With the advent of high resolution CT, MRI, and ultrasound scanning, the frequency of radiologists’ serendipitous discovery of incidental findings (colloquially referred to as “incidentalomas”) on radiological examinations is increasing. Incidentalomas account for approximately 20% of all findings, due to two reasons: (a) the number of hi-tech imaging exams (primarily CT) performed today, and (b) the increasing sophistication of the technology. In the early 1980s when CT scanning was in its infancy, 3 to 5 million scans were performed annually in the US. In the past few years, the annual number of CT scans performed in the US has increased exponentially to well over 80 million. In addition, the specificity of the equipment has advanced geometrically such that abnormalities and/or pseudo-abnormalities 1 mm or a fraction of 1 mm in size that were virtually “invisible” before can now be seen quite easily.
Statistically only 1% or less of these incidentalomas represent an early malignancy or other severe pathology. Thus, radiologists are faced with a dilemma: if they report every incidentaloma, many patients will be subjected to a cascade of costly testing, sometimes leading to biopsies or other invasive procedures, all of which on occasion may lead to complications and cause harm to the patient who was completely healthy and was never ill to begin with. On the other hand, should the radiologist decide not to report the presence of an incidentaloma, and it is later discovered that it was indeed an early malignancy and thus a fatal delay in diagnosis and treatment ensued, the patient could be permanently harmed or even die, and a medical malpractice lawsuit would almost certainly follow.
What, if anything, should the radiologist report to the patient or the referring physician, when faced with an incidentaloma? Should, or must, informed consent be required? This Chapter will focus on both the moral-ethical, and the medico-legal, aspects of the incidentaloma dilemma faced everyday by radiologists as well as treating physicians.
Down Syndrome Osteogenesis Imperfecta High Resolution Compute Tomography Medical Malpractice Compute Tomography Exam
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15,000 people are estimated to die each year because of cancers caused by radiation in CT scans alone. Consumer Reports Magazine, Mar 2015Google Scholar
2 or 3 CT scans = Hiroshima Radiation. Chicago Tribune. 7 Jan 2011Google Scholar
Advincula v United Blood Services, 678 NE2d 1009 (Ill 1996)Google Scholar
American Medical Association Council on Ethical and Judicial Affairs (2015) Code of medical ethics of the American Medical Association Council on Ethical and Judicial Affairs, 2014–2015 edn. American Medical Association, Chicago, pp 8.08, 8.082Google Scholar
Apfaltrer P, Schymik G, Reimer P et al (2012) Aortoiliac CT angiography for planning transcutaneous aortic valve implantation: aortic root anatomy and frequency of clinically significant incidental findings. AJR Am J Roentgenol 198:939–945CrossRefPubMedGoogle Scholar
Berland LL (2011) The American College of Radiology strategy for managing incidental findings on abdominal computed tomography. Radiol Clin North Am 49:238–243CrossRefGoogle Scholar
Berland LL, Silverman SG, Gore RM et al (2010) Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 7:754–773CrossRefPubMedGoogle Scholar
Berland LL, Silverman SG, Megibow MD et al (2014) ACR members’ response to ACR white paper on the management of incidental abdominal findings. J Am Coll Radiol 11:300–335CrossRefGoogle Scholar
Berlin L (1998) Standard of care. AJR Am J Roentgenol 170:273–278Google Scholar
Berlin L (2011) Communicating the harmful effects of radiation exposure from medical imaging: malpractice considerations. Health Phys 101:583–588CrossRefPubMedGoogle Scholar
Betesh v United States of America, 400 F Supp 238 (US Dist dc 1974)Google Scholar
Booth TC, Jackson A, Wardlaw JM (2010) Incidental findings found in “healthy” volunteers during imaging performed for research: current legal and ethical implications. Br J Radiol 83:456–465CrossRefPubMedPubMedCentralGoogle Scholar
Daly v United States of America, 946 F2d 1467 (9th cir 1991)Google Scholar
deGonzales AB, Mahadevappa M, Kim KP et al (2009) Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 169:2071–2077CrossRefGoogle Scholar
Dubroff JG, Nasrallah IM (2015) Will PET amyloid imaging lead to overdiagnosis of Alzheimer dementia? Acad Radiol 22:988–994CrossRefPubMedGoogle Scholar
Elmi A, Tabatabaei S, Talab S et al (2012) Incidental findings at initial imaging workup of patients with prostate cancer: clinical significance and outcomes. AJR Am J Roentgenol 199:1305–1311CrossRefPubMedGoogle Scholar
Epstein RM, Korones DN, Quill TE (2010) Withholding information from patients – when less is more. N Engl J Med 362:380–381CrossRefPubMedGoogle Scholar
Esmaili A, Munden RF, Mohammed TL (2011) Small pulmonary nodule management: a survey of members of the Society of Thoracic Radiology with comparison to the Fleischner Society guidelines. J Thorac Imaging 26:27–31CrossRefPubMedGoogle Scholar
Filly RA (2000) Obstetrical sonography: the best way to terrify a pregnant woman. (Editorial). J Ultrasound Med 19:1–5CrossRefPubMedGoogle Scholar
Hegenscheid K, Seipel R, Schmidt CO et al (2013) Potentially relevant incidental findings on research whole-body MRI in the general adult population: frequencies and management. Eur Radiol 23:816–826CrossRefPubMedGoogle Scholar
Hoang JK, Nguyen XV, Davies L (2015) Overdiagnosis of thyroid cancer: answers to five key questions. Acad Radiol 22:1024–1029CrossRefPubMedGoogle Scholar
Johnson G. When radiation isn’t the risk. New York Times, 22 Sept 2015:D3Google Scholar
Johnson PT, Horton KM, Megibow AJ et al (2012) Common incidental findings on MDCC: survey of radiologist recommendations for patient management. J Am Coll Radiol 8:762–767CrossRefGoogle Scholar
Salman RAS, Whiteley WN, Warlow C (2007) Screening using whole-body magnetic resonance imaging scanning: who wants an incidentaloma? J Med Screen 14:2–4CrossRefGoogle Scholar
Schloendorff v The Society of New York Hosp., 105 NE 92 (NY 1914)Google Scholar
Sgourakis G, Lanitis S, Korontzi M et al (2011) Incidental findings in focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients: speaking about cost to benefit. J Trauma 71:E123–E127PubMedGoogle Scholar
Smith-Bindman R, Lipson J, Markus R et al (2009) Radiation dose associated with common computed tomography examinations and associated lifetime attributable risk of cancer. Arch Intern Med 169:2078–2086CrossRefPubMedPubMedCentralGoogle Scholar
Sperry JL, Massaro MS, Collage RD et al (2010) Incidental radiographic findings after injury: dedicated attention results in improved capture, documentation, and management. Surgery 148:618–621CrossRefPubMedPubMedCentralGoogle Scholar
William Morris The American Heritage dictionary, Second College Edition (1985) Houghton Mifflin Company, Boston, pp 484–485Google Scholar
Tong GE, Staudenmayer MD, Hsia RY (2016) Use of emergency department imaging in patients with minor trauma. J Surg Res. doi: http:lldx.doi.org/10.1016/J.Jss.2015.11.046. Accessed February 27, 2016Google Scholar
Tubiana M, Feinnendegen LE, Yang C, Kaminski JM (2009) The linear no-threshold relationship is inconsistent with the radiation biologic and experimental data. Radiology 251:13–22CrossRefPubMedPubMedCentralGoogle Scholar
van Vugt MD, Dekker HM, Deunk J et al (2012) Incidental findings on routine thoracoabdominal blunt trauma patients. J Trauma 72:416–421Google Scholar
Vernooij MW, Ikram MA, Tanghe HL et al (2007) Incidental findings on brain MRI in the general population. N Engl J Med 357:1821–1828CrossRefPubMedGoogle Scholar