This practice guideline serves as an update to the Canadian Association of Radiologists’ 2013 Technical Standards for Bone Mineral Densitometry Reporting. It aims to align bone mineral density testing and reporting practices in Canada with current clinical best practices, including guidelines from Osteoporosis Canada and the International Society for Clinical Densitometry. Key updates include the endorsement of both FRAX and CAROC tools for evaluating fracture risk, guidance for analyzing male patients and transgender patients, and provision of clinical management guidance of relevance to BMD reporting harmonized with that of Osteoporosis Canada. The document emphasizes the importance of accurate data collection in fracture risk assessment and provides recommendations for reporting fracture risk, T-scores, and clinical management strategies. Additionally, it outlines indications for baseline BMD testing and reassessment timelines, aiming to facilitate appropriate patient management and enhance bone health outcomes. This guideline is intended to complement existing standards and support healthcare professionals in delivering optimal care for patients undergoing BMD testing in Canada.

BACKGROUND AND OBJECTIVES:Stereotactic intracavitary irradiation of cystic sellar masses (CSMs) with 90-Yttrium colloid ( 90 Y) may mitigate significant morbidity and/or recurrence rates associated with traditional microsurgical resection. In this study, we aimed to prospectively assess the long-term effect of 90 Y on tumor-cyst volume, endocrine, and vision outcomes after treatment of CSMs. METHODS:We conducted a Health Canada-approved, phase II, open label, prospective clinical trial. The primary indication for treatment was clinical evidence of mass effect on initial presentation or subsequent cyst enlargement. Patients underwent right frontal stereotactic insertion of 90 Y (200 Gy to the cyst wall). Cyst volumes were measured using serial MRI. Visual field (VF) assessment and hypothalamic-pituitary hormone panel were obtained. Outcomes were collected postoperatively at 3, 9, and 24 months, then annually up to 5 years. RESULTS:Twenty-two patients (55% women, mean age = 63.6 years [SD 15.4]) received 90 Y. The mean follow-up was 52 months (5-113). Primary diagnoses were the following: craniopharyngioma (86%), Rathke cleft cyst (9%), and cystic prolactinoma (5%). Preoperative clinical features included VF deficit (41%), VF deficit plus headache (36%), or headache alone (13%). For the aggregate cohort, statistically significant reduction in mean tumor-cyst volume for the cohort was observed at all follow-up visits beyond 3 months (all P < .01). At 5-year follow-up, cyst volume reduction was sustained in 82% of cases. The mean percent reduction in tumor-cyst volume was 77.2% (SD 16.8). Ninety-one percent of patients had stable or improved vision postoperatively. The overall proportion of patients with endocrine dysfunction preoperatively (59%) and postoperatively (68%) remained stable ( P > .05). Treatment failure requiring conventional surgery occurred in 3 patients who received 90 Y for cyst recurrence. CONCLUSION:Stereotactic treatment of CSMs with intracavitary 90 Y is associated with sustained reduction in tumor-cyst volume, improved visual function, and stable endocrine function at 5-year follow-up.

Radiologists and other diagnostic imaging specialists play a pivotal role in the management of osteoporosis, a highly prevalent condition of reduced bone strength and increased fracture risk. Bone mineral density (BMD) measurement with dual-energy X-ray absorptiometry (DXA) is a critical component of identifying individuals at high risk for fracture. Strategies to prevent fractures are consolidated in the Osteoporosis Canada clinical practice guideline which was updated in 2023. In this guideline, treatment recommendations are based upon a consideration of fracture history, 10-year major osteoporotic fracture (MOF) risk, and BMD T-score in conjunction with age. The current review aims to familiarize radiologists and other diagnostic imaging specialists with the reporting requirements needed to support implementation of this guideline using the FRAX™ risk calculation tool. Fortunately, for specialists already familiar with the Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool, the transition to FRAX-based reporting is readily accommodated in a radiology workflow.

PURPOSE:To correlate parathyroid scintigraphy results with patient biochemistry, surgery, and pathology to inform appropriateness criteria and assess biochemical metrics in the imaging workup of hyperparathyroidism. METHODS:This retrospective study included 421 patients who underwent parathyroid scintigraphy. Patients were grouped based on primary versus secondary hyperparathyroidism, and clinical profiles were reviewed for scan result, blood work, surgical results, and pathology. Performance metrics of scintigraphy were analyzed. Demographics, bloodwork, and location were compared between positive and negative scans. Predictors of positive scans were identified by multivariate logistic regression analysis. The performance of biochemistry to predict scan results was evaluated by ROC analyses. RESULTS:Positive tests-occurring in 52% of patients-were associated with higher parathyroid hormone (PTH) and corrected calcium. However, PTH was only predictive of a positive test in patients with secondary hyperparathyroidism. On multivariate analysis, male sex, corrected calcium, and younger age were predictors of a positive scan. Corrected calcium was the most predictive with an OR of 1.28 for every 0.1 mmol/L increase. Based on ROC analysis, corrected calcium had an AUC of 0.628 and a cutoff of 2.65 mmol/L maximized sensitivity (88%) and specificity (35%) for a positive test. CONCLUSION:In this large retrospective cohort, several biochemical metrics, including corrected calcium levels, were predictive of a positive scintigraphy study. Furthermore, biochemistry, including PTH levels, significantly differed between primary and secondary hyperparathyroidism suggesting that tailored biochemical metrics are required. This work sets a foundation for the development of a robust biochemical scoring system to optimize patient selection for parathyroid imaging.

Recent advances in Rosai-Dorfman-Destombes disease (RDD), notably molecular testing, targeted therapy, and PET-CT imaging, hold promise for better recognition and improved outcomes. This study presents patients diagnosed and treated in a “real world” setting, where navigating limited resources must be considered. This retrospective single-center review includes 15 adult patients diagnosed with RDD at Vancouver General Hospital between November 2015 and October 2023. The cohort comprised five males and ten females with a median age 53 years (range 19–80 years). All 15 patients had extra-nodal disease; 11 patients exclusively had extra-nodal disease, and four patients also had lymph node involvement. Seven patients had tissue next-generation sequencing, identifying MAP2K1 mutations in four cases and a KRAS p.K117N mutation in one case that was treated with targeted therapy using trametinib. PET-CT was used for disease staging in four cases. Six patients with refractory disease tolerated lenalidomide and dexamethasone without significant toxicity; three patients achieved complete response, and three had partial response. This study highlights RDD's diverse extra-nodal manifestations. Lenalidomide combined with dexamethasone is an effective and well-tolerated treatment option for select patients, especially those with refractory disease. Broad utilization of NGS and PET-CT can positively influence management decisions.

Background: Due to high risk of recurrence and complications associated with microsurgical resection or aspiration of enlarging cystic sellar lesions, stereotactic intracavitary irradiation with 90Yttrium (90Yt) has been proposed as an alternative to mitigate these challenges. Long-term efficacy data for this procedure is lacking. Methods: We conducted a Health Canada approved, single-centre, prospective cohort study to assess the effect of 90Yt therapy on cyst volume, visual field (VF) testing and endocrine function. All patients underwent right frontal stereotactic insertion of 90Yt colloid (200 Gy cyst wall). Results: 22 patients [mean age = 63.5 (± 15.4) years] received 90Yt therapy. Mean follow-up was 52 (5-113) months. Cysts included: craniopharyngioma (86%), Rathke’s cleft cyst (9%) and cystic prolactinoma (5%). Mean cyst volume reduction was 77% at 12-months (5.2 ± 4.5 cc to 1.2 ± 1.5 cc; p = 0.002). Rate of pre- and post-op hormonal dysfunction was 59% and 68%, respectively (p = 0.50). Pre-operative VF deficits were found in 68% of patients, of which 32% normalized and 36% remained stable (p = 0.180). Worsened vision was detected in 9% of patients post-operatively. Conclusions: 90Yttrium therapy significantly reduces sellar cyst size without having a deleterious effect on vision and endocrine function.

Contexte: Au Canada, plus de 2 millions de personnes vivent avec l'ost & eacute;oporose, une maladie qui accro & icirc;t le risque de fracture, ce qui fait augmenter la morbidit & eacute; et la mortalit & eacute;, et entra & icirc;ne une perte de qualit & eacute; de vie et d'autonomie. La pr & eacute;sente actualisation des lignes directrices vise & agrave; accompagner les professionnelles et professionnels de la sant & eacute; au Canada dans la prestation de soins visant & agrave; optimiser la sant & eacute; osseuse et & agrave; pr & eacute;venir les fractures chez les femmes m & eacute;nopaus & eacute;es et les hommes de 50 ans et plus.M & eacute;thodes: Le pr & eacute;sent document fournit une actualisation des lignes directrices de pratique clinique de 2010 d'Ost & eacute;oporose Canada sur le diagnostic et la prise en charge de l'ost & eacute;oporose au pays. Nous avons utilis & eacute; l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) et effectu & eacute; l'assurance de la qualit & eacute; conform & eacute;ment aux normes de qualit & eacute; et de pr & eacute;sentation des rapports de la grille AGREE II (Appraisal of Guidelines for Research & Evaluation). Les m & eacute;decins de premier recours et les patientes et patients partenaires ont & eacute;t & eacute; repr & eacute;sent & eacute;s & agrave; tous les niveaux des comit & eacute;s et des groupes ayant particip & eacute; & agrave; l'& eacute;laboration des lignes directrices, et ont particip & eacute; & agrave; toutes les & eacute;tapes du processus pour garantir la pertinence des informations pour les futurs utilisateurs et utilisatrices. Le processus de gestion des int & eacute;r & ecirc;ts concurrents a & eacute;t & eacute; entam & eacute; avant l'& eacute;laboration des lignes directrices et s'est poursuivi sur toute sa dur & eacute;e, selon les principes du R & eacute;seau international en mati & egrave;re de lignes directrices. Dans la formulation des recommandations, nous avons tenu compte des avantages et des risques, des valeurs et pr & eacute;f & eacute;rences de la patient & egrave;le, des ressources, de l'& eacute;quit & eacute;, de l'acceptabilit & eacute; et de la faisabilit & eacute;; la force de chacune des recommandations a & eacute;t & eacute; d & eacute;termin & eacute;e en fonction du cadre GRADE.Recommandations: Les 25 recommandations et les 10 & eacute;nonc & eacute;s de bonne pratique sont r & eacute;partis en sections : activit & eacute; physique, alimentation, & eacute;valuation du risque de fracture, instauration du traitement, interventions pharmacologiques, dur & eacute;e et s & eacute;quence du traitement, et monitorage. La prise en charge de l'ost & eacute;oporose devrait se fonder sur le risque de fracture, & eacute;tabli au moyen d'une & eacute;valuation clinique r & eacute;alis & eacute;e avec un outil d'& eacute;valuation du risque de fracture valid & eacute;. L'activit & eacute; physique, l'alimentation et la pharmacoth & eacute;rapie sont des & eacute;l & eacute;ments essentiels & agrave; la strat & eacute;gie de pr & eacute;vention des fractures, qui devraient & ecirc;tre personnalis & eacute;s.Interpr & eacute;tation: Les pr & eacute;sentes lignes directrices ont pour but d'outiller les professionnelles et professionnels de la sant & eacute; et la patient & egrave;le afin qu'ensemble ils puissent parler de l'importance de la sant & eacute; osseuse et du risque d

Au Canada, plus de 2 millions de personnes vivent avec l’ostéoporose, une maladie qui accroît le risque de fracture, ce qui fait augmenter la morbidité et la mortalité, et entraîne une perte de qualité de vie et d’autonomie. La présente actualisation des lignes directrices vise à accompagner les professionnelles et professionnels de la santé au Canada dans la prestation de soins visant à optimiser la santé osseuse et à prévenir les fractures chez les femmes ménopausées et les hommes de 50 ans et plus. MÉTHODES: Le présent document fournit une actualisation des lignes directrices de pratique clinique de 2010 d’Ostéoporose Canada sur le diagnostic et la prise en charge de l’ostéoporose au pays. Nous avons utilisé l’approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) et effectué l’assurance de la qualité conformément aux normes de qualité et de présentation des rapports de la grille AGREE II (Appraisal of Guidelines for Research & Evaluation). Les médecins de premier recours et les patientes et patients partenaires ont été représentés à tous les niveaux des comités et des groupes ayant participé à l’élaboration des lignes directrices, et ont participé à toutes les étapes du processus pour garantir la pertinence des informations pour les futurs utilisateurs et utilisatrices. Le processus de gestion des intérêts concurrents a été entamé avant l’élaboration des lignes directrices et s’est poursuivi sur toute sa durée, selon les principes du Réseau international en matière de lignes directrices. Dans la formulation des recommandations, nous avons tenu compte des avantages et des risques, des valeurs et préférences de la patientèle, des ressources, de l’équité, de l’acceptabilité et de la faisabilité; la force de chacune des recommandations a été déterminée en fonction du cadre GRADE.Les 25 recommandations et les 10 énoncés de bonne pratique sont répartis en sections : activité physique, alimentation, évaluation du risque de fracture, instauration du traitement, interventions pharmacologiques, durée et séquence du traitement, et monitorage. La prise en charge de l’ostéoporose devrait se fonder sur le risque de fracture, établi au moyen d’une évaluation clinique réalisée avec un outil d’évaluation du risque de fracture validé. L’activité physique, l’alimentation et la pharmacothérapie sont des éléments essentiels à la stratégie de prévention des fractures, qui devraient être personnalisés. INTERPRÉTATION: Les présentes lignes directrices ont pour but d’outiller les professionnelles et professionnels de la santé et la patientèle afin qu’ensemble ils puissent parler de l’importance de la santé osseuse et du risque de fracture tout au long de la vie adulte avancée. La détection et la prise en charge efficace de la fragilité osseuse peuvent contribuer à réduire les fractures et à préserver la mobilité, l’autonomie et la qualité de vie.

Neuroimaging with [2,2-dimethyl-3-[(2 R ,3 E )-3-oxidoiminobutan-2-yl]azanidylpropyl]-[(2 R ,3 E )-3-hydroxyiminobutan-2-yl]azanide;oxo( 99 Tc)technetium-99(3+) ([ 99m Tc]HMPAO) single photon emission computed tomography (SPECT) is used in Alzheimer’s disease (AD) to evaluate regional cerebral blood flow (rCBF). Hypoperfusion in select temporoparietal regions has been observed in human AD. However, it is unknown whether AD hypoperfusion signatures are also present in the 5XFAD mouse model. The current study was undertaken to compare baseline brain perfusion between 5XFAD and wild-type (WT) mice using [99mTc]HMPAO SPECT and determine whether hypoperfusion is recapitulated in 5XFAD mice. 5XFAD and WT mice underwent a 45 min SPECT scan, 20 min after [ 99m Tc]HMPAO administration. Whole brain and regional standardized uptake values (SUV) and regional relative standardized uptake values (SUVR) with whole brain reference were compared between groups. Brain perfusion was similar between WT and 5XFAD brains. Whole brain [ 99m Tc]HMPAO retention revealed no significant difference in SUV (5XFAD, 0.372 ± 0.762; WT, 0.640 ± 0.955; p = 0.536). Similarly, regional analysis revealed no significant differences in [ 99m Tc]HMPAO metrics between groups (SUV: 0.357 ≤ p ≤ 0.640; SUVR: 0.595 ≤ p ≤ 0.936). These results suggest apparent discrepancies in rCBF between human AD and the 5XFAD model. Establishing baseline perfusion patterns in 5XFAD mice is essential to inform pre-clinical diagnostic and therapeutic drug discovery programs.

Cutaneous malignant melanoma (CM) is the leading cause of skin cancer–related mortality and accounts for approximately 1,250 deaths in Canada each year. It is also one of few cancers continuing to display rates of increasing incidence throughout the world. The past decade has brought significant growth in our understanding of the pathogenesis and clinical management of CM. This evidence-based review synthesizes that knowledge, beginning with a review of the epidemiology and etiology of the disease followed by a broad review of the roles of diagnostic imaging in its management. Special attention is given to the role of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography–computed tomography (PET/CT) in supporting assessment at primary presentation of disease, follow-up to surgical and nonsurgical treatment, and for the surveillance of high-risk asymptomatic patients. After a brief review of current treatment options, this article concludes with a demonstration of how and when uncertainty exists at the point of care systematic review processes may be used to resolve clinical questions.Learning Objectives:By the end of this Continuing Medical Education article, participants will be able to1. Describe the epidemiology and etiology of cutaneous melanoma,2. Describe broadly the role of diagnostic imaging in the clinical management of cutaneous melanoma,3. Describe the specific roles and limitations of 18F-FDG PET/CT in the clinical management of cutaneous melanoma,4. Describe broadly the best practice in the treatment of cutaneous melanoma,5. Define the value of systematic review for synthesizing knowledge pertaining to a specific clinical question, and6. Discuss the utility of 18F FDG PET/CT in the management of early-stage (AJCC 0-IIc) cutaneous melanoma.This is a CME article and provides the equivalent of 2 hours of continuing education that may be applied to your professional development credit system. A 12-question multiple choice quiz follows this reading. Please note that no formalized credit (Category A) is available from CAMRT.

Background Our study's purpose is to determine the influence of surgical discipline, surgeon site, and volume on remnant thyroid tissue visualized on radioactive iodine-131 (I-131) scans after total thyroidectomy and I-131 ablation in patients with well-differentiated thyroid carcinomas. MethodsResultsWe retrospectively reviewed all cases of patients who received I-131 therapeutic ablation and postablation radioactive I-131 scans at our center after thyroidectomy to calculate the fraction of administered dose multiplied by 1000 (UDR1000). The remnant thyroid tissue (ie, the UDR1000), between academic and community surgeons was 0.471 (0.705) and 1.190 (+/- 2.487), respectively (P = .001). The UDR1000 between otolaryngology-head and neck surgery and general surgery was 0.654 (+/- 1.575) and 1.043 (+/- 1.625), respectively (P = .159). The UDR1000 partitioned by patient frequencies of <10, 10 to 19, and 20 patients yielded 1.255 (+/- 2.554), 0.926 (+/- 2.084), and 0.467 (+/- 0.721), respectively (P = .003). ConclusionOur study found statistically significant differences in residual thyroid tissue visualized on radioactive I-131 scans based on surgeon parameters.

Background: Traditional neurosurgical techniques and/or stereotactic radiotherapy, although effective for solid tumors, can be associated with high morbidity and be relatively ineffective for long-term control of cystic sellar/parasellar tumors. The rationale of our study was to examine the efficacy and safety of stereotactic intracavitary instillation of 90yttrium colloid for the primary treatment of cystic tumors. Methods: As part of a Health Canada approved clinical trial, we have enrolled nine patients (6 females, 3 males; mean age 64, range 43 to 83 years) for treatment of symptomatic and/or enlarging cysts. Ten cystic sellar/parasellar lesions underwent right frontal stereotactic insertion of 90yttrium colloid to deliver a radiation dose of 200 Gy to the cyst wall. Results: Compared with pre-treatment cyst volumes (mean 4.6 cc; range 0.8-16.1 cc), the cysts decreased in size at 3 months (2.6 cc; 0.2-10 cc) with further shrinkage (n=5) at 9 months (1 cc; 0.1-2.7 cc). Of 9 patients with pre-operation visual field defects, 6 showed improvement. The single complication was a delayed (1 month) incomplete CNIII palsy. Conclusions: Our early experience indicates that 90yttrium colloid delivered to a cystic craniopharyngioma provides an efficacious alternative to open surgery for primary treatment of these cystic lesions.

Non-Hodgkin lymphoma (NHL) frequently manifests in extranodal structures in the chest, often in the form of secondary involvement but occasionally as primary disease. Because staging and treatment are affected by the presence of extranodal disease at imaging, radiologists' interpretation and management of suspicious findings are critical to patient care. Unfortunately, owing to considerable imaging overlap with other diseases, primary extranodal lymphoma is difficult to diagnose with imaging alone. Radiologists should have a heightened degree of suspicion in patients at risk (including patients with immune compromise, autoimmune diseases, or a history of stem cell or solid organ transplant) or with particular imaging appearances (including the vertebral wraparound sign, nonresolving consolidation, an infiltrative soft-tissue mass, and lesions demonstrating vascular encasement without invasion). For patients with known NHL, positron emission tomography/computed tomography (PET/CT) using fluorine 18 (18F)-labeled fluorodeoxyglucose (FDG) is now preferred for routine staging in most cases. CT remains heavily used, and identification of subtle extranodal involvement with CT can be improved with use of intravenous contrast material and careful review of multiplanar images. Pericardial effusion, pleural soft tissue (even when mild), mass-like consolidation, perilymphatic nodularity, and new lytic bone lesions are particularly suggestive of secondary involvement in a patient with known NHL. Magnetic resonance imaging is a helpful problem-solving tool when equivocal findings would change staging and treatment. This comprehensive review illustrates the spectrum of CT manifestations of extranodal NHL in the chest, including the pleura, lung, airways, heart, pericardium, esophagus, chest wall, and breast. ©RSNA, 2017.

Ectopic thyroid is a rare developmental anomaly which may be either asymptomatic or present with thyroid dysfunction as well as pressure symptoms. Here we present a novel case of thyrotoxicosis associated with a hypopharyngeal multinodular thyroid in a female. Removal of the ectopic thyroid led to normalization of the thyroid status.

Objective. Large vessel uptake on positron emission tomography/computerized tomography (PET/CT) supports the diagnosis of giant cell arteritis (GCA). Its value, however, in patients without arteritis on temporal artery biopsy and in those receiving glucocorticoids remains unknown. We compared PET/CT results in GCA patients with positive (TAB+) and negative temporal artery biopsies (TAB-), and controls. Methods. Patients with new clinically diagnosed GCA starting treatment with glucocorticoids underwent temporal artery biopsy and PET/CT. Using a visual semiquantitative approach, 18F-fluorodeoxyglucose (FDG) uptake was scored in 8 vascular territories and summed overall to give a total score in patients and matched controls. Results. Twenty-eight patients with GCA and 28 controls were enrolled. Eighteen patients with GCA were TAB+. Mean PET/CT scores after an average of 11.9 days of prednisone were higher in patients with GCA compared to controls, for both total uptake (10.34 +/- 2.72 vs 7.73 +/- 2.56; p = 0.001), and in 6 of 8 specific vascular territories. PET/CT scores were similar between TAB+ and TAB-patients with GCA. The optimal cutoff for distinguishing GCA cases from controls was a total PET/CT score of >= 9, with an area under the receiver-operating characteristic curve of 0.75, sensitivity 71.4%, and specificity 64.3%. Among patients with GCA, these measures correlated with greater total PET/CT scores: systemic symptoms (p = 0.015), lower hemoglobin (p = 0.009), and higher platelet count (p = 0.008). Conclusion. Vascular FDG uptake scores were increased in most patients with GCA despite exposure to prednisone; however, the sensitivity and specificity of PET/CT in this setting were lower than those previously reported.

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