Common Incidental Findings on MDCT: Survey of Radiologist Recommendations for Patient Management

doi:10.1016/j.jacr.2011.05.012

Journal of the American College of Radiology

Volume 8, Issue 11, November 2011, Pages 762-767

https://doi.org/10.1016/j.jacr.2011.05.012 Get rights and content

Purpose

The aim of this study was to evaluate for agreement with respect to how radiologists report incidental findings encountered on CT.

Methods

A multiple-choice survey was designed to query radiologists about how they handle 12 incidental findings on body CT, assuming the patient is a 45-year-old woman with no history of malignancy. Included were a 1-cm thyroid nodule, a 5-mm noncalcified lung nodule, coronary artery calcification, a 2-cm adrenal nodule, a 2-cm pancreatic cyst, a 1-cm enhancing liver lesion, a 2-cm high-density renal cyst, short-segment small bowel intussusception, a 1-cm splenic cyst, focal gallbladder wall calcification, and a 3-cm ovarian cyst in both a premenopausal woman and a postmenopausal woman. Choices ranged from “do not report” to advising interventional procedures tailored to the organ. Surveys were administered to body CT attending radiologists at 3 academic institutions.

Results

Twenty-seven radiologists completed the survey. The mean experience level was 15.7 years after training. Seventy percent or greater agreement on interpretation was identified for only 6 findings: recommend ultrasound for a 1-cm thyroid nodule, recommend ultrasound for a 3-cm cyst in postmenopausal woman, follow Fleischner Society recommendations for a 5-mm lung nodule, describe only coronary calcification, and describe as likely benign both short-segment small bowel intussusception and a 1-cm splenic cyst.

Conclusions

Agreement is lacking, both across institutions and within departments, for the management of 6 commonly encountered incidental findings on body CT. Individual departments should develop internal guidelines to ensure consistent recommendations based on existing evidence.

Introduction

Advances in CT spatial and temporal resolution have improved radiologists' ability to identify small or subtle findings. In conjunction with increasing CT utilization, this has fueled the rate with which incidental findings are discovered. However, published guidelines for the management of many incidental findings are only just emerging [1, 2, 3, 4, 5]. Valuable information is derived from investigations aimed at distinguishing clinically significant findings from those that do not warrant additional workup [6, 7, 8, 9, 10], systematic evaluations of the literature [1, 4], and consensus statements [2, 3]. Another source lies in guidance from experienced radiologists at high-volume centers. Accordingly, the purpose of this study was to evaluate for agreement among body CT attending radiologists, both within departments and across academic institutions, for the management of a number of commonly encountered incidental findings on body CT.

Section snippets

Methods

This study was approved by the Johns Hopkins Hospital institutional review board, with a waiver of the requirement for informed consent. A survey was designed to query radiologists about 12 common incidental findings on body CT (Appendix). Participating radiologists were instructed to assume that the patient was a 45-year-old woman with no history of malignancy. Respondents could select from a list of possible interpretative practices or write in responses.

Three geographically dispersed

Results

A total of 27 radiologists participated, 7 from institution A, 12 from institution B, and 8 from institution C. The participants had an average of 15.7 years in practice (range, 1.5-30 years), with 16 having ≥10 years of experience (defined as experienced radiologists), and 10 having ≥20 years of experience. The majority (67% [18 of 27]) had completed fellowships that included CT.

Table 1 lists the most commonly selected interpretation for each finding. The rate of agreement ranged from 30% to

Discussion

Analysis of abdominal imaging utilization trends between 1996 and 2005 revealed that the use of CT and CT angiography increased by 141% [11], representing the greatest increase among imaging modalities. Rising utilization is fueled in a large part by improvements in resolution, which have expanded the clinical indications for CT imaging and improved the diagnostic accuracy. However, a repercussion of rising utilization is increasing identification of unsuspected findings. For those that are not

Conclusions

Our survey discloses 2 important pieces of information. The first pertains to evolving agreement for managing certain incidental findings, including thyroid nodules, coronary artery calcification, lung nodules, ovarian cysts in postmenopausal women, spleen lesions, and short small bowel intussusception. It is important to note that at present, 100% agreement was not identified for the management of any of these 12 findings. An equally essential discovery is the lack of agreement across academic

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The ACR IF white papers were reviewed for findings on LDCT that were age appropriate for LCS. A draft guide was created on the basis of recommendations in the IF white papers, the medical literature, and input from subspecialty content experts. The draft was piloted with LCS program navigators recruited through contacts by the ACR LCS Steering Committee. The navigators completed a survey on overall usefulness, clarity, adequacy of content, and user experience with the guide.
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The ACR Lung Cancer Screening CT Incidental Findings Quick Reference Guide outlines the common IFs in LCS and can serve as an easy-to-use resource for ordering providers and LCS program navigators to help guide management.
Pituitary incidentaloma
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Pituitary incidentalomas (PI) are lesions of the pituitary region discovered fortuitously by imaging for reasons unrelated to pituitary disease. They range from small cysts to large invasive adenomas. All over the world, improvements in the quality and availability of radiological examinations are leading to an increase in the discovery of PI.
In the last four decades, significant advances have been made in the understanding of PI. Autopsy studies have shown that about 10% of deceased individuals harbour a PI, most often a non-functioning microadenoma. In contrast, modern patient series showed that among PIs that come to endocrinological attention, a significant proportion are macroadenomas, and many patients suffer from asymptomatic or pauci-symptomatic endocrine or ophthalmologic disturbances. Other than adenomas, empty sella, Rathke's cleft cyst, craniopharyngioma and meningioma are the most frequent types of PIs.
About 10% of micro-incidentalomas and 25% of macro-incidentalomas grow over time. Most cases can be managed conservatively by mere surveillance. Follow-up is necessary in all patients with macroadenoma, but uncertainty remains for microadenomas as to the extent of endocrinological work-up as well as the necessity and duration of follow-up. Visual and endocrine anomalies constitute the most common indications for surgery. When needed, surgery yields better outcome in PIs than in symptomatic pituitary lesions.
Commentary on the World Federation for Ultrasound in Medicine and Biology Project “Incidental Findings”
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The evidence-based recommendations cited in this quality measure were developed to reduce the burden of evaluation by recommending no follow-up imaging for patients who have renal cystic lesions that are likely benign on the basis of imaging features. Although the majority of incidentally found renal cystic masses are benign, there is little consensus on follow-up imaging recommendations, with 43% of radiologists in one survey recommending a dedicated renal protocol CT in the final report [24,58]. In 2017, the ACR outlined certain findings on abdominal CT or MRI suggestive of a benign renal cyst and for which follow-up is not warranted [59].
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To describe the frequency, distribution and reporting patterns of incidental findings receiving the Lung-RADS S modifier on low-dose chest computed tomography (CT) among lung cancer screening participants.
This retrospective investigation included 581 individuals who received baseline low-dose chest CT for lung cancer screening between October 2013 and June 2017 at a single center. Incidental findings resulting in assignment of Lung-RADS S modifier were recorded as were incidental abnormalities detailed within the body of the radiology report only. A subset of 60 randomly selected CTs was reviewed by a second (blinded) radiologist to evaluate inter-rater variability of Lung-RADS reporting.
A total of 261 (45%) participants received the Lung-RADS S modifier on baseline CT with 369 incidental findings indicated as potentially clinically significant. Coronary artery calcification was most commonly reported, accounting for 182 of the 369 (49%) findings. An additional 141 incidentalomas of the same types as these 369 findings were described in reports but were not labelled with the S modifier. Therefore, as high as 69% (402 of 581) of participants could have received the S modifier if reporting was uniform. Inter-radiologist concordance of S modifier reporting in a subset of 60 participants was poor (42% agreement, kappa = 0.2).
Incidental findings are commonly identified on chest CT for lung cancer screening, yet reporting of the S modifier within Lung-RADS is inconsistent. Specific guidelines are necessary to better define potentially clinically significant abnormalities and to improve reporting uniformity.
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The appropriate communication and management of incidental findings on emergency department (ED) radiology studies is an important component of patient safety. Guidelines have been issued by the ACR and other medical associations that best define incidental findings across various modalities and imaging studies. However, there are few examples of health care facilities designing ways to manage incidental findings. Our institution aimed to improve communication and follow-up of incidental radiology findings in ED patients through the collaborative development and implementation of system-level process changes including a standardized loop-closure method. We assembled a multidisciplinary team to address the nature of these incidental findings and designed new workflows and operational pathways for both radiology and ED staff to properly communicate incidental findings. Our results are based on all incidental findings received and acknowledged between November 1, 2016, and May 30, 2017. The total number of incidental findings discovered was 1,409. Our systematic compliance fluctuated between 45% and 95% initially after implementation. However, after overcoming various challenges through optimization, our system reached a compliance rate of 93% to 95%. Through the implementation of our new, standardized communication system, a high degree of compliance with loop closure for ED incidental radiology findings was achieved at our institution.

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Original articleCommon Incidental Findings on MDCT: Survey of Radiologist Recommendations for Patient Management

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

J Am Coll Radiol

J Am Coll Surg

J Am Coll Radiol

J Am Coll Cardiol

Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society

Radiology

NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”)

NIH Consens State Sci Statements

Incidental thyroid nodules on chest CT: Review of the literature and management suggestions

AJR Am J Roentgenol

Incidental adnexal masses detected at low-dose unenhanced CT in asymptomatic women age 50 and older: implications for clinical management and ovarian cancer screening

Radiology

The incidental indeterminate adrenal mass on CT (>10 H) in patients without cancer: is further imaging necessary?Follow-up of 321 consecutive indeterminate adrenal masses

AJR Am J Roentgenol

Original article
Common Incidental Findings on MDCT: Survey of Radiologist Recommendations for Patient Management