NECA-C NECA-S 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선 노출수준에대한근거제공

Transcription

1 NECA-C NECA-S 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선 노출수준에대한근거제공

2 주의 1. 이연구는한국보건의료연구원연구윤리심의위원회승인 (NECA IRB15-013) 을받은연구사업입니다. 2. 이보고서는한국보건의료연구원과대한영상의학회에서공동으로수행한연구사업의결과보고서로한국보건의료연구원연구기획관리위원회 ( 또는연구심의위원회 ) 의심의를받았습니다. 3. 이보고서내용을신문, 방송, 참고문헌, 세미나등에인용할때에는반드시한국보건의료연구원에서시행한연구사업의결과임을밝혀야하며, 연구내용중문의사항이있을경우에는연구책임자또는주관부서에문의하여주시기바랍니다.

3 연구진연구책임자최미영한국보건의료연구원연구기획실부연구위원백정환울산대학교서울아산병원영상의학과교수 참여연구원김민정한국보건의료연구원보건의료근거연구본부연구위원최솔지한국보건의료연구원보건의료근거연구본부연구원조애정한국보건의료연구원보건의료근거연구본부연구원최진아한국보건의료연구원보건의료근거연구본부연구원이민한국보건의료연구원보건의료근거연구본부부연구위원정승은가톨릭대학교서울성모병원영상의학과교수도경현울산대학교서울아산병원영상의학과교수정우경삼성서울병원영상의학과교수용환석고려대학교구로병원영상의학과교수신승수아주대학교병원내과학교실교수

4 차례 요약문 i Executive Summary iv Ⅰ. 서론 1 1. 연구배경 1 2. 연구의필요성 7 2. 연구목적 7 Ⅱ. 연구방법 8 1. 근거기반임상영상가이드라인개발방법론 개발 위원회구성 개발단계별위원회역할 진료지침수용개작시범연구 (Pilot Study) 임상영상가이드라인수용개작과정 수용개작과정 임상영상의학분과별교육 델파이조사 근거수준및권고등급 방사선량평가및표기 방사선량평가에대한개요 방사선량정보의표기 22 Ⅲ. 연구결과 근거기반임상영상가이드라인개발방법론 한국형근거기반임상영상가이드라인 델파이조사결과 140 Ⅳ. 고찰및결론 연구의의의및제한점 결론및제언 146 Ⅴ. 참고문헌 147 Ⅵ. 부록 근거기반임상영상가이드라인개발방법론 Version 근거기반임상영상가이드라인수용개작단계별정리 델파이설문조사결과 ( 평균, 표준편차 ) 외부검토결과 이해관계선언문 410

5 표차례 표 1. 의료방사선안전관리원칙 1 표 2. 유관전문학회및핵심질문검토분과 10 표 3. 복부시범연구 PICO 선정 12 표 4. 흉부시범연구 PICO 선정 13 표 5. RCR Referral Guideline 및일본가이드라인근거수준 18 표 6. ACR Appropriateness Criteria 기준 19 표 7. RCR Referral Guideline 및일본가이드라인권고등급 19 표 8. 한국임상영상가이드라인의권고고려요인 21 표 9. 한국임상영상가이드라인의권고등급체계 21 표 10. 방사선량의상대적수준과예시 23 표 11. Glasgow Coma Scale (GCS) 36 표 12. Classification of traumatic brain injury and indication for immediate head CT 36 표 13. 위험요인 37 표 14. 다양한활동의예상에너지요구량 (MET) 63 표 15. Glasgow Coma Scale (GCS) 126 그림차례 그림 1. 정당화원칙의 3As 실행원칙 2 그림 2. 영국에서개발된정당화가이드라인 i-refer 3 그림 3. 미국 ACR Select 4 그림 4. 서호주가이드라인 5 그림 5. 위원회구성도 10 그림 6. 단계별개발위원회및실무위원회역할 11 그림 7. 근거기반임상영상가이드라인개발방법론 구성 14 그림 8. ACR Appropriateness Criteria의질평가요소및근거수준체계 17 그림 9. 한국형근거기반임상영상가이드라인 의근거수준 20 그림 10. 근거기반임상영상가이드라인개발방법흐름도 24 그림 11. 전문가평균동의정수의변동 ( 델파이조사 1차, 2차 ) 141

6 요약문 서론의료현장에서질병의진단등을목적으로의료방사선노출이필요한영상검사가시행되고있다. 이에관해국제원자력기구 (International Atomic Energy Agency, 이하 IAEA), 국제방사선방호위원회 (International Commission on Radiological Protection, 이하 ICRP) 등의주요방사선관리기구와전문가단체에서는의료목적의방사선안전관리를위해정당화 (justification) 와최적화 (optimization) 를준수하도록권장하고있다. 그러나지난 20년에걸쳐최적화를강화하기위한활동들은다수있었으나, 정당화는문제로인식되지않아상대적으로활동이적었다. 정당화원칙은최적화원칙이전에먼저고려되어야하며, 의료피폭에서불필요한방사선피복여부를결정하는중요한단계이다. 국제사회에서는정당화원칙의일환으로특정임상적조건에서가장적절한검사및시술이이루어지도록검사및시술에대한의사의의뢰 (referral) 또는임상적의사결정을지원하는임상영상가이드라인개발및적용을권고하고있다. 이에본연구는궁극적으로환자의불필요한방사선노출을줄이고, 영상진단검사의적절한시행을위하여한국형 근거기반의임상영상가이드라인 을개발하고자한다. 근거기반임상영상가이드라인개발방법론 개발 I. 임상영상가이드라인개발을위한방법론매뉴얼개발이연구에서는영상의학분야에적합한수용개작과정을진행하기위해서임상진료지침개발방법중수용개작 (adaptation) 방법을활용하여가이드라인을개발하였다. 방법론은임상영상가이드라인개발의목적, 임상영상가이드라인개발그룹의구성, 수용개작프로토콜 (flow chart), 단계별상세과정및작성양식을내용으로한다. 개발과정은기획 (set up), 수용개작 (adaptation), 최종화 (finalization) 로구성되고, 프로토콜은세부적으로 8단계로이루어진다. 개발한근거기반임상영상가이드라인개발방법론은 Version 1.0으로부록에제시하였다. 또한실제임상영상가이드라인수용개작과정에앞서시범연구 (pilot study) 를실시함으로써개발한방법론의실현가능성을높였다. i

7 II. 위원회구성임상영상가이드라인개발을위해개발위원회와실무위원회및자문위원회 ( 컨센서스그룹 ) 를구성하였다. 개발위원회는대한영상의학회진료지침위원회에서추천한임상전문가, 연구방법론전문가, 한국보건의료연구원연구진으로구성하였다. 개발위원회는주로방법론적컨설팅역할을수행하고, 가이드라인개발단계를전반적으로기획및관리한다. 실무위원회는대한영상의학회산하학회중개발우선순위가높은 10개분과를중심으로한다. 대한영상의학회산하학회 ( 심장, 흉부, 인터벤션, 유방, 신경두경부, 복부, 비뇨, 근골격, 소아, 갑상선 ) 에서추천한전문가로구성한다. 해당분과의핵심질문선정부터최종권고문도출까지실질적인수용개작과정을수행한다. 단계별프로토콜에개발위원회와실무위원회의담당역할을자세히서술하였다. 자문위원회는핵심질문별임상영상검사를의뢰하거나시행할최종사용자 (end-user) 로예상되는유관외부전문학회에서추천을받은임상전문가들로구성되었으며, 핵심질문의검토및권고문초안에대한검토와전문가패널조사에참여하였다. 임상영상가이드라인개발과정 : 수용개작과정임상영상가이드라인의모든권고개발 ( 수용개작방법 ) 과정은워크숍을통한실무위원회교육후시작된다. 수용개작과정의최종결과물은핵심질문별권고문이며, 연구결과에제시되어있다. 수용개작과정에서의단계별개발과정은부록에상세하게제시하였다. 권고문에는근거수준및권고등급, 근거요약, 권고고려사항 ( 이득과위해, 국내수용성과적용성 ), 검사별방사선량, 참고문헌이포함된다. 근거수준및권고등급은기존에있는주요가이드라인 (American College of Radiology, Royal College of Radiologists, Japan Radiological Society) 검토하여본지침에적절한기준을별도로결정하였다. 종합근거수준은높음 (I) - 중등도 (II) - 낮음 (III) - 매우낮음 (IV) 으로이루어진다. 권고등급은시행하는것을권고함 (A) - ( 조건부 ) 시행하는것을권고함 (B) - 시행하지않는것을권고함 (C) - 권고없음 (I) 으로제시한다. 방사선량정보는여러가이드라인에서사용되고있는방사선량에대한상대적수준 (Relative Radiation Level, 이하 RRL) 으로유효선량을기반으로정하였다. 권고의최종화과정에서는컨센서스그룹을대상으로권고문초안에대한동의정도를조사하는전문가패널조사 ( 델파이방식 ) 를실시하였다. ii

8 결론및제언본연구에서는우리나라영상의학분야에적합한한국형임상영상가이드라인개발방법론을확정하여근거기반임상영상가이드라인개발방법론을발간하였고, 영상의학전문의를중심으로유관학회임상전문가들의참여를고려한다학제적접근을통해근거기반의임상영상가이드라인을개발하였다. 이연구는정당화원칙을이행하고불필요한방사선노출로부터환자를보호하고한정된보건의료자원을효율적으로사용할수있도록기여하는것이궁극적인목표이다. 이를위해향후에는결과물을바탕으로국제원자력기구 (IAEA) 에서한국의수용개작사례로연구결과를확산시킬예정이다. 후속활동으로는가이드라인개발후실제권고가임상현장에적용되어야궁극적인정당화원칙을달성할수있으므로적용성평가및모니터링을제언한다. 주요어 : 영상진단, 임상진료지침, 적절성, 의료피폭정당화 연구비본연구는대한영상의학회와한국보건의료연구원의공동연구비 ( 과제번호 (NECA-NC , NS ) 로수행되었으며, 진료지침의내용은연구비의영향을받지않았다 이해관계 모든참여연구진은이해관계상충에대해공개하였고, 중대한이해관계상충사례가 없다. iii

9 iv

10 Development of evidence-based clinical imaging guidelines : to supply the evidence for appropriateness of diagnostic imaging studies and radiation exposure levels of patients Miyoung Choi 1, Jung Hwan Baek 2, Sol Ji Choi 1, Ae Jeong Jo 1, Jin a Choi 1, Seung Eun Jung 3, Kyung Hyun Do 2, Woo Kyung Jeong 4, Hwan Seok Yong 5, Seung Soo Sheen 6 1 National Evidence-based Healthcare Collaborating Agency 2 Asan Medical Center 3 Seoul St. Mary s Hospital 4 Samsung Medical Center 5 Korean University Guro Hospital 6 Ajou University Hospital Introduction Radiologic examination that require radiation exposure for the purpose o f diagnosis of the disease in the medical field have been implemented. In th is regard the IAEA (International Atomic Energy Agency, under), the Internati onal Commission on Radiological Protection (ICRP) and other radiation contr ol related agencies/professional organizations recommend to comply the justi fication and optimization for the purpose of medical radiation exposure cont rol. However, activity to enhance the optimization over the last two decades are numerous, relatively less justification activity is not recognized as a probl em. The principle of justification should be considered first, before the opti mization principle, is an important step to determine whether or not unnece ssary radiation. In the field of radiology, individual countries around the wor ld have developed and are utilizing evidence-based clinical guidelines in ord er to augment clinical decision-making by physicians when requesting or pre v

11 scribing a radiologic examination. This research is also one of these activity and will ultimately reduce unnecessary radiation exposure to the patient, and to develop a Korean 'evidence-based clinical guidelines for imaging' to ensur e proper enforcement of medical imaging tests. Development of Evidence-based clinical imaging guidelines I. Methodology for development of Korea clinical imaging guideline The methodology for guidelines is an adaptation, adopting and redevelopin g guidelines. Developing the Korean clinical imaging guidelines (K-CIG) invol ved three stages, set-up (planning), adaptation, and finalization (Figure. 1). T he set-up stage (planning and composition) outlines a process to form comm ittees and clarify their roles. The adaptation stage involves the stepwise deve lopment process to draft the guideline. The finalization stage includes the pr ocess of completing the recommendation document based on evidence, unde rgoing external review, and obtaining final approval. The adaptation process was divided into 8 stages, including 5 stages from selection of key questions to drafting of the guideline, and 3 stages from ext ernal review to final approval and at the finalization of the guideline. A dev eloped protocol is presented in the Appendix 1. II. Committee composition Two committees were involved in the development of the CIGs: the workin g group that writes the proposals, and the development committee, which is responsible for the overall planning and provides supports on research meth odologies. The working group was composed of 3 4 clinical imaging experts from the KSR subspecial societies, including the cardiovascular imaging, thor acic radiology, interventional radiology, breast imaging, neuroradiology and h ead & neck radiology, abdominal radiology, uroradiology, musculoskeletal rad iology, pediatric radiology, and thyroid radiology societies. The development committee is composed of clinical imaging experts, research methodology ex perts, and clinical guideline experts. Both committees contributed to improvi vi

12 ng the quality of the guidelines by providing their expertise at various steps in the development process and collaborating when needed. In clinical imaging examination, there are end-users who refer and perfor m the examinations. Therefore, it is important to include their opinions into the development process. After drafting key questions, an official document was sent to related clinical academic societies, which are the expected endusers, asking members of an advisory committee consensus group for their cl inical advice and to review the draft. A finally a consensus group, consisting of 23 nominated members from the final 14 related societies, was then form ed composed. Members participated in the review of key questions at the ad aptation set-up stage, drafting of the proposal, and expert panel based inves tigation using the delphi method. Guideline adaptation process All adaptation process begins after the training workshop for working grou ps. The final result of the acceptance process of adaptation is a key questio n specific recommendations, it is presented in the study. Step-by-step develo pment process of adaptation is presented in detail in the Appendix. A draft of the recommendation document consists of recommendations wit h responsible for key questions, summary of the evidence, considerations for the recommendation, and references. Level of evidence grading in K-CIG to assess the evidence level of indi vidual literature is composed of 5 elements aspects. After assessing evide nce level for individual literature, the overall evidence level for each key question is defined. They are categorized as high (I), intermediate moder ate (II), low (III), or very low (IV). Each recommendation document includes recommendation grading and overall evidence level. The recommendation grading for the K-CIG contai ns A, B, C, and I, indicating the direction of the recommendation. The radiation level of different imaging examinations is currently included in multiple guidelines. As existing guidelines, the RRL is organized based on vii

13 effective dose, which represents the expected risk level of radiation exposure in an entire population for an imaging examination measured in msv. In the finalization of the recommendation document, delphi method is used. The agreement level for recommendation, recommendation grading, and evidence level range from strongly disagree [1] to strongly agree [9]. After conducting two rounds of assessment, the recommendation docume nt is finalized. Conclusion and Suggestion In this study, the methodology for developing the evidence-based clinical i maging guidelines is published and the guidelines are developed by involving the clinical imaging specialists mainly and related clinical specialists. The research is contributing to the ultimate goal of justifying the principle s to be implemented to protect patients from unnecessary radiation exposure and effective use of limited health care resources. For that, the results of thi s study will be disseminated as the Korean Clinical Imaging Guideline adapta tion activities at the International Atomic Energy Agency (IAEA). As a followi ng activity, the applicability and monitoring is recommended to achieve the ultimate justification principle be applied in clinical settings. Keyword imaging test, clinical imaging guideline, appropriateness, justification of t he medical radiation exposure Funding This study was co-supported by the National Evidence-based Collaborating Agency (NECA-C ) and the Korean Society of Radiology (NECA-S ). Conflict of Interest All authors have no conflict of interest. viii

14 1. 서론 Ⅰ 서론 1. 연구배경 의료방사선은건강상의유익한목적을위하여인위적인전리방사선을의료분야에서사용하는것으로의료적진단이나치료, 건강검진프로그램등에서사용되고있고현대의료에서중요성과활용범위는점차증대되고있다 ( 김민정등, 2014). 이에불필요한의료방사선노출을줄이고적절하고안전한사용을위하여, 국제원자력기구 (International Atomic Energy Agency, 이하 IAEA), 국제방사선방호위원회 (International Commission on Radiological Protection, 이하 ICRP) 등의주요국제방사선관리기구와전문가단체에서는정당화와최적화원칙을준수할것을제안했다 (International Basic Safety Standard, 2014). 표 1. 의료방사선안전관리원칙 원칙 내용 정당화원칙 방사선피폭상황의변화를초래하는모든결정은해로움보다이로움이더커야 함, 반드시필요한검사만을실시해야함 최적화원칙 피폭발생가능성, 피폭자수및개인선량크기는경제적, 사회적인자를고려하 여합리적으로달성할수있는범위에서낮게유지되어야함, 검사수행시가능 한합리적인수준에서최대한방사선을적게사용해야함 지난 20 년에걸쳐최적화개념을발전시키고강화하기위한많은일들이성공적으로 이루어졌으나, 정당화개념은문제로인식되지않아상대적으로적은노력을기울였다.

15 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 정당화원칙은최적화원칙이전에먼저고려되어야하며의료피폭에서불필요한방사선피폭여부를결정하는중요한단계이다. 하지만, 전문가의판단이작용하는영역으로임상전문가의의료행위에대한자율권의문제와규제기관의실질적인개입이상충할수있는부분으로최적화대비현실적으로구현하기어려우며영상의학분야만의노력으로는달성하기어려운영역이다. 정당화원칙의액션플랜 (3As) 에는의료방사선피폭의위험성인지 (awareness), 검사나시술의적정성 (appropriateness) 확보, 감사 (audit) 가포함된다. 위험성인지를높이기위해서전문가교육및훈련, 환자에게정보제공, 사전동의 (informed consent) 등이이루어져야하며적정성확보를위해임상의뢰 / 결정지원가이드라인개발및적용이필요하다. 또한, 정당화이행에대한임상적감사 (clinical audit) 가실시되어야한다. 그림 1. 정당화원칙의 3As 실행원칙. 2

16 1. 서론 대표적인정당화가이드라인으로는영국의 referral guideline, 미국의 appropriate criteria, 서호주의 Western Australian imaging guidelines 등을들수있다. 영국의 referral guideline 은환자들에게빠르고정확한진단을내리는데기여하고진단기기의효율적인사용을도모하기위해개발되었다. 1989년부터시작되어 4년마다개정되고있으며 1판의가이드라인은 73개적응증에서현재 7판은 307개로증가하였다. 7판은 300 명의영상의학과전문의가참여하였고 3,000개의참고문헌을기반으로 Delphi 과정을모든가이드라인에적용하였다. 배포된국가는아일랜드, 노르웨이, 네덜란드, 스페인, 포르투갈, 벨기에, 말타, 덴마크, 스웨덴, 호주, 싱가포르, 일본, 캐나다, 사우디아라비아, 남아프리카공화국이다. 웹기반으로된형태가일반화되었고휴대폰어플로도개발되었다. 8번째개정판은정부의자금지원을받았으며 GP협회의도움을받아확산이시작되었다. 질환및신체조직별로큰분류가있으며각각의세부분류로들어갈수있다 1). 1) Royal College of Radiologists. irefer: Making the best use of clinical radiology. 7th ed. London: The Royal College of Radiologists;

17 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 그림 2. 영국에서개발된정당화가이드라인 i-refer 미국의 appropriateness criteria는 ACR Select 형태로개발되었으며환자의특정임상증상이나질병의진단을위해의사들이적합한검사를선택할수있도록도움을주고자하였다. 자발적으로참여하는 300명이상의의사와 20여개의영상의학과외다른분야의전문가주도하에개발되었으며 2년마다주기적인업데이트가이루어지고있다. ACR Select는검사지시과정에서 Electronic Health Record로볼수있게개발되었고 (ACR Appropriateness Criteria의 Web 형태 ) 전자의무기록시스템과연동이되어, 진단검사오더를내릴때마다프로그램이작동하도록설계되었다. 진단검사의적응증을선택하면적절함의근거에따라진단검사별점수가산출되는데매번지시할때마다점수가부여되고취합되어 ACR Select 데이터베이스로전송된다 2). 2) American College of Radiology. ACR Appropriateness CriteriaR Radiation Dose Assessment Intr oduction. Assessment Intro.pdf. Accessed January 7,

18 1. 서론 그림 3. 미국 ACR Select. 서호주의 Western Australian imaging guidelines 은 Diagnostic Imaging Pathways 형태로임상적응증에따른순서도형태로구성되어있다 ( 그림 4) 3). 현재방사선검사가상당부분부적절하게이루어지고있다는우려가있다. 출판된문헌에의하면, 임상세팅에서의뢰의학전문가 (referring medical practitioner) 및방사선의학전문가 (radiological medical practitioner) 모두방사선검사와관련된실제적선량과위험에대한인지가부족한경우가많다 4). 예를들면, 방사선 ( 및위험 ) 양을나타내는단위를잘아는사람이일부에지나지않으며환자들은대부분검사와관련된위험에대하여잘모르며혼동하고있다. 2007년 12월빈에서개최된 IAEA consultation 보고서에서는정당화과정에서특히환자의인지가강조되었으며자기의뢰 (self-referral) 5), 사회적, 경제적, 법의학적또는 3) Government of Western Australia. Diagnostic imaging pathways. ealth.wa.gov.au/index.php/about-imaging/ionising-radiation. Accessed January 7, ) Malone J, Guleria R, Craven C, Horton P, Jarvinen H, Mayo J, O'Reilly G, Picano E, Remedios D, Heron JL, Rehani M, Holmberg O, Czarwinski R. Justification of diagnostic medical exposures: some practical issues. Report of an International Atomic Energy Agency Consultation. The British Journal of Radiology. 2012;85: ) 영상의학설비를갖춘시설의의사가자신의진료소에서환자대신영상의학전문의에게검사수행을의뢰하 는대신스스로시행한다. 5

19 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 그림 4. 서호주가이드라인정치적압력으로초래되는일부스크리닝프로그램등의부적절한의뢰패턴이논의되었다. 또한, 의료피폭의많은부분에적용할수있는효과적인정당화과정을규명하였다 6). 하지만보다실제적으로정당화를적용하기위해서는전세계적으로의료기관 ( 개인 6) Malone J, Guleria R, Craven C, Horton P, Jarvinen H, Mayo J, O'Reilly G, Picano E, Remedios 6

20 1. 서론 병원 ) 내일상적 practice에서정당화적용을향상시킬수있는일들에관한추가적인논의들이필요하다. 그동안국내에서도정당화가이드라인의개발의필요성에의해 CT 검사및재검사가이드라인 ( 건강보험심사평가원 대한영상의학회, 2013), 심장질환심장T 사용권고안 ( 대한영상의학회 대한심장의학회 근거창출임상연구국가사업단, 2015) 이개발되었다. 그렇지만방사선을이용하는진단및인터벤션방사선학과의모든분야와핵의학분야의진단영상검사를포괄적으로다루는한국형근거기반임상영상가이드라인이필요한시점이다. D, Heron JL, Rehani M, Holmberg O, Czarwinski R. Justification of diagnostic medical exposures: some practical issues. Report of an International Atomic Energy Agency Consultation. The British Journal of Radiology. 2012;85:

21 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2. 연구의필요성 임상영상검사의의료피폭정당화원칙의실현을정당화원칙의실현을위해서는근거기반의뢰가이드라인이나수용가능성의기준및이의광범위한수용과확산의필요성이제기되었다. 또한의뢰가이드라인의수용, 사용및효과성에대한수준은국가마다다르기때문에각지역에맞는근거개발이필수적이다. 국내정당화관련가이드라인은 CT 검사및재검사가이드라인, 심장질환심장 CT 사용권고안 2개가존재한다. 투시중재시술을제외하고대부분의영상검사에대한임상적결정이일반의사에의해이루어지는구조인현재상황에서정당화된영상검사의선택이이루어질수있도록, 본연구에서는보다포괄적인의사결정지원을위한임상영상가이드라인을마련하고자한다. 3. 연구목적 본연구의목적은특정임상적조건에서가장적절한검사및시술이이루어지도록검사및시술에대한의사의의뢰또는임상적결정에도움을주는근거기반임상영상가이드라인 (clinical imaging guidelines) 개발이다. 또한기개발된국외임상영상가이드라인 / 도구를국내의료상황에맞도록수용개작을위한방법론을개발하고자한다. 8

22 2. 연구방법 Ⅱ 연구방법 1. 근거기반임상영상가이드라인개발방법론 개발 임상진료지침의개발방법중영상진단가이드라인은수용개작개발방법을선택하였다. 수용개작개발방법은기존진료지침을가장중요한근거원으로하여개발하는방법으로, 김수영등 (2015) 는 ʻʻ특정문화적, 제도적상황에맞게개발된진료지침을다른의료상황에서그대로사용하거나변경하여사용하는체계적인접근법ʼʼ으로정의한다. 본연구에서는기획단계에서선행연구와지침검토를통해국외에서양질의정당화임상영상가이드라인들이존재하고있고, 개발에필요한시간과비용등을고려하였을때수용개작방법이적절하다고결정하였다. 그리고, 영상의학분야에적합한수용개작과정을진행하기위해개발위원회는표준적인수용개작방법론을검토하여 근거기반임상영상가이드라인개발방법론 (Manual for Clinical Imaging Guideline Adaptation) 을개발하였다. 또한방법론개발과정에서 2개의핵심질문을사례로선정하여시범연구를실시하였다. 방법론은임상영상가이드라인개발의목적, 임상영상가이드라인개발그룹의구성, 수용개작프로토콜, 개발단계별상세업무 (task), 도구 (tool) 및작성양식을주내용으로한다. 개발된방법론은향후최신방법론동향을반영하여개정될수있으므로 version 1.0으로하였다 ( 부록 1 참고 ) 위원회구성 가. 개발위원회와실무위원회임상영상가이드라인을개발하기위해우선개발위원회와실무위원회를구성하였다. 개발위원회는대한영상의학회진료지침위원회에서추천한위원및연구방법론전문가 1인, 한국보건의료연구원의연구진으로한다. 개발위원회는진료지침개발의기획및개발방법 9

23 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 결정, 진료지침의검색과선별, 평가등상세수용개작과정에대한전체방법론마련, 실무위원회자문및개발과정검토, 진료지침의보급및실행전략마련등주로방법론적컨설팅역할을수행한다. 실무위원회는대한영상의학회산하학회에서추천한 3인이상으로구성한다. 산하학회는이전년도의권고개발우선순위가높은 10개학회로선정하였다. 실무위원회는해당분과의가이드라인개발계획공유및의견수렴, 근거기반임상영상가이드라인의개발에서핵심질문및키워드선정, 검색된진료지침의선별, 핵심질문별권고및근거정리, 권고문초안작성, 권고문최종도출과같이실질적인수용개작과정을수행한다. 실무위원회는총 42명으로구성되었다. 개발위원회와실무위원회는임상영상가이드라인을수용개작하기전에이해관계선언문을작성하고서명한다. 이해관계선언문은가이드라인의개발이나승인과정에참여한경력, 가이드라인의주제와관련있는의약품, 재화및서비스관련회사와관계를맺고있는경우등에대한것을내용으로한다. 이해관계선언문의서식과선언결과는부록으로제시한다. 나. 자문위원회 ( 컨센서스그룹 ) 영상검사는실제로검사를의뢰하고실행하는최종사용자가있다는특성이있어이들의의견을진료지침개발과정에서참여시키는것이바람직하다. 이에핵심질문별초안이나온상태에서최종사용자로예상되는유관학회에공문을발송하여, 지침개발과정에서임상적인자문및검토를받기위한자문위원추천을받았다. 최종 14개유관전문학회로부터추천을받은총 23명의자문위원단 ( 컨센서스그룹 ) 이구성되었다. 자문위원들은실제수용개작단계에서핵심질문의검토, 권고문초안에대한검토및전문가패널조사 ( 델파이방식 ) 에참여하였다. 그림 5는각위원회의구성과역할에대한모식도이다. 표 2는수용개작개발과정에참여한유관전문학회및해당학회에서담당한핵심질문검토분과목록이다. 핵심질문의내용에따라하나의핵심질문에대한유관학회는여러개가선정될수있어, 한학회당여러개의관련핵심질문과권고들을배정한경우도있다. 10

24 2. 연구방법 그림 5. 위원회구성도 표 2. 유관전문학회및핵심질문검토분과 유관외부전문학회 핵심질문검토분과 1 대한갑상선학회 갑상선분과 2 대한비뇨기과학회 비뇨분과 3 대한소화과학회 소아, 복부분과 4 대한소화기학회 복부분과 5 대한신경외과학회 신경두경부분과 6 한국유방암학회 유방분과 7 대한응급의학회 신경두경부, 소아, 복부분과 8 대한이비인후과학회 신경두경부분과 9 대한신생아학회 소아분과 10 대한정형외과학회 근골격분과 11 대한류마티스외과학회 근골격분과 12 대한심혈관외과학회 인터벤션분과 13 대한혈관외과중재학회 인터벤션분과 14 대한호흡기내과학회 흉부분과 1.2. 개발단계별위원회역할 각단계에서의개발위원회및실무위원회담당역할은그림 6과같다. 각각의단계의상세내용및단계별결과물등은 근거기반임상영상가이드라인개발방법론 ( 부록 1) 을참고한다. 원칙적으로실무위원회는핵심질문선정및실제권고문의내용을개발하는역할을담당하고, 개발위원회는방법론적인지원, 교육및자문을담당하였다. 개발위 11

25 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 원회내에서영상의학회위원들은임상영상검사의전문적인내용을검토및자문하는역할을, 한국보건의료연구원은문헌검색, 수용개작개발과정에서의방법론적지원을담당하였다. 유관학회에서추천받은전문가 23명은자문위원회 ( 컨센서스그룹 ) 로서 1단계핵심질문선정이후각전문분야별로핵심질문에대한자문을시행하였고, 6단계에서권고문초안이도출된이후 7단계권고문최종안도출시전문가패널조사에참여하였다. 단계내용담당 1 단계 핵심질문선정 실무위원회개발위원회 2 단계 진료지침검색 개발위원회 3 단계 검색된진료지침선별 실무위원회 4 단계 진료지침평가 개발위원회실무위원회 5 단계 핵심질문별권고및근거정리실무위원회권고문초안작성개발위원회 6 단계 권고문합의및권고등급결정 컨센서스그룹실무위원회 7 단계 권고문최종안도출 실무위원회개발위원회 8 단계 외부검토외부전문가임상진료지침승인대한의학회 그림 6. 단계별개발위원회및실무위원회역할 12

26 2. 연구방법 1.3. 진료지침수용개작시범연구 (Pilot Study) 개발위원회에서는실제각실무위원회별권고개발에앞서임상영상가이드라인수용개작방법론을개발하는과정에서 2개의핵심질문사례를선정해서시범연구를실시하였다. 사례로선정된핵심질문은복부분과의 우하복부 (right lower quadrant) 급성통증 과흉부분과의 흉부질환발견을위한통상적인흉부 X선촬영 이었고, 개발방법론을기준으로 5단계 ( 권고문초안작성 ) 까지시행한후, 문제점을보완하고사례를활용하여방법론의내용을최종확정하였다. 표 3. 복부시범연구 PICO 선정 Population Intervention Comparator Outcome 1 우하복부급성통증을나타내는성인환자영상검사 - 2 우하복부급성통증을나타내는소아환자영상검사 - 3 우하복부급성통증을나타내는환자조영증강 CT 조영증강전 CT 충수염진단 4 우하복부급성통증을나타내는임산부환자영상검사 - 13

27 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 4. 흉부시범연구 PICO 선정 Population Intervention Comparator Outcome 1 무증상입원환자 - 2 병력이있고이학적검사에서호흡기및심혈관 급성증상이있는입원환자 세이상의만성호흡기및심혈관질병력이있 는입원환자 (6 개월이내검사결과가있는경우 ) - 70세이상의만성호흡기및심혈관질병력이있 4 - 는입원환자 (6개월이내검사결과가없는경우 ) 통상적인흉부 X선검사 5 무증상수술전환자 - 흉부 질환발견 6 병력이있고이학적검사에서호흡기및심혈관 급성증상이있는수술전환자 세이상의만성호흡기및심혈관질병력이있 는수술전환자 (6 개월이내검사결과가있는경 우 ) 세이상의만성호흡기및심혈관질병력이있 는수술전환자 (6 개월이내검사결과가없는경 우 ) - 14

28 2. 연구방법 2. 임상영상가이드라인수용개작과정 2.1. 수용개작과정 수용개작과정은신규직접개발방법과달리이미개발되어있는국외가이드라인및임상적의사결정지원도구를근거로하여국내의료상황에적합하도록가이드라인을개발하는방법이다 ( 한국보건의료연구원, 2015). 임상영상가이드라인의실제수용개작과정은크게기획및구성, 수용개작과정, 최종화로이루어진다. 기획및구성은위원회의구성과방법론의개발, 수용개작과정은핵심질문을정의하는단계부터델파이방법을차용하여권고문의초안을마련하는단계까지로한다. 최종화는권고등급의확정, 외부검토및임상진료지침을승인받는단계까지로한다. 이중수용개작과정과최종화과정은프로토콜화하여매뉴얼로제작된부분이다. 그림 7. 한국형임상영상가이드라인수용개작구성 15

29 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.2. 임상영상의학분과별실무위원회대상교육 기획단계에서개발된 근거기반임상영상가이드라인개발방법론 은실무위원회를대상으로교육하는단계를거쳤다. 우선, 10개분과실무위원회전체를대상으로근거기반임상영상가이드라인개발방법론에대한전반적인교육을실시하였다. 그러나, 좀더실제적인이해와권고개발실무에의적용을촉진할필요가있어, 이후주요개발단계별 ( 핵심질문선정, 진료지침선별, 근거표작성, 권고문초안작성 ) 로워크숍형태의교육을여러차례실시하였다. 또한개발위원회위원들은 3인씩한팀을이루어 3~4개분과를집중담당하여, 필요시별도회의형태로개발과정에대한교육과자문을시행하였다 델파이조사 임상영상가이드라인개발의마지막과정인최종화를위해외부검토를수행하였으며, 핵심질문별권고문의동의정도에대한전문가설문조사를수행하였다. 설문조사대상의경우분과별학회추천전문가 2인이상, 개발위원회의위원, 그리고방법론전문가 1인이상으로, 핵심질문의해당분과에따라 6~9명으로구성되었다. 설문지는분과별핵심질문에따라권고된권고문에대한동의정도로 1점 ( 매우동의하지않음 ) 에서 9점 ( 매우동의함 ) 의범주를가진리커트척도를사용하였으며, 설문결과의요약통계량으로권고문에대한동의점수의평균을사용하였다. 평균점수 1~3점은동의하지않음, 4~6점은모르겠음, 7~9점은동의함으로사전정의하였으며, 세부권고문에있어권고등급에차이가날경우다른설문문항으로구성하여권고문별동의정도를세부적으로추출하였다. 설문조사는피설문조사대상자에게이메일로전송되었으며, 이메일설문지전송과동시에전화요청을통해설문지회수율을높였다. 이메일로전송된설문지는핵심질문과질문에따른세부권고문및권고등급, 근거수준을표기하였으며, 동의정도에따라 1~9 점응답란에 하는방식을적용하였다. 1차설문조사는 2주의기한으로수행되었으며, 수합된설문지의결과요약을통해 2차설문지를구성하였다. 2차설문조사역시조사방법및설문내용은동일하게적용하되, 1차설문대상자의응답분포 ( 최솟값, 제1사분위수, 중앙값, 제3사분위수, 최댓값 ) 및동의점수의평균을추가로제시하였다. 2차설문응답에대해 1차설문응답분포를벗어나는응답을고수하는경우, 그이유에대한상세기술역시추가하였다. 이메일을통해설문지전송과함께상세권고사항에대한부록을함께첨부하였으며, 2차설문에있어부록의양식은동일하게적용하였다. 16

30 2. 연구방법 2.4. 근거수준및권고등급 본임상영상가이드라인에서는기존주요가이드라인 (ACR, RCR, 일본임상영상가이드라인등 ) 및 GRADE (the Grading of Recommendations, Assessment, Development and Evaluation) 방법론을검토한후자체근거수준및권고등급결정체계를마련하였다. 가. 근거수준결정체계검토미국 ACR Appropriateness Criteria 의경우는아래그림과같이각연구별로연구설계, 환자선택, 참고표준검사의선정및결과해석등의요소를측정하고, 이를통해연구의질을범주화하여결정하였다. 이에반해 RCR Referral guideline과일본가이드라인은연구설계를중심으로하는 Oxford Centre for Evidence-based Medicine의결과를차용하여연구설계와환자선택및참고표준검사를중심으로근거수준을결정한다. 17

31 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 문헌별질평가요소 (8가지) 1) 통계적측정치의불확실성측정 ( 또는범위 ) : 표준오차, 신뢰구간, p값, 통계적비교시험의언급 (t-test, Fisher exact probability, Mann-Whitney U 등 ) 2) 전향적연구 : 예, 자료수집이중재검사 (index test) 와참고표준이수행되기전에계획되었는지 문헌별근거수준분류범주 1 : 8개모든질관련요소를포함 잘설계된연구 (well-designed study) 이며공통적비뚤림에대하여설명함 3) 환자모집이체계적인지또는연속적으로모집하였는지범주 2 : 6개내지 7개포함 중등도의잘설계된연구 (moderately well-designed study) 이며대부분의공통 4) 참고표준검사가있거나적어도두영상검사를비교하였는지적비뚤림에대하여설명함 5) 참고표준이같은방법으로모든대상자에게적용되거나연구에서각각의영상검사가같은방법으로모든대상자에게적용되었는지 6) 중재검사에둘혹은그이상의독립된판독자가있는지또는각시험을위한둘혹은그이상의독립된판독자가있는지 범주 3 : 3 개이상 6 개미만 연구설계에중대한제한점이있는연구 (important study design limitations) 7) 중재검사결과가참고표준결과를알지못한상태에서해석되었는지 8) 참고표준결과가중재검사결과를알지못한상태에서해석되었는지 * 참고표준이없이하나이상의검사가비교된경우, 모든검사의결과가다른검사의결과를알지못한상태에서해석되어야함 범주 4 : 2개이하 일차근거로유용하지않음 ( 임상연구가아니거나연구설계의질이떨어지거나, 전문가의견일치로결론을내림등 ) 그림 8. ACR Appropriateness Criteria 의질평가요소및근거수준체계 18

32 2. 연구방법 표 5. RCR Referral Guideline 및일본가이드라인근거수준 분류영국 RCR 일본임상영상가이드라인 Level Ⅰ - 연속적으로모집된환자들에서앞서개발된진단기준을확인한연구 ( 일반적으로적용되는참고표준검사를적용해서 ) - level-Ⅰ 연구들로이루어진체계적문헌고찰 일관된참조기준이이용되고맹검화 된횡단연구의체계적문헌고찰 Level Ⅱ - 연속적으로모집된환자에서진단기준의개발 ( 일반적으 로적용되는참고표준검사를적용해서 ) - level-Ⅱ 연구들로이루어진체계적문헌고찰 일관된참조기준이이용되고맹검화 된횡단연구 Level Ⅲ Level Ⅳ - 비-연속적환자대상연구 ( 일관성있게적용되는참고표준없이 ) - level-Ⅲ 연구들로이루어진체계적문헌고찰 - 환자-대조군연구 - 참고표준검사의부적절함 참조기준이일관되어있지않고또는연구대상을연속적으로모집하지않은경우증례대조연구, 참고기준이정확하지않거나독립적으로되어있지않은연구 Level Ⅴ - 전문가의견추론만있는경우 ( 근거가없음 ) Oxford Centre for Evidence-based Medicine 차용 나. 권고등급체계검토권고등급체계는 ACR Appropriateness Criteria의경우는근거수준과이득과위해 (risk-benefit) 비율을고려하는것으로결정하고있으며권고의강도가표시된다 ( 표 5). RCR Referral guideline 은근거수준을기반으로하며권고의강도나방향성은없다. 일본임상영상가이드라인의경우는근거수준을기반으로권고등급의강도와방향성을표기하고있다. 19

33 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 6. ACR Appropriateness Criteria 기준 Rating Category Category definition 일반적으로적절하지않음 (Usually not appropriate) 대부분의상황에서, 연구또는시술은이런특정임상상황을반영하지않거나출판된동료검토, 과학적연구들, 전문가의견에의해보충된경우에서보이듯이위험-편익비가선호되지않음 (unfavorable). * 위해또는위험 (harms or risks) 편익 (benefits) 적절할것임 (May be appropriate) 연구또는시술이특정임상상황을가리킬수도있고, 환자에대한위험 -편익비가출판된동료검토연구, 과학적연구, 전문가의견에의해보충된것연구들과비슷할수도있음 * 위해또는위험 (harms or risks) 편익 (benefits) 일반적으로적절함 (Usually appropriate) 연구또는시술이특정임상상황에서더나은환자의위험-편익비를가리킬수있음. 동료검토과학적연구, 전문가의견에의해보충받는연구들처럼출간된연구위해또는위험 (harms or risks) 편익 (benefits) 표 7. RCR Referral Guideline 및일본가이드라인권고등급 영국 RCR 일본임상영상가이드라인 분류 내용 분류 내용 추천됨 - 해당검사방법이임상진단또는관리강한과학적근거가있으며, 수행할것 A (Indicated) (management) 에기여함을강하게추천함 전문영역조사 (Specialised investigation) - 영상의학자와논의후에시행되거나, 협의된프로토콜 (locally agreed protocols) 에따라시행되어야함 * 전문화 (specialised): 복잡하고, 시간이소요되고, 자원집중적인것 ( resource-intensive) B 과학적근거가있으며, 수행할것을추 천함 - 임상의사의설득력있는사유가있거나, 특정상황에서 만조사 영상의학자가해당검사방법이진단또는관리에적합하다고판단하는경우시행함 * 단, 임상적문제가시간이흐름에따라 C1 과학적근거가없으나, 수행할것을추 천함 해결되는것인경우에는검사를연기 적합하지 않음 - 해당검사방법이적합하지않음 C2 과학적근거가없으며, 수행하지않을 것을추천함 20

34 2. 연구방법 다. 한국형임상영상가이드라인의근거수준및권고등급체계국외가이드라인의근거수준을검토한결과본연구에서는다음과같이결정하였다. 근거수준은문헌별로는연구설계와각연구별비뚤림위험을고려하고, 핵심질문별종합근거수준을결정하기로하였다. 권고등급은근거수준과이득및위해 ( 표 8) 그리고국내의수용성및적용성을고려하여권고의강도와방향성을최종결정 ( 표 9) 하는것으로결정하였다. 문헌별근거수준 종합근거수준 ( 핵심질문별 ) KCIG 내용 등급 의미 1 아래의 3 가지를조건을모두만족하는연구 1) 적절한참고표준검사 2) 연속적환자모집 3) 맹검적결과해석 Level 1 수준의체계적문헌고찰 중재 / 참고표준검사를적용하여결과를비교관찰한무 작위임상시험연구, 단면코호트연구 높음 I 적절한연구설계및비뚤림위 험이낮은연구들로부터추정된 결과이다 아래의 2 가지조건을만족하는연구 2 1) 적절한참고표준검사 2) 연속적환자모집연구또는맹검적결과해석 Level 2 수준의체계적문헌고찰중재 / 참고표준검사를적용하여결과를비교관찰한비교연구 ( 전향적코호트, 후향적코호트, Quasi-RCT) 중등 도 II 적절한연구설계및비뚤림위 험이중등도인연구들로부터추 정된결과이다 3 일관성있게적용한참고표준검사가없는경우환자-대조군연구 4 부적절하거나비-독립적참고표준검사 5 전문가의견 낮음 III 매우낮음 IV 연구설계가부적절하거나, 비뚤림위험이높은연구들로부터추정된결과이다연구설계가부적절하거나비뚤림위험이높은연구들로부터추정된결과이다 그림 9. 한국형근거기반임상영상가이드라인 의근거수준 21

35 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 8. 한국임상영상가이드라인의권고고려요인 고려요인 1. 근거수준 (level of evidence) 2. 이득 (benefit) 3. 위해 (harm) 내용핵심질문별로종합적인근거수준 (4단계) 을내림 - 높음 (I), 중등도 (II), 낮음 (III), 매우낮음 (IV) 진단정확성임상적유효성 - 임상적예후에미치는긍정적인영향 : 치료효과, 치료방향의변화등 - 불필요한자원이용의감소 : 재원일수감소, 침습적인수술또는시술 ( 검사 ) 의감소, 인력 / 비용 / 시설이용등의감소등환자만족도증가, 삶의질향상등에대한근거가있는경우방사선량 : 무증상, 소아, 임산부등고려가필요한대상집단의경우만고려함검사 ( 시술 ) 조영제관련부작용침습적인검사 ( 시술 ) 의경우합병증, 부작용등자원이용증가 - 불필요한자원이용의증가등에대한근거가있는경우환자만족도또는삶의질감소등에대한근거가있는경우 표 9. 한국임상영상가이드라인의권고등급체계 Grading 내용의미 A 시행하는것을권고함 해당중재 ( 검사 ) 는원하는효과에대한충분한근거가있어시행할 것을권고함 B ( 조건부 ) 시행하는것을권고함 해당중재 ( 검사 ) 의원하는효과에대한근거는중등도와충분한사 이임. 중재 ( 검사 ) 를선택적으로제공하거나, 전문가판단에따라특 정개인에게시행할것을권고함 C 시행하지않는것을권고함 해당중재 ( 검사 ) 의원하지않는효과에대한충분한근거가있어, 시행하는것을권고하지않음 ( 시행하지않는것을권고함 ) I 권고없음 (no recommendation) 해당중재 ( 검사 ) 의효과가있다거나없다는것에대한근거는불충분하고, 효과에대한추가적인연구가필요함. 해당중재 ( 검사 ) 의효과에대한확신도가매우낮아권고등급결정자체가의미없다고판단되는경우 22

36 2. 연구방법 3. 방사선량평가및표기 3.1. 방사선량평가에대한개요 다양한영상검사의다양한방사선량에대한상대적수준 (Relative Radiation Level, RRL) 이여러가이드라인에서사용되고있다. RLL은유효선량을기반으로정리하였으며유효선량은한영상검사와관련한인구전체의추정방사선위험도를나타내는양으로 msv의단위를사용한다. 하지만이는나이와성별에따른다른위험도를반영하지는않았다. 우리나라의근거기반임상영상가이드라인에서사용한방사선량의상대적수준은 American College of Radiology 의 ACR Appropriateness Criteria R, Royal College of Radiologists. irefer 7th edition, 서호주의 Diagnostic imaging pathways에사용된내용을검토하고최근의문헌들을검토하였으며. 특히우리나라에서의선량조사결과를반영하여개발하였다 방사선량정보의표기 개발된근거기반임상영상가이드라인에사용된방사선량의상대적수준과예시는아래의표와같다. 본연구에서는각권고문에서권고고려사항중방사선량항목에권고에서언급된임상영상검사별로검사명과해당되는선량을 symbol을사용하여알기쉽게표기하였다. 23

37 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 10. 방사선량의상대적수준과예시 Symbol 방사선량의상대적수준 (Relative Radiation Level, RRL) 예시 0 0 초음파검사, MRI < 1 msv Chest PA, Plain Mammography radiography, 1~5 msv IVU, UGIS, Low dose chest Brain CT, Brain CTA CT, >5 ~10 msv Routine Chest CT, Abdominal CT, Coronary CT > 10 msv 3 Phase dynamic CT (abdomen) MRI, Magnetic Resonance Imaging; IVU, intravenous urography; UGIS, upper gastrointestinal series; CT, Computed(Computer) Tomography; CTA, Computed Tomography Angiography 24

38 3. 연구결과 Ⅲ 연구결과 1. 근거기반임상영상가이드라인개발방법론 근거기반임상영상가이드라인개발과정은기존국내발간된수용개작매뉴얼을기초로개발위원회의논의및방법론자문을통해최종적으로개발단계를 8단계로정리하였다. 단계별로이루어지는주요작업내용및개발위원회와실무위원회의역할배분을요약정리한내용은그림 11과같고, 상세내용 ( 사례포함 ) 은방법론 ( 부록 ) 에자세히정리하였다. 그림 10. 근거기반임상영상가이드라인개발방법흐름도 25

39 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 단계 : 핵심질문선정 최종권고안은핵심질문을근거로도출한다. 핵심질문은영상의학분야별전문가로구성된실무위원회에서 PICO형태로 1차작성한다. 개발위원회는작성된 PICO를바탕으로문장형핵심질문을작성하고, 개발가능성을검토한다. PICO 구성시영상검사및중재법에해당하는 I(intervention) 는구체적으로정의하는것이일반적이지만특정검사법으로구체화하지않더라도연관된검사법을모두서술정의한다. 실무위원회와개발위원회의논의를통해문장형핵심질문을최종적으로확정한다 단계 : 진료지침검색 진료지침검색은 PICO 중 P와 I만을활용하여검색의민감도를높이는전략으로수행한다. 개발위원회에서체계적으로검색전략을구성하고국내외데이터베이스를활용하여검색을수행한다. 검색데이터베이스는국외 DB(Ovid-medline, Ovid-embase, NGC, G-I-N) 와국내DB(KoreaMed, KMbase, KoMGI, KGC) 를모두포함하여최종권고안이국내상황을반영할수있도록한다. 검색전략및결과를실무위원회에서검토하여누락된주요가이드라인은수기검색을통해보완한다. 최종검색전략과검색일자, 검색자등의정보를기록하여재현가능성을높인다 단계 : 검색진료지침선별 최종검색된진료지침선별과정은임상적전문지식이필요하므로각분과실무위원회에서실시한다. 문헌선별기준으로 1차선택 / 배제, 2차선택 / 배제를각개별문헌당 2 인이검토하여객관성을높인다. 1차선별은문헌의제목및초록을검토하여 2인이상수행한다. 2차선별은 1차선택된문헌의원문을검토하고, 배제시배제사유를기입한다. 두차례의선별과정모두검토자간이견이있을경우합의과정을거친다 단계 : 진료지침평가 2차선별과정에서선택된문헌은문헌질평가대상문헌으로한다. 2차선택된문헌중진료지침형태만을평가대상으로하며, 평가도구는한국형버전인 K-AGREE II로한다. 한문헌당 3인이상의평가자가해당과정을수행하고평가자는개발위원회로한다. 질평가시평가항목당 1 ~ 7점으로하고사유를기입하여평가결과의재현성 26

40 3. 연구결과 및명확성을확보한다. 평가자간동일항목내점수가 4점이상차이날경우재검토과정을거친다. 평가결과영역별점수중 개발의엄격성 이 50점이상인진료지침을권고및근거정리대상진료지침으로한다. 최종평가결과는실무위원회에제공하고, 질평가결과가낮더라도관련진료지침이현저하게적거나국내개발지침인경우등권고및근거정리를위한지침으로최종선정될수있다 단계 : 권고및근거정리, 권고문초안작성 실무위원회에서진료지침평가가완료된지침의권고및근거를핵심질문별로정리하고, 권고문초안을작성한다. 권고정리는핵심질문별권고의내용과고유권고등급을정리한다. 권고정리시진료지침의최신성및수용성, 적용성을평가한다. 권고들을국내상황과비교하여종합적인측면에서받아들여질수있는가, 실제적용할있는가를검토한다. 또한국내근거에대한검토가필요하다고판단하는경우에는국내에서지침또는개별연구를별도로검색하여최신성을높인다. 근거정리는핵심질문별로권고와관련된개별문헌을정리하고우리연구에서의근거수준을부여한다. 기본서지정보및대상자수, 연구유형, 연구결과, 근거의질등급을항목으로하고, 5가지항목 (reference standard 유무, 연속적환자모집여부, 판독의맹검화여부, 체계적문헌고찰여부, case-control 연구유형여부 ) 을검토하여근거수준을판단한다. 개별문헌의근거수준평가를위한근거등급은 5가지로구성된다. Oxford Centre for Evidence-based Medicine의기준을차용한일본 JRS와미국 ACR의지침은본연구의근거등급체계에바로적용할수있도록한다. 영국 RCR의경우개별문헌에대한근거수준을공개하고있지않으므로핵심질문별권고문만이활용가능하다. 개별문헌들의근거수준평가후핵심질문별종합근거수준을결정한다. 종합근거수준은높음 (Ⅰ)-중등도 (Ⅱ)-낮음(Ⅲ)- 매우낮음 (Ⅳ) 으로결정한다. 권고문초안은핵심질문에대한권고문, 근거의요약, 권고고려사항, 참고문헌으로구성한다. 각권고문은권고등급 (recommendation grading) 과종합근거수준을포함한다. 권고등급은 A, B, C, I로구성되며권고의방향성을제시하고, 근거수준은권고의강도를나타낸다. 권고고려사항에는이득과위해, 국내수용성과적용성, 검사별방사선량을내용으로한다. 27

41 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 단계 : 권고문합의및권고등급결정 실무위원회에서작성한권고문초안은개발위원회와의논의를거쳐근거수준과권고등 급을결정한다. 실무위원회와개발위원회의합의를통해권고문의타당성을높인다 단계 : 권고문최종안도출 컨센서스그룹을구성하여권고문에대한동의정도를조사한다. 컨센서스그룹의구성은영상의학분야전문가, 영상진단가이드라인의유관학회, 연구방법론전문가로한다. 핵심질문별권고문, 권고등급, 근거수준에대한동의정도는 1( 전혀동의하지않음 )~9( 매우동의함 ) 점으로조사항목을구성한다. 조사방법은델파이기법을차용하며, 총 2회실시후최종권고문을확정한다 단계 : 외부검토및임상진료지침승인 최종권고문에대한검토는임상영상가이드라인개발에참여하지않은영상의학전문의검토 ( 내부검토 ) 와지침의최종사용자가될유관학회검토 ( 외부검토 ) 로한다. 일정기간동안의대한영상의학회웹페이지게재, 공문서발송을통한서면의견수렴과세미나개최를통한현장의견수렴을방법으로한다. 의견수렴및수정을완료한후대한의학회의임상진료지침승인을요청함으로서근거기반임상영상가이드라인개발을종료한다. 28

42 3. 연구결과 2. 한국형근거기반임상영상가이드라인 분과핵심질문권고문 권고 등급 근거 수준 방사선량 KQ 1. 경미한뇌외상환자에서진단을위한적절한영상검사는무엇인가? 권고 1. 경미한뇌외상환자에게적절한영상검사로는 CT 또는 MRI 를권고한다. B II 뇌 MRI 0 단순두개골촬영 CT 뇌혈관조영검사 뇌 CT 신경 두경부 갑상선 KQ 2. 외상없이처음발생한뇌발작또는뇌전증성인환자에서진단을위한적절한영상검사는무엇인가? KQ 3. 난청을호소하는환자의중이질환진단을위한적절한영상검사는무엇인가? KQ 1. 갑상선결절이의심되는환자에서진단을위한일차적인영상검사는무엇인가? KQ 2. 갑상선결절의적절한조직검사방법은무엇인가? 권고 2. 외상없이처음발생한뇌발작또는뇌전증성인환자의평가를위해 MRI와 CT를권고한다. 권고 3-1. 전도성난청을주호소로내원한환자의중이질환영상을위한검사로는일반적으로비조영 Temporal bone CT를권고한다. 권고 3-2. 혼합성난청을주호소로내원한환자의중이질환영상을위한검사로는조영또는비조영 head and internal auditory canal MRI 혹은비조영 temporal bone CT 검사를권고한다. 권고 3-3. 진주종이나종양이의심되는환자의중이질환진단을위해수술전검사로는비조영 temporal bone CT를권고하며, 조영또는비조영 head and internal auditory canal MRI 역시권고한다. 권고 1. 갑상선결절이의심되거나초음파이외의영상기법으로발견된갑상선결절의세부진단에경부초음파를권고한다. 권고 2. 갑상선결절의조직검사를위한방법으로는초음파유도하세침흡인검사를권고한다. 뇌 MRI 0 A II 뇌 CT A II 측두골 CT A II 두부와내이도 MRI 0 측두골 CT A II 두부와내이도 MRI 0 측두골 CT A II 경부초음파검사 0 A II 경부초음파검사 0 29

43 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 분과 핵심질문 권고문 권고 1-1. 객혈이있는모든환자의초기검사로흉부 X-선검사를 시행할것을권고한다. 권고 1-2. 객혈이있는폐암위험인자를가진 (40세이상, 30갑년이상 흡연 ) 성인환자의원인진단을위한검사로조영증강흉부 CT를시행 KQ 1. 객혈이있는성인환자의 할것을권고한다. 권고 1-3. 중등증객혈 ( ml) 또는반복적객혈을보이는성인흉부원인진단을위한적절한영상검사환자의원인진단을위한검사로조영증강흉부 CT를시행할것을권는무엇인가? 고한다. 권고 1-4. 대량객혈 (>400ml) 이있으나, 심장폐기능은유지되는성인 환자의원인진단을위한검사로조영증강흉부 CT를시행할것을권 고한다. KQ 1. 관상동맥질환병력이없는권고 1-1. 증상이없는개인에서관상동맥질환의발견을위하여저위무증상개인 (individual) 에서관상험군과중등도위험군에서영상검사를시행하지않는것을권고한다. 동맥질환의발견과위험도평가를 위한적절할영상검사는무엇인 권고 1-2. 증상이없는개인에서관상동맥질환의발견을위하여고위 가? 험군에속한개인에서는관상동맥 CT검사를권고한다. 권고 2-1. 비지속성심실부정맥환자나실신환자에서심전도와심장 심장 초음파검사로원인을알수없는경우, 구조적심장질환의감별과심 KQ 2. 원인이불분명한부정맥 장의해부학적, 기능적평가를위한목적으로심장 CT와 MRI를시행 환자에게심장질환의발견을위한 하는것을권고한다. 적절한검사는무엇인가? 권고 2-2. 새롭게발병한심방세동의경우심장 CT 검사시행은초기 진단목적으로는부적절하나, 심방세동의전기소작술이전에심장과폐 정맥의해부학을알기위한목적으로고려할수있다. 전기소작술전 권고근거등급수준 방사선량 A I 흉부 X-선검사 A II 조영증강흉부 CT A II 조영증강흉부 CT A III 조영증강흉부 CT C III - - A III 관상동맥 CT 심장 MRI 0 A II 심장 CT B II 심장 MRI 0 30

44 3. 연구결과 분과핵심질문권고문 권고 등급 근거 수준 방사선량 후 MRI 의시행은좌심방의해부학적, 기능적평가나소작술시행부 위의섬유화평가를위해고려할수있다. 심장 CT 유방 KQ 3. 급성심장질환이없는중등위험도환자에게비심장수술전관상동맥질환의위험도평가를위한적절한영상검사는무엇인가? KQ 1. 무증상여성을대상으로한유방암검진에서유방암을발견하기위한적절한검사는무엇인가? 권고 3-1. 중등도위험도의환자에서비심장수술전에임상적으로위험인자가없고 4 METs 이상의심폐능력을보이는경우영상검사를 C II - - 시행하지않는것을권고한다. 권고 3-2. 중등도위험도의환자에서비심장수술전에임상적위험인자를두개이상가지고있고심폐능력을모르는경우관상동맥 CT B III 관상동맥 CT 를고려할수있다. 권고 3-3. 중등도위험도의환자에서비심장수술전에임상적위험인자를두개이상가지고있고, 4 METs 미만의심폐능력을보이는 B III 관상동맥 CT 경우관상동맥 CT를고려할수있다. 권고 3-4. 중등도위험도의환자에서비심장수술전에임상적위험인자를두개이상가지고있고, 4 METs 미만의심폐능력을보이면서관상동맥 CT의적응증이아닌경우심장 MRI를고려할수있다. B III 심장 MRI 0 권고 세무증상여성을대상으로한유방암검진으로유방촬영술을권고한다. A I 유방촬영검사 권고 세이상여성에서유방촬영술을이용한검진은개인위 유방초음파검사 0 험도에대한임상적판단과수검자의선호도를고려하여시행할수있 B I 다. 유방촬영검사 권고 세미만의여성에서의유방암검진은권고하지않는다. I III - - KQ 2. 만져지는종괴가있는여 성에서진단을위한적절한영상 권고 세이상여성에서만져지는종괴소견에대한일차검사 로유방촬영술을고려할수있다. B III 유방촬영검사 31

45 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 분과 핵심질문 권고문 권고 세이상여성에서만져지는종괴소견에대한일차검사 로시행한유방촬영술에서 정상 소견이라면다음단계검사는유방초 음파를고려할수있다. 권고 세미만의여성에서만져지는종괴소견에대한일차검 사로유방초음파를고려할수있다. 검사는무엇인가? 권고 세미만의여성에서만져지는종괴소견에대한일차검 사로시행한유방초음파에서 정상 소견이라면모든추가적인영상검 사를시행하지않는것을권고한다. 권고 세여성에서만져지는종괴소견에대한일차검사 로유방촬영술또는유방초음파를고려할수있다. 권고근거등급수준 방사선량 유방초음파검사 0 B III 유방촬영검사 B III 유방초음파검사 0 C III - - 유방초음파검사 0 B III 유방촬영검사 복부 KQ 1. 황달증상이있는환자의진단을위한적절한영상검사는무엇인가? KQ 2. 우상복부급성통증을호소하는환자에서급성담낭염진단을위한적절한영상검사는무엇인가? KQ3. 우하복부급성통증과발열을호소하는환자에서급성충수염진단을위한적절한영상검사 권고 1. 황달증상이있는환자의첫번째검사로초음파를권고한다. MRCT를포함하는조악성담관폐쇄가의심되는환자의경우에는조영증강복부 CT 또는 A I 영증강 MRI 0 MRCP를포함하는조영증강복부 MR를권고한다. 이중시기췌담도 CT 권고 2-1. 우상복부급성통증을호소하는환자에서급성담낭염진단을위해복부초음파검사를권고한다. A II 초음파검사 0 조영증강전후복부권고 2-2. 조영증강 CT 검사와조영증강전후복부자기공명영상검 0 B III MRI 사역시특수한상황에서고려할수있다. 조영증강복부 CR 권고 3-1. 우하복부급성통증과발열을호소하는환자에서급성충수염진단을위해복부 CT를권고한다. A II 복부 CT 권고 3-2. 복부초음파검사와복부 MRI 검사역시일반적또는특 B II 초음파검사 0 32

46 3. 연구결과 분과핵심질문권고문 권고 등급 근거 수준 방사선량 는무엇인가? 수한상황에서고려할수있다. 복부 MRI 0 권고 1-1. 지속적인무증상현미경적혈뇨 (microscopic hematuria) 경정맥요로조영검사 로내원한정상신기능성인환자에서조영증강 CT 요로조영술 (CT urography) 은초음파검사보다적절하다. A I CT 요로조영검사 권고 1-2. 지속적인무증상현미경적혈뇨로내원한신실질질환이 경정맥요로조영검사 KQ 1. 무증상혈뇨로내원한성 있는성인환자에서초음파검사가조영증강 CT 요로조영술보다적절하다. A II CT 요로조영검사 인환자의비뇨기계종양진단을 권고 1-3. 무증상육안적혈뇨로내원한성인환자에서비뇨기계종 초음파검사 0 위한적절한검사는무엇인가? 양의저위험군인경우초음파검사가 CT 요로조영술보다적절하다. A II 경정맥요로조영검사 비뇨 초음파검사에서이상이있을경우 CT 요로조영술을시행한다. 권고 1-4. 무증상육안적혈뇨로내원한성인환자에서비뇨기계종양의고위험군인경우 CT 요로조영술이초음파검사보다적절하다. 임신한환자, 요오드조영제알러지병력이있는환자에서 MR 요로조영술 (MR Urography) 이대안이될수있다. A I CT 요로조영검사경정맥요로조영검사 CT 요로조영검사 MR 요로조영술 0 KQ 2. 비정상질출혈로내원한 권고 2. 비정상질출혈로내원한가임기및폐경기여성에서경질초 여성의자궁내막병변진단을위한 음파검사를권고한다. 자궁내막암의위험인자가있는경우우선적으로 A I 경질초음파검사 0 적절한영상검사는무엇인가? 자궁내막조직검사를권고한다. KQ 3. 조직검사로확인된전립선 암환자의평가를위한적절한검 사는무엇인가? 권고 3. 조직검사로확인된전립선암환자의병기결정을위해전립선자기공명영상 (MRI) 을권고한다. A II 전립선 MRI 0 복부 CT 근골격 KQ 1. 천장골주변의통증을호 소하며병원에처음내원한성인 권고 1-1. 척추관절염의조기진단을위해서, 일반방사선검사에서명백한천장관절염이있을경우추가적인영상검사는권고하지않는다. C II 일반방사선검사 33

47 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 분과 핵심질문 권고문 권고 1-2. 일반방사선검사에서소견이정상이거나모호한경우, 천장 에서혈청음성척추관절염 ( 또는혈 관절과척추의염증성변화를발견하기위해서는 MRI를가장적절한 청음성척추관절병증 ) 진단을위한 검사로권고한다. 적절한영상검사는무엇인가? 권고 1-3. CT는천장관절의구조적변화를발견하기에민감한도구이 지만방사선노출의위험성을고려할것을권고한다. 권고 2-1. 만져지는연부조직종괴를주소로내원한성인에서연부 조직종양진단을위한첫번째영상검사로는일반방사선검사를권고 KQ 2. 만져지는연부조직종괴를 한다. 주호소로내원한성인에서연부조 권고 2-2. 만약임상소견에서해당종괴가단순지방종 (lipoma) 이나 직종양진단을위한적절한영상 결정종 (ganglion) 이의심되는상황이라면첫번째영상검사로초음파 검사는무엇인가? 검사를고려할수있다. 권고 2-3. 일반방사선검사만으로정확한진단에이르기어려운경우, 추가검사로 MRI을권고한다. KQ 3. 비외상성무릎통증을호권고 3. 비외상성무릎통증을호소하는성인환자에서일반방사선검소하는어른환자에서통증의원사에서이상소견이없을경우통증의원인을규명하기위한다음영상인을규명하기위한적절한영상검사로 MRI를권고한다. 검사는무엇인가? 권고근거등급수준 방사선량 일반방사선검사 A II MRI 0 B II 골반 CT A II 일반방사선검사 B II 초음파검사 0 A II 일반방사선검사 MRI 0 일반방사선검사 B II MRI 0 인터 벤션 KQ 1. 수술후급성복부통증을초음파검사 0 권고 1. 수술후급성복부통증을호소하는환자에서 infected fluid 호소하는환자에서체액감염진단을위해조영증강및조영증강전 CT를권고하며임산부의경우 A II 조영증강및조영증강 (infected fluid) 진단을위한적 CT 대신초음파검사및 MRI를권고한다. 전 CT 절한영상검사는무엇인가? KQ 2. 간헐적파행 (intermittent 권고 2-1. 혈관성파행의확진을위한일차적검사로듀플렉스초음 A II 듀플렉스초음파검사 0 34

48 3. 연구결과 분과 핵심질문 권고문 claudication) 환자에서혈관성파 파검사 (Duplex ultrasonography; DUS) 를권고한다. 행 (vascular claudication) 진단을권고 2-2. 혈관성파행환자의병변의위치와정도를평가하기위해위한적절한영상검사는무엇인서 CT 혈관조영술, 듀플렉스초음파및 MRI 혈관조영술을권고한다. 가? 권고 1-1. 출생직후부터간헐성비담즙성구토를하는 3개월이내의 소아환자에서는영상검사가필요하지않으나, 해부학적인구조이상 KQ 1. 구토가있는생후 3개월 의평가를위해상부위장관조영술을고려할수있다. 이내의소아환자에서진단을위 권고 1-2. 급성비담즙성구토를하는 3개월이내의소아환자에서는 한적절한영상검사는무엇인가? 초음파검사를고려할수있으며, 비대유문협착증의전형적인임상양 상을보이지않거나초음파를이용한유문부평가를할수없는경우 상부위장관조영술을고려할수있다. 권고 2-1. 글래스고혼수척도 (Glasgow Coma Scale, GCS) 가 14이 상이면서신경학적증상이나징후, 혹은고위험인자 ( 예 : 의식손상, 두개 소아저골절의심소견등 ) 가없는두부외상소아에서두부손상진단을 KQ 2. 소아두부외상에서두부외위한영상검사를시행하지않는것을권고한다. 상진단을위한적절한영상검사권고 2-2. GCS가 13이하이거나 GCS가 14이상이면서신경학적증상는무엇인가? 이나징후, 혹은고위험인자 ( 예 : 의식손상, 두개저골절의심소견등 ) 가 있는두부외상소아에서두부손상진단을위한영상검사로조영전 두부컴퓨터단층촬영 (non-contrast brain CT) 을고려할수있다. 권고 등급 A B B 근거 수준 II II II 방사선량 듀플렉스초음파검사 0 MRI 혈관조영검사 0 CT 혈관조영검사 상부위장관조영검사, 하부위장관조영검사 초음파검사 0 복부일반촬영 상부위장관조영검사, 하부위장관조영검사 C I - - B I 두부 CT KQ 3. 열성요로감염이있는소 아환자에서진단을위한적절한 영상검사는무엇인가? 권고 3. 첫열성요로감염소아에서해부학적구조이상의평가를위 한영상검사로초음파검사를고려할수있다. B II 초음파검사 0 배설성방광 - 요도조영 검사 35

49 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.1. 신경두경부분과 7) KQ 1. 경미한뇌외상환자에서진단을위한적절한영상검사는무엇인가? 권고 1. 경미한뇌외상환자에게적절한영상검사로는 CT 또는 MRI 를권고한다. ( 권고등급 B, 근거수준 II) 근거요약성인의급성뇌손상환자는, 글라스고척도 (Glasgow scale) 이 13~15점인경미한손상 (mild), 8~12점의중등도손상 (moderate), 8점이하의심한 (severe) 뇌손상으로구분할수있으며 (1,2), 이중경미한손상환자 (mild traumatic brain: MBT) 환자에게서부적절한검사를피하거나, 경미한손상환자 (MBT) 의일부에게서나타나는합병증, 동반손상및진행하는병변을진단하는것은임상적으로무척중요하다 (3). MBT 환자군의영상진단에대해가이드라인은검색후 6개의관련가이드라인이선택되었다. 6개의 class II 문헌리뷰결과, 주로 CT를일반적으로권고하며 (4-7), 보완적으로 MRI를권고하였고 (8,9), 일부제한적경우에조영제사용을권고하며 (10), 단순두개골촬영 (11, 12), 관류영상 (13), 기능적자기공명영상 (13) 과확산텐서영상 (13) 등은권고하지않았다. 소아환자의경우에는일반적으로권고하지않으며, 두개내손상위험요인이높은경우에만 CT 시행을권고하였다 (14,15,16). 7) 각분과별권고문의참고문헌기술양식은 vancouver 양식임. 핵심질문별로독립된내용으로구성되어있기 때문에본문에서인용된순서대로참고문헌기술하는것이더적절하다고판단함. 36

50 3. 연구결과 표 11. Glasgow Coma Scale (GCS) Category Adult Scale Infant Spontaneous 4 Spontaneous Eye Opening To speech 3 To speech To pain 2 To pain No response 1 No response obeys verbal command 6 obeys verbal command Localizes pain 5 Localizes pain Best moter Withdraws form pain 4 Withdraws form pain response Flexion abnormal* 3 Flexion - abnormal Extension** 2 Extension No response 1 No response Oriented and converses 5 Coos, babbles Disoriented and converses 4 Cries but consonlable Best verbal Inappropriate words 3 Persistently irritable response Incomprehensible sounds 2 Grunts to pain/restless No response 1 No response 표 12. Classification of traumatic brain injury and indication for immediate head CT 분류 분류항목 Immediate head CT 지표 Hospital admission Mild GCS=13~15 Loss of consciousness if present 30 min or less 1 GCS=15 No risk factors or only 1 minor risk factor present(chip rule) No 분류 Head injury, no traumatic barin injury GCS=15 2 With risk factor: >=1 major risk factor(s) or >= 2 Yes minor risk factor(chip rule) 3 GCS = Yes Moderate GCS=9-12 Yes Severe GCS<=8 Yes Critical GCS=3-4, with loss of pupillary reactions and absent or decelerate motor reactions Yes 37

51 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 13. 위험요인 분류 History Examination Mechanism 요인 Age Loss of consciousness Headache Vomiting Post-traumatic seizure Dizziness Pre-traumatic seizure Anticoagulation therapy GCS score < 15 Suspicion of open or depressed skull fracture Clinical signs of basal skull fracture Clinical signs of skull fracture Intoxication Persistent anterograde amnesia Focal neurologic deficit Retrograde amnesia Contusion of the skull Signs of facial fracture Contusion of the face GCS score deterioration Prolonged PTA Multiple injuries Dangerous mechanism (Dangerous mechanism in CHIP defined as ejected from vehicle, pedestrian or cyclist versus vehicle) High-energy trauma Unclear trauma mechanism 권고고려사항 1. 이득과위해일반적으로 CT를권고하나, 미만성축삭손상 (diffuse axonal injury)(17,18), 아급성및만성시기의뇌손상평가, 지주막하출혈등을목적으로하는경우에는 MRI를권고하였고, 소아나 2세미만의경우 CT는방사선피폭이나의료비 (cost) 를고려해야한다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 38

52 3. 연구결과 용성과적용성평가표는부록에제시한다. 3. 검사별방사선량뇌 CT, CT 뇌혈관조영검사 (Brain CT angiography) 단순두개골촬영뇌 MRI 0 참고문헌 1. National Institute for Health and Care Excellence. Head Injury: assessment and ear ly management. Clinical guideline. Available from: URL: e/cg176. Accessed Jan 22, Vos PE, Alekseenko Y, Battistin L, Ehler E, Gerstenbrand F, Muresanu DF, Potapov A, Stepan CA, Traubner P, Vecsei L, von Wild K, European Federation of Neurolo gical Societies. Mild traumatic brain injury. Eur J Neurol. 2012;19(2): Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L, Kraus J, Coronad o VG, Incidence, Risk Factors and Prevention of Mild Traumatic Brain Injury: Res ults of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2004;43(Suppl): Livingston DH, Loder PA, Hunt CD, Minimal Head Injury: Is Admission Necessary? Am Surg. 1991;57(1): Nagy KK, Joseph KT, Krosner SM, et al. The Utility of Head Computed Tomograp hy After Minimal Head Injury. J Trauma 1999;46(2): Stein SC, O'Malley KF, Ross SE, Is Routine Computed Tomography Scanning Too Expensive for Mild Head Injury. Ann Emerg Med. 1991;20(12): Undén Ingebrigtsen T, Romner B; Scandinavian Neurotrauma Committee (SNC). Sc andinavian Guidelines for Initial Management of Minimal, Mild and Moderate Hea d Injuries in Adults: an Evidence and Consensus-Based Update. BMC Med. 2013;25 (11): Kampfl A, Schmutzhard E, Franz G, et al. Prediction of Recovery from Post-Traum atic Vegetative State with Cerebral Magnetic-Resonance Imaging. Lancet 1998;351 (9118): Ashikaga R, Araki Y, Ishida O, MRI of Head Injury Using FLAIR. Neuroradiology 1997;39(4): Lang DA, Hadley DM, Teasdale GM, Macpherson P, Teasdale E, Gadolinium DTP A Enhanced Magnetic Resonance Imaging in Acute Head Injury. Acta Neurochir. (Wien) 1991;109(1-2): Jagoda AS, Bazarian JJ, Bruns JJ Jr, Cantrill SV, Gean AD, Howard PK, Ghajar J, Riggio S, Wright DW, Wears RL, Bakshy A, Burgess P, Wald MM, Whitson RR, Cli 39

53 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 nical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Inj ury in the Acute Setting. J Emerg Nurs. 2009;35(2): Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for Patie nts with Minor Head Injury. Lancet. 13. Ashikaga R, Araki Y, Ishida O, MRI of Head Injury Using FLAIR. Neuroradiology 2001;357(9266): Dunning J, Patrick Daly J, Lomas JP, Lecky F, Batchelor J, Mackway Jones K, Deri vation of the Children's Head Injury Algorithm for the Prediction of Important Cli nical Events Decision Rule for Head Injury in Children. 2006;91(11): Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nad el FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of Children a t Very Low Risk of Clinically-Important Brain Injuries after Head Trauma: a Prosp ective Cohort Study. Lancet 2009;374(9696): Atabaki SM, Stiell IG, Bazarian JJ, Sadow KE, Vu TT, Camarca MA, Berns S, Cha mberlain JM, A Clinical Decision Rule for Cranial Computed Tomography in Mino r Pediatric Head Trauma. Arch Pediatr Adolesc Med. 2008;162(5): Gentry LR, Imaging of Closed Head Injury. Radiology. 1994;191(1): Gentry LR, Godersky JC, Thompson B, MR Imaging of Head Trauma: Review of t he Distribution and Radiopathologic Features of Traumatic Lesions. AJR Am J Roe ntgenol. 1988;150(3):

54 3. 연구결과 KQ 2. 외상없이처음발생한뇌발작또는뇌전증성인환자에서진단을위한적절한영상검사는 무엇인가? 권고 2. 외상없이처음발생한뇌발작또는뇌전증성인환자의평가를위해 MRI 와 CT 를권고한다. ( 권고등급 A, 근거수준 II) 근거요약외상없이처음발생한뇌발작또는뇌전증성인환자의영상진단에대한가이드라인은검색후 6개의가이드라인이선택되었다. 처음발생한뇌발작은외상, 종양, 혹은감염등선행구조적및대사성이상이원인이되어발생하는유발성혹은급성증후성발작 (provoked or acute symptomatic seizures) 과, 유발원인이명확치않은비유발성, 잠복성, 특발성, 원인성증후성발작 (unprovoked, cryptogenic idiopathic, or remote symptomatic seizures) 으로나눌수있다. 두종류모두에서, 항경련성약물치료시작여부결정에뇌구조영상은중요한역할을하며 (1,2), 처음발생한뇌발작환자의평가시 EEG와더불어뇌영상을권고하고있다 (3). 7개의 class II 문헌리뷰결과, CT 및 MRI는유발요인없이처음발생한뇌발작성인환자의평균 10% 에서치료방침에변화를야기한중대한이상소견을발견한것으로보고되었다 (4). 처음발생한뇌발작의평가시 MRI가 CT보다대뇌이상소견을좀더민감하게발견할수있기때문에더선호하는검사법이나 (2,5), 응급상황이거나 MRI 금기증인환자에선 CT가적절한검사법일수있다 (1,2,6-10). 조영제의사용은종양, 감염, 염증성질환, 혹은혈관질환등의평가시유용하다 (8,10,11). 권고고려사항 1. 이득과위해외상없이처음발생한뇌발작또는뇌전증성인환자의일차진단검사로 MRI와 CT 모두적절하나, 대뇌병변을좀더민감하게발견할수있는 MRI를더선호한다. 하지만, 응급상황이거나 MRI 금기증인환자에선 CT가적절한검사법일수있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시한다. 41

55 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 3. 검사별방사선량 뇌 CT 뇌 MRI 0 참고문헌 1. Harden CL, Huff JS, Schwartz TH, et al. Reassessment: Neuroimaging in the Emerg ency Patient Presenting with Seizure (an Evidence-Based Review): Report of the T herapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007;69(18): Jagoda A, Gupta K, The Emergency Department Evaluation of the Adult Patient w ho Presents with a First-Time Seizure. Emerg Med Clin North Am. 2011;29(1): Pugh MJ, Berlowitz DR, Montouris G, et al. What Constitutes High Quality of Care for Adults with Epilepsy? Neurology 2007;69(21): Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: Evaluating an Appar ent Unprovoked First Seizure in Adults (an Evidence-Based Review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007;69(21): King MA, Newton MR, Jackson GD, et al. Epileptology of the First-Seizure Present ation: a Clinical, Electroencephalographic, and Magnetic Resonance Imaging Study of 300 Consecutive Patients. Lancet 1998;352(9133): Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Seizures. Ann Emerg Med. 2004;43 (5): Earnest MP, Feldman H, Marx JA, Harris JA, Biletch M, Sullivan LP, Intracranial Le sions Shown by CT Scans in 259 Cases of First Alcohol-Related Seizures. Neurolo gy 1988;38(10): Mower WR, Biros MH, Talan DA, Moran GJ, Ong S, Selective Tomographic Imagin g of Patients with New Onset Seizure Disorders. Acad Emerg Med. 2002;9(1): Schoenenberger RA, Heim SM, Indication for Computed Tomography of the Brain in Patients with First Uncomplicated Generalised Seizure. BMJ 1994;309(6960): Sempere AP, Villaverde FJ, Martinez-Menendez B, Cabeza C, Pena P, Tejerina JA, First Seizure in Adults: a Prospective Study from the Emergency Department. Acta Neurol Scand. 1992;86(2): Hauser WA, Annegers JF, Kurland LT, Incidence of Epilepsy and Unprovoked Seiz ures in Rochester, Minnesota: Epilepsia 1993;34(3):

56 3. 연구결과 KQ 3. 난청을호소하는환자의중이질환진단을위한적절한영상검사는무엇인가? 권고 3-1. 전도성난청을주호소로내원한환자의중이질환영상을위한검사로는일 반적으로조영증강전측두골 (Temporal bone) CT 를권고한다. ( 권고등급 A, 근거수준 II) 권고 3-2. 혼합성난청을주호소로내원한환자의중이질환영상을위한검사로는조영증강또는조영증강전두부와내이도 (head and internal auditory canal) MRI 또는조영증강전측두골 CT 를권고한다. ( 권고등급 A, 근거수준 II) 권고 3-3. 진주종이나종양이의심되는환자의중이질환진단을위해수술전검사로는조영증강전측두골 CT 를권고하며, 조영증강또는조영증강전두부와내이도 MRI 역시권고한다. ( 권고등급 A, 근거수준 II) 근거요약전도성난청환자에서영상검사는주로외이도와중이내병변을확인하려는목적으로시행되며, 특히급성및만성중이염의합병증을확인하는것이중요한데, 측두골 (temporal bone) CT의경우중이내작은골조직까지확인이가능하며, 진주종과관련된골미란의범위를정확하게확인할수있어전도성난청을주호소로내원한환자의중이질환진단을위한검사로조영증강전두부 CT에비해측두골 CT 검사가적절한것으로제시되고있다 (1). 다만, 고실천장 (tegmen tympani) 의누공 (fistula) 형성은고해상도측두골 CT로도확인이가능하지만뇌수막이나뇌정맥의침범여부를확인하는데는 MRI가 CT보다우월하므로, 내이나두개강내로병변의파급이의심되는중이질환에있어 MRI가도움이될수있다 (1). 혼합성난청의주된원인은시신경피막 (optic capsule) 의정상골조직대신불규칙한해면골이대치되어생기는귀경화증 (otosclerosis) 이다. 일반적으로귀경화증을포함한달팽이관에생기는질환은고해상도측두골 CT로평가가가능하며귀경화증은 CT에서는시신경피막의국소적인음영감소로, MRI에서는국소조영증강으로확인할수있다 (1). 인공와우이식을위한수술전검사로얇은절편 (thin-section) CT가일반적으로가장많이시행되고있으나, 선천성일경우고해상도 MRI가수술전계획을수립하는데 CT보다유용한것으로보고된바있다 (2,3). 수술전영상으로미세골구조와경막 (dura), 내이및시신경피막, 주변혈관과의 43

57 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 관계를확인하는것이중요하며, 측두골 CT에서중이내작은골조직까지확인이가능하므로진주종의수술전검사로적절하다 (1). 진주종에의한합병증으로뇌수막염이나혈전증이의심되거나, 중이의진주종이나종양의두개강내전파를보기위한목적으로 MRI 검사가도움이될수있다 (1). 전정신경초종의진단을목적으로하는경우조영증강 MRI가추천되지만최근고분해능 3D heavily T2강조영상을활용한조영증강전검사의경우에도감도가 89~100%, 특이도가 94~99.7% 로추천되고있다 (4-9). 권고고려사항 1. 이득과위해전도성난청환자의일차진단검사로측두골 CT검사를사용하는경우방사선피폭의단점이있으나, 방사선피폭의단점이같은두부 CT에비해진단정확도가높은장점이있다. 혼합성난청환자의진단검사로조영증강또는조영증강전두부와내이도 (head and internal auditory canal) MRI 또는조영증강전측두골 CT가모두유용하나 CT는방사선피폭의단점이있으며, 조영증강 MRI의경우에는드물지만신원성전신섬유증 (nephrogenic systemic fibrosis) 의위험이있으므로, 이를고려하여적용하여야한다. 진주종이나종양이의심되는환자의수술전검사로조영증강전측두골 CT가적절하며, 조영증강또는조영증강전두부와내이도 MRI가도움이되나 CT는방사선피폭의단점이있으며, 조영증강 MRI의경우에는드물지만신원성전신섬유증의위험이있으므로, 이를고려하여적용하여야한다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 측두골 CT 두부와내이도 MRI 0 44

58 3. 연구결과 참고문헌 1. American College of Radiology. ACR Appropriateness Criteria; Hearing Loss and or Vertigo Parry DA, Booth T, Roland PS, Advantages of Magnetic Resonance Imaging over C omputed Tomography in Preoperative Evaluation of Pediatric Cochlear Implant Ca ndidates. Otol Neurotol. 2005;26(5): Rauch SD, Clinical Practice. Idiopathic Sudden Sensorineural Hearing Loss. N Engl J Med. 2008;359(8): Fortnum H et al. The Role of Magnetic Resonance Imaging in the Identification of Suspected Acoustic Neuroma: a Systematic Review of Clinical and Cost-Effectivene ss and Natural History. Health Technology Assessment 2009;13: Newton JR et al. Magnetic Resonance Imaging Screening in Acoustic Neuroma. Am J Otolaryngol. 2010;31: Annesely-Williams DJ et al. Magnetic Resonance Imaging in the Investigation of Se nsorineural Hearing Loss: Is Contrast Enhancement Still Necessary? J Laryngol Oto l. 2001;115: Schmalbrock P et al. Assessment of Internal Auditory Canal Tumors: a Comparison of Contrast-Enhanced T1-Weighted and Steady State T2-Weighted Gradient Echo MR Imaging. AJNR 1999;20: Naganawa S et al. MR Imaging of the Inner Ear: Comparison of a Three-Dimensio nal Fast Spin-Echo Sequence with Use of a Dedicated Quadrature-Surface Coil wi th Gadolinium-Enhanced Spoiled Gradient-Recalled Sequence. Radiology 1998;208: Hermans R et al. MRI Screening for Acoustic Neuroma without Gadolinium: Value of 3DFT-CISS Sequence. Neuroradiology 1997;39:

59 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.2. 갑상선분과 KQ 1. 갑상선결절이의심되는환자에서진단을위한일차적인영상검사는무엇인가? 권고 1. 갑상선결절이의심되거나초음파이외의영상기법으로발견된갑상선결절의세부진단에경부초음파검사를권고한다. ( 권고등급 A, 근거수준 II) 근거요약갑상선결절의관리및치료에관한가이드라인을검색후최종 5개를선택했다 (1-5). 갑상선결절은흔한질환으로, 무증상성인인구의약 19~67% 에서발견된다고보고된바있으며 (6-8), 이들 5개의권고안에서는공통적으로갑상선결절이의심될때에진단을위하여경부초음파검사를권고한다. 초음파검사는갑상선결절에대한진단예민도가매우높은방법으로, 갑상선결절을일차적으로진단하게되고, 이를바탕으로세침흡인검사필요여부를결정할수있다. 2011년 Korean Society of Thyroid Radiology 에서발표된 Ultrasonography and the Ultrasound-Based Management of Thyroid Nodules Consensus Statement and Recommendations 에서는갑상선결절을발견하는데있어가장민감한검사법은고해상도경부초음파검사이며, 만져지는갑상선결절이있을때에이의진단을위해초음파검사를시행할것을권고하고있다. 또한결절의진단뿐만아니라추가적으로그크기와초음파검사에서형태학적특징을확인할수있고, 주변경부림프절의전이여부를판단할수있으며, 이들을바탕으로초음파유도하세침흡인세포검사의필요성및가능여부를결정할수있다고보고하였다. 2015년에개정되어발표된 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer에서는갑상선결절이의심되거나, 결절성갑상선종 (nodular goiter), 또는 CT, MRI, 양전자방사단층촬영 (positron emission tomography, PET) 등의다른영상검사에서우연히발견된갑상선결절의정확한진단을위해갑상선과경부림프절에대한초음파검사를권고하고있다 (Strong recommendation, High-quality evidence). 특히, 갑상선초음파검사를통해증상을유발하는갑상선병증이실제갑상선결절과연관성이있는지를확인할필요가있으며, 갑상선결절의위치, 크기, 초음파검사에서나타나는형태학적특징에대한분석및경부림프절전이유무에대한검사등을위해경부갑상선초음파검사를 46

60 3. 연구결과 권고한다. 또한이러한소견을바탕으로초음파유도하세침흡인검사의필요성및가능여부를판단할수있다고보고하였다 (9,10). BTA Guidelines for the Management of Thyroid Cancer에서는경부초음파검사를갑상선결절의확인에대해매우민감한검사기법으로정의하였고, 특히유두상갑상선암 (papillary thyroid carcinoma, PTC) 의감별진단에사용을권고하고있다 (Good Practice Point ). 또한, 경부초음파검사를통해갑상선결절의형태학적소견에따른초음파유도하세침흡인검사여부를결정할수있고, 이의진단률성적을높이는데유용하다고하였다 (2++, B)(11,12). AACE/AME/ETA Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules에서는고해상도경부초음파검사를갑상선결절의발견및진단, 갑상선결절이외의갑상선실질의변화를판단하는데에있어가장유용한검사로정의하였고, 만져지는결절이있거나갑상선병증이의심되는경우우선초음파검사를시행할것을권고하였다 (13). 또한, 만져지는경부림프절이있을경우, 무증상갑상선암으로인한경부림프절전이를배재할수없으므로경부초음파검사를통한갑상선병증의확인도필요함을권고하고있다 (Grade C, BEL 3). NCCN Clinical Practice Guidelines for Thyroid Carcinoma, ver 에서는경부초음파검사를갑상선결절이의심되는환자에서일차적인진단검사로시행할것을권고한다 (Category 2A). 발견된갑상선결절의초음파소견과함께환자의임상소견, thyroid stimulating hormone (TSH), thyroglobulin (Tg) 수치등을종합하여초음파유도하세침흡인검사또는초음파검사를통한추적관찰을결정하게된다. 권고고려사항 1. 이득과위해경부초음파검사는갑상선결절의발견및진단에있어매우민감한검사방법으로, 다른영상검사와는달리방사선노출에대한위험이없고, 갑상선결절진단을비롯하여갑상선실질의변화등에대한평가뿐만아니라주변경부림프절에대한검사까지가능하다. 또한, 갑상선결절의초음파영상소견을분석하여초음파유도하세침흡인세포검사의필요여부를판단하고, 그진단의정확도를높일수있다 (11,12). 그러나무증상성인인구에서갑상선결절은매우흔하게발견되는질환이며, 여러초음파소견들중단독으로악성갑상선결절에서특이적으로보이는초음파소견은아직까지밝혀진바없고 (4), 양성및악성갑상선결절모두에서여러초음파소견이중복되어나타날수 47

61 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 있다 (6,12,14). 이로인해악성결절진단을위한불필요한양성결절의초음파유도하 세침흡인세포검사를시행하게되어필요이상의의료비지출증가및검사로인한합병 증등의위해를초래할수있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 갑상선결절이의심되거나진단된환자의일차적인영상검사방법으로 5개의진료가이드라인들에서모두동일하게경부초음파검사를선택하였다. 이들 5개진료지침에대한국내수용성및적용성평가결과, 갑상선결절의발견과진단에있어경부초음파검사를적용하는것은모두큰무리가없는것으로판단되었다. 수용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 경부초음파검사 0 참고문헌 1. Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedus L, Vitti P, American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and E uropean Thyroid Association Medical Guidelines for Clinical Practice for the Diag nosis and Management of Thyroid Nodules. J Endocrinol Invest. 2010;33: Haugen BRM, Alexander EK, Bible KC, Doherty G, Mandel SJ, Nikiforov YE, Pacini F, Randolph G, Sawka A, Schlumberger M, et al American Thyroid Associati on Management Guidelines for Adult Patients with Thyroid Nodules and Differenti ated Thyroid Cancer. Thyroid Moon WJ, Baek JH, Jung SL, Kim DW, Kim EK, Kim JY, Kwak JY, Lee JH, Lee JH, Lee YH, et al. Ultrasonography and the Ultrasound-Based Management of Thyroid Nodules: Consensus Statement and Recommendations. Korean J Radiol. 2011;12: Perros P, Colley S, Boelaert K, Evans C, Evans RM, Gerrard G, Gilbert J, Harrison B, Johnson SJ, Giles TE, et al. British Thyroid Association Guidelines for the Mana gement of Thyroid Cancer. Clinical Endocrinology 2014; National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in O ncology (NCCN Guidelines) Thyroid Carcinoma version Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, et al. Management of Thyroid Nodules De tected at US: Society of Radiologists in Ultrasound Consensus Conference Stateme nt. Radiology 2005;237: Guth S, Theune U, Aberle J, Galach A, Bamberger CM, Very High Prevalence of T hyroid Nodules Detected by High Frequency (13 MHz) Ultrasound Examination. Eu 48

62 3. 연구결과 r J Clin Invest. 2009;39: Tan GH, Gharib H, Thyroid Incidentalomas: Management Approaches to Nonpalpa ble Nodules Discovered Incidentally on Thyroid Imaging. Ann Intern Med. 1997;12 6: Smith-Bindman R, Lebda P, Feldstein VA, Sellami D, Goldstein RB, Brasic N, Jin C, Kornak J, Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Chara cteristics: Results of a Population-based Study. JAMA Intern Med. 2013;173: Brito JP, Gionfriddo MR, Al Nofal A, Boehmer KR, Leppin AL, Reading C, Callstr om M, Elraiyah TA, Prokop LJ, Stan MN, et al. The Accuracy of Thyroid Nodule Ultrasound to Predict Thyroid Cancer: Systematic Review and Meta-Analysis. J Cli n Endocrinol Metab. 2014;99: Cesur M, Corapcioglu D, Bulut S, Gursoy A, Yilmaz AE, Erdogan N, Kamel N, Co mparison of Palpation-guided Fine-Needle Aspiration Biopsy to Ultrasound-Guided Fine-Needle Aspiration Biopsy in the Evaluation of Thyroid Nodules. Thyroid 200 6;16: Hambly NM, Gonen M, Gerst SR, Li D, Jia X, Mironov S, Sarasohn D, Fleming S E, Hann LE, Implementation of Evidence-Based Guidelines for Thyroid Nodule Bio psy: A Model for Establishment of Practice Standards. AJR Am J Roentgenol. 2011; 196: Solbiati L, Osti V, Cova L, Tonolini M, Ultrasound of Thyroid, Parathyroid Glands and Neck Lymph Nodes. Eur Radiol. 2001;11: Lee YH, Kim DW, In HS, Park JS, Kim SH, Eom JW, Kim B, Lee EJ, Rho MH, Dif ferentiation Between Benign and Malignant Solid Thyroid Nodules Using an US Cl assification System. Korean J Radiol. 2011;12:

63 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 KQ 2. 갑상선결절의적절한조직검사방법은무엇인가? 권고 2. 갑상선결절의조직검사를위한방법으로는초음파유도하세침흡인검사를권고한다. ( 권고등급 A, 근거수준 II) 근거요약갑상선결절이진단된환자에서조직학적진단을위한적절한조직검사방법에대한가이드라인은 5개의가이드라인이최종선택되었다 (1-5). 상기 5개의가이드라인은모두, 갑상선결절의조직검사방법으로, 세침흡인검사를권고하였으며, 촉진에의한세침흡인검사와초음파유도하세침흡인검사의표본의적절성 ( 비진단결과와표본오류 ), 위음성률에중점을두어가이드라인을작성하였다. BTA Guidelines for the Management of Thyroid Cancer에서는세침흡인검사가가치있고, 비용대비효과적인수술전검사방법이라고하였으며, 초음파유도하세침검사는정확도를높이고, 비적절한표본을얻을확률을줄인다고하였다. 215명을대상으로한전향적연구결과, 초음파유도하세침흡인검사의비진단결과율은 21.4% 로촉진에의한비진단결과율 (32.4%) 보다유의하게낮았으며, 위음성률역시, 초음파유도하세침흡인검사 (5.6%) 가촉진에의한경우 (15.8%) 보다유의하게낮았다 (6) ATA 가이드라인에서는세침흡인검사가갑상선결절을평가하는데있어가장정확하고비용대비효과적인검사라고강력히권고하였다. 후향적연구에서초음파유도하세침흡인검사의비진단결과율 (3.5%) 과위음성률 (1%) 이촉진에의한경우의비진단율 (8.7%) 과위음성률 (2.3%) 보다유의하게낮았다 (7). 특히, 낭성결절이나만져지지않는결절, 또는깊은곳에위치하는결절의경우, 비진단결과와표본오류가나올확률이높으므로, 초음파유도하세침검사가더욱권고된다고하였다. 촉진으로확인되는결절이초음파에서고형결절로확인되는경우에는세침흡인검사방법으로초음파유도와촉진에의한세침검사모두적용할수있다고하였다. 초음파유도하세침흡인검사의진단민감도는 97.1~100%, 특이도는 70.9~100%, 정확도는 75.9% 로보고되었다 (7,8). 2011년에발표된 KSThR 가이드라인의경우, 갑상선결절의조직검사방법으로초음파유도하세침검사를권고하였으나정확한근거는제시하지않았다. AACE/AME/ETA 가이드라인에서는, 갑상선결절의진료는초음파검사및세침흡인검사의결과에의해야한다고권고하였으며, 세침흡인검사는초음파유도하에이루어져야좀더신뢰할만하고비진단결과율을낮출수있다고권고하였다. 특히결절이만져지지 50

64 3. 연구결과 않거나, 환자가뚱뚱하거나, 경부근육이매우발달되어있거나, 다결절성인경우초음파유도하세침검사를강력히권고하였다 (7,9-13). 386명을대상으로한전향적연구결과초음파유도하세침흡인검사의비진단율 (12.5%) 은촉진에의한세침흡인검사의비진단율 (27.2%) 보다유의하게낮았다. NCCN Clinical Practice Guidelines for Thyroid Carcinoma, ver 에서는, 발견된갑상선결절의초음파소견에따라특정적응증에해당되면조직학적진단을위해세침흡인검사를시행한것을권고하였다. 또한, 이전세침흡인검사에서고형결절이면서부적절한검체를얻었던경우또는비진단결과인경우, 반드시초음파유도하세침흡인검사를시행할것을권고하였다. 그러나정확한근거는제시하지않았다. 권고고려사항 1. 이득과위해갑상선결절의초음파유도하세침검사는비교적쉽고안전한검사로적절한교육을받은갑상선진료를전문으로하는의사라면누구나시행할수있는검사법이다. 그러나시술자의기술적숙련도와다양한기술적인자에대한이해에따라다양한빈도의비진단적결과가나올수있어, 이를최대한줄이려는노력이필요하다 (3). 보고된합병증은 0~8.6% 이며, 대부분이갑상선주변의혈종, 갑상선의부종, 일시적인목소리변화등이며, 입원이필요한정도의중증합병증은거의보고되지않았다. 출혈성향이나이에대한기왕력이있는경우등에대한사전준비와합병증에대한적절한예방및처치방법등에대해잘알고있어야한다. 2. 국내수용성과적용성 (Acceptability and Applicability) 갑상선결절의적절한조직검사방법으로 5개의진료가이드라인들에서모두초음파유도하세침흡인검사를권고하였다. 이들 5개진료지침에대한국내수용성및적용성평가결과, 큰무리가없는것으로판단되었다. 수용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 경부초음파검사 0 51

65 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 참고문헌 1. Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedus L, Vitti P, American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and E uropean Thyroid Association Medical Guidelines for Clinical Practice for the Diag nosis and Management of Thyroid Nodules. J Endocrinol Invest. 2010;33: Haugen BRM, Alexander EK, Bible KC, Doherty G, Mandel SJ, Nikiforov YE, Pacini F, Randolph G, Sawka A, Schlumberger M, et al American Thyroid Associati on Management Guidelines for Adult Patients with Thyroid Nodules and Differenti ated Thyroid Cancer. Thyroid Moon WJ, Baek JH, Jung SL, Kim DW, Kim EK, Kim JY, Kwak JY, Lee JH, Lee JH, Lee YH, et al. Ultrasonography and the Ultrasound-Based Management of Thyroid Nodules: Consensus Statement and Recommendations. Korean J Radiol. 2011;12: Perros P, Colley S, Boelaert K, Evans C, Evans RM, Gerrard G, Gilbert J, Harrison B, Johnson SJ, Giles TE, et al. British Thyroid Association Guidelines for the Mana gement of Thyroid Cancer. Clinical Endocrinology 2014; National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in O ncology (NCCN Guidelines) Thyroid Carcinoma version Cesur M, Corapcioglu D, Bulut S, et al. Comparison of Palpation Guided Fine Nee dle Aspiration Biopsy to Ultrasound Guided Fine Needle Aspiration Biopsy in the Evaluation of Thyroid Nodules. Thyroid 2006;16: Danese D, Sciacchitano S, Farsetti A, Andreoli M, Pontecorvi A, Diagnostic Accura cy of Conventional Versus Sonography-Guided Fine-Needle Aspiration Biopsy of T hyroid Nodules. Thyroid 1998;8(1): Carmeci C, Jeffrey RB, McDougall IR, Nowels KW, Weigel RJ, Ultrasound-Guided F ine-needle Aspiration Biopsy of Thyroid Masses. Thyroid 1998;8(4): Gharib H, Papini E, Thyroid Nodules: Clinical Importance, Assessment, and Treatm ent. Endocrinol Metab Clin North Am. 2007;36: Wu HH, Jones JN, Osman J, Fine-Needle Aspiration Cytology of the Thyroid: Ten Years Experience in a Community Teaching Hospital. 1997;82: Yang J, Schnadig V, Logrono R, Wasserman PG, Fine Needle Aspiration of Thyroi d Nodules: A Study of 4703 Patients with Histologic and Clinical Correlations. Ca ncer 2007;111: Deandrea M, Mormile A, Veglio M, et al. Fine-Needle Aspiration Biopsy of the T hyroid: Comparison Between Thyroid Palpation and Ultrasonography. Endocr Prac t. 2002;8: Can AS, Peker K, Comparison of Palpation-Versus Ultrasound-Guided Fine-Needl e Aspiration Biopsies in the Evaluation of Thyroid Nodules. BMC Res Notes 2008; 1:12. 52

66 3. 연구결과 2.3. 흉부분과 권고 1-1. 객혈이있는모든환자의초기검사로흉부 X-선검사를시행할것을권고한다. ( 권고등급 A, 근거수준 I). 권고 1-2. 객혈이있는폐암위험인자를가진 (40세이상, 30갑년이상흡연 ) 성인환자의원인진단을위한검사로조영증강흉부 CT를시행할것을권고한다. ( 권고등급 A, 근거수준 II). 권고 1-3. 중등증객혈 ( ml) 또는반복적객혈을보이는성인환자의원인진단을위한검사로조영증강흉부 CT를시행할것을권고한다. ( 권고등급 A, 근거수준 II). 권고 1-4. 대량객혈 (>400ml) 이있으나, 심장폐기능은유지되는성인환자의원인진단을위한검사로조영증강흉부 CT를시행할것을권고한다. ( 권고등급 A, 근거수준 III). 근거요약객혈은호흡기에서발생한출혈을뱉어내는것으로객담에혈흔이섞여있는정도부터대량객혈까지다양한범위로나타난다. 객혈의원인은기관지확장증, 급성및만성기관지염, 결핵, 미만성폐질환, 폐혈관기형등의양성질환및폐종양등이있으며원인불명인경우도있어적절한선별검사및정밀검사가필요하다 (1-3). 따라서본가이드라인은객혈이있는성인환자의원인진단을위해적절한영상의학적검사에대해작성하였다. 객혈이있는성인환자의원인진단을위한영상검사의권고에대한가이드라인은검색후 1개의가이드라인이선택되었고, 해당가이드라인이사용한근거문헌들을검토하였다 (4). 본가이드라인에서는객혈이있는모든환자의초기검사로흉부 X-선검사를시행할것을권고한다. 흉부 X-선검사는출혈부위를확인하는데도움을줄뿐아니라, 폐실질이나흉막등의기저질환여부에대한선별검사 (screening) 의역할을한다 (1,5,6). 원인진단을위한영상의학적검사를결정하는데있어, 객혈의양에따라경증객혈 (<30ml/24hr), 중등증객혈 (30-400ml), 대량객혈 (>400ml 이상 ) 로나누어검사방법을고려하였다 (6-9). 53

67 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 객혈의양에상관없이폐암위험인자를가진성인환자의경우에는정밀검사로조영증강흉부 CT를시행할것을권고한다. 객혈이있는성인환자에서그원인이종양인경우는논문에따라 10-35% 정도이다 (1,2). 객혈의원인을발견하지못한환자를추적관찰한연구에서 6% 의환자에서 3년이내에절제불가능한폐암이발견되었으며, 폐암이발생한모든환자는 40세이상의흡연자였다 (10). 또한객혈이있는환자중흉부 X-선검사소견이정상인환자를대상으로시행한 CT 검사에서 9.6% 의환자에서종양이발견이되었으며, 종양이발견된환자의 96% 는과거혹은현재의흡연력이있었다 (11). 중등증이상의객혈 (>30ml) 이나반복적객혈은즉각적인처치를위한출혈부위의발견보다는기저원인을밝혀내는것이중요하다. CT는비침습적인방법으로객혈의원인및출혈부위를한번에알아낼수있다는장점이있다. 문헌고찰에따르면, 객혈의원인은기관지확장증으로인한경우가가장많았고, 다음으로활동성폐결핵, 폐결핵후유증이흔했다 (5). 그외폐렴, 아스페르길루스종, 폐종양, 기관지염, 기타원인및원인을알수없는경우도있었다 (5). 특히, 한국에서는객혈의원인이활동성결핵이나폐결핵의후유증등염증성질환과관련된경우가많아, 흉부 X-선검사만으로는출혈병소를알아내기힘든경우가많다. 이런경우 CT를시행하면, 객혈의원인및출혈부위를평가하는데도움이되겠다 (12, 13). 일부환자에서객혈의치료를위해기관지동맥색전술을시행하게되는경우가있는데, 시술전에 CT를시행하면출혈의위치나기관지동맥또는폐동맥에관한영상해부학적소견을제시함으로써기관지동맥색전술시술을가이드하고, 또시술시간을줄여줄수있다 (14). 대량객혈 (>400ml) 이있는환자라도심장폐기능이유지되는경우에는조영증강흉부 CT를시행할것을권고한다. 대량객혈이있으면기관지동맥색전술이나수술을시행하게되는데, 색전술혹은수술시행전에 CT를시행하면출혈의원인이되는혈관을파악하여시술및수술에도움이된다 (6,15). 권고고려사항 1. 이득과위해객혈이있는환자의초기검사로흉부 X-선검사를시행하는것은비교적낮은방사선량으로출혈부위를결정할수있고, 폐실질질환에대한선별검사로이용할수있다는점에서매우유용하다. 40세이상 30갑년이상의흡연자로폐암위험인자를가진경우객혈의양에상관없이흉부 CT를시행할것을권고하고있는데, 흉부 X-선검사에서잘보이지않은폐암을 54

68 3. 연구결과 발견할수있다는장점이있으나, CT 시행으로인한방사선피폭의위해가있다. 중등증이상의객혈이있거나반복적객혈이있는환자에서 CT를시행하면객혈의원인및출혈부위를한번에알아낼수있다는장점이있다. 한국에서는객혈이활동성결핵이나폐결핵의후유증등염증성질환과관련된경우가많은데, 이런환자에서는흉부 X-선검사만으로는출혈병소를평가하기가힘들다. 이런경우 CT를시행하면출혈병소도정확히평가하고, 원인이되는질환도알수있어매우유용하게사용할수있다. 대량객혈이있는환자나중등증이상의객혈혹은반복적객혈이있는환자에서는치료의목적으로기관지동맥색전술을시행할수있다. 색전술시행전에 CT를시행하면출혈의위치나기관지동맥또는폐동맥에관한영상해부학적소견을제시함으로써시술을가이드하고, 또시술시간을줄여줄수있어방사선피폭의위해보다는이득이더크기때문에유용하게사용할수있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 특히한국에서는결핵및그후유증으로인한객혈의빈도가높은현실을감안하여권고안을작성하였으며수용성과적용성평가표는부록에제시되었다. 3. 검사별방사선량 흉부 X 선검사 흉부 CT 참고문헌 1. Tsoumakidou M, Chrysofakis G, Tsiligianni I, Maltezakis G, Siafakas NM, Tzanakis N. A prospective analysis of 184 hemoptysis cases diagnostic impact of chest x-ra y, computed tomography, bronchoscopy. Respiration. 2006;73(6): Fidan A, Özdoğan S, Oruc Ö, Salepci B, Öcal Z, Cağlayan B. Hemoptysis: a retrosp ective analysis of 108 cases. Respiratory medicine. 2002;96(9): Bruzzi JF, Rémy-Jardin M, Delhaye D, Teisseire A, Khalil C, Rémy J. Multi Detecto r Row CT of Hemoptysis 1. Radiographics. 2006;26(1): Jeudy J, Khan AR, Mohammed T-L, Amorosa JK, Brown K, Dyer DS, et al. ACR Ap propriateness Criteria Hemoptysis. Journal of thoracic imaging. 2010;25(3):W67- W9. 5. Lee SJ, Rho JY, Yoo SM, Kim MD, Lee JH, Kim EK, et al. Usefulness of Multi-Dete ctor Computed Tomography before Bronchoscopy and/or Bronchial Arterial Embol 55

69 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 ization for Hemoptysis. Tuberculosis and Respiratory Diseases. 2010;68(2): Revel MP, Fournier LS, Hennebicque AS, Cuenod CA, Meyer G, Reynaud P, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? American Journal of Roentgenology. 2002;179(5): Delage A, Tillie-Leblond I, Cavestri B, Wallaert B, Marquette C-H. Cryptogenic he moptysis in chronic obstructive pulmonary disease: characteristics and outcome. R espiration. 2010;80(5): Menchini L, Remy-Jardin M, Faivre J, Copin M, Ramon P, Matran R, et al. Cryptog enic haemoptysis in smokers: angiography and results of embolisation in 35 patie nts. Eur Respir J. 2009;34(5): Poe RH, Israel RH, Marin MG, Ortiz CR, Dale RC, Wahl GW, et al. Utility of fiber optic bronchoscopy in patients with hemoptysis and a nonlocalizing chest roentge nogram. Chest. 1988;93(1): Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in p atients with hemoptysis of unknown origin. CHEST Journal. 2001;120(5): Thirumaran M, Sundar R, Sutcliffe IM, Currie DC. Is investigation of patients wit h haemoptysis and normal chest radiograph justified? Thorax. 2009;64(10): McGuinness G, Beacher JR, Harkin TJ, Garay SM, Rom WN, Naidich DP. Hemopt ysis: prospective high-resolution CT/bronchoscopic correlation. CHEST Journal ;105(4): Mlllar A, Boothroyd A, Edwards D, Hetzel M. The role of computed tomography (CT) in the investigation of unexplained haemoptysis. Respiratory medicine. 1992; 86(1): Khalil A, Fartoukh M, Parrot A, Bazelly B, Marsault C, Carette M-F. Impact of M DCT angiography on the management of patients with hemoptysis. American Jour nal of Roentgenology. 2010;195(3): Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB. Utility of fi beroptic bronchoscopy before bronchial artery embolization for massive hemoptys is. American Journal of Roentgenology. 2001;177(4):

70 3. 연구결과 2.4. 심장분과 KQ 1. 관상동맥질환병력이없는무증상개인 (individual) 에서관상동맥질환의발견과위험도평가를위한적절할영상검사는무엇인가? 권고 1-1. 증상이없는개인에서관상동맥질환의발견을위하여저위험군과중등도위험군에서영상검사를시행하지않는것을권고한다. ( 권고등급 C, 근거수준 III) 권고 1-2. 증상이없는개인에서관상동맥질환의발견을위하여고위험군에속한개인에서는관상동맥 CT를권고한다. ( 권고등급 A, 근거수준 III) 근거요약관상동맥질환병력이없는무증상개인에서관상동맥질환의영상평가에대한가이드라인은검색후 3개의가이드라인이선택되었다. 모든가이드라인에서고식적인관상동맥질환위험인자로평가된저위험군과중등도위험군에서는관상동맥전산화단층촬영검사 (Computed Tomography, CT) 가추천되지않았다. 다만고위험군에대해서는관상동맥 CT의효과에대해아직의견일치가이루어지지않아하나의가이드라인에서는무증상고위험군개인에서관상동맥 CT 시행을추천하였고, 나머지두가이드라인에서는고려할수있다고언급하였다. 관상동맥 CT는관상동맥질환을평가하는데정확도가높은검사이고증상이없는개인에서도관상동맥 CT에서상당수의환자에서관상동맥질환이발견된다 (1,2,5). 관상동맥질환의저위험군과중등도위험군에서는관상동맥질환의유병률이낮아관상동맥 CT 의추가적인이득이위해에비해크지않고, 이에관상동맥 CT가추천되지않는다. 그러나고위험군에서는고식적인위험도평가방법에비해정확도가높은관상동맥 CT를시행하는것이증상이나타나기전의관상동맥의동맥경화를확인하고치료하여예후를향상시킬가능성이있다. 무증상고위험군을대상으로한연구에서관상동맥 CT는의미있는관상동맥질환을발견하고위험도를재평가하는데유용하였다 (7-9). 그러나아직 CT로관상동맥질환을발견하고치료한예후에대한연구결과가부족하여가이드라인에서는의견일치를이루지못한상황이다. 57

71 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 권고고려사항 1. 이득과위해무증상개인에서관상동맥 CT를시행하여증상이나타나기전의관상동맥질환을발견할수있다. 그러나관상동맥 CT는방사선피폭의단점이있으며추가적인비용측면에서불리하다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 국내수용성과적용성평가결과는부록에제시한다. 3. 검사별방사선량 관상동맥 CT 참고문헌 1. Lee S, Choi EK, Chang HJ, Kim CH, Seo WW, Park JJ, et al. Subclinical Coronary Artery Disease as Detected by Coronary Computed Tomography Angiography in a n Asymptomatic Population. Korean Circ J. 2010;40: Yoo DH, Chun EJ, Choi SI, Kim JA, Jin KN, Yeon TJ, et al. Significance of Noncal cified Coronary Plaque in Asymptomatic Subjects with Low Coronary Artery Calciu m Score: Assessment with Coronary Computed Tomography Angiography. Int J Ca rdiovasc Imaging 2011;27 Suppl 1: Cho I, Chang HJ, Sung JM, Pencina MJ, Lin FY, Dunning AM, et al. Coronary Com puted Tomographic Angiography and Risk of All-Cause Mortality and Non-Fatal M yocardial Infarction in Subjects Without Chest Pain Syndrome from the CONFIRM Registry (COronary CT Angiography Evaluation for Clinical Outcomes: An Internati onal Multicenter Registry). Circulation 2012;126: Cademartiri F, Maffei E, Palumbo A, Seitun S, Martini C, Tedeschi C, et al. Coron ary Calcium Score and Computed Tomography Coronary Angiography in High-Ris k Asymptomatic Subjects: Assessment of Diagnostic Accuracy and Prevalence of N on-obstructive Coronary Artery Disease. Eur Radiol. 2010;20: Choi EK, Choi SI, Rivera JJ, et al. Coronary Computed Tomography Angiography a s a Screening Tool for the Detection of Occult Coronary Artery Disease in Asymp tomatic Individuals. J Am Coll Cardiol. 2008;52: Bluemke DA, Achenbach S, Budoff M, et al. Noninvasive Coronaryartery Imaging: Magnetic Resonance Angiography and Multidetector Computed Tomography Angio graphy: A Scientific Statement from the American Heart Association Committee o n Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radi ology and Intervention and the Councils on Clinical Cardiology and Cardiovascula 58

72 3. 연구결과 r Disease in the Young. Circulation 2008;118: Rivera JJ, Nasir K, Choi EK, et al. Detection of Occult Coronary Artery Disease in Asymptomatic Individuals with Diabetes Mellitus Using Non-Invasive Cardiac Angio graphy. Atherosclerosis 2009;203(2): Romeo F, Leo R, Clementi F, et al. Multislice Computed Tomography in an Asymp tomatic High-Risk Population. Am J Cardiol. 2007;99(3): Hadamitzky M, Meyer T, Hein F, et al. Prognostic Value of Coronary Computed T omographic Angiography in Asymptomatic Patients. Am J Cardiol. 2010;105(12):

73 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 KQ 2. 원인이불분명한부정맥환자에게심장질환의발견을위한적절한검사는무엇인가? 권고 2-1. 비지속성심실부정맥환자나실신환자에서심전도와심장초음파검사로원인을알수없는경우, 구조적심장질환의감별과심장의해부학적, 기능적평가를위한목적으로심장 CT와 MRI를시행하는것을권고한다. ( 권고등급 A, 근거수준 II) 권고 2-2. 새롭게발병한심방세동의경우심장 CT 검사시행은초기진단목적으로는부적절하나, 심방세동의전기소작술이전에심장과폐정맥의해부학을알기위한목적으로고려할수있다. 전기소작술전후 MRI의시행은좌심방의해부학적, 기능적평가나소작술시행부위의섬유화평가를위해고려할수있다. ( 권고등급 B, 근거수준 II) 근거요약비지속성심실부정맥 (non-sustained ventricular arrhythmias) 환자나실신환자의대다수의환자가 12-lead ECG와 echocardiography 로원인을규명할수있으나, 구조적심장질환 (structural heart disease) 즉, 확장성심근병증 (dilated cardiomyopathy), 비후성심근병증 (hypertrophic cardiomyopathy), 사르코이드증 (cardiac sarcoidosis), 아밀로이드증 (cardiac amyloidosis), 부정맥발생우심실형성이상 (arrhythmogenic right ventricular cardiomyopathy) 과같은기저질환을감별하고, 심실의기능과해부학적구조를평가하기위해심장 CT와자기공명영상검사 ( magnetic resonance imaging, MRI) 를시행하는것은환자치료와예후에추가적인정보를제공할수있기때문에권고된다 (1-4). 새롭게발병한심방세동 (atrial fibrillation) 의경우초기진단목적으로심장 CT 시행은부적절하나, 심방세동치료를위한전기소작술 (catheter ablation) 이전에심장과폐정맥의해부학파악하기위해심장 CT를시행하는것이적절하다. 심방세동환자에서전기소작술시술전후심장 MRI의시행은좌심방의해부학적, 기능적평가를하고소작술시행부위의섬유화평가를위해적절하다 (5-8). 권고고려사항 1. 이득과위해심실부정맥환자나실신환자에서임상적검사로원인규명을정확히하지못하는환자에서구조적심장질환을감별하고, 심실의기능과해부학적구조를평가하기위해심장 60

74 3. 연구결과 CT와 MRI를시행하는것은환자치료와예후에추가적인정보를제공할수있기때문에유용하게사용할수있다. 새롭게발병한심방세동환자의경우초기진단목적으로심장 CT의시행은방사선피폭으로인한잠재적위해가있으나, 심방세동치료를위한전기소작술이전에 CT의시행은방사선피폭의위해보다는심장과폐정맥의해부학파악할수있는이득이크기때문에유용하게사용할수있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 국 내수용성과적용성평가결과는부록에제시한다. 3. 검사별방사선량 심장 CT 심장 MRI 0 참고문헌 1. Marcus FI, McKenna WJ, Sherrill D, Basso C, Bauce B, Bluemke DA et al. Diagnosi s of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: Proposed Modifi cation of the Task Force Criteria. Eur Heart J. 2010;31: Aquaro GD, Pingitore A, Strata E, Di Bella G, Molinaro S, Lombardi M, Cardiac M agnetic Resonance Predicts Outcome in Patients with Premature Ventricular Comp lexes of Left Bundle Branch Block Morphology. J Am Coll Cardiol. 2010;56: Marcus FI, Bluemke DA, Calkins H, Sorrell VL, Cardiac Magnetic Resonance for Ri sk Stratification of Patients with Frequent Premature Ventricular Contractions. J A m Coll Cardiol. 2011;57:1636 7; author reply Jonnalagadda N et al. Role of Cardiac Imaging Evaluation of Patients with Docum ented or Suspected Ventricular Arrhythmias. J Nucl Cardiol. 2010;17(1): Wazni OM et al. Cardiovascular Imaging in the Management of Atrial Fibrillation. J Am Coll Cardiol. 2006;48(10): Kato R et al. Pulmonary Vein Anatomy in Patients Undergoing Catheter Ablation o f Atrial Fibrillation: Lessons Learned by Use of Magnetic Resonance Imaging. Circ ulation 2003;107: Lacomis JM et al. Direct Comparison of Computed Tomography and Magnetic Res onance Imaging for Characterization of Posterior Left Atrial Morphology. Journal of Interventional Cardiac Electrophysiology: An International Journal of Arrhythmi as and Pacing 2006;16: Mansour M et al. Three Dimensional Anatomy of the Left Atrium by Magnetic Res 61

75 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 onance Angiography: Implications for Catheter Ablation for Atrial Fibrillation. Jour nal of Cardiovascular Electrophysiology 2006;17:

76 3. 연구결과 KQ 3. 급성심장질환이없는중등위험도환자에게심장수술이외의수술전관상동맥질 환의위험도평가를위한적절한영상검사는무엇인가? 권고 3-1. 중등도위험도의환자에서심장수술이외의수술전에임상적으로위험인자가없고 4 METs 이상의심폐능력을보이는경우영상검사를시행하지않는것을권고한다. ( 권고등급 C, 근거수준 II) 권고 3-2. 중등도위험도의환자에서심장수술이외의수술전에임상적으로위험인자를두개이상가지고있고심폐능력을모르는경우관상동맥 CT를고려할수있다. ( 권고등급 B, 근거수준 III) 권고 3-3. 중등도위험도의환자에서심장수술이외의수술전에임상적으로위험인자를두개이상가지고있고, 4 METs 미만의심폐능력을보이는경우관상동맥 CT를고려할수있다. ( 권고등급 B, 근거수준 III) 권고 3-4. 중등도위험도의환자에서심장수술이외의수술전에임상적으로위험인자를두개이상가지고있고, 4 METs 미만의심폐능력을보이면서관상동맥 CT의적응증이아닌경우심장 MRI를고려할수있다. ( 권고등급 B, 근거수준 III) * MET: 예상에너지요구량 (Estimated metabolic equivalent of exercise) 근거요약심장수술이외의수술은수술로인하여심장에미칠수있는영향에따라저위험도 / 중등도-고위험도수술로나뉘며저위험도수술은환자상태나수술자체위험도에의해수술후주요심장사건 (major adverse cardiac event) 이나심근경색 (myocardial infarctions) 이일어날확률이 1% 미만인수술을의미하며 1% 이상인수술을중증도-고위험도수술로분류한다 (1,2). 두경부수술, 경동맥내막절제술, 근골격계수술, 전립선수술, 흉강, 복강수술이중등도위험을가진수술에속한다 (3,4). 또한주요심장사건이발생할확률에환자의심폐기능과임상적인위험인자 ( 이전허혈성심질환, 심부전, 혹은뇌혈관질환과거력, 당뇨, 신기능저하 )(5-7) 가고려대상이되며보통임상위험인자 63

77 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2개이상을가진경우술후 MACE 위험도에영향을미친다고보고되어있다 (1,2). 환자의심폐기능은일상생활을통해측정할수있다 (Table 1)(8). 4 METs(Estimated metabolic equivalent of exercise: 예상에너지요구량 ) 이상의심폐능력을보이는경우더이상의검사가필요없지만 4METs 미만의심폐능력을보이거나환자심폐기능을알수없는경우추가검사가필요하다 (1,2). 추가영상검사로는보통부하심초음파검사 (pharmacological or exercise stress echocardiography) 나핵의학관류영상검사 (radionuclide myocardial perfusion imaging, MPI), 단일광자단층촬영검사 (single photon emission computed tomography) 등이있으며 (1,2) 최근에장수술이외의수술전관상동맥질환선별검사로서관상동맥 CT의진단능력이침습적관상동맥조영술과비슷함이보고되었다 (9). 비침습적인검사로많이이용되는부하심초음파검사는약물혹은운동부하를이용하여평상시와심부하시심근의기능을평가할수있지만영상질이떨어지고관상동맥을직접평가하기어렵다는단점이있다 (10). 표 14. 다양한활동의예상에너지요구량 (MET) MET 1-4 METs 4-10METs 활동혼자서자신을돌볼수있는가? 먹고옷을입고화장실을사용할수있는가집근처실내를걸어다닐수있는가? 평지한두블록을 2-3 mile/h ( km/h) 의속도로걸을수있는가? 설거지나잔디깎기등의간단한집안일을할수있는가? 계단이나언덕을올라갈수있는가? 4 mile/h (6.4 km/h) 속도로평지를걸을수있는가? 짧은거리를뛸수있는가? 바닥을닦는다거나무거운가구를드는등의힘든집안일을할수있는가? 골프, 볼링, 댄스, 테니스복식경기, 축구, 야구공던지기등의레크리에이션활동을할수있는가? >10 METs 수영, 테니스단식경기, 축구, 야구, 스키등의격렬한스포츠에참여할수있는가? 권고고려사항 1. 이득과위해최근많이이용되고있는관상동맥 CT는방사선노출의위험이있지만부하심초음파에비해관상동맥과함께주변구조물을평가할수있고관류 CT를통하여기능적인평가도가능하다 (10). 또한다중채널개발과시간해상도향상, 재구성기법의발달에따라 64

78 3. 연구결과 영상의질과진단능을유지하면서최소 1 msv 이하의방사선노출로검사가가능하게되었다 (11). 최소 5 msv 이상의방사선에노출되는핵의학검사에비해훨씬적은양의방사선노출과시간해상도가높은영상을단시간에얻을수있게되었다 (11,12). 심장 MRI는우수한공간해상도 (spatial resolution) 를보이며심기능 (function) 평가가가능하고 CT나핵의학검사와다르게방사선노출이없다는장점이있지만촬영시간이오래걸리고여러가지금기사항 ( 폐쇄공포증, 인공심박동기등 ) 이있으며 CT에비해접근성이떨어져 CT를시행할수없는경우고려할수있다 (13). 2. 국내수용성과적용성 (Acceptability and Applicability) 현재국내심장관상동맥 CT와심장 MRI 이용에대한진료지침이발표되어있어진료지침의국내수용성과적용성은매우높을것으로기대된다. 그외다른참고지침의권고내용과이에대한국내수용성과적용성평가는부록에제시되었다. 3. 검사별방사선량 관상동맥 CT 심장 MRI 0 참고문헌 1. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and M anagement of Patients Undergoing Noncardiac Surgery: Executive Summary: A Rep ort of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Developed in Collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiogr aphy, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesi ologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Me dicine. J Nucl Cardiol. 2015;22: Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and M anagement of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guideli nes. J Am Coll Cardiol. 2014;64: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care fo r Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise 65

79 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Su rgery): Developed in Collaboration with the American Society of Echocardiograph y, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Card iovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventi ons, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007;116: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et a l. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluati on for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Soci ety, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiogr aphy and Interventions, Society for Vascular Medicine and Biology, and Society fo r Vascular Surgery. J Am Coll Cardiol. 2007;50: Cohen ME, Ko CY, Bilimoria KY, Zhou L, Huffman K, Wang X, et al. Optimizing ACS NSQIP Modeling for Evaluation of Surgical Quality and Risk: Patient Risk Adj ustment, Procedure Mix Adjustment, Shrinkage Adjustment, and Surgical Focus. J Am Coll Surg. 2013;217: e Gupta PK, Ramanan B, Lynch TG, Sundaram A, MacTaggart JN, Gupta H, et al. D evelopment and Validation of a Risk Calculator for Prediction of Mortality After I nfrainguinal Bypass Surgery. J Vasc Surg. 2012;56: Ford MK, Beattie WS, Wijeysundera DN, Systematic Review: Prediction of Perioper ative Cardiac Complications and Mortality by the Revised Cardiac Risk Index. Ann Intern Med. 2010;152: Reilly DF, McNeely MJ, Doerner D, Greenberg DL, Staiger TO, Geist MJ, et al. Self -Reported Exercise Tolerance and the Risk of Serious Perioperative Complication s. Arch Intern Med. 1999;159: Kaneko K, Ito M, Takanashi T, Hashizume E, Owashi K, Kaneko H, et al. Comput ed Tomography and Scintigraphy vs. Cardiac Catheterization for Coronary Disease Screening Prior to Noncardiac Surgery. Intern Med. 2010;49: Tweet MS, Arruda-Olson AM, Anavekar NS, Pellikka PA, Stress Echocardiography: What is New and How Does It Compare with Myocardial Perfusion Imaging and Other Modalities? Curr Cardiol Rep. 2015;17: Stehli J, Fuchs TA, Bull S, Clerc OF, Possner M, Buechel RR, et al. Accuracy of C oronary CT Angiography Using a Submillisievert Fraction of Radiation Exposure: C omparison with Invasive Coronary Angiography. J Am Coll Cardiol. 2014;64: Nabi F, Kassi M, Muhyieddeen K, Chang SM, Xu J, Peterson L, et al. Optimizing Evaluation of Patients with Low to Intermediate Risk Acute Chest Pain: A Random ized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stres s-only Imaging to Cardiac Computed Tomography. J Nucl Med

80 3. 연구결과 13. Yoon YE, Hong YJ, Kim HK, Kim JA, Na JO, Yang DH, et al Korean Guide lines for Appropriate Utilization of Cardiovascular Magnetic Resonance Imaging: A Joint Report of the Korean Society of Cardiology and the Korean Society of Radi ology. Korean J Radiol. 2014;15:

81 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.5. 유방분과 KQ 1. 무증상여성을대상으로한유방암검진에서유방암을발견하기위한적절한검사는무엇 인가? 권고 세무증상여성을대상으로한유방암검진으로유방촬영검사를권고한다. ( 권고등급 A, 근거수준 I) 권고 세이상여성에서유방촬영검사를이용한검진은개인위험도에대한임상적판단과수검자의선호도를고려하여시행할수있다. ( 권고등급 B, 근거수준 I) 권고 세미만의여성에서유방암검진은권고하지않는다. ( 권고등급 I, 근거수준 III) 근거요약무증상여성을대상으로한유방암검진에서사용될영상진단에대한가이드라인은검색후최종 4개 : 2015 유방암검진권고개정안, American College of Radiology (ACR) Appropriateness Criteria for Breast Cancer Screening, Canadian Task Force on Preventive Health Care의 breast cancer screening recommendations, 그리고 US Preventive Services Task Force (USPSTF) Recommendation Statement for Breast Cancer Screening 을선택하였다. 이중 3개는미국, 캐나다등의서구에서발표된유방암검사에대한권고안이고, 1개는국내에서발표된권고안이다 (1-4). 최근까지많은연구에서유방촬영검사를이용한검진이유방암으로인한사망률을감소시킨다고입증되어이들 4개의권고안에서는공통적으로무증상여성을대상으로한유방암검사를위한영상검사방법으로유방촬영검사 (mammography) 를권하고있다 (5-15). 권고안에따라유방촬영검사의시행연령과주기에일부차이가있는데, 그내용은아래와같다. 2015년에발표된국내유방암검진권고안개정안에서는 40-69세무증상여성을대상으로유방촬영검사를이용한유방암검진을 2년마다시행할것을권고하고있다 ( 권고등급 B). 70세이상의여성에서는유방촬영검사를이용한유방암검진이사망률을낮추는것에대한근거수준이낮아유방암에대한개인별위험도에대한임상적판단과수검자의선호도를고려해선택적으로시행할것을권하고있다 ( 권고등급 C). 또한, 유방암검진목적의유방초음파검사또는임상유방진찰은권고하거나반대하지않는다 ( 권고등급 I). 특히, 유방초음파검사의경우, 무작위배정비교임상시험이나코호트연구가없었 68

82 3. 연구결과 으므로이를이용한유방암사망률감소효과는평가할수없다. 유방촬영검사에서음성이고치밀유방인여성에서유방초음파검사를시행하였을때, 추가로진단되는유방암이 1,000명당 0.3~5.1명으로다양하게보고되고있어검진에서의효과는결론내리기가어렵다 (16-21). American College of Radiology (ACR) 의 Appropriateness Criteria for Breast Cancer Screening(2) 에서는 40세이상의 15% 미만의유방암발병위험률을가진여성에서매년검진목적의유방촬영검사를권하고있다 (rating 9). 유방 MRI를이용한유방암검진은진단의민감도는유방촬영검사에비해높으며, 유방촬영검사와병행하여시행하는경우민감도가약 92.7% 로가장높게나타나지만 (22), 이를이용한유방암검진은 20% 이상의유방암발병위험률을가진여성 (BRCA 유전자변이양성으로진단된여성및가족, 10~30세에흉부방사선치료받은과거력이있는여성 ) 에서는이득이있지만, 15% 미만의유방암발병위험률을보이는경우에는이득이상대적으로적다 (rating 3). 유방초음파검사를이용한검진에서는위양성률이높으며, 검사시간이길기때문에비용효과적인면에서좋지않아권하지않는다 (23)(rating 2). Canadian Task Force on Preventive Health Care(3) 에서는 50~69세여성에서매 2~3년마다유방촬영검사를이용한검진을권하고있다 ( 권고등급 weak, 근거수준중등도 ). 40~49세의여성이나 70~74세의여성의경우, 유방촬영검사를이용한검진을통해서얻을수있는이득이상대적으로적기때문에 40~49세여성의경우에는유방촬영검사를이용한검진을규칙적으로권고하거나반대하지않고 ( 권고등급 weak, 근거수준중등도 ), 70~74세여성의경우매 2~3년마다유방촬영검사를이용한검진을권하고있지만권고등급및근거수준이모두낮은정도이다. 유방 MRI나유방자가검진 (breast self examination)(24) 을이용한검진에대한근거는부족하므로이는권하거나반대하지않는다 ( 권고등급 low, 근거수준낮음 ). US Preventive Services Task Force (USPSTF)(4) 의유방암검진권고안에서는 50~74세여성에서 2년마다검진목적으로유방촬영검사를권하고있다 ( 권고등급 B). 40~49세여성에서는검진을위해유방촬영검사를시행함으로써얻는이득이적을것으로판단해권고하지않는다 ( 권고등급 C). 75세이상의여성에서유방촬영검사를이용한검진에대한근거가충분하지않아, 검진으로인한이득과위해를정확히평가하기어렵다 (I statement). 유방자가검진은위해가이득보다큰것으로판단해권하지않는다 (D recommendation). 임상유방진찰 (clinical breast examination) 이나유방 MRI 디지털유방촬영검사 (digital mammography) 는유방촬영검사를대신할근거가충분하지않고, 69

83 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 이로인한이득과위해를평가하기어렵다 (I statement). 권고고려사항 1. 이득과위해무증상여성에서유방암검진을목적으로유방촬영검사를시행하는경우, 유방암으로인한사망률이검진군에서대조군에비해약 19% 낮게나타나유방촬영검사를이용한검진으로이득을볼수있다 (6,7,9,10,12,13,15). 그러나유방촬영검사를이용할경우방사선피폭의문제가발생하게되는데, 검진간격이짧을수록, 유방촬영검사를이용한검진을이른연령에서시작할수록방사선에의해발생하는위해가큰것으로나타났다 (25-27). 치밀유방에서는유방촬영검사의진단민감도가감소하고유방촬영검사로인한과진단의문제가발생할수있는데, 유방촬영검사의위양성률이 3.4~61.3% 로다양하게나타나므로이로인한위해는정확히평가하기어렵다 (28-30). 이와같은내용을종합하였을때, 20~30대는유방촬영검사를이용한검진이이익보다위해가클수있으나, 40세이상에서는방사선피폭의위해보다검진으로인한사망률감소의이득이큰것으로추정된다 (25,31). 2. 국내수용성과적용성 (Acceptability and Applicability) 4개의진료가이드라인의국내수용성과적용성평가결과무증상의여성에대해서유방검진을시행하는검사방법으로유방촬영검사를선택하는데있어진료지침이일치하였다. 그러나유방촬영검사의시행연령과검사간격에대해서는진료지침별로다른결론을내리고있었다. 이러한차이는국가별검사장비의보급, 인종에따른여성유방형태의특징, 그리고보험급여적용여부및검사로인해발생하는의료비의차이로나타나는현상으로생각되고이의국내수용성과적용성은평가결과큰무리가없는것으로판단하였다. 수용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 유방촬영검사 유방초음파검사 0 70

84 3. 연구결과 참고문헌 1. 이은혜, 김남순, 서현주, 고경란, 민준원, 신명희, 이기헌, 이시연, 최나미, 허민희, 김동일, 김민정, 김성용, 선우성, 당지연, 김수영, 김열, 이원철, 정준, 유방암검진권고안개정안. J Ko rean Med Assoc. 2015;58: American College of Radiology. ACR Appropriateness CriteriaR Breast Cancer Scre ening. 2012; Tonelli M, Connor Gorber S, Joffres M, Dickinson J, Singh H, Lewin G, Birtwhistle R, Fitzpatrick-Lewis D, Hodgson N, Ciliska D, et al. Recommendations on Screeni ng for Breast Cancer in Average-risk Women Aged Years. CMAJ 2011;183: Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2009;151:716-26, w Reduction in Breast Cancer Mortality from Organized Service Screening with Mam mography: 1. Further Confirmation with Extended Data. Cancer Epidemiol Biomar kers Prev. 2006;15: Andersson I, Aspegren K, Janzon L, Landberg T, Lindholm K, Linell F, Ljungberg O, Ranstam J, Sigfusson B, Mammographic Screening and Mortality from Breast C ancer: the Malmo Mammographic Screening Trial. BMJ 1988;297: Bjurstam N, Bjorneld L, Warwick J, Sala E, Duffy SW, Nystrom L, Walker N, Cahlin E, Eriksson O, Hafstrom LO, et al. The Gothenburg Breast Screening Trial. Cancer 2003;97: Duffy SW, Tabar L, Chen HH, Holmqvist M, Yen MF, Abdsalah S, Epstein B, Frodis E, Ljungberg E, Hedborg-Melander C, et al. The Impact of Organized Mammograp hy Service Screening on Breast Carcinoma Mortality in Seven Swedish Counties. C ancer 2002;95: Frisell J, Lidbrink E, Hellstrom L, Rutqvist LE, Followup After 11 Years-update of Mortality Results in the Stockholm Mammographic Screening Trial. Breast Cancer Res Treat. 1997;45: Habbema JD, van Oortmarssen GJ, van Putten DJ, Lubbe JT, van der Maas PJ, Ag e-specific Reduction in Breast Cancer Mortality by Screening: an Analysis of the Results of the Health Insurance Plan of Greater New York study. J Natl Cancer In st. 1986;77: Hendrick RE, Smith RA, Rutledge JH 3rd, Smart CR, Benefit of Screening Mammo graphy in Women Aged 40-49: A New Meta-analysis of Randomized Controlled Tr ials. J Natl Cancer Inst Monogr. 1997: Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA, Twenty Five Year Follow-u p for Breast Cancer Incidence and Mortality of the Canadian National Breast Scre ening Study: Randomised Screening Trial. BMJ 2014;348: Moss SM, Cuckle H, Evans A, Johns L, Waller M, Bobrow L, Effect of Mammogra phic Screening from Age 40 Years on Breast Cancer Mortality at 10 Years' Follow -up: A Randomised Controlled Trial. Lancet 2006;368: Tabar L, Vitak B, Chen HH, Yen MF, Duffy SW, Smith RA, Beyond Randomized C 71

85 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 ontrolled Trials: Organized Mammographic Screening Substantially Reduces Breast Carcinoma Mortality. Cancer 2001;91: Tabar L, Vitak B, Chen TH, Yen AM, Cohen A, Tot T, Chiu SY, Chen SL, Fann J C, Rosell J, et al. Swedish Two-county Trial: Impact of Mammographic Screening on Breast Cancer Mortality During 3 Decades. Radiology 2011;260: Hooley RJ, Greenberg KL, Stackhouse RM, Geisel JL, Butler RS, Philpotts LE, Scre ening US in Patients with Mammographically Dense Breasts: Initial Experience wit h Connecticut Public Act Radiology 2012;265: Girardi V, Tonegutti M, Ciatto S, Bonetti F, Breast Ultrasound in 22,131 Asympto matic Women with Negative Mammography. Breast 2013;22: Moon HJ, Jung I, Park SJ, Kim MJ, Youk JH, Kim EK, Comparison of Cancer Yiel ds and Diagnostic Performance of Screening Mammography vs. Supplemental Scre ening Ultrasound in 4394 Women with Average Risk for Breast Cancer. Ultraschall Med. 2015;36: Chang JM, Koo HR, Moon WK, Radiologist-performed Hand-held Ultrasound Scre ening at Average Risk of Breast Cancer: Results from a Single Health Screening C enter. Acta Radiol. 2015;56: Kaplan SS, Clinical Utility of Bilateral Whole-breast US in the Evaluation of Wom en with Dense Breast Tissue. Radiology 2001;221: Corsetti V, Houssami N, Ferrari A, Ghirardi M, Bellarosa S, Angelini O, Bani C, S ardo P, Remida G, Galligioni E, et al. Breast Screening with Ultrasound in Women with Mammography-negative Dense Breasts: Evidence on Incremental Cancer Dete ction and False Positives, and Associated Cost. Eur J Cancer 2008;44: Berg WA, Tailored Supplemental Screening for Breast Cancer: What Now and Wh at Next? AJR Am J Roentgenol. 2009;192: Berg WA, Blume JD, Cormack JB, Mendelson EB, Lehrer D, Bohm-Velez M, Pisan o ED, Jong RA, Evans WP, Morton MJ, et al. Combined Screening with Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast Cancer. JAMA 2008;299: Humphrey L, Chan BKS, Detlefsen S, Helfand M, U.S. Preventive Services Task Fo rce Evidence Syntheses, formerly Systematic Evidence Reviews. Screening for Breas t Cancer. Rockville (MD): Agency for Healthcare Research and Quality (US) Beckett JR, Kotre CJ, Michaelson JS, Analysis of Benefit: Risk Ratio and Mortality Reduction for the UK Breast Screening Programme. Br J Radiol. 2003;76: Beemsterboer PM, Warmerdam PG, Boer R, de Koning HJ, Radiation Risk of Ma mmography Related to Benefit in Screening Programmes: A Favourable Balance? J Med Screen. 1998;5: Bijwaard H, Brenner A, Dekkers F, van Dillen T, Land CE, Boice JD Jr, Breast Ca ncer Risk from Different Mammography Screening Practices. Radiat Res. 2010;174: Hubbard RA, Kerlikowske K, Flowers CI, Yankaskas BC, Zhu W, Miglioretti DL, C umulative Probability of False-positive Recall or Biopsy Recommendation After 10 72

86 3. 연구결과 Years of Screening Mammography: A Cohort Study. Ann Intern Med. 2011;155: Marmot MG, Altman DG, Cameron DA, Dewar JA, Thompson SG, Wilcox M, The Benefits and Harms of Breast Cancer Screening: An Independent Review. Br J Can cer 2013;108: Salas D, Ibanez J, Roman R, Cuevas D, Sala M, Ascunce N, Zubizarreta R, Castell s X, Effect of Start Age of Breast Cancer Screening Mammography on the Risk of False-positive Results. Prev Med. 2011;53: Berrington de Gonzalez A, Estimates of the Potential Risk of Radiation-related Ca ncer from Screening in the UK. J Med Screen 2011;18:

87 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 KQ 2. 만져지는종괴가있는여성에서진단을위한적절한영상검사는무엇인가? 권고 세이상여성에서만져지는종괴소견에대한일차검사로유방촬영검사를고려할수있다. ( 권고등급 B, 근거수준 III) 권고 세이상여성에서만져지는종괴소견에대한일차검사로시행한유방촬영검사에서 정상 소견이라면다음단계검사는유방초음파검사를고려할수있다. ( 권고등급 B, 근거수준 III) 권고 세미만의여성에서만져지는종괴소견에대한일차검사로유방초음파검사를고려할수있다. ( 권고등급 B, 근거수준 III) 권고 세미만의여성에서만져지는종괴소견에대한일차검사로시행한유방초음파검사에서 정상 소견이라면모든추가적인영상검사를시행하지않는것을권고한다. ( 권고등급 C, 근거수준 III) 권고 세여성에서만져지는종괴소견에대한일차검사로유방촬영검사또는유방초음파검사를고려할수있다. ( 권고등급 B, 근거수준 III) 근거요약자가유방진찰 (breast self-examination; BSE) 이나임상유방진찰 clinical breast examination; CBE) 에서만져지는종괴소견을호소하는경우진단을위한검사권고의근거로 1개의진료지침 (American College of Radiology; ACR Appropriateness Criteria ) 을최종선택하였다 (1). 만져지는종괴소견은유방암의가장흔한증상중에하나이므로그확인이매우중요하나, 그증상자체가모호하고불분명한경우가많아반드시영상검사를통한확인이필요하다 (2-4). 유방촬영검사 (mammography) 시행시에는일반적으로만져지는종괴를호소하는부위의피부위에방사성비투과성표지 (radio-opaque marker) 를붙이고양측유방에대하여각각상하위 (creniocaudal) 와내외사위 (mediolateral oblique) 영상을얻어총 4장의기본영상을얻는다. 그러나만일검사시행 6개월내에양측유방에대한유방촬영검사를시행한적이있다면, 증상이있는유방에대하여만상하위 (creniocaudal) 와내 74

88 3. 연구결과 외사위 (mediolateral oblique) 영상을얻는다. 국소압박촬영 (spot compression views), 확대촬영 (magnification view), 또는접선촬영 (tangential views) 등의다양한보조유방촬영법 (supplemental mammographic views) 은만져지는부위의종괴병변유무를판단하고양성과악성병변의감별진단에도움을받을수있으므로필요에따라추가시행할수있다 (5). 유방촬영검사의암발견에대한민감도는 86~91% 로알려져있다. 유방촬영에서만져지는부위에이상소견을발견할수없거나, 확실한양성으로판정할수없는소견이있는경우는초음파검사등의이차적인추가검사를시행할수있다. 40세이상여성에서는일차적으로유방촬영검사시행을권고하며, 30세이상 39세이하의여성에서는선택적으로유방촬영검사또는초음파검사를시행할것을권고한다. 30세미만의여성의경우, 암빈도가낮고, 대부분의양성병변은유방촬영에서확인되기어려우므로 (6,7), 만져지는종괴의평가를위한일차검사로유방촬영검사가권고되지않는다. 유방초음파검사는임상진찰에서만져지는종괴소견이있는경우에진단에있어가장선호되는영상검사이다 (8). 유방초음파검사의가장큰장점은만져지는부위를실시간으로직접확인할수있다는점이다. 40세이하의여성에서는유방초음파검사의민감도가유방촬영검사보다높은것으로보고되어있으며 (9), 유방의증상을호소하는 1,208명의 30~39세여성에대하여분석한결과, 유방초음파검사 ( 민감도 : 95.7%) 가유방촬영검사에비하여높은민감도 ( 민감도 : 60.9%) 를보이며비슷한정도의특이도 ( 유방초음파검사대유방촬영검사 : 89.2% 대 94.4%) 를보이는것으로나타났다 (10). 단, 유방초음파검사에서의심되는소견이있을때는추가적으로유방촬영검사를시행할것을권고하며, 40세이상의여성에서는유방초음파검사소견이정상이더라도, 유방촬영검사를시행하여이상유무를확인할것을권고한다. 특히악성병변이의심되는미세석회화 (microcalcifications) 와흐릿한구조왜곡 (subtle architectural distortion) 은유방초음파검사에서는보이지않으므로유방촬영검사를반드시시행하여확인하여야한다 (11,12). 만져지는종괴소견에대한유방촬영검사나유방초음파검사외의다른영상검사의적용에대한유용성은아직연구단계이다. 그러나보통만져지는종괴소견이있는경우유방 MRI를시행할수는있으나유방촬영검사나유방초음파검사를시행하는것이비용적인면에서유리하다. 만일만져지는종괴가유방촬영검사나유방초음파검사에서보이지않는경우에진단목적의 MRI를시행할수는있지만이의유용성에대한연구결과가거의없다 (13). 이미유방암이진단된만져지는종괴가치밀유방안에있는경우에 75

89 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 전체병변의범위를결정하는데있어 MRI 가유방촬영검사나유방초음파검사에비하여 높은민감도를나타낸다 (14). 권고고려사항 1. 이득과위해만져지는유방종괴가있는여성에서진단을목적으로유방촬영검사나유방초음파검사를시행을사용하는경우, 만져지는종괴를확인하고이에대한자세한진단이가능하다는장점이있다. 유방촬영검사는유방의미세석회화및구조왜곡병변의발견및진단에유용하며전체유방을비교적객관적으로한눈에파악할수있다는장점이있다. 그러나검사당시압박에의한통증이나방사선피폭의문제, 치밀유방에서의낮은민감도등이문제가될수있다. 한편, 초음파검사의경우통증이나방사선피폭이없고실시간영상검사가용이하다는장점이있는반면에검사자의기술과경험, 유방의배경에코등에따라서검사결과에차이가있을수있다는제한점이있다. 유방 MRI의경우높은민감도를가진영상검사이나병변이과대평가되기쉽고석회화병변을보여주지못하며, 고비용이문제가될수있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 1개진료치침에대한수용성과적용성평가결과만져지는종괴를호소하는여성의진단을위한일차적검사로써연령에따라, 유방촬영검사및유방초음파검사의유용성에대해서는기존의진료지침이일치하였다. 1개진료지침의권고내용과이에대한국내수용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 유방촬영검사 유방초음파검사 0 76

90 3. 연구결과 참고문헌 1. American College of Radiology. ACR Practice Guideline for the Performance of a Breast Ultrasound Examination. Available from: URL: ymainmenucategories/quality_safety/guidelines/breast/us_breast.aspx. Accessed Apri l 5, Kaiser JS, Helvie MA, Blacklaw RL, Roubidoux MA, Palpable Breast Thickening: Role of Mammography and US in Cancer Detection. Radiology 2002;223(3): Rosner D, Blaird D, What Ultrasonography Can Tell in Breast Masses that Mamm ography and Physical Examination Cannot. J Surg Oncol. 1985;28(4): Boyd NF, Sutherland HJ, Fish EB, Hiraki GY, Lickley HL, Maurer VE, Prospective Evaluation of Physical Examination of the Breast. Am J Surg. 1981;142(3): Pearson KL, Sickles EA, Frankel SD, Leung JW, Efficacy of Step-oblique Mammogr aphy for Confirmation and Localization of Densities Seen on Only One Standard Mammographic View. AJR Am J Roentgenol. 2000;174(3): Ciatto S, Bravetti P, Bonardi R, Rosselli del Turco M, The Role of Mammograph y in Women Under ;80(5): Harris VJ, Jackson VP, Indications for Breast Imaging in Women Under Age 35 Years. Radiology 1989;172(2): Harvey JA, Sonography of Palpable Breast Masses. Semin Ultrasound CT MR ;27(4): Osako T, Iwase T, Takahashi K, et al. Diagnostic Mammography and Ultrasonogr aphy for Palpable and Nonpalpable Breast Cancer in Women Aged 30 to 39 Year s. Breast Cancer 2007;14(3): Lehman CD, Lee CI, Loving VA, Portillo MS, Peacock S, Demartini WB, Accuracy and Value of Breast Ultrasound for Primary Imaging Evaluation of Symptomatic W omen Years of Age. AJR Am J Roentgenol. 2012;199(5): Sabate JM, Clotet M, Torrubia S, et al. Radiologic Evaluation of Breast Disorders Related to Pregnancy and Lactation. Radiographics 2007;27 Suppl 1: Swinford AE, Adler DD, Garver KA, Mammographic Appearance of the Breasts D uring Pregnancy and Lactation: False Assumptions. Acad Radiol. 1998;5(7): Yau EJ, Gutierrez RL, DeMartini WB, Eby PR, Peacock S, Lehman CD, The Utili ty of Breast MRI as a Problem-solving Tool. Breast J. 2011;17(3): Berg WA, Gutierrez L, NessAiver MS, et al. Diagnostic Accuracy of Mammograph y, Clinical Examination, US, and MR Imaging in Preoperative Assessment of Breast Cancer. Radiology 2004;233(3):

91 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.6. 복부분과 KQ 1. 황달증상이있는환자의진단을위한적절한영상검사는무엇인가? 권고 1. 황달증상이있는환자의첫번째검사로초음파검사를권고한다. 악성담관폐쇄가의심되는환자의경우에는조영증강복부 CT 또는 MRCP를포함하는조영증강복부 MRI를권고한다. ( 권고등급 A, 근거수준 I) 근거요약황달이란여러가지질환에서보일수있는증상의하나로, 비용해성황달의원인은크게폐쇄성과비폐쇄성으로대별되며, 폐쇄의흔한원인은담관석과악성종양이다. 영상검사의역할은폐쇄의유무확인과폐쇄원인감별이며, 초음파검사, CT, 그리고 MRI(MRCP) 가시행된다. 초음파는방사선피폭이없고적은비용으로시행할수있어첫번째영상검사로적절하며, 담관확장확인과후속검사선택에도움을준다. 담관폐쇄에대한초음파의민감도와특이도는각각 55~95%, 71~96% 인데 (1), 폐쇄초기에담관확장이없는경우위음성을보일수있고, 주변장관의공기에의해간외담관평가가어려운경우담관폐쇄의위치와원인을평가하는데제한적이다 (1-3). 담관결석확인에있어서 MRCP 검사는가장민감한비침습적인방법으로 (4-11) 91~96% 의민감도, 98~100% 의특이도를보이며, 폐쇄된담관위치에상관없이정확한진단을할수있게해준다 (5). 또한임신부에서췌담도질환이의심될때방사선피폭이없으므로 CT보다는 MRCP 검사가권고된다 (12). CT도급성담관폐쇄환자에서폐쇄유무와원인및합병증을평가하는데유용하나, 담관결석에대한민감도는 65~89% 로 MRCP보다낮다 (4,13-15). 악성종양에의한담관폐쇄가의심되는경우, CT는진단및종양의병기판정을위해가장먼저시행할수있는검사이며 (16,17), 얇은절편으로재구성한이중시기췌담도 CT는종양의침습정도와병기결정, 수술가능여부평가에도도움을준다 (8, 17, 18). MRCP를포함한조영증강 MRI도악성종양, 특히간문담도암 (hilar cholangiocarcinoma) 의발견과병기결정에높은정확도를보인다 (8). 78

92 3. 연구결과 권고고려사항 1. 이득과위해황달환자에서일차영상검사로초음파검사를사용하는경우방사선피폭이없고, 쉽게이용이가능하다는장점이있다. CT의경우도 MDCT를보유하고있는병원이많아서쉽게쓰일수있는검사방법이며, 대부분의복부장기에대한평가및해부학적정보제공이가능하다는장점이있으나, 방사선피폭이라는단점이있으므로이에대한고려가필요하다. MRI는아직쉽게이용하기어렵고 (not readily available) 응급검사가어려울수있지만, 젊은환자나임신부와같이방사선위해의위험이큰환자에서는 CT보다 MRI 검사를먼저고려한다. 2. 국내수용성과적용성 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시한다. 3. 검사별방사선량이중시기췌담도 CT 초음파검사 0 MRCP를포함하는조영증강 MRI 0 참고문헌 1. Pasanen PA et al. A Comparison of Ultrasound, Computed-tomography and Endosc opic Retrograde Cholangiopancreatography in the Differential diagnosis of Benign and Malignant Jaundice and Cholestasis. European Journal of Surgery 1993;159(1): Baron RL et al. A Prospective Comparison of the Evaluation of Biliary Obstruction Using Computed Tomography and Ultrasonography. Radiology 1982;145(1): Chen WX et al. Multiple Imaging Techniques in the Diagnosis of Ampullary Carcin oma. Hepatobiliary & Pancreatic Diseases International 2008;7(6): Soto JA et al. Diagnosing Bile Duct Stones: Comparison of Unenhanced Helical C T, Oral Contrast-enhanced CT Cholangiography, and MR Cholangiography. Americ an Journal of Roentgenology 2000;175(4): Varghese JC et al. A Prospective Comparison of Magnetic Resonance Cholangiopa ncreatography with Endoscopic Retrograde Cholangiopancreatography in the Evalu ation of Patients with Suspected Biliary Tract Disease. Clinical Radiology 1999;54 (8):

93 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 6. Varghese JC et al. Diagnostic Accuracy of Magnetic Resonance Cholangiopancreato graphy and Ultrasound Compared with Direct Cholangiography in the Detection o f Choledocholithiasis. Clinical Radiology 2000;55(1): Williams EJ et al. Guidelines on the Management of Common Bile Duct Stones (CBDS). Gut 2008;57(7): Park HS et al. Preoperative Evaluation of Bile Duct Cancer: MRI Combined with MR Cholangiopancreatography Versus MDCT with Direct Cholangiography. Americ an Journal of Roentgenology 2008;190(2): Maurea S et al. Comparative Diagnostic Evaluation with MR Cholangiopancreatogr aphy, Ultrasonography and CT in Patients with Pancreatobiliary Disease. Radiologi a Medica. 2009;114(3): Choi JY et al. Navigator-trieretered Isotropic Three-dimensional Magnetic Resona nce Cholangiopancreatography in the Diagnosis of Malignant Biliary Obstructions: Comparison with Direct Cholangiography. Journal of Magnetic Resonance Imaging 2008;27(1): Aube C et al. MR Cholangiopancreatography Versus Endoscopic Sonography in S uspected Common Bile Duct Lithiasis: A Prospective, Comparative Study. America n Journal of Roentgenology 2005;184(1): Oto A et al. The Role of MR Cholangiopancreatography in the Evaluation of Preg nant Patients with Acute Pancreaticobiliary Disease. British Journal of Radiology 2 009;82(976): Mitchell SE, Clark RA, A Comparison of Computed Tomography and Sonography in Choledocholithiasis. AJR Am J Roentgenol. 1984;142(4): Tseng CW et al. Can Computed Tomography with Coronal Reconstruction Improv e the Diagnosis of Choledocholithiasis? Journal of Gastroenterology and Hepatolog y 2008;23(10): Anderson SW et al. Accuracy Diagnosis of MDCT in the of Choledocholithiasis. A merican Journal of Roentgenology 2006;187(1): Tongdee T, Amornvittayachan O, Tongdee R, Accuracy of Multidetector Compute d Tomography Cholangiography in Evaluation of Cause of Biliary Tract Obstructio n. J Med Assoc Thai. 2010;93(5): Bang BW et al. Curved Planar Reformatted Images of MDCT for Differentiation o f Biliary Stent Occlusion in Patients With Malignant Biliary Obstruction. American Journal of Roentgenology 2010;194(6): Choi YH et al. Biliary Malignancy: Value of Arterial, Pancreatic, and Hepatic Pha se Imaging with Multidetector-row Computed Tomography. Journal of Computer A ssisted Tomography 2008;32(3):

94 3. 연구결과 KQ 2. 우상복부급성통증을호소하는환자에서급성담낭염진단을위한적절한영상검사는무엇인가? 권고 2-1. 우상복부급성통증을호소하는환자에서급성담낭염진단을위해초음파검사를권고한다. ( 권고등급 A, 근거수준 II) 권고 2-2. 조영증강 CT와조영증강전후복부 MRI 역시특수한상황에서고려할수있다. ( 권고등급 B, 근거수준 III) 근거요약우상복부급성통증을호소하는환자에서급성담낭염진단을위한적절한영상검사에대한가이드라인은 1개의가이드라인이최종선택되었다 (ACR Appropriateness Criteria R) ). 급성담낭염진단을위한영상검사는복부초음파검사, 복부 CT, 복부 MRI 의진단정확도, 민감도, 특이도에중점을두어가이드라인을작성하였다 (2-29). 복부초음파검사는담석진단에있어서메타분석결과 97% 의민감도, 95% 의특이도를보였다 (4). 급성담낭염이의심되는환자에서복부초음파검사는메타분석결과 94% 의민감도, 78% 의특이도를보였다 (4). 조영증강복부 CT는민감도 94%, 특이도 59% 로조사되었고방사선피폭의문제를고려하지않을수없다 (5). 복부 MRI의진단정확도는민감도 85%, 특이도 81% 로조사되었으나, 방사선피폭문제가없는장점이있으나검사비용이상대적으로비싸고, 검사접근성에제약이있는단점이있다 (5). 초음파검사 (83~89%) 와 MRI(81~86%) 는급성담낭염진단에있어서특이도가높은검사이며, 두검사는급성담낭염진단에있어서유의한차이는없었다 (5, 22). 복부 CT는민감도 (94%) 가가장높았으나특이도 (59%) 는낮았다 (5). 복부 CT는초음파검사에서합병증이의심되는경우합병증의평가와적절한치료방법선택에도움이되는것으로조사되었다 (16,17). 복부 CT는음성예측치가매우높은검사로, 복부 CT에서급성담낭염소견이없는경우급성담낭염진단은배제가가능하다 (17). 복부 MRI 역시급성담낭염소견과이로인한합병증의진단에있어서복부 CT와유사한결과를보여주었다 (21-24). 제한된연구이지만복부 MRI는임신한여성에서안전하고유용하게시행할수있는검사이다 (25). 81

95 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 권고고려사항 1. 이득과위해우측상복부통증으로급성담낭염이의심되는환자의일차진단검사로서초음파검사는높은진단정확도와함께, 방사선피폭문제가없고, 검사장비에대한접근성이높아매우적절한검사방법이다. 하지만검사자의경험과환자조건 ( 비만도, 장관내가스음영 ) 에의해진단정확도가낮아질수있는단점이있으며, 초음파검사가불충분하게이루어진경우혹은급성담낭염의합병증이예상되는상황에서는조영증강 CT 또는 MRI 또한적절한검사로고려할수있다. 2. 국내수용성과적용성 (Acceptability and Applicability) ACR Appropriateness R 의국내수용성과적용성은평가결과큰무리가없는것으로 판단되었다. 수용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 조영증강복부 CT 조영증강전후복부 MRI 0 참고문헌 1. Trowbridge RL, Rutkowski NK, Shojania KG, Does This Patient Have Acute Cholec ystitis? JAMA 2003 Jan;289(1): Laing FC, Federle MP, Jeffrey RB, Brown TW, Ultrasonic Evaluation of Patients wit h Acute Right Upper Quadrant Pain. Radiology 1981;140(2): Bree RL, Further Observations on the Usefulness of the Sonographic Murphy Sign in the Evaluation of Suspected acute Cholecystitis. J Clin Ultrasound 1995;23(3): Shea JA, Berlin JA, Escarce JJ, et al. Revised Estimates of Diagnostic Test Sensitivit y and Specificity in Suspected Biliary Tract Disease. Arch Intern Med. 1994;154(2 2): Kiewiet JJ, Leeuwenburgh MM, Bipat S, Bossuyt PM, Stoker J, Boermeester MA, A S ystematic Review and Meta-analysis of Diagnostic Performance of Imaging in Acut e Cholecystitis. Radiology 2012 Sep;264(3): Bennett GL, Balthazar EJ, Ultrasound and CT Evaluation of Emergent Gallbladder P athology. Radiol Clin North Am. 2003;41(6): Hanbidge AE, Buckler PM, O'Malley ME, Wilson SR, From the RSNA Refresher Cou rses: Imaging Evaluation for Acute Pain in the Right Upper Quadrant. Radiographi 82

96 3. 연구결과 cs 2004;24(4): Smith EA, Dillman JR, Elsayes KM, Menias CO, Bude RO, Cross-sectional Imaging of Acute and Chronic Gallbladder Inflammatory Disease. AJR 2009;192(1): Cho JY, Han HS, Yoon YS, Ahn KS, Lee SH, Hwang JH, Hepatobiliary Scan for Ass essing Disease Severity in Patients with Cholelithiasis. Arch Surg. 2011;146(2): Alobaidi M, Gupta R, Jafri SZ, Fink-Bennet DM, Current Trends in Imaging Evalu ation of Acute Cholecystitis. Emerg Radiol. 2004;10(5): Kalimi R, Gecelter GR, Caplin D, et al. Diagnosis of Acute Cholecystitis: Sensitivi ty of Sonography, Cholescintigraphy, and Combined Sonography-cholescintigraph y. J Am Coll Surg. 2001;193(6): Ralls PW, Colletti PM, Halls JM, Siemsen JK, Prospective Evaluation of 99mTc-ID A Cholescintigraphy and Gray-scale Ultrasound in the Diagnosis of Acute Cholecy stitis. Radiology 1982;144(2): Ralls PW, Colletti PM, Lapin SA, et al. Real-time Sonography in Suspected Acute Cholecystitis. Prospective Evaluation of Primary and Secondary Signs. Radiology 1 985;155(3): Samuels BI, Freitas JE, Bree RL, Schwab RE, Heller ST. A Comparison of Radionu clide Hepatobiliary Imaging and Real-time Ultrasound for the Detection of Acute Cholecystitis. Radiology 1983;147(1): Bennett GL, Rusinek H, Lisi V, et al. CT Findings in Acute Gangrenous Cholecysti tis. AJR 2002;178(2): De Vargas Macciucca M, Lanciotti S, De Cicco ML, Coniglio M, Gualdi GF, Ultras onographic and Spiral CT Evaluation of Simple and Complicated Acute Cholecysti tis: Diagnostic Protocol Assessment Based on Personal Experience and Review of t he Literature. Radiol Med. 2006;111(2): Shakespear JS, Shaaban AM, Rezvani M, CT Findings of Acute Cholecystitis and It s Complications. AJR 2010;194(6): Tsai MJ, Chen JD, Tiu CM, Chou YH, Hu SC, Chang CY, Can Acute Cholecystitis with Gallbladder Perforation Be Detected Preoperatively by Computed Tomograph y in ED? Correlation with Clinical Data and Computed Tomography Features. Am J Emerg Med. 2009;27(5): Fuks D, Mouly C, Robert B, Hajji H, Yzet T, Regimbeau JM, Acute Cholecystitis: Preoperative CT Can Help the Surgeon Consider Conversion from Laparoscopic to Open Cholecystectomy. Radiology 2012;263(1): Akpinar E, Turkbey B, Karcaaltincaba M, et al. Initial Experience on Utility of G adobenate Dimeglumine (Gd-BOPTA) Enhanced T1-weighted MR Cholangiography in Diagnosis of Acute Cholecystitis. J Magn Reson Imaging 2009;30(3): Altun E, Semelka RC, Elias J Jr, et al. Acute Cholecystitis: MR Findings and Differ entiation from Chronic Cholecystitis. Radiology 2007;244(1): Oh KY, Gilfeather M, Kennedy A, et al. Limited Abdominal MRI in the Evaluation 83

97 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 of Acute Right Upper Quadrant Pain. Abdom Imaging 2003;28(5): Hakansson K, Leander P, Ekberg O, Hakansson HO, MR Imaging in Clinically Sus pected Acute Cholecystitis. A Comparison with Ultrasonography. Acta Radiol ;41(4): Regan F, Schaefer DC, Smith DP, Petronis JD, Bohlman ME, Magnuson TH, The Diagnostic Utility of HASTE MRI in the Evaluation of Acute Cholecystitis. Half- Fo urier Acquisition Single-shot Turbo SE. J Comput Assist Tomogr. 1998;22(4): Oto A, Ernst R, Ghulmiyyah L, Hughes D, Saade G, Chaljub G, The Role of MR Cholangiopancreatography in the Evaluation of Pregnant Patients with Acute Panc reaticobiliary Disease. Br J Radiol. 2009;82(976): Oto A, Ernst RD, Ghulmiyyah LM, et al. MR Imaging in the Triage of Pregnant P atients with Acute Abdominal and Pelvic Pain. Abdom Imaging 2009;34(2): Boland GW, Slater G, Lu DS, Eisenberg P, Lee MJ, Mueller PR, Prevalence and Si gnificance of Gallbladder Abnormalities Seen on Sonography in Intensive Care Uni t Patients. AJR 2000;174(4): Puc MM, Tran HS, Wry PW, Ross SE, Ultrasound Is Not a Useful Screening Tool f or Acute Acalculous Cholecystitis in Critically Ill Trauma Patients. Am Surg. 2002; 68(1): Ahvenjarvi L, Koivukangas V, Jartti A, et al. Diagnostic Accuracy of Computed To mography Imaging of Surgically Treated Acute Acalculous Cholecystitis in Criticall y Ill Patients. J Trauma 2011;70(1):

98 3. 연구결과 KQ 3. 우하복부급성통증과발열을호소하는환자에서급성충수염진단을위한적절한영상검사는무엇인가? 권고 3-1. 우하복부급성통증과발열을호소하는환자에서급성충수염진단을위해복부 CT를권고한다. ( 권고등급 A, 권고수준 II) 권고 3-2. 복부초음파검사와복부 MRI 역시일반적또는특수한상황에서고려할수있다. ( 권고등급 B, 권고수준 II) 근거요약우하복부급성통증과발열을호소하는환자에서급성충수염진단을위한적절한영상검사에대한가이드라인을위해 ACR Appropriateness Criteria R 가최종선택되었다. 본가이드라인은급성충수돌기염의진단정확도 ( 민감도와특이도 ) 또는음성충수돌기절제율 (negative appendectomy rate) 에중점을두어가이드라인을작성하였다. CT는급성충수돌기염의증상이부족한경우가장정확한진단을위해도움을주는검사로알려져있고 (1-16), 메타분석결과성인또는소아의경우 94% 의민감도, 94~95% 의특이도를보였다. 이는민감도성인 83%, 소아 88%, 특이도 93~94% 의초음파검사에비해정확하다고분석된바있다 (15). 초음파검사역시정확한검사이지만, 검사자의역량에좌우가많이되고비만이있는환자의경우검사가힘들다는단점이있다. CT 검사로인한방사선피폭문제로어린환자나임산부에서초음파검사가선호되는경향이있으나, 진단정확도는 CT나 MRI에비해낮은결과를얻었다. 어린환자나임산부에서일차적으로초음파를시행하고, 초음파로결론이나지않을경우, 선택적으로 CT나 MRI를시행하기도한다 (17-27). 권고고려사항 1. 이득과위해우하복부통증환자의일차진단검사로 CT를사용하는경우진단정확도가높은장점이있으나, 방사선피폭의단점이있다. 이에비해초음파검사를일차검사로시행할경우방사선위해는없으나검사자의경험과환자조건 ( 비만도 ) 에의한진단정확도가낮을수있다는단점이있으므로, 이를고려하여적용해야한다. 85

99 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시한다. 3. 검사별방사선량복부 CT 초음파검사 0 복부 MRI 0 참고문헌 1. Applegate KE, Sivit CJ, Salvator AE, et al. Effect of Cross-Sectional Imaging on Ne gative Appendectomy and Perforation Rates in Children. Radiology 2001;220(1): Bendeck SE, Nino-Murcia M, Berry GJ, Jeffrey RB Jr, Imaging for Suspected Appen dicitis: Negative Appendectomy and Perforation Rates. Radiology 2002;225(1): Cuschieri J, Florence M, Flum DR, et al. Negative Appendectomy and Imaging Acc uracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg. 2008;248(4): Lee CC, Golub R, Singer AJ, Cantu R Jr, Levinson H, Routine Versus Selective Abd ominal Computed Tomography Scan in the Evaluation of Right Lower Quadrant P ain: A Randomized Controlled Trial. Acad Emerg Med. 2007;14(2): Raja AS, Wright C, Sodickson AD, et al. Negative Appendectomy Rate in the Era o f CT: An 18-Year Perspective. Radiology 2010;256(2): Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ, Effect of Computed To mography of the Appendix on Treatment of Patients and Use of Hospital Resourc es. N Engl J Med. 1998;338(3): Rao PM, Rhea JT, Rattner DW, Venus LG, Novelline RA, Introduction of Appendice al CT: Impact on Negative Appendectomy and Appendiceal Perforation Rates. Ann Surg. 1999;229(3): Hershko DD, Sroka G, Bahouth H, Ghersin E, Mahajna A, Krausz MM, The Role of Selective Computed Tomography in the Diagnosis and Management of Suspected Acute Appendicitis. Am Surg. 2002;68(11): Raman SS, Lu DS, Kadell BM, Vodopich DJ, Sayre J, Cryer H, Accuracy of Nonfoc used Helical CT for the Diagnosis of Acute Appendicitis: A 5-Year Review. AJR A m J Roentgenol. 2002;178(6): van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J, Boermeester MA, Acute Appendicitis: Meta-Analysis of Diagnostic Performance of CT and Graded C 86

100 3. 연구결과 ompression US Related to Prevalence of Disease. Radiology 2008;249(1): Coursey CA, Nelson RC, Patel MB, et al. Making the Diagnosis of Acute Appendi citis: Do More Preoperative CT Scans Mean Fewer Negative Appendectomies? A 1 0-Year Study. Radiology 2010;254(2): Pooler BD, Lawrence EM, Pickhardt PJ, MDCT for Suspected Appendicitis in the Elderly: Diagnostic Performance and Patient Outcome. Emerg Radiol. 2012;19(1): Pickhardt PJ, Lawrence EM, Pooler BD, Bruce RJ, Diagnostic Performance of Mult idetector Computed Tomography for Suspected Acute Appendicitis. Ann Intern Me d. 2011;154(12):789-96, w Terasawa T, Blackmore CC, Bent S, Kohlwes RJ, Systematic Review: Computed T omography and Ultrasonography to Detect Acute Appendicitis in Adults and Adole scents. Ann Intern Med. 2004;141(7): Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for Diagnosis of Appen dicitis in Children and Adults? A Meta-Analysis. Radiology 2006;241(1): Lazarus E, Mayo-Smith WW, Mainiero MB, Spencer PK, CT in the Evaluation of Nontraumatic Abdominal Pain in Pregnant Women. Radiology 2007;244(3): Rybkin AV, Thoeni RF, Current Concepts in Imaging of Appendicitis. Radiol Clin North Am. 2007;45(3):411-22, vii. 18. Baldisserotto M, Marchiori E, Accuracy of Noncompressive Sonography of Childre n with Appendicitis According to the Potential Positions of the Appendix. AJR Am J Roentgenol. 2000;175(5): Hahn HB, Hoepner FU, Kalle T, et al. Sonography of Acute Appendicitis in Child ren: 7 Years Experience. Pediatr Radiol. 1998;28(3): Lessin MS, Chan M, Catallozzi M, et al. Selective Use of Ultrasonography for Acut e Appendicitis in Children. Am J Surg. 1999;177(3): Bachur RG, Hennelly K, Callahan MJ, Monuteaux MC, Advanced Radiologic Imagi ng for Pediatric Appendicitis, : Trends and Outcomes. J Pediatr. 2012;1 60(6): Lim HK, Bae SH, Seo GS, Diagnosis of Acute Appendicitis in Pregnant Women: V alue of Sonography. AJR Am J Roentgenol. 1992;159(3): Israel GM, Malguria N, McCarthy S, Copel J, Weinreb J, MRI vs. Ultrasound for Suspected Appendicitis During Pregnancy. J Magn Reson Imaging 2008;28(2): Oto A, Ernst RD, Ghulmiyyah LM, et al. MR Imaging in the Triage of Pregnant Patients with Acute Abdominal and Pelvic Pain. Abdom Imaging 2009;34(2): Pedrosa I, Levine D, Eyvazzadeh AD, Siewert B, Ngo L, Rofsky NM, MR Imaging Evaluation of Acute Appendicitis in Pregnancy. Radiology 2006;238(3): Blumenfeld YJ, Wong AE, Jafari A, Barth RA, El-Sayed YY, MR Imaging in Cases of Antenatal Suspected Appendicitis-A Meta-Analysis. J Matern Fetal Neonatal Me d. 2011;24(3):

101 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 27. Pedrosa I, Lafornara M, Pandharipande PV, Goldsmith JD, Rofsky NM, Pregnant P atients Suspected of Having Acute Appendicitis: Effect of MR Imaging on Negative Laparotomy Rate and Appendiceal Perforation Rate. Radiology 2009;250(3):

102 3. 연구결과 2.7. 비뇨분과 KQ 1. 무증상혈뇨로내원한성인환자의비뇨기계종양진단을위한적절한검사는무엇인가? 권고 1-1. 지속적인무증상현미경적혈뇨 (microscopic hematuria) 로내원한정상신기능성인환자에서조영증강 CT 요로조영술 (CT urography) 은초음파검사보다적절하다. ( 권고등급 A, 근거수준 I) 권고 1-2. 지속적인무증상현미경적혈뇨로내원한신실질질환이있는성인환자에서 초음파검사가조영증강 CT 요로조영술보다적절하다. ( 권고등급 A 근거수준 II) 권고 1-3. 무증상육안적혈뇨로내원한성인환자에서비뇨기계종양의저위험군인경 우초음파검사가 CT 요로조영술보다적절하다. 초음파검사에서이상이있을경 우 CT 요로조영술을시행한다. ( 권고등급 A 근거수준 II) 권고 1-4. 무증상육안적혈뇨로내원한성인환자에서비뇨기계종양의고위험군인경 우 CT 요로조영술이초음파검사보다적절하다. 임신한환자, 요오드조영제알러 지병력이있는환자에서 MR 요로조영술 (MR Urography) 이대안이될수있다. ( 권고등급 A 근거수준 I) 근거요약여타의증상이없이혈뇨로내원한성인환자의비뇨기계종양영상진단을위한가이드라인은검색후 4개의가이드라인이선택되었다. 2012년 AUA 가이드라인은성인환자에서무증상의현미경적혈뇨에대한임상진단및치료, 추적관찰지침으로영상의학적검사가소주제로포함되었다. 2013년 Japanese guidelines of the management of hematuria는현미경적및육안적혈뇨를아우르는임상지침으로이역시영상의학적검사는진단영역에서의소주제로포함되었다. ACR appropriateness guideline과 RCR irefer 7thedition은상황에따른영상의학적검사의적정성여부에대한지침으로, ACR에서는기저질환에따라, RCR에서는육안적 / 현미경적인지여부에따라영상검사권고를다르게하였다. 본가이드라인에서는기저신질환유무및육안적 / 현미경적혈뇨여부에따라상기가이드라인을참조하여작성하였다. 무증상현미경적혈뇨는적절히채취된소변검체에서 3개이상의적혈구가고배율 89

103 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 (high power field) 에서관찰될때를말하며원인이될수있는명백한양성질환이없는경우로정의된다. 원인이될수있는명백한양성질환은최근의감염, 월경, 심한운동, 기저신실질질환, 바이러스성질환, 외상또는최근의비뇨기과적시술등을포함한다. 신실질질환이있는무증상현미경적혈뇨환자의경우, urinalysis와함께초음파검사로병발된신장의해부학적이상을검사하는것은필요하지만, 종양을배제하기위한 extensive evaluation은불필요한것으로알려져있다 (1,2). 상기나열한다른양성질환들의경우초기단계에서영상의학적검사를시행하는것은이익이없다고알려져있으나, 혈뇨가지속될경우영상의학적검사가필요할수있음을 ACR 가이드라인에서언급하고있다 (3). 상기의양성질환들이배제된경우, AUA 가이드라인및 ACR 가이드라인모두에서 CT urography를권고하고있다. Madeb 등 (2012) 의연구에서 (4), dipstick으로혈뇨가검출된환자에서영상의학적검사를포함하는 thorough evaluation을시행하고그결과가음성이었을경우, 이후 14년간의추적검사에서 1% 미만의환자만이방광암과같은심각한질병에이환되었음을보고하였다. Thorough evaluation을 CT urography로시행하였을경우상기와같은이환율을보일수있으나, CT 대신초음파와경정맥요로조영술을같이시행하였을경우에는상기의결과를보이지못함이보고되었다 (5). 육안적혈뇨의경우, 일반적으로 CT 요로조영술 (CT urography, CTU) 이가장선호되는영상의학적검사이다. CTU는방광암의진단에있어최고 95% 의민감도, 92% 의특이도를보이며 (6,7), 신실질및상부요로의종양검출에있어 90% 이상의정확도를보인다고알려져있다. 특히경정맥요로조영술 (IVU) 과비교하였을때, CT는신장, 요관및방광악성종양의검출에있어더높은민감도및특이도를보임이알려져있다 (8,9,10). 초음파는 radiation dose 문제에서자유롭고비교적접근성이좋으며쉽게시행할수있는장점이있다. Knox 등 (2002) 의연구에서 (11), 초음파는방광암의진단에있어 CT와비슷한특이도를보이나 (96.5% vs. 94.7%), 민감도는떨어지는것으로알려져있다 (89.7% vs. 69%). 신장및상부요관악성종양의평가에있어, 초음파는신장종양의경우 100% 에가까운민감도를보였으나, 상부요관종양에있어서는 50~76% 의낮은민감도를보였다 (12,13). 그러나 Unsal 등 (2002) 의전향적연구에서초기초음파결과는 CTU 또는 MRU의결과를예측할수있는중요한예후인자임이기술되 90

104 3. 연구결과 었다 (14). 상기의결과를참조하여, RCR 가이드라인에서는육안적혈뇨의경우, 저위험군에서는초음파를초기검사로시행하며, 저위험군에서초음파상이상소견이보이거나고위험군환자의경우 CTU를시행할것을권고하고있으며, 이권고안에서 radiation dose 문제가중요하게고려되었음을언급하고있다 (15). 기기접근성등의문제로 CTU를시행할수없는경우만 IVU를시행하며, 임산부, 신부전증, 요오드조영제알러지의병력이있는경우 MRU가대안이될수있음을 4개의가이드라인모두에서언급하고있다. 신부전환자에서는비조영증강 MR 요로조영술 (Static-fluid MR urography) 이대안이될수있으나신우요관계가충분히확장되지않은상태에서평가가제한적일수있다. 저위험군과고위험군의기준을뚜렷하게언급하는가이드라인은없으나, 고령, 이전비뇨기계종양병력, 흡연, 화학적발암물질에의노출 ( 직업적, 환경적 ) 등이고위험군이될수있으며, 2010년네덜란드가이드라인에서는육안적혈뇨환자중 50세이상이거나이전비뇨기계종양병력이있는경우 CTU를우선적으로시행할것을권고하고있다 (16). 권고고려사항 1. 이득과위해무증상현미경적혈뇨환자중혈뇨를일으킬수있는기저신실질질환이있거나무증상육안적혈뇨환자중저위험군환자의경우는방사선선량을낮추기위하여초음파검사가우선적으로권고된다. 무증상현미경적혈뇨환자중기저질환이없거나, 무증상육안적혈뇨환자중고위험군환자 / 저위험군환자중일차초음파검사상이상이있는환자의경우는 CTU를우선적으로시행한다. 전자의경우는 thorough workup을시행할때초음파와 IVU를동시에시행하는것이 CTU를시행하는것보다 long-term 악성종양이환율이높기때문이며, 후자의경우는특히상부요로에있어초음파의진단능이 CT보다낮기때문에방사능노출의위험이있지만 CTU가우선적으로권고된다할수있다. AUA 가이드라인에서는이경우 low kvp, high mas, iterative reconstruction 을사용하여환자의방사선선량을최대한낮출것을권고하고있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시한다. 91

105 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 3. 검사별방사선량 CT 요로조영검사경정맥요로조영검사초음파검사 0 참고문헌 1. Davis R, Jones JS, Barocas DA, et al. Diagnosis, Evaluation and Follow-Up of Asy mptomatic Microhematuria (AMH) in Adults: AUA Guideline. J Urol. 2012;188 Supp l 6: Horie S, Ito S, Okada H, Kikuchi H, et al. Japanese Guidelines of the Manageme nt of Hematuria Clin Exp Nephrol Oct;18(5): American College of Radiology. ACR Appropriateness CriteriaR hematuria. https: // Accessed July 23, Royal College of Radiologists. irefer: Making the Best Use of Clinical Radiology. 7th ed. London: The Royal College of Radiologists McDonald MM, Swagerty D, Wetzel L, Assessment of Microscopic Hematuria in A dults. Am Fam Physician. 2006;73(10): Madeb R, Golijanin D, Knopf J et al. Long-Term Outcome of Patients with a Neg ative Work-Up for Asymptomatic Microhematuria. Urology 2010;75: Silverman S, Leyendecker J, Amis E, What Is the Current Role of CT Urography a nd MR Urography in the Evaluation of the Urinary Tract? Radiology 2009;250: Turney BW, Willatt JM, Nixon D, Crew JP, Cowan NC, Computed Tomography Ur ography for Diagnosing Bladder Cancer. BJU Int. 2006;98(2): Park SB, Kim JK, Lee HJ, Choi HJ, Cho KS, Hematuria: Portal Venous Phase Mult i Detector Row CT of the Bladder-A Prospective Study. Radiology 2007;245(3): Albani JM, Ciaschini MW, Streem SB, et al. The Role of Computerized Tomogra phic Urography in the Initial Evaluation of Hematuria. J Urol. 2007;177: Gray-Sears CL, Ward JF, Sears ST, et al. Prospective Comparison of Computerize d Tomography and Excretory Urography in the Initial Evaluation of Asymptomatic Microhematuria. J Urol. 2002;168: Chlapoutakis K, Theocharopoulos N, Yarmenitis S, et al. Performance of Compu ted Tomographic Urography in Diagnosis of Upper Urinary Tract Urothelial Carci noma, in Patients Presenting with Hematuria: Systematic Review and Meta-Analysi s. Eur J Radiol. 2010;73: Knox MK, Cowan NC, Rivers-Bowerman MD, Turney BW, Evaluation of Multidete ctor Computed Tomography Urography and Ultrasonography for Diagnosing Bladd 92

106 3. 연구결과 er Cancer. Clin Radiol. 2008;63: Datta SN, Allen GM, Evans R, et al. Urinary Tract Ultrasonography in the Evaluat ion of Haematuria-A Report of over 1,000 Cases. Ann R Coll Surg Engl. 2002;84: Edwards TJ, Dickinson AJ, Natale S, et al. A Prospective Analysis of the Diagnosti c Yield Resulting from the Attendance of 4020 Patients at a Protocol-Driven Hae maturia Clinic. BJU Int. 2006;97: Unsal A, Caliskan EK, Erol H, Karaman CZ, The Diagnostic Efficiency of Ultrasou nd Guided Imaging Algorithm in Evaluation of Patients with Hematuria. Eur J Rad iol. 2011;79(1): v.d.molen AJ, Hovius AJ, Hematuria: A Problem-Based Imaging Algorithm Illustrati ng the Recent Dutch Guidelines on Hematuria. AJR 2012;198:

107 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 KQ 2. 비정상질출혈로내원한여성의자궁내막병변진단을위한적절한영상검사는무엇인가? 권고 2. 비정상질출혈로내원한가임기및폐경기여성에서경질초음파검사를권고한다. 자궁내막암의위험인자가있는경우우선적으로자궁내막조직검사를권고한다. ( 권고등급 A, 근거수준 I) 근거요약경질초음파검사를시행하여자궁내막의두께를측정하여병변의유무를판단할수있다. 단, 성경험이없는환자의경우경질초음파검사보다복부초음파검사로진행할것을권고한다. 도플러초음파가병변의진단에도움이될수있다. 폐경후여성에있어서, 경질초음파를이용한자궁내막병변진단 ( 자궁내막두께 5 mm 기준시 ) 의민감도는 95(95~98)%, 특이도는 92(90~94)% 이다 (1). 그러나가임기여성의경우, 상대적으로진단의정확도는떨어지며, 자궁내막의두께가얇을경우병변이없을가능성이크지만병변의가능성을완전히배제할수없다 (2). 초음파자궁조영검사는경질초음파검사보다높은진단의정확도를보여준다 ( 경질초음파검사에서자궁내막두께가 5 mm를기준으로할때민감도 61%, 특이도 96%, 초음파자궁조영검사민감도 100%, 특이도 85%)(4). 그러나검사의순응도및용이성을감안할때초음파자궁조영검사를우선적으로시행하지는않는다. 따라서경질초음파검사로진단이명확하지않을때, 초음파자궁조영검사나자궁경검사및조직검사를추가로시행할수있다. MRI는자궁내막병변진단을위한초기검사로서시행하지는않으며진단받은자궁내막암의병기결정에제한적으로사용할수있다. 비만하거나장기간치료에반응없는무배란성출혈이있는청소년환자, 무배란성출혈이있는 35세이상환자, 35세이하의다음과같은위험인자가있는환자 ( 만성무배란, 당뇨, 대장암가족력, 불임, 미분만부, 비만, 타목시펜치료력 ) 의경우자궁내막암의위험도가증가하기때문에자궁내막조직검사를초기검사로시행할수있다 (5,6). 또한폐경기환자의경우에서도초기검사로서자궁내막조직검사를시행할수도있다. 또한, 출혈에대한자궁외원인감별을위해병력청취와실험실결과 ( 임신유무, 응고장애여부, 갑상선자극호르몬수치등 ) 도참고해야한다. 권고고려사항 1. 이득과위해 경질초음파검사는방사선노출이없으며, 비침습적인검사로서비정상질출혈환자 94

108 3. 연구결과 에게있어추천할만한일차진단검사이다. 그러나검사자체로서의진단의정확도가높 지않으며초음파자궁조영검사나자궁경검사혹은조직검사등의추가검사가필요할 수있다는단점이있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 경질초음파검사 0 참고문헌 1. Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal Ultrasound to E xclude Endometrial Cancer and Other Endometrial Normalities. JAMA 1998 Nov;28 0(17): Dueholm M, Jensen ML, Laursen H, Kracht P, Can the Endometrial Thickness as Measured by Trans-Vaginal Sonography Be Used to Exclude Polyps or Hyperplasia in Pre-Menopausal Patients with Abnormal Uterine Bleeding? Acta Obstet Gynecol Scand. 2001;80: Breitkopf DM, Frederickson RA, Snyder RR, Detection of Benign Endometrial Mass es by Endometrial Stripe Measurement in Premenopausal Women. Obstet Gynecol. 2004;104: Dijkhuizen FP, De Vries LD, Mol BW, Brolmann HA, Peters HM, Moret E, et al. Co mparison of Transvaginal Ultrasonography and Saline Infusion Sonography for the Detection of Intracavitary Abnormalities in Premenopausal Women. Ultrasound Ob stet Gynecol. 2000;15: Munro MG, Critchley HO, Broder MS, Fraser IS, FIGO Working Group on Menstrua l Disorders. FIGO Classification System (PALM-COEIN) for Causes of Abnormal Ute rine Bleeding in Nongravid Women of Reproductive Age. Int J Gynaecol Obstet Apr;113(1): Sweet MG, Schmidt-Dalton TA, W eiss PM, Madsen KP, Evaluation and Manageme nt of Abnormal Uterine Bleeding in Premenopausal Women. Am Fam Physician Jan;85(1):

109 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 KQ 3. 조직검사로확인된전립선암환자의평가를위한적절한검사는무엇인가? 권고 3. 조직검사로확인된전립선암환자의병기결정을위해전립선자기공명영상 (MRI) 을권고한다. ( 권고등급 A, 근거수준 II) 근거요약조직검사로확인된전립선암의영상진단에대한가이드라인은검색후 5개의가이드라인이선택되었으며, 대부분전립선암의병기결정및치료가필요한임상적으로의미있는암 (clinically significant cancer) 에대한영상진단의유용성에대해소개하고있었다 (1-5). 검색된가이드라인에따르면, 조직검사로확인된전립선암의병기결정과임상적으로의미있는암의유무를파악하기위한영상진단방법으로전립선 MRI를권고하고있으며, 반면 CT의사용은전립선의낮은조직대조도로인하여국소병기진단에있어서매우제한적인효용성을보여주었다 (5-10). 전립선 MRI의전립선암국소병기진단능력은메타분석결과, 민감도 61%, 특이도 88% 를보여주었으며, 기능성영상 (functional MRI), 예를들어, 확산강조영상 (diffusion-weighted imaging) 또는역동적조영증강영상 (dynamic contrast-enhanced imaging) 을함께시행했을때진단의민감도가증가하기때문에사용을권고하고있다. 따라서본가이드라인에서도전립선 MRI의국소병기진단정확도를향상시키기위해기능성영상기법이포함한전립선 MRI(multi-parametric MRI) 사용을권고한다 (4,11). 권고고려사항 1. 이득과위해조직검사로확인된전립선암의국소병기결정을위한일차적영상진단으로전립선 MRI가 CT보다유용하다. 하지만, 고위험군 (high-risk group) 에서발생할수있는원격전이의파악을위해서는신체의많은부위를효과적으로촬영할수있는 CT가유용할수있으므로, 환자의전이위험도에따라 MRI 단독또는 MRI와 CT의병합사용을적절히적용하여야한다 (2,9,12). 2. 국내수용성과적용성 (Acceptability and Applicability) 국내수용성및적용성에대한부분은부록에제시한다. 96

110 3. 연구결과 3. 검사별방사선량 전립선 MRI 0 복부 CT 참고문헌 1. Parker C, Gillessen S, Heidenreich A, Horwich A, Committee EG. Cancer of the Pr ostate: ESMO Clinical Practice Guidelines for Diagnosis, Treatment and Follow-Up. Annals of Oncology: Official Journal of the European Society for Medical Oncolog y(esmo) 2015;26 Suppl 5: Carroll PR, Parsons JK, Andriole G, et al. Prostate Cancer Early Detection, Version Featured Updates to the NCCN Guidelines. JNCCN Journal of the National Comprehensive Cancer Network 2014;12(9):1211-9; quiz Dickinson L, Ahmed HU, Allen C, et al. Magnetic Resonance Imaging for the Dete ction, Localisation, and Characterisation of Prostate Cancer: Recommendations fro m a European Consensus Meeting. European Urology 2011;59(4): Barentsz JO, Richenberg J, Clements R, et al. ESUR Prostate MR Guidelines European Radiology 2012;22(4): Mottet M (Chair), Bellmunt J, Briers E (Patient Representative), van den Bergh RCN (Guidelines Associate), Bolla M, van Casteren NJ (Guidelines Associate), Cornford P, Culine S, Joniau S, Lam T, Mason MD, Matveev V, van der Poel H, van der Kw ast TH, Rouvière O, Wiegel T, Guidelines on Prostate Cancer. European Associatio n of Urology 2015, Dickinson L, Ahmed HU, Allen C, et al. Scoring Systems Used for the Interpretatio n and Reporting of Multiparametric MRI for Prostate Cancer Detection, Localizati on, and Characterization: Could Standardization Lead to Improved Utilization of I maging Within the Diagnostic Pathway? JMRI Journal of magnetic resonance imagi ng 2013;37(1): Arumainayagam N, Ahmed HU, Moore CM, et al. Multiparametric MR Imaging for Detection of Clinically Significant Prostate Cancer: A Validation Cohort Study with Transperineal Template Prostate Mapping as the Reference Standard. Radiology 20 13;268(3): Schimmoller L, Quentin M, Arsov C, et al. Inter-Reader Agreement of the ESUR Sc ore for Prostate MRI Using in-bore MRI-Guided Biopsies as the Reference Standar d. European Radiology 2013;23(11): Falchook AD, Hendrix LH, Chen RC, Guideline-Discordant Use of Imaging During Work-Up of Newly Diagnosed Prostate Cancer. Journal of Oncology Practice / Am erican Society of Clinical Oncology 2015;11(2): Hamoen EH, de Rooij M, Witjes JA, Barentsz JO, Rovers MM, Use of the Prostate Imaging Reporting and Data System (PI-RADS) for Prostate Cancer Detection with Multiparametric Magnetic Resonance Imaging: A Diagnostic Meta-Analysis. Europe 97

111 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 an Urology 2015;67(6): de Rooij M, Hamoen EH, Witjes JA, Barentsz JO, Rovers MM, Accuracy of Magnet ic Resonance Imaging for Local Staging of Prostate Cancer: A Diagnostic Meta-An alysis. European Urology Wang L, Hricak H, Kattan MW, et al. Combined Endorectal and Phased-Array MR I in the Prediction of Pelvic Lymph Node Metastasis in Prostate Cancer. AJR Amer ican Journal of Roentgenology 2006;186(3):

112 3. 연구결과 2.8. 근골격분과 KQ 1. 천장관절주변의통증 (sacroiliac joint pain) 혹은아래허리통증을 (Lower back pain) 호소하며병원에처음내원한성인에서혈청음성척추관절염 (or 혈청음성척추관절병증 진단을위한적절한영상의학검사또는핵의학검사는무엇인가? 권고 1-1. 척추관절염의조기진단을위해서, 일반방사선검사에서명백한천장관절염이있을경우추가적인영상검사는권고하지않는다. ( 권고등급 C, 근거수준 II). 권고 1-2. 일반방사선검사에서소견이정상이거나모호한경우, 천장관절과척추의염증성변화를발견하기위해서는 MRI를가장적절한검사로권고한다. ( 권고등급 A, 근거수준 II) 권고 1-3. CT는천장관절의구조적변화를발견하기에민감한도구이지만방사선노출의위험성을고려할것을권고한다. ( 권고등급 B, 근거수준 II) 근거요약혈청음성척추관절염 (spondyloarthritis, SpA, 이하척추관절염 ) 은혈액에서류마티스인자는발견되지않으며 HLA-B27 항원의발현율이높은만성염증성관절염의한종류이다 (1-6). 척추관절염은특징적으로천장관절염 (sacroiliitis), 척추염 (spondylitis) 을일으키며부착부염 (enthesopathy) 을일으키는속성과함께포도막염 (uveitis) 등의관절외이상을동반하는질환군이다. 척추관절염은임상적특징에따라강직성척추염 (ankylosing spondylitis, AS), 건선관절염 (psoriatic arthritis, PsA), 반응관절염 / 라이터증후군 (reactive arthritis/reiter s arthritis, ReA/RD), 염증장질환관련관절염 (inflammatory bowel disease related arthritis, IBD-A), 미분화척추관절염 (undifferentiated spondyloarthritis, uspa) 등 5가지질환으로나누어지며, 임상적침범부위에따라천장관절과척추를주로침범하는축성척추관절염 (axial spondyloarthritis) 의형태로나타나거나말초관절을주로침범하는말초척추관절염 (peripheral spondyloarthritis) 의형태로나타난다. 척추관절염에서발생하는만성염증, 골파괴, 비정상적인골형성은결국류마티스관절 99

113 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 염의장애와비교할만한심각한장애를유발하게된다 (7). 척추관절염은다소이질적인질환으로환자들은천장관절이나척추만침범할수있고, 때로는말초의사지관절이나포도막염과같은관절외증상을보일수있다. 이러한질환의이질성이실제임상진료시에질환의활동성의정도나중증도등을명확히평가하지못하게한다. 척추관절염의진단에중요한두가지요소인척추관절운동의제한이있거나, 영상검사에서천장관절염이명확한경우는실제질환의초기에는나타나지않을수있어질환의진단을지연시킨다 (8). 척추관절염의조기진단은다음과같은이유로매우중요하다. 첫번째, 불필요한검사나부적당한치료를피할수있다. 두번째, 비방사선학적축성척추관절염과같은질환의초기에도나중단계와같은질환의활동성이나통증을갖는다 (9). 세번째, NSAIDs 를사용하는치료는증상이있는환자에서는진단이되면바로시작해야하고, 계속복용을유지해야한다. 결국, 조기진단이조기치료를촉진시킨다 (10). 마지막으로네번째, 기존의치료에반응하지않는환자들은 TNF blockers 에반응을잘하며 (11-13), 아마도질환의초기에사용하면더좋을것이다 (14,15). 방사선학적천장관절염은처음증상이발생하고수년이지난후에야정상적으로발견이가능하여, modified New York criteria를적용하여진단하는경우지연이발생할수있다 (16). 이러한기준의경우, 방사선학적천장관절염을진단하려면양측에등급 2가있거나편측에등급 3이상이필수이다 (17). 최근몇년동안 MRI를사용하여급성기의천장관절염과척추염을발견하려는연구가많았는데 (18), 이것은비방사선학적척추관절염의단계에서염증이지속되면방사선학적척추관절염으로진행하기때문이다 (16,19). CT 검사는천장관절의구조적변화를평가하는가장특이도가높은검사로고려된다 (20,21). 기존의일반방사선검사와비교하여 CT 검사는천장관절의경계면을따라발생하는구조적변화를관찰하는것이정확하여, 강직성척추염환자에서높은등급의천장관절염을발견하는데유용하다 (22). 하지만 MR과달리 CT는방사선피폭의문제가발생하고, 활동성염증을평가하지못한다는단점이있다 (23). 권고고려사항 1. 이득과위해천장관절주변의통증 (sacroiliac joint pain) 혹은아래허리통증을 (Lower back pain) 호소하는젊은성인에서일차적인검사는일반방사선검사이지만, 일반방사선검사의경우는골미란이나골경화의소견이뚜렷할때까지는발견이어렵고, 판독자에따라판독결 100

114 3. 연구결과 과가상이할수있다. CT는국내의대부분의병원이보유하고있어검사는쉬우나방사선피폭의위험을감수해야하며, 일반방사선검사에비해서는덜하지만판독자에따라상이한결과를보여주고, 비방사선학적축성척추관절염의진단은어려운점이있어이를고려해야한다. MRI는 CT에비해서쉽게이용하기어렵고고가인단점이있으나, 방사선피폭이없고, 골미란이나골경화소견과같은척추관절염의구조적변화가오기전에천장관절의연골하골수부종, 골염, 부착부염, 관절낭염과같은급성활동성염증병변을특징적으로보여주기때문에조기진단을위해먼저고려한다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시되었다. 3. 검사별방사선량일반방사선검사 MRI 0 골반 CT 참고문헌 1. Van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for an kylosing spondylitis: a proposal for modification of the New York criteria. Arthriti s Rheum 1984;27: Dougados M, vander Linden S, Juhlin R, Huitfeldt B, Amor B, Calin A, et al. The European Spondyloarthritis Study Group preliminary criteria for the classification of spondyloarthritis. Arthritis Rheum 1991;34: Resnick D, Kransdorf MJ. Bone and Joint Imaging, 3rd ed. Elsevier Saunders, 2005: Yochum TR, Rowe LJ. Essentials of skeletal radiology, 2nd ed. Williams and Wilkin s, 1996: Braun J, Bollow M, Sieper J. Radiologic diagnosis and pathology of the spondyloar thropathies. Rheum Dis Clin North Am 1998;24: Jacobson JA, Girish G, Jiang Y, Resnick D. Radiographic evaluation of arthritis: inf lammatory conditions. Radiology 2008;248: Zink A, Braun J, Listing J, Wollenhaupt J. Disability and handicap in rheumatoid a rthritis and ankylosing spondylitis results from the German rheumatological datab ase. German Collaborative Arthritis Centers. J Rheumatol 2000;27:

115 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 8. Sidiropoulos PI, Hatemi G, Song IH, et al. Evidence-based recommendations for th e management of ankylosing spondylitis: systematic literature search of the 3E Ini tiative in Rheumatology involving a broad panel of experts and practising rheuma tologists. Rheumatology 2008;47: Rudwaleit M, Listing J, Maerker-Hermann E, Zeidler H, Braun J, Sieper J. The burd en of disease in patients with ankylosing spondylitis and preradiographic axial sp ondyloarthritis is similar. Arthritis and Rheumatism 2004;50:S Dougados M, Dijkmans B, Khan M, Maksymowych W, van der Linden S, Brandt J. Conventional treatments for ankylosing spondylitis. Ann Rheum Dis. 2002;61(Suppl 3):iii Braun J, Brandt J, Listing J, et al. Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial. Lancet 2002;359: van der Heijde D, Kivitz A, Schiff MH, et al. Efficacy and safety of adalimumab i n patients with ankylosing spondylitis: Results of a multicenter, randomized, doubl e-blind, placebo-controlled trial. Arthritis Rheum 2006;54: Davis JC Jr, Van Der Heijde D, Braun J, et al. Recombinant human tumor necrosi s factor receptor (etanercept) for treating ankylosing spondylitis: a randomized, co ntrolled trial. Arthritis Rheum 2003;48: Rudwaleit M, Listing J, Brandt J, Braun J, Sieper J. Prediction of a major clinical response (BASDAI 50) to tumour necrosis factor alpha blockers in ankylosing spon dylitis. Ann Rheum Dis 2004;63: Sieper J, Rudwaleit M. How early should ankylosing spondylitis be treated with tu mour necrosis factor blockers? Ann Rheum Dis, 2005;64(Suppl 4), iv Rudwaleit M, Khan MA, Sieper J. The challenge of diagnosis and classification in early ankylosing spondylitis: do we need new criteria? Arthritis Rheum 2005;52: van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for an kylosing spondylitis. A proposal for modification of the New York criteria. Arthriti s Rheum 1984;27: Braun J, Bollow M, Eggens U, Konig H, Distler A, Sieper J. Use of dynamic magn etic resonance imaging with fast imaging in the detection of early and advanced sacroiliitis in spondylarthropathy patients. Arthritis Rheum1994;37: Oostveen J, Prevo R, den Boer J, van de Laar M. Early detection of sacroiliitis on magnetic resonance imaging and subsequent development of sacroiliitis on plain r adiography. A prospective, longitudinal study. J Rheumatol 1999;26: Carrera GF, Foley WD, Kozin F, Ryan L, Lawson TL. CT of sacroiliitis. AJR Am J Roentgenol 1981;136: Kozin F, Carrera GF, Ryan LM, Foley D, Lawson T. Computed tomography in the diagnosis of sacroiliitis. Arthritis Rheum 1981;24: Fam AG, Rubenstein JD, Chin-Sang H, Leung FY. Computed tomography in the d iagnosis of early ankylosing spondylitis. Arthritis Rheum 1985;28:

116 3. 연구결과 23. Puhakka KB, Jurik AG, Egund N, et al. Imaging of sacroiliitis in early seronegati ve spondylarthropathy: assessment of abnormalities by MR in comparison with rad iography and CT. Acta Radiol 2003;44(2):

117 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 KQ 2. 만져지는연부조직종괴를주호소로내원한성인에서연부조직종양진단을위한적절 한영상검사는무엇인가? 권고 2-1. 만져지는연부조직종괴를주소로내원한성인에서연부조직종양진단을위한첫번째영상검사로는일반방사선검사를권고한다. ( 권고등급 A, 근거수준 II) 권고 2-2. 만약임상소견에서해당종괴가단순지방종 (lipoma) 이나결정종 (ganglion) 이의심되는상황이라면첫번째영상검사로초음파검사를고려할수있다. ( 권고등급 B, 근거수준 II) 권고 2-3. 일반방사선검사만으로정확한진단에이르기어려운경우, 추가검사로 MRI 를권고한다. ( 권고등급 A, 근거수준 II) 근거요약만져지는연부조직종괴를주소로내원한환자의영상진단에대한가이드라인은검색후 5개의가이드라인이선택되었다. 대부분의가이드라인은종괴의양, 악성의감별, 혹은양성종양 / 종양유사병변의진단을위해시행해야할영상검사선택에대한지침을주었다. 따라서본가이드라인은만져지는종괴의위치와환자의증상을포함한임상적소견을바탕으로 1차진단검사선택에중점을두어작성되었다. 임상적으로만져지는종괴가있는경우일반방사선검사를통해뼈의병변의만져지는것은아닌지먼저확인하고, 종괴내의석회화여부를확인한다 (1). 일반방사선검사에서특이소견이발견되지않으면서동시에임상적으로악성종양의가능성을배제할수없는경우에는자기공명영상 (Magnetic Resonance Imaging) 이권장된다 (2-4). 단, 임상적으로지방종이나결절종이의심되는경우에는초음파검사를권고한다 (5-7). 자기공명영상 (Magnetic Resonance Imaging) 은연부조직대조도가높고다양한영상단면을얻을수있어서연부종괴의발견 (lesion conspicuity), 진단 (characterization, and local staging) 에이점을가진다 (8-15). 또한자기공명영상은인접한신경혈관조직 (8) 이나골수조직 (marrow) 의침범여부를판단하는데전산화단층촬영 (Computed Tomography) 검사보다더우월한것으로보고되어있다 (16). 그러나자기공명영상으로발견된종괴의양, 악성을판별하는것에는여전히이견이존재하는데 (14,16-26), 그정확도는 24% 에서 90% 까지다양하게보고되어있다. 그러나양악성의감별에대한다변량해석의결과 104

118 3. 연구결과 에서는, 악성종양진단을내린다고했을때가장감도가높은조합은 T2강조영상에서의고강도신호, 3.3 cm 이상의크기, T1 강조영상앙에서의불균일한신호라고보고되어있으며, 한편가장특이도가높은조합은종양괴사, 뼈또는신경혈관다발침윤, 6.6 cm 이상의크기라고알려져있다 (27-33). 질적진단연구에서는양성종양의 24~54%, 악성종양의 0~38% 에서질적진단이가능하다고하였으며 (27,31,33), 악성병변보다는양성병변의진단능이높다고보고하였다 (30, 32, 34-36). 조영제사용이일부종양에서는양, 악성판별에부분적으로도움을준다는보고도있으나 (21,22), 여전히양, 악성종양의소견이겹치는부분이많아제한점을가진다 (23,24). 권고고려사항 1. 이득과위해만져지는연부조직종괴가지방종이의심되거나, 일반방사선검사에서석회화가발견된경우, 외상후이소성석회화 (heterotopic ossification) 가의심되는경우에는일차검사로조영증강 CT 검사가사용될수있다. 또한매우체구가큰환자나심박동기를가지고있어서자기공명영상촬영이불가능한환자에서는일차검사로 CT 검사가유용하다. 일부연구에서는자기공명영상과조영증강 CT 검사가종괴의크기측정, 인접한구조물로의침범여부를확인하는데동등한유용성을가진다고보고하고있다 (18). 그러나방사선피폭이있고, 연부조직의대조도가낮아서주변부종이나혈관성등을보여주지못한다는단점이있다. 조영제사용에대해서도촬영시간과비용이늘어난다는점에서의견이분분한데, 조영증강자기공명영상을추가해도양, 악성감별의진단능이그다지향상되지않는다는보고가있다 (34,35). 그러나또한편에서는조영증강검사를추가함으로써양성종양의질적진단능이향상되고 (36), 고분화지방육종, 점액성분을가진육종의진단에도움이되는소견이보고되어있기도하다 (37,38,39). 따라서촬영시간과비용측면을고려할때, 조영증강자기공명영상을일상적으로시행할필요성은낮으나양, 악성감별에도움이되는경우도있으므로선별적으로시행할것을고려해야겠다. 2. 국내수용성과적용성 (Acceptability and Applicability) 5개진료가이드라인의국내수용성과적용성을평가한결과연부조직종괴진단을위한일차적검사로써자기공명영상의유용성에대해서는대부분의진료지침이일치하였다. 그러나, CT와초음파검사에대해서는진료가이드라인에따라다른결론을내리고 105

119 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 있었다. 국가별검사장비의보급, 검사자숙련도의차이, 그리고보험적용여부및검사로인해발생하는의료비의차이로나타나는현상으로생각되고이의국내수용성과적용성은평가결과큰무리가없는것으로판단하였다. 수용성과적용성평가표는부록에제시되었다. 3. 검사별방사선량일반방사선검사초음파검사 0 MRI 0 참고문헌 1. American College of Radiology. Manual on Contrast Media. Available at: w.acr.org/~/link.aspx?_id=29c40d1fe0ec4e5eab6861bd213793e5&_z=z. 2. The ESMO/European Sarcoma Network Working Group. Soft tissue and visceral sar comas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology25 (Supplement 3): iii102 iii112, P. G. Casali, & J.-Y. Blay. Soft tissue sarcomas: ESMO Clinical Practice Guidelines. Annals of Oncology21 (Supplement 5): v198 v203, Robert Grimer, Ian Judson, David Peake., nd Beatrice Seddon. Guidelines for the Management of Soft Tissue Sarcomas. Sarcoma. 2010; 2010: Sundaram M, McGuire MH, Herbold DR. Magnetic resonance imaging of soft tissue masses: an evaluation of fifty-three histologically proven tumors. Magn Reson Ima ging 1988;6(3): Griffith JF, Can DP, Kumta SM, Chow LT, Ahuja AT. Does Doppler analysis of mu sculoskeletal soft-tissue tumors help predict tumour malignancy? Clin Radiol 2004: 5994): Lakkaraju A, Sinha R, Garikipati R, Edward S, Robison P. Ultrasound for initial ev aluation and triage of clinically suspecious soft-tissue masses. Clin Radiol 2009,64 (6): Jelinek JS, Kransdorf MJ, Shmookler BM, Aboulafia AJ, Malawer MM. Liposarcoma of the extremities: MR and CT findings in the histologic subtypes. Radiology 199 3;186(2): Vanel D, Shapeero LG, De Baere T, et al. MR imaging in the follow-up of malign ant and aggressive soft-tissue tumors: results of 511 examinations. Radiology 199 4;190(1) Weekes RG, Berquist TH, McLeod RA, Zimmer WD. Magnetic resonance imaging of soft-tissue tumors: comparison with computed tomography. Magn Reson Imagi ng 1985;3(4):

120 3. 연구결과 11. Cohen EK. Kressle HY, Perosio T, et al. MR imaging of soft-tissue hemangiomas: correlation with pathologic findings. AJR 1988;150(5): Crim JR, Seeger LL, Yao L, Chandnani V, Eckardt JJ. Diagnosis of soft-tissue mas ses with MR imaging: cab benign masses be differentiated from malignant ones? Radiology 1992;185(2): De Schepper AM, Ramon FA, Degreyse HR. Magnetic resonance imaging of soft-ti ssue tumors. J Belge Radiol 1992;75(4): Jones BC, Sundaram M, Kransdorf MJ. Synovial sarcoma: MR imaging findings in 34 patients. AJR 1993;164(4): Wignall OJ, Moskovic EC, Thway K, Thomas JM. Solitary fibrous tumors of the so ft tissues: review of the imaging and cilinical features with histopathologic correla tion. AJR 2010;195(1):W White LM, Wunder JS, Bell RS, et al. Histologic assessment of peritumoral edema in soft tissue sarcoma. Int J Radiat Oncol Biol Phys 2005;61(5): Binkovitz LA, Berquist TH, McLeod RA. Masses of the hand and wrist: detection a nd characterization with MR imaging. AJR 1990; 154(2): Panicek DM, Gatsonis C, Rosenthal DI, et al. CT and MR imaging in the local st aging of primary malignant musculoskeletal neoplasms: Report of the Radiology D iagnostic Oncology Group. Radiology 1997;202(1): Gielen JL, De Schepper AM, Vanhoenacker F, et al. Accuracy of MRI in character ization of soft tissue tumors and tumor-like lesions, A prespective study in 548 p atients. Eur Radiol 2004;14(12): Moulton JS, Blebea JS, Dunco DM, Braley SE, Bisset GS, 3rd, Emery KH. MR imag ing of soft-tissue masses: diagnotic efficucy and value of distinguishing between b enign and malignant lesions. AJR 1995;164(5): Panzarella MJ, Naqvi AH, Cohen HE, Damron TA. Predictive value of gadolinium enhancement in differentiating ALT/WD liposarcomas from benign fatty tumors. S keletal Radiol 2005;34(5): Teo EL, Strouse PJ, Hernandez RJ. MR imaging differentiation of soft-tissue hema ngiomas from malignant soft-tissue masses. AJR 2000;174(6): Van der Woude HJ, Verstaete KL, Hogendoorn PC, Taminiau AH, Hermans J, Blo em JL. Musculoskeletal tumors: does fast dynamic contrast-enhanced subtraction MR imaging contribute to the characterization? Radiology 1998;208(3): Van Rijswijk CS, Geirnaerdt MJ, hogendoorn PC, et al. Soft-tissue tumors: value of static and dynamic gadopentetate dimeglumine-enhanced MR imaging in predic tion of malignancy. Radiology 2004;233(2): Van Rijswijk CS, Kunz P, Hogendoorn PC, Taminiau AK, Doornbos J, Bloem JL. Diffusion-weighted MRI in the characterization of soft-tissue tumors. Jmagn Reson Imaging 2002, 15(3): Wang CK, Li CW, Hsieh TJ, Chien SH. Liu GC, Tsai KB. Characterization of bon and soft-tissue tumors with in vivo 1H MR spectroscopy: initial results. Radiology 107

121 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2004;232(2): Kransdort MJ et al. Soft-tissue masses : diagnosis using MR imaging. AJR 153: , Berquit TH et al. Value of MR imaging in differentiating benign from malignant s oft-tissue masses: study of 95 lesions. AJR 155: , Crim JR et al. Diagnosis of soft-tissue masses with MR imaging : can benign mas ses be differentiated from malignant ones? Radiology 185: , Ma LD et al. Differentiation of benign and malignant musculoskeletal tumors: pot ential pitfalls with MR imaging. Radiographics 15: , Gielen JL et al. Accuracy of MRI in characterization of soft tissue tumors and tu mor-like lesions. A prospective study in 548 patients. Eur Radiol 14: , De Schepper AM et al. Statistical analysis of MRI parameters predicting malignan cy in 141 soft tissue masses. Rofo 156: , Moulton JS et al. MR imaging of soft-tissue masses : diagnostic efficacy and valu e of distinguishiung between benign and malignant lesions. AJR 164: , May DA et al. MR imaging of musculoskeletal tumors and tumor mimickers with intravenous gadolinium: experience with 242 patients. Skeletal Radiol 26:2-15, Kransdorf MJ et al. The use of gadolinium in the MR evaluation of soft tissue tu mors. Semin Ultrasound CT MR 18: , van Rijswijk CS et al. Soft-tissue tumors: value of static and dynamic gadopentet ate dimeglumine-enhanced MR imaging in prediction of malignancy. Radiology 23 3: Panzarella MJ et al. Predictive value of gadoliniun enhancement in differentiaing ALT/WD liposarcomas from benign fatty tumors. Skeletal Radiol 34 : , Kajhara M et al. Evaluation of tumor blood flow in musculoskeletal lesions: dyna mic contrast-enhanced MR imaging and its possibility when monitoring the respo nse to preoperative chemotherapy-work in pogress. Radiat Med 25:94-105, Mirowitz SA et al. Characterization in musculoskeletal masses using dynamic Gd- DTPA enhanced spin-echo MRI. J Comput Assist Tomogr 16 : ,

122 3. 연구결과 KQ 3. 비외상성무릎통증을호소하는어른환자에서통증의원인을규명하기위한적절한영상검사는무엇인가? 권고 3. 비외상성무릎통증을호소하는성인환자에서일반방사선검사에서이상소견이없을경우통증의원인을규명하기위한다음영상검사로 MRI를권고한다. ( 권고등급 B, 근거수준 II) 근거요약성인에서가장흔한비외상성무릎통증의원인은골관절염 (osteoarthritis) 이다 (1). 그밖에도슬내장증 (internal derangement of knee), 연골하긴장골절 (subchondral stress fracture), 염증성관절염 (inflammatory arthritis), 박리성골연골염 (osteochondritis dissecans), 일과성골다공증 (transient osteoporosis), 슬개건-외측대퇴과마찰증후군 (patellar tendon lateral femoral condyle friction syndrome), 장경골인대마찰증후군 (iliotibial band friction syndrome) 등다양한원인이통증을유발할수있다 (2-10). 일반촬영은유용한일차영상검사이지만제한점이있고이상소견이없을경우다음단계의검사가필요하다 (11-14). 일반촬영결과가진단적이지않고증상이지속된다면혹은치료시작전추가정보가필요하다면 MRI가적응증이된다 (15). MRI를통해관절액, 오금낭종, 활액막의변화, 골증식, 연골하낭종, 연골이상, 반월연골혹은인대의손상이나퇴행성변화, 골수부종, 골절, 골괴사등을높은민감도로확인할수있다 (16-23). 하지만 MRI 검사는항상이학적검사와일반촬영이후고려되어야하며일반촬영에서변화가뚜렷한골관절염, 염증성관절염, 긴장골절에서는추가영상검사가치료방침에영향을주지않는다면권장되지않는다 (24). 컴퓨터단층촬영 (CT) 은슬내장증을진단하는데민감도가낮으며초음파의경우오금낭종을확인하는등제한적인상황에한해진단적이다 (22,25). 권고고려사항 1. 이득과위해 MRI는접근성이낮고고가인단점이있으나, 방사선피폭이없고, 무릎내부의여러구조물들을한번에확인할수있다는장점이있다. 이를통해무릎통증을일으킬수있는다양한원인을진단하거나배제할수있다. MRI는비외상성무릎통증의원인을규명하는데 CT나초음파에비해우수하지만일차검사로시행하는데에는충분한근거가 109

123 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 확립되지않았으며일반촬영이진단적이지않을경우에한해다음영상검사로고려할 수있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시되었다. 3. 검사별방사선량 일반방사선검사 MRI 0 참고문헌 1. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: A revie w of community burden and current use of primary health care. Annals of the rh eumatic diseases 2001;60: Le Gars L, Savy JM, Orcel P, Liote F, Kuntz D, Tubiana JM et al. Osteonecrosis-lik e syndrome of the medial tibial plateau can be due to a stress fracture. Mr findin gs in 13 patients. Revue du rhumatisme (English ed.) 1999;66: Yamamoto T, Bullough PG. Spontaneous osteonecrosis of the knee: The result of s ubchondral insufficiency fracture. The Journal of bone and joint surgery. America n volume 2000;82: Hayes CW, Conway WF, Daniel WW. Mr imaging of bone marrow edema pattern: Transient osteoporosis, transient bone marrow edema syndrome, or osteonecrosis. Radiographics : a review publication of the Radiological Society of North Americ a, Inc 1993;13: ; discussion O'Connor MA, Palaniappan M, Khan N, Bruce CE. Osteochondritis dissecans of th e knee in children. A comparison of mri and arthroscopic findings. The Journal o f bone and joint surgery. British volume 2002;84: Kijowski R, Blankenbaker DG, Shinki K, Fine JP, Graf BK, De Smet AA. Juvenile v ersus adult osteochondritis dissecans of the knee: Appropriate mr imaging criteria for instability. Radiology 2008;248: Lo GH, Hunter DJ, Nevitt M, Lynch J, McAlindon TE. Strong association of mri me niscal derangement and bone marrow lesions in knee osteoarthritis: Data from th e osteoarthritis initiative. Osteoarthritis and cartilage / OARS, Osteoarthritis Resea rch Society 2009;17: Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M et al. Incidental meniscal findings on knee mri in middle-aged and elderly persons. The New Engl 110

124 3. 연구결과 and journal of medicine 2008;359: Chung CB, Skaf A, Roger B, Campos J, Stump X, Resnick D. Patellar tendon-latera l femoral condyle friction syndrome: Mr imaging in 42 patients. Skeletal radiology 2001;30: Vasilevska V, Szeimies U, Stabler A. Magnetic resonance imaging signs of iliotibia l band friction in patients with isolated medial compartment osteoarthritis of the knee. Skeletal radiology 2009;38: Hayes CW, Conway WF. Evaluation of articular cartilage: Radiographic and crosssectional imaging techniques. Radiographics : a review publication of the Radiolo gical Society of North America, Inc 1992;12: Brandt KD, Fife RS, Braunstein EM, Katz B. Radiographic grading of the severity of knee osteoarthritis: Relation of the kellgren and lawrence grade to a grade bas ed on joint space narrowing, and correlation with arthroscopic evidence of articul ar cartilage degeneration. Arthritis and rheumatism 1991;34: Kijowski R, Blankenbaker D, Stanton P, Fine J, De Smet A. Arthroscopic validatio n of radiographic grading scales of osteoarthritis of the tibiofemoral joint. AJR. A merican journal of roentgenology 2006;187: Messieh SS, Fowler PJ, Munro T. Anteroposterior radiographs of the osteoarthritic knee. The Journal of bone and joint surgery. British volume 1990;72: Vincken PW, ter Braak AP, van Erkel AR, Coerkamp EG, de Rooy TP, de Lange S et al. Mr imaging: Effectiveness and costs at triage of patients with nonacute kne e symptoms. Radiology 2007;242: McAlindon TE, Watt I, McCrae F, Goddard P, Dieppe PA. Magnetic resonance im aging in osteoarthritis of the knee: Correlation with radiographic and scintigraphi c findings. Annals of the rheumatic diseases 1991;50: Reiser MF, Vahlensieck M, Schüller H. Imaging of the knee joint with emphasis o n magnetic resonance imaging. European Radiology;2: Sabiston CP, Adams ME, Li DK. Magnetic resonance imaging of osteoarthritis: Co rrelation with gross pathology using an experimental model. Journal of orthopaedi c research : official publication of the Orthopaedic Research Society 1987;5: Chen CA, Lu W, John CT, Hargreaves BA, Reeder SB, Delp SL et al. Multiecho id eal gradient-echo water-fat separation for rapid assessment of cartilage volume at 1.5 t: Initial experience. Radiology 2009;252: Spritzer CE, Vogler JB, Martinez S, Garrett WE, Jr., Johnson GA, McNamara MJ et al. Mr imaging of the knee: Preliminary results with a 3dft grass pulse sequence. AJR. American journal of roentgenology 1988;150: Konig H, Sauter R, Deimling M, Vogt M. Cartilage disorders: Comparison of spinecho, chess, and flash sequence mr images. Radiology 1987;164: Ghelman B, Hodge JC. Imaging of the patellofemoral joint. The Orthopedic clinic s of North America 1992;23:

125 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 23. Pihlajamaki HK, Kuikka PI, Leppanen VV, Kiuru MJ, Mattila VM. Reliability of cli nical findings and magnetic resonance imaging for the diagnosis of chondromalac ia patellae. The Journal of bone and joint surgery. American volume 2010;92: Lo GH, McAlindon TE, Niu J, Zhang Y, Beals C, Dabrowski C et al. Bone marrow lesions and joint effusion are strongly and independently associated with weight-b earing pain in knee osteoarthritis: Data from the osteoarthritis initiative. Osteoart hritis and cartilage / OARS, Osteoarthritis Research Society 2009;17: Ward EE, Jacobson JA, Fessell DP, Hayes CW, van Holsbeeck M. Sonographic det ection of baker's cysts: Comparison with mr imaging. AJR. American journal of ro entgenology 2001;176:

126 3. 연구결과 2.9. 인터벤션분과 KQ 1. 수술후급성복부통증을호소하는환자에서체액감염 (infected fluid) 진단을위한적절한영상검사는무엇인가? 권고 1. 수술후급성복부통증을호소하는환자에서체액감염 (infected fluid) 진단을위해조영증강및조영증강전 CT를권고하며임산부의경우 CT 대신초음파검사및 MRI를권고한다. ( 권고등급 A, 근거수준 II) 근거요약수술후급성복부통증을호소하는체액감염의심환자의영상진단에대한권고의근거로삼기위한 1개의진료지침을최종선택하였다. 수술후급성복부통증이있는경우농양을비롯한여러응급질환의가능성이있으며특히복강내국소적체액감염이나농양의진단, 위치결정, 치료계획수립에있어영상의학적검사는매우결정적이다. 따라서본가이드라인은수술후체액감염진단을위한영상의학적검사에대해작성하였다. CT는수술후임상적으로복부농양이의심되는환자에서가장적절한검사이다 (1, 2). 복통의원인을찾는데 CT는 90~96% 의정확도를보인반면임상적평가는 60~76 % 의정확도를보였다 (3-5). 복부 CT는췌장농양, 게실염, 크론병농양, 요근농양을검출하는데유용하며 (6-11), 게실염, 충수염, 장폐색진단에높은관찰자간일치도 (interobserver agreement) 를보였다 (12). 조영증강 CT는좀더정확한병변진단을가능하게하며 (13,14), 다면상재구성 (multiplanar reformation) 을통해진단의신뢰도가증가한다 (15-17). 초음파검사는특정질병의경우효과적이나 CT와비교할때일반적으로진단의민감도와특이도가떨어진다 (18-20). 초음파검사의장점은방사선위해가없어소아에게유용하며 (21), 최소침습적경피적배액술에효율적으로사용할수있다는것이다 (22). 복부또는골반통증이있는임산부의경우유용성, 편의성, 방사선위해를고려할때초음파검사가초기영상기법으로적절하다 (23). MRI는초음파검사에서진단이되지않는경우자주사용되고있다. MRI는임신초기 (first trimester) 의충수염과농양진단에선호되는영상기법이며 (24), 우수한민감도와특이도를보인다 (25-27). 113

127 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 권고고려사항 1. 이득과위해수술후체액감염의심환자의일차진단검사로 CT 검사를사용하는경우진단정확도가높을뿐만아니라우리나라의현실상다른영상검사기법과비교하여보험의적용을받을수있어경제적으로유리하며검사장비가널리보급되어접근성이높은장점이있다. 그러나조영제주입에따른신독성 (nephrotoxicity) 이발생할수있고방사선노출의문제점이있다. 초음파검사및 MRI는 CT에비해정확도는떨어지나방사선위해가없어소아나임산부에게 CT 대신우선적으로사용가능한장점이있다. 그러나초음파검사의경우검사자의경험과환자조건 ( 비만도 ) 에의해진단정확도가낮을수있으며 MRI의경우심장박동조율기 (cardiac pacemaker), 이식형제세동기 (implantable cardioverter defibrillator), 신경자극장치 (neurostimulator), 인공와우 (cochlear implant) 등의금속물질이이식된환자에서검사에제한이있을수있고심한신부전환자에서조영제사용이제한될수있으며검사비용이상대적으로비싸다는단점이있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과큰무리가없는것으로판단되었다. 수 용성과적용성평가표는부록에제시한다. 3. 검사별방사선량조영증강및조영증강전 CT 초음파검사 0 MRI 0 참고문헌 1. Porter JA, Loughry CW, Cook AJ, Use of the Computerized Tomographic Scan in the Diagnosis and Treatment of Abscesses. Am J Surg. 1985;150(2): Antevil JL, Egan JC, Woodbury RO, Rivera L, Oreilly EB, Brown CV, Abdominal C omputed Tomography for Postoperative Abscess: Is It Useful During the First Wee k? J Gastrointest Surg. 2006;10(6): MacKersie AB, Lane MJ, Gerhardt RT, et al. Nontraumatic Acute Abdominal Pain: Unenhanced Helical CT Compared with Three-View Acute Abdominal Series. Radi ology 2005;237(1):

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129 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 19. Field TC, Pickleman J, Intra-Abdominal Abscess Unassociated with Prior Operatio n. Arch Surg. 1985;120(7): Lundstedt C, Hederstrom E, Brismar J, Holmin T, Strand SE, Prospective Investigat ion of Radiologic Methods in the Diagnosis of Intra-Abdominal Abscesses. Acta R adiol Diagn. (Stockh) 1986;27(1): Lameris W, van Randen A, van Es HW, et al. Imaging Strategies for Detection of Urgent Conditions in Patients with Acute Abdominal Pain: Diagnostic Accuracy St udy. BMJ 2009;338:b Azzarello G, Lanteri R, Rapisarda C, et al. Ultrasound-Guided Percutaneous Treat ment of Abdominal Collections. Chir Ital. 2009;61(3): Butala P, Greenstein AJ, Sur MD, Mehta N, Sadot E, Divino CM, Surgical Manage ment of Acute Right Lower-Quadrant Pain in Pregnancy: A Prospective Cohort Stu dy. J Am Coll Surg. 2010;211(4): Jaffe TA, Miller CM, Merkle EM, Practice Patterns in Imaging of the Pregnant Pat ient with Abdominal Pain: A Survey of Academic Centers. AJR 2007;189(5): Singh A, Danrad R, Hahn PF, Blake MA, Mueller PR, Novelline RA, MR Imaging o f the Acute Abdomen and Pelvis: Acute Appendicitis and Beyond. Radiographics 2 007;27(5): Oto A, Ernst RD, Ghulmiyyah LM, et al. MR Imaging in the Triage of Pregnant P atients with Acute Abdominal and Pelvic Pain. Abdom Imaging 2009;34(2): Lazarus E, Mayo-Smith WW, Mainiero MB, Spencer PK, CT in the Evaluation of Nontraumatic Abdominal Pain in Pregnant Women. Radiology 2007;244(3):

130 3. 연구결과 KQ 2. 간헐적파행 (intermittent claudication) 환자에서혈관성파행 (vascular claudication) 진단을위한적절한영상검사는무엇인가? 권고 2-1. 혈관성파행의확진을위한일차적검사로듀플렉스초음파검사 (Duplex ultrasonography, DUS) 를권고한다. ( 권고등급 A, 근거수준 II) 권고 2-2. 혈관성파행환자의병변의위치와정도를평가하기위해서 CT 혈관조영검사, 듀플렉스초음파검사및 MRI 혈관조영검사를권고한다. ( 권고등급 A, 근거수준 II) 근거요약간헐적파행을호소하는말초혈관질환이의심되는환자의영상진단에대한권고의근거로삼기위한 8개의진료지침을최종선택하였다. 듀플렉스초음파검사 (Duplex ultrasonography, DUS) 는비침습적이고검사기기에대한접근성이좋아서외래나침상의환자옆에서바로적용하기쉽다. 회색조 (gray scale) 영상을통한동맥벽을직접관찰할수있고, 색도플러검사, 파워도플러검사를이용하여혈류의관찰, 혈류속도측정, 도플러파형분석을통해서협착의정도도평가할수있는장점이있다. DUS는직경 50% 이상의협착부를진단하는데있어민감도와특이도가각각 90%, 95% 에이른다. 따라서 DUS는말초혈관질환이의심되는환자에서확진을위한일차적영상검사로사용될수있다 (1-5). 또한 DUS는동맥병변의해부학적위치와협착정도를평가하는데에도유용하며 (3,6-12) 이를바탕으로다리동맥에대한인터벤션혈관재개통술이나우회로조성술 (bypass surgery) 을시행할수도있다. CT 혈관조영술 (computed tomography angiography, CTA) 은단층촬영을통해혈관의벽과내강에대한세밀한분석뿐아니라, 폐쇄부이하와주변조직에대한관찰이가능하고, 삼차원적으로재구성하여혈관조영검사에버금가는영상을획득할수있으며전체혈관을한눈에파악할수있다는장점이있다 (13-15). 단일검출기 (single detector) CT를이용한초기연구에서다리동맥의직경 50% 이상협착부에대하여민감도는 89~100%, 특이도는 92~100% 였다 (13,16-19). 2009년에발표된메타분석에따르면장골동맥의직경 50% 이상협착부에대하여민감도는 93~100%, 대퇴-슬와동맥의직경 50% 이상협착에대해서는민감도 96%, 특이도 98% 였다 (20). 따라서 CTA는다리동맥폐쇄성질환이있는환자에서병변의위치와정도를파악하는데매우유용하다. MRI 기술의발달로다리동맥에대해서도자기공명혈관조영검사 (magnetic 117

131 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 resonance angiography, MRA) 를이용하여혈관조영검사나 CTA와비견할수있을만큼좋은영상의획득이가능해졌다. 다리동맥에대한적절한영상획득을위해서는높은자기장, 적절한코일의사용, 빠른영상획득시퀀스 (sequence) 가필수적이고, 영상을획득할때는조영제를사용하여야한다 (21). 디지털감산혈관조영검사 (digitial subtraction angiography) 와비교하여분석하였을때 MRA의민감도 (93~100%) 와특이도 (93~100%) 는매우높다. 따라서말초혈관질환환자에서병변의위치와정도를평가하기위한목적으로시행될수있으며인터벤션재개통술의대상환자를정하는기준검사로이용될수있다 (2,21-24). 권고고려사항 1. 이득과위해말초혈관질환환자에서병변의위치와정도를평가하기위한 CTA는진단정확도가높을뿐만아니라우리나라의현실에서다른영상검사기법과비교하여보험급여의적용을받을수있어경제적으로유리하며검사장비가널리보급으로접근성이높은장점이있다. 그러나뼈나인공물로가려지는부분과혈관벽의석회화가심한부분에서인공음영이발생하여분석하기어려운경우가있고, 발목에서발의작은동맥의분석에는한계가있다는단점이있다. 또한, 조영제주입에따른신독성 (nephrotoxicity) 이있고방사선조사량이많은것이문제점이다. 한편, 초음파검사의경우검사자의기술과경험에따라서검사결과에차이가있을수있다. 위치가깊고장 (intestine) 의공기에가려지며굴곡진주행을하는장골동맥은평가가어려우며, 석회화가심한혈관을평가하는데에도한계가있으며, 다발성협착부가있을때하부의협착부위를찾는데에는민감도가 60~65% 로낮다는단점이있다 (25, 26). 따라서상황에따라다른영상검사를추가하거나상호보완적으로시행하여야하는경우가많다. MRA의경우병변이과대평가되기쉽고, 석회화를보여주지못하며, 금속등에의한인공음영때문에영상의분석이어려운경우가생긴다는것이단점이다 (27). 심장박동조율기 (cardiac pacemaker), 이식형제세동기 (implantable cardioverter defibrillator), 신경자극장치 (neurostimulator), 인공와우 (cochlear implant) 등의금속물질이이식된환자에서도검사에제한이있을수있다. 심한신부전환자에서조영제사용이제한될수있다는단점도있다 (28-30). 118

132 3. 연구결과 2. 국내수용성과적용성 8개진료치침에대한수용성과적용성평가결과말초혈관질환의심환자의진단을위한일차적검사로써 DUS의유용성에대해서는대부분의진료지침이일치하였다. 그러나, 병변의위치와정도를평가하기위한검사로써 CTA, MRA, DUS의유용성에대해서는대부분의진료지침이인정하고있었지만검사방법사이의선호도또는우선순위에대해서는진료지침마다다른결론을내리고있었다. 이는국가마다검사장비의보급상황이다르고보험급여적용여부나검사에따른비용이다르며각검사방법이가지고있는이득과위해에대한작성주체별가치판단기준이다르기때문인것으로생각된다. 8 개진료지침의권고내용과이에대한국내수용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 CT 혈관조영검사듀플렉스초음파검사 0 MRI 혈관조영검사 0 참고문헌 1. Collins R, Cranny G, Burch J, et al. A Systematic Review of Duplex Ultrasound, M agnetic Resonance Angiography and Computed Tomography Angiography for the Diagnosis and Assessment of Symptomatic, Lower Limb Peripheral Arterial Diseas e Visser K, Hunink MM, Peripheral Arterial Disease: Gadolinium-Enhanced MR Angio graphy Versus Color-Guided Duplex US A Meta-Analysis1. Radiology Whelan J, Barry M, Moir J, Color Flow Doppler Ultrasonography: Comparison with Peripheral Arteriography for the Investigation of Peripheral Vascular Disease. Jour nal of Clinical Ultrasound 1992;20: Barnes R, Noninvasive Diagnostic Assessment of Peripheral Vascular Disease. Circu lation 1991;83:I Clement D, Van Maele G, De Pue N, Critical Evaluation of Venous Occlusion Plet hysmography in the Diagnosis of Occlusive Arterial Diseases in the Lower Limbs. International Angiology: A Journal of the International Union of Angiology 1984;4: Pinto F, Lencioni R, Napoli V, et al. Peripheral Ischemic Occlusive Arterial Diseas e: Comparison of Color Doppler Sonography and Angiography. Journal of Ultraso und in Medicine 1996;15: Davies A, Willcox J, Magee T, et al. Colour Duplex in Assessing the Infrainguinal 119

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135 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 소아분과 KQ 1. 구토가있는생후 3개월이내의소아환자에서진단을위한적절한영상검사는무엇인가? 권고 1-1. 출생직후부터간헐성비담즙성구토를하는 3개월이내의소아환자에서는영상검사가필요하지않으나, 해부학적인구조이상의평가를위해상부위장관조영검사를고려할수있다. ( 권고등급 B, 근거수준 II) 권고 1-2. 급성비담즙성구토를하는 3개월이내의소아환자에서는초음파검사를고려할수있으며, 비대유문협착증의전형적인임상양상을보이지않거나초음파검사를이용한유문부평가를할수없는경우상부위장관조영검사를고려할수있다. ( 권고등급 B, 근거수준 II) 근거요약구토가있는생후 3개월이내의소아환자에서영상진단을위한가이드라인은 3개가검색되었으며 (1-3), 장관폐색, 장관회전이상, 중간창자꼬임, 위식도역류, 비대유문협착등의진단에중점을두고있었다. 태생직후부터생긴간헐적인비담즙성구토의가장흔한원인은위식도역류이다. 현재위식도역류의진단에가장정확한검사는식도 ph 모니터링이다 (3). 위식도역류의진단에상부위장관조영검사는다양한민감도 (31%~86%) 와특이도 (21%~83%), 양성예측도 (80%~82%) 를보인다 (4). NASPGHAN (North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition) 과 ESPGHAN (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) 가이드라인에서는위식도역류가의심되는경우의기본검사로상부위장관조영검사는적절하지않은것으로권고하였다 (3). 그러나수술적치료나피부경유위조루가필요할정도로심한위식도역류나합병증이있는위식도역류에서해부학적인이상, 창자회전이상등을감별하기위하여상부위장관조영검사가필요할수있다 (1-3). 위식도역류에서초음파검사는보통유용하지않으며, 복부일반촬영은위식도역류증의진단에대부분도움이되지않는다 (1,2,4). 평소건강하던생후 6주경의영아에서발생한사출성급성비담즙성구토는비대유문협착증을고려하여야한다 (5). 초음파검사는비대유문협착증에높은정확도를보이기때 122

136 3. 연구결과 문에가장적절한검사이며, 유문부의정밀한평가가필요하다. 비대유문협착증의초음파진단은유문부근육층의두께와유문부의길이의측정으로진단할수있으며, 근육층의두께가 4 mm 이상, 유문부의길이가 18 mm 초과할때진단할수있으나 (5-9), 미숙아나어린신생아에서는 3~4 mm의근육층두께로도진단이가능하다 (10). 상부위장관조영검사는구토의폐색성원인의진단에매우유용하지만, 방사선노출로인해서비대유문협착증의선별검사로는초음파보다적절하지않다 (1, 2). 그러나비대유문협착증의전형적인증상을보이지않거나인적, 환경적요인에의해서유문부의적절한초음파검사를시행할수없는경우에는상부위장관조영검사를비대유문협착증의진단에서고려할수있다. 복부일반촬영은비대유문협착증의진단에대부분의경우도움이되지않는다 (1,2). 장관회전이상이나중간창자꼬임의진단을위해서가장적절한영상검사는상부위장관조영검사이다 ( 민감도 96%)(11-13). 현재까지장관회전이상이나중간창자꼬임의진단에있어초음파검사의정확도에대한근거는제한적이다 (14-17). 신생아에서하부위장관폐색이있는경우담즙성구토가발생할수있기때문에, 복부일반촬영에서하부위장관폐색이의심되는경우하부위장관조영검사가적절할수있으며, 이경우수용성조영제를사용하여야한다 (18,19). ACR 및 RCR의가이드라인에서는장관회전이상과중간창자꼬임의진단을위하여상부위장관조영검사를가장좋은검사방법으로제시하였으나 (1,2), 현재우리나라의의료환경과방사선노출에대한우려, 초음파검사의정확도에대한제한적인근거로인하여이번가이드라인에서는담즙성구토에대한권고를제외하였다. 권고고려사항 1. 이득과위해소아환자에서초음파검사는방사선피폭이없고, 손쉽게시행할수있어일차진단검사로유용하게사용할수있다. 그러나초음파창이적절히확보되어야하고검사자의숙련도에따라서다양한정확도를보일수있음을유의하여야한다. 상부위장관조영검사혹은하부위장관조영검사는방사선피폭으로인한잠재적위해가있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 비담즙성구토의권고안에대해서는 ACR과 RCR, NASPGHAN의가이드라인들이모두수용가능한것으로판단된다. 세가이드라인모두적용성에있어서는문제가없는것으로보인다. 담즙성구토의진단에상부위장관조영검사를권고하는 ACR과 RCR의권고는현재우리나라의의료현실및방사선노출을고려하여수용하기어려운것으로판 123

137 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 단되었다. 수용성및적용성평가표는부록에제시한다. 3. 검사별방사선량상부위장관조영검사, 하부위장관조영검사복부일반촬영초음파검사 0 참고문헌 1. American College of Radiology. Vomiting in Infants up to 3 Months of Age. Appro priateness criteria. ACR Appropriateness Criteria RCR. Recurrent Vomiting in Children. irefer Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric Gastroesophageal Reflu x Clinical Practice Guidelines: Joint Recommendations of the North American Soci ety for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and th e European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESP GHAN). Journal of Pediatric Gastroenterology and Nutrition 2009;49(4): Rudolph CD, Mazur LJ, Liptak GS, et al. Guidelines for Evaluation and Treatment of Gastroesophageal Reflux in Infants and Children: Recommendations of the Nor th American Society for Pediatric Gastroenterology and Nutrition. Journal of Pedia tric Gastroenterology and Nutrition 2001;32: Haller J, Cohen H, Hypertrophic Pyloric Stenosis: Diagnosis Using US. Radiology 1 986;161(2): Hernanz-Schulman M, Pyloric Stenosis: Role of Imaging. Pediatric Radiology 2009; 39: O'keeffe F, Stansberry S, Swischuk L, Hayden Jr C, Antropyloric Muscle Thickness at US in Infants: What Is Normal? Radiology 1991;178(3): Bowen A, The Vomiting Infant: Recent Advances and Unsettled Issues in Imaging. Radiologic Clinics of North America 1988;26(2): Blumhagen JD, Maclin L, Krauter D, Rosenbaum D, Weinberger E, Sonographic Di agnosis of Hypertrophic Pyloric Stenosis. American Journal of Roentgenology 198 8;150(6): Forster N, Haddad R, Choroomi S, Dilley A, Pereira J, Use of Ultrasound in 187 I nfants with Suspected Infantile Hypertrophic Pyloric Stenosis. Australasian Radiolo gy 2007;51(6): Hsiao M, Langer JC, Value of Laparoscopy in Children with a Suspected Rotation Abnormality on Imaging. J Pediatr Surg. 2011;46(7): Long FR, Kramer SS, Markowitz RI, Taylor GE, Liacouras CA, Intestinal Malrotatio n in Children: Tutorial on Radiographic Diagnosis in Difficult Cases. Radiology 19 96;198(3):

138 3. 연구결과 13. Sizemore AW, Rabbani KZ, Ladd A, Applegate KE, Diagnostic Performance of the Upper Gastrointestinal Series in the Evaluation of Children with Clinically Suspect ed Malrotation. Pediatr Radiol. 2008;38(5): Orzech N, Navarro OM, Langer JC, Is Ultrasonography a Good Screening Test for Intestinal Malrotation? J Pediatr Surg. 2006;41(5): Weinberger E, Winters WD, Liddell RM, Rosenbaum DM, Krauter D, Sonographic Diagnosis of Intestinal Malrotation in Infants: Importance of the Relative Positions of the Superior Mesenteric Vein and Artery. AJR Am J Roentgenol. 1992;159(4): Menten R, Reding R, Godding V, Dumitriu D, Clapuyt P, Sonographic Assessment of the Retroperitoneal Position of the Third Portion of the Duodenum: An Indicat or of Normal Intestinal Rotation. Pediatr Radiol. 2012;42(8): Karmazyn B, Duodenum Between the Aorta and the SMA Does Not Exclude Malr otation. Pediatric radiology 2013: Ryan S, Donoghue V, Gastrointestinal Pathology in Neonates: New Imaging Strate gies. Pediatric radiology 2010;40(6): Rescorla FJ, Grosfeld JL, Contemporary Management of Meconium Ileus. World Jo urnal of Surgery 1993;17(3):

139 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 KQ 2. 소아두부외상에서두부외상진단을위한적절한영상검사는무엇인가? 권고 2-1. 글래스고혼수척도 (Glasgow Coma Scale, GCS) 가 14 이상이면서신경학적증상이나징후, 혹은고위험인자 ( 예 : 의식손상, 두개저골절의심소견등 ) 가없는두부외상소아에서두부손상진단을위한영상검사를시행하지않는것을권고한다. ( 권고등급 C, 근거수준 I) 권고 2-2. GCS가 13이하이거나 GCS가 14이상이면서신경학적증상이나징후, 혹은고위험인자 ( 예 : 의식손상, 두개저골절의심소견등 ) 가있는두부외상소아에서두부손상진단을위한영상검사로조영증강전 CT(non-contrast brain CT) 를고려할수있다. ( 권고등급 B, 근거수준 I) 근거요약소아의두부외상에대해검색을통해 7개의진료지침을찾았으며이중 4개의진료지침을최종선택하였다 (1-4). 이진료지침들에서의공통적인관심사는경한두부손상 (GCS 14) 에서의적절한영상검사였다. 여러연구및진료지침을종합해서보았을때경한두부손상의정의는 14 이상의 GCS를보이는것으로함이적절하다 (5). GCS가 14 이상이면서신경학적증상이나징후, 또는고위험인자를보이지않는경우에심각한두부손상을보이는경우는매우드물며임상적으로의미있는외상성두부손상을보이는전체비율은 0.9% 이며검사나병력에서두개내이상의시사점이없다면 0.05% 로낮아진다 (7). 2세이상의환아에대한 PECARN (Pediatric Emergency Care Applied Research Network) 의연구에서정상적인의식, 의식소실, 구토, 심한손상기전, 두개저골절의심소견과심한두통을기준으로삼았을시 99.9% 의음성예상치 (negative predictive value), 96.0% 의민감도를보였다. 2세미만의경우에도비슷하며 1% 미만의의미있는외상성두부손상을보이며의식변화를보이면 4%, 골절이의심되면 3.6% 로증가한다. 또한 2세미만소아만명이상을대상으로한 PECARN에서정상적인의식, 의식소실, 전두부를제외한두피혈종, 심한손상기전, 만져지는두개골절, 부모가보기에평소와같은행동등을기준으로보았을때 100% 의음성예측치와 100% 의민감도를보였다 (7). 두부 CT 1회촬영시 0.02~0.1% 암이증가한다는점 (12) 을포함하여방사선에민감한소아라는점과이러한연구결과를고려한다면 GCS 14 이상의경한두부손상을보이는소아에서는영상검사를시행하지않는것이적절하다. 126

140 3. 연구결과 표 15. Glasgow Coma Scale (GCS) Category Adult Scale Infant Spontaneous 4 Spontaneous Eye Opening To speech 3 To speech To pain 2 To pain No response 1 No response obeys verbal command 6 obeys verbal command Localizes pain 5 Localizes pain Best response moter Withdraws form pain 4 Withdraws form pain Flexion abnormal* 3 Flexion - abnormal Extension** 2 Extension No response 1 No response Oriented and converses 5 Coos, babbles Best response verbal Disoriented and converses 4 Cries but consonlable Inappropriate words 3 Persistently irritable Incomprehensible sounds 2 Grunts to pain/restless No response 1 No response 2세미만에서두개저골절이의심되는경우약 7.5% 에서임상적으로중요한두부손상이있었으며 (7), GCS가낮아질수록두개내손상확률이증가한다 (33). 따라서신경학적증상이나징후, 혹은고위험인자를보이는경한두부손상이나 13이하의 GCS를보이는두부손상소아의경우에는영상검사가필요하다. 급성출혈여부및두개골절을잘보여주는 CT와달리두개골단순촬영은골절유무만보여주며 CT에서보이는골절중약 21% 가단순촬영에서는보이지않을수있으며, 골절이없는경우에도최대 50% 까지두개내손상이있을수있다 (1,21). 또한 Reed의연구 (20) 에서는단순촬영없이병력청취와 CT만가지고검사를하였을때두개내손상을놓치는비율이나전반적인방사선량의증가가없었다. 이러한점을고려했을때신경학적증상이나징후, 혹은고위험인자를보이는경한두부손상이나 13이하의 GCS를보이는두부손상환아의경우에는 CT를시행함이적절하다하겠다. 중등도이상의두부손상에서미만성축삭손상이약 75% 에서보인다는보고 (17) 가있어 MRI가필요할수도있으나외상환자에게 MRI를적용하는것이시간상으로혹은접근성에있어부적절하며소아에있어서는추가 127

141 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 적인진정이나마취와같이조치가필요할수있어응급상황에서는 CT 가우월하다할 수있다. 권고고려사항 1. 이득과위해소아두부외상환자의일차진단검사로 CT 검사를사용하는경우진단정확도가높은장점이있으나방사선피폭의단점이있다. 따라서신체검진과병력청취를통해검사를시행할환자를정할필요가있다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은평가결과 Eastern Association for the Surgery of Trauma Practice management guideline 에서발간한 Evaluation and management of mild traumatic brain injury(2012) 와 Scandinavian Guidelines for initial management of minimal, mild and moderate head injuries(2000) 의경우적용성에무리는없으나연구군이전반적으로우리현실과맞지않아수용하기어렵다. 나머지진료지침의국내수용성과적용성에큰무리가없는것으로판단되었다. 수용성과적용성평가표는부록에제시한다. 3. 검사별방사선량 두부 CT 참고문헌 1. Pinto PS, Poretti A, Meoded A, Tekes A, Huisman TA, The Unique Features of Tra umatic Brain Injury in Children. Review of the Characteristics of the Pediatric Sk ull and Brain, Mechanisms of Trauma, Patterns of Injury, Complications and Their Imaging Findings-Part 1. J Neuroimaging 2012;22(2): Faul M, Xu L, Wald MM, Coronado VG, Traumatic Brain Injury in the United State s: Emergency Department Visits, Hospitalizations and Deaths Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Preve ntion and Control. 2010; Available from: URL: njury/tbi_ed.html. Accessed September 16, Schnadower D, Vazquez H, Lee J, Dayan P, Roskind CG, Controversies in the Eval uation and Management of Minor Blunt Head Trauma in Children. Curr Opin Pedi atr. 2007;19(3): Willis AP, Latif SA, Chandratre S, Stanhope B, Johnson K, Not a NICE CT Protoc 128

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147 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 79. Head Injury Triage, Assessment, Investiation and Early Management of Head Injur y in Children, Young People and Adults. NICE Clinical Guideline

148 3. 연구결과 KQ 3. 열성요로감염이있는소아환자에서진단을위한적절한영상검사는무엇인가? 권고 3. 첫열성요로감염소아에서해부학적구조이상의평가를위한영상검사로초음파검사를고려할수있다. ( 권고등급 B, 근거수준 II) 근거요약소아의열성요로감염 (Febrile Urinary Tract Infection) 의영상진단에대한가이드라인은검색을통해 5개의가이드라인이선택되었으며, 지침들은연령과임상상황에따라선별적으로시행하도록되어있다 (1-5). 소아요로감염환자에서영상검사는반복적요로감염의위험이높은구조적이상이있는환자를선별하여치료를가이드하기위해시행된다. 위험이높은환자군을확인하는것은효과적인치료가있는경우에유용하며현재의치료방침은예방적항생제와방광요관역류의선택적인수술적교정을기반으로한다. 전향적연구들은예방적항생제의사용이열성요로감염환자에서신반흔을감소시키는것을입증하는데실패하였다 (6-8). 또한방광요관역류의수술적교정이예후를향상시키지못하였다 (9). 과거에는신우신염에의한신반흔이요로감염의가장심각한만기후유증인고혈압과만성신부전의가장흔한원인으로여겨졌으나산전초음파검사의증가로심각한신반흔의대부분이실제로태아기에발생하며신장형성이상에의한것이어서예방이불가능한것으로알려졌다 (10-14). 따라서첫요로감염후에신반흔의예방목적으로시행하고있는광범위한요로계영상검사의역할에대한의문이제기되고있다 (6,10, 14-16). 현재요로감염소아의평가방법은신우신염진단에중점을두어신스캔을먼저시행하여이상이있을경우배설성방광-요도조영검사 (Voiding Cystourethrography: VCUG) 를시행하는 top-down 방식과 (2,10) 방광요관역류진단에중점을두어 VCUG를시행하여이상이발견될경우신스캔을시행하는 bottom-up 방식으로크게나눠진다 (1,10,14,17). 초음파검사는손쉽게사용할수있는검사방법으로방사선을사용하지않는다는큰장점이있다. 초음파검사에서수신증, 중복신장, 요로확장, 요관류등의요로계의구조적이상을발견하고, 방광용적을평가할수있으며 (18-19), 2년이상의기간동안추적검사를한다면신장의성장을평가할수있다 (20-21). 하지만방광요관역류감지및신반흔에대한민감도는낮은편이다 (2,22-26). 산전초음파검사의증가로추가적인검사및조치를필요로하는이상이초음파검사에서발견되는경우는적다 (16). 말기산전초음파가정상이었다면초음파가필요하지는않을수있다. 초음파검사를시행하는시기와 135

149 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 나이구분은지침마다다양하게제시하고있으며 (1-5) 영국 NICE 가이드라인에서는첫요로감염소아에서일률적인초음파검사의시행은적절하지않으며비전형적인합병증이있는요로감염의경우 (48시간이내에항생제에반응하지않거나, 패혈증, 소변저류, 크레아티닌상승, E.coli외의균에의한요로감염 ) 나재발성요로감염시에는급성기에초음파검사를권고하고있다 (1). VCUG의주요역할은방광요관역류 (10-14) 를검출하는것이다. 고도방광요관역류 (Grade 3~5) 환자는재발성요로감염과신반흔의가능성이더높다 (27-32). 요로감염소아에서방광요관역류의유병률은 30~40% 로연령이높아질수록감소한다 (2, 33). 재발성요로감염소아에서방광요관역류가증가한다 (2). 2011년미국소아과학회에서가이드라인에서는첫째요로감염소아에서일상적으로 VCUG를시행하는것을권고하지않으며초음파검사에서고도의방광요관역류나요폐색을시사하는수신증이나실질변화가있을경우시행하는것을권고하고있다 (2). VCUG와핵의학방광요관역류검사의민감도는동일하며 (34-36) 핵의학 VCUG는 VCUG보다환자선량이낮지만요도, 방광및요관의해부학적이상을식별하기에는공간식별력이낮다. 따라서여아의첫번째검사와추적검사의경우선호된다 (37). VCUG는요로의이상을확인할수있기때문에남아에서방광요관역류를평가하는데선호된다 (3). 신스캔은급성신우신염과신반흔을확인하기위한가장적절한검사방법으로신반흔은지속적인신결손, 신장윤곽또는피질의흡수손실로나타난다. 신스캔은신우신염검출의 95% 민감도와 90% 특이도를가지고있다 (38-39). 하지만단기연구에따르면이러한이상들의대부분은예방적항생제치료와관계없이시간의경과에따라호전이되므로 (7,8,40) 첫요로감염시신장스캔은이득이적다 (14). 영국 NICE 가이드라인에서는위험도가높은환자에서신스캔을이용한신반흔에대한평가를 4~6개월뒤에할것을제안하고있다 (1). 신스캔은정맥주사를통한약제주입후 3~4시간후에시행되며진정이필요할수있다 (41). 신스캔의대략적인유효선량은 1 msv로핵의학 VCUG에비해 100배, 저선량 VCUG에비해 10배정도이다 (37,42). 요로감염소아에서시행하게되는영상검사는초음파, VCUG, 신스캔의 3가지인데해부학적구조이상을보기위한일차적검사로는초음파가적절하다. 하지만여러가지검사들의적응증, 시행시기및검사들의조합및알고리즘에는아직논란이있다 (43-46). 136

150 3. 연구결과 권고고려사항 1. 이득과위해초음파는방사선피폭이없고손쉽게시행할수있어해부학구조이상을보기위한일차적검사로적합하다. 방광요관역류진단에는 VCUG가 gold standard이나방사선피폭의단점이있고침습적이며환자에게불편감을줄수있다. 신우신염과신반흔의진단에는신스캔이 gold standard이나방사선피폭, 주사및진정등이필요하다. 따라서이두검사들은선별적으로시행할것이권고된다. 2. 국내수용성과적용성 (Acceptability and Applicability) 진료지침의국내수용성과적용성은첫열성소아요로감염에서초음파를사용한다는결론에서는평가결과무리가없는것으로판단되었다. 하지만가이드라인마다연령과임상상황에따라선별적으로시행하는적응증, 나이및시행시기에있어상당한차이를보이고있어권고를더상세히하기는어려웠다. 적용성평가표는부록에제시한다. 3. 검사별방사선량 초음파검사 0 배설성방광 - 요도조영검사 (Voiding Cystourethrography) 참고문헌 1. National Institute for Health and Clinical Excellence. Urinary Tract Infection in Ch ildren: Diagnosis, Treatment and Long-Term Management. August Subcommittee on Urinary Tract Infection SCoQI and Management. Urinary Tract I nfection: Clinical Practice Guideline for the Diagnosis and Management of the Ini tial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics 2011;128: Karmazyn B, Coley BD, Binkovitz LA, Dempsey-Robertson ME, Dillman JR, Dory C E, Garber M, Hayes LL, Keller MS, Meyer JS, Milla SS, Paidas C, Raske ME, Rigsby CK, Strouse PJ, Wootton-Gorges SL, ACR Appropriateness Criteria Urinary Tract Infection Child. Expert Panel on Pediatric Imaging McTaggart S, Danchin M, Ditchfield M, Hewitt I, Kausman J, Kennedy S, Trnka P and Williams G, KHA-CARI Guideline: Diagnosis and Treatment of Urinary Tract I nfection in Children. Nephrology 2015;20(2): Stein R, Dogan HS, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C, Tekgül S; Eur opean Association of Urology; European Society for Pediatric Urology. Urinary Tra ct Infections in Children: EAU/ESPU Guidelines. Eur Urol. 2015;67(3): Keren R, Carpenter MA, Hoberman A, et al. Rationale and Design Issues of the R 137

151 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 andomized Intervention for Children with Vesicoureteral Reflux (RIVUR) Study. Pe diatrics 2008;122 Suppl 5: Montini G, Rigon L, Zucchetta P, et al. Prophylaxis After First Febrile Urinary Tr act Infection in Children? A Multicenter, Randomized, Controlled, Noninferiority T rial. Pediatrics 2008;122(5): Pennesi M, Travan L, Peratoner L, et al. Is Antibiotic Prophylaxis in Children wit h Vesicoureteral Reflux Effective in Preventing Pyelonephritis and Renal Scars? A Randomized, Controlled Trial. Pediatrics 2008;121(6): Hodson EM, Wheeler DM, Vimalchandra D, Smith GH, Craig JC, Interventions for Primary Vesicoureteric Reflux. Cochrane Database Syst Rev. 2007;(3):CD Koyle MA, Elder JS, Skoog SJ, et al. Febrile Urinary Tract Infection, Vesicoureter al Reflux, and Renal Scarring: Current Controversies in Approach to Evaluation. P ediatr Surg Int. 2011;27(4): Lim R, Vesicoureteral Reflux and Urinary Tract Infection: Evolving Practices and Current Controversies in Pediatric Imaging. AJR 2009;192(5): Merguerian PA, Sverrisson EF, Herz DB, McQuiston LT, Urinary Tract Infections in Children: Recommendations for Antibiotic Prophylaxis and Evaluation. An Evide ncebased Approach. Curr Urol Rep. 2010;11(2): Riccabona M, Avni FE, Blickman JG, et al. Imaging Recommendations in Paediat ric Uroradiology: Minutes of the ESPR Workgroup Session on Urinary Tract Infecti on, Fetal Hydronephrosis, Urinary Tract Ultrasonography and Voiding Cystourethro graphy, Barcelona, Spain, June Pediatr Radiol. 2008;38(2): Williams GJ, Hodson EH, Isaacs D, Craig JC, Diagnosis and Management of Urin ary Tract Infection in Children. J Paediatr Child Health 2012;48(4): Montini G, Tullus K, Hewitt I, Febrile Urinary Tract Infections in Children. N En gl J Med. 2011;365(3): Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER, Imaging Studies After a First Febrile Urinary Tract Infection in Young Children. N Engl J Med. 2003;348(3): Marks SD, Gordon I, Tullus K, Imaging in Childhood Urinary Tract Infections: Ti me to Reduce Investigations. Pediatr Nephrol. 2008;23(1): Shaikh N, Abedin S, Docimo SG, Can Ultrasonography or Uroflowmetry Predict Which Children with Voiding Dysfunction Will Have Recurrent Urinary Tract Infec tions? J Urol. 2005;174(4 Pt 2):1620-2; discussion Sillen U, Brandstrom P, Jodal U, et al. The Swedish Reflux Trial in Children: v. Bladder Dysfunction. J Urol. 2010;184(1): Sargent MA, Long G, Karmali M, Cheng SM, Interobserver Variation in the Sono graphic Estimation of Renal Volume in Children. Pediatr Radiol. 1997;27(8): Schlesinger AE, Hernandez RJ, Zerin JM, Marks TI, Kelsch RC, Interobserver and Intraobserver Variations in Sonographic Renal Length Measurements in Children. AJR 1991;156(5):

152 3. 연구결과 22. Foresman WH, Hulbert WC, Jr, Rabinowitz R, Does Urinary Tract Ultrasonograph y at Hospitalization for Acute Pyelonephritis Predict Vesicoureteral Reflux? J Urol. 2001;165(6 Pt 2): Kenney IJ, Negus AS, Miller FN, Is Sonographically Demonstrated Mild Distal Ur eteric Dilatation Predictive of Vesicoureteric Reflux as Seen on Micturating Cystou rethrography? Pediatr Radiol. 2002;32(3): Mahant S, Friedman J, MacArthur C, Renal Ultrasound Findings and Vesicoureter al Reflux in Children Hospitalised with Urinary Tract Infection. Arch Dis Child 20 02;86(6): Moorthy I, Wheat D, Gordon I, Ultrasonography in the Evaluation of Renal Scar ring Using DMSA Scan as the Gold Standard. Pediatr Nephrol. 2004;19(2): Muensterer OJ, Comprehensive Ultrasound Versus Voiding Cysturethrography in t he Diagnosis of Vesicoureteral Reflux. Eur J Pediatr. 2002;161(8): Shaikh N, Ewing AL, Bhatnagar S, Hoberman A, Risk of Renal Scarring in Childr en with a First Urinary Tract Infection: A Systematic Review. Pediatrics 2010;126 (6): Lee JH, Son CH, Lee MS, Park YS, Vesicoureteral Reflux Increases the Risk of R enal Scars: A Study of Unilateral Reflux. Pediatr Nephrol. 2006;21(9): Orellana P, Baquedano P, Rangarajan V, et al. Relationship Between Acute Pyelo nephritis, Renal Scarring, and Vesicoureteral Reflux. Results of a Coordinated Res earch Project. Pediatr Nephrol. 2004;19(10): Polito C, Rambaldi PF, Signoriello G, Mansi L, La Manna A, Permanent Renal Pa renchymal Defects After Febrile UTI Are Closely Associated with Vesicoureteric Re flux. Pediatr Nephrol. 2006;21(4): Peters CA, Skoog SJ, Arant BS, Jr, et al. Summary of the AUA Guideline on Man agement of Primary Vesicoureteral Reflux in Children. J Urol. 2010;184(3): Lin KY, Chiu NT, Chen MJ, et al. Acute Pyelonephritis and Sequelae of Renal S car in Pediatric First Febrile Urinary Tract Infection. Pediatr Nephrol. 2003;18(4): Chand DH, Rhoades T, Poe SA, Kraus S, Strife CF, Incidence and Severity of Ve sicoureteral Reflux in Children Related to Age, Gender, Race and Diagnosis. J Uro l. 2003;170(4 Pt 2): Polito C, Rambaldi PF, La Manna A,Mansi L, Di Toro R, Enhanced Detection of Vesicoureteric Reflux with Isotopic Cystography. Pediatr Nephrol. 2000;14(8-9): Sukan A, Bayazit AK, Kibar M, et al. Comparison of Direct Radionuclide Cystogr aphy and Voiding Direct Cystography in the Detection of Vesicoureteral Reflux. A nn Nucl Med. 2003;17(7): Unver T, Alpay H, Biyikli NK, Ones T, Comparison of Direct Radionuclide Cysto graphy and Voiding Cystourethrography in Detecting Vesicoureteral Reflux. Pediat r Int. 2006;48(3):

153 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 37. Bisset GS, 3rd, Strife JL, Dunbar JS, Urography and Voiding Cystourethrography: Findings in Girls with Urinary Tract Infection. AJR 1987;148(3): Majd M, Nussbaum Blask AR, Markle BM, et al. Acute Pyelonephritis: Compariso n of Diagnosis with 99mTc-DMSA, SPECT, Spiral CT, MR Imaging, and Power Do ppler US in an Experimental Pig Model. Radiology 2001;218(1): Rossleigh MA, Farnsworth RH, Leighton DM, Yong JL, Rose M, Christian CL, Tec hnetium-99m Dimercaptosuccinic Acid Scintigraphy Studies of Renal Cortical Scar ring and Renal Length. J Nucl Med. 1998;39(7): Rosenberg AR, Rossleigh MA, Brydon MP, Bass SJ, Leighton DM, Farnsworth RH, Evaluation of Acute Urinary Tract Infection in Children by Dimercaptosuccinic Aci d Scintigraphy: A Prospective Study. J Urol. 1992;148(5 Pt 2): Flynn JT, Don't Stop Performing Voiding Cystourethrography in Young Children After the Initial Febrile Urinary Tract Infection--At Least Not Yet. J Pediatr. 2009; 155(5): Ward VL, Strauss KJ, Barnewolt CE, et al. Pediatric Radiation Exposure and Effe ctive Dose Reduction During Voiding Cystourethrography. Radiology 2008;249(3): Lee HY, Soh BH, Hong CH, Kim MJ, Han SW, The Efficacy of Ultrasound and D imercaptosuccinic Acid Scan in Predicting Vesicoureteral Reflux in Children Below the Age of 2 Years with Their First Febrile Urinary Tract Infection. Pediatr Nephr ol. 2009;24(10): Quirino IG, Silva JM, Diniz JS, et al. Combined Use of Late Phase Dimercaptosu ccinic Acid Renal Scintigraphy and Ultrasound as First Line Screening After Urinar y Tract Infection in Children. J Urol. 2011;185(1): Jahnukainen T, Honkinen O, Ruuskanen O, Mertsola J, Ultrasonography After th e First Febrile Urinary Tract Infection in Children. Eur J Pediatr. 2006;165(8): La Scola C, De Mutiis C, Hewitt IK, et al. Different Guidelines for Imaging After First UTI in Febrile Infants: Yield, Cost, and Radiation. Pediatrics 2013;131:

154 3. 연구결과 3. 델파이조사결과 임상영상가이드라인개발의마지막과정인최종화를위해총 2회에걸친전문가대상델파이설문조사를수행하였다. 부록 3을통해 1차설문조사에비해 2차설문조사의분과별동의점수에대한평균및변동 ( 표준편차 ) 을제시하였다. 동의점수에대한변동이 1 차설문조사에비해 2차설문조사에서감소한것을확인할수있으며, 전문가들의합의가이루어진것으로판단된다. 분과별핵심질문에대한권고가모두독립적이며, 권고별응답대상자역시각기다른전문가그룹으로나타나기때문에전체응답의일관성정도 ( 신뢰도 ) 를나타내는크론바하알파의제시는맞지않다고판단되며, 감소된동의점수의변동을근거로전문가합의가이루어졌음을확인하였다. 설문문항의동의정도는 1점에서 9점의리커트척도를사용하였으며, 설문결과에서나타난평균점수에따라 매우동의하지않음 (1~3점), 모르겠음 (4~6점), 매우동의함 (7~9점) 으로재범주화하여권고별동의정도를측정하였다. 신경두경부분과의경우핵심질문 1의권고에대한 1차델파이조사결과동의평균점수 ( 표준편차 ) 가 6.4(1.4), 핵심질문 2의권고에대해 6.9(1.6) 점을나타내전문가들의평균동의정도가 모르겠음 으로나타났으나, 2차델파이조사를통해핵심질문 2의동의점수 ( 표준편차 ) 는 7.1(0.8) 점 ( 매우동의함 ) 으로갱신되었다. 핵심질문 1의경우동의점수는 1차델파이조사와유사하게나타났지만, 핵심질문의변동이감소한것으로보아전문가들의합의가이루어진것으로보인다. 1차델파이설문조사에서심장분과의핵심질문 1에대한권고 2의경우평균동의점수 ( 표준편차 ) 6.4(2.5) 점을나타내 모르겠음 을보였으며, 그외핵심질문에대해서는모두 매우동의함 의결과를나타냈다. 핵심질문 1의권고 2의경우 2차조사결과 5.7(2.1) 점의동의정도로전문가합의가이루어졌지만결과는 모르겠음 으로결론지어졌다. 비뇨분과에서핵심질문 1의권고 3에대한 1차델파이설문조사결과동의점수 ( 표준편차 ) 7.0(1.9) 로 매우동의함 의결과를나타냈지만 2차델파이설문조사결과동의점수 ( 표준편차 ) 6.6(0.7) 로권고 4에대해 모르겠음 으로합의를마쳤다. 변동정도는다른핵심질문의권고들과같이감소하였으며, 전문가합의가이루어졌음을확인할수있다. 근골격분과의핵심질문 2에대한권고 1의경우 1차델파이설문조사결과평균동의점수 ( 표준편차 ) 6.7(1.1) 로전문가들은 모르겠음 의의견을나타냈지만, 2차델파이설문을통해평균동의점수 ( 표준편차 ) 7.3(0.5) 로 매우동의함 의결과로합의를나타냈다. 특 141

155 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 히권고 1의경우변동이절반으로감소하여 2차델파이설문조사의합의정도를명확히볼수있었다. 그외방사선노출저감을위한영상검사의뢰가이드라인개발의해당분과인갑상선, 흉부, 유방, 복부분과의경우 2차에걸친델파이선문조사에서모두 매우동의함 의의견을나타냈으며, 1차에비해 2차델파이설문조사의전문가응답에대한변동정도가감소된것으로보아전문가들의합의가이루어짐을확인할수있다 ( 그림 11). 델파이설문조사과정에서전문가들의핵심질문별권고내용및권고양식에대한추가적인의견이나타났으며, 추가적인의견에맞추어분과별권고의세부내용에대한수정과정이이루어졌고, 최종권고문이도출되었다. 그림 11(a). 신경두경부, 갑상선분과평균동의점수 그림 11(b). 흉부분과평균동의점수 142

156 3. 연구결과 그림 11(c). 심장분과평균동의점수 그림 11(d). 유방분과평균동의점수 그림 11(e). 복부분과평균동의점수 그림 11(f). 비뇨분과평균동의점수 143

157 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 그림 11(g). 근골격, 인터벤션분과평균동의점수 그림 11(h). 소아분과평균동의점수 그림 11. 전문가평균동의정수의변동 ( 델파이조사 1 차, 2 차 ). 144

158 4. 고찰및결론 Ⅳ 고찰및결론 1. 연구의의의및제한점 1.1. 방법론적측면 본연구는한국보건의료연구원과대한의학영상회의공동연구로전문학회의임상적전문성을기반으로하면서한국보건의료연구원의방법론지원이이루어진협업연구이다. 즉, 방법론의검토및자료제공, 체계적문헌검색지원, 전문가패널조사시행및분석등을한국보건의료연구원이지원하였고, 학회측실무위원들은임상적전문성에근거하여핵심질문에적절한진료지침및문헌의선정, 개별근거의내용검토및권고안을작성하였다. 가이드라인의특성상실제임상영상검사를실행하는다른임상진료과의의견을적극반영하여야하므로, 핵심질문검토단계부터각유관학회에서추천받은전문위원들의자문을시행하였고, 권고문합의를위한전문가패널조사를통해의견을수렴하였다. 본연구는특히임상영상의학가이드라인개발에적합한수용개작과정을진행하기위해기획단계에서국제적인기준에합당한수용개작단계를정의함과동시에개발위원회에서핵심질문을정하여권고문초안을작성하는과정을거쳐실제실무위원회에서활용가능한 근거기반임상영상가이드라인개발방법론 을개발하였다. 근거수준과권고등급체계결정에앞서주요국외임상영상가이드라인의권고와방법론을고찰한결과, 시술이나치료중심의중재와는핵심질문의구성요소특징이나질평가고려요소가차이가있어방법론자문을거쳐본지침에적절한체계를새롭게정의하였다. 또한, 시범연구결과권고문의실제작성시에는단순히해당권고를지지하는근거문헌을검토하는것을원칙으로결정하여개별근거문헌들의질평가를시행하였다. 이과정에서근거수준에서일반적으로고려하는 5가지요소 ( 연구설계, 근거의질, 근거의양, 근거의직접성, 근거의일관성 ) 중연구설계와근거의질 2가지를중심으로근거 145

159 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 수준을결정하였고, 권고등급은근거수준과이득및위해를고려하여권고의강도및방향을고려하였다. 방법론개발단계에서일본과미국, 영국등주요가이드라인의근거수준과권고등급을분석한결과우리체계로변환이가능한경우는가이드와함께사례를제공하였다 실제수용개작개발과정측면 개발위원회에서시범적용을통해확정한방법론과서식을각실무위원회에배포하고개발단계별로수차례공동워크샵을실행하였고, 개발위원회위원들은각분과별자문을통해실무위원들이개발과정을숙지하고공통된양식과과정을적용할수있도록지원하였다. 임상진료지침개발을처음경험하는위원이많아서초기에전체적인방법론에대한전체교육도제공되었으나, 실제로는주요개발단계별로진행한워크샵이효과적이었다. 수용개작개발과정중가장오랜시간이소요된과정은핵심질문의선정이었다. 실무위원회의제안및개발위원회의검토를거쳐외부유관학회에서추천받은임상전문가들의자문을받아서최종확정하였는데, 정당화원칙에적절한핵심질문을선정하는것자체가어려웠다. 주된이유는임상영상검사에서는중재에서보통고려하는핵심질문이주요 4가지요소 (population, intervention, comparator, outcomes) 와부합하지않는경우들이있어, I( 중재검사 ) 및 C( 비교검사또는참조표준검사 ) 를명확히구분하기어렵다고판단되었다. 따라서 4가지요소를고려하기는하되문장형으로핵심질문을완성할때는 P( 환자또는증상 ) 와 I 및 C를동시에고려하여목적 ( 선별또는진단 ) 을기술하는형태로작성하였다. 수용개작개발과정을거쳐국외주요진료지침들이선정되었으나, 분과별로핵심질문의특성에따라선정된진료지침의수는상당한차이를보이기도하였다. 원칙적으로는선택된지침별로모든근거문헌확인이원칙이었으나갑상선분과또는유방분과같은경우는중요한국외지침의경우권고자체를수용하기도하였다. 권고문에는국내수용성과적용성, 이득과위해, 방사선량을포함하였고, 이들요소들은권고등급결정의중요한고려요소들이었다. 기본적으로의학적필요에의해시행하는임상영상검사는위해보다는이득이더크다는것이기본적인전제이다. 그럼에도본가이드라인의궁극적인목적인정당화실현을위해국제지침동향을참고하여권고마다상대적방사선량을병기하여, 임상영상검사를의뢰하는의사의합리적인의사결정지원에도움을주고자하였다. 146

160 4. 고찰및결론 1.3. 제한점 근거기반임상영상가이드라인개발방법론을먼저개발하여 10개분과에방법론을숙지하도록해야했고, 분과별평균 3개정도의핵심질문을선정하였기때문에실제개발에필요한시간이충분하지는않았다. 분과별및핵심질문별선택가능한지침의수특히근거의양에차이가있어서근거가부족한경우는핵심질문의수정, 검색전략의수정과재검색등으로진행속도에차이가있었다. 이런시간적인제약으로인해다학제개발을실현하기위해서는실무위원회에도외부유관학회전문의들이권고작성에직접참여하는것이이상적이었을것이나효율적인진행을위해핵심질문과전문가패널조사형태로참여한점이제한점일수있다. 또한, 앞서의물리적인제약때문에가이드라인에서중요한요소인환자참여를고려하지못하였으나, 최대한문헌적인근거에서확인할수있는환자의가치를반영하고자노력하였다. 향후추가개발시실제적으로실무위원회가유관학회를포함하여다학제구성이될수있도록고려할수있다. 2. 결론및제언 본연구에서는임상영상가이드라인개발및적용을통해궁극적으로정당화원칙을이행하여불필요한방사선노출로부터환자를보호하고한정된보건의료자원을효율적으로사용할수있도록기여하고자하였다. 이를위해한국형임상영상가이드라인개발방법론을확정하여방법론을발간한것은중요한성과중하나이다. 대한영상의학회산하 10개분과실무위원회는과학적인근거를체계적으로검토하여권고를도출하였고개발과정에서는유관임상학회의의견을수렴하였다. 임상영상가이드라인은매년지속적인개정및권고추가개발이진행될예정이며, 본성과물이실제임상영상검사를의뢰하는의사의의사결정을지원하는역할을할수있도록, 학술적인발표, 홍보활동등다양한채널로결과물을확산할예정이다, 또한, 국제원자력기구 (IAEA) 에서발간예정인임상영상가이드라인에대한간행물에한국의수용개작사례를반영하여연구결과를국제적으로확산 ( 가제 : On adopting, adapting and implementing Clinical Imaging Guideline) 하고자한다. 한편으로실제권고가임상에적용 (implementation) 되어야궁극적인정당화원칙의이행이가능하므로추후적용성평가및모니터링계획등적용성을향상시킬수있는후속연구를제언한다. 147

161 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 Ⅴ 참고문헌 건강보험심사평가원, 대한영상의학회. CT 검사및재검사가이드라인. 대한영상의학회 김민정, 도경현, 김광표, 황재연, 최하진, 김수경. 환자의진단방사선피폭선량관리체계및방안구축연구. 한국보건의료연구원 김혁주. 의료방사선안전가이드라인마련을위한연구. 식품의약품안전청 대한영상의학회, 대한심장의학회, 근거창출임상연구국가사업단. 심장질환에서심장 CT 의사용에대한권고안. 근거창출임상연구국가사업단 한국보건의료연구원임상진료지침지원국. 임상진료지침수용개작매뉴얼 Ver 2.0. 한국보건의료연구원 한국보건의료연구원. 임상진료지침실무를위한핸드북 식품의약품안전청. 흉부촬영시환자선량평가가이드라인개발. 식품의약품안전청 식품의약품안전청. CT 엑스선검사에서의환자선량권고량가이드라인. 식품의약품안전청 American College of Radiology. ACR Appropriateness CriteriaR Radiation Dose Assessment Introduction. Available from: URL: AssessmentIntro.pdf. American College of Radiologists. Appropriateness Criteria, ACR Select. Available from: URL: Bor D, Sancak T, Olgar T, et al. Comparison of effective doses obtained from dose-area product and air kerma measurements in interventional radiology. Br J Radiol. 2004;77(916): Government of Western Australia. Diagnostic imaging pathways. Available from: URL: IAEA. Justification of Medical Exposure in Diagnostic Imaging Proceedings of an International Workshop. 2009IARC Working Group. A review of human carcinogens. Part D: Radiation. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, Lyon, France Jang J, Jung SE, Jeong W, et al. Radiation doses of various CT protocols: a multicenter longitudinal observation study. J Korean Med Sci. 2016;31:e61 Jing Chen, Deborah Moir and Jack Cornett, Considerations and preliminary design of patient 148

162 5. 참고문헌 Mettler FA, Jr., Bhargavan M, Faulkner K, et al. Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources Radiology. 2009;253(2): Mettler FA, Jr., Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology. 2008;248(1): Malone J, Guleria R, Craven C, Horton P, Jarvinen H, Mayo J, O'Reilly G, Picano E, Remedios D, Heron JL, Rehani M, Holmberg O, Czarwinski R. Justification of diagnostic medical exposures: some practical issues. Report of an International Atomic Energy Agency Consultation. The British Journal of Radiology. 2012;85: Mammography Quality Standards Act (MQSA) Malone J, Guleria R, Craven C, Horton P, Jarvinen H, Mayo J, O'Reilly G, Picano E, Remedios D, Heron J LE, Rehani M, Holmberg O and Czarwinski R. Justification of diagnostic medical exposures: some practical issues. Report of an International Atomic Energy Agency Consultation. Br J Radiol. 2012;85: NCRP. Ionizing radiation exposure of the population of the United States. NCRP Report 160. National Council on Radiation Protection and Measurements. Bethesda, Maryland, Royal College of Radiologists. irefer: Making the best use of clinical radiology. 7th ed. London: The Royal College of Radiologists; Japan Radiological Society, Japanese College of Radiology. The Japanese Imaging Guideline Japan Radiological Society Wall BF, Hart D. Revised radiation doses for typical X-ray examinations. Report on a recent review of doses to patients from medical X-ray examinations in the UK by NRPB. National Radiological Protection Board. Br J Radiol. 1997;70(833): Western Australian imaging guidelines. Diagnostic Imaging Pathways 149

163 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 Ⅵ 부록 1. 근거기반임상영상가이드라인개발방법론 Version 1.0 근거기반임상영상가이드라인개발방법론 Manual for Clinical Imaging Guideline Adaptation Version 1.0 한국보건의료연구원 대한영상의학회 150

164 6. 부록 임상영상가이드라인의개발목적 1. 의료피폭의기본원칙ㅇ방사선과관련된국제기구및전문가단체에서의료피폭 (medical exposure) 의안전관리를위하여 정당화 (justification) 및 최적화 (optimization) 두가지원칙을이행할것을강조한다. - 정당화원칙 : 방사선피폭상황의변화를초래하는모든결정은해로움보다이로움이더커야하며, 반드시필요한검사만을실시해야한다. - 최적화원칙 : 피폭발생가능성, 피폭자수및개인선량크기는경제적, 사회적인자를고려하여합리적으로달성할수있는범위에서낮게유지되어야한다. 방사선검사를수행시, 가능한합리적인수준에서최대한방사선을적게사용한다. 2. 정당화원칙ㅇ의료피폭의두가지기본원칙은함께이행되어야하나, 정당화원칙은의료피폭에서불필요한방사선피폭여부를결정하는중요한단계로최적화원칙이전에먼저고려되어야한다. ㅇ정당화의문제는임상전문가의의료행위에대한자율권의문제와규제기관의개입이상충할수있는영역으로, 정당화원칙은최적화원칙에비하여현실적으로구현하기어려우며영상의학분야만의노력으로는달성하기어렵다. ㅇ정당화원칙의이행을용이하게하고향상시키기위하여 3As의실행원칙을도입 적용하는것이필요하다. - 의료방사선피폭의위험성인지 (awareness) : 전문가교육및훈련, 환자및일반인에게적절한정보제공, 사전동의등을통해서향상시킬수있다. - 검사나시술의적정성확보 (appropriateness) : 임상영상가이드라인및도구의개발과적용이필요하다. - 정당화원칙이행에대한임상적감사 (audit) 를실시한다. 3. 임상영상가이드라인 (clinical imaging guideline) ㅇ근거기반 (evidence-based) 임상영상가이드라인은특정임상적조건에서가장 적절한검사및시술이이루어지도록검사나시술에대한의사의의뢰 151

165 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 (referral) 또는임상적결정 (clinical decision) 을도와준다. ㅇ가이드라인의확산과적용을통하여궁극적으로정당화원칙의이행을통한의 료방사선방어및한정된보건의료자원의효율적이용에기여한다. 그림 12. 의료방사선방어및안전향상을위한원칙 임상영상가이드라인개발그룹 1. 개발위원회ㅇ구성 : 대한영상의학회진료지침위원회에서추천한 6인및방법론전문가 1인, 한국보건의료연구원의연구진ㅇ역할 - 진료지침개발기획및개발방법결정 - 진료지침검색과선별, 평가등상세수용개작과정에대한전체방법론마련 - 실무위원회자문및개발과정검토 152

166 6. 부록 - 진료지침의보급및실행전략마련 2. 실무위원회ㅇ대한영상의학회산하 10개분과학회별실무위원회구성 - 10개산하학회대상가이드라인개발계획공유및의견수렴, 수용개작을담당할 10개실무위원회구성 - 15년도개발할우선순위가높은분야선정ㅇ가이드라인개발범위에따른핵심질문결정 - 우선개발할분야선정에따른핵심질문결정 임상영상가이드라인수용개작프로토콜 (flow chart) 단계내용담당 1 단계 핵심질문선정 실무위원회개발위원회 2 단계 진료지침검색 개발위원회 3 단계 검색된진료지침선별 실무위원회 4 단계 진료지침평가 개발위원회실무위원회 5 단계 핵심질문별권고및근거정리실무위원회권고문초안작성개발위원회 6 단계 권고문합의및권고등급결정 컨센서스그룹실무위원회 7 단계 권고문최종안도출 실무위원회개발위원회 8 단계 외부검토외부전문가임상진료지침승인대한의학회 그림 13. 단계별개발위원회및실무위원회역할 153

167 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 1 단계핵심질문선정 1. 담당 Ÿ 핵심질문및핵심질문과관련된검색어를각분과실무위원회에서일차작성한다. Ÿ 실무위원회에서작성한핵심질문및검색어를개발위원회에서취합하여검토한후최종선정한다. 2. 내용 2.1. 핵심질문 Ÿ 진료지침의최종권고안은핵심질문을근거로도출한다. Ÿ 핵심질문은대상환자 인구집단 (P, patient population), 영상검사 중재법 (I, inte rvention), 비교검사 중재법 (C, comparator), 진단목적 중재결과 (O, outcome) 내용을구체적으로포함한다. - 대상환자 인구집단 : 대상환자 인구집단의연령, 성별, 임상적특성및증상, 특정질환에대한이력, 사전검사등의구체적특성을하위집단 (subgroup) 개념으로최대한구분하여기술한다. - 영상검사 중재법 : 대상영상검사법이나중재법을구체적으로정의하는것이일반적이나, 경우에따라특정영상검사법을구체적으로기술하는것이적절하지않을수있다. 핵심질문에서특정영상검사법을구체화하지않는경우라도, 관련진료지침검색을위한검색어선정시에는연관된검사법들을모두구체적으로정하는것이필요하다. - 비교검사 중재법 : 영상검사법간의비교가필요한경우포함하며, 경우에따라핵심질문에포함되지않을수있다. - 진단목적 중재결과 : 진단또는검사의목적대상이되는특정질환, 중재법의임상적결과 ( 사망률, 유병률, 재발률, 재입원율등 ) 등을기술한다 검색어 Ÿ 핵심질문의 PICO 에해당하는영문검색어를정리한다. - P : 연령이나성별은검색어에포함하지않는다. 154

168 6. 부록 2.3. 결과물 Ÿ 실무위원회에서선정한핵심질문및검색어는해당서식1) 을활용하여정리하며, 관련진료지침검색을위하여정리된결과물을개발위원회에제공한다. *1) 별첨 : 서식 1( 핵심질문및검색어서식 ) < 예시 1> 복부 P I C O P I C O 1 우하복부급성통증을나타내는성인환자 영상검사 - 2 우하복부급성통증을나타내는소아환자 영상검사 - 3 우하복부급성통증을나타내는환자 조영증강조영증강 CT CT 전 충수염진단 선정및핵심질문도출 4 우하복부급성통증을나타내는임산부환자영상검사 - 1. 우하복부 (right lower quadrant) 급성통증을나타내는성인환자에서, 충수염진단을위하여, 일차적으로어떤검사가적절한가? 2. 우하복부 (right lower quadrant) 급성통증을나타내는소아환자에서, 충수염진단을위하여, 일차적으로어떤검사가적절한가? 3. 우하복부 (right lower quadrant) 급성통증을나타내는임산부환자에서, 충수염진단을위하여, 일차적으로어떤검사가적절한가? 4. 우하복부 (right lower quadrant) 급성통증을나타내는환자에서, 충수염진단을위하여, 조영증강 CT는조영증강전 (non-contrast) CT보다적절한가? P I C O 검색어 right lower quadrant pain, abdominal pain, acute abdominal pain diagnostic imaging, computer tomography, ultrasonography, magnetic resonance imaging, radiography appendicitis 155

169 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 < 예시 2> 흉부핵심질문 P I C O 1 무증상입원환자 - 2 병력이있고이학적검사에서호흡기및심혈관급성 증상이있는입원환자 세이상의만성호흡기및심혈관질병력이있는 입원환자 (6 개월이내검사결과가있는경우 ) - P I C O 선정 4 70세이상의만성호흡기및심혈관질병력이있는입원환자 (6개월이내검사결과가없는경우 ) - 5 무증상수술전환자 통상적인흉부 X선검사 - 6 병력이있고이학적검사에서호흡기및심혈관급성증상이있는수술전환자 - 흉부 질환발견 및 핵심질문도출 7 70세이상의만성호흡기및심혈관질병력이있는수술전환자 (6개월이내검사결과가있는경우 ) 세이상의만성호흡기및심혈관질병력이있는수술전환자 (6개월이내검사결과가없는경우 ) - 1. 무증상입원환자에서, 흉부질환발견을위하여통상적인 (routine) 흉부 X선검사를실시하는것이적절한가? 2. 병력이있고이학적검사에서호흡기및심혈관급성증상이있는입원환자에서, 흉부질환발견을위하여통상적인흉부 X선검사를실시하는것이적절한가? 3. 70세이상의만성호흡기및심혈관질병력이있는입원환자에서 (6개월이내검사결과가있는경우 ), 흉부질환발견을위하여통상적인흉부 X선검사를실시하는것이적절한가? 156

170 6. 부록 4. 70세이상의만성호흡기및심혈관질병력이있는입원환자에서 (6개월이내검사결과가없는경우 ), 흉부질환발견을위하여통상적인흉부 X선검사를실시하는것이적절한가? 5. 무증상수술전환자에서, 흉부질환발견을위하여통상적인흉부 X선검사를실시하는것이적절한가? 6. 병력이있고이학적검사에서호흡기및심혈관급성증상이있는수술전환자에서, 흉부질환발견을위하여통상적인흉부 X선검사를실시하는것이적절한가? 7. 70세이상의만성호흡기및심혈관질병력이있는수술전환자에서 (6개월이내검사결과가있는경우 ), 흉부질환발견을위하여통상적인흉부 X선검사를실시하는것이적절한가? 8. 70세이상의만성호흡기및심혈관질병력이있는수술전환자에서 (6개월이내검사결과가없는경우 ), 흉부질환발견을위하여통상적인흉부 X선검사를실시하는것이적절한가? P I C O 검 색 어 asymptomatic, preoperative, history, pulmonary disease(symptom) cardiovascular disease(symptom) (routine) X-ray, radiography p u l m o n a r y disease 2 단계진료지침검색 1. 담당 Ÿ 개발위원회에서핵심질문과관련된진료지침의체계적검색을수행한다. 2. 내용 2.1. 주요정보원 Ÿ 국외정보원 : MEDLINE, EMBASE 157

171 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 Ÿ 국내정보원 : KoreaMed, KMbase Ÿ 임상진료지침주요정보원 : NGC, G-I-N, KoMGI, KGC Ÿ 임상영상가이드라인정보원 ( 수기검색정보원 ) : ACR, RCR, JSR 2.2. 검색전략 Ÿ P 및 I 검색어를활용하여포괄적으로검색한다. Ÿ 수기검색 (hand search) 을통해관련분야임상영상진료지침을추가로검색한다. Ÿ 검색정보원, 검색어등의검색전략, 검색일자, 검색자등의정보를기록한다 결과물 Ÿ 검색결과는해당서식2) 을활용하여정리하며, 정리된결과물을실무위원회에제공한다. *2) 별첨 : 서식 2( 진료지침검색결과 ) 3 단계검색된진료지침선정 1. 담당 Ÿ 각분과실무위원회에서검색된결과로부터핵심질문에적합한진료지침을선정한다. 2. 내용 2.1. 선발기준 Ÿ 선택기준 1 핵심질문과일치하는 PICO 를포함하는진료지침 2 한국어또는영어로출판된진료지침 ( 단, 일본가이드라인에서관련핵심질문이있는경우번역하여포함함 ) 년이후에출판된진료지침 158

172 6. 부록 Ÿ 배제기준 1 P: 핵심질문의관심환자를대상으로하지않은경우 2 I&C: 핵심질문관련영상검사가포함되지않은경우 3 O: 적절한결과 ( 진단정확성, 유효성, 안전성, 예후영향및환자선호도등 ) 를보고하지않은경우진료지침 (Practice Guideline) 이아닌경우 4 - 단순한종설 (review), 개별임상연구, critical Pathway( 진료계획표 ) - 대표성없는단일저자가작성한진료지침등 5 권고 (recommendation) 가제시되지않은경우 6 근거기반방법으로작성되지않은경우 - 체계적근거검색없이합의만으로작성한지침의경우배제함 7 영어또는한국어로보고되지않은지침 8 중복으로게재된경우 - 동일내용으로다른저널에게재혹은출판형태만차이가있는경우배제 9 원문확보가불가능한경우 2.2. 진료지침선정단계 1 차선별 사전에정의한배제기준을기준으로검색된문헌의제목및초록을검토하여 1 차선별을 수행한다. - 2 인이상이수행하며, 의견불일치시토의후합의과정을거친다. 2 차선정 사전에정의한배제기준을기준으로 1차선별된문헌의원문을검토하여 2차선정을수행한다. - 2인이상이수행하며, 의견불일치시토의후합의과정을거친다. - 문헌배제시배제사유를기입한다. 최종지침 선택 최종선택된지침은진료지침평가대상이된다 결과물 Ÿ 진료지침선정결과는해당서식3) 을활용하여정리하며, 정리된결과물을개발위원회에제공한다. *3) 별첨 : 서식 3( 진료지침선별 / 선정결과 ) 159

173 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 4 단계진료지침평가 1. 담당 Ÿ 개발위원회에서각분과실무위원회에서최종선정한진료지침에대한질평가를수행한다 ( 지침당 3인이상의평가자가참여한다 ). Ÿ 실무위원회에서최종선정된진료지침의최신성과권고의수용성및적용성을평가한다. 2. 내용 2.1. 진료지침의질평가 Ÿ 질평가도구는 K-AGREE 를이용한다. - 질평가시, 평가결과의재현성과명확성을확보하기위하여점수를부여하는데근거가된내용을코멘트란에기입한다. - 평가자들의평가결과를공유하며, 필요시오류나실수에의한잘못된평가결과를수정할수있는재검토과정을거친다 ( 예 : 평가자간 4점이상점수차이가나는경우 ). - 평가결과는영역별점수화수식을활용하여자동도출한다. Ÿ 평가결과 영역 3 개발의엄격성 이 50점이상인진료지침을최종선정한다. - 질평가결과가낮더라도관련진료지침이현저하게적은경우, 국내에서개발된지침인경우등예외적사항이있는경우에는실무위원회에서판단하여권고및근거정리를위한지침을최종적으로선정한다 ( 예외사항에대해서는사유를기술한다 ) 결과물 Ÿ 진료지침평가결과는해당서식4) 을활용하여정리하며, 정리된결과물을개발위원회및실무위원회가공유한다. *4) 별첨 : 서식 4( 진료지침평가결과 ) 5 단계핵심질문별권고및근거정리, 권고문초안작성 1. 담당 Ÿ 실무위원회에서진료지침평가가완료된지침의권고및근거를핵심질문별로정리하고, 권고문초안을작성한다. 160

174 6. 부록 2. 내용 Ÿ 2.1. 핵심질문별권고및근거정리 권고정리 : 핵심질문별로권고의내용과권고등급 ( 등급이표기되어있는경우 ) 을 정리한다. 세로에핵심질문과 AGREEⅡ 평가내용, 권고등급이들어가고, 가로에는 진료지침별핵심질문에대한권고내용이들어간다. < 예시 > 핵심질문별권고정리 지침제목지침 1 지침 2 지침 3 발행년도 AGREEⅡ 점수 ( 개발의엄격성 ) 핵심권고내용 질문1 핵심 질문2 핵심 질문 3 권고등급 권고내용 권고등급권고내용 권고등급 권고정리시고려사항 Ÿ 진료지침의최신성을평가한다. - 진료지침에포함된근거중주요한최신근거가포함되었는지등을검토한다. Ÿ 권고의수용성과적용성을평가한다. - 인구집단의유사성, 이용가능성, 선호도의차이, 법적및정책적장벽등을종합적으로검토하여, 해당권고를받아들일수있는가 ( 수용성, acceptability) 와권고를실제적용할수있는가 ( 적용성, applicability) 를평가한다. - 원진료지침의대상인구집단과수용개작진료지침의대상인구집단이일치하는가 ( 수용성 )? - 중재와관련된환자의관점및선호도가유사한가 ( 적용성 )? - 중재, 장비가이용가능한가 ( 적용성 )? - 필요한전문지식및기술이이용가능한가 ( 적용성 )? - 권고이행에법적, 정책적장벽은없는가 ( 적용성 )? - 권고는문화, 가치에부합하는가 ( 수용성과적용성 )? - 권고실행으로인한이득은실제적가치가있는것인가 ( 수용성 )? Ÿ 국내근거에대한검토가필요하다고판단되는경우, 국내에서생산된근거 ( 지침이아닌개별연구 ) 를별도로검색하여근거정리시추가한다. 161

175 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 < 예시 > 권고의수용성과적용성평가도구 구분지침 1 지침 2 지침 3 권고 인구집단 ( 유병률, 발생률등 ) 이유사하다 수용성 가치와선호도가유사하다 권고로인한이득은유사하다 해당권고는수용할만하다. 해당중재 / 장비는이용가능하다. 적용성 필수적인전문기술이이용가능하다 법률적 / 제도적장벽이없다. 해당권고는적용할만하다. 예 / 아니오 / 불확실중의하나를선택한다. Ÿ 근거정리 : 핵심질문별로지침의권고와관련된근거들을정리한다. - 기본서식 : 서지정보, 대상자수, 연구결과, 근거의질등급 ( 원래지침의질등급및우리체계에서등급을구분하여기입 ) 을포함한다. - 단, 체크사항은다음의경우만추가시행하도록한다. 1) 미국 ACR 또는일본지침에서표시한근거수준이없는문헌 2) 기존지침에서근거수준을표시하지않은문헌 - 체크사항 : reference standard 유무, 연속적환자모집여부, 판독의맹검화 (reference standard 또는비교검사 중재의결과를알지못한상태에서대상검사 중재의결과를판독 ) 여부, 체계적문헌고찰연구유형여부, case-control 연구유형여부총 5개항목을포함한다. * 체크사항중 (1), (2), (3) 은 Y/N/U( 예 / 아니오 / 불확실 ) 로평가하고, (4), (5) 는 o, x 로평가한다. 162

176 6. 부록 < 예시 1> 핵심질문별근거정리 : 지침별권고내용이상이한경우 핵심질문 1: 서술형핵심질문 문헌정보연구유형대상자수연구결과 체크사항 * 근거수준 (original) 근거수준 (KCIG) 1. reference standard, 2. consecutive patient, 3. blind interpretation, 4. systematic review, 5. case-control study Ÿ 2.2. 근거수준 (level of evidence) 결정개별문헌의근거수준 (level of evidence) - 개별문헌의근거등급을우리의등급체계를기준으로다시설정한다. - 단, 다음의사항을추가로고려할수있다. 1) ACR과일본가이드라인에포함된경우, 위예시2 표에서체크사항의 (1)~(3) 을반드시확인하지않아도된다. 2) ACR 과일본가이드라인에포함되지않은경우는체크사항의 (1)~(3) 에서많이나온결과에따라, 확인이어려운경우 ( 불확실이 2개이상 ) 는 Level 3으로결정한다. 표. 문헌별근거수준결정기준 (KCIG) KCIG 내용일본지침 ACR 지침 1 아래의 3가지를조건을모두만족하는연구 1) 적절한참고표준검사 2) 연속적환자모집 3) 맹검적결과해석 Level 1 수준의체계적문헌고찰중재 / 참고표준검사를적용하여결과를비교관찰한무작위임상시험연구, 단면코호트연구

177 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2 2 아래의 2가지조건을만족하는연구 1) 적절한참고표준검사 2) 연속적환자모집또는맹검적결과해석 Level 2 수준의체계적문헌고찰중재 / 참고표준검사를적용하여결과를비교관찰한비교연구 ( 전향적코호트, 후향적코호트, quasi-rct) 3 4 (systematic review) 3 (consecutive) 3 일관성있게적용한참고표준검사가없는경우 환자 - 대조군연구 부적절하거나비 - 독립적참고표준검사 4 3 (case-control) 5 전문가의견 5 4 Ÿ 근거문헌종합근거수준 (overall level of evidence) - 핵심질문별로종합근거수준을결정한다. - 권고초안작성에가장중요하게고려된진료지침들의근거수준 ( 연구설계와비뚤림위험 ) 을고려하여높음 (Ⅰ)-중등도 (Ⅱ)-낮음 (Ⅲ)-매우낮음 (Ⅳ) 으로결정한다. - 진단검사에서의적절한연구설계는보통아래와같다 (1) 단면코호트연구로진단이불확실한환자에게참조표준검사 (reference standard) 와평가대상검사 (index test 또는 intervention) 를모두시행하고, 정확도를계산, 각검사에서양성결과를얻은환자를대상으로치료결과를비교한연구 (2) 환자를무작위로새로운검사또는기존검사에배정하여검사결과양성인환자에게적절한치료를시행한후두군에서의치료결과를비교한경우 164

178 6. 부록 표. 검사결과의영향을평가하기위한일반적인연구설계 예 ) 급성호흡곤란을주소로응급실에내원한환자를대상으로심부전진단을위한 BNP 검사의무작위배정비교임상시험결과, 해당검사를시행받은환자의경우이환율및사망률의차이는없는채로재원기간, 비용의감소가있었다. 예 ) 급성요로결석을진단하기위한연구에서조영제를사용하지않은 CT 검사가신우조영술에비해위음성결과측면에서우월한것으로나타났다. 그렇지만신우조영술이놓쳤던요관의결석은자연배출이용이한부위이다. 두가지검사의임상결과를비교한무작위배정비교임상시험은존재하지않으나이상의가능성을고려할때 CT가신우조영술에비해편익이높은지에대한근거는불확실하다. 표. 종합근거수준기준 (KCIG) 1) 권고내용비교에서 2) 개별문헌근거수준 KCIG 의미도출된경우 * 확인한경우 ACR의경우범주 1 높음적절한연구설계및비뚤림위험이 RCR의경우 Level 1 (Ⅰ) 낮은연구들로부터추정된결과이다일본지침의경우 Level1,2 적절한연구설계및비뚤림위험 ACR의경우범주 2 중등도이중등도인연구들로부터추정된 RCR의경우 Level 2 (Ⅱ) 결과이다일본지침의경우 Level 3 연구설계가부적절하거나, 비뚤림 ACR의경우범주 3 낮음위험이높은연구들로부터추정된 RCR의경우 Level 3 (Ⅲ) 결과이다일본지침의경우 Level 4 매우 연구설계가부적절하거나비뚤림 ACR의경우범주 4 낮음 위험이높은 연구들로부터추정된 RCR의경우 Level 4-5 (Ⅳ) 결과이다 일본지침의경우 Level 5 * 가장중요하게고려된진료지침근거수준고려 Ÿ ACR, RCR, 일본지침이아닌지침의근거수준의내용을참고해서 KCIG 에해당 되는근거수준을정하고, 회의록에남기도록한다. 권고안의중요한결론을제시하고있는연구들의근거수준이대부분 1 또는 2로구성된경우권고안의중요한결론을제시하고있는연구들의근거수준이대부분 2 또는 3으로구성된경우권고안의중요한결론을제시하고있는연구들의근거수준이대부분 3또는 4으로구성된경우권고안의중요한결론을제시하고있는연구들의근거수준이대부분 5로구성된경우 165

179 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.3. 권고문초안작성 Ÿ KCIG 권고등급 (recommendation grading) Grading 내용 의미 A 시행하는것을권고함 해당중재 ( 검사 ) 는원하는효과에대한충분한근거가있어시행할것을권고함. B ( 조건부 ) 시행하는것을권고함 해당중재 ( 검사 ) 의원하는효과에대한근거는중등도와충분한사이임 중재 ( 검사 ) 를선택적으로제공하거나, 전문가의판단에따라특정개인 에게시행할것을권고함. C 시행하지않는것을 권고함 해당중재 ( 검사 ) 의원하지않는효과에대한충분한근거가있어, 시행 하는것을권고하지않음 ( 시행하지않을것을권고함 ) Ÿ Ÿ 해당중재 ( 검사 ) 의효과가있다거나없다는것에대한근거는불충분하권고없음고, 효과에대한추가적인연구가필요함. I (no recommendation) 해당중재 ( 검사 ) 의효과에대한확신도가매우낮아권고등급결정자체가의미가없다고판단됨. 근거수준결과를포함한근거정리결과와권고정리결과를종합적으로검토하여권고문초안을작성한다. 권고등급결정을위한고려사항 고려요인 1. 근거수준 (level of evidence) 2. 이득 (benefit) 3. 위해 (harm) 내용핵심질문별로종합적인근거수준 (4단계) 을내림 - 높음 (I), 중등도 (II), 낮음 (III), 매우낮음 (IV) 진단정확성임상적유효성 - 임상적예후에미치는긍정적인영향 : 치료효과, 치료방향의변화등 - 불필요한자원이용의감소 : 재원일수감소, 침습적인수술또는시술 ( 검사 ) 의감소, 인력 / 비용 / 시설이용등의감소등환자만족도증가, 삶의질향상등에대한근거가있는경우방사선량 : 무증상, 소아, 임산부등고려가필요한대상집단의경우만고려함검사 ( 시술 ) 조영제관련부작용침습적인검사 ( 시술 ) 의경우합병증, 부작용등자원이용증가 - 불필요한자원이용의증가등에대한근거가있는경우환자만족도또는삶의질감소등에대한근거가있는경우 166

180 6. 부록 Ÿ 검토한진료지침간권고내용이불일치하거나상충될경우, 근거수준이높은근거의내용, 진료지침질평가결과가높은지침 ( 및포함된근거내용 ) 및국내의료상황에더적합한권고를우선적으로고려할수있다. Ÿ 판단이불가한경우에는개별근거를참고하여권고를새로작성한다. Ÿ 이득과위해에관한내용은근거문헌들을참고하여서술형식으로기술한다. < 예시 > 복부핵심질문에대한권고문요약초안 1. 우하복부 (right lower quadrant) 급성통증을호소하는어른환자에서충수염진단을위한검사로는 CT 검사를권고하며, 복부초음파검사또한권고한다. ( 권고등급 O, 근거수준 O) 2. 우하복부급성통증을나타내는소아환자에서충수염진단을위하여일차검사로초음파검사를시행하는것을권고한다. 필요한경우조영증강 CT 검사를시행하는것을권고한다. ( 권고등급 O, 근거수준 O) 3. 우하복부급성통증을나타내는임산부환자에서충수염진단을위하여일차검사로초음파검사를시행하는것을권고한다. 진단이불분명한경우 MRI 혹은 CT 검사를시행할수있다. 조영증강 CT 검사는시행하지않는것을권고한다. ( 권고등급 O 근거수준 O) 4. 비교적특징적인충수염의심증상을보이는환자의진단을위하여조영증강 CT와조영중간전 (non-contrast) CT를시행하는것은모두적절하다. 하지만, 충수염외다른질환의가능성이있는경우에는조영증강 CT 검사는적절하며, 조영증강전 CT는특수한경우적절할수있다. ( 권고등급 O, 근거수준 O) 3. 결과물 Ÿ 해당서식5) 을활용하여핵심질문별권고및근거를정리 ( 근거수준포함 ) 하며, 이를바탕으로작성한권고문초안을함한모든결과물을개발위원회및실무위원회가공유한다. 본결과물은권고합의를위한컨센서스그룹에제공된다. *5) 별첨 : 서식 5( 권고및근거정리결과 ) 167

181 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 6 단계권고합의및권고등급결정 1. 담당 Ÿ 일차로작성된권고문초안에대하여관련분야전문가로구성된컨센서스그룹에서검토후합의한다. Ÿ 컨센서스그룹의합의결과를바탕으로실무위원회에서최종권고등급을기술한다. 2. 내용 2.1. 권고합의 Ÿ 컨센서스그룹구성 - 영상의학과전문의및관련임상분야전문가로구성하며 7인 15 인사이로한다. Ÿ 합의방법론 - 델파이방법을사용하며, 최소 2 round로구성한다 권고등급 (recommendation grading) Grading 내용 A B C I 시행하는것을권고함 ( 조건부 ) 시행하는것을권고함시행하지않는것을권고함권고없음 (no recommendation) 7 단계권고문최종안도출 1. 담당 Ÿ 최종권고문을실무위원회에서작성한다. Ÿ 개발위원회에서작성된권고문을취합하여최종검토한다. 2. 내용 Ÿ 컨센서스그룹의합의를바탕으로한권고등급을반영하여최종권고안을확정하고문서화한다. 168

182 6. 부록 8 단계외부검토및임상진료지침승인 Ÿ 가이드라인개발에참여하지않은관련전문가의검토 ( 외부검토 ) 를거쳐가이드 라인최종본을확정한다. Ÿ 개발된가이드라인은대한의학회의임상진료지침승인을받은후배포한다. 붙임자료서식 1. 핵심질문및검색어서식 1. 핵심질문서식 [PICO 형 ] P (patient population) I (intervention) C (comparator) O (outcome) [ 서술형 ] 검색어서식 P I C O 필요한경우

183 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 서식 2. 진료지침검색결과 1. 검색전략 (excel) 구분 DB 검색전략검색건수비고 MEDLINE 국외 EMBASE NGC GIN KoreaMed 국내 KMBASE KoMGI KGC ACR 수기 RCR 검색일본지침검색일자 : 검색자 : 2. 검색결과 (excel) Author Title Source Type Year Abstract

184 6. 부록 서식 3. 진료지침선별 / 선정결과 1. 1 차선별 (excel) 고유 번호 저자제목출처유형연도초록 선택 :1, 배제 :0 주담당 부담당 불일치여부일치 : 0 불일치 : 1 1차선별결과선택 :1 배제 : 차선정 (excel) 저자제목출처유형연도원문 주 담당 선택 :1, 배제 :0 배제 부 사유 담당 배제 사유 불일치 여부 2 차 선정결과 고유 번호 첨부 일치 : 0 불일치 : 1 선택 :1 배제 :0 서식 4. 진료지침평가결과 1. 진료지침평가결과 (excel) 고유 번호 지침제목연도진료지침여부판정 Yes / No AGREE II 평가표준화영역점수 (%) Overall Guideline Assessment 영역 1. 범위와목적, 영역 2. 이해당사자의참여, 영역 3. 개발의엄격성, 영역 4. 명확성과표현, 영역 5. 적용 성, 영역 6. 편집독립성 171

185 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 서식 5. 권고및근거정리결과 1. 권고정리 (excel) 구분 지침1 지침2 지침3 AGREEⅡ 점수 ( 개발의엄격성 ) 핵심질문1 핵심질문2 핵심질문3 핵심질문4 권고내용권고등급권고내용권고등급권고내용권고등급권고내용권고등급 2. 핵심질문별근거정리서식 (excel) 핵심질문 1: 서술형핵심질문 문헌정보연구유형대상자수연구결과 체크사항 * 근거수준 (original) 근거수준 (KCIG) 1. reference standard, 2. consecutive patient, 3. blind interpretation, 4. systematic review, 5. case-control study 3. 권고문초안작성서식 Ÿ 권고문요약 : 권고문만요약한다. Ÿ 권고문초안 : 핵심질문별로권고문, 근거요약, 국내수용성 / 적용성, 참고문헌까지 172

186 6. 부록 포함하여기술한다. KQ 1 KQ 2 KQ 3 ( 워킹그룹분과명 ) 권고문요약초안 ( 서술형 ) ( 권고등급 O, 근거수준 O) ( 서술형 ) ( 권고등급 O, 근거수준 O) ( 서술형 ) ( 권고등급 O, 근거수준 O) ( 워킹그룹분과명 ) 권고문초안 핵심질문 1: ( 서술 ) 권고문 ( 서술 ) ( 권고등급 O, 근거수준 O) 근거요약 (Evidence Summary) -( 서술형기술, 근거표 (evidence table) 는부록으로 ) 권고고려사항 - 이득 (benefit) 과위해 (harm) ( 서술형기술 ) - 국내수용성과적용성 ( 서술형기술 ) - ( 최신성검토 ) 필요시 PubMed 또는 Medline 에서검색 ( 개발위원회와협의 ) - 검사별방사선량 ( 표로제시 : 개발위원회에서제공 ) 참고문헌 173

187 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2. 근거기반임상영상가이드라인수용개작단계별정리 2.1. 신경두경부분과 가. 핵심질문선정 1) PICO의선정표 14. 신경두경부 PICO 선정 Population Intervention Comparator Outcome 1 아급성혹은만성폐쇄성두부손 CT head w/o 1-1 MRI w/o contrast 진단정확성및임상이의심되는환자 contrast 상적유용성 1-2 두개골골절이의심되는환자 CT head w/o contrast skull X-ray 2 뇌발작및뇌전증을주소로내원한환자 두개손상과관련이없으며, 알코 2-1 올혹은약물남용과관련있는새로발생한뇌발작을주소로내원 한환자 2-2 두개손상과관련이없는 18~40세의새로발생한뇌발작을주소로내원한환자 MRI head w/o and w contrast CT w and w/o contrast 진단정확성및임상적유용성 2-3 두개손상과관련이없으며 40세이상에서처음발생한뇌발작을주소로내원한환자 전도성난청을주소로내원한환 자 CT temporal bone wit hout contrast CT head witho ut contrast 3-2 혼합성난청을주소로내원한환 자 MR head and internal auditorycanal without and with contrast CT head witho ut contrast/ct temporal witho ut contrast 진단정확성및임 상적유용성 3-3 임상적으로진주종이나종양이의 심되는환자의수술전검사로시 행하는경우 MR head and internal auditorycanal without and with contrast CT temporal b one without co ntrast 174

188 6. 부록 2) 문장형핵심질문표 15. 신경두경부문장형핵심질문핵심질문 핵심질문 1 경미한뇌외상환자에서진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-1 아급성혹은만성폐쇄성경미한뇌외상환자에서진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-2 두개골골절환자에서진단을위한적절한영상검사는무엇인가? 핵심질문 2 외상없이처음발생한뇌발작또는뇌전증환자에서진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-1 외상없이처음발생한알콜혹은약물관련뇌발작또는뇌전증환자에서진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-2 외상없이처음발생한 18~40세의뇌발작또는뇌전증환자에서진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-3 외상없이처음발생한 40세이상의뇌발작또는뇌전증환자에서진단을위한적절한영상검사는무엇인가? 핵심질문 3 난청을호소하는환자의중이질환진단을위한적절한영상검사는무엇인가? 세부핵심질문 3-1 전도성난청을주호소로내원한환자의중이질환진단을위한적절한영상검사는무엇인가? 세부핵심질문 3-2 혼합성난청을주호소로내원한환자의중이질환진단을위한적절한영상검사는무엇인가? 세부핵심질문 3-3 임상적으로진주종이나종양이의심되는환자의중이질환진단을위해수술전검사로적절한영상검사는무엇인가? 나. 핵심질문별진료지침검색 1) 핵심질문 1 검색대상핵심질문 KQ 1. 경미한뇌외상환자에서진단을위한적절한영상검사는무엇인가? 국내DB 검색전략및결과표 16. 신경두경부국내문헌DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 1 "head injur*" [ALL] 0 2 "head trauma" [ALL] 0 3 "brain injur*" [ALL] 2 4 "brain trauma" [ALL] 0 175

189 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 검색사이트 N 검색어관련문헌비고 2. KMBASE 5 "skull fracture*" [ALL] 0 6 소계 2 7 단순중복제거후 2 1 [ALL=head injur*] AND [ALL=guideline*] 7 2 [ALL=head trauma] AND [ALL=guideline*] 3 3 [ALL=brain injur*] AND [ALL=guideline*] 9 4 [ALL=brain trauma] AND [ALL=guideline*] 0 5 [ALL=skull fracture*] AND [ALL=guideline*] 4 6 [ALL=head injur*] AND [ALL=recommendation*] 1 7 [ALL=head trauma] AND [ALL=recommendation*] 0 8 [ALL=brain injur*] AND [ALL=recommendation*] 2 9 [ALL=brain trauma] AND [ALL=recommendation*] 0 10 [ALL=skull fracture*] AND [ALL=recommendation*] 0 11 [ALL= 두부외상 ] AND [ALL=guideline*] 1 12 [ALL= 두부손상 ] AND [ALL=guideline*] 1 13 [ALL= 두개골골절 ] AND [ALL=guideline*] 0 14 [ALL= 두부외상 ] AND [ALL=recommendation*] 0 15 [ALL= 두부손상 ] AND [ALL=recommendation*] 0 16 [ALL= 두개골골절 ] AND [ALL=recommendation*] 0 17 [ALL= 두부외상 ] AND [ALL= 지침 ] 1 18 [ALL= 두부손상 ] AND [ALL= 지침 ] 0 19 [ALL= 두개골골절 ] AND [ALL= 지침 ] 0 20 [ALL= 두부외상 ] AND [ALL= 권고 ] 1 21 [ALL= 두부손상 ] AND [ALL= 권고 ] 0 22 [ALL= 두개골골절 ] AND [ALL= 권고 ] 0 23 [ALL= 두부외상 ] AND [ALL= 가이드라인 ] 0 24 [ALL= 두부손상 ] AND [ALL= 가이드라인 ] 0 25 [ALL= 두개골골절 ] AND [ALL= 가이드라인 ] 0 26 소계 단순중복제거후

190 6. 부록 표 17. 신경두경부국내진료지침 DB 검색사이트 N 지침제목연도개발학회 1. KGC 1 2 소계 ( 0 건 ) 2. KoMGI 1 2 소계 ( 0 건 ) 국외DB 검색전략및결과 표 18. 신경두경부국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 1 exp Head/ or head.mp brain.mp. or exp Brain/ or P 4 (injur$ or trauma).mp AND exp Skull Fractures/ or skull fracture*.mp or exp Magnetic Resonance Imaging/ or MRI.mp exp Tomography, X-Ray Computed/ or CT.mp Comput$ Tomogr$.mp 검사 11 9 or X-ray$.mp. or exp X-Rays/ or 11 or AND P& 검사 15 7 AND guideline.pt practice guideline.pt 포함 18 guideline$.ti 기준 19 recommendation$.ti OR/ AND 종합 23 limit 22 to yr=" Current" 단순중복제거후

191 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 19. 신경두경부국외 Ovid-Embase 검색일 : 구분 N 검색어 검색결과 1 exp head/ or head.mp exp brain/ or brain.mp or exp injury/ or injur$.mp P 5 trauma.mp OR/ AND skull fracture$.mp. or exp skull fracture/ OR/ MRI.mp. or exp nuclear magnetic resonance imaging/ CT.mp. or exp whole body CT/ 검사 12 exp computer assisted tomography/ or Comput$ Tom ogr$.mp X-ray$.mp. or exp X Ray/ OR/ AND P& 검사 16 9 AND guideline$.ti 포함 기준 18 recommendation$.ti OR/ AND 종합 21 limit 20 to yr=" Current" 단순중복제거후 264 표 20. 신경두경부국외 GIN 검색일 : N 검색어 검색결과 1 head injury 2 2 head trauma 2 3 brain injury 1 178

192 6. 부록 검색일 : N 검색어 검색결과 4 brain trauma 1 5 단순중복제거후 3 표 21. 신경두경부국외 NGC 검색일 : N 검색어 검색결과 1 "head injur*" 2 2 head trauma 2 3 brain injur* 4 4 brain trauma 12 5 단순중복제거후 12 2) 핵심질문 2 검색대상핵심질문 KQ 2. 외상없이처음발생한뇌발작또는뇌전증환자에서진단을위한적절한영상검사는무엇인가? 국내 DB 검색전략및결과 표 22. 신경두경부국내문헌 DB 검색일 : 검색사이트 N 검색어 관련문헌 비고 1 seizure* [ALL] 0 1.KoreaMed 2 epilepsy [ALL] 0 3 소계 0 4 단순중복제거후 0 1 [ALL=seizure*] AND [ALL=guideline*] 6 2 [ALL=epilepsy] AND [ALL=guideline*] 6 3 [ALL=seizure*] AND [ALL=recommendation*] 1 4 [ALL=epilepsy] AND [ALL=recommendation*] 1 2.KMBASE 5 [ALL= 뇌발작 ] AND [ALL=guideline*] 0 6 [ALL= 뇌전증 ] AND [ALL=guideline*] 0 7 [ALL= 뇌발작 ] AND [ALL=recommendation*] 0 8 [ALL= 뇌전증 ] AND [ALL=recommendation*] 0 9 [ALL= 뇌발작 ] AND [ALL= 지침 ] 0 10 [ALL= 뇌전증 ] AND [ALL= 지침 ] 0 179

193 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 검색사이트 N 검색어 관련문헌 비고 11 [ALL= 뇌발작 ] AND [ALL= 권고 ] 0 12 [ALL= 뇌전증 ] AND [ALL= 권고 ] 1 13 소계 단순중복제거후 7 표 23. 신경두경부국내진료지침 DB 검색사이트 N 지침제목연도개발학회 1. KGC 1 2 소계 ( 0 건 ) 2. KoMGI 1 2 소계 ( 0 건 ) 국외DB 검색전략및결과 표 24. 신경두경부국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 1 seizure$.mp. or exp Seizures/ P 2 exp Epilepsy/ or epilepsy.mp or exp Magnetic Resonance Imaging/ or MRI.mp exp Tomography, X-Ray Computed/ or CT.mp Comput$ Tomogr$.mp 검사 7 OR/ exp Head/ or head.mp brain.mp. or exp Brain/ or AND P& 검사 12 3 AND guideline.pt practice guideline.pt guideline$.ti 포함 16 recommendation$.ti 기준 17 standard$.ti OR/ AND 종합 20 limit 19 to yr=" Current" 단순중복제거후

194 6. 부록 표 25. 신경두경부국외 Ovid-Embase 검색일 : 구분 N 검색어 검색결과 1 seizure$.mp. or exp seizure/ P 2 epilepsy.mp. exp epilepsy/ or MRI.mp. or exp nuclear magnetic resonance imaging/ CT.mp. or exp whole body CT/ exp computer assisted tomography/ or comput$ tomogr$.mp 검사 7 OR/ exp head/ or head.mp. or exp head injury/ exp brain injury/ or exp brain/ or brain.mp or AND P& 검사 12 3 AND guideline$.ti 포함 14 recommendation$.ti 기준 15 OR/ AND 종합 17 limit 16 to yr=" Current" 단순중복제거후 90 표 26. 신경두경부국외 GIN 검색일 : N 검색어 검색결과 1 seizure* 0 2 epilepsy 4 3 단순중복제거후 3 표 27. 신경두경부국외 NGC 검색일 : N 검색어 검색결과 1 seizure* 14 2 epilepsy 18 3 단순중복제거후

195 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 3) 핵심질문 3 검색대상핵심질문 KQ 3. 난청을호소하는환자의중이질환진단을위한적절한영상검사는무엇인가? 국내DB 검색전략및결과 표 28. 신경두경부국내문헌DB 검색일 : 검색사이트 N 검색어 관련문헌 비고 1 "hearing loss" [ALL] 0 2 cholesteatoma [ALL] 0 1.Korea Med 3 "middle ear tumor" [ALL] 0 4 vertigo [ALL] 0 5 소계 0 6 단순중복제거후 0 2.KMBAS E 1 [ALL=hearing loss] AND [ALL=guideline*] 3 2 [ALL=cholesteatoma] AND [ALL=guideline*] 0 3 [ALL=middle ear tumor*] AND [ALL=guideline*] 0 4 [ALL=vertigo] AND [ALL=guideline*] 4 5 [ALL=hearing loss] AND [ALL=recommendation *] 1 6 [ALL=cholesteatoma] AND [ALL=recommendatio n*] 0 7 [ALL=middle ear tumor*] AND [ALL=recommen dation*] 0 8 [ALL=vertigo] AND [ALL=recommendation*] 0 9 [ALL= 난청 ] AND [ALL=guideline*] 2 10 [ALL= 중이질환 ] AND [ALL=guideline*] 0 11 [ALL= 난청 ] AND [ALL=recommendation*] 1 12 [ALL= 중이질환 ] AND [ALL=recommendation*] 0 13 [ALL= 난청 ] AND [ALL= 지침 ] 0 14 [ALL= 중이질환 ] AND [ALL= 지침 ] 0 15 [ALL= 난청 ] AND [ALL= 권고 ] 0 16 [ALL= 중이질환 ] AND [ALL= 권고 ] 0 18 소계 19 단순중복제거후 7 182

196 6. 부록 표 29. 신경두경부국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 국외DB 검색전략및결과 표 30. 신경두경부국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 1 hearing loss.mp. or exp Hearing Loss/ exp Cholesteatoma/ or cholesteatoma.mp P 3 exp Ear Neoplasms/ or middle ear tumor.mp otitis media.mp. or exp Otitis Media/ exp vertigo/ or vertigo.mp OR/ guideline.pt practice guideline.pt guideline$.ti 포함 10 recommendation$.ti 기준 11 OR/ AND limit 13 to yr=" Current" 284 종합 14 단순중복제거후 표 31. 신경두경부국외 Ovid-Medline 검색일 : 구분 N 검색어검색결과 P 1 hearing loss.mp. or exp hearing impairment/ cholesteatoma.mp. or exp cholesteatoma/ middle ear tumor.mp. or exp middle ear tumor/ vertigo.mp. or exp vertigo/ OR/

197 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 구분 N 검색어검색결과 검사 6 MR.mp. or exp nuclear magnetic resonance/ CT.mp. or exp whole body CT/ exp computer assisted tomography/ or comput$ tomogr$. mp OR/ exp brain/ or brain.mp exp head/ or head.mp temporal.mp auditory.mp OR/ AND P& 검사 16 5 AND 포함 기준 종합 17 guideline$.ti recommendation$.ti standard$.ti exp practice guideline/ OR/ AND limit 22 to yr=" Current" 단순중복제거후 표 32. 신경두경부국외 GIN 검색일 : N 검색어 검색결과 1 hearing loss 1 2 cholesteatoma 0 3 middle ear tumor 0 4 middle ear disease 0 5 단순중복제거후 1 184

198 6. 부록 표 33. 신경두경부국외 NGC 검색일 : N 검색어 검색결과 1 hearing loss 14 2 cholesteatoma 3 3 middle ear tumor 2 4 middle ear disease* 0 5 단순중복제거후 16 다. 진료지침선별 1) 핵심질문 1 흐름도 그림 14. 신경두경부핵심질문 1 흐름도. 185

199 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2) 핵심질문 2 흐름도 그림 15. 신경두경부핵심질문 2 흐름도. 3) 핵심질문 3 흐름도 그림 16. 신경두경부핵심질문 3 흐름도. 186

200 6. 부록 라. 진료지침평가 1) 진료지침질평가결과 표 34. 신경두경부핵심질문 1 질평가결과 핵심질문 1 지침제목 AGREE 점수개발위원회의견 Head Trauma (ACR) 69 추천함 일본가이드라인 64 추천함 Scandinavian guidelines for initial management of minimal, mil d and moderate head injuries in adults: an evidence and cons ensus-based update Clinical Policy: Neuroimaging and Decision making in Adult Mil d Traumatic Brain Injury in the Acute Setting Clinical practice guidelines in severe traumatic brain injury in Taiwan Evaluation and Management of Children Younger Than Two Y ears Old With Apparently Minor Head Trauma: Proposed Guid 76 추천함 53 추천함 44 추천안함 1 51 추천함 elines Mild Traumatic Brain Injury 49 추천안함 2 Imaging Evidence and Recommendations for Traumatic Brain I njury: Advanced Neuro-and Neurovascular Imaging Techniques 37 추천안함 3 Imaging Evidence and Recommendations for Traumatic Brain I njury: Conventional Neuroimaging Techniques 31 추천안함 3 Summary of evidence-based guideline update: Evaluation and management of concussion in sports 51 추천함 Head injury: assessment and early management (NICE CG 17 6) 92 추천함 1. Clinical practice guideline, agree II < management guideline, agree II < agree II < 50 표 35. 신경두경부핵심질문 2 질평가결과 핵심질문 2 지침제목 AGREE점수 개발위원회의견 Seizures and Epilepsy (ACR) 69 추천함 ACR-ASNR practice guideline for the performance of compute d tomography (CT) of the brain 69 추천함 일본가이드라인 CQ5 Is CT appropriate for children with minor 64 추천함 187

201 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 head trauma? Epilepsies: diagnosis and management (NICE) 87 추천함 Clinical polish: critical issues in the evaluation and manageme nt of adult patients presenting to the emergency department with seizures 60 추천함 Practice parameter: Evaluating an apparent unprovoked first s eizure in adults (an evidence-based review) 56 추천함 The epilepsies the diagnosis and management of the epilepsi es in adults and children in primary and secondary care 77 추천함 표 36. 신경두경부핵심질문 3 질평가결과 핵심질문 3 지침제목 AGREE점수 개발위원회의견 Hearing Loss and/or Vertigo 69 추천함 일본가이드라인 64 추천함 Sudden Hearing Loss: Guideline for Diagnosis and Management 22 추천안함 Clinical Practice Guideline: Sudden Hearing Loss 62 추천함 Treatment Strategy for Sudden Sensorineural Hearing Loss 19 추천함 ( 수정필요 ) 2) 수용성과적용성평가결과 표 37. 신경두경부핵심질문 1 수용성과적용성평가결과 핵심질문 1 구분 평가항목 지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 수 인구집단 ( 유병률, 발생률등 ) 이유사하다. 예 예 예 예 예 예 가치와선호도가유사하다. 예예예예예예용권고로인한이득은유사하다. 예예예예예예성해당권고는수용할만하다. 예예예예예예 적 해당중재및장비는이용가능하다. 예 예 예 예 예 예 필수적인전문기술이이용가능하다. 예예예예예예용법률적 / 제도적장벽이없다. 예예예예예예성해당권고는적용할만하다. 예예예예예예 지침 A : Head Trauma (ACR) 지침 B : 일본가이드라인 지침 C : Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update 지침 D : Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain 188

202 6. 부록 Injury in the Acute Setting 지침 E : Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelilnes 지침 F : Head injury: assessment and early management (NICE CG 176) 표 38. 신경두경부핵심질문 2 수용성과적용성평가결과 핵심질문 2 구지침지침지침지침지침지침평가항목분 A B C D E F 수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예예예예예예가치와선호도가유사하다. 예예예예예예용권고로인한이득은유사하다. 예예예예예예성해당권고는수용할만하다. 예예예예예예적해당중재및장비는이용가능하다. 예예예예예예필수적인전문기술이이용가능하다. 예예예예예예용법률적 / 제도적장벽이없다. 예예예예예예성해당권고는적용할만하다. 예예예예예예지침 A : Seizures and Epilepsy (ACR) 지침 B : ACR-ASNR practice guideline for the performance of computed tomography(ct) of the brain 지침 C : 일본가이드라인 지침 D : Epilepsies: diagnosis and management (NICE) 지침 E : Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizuress 지침 F : Practice parameter: Evaluating an apprent unprovoked first seizure in adults (an evidence-based review) 지침 G : The epilepsies the diagnosis and management of the epilepsies in adults and children in primary and secondary care 지침 G 189

203 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 39. 신경두경부핵심질문 3 수용성과적용성평가결과핵심질문 3 구평가항목지침 A 지침 B 지침 C 지침 D 지침 E 분수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예가치와선호도가유사하다. 예용권고로인한이득은유사하다. 예성해당권고는수용할만하다. 예적해당중재및장비는이용가능하다. 예필수적인전문기술이이용가능하다. 예용법률적 / 제도적장벽이없다. 예성해당권고는적용할만하다. 예지침 A : Hearing Loss and/or Vertigo 지침 B : 일본가이드라인지침 C : Sudden Hearing Loss: Guideline for Diagnosis and Management 지침 D : Clinical Practice Guideline: Sudden Hearing Loss 지침 E : Treatment Strategy for Sudden Sensorineural Hearing Loss 190

204 6. 부록 마. 핵심질문별권고및근거정리 1) 권고비교표 표 40. 신경두경부핵심질문 1 권고비교표 핵심질문 1 구 분 권고 권고 일반적으로 지침 A 지침 B 지침 C 지침 D 지침 E 지침 F CT 와 MRI 를권고함. 경 미한두부외상시단 순두개골사진은권 고하지않으며, 조 영증강 CT 와 MRI 는일부경우에제 한적으로권장하며, PET, 확산텐서및 기능적 자기공명영 상등은권장하지 않음. 소아에서는 C T 를권고하지 않음. 위험요 인이있는경 우에한해제 한적으로 CT 를권고함 CT 를 권고 함. (MRI 는 배제된가이 드라인임 ) 일반적으로 CT 와 M RI 를권고함. 경미 한두부외상시단순 두개골사진은권고 하지않으며, 조영증 강 CT 와 MRI 는 일부경우에제한적 으로권장하며, PE T, 확산텐서및기능 적자기공명영상등은 은권장하지않음. 2 세미만의 경우일부에 한해제한적 으로 권고함 CT 를 일반적으로 CT 를 함 권고 소아의 경우일부에 한해제한적 으로 권고함 등급지침 A : Head Trauma (ACR) 지침 B : 일본가이드라인지침 C : Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update 지침 D : Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting 지침 E : Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelilnes 지침 F : Head injury: assessment and early management (NICE CG 176) CT 를 표 41. 신경두경부핵심질문 2 권고비교표 핵심질문 2 구분 지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 지침 G 외상없이처 MRI를사용 두엽간질의 성인뇌전증 성인환자가 외상없이처 성인뇌전증 음 발생한 할수없거 뇌발작또는 나, MRI 금 권고 뇌전증성인 기증이거나, 환자에서 M 의료진이 CT RI와 CT 모 가적절하다 두일반적으 고판단하는 영상검사에환자에서뇌처음발생한음발생한환자에서뇌는 MRI가구조적이상뇌발작으로유발되지않구조적이상첫번째선을확인하기응급실에내은뇌발작을확인하기택이며 (gra 위해 MRI가원한경우성인환자에위해 MRI가 de B), CT 시행되어야가능하면 (w 서 CT 나시행되어야는책임병변한다 (shoul hen feasibl MRI는진단한다 (shoul 191

205 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 권고 로적절 (usu ally approp riate) 하나, MRI 를 더 선호한다. 그 러나응급상 황에서는 CT 가더적절 할수있다. 상황에서, 뇌 발작환자에 서 CT 가적 응증이 될 수있다 (se condary in dication). 의검출면 에서는감도 가떨어지나 병변내석 회화가의심 되는 경우 검사추가가 유용할 수 있다 (grade C1). 그외 응급상황및 MRI 금기증 인환자에서 는 CT 가더 적절할 있다. 수 d). CT 는 M RI 를시행할 수 없거나 금기증일때 ( s hou l d), 혹은응급상 황에서시행 될수있다 (may be). e) 즉시 CT 를시행하고, 의식이명료 하고증상이 사라진경우 뇌영상을외 래에재내원 시 시행할 수있다 (Le vel B) 평가시시 행되어야한 다 B) (Level d). CT 는 M RI 를시행할 수 없거나 금기증일때 ( s hou l d ), 혹은응급상 황에서시행 될수있다 (may be). 등급지침 A : Seizures and Epilepsy (ACR) 지침 B : ACR-ASNR practice guideline for the performance of computed tomography(ct) of the brain 지침 C : 일본가이드라인지침 D : Epilepsies: diagnosis and management (NICE) 지침 E : Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizuress 지침 F : Practice parameter: Evaluating an apprent unprovoked first seizure in adults (an evidence-based review) 지침 G : The epilepsies the diagnosis and management of the epilepsies in adults and children in primary and secondary care 표 42. 신경두경부핵심질문 3 권고비교표 핵심질문 3 구분 지침 A 지침 B 지침 C 지침 D 지침 E 진주종이나종양이 의심되는 환자의 권고 중이질환진단을전정신경초종의검위해수술전검사색을목적으로하로는비조영 temp 는경우조영 MRI oral bone CT가가추천된다. 적절하며, 조영또 는비조영 head a nd internal audit 192

206 6. 부록 권고 ory canal MRI 또한도움이된다. 등급지침 A : Head Trauma (ACR) 지침 B : 일본가이드라인지침 C : Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update 지침 D : Clinical Policy: Neuro imaging and Decision making in Adult Mild Traumatic Brain Injury in the Acute Setting 지침 E : Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines 지침 F : Head injury: assessment and early management (NICE CG 176) 2) 근거표표 43. 신경두경부핵심질문 1 근거표 핵심질문 1 문헌정보연구유형대상자수문헌질 KCIG 17. Masters SJ, McClean PM, Arcarese JS, et al. Skull x-ray examinations after head trauma. Recommendatio Review/Otherns by a multidisciplinary panel and validation study. N Dx Engl J Med. 1987;316(2): Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudea u E, DeBlieux PM. Indications for computed tomograph Observationaly in patients with minor head injury. N Engl J Med. 2 Dx 000;343(2): Stiell IG, Wells GA, Vandemheen K, et al. The Can Observationaladian CT Head Rule for patients with minor head injur Dx y. Lancet. 2001;357(9266): Ashikaga R, Araki Y, Ishida O. MRI of head injury observational Dx using FLAIR. Neuroradiology 1997; 39(4): Lang DA, Hadley DM, Teasdale GM, Macpherson Review/Other D P, Teasdale E. Gadolinium DTPA enhanced magnetic re x 7, patients 1 s t phase consecuti v e patients; 2 2 n d phase consecuti v e patients 3, consecuti v e 2 patients 5 6 patients patients 2 193

207 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 sonance imaging in acute head injury. Acta Neurochir (Wien) 1991; 109(1-2): Gentry LR. Imaging of closed head injury. Radiology 1994; 191(1): Gentry LR, Godersky JC, Thompson B. MR imaging of head trauma: review of the distribution and radiopathologic features of traumatic lesions. AJR 1988; 150(3): Gentry LR, Thompson B, Godersky JC. Trauma to the corpus callosum: MR features. AJNR 1988; 9(6): Arfanakis K, Haughton VM, Carew JD, Rogers BP, Dempsey RJ, Meyerand ME. Diffusion tensor MR imaging in diffuse Dx Dx Dx 4 0 patients 78 total patients axonal injury. AJNR 2002; 23(5): controls ACR 2 7. Dunning J, Batchelor J, Stratford-Smith P, Teece S, Browne J, Sharpin C, Mackway-Jones K.A meta-analys is of variables that predict significant intracranial injury in minor head trauma.arch Dis Child Jul;89(7): Kuppermann N, Holmes JF, Dayan PS, Hoyle JD J r, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanl ey RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jac obs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melvil le KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN).Identification of children a t very low risk of clinically-important brain injuries afte r head trauma: a prospective cohort study.lancet Oct 3;374(9696): doi: /S (09) Epub 2009 Sep Osmond MH1, Klassen TP, Wells GA, Correll R, Jar vis A, Joubert G, Bailey B, Chauvin-Kimoff L, Pusic M, Dx Review/Other- Observational- Observational- Observational- Review/Other- Dx observational Dx observational Dx 5 patients; children (derivatio n and validation populatio ns: 8502 and 2216 younger than 2 y e a r s, and and aged 2 y e a r s a n d older) patients

208 6. 부록 McConnell D, Nijssen-Jordan C, Silver N, Taylor B, Sti ell IG; Pediatric Emergency Research Canada (PERC) H ead Injury Study Group.CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury.cmaj Mar 9;182(4): doi: /cmaj Epub 2010 Feb 8. Johan Undén. Tor Ingebrigtsen and Bertil Romner, for the Scandinavian Neurotrauma Committee (SNCScandin avian guidelines for initial management of minimal, mild and moderate head injuries in adults: guideline 1 an evidence and consensus-based update American College of Emergency Physiciansc guideline 1 NICE guidline: head injury guideline 1 표 44. 신경두경부핵심질문 2 근거표 핵심질문 2 문헌정보연구유형대상자수문헌질 KCIG Harden CL, Huff JS, Schwartz TH, et al. Reassessmen t: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the 1 5 Review Therapeutics and Technology Assessment studies 2 Subcommittee of the American Academy of Neurology. Neurology. 2007;69(18): Jagoda A, Gupta K. The emergency department evalua tion of the adult patient who presents with a first-tim e seizure. Emerg Med Clin North Am. 2011;29(1):41-4 Expert opinion 5 9. Pugh MJ, Berlowitz DR, Montouris G, et al. What cons titutes high quality of care for adults with epilepsy? N Review 2 eurology. 2007;69(21): Krumholz A, Wiebe S, Gronseth G, et al. Practice Para meter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Qu ality Standards Subcommittee of the American Academ Review 7 studies 2 y of Neurology and the American Epilepsy Society. Ne urology. 2007;69(21): King MA, Newton MR, Jackson GD, et al. Epileptology of the first-seizure presentation: a clinical, electroence phalographic, and magnetic resonance imaging study of Observational

209 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 300 consecutive patients. Lancet. 1998;352(9133): Clinical policy: Critical issues in the evaluation and ma nagement of adult patients presenting to the emergen cy department with seizures. Ann Emerg Med. 2004;4 3(5): Earnest MP, Feldman H, Marx JA, Harris JA, Biletch M, Sullivan LP. Intracranial lesions shown by CT scans in 259 cases of first alcohol-related seizures. Neurolog y. 1988;38(10): Mower WR, Biros MH, Talan DA, Moran GJ, Ong S. S elective tomographic imaging of patients with newonse t seizure disorders. Acad Emerg Med. 2002;9(1): Schoenenberger RA, Heim SM. Indication for compute dtomography of the brain in patients with first uncomp licated generalised seizure. BMJ. 1994;309(6960): Sempere AP, Villaverde FJ, Martinez-Menendez B, Cab eza C, Pena P, Tejerina JA. First seizure in adults: a p rospective study from the emergency department. Acta Neurol Scand. 1992;86(2): Hauser WA, Annegers JF, Kurland LT. Incidence of epi lepsy and unprovoked seizures in Rochester, Minnesota: Epilepsia. 1993;34(3): Review (guidelin e) 5 studies 1 Observational Observational Observational Observational 98 2 Observational 2 표 45. 신경두경부핵심질문 3 근거표 핵심질문 3 문헌정보연구유형대상자수문헌질 ACR Appropriateness Criteria; hearing loss and/or verti go ACR Appropriateness Criteria; hearing loss and/or verti go Fortnum H et al: The role of magnetic resonance imag ing in the identification of suspected acoustic neurom a: a systematic review of clinical and cost-effectivenes s and natural history. Health Technology Assessment 1 3:1-154, 2009 Newton JR et al: Magnetic resonance imaging screenin g in acoustic neuroma, Am J Otolaryngol 31: , 1 3 KCIG 196

210 6. 부록 2010 Annesely-Williams DJ et al: Magnetic resonance imagi ng in the investigation of sensorineural hearing loss:is contrast enhancement still necessary? J Laryngol Otol 115: Schmalbrock P et al: Assessment of internal auditory c anal tumors: a comparison of contrast-enhanced T1-w eighted and steadystate T2-weighted gradient echo M R imaging. AJNR 20: , 1999 Naganawa S et al: MR imaging of the inner ear: comp arison of a three-dimensional fast spin-echo sequence with use of a dedicated quadrature-surface coil with g adolinium-enhanced spoiled gradient-recalled sequenc e. Radiology 208: , 1998 Hermans R et al: MRI screening for acoustic neuroma without gadolinium: value of 3DFT-CISS sequence. Ne uroradiology 39: ,

211 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.2. 갑상선분과 가. 핵심질문선정 1) PICO의선정표 46. 갑상선 PICO 선정 Population Intervention Comparator Outcome 1 갑상선결절의심환자 US 조영증강 CT, 갑상선결절진단, MRI, PET-CT 분류의정확성 2 갑상선결절환자 US-guided FNA 갑상선결절의진단 O p e r a t i o n, 정확성및미확정 blind FNA 결절의감소 2) 문장형핵심질문표 47. 갑상선문장형핵심질문핵심질문 핵심질문 1 갑상선결절이의심되는환자에서진단을위한일차검사로적절한영상검사는무엇인가? 핵심질문 2 갑상선결절의적절한조직검사방법은무엇인가? 나. 핵심질문별진료지침검색 1) 핵심질문 1 검색대상핵심질문 KQ 1. 갑상선결절이의심되는환자에서진단을위한일차적인영상검사는무엇인가? 국내 DB 검색전략및결과 표 48. 갑상선국내문헌 DB 검색일 : 검색사이트 N 검색어관련문헌비고 1 thyroid [ALL] nodule [ALL] 2 1. KoreaMed 2 thyroid [ALL] cancer [ALL] 1 3 소계 2 4 단순중복제거후 2 198

212 6. 부록 검색일 : 검색사이트 N 검색어 관련문헌 비고 1 ([ALL=thyroid nodule] AND [ALL=guideline]) 8 2 ([ALL=thyroid nodule] AND [ALL=recommendation]) 6 3 ([ALL=thyroid cancer] AND [ALL=guideline]) 9 4 ([ALL=thyroid cancer] AND [ALL=recommendation]) 6 5 ([ALL= 갑상선결절 ] AND [ALL= 지침 ]) 1 6 ([ALL= 갑상선결절 ] AND [ALL= 지침 ]) 1 2. KMBASE 7 ([ALL= 갑상선결절 ] AND [ALL= 권고 ]) 3 8 ([ALL= 갑상선결절 ] AND [ALL= 권고 ]) 7 9 ([ALL= 갑상선암 ] AND [ALL= 지침 ]) 1 10 ([ALL= 갑상선암 ] AND [ALL= 지침 ]) 0 11 ([ALL= 갑상선암 ] AND [ALL= 권고 ]) 3 12 ([ALL= 갑상선암 ] AND [ALL= 권고 ]) 0 13 소계 단순중복제거후 9 표 49. 갑상선국내진료지침 DB 검색사이트 N 지침제목 연도 개발학회 1. KGC 1 없음 2 소계 ( 0건 ) 2. KoMGI 1 없음 2 소계 ( 0건 ) 국외DB 검색전략및결과 표 50. 갑상선국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 1 exp Thyroid Nodule/ 3,857 P 2 exp Thyroid Neoplasms/ 40,969 3 exp Thyroid Diseases/ 125,280 4 OR/ ,280 5 exp Ultrasonography/ or Ultrasonography.mp. 15,616 6 exp Tomography, X-Ray Computed/ or CT.mp. 410,553 I 7 exp Magnetic Resonance Imaging/ or MRI.mp. 371,708 8 exp Positron-Emission Tomography/ 36,930 9 OR/ ,

213 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 구분 N 검색어검색결과 filter 10 guideline.pt. 15, practice guideline.pt. 20, guideline$.ti. 49, recommendation$.ti. 24, standard$.ti. 66, OR/ , AND 9 AND 연도 17 limit 16 to yr="2000 -Current" 53 종합 표 51. 갑상선국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 1 exp Thyroid Nodule/ 7,116 P 2 exp Thyroid Neoplasms/ 43,356 3 exp Thyroid Diseases/ 110,868 4 OR/ ,868 5 exp Ultrasonography/ or Ultrasonography.mp. 477,474 6 exp Tomography, X-Ray Computed/ or CT.mp. 671,901 I 7 exp Magnetic Resonance Imaging/ or MRI.mp. 586,090 8 exp Positron-Emission Tomography/ 86,409 9 OR/5-8 1,470, guideline$.ti. 59,222 filter 11 recommendation$.ti. 26, OR/ , AND 9 AND 연도 14 limit 13 to yr="2000 -Current" 182 종합 표 52. 갑상선국외 GIN 검색일 : N 검색어 검색결과 1 thyroid( 제한 : ( 언어 ) 영어, ( 출판형태 ) : Guideline) 2 2 단순중복제거후 2 표 53. 갑상선국외 NGC 검색일 : N 검색어검색결과 200

214 6. 부록 검색일 : N 검색어 검색결과 1 Keyword: thyroid nodule 12 2 Keyword: thyroid cancer Guideline Category: Diagnosis 41 3 Keyword: thyroid disease Guideline Category: Diagnosis, Screening 104 2) 핵심질문 2 검색대상핵심질문 KQ 2. 갑상선결절의적절한조직검사방법은무엇인가? 국내 DB 검색전략및결과 표 54. 갑상선국내문헌 DB 검색일 : 검색사이트 N 검색어 관련문헌 1 thyroid [ALL] nodule [ALL] 2 비고 1. KoreaMed 2. KMBASE 2 thyroid [ALL] cancer [ALL] 1 3 소계 2 4 단순중복제거후 2 1 ([ALL=thyroid nodule] AND [ALL=guideline]) 8 2 ([ALL=thyroid nodule] AND [ALL=recommendation]) 6 3 ([ALL=thyroid cancer] AND [ALL=guideline]) 9 4 ([ALL=thyroid cancer] AND [ALL=recommendation]) 6 5 ([ALL= 갑상선결절 ] AND [ALL= 지침 ]) 1 6 ([ALL= 갑상선결절 ] AND [ALL= 지침 ]) 1 7 ([ALL= 갑상선결절 ] AND [ALL= 권고 ]) 3 8 ([ALL= 갑상선결절 ] AND [ALL= 권고 ]) 7 9 ([ALL= 갑상선암 ] AND [ALL= 지침 ]) 1 10 ([ALL= 갑상선암 ] AND [ALL= 지침 ]) 0 11 ([ALL= 갑상선암 ] AND [ALL= 권고 ]) 3 12 ([ALL= 갑상선암 ] AND [ALL= 권고 ]) 0 13 소계 단순중복제거후 9 201

215 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 55. 갑상선국내진료지침 DB 검색사이트 N 지침제목 연도 개발학회 1. KGC 1 없음 2 소계 ( 0건 ) 2. KoMGI 1 없음 2 소계 ( 0건 ) 국외 DB 검색전략및결과 표 56. 갑상선국외 Ovid-Medline 검색일 : 구분 N 검색어검색결과 1 exp Thyroid Nodule/ 3,857 P 2 exp Thyroid Neoplasms/ 40,969 3 exp Thyroid Diseases/ 125,280 4 OR/ ,280 5 exp Biopsy, Needle/ 55,370 I 6 exp Biopsy, Fine-Needle/ 10,544 7 exp Image-Guided Biopsy/ 1,482 8 OR/5-7 55,792 9 guideline.pt. 15, practice guideline.pt. 20, guideline$.ti. 49,759 filter 12 recommendation$.ti. 24, standard$.ti. 66, OR/ , AND 8 AND 연도 16 limit 15 to yr="2000 -Current" 61 종합 표 57. 갑상선국외 Ovid-Embase 검색일 : P I 구분 N 검색어검색결과 1 exp Thyroid Nodule/ 7,116 2 exp Thyroid Neoplasms/ 43,356 3 exp Thyroid Diseases/ 110,868 4 OR/ ,868 5 exp Biopsy, Needle/ exp Biopsy, Fine-Needle/ 10,133 7 exp Image-Guided Biopsy/ 2,960 8 OR/5-7 11,

216 6. 부록 검색일 : 구분 N 검색어검색결과 9 guideline$.ti. 59,222 filter 10 recommendation$.ti. 26, OR/ , AND 8 AND 연도 13 limit 10 to yr="2000 -Current" 29 종합 표 58. 갑상선국외 GIN 검색일 : N 검색어 검색결과 1 thyroid( 제한 : ( 언어 ) 영어, ( 출판형태 ) : Guideline) 2 단순중복제거후 2 표 59. 갑상선국외 NGC 검색일 : N 검색어 검색결과 1 Keyword: thyroid nodule 12 2 Keyword: thyroid cancer Guideline Category: Diagnosis 41 3 Keyword: thyroid disease Guideline Category: Diagnosis, Screening

217 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 다. 진료지침선별 1) 핵심질문 1 흐름도 그림 17 갑상선핵심질문 1 흐름도 2) 핵심질문 2 흐름도 그림 18 갑상선핵심질문 2 흐름도 204

218 6. 부록 라. 진료지침평가 1) 진료지침질평가결과표 60. 갑상선핵심질문1 질평가결과 핵심질문 1 지침제목 AGREE점수 개발위원회의견 AIUM practice guideline for the performance of ultrasound exam inations of the Head and Neck 36 추천안함 AIUM Practice Guideline for the performance of a Thyroid and P arathyroid Ultrasound Examination 36 추천안함 Ultrasonography and the Ultrasound-Based Management of Thyroid Nodules: Consensus Statement and Recommendations 41 추천안함 British Thyroid Association Guidelines for the Management of Th yroid Cancer 84 추천함 Medullary carcinoma: Clinical practice guidelines in oncology TM 74 추천함 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer 63 추천함 AACE/AME/ETA medical guidelines for clinical practice for the diagnosis and management of thyroid nodules 69 추천함 Guidelines of the American Thyroid Association for the Diagnosi s and Management of Thyroid Disease During Pregnancy and P 63 추천함 ostpartum Thyroid carcinoma, version (NCCN guideline) 74 추천함 추천안함 : AGREE II < 50 표 61. 갑상선핵심질문 2 질평가결과 핵심질문 2 지침제목 AGREE 점수개발위원회의견 Ultrasonography and the Ultrasound-Based Management of Thyr oid Nodules: Consensus Statement and Recommendations Guidelines of the American Thyroid Association for the Diagnosi s and Management of Thyroid Disease During Pregnancy and P ostpartum 41 추천안함 63 추천함 Thyroid carcinoma, version (NCCN guideline) 74 추천함 205

219 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2) 수용성과적용성평가결과 표 62. 갑상선핵심질문 1 수용성과적용성평가결과 핵심질문 1 구지침지침지침지침지침지침지침지침평가항목분 A B C D E F G H 수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예아니오아니오아니오아니오가치와선호도가유사하다. 예예예예예용권고로인한이득은유사하다. 예예예예예성해당권고는수용할만하다. 예불확실예예예적해당중재및장비는이용가능하다. 예예예예예필수적인전문기술이이용가능하다. 예예예예예용법률적 / 제도적장벽이없다. 예예예예예성해당권고는적용할만하다. 예불확실예예예지침 A : (2013) AIUM practice guideline for the performance of ultrasound examinations of the Head and Neck / AIUM Practice Guideline for the performance of a Thyroid and Parathyroid Ultrasound Examination 지침 B : (2011) Ultrasonography and the Ultrasound-Based Management of Thyroid Nodules: Consensus Statement and Recommendations 지침 C : (2014) British Thyroid Association Guidelines for the Management of Thyroid Cancer 지침 D : (2010) Medullary carcinoma: Clinical practice guidelines in oncology TM 지침 E : (2015) American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer 지침 F : (2010) AACE/AME/ETA medical guidelines for clinical practice for the diagnosis and management of thyroid nodules 지침 G : (2011) Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum 지침 H : (2015) Thyroid carcinoma, version (NCCN guideline) 표 63. 갑상선핵심질문 2 수용성과적용성평가결과 핵심질문 2 구지침지침지침지침지침지침지침지침평가항목분 A B C D E F G H 수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예아니오아니오아니오아니오가치와선호도가유사하다. 예예예예예용권고로인한이득은유사하다. 예예예예예성해당권고는수용할만하다. 예예예예예적해당중재및장비는이용가능하다. 예예예예예필수적인전문기술이이용가능하다. 예예예예예용법률적 / 제도적장벽이없다. 예예예예예성해당권고는적용할만하다. 예예예예예지침 A : (2013) AIUM practice guideline for the performance of ultrasound examinations of the Head and Neck / AIUM Practice Guideline for the performance of a Thyroid and Parathyroid 206

220 6. 부록 Ultrasound Examination 지침 B : (2011) Ultrasonography and the Ultrasound-Based Management of Thyroid Nodules: Consensus Statement and Recommendations 지침 C : (2014) British Thyroid Association Guidelines for the Management of Thyroid Cancer 지침 D : (2010) Medullary carcinoma: Clinical practice guidelines in oncology TM 지침 E : (2015) American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer 지침 F : (2010) AACE/AME/ETA medical guidelines for clinical practice for the diagnosis and management of thyroid nodules 지침 G : (2011) Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum 지침 H : (2015) Thyroid carcinoma, version (NCCN guideline) 마. 핵심질문별권고및근거정리 1) 권고비교표 표 64. 갑상선핵심질문1 권고비교표 핵심질문 1 구 분 지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 지침 G 지침 H Among t US is an Thyroid s US evalu he mode extremel onograph ation is r rn imagin y sensitiv y with s ecomme g modalit e examin urvey of nded for 권고 ies, high ation for the cervi (Grade B; For thyroi -resolutio thyroid n cal lymp BEL 3): d nodule n US is t odules. It h nodes o Patient s known he most can be s should b s at risk or suspe sensitive pecific fo e perfor for thyroi cted on diagnosti r the dia med in a d malign clinical or c odality gnosis of ll patient ancy o P imaging f for the d thyroid c s with k atients w indings, etection arcinoma nown or ith palpa US reco of the th (particular suspecte ble thyroi mmende yroid nod ly papillar d thyroid d nodule d categor ules and y carcino nodules. s or MN y 2A it is nec ma), and (Strong r Gs o Pati essary to aids deci ecomme ents with perform sion maki ndation, lymphade US for th ng about High-qua nopathy e nodule which no lity evide suggestiv 207

221 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 dules to perform FNAC. i. All patien ts being s found investigat ed for p ossible t hyroid ca ncer sho e of a m after palp ation uld under go an U S of the neck in s econdary nce) alignant l esion care by an appro priate, co mpetent practition er. S t r o n g recomme G o o d 권고 ndation, Grade B, category 없음 practice 등급 High-qua BEL 3 2A Point l i t y evidence 지침 A : (2013) AIUM practice guideline for the performance of ultrasound examinations of the Head and Neck / AIUM Practice Guideline for the performance of a Thyroid and Parathyroid Ultrasound Examination 지침 B : (2011) Ultrasonography and the Ultrasound-Based Management of Thyroid Nodules: Consensus Statement and Recommendations 지침 C : (2014) British Thyroid Association Guidelines for the Management of Thyroid Cancer 지침 D : (2010) Medullary carcinoma: Clinical practice guidelines in oncology TM 지침 E : (2015) American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer 지침 F : (2010) AACE/AME/ETA medical guidelines for clinical practice for the diagnosis and management of thyroid nodules 지침 G : (2011) Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum 지침 H : (2015) Thyroid carcinoma, version (NCCN guideline) 208

222 6. 부록 표 65. 갑상선핵심질문 2 권고비교표 핵심질문 2 구분권고 지침 A 지침 B Figur e 8. 지침 C i. US appeara nces that are indicative of a benign nod ule (U1-2) sh ould be regar ded as reass uring not req uiring fi ne n eedle aspirat ion cytology (FNAC), unles s the patient has a statistic ally high risk of malignancy (Chapter 3.7) (2++, B). ii. If the US appearances are equivocal, indeterminate or suspicious of malignancy (U3-5), an U S guided FNA C should follo w (2++, B). 지침 D 지침 E (a) FNA i s the pr ocedure of choice in the ev aluation of thyroi d nodule s, when clinically indicated (Strong r ecomme ndation, High-qua lity evide nce) 지침 F How to Select Nodule(s) for FNA Bio psy (Grade B; BEL 3): FNA biopsy is reco mmended for nodule (s): o Of diameter larger t han 1.0 cm that is sol id and hypoechoic on US o Of any size with U S findings suggestive of extracapsular growt h or metastatic cervic al lymph nodes o Of any size with pa tient history of neck ir radiation in childhood or adolescence; PTC, MTC, or MEN 2 in fir st-degree relatives; pr evious thyroid surgery for cancer; increased calcitonin levels in the absence of interfering factors o Of diameter smaller than 10 mm along wit h US findings associat ed with malignancy (s ee section ); t he coexistence of 2 o r more suspicious US criteria greatly increas es the risk of thyroid 지침 G 지침 H FNA i ndicat ions있음. Ca tegory 2A 209

223 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 cancer Nodules that are ho t on scintigraphy shou ld be excluded from F NA biopsy (see differe nce in recommendatio ns for children; sectio n 8.4.) FNA Biopsy of Multinodular Glands It is rarely necessar y to biopsy more than 2 nodules when they are selected on the b asis of previously des cribed criteria (Grade D) If a radioisotope sca n is available, do not biopsy hot areas (Gra de B; BEL 4) In the presence of suspicious cervical ly mphadenopathy, FNA biopsy of both the ly mph node and suspici ous nodule(s) is essen tial (Grade B; BEL 4) FNA Biopsy o f Complex (Solid-Cysti c) Thyroid Nodule(s) Always sample the solid component of th e lesion by UGFNA bi opsy (Grade B; BEL 4) Submit both the FN A biopsy specimen an d the drained fluid for cytologic examination (Grade B; BEL 4) 210

224 6. 부록 FNA Biopsy o f Thyroid Incidentalom as Thyroid incidentalom as should be manage d according to previou sly described criteria f or nodule diagnosis (G rade C; BEL 3) Incidentalomas dete cted by CT or MRI sh ould undergo US eval uation before consider ation for UGFNA biops y (Grade C; BEL 3) Incidentalomas dete cted by positron emis sion tomography with 18F-fluorodeoxyglucos e should undergo US evaluation plus UGFN A biopsy because of t he high risk of malign ancy (Grade C; BEL 3) GradeB ; BEL 3 Strong re Grade D, Gra commen de B; BEL 4, Grade Categ 권고 dation, H (2++, B). B; BEL 4 ory 2 등급 igh-qualit Grade B; BEL A y eviden 4 ce Grade C; BEL 3 지침 A : (2013) AIUM practice guideline for the performance of ultrasound examinations of the Head and Neck / AIUM Practice Guideline for the performance of a Thyroid and Parathyroid Ultrasound Examination 지침 B : (2011) Ultrasonography and the Ultrasound-Based Management of Thyroid Nodules: Consensus Statement and Recommendations 지침 C : (2014) British Thyroid Association Guidelines for the Management of Thyroid Cancer 지침 D : (2010) Medullary carcinoma: Clinical practice guidelines in oncology TM 211

225 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 지침 E : (2015) American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer 지침 F : (2010) AACE/AME/ETA medical guidelines for clinical practice for the diagnosis and management of thyroid nodules 지침 G : (2011) Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum 지침 H : (2015) Thyroid carcinoma, version (NCCN guideline) 2) 근거표표 66. 갑상선핵심질문1 근거표 핵심질문 1 문헌정보연구유형대상자수문헌질 KCIG American Thyroid Association (ATA) Guidelines Taskforc e on Thyroid Nodules and Differentiated Thyroid Cance r, Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, et al. Revised American Thyroid Association manag Guideline N/A 5 ement guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19: Frates, M.C., Benson, C.B. & Charbonneau, J.W. (200 5) Management of thyroid nodules detected at US: soc C o n s e n s u s iety of radiologists in ultrasound consensus statement. statement N/A 5 Radiology, 237, Hambly, N.M., Gonen, M. & Gerst, S.R. (2011) Implem entation of Evidence-based guidelines for thyroid nodul e biopsy: a model for establishment of practice standa retrospective rds. American Journal of Roentgenology, 196, Brito JP, Gionfriddo MR, Al NA, Boehmer KR, Leppin AL, Reading C, Callstrom M, Elraiyah TA, Prokop LJ, S s y s t e m a t i c tan MN, Murad MH, Morris JC, Montori VM 2014 The r e v i e w, accuracy of thyroid nodule ultrasound to predict thyroid metaanalysis cancer: systematic review and meta-analysis. J Clin E N/A 2 ndocrinol Metab 99: Solbiati L, Osti V, Cova L, Tonolini M. Ultrasound of th yroid, parathyroid glands and neck lymph nodes. Eur R recommendation N/A 5 adiol. 2001;11: [EL 4 review] (2015) Thyroid carcinoma, version (NCCN guidel ine) recommendation N/A 5 212

226 6. 부록 표 67. 갑상선핵심질문2 근거표 핵심질문 2 문헌정보연구유형대상자수문헌질 KCIG Cesur, M., Corapcioglu, D., Bulut, S. et al. (2006) Comp arison of palpation guided fine needle aspiration biopsy p r o s p e c t i v e to ultrasound guided fine needle aspiration biopsy in the study evaluation of thyroid nodules. Thyroid, 16, Diagnostic accuracy of conventional versus sonographyguided fine-needle aspiration biopsy of thyroid nodules, Danese D, Sciacchitano S, Farsetti A, Andreoli M, Ponte retrospective corvi A. Thyroid 1998;8(1):15-21 Ultrasound-guided fine-needle aspiration biopsy of thyro id masses, Carmeci C, Jeffrey RB, McDougall IR, Nowel retrospective s KW, Weigel RJ. Thyroid Apr;8(4):283-9 Gharib H, Papini E. Thyroid nodules: Clinical importance, assessment, and treatment. Endocrinol Metab Clin North review N/A 5 Am. 2007;36: [EL 4 review] Wu HH, Jones JN, Osman J. Fine-needle aspiration cyt ology of the thyroid: Ten years experience in a commu retrospective nity Teaching Hospital 1997;82: [EL 3] Yang J, Schnadig V, Logrono R, Wasserman PG. Finene edle aspiration of thyroid nodules: A study of 4703 pati ents with histologic and clinical correlations. Cancer. 20 retrospective ;111: [EL 3] Danese D, Sciacchitano S, Farsetti A, Andreoli M, Ponte corvi A. Diagnostic accuracy of conventional versus son ography-guided fine-needle aspiration biopsy of thyroid retrospective nodules. Thyroid. 1998;8: Deandrea M, Mormile A, Veglio M, et al. Fine-needle a spiration biopsy of the thyroid: comparison between thyr p r o s p e c t i v e oid palpation and ultrasonography. Endocr Pract. 2002;8: study [EL 3] Can AS, Peker K. Comparison of palpation-versus ultras ound-guided fine-needle aspiration biopsies in the evalu p r o s p e c t i v e ation of thyroid nodules. BMC Res Notes. 2008;1:12. [E study L 4] Fine-needle aspiration of thyroid nodules: a study of patients with histologic and clinical correlations, Yang J, Schnadig V, Logrono R, Wasserman PG, Cancer Oct 25;111(5): retrospective

227 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.3. 흉부분과 가. 핵심질문선정 1) PICO 의선정 표 68. 흉부 PICO 선정 Population Intervention Comparator Outcome 1 Hemoptysis 진단 일회성소량객혈이처음있는성인 1-1 정확성환자임상적유효성조영증강 CT Hemoptysis 진단 1-2 단기간동안반복되는객혈이있는 Bronchoscopy 정확성성인환자임상적유효성 Hemoptysis 진단 1-3 대량객혈 (>400ml) 이있는성인 CT angiography 정확성환자임상적유효성 폐렴의증상및증후가있는경우 흉부단순촬영 비조영증강 CT Acute pneumonia 진단정확성임상적유효성 2-2 폐렴의증상및증후가없는경우 Physical examination Asthma 진단정확성 임상적유효성 2-3 심한발열, 객혈을동반하는경우 조영증강 CT 흉부단순촬영 Acute respiratory distress 의합병증진단정확성임상적유효성 2) 문장형핵심질문표 69. 흉부문장형핵심질문핵심질문 핵심질문 1 객혈이있는성인환자의원인진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-1 일회성소량객혈이처음있는성인환자의원인진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-2 단기간동안반복되는객혈이있는성인환자의원인진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-3 대량객혈이있는성인환자의원인진단을위한적절한영상검사는무엇인가? 핵심질문 2 급성호흡곤란성인환자의원인진단을위한적절한영상검사는무엇인가? 214

228 6. 부록 세부핵심질문 2-1 세부핵심질문 2-2 세부핵심질문 2-3 폐렴의증상및증후가있는급성호흡곤란성인환자의원인진단을위한적절한영상검사는무엇인가? 폐렴의증상및증후가없는급성호흡곤란성인환자의원인진단을위한적절한영상검사는무엇인가? 심한발열, 객혈을동반하는급성호흡곤란성인환자의원인진단을위한적절한영상검사는무엇인가? 나. 핵심질문별진료지침검색 1) 핵심질문 1 검색대상핵심질문 KQ 1. 객혈이있는성인환자의원인진단을위한적절한영상검사는무엇인가? 국내 DB 검색전략및결과 표 70. 흉부국내문헌 DB 검색일 : 검색사이트 N 검색어관련문헌비고 1 hemoptysis [ALL] AND guideline [ALL] 1 2 hemoptysis [ALL] AND standard [ALL] 0 1. KoreaMed 3 hemoptysis [ALL] AND CT [ALL] AND standard [ALL] 3 4 소계 4 5 단순중복제거후 4 1 ([ALL= 객혈 ] AND [ALL= 지침 ]) 1 2 ([ALL= 객혈 ] AND [ALL= 권고 ]) 0 2. KMBASE 3 ([ALL= 객혈 ] AND [ALL= 가이드라인 ]) 0 4 소계 1 5 단순중복제거후 1 표 71. 흉부국내진료지침 DB 검색사이트 N 지침제목 연도 개발학회 1. KGC 1 폐암진료지침 2010 대한폐암학회 2 소계 ( 0건 ) 215

229 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색사이 N 지침제목연도개발학회트 2. KoMGI 1 2 소계 ( 0건 ) 국외DB 검색전략및결과 표 72. 흉부국외 Ovid-Medline 검색일 : N 검색어 검색결과 P 1 hemoptysis.mp. or exp Hemoptysis/ exp Tomography, X-Ray Computed/ or computer assisted tomo graphy.mp CT.mp Comput$ Tomogr$.mp 검사 5 2 or 3 or (enhanced or contrast).mp bronchoscopy.mp. or exp Bronchoscopy/ bronchoscop$.mp and or 8 or P& 검사 11 1 and guideline$.ti practice guideline.pt 지침 14 guideline$.ti recommendation$.ti standard$.ti or 13 or 14 or 15 or and 17 4 연도 19 limit 18 to yr="2000 -Current" 4 종합 20 단순중복제거후 4 21 언어제한후 4 표 73. 흉부국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 P 1 exp hemoptysis/

230 6. 부록 검색일 : 구분 N 검색어검색결과 2 exp computer assisted tomography/ CT.mp Comput$ Tomogr$.mp or 3 or 검사 6 (enhanced or contrast).mp exp bronchoscopy/ or Bronchoscopy.mp bronchoscop$.mp and or 8 or P& 검사 11 1 and guideline$.ti recommendation$.ti 지침 14 standard$.ti or 13 or and 연도 17 limit 16 to yr="2000 -Current" 15 종합 18 단순중복제거후 언어제한후 13 표 74. 흉부국외 GIN 검색일 : N 검색어 검색결과 1 hemoptysis 2 2 Bronchoscopy 3 3 lung CT 1 단순중복제거후 6 표 75. 흉부국외 NGC 검색일 : N 검색어 검색결과 1 "hemoptysis" and "CT" 8 2 "hemoptysis"' and '"bronchoscopy"' 5 단순중복제거후관련 9 다. 진료지침선별 1) 핵심질문 1 흐름도 217

231 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 그림 19. 흉부핵심질문 1 흐름도 라. 진료지침평가 1) 진료지침질평가결과표 76. 흉부핵심질문 1 질평가결과 핵심질문 1 지침제목 AGREE점수 개발위원회의견 American College of Radiology Appropriateness Criteria : H emoptysis 69 추천 Symptom Management in Patients With Lung Cancer Diagnosis and Management of Lung Cancer, 3rd ed: Americ an College of Chest Physicians Evidence-Based Clinical Prac tice Guidelines 61 추천 218

232 6. 부록 2) 수용성과적용성평가결과표 77. 흉부핵심질문 1 수용성과적용성평가결과 핵심질문 1 구분 평가항목 지침 A 지침 B 수 인구집단 ( 유병률, 발생률등 ) 이유사하다. 아니오 가치와선호도가유사하다. 예용권고로인한이득은유사하다. 예성해당권고는수용할만하다. 예 적 해당중재및장비는이용가능하다. 예 필수적인전문기술이이용가능하다. 예용법률적 / 제도적장벽이없다. 예성해당권고는적용할만하다. 예 지침 A : American College of Radiology Appropriateness Criteria : Hemoptysis 지침 B : Symptom Management in Patients With Lung Cancer Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines 마. 핵심질문별권고및근거정리 1) 권고비교표표 78. 흉부핵심질문 1 권고비교표 핵심질문 1 구분 지침 A 지침 B ' 객혈이있는환자의일차영상검사는흉부촬영이 다. CT는폐암의위험인자가있거나흉부촬영에 권고 이상이있는경우에권고한다. 30ml 이상의객혈객혈이있는폐암환자에서출혈병소 (source) 를밝이있으며 40세이상, 30갑년이상의흡연력이히기위해 bronchoscopy 가권고된다. 있을경우CT 를권고한다. 반복적객혈이있을경 우 CTA를권고한다. 대량객혈의경우 CTA를촬 영할수있다. 권고등급 Usually appropriate(7-9) 1C 지침 A : American College of Radiology Appropriateness Criteria : Hemoptysis 지침 B : Symptom Management in Patients With Lung Cancer Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines 219

233 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2) 근거표표 79. 흉부핵심질문 1 근거표 핵심질문 1 문헌정보연구유형대상자수문헌질 KCIG Tsoumakidou M, Chrysofakis G, Tsiligianni I, Maltezakis G, Siafakas NM, Tzanakis N. A Prospective Analysis of 184 Hemoptysis Cases Diagnostic Impact of Chest X -Ray, Computed Tomography, Bronchoscopy. Respiratio n 2006;73(6): Fidan A, Ozdoğan S, Oruç O, Salepçi B, Ocal Z, Cağla yan B. Hemoptysis: a retrospective analysis of 108 cas es. Respir Med. 2002;96(9): Bruzzi JF, Remy-Jardin M, Delhaye D, Teisseire A, Kh alil C, Remy J. Multidetector row CT of hemoptysis. R adiographics. 2006; 26(1): Ketai LH, Mohammed TL, Kirsch J, et al. ACR apropria teness criteria hemoptysis. J Thorac Imaging. 2014;2 9(3):W Lee SJ, Rho JY, Yoo SM, Kim MD, Lee JH, Kim EK, Cho YA, Lee SM. Usefulness of Multi-Detector Compu ted Tomography before Bronchoscopy and/or Bronchial Arterial Embolization for Hemoptysis. Tuberc Respir Di s. 2010;68(2): Korean. Revel MP, Fournier LS, Hennebicque AS, et al. Can C T replace bronchoscopy in the detection of the site an d cause of bleeding in patients with large or massive hemoptysis? AJR Am J Roentgenol. 2002; 179(5): Delage A, Tillie-Leblond I, Cavestri B, Wallaert B, Mar quette CH. Cryptogenic hemoptysis in chronic obstructi ve pulmonary disease: characteristics and outcome. Re spiration. 2010; 80(5): Menchini L, Remy-Jardin M, Faivre JB, et al. Cryptoge nic haemoptysis in smokers: angiography and results o f embolisation in 35 patients. Eur Respir J. 2009; 34 (5): Poe RH, Israel RH, Marin MG, et al. Utility of fiberopti c bronchoscopy in patients with hemoptysis and a nonl ocalizing chest roentgenogram. Chest. 1988; 93(1): Observational ( 후향적 )_Dx Observational ( 전향적 )_Dx Review/Other- Dx N/A 2 Review/Other- Dx N/A 2 Observational ( 전향적 )_Dx Observational- Dx 80 3 Observational- Dx 39 3 Observational- Dx 35 3 Observational Dx 220

234 6. 부록 Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in patients with hemoptysis of u nknown origin. Chest. 2001; 120(5): Thirumaran M, Sundar R, Sutcliffe IM, Currie DC. Is in vestigation of patients with haemoptysis and normal ch est radiograph justified? Thorax. 2009; 64(10): McGuinness G, Beacher JR, Harkin TJ, Garay SM, Ro m WN, Naidich DP. Hemoptysis: prospective high-reso lution CT/bronchoscopic correlation. Chest. 1994; 105 (4): Millar AB, Boothroyd AE, Edwards D, Hetzel MR. The r ole of computed tomography (CT) in the investigation of unexplained haemoptysis. Respir Med. 1992; 86(1): Khalil A, Fartoukh M, Parrot A, Bazelly B, Marsault C, Carette MF. Impact of MDCT angiography on the mana gement of patients with hemoptysis. AJR Am J Roent genol. 2010; 195(3): Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB. Utility of fiberoptic bronchoscopy befor e bronchial artery embolization for massive hemoptysis. AJR Am J Roentgenol. 2001; 177(4): Review/Other- Dx Observational- Dx Observational- Dx Review/Other- Dx Observational- Dx Review/Other-D x

235 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.4. 심장분과 가. 핵심질문선정 1) PICO의선정 표 80. 심장 PICO 선정 Population Intervention Comparator Outcome 고위험군 1) F r a mi n g h a m 관상동맥 CT mortality, MACE 1-2 중등도위험군 2) Risk Score 부정맥의원인이될 2 원인이불분명한부정맥환자수있는심장질환 CT 이외비침습심장 CT 진단적검사3) 급성심장질환이없는중등도위험수술전심장질환 3 도환자위험도평가 1) 고위험군의정의 : Adult Treatment Panel III 에서 10 year risk 20% 이상, 또는 coronary heart disease risk equivalent (symptomatic carotid artery disease, peripheral artery disease, abdominal aortic aneurysm, diabetes, chronic kidney disease) 2) 중등도위험군의정의 : Adult Treatment Panel III 에서 10 year risk 10% 이상 20% 미만 3) 비침습적검사의종류 : echo, MR, SPECT, PET 2) 문장형핵심질문표 81. 심장문장형핵심질문핵심질문 핵심질문 1 세부핵심질문 1-1 세부핵심질문 1-2 관상동맥질환병력이없는무증상개인 (individual) 에서관상동맥질환의발견과위험도평가를위한적절한영상검사는무엇인가? 관상동맥질환병력이없는고위험무증상환자에서관상동맥질환의발견과위험도평가를위한적절한영상검사는무엇인가? 관상동맥질환병력이없는중증도위험무증상환자에서관상동맥질환의발견과위험도평가를위한적절한영상검사는무엇인가? 핵심질문 2 원인이불분명한부정맥환자에게심장질환의발견을위한적절한영상검사는무엇인가? 핵심질문 3 급성심장질환이없는중등위험도환자에서비심장수술전관상동맥질환의위험도평가 를위한적절한영상검사는무엇인가? 222

236 6. 부록 나. 핵심질문별진료지침검색 1) 핵심질문 1/ 핵심질문3 검색대상핵심질문 KQ 1. 관상동맥질환병력이없는무증상개인 (individual) 에서관상동맥질환의발견과위험도평가를위한적절할영상검사는무엇인가? KQ 3. 급성심잘질환이없는중등위험도환자에게비심장수술전관상동맥질환의위험도평가를위한적절한영상검사는무엇인가? 국내DB 검색전략및결과 표 82. 심장국내문헌DB 검색일 : 검색사이트 N 검색어 관련문헌 비고 1 coronary [ALL] AND asymptomatic [ALL] AND guideline [ALL] 2 2 cardiac [ALL] AND ct [ALL] AND guideline [ALL] 3 1. cardiac [ALL] AND 'risk assessment' [ALL] AND KoreaMed 3 guideline [ALL] 2 4 소계 7 5 단순중복제거후 7 1 (([ALL= 관상동맥 ] AND [ALL=CT]) AND [ALL= 지침 ]) 1 2. KMBASE 2 (([ALL= 관상동맥 ] AND [ALL=CT]) AND [ALL= 권고 ]) 0 3 (([ALL= 관상동맥 ] AND [ALL=CT]) AND [ALL= 가이드라인 ]) 0 4 소계 1 5 단순중복제거후 1 표 83. 심장국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 223

237 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 국외 DB 검색전략및결과 Ovid- Medline 표 84. 심장국외 Ovid-Medline 검색일 : 구분 N 검색어검색결과 1 exp Asymptomatic Diseases/ or asymptomatic.mp coronary.mp. or exp Coronary Vessel Anomalies/ or exp Acute 2 Coronary Syndrome/ or exp Coronary Artery Disease/ or exp C P oronary Disease/ or exp Coronary Vessels/ 3 1 and coronary artery disease.mp. or exp Coronary Artery Disease/ or tomography.mp. or exp Tomography, X-Ray Computed/ Comput$ Tomogr$.mp coronary CT.mp 검사 9 coronary artery CT.mp cardiac CT.mp exp Risk Assessment/ or framingham.mp or 7 or 8 or 9 or 10 or P& 검사 13 5 and guideline.pt practice guideline.pt 지침 16 guideline$.ti recommendation$.ti or 15 or 16 or 17 or and 연도 20 limit 19 to yr="2000 -Current" 175 종합 21 단순중복제거후 언어제한후 162 표 85. 심장국외 Ovid-Embase 검색일 : P 구분 N 검색어검색결과 1 exp asymptomatic disease/ or asymptomatic.mp exp coronary vein/ or exp coronary artery/ or exp coronary blo 2 od vessel/ or exp coronary artery anomaly/ or coronary.mp. or exp coronary artery disease/ 3 1 and coronary artery disease.mp. or exp coronary artery disease/ or

238 6. 부록 검색일 : 구분 N 검색어검색결과 6 exp computer assisted tomography/ or tomography.mp Comput$ Tomogr$.mp coronary CT.mp 검사 9 coronary artery CT.mp cardiac CT.mp framingham risk.mp. or exp Framingham risk score/ or 7 or 8 or 9 or 10 or P& 검사 13 5 and guideline$.ti 지침 15 recommendation$.ti or and 연도 18 limit 17 to yr="2000 -Current" 199 종합 19 단순중복제거후 언어제한후 181 표 86. 심장국외 GIN 검색일 : N 검색어 검색결과 1 cardiac disease 2 2 coronary artery 4 3 coronary artery disease 3 4 coronary CT 0 5 cardiac CT 0 6 framingham 0 7 heart risk assessment 2 8 단순중복제거후 8 표 87. 심장국외 NGC 검색일 : N 검색어 검색결과 1 coronary disease 7 2 coronary CT 10 3 framingham risk assessment 2 4 단순중복제거후관련 17 2) 핵심질문 2 225

239 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색대상핵심질문 KQ 2. 원인이불분명한부정맥환자에게심장질환의발견을위한적절한검사는무엇인가? 국내DB 검색전략및결과 표 88. 심장국내문헌DB 검색일 : 검색사이트 N 검색어 관련문헌 비고 1 arrhythmia [ALL] AND CT [ALL] AND guideline [ALL] 0 1. KoreaMed 2 arrhythmia [ALL] AND guideline [ALL] 2 3 소계 2 4 단순중복제거후 2 1 ([ALL= 부정맥 ] AND [ALL= 지침 ]) 4 2. KMBASE 2 ([ALL= 부정맥 ] AND [ALL= 권고 ]) 1 3 ([ALL= 부정맥 ] AND [ALL= 가이드라인 ]) 0 4 소계 5 5 단순중복제거후 5 표 89. 심장국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 국외DB 검색전략및결과표 90. 심장국외 Ovid-Medline 검색일 : 구분K N 검색어검색결과 Q2 P 1 arrhythmia.mp. or exp Arrhythmias, Cardiac/

240 6. 부록 검색일 : 구분K Q2 N 검색어 검색결과 2 diagnostic test.mp. or exp Diagnostic Tests, Routine/ 검사 3 exp Diagnostic Imaging/ or diagnostic.mp or P& 검사 5 1 and guideline.pt practice guideline.pt 지침 8 guideline$.ti recommendation$.ti or 7 or 8 or and 연도 12 limit 11 to yr="2000 -Current" 68 종합 13 단순중복제거후 언어제한후 55 표 91. 심장국외 Ovid-Embase 검색일 : 구분K Q2 N 검색어 검색결과 P 1 arrhythmia.mp. or exp heart arrhythmia/ 검사 2 diagnostic test.mp. or exp diagnostic test/ P& 검사 3 1 and guideline$.ti 지침 5 recommendation$.ti or and 연도 8 limit 7 to yr="2000 -Current" 291 종합 9 단순중복제거후 언어제한후 260 표 92. 심장국외 GIN 검색일 : N 검색어 검색결과 1 arrhythmia 8 2 단순중복제거후 8 227

241 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 93. 심장국외 NGC 검색일 : N 검색어 검색결과 1 'arrhythmia' and 'diagnostic' 단순중복제거후관련 9 다. 진료지침선별 1) 핵심질문 1 / 핵심질문 3 흐름도 그림 20. 심장핵심질문 1, 3 흐름도. 228

242 6. 부록 2) 핵심질문 2 흐름도 그림 21. 심장핵심질문 2 흐름도. 라. 진료지침평가 1) 진료지침질평가결과 표 94. 심장핵심질문 1 / 핵심질문 3 질평가결과 핵심질문 1 / 핵심질문 3 지침제목 AGREE 점수개발위원회의견 SCCT guidelines for performance of coronary computed tom ographic angiography: A report of the Society of Cardiovasc 31 추천함 ( 수정필요 ) ular Computed Tomography Guidelines Committee Korean guidelines for the appropriate use of cardiac CT 73 추천함 ACC/AHA 2007 Guidelines on Perioperative Cardiovascular E valuation and Care for American College of Cardiology/American Noncardiac Surgery: A Report of the Heart Association Task Force on Practice Guidelines (Writing Committee to Re vise the 2002 Guidelines on Perioperative Cardiovascular Eval uation for Noncardiac Surgery). (...) 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults 42 추천함 62 추천함 229

243 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert conse nsus document on coronary computed tomographic angiograp hy: a report of the American College of Cardiology Foundati 40 추천함 on Task Force on Expert Consensus Documents ACR Appropriateness Criteria asymptomatic patient at r isk for coronary artery disease 69 추천함 Guideline for Appropriate Use of Cardiac CT in Heart Diseas e 73 추천안함 * * 2015_ 대한영상의학회 Cardiac CT와동일한내용으로판단하여추천하지않음 표 95. 심장핵심질문 2 질평가결과 핵심질문 2 지침제목 AGREE 점수개발위원회의견 2014 Korean guidelines for appropriate utilization of cardiova scular magnetic resonance imaging: A joint report of the Ko rean society of cardiology and the Korean society of radiolo gy ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. A Report of the American College of Cardiol ogy/american Heart Association Task Force and the Europea n Society of Cardiology Committee for Practice Guidelines EHRA/HRS/APHRS expert consensus on ventricular arrhyth mias 2012 HRS/EHRA/ECAS expert consensus statement on cath eter and surgical ablation of atrial fibrillation: recommendatio ns for patient selection, procedural techniques, patient mana gement and follow-up, definitions, endpoints, and research trial design ASCI 2010 appropriateness criteria for cardiac magnetic reso nance imaging: a report of the Asian Society of Cardiovascu lar Imaging cardiac computed tomography and cardiac magn etic resonance imaging guideline working group 69 추천함 44 추천안함 38 추천안함 38 추천안함 33 추천안함 230

244 6. 부록 2) 수용성과적용성평가결과 표 96. 심장핵심질문 1 / 핵심질문 3 수용성과적용성평가결과 핵심질문 1 구 분 수 용 성 적 용 성 평가항목 지침지침지침지침지침 A B C D E 지침 F 인구집단 ( 유병률, 발생률등 ) 이유사하다. 예 예 예 가치와선호도가유사하다. 예 예 예 권고로인한이득은유사하다. 예 예 예 해당권고는수용할만하다. 예 예 예 해당중재및장비는이용가능하다. 예 예 예 필수적인전문기술이이용가능하다. 예 예 예 법률적 / 제도적장벽이없다. 예 예 예 해당권고는적용할만하다. 예 예 예 지침 A : 2009_SSCT 지침 B : 2015_ 대영회 _cardiac CT 지침 C : 2007_ACC/AHA_noncardiac surgery 지침 D : 2010_ACCF/AHA_asymptomatic 지침 E : 2010_ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT_ 관상동맥 CT 지침 F : 2013_ACR_Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease 표 97. 심장핵심질문 2 수용성과적용성평가결과 핵심질문 2 구 분 수 용 성 적 용 성 평가항목지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 인구집단 ( 유병률, 발생률등 ) 이유사하다. 예 예 예 예 예 예 가치와선호도가유사하다. 예 예 예 예 예 예 권고로인한이득은유사하다. 예 예 예 예 예 예 해당권고는수용할만하다. 예 예 예 예 예 예 해당중재및장비는이용가능하다. 예 예 예 예 예 예 필수적인전문기술이이용가능하다. 예 예 예 예 예 예 법률적 / 제도적장벽이없다. 예 예 예 예 예 예 해당권고는적용할만하다. 예 예 예 예 예 예 지침 A : 2014 Korean guideline - cardiac MRI 지침 B : 2015_ 대영회 _cardiac CT 지침 C : 2010 ASCI - cardiac MRI 지침 D : 2012 HRS/EHRA/ECAS expert consensus statement - atrial fibrillation 지침 E : 2006 ACC/AHA/ESC guideline -ventricular arrhythmias 지침 F : 2014 EHRA/HRS/APHRS expert consensus - ventricular arrhythmias 231

245 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 98. 심장핵심질문 3 수용성과적용성평가결과 핵심질문 3 지지지지지지지지구평가항목침침침침침침침침분 A B C D E F G H 수 인구집단 ( 유병률, 발생률등 ) 이유사하다. 불확불확불확불확불확불확예예실실실실실실 용 가치와선호도가유사하다. 예 예 예 예 예 예 예 예 성 권고로인한이득은유사하다. 예 예 예 예 예 예 예 예 해당권고는수용할만하다. 예 예 예 예 예 예 예 예 해당중재및장비는이용가능하다. 예 예 예 예 예 예 예 예 적 필수적인전문기술이이용가능하다. 예 예 예 예 예 예 예 예 용불확불확불확불확불확불확법률적 / 제도적장벽이없다. 예예성실실실실실실 해당권고는적용할만하다. 예 예 예 예 예 예 예 지침 A : 2014 Korean guideline - cardiac MRI 지침 B : 2015_ 대영회 _cardiac CT 지침 C : 2010 ASCI - cardiac MRI 지침 D : 2012 HRS/EHRA/ECAS expert consensus statement - atrial fibrillation 지침 E : 2006 ACC/AHA/ESC guideline -ventricular arrhythmias 지침 F : 2014 EHRA/HRS/APHRS expert consensus - ventricular arrhythmias 지침 G : 2010_ACCF/AHA_asymptomatic 지침 H : 2010_ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT_ 관상동맥 CT 지침 I : 2013_ACR_Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease 지 침 I 마. 핵심질문별권고및근거정리 1) 권고비교표표 99. 심장핵심질문 1 권고비교표 핵심질문 1 구분 지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 권고 Coronary CT ngiogr Using CCTA in asympt Coronary com aphy for risk asses omatic patients remain puted tomogra sment and detecti s controversial, primaril phy angiograp on of CAD in sym y because of the high hy is not reco ptomatic patients. er radiation dose, adde mmended for 1. Coronary CT an d cost, and use of ne cardiovascular giography is inappr phrotoxic contrast, but risk assessme opriate in patients it has the potential to nt in asympto at low risk for AD identify useful data be matic adults. (Appropriate Criteri yond what is derived f 232

246 6. 부록 a I, Level of Evide nce A). 2. Coronary CT an giography can be c onsidered in patien ts at intermediate risk for CAD (Appr opriate Criteria U, Level of Evidence A). 3. Coronary CT an giography is recom mended in patients at high risk for CA D (Appropriate Crit eria A, Level of Ev rom CACS. idence C). 권고등급 A/C C 1,3/4 지침 A : 2009_SSCT 지침 B : 2015_ 대영회 _cardiac CT 지침 C : 2007_ACC/AHA_noncardiac surgery 지침 D : 2010_ACCF/AHA_asymptomatic 지침 E : 2010_ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT_ 관상동맥 CT As detailed in the ACCF/AHA Guideline for Assessment of Car diovascular Risk in Asy mptomatic Adults: Exe cutive Summary, CCTA is not recommended f or cardiovascular risk a ssessment in asympto matic adults. 지침 F : 2013_ACR Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease 표 100. 심장핵심질문 2 권고비교표핵심질문 2 구분지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 1. Evaluation 1. 원인이불 CT and/or MRI, cardiac Although the for ARVD/C patients pres enting with syncope or ventricular ar 권고 rhythmia (Le vel of evide nce: A, Appr opriateness criteria: A) 2. Evaluation of pulmonary 분명한부정맥의원인을밝히기위한목적으로의관상동맥 CT 1) 새롭게발병한심방세동의경우관상동맥 CT는부적절하다. ( 권고등급 I, 근거수준 C), 1) Evaluation for arrhythm ogenic right ventricular c ardiomyopath y. (ARVC) 2) Patients p resenting wit h syncope o r ventricular arrhythmia. 2. MRI scans a computed to nd rotational mography (C angiography T), or radion to define th uclide angiog e anatomy o raphy can b f the atrium, e useful in PVs, and ant patients with rum. ventricular ar 2. Assessme rhythmias w nt of left atr hen echocar ial volume. diography do 3. MR imagi es not provi majority of p atients with PVCs can be accurately as sessed with a 12-lead E CG and ech ocardiograph y, contrasten hanced MRI may provide additional dia 233

247 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 veins prior t o radiofrequ ency ablation for atrial fibri llation/left at rial and pul monary veno us including anatomy di mensions of veins for ma pping purpos es (Level of evidence: B, Appropriaten ess A) criteria: 2) 비지속성 심실빈맥의경 우관상동맥 C T 시행을 고려 할수있다. ( 권고등급 U, 근거수준 C) 3) 실신의경 우관상동맥 C T 시행을 고려 할수있다. ( 권고등급 U, 근거수준 C) 2. 심방세동의 전기소작술이 전에폐정맥의 해부학을알기 위한심장 CT 의시행은적 절하다. ( 권고 등급 A, 근거 수준 A) 1) Evaluation of pulmonary vein anatom y prior to in vasive radiof requency abl ation for atri al fibrillation. 2) Left atrial and pulmona ry venous a natomy inclu ding dimensi ons of veins for mapping purposes. ng of atrial f ibrosis and a blation lesion 권고등급 A A Ⅱa 지침 A : 2014 Korean guideline - cardiac MRI 지침 B : 2015_ 대영회 _cardiac CT 지침 C : 2010 ASCI - cardiac MRI s. de accurate assessment of LV and R V function a nd/or evalua tion of struc tural change s. (Level of Evidence: B) 지침 D : 2012 HRS/EHRA/ECAS expert consensus statement - atrial fibrillation 지침 E : 2006 ACC/AHA/ESC guideline -ventricular arrhythmias gnostic and prognostic d ata when th e presence or absence of SHD rem ains in doub t. While there are no large -scale studi es investigati ng which pa tients should undergo MR I, the manag ement of se veral forms of SHD asso ciated with PVCs may b e guided by MRI, includin g dilated car diomyopathy, hypertrophic cardiomyopat hy (HCM), s arcoidosis, a myloidosis, a nd arrhythm ogenic right ventricular c ardiomyopath y(arvc). 234

248 6. 부록 지침 F : 2014 EHRA/HRS/APHRS expert consensus - ventricular arrhythmias 표 101. 심장핵심질문 3 권고비교표 핵심질문 3 구분 지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 지침 G 지침 H 지침 I For pati Coronar Class II There i ents wi y CT a th elev ngiogra ated ris phy is i k and napprop 권고 excelle riate w Interm nt func hen th e d i a t e tional c ere are or high apacity, no clini risk no it is re cal risk n-cardi In patie asonabl factors ac surg nts wit e to fo (Approp ery in h no cli rgo furt riatenes patients nical ris her exe s Criter with int k factor rcise te ia I, Le ermedi s, proc sting a vel of ate peri eeding nd proc Evidenc operativ with su eed to e C). e risk rgery is surgery Coronar predict appropri (IIa, B) y CT a ors (Le ate (Cla For pati ngiogra vel of ss I, L ents wi phy ca evidenc OE B) th elev n be c e: C, A ated ris onsider ppropria k and ed in p teness unknow atients criteria: n functi with m U onal ca ore tha pacity i n one t may clinical be reas risk fac onable tor and to perf with fu a 1. It is probabl y reco mmend ed that patients with fu nctional capacit y great er than or equa l to 4 M E T s without sympto ms p roceed to plan ned sur g e r y. ( L e v e l of Evid e n c e : B) Clas s IIb N oninvasi ve testi ng mig ht be c onsider s very little inf ormatio n in th e literat ure on the use of stres s echo cardiogr aphy in asympt omatic individu als for the pur poses of cardi ovascul ar risk assess m e n t. Accordi ngly, th e Class III (LO E: C) r ecomm endatio n for st ress ec hocardi 언급없음 (Stre ss ech ocardio graphy can be used fo r scree ning hi gh-risk asympt omatic patient s. It is most c ommon ly used before major n oncardi ac surg ery.) 235

249 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 orm ex ercise t esting t o asses s for fu nctional capacit y if it will cha nge ma nageme nt (IIb, B) For patients with el evated risk an d mode rate to good fu nctional capacit y, it m ay be r easona ble to f orgo fu rther e xercise testing and pro ceed to surgery (IIb, B) For pati ents wi th elev ated ris k and poor or unknow nctional capacit y less t han 4 M E T s (Approp riatenes s Criter ia U, L evel of Evidenc e C). ed if it will cha nge ma nageme nt for patients with po or (less than 4 M E T s ) or unkn own fu nctional capacit y and 3 or m ore clinical risk fac tors wh o are s chedule d for in termedi ate risk surger y.(level of Evid e n c e : B) 2. N oninvasi ve testi ng mig ht be c o ography reflects a lack of popu lation e vidence of this test for risk ass essmen t purpo ses. Th is contr aindicat ion to t e s t i n g must b e place d withi n the c oncept of acce pted in dication s for te sting a sympto matic p atients for diag nosis o f CAD, such as for asy mptom atic ind ividuals underg oing pr eoperati ve 236

250 6. 부록 n functi onal ca pacity i t may be reas onable to perform exercis e testin risk ass essmen g with t cardiac imaging to asse ss for myocar dial isc hemia (IIb, C) 권고등급 Ⅰ Ⅱa/b U U Ⅱa/b Ⅲ 지침 A : 2014 Korean guideline - cardiac MRI 지침 B : 2015_ 대영회 _cardiac CT 지침 C : 2010 ASCI - cardiac MRI 지침 D : 2012 HRS/EHRA/ECAS expert consensus statement - atrial fibrillation 지침 E : 2006 ACC/AHA/ESC guideline -ventricular arrhythmias 지침 F : 2014 EHRA/HRS/APHRS expert consensus - ventricular arrhythmias 지침 G : 2010_ACCF/AHA_asymptomatic 지침 H : 2010_ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT_ 관상동맥CT 지침 I : 2013_ACR_Acute Nonspecific Chest Pain Low Probability of Coronary Artery Disease 2) 근거표표 102. 심장핵심질문 1 근거표 핵심질문 1 문헌정보연구유형대상자수문헌질 KCIG Lee S, Choi EK, Chang HJ, Kim CH, Seo WW, Park J Cross sectional J, et al. Subclinical coronary artery disease as detecte study without d by coronary computed tomography angiography in an r e f e r e n c e asymptomatic population. Korean Circ J 2010;40:434-4 standard 237

251 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 41 Yoo DH, Chun EJ, Choi SI, Kim JA, Jin KN, Yeon TJ, et al. Significance of noncalcified coronary plaque in as ymptomatic subjects with low coronary artery calcium score: assessment with coronary computed tomograph y angiography. Int J Cardiovasc Imaging 2011;27 Suppl 1:27-35 Cho I, Chang HJ, Sung JM, Pencina MJ, Lin FY, Dunni ng AM, et al. Coronary computed tomographic angiogra phy and risk of all-cause mortality and non-fatal myoc ardial infarction in subjects without chest pain syndrom e from the CONFIRM Registry (COronary CT Angiograp hy EvaluatioN for Clinical Outcomes: an InteRnational Multicenter Registry). Circulation 2012;126: A, Seitun S, Martini C, Tedeschi C, et al. Coronary cal cium score and computed tomography coronary angiogr aphy in high-risk asymptomatic subjects: assessment of diagnostic accuracy and prevalence of non-obstructi ve coronary artery disease. Eur Radiol 2010;20: Choi EK, Choi SI, Rivera JJ, et al. Coronary computed tomography angiography as a screening tool for the de tection of occult coronary artery disease in asymptoma tic individuals. J Am Coll Cardiol. 2008;52: Bluemke DA, Achenbach S, Budoff M, et al. Noninvasi ve coronary artery imaging: magnetic resonance angiog raphy and multidetector computed tomography angiogra phy: a scientific statement from the American Heart A ssociation Committee on Cardiovascular Imaging and In tervention of the Council on Cardiovascular Radiology a nd Intervention and the Councils on Clinical Cardiology and Cardiovascular Disease in the Young. Circulation ;118: Rivera JJ, Nasir K, Choi EK, et al. Detection of occult coronary artery disease in asymptomatic individuals wit h diabetes mellitus using non-invasive cardiac angiogra Cross study sectional without r e f e r e n c e standard cohort study Well-designed cross study sectional cohort study AHA Statemen Cross study Scientific sectional without r e f e r e n c e phy. Atherosclerosis. 2009;203(2): standard Cross sectional Romeo F, Leo R, Clementi F, et al. Multislice compute study without d tomography in an asymptomatic high-risk population r e f e r e n c e Am J Cardiol. 2007;99(3): standard Hadamitzky M, Meyer T, Hein F, et al. Prognostic valu Cross sectional

252 6. 부록 e of coronary computed tomographic angiography in as ymptomatic patients. Am J Cardiol. 2010;105(12): study without r e f e r e n c e standard 표 103. 심장핵심질문 2 근거표 핵심질문 2 문헌정보연구유형대상자수문헌질 KCIG Marcus FI, McKenna WJ, Sherrill D, Basso C, Bauce B, Bluemke DA et al. Diagnosis of arrhythmogenic righ t ventricular cardiomyopathy/dysplasia: proposed modifi cation of the task force criteria. Eur Heart J 2010;31: Special Report 2 AquaroGD, Pingitore A, Strata E, Di Bella G, Molinaro S, Lombardi M. Cardiac magnetic resonance predicts o consecuti utcome in patients with premature ventricular complex Observational v e es of left bundle branch block morphology. J Am Coll patients Cardiol 2010;56: Marcus FI, Bluemke DA, Calkins H, Sorrell VL. Cardiac magnetic resonance for risk stratification of patients wi Letter to the th frequent premature ventricular contractions. JAmColl Editor 5 Cardiol 2011;57:1636 7; author reply Jonnalagadda, N., et al., Role of cardiac imaging evalu ation of patients with documented or suspected ventri cular arrhythmias. J Nucl Cardiol, (1): p Review Wazni, O.M., et al., Cardiovascular imaging in the man agement of atrial fibrillation. J Am Coll Cardiol, (10): p Review 2 Kato R, et al. Pulmonary vein anatomy in patients und Studies without ergoing catheter ablation of atrial fibrillation: Lessons le c o n s i s t e n t l y 2 8 arned by use of magnetic resonance imaging. Circulati a p p l i e d patients 3 on 2003;107: reference Lacomis JM, et al. Direct comparison of computed to Studies with mography and magnetic resonance imaging for charact erization of posterior left atrial morphology. Journal of i nterventional cardiac electrophysiology : an international journal of arrhythmias and pacing 2006;16:7-13 c o n s i s t e n t l y a p p l i e d r e f e r e n c e standards 2 Mansour M, et al. Threedimensional anatomy of the lef 5 0 Case series t atrium by magnetic resonance angiography: Implicatio consecuti 3 239

253 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 ns for catheter ablation for atrial fibrillation. Journal of cardiovascular electrophysiology 2006;17: v patients e 표 104. 심장핵심질문 3 근거표핵심질문 3 문헌정보연구유형대상자수문헌질 KCIG Fleisher, L.A., et al ACC/AHA Guideline on Perio G u i d e l i n e / perative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery Fleisher, L.A., et al., ACC/AHA 2007 Guidelines on Per ioperative Cardiovascular Evaluation and Care for Nonca rdiac Surgery: Executive Summary: A Report of the A merican College of Cardiology/American Heart Associati on Task Force on Practice Guidelines (Writing Committ ee to Revise the 2002 Guidelines on Perioperative Car diovascular Evaluation for Noncardiac Surgery): Developed in Collab oration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, So ciety for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation, (17): p Williams, F.M. and J.D. Bergin, Cardiac screening befor e noncardiac surgery. Surg Clin North Am, (4): p , vii. Holt, N.F., Perioperative cardiac risk reduction. Am Fa m Physician, (3): p Older P, Hall A, Hader R. Cardiopulmonary exercise te sting as a screening test for perioperative managemen t of major surgery in the elderly. Chest. 1999;116: Kaneko, K., et al., Computed tomography and scintigra phy vs. cardiac catheterization for coronary disease scr eening prior to noncardiac surgery. Intern Med, (16): p M e c h a n i s m based reasoning G u i d e l i n e / M e c h a n i s m 1 based reasoning G u i d e l i n e / M e c h a n i s m 1 based reasoning G u i d e l i n e / M e c h a n i s m based reasoning 5 t 3 patients consecuti v e 3 preoperat i v e 240

254 6. 부록 Freeman, W.K. and R.J. Gibbons, Perioperative cardiov ascular assessment of patients undergoing noncardiac surgery. Mayo Clin Proc, (1): p G u i d e l i n e / M e c h a n i s m based reasoning patients 1 241

255 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.5. 유방분과 가. 핵심질문선정 1) PICO의선정표 105. 유방 PICO 선정 Population Intervention Comparator Outcome 고위험군 1 유방 US, 유방유방암진단성능, 1-2 중등도위험군 2 유방촬영검사 MRI 임상적유용성 1-3 평균위험여성 세이상여성, 최초검사 40세이상여성, 유방촬영상이상 2-2 유방 US, 유방소견이의심되는경우유방촬영검사 MRI 40세이상여성, 유방촬영상정상종괴진단성능 2-3 이거나양성병변소견이있는경우 세이하여성, 최초검사유방 US 유방 MRI 1 : BRCA mutation, first-degree relative of BRCA carrier, life-time risk>20% 2 : life-time risk 15-20%, lobular neoplasm, atypical ductal hyperplasia, pernsonal history of breast cancer 3: 고위험군과중등도위험군이아닌여성 2) 문장형핵심질문 표 106. 유방문장형핵심질문 핵심질문 핵심질문 1 무증상여성을대상으로한유방암검진에서유방암을발견하기위한적절한영상검사는무엇인가? 세부핵심질문 1-1 무증상고위험군여성의유방암검진에서유방암발견을위해적절한영상검사는무엇인가? 세부핵심질문 1-2 무증상중등도위험군여성의유방암검진에서유방암발견을위해적절한영상검사는무엇인가? 세부핵심질문 1-3 무증상평균위험군여성의유방암검진에서유방암발견을위해적절한영상검사는무엇인가? 핵심질문 2 만져지는종괴가있는여성에서진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-1 세부핵심질문 2-2 세부핵심질문 2-3 세부핵심질문 2-4 만져지는종괴가있는 40 세이상여성에서최초검사시진단을위한적절한영상검사는 무엇인가? 만져지는종괴가있는 40세이상여성에서유방촬영상이상소견이의심되는경우에진 단을위한적절한영상검사는무엇인가? 만져지는종괴가있는 40세이상여성에서유방촬영상정상이거나, 양성병변의소견이 있는경우진단을위한적절한영상검사는무엇인가? 만져지는종괴가있는 40세이하여성에서최초검사시진단을위한적절한영상검사는 무엇인가? 242

256 6. 부록 나. 핵심질문별진료지침검색 1) 핵심질문 1/ 핵심질문 2 검색대상핵심질문 KQ 1. 무증상여성을대상으로한유방암검진에서유방암을발견하기위한적절한영상검사는무엇인가? KQ 2. 만져는종괴가있는여성에서진단을위해적절한영상검사는무엇인가? 국내 DB 검색전략및결과 표 107. 유방국내문헌 DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 2. KMBASE 1 breast [ALL] 1 2 소계 1 3 단순중복제거후 1 1 ([ALL=breast] AND [KEYWORD=guideline]) 2 2 ([ALL=breast] AND [ALL=recommendation]) 1 3 ([ALL= 유방 ] AND [ALL= 지침 ]) 0 4 ([ALL= 유방 ] AND [ALL= 권고 ]) 2 5 소계 2 6 단순중복제거후 2 표 108. 유방국내진료지침 DB 검색사이트 N 지침제목 연도 개발학회 1. KGC 1 제3차유방암진료권고안 2008 한국유방암학회 2 소계 ( 1 건 ) 2. KoMGI 1 제3차유방암진료권고안 2008 한국유방암학회 2 소계 ( 1 건 ) 국외DB 검색전략및결과 표 109. 유방국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 1 exp Breast Neoplasms/ 234,012 P 2 exp Breast Diseases/ 248,

257 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 구분 N 검색어 검색결과 3 OR/ ,989 4 exp Mammography/ 25,527 breast ultrasonography.mp. or exp Ultrasonography, 5 I Mammary/ 4,061 6 exp Magnetic Resonance Imaging/ or MRI.mp. 371,708 7 OR/ ,453 8 guideline.pt. 15,621 9 practice guideline.pt. 20,435 filter 10 guideline$.ti. 49, recommendation$.ti. 24, OR/ , AND 7 AND 연도 15 limit 14 to yr="2000 -Current" 266 종합 표 110. 유방국외 Ovid-Embase 검색일 : 구분 N 검색어 검색결과 1 exp Breast Neoplasms/ 305,832 P 2 exp Breast Diseases/ 322,982 3 OR/ ,982 4 exp Mammography/ 33,945 breast ultrasonography.mp. or exp Ultrasonography, 5 I Mammary/ 5,378 6 exp Magnetic Resonance Imaging/ or MRI.mp. 586,090 7 OR/ ,655 8 guideline$.ti. 59,222 filter 9 recommendation$.ti. 26, OR/ , AND 7 AND 연도 12 limit 11 to yr="2000 -Current" 527 종합

258 6. 부록 표 111. 유방국외 GIN 검색일 : N 검색어 검색결과 1 breast( 제한 : ( 언어 ) 영어, ( 출판형태 ) : Guideline) 49 단순중복제거후 49 표 112. 유방국외 NGC 검색일 : N 검색어 검색결과 1 Keyword: breast cancer Guideline Category: Diagnosis, Screening 84 다. 진료지침선별 1) 핵심질문 1/ 핵심질문 2 흐름도 그림 22. 유방핵심질문 1 / 핵심질문 2 흐름도. 245

259 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 라. 진료지침평가 1) 진료지침질평가결과 표 113. 유방핵심질문 1/ 핵심질문 2 질평가결과 핵심질문 1/ 핵심질문 2 지침제목 AGREE 점수개발위원회의견 유방암검진권고안개정안 47 추천함 유방암진료권고안 22 추천안함 ACR Appropriateness Criteria: palpable breast masses. 69 추천함 ACR Appropriateness Criteria: nonpalpable mammographic findin gs (excluding calcifications). 69 추천함 ACR Appropriateness Criteria: breast cancer screening. 69 추천함 NGC: Recommendations on screening for breast cancer in aver age-risk women aged years 55 추천함 NGC: Common Breast Problems 37 추천안함 Screening for Breast Cancer: U.S. Preventive Services Task For ce Recommendation Statement 53 추천함 Breast Cancer Screening with imaging: Recommendations from the Society of Breast imaging and the ACR on the Use of Ma mmography, Brest MRI, Breast Ultrasound, and other Technolog 21 추천안함 ies for the Detection of Clinically ESMO Pocket Guidelines 26 추천안함 NCCN: Breast Cancer Screening and Diagnosis 31 추천함 2) 수용성과적용성평가결과 표 114. 유방핵심질문 1 수용성과적용성평가결과 핵심질문 1 구평가항목지침 A 지침 B 지침 C 지침 D 분수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예아니오아니오아니오가치와선호도가유사하다. 예아니오예아니오용권고로인한이득은유사하다. 예아니오예아니오성해당권고는수용할만하다. 예불확실예아니오적해당중재및장비는이용가능하다. 예예예예필수적인전문기술이이용가능하다. 예예예예용법률적 / 제도적장벽이없다. 예아니오예아니오성해당권고는적용할만하다. 예아니오예아니오지침 A : 유방암검진권고안개정안 지침 B : NGC: Recommendations on screening for breast cancer in average-risk women aged years 246

260 6. 부록 지침 C : ACR Appropriateness Criteria: breast cancer screening. 지침 D : Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement 표 115. 유방핵심질문 2 수용성과적용성평가결과핵심질문 2 구평가항목지침 A 분수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예가치와선호도가유사하다. 예용권고로인한이득은유사하다. 예성해당권고는수용할만하다. 예적해당중재및장비는이용가능하다. 예필수적인전문기술이이용가능하다. 예용법률적 / 제도적장벽이없다. 예성해당권고는적용할만하다. 예지침 A : (2012) ACR Appropriateness Criteria palpable breast masses 마. 핵심질문별권고및근거정리 1) 권고비교표표 116. 유방핵심질문 1 권고비교표 핵심질문 1 구분 지침 A 지침 B 지침 C 지침 D 세무증상여성을 40-49yrs: no MMG The USPSTF recommends a 대상으로 유방촬영술을 (weak/mod) gainst routine screening ma 이용한유방암검진을 50-69yrs: routine scr mmography in women aged 권고 2년마다시행할것을권 eening MMG every 2 40 to 49 years. The decisio 40yrs: annu 고한다 ( 권고등급 B). 70-3yrs (weak/mod) n to start regular, biennial s al screening 세이상에서유방촬영술 70-74yrs: routine scr creening mammography bef MMG (rating: 을이용한유방암검진 eening MMG every 2 ore the age of 50 years sh 9), screening 은개인별위험도에대 -3yrs (weak/low) ould be an individual one a MRI (rating 한임상적판단과수검 MRI: not recommend nd take into account patient 3), screening 자의선호도를고려하여 ed for asymptomatic context, including the patien US (rating 2) 선택적으로시행할것을 women (weak/no) t s values regarding specific 권고한다 ( 권고등급 C). 유방초음파검사단독또 BSE: not recommend ed (weak/low) benefits and harms. (Grade C recommendation) 는 유방촬영술과 병행 The USPSTF recommends b 247

261 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 iennial screening mammogra phy for women between th e ages of 50 and 74 years. (Grade B recommendation) The USPSTF concludes that the current evidence is insu fficient to assess the additi onal benefits and harms of screening mammography in women 75 years or older. (I 하여 유방초음파검사를 유방암검진으로시행하 는것을권고하거나반 대하지 않는다 ( 권고등급 I). 임상유방진찰 단독 또는유방촬영술과병 행하여 임상유방진찰을 유방암검진으로시행하 는것을 권고하거나 반대하지 않는다 ( 권고등 급 I). statement) The USPSTF con cludes that the current evid ence is insufficient to asses s the additional benefits an d harms of clinical breast e xamination beyond screenin g mammography in women 40 years or older. (I statem ent) The USPSTF recommen ds against clinicians teachin g women how to perform b reast self-examination. (Gra de D recommendation) The USPSTF concludes that the current evidence is insuffici ent to assess additional ben efits and harms of either di gital mammography or mag netic resonance imaging ins tead of film mammography as screening modalities for breast cancer. (I statement) 40-49yrs: no MMG 40-49yrs: recommends agai 권고 등급 40-69yrs: biannual M MG ( 권고등급 B) 70yrs이상 : 검진선택적시행 ( 권고등급 C) US & BSE: ( 권고등급 I) (weak/mod) 50-69yrs: routine scr eening MMG every 2-3yrs (weak/mod) 70-74yrs: routine scr eening MMG every 2-3yrs (weak/low) 40yrs: annu al screening MMG (rating: 9), screening MRI (rating 3), screening US (rating 2) nst routine screening MMG (Grade C) 50-74yrs: biennial screening MMG (Grade B) 75yrs: insufficient evidenc e for screening mammograp hy (I statement) MRI: not recommend BSE: recommends against 248

262 6. 부록 ed for asymptomatic women (weak/no) BSE: not recommend ed (weak/low) (Grade D) Digital MMG or MRI (I state ment) 지침 A : 유방암검진권고안개정안지침 B : NGC: Recommendations on screening for breast cancer in average-risk women aged years 지침 C : ACR Appropriateness Criteria: breast cancer screening. 지침 D : Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement 표 117. 유방핵심질문 2 권고비교표 핵심질문 2 구 분 지침 A 권고 40yrs: annual screening MMG (rating 9), US (rating 4), MRI (rating 1 or 2) 40yrs: annual screening MMG (rating 9), US (rating 4), MRI (rating 1 or 2) 권고 30yrs: US (rating 9), MMG (rating 3), MRI (rating 1), 등급 30-39yrs: both US or MMG can be used, US (rating 8), MMG (rating 8), MRI (rating 1 or 2) 지침 A : (2012) ACR Appropriateness Criteria palpable breast masses 2) 근거표 표 118. 유방핵심질문 1 근거표 핵심질문 1 연구유형 대상자수 문헌질 KCIG Johns LE, Moss S, Cuckle H, et al. False-positive results i n the randomised controlled trial of mammographic screeni ng from age 40 ( Age trial). Cancer Epidemiol Biomarkers Prev 2010;19: RCT Miller Anthony B, Wall Claus, Baines Cornelia J, Sun Ping, To Teresa, Narod Steven A et al. Twenty five year follow-u p for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial BMJ 2014; 348 :g366 RCT 89,

263 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 Bjurstam N et al. The Gothenburg Breast Screening Trial. C ancer May 15;97(10): Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2011;(1):CD Andersson I et al. Mammographic screening and mortality f rom breast cancer: the Malmo mammographic screening tri al. British Medical Journal Oct 15; 297(6654): RCT RCT RCT Frisell J et al. Followup after 11 years--update of mortality results in the Stockholm mammographic screening trial. Bre ast Cancer Res Treat Sep;45(3): RCT László Tabár et al. Swedish Two-County Trial: Impact of M ammographic Screening on Breast Cancer Mortality during 3 Decades. Radiology (3): RCT Donna Fitzpatrick-Lewis et al. Breast Cancer Screening. CT FPHC systematic review N/A 4 Lee CH, Dershaw DD, Kopans D, et al. Breast cancer scre ening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for t N/A N/A 4 he detection of clinically occult breast cancer. J Am Coll R adiol 2010; 7(1): U.S. Preventive Services Task Force. Screening for breast c ancer: recommendations and rationale. Ann Intern Med. 20 N/A N/A 4 02; 137: 지침 A : 유방암검진권고안개정안 지침 B : NGC: Recommendations on screening for breast cancer in average-risk women aged years 지침 C : ACR Appropriateness Criteria: breast cancer screening. 지침 D : Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement 250

264 6. 부록 표 119. 유방핵심질문 2 근거표 핵심질문 2 문헌정보 연구유형 대상자수 문헌질 KCIG American Cancer Society. Cancer Facts & Figures 2012: Atla nta: American Cancer Society; Review - 4 지침 A : (2012) ACR Appropriateness Criteria palpable breast masses 251

265 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.6. 복부분과 가. 핵심질문선정 1) PICO의선정표 120. 복부 PICO 선정 Population Intervention Comparator Outcome 1 황달과급성복통혹은발열증상 1-1 조영증강 CT US Jaundice 진단정확을보이는성인성황달외특이증상이없는성인 ( 무조영증강 CT, 1-2 US 임상적유효성증상혹은피로, 체중감소, 오심 ) MRCP 성인환자조영증강 CT US Acute cholecystitis 우상복부 (Right upper quadrant) 진단정확성 2-2 통증 (tenderness) 과발열을동반하 US 조영증강 CT 임상적유효성는중환자실성인환자 임산부를제외한성인환자 CT Acute appendicitis 3-2 임신여성 MRI US 급성충수염의진단정확성 3-3 소아환자 임상적유효성 2) 문장형핵심질문 표 121. 복부문장형핵심질문 핵심질문 핵심질문 1 황달증상이있는환자의진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-1 황달증상이있는환자에서급성간염진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-2 황달증상이있는환자에서담관암진단을위한적절한영상검사는무엇인가? 핵심질문 2 우상복부 (right upper quadrant) 급성통증을호소하는환자에서급성담낭염진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-1 우상복부급성통증을호소하는성인환자에서급성담낭염진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-2 우상복부급성통증을호소하는발열동반중환자실성인환자에서급성담낭염진단을위한적절한영상검사는무엇인가? 핵심질문 3 우하복부급성통증과발열을호소하는환자에서급성충수염진단을위한적절한영상검사는무엇인가? 세부핵심질문 3-1 우하복부급성통증과발열을호소하는환자 ( 임산부제외 ) 에서급성충수염진단을위한적절한영상검사는무엇인가? 세부핵심질문 3-2 우하복부급성통증과발열을호소하는임신여성환자에서급성충수염진단을위한적절한영상검사는무엇인가? 세부핵심질문 3-3 우하복부급성통증과발열을호소하는소아환자에서급성충수염진단을위한적절한영상검사는무엇인가? 252

266 6. 부록 나. 핵심질문별진료지침검색 1) 핵심질문 1 검색대상핵심질문 KQ 1. 황달증상이있는환자의진단을위한적절한영상검사는무엇인가? 국내 DB 검색전략및결과 표 122. 복부국내문헌 DB 검색일 : 검색 N 검색어관련문헌비고사이트 1. KoreaMe d 2. KMBASE 1 jaundice [ALL] 0 2 bile duct [ALL] 0 3 hyperbilirubinemia [ALL] 0 4 hepatitis [ALL] 6 5 Pancrea [ALL] 0 6 소계 6 1 ([ALL=jaundice] AND [ALL=guideline]) 0 2 ([ALL=jaundice] AND [ALL=recommendation]) 0 3 ([ALL=bile duct] AND [ALL=guideline]) 6 4 ([ALL=bile duct] AND [ALL=recommendation]) 0 5 ([ALL=hepatitis] AND [ALL=guideline]) 6 6 ([ALL=hepatitis] AND [ALL=recommendation]) 0 7 ([ALL=pancrea] AND [ALL=guideline]) 7 8 ([ALL=pancrea] AND [ALL=recommendation]) 0 9 황달 AND 지침 1 10 황달 AND 권고 0 11 황달 AND 가이드라인 0 12 간염 AND 지침 0 13 간염 AND 권고 0 14 간염 AND 가이드라인 1 15 췌장 AND 권고 5 16 췌장 AND 지침 1 17 췌장 AND 가이드라인 5 18 소계 단순중복제거후

267 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 123. 복부국내진료지침 DB 검색사이트 N 지침제목 연도 개발학회 1. KGC 1 간경변증진료가이드라인 2011 간경변증임상연구센터 2 소계 ( 1 건 ) 2. KoMGI 간암조기진단을위한권고안 2001 대한간학회 C형간염치료가이드라인 2004 대한간학회 3 만성췌장염가이드라인 2008 대한췌담도학회 4 담낭용종진료권고안 2010 한국간담췌외과학회 5 만성B형간염치료가이드라인 2011 대한간학회 6 간경변진료가이드라인 2011 대한간학회 7 소계 ( 6 건 ) 8 단순중복제거후 (6건) 국외 DB 검색전략및결과 표 124. 복부국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 1 jaundice.mp. or exp Jaundice/ exp Hyperbilirubinemia/ ((increase or elevation) and bilirubin).mp ((biliary or bile) and duct$).mp (exp Hepatitis/ or hepatitis.mp) and Acute.mp exp Cholangiocarcinoma/ 5876 P 7 exp Biliary Tract Diseases/ OR/ exp Tomography, X-Ray Computed/ or CT.mp Comput$ Tomogr$.mp OR/ (enhanced or contrast).mp and exp Ultrasonography/ Ultrasonogra$.mp Sonogra$.mp 검사 17 exp Magnetic Resonance Imaging/ MRCP.mp exp Cholangiopancreatography, Magnetic Resonance/ OR/ P& 검사 21 8 AND guideline.pt practice guideline.pt guideline$.ti fillter 25 recommendation$.ti OR/ AND 연도 28 limit 27 to yr="2000 -Current"

268 6. 부록 표 125. 복부국외 Ovid-Embase 검색일 : 구분 N 검색어 검색결과 1 jaundice.mp. or exp Jaundice/ exp Hyperbilirubinemia/ ((increase or elevation) and bilirubin).mp ((biliary or bile) and duct$).mp P 5 exp Hepatitis/ exp Cholangiocarcinoma/ exp Biliary Tract Diseases/ OR/ exp computer assisted tomography/ or CT.mp Comput$ Tomogr$.mp OR/ (enhanced or contrast).mp and exp echography/ 검사 15 Ultrasonogra$.mp Sonogra$.mp exp nuclear magnetic resonance imaging/ MRI.mp exp magnetic resonance cholangiopancreatography MRCP.mp OR/ P& 검사 22 8 AND guideline$.ti 제외 24 recommendation$.ti 기준 25 OR/ AND 연도 26 limit 26 to yr="2000 -Current" 209 표 126. 복부국외 GIN 검색일 : N 검색어 검색결과 1 jaundice 1 2 acute hepatitis 1 255

269 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : N 검색어 검색결과 3 bile duct 0 4 biliary duct 0 5 cholangiocarcinoma 1 6 cholangioma 2 7 소계 6 단순중복제거후 4 표 127. 복부국외 NGC 검색일 : N 검색어 검색결과 1 jaundice 2 2 acute hepatitis 4 3 cholangiocarcinoma 2 4 cholangioma 2 5 단순중복제거후 7 2) 핵심질문 2 검색대상핵심질문 KQ 2. 우상복부급성통증을호소하는환자에서급성담낭염진단을위한적절한영상검사는무엇인가? 국내 DB 검색전략및결과 표 128. 복부국내문헌 DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 1 bile [ALL] 0 2 abdom* [ALL] 0 3 cholangio* [ALL] 0 4 Cholecyst* 0 5 biliary [ALL] 1 5 소계 1 256

270 6. 부록 검색일 : 검색사이트 N 검색어관련문헌비고 2. KMBASE 1 ([ALL=biliary] AND [ALL=guideline]) 0 2 ([ALL=bile] AND [ALL=recommendation]) 0 3 ([ALL=bile duct] AND [ALL=guideline]) 4 4 ([ALL=bile duct] AND [ALL=recommendation]) 0 5 ([ALL=cholangio] AND [ALL=guideline]) 3 6 ([ALL=cholangio] AND [ALL=recommendation]) 0 7 ([ALL=Cholecyst] AND [ALL=guideline]) 4 8 ([ALL=Cholecyst] AND [ALL=recommendation]) 0 소계 10 단순중복제거후 5 표 129. 복부국내진료지침 DB 검색사이트 N 지침제목 연도 개발학회 KoMGI 1 담낭용종진료권고안 2010 한국간담췌외과학회 단순중복제거후 ( 1건 ) 국외 DB 검색전략및결과 표 130. 복부국외 Ovid-Medline 검색일 : P 구분 N 검색어검색결과 1 exp Abdominal Pain/ abdom$ pain.mp quadrant.mp OR/ right upper.mp AND (biliary or bile).mp exp Biliary Tract Disease/ OR stone$.mp AND exp Gallbladder Disease/ Cholecyst$.mp or 11 or 12 or

271 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 구분 N 검색어검색결과 15 guideline.pt practice guideline.pt 지침 17 guideline$.ti recommendation$.ti OR/ P& 지침 AND 연도 21 limit 20 to yr="2000 -Current" 147 표 131. 복부국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 1 exp Abdominal Pain/ abdom$ pain.mp quadrant.mp OR/ P 5 right upper.mp AND (biliary or bile).mp exp Biliary Tract Disease/ OR stone$.mp AND exp Gallbladder Disease/ Cholecyst$.mp or 11 or 12 or exp computer assisted tomography/ or CT.mp 검사 16 Comput$ Tomogr$.mp OR/ (enhanced or contrast).mp and exp echography/ Ultrasonogra$.mp Sonogra$.mp OR/ AND P& 검사 25 guideline$.ti recommendation$.ti 제외 27 OR/ 기준 AND 연도 29 limit 28 to yr="2000 -Current"

272 6. 부록 표 132. 복부국외 GIN 검색일 : N 검색어 검색결과 1 right upper quadrant 1 2 (bile OR biliary) stone 0 3 Cholecyst* 0 4 acute abdominal pain 5 단순중복제거후 5 표 133. 복부국외 NGC 검색일 : N 검색어 검색결과 1 right upper quadrant 3 2 (bile OR biliary) stone 3 3 Cholecyst* 3 4 abdominal pain 5 단순중복제거후 5 3) 핵심질문 3 검색대상핵심질문 KQ 3. 우상복부급성통증과발열을호소하는환자에서급성충수염진단을위한적절한영상검사는무엇인가? 국내 DB 검색전략및결과 표 134. 복부국내문헌 DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 1 Appendicitis[ALL] 0 2 abdom* [ALL] pain [ALL] 0 소계 0 259

273 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 검색사이트 N 검색어 관련문헌 비고 1 ([ALL=Appendicitis] AND [ALL=guideline]) 0 2 ([ALL=Appendicitis] AND [ALL=recommendation]) 0 3 ([ALL=abdominal pain] AND [ALL=guideline]) 2 2. KMBASE 4 ([ALL=abdominal pain] AND [ALL=recommendation]) 0 5 충수 AND ( 지침 OR 권고 OR 가이드라인 ) 0 6 맹장 AND ( 지침 OR 권고 OR 가이드라인 ) 0 7 급성복통 AND ( 지침 OR 권고 OR 가이드라인 ) 0 소계 2 단순중복제거후 0 표 135. 복부국내진료지침 DB 검색사이 N 지침제목연도개발학회트 KoMGI 1 2 단순중복제거후 ( 건 ) 국외 DB 검색전략및결과 표 136. 복부국외 Ovid-Medline 검색일 : P 구분 N 검색어검색결과 지침 P AND 지침 1 exp Abdominal Pain/ abdom$ pain.mp quadrant.mp OR/ right lower.mp AND exp Appendicitis/ appendicitis.mp OR/ guideline.pt practice guideline.pt guideline$.ti recommendation$.ti OR/ AND

274 6. 부록 검색일 : 구분 N 검색어검색결과 연도 16 limit 15 to yr="2000 -Current" 35 표 137. 복부국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 1 exp Abdominal Pain/ abdom$ pain.mp quadrant.mp P 4 OR/ right lower.mp AND exp Appendicitis/ appendicitis.mp OR/ guideline$.ti 지침 11 recommendation$.ti OR/ P& 지침 13 9 AND 연도 14 limit 14 to yr="2000 -Current" 62 표 138. 복부국외 GIN 검색일 : N 검색어 검색결과 1 appendicitis 2 2 right lower quadrant 1 단순중복제거후 2 표 139. 복부국외 NGC 검색일 : N 검색어 검색결과 1 appendicitis 3 2 right lower quadrant 2 단순중복제거후 3 다. 진료지침선별 1) 핵심질문 1 흐름도 261

275 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 그림 23. 복부핵심질문 1 흐름도. 2) 핵심질문 2 흐름도 그림 24. 복부핵심질문 2 흐름도. 262

276 6. 부록 3) 핵심질문 3 흐름도 그림 25. 복부핵심질문 3 흐름도. 라. 진료지침평가 1) 진료지침질평가결과표 140. 복부핵심질문 1 질평가결과 핵심질문 1 지침제목 AGREE점수 개발위원회의견 Updated clinical practice guidelines for the management of bil iary tract cancers: revision concepts and major revised points 35 추천 Asia-Pacific consensus recommendations for endoscopic and i nterventional management of hilar cholangiocarcinoma 31 추천 Flowcharts for the management of biliary tract and ampullary carcinomas 22 추천 Guidelines for the diagnosis and treatment of cholangiocarcino ma: An update 30 추천 EASL Clinical Practice Guidelines: Management of cholestatic l iver diseases 29 추천 Guidelines on the management of common bile duct stones (CBDS) 36 추천 총담관결석의진료가이드라인 : 총담관결석의진단 18 추천안함 263

277 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 141. 복부핵심질문 2 질평가결과 핵심질문 2 지침제목 AGREE 점수개발위원회의견 Diagnosis and management of gallstone disease: summary of NICE guidance 44 추천 Flowcharts for the diagnosis and treatment of acute cholangit is and cholecystitis: Tokyo Guidelines 18 추천 (2013) ACR guideline_right Upper Quadrant Pain 69 추천 표 142. 복부핵심질문 3 질평가결과 핵심질문 3 지침제목 AGREE 점수개발위원회의견 Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis 32 추천 Abdominal pain: A synthesis of recommendations for its correct management 31 추천 Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy: This statement was review ed and approved by the Board of Governors of the Society of A merican Gastrointestinal and Endoscopic Surgeons (SAGES), Sep tember It was prepared by the SAGES Guidelines Commit tee 34 추천 (2013) ACR guideline_right Lower Quadrant Pain - Suspected A ppendicitis 69 추천 264

278 6. 부록 2) 수용성과적용성평가결과 표 143. 복부핵심질문 1 수용성과적용성평가결과 핵심질문 1 구평가항목지침 A 지침 B 지침 C 분수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예예예가치와선호도가유사하다. 예예예용권고로인한이득은유사하다. 예예예성해당권고는수용할만하다. 예예예적해당중재및장비는이용가능하다. 예예예필수적인전문기술이이용가능하다. 예예예용법률적 / 제도적장벽이없다. 예예예성해당권고는적용할만하다. 예예예지침 A : Guidelines on the management of common bile duct stones (CBDS) 지침 B : 총담관결석의진료가이드라인 : 총담관결석의진단 지침 C : ACR Appropriateness Criteria: jaundice 표 144. 복부핵심질문 2 수용성과적용성평가결과 핵심질문 2 구평가항목지침 A 지침 B 지침 C 분수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예예가치와선호도가유사하다. 예예용권고로인한이득은유사하다. 예예성해당권고는수용할만하다. 예예적해당중재및장비는이용가능하다. 예예필수적인전문기술이이용가능하다. 예예용법률적 / 제도적장벽이없다. 예예성해당권고는적용할만하다. 예예지침 A : Diagnosis and management of gallstone disease: summary of NICE guidance 지침 B : Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines 지침 C :(2013) ACR guideline_right Upper Quadrant Pain 265

279 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 145. 복부핵심질문 3 수용성과적용성평가결과핵심질문 3 구평가항목지침 A 지침 B 지침 C 지침 D 분수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예가치와선호도가유사하다. 예용권고로인한이득은유사하다. 예성해당권고는수용할만하다. 예적해당중재및장비는이용가능하다. 예필수적인전문기술이이용가능하다. 예용법률적 / 제도적장벽이없다. 예성해당권고는적용할만하다. 예지침 A : Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis 지침 B : Abdominal pain: A synthesis of recommendations for its correct management 지침 C : Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy: This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), September It was prepared by the SAGES Guidelines Committee 지침 D : (2013) ACR guideline_right Lower Quadrant Pain - Suspected Appendicitis 266

280 6. 부록 마. 핵심질문별권고및근거정리 1) 권고비교표표 146. 복부핵심질문 1 권고비교표 핵심질문 1 구분 지침 A 지침 B 지침 C 황달환자에있어서초음파검 황달환자에서초음파는첫번째검사로적절하 권고 사 (Ultrasound) 는담관석이며, 담관폐쇄확인하고, 폐쇄가있는경우담 1. 복부초음파검사는총의심될경우비침습적으로시석유무평가와후속검사선택에도움을준다. 담관결석진단을위한초행할수있는첫번째검사로만약담관폐쇄가의심되고, 우상복부통증및기검사로고려해볼수적절하다. 하지만민감도가낮담석의병력이동반되어있다면 MRI 와 MR 있다. 은점을고려해야한다. 자기 CP가후속검사로적절하다. 만약담관폐쇄가 2. 복부전산화단층촬영공명영상을이용한담관조영있으나, 담석증이없고, 악성종양이강력히의 (CT) 은총담관결석및술 (magnetic resonance c 심되는경우에는, biphasic pancreas CT wit 합병증진단을위한유용 holangiopancreatography) 은 h thin reconstruction 이폐쇄지점확인과수한검사이다. 담석의확인을위해서효과적술가능성평가및병기결정에도움을줄수 인비침습적검사이다. 있다. 권고등급 1B/1C 지침 A : Guidelines on the management of common bile duct stones (CBDS) 지침 B : 총담관결석의진료가이드라인 : 총담관결석의진단 지침 C : ACR Appropriateness Criteria: jaundice 표 147. 복부핵심질문 2 권고비교표 핵심질문 2 구 분 권고 권고 지침 A 지침 B 지침 C 우상복부급성통증을호소하는환자에서급성담낭염진단을위 해초음파검사는가장높은민감도와특이도를보여적절한 (a ppropirate) 검사이며조영증강 MRI 혹은 CT 검사역시초음파 와비교하여다소낮은민감도와특이도를보이나특수한상황 에서는적절한 (may be appropriate) 검사이다. 등급지침 A : Diagnosis and management of gallstone disease: summary of NICE guidance 지침 B : Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines 지침 C : ACR guideline_right Upper Quadrant Pain 267

281 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 148. 복부핵심질문 3 권고비교표 핵심질문 3 구 분 권고 권고 지침 A 지침 B 지침 C 지침 D 우하복부급성통증과발열을호소하는환 자에서급성충수염진단을위한 CT 검사 는가장높은진단정확도를보여적절한 (appropriate) 검사이다. 하지만, CT 검사 의방사선피폭문제로인하여어린환자나 임산부의경우일차적으로초음파를시행 하고, 초음파로결론이나지않을경우, 선 택적으로 CT 나 MRI 를시행하기도한다. 등급지침 A : Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis 지침 B : Abdominal pain: A synthesis of recommendations for its correct management 지침 C : Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy: This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), September It was prepared by the SAGES Guidelines Committee 지침 D : ACR guideline_right Lower Quadrant Pain - Suspected Appendicitis 2) 근거표표 149. 복부핵심질문 1 근거표 핵심질문 1 문헌정보연구유형대상자수문헌질 KCIG Thornton JR1, Lobo AJ, Lintott DJ, Axon AT. Value of ultr asound and liver function tests in determining the need f Observational or endoscopic retrograde cholangiopancreatography in unex ( 후향적 ) plained abdominal pain. Gut Nov;33(11): Soto JA1, Alvarez O, Múnera F, Velez SM, Valencia J, Ra mírez N., Diagnosing bile duct stones: comparison of une Observational nhanced helical CT, oral contrast-enhanced CT cholangiogr ( 후향적 ) aphy, and MR cholangiography., AJR Am J Roentgenol Oct;175(4): Varghese JC1, Liddell RP, Farrell MA, Murray FE, Osborne Observational DH, Lee MJ., Diagnostic accuracy of magnetic resonance ( 후향적 ) cholangiopancreatography and ultrasound compared with di

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291 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 Altun E, Semelka RC, Elias J, Jr., et al. Acute cholecystiti s: MR findings and differentiation from chronic cholecystiti s. Radiology 2007; 244(1): Oh KY, Gilfeather M, Kennedy A, et al. Limited abdominal MRI in the evaluation of acute right upper quadrant pain. A bdom Imaging 2003; 28(5): Hakansson K, Leander P, Ekberg O, Hakansson HO. MR i maging in clinically suspected acute cholecystitis. A compar ison with ultrasonography. Acta Radiol 2000; 41(4): Regan F, Schaefer DC, Smith DP, Petronis JD, Bohlman ME, Magnuson TH. The diagnostic utility of HASTE MRI in the evaluation of acute cholecystitis. Half- Fourier acquisiti on single-shot turbo SE. J Comput Assist Tomogr 1998; 2 2(4): Oto A, Ernst R, Ghulmiyyah L, Hughes D, Saade G, Chalju b G. The role of MR cholangiopancreatography in the evalu ation of pregnant patients with acute pancreaticobiliary dise ase. Br J Radiol 2009; 82(976): Oto A, Ernst RD, Ghulmiyyah LM, et al. MR imaging in th e triage of pregnant patients with acute abdominal and pel vic pain. Abdom Imaging 2009; 34(2): Boland GW, Slater G, Lu DS, Eisenberg P, Lee MJ, Muelle r PR. Prevalence and significance of gallbladder abnormaliti es seen on sonography in intensive care unit patients. AJR 2000; 174(4): Puc MM, Tran HS, Wry PW, Ross SE. Ultrasound is not a useful screening tool for acute acalculous cholecystitis in cr itically ill trauma patients. Am Surg 2002; 68(1): Ahvenjarvi L, Koivukangas V, Jartti A, et al. Diagnostic acc uracy of computed tomography imaging of surgically treate d acute acalculous cholecystitis in critically ill patients. J Tr auma 2011; 70(1): Observational- Dx Observational- Dx Observational- Dx Observational- Dx Review/Other- D x Observational-Dx Observational- Dx Observational- Dx Observational- Dx ntrols 32 patient s; 4 blind ed review ers 24 patient s 94 patient s 72 patient s 18 pregna nt patient s had MR CP; 15 pa tients eval uated wit h US 18 pregna nt patient s 55 patient s 62 patient s 127 patie nts 278

292 6. 부록 표 151. 복부핵심질문 3 근거표 핵심질문 3 문헌정보연구유형대상자수문헌질 KCIG 8,959,15 5 visits a t 40 pedi Bachur RG, Hennelly K, Callahan MJ, Chen C, Monute atric eme aux MC. Diagnostic imaging and negative appendectom Observational-Dx rgency d y rates in children: effects of age and gender. Pediatri epartmen cs 2012; 129(5): ts; 55, childre n Sun JS, Noh HW, Min YG, et al. Receiver operating c haracteristic analysis of the diagnostic performance of a computed tomographic examination and the Alvarado 372 patie Observational-Dx score for diagnosing acute appendicitis: emphasis on a nts 2 ge and sex of the patients. J Comput Assist Tomogr 2008; 32(3): Applegate KE, Sivit CJ, Salvator AE, et al. Effect of c ross-sectional imaging on negative appendectomy and 292 child Observational-Dx perforation rates in children. Radiology 2001; 220(1):10 ren Bendeck SE, Nino-Murcia M, Berry GJ, Jeffrey RB, Jr. Imaging for suspected appendicitis: negative appendect 462 patie Observational-Dx omy and perforation rates. Radiology 2002; 225(1):131 nts Chooi WK, Brown JA, Zetler P, Wiseman S, Cooperber g P. Imaging of acute appendicitis and its impact on n egative appendectomy and perforation rates: the St. Pa Observational-Dx 380 appe ndectomi 2 ul's experience. Can Assoc Radiol J 2007; 58(4): es Cuschieri J, Florence M, Flum DR, et al. Negative app endectomy and imaging accuracy in the Washington St 3,540 pat Observational-Dx ate Surgical Care and Outcomes Assessment Program. ients 2 Ann Surg 2008; 248(4): Kim K, Lee CC, Song KJ, Kim W, Suh G, Singer AJ. T he impact of helical computed tomography on the neg 339 patie Observational-Dx ative appendectomy rate: a multi-center comparison. J nts 2 Emerg Med 2008; 34(1):3 6. Lee CC, Golub R, Singer AJ, Cantu R, Jr., Levinson H. Experimental-Dx 152 patie 1 279

293 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 Routine versus selective abdominal computed tomogra phy scan in the evaluation of right lower quadrant pai n: a randomized controlled trial. Acad Emerg Med 200 7; 14(2): Partrick DA, Janik JE, Janik JS, Bensard DD, Karrer F M. Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children. J Pediat r Surg 2003; 38(5): Raja AS, Wright C, Sodickson AD, et al. Negative appe ndectomy rate in the era of CT: an 18-year perspectiv e. Radiology 2010; 256(2): Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCab e CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resource s. N Engl J Med 1998; 338(3): Rao PM, Rhea JT, Rattner DW, Venus LG, Novelline R A. Introduction of appendiceal CT: impact on negative appendectomy and appendiceal perforation rates. Ann Surg 1999; 229(3): Hershko DD, Sroka G, Bahouth H, Ghersin E, Mahajna A, Krausz MM. The role of selective computed tomogr aphy in the diagnosis and management of suspected a cute appendicitis. Am Surg 2002; 68(11): Raman SS, Lu DS, Kadell BM, Vodopich DJ, Sayre J, Cryer H. Accuracy of nonfocused helical CT for the dia gnosis of acute appendicitis: a 5-year review. AJR 200 2; 178(6): van Randen A, Bipat S, Zwinderman AH, Ubbink DT, S toker J, Boermeester MA. Acute appendicitis: meta-an alysis of diagnostic performance of CT and graded co Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Review/Other-D x nts 616 child ren 719-bed tertiary c are adult teaching hospital; 58,000 a nnual em ergency departme nt visits 100 patie nts 493 ( ) 209 (199 7) 206 (without subseque nt appen d e c t o m y) 308 patie nts 650 patie nts 6 studie s; 671 p atients

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295 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 Kim K, Kim YH, Kim SY, et al. Low-dose abdominal C T for evaluating suspected appendicitis. N Engl J Med 2012; 366(17): Johnson PT, Horton KM, Kawamoto S, et al. MDCT for suspected appendicitis: effect of reconstruction section thickness on diagnostic accuracy, rate of appendiceal v isualization, and reader confidence using axial images. AJR 2009; 192(4): Kim HC, Yang DM, Jin W, Park SJ. Added diagnostic value of multiplanar reformation of multidetector CT da ta in patients with suspected appendicitis. Radiographic s 2008; 28(2): ; discussion Neville AM, Paulson EK. MDCT of acute appendicitis: v alue of coronal reformations. Abdom Imaging 2009; 34 (1): Lane MJ, Liu DM, Huynh MD, Jeffrey RB, Jr., Mindelz un RE, Katz DS. Suspected acute appendicitis: nonenh anced helical CT in 300 consecutive patients. Radiolog y 1999; 213(2): Hlibczuk V, Dattaro JA, Jin Z, Falzon L, Brown MD. Di agnostic accuracy of noncontrast computed tomography for appendicitis in adults: a systematic review. Ann E merg Med 2010; 55(1):51 59 e51. Anderson SW, Soto JA, Lucey BC, et al. Abdominal 64 -MDCT for suspected appendicitis: the use of oral and IV contrast material versus IV contrast material only. A JR 2009; 193(5): Kepner AM, Bacasnot JV, Stahlman BA. Intravenous co ntrast alone vs intravenous and oral contrast computed tomography for the diagnosis of appendicitis in adult E D patients. Am J Emerg Med 2012; 30(9): Experimental-Dx Observational-Dx Review/Other-D x Review/Other-D x Observational-Dx Review/Other-D x Experimental-Dx Experimental-Dx 891 patie nts patie nts 1 N/A 2 N/A cons ecutive p 2 atients 7 studie s; 1,060 2 patients 303: 151 Gr o u p 1: 64 M DCT with oral and IV contra 2 st; 152- Group 2: 64-MDCT with IV c ontrast o nly 114 IV p atients a nd 113 I 2 V and or al contra st patient 282

296 6. 부록 Keyzer C, Cullus P, Tack D, De Maertelaer V, Bohy P, Gevenois PA. MDCT for suspected acute appendicitis i n adults: impact of oral and IV contrast media at stan dard-dose and simulated low-dose techniques. AJR 20 09; 193(5): Pickhardt PJ, Lawrence EM, Pooler BD, Bruce RJ. Dia gnostic performance of multidetector computed tomogr aphy for suspected acute appendicitis. Ann Intern Med 2011; 154(12): , W-291. Barger RL, Jr., Nandalur KR. Diagnostic performance of magnetic resonance imaging in the detection of appen dicitis in adults: a meta-analysis. Acad Radiol 2010; 17 (10): Cobben L, Groot I, Kingma L, Coerkamp E, Puylaert J, Blickman J. A simple MRI protocol in patients with cli nically suspected appendicitis: results in 138 patients a nd effect on outcome of appendectomy. Eur Radiol 20 09; 19(5): Heverhagen JT, Pfestroff K, Heverhagen AE, Klose KJ, Kessler K, Sitter H. Diagnostic accuracy of magnetic re sonance imaging: a prospective evaluation of patients with suspected appendicitis (diamond). J Magn Reson I maging 2012; 35(3): Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Syste matic review: computed tomography and ultrasonograp hy to detect acute appendicitis in adults and adolescen ts. Ann Intern Med 2004; 141(7): Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for Diagnosis of Appendicitis in children and Adult s? A Meta-Analysis. Radiology 2006; 241(1): Baldisserotto M, Marchiori E. Accuracy of noncompress ive sonography of children with appendicitis according to the potential positions of the appendix. AJR 2000; 175(5): Experimental-Dx Observational-Dx Review/Other-D x Observational-Dx Observational-Dx Review/Other-D x Review/Other-D x Observational-Dx s 131 cons ecutive p atients 2,871 ad ults 8 article s; 363 to tal patien ts 138 patie nts 52 patien ts 12 CT st udies an d 14 US studies children: (26 studi es, 9,356 patients); Adults (3 1 studie s, 4,341 patients) 425 patie nts Hahn HB, Hoepner FU, Kalle T, et al. Sonography of a cute appendicitis in children: 7 years experience. Pedia Observational-Dx 3,859 chi ldren 2 283

297 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 tr Radiol 1998; 28(3): Lessin MS, Chan M, Catallozzi M, et al. Selective use of ultrasonography for acute appendicitis in children. A m J Surg 1999; 177(3): Schulte B, Beyer D, Kaiser C, Horsch S, Wiater A. Ultr asonography in suspected acute appendicitis in childho od-report of 1285 cases. Eur J Ultrasound 1998; 8(3): Krishnamoorthi R, Ramarajan N, Wang NE, et al. Effect iveness of a staged US and CT protocol for the diagno sis of pediatric appendicitis: reducing radiation exposur e in the age of ALARA. Radiology 2011; 259(1): Bachur RG, Hennelly K, Callahan MJ, Monuteaux MC. Advanced radiologic imaging for pediatric appendicitis, : trends and outcomes. J Pediatr 2012; 16 0(6): Kim YJ, Kim JE, Kim HS, Hwang HY. MDCT with coro nal reconstruction: clinical benefit in evaluation of susp ected acute appendicitis in pediatric patients. AJR 200 9; 192(1): Johnson AK, Filippi CG, Andrews T, et al. Ultrafast 3- T MRI in the evaluation of children with acute lower a bdominal pain for the detection of appendicitis. AJR 2 012; 198(6): Moore MM, Gustas CN, Choudhary AK, et al. MRI for clinically suspected pediatric appendicitis: an implement ed program. Pediatr Radiol 2012; 42(9): Lim HK, Bae SH, Seo GS. Diagnosis of acute appendic itis in pregnant women: value of sonography. AJR 199 2; 159(3): Lazarus E, Mayo-Smith WW, Mainiero MB, Spencer P K. CT in the evaluation of nontraumatic abdominal pain in pregnant women. Radiology 2007; 244(3): Basaran A, Basaran M. Diagnosis of acute appendicitis during pregnancy: a systematic review. Obstet Gynecol Surv 2009; 64(7): ; quiz 499. Israel GM, Malguria N, McCarthy S, Copel J, Weinreb J. MRI vs. ultrasound for suspected appendicitis during pregnancy. J Magn Reson Imaging 2008; 28(2): Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Review/Other-D x Observational-Dx 215 child ren 1,285 chi ldren 631 patie nts 55,238 c hildren 61 patien ts 42 patien ts 208 child ren 45 patien ts 78 patien ts 3 articles on CT; 5 articles o n MRI 33 patien ts

298 6. 부록 Oto A, Ernst RD, Ghulmiyyah LM, et al. MR imaging i n the triage of pregnant patients with acute abdominal and pelvic pain. Abdom Imaging 2009; 34(2): Pedrosa I, Levine D, Eyvazzadeh AD, Siewert B, Ngo L, Rofsky NM. MR imaging evaluation of acute appendi citis in pregnancy. Radiology 2006; 238(3): Blumenfeld YJ, Wong AE, Jafari A, Barth RA, El-Saye d YY. MR imaging in cases of antenatal suspected app endicitis--a meta-analysis. J Matern Fetal Neonatal M ed 2011; 24(3): Pedrosa I, Lafornara M, Pandharipande PV, Goldsmith J D, Rofsky NM. pregnant patients suspected of having acute appendicitis: effect of MR imaging on negative l aparotomy rate and appendiceal perforation rate. Radiol ogy 2009; 250(3): Observational-Dx Observational-Dx Review/Other-D x Observational-Dx 118 patie nts 51 patien ts 229 patie nts 148; Mea n gestati onal age, 20 week s

299 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2.7. 비뇨분과 가. 핵심질문선정 1 1) PICO 의선정 표 152. 비뇨 PICO 선정 Population Intervention Comparator Outcome 현미경적혈뇨 (microscopic hem aturia) 로내원한정상신기능어 른환자육안적혈뇨 (gross hematuria) 로 내원한정상신기능어른환자현미경적혈뇨 (microscopic hem aturia) 로내원한신기능저하어른 환자육안적혈뇨 (gross hematuria) 로 1-4 내원한신기능저하어른환자 가임기환자 2-2 폐경기환자 조직검사로증명된전립선암고위 험환자 ( 고위험군 : 1) PSA>20 ng/ml or Gleason score>7 or clinical st age T2C / 2) clinical stage T 3-4 or N(+) (any PSA any Gl eason score) 조직검사로증명된전립선암저위 험환자 ( 저위험군 : PSA<10 ng/ml and Gleason score<7 and clinical s tage T1-T2A) 조영증강 CT 경질초음파 MRI US MRI CT 혈뇨의원인질환 d etection, 유용성 자궁내막병변 임상적 진단 정확성, 임상적유 용성 전립선암특이생존 률, 전립선암병기, 임상적유용성 286

300 6. 부록 2) 문장형핵심질문표 153. 비뇨문장형핵심질문핵심질문 핵심질문 1 기타증상이없이혈뇨로내원한어른환자의비뇨기계종양진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-1 기타증상이없이혈뇨로내원한정상신기능어른환자의비뇨기계종양진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-2 기타증상이없이혈뇨로내원한정상신기능어른환자의비뇨기계종양진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-3 기타증상이없이혈뇨로내원한신기능저하어른환자의비뇨기계종양진단을위한적절한영상검사는무엇인가? 세부핵심질문 1-4 기타증상이없이혈뇨로내원한신기능저하어른환자의비뇨기계종양진단을위한적절한영상검사는무엇인가? 핵심질문 2 비정상질출혈을주호소로내원한환자의자궁내막병변진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-1 비정상질출혈을주호소로내원한가임기환자의자궁내막병변진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-2 비정상질출혈을주호소로내원한폐경기환자의자궁내막병변진단을위한적절한영상검사는무엇인가? 핵심질문 3 조직검사로확인된전립선암환자의평가를위한적절한영상검사는무엇인가? 세부핵심질문 3-1 조직검사로확인된전립선암고위험환자의평가를위한적절한영상검사는무엇인가? 세부핵심질문 3-2 조직검사로확인된전립선암저위험환자의평가를위한적절한영상검사는무엇인가? 나. 핵심질문별진료지침검색 1) 핵심질문 1 검색대상핵심질문 KQ 1. 기타증상이없는혈뇨로내원한어른환자의비뇨기계종양진단을위한적절한검사는무엇인가? 국내DB 검색전략및결과표 154. 비뇨국내문헌DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 1 hematuria [ALL] 0 2 Urologic Neoplasms [ALL] 0 287

301 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 3 urinary tract cancer [ALL] 0 2. KMBASE 1 ([ALL=hematuria] AND [ALL= 지침 ]) 0 2 ([ALL=hematuria] AND [ALL= 권고 ]) 0 3 ([ALL=hematuria] AND [ALL= 가이드라인 ]) 0 4 ([ALL=hematuria] AND [ALL=recommendation]) 1 5 ([ALL=hematuria] AND [ALL=guideline]) 8 6 ([ALL=Urologic Neoplasms] AND [ALL= 지침 ]) 0 7 ([ALL=Urologic Neoplasms] AND [ALL= 권고 ]) 0 8 ([ALL=Urologic Neoplasms] AND [ALL= 가이드라인 ]) 0 9 ([ALL=Urologic Neoplasms] AND [ALL=recommendation]) 0 10 ([ALL=Urologic Neoplasms] AND [ALL=guideline]) 0 11 ([ALL=urinary tract cancer] AND [ALL= 지침 ]) 0 12 ([ALL=urinary tract cancer] AND [ALL= 권고 ]) 0 13 ([ALL=urinary tract cancer] AND [ALL= 가이드라인 ]) 0 14 ([ALL=urinary tract cancer] AND [ALL=recommendation]) 0 15 ([ALL=urinary tract cancer] AND [ALL=guideline]) 0 16 ([ALL= 혈뇨 ] AND [ALL= 지침 ]) 1 17 ([ALL= 혈뇨 ] AND [ALL= 권고 ]) 0 18 ([ALL= 혈뇨 ] AND [ALL= 가이드라인 ]) 0 19 ([ALL= 혈뇨 ] AND [ALL=recommendation]) 0 20 ([ALL= 혈뇨 ] AND [ALL=guideline]) 4 표 155. 비뇨국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 288

302 6. 부록 국외DB 검색전략및결과 표 156. 비뇨국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 1 exp Hematuria/ P 2 exp Urologic Neoplasms/ or exp Tomography, X-Ray Computed/ or CT.mp Comput$ Tomogr$.mp or enhanced.mp contrast.mp 검사 9 7 or and exp Urography/ ultrasonogra$.mp exp Ultrasonography/ Sonogra$.mp or 10 or 11 or 12 or 13 or P& 검사 16 3 and guideline.pt practice guideline.pt 제외기 19 guideline$.ti 준 20 recommendation$.ti standard$.ti or 18 or 19 or 20 or P&G and 연도 24 limit 23 to yr="2000 -Current" 67 표 157. 비뇨국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 P 검사 1 exp hematuria/ Urologic Neoplasms.mp. or exp urinary tract cancer/ or CT.mp computer assisted tomography/ or Comput$ Tomogr$.mp or

303 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 7 enhanced.mp exp contrast/ or exp contrast induced nephropathy/ or exp co ntrast enhancement/ or and exp urography/ ultrasonogra$.mp. or exp echography/ Ultrasonography.mp Sonogra$.mp. or exp ultrasound/ or 10 or 11 or 12 or 13 or P& 검사 16 3 and 제외기 준 17 guideline$.ti recommendation$.ti or P&I&G and 연도 21 limit 20 to yr="2000 -Current" 117 표 158. 비뇨국외 GIN 검색일 : N 검색어 검색결과 1 Urologic Neoplasms 11 2 urinary tract cancer 0 3 hematuria 0 표 159. 비뇨국외 NGC 검색일 : N 검색어 검색결과 1 hematuria and Urologic Neoplasms 1 2 hematuria and urinary tract cancer 7 290

304 6. 부록 2) 핵심질문 2 검색대상핵심질문 KQ 2. 비정상질출혈을주호소로내원한환자의자궁내막병변진단을위한적절한검사는무엇인가? 국내 DB 검색전략및결과 문헌 DB 표 160. 비뇨국내문헌 DB 검색일 : 검색사이트 N 검색어 1. KoreaMed 1 Uterine Diseases [ALL] 0 2 Endometrial pathology [ALL] 0 3 vaginal bleeding [ALL] 0 4 Uterine Hemorrhage [ALL] 0 5 vaginal spotting [ALL] 0 관련문 헌 비고 291

305 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 검색사이트 N 검색어 2. KMBASE 1 ([ALL=Uterine Diseases] AND [ALL= 권고 ]) 0 2 ([ALL=Uterine Diseases] AND [ALL= 가이드라인 ]) 0 3 ([ALL=Uterine Diseases] AND [ALL=recommendation]) 0 4 ([ALL=Uterine Diseases] AND [ALL=guideline]) 0 5 ([ALL=Endometrial pathology] AND [ALL= 지침 ]) 0 6 ([ALL=Endometrial pathology] AND [ALL= 권고 ]) 0 7 ([ALL=Endometrial pathology] AND [ALL= 가이드라인 ]) 0 8 ([ALL=Endometrial pathology] AND [ALL=recommendation]) 0 9 ([ALL=Endometrial pathology] AND [ALL=guideline]) 0 10 ([ALL=vaginal bleeding] AND [ALL= 지침 ]) 0 11 ([ALL=vaginal bleeding] AND [ALL= 권고 ]) 0 12 ([ALL=vaginal bleeding] AND [ALL= 가이드라인 ]) 0 13 ([ALL=vaginal bleeding] AND [ALL=recommendation]) 0 14 ([ALL=vaginal bleeding] AND [ALL=guideline]) 0 15 ([ALL=Uterine Hemorrhage] AND [ALL= 지침 ]) 0 16 ([ALL=Uterine Hemorrhage] AND [ALL= 권고 ]) 0 17 ([ALL=Uterine Hemorrhage] AND [ALL= 가이드라인 ]) 0 18 ([ALL=Uterine Hemorrhage] AND [ALL=recommendation]) 0 19 ([ALL=Uterine Hemorrhage] AND [ALL=guideline]) 0 20 ([ALL=vaginal spotting] AND [ALL= 지침 ]) 0 21 ([ALL=vaginal spotting] AND [ALL= 권고 ]) 0 22 ([ALL=vaginal spotting] AND [ALL= 가이드라인 ]) 0 23 ([ALL=vaginal spotting] AND [ALL=recommendation]) 0 24 ([ALL=vaginal spotting] AND [ALL=guideline]) 0 25 ([ALL= 자궁내막병 ] AND [ALL= 지침 ]) 0 26 ([ALL= 자궁내막병 ] AND [ALL= 권고 ]) 0 27 ([ALL= 자궁내막병 ] AND [ALL= 가이드라인 ]) 0 28 ([ALL= 자궁내막병 ] AND [ALL=recommendation]) 0 29 ([ALL= 자궁내막병 ] AND [ALL=guideline]) 0 관련문 헌 비고 표 161. 비뇨국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 292

306 6. 부록 국외 DB 검색전략및결과 표 162. 비뇨국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 1 "vaginal bleeding".mp. or exp Uterine Hemorrhage/ vaginal spotting.mp exp Hemorrhage/ P 4 exp Hysterectomy, Vaginal/ and "uterine bleeding".mp exp Uterine Diseases/ or Endometrial pathology.mp or 2 or 5 or 6 or exp Urography/ ultrasonogra$.mp 검사 11 exp Ultrasonography/ Sonogra$.mp exp Magnetic Resonance Imaging/ or MRI.mp or/ P& 검사 15 8 and guideline.pt practice guideline.pt 제외기 18 guideline$.ti 준 19 recommendation$.ti standard$.ti or 17 or 18 or 19 or P&I&G and 연도 23 limit 22 to yr="2000 -Current" 69 표 163. 비뇨국외 Ovid-Embase 검색일 : P 구분 N 검색어검색결과 1 "vaginal bleeding".mp. or exp Uterine Hemorrhage/ vaginal spotting.mp exp Hemorrhage/ exp Hysterectomy, Vaginal/ and "uterine bleeding".mp exp uterus disease/ 검사 8 1 or 2 or 5 or 6 or

307 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 9 exp urography/ ultrasonogra$.mp. or exp echography/ Ultrasonography.mp Sonogra$.mp. or exp ultrasound/ MRI.mp. or exp nuclear magnetic resonance imaging/ or/ P& 검사 15 8 and guideline$.ti 제외기 17 recommendation$.ti 준 or P&I&G and 연도 20 limit 19 to yr="2000 -Current" 151 표 164. 비뇨국외 GIN 검색일 : N 검색어검색결과 1 uterine diseases 4 2 vaginal bleeding 0 3 vaginal spotting 0 표 165. 비뇨국외 NGC 검색일 : N 검색어 검색결과 1 hemorrhage and uterine diseases 15 2 vaginal bleeding and uterine diseases 29 3 vaginal spotting and uterine diseases 6 294

308 6. 부록 3) 핵심질문 3 검색대상핵심질문 KQ 3. 조직검사로확인된전립선암환자의평가를위한적절한검사는무엇인가? 국내 DB 검색전략및결과 표 166. 비뇨국내문헌 DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 2. KMBASE 1 prostate cancer [ALL] 0 2 Prostatic Neoplasms [ALL] 0 1 ([ALL=prostate cancer] AND [ALL= 지침 ]) 0 2 ([ALL=prostate cancer] AND [ALL= 권고 ]) 1 3 ([ALL=prostate cancer] AND [ALL= 가이드라인 ]) 0 4 ([ALL=prostate cancer] AND [ALL=recommendation]) 7 5 ([ALL=prostate cancer] AND [ALL=guideline]) 14 6 ([ALL=prostate cancer] AND [ALL= 지침 ]) 0 7 ([ALL=prostate cancer] AND [ALL= 권고 ]) 1 8 ([ALL=prostate cancer] AND [ALL= 가이드라인 ]) 0 9 ([ALL=prostate cancer] AND [ALL=recommendation]) 7 10 ([ALL=prostate cancer] AND [ALL=guideline]) ([ALL=Prostatic Neoplasms] AND [ALL= 지침 ]) 1 12 ([ALL=Prostatic Neoplasms] AND [ALL= 권고 ]) 0 13 ([ALL=Prostatic Neoplasms] AND [ALL= 가이드라인 ]) 0 14 ([ALL=Prostatic Neoplasms] AND [ALL=recommendation]) 1 15 ([ALL=Prostatic Neoplasms] AND [ALL=guideline]) 5 16 ([ALL= 전립선암 ] AND [ALL= 지침 ]) 0 17 ([ALL= 전립선암 ] AND [ALL= 권고 ]) 2 18 ([ALL= 전립선암 ] AND [ALL= 가이드라인 ]) 0 19 ([ALL= 전립선암 ] AND [ALL=recommendation]) 4 20 ([ALL= 전립선암 ] AND [ALL=guideline]) 5 표 167. 비뇨국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 3 소계 ( 0건 ) 295

309 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 국외DB 검색전략및결과 표 168. 비뇨국외 Ovid-Medline 검색일 : 구분 N 검색어 검색결과 P 1 exp Prostatic Neoplasms/ exp Magnetic Resonance Imaging/ or MRI.mp exp Tomography, X-Ray Computed/ or CT.mp Comput$ Tomogr$.mp or 검사 6 enhanced.mp contrast.mp or and or 5 or P& 검사 11 1 and guideline.pt practice guideline.pt 제외기 14 guideline$.ti 준 15 recommendation$.ti standard$.ti or 13 or 14 or 15 or P&I&G and 연도 19 limit 18 to yr="2000 -Current" 76 종합 표 169. 비뇨국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 P 1 exp prostate cancer/ MRI.mp. or exp nuclear magnetic resonance imaging/ CT.mp computer assisted tomography/ or Comput$ Tomogr$.mp or enhanced.mp 검사 exp contrast/ or exp contrast induced nephropathy/ or exp con trast enhancement/ 8 6 or and or 5 or P& 검사 11 1 and

310 6. 부록 제외기 12 guideline$.ti 준 13 recommendation$.ti or P&I&G and 연도 16 limit 15 to yr="2000 -Current" 101 종합 표 170. 비뇨국외 GIN 검색일 : N 검색어검색결과 1 prostatecancer 18 2 Prostatic Neoplasms 20 표 171. 비뇨국외 NGC 검색일 : N 검색어 검색결과 1 prostate cancer and diagnosis 6 2 Prostatic Neoplasms and diagnosis

311 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 다. 진료지침선별 1) 핵심질문 1 흐름도 2) 핵심질문 2 흐름도 그림 26. 비뇨핵심질문 1 흐름도. 그림 27. 비뇨핵심질문 2 흐름도. 298

312 6. 부록 3) 핵심질문 3 흐름도 그림 28. 비뇨핵심질문 3 흐름도. 라. 진료지침평가 1) 진료지침질평가결과표 172. 비뇨핵심질문 1 질평가결과 핵심질문 1 지침제목 AGREE점수 개발위원회의견 Japanese guidelines of the management of hematuria 추천 Diagnosis, Evaluation and Follow-up of Asymptomatic Microhe maturia(amh) in Adults: AUA Guideline 39 추천 ACR Prostate Cancer Pretreatment Detection, Staging, and Surveillance 69 추천 RCR irefer 7th Prostate Cancer 67 추천 299

313 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 173. 비뇨핵심질문 2 질평가결과 핵심질문 2 지침제목 AGREE 점수개발위원회의견 Diagnosis of Abnormal Uterine Bleeding in Reproductive-age d Women 33 추천 Investigation of Women with Postmenopausal Uterine Bleedin g: Clinical Practice Recommendations 35 추천 Evaluation and management of ovulatory heavy menstrual bleeding (HMB) in primary care 41 추천 Clinical practice guidelines on menorrhagia: management of a bnormal uterine bleeding before menopause 24 추천 Abnormal Uterine Bleeding in Pre-Menopausal Women 38 추천 (2014) ACR guideline_abnormal Vaginal Bleeding 69 추천 표 174. 비뇨핵심질문 3 질평가결과 핵심질문 3 지침제목 AGREE 점수개발위원회의견 Prostate cancer: ESMO Clinical Practice Guidelines for diagno sis, treatment and follow-up 13 추천 Prostate Cancer, version 추천 Guidelines on Prostate Cancer 41 추천 2) 수용성과적용성평가결과 표 175. 비뇨핵심질문 1 수용성과적용성평가결과 핵심질문 1 구 평가항목지침 A 지침 B 지침 C 지침 D 분 수 인구집단 ( 유병률, 발생률등 ) 이유사하다. 예 예 불확실 불확실 가치와선호도가유사하다. 예예예예용권고로인한이득은유사하다. 예예예예성해당권고는수용할만하다. 예예예예 적 해당중재및장비는이용가능하다. 예 예 예 예 필수적인전문기술이이용가능하다. 예예예예용법률적 / 제도적장벽이없다. 예예예예성해당권고는적용할만하다. 예예예예 지침 A : (2013) Japanese guidelines of the management of hematuria 2013 지침 B : (2012) Diagnosis, Evaluation and Follow-up of Asymptomatic Microhematuria(AMH) in Adults: AUA Guideline 지침 C : (2014) ACR Guideline_Prostate Cancer Pretreatment Detection, Staging, and Surveillance 지침 D : RCR irefer 7th 300

314 6. 부록 표 176. 비뇨핵심질문 2 수용성과적용성평가결과 핵심질문 2 구지침지침지침지침지침평가항목지침 F 분 A B C D E 수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예예예예예예가치와선호도가유사하다. 예예예예예예용권고로인한이득은유사하다. 예예예예예예성해당권고는수용할만하다. 예예예예예예적해당중재및장비는이용가능하다. 예예예예예예필수적인전문기술이이용가능하다. 예예예예예예용법률적 / 제도적장벽이없다. 예예예예예예성해당권고는적용할만하다. 예예예예예예지침 A : (2012) Diagnosis of Abnormal Uterine Bleeding in Reproductive-aged Women 지침 B : (2014) Investigation of Women with Postmenopausal Uterine Bleeding: Clinical Practice Recommendations 지침 C : (2012) Evaluation and management of ovulatory heavy menstrual bleeding (HMB) in primary care 지침 D : (2010) Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause 지침 E : (2013) Abnormal Uterine Bleeding in Pre-Menopausal Women 지침 F : ACR guideline_abnormal Vaginal Bleeding 표 177. 비뇨핵심질문 3 수용성과적용성평가결과 핵심질문 3 구평가항목지침 A 지침 B 지침 C 분수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예예예가치와선호도가유사하다. 예예예용권고로인한이득은유사하다. 불확실불확실예성해당권고는수용할만하다. 불확실불확실예적해당중재및장비는이용가능하다. 예예예필수적인전문기술이이용가능하다. 예예예용법률적 / 제도적장벽이없다. 예예예성해당권고는적용할만하다. 불확실불확실예지침 A : (2015) Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up 지침 B : (2014) Prostate Cancer, version 지침 C : (2015) Guidelines on Prostate Cancer 301

315 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 마. 핵심질문별권고및근거정리 1) 권고비교표표 178. 비뇨핵심질문 1 권고비교표 핵심질문 1 구분 지침 A 지침 B 지침 C 지침 D Most adults with gro ss or persistent micr ohematuria 현미경적혈뇨에서위험 권고 require urinary tract i 도가낮은환자의경우성인의무증상현미경적 25세이상성인환자의 maging, with CTU re 초음파가 upper tract 혈뇨가이드라인임. 육안적혈뇨를영상의학 placing the traditional 의평가를위해일차적무증상혈뇨의초기평가적으로평가할때 CT u IVU for this indicatio 으로권고된다. 비조영증에는영상의학적평가가 rography 는높은민감 n. 강 CT 는초음파나단반드시포함되어야하며도특이도를보이며육순촬영에서보이지않는 CT urography 가상부안적혈뇨의 primary i * 신실질질환이혈뇨의결석을찾는데유용하요로의평가에민감도 maging modality 임. 원인으로생각되는환자다. 위험도가높은현미특이도가가장높기때초음파는 screening 용 : 신장및방광초음파경적혈뇨환자의경우문에 imaging of choic 도로권장할수있음. (usually appropriate, r 초음파가일차적인검사 e 임. 신기능저하, 조영 MR urography 는폐쇄 ating 8). CT 및 MRI 이나, 혈뇨가지속되거나제알러지, 임신등으로성요로병변을평가하는는 usually not approp urine cytology 에서이 CTU 를촬영할수없는데주로r권장됨. IVP는 riate (rating 2) 상이있는경우, 또는경우 MRU 가대안이며, CT urography 가널리 ** 신실질질환도없고 tra 이전요로계악성종양 MRU 는집합계의평가쓰이고있고더많은정 uma / infection / rec 병력이있는경우 CTU 에제한이있으므로집보를줌에따라육안적 ent menstruation 도를고려하여야한다. 합계의평가가반드시혈뇨의평가에권장되지없는혈뇨환자 : Pre+ 육안적혈뇨의경우, 저필요한경우 MRU 와않음. CT urography 가 post contrast CT (us 위험군에서는초음파를, 함께 RGU 를시행할방광평가에제한이있 ually appropriate, rati 초음파상이상이있거수있다. 또는 MRI 와고 cystoscopy 를대체 ng 9). RGU 는조영제나고위험군의경우 CT CT 모두에절대적또는할수없음. 육안적혈알러지가있거나 urothe U를시행한다. (Radiat 상대적금기증인환자에뇨의평가는 initial US lial lesion 이 CT 또는 ion dose 문제 ) CTU 서집합계의평가가반 G 와 CT Urography, IVU 상에서강력히의심를시행할수없는경우드시필요한경우비조 cystoscopy 를포함하될때사용 (maybe ap 만 IVU 를시행하며, 임영증강 CT 또는초음파는 multimodal examin propriate rating 6). 초산부, 신부전증, 요오드와함께 RGU 를같이 ation 이필요함. 음파는 initial screenin 조영제알러지의병력이시행할수있다. g tool 로사용가능. 특있는경우 MRU 가대 히악성의위험도가매 안이될수있다. 우낮은환자군이거나 C T 에금기증인환자에서 302

316 6. 부록 권고 initial 로사용가능 (ma y be appropriate rati ng 5), MRI 는 MR ur ography 로촬영하여야 하며요오드성조영제에 금기증일때사용. 등급 B B A B 지침 A : (2013) Japanese guidelines of the management of hematuria 2013 지침 B : (2012) Diagnosis, Evaluation and Follow-up of Asymptomatic Microhematuria(AMH) in Adults: AUA Guideline 지침 C : (2014) ACR_ Prostate Cancer Pretreatment Detection, Staging, and Surveillance 지침 D : RCR irefer 7th 303

317 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 179. 비뇨핵심질문 2 권고비교표 핵심질문 2 구분 지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 비정상질출혈을주소로내원한가임기여성 1. 생리과다출혈시초음파는 권고 에서초기영상기본적인영상비정상질출혈비정상질출혈의학검사로질의학적검사이로내원한폐경로내원한여성초음파를시행다. 초음파결폐경전여성의전여성에서영에서첫영상의한다. 그러나과가불충분할비정상질출혈상의학적검사학적검사로골그결과는폐경경우자궁경검의경우, 골반가필요한경우반초음파 ( 복부기여성의경우폐경기여성의사를시행할수초음파 ( 복부혹 ( 출혈의원인이혹은질 ) 가가보다, 자궁내막비정상질출혈있다. 초음파자은질 ) 는초기해부학적인이장적합하다. 두께측정을이의경우, 질초궁조영술을첫진단술기로권유로생각되거도플러초음파용한진단의정음파혹은자궁번째영상의학장된다. 도플러나, 대증적치가도움이될확도는떨어진내막조직검사적검사로시행검사를통해자료가실패하거수있다. 초음다. 필요시초를시행할것을하지는말아야궁내막과근에나, 악성종양의파자궁조영술은음파자궁조영술권고한다. 한다. 대한추가적인가능성이있는폐경이후의여이나자궁경검 2. 자궁내막암정보를얻을수경우 ), 질초음성에서폐경전사를추가로시의위험인자를도있다. 파가필요한첫여성의경우보행할수있다. 가지고있는 1 번째검사법이다더도움이또한, 청소년기 8-35세여성의다. 될수있다. 환자의경우, 경우, 자궁내막 경복부초음파시행이더적절 생검을시행할수있다. 하다. 권고 Grade A 등급 /Grade B Grade A I-A 지침 A : (2012) Diagnosis of Abnormal Uterine Bleeding in Reproductive-aged Women 지침 B : (2014) Investigation of Women with Postmenopausal Uterine Bleeding: Clinical Practice Recommendations 지침 C : (2012) Evaluation and management of ovulatory heavy menstrual bleeding (HMB) in primary care 지침 D : (2010) Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause 지침 E : (2013) Abnormal Uterine Bleeding in Pre-Menopausal Women 지침 F : ACR guidline_abnormal Vaginal Beelding 304

318 6. 부록 표 180. 비뇨핵심질문 3 권고비교표 핵심질문 3 구분 지침 A 지침 B 지침 C 조직학적으로진단된전립선암환 권고 자에서병기결정을위해전립선조직학적으로진단된전립선암환조직학적으로진단된전립선암환 MRI는유용하다. 하지만, 임상적자에서병기결정을위해전립선자에서병기결정및치료방침수으로임파선전이의위험도가 1 MRI 검사는정확하며수술방침립을위해전립선 MRI 검사가최 0% 미만인경우에서 MRI의유용수림에도움을준다우선적으로권장된다. 성은아직불분명하다 권고 등급지침 A : (2015) Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up 지침 B : (2014) Prostate Cancer, version 지침 C : (2015) Guidelines on Prostate Cancer 2) 근거표표 181. 비뇨핵심질문 1 근거표 핵심질문 1 문헌정보연구유형대상자수문헌질 KCIG S. Horie, S. Ito, H. Okada, H. Kikuchi, I. Narita, T. Nis hiyama, T. Hasegawa, H. Mikami, K. Yamagata, T. Yun o and S. Muto. Japanese guidelines of the manageme Guideline nt of hematuria Clin Exp Nephrol 2014;18: A. J. Van Der Molen and M. C. Hovius. Hematuria: A problem-based imaging algorithm illustrating the recent Review Dutch Guidelines on Hematuria. Am J Roentqenol 201 2;198(6): R. Davis, J. S. Jones, D. A. Barocas, E. P. Castle, E. K. Lang, R. J. Leveillee, E. M. Messing, S. D. Miller, A. C. Peterson, T. M. T. Turk and W. Weitzel. Diagno Guideline sis, evaluation and follow-up of asymptomatic microhe maturia (AMH) in adults: AUA guideline. J Urol. 2012;1 88(6):

319 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 182. 비뇨핵심질문 2 근거표 핵심질문 2 문헌정보연구유형대상자수문헌질 KCIG Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer a nd other endometrial normalities. JAMA 1998 Nov 4;28 review 0(17): Dueholm M, Jensen ML, Laursen H, Kracht P. Can the endometrial thickness as measured by trans-vaginal so nography be used to exclude polyps or hyperplasia in cross sectional pre-menopausal patients with abnormal uterine bleedin g? Acta Obstet Gynecol Scand 2001;80: Breitkopf DM, Frederickson RA, Snyder RR. Detection of benign endometrial masses by endometrial stripe m easurement in premenopausal women. Obstet Gynecol cross sectional ; 104: Dijkhuizen FP, De Vries LD, Mol BW, Brolmann HA, P eters HM, Moret E, et al. Comparison of transvaginal ultrasonography and saline infusion sonography for the cross sectional 50 2 detection of intracavitary abnormalities in premenopaus al women. Ultrasound Obstet Gynecol 2000;15: Munro MG, Critchley HO, Broder MS, Fraser IS, FIGO Working Group on Menstrual Disorders. FIGO classifica tion system (PALM-COEIN) for causes of abnormal ute review 5 rine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet Apr;113(1):3-13. Sweet MG, Schmidt-Dalton TA, W eiss PM, Madsen K P. Evaluation and management of abnormal uterine ble eding in premenopausal women. Am Fam Physician. 2 review Jan 1;85(1): Dimitraki M, Tsikouras P, Bouchlariotou S, et al. Clinica l evaluation of women with PMB. Is it always necessa ry an endometrial biopsy to be performed? A review o review f the literature. Arch Gynecol Obstet. 2011; 283(2): Doubilet PM. Diagnosis of abnormal uterine bleeding w ith imaging. Menopause. 2011; 18(4): review Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal blee review 306

320 6. 부록 ding. Ultrasound Obstet Gynecol. 2004; 24(5): Dijkhuizen FP, Mol BW, Brolmann HA, Heintz AP. Cost -effectiveness of the use of transvaginal sonography i n the evaluation of postmenopausal bleeding. Maturita s. 2003; 45(4): Dubinsky TJ. Value of sonography in the diagnosis of abnormal vaginal bleeding. J Clin Ultrasound. 2004; 32 (7): Smith P, Bakos O, Heimer G, Ulmsten U. Transvaginal ultrasound for identifying endometrial abnormality. Acta Obstet Gynecol. Scand. 1991; 70(7-8): Delisle MF, Villeneuve M, Boulvain M. Measurement of endometrial thickness with transvaginal ultrasonograph y: is it reproducible? J Ultrasound Med. 1998;17(8): ; quiz Shi AA, Lee SI. Radiological reasoning: algorithmic wor kup of abnormal vaginal bleeding with endovaginal son ography and sonohysterography. AJR Am J Roentgeno l. 2008; 191(6 Suppl):S Gupta JK, Chien PF, Voit D, Clark TJ, Khan KS. Ultras onographic endometrial thickness for diagnosing endom etrial pathology in women with postmenopausal bleedin g: a meta-analysis. Acta Obstet Gynecol. Scand. 2002; 81(9): ACOG Committee Opinion No. 426: The role of transv aginal ultrasonography in the evaluation of postmenopa usal bleeding. Obstet Gynecol. 2009; 113(2 Pt 1): Dreisler E, Sorensen SS, Ibsen PH, Lose G. Value of endometrial thickness measurement for diagnosing foca l intrauterine pathology in women without abnormal ut erine bleeding. Ultrasound Obstet Gynecol. 2009; 33( 3): Ozdemir S, Celik C, Gezginc K, Kiresi D, Esen H. Eval uation of endometrial thickness with transvaginal ultras onography and histopathology in premenopausal wome n with abnormal vaginal bleeding. Arch Gynecol Obste t. 2010; 282(4): Goldstein SR. Use of ultrasonohysterography for triage of perimenopausal patients with unexplained uterine bl review review observational 96 observational 55 review 2 review 9031 review observational 686 observational 144 review eeding. Am J Obstet Gynecol. 1994; 170(2): Erdem M, Bilgin U, Bozkurt N, Erdem A. Comparison observational

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322 6. 부록 표 183. 비뇨핵심질문 3 근거표 핵심질문 3 문헌정보연구유형대상자수문헌질 KCIG L. Dickinson, H. U. Ahmed, C. Allen, J. O. Barentsz, B. Carey, J. J. Futterer, S. W. Heijmink, P. Hoskin, A. P. Kirkham, A. R. Padhani, R. Persad, P. Puech, S. Pu nwani, A. Sohaib, B. Tombal, A. Villers and M. Embert on. Scoring Systems Used for the Interpretation and R eporting of Multiparametric MRI for Prostate Cancer De Review 1 tection, Localization, and Characterization: Could Standa rdization Lead to Improved Utilization of Imaging Withi n the Diagnostic Pathway?. J Magn Reson Imaging Jan;37(1):48-58 Parker C, Gillessen S, Heidenreich A, Horwich A; ESM O Guidelines Committee. Prostate cancer: ESMO Clinic al Practice Guidelines for diagnosis, treatment and follo Guideline 1 w-up. Ann Oncol Sep;26 Suppl 5:v69-77 Mohler JL, Kantoff PW, Armstrong AJ, Bahnson RR, C ohen M, D'Amico AV, Eastham JA, Enke CA, Farringto n TA, Higano CS, Horwitz EM, Kane CJ, Kawachi MH, Kuettel M, Kuzel TM, Lee RJ, Malcolm AW, Miller D, Plimack ER, Pow-Sang JM, Raben D, Richey S, Roach M 3rd, Rohren E, Rosenfeld S, Schaeffer E, Small EJ, Guideline 1 Sonpavde G, Srinivas S, Stein C, Strope SA, Tward J, Shead DA, Ho M; National Comprehensive Cancer Net work. Prostate Cancer, Version J Natl Compr Canc Netw May;12(5): Arumainayagam N, Ahmed HU, Moore CM, Freeman A, Allen C, Sohaib SA, Kirkham A, van der Meulen J, Emberton M. Multiparametric MR Imaging for Detection of Clinically Significant Prostate Cancer: A Validation C Cross-sectional 64 2 ohort Study with Transperineal Template Prostate Mapp ing as the Reference Standard. Radiology Sep;26 8(3):761-9 Dickinson L, Ahmed HU, Allen C, Barentsz JO, Carey B, Futterer JJ, Heijmink SW, Hoskin PJ, Kirkham A, P adhani AR, Persad R, Puech P, Punwani S, Sohaib AS, Tombal B, Villers A, van der Meulen J, Emberton M. Magnetic Resonance Imaging for the Detection, Localis ation, and Characterisation of Prostate Cancer: Recom Guideline 1 309

323 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 mendations from a European Consensus Meeting. Eur Urol Apr;59(4): Schimmöller L, Quentin M, Arsov C, Lanzman RS, Hies ter A, Rabenalt R, Antoch G, Albers P, Blondin D. Inte r-reader agreement of the ESUR score for prostate M RI using in-bore MRI-guided biopsies as the reference standard. Eur Radiol Nov;23(11): Falchook AD, Hendrix LH, Chen RC. Guideline-Discorda nt Use of Imaging During Work-Up of Newly Diagnose d Prostate Cancer. J Oncol Pract Mar;11(2):e Barentsz JO, Richenberg J, Clements R, Choyke P, Ve rma S, Villeirs G, Rouviere O, Logager V, Fütterer JJ; European Society of Urogenital Radiology. ESUR prosta te MR guidelines Eur Radiol Apr;22(4): N. Mottet (Chair), J. Bellmunt, E. Briers (Patient Repre sentative), R.C.N. van den Bergh (Guidelines Associat e), M. Bolla, N.J. van Casteren (Guidelines Associate), P. Cornford, S. Culine, S. Joniau, T. Lam, M.D. Mason, V. Matveev, H. van der Poel, T.H. van der Kwast, O. Rouvière, T. Wiegel. Guidelines on Prostate Cancer. Eu ropean Association of Urology 2015 de Rooij M, Hamoen EH, Witjes JA, Barentsz JO, Rov ers MM. Accuracy of Magnetic Resonance Imaging for Local Staging of Prostate Cancer: A Diagnostic Meta-a nalysis. Eur Urol Jul 24 Wang L, Hricak H, Kattan MW, Schwartz LH, Eberhard t SC, Chen HN, Scardino PT. Combined Endorectal and Phased-Array MRI in the Prediction of Pelvic Lymph N ode Metastasis in Prostate Cancer. AJR Am J Roentge nol Mar;186(3): Hamoen EH, de Rooij M, Witjes JA, Barentsz JO, Rov ers MM. Use of the Prostate Imaging Reporting and D ata System (PI-RADS) for Prostate Cancer Detection w ith Multiparametric Magnetic Resonance Imaging: A Dia gnostic Meta-analysis. Eur Urol Jun;67(6): Cross-sectional 67 2 Cross-sectional Guideline 1 Guideline 1 Meta-analysis Cross-sectional Meta-analysis

324 6. 부록 2.8. 근골격분과 가. 핵심질문선정 1) PICO의선정표 184. 근골격 PIOO 선정 Population Intervention Comparator Outcome 1 천장골주변의통증을호소하는성인 seronegative spondylo arthropathy( 혈청음성척 Sacroiliac joint s 추관절염 or 혈청음성 CT, MRI eries X-ray 척추관절병증 ) 진단을위한영상검사의임상적유용성 만져지는연부조직종괴를주소로내 X-ray MRI, CT, US 원하여첫번째검사를시행할성인연부조직종양진단을위 2-2 만져지는연부조직종괴를주소로내원하여 X-ray 검사에서특이소견없 MRI CT, US 한영상검사의임상적유용성 어다음검사를진행할성인 비외상성무릎통증을호소하여첫번 X-ray, CT, U 째검사를시행하는성인환자 S 비외상성무릎통증의원 비외상성무릎통증을호소하여첫번 MRI 인규명에있어서 MRI의 3-2 째 X-ray검사에서이상이없는성인환자 CT, US 유용성 2) 문장형핵심질문표 185. 근골격문장형핵심질문핵심질문 핵심질문 1 천장골주변의통증을호소하며병원에처음내원한성인에서혈청음성척추관절염 ( 또는혈청음성척추관절병증 ) 진단을위한적절한영상검사는무엇인가? 핵심질문 2 만져지는연부조직종괴를주호소로내원한성인에서연부조직종양진단을위한적절한영상검사는무엇인가? 세부핵심질문 2-1 만져지는연부조직종괴를주호소로내원한성인에서연부조직종양진단을위한일차검사로적절한영상검사는무엇인가? 세부핵심질문 2-2 만져지는연부조직종괴를주호소로내원하여 X-ray 검사후특이소견이없는성인에서후속검사로적절한영상검사는무엇인가? 핵심질문 3 비외상성무릎통증을호소하는어른환자에서통증의원인을규명하기위한적절한영상검사는무엇인가? 세부핵심질문 3-1 비외상성무릎통증을호소하는어른환자에서일차검사로적절한영상검사는무엇인가? 세부핵심질문 3-2 비외상성무릎통증을호소하는어른환자에서 X-ray 검사결과이상이없을때후속검사로적절한영상검사는무엇인가? 311

325 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 나. 핵심질문별진료지침검색 1) 핵심질문 1 검색대상핵심질문 KQ 1. 아래허리통증을 (Lower back pain) 호소하며병원에처음내원한성인에서혈청음성척추관절염 (or 혈청음성척추관절병증진단을위한적절한영상의학검사또는핵의학검사는무엇인가? 국내 DB 검색전략및결과 표 186. 근골격국내문헌 DB 검색일 : 검색사이 트 N 검색어 관련문 헌 비고 1. KoreaMed 1 "lower back pain" [ALL] 0 2 "lower back" [ALL] 0 1 [ALL=lower back pain] AND [ALL=guideline]) 3 2. KMBASE 2 [ALL=lower back pain] AND [ALL=recommendation]) 0 3 [ALL=lower back pain] AND [ALL= 가이드라인 ]) 0 6 [ALL=lower back pain] AND [ALL= 권고 ]) 0 7 ([ALL=lower back pain] AND [ALL= 지침 ]) 0 표 187. 근골격국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 312

326 6. 부록 국외 DB 검색전략및결과 표 188. 근골격국외 Ovid-Medline 검색일 : 구분 N 검색어검색결과 P 1 "lower back pain".mp. or exp Low Back Pain/ X-Rays.mp. or exp X-Rays/ exp Tomography, X-Ray Computed/ or CT.mp Comput$ Tomogr$.mp exp Magnetic Resonance Imaging/ or MRI.mp exp Urography/ ultrasonogra$.mp 검사 8 exp Ultrasonography/ Sonogra$.mp "Bone scan".mp Positron-Emission Tomography/ or PET-CT.mp SPECT.mp. or Tomography, Emission-Computed, Single-Photon / "single photon emission computed tomography".mp or/ P& 검사 15 1 and guideline.pt practice guideline.pt 제외기준 18 guideline$.ti recommendation$.ti standard$.ti or/ P&I&G and 연도 23 limit 22 to yr="2000 -Current" 23 종합 23 표 189. 근골격국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 P 1 "lower back pain".mp. or exp low back pain/ exp X ray/ pelvis x-ray.mp CT.mp computer assisted tomography/ or Comput$ Tomogr$.mp MRI.mp. or exp nuclear magnetic resonance imaging/ 검사 7 exp urography/ ultrasonogra$.mp. or exp echography/ Ultrasonography.mp Sonogra$.mp. or exp ultrasound/ Bone scan.mp. or exp bone scintiscanning/ exp positron emission tomography/ or PET-CT.mp

327 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 13 SPECT.mp. or exp single photon emission computer tomograp hy/ or/ P& 검사 15 1 and guideline$.ti 제외기 17 recommendation$.ti 준 18 standard$.ti or/ P&I&G and 연도 21 limit 20 to yr="2000 -Current" 64 종합 64 표 190. 근골격국외 GIN 검색일 : N 검색어 검색결과 1 2 표 191. 근골격국외 NGC 검색일 : N 검색어 검색결과 1 lower back pain 314

328 6. 부록 2) 핵심질문 2 검색대상핵심질문 KQ 2. 만져지는연부조직종괴를주호소로내원한성인에서연부조직종양진단을위한적절한검사는무엇인가? 국내DB 검색전략및결과표 192. 근골격국내문헌DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 2. KMBASE 1 soft tissue tumor [ALL] 0 2 soft tissue [ALL] 1 3 superficial [ALL] mass [ALL] 0 4 palpable [ALL] mass [ALL] 0 1 ([ALL=soft tissue tumor] AND [ALL= 지침 ]) 2 2 ([ALL=soft tissue tumor] AND [ALL= 권고 ]) 0 3 ([ALL=soft tissue tumor] AND [ALL= 가이드라인 ]) 0 4 ([ALL=soft tissue tumor] AND [ALL=recommendation]) 0 5 ([ALL=soft tissue tumor] AND [ALL=guideline]) 3 6 ([ALL=superficial mass] AND [ALL= 지침 ]) 0 7 ([ALL=superficial mass] AND [ALL= 권고 ]) 0 8 ([ALL=superficial mass] AND [ALL= 가이드라인 ]) 0 9 ([ALL=superficial mass] AND [ALL=recommendation]) 0 10 ([ALL=superficial mass] AND [ALL=guideline]) 0 11 ([ALL=palpable mass] AND [ALL= 지침 ]) 0 12 ([ALL=palpable mass] AND [ALL= 권고 ]) 1 13 ([ALL=palpable mass] AND [ALL= 가이드라인 ]) 0 14 ([ALL=palpable mass] AND [ALL=recommendation]) 0 15 ([ALL=palpable mass] AND [ALL=guideline]) 1 16 ([ALL= 연부조직종괴 ] AND [ALL= 지침 ]) 0 17 ([ALL= 연부조직종괴 ] AND [ALL= 권고 ]) 1 18 ([ALL= 연부조직종괴 ] AND [ALL= 가이드라인 ]) 0 19 ([ALL= 연부조직종괴 ] AND [ALL=recommendation]) 0 20 ([ALL= 연부조직종괴 ] AND [ALL=guideline]) 0 21 ([ALL= 연부조직종양 ] AND [ALL= 지침 ]) 0 22 ([ALL= 연부조직종양 ] AND [ALL= 권고 ]) 0 23 ([ALL= 연부조직종양 ] AND [ALL= 가이드라인 ]) 0 24 ([ALL= 연부조직종양 ] AND [ALL=recommendation]) 1 25 ([ALL= 연부조직종양 ] AND [ALL=guideline]) 0 315

329 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 193. 근골격국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 국외 DB 검색전략및결과 표 194. 근골격국외 Ovid-Medline 검색일 : 구분 N 검색어검색결과 1 exp Soft Tissue Neoplasms/ or soft tissue mass.mp P 2 superficial mass.mp palpable mass.mp or 2 or X-Rays.mp. or exp X-Rays/ exp Radiography/ exp Magnetic Resonance Imaging/ or MRI.mp exp Tomography, X-Ray Computed/ or CT.mp 검사 9 Comput$ Tomogr$.mp exp Urography/ ultrasonogra$.mp exp Ultrasonography/ Sonogra$.mp or/ P& 검사 15 4 and guideline.pt practice guideline.pt 제외기 18 guideline$.ti 준 19 recommendation$.ti standard$.ti or 17 or 18 or 19 or P&I&G and 연도 23 limit 22 to yr="2000 -Current" 10 종합 표 195. 근골격국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 exp soft tissue tumor/ or exp soft tissue cancer/ or soft tissu P e mass.mp. 2 superficial mass.mp

330 6. 부록 검사 3 palpable mass.mp or 2 or exp X ray/ exp radiography/ MRI.mp. or exp nuclear magnetic resonance imaging/ CT.mp computer assisted tomography/ or Comput$ Tomogr$.mp exp urography/ ultrasonogra$.mp. or exp echography/ Ultrasonography.mp Sonogra$.mp. or exp ultrasound/ or/ P& 검사 15 4 and guideline$.ti 제외기 17 recommendation$.ti 준 18 standard$.ti or 17 or P&I&G and 연도 21 limit 20 to yr="2000 -Current" 38 종합 표 196. 근골격국외 GIN 검색일 : N 검색어검색결과 1 soft tissue 2 2 superficial 0 3 palpable 0 표 197. 근골격국외 NGC 검색일 : N 검색어검색결과 1 soft tissue tumor 4 2 soft tissue cancer 6 3 soft tissue Neoplasms 0 4 superficial mass 3 5 palpable mass 4 317

331 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 3) 핵심질문 3 검색대상핵심질문 KQ 3. 비외상성무릎통증을호소하는어른환자에서통증의원인을규명하기위한적절한검사는무엇인가? 국내DB 검색전략및결과표 198. 근골격국내문헌 DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 2. KMBASE 1 Knee Joint [ALL] 0 2 knee meniscus [ALL] 0 3 tibiofemoral [ALL] 0 4 femur [ALL] 0 5 patellofemoral [ALL] 0 6 collateral ligament [ALL] 0 1 ([ALL=Knee Joint pain] AND [ALL= 지침 ]) 0 2 ([ALL=Knee Joint pain] AND [ALL= 권고 ]) 0 3 ([ALL=Knee Joint pain] AND [ALL= 가이드라인 ]) 0 4 ([ALL=Knee Joint pain] AND [ALL=recommendation]) 0 5 ([ALL=Knee Joint pain] AND [ALL=guideline]) 0 6 ([ALL= 무릅통증 ] AND [ALL= 지침 ]) 0 7 ([ALL= 무릅통증 ] AND [ALL= 권고 ]) 0 8 ([ALL= 무릅통증 ] AND [ALL= 가이드라인 ]) 0 9 ([ALL= 무릅통증 ] AND [ALL=recommendation]) 0 10 ([ALL= 무릅통증 ] AND [ALL=guideline]) 0 표 199. 근골격국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 국외DB 검색전략및결과표 200. 근골격국외 Ovid-Medline 검색일 : 구분 N 검색어검색결과 318

332 6. 부록 1 Femur/ or tibiofemoral.mp exp Patellofemoral Joint/ or patellofemoral.mp exp Patella/ exp Menisci, Tibial/ or meniscus.mp exp Posterior Cruciate Ligament/ or exp Anterior Cruciate Liga 5 P ment/ or cruciate ligament.mp exp Collateral Ligaments/ exp Knee Joint/ or articular cartilage of knee.mp exp Knee Joint/ exp Knee/ or knee.mp or/ exp Magnetic Resonance Imaging/ or MRI.mp exp Tomography, X-Ray Computed/ or CT.mp Comput$ Tomogr$.mp MDCT.mp 검사 15 Multidetector CT.mp exp Urography/ ultrasonogra$.mp exp Ultrasonography/ Sonogra$.mp or/ P& 검사 and guideline.pt practice guideline.pt 제외기 24 guideline$.ti 준 25 recommendation$.ti standard$.ti or/ P&I&G and 연도 29 limit 28 to yr="2000 -Current" 95 종합 표 201. 근골격국외 Ovid-Embase 검색일 : P 구분 N 검색어검색결과 1 exp knee/ or tibiofemoral.mp. or exp femur/ patellofemoral.mp. or exp patellofemoral joint/ exp patella/ exp knee meniscus/ exp knee cruciate ligament/ collateral ligament.mp

333 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 7 exp articular cartilage/ or articular cartilage of knee.mp Knee Joint.mp or/ MRI.mp. or exp nuclear magnetic resonance imaging/ CT.mp computer assisted tomography/ or Comput$ Tomogr$.mp MDCT.mp. or exp multidetector computed tomography/ 검사 14 "multidetector CT".mp exp urography/ ultrasonogra$.mp. or exp echography/ Ultrasonography.mp Sonogra$.mp. or exp ultrasound/ or/ P& 검사 20 9 and guideline$.ti 제외기 22 recommendation$.ti 준 23 standard$.ti or 22 or P&I&G and 연도 26 limit 25 to yr="2000 -Current" 127 종합 표 202. 근골격국외 GIN 검색일 : N 검색어검색결과 1 knee 5 2 tibiofemoral 0 3 femur 0 4 patellofemoral 0 표 203. 근골격국외 NGC 검색일 : N 검색어검색결과 1 Knee Joint pain 4 2 knee meniscus 1 3 tibiofemoral 1 4 femur 2 5 patellofemoral 0 320

334 6. 부록 다. 진료지침선별 1) 핵심질문 1 흐름도 2) 핵심질문 2 흐름도 그림 29. 근골격핵심질문 1 흐름도. 그림 30. 근골격핵심질문 2 흐름도. 321

335 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 3) 핵심질문 3 흐름도 그림 31. 근골격핵심질문 3 흐름도. 라. 진료지침평가 1) 진료지침질평가결과표 204. 근골격핵심질문 1 질평가결과 핵심질문 1 지침제목 AGREE점수 개발위원회의견 (2013) Referral strategy for early recognition of axial spo ndyloarthritis: Consensus recommendations from the Hon 22 추천안함 g Kong Society of Rheumatology (2008) Evidence-based recommendations for the manage ment of ankylosing spondylitis: systematic literature searc h of the 3E Initiative in Rheumatology involving a broad panel of experts and practising rheumatologists 34 추천안함 322

336 6. 부록 표 205. 근골격핵심질문 2 질평가결과 핵심질문 2 지침제목 AGREE 점수개발위원회의견 (2010) Soft Tissue Sarcomas: ESMO Clinical Practice Gui delines for diagnosis, treatment and follow-up (2014) Soft tissue and visceral sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-u 26 추천안함 29 추천안함 p (2010) Guidelines for the Management of Soft Tissue Sar comas 25 추천안함 ACR_Soft-Tissue Masses 69 추천 일본지침 _CQ152 Is MRI appropriate for the diagnosis of s oft tissue tumors/tumor-like lesions? Is contrast-enhanced MRI necessary? 64 추천 표 206. 근골격핵심질문 3 질평가결과 핵심질문 3 지침제목 AGREE점수 개발위원회의견 VA/DoD clinical practice guideline for the non-surgical m anagement of hip and knee osteoarthritis 27 추천안함 (2011) Summary and recommendations of the OARSI FD A osteoarthritis Assessment of Structural Change Workin 22 추천안함 g Group (2005) Recommendations for musculoskeletal ultrasonogra phy by rheumatologists: setting global standards for best 31 추천안함 practice by expert consensus (2011) Diagnosis and treatment of osteochondritis dissec ans 38 추천안함 ACR SSR practice guideline for the performance a nd interpretation of magnetic resonance imaging (MRI) of 47 추천안함 the knee (2011) AAOS clinical practice guideline: Diagnosis and tre atment of osteochondritis dissecans 51 추천안함 ACR_Nontraumatic Knee Pain 69 추천 일본가이드라인 CQ 150 Is MRI appropriate for the diagnosi s of meniscus/cruciate ligament tears of the knee? 64 추천 323

337 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 2) 수용성과적용성평가결과 표 207. 근골격핵심질문 1 수용성과적용성평가결과 핵심질문 1 구평가항목지침 A 지침 B 분수인구집단 ( 유병률, 발생률등 ) 이유사하다. 아니오예가치와선호도가유사하다. 아니오예용권고로인한이득은유사하다. 아니오예성해당권고는수용할만하다. 아니오예적해당중재및장비는이용가능하다. 아니오예필수적인전문기술이이용가능하다. 아니오예용법률적 / 제도적장벽이없다. 아니오예성해당권고는적용할만하다. 아니오예지침 A : (2013) Referral strategy for early recognition of axial spondyloarthritis: Consensus recommendations from the Hong Kong Society of Rheumatology 지침 B : (2008) Evidence-based recommendations for the management of ankylosing spondylitis: systematic literature search of the 3E Initiative in Rheumatology involving a broad panel of experts and practising rheumatologists 표 208. 근골격핵심질문 2 수용성과적용성평가결과 핵심질문 2 구분 평가항목 지침 A 지침 B 지침 C 지침 D 지침 E 수 인구집단 ( 유병률, 발생률등 ) 이유사하다. 불확실 불확실 불확실 불확실 불확실 가치와선호도가유사하다. 예예예예예용권고로인한이득은유사하다. 예예예예예성해당권고는수용할만하다. 예예예예예 적 해당중재및장비는이용가능하다. 예 예 예 예 예 필수적인전문기술이이용가능하다. 예예예예예용법률적 / 제도적장벽이없다. 예예예예예성해당권고는적용할만하다. 예예예예예 지침 A : (2010) Soft Tissue Sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up 지침 B : (2014) Soft tissue and visceral sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up 지침 C : (2010) Guidelines for the Management of Soft Tissue Sarcomas 지침 D : (2012) ACR_Soft-Tissue Masses 지침 E : 일본지침 CQ152 Is MRI appropriate for the diagnosis of soft tissue tumors/tumor-like lesions? Is contrast-enhanced MRI necessary? 324

338 6. 부록 표 209. 근골격핵심질문 3 수용성과적용성평가결과 핵심질문 3 구지침지침지침지침지침지침지침지침평가항목분 A B C D E F G H 수인구집단 ( 유병률, 발생률등 ) 이유사하다. 예예예예예예예가치와선호도가유사하다. 예예예예예예예용권고로인한이득은유사하다. 예예예예예예예성해당권고는수용할만하다. 예예예예예예예적해당중재및장비는이용가능하다. 예예예예예예예필수적인전문기술이이용가능하다. 예예예예예예예용법률적 / 제도적장벽이없다. 예예예예예예예성해당권고는적용할만하다. 예예예예예예예지침 A : VA/DoD clinical practice guideline for the non-surgical management of hip and knee osteoarthritis 지침 B : (2011) Summary and recommendations of the OARSI FDA osteoarthritis Assessment of Structural Change Working Group 지침 C : (2005) Recommendations for musculoskeletal ultrasonography by rheumatologists: setting global standards for best practice by expert consensus 지침 D : (2011) Diagnosis and treatment of osteochondritis dissecans 지침 E : ACR SSR practice guideline for the performance and interpretation of magnetic resonance imaging (MRI) of the knee 지침 F : (2011) AAOS clinical practice guideline: Diagnosis and treatment of osteochondritis dissecans 지침 G : (2012) ACR_Nontraumatic Knee Pain 지침 H : 일본가이드라인 CQ 150 Is MRI appropriate for the diagnosis of meniscus/cruciate ligament tears of the knee? 마. 핵심질문별권고및근거정리 1) 권고비교표 표 210. 근골격핵심질문 1 권고비교표 핵심질문 1 구분 지침 A 지침 B 척추관절염의조기진단을위해서, 단순촬영에명백한천장관절염이있을경우추가적 권고 2 차선택에 서배제 인영상검사는필요하지않다. 단순방사선촬영에서소견이정상이거나모호한경우, 천 장관절과척추의염증성변화를발견하기위해서는 MRI 의촬영이가장좋은영상검사 가된다. CT 검사는천장관절의구조적변화를발견하기에민감한도구이지만방사선 노출의위험성을고려해야한다권고등급 B 지침 A : (2013) Referral strategy for early recognition of axial spondyloarthritis: Consensus recommendations from the Hong Kong Society of Rheumatology 지침 B : (2008) Evidence-based recommendations for the management of ankylosing spondylitis: systematic literature search of the 3E Initiative in Rheumatology involving a broad panel of experts and practising rheumatologists 325

339 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 211. 근골격핵심질문 2 권고비교표 핵심질문 2 구 분 권고 권고 지침 A 지침 B 지침 C 지침 D 지침 E In soft tissue tumours, MR is the main i maging moda lity, although radiographs s hould be the first step to rule out a bo ne tumour, t o detect a b one erosion with a risk o f fracture an d to show c alcifications. CT has a rol e in calcified lesions to rul e out a myo sitis ossifican s, and in retr operitoneal t umours, whe re the perfor mance is ide ntical to MR. In soft tissue tumours, MR i s the main im aging modality, although radio graphs should be the first st ep to rule out a bone tumou r, to detect a bone erosion with a risk of fracture and to show calcificati ons. CT has a role in calcifie d lesions to ru le out a myosi tis ossificans, and in retroper itoneal tumour s, where the performance is identical to M R. In soft tissu e tumours, MR is the main imagin g modality, although radi ographs sho uld be the f irst step to rule out a b one tumour, to detect a bone erosio n with a ris k of fracture and to show calcification s. CT has a role in calcif ied lesions t o rule out a myositis oss ificans, and in retroperit oneal tumou rs, where th e performan ce is identic al to MR. CT may be of greater value in patients who demonstrate subtle cortical bone involveme nt or soft-tissue calcifications on radiographs. An alternative technique ma y be required in some patient s with a very large body habit us, or other factors rendering MRI unfeasible such as claust rophobia, the presence of so me metallic or electrical impla nts or devices, or inability to remain motionless for the len gth of an MRI examination du e to pain, Parkinson s disease, etc. CT would be selected in most of these situations. Focused US examination ca n be a valuable tool in the ini tial assessment of some softtissue lesions, especially cysts and lipomas. Radiographs remain an impo rtant initial imaging study and often serve as a valuable com plement to MRI or CT assess ment. 단순 MRI 는 양악성 ( 良惡 性 ) 의감별, 양성종류 ( 腫 瘤 ; 종기, 혹 ) 의질적진 단에유용하 기에권장함, 임상소견이나 단순 X 선사진 과병행하여 시행해야함 는 조영 MRI 양악성 감별에도움 이되는경 우가있으며 시행을고려 해도좋음 등급지침 A : (2010) Soft Tissue Sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up 지침 B : (2014) Soft tissue and visceral sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up 326

340 6. 부록 지침 C : (2010) Guidelines for the Management of Soft Tissue Sarcomas 지침 D : (2012) ACR_Soft-Tissue Masses 지침 E : 일본지침 CQ152 Is MRI appropriate for the diagnosis of soft tissue tumors/tumor-like lesions? Is contrast-enhanced MRI necessary? 표 212. 근골격핵심질문3 권고비교표핵심질문 3 구지침 A 지침 B 지침 C 지침 D 지침 E 지침 F 지침 G 지침 H 분 In a pa MRI of the kne 무릎골관 tient wi e may be usefu 절염환자에 th a kn l to evaluate sp In a pati 임상의는서 MRI를 own O ecific clinical sc ent with 골관절염의이용하여 Nontrau 무릎관절 CD lesi enarios, includin a known 진단, 확인연골을평 matic k 의반월 on on r g, but not limit OCD lesi 및치료가하는것 nee pai 판 십자 adiogra ed to, the follo on on x- 평가에자은타당성 n, varia 인대손상 ph, an wing: 1. Prolong ray, an 기공명영상이있고 nt 5 & 의진단 MRI of ed, refractory, o MRI of t ( M R I ) 를신뢰성과 6: Kne 에 MRI the kne r unexplained k he knee 이용해서는민감성이 e symp 를권장 e is an nee pain [57] 2. is an opt 안된다. (C 좋다. (For toms, i 하는가? option t Acute knee trau ion to ch linicians assessin nitial ra M R I 는 o chara ma [58] 3. Mec aracterize should n g MRI ca diograp 경시하 cterize hanical knee sy the OCD ot use rtilage m hs are ( 鏡視下 ) the OC mptoms: catchi lesion or magnetic orphomet negativ 치료가권고 D lesio ng, locking, limi when co resonanc ry in kne e: MRI, 필요한 n or w ted or painful ra ncomitan e imagin e OA, th If additi 환자의 hen co nge of motion, t knee p g (MRI) ere is so onal im 선별에 ncomita snapping, crepit athology as an ev me evide aging i 유용하며 nt knee us [59] 4. Tibi is suspe aluative t nce for c s nece 권장함, patholo ofemoral and/or cted suc ool to di onstruct ssary a 정형외과 gy is s patellofemoral in h as me agnose, and predi nd if in 의사에 uspecte stability: chroni niscal pa confirm, ctive vali ternal d 의한진 d, such c, recurrent, su thology, or mana dity, with erange 찰과조 as men bacute, acute di ACL injur ge the tr good evi ment is 합하여 iscal pa slocation, and s y, or arti eatment dence fo suspect 시행해야 thology, ubluxation [55, cular cart of osteoa r reliabilit ed 함 ACL inj 56,60] 5. Tibiof ilage inju rthritis.) y and re ury, or emoral malalign ry. sponsive articular ment and/or pat ness.) cartilag ellofemoral mala 327

341 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 lignment or mal tracking [61-63] 6. Swelling, enl argement, mas s, or atrophy* 7. Patients for whom diagnosti c or therapeutic e injury arthroscopy is p lanned [57,6 4-69] 8. Patient s with recurren t, residual, or n ew symptoms f ollowing knee s urgery [8,10,1 1,22,70-72] D (recom mends a 9: usua 권고 gainst th weak limited lly appr B 등급 e servic opriate e.) 지침 A : VA/DoD clinical practice guideline for the non-surgical management of hip and knee osteoarthritis 지침 B : (2011) Summary and recommendations of the OARSI FDA osteoarthritis Assessment of Structural Change Working Group 지침 C : (2005) Recommendations for musculoskeletal ultrasonography by rheumatologists: setting global standards for best practice by expert consensus 지침 D : (2011) Diagnosis and treatment of osteochondritis dissecans 지침 E : ACR SSR practice guideline for the performance and interpretation of magnetic resonance imaging (MRI) of the knee 지침 F : (2011) AAOS clinical practice guideline: Diagnosis and treatment of osteochondritis dissecans 지침 G : (2012) ACR_Nontraumatic Knee Pain 지침 H : 일본가이드라인 CQ 150 Is MRI appropriate for the diagnosis of meniscus/cruciate ligament tears of the knee? 328

342 6. 부록 2) 근거표 표 213. 근골격핵심질문 1 근거표 핵심질문 1 문헌정보연구유형대상자수문헌질 Ann Rheum Dis Nov;66(11): Epub 2007 Apr 24. Brandt HC1, Spiller I, Song IH, Vahldiek JL, R observation udwaleit M, Sieper J. Scand J Rheumatol. 1983;12(3): observation 82 3 Preliminary data J Rheumatol Jan;28(1): from uncontrolled 9 4 studies Ann Rheum Dis May;63(5): systematic 2 J Rheumatol Sep;26(9): observation 25 2 Arthritis Rheum Dec;33(12): observation 27 4 Arthritis Rheum Jul;37(7): observation 52 2 KCIG 표 214. 근골격핵심질문2 근거표 핵심질문 2 문헌정보연구유형대상자수문헌질 KCIG American College of Radiology. Manual on Contrast Me Review/Other-D dia. Available at: x C4 0D1FE0EC4E5EAB6861BD213793E5&_z=z. N/A 2 The ESMO/European Sarcoma Network Working Group. Soft tissue and visceral sarcomas: ESMO Clinical Practi ce Guidelines for diagnosis, treatment and follow-up. Guideline N/A 2 Annals of Oncology25 (Supplement 3): iii102 iii112, P. G. Casali, & J.-Y. Blay. Soft tissue sarcomas: ESM O Clinical Practice Guidelines. Annals of Oncology21 (S upplement 5): v198 v203, 2010 for diagnosis, treatmen Guideline N/A 3 t and follow-up Robert Grimer, Ian Judson, David Peake., nd Beatrice Seddon. Guidelines for the Management of Soft Tissue Guideline N/A 3 Sarcomas. Sarcoma. 2010; 2010: Sundaram M, McGuire MH, Herbold DR. Magnetic reso nance imaging of soft tissue masses: an evaluation of Review/Other-D 48 Patien fifty-three histologically proven tumors. Magn Reson I x ts 2 maging 1988;6(3): Griffith JF, Can DP, Kumta SM, Chow LT, Ahuja AT. D Observational-Dx 148 Patie 3 329

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344 6. 부록 MR imaging in the local staging of primary malignant musculoskeletal neoplasms: Report of the Radiology Di agnostic Oncology Group. Radiology 1997;202(1):237-2 nts lesio Gielen JL, De Schepper AM, Vanhoenacker F, et al. A ns; 930 ccuracy of MRI in characterization of soft tissue tumor Observational-Dx consecuti s and tumor-like lesions, A prespective study in 548 p ve patien atients. Eur Radiol 2004;14(12): ts Moulton JS, Blebea JS, Dunco DM, Braley SE, Bisset GS, 3rd, Emery KH. MR imaging of soft-tissue masse 225 Patie s: diagnotic efficucy and value of distinguishing betwe Observational-Dx nt and m en benign and malignant lesions. AJR 1995;164(5):119 asses Panzarella MJ, Naqvi AH, Cohen HE, Damron TA. Predi ctive value of gadolinium enhancement in differentiatin Observational-Dx g ALT/WD liposarcomas from benign fatty tumors. Ske letal Radiol 2005;34(5): Teo EL, Strouse PJ, Hernandez RJ. MR imaging differe ntiation of soft-tissue hemangiomas from malignant so Observational-Dx ft-tissue masses. AJR 2000;174(6): van der Woude HJ, Verstaete KL, Hogendoorn PC, Ta miniau AH, Hermans J, Bloem JL. Musculoskeletal tum ors: does fast dynamic contrast-enhanced subtraction Observational-Dx MR imaging contribute to the characterization? Radiolog y 1998;208(3): van Rijswijk CS, Geirnaerdt MJ, hogendoorn PC, et al. Soft-tissue tumors: value of static and dynamic gadop Observational-Dx entetate dimeglumine-enhanced MR imaging in predicti on of malignancy. Radiology 2004;233(2): van Rijswijk CS, Kunz P, Hogendoorn PC, Taminiau AK, Doornbos J, Bloem JL. Diffusion-weighted MRI in the Observational-Dx characterization of soft-tissue tumors. Jmagn Reson I maging 2002, 15(3): Wang CK, Li CW, Hsieh TJ, Chien SH. Liu GC, Tsai K B. Characterization of bon and soft-tissue tumors with Observational-Dx in vivo 1H MR spectroscopy: initial results. Radiology 2 004;232(2): Kransdort MJ et al :Soft-tissue masses : diagnosis usi Observational-Dx ng MR imaging. AJR 153: , tumor s 44 total patients 175 cons ecutive p atients 140 cons ecutive p atients 23 mass es 36 conse cutive pa tients 112 soft tissue m asses Berquit TH et al : Value of MR imaging in differentiati Observational-Dx 95 conse

345 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 ng benign from malignant soft-tissue masses: study of 95 lesions. AJR 155: , 1990 Crim JR et al : Diagnosis of soft-tissue masses with MR imaging : can benign masses be differentiated fro m malignant ones? Radiology 185: , 1992 Ma LD et al : Differentiation of benign and malignant musculoskeletal tumors: potential pitfalls with MR imag ing. Radiographics 15: , 1995 Gielen JL et al : Accuracy of MRI in characterization o f soft tissue tumors and tumor-like lesions. A prospec tive study in 548 patients. Eur Radiol 14: , De Schepper AM et al: Statistical analysis of MRI para meters predicting malignancy in 141 soft tissue masse s. Rofo 156: , 1992 Moulton JS et al : MR imaging of soft-tissue masses : diagnostic efficacy and value of distinguishiung betwe en benign and malignant lesions. AJR 164: , 1995 May DA et al : MR imaging of musculoskeletal tumors and tumor mimickers with intravenous gadolinium: exp erience with 242 patients. Skeletal Radiol 26:2-15, Kransdorf MJ et al: The use of gadolinium in the MR evaluation of soft tissue tumors. Semin Ultrasound CT MR 18: , 1997 van Rijswijk CS et al: Soft-tissue tumors: value of stat ic and dynamic gadopentetate dimeglumine-enhanced Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Observational-Dx Review/Other-D x Observational-Dx cutive les ions (50 benign a nd 45 m alignant) 83 soft-ti ssue ma sses (49 benign a nd 34 m alignant) 87 conse cutive ca ses of m usculoske letal tum ors 930 cons ecutive p atients w ith STT 141 soft tissue tu mours (8 4 benign, 57 malig nant) 225 soft tissue tu mors (17 9 benign, 46 malig nant) 242 MR scans N/A 140 cons ecutive p 332

346 6. 부록 MR imaging in prediction of malignancy. Radiology 23 3: Panzarella MJ et al : Predictive value of gadoliniun enh ancement in differentiaing ALT/WD liposarcomas from benign fatty tumors. Skeletal Radiol 34 : , 2005 Kajhara M et al: Evaluation of tumor blood flow in mu sculoskeletal lesions: dynamic contrast-enhanced MR i maging and its possibility when monitoring the respons e to preoperative chemotherapy-work in pogress. Radi at Med 25:94-105, 2007 Mirowitz SA et al : Characterization in musculoskeletal masses using dynamic Gd-DTPA enhanced spin-echo MRI. J Comput Assist Tomogr 16 : , 1992 Observational-Dx Observational-Dx Observational-Dx atients 129 patie nts 33 patien ts 18 musc uloskelet al lesions 333

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348 6. 부록 ith isolated medial compartment osteoarthritis of the k nee. Skeletal Radiol 2009; 38(9): Hayes CW, Conway WF. Evaluation of articular cartilag e: radiographic and crosssectional imaging techniques. Radiographics 1992; 12(3): Brandt KD, Fife RS, Braunstein EM, Katz B. Radiograp hic grading of the severity of knee osteoarthritis: relati on of the Kellgren and Lawrence grade to a grade bas ed on joint space narrowing, and correlation with arthr oscopic evidence of articular cartilage degeneration. Art hritis Rheum 1991; 34(11): Kijowski R, Blankenbaker D, Stanton P, Fine J, De Sm et A. Arthroscopic validation of radiographic grading sc ales of osteoarthritis of the tibiofemoral joint. AJR 200 6; 187(3): Messieh SS, Fowler PJ, Munro T. Anteroposterior radio graphs of the osteoarthritic knee. J Bone Joint Surg B r 1990; 72(4): Vincken PW, ter Braak AP, van Erkel AR, et al. MR i maging: effectiveness and costs at triage of patients with nonacute knee symptoms. Radiology 2007; 242( 1): McAlindon TE, Watt I, McCrae F, Goddard P, Dieppe P A. Magnetic resonance imaging in osteoarthritis of the knee: correlation with radiographic and scintigraphic fin dings. Ann Rheum Dis 1991; 50(1): Reiser MF, Vahlensieck M, Schuller H. Imaging of the knee joint with emphasis on magnetic resonance imagi ng. Eur Radiol 1992; 2: Sabiston CP, Adams ME, Li DK. Magnetic resonance i maging of osteoarthritis: correlation with gross patholo gy using an experimental model. J Orthop Res 1987; 5(2): Chen CA, Lu W, John CT, et al. Multiecho IDEAL grad ient-echo water-fat separation for rapid assessment of cartilage volume at 1.5 T: initial experience. Radiology 2009; 252(2): Spritzer CE, Vogler JB, Martinez S, et al. MR imaging of the knee: preliminary results with a 3DFT GRASS p ulse sequence. AJR 1988; 150(3): Review/Other-D N/A 2 x Review/Other-D x Observational-Dx Review/Other-D x Review/Other-D x Review/Other-D x Review/Other-D x 92 patien ts patie nts 2 64 patien ts patie nts 2 12 knees 2 20 patien 2 ts Observational-Dx N/A 2 6 healthy Observational-Dx knees; 1 0 cadave 2 r knees 17 patien Observational-Dx ts; (18 e xtremitie 2 s) Konig H, Sauter R, Deimling M, Vogt M. Cartilage diso Review/Other-D 28 patien 2 335

349 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 rders: comparison of spinecho, CHESS, and FLASH se quence MR images. Radiology 1987; 164(3): Ghelman B, Hodge JC. Imaging of the patellofemoral j oint. Orthop Clin North Am 1992; 23(4): Pihlajamaki HK, Kuikka PI, Leppanen VV, Kiuru MJ, Ma ttila VM. Reliability of clinical findings and magnetic re sonance imaging for the diagnosis of chondromalacia p atellae. J Bone Joint Surg Am 2010; 92(4): Lo GH, McAlindon TE, Niu J, et al. Bone marrow lesio ns and joint effusion are strongly and independently as sociated with weight-bearing pain in knee osteoarthriti s: data from the osteoarthritis initiative. Osteoarthritis Cartilage 2009; 17(12): Ward EE, Jacobson JA, Fessell DP, Hayes CW, van H olsbeeck M. Sonographic detection of Baker's cysts: co mparison with MR imaging. AJR 2001; 176(2): x Review/Other-D x Observational-Dx Observational-Dx Observational-Dx ts;8 volu nteers N/A 2 56 patien 2 ts 160 parti 2 cipants 36 conse cutive kn 2 ees/patie nts 336

350 6. 부록 2.9. 인터벤션분과 가. 핵심질문선정 1) PICO의선정 표 216. 인터벤션 PICO 선정 Population Intervention Comparator Outcome 성인환자 조영증강 CT US infected fluid 진 1-2 소아환자조영증강 CT 단정확성임상적유 US 1-3 임신여성 MRI 효성 2 V a s c u l a r Duplex 초음파간헐적파행 (Intermittent Claudication 진단 CT 혈관조영술 Claudication) 증상있는환자정확성임상적유효 MRI 혈관조영술 성 2) 문장형핵심질문 표 217. 인터벤션문장형핵심질문 핵심질문 1 세부핵심질문 1-1 세부핵심질문 1-2 세부핵심질문 1-3 핵심질문 2 핵심질문수술후급성복부통증을호소하는환자에서체액감염 (infected fluid) 진단을위한적절한영상검사는무엇인가? 수술후급성복부통증을호소하는성인환자에서체액감염 (infected fluid) 진단을위한적절한영상검사는무엇인가? 수술후급성복부통증을호소하는소아환자에서체액감염 (infected fluid) 진단을위한적절한영상검사는무엇인가? 수술후급성복부통증을호소하는임신여성환자에서체액감염 (infected fluid) 진단을위한적절한영상검사는무엇인가? 간헐적파행 (intermittent claudication) 환자에서혈관성파행 (vascular claudication) 진단을위한적절한영상검사는무엇인가? 337

351 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 나. 핵심질문별진료지침검색 1) 핵심질문 1 검색대상핵심질문 KQ 1. 수술후급성복부통증을호소하는환자에서체액감염 (infected fluid) 진단을위한적절한영상검사는무엇인가? 국내 DB 검색전략및결과 표 218. 인터벤션국내문헌 DB 검색일 : 검색사이트 N 검색어 관련문헌 비고 1 post [ALL] surg* [ALL] pain [ALL] 0 2 post [ALL] op* [ALL] pain [ALL] 0 1. KoreaMed 3 abdm* [ALL] abcess [ALL] 0 4 abdm* [ALL] infect* [ALL] 0 5 소계 0 1 ([ALL=post operative pain] AND [ALL=guidelin e]) 0 2 ([ALL=post operative pain] AND [ALL=recomme ndation]) 0 2. KMBASE 3 ([ALL= 급성복통 ] AND [ALL= 권고 ]) 0 4 ([ALL= 급성복통 ] AND [ALL= 지침 ]) 0 5 ([ALL= 급성복통 ] AND [ALL= 가이드라인 ]) 0 6 ([ALL= 복부통증 ] AND [ALL= 권고 ]) 0 7 ([ALL= 복부통증 ] AND [ALL= 지침 ]) 0 8 ([ALL= 복부통증 ] AND [ALL= 가이드라인 ]) 0 6 소계 0 7 단순중복제거후 0 표 219. 인터벤션국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 338

352 6. 부록 국외 DB 검색전략및결과 표 220. 인터벤션국외 Ovid-Medline 검색일 : 구분 N 검색어검색결과 1 exp Postoperative Complications/ post?op$.mp post?surg$.mp OR/ exp Abdominal Pain/ abdom$ pain.mp exp Abdominal Abscess/ P 8 abdom$ abscess.mp exp Intraabdominal Infections/ abdom$ infection$.mp exp Peritonitis/ peritonitis.mp abdom$ fluid$.mp OR/ AND guideline.pt practice guideline.pt 지침 18 guideline$.ti recommendation$.ti OR/ P& 지침 AND 연도 22 limit 21 to yr="2000 -Current" 28 표 221. 인터벤션국외 Ovid-Embase 검색일 : 구분 N 검색어검색결과 339

353 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 검색일 : 구분 N 검색어 검색결과 1 exp Postoperative Complications/ post?op$.mp post?surg$.mp OR/ exp Abdominal Pain/ abdom$ pain.mp exp Abdominal Abscess/ 6939 P 8 abdom$ abscess.mp exp Intraabdominal Infections/ abdom$ infection$.mp exp Peritonitis/ peritonitis.mp abdom$ fluid$.mp OR/ AND guideline$.ti 지침 17 recommendation$.ti OR/ P& 지침 AND 연도 20 limit 19 to yr="2000 -Current" 74 표 222. 인터벤션국외 GIN 검색일 : N 검색어 검색결과 1 infected fluid 1 2 postoperative 1 3 acut abdominal pain 3 4 post surgical(surgery) OR abdominal infection OR peritonitis 0 5 단순중복제거후 5 표 223. 인터벤션국외 NGC 검색일 : N 검색어 검색결과 1 infected fluid 3 2 abdominal infection 3 340

354 6. 부록 검색일 : N 검색어 검색결과 3 post surgical(surgery) OR abdominal infection OR peritonitis 0 4 단순중복제거후 4 2) 핵심질문 2 검색대상핵심질문 KQ 2. 간헐적파행 (intermittent claudication) 환자에서혈관성파행 (vascular claudication) 진단을위한적절한영상검사는무엇인가? 국내 DB 검색전략및결과 표 224. 인터벤션국내문헌 DB 검색일 : 검색사이트 N 검색어관련문헌비고 1. KoreaMed 2. KMBASE 1 claudication [ALL] 0 2 peripheral [ALL] arter* [ALL] 1 3 vascular [ALL] obstruc* [ALL] 0 4 소계 1 1 ([ALL=claudication] AND [ALL=guideline]) 1 2 ([ALL=claudication] AND [ALL=recommendatio n]) 0 3 ([ALL= 파행 ] AND [ALL= 지침 ]) 0 4 ([ALL= 파행 ] AND [ALL= 권고 ]) 1 5 ([ALL= 파행 ] AND [ALL= 가이드라인 ]) 0 6 소계 2 7 단순중복제거후 2 표 225. 인터벤션국내진료지침 DB 검색사이 N 지침제목연도개발학회트 1. KGC 1 2 소계 ( 0건 ) 2. KoMGI 1 2 소계 ( 0건 ) 국외 DB 검색전략및결과 341

355 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 표 226. 인터벤션국외 Ovid-Medline 검색일 : 구분 N 검색어검색결과 P 지침 1 exp Intermittent Claudication/ 7,184 2 intermittent claudication.mp. 8,658 3 vascular claudication.mp OR/1-3 8,684 5 guideline.pt. 15,628 6 practice guideline.pt. 20,483 7 guideline$.ti. 54,058 8 recommendation$.ti. 26,289 9 OR/5-8 91,434 P& 지침 10 4 AND 9 38 연도 11 limit 10 to yr="2000 -Current" 30 표 227. 인터벤션국외 Ovid-Embase 검색일 : 구분 N 검색어 검색결과 1 exp Intermittent Claudication/ 8,316 P 2 intermittent claudication.mp vascular claudication.mp OR/1-3 9,524 5 guideline$.ti. 69,884 지침 6 recommendation$.ti. 32,714 7 OR/ ,889 P& 지침 8 4 AND 7 51 연도 9 limit 8 to yr="2000 -Current" 45 표 228. 인터벤션국외 GIN 검색일 : N 검색어 검색결과 1 claudication 3 2 peripheral artery 2 4 단순중복제거후 3 342

356 6. 부록 표 229. 인터벤션국외 NGC 검색일 : N 검색어 검색결과 1 claudication 3 2 peripheral artery 2 3 단순중복제거후 4 343

357 근거기반임상영상가이드라인개발 : 영상진단검사의적절성과환자의방사선노출수준에대한근거제공 다. 진료지침선별 1) 핵심질문 1 흐름도 그림 32. 인터벤션핵심질문 1 흐름도. 2) 핵심질문 2 흐름도 그림 33. 인터벤션핵심질문 2 흐름도. 344