Management of Incidental Adnexal Findings on CT and MRI: A White Paper of the ACR Incidental Findings Committee

Incidental findings on staging rectal MRI: clinical significance and outcomes

BACKGROUND

Incidental findings (IFs) are commonly seen in staging rectal magnetic resonance imaging (MRI) scans. Their prevalence and clinical significance have not been previously documented.

PURPOSE

To assess the prevalence, clinical significance, and outcomes of incidental findings in MRI scans performed for the staging of rectal cancer.

MATERIAL AND METHODS

A retrospective study was performed at a tertiary colorectal imaging institution. Consecutive MRI rectal staging scans with correlative pathology confirmed primary rectal cancer between March 2014 and March 2021 were identified. The respective imaging reports were reviewed for IFs, which were classified as high, moderate, and low, according to their clinical significance. Medical records were reviewed to assess the outcomes of the highly significant IFs.

RESULTS

There were 266 eligible patients (97 women; mean age = 64.2 years) during the study period. A total of 120 (45%) patients did not have any IFs. A total of 238 IFs in 146 (55%) patients were found. There were 21 (9%) IFs of high clinical significance, 122 (51%) of moderate clinical significance, and 95 (40%) of low clinical significance. The prostate and uterus had the most IFs of high clinical significance, two of which were subsequently pathology confirmed as prostate adenocarcinomas.

CONCLUSION

IFs were seen in more than half of the staging MRI scans in rectal cancer but less than 10% of these were of high clinical significance. The results of this study highlight the range of potential IFs and can guide future research assessing the potential impact of these IFs on patients and the healthcare system.

Imaging of a Pelvic Mass: Uterine

The most common origin of a non-uterine pelvic mass is from the ovary. Ultrasound is the initial imaging modality of choice, additional imaging with computed tomography (CT) and/or magnetic resonance imaging (MRI) is performed in selected cases. Adnexal masses are also encountered as incidental findings during ultrasound, CT or MRI. Many of the adnexal masses that are surgically removed are benign. For optimal outcome and cost effective management, noninvasive risk stratification of such adnexal masses is necessary when discovered incidentally or when identified in a patient with a clinically detected pelvic mass. The American College of Radiology Ovarian-Adnexal Reporting Data System is a pattern-based scoring system for adnexal masses imaged with ultrasound and MRI, which assists clinicians to guide in the appropriate management based on evidence-based risk categories. Non-ovarian and non-uterine pelvic masses include fallopian tube abnormalities, paraovarian cysts, peritoneal inclusion cysts, and rare causes include masses that arise from the gastrointestinal tract or the sacrum. To distinguish non-ovarian masses from an ovarian tumor, a critical step is to identify a normal appearing ovary separate from the pelvic mass. This may be challenging in the post-menopausal woman with an atrophic ovary. MRI is a useful adjunctive modality in such cases. Extraovarian masses typically displace pelvic side wall vasculature medially, compress, encase or medially displace the ureters.

A systematic review and meta-analysis of incidental findings in computed tomography scans for pediatric trauma patients

PURPOSE

To quantitatively synthesize and report the frequency and category of incidental findings on Computed Tomography (CT) scans in pediatric trauma patients.

METHODS

A thorough literature search was carried out in PubMed, Scopus, and Web of Science databases until March 6, 2023, in adherence to the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. Studies describing incidental findings on CT scans in trauma patients ≤21 years were included. Incidental findings were grouped into three categories: Category 1 (requiring immediate or urgent evaluation or treatment), Category 2 (likely benign but which may require outpatient follow-up), and Category 3 (benign anatomic variants or pathologic findings that do not require follow-up or intervention).

RESULTS

Seven studies were included in this study, which revealed a combined rate of 27.10 % of incidental findings with notable heterogeneity among the studies. Aggregated frequencies were 10.15 % for Category 1, 32.18 % for Category 2 and 51.44 % for Category 3. Subgroup meta-analysis on abdominal CT scans showed a higher pooled incidence of incidental findings at 47.17 %, but with lower heterogeneity than the general meta-analysis.

CONCLUSION

The study underscores the prevalence of incidental findings in pediatric trauma patients undergoing CT scans. The categorization of these findings provides useful information for clinicians in determining appropriate follow-up and management strategies.

Machine learning for differentiation of lipid-poor adrenal adenoma and subclinical pheochromocytoma based on multiphase CT imaging radiomics

BACKGROUND

There is a paucity of research investigating the application of machine learning techniques for distinguishing between lipid-poor adrenal adenoma (LPA) and subclinical pheochromocytoma (sPHEO) based on radiomic features extracted from non-contrast and dynamic contrast-enhanced computed tomography (CT) scans of the abdomen.

METHODS

We conducted a retrospective analysis of multiphase spiral CT scans, including non-contrast, arterial, venous, and delayed phases, as well as thin- and thick-thickness images from 134 patients with surgically and pathologically confirmed. A total of 52 patients with LPA and 44 patients with sPHEO were randomly assigned to training/testing sets in a 7:3 ratio. Additionally, a validation set was comprised of 22 LPA cases and 16 sPHEO cases from two other hospitals. We used 3D Slicer and PyRadiomics to segment tumors and extract radiomic features, respectively. We then applied T-test and least absolute shrinkage and selection operator (LASSO) to select features. Six binary classifiers, including K-nearest neighbor (KNN), logistic regression (LR), decision tree (DT), random forest (RF), support vector machine (SVM), and multi-layer perceptron (MLP), were employed to differentiate LPA from sPHEO. Receiver operating characteristic (ROC) curves and area under the curve (AUC) values were compared using DeLong's method.

RESULTS

All six classifiers showed good diagnostic performance for each phase and slice thickness, as well as for the entire CT data, with AUC values ranging from 0.706 to 1. Non-contrast CT densities of LPA were significantly lower than those of sPHEO (P < 0.001). However, using the optimal threshold for non-contrast CT density, sensitivity was only 0.743, specificity 0.744, and AUC 0.828. Delayed phase CT density yielded a sensitivity of 0.971, specificity of 0.641, and AUC of 0.814. In radiomics, AUC values for the testing set using non-contrast CT images were: KNN 0.919, LR 0.979, DT 0.835, RF 0.967, SVM 0.979, and MLP 0.981. In the validation set, AUC values were: KNN 0.891, LR 0.974, DT 0.891, RF 0.964, SVM 0.949, and MLP 0.979.

CONCLUSIONS

The machine learning model based on CT radiomics can accurately differentiate LPA from sPHEO, even using non-contrast CT data alone, making contrast-enhanced CT unnecessary for diagnosing LPA and sPHEO.

Adnexal Mass Imaging: Contemporary Guidelines for Clinical Practice

Several recent guidelines have been published to improve accuracy and consistency of adnexal mass imaging interpretation and to guide management. Guidance from the American College of Radiology (ACR) Appropriateness Criteria establishes preferred adnexal imaging modalities and follow-up. Moreover, the ACR Ovarian-Adnexal Reporting Data System establishes a comprehensive, unified set of evidence-based guidelines for classification of adnexal masses by both ultrasound and MR imaging, communicating risk of malignancy to further guide management.

Adnexal Lesion Imaging: Past, Present, and Future

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

Applying Implementation Science Principles to Systematize High-Quality Care for Potentially Significant Imaging Findings

OBJECTIVE

Use principles of implementation science to improve the diagnosis and management of potentially significant imaging findings.

METHODS

Multidisciplinary stakeholders codified the diagnosis and management of potentially significant imaging findings in eight organs and created a finding tracking management system that was embedded in radiologist workflows and IT systems. Radiologists were trained to use this system. An automated finding tracking management system was created to support consistent high-quality care through care pathway visualizations, increased awareness of specific findings in the electronic medical record, templated notifications, and creation of an electronic safety net. Primary outcome was the rate of quality reviews related to eight targeted imaging findings. Secondary outcome was radiologist use of the finding tracking management tool.

RESULTS

In the 4 years after implementation, the tool was used to track findings in 7,843 patients who received 10,015 ultrasound, CT, MRI, x-ray, and nuclear medicine examinations that were interpreted by all 34 radiologists. Use of the tool lead to a decrease in related quality reviews (from 8.0% to 0.0%, P < .007). Use of the system increased from 1.7% of examinations in the early implementation phase to 3.1% (+82%, P < .00001) in the postimplementation phase. Each radiologist used the tool on an average of 294.6 unique examinations (SD 404.8). Overall, radiologists currently use the tool approximately 4,000 times per year.

DISCUSSION

Radiologists frequently used a finding tracking management system to ensure effective communication and raise awareness of the importance of recommended future follow-up studies. Use of this system was associated with a decrease in the rate of quality review requests in this domain.

Malignant Epithelial Tumors of the Ovary

Epithelial ovarian neoplasms (EON) constitute the majority of ovarian cancers. Among EON, high-grade serous carcinoma (HGSC) is the most common and most likely to present at an advanced stage. Radiologists should recognize the imaging features associated with HGSC, particularly at ultrasound and MR imaging. Computed tomography is used for staging and to direct care pathways. Peritoneal carcinomatosis is common and does not preclude surgical resection. Other less common malignant EON have varied appearances, but share a common correlation between the amount of vascularized solid tissue and the likelihood of malignancy.

Abdominal peer learning: advantages and lessons learned

In 2017, our tertiary hospital-based imaging practice transitioned from score-based peer review to the peer learning methodology for learning and improvement. In our subspecialized practice, peer learning submissions are reviewed by domain experts, who then provide feedback to individual radiologists, curate cases for group learning sessions, and develop associated improvement initiatives. In this paper, we share lessons learned from our abdominal imaging peer learning submissions with the assumption that trends in our practice likely mimic others', and hope that other practices can avoid future errors and elevate the level of the quality of their own performance. Adoption of a nonjudgmental and efficient method to share peer "learning opportunities" and "great calls" has increased participation in this activity and increased transparency into our practice, thus allowing for visualization of trends in performance. Peer learning allows us to bring our own individual knowledge and practices together for group review in a collegial and safe environment. We learn from each other and decide how to improve together.

Impact of Adding Mean Apparent Diffusion Coefficient (ADCmean) Measurements to O-RADS MRI Scoring For Adnexal Lesions Characterization: A Combined O-RADS MRI/ADCmean Approach

RATIONALE AND OBJECTIVES

Evaluate the impact of adding mean apparent diffusion coefficient (ADCmean) measurements to the Ovarian-Adnexal Imaging Reporting and Data System MRI (O-RADS MRI) scoring for adnexal lesion characterization using a combined O-RADS MRI/ADCmean reading approach.

MATERIALS AND METHODS

This prospective study included 90 women who underwent pelvic MRI for adnexal lesions diagnosis and characterization. Two readers scored the adnexal lesions using the O-RADS MRI scoring independently and in consensus. A third reader calculated ADCmean measurements. The final diagnoses were determined by histo-pathology (n = 77) or follow-up imaging (n = 13). Areas under the curves (AUCs) and diagnostic performance metrics were calculated for the O-RADS MRI scoring, ADCmean, and combined O-RADS MRI/ADCmean thresholds. P-value <0.05 was significant.

RESULTS

116 adnexal lesions (71 benign, 45 malignant) were analyzed. The optimal thresholds to predict malignant adnexal lesions were O-RADS MRI score >3 and ADCmean value ≤1.08 × 10^-3 mm²/s (AUC 0.926 and 0.823; sensitivity 97.7% and 95.5%; specificity 87.3% and 68%; positive predictive value (PPV) 83% and 66.2%; positive likelihood ratio (PLR) 7.7 and 3.08, respectively). Compared to the O-RADS MRI scoring, a combined threshold of O-RADS MRI >3/ADCmean ≤1.08 × 10^-3 mm²/s, yielded a reduction of false positives, a significant increase in the specificity (97.1%, p = 0.005), PPV (95.4%, p = 0.002), and PLR (33.1, p <0.0001), and non-significant change in the AUC (0.953, p = 0.252), and sensitivity (93.3%, p = 0.467).

CONCLUSION

The diagnostic performance of O-RADS MRI scoring to characterize adnexal lesions could be improved by adding the ADCmean values through reducing false positives, increasing specificity, and maintaining good sensitivity.

Spectrum of Ovarian Incidentalomas: Diagnosis and Management

Incidental ovarian lesions are asymptomatic lesions that are accidentally discovered during a CT or MRI examinations that involves the pelvic cavity or during a routine obstetric ultrasound study. Incidental ovarian masses are usually benign with a very low risk of malignancy yet underlying malignant pathology may be discovered during the diagnostic work-up of these lesions. Suspicion of malignancy is directly correlating with the increase in the patient's age, the increase in the size of the lesion, the presence of the solid components or thick septa and a high color scale of the ovarian mass. Following standard reporting and management protocols are essential to choose the proper work-up of these lesions to avoid unnecessary additional imaging and operative intervention. In this article, we will provide a review of the characteristic imaging features of some incidental and yet commonly encountered ovarian lesions. We will also summarize the recently published algorithms that are important for consistent reporting and standard management of these lesions.

Ovarian Cystadenomas: Growth Rate and Reliability of Imaging Measurements

OBJECTIVES

To evaluate the growth rate of benign ovarian cystadenomas and the degree of variability in ultrasound measurements.

METHODS

Two independent retrospective cohorts of women found to have benign cystadenomas at surgery were identified. To assess growth rate, ultrasounds on women in a community-based health system were reviewed and the growth rate was determined based on the maximum reported size dimension using a mixed effect model. To assess measurement variability, two radiologists independently measured presurgical adnexal imaging findings for women in a tertiary care referral setting. Interobserver, intra-observer, and intermodality (cine clip versus still images) variability in measurements was determined using correlation coefficients (CC) and Bland-Altman analysis, with the proportion of measurements varying by more than 1 cm calculated.

RESULTS

For growth rate assessment, 405 women with 1412 ultrasound examinations were identified. The median growth rate was 0.65 cm/year with mucinous cystadenomas growing faster at 0.83 cm/year compared to 0.51 cm/year for serous cystadenomas (median test P < .0001). To evaluate measurement variability, 75 women were identified with 176 ultrasound studies. The within-subject standard deviations for ultrasound measurements were 0.74 cm for cine clip images and 0.41 cm for static images, with 11% of measurements overall differing by more than 1 cm.

CONCLUSIONS

Cystadenomas grow on average 0.65 cm/year, which is similar in magnitude to the inherent error observed in measurement on ultrasound, suggesting that repeat ultrasound at intervals of longer than a year will often be needed to accurately assess growth if a cyst represents a benign cystadenoma.

The Female Genital Tract on MDCT: A Pictorial Review of Normal Anatomy and Incidental Abnormalities

Purpose This article aims to review the pertinent anatomy and the incidental abnormalities involving the female genital tract on multidetector computed tomography (MDCT) through a pictorial review.

Methods The review is based on critical analysis of the existing literature as well as our experience in dealing with incidental lesions involving the female genital tract.

Results The lack of awareness regarding the normal appearances of the female pelvis on MDCT can puzzle the inexperienced radiologist and create management dilemmas for the treating clinician. It is important for radiologists to recognize normal appearances of the female genital tract on MDCT to prevent misinterpretation as pathology. The identification of incidentalomas of the female genital tract on CT can further guide whether additional workup is required or not. This pictorial review familiarizes radiologists with the normal appearances of the female genital tract on MDCT and a few common incidentalomas.

Conclusion It is imperative for a clinical radiologist to be familiar with the anatomy and common incidental lesions involving the female genital tract.

Benign-appearing Incidental Adnexal Cysts at US, CT, and MRI: Putting the ACR, O-RADS, and SRU Guidelines All Together

Adnexal cysts are a common incidental finding at US, CT, and MRI but have historically caused a diagnostic dilemma for determining when to follow up and how to manage them. Characteristic imaging features of simple adnexal cysts include a simple fluid collection with smooth walls and no solid or vascular components. Day-to-day practice guidelines were recently updated to reflect the overwhelming evidence that incidental cystic adnexal masses are almost always benign. Three major consensus articles on adnexal cystic masses were published between 2019 and 2020: the Society of Radiologists in Ultrasound (SRU) consensus update on adnexal cysts, the Ovarian-Adnexal Reporting and Data System (O-RADS) US consensus guideline, and the American College of Radiology (ACR) white paper on the management for incidental adnexal findings at CT and MRI. All three standardize reporting terminology, are based on evidence-based data and institutional practice patterns, and apply to nonpregnant women of average risk for ovarian cancer. While there are small differences in follow-up recommendations based on size thresholds, the goal of each is the same-to limit unnecessary imaging follow-up and, by doing so, save the patient time, money, and anxiety. For the diagnostic radiologist to use these guidelines, it is essential that the entire mass is visualized well. Without adequate visualization, further characterization of the mass may be necessary. To put it all together, the SRU consensus guideline and ACR white paper are easily applied in day-to-day practice for masses that are O-RADS 2 and below. An invited commentary by Patel is available online. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2022.

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

PURPOSE

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.

MATERIALS AND METHODS

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 18 months (range 1-80 months) 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.

RESULTS

Of 276 women (mean age 45 years), 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 > 5 cm (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.

CONCLUSION

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.

Revisiting Secondary Information Related to Pharmacogenetic Testing

Incidental or secondary findings have been a major part of the discussion of genomic medicine research and clinical applications. For pharmacogenetic (PGx) testing, secondary findings arise due to the pleiotropic effects of pharmacogenes, often related to their endogenous functions. Unlike the guidelines that have been developed for whole exome or genome sequencing applications for management of secondary findings (though slightly different from PGx testing in that these refer to detection of variants in multiple genes, some with clinical significance and actionability), no corresponding guidelines have been developed for PGx clinical laboratories. Nonetheless, patient and provider education will remain key components of any PGx testing program to minimize adverse responses related to secondary findings.

Computed Tomography Image Texture under Feature Extraction Algorithm in the Diagnosis of Effect of Specific Nursing Intervention on Mycoplasma Pneumonia in Children

To evaluate the effect of specific nursing intervention in children with mycoplasma pneumonia (MP), a feature extraction algorithm based on gray level co-occurrence matrix (GLCM) was proposed and combined with computed tomography (CT) image texture features. Then, 98 children with MP were rolled into the observation group with 49 cases (specific nursing) and the control group with 49 cases (routine nursing). CT images based on feature extraction algorithm of optimized GLCM were used to examine the children before and after nursing intervention, and the recovery of the two groups of children was discussed. The results showed that the proportion of lung texture increase, rope shadow, ground glass shadow, atelectasis, and pleural effusion in the observation group (24.11%, 3.86%, 8.53%, 15.03%, and 3.74%) was significantly lower than that in the control group (28.53%, 10.23%, 13.34%, 21.15%, and 8.13%) after nursing (P < 0.05). There were no significant differences in the proportion of small patchy shadows, large patchy consolidation shadows, and bronchiectasis between the observation group and the control group (P > 0.05). In the course of nursing intervention, in the observation group, the disappearance time of cough, normal temperature, disappearance time of lung rales, and absorption time of lung shadow (2.15 ± 0.86 days, 4.81 ± 1.14 days, 3.64 ± 0.55 days, and 5.96 ± 0.62 days) were significantly shorter than those in the control group (2.87 ± 0.95 days, 3.95 ± 1.06 days, 4.51 ± 1.02 days, and 8.14 ± 1.35 days) (P < 0.05). After nursing intervention, the proportion of satisfaction and total satisfaction in the experimental group (67.08% and 28.66%) was significantly higher than that in the control group (40.21% and 47.39%), while the proportion of dissatisfaction (4.26%) was significantly lower than that in the control group (12.4%) (P < 0.05). To sum up, specific nursing intervention was more beneficial to improve the progress of characterization recovery and the overall recovery effect of children with MP relative to conventional nursing. CT image based on feature extraction algorithm of optimized GLCM was of good adoption value in the diagnosis and treatment of MP in children.

Frequency of potential causes of lower back pain and incidental findings in patients with suspected sacroiliitis: retrospective analysis of 886 patients with negative sacroiliac MRI examination for sacroiliitis

BACKGROUND

In a majority of patients with suspected sacroiliitis (SI) who underwent sacroiliac magnetic resonance imaging (MRI), imaging studies may be normal, may depict other causes for pain, or may show clinically irrelevant incidental findings.

PURPOSE

To determine the prevalence of possible etiologies other than SI and frequency of incidental findings demonstrated on sacroiliac MRI examinations in a cohort of patients with lower back pain and suspected SI.

MATERIAL AND METHODS

Sacroiliac MRI examinations of 1421 patients with suspected SI were retrospectively reviewed. In patients without SI findings, other potential causes for lower back pain and incidental findings were documented.

RESULTS

SI was present in 535 of 1421 patients (37.6%). In 886 of the patients whose MRI studies were negative for SI, other possible causes for lower back pain or incidental findings were seen in 386 (43.5%). The most common musculoskeletal (MSK) finding was lumbosacral transitional vertebra (8.6%) followed by findings suggesting piriformis syndrome (4.2%), spondylosis (3.7%), and sacral insufficiency fractures (1.8%). The most common non-MSK findings were follicular cysts (15.3%) and uterine fibroids (4.9%).

CONCLUSION

In patients with suspected SI but negative MRI examinations for SI, some other possible causes for lower back pain and several incidental findings can be seen on imaging. The presence of these findings may explain the patient's symptoms, and awareness of these conditions may be helpful in patient management and individualizing treatment.

Growth Rate of Ovarian Serous Cystadenomas and Cystadenofibromas

OBJECTIVES

We analyzed growth rates of benign ovarian serous cystadenomas and cystadenofibromas to understand what percentage would show a volume doubling time (DT) of less than 3 years, between 3 and 5 years, or greater than 5 years.

METHODS

We retrospectively reviewed pathology records (January 1, 2014, to June 30, 2019) to find all surgically excised ovarian serous cystadenomas and cystadenofibromas. Imaging records were then reviewed to identify those that had been confidently identified with ultrasound imaging, magnetic resonance imaging, or computed tomography at least twice before surgical removal, with at least a 60-day interval between studies. Three orthogonal measurements were recorded on the first and last imaging studies on which the mass was detected, with volume calculations by the prolate formula (product of 3 measurements multiplied by 0.52). The volume DT was calculated and grouped into 1 of 5 categories: (1) DT of less than 1 year; (2) DT of 1 to 3 years; (3) DT of 3 to 5 years; (4) DT of 5 to 10 years; and (5) no growth (any mass with a DT >10 years or showing a decrease in volume).

RESULTS

A total of 102 of 536 cystadenomas and 44 of 227 cystadenofibromas met inclusion criteria. Of the 146 tumors, 40 (27.4%) had a DT of less than 1 year; 38 (26.0%) had a DT of 1 to 3 years; 22 (15.1%) had a DT of 3 to 5 years; 10 (6.8%) had a DT of 5 to 10 years; and 36 (24.7%) showed no growth.

CONCLUSIONS

A total of 53.4% of ovarian serous cystadenomas/cystadenofibromas have a DT of less than 3 years; 15.1% have a DT between 3 and 5 years; and 31.5% have a DT of greater than 5 years or show no growth.

Incidentalomas of the female genital tract on 64-slice MDCT: a clinico-radiological pictorial review

Sonography is the imaging modality of choice for diagnosing diseases of the female genital tract due to its high resolution, easy availability, low cost and lack of radiation. CT is not advocated for the primary evaluation of the female pelvis. However, with the advent of Multidetector CT (MDCT), females of all ages undergo CT scan of the abdomen and pelvis for myriad non-gynaecological diseases, e.g. subacute intestinal obstruction, abdominal lump, abdominal tuberculosis, appendicitis, ureteric colic, pancreatitis, oncological staging, follow-up, etc. Incidental female genital tract disorders were seen on these scans that are a dilemma for both, the radiologists and the clinicians. The objective of this pictorial review is to characterise the incidentally detected lesions of the female genital tract observed on 64-slice MDCT by correlating with sonography, if necessary, and establishing a clinico-radiological diagnosis. Our aim is to emphasise that the radiologist may be the first person to recognise a gynaecologic disorder and hence can play a significant role in patient management.

Radiologists' Increasing Role in Population Health Management: AJR Expert Panel Narrative Review

Population health management (PHM) is the holistic process of improving health outcomes of groups of individuals through the support of appropriate financial and care models. Radiologists' presence at the intersection of many aspects of healthcare, including screening, diagnostic imaging, and image-guided therapies, provides significant opportunity for increased radiologist engagement in PHM. Further, innovations in artificial intelligence and imaging informatics will serve as critical tools to improve value in healthcare through evidence-based and equitable approaches. Given radiologists' limited engagement in PHM to date, it is imperative to define the specialty's PHM priorities so that the radiologists' full value in improving population health is realized. In this expert review, we explore programs and future directions for radiology in PHM.

Incidental Ovarian and Uterine Findings on Cross-sectional Imaging

Incidental adnexal masses and uterine findings occur with a high frequency on cross-sectional imaging examinations, particularly in postmenopausal women in whom imaging is performed for a different reason. These incidentalomas encompass a gamut of potential pelvic gynecologic disorders. Most are benign ovarian cysts; however, other less commonly encountered disorders and improperly positioned gynecologic devices may be seen. A knowledge of the management recommendations for such pelvic incidental findings is critical to avoid unnecessary imaging and surgical interventions, as well as to avoid failure in diagnosis and management of some of these conditions.

General Review on the Current Management of Incidental Findings on Cross-Sectional Imaging: What Guidelines to Use, How to Follow Them, and Management and Medical-Legal Considerations

"Incidentalomas" are a common part of daily practice for radiologists, and knowledge of appropriate management guidelines is important in ensuring that no potentially clinically relevant findings are missed or are lost to follow-up in asymptomatic patients. Incidental findings of the brain, spine, thyroid, lungs, breasts, liver, adrenals, spleen, pancreas, kidneys, bowel, and ovaries are discussed, including where to find guidelines for management recommendations, how to follow them, and medical-legal considerations.

Incidence, Impact, and Management of Incidentalomas on Preoperative Computed Tomographic Angiograms for Breast Cancer Patients with and without Genetic Mutations

BACKGROUND

Preoperative abdominal computed tomographic angiograms for free flap breast reconstruction improve operative safety and efficiency, but incidental findings are common and potentially affect management. In addition, the authors hypothesized that patients with genetic mutations might have a higher rate of significant findings. The authors present the largest series of computed tomographic angiogram "incidentalomas" in these two populations and an evidence-based algorithm for managing common findings.

METHODS

All patients undergoing free flap breast reconstruction at Northwell Health between 2009 and 2017 were eligible. Medical history, perioperative details, and radiology reports were examined with abnormal findings recorded. Published literature was reviewed with radiologists to develop standardized guidelines for incidentaloma management.

RESULTS

Of 805 patients included, 733 patients had abdominal imaging. One hundred ninety-five (27 percent) had a completely negative examination. In the remaining 538 patients, benign hepatic (22 percent) and renal (17 percent) findings were most common. Sixteen patients (2.2 percent) required additional imaging (n = 15) or procedures (n = 5). One finding was concerning for malignancy-renal cell carcinoma-which interventional radiology ablated postoperatively. Seventy-nine patients (10.8 percent) had a genetic mutation but were not found to have a statistically significant higher rate of incidentalomas.

CONCLUSIONS

The authors' rate of computed tomographic angiography incidental findings (73 percent) is consistent with previous studies, but the rate requiring further intervention (2.2 percent) is lower. Incidental findings were no more common or pathologic among genetic mutation carriers. The authors also introduce an evidence-based algorithm for the management of common incidentalomas. Using these guidelines, plastic surgeons can reassure patients, regardless of mutation status, that incidentalomas are most commonly benign and have minimal impact on their surgical plan.

Contemporary Guidelines for Adnexal Mass Imaging: A 2020 Update

Incidental adnexal masses are commonly encountered at ultrasound, computed tomography, and magnetic resonance imaging. Since many of these lesions are surgically resected and ultimately found to be benign, patients may be exposed to personal and economic costs related to unnecessary oophorectomy. Thus, accurate non-invasive risk stratification of adnexal masses is essential for optimal management and outcomes. Multiple consensus guidelines in radiology have been published to assist in characterization of these masses as benign, indeterminate, or likely malignant. In the last two years, several new and updated stratification systems for assessment of incidental adnexal masses have been published. The purpose of this article is to offer a concise review of four recent publications: ACR 2020 update on the management of incidental adnexal findings on CT and MRI, SRU 2019 consensus update on simple adnexal cysts, O-RADS ultrasound risk stratification system (2020), and O-RADS MRI risk stratification system (2020).

Oncologically Relevant Findings Reporting and Data System (ONCO-RADS): Guidelines for the Acquisition, Interpretation, and Reporting of Whole-Body MRI for Cancer Screening

Acknowledging the increasing number of studies describing the use of whole-body MRI for cancer screening, and the increasing number of examinations being performed in patients with known cancers, an international multidisciplinary expert panel of radiologists and a geneticist with subject-specific expertise formulated technical acquisition standards, interpretation criteria, and limitations of whole-body MRI for cancer screening in individuals at higher risk, including those with cancer predisposition syndromes. The Oncologically Relevant Findings Reporting and Data System (ONCO-RADS) proposes a standard protocol for individuals at higher risk, including those with cancer predisposition syndromes. ONCO-RADS emphasizes structured reporting and five assessment categories for the classification of whole-body MRI findings. The ONCO-RADS guidelines are designed to promote standardization and limit variations in the acquisition, interpretation, and reporting of whole-body MRI scans for cancer screening. Published under a CC BY 4.0 license Online supplemental material is available for this article.

Maternal and fetal incidental findings on antenatal magnetic resonance imaging

BACKGROUND

Magnetic resonance imaging (MRI) examinations are increasingly used in antenatal clinical practice. Incidental findings are a recognized association with imaging and although in some circumstances their identification can alter management, they are often associated with increased anxiety, for both patient and clinician, as well as increased health care costs.

OBJECTIVE

This study aimed to evaluate the incidence of unexpected findings in both the mother and fetus during antenatal MRI examinations.

MATERIALS AND METHODS

A retrospective study was undertaken over a five-year period at St.. Thomas' Hospital in London. Maternal incidental findings were recorded from all clinical reports of all fetal MRIs performed (for clinical reasons and in healthy volunteers) during this period. Fetal incidental findings were recorded only in cases where women with uncomplicated pregnancies were participating as healthy volunteers.

RESULTS

A total of 2,569 MRIs were included; 17% of women had maternal incidental findings. Of these, 1,099 were women with uncomplicated pregnancies who undertook research MRIs as healthy volunteers; fetal incidental findings were identified in 12.3%.

CONCLUSION

Incidental findings are a common occurrence in antenatal MRI. Consideration should be given to counseling women appropriately before imaging and ensuring that robust local protocols are in place for follow-up and further management of such cases.

Surveillance in Older Women With Incidental Ovarian Cysts: Maximal Projected Benefits by Age and Comorbidity Level

PURPOSE

The aim of this study was to estimate effects on life expectancy (LE) of imaging-based ovarian surveillance after detection of incidental postmenopausal ovarian cysts, under different assumptions of patient age, comorbidity level, and cancer risk and detection.

METHODS

A decision-analytic Markov model was developed to estimate LE benefits. Hypothetical cohorts of postmenopausal women with simple ovarian cysts were evaluated, with varied age (66-80 years) and comorbidity level (none, mild, moderate, severe). For each cohort, imaging "follow-up" (2 years) and "no-follow-up" strategies were compared. Consistent with current evidence, increased cancer risk in patients with cysts was not assumed; however, incident ovarian cancers could be detected during follow-up. To estimate theoretical maximal LE gains from follow-up, perfect ovarian cancer detection and treatment during follow-up were assumed. This and other key assumptions were varied in sensitivity analysis.

RESULTS

Projected LE gains from follow-up were limited. For 66-, 70-, 75-, and 80-year-old women with no comorbidities, LE gains were 5.1, 5.1, 4.5, and 3.7 days; with severe comorbidities, they were 3.5, 3.2, 2.7, and 2.1 days. With sensitivity of 50% for cancer detection, they were 3.7 days for 66-year-old women with no comorbidities and 1.3 days for 80-year-old women with severe comorbidities. When cancer risk for women with cysts was assumed to be elevated (1.1 times average risk), LE gains increased only modestly (5.6 and 2.3 days for analogous cohorts).

CONCLUSIONS

Even in the circumstance of perfect ovarian cancer detection and treatment, surveillance of postmenopausal women (≥66 years of age) with simple cysts affords limited benefits, particularly in women with advanced age and comorbidities.