Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: White Paper of the ACR Incidental Findings Committee II on Adnexal Findings

A systematic review and meta-analysis of incidental findings in computed tomography scans for pediatric trauma patients

PURPOSE

To quantitatively synthesize and report the frequency and category of incidental findings on Computed Tomography (CT) scans in pediatric trauma patients.

METHODS

A thorough literature search was carried out in PubMed, Scopus, and Web of Science databases until March 6, 2023, in adherence to the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. Studies describing incidental findings on CT scans in trauma patients ≤21 years were included. Incidental findings were grouped into three categories: Category 1 (requiring immediate or urgent evaluation or treatment), Category 2 (likely benign but which may require outpatient follow-up), and Category 3 (benign anatomic variants or pathologic findings that do not require follow-up or intervention).

RESULTS

Seven studies were included in this study, which revealed a combined rate of 27.10 % of incidental findings with notable heterogeneity among the studies. Aggregated frequencies were 10.15 % for Category 1, 32.18 % for Category 2 and 51.44 % for Category 3. Subgroup meta-analysis on abdominal CT scans showed a higher pooled incidence of incidental findings at 47.17 %, but with lower heterogeneity than the general meta-analysis.

CONCLUSION

The study underscores the prevalence of incidental findings in pediatric trauma patients undergoing CT scans. The categorization of these findings provides useful information for clinicians in determining appropriate follow-up and management strategies.

Sustainability and Climate Protection in Radiology - An Overview

BACKGROUND

Sustainability is becoming increasingly important in radiology. Besides climate protection - economic, ecological, and social aspects are integral elements of sustainability. An overview of the scientific background of the sustainability and environmental impact of radiology as well as possibilities for future concepts for more sustainable diagnostic and interventional radiology are presented below.The three elements of sustainability:1. EcologyWith an annually increasing number of tomographic images, Germany is in one of the leading positions worldwide in a per capita comparison. The energy consumption of an MRI system is comparable to 26 four-person households annually. CT and MRI together make a significant contribution to the overall energy consumption of a hospital. In particular, the energy consumption in the idle or inactive state is responsible for a relevant proportion.2. EconomyA critical assessment of the indications for radiological imaging is important not only because of radiation protection, but also in terms of sustainability and "value-based radiology". As part of the "Choosing Wisely" initiative, a total of 600 recommendations for avoiding unnecessary examinations were compiled from various medical societies, including specific indications in radiological diagnostics.3. Social SustainabilityThe alignment of radiology to the needs of patients and referring physicians is a core aspect of the social component of sustainability. Likewise, ensuring employee loyalty by supporting and maintaining motivation, well-being, and job satisfaction is an essential aspect of social sustainability. In addition, sustainable concepts are of relevance in teaching and research, such as the educational curriculum for residents in radiology, RADUCATION or the recommendations of the International Committee of Medical Journal Editors.

KEY POINTS

· Sustainability comprises three pillars: economy, ecology and the social component.. · Radiologies have a high optimization potential due to a significant demand of these resources.. · A dialogue between medicine, politics and industry is necessary for a sustainable radiology.. · The discourse, knowledge transfer and public communication of recommendations are part of the sustainability network of the German Roentgen Society (DRG)..

CITATION FORMAT

· Palm V, Heye T, Molwitz I et al. Sustainability and Climate Protection in Radiology - An Overview. Fortschr Röntgenstr 2023; 195: 981 - 988.

[Patient-centered, value-based management of incidental findings in radiology]

As a byproduct of the increased use of high-resolution radiological imaging, the prevalence of incidental findings (IFs) has been increasing for years. The discovery of an incidental finding can allow early treatment of a potentially health-threatening disease and thus decisively change the course of the disease. However, many incidental findings are of low risk with little or no health impact, and yet their discovery often leads to a cascade of additional investigations. It is undisputed that incidental findings can have a direct impact on the life of the person and that not only psychosocial aspects such as worries and anxiety due to false-positive findings play a role, but that insurance, legal or professional problems can also occur under certain circumstances, which is why the correct handling of incidental findings and the accompanying ethical challenges that apply to them regularly give rise to discussions. General principles to consider when managing incidental findings are responsibility for the well-being of the patient/study participant and of society. In order to avoid overdiagnosis and overtreatment and to achieve high patient benefit, radiologists and clinicians must know how to properly deal with IFs. In recent years, various national and international societies have published important guidelines ("white papers") on how to deal with the management of IFs. It is important that radiologists are fully aware of and follow these guidelines and are also available to referring physicians for further discussions and advice. The most important fact is that the well-being of the patient must always be at the center of all decisions.

Applying Implementation Science Principles to Systematize High-Quality Care for Potentially Significant Imaging Findings

OBJECTIVE

Use principles of implementation science to improve the diagnosis and management of potentially significant imaging findings.

METHODS

Multidisciplinary stakeholders codified the diagnosis and management of potentially significant imaging findings in eight organs and created a finding tracking management system that was embedded in radiologist workflows and IT systems. Radiologists were trained to use this system. An automated finding tracking management system was created to support consistent high-quality care through care pathway visualizations, increased awareness of specific findings in the electronic medical record, templated notifications, and creation of an electronic safety net. Primary outcome was the rate of quality reviews related to eight targeted imaging findings. Secondary outcome was radiologist use of the finding tracking management tool.

RESULTS

In the 4 years after implementation, the tool was used to track findings in 7,843 patients who received 10,015 ultrasound, CT, MRI, x-ray, and nuclear medicine examinations that were interpreted by all 34 radiologists. Use of the tool lead to a decrease in related quality reviews (from 8.0% to 0.0%, P < .007). Use of the system increased from 1.7% of examinations in the early implementation phase to 3.1% (+82%, P < .00001) in the postimplementation phase. Each radiologist used the tool on an average of 294.6 unique examinations (SD 404.8). Overall, radiologists currently use the tool approximately 4,000 times per year.

DISCUSSION

Radiologists frequently used a finding tracking management system to ensure effective communication and raise awareness of the importance of recommended future follow-up studies. Use of this system was associated with a decrease in the rate of quality review requests in this domain.

Using Genomic Variation to Distinguish Ovarian High-Grade Serous Carcinoma from Benign Fallopian Tubes

The preoperative diagnosis of pelvic masses has been elusive to date. Methods for characterization such as CA-125 have had limited specificity. We hypothesize that genomic variation can be used to create prediction models which accurately distinguish high grade serous ovarian cancer (HGSC) from benign tissue.

METHODS

In this retrospective, pilot study, we extracted DNA and RNA from HGSC specimens and from benign fallopian tubes. Then, we performed whole exome sequencing and RNA sequencing, and identified single nucleotide variants (SNV), copy number variants (CNV) and structural variants (SV). We used these variants to create prediction models to distinguish cancer from benign tissue. The models were then validated in independent datasets and with a machine learning platform.

RESULTS

The prediction model with SNV had an AUC of 1.00 (95% CI 1.00-1.00). The models with CNV and SV had AUC of 0.87 and 0.73, respectively. Validated models also had excellent performances.

CONCLUSIONS

Genomic variation of HGSC can be used to create prediction models which accurately discriminate cancer from benign tissue. Further refining of these models (early-stage samples, other tumor types) has the potential to lead to detection of ovarian cancer in blood with cell free DNA, even in early stage.

The Female Genital Tract on MDCT: A Pictorial Review of Normal Anatomy and Incidental Abnormalities

Purpose This article aims to review the pertinent anatomy and the incidental abnormalities involving the female genital tract on multidetector computed tomography (MDCT) through a pictorial review.

Methods The review is based on critical analysis of the existing literature as well as our experience in dealing with incidental lesions involving the female genital tract.

Results The lack of awareness regarding the normal appearances of the female pelvis on MDCT can puzzle the inexperienced radiologist and create management dilemmas for the treating clinician. It is important for radiologists to recognize normal appearances of the female genital tract on MDCT to prevent misinterpretation as pathology. The identification of incidentalomas of the female genital tract on CT can further guide whether additional workup is required or not. This pictorial review familiarizes radiologists with the normal appearances of the female genital tract on MDCT and a few common incidentalomas.

Conclusion It is imperative for a clinical radiologist to be familiar with the anatomy and common incidental lesions involving the female genital tract.

Estimated costs of preoperative evaluation of postmenopausal hysterectomy for prolapse at a safety-net hospital: an observational descriptive study

BACKGROUND

In practice, preoperative evaluation prior to hysterectomy varies. Unnecessary preoperative evaluation may add cost and risk with little benefit to the patient.

OBJECTIVE

This study aimed to describe practice patterns and the associated costs related to preoperative evaluations before hysterectomy for prolapse at a safety-net hospital.

STUDY DESIGN

This was a retrospective cohort study of postmenopausal women who underwent a hysterectomy for prolapse. Nonfacility-associated cost data were obtained from the Centers for Medicare Services. The biopsy cost was estimated to be $172.55 and $125.23 for ultrasounds.

RESULTS

A total of 505 postmenopausal cases were identified. Of those, 155 (31%) underwent a preoperative biopsy, 305 (60%) had an ultrasound, and 124 (25%) had both. Of those, 72.9% had an indication for a biopsy. A total of 64 biopsies and 216 ultrasounds lacked clear indication. Of those, 56 biopsies were performed for bleeding in cases with an endometrial thickness of <4 mm. The total cost of nonvalue-added testing was $42,576.

CONCLUSION

Adherence to a strict preoperative algorithm would have saved $38,092 over the study period, although 0.50% of these biopsies would potentially have detected endometrial cancer preoperatively. These results underscore the value of clinical algorithms at teaching institutions.

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.

Benign-appearing Incidental Adnexal Cysts at US, CT, and MRI: Putting the ACR, O-RADS, and SRU Guidelines All Together

Adnexal cysts are a common incidental finding at US, CT, and MRI but have historically caused a diagnostic dilemma for determining when to follow up and how to manage them. Characteristic imaging features of simple adnexal cysts include a simple fluid collection with smooth walls and no solid or vascular components. Day-to-day practice guidelines were recently updated to reflect the overwhelming evidence that incidental cystic adnexal masses are almost always benign. Three major consensus articles on adnexal cystic masses were published between 2019 and 2020: the Society of Radiologists in Ultrasound (SRU) consensus update on adnexal cysts, the Ovarian-Adnexal Reporting and Data System (O-RADS) US consensus guideline, and the American College of Radiology (ACR) white paper on the management for incidental adnexal findings at CT and MRI. All three standardize reporting terminology, are based on evidence-based data and institutional practice patterns, and apply to nonpregnant women of average risk for ovarian cancer. While there are small differences in follow-up recommendations based on size thresholds, the goal of each is the same-to limit unnecessary imaging follow-up and, by doing so, save the patient time, money, and anxiety. For the diagnostic radiologist to use these guidelines, it is essential that the entire mass is visualized well. Without adequate visualization, further characterization of the mass may be necessary. To put it all together, the SRU consensus guideline and ACR white paper are easily applied in day-to-day practice for masses that are O-RADS 2 and below. An invited commentary by Patel is available online. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2022.

Incidentalomas of the female genital tract on 64-slice MDCT: a clinico-radiological pictorial review

Sonography is the imaging modality of choice for diagnosing diseases of the female genital tract due to its high resolution, easy availability, low cost and lack of radiation. CT is not advocated for the primary evaluation of the female pelvis. However, with the advent of Multidetector CT (MDCT), females of all ages undergo CT scan of the abdomen and pelvis for myriad non-gynaecological diseases, e.g. subacute intestinal obstruction, abdominal lump, abdominal tuberculosis, appendicitis, ureteric colic, pancreatitis, oncological staging, follow-up, etc. Incidental female genital tract disorders were seen on these scans that are a dilemma for both, the radiologists and the clinicians. The objective of this pictorial review is to characterise the incidentally detected lesions of the female genital tract observed on 64-slice MDCT by correlating with sonography, if necessary, and establishing a clinico-radiological diagnosis. Our aim is to emphasise that the radiologist may be the first person to recognise a gynaecologic disorder and hence can play a significant role in patient management.

Radiologists' Increasing Role in Population Health Management: AJR Expert Panel Narrative Review

Population health management (PHM) is the holistic process of improving health outcomes of groups of individuals through the support of appropriate financial and care models. Radiologists' presence at the intersection of many aspects of healthcare, including screening, diagnostic imaging, and image-guided therapies, provides significant opportunity for increased radiologist engagement in PHM. Further, innovations in artificial intelligence and imaging informatics will serve as critical tools to improve value in healthcare through evidence-based and equitable approaches. Given radiologists' limited engagement in PHM to date, it is imperative to define the specialty's PHM priorities so that the radiologists' full value in improving population health is realized. In this expert review, we explore programs and future directions for radiology in PHM.

Incidental Ovarian and Uterine Findings on Cross-sectional Imaging

Incidental adnexal masses and uterine findings occur with a high frequency on cross-sectional imaging examinations, particularly in postmenopausal women in whom imaging is performed for a different reason. These incidentalomas encompass a gamut of potential pelvic gynecologic disorders. Most are benign ovarian cysts; however, other less commonly encountered disorders and improperly positioned gynecologic devices may be seen. A knowledge of the management recommendations for such pelvic incidental findings is critical to avoid unnecessary imaging and surgical interventions, as well as to avoid failure in diagnosis and management of some of these conditions.

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.

Decoding incidental ovarian lesions: use of texture analysis and machine learning for characterization and detection of malignancy

PURPOSE

To compare CT texture features of benign and malignant ovarian lesions and to build a machine learning model to detect malignancy in incidental ovarian lesions.

METHODS

In this IRB-approved, HIPAA-compliant, retrospective study, 427 consecutive patients with incidental ovarian lesions detected on contrast-enhanced CT (348, 81.5% benign and 79, 18.5% malignant) were included. The following CT texture features were analyzed using commercially available software (TexRAD, Feedback Plc, Cambridge, UK): total pixel, mean, standard deviation (SD), entropy, mean value of positive pixels (MPP), skewness, kurtosis and entropy. Three machine learning models were created by combining texture features and patients' age, and performance of these models was assessed using tenfold cross-validation. Receiver operating characteristics (ROC) were constructed to assess sensitivity and specificity. The cutoff value was picked using a cost-weighted method.

RESULTS

Total pixels, mean, SD, entropy, MPP, and skewness were significantly different between benign and malignant groups (p < 0.05). With a selected 10 as a cost factor to optimize cutoff value selection, sensitivity 92%, specificity 60% in the random forest (RF) model, sensitivity 91%, specificity 69% in SVM model, and sensitivity 92%, specificity 61% in the logistic regression, respectively.

CONCLUSION

CT texture analysis could provide objective imaging analysis of incidental ovarian lesions and ML models using CT texture features and age demonstrated high sensitivity and moderate specificity for detection of malignant lesions.

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.

ACR Appropriateness Criteria® Postmenopausal Acute Pelvic Pain

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Contemporary Guidelines for Adnexal Mass Imaging: A 2020 Update

Incidental adnexal masses are commonly encountered at ultrasound, computed tomography, and magnetic resonance imaging. Since many of these lesions are surgically resected and ultimately found to be benign, patients may be exposed to personal and economic costs related to unnecessary oophorectomy. Thus, accurate non-invasive risk stratification of adnexal masses is essential for optimal management and outcomes. Multiple consensus guidelines in radiology have been published to assist in characterization of these masses as benign, indeterminate, or likely malignant. In the last two years, several new and updated stratification systems for assessment of incidental adnexal masses have been published. The purpose of this article is to offer a concise review of four recent publications: ACR 2020 update on the management of incidental adnexal findings on CT and MRI, SRU 2019 consensus update on simple adnexal cysts, O-RADS ultrasound risk stratification system (2020), and O-RADS MRI risk stratification system (2020).

Whole-body MRI for preventive health screening: Management strategies and clinical implications

PURPOSE

To document the diagnostic yields of whole-body MRI (WB-MRI) screening for asymptomatic individuals by using a classification system that categorizes the findings by clinical relevance and provides a flowchart for further investigations, and to determine the influence of WB-MRI findings on clinical decision-making.

METHODS

In this institutional review board-approved study, a retrospective review of individuals who underwent WB-MRI between 2009 and 2020 was conducted, and asymptomatic participants who underwent non-contrast-enhanced comprehensive WB-MRI for screening were enrolled. Participants were classified into four categories based on WB-MRI findings, and those with relevant findings (i.e., categories 3 and 4) were referred for further diagnostic workup. The participants' medical records were investigated, and interviews were conducted to reveal false-negative findings and identify the number of WB-MRI-triggered treatments.

RESULTS

We included 576 participants (377 [65.4 %] men, 199 [34.6 %] women; mean age, 48.40 ± 10.82 years), of which 266 (46.2 %) and 310 (53.8 %) underwent WB-MRI with 1.5 T and 3.0 T magnets, respectively. Approximately one-third of the participants showed clinically relevant findings, and 65 (11.2 %) received a treatment triggered by WB-MRI. Notably, 15 (2.6 %) and 28 (4.8 %) participants had cancers and intracranial aneurysms, respectively. Of the 576 participants, 16 (2.8 %) had false-negative findings, among which five had cancers.

CONCLUSION

WB-MRI yields numerous important findings that trigger therapeutic interventions in a large sample of asymptomatic adults. However, considering its inherent limitations, WB-MRI might be inadequate for detecting malignancies such as colon, thyroid, and breast cancers; thus, it may serve as a complementary screening method for health-conscious individuals.

Maternal and fetal incidental findings on antenatal magnetic resonance imaging

BACKGROUND

Magnetic resonance imaging (MRI) examinations are increasingly used in antenatal clinical practice. Incidental findings are a recognized association with imaging and although in some circumstances their identification can alter management, they are often associated with increased anxiety, for both patient and clinician, as well as increased health care costs.

OBJECTIVE

This study aimed to evaluate the incidence of unexpected findings in both the mother and fetus during antenatal MRI examinations.

MATERIALS AND METHODS

A retrospective study was undertaken over a five-year period at St.. Thomas' Hospital in London. Maternal incidental findings were recorded from all clinical reports of all fetal MRIs performed (for clinical reasons and in healthy volunteers) during this period. Fetal incidental findings were recorded only in cases where women with uncomplicated pregnancies were participating as healthy volunteers.

RESULTS

A total of 2,569 MRIs were included; 17% of women had maternal incidental findings. Of these, 1,099 were women with uncomplicated pregnancies who undertook research MRIs as healthy volunteers; fetal incidental findings were identified in 12.3%.

CONCLUSION

Incidental findings are a common occurrence in antenatal MRI. Consideration should be given to counseling women appropriately before imaging and ensuring that robust local protocols are in place for follow-up and further management of such cases.

Incidental Findings in CT and MR Angiography for Preoperative Planning in DIEP Flap Breast Reconstruction

Autologous breast reconstruction with deep inferior epigastric perforator flaps is considered a standard of care in the treatment after mastectomy, yet vascular anatomy is highly variable and perforator selection remains challenging. The use of preoperative imaging can influence surgical planning and assist intraoperative decision-making. However, this imaging can inevitably uncover incidental findings. The purpose of this study was to analyze incidental findings, evaluate correlation with patient factors, and examine effects on overall care.

Evaluation of a convolutional neural network for ovarian tumor differentiation based on magnetic resonance imaging

OBJECTIVES

There currently lacks a noninvasive and accurate method to distinguish benign and malignant ovarian lesion prior to treatment. This study developed a deep learning algorithm that distinguishes benign from malignant ovarian lesion by applying a convolutional neural network on routine MR imaging.

METHODS

Five hundred forty-five lesions (379 benign and 166 malignant) from 451 patients from a single institution were divided into training, validation, and testing set in a 7:2:1 ratio. Model performance was compared with four junior and three senior radiologists on the test set.

RESULTS

Compared with junior radiologists averaged, the final ensemble model combining MR imaging and clinical variables had a higher test accuracy (0.87 vs 0.64, p < 0.001) and specificity (0.92 vs 0.64, p < 0.001) with comparable sensitivity (0.75 vs 0.63, p = 0.407). Against the senior radiologists averaged, the final ensemble model also had a higher test accuracy (0.87 vs 0.74, p = 0.033) and specificity (0.92 vs 0.70, p < 0.001) with comparable sensitivity (0.75 vs 0.83, p = 0.557). Assisted by the model's probabilities, the junior radiologists achieved a higher average test accuracy (0.77 vs 0.64, Δ = 0.13, p < 0.001) and specificity (0.81 vs 0.64, Δ = 0.17, p < 0.001) with unchanged sensitivity (0.69 vs 0.63, Δ = 0.06, p = 0.302). With the AI probabilities, the junior radiologists had higher specificity (0.81 vs 0.70, Δ = 0.11, p = 0.005) but similar accuracy (0.77 vs 0.74, Δ = 0.03, p = 0.409) and sensitivity (0.69 vs 0.83, Δ = -0.146, p = 0.097) when compared with the senior radiologists.

CONCLUSIONS

These results demonstrate that artificial intelligence based on deep learning can assist radiologists in assessing the nature of ovarian lesions and improve their performance.

KEY POINTS

• Artificial Intelligence based on deep learning can assess the nature of ovarian lesions on routine MRI with higher accuracy and specificity than radiologists. • Assisted by the deep learning model's probabilities, junior radiologists achieved better performance that matched those of senior radiologists.

Size threshold for follow-up of postmenopausal adnexal cysts: 1 cm versus 3 cm

OBJECTIVES

To assess 3 cm size threshold for follow-up of simple cysts in postmenopausal women.

MATERIALS AND METHODS

Radiology information system was retrospectively queried for "US pelvis complete" over 8 years in women > 50 years, with keywords ovarian cyst, adnexal cyst, ovarian mass, cystic mass, cystic neoplasm, ovarian neoplasm, and ovarian mass. Premenopausal women were excluded. Cysts, were classified as ≤ 1 cm, 1-3 cm, 3-5 cm, and ≥ 7 cm. Largest cysts on each ovary was recorded. EMR and imaging archives were reviewed for assessing size, stability duration, and surgical records. Descriptive statistics and confidence interval were performed.

RESULTS

4388 patients met the initial search criteria. 919 cysts in 896 women (age: 50-91 years, mean: 61.5 years) were identified. We found 162 cysts ≤ 1 cm, 352 1-3 cm, 296 3-7 cm , and 51 ≥ 7 cm cysts. 127 patients with 1-3 cm cysts had no follow-up. Final analysis of 225 1-3 cm cysts included 203 ovarian and 22 paraovarian cysts (average size = 1.95 cm (1.1-3.0 cm)). 103 ovarian cysts had less than 2 years, and 100 cysts had more than 2 years follow-up. All except one ovarian cyst were stable for the entire duration of their follow-up (Mean duration of follow-up 5.4 years) (0.3%, 95% CI 0.0-0.05). 40 cysts resolved. One simple cyst increased in size (followed over 3.25 years) without suspicious imaging features and benign on surgery.

CONCLUSION

1-3 cm cysts represented the most common size range (> 40%) in postmenopausal women, majority of which are stable over follow-up with benign outcome. 3 cm size threshold is appropriate for simple cyst follow-up in postmenopausal women.

Contextual Structured Reporting in Radiology: Implementation and Long-Term Evaluation in Improving the Communication of Critical Findings

Structured reporting contributes to the completeness of radiology reports and improves quality. Both the content and the structure are essential for successful implementation of structured reporting. Contextual structured reporting is tailored to a specific scenario and can contain information retrieved from the context. Critical findings detected by imaging need urgent communication to the referring physician. According to guidelines, the occurrence of this communication should be documented in the radiology reports and should contain when, to whom and how was communicated. In free-text reporting, one or more of these required items might be omitted. We developed a contextual structured reporting template to ensure complete documentation of the communication of critical findings. The WHEN and HOW items were included automatically, and the insertion of the WHO-item was facilitated by the template. A pre- and post-implementation study demonstrated a substantial improvement in guideline adherence. The template usage improved in the long-term post-implementation study compared with the short-term results. The two most often occurring categories of critical findings are “infection / inflammation” and “oncology”, corresponding to the a large part of urgency level 2 (to be reported within 6 h) and level 3 (to be reported within 6 days), respectively. We conclude that contextual structured reporting is feasible for required elements in radiology reporting and for automated insertion of context-dependent data. Contextual structured reporting improves guideline adherence for communication of critical findings.

Prevalence and clinical significance of incidental extra-intestinal findings in MR enterography: experience of a single University Centre

PURPOSE

To determine the incidence and clinical relevance of extra-intestinal incidental findings (IF) in a cohort of patients with proven or suspected Crohn disease (CD) examined with magnetic resonance enterography (MR-E) in a single University Centre.

METHODS

Between January 2018 and June 2019, 182 patients with proven or suspected CD with a planned first MR-E examination, were retrospectively included in this study. Incidental findings were considered as any abnormality identified in the absence of previous clinically suspected or known disease. IF were categorized as unremarkable, benign or potentially relevant findings requiring further imaging or specific treatment.

RESULTS

Of the 182 revised MR-E, extra-intestinal IF were recorded in 70 cases (38.5%); 35 (50%) incidental lesions were recognized as non-significant, 24 (34%) as benign and 11 (16%) as clinically relevant. Moreover, there was a positive correlation between IF and patients' age (p < 0.0001).

CONCLUSIONS

In our experience, a high number of IF (38.5%) was found, with a prevalence that increases with patients' age. Clinically relevant findings were found in 16% of MR-E. This means that MR-E is a useful tool to detect IF, therefore, the presence of a radiologist during the image acquisition is crucial in adding sequences to the examination.

Prevalence of Incidental Benign and Malignant Lesions on Radiographs Ordered by Orthopaedic Surgeons

BACKGROUND

Radiographs are the most commonly available diagnostic imaging modalities used to evaluate orthopaedic conditions. In addition to suspected findings based on the initial indication to obtain radiographic images, incidental findings may be observed as well, some of which may have notable medical and legal ramifications. This study evaluates the number of incidental findings reported from orthopaedic radiographs ordered in an academic orthopaedic multispecialty group over 1 year.

METHODS

A retrospective review was conducted of 13,948 eligible radiographs recorded at our institution over a 12-month period. Reports were categorized based on examination type. Incidental findings were categorized as having concern for possible malignancy versus likely benign conditions. The possibly malignant findings were then further subdivided into either bone or lung malignancies. The benign findings were subcategorized by etiology and anatomic location.

RESULTS

Thirteen thousand nine hundred forty-eight radiographs were evaluated, and 289 (2.07%) incidental findings were identified. The three study categories with the highest prevalence of incidental findings were spine (3.96%), leg length alignment (3.94%), and pelvic and hip (2.81%) radiographs. The three most common types of incidental findings identified were for possible malignancy or metastases in bone (30.1%), benign bone disease (24.9%), and gastrointestinal conditions (6.57%). Follow-up was recommended for 122 (42.2%) incidental findings.

DISCUSSION

This study describes the prevalence of incidental findings on orthopaedic radiographs in adults. Axial radiographs such as of the spine and pelvis are more likely to report an incidental finding as opposed to appendicular radiographs of distal extremities. The exception is leg alignment radiographs that include the entire lower extremity and pelvis and image a larger area of the body. Nearly one-third of incidental findings were suspicious for possible malignancy or metastases. Additional diagnostic workup with focused imaging is often recommended. This information is useful to orthopaedic surgeons who read their own radiographs (without formal radiologist interpretation) to increase awareness of common, concerning incidental findings that may be missed and warrant additional follow-up.

LEVEL OF EVIDENCE

Level III.

Imaging in pediatric ovarian tumors

The spectrum of ovarian tumors in the pediatric population differs significantly from that in adults. Germ cell tumors are the predominant class of ovarian tumors in children, whereas epithelial tumors are the most common in adults. Ultrasonography is the modality of choice for the initial evaluation of pediatric ovarian tumors. Determining the diagnosis based on imaging may prove difficult, and combining the imaging findings with the clinical scenario is very helpful in reaching a differential diagnosis during clinical practice. We will discuss the spectrum of ovarian neoplasms in the pediatric population and describe their clinical, pathologic, and imaging characteristics. A few unique entities related to ovarian tumors, such as growing teratoma syndrome, anti-N-methyl-D-aspartate receptor encephalitis, and hereditary ovarian tumor syndromes, are also discussed. In addition, we will review several entities that may mimic ovarian neoplasms as well as their distinct imaging features.

Adnexal incidentalomas on multidetector CT: how to manage and characterise

Although CT is not considered the examination of choice for the detection and characterisation of adnexal diseases, adnexal masses may be incidentally detected during CT examination performed for other clinical indications. Most adnexal incidentalomas are benign, and therefore may not require further investigation, follow-up or intervention; however, few of them may prove malignant. Multidetector CT has improved the diagnostic performance of the technique in the detection and differentiation of adnexal mass lesions. Radiologists should be able to recognise the normal CT appearance of the ovaries and the CT characteristics of various adnexal incidentalomas. This may obviate unnecessary imaging evaluation and allow optimal treatment planning. Regarding the management of adnexal lesions incidentally found on CT, recommendations based on the collective experience of the members of the American College of Radiology Incidental Findings Committee II have recently been presented.

Diagnostic accuracy of gynecology imaging reporting and data system in evaluation of adnexal lesions

Background:

Considering the increasing incidence rate of ovarian cancer in worldwide and the utility of Gynecologic Imaging Reporting and Data System (GI-RADS) in diagnosing malignant adnexal lesions such as ovarian cancer, we aimed to evaluate the diagnostic performance of this reporting system in differentiating between malignant and benign adnexal lesions.

Materials and Methods:

In this cross-sectional study, women with suspected adnexal lesions were enrolled. For differentiating of malignant adnexal lesions, Grade II and III of GI-RADS system were classified as low risk for malignancy and Grades IV and V as high risk. Results of histopathologic diagnosis were compared with the results of the mentioned GI-RADS system classification, and the diagnosed accuracy of the system was determined. Patients who did not have histopathologic diagnosis were followed up.

Results:

In this study, 197 women with suspected adnexal lesions were evaluated. Frequency of GI-RADS II, III, IV, and V were 34.5% (69 cases), 38.0% (76 cases), 19.5% (39 cases), and 6.5% (13 cases), respectively. According to the low- and high-risk classification of GI-RADS, 72.5% were classified as GI-RADS II and III and 26% as GI-RADS IV and V, respectively. Definitive histopathologic diagnosis was reported for 158 cases. Histopathologic evaluation indicated that 12 (7.6%) of the masses were malignant and 146 (92.6%) were benign. Comparing with the histopathologic diagnosis, the GI-RADS system sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio (LR), and negative LR were 91.6%, 80.82%, 28.2%, 99.1%, 4.77, and 0.10, respectively. The accuracy of the scoring system was 81.64%.

Conclusion:

Our findings indicated that using GI-RADS, we could quantify the risk of malignancy by such a structured as well as simple reporting system so that the system could be useful for clinicians for performing an appropriate clinical management.

Incidentalomas in Spine and Spinal Cord Imaging

Incidentalomas are common in magnetic resonance imaging (MRI) of the spine. These incidental findings (IFs) can be seen involving the spinal cord, nerve root, vertebral body, posterior arch and the extraspinal region. This review article describes the imaging findings, stratifies the IFs similar to the computed tomography (CT) colonography reporting and data system and briefly mentions the current recommendations for further evaluation and management of IFs. Radiologists are the first to detect these lesions, suggest further evaluation and management of IFs. It is therefore mandatory for them to be aware of recommendations in clinical practice in order to avoid increased patient anxiety, excessive healthcare expenditure and inadvertent therapeutic procedures.

Adnexal lesions detected on CT in postmenopausal females with non-ovarian malignancy: do simple cysts need follow-up?

PURPOSE

To assess whether CT morphology of adnexal lesions in postmenopausal women with history of non-ovarian cancer could be used to discriminate benign and malignant lesions, particularly focusing on applicability of the ACR criteria.

MATERIALS AND METHODS

This was an IRB-approved HIPAA-compliant retrospective review of contrast-enhanced CTs of 199 women, 55 years and older. Lesions were classified as simple cystic, complex cystic, solid-cystic, or solid based on CT morphology, and were diagnosed as benign, indeterminate, or malignant on follow-up imaging or pathology. Associated metastatic disease was noted, if present. Findings were analyzed to correlate CT morphology, primary tumor pathology, and metastatic disease pattern with eventual lesion diagnosis.

RESULTS

There were 223 adnexal lesions, including 123 (55%) simple cystic, 48 (22%) complex cystic, 40 (18%) solid-cystic, and 12 (5%) solid lesions. 186/223 (83%) lesions were benign, and 37/223 (17%) were malignant. Primary colorectal cancer was significantly associated with an increased likelihood of malignant adnexal lesions (OR 10.2, p < 0.001) compared to patients with other cancers. Adnexal malignancy was significantly associated with the presence of non-ovarian peritoneal metastases (p < 0.001). None of the simple cysts (including 85 cysts between 1-3 cm and 38 cysts > 3 cm) were found to be malignant (malignancy rate: 0.0%, 95% CI 0.0-3.0%). Complex cysts were more likely to be malignant than simple cysts (p = 0.002) and solid-cystic lesions were more likely to be malignant than complex cysts (p < 0.001).

CONCLUSION

Simple adnexal lesions on CT in this cohort were unlikely to be malignant, supporting the ACR guidelines. A higher size threshold of 3 cm (vs. 1 cm) may be preferred in all cases of simple cysts for recommending further follow-up. However, more complex-appearing cysts need further evaluation as the risk of malignancy is increased. Peritoneal metastases have a significant correlation with malignant adnexal involvement.

Preoperative Computed Tomography Angiography in Autologous Breast Reconstruction-Incidence and Impact of Incidentalomas

Background

Incidentalomas are lesions found coincidentally during examination, imaging, or surgical procedures. Preoperative computed tomography angiography (CTA) before abdominal flap harvest for breast reconstruction can lead to identification of incidentalomas leading to the need for further investigations. The aim of this study was to examine the prevalence of incidental findings on preoperative CTA and to determine their impact on management.

Methods

A retrospective chart review was performed at a single tertiary institution. CTA reports were analyzed for the presence of incidental findings and details of follow-up were studied. Logistic regression was used to identify factors associated with incidental findings.

Results

One hundred eighteen patients with a mean age of 49 years were included in the study. The majority of patients underwent bilateral reconstruction (65%, n = 77) in the immediate setting (70%, n = 83). Fifty-six percentage had an incidental finding on CTA, with hepatic (20%), renal (14%), and osseous (11%) abnormalities being most common. Additional imaging including ultrasound, CT, and magnetic resonance imaging were recommended in 19 cases (16%). Additional consultations were sought for 3 patients before reconstruction (with suspicion of bone metastases, an intraabdominal mass, and suspicion of colonic malignancy, respectively). No significant surgical delay secondary to CT findings was noted.

Conclusions

Incidentalomas following preoperative CTA of the abdomen/pelvis are common (56%). However, unlike previous reports, we did not observe a change in reconstructive plan following incidentaloma discovery. We recommend that all patients are counseled pre-CTA regarding the possibilities of incidentaloma detection and need for additional imaging.

Beyond the Spinal Canal

Cross-sectional spinal imaging is common, and extraspinal findings are often incidentally identified during interpretation. Although some of these findings may cause symptoms that mimic a spinal disorder, the majority are entirely asymptomatic and incidental. It is essential that the radiologist not only identify those abnormalities that may have clinical significance but also recognize those that are clinically irrelevant and thereby prevent patients from being subjected to further unnecessary, expensive and potentially harmful interventions. This article focuses on those abnormalities that are commonly encountered and provides practical guidance for follow-up and management based on current recommendations.

Improving diagnosis in health care: perspectives from the American College of Radiology

In September of 2014, the American College of Radiology joined a number of other organizations in sponsoring the 2015 National Academy of Medicine report, Improving Diagnosis In Health Care. Our presentation to the Academy emphasized that although diagnostic errors in imaging are commonly considered to result only from failures in disease detection or misinterpretation of a perceived abnormality, most errors in diagnosis result from failures in information gathering, aggregation, dissemination and ultimately integration of that information into our patients' clinical problems. Diagnostic errors can occur at any point on the continuum of imaging care from when imaging is first considered until results and recommendations are fully understood by our referring physicians and patients. We used the concept of the Imaging Value Chain and the ACR's Imaging 3.0 initiative to illustrate how better information gathering and integration at each step in imaging care can mitigate many of the causes of diagnostic errors. Radiologists are in a unique position to be the aggregators, brokers and disseminators of information critical to making an informed diagnosis, and if radiologists were empowered to use our expertise and informatics tools to manage the entire imaging chain, diagnostic errors would be reduced and patient outcomes improved. Heath care teams should take advantage of radiologists' ability to fully manage information related to medical imaging, and simultaneously, radiologists must be ready to meet these new challenges as health care evolves. The radiology community stands ready work with all stakeholders to design and implement solutions that minimize diagnostic errors.

Imaging characterization of adnexal lesions: Do CT findings correlate with US?

OBJECTIVE

To compare contrast-enhanced CT and US agreement in characterizing adnexal lesions in late post-menopausal women.

MATERIALS AND METHODS

This was a HIPAA-compliant IRB-approved retrospective review of the contrast-enhanced CTs of 130 late post-menopausal women (> 55 years). The lesions were classified as simple cystic, minimally complex cystic, complex cystic, solid-cystic, or solid based on CT and US morphology. Findings were analyzed to evaluate agreement between CT and US on adnexal lesion characterization.

RESULTS

One forty-one adnexal lesions were assessed by both contrast-enhanced CT and US. Overall, there was good agreement between CT and US, which agreed on the lesion morphology in 114 (81%) cases with an unweighted kappa value of 0.68 (95% CI 0.56-0.78). By CT, 83 (59%) were classified as simple cystic, of which 73/83 (88%) were confirmed as simple cystic by US. Of the remaining 10 CT simple cysts, 9 were reclassified by US as minimally complex cystic and one as complex cystic. Eight of these lesions were benign based on pathology or follow-up imaging, while two lesions remained indeterminate. By CT, 27 lesions (19%) were classified as minimally complex, while US reclassified 13 (48%) of the lesions (eight to simple cystic and five as complex or solid-cystic). Among the 31 remaining lesions, there were 4 (13%) discordances between CT and US.

CONCLUSION

There is good agreement between CT and US in characterizing adnexal lesion morphology, particularly simple cysts. However, there was significant discordance seen with characterization of minimally complex cysts, indicating that these lesions need US follow-up.

Prevalence and outcomes of incidental imaging findings: umbrella review

OBJECTIVE

To provide an overview of the evidence on prevalence and outcomes of incidental imaging findings.

DESIGN

Umbrella review of systematic reviews.

DATA SOURCES

Searches of MEDLINE, EMBASE up to August 2017; screening of references in included papers.

ELIGIBILITY CRITERIA

Criteria included systematic reviews and meta-analyses of observational studies that gave a prevalence of incidental abnormalities ("incidentalomas"). An incidental imaging finding was defined as an imaging abnormality in a healthy, asymptomatic patient or an imaging abnormality in a symptomatic patient, where the abnormality was not apparently related to the patient's symptoms. Primary studies that measured the prevalence of incidentalomas in patients with a history of malignancy were also considered in sensitivity analyses.

RESULTS

20 systematic reviews (240 primary studies) were identified from 7098 references from the database search. Fifteen systematic reviews provided data to quantify the prevalence of incidentalomas, whereas 18 provided data to quantify the outcomes of incidentalomas (13 provided both). The prevalence of incidentalomas varied substantially between imaging tests; it was less than 5% for chest computed tomography for incidental pulmonary embolism in patients with and without cancer and whole body positron emission tomography (PET) or PET/computed tomography (for patients with and without cancer). Conversely, incidentalomas occurred in more than a third of images in cardiac magnetic resonance imaging (MRI), chest computed tomography (for incidentalomas of thorax, abdomen, spine, or heart), and computed tomography colonoscopy (for extra-colonic incidentalomas). Intermediate rates occurred with MRI of the spine (22%) and brain (22%). The rate of malignancy in incidentalomas varied substantially between organs; the prevalence of malignancy was less than 5% in incidentalomas of the brain, parotid, and adrenal gland. Extra-colonic, prostatic, and colonic incidentalomas were malignant between 10% and 20% of the time, whereas renal, thyroid, and ovarian incidentalomas were malignant around a quarter of the time. Breast incidentalomas had the highest percentage of malignancy (42%, 95% confidence interval 31% to 54%). Many assessments had high between-study heterogeneity (15 of 20 meta-analyses with I² >50%).

CONCLUSIONS

There is large variability across different imaging techniques both in the prevalence of incidentalomas and in the prevalence of malignancy for specific organs. This umbrella review will aid clinicians and patients weigh up the pros and cons of requesting imaging scans and will help with management decisions after an incidentaloma diagnosis. Our results can underpin the creation of guidelines to assist these decisions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42017075679.

Designing a Curriculum for Professionalism and Ethics Within Radiology: Identifying Challenges and Expectations

Although professionalism and ethics represent required competencies, they are more challenging than other competencies to design a curriculum for and teach. Reasons include variability in agreed definitions of professionalism within medicine and radiology. This competency is also framed differently whether as roles, duties, actions, skills, behavior, beliefs, and attitudes. Standardizing a curriculum in professionalism is difficult because each learner's (medical student/resident) professional experiences and interactions will be unique. Professionalism is intertwined throughout all (sub) specialties and areas and its teaching cannot occur in isolation as a standalone curriculum. In the past, professionalism was not emphasized enough or at all, with global (or no) assessments, with the potential effect of trainees not valuing it. Although we can teach it formally in the classroom and informally in small groups, much of professionalism is witnessed and learned as "hidden curricula". The formal, informal, and hidden curricula often contradict each other creating confusion, disillusion, and cynicism in trainees. The corporatization of medicine pressurizes us to increase efficiency (throughput) with less focus on aspects of professionalism that add value, creating a disjoint between what we do in practice and preach to trainees. Progressively, expectations for our curriculum include providing evidence for the impacts of our efforts on patient outcomes. Generational differences in the perception of professionalism and the increasingly diverse and multicultural society in which we live affects our interpretation of professionalism, which can add to confusion and misunderstanding. The objectives of this article are to outline challenges facing curriculum design in professionalism and to make suggestions to help educators avoid or overcome them.

[Incidental findings of the kidneys, adrenal glands, adnexa uteri, gastrointestinal tract, mesentery and lymph nodes : Assessment and management recommendations]

CLINICAL ISSUE

Besides the upper abdominal parenchymal organs, the increasing application of cross-sectional imaging has also led to a rising number of incidental findings in the kidneys, adrenal glands, adnexa uteri, the gastrointestinal tract, mesentery and abdominal lymph nodes.

STANDARD RADIOLOGICAL METHODS

Abdominal computed tomography investigations often show unexpected findings without any correlating symptoms. The growing clinical relevance is due to the large number of incidental findings as well as an increasing awareness of ethical and socioeconomic factors.

ACHIEVEMENTS

When interpreting radiological findings not only morphological criteria but also individual risk factors of the patient and the clinical context are of great importance.

PRACTICAL RECOMMENDATIONS

The aims of this article are the description and evaluation of frequent incidental findings detected by computed tomography and to provide information about management recommendations.

Extracolonic findings and radiation at CT colonography: what the referring provider needs to know

A better understanding of the risks and benefits of extracolonic findings and radiation dose will aid in the safe and proper implementation of CT colonography in clinical practice. The majority of extracolonic findings in screening patients are benign and can be ignored by referring physicians. Radiologists also need to be responsible in reporting extracolonic findings. Referring providers must be knowledgeable about the theoretic risks and controversies regarding the use of ionizing radiation. Screening CT colonography imparts a low-level of radiation to patients that is equivalent or less than annual background dose.

Filling the void: a low-cost, high-yield approach to addressing incidental findings in trauma patients

BACKGROUND

Incidental findings are prevalent in imaging but often go unreported to patients. Such unreported findings may present the potential for harm as well as medico-legal ramifications.

METHODS

A chart review of trauma patients was undertaken over a year. Systems-based changes were made utilizing our electronic medical record system and our staff protocols to improve the disclosure of clinically relevant incidental findings to patients.

RESULTS

During the preintervention period, 674 charts were reviewed. Trauma patients had a rate of incidental findings of 70%, and 36% of patients had clinically relevant incidentals. Rates of follow-up recommendation and disclosure to patients were 22% and 27%, respectively. In the postintervention period, of the 648 charts were reviewed, the rates of a clinically relevant incidental finding were 35%, but the rates of follow-up recommendation and disclosure to patients were 68% and 85%, respectively.

CONCLUSION

Incidental findings are more prevalent herein than previously reported. With simple changes and minimal resources, clinically relevant and important improvement in reporting incidental findings can be made to mitigate the harm and medico-legal impact of an incidental finding going unreported.

Appearance of Adrenal Myelolipomas on 2-deoxy-2-(18F) fluoro-D-glucose Positron Emission Tomography-Computed Tomography

With the widespread use of 2-deoxy-2-(¹⁸F) fluoro-D-glucose positron emission tomography-computed tomography (FDG PET/CT) in oncologic imaging, it has become increasingly important for physicians who interpret FDG PET/CT scans to confidently recognize the spectrum of incidentally encountered benign and malignant findings. The adrenal glands represent an interesting nexus of multiple rare and common benign intrinsic tumors as well as metastases from a variety of primary malignancies. Given the breadth of adrenal gland pathology, careful description of the FDG PET/CT appearance of these pathologies is of value to help reduce misinterpretation. In this manuscript, we retrospectively and systematically review the FDG PET/CT imaging characteristics of benign adrenal myelolipomas in a small consecutive patient series. The myelolipomas in this series demonstrated differing degrees of macroscopic fat visible on CT, with generally mild FDG uptake fusing to the nonfatty portions of the lesions. At imaging follow-up, all of the myelolipomas in this series remained unchanged in appearance, helping to confirm their benign nature. The typical appearance of a myelolipoma on FDG PET/CT is a fat-containing adrenal mass with low-level FDG uptake in the nonfatty aspects of the mass, and such a lesion requires no further imaging workup.