16 Aug Safe and Sorry?

ImagingEconomics | Incidental findings can lead to unnecessary testing, expense, and malpractice suits.

Radiologists inevitably worry about missing something, but an equally vexing part of the job is seeing too much. Looking for one thing and finding another—the so-called “incidentaloma”—has long been a familiar conundrum that only gets worse as technology gets better. “The more we can see,” said Leonard Berlin, MD, FACR, “the more we find.”

Incidental findings have likely been a part of the profession since Röntgen discovered x-rays, but the advent of CT in the early 1970s brought the possibilities to a whole new level. “Then came MRI and more sophisticated CT technology, and we could see 1/2-mm structures,” said Berlin, professor of radiology at Rush University Medical College, Chicago. “People have likened this to looking at a map. With magnified maps, you see all these little islands. It’s similar in medicine, and it’s a major problem. Today we are seeing a lot of things, most of which are normal. But once we see something, what do we do with it?”

The fact is that “better safe than sorry” is not an apt cliché when it comes to incidentalomas. Instead, too safe can lead to a lot of needless expense and pain for patients. “About 98% of incidental findings are of no significance,” Berlin estimated. “If we do a CT of the abdomen for other reasons, and we look at the kidneys, the statistics are that up to 23% of people will have an abnormality in their kidney. Statistically, only two tenths of 1% will turn out to be problematic.”

“If you see a 1-cm lesion in the kidney, and you can’t tell whether it is solid or cystic, the question will be what is the chance that it could turn into a cancer that could metastasize and potentially kill the patient?” asked Lincoln L. Berland, MD, FACR, professor emeritus and vice-chairman for Quality Improvement and Patient Safety, Department of Radiology, University of Alabama at Birmingham. “The answer could be half of 1%, it could be a hundredth of 1% or even less. No one really knows, and that is part of the problem.”

Berlin likens the entire process to a one-way trapdoor. Once you go through, you can’t go back. “I call it the medical maze,” he said. “Once you take the first step in a medical test, there is no backing up. Because if that is equivocal, you are going to the next step. Others refer to it as the cascade of testing. One marginally abnormal test result usually begets another marginally abnormal test result. And that is the problem.”

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