For some patients, identifying biopsy clips on breast magnetic resonance imaging (MRI) may be challenging due to variabilities in the size and shape of the biopsy clips, associated susceptibility artifacts and the types of sequences and acquisition parameters.

Based on the findings of a recently published study looking at four sequences to assess breast MRI for biopsy clips, researchers said the contrast-enhanced, in-phase Dixon sequence provided the highest sensitivity, contrast-to-noise ratio (CNR) and reader confidence in comparison to clinical sequencing techniques.

For the retrospective study, recently published in the 

, researchers reviewed contrast-enhanced breast MRI exams from 164 women with a total of 281 breast biopsy clips. The study authors subsequently compared the contrast-enhanced, in-phase Dixon MRI sequence with three standard sequences including short tau inversion recovery (STIR); T1-weighted, non-fat-suppressed (T1W NFS) sequencing; and first phase sequencing from dynamic, contrast-enhanced T1W fat-suppressed (T1W FS) imaging.

The contrast-enhanced, in-phase Dixon sequence had an 85.1 percent pooled sensitivity rate in comparison to 78.2 percent for T1W NFS, 61.7 percent for T1W FS and 26.6 percent for STIR sequencing, according to the study. The researchers added that the contrast-enhanced, in-phase Dixon sequence also maintained similar positive predictive value (96.4 percent) in comparison to STIR (92.2 percent), T1W NFS (96.1 percent) and T1W FS (92.8 percent).

“The (contrast-enhanced in-phase Dixon) sequence resulted in significantly improved reader sensitivity at both the clip and breast level, as well as significantly improved reader confidence and CNR,” wrote Jay A. Baker, M.D., a professor in the Department of Radiology and chief of the Division of Breast Imaging at the Duke University Medical Center in Durham, N.C., and colleagues. 

“However, this improved detection was not associated with a significant loss in PPV at the clip level or in specificity at the breast level. Thus, the (contrast-enhanced in-phase Dixon) sequence may reduce the need for radiologists to correlate with other imaging modalities to identify areas of prior biopsy when interpreting breast MRI examinations.”

Baker and colleagues also noted a higher mean contrast-to-noise ratio (CNR) with the contrast-enhanced, in-phase Dixon sequence (4.05) in comparison to T1W NFS (1.21), STIR (0.57) and T1W FS (0.54). They attributed the significantly higher CNR to administration of IV contrast and the absence of fat suppression.

“Fat suppression … is undesirable when identifying biopsy clips because it causes the fat in the breast to become hypointense and therefore closer in signal intensity to the biopsy marker clip,” pointed out Baker and colleagues. “In addition, the administered contrast media reduces anatomic noise by increasing the signal intensity of fibroglandular tissue to approach that of relatively hyperintense fat, thereby reducing the variability of signal intensities present in the underlying breast tissue.”

The researchers added that titanium clips contributed to the lowest reader confidence with T1W NSF and the contrast-enhanced, in-phase Dixon sequencing. The highest reader confidence with T1W NSF and the contrast-enhanced, in-phase Dixon sequencing was associated with stainless steel and BioDur 108 clips, according to the study.

In regard to study limitations, the authors noted that simultaneous review of the four imaging sequences may have influenced clip detection on a given sequence. Pointing out that all the breast MRI examinations were completed with 3T MRI, Baker and colleagues acknowledged that sequence comparisons may have different results with 1.5T MRI. The study also did not assess the impact of clip visibility on post-biopsy changes, breast density or the time interval between biopsy and MRI, according to the study authors.

Articles

Emerging research suggests that the contrast-enhanced, in-phase Dixon sequence may be the most optimal sequence for detecting biopsy clips on breast magnetic resonance imaging (MRI).

Locating Biopsy Marker Clips on Breast MRI: What a New Study Reveals

The new Chiropractic Straight Arm (CSA) system with Dynamic Digital Radiography (DDR) has garnered 510(k) clearance from the Food and Drug Administration (FDA), according to 20/20 Imaging, a division of Konica Minolta Healthcare Americas, Inc.

 allows low-cost, high-speed capture of static and dynamic images. A cine loop with the DDR technology allows one view acquisition on conventional digital radiography to provide up to a 20-second snapshot of anatomical motion, according to 20/20 Imaging.

Other features of the compact CSA include detailed bone and soft tissue visualization with a 17” x 17” field of view detector as well as predetermined anatomy-specific patient positioning to help simplify workflow. The company emphasized that flexibility and range of motion of the CSA system accommodate a variety of patient positioning needs from standing to lying on a table and those using wheelchairs.

20/20 Imaging also noted the combination of CSA and DDR enables one to obtain dynamic views of the cervical spine during flexion and extension, a key attribute that can be helpful with the documentation of whiplash injuries.

“CSA with DDR is the next-generation imaging solution allowing chiropractors to examine and measure a patient’s biomechanics and musculoskeletal injury, including whiplash, and more confidently evaluate treatment follow-up,” noted Bob Salzman, the president of 20/20 Imaging. “Designed to boost clinical capabilities to the next level by capturing patient movement, CSA with DDR gives chiropractors the immediate results they need to make informed decisions faster.”

Combining low-cost, high-resolution radiography with dynamic imaging capabilities and design attributes to optimize workflow efficiency, the Chiropractic Straight Arm system may enhance musculoskeletal imaging.

FDA Grants 510(k) Clearance to Chiropractic Straight Arm Radiography System

Offering the promise of enhanced efficiencies, reduced costs and improved patient care for expectant mothers, Philips will launch FetView, 

a cloud-based fetal ultrasound platform with enhanced reporting and image-sharing capabilities

, at the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) World Congress (Sept. 16-18) in London.

Utilizing a secure encrypted DICOM interface, the vendor-neutral software enables remote access to a patient’s fetal ultrasound images and medical history. FetView also allows physicians to share new images, convey fetal growth projections and reduce the number of rescans.

Alexander Scharf, MD, the managing director of MVZ PraenatGyn in Mainz, Germany, said the FetView software has provided a productivity “turbo boost” for his practice.

“The flexibility of the software is seamlessly integrated into my existing workflows and everything I need to access in the reporting is just one click away,” noted Dr. Scharf, who will be lecturing at the ISUOG conference. “The digital sharing of ultrasound images taken as part of prenatal care in accordance with data protection regulations and shared via a secure portal help provide added peace of mind, which is so important to expectant mothers.”

Philips said the remote access capabilities of the FetView ultrasound software improve access to quality care and can help reduce mobility for patients in high-risk pregnancies and those who have recently had surgery.

“The cloud-based reporting and image sharing capabilities of Philips FetView enhance remote communication between physicians and patients,” said Matthijs Groot Wassink, the general manger of OB/GYN Ultrasound at Philips. “By digitizing the workflow, we are taking ultrasound to the next level, delivering smart ultrasound documentation to any OB/GYN practice. The digital reporting and image sharing, and fully customizable design are hugely helpful for physicians, helping to drive efficiency and cost savings with increasing patient satisfaction in their daily practice.”

Emphasizing the digitalization of OB/GYN workflows and patient management, the cloud-based system reportedly facilitates real-time access to fetal ultrasound images and related data from any ultrasound system.

Philips Set to Launch FetView Fetal Ultrasound Platform at ISUOG Conference

B) A crazy paving pattern associated with pulmonary alveolar proteinosis

Image IQ Quiz: HIV-Positive Patient with Respiratory Distress

In light of radiology shortages, the authors of a new study suggest that radiographers could play a role in assessing mammograms.

, researchers in the United Kingdom compared radiologists (224) versus radiographers (177) in the assessment of 1,404,395 digital screening mammograms between April 2015 to March 2016.

The mean cancer detection rate (CDR) for radiologists was 7.84 per 1,000 mammograms versus 7.53 per 1,000 mammograms for radiographers, according to the study authors. The researchers also saw no significant differences with mean recall rates (5.0 percent for radiologists in comparison to 5.2 percent for radiographers) nor positive predictive values (17.1 percent for radiologists and 16.1 percent for radiographers), according to the study.

“Readers from each professional group showed no statistically significant difference in the key screening performance metrics of cancer detection rate, recall rate (RR), and positive predictive value (PPV) and demonstrated lower RR and higher PPV with more reader experience,” wrote lead study author Yan Chen, M.D., an associate professor of Cancer Screening within the Faculty of Medicine and Health Sciences at the University of Nottingham School of Medicine, and colleagues.

Chen and colleagues also noted no significant differences in the mean CDR between readers with five years of experience or less (7.71 per 1,000 mammography exams) and readers with more than a decade of experience (7.75 per 1,000 mammography exams).

Regardless of professional group, the researchers noted that readers with five years of experience or less had a higher mean RR (5.8 percent) versus those with greater than 10 years of experience (4.8 percent). Similarly, Chen and colleagues noted little variation in PPV between radiologists and radiographers but readers with more than 10 years of experience had a 17.5 percent PPV in comparison to a 14.9 percent PPV for readers with five year of experience or less.

While acknowledging that more studies are necessary to assess the potential role of physician extenders to review mammograms, Chen and colleagues said the study findings suggest “(the) use of trained radiographer readers in the double-reading workflow may offer a potential solution to the shortage of radiologists experienced by some breast screening programs.”

, Regina J. Hooley, M.D. and Melissa A. Durand, M.D., who are both affiliated with the Department of Diagnostic Radiology and Biomedical Imaging at the Yale University School of Medicine, noted that European breast screening requirements for clinicians are more rigorous than those in other countries, including the United States. They pointed out that mammography readers in Europe are professionally required to assess between 3,000 to 5,000 mammograms annually in comparison to U.S.-based radiologists who are required to interpret 960 mammograms every two years.

While Drs. Hooley and Durand noted the “potential (of physician extenders) to mitigate the high breast imaging workload without sacrificing patient care,” they maintained that investment and resources would be necessary to develop training programs for these clinicians.

In regard to study limitations, the authors said potential sources of bias may have stemmed from the exclusion of 124 clinicians who did not consent to analysis of their mammography assessments, and a possible exclusion of lower volume readers due to the study’s focus on readers who completed the minimum National Health Service Breast Screening Program (NHSBSP) standard of 1,500 first reader assessments a year. The study authors also pointed out the three-year screening interval in their study population and the focus on two-dimensional digital mammography as opposed to digital breast tomosynthesis (DBT).

In a new United Kingdom study comparing radiologist and radiographer assessment of over 1.4 million digital mammograms, researchers said there were no significant differences with cancer detection rates or recall rates.

What a New Study Reveals About Radiographers and Mammography Assessment

Noting that nearly 40 percent of pancreatic cancer tumors smaller than 2 cm are missed on computed tomography (CT) assessment, the authors of a new study suggest that an emerging deep learning tool could have an impact in improving detection.

In the study, conducted in Taiwan and published earlier today in 

, researchers examined the effectiveness of a deep learning tool for detecting malignant pancreatic tumors on contrast-enhanced CT in a nationwide validation test set consisting of 669 patients with pancreatic cancer and 804 participants in the control group.

 The deep learning tool was trained with contrast-enhanced CT scans from 546 patients with pancreatic cancer and 733 healthy control patients, according to the study.

The researchers found that the deep learning tool had an 89.7 sensitivity rate and a 92.8 percent specificity rate for detecting pancreatic cancer in the nationwide validation test set. In local test set data drawn from 109 patients with pancreatic cancer at a tertiary referral center and 147 control participants, the study authors noted no significant differences in sensitivity between assessment by attending radiologists (96.1 percent) and the deep learning tool (90.2 percent).

“This study developed an end-to-end, deep learning-based, computer-aided detection (CAD) tool that could accurately and robustly detect pancreatic cancers on contrast-enhanced CT scans. The CAD tool may be a useful supplement for radiologists to enhance detection of (prostate cancer).” wrote study co-author Weichung Wang, Ph.D, who is affiliated with the National Taiwan University Center for Artificial Intelligence and Advanced Robotics, and colleagues.

The study findings also suggested promising potential for the deep learning tool with respect to smaller pancreatic lesions that are frequently missed on CT, according to the study authors.

“The comparable sensitivity between the CAD tool and experienced radiologists at a tertiary referral center supports the idea that the CAD tool might be useful for reducing the miss rate attributed to disparities in expertise,” explained Wang and colleagues. “ … Previous research showed that approximately 40 percent of (pancreatic cancers) smaller than 2 cm were missed on CT scans whereas our CAD tool achieved 87.5% and 74.7% sensitivity for (pancreatic cancers) smaller than 2 cm in the local and nationwide test sets respectively.”

, Alex M. Eisen, M.D and Pedro Rodrigues, Ph.D. praised the “quantity and quality of the training and test data,” the algorithm’s evaluation of three-dimensional data and the robust measurement of the algorithm’s effectiveness.

 The use of artificial intelligence (AI) to perform mundane tasks and track tumor progression over time “may become ubiquitous in the reading room,” according to Dr. Aisen, a professor emeritus of Radiology and Imaging Sciences at Indiana University, and Dr. Rodrigues, a clinical scientist at Philips Healthcare.

In regard to study limitations, the authors concede that the sensitivity rate findings coming from a tertiary referral center for prostate cancer may limit extrapolation of the data to general settings. They also noted a lack of access to radiologist reports from the nationwide data set and a predominantly Asian population in the test set that was fairly homogenous in terms of ethnic and racial diversity. The control group lacked patients with pancreatic abnormalities other than prostate cancer, according to the study authors.

1. Chen PT, Wu T, Wang P, et al. Pancreatic cancer detection on CT scans with deep learning: a nationwide population-based study. 

 . Published September 13, 2022. Accessed September 13, 2022.

2. Dewitt J, Devereaux BM, Lehman GA, Sherman S, Imperiale TF. Comparison of endoscopic ultrasound and computed tomography for the preoperative evaluation of pancreatic cancer: a systematic review. 

3. Aisen AM, Rodrigues PS. Deep learning to detect pancreatic cancer at CT: Artificial intelligence living up to its hype. 

https://pubs.rsna.org/doi/10.1148/radiol.222126

New research reveals that an emerging deep learning tool had comparable sensitivity and specificity to radiologist assessment of contrast-enhanced computed tomography (CT) scans for pancreatic cancer, and a 74.7 percent sensitivity rate for tumors smaller than 2 cm. 

Could a New Deep Learning Tool Enhance CT Detection of Pancreatic Cancer?

The Food and Drug Administration (FDA) has granted a breakthrough device designation for OssView, a software program that may represent a significant advance over bone mineral density (BMD) measurements for assessing fragility fracture risk in women over the age of 70.

CurveBeam AI, the manufacturer of OssView, said the software assesses bone microstructural deterioration from high-resolution peripheral quantitative computed tomography (HR-pQCT) scans of the wrist and subsequently calculates a structural fragility score (SFS).

In contrast to the measurement of bone mineral content and density with BMD testing, CurveBeam AI said the SFS can provide 

a better evaluation of fragility fracture risk through the assessment of bone architecture

. Citing previous research published in the 

, CurveBeam AI noted that reliance on bone density testing may miss up to 80 percent of fragility fractures.

“Most fractures occur in women with modest deficits in BMD called osteopenia. The many women in the community with osteopenia who are at risk of a fracture are unlikely to be offered treatment because of the mistaken belief that finding BMD in the osteopenia range means the bone is not fragile,” noted Ego Seeman, MD, an endocrinologist, and professor of medicine in the Departments of Medicine and Endocrinology at the University of Melbourne in Australia.

“There is a clear need for an improved clinical aid like SFS to help clinicians more effectively assess bone health and prevent fractures,” noted Greg Brown, the CEO of CurveBeam AI. “We are looking forward to progressing its clearance with the FDA.”

Noting that OssView is not commercially available in the United States, CurveBeam AI said the software program is currently reserved only for investigational use.

1. Samelson EJ, Broe KE, Xu H, et al. Cortical and trabecular bone microarchitecture as an independent predictor of incident fracture risk in older women and men in the Bone Microarchitecture International Consortium (BoMIC): a prospective study. 

Assessing high-resolution computed tomography (CT) scans of the wrist, CurveBeam AI’s OssView software reportedly enables clinicians to ascertain bone fragility and fracture risk for women over the age of 70.

CT AI Software for Fracture Risk Gets Breakthrough Device Designation from FDA

C) Metastatic disease with pathologic fractures

Image IQ Quiz: Multiple Rib Fractures in a Two-Month-Old Baby

Incidental findings, or incidentalomas, are coincidental imaging findings in an asymptomatic patient or findings in a symptomatic patient undergoing imaging for an unrelated reason. With higher imaging utilization and improved imaging resolution, the prevalence and burden of incidentalomas are rising.

 Management of incidentalomas is frequently challenging because of uncertain or absent classification systems. Poor patient communication often complicates the situation, resulting in under- or overdiagnosis. These factors could increase clinical practice errors and raise legal liability.

Due to the heterogeneity of imaging modalities and disease processes, the prevalence of incidentalomas is highly variable. A 2018 umbrella review revealed that CT chest incidentalomas (including CT cardiac, thorax, abdomen, spine, and heart) are the most prevalent at 45 percent, followed by CT colonography (38 percent), cardiac MRI (34 percent), and MRI of the brain (22 percent) and spine (22 percent).

 Conversely, incidentalomas found on CT chest for pulmonary embolism (2 percent) and whole-body PET/CT (< 2 percent) were the least prevalent.

Although most incidentalomas are not an immediate danger to patients, some findings, such as neoplasms, may have a significant impact on one’s health. Malignancy rates vary substantially between organs. Breast incidentalomas reportedly have the highest malignancy rates at 42 percent.

 Renal, thyroid, and ovarian incidentalomas were malignant in greater than 25 percent of cases while extra-colonic, prostatic, and colonic incidentalomas were malignant 10 to 20 percent of the time.

 Brain, parotid, and adrenal glands had the lowest malignancy rates at less than 5 percent.

Unsurprisingly, incidentalomas have become a challenging clinical issue for radiologists, referring providers, and patients. Adherence and follow-up have ranged from 36 to 67 percent depending on patient population, availability of guidelines, clinical settings, and system-level communication.

Accordingly, let us take a closer look at avenues for improvement and examples of strategies to improve the management of incidentalomas.

Addressing Communication Concerns About Incidentalomas

It is uncommon for radiologists to communicate directly with patients regarding their results as patients often receive instructions from their primary care physicians (PCPs) or the ordering physicians.

 However, Zafar and colleagues found that PCPs were unlikely to act on incidentalomas without "explicit radiologist recommendations" if they had no prior experience with the finding or if it occurred in an unusual clinical context.

 Surveys have shown that "clear and actionable follow-up recommendations" exist in only 52 percent of cases.

 As such, incidentalomas without specific recommendations may not receive adequate follow-up.

Specific and clear recommendations can also alleviate overdiagnosis. Ambiguity in reporting language has increased misunderstandings in referring providers and patients. In Rosenkrantz's study, descriptions such as "statically likely to be a cyst," “too small to characterize," or "most likely a cyst" were all associated with less than 1 percent perceived likelihood of malignancy by radiologists but resulted in up to 46 percent follow-up by the referring physician.

 Rather than qualitative recommendations, radiologists could provide a numerical risk estimate to minimize ambiguity in their reports. The increased clarity would prevent patient misunderstandings and alleviate anxiety.

The American College of Radiology (ACR) Incidental Findings Committee has published white papers outlining imaging and clinical criteria for follow-up of incidentalomas and has made them readily available for use.

 Radiologists may use these guidelines to improve potential areas of ambiguity in their reports and direct referring physicians to evidence-based management.

However, no guidelines exist for incidentalomas in the spine, breast, brain, colon, prostate, or parotid glands.

 In those cases, specific evidence-based recommendations may be challenging. Furthermore, risk assessment for some incidentalomas is not possible without further imaging. For example, liver lesions on single-phase CT require additional imaging to characterize the lesions, and multiple co-morbidities in the patient could further complicate the read.

 The incidentalomas should trigger an interdisciplinary conversation between the radiologist and the referring provider.

While the radiologist provides expertise on the image findings, the referring provider can provide clinical context via history, physical examination, and previous treatments because the clinical context may be challenging for radiologists to ascertain. The benefit of interdisciplinary collaboration would extend to the patients as it prevents discordant treatment and follow-up plans, minimizing patient confusion and alleviating anxiety.

While more precise reporting would improve incidentaloma follow-up, patients could still fall through the cracks. The Joint Commission identified timely reporting of critical tests and diagnostic procedures as part of the National Patient Safety Goals in 2005.

 In practice, however, implementation has been inconsistent. Surveys have shown that in institutions with policy guidelines requiring closed-loop communication, actual compliance with these guidelines occurred 26 percent of the time.

 Clinical effectiveness outcomes looking for rates of treatment, diagnosis, and clinical outcomes are limited so there is potential for a large number of incidentalomas going undetected.

Emphasizing Closed-Loop Communications and System-Level Changes

Closed-loop communication requires close interdisciplinary collaboration. Multiple studies have attempted to evaluate intervention strategies that improve follow-up, and those that demonstrate the highest levels of improvement utilized system-level interventions.

 After reviewing these study findings, we have categorized three central communication nodes as common intervention points and discuss the available methods to improve incidentaloma follow-up.

Communication Node 1: Radiology Team to Clinical Team

The radiologist has reviewed the index imaging study and is now relaying the information to referring provider. Due to the 21st Century Cures Act, which was signed into law on December 13, 2016, the patient can also view the radiology report. In this communication node, the radiologist has the most expertise. The purpose of this communication node is to accurately convey findings and recommendation guidelines to the clinical care team.

Several studies have demonstrated improved adherence and management when evidence-based guidelines are readily available to radiologists. After Zygmont and colleagues created a 16-page electronic summary guideline for the emergency department (ED), the correct management of ultrasound and CT incidentalomas improved from 67.5 percent to 80.2 percent.

 Interestingly, the team did not teach radiologists guideline content but rather informed the radiologists on the importance of following guidelines. The ease of accessibility was sufficient to yield improvement in management.

Similarly, Kim et al. found that adherence for society recommendations on follow-up imaging of ovarian cysts increased from 50 percent to 80 percent after integrating electronic guidelines.

The availability of guidelines for references eliminated potential confusion when recommending follow-up. The integration of guidelines into dictation devices would serve to optimize workflow.

However, providing electronic guidelines to radiologists without sufficient referring clinician involvement did not demonstrate a statistically significant increase in adherence.

 A potential solution without significant workflow disruption would be creating a guideline-based radiology report. In a preliminary study, Woloshin and colleagues utilized an "enhanced report" to include clinician management strategies for pulmonary nodules. Eighty-eight percent of the surveyed clinicians strongly preferred the enhanced report, and 75 percent felt that the information gave them more confidence in management.

 While the utility of the "enhanced report" has not yet been tested in clinical practice, the study demonstrates a proof of concept that would enhance communication between the radiologist and the referring clinician.

Communication Node 2: Clinical Team to Patient

Once the information has been accurately relayed, the clinical care team would inform patients about the results, educate them on treatment options, and coordinate follow-up plans. The radiologist plays a more supportive role while the clinical team takes on the primary responsibility to ensure a shared-decision plan.

The type of clinical team plays an influential role in incidentaloma follow-up. Outpatients had the highest follow-up at 66.7 percent, followed by the emergency department (ED) patients at 46.0 percent and inpatients at 36.0 percent.5 Among outpatient physicians, PCPs were most likely to follow up at 67 percent, followed by internal medicine at 50 percent and surgery at 38 percent.

 The results are unsurprising. Outpatient PCPs and internal medicine physicians are comfortable with the longitudinal management of patients whereas surgeons are more likely to be focused on surgical issues. Patients who arrive at the ED may not have regular PCPs in the institution, contributing to lower follow-up rates.

Therefore, closed-loop communication would be essential to ensure that clinicians adequately adhere to evidence-based guidelines for follow-up. Shelver and colleagues utilized a lung nodule registry that interacted with the electronic health record (EHR) to ensure tracking completion.

 If tracking is indicated for the patient, support staff will activate an EHR alert until the referring physician addresses the incidentaloma. After the implementation of the tracking system, patients who were lost to follow-up or received delayed care decreased from 74 percent pre-intervention to 10 percent post-intervention.

Baccei and colleagues implemented a similar alert system in the ED with positive effects.

 If an incidentaloma was discovered, the radiologist selected a checkbox labeled "incidental ED findings," which would route a report directly to the ordering ED physician's email. The alert would prompt the ED physician to converse with the patient or family regarding the findings. With additional optimization, the researchers noted a greater than 93 percent compliance rate in the study.

 The dramatic improvement after implementation demonstrates the value of closing the communication loop.

Communication Node 3: Health System to Patient

Once the patients have been informed of the incidentalomas and understand the following steps, the health system must actively ensure appropriate follow-up. The support staff becomes a significant part of the communication node as time progresses beyond the index imaging and patient discussion.

The support staff role is particularly vital when physicians do not receive the radiology report prior to patient discharge, such as in the ED. Baccei and colleagues created a "safety net" that used an Outlook e-mail inbox to track incidentalomas.

 A dedicated follow-up team monitored the inbox for incidentalomas to ensure that the ED provider had completed the workflow. The radiology report was also faxed to the patient's primary care provider if one was listed in the EHR. Furthermore, phone messages and certified mail requesting a call back serve as additional protection in preventing losses through follow-up.

In a separate study, Wandtke and colleagues took a similar approach.

 They re-sent the radiology report, called the PCP’s office, and sent a letter to the patient if follow-up was incomplete. These interventions increased the examination completion rate from 43.1 percent to 70.5 percent. This follow-up tracking system may be even more vital for ED patients, inpatients, and surgical patients who are more likely to be lost to follow-up.

Successful intervention strategies to appropriately address incidentalomas will likely involve system-level changes. The identified communication nodes serve as targets for intervention. Differences in institutional resources and workflow likely prohibit a universal solution. Therefore, early interdisciplinary involvement in designing and executing interventions would minimize misunderstandings in intervention strategies.

Managing incidentalomas presents both a challenge and an opportunity. Their increased prevalence, complicated by unclear clinical context, has the possibility of leading to critical safety errors without sufficient follow-up. At the same time, there is also a risk of overtreatment for incidentalomas, and this causes undue anxiety for patients.

However, the situation creates the opportunity to improve interdisciplinary care. When radiologists make guideline-directed recommendations, referring clinicians can become more knowledgeable in managing incidentalomas, and radiologists can receive feedback to optimize their reporting and minimize ambiguity. It also opens a discussion between different disciplines on management strategies when there are separate medical society guidelines.

When there are incidentalomas without clear guidelines, close patient follow-up would provide us with the opportunity to better characterize the disease. Despite the current challenges, interventions like the ones mentioned above have shown dramatic improvements in patient follow-up and appropriate management and have the potential to become best practices across image modalities and practice settings.

1. Berland LL. Overview of white papers of the ACR incidental findings committee ii on adnexal, vascular, splenic, nodal, gallbladder, and biliary findings. 

2. O'Sullivan JW, Muntinga T, Grigg S, Ioannidis JPA. Prevalence and outcomes of incidental imaging findings: umbrella review. 

3. Liao GJ, Liao JM, Lalevic D, Zafar HM, Cook TS. Location, location, location: The association between imaging setting and follow-up of findings of indeterminate malignant potential. 

4. Mabotuwana T, Hombal V, Dalal S, Hall CS, Gunn M. Determining adherence to follow-up imaging recommendations. 

5. Hansra SS, Loehfelm TW, Wilson M, Corwin MT. Factors affecting adherence to recommendations for additional imaging of incidental findings in radiology reports. 

6. Moore CL, Kadom N, Seidenwurm D, et al. Incidental findings: a survey of radiologists and emergency physicians. 

7. Zafa HM, Bugos EK, Langlotz CP, Frasso R. "Chasing a ghost": factors that influence primary care physicians to follow up on incidental imaging findings. 

8. Rosenkrantz AB. Differences in perceptions among radiologists, referring physicians, and patients regarding language for incidental findings reporting. 

9. American College of Radiology. Incidental findings publications. Available at: 

https://www.acr.org/Clinical-Resources/Incidental-Findings

10. Oren O, Gersh BJ, Bhatt DL. Improving communication of incidental imaging findings: transforming uncertainty into opportunity. 

11. Joint Commission. Advancing safety with closed-loop communication of test results. 

12. Crable EL, Feeney T, Harvey J, et al. Management strategies to promote follow-up care for incidental findings: a scoping review. J Am Coll Radiol. 2021;18(4):566-579.

13. Zygmont ME, Shekhani H, Kerchberger JM, Johnson JO, Hanna TN. Point-of-care reference materials increase practice compliance with societal guidelines for incidental findings in emergency imaging. 

14. Kim DC, Bennett GL, Somberg M, et al. A multidisciplinary approach to using appropriate follow-up imaging of ovarian cysts: a quality improvement initiative. 

15. Woloshin S, Schwartz LM, Dann E, Black WC. Using radiology reports to encourage evidence-based practice in the evaluation of small, incidentally detected pulmonary nodules. A preliminary study. 

16. Shelver J, Wendt CH, McClure M, et al. Effect of an automated tracking registry on the rate of tracking failure in incidental pulmonary nodules. 

17. Baccei SJ, Chinai SA, Reznek M, Henderson S, Reynolds K, Brush DE. System-level process change improves communication and follow-up for emergency department patients with incidental radiology findings. 

18. Wandtke B, Gallagher S. Reducing delay in diagnosis: multistage recommendation tracking. 

Greater imaging utilization has increased the prevalence of incidental findings or incidentalomas, but unclear clinical context and guidelines complicate management. Accordingly, these authors offer a thorough review of the literature and discuss new opportunities for improving interdisciplinary management strategies. 

Managing Incidentalomas in Radiology: Embracing Challenges as Opportunities

Eric Postal, MD, is a diagnostic radiologist with the University of Pittsburgh Medical Center. 

My recent blogs about “finishing school” for radiologists were partly in jest. It’s really not that hard to socially interact in constructive ways. A lot of people just get out of the habit of interacting with others, especially if their work isolates them, or they spend time on (anti)social media.

Many remedies many seem downright basic, a la 

All I Really Need to Know I Learned in Kindergarten

. I will simplify it even further by saying that the advice from my previous blogs could prevent most of the antisocial behavior I have seen. The remaining pointers offered in this blog are arguably correlates of the principles I have already recommended: Being generous and avoiding negativity.

(Editor’s note: For previous related blogs, see “

Finishing School for Radiologists, Part 2: The Power of Generosity

Finishing School for Radiologists: Common Anti-Social Pitfalls to Avoid, Part 1

They can also be summed up as taking care not to press other people’s buttons and making it as difficult as possible for them to press your buttons. It makes sense to focus on that second part as you have a lot more control over it than the first.

The second part is easier said than done. Circumstances can conspire to get your goat, especially if there are others involved who want that to happen (Internet trolls, for instance, and even certain portions of the media). The better they know you, the more adept they will be at pressing your buttons and eliciting an emotional response.

Take action only after your emotions have cooled.

 Otherwise, the emotions will cloud your judgment. In the heat of the moment, you can say or do things that you would subsequently recognize as obvious mistakes. Such needlessly hasty moves also have a way of escalating things. Someone pressing your buttons to get you angry will likely respond to your anger-driven reaction in a way that gives you opportunity to dig the hole you’re standing in even deeper.

The tricky part is that those emotions are powerful motivators, and it feels urgently right to do something with them. However, your emotional “fight or flight” response might do more harm than good if you are in a contentious meeting, or just trying to hold your own in a bickering Twitter thread. Fighting against that sense of “react NOW!” urgency can be learned, but it takes more than a little practice.

 A podcaster I have previously referenced in this blog talks about mantra-like usage of statements like “I could be wrong.” This approach is valuable in many respects, but I will just mention a couple of reasons here.

First, it helps make you less of a target for fault finding. Trolls, especially (including Dr. Negative), love the “gotcha” of poking holes in something they say you claimed with certainty. Take that easy target away from them. It also demonstrates an awareness that you don’t have all the answers. An exception is if you’re in a leadership position that requires a confident demeanor. You might notice that successful politicians display an “often wrong, never in doubt” persona.

Secondly, you don’t even have to say your “I could be wrong” mantra aloud. Just get in the habit of thinking it, and you will be less emotionally invested in being right. When you do turn out to be incorrect, your embarrassment button or anger button won’t be pushed as easily if one or more negative people take visible joy in calling out your imperfection.

 Just like anything else, you can be wrong about someone’s response to something you have said. The more you want or expect a particular answer, the more it can push your buttons if you don’t get it. For example, “I thought for sure my boss would see that I deserved that raise.” Also, longer-term readers may recall previous blogs in which I shared the strategic value of using someone’s current “no” to pave the way for a future “yes.”

Expect that anything you say can offend anyone or make them claim this is the case.

 This gets into the murkier waters of pressing other folks’ buttons. Sometimes it is unavoidable. You can’t know all the things going on in someone else’s mind. It might have nothing to do with you other than being in the wrong place at the wrong time. Offended individuals may be having a bad day, or you might remind them of someone they don’t like. (I am even told that some people don’t like doctors or radiologists if you can believe that.)

In recent years, some have turned being offended into a full-time occupation. A rad I knew referred to them as “offensitarians.” You never know when you will be accused of saying something harmful, insensitive, or otherwise bad. It can derail your message or an entire interaction, burying whatever point you were trying to make. If you consider yourself a decent person, let alone one who takes pains to be politically correct, getting blindsided by such an accusation can push your buttons as well.

In the name of not pushing anybody else’s buttons, sometimes the best you can do is be ready to go into damage-control mode. That means sincerely apologizing rather than armoring up with defenses and explanations. You can always offer those later when you have assured whoever claimed offense that you meant no harm. If you lead by insisting that you did nothing wrong (however correct that may be), that can make things irreparably worse.

On the other hand, you might find yourself dealing with someone who is clearly uninterested in defusing the situation. This person may be keen on how you knocked a chip off his or her shoulder and use it as an excuse to go on the offensive against you. In such unwinnable circumstances, you don’t owe it to anybody to stand there and be a punching bag. Once it is clear your peacemaking efforts are unwelcome, it is time to end the interaction, or at least table it for another time when you have a more receptive audience.

Humility, perspective and refraining from hasty, emotional responses can go a long way toward defusing confrontations.