Management of Abdominal Incidentalomas Found on Cross-sectional Imaging: Magnitude of the Problem

Transcription

1 Management of Abdominal Incidentalomas Found on Cross-sectional Imaging: Magnitude of the Problem Michael Nipper, MD With Chuck Norris* *Without his permission, but with admiration.

2 Michael Nipper, MD Associate Professor of Radiology Former Diagnostic Radiology Division Director Chairman, Institutional Radiation Safety Committee Radiology Department Safety Officer

3 Chuck Norris: The World s Greatest Human Being

4 Sample Question Which of the following is/are true? 1. A. Chuck Norris does not sleep; he waits. 2. B. The tears of Chuck Norris cure cancer; unfortunately he has never cried. 3. C. Chuck Norris has counted to infinity, twice! 4. D. Chuck Norris does not need a watch; he decides what time it is. 5. E. All of the above.

5 Q1: The detection of incidental lesions on cross-sectional imaging generally benefits the patient. 1. A. True. 2. B. False. 3. C. I am not sure.

6 Has This Ever Happened to You? You order a CT scan of the abdomen and pelvis with intravenous contrast for abdominal pain in an elderly female.

7 Has This Ever Happened to You? And you get this report: No acute abnormality. A 0.4 cm NCPN in the RML. Recommend CT scan of the chest. A 0.9 cm right adrenal mass. Recommend a repeat CT scan of the abdomen with adrenal mass protocol. A 1.2 hypodense lesion in the pancreas which may be a tiny cystic neoplasm (IPMT). Recommend abdominal MRI or EUS. A 2.7 right ovarian cyst. Recommend pelvic US for further evaluation. A focal area of sclerosis in the L2 vertebra. Radionuclide bone scan is recommended.

8 Has This Ever Happened to You? If so, welcome to Modern Radiology. You may find this lecture of interest

9 Definition Incidentaloma: unsought information generated in the seeking of the information one desires. Or: an incidentally discovered mass or lesion, detected by CT, MRI or other imaging modality performed for an unrelated reason. Detection of incidental lesions may or may not be beneficial to the patient: AAA Renal hypodensities Davis DS. Medicine and Philosophy 2007 Werth B. Damages 1998

10 What is Considered an Incidental Finding? No known malignancy in the patient No signs or symptoms referable to the finding A renal mass found in patient with hematuria is not incidental Infection is not clinically suspected

11 Why is this an issue now? Technological advances in CT, MRI and US Higher spatial resolution ( thinner slices ) Currently, most body CT is routinely acquired at 1 mm resolution and reconstructed into 3mm thick images Better temporal resolution (faster scans, less motion) IV contrast bolusing US use of CT scans: 1998: 21 million 2006: 61 million Incidentalomas have evolved from a perceived advantage to a (correctly) perceived problem. Levin DC, Rao VM. JACR 2008;5(7):806-10

12 Tiny Masses The ability of screening tests to detect very tiny tumors has outstripped our understanding of how to interpret and respond to the findings. Cancer screening and the individual patient. New York Times April 14, 2002; A12.

13 Alec Megibow (Past Editor of AJR and Radiology) Writes There is a clear need for some level of a rational baseline whereby radiologists can find some level of guidance when they encounter an incidentaloma on an imaging study.

14 Missing Data Because of the paucity of data regarding the importance of reporting and following up incidental findings and the paucity of guidance for managing such findings, there is marked inconsistency in the approach to such findings. Lincoln Berland, MD (University of Alabama)

15 Incidentalomas: The Radiologist s Recommendations Should Be: Broadly accepted Easy to access Straightforward to understand and apply

16 Q2: What percentage of adults have an incidental adrenal mass on CT? 1. A. 0.1% 2. B. 1% 3. C. 3% 4. D. 15% 5. E. Only Chuck Norris knows

17 Prevalence of Incidentalomas Up to 67% of adults having a thyroid sonogram have an incidental nodule 6-13% are malignant Most are low grade papillary tumors 95% 20 year survival rate untreated Pituitary incidentalomas: 20% (most are microadenomas) Adrenal incidentalomas: 3-5% 50% of smokers who have chest CT done have a NCPN. Well over 90% of NCPNs found incidentally on chest CT are benign (1/1000)

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19 Detriments of the Incidentaloma to the Patient Excessive workups Added cost Added radiation (CT) Inducement of cancers ( % of all cancers) Over-diagnosis Biopsy: morbidity Over-treatment Patient anxiety (ex: OB patients)

20 Cancer Overdiagnosis 50% of lung cancers found on chest radiography 60% of PSA detected prostate cancers Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst 2010; 102:

21 Detriments of the Incidentaloma to the Physicians Undermines the credibility of the radiologist Defensive medicine: better safe than sorry Disparate recommendations by different radiologists Auto-referral ( Greedy jerks ) Busy work : reading follow-up exams Undermines the job of the clinician Distraction: busy work following incidental lesions instead of taking care of patients Explaining the significance of the findings to the patient Making decisions whether to withhold useless information Medicolegal issues for both You ignored my cancer!

22 A Dilemma Initiate a cascade of testing and intervention including long-term follow-up, biopsy and treatment for what is, ultimately, benign disease Ignore a lesion which may develop into a clinically significant cancer later

23 Dr. Casarella Has a Bad Year Former chairman of the Department of Radiology of Emory University School of Medicine Had a screening CT colonography done Incidentals found: Renal lesion Hepatic mass Noncalcified pulmonary nodules in lung bases Casarella WJ. A patient s viewpoint on a current controversy. Radiology 2002; 224:927.

24 Dr. Casarella is Put on the Wheel A cascade of testing and intervention CECT abdomen: renal cyst, but noncystic liver lesion CT guided liver biopsy: benign granuloma CT of the chest: NCPNs PET scan: negative VATS: benign granulomas of the lung

25 Dr. Casarella Recovers He woke up in the recovery room with a chest tube, a Foley catheter, a subclavian central line, a nasal oxygen tube, an epidural catheter, an arterial line, on subcutaneous heparin, prophylactic antibiotics and intravenous narcotics He missed five weeks of work Total charges: $50,000 All for benign disease

26 Chuck Norris Says, You Just Need One: Me.

27 Q3: Discovery of Which of the Following Incidental Findings is Likely to Benefit the Patient? A. Small adrenal mass B. Abdominal aortic aneurysm C. Small pulmonary nodule D. Small renal hypodensity E. Ovarian cyst

28 A Positive Example of Finding an Incidental Lesion: AAA In abdominal imaging, finding an AAA incidentally has the most benefit to a patient in terms of lives saved Hassan C, et al. CT colonography to screen for colorectal cancer, extracolonic cancer and AA. Arch Intern Med 2008; 168:

29 A Negative Example of Finding an Incidental Lesion: Solid Renal Mass About 60% of RCCs are found incidentally on CT of the abdomen done for other reasons The overall death rate for RCC has changed little in the past decade Potential problems Overdiagnosis Overtreatment Fenton JJ, et al. Screening CT: will it result in overdiagnosis of renal carcinoma? Cancer 2004; 100(5):

30 What is the Patient Entitled to Know? Any human being of adult years and sound mind has a right to determine what shall be done with his own body. A physician undertaking an examination has a duty to disclose any finding that would indicate the patient is in any danger. As part of the duty, the physician must reveal to the patient that which in his best interest he should know. The radiologist must share liability if he has failed in adequately communicating the diagnosis to the attending physician. Legal quotes cited by Dr. Leonard Berlin

31 Perspective from University of Rochester Medical Center Researchers A patient s right to autonomy must be balanced with the ethical obligations of physicians to do good for patients (beneficence) and to not harm them (nonmaleficence). Examples: Creating more cancers with radiation than we find doing the follow-up CT scans ( % of cancers in the US). Morbidity and mortality related to biopsy Morbidity and mortality related to treating an indolent tumor

32 More Perspective from Researchers at URMC More information is not always better. Dumping all available information on patients can be overwhelming and may paradoxically undermine their ability to choose wisely. Clinicians should withhold information that is likely to overwhelm and distress patients if their having the information will provide no obvious benefit and they don t ask for it. Epstein RM, et al. Withholding information from patients: when less is more. N Engl J Med 2010;362:380-1.

33 An Example from OB US Down syndrome markers found in normal pregnancies: Echogenic intracardiac focus: 10% of normal fetuses Choroid plexus cysts: 1-2% of normals Echogenic bowel: 10% of normals Mild pyelectasis: 3% of normals Once the parents are informed of this abnormality, enjoyment of the anticipation of birth of their son or daughter is now replaced by anxiety. To find a handful of residual cases of Down s syndrome, should we put over 10% of patients with normal pregnancies through anxiety instead of joy? Filly RA. Obstetrical sonography: the best way to terrify a pregnant woman. J Ultrasound Med 2000;19:1-5.

34 From the Code of Ethics of the AMA: The physician s obligation is to present the medical facts accurately to the patient Physicians should disclose all relevant medical information to patients. AMA Council on ethical and judicial affairs. Code of medical ethics

35 Public Perception 87% of surveyed adults believe that routine cancer screening is almost always a good idea and that finding cancers early saves lives (Despite the fact that 43% of persons undergoing screening test experience at least one false positive) 75% of eligible jurors said that they would act on their own beliefs, regardless of legal instruction from the judge

36 An Example of Incidental Findings during Research 1426 imaging studies 40% (570) of patients had at least one incidental finding Further workup benefited 6 patients (1% of those with incidental findings) Orme NM, et al. Arch Intern Med 2010.

37 The Costs of Following Incidental Lesions Economic burden of follow-up exams Inconvenience Confusion, anxiety Loss of patient productivity Radiation exposure from CT scanning Cancer induction (20,000 CT scans done each day in the US) Up to 2% of cancers found in US adults are due to medical radiation Physician time: clinician, radiologist

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39 Ordering Patterns If you don t need to see it, don t order it Train your nurses and desk clerks Examples: Pelvic CT ordered automatically with abdominal CT Complete abdominal sonogram vs. limited RUQ sonogram UGI vs. UGI and SBFT CT abdomen and pelvis for GI bleed

40 Incidentalomas and Cost-effectiveness CT colonography and CMS The cost of managing incidental findings affects the cost-effectiveness of an imaging strategy

41 Incidentals Do Matter: CT Colonography 50% of CTC patients have an incidental finding About 10% of these patients undergo further testing CMS has declined to cover the cost of screening CT colonography recently One of the main reasons cited: added cost related to incidentally discovered lesions USPSTF. Screening for colorectal cancer. Ann Intern Med 2008; 149(9):

42 What Does the Scan Really Cost? Baseline cost: $ ($310 Medicare) Cost of follow up exams and other tests in those patients with incidental findings averaged over the entire group Incidental workup costs range from $13 to $248 additional cost per patient in various studies About half the studies reviewed estimated additional cost from work up of incidental findings at under $50

43 $13 Additional Cost For Incidental Findings Zalis, et al. (Radiology 2005;236(1):3-9) CT colonography group Developed a classification of incidental findings and used it to stratify follow up $248 Kimberly, et al. (J Gen Intern Med 2009;24(1):69-73) Reported all incidental findings Made no recommendations for the type of follow up

44 Zalis Extracolonic Findings Stratification System

45 Major References Imaging of Incidentalomas. RCNA. March Managing Incidental Findings on Abdominal CT. ACR White Paper. JACR 2010;7: