Preface| Volume 59, ISSUE 4, Pxv-xvi, July 2021

How Do You Solve a Problem like Incidentalomas (version 2.0)?

      Figure thumbnail fx1
      Douglas S. Katz, MD, FACR, FASER, FSAR, Editor
      It has been a decade since Dr Alec Megibow, a colleague at the same institution across town for one of us, a former attending during fellowship for the other of us, and a mentor to both of us, organized and edited an issue on the major problem of “incidentalomas” in medical imaging. In our clinical practices, regardless of what this encompasses for the individual radiologist, and for our referring practitioners, it seems literally every hour of every day we are faced with incidental findings. These are either truly asymptomatic and frequently are previously unknown, or in some patients, aren’t really incidental but are unexpected findings. It may be difficult to determine what truly is “incidental” in a particular patient. In addition, if we are neuroradiologists, for example, we have to identify and sort out lung, kidney, and other findings, which usually do not correspond to our areas of expertise. If we are generalists or emergency radiologists, any cross-sectional imaging examination of any part of the human body can contain one, and sometimes more, incidental findings. The vast majority of these incidental findings are benign and are and will be of no consequence to most patients, but unfortunately a nontrivial minority do have implications and cannot be ignored. Sorting these out prospectively can be problematic and challenging in some patients.
      Incidentalomas identified on cross-sectional imaging examinations present us with on-going challenges: how to report them, how to keep up with the increasing and evolving societal guidelines on handling them, what follow-up to recommend if any, how to counsel referring clinicians, and, increasingly, how to direct patient concerns. With portals and apps, many patients in various parts of the world, including those patients with incidental findings, now have immediate access to their imaging reports. Patients read and examine them, sometimes before the health care practitioners, frequently generating agita for everyone involved. Incidental findings pose other substantive challenges that the radiologist and the clinician have to tackle: ethical, economic, and medical-legal, among others. And to add to these challenges, there is the on-going COVID-19 pandemic, with medical and imaging resources still stretched thinly in some places of the world. How do we categorize such findings and keep everyone, patients, referrers, and ourselves, out of trouble? How do we reduce risk and anxiety, while simultaneously avoiding unnecessary imaging and other subsequent procedures, some of which can be quite invasive? What have we learned and what has changed since the initial series of guidelines the American College of Radiology (ACR) and other societies and expert panels have published?
      We have assembled a team of experts from North America who present their take on the latest literature and guidelines on how to handle incidental findings on cross-sectional imaging examinations, combined with case material from their own practices, and insights from their own experiences. These radiologists have frequently been the leaders behind the ACR and other national and international societal guidelines and White Papers on incidental findings and have been leaders behind the various ACR “RADS” and in their own areas of related research. They cover multiple organs and organ systems and provide us with knowledge and reassurance. We hope that this issue builds on the previous work of Dr Megibow and colleagues and will be of utility and interest to many of us in clinical practice, regardless of our specific areas of concentration.
      We thank everyone for their efforts, and particularly during this challenging time, where completing any task seems more difficult than usual. It has been an honor and a privilege to be given the responsibility of overseeing this project. We cannot cover every scenario and every body part and imaging modality, but we have tried to include some of the most common situations encountered in actual practice, some of them common and some less common. We hope this issue of the Radiologic Clinics of North America will also be helpful for our referring clinicians, who wrestle with these incidentalomas as much as we do now, if not even more so, as they have to counsel patients and to direct their further management.
      We would also like to thank Dr Frank Miller, Radiologic Clinics of North America Series Editor, as well as the Elsevier staff, particularly John Vassallo and Karen Solomon, for their assistance, their guidance, and particularly, their patience.