Managing Incidental Findings on Thoracic CT: Lung Findings. A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee presents recommendations for managing incidentally detected lung findings on thoracic CT. The Chest Subcommittee is composed of thoracic radiologists who endorsed and developed the provided guidance. These recommendations represent a combination of current published evidence and expert opinion and were finalized by informal iterative consensus. The recommendations address commonly encountered incidental findings in the lungs and are not intended to be a comprehensive review of all pulmonary incidental findings. The goal is to improve the quality of care by providing guidance on management of incidentally detected thoracic findings.     

Management of the Incidental Renal Mass on CT: A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee (IFC) presents recommendations for renal masses that are incidentally detected on CT. These recommendations represent an update from the renal component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Renal Subcommittee, consisting of six abdominal radiologists and one urologist, developed this algorithm. The recommendations draw from published evidence and expert opinion and were finalized by informal iterative consensus. Each flowchart within the algorithm describes imaging features that identify when there is a need for additional imaging, surveillance, or referral for management. Our goal is to improve quality of care by providing guidance for managing incidentally detected renal masses.     

Management of Incidental Pituitary Findings on CT,MRI, and 18F-Fluorodeoxyglucose PET: A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee presents recommendations for managing pituitary findings that are incidentally detected on CT, MRI and ¹⁸F-fluorodeoxyglucose PET. The Pituitary Subcommittee, which included radiologists practicing neuroradiology and an endocrinologist, developed this algorithm. The recommendations draw from published evidence and expert opinion and were finalized by informal iterative consensus. Algorithm branches successively categorize pituitary findings on the basis of imaging features. They terminate with an ascertainment of an indolent lesion (with sufficient confidence to discontinue follow-up) or a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. The goal is to improve the quality of care by providing guidance on how to manage incidentally detected pituitary findings.     

Incidental Cardiac Findings on Thoracic Imaging

The cardiac structures are well seen on nongated thoracic computed tomography studies in the investigation and follow-up of cardiopulmonary disease. A wide variety of findings can be incidentally picked up on careful evaluation of the pericardium, cardiac chambers, valves, and great vessels. Some of these findings may represent benign variants, whereas others may have more profound clinical importance. Furthermore, the expansion of interventional and surgical practice has led to the development and placement of new cardiac stents, implantable pacemaker devices, and prosthetic valves with which the practicing radiologist should be familiar. We present a collection of common incidental cardiac findings that can be readily identified on thoracic computed tomography studies and briefly discuss their clinical relevance.     

Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee (IFC) presents recommendations for managing adnexal masses incidentally detected on CT and MRI. These recommendations represent an update of those provided in our previous JACR 2013 white paper. The Adnexal Subcommittee, which included six radiologists with subspecialty expertise in abdominal imaging or ultrasound and one gynecologist, developed this algorithm. The recommendations draw from published evidence and expert opinion and were finalized by iterative consensus. Algorithm branches successively categorize adnexal masses based on patient characteristics (eg, pre- versus postmenopausal) and imaging features. They terminate with a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. Our goal is to improve quality of care by providing guidance on how to manage incidentally detected adnexal masses.     

Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Thyroid Findings Committee

The incidental thyroid nodule (ITN) is one of the most common incidental findings on imaging studies that include the neck. An ITN is defined as a nodule not previously detected or suspected clinically, but identified by an imaging study. The workup of ITNs has led to increased costs from additional procedures, and in some cases, to increased risk to the patient because physicians are naturally concerned about the risk of malignancy and a delayed cancer diagnosis. However, the majority of ITNs are benign, and small, incidental thyroid malignancies typically have indolent behavior. The ACR formed the Incidental Thyroid Findings Committee to derive a practical approach to managing ITNs on CT, MRI, nuclear medicine, and ultrasound studies. This white paper describes consensus recommendations representing this committee’s review of the literature and their practice experience.     

Anatomical variant of large mediastinal veins: Incidental findings on MDCT chest

Thoracic veins congenital abnormalities are important uncommon developmental anomalies that have a wide range of presentation from isolated incidental findings to a part of more complex anomalies. It can be categorized into systemic venous system and pulmonary venous system. It is of important value to understand the mediastinal vascular anatomy to help to identify variable vascular anomalies.In this study we attempt to describe some incidentally encountered mediastinal large venous anatomical variants in patients undergoing MDCT chest in order to avoid further unnecessary studies.     

Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings

The authors explore the benefits and risks of not reporting imaging findings that do not have clinical relevance, with the goal of developing recommendations to reduce their reporting. The authors review the example of incidentally detected, simple renal cysts (Bosniak category I), including medicolegal conditions required for such a shift in reporting practices to be acceptable. The authors propose four potential criteria for not reporting clinically unimportant findings and recommend that these criteria be debated in other contexts, so that they can be refined and implemented.     

Incidence and Economic Impact of Incidental Findings on 18F-FDG PET/CT Imaging

Purpose

The study sought to determine the incidence of incidental findings on whole-body positron emission tomography with computed tomography (PET/CT) imaging and the average costs of investigations to follow-up or further characterize incidental findings.

Navigating Uncertainty in the Management of Incidental Findings

The lack of prospective outcomes studies for many types of incidental findings limits our understanding of both their natural history and the potential efficacy of treatment. To support decision making for the management of incidental findings, major sources of uncertainty in management pathways can be mapped and analyzed using mathematical models. This process yields important insights into how uncertainty influences the best treatment decision. Here, we consider a classification scheme, grounded in decision science, which exposes various levels and types of uncertainty in the management of incidental findings and addresses (1) disease-related risks, which are considered in context of a patient’s competing causes of mortality; (2) potential degrees of intervention; (3) strength of evidence; and (4) patients’ treatment-related preferences. Herein we describe how categorizing uncertainty by the sources, issues, and locus can build a framework from which to improve the management of incidental findings. Accurate and comprehensive handling of uncertainty will improve the quality of related decision making and will help guide future research priorities.     

Factors Affecting Adherence to Recommendations for Additional Imaging of Incidental Findings in Radiology Reports

ObjectiveTo determine the rate at which recommendations for additional imaging (RAIs) of incidental findings on CT are adhered to at a tertiary-care medical center and what factors influence adherence.MethodsWe used a radiology clinical informatics tool (mPower, Nuance Communications Inc, Burlington, Massachusetts) to identify RAIs in reports from all CT examinations performed at a tertiary-care medical center during a 6-month period. For those studies in which the RAI was for incidental findings, we reviewed the patients’ charts to determine if there was appropriate follow-up of the lesion in question.ResultsThe overall rate of adherence to RAIs was 39.1%, and in patients with a same-institution primary care provider (PCP), 56.8% (P < .0001). Adherence was higher in studies ordered in the outpatient setting (P < .0001) and in patients with a same-institution PCP (P < .0001). Among patients with a same-institution PCP, adherence was highest for outpatients (66.7%), followed by patients seen in the emergency department (46.0%) and inpatients (36.0%). Among outpatients, adherence was highest with PCPs (67%) followed by internal medicine subspecialties (50%) and surgery (38%).DiscussionThe rate of adherence to recommendations for additional imaging of incidental findings was 39.1% in this study and higher for patients with a same-institution PCP, studies ordered in the outpatient setting, and in studies ordered by PCPs.     

Incidental pathologic extracardiac uptake of 99mTc-tetrofosmin in myocardial perfusion imaging

Technetium-99m-tetrofosmin ((99m)Tc-TF) myocardial perfusion studies have incidentally detected various extracardiac abnormalities. The interpretation of these findings may be essential for early diagnosis and treatment of important diseases. We present a rare case of a mediastinal thymoma incidently detected during myocardial perfusion imaging. A 60 year-old woman, with precardiac symptoms of possible myocardial ischemia, underwent a (99m)Tc-TF stress-rest single photon emission tomography test. Intense uptake of the radiotracer in the left paracardiac area, was observed. The computerized tomography and the magnetic resonance imaging tests revealed a mass in the left lower anterior mediastinal area. Biopsy and subsequent histology showed that this mass was a thymoma.     

A Quick Reference Guide for Incidental Findings on Lung Cancer Screening CT Examinations

PurposeThe US Preventive Services Task Force has recommended lung cancer screening (LCS) with low-dose CT (LDCT) in high-risk individuals since 2013. Because LDCT encompasses the lower neck, chest, and upper abdomen, many incidental findings (IFs) are detected. The authors created a quick reference guide to describe common IFs in LCS to assist LCS program navigators and ordering providers in managing the care continuum in LCS.MethodsThe 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.ResultsSeven anatomic regions including 15 discrete organs with 45 management recommendations were identified as relevant to the age of individuals eligible for LCS. The draft was piloted by 49 LCS program navigators from 32 facilities. The guide was rated as useful and clear by 95% of users. No unexpected or adverse experiences were reported in using the guide. On the basis of feedback, relevant sections were reviewed and edited.ConclusionsThe 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.     

System-Level Process Change Improves Communication and Follow-Up for Emergency Department Patients With Incidental Radiology Findings

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.     

Process Improvement for Communication and Follow-up of Incidental Lung Nodules

ObjectiveGuideline-concordant follow-up of incidental lung nodules (ILNs) is suboptimal. We aimed to improve communication and tracking for follow-up of these common incidental findings detected on imaging examinations.MethodsWe implemented a process improvement program for reporting and tracking ILNs at a large urban academic health care system. A multidisciplinary committee designed, tested, and implemented a multipart tracking system in the electronic health record (EHR) that included Fleischner Society management recommendations for each patient. Plan-do-study-act cycles addressed gaps in the follow-up of ILNs, broken into phases of developing and testing components of the conceived EHR toolkit.ResultsThe program resulted in standardized text macros with discrete categories and recommendations for ILNs, with ability to track each case in a work list within the EHR. The macros incorporated evidence-based guidelines and also input of collaborating clinical referrers in the respective specialty. The ILN macro was used 3,964 times over the first 2 years, increasing from 104 to over 300 uses per month. Usage spread across all subspecialty divisions, with nonthoracic radiologists currently accounting for 80% (56 of 70) of the radiologists using the system and 31% (1,230 of 3,964) of all captured ILNs. When radiologists indicated ILNs as warranting telephone communication to provider offices, completion was documented in 100% of the cases captured in the EHR-embedded tracking report.ConclusionAn EHR-based system for managing incidental nodules enables case tracking with exact recommendations, provider communication, and completion of follow-up testing. Future efforts will target consistent radiologist use of the system and follow-up completion.     

Variation in Downstream Relative Costs Associated With Incidental Ovarian Cysts on Ultrasound

PurposeTo explore variation in downstream relative costs associated with ovarian cysts incidentally detected on ultrasound.MethodsFor 200 consecutive incidental ovarian cysts on ultrasound, ultrasound reports were classified in terms of presence of a radiologist recommendation for additional imaging. All downstream events (imaging, office visits, and surgery) associated with the cysts were identified from the electronic health record. Medical costs associated with these downstream events were estimated using national Medicare rates. Average cost per cyst was stratified by various factors; cost ratios were computed among subgroups.ResultsAverage costs per cyst were 1.9 times greater in postmenopausal than premenopausal women. Relative to when follow-up imaging was neither recommended nor obtained, costs were 1.1 times greater when follow-up imaging was recommended but not obtained, 5.1 times greater when follow-up imaging was both recommended and obtained, and 8.1 times greater when follow-up imaging was obtained despite not being recommended. Costs were 2.5 times greater when the radiologist underrecommended follow-up compared with Society of Radiologists in Ultrasound (SRU) guidelines for management of ovarian cysts, 3.0 times greater when the ordering physician overmanaged compared with the radiologist’s recommendation, as well as 1.7 times and 3.8 times greater when the ordering physician undermanaged and overmanaged compared with SRU guidelines, respectively. Four ovarian neoplasms, although no ovarian malignancy, were diagnosed in the cohort.ConclusionFollow-up costs for incidental ovarian cysts are highly variable based on a range of factors. Radiologist recommendations may contribute to lower costs among patients receiving follow-up imaging. Such recommendations should reflect best practices and support the follow-up that will be of likely greatest value for patient care.     

Incidental vascular findings on CT pulmonary angiography (CTPA)

Background:

CT pulmonary angiography (CTPA) is being used increasingly as a diagnostic modality for patients with suspected pulmonary embolism (PE). CTPA frequently reveals incidental findings that may explain the patient’s presentation. These findings could be parenchymal, pleural, or vascular. The aim of this study was to evaluate the spectrum of incidental vascular findings and their significance.

Methods

A retrospective review was done on 508 CTPAs of adults with suspicion of PE in the University of Missouri between June and December of 2009. Forty-three scans were excluded because of motion artifacts or poor contrast. Of the total 465 scans, 39% (180/465) scans were done in the emergency room.

Results

Calcification of the aorta and coronary arteries was the most common finding 27% (124/465), followed by dilatation of the pulmonary trunk 3.4% (16/465) and thoracic aortic aneurysms 1.5% (7/465). Four cases of aberrant right subclavian artery were found. The rest of the findings were rare and were detected in only one or two patients.

Conclusion

CTPA delineates vascular findings other than PE. The majority of these findings are not acute, but warrant recognition and follow up. In less than 1% of the cases, aortic dissection is detected, which might explain the patient’s presentation.     

Education Level Predicts Appropriate Follow-Up of Incidental Findings From Lung Cancer Screening

PurposeThe aim of this study was to identify predictors of appropriate follow-up for clinically significant incidental findings (IFs) detected with low-dose CT during lung cancer screening.MethodsCharts of 1,458 prospectively enrolled lung screening patients from January 1, 2015, to October 31, 2018, were reviewed. IFs, other than coronary artery calcification and emphysema, were identified. ACR practice guidelines defined appropriate patient follow-up. Patient demographic and social characteristics were obtained from the initial shared decision-making visit and the electronic medical record. Factors of interest included age, gender, race, education level, and insurance status. Education level was reported as high school graduate or less or education past high school. A multivariate logistic regression was estimated to assess patient factors associated with appropriate follow-up.ResultsOne hundred thirty-eight participants (9%) with 141 actionable IFs were identified. The overall appropriate follow-up rate was 82%. The most common IFs were renal lesions (16%), dilated thoracic aorta (10%), and pulmonary fibrosis (10%). Univariate analysis of appropriate patient follow-up revealed a significant difference for education level (P = .02). A greater than high school education remained strongly associated with appropriate follow-up after controlling for other demographic factors.ConclusionsAppropriate patient follow-up of clinically significant IFs from lung cancer screening is a well-recognized avenue to improve population health. Education level is a significant independent predictor of appropriate follow-up of IFs, whether as a surrogate for low socioeconomic status or as an indication of health literacy. To address these realities, lung screening shared decision making should adapt to consider health care access and health literacy.     

The economic burden of incidentally detected findings

Practitioners in all medical disciplines recognize the high frequency of incidentally detected findings. Although some findings are discovered on physical examination, an increasing majority are detected at imaging performed for another indication. With increasing federal scrutiny on the net value of imaging services, the costs and benefits of incidental findings need to be more rigorously quantified. In this article, the authors examine current related work on imaging expenditures for incidental findings and provide a framework for future investigations that will efficiently and substantially advance the knowledge in this field.     

Incidental findings on pediatric MR images of the brain

BACKGROUND AND PURPOSE: Previous studies have addressed the prevalence of incidental findings in symptomatic and healthy adult populations. Our study aims to elucidate the prevalence of incidental findings in a healthy pediatric population. METHODS: We retrospectively reviewed 225 conventional brain MR imaging studies obtained during structural and functional brain imaging research in a cohort of neurologically healthy children (100 boys [44%] and 125 girls [56%]) ranging in age from younger than 1 month to 18 years. All MR images were reviewed, and two board-certified neuroradiologists categorized the findings by consensus. RESULTS: Incidental abnormalities were detected in 47 subjects (21%), while 79% of the images were normal. Of the 47 abnormalities detected, 17 (36%) required routine clinical referral; a single lesion (2%) required urgent referral. The occurrence of these findings in the male cohort was twice that of the female cohort; however, the percentage of subjects requiring either routine or urgent referral did not differ by sex (male subjects, 34%; female subjects, 39%). CONCLUSION: Although the frequency of clinically important incidental abnormalities was not high in the sample of children studied, the presence and variety of findings in any pediatric group is particularly important for both the welfare of the subject and for research in which knowledge of the subject's neurologic status is vital to the interpretation of the results. Despite the limitations of the study in terms of the age and ethnic distribution, this work highlights the need for the routine involvement of trained radiologists in these studies to ensure that such incidental findings are detected and that appropriate follow-up is provided.