Management Of Incidental Findings Research Articles

"ERS/ESTS/ESTRO/ESR/ESTI/EFOMP statement on management of incidental findings from low dose CT screening for lung cancer." E.L. O'Dowd, I. Tietzova, E. Bartlett, et al. Eur Respir J 2023; 62: 2300533.

"ERS/ESTS/ESTRO/ESR/ESTI/EFOMP statement on management of incidental findings from low dose CT screening for lung cancer." E.L. O'Dowd, I. Tietzova, E. Bartlett, et al. Eur Respir J 2023; 62: 2300533.

Unilateral gemination: A case report

Introduction: Dental gemination is an uncommon developmental anomaly characterized by an enlarged bifid tooth crown. Case Report: This case report presents clinical and radiographic findings of gemination affecting a mandibular left lateral incisor in a 20-year-old female patient. The patient presented for a routine dental examination, which revealed an abnormal crown morphology of the mandibular left lateral incisor. There was no associated symptomology. Radiographic analysis confirmed the presence of a single root and root canal beneath the bifid tooth crown. Based on the clinical and radiographic features, a diagnosis of gemination was made. The treatment plan options were discussed with the patient, who opted not to restore the anomalous tooth. Instead, the geminated tooth will be kept under observation with regular monitoring and preventive care. Conclusion: This case provides an example of the importance of proper diagnosis of developmental dental anomalies. It also underscores the role of patient preferences in determining appropriate management of incidental findings like asymptomatic geminated teeth.

Whole-body Magnetic Resonance Imaging in the German National Cohort (NAKO): Design & Current Status

Abstract Background Whole-body magnetic resonance imaging (MRI) permits non-invasive, non-ionizing phenotyping of the human body and ideally complements the epidemiological assessment of the NAKO participants. As such, it allows for the detection of morphologic or functional predisposition, early disease stages prior to overt clinical events as well as evident pathological changes. The assessment of progression and regression of imaging phenotypes over time will provide the basis to identify and understand the relevance of imaging-based risk factor profiles for disease development. Methods Integrated in the general NAKO study program and managed by a central Imaging Core, study participants underwent whole-body imaging at five dedicated MR imaging sites. Imaging was performed on five identical 3 Tesla scanners (Magnetom Skyra, Siemens Healthineers, Erlangen, Germany) applying a one hour protocol, including sequences for the brain, the cardiovascular and musculoskeletal system as well as for the thorax and abdomen. Comprehensive measures to assure high image quality and management of incidental findings were established. Results As part of the baseline examination program, a total of 30,861 participants successfully underwent the MR imaging program. All measures of quality assurance and incidental findings management were successfully employed throughout the study period and obtained image quality and completeness of all MR sequences was excellent (>94.2% completeness). While MR imaging as part of the first re-examination is ongoing, baseline MRI data is currently accessible for scientific analyses. Conclusions The MRI-Study of the NAKO will provide a comprehensive imaging phenotypic biobank covering different organ systems with highest morphological and functional detail. MRI data analysis will gain novel insights into the natural history of disease development, the role of subclinical disease burden, and revolutionize our understanding of imaging biomarkers of risk.

Single CT Appointment for Double Lung and Colorectal Cancer Screening: Is the Time Ripe?

Annual screening of lung cancer (LC) with chest low-dose computed tomography (CT) and screening of colorectal cancer (CRC) with CT colonography every 5 years are recommended by the United States Prevention Service Task Force. We review epidemiological and pathological data on LC and CRC, and the features of screening chest low-dose CT and CT colonography comprising execution, reading, radiation exposure and harm, and the cost effectiveness of the two CT screening interventions. The possibility of combining chest low-dose CT and CT colonography examinations for double LC and CRC screening in a single CT appointment is then addressed. We demonstrate how this approach appears feasible and is already reasonable as an opportunistic screening intervention in 50–75-year-old subjects with smoking history and average CRC risk. In addition to the crucial role Computer Assisted Diagnosis systems play in decreasing the test reading times and the need to educate radiologists in screening chest LDCT and CT colonography, in view of a single CT appointment for double screening, the following uncertainties need to be solved: (1) the schedule of the screening CT; (2) the effectiveness of iterative reconstruction and deep learning algorithms affording an ultra-low-dose CT acquisition technique and (3) management of incidental findings. Resolving these issues will imply new cost-effectiveness analyses for LC screening with chest low dose CT and for CRC screening with CT colonography and, especially, for the double LC and CRC screening with a single-appointment CT.

Non-oncologic incidental uptake on FAPI PET/CT imaging.

Fibroblast-activation protein (FAP) is a serine protease classified in the dipeptidyl peptidase 4 (DPP4) family. FAP is predominantly expressed in activated fibroblasts such as the cancer-associated fibroblasts (CAFs). FAP expression in CAFs is associated with tumor progression and poor prognosis in solid cancers. Recently, radiolabeled FAP inhibitors (FAPI) has been developed, which enables positron emission tomography (PET) imaging of FAP. FAPI PET/CT can provide a higher tumor-to-background ratio (TBR) than 18F-fludeoxyglucose PET/CT in various cancers, and thus has attracted substantial attention. As studies on FAPI PET grow in number and size, incidental findings related to non-oncologic conditions have been increasingly reported. FAPI PET uptake has been reported in various conditions such as benign tumors, fibrotic, granulomatosis, scarring/wound, degenerative diseases, and inflammatory diseases.The knowledge of physiological and non-oncologic causes of FAPI uptake is indispensable for accurate FAPI PET/CT interpretation and can help appropriate management of incidental findings on FAPI PET/CT in patients referred for cancer staging indications. In this review article, we describe for each organ system (Brain, Oral mucosa, Salivary Glands, Thyroid, Lung, Myocardium, Breast, Esophagus, Stomach, Intestine, Liver, Gallbladder, Pancreas, Spleen, Kidney, , Uterus, Bone marrow, Joints, Muscle, Vessels, Lymph nodes), the patterns of physiological FAPI uptake and the main causes of non-oncological uptake reported from the literature with FAPI-02, FAPI-04 and FAPI-46. We also illustrate some examples from our institutional database at UCLA.

Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis

An incidental finding is defined as a newly discovered mass or lesion detected on imaging performed for an unrelated reason. The identification of an incidental finding may be an opportunity for the early detection of a serious medical condition, including a malignancy. However, little is known about the prevalence of incidental findings in the emergency department (ED) setting and the strategies that can be used to mitigate the risk associated with them in the ED. This study aimed to estimate the overall prevalence of incidental findings and to summarize the currently described measures to mitigate the risks associated with incidental findings. On November 22, 2020, a systematic literature search of PubMed, EMBASE, and Scopus was performed for studies that were published in peer-reviewed journals and reported the prevalence of incidental findings in computed tomography (CT) scans in patients in the ED. Patients who received CT scans that included the head, neck, chest, or abdomen/pelvis were included. The study characteristics, overall prevalence of incidental findings, prevalence of incidental findings by body region, and prespecified subgroups were extracted. The criteria used for risk stratification within individual studies were also extracted. Pooled estimates were calculated using a random-effects meta-analysis. A total of 1,385 studies were identified, and 69 studies met the inclusion criteria. The included studies represented 147,763 ED encounters or radiology reports across 16 countries, and 83% of studies were observational, cross-sectional studies. A total of 35 studies (50.7%) were in trauma patients. A large degree of heterogeneity was observed across the included studies. The overall pooled prevalence estimate for any incidental finding was 31.3% (95% confidence interval 24.4% to 39.1%). We found great variation in the methods described to mitigate the risk associated with incidental findings, including a lack of standardized risk stratification, inconsistent documentation practices, and only a small subset of studies describing prospective interventions aimed at improving the recognition and management of incidental findings from the ED. In patients in the ED receiving CT scans, incidental findings are commonly encountered across a broad range of ED chief complaints. This review highlights the existence of great heterogeneity in the definitions used to classify incidental findings. Future studies are needed to determine a clinically feasible categorization standard or terminology for commonly encountered incidental findings in the ED setting to standardize classification and documentation.

Incidental Findings in POCUS: "Chance favors the prepared mind".

Point of Care Ultrasound (POCUS) has the potential to rapidly aide in diagnostic algorithms at the bedside, however POCUS users are often faced with the dilemma of appropriate management of incidental findings [1]. Incidental findings in POCUS are defined as any indeterminate, benign, or potentially concerning finding found unexpectedly that is not related to the patient’s chief complaint [2]. Increased use of POCUS has driven the increased discovery of incidental findings, with a reported frequency between 1.6% to 26% depending on the institution, frequency of documentation, and level of experience [1,2]. While many incidental findings are benign, some are not and benefit from follow-up. This raises important concerns regarding the need for systematic, evidence-based guidelines to ensure necessary follow-up while avoiding unnecessary additional imaging, patient anxiety and increased healthcare costs [1,3].

Shining a Light also Casts a Shadow: Neuroimaging Incidental Findings in Neuromarketing Research

Rapid growth in structural and functional brain research has led to increasing ethical discussion of what to do about incidental findings within the brains of healthy neuroimaging research participants that have potential health importance, but which are beyond the original aims of the study. This dilemma has been widely debated with respect to general neuroimaging research but has attracted little attention in the context of neuromarketing studies. In this paper, I argue that neuromarketing researchers owe participants the same ethical obligations as other neuroimaging researchers. The financial resources available to neuromarketing firms and the social value of neuromarketing studies should command greater attention to the elucidation and management of incidental findings. However, this needs to be balanced against finite resources available within most public health systems.

Incidental findings associated with magnetic resonance imaging of the brachial plexus.

The identification and management of incidental findings is becoming increasingly problematic, particularly in relation to brachial plexus imaging because the prevalence is unknown. Therefore, we aimed to estimate the prevalence of incidental findings in symptomatic patients undergoing MRI of the brachial plexus. This retrospective cohort study included all children and adults who underwent MRI over a 12-year period, in a tertiary care centre in the UK. An incidental finding was any abnormality which was not a direct injury to or disease-process of the brachial plexus. An "incidentaloma" was defined by the need for further investigation or treatment. Multivariable logistic regression was used to estimate the odds ratio (OR) of an "incidentaloma". To estimate which factors were associated with the incident rate ratio (IRR) of incidental findings, multivariable Poisson regression was used. Overall, 502 scans (72%) reported incidental anomalies. Although the number of MRIs performed per annum increased by 23%, the prevalence of "incidentalomas" remained static (p = 0.766). Musculoskeletal incidental findings were the most prevalent (63%) and when identified, there were a median of 3 incidental anomalies per patient. Overall, 125 (18%) anomalies were "incidentalomas" which required further investigation or treatment. The odds of having further investigation or treatment was strongly related to the frequency of incidental findings [adjusted OR 1.16 (95% CI 1.08, 1.24)] and when a tumour was identified [adjusted OR 2.86 (95% CI 1.81, 4.53)]. The number of incidental findings recorded per scan increased when trainees co-reported with consultants [adjusted IRR 0.36 (95% CI 0.05, 0.67)] and in the presence of a tumour [adjusted IRR 0.39 (95% CI 0.28, 0.49)]. The prevalence of clinically important incidental findings on brachial plexus MRI is lower than organ-specific imaging, but still 18% of scans identified an 'incidentaloma' which required further investigation or treatment. This cohort study shows that approximately 1 in 5 symptomatic patients undergoing a brachial plexus MRI had a clinically important incidental findings, which required further investigation or treatment. This information can be used to inform patients consenting to clinical or research imaging.

The Impact of Incidental Findings Detected During Brain Imaging on Research Participants of the Rotterdam Study: An Interview Study.

This interview study investigates the short- and long-term implications of incidental findings detected through brain imaging on research participants' lives and their surroundings. For this study, nine participants of the Rotterdam Scan Study with an incidental finding were approached and interviewed. When examining research participants' narratives on the impact of the disclosure of incidental findings, the authors identified five sets of tensions with regard to motivations for and expectations of research participation, preferences regarding disclosure, short- and long-term impacts and impacts on self and others. The paper shows: (1) that the impact of incidental findings may be greater than participants at first let on; (2) incidental findings can have significant effects on participants' social environment; and (3) participants may not feel prepared for disclosure even if incidental findings have been discussed during the informed consent process. The authors call for investigators to be aware of research participants' experiences and these short- and long-term impacts when designing suitable courses of action for the detection and management of incidental findings in research settings.

Delivering low-dose CT screening for lung cancer: a pragmatic approach

Lung cancer kills an estimated 35 000 people in the UK every year. Despite the improvements in treating late-stage disease, lung cancer outcomes have changed little in the last 40...

Differences in Conceptual Understanding of the “Actionability” of Incidental Findings and the Resultant Difference in Ethical Responsibility: An Empirical Study in Japan

BackgroundThe issue of incidental findings encountered in medical researches and in clinical practices becomes controversial in recent years. In what situations should researchers and clinicians disclose incidental findings to study participants or patients? According to previous studies, the concept of “actionability” is one of most important notions in determining the management of incidental findings, however, the understanding of this concept is also inconsistent among people and the inconsistency can affect the management of incidental findings. That is why we surveyed the difference in conceptual understanding of “actionability” for incidental findings with genomic researches in Japan. Methods: We conducted focus groups with individuals conducting genomics research or genetic testing at the National Centers in Japan, all of which are expected to contribute significantly to genomics research and subsequent clinical practice in Japan. Results: As far as our survey and analysis, there exists crucial discrepancy; one might consider that an “actionable” finding should be one that would be useful in treatment or prevention; another might consider if the finding could lead to a definitive diagnosis, it should be considered “actionable,” regardless of the treatment potential of the disease; moreover another might considered that a finding that would lead to the opportunity to participate in a clinical trial was “actionable”. Conclusion: Based on the present study which we conducted, we have examined thus far the concept of “actionability”, which may influence the management of incidental findings. The present study revealed discrepancies in the understanding of this concept among the National Centers in Japan, which all bear similar expectations from society. And this difference in “actionability” would lead to variations in management of incidental findings.

Incidental Findings Coordinator: A New Role for Advanced Practice Registered Nurses

Incidental findings are commonly found during routine, diagnostic imaging. Prevalence varies widely; but research shows that follow-up of incidental findings is poor. Further, incidental findings that are likely to change clinical outcomes are not necessarily more likely to receive follow-up care. It has also been shown that both lack of management and over-management can lead to poor patient outcomes. Innovative solutions are needed to ensure timely follow-up care and appropriate management of incidental findings. One possible solution to address low clinical follow-up care of incidental findings is to employ advanced practice registered nurses (APRN) as incidental findings coordinators. The coordinator would have the potential to improve communication and defragment care. The aims of this article are to discuss the problem of low follow-up care of clinically relevant incidental findings and to present a recommendation for a new role for APRNs to address the problem. In this article the authors will review the literature, describe the search for answers, present a new role for the APRN as an incidental findings coordinator, and conclude that the APRN incidental findings coordinator role has the potential to solve many problems encountered in current practice.

Big data phenotyping in rare diseases: some ethical issues

Big data phenotyping in rare diseases: some ethical issues

The Use of Ultrasound in Educational Settings: What Should We Consider When Implementing this Technique for Visualisation of Anatomical Structures?

Ultrasound is a well-established medical imaging technique with pioneering work conducted by Professor Ian Donald and his colleagues at the University of Glasgow, from the mid-1950s onwards, in terms of introducing it as a diagnostic tool in the field of obstetrics and gynaecology. Since then, ultrasound has been extensively used in clinical and research settings. There are few imaging techniques that have undergone such a fast and thriving evolution since their development. Nowadays, diagnostic ultrasound benefits from two-dimensional (2D), three-dimensional (3D), four-dimensional (4D), and a variety of Doppler modes with technologically advanced transducers (probes) producing images of high anatomical fidelity. In the future, there may even be a place for ultrasound in molecular imaging allowing for visualisationat the microscale. Ultrasound is characterised by real-time non-invasive scanning, relative ease of administration, and lack of ionising radiation. All of these features, make ultrasound an appealing option in educational settings for learning topographic anatomy and potentially enhancing future clinical practice for vocational learners. Sophisticated, but relatively inexpensive, portable handheld devices have also contributed to point-of-care ultrasound (POCUS) becoming the norm for bedside and pre-hospital scanning. It has been argued that ultrasound will become the next stethoscope for healthcare professionals. For this to become a reality, however, training is required on increasing familiarity with knobology, correct use of the machine and transducers, and accurate interpretation of anatomy followed by identification of pathologies. The above require incorporation of ultrasound teaching in undergraduate curricula, outwith the realm of opportunistic bedside learning, accompanied by consideration of ethical topics such as the management of incidental findings and careful evaluation of its pedagogical impact cross-sectionally and longitudinally.

Actionable vascular and other incidental findings on CTA in patients undergoing acute stroke intervention.

Providing a fast and accurate diagnosis of acute large-vessel occlusion on computed tomography angiograms (CTAs) is essential for timely intervention and good stroke outcomes. However, the detection and appropriate management of incidental findings are also important parts of any clinical radiology practice and can greatly affect patient care. The intricate anatomy covered by CTAs of the head and neck coupled with the time pressures of acute stroke diagnosis creates an environment in which unrelated, important findings can potentially be missed. The purpose of our study was to document clinically actionable incidental findings on CTA in 225 patients undergoing acute stroke intervention. After institutional review board approval, a retrospective six-year review of CTAs of the head and neck in patients undergoing acute stroke intervention was performed for actionable incidental vascular and nonvascular findings. A total of 225 patients undergoing acute stroke intervention with documented intracranial large-vessel occlusion on CTAs were consecutively enrolled in the study. Incidental vascular findings were identified in 17 of 225 patients (7.5%, 95% confidence interval 5% to 12%). Previously unreported aneurysms ranging from 2 mm to 10 mm in size represented 18 of 19 vascular findings in these patients. Incidental nonvascular findings were identified in 32 patients (14%, 95% confidence interval 5% to 12%). These included malpositioned support lines and tubes; pneumothorax; interstitial lung disease; newly diagnosed metastatic disease; nasopharyngeal, parotid, and pituitary masses; and cervical spine compression fractures. CTAs of the head and neck in patients undergoing acute stroke intervention contain a relatively high frequency of vascular and nonvascular incidental findings requiring further follow-up, and therefore should be evaluated carefully and systematically.

Incidental findings on brain MRI in a cohort of diabetic patients

ObjectiveTo study the frequency and management of incidental findings in nonenhanced brain MRI of a middle-aged population of type 2 diabetic patients. MethodsWe retrospectively analyzed the results of 289 brain MRI obtained from subjects between 40–75 years recruited from a previous study. Incidental findings were classified into three categories: (1) Vascular findings; (2) neoplastic findings; and (3) others. On the other side, we made a classification of referral findings. To compare our results, we reviewed the prevalence and evidence about management of both incidental and referral findings in other series. ResultsWe found an overall prevalence of incidental findings of 10.4% (30/289). Incidental findings raised according to age. The most common incidental findings were: 7 vascular (2.4%), 6 calcifications (2.1%), 6 cystic (2.1%) and 5 neoplastic (1.7%) lesions. A percentage of 1.7% (5/289) were referral findings which required further clinical work-up. ConclusionIncidental findings are relatively common in patients with type 2 diabetes. The most frequent are vascular findings, accordance with previous studies. Referral findings are uncommon. Clinical evidence about how to best manage the majority of incidental findings is lacking.

System-Level Process Change Improves Communication and Follow-Up for Emergency Department Patients With Incidental Radiology Findings

The appropriate communication and management of incidental findings on emergency department (ED) radiology studies is an important component of patient safety. Guidelines have been issued by the ACR and other medical associations that best define incidental findings across various modalities and imaging studies. However, there are few examples of health care facilities designing ways to manage incidental findings. Our institution aimed to improve communication and follow-up of incidental radiology findings in ED patients through the collaborative development and implementation of system-level process changes including a standardized loop-closure method. We assembled a multidisciplinary team to address the nature of these incidental findings and designed new workflows and operational pathways for both radiology and ED staff to properly communicate incidental findings. Our results are based on all incidental findings received and acknowledged between November 1, 2016, and May 30, 2017. The total number of incidental findings discovered was 1,409. Our systematic compliance fluctuated between 45% and 95% initially after implementation. However, after overcoming various challenges through optimization, our system reached a compliance rate of 93% to 95%. Through the implementation of our new, standardized communication system, a high degree of compliance with loop closure for ED incidental radiology findings was achieved at our institution.

Ethical Issues in the Beauty Salon: The Development of National Ethics Guidelines for Aestheticians in the Netherlands.

The Netherlands awoke with a shock to some highly publicized cases of clients suffering second-degree burns from inadequate use of laser technology for hair removal in the beauty salon. Aestheticians are increasingly offering risky and sometimes irreversible skin-enhancing treatments. Because of the complexity and hazards of the beauty profession and its proximity at times to the domain of health care, it merits attention from bioethicists. This article presents an overview of ethical issues arising within the everyday practice of the beauty salon, based on discussions with aestheticians and a survey, and reports on the development of the world's first national ethics guidelines for aestheticians. Key recommendations pertain to age limits, informed consent, confidentiality, tensions arising from aestheticians' dual role as care providers and entrepreneurs, and the management of incidental findings. This article directs scholarly effort at ethical issues in the beauty salon, and invites further discussion of a hitherto underserved field.

Managing Incidentalomas Safely: Do Computed Tomography Requisitions Tell Us What We Need to Know?

PurposeTechnological advancements and the ever-increasing use of computed tomography (CT) have greatly increased the detection of incidental findings, including tiny pulmonary nodules. The management of many “incidentalomas” is significantly influenced by a patient's history of cancer. The study aim is to determine if CT requisitions include prior history of malignancy. MethodsRequisitions for chest CTs performed at our adult tertiary care hospital during April 2012 were compared to a cancer history questionnaire, administered to patients at the time of CT scan. Patients were excluded from the study if the patient questionnaire was incomplete or if the purpose of the CT was for cancer staging or cancer follow-up. ResultsA total of 569 CTs of the chest were performed. Of the 327 patients that met inclusion criteria, 79 reported a history of cancer. After excluding patients for whom a history of malignancy could not be confirmed through a chart review and excluding nonmelanoma skin cancer, dysplasia, and in situ neoplasm, 68 patients were identified as having a history of malignancy. We found 44% (95% confidence interval [0.32-0.57]) of the chest CT requisitions for these 68 patients did not include the patient's history of cancer. Of the malignancies that were identified by patient questionnaire but omitted from the clinical history provided on the requisitions, 47% were malignancies that commonly metastasize to the lung. ConclusionsA significant number of requisitions failed to disclose a history of cancer. Without knowledge of prior malignancy, radiologists cannot comply with current guidelines regarding the reporting and management of incidental findings.