2025 CAR指南：癌症诊断影像学转诊

Abstract

The Canadian Association of Radiologists (CAR) Cancer Expert Panel is made up of physicians from the disciplines of radiology, medical oncology, surgical oncology, radiation oncology, family medicine/general practitioner oncology, a patient advisor, and an epidemiologist/guideline methodologist. The Expert Panel developed a list of 29 clinical/diagnostic scenarios, of which 16 pointed to other CAR guidelines. A rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of the remaining 13 scenarios. Recommendations from 21 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop the recommendation for these scenarios. During recommendation formulation, one additional scenario was mapped to an existing CAR guideline scenario, leaving 12 scenarios with new recommendations. The guideline focuses on cancer diagnosis and does not cover cancer staging, follow-up, and surveillance. This guideline presents the methods of development and the referral recommendations for suspected pancreatic cancer, suspected liver cancer, incidental liver mass, incidental colon mass or suspected colon cancer, suspected anal cancer, suspected penile cancer, suspected cervical cancer, suspected endometrial/uterine cancer, suspected vulvar cancer, suspected vaginal cancer, suspected haematologic malignancies, and suspected skin cancer. The guideline also points to other CAR guidelines for suspected neck, thyroid, brain, lung, intracardiac/pericardial, esophageal/gastric, renal, adrenal, bladder, testicular, prostate and ovarian cancers, suspected soft tissue mass or tumour, suspected bone tumour, suspected bone tumour --myeloma, suspected spine tumours, and incidental lung cancer.

Keywords

cancer, diagnostic imaging, referrals, guideline, recommendations

Introduction

Beginning in March 2024, an Expert Panel (EP) made up of physicians from the disciplines of radiology, medical oncology, surgical oncology, radiation oncology, family medicine/general practitioner oncology, a patient advisor, and an epidemiologist/ guideline methodologist met to develop a new set of recommendations specific to referral pathways for suspected and incidental cancers. Through discussion (via a virtual meeting) followed by offline communication, the EP developed a list of 29 clinical/diagnostic scenarios to be covered by this guideline. These recommendations are intended primarily for referring clinicians (eg, family physicians, specialty physicians, nurse practitioners); however, they may also be used by radiologists, individuals/patients, and patient representatives.

1 Canadian Association of Radiologists, Ottawa, ON, Canada 2 North York General Hospital, Toronto, ON, Canada 3 BC Cancer, Vancouver Centre, University of British Columbia, Vancouver, BC, Canada 4 Memorial University, St. John’s, NL, Canada 5 University of Waterloo, Waterloo, ON, Canada 6 McGill University, Montreal, QC, Canada 7 University of Ottawa, Ottawa, ON, Canada 8 The Ottawa Hospital, Ottawa, ON, Canada 9 University of Alberta, Edmonton, AB, Canada

## Corresponding Author:

Karim Samji, Faculty of Medicine & Dentistry, Royal Alexandra Hospital, University of Alberta, 116 Street & 85 Avenue, Edmonton, AB T6G 2R3, Canada. Email: karimsamji02@mic.ca

Table 1. Recommendation Text, Symbol, and Interpretation.

|Recommendation|AGAINST||FOR| |---|---|---|---| |STRONG|Strong, against||Strong, for| |||"we recommend against'|"we recommend"| ||（←>||（↑个)| ||·All or almost all informed people would not||· All or almost all informed people would recommend/| || recommend/choose the course of action and only a small proportion would. ||choose the course of action and only a small| |||| proportion would not. | |CONDITIONAL|Conditional, against || Request discussion if the intervention is not offered.| ||||Conditional, for| || "we suggest against'" |||

Note. Down arrows are red and Up arrows are green when available in colour. Created using the guidance provided in Andrews etal. 6

Our methods describing the guideline development process, including the rapid scoping review to identify the evidence base, has been published in CMAJ Open 1 and an editorial to this series of guideline publications is available in CARJ . 2 The application of well-established scoping review and rapid review guidance (JBI, 3 Cochrane Handbook, 4 Cochrane Rapid Review Methods Group 5 ) and guideline methodology (ie, Grading of Recommendations Assessment, Development, and Evaluation or GRADE 6,7 ) were used to identify the evidence-base and to guide the Expert Panel in determining the strength and direction of the recommendations for each clinical scenario (Table 1). The quality of conduct and reporting of the included guidelines identified in the scoping review were evaluated with the AGREE-II checklist, 8 using a modified scoring system. In instances where guidelines were lacking, expert consensus was used to develop the recommendation. Contextualization to the Canadian health care system was considered for each recommendation, with discussion around the factors found in the Evidence to Decision framework in GRADE for guidelines (eg, balance of desirable and undesirable outcomes, values and preferences, resources implications). 7

A systematic search for guidelines (with an a priori defined inclusion criteria) was run in Medline and Embase on May 25, 2024. The search was limited to publications from 2019 onward (Supplemental Appendix 1). Supplemental searching included the following national radiology and/or guideline groups: the American College of Radiology and the National Institute for Health and Care Excellence. Recommendations for each clinical scenario were formulated over one virtual meeting on October 19th, 2024. External review and feedback were obtained from radiologists, an emergency physician, a family physician, a spine surgeon, and a nurse practitioner. The full guideline can be found on the CAR website (www.car.ca).

Results

## Systematic Scoping Review

A total of 6217 records were identified through the electronic database and 2 additional records were added from the supplemental search. Twenty-one guidelines were included (Figure 1). Potentially relevant guidelines published in languages other than English can be found in Supplemental Appendix 2. A list of excluded records with justifications for exclusion is available upon request. Most guidelines were rated as moderate or high quality, using the modified AGREE-II checklist 8 (Supplemental Appendix 3). The number of guidelines included per clinical/ diagnostic scenario ranged from 0 to 7, with a median of 2 guidelines per clinical scenario.

Recommendations

Additional details of the included guidelines, including which imaging modalities (eg, computed tomography [CT], magnetic resonance imaging [MRI], radiograph [XR], ultrasound [US]) that were discussed can be found in Supplemental Appendix 4.

A guideline is intended to guide and not be an absolute rule. Medical care is complex and should be based on evidence, a clinician’s expert judgment, the patient’s circumstances, values, preferences, and resource availability. Not all imaging modalities are available in all clinical environments, particularly in rural or remote areas of Canada. Decisions about patient transfer, use of alternative imaging or serial clinical examination and observation can be complex and difficult. Therefore, the expected benefits of recommended imaging, risks of travel, patient preference, and other factors must be considered. The guideline recommendations are designed to assist the choice of imaging modality in situations where it is deemed clinically necessary to obtain imaging.

Unless the panel agreed a specific protocol is required to optimize patient care/diagnosis, the recommendations do not specify when contrast should or should not be used, as this decision may vary based on clinical presentation, regional practice preferences, preference of the referring clinician, radiologist, and/or the patient, and resource availability.

We reviewed relevant recommendations related to the 13 clinical/diagnostic scenarios previously published by radiology and specialty societies, including: the Canadian Association of Radiologists, 9 the American College of Radiology, 10 American

 Figure 1. PRISMA flow diagram.

Association for the Study of Liver Diseases, 11 the American Society of Clinical Oncology, 12 the Argentinian clinical practice guideline, 13 the British Gynaecological Cancer Society, 14 the British Society for Haematology, 15 the European Association of Urology-American Society of Clinical Oncology, 16 the European Society of Gynaecological Oncology, the International Society of Ultrasound in Obstetrics and Gynecology, the International Ovarian Tumour Analysis group and the European Society for Gynaecological Endoscopy, 17 the European Society of Gynaecological Oncology jointly with the European Society for Radiotherapy & Oncology and the European Society of Pediatric Oncology, 18 the German Clinical Practice guideline, 19 the German Society for Digestive and Metabolic Disorders, 20 the German Society for Gynecology and Obstetrics, the Gynecology Oncology Working Group of the German Cancer Society and the German Cancer Aid, 21 the Italian Association of Medical Oncology, 22 the Italian Society for Ultrasound in Obstetrics and Gynecology, 23 the Japan Pancreas Society, 24 the Joint French clinical practice guideline, 25 the Korean Liver Cancer Association, 26 the Korean National Cancer Center, 27 the Liver Cancer Study Group of Japan, 28 and the Philippine guideline. 29

Seventeen scenarios (see note below) in this guideline refer to the CAR Head and Neck guideline, 30 the CAR Central Nervous System guideline (accepted in CARJ December 2024), the CAR Thoracic guideline, 31 the CAR Cardiovascular guideline, 32 the CAR Musculoskeletal guideline, 33 the CAR Spine guideline, 34 the CAR Gastrointestinal guideline, 35 the CAR Genitourinary guideline, 36 and the CAR Obstetrics and Gynecology guideline. 37

Note: During the formulation of the recommendations for CA23. Suspected ovarian cancer, the Cancer EP noted that the recommendations from the CAR Obstetrics and Gynecology guideline aligned with the recommendations being discussed. Therefore, we direct the reader to that guideline. 37

Recommendations are presented in Table 2.

Table 2. Cancer Recommendations.

|Clinical/diagnostic scenario and recommendations| |---| |CAOI.SUSPECTEDNECKCANCER| |For suspected neck cancer, see the CAR Head and Neck guideline,30 scenario:| |· H04. Neck mass of unknown origin, including salivary gland mass| |CA02.SUSPECTEDTHYROIDCANCER| |For suspected thyroid cancer, see the CAR Head and Neck guideline,30 scenario:| |·H03A. Thyroid and parathyroid disease: Palpable nodule, including goiter|

CA03. SUSPECTED BRAIN CANCER

For suspected brain cancer, see the CAR Central Nervous System guideline (accepted in CARJ Dec 2024), scenarios:

▪ CN04. Headache ▪ CN07. Cranial neuropathy, brain stem symptoms ▪ CN09A. Vestibular cochlear symptoms, Hearing loss ▪ CN09B. Vestibular cochlear symptoms, Vertigo ▪ CN12. Epilepsy and seizure ▪ CN14. Intracranial space-occupying lesions

Table 2. (continued)

Clinical/diagnostic scenario and recommendations

CA04. SUSPECTED LUNG CANCER

For suspected lung cancer, see the CAR Thoracic guideline, 31 scenarios:

▪ TH13. Chronic cough ▪ TH16. Haemoptysis ▪ TH20. Suspected mediastinal lesion ▪ TH21. Suspected mediastinal lymphadenopathy ▪ TH22. Elevated diaphragm on chest radiograph

CA05. INCIDENTAL LUNG CANCER

For incidental lung nodule, see the CAR Thoracic guideline, 31 scenario: ▪ TH19. Incidental lung nodule

CA06. SUSPECTED INTRACARDIAC/PERICARDIAL CANCER

For suspected intracardiac/pericardial cancer, see the CAR Cardiovascular guideline, 32 scenario: ▪ CV05B. Intracardiac/pericardial: Masses

CA07. SUSPECTED SOFT TISSUE MASS OR TUMOUR

For suspected soft tissue mass or tumour, see CAR Musculoskeletal system guideline, 33 scenario: ▪ M07. Soft tissue mass or tumour

CA08. SUSPECTED BONE TUMOUR

For suspected soft tissue mass or tumour, see the CAR Musculoskeletal system guideline, 33 scenario: ▪ M04. Bone tumour—Primary For suspected bone tumour metastases, see the CAR Musculoskeletal system guideline, 33 scenario: ▪ M05. Bone tumour—Metastases

CA09. SUSPECTED BONE TUMOUR — MYELOMA

For suspected primary bone tumour—myeloma, see the CAR Musculoskeletal system guideline, 33 scenario:

▪ M6. Bone tumour—Myeloma

CA10. SUSPECTED SPINE TUMOUR

For suspected tumour of the spine, see the CAR Spine guideline, 34 see scenario: ▪ SP07. Suspected spinal tumour

CA11. SUSPECTED ESOPHAGEAL/GASTRIC CANCER

For suspected esophageal/gastric cancer, see the 2024 CAR Gastrointestinal guideline, 35 scenarios:

▪ GI01. Dysphagia/dyspepsia ▪ GI03A. Epigastric pain ▪ GI04. Chronic abdominal pain ▪ GI07. Chronic GI bleeding

CA12. SUSPECTED PANCREATIC CANCER 9,22,24,27

1. In adults with suspected pancreatic cancer, we recommend CT as the initial imaging modality ( ↑↑ ).

CA13. SUSPECTED LIVER CANCER 9-11,13,26,28,29

1. In adults with suspected hepatocellular carcinoma, we recommend liver protocol MRI or CT as the initial imaging modality ( ↑↑ ). MRI is preferred, as there is better contrast resolution. The decision for CT or MRI may be based on availability and expertise.

CA14. INCIDENTAL LIVER MASS 10

1. In adults with suspicious liver mass on US, non-contrast/single-phase CT or non-contrast MRI, we recommend liver protocol MRI or CT as the next imaging modality ( ↑↑ ).

CA15. INCIDENTAL COLON MASS OR SUSPECTED COLON CANCER

1. In adults with incidental colon mass or suspected colon cancer, where colonoscopy is not feasible/possible, where colonoscopy was incomplete, or if the patient declines colonoscopy, we recommend CT colonography as the initial imaging modality (EP consensus).

Table 2. (continued)

Clinical/diagnostic scenario and recommendations

CA16. SUSPECTED ANAL CANCER 9,20

Diagnosis of anal cancer should be based on clinical examination/direct visualization.

CA17. SUSPECTED RENAL CANCER

For suspected renal cancer, see the CAR Genitourinary guideline, 36 scenario: ▪ GU06. Renal lesion

CA18. SUSPECTED ADRENAL CANCER

For suspected adrenal cancer, see the CAR Genitourinary guideline, 36 scenario: ▪ GU10. Adrenal mass

CA19. SUSPECTED BLADDER CANCER

For suspected bladder cancer, see the CAR Genitourinary guideline, 36 scenarios: ▪ GU01A. Haematuria: Gross haematuria ▪ GU01B. Haematuria: Microhaematuria ▪ GU11. Incontinence, urgency, and frequency

CA20. SUSPECTED TESTICULAR CANCER

For suspected testicular cancer, see the CAR Genitourinary guideline, 36 scenario: ▪ GU09. Scrotal mass or pain

CA21. SUSPECTED PENILE CANCER 16

Diagnosis of penile cancer should be based on clinical examination/direct visualization.

CA22. SUSPECTED PROSTATE CANCER

For suspected prostate cancer, see the CAR Genitourinary guideline, 36 scenario: ▪ GU13. Elevated PSA

CA23. SUSPECTED OVARIAN CANCER 9,12,17,23,25

For suspected ovarian cancer, see the CAR Obstetrics and Gynecology guideline, 37 scenario: ▪ OG07. Evaluation of Adnexal mass

CA24. SUSPECTED CERVICAL CANCER 9

Diagnosis of cervical cancer should be made clinically (eg, Pap [Papanicolaou] smear, biopsy).

CA25. SUSPECTED ENDOMETRICAL/UTERINE CANCER 9,14,21,23

1. In adults with suspected endometrial/uterine cancer, we recommend combined transabdominal and transvaginal US with Doppler as the initial imaging modalities ( ↑↑ ).

CA26. SUSPECTED VULVAR CANCER 9

Diagnosis of vulvar cancer should be based on clinical examination/direct visualization.

CA27. SUSPECTED VAGINAL CANCER 9,18

Diagnosis of vaginal cancer should be based on clinical examination/direct visualization.

CA28. SUSPECTED HAEMATOLOGIC MALIGNANCIES 9,15,19

Suspected lymphoma 1. In adults with suspected lymphoma, we recommend CT neck, chest, abdomen, pelvis as the initial imaging modality ( ↑↑ ). Suspected myeloma For suspected myeloma, see the CAR Musculoskeletal system guideline, 33 scenario: ▪ M6. Bone tumour—Myeloma

Other haematologic malignancies Other haematologic malignancies may be diagnosed based on laboratory investigations.

CA29. SUSPECTED SKIN CANCER

Diagnosis of skin cancer should be based on clinical examination/direct visualization.

Acknowledgments

We would like to thank: Becky Skidmore for creating the search strategies for the systematic scoping review, and the following individuals on the Diagnostic Imaging Referral Guidelines Working Group and external reviewers for providing feedback on the guideline (listed alphabetically): Alanna Coleman, Nicolas Dea, Cathy MacLean, Ryan Margau (WG co-chair), Paul Pageau (WG co-chair), Charlotte Yong-Hing, Kaitlin Zaki-Metias.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Canadian Medical Association.

ORCID iDs

Candyce Hamel https://orcid.org/0000-0002-5871-2137 Alan Michaud https://orcid.org/0000-0001-9217-7361 Jason Pantarotto https://orcid.org/0000-0002-8000-9704 Anna Wilkinson https://orcid.org/0000-0002-5422-8428

Supplemental Material

Supplemental material for this article is available online.

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