Use of Imaging Prior To Referral Of Musculoskeletal Specialist

Publication Date: February 1, 2018
Last Updated: March 14, 2022

Recommendations

PLAIN RADIOGRAPHS

A. Moderate evidence supports using conventional radiographs in the initial evaluation of a bone tumor of unknown etiology. (M)
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B. 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. (C)
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MRI: USE OF CONTRAST

A. Strong evidence supports that contrast enhancement on MRI can assist in determining if a soft tissue tumor is benign or malignant. (S)
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B. Strong evidence supports that a heterogenous signal in a contrast-enhanced MRI can assist in determining if a soft tissue tumor is benign or malignant. (S)
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C. 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 non-contrast study. (C)
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MRI: MAGNET STRENGTH

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. (C)
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MRI AND CT SCANS: AREA TO VISUALIZE

A. 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. (C)
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B. 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. (C)
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CT SCANS: STAGING

A. 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. (C)
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B. 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. (C)
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CT SCANS: PRIOR CHEST RADIOGRAPH

In the absence of reliable evidence, it is the opinion of the work group that it is not necessary to perform a chest radiograph prior to a chest CT in the staging of a bone or soft tissue malignancy (C)
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ULTRASOUND

A. Moderate evidence supports that ultrasound helps to distinguish benign from malignant soft tissue tumors. (M)
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B. 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. (C)
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C. In the absence of reliable evidence, it is the opinion of the work group that ultrasounds in large (>5 cm), deep soft tissues tumors are unlikely to adequately assess the benign or malignant nature of the lesion and should not be the imaging modality of choice. (C)
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HISTORY OF PAIN

A. 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. (M)
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B. 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. (L)
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C. 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 complaint of pain at the site of the identified tumor. (C)
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D. 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. (C)
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E. 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 complaint 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 utilized at the discretion of the treating oncologic specialists. (C)
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HISTORY OF GROWTH

A. 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. (M)
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B. 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. (C)
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C. 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. (C)
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D. 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 utilized at the discretion of the treating oncologic specialists. (C)
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TUMOR SIZE

A. 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. (S)
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B. 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 orthopedic oncologist or musculoskeletal radiologist. (C)
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CORTICAL IRREGULARITY/PERIOSTEAL REACTION

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

Overview

Title

Use of Imaging Prior Referral To A Musculoskeletal Oncologist

Authoring Organizations

American Academy of Orthopaedic Surgeons

Pediatric Orthopaedic Society

Publication Month/Year

February 1, 2018

Last Updated Month/Year

January 22, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physical therapist, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D010016 - Osteoma, D018204 - Neoplasms, Connective and Soft Tissue, D012509 - Sarcoma

Keywords

musculoskeletal oncology, soft tissue tumor, bone tumor, osteoid osteoma, soft tissue neoplasm, sarcoma

Supplemental Methodology Resources

Systematic Review Document

Methodology

Number of Source Documents
159
Literature Search Start Date
April 6, 2016
Literature Search End Date
February 2, 2017