Gastric Emptying Scintigraphy: SNM Recommendation

Facts: Gastric Emptying Scintigraphy

• Performed to evaluate patients with symptoms suggesting alteration of gastric emptying or motility
• Provide physiologic, noninvasive, quantitative measurement of solid or liquid gastric emptying
• Used to diagnose delayed gastric emptying (ie, gastroparesis) or rapid emptying (dumping syndrome)

Factors affecting gastric emptying (potentially creating false-positive or false-negative tests)

• Medications: prokinetics (shorten gastric emptying), narcotic analgesics (prolong gastric emptying)
• Tobacco smoking (prolong gastric emptying)
• Hyperglycemia (prolong gastric emptying)
• Premenopausal status (prolong gastric emptying)

Standards for performing GES as recommended by Society of Nuclear Medicine (SNM)

• Full recommendation paper (link) provides recommended timing of imaging, composition of meal, glycemic control, monitoring of symptoms and assessment of severity
• Low-fat, egg white meal
• Imaging at a minimum at 0,1,2 and 4 hours after radiolabeled meal ingestion

Who Should Get CT Screening for Lung Cancer? USPSTF Reveals

Who Should Get CT Screening for Lung Cancer?

• Adults 55-80 years with a 30 pack-year smoking history AND currently smoke
• Adults 55-80 years with a 30 pack-year smoking history AND have quit within the past 15 years

Screening Should Be Discontinued If:

• Once a person has not smoked for 15 years
• Once a person develops a health problem that substantially limits life expectancy or ability/willingness to have curative lung surgery

Reference:

Moyer VA on behalf of the U.S. Preventive Services Task Force. 

Moyer VA et al. Screening for lung cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2013 Dec 31; [e-pub ahead of print]. 

Criteria and Consensus Method for Blunt Cervical Vascular Injury (BCVI) Screening with Imaging

According to the updated Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries (published on March 2013, Neurosurgery 2013;72), 

• Computed tomography is the imaging study of choice for obtunded or un-evaluable patients with potential cervical spine injuries. (Level I)
• Computed tomographic angiography is recommended to assess for vertebral artery injury in selected patients who meet the modified Denver Screening Criteria after blunt cervical trauma. (Level I)

Currently accepted standard used for BCVI screening is that of Modified Denver Criteria applying to acute trauma patients suffering blunt cervical vascular injury with details listed below. In this post, they have been rearranged from the original description.

Injury Mechanisms/Patterns

• High-energy mechanism causing 1) displaced Le Fort II or III, or 2) complex mandible fracture
• Cervical hyperextension/rotation/flexion injury with 1) midface fracture, 2) complex mandible fracture or 3) closed-head injury and diffuse axonal injury

Symptoms

• Massive epistaxis
• Central or lateralizing neurologic deficit that is unexplained or incongruent with CT
• Transient ischemic attack or stroke after blunt neck trauma

Signs

• Expanding neck hematoma
• Honor syndrome
• Cervical vascular bruit in a patient less than 50 years old with blunt neck trauma
• Seat belt abrasion, hanging bruise, or unexplained contusion or hematoma of neck, resulting in significant cervical swelling or altered mental status

Findings on C-spine NCCT

• Upper cervical vertebral fracture (C1-C3)
• Cervical vertebral fracture extending through the transverse foramen
• Cervical vertebral subluxation
• Cervical spine fracture with cervical hyperextension/rotation/flexion injury

Findings on head NCCT

• Acute or subacute cerebral infarction
• Skull base fracture involving foramen lacerum, sphenoid, mastoid, or petrous bones

References: 

1. Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg 1999;178:517–22; 
2. Cothren CC, Moore EE, Biffl WL, et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 2003;55:811–3.
3. Neurosurgery 2013;72 Supplement 2. Full-text access is FREE

Updated Nomenclature of Vasculitides

A sagittal-curved-reformatted CT image of the aorta of a 31-year-old man demonstrate extensively calcified intima and focal narrowing of the mid/distal thoracic aorta, consistent with Takayasu arteritis.

Very recently, the international consensus conference addressed the revision of the nomenclature of systemic vasculitides as follows:

• LARGE-vessel vasculitis: Takayasu arteritis and giant cell arteritis
• MEDIUM-vessel vasculitis: polyarteritis nodosa, Kawasaki disease
• SMALL-vessel vasculitis: ANCA-associated vasculitis (microscopic polyangiitis, Wegener, Churg-Strauss), immune complex vasculitis 
• VARIABLE-vessel vasculitis: Behcet disease, Cogan syndrome
• SINGLE-ORGAN vascuiltis: cutaneous leukocytoclastic angiitis, primary CNS vasculitis, and others
• Vasculitis associated with systemic diseases such as lupus, rheumatoid arthritis and sarcoid
• Vasculitis associated with probable etiology (e.g., associated with viral hepatitis, drugs) 

Categorization by vessel size reflects the arteries those are predominantly affected. Vasculitis in each category can affect any size artery. 

Reference:

Jennette JC, et al. 2012 revised international chapel hill consensus conference nomenclature of vasculitides. Arthritis Rheum 2013;65:1-11.

Superficial Femoral Vein: Misleading Medical Nomenclature

Anatomy and Definition of Superficial Femoral Vein (SFV)

• SFV, as understood by vascular surgeons and radiologists, is a continuation of the popliteal vein. After joining the deep femoral vein, it becomes common femoral vein
• Superficial femoral vein is actually a "deep" vein

The Problem

• Most vascular surgeons and radiologists understand that SFV is a deep vein, but many physicians in other specialty or general practitioners do not
• Based on a survey of multispecialty groups, only 24% of physicians would give anticoagulants to patients having "acute thrombosis of the superficial femoral vein". There is a misperception of many physicians that SFV is superficial vein, therefore it would not be treated as deep vein thrombosis

Recommendations: Don't Use "Superficial Femoral Vein". Use "Femoral Vein"

• Current consensus developed by experts in phlebology officially established “femoral vein” as the vein that originates from the popliteal vein and courses in the femoral canal and bluntly discarded “superficial femoral vein” as an “unauthorized term" … because it is a deep vein 
• SFV is not in the official Terminologica Anatomica
• The other vein is "deep femoral vein" or "profunda femoris vein"
• Supported by International Interdisciplinary Consensus Committee on Venous Anatomical Terminology convened on September 8–9, 2001 (Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg 2002; 36:416-422)
•  Supported by Society of Interventional Radiology

Reference:
Hammond I. The superficial femoral vein. Radiology 2003;229;604-666 (link)

USPSTF Recommends Against PSA-based Prostate Cancer Screening

In its newest Statement published yesterday in the Annals of Internal Medicine, the U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer. Read the full paper (free) here.

Prostate Cancer: Facts

• Most commonly diagnosed non-skin cancer in men in USA, estimated lifetime risk 15.9%
• Most cases have good prognosis even without treatment
• Lifetime risk of dying of prostate cancer 2.8%

Screening with PSA

• PSA-based screening programs detect many cases of asymptomatic prostate cancer but evidence suggests that many of them will not progress or will progress slowly that it would have remained asymptomatic for the lifetime
• "Overdiagnosis" of prostate cancer based on PSA is between 17-50% 
• Screening resulted in none or minimal reduction in prostate cancer mortality (0 to 1 prostate cancer deaths avoided per 1000 men screened)
• "False positivity" near 80% (cutoffs value 2.5-4 ug/L)

Recommendation

• Applies to men in general US population. Although older age is the strongest risk factor for development of prostate cancer, neither screening nor treatment trials show benefit in men older than 70 years
• Decision to initiate or continue PSA screening should be understood by patients about possible benefits and harms of screening

Recommendations of Others

• The American Urological Association, the American Academy of Family Physicians and the American College of Physicians: currently updating their guideline
• The American Cancer Society: men at average risk beginning at age 50 years and black men or men with a family history of prostate cancer beginning at age 45 years

Reference:

Annals of Internal Medicine May 21, 2012  LINK

ACR Appropriateness Criteria for Suspected Aortic Injury

Axial contrast-enhanced CT image shows a pseudoaneurysm (arrow), intimal flap and periaortic hematoma of the proximal descending thoracic aorta in a patient experienced severe blunt chest trauma.

A newly revised American College of Radiology (ACR)'s Appropriateness Criteria for blunt chest trauma - suspected aortic injury has been published in March 2012 in the journal Emergency Radiology, summary and useful points are provided below

• Chest x-ray remains an initial screening examination in patients who has sustained blunt chest trauma
• In the appropriate clinical setting and with a CXR demonstrating mediastinal widening or other signs of mediastinal hemorrhage, thoracic aortography or helical chest CT is indicated
• CTA is emerging as a very sensitive and specific examination for aortic injury and has replaced aortography in many trauma centers

Useful Points

• Mediastinal widening has been defined as a transverse diameter of 8 cm from the left side of aortic arch to the right margin of the mediastinum (even on AP portable CXR)
• Mediastinal widening is 90% sensitive but 10% specific for aortic injury
• Approx 7% of patients with aortic injury have normal initial CXR
• If no mediastinal hematoma seen on CT, probability of significant aortic injury is very low

Reference

Demehri S, et al. ACR Appropriateness Criteria blunt chest trauma--suspected aortic injury. Emerg Radiol 2012 (published online: 18 Mar 2012)

Predictors of Cervical Spine Fractures and Fracture Risk

Flow diagram (originally published by Blackmore CC, et al, Radiology 1999) demonstrating a prediction rule for determination of risk of cervical spine fracture in blunt trauma patients. Percentages indicate the risk of fracture for each group with 95% CIs. Area under the ROC curve = 0.87

Facts:

• Three common options exist to "clear" cervical spine in trauma patients: clinical evaluation, radiography or CT
• Canadian C-spine Rule (CCR) or NEXUS criteria are generally used by emergency physicians and trauma surgeons to determine which patients require imaging clearance
• Among patients who, based on CCR or NEXUS, need imaging clearance: an issue exists whether to choose x-ray vs. CT
• In general, CT is preferred for patients with moderate or high likelihood of having C-spine injury given its higher accuracy, cost-effectiveness and ease of performance. However, C-spine CT has not been tested as cost-effective among patients with low likelihood of C-spine injury - practice has been different from one place to another

According to Blackmore CC, et al

• We can stratify patients into groups of different fracture probabilities by using 4 predictors: severe head injury, high-energy cause, age and focal neurologic deficit
• Definition of severe head injury = intracranial hematoma, brain contusion, skull fracture or unconsciousness
• Definition of high-energy cause = high-speed MVC (greater than 30 mph), pedestrian struck by car
• Definition of moderate-energy cause = low-speed MVC, MVC at unknown speed, bicycle accident, motorcycle accident or fall
• Definition of focal deficit = those that could be in a spinal cord or spinal nerve distribution

Reference:

Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use. Radiology 1999; 211:759-765.

2010 McDonald MRI Criteria for Diagnosis of Multiple Sclerosis

Diagnosis of Multiple Sclerosis (MS)

• Clinical + paraclinical lab assessment
• Need to demonstrate dissemination of lesions in space (DIS) and time (DIT), and exclude other diagnoses
• Since the last McDonald Criteria (2005-version), new data and consensus have agreed upon simplification of the criteria to improve comprehension and utility
• McDonald Criteria should only be applied in patients presenting with a typical clinically isolated syndrome suggestive of MS, or symptoms consistent with a CNS inflammatory demyelinating disease
• Clinical isolated syndrome typically involve the optic nerve, brainstem/cerebellum, spinal cord or cerebral hemispheres; can be monofocal or multifocal

MR Imaging Criteria for DIS / DIT

• At least one T2 lesion in at least 2 of 4 locations considered characteristic for MS (juxtacortical, periventricular, infratentorial, and spinal cord)
• A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, with reference to a baseline scan, irrespective of the timing of the baseline MRI
• Simultaneous presence of asymptomaatic gadolinium-enhancing and nonenhancing lesions at any time

Read full article here.

Reference:

Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald Criteria. Ann Neurol 2011;69 (first published online 8 Mar 2011)

Nuclear Accident And Potassium Iodide

Given the current situation in Japan, some of you may be interested in this topic.

The full FAQ is located at the National Regulatory Committee (NRC) website, here.

Potassium Iodide

• Blocks thyroid uptake of radioactive iodine, therefore it reduces the risk of thyroid cancers that might be caused by exposure to radioactive iodine that could be dispersed in a severe nuclear accident
• It is ingested, then taken up by thyroid gland -- if taken in a proper dosage at an appropriate time, it saturates the thyroid gland so that inhaled or ingested radioactive iodine will not be accumulated in the thyroid
• Two KI tablets will protect the thyroid gland for approx 48 hours
• Population within 10 mile emergency planning zone to the nuclear power plant are at the greatest risk of exposure to radiation, therefore KI is provided to protect them from effect of exposure after an accident
• Best protective measures for nuclear accident are evacuation and sheltering. KI tablets are used to supplement evacuation or sheltering

Image from www.ask.com

ACR-Proposed Premedication Regimen to Reduce Contrast Reactions

According to the version #7 (2010) ACR Manual on Contrast Media, the following regimens are recommended for premedication of patients at risk for developing contrast reaction.

Elective Premedication

1. Prednisolone: 50 mg PO at 13 hours, 7 hours and 1 hour before contrast media injection, PLUS Diphenhydramine 50 mg IV, IM or PO 1 hour before contrast medium OR
2. Methylprednisolone 32 mg PO 12 hours and 2 hours before contrast media injection. An anti-histamine (as in option 1) can be added. If unable to take oral medication, use hydrocortisone 200 mg IV instead

Emergency Premedication

1. Methylprednisolone 40 mg or hydrocortisone 200 mg IV every 4 hours until contrast study required PLUS Diphenhydramine 50 mg IV 1 hour prior to contrast injection OR
2. Dexamethasone 7.5 mg or betamethasone 6 mg IV every 4 hours until contrast study PLUS diphenhydramine 50 mg IV 1 hour prior to contrast injection OR
3. Omit steroid entirely and give diphenhydramine 50 mg IV

"IV steroids have not been shown to be effective when administered less than 4 to 6 hours prior to contrast injection."

Reference:

ACR Manual on Contrast Media (7th version, 2010)

Appropriate Use Criteria for Cardiac CT (2010)

On its update published in the Journal of the American College of Cardiology, the appropriate indications for cardiac CT are greatly expanded but they are closely related to the results of prior test (i.e., ECG, biomarkers), pretest probability of CAD and ability of patients to exercise.

For the detection of coronary artery disease (CAD), many indications are considered appropriate:

1. Symptomatic patients with nonacute symptoms possibly representing an ischemic event -- when the patient has intermediate probability of CAD, or low probability but unable to exercise or ECG uninterpretable

2. Symptomatic patients with acute symptoms suspicious of acute coronary syndrome -- when there is a low or intermediate probability

3. CAD/Risk assessment in asymptomatic individuals (coronary calcium scoring)

4. New-onset or newly diagnosed clinical heart failure and no prior CAD

5. Preoperative coronary assessment prior to noncoronary cardiac surgery

This is just a small part of the recommendation, please follow the link to get to the full paper.

Reference:

ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. J Am Coll Cardiol 2010;56:1864-1894.

Image Wisely Campaign Launched

Image Wisely is a campaign to encourage imaging providers to

• Optimize imaging examinations to use only the radiation necessary to produce diagnostic quality images
• Convey messages to the imaging team to ensure that the facility optimizes its use of radiation when imaging patients
• Communicate optimal patient imaging strategies to referring physicians, and be available for consultation
• Routinely review imaging protocols to ensure the use of the least amount of radiation necessary to acquire a diagnostic quality image for each exam

Image Wisely is a collaborative initiative of the ACR, RSNA, ASRT and AAPM

Imagine Wisely campaign initially focuses on CT

Take the PLEDGE

More information: www.imagewisely.org

ACR Appropriateness Criteria on Colorectal Cancer Screening

Rationale for Colorectal Cancer Screening

• Colorectal cancer is the 2nd leading cause of cancer death in the USA
• Treatment for localized disease is associated with high survival rate
• Almost all colorectal cancers develop from benign adenomas and this process is slow (average of 10 years)

Current Screening Recommendation

• By WHO, US Agency for Health Care Policy and Research, US Preventive Service Task Force: 4 options = annual or biennial fecal occult blood test (FOBT), flexible sigmoidoscopy every 5 years, double-contrast barium enema (DCBE) every 5 years, and colonoscopy every 10 years
• By the American Cancer Society (jointly issued with the US Multi-Society Task Force on Colorectal Cancer and the ACR): adding CT colonography (CTC) every 5 years as an option

ACR Appropriateness Criteria Rating

• Average-risk individual, age greater than 50 years: CTC every 5 years after negative screen (rate 8), DCBE every 5 years after negative scan (rate 7)
• Average-risk individual after positive FOBT indicating relative elevation in risk: CTC every 5 years after negative scan (rate 8), DCBE every 5 years after negative scan (rate 7)
• Individual of any risks after incomplete colonoscopy: CTC (rate 9), DCBE (rate 7)
• High-risk individual with hereditary nonpolyposis colorectal cancer, ulcerative colitis or Crohn's colitis: colonoscopy preferred for ability to obtain biopsies to look for dysplasia

Reference:

Yee J, Rosen MP, Blake MA, et al. ACR appropriateness criteria on colorectal cancer screening. JACR 2010; 7:670-678.

Measuring Radiologist Productivity

What is Productivity?

• "Hourly worker output"
• Productivity in physician practice reflects efficiency with which work is performed
• Productivity gain closely correlates with health of overall economy, rising living standards and growth of real wages

Why Measuring Productivity?

• Practice of radiologists has changed from traditional, small (less than 10 members) group to larger groups with subspecialization.
• Increase employment of part-time radiologists
• These factors result in difference in case mix, on-call demands and increased difficulty of informal monitoring of each radiologist's work

How?

• Several methods exist including using revenue, hours worked, volume of examination and Relative Value Units (RVUs)
• Because RVUs combine many facets of other methods (volumes, hours) and easily/timely availability, it is most widely used as an indicator of radiologist productivity
• RVUs are work component of professional Resource-Based Relative Value Scale per time period. Each Current Procedural Terminology (CPT) code is assigned an RVU for physician work (wRVU) as well as RVU for practice and malpractice expenses.
• wRVUs are intended to reflect time and effort expended by radiologists to perform services

Reference Authors' Recommendations

• Quoted from the below reference, authors are from Mass. General Hospital in Boston and Sloan School of Management at MIT
• RVUs seem to be the most reasonable means to evaluate radiologist productivity, however practices may elect to monitor more than one productivity measures because no single measure is perfect
• Authors recommend measuring "team-based" RVUs rather than individual's. This is to value members who perform duties with lower RVU assignment or no RVUs (i.e., consultation, conference participation, administration, teaching)
• Productivity measures reporting should be coupled with quality metrics

Reference:

Ding A, Saini S, Berndt ER. Radiologist productivity: what, why, and how. JACR 2009;6:824-827.

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2009 Non-Small Cell Lung Cancer Staging System (3)

Click the image to view a larger version

As a radiologist, it may be easier to memorize "T" classification based on imaging appearance. The scheme below may be used as a guidance to stage these tumors, however a full text of the New Staging System should be reviewed for comprehensiveness.

1. Peripheral mass abutting chest wall or diaphragm --- see if there is evidence of invasion of chest wall or diaphragm (T3)
2. Peripheral mass, distal to lobar bronchus, completely surrounded by lung --- measuring size (less than 3cm = T1, 3-7cm = T2, more than 7cm = T3)
3. Mass distal to 2 cm from the carina but proximal to lobar bronchus --- T2 by definition
4. Endobronchial mass: distal to 2 cm from the carina = T2; within 2 cm from the carina = T3
5. Central mass with postobstructive pneumonitis or atelectasis: lobar or segmental = T2;entire lung = T3
6. Central mass abutting the mediastinum: invade mediastinal pleura, parietal pericardium = T3; diaphramatic paralysis (phrenic nerve involvement) = T3; invade heart, great vessels, trachea, esophagus, carina, vertebral body = T4
7. Additional malignant lung nodules: same lobe = T3; ipsilateral different lobe = T4; contralateral = M1a
8. Malignant pleural effusion or pleural nodule = M1a

Reference:

Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest 2009:136;260-271.

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2009 Non-Small Cell Lung Cancer Staging System (2)

Axial CT images show a large mass (stars) in the left lower lobe with a large left pleural effusion with focal pleural thickening (arrowheads). The lung mass is better seen on a post-thoracentesis image. Transbronchial biopsy revealed adenocarcioma and pleural fluid cytology confirmed the presence of malignant cells. Based on the new staging system, this patient has at least M1a disease.

Based on multiple data sources and available clinical outcome (overall survival), additional schemes to stage NSCLC are implemented in this 7th edition. The subgroups and staging grouping are based on the overall survival as a major determinant. For example, overall survival of patients with "satellite nodule in the same lobe" is similar to those with T3 -- therefore it is classified as T3.

What Have Changed in the New Edition?

• Additional "satellite nodule in the same lobe" now classified as T3 (previously T4)
• Additional "satellite nodule in the different ipsilateral lobe" now classified as T4 (previously M1)
• No change in N staging, but a new node map has been developed to address the issue of boundaries between different nodal stations
• M staging is now subdivided into M1a and M1b to address significantly different prognosis: "contralateral pulmonary nodule (malignant)" and "pleural dissemination" now classified as M1a; distant metastasis as M1b

Reference:

Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest 2009;136:260-271.

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2009 Non-Small Cell Lung Cancer Staging System (1)

Click the image to view a larger version

The latest (7th edition) version has been accepted by the UICC (Union Internationale Contre le Cancer) and the AJCC (American Joint Committee on Cancer) and was published earlier this year.

Non-Small Cell Lung Cancer (NSCLC) Staging System

• Based solely on anatomic extent of disease (clinical symptoms or molecular behavior of tumors not included)
• T = tumor; increasing T meaning larger tumor or invasive into more peripheral or central structures
• N = lymph node location (not number)
• M = metastasis
• Two methods of staging = clinical (c) and pathological (p); clinical staging includes all information available PRIOR to any treatment (including invasive staging technique); pathological staging include information AFTER a resection

Sources of Data for the 7th Edition

• 81,015 included cases from 45 sources in 20 countries
• Only NSCLC included
• Major determinant is the overall survival

Reference:

Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest 2009;136:260-271.

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An Expert's Response to the Recent USPSTF Recommendations for Mammography

A recent release of the US Preventive Services Task Force (USPSTF) recommendations for breast cancer screening has brought about so many controversies. Below is the summary view of Dr. Daniel B. Kopans, a Mass General radiologist and Harvard professor, internationally known as a breast imaging expert:

Mass General Imaging believes that the USPSTF recommendations are based on flawed analysis of the data and continues to support the scientifically based recommendations of the American Cancer Society for the early detection of breast cancer:

1. Annual mammographic screening should begin at age 40
2. Women at high risk for developing breast cancer should have annual MRI screening in addition to mammography

View full article by Dr. Kopans (MGH Radiology Rounds) HERE

Read more controversies in the New York Times and Washington Post

Read where the American College of Radiology stands

Additional opinions from the New England Journal of Medicine (November 25, 2009)
- Screening mammography and the "R" word
- On mammography - more agreement than disagreement

New Guidelines for Cervical Cytology Screening Released

The American College of Obstetricians and Gynecologists (ACOG) released its new clinical management guidelines for cervical cytology screening today.

New Recommendations

• Screening should begin at age 21 years (previously at the age of first sexual intercourse)
• Frequency of screening: every two years for women aged 21-29 years; for women aged 30 and older -- if results have been negative for intraepithelial lesions and malignancy for three times they may be screened at every three years
• More frequent screening may be done in high-risk groups including: HIV infection, immunosuppression, exposure to diethylstilbestrol in utero, previously treated for CIN2, CIN3 or cancer
• Discontinue screening: at either 65 or 70 years in women with three or more negative cytology test results in a row and no abnormal results in the past 10 years; immediately after total hysterectomy for benign indications and no prior history of high-grade CIN
• Both liquid-based and conventional methods for cervical cytology are acceptable for screening
• Co-testing with a combination of cytology and HPV DNA testing: appropriate for women older than 30 years.

Full text from the ACOG (Free)

New York Times story (Free)