Incidental Lesions Research Articles

Enchondromas of Long Bones and Other Skeletal Lesions Found Incidentally Need Critical Evaluation, But Rarely Systematic Follow-Up

Purpose: Incidental bone lesions are a challenge for the specialist, who has to give recommendations for further management. This review of our cases will assist in the decision whether the lesion can be “neglected”, needs further active follow-up or direct initiation of treatment. Patients and Methods: 153 cases of incidental bone findings were presented to our musculoskeletal tumor service for evaluation from July 2008 through June 2021. 73 of them were cartilaginous tumors and 63 of these were diagnosed as enchondroma of a long bone based on X-Ray and MRI. Results: Follow-up imaging of the enchondroma patients was available for 35 patients at 1 to 13 years (mean 4.3 y), with no change in size except for one femoral diaphyseal enchondroma with increasing diameter from age 18 to 20 years. 14 additional patients answered written contact stating that they remained asymptomatic at 2 to 12 years (mean 5.6 y). None of the patients has been reported to the Swiss Confoederation Cancer Registry to have developed malignancy. Among the 10 other cartilaginous tumors were one chondrosarcoma grade II exhibiting different imaging, 3 non-long-bone localizations (pelvis, scapula and rib), 2 Ollier-type enchondromas, and 2 osteochondromas. Incidental findings other than cartilaginous tumors were fibrous dysplasia (n = 31), non-ossifying fibroma (n = 31) and 18 other “sporadic” entities. Conclusions: Incidentally found enchondromas not exhibiting aggressive features need no systematic follow-up and patients can be “discharged” with the advice to present, if symptoms would develop. This also applies to fibrous dysplasia and the other sporadic lesions. 6 cases with other diagnoses needed specific treatment.

Lumber Spine Incidental Findings During Discopathy Evaluation Using MRI

Magnetic Resonance Imaging (MRI) of the lumbar spine with the standard protocol can be useful in the diagnosis of incidental extraspinal lesions. The study aims to find the frequency and types of incidental findings (IF)of lumbosacral spine MRI in adult patients with suspected discopathy. It was a prospective analytical study involving MRI scans performed on a group of 50 patients (22 males and 28 females) in the age range of 25-85 years old reporting clinically chronic back pain without a histo

Coincidence of Gastrointestinal Stromal Tumor and Sessile Serrated Lesion in the Appendix

Although gastrointestinal stromal tumor (GIST) is one of the most commonly seen mesenchymal tumor of gastrointestinal system, it's rare in appendix. Incidental sessile serrated lesions (SSLs) which are seen during colonoscopy are also rare in the appendix. In our patient who was operated with a diagnosis of acute appendicitis, we detected an incidental GIST and accompanying SSL. Up to date, coincidence of these 2 entities in the same case hasn't been reported in the literature. Despite its small size and absence of mitotic activity of the GIST in our case, GISTs are a special tumor group. It is also reported that SSLs located in the appendix are more aggressive than located in colorectal region. Due to the rarity and clinical courses of these entities in the appendix, we wanted to present our case with the literature.

Follow-Up Strategies in Focal Liver Lesions and Treatment Methods

Today, advances in cross-sectional imaging have led to the detection and early recognition of incidental/focal liver lesions (FCL). In approximately 17,000 cases of chest CT, incidental liver lesions were found in 6% [1]. In general, FCL consists of hepatocytes, biliary epithelium, mesenchymal tissue, connective tissue, or metastasized cells from distant sites. Most incidental lesions are benign, some may require careful management and treatment. In evaluating the lesion, the patient’s clinical history, underlying disease and age factor should be considered. FCL can be detected at a rate of 10-30% in normal healthy and chronic liver disease patients, and even in oncology patients with malignancy, FCLs can be highly benign (50-80%).

Common Skeletal Neoplasms and Nonneoplastic Lesions at 18F-FDG PET/CT.

Numerous primary and metastatic osseous lesions and incidental osseous findings are encountered at fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/CT. These lesions show varying degrees of FDG uptake. Malignancies are generally more FDG avid than are benign lesions, but many exceptions exist. Although aggressive lesions tend to be more FDG avid than nonaggressive lesions, this concept holds true particularly for lesions of the same histologic subtype. In addition, some benign osseous processes such as Paget disease have variable degrees of FDG avidity on the basis of disease metabolic activity. This creates a diagnostic dilemma for radiologists and clinicians, especially in patients with known malignancies, and can result in unnecessary diagnostic imaging or interventions for incidental osseous lesions. Evaluation of morphologic CT characteristics of osseous lesions at FDG PET/CT can be a valuable adjunct to metabolic analysis to further characterize lesions, enhance diagnostic and staging accuracy, and avoid unnecessary invasive biopsy procedures. The authors review the common primary and metastatic bone lesions at FDG PET/CT, with an emphasis on morphologic CT assessment of lesions to help narrow the differential diagnosis. Imaging manifestations of common incidental nonneoplastic bone lesions at FDG PET/CT are discussed to provide information on differentiation of these lesions from osseous neoplasms. The guidelines of the National Comprehensive Cancer Network (NCCN) for common primary osseous malignancies are also summarized. Online supplemental material is available for this article. ©RSNA, 2021.

Follow-up strategies in focal liver lesions and treatment methods

Today, advances in cross-sectional imaging have led to the detection and early recognition of incidental/focal liver lesions (FCL). In approximately 17,000 cases of chest CT, incidental liver lesions were found in 6% [1]. In general, FCL consists of hepatocytes, biliary epithelium, mesenchymal tissue, connective tissue, or metastasized cells from distant sites. Most incidental lesions are benign, some may require careful management and treatment. In evaluating the lesion, the patient’s clinical history, underlying disease and age factor should be considered. FCL can be detected at a rate of 10-30% in normal healthy and chronic liver disease patients, and even in oncology patients with malignancy, FCLs can be highly benign (50-80%).

Pancreatic Cystic Lesions and Malignancy: Assessment, Guidelines, and the Field Defect.

The widespread use of high-spatial-resolution cross-sectional imaging has led to an increase in detection of incidental pancreatic cystic lesions. These lesions are a diverse group, ranging from indolent and premalignant lesions to invasive cancers. The diagnosis of several of these lesions can be suggested on the basis of their imaging appearance, while many other lesions require follow-up imaging and/or aspiration. The smaller cystic lesions, often branch-duct intraductal papillary mucinous neoplasms, have overlapping imaging characteristics that make diagnostic assessment of the natural history and malignancy risk confusing. Expert panels have developed societal guidelines, based on a consensus, for surveillance of these lesions. However, these guidelines are often inconsistent and are constantly evolving as additional scientific data are accumulated. Identification of features associated with increased risk of malignancy is important for proper management. The concept of field defect, whereby pancreatic adenocarcinoma develops at a site different from the site of the pancreatic cyst, adds to the complexity of screening guidelines. As a result of the differences in guidelines, key stakeholders (eg, radiologists, gastroenterologists, and surgeons) must review and come to a consensus regarding which guideline, or combination of guidelines, to follow at their individual institutions. Standardized reporting and macros are helpful for ensuring the uniformity of interpretations. Radiologists play a critical role in the detection and characterization of pancreatic cystic lesions, in the follow-up recommendations for these lesions, and in the detection of associated cancer. An invited commentary by Zaheer is available online. Online supplemental material is available for this article. ©RSNA, 2021.

NIMG-61. CLINICAL UTILITY OF SOMATOSTATIN RECEPTOR PET IMAGING BIOMARKERS FOR CHARACTERIZATION OF MENINGIOMA AMONG INCIDENTAL CNS LESIONS

Abstract BACKGROUND Somatostatin receptor (SSTR) PET/CT is utilized with increasing frequency in the clinical treatment of neuroendocrine tumors. Incidental CNS lesions are commonly noted and presumed to be meningiomas, however 68Gallium (Ga-68)-DOTATATE radionuclide use lacks specificity for meningioma identification. Currently there is no established SSTR-based imaging criteria for classification of incidental CNS lesions. METHODS We retrospectively analyzed patients across clinical and radiological databases at Mayo Clinic who had undergone both Ga-68-DOTATATE PET/CT and brain MR imaging who had an incidental CNS lesion identified with clinical or radiographic prediction of meningioma. Known meningioma diagnoses prior to imaging were excluded. Imaging indication, semi-quantitative measures, and corresponding clinical history were analyzed to identify metrics impacting both the predictive and descriptive utility of SSTR-based imaging as compared to corresponding MRI prediction in incidental CNS lesions. RESULTS Among 59 patients with a CNS lesion identified on both imaging modalities, most scans were performed for a history of neuroendocrine tumor (71%). Cases with concordant lesion type prediction of meningioma between imaging modalities (N = 25) displayed a higher median SUV max and Krenning score on Ga-68-DOTATATE PET compared to cases with concordant prediction of other lesions (N=10) or discordant prediction of meningioma (N=24). Ga-68-DOTATATE was more likely to discordantly predict meningioma as compared to the corresponding patient MRI in cases with lower SUV max values. The addition of Qclear technology was significantly associated with diagnostic clarification in cases of imaging discordant tumor type prediction. Prior cranial radiation or use of a somatostatin mimetic did not affect quantitative radiographic measures in lesion characterization, and MRI-based tumor size was similar across groups. CONCLUSION The continued development of SSTR-based imaging biomarker signatures across incidental CNS lesion subtypes will further define the role of this imaging modality in the clinical diagnosis and management of presumed meningiomas.

Leydig cell tumor of the testis: an incidental finding at 18F-FDG PET/CT imaging

BackgroundLeydig cell tumors (LCTs) represent the most common form of stromal tumors. We reported the 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) findings of a patient with testicular LCT.Case presentationA 50-year-old man with a history of end-stage renal disease and renal transplantation 19 years ago. One year earlier, he started to have a chronic rejection. During the investigation to determine the cause of chronic rejection, a suspicious lesion in the graft with a collection around it was seen on ultrasound (US) images, raising the possibility of post-transplant lymphoproliferative disorder (PTLD). The patient was referred for further evaluation by whole body 18F-FDG PET/CT imaging. The image finding revealed an incidental hypermetabolic focal lesion in the right testicle—no other specific findings in the remaining parts of the body nor definitive FDG avid lymphadenopathy to suggest PTLD. Testicular US was requested and showed a well-defined right-sided heterogeneous hypoechoic intratesticular focal mass at the upper pole of the right testis with significant internal vascularity on the color Doppler imaging. The patient underwent a right radical orchidectomy, and the tumor was pathologically confirmed as an LCT.ConclusionIn our case, 18F-FDG-PET/CT has been helpful in incidentally detecting this rare testicular tumor in a patient with suspected PTLD.

An Australasian Leukemia Lymphoma Group (ALLG) Phase 2 Study to Investigate Novel Triplets to Extend Remission with Venetoclax in Elderly (INTERVENE) Acute Myeloid Leukemia

An Australasian Leukemia Lymphoma Group (ALLG) Phase 2 Study to Investigate Novel Triplets to Extend Remission with Venetoclax in Elderly (INTERVENE) Acute Myeloid Leukemia

The sternum: An important review area when reporting pre-surgical staging breast MRI studies.

Identification and assessment of extramammary findings on contrast-enhanced breast MRI scans is particularly important in the setting of newly diagnosed invasive cancer as metastatic lesions may be encountered in the liver, lungs, pleural cavity or bones. Establishing that stage IV disease is present has a profound effect on patient management. The sternum is routinely included on breast MRI studies and can be an early site for breast cancer metastases. These appear as enhancing lesions with high signal on fat-suppressed T2-weighted images. However, incidental benign lesions, notably haemangiomas, may also be encountered, and careful analysis is required to avoid false-positive results. Clinical context is important with a much lower likelihood of malignancy in the setting of routine screening of young women with no personal history of breast cancer. This pictorial essay illustrates findings encountered with lesions in the sternum and offers insights into how to interpret and manage them.

Aspiration pneumonia complicated by disseminated fungal sepsis in the setting of incidental esophagitis cystica: A rare autopsy case report with review of the literature

Abstract Introduction/Objective Esophageal retention cysts are presumed to arise from obstruction of the excretory ducts of the submucosal glands of the esophagus. Since the first description by Kuhne in 1899, different terminologies have been used to denote these lesions including retention cysts, mucocele, esophagitis cystica, and cyst of esophageal submucosal gland duct. Esophageal retention cysts are generally benign, asymptomatic and discovered incidentally. However, a few studies have reported symptomatic dysphagia and to date, only one autopsy case report described esophageal retention cysts contributing to aspiration pneumonia and cause of death. Methods/Case Report We present a case of aspiration pneumonia, associated with both reduced oropharyngeal tone secondary to alcohol consumption and esophageal dysphagia due to esophagitis cystica in a 69 year old female with alcohol use disorder complicated by alcoholic liver disease. The patient was found unresponsive at home with bloody oral secretions and evidence of head trauma. On autopsy all lung lobes demonstrated that large and small airways and alveoli were filled with vegetable matter, associated with prominent bacterial and fungal forms. EVG stain demonstrated vascular disruption with red blood cell extravasation, next to a focus of aspiration pneumonia. This explained the patient’s “bloody oral secretions”, originating from the respiratory tract. Demonstration of fungal hyphae in sections from lungs as well as necrotic colon was consistent with disseminated fungal sepsis. While sections from esophagus showed no varices which could explain the patient’s “bloody oral secretions” in the setting of alcoholic liver disease, there were numerous dilated esophageal submucosal cysts. Cysts were lined by a single to double layer of cuboidal epithelium with eosinophilic cytoplasm and basally-located, bland-appearing nuclei. Conclusion In summary, we present a rare case of esophageal retention cyst associated aspiration pneumonia complicated by pulmonary hemorrhage, adding to the growing body of knowledge regarding fatal complications of these usually incidental lesions.

Clinical Management of Pancreatic Premalignant Lesions

Clinical Management of Pancreatic Premalignant Lesions

HEART FAILURE AS INITIAL PRESENTATION OF A DEVIOUS METASTATIC CARCINOID DISEASE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Common presentations of carcinoid syndrome include flushing, palpitations, secretory diarrhea, bronchospasm and hypotension. In 20% of patients, symptoms may present initially with progressive exertional dyspnea indicating possible carcinoid heart disease (CHD). CASE PRESENTATION: A 74 y/o AA F with history T2DM, HTN, dyslipidemia, COPD, asthma presented with progressive exertional dyspnea for 6 month and 1 month history of diarrhea. Her physical exam was pertinent for T 36.2°C, BP 136/86, HR/80, RR/18 saturating 95%, loud blowing holosystolic murmur, bilateral LE pitting edema and abdominal ascites. Laboratory were significant for Na 147 mmol/L, K 2.9 mmol/L, creatinine at 1.65 mg/dL, BUN at 23 mg/dL and elevated NT-proBNP 4,866 pg/mL. A TTE showed normal LV systolic function with EF of 50-55% and severe RV and atrial dilatation, severe TR and dyssynergia with a flattened septum and PA of 50-55 mmHg. She underwent RHC which showed elevated right-sided filling pressures and low CO/CI. She was admitted to the hospital and was treated with aggressive diuresis and started on dobutamine. Further work up looking for infiltrative diseases were performed including ANA w/ reflex, RF, SPEP/UPEP, and Kappa/Lambda ratio and were all normal. CT scan showed an incidental hypodense lesion in the right hepatic dome. Serum serotonin was elevated at 930 ng/mL, 24 hr for 5-HIAA at 177mg/d and chromogranin A 3,257 ng/mL. She was started on octreotide and FNA of the right liver lesion was positive for a low-grade/well-differentiated neuroendocrine tumor. The patient was maintained on octreotide therapy for symptomatic relief and no further management was pursued due to critical health condition. DISCUSSION: CHD has an insidious presentation. Patients may be asymptomatic until the tumor metastasizes to the liver. A high suspicion coupled with serologic and imaging tests is crucial for earlier diagnosis. The left side of the heart is usually spared because the lungs metabolize the vasoactive substances before reaching the left-sided heart valves. Rarely, when the disease is found on the left side of the heart usually a right-to-left shunt is present. Typical TTE findings show a pattern of RV volume overload with enlarged RV and TV leaflet thickening. CONCLUSIONS: Early detection of carcinoid heart disease can improve prognosis and symptoms in patients with heart valve involvement. Treatment is aimed for symptomatic relief with somatostatin-analogs, telotristat therapy and temporary diuretic therapy with definitive surgical valve replacement. REFERENCE #1: Ram P et al, Carcinoid Heart Disease: Review of Current Knowledge. Tex Heart Inst J. 2019 Feb; 46(1): 21–27. REFERENCE #2: Fox DJ and Khattar RS. Carcinoid heart disease: presentation, diagnosis, and management. Heart. 2004 Oct; 90(10): 1224–1228. REFERENCE #3: Agha AM, Lopez-Mattei J, Donisan T, et alMultimodality imaging in carcinoid heart diseaseOpen Heart 2019;6:e001060. doi: 10.1136/openhrt-2019-001060 DISCLOSURES: No relevant relationships by Katherine Orengo Gomez, source=Web Response

Opportunistic Detection for Pancreatic Cystic Lesions During Chest Multidetector CT Scans for Lung Cancer Screening

PurposeThe purpose of this study was to analyze the prevalence of and risk factors for incidental pancreatic cystic lesions (PCLs) in the Chinese general population. Furthermore, the association between baseline imaging findings and PCL progression was also investigated.Patients and MethodsA total of 9826 individuals who underwent computed tomography (CT) examinations for lung cancer screening between January 1, 2018 and January 1, 2019 were included in this study. The participants’ CT imaging findings and biochemical biomarker levels were reviewed and analyzed. PCLs detected during the screening were followed up for 12 months. Associations between imaging findings and clinical factors with PCL progression were explored.ResultsPCLs were observed in 172 of the 9826 participants. The crude prevalence of PCLs in total population was 1.75%. In subjects aged >60 years, the prevalence of PCLs was 3.2% (102/3151). The occurrence of PCLs was significantly increased with an increase of age in both men and women (p < 0.001). High-risk PCLsL commonly located in pancreatic head showed extrapancreatic growth, and had high urea levels (p = 0.005, p = 0.015, p = 0.002, respectively) compared with low-risk PCLs. Location in the pancreatic head (odds ratio (OR) = 6.286, 95% confidence interval (CI): 1.842–21.452) and extrapancreatic growth (OR = 4.049, 95% CI: 1.235–13.333) were risk factors for PCL progression.ConclusionPCLs are not uncommon in the Chinese general population. Location in the pancreatic head and extrapancreatic growth are the independent predictors of high-risk of PCLs and PCL progression.

S1881 Colonic Intussusception From a Necrotic Giant Lipoma

Introduction: Lipomas are the most common benign subepithelial lesions (SEL) of the colon. They usually originate in the submucosa, however, could rarely be found within muscularis propria or subserosa. Although usually asymptomatic, lipomas can become symptomatic depending on their size and/or location. Herein we present a case of colonic intussusception secondary to a necrotic giant lipoma. Case description/methods: Patient is a 58 year old woman with past medical history of uncontrolled hypertension resulting in two cerebrovascular accidents without residual deficits (currently on clopidogrel) and uncontrolled insulin dependent diabetes type 2 with nephropathy resulting in stage 5 chronic kidney disease leading to iron deficiency anemia (IDA) who presented to ambulatory surgery unit for colonoscopy for further evaluation of IDA. Colonoscopy revealed a 5 cm nearly obstructing ulcerated and necrotic SEL in distal transverse colon. Procedure was complicated by transient desaturation and patient underwent post-procedural computerized tomography (CT) scan to rule aspiration pneumonia as patient was found to have a pieces of ginseng root within the oral cavity. CT scan revealed a 4.8 cm predominantly fatty mass-like lesion at splenic flexure with edematous fat and mild circumferential thickening of wall of proximal descending colon possibly suggesting colocolic intussusception without evidence of bowel obstruction. The patient was admitted to surgical service and taken to the operating room for laparoscopic left hemicolectomy. Pathology revealed a partially necrotic submucosal lipoma with acute inflammation, fat necrosis, ulceration and granulation tissue. Discussion: Colonic lipoma leading to intussusception is a rare complication of otherwise benign SEL. They are typically asymptomatic but can present with obstruction, bleeding, intussusception, and/or abdominal pain. CT scan is the preferred imaging modality for diagnosing aforementioned complications. The differential diagnosis for incidental lesions identified on imaging includes malignancy, large pedunculated polyps or liposarcomas. Management for symptomatic colonic lipomas can be either endoscopic or surgical. Size, location and presenting symptoms are the determining factors for deciding on type of management. Endoscopic ligation (“Loop-And-Let-Go”) technique was contemplated, however, due to finding of intussusception and the fact that patient had to resume clopidogrel, a decision was made to proceed with surgical resection.Figure 1.: A. Image from CT scan revealing a mass in the colon B. Imaging from colonoscopy depicting large lesion nearly obstructing with intussusception C. Microscopic Appearance: Necrotic mucosa and fat globules with foamy macrophages consistent with necrotic lipoma.

Birt-Hogg-Dubé Syndrome and Hereditary Leiomyomatosis and Renal Cell Carcinoma Syndrome: An Effective Multidisciplinary Approach to Hereditary Renal Cancer Predisposing Syndromes.

AimWe aimed to describe and analyse clinical features, characteristics, and adherence to surveillance guidelines in an Australian Birt-Hogg-Dubé syndrome (BHD) and hereditary leiomyomatosis and renal cell cancer (HLRCC) cohort.MethodsAll identified patients with a diagnosis of BHD or HLRCC at RBWH 01/01/2014-01/09/2019 were included (HREC/17/QRBW/276). All patients were initially assessed and counselled by a clinical geneticist and then referred to an adult nephrologist. Baseline and incidental clinical variables were extracted and analysed.ResultsFifty-seven patients were identified (28 BHD, 29 HLRCC) with a median age of 47 years. The median and cumulative follow-up were 1 and 99 years, respectively. Baseline renal MRI occurred in 40/57 patients, and 33/57 had regular MRI as per the national guidelines (eviQ). Of 18/57 without baseline imaging, nine were yet to have imaging, seven were lost follow-up, and two patients had logistic difficulties. RCC was diagnosed in 11/57 patients: two of 28 with BHD were diagnosed with RCC aged 73 and 77, both prior to commencement of surveillance. Nine of 29 patients with HLRCC were diagnosed with RCC (one of 29 during surveillance at 47 years of age) and eight of 29 prior to commencement of surveillance (11–55 years). Amongst BHD patients, cutaneous fibrofolliculomas were noted in 15 patients, lung cysts were detected in seven patients, spontaneous pneumothoraces in five patients, and parotid oncocytoma in two of 28. Amongst those with HLRCC, cutaneous leiomyomas were noted in 19/29, cutaneous leiomyosarcoma diagnosed in one of 29, and uterine fibroids in 13 female patients.ConclusionEvidence-based RCC screening in BHD and HLRCC cohort is feasible and able to identify incidental renal lesions. Multidisciplinary patient management enables expedited genetic counselling, diagnosis, longitudinal screening, and RCC management. The success of this clinical model warrants consideration of undertaking longitudinal screening of BHD and HLRCC patients by nephrologists.

Pituitary incidentalomas in paediatric population: Incidence and characteristics

Objective To determine the incidence of pituitary incidentalomas in the paediatric population and among its different age subgroups as well as to identify the characteristics of these lesions. Additionally, we aim to give a perspective on the management and follow-up of these patients. Design and patients We retrospectively studied MRI of children aged 18 years or below who underwent MRI with sellar region within their field of view between January 2010 and December 2018. Measurements Pituitary lesions were considered incidental according to the definition by the Endocrine Society. We reported the size, location and signal characteristics of each lesion. Medical charts of the subjects were reviewed for age, sex, the MRI indication and the hormonal assays levels. Results We identified 40 pituitary lesions of which 31 were incidental lesions. The incidence of pituitary incidentaloma in our cohort was 22 per 1000 patients with female predisposition ( 64.5%) and a mean age of 11 ± 6 years. Rathke's cleft cyst was the most prevalent lesion, accounting for 67.7% followed by cystic pituitary lesions and microadenomas. The most common indications for imaging were growth disturbance (12.9%) followed by headache (9.7%). Abnormal laboratory workup was present in 13% of the subjects. Incidental lesions were more common in the older age groups compared to young children. Conclusion Incidental pituitary lesions in the paediatric population are relatively infrequent and increases with age. Rathke's cleft cyst is the most common incidentally encountered pituitary lesion followed by cystic pituitary lesions and microadenomas.

Rate of Incidental Pathological Lesions ın Reduction Mammoplasty Specimens and Incidence of Invasive Breast Carcinoma Following Breast Reduction Operation.

Reduction mammoplasty (RM) is one of the most frequently performed surgical procedures. The incidental determination of significant pathologic lesions (SPL), that is precursor and malignant lesions, in RM specimens is rare. The aim of this study was to determine the frequency of SPL in RM specimens, to evaluate the relationship between SPL and clinicopathological factors, and to examine the incidence of invasive breast carcinoma forming in the remaining breast tissue during the postoperative follow-up period developing in patients after RM operation. This retrospective study included 874 females who underwent RM operation between January 2012 and January 2021. Demographic, clinicopathological findings, and preoperative radiological findings were recorded. The patients were followed up after the RM operation in respect of the first occurrence of breast cancer. Invasive carcinoma was determined in 0.2% and SPL in 3.5% in RM. The probability of SPL determination was greater in patients aged ≥ 40 years and with ≥ 4 paraffin blocks (p=0.038, p=0.01, respectively). No statistically significant difference was found between patients with and without SPL in respect of radiological findings (p=0.35). The mean postoperative follow-up period was 53.6 months, and invasive carcinoma was diagnosed during follow-up in 0.2% of all patients (6.9% of the patients with SPL). Age over 40 years and an increased number of sampled blocks were found to be factors increasing the possibility of the determination of precursor and malignant lesions in RM specimens. RM could decrease the risk of the development of breast cancer. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictors of malignancy in incidental adnexal lesions identified on CT in patients with prior non-ovarian cancer.

To identify imaging features in incidental adnexal lesions which are associated with malignancy on portal venous phase contrast-enhanced CT in patients with known non-ovarian cancer. This IRB-approved, HIPAA-compliant retrospective study was performed at a tertiary cancer center. Portal venous phase contrast-enhanced CT from January 2010 to December 2015 was reviewed to identify women with non-ovarian malignancy and incidental adnexal lesion, with mean 18months (range 1-80months) to definitive diagnosis or last imaging follow-up. Imaging features of adnexal lesions were recorded (size, laterality, shape, attenuation, and composition) and correlated with outcome (benign or malignant) using univariate and multivariate logistic regression analysis. A point-based system was used to predict likelihood of malignancy. Of 276 women (mean age 45years), 216 (78.3%) had benign lesions, 58 (21.0%) ovarian metastasis, and 2 (0.7%) had primary ovarian malignancy. On logistic regression model, lesion size > 5cm (p-value, OR, 95% CI 0.01, 9.11, 1.70-48.87), bilaterality (< 0.0001, 28.34, 7.46-107.67), irregular shape (0.01, 12.31, 1.61-94.05), higher-than-simple-fluid attenuation (< 0.0001, 28.27, 5.65-141.59), and heterogeneous composition (0.0017, 10.75, 2.45-47.23) were associated with malignant outcome (AUC 0.97). A point-based system incorporating these five features (possible 0-5 points) had AUC of 0.97. Rate of malignancy was 0% (0/147) if none of the features of malignancy were present, 12.7% (8/63) if one feature was present, 51.7% (15/29) if two features were present, and 100% (37/37) if three or more features present. Risk of malignancy of incidental adnexal lesions in women with prior non-ovarian cancer can be estimated based on lesion features seen on portal venous phase contrast-enhanced CT.