ER Division Incidentaloma Guidelines.pdf

ER Division Incidentaloma Practice Guidelines CONTENTS

A. Pulmonary Nodules i. Solid

ii. Subsolid/Groundglass B. Liver Lesions C. Gallbladder Findings D. Pancreatic Cysts E. Splenic Lesions F. Adrenal Nodules G. Renal Masses

i. Solid ii. Cystic

H. Lymph Nodes I. Adnexal Cysts

i. CT ii. US

J. Thyroid Nodules by CT K. Additional findings that may benefit from standardized reporting

a. testicular microlithiasis b. no IUP w/ positive beta c. subchorionic Bleed d. first trimester pregnancy evaluation: SRU criteria

2 Solid Pulmonary Nodules Fleischner Guidelines (MACRO: Incidental pulmonary nodule solid)

SIZE* LOW RISK HIGH RISK 4 mm No follow-up needed. Single follow-up in 12 months. Discontinue if stable.

>4 to 6 mm Single follow-up in 12 months. Discontinue if stable.

Initial follow-up in 6-12 months, then 18-24 months if stable.

>6 to 8 mm Initial follow-up in 6-12 months, then 18-24 months if stable.

Initial follow-up in 3-6 months, then 9-12 months and again at 24 months if stable.

>8 mm One of more of the following: serial follow-up at 3, 9, and 24 months; PET; biopsy.

NOTES Guidelines are intended for newly detected indeterminate nodules in persons age 35 or older without a history

of cancer. *Size is the average of length and width. Low risk: minimal/absent smoking history. No other known risk factors. High risk: smoking or other known risk factors. Nodules in patients with a history of cancer should be evaluated per clinical protocol pertaining to the

patients cancer type and treatment history. For larger solid nodules, beware for PET: carcinoids and low grade adenocarcinomas may not be metabolically

active. Consider phrasing: PET or 3 month follow-up if biopsy is not elected.

3 Subsolid Pulmonary Nodules New Fleischner Recommendations

Nodule Type Recommendations Remarks Solitary Pure GGN MACRO: Incidental pulmonary nodule pure groundglass

5 mm No follow-up needed. Use 1-mm slices to ensure purely GGN.

>5mm Initial follow-up at 3 months, then annually for at least 3 years if persistent.

FDG-PET not generally advised.

Solitary Subsolid Nodule MACRO: Incidental pulmonary nodule subsolid

Solid portion 5 mm without dominant nodule

Initial follow-up at 3 months, then annually for at least 3 years if persistent.

FDG-PET not generally advised.

Dominant nodule with solid component

Initial follow-up at 3 months. Surgical resection or biopsy if persistent.

NOTES No distinction between high and low risk. Transbronchial needle biopsy generally not advised for pure ground glass nodules due to low diagnostic yield. The solid component of a subsolid nodule may be targeted for percutaneous biopsy if of adequate size (>8mm). Subsolid adenocarcinomas may not be metabolically active on PET; PET can be used for staging but should not

be used to exclude adenocarcinoma in cases of subsolid (or pure ground glass) lesions. Evaluate morphology using 1-mm axial slices. Measurements based on average of length and width. Always compare to earliest exam to detect slow growth. Bronchoalveolar cell carcinoma. Preferred terms: adenocarcinoma in situ (pure ground glass lesion

4 Incidental Liver Masses (CT)

Source: JACR White Paper 2010

5 Incidental Gallbladder Findings Gallstones

Asymptomatic no action. Symptomatic consider ultrasound.

Wall Calcification Diffuse (porcelain gallbladder) no specific recommendation. Lower risk for cancer than historically thought. Focal no specific recommendation. Higher risk for cancer than diffuse, still low overall.

Hyperattenuating Contents Caused by concentrated bile, sludge, noncalcified stones, vicarious contrast excretion. No action.

Wall Thickening Diffuse, asymptomatic no action. Focal > 3 mm, potential polyp or mass consider ultrasound. MACRO: Incidental Gallbladder Polyp

o Polyp 6 mm no action. o Polyp 7-9 mm annual ultrasound. o Polyp 10 mm surgical consultation.

Distention Defined as transverse diameter > 4 cm and longitudinal diameter > 9 cm. Asymptomatic no action. Likely secondary to fasting state. Symptomatic clinical action ultrasound.


6 Pancreatic Cysts (CT/US) Basic Differential by Morphology

Unilocular: lymphoepithelial cyst, pseudocyst, mucinous cystic neoplasm (MCN), small IPMN, small serous cystadenoma

Microcystic: lymphoepithelial cyst, serous cystadenoma Macrocystic: MCN, IPMN, oligocystic serous tumor Cyst w/ solid component: serous cystadenoma (spongy architecture mimics solid), SPEN, islet cell tumor

Red Flags for Malignancy Symptomatic patient: hyperamylasemia, weight loss, epigastric pain, jaundice, recent onset diabetes Mucinous features: macrocystic, peripheral calcs, tail position, middle-aged woman Dilated CBD Involvement of main pancreatic duct Lymphadenopathy Mural nodules

Management of an Incidental Cyst in an Asymptomatic Patient 3 cm cyst o Characterization with pancreas protocol MRI/MRCP.

Uncharacterized consider cyst aspiration and/or surgical resection. Probable serous cystadenoma consider resection when 4 cm. Other cystic neoplasm consider cyst aspiration and/or consider resection.


7 Incidental Splenic Lesions (MACRO: Incidental splenic lesion) Benign Features Indeterminate Features Suspicious Features

Homogeneous Attenuation < 20 HU Nonenhancing Smooth margins Hemangioma pattern

Heterogeneous Attenuation > 20 HU Enhancing Smooth margins

Heterogeneous Enhancing Irregular margins Necrotic Invasive

No Follow-up Needed Cyst Classic hemangioma (same pattern as liver, uncommon in spleen) Not suspicious, stable x1 year

Follow-up Imaging (MRI in 6 + 12 months) No known cancer, indeterminate features Known cancer, lesion

8 Adrenal Nodules (< 1 cm, no F/U)

Keys for ED practice (most commonly encountered):

MACRO: Incidental Adrenal is a decision tree macro. If there is prior imaging, no cancer history, lesion indeterminate, but stable 1 yr, presumed benign. Adrenal nodules 1 cm but < 4 cm: No priors. No cancer history. Presumed benign. Recommend

imaging follow-up in 12 months with MRI. Adrenal Nodules < 1 cm: presumed benign. MACRO: Incidental adrenal adenoma. If benign adenoma white paper recommended impression:

Findings consistent with a benign adenoma. If there are clinical signs or symptoms of adrenal hyperfunction, biochemical evaluation may be appropriate.

Source: JACR White Paper 2010 Berland et al.

9 Solid Renal Masses Management in the General Population*

Size Probable Diagnosis Recommendation Comments

10 Renal Cysts Bosniak Classification (CT/MR, not US)

Category 1 ~0% malignant Hairline or imperceptible wall No septa, calcification, nodule, or enhancement Fluid signal/attenuation Benign, no follow-up.

Category 2 ~0% malignant Few hairline septa, with or without perceived enhancement Fine calcification or short segment of slightly thickened calcification along wall or septa Hemorrhagic/proteinaceous cyst 3 cm Benign, no follow-up.

Category 2F (MACRO: incidental renal bosniak) ~25% malignant Multiple hairline septa, with or without perceived enhancement Minimally thickened wall or septa Thick or nodular calcification No enhancement Intrarenal hemorrhagic/proteinaceous cyst >3 cm CT/MR at 6 and 12 months, then yearly for 5 years.

Category 3 ~50% malignant Thickened irregular or smooth walls or septa, with measurable enhancement Surgery*

Category 4 ~99% malignant Enhancing soft tissue components adjacent to or separate from walls or septa Surgery*

* Imaging observation may be appropriate in patients with limited life expectancy or poor surgical candidates.

11


12 Incidental Lymph Nodes Benign Features Suspicious Features

Short axis

13 Incidental Adnexal Cyst (CT) Benign-Appearing Cyst (MACRO: Incidental Ovarian cyst CT (benign appearing)) All of the following: round or oval, regular wall, uniform fluid or layering blood if premenopausal, 5 cm US in 6-12 weeks.

Early Postmenopausal (If unknown menstrual status, this is 50-55 yoa) 3 cm benign, no follow-up. >3 to 5 cm US in 6-12 months. >5 cm US now.

Late Postmenopausal (if unknown menstrual status, this is > 55 yoa) 3 cm benign, no follow-up. *Option to lower threshold to 1 cm to increase sensitivity for neoplasm. >3 cm US now.

Probably Benign Cyst Benign features except: angulated margins, not round or oval, poorly imaged (streak artifact, noise), etc.

Premenopausal (< 50 years old) 3 cm benign, no follow-up. >3 to 5 cm US in 6-12 weeks. >5 cm US now.

Early Postmenopausal (50-55 years old) 3 cm benign, no follow-up. >3 cm US now.

Late Postmenopausal (>55 years old) 1 cm benign, no follow-up. >1 cm US now.

Other Features Solid component, mural nodule, septations, nonsimple fluid, layering blood if postmenopausal.

Diagnostic features appropriate clinical/surgical management.

Nonspecific features US


14 Adnexal Cysts (US) (MACRO: Incidental ovarian cyst sonography) *If menopausal status is unknown: 55 is late post-menopausal

Simple Cyst (ovarian or extraovarian) Premenopausal (5 to 7 cm annual follow-up US. o >7 cm follow-up MRI (contrast enhanced).

Postmenopausal (>55 years old) o 1 cm no follow-up. Considered clinically unimportant. o >1 to 7 cm annual follow-up US. o >7 cm Surgical consultation and/or MRI (contrast enhanced).

Hemorrhagic Cyst Premenopausal (< 50 years old)

o 3 cm no follow-up. Optional whether to mention. o 5 cm no follow-up. o >5 cm follow-up US in 6-12 weeks.

Early Postmenopausal (50-55 years old) o Any size follow-up US in 6-12 weeks.

Late Postmenopausal (>55 years old) o Any size Surgical consultation.

Suspected Endometriomas (any age)

Initial follow-up US in 6-12 weeks (to distinguish from hemorrhagic cysts, which should involute). Annual US thereafter if not surgically removed.

Dermoid (any age) Annual US if not surgically removed.

15 Thyroid Nodules Seen by CT Background: Present in up to 16% of all Chest CTs. 1.5 cm short axis, proceed to Thyroid US.

General population (thyroid nodules without suspicious features): MACRO:

Incidental thyroid nodule o Age < 35 yrs: Solitary or few Thyroid Nodules < 1 cm : Ignore o Age < 35 yrs: Solitary or few Thyroid Nodules 1 cm : Non-emergent Thyroid US Follow-Up o Age 35 yrs: Solitary or few Thyroid Nodules < 1.5 cm : Ignore o Age 35 yrs: Solitary or few Thyroid Nodules 1.5 cm : Non-emergent Thyroid US Follow-Up

In patients with limited life expectancy or serious co-morbidities that increase risk

of treatment no further evaluation is appropriate.

Multinodular Goiter: [MACRO: Incidental thyroid goiter] Controversial. If we see any individual nodule in the goiter that meets the above criteria or if this is previously unknown and the gland is not entirely seen Thyroid US follow-up.

Source: JACR 2014 Hoang et al. This would be compatible with ATA 2006 and NCCN 2010 guidelines. Summarized in Ahmed S et al. Incidental Nodules on Chest CT: Review of the Literature and Management Suggestions. AJR Nov 2010, Vol 195, Number 5.

16 Additional Findings: Standardized Reporting MACRO: Incidental testicular microlithiasis: Findings of testicular microlithiasis, which may be associated with slight increased risk for testicular neoplasms. As such, patient education regarding self-examination and annual follow-up sonography should be considered.

MACRO: Incidental ectopic not excluded: No intrauterine pregnancy. In the setting of positive Beta HcG, considerations include a missed abortion or an unseen ectopic. Serial Beta HCG and sonographic follow-up should be obtained based on clinical factors.

(SRU based) MACRO: Incidental Failed first trimester pregnancy: Given [pick list with below options] findings are diagnostic of pregnancy failure.

CRL of 7 mm with no fetal heartbeat mean gestational sac diameter 25 mm with no visible embryo absence of an embryo with heartbeat greater than 2 weeks after the prior scan showed a GS without a YS absence of an embryo with heartbeat 11 days after a scan that showed GS with a YS

(SRU based) MACRO: Possible first trimester pregnancy failure: Given [pick list with below options] findings are suspicious for but not diagnostic of pregnancy failure. Two week sonographic follow-up recommended.

CRL of < 7 mm and no heartbeat mean gestational sac diameter of 16-24 mm and no embryo empty amnion small gestational sac in relation to the size of the embryo (< 5 mm difference between MSD and CRL) absence of embryo with heartbeat 7-13 days after a scan that showed a GS without YS absence of embryo with heartbeat 7-10 days after a scan that showed GS with YS findings

Subchorionic Hemorrhage (SCH):

Risk of spontaneous abortion ~ doubles with large vs. small/moderate size SCH. Greater circumferential involvement of the gestational sac increases risk of spontaneous abortion. Retroplacental involvement increases risk of poor fetal outcomes. Maternal age > 35 yrs increases risk of spontaneous abortion. Fetal age > 8 weeks increases risk of spontaneous abortion. Size of hematoma is described by % of chorionic sac circumference elevated:

o Small is < o Moderate is to o Large is >

Volume of hematoma can be described. Compare to GS size. Location of hematoma in uterus (adjacent to internal os, retroplacental, other)

*Source: Variety of papers, most significantly Bennett et al. Radiology 1996.

Fleischner Guidelines (MACRO: Incidental pulmonary nodule solid)NOTES

New Fleischner RecommendationsNOTESGallstonesWall CalcificationHyperattenuating ContentsWall ThickeningDistentionBasic Differential by MorphologyRed Flags for MalignancyManagement of an Incidental Cyst in an Asymptomatic PatientNo Follow-up NeededFollow-up Imaging (MRI in 6 + 12 months)Further Workup (PET, MR, Biopsy)

Management in the General Population** Imaging observation may be appropriate in patients with limited life expectancy or poor surgical candidates.

Bosniak Classification (CT/MR, not US)Category 1Category 2Category 2F (MACRO: incidental renal bosniak)Category 3Category 4* Imaging observation may be appropriate in patients with limited life expectancy or poor surgical candidates.No Follow-up Needed Benign features Suspicious features but stable x1 yearFollow-up Imaging (CT/MR in 3 months) No known malignancy and clinical/laboratory data suggest benign process.Further Workup (PET, EUS, Biopsy, MIBG, etc.)

Benign-Appearing Cyst (MACRO: Incidental Ovarian cyst CT (benign appearing))Premenopausal (in absence of last known menstrual period, 50 yoa used for arbitrary designation of menopause)Early Postmenopausal (If unknown menstrual status, this is 50-55 yoa)Late Postmenopausal (if unknown menstrual status, this is > 55 yoa)

Probably Benign CystPremenopausal (< 50 years old)Early Postmenopausal (50-55 years old)Late Postmenopausal (>55 years old)

Other Features*If menopausal status is unknown: 55 is late post-menopausalSimple Cyst (ovarian or extraovarian)Hemorrhagic CystDermoid (any age)Background: Present in up to 16% of all Chest CTs.

Documents

ER Division Incidentaloma Guidelines.pdf