Radiography First, Then CT if Needed
For a palpable bony growth over the xiphoid process, obtain plain radiographs (including a lateral chest X-ray) as the initial imaging study, followed by CT without contrast if the diagnosis remains unclear or to better characterize the anatomy.
Initial Imaging Approach
Start with plain radiographs as your first-line imaging modality. The 2024 ACR Appropriateness Criteria explicitly recommends radiography as the initial imaging study for any suspected bone lesion, including those of the xiphoid process 1. A lateral chest radiograph is particularly valuable here, as it can readily identify a prominent or jointed xiphoid process that may be mistaken for an abdominal mass on physical examination 2.
Why Radiographs First?
- Cost-effective and readily available
- Adequate for identifying most xiphoid variants including elongated, curved, bifid, or forked configurations
- Can distinguish normal anatomical variants from true pathology in most cases
- The xiphoid process displays remarkable morphological diversity—pointed (45%), oval (41%), or forked (14%)—and radiographs can capture these variations 3
When to Proceed to CT
If radiographs are inconclusive or you need better anatomical detail, CT without IV contrast is the next appropriate study 1. CT provides superior characterization of:
- Ossification patterns and degree of the xiphoid process 3
- Three-dimensional anatomy using multiplanar reconstruction and volume rendering 3, 4
- Relationship to surrounding structures
- Presence of foramina (found in 58% of xiphoid processes) 3
The ACR guidelines specifically recommend CT without contrast for benign bone lesions when you need to assess complications, determine fracture risk, or plan surgery 1.
Common Pitfalls to Avoid
Do not mistake normal xiphoid variants for pathology. The xiphoid process commonly:
- Curves ventrally (23%) or dorsally (20%) 3
- May have a hook-shaped configuration 5
- Contains cartilage in 85% of adults, which appears radiolucent on imaging 6
- Can be partially ossified well into adulthood 7, 6
Ultrasound has limited utility for xiphoid evaluation. While it may show acoustic shadowing and can identify the structure as bony 2, it cannot adequately characterize the ossification pattern or anatomical relationships that CT provides.
When to Consider MRI
Reserve MRI for situations where you suspect:
- An aggressive or indeterminate lesion on radiographs requiring evaluation of soft tissue extent 1
- Alternative diagnoses such as soft tissue masses or infection
- True neoplastic processes rather than normal variants
However, for a straightforward palpable bony prominence at the xiphoid, MRI is typically unnecessary and represents overutilization of resources.
Clinical Context Matters
The xiphoid process normally extends into the epigastric region and serves as a muscle attachment point. Its variable morphology—including forward-then-backward curvature in 70% of cases 8—means that what feels like a "growth" is often simply a prominent normal variant. The key is distinguishing this from true pathology through systematic imaging, starting with the most cost-effective and appropriate modality: plain radiographs.