Indeterminate Renal Mass

Indeterminate Renal Mass. CT Abdomen Iodinated CT contrast is contraindicated in some patients with severe allergy to the CT contrast or patients who are at high risk for contrast-induced nephropathy. For more details, please refer to the ACR Manual on Contrast Media [71]. The inability to utilize IV contrast to evaluate a renal mass markedly limits whether it can be classified as benign or malignant on CT, but it does provide some information if calcifications, nodules, or septations are visible. Homogenous renal masses measuring <20 HU or >70 HU [1,2] or lesions containing macroscopic fat can be characterized as benign lesions, but all other small lesions cannot be characterized using CT without IV contrast. Large lesions with calcifications and necrosis may not need further characterization, but detection of venous invasion and metastases is also limited.


Indeterminate Renal Mass

Indeterminate Renal Mass

Indeterminate Renal Mass. Indeterminate Renal Mass


Indeterminate Renal Mass

Indeterminate Renal Mass. CTU There is no relevant literature regarding the use of CTU in the evaluation of indeterminate renal masses.


Indeterminate Renal Mass

Indeterminate Renal Mass. MRI Abdomen Because of the risk for nephrogenic systemic fibrosis [72], certain gadolinium-based contrast agents may be contraindicated in patients with renal failure. Another contraindication is severe allergy to gadolinium agents. For more details, please refer to the ACR Manual on Contrast Media [71]. In the absence of contrast, unenhanced MRI has some advantages over unenhanced CT in the characterization of renal masses. Simple cystic lesions or even those with thin septations can often be characterized on noncontrast T2-weighted imaging based on their homogeneous and very high T2 signal intensity. To differentiate between hemorrhagic or proteinaceous cysts and RCC, a retrospective study shows that homogenous high T1 signal intensity lesions with smooth borders and lesion to renal parenchyma signal intensity ratio of >1.6 predicted the lesion as a benign cyst [53]. Another study of 144 T1-hyperintense lesions demonstrated that diffuse and marked T1-hyperintensity achieved accuracies of 73.6% to 79.9% for the diagnosis of T1-hyperintense cysts [54]. An angular interface with the renal parenchyma on T2- weighted imaging has been shown to be 78% sensitive and 100% specific for differentiating benign exophytic renal masses from malignant masses [55]. Diffusion-weighted imaging, although less accurate than contrast-enhanced MRI, may have some ability to differentiate solid RCC from oncocytomas and characterize the histologic subtypes of RCC [56]. New and specialized MRI sequences have been proposed for the purposes of characterizing the vascularity of renal lesions in patients with renal dysfunction. For example, one small study of 17 renal lesions used arterial spin labeling to detect blood flow in renal masses, which correlated with malignancy [57]. A drawback of MRI compared with CT is the limited ability of MRI for detection of calcifications.


Indeterminate Renal Mass

Indeterminate Renal Mass. MRU There is no relevant literature regarding the use of MRU in the evaluation of indeterminate renal masses.


Indeterminate Renal Mass

Indeterminate Renal Mass. Radiography Intravenous Urography There is no relevant literature regarding the use of IVU for the evaluation of indeterminate renal masses. IVU requires IV administration of iodinated contrast.


Indeterminate Renal Mass

Indeterminate Renal Mass. US Abdomen with IV Contrast CEUS using microbubble agents is emerging as a useful way to characterize previously indeterminate renal lesions [16-18]. It is not limited by renal or hepatic failure. In one study of 1,018 indeterminate renal lesions, CEUS had a per patient sensitivity of 100% (126 of 126 patients), specificity of 95% (132 of 139 patients), positive predictive value of 94.7% (126 of 133 patients), and negative predictive value of 100% (132 of 132 patients) for classifying benign versus malignant renal masses [16]. In that study, any echogenic masses with enhancement at least of normal renal cortex and wash-out as well as any masses with blood flow were considered malignant. In another study, CEUS successfully classified 95.7% (90 of 94) of previously indeterminate lesions and has an accuracy of 90.2% (37 of 41 lesions) when compared with the reference standard, including histopathology and follow-up [18]. In the subgroup analysis, CEUS was definitive for 94.4% (17 of 18) of cases referred because of equivocal enhancement


Indeterminate Renal Mass

Indeterminate Renal Mass


Indeterminate Renal Mass

Indeterminate Renal Mass. at CT [18]. In that same study, CEUS was able to classify lesions in 100% (10 of 10) of the cases in which the lesions were indeterminate on prior MRI [18]. Another study of CEUS in 83 CT indeterminate renal masses reported that the accuracy of characterization by CEUS was 95.2% compared with 42.2% using unenhanced US [17].


Indeterminate Renal Mass

Indeterminate Renal Mass. Studies have shown CEUS to be more sensitive than contrast-enhanced CT in characterizing cystic renal masses [19,65]. In a study of 31 cystic renal masses evaluated by both CT and CEUS using the Bosniak classification, 26% of the lesions were upgraded by CEUS [19]. In a prospective CEUS study of 94 solid renal lesions excluding lipid- rich AMLs, hypovascularity of small solid renal masses relative to the cortex in the arterial phase has 100% specificity for detecting malignancy, especially for detecting papillary RCC [66]. Quantitative analysis of CEUS has also been reported to be useful to stratify RCC and benign renal tumors [67,68].


Indeterminate Renal Mass

Indeterminate Renal Mass. Variant 3: Indeterminate renal mass. Contraindication only to iodinated CT intravenous contrast. Initial imaging. Arteriography Kidney Cross-sectional imaging has replaced arteriography for the evaluation of indeterminate renal masses. There is no relevant literature regarding the use of arteriography in the evaluation of indeterminate renal masses.


Indeterminate Renal Mass

Indeterminate Renal Mass. CT Abdomen Iodinated CT contrast is contraindicated in some patients with severe allergy to the CT contrast or in patients who are at high risk for contrast-induced nephropathy. For more details, please refer to the ACR Manual on Contrast Media [71]. The inability to utilize IV contrast to evaluate a renal mass markedly limits whether it can be classified as benign or malignant on CT, but it can provide some information. Homogenous renal masses measuring <20 HU or >70 HU [1,2] or lesions containing macroscopic fat can be characterized as benign lesions, but all other small lesions cannot be characterized using CT without IV contrast. Large lesions with calcifications and necrosis may not need further characterization, but detection of venous invasion and metastases is also limited.


Indeterminate Renal Mass


Indeterminate Renal Mass

Indeterminate Renal Mass. Ho et al [51] showed that the optimal percentage of enhancement threshold for distinguishing cysts from solid tumors on MRI was 15%. Hecht et al [52] reported that both quantitative and qualitative methods are sensitive in the detection of enhancement in a renal lesion on MRI and that subtracted images enables accurate assessment of tumor enhancement for intrinsically hyperintense lesions using qualitative methods.


Indeterminate Renal Mass

Indeterminate Renal Mass. Although MRI without and with IV contrast is optimal for renal lesion characterization, MRI without IV contrast can also provide diagnostic information. For example, simple cystic lesions or even those with thin septations can often be characterized on noncontrast T2-weighted imaging based on their homogeneous and very high T2 signal intensity. To differentiate between hemorrhagic or proteinaceous cysts and RCC, a retrospective study shows that homogenous high T1 signal intensity lesions with smooth borders and lesion to renal parenchyma signal intensity ratio of >1.6 predicted the lesion as a benign cyst [53]. Another study of 144 T1-hyperintense lesions demonstrated that diffuse and marked T1 hyperintensity achieved accuracies of 73.6% to 79.9% for the diagnosis of T1- hyperintense cysts [54]. An angular interface with the renal parenchyma on T2-weighted imaging has been shown to be 78% sensitive and 100% specific for differentiating benign exophytic renal masses from malignant masses [55]. Diffusion-weighted imaging, although less accurate than contrast-enhanced MRI, may have some ability to differentiate solid RCC from oncocytomas and characterize the histologic subtypes of RCC [56]. New and specialized MRI sequences have been proposed for the purposes of characterizing the vascularity of renal lesions in patients with renal dysfunction. For example, one small study of 17 renal lesions used arterial spin labeling to detect blood flow in renal masses, which correlated with malignancy [57].


Indeterminate Renal Mass

Indeterminate Renal Mass. Cystic Renal Masses In a patient who cannot receive iodinated contrast, MRI without and with IV contrast is a good alternative. MRI may depict findings like an increase in number of septa, septal or wall thickness, and enhancement; these may result in MRI upgrading cystic lesions and thus might alter patient management [29]. Another study of 33 cystic lesions imaged with both 1.5T and 3.0T MRI showed that there is a greater tendency to upgrade cyst complexity and Bosniak cyst category at 3.0T than at 1.5T and thus suggested that serial follow-up of cystic renal lesions be performed at constant field strength [58].


Indeterminate Renal Mass

Indeterminate Renal Mass. Radiography Intravenous Urography There is no relevant literature regarding the use of IVU for the evaluation of indeterminate renal masses.


Indeterminate Renal Mass

Indeterminate Renal Mass. US Abdomen with IV Contrast CEUS using microbubble agents is emerging as a useful way to characterize previously indeterminate renal lesions [16-18]. In one study of 1,018 indeterminate renal lesions, CEUS had a per patient sensitivity of 100% (126 of 126 patients), specificity of 95% (132 of 139 patients), positive predictive value of 94.7% (126 of 133 patients), and negative predictive value of 100% (132 of 132 patients) for classifying benign versus malignant renal masses [16]. In that study, any echogenic masses with enhancement at least of normal renal cortex and wash-out, as well as any masses with blood flow, were considered malignant. In another study, CEUS successfully classified 95.7% (90 of 94) previously indeterminate lesions, and had an accuracy of 90.2% (37 of 41 lesions) when compared with the reference standard, including histopathology and follow-up [18]. In the subgroup analysis, CEUS was definitive for 94.4% (17 of 18) of cases referred because of equivocal enhancement at CT [18]. In that same study, CEUS was able to classify lesions in 100% (10 of 10) of the cases in which the lesions were indeterminate on prior MRI [18]. Another study of CEUS in 83 CT indeterminate renal masses reported that the accuracy of characterization by CEUS was 95.2% compared with 42.2% using unenhanced US [17].


Indeterminate Renal Mass

Indeterminate Renal Mass. In a prospective CEUS study of 94 solid renal lesions, excluding lipid-rich AML, hypovascularity of small solid renal masses relative to the cortex in the arterial phase has 100% specificity for detecting malignancy, especially for detecting papillary RCC [66]. Quantitative analysis of CEUS has also been reported to be useful to stratify RCC and benign renal tumors [67,68].


Indeterminate Renal Mass

Indeterminate Renal Mass. 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 rating round tabulations for each recommendation.


Indeterminate Renal Mass

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


Indeterminate Renal Mass

Indeterminate Renal Mass

Indeterminate Renal Mass. Indeterminate Renal Mass


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. OR aUniversity of Missouri Health Care, Columbia, Missouri. bPanel Chair, Mayo Clinic Arizona, Phoenix, Arizona. cPanel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia. dUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. eMayo Clinic, Rochester, Minnesota. fHospital for Special Surgery, New York, New York. gThe Centers for Advanced Orthopaedics, George Washington University, Washington, DC and Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; American Academy of Orthopaedic Surgeons. hDuke University Medical Center, Durham, North Carolina. iUniversity of Missouri School of Medicine, Columbia, Missouri, Primary care physician. jCleveland Clinic, Cleveland, Ohio. kPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. lThe Ohio State University Wexner Medical Center, Columbus, Ohio; Commission on Nuclear Medicine and Molecular Imaging. mSpecialty Chair, VA San Diego Healthcare System, San Diego, California.


Chronic Hand and Wrist Pain

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


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Reprint requests to: publications@acr.org


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Chronic Hand and Wrist Pain


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Discussion of Procedures by Variant Variant 1: Adult. Chronic hand or wrist pain. Initial imaging. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Area of Interest Without and With IV Contrast There is no relevant literature to support the use of MRI without and with IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Area of Interest Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of radiographic arthrography contrast as the first imaging study in the evaluation of chronic hand or wrist pain.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiography Area of Interest The imaging evaluation of chronic hand or wrist pain should begin with radiographs [6-12]. In many cases, radiographs may be the only imaging examination needed to establish a diagnosis or confirm a clinically expected diagnosis. The standard radiographic evaluation of both the hand and wrist includes 3 views: posteroanterior, lateral, and oblique [9]. The standard projections allow assessment of alignment including ulnar variance, joint spaces, impaction syndromes, static instability, chronic healed and nonunited fractures, soft tissue mineralization, erosions, and soft tissue swelling.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. US Area of Interest Given the superficial location of the joints, ligaments, muscles, tendons, and nerves of the hand and wrists, US is a useful tool in the assessment of chronic hand and wrist pain bolstered by the ability to readily perform and dynamic examination and evaluate the contralateral side [9,13]. US is optimally performed using high-frequency (10-15 MHz) linear transducers [11,13].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, pulley injury, carpal tunnel syndrome (CTS), and retained foreign body [6,13-16]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the wrist, metacarpophalangeal, and interphalangeal joints; US is reasonable to evaluate tendon and soft tissue pathology of the hand and wrist and to assess for entrapment of the median or ulnar nerves [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan in 76% of all patients and 67% of patient who presented without a history


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Chronic Hand and Wrist Pain of trauma [17]. Although there are many advantages to US evaluation for chronic hand and wrist pain, an interdisciplinary group of hand surgeons and radiologists recommended against the inclusion of US in the standard evaluation of scapholunate instability [18].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Variant 2: Adult. Chronic wrist pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study. This variant is a guide on appropriate imaging use early in the assessment of chronic wrist pain, when standard radiographic projections are normal or show nonspecific arthritis. For purposes of this variant, a nonspecific arthritis is defined as articular changes at a single joint and/or a pattern of arthritis throughout the hand and wrist that, when combined with the appropriate clinical history, does not allow distinction between degenerative or post-traumatic osteoarthritis, inflammatory arthritis, and crystalline arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Bone Scan Wrist There is no relevant literature discussing routine use of bone scan in the assessment of nonspecific chronic wrist pain. Bone scans offer the ability to differentiate metabolically active abnormalities, which may be the cause of pain, from those that are inactive [19]. Bone scans can reliably detect chronic or occult scaphoid fracture with a sensitivity and specificity of 97% and 89%, respectively [20]. Although bone scans are sensitive for the detection of bone abnormalities, the findings may be nonspecific [19]. There are established imaging patterns for fracture, osteonecrosis, nonunited fracture, arthritis, and complex regional pain syndrome [19]. Bone scan of the wrist offers improved specificity when single-photon emission CT is performed [19].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Arthrography Wrist Performing arthrography before a CT scan of the wrist aids in the detection of ligament injuries and cartilage abnormalities. CT arthrography allows direct visualization of full thickness ligament tears and visualization of partial thickness tears of the appropriate compartment [6,21]. An interdisciplinary group of hand surgeons and radiologists supports the use of CT arthrography for the assessment of clinically suspected scapholunate instability and cartilage defects [18]. CT arthrography has demonstrated a sensitivity, specificity, and accuracy between 92% and 94% for triangular fibrocartilage (TFC) complex tears, between 80% and 100% for intrinsic ligament tears located within the proximal carpal compartment, and between 94% and 100% for articular cartilage abnormalities [22]. In a study assessing the diagnostic performance of CT arthrography in cadavers, CT arthrography was more sensitive for the diagnosis of scapholunate and lunotriquetral tears when compared with MRI at 1.5T and performed particularly well in assessment of the dorsal segment of the scapholunate ligament [23].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Wrist With IV Contrast There is no relevant literature to support the use of CT wrist with IV contrast in the setting of chronic wrist pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Wrist Without and With IV Contrast There is no relevant literature to support the use of CT wrist without and with IV contrast in the setting of chronic wrist pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Wrist Without IV Contrast CT of the wrist provides a detailed assessment of the cortical and trabecular bone with a high spatial resolution. CT is the ideal modality to assess fracture healing, malunion, and articular surface incongruity [6,24]. CT is particularly useful in assessment of the DRUJ. When there is clinical concern for DRUJ instability, CT can be used to image the symptomatic and contralateral wrist simultaneously in the neutral, supinated, and pronated positions to assess for instability [24-26].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT without IV contrast has been shown to be beneficial in operative planning for scaphoid fracture [27,28].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. A disadvantage of CT compared with both MRI and US is its decreased contrast resolution and lower sensitivity in the detection of soft tissue abnormalities.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MR Arthrography Wrist Direct MR arthrography is performed following the intra-articular injection of gadolinium and improves the detection and interobserver agreement for abnormalities of the wrist. MR arthrography is a minimally invasive imaging examination that may be appropriate for cases of suspected intrinsic ligament injury, TFC complex injury, cartilage abnormality, or surgical planning. Injection of any combination of the 3 compartments (DRUJ, radiocarpal, midcarpal) can be performed depending on the clinical question [13]. If the injection is performed with fluoroscopy,


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Chronic Hand and Wrist Pain comparison of the MR images with the fluoroscopic images is an essential step in image interpretation [13]. In most cases, a radiocarpal injection is performed; however, if there is concern for an ulnar sided detachment of the TFC, an additional DRUJ injection should be considered [7]. With single, radiocarpal injection, the sensitivity for TFC tears, intrinsic ligament injury, and cartilage lesions of the radiocarpal joint ranged from 63% to 100%, with specificity ranging from 89% to 97% [29].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Wrist Without and With IV Contrast There is no relevant literature discussing the routine use of MRI wrist without and with IV contrast for the evaluation of chronic wrist pain and normal or nonspecific radiographs. The addition of postcontrast imaging to wrist MRI aids in distinguishing synovitis from joint effusion and ganglion cysts [9,35]. Similarly, postcontrast MRI aids in the detection of tenosynovitis [35]. For these reasons, MRI without and with IV contrast is usually appropriate in the evaluation of chronic joint pain with clinical suspicion of rheumatoid arthritis or seronegative spondyloarthropathy [2] and in cases of suspected septic arthritis or soft tissue infection [3].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Wrist Without IV Contrast MRI without IV contrast is useful in the assessment of wrist pain. MRI is useful in assessing abnormalities of the bones, including bone marrow, and soft tissues, including the ligaments, TFC, tendons, and nerves. When using arthroscopy as the reference standard, the sensitivity and specificity of 3.0T MRI in the evaluation of scapholunate tear range from 70% to 87% and 90% to 97%, respectively, for lunotriquetral tear range from 50% to 63% and 94% to 97% respectively, and for TFC tear range from 63% to 100% and 42% to 100%, respectively [32,36-40]. A study of 18 patients demonstrated good correlation between cartilage lesions at 3.0T MRI and arthroscopy [37]. If a study is specifically performed to assess the intrinsic ligaments or TFC, MR arthrography has been demonstrated to be superior to MRI without IV contrast [30-32,41].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI is helpful in the diagnosis of tendon abnormalities including tendinopathy, tenosynovitis, and intersection syndromes [12,13,42,43]. In a retrospective review of 316 consecutive patients referred to a hand surgeon with MRI of the hand or wrist, MRI changed clinical management in 69.5% of cases [44]. MRI was particularly useful in reassuring patients that no further follow-up was necessary in 70% of cases [44].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiographic Arthrography Wrist There is no relevant literature to support the use of radiographic arthrography of the wrist in the setting of chronic wrist pain and normal or nonspecific radiographs. Although a meta-analysis has demonstrated a pooled sensitivity of 76.2% and a specificity of 92.5% for the detection of complete TFC complex tear, radiographic arthrography is not routinely performed in isolation [45]. In current practice it is infrequently performed as a standalone imaging examination; rather, it is typically performed in conjunction with CT or MR arthrography.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiography Wrist Additional Views A variety of additional radiographic projections of the wrist may be obtained to supplement the standard 3-view series depending on the specific clinical indication. However, there is no recent literature to support obtaining additional views in the setting of chronic wrist pain and normal or nonspecific radiographs. An interdisciplinary group of hand surgeons and radiologists consensus statements concluded stress views are indicated for the diagnosis of scapholunate instability [18].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. US Wrist US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, CTS, metacarpophalangeal joint collateral ligament injury, extensor hood injury, and retained foreign body [6,13,14,16,46]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the wrist; US is reasonable to evaluate tendon and soft tissue pathology of the wrist and to assess for entrapment of the median or ulnar nerves [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan, in 76% of all patients and 67% of patients who presented without a history of trauma


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Chronic Hand and Wrist Pain [17]. Although there are many advantages to US evaluation for chronic hand and wrist pain, an interdisciplinary group of hand surgeons and radiologists recommended against the inclusion of US in the standard evaluation of scapholunate instability [18].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Variant 3: Adult. Chronic hand pain. Radiographs normal or remarkable for nonspecific arthritis. Next imaging study. Bone Scan Hand There is no relevant literature to support the use of bone scan in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Arthrography Hand There is no relevant literature to support the use of CT arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Hand With IV Contrast There is no relevant literature to support the use of CT hand with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Hand Without and With IV Contrast There is no relevant literature to support the use of CT hand with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Hand Without IV Contrast There is no relevant literature to support the use of CT hand without IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MR Arthrography Hand There is no relevant literature to support the use of MR arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Hand Without and With IV Contrast There is no relevant literature discussing routine use of MRI hand without and with IV contrast in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis. In the research setting, contrast-enhanced MRI can identify synovitis, periarticular bone marrow edema, and tenosynovitis, which correlates with patient pain in the setting of hand osteoarthritis [47,48].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Hand Without IV Contrast MRI hand without IV contrast is of limited benefit in the setting of nonspecific pain. A study evaluating hand MRI in the setting of erosive osteoarthritis showed no difference in the assessment of joint space narrowing, bone erosion, and malalignment compared with radiographs [49]. MRI can demonstrate many abnormalities that result in chronic pain including arthritis, carpal boss, tendinopathy, tenosynovitis, pulley injury, extensor hood injury, sagittal band injury, volar plate injury, chondral injury, and ligament injury [13,50-54]. In a retrospective review of 316 consecutive patients referred to a hand surgeon with MRI of the hand or wrist, MRI changed clinical management in 69.5% of cases [44]. MRI was particularly useful in reassuring patients that no further follow-up was necessary in 70% of cases [44].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiographic Arthrography Hand There is no relevant literature to support the use of radiographic arthrography in the setting of chronic hand pain and normal radiographs or radiographs remarkable for nonspecific arthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. US Hand US can be used to identify synovitis, joint effusion, tenosynovitis, tendinopathy and tendon injury, pulley injury, CTS, and retained foreign body [6,13-16]. The American College of Rheumatology has concluded there is reasonable evidence to support the use of musculoskeletal US in patients without definitive diagnosis presenting with pain, swelling, or mechanical symptoms of the metacarpophalangeal and interphalangeal joints, and US is reasonable to evaluate tendon and soft tissue pathology of the hand [14]. In a study of patients referred from hand surgeons, US of the hand and wrist was contributory to the clinical assessment, defined as confirming the clinical suspicion or modifying the diagnostic/therapeutic plan, in 76% of all patients and 67% of patient who presented without a history of trauma [17].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Chronic Hand and Wrist Pain


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Variant 4: Adult. Chronic wrist pain. Radiographs show old scaphoid fracture. Evaluate for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis. Next imaging study. Bone Scan Wrist There is no relevant literature to support the use of bone scan in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Arthrography Wrist There is no relevant literature to support the use of CT arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, or osteonecrosis. If the specific clinical concern requires assessment of the articular cartilage in post-traumatic osteoarthritis, the spatial resolution of CT when combined with intra-articular contrast makes CT arthrography an ideal study. CT arthrography has demonstrated a sensitivity, specificity, and accuracy between 94% and 100% for articular cartilage injury [22].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Wrist With IV Contrast CT wrist with IV contrast is not routinely performed in clinical practice, although there is an isolated report of dual- energy CT with IV contrast used to assess scaphoid osteonecrosis. In addition to the benefits afforded by the high spatial resolution of CT in the assessment of scaphoid fracture, the addition of contrast has been shown to be beneficial in the determination of proximal pole viability. A study of 19 wrists in 18 patients with dual-energy contrast-enhanced CT showed promising results in the assessment of proximal pole osteonecrosis in the setting of scaphoid fracture [55]. When compared with intraoperative assessment or histologic analysis, in a series of 18 patients who underwent dual-energy contrast-enhanced CT of the wrist there was a sensitivity of 100% and a specificity of 94% for the assessment of osteonecrosis of the proximal pole of the scaphoid following fracture [55].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Wrist Without and With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Wrist Without IV Contrast The spatial resolution obtained with CT makes it well suited to assess for any trabecular bridging at the fracture site, nonunion, malunion, and the sclerosis and fragmentation of avascular necrosis. The isotropic acquisition and the ability to create 3-D models assists in surgical planning [27,28].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MR Arthrography Wrist There is no relevant literature to support the use of MR arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, or osteonecrosis. If the specific clinical concern requires assessment of the articular cartilage in post-traumatic osteoarthritis, the addition of arthrography to MRI improves the assessment of the articular cartilage [31]. However, CT arthrography has a higher sensitivity and specificity for articular cartilage defect compared with MR arthrography [31,56].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Wrist Without and With IV Contrast MRI wrist without and with IV contrast can demonstrate both nonunited and malunited scaphoid fractures. Although 3.0T MRI without IV contrast falls behind MR and CT arthrography in the assessment of the articular cartilage, it has demonstrated a modest sensitivity of 48% to 52% and a good specificity of 82% compared with visual inspection in a cadaver study [57]. The added benefit of MRI comes in the assessment for osteonecrosis in the proximal pole scaphoid following scaphoid fracture. Whether contrast-enhanced MRI is superior to noncontrast MRI for assessment of scaphoid osteonecrosis is controversial. In a study comparing the addition of postcontrast images with the unenhanced MRI in 30 patients, the addition of contrast increased the sensitivity (66% versus 36%), specificity (88% versus 78%), and accuracy (83% versus 68%) when compared with the noncontrast images alone [58].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Wrist Without IV Contrast MRI wrist without IV contrast can demonstrate both nonunited and malunited scaphoid fractures. Although 3.0T MRI without IV contrast falls behind MR and CT arthrography in the assessment of the articular cartilage, it has demonstrated a modest sensitivity of 48% to 52% and a good specificity of 82% compared with visual inspection in a cadaver study [57]. The added benefit of MRI comes in the assessment for osteonecrosis in the proximal pole scaphoid following scaphoid fracture. Whether contrast-enhanced MRI is superior to noncontrast MRI for assessment of scaphoid osteonecrosis is controversial. A study of noncontrast MRI in 29 patients with scaphoid


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. nonunion demonstrated a sensitivity of 55%, a specificity of 94%, and an accuracy of 79% for the diagnosis of osteonecrosis compared with intraoperative assessment [59].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiographic Arthrography Wrist There is no relevant literature to support the use of radiographic arthrography in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. US Wrist There is no relevant literature to support the use of US in the setting of chronic wrist pain, remote scaphoid fracture, and clinical concern for nonunion, malunion, osteonecrosis, or post-traumatic osteoarthritis.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Variant 5: Adult. Chronic hand or wrist pain. Radiographs normal or indeterminate. Symptoms suspicious for carpal tunnel syndrome. Next imaging study. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Area of Interest Without and With IV Contrast There is no relevant literature to support the use of MR without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Area of Interest Without IV Contrast MRI can identify enlargement and flattening of the median nerve, bowing of the flexor retinaculum, space occupying lesions, anatomic variants including bifid median nerve and persistent median artery, and tendon pathology in the carpal tunnel [60-62]. When compared with clinical assessment and nerve conduction studies, MRI can diagnose CTS with a high accuracy and stage severity with moderate accuracy [62,63]. There is good correlation between the cross-sectional area of the median nerve as assessed by both US and MRI [63,64]. However, MRI of the wrist is typically not indicated in the setting of suspected CTS [60-62].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of radiographic arthrography in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiography Wrist Additional Views There is no relevant literature to support the use of additional radiographic views in the setting of chronic hand and wrist pain with clinical concern for CTS.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. US Area of Interest When compared with clinical assessment and electrophysiologic studies, multiple systematic reviews and meta- analyses have demonstrated US to be highly sensitive and specific for the diagnosis of CTS [65-69]. The measurements and calculations used in the literature for US evaluation of the median nerve are heterogeneous;


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Chronic Hand and Wrist Pain


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. cross-sectional area measurements of the median nerve at multiple locations in the forearm and wrist and ratios or differences in cross-sectional area comparing the various measurements have been reported. Some authors have advocated for the use of US as the confirmatory test of choice or as a complementary test for the suspected diagnosis of CTS due to the ability to identify space occupying lesions, anatomic variants including bifid median nerve and persistent median artery, and tendon pathology in the carpal tunnel and the false-positive rate of electrodiagnostic studies [70-73]. Despite evidence supporting the diagnostic capabilities of US in the setting of CTS, there is disagreement among hand surgeons regarding the necessity of diagnostic tests [73,74]. The 2016 American Academy of Orthopedic Surgeons guidelines reports limited evidence supports not routinely using US for the diagnosis of CTS [60].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Variant 6: Adult. Chronic hand or wrist pain. Radiographs normal or show nonspecific arthritis. Suspect tendon injury, tenosynovitis, or tendon pathology. Next imaging study. Bone Scan Area of Interest There is no relevant literature to support the use of bone scan in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT with IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT without and with IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Area of Interest Without IV Contrast There is no relevant literature to support the use of CT without IV contrast in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. CT Arthrography Area of Interest There is no relevant literature to support the use of CT arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MR Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Area of Interest Without and With IV Contrast The inclusion of postcontrast images to MRI of the wrist improves detection of tenosynovitis [43,75].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. MRI Area of Interest Without IV Contrast The contrast resolution of MRI makes it ideal to assess soft tissue abnormalities in the hand and wrist. MRI of the hand or wrist without IV contrast can diagnose or confirm a multitude of tendon abnormalities including tendinopathy, tendon tear, intersection syndrome, tenosynovitis, stenosing tenosynovitis, pulley injuries, sagittal band, and palmar fibromatosis [13,43,76,77].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. Radiographic Arthrography Area of Interest There is no relevant literature to support the use of MR arthrography in the setting of chronic hand and wrist pain with clinical concern for tendon injury, tenosynovitis, or tendon pathology.


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain. US Area of Interest Tendon injuries of the hand and wrist are well suited to US evaluation due to their superficial location and the ability to dynamically assess the tendons. US of the hand or wrist can diagnose or confirm a multitude of tendon abnormalities including tendinopathy, tendon tear, intersection syndrome, tenosynovitis, stenosing tenosynovitis, pulley injuries, sagittal band, and palmar fibromatosis [6,13,46,77,78]. US assists in operative and injection planning in patients with De Quervain tenosynovitis with accurate identification of an intracompartmental septum [79]. In a study of 50 injured tendons of the hand and wrist in 35 patients, 25 with surgical comparison, US demonstrated high accuracy in the setting of complete tears, partial tears, and tenosynovitis [80].


Chronic Hand and Wrist Pain

Chronic Hand and Wrist Pain


Chronic Hand and Wrist Pain

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


Chronic Hand and Wrist Pain

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


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. This document is specific to malignant or aggressive primary tumors of bone or soft tissue origin. This document specifically does not pertain to 1) metastatic disease to bone or soft tissues, 2) primary tumors of spine or neuroaxis origin, 3) primary tumors of head or neck origin, 4) intraabdominal or retroperitoneal tumors, 5) primary tumors of skin origin, and 6) plasma cell or other hematologic disorders that involve bone (ie, multiple myeloma). The variants in this document assume a diagnosis of a primary malignant or aggressive bone or soft tissue tumor has already been established. This document does not address the evaluation of chemotherapy or radiation therapy effectiveness or issues of cost-effectiveness and radiation dose.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Special Imaging Considerations Hardware reconstruction is often needed following limb-sparing surgery for the management of bone tumors and occasionally for soft tissue tumors. This hardware creates artifact and limits evaluation of the adjacent structures with traditional CT, PET/CT, and MRI sequences and techniques. Although metal artifact can negatively impact CT, PET/CT, and/or MRI image quality, this document assumes metal artifact can be minimized with current metal artifact reduction protocols. There may still be instances where metal artifact cannot be sufficiently suppressed, and CT, PET/CT, and/or MRI become of limited benefit. In these cases, deviations from the variant recommendations may be necessary and should be informed by the clinical experience and expertise of the treatment team.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. aResearch Author, Mayo Clinic Florida, Jacksonville, Florida. bDiagnostic Imaging Associates, Chesterfield, Missouri. 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. gNova Southeastern University, Fort Lauderdale, Florida. hMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. iMayo Clinic Florida, Jacksonville, Florida. jStritch School of Medicine Loyola University Chicago, Maywood, Illinois; Commission on Radiation Oncology. kUniversity of Texas Health Science Center, Houston, Texas; American Academy of Orthopaedic Surgeons. lBrigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts; American Association of Neurological Surgeons/Congress of Neurological Surgeons. mMayo Clinic Florida, Jacksonville, Florida, Primary care physician. nUniversity of Virginia, Charlottesville, Virginia. oSUNY Downstate Health Sciences University, Brooklyn, New York. pMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. qSpecialty Chair, University of Kentucky, Lexington, Kentucky.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance 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.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Reprint requests to: publications@acr.org


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Discussion of Procedures by Variant Variant 1: Malignant or aggressive primary musculoskeletal tumor. Initial staging. Evaluation for pulmonary metastasis. Approximately 20% of patients with primary extremity sarcomas will have or develop distant metastatic disease. Pulmonary metastases account for approximately 75% of all sarcoma metastases, with variations of incidence depending on tumor histology and grade [4,5]. Metastatic disease decreases survival, with pulmonary metastases as the primary cause of death in patients with osteosarcoma [6,7]. Metastasectomy improves survival, and thermal ablation and radiation therapy are emerging as promising alternative treatment options [8-10]. Therefore, evaluation for pulmonary metastases is an essential part of primary musculoskeletal tumor initial staging.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Chest With IV Contrast There is no relevant literature regarding the specific use of CT chest with intravenous (IV) contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared with CT chest without IV contrast in this setting.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Chest Without and With IV Contrast There is no relevant literature regarding the specific use of CT chest without and with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared with CT chest without IV contrast in this setting.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Chest Without IV Contrast CT chest is the most sensitive imaging modality for identifying pulmonary nodules compared with radiography, fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT, or FDG-PET/MRI. However, studies have shown that even CT underestimates the number of pulmonary metastases compared with lung palpation during thoracotomy. Specific to osteosarcoma pulmonary metastases, CT missed approximately 10% of palpable lung lesions, of which nearly half were confirmed metastases in a series of 118 patients with osteosarcoma [9]. A smaller series of 28 patients with osteosarcoma also showed that CT missed 26% of viable metastases compared with palpation [11]. However, as CT technology improves and slice thickness decreases, more and smaller pulmonary nodules can be identified resulting in the dilemma of increased false-positive rates. A study of 283 lung nodules in patients with osteosarcoma found a statistically significant cutoff of 6 mm to differentiate benign and malignant pulmonary nodules (specificity 89.8%) [9]. A study of 311 subcentimeter pulmonary nodules in 195 patients with soft tissue sarcoma found combining morphologic criteria, in addition to size criteria, helped differentiate benign and malignant pulmonary nodules, with round solid nodules >5 mm more likely to be malignant (76% P = .002) and complex ground-glass nodules <5 mm more likely to be benign (84%, P < .0001) [12]. Given the survival benefit of treating pulmonary metastases, if pulmonary nodules are identified on any other modality in patients with primary musculoskeletal sarcoma, CT chest is then often indicated for biopsy and/or pretreatment planning.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/CT Whole Body A meta-analysis of FDG-PET/CT for the staging of patients with osteosarcoma demonstrated 81% combined sensitivity and 94% specificity for detection of lung metastases [6]. The superiority of PET when combined with CT has been established [13]. Comparison studies between PET imaging alone versus CT acquired during FDG- PET/CT have been reported, although the CT acquired for attenuation correction and anatomic registration is not regarded as equivalent to dedicated diagnostic CT chest imaging [13]. Roberge et al [14] compared FDG-PET/CT with conventional imaging in a cohort of 109 patients during staging of extremity and body wall soft tissue sarcomas. In this cohort, 16 of the 109 patients had lung metastases, 10 of which were only identified on CT chest. Only 1 of the 16 patients with lung metastases was identified with FDG-PET/CT imaging but not CT chest. The authors concluded that FDG-PET/CT added little benefit over CT chest alone in evaluating for pulmonary metastasis [14].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. A study comparing staging and follow-up imaging studies in 41 children with primary bone sarcomas showed greater sensitivity of CT chest (93%) versus FDG-PET/CT (80%) in detecting pulmonary metastases (although


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. 4 Malignant or Aggressive Primary Musculoskeletal Tumor


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. specificity was higher with FDG-PET/CT at 96% compared with 87% for CT chest). Of the false-negative FDG- PET/CT results in that study, half were pulmonary nodules <10 mm [15]. Evaluation of subcentimeter pulmonary nodules is a known limitation of FDG-PET/CT because of the inherent resolution constraints of PET/CT technology and respiratory motion artifact. However, a study of 63 lung nodules in 18 pediatric patients with bone sarcoma did demonstrate the value of using an FDG-PET standardized uptake value (SUV) cutoff in evaluating small pulmonary nodules; using an SUVmax >1 cutoff value and a nodule diameter cutoff of 6 mm can differentiate benign and malignant nodules with an accuracy of 92.1% compared with an accuracy of 88.9% with FDG-PET/CT visual analysis alone [16].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/MRI Whole Body Literature specific to sarcoma staging with FDG-PET/MRI is scarce. A single study by Platzek et al [17] in 2017 evaluated FDG-PET/MRI in sarcoma staging in 29 patients and compared results with conventional CT or MRI studies. Eight of the 29 patients had lung metastases, which were identified on both the FDG-PET/MRI and conventional imaging. However, the small sample size precludes application of this data to larger populations. The inherent decreased spatial resolution of MRI compared to CT raises doubts about the ability to identify small pulmonary metastases with FDG-PET/MRI as accurately as CT. MRI of the lungs relies heavily on the ability to minimize respiratory motion.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Radiography Chest There is no relevant literature to support the use of chest radiography in the evaluation of pulmonary metastases in the initial staging of malignant or aggressive primary musculoskeletal tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Variant 2: Malignant or aggressive primary musculoskeletal tumor. Initial staging. Evaluation for extrapulmonary metastasis. The body regions covered in this clinical scenario are ankle, chest, shoulder, elbow, femur, foot, forearm, hand, humerus, knee, pelvis, tibia/fibula, and wrist.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Bone Scan Whole Body Although historically Tc-99m bone scan has been used to detect bone metastasis, more recent studies have shown Tc-99m bone scan is inferior to FDG-PET/CT in the detection of bone metastases in general oncologic populations [23]. This conclusion has also been supported in patients with bone sarcoma. A study of 206 patients with stage IV osteosarcoma who underwent both Tc-99m bone scan and FDG-PET/CT calculated a 95% sensitivity and 98% accuracy for FDG-PET/CT versus 76% and 96%, respectively, for Tc-99m bone scan [24]. A smaller study of 64 pediatric patients with bone sarcoma also showed greater accuracy of FDG-PET/CT (84%) versus Tc-99m bone scan (70%) in detecting bone metastases during initial staging [22]. Other studies have suggested that this FDG- PET/CT superiority may be specific only to osteolytic metastases but not osteoblastic metastases [25-27]. The ability to detect extraosseous metastases that are usually occult on Tc-99m bone scan is an additional benefit of FDG-PET/CT [28].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Similarly, studies have demonstrated MRI whole body is superior to Tc-99m bone scan in detecting bone metastases in general populations. A study specific to patients with Ewing sarcoma of bone that had both MRI whole body and Tc-99m bone scan showed not only more bone metastases were identified with MRI, but 4 of the 71 patients had bone metastases only detected on MRI which changed the tumor stage for these patients [29].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The addition of single-photon emission computed tomography (SPECT) and SPECT/CT to Tc-99m bone scans can increase diagnostic confidence. A study of 2,954 Tc-99m bone scans in a general oncologic population increased diagnostic confidence by 75% and reduced equivocal findings by 27% [30]. However, there is no relevant literature


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. 5 Malignant or Aggressive Primary Musculoskeletal Tumor


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. to support the specific use of SPECT or SPECT/CT with bone scans in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest With IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest Without and With IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest Without IV Contrast CT can be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of localized CT at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors; rather, a systemic approach to initial staging is recommended.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/CT Whole Body A meta-analysis of FDG-PET/CT for the staging of patients with osteosarcoma demonstrated an overall sensitivity of 93% and a specificity of 97% for detection of bone metastases [6]. Coverage of a whole body FDG-PET/CT varies and usually extends either from skull base to thighs or skull vertex to feet. A study of FDG-PET/CT in patients with sarcoma and melanoma showed inclusion of the entire lower extremities does not add additional benefit in identifying metastases [31].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/CT is considered superior to Tc-99m bone scan in the detection of osseous metastases. Literature has concluded this in both general oncologic and bone sarcoma populations [30]. FDG-PET/CT is also superior to CT imaging in this regard. Quartuccio et al [22] studied 64 pediatric patients with bone sarcoma and found greater accuracy of FDG-PET/CT (85% accuracy) versus CT (44% accuracy) in detecting bone metastases during initial staging of patients with Ewing sarcoma. There are mixed conclusions when comparing FDG-PET/CT versus MRI whole body in detecting osseous metastases in general oncology populations [32-34]. In a small study of 20 patients with Ewing sarcoma comparing FDG-PET/CT with MRI whole body, a single patient had a false-positive bone finding on FDG-PET/CT. Overall, 39% more bone lesions in this study were identified with MRI whole body versus FDG-PET/CT [35]. In the Quartuccio et al [22] study of 64 pediatric patients with bone sarcoma, when FDG- PET/CT was compared with MRI for the detection of bone metastases, accuracy was similar (85% versus 89%). MRI better discriminates bone metastases from hematopoietic marrow, both of which can have increased metabolic activity on PET imaging. An advantage of PET over MRI is the ability to quantify tumor metabolic activity, which can serve as a prognostic indicator [15].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/CT can also be useful to detect nonskeletal metastases, more frequently in the lung, but also lymph nodes and other organs. FDG-PET/CT can detect a greater number of nodal metastases in soft tissue sarcoma versus conventional imaging alone [36,37]. The incidence of nodal metastases is dependent on tumor histology.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/MRI Whole Body Literature specific to sarcoma staging with FDG-PET/MRI is scarce. A study of 29 patients with sarcoma who underwent FDG-PET/MRI and conventional imaging (CT chest/abdomen and/or local MRI) showed no significant difference in accuracy for detecting metastases with sensitivities and specificities of 97.8% and 100% for FDG- PET/MRI compared with 94.4% and 100% for conventional imaging. Of the 10 patients in this study with metastases, 6 had extrapulmonary metastases [17]. Another study of 98 bone lesions in a general oncologic population undergoing simultaneous FDG-PET/CT and FDG-PET/MRI showed these modalities to be equivalent for the detection and characterization of bone lesions [38]. Although FDG-PET/MRI whole body scans may prove to be useful in this setting, additional evidence is needed to compare its utility with existing modalities.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Fluoride PET/CT Whole Body Fluoride PET/CT can increase diagnostic confidence when detecting bone metastases in general oncologic populations when compared with planar Tc-99m bone scans [39]. There is no relevant literature to specifically


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. 6 Malignant or Aggressive Primary Musculoskeletal Tumor


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. support the use of fluoride PET/CT in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. Specifically, extraosseous extrapulmonary metastases will usually be occult on fluoride PET/CT whole body scans.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. MRI Whole Body Without and With IV Contrast There is no relevant literature to support the use of MRI whole body without and with IV contrast in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. However, the addition of IV contrast can be helpful for assessing soft tissue masses and therefore could be beneficial in this setting.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. MRI Whole Body Without IV Contrast The ability of MRI to characterize soft tissue and bone marrow make it ideal for identifying extrapulmonary metastases. MRI is particularly useful in identifying and accurately characterizing bone marrow abnormalities as metastases versus nonmalignant processes. Hematopoietic marrow, or red marrow, is a frequently encountered nonmalignant marrow abnormality that can be mistaken for a metastasis on other modalities, particularly on PET imaging, when there is relatively increased metabolic activity. Hematopoietic marrow is abundant in the pediatric and young adult populations making it problematic for the staging of bone sarcomas in these populations. Multiple medications and other systemic illnesses can activate hematopoietic marrow in the adult population.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Specific to myxoid liposarcoma, a sarcoma subtype known to metastasize preferentially to extrapulmonary locations, multiple studies have found MRI to be more accurate than FDG-PET, FDG-PET/CT, CT, radiography, and bone scintigraphy imaging to detect extrapulmonary metastases [40-44].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. A small study in patients with Ewing sarcoma showed more bone lesions were more accurately identified on MRI whole body when compared with FDG-PET/CT [35]. There are mixed conclusions when comparing FDG-PET/CT versus MRI whole body in detecting osseous metastases in general oncology populations [32-34].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. MRI whole body is more sensitive than Tc-99m bone scan for detecting osseous metastasis in a variety of tumors known to metastasize to bone. Sensitivity was also higher specifically in patients with Ewing sarcoma [29].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Radiography Area of Interest Radiographs could be used to evaluate an area of interest identified clinically or from another imaging modality. There is no relevant literature to support the use of radiography at an area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. US Area of Interest There is no relevant literature to support the use of ultrasound (US) area of interest in the initial staging for extrapulmonary metastasis of malignant or aggressive musculoskeletal tumors. US could be used to evaluate an area of interest identified clinically or from another imaging modality. US is more useful to evaluate superficial soft tissue masses as opposed to bone lesions, which are usually occult if there is no cortical breakthrough.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Variant 3: Malignant or aggressive primary musculoskeletal tumor with no suspected or known recurrence. Surveillance for pulmonary metastasis. Pulmonary metastases account for the majority of distant metastatic disease in patients with primary extremity sarcoma as a whole. Risk of pulmonary metastasis varies with tumor histology and grade. Although patients with high-grade soft tissue sarcomas develop lung metastasis at a rate of ~60%, those with low-grade sarcomas have lung metastasis rates <10% [45,46]. Therefore, guidance regarding modality for lung screening often differ between low-risk and high-risk patients. There is also debate concerning the frequency of lung surveillance. Given most pulmonary metastases will occur within 2 years of primary resection [47], many experts support more frequent surveillance initially in the first few years after diagnosis. Surveillance regimens usually de-escalate to annual follow-up after 5 years postresection [48-52]. Although these dynamic protocols are often used, a prospective randomized trial of 500 patients with resected extremity sarcomas and no baseline metastatic disease found no difference in overall survival or recurrence-free survival between groups whether surveilled at 3 month or 6-month consistent intervals [53,54]. Pulmonary metastases are associated with a worse prognosis [45], and treatment of these pulmonary metastases can improve survival [8,10]. Identification of pulmonary metastases is an essential part of primary musculoskeletal tumor screening. There is little to no variation in the ability of a certain modality to detect pulmonary metastasis whether performed at initial staging (see Variant 1), surveillance, or restaging in the setting of recurrence.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. 7 Malignant or Aggressive Primary Musculoskeletal Tumor


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Chest With IV Contrast There is no relevant literature regarding the specific use of CT chest with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization, which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared to CT chest without IV contrast in this setting.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Chest Without and With IV Contrast There is no relevant literature regarding the specific use of CT chest without and with IV contrast in the evaluation of pulmonary metastasis from malignant or aggressive primary musculoskeletal tumors. However, IV contrast may lead to equivocal assessment of mineralization which can be a useful morphologic feature to distinguish benign versus malignant pulmonary nodules. Therefore, CT chest with IV contrast is not generally useful as the sole imaging technique, and there is felt to be little additional benefit in the CT assessment of pulmonary nodules without and with IV contrast compared to CT chest without IV contrast in this setting.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Chest Without IV Contrast CT chest is the most sensitive imaging modality for the detection of pulmonary metastases. CT imaging for lung metastases has been criticized by some as being too sensitive. Several studies have attempted to find size and morphologic criteria to help discriminate between malignant and benign pulmonary nodules [9,12]. Rissing et al [55] showed that those only with pulmonary lesions <5 mm were associated with equivalent survival to those with normal scans. Often when a pulmonary metastasis is identified on a different imaging modality, CT is then required for biopsy or treatment planning.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Guidance varies regarding whether to use CT chest versus chest radiography as surveillance for lung metastases in patients with sarcoma. Much of the debate also takes cost-analysis and radiation exposure into consideration. A retrospective study by Cho et al [56] of 176 patients with stage II or stage III high-grade extremity sarcomas calculated similar 5-year survival rates whether surveilled with chest radiography or CT chest. However, when stratifying survival rates by stage, they found a survival benefit for stage III patients when monitored with CT chest likely related to the increased rates of lung metastasis with high-grade sarcoma. Other studies have differing conclusions. A large multicenter retrospective study by Gamboa et al [45] comparing lung surveillance in 909 patients with extremity, truncal, or retroperitoneal high-grade soft tissue sarcomas found the 5-year survival rate was noninferior for patients followed with chest radiography versus CT chest (71% versus 60%). This study also found there was no difference in the rate or type of intervention for these lung metastases when detected. Selection bias was a limitation of both of these retrospective studies because the rationale of which modality used to screen was not known or reported. Additionally, the Gamboa et al [45] study included 151 patients with retroperitoneal sarcoma, which has a high rate of local recurrence; this group was overrepresented in the CT imaging group, which had the worse survival rate. A prospective randomized trial of 500 patients with resected extremity bone and soft tissue sarcomas without baseline metastases showed noninferiority of chest radiography compared with CT chest with similar overall survival (56% versus 53% respectively) and recurrence-free survival (59% versus 54% respectively) when used for lung surveillance [53,54].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/CT Whole Body Although FDG-PET/CT is not as sensitive for detecting pulmonary metastases as CT chest imaging, it has been shown to be more specific and therefore may be useful as a problem-solving tool when an indeterminate pulmonary nodule is detected on diagnostic chest CT. A study comparing staging and follow-up imaging studies in 41 children with primary bone sarcomas showed greater sensitivity of CT chest (93%) versus FDG-PET/CT (80%) in detecting pulmonary metastases (although specificity was higher with FDG-PET/CT at 96% compared with 87% for CT chest). Of the false-negative FDG-PET/CT results in that study, half were pulmonary nodules <10 mm [15]. Evaluation of subcentimeter pulmonary nodules is a known limitation of FDG-PET/CT because of the inherent resolution constraints of PET/CT technology and respiratory motion artifact. However, a study of 63 lung nodules in 18 pediatric patients with bone sarcoma did demonstrate the benefit of using an FDG-PET SUV cutoff in evaluating small pulmonary nodules; using an SUVmax >1 cutoff value and a nodule diameter cutoff of 6 mm can differentiate benign and malignant nodules with an accuracy of 92.1% compared with an accuracy of 88.9% with FDG-PET/CT visual analysis alone [16].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. 8 Malignant or Aggressive Primary Musculoskeletal Tumor


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/MRI Whole Body There is no relevant literature to support the use of FDG-PET/MRI in the evaluation of pulmonary metastases during surveillance of malignant or aggressive primary musculoskeletal tumors. The inherent decreased spatial resolution of MRI compared with CT raises doubts about the ability to identify small pulmonary metastases with FDG- PET/MRI as accurately as CT. MRI of the lungs relies heavily on the ability to minimize respiratory motion.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Radiography Chest Chest radiography is less sensitive than CT chest imaging for the detection of pulmonary nodules. Whooley et al [57] found that 83% of asymptomatic metastases were detected radiographically with a positive predictive value of 92% and a negative predictive value of 97%. However, the detection of more and smaller pulmonary metastases with CT versus radiography has definitely not improved survival rates. Although radiography is less sensitive for detection of lung metastases, how that correlates with clinically significant metastases is less certain.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Variant 4: Malignant or aggressive primary bone tumor. Surveillance for local recurrence. The body regions covered in this clinical scenario are ankle, chest, elbow, shoulder, femur, foot, forearm, hand, humerus, knee, pelvis, tibia/fibula, and wrist.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Local recurrence rates following primary resection of a malignant or aggressive bone tumor vary and depend on tumor grade and histology. Local recurrence rates of bone sarcomas are reported to be approximately 10% to 15% in patients with osteosarcoma and Ewing sarcoma [58-61]. Prognosis is poor for locally recurrent malignant or aggressive bone tumors, with postrecurrence 5-year survival rates reported approximately 15% to 30% in patients with osteosarcoma and 5% in patients with Ewing sarcoma [60,62]. Factors associated with poorer prognosis in patients with osteosarcoma were size of local recurrence (>5 cm) and presence of distant metastasis [60].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Recommendations for local recurrence surveillance imaging vary amongst expert guidelines, although all acknowledge the benefit of clinical evaluation. Locally recurrent bone tumors can often present as a soft tissue mass, and in a study of osteosarcoma local recurrences, the majority (approximately 75%) were soft tissue masses rather than bone lesions [60]. Some guidelines recommend clinical examination to be performed solely, whereas others recommend in combination with imaging [49,51,52,63]. Time to recurrence also varies with tumor histology. Most osteosarcoma local recurrences have been shown to occur within 5 years of resection. However, late recurrence of both osteosarcoma and Ewing sarcoma have been reported [60,61]. In a study of locally recurrent osteosarcoma, survival rates decreased from 30% at 5 years to 13% at 10 years, suggesting long-term follow-up beyond 5 years is beneficial. Tumor histology, grade, and clinical scenario remain paramount when deciding how to surveil for local recurrence.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Bone Scan Whole Body Historically, bone scans have been used for the surveillance of local recurrence. Increased bone uptake at the primary resection site is nonspecific and can occur for many reasons, including stress changes from adjacent hardware, fractures, and possibly recurrence. With advances in MRI, CT, and PET imaging, the use of bone scan for local recurrence surveillance has decreased. Studies have shown superiority of FDG-PET/CT and MRI versus bone scan for assessment of bone metastases (see Variant 2). Although historically, Tc-99m bone scan has been used to detect bone metastasis, more recent studies have shown Tc-99m bone scan is inferior to FDG-PET/CT in the detection of bone metastases in general oncologic populations [23]. A smaller study of 64 pediatric patients with bone sarcoma also showed greater accuracy of FDG-PET/CT (84%) versus Tc-99m bone scan (70%) in detecting bone metastases during initial staging [22]. There is no relevant literature to support the use of bone scan whole body for surveillance of local recurrence of malignant or aggressive primary bone tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest There is no relevant literature to support the use of bone scan whole body with SPECT or SPECT/CT area of interest for surveillance of local recurrence of malignant or aggressive primary bone tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest With IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. 9 Malignant or Aggressive Primary Musculoskeletal Tumor


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest Without and With IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors. However, given increased radiation dose without clinical benefit, CT without and with IV contrast is usually not recommended over CT with IV contrast alone.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest Without IV Contrast CT can be useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted, CT is also susceptible to artifact from metal hardware. Although IV contrast does not provide added benefit for evaluation of bone, given many bone sarcoma recurrences present as soft tissue masses, IV contrast can be useful to increase the conspicuity of enhancing soft tissue tumors and is usually recommended in this setting.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/MRI Whole Body There is no relevant literature to support the use of FDG-PET/MRI whole body as surveillance of local recurrence of malignant or aggressive primary bone tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Fluoride PET/CT Whole Body There is no relevant literature to support the use of fluoride PET/CT whole body as surveillance of local recurrence of malignant or aggressive primary bone tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. MRI Area of Interest Without and With IV Contrast MRI of the primary tumor resection site has further asserted its usefulness for surveillance of local recurrence with improvements in metal artifact reduction. Given the preference for limb-sparing surgeries, many bone tumor resections require the implantation of hardware which creates local artifact that can obscure the adjacent tissues. Few studies comparing the use of MRI for local recurrence of bone tumors compared with other modalities have been published in recent years likely given its widespread adoption clinically. MRI is often requested before surgery and radiation when local recurrence is established.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Given many local recurrences are soft tissue masses, the use of IV contrast remains beneficial to help characterize masses as malignant or benign and can also increase reader confidence [67,68].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. MRI Area of Interest Without IV Contrast MRI of the primary tumor resection site has further asserted its usefulness for surveillance of local recurrence with improvements in metal artifact reduction. Given the preference for limb-sparing surgeries, many bone tumor resections require the implantation of hardware, which creates local artifact that can obscure the adjacent tissues. Few studies comparing the use of MRI for local recurrence of bone tumors compared with other modalities have been published in recent years likely given its widespread adoption clinically. MRI is often requested before surgery and radiation when local recurrence is established.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Given many local recurrences are soft tissue masses, the use of IV contrast remains beneficial to help characterize masses as malignant or benign and can also increase reader confidence. However, the inherent contrast resolution of MRI, even in the absence of IV contrast, makes this a useful modality to assess for local recurrence of malignant or aggressive primary bone tumors [67,68].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. 10 Malignant or Aggressive Primary Musculoskeletal Tumor


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Radiography Area of Interest Not only is radiography useful to evaluate for bone tumor recurrence, but it is also an invaluable adjunct to MRI interpretation. When hardware is present, even with modern metal-artifact reduction techniques, radiography can visualize the bone-metal or bone-cement interface, which can be critical to evaluate for tumor recurrence. Radiographs are recommended for the surveillance of local recurrence of malignant or aggressive primary bone tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. US Area of Interest US is not useful for evaluating bone lesions when there is no extraosseous tumor extension. However, US may be beneficial if a mass is identified clinically. There is no relevant literature to support the use of US as surveillance for asymptomatic local recurrence of malignant or aggressive primary bone tumors.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Variant 5: Malignant or aggressive primary soft tissue tumor. Surveillance for local recurrence. The body regions covered in this clinical scenario are abdomen, ankle, chest, elbow, shoulder, thigh, foot, forearm, hand, arm, knee, pelvis, leg, and wrist.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Local recurrence rates of soft tissue sarcomas have been reported to occur at rates of 5% to 25% in larger historic studies [69-72]. Although rates of local recurrence following primary resection depend on tumor histology and grade, several other factors have been identified that increase risk. Tumor location is associated with local recurrence, with those tumors located deep to fascia or in the upper extremities/trunk as more likely to recur [73]. Positive or close resection margins have also been associated with increased likelihood of local recurrence [70,73,74]. Local recurrence is associated with metastatic disease and increased mortality [70], and if the recurrence can be treated before developing metastatic disease there is a survival benefit [73]. Size of the recurrence has also been linked with not only survival [75] but also morbidity, because larger tumors often require more extensive surgery [48]. Therefore, surveillance for local recurrence is important to reduce both mortality and morbidity.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. There remains some controversy not only on how to surveil resected soft tissue sarcomas but also if imaging surveillance is even necessary. The primary dispute against the need for imaging surveillance is the argument that recurrences are usually clinically detectable [54,76]. The literature also has some conflicting evidence on this topic. For example, a prospective study of 500 patients with sarcoma found 90% of local recurrences were clinically detected [54]. Conversely, a large recent study of 325 patients with soft tissue sarcomas found a rate of 60% of the local recurrences were not detected clinically [77]. Expert guidelines vary on recommendations for local recurrence imaging, although all acknowledge the benefit of clinical evaluation; some guidelines recommend clinical examination to be performed solely, whereas others recommend in combination with imaging [49,51,52,63]. Clinical evaluation of deep soft tissue local recurrence remains a limitation of this approach. Most local recurrences of soft tissue sarcomas occur within 5 years of primary resection [78]. Therefore, those guidelines that recommend imaging usually advocate for more aggressive imaging in the first 5 years that taper off to annual imaging. Tumor histology, grade, and clinical scenario remain paramount when deciding how to surveil for local recurrence.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest With IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest Without and With IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment. However, CT without and with IV contrast is usually not recommended over CT with IV contrast alone.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. CT Area of Interest Without IV Contrast CT remains useful for surveillance of local recurrence when MRI is unable to be obtained. CT imaging can also be of benefit if metal artifact on MRI cannot be resolved, although it should be noted CT is also susceptible to artifact from metal hardware. When evaluating the soft tissues, postcontrast imaging is recommended to increase the


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. 11 Malignant or Aggressive Primary Musculoskeletal Tumor


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. conspicuity of enhancing tumors and, if so, areas of necrosis that can help with biopsy planning and to serve as a baseline for future therapy response assessment.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/CT Whole Body FDG-PET/CT has the added benefit of not only thin-slice CT imaging but also the ability to detect metabolically active disease. FDG-PET/CT is highly accurate in detecting recurrent soft tissue and bone sarcomas, and may be useful as a problem-solving tool when other imaging of the area of interest is equivocal. A retrospective single- institution study of 43 patients with bone or soft tissue sarcomas found better sensitivity and specificity of FDG- PET/CT follow-up versus contrast-enhanced CT imaging (94% and 92% versus 78% and 67%, respectively) [79]. A retrospective single-institution study of 152 patients with soft tissue sarcomas comparing whole body FDG- PET/CT with MRI at the primary treatment site did not detect a significant difference in performance for detecting local recurrence (MRI sensitivity of 90% and specificity of 98%, compared with FDG-PET/CT sensitivity of 95% and specificity of 96%) [80].


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. FDG-PET/MRI Whole Body A retrospective single-institution study of 41 patients with resected soft tissue sarcomas and with clinically suspicious recurrence underwent FDG-PET/MRI, either whole body if a truncal primary or localized to the primary tumor site if an extremity sarcoma. The MRI portion and then FDG-PET/MRI portions were interpreted independently. With the addition of FDG-PET imaging to the MRI, sensitivity increased from 82% to 96%, although specificity mildly decreased from 85% to 79%. Diagnostic confidence increased for the readers [81]. FDG- PET/MRI whole body may be useful as a problem-solving tool when other imaging of the area of interest is equivocal.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. MRI Area of Interest Without and With IV Contrast MRI used as surveillance of the primary soft tissue tumor site is the mainstay for evaluating local recurrence. Few studies regarding the diagnostic utility of MRI for local recurrence of soft tissue sarcomas have been published in recent years, likely given its widespread adoption clinically. MRI is useful not only for asymptomatic surveillance but also if a clinical area of concern at the resection site develops. MRI is often requested before surgery and radiation when local recurrence is established. A retrospective single-institution study by Park et al [77] of 325 patients with extremity sarcoma with a local recurrence rate of 11% found MRI detected 60% of those patients with recurrence not identified clinically or with US. Those with MRI detected local recurrence trended towards better survival, but this did not reach statistical significance.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. MRI has been criticized as having many false-positive results, leading to unnecessary procedures and emotional distress [82]. A retrospective single-institution study of 11 local recurrences in 124 patients with soft tissue sarcoma found MRI had a positive predictive value of only 42% with 11 false-positive examinations in this cohort and advocated for clinical surveillance only [83]. However, the Park et al [77] larger single-institution studies found a positive predictive value of 93%.


Malignant or Aggressive Primary Musculoskeletal Tumor Staging And Surveillance PCAs. Postcontrast imaging has been shown to add benefit in evaluation of soft tissue tumors to differentiate benign versus malignant lesions [68]. A more recent retrospective study assessing the added value of postcontrast MRI showed contrast improved reader confidence even for experienced readers and improved accuracy of a more inexperienced reader from 65% to 72% [67].