Impact of incidental findings in preoperative CTA imaging for autologous breast reconstruction

Importance of Incidental Findings in Preoperative Computed Tomography Angiography for Abdominal-Based Free Flap Breast Reconstruction: A Multi-institutional Study

BACKGROUND

Besides its intended purpose of perforator mapping, CTA can also identify incidental findings that may require further evaluation. In this multi-institutional study, we evaluated the frequency of incidental findings and their significance and impact on treatment course. We also aimed to identify risk factors for detecting such findings.

METHOD

A retrospective review of patients who underwent perforator mapping with CTA was performed over a 5-year period from three academic institutions. Relevant sociodemographic and clinicopathologic information were reviewed, as well as CTA reports and follow up visits and treatment outcomes. Univariate and multivariate analyses were performed to assess the relationship between risk factors and incidental findings.

RESULTS

From January 2015 to July 2020, a total of 656 patients were identified that met inclusion criteria. Overall, 342 incidental findings were found, out of which 76 required additional imaging or consultation. Ultimately, 10 (1.5%) patients had findings that altered reconstructive management, including 5 (0.8%) patients having severe disease that cancelled their reconstruction altogether. Advanced age and immediate reconstruction timing were independent risk factors for incidental findings.

CONCLUSION

Incidental findings can be commonly identified on preoperative CTA for DIEP flap breast reconstruction. Suspicious findings should be investigated thoroughly as they can alter the reconstructive course. Understanding of high-risk groups for incidental findings can further advance patient education during initial consultation.

Incidence, Impact, and Management of Incidentalomas on Preoperative Computed Tomographic Angiograms for Breast Cancer Patients with and without Genetic Mutations

BACKGROUND

Preoperative abdominal computed tomographic angiograms for free flap breast reconstruction improve operative safety and efficiency, but incidental findings are common and potentially affect management. In addition, the authors hypothesized that patients with genetic mutations might have a higher rate of significant findings. The authors present the largest series of computed tomographic angiogram "incidentalomas" in these two populations and an evidence-based algorithm for managing common findings.

METHODS

All patients undergoing free flap breast reconstruction at Northwell Health between 2009 and 2017 were eligible. Medical history, perioperative details, and radiology reports were examined with abnormal findings recorded. Published literature was reviewed with radiologists to develop standardized guidelines for incidentaloma management.

RESULTS

Of 805 patients included, 733 patients had abdominal imaging. One hundred ninety-five (27 percent) had a completely negative examination. In the remaining 538 patients, benign hepatic (22 percent) and renal (17 percent) findings were most common. Sixteen patients (2.2 percent) required additional imaging (n = 15) or procedures (n = 5). One finding was concerning for malignancy-renal cell carcinoma-which interventional radiology ablated postoperatively. Seventy-nine patients (10.8 percent) had a genetic mutation but were not found to have a statistically significant higher rate of incidentalomas.

CONCLUSIONS

The authors' rate of computed tomographic angiography incidental findings (73 percent) is consistent with previous studies, but the rate requiring further intervention (2.2 percent) is lower. Incidental findings were no more common or pathologic among genetic mutation carriers. The authors also introduce an evidence-based algorithm for the management of common incidentalomas. Using these guidelines, plastic surgeons can reassure patients, regardless of mutation status, that incidentalomas are most commonly benign and have minimal impact on their surgical plan.