Comparing Breast and Abdominal Subspecialists' Follow-Up Recommendations for Incidental Liver Lesions on Breast MRI

WFUMB Review Paper. Incidental Findings in Otherwise Healthy Subjects, How to Manage: Liver

An incidental focal liver lesion (IFLL) is defined as a hepatic lesion identified in a patient imaged for an unrelated reason. They are frequently encountered in daily practice, sometimes leading to unnecessary, invasive and potentially harmful follow-up investigations. The clinical presentation and the imaging aspects play an important role in deciding if, and what further evaluation, is needed. In low-risk patients (i.e., without a history of malignant or chronic liver disease or related symptoms), especially in those younger than 40 years old, more than 95% of IFLLs are likely benign. Shear Wave liver Elastography (SWE) of the surrounding liver parenchyma should be considered to exclude liver cirrhosis and for further risk stratification. If an IFLL in a low-risk patient has a typical appearance on B-mode ultrasound of a benign lesion (e.g., simple cyst, calcification, focal fatty change, typical hemangioma), no further imaging is needed. Contrast-Enhanced Ultrasound (CEUS) should be considered as the first-line contrast imaging modality to differentiate benign from malignant IFLLs, since it has a similar accuracy to contrast-enhanced (CE)-MRI. On CEUS, hypoenhancement of a lesion in the late vascular phase is characteristic for malignancy. CE-CT should be avoided for characterizing probable benign FLL and reserved for staging once a lesion is proven malignant. In high-risk patients (i.e., with chronic liver disease or an oncological history), each IFLL should initially be considered as potentially malignant, and every effort should be made to confirm or exclude malignancy. US-guided biopsy should be considered in those with unresectable malignant lesions, particularly if the diagnosis remains unclear, or when a specific tissue diagnosis is needed.

Comparing thoracic and abdominal subspecialists' follow-up recommendations for abdominal findings identified on chest CT

PURPOSE

To compare thoracic and abdominal radiologists' follow-up recommendations for abdominal findings identified on chest CT.

METHODS

This Institutional Review Board-exempt, retrospective study was performed at a large academic medical center with subspecialty radiology divisions. We used a combination of natural language processing and manual reviews to identify chest CT reports with and without abdominal findings that were interpreted by thoracic radiologists in 2019. Three random samples of reports were reviewed by two subspecialty trained abdominal radiologists for their agreement with thoracic radiologists' reporting: abdominal findings with follow-up recommendation (Group 1), abdominal findings without follow-up recommendation (Group 2), and no abdominal findings reported (Group 3). Primary outcome was agreement between thoracic and abdominal radiologists for the need for follow-up of abdominal findings. Secondary outcomes were agreement between subspecialists for the presence of abdominal findings and referring clinician adherence to recommendations. Fischer's exact test was used to compare proportions.

RESULTS

Abdominal radiologists agreed with need for follow-up in 48.5% (16/33) of Group 1 cases and agreed follow-up was not necessary for 100% (34/34) of Group 2 cases (p < 0.001). Abdominal radiologists identified abdominal findings in 31.4% (11/35) of Group 3 cases, none of which required follow-up. Referring clinician adherence to thoracic radiologist follow-up recommendations for abdominal findings was 13/33 (39.4%).

CONCLUSION

Abdominal radiologists frequently disagreed with thoracic radiologist recommendations for follow-up of abdominal findings on chest CT. Chest radiologists may consider abdominal subspecialty consultation or clinical decision support to reduce unnecessary imaging.

Incidental liver lesions on baseline breast MRI: Outcomes on subsequent abdominal imaging

PURPOSE

To examine outcomes of incidental liver lesions on baseline breast magnetic resonance imaging (MRI) that were further evaluated with dedicated abdominal imaging.

METHODS

Consecutive breast MRI reports from 2011 to 2016 were retrospectively reviewed to identify incidental liver lesions. Only patients without prior breast MRI, without prior abdominal imaging, and with subsequent abdominal imaging were included. Patient demographics, breast MRI indication, and final liver lesion diagnosis were recorded.

RESULTS

Of 131 women (mean age 53.8 years), 94/131 (71.8%) underwent breast MRI for extent of disease evaluation, 25/131 (19.1%) for high-risk screening, 11/131 (8.4%) for implant evaluation, and 1/131 (0.8%) for problem-solving. Of 131 liver lesions (6-80 mm), 117/131 (89.3%) were deemed benign on subsequent abdominal imaging; 10/131 (7.6%) probably benign; and 4/131 lesions (3.1%) were confirmed breast cancer metastases. Metastatic liver lesions identified on breast MRI were more likely for women with a current diagnosis of breast cancer than for women without a current diagnosis of breast cancer: 4.3% vs 0%. Similarly, metastatic liver lesions identified on breast MRI were more likely for those with a higher prognostic stage (2 or 3) vs a lower prognostic stage (0 or 1) or no current breast cancer: 11.1% vs 0%.

CONCLUSION

Baseline breast MRIs showing incidental liver lesions showed unsuspected liver metastases only in women with a current diagnosis of clinical stage 2 or 3 breast cancer. This suggests breast MRI indication and clinical staging of current breast cancer, if present, can help plan management and decisions to obtain follow-up of liver lesions.

Integrity of clinical information in radiology reports documenting pulmonary nodules

OBJECTIVE

Quantify the integrity, measured as completeness and concordance with a thoracic radiologist, of documenting pulmonary nodule characteristics in CT reports and assess impact on making follow-up recommendations.

MATERIALS AND METHODS

This Institutional Review Board-approved, retrospective cohort study was performed at an academic medical center. Natural language processing was performed on radiology reports of CT scans of chest, abdomen, or spine completed in 2016 to assess presence of pulmonary nodules, excluding patients with lung cancer, of which 300 reports were randomly sampled to form the study cohort. Documentation of nodule characteristics were manually extracted from reports by 2 authors with 20% overlap. CT images corresponding to 60 randomly selected reports were further reviewed by a thoracic radiologist to record nodule characteristics. Documentation completeness for all characteristics were reported in percentage and compared using χ2 analysis. Concordance with a thoracic radiologist was reported as percentage agreement; impact on making follow-up recommendations was assessed using kappa.

RESULTS

Documentation completeness for pulmonary nodule characteristics differed across variables (range = 2%-90%, P < .001). Concordance with a thoracic radiologist was 75% for documenting nodule laterality and 29% for size. Follow-up recommendations were in agreement in 67% and 49% of reports when there was lack of completeness and concordance in documenting nodule size, respectively.

DISCUSSION

Essential pulmonary nodule characteristics were under-reported, potentially impacting recommendations for pulmonary nodule follow-up.

CONCLUSION

Lack of documentation of pulmonary nodule characteristics in radiology reports is common, with potential for compromising patient care and clinical decision support tools.

Should We Report Incidental Low-Density Liver Lesions with Benign Features? A Retrospective Single-Center Analysis of Trauma CT Scans

Background Many incidental liver lesions are benign and require no additional workup. Investigation of such lesions can have a negative impact of both the patient and health care system. However, the impact of how radiologists report these incidental lesions is not clear. We aimed to investigate how reporting of incidental liver lesions on trauma computed tomography (CT) scan affects follow-up.

Methods This is a retrospective single-center analysis of body CT scans performed following abdominal trauma. Information was collected on the reporting of incidental low-density liver lesions and any additional imaging performed.

Results A total of 3,595 trauma body CT scan reports were reviewed. Incidental liver lesions were identified in 527 (15%) patients, with 347 (10%) fulfilling the inclusion criteria. Additional imaging was requested by the referring doctor for 43 out of 285 patients (15%) when lesions were mentioned in the body of the report only, compared with 41 out of 62 patients (66%) when mentioned in the conclusion (odds ratio [OR] = 10.99, p < 0.0001). When additional imaging was recommended in the report, follow-up was arranged for 36 out of 52 patients (69%), compared with 48 out of 285 patients (16%) when it was not suggested (OR = 11.58, p < 0.0001). Additional imaging was requested for 84 of the 347 patients (24%), with 24 of these performed at our institution. All patients followed-up at our institution were diagnosed with a benign lesion.

Conclusion Reporting incidental hypodense liver lesions in the conclusion or specifically recommending further additional imaging, both led to significantly increased likelihood of additional imaging being performed. Radiologists who encounter such lesions should consider excluding them from the conclusion if there are no malignant features or patient risk factors.