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Incidentaloma: Reporting Incidental Findings Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Incidentaloma ❯ Reporting Incidental Findings

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  • Introduction Incidental findings on comprehensive imaging in the adult trauma population occur at rates as high as 54.8%. We sought to determine the incidence of potentially malignant or pre-malignant incidental findings in a high-volume level 1 trauma center and to evaluate follow-up recommendations
    Conclusion The results of our study suggest that potentially malignant or pre-malignant incidental findings are common among trauma patients. Specific follow-up recommendations were not presented in 61% of the radiology reports, highlighting the need to standardize medical record capture of an incidentaloma to ensure adequate and appropriate follow-up.
    Expecting the unexpected: incidental findings at a level 1 trauma center
    Hordur M Kolbeinsson et al.
    Emergency Radiology (2023) 30:343–349
  • “The study included 495 patients who had incidental findings, 410 of whom had potentially malignant or premalignant findings on imaging, resulting in a cumulative incidence of 6.6%. The mean age was 65 and 217 (52.9%) patients were male. The majority of “incidentalomas” were discovered on CT imaging (n=665, 98.1%); over half were solid (n=349, 51.5%), while 27.4% were cystic (n=186) in nature. The lungs (n=199, 29.4%), kidneys (n=154, 22.8%), liver (n=74, 10.9%), thyroid gland (n=58, 8.6%), and adrenal glands (n=53, 7.8%) harbored the most incidentalomas. Less than half of patients with incidental findings received specific follow-up recommendations on the radiologist’s report (n=150, 39%). Sixty-one percent of patients (n=250) had their incidentalomas detailed in the discharge paperwork.”
    Expecting the unexpected: incidental findings at a level 1 trauma center
    Hordur M Kolbeinsson et al.
    Emergency Radiology (2023) 30:343–349
  • “The incidence of benign, potentially malignant, and premalignant incidental findings in adult trauma patients has increased over the years due to the utilization of advanced imaging. The results of our study suggest that potentially malignant or pre-malignant incidental findings are common among trauma patients. Our study found that 6.6% (n=410) of patients had potentially malignant or pre-malignant findings, and 43% of patients with incidental findings had multiple incidentalomas. Thirty nine percent of patients had their incidental findings recorded in the radiology report with recommendations to follow-up. Sixty one percent of patients had incidentaloma-specific documentation or follow-up recommendations provided to them at discharge.”
    Expecting the unexpected: incidental findings at a level 1 trauma center
    Hordur M Kolbeinsson et al.
    Emergency Radiology (2023) 30:343–349
  • “These findings, while distinctly improved over other studies, leave considerable room for improvement. This highlights the need to standardize medical record capture of incidentalomas to ensure adequate and appropriate follow-up. Future studies should evaluate the percentage of patients who act on any follow-up recommendations to seek further care or imaging. Challenges and barriers to further examination, as well as long-term outcomes, are important to research. As a result of our findings, our level 1 trauma center implemented a process change to better document incidentalomas in a letter that is included in the patient’s discharge summary and available to the primary care team.”
    Expecting the unexpected: incidental findings at a level 1 trauma center
    Hordur M Kolbeinsson et al.
    Emergency Radiology (2023) 30:343–349
  • “In this article, we consider the following question: if such an incidental finding has no known clinical consequence, does it merit mention in a radiology report? We contend that the radiologist’s report should minimize the traditional descriptive catalog of find- ings and take a form similar to a consulting physician’s report, focusing on the clinical question.”

    Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings 
Pari V. Pandharipande et al.
J Am Coll Radiol 2016;13:764-767
  • “Potential benefits of nondisclosure include the following: (1) Simplifying the report and implying that the radiologist accepts responsibility for concluding that the cyst is not important. This would streamline care and minimize “noise” in the medical record. (2) Avoiding the risk of unnecessary follow-up or workup, on the basis of referrers’ possible misunderstandings about the clinical importance of a renal cyst. To our knowledge, the prevalence of unnecessary further workup (which may involve further imaging or subspecialty referral) is not documented. However, this is a common problem that is well known to practicing radiologists, nephrologists, and urologists.”


    Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings 
Pari V. Pandharipande et al.
J Am Coll Radiol 2016;13:764-767
  • “Many radiologists object to the concept of nondisclosure on the basis of their perceptions of the medicolegal risks. However, the failure to disclose an incidental imaging finding by itself is not sufficient to lead to legal liability. To succeed in a medical malpractice claim of negligence, the patient alleging negligence must demonstrate that (1) a reasonable radiologist would have identified and re- ported the incidental finding, (2) failure to disclose the incidental finding caused the patient to suffer a legally compensable harm, and (3) the harm resulted in quan- tifiable damages. On the basis of these requirements, not reporting imaging findings that meet the criteria we recommend for nondisclosure is unlikely to lead to a successful legal claim. However, it is well known that juries and other reasonable individuals may differ on conclusions in individual cases.”

    Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings 
Pari V. Pandharipande et al.
J Am Coll Radiol 2016;13:764-767
  • “A few additional conditions could further reduce possible legal risk from not reporting unimportant incidental findings. First, the nondisclosure policy would need to be recognized as the standard of care. When appropriately vetted, it would need to be published as an expert consensus opinion, with justification as to why its benefits outweigh its risks. This article is intended to stimulate such discussions.”


    Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings 
Pari V. Pandharipande et al.
J Am Coll Radiol 2016;13:764-767
  • “Threats of the replacement of radiologists by com- puters are widely circulated. There is no doubt that computers will eventually more consistently detect “aberrant pixels” than even the most well-honed radiolo- gist’s eye. For radiologists to provide value to our patients and referrers, we must fully partner with our referrers to determine the clinical importance of all of the findings on an imaging study. We believe that this is what we, as physicians, are expected to do. If we continue to rely on referring physicians as the final arbiters of findings that we list, then we are diminished in a value-based world.”


    Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings 
Pari V. Pandharipande et al.
J Am Coll Radiol 2016;13:764-767
  • “Nondisclosure of clinically unimportant incidental findings reflects a conceptual shift in our reporting practices away from catalog-like descriptions of findings and toward reporting that more directly answers the referrer’s question. Using simple (Bosniak category I) renal cysts as a case example, we proposed four criteria for not reporting clinically unimportant incidental findings and explored the risks and benefits of our approach. The proposed criteria do not represent a formal recommendation; instead, we believe that they should be iteratively critiqued, improved, and adapted to other similar imaging scenarios before implementation.”

    Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings 
Pari V. Pandharipande et al.
J Am Coll Radiol 2016;13:764-767
  • “AAA represents a progressive increase in the aortic luminal diameter and is the 10th most common cause of death in the Western world. AAA is usually described by its relationship to renal arteries (ie, suprarenal or infrarenal). The normal diameter of the suprarenal abdominal aorta is up to 3.0 cm, and that of the infrarenal abdominal aorta is 2.0 cm. Aneurysmal dilation of the infrarenal aorta is defined as a diameter ≥3.0 cm or dilation of the aorta ≥1.5 times the normal diameter; on the basis of these criteria, 9% of people aged >65 years have an AAA.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Emergency surgery for aortic aneurysm rupture is associated with 46% mortality (as opposed to 4%-6% for elective repair), and rupture occurs with increasing frequency as the aneurysm size exceeds 5 cm. It is therefore valuable to detect AAAs and follow up until elective repair is indicated.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • When do you followup aneurysms for interval change?
    Aortic Diameter (cm)     Imaging Interval
    2.5-2.9                                   5 y
    3.0-3.4                                   3 y
    3.5-3.9                                   2 y
    4.0-4.4                                   1 y
    4.5-4.9                                   6 mo
    5.0-5.5                                   3-6 mo
  • “Aneurysms involve common and internal iliac arteries more commonly than external iliac arteries. Iliac artery aneurysm is defined as a vessel diameter ≥1.5 times the normal iliac artery diameter or ≥2.5 cm in diameter. Iliac artery aneurysms are rare in isolation; Lawrence et al reported a prevalence of 6.58 per 100,000 hospitalized men and 0.26 per 100,000 hospitalized women in the United States. Aneurysms that are <3.0 cm in diameter tend to be asymptomatic, rarely rupture, and expand slowly; those that are 3.0 to 3.5 cm should be followed up with cross-sectional imaging initially at about 6 months. If stable, repeat scanning can be performed annually. Iliac artery aneurysms >3.5 cm have a greater tendency to rupture and should be followed more closely or treated expeditiously.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Aneurysms involve common and internal iliac arteries more commonly than external iliac arteries. Iliac artery aneurysm is defined as a vessel diameter ≥1.5 times the normal iliac artery diameter or ≥2.5 cm in diameter. Iliac artery aneurysms are rare in isolation; Lawrence et al reported a prevalence of 6.58 per 100,000 hospitalized men and 0.26 per 100,000 hospitalized women in the United States. Aneurysms that are <3.0 cm in diameter tend to be asymptomatic, rarely rupture, and expand slowly; those that are 3.0 to 3.5 cm should be followed up with cross-sectional imaging initially at about 6 months. If stable, repeat scanning can be performed annually.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Splenic artery aneurysms are the most common visceral aneurysms and the third most common intra-abdominal aneurysm, after those occurring in the aorta and iliac arteries . In a series of >300 visceral artery aneurysms, 70.9% were of the splenic artery. The vast majority are true aneurysms, although pseudoaneurysms related to prior inflammation, especially pancreatitis, or infection may occur. The estimates of prevalence of splenic artery aneurysms vary, but a retrospective review of nonselective angiograms suggests that an incidence estimate of 0.8% may be the most accurate .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Risk factors for developing these aneurysms are similar to those for other aneurysms. In a review of the clinical features of 217 patients with splenic artery aneurysms, hypertension was present in 50.2%, obesity in 27.6%, coronary artery disease in 23.5%, and hypercholesterolemia in 21.7%. Splenic artery aneurysms occur more frequently in women .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Spontaneous rupture of a splenic artery aneurysm is rare, especially for smaller (<2 cm) aneurysms, but may occur, usually with larger aneurysms. Additional risk factors associated with rupture include rapidly increasing size, occurrence in women of childbearing years, cirrhosis (especially associated with α1 antitrypsin deficiency), and symptoms that can be attributable to the aneurysm.”
    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “The surgical literature suggests a consensus that such an aneurysm should be considered for endovascular therapy when ≥2 cm. Smaller aneurysms probably can be safely followed, although the clinical risk factors for rupture should be carefully assessed. In one review of patients who were followed with small splenic artery aneurysms, the mean aneurysm growth rate was 0.06 cm/y, with the most rapid growth rate noted to be 1 cm over 63 months. In this group of patients, none of the aneurysms ruptured. Given these data, yearly surveillance for small splenic artery aneurysms is recommended, although for the smaller aneurysms among those ≥2 cm, surveillance intervals of >1 year may be reasonable, depending on comorbidities and life expectancy.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “RAA is uncommon, occurring in about 0.09% of the population . Etiologies include fibromuscular dysplasia (FMD), atherosclerosis, and pseudoaneurysms that may occur after trauma. In a review of 168 patients with 252 RAAs, 34% had FMD, 25% had atherosclerosis, 6.5% had concurrent aneurysms of other vessels, and 73% had hypertension [22]. RAAs are usually detected incidentally at cross-sectional imaging, are small, are asymptomatic, and have uncertain clinical relevance. However, they may rupture, especially if they enlarge, and may be associated with renal arterial hypertension.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “One approach that has been suggested is to repair all aneurysms ≥1 cm in patients with uncontrolled hypertension. An incidentally discovered RAA measuring 1.0 to 1.5 cm can be safely followed . In a series of 86 RAAs with a mean size of 1.3 cm, none ruptured after an average follow-up of 72 months. We recommend that a reasonable imaging follow-up interval in these asymptomatic individuals is every 1 to 2 years. Larger aneurysms, measuring >1.5 to 2.0 cm, should be considered for surgical or endovascular repair .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “One approach that has been suggested is to repair all aneurysms ≥1 cm in patients with uncontrolled hypertension. An incidentally discovered RAA measuring 1.0 to 1.5 cm can be safely followed . In a series of 86 RAAs with a mean size of 1.3 cm, none ruptured after an average follow-up of 72 months. We recommend that a reasonable imaging follow-up interval in these asymptomatic individuals is every 1 to 2 years. Larger aneurysms, measuring >1.5 to 2.0 cm, should be considered for surgical or endovascular repair .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Outside of the splenic and renal circulations, visceral aneurysms can affect the celiac, hepatic, gastroduodenal, pancreaticoduodenal, gastric, or mesenteric arteries. After splenic and renal arterial aneurysms, the hepatic artery is the next most common location. When discovered incidentally, these aneurysms are typically caused by atherosclerosis and may be associated with aneurysmal disease elsewhere. They can also be mycotic, traumatic (including iatrogenic trauma for hepatic aneurysms after liver biopsy), or, less commonly, related to polyarteritis nodosa, FMD, or visceral inflammatory disease, such as pancreatitis.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Treatment is generally recommended for aneurysms >2 cm in diameter, possibly with a smaller threshold for nonatherosclerotic aneurysm. For hepatic aneurysms, Abbas et al  established that multiplicity and nonatherosclerotic origin were linked to increased rupture rate. Criteria for which it is safe to observe visceral arterial aneurysms have not been clearly established. In the study of Abbas et al, of 21 patients with a mean follow-up interval of 68.4 months and mean diameter of 2.3 cm, none required intervention during the follow-up period.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Ovarian veins originate from the plexus in the broad ligament near the ovary and fallopian tubes and communicate with the uterine plexus, then course anterior to the psoas muscle and the ureter. The right ovarian vein typically drains into the IVC and the left ovarian vein into the left renal vein. Autopsy studies have shown that valves are absent in the cranial portion of the ovarian vein in 15% of women on the left and 6% on the right . The valves are incompetent on either side in 35% to 43%, with a higher frequency in multiparous women, resulting in dilation >8 mm and incompetence in many asymptomatic patients who undergo CT.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Incompetence of the ovarian and draining pelvic veins and venous reflux are considered the main cause of pelvic congestion syndrome in women, symptoms of which include persistent dull pelvic pain lasting >6 months, dysmenorrhea, dyspareunia, postcoital ache, and urinary symptoms. However, dilated pelvic veins are often seen incidentally in asymptomatic multiparous women . If dilated pelvic veins are noted in a woman and are asymptomatic, no further imaging or intervention is recommended..”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “In a CT angiographic study of potential renal donors, dilated ovarian veins were found in 16 (47%) of 34 asymptomatic women . In another CT study of patients with severe ovarian vein reflux, but without PCS, both right and left parauterine veins were tortuous and dilated in all cases, with a mean vein diameter of 5.9 ± 1.6 mm (range, 4.3-8.0 mm). Pelvic varices, and early opacification and dilation of the gonadal veins, may occur without venous reflux, particularly if uterine fibroids or other pelvic abnormalities are present.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Gonadal vein thrombosis can be seen in up to 80% of asymptomatic women who undergo routine CT after hysterectomy and lymphadenectomy for neoplasm. When acute, the central thrombus typically demonstrates low attenuation and is associated with mural enhancement. The vessel chronically becomes fibrotic and contracted, and phleboliths may develop.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Pancreaticoduodenal aneurysms are felt to be at higher risk for rupture, and all of these aneurysms should be considered for surgical or endovascular treatment.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “If there are one or more visible gallstones with no associated ductal dilation, mass, or clinical symptoms, no additional workup is recommended. Gallbladder ultrasound may be indicated when symptoms such as biliary colic develop.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “Although gallbladder wall calcification (porcelain gallbladder) had been long thought to be associated with a substantially increased risk for gallbladder carcinoma, large retrospective studies have shown that the risk is approximately 5% to 7%. One study of 25,900 gallbladder specimens found that calcification was present in 44 of the specimens. One hundred fifty of 25,900 patients had gallbladder carcinoma, but only 2 of the 44 patients with gallbladder wall calcifications were among the 150 patients who had carcinoma.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “Therefore, the committee generally does not recommend follow-up in patients with gallbladder wall calcifications. However, if the referring physician desires follow-up, this should be individualized on the basis of the patient's comorbidities and life expectancy. Ultrasound may not be worthwhile for following asymptomatic gallbladder wall calcifications, particularly when concentric, because this would obscure the gallbladder contents. Furthermore, a gallbladder mass may be nearly isoattenuating on noncontrast CT, so when follow-up is performed, contrast-enhanced CT is recommended.”

     Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “If the nature of these findings is not known from recent abdominal sonography, this may represent gallbladder sludge, biliary excretion of intravascularly administered contrast (iodine or gadolinium based), hyperconcentrated bile, hemorrhage, or noncalcified gallstones. The patient's clinical history should help narrow the differential diagnosis. Generally, in the absence of other findings such as wall thickening and pericholecystic changes, hyperattenuating gallbladder contents do not warrant further prompt evaluation or follow-up.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “In the absence of secondary causes of gallbladder wall thickening, such as hepatitis, congestive heart failure, acute or chronic liver disease, pancreatitis, or hypoproteinemia, a primary cause should be excluded by clinical history. If the thickening is uniform or nearly so, the risk for an underlying gallbladder carcinoma is negligible. There are no data suggesting value in following generalized gallbladder wall thickening, so the committee recommends no specific further evaluation or follow-up for such a finding.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “ Pericholecystic fluid may occur from gallbladder wall perforation or necrosis and is usually symptomatic and therefore not an incidental finding. Gallbladder wall edema usually has no specific clinical importance but may be mistaken for pericholecystic fluid. However, truly pericholecystic fluid may be an unexpected finding in patients with multiple injuries or altered mental status. In the absence of symptomatic causes of pericholecystic fluid, further evaluation should be individualized on the basis of the patient's condition and the specific nature of the finding.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
    Distended Gallbladder (>4 cm Transversely and >9 cm Longitudinally) on CT or MRI
  • “In the absence of right upper quadrant symptoms, physiologic distention secondary to fasting is most likely. Otherwise, acute obstruction should be considered. Prompt further evaluation should depend on the patient's symptoms and laboratory findings.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “When measuring a bile duct, short-axis measurements are the most accurate on CT and MR because a tubular structure may seem larger when seen obliquely. Biliary ductal dilation is defined as a common bile duct or common hepatic duct >6 mm in a patient <60 years of age with the gallbladder present or a common duct >10 mm with the gallbladder absent. A diameter >7 mm suggests bile duct obstruction in patients without previous cholecystectomy. Because biliary dilation is often chronic and asymptomatic, liver function tests can help assess the importance of this imaging finding. Mild dilation is unlikely to be clinically important when alkaline phosphatase and bilirubin are normal, and no further imaging evaluation is recommended in these circumstances.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “Incidental findings include calcified or noncalcified gallstones, diffuse or focal gallbladder wall thickening, distended gallbladder, gallbladder wall polyp or mass, gallbladder wall calcifications, hyperdense gallbladder contents, and biliary ductal dilation. Although cholelithiasis, acute and chronic cholecystitis, carcinoma of the gallbladder, and other serious gallbladder conditions are often symptomatic, they may occasionally be detected incidentally.” 

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.
    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “The increasing use of computed tomography (CT) scans in the evaluation of trauma patients has led to increased detection of incidental radiologic findings. Incidental findings (IFs) of the abdominal viscera are among the most commonly discovered lesions and can carry a risk of malignancy. Despite this, patient notification regarding these findings is often inadequate.”

    J Trauma Manag Outcomes. 2015 Feb 4;9(1):1
    Improving patient notification of solid abdominal viscera incidental findings with a standardized protocol.
    J Trauma Manag Outcomes. 2015 Feb 4;9(1):1
    Collins CE et al.
  • “We identified patients who underwent abdominopelvic CTs as part of their trauma evaluation during a recent 1-year period (9/2011-8/2012). Patients with IFs of the kidneys, liver, adrenal glands, pancreas and/or ovaries had their charts reviewed for documentation of the lesion in their discharge paperwork or follow-up. A quality improvement project was initiated where patients with abdominal IFs were verbally informed of the finding, it was noted on their discharge summary and/or were referred to specialists for evaluation. Nine months after the implementation of the IF protocol, a second chart review was performed to determine if the rate of patient notification improved.”

    Improving patient notification of solid abdominal viscera incidental findings with a standardized protocol.
    Collins CE et al
    J Trauma Manag Outcomes. 2015 Feb 4;9(1):1
  • “Of 1,117 trauma patients undergoing abdominopelvic CT scans during the 21 month study period, 239 patients (21.4%) had 292 incidental abdominal findings. Renal lesions were the most common (146 patients, 13% of all patients) followed by hepatic (95/8.4%) and adrenal (38/3.4%) lesions. Pancreatic (10/0.9%) and ovarian lesions (3/0.3%) were uncommon. Post-IF protocol implementation patient notification regarding IFs improved by over 80% (32.4% vs. 17.7% pre-protocol, p = 0.02).”
    Improving patient notification of solid abdominal viscera incidental findings with a standardized protocol.

    Collins CE et al
    J Trauma Manag Outcomes. 2015 Feb 4;9(1):1
  • “IFs of the solid abdominal organs are common in trauma patients undergoing abdominopelvic CT scan. Patient notification regarding these lesions is often inadequate. A systematic approach to the documentation and evaluation of incidental radiologic findings can significantly improve the rate of patient notification.”

    Improving patient notification of solid abdominal viscera incidental findings with a standardized protocol.
    Collins CE et al
    J Trauma Manag Outcomes. 2015 Feb 4;9(1):1
  • “The aim of this study was to evaluate for agreement with respect to how radiologists report incidental findings encountered on CT.”
    Common Incidental Findings on MDCT: Survey of Radiologist Recommendations for Patient Management
    Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK
    J Am Coll Radiol 2011;8:762-767
  • 12 Common Incidental CT Findings: What do you do-
    - Incidental 1 cm thyroid nodule
    - Incidental 5 mm non-calcified lung nodule
    - Incidental coronary artery calcification
    - Incidental 2 cm adrenal nodule (40 HU after IV)
    - Incidental 2 cm cystic lesion pancreas
    - Incidental 1 cm enhancing liver lesion in non-cirrhotic liver
  • 12 Common Incidental CT Findings: What do you do-
    - Incidental high density renal lesion on contrast enhanced CT (30HU)
    - Incidental short segment jejunal intussusception
    - Incidental 1 cm low density/cystic splenic lesion
    - Incidental focal gallbladder wall calcifications
    - Incidental 3 cm ovarian cyst in post-menpausal female
    - Incidental 3 cm cyst in premenopausal female
  • “ 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.”
    Common Incidental Findings on MDCT: Survey of Radiologist Recommendations for Patient Management
    Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK
    J Am Coll Radiol 2011;8:762-767
  • “ 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.”
    Common Incidental Findings on MDCT: Survey of Radiologist Recommendations for Patient Management
    Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK
    J Am Coll Radiol 2011;8:762-767
  • “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.”
    Common Incidental Findings on MDCT: Survey of Radiologist Recommendations for Patient Management
    Johnson PT, Horton KM, Megibow AJ, Jeffrey RB, Fishman EK
    J Am Coll Radiol 2011;8:762-767
  • “ Given that incidental findings are very common in high-resolution imaging, patients should be provided information about the possibility of an incidental finding as part of radiologic informed consent.”
    Incidental Findings and the Need for a Revised Informed Consent Process
    Kole J, Fiester A
    AJR 2013; 201:1064-1068
  • “ The frequency of IFs, the very high rate of false-positives among incidentalomas, the very low rates of malignancies among incidentalomas, and the potential financial and emotional costs to both patients and the health care system of monitoring Ifs necessitate a through informed consent process.”
    Incidental Findings and the Need for a Revised Informed Consent Process
    Kole J, Fiester A
    AJR 2013; 201:1064-1068
  • “ The range of normal ovarian size varies as a function of hormonal status; in premenopausal patients, ovaries up to 20 cm3 in volume are within the upper 95% confidence interval for normal, whereas in postmenopausal woman, the upper 95% confidence interval for normal volume is 10cm3.”
    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings
    Patel MD et al
    J Am Coll Radiol 2013;10:675-681
  • “ For an oval shaped structure, these volume limits generally translate to a maximum linear diameter of 5 cm for premenopausal woman and 3-4 cm for post menopausal woman, with the size of the ovary normally decreasing progressively after 30 years of age.”
    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings
    Patel MD et al
    J Am Coll Radiol 2013;10:675-681
  • “ The committee recommends short interval follow-up (premenopause) ultrasound in 6-12 weeks for benign appearing adnexal cysts >5cm in diameter and probably benign adnexal cysts>3cm in diameter.”
    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings
    Patel MD et al
    J Am Coll Radiol 2013;10:675-681
  • “ The committee recommends that an adnexal cyst identified on CT or MRI - 1cm in maximum size in any phase of the postmenopausal period should be considered benign unless there are clearly identified imaging findings suspicious for malignancy or evidence of possible metastatic ovarian cancer.”
    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings
    Patel MD et al
    J Am Coll Radiol 2013;10:675-681
  • “ When an incidentally identified benign appearing cyst in a woman in early postmenopause is >5cm in size, the committee recommends prompt sonographic evaluation to ensure that small wall nodules have not been overlooked”
    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings
    Patel MD et al
    J Am Coll Radiol 2013;10:675-681
  • “ In late postmenopause, the committee does not recommend prompt or follow-up ultrasound of an asymptomatic benign appearing cyst - 3 cm in maximum diameter.”
    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings
    Patel MD et al
  • J Am Coll Radiol 2013;10:675-681
    “ In early postmenopause, the committee recommends prompt ultrasound for a probably cyst >3cm and in late menopause  for a probably benign cyst >1 cm in maximum diameter.”
    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings
    Patel MD et al
    J Am Coll Radiol 2013;10:675-681

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