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Perivascular epithelioid cell neoplasm (PEComa) is a rare type of tumour, and primary retroperitoneal PEComa is rarer still. Although pulmonary lymphangioleiomyomatosis (LAM), angiomyolipomas and clear cell ‘sugar’ tumours of the lung are well described, relatively little is known about other members of the PEComa family. We describe a case of an asymptomatic retroperitoneal PEComa, lymphangioleiomyoma type, which appeared in a previously healthy middle-aged woman as an incidental finding, in a CT scan performed in the context of spontaneous pneumothorax. The patient underwent surgical excision of the tumour and the histopathological and immunohistochemical analysis of the surgical specimen made the definitive diagnosis. Although rare, reports of isolated retroperitoneal lymphangioleiomyoma and primary retroperitoneal PEComas NOS (not otherwise specified) are described in the literature, normally associated with pulmonary LAM. The patient’s pulmonary imaging was normal. Short-term re-examination did not detect any recurrence. We also provide a literature review of this rare group of tumours.

There is a paradigm shift in the detection of phaeochromocytomas with more being identified as adrenal ‘incidentalomas’. While majority of these individuals are asymptomatic, they are nevertheless at risk of subtle cardiovascular dysfunction and phaeochromocytoma crises. Therefore, early resection of phaeochromocytomas, even if subclinical, is recommended. However, the perioperative management can be challenging as the normotension can limit the initiation and titration of alpha-blockade. We present a man in his 60s with a subclinical phaeochromocytoma, discuss the evaluation of an incidentally discovered adrenal nodule, as well as the practical considerations in the perioperative management.

We herein report a relatively rare case of a woman in her 30s with an incidental lung finding. She subsequently underwent resection for what was considered to be a solitary fibrous tumour of the pleura (SFTP). SFTPs are rare, slow-growing neoplasms from mesenchymal origin. These tumours are histologically characterised by proliferation of bland-looking spindled cells, arranged in a patternless pattern, with hypocellular and hypercellular areas set in a hyalinised stroma. Complete en bloc surgical excision (with margin negativity) is the treatment of choice for both benign and malignant SFTPs. Due to the possibility of local recurrence with benign and malignant SFTPs, clinical and radiological follow-up is recommended.

A 4-week-old boy presented to the hospital with symptoms of diarrhoea and vomiting initially thought to be due to cow’s milk allergy. He was discharged with extensively hydrolysed formula. The patient represented with worsening of symptoms with metabolic acidosis and was screened and treated for sepsis. However, his condition deteriorated further and he developed methaemoglobinaemia. He was transferred to the high dependency unit and was given two doses of methylene blue. Further investigations were carried out, including rapid trio exome sequencing, which identified a homozygous pathogenic Peptidase D (PEPD) variant (c.978G>A, p.(Trp326*)). This was consistent with a diagnosis of prolidase deficiency.

Emphysematous cystitis (EC) is a rare severe urinary tract infection characterised by pockets of air in and around the urinary bladder wall caused by gas-forming organisms. Common predisposing factors are chronic infection, immunosuppression, diabetes and neurogenic bladder. The presentation may vary from mild illness to severe life-threatening cystitis. We report two cases of incidental detection of EC diagnosed on imaging for the evaluation of unrelated symptoms. Although asymptomatic, this lethal disease still warrants prompt recognition and treatment with broad-spectrum antibiotics and urinary bladder drainage to prevent severe morbidity and mortality.

In dieser retrospektiven Studie konnten wir mit Daten von insgesamt 392 Patienten über einen Zeitraum von 5 Jahren eine Übersicht über das Auftreten von Zufallsbefunden in der Prostataspezifischen-Membranantigen-Positronenemissionstomographie/ Computertomographie erstellen. Erstmalig wurde in dieser Studie die Häufigkeit von Prostataspezifischen-Membranantigen-positiven und -negativen Inzidentalomen in dieser nuklearmedizinischen Bildgebung untersucht. Unsere Ergebnisse zeigen, dass bei 10 % der Untersuchungen mit dem Auftreten eines abklärungsbedürftigen Zufallsbefundes gerechnet werden muss. Das Ziel dieser Forschungsarbeit war es, die Inzidenz und die klinische Relevanz zufällig entdeckter Raumforderungen in der Prostataspezifischen-Membranantigen- Positronenemissionstomographie/ Computertomographie zu evaluieren. Im Einzelnen sollte die Inzidenz sogenannter Inzidentalome in verschiedenen Organen, der Anteil abklärungsbedürftiger Inzidentalome sowie der Anteil 68Gallium-Prostataspezifisches-Membranantigen-positiver Inzidentalome und die Detektion von Zweitmalignomen untersucht werden. Die Daten aus dieser Studie sollen dazu beitragen, den Umgang mit Inzidentalomen zukünftig zu standardisieren und zu verbessern. Insgesamt wurden in dieser Arbeit 486 Untersuchungen an 392 Patienten im Zeitraum zwischen Januar 2014 und Januar 20019 ausgewertet. Auffällige Befunde wurden zusammen mit den zugehörigen Bilddaten anschließend mit einem erfahrenen Nuklearmediziner ein zweites Mal gesichtet. 16 zuvor abklärungsbedürftige Zufallsbefunde konnten hierdurch bildmorphologisch einer Entität zugeordnet werden. Bei der Auswertung der detektierten Zufallsbefunde wurde unterschieden zwischen Inzidentalomen, die bildmorphologisch sicher benigne identifiziert werden konnten (ohne klinische Relevanz) und Inzidentalomen, die suspekt bzw. abklärungsbedürftig erschienen. Insgesamt konnten 223 Inzidentalome festgestellt werden, wobei am häufigsten die Niere (31,4 %), Leber (29,1 %) und Lunge (19,7 %) betroffen waren, gefolgt von Schilddrüse (8,1 %) und Nebenniere (4,9 %). Faktoren wie der Einsatz von CT-Kontrastmittel und ein steigendes Alter der Patienten konnten mit einer deutlich höheren Detektionsrate in Verbindung gebracht werden. Der Anteil abklärungsbedürftiger Inzidentalome schwankte abhängig vom betroffenen Organ zwischen 59,1 % (Lunge) und 2,9 % (Niere) und lag insgesamt bei 22 % (49 von 223 Inzidentalomen). In 16 Fällen konnte eine radiologische oder sonographische Kontrolle verzeichnet werden und in 7 Fällen war anhand histopathologischer Untersuchungen sogar eine eindeutige Charakterisierung erfolgt. Zu den gesicherten Prostataspezifisches-Membranantigen-negativen Zufallsbefunden in dieser Studie zählen ein Kolonkarzinom mit Lebermetastasierung, ein pulmonales Adenokarzinom sowie eine intraduktale papillär-muzinöse Neoplasie des Pankreas. Ohne endgültige Sicherung des Verdachtes konnten außerdem ein Nierenzellkarzinom, eine Bosniak IV Zyste, 5 metastasensuspekte Raumforderungen in der Leber sowie malignitätsverdächtige Raumforderungen in der Lunge, Schilddrüse, Nebenniere, Milz und Harnblase dokumentiert werden. Darüber hinaus konnten in dieser Studie auch 17 Inzidentalome mit Anreicherung des 68Gallium-Prostataspezifisches-Membranantigen-Tracers festgestellt werden. Am häufigsten war die Lunge betroffen. In vielen Fällen war allerdings kein klinisch relevantes Ergebnis ermittelt worden, da Raumforderungen häufig nicht am Universitätsklinikum Marburg nachuntersucht wurden oder sich im Verlauf als Metastasen des bekannten Prostatakarzinoms erwiesen. Zwei benigne Inzidentalome, ein frontobasales Meningeom und mehrere dysontogenetische Zysten in der Leber zeigten eine signifikante Traceranreicherung. Zu den malignen Prostataspezifisches-Membranantigen-positiven Zufallsbefunden gehörten ein papilläres Schilddrüsenkarzinom (neben zwei weiteren ähnlichen Befunden ohne abschließende Charakterisierung) und ein Gastrointestinaler Stromatumor, der allerdings nicht abschließend bestätigt werden konnte. Die größte Limitation dieser Arbeit bestand darin, dass ausschließlich Daten zu Follow-Up Untersuchungen am Universitätsklinikum Marburg ausgewertet wurden, wodurch Ergebnisse zu 53 % der suspekten Inzidentalome fehlten. Für zukünftige Forschung wäre interessant, bestimmte Malignome, insbesondere Schilddrüsenkarzinome, Nierenzellkarzinome und andere solide Tumore, gezielt auf die Expression des Prostataspezifischen Membranantigens zu untersuchen. So könnte der Einsatz der Prostataspezifischen-Membranantigen-Positronenemissionstomographie/ Computertomographie auch zur Metastasensuche bei anderen Tumoren diskutiert werden. Die Wertigkeit im Vergleich zur Fluordesoxyglukose-Positronenemissionstomographie/Computertomographie müsste dann überprüft werden. Darüber hinaus wird auch die Erforschung des Prostataspezifischen-Membranantigens als Target in der anti-angiogenetischen Therapie Gegenstand zukünftiger Forschungen sein.

Currently, there are no consensus guidelines about handling incidental radiological findings on radiotherapy planning CT simulation scans. Retrospective studies analyzing incidental findings on CT simulations show a small, but not insignificant, rate of both oncologic and non-oncologic findings. These findings may have medico-legal, financial, and clinical implications. Given a lack of guidelines, we obtained a formal survey of multiple academic institutions to evaluate how CT simulations are handled in regard to incidental findings.A formal survey was developed consisting of 12 questions related to institutional practices regarding CT simulation scans. From 7/18/21 to 8/27/21 and 5/6/22 to 5/24/22, the survey was administered electronically by REDCap to key personnel at Academic Radiation Oncology Programs identified through the American Society for Radiation Oncology (ASTRO) with inclusion criteria including an active ACGME approved Radiation Oncology residency program.In total, 88 academic radiation oncology programs were surveyed with total of 45 responses (51%). 1 out of 45 departments who responded has formal guidelines regarding workup of incidental findings. There is variability about sending CT simulation scans for official radiology review if an incidental finding is identified.Based on a measurable rate of incidental findings on radiotherapy planning CT simulations and their possible implications, our survey illustrates a likely need for consensus recommendations for handling such findings to improve patient care and safety.

The Fleischner Society aims to limit further evaluations of incidentally detected pulmonary nodules when the probability of lung cancer is1% and to pursue further evaluations when the probability of lung cancer is ≥1%. To evaluate the internal consistency of guideline goals and recommendations, the authors evaluated stratum-specific recommendations and 2-year probabilities of lung cancer.A retrospective cohort study (2005-2015) was conducted of individuals enrolled in one of two integrated health systems with solid nodules incidentally detected on CT. The 2017 Fleischner Society guidelines were used to define strata on the basis of smoking status and nodule size and number. Lung cancer diagnoses within 2 years of nodule detection were ascertained using cancer registry data. Confidence interval (CI) inspection was used to determine if stratum-specific probabilities of lung cancer were different than 1%.Among 5,444 individuals with incidentally detected lung nodules (median age, 66 years; 54% women; 57% smoked; median nodule size, 5.5 mm; 55% with multiple nodules), 214 (3.9%; 95% CI, 3.4%-4.5%) were diagnosed with lung cancer within 2 years. For 7 of 12 strata (58%), 2,765 patients (51%), and 194 lung cancer cases (91%), there was alignment between Fleischner Society goals and recommendations. Alignment was indeterminate for 5 strata (42%), 2,679 patients (49%), and 20 lung cancer cases (9%) because CIs for the probability of lung cancer spanned 1%.Fleischner Society guideline goals and recommendations align at least half the time. It is uncertain whether alignment of guideline goals and recommendations occurs more often.

Aim: Our study aimed to determine the prevalence and clinical significance of incidental findings detected in thorax computed tomography (CT) scans of patients who were admitted to the emergency department (ED) due to Coronavirus disease 2019 (COVID-19).Methods: In this retrospective, cross-sectional, observational, and single-center study, we included adult (≥18 years old) patients who were admitted to the emergency department with symptoms of COVID-19 and underwent thoracic CT between May-July 2020. Patients with incidental findings on CT scans were evaluated in three groups according to international classifications. Patient groups and patients with and without incidental findings were compared in terms of age, gender, and age distribution.Results: Incidental findings were found in 41.8% of 5,667 patients who were admitted to ED with COVID-19 symptoms and underwent thoracic CT. The mean age was significantly higher among the patients with incidental findings than among the patients without incidental findings. However, there was no significant difference between the groups in terms of gender. Clinically significant findings were observed in 11.8% (n=670) of the patients. The most common incidental finding on thorax CT was atherosclerotic changes in the mediastinal main vascular structures with a rate of 27.7% (n=655). The most common clinically significant finding was cardiomegaly, with a rate of 13.7% (n=325).Conclusion: No incidental finding was found in most of the patients. On the other hand, as the age increased, the probability of detecting an incidental finding increased. Clinically insignificant findings were found in the majority of patients with incidental findings., Amaç: Çalışmamızda Koronavirüs hastalığı (COVID-19) şüphesiyle acil servise başvuran hastalara çekilen toraks bilgisayarlı tomografi (BT) görüntülemelerinde tespit edilen rastlantısal bulguların prevelansını belirlemek ve klinik önemini değerlendirmeyi amaçladık.Yöntemler: Retrospektif, kesitsel, gözlemsel ve tek merkezli olarak planlanan çalışmamıza hastanemiz Acil Tıp Kliniği’ne Mayıs-Temmuz 2020 tarihleri arasında, COVID-19 bulguları nedeniyle başvuran ve toraks BT çekilen yetişkin hastalar (≥18 yaş) dâhil edildi. BT görüntülemelerinde insidental bulguya sahip olan hastalar uluslararası sınıflandırmalara göre üç grup olarak değerlendirildi. Hasta grupları ve insidental bulgu saptanan hastalar ile insidental bulgu saptanmayan hastalar yaş, cinsiyet ve yaş dağılımı açısından karşılaştırıldı.Bulgular: COVID-19 semptom ve bulguları ile acil servise başvuran ve toraks BT çekilen 5,667 hastanın %41,8’inde tesadüfi bulgular olduğu saptandı. İnsidental bulgu saptanmayan hasta grubu ile karşılaştırıldığında, insidental bulgu saptanan hasta grubunda ortalama yaş anlamlı yüksek olarak gözlemlendi. Ancak, gruplar arasında cinsiyet bakımından anlamlı bir fark bulunmadı. Hastaların %11,8’lik (n=670) bölümünde klinik olarak yüksek düzeyde önemli bulgular saptandı. Toraks BT’de en sık rastlanan insidental bulgu %27,7’lik (n=655) oran ile mediastinal ana vasküler yapılarda aterosklerotik değişiklikler olarak saptandı. Klinik olarak yüksek düzeyde önemli insidental bulgu olarak en sık %13,7’lik (n=325) oran ile kardiyomegali tespit edildi.Sonuç: Toraks BT çekilen hastaların büyük bir kısmında insidental bulguya rastlanmadı. Diğer yandan yaş arttıkça özellikle insidental bulgunun saptanma olasılığında artış gözlemlendi. İnsidental bulgusu bulunan hastaların çoğunluğunda ise klinik olarak önemsiz bulgulara rastlandı.

BACKGROUND: In addition to its intended purpose of perforator mapping, computed tomography angiography can also identify incidental findings that may require further evaluation. In this multi-institutional study, the authors evaluated the frequency of incidental findings and their significance and effects on treatment course and aimed to identify risk factors for detecting such findings. METHODS: A retrospective review of patients who underwent perforator mapping with computed tomography angiography was performed over a 5-year period from three academic institutions. Relevant sociodemographic and clinicopathologic information, computed tomography angiography reports, follow-up visits, and treatment outcomes were reviewed. Univariate and multivariate analyses were performed to assess the relationship between risk factors and incidental findings. RESULTS: From January of 2015 to July of 2020, a total of 656 patients were identified who met inclusion criteria. Overall, 342 incidental findings were found, 76 of which required additional imaging or consultation. Ultimately, 10 patients (1.5 percent) had findings that altered reconstructive management, including five patients (0.8 percent) having severe disease that resulted in the cancellation of their reconstruction. Advanced age and immediate reconstruction timing were independent risk factors for incidental findings. CONCLUSIONS: Incidental findings are commonly identified on preoperative computed tomography angiography for deep inferior epigastric perforator flap breast reconstruction. Suspicious findings should be investigated thoroughly because they can alter the reconstructive course. Understanding of high-risk groups for incidental findings can further advance patient education during initial consultation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

An incidental finding is defined as a newly discovered mass or lesion detected on imaging performed for an unrelated reason. The identification of an incidental finding may be an opportunity for the early detection of a serious medical condition, including a malignancy. However, little is known about the prevalence of incidental findings in the emergency department (ED) setting and the strategies that can be used to mitigate the risk associated with them in the ED. This study aimed to estimate the overall prevalence of incidental findings and to summarize the currently described measures to mitigate the risks associated with incidental findings.On November 22, 2020, a systematic literature search of PubMed, EMBASE, and Scopus was performed for studies that were published in peer-reviewed journals and reported the prevalence of incidental findings in computed tomography (CT) scans in patients in the ED. Patients who received CT scans that included the head, neck, chest, or abdomen/pelvis were included. The study characteristics, overall prevalence of incidental findings, prevalence of incidental findings by body region, and prespecified subgroups were extracted. The criteria used for risk stratification within individual studies were also extracted. Pooled estimates were calculated using a random-effects meta-analysis.A total of 1,385 studies were identified, and 69 studies met the inclusion criteria. The included studies represented 147,763 ED encounters or radiology reports across 16 countries, and 83% of studies were observational, cross-sectional studies. A total of 35 studies (50.7%) were in trauma patients. A large degree of heterogeneity was observed across the included studies. The overall pooled prevalence estimate for any incidental finding was 31.3% (95% confidence interval 24.4% to 39.1%). We found great variation in the methods described to mitigate the risk associated with incidental findings, including a lack of standardized risk stratification, inconsistent documentation practices, and only a small subset of studies describing prospective interventions aimed at improving the recognition and management of incidental findings from the ED.In patients in the ED receiving CT scans, incidental findings are commonly encountered across a broad range of ED chief complaints. This review highlights the existence of great heterogeneity in the definitions used to classify incidental findings. Future studies are needed to determine a clinically feasible categorization standard or terminology for commonly encountered incidental findings in the ED setting to standardize classification and documentation.

Objective: To assess the diagnostic accuracy of histogram analysis on unenhanced computed tomography (CT) for differentiating between adrenal adenomas and pheochromocytomas (PCCs). Materials and Methods: We retrospectively identified patients with proven PCCs who had undergone CT examinations between January 2009 and July 2019 at one of two institutions. For each PCC, we selected one or two adenomas diagnosed within two weeks of the date of diagnosis of the PCC. For each lesion, two readers scored the size, determined the mean attenuation, and generated a voxel histogram. The 10th percentile (P10) was obtained from the conventional histogram analysis, as well as being calculated with the following formula: P10 = mean attenuation – (1.282 × standard deviation). The mean attenuation threshold, histogram analysis (observed) P10, and calculated P10 (calcP10) were compared in terms of their diagnostic accuracy. Results: We included 52 adenomas and 29 PCCs. The sensitivity, specificity, and accuracy of the mean attenuation threshold were 75.0%, 100.0%, and 82.5%, respectively, for reader 1, whereas they were 71.5%, 100.0%, and 81.5%, respectively, for reader 2. The sensitivity, specificity, and accuracy of the observed P10 and calcP10 were equal for both readers: 90.4%, 96.5%, and 92.6%, respectively, for reader 1; and 92.3%, 93.1%, and 92.6%, respectively, for reader 2. The increase in sensitivity was significant for both readers (p = 0.009 and p = 0.005, respectively). Conclusion: For differentiating between adenomas and PCCs, the histogram analysis (observed P10 and calcP10) appears to outperform the mean attenuation threshold as a diagnostic criterion. Resumo Objetivo: Avaliar a acurácia diagnóstica da análise por histograma na tomografia computadorizada (TC) sem contraste para a diferenciação entre adenomas adrenais e feocromocitomas (FCCs). Materiais e Métodos: Identificamos, retrospectivamente, pacientes com diagnóstico de FCC confirmado que foram submetidos a exames de TC entre janeiro de 2009 e julho de 2019 em duas instituições distintas. Para cada FCC, selecionamos um ou dois adenomas diagnosticados em até duas semanas da data do diagnóstico do FCC. Para cada lesão, dois leitores pontuaram o tamanho, determinaram a atenuação média e geraram um histograma com os voxels das imagens. O percentil 10 (P10) foi obtido a partir da análise convencional do histograma, além de ser calculado com a seguinte fórmula: P10 = atenuação média - (1,282 × desvio-padrão). O limiar de atenuação média, o P10 da análise por histograma (P10 observado) e o P10 calculado (P10calc) foram comparados em termos de acurácia diagnóstica. Resultados: Foram incluídos 52 adenomas e 29 FCCs. A sensibilidade, especificidade e acurácia do limiar de atenuação média foram de 75,0%, 100,0% e 82,5% para o leitor 1, respectivamente, e de 71,5%, 100,0% e 81,5% para o leitor 2, respectivamente. A sensibilidade, especificidade e acurácia do P10 observado e do P10calc foram idênticas para os dois leitores: 90,4%, 96,5% e 92,6%, respectivamente, para o leitor 1; e 92,3%, 93,1% e 92,6%, respectivamente, para o leitor 2. O aumento da sensibilidade foi significativo para ambos os leitores (p = 0,009 e p = 0,005, respectivamente). Conclusão: Para a diferenciação entre adenomas e FCCs, a análise por histograma (P10 observado ou P10calc) parece superar o limiar de atenuação média como critério diagnóstico.

Omental herniation, located between the rectus abdominis muscle and the anterior blade of the rectus sheath, can be triggered after a transverse suprapubic incision. It causes the development of an incisional interstitial hernia (IIH), which is an extremely rare and poorly understood condition. Based on this information, our work presents the first anatomical description of incisional interstitial hernia found during routine dissection at the Human Anatomy Laboratory of the Federal University of Ceará in a formalized female corpse.

Liver transplantation is the only potentially curative treatment for patients with end-stage liver disease. After the procedure, histopathologic analysis of the liver explant may reveal neoplasms that were not previously diagnosed in preoperative imaging examinations. This incidental finding of primary liver neoplasms in the explant is not an uncommon situation in liver transplant, and hepatocarcinomas and cholangiocarcinomas are the types of tumors most frequently encountered in this scenario. These are the most common primary neoplasms of the liver, and liver transplantation is often a curative treatment for these types of tumors when they are in their earlier stages. In contrast, liver plasmacytoma is a rare type of plasma cell neoplasm, consisting of a single mass of monoclonal plasma cells, which is treated primarily by radiotherapy and is seldom encountered in the setting of liver transplant. We report the case of a patient who underwent liver transplantation for the treatment of cryptogenic cirrhosis, with no preoperative diagnosis of liver tumors. Analysis of the liver explant revealed the presence of three synchronous neoplasms with different histologic origins: a 27-mm hepatocellular carcinoma, a 17-mm intrahepatic cholangiocarcinoma, and a 25-mm solitary hepatic plasmacytoma. The patient received no further adjuvant treatment and remained well and with no signs of disease recurrence over an observation period of 44 months. We found no previous report in the literature of the synchronous presence of these three types of liver neoplasms.

Incidental gallbladder cancer (IGBC) represents 50%-60% of gallbladder cancer cases. Data are conflicting on the role of IGBC diagnosis in oncological outcomes. Some studies suggest that IGBC diagnosis does not affect outcomes, while others that overall survival (OS) is longer in these cases compared to non-incidental diagnosis (NIGBC). Furthermore, some studies reported early tumour stages and histopathologic characteristics as possible confounders, while others not.To investigate the role of IGBC diagnosis on patients' overall survival, especially after surgical treatment with curative intent.Retrospective analysis of all patient referrals with gallbladder cancer between 2008 and 2020 in a tertiary hepatobiliary centre. Statistical comparison of patient and tumour characteristics between IGBC and NIGBC subgroups was performed. Survival analysis for the whole cohort, surgical and non-surgical subgroups was done with the Kaplan-Meier method and the use of log rank test. Risk analysis was performed with univariable and multivariable Cox regression analysis.The cohort included 261 patients with gallbladder cancer. 65% of cases had NIGBC and 35% had IGBC. A total of 90 patients received surgical treatment (66% of IGBC cases and 19% of NIGBC cases). NIGBC patients had more advanced T stage and required more extensive resections than IGBC ones. OS was longer in patients with IGBC in the whole cohort (29IGBC diagnosis may confer a survival advantage independently of the pathological stage and tumour characteristics. Prospective studies are required to further investigate this, including detailed pathological analysis and molecular gene expression.

Background As the volume and fidelity of magnetic resonance imaging (MRI) of the brain increase, observation of incidental findings may also increase. We performed a systematic review and meta-analysis to determine the prevalence of various incidental findings. Methods PubMed/MEDLINE, EMBASE and SCOPUS were searched from inception to May 24, 2021. We identified 6536 citations and included 35 reports of 34 studies, comprising 40,777 participants. A meta-analysis of proportions was performed, and age-stratified estimates for each finding were derived from age-adjusted non-linear models. Results Vascular abnormalities were observed in 423/35,706 participants (9.1/1000 scans, 95%CI 5.2–14.2), ranging from 2/1000 scans (95%CI 0–7) in 1-year-olds to 16/1000 scans (95%CI 1–43) in 80-year-olds. Of these, 204/34,306 were aneurysms (3.1/1000 scans, 95%CI 1–6.3), which ranged from 0/1000 scans (95%CI 0–5) at 1 year of age to 6/1000 scans (95%CI 3–9) at 60 years. Neoplastic abnormalities were observed in 456/39,040 participants (11.9/1000 scans, 95%CI 7.5–17.2), ranging from 0.2/1000 scans (95%CI 0–10) in 1-year-olds to 34/1000 scans (95%CI 12–66) in 80-year-olds. Meningiomas were the most common, in 246/38,076 participants (5.3/1000 scans, 95%CI 2.3–9.5), ranging from 0/1000 scans (95%CI 0–2) in 1-year-olds to 17/1000 scans (95%CI 4–37) in 80-year-olds. Chiari malformations were observed in 109/27,408 participants (3.7/1000 scans, 95%CI 1.8–6.3), pineal cysts in 1176/32,170 (9/1000 scans, 95%CI 1.8–21.4) and arachnoid cysts in 414/36,367 (8.5/1000 scans, 95%CI 5.8–11.8). Conclusion Incidental findings are common on brain MRI and may result in substantial resource expenditure and patient anxiety but are often of little clinical significance.

INTRODUCTION: With improved imaging technology, the number of incidental findings detected in cerebral MRI is increasing. This is a challenge that the German Air Force has to deal with in the context of standardized MRI examinations of young pilot candidates and pilots.METHODS: The German Air Force Centre of Aerospace Medicine hosted a 2-d conference to develop recommendations and procedures for the handling of some of the most frequently encountered cerebral incidental findings.RESULTS: Radiological MRI findings from a total of 2724 routine examinations of the skull of pilots and pilot applicants (26.8 ± 10.6 yr old; range from 16 to 62; over 80% range from 17 to 33; 96% men) revealed that in 28.1% of the examinations, one or more incidental findings were discovered. For seven of the following categories of incidental findings, decision guidelines could be established: white matter hyperintensities (N = 393; prevalence 14.4%; 95% CI 13.11–15.75), pinealis cysts (317; 11.6%; 10.43–12.84), developmental venous anomalies (64; 2.3%; 1.78–2.92), cavernomas (15; 0.6%; 0.27–0.83), aneurysms (14; 0.5%; 0.25–0.78), cholesterol granulomas (22; 0.8%; 0.47–1.14), and heterotopias of the gray matter (6; 0.2%; 0.04–0.4).CONCLUSION: Considering pilots health and aviation safety, a waiver decision is often possible after thorough discussion, depending on the specific criteria of the incidental finding and of the type of license.Kühn S, Sönksen S-E, Noble H-J, Knopf H, Frischmuth J, Waldeck S, Müller-Forell W, Weber F, Bressem L. Incidental findings in head and brain MRI of military pilots and applicants: consequences for medical flight fitness. Aerosp Med Hum Perform. 2022; 93(5):450–457.

The purpose of this study was to analyze the prevalence and significance of incidental findings on computed tomography pulmonary angiography (CTPA) studies and to assess the diagnostic yield of CTPA in identifying an alternate diagnosis to pulmonary embolism (PE) on PE negative exams.All patients who had a CTPA exam for PE evaluation between Jan 2016 and Dec 2018 with a negative PE result were included in the study. A total of 2083 patients were identified. We retrospectively queried the electronic medical record and the radiology report and recorded the following: Age, Sex, BMI, Patient location and Incidental findings. The incidental findings were classified into type 1 (Alternate diagnosis other than PE which could explain the patient's symptoms), type 2 (non-emergent findings which needed further work up) and type 3 findings (non-emergent findings which did not need further work up). Logistic regression analysis was performed to determine what factors affected the probability of finding a type 1 incidental (alternate diagnosis) or a type 2 incidental.74.5% of the patients in our study had at least one incidental finding. Type 1 incidental findings (alternate diagnosis to PE) were found in 864 patients (41.5%). The most common type 1 finding was pneumonia followed by fluid overload. Male sex, increased age and lower BMI were significantly associated with increased odds of a type 1 incidental(p0.05). Similarly, all the patient locations had significantly different odds of finding a type-1 incidental, with ICU having the highest odds, followed by inpatient, ED and outpatient locations (p0.05). 563 patients (27%) had at least one type 2 incidental findings and the most common type 2 findings were progressive lung malignancy/ metastatic disease and new pulmonary nodule. Increased age was significantly associated with the probability of a type 2 finding (p0.05).CTPA may suggest an alternative diagnosis to pulmonary embolism in approximately 40% of the patients with a negative study. The probability of finding an alternate diagnosis (type 1 incidental) is higher in elderly patients and in patients referred from ICU and inpatient units.

Incidental respiratory disease-related findings are frequently observed on low-dose CT (LDCT) lung cancer screenings. This study analyzed data from the National Lung Screening Trial (NLST) to assess the relationship between such findings and respiratory disease mortality (RDM), excluding lung cancer.Are incidental respiratory findings on LDCT scanning associated with increased RDM?Subjects in the NLST LDCT arm received three annual screens. Trial radiologists noted findings related to possible lung cancer, as well as respiratory-related incidental findings. Demographic characteristics, smoking history, and medical history were captured in a baseline questionnaire. Kaplan-Meier curves were used to assess cumulative RDM. Multivariate proportional hazards models were used to assess risk factors for RDM; in addition to incidental CT scan findings, variables included respiratory disease history (COPD/emphysema, and asthma), smoking history, and demographic factors (age, race, sex, and BMI).Of 26,722 subjects in the NLST LDCT arm, 25,002 received the baseline screen and a subsequent LDCT screen. Overall, 59% were male, 26.5% were aged ≥ 65 years at baseline, and 10.6% reported a history of COPD/emphysema. Emphysema on LDCT scanning was reported in 30.7% of subjects at baseline and in 44.2% at any screen. Of those with emphysema on baseline LDCT scanning, 18% reported a history of COPD/emphysema. Median mortality follow-up was 10.3 years. There were 3,639 deaths, and 708 were from respiratory diseases. Among subjects with no history of COPD/emphysema, 10-year cumulative RDM ranged from 3.9% for subjects with emphysema and reticular opacities to 1.1% for those with neither condition; the corresponding range among subjects with a COPD/emphysema history was 17.3% (both) to 3.7% (neither). Emphysema on LDCT imaging was associated with a significantly elevated RDM hazard ratio (2.27; 95% CI, 1.92-2.7) in the multivariate model. Reticular opacities (including honeycombing/fibrosis/scar) also had a significantly elevated hazard ratio (1.39; 95% CI, 1.19-1.62).Incidental respiratory disease-related findings observed on NLST LDCT screens were frequent and associated with increased mortality from respiratory diseases.

A healthy multiparous woman presented at 35 weeks and 4 days’ gestation with threatened preterm labour on multiple occasions. An incidental finding of severe hypokalaemia (2.4 mmol/L) was detected on routine blood tests. The cause of this hypokalaemia was not initially obvious. It was eventually linked to overuse of over-the-counter antacids for pregnancy-associated heartburn. The patient was managed with parenteral and then oral electrolyte replacement which corrected a pH of 7.55, bicarbonate of 36.7 mEq/L and a base excess 13.1. In this case report we consider whether hypokalaemia could be linked to uterine irritability and threatened preterm labour, whether antacids were being abused in the context of an eating disorder and the importance of taking a full drug history.

Adequate sampling of gross pathology specimens and attention to microscopic details is crucial in establishing the correct diagnosis in a patient, regardless of a benign pre-surgical diagnosis. Adenoma malignum is a rare HPV-negative variant of well-differentiated adenocarcinoma of the endocervix. It is difficult to diagnose in surgical pathology specimens due to its deceptively-benign appearance. This was a case of a 43-year-old woman with a history of menorrhagia and metrorrhagia and radiology interpretation of degenerating uterine fibroids. Pre-operative Pap testing and hysteroscopic dilatation and curettage were non-contributory. Following surgery, microscopic examination of the cervix revealed well-spaced, deeply-invasive, variably-sized glands with irregular outlines/haphazard arrangements, lined by cells showing mild to moderate cytologic atypia. These cells were positive for p53 and CK7 on Immunohistochemistry and Ki-67 showed a high proliferative index. Monoclonal CEA, calretinin, CD10, and P16 were all negative. A diagnosis of adenoma malignum stage pT1b2 was made. The patient was subsequently placed on platinum-based chemotherapy and is doing well 2 years after her diagnosis. Cases such as this, underscore the importance of adequately sampling surgical resection specimens, with careful attention to microscopic details as incidental pathologies may be unearthed which could have significant implications on a patient's clinical outcome.

Στην παρούσα διπλωματική εργασία περιγράφονται οι ειδικές ανακριτικές πράξεις που διενεργούνται επί ορισμένων εγκλημάτων (αρ. 254 ΚΠΔ) για τη συλλογή του αποδεικτικού υλικού. Οι ανακριτικές πράξεις μπορούν να διενεργηθούν από ανακριτικό υπάλληλο σύμφωνα με τους όρους, τις διακρίσεις και τις εξαιρέσεις που θέτει ο νόμος. Σε πρώτη φάση, επιχειρείται να διερευνηθεί η προβληματική όψη θέσπισης των ειδικών ανακριτικών πράξεων και να καταγραφούν οι αλλαγές που επέφερε ο νέος ΚΠΔ. Επί της ουσίας, επεξηγούνται η έννοια, τα ιδιαίτερα χαρακτηριστικά, οι προϋποθέσεις διενέργειας ειδικών ανακριτικών πράξεων, οι ελλείπουσες εγγυήσεις και οι προϋποθέσεις σχετικού πλαισίου. Σε δεύτερη φάση, γίνεται ειδικά μνεία στα λεγόμενα «τυχαία ευρήματα» που ανευρίσκονται στο πλαίσιο διεξαγωγης ειδικών ανακριτικών πράξεων και κατά πόσο αυτά είναι αξιοποιήσιμα, εκκινώντας από τη δικονομική αξιολόγηση αυτών αφενός όταν η απόκτησή τους είναι συμπτωματική ή σκόπιμη και αφετέρου όταν παρατηρείται η απομάκρυνση από τον αρχικό ανακριτικό σκοπό. Κατόπιν, κρίθηκε αναγκαίο να επεξηγηθούν τα διαδικαστικά στάδια για τη νόμιμη διενέργεια των ειδικών ανακριτικών πράξεων. Συν τις άλλοις, γίνεται λόγος για τις ανακριτικές πράξεις οι οποίες λαμβάνουν χώρα σε βάρος τρίτων, αμέτοχων στο έγκλημα, για τους περιορισμούς που έχουν εγκαθιδρυθεί κατά τη χρησιμοποίηση του αποδεικτικού υλικού, ενώ επιπλέον εντοπίζεται το ζήτημα της παράνομης διεξαγωγής των ειδικών ανακριτικών πράξεων. Στην αμέσως επόμενη στ’ ενότητα αναλύονται διεξωδικά τα είδη των ειδικών ανακριτικών πράξεων υπό το προϊσχύσαν νομοθετικό καθεστώς (αρ. 253Α ΚΠΔ). Στη ζ’ ενότητα εξετάζοντται λεπτομερώς το νομικό πλαίσιο που διέπει τις ειδικές ανακριτικές πράξεις και αυτή καθεαυτή η δικονομική διάσταση της ανακριτικής διείσδυσης, καταλήγοντας σε κρίσιμες κατ’ επέκταση ερμηνευτικές επισημάνσεις με βάση προγενέστερες τοποποιήσιες του ΚΠΔ που επήλθαν δυνάμει του Ν. 4620/2019 και στα συμπεράσματα που τελικώς διεξέγωνται. Στην η’ ενόητητα αναφερόμαστε στην άρση του απορρήτου, που λαμβάνει ηθελημένα εκτενές τμήμα, ακριβώς διότι συνιστά ένα πολύ σημαντικό και σύνηθες εργαλείο για την εξάρθρωση του εγκλήματος, με όλες τις παρέπομενες συνέπειες που συνεπάγεται στην σφαίρα επιρροής των ατομικών συνταγματικών δικαιωμάτων. Ακολούθως, εξειδιεκύεται έτι περισσότερο ως προανακριτική πράξη στα κακουργήματα. Εν κατακλήδει, συνάγονται επιγραμματικά συμπεράσματα και αξιολογικές πρσωπικές κρίσεις, ενώ παρατίθεται νομολογία με συναφείς -επιπρόσθετα αυτών που αναφέρονται στο σώμα της παρούσας- ελληνικές δικαστικές αποφάσεις, καθώς και αποφάσεις του ΕΔΔΑ/ΔΕΕ (σημειωτέον ότι λόγω πειρορισμένης έκτασης της εργασίας δεν ήτο εφικτό να αναλυθούν περαιτέρω οι πιο ενδιαφέρουσες εξ αυτών)., This thesis describes the special investigative acts carried out on certain crimes (ar. 254 of the CPC) for the collection of evidence. Investigative acts may be carried out by an investigative officer in accordance with the conditions, distinctions and exceptions set by law. In the first phase, an attempt is made to investigate the problematic aspect of the establishment of special investigative acts and to record the changes brought about by the new of the CPC. In essence, the concept, the special characteristics, the conditions for carrying out special investigative acts, the missing guarantees and the conditions of the relevant framework are explained. In a second phase, special mention is made of the so-called "accidental findings" that are found in the context of conducting special investigative acts and whether they are usable, starting from the procedural evaluation of these on the one hand when their acquisition is accidental or intentional and on the other hand when the departure from the original investigative purpose. Then, it was deemed necessary to explain the procedural stages for the legal conduct of special investigative acts. In addition, there is talk about the investigative acts that take place against third parties, uninvolved in the crime, about the limitations that have been established during the use of the evidential material, while in addition the question of the illegal conduct of the special investigative acts is identified. In the next section, the types of special investigative acts under the previous legislative regime (ar. 253A of the CPC) are analyzed in detail. In seventh section, the legal framework governing special investigative acts and the procedural dimension of investigative penetration are examined in detail, culminating in critical, by extension, interpretive remarks based on previous rulings of the CPC that came under Law 4620/2019 and in conclusions that are ultimately held. In the eighth section we refer to the removal of privacy, which takes an intentionally extensive section, precisely because it constitutes a very important and common tool for the dismantling of crime, with all the collateral consequences it entails in the sphere of influence of individual constitutional rights. Subsequently, it is more specialized as a pre-investigative act in felonies. In conclusion, epigrammatic conclusions and evaluative personal judgments are drawn, while jurisprudence is cited with relevant -in addition to those mentioned in the body of the present- Greek judicial decisions, as well as decisions of the ECtHR/CJEU (it should be noted that due to the limited scope of the work it was not possible to analyze further the most interesting of them)., Σε συνεργασία με: Νομικής (Δημοκρίτειο Πανεπιστήμιο Θράκης)

Σκοπός της παρούσας διπλωματικής εργασίας ήταν να παρουσιαστεί και αναλυθεί αφενός το ζήτημα των τυχαίων ευρημάτων, τα οποία ανακύπτουν από την διενέργεια των ρητά προβλεπόμενων στον Κώδικα Ποινικής Δικονομίας ειδικών ανακριτικών πράξεων και αφετέρου ο τρόπος, με τον οποίο αυτά αξιοποιούνται. Σε ένα πρώτο στάδιο παρουσιάστηκαν εννοιολογικές προσεγγίσεις και κατηγοριοποιήσεις των τυχαίων ευρημάτων. Στην πορεία αναλύθηκαν, κατά τα βασικά χαρακτηριστικά τους, οι ειδικές ανακριτικές πράξεις, όπως προβλέπονται στον Κώδικα Ποινικής Δικονομίας. Επιχειρήθηκε στην συνέχεια να αποτυπωθούν κάποια ζητήματα περί αποδεικτικών απαγορεύσεων, καθώς και ορισμένες κατηγοριοποιήσεις τους, προκειμένου να μεταβούμε στο επόμενο και τελευταίο κεφάλαιο περί της ένταξης των τυχαίων ευρημάτων στον χώρο της απόδειξης. Στο εν λόγω κεφάλαιο έγινε αναφορά στον κανόνα και την εξαίρεση περί της αποδεικτικής αξιοποίησης των γνήσιων και μη γνήσιων τυχαίων ευρημάτων, στην νομοθετική πρόβλεψη σχετικά με την αποδεικτική αξιοποίηση των τυχαίων ευρημάτων στα πλαίσια των ειδικών ανακριτικών πράξεων καθώς και στην ειδική πρόβλεψη περί αξιοποίησης των τυχαίων ευρημάτων κατά την διενέργεια της άρσης του απορρήτου των επικοινωνιών., In the recourse of the following dissertation there is a presentation and an analysis of both the issue of incidental findings, which originate at the provisions of the Code of Criminal Procedure concerning the specific investigations, and also the way these investigations can be utilized. Initially, there is an introduction of the relevant terminology and the categorizations of the incidental findings. Following , there is an analysis of the fundamental characteristics of the specific investigations, according to the provisions of the Code of Criminal Procedure. The analysis of individual matters concerning evidentiary prohibitions and their categorization helped for the understanding of the issue of the following chapter, namely the use of the incidental findings during the procedure of taking evidence. Specifically, the rule and its exceptions concerning the evidentiary usage of both authentic and non incidental findings, the legislative provisions for the evidentiary usage of the incidental findings in the framework of specific investigations as well as the provisions concerning the evidentiary usage of incidental findings in the framework of the removal of confidentiality of communications.

Purpose: Conventional diagnostic methods have limitations in the diagnosis of prostate cancer (PCa); therefore, the use of multiparametric magnetic resonance imaging (mpMRI) in PCa has become widespread. We aimed to determine the frequency of IF detected in the mpMRI examination according to organ distribution and clinical significance. Material and methods: mpMRI examinations performed between January 2015 and 2020 based on the diagnosis or suspicion of PCa were retrospectively evaluated. IFs were divided into 2 groups, as genitourinary system and nongenitourinary system findings. In addition, IFs were also evaluated in 2 groups, as clinically significant and clinically non-significant. The patient population was divided into age ranges, and the frequency of IFs in these age ranges and their clinical significance were recorded. Results: The mpMRI examinations of 426 patients revealed a total of 321 Ifs, comprising 212 (49.8%) genitourinary (41.1%) and 189 (58.9%) extragenitourinary findings. The mean age of the patients was 63.53 ± 7.89 years. As the age increased, the rate of IFs increased (p = 0.001). However, there was no increase for the 75-year-old group compared to the 65-74-year-old age range (p = 0.853). There were a total of 22 (6.9%) clinically significant Ifs - 4 associated with the genitourinary system and 18 extragenitourinary. Conclusions: Although the rate of clinically significant IF was only 6.9%, this rate was high in patients, especially in those over the age of 65 years. It should be kept in mind that the early detection of these findings in the asymptomatic period will increase the survival and successful treatment of patients.

In order to report clinically actionable incidental findings in genetic testing, the American College of Medical Genetics and Genomics (ACMG) recommended the evaluation of variants in 59 genes associated with highly penetrant mutations. However, there is a lack of epidemiological data on medically actionable rare variants in these genes in Arab populations. We used whole genome sequencing data from 6045 participants from the Qatar Genome Programme and integrated it with phenotypic data collected by the Qatar Biobank. We identified novel putative pathogenic variants in the 59 ACMG genes by filtering previously unrecorded variants based on computational prediction of pathogenicity, variant rarity and segregation evidence. We assessed the phenotypic associations of candidate variants in genes linked to cardiovascular diseases. Finally, we used a zebrafish knockdown and synthetic human mRNA co-injection assay to functionally characterize two of these novel variants. We assessed the zebrafish cardiac function in terms of heart rate, rhythm and hemodynamics, as well as the heart structure. We identified 52 492 novel variants, which have not been reported in global and disease-specific databases. A total of 74 novel variants were selected with potentially pathogenic effect. We prioritized two novel cardiovascular variants, DSP c.1841A > G (p.Asp614Gly) and LMNA c.326 T > G (p.Val109Gly) for functional characterization. Our results showed that both variants resulted in abnormal zebrafish heart rate, rhythm and structure. This study highlights medically actionable variants that are specific to the Middle Eastern Qatari population.

ObjectiveWhen reporting coronary CT angiography (CCTA), extracardiac structures are routinely assessed, usually on a wide field-of-view (FOV) reconstruction. We performed a retrospective observational cross-sectional study to investigate the impact of incidental extracardiac abnormalities on resource utilisation and treatment, and cost-effectiveness.MethodsAll patients undergoing CCTA at a single institution between January 2012 and March 2020 were identified. The indication for CCTA was chest pain or dyspnoea in >90%. Patients with ≥1 significant extracardiac findings were selected. Clinical follow-up, investigations and treatment were documented, and costs were calculated.Results4340 patients underwent CCTA; 717 extracardiac abnormalities were identified in 687 individuals (15.8%; age 62±12 years; male 336, 49%). The abnormality was already known in 162 (23.6%). Lung nodules and cysts were the most common abnormalities (296, 43.1%). Clinical and/or imaging follow-up was pursued in 292 patients (42.5%). Treatment was required by 14 patients (0.3% of the entire population), including lung resection for adenocarcinoma in six (0.1%). All but two abnormalities (both adenocarcinomas) were identifiable on the limited cardiac FOV. The cost of reporting (£20) and follow-up (£33) of extracardiac abnormalities was £53 per patient. The cost per discounted quality-adjusted life year was £23 930, increasing to £46 674 for reporting the wide FOV rather than the cardiac FOV alone.ConclusionsExtracardiac abnormalities are common on CCTA, but identification and follow-up are costly. The few requiring treatment are usually identifiable without review of the wide FOV. The way in which CCTAs are scrutinised for extracardiac abnormalities in a resource-limited healthcare system should be questioned.

The aim of this study is to elucidate the prevalence and factors associated with follow-up chest computed tomography (CT) imaging in patients undergoing stress-perfusion cardiac magnetic resonance imaging (sCMR) and coronary CT angiography (cCTA).Cardiac imaging encounters between January 1, 2015 and May 16, 2020 were selected for analysis. Follow-up was tracked within 1-year of initial cardiac imaging, up to May 16, 2021. Patient demographics, comorbidities, and cardiopulmonary outcomes were also analyzed.Between 2015 and 2020, there were 4024 cCTA and 837 sCMR imaging procedures on unique patients with 1.1% and 0.5% of patients having follow-up CT chest studies within 1 year, respectively. When controlling for patient demographic factors, body mass index, insurance status, smoking history, and comorbid diagnostic codes, there was statistically significant increased odds (adjusted odds ratio [95% confidence interval]: 2.864 [1.129-7.265]) of undergoing follow-up within the cCTA cohort. Pulmonary nodules represented the most common incidental finding, with cCTA associated with higher rates of pulmonary nodules detected on imaging (adjusted odds ratio [95% confidence interval]: 5.947 [4.136-8.552]). sCMR was associated with higher rates of MI, percutaneous coronary intervention, and lung malignancy within 1 year, with no difference in all-cause mortality.Patients undergoing either cCTA and sCMR demonstrated a low prevalence of follow-up CT chest imaging; however, follow-up was 2 times greater after cCTA due to greater pulmonary nodule detection. Potential for follow-up should be considered when evaluating the comparative effectiveness of these modalities, including the impact of follow-up imaging on cost and patient outcomes. Strategies to improve lung nodule detection and characterization at the time of sCMR may provide added value in these patients.

To evaluate the impact of structured recommendations on follow-up completion for incidental lung nodules (ILNs).Patients with ILNs before and after implementation of structured Fleischner recommendations and electronic tracking were sampled randomly. The cohorts were compared for imaging follow-up. Multivariable logistic regression was used to assess appropriate follow-up and loss to follow-up, with independent variables including use of structured recommendations or tracking, age, sex, race, ethnicity, setting of the index test (inpatient, outpatient, emergency department), smoking history, and nodule features.In all, 1,301 patients met final inclusion criteria, including 255 patients before and 1,046 patients after structured recommendations or tracking. Baseline differences were found in the pre- and postintervention groups, with smaller ILNs and younger age after implementing structured recommendations. Comparing pre- versus postintervention outcomes, 40.0% (100 of 250) versus 29.5% (309 of 1,046) of patients had no follow-up despite Fleischner indications for imaging (P = .002), and among the remaining patients, 56.6% (82 of 145) versus 75.0% (553 of 737) followed up on time (P.001). Delayed follow-up was more frequent before intervention. Differences postintervention were mostly accounted for by nodules ≤8 mm in the outpatient setting (P.001). In multivariable analysis, younger age, White race, outpatient setting, and larger nodule size showed significant association with appropriate follow-up completion (P.015), but structured recommendations did not. Similar results applied for loss to follow-up.Consistent use of structured reporting is likely key to mitigate selection bias when benchmarking rates of appropriate follow-up of ILN. Emergency department patients and inpatients are at high risk of missed or delayed follow-up despite structured recommendations.

Objective The purpose of this study was to develop a natural language processing (NLP) pipeline to identify incidental thyroid nodules (ITNs) meeting criteria for sonographic follow-up and to assess both adherence rates to white paper recommendations and downstream outcomes related to these incidental findings. Methods 21583 non-contrast chest CT reports from 2017 and 2018 were retrospectively evaluated to identify reports which included either an explicit recommendation for thyroid ultrasound, a description of a nodule ≥ 1.5 cm, or description of a nodule with suspicious features. Reports from 2018 were used to train an NLP algorithm called fastText for automated identification of such reports. Algorithm performance was then evaluated on the 2017 reports. Next, any patient from 2017 with a report meeting criteria for ultrasound follow-up was further evaluated with manual chart review to determine follow-up adherence rates and nodule-related outcomes. Results NLP identified reports with ITNs meeting criteria for sonographic follow-up with an accuracy of 96.5% (95% CI 96.2-96.7) and sensitivity of 92.1% (95% CI 89.8-94.3). In 10006 chest CTs from 2017, ITN follow-up ultrasound was indicated according to white paper criteria in 81 patients (0.8%), explicitly recommended in 46.9% (38/81) of patients, and obtained in less than half of patients in which it was appropriately recommended (17/35, 48.6%). Discussion NLP accurately identified chest CT reports meeting criteria for ITN ultrasound follow-up. Radiologist adherence to white paper guidelines and subsequent referrer adherence to radiologist recommendations showed room for improvement.

Dextrocardia is an unusual inherent positioning of the heart: during fetal life, the heart is flipped to the right side rather than the usual left side. Situs inversus is a rare congenital ailment in which the main internal organs are rearranged or reflected from their natural positions, and when both conditions are present, it is called situs inversus totalis. The majority of the people with situs inversus totalis are unaware of the situation they have because most of them are asymptomatic. It is usually discovered incidentally when they consult the doctor for an unrelated condition. We are reporting a case of a 55-year-old woman who was found to have a situs inversus totalis with an absent left kidney.

We aim to compare the clinical characteristics, disease course and visual outcomes between Canadian patients with idiopathic intracranial hypertension (IIH) who were incidentally discovered and those who sought care due to symptoms of IIH.Retrospective chart review of consecutive IIH patients conducted at tertiary neuro-ophthalmology clinics. Patients were divided into Group 1 (incidentally discovered disease) and Group 2 (patients seeking medical care due to symptoms of intracranial hypertension).One hundred eighty-six patients were included in the study; of which, 75 (40.3%; Group-1) were incidentally discovered and 111 presented due to symptoms of IIH (Group-2). There were no differences in proportion of females (P = 0.101), age (P = 0.450), body mass index (P = 0.386), MRI findings of empty or partially empty sella (P = 0.41), and sella grade (P = 0.704). Group-1 patients were less likely to have experienced headache (P = 0.001), transient visual obscurations (P0.001), and diplopia (P = 0.026) at presentation. Group-1 patients were less likely to receive medical (P0.001) and surgical (P = 0.004) treatment. There was no difference in proportion of patients who lost weight between the groups (P = 0.848). At baseline, Group-1 patients exhibited better visual acuity (P = 0.001), Humphrey mean deviation (P0.001) and retinal nerve fiber layer thickness (P0.001). Group-1 patients continued to have better visual acuity (P = 0.002) and Humphrey mean deviation (P0.001) at final follow-up.A significant portion of IIH patients were incidentally discovered. This group exhibited a favorable prognosis and only a minority of these patients required treatment. The way in which patients enter the medical system may be a valuable way to risk stratify IIH patients.

Adrenal schwannomas (AS) are rare tumours arising from Schwann cells. Due to the high prevalence of adrenal incidentalomas, running into very rare adrenal tumours has become a possibility for high volume expert centres. So far, the clinical behaviour and the radiological characteristics of AS make the pre-operative diagnosis of AS extremely challenging. Due to limited information available, we wanted to summarise the main features of this tumours, in order to raise the profile of an uncommon disease.We performed a MEDLINE and EMBASE research to review the literature. We found 57 case reports and case series and a total of 169 cases, including 2 more cases found in our Institutions. We collected data regarding year of publication, sex, age, and, when available, clinical presentation, hormonal data, radiological features, tumour site and size, treatment, histology and follow-up.We analysed and discussed the clinical, radiological and pathological characteristics of cases identified, underlying the critical aspects of assessment and management of these tumours which still remain questioned, as, currently, pathologic examination is the only way to make the diagnosis.The pre-operative diagnosis of AS is more than challenging and pathologic examination is so far the only way to make a certain diagnosis. Therefore, it is important to consider also the AS in the list of possible diagnoses when faced with a large not secreting adrenal tumour, with suspicious radiological features.

Genome-wide (exome or genome) sequencing (GWS) has the potential to detect incidental findings (IFs): variants unrelated to the primary indication for testing that may be of medical or personal utility. As GWS becomes increasingly common in clinical practice, it is important to understand the impact of IFs on the individuals and their families. Our goal was to explore the immediate and long-term lived experience of individuals who received IFs as part of diagnostic GWS. We interviewed parents who received an IF as part of the CAUSES translational research study at Children's and Women's Health Centre of British Columbia. Five hundred families were offered trio-based GWS for their child with a suspected, undiagnosed genetic condition. Nine hundred and one of the 1000 parents chose to find out about IFs and 21 parents received an IF for themselves. Twelve of these parents participated in this study. They were interviewed an average of 2.3 years after the IFs were returned. Thematic analysis of transcribed interviews revealed that the participants' decisions and motivations to receive IFs were influenced by personal values and beliefs and by having a child with a suspected genetic condition. Participants' experiences were also influenced by the type of IF received, having a personal or family history of a related condition, their personal interpretation and perceived utility of the information, and the impact of the IF on other family members. Participants expressed either no regret or mild decisional regret on the Decisional Regret Scale. Two years post results, most participants reported little negative impact from receiving the IF. The utility of the information varied: some reported lifestyle changes and proactive screening, while others felt the information may be more relevant in the future. Understanding the immediate and longer term impact of receiving IFs from GWS can inform both pre- and post-test genetic counseling.

Background Incidental adrenal masses (IAMs) are common. Primary care providers (PCPs) are frequently responsible for incidentaloma evaluations. We evaluated whether PCPs view this paradigm effective, barriers faced, and strategies to optimize care delivery. Methods This is a sequential explanatory study, comprised of surveys followed by focus groups of PCPs. Because lung nodules are another type of common incidental finding, we compared PCP views on management of lung nodules to their views on IAMs. Results For IAMs, 22.3% of PCPs “always refer” to specialists, but for lung nodules this was 11.5% (p = 0.026). For lung nodules, the most significant barrier was insufficient time/support to longitudinally follow results (69%), but for IAMs it was uncertainty about which tests to order (68%). Fear of litigation was equal (lung = 22.5%, IAMs = 21.3%). Consistent themes regarding the “ideal” system included specific recommendations in radiology reports; automation of orders for follow-up tests; longitudinal tracking tools; streamlined consultations; and decision guides embedded within the electronic health record. Conclusions Respondents are more comfortable with lung nodules than IAMs. Management of “incidentalomas” is within their scope of practice, but the current system can be optimized.

To assess the impact of using a computer-assisted reporting and decision support (CAR/DS) tool at the radiologist point-of-care on ordering provider compliance with recommendations for adrenal incidentaloma workup.Abdominal CT reports describing adrenal incidentalomas (2014 - 2016) were retrospectively extracted from the radiology database. Exclusion criteria were history of cancer, suspected functioning adrenal tumor, dominant nodule size1 cm or ≥ 4 cm, myelolipomas, cysts, and hematomas. Multivariable logistic regression models were employed to predict follow-up imaging (FUI) and hormonal screening orders as a function of patient age and sex, nodule size, and CAR/DS use. CAR/DS reports were compared to conventional reports regarding ordering provider compliance with, frequency, and completeness of, guideline-warranted recommendations for FUI and hormonal screening of adrenal incidentalomas using Chi-square test.Of 174 patients (mean age 62.4; 51.1% women) with adrenal incidentalomas, 62% (108/174) received CAR/DS-based recommendations versus 38% (66/174) unassisted recommendations. CAR/DS use was an independent predictor of provider compliance both with FUI (Odds Ratio [OR]=2.47, p = 0.02) and hormonal screening (OR=2.38, p = 0.04). CAR/DS reports recommended FUI (97.2%,105/108) and hormonal screening (87.0%,94/108) more often than conventional reports (respectively, 69.7% [46/66], 3.0% [2/66], both p0.0001). CAR/DS recommendations more frequently included instructions for FUI time, protocol, and modality than conventional reports (all p0.001).Ordering providers were at least twice as likely to comply with report recommendations for FUI and hormonal evaluation of adrenal incidentalomas generated using CAR/DS versus unassisted reporting. CAR/DS-directed recommendations were more adherent to guidelines than those generated without.

Background Guidelines recommending additional imaging for adrenal nodules lack relevant epidemiologic evidence. Purpose To measure the prevalence of adrenal nodules detected at staging CT in patients with potentially resectable gastric cancer and the proportion of patients with malignant nodules among them. Materials and Methods This retrospective study included 10 250 consecutive patients (median age, 63 years; interquartile range, 53-71 years; 6884 men) who underwent staging CT and had potentially resectable gastric cancer in a tertiary center (May 2003 to December 2018). All 10 250 CT studies were retrospectively reviewed, and patients with adrenal nodules (or thickening ≥10 mm) were identified to measure the prevalence of adrenal nodules. Among patients with adrenal nodules, the per-patient proportions of malignant nodules, adrenal metastasis from gastric cancer, and additional adrenal examinations were measured. A secondary analysis was performed by using data from the original CT reports. The same metrics that were used in the retrospective review were assessed. Results The prevalence of adrenal nodules was 4.5% (95% CI: 4.1, 4.9; 462 of 10 250). The proportions of malignant nodules and adrenal metastasis from gastric cancer were 0.4% ( 95% CI: 0.1, 1.6; two of 462) and 0% (95% CI: 0.0, 0.8; 0 of 462), respectively. A total of 27% of the patients (95% CI: 23, 31; 123 of 462) underwent additional adrenal examination. According to original CT reports, the prevalence of adrenal nodules and the proportions of malignant nodules, adrenal metastases from gastric cancer, and additional adrenal examination were 2.7% (95% CI: 2.4, 3.0; 272 of 10 250), 0.7% (95% CI: 0.1, 2.6; two of 272), 0% (95% CI: 0.0, 1.4; 0 of 272), and 42.6% (95% CI: 36.7, 48.8; 116 of 272), respectively. Conclusion Although adrenal nodules were detected frequently on staging CT images of patients with otherwise resectable gastric cancer, these nodules were rarely malignant. ©RSNA, 2021

Extralobar pulmonary sequestration is generally located in the left thoracic cavity and is often identified prenatally or in infants. We experienced a rare case of multiple extralobar pulmonary sequestrations in the thoracic and abdominal cavities, incidentally detected in a 60-year-old woman by cancer screening. The patient underwent surgery by thoracoscopic and laparoscopic approaches simultaneously, and extralobar sequestration was histologically confirmed in each lesion. Preoperative diagnosis was difficult because of unusual multiple localization and an undetectable aberrant artery on imaging examinations.

The classification according to uptake patterns and metabolic parameters on ring-type dedicated breast positron emission tomography (dbPET) is useful for detecting breast cancer. This study investigated the performance of dbPET for incidental findings that were not detected by mammography and ultrasonography. In 1,076 patients with breast cancer who underwent dbPET, 276 findings were incidentally diagnosed before treatment. Each finding was categorized as focus (uptake size ≤ 5 mm), mass (> 5 mm), or non-mass (multiple uptake) according to uptake patterns. Non-mass uptakes were additionally classified based on their distributions as—linear, focal, segmental, regional, or diffuse. Thirty-two findings (11.6%) were malignant and 244 (88.4%) were benign. Visually, 227 (82.3%) findings were foci, 7 (2.5%) were masses, and 42 (15.2%) were non-masses. Malignant rates of focus, mass, and non-mass were 9.7%, 28.6%, and 19.0%, respectively. In the non-mass findings, 23 were regional and diffuse distributions, and presented as benign lesions. Focus uptake with low lesion-to-background ratio (LBR) and no hereditary risk were relatively low (2.7%) in breast cancer. In multivariate analysis, LBR and hereditary risk were significantly associated with breast cancer (p = 0.006 and p = 0.013, respectively). Uptake patterns, LBR, and hereditary risk are useful for predicting breast cancer risk in incidental dbPET findings.

INTRODUCTION: The exact correlation of testicular microlithiasis (TM) with benign and malignant conditions remains unknown, especially in the paediatric population. The potential association of TM with testicular malignancy in adulthood has led to controversy regarding management and follow-up. OBJECTIVE: To determine the prognostic importance of TM in children in correlation to the risk of testicular malignancy or infertility and compare the differences between the paediatric and adult population. STUDY DESIGN: We performed a literature review of the Medline, Embase and Cochrane controlled trials databases until November 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) Statement. Twenty-six publications were included in the analysis. RESULTS: During the follow-up of 595 children with TM only one patient with TM developed a testicular malignancy during puberty. In the other 594 no testicular malignancy was found, even in the presence of risk factors. In the adult population, an increased risk for testicular malignancy in the presence of TM was found in patients with history of cryptorchidism (6% vs 0%), testicular malignancy (22% vs 2%) or sub/infertility (11-23% vs 1.7%) compared to TM-free. The difference between paediatric and adult population might be explained by the short duration of follow-up, varying between six months and three years. With an average age at inclusion of 10 years and testicular malignancies are expected to develop from puberty on, testicular malignancies might not yet have developed. CONCLUSION: TM is a common incidental finding that does not seem to be associated with testicular malignancy during childhood, but in the presence of risk factors is associated with testicular malignancy in the adult population. Routine monthly self-examination of the testes is recommended in children with contributing risk factors from puberty onwards. When TM is still present during transition to adulthood a more intensive follow-up could be considered. ispartof: JOURNAL OF PEDIATRIC UROLOGY vol:17 issue:6 pages:815-831 ispartof: location:England status: published

Incidental findings are common in the evaluation of surgical patients. Understanding the appropriate assessment and management of these frequent occurrences is important for the provision of comprehensive quality care. This review details the epidemiology, considerations, and recommendations for management of common incidental manifestations in surgical patients, including Meckel diverticulum, adrenal incidentaloma, thyroid nodule, solitary pulmonary nodule, small bowel intussusception, gallstones, and incidental appendectomy.

Objective and aims The primary aim of this study was to evaluate the correlation between incidental focal colorectal foci on fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) with colonoscopic and histopathological results. The secondary aim was to determine to what extent these findings led to a change in patient management. Materials and methods A retrospective study was performed among 5850 patients who had an FDG-PT/CT scan from July 2015 to July 2018. Among these patients, we identified patients with a PET/CT description of incidental colorectal FDG uptake, and a colonoscopy within 90 days from the PET/CT scan. PET/CT findings were compared with colonoscopy-detected lesions and eventually histopathology on a per-lesion analysis and a per-person analysis. Results A total of 145 patients were included in the study. A total of 180 foci of colorectal FDG uptake were detected on FDG-PET/CT. Of these, 86 foci corresponded to advanced colorectal neoplasia (ACRN), positive predictive value (PPV) 47.8%; 95% CI: 40.5-55.1%). On a per-patient analysis 81 patients had a least one ACRN at colonoscopy (PPV 55.9%; 95% CI: 47.6-63.8), this group included 20 patients (13.8%) diagnosed with cancer. There was a small positive correlation between focal FDG-uptake and the finding of ACRN at the same colonic segment at colonoscopy, which was statistically significant, rho = 0.2565, p = .002. The findings changed patient management in 67 (46.2%) cases. Conclusions Incidental focal colorectal FDG uptake on PET/CT is associated with a high risk of ACRN and is affecting subsequent patient management. Further evaluation with colonoscopy is recommended when the patient is considered suitable for further treatment.

Background In countries without organized population screening, incidental detection remains the major form of abdominal aortic aneurysm (AAA) diagnosis. Despite the presumed homogeneity in AAA prevalence, its rate of repair is highly variable, with Portugal treating 2 to 6 times fewer AAA per habitant than other western countries. Objectives To evaluate the detection rate and monitoring of incidental AAA in a multicentre cohort from Portuguese hospitals. Methods All abdominal CT scans performed in men ≥ 65 years old in three major Portuguese hospitals between January and June 2018 were selected for review. CT scans prescribed by the Vascular Surgery or Emergency Departments were excluded. Patients with previously known AAA were also excluded. Subjects with newly detected aneurysms were assessed for the two primary outcomes: the description of the finding by the radiologist in the written report; the effective follow-up recommendations by the prescriber of the CT or by the general practitioner (GP). Patients with newly found AAA that met criteria for monitoring or treatment and failed to be given guidance were contacted and included in surveillance programs. Results Overall, 3292 abdominal CT scans were selected for review. A total of 133 newly found aneurysms were detected (4.2% prevalence in the cohort). Of those, 48 cases (36%) were not described by the radiologist in the written report. Further 42 patients (32%) were not successfully oriented by the ordering physician or GP, despite having had their AAA mentioned. Overall, only 32% (n = 42) of the newly diagnosed AAA were correctly identified and referred to monitoring. Conclusions Incidental AAA is a common occurrence in in-hospital abdominal CTs. A significant number is not documented by the radiologist and the vast majority is not referred to monitoring. This could be a major reason for the low elective treatment rate of AAA in Portugal.

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Adrenal masses are frequently incidentally identified from cross-sectional imaging studies, which are performed for other reasons. The intensity of the approach to the patient with such a mass is tailored to the clinical situation, ranging from a quick evaluation to a detailed work-up. In all cases, the three components of the evaluation are clinical assessment, review of the images, and biochemical testing with the goal of ruling out malignancy and identifying hormonally active lesions. This article incorporates recent information to produce a logical, systematic assessment of these patients with risk stratification and proportionate follow-up.