Q&A | Incidentalomas: Managing Ancillary Findings

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 - Lincoln L. Berland, MD
Lincoln L. Berland, MD

As the government and payors try to rein in imaging costs and eliminate inappropriate exams, a cascade of studies has attacked radiology's handling of incidental findings. Recent articles on pulmonary emboli, cardiac CT, emergency imaging and internal medicine have pointed to the high volume of "incidentalomas" that bring about additional testing, potential complications and on the whole, little change to patient management.

Beginning in 2006, the American College of Radiology (ACR) convened an Incidental Findings Committee to begin to provide radiologists with generalizable standards for managing incidental findings. The committee's work has thus far culminated in a voluminous white paper offering recommendations for incidental findings on abdominal and pelvic CT. The paper's lead author, Lincoln L. Berland, MD, a radiologist at the University of Alabama at Birmingham, spoke with Health Imaging & IT about the committee's recommendations regarding incidentalomas.

Q: Can you describe the objectives of the ACR Incidental Findings Committee?

Berland: Our objective was to bring some consistency to the diagnosis of and approach to incidental findings; they are often handled rather haphazardly and there's not a lot of data or literature to guide physicians in trying to manage such things. Incidental findings have become increasingly recognized as a cost—usually not yielding very many positive results and sometimes potentially harming the patient.

We established a committee and subcommittees, each assigned to a different organ system. We decided to start with the kidneys, liver, pancreas and adrenal glands.

Q: How did the ACR Committee approach the issue of incidental findings?

Berland: One of the biggest problems radiologists have with incidental findings is inconsistent recommendations. As is the situation with any recommendations, the physician, in this case the radiologist, has to provide recommendations in the context of the individual patient. That is, the radiologist has to consider a patient's comorbidities and life expectancy.

As we developed the recommendations, we also were quite specific about the types of conditions we were talking about, the size of the lesions we were looking at, what their appearance was and so on.

One of our primary objectives was to present the recommendations with a common appearance so that they could be easily referenced and used to guide physicians. We did this by developing flow charts which allow the radiologist to go through an algorithmic pathway in deciding how to manage findings.

Q: Physicians and researchers have responded to the reported inefficacies of incidentalomas, with some calling for physicians to ignore incidental findings altogether. How would you characterize your attitude?

Berland: It would be very difficult to convince a radiologist simply to ignore or not report most incidental findings. That's anathema to our culture. Our objective as a specialty is to report findings and indicate their potential significance. Not talking about them at all would be tantamount to burying your head in the sand. They're there; you can't ignore them completely all the time. You just have to know what to do with them.

Q: How have the committee's recommendations been received? Where do you see the discussion heading in the future?

Berland: The white paper has been very well received and we hope to build on that in different ways. We had a refresher course at this past year's RSNA, and so many people were interested in the issue that they had to open up another room with a video feed.

It's still a hot topic, and because it has only been nine months since the recommendations were published, the standards have not been really well disseminated. It will take time for them to be integrated into practice. It's also an evolving process and is still in a fairly early stage of development. There is a lot of research yet to be done and a lot of consensus yet to be reached on how to approach these things. We're trying to find ways to disseminate the recommendations, but we've also moved on to approach other organ systems and less common findings, including lymph nodes, gallbladder disease and ovarian cystic findings