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Jul 03
2010
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Incidentalomas…. Do you ignore this or ask for further Investigations?Posted by: Dr. Sridhar V on Jul 03, 2010  |
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How do you deal when you discover ‘Incidentalomas’ while doing a scan …be USG, CT or MRI??
Definition of Incidentaloma:
“An incidentally discovered mass or lesion, detected by CT, MRI, or other imaging modality performed for an unrelated reason.”
From Free Dictionary
Sometime back a patient came for routine USG study of Abdomen while undergoing Master Check Up. The USG picked up a cystic lesion with internal echoes in the pelvis of the Kidney.
USG report was
Now the patient got terribly worried and went to an Urologist who advised CECT. Patient underwent the same and the report read as (pardon me …no CT films available)
Based on this report Urologist told the patient that there is every possibility of Kidney having a malignant growth and patient needs immediate Nephrectomy. When Nephrologist explained that Nephrectomy solves the entire problem, the patient was relieved. When the nephrectomy specimen was sent for biopsy the report came as
.
That means ‘Radical Nephrectomy’ done for a’ Simple Rena Cyst’ !!!!
Losing a Kidney for Nothing ??
Now just review the CT report… which said that renal vein is infiltrated ! How do you react to this??
How about these routinely discovered incidentalomas ?
Angiomyolipoma of Kidney –young boy Simple Hepatic Cyst-Asymptomatic Lady
What about Thyroid nodular lesions picked up during Carotid Doppler Studies ?
or
Adrenal Incidentalomas while doing CT/MRI scans
or
even Pituitary Incidentalomas ?
Then you have bizarre appearances of Hemangioma of Liver picked up on a routine check ups
One can even come across confusing varieties of fatty infiltration in USG/CT/MRI studies mimicking the terrible malignancies
Ex. Focal fatty sparing
Focal fatty infiltrations etc etc.
When an incidentaloma is discovered (Can one scream excitedly Eureka??) On diagnostic imaging,…. whose responsibility is it now to prove that the discovery is indeed harmless ? Radiologist or Ref Clinician?
Or
Is it really necessary that one has to prove that the lesion detected… indeed is ‘Benign’
Who is the most worried person ?
Is it the patient ? or the Radiologist ? or The Ref. Clinician ?
Patient
No doubt patient is the most worried lot. He is as ignorant as our Radiologist or Clinician. He will start counting his/her days .Becomes more religious. Start visiting all the Shrines.
In my experience one patient became cancer phobic when the USG report showed a simple renal cyst and this patient decided to starve until death( As a Penance.. since he committed mistakes in previous birth to suffer this cancer )
Radiologist
Most of the time we are happy mentioning the finding with an add on…..i.e. suggested follow up studies.. then what has happened afterwards to the patient is none of our concern and we are busy with our practice as usual.(unless one is attached to an academically oriented institute).
The Indian Radiologist has already become a laughing stock with the usual reporting style…
‘To correlate clinically if warranted’ or
‘Malignancy can not be ruled out’ etc etc….. trying to escape or pass on the burden to somebody else.
Then there is a fear of demacle sword hanging in the form of medico legal litigations if you avoid or miss to mention or take care of the incidentalomas picked up innocently.
Ref.Clinician
They also worried due to litigation problem and can simply ask for more and more studies to identify the lesion. The expenses incurred by patient can take monstrous proportions. Clinician comes into picture again only after ‘Pucca’ diagnosis made by hard work of radiologist through invasive modalities and finally from biopsy diagnosis..
Is it not a fact that to prove that the lesion picked up, is benign is a ‘ Herculean Task’ needing further imaging studies both invasive and non invasive and finally Biopsy….each study having its own limitations and frightening Complications …let alone the fact that lesion may turn malignant over the years.
As crazy as it sounds…. sometimes guidelines tell you to have yearly FNAC for the thyroid nodules!!
This adds up to the worries of an already harried patient.
“Worry gives a small thing a big shadow”
Swedish Proverb.
Incidence of Incidentalomas are increasing very rapidly due to the advancement in technology and also due to the Superb Resolution of the Images.
Incidentaloma problems with Medical scans
http://consults.blogs.nytimes.com/2010/06/08/the-incidentaloma-problem-with-medical-scans/
Another interesting article-Thyroid nodules… it is time to turn off Ultrasound Machines ?
http://radiology.rsna.org/content/247/3/602.full
John J Cronan, MD
“With every passing year, our US units are better, our biopsy techniques are improved, cytologic interpretation is refined, and we are essentially able to perform FNA on any lesion we can visualize. As Ross (4) pointed out to his endocrinology colleagues, we have an epidemic of thyroid nodules secondary to technology. There is no proof that our intervention on these nonpalpable nodules has any effect on improving the health and welfare of the population.”
It is true that Incidentalomas are causing tremendous drain on the resources of the patient and also over all increase in cost of Health care for the Government t owned Hospitals. Discovery of Incidentaloma is the starting point for ‘Chain reaction”
Who is the is the biggest beneficiary of this Chain reaction ?
1. Ref clinician ? 2.Diagnostic centers ? 3. Interventional Radiologist ? 4. Pathologist ? 5. or the Industry by selling its sophisticated machinery which can diagnose smallest incidentalomas ?
No doubt there are a quite few Guidelines & Consensuses developed as to how to proceed with incidentalomas..once discovered…. Again a cumbersome protocol.
I request the readers to have lot of patience while going through the following ref as far as guidelines are concerned
Guidelines for adrenal incidentalomas
http://www.aace.com/pub/pdf/guidelines/AdrenalGuidelines.pdf
Evaluation of adrenal incidentalomas; time for a re-think?
http://www.eje-online.org/cgi/content/short/161/4/513
Guidelines for pituitary incidentalomas ( mind you… still in preliminary stage)
http://www.endocrinetoday.com/view.aspx?rid=65692
Guidelines for thyroid nodules
http://www.guideline.gov/summary/summary.aspx?doc_id=8947
Guidelines for Solitary Pulmonary Nodule- Of course this is a well known entity
Guidelines for Renal and Hepatic incidentalomas—Yet to evolve
Finally a note on the prevalence of Endocrine Incidentalomas
Thyroid incidentalomas- 50% on imaging studies
Adrenal incidentalomas- said to be 5% on imagines studies
Pituitary incidentalomas- Between 10% to 20 %
Source: International Journal of Clinical Practice Vol-62.Issue 9 Pages 1423-1431Published 24 July ‘08
Nobody knows , how many of these incidentalomas are potentially malignant.
Since there going to be explosion of incidence of incidentalomas being picked up…is worth taking all the pains to prove that the lesion is non malignant ??
In the end …. What is the judgment of our esteemed readers ?
Now on the lighter side….…
A Short History of Medicine
2000 B.C. - "Here, eat this root."
1000 B.C. - "That root is heathen, say this prayer."
1850 A.D. - "That prayer is superstition, drink this potion."
1940 A.D. - "That potion is snake oil, swallow this pill."
1985 A.D. - "That pill is ineffective, take this antibiotic."
2000 A.D. - "That antibiotic is artificial. Here, eat this root."
~Author Unknown
So it is BACK TO BASICS…. Is not our basic knowledge is far superior to our advanced and highly complicated knowledge ?
“The medicalization of early diagnosis not only hampers and discourages preventative health-care but it also trains the patient-to-be to function in the meantime as an acolyte to his doctor. He learns to depend on the physician in sickness and in health. He turns into a life-long patient.” ~Ivan Illich
In Summary…. patient has no right to lead full time normal health. Make him Sick……sicker…….sickest…. in shortest possible time in the name of Medical Advancement.
“Doctors are just the same as lawyers; the only difference is that lawyers merely rob you, whereas doctors rob you and kill you, too.” ~Anton Chekhov, Ivanov
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Alok Varshney
said:
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... A professional has to use his acumen, skill and judgment to the best of his capabilities. Still at times his effort will fall short, no matter what; a topnotch lawyer will at times squander the liberty and life of his client. Thats the nature of our professions- when we go out to help others it is really not possible that we will always succeed or be always in the right. But if one is consistently wrong, he should seek out the reasons and re-train himself. Incidentalomas pose peculiar problems- they are incidentally picked up during a study and some are of sufficiently ambiguous nature to defy their classification into benign or malignant ones. The onus of guiding further management lies mostly with radiologists - they are the ones picking the lesions. If biopsy/ FNAC are not possible and imaging features are not characteristic, one should not hasten in making a diagnosis of malignancy and rather depend on close observation of the lesion (watchful neglect as Prashant says). But another problem is that radiologists get forced into taking a side (benign vs malignant) even when it is not possible to do so. They start imagining or over-interpreting the findings. Thats when help of a senior colleague matters the most. One should always seek second opinions before rendering judgments, a method often ignored in the hectic practice schedules. Perhaps it is better at times to say - I Don't Know. |
Anuj Mishra
said:
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... Thanks Dr. Sridhar for yet another thought-provoking article.... The example you quoted of the renal cyst has inherent wrong conclusions as the renal cyst must be categorized according to Bosniak classification. The cyst type IIF would require follow-up by ultrasound while the cysts type III and IV would warrant further imaging like CT/MRI. The cyst shown on ultrasound was clearly type II cyst and hence benign. New studies have shown that adrenal solid lesions found incidentally must undergo plain thin-section CT scan and the CT density of the lesion must be measured. If the density is < 15 HU, it should be regarded as benign. For denser lesions, further imaging should be considered. As for the other incidentalomas, if the evidence for malignancy is not present, they should best be ignored. For example, calcification in thyroid nodules is not a good prognosticator. Often, it helps to just follow these lesions by ultrasound serially to see for any evidence of growth. Doubling time is an important indicator to suggest prognosis. In my daily practice, I find quite useful to ask for any previous scans from the patient. If that is not useful, I ask the patient to come after 2 weeks for a free re-scan. (As some patients would be very anxious and would not wish to wait for a month !). And then depending on the site of incidentaloma, I decide what next to do for the patient. I am glad you have brought forth a very important and confusing topic for discussion. I hope everyone of us would learn from your references. |
Keshav Kulkarni
said:
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... Good discussion about incidentalomas. I am sure incidentalomas are going to increase further in future. The guidelines are useful, but there are no guidelines for every incedentaloma. It is worth having guidelines in every radiology department to deal with these incidentalomas (at least in hospital setting practice). |
Dr. Sridhar V
said:
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... Thank you so much Dr.Alok Varshney,Dr.Anuj Mishra and Dr.Keshav Kulkarni for enriching me further by sharing your experience. I have a doubt Can we apply Bosniak's criteria and grade the cysts in Ultrasonography, since Bosniak research is Based on on CT appearance of the Cysts ? How about MRI ? Is not MRI much more superior to CT due to excellent tissue characterization ? If grading is not possible in 2 D USG will CEUS help ? |
Anuj Mishra
said:
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... Ultrasound has been proven to be complementary to CT scan for classifying renal cysts according to Bosniak's criteria. An interesting reference is : Urol Radiol. 1991;13(2):83-90. Cystic renal masses: usefulness of the Bosniak classification. Aronson S, Frazier HA, Baluch JD, Hartman DS, Christenson PJ. where the authors evaluated both ultrasound and CT scan to characterize renal cysts. More recently, Dr. Clevert has published an article (Urologe A. 2010 Mar;49(3):421-31) where they conclude "The method of choice for diagnosis of renal cysts is ultrasound. Besides the conventional B-mode ultrasound, contrast enhanced ultrasound with SonoVue provides a promising new technique for distinguishing cysts according to the Bosniak classification". In another paper by Dr. Clevert in 2008 (Clin Hemorheol Microcirc. 2008;39(1-4):171-  , where his team compared MSCT with CEUS, they found 'CEUS depicted more thin septa than MS-CT, or upgraded wall thickness, resulting in a Bosniak score upgrade from category II to IIF in 5 lesions.'They concluded 'additional information about perfusion of the cystic septa or cystic renal cancer can be gained.' In another article by Dr. Ascenti from Italy (Radiology. 2007 Apr;243(1):158-65), where they evaluated the role of CEUS in characterizing renal cysts by Bosniak criteria and compared their results with MDCT, they concluded 'that contrast-enhanced US is appropriate for renal cyst classification with the Bosniak system.' There is a recent shift from MDCT to USG to characterize renal cysts according to Bosniak classification. As of today, Computed tomography still remains the 'gold standard'. However, newer diagnostic imaging modalities such as contrast-enhanced ultrasonography is demonstrating promising results. As far as role of MRI is considered, CT and MR imaging findings are similar in the majority of cystic renal masses. In some cases, however, MR images may depict additional septa, thickening of the wall and/or septa, or enhancement, which may lead to an upgraded Bosniak cyst classification and can affect case management. (Radiology. 2004 May;231(2):365-71). But the cost and availability are the constraints. The advantages of USG over any other modality are known to all of us. And I am strong believer in Ultrasound ! |
Alok Varshney
said:
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... For the purpose of renal cyst evaluation, I also tend to rely more on ultrasound than on CT/MR. With a good USG machine the morphologic characteristics of a cyst are well evaluated. I find difficulty in characterizing a cyst on CT when the cyst is small ( |
Alok Varshney
said:
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... ..... Somehow just a part of comment got posted... I find difficulty in characterizing small cysts on CT, becuase at times thin septae or small mural components are not well visualized on CT. However if the cyst is solid appearing or filled with echoes, it is difficult at times on USG to differentiate between benign vs mitotic lesion. Multimodality approach using USG + CT/MR or CEUS is helpful, but by no means foolproof. Some lesions invariably will get mis-classified. |
Dr. Sridhar V
said:
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... Thank you Dr.Anuj Mishra and Dr.Alok Varshney for your valuable inputs. So at times each modality comes out with its inherent deficiencies. At times ....some adjustments needed...... |
Anuj Mishra
said:
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... Thanks Dr. Sridhar. I too, like Dr. Alok has mentioned, rely on Ultrasound for characterizing renal cysts and find harmonic imaging quite useful. In confusing situations, I take recourse to contrast-enhanced ultrasound. Only if I find a lesion that is not IIF or below, do I proceed further to MDCT. And that is mainly for surgical planning and not for diagnostic purposes! I hope my dear colleagues would agree with this approach. |
Tufail
said:
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... The discussion on Incidental lesions was very interesting.This becomes a much bigger problem in research patients and many of us dont know what to do yet. We are in process of formulating some guidelines in UK to deal with this.In clinical practice I would not go chasing an incidental lesion unless its necessary based on the characteristics of lesion. As a radiologist you are a clinician and you have responsibility to patient. If you think its cancer or something worrying you will have to chase it and make sure other tests that are required are done to confirm it. I guess every case has to be taken on its own merit. But its our responsibility too. |
adv kuldeep mahant
said:
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... this information is good , but i want one question,that"roundish hetrogenus small tsoft tissue lesion in the cervix:?Ca cervix " i want to know the meaning of that dignosis please send the reply |
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