Management of Abdominal Incidentalomas Found on Cross-sectional Imaging: Management Strategies

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1 Management of Abdominal Incidentalomas Found on Cross-sectional Imaging: Management Strategies Michael Nipper, M.D.

2 Q1: What Percentage of the Time Does My Radiology Group Give Specific Follow-up Recommendations for Incidental Findings? 1. A. 5% 2. B. 20% 3. C. 50% 4. D. 75% 5. E. 100%

3 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

4 What is Incidental? 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

5 Q 2: Which of the Following Factors Should be Mentioned by the Radiologist when He Recommends Follow-up? 1. A. Time frame to follow-up 2. B. Modality of follow-up 3. C. Likelihood of the lesion being malignant 4. D. Both A and B 5. E. All three

6 Incidentalomas: The Radiologist s Recommendations Should Be: Broadly accepted Easy to access Straightforward to understand and apply Which modality Timing of follow-up Likelihood of lesion being significant

7 CT Scanning Handicaps Nowadays : IV Contrast The classic definition of a cyst on CT scanning Homogeneous, circumscribed, no thick wall or septation NCCT: Density under 20 HU CECT: May enhance 10 HU with IV contrast enhancement Most protocols now are NCCT or CECT only Thank you CMS! The old definitions for a cyst do not apply Most radiologists are NOT recommending bringing back patients for full assessment of hepatic, renal or splenic hypodense lesions 1 cm or less

8 Chuck of All Trades

9 Incidental Renal Masses No history of malignancy No added risk factor for renal malignancy No clinical suspicion of infection No GU signs or symptoms

10 Renal Oncocytoma

11 Incidental Renal Masses Lesion under 1 cm and low density: presumed cyst Subcentimeter renal hypodensity which is too small to fully characterize but which statistically represents a tiny renal cyst * If you must image further: MRI, not US for tiny ( 8 mm and under) hypodensities in the kidney or liver Any amount of fat in the lesion on imaging: angiomyolipoma (AML) Review the CT with the radiologist MRI is useful to detect small amounts of fat Hyperdense masses: biopsy, AML with minimal fat Exclude infection as a cause * Silverman, et al. RCNA Imaging of Incidentalomas. March 2011 p. 375.

12 Incidental Cystic Renal Masses: Bosniak Criteria Lesions over 1 cm: use Bosniak criteria Bosniak 1: simple cyst Bosniak 2: hyperdense, one or two thin septations, thin septal or wall calcification Bosniak 2f: many septations, thick wall or septation, thick calcification, but no suspicious enhancement Bosniak 3: complex cystic mass, about half are malignant Needle biopsy (AML with minimal fat) or Urology consultation Bosniak 4: solid component, presumed RCC, Urology consultation If under 1 cm: follow (6 months X2, then yearly to 5 years) 1-3 cm: follow (elderly), surgery or percutaneous ablation Lesions over 3 cm: surgery (ablation?) Following: a change in characteristics is as important as a change in size Silverman, et al. Radiology 2008

13 Berland, et al: Incidental Cystic Renal Mass Management

14 Berland, et al: Incidental Solid Renal Mass

15 Incidental Solid Renal Mass: Hyperdense Renal Mass on NCCT Hyperattenuating renal mass on NCCT Abdominal US if large enough (> 1 cm): often due to cysts with proteinaceous fluid Otherwise, bring back for CECT or MRI Consider percutaneous biopsy of hyperdense solid renal lesions (1-3 cm) that may go to surgery May be an AML with minimal fat

16 Renal AML with Minimal Fat

17 Percutaneous Ablation of Renal Masses For small peripheral renal masses Often percutaneous biopsy done first Either RFA (heating) or cryoablation (freezing)

18 Chuck Norris Cat

19 Adrenal Incidentalomas Seen in 3-5% of abdominal CT scans Under 1 cm: do nothing? Most are benign cortical adenomas Most adrenal adenomas do not function Suspicious imaging findings Central necrosis Heterogeneous Irregular margins Larger than 4 cm Enlarging adrenal mass (except infection or hematoma)

20 Adrenal Incidentalomas Lipid rich adenomas Homogenous with smooth margins Under 10 HU on NCCT Signal dropout on chemical shift MRI imaging Lipid poor adenomas Homogenous with smooth margins Over 10 HU on NCCT High adrenal percentage IV contrast washout (60% absolute, 40% relative at 15 minutes) Myelolipomas Macroscopic fat by CT or MRI Rare case of AML with minimal fat: hyperdense on NCCT PET/CT

21 Berland, et al: Incidental Adrenal Mass

22 Adrenal Adenoma

23 Adrenal Washout Calculator

24 MRI with Chemical Shift Imaging

25 Chuck Norris Toilet Paper

26 Incidental Hepatic Lesions No known cancer No known added risk factors for liver cancer No known liver dysfunction No clinical suspicion of infection

27 Hepatic Incidentalomas: Flash-filling Arterial Lesions In a patient with no liver risk factors: benign Do not assess further Do not follow-up Benign causes THAD, THID: hepatic arterial compensation for low PV flow Type 1 hemangioma FNH, adenoma Nodular regenerative hyperplasia: multiple, subcapsular AV malformation Shunts: AV, PV, AP Malignant causes Usually Not Incidental Dysplastic nodule or well-differentiated hepatoma Hypervascular metastases

28 Liver Segment IV THAD

29 SVC Obstruction by Lung Cancer

30 Hepatic Incidentalomas: The Left Lobe is a Trouble-maker Focal fatty infiltration Focal fatty sparing Seen in arterial phase only, invisible in portal venous phase Perfusion and drainage of this portion of the liver partially by systemic blood flow Same distribution, see in portal venous phase only THADS Same type of distribution Perfusion defect Geometric, no bulging of liver capsule Normal vessels course through area Along falciform ligament (especially segment 4) and near GB Internal mammary vein and paraumbilical veins Vein of Sappey (medial diaphragm and liver segment 4) Different trophism? If you must image further: MRI Fat sequences Hepatocyte specific contrast agents

31 Focal Fatty Infiltration/ Perfusion Defect Liver

32 Hepatic Incidentalomas Simple cysts: 15-20% of patients Bile duct hamartomas Under 1.5 cm Multiple, uniform, no enhancement Hemangioma Characteristic findings on CT or MRI FNH Characteristic findings on MRI

33 Simple Liver Cyst

34 Bile Duct Harmatomas

35 Liver Hemangioma

36 FNH Liver

37 MRI of FNH

38 MRI FNH: Hepatocyte Specific Agents Multihance Gadobenate Dimeglumine 4% Eovist Gadodexic acid 50% Taken up by hepatocytes and excreted into biliary tree

39 Berland, et al: Incidental Hepatic Mass

40 Incidental Liver Lesions on CT Lesion under 1 cm: no further evaluation Lesion over 1 cm Low risk: No further evaluation (elderly) Follow-up (middle-aged) High risk: Further immediate imaging with MRI or US Biopsy

41

42 Incidental Pancreatic Cysts 1-3% of abdominal CT scans demonstrate incidental pancreatic cystic lesion Pancreatic cysts are seen on fluid sensitive sequences in 13-20% of patients having abdominal MRI Most are intraductal papillary mucinous neoplasms (IPMNs, IPMTs) Low grade, indolent neoplasms

43 Imaging Classification of Pancreatic Cysts Unilocular Pseudocyst, true cysts, small IPMNs Cysts under 2 cm will seem unilocular on CT Microcystic Six or more cysts under 2 cm Serous cystadenoma 30% have calcifications Macrocystic Less than six cysts over 2 cm Mucinous cystadenoma, adenocarcinoma Cystic and Solid Mucinous cystic tumor Solid pseudopapillary tumor

44 Small Pancreatic Cyst

45 Small Pancreatic Cyst

46 Worrisome Features of Pancreatic Cysts Larger than 3 cm 97% of pancreatic cysts under 3 cm in asymptomatic patients are benign Mural nodule Dilation of pancreatic duct (6 mm) or CBD 3 mm pancreatic duct up to 50 y/o 5 mm pancreatic duct after age 50 Duct wall enhancement Lymphadenopathy

47 Berland, et al: Incidental Cystic Pancreatic Mass

48 Incidental Pancreatic Cysts Under 2 cm No follow-up (elderly) Follow with CT in 6-12 months (middle aged) 2-3 cm CT follow-up (elderly) GI consultation for EUS (middle aged) Over 3 cm GI Consultation: EUS or CT follow-up

49 Don t Make Chuck Mad

50 Incidental Splenic Lesions Splenic clefts, splenules, calcified granulomas Cysts Pseudocysts: trauma, pancreatitis, old infarct Often thick rim of calcification True cysts: epidermoid, hydatid Under 5 cm and asymptomatic: leave alone

51 Splenic Hemangioma

52 Incidental Splenic Lesions Incidental splenic masses uncommon: under 1% Most lesion are not pathognomonic by imaging Splenic hemangioma 1-2 cm in size Most are not classic (like in the liver) Hamartoma Bulges splenic margin Persistent enhancement Lymphangioma Subcapsular Cystic and without contrast enhancement

53 Incidental Splenic Masses Lymphoma Angiosarcoma Littoral cell angioma PET/CT Sensitivity 100%, specificity 80% PPV 80%, NPV 100% Biopsy Safe

54 Isolated Splenic Lesion in a Patient with Known Malignancy Spleen is an uncommon site for metastases (#10). Rare to have metastases to the spleen without other sites (liver) of metastatic disease Same is true of splenic sarcoidosis

55 Solitary Isolated Asymptomatic Splenic Lesion Splenic cystic lesions Under 5 cm No follow-up, especially if there is a good history Over 5 cm Follow if there is no good history Refer to GI or General Surgery if symptomatic Splenic solid lesions Under 1-2 cm Do nothing: elderly Follow with imaging: middle age Over 2 cm Characterize with splenic mass CT or MRI And/or follow with imaging (US?) PET/CT Biopsy Nipper, 2011.

56

57 Incidental Adnexal Cysts in Asymptomatic Women: Postmenopausal Postmenopausal One year or more of amenorrhea after final menstrual period Simple cysts 1 cm or less need no follow-up Adnexal cysts 1-7 cm: one year follow-up Cysts over 7 cm: Gynecology consult or pelvic MRI Management of Asymptomatic Ovarian and other Adnexal Cysts Imaged at Ultrasound. Levine D., et. al. Radiology; September 2010, 256:

58 Incidental Adnexal Cysts in Asymptomatic Women: Premenopausal Simple cysts or classic hemorrhagic cysts 5 cm or less need no follow-up Simple cysts or classic hemorrhagic cysts 5-7 cm: one year follow-up Any cyst over 7 cm: gynecology consultation and/or pelvic MRI Often, cysts over 3 cm are reported, but no followup is required

59 Simple and Hemorrhagic Cysts

60 Corpus Luteum

61 Chuck and I Thank You

62 Major References Imaging of Incidentalomas. RCNA. March Managing Incidental Findings on Abdominal CT. ACR White Paper. JACR 2010;7: Management of Asymptomatic Ovarian and other Adnexal Cysts Imaged at Ultrasound. Levine D., et. al. Radiology; September 2010, 256:

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