaluation of multiple middle cranial palsies.


Cranial Neuropathy

Cranial Neuropathy. Variant 5: Oropharyngeal neurogenic dysphagia or oropharyngeal pain (glossopharyngeal nerve, CN IX). Initial imaging. The glossopharyngeal nerve (CN IX) arises in the medulla and is responsible for branchial motor innervation to the stylopharyngeus muscle, which elevates the palate, and visceral motor parasympathetic innervation to the parotid gland [2]. Visceral sensory innervation to the carotid sinus plays a role in regulating circulation and general and special sensory innervation supply sensation and taste to the posterior tongue. The nerve exits the jugular foramen in close proximity to the vagus (CN X) and the spinal accessory (CN XI) nerves [2,24]. Noniatrogenic isolated syndromes involving the glossopharyngeal nerve are very rare. Nerve root section or nerve ablation results in


Cranial Neuropathy

Cranial Neuropathy

Cranial Neuropathy. Cranial Neuropathy


Cranial Neuropathy

Cranial Neuropathy. variable degrees of dysphagia and ipsilateral sensory loss on the pharynx and posterior tongue [139]. Intra- parenchymal lesions can affect CN IX, including gliomas, lymphomas, metastases, vascular malformations, infarctions, demyelinating lesions, and inflammatory abnormalities. Leptomeningeal metastases, granulomatous disease, and even tortuosity or aneurysmal dilatation of vessels may affect the nerve as it enters the subarachnoid cistern. Lesions in the region of the posterior skull base and jugular foramen, such as metastases, schwannomas, paragangliomas, and meningiomas, usually also involve the other lower CNs [140,141]. Tonsillar pain syndromes and loss of a gag reflex accompanied by impaired taste and sensation along the posterior one-third of the tongue and palate may signal a glossopharyngeal nerve lesion [2,141]. Glossopharyngeal neuralgia presents as severe pain in the oropharyngeal and otic regions, classically triggered by swallowing, and is typically caused by neurovascular compression, although a minority of cases may be caused by trauma, an elongated calcified stylohyoid ligament, and neoplasms along the course of the nerve, including in the neck [142,143]. CT Head There is no relevant literature to support the use of routine noncontrast head CT in the initial evaluation of oropharyngeal neurogenic dysphagia or oropharyngeal pain.


Cranial Neuropathy

Cranial Neuropathy. CT Maxillofacial There is no relevant literature to support the use of maxillofacial CT in the initial evaluation of oropharyngeal neurogenic dysphagia or oropharyngeal pain.


Cranial Neuropathy

Cranial Neuropathy. CT Temporal Bone There is no relevant literature to support the use of temporal bone CT in the initial evaluation of oropharyngeal neurogenic dysphagia or oropharyngeal pain.


Cranial Neuropathy

Cranial Neuropathy. CT Neck Neck CT is complementary to MRI orbits, face, and neck in assessing patients with isolated CN IX palsy. Neck CT can delineate skull base erosion, identify deep space neck masses, intratumoral calcification, and the bony margins of the jugular foramen and nearby skull base foramina as well as image the extracranial course of the CN IX and its innervated structures in the pharynx and carotid space [144-148]. It does not image the intracranial course of CN IX or the brainstem well, which are best assessed with MRI. Imaging protocols should include thin-cut high- resolution bone windows through the posterior skull base. Contrast is strongly preferred for soft tissue characterization. There is no relevant literature to support the use of combined pre- and postcontrast imaging.


Cranial Neuropathy

Cranial Neuropathy. CT neck is also useful to characterize the anatomy of the stylohyoid ligament in patients with glossopharyngeal pain [142]. In cases of glossopharyngeal neuralgia, imaging should include the pharynx and larynx to exclude a mucosal neoplasm as an etiology.


Cranial Neuropathy

Cranial Neuropathy. CTA Head and Neck There is no relevant literature to support the use of CTA in the initial evaluation of oropharyngeal neurogenic dysphagia or oropharyngeal pain.


Cranial Neuropathy

Cranial Neuropathy. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT skull base to mid-thigh in the initial evaluation of oropharyngeal neurogenic dysphagia or oropharyngeal pain.


Cranial Neuropathy

Cranial Neuropathy. MRA Head and Neck There is no relevant literature to support routine use of MRA head and neck to assess vasculature in the initial evaluation of glossopharyngeal palsy, although MRA focused on the posterior skull base can be complementary to thin-cut high-resolution skull base technique, contrast-enhanced MRI orbits, face, and neck, or MRI head in patients with glossopharyngeal nerve palsy. Contrast-enhanced MRA focused on the posterior skull provides detailed imaging of the lower CNs within the jugular foramen and their relationship to the hypoglossal nerve as they exit the skull base, with CN IX reportedly well imaged in 100% of cases using contrast-enhanced high-resolution MRA [24,149].


Cranial Neuropathy

Cranial Neuropathy. MRA can be complementary to thin-cut high-resolution MRI sequences to assess for neurovascular compression in patients with glossopharyngeal neuralgia and has demonstrated agreement with surgically confirmed neurovascular compression in all patients in 2 small studies [143,149,150].


Cranial Neuropathy

Cranial Neuropathy. Thin-cut heavily T2-weighted contrast-enhanced modified balanced SSFP sequences and contrast-enhanced MRA focused on the posterior skull provide detailed imaging of the nerves within the jugular foramen and their relationship to the hypoglossal nerve as they exit the skull base, visualizing CN IX in 90% to 100% of imaged patients [24].


Cranial Neuropathy

Cranial Neuropathy. Various combinations of high-resolution 3-D T2-weighted imaging, MRA, and 3-D T1-weighted contrast-enhanced sequences can be used to assess for neurovascular compression [143,149-151] and have demonstrated agreement with surgical findings in all patients in two small studies [143,150].


Cranial Neuropathy

Cranial Neuropathy. US Neck There is no relevant literature to support the use of US neck in the initial evaluation of oropharyngeal neurogenic dysphagia or oropharyngeal pain.


Cranial Neuropathy

Cranial Neuropathy. Variant 6: Unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging. The vagus nerve (CN X) supplies visceral sensation to the pharynx, larynx, and viscera and general sensation to the ear. Branchial motor branches innervate muscles of the pharynx via the pharyngeal branches and the larynx via the superior and recurrent laryngeal nerves, and visceral motor branches play a predominant role in parasympathetic supply to the thorax and abdomen [2]. The vagus nerve runs the longest course in the body of any CN and is therefore vulnerable to a wide range of pathologies occurring throughout its trajectory from the posterior fossa and skull base to the neck, thorax, and abdomen. Within the neck it descends in the posterior carotid sheath. At the base of the neck, the recurrent laryngeal branch of the right vagus nerve turns upward and medial posterior to the subclavian artery, ascending in the tracheoesophageal groove. The left recurrent laryngeal nerve arises to the left of the aortic arch, turns upward in the aortopulmonary window beneath the ligamentum arteriosum, ascending in the left tracheoesophageal groove. The recurrent laryngeal nerves innervate all the laryngeal muscles, with the exception of the cricothyroid.


Cranial Neuropathy

Cranial Neuropathy. Isolated vagal palsy can be central or peripheral, due to complete vagal nerve dysfunction or isolated impairment of the recurrent laryngeal nerve, respectively. Lesions proximal to the pharyngeal branches cause ipsilateral palatal weakness. Because lesions anywhere along the course of the vagus nerve may potentially cause vocal cord paralysis,


Cranial Neuropathy

Cranial Neuropathy. the imaging protocol must visualize the full extent of the nerve from the skull base to the mid chest in this situation [2,152]. In the case of a central palsy, careful neurologic examination and patient history may help to locate the lesion to the central nervous system. Intramedullary lesions that can affect the vagus nucleus include demyelination, infarction, neoplasms, motor neuron disorders, and syringobulbia. Intracranial processes such as meningiomas, schwannomas, metastases, granulomatous disease, and infection may affect the nerve as it exits the medulla. Paragangliomas, schwannomas, meningiomas, and metastases involving the skull base may affect the vagus nerve and the neighboring glossopharyngeal nerve (CN IX) or accessory nerve (CN XI) by infiltration of fibers or by compression [2,152,153]. Direct and indirect signs of vocal cord paralysis can be seen on CT [152]. Optimal evidence-based imaging algorithms in the setting of unilateral vocal cord paralysis without an apparent cause are not established.


Cranial Neuropathy

Cranial Neuropathy. One of the most troubling symptoms of vagus dysfunction is vocal cord paralysis. Injury of the recurrent laryngeal branch in the neck or upper thorax can be idiopathic, due to iatrogenic injury from surgery or intubation, trauma, infection, inflammation, vascular lesions, and neoplasms arising in the neck and thorax. Moreover, thoracic causes of vocal cord paralysis, such as lung cancer, tuberculosis, and thoracic aortic aneurysm, are common [154-157].


Cranial Neuropathy

Cranial Neuropathy. CT Chest Evaluation of the posterior fossa, neck, and upper chest is necessary for complete evaluation of the CN X, including the recurrent laryngeal nerve. Below the skull base, the vagus nerve is not directly imaged, although its course from the skull base to the carina can be imaged with contrast-enhanced neck CT extended through the aortopulmonary window. CT chest alone does cover the entire course of the vagus nerve, but it can be combined simultaneously and sequentially with CT neck to image the intrathoracic course of the vagus nerve. Preferably contrast should be administered. There is no relevant literature to support the use of combined pre- and postcontrast imaging.


Cranial Neuropathy

Cranial Neuropathy. Although chest radiographs may detect large thoracic causes of vocal cord paralysis, chest CT is more sensitive, particularly for detecting aortopulmonary window and paratracheal lesions [158].


Cranial Neuropathy

Cranial Neuropathy. CT Head There is no relevant literature to support the use of routine CT head alone in the evaluation of unilateral isolated vagal nerve palsy.


Cranial Neuropathy

Cranial Neuropathy. CT Maxillofacial There is no relevant literature to support the use of maxillofacial CT in the evaluation of isolated CN X palsy. Contrast-enhanced neck CT extended through the aortopulmonary window is useful for initial evaluation of isolated CN X palsy and allows imaging of the osseous integrity of the skull base and assessment of the full extent of the recurrent laryngeal nerve.


Cranial Neuropathy

Cranial Neuropathy. CT Temporal Bone There is no relevant literature to support the use of temporal bone CT in the evaluation of isolated CN X palsy.


Cranial Neuropathy

Cranial Neuropathy. CT Neck Evaluation of the posterior fossa, neck, and upper chest is necessary for complete evaluation of the CN X, including the recurrent laryngeal nerve, and can be achieved well with contrast-enhanced neck CT extended through the AP window. Below the skull base, the vagus nerve is not directly visualized, although its course from the skull base to the carina can be imaged with neck CT. With its rapid scanning time, high-spatial resolution, and multiplanar capability, contrast-enhanced neck CT conveniently allows imaging of the jugular foramen, the full extracranial course of the vagus nerve, direct imaging of the larynx, and assessment of the full extent of the recurrent laryngeal nerve when extended through the aortopulmonary window. Imaging protocols should include thin-cut high- resolution bone windows through the posterior skull base. Contrast should be administered. Noncontrast neck CT offers limited evaluation of the neck and may be an alternate option for this clinical scenario. There is no relevant literature to support the use of combined pre- and postcontrast imaging. Direct and indirect signs of vocal cord paralysis can be seen on CT [152]. CT may differentiate traumatic arytenoid dislocation from neurogenic paralysis [153].


Cranial Neuropathy

Cranial Neuropathy. Optimal evidence-based imaging algorithms in the setting of unilateral vocal cord paralysis without an apparent cause are not established. Several studies support the use of CT for detecting a cause for unilateral vocal cord paralysis with diagnostic yields ranging from 23.5% to 47.5% [155,157]. One study found CT had a higher diagnostic yield of 40% among patients >65 years of age [131]. In patients with a diagnosis of idiopathic vocal cord


Cranial Neuropathy

Cranial Neuropathy. Cranial Neuropathy paralysis, repeat CT may be helpful to detect occult causes of paralysis [156]. Other studies report low diagnostic yields ranging from 0% to 6% [159-161].


Cranial Neuropathy

Cranial Neuropathy. Noninvasive virtual laryngoscopy using ultrahigh-resolution CT and cine MRI allowing the patient to perform phonation and breathing maneuvers during imaging are emerging technologies [162,163].


Cranial Neuropathy

Cranial Neuropathy. CTA Head and Neck There is no relevant literature to support the use of CTA in the evaluation of unilateral isolated vagal nerve palsy.


Cranial Neuropathy

Cranial Neuropathy. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is not routinely used in the initial evaluation of vocal cord paralysis or vagus nerve palsy. FDG- PET/CT may be useful after initial cross-sectional imaging in patients with a known primary malignancy for both staging and therapy assessment [164]. It may yield false-positive findings if not interpreted carefully in the clinical context in patients with vocal cord palsy or following vocal fold augmentation [152,165-167].


Cranial Neuropathy

Cranial Neuropathy. MRA Head and Neck There is no relevant literature to support the use of MRA in the evaluation of vasculature in unilateral isolated vagal nerve palsy.


Cranial Neuropathy

Cranial Neuropathy. Thin-cut heavily T2-weighted contrast-enhanced modified balanced SSFP sequences and contrast-enhanced MRA focused on the posterior skull provide detailed imaging of the lower nerves within the jugular foramen, including CN X, which is well visualized in 94% to 100% of imaged patients [24].


Cranial Neuropathy

Cranial Neuropathy. Below the skull base, the vagus nerve is not directly imaged by CT and MRI, though its course from the skull base to the carina can be imaged by either modality. Contrast-enhanced CT is typically accessible and conveniently allows complete and rapid imaging of the full extracranial course of the vagus nerve and direct imaging of the larynx and can be extended into the upper thorax to cover the entire course of the left recurrent laryngeal nerve.


Cranial Neuropathy


Cranial Neuropathy

Cranial Neuropathy. Below the skull base, the vagus nerve is not directly visible by CT and MRI, although its course from the skull base to the carina can be imaged by either modality. Contrast-enhanced CT is typically accessible and conveniently allows complete and rapid imaging of the full extracranial course of the vagus nerve and direct imaging of the larynx and can be extended into the upper thorax to cover the entire course of the left recurrent laryngeal nerve.


Cranial Neuropathy

Cranial Neuropathy

Cranial Neuropathy. Cranial Neuropathy


Cranial Neuropathy

Cranial Neuropathy. Radiography Chest Chest radiography is not sufficient for the complete evaluation of thoracic causes that can contribute to vocal cord paralysis. Chest CT is more sensitive, particularly for detecting aortopulmonary window and paratracheal lesions [168]. Radiography can only reveal large lesions in the lung apex or mediastinum that may cause CN X deficits but fails to detect small clinically relevant lesions or pathology in the aortopulmonary window and the paratracheal region that can contribute to vocal cord paralysis [158,168].


Cranial Neuropathy

Cranial Neuropathy. US Neck US is not able to fully image the entire course of CN X in the posterior fossa or the recurrent laryngeal nerve extending into the upper thorax, both of which can be simultaneously imaged with contrast-enhanced neck CT extended through the AP window [157,158]. US is a complementary modality that can be used to guide biopsies of lesions in the neck that contribute to a CN X palsy [158]. Transcutaneous laryngeal US is an innovative, noninvasive technique that may be suitable to directly assess vocal cord movement in select patients at high risk for iatrogenic vocal cord palsy following surgery or intubation [169-174].


Cranial Neuropathy

Cranial Neuropathy. Variant 7: Unilateral isolated weakness or paralysis of the sternocleidomastoid and trapezius muscles (accessory nerve, CN XI). Initial imaging. The accessory nerve (CN XI) consists of a small cranial root originating from the nucleus ambiguous within the medulla oblongata and a large spinal root originating from the ventral horn of the spinal cord, between the C1 and C5 levels. The two components join and enter the pars vascularis of the jugular foramen [2]. The accessory nerve supplies portions of the sternocleidomastoid muscle and the upper portion of the trapezius muscle. Accessory nerve palsy is clinically manifested by weakness and atrophy of these muscles, causing decreased shoulder abduction, shoulder pain, cosmetic disfiguration, and disability. Isolated accessory nerve palsy is typically iatrogenic (due to injury from surgery or internal jugular vein cannulation) or may be due to trauma [175]. Accessory nerve palsy can also be accompanied by variable palsies of the glossopharyngeal (CN IX), vagus (CN X), and hypoglossal nerves (CN XII) in combined syndromes, particularly from lesions arising in the brainstem or jugular foramen, as discussed in Variant 9.


Cranial Neuropathy

Cranial Neuropathy. CT Head There is no relevant literature to support the use of routine CT head alone in the evaluation of unilateral isolated CN XI palsy.


Cranial Neuropathy

Cranial Neuropathy. CT Maxillofacial There is no relevant literature to support the use of maxillofacial CT in the evaluation of unilateral isolated CN XI palsy.


Cranial Neuropathy

Cranial Neuropathy. CT Temporal Bone There is no relevant literature to support the use of temporal bone CT in the evaluation of unilateral isolated CN XI palsy.


Cranial Neuropathy

Cranial Neuropathy. CT Neck Accessory nerve palsy is clinically manifested by weakness and atrophy of the sternocleidomastoid muscle and trapezius muscle and, as an isolated palsy, is typically due to iatrogenic injury. Contrast-enhanced CT neck may be useful to characterize lesions in the carotid space or posterior cervical space along the extracranial course of CN XI, as well as demonstrating atrophy of the trapezius or sternocleidomastoid muscles. MRI offers superior soft tissue contrast to demonstrate denervation changes or directly image features of neuritis and offers the benefit of being able to directly image the intracranial and high cervical portions of the nerve [2]. Imaging protocols should include thin-cut high-resolution bone windows through the posterior skull base. Noncontrast neck CT offers limited evaluation of the neck and may be an alternate option for this clinical scenario. There is no relevant literature to support the use of combined pre- and postcontrast imaging.


Cranial Neuropathy

Cranial Neuropathy. CTA Head and Neck There is no relevant literature to support the use of CTA in the evaluation of unilateral isolated CN XI palsy.


Cranial Neuropathy

Cranial Neuropathy. MRA Head and Neck There is no relevant literature to support the use of MRA in the evaluation of vasculature in unilateral isolated CN XI palsy.


Cranial Neuropathy

Cranial Neuropathy. Contrast-enhanced modified balanced SSFP sequences and MRA focused on the posterior skull provide detailed imaging of the lower CNs within the jugular foramen and as they exit the skull base [24]. Thin-cut high-resolution heavily T2-weighted imaging combined with MRA provides variable direct visualization of CN XI with the cranial segment identified in 88% of the sides and the spinal segment identified in 93% of the sides in one study [149]. Another study reported lower rates with the spinal root of CN XI visualized in 51% of subjects using contrast- enhanced modified balanced SSFP sequences [24].


Cranial Neuropathy

Cranial Neuropathy. MRI offers excellent soft tissue contrast to directly image features of neuritis or nerve sheath tumors as well as fully characterize the carotid space and posterior cervical space [2]. In patients with accessory nerve palsy, atrophy, and denervation, signal changes can be seen in the trapezius muscle on MRI [2,176].


Cranial Neuropathy

Cranial Neuropathy. US Neck The accessory nerve can be directly imaged by US within the posterior cervical triangle and can provide a supportive role in the diagnosis of spinal accessory nerve injuries, although sensitivity may be user dependent [177-180].


Cranial Neuropathy

Cranial Neuropathy. Variant 8: Unilateral isolated weakness or paralysis of the tongue (hypoglossal nerve, CN XII). Initial imaging. The hypoglossal nerve (CN XII) nucleus arises in the dorsal medulla. The hypoglossal rootlets traverse the premedullary cistern dorsal to the vertebral artery and then form the nerve, which enters the hypoglossal canal where it is surrounded by a venous plexus. The extracranial hypoglossal nerve travels caudally within the carotid space after which it courses anteriorly inferior to the hyoid where it distributes terminal branches providing somatic motor innervation to the intrinsic and extrinsic muscles of the tongue (except the palatoglossus muscle) and the infrahyoid strap muscles via the ansa cervicalis [2,13,181]. Hypoglossal nerve palsy typically presents clinically when a nuclear or infranuclear lesion is present and is characterized by dysarthria and deviation of the tongue to the side of the lesion upon tongue protrusion. Hypoglossal nerve palsy can occur because of injury of the nerve at any point along its course. There are a multitude of causes for hypoglossal nerve palsy including brainstem infarct, demyelinating disease, tumors, vascular lesions, trauma, inflammatory, and infectious processes. Nuclear lesions are usually accompanied by additional neurologic deficits indicative of brainstem involvement. Most hypoglossal nerve palsies are due to neoplasm involving the hypoglossal canal [2,182,183]. Within the extracranial segment, the most common causes of isolated hypoglossal nerve palsy are malignant tumors both along the course of CN XII


Cranial Neuropathy

Cranial Neuropathy. in the carotid space and in the sublingual space [184]. Dissection of the internal carotid artery can result in isolated acute CN XII palsy or multiple variable patterns of CN palsies including involvement of CN IX through CN XII [185-187]. Associate denervation signal alterations can be seen on MRI that vary with the duration of the palsy [2,186-188].


Cranial Neuropathy

Cranial Neuropathy. Hypoglossal nerve palsy can also be accompanied by variable palsies of the glossopharyngeal (CN IX), vagus (CN X), and accessory nerves (CN XI) in combined syndromes, particularly from lesions arising in the brainstem or jugular foramen, as discussed in Variant 9 [183].


Cranial Neuropathy

Cranial Neuropathy. CT Head There is no relevant literature to support the use of routine CT head alone in the initial evaluation of unilateral isolated CN XII palsy.


Cranial Neuropathy

Cranial Neuropathy. CT Maxillofacial There is no relevant literature to support the use of maxillofacial CT in the initial evaluation of unilateral isolated CN XII palsy.


Cranial Neuropathy

Cranial Neuropathy. CT Temporal Bone There is no relevant literature to support the use of temporal bone CT in the initial evaluation of unilateral isolated CN XII palsy.


Cranial Neuropathy

Cranial Neuropathy. CT Neck Evaluation of the entire course of the hypoglossal nerve is required with a hypoglossal nerve palsy. MRI is useful for evaluating hypoglossal nerve palsy, directly imaging the brainstem, the intracranial and skull base segments of the hypoglossal nerve and assessing for possible lesions along the extracranial segments of the nerve while providing improved soft tissue contrast [5,13,181,183,189]. The extracranial segment of the hypoglossal nerve within the suprahyoid neck is difficult to see with MRI and CT and inferred by knowledge of the nerve course and surrounding anatomy.


Cranial Neuropathy

Cranial Neuropathy. Neck CT provides complementary information to MRI, characterizing the osseous integrity of the hypoglossal canal and surrounding skull base [183]. Imaging protocols should include thin-cut high-resolution bone windows through the posterior skull base. Contrast should be administered, because tumors are the most common cause of isolated hypoglossal nerve palsy in this segment. Noncontrast CT may also be an alternate option for this clinical scenario. There is no relevant literature to support the use of combined pre- and postcontrast imaging.


Cranial Neuropathy

Cranial Neuropathy. For detecting hypoglossal canal invasion by glomus tumors, CT had a sensitivity and specificity of 87.5% and 66.7%, respectively, compared with MRI which had a sensitivity of 100% and a specificity of 59% [183].


Cranial Neuropathy

Cranial Neuropathy. CTA Head and Neck When dissection of the internal carotid artery is clinically suspected as a cause of acute isolated CN XII palsy, CTA may be useful to evaluate for dissection, particularly in the emergent setting. In a study comparing CTA with conventional angiography, CTA had a sensitivity of 66% when evaluating for blunt carotid vascular injury, with most false-negatives representing low grade injuries [190]. In a comparative study, multidetector CT/CTA demonstrated more features of cervical artery (internal carotid and vertebral arteries) dissection compared with MRI/MRA. There was no significant reader preference for MRI/MRA compared with CT/CTA when evaluating for internal carotid artery dissection. MRI/MRA provided additional characterization of ischemic complications [191]. In a retrospective review of the literature comparing test performance of MRI/MRA with CTA in the assessment of cervicocephalic arterial dissection with a reference standard of catheter angiography, the authors report MRI sensitivities and specificities of 50% to 79% and 67% to 99%, respectively, and CTA sensitivities and specificities of 51% to 98% and 67% to 100%, respectively (based on prospective studies) [192]. The authors concluded that the test characteristics of MRI/MRA and CTA for diagnosis of cervicocephalic arterial dissection were similar and study selection should be based on individual factors including urgency of imaging. A limitation of the literature assessing MRA and CTA for dissection is that most studies evaluate test performance in the clinical setting of traumatic dissection rather than spontaneous dissection. CTA is often used as a primary screening tool when carotid dissection is suspected in the emergent setting [190].


Cranial Neuropathy

Cranial Neuropathy. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT skull base to mid-thigh in the initial evaluation of unilateral isolated CN XII palsy.


Cranial Neuropathy

Cranial Neuropathy

Cranial Neuropathy. Cranial Neuropathy


Cranial Neuropathy

Cranial Neuropathy. MRA Head and Neck When dissection of the internal carotid artery is suspected as a cause of acute isolated CN XII palsy, MRA may be useful to evaluate for dissection. In a retrospective review of the literature comparing test performance of MRI/MRA with CTA in the assessment of cervicocephalic arterial dissection with a reference standard of catheter angiography, the authors report MRI sensitivities and specificities of 50% to 79% and 67% to 99%, respectively, and CTA sensitivities and specificities of 51% to 98% and 67% to 100%, respectively (based on prospective studies) [192]. The authors concluded that the test characteristics of MRI/MRA and CTA for diagnosis of cervicocephalic arterial dissection were similar and study selection should be based on individual factors including urgency of imaging. In another comparative study, multidetector CT/CTA demonstrated more features of cervical artery (internal carotid and vertebral arteries) dissection compared with MRI/MRA. There was no significant reader preference for MRI/MRA compared with CT/CTA when evaluating for internal carotid artery dissection. MRI/MRA provided additional characterization of ischemic complications [191]. A limitation of the literature assessing MRA and CTA for dissection is that most studies evaluate test performance in the clinical setting of traumatic dissection rather than spontaneous dissection. CTA is often used as a primary screening tool when carotid dissection is suspected in the emergent setting [190].


Cranial Neuropathy

Cranial Neuropathy. MRI had greater sensitivity (100%) but lower specificity (59%) for detecting hypoglossal canal invasion by glomus jugulare tumors when compared with CT (sensitivity of 87.5% and specificity of 66.7%) [183]. Denervation injury changes that occur within the tongue in the setting of hypoglossal nerve palsy vary with acuity and can be detected on MRI and CT, with MRI providing better soft tissue contrast [186-188]. Thin-cut heavily T2-weighted contrast- enhanced modified balanced SSFP sequences and contrast-enhanced MRA focused on the posterior skull provide detailed imaging of the lower nerves with 90% to 100% of imaged CN XII visible [24].


Cranial Neuropathy


Cranial Neuropathy

Cranial Neuropathy. US Neck There is no relevant literature to support the use of US neck in the initial evaluation of unilateral isolated CN XII palsy.


Cranial Neuropathy

Cranial Neuropathy. Variant 9: Multiple different lower cranial nerve palsies or combined lower cranial nerve syndromes (CN IX-XII). Initial imaging. The medulla oblongata joins the pons to the spinal cord and is composed of a ventral portion and a dorsal tegmentum. The ventral portion contains the pyramids and olives, and the dorsal tegmentum contains CN IX through CN XII nuclei along with the white matter sensory tracts. Vascular supply to the medulla is from the anterior spinal artery, branches of the vertebral arteries, and the posterior inferior cerebellar arteries [1,131]. Outside the brainstem, CN IX through CN XI traverse the jugular foramen, and CN XII traverses the hypoglossal canal in the posterior skull base before extending caudally into the neck. Lesions affecting the medulla oblongata, the subarachnoid space, or the posterior skull base, including the jugular foramen and hypoglossal canal, can lead to multiple CN palsies affecting CN IX through CN XII in variable patterns. Patients with medullary lesions will typically have additional neurologic findings such as long tract signs, nystagmus, vertigo, ataxia, nausea, and vomiting. A thorough neurologic examination evaluating for these associated signs can localize a process to the brainstem [18,135]. Imaging protocols can then be tailored to evaluate the suspected region of anatomy affected.


Cranial Neuropathy

Cranial Neuropathy. Most brainstem syndromes are due to brainstem infarctions and hemorrhages [132]. Wallenberg syndrome or lateral medullary syndrome is typically due to occlusion of the posterior inferior cerebellar artery. Additional disorders that may affect the brainstem include demyelinating disease, primary brainstem tumors, metastasis, encephalitis, Arnold-Chiari malformations, and syringobulbia [18,132].


Cranial Neuropathy

Cranial Neuropathy. Multiple different jugular foramen syndromes are described based on variable patterns of CN palsies affecting CN IX through CN XII and include Vernet syndrome (IX, X, XI), Collet-Sicard syndrome (IX, X, XI, XII), and Villaret syndrome (IX, X, XI, XII and cervical sympathetic trunk). Lesions affecting the jugular foramen leading to jugular foramen syndromes include jugular foramen tumors (paragangliomas, schwannomas, and meningiomas), infection, leptomeningeal processes, metastasis, trauma, cholesteatoma, and vascular lesions [147,148,193].


Cranial Neuropathy

Cranial Neuropathy. Dissection of the internal carotid artery can result in isolated acute CN XII palsy or less commonly multiple variable patterns of CN palsies including involvement of CN IX through CN XII [185-187].


Cranial Neuropathy

Cranial Neuropathy. Leptomeningeal processes can lead to variable patterns of cranial neuropathy [18,132].


Cranial Neuropathy

Cranial Neuropathy. CT Head There is no relevant literature to support the use of routine head CT in the initial evaluation of multiple lower CN palsies.


Cranial Neuropathy

Cranial Neuropathy. CT Maxillofacial There is no relevant literature to support the use of maxillofacial CT in the initial evaluation of multiple lower CN palsies.


Cranial Neuropathy

Cranial Neuropathy. CT Temporal Bone There is no relevant literature to support the use of temporal bone CT in the initial evaluation of multiple lower CN palsies.


Cranial Neuropathy

Cranial Neuropathy. CT Neck Multiple different jugular foramen syndromes can result in variable patterns of CN palsies affecting CN IX through CN XII. Lesions involving the jugular foramen can extend caudally in the neck to involve the carotid space. CT is complementary to MRI in assessing jugular foramen lesions or for evaluating for carotid space lesions. Thin-cut high-resolution bone algorithm windows are useful to delineate skull base fractures, hyperostosis, skull base erosion, intratumoral calcification, and the bony margins of the jugular foramen and nearby skull base foramina [144-148]. Contrast should be administered. There is no relevant literature to support the use of combined pre- and postcontrast imaging.


Cranial Neuropathy

Cranial Neuropathy. CTA Head and Neck Most brainstem syndromes are due to brainstem infarctions and hemorrhages, which are best imaged with MRI [132]. CTA may be complementary to CT or MRI to characterize the vasculature in these clinical scenarios.


Cranial Neuropathy

Cranial Neuropathy. When dissection of the internal carotid artery is clinically suspected as a cause of multiple lower CN palsies, CTA may be useful to evaluate for dissection, particularly in the emergent setting. In a study comparing CTA with conventional angiography, CTA had a sensitivity of 66% when evaluating for blunt carotid vascular injury, with most false-negatives representing low grade injuries [190]. In a comparative study, multidetector CT/CTA demonstrated more features of cervical artery (internal carotid and vertebral arteries) dissection compared with MRI/MRA. There was no significant reader preference for MRI/MRA compared with CT/CTA when evaluating for internal carotid artery dissection. MRI/MRA provided additional characterization of ischemic complications [191]. In a retrospective review of the literature comparing test performance of MRI/MRA with CTA in the assessment of cervicocephalic arterial dissection with a reference standard of catheter angiography, the authors report MRI sensitivities and specificities of 50% to 79% and 67% to 99%, respectively, and CTA sensitivities and specificities of 51% to 98% and 67% to 100%, respectively (based on prospective studies) [192]. The authors concluded that the test characteristics of MRI/MRA and CTA for diagnosis of cervicocephalic arterial dissection were similar and study selection should be based on individual factors including urgency of imaging. Limitations of the literature assessing MRA and CTA for dissection include most studies evaluate test performance in the clinical setting of traumatic dissection rather than spontaneous dissection. CTA is often used as a primary screening tool when carotid dissection is suspected in the emergent setting [190].


Cranial Neuropathy

Cranial Neuropathy. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT skull base to mid-thigh in the initial evaluation of multiple lower CN palsies.


Cranial Neuropathy

Cranial Neuropathy. MRA Head and Neck Most brainstem syndromes are due to brainstem infarctions and hemorrhages [132]. MRA may be complementary to MRI to characterize the vasculature in these clinical scenarios. When dissection of the internal carotid artery is clinically suspected as a cause of multiple lower CN palsies clinically, MRA may be useful to evaluate for dissection although it is less accessible emergently compared with CTA. In a comparative study, multidetector CT/CTA demonstrated more features of cervical artery (internal carotid and vertebral arteries) dissection compared with MRI/MRA. There was no significant reader preference for MRI/MRA compared with CT/CTA when evaluating for internal carotid artery dissection. MRI/MRA provided additional characterization of ischemic complications [187]. In a retrospective review of the literature comparing test performance of MRI/MRA with CTA in the assessment of cervicocephalic arterial dissection with a reference standard of catheter angiography, the authors report MRI sensitivities and specificities of 50% to 79% and 67% to 99%, respectively, and CTA sensitivities and specificities of 51% to 98% and 67% to 100%, respectively (based on prospective studies) [188]. The authors concluded that the test characteristics of MRI/MRA and CTA for diagnosis of cervicocephalic arterial dissection were similar and study selection should be based on individual factors including urgency of imaging. Limitations of the literature assessing MRA and CTA for dissection include most studies evaluate test performance in the clinical setting of traumatic dissection rather than spontaneous dissection. CTA is often used as a primary screening tool when carotid dissection is suspected in the emergent setting [186].


Cranial Neuropathy

Cranial Neuropathy. Thin-cut heavily T2-weighted contrast-enhanced modified balanced SSFP sequences and contrast-enhanced MRA focused on the posterior skull provide detailed imaging of the lower nerves within the jugular foramen, and their relationship to the hypoglossal nerve as they exit the skull base, with 90% to 100% of imaged CN IX, CN X, and CN XII visible [24]. There is variable direct visualization of CN XI with the cranial segment identified in 88% of the sides and the spinal segment identified in 93% of the sides in one study [149]. Another study reported lower rates with the spinal root of CN XI visualized in only 51% of subjects using heavily T2-weighted contrast-enhanced modified balanced SSFP sequences [24].


Cranial Neuropathy

Cranial Neuropathy

Cranial Neuropathy. Cranial Neuropathy


Cranial Neuropathy

Cranial Neuropathy. DWI can be used to assess for acute brainstem infarction, cholesteatoma, and for characterizing tumor cellularity. False-negative DWI can occur in the setting of very small ischemic brainstem infarcts [137,138]. Thinner slice axial DWI or thin-section coronal DWI may improve sensitivity for detecting small acute brainstem infarction, with nearly 25% of acute brainstem infarcts more easily seen on thin-cut coronal DWI compared with standard axial DWI in one study [138,194].


Cranial Neuropathy


Cranial Neuropathy

Cranial Neuropathy. DWI can be used to assess for acute brainstem infarction, cholesteatoma, and for characterizing tumor cellularity. False-negative DWI can occur in the setting of very small ischemic brainstem infarcts [137,138]. Thinner slice axial DWI or thin-section coronal DWI may improve sensitivity for detecting acute brainstem infarction, with nearly 25% of acute brainstem infarcts more easily seen on thin-cut coronal DWI compared with standard axial DWI in one study [138,194].


Cranial Neuropathy

Cranial Neuropathy. US Neck There is no relevant literature to support the use of US neck in the initial evaluation of multiple lower CN palsies.


Cranial Neuropathy

Cranial Neuropathy. Variant 10: Head and neck cancer. Suspected or known perineural spread of tumor. Initial imaging. The compact anatomy of the brainstem results in close proximity of multiple CN nuclei, and the complex anatomy of the head and neck results in close proximity and interconnection of multiple CNs, which can lead to multiple cranial neuropathies. Multiple middle and lower CN palsies are discussed in Variant 4 and 9, respectively. Perineural tumor spread can lead to isolated or multiple CN palsies and is the macroscopic spread of tumor along the course of a nerve distant from the site of the primary tumor as detected on imaging. It should be distinguished from perineural invasion, which is local invasion detected on histopathologic diagnosis at the primary tumor site [66,124]. Perineural tumor spread on imaging is associated with a worse prognosis [195]. The trigeminal (CN V) and facial (CN VII) nerves are most commonly affected by perineural tumor spread, although any nerve traveling in the vicinity of a malignancy may become involved. A multitude of tumors can result in perineural tumor spread, with squamous cell carcinoma (cutaneous and mucosal), adenoid cystic carcinoma, melanoma, lymphoma, basal cell carcinoma, and mucoepidermoid carcinoma most commonly occurring in the head and neck. Clues to perineural tumor spread include effacement of perineural and juxtaforaminal fat; asymmetric nerve enlargement or enhancement; osseous foraminal enlargement or erosion; and imaging features of denervation injury [65,66,104,123,124,196].


Cranial Neuropathy

Cranial Neuropathy. CT Head There is no relevant literature to support the use of routine head CT in the initial evaluation of perineural spread of tumor.


Cranial Neuropathy

Cranial Neuropathy. CT Maxillofacial There is no relevant literature to support the use of routine maxillofacial CT in the initial evaluation of perineural spread of tumor. Contrast-enhanced maxillofacial CT may be complementary to MRI and is useful for characterizing osseous changes of skull base and neural foramina; however, contrast-enhanced neck CT with thin- cut high-resolution bone algorithm windows through the skull base can provide similar information while


Cranial Neuropathy

Cranial Neuropathy. simultaneously staging the neck [64,66]. There is no relevant literature to support the use of combined pre- and postcontrast imaging.


Cranial Neuropathy

Cranial Neuropathy. CT Temporal Bone There is no relevant literature to support the use of routine temporal bone CT in the initial evaluation of perineural spread of tumor. Temporal bone CT with IV contrast may be complementary to MRI and is useful for characterizing osseous changes of the skull base and neural foramina and may be useful to characterize perineural fat planes; however, contrast-enhanced neck CT with thin-cut high-resolution bone algorithm windows through the skull base can provide similar information while simultaneously staging the neck [64,66]. There is no relevant literature to support the use of combined pre- and postcontrast imaging.


Cranial Neuropathy

Cranial Neuropathy. CT Neck MRI has better sensitivity for detection of perineural spread of tumor compared with CT and is the preferred study for initial assessment of perineural spread of tumor [65]. The trigeminal (CN V) and facial (CN VII) nerves are most commonly affected by perineural tumor spread and have branches extending into the face and neck. Neck CT may be complementary to MRI and is useful for characterizing osseous changes of the skull base and neural foramina and may be useful to characterize perineural fat planes while simultaneously staging the neck [64,66]. Contrast should be administered. There is no relevant literature to support the use of combined pre- and postcontrast imaging.


Cranial Neuropathy

Cranial Neuropathy. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of perineural spread of tumor.


Cranial Neuropathy

Cranial Neuropathy. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is not routinely used in the initial evaluation of the perineural spread of tumor, although perineural tumor spread may be detected on metabolic imaging. FDG-PET/CT may be useful for staging and response assessment in patients with a known primary malignancy [195,197]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164].


Cranial Neuropathy

Cranial Neuropathy. MRA Head and Neck There is no relevant literature to support the use of MRA in the initial evaluation of perineural spread of tumor.


Cranial Neuropathy

Cranial Neuropathy. Sensitivities for MRI detection of perineural spread of tumor range from 73% to 100% and vary according to the nerve evaluated and timing of imaging relative to tissue sampling [65,104,123-125]. MRI may underestimate microscopic perineural spread of a tumor [123-125]. Advanced imaging techniques such as tractography may be useful to detect perineural tumor spread but require further investigation [130]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164].


Cranial Neuropathy

Cranial Neuropathy. Sensitivities for MRI detection of perineural spread of a tumor range from 73% to 100% and vary according to the nerve evaluated and timing of imaging relative to tissue sampling [65,104,123-125]. MRI may underestimate microscopic perineural spread of a tumor [123-125]. Advanced imaging techniques such as tractography may be useful to detect perineural tumor spread but require further investigation [130]. Contrast-enhanced PET/MR may detect perineural spread of a tumor and may be useful as an alternate to PET/CT in the evaluation of patients with head and neck cancers [164].


Cranial Neuropathy

Cranial Neuropathy. 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.


Cranial Neuropathy

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


Cranial Neuropathy

Cranial Neuropathy. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate


Cranial Neuropathy

Cranial Neuropathy

Cranial Neuropathy. Cranial Neuropathy


Palpable Breast Masses

Palpable Breast Masses. Imaging evaluation is necessary to adequately characterize a palpable breast mass. After thorough clinical breast examination, usually by the referring clinician or by a specialist breast clinician, the radiologist must be able to establish concordance between the clinically detected mass and the imaging features at that location [2]. The negative predictive value of mammography with ultrasound (US) in the context of a palpable mass ranges from 97.4% to 100% [7-10]. Nevertheless, negative imaging evaluation should not deter biopsy when a strongly suspicious finding is present on physical examination.


Palpable Breast Masses

Palpable Breast Masses. OR aUniversity of Michigan, Ann Arbor, Michigan. bResearch Author, Duke University Medical Center, Durham, North Carolina. cPanel Chair, Alpert Medical School of Brown University, Providence, Rhode Island. dPanel Vice-Chair, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. eWashington University School of Medicine, Saint Louis, Missouri. fPenn State Health Hershey Medical Center, Hershey, Pennsylvania. gUniversity of Utah, Salt Lake City, Utah. hKaiser Permanente, Atlanta, Georgia. iMemorial Sloan Kettering Cancer Center, New York, New York. jUniversity of Washington, Seattle, Washington; American College of Obstetricians and Gynecologists. kSt. Bernards Healthcare, Jonesboro, Arkansas. lDuke Signature Care, Durham, North Carolina; American College of Physicians. mUMass Memorial Medical Center/UMass Chan Medical School, Worcester, Massachusetts. nProMedica Breast Care, Toledo, Ohio. oFox Chase Cancer Center, Philadelphia, Pennsylvania; American College of Surgeons. pHoag Family Cancer Institute, Newport Beach, California and University of Southern California, Los Angeles, California; Commission on Nuclear Medicine and Molecular Imaging. qSpecialty Chair, NYU Clinical Cancer Center, New York, New York.


Palpable Breast Masses

Palpable Breast Masses. 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.


Palpable Breast Masses

Palpable Breast Masses. Reprint requests to: publications@acr.org


Palpable Breast Masses

Palpable Breast Masses

Palpable Breast Masses. Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. Discussion of Procedures by Variant Variant 1: Adult female, 40 years of age or older. Palpable breast mass. Initial imaging. Digital Breast Tomosynthesis Diagnostic Diagnostic digital breast tomosynthesis (DBT) should be used for initial imaging evaluation. A small radio-opaque marker is placed on the skin over the palpable finding to identify its location. Several prior studies have shown the diagnostic accuracy of DBT is equivalent to or better than supplemental diagnostic mammographic views in the workup of women with clinical signs and symptoms and in women recalled from screening [11-14]. The added features of planar imaging and thin-section reconstructions allow further assessment of potential false-positive findings. In a recent study, DBT provided similarly accurate diagnostic results as compared with digital mammography (DM) in women with palpable breast masses for detecting breast cancer using either combination DM with DBT (DM/DBT) or DM alone [15]. Several small studies, which specifically included women presenting with clinical symptoms including palpable lumps, demonstrated increased accuracy on combination DM/DBT compared with DM alone [13,16,17]. Additionally, it was demonstrated that DBT may improve lesion detection and characterization with higher conspicuity scores as compared with conventional DM imaging, particularly for cancers presenting as spiculated masses and distortions [17].


Palpable Breast Masses

Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. FDG-PET Breast Dedicated There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET breast dedicated in the initial evaluation of a woman presenting with a palpable mass [2].


Palpable Breast Masses

Palpable Breast Masses. In several series evaluating palpable breast abnormalities [18-20], the sensitivity of mammography alone was 86% to 91%. Mammography likely does not need to be repeated if it was performed within the past 6 months [21]. This


Palpable Breast Masses

Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. modality may be particularly useful in women with almost entirely fatty breasts, in which mammography alone was shown to have a high sensitivity (96%) and specificity (93%) in the evaluation of palpable breast masses [22].


Palpable Breast Masses

Palpable Breast Masses. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. MRI Breast There is no relevant literature to support the use of MRI breast with or without intravenous (IV) contrast in the initial evaluation of a woman presenting with a palpable mass [2,23-25].


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi molecular breast imaging (MBI) in the initial evaluation of a woman presenting with a palpable mass.


Palpable Breast Masses

Palpable Breast Masses. US Breast US may be considered as an initial means of imaging if the patient has had a recent negative mammogram within the past 6 months. In a study of women presenting with a palpable breast mass with a negative mammogram within the previous 6 to 12 months, US detected a finding in 50.3% of 311 cases, whereas repeat mammography detected a change in 12.9% of cases [21]. US is more frequently used following DBT/mammography in this age group [2,26] (see Variants 2, 3, and 5). The negative predictive value of mammography with US in the context of a palpable mass ranges from 97.4% to 100% [7-9].


Palpable Breast Masses

Palpable Breast Masses. Variant 2: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast It is preferable for imaging to occur before biopsy because changes related to the biopsy may confuse, alter, obscure, and/or limit image interpretation. If a mammographically suspicious lesion is identified that correlates with the palpable mass, US is recommended as the next step in evaluation before image-guided core biopsy is pursued. However, the lack of sonographic correlate should not deter biopsy of a suspicious mammographic or DBT abnormality in this setting. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. When a mammographically or DBT-detected suspicious lesion is identified that correlates with a palpable mass, biopsy is warranted. If a lesion is only identified on mammography or DBT, mammographically or DBT- guided core biopsy may be pursued [28,29]. If the lesion can be seen with US, US-guided biopsy may be pursued [30]. At image-guided biopsy, a marker clip is placed, and a postbiopsy diagnostic mammogram confirms that the US and mammographic findings correlate. Similarly, a postbiopsy DBT confirms that the US and DBT findings correlate. US-guided core biopsy is also usually more easily tolerated because of a lack of breast compression and may allow biopsy of lesions difficult to access stereotactically (eg, far posterior lesions or axillary lesions) [30].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast It is preferable for imaging to occur before biopsy because changes related to the biopsy may confuse, alter, obscure, and/or limit image interpretation. If a mammographically suspicious lesion is identified that correlates with the palpable mass, US is recommended as the next step in evaluation before image-guided FNA is pursued. However, the lack of sonographic correlate should not deter biopsy of a suspicious mammographic or DBT abnormality in this setting. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. An additional consideration of FNAB over a core biopsy may be the faster turnover time for a pathology diagnosis without a difference in time to treatment [31]. At US-guided FNA, a marker clip is placed and a postprocedure mammogram confirms that the US and mammographic findings correlate. Similarly, a postprocedure DBT confirms that the US and DBT findings correlate.


Palpable Breast Masses

Palpable Breast Masses. MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding [2,23-25]. If malignancy is subsequently established by biopsy, MRI may be useful in delineating extent of disease in certain circumstances [32].


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass in the context of a suspicious mammographic finding.


Palpable Breast Masses

Palpable Breast Masses. US Breast US may be helpful in characterizing a suspicious mammographic finding [33]. In a study of women presenting with palpable breast thickening, the sensitivity of diagnostic mammography for invasive cancer detection was 60%, whereas the sensitivity of US alone was 100% [34].


Palpable Breast Masses

Palpable Breast Masses. Breast US should be performed using a high-resolution, real-time linear array scanner with an adjustable focal zone and a transducer with a minimum center frequency of 12 MHz [35]. Some mammographers also perform screening US of the remainder of the ipsilateral breast and the contralateral breast in the setting of a suspicious finding [33]. If there is no sonographic correlate for a suspicious mammographic finding, tissue sampling (stereotactic biopsy) should be guided by the suspicious mammographic finding. If there is no sonographic correlate for a suspicious DBT finding, tissue sampling (tomosynthesis-guided biopsy) should be guided by the suspicious DBT finding.


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast If a palpable mass has probably benign features as identified on mammogram and/or US, imaging follow-up may be appropriate. However, if a mass is new on imaging or increasing by >20% in volume or >20% in each diameter in a 6-month period, the mass is considered suspicious, and image-guided biopsy is recommended [36]. Core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, there are certain cases in which biopsy may be performed even on probably benign lesions. For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling [30,37]. If an image-guided biopsy is pursued, a marker clip is placed and a postbiopsy mammogram/DBT confirms that the clip placement and mammographic/DBT findings correlate.


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast If a palpable mass has probably benign features as identified on mammogram and/or US, imaging follow-up may be appropriate. However, if a mass is new on imaging or increasing by >20% in volume or >20% in each diameter in a 6-month period, image-guided biopsy is recommended [36]. In addition, there are certain cases in which biopsy may be performed even on probably benign lesions. For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling [30,37]. Large series have demonstrated core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. FNAB; however, may allow a faster turnover time as compared with core biopsy for a pathology diagnosis without a difference in time to treatment [31]. At image-guided FNA, a marker clip is placed and a postprocedure mammogram/DBT confirms that the marker clip and mammographic/DBT findings correlate.


Palpable Breast Masses

Palpable Breast Masses

Palpable Breast Masses. Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. Variant 4: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are benign (BI-RADS 2) at the site of palpable mass. Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass in the context of a benign mammographic finding [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy breast as the next step in evaluating a palpable mass in the context of a benign mammographic finding.


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the next step in evaluating a palpable mass in the context of a benign mammographic finding. However, image-guided aspiration can be considered for symptomatic relief of a palpable simple cyst.


Palpable Breast Masses

Palpable Breast Masses. MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast of the breast as the next step in evaluating a palpable mass in the context of a benign mammographic finding.


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass in the context of a benign mammographic finding.


Palpable Breast Masses

Palpable Breast Masses. US Breast When the mammogram shows a definite benign mass (eg, lymph node, hamartoma, lipoma, calcified fibroadenoma, or oil cyst), US is not necessary as long as the benign mass identified on mammography is a definitive correlate of the clinical finding.


Palpable Breast Masses

Palpable Breast Masses. If correlation between the mammographic finding and the palpable lesion is uncertain, US is useful. US is preferably targeted specifically to the palpable finding [33]. When both mammography and US are negative or benign in the evaluation of a palpable breast mass, the negative predictive value exceeds 97% [8,9,38]. Together, these imaging modalities can be reassuring when the physical examination is not highly suspicious and clinical follow-up is planned. However, a suspicious physical examination should prompt biopsy regardless of benign imaging findings [38].


Palpable Breast Masses

Palpable Breast Masses. Variant 5: Adult female, 40 years of age or older. Palpable breast mass. Mammography findings are negative (BI-RADS 1). Next imaging study. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass. US should be performed, and if a suspicious correlate is identified, then US-guided core biopsy is recommended. However, a suspicious physical examination should prompt biopsy guided by palpation, regardless of negative imaging findings [38].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass. US should be performed, and if a suspicious correlate is identified, then US-guided core biopsy is recommended. However, a suspicious physical examination should prompt biopsy guided by palpation, regardless of negative imaging findings [38].


Palpable Breast Masses

Palpable Breast Masses. MRI Breast MRI of the breast with or without IV contrast for women with a palpable mass and negative mammography is not recommended as the next imaging study [2,23-25]. US should be performed next [8,9,19].


Palpable Breast Masses

Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in the evaluation of a woman presenting with a negative mammogram and a palpable mass.


Palpable Breast Masses

Palpable Breast Masses. US Breast A major advantage of US is the ability to directly correlate the clinical and imaging findings. The use of multiple modalities in diagnosing palpable masses has been advocated as a measure to increase the true-positive rate. In 3 series evaluating palpable breast abnormalities [18-20], the sensitivity of mammography was 86% to 91%. The addition of US detects 93% to 100% of cancers [8,9,19]. The addition of US to mammography may also improve detection of a benign etiology for a palpable finding and may also identify lesions that are mammographically occult [26]. In a series, 40% of benign palpable masses were identified only on US [20]. In another study of 375 palpable masses in 320 women, 68.8% of the masses (n = 258) were only identified with US and were typically oval (n = 275, 73.3%) and hypoechoic (n = 336 in 372 US examinations, 90.3%) [39]. When both mammography and US are negative or benign in the evaluation of a palpable breast mass, the negative predictive value is very high, more than 97% [8,9,38,40]. Together, these imaging modalities can be reassuring when the physical examination is not highly suspicious and clinical follow-up is planned.


Palpable Breast Masses

Palpable Breast Masses. If almost entirely fatty tissue is identified in the palpable region of concern, US may not be necessary [2]. In a study that included 323 palpable masses in 271 women with almost entirely fatty tissue on diagnostic mammography, mammography alone yielded a negative predictive value of 99.6% [22]. Of the 294 (91%) of women with almost entirely fatty breasts who also underwent targeted US for the evaluation of palpable symptoms, US yielded 11 false- positives and 8 benign correlates at sites with no mammographic findings [22].


Palpable Breast Masses

Palpable Breast Masses. Variant 6: Adult female, younger than 30 years of age. Palpable breast mass. Initial imaging. Digital Breast Tomosynthesis Diagnostic Because of the low incidence of breast cancer (<1%) in younger women, the recommended initial imaging differs from older patients [41-44]. Younger women tend to have relatively denser breast tissue [45], which is associated with decreased mammographic/DBT sensitivity [46]. DBT is not useful as the initial imaging modality in younger women.


Palpable Breast Masses

Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the initial imaging workup in women <30 years of age with a palpable mass [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy as the initial imaging workup in women <30 years of age with a palpable mass.


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNAB as the initial imaging workup in women <30 years of age with a palpable mass.


Palpable Breast Masses

Palpable Breast Masses. Mammography Diagnostic Because of the low incidence of breast cancer (<1%) in younger women, the recommended initial imaging differs from older patients [41-44]. Younger women tend to have relatively denser breast tissue [45], which is associated with decreased mammographic/DBT sensitivity [46]. Most benign lesions in young women are not visualized on mammography [41,43]. Diagnostic mammography is not useful as the initial imaging modality in younger women.


Palpable Breast Masses

Palpable Breast Masses. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses

Palpable Breast Masses. Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast as the initial imaging workup in women <30 years of age with a palpable mass [2,23-25].


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the initial imaging workup in women <30 years of age with a palpable mass.


Palpable Breast Masses

Palpable Breast Masses. Variant 7: Adult female, younger than 30 years of age. Palpable breast mass. US findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study. Digital Breast Tomosynthesis Diagnostic DBT may be useful in a woman <30 years of age with a suspicious sonographic finding that correlates to a palpable mass. DBT may demonstrate findings not readily detected at US (calcifications or subtle architectural distortion); this may provide a more accurate assessment of the extent of disease in the ipsilateral breast and can identify contralateral lesions as well. In addition, DBT may have relatively high diagnostic accuracy in dense breast tissue, often encountered in younger patients [48,49].


Palpable Breast Masses

Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast If a suspicious mass has been identified on US, tissue sampling (US guided) is warranted. It may be appropriate to proceed directly to image-guided biopsy if a palpable lesion has suspicious features on US followed by placement of a biopsy clip. If US findings are particularly worrisome for malignancy, diagnostic mammography or DBT may be performed prior to tissue sampling to delineate disease extent (eg, calcifications extending beyond the margins of the US-identified solid mass) and identify any additional suspicious findings in the ipsilateral or contralateral breast. Core-needle biopsy has been shown in large series to be superior to FNA in terms of sensitivity, specificity, and correct histological grading [27]. Some practices have had good results using FNAB, but this may be facility specific, and a lower threshold for radiologic-pathologic discordance may need to be applied [50,51].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast If a suspicious mass has been identified on US, tissue sampling (US guided) is warranted. It may be appropriate to proceed directly to image-guided biopsy if a palpable lesion has suspicious features on US. If US findings are particularly worrisome for malignancy, diagnostic mammography or DBT may be performed before tissue sampling to delineate disease extent (eg, calcifications extending beyond the margins of the US-identified solid mass) and identify any additional suspicious findings in the ipsilateral or contralateral breast. Core-needle biopsy has been shown in large series to be superior to FNA in terms of sensitivity, specificity, and correct histological grading [27]. Some practices have had good results using FNAB, but this may be facility specific, and a lower threshold for radiologic-pathologic discordance may need to be applied [50,51]. US-guided FNAB may be preferred over core biopsy in rare situations but should be used judiciously.


Palpable Breast Masses

Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. Mammography Diagnostic Mammography may be useful in a woman <30 years of age with a suspicious sonographic finding that correlates to a palpable mass. If US findings are particularly worrisome for malignancy, mammography diagnostic or diagnostic DBT would usually be performed before tissue sampling to identify any additional suspicious findings and/or delineate the extent of disease (eg, calcifications extending beyond the margins of the US-identified solid mass) in the ipsilateral breast. Mammography diagnostic is recommended as a prebiopsy assessment in cases in which cancer is strongly suspected clinically [41].


Palpable Breast Masses

Palpable Breast Masses. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age [2,23-25].


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI as the next step in evaluating a palpable mass with suspicious sonographic features in women <30 years of age.


Palpable Breast Masses

Palpable Breast Masses. Variant 8: Adult female, younger than 30 years of age. Palpable breast mass. US findings probably benign (BI-RADS 3). Next imaging study. Digital Breast Tomosynthesis Diagnostic If a correlate for a palpable mass has been identified on US and is probably benign, there is no indication for DBT to further evaluate the palpable mass in women <30 years of age.


Palpable Breast Masses

Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is unnecessary for imaging surveillance. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast dedicated in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast If a palpable mass has probably benign features as identified on US, US follow-up is recommended. However, image-guided core biopsy may be performed after complete imaging assessment in some cases. For example, BI- RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for biopsy instead of imaging follow-up. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling and a biopsy marker clip should be placed [30].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast If a palpable mass has probably benign features as identified on US, US follow-up is recommended. Image-guided FNAB may be performed after complete imaging assessment in some cases. For example, BI-RADS 3 lesions in high-risk patients, patients awaiting organ transplant, patients with known synchronous cancers, or patients trying to get pregnant may be appropriate for tissue sampling. In addition, situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling, and a biopsy marker clip should be placed [30]. However, large series demonstrate that core biopsy is superior to FNAB in terms of sensitivity, specificity, and correct histological grading of palpable masses [27]. In addition, core biopsy allows for ready evaluation of tumor receptor status. US-guided FNAB may be preferred in rare situations (lesion abuts an implant).


Palpable Breast Masses

Palpable Breast Masses. Mammography Diagnostic If a correlate for a palpable mass has been identified on US and is probably benign, there is no indication for diagnostic mammography to further evaluate the palpable mass in women <30 years of age.


Palpable Breast Masses

Palpable Breast Masses

Palpable Breast Masses. Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is unnecessary for imaging surveillance. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass [2,23-25].


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI in women <30 years of age with probably benign sonographic findings in the setting of a palpable mass.


Palpable Breast Masses

Palpable Breast Masses. Variant 9: Adult female, younger than 30 years of age. Palpable breast mass. US findings benign (BI-RADS 2). Next imaging study. Digital Breast Tomosynthesis Diagnostic If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for further evaluation with diagnostic DBT in women <30 years of age.


Palpable Breast Masses

Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is unnecessary for confirmation of benignity. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. FDG-PET Breast Dedicated If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for FDG- PET breast dedicated in women <30 years of age [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for tissue sampling. The likelihood of a palpable mass in a young woman that is benign on both clinical examination and US resulting in a cancer is extremely low; one study prospectively evaluating US-guided core biopsy in 248 young women <25 years of age with clinically benign masses and predominantly benign findings found no cancers in this group [52].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for image- guided FNAB in women <30 years of age.


Palpable Breast Masses

Palpable Breast Masses. Mammography Diagnostic If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for further evaluation with diagnostic mammography in women <30 years of age.


Palpable Breast Masses

Palpable Breast Masses. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is unnecessary for confirmation of benignity. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. MRI Breast If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no role for MRI of the breast with or without IV contrast in women <30 years of age [2,23-25].


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI If a benign entity has been found on US and is the definitive correlate for a palpable mass, there is no evidence for Tc-99m sestamibi MBI in women <30 years of age.


Palpable Breast Masses

Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. age, if physical examination is highly suspicious and DBT and US are negative, tissue sampling with core biopsy or surgical biopsy is warranted.


Palpable Breast Masses

Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. FDG-PET Breast Dedicated There is no relevant literature to support the use of the use of FDG-PET breast dedicated in women <30 years of age with negative US findings [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of the use of image-guided core biopsy in women <30 years of age with negative US findings.


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of the use of image-guided FNAB in women <30 years of age with negative US findings.


Palpable Breast Masses

Palpable Breast Masses. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the next imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. MRI Breast There is no relevant literature to support the use of the use of MRI of the breast with or without IV contrast in women in women <30 years of age with negative US findings [2,23-25].


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of the use of Tc-99m sestamibi MBI in women <30 years of age with negative US findings.


Palpable Breast Masses

Palpable Breast Masses. Digital Breast Tomosynthesis Screening In women presenting with signs or symptoms, including a palpable breast mass, screening DBT, with or without DM, is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses

Palpable Breast Masses. Palpable Breast Masses


Palpable Breast Masses

Palpable Breast Masses. FDG-PET Breast Dedicated There is no relevant literature to support the use of the use of FDG-PET breast dedicated in the initial evaluation of women 30 to 39 years of age with a palpable mass [2].


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Core Biopsy Breast There is no relevant literature to support the use of the use of image-guided core biopsy in the initial evaluation of women 30 to 39 years of age with a palpable mass.


Palpable Breast Masses

Palpable Breast Masses. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of the use of image-guided FNAB in the initial evaluation of women 30 to 39 years of age with a palpable mass.


Palpable Breast Masses

Palpable Breast Masses. One study of 1,208 women 30 to 39 years of age presenting with focal breast symptoms found a higher sensitivity for US compared with mammography (95.7% versus 60.9%) but with a similar specificity (89.2% and 94.4%, respectively), negative predictive value (99.9% and 99.2%, respectively), and positive predictive value (13.2% and 18.4%, respectively) [40].


Palpable Breast Masses

Palpable Breast Masses. Mammography Screening In women presenting with signs or symptoms, including a palpable breast mass, screening mammography is not useful as the initial imaging study. Screening mammography is provided to women without signs or symptoms of breast disease.


Palpable Breast Masses

Palpable Breast Masses. MRI Breast There is no relevant literature to support the use of MRI of the breast with or without IV contrast in the initial evaluation of women 30 to 39 years of age with palpable mass [2,23-25].


Palpable Breast Masses

Palpable Breast Masses. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in the initial evaluation of women 30 to 39 years of age with palpable mass.


Palpable Breast Masses

Palpable Breast Masses. 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.


Palpable Breast Masses

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


Palpable Breast Masses

Palpable Breast Masses


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Introduction/Background The acute scrotum is a medical emergency defined as scrotal pain, swelling and redness of acute onset, from minutes to 1 to 2 days [1] and comprises at least 0.5% of all emergency department visits [2]. Etiologies of acute scrotum are numerous, and rapid accurate diagnosis is essential to appropriately triage potentially surgical and irreversible conditions from patients for whom conservative management is sufficient. Diagnostic considerations include testicular torsion, torsion of testicular appendage, epididymoorchitis, epididymitis, idiopathic scrotal edema, hydrocele, inflammation of the tunica vaginalis, trauma, testicular tumors, epididymal cysts, Fournier gangrene, scrotal abscess, and strangulated inguinal hernia [3-6]. Torsion of a testicular appendage, epididymitis, and testicular torsion are the three most common causes of acute scrotal pain and account for approximately 85% to 90% of cases [7]. Large differential diagnoses and overlapping clinical presentation make the acute scrotum a diagnostic challenge.


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Acute epididymoorchitis or epididymitis is the most common cause of acute scrotum in adolescent boys and adults [8,9]. In 2002, epididymitis or epididymoorchitis accounted for 1 in 44 outpatient visits in men 18 to 50 years of age [9,10]. Although uncommon in pediatric populations, it can be associated with urinary tract infections and/or structural and functional abnormalities of the urinary tract [11,12]. Epididymitis has a more insidious and gradual onset than testicular torsion. As inflammation and edema progress, a reactive hydrocele may develop making it difficult to differentiate from testicular torsion. Clinically, scrotal pain associated with epididymitis is usually relieved when the testes are elevated over the symphysis pubis (the Prehn sign) [8,13]. This sign may help clinically differentiate between epididymitis and torsion of the spermatic cord, in which scrotal pain is not lessened with this maneuver [14].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Testicular torsion is defined as twisting of the spermatic cord, compromising blood flow to and from the testes [2]. It is a surgical emergency with a bimodal distribution presenting more frequently in neonates and postpubertal boys than in adults, although it can occur at any age [19]. It has an estimated reported yearly incidence ranging from 2.9 to 3.8 in 100,000 boys <18 years of age [20,21]. Prompt recognition and surgical exploration within 6 to 8 hours after symptom onset is essential to prevent testicular loss [22]. A validated [23-26], clinical risk scoring system, Testicular Workup for Ischemia and Suspected Torsion Score, has shown high positive predictive value; however, it has not been widely adopted [20].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Special Imaging Considerations Contrast-enhanced ultrasound (US) has expanded considerably in the last few decades and has proved to be a useful tool in determining the presence or absence of organ perfusion by improving the signal-to-noise ratio of tissue


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Reprint requests to: publications@acr.org


Acute Onset of Scrotal Pain

Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Acute Onset of Scrotal Pain


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Microvascular imaging US is a new Doppler module that better differentiates slow flow via mathematical algorithms based on signal amplitude width [33], by separating low frequency of static tissue artifacts from low frequencies of very weak flow. Microvascular imaging obtains a higher resolution by separating the Doppler components of the 2 different sources [34].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Shear wave elastography (SWE) is a recently developed technique capable of quantitatively evaluating soft tissue stiffness [35,36]. This serves as a surrogate marker for tissue composition. Studies have shown that SWE values of testicular parenchyma increase during testicular torsion; however, there are limited studies showing whether these changes can be distinguished from other pathologies such as acute inflammation [36].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. OR Discussion of Procedures by Variant Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging. This discussion will be limited to patients with acute pain, without history of trauma, and no history of antecedent or known scrotal or testicular mass because these scenarios are discussed elsewhere [37,38].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. CT Pelvis With IV Contrast CT of the pelvis with intravenous (IV) contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients. However, in the setting of Fourniers gangrene, CT can lead to early diagnosis with accurate assessment of disease extent [3].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. CT Pelvis Without and With IV Contrast CT of the pelvis without and with IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients.


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. CT Pelvis Without IV Contrast CT of the pelvis without IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of CT of the pelvis in these patients.


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. MRI Pelvis (Scrotum) Without and With IV Contrast MRI of the pelvis without and with IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. However, it may be used as a problem solving second-line modality when findings on US are indeterminate [39,40]. Diagnoses such as minor tunica albuginea tears and blunt scrotal trauma, chronic epididymoorchitis, and partial or intermittent torsion may sometimes be missed on US [39,41,42]. Due to its larger field of view and multiplanar capabilities, MRI of the scrotum provides excellent anatomical detail of all scrotal contents and inguinal region. In addition, MRI provides high soft-tissue contrast, high sensitivity for contrast enhancement, and functional information. These features contribute to a more precise treatment strategy, reducing unwarranted surgical exploration [39,40,43-47]. Limitations of MRI in the


Acute Onset of Scrotal Pain


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. evaluation of acute scrotum include long scan time, potentially delaying surgical exploration, and possible need for anesthesia in pediatric patients [39,40,48] and patients with claustrophobia or anxiety.


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. MRI has high accuracy in establishing the diagnosis of segmental testicular infarction [39,49-51]. Segmental testicular infarction is an uncommon entity that can mimic a small hypovascular tumor on US [50,52-55]. MRI findings include a T2 hypointense, avascular lesion with marked rim enhancement. Intralesional hyperintense T1 signal may coexist due to hemorrhagic products [39,44,50,55-57].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Diffusion-weighted imaging and apparent diffusion coefficient (ADC) provide qualitative and quantitative analysis by adding functional information about molecular activity and cellular function, in addition to the morphological information provided by other MRI sequences, like dynamic contrast-enhanced and T2- and T2*-weighted images [60,61]. Diffusion-weighted imaging and ADC images demonstrate lower ADC values of the torsed testicle compared to the normal contralateral testicle [62].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. MRI Pelvis (Scrotum) Without IV Contrast MRI of the pelvis without IV contrast is not routinely used as an initial imaging modality for the evaluation of acute scrotal pain without trauma and without antecedent mass. There is no relevant literature regarding the use of MRI of the pelvis without IV contrast in these patients.


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Nuclear Medicine Scan Scrotum Radionuclide scrotal imaging (RNSI) has been replaced by Doppler US as the primary imaging modality for evaluation of the acute scrotum. RSNI has a reported sensitivity and specificity for differentiation between testicular torsion and epididymoorchitis from 89% to 98% and 90% to 100%, respectively [68,69]. RSNI is limited by technical challenges in children whose small genitalia are difficult to image with radiotracers. RNSI also can have photon-deficient areas secondary to hydrocele, spermatocele, and inguinal hernias, which can be erroneously diagnosed as avascular testis [70].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. US Duplex Doppler Scrotum Spectral analysis of the Doppler waveform allows a quantitative assessment of organ perfusion.


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. contralateral testicle or a different region within the same testicle. Variability of the amplitude was the most common abnormality, followed by reversal of diastolic flow [6]. Additional characteristic spectral Doppler waveforms seen in partial testicular torsion include monophasic waveform, tardus-parvus morphology, and spectral Doppler waveform variations within the same testis, all worrisome for underlying ischemia. Spectral Doppler analysis should be performed in the upper, mid, and lower poles of each testicle [6,72,74].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. US Scrotum US is the established first-line imaging modality for acute scrotal disease [75] and can be used to diagnose most scrotal disorders when combined with clinical history and physical examination. US is generally well tolerated and widely available, making it ideal for scrotal evaluation. High-resolution grayscale and color Doppler US allow prompt and accurate differentiation of scrotal emergencies [49,54,76,77].


Acute Onset of Scrotal Pain Without Trauma Without Antecedent Mass. Testicular perfusion can be evaluated with color Doppler, power Doppler, and spectral Doppler US [76]. Power Doppler is valuable in scrotal US because of its increased sensitivity to low-flow states and its independence from Doppler angle correction [76,78].