Female Breast Cancer Screening

Female Breast Cancer Screening. Within the limited studies of women at elevated risk due to personal and/or family history of breast cancer, DBT decreased recall rate without a significant increase in CDR compared to FFDM; however, small sample sizes restrict analyses [3,40].


Female Breast Cancer Screening

Female Breast Cancer Screening. Because screening mammography decreases breast cancer mortality, screening mammography or screening DBT is still performed in women undergoing supplemental screening studies [3,8,35]. The ACR recommends annual screening mammography beginning no later than 40 years of age for women at intermediate risk [3]. For those with a family history of breast cancer, mammography should begin earlier if familial breast cancer occurred at a young age, typically 10 years prior to the youngest age at presentation but generally not before age 30 [6]. For women who have lobular neoplasia or atypical hyperplasia diagnosed prior to 40 years of age, annual screening mammography should be performed from time of diagnosis but generally not prior to 30 years of age [38]. Early detection of second breast cancers improves survival, so patients with a personal history of breast cancer should undergo annual mammography or DBT for surveillance following breast conservation therapy [3].


Female Breast Cancer Screening

Female Breast Cancer Screening. Despite the established mortality benefit, published guidelines differ in their recommendations for screening mammography due to variations in the perceptions of the relative risks and benefits [5,38]. The degree of breast cancer mortality reduction from screening mammography varies with different screening regimens. Mortality reduction is greater when screening begins 40 years of age rather than 45 or 50 years of age and when screening is done more frequently (annually rather than biennially) [8,31]. Annual screening mammography for women 40 to 84 years of age decreases mortality by 40% (12 lives per 1,000 women screened), whereas biennial screening mammography for women 50 to 74 years of age only decreases mortality by 23% (7 lives per 1,000 women screened) [32]. Earlier initiation of screening and more frequent screening result in a greater number of imaging


Female Breast Cancer Screening

Female Breast Cancer Screening. For women 40 to 49 years of age, randomized controlled trials and observational studies demonstrate that screening mammography decreases breast cancer mortality by 15% to 50% [1,8,32,33,39]. Results from the CISNET suggest that annual screening mammography in women 40 to 49 years of age saves 42% more lives and life-years than biennial screening due to faster growing tumors in younger women [31]. Women screened between 40 and 49 years of age are also less likely to require mastectomy or chemotherapy than women diagnosed with palpable tumors [2].


Female Breast Cancer Screening

Female Breast Cancer Screening. Non-Hispanic black women, Hispanic black, and Hispanic white women have higher breast cancer mortality than non-Hispanic white women, and minority women often present at younger ages with more aggressive tumor subtypes [3,8]. Therefore, decreasing access to screening mammography, especially in women 40 to 49 years of age, may disproportionately impact minority women.


Female Breast Cancer Screening

Female Breast Cancer Screening. Annual screening mammography results in a greater reduction in mortality compared to biennial screening [8]. In women 40 to 84 years of age, annual screening reduces mortality by 40%, compared to a 32% reduction for biennial screening [32]. With regular screening, interval breast cancers do occur with a higher frequency in women undergoing biennial or triennial screening compared to annual screening. The sensitivity of mammography is decreased in some groups of women, including those with dense breasts [40]. Dense breast tissue decreases the sensitivity of mammography [26] and is an independent risk factor for developing breast cancer [27]. Compared to average breast density (near the threshold between heterogeneously dense and scattered areas of fibroglandular density), the relative risks for developing breast cancer are 1.2 for heterogeneously dense and 2.1 for extremely dense breasts [28]. Some health care providers may therefore consider women with extremely dense breasts to no longer be average risk. Given the limitations of mammography and to minimize interval cancers, supplemental screening modalities have been investigated in women at intermediate risk.


Female Breast Cancer Screening

Female Breast Cancer Screening. Because screening mammography decreases breast cancer mortality, screening mammography or screening DBT is still performed in women undergoing supplemental screening studies [3,8,35]. Rather than supplementing screening mammography with additional imaging modalities, some have suggested limiting women offered screening mammography based upon individual patient risk assessed by various risk models, breast density, or genetic information such as single-nucleotide polymorphisms. However, the randomized controlled trials demonstrating mortality reduction and most large-scale observational studies enrolled women based upon age and geographic location, not individual patient risk factors. In one observational study in women <50 years of age, restricting screening to women with a first-degree family history, extremely dense breast tissue, or both, would cause 66% of potentially screen-detected cancers to be missed [41].


Female Breast Cancer Screening

Female Breast Cancer Screening. To maximize the benefits, the ACR recommends annual screening mammography beginning no later than 40 years of age for women at intermediate risk [3]. Women should continue screening mammography as long as they remain in overall good health and are willing to undergo the examination and subsequent testing or biopsy, if an abnormality is identified [5,8]. For those with a family history of breast cancer, mammography should begin earlier if familial breast cancer occurred at a young age, typically 10 years prior to the youngest age at presentation but generally not before 30 years of age [6]. For women who have lobular neoplasia or atypical hyperplasia diagnosed prior to 40 years of age, annual screening mammography should be performed from time of diagnosis but generally not prior to 30 years of age [38]. Early detection of second breast cancers improves survival, so patients with a personal history of breast cancer should undergo annual mammography or DBT for surveillance following breast conservation therapy [3].


Female Breast Cancer Screening

Female Breast Cancer Screening. Mammography With IV Contrast Data are limited regarding the use of mammography with IV contrast for breast cancer screening in intermediate- risk women. To date, published studies have predominantly included women with dense breasts and other risk factors resulting in intermediate- or high-risk profiles. Compared to mammography alone, mammography with IV contrast increases cancer detection (incremental CDR = 6.6-13 per 1,000) in women at elevated risk [57-60].


Female Breast Cancer Screening

Female Breast Cancer Screening

Female Breast Cancer Screening. Female Breast Cancer Screening


Female Breast Cancer Screening

Female Breast Cancer Screening. MRI Breast Without and With IV Contrast MRI has a higher CDR than mammography alone, DBT, or mammography/DBT combined with US [61-64]. The incremental CDR of MRI in elevated-risk women ranges from 8 to 29 per 1,000 women, with lower CDR estimates in intermediate-risk women compared to high-risk BRCA mutation carriers [61-63,65,66]. In one study, breast MRI CDR was 15 per 1,000 in women with a prior biopsy demonstrating a high-risk lesion compared to 8 per 1,000 in women reporting a family history [65]. In women with a personal history of breast cancer, a meta-analysis estimated a CDR of 9 to 15 per 1,000 breast MRI [67]. Breast MRI detects small, node-negative invasive cancers at earlier tumor stages compared to mammography, as well as ductal carcinoma in situ [68,69]. Screening MRI also reduces interval cancers [69]. However, breast MRI has a higher recall rate than mammography (15.1% versus 6.4%) [70], higher frequency of BI-RADS category 3 assessment than mammography (14.8% versus 11.8%), and greater frequency of image-guided biopsies than mammography (11.8% versus 2.4%) [63].


Female Breast Cancer Screening

Female Breast Cancer Screening. MRI Breast Without IV Contrast There is no relevant literature to support the use of breast MRI without IV contrast for screening women at intermediate risk.


Female Breast Cancer Screening

Female Breast Cancer Screening. MRI Breast Without IV Contrast Abbreviated There is no relevant literature to support the use of abbreviated breast MRI without IV contrast for screening women at intermediate risk.


Female Breast Cancer Screening

Female Breast Cancer Screening. Sestamibi MBI Data are limited regarding the use of sestamibi MBI for screening women at intermediate risk. Most studies have focused upon women with dense breasts and variable risk profiles. Retrospective and prospective studies have demonstrated similar incremental CDR for sestamibi MBI of 6.5 to 9 over mammography, with a study demonstrating an incremental CDR of 16.5 per 1,000 in women at increased risk primarily due to family or personal history of breast cancer [40,47]. Sestamibi MBI demonstrates similar sensitivity, better specificity, and lower recall rate compared to supplemental screening US in women with dense breasts [47,48].


Female Breast Cancer Screening

Female Breast Cancer Screening. US Breast Most studies evaluating the utility of screening with breast US have focused on women with dense breast tissue with or without other risk factors. Dense breast tissue decreases the sensitivity of mammography [26] and is an independent risk factor for developing breast cancer [27]. Screening breast US in women with mammographically dense breasts, including those with risk factors placing them at increased breast cancer risk, identifies predominantly mammographically occult, small, node-negative invasive tumors with an increased CDR of 1.8 to 4.6 cancers per 1,000 women screened [40,49]. Although supplemental screening US in women with dense breasts results in an increased CDR, US also increases recall rate, false-positive examinations, and false-positive biopsies [26,49-55]. In women undergoing annual mammography plus annual supplemental screening MRI, the addition of supplemental screening with US does not identify additional cancers and is therefore not routinely performed.


Female Breast Cancer Screening

Female Breast Cancer Screening. The ACRIN 6666 trial enrolled women with dense breast tissue and at least one other breast cancer risk factor [61]. Compared to mammography alone, screening US detected 5.3 cancers per 1,000 in year 1, 3.7 cancers per 1,000 in years 2 and 3, and resulted in a larger number of false-positive examinations and false-positive biopsies each year [61]. In a prospective study limited to intermediate-risk women, sensitivity of mammography was 57%, US was 24.5%, and mammography combined with biannual US demonstrated 80.4% sensitivity [76]. In women with a


Female Breast Cancer Screening

Female Breast Cancer Screening. Female Breast Cancer Screening personal history of breast cancer, supplemental US screening results in an incremental CDR of 2.4 to 2.9 cancers per 1,000 examinations over mammography alone; however, US screening has lower specificity [10,66].


Female Breast Cancer Screening

Female Breast Cancer Screening. Digital Breast Tomosynthesis Screening DBT displays reconstructed stacked images of the breast in combination with digital mammographic views, which may be synthetic mammograms reconstructed from the acquired tomosynthesis data set or FFDM. Compared to FFDM or synthetic mammograms alone, most studies demonstrate that DBT increases CDR and decreases recall rate [14-22]; although, some studies have not reached statistical significance [23] or have found less compelling results in subsets of women, such as those with extremely dense breasts [24,25]. Dense breast tissue decreases the sensitivity of mammography [26] and is an independent risk factor for developing breast cancer [27]. Irrespective of risk category, meta-analyses have demonstrated an incremental increase in CDR of 1.6 to 3.2 per 1,000 screening DBT examinations and a 2.2% pooled decrease in recall rate compared to digital mammography [18,29,30].


Female Breast Cancer Screening

Female Breast Cancer Screening. Within the limited studies of women at elevated risk due to personal and/or family history of breast cancer, DBT decreased recall rate without a significant increase in CDR compared to FFDM; however, small sample sizes restrict analyses [3,40].


Female Breast Cancer Screening

Female Breast Cancer Screening. High-risk women should begin annual screening mammography at 30 years of age or 10 years prior to the youngest family member who had breast cancer, but generally not before 30 years of age [3]. Approximately one-third of breast cancers may only be detected on mammography in BRCA2 mutation carriers who are <40 years of age [79]. In some mutation carriers, some referring providers use mammography or DBT beginning at 40 years of age if patients undergo annual MRI [80]. Women who underwent thoracic or upper abdominal radiation therapy at an early age (<30 years) should begin screening mammography 8 years after radiation therapy but not before 25 years of age [3].


Female Breast Cancer Screening

Female Breast Cancer Screening. Because screening mammography decreases breast cancer mortality, screening mammography or screening DBT is still performed in women undergoing supplemental screening studies [3,8,35].


Female Breast Cancer Screening

Female Breast Cancer Screening. Mammography Screening To date, mammography is the only screening modality shown to decrease breast cancer mortality. Multiple randomized controlled trials demonstrate that invitation to screening mammography results in at least a 22%


Female Breast Cancer Screening

Female Breast Cancer Screening


Female Breast Cancer Screening

Female Breast Cancer Screening. For women 40 to 49 years of age, randomized controlled trials and observational studies demonstrate that screening mammography decreases breast cancer mortality by 15% to 50% [1,8,32,33,39]. Results from the CISNET suggest that annual screening mammography in women 40 to 49 years of age saves 42% more lives and life-years than biennial screening due to faster growing tumors in younger women [31]. Women screened between 40 and 49 years of age are also less likely to require mastectomy or chemotherapy than women diagnosed with palpable tumors [2].


Female Breast Cancer Screening

Female Breast Cancer Screening. Non-Hispanic Black, Hispanic Black, and Hispanic White women have higher breast cancer mortality than non- Hispanic White women, and minority women often present at younger ages with more aggressive tumor subtypes [3,8]. Therefore, decreasing access to screening mammography, especially in women 40 to 49 years of age, may disproportionately impact minority women.


Female Breast Cancer Screening

Female Breast Cancer Screening. Annual screening mammography results in a greater reduction in mortality compared to biennial screening [8]. In women 40 to 84 years of age, annual screening reduces mortality by 40%, compared to a 32% reduction for biennial screening [32]. With regular screening, interval breast cancers do occur with a higher frequency in women undergoing biennial or triennial screening compared to annual screening. The sensitivity of mammography is decreased in some groups of women, including those with dense breasts [40]. Dense breast tissue decreases the sensitivity of mammography [26] and is an independent risk factor for developing breast cancer [27]. Given the limitations of mammography and to minimize interval cancers, supplemental screening modalities have been investigated in women at high risk. Because screening mammography decreases breast cancer mortality, screening


Female Breast Cancer Screening

Female Breast Cancer Screening. Female Breast Cancer Screening mammography or screening DBT is still performed in women undergoing supplemental screening studies [3,8,35]. Rather than supplementing screening mammography with additional imaging modalities, some have suggested limiting women offered screening mammography based upon individual patient risk assessed by various risk models, breast density, or genetic information such as single-nucleotide polymorphism. However, the randomized controlled trials demonstrating mortality reduction and most large-scale observational studies enrolled women based upon age and geographic location, not individual patient risk factors. In one observational study in women <50 years of age, restricting screening to women with a first-degree family history, extremely dense breast tissue, or both, would cause 66% of potentially screen-detected cancers to be missed [41].


Female Breast Cancer Screening

Female Breast Cancer Screening. Numerous studies in high-risk women have evaluated the performance of mammography and supplemental screening modalities, such as US and MRI. Mammography consistently demonstrates lower sensitivity (25%-69%) than US or MRI, and high-risk women experience higher interval cancer rates than the general population [3,40]. The combination of mammography with MRI yields the highest sensitivity across high-risk groups of women (91%- 98%) [3,40,81]. Because screening mammography decreases breast cancer mortality, screening mammography or screening DBT is still performed in women undergoing supplemental screening studies [3,8,35]. High-risk women should begin annual screening mammography at 30 years of age or 10 years prior to the youngest family member who had breast cancer, but generally not before 30 years of age [3]. Approximately one-third of breast cancers may only be detected on mammography in BRCA2 mutation carriers who are <40 years of age [79]. In some mutation carriers, some referring providers use mammography or DBT beginning at 40 years of age if patients undergo annual MRI [80]. Women who underwent thoracic or upper abdominal radiation therapy at an early age (<30 years) should begin screening mammography 8 years after radiation therapy but not before 25 years of age [3].


Female Breast Cancer Screening

Female Breast Cancer Screening. Mammography With IV Contrast Data are limited regarding the use of mammography with IV contrast for breast cancer screening in high-risk women. To date, published studies have predominantly included women with dense breasts and other risk factors resulting in intermediate or high-risk profiles. Compared to mammography alone, mammography with IV contrast increases sensitivity and cancer detection (incremental CDR = 6.6-13 per 1,000) in women at elevated risk [57-60]. Mammography with IV contrast may be useful in high-risk women as an alternative to MRI.


Female Breast Cancer Screening

Female Breast Cancer Screening. MRI Breast Without and With IV Contrast MRI has a higher CDR than mammography alone, DBT, or mammography/DBT combined with US [61-64]. In high-risk women, supplemental screening MRI combined with mammography yields a 91% to 98% sensitivity, although the reported specificity of MRI is typically lower than mammography [40,81]. The incremental CDR of MRI in elevated-risk women ranges from 8 to 29 per 1,000 women, with higher CDR (26 per 1,000) in BRCA mutation carriers [61-63,65,66]. Breast MRI detects small, node-negative invasive cancers at earlier tumor stages compared to mammography, as well as ductal carcinoma in situ [68,69]. Screening MRI also reduces interval cancers [69]. However, breast MRI has a higher recall rate than mammography (15.1% versus 6.4%) [70], higher frequency of BI-RADS category 3 assessment than mammography (14.8% versus 11.8%), and a greater frequency of image-guided biopsies than mammography (11.8 versus 2.4%) [63].


Female Breast Cancer Screening

Female Breast Cancer Screening. Since 2007, the American Cancer Society has recommended annual breast MRI for breast cancer screening in high- risk women [4]. The ACR recommends annual breast MRI in high-risk women beginning as early as 25 years of age [3].


Female Breast Cancer Screening

Female Breast Cancer Screening

Female Breast Cancer Screening. Female Breast Cancer Screening


Female Breast Cancer Screening

Female Breast Cancer Screening. MRI Breast Without and With IV Contrast Abbreviated Data are limited regarding the use of abbreviated breast MRI without and with IV contrast for screening in high- risk women. Following the publication of the American Cancer Society guidelines for supplemental screening breast MRI in 2007, high-risk women have traditionally undergone conventional full protocol breast MRI without and with IV contrast [3,4]. However, multiple studies have demonstrated similar diagnostic accuracy for abbreviated protocol MRI compared to conventional full protocol breast MRI [73-75]. In a study evaluating 3,037 abbreviated breast MRI in 1,975 high-risk women, the CDR was 29 per 1,000, the interval cancer rate was 0.66 per 1,000, and all cancers missed by abbreviated breast MRI were node negative early-stage invasive malignancies [72].


Female Breast Cancer Screening

Female Breast Cancer Screening. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening women at high risk.


Female Breast Cancer Screening

Female Breast Cancer Screening. MRI Breast Without IV Contrast Abbreviated There is no relevant literature to support the use of abbreviated breast MRI without IV contrast for screening women at high risk.


Female Breast Cancer Screening

Female Breast Cancer Screening. Sestamibi MBI Data are limited regarding the use of sestamibi MBI for screening women at high risk. Most studies have focused upon women with dense breasts and variable risk profiles. Retrospective and prospective studies have demonstrated similar incremental CDR for sestamibi MBI of 6.5 to 9 over mammography, with one study demonstrating an incremental CDR of 16.5 per 1,000 in women at increased risk primarily due to family or personal history of breast cancer [40,47]. Sestamibi MBI demonstrates similar sensitivity, better specificity, and lower recall rate compared to supplemental screening US in women with dense breasts [47,48].


Female Breast Cancer Screening

Female Breast Cancer Screening. US Breast In high-risk women undergoing annual mammography plus annual supplemental screening MRI, the addition of supplemental screening with US does not identify additional cancers and is therefore not routinely performed. Screening US may be useful in high-risk patients as an alternative to MRI. However, high-risk women who do not undergo supplemental screening MRI should be counseled that the CDR of US is inferior to MRI. MRI has a higher CDR than mammography, DBT, or mammography/DBT combined with US [61-64]. The ACRIN 6666 trial enrolled women with elevated breast cancer risk [61]. Compared to mammography alone, screening US detected 5.3 cancers per 1,000 in year 1 and 3.7 cancers per 1,000 in years 2 and 3 and resulted in a larger number of false- positive examinations and false-positive biopsies each year [61]. After 3 consecutive rounds of mammography plus US, the incremental CDR of MRI was 14.7 per 1,000, although false-positive examinations also increased [61]. In a prospective multicenter study of 687 high-risk women who underwent clinical breast examination, mammography, US, and MRI for screening, the combination of MRI plus mammography maximized the breast cancers detected [62]. Mammography identified 5 cancers per 1,000 compared to 6 per 1,000 for US, 7.7 per 1,000 for mammography plus US, 14.9 per 1,000 for MRI, 14.9 per 1,000 for MRI plus US, 16 per 1,000 for mammography plus MRI, and 16 per 1,000 for mammography plus US plus MRI [62].


Female Breast Cancer Screening

Female Breast Cancer Screening. In a prospective study of BRCA mutation carriers and high-risk women, sensitivity of mammography was 25% and 66% whereas US was 23% and 34%, respectively [76]. In the high-risk group, mammography combined with biannual US demonstrated 100% sensitivity [76]; however, MRI was not performed. In a subset analysis of BRCA mutation carriers, MRI sensitivity was 94% [76]. In another study of 529 high-risk women suspected or proven to carry a deleterious BRCA mutation, the performance of US was also inferior to MRI [82]. The sensitivity of mammography was 33%, US was 40%, mammography plus US was 49%, and MRI was 91% [82].


Female Breast Cancer Screening

Female Breast Cancer Screening. In women with a personal history of breast cancer, supplemental US screening results in an incremental CDR of 2.4 to 2.9 cancers per 1,000 examinations over mammography alone; however, US screening has lower specificity [10,66].


Female Breast Cancer Screening

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


Female Breast Cancer Screening

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


Female Breast Cancer Screening

Female Breast Cancer Screening


Staging and Follow up of Primary Vaginal Cancer. Introduction/Background Primary vaginal cancer is rare, comprising 1% to 2% of gynecologic malignancies and 20% of all malignancies involving the vagina [1,2]. More frequently, the vagina is involved secondarily either by direct invasion from malignancies originating in adjacent organs, most commonly the cervix or vulva, or by metastases from other pelvic or extrapelvic primary malignancies [1,2]. Additionally, any vaginal tumor involving the cervix or vulva, whether or not the lesion is centered in the vagina, is classified by the International Federation of Gynecology and Obstetrics (FIGO) system as a primary cervical or vulvar cancer, respectively. Squamous cell carcinoma is the most common underlying histology in primary vaginal cancer, representing 80% to 90% of primary vaginal cancer [3] and occurs most frequently in postmenopausal women, with adenocarcinoma representing around 5% to 10% of cases and even rarer histologies such as sarcoma, melanoma, and lymphoma accounting for the remainder [1,2].


Staging and Follow up of Primary Vaginal Cancer. Primary vaginal cancer is staged according to two systems, FIGO and the American Joint Committee on Cancer (AJCC). FIGO stipulates a clinical staging paradigm, whereby features derived from bimanual and/or rectovaginal examination, cystoscopy, proctoscopy, and radiography are permissible for incorporation into staging [4]. Although FIGO encourages the use of advanced imaging modalities such as CT, MRI, and PET to guide management, information derived from these examinations does not alter the formal clinical FIGO stage [4]. Given the rarity of primary vaginal cancer, treatment principles are derived from retrospective data in addition to extrapolation from more established management paradigms for cervical and anal squamous cell cancers. Surgical management for vaginal cancer is limited primarily to small (<2 cm) early stage lesions, with larger lesions posing greater difficultly for achieving negative surgical margins. Although surgical options exist for locally advanced disease, they often involve a degree of pelvic exenteration and therefore confer substantial morbidity. For this reason, the management paradigm for locally advanced disease has largely trended toward definitive radiation therapy with concurrent chemotherapy [1,5]. Though data on the use of imaging in vaginal cancer are sparse, insights derived from the study of imaging in cervical cancer have reasonable generalizability to vaginal cancer because of similar tumor biology. Moreover, given the trend toward definitive chemoradiation for both cancers in all but early stage lesions, principles of postchemoradiation the recommendations outlined in this document are informed by principles translated from the literature on cervical cancer.


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


Staging and Follow up of Primary Vaginal Cancer. Staging and Follow-up of Primary Vaginal Cancer imaging in initial and adaptive radiation planning for vaginal cancer is not specifically addressed in this document, and analogous principles for cervical cancer are covered in extensive detail elsewhere [6].


Staging and Follow up of Primary Vaginal Cancer. OR Discussion of Procedures by Variant Variant 1: Vaginal cancer. Pretreatment staging. Initial imaging. Although the 2009 FIGO staging system for vaginal cancer indicates that findings on advanced imaging (CT, MRI, PET/CT) should not modify stage designation [4], such imaging findings are routinely employed in clinical practice to prognosticate and guide management decisions in patients with vaginal cancer. Recent updates to the FIGO staging system for cervical cancer, which incorporate advanced imaging results into staging [10], reflect the wide recognition that cross-sectional imaging provides actionable staging information not readily obtained by physical examination or conventional radiography. Moreover, the increasing use of definitive radiotherapy across all stages of vaginal cancer obligates the incorporation of advanced imaging into pretreatment evaluation, because it is essential for treatment planning.


Staging and Follow up of Primary Vaginal Cancer. The rationale for optimizing staging accuracy in vaginal cancer, in part via the inclusion of cross-sectional imaging, is multifold. First, accurate initial staging is fundamental to prognostication [11], facilitating incorporation of expectations of treatment efficacy into goals of care. Second, proper initial staging permits selection of the most appropriate treatment based on extent of disease. Regarding local extent, for vaginal lesions deemed likely confined to the vaginal wall (stage I) based on clinical examination, exclusion of extravaginal invasion with further testing is essential for ensuring that planned definitive surgery is likely to achieve a disease-free margin or that a radiation field properly incorporates the tumor volume. Regional nodal metastases include pelvic nodal metastases, which are primarily detected with cross-sectional imaging, and inguinal nodes (in lower vaginal cancers), a subset of which can be identified on clinical examination. Pretreatment knowledge of suspicious nodes may impact the decision to pursue surgery versus radiation. In addition, the distribution of suspicious nodes has the potential to influence radiation-specific factors such as field and dose planning, including possible node-directed boost doses as employed in cervical cancer [12]. Regarding distant metastases, detection of extraregional nodal or solid organ lesions can obviate unnecessarily morbid radical pelvic surgery and instead direct care toward palliative regimens or radiotherapy with an extended field. Finally, the ability to accurately stage noninvasively can avoid the need for invasive staging procedures such as cystoscopy (for bladder mucosal invasion) and proctoscopy (for rectal mucosal invasion), both of which are historical components of the FIGO clinical staging system [1].


Staging and Follow up of Primary Vaginal Cancer. CT Chest Although thoracic metastases are known to occur in vaginal cancer, no studies specifically address their incidence or the incremental value of chest CT for initial staging. Pulmonary metastases have been studied to a limited degree in cervical cancer, occurring in approximately 5% to 10% of patients at diagnosis [13,14]. Pulmonary metastases appear to occur slightly more frequently as a site of recurrent disease, with one large study of recurrent cervical cancer indicating an overall incidence of 13%, and the lungs representing the only site of recurrence in 6% of cases [15]. In studies evaluating pulmonary metastases from cervical cancer, chest CT was the most frequent diagnostic modality employed, with the vast majority of patients asymptomatic at the time of imaging [16,17]. These findings support the use of chest CT with or without intravenous (IV) contrast in the early posttreatment evaluation of cervical cancer, as endorsed by the National Comprehensive Cancer Network (NCCN) guidelines, and suggest that a similar strategy would be useful for vaginal cancer.


Staging and Follow up of Primary Vaginal Cancer. Staging and Follow-up of Primary Vaginal Cancer CT Abdomen and Pelvis Data on the diagnostic performance of CT in primary vaginal cancer staging are very limited. A small retrospective study evaluating fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT in 23 patients with primary vaginal cancer found that CT and FDG-PET detected pelvic nodal metastases in 17% (4 of 23) and 35% (8 of 23) of patients, respectively, suggesting inferior sensitivity of CT alone [18].


Staging and Follow up of Primary Vaginal Cancer. CT has been studied more extensively in cervical cancer staging, with available data comparing CT to MRI for local staging and CT (with or without IV contrast) to PET for regional and distant staging. For local staging, the ACRIN 6651 study showed that CT and MRI had sensitivity of 42% and 53%, respectively, and specificity of 82% and 75%, respectively, for classifying disease as stage IIB (parametrial invasion) or higher, with none of these differences reaching statistical significance [19]. However, a more recent meta-analysis suggested improved performance of MRI for parametrial invasion with modern hardware (sensitivity 76%, specificity 94%), particularly when the field strength was 3T and diffusion-weighted imaging was included [20], whereas a recent study of multidetector CT showed only 50% sensitivity for parametrial invasion [21].


Staging and Follow up of Primary Vaginal Cancer. Although older literature suggested lower sensitivity of CT compared with FDG-PET/CT for nodal metastases [22], the more recent ACRIN 6671/Gynecology Oncology Group (GOG) 0233 trial demonstrated a more modest difference in sensitivity for abdominal nodes (42% versus 50%, respectively) [23]. Likewise, in a recent meta- analysis, CT had only modestly lower area under the curve (AUC) (0.83) compared with PET/CT (0.90) for detection of nodal metastases from cervical cancer [24]. For distant metastases from cervical cancer, CT is inferior in the detection of osseous metastases (sensitivity 66%) compared with FDG-PET/CT (sensitivity 96%) [25].


Staging and Follow up of Primary Vaginal Cancer. These findings, if applied to vaginal cancer, suggest that modern multidetector CT abdomen and pelvis is a reasonable staging tool for regional and distant metastases, although is likely inferior to MRI for local staging, modestly inferior to FDG-PET/CT for nodal metastases, and inferior to FDG-PET/CT for osseous metastases. The use of IV contrast is strongly encouraged when possible, because the improved tissue contrast likely benefits primary tumor evaluation, delineation of lymph nodes from adjacent vessels, and detection of hepatic metastases. No studies have specifically evaluated the performance of CT of the abdomen and pelvis without IV contrast for vaginal cancer staging.


Staging and Follow up of Primary Vaginal Cancer. FDG-PET/CT Skull Base to Mid-Thigh Data regarding the diagnostic performance of PET/CT for initial staging in patients with vaginal cancer are limited. Lamoreaux et al [18], in a prospective study, evaluated the comparative performance of PET versus CT in 23 patients with primary vaginal cancer prior to treatment. PET identified suspicious pelvic and/or groin lymph nodes in 35% (8 of 23) of patients, whereas CT did so in only 17% (4 of 23) of patients, although a pathologic reference standard was present in only two sampled groin nodes. No patient had extrapelvic nodal or distant disease, limiting the applicability of this study to metastases outside of the pelvis.


Staging and Follow up of Primary Vaginal Cancer. Although data are limited for primary vaginal cancer staging, a growing body of literature supports the role of FDG- PET/CT in the initial staging of cervical cancer. Prospective data from the ACRIN 6671/GOG 0233 trial suggested, with borderline statistical significance, that FDG-PET/CT is more sensitive than CT alone for extrapelvic nodal metastases in cervical cancer (50% versus 42%, respectively), with similar specificity (85% versus 89%, respectively) [23], supporting prior retrospective data [22]. FDG-PET/CT is also more sensitive than conventional CT for osseous metastases [25], with sensitivity and specificity of 55% and 98%, respectively, for all distant metastases [13]. Accordingly, the NCCN guidelines endorse preference for whole-body FDG-PET/CT over conventional CT for initial staging of all cervical cancer designated stage II and above, with either FDG-PET/CT or conventional CT recommended in stage I disease [27].


Staging and Follow up of Primary Vaginal Cancer. Staging and Follow-up of Primary Vaginal Cancer Fluoroscopy Contrast Enema There is no relevant literature regarding the use of fluoroscopic contrast enema in the modern imaging workup of vaginal cancer, and its use has largely been replaced by cross-sectional imaging techniques.


Staging and Follow up of Primary Vaginal Cancer. MRI Pelvis Because of the rarity of vaginal cancer, the primary data regarding the use of MRI in initial staging of vaginal cancer are sparse. Taylor et al [28] retrospectively evaluated pelvic MRI for initial staging in 25 patients with primary vaginal cancer spanning all disease stages. MRI depicted the primary tumor in 96% (24 of 25) of patients, demonstrating hyperintense signal compared to muscle on T2-weighted images, and enabled assignment of a radiologic disease stage based on adaptation of FIGO clinical staging criteria. Because 80% (20 of 25) of patients received either radiation or palliative therapy, pathologic confirmation of imaging findings could be obtained in only 20% (5 of 25) of cases. Of these cases, MRI stage was concordant with pathologic stage in 40% (2 of 5) of the cases. More recent data in cervical cancer patients support the use of MRI for initial staging, with a meta-analysis suggesting high sensitivity (76%) and specificity (94%) of MRI for parametrial invasion [20].


Staging and Follow up of Primary Vaginal Cancer. Although MRI readily depicts lymph nodes, it has constraints similar to CT with regard to the limited sensitivity and specificity of size and morphologic criteria. No study has specifically evaluated the performance of MRI for pretreatment nodal staging in vaginal cancer. However, data from mixed cohorts of patients with recurrence of cervical, vaginal, and other gynecologic cancers have suggested superior sensitivity of FDG-PET/CT for pelvic nodal metastases compared with pelvic MRI and CT [29,30].


Staging and Follow up of Primary Vaginal Cancer. The use of IV contrast may improve tissue characterization but is not considered essential, with variable inclusion in published protocols for evaluation of vaginal [28,31] and cervical cancer [7,32-34]. No study has specifically compared the incremental utility of contrast-enhanced sequences over T2-weighted sequences for pelvic MRI in this context. Regarding the use of vaginal gel in MRI of the pelvis, there is insufficient primary data in the literature to support its routine use.


Staging and Follow up of Primary Vaginal Cancer. MRI Abdomen and Pelvis Because of the rarity of vaginal cancer, the primary data regarding the use of MRI in initial staging of vaginal cancer are sparse. Taylor et al [28] retrospectively evaluated pelvic MRI for initial staging in 25 patients with primary vaginal cancer spanning all disease stages. MRI depicted the primary tumor in 96% (24 of 25) of patients, demonstrating hyperintense signal compared to muscle on T2-weighted images, and enabled assignment of a radiologic disease stage based on adaptation of FIGO clinical staging criteria. Because 80% (20 of 25) of patients received either radiation or palliative therapy, pathologic confirmation of imaging findings could be obtained in only 20% (5 of 25) of cases. Of these cases, MRI stage was concordant with pathologic stage in 40% (2 of 5). More recent data in cervical cancer patients support the use of MRI for initial staging, with a meta-analysis suggesting high sensitivity (76%) and specificity (94%) of MRI for parametrial invasion [20].


Staging and Follow up of Primary Vaginal Cancer. If MRI of the abdomen and pelvis is used in place of CT of the abdomen and pelvis, the addition of chest CT is encouraged to evaluate for pulmonary metastases. The use of IV contrast may improve tissue characterization and is particularly beneficial when MRI of the abdomen is included, because it improves detection of hepatic metastases.


Staging and Follow up of Primary Vaginal Cancer. Radiography Intravenous Urography There is no relevant literature regarding the use of radiographic IV urography in the modern imaging workup of vaginal cancer, and its use has largely been replaced by cross-sectional imaging techniques.


Staging and Follow up of Primary Vaginal Cancer. US Abdomen and Pelvis Transabdominal There is no relevant literature regarding the role of transabdominal abdominopelvic (TA) US in vaginal cancer staging. TAUS is inferior for visualizing the female genital tract compared with TVUS, and neither technique has a role in the evaluation of regional or distant disease.


Staging and Follow up of Primary Vaginal Cancer. Variant 2: Posttreatment evaluation of vaginal cancer. No suspected recurrence. Initial imaging. As the use of definitive chemoradiation for the treatment of primary vaginal cancer has grown, so too has the role of cross-imaging for assessment of treatment response. In contrast to extirpative surgery, in which pathologic margin assessment can confirm removal of viable tumor, evaluation for tumor eradication following chemoradiation relies in part on imaging assessment. Much of the support for the value of early posttreatment imaging in primary vaginal cancer is extrapolated from the large body of literature on cervical cancer, for which the treatment paradigm and endpoints are analogous. Early posttreatment imaging is performed most commonly following a period of approximately 3 to 6 months after the completion of chemoradiation. Some centers also image during therapy for early response assessment and/or adaptive radiation planning [7].


Staging and Follow up of Primary Vaginal Cancer. The goals of early posttreatment imaging are multiple. First, imaging response after chemoradiation is a potent predictor of oncologic outcome, therefore providing crucial prognostic data [40-42]. Second, the degree of imaging response directly informs therapeutic decision-making, because persistent or progressive disease following chemoradiation requires salvage therapy [40]. For persistent pelvic disease, options include salvage radical surgery or less commonly reirradiation. Detection of new distant disease following initial treatment obviates curative surgery and may direct therapy toward chemotherapeutic and/or palliative options. Finally, the degree of response can influence the frequency of subsequent surveillance, with complete response enabling more conservative follow- up testing [42].


Staging and Follow up of Primary Vaginal Cancer. Following complete response, there is no formally established role for routine surveillance imaging in asymptomatic patients treated for vaginal cancer nor has a role been established for cervical cancer. Guidelines generally advocate for routine clinical examination for surveillance in asymptomatic patients, with imaging suggested in the setting of symptoms or abnormal physical examination findings [43].


Staging and Follow up of Primary Vaginal Cancer. CT Chest Although thoracic metastases are known to occur in vaginal cancer, no studies specifically address their incidence or the incremental value of chest CT in early posttreatment evaluation. Pulmonary metastases have been studied to a limited degree in cervical cancer, occurring in approximately 5% to 10% of patients at diagnosis [13,14]. Pulmonary metastases appear to occur slightly more frequently as a site of recurrent disease, with one large study of recurrent cervical cancer indicating an overall incidence of 13%, and the lungs representing the only site of recurrence in 6% of cases [15]. Moreover, the lungs can uncommonly represent a site of distant disease that newly arises following definitive chemoradiation for disease that was initially locoregional [41]. In studies evaluating pulmonary metastases from cervical cancer, chest CT was the most frequent diagnostic modality employed, with the vast majority of patients asymptomatic at the time of imaging [16,17]. These findings support the use of chest CT with or without IV contrast in the early posttreatment evaluation of cervical cancer, as endorsed by the NCCN guidelines, and suggest that a similar strategy would be useful for vaginal cancer.


Staging and Follow up of Primary Vaginal Cancer. CT Abdomen and Pelvis For detection of residual primary tumor after chemoradiation, CT alone is likely inferior compared with FDG- PET/CT and pelvic MRI based on extrapolation from data on comparative imaging performance in the pretreatment evaluation of cervical cancer [21,44]. CT lacks the tissue contrast of MRI and the metabolic data of FDG-PET, both of which are useful in deciphering posttreatment changes from residual disease. Because CT relies primarily on size criteria for nodal evaluation, it has limitations similar to MRI with respect to sensitivity and specificity for nodal metastases. Therefore, although CT may depict size regression of nodal metastases following therapy, it is likely at least modestly inferior for detecting new or residual disease in subcentimeter lymph nodes compared with FDG- PET/CT [22,23,29,30].


Staging and Follow up of Primary Vaginal Cancer. Staging and Follow-up of Primary Vaginal Cancer CT of the abdomen and pelvis is not commonly performed in the absence of chest CT, given that the lungs are a potential site of distant disease that may newly arise in patients who have undergone definitive chemoradiation for disease that was initially locoregional [41]. Importantly, CT alone is inferior to FDG/PET-CT for evaluation of distant disease in the bones [25] and modestly inferior for nodal assessment [23,41].


Staging and Follow up of Primary Vaginal Cancer. The use of IV contrast is strongly encouraged when possible, because the improved tissue contrast likely benefits primary tumor evaluation, delineation of lymph nodes from adjacent vessels, and detection of hepatic metastases. No studies have specifically assessed the performance of CT of the abdomen and pelvis without IV contrast for posttreatment evaluation of primary vaginal cancer.


Staging and Follow up of Primary Vaginal Cancer. FDG-PET/CT Skull Base to Mid-Thigh Although data in primary vaginal cancer patients are limited, studies substantiating its treatment response assessment role in cervical cancer are numerous. In one prospective study in cervical cancer patients treated with definitive chemoradiation, FDG-PET/CT responses classified as complete metabolic response (absence of abnormal uptake at prior sites of disease), partial metabolic response and progressive disease at a mean of 3 months after therapy correlated closely with prognosis, with 3 year progression-free survival of 78%, 33%, and 0%, respectively [40]. In another prospective study, 9% (5 of 55) of patients developed new distant disease at the time of a posttreatment FDG-PET/CT scan, underscoring the value of whole-body imaging rather than pelvic-only imaging at the time of response evaluation [41]. Accordingly, the NCCN guidelines for cervical cancer recommend whole- body FDG-PET/CT at 3 to 6 months after completion of definitive therapy for disease stages II to IV, because it directly informs prognosis, therapy, and intensity of surveillance [27].


Staging and Follow up of Primary Vaginal Cancer. Fluoroscopy Contrast Enema There is no relevant literature regarding the use of fluoroscopic contrast enema in the modern imaging workup of vaginal cancer, and its use has largely been replaced by cross-sectional imaging techniques.


Staging and Follow up of Primary Vaginal Cancer. MRI Pelvis Although no study has specifically evaluated pelvic MRI for treatment response assessment in vaginal cancer patients, multiple studies support its potential value in cervical cancer to which analogous principles apply. Following successful therapy with chemoradiation, the initially intermediate to high-signal-intensity tumor on T2- weighted images decreases in both size and signal intensity, with eventual conversion to low-signal-intensity fibrotic tissue [7,31]. However, the main limitation of MRI in the very early posttreatment period (<2 months after completion) is its difficulty distinguishing early postradiation change from residual tumor, both of which can demonstrate intermediate- to high-signal T2-weighted intensity and avid gadolinium enhancement [33,34].


Staging and Follow up of Primary Vaginal Cancer. One retrospective study evaluating pelvic MRI at a median of 5 weeks after completion of chemoradiation for cervical cancer found that 37% (16 of 44) of MRI examinations were considered indeterminate for discriminating residual disease and fibrosis [34]. Despite diagnostic confidence in the remainder of cases, sensitivity and specificity for residual disease were 80% and 55%, respectively, indicating a high false-positive rate because of posttreatment change. A more recent retrospective study in cervical cancer patients found better performance of pelvic MRI at a later postchemoradiation time point (median 9 weeks) with strict objective diagnostic criteria, achieving sensitivity and specificity of 91% and 85%, respectively, for residual disease [33]. Therefore, for cervical cancer, the suggested time interval for determining posttherapy treatment response with pelvic MRI is 3 to 6 months after completion of therapy [27], although earlier imaging is sometimes used for interim assessment of tumor regression for prognostication and/or adaptive radiation planning. Because MRI relies primarily on size criteria for nodal evaluation, it has limitations similar to CT with respect to sensitivity and specificity for nodal metastases. Therefore, although MRI may depict size regression of nodal metastases following therapy, it is likely at least modestly inferior for detecting new or residual disease in subcentimeter lymph nodes compared to FDG-PET/CT [22,23,29,30].


Staging and Follow up of Primary Vaginal Cancer. The use of IV contrast may improve tissue characterization but is not considered essential, with variable inclusion in published protocols for evaluation of vaginal [28,31] and cervical cancer [7,32-34]. No study has specifically compared the incremental utility of gadolinium-enhanced sequences over T2-weighted sequences for pelvic MRI in this context. Regarding the use of vaginal gel in MRI of the pelvis, there is insufficient primary data in the literature to support its routine use.


Staging and Follow up of Primary Vaginal Cancer. MRI Abdomen and Pelvis MRI of the abdomen and pelvis can be considered in the early posttreatment evaluation of primary vaginal cancer, although its main value is in the utility of pelvic MRI for primary tumor response assessment. MRI of the abdomen is not commonly included, given the availability of whole-body FDG-PET/CT or CT of the chest, abdomen, and


Staging and Follow up of Primary Vaginal Cancer. Staging and Follow-up of Primary Vaginal Cancer


Staging and Follow up of Primary Vaginal Cancer. pelvis for evaluation of distant disease. Although no study has specifically evaluated pelvic MRI for treatment response assessment in vaginal cancer patients, multiple studies support its potential value in cervical cancer to which analogous principles apply. Following successful therapy with chemoradiation, the initially intermediate- to high-signal-intensity tumor on T2-weighted images decreases in both size and signal intensity, with eventual conversion to low-signal-intensity fibrotic tissue [7,31]. However, the main limitation of MRI in the very early posttreatment period (<2 months after completion) is its difficulty distinguishing early postradiation change from residual tumor, both of which can demonstrate intermediate- to high-signal T2-weighted intensity and avid gadolinium enhancement [33,34].


Staging and Follow up of Primary Vaginal Cancer. If MRI of the abdomen and pelvis is used in place of CT of the abdomen and pelvis, the addition of chest CT is encouraged to evaluate for pulmonary metastases. The use of IV contrast may improve tissue characterization and should be used especially when MRI of the abdomen is included, because it improves detection of hepatic metastases.


Staging and Follow up of Primary Vaginal Cancer. Radiography Intravenous Urography There is no relevant literature regarding the use of radiographic IV urography in the modern imaging workup of vaginal cancer, and its use has largely been replaced by cross-sectional imaging techniques.


Staging and Follow up of Primary Vaginal Cancer. US Abdomen and Pelvis Transabdominal There is no relevant literature regarding the role of TAUS in vaginal cancer staging. TAUS is inferior for visualizing the female genital tract compared with TVUS, and neither technique has a role in nodal or distant evaluation.


Staging and Follow up of Primary Vaginal Cancer. US Pelvis Transvaginal There is no relevant literature regarding the role of TVUS in the early posttreatment evaluation of primary vaginal cancer. Limited studies in cervical cancer patients have evaluated the use of color and/or power Doppler US for detecting changes in tumor vascularity as a marker of treatment response [45]. However, the applicability of these findings to clinical practice remains unclear. The NCCN guidelines do not currently endorse the use of TVUS for early posttreatment evaluation in cervical cancer, and its role in vaginal cancer remains undefined. Additionally, TVUS has limited utility for pelvic nodal evaluation [39].


Staging and Follow up of Primary Vaginal Cancer. Variant 3: Vaginal cancer. Suspected or known recurrence. Evaluate extent of disease. Initial imaging. Cross-sectional imaging plays a crucial role in the evaluation of patients with known or suspected vaginal cancer recurrence, in which physical examination is of limited value in determining disease extent. In one retrospective study of patients with primary vaginal cancer who underwent definitive radiation and experienced recurrence, the mechanism of recurrence was locoregional alone in 56% for disease stages I and II and 71% for disease stages III to IVA, whereas the remainder of recurrences were distant [46]. Once locoregional recurrence is identified, the presence or absence of distant recurrence becomes a discriminating factor in eligibility for salvage pelvic exenteration. In the presence of distant recurrence, exenteration confers morbidity without significantly improving oncologic outcomes, whereas in the absence of distant recurrence, exenteration can potentially eradicate pelvic tumor burden. When distant disease has been excluded by imaging and a patient is deemed eligible for pelvic exenteration, the degree of local organ invasion determines whether partial (anterior or posterior) or total exenteration is indicated [32]. Therefore, imaging findings in patients with known or suspected vaginal cancer recurrence can influence both the appropriateness and type of salvage therapy, in addition to predicting prognosis.


Staging and Follow up of Primary Vaginal Cancer. Staging and Follow-up of Primary Vaginal Cancer CT Chest Although thoracic metastases are known to occur in vaginal cancer, no studies specifically address their incidence or the incremental value of chest CT for suspected recurrence. Pulmonary metastases have been studied to a limited degree in cervical cancer, occurring in approximately 5% to 10% of patients at diagnosis [13,14]. Pulmonary metastases appear to occur slightly more frequently as a site of recurrent disease, with one large study of recurrent cervical cancer indicating an overall incidence of 13% and the lungs representing the only site of recurrence in 6% of cases [15]. In studies evaluating pulmonary metastases from cervical cancer, chest CT was the most frequent diagnostic modality employed, with the vast majority of patients asymptomatic at the time of imaging [16,17]. These findings support the use of chest CT with or without IV contrast in the early posttreatment evaluation of cervical cancer, as endorsed by the NCCN guidelines, and suggest that a similar strategy would be useful for vaginal cancer.


Staging and Follow up of Primary Vaginal Cancer. CT Abdomen and Pelvis Data on the diagnostic performance of CT in known or suspected recurrence of vaginal cancer are very limited, requiring extrapolation from pretreatment vaginal cancer cohorts as well as cohorts of patients with other gynecologic malignancies.


Staging and Follow up of Primary Vaginal Cancer. Regarding local extent evaluation, the prospective ACRIN 6651 study of patients with cervical cancer prior to treatment, found that CT was insensitive for detection of rectal and bladder invasion, suggesting that performance would be similarly poor in the setting of recurrent disease prior to pelvic exenteration [19].


Staging and Follow up of Primary Vaginal Cancer. A small retrospective study evaluating FDG-PET/CT in 23 patients with primary vaginal cancer prior to treatment found that CT and FDG-PET detected pelvic nodal metastases in 17% (4 of 23) and 35% (8 of 23) of patients, respectively, suggesting inferior sensitivity of CT alone for nodal metastases. Although older literature suggested that CT is less sensitive than PET/CT for nodal metastases [22], the more recent ACRIN 6671/GOG 0233 trial in cervical cancer patients prior to treatment showed a more modest difference in sensitivity for abdominal nodes (42% versus 50%, respectively), and no significant difference in sensitivity for pelvic nodes (79% versus 83%, respectively) [23]. Likewise, CT had only modestly lower AUC (0.83) compared with PET/CT (0.90) for detection of nodal metastases from cervical cancer in a recent meta-analysis [24]. For distant metastases from cervical cancer, CT is inferior in the detection of osseous metastases (sensitivity 66%) compared with FDG-PET/CT (sensitivity 96%) [25].


Staging and Follow up of Primary Vaginal Cancer. These findings, if applied to vaginal cancer, suggest that CT is a reasonable staging tool for known or suspected tumor recurrence in the abdomen and pelvis, although it is likely inferior to MRI for evaluating local tumor extent, modestly inferior to FDG-PET/CT for nodal metastases, and inferior to FDG-PET/CT for osseous metastases. The use of IV contrast is strongly encouraged when possible, because the improved tissue contrast likely benefits primary tumor evaluation, delineation of lymph nodes from adjacent vessels, and detection of hepatic metastases. No studies have specifically assessed the performance of CT of the abdomen and pelvis without IV contrast for evaluation of known or suspected vaginal cancer recurrence.


Staging and Follow up of Primary Vaginal Cancer. FDG-PET/CT Skull Base to Mid-Thigh No study has evaluated FDG-PET/CT in a cohort limited to patients with recurrent vaginal cancer. Data on the utility of FDG-PET/CT in this setting is limited to mixed cohorts of patients with various gynecologic malignancies, including vaginal cancer, with cervical squamous cell carcinoma generally comprising the majority of patients. One such cohort of 27 patients with recurrent gynecologic malignancies prior to pelvic exenteration was studied prospectively to compare FDG-PET and CT. FDG-PET was 100% sensitive and 73% specific for identifying extrapelvic metastases, most notably outperforming CT in the detection of pelvic and para-aortic nodal metastases [29].


Staging and Follow up of Primary Vaginal Cancer. A retrospective study of 85 patients with recurrent gynecologic malignancies reached similar conclusions, identifying findings suspicious for extraregional recurrence in 28% (24 of 85) of patients by PET versus 9% (8 of 85) of patients by conventional imaging (CT and pelvic MRI), with nodal metastases accounting for many of the discrepancies [30]. Concordant with these findings, the NCCN guidelines recommend whole-body FDG-PET/CT in patients with suspected recurrence of cervical cancer [27], although no such formal guidelines exist for vaginal cancer.


Staging and Follow up of Primary Vaginal Cancer. Fluoroscopy Contrast Enema There is no relevant literature regarding the use of fluoroscopic contrast enema in the modern imaging workup of vaginal cancer, and its use has largely been replaced by cross-sectional imaging techniques.


Staging and Follow up of Primary Vaginal Cancer. Although MRI readily depicts lymph nodes, it has constraints similar to CT with regard to the limited sensitivity and specificity of size and morphologic criteria. No study has evaluated the diagnostic performance of MRI for nodal staging isolated to a cohort of primary vaginal cancer patients with disease recurrence. However, data from mixed cohorts of patients with recurrence of cervical, vaginal, and other gynecologic cancers have suggested superior sensitivity of FDG-PET/CT for pelvic nodal metastases compared with pelvic MRI and CT [29,30].


Staging and Follow up of Primary Vaginal Cancer. The use of IV contrast may improve tissue characterization but is not considered essential, with variable inclusion in published protocols for evaluation of vaginal [28,31] and cervical cancer [7,32-34]. No study has specifically compared the incremental utility of gadolinium-enhanced sequences over T2-weighted sequences for pelvic MRI in this context. Regarding the use of vaginal gel in MRI of the pelvis, there is insufficient primary data in the literature to support its routine use.


Staging and Follow up of Primary Vaginal Cancer. If MRI of the abdomen and pelvis is used in place of CT of the abdomen and pelvis, the addition of chest CT is encouraged to evaluate for pulmonary metastases. The use of IV contrast may improve tissue characterization and is particularly beneficial when MRI of the abdomen is included, because it improves detection of hepatic metastases.


Staging and Follow up of Primary Vaginal Cancer. US Pelvis Transvaginal There is no relevant literature regarding the role of TVUS in the evaluation of known or suspected vaginal cancer recurrence nor is there any such literature for cervical cancer recurrence. Additionally, the potential applicability of TVUS for recurrent vaginal cancer would be limited to local recurrence, because TVUS has little to no utility for pelvic nodal evaluation [39].


Staging and Follow up of Primary Vaginal Cancer. 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.


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


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


Endometriosis

Endometriosis. Introduction/Background Endometriosis is a common condition impacting approximately 10% of individuals assigned female at birth [1]. The disorder is caused by endometrial-like tissue located outside of the endometrial cavity, associated with inflammation and fibrosis, on or extending below the peritoneal surface [2]. Endometriosis that extends below the peritoneum is often referred to as deep endometriosis (DE). Endometriosis is usually multifocal and typically occurs in predictable locations in the pelvis.


Endometriosis

Endometriosis. The diagnosis of endometriosis is challenging due to variable presenting symptoms and nonspecific physical examination findings [5]. Historically, the diagnosis of endometriosis was made by diagnostic laparoscopy with histologic inspection. Studies have shown that preoperative imaging is associated with decreased morbidity and mortality and reduces the need for repeat surgeries by reducing the number of incomplete surgeries. The literature now supports the use of imaging before surgery, because information gained from imaging studies helps inform patient decision making, is important for surgical planning, and impacts management [1,6,7].


Endometriosis

Endometriosis. Expert consensus groups advise using an MRI protocol tailored for detection of DE. Moderate bladder distention and vaginal contrast are recommended to help improve lesion conspicuity involving these structures [29]. There is


Endometriosis

Endometriosis. aCleveland Clinic, Cleveland, Ohio. bPanel Chair, University of Michigan, Ann Arbor, Michigan. cClinica Family Health, Lafayette, Colorado; American Academy of Family Physicians. dUniversity of Kentucky, Lexington, Kentucky. eAlpert Medical School of Brown University, Providence, Rhode Island; Commission on Nuclear Medicine and Molecular Imaging. fHospital of the University of Pennsylvania, Philadelphia, Pennsylvania. gEmory University School of Medicine, Atlanta, Georgia; Committee on Emergency Radiology-GSER. hNew York University Langone Health, New York, New York. iVanderbilt University Medical Center, Nashville, Tennessee. jUniversity of Michigan, Ann Arbor, Michigan. kMayo Clinic, Rochester, Minnesota. lSpecialty Chair, New York University Medical Center, New York, New York.


Endometriosis

Endometriosis. 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.


Endometriosis

Endometriosis. Reprint requests to: publications@acr.org


Endometriosis

Endometriosis. Endometriosis less agreement surrounding maneuvers to help improve detection of bowel lesions, including bowel preparation, rectal contrast, fasting, and administration of anti-peristaltic agents [30-34].


Endometriosis

Endometriosis. Though fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT has not been studied for the clinical variants described in this paper, a retrospective study showed that endometriosis can be detected on FDG-PET/CT [35]. The radiopharmaceutical fluoroestradiol, an estrogen analog PET agent currently approved for use in patients with metastatic breast cancer, has shown promise as an agent that can be used to detect endometriosis in early clinical trials [36].


Endometriosis

Endometriosis. OR Discussion of Procedures by Variant Variant 1: Adult. Clinically suspected pelvic endometriosis. Initial imaging. CT Pelvis With IV Contrast There is no relevant literature to support the use of pelvic CT with intravenous (IV) contrast as the initial imaging modality for clinically suspected endometriosis.


Endometriosis

Endometriosis. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of pelvic CT without and with IV contrast as the initial imaging modality for clinically suspected endometriosis.


Endometriosis

Endometriosis. CT Pelvis Without IV Contrast There is no relevant literature to support the use of pelvic CT without IV contrast as the initial imaging modality for clinically suspected endometriosis.


Endometriosis

Endometriosis. MRI Pelvis Without and With IV Contrast MRI pelvis is an excellent imaging modality for the preoperative diagnosis of endometriosis [37-39] and has been shown to correspond well with surgical staging systems and histopathologic findings [40-43]. Variability in the literature surrounding accuracy of MRI compared to other modalities for detection of endometriosis may be attributed to differences in imaging techniques used [40]. The performance of MRI for detection of endometriosis varies by lesion location. MRI is excellent for identification of DE but has shown poorer diagnostic accuracy for detection of superficial peritoneal disease [44-46].


Endometriosis

Endometriosis. Image acquisition is more automated for MRI than US [47]. The large field-of-view afforded by MRI can decrease the need for multiple additional imaging studies that are sometimes required to supplement US pelvis studies, which do not include the entire urinary or gastrointestinal tracts [48].


Endometriosis

Endometriosis. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is helpful for the diagnosis of DE as described in the preceding paragraph. Although much of the literature surrounding MRI of the pelvis for detection of DE describes using IV contrast agents, a study that specifically compared MRI without IV contrast to MRI with IV contrast found no benefit of IV contrast media [50].


Endometriosis

Endometriosis

Endometriosis. Endometriosis


Endometriosis

Endometriosis. US Pelvis Transabdominal Although it is possible that larger ovarian endometriomas could be detected by transabdominal pelvic US, many of the structures involved by superficial and DE are not well seen by transabdominal technique alone.


Endometriosis

Endometriosis. US Pelvis Transabdominal and US Pelvis Transvaginal Transabdominal pelvic US imaging is described in some endometriosis protocols as an adjunct to TVUS imaging to evaluate the urinary tract or gastrointestinal tract [51]. Transabdominal US can serve as an important adjunct to TVUS studies because it widens the field-of-view beyond what is possible by TVUS imaging. Transabdominal US imaging is useful for detection of urinary tract endometriosis. Urinary obstruction caused by involvement of the ureters or bladder can be silent and associated with loss of renal function [51]. Transabdominal US imaging can also help identify sites of bowel involvement beyond the pelvis, including the appendix, terminal ileum, cecum, and sigmoid [14]. DE TVUS supplemented by transabdominal US imaging was found to accurately predict intraoperative endometriosis staging at a multi-institutional study performed at centers of endometriosis excellence [52].


Endometriosis

Endometriosis. Variant 2: Adult. Clinically suspected pelvic endometriosis. Indeterminate or negative ultrasound. Next imaging study for characterization or treatment planning. CT Pelvis With IV Contrast There is no relevant literature to support the use of routine pelvic CT with IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis.


Endometriosis

Endometriosis. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of routine pelvic CT without and with IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis.


Endometriosis

Endometriosis. CT Pelvis Without IV Contrast There is no relevant literature to support the use of routine pelvic CT without IV contrast as a next imaging study for characterization or treatment planning of suspected pelvic endometriosis.


Endometriosis

Endometriosis. MRI Pelvis Without and With IV Contrast A study that evaluated patients who underwent routine pelvic US and pelvic MRI with IV contrast and later went on to surgery for endometriosis found 51% of patients with a negative US went on to have disease identified on MRI. The same study showed that 78% of patients with endometriosis identified by US were found to have additional sites of disease by MRI [73].


Endometriosis

Endometriosis. MRI is known to correspond well with surgical staging systems and histopathologic findings [40-43]. Some pelvic MRI classification systems can predict surgical time, length of hospital stay, and postoperative complications [74]. Structured reporting of pelvic MRI studies can improve sensitivity compared to routine read studies and are preferred by referring physicians [75,76].


Endometriosis

Endometriosis. MRI pelvis allows imaging with a large field-of-view to include anatomy that is generally beyond the field-of-view for TVUS. Structures that are not well seen by US, such as pelvic nerves, can be depicted by MRI [77,78]. MRI pelvis can be used for surgical planning for bladder endometriosis because it can accurately predict lesion size and


Endometriosis

Endometriosis. Endometriosis involvement of the ureter orifices [46,79]. These studies are also helpful for surgical planning when bowel disease is present as described under Variant 3.


Endometriosis

Endometriosis. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is helpful for the diagnosis of DE, for further characterization of indeterminate findings on US, and for treatment planning as described in the preceding paragraph. Assessment of ovarian lesions is limited without IV contrast.


Endometriosis

Endometriosis. Variant 3: Adult. Clinically suspected rectosigmoid endometriosis. Initial imaging. The intestinal tract is the most common site of nongynecologic endometriosis. Endometriosis can infiltrate the muscular bowel wall leading to gastrointestinal symptoms. The anterior wall of the rectosigmoid colon is the most common location for bowel endometriosis, followed by the sigmoid colon, cecum and ileocecal valve, appendix. and small bowel [80]. Rectosigmoid bowel lesions can be removed by surgical shaving, discoid resection, or segmental resection. Information from imaging studies is used to predict which of these surgical approaches will be needed.


Endometriosis

Endometriosis. CT Pelvis With IV Contrast There is no relevant literature to support the use of standard pelvic CT without a water enema as an initial imaging modality for clinically suspected rectosigmoid endometriosis. Studies looking into specialized CT techniques that are not widely available, such as CT with colonic distention by water enema or CT colonography have found these methods to be accurate for identifying and characterizing gastrointestinal tract endometriotic lesions for surgical planning. Both of these techniques allow for detection of multifocal lesions and lesions proximal to the rectosigmoid beyond the field-of-view of TVUS [81-89].


Endometriosis

Endometriosis. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of standard CT pelvis without and with IV contrast in the evaluation of clinically suspected rectosigmoid endometriosis.


Endometriosis

Endometriosis. CT Pelvis Without IV Contrast There is no relevant literature to support the use of CT pelvis without IV contrast for clinically suspected rectosigmoid endometriosis.


Endometriosis

Endometriosis. Fluoroscopy Contrast Enema Fluoroscopic enema studies allow for evaluation of the entire colon, allowing for diagnosis of cecal lesions. These studies are less specific than other imaging modalities because the cause of the mass effect on the bowel wall is not directly visualized and cannot be characterized. A study comparing double-contrast barium enema to TVUS performed with rectal water contrast shows similar accuracy for both studies with slightly better tolerance of TVUS with bowel preparation compared to barium enema [90].


Endometriosis

Endometriosis. MRI Pelvis Without and With IV Contrast MR pelvis is an excellent modality to detect and classify rectosigmoid bowel endometriosis for surgical planning [42,91,92]. Surgical approach can be predicted based on morphologic characteristics of lesions and quantitative assessment of lesion length, thickness, and circumferential involvement of the bowel lumen [93,94]. This information can be used to predict the type of resection that will be needed, aiding in informed decision making and treatment planning [42,91,92,94-96].


Endometriosis

Endometriosis. The field-of-view for pelvic MRI includes the entire rectum and sigmoid colon. The cecum and terminal ileum are often included within the field-of-view. A small percentage of small bowel loops are also included within the field- of-view.


Endometriosis

Endometriosis. Added MR cine sequences have been suggested to evaluate immobility from pelvic adhesions like the US sliding sign [97]. MR colonography has also been described as an accurate tool for evaluation of bowel lesions before surgery [98].


Endometriosis

Endometriosis

Endometriosis. Endometriosis


Endometriosis

Endometriosis. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is excellent for diagnosis of rectosigmoid endometriosis and for treatment planning as described in the preceding paragraph. Assessment of ovarian lesions, or other pelvic pathology, is a finding that is often seen in association with rectosigmoid endometriosis and is limited without IV contrast.


Endometriosis

Endometriosis. US Pelvis Transabdominal Transabdominal US imaging cannot be used to evaluate rectosigmoid lesions but can be used as an adjunct to identify sites of bowel involvement beyond the pelvis including the appendix, terminal ileum, cecum, and sigmoid [14].


Endometriosis

Endometriosis. US Pelvis Transabdominal and US Pelvis Transvaginal A study evaluating a combined transabdominal US and TVUS protocol found excellent sensitivity and specificity for rectosigmoid lesions and slightly decreased sensitivity for sigmoid lesions. The study did not report data on more proximal lesions [80]. As described in the previous paragraph, other studies have shown that transabdominal pelvis US can be used to evaluate the appendix, terminal ileum, cecum, and sigmoid colon, and therefore the addition of transabdominal imaging is likely to be of benefit in evaluating lesions proximal to the rectosigmoid.


Endometriosis

Endometriosis. US Pelvis Transrectal Transrectal pelvic US allows for evaluation of the bowel wall layers involved by an endometriotic lesion, which can help with surgical planning, as rectosigmoid endometriotic lesions involving the muscular layer may require discoid or segmental resection, whereas more superficial lesions can be treated with rectal shaving. Transrectal pelvic US also allows for accurate measurements from the caudal margin of an endometriotic lesion to the anal verge, which is important for surgical planning in the setting of low-lying lesions that may require a diverting ostomy. These studies are limited by a narrow field-of-view that allows for evaluation of the rectosigmoid colon but cannot evaluate more proximal structures [40,99,100].


Endometriosis

Endometriosis. US Pelvis Transvaginal TVUS can be used to evaluate rectosigmoid endometriosis but cannot be used to evaluate for lesions proximal to the rectosigmoid junction, which is beyond the field-of-view for a transvaginal probe. Literature surrounding the use of TVUS for the evaluation of rectosigmoid endometriosis has exclusively evaluated protocols that include scanning maneuvers beyond what is included in a routine TVUS as defined by the ACR Practice Parameters. TVUS performed with added maneuvers including scanning with probe in the posterior vaginal fornix and the sliding sign has been shown to be a reliable predictor of bowel endometriosis [101-104]. These protocols can also be used for surgical planning when the lesion length, circumferential extent, distance to the anal verge, and muscular involvement are reported [105-107]. When specialist-performed DE TVUS is used, the accuracy of surgical planning measurements is similar to MRI [108]. A study comparing DE TVUS performed by a trained versus untrained operator showed the modality predicted bowel endometriosis when performed by the trained operator but not by the untrained operator [109].


Endometriosis

Endometriosis. Variant 4: Adult. Established postoperative endometriosis diagnosis. New or ongoing symptoms of endometriosis. Follow-up imaging. CT Pelvis With IV Contrast There is no relevant literature to support the use of pelvic CT for patients with an endometriosis diagnosis established by surgery with new or ongoing symptoms. CT with IV contrast could help identify and characterize other etiologies of pelvic pain.


Endometriosis

Endometriosis. CT Pelvis Without and With IV Contrast There is no relevant literature to support the use of pelvic CT without and with IV contrast for patients with endometriosis diagnosis established by surgery and new or ongoing symptoms.


Endometriosis

Endometriosis. CT Pelvis Without IV Contrast There is no relevant literature to support the use of pelvic CT without IV contrast for patients with endometriosis diagnosis established by surgery and new or ongoing symptoms.


Endometriosis

Endometriosis. MRI Pelvis Without and With IV Contrast MRI pelvis is known to be an excellent modality for detecting endometriosis. An imaging review paper describes findings that may be seen postoperatively, including susceptibility artifacts related to surgical material and fibrotic adhesions that appear as linear hypointense bands on T2-weighted images with signal intensity lower than that is seen with endometriosis [110]. Semicircular suture may be seen along the anterior rectosigmoid wall in patients


Endometriosis

Endometriosis. who have undergone discoid resection. Bladder volumes may be decreased, and the bladder contour may be irregular following partial cystectomy for endometriosis lesion resection [110].


Endometriosis

Endometriosis. MRI Pelvis Without IV Contrast MRI pelvis without IV contrast is known to be an excellent modality for detecting and mapping endometriosis as summarized in the preceding paragraph; however, there are little data on the use of MRI without IV contrast to evaluate patients with ongoing or new symptoms following laparoscopy. IV contrast can be helpful in diagnosing other causes for recurrent symptoms in the postoperative time period.


Endometriosis

Endometriosis. US Pelvis Transabdominal There are no data describing the use of transabdominal pelvic US to evaluate for endometriosis in patients with ongoing or new symptoms following surgery. As in the preoperative setting, it is possible that larger ovarian endometriomas could be detected by transabdominal US, but many of the structures involved by superficial and DE are not well seen by transabdominal US technique alone.


Endometriosis

Endometriosis. US Pelvis Transabdominal and US Pelvis Transvaginal Although there is no relevant literature to support the use of US pelvis transabdominal and US pelvis transvaginal as a follow-up imaging modality for patients with known deep infiltrative endometriosis with ongoing or new symptoms, transabdominal and transvaginal pelvic US studies that follow an expanded protocol to include additional anatomic imaging considerations) are known to be excellent for detection of endometriosis.


Endometriosis

Endometriosis. Transabdominal US imaging is helpful for evaluation of the urinary tract or gastrointestinal tract and can serve as an important adjunct to TVUS studies because it widens the field-of-view beyond what is possible by TVUS imaging. TVUS supplemented by transabdominal US imaging was found to accurately predict intraoperative endometriosis staging at a multi-institutional study performed at centers of endometriosis excellence [52].


Endometriosis

Endometriosis. 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.


Endometriosis

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


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Introduction/Background Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings. Of the many causes for undifferentiated chest pain, acute cardiovascular processes (eg, myocardial infarction or aortic dissection) are the most important to distinguish from less life-threatening etiologies. Distinguishing visceral (eg, angina) from musculoskeletal (ie, chest wall) pain is an essential step in the diagnostic approach. An estimated 20% to 40% of the general population may be affected by chest pain in their lifetime [1], and almost half of patients presenting to primary care settings with chest pain were diagnosed with musculoskeletal causes. Patients presenting to ambulatory care settings more often are found to have noncardiovascular causes of chest pain (musculoskeletal, gastrointestinal, and psychopathologic) than those presenting to emergency departments [1,2]. One large series of ambulatory patients described their chest wall symptoms as stinging (53.0%) or pressing (35.1%), retrosternal (52.0%) or left-sided (69.2%), occurring more than once daily (62.9%), with more than half (55.4%) having chronic symptoms lasting >6 months [1].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. 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.


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Reprint requests to: publications@acr.org


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Discussion of Procedures by Variant Variant 1: Nontraumatic chest wall pain. No history of malignancy. Initial imaging. Bone Scan Whole Body Bone scintigraphy using diphosphonate radiotracer has been used to detect a variety of bone diseases that may cause chest wall pain, including fractures, metastases, arthritis, osteomyelitis, osteonecrosis, and costochondritis [9], but is usually not useful as an initial imaging modality. In a retrospective study of 225 patients with atypical chest pain considered to be of low to intermediate Framingham coronary risk, Tc-99m methylene diphosphonate bone scintigraphy showed a focal abnormality in nearly half (49.4%), with most (42.7%) being posttraumatic lesions of the rib, sternum, vertebral bodies, or clavicle; 4.9% costochondritis; and 1.8% neoplastic lesions [9]. Bone scintigraphy was positive in 5/7 (71.4%) patients diagnosed with costochondritis [9]. Overall, bone scintigraphy helped determine a cause for chest pain in 94/225 (41.8%) of patients, but in 15.3% of patients with abnormalities on bone scintigraphy, the true cause for chest pain was considered irrelevant to those findings [9].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. CT Chest Despite its superior sensitivity for detection and characterization of chest wall abnormalities, in the absence of other clinical risk factors like trauma, infection, or malignancy, CT may not be useful as a first-line modality for evaluation of chest wall pain [10]. For diagnosis of cough-induced rib fractures, some authors suggest that chest CT be reserved for patients who require evaluation of other pulmonary diseases [11]. Although not validated in nontraumatic settings, diagnostic accuracy for rib fractures may be improved and reading time decreased when the radiologist incorporates unfolded rib reformatted images [12,13]. Chest CT might also diagnose other causes of chest wall pain, such as mediastinal fat necrosis (also variably referred to in the literature as pericardial, epicardial, and epipericardial fat necrosis) [14].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT as initial imaging in the evaluation of chest wall pain in patients with no history of malignancy.


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. MRI Chest MRI may be complementary to other modalities in characterization of various processes and to delineate the extent of chest wall or osseous involvement on a case-by-case basis [15].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Radiography Chest After a thorough history and physical examination, chest radiography may be a useful initial imaging test to evaluate for specific etiologies of chest wall pain (eg, rib fracture, infection, or neoplasm) and to evaluate for other conditions that may simulate chest wall pain, such as spontaneous pneumothorax [16]. However, chest radiographs may be insensitive to detect abnormalities of the rib cartilages, costochondral junctions, costovertebral joints, and chest wall soft tissues. In a series of 183 stable adult outpatients presenting with nontraumatic chest pain imaging with both chest radiography and rib series, rib fractures were detected in only 4.9% of cases [17]. In another study of 1,089 patients presenting to the emergency department who underwent chest radiography for evaluation of nontraumatic chest pain, only 70 (6.4%) were deemed to have findings clinically relevant to emergency department care [18]. In one series of patients with rupture of the costal margin associated with severe coughing fits, all patients had widening of the rib spaces on chest radiographs, whereas 4/9 patients had associated rib fractures [19].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Nontraumatic Chest Wall Pain US Chest Although diagnostic ultrasound (US) of the chest is not typically utilized for the evaluation of chest wall pain, point- of-care US has been shown to be feasible for detection of rib fractures in the setting of minor trauma in emergency settings, with 27/94 (29%) detecting rib fractures after negative chest radiography [22]. Another study showed US to detect costochondral fractures in 68.8% of radiographically occult cases [23]. US of the chest has several diagnostic limitations, including technical difficulties related to posterior location of fractures, and soft-tissue penetration in patients with large breasts [22]. Patient-reported pain during the US examination limited evaluation in only 14% of cases but may be helpful in targeting the examination to the focal abnormality. US has added benefits of dynamic imaging capabilities as well as relative ease [15,24]. Dynamic US detected slipping rib syndrome in 32/36 (89%) and ruled it out in 10/10 (100%) [25].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. WBC Scan Chest There is no relevant literature to support the use of nuclear medicine white blood cell (WBC) chest scans as initial imaging in the evaluation of chest wall pain in patients with no history of malignancy.


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Variant 2: Nontraumatic chest wall pain. Known or suspected malignancy. Secondary evaluation after normal chest radiograph. Next imaging study. Bone Scan Whole Body Bone scintigraphy has been shown to have 95% sensitivity for detection of skeletal metastases and defines extent of involvement across the entire skeleton [26]. It may have a role in characterization of primary chest wall neoplasms, especially those that may contain chondroid or osteoid components [26]. Limitations of bone scintigraphy occur in the setting of nonosteoblastic processes such as multiple myeloma that may not be detected by this modality.


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Although uncommon, chest wall metastases usually indicate advanced disease. Osseous metastases may manifest as sclerotic (eg, prostate cancer), mixed lytic and sclerotic (eg, breast cancer), or purely lytic (eg, renal cell carcinoma) and are best characterized at CT [27]. Soft-tissue metastases may be readily detected at CT if they involve the skin or subcutaneous fat. However, intramuscular lesions may have similar attenuation as the skeletal muscle and may be missed, unless there is muscle expansion, invasion of adjacent osseous structures, or enhancement after administration of intravenous (IV) contrast material. CT is also useful for image-guided biopsy of lesions [32].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is valuable in the staging (presurgical planning, detection of distant metastases) and follow-up of patients with primary soft-tissue sarcomas, with maximum standardized uptake value (SUVmax) measurements being correlated with greater glucose transporter protein expression and histologic aggressiveness [33]. In one study, FDG-PET/CT was shown to have prognostic value, with greater event-free survival in patients whose tumors measured less than SUVmax 10.2 [33]. In addition, FDG-PET/CT may be helpful in directing image-guided needle biopsy to areas of metabolic activity to improve diagnostic accuracy in heterogeneous tumors [32]. Although FDG- PET/CT is sensitive for the detection of FDG-avid tumors, false-positives may result from misinterpretation of various normal physiologic states, including skeletal muscle uptake, brown fat uptake, and some benign lesions, such as infection, inflammation, healing fractures, and fibrous dysplasia. In one large retrospective series, benign nonphysiologic FDG uptake was present in >25% of oncologic FDG-PET/CT, with 55.7% of lesions showing moderate or marked FDG uptake relative to background [34]. Choi et al [35] determined that FDG-PET/CT had poor performance (accuracy 57.2%) in differentiating between benign and metastatic rib lesions, with the best SUVmax cutoff to differentiate being low at 2.4. However, predictive value for metastases was improved when FDG- PET activity was combined with CT findings of correlative osteolytic and osteoblastic lesions [35]. FDG-PET/CT may identify CT occult bone metastases, which demonstrate focal FDG uptake without a corresponding lesion on


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Nontraumatic Chest Wall Pain


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. MRI Chest Chest MRI is often complementary to CT in comprehensive tissue characterization of chest wall neoplasms, defining their extent, and for planning of therapeutic interventions [15,27-30,38]. The soft-tissue contrast afforded by MRI may allow for tissue characterization of lesions, including differentiation of neoplastic processes from nonneoplastic mimics (eg, infection) [27,30,39]. Chest MRI also has been utilized for determining neurovascular involvement [40]. Some studies have shown added value of respiratory dynamic chest MRI in determination of chest wall invasion, defined as restricted movement of a tumor by the chest wall during breathing maneuvers [41,42]. One study of 61 patients whose static CT or MRI were equivocal for invasion showed respiratory dynamic chest MRI to have 100% sensitivity, 82.9% specificity, and 88.5% accuracy for predicting chest wall invasion with positive and negative predictive values of 74.1% and 100%, respectively [41]. False-positives occurred in the setting of pleural adhesions that restricted movement, but in most cases, they could be differentiated from true invasion at surgery [41].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. Radiography Rib Views For focal chest wall pain in patients with suspected malignancy, a radiographic rib series may be helpful to assess for a rib lesion [16]. However, as for chest radiography, further characterization with CT, MRI, or nuclear medicine studies may be beneficial to detect radiographically occult lesions.


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. US Chest Generally, US serves a limited role in the primary evaluation of suspected primary chest wall neoplasms but may serve a role in determining secondary invasion of the chest wall by intrathoracic tumors. In a study of 23 patients who had a chest CT that showed findings suspicious for chest wall invasion by intrathoracic tumors or lung invasion by chest wall tumors, the sensitivity and specificity for chest wall invasion (using absence of a sliding pleura sign) were 88.9% and 100%, respectively, with 100% and 93.3% positive and negative predictive values, respectively [43]. Surgeon-performed US outperformed CT in diagnosis of chest wall invasion, with 90.9% sensitivity and 85.7% specificity versus 61.5% sensitivity and 84.6% specificity for CT [44]. Respective positive and negative predictive values in the same study of 28 patients were 83.3% and 92.3% for US compared with 80% and 68.8% for CT [44]. Another study showed US to have a higher sensitivity than CT for determining chest wall invasion by lung cancer (89% versus 42%, respectively) but had a lower specificity (95% versus 100%, respectively) [45]. However, a study of 131 patients with thoracic masses showed overlap in performance of US and CT for diagnosing chest wall invasion [46]. US may be helpful for image-guided biopsy of superficial lesions [27,32,39,46].


Nontraumatic Chest Wall Pain

Nontraumatic Chest Wall Pain. WBC Scan Chest There is no relevant literature to support the use of nuclear medicine WBC scans as initial imaging in the evaluation of chest wall pain in patients with known or suspected malignancy.