CT Scans: Prior Chest Radiograph
In the absence of reliable evidence, it is the opinion of the work group that it is not necessary to perform a chest radiograph prior to a chest CT in the staging of a bone or soft tissue malignancy.

Rationale
We did not find any acceptable investigations that directly addressed the question of whether performing a chest radiograph prior to a CT scan is warranted or not. The theoretical justification for performing a chest radiograph initially is that the results may influence the decision to obtain a subsequent CT scan. Our work group agreed that when the clinical presentation is concerning enough to justify a CT scan to evaluate for other sites of disease or metastatic spread regardless of the findings on a chest radiograph, as is the case with this scenario, a chest radiograph is of low utility and does not influence the decision to obtain a CT scan. In the clinical setting of a destructive bone lesion or soft tissue mass concerning for malignancy, visualization of the lungs is necessary to determine the presence of distant disease. Chest CT scans provide more detail than chest radiographs and are the study of choice for most practitioners. Because the chest CT and its scout image provide more detailed information, a chest x-ray prior to chest CT is redundant and unnecessary in this situation. If the treating cancer specialists anticipate post-treatment pulmonary surveillance with chest radiographs, a baseline chest radiograph may be useful as a comparison for future studies.

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