management of common findings in abdominal imaging reports · management of common findings in...
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Faculty/Presenter Disclosure � Faculty: Anthony Hanbidge
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1) Describe radiologist’s role in patient assessment
2) Recognize the importance of context in image interpretation
3) Discuss the management of common abdominal imaging findings
Learning Objectives
For discussion: � Incidental gallbladder polyp � Asymptomatic simple ovarian cyst � Asymptomatic cystic pancreatic
mass � Incidental cystic renal mass � Incidental solid renal mass
Incidental gallbladder polyp
≤0.6 cm
Dismiss
0.6-0.9 cm
F/u yearly for 2 years
≥1 cm
Surgical opinion
Incidental gallbladder polyp
≤0.6 cm
Dismiss
0.6-0.9 cm
F/u yearly for 2 years
≥1 cm
Surgical opinion
Asymptomatic simple ovarian cyst - premenopausal
≤3 cm
Normal
>3-≤5cm
Report, no f/u
>5-≤7cm
F/u US yearly
>7cm
MRI or surgical
Asymptomatic simple ovarian cyst - premenopausal
≤3 cm
Normal
>3-≤5cm
Report, no f/u
>5-≤7cm
F/u US yearly
>7cm
MRI or surgical
Asymptomatic simple ovarian cyst - postmenopausal
≤1 cm
Report, no f/u
>1-≤7cm
F/u US yearly
>7cm
MRI or surgical
Asymptomatic simple ovarian cyst - postmenopausal
≤1 cm
Report, no f/u
>1-≤7cm
F/u US yearly
>7cm
MRI or surgical
Asymptomatic simple ovarian cyst - postmenopausal
≤3 cm
Report, no f/u
>3-≤7cm
F/u US yearly
>7cm
MRI or surgical
Asymptomatic cystic pancreatic mass
<2 cm
Single f/u 1 yr *
Stable
Benign, no further f/u
Growth
2–3 cm
Imaging characterization
(MRI/MRCP)
Uncharacterized cystic mass
F/u yearly
BD-IPMN
F/u every 6 months for 2 years*
Serous cystadenoma
F/u every 2 years
>3cm
Serous cystadenoma
Consider resection when ≥4
cm
Uncharacterized cystic mass
Cyst aspiration
Resect, co-morbidities/risk
Asymptomatic cystic pancreatic mass
<2 cm
Single f/u 1 yr *
Stable
Benign, no further f/u
Growth
2–3 cm
Imaging characterization
(MRI/MRCP)
Uncharacterized cystic mass
F/u yearly
BD-IPMN
F/u every 6 months for 2 years*
Serous cystadenoma
F/u every 2 years
>3cm
Serous cystadenoma
Consider resection when ≥4
cm
Uncharacterized cystic mass
Cyst aspiration
Resect, co-morbidities/risk
Unless limited life expectancy or severe co-morbidities
I - simple cyst II - minimally complex, few hairline
septa, fine Ca++ or short segment thickened Ca++ in wall or septa, homogeneously high attenuation masses <3 cm that do not enhance
Bosniak classification
IIF - multiple hairline septa, smooth thickening of wall or septa, thick nodular calcification, no enhancing soft tissue components, intrarenal, non-enhancing high attenuation masses (>3 cm)
Bosniak classification
III - Thickened irregular or smooth walls or septa with measurable enhancement
IV – Criteria of III but also containing enhancing soft tissue components adjacent to or separate from the walls or septa
Bosniak classification
Incidental cystic renal mass*
Bosniak I or II
Benign No f/u
Bosniak IIF
General population
US, CT or MRI at 6 and 12 mo, then yearly x 5
Morphologic change*
Surgery*
No morphologic
change
Benign No f/u
Limited life expectancy
If f/u appropriate, US, CT or MRI at 6 and 12 mo, then yearly x 5*
Morphologic change*
Surgery, f/u, no f/u
Bosniak III or IV
General population
Surgery*
Limited life expectancy
If f/u appropriate, US, CT or MRI at 6 and12 mo,
then yearly x 5*
Action based on change and life expectancy
Incidental cystic renal mass*
Bosniak I or II
Benign No f/u
Bosniak IIF
General population
US, CT or MRI at 6 and 12 mo, then yearly x 5
Morphologic change*
Surgery*
No morphologic
change
Benign No f/u
Limited life expectancy
If f/u appropriate, US, CT or MRI at 6 and 12 mo, then yearly x 5*
Morphologic change*
Surgery, f/u, no f/u
Bosniak III or IV
General population
Surgery*
Limited life expectancy
If f/u appropriate, US, CT or MRI at 6 and12 mo,
then yearly x 5*
Action based on change and life expectancy
Incidental solid renal mass*
<1 cm*
General population
F/u until 1 cm
Limited life expectancy
F/u until 1.5 cm
1-3 cm*
General population
Surgery*
Hyperattenuating, Homogeneously*
Limited life expectancy
Surgery* F/u*
>3 cm*
General population
Surgery*
Limited life expectancy
Surgery* F/u*
Incidental solid renal mass*
<1 cm*
General population
F/u until 1 cm
Limited life expectancy
F/u until 1.5 cm
1-3 cm*
General population
Surgery*
Hyperattenuating, Homogeneously*
Limited life expectancy
Surgery* F/u*
>3 cm*
General population
Surgery*
Limited life expectancy
Surgery* F/u*
Summary � Imaging 1 piece of puzzle � History, physical, labs � Communication is key in directing appropriate care
References Berland ll et al. Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol. 2010 Oct;7(10):754-73. doi: 10.1016/j.jacr.2010.06.013. Levine D et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010 Sep;256(3):943-54. doi: 10.1148/radiol.10100213. Epub 2010 May 26. Review. Corwin MT et al. Incidentally detected gallbladder polyps: is follow-up necessary?--Long-term clinical and US analysis of 346 patients. Radiology 2011;258:277-282. doi: 10.1148/radiol.10100273. Epub 2010 Aug 9.
Follow-up imaging � Consider decreasing interval if
younger � Consider omitting if limited life
expectancy � US vs. MRI
Follow-up imaging � If no growth after 2 years, follow
yearly � If growth or suspicious features
develop, consider resection
Solid renal mass � Follow guidelines only if infections
and fat containing angiomyolipomas have been excluded
Differential diagnosis � Renal cell cancer � Oncocytoma � Fat poor angiomyolipoma � Benign entities more likely in small
renal masses than large ones
If hyperattenuating and homogeneously enhancing � Consider MRI and biopsy to
diagnose fat poor angiomyolipoma
Surgery � Open or laparoscopic nephrectomy
or partial nephrectomy (all provide tissue diagnosis)
� Open, laparoscopic or percutaneous RFA (biopsy first for tissue diagnosis)
Surgery � Open or laparoscopic nephrectomy
or partial nephrectomy (all provide tissue diagnosis)
� Open, laparoscopic or percutaneous RFA (biopsy first for tissue diagnosis)
� Biopsy first to confirm RCC
Differential diagnosis � Probable diagnosis renal cell
cancer � Fat poor angiomyolipoma,
oncocytoma and other benign neoplasms may be found at surgery
Follow-up � Observation may be considered for
a solid renal mass of any size in a patient with limited life expectancy or co-morbidities that increase the risk of treatment
Incidental cystic renal mass � Follow guidelines only if non-
neoplastic causes of mass excluded (e.g. infection)
Morphologic change � Change refers to change in feature
characteristics, such as number of septations or thickness
� Growth should be noted but by itself does not indicate malignancy
? No follow-up � Cystic masses 1.5 cm or smaller
that are not clearly simple cysts or that cannot be characterized completely may not require further evaluation in this group
Surgery � Open or laparoscopic nephrectomy
or partial nephrectomy (all provide tissue diagnosis)
� Open, laparoscopic or percutaneous RFA (biopsy first for tissue diagnosis)