- Email: [email protected]
Re: “Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee”
Letters to the Editor e3
contrast: Can isodense masses ever be excluded? Arnold C. Friedman, MD University of Arizona Department of Radiology 1501 N. Campbell Tucson, AZ 85724 e-mail: [email protected] REFERENCE 1. Vick CW. Lexicon for uncertain times. J Am Coll Radiol 2010;7:827-8. DOI 10.1016/j.jacr.2010.12.008 ● S1546-1440(10)00702-7
Re: “Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee” The use of CT in an innumerable number of clinical scenarios has made diagnosis more accurate, less invasive, and more expeditious. The result has been a rapid growth in CT use in the past two decades and a parallel escalation in concern over its growth as a proportion of the health care budget. Recent fiscal scrutiny has focused on incidentalomas and the incurred cost of the downstream testing, procedures, physician services, and patient morbidity [1]. Thus, “Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee,” authored by the experts in abdominal radiology [2], is a welcome effort at providing practice guidelines for the body radiologist who struggles with the incidentaloma problem on a daily basis. The document is useful and hits many high points, but it neglects one of the most commonly encountered of all incidentalomas: the adnexal mass in the female pelvis. The vast majority of abdominal CT studies are performed concurrently with pelvic CT to evaluate
the major organs (bowel, urinary collecting system), anatomic spaces (peritoneal cavity, retroperitoneum), and disease processes (cancer, infection, hemorrhage) that traverse the iliac crests. Benign adnexal masses are diagnosed in 5% of CT studies in postmenarcheal women [3] and in 4% of CT studies in women aged ⬎50 years [4]. A woman in the United States has a 5% to 10% lifetime chance of undergoing an oophorectomy for a benign adnexal mass [5], with resultant long-term morbidity of decreased fertility and premature menopause [6,7]. Admittedly, CT is not the preferred modality for evaluating adnexal masses. Nevertheless, this represents a significant incidentaloma problem. An adnexal mass detected on CT is most often recommended for further imaging with ultrasound, not necessarily because this is the next best step in the workup but because this is where radiology’s expertise in gynecologic pathology resides. This reflexive reaction neglects other possible options that may, in many cases, be preferred. These include MRI, surgical evaluation, or, most important of all, no further workup because the lesion is most likely benign. A consideration of all the downstream options and the choice of the one most likely to minimize overall cost and patient morbidity is the goal in the optimal management of incidentalomas. We applaud the committee for their efforts toward delineating the incidentaloma problem. However, we would urge them to consider additional incidentalomas on the basis of their prevalence and consequent morbidity. This would entail evaluation of not only adnexal masses but other common findings, such as lymphadenopathy, vascular disease (eg, aneurysms), and bony abnormalities (eg, osteopenia). A
thoughtful discussion of these topics would require input, not only from other subspecialties in radiology, but also from our colleagues in surgery, oncology, gynecology, urology, and internal medicine. The management of incidentalomas has widespread ramifications for all of medical practice and health care policy. It is a large issue, and many are vying to define the talking points. Radiologists, as the physicians who most often encounter and triage incidentalomas, are well suited to shape the discussion. But to do so, a broader vision is needed. For as Winston Churchill observed, “When the eagles are silent, the parrots begin to jabber.” Susanna I. Lee, MD, PhD Peter R. Mueller, MD James H. Thrall, MD Massachusetts General Hospital Department of Radiology 55 Fruit Street Boston, MA 02114 E-mail: [email protected] REFERENCES 1. Orme NM, Fletcher JG, Siddiki HA, et al. Incidental findings in imaging research: evaluating incidence, benefit, and burden. Arch Intern Med 2010;170:1525-32. 2. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010;7: 754-73. 3. Slanetz PJ, Hahn PF, Hall DA, Mueller PR. The frequency and significance of adnexal lesions incidentally revealed by CT. AJR Am J Roentgenol 1997;168:647-50. 4. Pickhardt PJ, Hanson ME. Incidental adnexal masses detected at low-dose unenhanced CT in asymptomatic women age 50 and older: implications for clinical management and ovarian cancer screening. Radiology 2010;257:144-50. 5. DiSaia PJ, Creasman WT. The adnexal mass and early ovarian cancer. In: Clinical gynecologic oncology. 5th ed. St Louis, Mo: Mosby; 1997:253-81. 6. Lass A. The fertility potential of women with a single ovary. Hum Reprod Update 1999;5: 546-50.
e4 Letters to the Editor
7. Shuster LT, Gostout BS, Grossardt BR, Rocca WA. Prophylactic oophorectomy in premenopausal women and long-term health. Menopause Int 2008;14:111-6. DOI 10.1016/j.jacr.2010.11.004 ● S1546-1440(10)00629-0
Authors’ Reply We very much appreciate the interest of Drs Lee, Mueller, and Thrall in the work of the ACR Incidental Findings Committee. We also wholeheartedly agree that incidental findings in the adnexae and in other structures in the abdomen and pelvis are worthy of approaching in a similar manner. When the work began that culminated in the white paper [1], the task seemed daunting, and we had no predetermined methodology or infrastructure similar to that of the ACR Appropriateness Criteria® committees. Therefore, our mission, methods, and results were subject to repeated discussion and refinement over the several years during which the report was developed. Although we recognized the importance of adnexal incidental findings, we made a deliberate decision to limit this first project of the committee, believing that to include these would simply be one too many topics to address concurrently while still hoping to arrive at
a consensus effectively and in a reasonable time. Also, regarding adnexal incidental findings, a statement of a consensus conference of the Society of Radiologists in Ultrasound was recently published on managing asymptomatic adnexal cysts [2]. Dr Gore (chair of the Liver Subcommittee of the ACR Incidental Findings Committee) and colleagues have also published a comprehensive review of such incidental findings on CT, MRI, and ultrasound [3], and many other papers have discussed this problem. Nevertheless, there may yet be a role for specific algorithms such as found in our white paper to help guide the management of adnexal incidental findings detected on CT and MRI. The committee’s current priority is to ensure that the recommendations we have described are widely known and applied. However, we have already discussed how, with the support of the ACR and other groups, we might continue our work to address the other important topics you have highlighted. Lincoln L. Berland, MD Department of Radiology University of Alabama Hospital 619 19th Street S Birmingham, AL 35249-0001 e-mail: [email protected]
Stuart G. Silverman, MD Department of Radiology Brigham and Women’s Hospital Boston, MA William W. Mayo-Smith, MD Department of Diagnostic Imaging Rhode Island Hospital Providence, RI Alec J. Megibow, MD, MPH Department of Radiology NYU-Langone Medical Center New York, NY James A. Brink, MD Department of Diagnostic Radiology Yale University School of Medicine New Haven, CT REFERENCES 1. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010;7: 754-73. 2. Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 2010;256: 943-54. 3. Gore RM, Newmark GM, Thakrar KH, Mehta UK, Berlin JW. Pelvic incidentalomas. Cancer Imaging 2010;10:1-12. DOI 10.1016/j.jacr.2010.11.018 ● S1546-1440(10)00686-1
contrast: Can isodense masses ever be excluded? Arnold C. Friedman, MD University of Arizona Department of Radiology 1501 N. Campbell Tucson, AZ 85724 e-mail: [email protected] REFERENCE 1. Vick CW. Lexicon for uncertain times. J Am Coll Radiol 2010;7:827-8. DOI 10.1016/j.jacr.2010.12.008 ● S1546-1440(10)00702-7
Re: “Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee” The use of CT in an innumerable number of clinical scenarios has made diagnosis more accurate, less invasive, and more expeditious. The result has been a rapid growth in CT use in the past two decades and a parallel escalation in concern over its growth as a proportion of the health care budget. Recent fiscal scrutiny has focused on incidentalomas and the incurred cost of the downstream testing, procedures, physician services, and patient morbidity [1]. Thus, “Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee,” authored by the experts in abdominal radiology [2], is a welcome effort at providing practice guidelines for the body radiologist who struggles with the incidentaloma problem on a daily basis. The document is useful and hits many high points, but it neglects one of the most commonly encountered of all incidentalomas: the adnexal mass in the female pelvis. The vast majority of abdominal CT studies are performed concurrently with pelvic CT to evaluate
the major organs (bowel, urinary collecting system), anatomic spaces (peritoneal cavity, retroperitoneum), and disease processes (cancer, infection, hemorrhage) that traverse the iliac crests. Benign adnexal masses are diagnosed in 5% of CT studies in postmenarcheal women [3] and in 4% of CT studies in women aged ⬎50 years [4]. A woman in the United States has a 5% to 10% lifetime chance of undergoing an oophorectomy for a benign adnexal mass [5], with resultant long-term morbidity of decreased fertility and premature menopause [6,7]. Admittedly, CT is not the preferred modality for evaluating adnexal masses. Nevertheless, this represents a significant incidentaloma problem. An adnexal mass detected on CT is most often recommended for further imaging with ultrasound, not necessarily because this is the next best step in the workup but because this is where radiology’s expertise in gynecologic pathology resides. This reflexive reaction neglects other possible options that may, in many cases, be preferred. These include MRI, surgical evaluation, or, most important of all, no further workup because the lesion is most likely benign. A consideration of all the downstream options and the choice of the one most likely to minimize overall cost and patient morbidity is the goal in the optimal management of incidentalomas. We applaud the committee for their efforts toward delineating the incidentaloma problem. However, we would urge them to consider additional incidentalomas on the basis of their prevalence and consequent morbidity. This would entail evaluation of not only adnexal masses but other common findings, such as lymphadenopathy, vascular disease (eg, aneurysms), and bony abnormalities (eg, osteopenia). A
thoughtful discussion of these topics would require input, not only from other subspecialties in radiology, but also from our colleagues in surgery, oncology, gynecology, urology, and internal medicine. The management of incidentalomas has widespread ramifications for all of medical practice and health care policy. It is a large issue, and many are vying to define the talking points. Radiologists, as the physicians who most often encounter and triage incidentalomas, are well suited to shape the discussion. But to do so, a broader vision is needed. For as Winston Churchill observed, “When the eagles are silent, the parrots begin to jabber.” Susanna I. Lee, MD, PhD Peter R. Mueller, MD James H. Thrall, MD Massachusetts General Hospital Department of Radiology 55 Fruit Street Boston, MA 02114 E-mail: [email protected] REFERENCES 1. Orme NM, Fletcher JG, Siddiki HA, et al. Incidental findings in imaging research: evaluating incidence, benefit, and burden. Arch Intern Med 2010;170:1525-32. 2. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010;7: 754-73. 3. Slanetz PJ, Hahn PF, Hall DA, Mueller PR. The frequency and significance of adnexal lesions incidentally revealed by CT. AJR Am J Roentgenol 1997;168:647-50. 4. Pickhardt PJ, Hanson ME. Incidental adnexal masses detected at low-dose unenhanced CT in asymptomatic women age 50 and older: implications for clinical management and ovarian cancer screening. Radiology 2010;257:144-50. 5. DiSaia PJ, Creasman WT. The adnexal mass and early ovarian cancer. In: Clinical gynecologic oncology. 5th ed. St Louis, Mo: Mosby; 1997:253-81. 6. Lass A. The fertility potential of women with a single ovary. Hum Reprod Update 1999;5: 546-50.
e4 Letters to the Editor
7. Shuster LT, Gostout BS, Grossardt BR, Rocca WA. Prophylactic oophorectomy in premenopausal women and long-term health. Menopause Int 2008;14:111-6. DOI 10.1016/j.jacr.2010.11.004 ● S1546-1440(10)00629-0
Authors’ Reply We very much appreciate the interest of Drs Lee, Mueller, and Thrall in the work of the ACR Incidental Findings Committee. We also wholeheartedly agree that incidental findings in the adnexae and in other structures in the abdomen and pelvis are worthy of approaching in a similar manner. When the work began that culminated in the white paper [1], the task seemed daunting, and we had no predetermined methodology or infrastructure similar to that of the ACR Appropriateness Criteria® committees. Therefore, our mission, methods, and results were subject to repeated discussion and refinement over the several years during which the report was developed. Although we recognized the importance of adnexal incidental findings, we made a deliberate decision to limit this first project of the committee, believing that to include these would simply be one too many topics to address concurrently while still hoping to arrive at
a consensus effectively and in a reasonable time. Also, regarding adnexal incidental findings, a statement of a consensus conference of the Society of Radiologists in Ultrasound was recently published on managing asymptomatic adnexal cysts [2]. Dr Gore (chair of the Liver Subcommittee of the ACR Incidental Findings Committee) and colleagues have also published a comprehensive review of such incidental findings on CT, MRI, and ultrasound [3], and many other papers have discussed this problem. Nevertheless, there may yet be a role for specific algorithms such as found in our white paper to help guide the management of adnexal incidental findings detected on CT and MRI. The committee’s current priority is to ensure that the recommendations we have described are widely known and applied. However, we have already discussed how, with the support of the ACR and other groups, we might continue our work to address the other important topics you have highlighted. Lincoln L. Berland, MD Department of Radiology University of Alabama Hospital 619 19th Street S Birmingham, AL 35249-0001 e-mail: [email protected]
Stuart G. Silverman, MD Department of Radiology Brigham and Women’s Hospital Boston, MA William W. Mayo-Smith, MD Department of Diagnostic Imaging Rhode Island Hospital Providence, RI Alec J. Megibow, MD, MPH Department of Radiology NYU-Langone Medical Center New York, NY James A. Brink, MD Department of Diagnostic Radiology Yale University School of Medicine New Haven, CT REFERENCES 1. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010;7: 754-73. 2. Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 2010;256: 943-54. 3. Gore RM, Newmark GM, Thakrar KH, Mehta UK, Berlin JW. Pelvic incidentalomas. Cancer Imaging 2010;10:1-12. DOI 10.1016/j.jacr.2010.11.018 ● S1546-1440(10)00686-1