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

Definitions of Incidental [18F]FDG PET/CT Findings in the Literature: A Systematic Review and Definition Proposal

Objectives: The objectives of this study were (1) to systematically review the currently used definitions of incidental 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography findings (IPFs) in the literature and (2) to propose an IPF definition. Methods: A systematic search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search was guided by the question "How is IPF defined?" and was performed in MEDLINE, Embase, and the Cochrane Library. The retrieved studies were reviewed and analyzed. The definitions of IPFs in the included studies were compiled into two sets of categories based on the description of FDG uptake and the specification of clinical factors in defining IPFs. Results: The systematic literature search identified 4852 publications accessible for title-abstract screening, which yielded 395 studies for full-text assessment. Sixty-five studies met the eligibility criteria and were included. Sixty-two percent mentioned "FDG uptake" in their definition. In 40% of the definitions, "Focal FDG uptake" was specified, while "FDG uptake in the surrounding tissue" was included in 15%. Fifty-seven percent stated that IPFs were "Unrelated to PET/CT indication". Thirty-four percent specified IPFs as "Present in other organ than PET/CT indication", whereas 20% included "No known disease related to IPF". Seventeen percent of the definitions comprised a "New finding", while 15% and 11% encompassed a "Clinical asymptomatic patient" and "Not a metastasis", respectively. Finally, 5% of the definitions included "Potential clinical significance". Conclusions: No generally accepted definition of IPFs currently exists. We propose an IPF definition based on explicit FDG uptake and clinical patient-related factors.

Clinical‑imaging‑radiomic nomogram based on unenhanced CT effectively predicts adrenal metastases in patients with lung cancer with small hyperattenuating adrenal incidentalomas

The aim of the present study was to develop and evaluate a clinical-imaging-radiomic nomogram based on pre-enhanced computed tomography (CT) for pre-operative differentiation lipid-poor adenomas (LPAs) from metastases in patients with lung cancer with small hyperattenuating adrenal incidentalomas (AIs). A total of 196 consecutive patients with lung cancer, who underwent initial chest or abdominal pre-enhanced CT scan with small hyperattenuating AIs, were included. The patients were randomly divided into a training cohort with 71 cases of LPAs and 66 cases of metastases, and a testing cohort with 31 cases of LPAs and 28 cases of metastases. Plain CT radiological and clinical features were evaluated, including sex, age, size, pre-enhanced CT value (CTpre), shape, homogeneity and border. A total of 1,316 radiomic features were extracted from the plain CT images of the AIs, and the significant features selected by the least absolute shrinkage and selection operator were used to establish a Radscore. Subsequently, a clinical-imaging-radiomic model was developed by multivariable logistic regression incorporating the Radscore with significant clinical and imaging features. This model was then presented as a nomogram. The performance of the nomogram was assessed by calibration curves and decision curve analysis (DCA). A total of 4 significant radiomic features were incorporated in the Radscore, which yielded notable area under the receiver operating characteristic curves (AUCs) of 0.920 in the training dataset and 0.888 in the testing dataset. The clinical-imaging-radiomic nomogram incorporating the Radscore, CTpre, sex and age revealed favourable differential diagnostic performance (AUC: Training, 0.968; testing, 0.915) and favourable calibration curves. The nomogram was revealed to be more useful than the Radscore and the clinical-imaging model in clinical practice by DCA. The clinical-imaging-radiomics nomogram based on initial plain CT images by integrating the Radscore and clinical-imaging factors provided a potential tool to effectively differentiate LPAs from metastases in patients with lung cancer with small hyperattenuating AIs.

Towards a Simplified and Cost-Effective Diagnostic Algorithm for the Surveillance of Intraductal Papillary Mucinous Neoplasms (IPMNs): Can We Save Contrast for Later?

The increased detection of pancreatic cysts in recent years has triggered extensive diagnostic investigations to clarify their potential risk of malignancy, resulting in a large number of patients undergoing numerous imaging follow-up studies for many years. Therefore, there is a growing need for optimization of the current surveillance protocol to reduce both healthcare costs and waiting lists, while still maintaining appropriate sensibility and specificity. Imaging is an essential tool for evaluating patients with intraductal papillary mucinous neoplasms (IPMNs) since it can assess several predictors for malignancy and thus guide further management recommendations. Although contrast-enhanced magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) has been widely recommended by most international guidelines, recent results support the use of unenhanced abbreviated-MRI (A-MRI) protocols as a surveillance tool in patients with IPMN. In fact, A-MRI has shown high diagnostic performance in malignant detection, with high sensitivity and specificity as well as excellent interobserver agreement. The aim of this paper is, therefore, to discuss the current available evidence on whether the implementation of an abbreviated-MRI (A-MRI) protocol for cystic pancreatic lesion surveillance could improve healthcare economics and reduce waiting lists in clinical practice without significantly reducing diagnostic accuracy.

Multiple and large simple renal cysts are associated with glomerular filtration rate decline: a cross-sectional study of Chinese population

BACKGROUND

Although simple renal cyst (SRC) is a kind of structural alterations of kidney with age, the relationship between SRC and renal function is still obscure. We investigated the relationship between SRC and renal function in Chinese population.

METHODS

The medical records of 41,842 individuals who underwent physical examinations at the Health Check-up Center at our institution in 2018 were reviewed. According to whether with SRC, they were divided into no-SRC and SRC groups. SRCs were classified into subgroups based on number (< 2 vs. ≥ 2) and size (< 2 cm vs. ≥ 2 cm). Logistic regression was used to examine the relationship between SRC and estimated glomerular filtration rate (eGFR).

RESULTS

Multinomial logistic regression analysis showed that the adjusted odds ratio (OR) for eGFR slight decline in subjects with SRC was 1.26(95% confidence interval (95% CI):1.17-1.35, p < 0.001), and the OR for eGFR severe decline was 1.35(95% CI: 1.16-1.56, p < 0.001) compared with no-SRC. The adjusted OR of SRC number ≥ 2 and ≥ 2 cm on the risk of eGFR severe decline was the highest (OR:1.68, 95% CI:1.25-2.23, p < 0.01) of four SRC subgroups.

CONCLUSIONS

SRC is related to eGFR decline, especially when the person with one more SRCs and the size of SRC is more than 2 cm. SRC could be a warning sign for clinicians to judge the decline of renal function.

Small hyperattenuating adrenal nodules in patients with lung cancer: Differentiation of metastases from adenomas on biphasic contrast-enhanced computed tomography

Objective

The objective of this study was to evaluate the value of biphasic contrast-enhanced computed tomography (CECT) in the differential diagnosis of metastasis and lipid-poor adenomas (LPAs) in lung cancer patients with unilateral small hyperattenuating adrenal nodule.

Materials and methods

This retrospective study included 241 lung cancer patients with unilateral small hyperattenuating adrenal nodule (metastases, 123; LPAs, 118). All patients underwent plain chest or abdominal computed tomography (CT) scan and biphasic CECT scan, including arterial and venous phases. Qualitative and quantitative clinical and radiological characteristics of the two groups were compared using univariate analysis. An original diagnostic model was developed using multivariable logistic regression, and then, according to odds ratio (OR) of the risk factors of metastases, a diagnostic scoring model was developed. The areas under the receiver operating characteristic curves (AUCs) of the two diagnostic models were compared by DeLong test.

Results

Compared with LAPs, metastases were older and showed more frequently irregular in shape and cystic degeneration/necrosis (all p < 0.05). Enhancement ratios on venous (ERV) and arterial (ERA) phase of LAPs were noticeably higher than that of metastases, whereas CT values in unenhanced phase (UP) of LPAs were noticeably lower than that of metastases (all p < 0.05). Compared with LAPs, the proportions of male and III/IV clinical stage and small-cell lung cancer (SCLL) were significantly higher for metastases (all p < 0.05). As for peak enhancement phase, LPAs showed relatively faster wash-in and earlier wash-out enhancement pattern than metastases (p < 0.001). Multivariate analysis revealed age ≥ 59.5 years (OR: 2.269; p = 0.04), male (OR: 3.511; p = 0.002), CT values in UP ≥ 27.5 HU (OR: 6.968; p < 0.001), cystic degeneration/necrosis (OR: 3.076; p = 0.031), ERV ≤ 1.44 (OR: 4.835; p < 0.001), venous phase or equally enhanced (OR: 16.907; p < 0.001 or OR: 14.036; p < 0.001), and clinical stage II or III or IV (OR: 3.550; p = 0.208 or OR: 17.535; p = 0.002 or OR: 20.241; p = 0.001) were risk factors for diagnosis of metastases. AUCs of the original diagnostic model and the diagnostic scoring model for metastases were 0.919 (0.883-0.955) and 0.914 (0.880-0.948), respectively. There was no statistical significance of AUC between the two diagnostic model (p = 0.644).

Conclusions

Biphasic CECT performed well diagnostic ability in differentiating metastases from LAPs. The diagnostic scoring model is easy to popularize due to simplicity and convenience.

Radiomics approach based on biphasic CT images well differentiate "early stage" of adrenal metastases from lipid-poor adenomas: A STARD compliant article

The aim of the study was to develop an optimal radiomics model based on abdominal contrast-enhanced computed tomography (CECT) for pre-operative differentiation of "early stage" adrenal metastases from lipid-poor adenomas (LPAs). This retrospective study included 188 patients who underwent abdominal CECT (training cohort: LPAs, 68; metastases, 64; validation cohort: LPAs, 29; metastases, 27). Abdominal CECT included plain, arterial, portal, and venous imaging. Clinical and CECT radiological features were assessed and significant features were selected. Radiomic features of the adrenal lesions were extracted from four-phase CECT images. Significant radiomics features were selected using the least absolute shrinkage and selection operator (LASSO) and multivariable logistic regression. The clinical-radiological, unenhanced radiomics, arterial radiomics, portal radiomics, venous radiomics, combined radiomics, and clinical-radiological-radiomics models were established using a support vector machine (SVM). The DeLong test was used to compare the areas under the receiver operating characteristic curves (AUCs) of all models. The AUCs of the unenhanced (0.913), arterial (0.845), portal (0.803), and venous (0.905) radiomics models were all higher than those of the clinical-radiological model (0.788) in the testing dataset. The AUC of the combined radiomics model (incorporating plain and venous radiomics features) was further improved to 0.953, which was significantly higher than portal radiomics model (P = .033) and clinical-radiological model (P = .009), with the highest accuracy (89.13%) and a relatively stable sensitivity (91.67%) and specificity (86.36%). As the optimal model, the combined radiomics model based on biphasic CT images is effective enough to differentiate "early stage" adrenal metastases from LPAs by reducing the radiation dose.

Diagnostic performance of radiomics in adrenal masses: A systematic review and meta-analysis

Objectives

(1) To assess the methodological quality and risk of bias of radiomics studies investigating the diagnostic performance in adrenal masses and (2) to determine the potential diagnostic value of radiomics in adrenal tumors by quantitative analysis.

Methods

PubMed, Embase, Web of Science, and Cochrane Library databases were searched for eligible literature. Methodological quality and risk of bias in the included studies were assessed by the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) and Radiomics Quality Score (RQS). The diagnostic performance was evaluated by pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC). Spearman’s correlation coefficient and subgroup analysis were used to investigate the cause of heterogeneity. Publication bias was examined using the Deeks’ funnel plot.

Results

Twenty-eight studies investigating the diagnostic performance of radiomics in adrenal tumors were identified, with a total of 3579 samples. The average RQS was 5.11 (14.2% of total) with an acceptable inter-rater agreement (ICC 0.94, 95% CI 0.93–0.95). The risk of bias was moderate according to the result of QUADAS-2. Nine studies investigating the use of CT-based radiomics in differentiating malignant from benign adrenal tumors were included in the quantitative analysis. The pooled sensitivity, specificity, DOR and AUC with 95% confidence intervals were 0.80 (0.68-0.88), 0.83 (0.73-0.90), 19.06 (7.87-46.19) and 0.88 (0.85–0.91), respectively. There was significant heterogeneity among the included studies but no threshold effect in the meta-analysis. The result of subgroup analysis demonstrated that radiomics based on unenhanced and contrast-enhanced CT possessed higher diagnostic performance, and second-order or higher-order features could enhance the diagnostic sensitivity but also increase the false positive rate. No significant difference in diagnostic ability was observed between studies with machine learning and those without.

Conclusions

The methodological quality and risk of bias of studies investigating the diagnostic performance of radiomics in adrenal tumors should be further improved in the future. CT-based radiomics has the potential benefits in differentiating malignant from benign adrenal tumors. The heterogeneity between the included studies was a major limitation to obtaining more accurate conclusions.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/ CRD 42022331999 .

Incidental findings on coronary computed tomography in women with selected reproductive disorders

OBJECTIVE

To determine the prevalence of incidental findings (IFs) on coronary computed tomography (CCT) in women aged 45-55 years and previously diagnosed with reproductive disorders such as polycystic ovary syndrome (PCOS), premature ovarian insufficiency (POI) or preeclampsia (PE).

METHODS

A total of 486 middle-aged women with PCOS (n = 101), POI (n = 97) or a history of PE (n = 288) underwent a CCT as part of a prior prospective study. IFs were categorized by their significance (minor, moderate and major). Follow-up information was collected from patients' records. To investigate the impact of different field of views (FOVs), a subset of scans was analyzed in full FOV and small FOV.

RESULTS

In 96/486 (19.8%) women, one or more IFs were detected, of which 54/486 (11.1%) were classified as moderate/major and 48/486 (9.9%) required follow-up. A moderate/major IF was detected in 16/101 (15.9%) women with PCOS, 13/97 (13.4%) women with POI and 25/288 (8.7%) women with a history of PE. In 78 women with an IF detected in the full FOV, the IF was still visible in 60 (76.9%) women in the small FOV. In the full FOV, 46 women required follow-up, but using the small FOV this was reduced to 30 women.

CONCLUSION

Using CCT as a cardiovascular disease screening tool in women with selected reproductive disorders increases the probability of detecting IFs that can cause anxiety and may generate extra costs, but can also reveal clinically relevant findings. Using a small FOV centered around the heart resulted in a lower prevalence of IFs and required less follow-up.

Whole-body magnetic resonance imaging (WB-MRI) with diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) in prostate cancer: Prevalence and clinical significance of incidental findings

OBJECTIVE

Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) is now recommended as a first-line staging modality in prostate cancer patients, and the widespread use of DWIBS may lead to an increased frequency of incidental findings. The aim of this study was to evaluate the prevalence and clinical significance of incidental findings on whole-body magnetic resonance imaging (WB-MRI) with DWIBS.

METHODS

Data from 124 patients with prostate cancer (age, 76.5 ± 5.6 years), who underwent 1.5 T WB-MRI with STIR, TSE-T2, TSE-T1, In/Out GRE, and DWIBS sequences, were retrospectively analyzed. Findings unrelated to prostate cancer were considered as incidental findings and categorized into two groups based on their clinical implications as follows: imaging follow-up or additional examinations was required (significant incidental findings) and no need to additional work-up (non-significant incidental findings). A chi-square test was performed to compare the differences in the prevalence of significant incidental findings based on age (≤75 and>75 years old).

RESULTS

A total of 334 incidental findings were found with 8.1% (n = 27) as significant incidental findings. Significant incidental findings were more frequent in patients over 75 years old than those of 75 years old or younger (28.6% vs  11.1%, p = 0.018).

CONCLUSION

Clinically significant incidental findings, which required imaging follow-up or additional examinations, were commonly observed in prostate cancer patients on WB-MRI/DWIBS.

ADVANCES IN KNOWLEDGE

Some incidental findings were clinically significant that may lead to changes in treatment strategy. Checking the entire organ carefully for abnormalities and reporting any incidental findings detected are important.

Machine learning-based texture analysis for differentiation of radiologically indeterminate small adrenal tumors on adrenal protocol CT scans

GOAL

To evaluate the ability of radiomic feature extraction and a machine learning algorithm to differentiate between benign and malignant indeterminate adrenal lesions on contrast-enhanced computed tomography (CT) studies.

BACKGROUND

Adrenal "incidentalomas" are adrenal lesions that are accidentally discovered during workup not related to the adrenal glands; they have an incidence as high as 5%. Small adrenal incidentalomas (< 4 cm) with high attenuation values on pre-contrast CT(> 10 HU) need further evaluation to calculate the absolute percentage of washout (APW). If the APW is < 60%, these lesions are considered non-adenomas and commonly classified as indeterminate adrenal lesions. Further workup for indeterminate lesions includes more complicated and expensive radiological studies or invasive procedures like biopsy or surgical resection.

METHODS

We searched our institutional database for indeterminate adrenal lesions with the following characteristics: < 4 cm, pre-attenuation value > 10 HU, and APW < 60%. Exclusion criteria included pheochromocytoma and no histopathological examination. CT images were converted to Nifti format, and adrenal tumors were segmented using Amira software. Radiomic features from the adrenal mask were extracted using PyRadiomics software after removing redundant features (highly pairwise correlated features and low-variance features) using recursive feature extraction to select the final discriminative set of features. Lastly, the final features were used to build a binary classification model using a random forest algorithm, which was validated and tested using leave-one-out cross-validation, confusion matrix, and receiver operating characteristic curve.

RESULTS

We found 40 indeterminate adrenal lesions (21 benign and 19 malignant). Feature extraction resulted in 3947 features, which reduced down to 62 features after removing redundancies. Recursive feature elimination resulted in the following top 4 discriminative features: gray-level size zone matrix-derived size zone non-uniformity from pre-contrast and delayed phases, gray-level dependency matrix-derived large dependence high gray-level emphasis from venous-phase, and gray-level co-occurrence matrix-derived cluster shade from delayed-phase. A binary classification model with leave-one-out cross-validation showed AUC = 0.85, sensitivity = 84.2%, and specificity = 71.4%.

CONCLUSION

Machine learning and radiomic features extraction can differentiate between benign and malignant indeterminate adrenal tumors and can be used to direct further workup with high sensitivity and specificity.

Acute aortic syndrome and radiology liability in Italy: Case reports and medico-legal considerations

The trend for medical malpractice claims has increased in recent years, both in the USA and in Europe. Although diagnostic radiology is not considered a high-risk field, malpractice claims in this area follow this general trend. The most common legal action taken against radiologists includes failure to diagnose, poor communication between physicians, failure to supervise technologists properly and improper procedures. Recently, the Italian Civil Supreme Court delivered a judgment (Cass. Civ., N.10158-18) regarding the liability of radiologists, stating that in radiological practice, a correct and timely execution of the diagnostic investigation is required. By contrast, the same judgment states that requesting further clinical consultations and/or the execution of in-depth diagnostic examinations are not within their duties. Considering this judgment, we report two cases of radiologist malpractice and related responsibility for negligent conduct regarding the diagnosis of thoracic aortic dissection and the prevention and management of acute aortic syndrome.

Towards better metainterpretation: improving the clinician's interpretation of the radiology report

How the clinician interprets the radiology report has a major impact on the patient's care. It is a crucial cognitive task, and can also be a significant source of error. Because the clinician must secondarily interpret the radiologist's interpretation of the images, this step can be referred to as a "metainterpretation". Some considerations for that task are offered from the perspective of a radiologist. A revival of the tradition of discussing cases with the radiologist is encouraged.

Prevalence, documentation, and communication of incidental findings in focused assessment with sonography for trauma (FAST) examinations

BACKGROUND

As the focused assessment with sonography for trauma (FAST) examination becomes increasingly ubiquitous in the emergency department (ED), a parallel increase in incidental findings can also be expected. The purpose of this study was to determine the prevalence, documentation, and communication of incidental findings on emergency physician-performed FAST examinations.

METHODS

Retrospective review at two academic EDs. Adult trauma patients undergoing FAST examinations used for clinical decision-making at the bedside were identified from an ED ultrasound image archival system. Expert sonologists reviewed ultrasound images for incidental findings, as well as electronic medical records for demographic information, mechanism of injury, type of incidental findings, documentation of incidental findings, and communication of incidental findings to the patient.

RESULTS

A total of 1,452 FAST examinations were reviewed. One hundred and thirty-seven patients with incidental findings were identified (9.4%); 7 patients had an additional incidental finding. Renal cysts were most common (49/144, 34.0%), followed by pelvic cysts in women (32/144, 22.2%). While 31/144 (21.5%) incidental findings were identified and documented in the ultrasound reports or medical records by ED providers, only 6/137 (4.4%) patients were noted to be informed of their incidental findings.

CONCLUSION

Incidental findings were often encountered in FAST examinations, with cysts of the kidneys and pelvis being the most common findings. A vast majority of incidental findings were not documented or noted to be communicated to patients, which can be a barrier to follow-up care.

Assessment of Explicitly Stated Interval Change on Noncontrast Head CT Radiology Reports

BACKGROUND AND PURPOSE

Consistent and standardized reporting of interval change for certain diagnoses may improve the clinical utility of radiology reports. The purpose of this study was to assess explicitly stated interval change of various findings in noncontrast head CT reports.

MATERIALS AND METHODS

A retrospective review was performed on successive noncontrast head CT radiology reports from the first 2 weeks of January 2014. Reports with at least 1 prior comparison CT scan were included. Reports with normal examination findings and those that made comparison with only other types of examinations (eg, MR imaging) were excluded. Descriptive and subgroup statistical analyses were performed.

RESULTS

In total, 200 patients with 230 reports and 979 radiographic findings were identified. The average interval between reports was 344.9 ± 695.9 days (range, 0-3556 days). Interval change was mentioned 67.3% (n = 659) of the time for all findings (n = 979). Explicitly stated interval change was significantly associated with nonremote findings (P < .001) and generalized statements of interval change (P < .001). The proportion of interval change reported ranged from 95.3% of the time for hemorrhagic to 36.4% for soft-tissue/osseous categorizations.

CONCLUSIONS

Interval change reporting was variable, mentioned for 67.3% of noncontrast head CT report findings with a prior comparison CT scan. Structured radiology reports may improve the consistent and clear reporting of interval change for certain findings.

Eye Movements in Medical Image Perception: A Selective Review of Past, Present and Future

The eye movements of experts, reading medical images, have been studied for many years. Unlike topics such as face perception, medical image perception research needs to cope with substantial, qualitative changes in the stimuli under study due to dramatic advances in medical imaging technology. For example, little is known about how radiologists search through 3D volumes of image data because they simply did not exist when earlier eye tracking studies were performed. Moreover, improvements in the affordability and portability of modern eye trackers make other, new studies practical. Here, we review some uses of eye movements in the study of medical image perception with an emphasis on newer work. We ask how basic research on scene perception relates to studies of medical 'scenes' and we discuss how tracking experts' eyes may provide useful insights for medical education and screening efficiency.

How We Do It: Creating Consistent Structure and Content in Abdominal Radiology Report Templates

OBJECTIVE

The purposes of this article are to describe the creation of template report formats and content for a variety of abdominal and pelvic CT and MRI examinations and discuss a review-of-systems approach to text and avoidance of pitfalls of report templates.

CONCLUSION

Organ system-specific report templates for CT and MRI incorporate radiologist preferences. Disease-specific report templates are created from these reports to provide a consistent radiologist and referring physician experience across the report templates.

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

PURPOSE

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

METHODS

Imaging reports of 215 patients who underwent whole-body PET/CT imaging were retrospectively reviewed. Our provincial picture archiving and communication system was queried and patient charts were reviewed to identify all investigations performed to follow-up incidental findings within 1 year of the initial PET/CT study. Costs of follow-up imaging studies (professional and technical components) and other diagnostic tests and procedures were determined in Canadian dollars (CAD) and U.S. dollars (USD) using the 2015 Ontario Health Insurance Plan Schedule of Benefits and Fees and 2016 U.S. Medicare Physician Fee Schedule, respectively.

RESULTS

At least 1 incidental finding was reported in 161 reports (74.9%). The mean number of incidental findings ranged from 0.64 in patients <45 years of age to 2.2 in patients 75 years of age and older. Seventy-five recommendations for additional investigations were made for 64 (30%) patients undergoing PET/CT imaging, and 14 of those were carried out specifically to follow-up incidental findings. Averaged across all 215 patients, the total cost of investigations recommended to follow-up incidental findings was CAD$105.51 (USD$127.56) per PET/CT study if all recommendations were acted on, and CAD$22.77 (USD$29.14) based on investigations actually performed.

CONCLUSIONS

As the incidence of incidental findings increases with age and a larger proportion of elderly patients is expected as population demographics change, it will be increasingly important to consider incidental findings on PET/CT imaging with standardized approaches to follow-up.

Implications of Direct Patient Online Access to Radiology Reports Through Patient Web Portals

In an era of increasing health information transparency and informed decision making, more patients are being provided with direct online access to their medical records, including radiology reports, via web-based portals. Although radiologists' narrative reports have previously been the purview of referring physicians, patients are now reading these on their own. Many potential benefits may result from patients reviewing their radiology reports, including improvements in patients' own understanding of their health, promotion of shared decision making and patient-physician communication, and, ultimately, improvements in patient outcomes. However, there may also be negative consequences, including confusion and anxiety among patients and longer patient-physician interactions. The rapid adoption of this new technology has led to major questions regarding ethics and professionalism for radiologists, including the following: Who is the intended audience of radiology reports? How should content be presented or worded? How will open access influence radiologists' relationships with patients and referring physicians? What legal ramifications may arise from increased patient access? The authors describe the current practices and research findings associated with patient online access to medical records, including radiology reports, and discuss several implications of this growing trend for the radiology profession.

How did I miss that? Developing mixed hybrid visual search as a 'model system' for incidental finding errors in radiology

In a real world search, it can be important to keep ‘an eye out’ for items of interest that are not the primary subject of the search. For instance, you might look for the exit sign on the freeway, but you should also respond to the armadillo crossing the road. In medicine, these items are known as “incidental findings,” findings of possible clinical significance that were not the main object of search. These errors (e.g., missing a broken rib while looking for pneumonia) have medical consequences for the patient and potential legal consequences for the physician. Here we report three experiments intended to develop a ‘model system’ for incidental findings – a paradigm that could be used in the lab to develop strategies to reduce incidental finding errors in the clinic. All the experiments involve ‘hybrid’ visual search for any of several targets held in memory. In this ‘mixed hybrid search task,’ observers search for any of three specific targets (e.g., this rabbit, this truck, and this spoon) and three categorical targets (e.g., masks, furniture, and plants). The hypothesis is that the specific items are like the specific goals of a real world search and the categorical targets are like the less well-defined incidental findings that might be present and that should be reported. In all these experiments, varying target prevalence, number of targets, etc., the categorical targets are missed at a much higher rate than the specific targets. This paradigm shows promise as a model of the incidental finding problem.

"Incidentalomas" on abdominal and pelvic CT in emergency radiology: literature review and current management recommendations

The purpose of this article is to familiarize radiologists and clinicians with a subset of common and uncommon incidental findings on abdominal and pelvic computed tomography examinations, including hepatic, splenic, renal, adrenal, pancreatic, aortic/iliac arterial, gynecological, and a few other miscellaneous findings, with an emphasis on "incidentalomas" discovered in the emergency setting. In addition, we will review the complex problem of diagnosing such entities, and provide current management recommendations. Representative case examples, which we have encountered in our clinical practices, will be demonstrated.