Management of Common Findings in Abdominal Imaging Reports Anthony E. Hanbidge

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1)  Describe radiologist’s role in patient assessment

2) Recognize the importance of context in image interpretation

3) Discuss the management of common abdominal imaging findings

Learning Objectives

Patient Management

For discussion: � Incidental gallbladder polyp � Asymptomatic simple ovarian cyst � Asymptomatic cystic pancreatic

mass � Incidental cystic renal mass � Incidental solid renal mass

Gallbladder Polyp

8 mm

Incidental gallbladder polyp

≤0.6 cm

Dismiss

0.6-0.9 cm

F/u yearly for 2 years

≥1 cm

Surgical opinion

Incidental gallbladder polyp

≤0.6 cm

Dismiss

0.6-0.9 cm

F/u yearly for 2 years

≥1 cm

Surgical opinion

Simple Ovarian Cyst

2.5 cm

Asymptomatic simple ovarian cyst - premenopausal

≤3 cm

Normal

>3-≤5cm

Report, no f/u

>5-≤7cm

F/u US yearly

>7cm

MRI or surgical

Asymptomatic simple ovarian cyst - premenopausal

≤3 cm

Normal

>3-≤5cm

Report, no f/u

>5-≤7cm

F/u US yearly

>7cm

MRI or surgical

Asymptomatic simple ovarian cyst - postmenopausal

≤1 cm

Report, no f/u

>1-≤7cm

F/u US yearly

>7cm

MRI or surgical

Asymptomatic simple ovarian cyst - postmenopausal

≤1 cm

Report, no f/u

>1-≤7cm

F/u US yearly

>7cm

MRI or surgical

Asymptomatic simple ovarian cyst - postmenopausal

≤3 cm

Report, no f/u

>3-≤7cm

F/u US yearly

>7cm

MRI or surgical

Cystic Pancreatic Mass Serous (Microcystic) Cystadenoma

Asymptomatic cystic pancreatic mass

<2 cm

Single f/u 1 yr *

Stable

Benign, no further f/u

Growth

2–3 cm

Imaging characterization

(MRI/MRCP)

Uncharacterized cystic mass

F/u yearly

BD-IPMN

F/u every 6 months for 2 years*

Serous cystadenoma

F/u every 2 years

>3cm

Serous cystadenoma

Consider resection when ≥4

cm

Uncharacterized cystic mass

Cyst aspiration

Resect, co-morbidities/risk

Asymptomatic cystic pancreatic mass

<2 cm

Single f/u 1 yr *

Stable

Benign, no further f/u

Growth

2–3 cm

Imaging characterization

(MRI/MRCP)

Uncharacterized cystic mass

F/u yearly

BD-IPMN

F/u every 6 months for 2 years*

Serous cystadenoma

F/u every 2 years

>3cm

Serous cystadenoma

Consider resection when ≥4

cm

Uncharacterized cystic mass

Cyst aspiration

Resect, co-morbidities/risk

Unless limited life expectancy or severe co-morbidities

Renal Cyst

I - simple cyst II - minimally complex, few hairline

septa, fine Ca++ or short segment thickened Ca++ in wall or septa, homogeneously high attenuation masses <3 cm that do not enhance

Bosniak classification

IIF - multiple hairline septa, smooth thickening of wall or septa, thick nodular calcification, no enhancing soft tissue components, intrarenal, non-enhancing high attenuation masses (>3 cm)

Bosniak classification

III - Thickened irregular or smooth walls or septa with measurable enhancement

IV – Criteria of III but also containing enhancing soft tissue components adjacent to or separate from the walls or septa

Bosniak classification

Incidental cystic renal mass*

Bosniak I or II

Benign No f/u

Bosniak IIF

General population

US, CT or MRI at 6 and 12 mo, then yearly x 5

Morphologic change*

Surgery*

No morphologic

change

Benign No f/u

Limited life expectancy

If f/u appropriate, US, CT or MRI at 6 and 12 mo, then yearly x 5*

Morphologic change*

Surgery, f/u, no f/u

Bosniak III or IV

General population

Surgery*

Limited life expectancy

If f/u appropriate, US, CT or MRI at 6 and12 mo,

then yearly x 5*

Action based on change and life expectancy

Incidental cystic renal mass*

Bosniak I or II

Benign No f/u

Bosniak IIF

General population

US, CT or MRI at 6 and 12 mo, then yearly x 5

Morphologic change*

Surgery*

No morphologic

change

Benign No f/u

Limited life expectancy

If f/u appropriate, US, CT or MRI at 6 and 12 mo, then yearly x 5*

Morphologic change*

Surgery, f/u, no f/u

Bosniak III or IV

General population

Surgery*

Limited life expectancy

If f/u appropriate, US, CT or MRI at 6 and12 mo,

then yearly x 5*

Action based on change and life expectancy

3.5 cm

Solid Renal Mass

Incidental solid renal mass*

<1 cm*

General population

F/u until 1 cm

Limited life expectancy

F/u until 1.5 cm

1-3 cm*

General population

Surgery*

Hyperattenuating, Homogeneously*

Limited life expectancy

Surgery* F/u*

>3 cm*

General population

Surgery*

Limited life expectancy

Surgery* F/u*

Incidental solid renal mass*

<1 cm*

General population

F/u until 1 cm

Limited life expectancy

F/u until 1.5 cm

1-3 cm*

General population

Surgery*

Hyperattenuating, Homogeneously*

Limited life expectancy

Surgery* F/u*

>3 cm*

General population

Surgery*

Limited life expectancy

Surgery* F/u*

Summary � Imaging 1 piece of puzzle � History, physical, labs � Communication is key in directing appropriate care

References Berland ll et al. Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol. 2010 Oct;7(10):754-73. doi: 10.1016/j.jacr.2010.06.013. Levine D et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010 Sep;256(3):943-54. doi: 10.1148/radiol.10100213. Epub 2010 May 26. Review. Corwin MT et al. Incidentally detected gallbladder polyps: is follow-up necessary?--Long-term clinical and US analysis of 346 patients. Radiology 2011;258:277-282. doi: 10.1148/radiol.10100273. Epub 2010 Aug 9.

PubMed

Managing incidental findings

and

ACR

Follow-up imaging � Consider decreasing interval if

younger � Consider omitting if limited life

expectancy � US vs. MRI

Follow-up imaging � If no growth after 2 years, follow

yearly � If growth or suspicious features

develop, consider resection

Solid renal mass � Follow guidelines only if infections

and fat containing angiomyolipomas have been excluded

Differential diagnosis � Renal cell cancer � Oncocytoma � Fat poor angiomyolipoma � Benign entities more likely in small

renal masses than large ones

Differential diagnosis � Renal cell cancer more probable

If hyperattenuating and homogeneously enhancing � Consider MRI and biopsy to

diagnose fat poor angiomyolipoma

Surgery � Open or laparoscopic nephrectomy

or partial nephrectomy (all provide tissue diagnosis)

� Open, laparoscopic or percutaneous RFA (biopsy first for tissue diagnosis)

Surgery � Open or laparoscopic nephrectomy

or partial nephrectomy (all provide tissue diagnosis)

� Open, laparoscopic or percutaneous RFA (biopsy first for tissue diagnosis)

� Biopsy first to confirm RCC

Differential diagnosis � Probable diagnosis renal cell

cancer � Fat poor angiomyolipoma,

oncocytoma and other benign neoplasms may be found at surgery

Follow-up � Observation may be considered for

a solid renal mass of any size in a patient with limited life expectancy or co-morbidities that increase the risk of treatment

Incidental cystic renal mass � Follow guidelines only if non-

neoplastic causes of mass excluded (e.g. infection)

Morphologic change � Change refers to change in feature

characteristics, such as number of septations or thickness

� Growth should be noted but by itself does not indicate malignancy

? No follow-up � Cystic masses 1.5 cm or smaller

that are not clearly simple cysts or that cannot be characterized completely may not require further evaluation in this group

Surgery � Open or laparoscopic nephrectomy

or partial nephrectomy (all provide tissue diagnosis)

� Open, laparoscopic or percutaneous RFA (biopsy first for tissue diagnosis)

Percutaneous biopsy � Percutaneous biopsy of Bosniak III

masses can be considered but may not be diagnostic