Use of Imaging Prior to Referral to a Musculoskeletal Oncologist

Benjamin J. Miller, MD, MS

Disclosures

J Am Acad Orthop Surg. 2019;27(22):e1001-e1008. 

In This Article

Recommendations

Indications for Plain Radiographs

Bone Tumors. Moderate evidence supports using conventional radiographs in the initial evaluation of a bone tumor of unknown etiology.

Strength of Recommendation: Moderate

Implication: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

Soft-tissue Tumors. In the absence of reliable evidence, it is the opinion of the work group that conventional radiographs are a reasonable diagnostic test and may be considered during the initial evaluation of a soft-tissue tumor.

Strength of Recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

Indications for Advanced Imaging Based on Radiographic Findings

Cortical Irregularity or Periosteal Reaction. Moderate evidence supports the use of an MRI scan (or CT if MRI is not available) for evaluation of a cortical irregularity or periosteal reaction in patients with a potentially malignant bone tumor.

Strength of Recommendation: Moderate

Implication: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

Tumor Interface. Moderate evidence suggests that characterizing the tumor interface (borders and zone of transition) on MRI and CT may assist with obtaining a diagnosis or planning further diagnostic studies or treatment for bone or soft-tissue tumor of unknown etiology.

Strength of Recommendation: Moderate

Implication: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

Indications for Advanced Imaging Based on Patient History

History of Pain. Moderate evidence supports that both radiographs and MRI have weak sensitivity in determining malignancy but moderate to strong specificity in determining benignity of bone tumors in patients reporting pain.

Strength of Recommendation: Moderate

Implication: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

Limited evidence supports that a Tc99 bone scan may assist with obtaining a diagnosis or planning further diagnostic studies or treatment in patients with a bone tumor of unknown etiology and pain in the area of the tumor.

Strength of recommendation: Limited

Implication: Practitioners should feel little constraint in following a recommendation labeled as Limited, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.

In the absence of reliable evidence, it is the opinion of this work group that an MRI of a bone or soft-tissue tumor of unknown etiology should be considered and is the preferred advanced imaging study in patients with a report of pain at the site of the identified tumor.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

In the absence of reliable evidence, it is the opinion of this work group that contrast-enhanced CT scan of the site should be considered in patients with pain at the site of a bone or soft-tissue mass when there are patient-specific contraindications to MRI, such as a pacemaker or cerebral aneurysm clips.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

In the absence of reliable evidence, it is the opinion of this work group that, in the setting of a bone or soft-tissue tumor of unknown etiology with a report of pain at the site of the identified but undiagnosed tumor, CT of the chest/abdomen/pelvis, PET-CT, and Tc99 bone scan may assist with the diagnostic workup but should be used at the discretion of the treating oncologic specialists.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

History of Growth. Moderate strength evidence supports that, in patients suspected of soft-tissue tumor recurrence, an MRI of the tumor site can reliably identify neoplastic tissue and differentiate between solid and cystic areas.

Strength of Recommendation: Moderate

Implication: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

In the absence of reliable evidence, it is the opinion of this work group that an MRI should be considered, and is the preferred advanced imaging study, in patients with a clear history of rapid growth of a bone or soft-tissue mass.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

In the absence of reliable evidence, it is the opinion of this work group that contrast-enhanced CT scan of the site should be considered in patients with a clear history of rapid growth of a bone or soft-tissue mass when there are patient-specific contraindications to MRI, such as a pacemaker or cerebral aneurysm clips.

Strength of Recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.'

In the absence of reliable evidence, it is the opinion of this work group that, in the setting of a bone or soft-tissue tumor of unknown etiology with rapid growth, CT of the chest/abdomen/pelvis, PET-CT, and Tc99 bone scan may assist with the diagnostic workup but should be used at the discretion of the treating oncologic specialists.

Strength of Recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

Tumor Size: Strong evidence supports the use of MRI imaging for a bone or soft-tissue tumor of unknown etiology with a size greater than 5 cm to assist with obtaining a diagnosis and planning further treatment.

Strength of recommendation: Strong

Implication: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

In the absence of reliable evidence, the work group recommends that, in aggressive-appearing bone or soft-tissue tumors, advanced imaging studies be requested with the guidance of an orthopaedic oncologist or musculoskeletal radiologist.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

Indications for Staging Studies

Chest Radiograph Before Chest CT. In the absence of reliable evidence, it is the opinion of the work group that performing a chest radiograph is not necessary before a chest CT in the staging of a bone or soft-tissue malignancy.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

Staging CT Scan. In the absence of reliable evidence, it is the opinion of the work group that CT chest/abdomen/pelvis scans performed in patients with a destructive bone lesion highly suspicious for metastatic disease of bone should use oral and IV contrast.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

In the absence of reliable evidence, it is the opinion of the work group that staging CT scans in the setting of a destructive bone lesion should be ordered by, or in consultation with, an oncology specialist.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

Technical Aspects of Cross-sectional Imaging Studies

Use of Contrast in MRI. Strong evidence supports that contrast enhancement on MRI can assist in determining whether a soft-tissue tumor is benign or malignant.

Strength of recommendation: Strong

Implication: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

Strong evidence supports that a heterogeneous signal in a contrast-enhanced MRI can assist in determining whether a soft-tissue tumor is benign or malignant.

Strength of recommendation: Strong

Implication: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

In the absence of reliable evidence, it is the opinion of the work group that IV contrast does not offer any advantages for detecting tumor presence over a noncontrast study.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

Magnet Strength in MRI. In the absence of reliable evidence, it is the opinion of the work group that a magnet of at least 1.5 Tesla should be used when imaging musculoskeletal neoplasms.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

Area to Visualize in MRI and CT. In the absence of reliable evidence, it is the opinion of the work group that MRI or CT scans performed to visualize a potentially malignant bone tumor should include a detailed assessment of the tumor and surrounding soft tissue, with additional sequences that visualize the entire bone compartment, from the proximal joint to the distal joint.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

In the absence of reliable evidence, it is the opinion of the work group that MRI or CT scans performed to visualize a soft-tissue tumor should include a detailed assessment of the tumor and surrounding soft tissue, including complete visualization of enhancement along fascial planes and peritumoral edema.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

Use of Ultrasonography in Extremity Tumors

Moderate evidence supports that ultrasonography helps to distinguish benign from malignant soft-tissue tumors.

Strength of Recommendation: Moderate

Implication: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

In the absence of reliable evidence, it is the opinion of the work group that ultrasounds in small (<5 cm), superficial soft-tissues tumors can help distinguish between benign lipomas, vascular malformations, cystic structures, and solid tumors that require further characterization.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

In the absence of reliable evidence, it is the opinion of the work group that ultrasonographies in large (>5 cm), deep soft-tissue tumors are unlikely to adequately assess the benign or malignant nature of the lesion and should not be the imaging modality of choice.

Strength of recommendation: Consensus

Implication: In the absence of reliable evidence, practitioners should remain alert to new information because emerging studies may change this recommendation. Practitioners should weigh this recommendation with their clinical expertise and be sensitive to patient preferences.

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