Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer MRI Abdomen and Pelvis Without IV Contrast There is limited evidence to support the use of MRI abdomen and pelvis without IV contrast for initial imaging of patients with clinically suspected prostate cancer and no prior biopsy.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Pelvis Without IV Contrast More recently, there has been increase in the performance of MRI pelvis without IV contrast, albeit with controversy regarding the additive benefit of IV gadolinium-based contrast media for assessing prostate cancer. Unlike diffusion-weighted imaging, which is undoubtedly an essential component of prostate MRI, there has been debate over whether dynamic contrast-enhanced imaging should be retained, used but limited to assessing the presence of early and/or contemporaneous enhancement (as in the current PI-RADS schema), or even omitted altogether [50,51]. Despite the notion that detection of prostate cancer could be improved by using dynamic contrast-enhanced imaging, owing to the fact that prostate cancer typically enhances more rapidly and washes out more quickly than benign prostatic tissue, many studies have shown that the incremental diagnostic yield is minimal [52-54]. For instance, in a meta-analysis of 20 studies (2,142 patients) performing a head-to-head comparison of biparametric and multiparametric MRI, sensitivity and specificity were similar: 0.74 (95% CI: 0.66-0.81) and 0.90 (95% CI: 0.86-0.93) for biparametric and 0.76 (95% CI: 0.69-0.82) and 0.89 (95% CI: 0.85-0.93) for multiparametric, respectively [54]. Omitting dynamic contrast-enhanced imaging additionally offers benefits of decreasing study time. Nevertheless, biparametric MRI is not yet widely adopted, and it is recommended that when performed, several requirements need to be met, such as good image quality (especially diffusion-weighted imaging), potential radiologist monitoring, and a safety net for missing significant cancers (eg, PSA follow-up).


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without and With IV Contrast There is limited evidence to support the use of MRI whole body without and with IV contrast for initial imaging of patients with clinically suspected prostate cancer and no prior biopsy.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without IV Contrast There is limited evidence to support the use of MRI whole body without IV contrast for initial imaging of patients with clinically suspected prostate cancer and no prior biopsy.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. PSMA PET/CT Skull Base to Mid-Thigh There is limited evidence to support the use of prostate-specific membrane antigen (PSMA) PET/CT (or PET/MRI) for initial imaging of patients with clinically suspected prostate cancer and no prior biopsy.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS Prostate In North America, TRUS is generally performed by urologists for purposes of localizing the prostate gland (not the cancer) prior to systematic biopsy. Conventional grayscale TRUS is not widely used for localizing the tumor, first because lesions (usually hypoechoic in appearance) are visible only in a small proportion (11%-35%) of patients [65]. In a study of 142 patients, grayscale TRUS was able to detect only 62.2% of lesions visible on multiparametric MRI [66]. Second, only a small proportion (17%-57%) of those hypoechoic lesions are confirmed to be malignant [65]. In a study of 31,296 cores obtained from 3,912 consecutive patients undergoing TRUS with biopsy, there was no statistically significant association between the presence of a hypoechoic lesion and the detection of cancer [67]. Therefore, in isolation, TRUS is inaccurate for prostate cancer detection and is not beneficial for this purpose [65].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Variant 2: Clinically suspected prostate cancer. Negative TRUS-guided biopsy. Initial diagnosis. Next imaging study. Bone Scan Whole Body There is limited evidence to support the use of bone scan as the next imaging study of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer Choline PET/CT Skull Base to Mid-Thigh There is limited evidence to support the use of choline PET/CT for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Choline PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of choline PET/MRI for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis With IV Contrast There is limited evidence to support the use of CT abdomen and pelvis with IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis Without and With IV Contrast There is limited evidence to support the use of CT abdomen and pelvis without and with IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis Without IV Contrast There is limited evidence to support the use of CT abdomen and pelvis without IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis With IV Contrast There is limited evidence to support the use of CT chest, abdomen, and pelvis with IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There is limited evidence to support the use of CT chest, abdomen, and pelvis without and with IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis Without IV Contrast There is limited evidence to support the use of CT chest, abdomen, and pelvis without IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. FDG-PET/CT Whole Body Because prostate cancer and metastases from it are generally not FDG-avid unlike most other malignancies, FDG- PET/CT may not be beneficial as part of initial imaging.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. FDG-PET/MRI Skull Base to Mid-Thigh Because prostate cancer and metastases from it are generally not FDG-avid unlike most other malignancies, FDG- PET/MRI may not be beneficial as part of initial imaging.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluciclovine PET/CT Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/CT for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluciclovine PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/MRI for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluoride PET/CT Whole Body There is limited evidence to support the use of fluoride PET/CT for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Abdomen and Pelvis Without and With IV Contrast There is limited evidence to support the use of MRI abdomen and pelvis without and with IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer MRI Abdomen and Pelvis Without IV Contrast There is limited evidence to support the use of MRI abdomen and pelvis without IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Pelvis Without IV Contrast In patients with clinically suspected prostate cancer who had a negative TRUS-guided biopsy, imaging without using IV contrast is also a viable option based on the identical rationales for using MRI of the pelvis with IV contrast [29,40,44,45,49]. Nevertheless, controversies exist with regard to balancing between the small incremental yield for detecting clinically significant cancer using IV contrast and potential benefits such as decreased scan time when forgoing IV contrast [50-54].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without and With IV Contrast There is limited evidence to support the use of MRI whole body without and with IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without IV Contrast There is limited evidence to support the use of MRI whole body without IV contrast for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. PSMA PET/CT Skull Base to Mid-Thigh There is limited evidence to support the use of PSMA PET/CT (or PET/MRI) for initial imaging of patients with clinically suspected prostate cancer unless or until the presence of higher-risk disease has been established histologically.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS Prostate In isolation, TRUS is inaccurate for prostate cancer detection and is not useful for this purpose [65,66].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS-Guided Biopsy Prostate In patients with clinically suspected prostate cancer who have had 1 negative standard TRUS-guided systematic biopsy, a second TRUS-guided systematic biopsy will be positive in 15% to 20% of cases [73-76], and so a second repeat biopsy in this setting is reasonable. The yield from additional systematic biopsies after a second biopsy falls off rapidly, with reported positive rates of 8% to 17% for the third biopsy and 7% to 12% for the fourth [73-75,77], suggesting alternative approaches such as MRI-targeted biopsy or saturation biopsy may be more useful in this specific setting of patients with 2 or more negative TRUS-guided systematic biopsies and persistent clinical suspicion for prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Choline PET/CT Skull Base to Mid-Thigh There is limited evidence to support the use of choline PET/CT for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Choline PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of choline PET/MRI for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis With IV Contrast There is limited evidence to support the use of CT abdomen and pelvis with IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis Without and With IV Contrast There is limited evidence to support the use of CT abdomen and pelvis without and with IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis Without IV contrast There is limited evidence to support the use of CT abdomen and pelvis without IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis With IV Contrast There is limited evidence to support the use of CT chest, abdomen, and pelvis with IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There is limited evidence to support the use of CT chest, abdomen, and pelvis without and with IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis Without IV Contrast There is limited evidence to support the use of CT chest, abdomen, and pelvis without IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. FDG-PET/CT Whole Body Because prostate cancer and metastases from it are generally not FDG-avid unlike most other malignancies, FDG- PET/CT may not be beneficial as part of active surveillance.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. FDG-PET/MRI Skull Base to Mid-Thigh Because prostate cancer and metastases from it are generally not FDG-avid unlike most other malignancies, FDG- PET/MRI may not be beneficial as part of active surveillance.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluciclovine PET/CT Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/CT for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluciclovine PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/MRI for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluoride PET/CT Whole Body There is limited evidence to support the use of fluoride PET/CT for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer MRI Abdomen and Pelvis Without and With IV Contrast There is limited evidence to support the use of MRI abdomen and pelvis without and with IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Abdomen and Pelvis Without IV Contrast There is limited evidence to support the use of MRI abdomen and pelvis without IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Pelvis Without and With IV Contrast There has been a substantial increase in the role of MRI in active surveillance in terms of detecting/predicting disease progression and identifying targets amenable for biopsy. In a meta-analysis of 43 studies (6,605 patients), the sensitivity and negative predictive value of predicting disease reclassification were 0.60 and 0.75 using 1.5T scanners and 0.81 and 0.78 using 3.0T scanners [81]. In addition, several studies have shown that MRI is at least equivalent or superior to systematic TRUS-guided biopsies in identifying pathological progression during follow- up in patients on active surveillance [82-84]. In a prospective trial of 172 patients who underwent active surveillance, in which at 3 years 21% experienced pathological progression, MRI using PI-RADS was able to identify many of them (a sensitivity of 61% and a specificity of 80%) [82]. In addition, in a study in which 86 patients who had diffusion-weighted imaging as part of their baseline assessment for active surveillance and followed up for a median of 9.5 years, it was able to predict patients with a shorter time to adverse histology (hazard ratio [HR] = 2.13, 95% CI: 1.17-3.89) and a shorter time to radical treatment (HR 2.54, 95% CI: 1.49-4.32; P < .001) [83]. MRI can also be used in conjunction with nonimaging biomarkers to better identify patients with an increased risk of biopsy upgrading [84].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Pelvis Without IV Contrast Initial imaging without using IV contrast is also a viable option based on the identical rationales for using MRI of the pelvis with IV contrast [81-84]. Especially, there are studies that specifically address the usage of diffusion- weighted imaging (which is typical done without or prior to administration of IV contrast) for baseline assessment on active surveillance, demonstrating that it was helpful for predicting patients with shorter time to adverse histology and radical treatment [83].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without and With IV Contrast There is limited evidence to support the use of MRI whole body without and with IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without IV Contrast There is limited evidence to support the use of MRI whole body without IV contrast for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. PSMA PET/CT Skull Base to Mid-Thigh There is limited evidence to support the use of PSMA PET/CT (or PET/MRI) for active surveillance of patients with clinically established low-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer


Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS Prostate In general, TRUS is inaccurate for prostate cancer detection [65,67] and has a limited accuracy for staging prostate cancer [93]. Other than one retrospective study of 875 patients who demonstrated the association between imaging progression on TRUS and biopsy Gleason upgrade [94], there is lack of evidence to support TRUS in evaluating on active surveillance.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS-Guided Biopsy Prostate Many active surveillance programs incorporate serial PSA testing and some form of serial biopsy regimen, either in the form of 1) systemic biopsy only or 2) systemic biopsy with MRI-targeted biopsy of a suspicious lesion on MRI. Because some tumors are invisible on MRI [82] and missed by MRI-targeted biopsies [91,92], even when performing an MRI-targeted biopsy as part of active surveillance, concurrent systemic biopsies cannot be omitted at the moment.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Choline PET/CT Skull Base to Mid-Thigh Choline PET, although it was approved by the FDA in 2013 for evaluating recurrence, has been widely investigated on its ability to detect nodal and distant metastases for pretreatment assessment of prostate cancer. The pooled sensitivity of choline PET/CT is low (0.57, 95% CI: 0.42-0.70) for detecting nodal metastases prior to treatment despite its high specificity (0.94, 95% CI: 0.89-0.97) in a meta-analysis of 7 studies (627 patients) [98]. Nevertheless, in patients with intermediate- and high-risk prostate cancer, choline PET/CT and PET/MRI has shown to identify more nodal and distant metastatic lesions than conventional imaging [96,98]. For example, in a study of 48 patients, choline PET/CT showed higher sensitivity (46.2% versus 69.2%) with identical specificity (92.3%) for detecting nodal metastases [99]. This in turn has shown to change in management in 33% to 71% of patients [99,100].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Choline PET/MRI Skull Base to Mid-Thigh Choline PET/MRI is less commonly used than choline PET/CT but can be considered in the pretreatment assessment of prostate cancer based on the same principles that it better detects nodal and distant metastases than CT and bone scan [96,98-100]. For example, in a study of 48 patients with intermediate- and high-risk disease, choline PET/CT showed a higher sensitivity (46.2% versus 69.2%) with identical specificity (92.3%) for detecting nodal metastases [99]. In a prospective study specifically assessing choline PET/MRI in 58 patients, it was superior to CT and bone scan for detecting distant metastases (100% versus 63.6%, respectively) [101].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis With IV Contrast CT abdomen and pelvis with IV contrast for nodal staging is generally useful in intermediate-risk patients because the a priori risk of nodal disease exceeds 10% [20].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis Without and With IV Contrast There is limited evidence to support the use of CT abdomen and pelvis without and with IV contrast because obtaining CT with both techniques does not provide additional benefit in terms of detecting nodal and distant metastases.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer CT Abdomen and Pelvis Without IV Contrast CT abdomen and pelvis without IV contrast can be a viable option as an alternative for using IV contrast for nodal staging because it is generally useful in intermediate-risk patients because the a priori risk of nodal disease exceeds 10% [20]. However, it should be recognized that without using IV contrast there is possibility of less optimal detection of metastases to visceral organs.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis With IV Contrast CT chest, abdomen, and pelvis with IV contrast for nodal staging is generally useful in intermediate-risk patients because the a priori risk of nodal disease exceeds 10% [20].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There is limited evidence to support the use of CT chest, abdomen, and pelvis without and with IV contrast because obtaining CT with both techniques does not provide additional benefit in terms of detecting nodal and distant metastases.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis Without IV Contrast CT chest, abdomen, and pelvis without IV contrast for nodal staging is generally useful in intermediate-risk patients because the a priori risk of nodal disease exceeds 10% [20]. However, it should be recognized that without using IV contrast there is a possibility of less optimal detection of metastases to visceral organs.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. FDG-PET/CT Whole Body Because prostate cancer and metastases from it are generally not FDG-avid unlike most other malignancies, FDG- PET/CT may not be beneficial as part of staging clinically established intermediate-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. FDG-PET/MRI Skull Base to Mid-Thigh Because prostate cancer and metastases from it are generally not FDG-avid unlike most other malignancies, FDG- PET/MRI may not be beneficial as part of staging clinically established intermediate-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluciclovine PET/CT Skull Base to Mid-Thigh Although fluciclovine PET/CT is primarily used in the recurrent setting, it can also be considered in the pretreatment assessment of prostate cancer based on its ability to better detect nodal and distant metastases than CT and bone scan [98,102-105]. The specificity of fluciclovine PET/CT is high (0.98, 95% CI: 0.88-1.00) [98], and in a study of 57 patients, it demonstrated higher sensitivity for detecting nodal metastases (55.3% versus 33.3%) and was able to identify 12.3% (7/57) additional patients with distant metastasis when compared to conventional imaging (bone scan and CT) in patients with intermediate- and high-risk disease [106].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluciclovine PET/MRI Skull Base to Mid-Thigh Fluciclovine PET/MRI is less commonly used than fluciclovine PET/CT but shares similar principles and can be considered in the pretreatment assessment of prostate cancer based on its ability to better detect nodal and distant metastases than CT and bone scan [102,105]. The specificity of fluciclovine PET/CT is high (0.98, 95% CI: 0.88- 1.00) [98], and in a study of 57 patients, it demonstrated a higher sensitivity for detecting nodal metastases (55.3% versus 33.3%) and was able to identify 12.3% (7/57) additional patients with distant metastasis when compared with conventional imaging (bone scan and CT) in patients with intermediate- and high-risk disease [106]. Although no specific study deals with only patients with intermediate-risk disease, it is notable that in a study of 28 patients with high-risk disease, the sensitivity and specificity of fluciclovine PET/MRI for detecting nodal metastases was 40% and 100%, respectively [105]. Also, fluciclovine PET/MRI has been shown to potentially improve characterization of the primary tumor compared with PET/CT [103].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer MRI Abdomen and Pelvis Without and With IV Contrast The literature indicates that MRI abdomen and pelvis without and with IV contrast may be used in intermediate- risk patients for 1) nodal and distant metastasis staging in addition to 2) assessment of the local extent of primary tumor [109-112]. This can be supported by the fact that a priori risk of nodal disease (most of which are in the pelvis and some up to the retroperitoneum) exceeds 10% [20]. In addition, because a majority of the distant metastases occur (at least in the pretreatment setting) in the axial skeleton and it is rare to harbor isolated bone metastases without simultaneously harboring metastases in the pelvic and lumbosacral vertebral bones, MRI abdomen and pelvis is usually sufficient to detect the presence of bone metastasis at the patient level [113].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Abdomen and Pelvis Without IV Contrast Because the main purpose for imaging the abdomen and pelvis would be to identify nodal and distant metastases, MRI abdomen and pelvis without IV contrast is a viable option as an alternative to that using IV contrast [109-113]. However, it should be recognized that without using IV contrast there is the possibility of less optimal detection of metastases to visceral organs.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without IV Contrast Because the main purpose for imaging the whole body would be to identify nodal and distant metastases, MRI whole body without IV contrast is a viable option as an alternative to that using IV contrast [49,96,108-112,114- 117]. However, it should be recognized that without using IV contrast there is the possibility of less optimal detection of metastases to visceral organs.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer PSMA PET/CT Skull Base to Mid-Thigh The literature indicates PSMA PET/CT is useful in patients with intermediate- and high-risk disease. PSMA PET, which can be used with CT or MRI (PET/CT and PET/MRI, respectively), is one of the newer imaging modalities, which has been primarily investigated in the setting of biochemical recurrence and biochemical failure, where, because of its superior capability to detect recurrent disease, has shown to substantially change management [118]. Nevertheless, many recent studies have shown its potential to detect metastatic disease in patients with intermediate- and high-risk prostate cancer undergoing pretreatment assessment, and it has recently received approval from the FDA for both recurrent and primary staging settings [117,119-121].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. PSMA PET/CT examination has higher diagnostic performance for prostate cancer compared to fluciclovine PET/CT, which was able to identify additional patients with distant metastasis when compared to conventional imaging (bone scan and CT) in patients with intermediate- and high-risk disease. In a study of 130 patients with intermediate- and high-risk patients, PSMA PET demonstrated superior sensitivity and a similar specificity to morphological imaging alone (CT or MRI) [121]: 68.3% and 99.1%, respectively, for PSMA PET and 27.3% and 97.1%, respectively, for morphological imaging. Additionally, PSMA PET, especially when combined with MRI, can potentially improve detection and characterization (eg, assessment of local extent) of the primary tumor, by using different types of PSMA-targeted radiotracers, compared with multiparametric MRI alone or clinical nomograms [19,122,123].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS Prostate TRUS is unlikely to provide useful incremental information in patients with an established diagnosis of intermediate-risk prostate cancer and so it is not beneficial.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS-Guided Biopsy Prostate Active surveillance may be beneficial in carefully selected patients with intermediate-risk prostate cancer [109- 111]. In that setting, some form of serial TRUS-guided biopsy would be useful as part of the monitoring regimen.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Choline PET/CT Skull Base to Mid-Thigh Although choline PET/CT is primarily used in the recurrent setting, it can also be considered in the pretreatment assessment of prostate cancer based on its ability to better detect nodal and distant metastases than CT and bone scan. In patients with intermediate- and high-risk prostate cancer, choline PET/CT has shown to identify more nodal and distant metastatic lesions than conventional imaging [96,98-100]. For example, in a study of 48 patients, choline PET/CT showed a higher sensitivity (46.2% versus 69.2%) with an identical specificity (92.3%) for detecting nodal metastases [99]. In another multicenter study of 269 patients, choline PET/CT was shown to identify more nodal and distant metastatic lesions than conventional imaging, which led to a change in therapeutic indication in approximately 70% of patients [100].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Choline PET/MRI Skull Base to Mid-Thigh Choline PET/MRI is less commonly used than choline PET/CT but can be considered in the pretreatment assessment of prostate cancer based on the same principles that it better detects nodal and distant metastases than CT and bone scan [96,98-100]. For example, in a study of 48 patients with intermediate- and high-risk disease, choline PET/CT showed a higher sensitivity (46.2% versus 69.2%) with an identical specificity (92.3%) for detecting nodal metastases [99]. In a prospective study of 58 patients with high-risk disease, which specifically assessed choline PET/MRI, it was superior to CT and bone scan for detecting distant metastases (100% versus 63.6%, respectively) [101].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer CT Abdomen and Pelvis With IV Contrast CT abdomen and pelvis with IV contrast for nodal staging is generally useful in high-risk patients because a priori risk of nodal disease exceeds 10% [20].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis Without and With IV Contrast There is limited evidence to support the use of CT abdomen and pelvis without and with IV contrast because obtaining CT with both techniques does not provide additional benefit in terms of detecting nodal and distant metastases.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Abdomen and Pelvis Without IV Contrast CT abdomen and pelvis without IV contrast for nodal staging is generally useful in high-risk patients because a priori risk of nodal disease exceeds 10% [20]. However, it should be recognized that without using IV contrast there is the possibility of less optimal detection of metastases to visceral organs.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis With IV Contrast CT chest, abdomen, and pelvis with IV contrast for nodal staging is generally useful in high-risk patients because a priori risk of nodal disease exceeds 10% [20].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There is limited evidence to support the use of CT chest, abdomen, and pelvis without and with IV contrast because obtaining CT with both techniques does not provide additional benefit in terms of detecting nodal and distant metastases.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. CT Chest, Abdomen, and Pelvis Without IV Contrast CT chest, abdomen, and pelvis without IV contrast for nodal staging is generally useful in high-risk patients because a priori risk of nodal disease exceeds 10% [20]. However, it should be recognized that without using IV contrast there is the possibility of less optimal detection of metastases to visceral organs.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. FDG-PET/CT Whole Body Because prostate cancer and metastases from it are generally not FDG-avid unlike most other malignancies, FDG- PET/CT may not be beneficial as part of staging clinically established high-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. FDG-PET/MRI Skull Base to Mid-Thigh Because prostate cancer and metastases from it are generally not FDG-avid unlike most other malignancies, FDG- PET/MRI may not be beneficial as part of staging clinically established high-risk prostate cancer.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluciclovine PET/CT Skull Base to Mid-Thigh Although fluciclovine PET/CT is primarily used in the recurrent setting, it can also be considered in the pretreatment assessment of prostate cancer based on its ability to better detect nodal and distant metastases than CT and bone scan [98,102]. The specificity of fluciclovine PET/CT is high (0.98, 95% CI: 0.88-1.00) [98], and in a study of 57 patients, it demonstrated a higher sensitivity for detecting nodal metastases (55.3% versus 33.3%) and was able to identify 12.3% (7/57) additional patients with distant metastasis when compared with conventional imaging (bone scan and CT) in patients with intermediate- and high-risk disease [106].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Fluciclovine PET/MRI Skull Base to Mid-Thigh Fluciclovine PET/MRI is less commonly used than fluciclovine PET/CT but shares similar principles and can be considered in the pretreatment assessment of prostate cancer based on its ability to better detect nodal and distant metastases than CT and bone scan [102,105]. The specificity of fluciclovine PET/CT is high (0.98, 95% CI: 0.88- 1.00) [98], and in a study of 57 patients, it demonstrated a higher sensitivity for detecting nodal metastases (55.3% versus 33.3%) and was able to identify 12.3% (7/57) additional patients with distant metastasis when compared with conventional imaging (bone scan and CT) in patients with intermediate- and high-risk disease [106]. In a study of 28 patients with high-risk disease who underwent fluciclovine PET/MRI, the sensitivity and specificity for detecting nodal metastases was 40% and 100%, respectively [105].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer MRI Abdomen and Pelvis Without and With IV Contrast The literature indicates MRI abdomen and pelvis may be used in high-risk patients for 1) nodal and distant metastasis staging in addition to 2) assessment of the local extent of primary tumor [109-112]. This can be supported by the fact that a priori risk of nodal disease (most of which are in the pelvis and some up to the retroperitoneum) exceeds 10% [20]. In addition, because a majority of the distant metastases occur (at least in the pretreatment setting) in the axial skeleton and it is rare to harbor isolated bone metastases without simultaneously harboring metastases in the pelvic and lumbosacral vertebral bones, MRI abdomen and pelvis is usually sufficient to detect the presence of bone metastasis at the patient level [113].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Abdomen and Pelvis Without IV Contrast Because the main purpose for imaging the abdomen and pelvis would be to identify nodal and distant metastases, MRI abdomen and pelvis without IV contrast is a viable option as an alternative to using IV contrast [20,109-113]. However, it should be recognized that without using IV contrast there is possibility of less optimal detection of metastases to visceral organs.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Pelvis Without and With IV Contrast In addition to standard local and nodal staging, multiparametric MRI may be helpful in the management of high- risk prostate cancer by identifying more extensive disease that may merit supplementary extended androgen deprivation therapy, localizing dominant disease for focal therapy, guiding surgical planning, or changing management plan from surgery to radiation [49,114,115].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Pelvis Without IV Contrast In addition to standard local and nodal staging, multiparametric MRI without IV contrast may be a viable option as an alternative to using IV contrast in the management of high-risk prostate cancer [49,114,115]. Although the same principles and controversies regarding the use of IV contrast persists, many of these scenarios are less dependent on the potential advantages of IV contrast.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI-Targeted Biopsy Prostate Most patients with high-risk disease require definitive therapy, and targeted biopsy is unlikely to significantly alter management.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without and With IV Contrast The literature indicates that MRI whole body can be used to assess the nodal and distant metastatic state in patients with intermediate- and high-risk prostate cancer prior to treatment [96,108,117]. In a prospective study of 56 intermediate- and high-risk patients, whole body MRI was more accurate than bone scan and similar to choline PET/CT for detecting nodal and distant metastases [96]. In a prospective study of 36 high-risk patients, whole body MRI was concordant with PSMA PET/CT for determining nonregional nodal metastases in 72.2% and for distant metastases in 86.1% of the patients [117]. In addition to standard local, nodal, and distant metastasis staging, multiparametric MRI of the prostate may be added in the whole body MRI protocol, providing additional information to assist management of high-risk prostate cancer by identifying more extensive disease that may merit supplementary extended androgen deprivation therapy, localizing dominant disease for focal therapy, guiding surgical planning, or changing management plan from surgery to radiation [49,114,115].


Pretreatment Detection Surveillance and Staging of Prostate Cancer. MRI Whole Body Without IV Contrast Because the main purpose for imaging the whole body would be to identify nodal and distant metastases, MRI whole body without IV contrast is a viable option as an alternative to using IV contrast [49,96,108,114,115,117]. However, it should be recognized that without using IV contrast there is the possibility of less optimal detection of metastases to visceral organs.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. PSMA PET/CT Skull Base to Mid-Thigh PSMA PET, which can be used either with CT or MRI (PET/CT and PET/MRI, respectively) has shown its potential to detect metastatic disease in patients with high-risk prostate cancer undergoing pretreatment assessment [117,119- 121]. In a prospective randomized trial of 302 high-risk patients, PSMA PET demonstrated superior sensitivity and specificity to conventional imaging (CT, MRI, and bone scan) [119]: 85% and 98%, respectively, for PSMA PET and 38% and 91%, respectively, for conventional imaging.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS Prostate TRUS is unlikely to provide useful incremental information in patients with an established diagnosis of high-risk prostate cancer and so it is not beneficial.


Pretreatment Detection Surveillance and Staging of Prostate 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.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Pretreatment Detection Surveillance and Staging of Prostate Cancer. Pretreatment Detection of Prostate Cancer


Routine Chest Imaging

Routine Chest Imaging. Historically, routine chest radiography served as a method of screening a general population for disease. Early use of routine chest imaging was used to identify tuberculosis in asymptomatic individuals for public health and safety measures [2]. However, as the overall rates of undiagnosed tuberculosis have decreased, its usefulness is now being questioned [2]. More recent studies have shown that routine imaging in an otherwise healthy and asymptomatic population has a low diagnostic yield [3,4]. Preprocedural routine imaging has also been used for detection of subclinical disease, such as malignant neoplasms, emphysema, or cardiovascular disease, that could be associated with perioperative complications [2]. Multiple studies have shown that routine imaging studies in the preoperative setting have no significant impact on the decision to operate [5] and usually do not yield information that is not available by clinical history or physical examination [6]. However, there are no randomized control trials to show whether routine chest imaging improves outcomes. This document reviews the use of routine chest imaging performed on adult patients for evaluation on hospital admission, preoperative preparation, and asymptomatic outpatient follow-up and evaluation.


Routine Chest Imaging

Routine Chest Imaging. Special Imaging Considerations Chest radiography can be performed as a 2-view or a single-view imaging study. A 2-view (posterior-anterior and lateral views) chest radiograph requires that a patient is able to stand and appropriately position their arms to be out of the field of view. Alternatively, a single-view chest radiograph using anterior-posterior technique (also refered to as portable technique) can be performed in a patient who is not ambulatory or unable to tolerate positioning of a posterior-anterior radiograph. However, anterior-posterior/portable technique is associated with lower image quality, distortion of normal structures (eg, magnification of the cardiac silhouette), and higher rates of artifactual findings [7].


Routine Chest Imaging

Routine Chest Imaging. 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.


Routine Chest Imaging

Routine Chest Imaging. Reprint requests to: publications@acr.org


Routine Chest Imaging

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


Routine Chest Imaging

Routine Chest Imaging. OR Discussion of Procedures by Variant Variant 1: Routine chest imaging for hospital admission. No clinical concern for cardiopulmonary disease. Initial Imaging. CT Chest With IV Contrast There is no relevant literature to support the use of CT chest with intravenous (IV) contrast as routine imaging for hospital admission.


Routine Chest Imaging

Routine Chest Imaging. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast as routine imaging for hospital admission.


Routine Chest Imaging

Routine Chest Imaging. CT Chest Without IV Contrast CT chest is known to have a higher sensitivity than chest radiography for the detection of pulmonary infections and malignancies. Millor et al [9] performed a retrospective review of 6,516 adult patients who underwent a self-referred whole-body CT (including a CT chest without IV contrast), performed in the absence of specific symptoms and no history of malignancy. The authors found that the incidence of abnormal whole-body CT findings increased with age and found a higher rate of abnormal findings in men. Although most findings were benign, there was a 1.47% rate of primary neoplasm detection, the majority of which were found before metastatic spread. The authors suggested that the early detection of these abnormalities (eg, before metastatic spread of malignancy) allows for earlier intervention and sometimes curative treatment.


Routine Chest Imaging

Routine Chest Imaging. A number of incidental and relatively common cardiac abnormalities can be detected on routine CT chest without IV contrast [9,10]. These include pericardial, myocardial, coronary, aortic, and valvular abnormalities.


Routine Chest Imaging

Routine Chest Imaging. CTA Chest With IV Contrast There is no relevant literature to support the use of CTA chest with IV contrast as routine imaging for hospital admission.


Routine Chest Imaging

Routine Chest Imaging. CTA Chest Without and With IV Contrast There is no relevant literature to support the use of CTA chest without and with IV contrast as routine imaging for hospital admission.


Routine Chest Imaging

Routine Chest Imaging. 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 for routine initial chest imaging on hospital admission in the absence of cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for routine chest imaging on hospital admission in the absence of cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging

Routine Chest Imaging. Routine Chest Imaging


Routine Chest Imaging

Routine Chest Imaging. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast as routine imaging for hospital admission in the absence of cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging. Radiography Chest Chest radiography is a commonly ordered study on hospital admission. In a retrospective study by Shimoni et al [11] of 238 patient records and interviews with treating physicians, the investigators found that routine admission chest radiography yielded minimal benefit in patients without respiratory symptoms. In addition, routine admission chest radiography was also associated with false-positive findings, leading to inappropriate hospitalization and unnecessary antibiotic therapy. The authors concluded that admission chest radiography was not warranted in patients without respiratory symptoms but could be considered in patients with an uncertain diagnosis who may present atypically, such as older patients, patients who are immunocompromised, or who cannot communicate symptoms with multiple comorbidities and uncertain diagnosis on admission.


Routine Chest Imaging

Routine Chest Imaging. Malnik et al [12] conducted a retrospective investigation of medical records and found that a very small number of admission chest radiographs altered patient management if there was no clinical indication or abnormal physical examination finding. The authors concluded that a routine admission radiograph only altered management if there was a clinical indication for performance or abnormal physical examination findings in the thorax.


Routine Chest Imaging

Routine Chest Imaging. Variant 2: Routine preoperative chest imaging for noncardiothoracic surgery. No history of chronic cardiopulmonary disease or cardiothoracic surgery. Initial imaging. CT Chest With IV Contrast Patients undergoing evaluation for abdominal solid organ transplant (eg, liver or kidney) are known to have higher rates of intrathoracic diseases, including coronary artery disease, pleural effusions, pulmonary hypertension, and hepatopulmonary syndrome, which may not be clinically apparent [13,14]. Currently, the American Association for the Study of Liver Diseases recommends screening of liver transplant candidates for hepatopulmonary syndrome. This is initially done by pulse oximetry, although CT chest with IV contrast may be pursued to exclude other causes of pulmonary disease [15].


Routine Chest Imaging

Routine Chest Imaging. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast for routine preoperative evaluation of patients without cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. CT Chest Without IV Contrast Patients undergoing evaluation for abdominal solid organ transplant (eg, liver or kidney) are known to have higher rates of intrathoracic diseases, including coronary artery disease, pleural effusions, pulmonary hypertension, and hepatopulmonary syndrome, which may not be clinically apparent [13,14]. Currently, the American Association for the Study of Liver Diseases recommends screening of liver transplant candidates for hepatopulmonary syndrome. This is initially done by pulse oximetry, although CT chest without IV contrast may be pursued to exclude other causes of pulmonary disease [15].


Routine Chest Imaging

Routine Chest Imaging. CTA Chest With IV Contrast There is no relevant literature to support the use of CTA chest with IV contrast for routine preoperative evaluation of patients without cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. CTA Chest Without and With IV Contrast There is no relevant literature to support the use of CTA chest without and with IV contrast for routine preoperative evaluation of patients without cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for routine preoperative evaluation of patients without cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for routine preoperative evaluation of patients without cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast for routine preoperative evaluation of patients without cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging


Routine Chest Imaging

Routine Chest Imaging. Radiography Chest Multiple guidelines for preoperative chest radiography have been published, largely advocating against the use of routine preoperative chest radiographs for elective surgery [16]. This is based on multiple studies that have shown minimal benefit from the routine use of chest radiography before surgery. Joo et al [17] conducted a systematic literature review to investigate the value of screening chest radiographs before surgery. They found that the diagnostic yield of preoperative chest radiographs in patients <50 years of age is low and are generally not recommended in patients <70 years of age. Most radiologic abnormalities found on preoperative imaging were chronic diseases and did not affect management or outcome [17].


Routine Chest Imaging

Routine Chest Imaging. A large retrospective study in 1983 found that preoperative chest radiographs in low-risk patients were unnecessary with only 0.3% of chest radiographs finding a relevant finding [6]; furthermore, these abnormalities were not associated with any perioperative complications or need for additional interventions. However, radiographic abnormalities were more common in patients with known risk factors based on clinical history and examination. The authors contended that clinical evaluation could appropriately predict which patients should undergo preoperative chest radiography and argued against the use of chest radiography for routine preoperative evaluation [6]. A meta-analysis by Archer et al [18] found that unsuspected radiologic findings on routine preoperative chest radiography were rare, occurring in only 1.3% of cases; these rare findings resulted in a change in management in only 0.1% of cases.


Routine Chest Imaging

Routine Chest Imaging. Gagner et al [19] performed a retrospective review of 1,000 patients who underwent a preoperative chest radiograph and found that 7.4% of studies were abnormal. Abnormal chest radiographs were more common in older individuals than in younger individuals (30% of patients >50 years of age versus 3% in patients <50 years of age), and there were no changes in clinical outcomes due to chest radiographic findings.


Routine Chest Imaging

Routine Chest Imaging. A large, multicenter study found that preoperative radiographs performed in patients undergoing noncardiothoracic surgery rarely influenced the decision to undergo surgery [5]; in fact, 25.7% of cases proceeded to surgery before the radiology report was even available [5]. The authors also found wide variability in the use of preoperative chest radiography between different surgical departments, despite clinical risk factors for cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging. Patients undergoing evaluation for abdominal solid organ transplant (eg, liver or kidney) are known to have higher rates of intrathoracic diseases, including coronary artery disease, pleural effusions, pulmonary hypertension, and hepatopulmonary syndrome, which may not be clinically apparent [13,14]. In a study of 341 patients being evaluated for liver transplantation, Bozbas et al [20] determined that 48% of patients had an abnormal chest radiograph. Other studies have shown that increasing severity of liver disease correlates to the degree of abnormality on chest radiography [14]. Currently, the American Association for the Study of Liver Diseases recommends screening of liver transplant candidates for hepatopulmonary syndrome. This is initially done by pulse oximetry, although chest radiography may be pursued to exclude other causes of pulmonary disease [15].


Routine Chest Imaging

Routine Chest Imaging. Variant 3: Routine preoperative chest imaging for noncardiothoracic surgery. History of chronic cardiopulmonary disease or cardiothoracic surgery. Initial imaging. CT Chest With IV Contrast Patients undergoing evaluation for abdominal solid organ transplant (eg, liver or kidney) are known to have higher rates of intrathoracic diseases, including coronary artery disease, pleural effusions, pulmonary hypertension, and hepatopulmonary syndrome, which may not be clinically apparent [13,14]. Currently, the American Association for the Study of Liver Diseases recommends screening of liver transplant candidates for hepatopulmonary syndrome. This is initially done by pulse oximetry, although CT chest with IV contrast may be pursued to exclude other causes of pulmonary disease [15].


Routine Chest Imaging

Routine Chest Imaging. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast for routine preoperative evaluation of patients with chronic cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. CT Chest Without IV Contrast Patients undergoing evaluation for abdominal solid organ transplant (eg, liver or kidney) are known to have higher rates of intrathoracic diseases, including coronary artery disease, pleural effusions, pulmonary hypertension, and hepatopulmonary syndrome, which may not be clinically apparent [13,14]. Currently, the American Association for the Study of Liver Diseases recommends screening of liver transplant candidates for hepatopulmonary syndrome.


Routine Chest Imaging

Routine Chest Imaging

Routine Chest Imaging. Routine Chest Imaging


Routine Chest Imaging

Routine Chest Imaging. This is initially done by pulse oximetry, although CT chest without IV contrast may be pursued to exclude other causes of pulmonary disease [15].


Routine Chest Imaging

Routine Chest Imaging. CTA Chest With IV Contrast There is no relevant literature to support the use of CTA chest with IV contrast for routine preoperative evaluation of patients with chronic cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. CTA Chest Without and With IV Contrast There is no relevant literature to support the use of CTA chest without and with IV contrast for routine preoperative evaluation of patients with chronic cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for routine preoperative evaluation of patients with chronic cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast for routine preoperative evaluation of patients with chronic cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast for routine preoperative evaluation of patients with chronic cardiopulmonary disease undergoing noncardiothoracic surgery.


Routine Chest Imaging

Routine Chest Imaging. Radiography Chest In a retrospective cohort study of patients with known cardiothoracic disease, abnormal chest radiographic findings were a common finding [21]. However, a review of preoperative chest radiographs in a general population (performed before a variety of different types of surgeries) found that only 5% of studies had an impact on anesthetic management [22]. The authors suggested that discontinuing the use of routine preoperative chest radiographs did not result in any adverse effects on patient care.


Routine Chest Imaging

Routine Chest Imaging. A study of 240 patients with known vascular disease investigated the role of preprocedural chest radiographs before peripheral or coronary angiography. Although nearly half of preprocedural chest radiographs had at least one abnormality, no procedures were postponed or canceled because of the radiographic findings [23].


Routine Chest Imaging

Routine Chest Imaging. Given these findings, multiple societal guidelines have been published, largely recommending against the use of routine preoperative chest radiography for patients with known cardiovascular disease. The European Society of Anaesthesia does not recommend routine preoperative chest radiography for elective noncardiac surgery because it rarely changes perioperative course [24]. A practice advisory by the American Society of Anesthesiologists Task Force acknowledged that radiographic abnormalities are higher in older patients and those with stable cardiothoracic disease but did not recommend routine chest radiography in the preanesthesia evaluation of these patients [25]. Evidence generally suggests that most preoperative abnormalities may be predicted by clinical evaluation, although chest radiography may be helpful in patients with known chronic disease or patients >50 years of age [26].


Routine Chest Imaging

Routine Chest Imaging. One exception is patients with cardiac implantable electronic devices (implanted cardioverter-defibrillators and pacemakers), in whom certain procedures and surgical instruments can be associated with electromagnetic interference (eg, extracorporeal shock wave lithotripsy, radiofrequency ablation, electrocautery) [27]. In the setting of known cardiovascular disease and implanted electronic device, preoperative/preprocedural chest radiograph may be useful for identification of the device type as well as identification of device location [27-29] because these device-related factors may direct selection of surgical instruments or surgical approach.


Routine Chest Imaging

Routine Chest Imaging. Patients undergoing evaluation for abdominal solid organ transplant (eg, liver or kidney) are known to have higher rates of intrathoracic diseases including coronary artery disease, pleural effusions, pulmonary hypertension, and hepatopulmonary syndrome, which may not be clinically apparent [13,14]. In a study of 341 patients being evaluated for liver transplantation, Bozbas et al [20] determined that 48% of patients had an abnormal chest radiograph. Other studies have shown that increasing severity of liver disease correlates to degree of abnormality on chest radiography [14]. Currently, the American Association for the Study of Liver Diseases recommends screening of liver transplant candidates for hepatopulmonary syndrome. This is initially done by pulse oximetry, although chest radiography may be pursued to exclude other causes of pulmonary disease [15].


Routine Chest Imaging

Routine Chest Imaging


Routine Chest Imaging

Routine Chest Imaging. Variant 4: Routine chest imaging. History of chronic cardiopulmonary disease with stable clinical findings. Surveillance chest imaging. CT Chest With IV Contrast There is no relevant literature to support the use of CT chest with IV contrast for surveillance of patients with unspecified chronic, stable cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast for surveillance of patients with unspecified chronic, stable cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging. CTA Chest With IV Contrast There is no relevant literature to support the use of CTA chest with IV contrast for surveillance of patients with unspecified chronic, stable cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging. CTA Chest Without and With IV Contrast There is no relevant literature to support the use of CTA chest without and with IV contrast for surveillance of patients with unspecified chronic, stable cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of FDG-PET/CT for surveillance imaging in the setting of chronic, stable cardiopulmonary disease.


Routine Chest Imaging

Routine Chest Imaging. MRI Chest Without and With IV Contrast MRI chest without and with IV contrast has potential uses in the evaluation of pulmonary nodules, although MRI chest is not yet considered part of the standard diagnostic work-up [34]. MRI chest is routinely used in the follow- up of cystic fibrosis in other countries but has not been widely adopted for routine use in the United States [34].


Routine Chest Imaging

Routine Chest Imaging. MRI Chest Without IV Contrast Emerging uses for MRI chest include screening for hereditary thoracic masses and evaluation of chronic lung disease [35]. MRI chest is routinely used in the follow-up of cystic fibrosis in other countries but has not been widely adopted for routine use in the United States [34].


Routine Chest Imaging

Routine Chest Imaging

Routine Chest Imaging. Routine Chest Imaging


Routine Chest Imaging

Routine Chest Imaging. 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.


Routine Chest Imaging

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


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Introduction/Background Pulmonary tuberculosis (TB) predominantly results from the transmission of aerosolized mycobacterium TB to susceptible hosts [1]. In the vast majority of cases, this results in subclinical disease with the immune system isolating the organism. In this setting, a person has latent TB and does not pose a risk to the community at large. The development of active infection within 1 year following exposure is termed primary TB and is classically described as a lobar pneumonia and/or mediastinal and hilar adenopathy. This pattern is most often seen in children and severely immunocompromised individuals. If active infection develops later than 1 year after initial exposure, it is considered to be reactivation TB, often presenting with apical posterior upper-lobe or superior- segment lower-lobe fibrocavitary disease and endobronchial spread through the airways.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. With modern molecular techniques it has been shown that radiographic patterns of primary and reactivation TB overlap, and thus the preferred terminology for TB infection is active TB [2]. The important public health issue is that both primary and reactivation TB present a risk of exposing the general population to TB infection.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. A high level of suspicion should be maintained in immunocompromised hosts, particularly those with AIDS, as imaging manifestations may not fit a classic primary or reactivation pattern; instead, these patients may present with mediastinal lymphadenopathy alone or a deceptively normal chest radiograph.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Overview of Imaging Modalities Chest radiograph The chest radiograph is usually the first study performed in patients suspected of having TB. Although frontal and lateral radiographs are often performed in this setting, it has been shown that the lateral radiograph does not improve the detection of findings related to TB [3]. In those with signs or symptoms of disease, the radiographic pattern of upper-lobe or superior-segment lower-lobe fibrocavitary disease in the appropriate clinical setting is sufficient to warrant respiratory isolation and sputum culture for definitive diagnosis. Using radiographs in combination with clinical evaluation results in a high sensitivity for the diagnosis but a relatively low specificity for both latent [4] and active TB [5]. In addition, radiographs may reveal ancillary findings of TB such as pleural effusion or spondylitis. For immunocompromised hosts, particularly those with a low CD4 count, computed tomography (CT) should be considered.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. 1Principal Author and Panel Chair, Medical University of South Carolina, Charleston, South Carolina. 2Panel Vice-chair, National Jewish Health, Denver, Colorado. 3Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. 4University of Texas MD Anderson Cancer Center, Houston, Texas. 5Mayo Clinic, Rochester, Minnesota. 6Mayo Clinic, Phoenix, Arizona. 7Vanderbilt University Medical Center, Nashville, Tennessee, American College of Chest Physicians. 8Mayo Clinic, Jacksonville, Florida. 9Columbia University Medical Center New York and Temple University Health System, Philadelphia, Pennsylvania. 10Specialty Chair, University of Florida College of Medicine, Gainesville, Florida.


Imaging of Possible Tuberculosis

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


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Reprint requests to: publications@acr.org


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Imaging of Possible Tuberculosis


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Magnetic resonance imaging Only 1 study has been performed evaluating magnetic resonance imaging (MRI) for suspected TB. In this study the accuracy of MRI was similar to CT in describing findings related to culture-positive patients [12]. Inferential data regarding the value of MRI can also be derived from its role in cystic fibrosis and the observation in other settings that MRI correlates well with CT for parenchymal findings including bronchiectasis, cavitation, and tree- in-bud nodules [13]. Although MRI is technically feasible and described in the literature, MRI has not been specifically evaluated as a primary imaging modality for patients with suspected or proven TB.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Nuclear scintigraphy Several nuclear radiopharmaceuticals have been employed for the purpose of evaluating possible TB, particularly for differentiating active from inactive tuberculomas and distinguishing tuberculomas from neoplasms. In small studies, Tc-99m methoxyisobutylisonitrile has shown higher activity over background in active tuberculomas compared with inactive tuberculomas [14,15]. Similarly, metabolic activity measured by fluorine-18-2-fluoro-2- deoxy-D-glucose positron emission tomography (FDG-PET) is higher in active tuberculomas. Dual-time-point FDG-PET imaging (1 and 2 hours postinjection) can also help differentiate active tuberculomas from neoplasms, owing to the longer retention of FDG in benign lesions [16]. Gallium 67 has been used to follow patients for disease activity and correlates with the number of organisms on sputum smears [17]. Evidence for the use of nuclear imaging to diagnose active TB is limited to either small single-site studies or several small studies, and the impact on clinical practice and patient care at this time is minimal.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Discussion of the Imaging Modalities by Variant Variant 1: Suspect active tuberculosis. The initial suspicion of active TB should be made based on clinical symptoms and demographics. Those at particular risk include those in close contact with patients having active TB, spending time in a TB-endemic country, or working/spending time in sites where TB is more prevalent, such as prisons, homeless shelters, and long-term care facilities. Those who are immunocompromised are at particular risk. Included in this category are also individuals with a newly positive purified protein derivative (PPD) skin test or a positive interferon-gamma release assay (IGRA) and who have symptoms that could be related to active TB. Clinical symptoms of active TB may include unexplained weight loss, night sweats, fever, prolonged cough, hemoptysis, and fatigue.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Chest radiography Identified individuals should undergo chest radiography as the initial test. Chest radiographs have been shown to have a high sensitivity for detecting manifestations of active TB [5]. Chest radiography has a high sensitivity but relatively poor specificity owing to the overlap of findings with nontuberculous pulmonary infection. The yield of chest radiographs in high-risk patients ranges from 1% to 7%, although it is not clear how many of these cases would have been suspected based on clinical symptoms alone [18,19].


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. In particular, lobar pneumonia with associated hilar and/or mediastinal adenopathy or cavitary air space disease involving the apical posterior segments of the upper lobe or superior segment of the lower lobe should raise particular concern [20]. When a chest radiograph confirms the clinical suspicion of active TB, it is sufficient to warrant respiratory isolation pending sputum cultures. However, in patients who are immunocompromised, particularly those with AIDS and very low CD4 counts, chest radiographs may be deceptively normal.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Magnetic resonance imaging MRI is a reasonable consideration for use in select patients for whom there is a desire to avoid ionizing radiation.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Variant 2: Newly positive PPD or IGRA OR positive PPD or IGRA with unknown prior status. No clinical symptoms. Chest radiography One key principal of PPD testing is application in those at high risk for developing latent TB infection. This may include those who work in settings where contact with active TB is possible and those coming from regions where


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. TB is endemic. Although screening of low-risk individuals is discouraged, it is recommended for those whose future activity will place them at high risk for exposure or reactivation. The rationale behind performing chest radiography following a positive PPD is to distinguish latent TB from active TB, as these are managed differently. However, in patients without clinical symptoms the yield of radiographs for active TB (that would change management) is negligible [21]. Furthermore, parenchymal findings of latent TB are relatively poor predictors of future reactivation. If a chest radiograph is performed, a frontal view is sufficient [3].


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Computed tomography CT should be reserved for the rare case in which a chest radiograph may be equivocal for active TB and cases for which knowledge of latent TB abnormalities may inform future care, such as patients undergoing solid organ transplantation and biologic therapy for rheumatologic disease [4,11].


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Magnetic resonance imaging Like CT, there is a very limited role for MRI, although it may be considered when cross-sectional imaging is deemed necessary in a patient for whom there is a desire to avoid ionizing radiation.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Variant 3: PPD not available. Placement in group home or skilled nursing facility. No clinical symptoms. Chest radiography Low-risk screening also frequently occurs in patients being transferred to correctional institutions, group homes, and skilled nursing facilities. Because of time constraints related to placing and interpreting a PPD, chest radiography has emerged as a surrogate measure. A meta-analysis of homeless populations suggests that using chest radiography as a screening measure is sufficient and can lead in some cases to a decline in the incidence of TB over time [19]. This study, however, did not compare chest radiography screening to other screening strategies in terms of efficacy. Screening procedures vary from one prison site to another. There does not appear to be a large discrepancy in TB incidence regardless of screening technique (symptom survey, PPD, or chest radiograph) [22]. There is no evidence regarding the performance of routine radiography in low-risk patients who did not receive other TB screening before transfer to a group home or nursing facility.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Computed tomography CT should be reserved for the rare case in which a chest radiograph is equivocal for active TB and more definitive testing such as sputum culture is impractical.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Magnetic resonance imaging Like CT, there is a very limited role for MRI, although it might be considered when cross-sectional imaging is deemed necessary in a patient for whom there is a desire to avoid ionizing radiation.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Summary of Recommendations Chest radiography is the first recommended test in patients with suspected tuberculosis. Chest radiography is generally appropriate for patients with new evidence of exposure or at high risk for development of tuberculosis, although it may be of low yield in patients who have no clinical symptoms. Chest CT is appropriate when tuberculosis is suspected and radiography is nonrevealing or nondiagnostic.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Although there are references that report on studies with design limitations, 11 well-designed or good-quality studies provide good evidence.


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. 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 exposure 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


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Imaging of Possible Tuberculosis


Imaging of Possible Tuberculosis

Imaging of Possible Tuberculosis. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Introduction/Background Infections of the musculoskeletal system are a leading cause of pain, disability, and health care encounters. Because of the rise of an aging population, diabetes and obesity, and orthopedic surgeries, the incidence of musculoskeletal infections are also increasing. The overall infection rate following orthopedic hardware placement is estimated to be approximately 5%, and the overall mortality rate associated with necrotizing fasciitis (NF) is >10% [1].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Musculoskeletal infections may have bone and soft tissue involvement and often need imaging using a multimodality approach [2]. The nonspecific signs and symptoms of musculoskeletal infections can make their diagnosis particularly challenging. Predisposing conditions inflammatory arthritis, diabetes, immunosuppression, drug and alcohol abuse, surgery, burns, extremes of body habitus, and poor socioeconomic status can further add to the difficulty of diagnosing musculoskeletal infections both clinically and with imaging [3]. Placement of orthopedic hardware can make imaging diagnosis challenging because of metal artifact, especially on CT and MRI.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Imaging plays a critical role in the diagnosis and treatment of musculoskeletal infections. When imaging is appropriately used, proper characterization of bone and soft tissue infections often guides clinical management. Even when infection is clinically apparent, imaging often provides additional information including the extent of infection into deeper tissues, presence of abscesses, joint involvement, and vascular complications. These assessments are central to medical, surgical, and image-guided treatments [4].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. OR Discussion of Procedures by Variant Variant 1: Suspected osteomyelitis or septic arthritis or soft tissue infection (excluding spine and diabetic foot). Initial imaging. For osteomyelitis, the body regions covered are ankle, chest, elbow, femur, foot, forearm, hand, hip, humerus, knee, pelvis, shoulder, tibia/fibula, wrist.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. For septic arthritis, the body regions covered are ankle, elbow, hip, knee, shoulder, wrist.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. aUniversity of Virginia, Charlottesville, Virginia. bResearch Author, University of Virginia Health Center, Charlottesville, Virginia. cPanel Chair, Mayo Clinic, Jacksonville, Florida. dPanel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina. eThe Johns Hopkins University School of Medicine, Baltimore, Maryland. fMallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri. gAventura Hospital, Aventura, Florida and Nova Southeastern University, Fort Lauderdale, Florida. hMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. iUniversity of Virginia, Charlottesville, Virginia, Primary care physician. jDiagnostic Imaging Associates, Chesterfield, Missouri. kMayo Clinic Florida, Jacksonville, Florida. lSUNY Downstate Health Sciences University, Brooklyn, New York. mMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. nSpecialty Chair, University of Kentucky, Lexington, Kentucky.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Reprint requests to: publications@acr.org


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Suspected Osteomyelitis, Septic Arthritis


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. For soft tissue infection, the body regions covered are abdomen, neck, ankle, chest, elbow, thigh, foot, forearm, hand, hip, arm, knee, pelvis, shoulder, leg, wrist.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. 3-Phase Bone Scan Area of Interest There is insufficient evidence to support the use of a 3-phase bone scan area of interest for the initial evaluation of osteomyelitis, septic arthritis, or soft tissue infections.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. CT Area of Interest There is insufficient evidence to the support the use of CT area of interest for the initial evaluation of osteomyelitis, septic arthritis, or soft tissue infections.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. MRI Area of Interest There is insufficient evidence to support the use of MRI area of interest for the initial evaluation of osteomyelitis, septic arthritis, or soft tissue infections.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Radiography Area of Interest The literature indicates that radiographs should be used for the initial evaluation of musculoskeletal infections, including osteomyelitis, septic arthritis, and soft tissue infection. Erosions and periosteal reaction are common findings in acute osteomyelitis, whereas bone sclerosis is commonly associated with chronic osteomyelitis. In early acute osteomyelitis (<14 days), radiographs may be normal or show only mild soft tissue swelling [5]. Soft tissue swelling, joint effusion, ulcers, effacement of fat planes, gas, and foreign bodies may indicate soft tissue infections or septic arthritis [2].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Many radiographic findings are not specific for infection, and a differential diagnosis may include tumors, trauma, arthritides, metabolic conditions, cardiovascular etiologies, and venous insufficiency or thrombosis. However, obtaining the initial radiograph provides an excellent overview of the anatomic area of interest and can exclude fractures and tumors as the cause of swelling or pain. Radiographs also help with the interpretation of future imaging studies such as CT, MRI, ultrasound (US), and nuclear medicine scans [6].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. US Area of Interest There is insufficient evidence to support the use of US area of interest for the initial evaluation of osteomyelitis, septic arthritis, or soft tissue infections.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Variant 2: Suspected septic arthritis or soft tissue infection. Initial radiographs normal or with findings suggestive of joint effusion or soft tissue swelling. Next imaging study. For septic arthritis, the body regions covered are ankle, elbow, hip, knee, shoulder, wrist.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. 3-Phase Bone Scan Area of Interest Radionuclide imaging, which includes 3-phase bone scan, is of limited use for the diagnosis of septic arthritis and soft tissue infection [7]. On 3-phase bone scans, early images may show increased activity with hyperperfusion and hyperemia on flow and blood pool phases. Delayed images may be normal or have increased activity limited to the articular surfaces, in the case of a septic joint [7]. Compared with US, CT, and MRI, bone scan has poor spatial resolution and lacks specificity [4]. However, bone scan can be useful for the evaluation of multifocal infections.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Image-Guided Aspiration Area of Interest In many cases, imaging cannot distinguish infected from noninfected joints or fluid collections, and aspiration and culture are needed for diagnosis [8,9]. Culture allows for identification of the infectious organism, which directly affects treatment. Although imaging may delay performing the aspiration, preaspiration imaging with US, CT, or MRI can be essential for planning for a safe aspiration [8]. Image-guided aspiration is ideal because proper, accurate needle placement is confirmed with fluoroscopy, US, CT, and rarely MRI. Also, image guidance significantly reduces vascular complications and injury to nerves. Using image guidance, needle trajectory and placement can be planned to reduce the risk of contaminating normal adjacent tissues [10].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. CT Area of Interest CT allows for the evaluation of various soft tissue compartments and may help differentiate cellulitis, myositis, tenosynovitis, abscess, and septic arthritis [11]. CT with intravenous (IV) contrast can assess soft tissue and the extent of infection, which can guide aspiration or surgical debridement. Contrast-enhanced CT can also improve


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Suspected Osteomyelitis, Septic Arthritis the detection of synovitis, inflammation, fistulas, abscesses, and vascular complications [4]. CT is also the most sensitive modality for detecting soft tissue gas. Although CT is not sensitive at detecting early bone marrow changes, it can show early periosteal reaction and bone erosions, adjacent soft tissue infection, or septic arthritis.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. MRI Area of Interest MRI allows for the evaluation of musculoskeletal soft tissue infections because of its high sensitivity to fluid and inflammation in bones, joints, muscles, tendons, and other soft tissues [2,6,12]. Because of its excellent spatial and contrast resolution, MRI is excellent at detecting and evaluating the extent of both superficial and deep soft tissue infections [13]. MRI can also exclude soft tissue infection, if edema or fluid signal representing inflammation, joint effusion, or abscess are not present [2,6]. Contrast-enhanced MRI further increases the diagnostic sensitivity for abscesses, fistulas, and vascular complications. Detection of inflammation of joints, bursa, tendons, and muscles is also improved with contrast-enhanced MRI.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Compared to CT, soft tissue gas is not as well visualized on MRI. Although MRI often provides imaging for preoperative planning, MRI is not commonly used for image-guided aspiration or drainage.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. US Area of Interest US is useful for detecting fluid, including joint effusions, abscesses, and infected tendon sheaths. US-guided aspirations of soft tissue fluid collections and joint effusions is becoming increasingly common [14]. With the use of color Doppler, vascularity and hyperemia can be assessed without the administration of IV contrast. If needed, US can examine the contralateral side for comparison or extend the area of imaging of suspected infection. Absence of a fluid essentially excludes the diagnosis of septic arthritis, tenosynovitis, and abscess.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Gaspari et al [14] reported that US correctly diagnosed an abscess in 29 out of 30 patients and no abscess in 30 of 35 patients with an alternative diagnosis. In comparison, CT correctly diagnosed 23 out of the same 30 patients with abscess and correctly diagnosed 32 of the 35 patients without an abscess. They reported the overall sensitivity and specificity of US for the diagnosis of an abscess as 96.7% and 85.7%, respectively, whereas CT had 76.7% sensitivity and 91.4% for specificity. They concluded that both CT and US are accurate for diagnosing superficial abscesses. US can evaluate the internal characteristics of the abscess cavity, such as necrosis or debris, and associated pathology like foreign bodies, fistulas, and vascular injury.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. For deeper soft tissue structures and the evaluation of adjacent bone involvement, US is limited compared with MRI and CT.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Variant 3: Suspected osteomyelitis. Initial radiographs normal or with findings suggestive of osteomyelitis. Next imaging study. For osteomyelitis, the body regions covered are ankle, chest, elbow, femur, foot, forearm, hand, hip, humerus, knee, pelvis, shoulder, tibia/fibula, wrist.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. 3-Phase Bone Scan and WBC Scan and Sulfur Colloid Scan Area of Interest These 3 scans are ordered in progression to increase the accuracy of diagnosing osteomyelitis. If the 3-phase bone scan is positive with increased activity, also obtaining a white blood cell (WBC) scan and Tc-99m sulfur colloid scan may increase specificity for the evaluation of acute osteomyelitis. Addition of sulfur colloid scan may be considered if results remain equivocal following a WBC and 3-phase bone scans. In cases in which radiotracer uptake is increased on WBC scan and 3-phase bone scans, sulfur colloid imaging will show no corresponding radiotracer uptake in cases of osteomyelitis [15,16].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. 3-Phase Bone Scan and WBC Scan Area of Interest In patients with low pretest probability of infection who have a positive 3-phase bone scan, the addition of WBC scan may increase specificity for infection, particularly in the setting of recent surgery or fracture at the suspected site of infection [17].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. 3-Phase Bone Scan Area of Interest A 3-phase bone scan can be used to rule out osteomyelitis. However, a positive 3-phase bone scan is nonspecific. A meta-analysis performed by Wang et al [17] showed specificity of only 45% for diagnosis of osteomyelitis, whereas sensitivity was 83%. A 3-phase bone scan is most accurate in the diagnosis of osteomyelitis when bone is not affected by other underlying condition such as osteoarthritis, recent fracture, or recent hardware implantation [18]. Addition of single-photon emission CT (SPECT)/CT may be helpful in localization of acute osteomyelitis [19].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. Suspected Osteomyelitis, Septic Arthritis CT Area of Interest CT is insensitive in evaluation of acute osteomyelitis. IV contrast administration is helpful for assessing soft tissue involvement. CT may be most useful in characterizing osseous changes from chronic osteomyelitis including detection of sequestrum. Although the use of IV contrast does not improve diagnostic sensitivity for acute osteomyelitis, it may be helpful in the identification of soft tissue infection such as abscess formation [11]. There is no added benefit in performing multiphase CT imaging before and after IV contrast administration in the evaluation of infection.


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. MRI Area of Interest MRI is highly accurate for detection of acute osteomyelitis. Noncontrast MRI has high sensitivity and specificity in the diagnosis of osteomyelitis. MRI is sensitive at depicting marrow signal changes of acute osteomyelitis. Additionally MRI provides excellent evaluation of the adjacent soft tissues including abscess or fistulas [13,23-26]. The use of IV contrast does not improve diagnosis of peripheral osteomyelitis; however, its use may improve the evaluation of soft tissue infections [27].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. US Area of Interest US is of limited benefit in the diagnosis of osteomyelitis. Although findings such as juxtacortical fluid collections and fistulous tracts may be seen, these findings are not specific for osteomyelitis [28].


Suspected Osteomyelitis Septic Arthritis or Soft Tissue Infection Excluding Spine and Diabetic Foot PCAs. WBC Scan and Sulfur Colloid Scan Area of Interest A sulfur colloid scan is often performed when WBC scan results are equivocal. If osteomyelitis is present, a sulfur colloid scan will show no radiotracer activity in areas of WBC scan activity. WBC scan combined with marrow imaging has been reported up to 90% accurate in diagnosing osteomyelitis [18]. Disadvantages include low spatial resolution [15,16].