Frequent Incidental Finding Research Articles

Incidental non-infectious masses on cardiac implantable electronic device leads

Abstract Introduction Incidentally detected masses on the leads of cardiac implantable electronic devices (CIED) present a clinical challenge, raising suspicion of infective device endocarditis. Data on the prevalence of such findings are scarce and outdated. Purpose Our aim was to determine the prevalence and evaluate predisposing clinical factors of incidental non-infectious CIED lead masses during transoesophageal echocardiography (TOE). Methods In this retrospective single-centre study, we analysed all TOE examinations performed in patients with CIED leads between January 2010 and November 2023. Patients with suspected or confirmed infectious endocarditis were excluded from this study. Patients with and without incidental non-infectious lead masses were compared regarding clinical characteristics, anticoagulation, type of CIED, and indication for TOE. Results In total, 120 patients with CIED were included. Twenty-five patients (20,8%) presented with non-infectious CIED lead masses. Laboratory findings and cardiovascular risk factors, such as arterial hypertension, dyslipidaemia, diabetes mellitus or chronic kidney disease did not differ significantly between both groups. Moreover, no association was observed between the incidence of CIED lead masses and the type of CIED implanted. Of notice, patients without therapeutic anticoagulation had significantly higher prevalence of CIED lead masses (OR 2.59, 95% CI: 1.04-6.46.; p=0.02), whereas the distribution of CHA2DS2-VASc scores did not differ significantly between both groups. Conclusion Non-infectious CIED lead masses in TOE is a frequent incidental finding. The absence of the oral anticoagulation seems to be the only clinical risk factor for such finding in our study, suggesting possible thrombogenic etiology. The high prevalence of incidental non-infectious lead masses should be kept in mind in order to avoid overdiagnosis of CIED infection and unnecessary lead extraction.

Hereditary and clinical insights into paraganglioma and pheochromocytoma.

Approximately 30-40% of paragangliomas (PGLs) and pheochromocytomas (PCCs) harbor an underlying hereditary cause. Early identification of at-risk individuals is imperative given the early onset, aggressiveness of tumors, and other tumor/cancer risks associated with hereditary PGLs/PCCs. This study analyzes the clinical presentations and genetic histories of patients with PGL/PCC and/or hereditary risk to contribute to the expanding knowledge in this rare population. A retrospective chart review identified two cohorts of patients seen in cancer genetics clinics at an academic medical center and a safety-net hospital between August 2016 and December 2022. Cohort 1 consisted of patients with likely pathogenic variants (LPVs)/pathogenic variants (PVs) in hereditary PGL/PCC predisposition genes. Cohort 2 consisted of patients with a personal history of a PGL/PCC. Demographics, personal/family history, and genetic testing outcomes were analyzed. A total of 560 patients met the study criteria (Cohort 1, n = 364; Cohort 2, n = 269). In Cohort 1, 77 (21.1%) patients had an incidental LPV/PV in a PGL/PCC gene. Nearly half (n = 36, 46.8%) were in SDHx genes, with a majority in SDHA (n = 21). In Cohort 2, 86 patients tested positive for 87 LPV/PV in a hereditary cancer predisposition gene. The SDHx genes were most likely to have an LPV/PV identified (SDHB n = 24, SDHD n = 23). Multigene panels identify patients at risk for hereditary PGL/PCC, many of whom are incidentally found. While SDHA LPV/PVs were the most frequent incidental finding, they were less common in patients with PGL/PCC, indicating the need for longitudinal studies to better understand the prevalence and penetrance of these tumors.

Review of High-Resolution Computed Tomography Chest Incidental Findings in COVID and Post-COVID Era in PIMS Hospital Islamabad

Objective: To scrutinize the frequency of alternative pulmonary infectious diseases, and incidental findings ofthe High resolution CT scan chest in COVID-19 screening trials during peak and late COVID era.Study Design: A cross-sectional study.Place and Duration of Study: The study was carried out at the Department of Radiology, Pakistan Institute ofMedical Sciences (PIMS), Islamabad, Pakistan from June 2021 to June 2022.Methods: High-resolution computed tomography (HRCT) scan chest reports of 191 patients were analyzedfrom the Peak COVID period from May 2020 to May 2021 and 191 reports of patients in the late COVID periodfrom June 2021 to June 2022. Reports were evaluated for any alternative disease process or incidental findings,further classified according to their clinical significance.Results: Incidental findings were seen in 60% of scans in the Peak period of SARS-CoV-2 infection and 75% in the late COVID era. The mean age group of patients in the peak period was 50.76 years and in the late COVID period was 56.65 years, with significant male predominance (76%) in the peak period. Around 30.5% and 56.7% of “major" incidental findings in each peak and late COVID period were recorded, respectively, with Pulmonarynodule being the most frequent incidental finding in the peak period and Tuberculosis often repeatedlyencountered incidental finding in the late COVID period.Conclusion: Incidental findings appear in more than half of the High-resolution CT chest scans in suspectedCOVID-19 patients, with a substantial number requiring further workup. How to cite this: Shahid S, Isani A, Abbasi HW, Rizvi A, Mubarik HH. Review of High-Resolution Computed Tomography Chest Incidental Findings in COVID and Past COVID Era. Life and Science. 2024; 5(2): 237-243. doi: http://doi.org/10.37185/LnS.1.1.417

Tumor-Like Distal Femoral Cortical Irregularities of the Knee in Adolescent Competitive Alpine Skiers: Longitudinal Assessment Over 48 Months

Background: Tumor-like distal femoral cortical irregularities (DFCIs) are a frequent incidental finding on knee magnetic resonance imaging (MRI) and are common in young competitive athletes. Purpose: To assess and compare the morphology and prevalence of DFCIs in competitive alpine skiers over 48 months during adolescence. Study Design: Case series; Level of evidence, 4. Methods: Adolescent competitive alpine skiers were prospectively recruited in 2018 and received bilateral 3-T MRI of the knee at baseline and after 48 months. All MRIs were evaluated for the presence and location of DFCIs, which were marked at 1 of 3 anatomic positions: (1) the femoral attachment of the medial head of the gastrocnemius muscle, (2) the lateral head of the gastrocnemius muscle, or (3) the attachment of the adductor magnus aponeurosis. The size of the DFCI was measured by 2 radiologists independently. The measurements were compared using the Wilcoxon signed-rank test, the interclass correlation coefficient (ICC), and Cohen Kappa. Results: A total of 63 athletes (mean age at follow-up, 19.6 ± 1.2 years; n = 25 female) were included in the study. At baseline, DFCIs were detected in 84 out of 126 knees (67%). At the 48-month follow-up, DFCIs were found in 88 out of 126 knees (70%), with multiple DFCIs in 3 knees and no significant difference between male and female patients (n = 24 male, n = 19 female; P = .71). No significant increase was detected for the number (P = .21) and size of the DFCIs between the baseline and the 48-month follow-up (mean size: baseline, 3.7 ± 0.8 mm; 48-month follow-up: 3.6 ± 0.9 mm; P = .66). The interrater agreement for the mean size measurements of DFCIs was good to excellent (ICC 0.88). Conclusion: DFCIs remain a frequent finding on knee MRI in competitive alpine skiers after skeletal maturation and do not disappear during adolescence. The DFCI size was constant in athletes aged between 15 and 19 years. Moreover, DFCIs should not be mistaken for a pathologic finding.

Beyond pulmonary embolism: Alternative diagnosis and incidental findings on CT pulmonary angiography in sickle cell disease.

Sickle cell disease (SCD) is a genetic hematological disorder associated with severe complications, such as vaso-occlusive crises, acute chest syndrome (ACS), and an increased risk of thromboembolic events, including pulmonary embolism (PE). The diagnosis of PE in SCD patients presents challenges due to the overlapping symptoms with other pulmonary conditions. Our previous study revealed that nearly 96% of computed tomography pulmonary angiography (CTPA) scans in SCD patients were negative for PE, highlighting a gap in understanding the significance of CTPA findings when PE is absent. In this retrospective follow-up study conducted at the Salmaniya Medical Complex in Bahrain, we examined SCD patients with HbSS genotypes who underwent CTPA from January 1, 2018, to December 31, 2021, for suspected PE, but the results were negative. The aim of this study was to identify alternative diagnoses and incidental findings from CTPA scans. Experienced radiologists reviewed the CTPA images and reports to assess potential alternative diagnoses and incidental findings, incorporating an additional analysis of chest X-rays to evaluate the diagnostic value of CTPA. Incidental findings were classified based on their location and clinical significance. Among the 230 evaluated SCD patients (average age 39.7 years; 53% male) who were CTPA negative for PE, 142 (61.7%) had identifiable alternative diagnoses, primarily pneumonia (49.1%). Notably, 88.0% of these alternative diagnoses had been previously suggested by chest radiographs. Furthermore, incidental findings were noted in 164 (71.3%) patients, with 11.0% deemed clinically significant, necessitating immediate action, and 87.8% considered potentially significant, requiring further assessment. Notable incidental findings included thoracic abnormalities such as cardiomegaly (12.2%) and an enlarged pulmonary artery (11.3%), as well as upper abdominal pathologies such as hepatomegaly (19.6%), splenomegaly (20.9%), and gallstones (10.4%). This study underscores the limited additional diagnostic yield of CTPA for identifying alternative diagnoses to PE in SCD patients, with the majority of diagnoses, such as pneumonia, already suggested by chest radiographs. The frequent incidental findings, most of which necessitate further evaluation, highlight the need for a cautious and tailored approach to using CTPA in the SCD population.

COVID-19-associated cerebral microbleeds in the general population.

Cerebral microbleeds are frequent incidental findings on brain MRI and have previously been shown to occur in Coronavirus Disease 2019 (COVID-19) cohorts of critically ill patients. We aimed to determine the risk of having microbleeds on medically indicated brain MRI and compare non-hospitalized COVID-19-infected patients with non-infected controls. In this retrospective case-control study, we included patients over 18 years of age, having an MRI with a susceptibility-weighted sequence, between 1 January 2019 and 1 July 2021. Cases were identified based on a positive reverse transcriptase polymerase chain reaction test for SARS-CoV-2 and matched with three non-exposed controls, based on age, sex, body mass index and comorbidities. The number of cerebral microbleeds on each scan was determined using artificial intelligence. We included 73 cases and 219 matched non-exposed controls. COVID-19 was associated with significantly greater odds of having cerebral microbleeds on MRI [odds ratio 2.66 (1.23-5.76, 95% confidence interval)], increasingly so when patients with dementia and hospitalized patients were excluded. Our findings indicate that cerebral microbleeds may be associated with COVID-19 infections. This finding may add to the pathophysiological considerations of cerebral microbleeds and help explain cases of incidental cerebral microbleeds in patients with previous COVID-19.

Association of covert brain infarct phenotype with stroke recurrence in first-ever manifest ischemic stroke according to etiology.

Covert brain infarcts (CBI) are frequent incidental findings on MRI and associated with future stroke risk in patients without a history of clinically evident cerebrovascular events. However, the prognostic value of CBI in first-ever ischemic stroke patients is unclear and previous studies did not report on different etiological stroke subtypes. We aimed to test CBI phenotypes and their association with stroke recurrence in first-ever ischemic stroke patients according to stroke etiology. This study is a pooled data analysis of two prospectively collected cohorts of consecutive first-ever ischemic stroke patients admitted to the comprehensive stroke centers of Bern (Switzerland) and Graz (Austria). CBI phenotypes were identified on brain MRI within 72 h after admission. All patients underwent a routine follow-up (median: 12 months) to identify stroke recurrence. Of 1577 consecutive ischemic stroke patients (median age: 71 years), 691 patients showed CBI on brain MRI (44%) and 88 patients had a recurrent ischemic stroke (6%). Baseline CBI were associated with stroke recurrence in multivariable analysis (HR 1.9, 95% CI 1.1-3.3). CBI phenotypes with the highest risk for stroke recurrence were cavitatory CBI in small vessel disease (SVD)-related stroke (HR 7.1, 95% CI 1.6-12.6) and cortical CBI in patients with atrial fibrillation (HR 3.0, 95% CI 1.1-8.1). This study reports a ≈ 2-fold increased risk for stroke recurrence in first-ever ischemic stroke patients with CBI. The risk of recurrent stroke was highest in patients with cavitatory CBI in SVD-related stroke and cortical CBI in patients with atrial fibrillation.Subject terms: Covert brain infarcts, stroke.

Deep Learning to Detect Pancreatic Cystic Lesions on Abdominal Computed Tomography Scans: Development and Validation Study.

Pancreatic cystic lesions (PCLs) are frequent and underreported incidental findings on computed tomography (CT) scans and can evolve to pancreatic cancer-the most lethal cancer, with less than 5 months of life expectancy. The aim of this study was to develop and validate an artificial deep neural network (attention gate U-Net, also named "AGNet") for automated detection of PCLs. This kind of technology can help radiologists to cope with an increasing demand of cross-sectional imaging tests and increase the number of PCLs incidentally detected, thus increasing the early detection of pancreatic cancer. We adapted and evaluated an algorithm based on an attention gate U-Net architecture for automated detection of PCL on CTs. A total of 335 abdominal CTs with PCLs and control cases were manually segmented in 3D by 2 radiologists with over 10 years of experience in consensus with a board-certified radiologist specialized in abdominal radiology. This information was used to train a neural network for segmentation followed by a postprocessing pipeline that filtered the results of the network and applied some physical constraints, such as the expected position of the pancreas, to minimize the number of false positives. Of 335 studies included in this study, 297 had a PCL, including serous cystadenoma, intraductal pseudopapillary mucinous neoplasia, mucinous cystic neoplasm, and pseudocysts . The Shannon Index of the chosen data set was 0.991 with an evenness of 0.902. The mean sensitivity obtained in the detection of these lesions was 93.1% (SD 0.1%), and the specificity was 81.8% (SD 0.1%). This study shows a good performance of an automated artificial deep neural network in the detection of PCL on both noncontrast- and contrast-enhanced abdominal CT scans.

A case of urgent neurosurgical treatment of intracerebral hemorrhage due to rupture of a cavernous hemangioma because of the progressive clinical deterioration

Cavernous hemangiomas (CH) are benign vascular lesions of the central nervous system, which are thin-walled vascular sinusoids without smooth muscle with hemosiderin deposits. CH is the second (after aneurysms) most frequent incidental vascular finding on magnetic resonance imaging of the brain, with a prevalence of 1 case per 625. CHs can be asymptomatic, cause seizures, intracranial hemorrhage due to rupture, or be the cause of focal neurological deficits without signs of previous hemorrhage. Intracranial hemorrhages of varying degrees of severity can occur both in supratentorial and infratentorial CH. The annual frequency of bleeding in CH is 0.3‒2.4 %, but they are rarely fatal, especially with supratentorial localization. Indications and timing of surgical intervention in CH are the question of debate.The presented case demonstrates the possibility of intracerebral hematoma formation as a result of the rupture of one of the multiple supratentorial CHs, which led to clinical deterioration and required urgent neurosurgical treatment. Although such clinical course is rare, it should be taken into account when planning treatment and informing patients with CH. A 62-year-old woman fell ill suddenly. The disease manifested with the onset of headache and left-sided hemiplegia At the local hospital, magnetic resonance imaging of the brain was performed and an intracranial hemorrhage in the right subcortical area due to rupture of the CH, and another asymptomatic CH in the triangle of the left lateral ventricle, ware founded. The patient initially received conservative therapy, but 48 hours after the onset of the disease, the patient's consciousness declined to 10 GCS points, and she was urgently transferred to the SO «Scientific-Practical Center of Endovascular Neuroradiology NAMS of Ukraine», and an emergency operation was performed for removal of intracerebral hematoma and CH. Histological examination confirmed the diagnosis «cavernous hemangioma». The postoperative course was uneventful, and the neurological deficit regressed to mild left-sided hemiparesis. Indications and timing of surgical intervention in CH remain uncertain.

Endoscopic Technologies for Peripheral Pulmonary Lesions: From Diagnosis to Therapy

Peripheral pulmonary lesions (PPLs) are frequent incidental findings in subjects when performing chest radiographs or chest computed tomography (CT) scans. When a PPL is identified, it is necessary to proceed with a risk stratification based on the patient profile and the characteristics found on chest CT. In order to proceed with a diagnostic procedure, the first-line examination is often a bronchoscopy with tissue sampling. Many guidance technologies have recently been developed to facilitate PPLs sampling. Through bronchoscopy, it is currently possible to ascertain the PPL's benign or malignant nature, delaying the therapy's second phase with radical, supportive, or palliative intent. In this review, we describe all the new tools available: from the innovation of bronchoscopic instrumentation (e.g., ultrathin bronchoscopy and robotic bronchoscopy) to the advances in navigation technology (e.g., radial-probe endobronchial ultrasound, virtual navigation, electromagnetic navigation, shape-sensing navigation, cone-beam computed tomography). In addition, we summarize all the PPLs ablation techniques currently under experimentation. Interventional pulmonology may be a discipline aiming at adopting increasingly innovative and disruptive technologies.

Common incidental findings on sacroiliac joint MRI: Added value of MRI-based synthetic CT

PurposeTo determine the prevalence of incidental findings on sacroiliac joint MRI and to determine the added value of MRI-based synthetic CT in the detection and evaluation of these incidental findings. MethodIn this retrospective study 210 patients clinically suspected of spondyloarthritis who underwent MRI of the sacroiliac joint with synthetic CT sequence were included. The images were reviewed by two radiologists in consensus for the prevalence of sacroiliitis, incidental findings, and the ability of synthetic CT and the conventional MRI to detect and diagnose these findings. ResultsIn 44.7% of patients sacroiliitis was present. In 89.0% of patients MRI showed at least one incidental finding other than sacroiliitis. Degeneration of the sacroiliac joint was the most prevalent finding (140 patients, 66.6%). The most frequent incidental findings outside the sacroiliac joint were facet joint degeneration (29.0%), disc degeneration (25.2%), enostosis (19.5%) and lumbosacral transitional vertebrae (14.3%). A total of 788 lesions was recorded and synthetic CT was found to be problem solving or necessary for diagnosis in 543 (68.9%) of these lesions. 42.1% of lesions were not visible on conventional MRI (T1 TSE and STIR), most often degenerative osteophytes in the sacroiliac joint or lower lumbar spine. ConclusionIncidental findings are seen more frequently on sacroiliac joint MRI than sacroiliitis, which is relevant as some will have clinical significance or require treatment. Nearly half of these incidental lesions were only visible on synthetic CT, which additionally has been shown to be problem solving for diagnosis in many other cases.

Calcific Discitis Seems to be a Common Incidental Finding in Adults.

Calcific discitis seems to be a rare cause of back pain in adults. Imaging shows a calcification of the nucleus pulposus with extension through the endplates on computed tomography. This can be accompanied by bone marrow edema on magnetic resonance imaging. In a retrospective review of 150 patients, 4 cases of calcific discitis were found (2.8%). None of the patients reported about back pain. Therefore, it seems that symptomatic cases of calcific discitis are a rare occurrence in contrast to the quite frequent incidental finding of asymptomatic cases on imaging. Knowledge of the various imaging appearances of calcific discitis is necessary for radiologists, because especially in acute cases with substantial bone marrow edema, this benign entity may be confused with infectious spondylodiscitis or malignancy.

A Systematic Comparative Study on the Diagnostic Value of Transabdominal Ultrasound in Patients with Pancreatic Cystic Lesions.

Pancreatic cystic lesions are a frequent incidental finding in abdominal imaging. Despite its usually benign background, a small fraction exhibiting features suspicious for cancerous development demands continuous follow-up or surgical removal. Current guidelines advocate magnetic resonance imaging and endoscopic ultrasound to evaluate the risk of malignancy, whereas transabdominal ultrasound is perceived as subordinate imaging. The objective of this study was to analyze cyst detection rates of latest-generation ultrasound machines compared to magnetic resonance imaging, computed tomography, and endosonographic ultrasound and to determine inter-rater reliability. The results showed that large cysts facilitate their visualization by transabdominal ultrasound while detection rates are independent of the anatomical part of the pancreas in which they were sited. Changes in the pancreatic duct width, a connection to the pancreatic duct system, and the architectural characteristics of cysts are poorly recognized by transabdominal ultrasound compared to magnetic resonance imaging and endoscopic ultrasound. Computed tomography imaging is preferred over transabdominal ultrasound to detect calcifications and regional lymphadenopathy. Even if conducted by experienced investigators, transabdominal ultrasound examinations fail to agree with magnetic resonance imaging scans regarding cyst detection rates (κ = 0.093).

Pathogenesis mechanisms of endometrial polyps in women of reproductive age: a literature review

Endometrial polyp (EP) is a frequent incidental finding during hysteroscopy in asymptomatic patients. To date, the pathogenesis of EPs has not been fully disclosed, which challenges the primary and secondary prevention of EPs and their targeted therapy. It determined the focus of our work. We searched for scientific publications in Cochrane Library, ScienceDirect, PubMed (MEDLINE), eLIBRARY using the keywords "polyps", "endometrial polyps", "pathogenesis", "reproductive age", "recidive" for 20122022. Analysis of the literature data allowed us to conclude that ES pathogenesis most likely involves several mechanisms, both estrogen-mediated (hyperestrogenism, including related to impaired progesterone reception and deficiency) and non-hormonal (inflammatory, immune, genetic factors, neoangiogenesis). Hormonal and non-hormonal factors disturb normal cyclic changes of the endometrium during the menstrual cycle, alter the balance and dynamics of proliferation and apoptosis, and initiate neoangiogenesis that serves as a resolving mechanism of polyposis formation, persistence of ES, and their recurrence after surgical removal. The objective of our study was to analyze and summarize the scientific data available on the mechanisms of ES pathogenesis in women of reproductive age.

Beyond the Hip Labrum: A Pictorial Review.

Magnetic resonance arthrography and 3T magnetic resonance imaging of the hip are a technique commonly performed in young, physically active patients presenting with pain relating to the hip, with the focus on assessing for the presence of labral tears and femoroacetabular impingement. Abnormal signal within the labrum can be misleading, however, as labral tears are a frequent incidental finding and have been identified in a large proportion of the asymptomatic population. A range of extralabral conditions can cause hip-related pain in young patients, including pathology related to the bones, joints, and periarticular soft tissues. It is vital that the radiologist is aware for these pathologies and examines for them even in the presence of a confirmed labral tear. In this article, we review a range of common extralabral pathologies responsible for hip pain and highlight review areas that aid in their diagnosis.

Predictive Value of Coronary Artery Calcium in Patients Receiving Computed Tomography Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department.

Coronary artery calcium (CAC) is a frequent incidental finding on computed tomography pulmonary angiogram (CTPA) in the evaluation of pulmonary embolism (PE) in the emergency department (ED); however, its prognostic value is unclear. In this study, we interrogate the prognostic value of CAC identified on CTPA in predicting adverse outcomes in the evaluation of PE in the ED. In this retrospective cohort study, we identified 610 patients presenting to the ED in 2013 and evaluated with CTPA for suspected PE. Ordinal CAC scores were evaluated as absent (0), mild (1), moderate (2), or severe (3) in each of the 4 main coronary arteries. Composite CAC scores were subsequently compared against adverse clinical outcomes, defined as intensive care unit admission, hospital stay longer than 72 hours, or death during hospital course or at 6-month follow-up, using univariate and multivariate logistic regression analyses. Relevant exclusion criteria included a history of cardiovascular disease. In all, 365 patients met the inclusion criteria (231 women, mean age 56±16 y) with 132 patients (36%) having some degree of CAC and 16 (4%) having severe CAC. Known malignancy was present in 151 (41%) patients and composite adverse clinical outcomes were observed in 98 patients (32%). Age, presence of acute PE, malignancy, and presence of CAC were significant predictors of adverse outcomes on both univariate and multivariate analyses. CAC was not an independent predictor of short-term adverse outcomes on multivariate analysis ( P =0.06) when all patients were considered. However, when patients with known malignancy were excluded, CAC was an independent predictor of short-term adverse outcomes (odds ratio=2.5, confidence interval=1.1-5.5, P =0.03) independent of age and presence of PE. The presence of CAC on CT PA was predictive of adverse outcomes in patients without known cardiac disease presenting to the ED with suspected PE.

Antikoagulace u onkologických pacientů, nová doporučení na základě randomizovaných klinických studií

Venous thromboembolic disease (VTD) is currently the second leading cause of death in cancer patients with a prevalence of approximately 20% compared with that of 5% in the entire adult population. Cancer patients are a heterogeneous group with significant differences in the risk of VTD which is, in particular, determined by the type of tumour, its extent, location, and the presence of metastases. Some tumours represent a mean 3- to 5-fold increase in risk, while in others the risk of developing VTD is even several times higher. In comparison with non-cancer patients, those with a tumour are not only at an increased risk of an initial thromboembolic event, but also of its recurrence, regardless of ongoing anticoagulation which is associated with a higher risk of bleeding, particularly in mucosal involvement. Venous thrombosis and its treatment may interfere with the ongoing diagnosis and treatment. In cancer patients, VTD is a frequent incidental finding on imaging studies. Primary thromboprophylaxis (apixaban, rivaroxaban, LMWH) is currently recommended in selected groups of cancer patients who are either hospitalized for acute internal disease or immobilized and have an active malignancy, undergo outpatient systemic chemotherapy for a tumour with a high risk of VTD (a Khorana score of 2) or surgery and are not at high risk of bleeding. DOACs should be administered six months after the initiation of chemotherapy. If there is a risk of drug interactions or mucosal bleeding, LMWHs are recommended. At present, DOACs (apixaban, edoxaban, rivaroxaban) and LMWHs are the first-choice drugs in treating VTD. LMWHs are preferred in mucosal tumours, when there is a high risk of bleeding, in progressive malignancy, concomitant emetogenic therapy, and dyspeptic difficulties. In severe renal insufficiency (CrCl < 15 ml/min), vitamin K antagonists may be of value. Individualized treatment should take into consideration the patients general condition, prognosis, and personal preferences.

What should we do about Coronary Calcification on Thoracic CT?

Coronary artery calcification is a frequent incidental finding on thoracic computed tomography (CT) performed for non-cardiac indications. On electrocardiogram-gated cardiac CT, it is an established marker of coronary artery disease and is associated with increased risk of subsequent cardiac events. This review discusses the current evidence and guidelines regarding the reporting of coronary artery calcification on non-electrocardiogram-gated thoracic CT performed for non-cardiac indications. For patients undergoing routine thoracic CT, coronary artery calcification is associated with an increased risk of myocardial infarction and mortality. Coronary artery calcification can be accurately assessed on non-gated thoracic CT compared to gated CT. Guidelines support the reporting of coronary artery calcification on thoracic CT. However, radiologist opinions vary. The identification of coronary artery calcification on thoracic CT may identify patients with previously unknown coronary artery disease. For asymptomatic patients this may trigger an assessment of modifiable cardiovascular risk factors and guide the appropriate use of preventative medications. Future research will address whether changing management based on calcification on thoracic CT will improve outcomes and automated assessment of calcification using machine learning techniques. · Coronary artery calcification is a frequent incidental finding on thoracic CT.. · The presence and severity of coronary artery calcification is associated with cardiac outcomes and mortality.. · Reporting coronary artery calcification on thoracic CT is supported by national and international guidelines.. · Williams MC, Llewellyn O, . What Should We Do About Coronary Calcification on Thoracic CT?. Fortschr Röntgenstr 2022; 194: 833 - 840.

Extra-articular findings with FDG-PET/CT in rheumatoid arthritis patients: more harm than benefit

ObjectiveWhole-body PET with CT scanning using 18F-fluorodeoxyglucose (18F-FDG) is used occasionally in RA patients to detect arthritis. FDG-PET/CT might also detect malignancies, but the amount of incidental findings and the number of relevant malignant diseases that could be missed are currently unknown. We aimed to study the malignancy screening performance of whole-body FDG-PET/CT in longstanding RA patients with low disease activity.MethodsFDG-PET/CT scanning was done in the intervention arm of the Dose REduction Strategy of Subcutaneous TNF-inhibitors (DRESS) study, a randomized controlled trial on dose-tapering of biological DMARDs. The reference standard was clinical diagnosis of malignancy during the 3-year follow-up period of the study. Prevalence of extra-articular abnormalities, follow-up and treatments were summarized post hoc.ResultsOne hundred and twenty-one scans were carried out in 79 patients. Extra-articular abnormalities were found in 59 of 121 (49%) scans, resulting in additional diagnostic procedures in 21 of 79 (26.6%) patients. Nine patients (7.4%) were suspected of malignancy; none turned out to be malignant. Six clinical malignancies that developed during follow-up were all negative on baseline FDG-PET/CT.ConclusionWhole-body FDG-PET/CT scanning used in RA patients for imaging of arthritis results in frequent incidental extra-articular findings, whereas some who apparently had normal scans also developed malignancies.Trial registrationNetherlands Trial Register, www.trialregister.nl, NL6771.

Radiologist opinions regarding reporting incidental coronary and cardiac calcification on thoracic CT.

Objectives:Coronary and cardiac calcification are frequent incidental findings on non-gated thoracic computed tomography (CT). However, radiologist opinions and practices regarding the reporting of incidental calcification are poorly understood.Methods:UK radiologists were invited to complete this online survey, organised by the British Society of Cardiovascular Imaging (BSCI). Questions included anonymous information on subspecialty, level of training and reporting practices for incidental coronary artery, aortic valve, mitral and thoracic aorta calcification.Results:The survey was completed by 200 respondents: 10% trainees and 90% consultants. Calcification was not reported by 11% for the coronary arteries, 22% for the aortic valve, 35% for the mitral valve and 37% for the thoracic aorta. Those who did not subspecialise in cardiac imaging were less likely to report coronary artery calcification (p = 0.005), aortic valve calcification (p = 0.001) or mitral valve calcification (p = 0.008), but there was no difference in the reporting of thoracic aorta calcification. Those who did not subspecialise in cardiac imaging were also less likely to provide management recommendations for coronary artery calcification (p < 0.001) or recommend echocardiography for aortic valve calcification (p < 0.001), but there was no difference for mitral valve or thoracic aorta recommendations.Conclusion:Incidental coronary artery, valvular and aorta calcification are frequently not reported on thoracic CT and there are differences in reporting practices based on subspeciality.Advances in knowledge:On routine thoracic CT, 11% of radiologists do not report coronary artery calcification. Radiologist reporting practices vary depending on subspeciality but not level of training.