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## Complete Summary

#### GUIDELINE TITLE

Staging of testicular malignancy.

#### BIBLIOGRAPHIC SOURCE(S)

Papanicolaou N, Francis IR, Baumgarten DA, Bluth EI, Bush WH Jr,
Casalino DD, Curry NS, Israel GM, Jafri SZ, Kawashima A, Remer EM,
Sandler CM, Spring DB, Fulgham P, Expert Panel on Urologic Imaging.
Staging of testicular malignancy. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2007. 6 p. \[60 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Choyke PL, Bluth EI, Bush WH
Jr, Casalino DD, Francis IR, Jafri SZ, Kawashima A, Papanicolaou N,
Rosenfield AT, Sandler CM, Segal AJ, Tempany C, Resnick MI, Expert Panel
on Urologic Imaging. Staging of testicular malignancy. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2005. 6
p. \[57 references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Testicular cancer

#### GUIDELINE CATEGORY

Evaluation

#### CLINICAL SPECIALTY

Nuclear Medicine\
Oncology\
Radiology\
Urology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of radiologic procedures for patients
with testicular cancer

#### TARGET POPULATION

Patients with testicular cancer

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Computed tomography (CT)

    -   Abdomen and pelvis

    -   Chest

2.  X-ray

    -   Chest

    -   Abdomen

    -   Intravenous urography

3.  Magnetic resonance imaging (MRI), abdomen and pelvis

4.  Fluorodeoxyglucose positron emission tomography (FDG-PET)

5.  Nuclear medicine (NUC), bone scan whole body

6.  Invasive (INV) lymphangiography, bipedal, abdomen and pelvis

7.  Ultrasound (US)

    -   Scrotum (gray-scale)

    -   Abdomen, retroperitoneal

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic procedures in staging of testicular malignancy

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by this Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Staging of Testicular Malignancy**

**Variant: Testis tumor (diagnosed by orchiectomy)**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  CT abdomen and pelvis 9                                              High

  X-ray chest           8                                              Min

  CT chest              7                                              Med

  MRI abdomen and       5            Alternative method of imaging     None
  pelvis                             nodes if CT is indeterminate or   
                                     technically unsatisfactory. See   
                                     comments regarding contrast in    
                                     text under \"Anticipated          
                                     Expectations.\"                   

  FDG-PET whole body    4            Most likely indicated for         High
                                     follow-up of residual or          
                                     recurrent disease/differentiation 
                                     of residual nonseminomatous tumor 
                                     from mature teratoma.             

  NUC bone scan whole   3                                              Med
  body                                                                 

  US abdomen            3            In patients with lean or average  None
  retroperitoneal                    body habitus it is worth trying   
                                     to visualize the retroperitoneum. 

  INV lymphangiography  2                                              IP
  abdomen and pelvis                                                   
  bipedal                                                              

  US scrotum gray-scale 2            Essential for initial diagnosis,  None
  only                               usually not useful for staging.   
                                     If questionable for opposite      
                                     testes.                           

  X-ray abdomen         1                                              Low

  X-ray intravenous     1                                              Low
  urography                                                            

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

**Summary of the Literature**

Although carcinoma of the testicle is relatively uncommon, representing
only 1% of all malignancies occurring in men, it is the most frequent
malignancy in men between the ages of 20 and 35 and accounts for 11% to
14% of all deaths due to cancer in the 25 to 34 year age group. The
American Cancer Society estimates that in 2005, over 8,000 men will be
diagnosed with the disease and that the number of deaths secondary to
testicular cancer will be 390.

Over 90% of testicular tumors are of germ cell origin and are malignant.
Of these, 40% are seminoma. The nonseminomatous tumors include embryonal
cell carcinoma (15%--20%), teratoma (5%--10%) and choriocarcinoma (less
than 1%). Non-germ-cell tumors are typically benign and have their
origin from the Leydig and Sertoli cells or from connective tissue
stroma.

Various staging systems have been used for staging patients with
testicular cancer, but most commonly the American Joint Commission on
Cancer\'s staging and end-results reporting are used (see Appendix 1 in
the original guideline document).

Testicular tumors spread or metastasize by either the hematogenous or
lymphatic route. Most follow the regional lymphatic chain alongside the
spermatic vessels. Typically, the first order of metastases is the
\"sentinel\" lymph node, which on the left is located at the renal hilar
region and on the right in the paracaval region below the renal artery
and vein. Left-sided tumors typically spread to the periaortic nodes and
preaortic nodes, and right-sided tumors most commonly involve
interaortocaval, precaval, and preaortic nodes. Crossover is not
uncommon, but typically is from the right to the left. Further drainage
is through the thoracic duct, resulting in more widespread metastases.

**Tumor Markers**

Tumor markers such as alpha-fetoprotein (AFP) and beta-human chorionic
gonadotropin (β-hCG) are helpful not only in diagnosing patients with
testicular tumors but in staging them as well. Approximately 90% of
patients with advanced nonseminomatous tumors will have elevated levels
of one or both of these markers.

AFP is elevated in approximately 50% to 70% of those with embryonal cell
carcinoma, yolk sac carcinoma, or tumors of mixed composition. β-hCG is
elevated in 40% to 60% of patients with testicular cancer, including all
those with choriocarcinoma, 80% of those with embryonal cell carcinoma,
and 10% to 25% of those with histologically pure seminoma. An elevated
AFP is never found in pure seminomas or choriocarcinomas.

The obtaining of tumor markers before and after orchiectomy is also very
helpful in determining whether any residual disease is present and in
planning further therapy. Additionally, tumor markers are essential in
the follow-up evaluation to assess both the need for and response to
therapy (e.g., chemotherapy).

A number of patients with nonseminomatous tumors post-treatment may
develop retroperitoneal masses of relatively low attenuation, which
represent mature teratoma (differentiated teratoma in the British
literature) rather than lymphadenopathy, new or residual. This process
is benign; however, the tumors continue to grow over time and may result
in significant morbidity due to its bulk. Mature teratoma is treated by
surgical resection. Differentiation between mature teratoma and residual
or recurrent lymphadenopathy may be possible by measuring serum marker
levels. Treatment options may differ depending on the histology of the
mass(es). CT and, often, MRI cannot reliably separate the two entities,
which may sometimes coexist.

**Imaging Studies**

Many imaging studies have been used in assessing patients with
testicular tumors. In years past, intravenous urography was commonly
used for staging purposes; however, with the development of newer
techniques the use of this imaging study is of historical interest for
this purpose. Studies used today to assess the retroperitoneum include
abdominal ultrasonography (US), CT, MRI, and pedal lymphangiography.
Studies used to assess pulmonary disease include chest x-ray and chest
CT. US continues to be used preferentially for assessing the primary
tumors.

**Ultrasonography**

Scrotal ultrasonography is frequently used, and should always be the
initial imaging modality, in assessing patients with scrotal masses.
This study can often differentiate fluid-filled spermatoceles and
hydroceles from solid intratesticular tumors. Oftentimes, the diagnosis
is apparent by clinical evaluation, and ultrasound can be used for
confirmation and for local staging. The finding of testicular
microlithiasis should increase the suspicion of testicular malignancy,
and if none is found periodic follow-up is recommended.

With the development of newer imaging studies, (e.g., CT) staging with
US has found little application in the assessment of patients with some
metastatic testicular tumors to the retroperitoneum. Unfortunately, US
is operator-dependent, making the uniformity and the reproducibility of
the study less than would be desirable. Additionally, because of the
interference of overlying intestinal gas and obesity, this study is
nondiagnostic in approximately 15%--17% of patients.

**Computed Tomography**

CT is the most common study used for assessing the retroperitoneum for
the presence of metastatic testicular malignancy. This study is
noninvasive and reproducible and provides excellent imaging of the
periaortic and pericaval regions. Difficulties with CT are that many
young men have little retroperitoneal fat, which tends to be an
impediment to the study, and that CT cannot detect the presence of
metastatic disease in lymph nodes of normal size. Additionally,
inflammatory lymph nodes cannot be differentiated from those that are
enlarged secondary to malignant disease.

CT interpretation is aided by understanding the lymphatic drainage of
the testicles. Node involvement is usually limited to the side of the
primary tumor, and crossover is usually present only in the presence of
advanced disease. Various benign conditions have also been found to
mimic metastases from testicular tumors. Lymph nodes larger than 1 cm
are suspicious for metastatic disease, particularly if they are located
in the hilar regions of the kidney or in the periaortic or caval areas.
Various studies have established the accuracy of CT in detecting
metastatic retroperitoneal lymph nodes, which ranges from 73% to 97%.
Sensitivity ranges from 65% to 96% and specificity from 81% to 100%.
Experience also indicates that accuracy declines in patients with
limited disease (stage N1 and stage N2) and also if the upper limit of
normal lymph node size is lowered to 4 mm.

**Lymphangiography**

Lymphangiography is now rarely used because of its disadvantages, which
include its invasiveness, its inability to opacify the sentinel lymph
node, and its inability to demonstrate the upper limits of involvement
in patients with extensive disease. The accuracy of bipedal
lymphangiography has been shown to be comparable to that of CT and
varies from 62% to 89%. Sensitivity ranges from 54% to 90% and
specificity from 67% to 100%. Studies have also indicated that a
combination of lymphangiography and CT improves accuracy, but evidence
indicates that this approach is not cost-effective. Magnetic resonance
lymphangiography may have potential in the future, but experience is
still too limited and the agent, ferumoxtran, has not yet been approved
by the FDA for clinical use.

**Magnetic Resonance Imaging**

Magnetic resonance imaging has also been used in the staging of
testicular tumors; however, evidence indicates that it is comparable to
CT. MRI does offer an advantage, allowing for the differentiation of
blood vessels from lymph nodes, and it may also have the potential of
distinguishing residual tumor from fibrosis.

**Chest X-Ray**

Many studies have addressed the value of chest x-ray in assessing
pulmonary metastases. These studies indicate that chest x-ray alone is
satisfactory in the initial staging in patients with testicular
malignancies. Chest CT offers little in these patients; however, it may
offer slight benefit in those with more advanced disease. More recent
studies have suggested that initial and recurrent disease in the chest
can be detected on chest CT and that routine chest x-rays have a very
low yield for early disease and are not considered useful for initial
staging for follow-up after therapy.

**Radionuclide Imaging**

Radionuclide studies have limited value for detecting retroperitoneal
metastases. Radioimmunoassays for β-hCG and AFP the labeled antibodies
to these markers, show promise, but further experience with them is
needed. Gallium scintigraphy has also been used to detect metastatic
disease, but clinical experience is limited. Positron-emission
tomography (PET) imaging with 2-(F-18)-fluoro-2-deoxy-D-glucose (FDG)
has been used in assessing patients with testicular cancers and, though
its true value in staging patients has yet to be defined, initial
experience has been promising. In initial staging PET has proven only
slightly more sensitive than CT. Its use in follow-up for residual
masses is more controversial, with some authors recommending it
routinely to distinguish mature teratoma from residual disease and
others seeing no benefit in assessing residual masses. The study may be
most efficacious for assessing the presence of residual disease after
chemotherapy.

Bone scans can be useful in assessing early bone lesions before they are
detectable by CT, although one study suggests that FDG-PET scans are
more sensitive and can substitute for conventional bone scans.

**Summary**

In most instances, the diagnosis of testicular tumors is established
with a carefully performed physical examination and scrotal US. Tumor
markers are useful for determining the presence of residual disease, and
cross-sectional imaging studies (CT, MRI) are useful in determining the
location of metastases. FDG-PET scans are have a slightly higher
sensitivity than CT, but their role in staging testicular cancer has not
been determined in a large study. Bone scans are useful in the absence
of FDG-PET scans and should be used when bone metastases are suspected.

**Anticipated Exceptions**

Nephrogenic systemic fibrosis (NSF, also known as nephrogenic fibrosing
dermopathy) was first identified in 1997 and has recently generated
substantial concern among radiologists, referring doctors and lay
people. Until the last few years, gadolinium-based MR contrast agents
were widely believed to be almost universally well tolerated, extremely
safe and non-nephrotoxic, even when used in patients with impaired renal
function. All available experience suggests that these agents remain
generally very safe, but recently some patients with renal failure who
have been exposed to gadolinium contrast agents (the percentage is
unclear) have developed NSF, a syndrome that can be fatal. Further
studies are necessary to determine what the exact relationships are
between gadolinium-containing contrast agents, their specific components
and stoichiometry, patient renal function and NSF. Current theory links
the development of NSF to the administration of relatively high doses
(e.g., \>0.2mM/kg) and to agents in which the gadolinium is least
strongly chelated. The FDA has recently issued \"black box\" warning
concerning these contrast agents
(<http://www.fda.gov/cder/drug/InfoSheets/HCP/gcca_200705HCP.pdf>).

This warning recommends that, until further information is available,
gadolinium contrast agents should not be administered to patients with
either acute or significant chronic kidney disease (estimated GFR \<30
mL/min/1.73m^2^), recent liver or kidney transplant or hepato-renal
syndrome, unless a risk-benefit assessment suggests that the benefit of
administration in the particular patient clearly outweighs the potential
risk(s).

**Abbreviations**

-   CT, computed tomography

-   FDG-PET, fluorodeoxyglucose positron emission tomography

-   INV, invasive

-   IP, in progress

-   IVU, intravenous urography

-   Med, medium

-   Min, minimal

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with testicular malignancy

#### POTENTIAL HARMS

-   Computed tomography (CT) accuracy declines in patients with limited
    disease (stage N1 and stage N2) and also if the upper limit of
    normal lymph node size is lowered to 4 mm.

-   Lymphangiography is used with decreasing frequency because of its
    disadvantages, which include its invasiveness, its inability to
    opacify the sentinel lymph node, and its inability to demonstrate
    the upper limits of involvement in patients with extensive disease.

-   The relative radiation level is high for computed tomography (CT) of
    the abdomen and pelvis and fluorodeoxyglucose positron emission
    tomography (FDG-PET) of the whole body; medium for CT of the chest
    and nuclear medicine (NUC) bone scan of the whole body; and low for
    X-ray of the abdomen and X-ray intravenous urography.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologist, radiation oncologist, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Papanicolaou N, Francis IR, Baumgarten DA, Bluth EI, Bush WH Jr,
Casalino DD, Curry NS, Israel GM, Jafri SZ, Kawashima A, Remer EM,
Sandler CM, Spring DB, Fulgham P, Expert Panel on Urologic Imaging.
Staging of testicular malignancy. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2007. 6 p. \[60 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2007)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Urologic Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Nicholas Papanicolaou, MD; Isaac R. Francis, MD;
Deborah A. Baumgarten, MD, MPH; Edward I. Bluth, MD; William H. Bush,
Jr., MD; David D. Casalino, MD; Nancy S. Curry, MD; Gary M. Israel, MD;
S. Zafar H. Jafri, MD; Akira Kawashima, MD; Erick M. Remer, MD; Carl M.
Sandler, MD; David B. Spring, MD; Pat Fulgham, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Choyke PL, Bluth EI, Bush WH
Jr, Casalino DD, Francis IR, Jafri SZ, Kawashima A, Papanicolaou N,
Rosenfield AT, Sandler CM, Segal AJ, Tempany C, Resnick MI, Expert Panel
on Urologic Imaging. Staging of testicular malignancy. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2005. 6
p. \[57 references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/StagingofTesticularMalignancyDoc18.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx).

-   ACR Appropriateness Criteria®. Relative radiation level information.
    Reston (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/RRLInformation.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on March 7, 2006. This NGC
summary was updated by ECRI Institute on December 5, 2007.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx).

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008