Recommendations for the Management of the Incidental Renal Mass in Adults: Endorsement and Adaptation of the 2017 ACR Incidental Findings Committee White Paper by the Canadian Association of Radiologists Incidental Findings Working Group

Adequacy of clinical guideline recommendations for patients with low-risk cancer managed with monitoring: systematic review

OBJECTIVES

The aim of this systematic review was to summarize national and international guidelines that made recommendations for monitoring patients diagnosed with low-risk cancer. It appraised the quality of guidelines and determined whether the guidelines adequately identified patients for monitoring, specified which tests to use, defined monitoring intervals, and stated triggers for further intervention. It then assessed the evidence to support each recommendation.

STUDY DESIGN AND SETTING

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, we searched PubMed and Turning Research into Practice databases for national and international guidelines' that were written in English and developed or updated between 2012 and 2023. Quality of individual guidelines was assessed using the AGREE II tool.

RESULTS

Across the 41 published guidelines, 48 different recommendations were identified: 15 (31%) for prostate cancer, 11 (23%) for renal cancer, 6 (12.5%) for thyroid cancer, and 10 (21%) for blood cancer. The remaining 6 (12.5%) were for brain, gastrointestinal, oral cavity, bone and pheochromocytoma and paraganglioma cancer. When combining all guidelines, 48 (100%) stated which patients qualify for monitoring, 31 (65%) specified which tests to use, 25 (52%) provided recommendations for surveillance intervals, and 23 (48%) outlined triggers to initiate intervention. Across all cancer sites, there was a strong positive trend with higher levels of evidence being associated with an increased likelihood of a recommendation being specific (P = 0.001) and the evidence for intervals was based on expert opinion or other guidance.

CONCLUSION

With the exception of prostate cancer, the evidence base for monitoring low-risk cancer is weak and consequently recommendations in clinical guidelines are inconsistent. There is a lack of direct evidence to support monitoring recommendations in the literature making guideline developers reliant on expert opinion, alternative guidelines, or indirect or nonspecific evidence.

Comparison of true non-contrast and virtual non-contrast images in the characterization of renal lesions using detector-based spectral CT

OBJECTIVES

Renal lesions are sometimes incidentally detected during computed tomography (CT) examinations in which an unenhanced series is not included, preventing the lesions from being fully characterized. The aim of this study was to investigate the feasibility to use virtual non-contrast (VNC) images, acquired using a detector-based dual-energy CT, for the characterization of renal lesions.

METHODS

Twenty-seven patients (12 women) underwent a renal CT scan, including a non-contrast, an arterial, and a venous phase contrast-enhanced series, using a detector-based dual-energy CT scanner. VNC images were reconstructed from the venous contrast-enhanced series. The mean attenuation values of 65 renal lesions in both the VNC and true non-contrast (TNC) images were measured and compared quantitatively. Three radiologists blindly assessed all lesions using either VNC or TNC images in combination with contrast-enhanced images.

RESULTS

Sixteen patients had cystic lesions, five had angiomyolipoma (AML), and six had suspected renal cell carcinomas (RCC). Attenuation values in VNC and TNC images were strongly correlated (ρ = 0.7, mean difference -6.0 ± 13 HU). The largest differences were found for unenhanced high-attenuation lesions. Radiologists classified 86% of the lesions correctly using VNC images.

CONCLUSIONS

In 70% of the patients, incidentally detected renal lesions could be accurately characterized using VNC images, resulting in less patient burden and a reduction in radiation exposure.

ADVANCES IN KNOWLEDGE

This study shows that renal lesions can be accurately characterized using VNC images acquired by detector-based dual-energy CT, which is in agreement with previous studies using dual-source and rapid X-ray tube potential switching technique.

Recommendations for the Management of Incidental Musculoskeletal Findings on MRI and CT

The Canadian Association of Radiologists (CAR) Incidental Findings Working Group consists of both academic subspeciality and general radiologists tasked with either adapting American College of Radiology (ACR) guidelines to meet the needs of Canadian radiologists or authoring new guidelines where appropriate. In this case, entirely new guidelines to deal with incidental musculoskeletal findings that may be encountered on thoracoabdominal computed tomography or magnetic resonance imaging were drafted, focussing on which findings should prompt recommendations for further workup. These recommendations discuss how to deal with incidental marrow changes, focal bone lesions, abnormalities of the pubic symphysis and sacroiliac joints, fatty soft tissue masses, manifestations of renal osteodystrophy and finally discuss opportunistic osteoporosis evaluation.

General Review on the Current Management of Incidental Findings on Cross-Sectional Imaging: What Guidelines to Use, How to Follow Them, and Management and Medical-Legal Considerations

"Incidentalomas" are a common part of daily practice for radiologists, and knowledge of appropriate management guidelines is important in ensuring that no potentially clinically relevant findings are missed or are lost to follow-up in asymptomatic patients. Incidental findings of the brain, spine, thyroid, lungs, breasts, liver, adrenals, spleen, pancreas, kidneys, bowel, and ovaries are discussed, including where to find guidelines for management recommendations, how to follow them, and medical-legal considerations.

Recommendations for the Management of Incidental Hepatobiliary Findings in Adults: Endorsement and Adaptation of the 2017 and 2013 ACR Incidental Findings Committee White Papers by the Canadian Association of Radiologists Incidental Findings Working Group

The Canadian Association of Radiologists Incidental Findings Working Group consists of both academic subspecialty and general radiologists and is tasked with adapting and expanding upon the American College of Radiology incidental findings white papers to more closely apply to Canadian practice patterns, particularly more comprehensively dealing with the role of ultrasound and pursuing more cost-effective approaches to the workup of incidental findings without compromising patient care. Presented here are the 2020 Canadian guidelines for the management of hepatobiliary incidental findings. Topics covered include initial assessment of hepatic steatosis and cirrhosis, the workup of incidental liver masses identified on ultrasound and computed tomography (with algorithms presented), incidental gallbladder findings (wall thickening, calcification, and polyps), and management of incidental biliary dilatation.