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How to Avoid the Risks of a CT Incidentaloma

Posted May 02 2011 12:00am

Pathologists use the suffix -oma to designate a tumor. Hence, a so-called incidentaloma is a lesion discovered by a radiologist during a CT exam. Here's a common scenario that patients may encounter. The treating physician is trying to diagnose lesion A. The radiologist discovers lesion B while seeking to confirm lesion A. Lesion B is perhaps a small lung mass that may be clinically significant (e.g., an early cancer) but may also be benign and better off undiscovered. Once discovered, the physician treating the patient may react "defensively" and seek to pin down the diagnosis. This new diagnostic goal may be associated with its own set of morbidities and even mortalities. A recent article discussed the dangers of incidentalomas (see: Dangers of the Incidentaloma: Why to Think Twice Before Getting a CT Scan ), Below is an excerpt from it:

A study published recently in the journal Radiology found that children visiting U.S. emergency rooms had five times as many CT scans in 2008 as in 1995. By 2008, 6 percent of pediatric ER visits involved a CT scan. The same research group....previously found an even greater rise in scanning during adult ER visits, with 25 percent of patients age 65 and older, and 12 to 16 percent of younger adults, getting a CT scan in 2007. In addition to increasing risks associated with radiation exposure, all of those CT scans turn up an awful lot of "incidentalomas," the term that doctors use for incidental findings that could be (but probably aren't) cancer.

A study published last year...found that nearly 40 percent of CT and MRI scans performed for research purposes at the Mayo Clinic from January through March 2004 turned up at least 1 incidental finding. In the 35 patients in whom doctors took further action (additional testing, specialist consultation, or surgery), only 6 were judged by researchers to have clearly benefited from an investigation, while in the rest there was no clear benefit or clear harm, such as complications from surgery for a benign tumor. Of all types of scans, CT of the abdomen and pelvis...was the most likely to turn up an incidental finding. In fact, the American College of Radiology has become so concerned about the problem of incidentalomas on CT scans of the abdomen and pelvis that they recently published detailed guidance for clinicians about how to approach such findings. "Subjecting a patient with an incidentaloma to unnecessary testing and treatment can result in a potentially injurious and expensive cascade of tests and procedures," the radiology group warns, advising that doctors carefully consider an individual patient's risk for cancer in deciding whether or not to recommend further evaluation.

So what can you do to reduce the chance you will be harmed by an incidentaloma? Three experts in diagnostic medicine...recently recommended that patients who are told about an incidental finding always seek a second opinion to verify that the radiologist's interpretation of their scan is correct, and understand that clinical observation of an incidentaloma is often a safer option than more testing or surgery. Also, they advise that patients adopt a "healthy skepticism" about testing and only consent to scans that are absolutely necessary to establish a diagnosis or plan of action, rather than ordered “just to be sure.”

I really like the advice in the last paragraph above designed for patients who are presented with an incidentaloma and need to make decisions based on this fact. First of all, seek a second opinion from another radiologist about the nature of the lesion. The appearance of lesions on CT may not be clear-cut so there may be disagreement about its nature among radiologists. The patient may want to turn to radiologists in a different department who may be less apt to agree with the first diagnosis rendered in their own department. If the presence of the lesion is confirmed, the patient next needs to put the following question to both the radiologist and to one or more clinicians: Which is the safer option for me -- to continue to observe the lesion over time or to pursue more aggressive diagnostic procedures, each of which may be associated with its own set of risks? Always think "healthy skepticism" when confronted with an incidentaloma.

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