Detection Of Incidental Findings Research Articles

Co-occurrence of germline pathogenic variants in a Brazilian cohort of patients with breast cancer.

e22532 Background: The estimated prevalence of germline pathogenic variants (PV) or likely pathogenic variants (LPV) in high and moderate penetrance genes is around 7-10% among women with breast cancer (BC). The emergence of next-generation sequencing (NGS) technology allowed multi-gene panel testing (MGPT) analysis at a lower cost. However, the detection of incidental findings with unknown significance (VUS) and challenges with variant interpretation increase substantially with MGPT. The effect of co-existing PV/LPV in two or more genes is still understudied. Here, we present the prevalence of concurrent germline LPV/PV in a cohort of Brazilian women with BC who underwent a MGPT in a single reference laboratory. Methods: Retrospective observational study using a laboratory cohort (Oncoclínicas Precision Medicine). This study includes women with BC who performed a germline MGPT (able to call SNVs, indels and CNVs) from 2019 to 2023. All patients were tested in a single reference laboratory (OC Precision Medicine) and originated from several Brazilian centers within the Oncoclínicas network. Two distinct germline NGS assays were used: breast and ovarian cancer (BOC) panel (36 genes) and a pan-cancer (PC) panel (105 genes). Results: In the overall cohort, 2,651 women with BC were included in this analysis. The median age at genetic testing was 51 years. 1,867 pts (70.4%) underwent a PC panel testing and the remaining 784 pts (29.6%) a BOC panel.Overall, 314 (12%) pts carrier of LP/PV in high- and/or moderate-penetrance genes. Two or more heterozygous LP/PV were found in 35 pts (1.32%), including 8 pts (1.02%) in the BOC panel and 27 pts (1.44%) in the PC panel subgroups. There were no differences in age of onset of BC in single vs co-occurring double mutants. The most frequent co-existing PV/LPV were found in BRCA2 (11) / BRCA1 (8) / PALB2 (4) / TP53 (3) and MUTYH (7) / CHEK2 (3) in the high and moderate penetrance genes, respectively. Six pts (0.23%) had a double heterozygous involving high and/or moderate penetrance genes. Interestingly, there was a case with four heterozygous variants in TP53, MUTYH, MUTYH and APC. Conclusions: In times of rapid incorporation of MGPT in the clinical practice, our real-world data showed that a small proportion of BC patients could be carriers of two or more germline heterozygous LP/PV in cancer genes. However, this represents a challenging scenario for patient and family management, especially in a co-occurrence of high and moderate penetrance genes.

#2955 Incidental findings in a renal magnetic resonance imaging study for evaluation of chronic kidney disease in type 2 diabetes population

Abstract Background and Aims Novel Magnetic Resonance Imaging (MRI) techniques are potential methods to non-invasively assess and quantify functional, structural and pathophysiological changes in chronic kidney disease (CKD) that may improve diagnosis, prognosis and treatment of these patients. Advances in imaging techniques are also likely to result in the detection of unexpected and asymptomatic incidental findings. We retrospectively analyzed the overall prevalence of incidental findings in the participants of our previously reported study utilizing a non-contrast multiparametric MRI protocol in patients with type 2 DM (T2DM) as compared to healthy controls. Method The subjects of this sub-study were participants of our original prospective, single-center, observational study, in which several MRI biomarkers were evaluated to differentiate diabetic versus healthy kidneys, and various stages of CKD. A complete medical history and physical examination were performed. The inclusion criteria for the T2DM cohort were: Age 18-70 years, type II DM with CKD staged 3-4 (estimated glomerular filtration rate [eGFR] 15-60 ml/min/1.73 m2, body mass index (BMI) 18-35 and provision of written informed consent. The control group comprised of healthy volunteers who were age- and sex-matched and had the following inclusion criteria: Age 18-70 years, eGFR >80 ml/min/1.73 m2, UACR <30 mmol/g, BMI 18-35 and provision of written informed consent. Exclusion criteria for the diabetic group were any apparent cause/s of CKD other than diabetes, previous kidney transplantation, pregnancy, contraindication for MRI examination, heart failure (NYHA class III or IV), allergies to iodine-based contrast agents. Factors that excluded healthy participants were pregnancy, contraindication for MRI examination, allergy to iodine-based contrast agents and any active or chronic disease/diagnosis. Measured GFR (mGFR) was assessed in all participants using iohexol clearance. An MRI scan using a wide range of non-contrast techniques was performed at baseline. Total scan time for patients did not exceed 45 min per session and no gadolinium-based contrast agents were used in any of the MRI examinations. All patients with incidental findings on MRI were further evaluated and referred to appropriate specialists for management. Results A total of 38 T2DM patients with CKD and 20 age- and gender-matched healthy volunteers who completed the study were included in the analysis. Of the T2DM patients, 2 were found to have CKD stage 2 by mGFR and 36 CKD stages 3–4. Clinically significant incidental findings (excluding 4 cases of renal cysts requiring only follow-up without further intervention) were found in 13 of the 38 (34%) T2DM patients. The most frequent findings were intraductal papillary mucinous neoplasm (IPMN) in 7 patients, followed by 3 cancers (1 case of kidney cancer, 1 bladder cancer and 1 lymphoma) and 3 cases of adrenal gland mass later diagnosed to be benign adenoma on further investigation. In contrast, of the 20 healthy volunteers, 2 (10%) were found to have significant incidental findings, which were IPMN in both. The follow-up duration varied between 2-6 years. The patient with bladder cancer had metastatic disease and died shortly after the diagnosis, the one with kidney cancer is under observation and the one with lymphoma underwent adequate treatment and is under remission. The cases of IPMN are being followed up regularly at our surgical department. Conclusion Clinically important incidental findings on renal MRI appear to be more common in T2DM patients than in healthy volunteers, which would have been missed without MRI examination. Mechanisms for reporting and strategies for dealing with incidental findings need to be taken into account in such investigational imaging studies. The detection of incidental findings also poses various practical and ethical issues. Further larger studies with long-term follow-up are needed to delineate the clinical relevance, natural course and management of such incidental findings.

Incidental finding of leukaemia in circulating tumour DNA— the importance of a molecular tumour board

As the use of liquid biopsies are increasing across multiple indications in cancer medicine, the detection of incidental findings on circulating tumour DNA is of increasing importance. We report the finding of leukaemia detected in a patient who underwent plasma-based circulating tumour DNA next generation screening as part of a screening liquid biopsy study. A BRAF V600E mutation detected was deemed pathogenic following discussion at a molecular tumour board, and recommendation of further investigations led to the diagnosis of an occult haematological malignancy. We report the importance of molecular tumour board discussion and recommendations in the identification of incidental, pathogenic findings on circulating tumour DNA.

Radiodiagnostics of standard orthodontic radiographs-dental and extradental incidental findings : Do we see everything we should see?

The extent of undetected incidental findings in routine orthodontic radiographs is still unknown. However, incidental findings that are not in the primary focus of orthodontic diagnostics may be of high medical relevance. Therefore, this study aimed to analyse whether incidental findings are reliably detected and which parameters influence the orthodontist's assessment. In aclinical cross-sectional study 134 orthodontists evaluated two orthopantomogram (OPT) and two lateral cephalogram (LC) radiographs each via astandardised online survey. The radiographs were previously examined by three dentists and one radiologist-in apilot phase-regarding the number of incidental findings and subsequently defining as gold standard in aconsensus procedure. The radiographs were presented consecutively, the number of incidental findings detected were noted and the individual findings could be described in free text form. Overall, 39.1% of the incidental findings were detected. The orthodontists' focus was primarily on the dental region. Here, 57.9% of incidental findings were detected, while 20.3% were detected in extradental regions (p < 0.001). Ahighly relevant finding of suspected arteriosclerotic plaque was detected in 7.5% of cases (OPT). Significantly more incidental findings were detected on OPTs than on LCs (OPT 42.1%, LC 36.0%, p < 0.001). As participants' length of professional experience increased, significantly more time was spent on the assessment (p < 0.001), correlating positively with the detection of incidental findings. Even in daily routine practice, attention must be paid to athorough assessment of all radiographed regions. The factors time and professional experience can prevent practitioners from overlooking findings outside the orthodontic focus.

Utilization of Chest and Abdominopelvic CT for Traumatic Injury From 2011 to 2018: Evaluation Using a National Commercial Database.

Background: Recent increases in utilization of CT in patients presenting with trauma have raised concern of inappropriate imaging. The evolving utilization of CT for trauma evaluation may be impacted by injury severity. Objective: To explore patterns in utilization of chest and abdominopelvic CT among trauma-related emergency department (ED) visits across the United States. Methods: This retrospective study used national commercial claims information extracted from the IBM MarketScan Commercial Database. Trauma-related ED encounters were identified from the 2011 to 2018 MarketScan files and classified using the Injury Severity Score (minor, intermediate, or major injuries) based on International Classification of Diseases codes. ED encounters were also assessed for chest CT, abdominopelvic CT, and single-encounter thoracoabdominopelvic CT examinations. Utilization per 1000 trauma-related ED encounters was determined. Multivariable Poisson regression models were used to determine incidence rate ratios (IRRs) as a measure of temporal changes in utilization. Results: From 2011 to 2018, 8,369,092 trauma-related ED encounters were identified (5,685,295 for minor, 2,624,944 for intermediate, and 58,853 for major injuries). Utilization of chest CT per 1000 trauma-related ED encounters increased from 4.9 to 13.5 (adjusted IRR, 1.15 per year) [2.2 to 7.7 (1.17) for minor, 8.5 to 21.5 (1.16) for intermediate injuries, and 117.8 to 200.1 (1.08) for major injuries]. Utilization of abdominopelvic CT per 1000 trauma-related ED encounters increased from 7.5 to 16.4 (1.12) [4.8 to 12.2 (1.13) for minor, 10.6 to 21.7 (1.13) for intermediate, and 134.8 to 192.6 (1.07) for major injuries]. Utilization of single-encounter thoracoabdominopelvic CT per 1000 trauma-related ED encounters increased from 3.4 to 8.9 (1.16) [1.1 to 4.6 (1.18) for minor, from 6.4 to 16.4 (1.16) for intermediate, and 99.6 to 179.9 (1.08) for major injuries]. Conclusions: National utilization of chest and abdominopelvic CT for trauma-related ED encounters increased in commercially insured patients from 2011 to 2018, particularly for single-encounter thoracabdominopelvic CT examinations and for minor injuries. Clinical Impact: Given concerns of increased cost and incidental findings detection, further investigation is warranted to explore the potential benefit of single-encounter thoracabdominopelvic CT examinations in patients with minor injuries, as well as strategies to optimize order appropriateness.

Hysterectomies: An Audit at A Tertiary Care Public Sector Hospital in Lahore, Pakistan

Background: Hysterectomy is a common gynecological surgery worldwide. Thorough preoperative clinical and radiological assessment of the patients followed by histopathological evaluation of the specimens is mandatory for providing good health care services to the patients. Objective: The objective of the study was to analyze the spectrum of histopathological findings in hysterectomy specimens &amp; correlate them with their clinical &amp; radiological findings. Patients and Methods: This was a retrospective, descriptive, cross sectional study, carried out at the Pathology Department of Fatima Jinnah Medical University, Lahore. All the gynecological hysterectomies received at the department from 1st December 2018 to 30th November 2020 were included in the study. Data collected, included age of the patient, clinical presentation, radiological findings, type of hysterectomy performed and complete histopathology report of the specimen. Data was analyzed using SPSS version 17. Results: A total of 637 hysterectomy specimens were included in the study. The age of the patients ranged from 22 years to 80 years with a mean age of 46 ± 9 years. The commonest clinical indication was a uterine mass (47.7%). Most frequent preoperative radiological (USG/ CT scan/MRI) finding was uterine mass/polyps (52%). The commonest surgical procedure was total abdominal hysterectomy (52.4%). On histopathological evaluation, 99% of the cases showed chronic cervicitis. The commonest diagnosis in the uterine corpus was leiomyoma. Uterine malignancy accounted for 7.3% of the cases and 4.7% of hysterectomies were done for ovarian malignancies. Practical implicationThis study aims to highlight the need for a multi-disciplinary audit for all hysterectomy cases to reduce the incidence of this surgery &amp; for better patient care &amp; management. Conclusion: Hysterectomy is a major, invasive surgical procedure. A vigilant preoperative clinical and radiological evaluation of the patient can reduce the incidence of this surgery. Histopathological analysis of all hysterectomy specimens is mandatory for diagnosis of benign and malignant conditions, recognition of precancerous lesions and detection of incidental findings. Keywords: Hysterectomies, Audit, Leiomyoma, preoperative radiological evaluation, histopathological evaluation

EP01.04-006 Clinical Scores, Biomarkers and It Tools in Lung Cancer Screening - Can an Integrated Approach Overcome Current Challenges?

Lung cancer (LC) is the leading cause of cancer related mortality. One reason is that still more than two thirds of patients are diagnosed with advanced disease. Cigarette smoking is the most important risk factor (RF). Recent LC screening studies demonstrated that annual low dose chest CT (LDCT) screening can reduce LC related mortality. Challenges still exist with LDCT based LC screening like optimal selection of individuals for LC screening programs, personalization of screening intervals, specification of individualized follow up intervals for nodule management or the detection of incidental findings

A PAncreatic cancer screening study in individuals with New-onset or DeteriOrating diabetes MEllitus (PANDOME study).

TPS10607 Background: Pancreatic adenocarcinoma (PC) has a persistently high mortality as it presents in the advanced stages and has largely not benefited from the genomic and immunotherapeutic revolutions in oncology. Improvements in screening to detect early stage cancers are therefore urgently needed. Screening studies such as those from the International CAPS Consortium have demonstrated improved survivals in hereditary high risk individuals. In the sporadic population, individuals with new-onset diabetes (NOD) or long-standing deteriorating diabetes (DD) are at substantially increased risk of PC in the 12 months following these diagnoses and have been proposed as target populations for screening efforts. This trial will study the benefits of PC screening in the latter populations in a community setting. Methods: Individuals ≥ 50 years of age with either NOD or DD will be eligible. Criteria for NOD (within the past 12 months) include: fasting blood glucose ≥ 126 mg/dL, random blood glucose ≥ 200 mg/dL, or HbA1c ≥ 6.5%, with confirmed prior normal values. For those without prior glycemic values, a HbA1c ≥ 7.0% is required. Transition from pre-diabetes requires an increase in HgA1c of ≥ 0.5%. DD is defined by an increase in HbA1c of ≥ 2% within the past six months that is not associated with medication non-compliance or weight gain. Study participants will undergo every 6 months: evaluation by an APRN, testing for anxiety and depression and blood donation for biobanking purposes. High resolution MRI/MRCP with gadolinium will be performed at study entry and annually for 2 years. Images will be reviewed at a multi-disciplinary tumor board consisting of body-image certified radiologists, interventional gastroenterologists, hepatobiliary surgeons and medical oncologists. MRI results will be classified according to a novel PANC-RADS system. High-risk pancreatic findings will be further interrogated by endoscopic ultrasound (EUS). Study endpoints include detection rate of high-risk lesions, referrals for EUS and surgery and detection of incidental findings leading to unnecessary procedures. Adverse psychological impacts will be assessed through HADS testing. Target accrual: 500 patients within 3 years. Clinical trial information: NCT03937453 .

Diagnostic accuracy, yield, and comparative effectiveness of whole-body computed tomography in blunt trauma: A protocol for systematic review and meta-analysis.

Controversies emerge over routine performances of whole-body computed tomography (WBCT) in patients with blunt polytrauma. The existing randomized and non-randomized evidence is inconclusive, and during observations of non-trauma, incidental findings, detected by WBCT, have left uncertainty regarding their consequences and optimal management. Additionally, previous meta-analyses have failed to address the limitations of primary studies and issues associated with incidental findings. Therefore, we planned a new systematic review to address these points. We will search the PubMed, EMBASE, and Cochrane Central databases from inception to December 31, 2020, with no language restriction and perform full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies with a single-gate design that assessed diagnostic accuracy and/or yield of WBCT to detect traumatic injuries, and studies that assessed incidental findings detected by WBCT. Additionally, we will include randomized controlled trials and non-randomized comparative studies that assessed the effectiveness of WBCT against conventional care, including selective computed tomography (CT). Studies of patients of all ages with blunt traumatic injuries, assessed at an emergency department, will be included. Two reviewers will extract data and rate the study validity via standard quality assessment tools. The primary outcome of interest will be reduction in mortality. Our secondary outcomes will include diagnostic accuracy and yield, detection of incidental findings and clinical outcomes associated with these detections, and improvement in other non-mortality clinical outcomes. We will qualitatively assess study, patient, and intervention characteristics and clinical outcomes. If appropriate, we will perform random-effects model meta-analyses to obtain summary estimates. Finally, we will assess the certainty of evidence by the grading the quality of evidence and strength of recommendations. Ethics approval is not applicable, as this is a secondary analysis of publicly available data. The review results will be submitted for publication in peer-reviewed journals. CRD42020187852.

Detection of incidental findings on chest CT scans in patients with suspected COVID-19 pneumonia

This study aimed to evaluate the chest Computed Tomography (CT) scans of COVID-19 suspected patients in the first period of the pandemic, to reveal the frequency of parenchymal-extraparenchymal incidental findings (IFs). Our single-center retrospective observational study was initiated with the approval of the ethics committee. Chest CT records taken during March-August 2020 due to the suspicion of COVID-19 pneumonia were scanned using the imaging archive of our center. The study was conducted with 1540 patients with non-contrast chest CT without prior CT imaging to detect IFs. Histopathological results and clinical-radiological follow-up data of the patients were scanned from medical records. Of the 1540 patients in our study, 902 (58.57%) were male and 638 (41.43%) were female, with a mean age of 41.96±17.08 (5-92) years. While 248 (16.1%) patients had a typical appearance for COVID-19 pneumonia on thorax CT, no findings were found in 1180 (76.6%) patients. Except for COVID-19 pneumonia, parenchymal IFs(primary malignant lung lesions, metastatic lesions, benign pathologies) were detected in 73 patients (4.74%) and extraparenchymal IFs(lymphadenopathy, breast lesions, thyroid nodule, bone, liver and kidney lesions…) in 280 patients (18.8%). Our study showed that the number of patients without any findings in terms of COVID-19 pneumonia on CT scans is high. It is understood that CT scans for pneumonia are unnecessary due to radiation exposure and should be used when clinically necessary. However, due to the ability of CT to detect incidental findings, it is also important to define IFs oth er than pneumonia in patients who underwent chest CT examination during the pandemic.

Incidental Brain MRI Findings in Children: A Systematic Review and Meta-Analysis.

The detection of incidental findings on children's brain MR imaging poses various practical issues because the life-long implications of such findings may be profound. Our aim was to assess the prevalence and characteristics of incidental brain MR imaging findings in children. Electronic databases (PubMed, EMBASE, and Cochrane) were searched for articles published between 1985 to July 2018, with the following search terms: "incidental," "findings," "brain," "MR imaging." Inclusion criteria were the following: 1) patients younger than 21 years of age, 2) healthy children without any clinical condition, 3) MR images obtained with at least a 1.5T magnet, 4) original articles, and 5) a methodologic quality score of ≥10. Two observers independently extracted data and assessed data quality and validity. The number and type of incidental findings were pooled. Heterogeneity was assessed using the Cochran Q statistic and the I2 statistic. Seven studies were included, reporting 5938 children (mean age, 11.3 ± 2.8 years). Incidental findings were present in 16.4% (99% CI, 9.8-26.2; Q = 117.5, I2= 94.9%) of healthy children, intracranial cysts being the most frequent (10.2%, 99% CI, 3.1-28.5; Q = 306.4, I2 = 98.0%). Nonspecific white matter hyperintensities were reported in 1.9% (99% CI, 0.2-16.8; Q = 73.6, I2 = 94.6%), Chiari 1 malformation was found in 0.8% (99% CI, 0.5-1.3; Q = 7.6, I2 = 60.5%), and intracranial neoplasms were reported in 0.2% (99% CI, 0.1-0.6; Q = 3.4, I2 = 12.3%). In total, the prevalence of incidental findings needing follow-up was 2.6% (99% CI, 0.5-11.7; Q = 131.2, I2 = 95.4%). Incidental findings needing specific treatment were brain tumors (0.2%) and cavernomas (0.2%). Limitations were no age stratification or ethnicity data and variation in the design of included studies. The prevalence of incidental findings is much more frequent in children than previously reported in adults, but clinically meaningfull incidental findings were present in <1 in 38 children.

Grading fatty liver and detecting liver pathological features - Is there consensus between sonographers and radiologists?

Introduction Hepatic steatosis is the leading cause of chronic liver disease. Reliable detection and staging of liver disease is important to facilitate diagnosis and treatment. The aim of this study was to evaluate the interobserver agreement between trainee sonographers, qualified sonographers and radiologists in grading non-alcoholic fatty liver disease (NAFLD) and detecting common liver pathological features in B-mode images. Methods 150 B-mode liver ultrasound images from 50 adult patients referred for an abdominal ultrasound were obtained retrospectively from a PACS system. The images were independently graded for the severity of hepatic steatosis (normal, mild, moderate or severe) and the detection of incidental 0findings, focal fatty sparing, liver surface irregularity and rounded liver edge (present or absent) by 17 qualified, six trainee sonographers and six radiologists. Fleiss’ kappa statistics were used to calculate interobserver agreement among participants in grading common liver pathological features. Intraclass correlation coefficient (ICC) were used to calculate the level of absolute agreement among participants in grading NAFLD. Results The interobserver agreement rates among trainee sonographers for the detection of incidental findings, focal fatty sparing, liver surface irregularity and rounded liver edge were: κ = 0.243, 0.486, 0.155 and 0.079 respectively. Among qualified sonographers, the agreement rates were: κ = 0.323, 0.428, 0.167 and 0.152 respectively. Among radiologists, the agreement rates were: κ = 0.156, 0.266, 0.015 and 0.154 respectively. The intraclass correlation coefficient average scores among trainee sonographers, qualified sonographers, all the sonographers combined and radiologists were: 0.927, 0.978, 0.985 and 0.954 respectively. Conclusion Visual assessment of common liver pathology in B-mode imaging has low interobserver agreement among sonographers and radiologists, but excellent inter-rater reliability in grading NAFLD. The low agreement levels are likely caused by a lack of standardised assessment criteria. The development of a standardised criteria for staging NAFLD and common liver pathological features are recommended.

Value of low-dose whole-body CT in the management of patients with multiple myeloma and precursor states.

To determine the value of low-dose whole-body CT (WBCT) in the management of patients with multiple myeloma (MM) and precursor states. The study group comprised 116 patients (mean age: 68 ± 11years, 48% women) who underwent WBCT for the work-up or surveillance of MM or MM precursor disease. WBCTs were reviewed for the presence of MM-related bone disease and incidental findings requiring therapy. The medical records, results from bone marrow aspirations and biopsies and follow-up imaging studies were reviewed to assess the influence of WBCT on patient management. Whole-body CT led to a change in management in 32 patients (28%). Of those, 17 patients with MM precursor disease were found to have MM-related bone disease, 13 patients had progression of MM, requiring a change in treatment, in one patient hepatocellular carcinoma was diagnosed, requiring a change in therapy, and one patient had a rib lesion requiring intervention. In 65 patients (56%), WBCT was performed for surveillance of MM precursor disease or stable treated MM, and did not detect new lesions, thereby providing reassurance to the hematologist on disease status and management. In 15 patients (13%) WBCT was performed as a new baseline before a change or new therapy. In 4 patients (3%), WBCT was performed for a change in symptoms, but did not detect lesions that would lead to a change in management. Whole-body CT provides important information for disease monitoring and detection of incidental findings, thereby improving the management of patients with MM.

Ethical framework for the detection, management and communication of incidental findings in imaging studies, building on an interview study of researchers\u2019 practices and perspectives

BackgroundAs thousands of healthy research participants are being included in small and large imaging studies, it is essential that dilemmas raised by the detection of incidental findings are adequately handled. Current ethical guidance indicates that pathways for dealing with incidental findings should be in place, but does not specify what such pathways should look like. Building on an interview study of researchers’ practices and perspectives, we identified key considerations for the set-up of pathways for the detection, management and communication of incidental findings in imaging research.MethodsWe conducted an interview study with a purposive sample of researchers (n = 20) at research facilities across the Netherlands. Based on a qualitative analysis of these interviews and on existing guidelines found in the literature, we developed a prototype ethical framework, which was critically assessed and fine-tuned during a two-day international expert meeting with bioethicists and representatives from large population-based imaging studies from the United Kingdom, Germany, Sweden and Belgium (n = 14).ResultsPractices and policies for the handling of incidental findings vary strongly across the Netherlands, ranging from no review of research scans and limited feedback to research participants, to routine review of scans and the arrangement of clinical follow-up. Respondents felt that researchers do not have a duty to actively look for incidental findings, but they do have a duty to act on findings, when detected. The principle of reciprocity featured prominently in our interviews and expert meeting.ConclusionWe present an ethical framework that may guide researchers and research ethics committees in the design and/or evaluation of appropriate pathways for the handling of incidental findings in imaging studies. The framework consists of seven steps: anticipation of findings, information provision and informed consent, scan acquisition, review of scans, consultation on detected abnormalities, communication of the finding, and further clinical management and follow-up of the research participant. Each of these steps represents a key decision to be made by researchers, which should be justified not only with reference to costs and/or logistical considerations, but also with reference to researchers’ moral obligations and the principle of reciprocity.

Cone beam computed tomography in orthodontics: Indications, insights, and innovations

Cone Beam Computed Tomography in Orthodontics: Indications, Insights, and Innovations provides a detailed and comprehensive look at one such area. It is a timely contribution to the literature on CBCT and will be of considerable interest to orthodontists, orthodontic researchers, and residents who are studying the use of this technology.The book covers 4 areas of the use of CBCT imaging in orthodontics: technology assessment and enhancement, protocols and principles for CBCT in orthodontics, diagnosis and treatment planning, and clinical applications and treatment outcomes.With leading experts contributing to the book, each of the 23 chapters examines 1 aspect of the use of CBCT in orthodontics, including concepts and characteristics, perspectives on radiation risk, selection criteria, medicolegal implications, protocols for its use, how to interpret the scans, detection of incidental findings, 3-dimensional diagnosis and treatment planning, temporomandibular joint and airway applications, assessment of impacted teeth and root positions, use of CBCT for orthognathic surgery treatment planning, and other clinical applications.The book comes with 2 DVDs, which provide 15 hours of video presentations from the 39th Annual Moyers Symposium and the 38th Annual International Conference on Craniofacial Research. The videos are well made and worth watching.As CBCT technology develops, so will attitudes concerning its use, which presently run from considerable interest to little faith. This book is so structured that it might easily go to several editions, with chapters revised or removed as the technology changes.Some manufacturers of CBCT units are advising clinicians to acquire CBCT images for their initial, progress, and final records. Although some clinicians have followed this advice, others have questioned whether CBCT, because of its radiation dose and cost, benefits patients by improving treatment outcomes.One of the more problematic aspects of CBCT is that the units vary considerably. They differ in major characteristics, such as effective radiation dose, image detector, scan time, patient positioning, and field of view. They also come with different operating softwares and footprints. Such differences are not typically seen in other dental and medical imaging techniques, but there is no reason to believe that manufacturers are likely to standardize CBCT machines anytime soon.Therefore, it behooves whoever uses CBCT to understand this technique to ensure effective and meaningful implementation. This text provides a great resource to help with understanding of several aspects of CBCT in orthodontic practice and research. Cone Beam Computed Tomography in Orthodontics: Indications, Insights, and Innovations provides a detailed and comprehensive look at one such area. It is a timely contribution to the literature on CBCT and will be of considerable interest to orthodontists, orthodontic researchers, and residents who are studying the use of this technology. The book covers 4 areas of the use of CBCT imaging in orthodontics: technology assessment and enhancement, protocols and principles for CBCT in orthodontics, diagnosis and treatment planning, and clinical applications and treatment outcomes. With leading experts contributing to the book, each of the 23 chapters examines 1 aspect of the use of CBCT in orthodontics, including concepts and characteristics, perspectives on radiation risk, selection criteria, medicolegal implications, protocols for its use, how to interpret the scans, detection of incidental findings, 3-dimensional diagnosis and treatment planning, temporomandibular joint and airway applications, assessment of impacted teeth and root positions, use of CBCT for orthognathic surgery treatment planning, and other clinical applications. The book comes with 2 DVDs, which provide 15 hours of video presentations from the 39th Annual Moyers Symposium and the 38th Annual International Conference on Craniofacial Research. The videos are well made and worth watching. As CBCT technology develops, so will attitudes concerning its use, which presently run from considerable interest to little faith. This book is so structured that it might easily go to several editions, with chapters revised or removed as the technology changes. Some manufacturers of CBCT units are advising clinicians to acquire CBCT images for their initial, progress, and final records. Although some clinicians have followed this advice, others have questioned whether CBCT, because of its radiation dose and cost, benefits patients by improving treatment outcomes. One of the more problematic aspects of CBCT is that the units vary considerably. They differ in major characteristics, such as effective radiation dose, image detector, scan time, patient positioning, and field of view. They also come with different operating softwares and footprints. Such differences are not typically seen in other dental and medical imaging techniques, but there is no reason to believe that manufacturers are likely to standardize CBCT machines anytime soon. Therefore, it behooves whoever uses CBCT to understand this technique to ensure effective and meaningful implementation. This text provides a great resource to help with understanding of several aspects of CBCT in orthodontic practice and research.

Value of non-contrast CT examination of the urinary tract (stone protocol) in the detection of incidental findings and its impact upon the management

BackgroundUrolithiasis is one of the most common urinary tract diseases worldwide, with a wide range of affected age groups. Non-contrast CT examination of the urinary tract is the gold-standard examination for detection and characterization of urinary tract stones, with great impact upon the choice of method of management. Aside from detection of stones, non-contrast CT examination of the abdomen and pelvis also offers a valuable overlook upon the other abdominal organs, pathologies of which may simulate a stone disease, or accompany stone disease and can be detected incidentally, which may shift management plan dramatically. Aim of workTo demonstrate the use of non-contrast CT examinations (stone protocol) in the detection of abdominal pathologies other than stones, whether or not simulating the clinical picture of urolithiasis, and its impact upon patient management. Patients and methodsAssessment of the non-contrast examinations of the urinary tract of patients referred for suspected stone urolithiasis recording any incidental finding and follow-up of the impact of these incidental findings upon the management delivered to the patient. ResultsA total of 719 examinations were performed, of which 334 had urinary tract stones only, 211 had incidental finding beside urinary tract stones, 170 had an incidental finding with no urinary tract stones, and four patients had neither stones nor incidental findings. A total number of 381 patients had incidental findings, 198 (47%) of which had an impact upon the management. ConclusionNon-contrast CT examination of the urinary tract (stone protocol) is a valuable tool in the detection of incidental findings which may simulate, or coincide with urolithiasis and it has a significant impact upon the management of the patients.

Clinical, Ethical and Financial Implications of Incidental Imaging Findings: Experience from a Phase I Trial in Healthy Elderly Volunteers

BackgroundThe detection of incidental findings (IF) in magnetic resonance imaging (MRI) studies is common and increases as a function of age. Responsible handling of IF is required, with implications for the conduct of research and the provision of good clinical care.AimTo investigate the prevalence and clinical significance of IF in a prospective cohort of healthy elderly volunteers who underwent MRI of the torso as a baseline investigation for a phase I trial. We assessed the follow-up pathway with consequent cost implications and impact on trial outcomes.MethodsA total of 29 elderly healthy volunteers (mean age 67, range 61–77, 59% female) were eligible at screening and underwent MRI for assessment of visceral and subcutaneous fat.ResultsIF were detected in 19 subjects (66%). Suspected IF of high and low clinical significance were found in 14% and 52% of participants, respectively. Follow up of IF was conducted in 18 individuals, confirming abnormalities in 13 subjects, 3 of whom were recommended for deferred clinical re-evaluation. The remaining 5 subjects had false positive IF based on second line imaging tests. Costs of follow-up medical care were considerable.ConclusionMRI abnormalities are common in elderly individuals, as a result of age and non-diagnostic quality of research scans. In the presence of IF in the context of clinical trials, immediate referrals and follow up assessments may be required to rule out suspected pathology prior to exposing trial participants to investigational medicine products (IMP). Unanticipated costs, ethical implication and the possible impact of IF on trial outcomes need to be taken into account when designing and conducting trials with an IMP.

Incidental findings on routine thoracoabdominal computed tomography in blunt trauma patients

BACKGROUND:: Thoracoabdominal MultiDetector-row Computed Tomography (MDCT) is frequently used as a diagnostic tool in trauma patients. One potential side-effect of performing MDCT is the detection of incidental findings and their subsequent consequences on medical treatment. The objective was to evaluate frequency and effects of incidental findings in trauma patients. METHODS:: The reports of 1,047 consecutive blunt trauma patients (mean age, 40 years) who underwent routine contrast-enhanced thoracoabdominal MDCT were evaluated. Incidental findings were categorized by a trauma radiologist into four hierarchic categories based on their clinical consequences. We recorded additional diagnostic workup and treatment performed in conjunction with these incidental findings. RESULTS:: Of the 1,047 patients, 372 (mean age, 56 years; 61% male) had one or more incidental findings on thoracoabdominal MDCT. Complementary investigation or therapy was performed in 72 of these 372 patients; 29 of these patients required additional invasive evaluation or treatment. Nineteen patients underwent surgery due to an incidental finding. Nine patients were diagnosed with a not previously identified malignancy. CONCLUSIONS:: Routine thoracoabdominal MDCT in the evaluation of trauma patients revealed a significant number of incidental findings. Based on radiologic findings it is possible to decide whether additional follow-up or treatment is necessary.

A Single Center Experience of EUS Evaluation of Incidental Pancreatic Lesions

Purpose: The liberal use of CT scans as part of the initial evaluation of patients often results in the detection of incidental findings. In one recent study, a total of 1474 incidental findings in 1103 patients were found in a 2 year period. Pancreatic lesions, which are frequently asymptomatic, are often found incidentally on imaging. Endoscopic ultrasound (EUS) is increasingly being used in the diagnostic evaluation of incidentally found pancreatic lesions. EUS evaluation, with guided fine needle aspiration, allows for tissue characterization, cytologic analysis, and measures of various tumor markers. This can give valuable information as to a lesion's malignant potential, as even cystic lesions of the pancreas may represent malignant or premalignant neoplasms. The aim of our study was to assess the effectiveness of EUS and EUS-guided FNA in the evaluation of pancreatic lesions found incidentally on radiographic imaging. Methods: The medical records of 83 patients referred for EUS because of an abnormal CT of the pancreas were reviewed. All patients who were found to have a suspicious pancreatic lesion and underwent EUS were included in the study; we excluded those <18 years of age. Results: There were 51 men and 32 women, with no significant difference in age. EUS FNA noted 76% (n=63) of patients to have advanced pathology (neoplastic or pre-cancerous lesions). Of those with advanced pathology, 47% (n=39) were adenocarcinomas, 20.5% (n=17) were indeterminate in which carcinoma could not be excluded, and 8.4 (n=7) were other types of precancerous lesions. The average age of those with advanced pathology was 67.7 years and with benign lesions was 60.2 years. EUS noted that of the all the pancreatic lesions found, 79.5% were solid, 15.6% cystic, and 4.8% were a mixed consistency. 75.8% (n=50) of solid lesions had advanced pathology and 69.2% (n=9) of cystic lesions had advanced pathology. Carcinomas (n=39) had a variable distribution within the pancreas. 38.5% were located in the head, 35.9% in the body, 7.7% in the tail, 5.1% uncinate, and 12.8% in multiple locations. Tumor markers were not elevated in all noted carcinomas; only 56.4 % of carcinomas had elevated tumor markers (CA19-9 or CEA). Conclusion: EUS in a reliable modality for diagnosing suspicious pancreatic lesions. EUS in association with FNA is more effective in diagnosing pancreatic adenocarcinoma than EUS with tumor markers alone. It is also proven useful in distinguishing between benign and advanced pathology in both solid and cystic lesions found on CT. Our single center experience is compatible with current literature, and lends further credence for the use of multiple diagnostic modalities and the need for more accurate tumor markers.