Incidentalomas - The Coming Wave: Applying

Incidental Guidelines

Lincoln L. Berland, M.D., F.A.C.R.

University of Alabamaat Birmingham

University of Alabamaat Birmingham

Disclosure

Consultant to Nuance, Inc.

Scourge of Incidental FindingsMore CTs (26M in 1998, 61M in 2006)If CTC reimbursed: 3.5M/yr at 10 yearsCTC brings problems of whole-body screening, with benefits of polyp detectionExtracolonic Findings (ECFs) helping to keep CTC from reimbursement

Cascade EffectWilliam William CasarellaCasarella, MD, Former Chair, Emory , MD, Former Chair, Emory Radiology:Radiology:

Negative Virtual colonoscopyNegative Virtual colonoscopyRenal, hepatic and lung masses detected Renal, hepatic and lung masses detected

Additional CT scansAdditional CT scansPET scanPET scanLiver biopsy Liver biopsy VideoVideo--aided aided thoracoscopy thoracoscopy with wedge resectionwith wedge resection

Excruciating postExcruciating post--operative pain, 5 weeks of operative pain, 5 weeks of recuperation, over $50,000 in chargesrecuperation, over $50,000 in chargesAll findings benignAll findings benign

Frequency, Cost of Incidentalomas

Extracolonic Findings on CTC

Pickhardt, UWisc: 2195 asymptomatic adults6.1% had extra workup (US, CT, MRI, other)

14% of those: not recommended1.9% Noninvasive or surgical procedureCost $98.56/patientMuch cost from a few major operations, e.g. nephrectomies

Extracolonic Findings on CTC

Hassan, et al:100,000 patients - Monte Carlo simulationCost: $162/patient2292 life years gained, mostly from AAA

Only 13% of life years saved from cancer

Classifying Incidental Findings

Identified and categorized inconsistentlyNo established guidelines for work-up or follow-upMedicolegal risk

Classifying IncidentalomasNo incidental finding

E1: Normal variant

E2: Unimportant

E3: Likely unimportant

E4: Significant, needs WU

JCAT 32: 497-503, August, 2008376 patients

ACR, SCBT-MR, SGR, SUR to the

Rescue

ACR Involvement in Incidentaloma Problem

Commission: Reed Dunnick, then James BrinkChair: Lincoln Berland

Four subcommittees establishedRenal – Stuart Silverman Liver – Richard GoreAdrenal – William Mayo-SmithPancreas – Alec Megibow

Decided to defer other (vascular, ovarian, etc.)Work accelerated because of CTC issuePlans to submit white paper Fall, 2009

Challenges

Setting guidelines by consensus with limited scientific evidenceWhat level of uncertainty is acceptable? I.e. when can we feel comfortable not working up or following an extracolonic finding?Risk of guidelines leading to an increase, rather than a decrease in work-up of extracolonic findings

Renal Incidentalomas

Managing Incidental Renal Cystic Mass

Silverman SG, Israel GM, Herts B, Richie JP.Management of the incidental renal mass. Radiology 2008;249:16-31.

Summary-Renal Parameters Affecting Management

Cystic vs. solidAttenuation, other imaging features

Bosniak classification for cystic massesSize (<1, 1-3, >3 cm), but not growthLife expectancy, co-morbiditiesObservation, intervention strategies described

Hepatic Incidentalomas

Summary-Hepatic Parameters Affecting Management

Attenuation-enhancementFlash-filling vs. low attenuation

Other imaging featuresSize (<0.5, 0.5-1.5, >1.5 cm)RiskObservation, intervention strategies described

Adrenal Incidentalomas

Adrenal Nodules >10 HU

321 adrenal nodules/290 patientsNo known malignancy, benign appearanceFollowed > 1 year

318 benign, clinically insignificant3 functioning, but benign

Summary-Adrenal Parameters Affecting Management

Attenuation, MRI characteristics<10 or >10 HU noncontrastEnhancement patternsDecreased signal on CS-MR

Other imaging featuresSize (1-4, >4 cm)Risk

History of cancerObservation, intervention strategies described

Imaging Features are Diagnostic

Myelolipoma, Ca++

= Benign, No F/U

Incidental Adrenal Mass (≥1 cm)Detected on CT or MR

No Prior ImagingNo Hx of Cancer

< 4cm ≥ 4cm

Imaging Features Not Diagnostic

Benign*

Stable ≥ 1 Year

Prior Imaging

Concerning for MalignancyConsider biopsy or resection**

Lesion Enlarging

No Prior Imaging+ Hx of Cancer

Unenhanced CTor CS-MR

Adrenal Washout CT

Biopsy if Appropriate**Consider CS-MR if not done

Benign Imaging Features+: Presume Benign*

Consider 12 month F/U CT or MR

Suspicious Imaging Features++

No Enhancement (≤10HU)= cyst or hemorrhage

HU >10 or No ↓ Signal on CS-MR

APW/RPW≥60/40%

= Adenoma*

APW/RPW<60/40%

No Hx Cancer: consider

resection**

Benign, No F/U

HU≤10 or ↓ Signal on CS-MR

= Adenoma*

HU≤10 or ↓ Signal on CS-MR

= Adenoma*

+ Hx of Cancer:consider

PET or Biopsy**

Consider PET or

Pancreatic Incidentalomas

Pancreatic Cysts

73 (2.6%) pancreatic cysts in 2,832 patients8.7% 80-89 yo~3% benign-appearing cystic masses < 3 cm are malignant, can be followed.

Summary-Pancreas Parameters Affecting Management

SymptomsOther imaging featuresSize (<2, 2-3, >3 cm)Aspiration resultsChange over timeObservation, intervention strategies described

Benign,No further follow-up

Asymptomatic* Patient with Incidental Pancreatic Cystic MassDiscovered on CT, MRI (with or without contrast) or US

Single follow-upin 1 year**

< 2 cm

2-3 cm

> 3 cm

Serous Cystadenoma

Follow-up every 2 years

Follow-up every 6 months for 2 years§§

Follow-upyearly

Attemptto Characterize§

Consider resectionWhen ≥ 4 cm

Resect, depending onco-morbidities and risk

No growth

BD-IPMN UncharacterizedCystic Mass

Serous CystadenomaUncharacterized Cystic Mass

or Other Cystic Neoplasm

Growth

Cyst aspiration

Incidental Findings – What Should We Do?

A consistent approach may minimize the economic A consistent approach may minimize the economic implications and optimize the health effects of implications and optimize the health effects of extracolonicextracolonic incidental findingsincidental findingsStrive to definitively characterize Strive to definitively characterize extracolonicextracolonic findings, findings, but balance with risk and cost of additional studiesbut balance with risk and cost of additional studiesHelp direct referring clinicians to the most costHelp direct referring clinicians to the most cost--effective effective approach to managing the few approach to managing the few extracolonicextracolonic findings that findings that must be pursuedmust be pursued