Recurrent Lower Urinary Tract Infections in Females. Special Imaging Considerations CTU CT urography (CTU) is an imaging study that is tailored to improve visualization of both the upper and lower urinary tracts. There is variability in the specific parameters, but it usually involves unenhanced images followed by intravenous (IV) contrast-enhanced images, including nephrographic and excretory phases acquired at least 5 minutes after contrast injection. Alternatively, a split-bolus technique uses an initial loading dose of IV contrast and then obtains a combined nephrographic-excretory phase after a second IV contrast dose; some sites include arterial phase. CTU should use thin-slice acquisition. Reconstruction methods commonly include maximum intensity projection or 3-D volume rendering. For the purposes of this document, we make a distinction between CTU and CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases, as is the case for CTU.


Recurrent Lower Urinary Tract Infections in Females. CT Pelvis with Bladder Contrast (CT Cystography) CT cystography is an imaging study that is tailored to visualize traumatic bladder lesions. This technique involves retrograde drip infusion of diluted iodinated contrast into the urinary bladder followed by pelvic CT imaging at maximal bladder distension. IV contrast may be administered, particularly if evaluating for underlying neoplastic or inflammatory processes [19].


Recurrent Lower Urinary Tract Infections in Females. For the purposes of this document, we distinguish CT cystography from CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is also defined as any protocol not specifically tailored for evaluation of the integrity of the urinary bladder wall and without retrograde instillation of contrast into the urinary bladder, as is the case for CT cystography.


Recurrent Lower Urinary Tract Infections in Females. MRU MR urography (MRU) is also tailored to improve imaging of the urinary system. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic high signal intensity from urine for evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory phase. Thin-slice acquisition and multiplanar imaging should be obtained. For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases and without heavily T2-weighted images of the urinary tract, as is the case for MRU.


Recurrent Lower Urinary Tract Infections in Females. US Abdomen with IV Contrast Prior studies show promise regarding the potential role of contrast-enhanced ultrasound (US) for the initial diagnosis and follow-up of patients with complicated acute pyelonephritis [20-22]. Using CT as a reference standard, Mitterberger et al [22] demonstrated a sensitivity of 98% and a specificity of 100% for contrast-enhanced US in the diagnosis of acute pyelonephritis in 100 patients. Its use in current mainstream practice remains limited, however, with only recent FDA approval for abdominal imaging applications.


Recurrent Lower Urinary Tract Infections in Females. Recurrent Lower Urinary Tract Infections in Females Discussion of Procedures by Variant Variant 1: Recurrent lower urinary tract infections in a female. Uncomplicated with no underlying risk factors. In women with recurrent uncomplicated UTIs, cystoscopy and imaging are not routinely used [1]. Lawrentschuk et al [23] showed that women with no risk factors for UTI had a negative predictive value of 93% for normal cystoscopy. Prior series have demonstrated a low yield of nonincidental findings in those patients with a low pretest probability of complicated UTI [1,24].


Recurrent Lower Urinary Tract Infections in Females. CT Abdomen and Pelvis There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,25]. As such, CT is not generally performed for evaluation of uncomplicated UTI.


Recurrent Lower Urinary Tract Infections in Females. CT Pelvis with Bladder Contrast (CT Cystography) There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,20]. As such, CT cystography is not generally performed for evaluation of uncomplicated UTI.


Recurrent Lower Urinary Tract Infections in Females. CTU There are no specific guidelines recommending imaging studies in women who have recurrent UTIs but no known underlying medical or anatomic conditions [6,20]. As such, CTU is not generally performed for evaluation of uncomplicated UTI.


Recurrent Lower Urinary Tract Infections in Females. Fluoroscopy Contrast Enema Although fluoroscopic contrast enema may be useful in the setting of suspected vesicoenteric fistula, it is not used for imaging in women with recurrent uncomplicated UTIs in the absence of risk factors.


Recurrent Lower Urinary Tract Infections in Females. Fluoroscopy Cystography A prior prospective study of findings with excretory urography, cystography, and cystoscopy in women with symptomatic UTI revealed only rare instances of abnormalities important in the treatment of UTI in this group of patients, primarily urethral diverticula [26]. Most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with fluoroscopic cystography.


Recurrent Lower Urinary Tract Infections in Females. Fluoroscopy Voiding Cystourethrography As most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts, they do not routinely require imaging with voiding cystourethrography. A prior prospective study including findings of excretory urography in women with symptomatic UTI revealed only rare instances of structural abnormalities important in the treatment of UTI in this group of patients [26].


Recurrent Lower Urinary Tract Infections in Females. MRI Abdomen and Pelvis CT and MRU have supplanted the use of IV urography (IVU) at most institutions for most types of urinary applications [27]. However, most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with MRI.


Recurrent Lower Urinary Tract Infections in Females. MRU CT and MRU have supplanted the use of IVU at most institutions for most types of urinary applications [27]. However, most women with recurrent uncomplicated UTIs in the absence of risk factors have normal urinary tracts and do not routinely require imaging with MRI.


Recurrent Lower Urinary Tract Infections in Females. Radiography Abdomen As most women with recurrent symptomatic UTI have normal urinary tracts, they do not routinely require imaging with radiography of the abdomen.


Recurrent Lower Urinary Tract Infections in Females. Radiography Intravenous Urography Historically, intravenous urography (IVU) was the imaging study of choice to evaluate the urinary tract, but it is no longer used at most institutions [13]. IVU is not used for evaluation of uncomplicated UTI.


Recurrent Lower Urinary Tract Infections in Females. US Kidneys and Bladder Retroperitoneal As most women with recurrent symptomatic UTI have normal urinary tracts, they do not routinely require imaging with US of the kidneys, bladder, and retroperitoneum.


Recurrent Lower Urinary Tract Infections in Females. Recurrent Lower Urinary Tract Infections in Females Variant 2: Recurrent lower urinary tract infections in a female. Complicated, or patients who are nonresponders to conventional therapy, develop frequent reinfections or relapses, or have known underlying risk factors. Complicated causes of UTI can be evaluated by history and physical examination. In women suspected of having a recurrent complicated UTI, cystoscopy and imaging should be considered [24].


Recurrent Lower Urinary Tract Infections in Females. CT Abdomen and Pelvis Historically, unenhanced CT has been used predominantly for the emergency patient with renal colic and/or hematuria. It has also been used to define the severity and extent of upper tract calculi, which are occasionally associated with recurrent complicated UTIs. The lack of additional contrast-enhanced CT imaging and the lack of dedicated imaging of the collecting systems, kidneys, and bladder limits further evaluation of underlying anatomical or pathophysiologic processes.


Recurrent Lower Urinary Tract Infections in Females. Contrast-enhanced CT has been used effectively to evaluate a range of urinary tract abnormalities, including renal masses, genitourinary trauma, and specific aspects of renal infection, including the presence of pyelonephritis, renal abscesses, and obstruction. However, a contrast-enhanced CT of the abdomen and pelvis remains a study that is not tailored for evaluation of the urothelium and therefore does not optimally evaluate the collecting systems, ureters, and bladder. Moreover, lacking an unenhanced CT component, a contrast-enhanced CT of the abdomen and pelvis can limit the detection of calculi and the characterization of enhancement within masses [24]. The addition of rectal contrast or oral contrast with delayed scanning of an enhanced CT of the abdomen and pelvis is useful to detect enterovesical fistulas and infected fistulous tracts [28].


Recurrent Lower Urinary Tract Infections in Females. CT Pelvis with Bladder Contrast (CT Cystography) CT cystography has supplanted fluoroscopic cystogram for the evaluation of traumatic bladder injuries, including intraperitoneal, extraperitoneal, or combined rupture and bladder contusions [29]. It is also useful for diagnosing bladder fistulas and leaks, particularly colovesical fistulas occurring as a result of sigmoid diverticular disease, which can remain undiagnosed despite evaluation with cystoscopy and contrast-enhanced CT [19].


Recurrent Lower Urinary Tract Infections in Females. CTU CTU CTU is a primary test for the evaluation of recurrent complicated UTIs. It includes unenhanced, nephrographic phase, and excretory phase images, with the latter providing a detailed anatomic depiction of each of the major portions of the urinary tract including the kidneys, intrarenal collecting systems, ureters, and bladder [30]. Diuretic administration prior to the excretory phase can augment both urinary tract distention and opacification [30]. CTU has excellent sensitivity and specificity for the identification of renal and urothelial lesions [31]. This allows patients with hematuria to be evaluated comprehensively and can identify abnormalities of the collecting systems [27]. It is also useful for detecting or excluding congenital anomalies or obstruction of the urinary tract in patients with complicated recurrent UTIs. Given the low yield of CTU screening for asymptomatic hematuria in patients <30 years of age, or without risk factors for urinary tract malignancy, US or noncontrast CT may be the first-line imaging examinations in these patients. When there are risk factors present for urinary tract malignancy and the patient is >50 years of age, CTU is the preferred examination [31].


Recurrent Lower Urinary Tract Infections in Females. Fluoroscopy Contrast Enema Contrast enema is generally not useful for women with recurrent complicated UTIs. Although it may be utilized for imaging of vesicoenteric fistulas, CT is the primary imaging modality for suspected cases of enterovesical fistulas and has been found to have a higher rate of detection and also capable of identifying the underlying etiology [32,33]. If an enema is performed, water-soluble contrast should be selected rather than barium.


Recurrent Lower Urinary Tract Infections in Females. Fluoroscopy Cystography Fluoroscopic cystography is generally not useful for women with recurrent complicated UTIs. Although it can delineate bladder diverticuli and vesicoenteric fistulas, CT has supplanted fluoroscopic cystography at most institutions.


Recurrent Lower Urinary Tract Infections in Females. Fluoroscopy Urethrography Double Balloon Double-balloon urethrography can be useful for demonstration of urethral diverticula, although MRI best assesses the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning. MRI to evaluate for urethral diverticulum has replaced double-balloon urethrography at most institutions. Double- balloon urethrography can be technically difficult and may be uncomfortable for the patient. For this document, it is assumed the procedure is performed and interpreted by an expert.


Recurrent Lower Urinary Tract Infections in Females. Recurrent Lower Urinary Tract Infections in Females Fluoroscopy Voiding Cystourethrography When a bladder diverticulum is at or near a ureteral orifice, voiding cystourethrography can be considered to evaluate the possibility of vesicoureteral reflux [34]. It can also be employed for imaging of suspected bladder or urethral fistula, urethral diverticulum, or bladder prolapse.


Recurrent Lower Urinary Tract Infections in Females. MRI Abdomen and Pelvis Both MRI of the abdomen and pelvis and MRU can be used to evaluate the urinary tract and have the advantage to provide more functional information than CT. MRI has been shown to be useful in the diagnosis and follow-up of UTI and acute pyelonephritis [27,35,36]. MRI is effective at diagnosing pelvic-organ prolapse. The resultant cystoceles and urinary incontinence associated with pelvic-organ prolapse are significant risk factors for recurrent UTIs in postmenopausal women [13,37,38].


Recurrent Lower Urinary Tract Infections in Females. MRI is the optimum imaging modality for assessment of the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning [39]. Given the excellent soft-tissue contrast on MRI, this modality is equally sensitive to CT for evaluating vesicovaginal and enterovesicular fistulae [40,41]. In at least one study, MRI altered the surgical management in 15% of patients [39].


Recurrent Lower Urinary Tract Infections in Females. A history of recurrent UTI is seen in 30% to 50% of patients with urethral diverticula. Diverticula of the urethra can be evaluated with high sensitivity and specificity by double-balloon urethrography, voiding CT urethrography, and MRI [42-44]. MRI best assesses the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning. Patients with suspected bladder diverticula may be imaged with cystography, US, or CT [45]. Bladder diverticula are unusual in women and are associated with a neurogenic or postoperative bladder; they are rarely congenital. MRI has also been shown to be accurate in the diagnosis of colovesical fistula. The multiplanar imaging capability and high soft-tissue resolution inherent to MRI also makes this modality suitable for imaging suspected fistulae, particularly when repeat imaging is an issue [40,41]. IVU, US, and upper gastrointestinal or small-bowel follow-through have very low yields for fistula [46,47].


Recurrent Lower Urinary Tract Infections in Females. MRU MRU is useful to evaluate suspected urinary tract obstruction, hematuria, and congenital anomalies, as well as postoperative anatomy. The most common MRU techniques for displaying the urinary tract can be divided into two categories: static-fluid MRU and excretory MRU. Static-fluid MRU makes use of heavily T2-weighted sequences to image the urinary tract as a static collection of fluid, can be repeated sequentially (cine MRU) to better demonstrate the ureters in their entirety and to confirm the presence of fixed stenoses, and is most successful in patients with dilated or obstructed collecting systems. Excretory MRU is performed during the excretory phase of enhancement after the IV administration of gadolinium-based contrast material. Diuretic administration is integral to excretory MRU to better demonstrate nondilated systems. Static-fluid and excretory MRU can be combined with conventional MRI for comprehensive evaluation of the urinary tract [48]. MRU can be used to evaluate the urinary tract and provides more functional information than CT provides. However, MRU is less established and less reliable and thus results in lesser diagnostic image quality relative to CTU [23]. In comparison to CTU, it necessitates a longer examination time and is less sensitive than CT for detecting urinary tract calculi. In a study of 149 patients, MRU demonstrated 69% sensitivity for detecting calculi versus 100% for CT [49]. However, MRU has shown increased sensitivity for perirenal fluid and ureteric dilatation in comparison with CT in the setting of acute obstruction [50]. Multiplanar reconstruction images in the coronal and sagittal planes are commonly included in MRU images to improve visualization of urinary tract abnormalities [27,48]. Additional benefits for MRU are in documenting active upper-tract infection versus scar formation to determine whether therapy has been effective in the high-risk patient.


Recurrent Lower Urinary Tract Infections in Females. Radiography Abdomen Radiography of the abdomen has long been employed for the detection of calculi, intramural bladder wall calcification, gas in the wall or lumen of the urinary bladder, and/or foreign bodies that may be the etiology of a UTI. Use of digital tomosynthesis of the abdomen results in improved detection of urinary stones in general over digital radiography [51]. Bladder-wall calcification, when present, is typically due to prior infection with Schistosoma (uncommon in the United States, but very common in other parts of the world), tuberculosis, Cytoxan cystitis, or radiation cystitis [52]. For women with recurrent UTIs, however, abdominal radiography is generally not a useful diagnostic tool as other imaging modalities have higher sensitivity and specificity in this setting.


Recurrent Lower Urinary Tract Infections in Females. Recurrent Lower Urinary Tract Infections in Females Radiography Intravenous Urography CT and MRU have supplanted the use of IVU for evaluation of urinary abnormalities at most institutions [27], and it is generally not useful for women with recurrent complicated UTIs.


Recurrent Lower Urinary Tract Infections in Females. US Kidneys and Bladder Retroperitoneal US may be useful in women with recurrent UTIs, particularly prior to pregnancy, to evaluate for hydronephrosis and risk factors for recurrent infection. Hydronephrosis can be demonstrated as an indication of obstruction, although US may not yield a specific etiology [53-55]. US is a useful initial screening tool for obstructive uropathy and for postvoid residual volume determination to detect incomplete bladder emptying [56]. It should be noted, although US can detect renal stones, it is generally less sensitive than CT [57-59]. Renal abscess or perinephric collections can also be detected sonographically, and US of the bladder can be employed to evaluate for bladder diverticula detection [45].


Recurrent Lower Urinary Tract Infections in Females. 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.


Recurrent Lower Urinary Tract Infections in Females. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Recurrent Lower Urinary Tract Infections in Females. 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


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Diagnostic imaging plays a key role in the assessment of acute elbow pain. A thorough understanding of diagnostic imaging modalities is essential to expeditiously identify the damaged structures and assist in treatment/surgical planning, thus allowing for rapid return to play/activity.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. In a more recent study, the same authors tested joint widening on cadaveric human elbows at various stages of ligamentous transection. The 5 sequential stages, evaluated with varus stress, included 1) intact, 2) transection of the lateral ulnar collateral ligament (UCL), 3) complete transection of the lateral collateral ligament complex, 4) transection of the anterior aspect of the capsule, and 5) transection of the medial collateral ligament. The 5 sequential stages, evaluated by valgus stress, included 1) intact, 2) transection of the anteromedial collateral ligament, 3) complete transection of the medial collateral ligament, 4) transection of the anterior capsule, and 5) transection of


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Reprint requests to: publications@acr.org


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Acute Elbow and Forearm Pain


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. the lateral collateral ligamentous complex. The authors concluded that dynamic fluoroscopy makes it possible to distinguish among different stages of collateral ligament injury of the elbow [5].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. OR Discussion of Procedures by Variant Variant 1: Adult. Acute elbow or forearm pain. Initial imaging. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan as the initial imaging study for the evaluation of acute elbow and forearm pain.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. CT Area of Interest With IV Contrast There is no evidence to support the use of contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. CT Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. CT Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast CT of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. MRI Area of Interest Without IV Contrast There is no evidence to support the use of contrast-enhanced MRI of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Radiography Area of Interest Radiographs are beneficial as the initial imaging assessment for acute elbow and proximal forearm pain. Conventional radiographs are often the first-imaging modality used to exclude a fracture or dislocation. In adults, the most frequent fracture involves the radial head or neck and accounts for 50% of cases [1].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. An elbow joint effusion can be identified on conventional radiography with the presence of posterior and anterior fat pad elevation. In combination with the clinical context of acute trauma, the presence of a joint effusion can imply an occult elbow fracture. Avulsion fractures can also be identified at the attachment sites of tendons and ligaments. Occasionally, triceps tendon tears may result in avulsion fractures of the olecranon or an olecranon enthesophyte.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Injuries to the coronoid process are sequela of prior elbow dislocation, which is typically associated with soft tissue injury. As such, coronoid process fractures should prompt the referring provider to assess for associated tendon or ligament injury because these are commonly associated with elbow dislocation.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. US Area of Interest There is limited evidence to support the use of ultrasound (US) of the elbow/proximal forearm as the initial imaging study for the evaluation of acute elbow and forearm pain.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Variant 2: Adult. Acute elbow or forearm pain. Suspect fracture. Radiographs normal or indeterminate. Next imaging study. This variant is associated with osseous injury only. Please refer to Variant 3 for recommendations for the evaluation of soft tissue injury.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan as the initial imaging study for the evaluation of acute elbow and forearm pain.


Acute Elbow and Forearm Pain


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. In the elbow, the additional knowledge gleaned from CT includes size of fracture fragments and amount of displacement or angulation, which may affect the surgical treatment options. Isolated radial head fractures, Essex- Lopresti injuries, and Monteggia fractures with dislocation of the elbow can be diagnosed. Traumatic elbow injuries are categorized into radial head fracture with posterior dislocation, terrible triad injury, posterior and anterior fracture-dislocation, trans-olecranon (anterior) fracture-dislocation, and varus posteromedial rotational instability. Fracture mapping and quantitative 3-D CT analysis of coronoid and olecranon fractures have identified specific shapes, sizes, and orientations of fracture fragments according to a pattern of traumatic elbow instability.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Specifically, with regards to proximal olecranon fractures, plate and screw constructs tend to have only a few short proximal screws, and further stabilization with a supplementary wire or suture fixation incorporating the triceps attachment has been found to be helpful and knowledge of the fracture morphology is helpful for this surgical planning. Furthermore, CT can assess the degree of ulnohumeral incongruity, which is inversely proportional to the proximal olecranon fracture size [8].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the next imaging study for the evaluation of occult fracture of the elbow and/or proximal forearm.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. MRI Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast MRI of the elbow/proximal forearm as the next imaging study for the evaluation of occult fracture of the elbow and/or proximal forearm. In the setting of the Osborne- Cotterill lesion, occasionally the impaction, avulsion, and shear fracture of the posterolateral capitellum during elbow fracture-dislocation could be nondisplaced on CT; however, MRI is able to demonstrate the injury with marrow edema at the fracture site [9].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Radiography Area of Interest Repeat in 10-14 Days Pavic et al [10] evaluated 193 patients with acute elbow trauma with no acute fracture identified at the time of initial radiographic evaluation. Of note, these patients all had elbow joint effusions. Follow-up conventional radiographs were performed in 184 patients (95%) and showed fractures of the radial neck in 58% and nondisplaced fractures of the radial head in 37% of cases. Five percent of patients continued to have normal radiographs and were further evaluated with MRI and found to have intraarticular joint effusions, bone contusion, and radial and UCL ruptures.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Acute Elbow and Forearm Pain US Area of Interest There is no evidence to support the use of diagnostic US of the elbow/proximal forearm as the imaging study for the evaluation of acute elbow and forearm pain. There are 2 studies discussing point-of-care US that are too small to support use in this setting [11,12].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Variant 3: Adult. Acute elbow or forearm pain. Suspect tendon or ligament or muscle injury. Radiographs normal or indeterminate. Next imaging study. Bone Scan Area of Interest There is no evidence to support the use of 3-phase bone scan for the assessment of tendon, ligamentous, or muscle injury.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. CT Area of Interest With IV Contrast There is no evidence to support the use of contrast-enhanced CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. CT Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. CT Area of Interest Without IV Contrast There is no evidence to support the use of noncontrast CT of the elbow/proximal forearm for the assessment of tendon, ligamentous, or muscle injury.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. MRI Area of Interest Without and With IV Contrast There is no evidence to support the use of noncontrast/contrast-enhanced MRI of the elbow/proximal forearm as the for the assessment of tendon, ligamentous, or muscle injury.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. MRI Area of Interest Without IV Contrast Several studies have evaluated the use of noncontrast MRI in the assessment for ligamentous and tendinous injury [13]. Tarallo et al showed the best interobserver agreement in the assessment of lateral collateral complex injuries and the worst interobserver reliability for the UCL [7,14-18].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Athletes are prone to both acute and chronic overuse injuries of the elbow [13]. In a study of elbow injuries incurred during participation of the Rio de Janeiro 2016 Summer Olympic Games, Alizai et al [20] showed a predominance of UCL injury. For the purposes of this document, it is difficult to ascertain the acuity of the injuries from this report.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Furthermore, MRI is particularly useful in the assessment of biceps tears [21-24]. MRI has an improved sensitivity for the detection of partial tears of the biceps and triceps tendons. In a study of 77 patients, Nicolay et al [24] showed partial rupture of the long head of the biceps with an intact short head of the biceps to be the most common injury. On the other hand, isolated complete ruptures of the long head represented the least common injury pattern. Traumatic ruptures had a significantly higher association with ruptures of the short head of the biceps tendon, whereas ruptures of the long head of the biceps tendon accounted for 89% of atraumatic ruptures.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Acute Elbow and Forearm Pain


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. diagnosis of partial distal biceps tendon tears. However, the interrater reliability was better for FABS view and significantly more accurate than surgical findings in grading the extent of pathology.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. MRI is also useful in the assessment of rare triceps tears [21-24]. Lee et al [23] evaluated a small subset of patients and found 2 major causes for acute traumatic rupture of the triceps tendon at the elbow. A fall on an outstretched hand was categorized as an indirect injury, whereas a direct blow to the triceps by an object was considered a direct injury. The authors found that the indirect injury was most likely to result in injury of the lateral and long heads of the distal triceps tendon with an intact medial head tendon. Direct injuries were more likely to have a full-thickness rupture with an odds ratio of 1.75 (95% confidence interval, 0.92-3.32; P = .02). In addition, they found that the indirect injuries had associated ligamentous injuries with an odds ratio of 0.13 (95% confidence interval, 0.02-0.78; P < .001). However, one paper noted the overestimation of triceps tear severity compared with surgical assessment [28].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. US Area of Interest The use of US to evaluate the distal biceps tendon is well described in the literature [21,29,30]. A study by de la Fuente et al [30] investigated the sensitivity of US in detecting injuries of the distal biceps brachii tendon. The authors compared US examinations with MRI and surgery and found a slight statistical advantage of US over MRI. However, US is at a disadvantage with regard to the detection of partial tearing and tendinopathy.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Lynch et al [31] showed the accuracy of US in the diagnosis of complete distal biceps tendon rupture was inferior to MRI, 45.5% compared with 86.4%. The accuracy rate of US to detect partial tears of the biceps was the same as MRI at 66.7%. The sensitivity and specificity of US for the detection of biceps tendon tears were 62.5% and 20.0%, respectively, inferior to MRI at 76% and 50%. The authors concluded that MRI is a more accurate imaging modality at correctly identifying the type of distal biceps tendon tear, thus enabling the orthopedic surgeon to provide a more precise treatment plan.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Deschrijver et al [32] conducted an extensive literature search and meta-analysis to assess the usefulness of clinical examination testing as well as the usefulness of US. They further investigated whether supplementary sonographic views/maneuvers (eg, posterior approach Cobra technique, lateral approach supinator view, and medial approach pronator view) added benefit to the standard US examination. Their conclusion was that US can be considered an alternative to MRI in the evaluation of the distal biceps tendon ruptures. In a recent study by Miller et al, it was shown that radiologists preferred the medial imaging approach. Furthermore, this particular imaging approach demonstrated substantial interreader agreement [33].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Triceps tendon ruptures are rare, and a handful of studies have shown that US can identify both complete and isolated partial tears of the triceps brachii tendon [34,35]. In addition, in a feasibility study, Barret et al [12] showed that traumatic ligamentous lesions could be detected on US examination with the identified pathology matching the clinical symptomatology. Of note, no traumatic ruptures of the flexor or extensor tendon origins were detected on this study; however, this was a small study with only 9 patients. Assessment of the anterior bundle of the UCL in athletes is well documented and thus could be useful in the setting of acute trauma as well [20,36-38].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. The ability of US to visualize tendinous and ligamentous structures in cadaveric and normal volunteers of the medial and lateral elbow is well accepted; however, there are few articles evaluating its usefulness in the acute setting. A case report by van Duijn and Felton [39] described a case of an 18-year-old collegiate baseball pitcher with preinjury and postinjury US with MR arthrographic correlation. This patient was already participating in a research study evaluating the reliability of UCL thickness measurements using US imaging. In this study, the preinjury US image showed a normal hyperechoic appearance of the anterior band of the UCL. Postinjury images showed disruption of the ligamentous fibers of the anterior band of the UCL, with a large hypoechoic gap separating the 2 torn ends of the UCL, which was confirmed at the time of MR arthrography. A single study by Bilger et al [40] evaluated the use of US in the acute phase of closed elbow injuries and found a strong interrater reliability for injuries of the radial collateral, annular, and anterior bundle of the medial collateral ligaments. They further showed 100% US-surgical correlation in a subset of patients who had surgery. In a cadaveric study, Arrigoni et al [41] evaluated the lateral compartment of the elbow after release of the anterior half of the common extensor origin and after complete radial collateral ligament release. They concluded that US evaluation can detect changes related to tendon tears or


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Acute Elbow and Forearm Pain muscular avulsions of the common extensor origin and can depict lateral elbow compartmental pathologic laxity as evidence by widening of the articular joint space under dynamic stress maneuvers. Unfortunately, accurate identification of injuries to the lateral collateral ligament was not reliable.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. The majority of literature using US for the diagnosis of tendinous injuries is found in the setting of chronic elbow pain, particularly in the athlete. US of the elbow has moderate agreement with MRI of the elbow for the diagnosis and grading of common extensor tendon tears, with the sensitivity, specificity, and accuracy reported at 64.52%, 85.19%, and 72.73%, respectively [42]. Sonoelastography has shown promise for the detection of medial epicondylalgia with a sensitivity, specificity, accuracy, and positive predictive value, and negative predictive value of 95.2%, 92%, 93.5%, 90.0%, and 95.8%, respectively [43].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Conventional US has a sensitivity and specificity of 81% and 91%, respectively, in the detection of full-thickness UCL tears [44]. The sensitivity and specificity of dynamic stress US for the detection of UCL injury are 96% and 81%, respectively [44].


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. In a review of the literature, Sutterer et al [45] found that stress US can aid in the diagnosis of medial UCL tears, with an injured elbow stress delta (change in ulnohumeral joint space with valgus stress) of 2.4 mm and a stress delta difference (side-side difference in stress delta) of 1 mm, compatible with abnormal ulnohumeral joint laxity as a result of medial UCL injury.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. Given the scarcity of literature with regards to lateral and medial supporting structures, more rigorous studies evaluating the usefulness of US in the acute setting are needed; however, given US accuracy in the evaluation of chronic injuries, it will likely provide clinical usefulness for assessment of acute injury.


Acute Elbow and Forearm Pain

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


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Acute Elbow and Forearm Pain

Acute Elbow and Forearm Pain


Soft Tissue Masses

Soft Tissue Masses. Introduction/Background A variety of benign and malignant processes may present clinically as a soft tissue mass. The behavior of a mass, whether nonaggressive, indeterminant, or aggressive, can often be discerned based on history and physical examination. However, when a benign clinical diagnosis cannot be confidently provided, further characterization of a soft tissue mass with imaging is warranted [1]. Urgent imaging requests should be sought for masses that are >5 cm in diameter, deep in location, or have shown rapid growth [2]. Modern imaging techniques allow for a detailed analysis of the morphology of a soft tissue mass as well as further insight into its biologic activity, which informs the interpreter on diagnosis and appropriate next steps in management [3,4].


Soft Tissue Masses

Soft Tissue Masses. The purpose of this document is to identify the most appropriate imaging study(ies) to order for the assessment of a soft tissue mass based on the most frequently encountered clinical scenarios in medical practice. The rationale for the level of appropriateness granted to each study option is also described in accordance with the current literature and the consensus opinion of the members of the ACR Appropriateness Criteria Expert Panel on Musculoskeletal Imaging. This document does not address follow-up recommendations for patients with previously diagnosed masses or the appropriate approach or techniques for the imaging-guided biopsy of known masses. The former is covered by a separate ACR Appropriateness Criteria document [4], whereas the latter requires direct communication with the clinician or orthopedic oncologist supervising and coordinating patient care.


Soft Tissue Masses

Soft Tissue Masses. OR aMayo Clinic Florida, Jacksonville, Florida. bPanel Chair, Mayo Clinic, Jacksonville, Florida. cPanel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina. dJohns Hopkins University School of Medicine, Baltimore, Maryland. eMallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri. fNova Southeastern University, Fort Lauderdale, Florida. gDiagnostic Imaging Associates, Chesterfield, Missouri. hThe University of Texas MD Anderson Cancer Center, Houston, Texas; American Academy of Orthopaedic Surgeons. iUniversity of Virginia, Charlottesville, Virginia. jSUNY Downstate Health Sciences University, Brooklyn, New York. kDuke University School of Medicine, Durham, North Carolina; American Geriatrics Society. lThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. mBillings Clinic, Billings, Montana; American Academy of Family Physicians. nSpecialty Chair, VA San Diego Healthcare System, San Diego, California.


Soft Tissue Masses

Soft Tissue 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.


Soft Tissue Masses

Soft Tissue Masses. Reprint requests to: publications@acr.org


Soft Tissue Masses

Soft Tissue Masses. Soft Tissue Masses Discussion of Procedures by Variant Variant 1: Superficial soft tissue mass. Initial imaging. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot.


Soft Tissue Masses

Soft Tissue Masses. US Area of Interest Ultrasound (US) has become increasingly recognized as an excellent triage tool for evaluation of superficial soft tissue masses [12-15]. This recognition has been further supported by a recent prospective study of 219 histologically proven masses that showed US had a sensitivity, specificity, positive predictive value, and negative predictive value of 93.3%, 97.9%, 45.2%, and 99.9%, respectively, for discriminating benign from malignant tumors in the superficial soft tissues [16]. The same group of researchers had similar results in an earlier separate retrospective analysis of 247 histologically proven masses [17]. However, although these results highlight the benefits of US in the initial assessment of superficial masses, the overall number of malignancies in both the prospective [16] and retrospective [17] studies was very small (12 patients and 11 patients, respectively). Another recent study of 42 histologically proven masses concluded that MRI performed after US does not frequently change the working diagnosis or add diagnostic value, but again, this study only included a small number of malignancies and the value of MRI for these malignancies was not separately addressed in the study [18]. Therefore, we emphasize that these studies do not have sufficient power for showing high accuracy of US in the diagnosis of malignancy. Ultimately, US is most beneficial for triage, and when US features are not clearly benign or when history and physical examination findings are otherwise concerning, further imaging is required [9,19].


Soft Tissue Masses

Soft Tissue Masses. US Area of Interest With IV Contrast The use of intravenous (IV) contrast during US evaluation of soft tissue tumors may add further confidence in discriminating benign from indeterminate or malignant masses [20-22]. However, there is no literature showing that the addition of contrast provides a gain in diagnostic accuracy over standard grayscale and Doppler US features in the assessment of a soft tissue mass. Therefore, the literature does not support the use of US contrast in the initial examination of a superficial soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. MRI Area of Interest Without and With IV Contrast There is insufficient literature to support the routine use of MRI without or with IV contrast as the initial examination for a soft tissue mass. The inherent limitations of this modality, most notably in the identification of mineralization, limit its use in isolation.


Soft Tissue Masses

Soft Tissue Masses. MRI Area of Interest Without IV Contrast There is insufficient literature to support the routine use of MRI without IV contrast as the initial examination for a soft tissue mass. The inherent limitations of this modality, most notably in the identification of mineralization, limit its use in isolation.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest With IV Contrast CT with IV contrast does not typically play a role in the initial evaluation of a superficial soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses

Soft Tissue Masses. Soft Tissue Masses


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest Without and With IV Contrast CT does not typically play a role in the initial evaluation of a superficial soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest Without IV Contrast CT does not typically play a role in the initial evaluation of a superficial soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. FDG-PET/CT Area of Interest There is insufficient literature to support the routine use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT for the initial evaluation of a soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24].


Soft Tissue Masses

Soft Tissue Masses. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant fine needle aspiration. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy or fine needle aspiration should be performed only after adequate imaging [24].


Soft Tissue Masses

Soft Tissue Masses. Variant 2: Nonsuperficial (deep) soft tissue mass. Initial imaging. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot.


Soft Tissue Masses

Soft Tissue Masses. Radiography Area of Interest Initial imaging assessment of a suspected musculoskeletal soft tissue mass should almost invariably begin with radiographic evaluation and is advocated by ESMO-EURACAN [9]. Radiographs remain the modality best suited for the initial assessment of a suspected soft tissue mass and are the initial study of choice for orthopedic oncologists [25,26]. However, radiographs have limitations and may not reveal an abnormality when a mass is small, deep- seated, nonmineralized, or in an area with complex anatomy such as the flank, paraspinal region, groin, or deep soft tissues of the hands and feet [11].


Soft Tissue Masses

Soft Tissue Masses. US Area of Interest The diagnostic accuracy of US is considerably less when lesions outside the subcutaneous tissue are included. It is also less reliable for defining deep masses in large anatomical areas [27]. Although a recent prospective study of US accuracy in the characterization of 134 histologically proven deep soft tissue masses showed promising results, there were only a small number of malignancies in the study cohort, and the investigators had a high level of US expertise [28]. Therefore, US is most appropriate for superficial masses that are small (<5 cm) in size [13] but may be appropriate for deep soft tissue masses in specific settings, such as a deep mass in a thin patient.


Soft Tissue Masses

Soft Tissue Masses. US Area of Interest With IV Contrast The diagnostic accuracy of US is considerably less when lesions outside the subcutaneous tissue are included. It is also less reliable for defining deep masses in large anatomical areas [27]. Although an assessment of diagnostic accuracy of US with IV contrast in the setting of a deep soft tissue mass is not available in the current literature, there is presumably no added benefit over standard grayscale and Doppler US. Therefore, the US with IV contrast is not useful for the initial assessment of deep soft tissue masses.


Soft Tissue Masses

Soft Tissue Masses. MRI Area of Interest Without and With IV Contrast The current radiology, orthopedic oncology, and surgical oncology literature does not support the use of MRI without and with IV as the initial examination for a soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. MRI Area of Interest Without IV Contrast The current radiology, orthopedic oncology, and surgical oncology literature does not support the use of MRI without IV contrast as the initial examination for a soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest With IV Contrast CT with IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31].


Soft Tissue Masses

Soft Tissue Masses. For myositis ossificans, CT is superior to radiography in detecting the zonal pattern of mineralization, which is essential for early diagnosis [11]. In addition, CT allows for differentiation of soft tissue masses based on lesion density and can delineate vascular and bone involvement [29,30]. This differentiation may be better defined by immediately repeating the scan after contrast administration. During the assessment of cortical remodeling or invasion, the character of the interface between a soft tissue mass and the adjacent osseous cortex can usually be visualized to better advantage with CT compared to radiographs.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest Without and With IV Contrast CT without and with IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual- source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31].


Soft Tissue Masses


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest Without IV Contrast CT without IV contrast does not typically play a role in the initial evaluation of a deep soft tissue mass. However, CT can be useful in areas where the osseous anatomy is complex or obscured for the distinction of ossification from calcification and the identification of characteristic patterns of mineralization [29,30]. In anatomically complex areas where radiographs would be less sensitive, CT may be beneficial as the initial or complementary imaging modality. Fortunately, the advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31].


Soft Tissue Masses

Soft Tissue Masses. FDG-PET/CT Area of Interest FDG PET/CT does not typically play a role in the initial evaluation of a soft tissue mass. The CT component associated with PET/CT is of lower resolution compared with conventional CT and is not optimal for accurate characterization of soft tissue mineralization.


Soft Tissue Masses

Soft Tissue Masses. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the initial examination for a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the


Soft Tissue Masses

Soft Tissue Masses

Soft Tissue Masses. Soft Tissue Masses


Soft Tissue Masses

Soft Tissue Masses. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24].


Soft Tissue Masses

Soft Tissue Masses. Variant 3: Soft tissue mass. Nondiagnostic radiograph and noncontrast-enhanced ultrasound. Next imaging study. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot.


Soft Tissue Masses

Soft Tissue Masses. Of note, this variant addresses the scenario in which radiographs and/or noncontrast US have been performed but did not sufficiently characterize a soft tissue mass. In addition, this variant presumes there are no contraindications to any imaging modality. Variant 4 specifically addresses the situation of a contraindication to MRI.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest With IV Contrast Although CT with IV contrast lacks the specificity afforded by MRI in many cases, it does provide useful staging data [32]. In a multi-institutional study of 133 patients with primary soft tissue malignancies, Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures. Therefore, CT with IV contrast remains an important adjunct in the evaluation of a soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. The advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. Similar to CT without IV contrast [21, 22], virtual noncontrast imaging allows distinction of ossification from calcification and identification of characteristic patterns of mineralization [29,30] and is particularly useful in assessment of mass mineralization in areas where the osseous anatomy is complex or obscured and radiographs would be less sensitive.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest Without and With IV Contrast The advent of virtual noncontrast reconstruction with modern dual-source CT scanners allows for acquisition of a single postcontrast scan with reconstruction of virtual noncontrast images, which can preclude the need for a separate precontrast scan phase [31]. However, a traditional CT without and with IV contrast may be appropriate for characterization of mineralization in an anatomically complex area. Although a multi-institutional study of 133 patients with primary soft tissue malignancies by Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures, this study did not specifically endorse the usefulness of dual-phase CT without and with IV contrast. CT with IV contrast remains an important adjunct in the evaluation of a soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest Without IV Contrast The literature does not support the use of single-phase CT without IV contrast as the next imaging study for the evaluation of a soft tissue mass. Although a multi-institutional study of 133 patients with primary soft tissue malignancies by Panicek et al [32] found no statistically significant difference between MRI and contrast-enhanced CT imaging in determining tumor involvement of muscle, bone, joint, or neurovascular structures, this study did not endorse the usefulness of single-phase CT without IV contrast.


Soft Tissue Masses

Soft Tissue Masses. MRI Area of Interest Without and With IV Contrast MRI without and with IV contrast is the technique of choice as the next imaging study for the evaluation of soft tissue masses. Its improved soft tissue contrast and multiplanar capability have provided significant advantages for lesion conspicuity, intrinsic tumor characterization, and local staging [3,11]. Vascular structures and neurovascular involvement are more easily defined when compared with CT.


Soft Tissue Masses

Soft Tissue Masses. The use of MR contrast agents improves the differentiation of benign from malignant soft tissue masses [33]. The contrast allows for better demarcation between viable tumor and muscle, edema-like reactive change, hemorrhage, and tumor necrosis, as well as providing information on tumor vascularity.


Soft Tissue Masses

Soft Tissue Masses. In addition to static MR contrast imaging, there are several additional modern MR techniques that provide greater insight into the character and behavior of soft tissue masses and can assist with differentiation of benign from malignant tumors. These include diffusion-weighted imaging [34-37], dynamic contrast-enhanced perfusion imaging [38,39], and MR spectroscopy [38,39]. Of note, chemical-shift imaging has not shown utility in differentiating benign from malignant soft tissue masses [40]. However, the Dixon technique will likely be increasingly recognized as beneficial for soft tissue tumor imaging through its potential to provide more homogenous fat suppression when compared to traditional T2-fat saturated imaging and better resolution than inversion recovery imaging. Furthermore, it may help decrease imaging time because the Dixon water-only and fat- only images are acquired simultaneously [41,42].


Soft Tissue Masses

Soft Tissue Masses. MRI Area of Interest Without IV Contrast MRI without IV contrast may be beneficial as the next imaging study for the evaluation of soft tissue masses. Its improved soft tissue contrast and multiplanar capability have provided significant advantages for lesion conspicuity, intrinsic tumor characterization, and local staging [3,11]. Vascular structures and neurovascular involvement are more easily defined when compared with CT.


Soft Tissue Masses

Soft Tissue Masses. FDG-PET/CT Area of Interest As a general rule, PET/CT imaging maximum standard uptake value can be useful for differentiating between benign and malignant musculoskeletal masses. When combined with anatomic data provided by CT, FDG-PET/CT can be useful in distinguishing aggressive soft tissue tumors from benign lesions [43-45]. Benz et al [46] showed that FDG-PET can be used to determine a tumor glycolytic phenotype in sarcomas, which correlates significantly with histologic grade. Fused FDG-PET/CT images can be used to plan biopsy, targeting areas with more metabolic activity that may give higher diagnostic yield. Furthermore, a meta-analysis found that FDG-PET can be a helpful tool for predicting outcome in patients with soft tissue sarcoma [47]. Lastly, FDG-PET/CT is an excellent modality to detect metastatic disease and assess treatment response [48]. Despite these benefits, FDG-PET/CT does not usually play a role as the next imaging study for the characterization of a soft tissue mass when initial radiographs or US are nondiagnostic.


Soft Tissue Masses

Soft Tissue Masses. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24].


Soft Tissue Masses

Soft Tissue Masses. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. At least 20% to 25% of soft tissue masses can demonstrate features that allow for confident diagnosis based on MRI alone [23], many of which are benign and


Soft Tissue Masses

Soft Tissue Masses. thus would not warrant biopsy. Therefore, diagnostic imaging that includes comprehensive characterization of the mass should routinely be performed before biopsy. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24].


Soft Tissue Masses

Soft Tissue Masses. US Area of Interest With IV Contrast Although prospective studies have emerged suggesting that US is accurate in the discrimination of benign from malignant soft tissue masses, the number of malignancies in these studies was limited [16,28]. Therefore, the use of US for the final evaluation and staging of a deep soft tissue mass is not recommended.


Soft Tissue Masses

Soft Tissue Masses. Variant 4: Soft tissue mass. Nondiagnostic radiograph and noncontrast-enhanced ultrasound. MRI contraindicated. Next imaging study. The body regions covered in this clinical scenario include the neck, chest, abdomen, pelvis, humerus/upper arm, shoulder, elbow, forearm, wrist, hand, hip, femur/thigh, knee, tibia/lower leg, ankle, and foot.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest With IV Contrast CT has become a useful technique for the evaluation of patients who cannot undergo MRI and is the modality of choice in this scenario [29]. In the evaluation of suspected tumors, contrast imaging is especially useful in distinguishing vascularized from potentially necrotic regions of the tumor. With modern CT technology, calcification can usually be distinguished from vascular enhancement.


Soft Tissue Masses

Soft Tissue Masses. Of note, dual-energy CT is a relatively newer technology that has shown utility in evaluation of soft tissue masses. Using the differences in energy attenuation of soft tissue at 80 kVp and 140 kVp, this technique can allow reconstruction of virtual noncontrast CT images as well as significantly reduce metal artifact in the assessment of metal implants, improving the diagnostic value of imaging in the surrounding soft tissues [49,50]. It has also shown application in the assessment of marrow edema [51,52] and has been investigated in the distinction of marrow edema from intramedullary tumor invasion [53]. Furthermore, spectral CT is emerging as a useful tool for distinguishing benign from malignant soft tissue masses [54].


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest Without and With IV Contrast Dual-phase CT without and with IV contrast as the next imaging study for the evaluation of a soft tissue mass may be appropriate when MRI is contraindicated. Although single-phase CT with IV contrast is considered most appropriate in this clinical scenario given the advent of virtual noncontrast reconstruction with modern dual-source CT scanners [31], a traditional CT without and with IV contrast can be helpful for characterization of mineralization in an anatomically complex area.


Soft Tissue Masses

Soft Tissue Masses. CT Area of Interest Without IV Contrast The literature does not support the use of a single-phase CT without IV contrast as the next imaging study for the evaluation of a soft tissue mass when MRI is contraindicated. However, single-phase CT with IV contrast is a useful technique for the evaluation of patients who cannot undergo MRI and is the modality of choice in this scenario [29]. In the evaluation of suspected tumors, contrast imaging is especially useful in distinguishing vascularized from potentially necrotic regions of the tumor. With modern CT technology, calcification can usually be distinguished from vascular enhancement. Therefore, CT without IV contrast is usually not beneficial.


Soft Tissue Masses

Soft Tissue Masses. FDG-PET/CT Area of Interest Although FDG-PET/CT is not typically used as the next imaging study for the characterization of a soft tissue mass, PET/CT imaging maximum standard uptake value can be useful for differentiating between benign and malignant musculoskeletal masses. When combined with anatomic data provided by CT, FDG-PET/CT can be useful in distinguishing aggressive soft tissue tumors from benign lesions [43-45]. Benz et al [46] showed that FDG-PET can be used to determine a tumor glycolytic phenotype in sarcomas, which correlates significantly with histologic grade. Fused FDG-PET/CT images can be used to plan biopsy, targeting areas with more metabolic activity that may give higher diagnostic yield. Furthermore, a meta-analysis found that FDG-PET can be a helpful tool for predicting outcome in patients with soft tissue sarcoma [47]. Lastly, FDG-PET/CT is an excellent modality to detect metastatic disease and assess treatment response [48]. Despite these benefits, FDG-PET/CT does not usually play a role in the initial assessment of a soft tissue mass.


Soft Tissue Masses

Soft Tissue Masses. Image-Guided Biopsy Area of Interest The literature does not support the use of image-guided biopsy as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. If MRI is contraindicated, characterization of the mass using


Soft Tissue Masses

Soft Tissue Masses

Soft Tissue Masses. Soft Tissue Masses


Soft Tissue Masses

Soft Tissue Masses. CT with IV contrast should routinely be performed before biopsy [29]. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24].


Soft Tissue Masses

Soft Tissue Masses. Image-Guided Fine Needle Aspiration Area of Interest The literature does not support the use of image-guided fine needle aspiration as the next step in evaluation following nondiagnostic radiographs or US of a soft tissue mass. If MRI is contraindicated, characterization of the mass using CT with IV contrast should routinely be performed before biopsy [29]. In fact, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma state that biopsy should be performed only after adequate imaging [24].


Soft Tissue Masses

Soft Tissue Masses. US Area of Interest With IV Contrast There is insufficient literature to support the routine use of US with IV contrast as the next imaging study for the evaluation of a soft tissue mass when MRI is contraindicated.


Soft Tissue Masses

Soft Tissue 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.


Soft Tissue Masses

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


Staging and Follow up of Esophageal Cancer. Introduction/Background Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer death worldwide. The American Cancer Society estimates there will be 19,260 new cases of and 15,530 deaths from esophageal cancer in the United States in 2021 [1]. Squamous cell carcinoma and adenocarcinoma comprise 98% of malignant tumors of the esophagus. Worldwide, squamous cell carcinoma is still more common, but in Western countries, adenocarcinoma now predominates and accounts for more than 60% of cases. In general, squamous cell carcinoma usually occurs in the upper and middle esophagus, whereas adenocarcinoma predominates in the lower esophagus [2].


Staging and Follow up of Esophageal Cancer. For esophageal cancers, initial clinical staging uses a combination of imaging modalities with biopsies used to confirm suspected sites of disease. Specific strategies for the evaluation of the patient with esophageal cancer vary by institution not only in terms of the modalities used but in the order in which they are used. One common strategy is initial esophagogastroduodenoscopy and esophageal ultrasound (US) to determine cell type, grade, local extent, and locoregional nodal involvement followed by fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT to provide additional information on nodal disease and to evaluate for distant metastases. Another common strategy involves using CT or FDG-PET/CT first to evaluate for findings of metastatic disease. If metastatic disease is found, further evaluation with esophagogastroduodenoscopy and esophageal US may not be warranted [3]. The identification of distant metastatic disease is critical in the evaluation of the patient with newly diagnosed esophageal cancer because it will direct them to a treatment pathway centered on palliative chemoradiation rather than surgery. A secondary concern is the confirmation of locoregional spread because this is often an important determinant in whether neoadjuvant chemoradiation is used. If neoadjuvant chemoradiation is employed, follow- up imaging before definitive surgical treatment is necessary. Although the utility of follow-up imaging, particularly FDG-PET/CT, is of debate during and after neoadjuvant therapy to predict response, it does have a critical role in evaluating for the interval development of distant metastases and is commonly used for this purpose.


Staging and Follow up of Esophageal Cancer. OR aMallinckrodt Institute of Radiology, Saint Louis, Missouri. bUMass Medical School, Worcester, Massachusetts. cPanel Chair, Duke University, Durham, North Carolina. dPanel Chair, University of Alabama Medical Center, Birmingham, Alabama. eThe University of Chicago, Chicago, Illinois; American Society of Clinical Oncology. fEmory University Hospital, Atlanta, Georgia. gHampton VA Medical Center, Hampton, Virginia. hUniversity of California San Francisco, San Francisco, California, Hospitalist. iUniversity of Michigan Health System, Ann Arbor, Michigan. jUniversity of North Carolina Hospital, Chapel Hill, North Carolina; The Society of Thoracic Surgeons. kUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. lUniversity of Arizona College of Medicine, Phoenix, Arizona. mVanderbilt University Medical Center, Nashville, Tennessee. nNational Institutes of Health, Bethesda, Maryland. oThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. pDavid Grant Medical Center, Travis AFB, California. qSpecialty Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. rSpecialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio.


Staging and Follow up of Esophageal Cancer. 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.


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


Staging and Follow up of Esophageal Cancer. Staging and Follow-up of Esophageal Cancer Discussion of Procedures by Variant Variant 1: Newly diagnosed esophageal cancer. Pretreatment clinical staging. Initial imaging. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with intravenous (IV) contrast. There is no relevant literature supporting the use of CT for evaluation of the extent of tumor extension into the esophageal wall in T1 to T3 tumors. There are, however, older studies that investigated the use of CT for the evaluation of extension into adjacent structures. Picus et al [4] reviewed CT examinations in 52 patients with esophageal carcinoma, 30 of whom had surgery or autopsy, and found that CT appearance correctly determined aortic involvement in 24 of 25 cases, with 5 indeterminate. Takashima et al [5] prospectively reviewed CT examinations on 35 patients and the reported sensitivity, specificity, and accuracy for resectability (defined as absence of evidence of invasion of adjacent structures) to be 100%, 80%, and 84%, respectively. A meta-analysis by Puli et al [6] reviewed data from 49 studies and 2,558 patients and reported pooled sensitivity and specificity of 92.4% and 97.4%, respectively, in the diagnosis of T4 disease. Unlike CT, esophageal US can also evaluate wall involvement of lower T stage tumors, with the meta-analysis by Puli et al [6] reporting sensitivity and specificity for T1 tumors of 81.6% and 99.4%, T2 tumors of 81% and 96%, and T3 tumors of 91.4% and 94.4%, respectively.


Staging and Follow up of Esophageal Cancer. There is no relevant literature supporting the use of CT for nodal staging. A study by Choi et al [7], which prospectively evaluated 109 patients with esophageal cancer, used a short-axis diameter of 8 mm for the determination of positive nodes and reported a sensitivity of 35% and specificity of 93% for CT. CT is limited in the evaluation of nodal metastatic disease because multiple studies have shown that nodal metastases often occur in small lymph nodes in patients with esophageal cancer. Foley et al [8] evaluated 112 patients with multiple modalities and reported an accuracy of 54.5%, a sensitivity of 55.4%, a sensitivity of 39.7%, and a specificity of 77.4% for CT. Foley et al [8] also reported that 82% of positive lymph nodes measured <6 mm. Similarly, Kajiyama et al [9] reported that two-thirds of 320 metastatic lymph nodes assessed by surgery were <5 mm, further reinforcing that preoperative anatomic imaging evaluation will have a limited role in the detection of nodal metastatic disease. In terms of clinical relevance, Bunting et al [10] prospectively studied 133 patients undergoing surgery and reported an N stage accuracy of 75.6%. Their conclusion was that staging accuracy of locoregional disease with respect to the neoadjuvant threshold was poor with all modalities, including CT, and could potentially lead to over- and undertreatment.


Staging and Follow up of Esophageal Cancer. The principle use of CT in the initial evaluation of patients with esophageal cancer is in detecting metastatic disease. CT has been compared with PET and FDG-PET/CT by several authors. Heeren et al [11] compared combined CT/esophageal US with PET and reported that sensitivity for distant nodal and systemic metastatic disease increased from 37% with CT/esophageal US to 78% with PET. Similarly, Hocazade et al [12] prospectively evaluated 91 patients with PET/CT and CT and reported that 47.3% of patients had metastases detected on PET/CT that were not detected by CT. Thus, although CT can detect metastases in the setting of esophageal cancer, it has been found to be less sensitive than PET and FDG-PET/CT even when combined with esophageal US.


Staging and Follow up of Esophageal Cancer. The described literature presented here is based on contrast-enhanced CT. There are no reliable studies reporting the use of CT without IV contrast. When CT is used in the initial staging of esophageal cancer, contrast is recommended for optimal performance.


Staging and Follow up of Esophageal Cancer. CT Chest, Abdomen, and Pelvis For the purposes of this document, CT examinations are considered as being performed with IV contrast. Including the pelvis in CT for esophageal cancer would not affect the performance of CT for locoregional staging. The studies presented above by Heeren et al [11] and Hocazade et al [12] for the evaluation of systemic metastatic disease used CT of the chest and abdomen only. There are no studies that directly compare CT of the chest and abdomen with CT of the chest, abdomen, and pelvis; thus, the utility or added value of including the pelvis for the initial staging of esophageal cancer is not known.


Staging and Follow up of Esophageal Cancer. FDG-PET/CT Skull Base to Mid-Thigh Although there have been many studies evaluating the use of FDG-PET/CT in the evaluation of the primary tumor for prognosis, data supporting its use for T and N staging are limited. Walker et al [13] prospectively evaluated 81 patients with esophageal cancer with FDG-PET/CT and esophageal US and determined that esophageal US was superior to FDG-PET/CT for T staging and identifying locoregional lymph nodes. Hsu et al [14] investigated the use of PET/CT in 45 patients undergoing surgical resection for esophageal cancer and found that the maximum standardized uptake value (SUV)max showed potential in differentiating T1 from higher T stage tumors. In the same


Staging and Follow up of Esophageal Cancer. Staging and Follow-up of Esophageal Cancer study, however, the sensitivity, specificity, and accuracy of PET/CT for nodal involvement were 57.1%, 83.3%, and 71.1%, respectively. Foley et al [8] also reported sensitivity, specificity, and accuracy of FDG-PET/CT of 77.3%, 75%, and 90.9%, respectively, for nodal involvement in a prospective study of 112 patients with esophageal cancer. Given that 82% of lymph node metastases were <6 mm in this study, the authors concluded that imaging staging for N disease was poor. Bunting et al [10] prospectively evaluated 133 patients with esophageal cancer undergoing surgery and reported an N stage accuracy of 78.6% for FDG-PET/CT. Bunting et al [10] also concluded that staging accuracy with respect to the threshold for treatment for neoadjuvant chemoradiation was poor and could lead to over- and undertreatment. A meta-analysis by van Westreenen et al [15] reported pooled sensitivity of 51% and specificity of 84% for FDG-PET/CT for locoregional metastases. Limited performance of FDG-PET/CT in locoregional staging is likely due to poor spatial resolution of PET and the reality that metastatic lymph nodes in esophageal cancer are often small. Even some primary tumors may not be detected with FDG-PET/CT either because of small size or in histologic subtypes with low FDG uptake [2].


Staging and Follow up of Esophageal Cancer. There are many studies that have evaluated the use of FDG-PET/CT in detecting M disease in initial staging. Heeren et al [11] investigated 74 patients with FDG-PET/CT and found that FDG-PET/CT increased detection of M1 disease from 37% to 78% in comparison with CT/esophageal US. Vyas et al [16] prospectively investigated 114 patients with biopsy-proven esophageal adenocarcinoma and reported a sensitivity of 57.14% and specificity of 84.53% in detecting metastatic disease. A larger meta-analysis by van Westreenen et al [15] reported a pooled sensitivity and specificity for FDG-PET/CT of 67% and 97%, respectively, in the detection of M1 disease in esophageal cancer.


Staging and Follow up of Esophageal Cancer. In terms of effects on clinical staging, You et al [17] prospectively evaluated 491 patients with esophageal cancer with FDG-PET/CT and reported clinically important stage changes in 188 (24%) patients. In a smaller cohort, Williams et al [18] reported the use of FDG-PET/CT changing initial staging in 10 of 38 (26%) patients with esophageal cancer, with 7 of 38 (18%) patients having a concomitant management change.


Staging and Follow up of Esophageal Cancer. FDG-PET/MRI Skull Base to Mid-Thigh There are no substantial data supporting the use of FDG-PET/MRI in the staging of esophageal cancer. In a small study evaluating 19 patients with esophageal cancer who underwent esophageal US, CT, FDG-PET/CT, and FDG- PET/MRI, Lee et al [19] reported acceptable T staging compared with esophageal US and statistically nonsignificant but higher accuracy than esophageal US and FDG-PET/CT for N staging. Impact on M staging was not reported. Given available data on the performance of FDG-PET/CT in the evaluation of M disease, it would be expected that FDG-PET/MRI may have similar potential, but data supporting its use are not yet available.


Staging and Follow up of Esophageal Cancer. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper gastrointestinal (GI) series in the staging of esophageal cancer.


Staging and Follow up of Esophageal Cancer. MRI Chest and Abdomen There is only limited evidence supporting the use of MRI chest and abdomen in the evaluation of patients with esophageal cancer. Giganti et al [20] compared MRI, CT, esophageal US, and FDG-PET/CT in 27 patients with esophageal cancer. In this small study, contrast-enhanced MRI with diffusion-weighted imaging showed higher specificity (92%) and accuracy (82%) for T staging, but esophageal US was the most sensitive modality. MRI showed the highest reported accuracy for N stage (66%) in this study, although this would be in line with values previously determined for other imaging modalities. Qu et al [21] prospectively evaluated the use of contrast- enhanced radial VIBE sequences in the T staging of 43 patients with esophageal cancer and determined higher accuracy with MRI for T3 and T4 tumors. Malik et al [22] compared FDG-PET/CT and whole-body MRI in 49 patients, reporting similar performance for locoregional staging. Both modalities identified distant metastases that were present in 2 of the patients.


Staging and Follow up of Esophageal Cancer. Radiography Chest There is no relevant literature to support the use of chest radiography in the initial staging of patients with esophageal cancer.


Staging and Follow up of Esophageal Cancer. Variant 2: Esophageal cancer. Imaging during treatment. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. There is no relevant literature supporting the use of CT in patients who have undergone neoadjuvant chemoradiation. There


Staging and Follow up of Esophageal Cancer. Staging and Follow-up of Esophageal Cancer are 2 studies that discourage its use for the evaluation of tumor response. In a study investigating 39 patients, van Heijl et al [23] reported that tumor volume changes identified on CT at 14 days were not associated with histopathologic tumor response. In a study evaluating the use of CT before and after neoadjuvant therapy in 35 patients with esophageal cancer, Konieczny et al [24] determined that CT accurately predicted complete histopathologic response in 20% and overstaged in 80%. An older systematic review by Westerterp et al [25] that reviewed 4 studies with CT showed the maximum joint value for sensitivity and specificity for CT in predicting response to neoadjuvant therapy was 54%. It should be noted that another important purpose of imaging patients after neoadjuvant therapy is to evaluate for the interval development of metastases. Although there are no studies evaluating CT specifically for this purpose, it would be expected to perform similarly to initial staging.


Staging and Follow up of Esophageal Cancer. CT Chest, Abdomen, and Pelvis There is no relevant literature to support the inclusion of the pelvis in CT examinations during treatment.


Staging and Follow up of Esophageal Cancer. FDG-PET/CT Skull Base to Mid-Thigh There are conflicting data on the use of FDG-PET/CT for the evaluation of patients undergoing neoadjuvant chemotherapy. A systematic review of the literature in 2004 by Westerterp et al [25] assessed 7 studies using FDG- PET for the assessment of response to neoadjuvant chemotherapy in esophageal cancer. The maximum joint sensitivity and specificity for FDG-PET for in detecting response was 85%, with an accuracy similar to esophageal US and superior to CT. Subsequent studies showed promising results for FDG-PET/CT. Gabrielson et al [26] prospectively evaluated 51 patients undergoing neoadjuvant chemotherapy for esophageal cancer and found that SUVs could be used to differentiate responders from nonresponders but were not found to demonstrate statistical significance in patients with complete versus subtotal response. Beukinga et al [27] prospectively evaluated 74 patients using a radiomics-based quantitative assessment of postneoadjuvant chemoradiation FDG-PET/CT examinations and concluded that posttreatment FDG-PET/CT orderliness combined with clinical T staging resulted in high discriminatory accuracy in predicting complete histopathologic response. Thurau et al [28] conducted a retrospective review of 83 patients with esophageal cancer who had FDG-PET/CT performed at 6 weeks after induction of neoadjuvant therapy. The authors reported that an SUV reduction of >50% correlated with major histomorphologic response and that patients with this reduction also showed significantly increased survival.


Staging and Follow up of Esophageal Cancer. Other authors, however, found fewer promising results when evaluating FDG-PET/CT for the assessment of response to neoadjuvant therapy. Vallbohmer et al [29] prospectively evaluated 119 patients with FDG-PET/CT 2 to 3 weeks after induction of neoadjuvant chemotherapy and found no significant association between major responders and FDG-PET/CT results; receiver operating characteristic analysis could not identify an SUV threshold to predict histomorphologic response, and there was no association between metabolic imaging and prognosis. Elliot et al [30] prospectively evaluated 100 patients with esophageal cancer who underwent FDG-PET/CT at 2 to 4 weeks after completion of neoadjuvant therapy and concluded FDG-PET/CT had poor prognostic value and clinical application for determining responders. Piessen et al [31] prospectively evaluated 46 patients with esophageal cancer who had FDG-PET/CT performed 4 to 6 weeks after completion of neoadjuvant therapy and concluded that FDG-PET/CT did not correlate with pathological response and long-term survival in patients with locally advanced esophageal cancer. Van Heijl et al [32] prospectively studied patients with esophageal cancer who had FDG- PET/CT at 2 weeks after the induction of chemotherapy and found FDG-PET/CT showed a statistically significant decrease in SUV in responders and correctly identified 58 of 64 responders and 18 of 36 nonresponders. The authors concluded that the low accuracy in detecting nonresponders did not justify using FDG-PET/CT for early discontinuation of neoadjuvant chemotherapy.


Staging and Follow up of Esophageal Cancer. FDG-PET/CT also has the potential to detect metastases that have developed in the interval after the induction of neoadjuvant therapy. A systematic review and meta-analysis performed by Kroese et al [33] evaluated 14 studies (1,110 patients) and found a pooled proportion of 8% of patients having interval metastases detected by FDG- PET/CT. The authors also reported an additional pooled proportion of 5% of patients who had false-positive concerning distant findings. Kroese et al [33] concluded that the detection of distant metastases on restaging FDG- PET/CT after induction of neoadjuvant therapy can considerably impact decision making but that suspicious imaging findings required pathologic confirmation.


Staging and Follow up of Esophageal Cancer. FDG-PET/MRI Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/MRI during treatment.


Staging and Follow up of Esophageal Cancer. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper GI series during treatment.


Staging and Follow up of Esophageal Cancer. Staging and Follow-up of Esophageal Cancer MRI Chest and Abdomen There are limited data from small series investigating the use of MRI for the evaluation of patients undergoing treatment. A prospective study of 26 patients undergoing neoadjuvant therapy for esophageal cancer who underwent dynamic contrast-enhanced MRI by Heethuis et al [34] demonstrated that the area under the curve could predict good responders and poor responders with a sensitivity of 92% and a specificity of 77%. Sun et al [35] used dynamic contrast-enhanced MRI to evaluate patients with advanced squamous cell cancer of the esophagus and reported that the change in Ktrans was a parameter that could be potentially used to assess treatment response. Wang et al [36] studied 38 patients with squamous cell cancer of the esophagus undergoing chemoradiotherapy with weekly MRI including diffusion-weighted imaging. The authors reported that treatment-induced change in apparent diffusion coefficient during the first 2 to 3 weeks could be used to assess response to therapy. Wang et al [37] prospectively studied 79 patients with esophageal cancer who had 3T MRI before and after neoadjuvant therapy and reported a sensitivity, specificity, and accuracy of more than 90% for several sequences in T staging after neoadjuvant therapy.


Staging and Follow up of Esophageal Cancer. No studies are available that investigate the performance of MRI for detecting interval metastases in patients undergoing neoadjuvant therapy.


Staging and Follow up of Esophageal Cancer. Radiography Chest There is no relevant literature to support the use of chest radiography during treatment.


Staging and Follow up of Esophageal Cancer. Variant 3: Esophageal cancer. Posttreatment imaging. No suspected or known recurrence. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. CT has been studied in the evaluation of patients who have completed treatment. Recent data exist from studies comparing FDG-PET and FDG-PET/CT with contrast-enhanced CT in the detection of recurrence. Kato et al [38] studied 55 patients and reported 89% sensitivity, 79% specificity, and 84% accuracy for CT in detecting recurrent disease in comparison with 96% sensitivity, 68% specificity, and 82% accuracy for FDG-PET. The authors did note that CT was more sensitive than FDG-PET for the detection of lung metastases. Teyton et al [39] prospectively studied 41 patients postsurgery for esophageal cancer and reported 65% sensitivity and 91% specificity for chest and abdomen CT versus 100% sensitivity and 85% specificity for FDG-PET. Of note, in a retrospective review by Antonowicz et al [40], 169 patients who underwent esophagectomy and were followed with annual CT had no change in management or survival.


Staging and Follow up of Esophageal Cancer. CT Chest, Abdomen, and Pelvis There are no specific studies comparing body CT scans that include the pelvis with those that do not in asymptomatic patients undergoing CT to evaluate for recurrent disease.


Staging and Follow up of Esophageal Cancer. FDG-PET/CT Skull Base to Mid-Thigh Several studies have evaluated FDG-PET/CT in the evaluation of asymptomatic patients who have had definitive treatment for esophageal cancer. Betancourt et al [41] studied 162 asymptomatic patients who underwent surgery for esophageal cancer and were followed with FDG-PET/CT. They reported a sensitivity of 77% and specificity of 76% for recurrence at the anastomosis, sensitivity of 88% and specificity of 85% for regional node recurrence, and sensitivity of 97% and specificity of 96% for distant metastases. A systematic review of the literature by Goense et al [42] evaluating 486 patients across 8 studies reported a pooled sensitivity of 96% and a specificity of 78% in detecting recurrent disease. There was no statistically significant difference in the performance of FDG-PET/CT in patients who were asymptomatic or had a clinical indication for the examination.


Staging and Follow up of Esophageal Cancer. FDG-PET/MRI Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/MRI to follow asymptomatic patients after treatment.


Staging and Follow up of Esophageal Cancer. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper GI series to follow asymptomatic patients after treatment.


Staging and Follow up of Esophageal Cancer. MRI Chest and Abdomen There is no relevant literature to support the use of MRI chest and abdomen to follow asymptomatic patients after treatment.


Staging and Follow up of Esophageal Cancer. Staging and Follow-up of Esophageal Cancer Radiography Chest There is no relevant literature to support the use of chest radiography to follow asymptomatic patients after treatment.


Staging and Follow up of Esophageal Cancer. Variant 4: Esophageal cancer. Posttreatment imaging. Suspected or known recurrence. CT Chest and Abdomen For the purposes of this document, CT examinations are considered as being performed with IV contrast. Sharma et al [43] studied 227 patients with suspected esophageal cancer who had suspected metastasis. All patients underwent FDG-PET/CT, whereas 109 patients also underwent contrast-enhanced CT. The authors reported a sensitivity of 96% and a specificity of 81% for FDG-PET/CT compared with a 97% sensitivity and a 21% specificity for contrast-enhanced CT.


Staging and Follow up of Esophageal Cancer. CT Chest, Abdomen, and Pelvis There are no specific studies comparing body CT scans that include the pelvis with those that do not in patients undergoing CT to evaluate for clinically suspected recurrent disease.


Staging and Follow up of Esophageal Cancer. FDG-PET/CT Skull Base to Mid-Thigh As above, Sharma et a [43] studied 227 patients with suspected esophageal cancer who had suspected metastasis. All patients underwent FDG-PET/CT, whereas 109 patients also underwent contrast-enhanced CT. The authors reported a sensitivity of 96% and specificity of 81% for FDG-PET/CT compared with a 97% sensitivity and a 21% specificity for contrast-enhanced CT. Also, as discussed previously, a systematic review of the literature by Goense et al [42] evaluating 486 patients across 8 studies reported a pooled sensitivity of 96% and a specificity of 78% in detecting recurrent disease. There was no statistically significant difference in the performance of FDG-PET/CT in patients who were asymptomatic or had a clinical indication for the examination.


Staging and Follow up of Esophageal Cancer. FDG-PET/MRI Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/MRI to evaluate patients suspected to have metastases after treatment.


Staging and Follow up of Esophageal Cancer. Fluoroscopy Upper GI Series There is no relevant literature to support the use of fluoroscopy upper GI series to evaluate patients suspected to have metastases after treatment.


Staging and Follow up of Esophageal Cancer. MRI Chest and Abdomen There is no relevant literature to support the use of MRI chest and abdomen to evaluate patients suspected to have metastases after treatment.