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Prevalence and Outcomes of Incidental Imaging Findings: Umbrella Review BMJ: First Published As 10.1136/Bmj.K2387 on 18 June 2018

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Prevalence and Outcomes of Incidental Imaging Findings: Umbrella Review BMJ: First Published As 10.1136/Bmj.K2387 on 18 June 2018 RESEARCH Prevalence and outcomes of incidental imaging findings: umbrella review BMJ: first published as 10.1136/bmj.k2387 on 18 June 2018. Downloaded from Jack W O’Sullivan,1 Tim Muntinga,1 Sam Grigg,2 John P A Ioannidis3,4,5,6,7 1Centre for Evidence-Based ABSTRACT imaging (MRI), chest computed tomography (for Medicine, Nuffield Department OBJECTIVE incidentalomas of thorax, abdomen, spine, or heart), of Primary Care Health Sciences, To provide an overview of the evidence on prevalence and computed tomography colonoscopy (for extra- University of Oxford, Oxford OX2 6GG, UK and outcomes of incidental imaging findings. colonic incidentalomas). Intermediate rates occurred 2University of Melbourne, DESIGN with MRI of the spine (22%) and brain (22%). The rate Victoria, Australia Umbrella review of systematic reviews. of malignancy in incidentalomas varied substantially 3Stanford Prevention Research between organs; the prevalence of malignancy was DATA SOURCES Center, Stanford University less than 5% in incidentalomas of the brain, parotid, School of Medicine, Stanford, Searches of MEDLINE, EMBASE up to August 2017; and adrenal gland. Extra-colonic, prostatic, and CA, USA screening of references in included papers. 4Department of Health Research colonic incidentalomas were malignant between and Policy, Stanford University ELIGIBILITY CRITERIA 10% and 20% of the time, whereas renal, thyroid, School of Medicine, Stanford, Criteria included systematic reviews and and ovarian incidentalomas were malignant around CA, USA meta-analyses of observational studies that a quarter of the time. Breast incidentalomas had 5 Department of Biomedical gave a prevalence of incidental abnormalities the highest percentage of malignancy (42%, 95% Data Science, Stanford (“incidentalomas”). An incidental imaging finding University School of Medicine, confidence interval 31% to 54%). Many assessments Stanford, CA, USA was defined as an imaging abnormality in a healthy, had high between-study heterogeneity (15 of 20 meta- 6Department of Statistics, asymptomatic patient or an imaging abnormality in analyses with I2 >50%). Stanford University School a symptomatic patient, where the abnormality was CONCLUSIONS of Humanities and Sciences, not apparently related to the patient’s symptoms. Stanford, CA, USA There is large variability across different imaging Primary studies that measured the prevalence 7Meta-Research Innovation techniques both in the prevalence of incidentalomas of incidentalomas in patients with a history of Center at Stanford (METRICS), and in the prevalence of malignancy for specific Stanford University, Stanford, malignancy were also considered in sensitivity organs. This umbrella review will aid clinicians and CA, USA analyses. Correspondence to: patients weigh up the pros and cons of requesting RESULTS J W O’Sullivan imaging scans and will help with management http://www.bmj.com/ [email protected] 20 systematic reviews (240 primary studies) were decisions after an incidentaloma diagnosis. Our (or @DrJackOSullivan on Twitter; identified from 7098 references from the database results can underpin the creation of guidelines to ORCID 0000-0003-3629-2546) search. Fifteen systematic reviews provided data to assist these decisions. Additional material is published quantify the prevalence of incidentalomas, whereas online only. To view please visit SYSTEMATIC REVIEW REGISTRATION 18 provided data to quantify the outcomes of the journal online. PROSPERO: CRD42017075679. C ite this as: BMJ 2018;361:k2387 incidentalomas (13 provided both). The prevalence http://dx.doi.org/10.1136/bmj.k2387 of incidentalomas varied substantially between Accepted: 29 April 2018 imaging tests; it was less than 5% for chest computed Introduction on 4 October 2021 by guest. Protected copyright. tomography for incidental pulmonary embolism in Incidentalomas, incidental imaging findings patients with and without cancer and whole body serendipitously diagnosed in an asymptomatic patient positron emission tomography (PET) or PET/computed or symptomatic patient undergoing imaging for an tomography (for patients with and without cancer). unrelated reason,1-3 are fast becoming a modern Conversely, incidentalomas occurred in more than medical crisis.4 The rapid rise in demand for imaging,5 6 a third of images in cardiac magnetic resonance coupled with rapidly advancing image resolution is driving a surge in incidentalomas.7-9 WHat IS ALREADY KNOWN ON THIS TOPIC Incidentalomas are problematic because they 10 Imaging scans are increasingly performed, and imaging resolution continues to can lead to patient anxiety. Given the clinical improve uncertainty surrounding their ideal management, they can encourage further investigations and Thus, “incidentalomas” (that is, incidental abnormalities) are increasingly potentially overtreatment. In response to the risks common of incidentalomas, a US Presidential Commission Estimates concerning the prevalence and outcomes of incidentalomas vary encouraged clinicians to discuss with patients WHat THIS stUDY ADDS incidentalomas as a risk of imaging before they order a scan.4 Despite this, informed consent before The prevalence as well as outcomes of incidentalomas (including the meta- imaging remains poor.11 It is difficult for clinicians analysed estimates of malignancy rate) can now be quantified, stratified by to appropriately inform patients of the chance of imaging scan and organ incidental findings because the data quantifying Data will aid clinicians and patients weigh up the pros and cons of requesting prevalence is inconsistent and unclear. imaging scans and assist with management decisions after an incidentaloma Clinicians have also expressed uncertainty about diagnosis the ideal management of incidentalomas, particularly These results can underpin the creation of guidelines to assist these decisions primary care physicians.3 12 Although some guidelines the bmj | BMJ 2018;361:k2387 | doi: 10.1136/bmj.k2387 1 RESEARCH exist,1 13-17 they are often directed at radiologists15-17 inclusion and exclusion criteria (fig 1). Disagreements and for many organs (eg, colon, spine, breast, brain, were resolved by a third author (JWOS). We included BMJ: first published as 10.1136/bmj.k2387 on 18 June 2018. Downloaded from prostate, and parotid) there are no guidelines to systematic reviews and meta-analyses of observational address the management of incidentalomas. studies that gave a prevalence of incidental Several systematic reviews have been published abnormalities (incidentalomas). An incidental imaging exploring the prevalence and outcomes of finding was defined as an imaging abnormality in a incidentalomas. These studies use inconsistent and healthy, asymptomatic patient or in a symptomatic often inappropriate synthesis methods, and commonly patient, where the abnormality was not apparently only focus on one imaging scan or organ. We set out to related to the patient’s symptoms.1-3 For instance, an conduct an umbrella review of all existing systematic adrenal lesion noted in a patient who is undergoing reviews, meta-analysing data with appropriate computed tomography of the abdomen after a methods and including data for all imaging scans traumatic accident. Primary studies that measure and organs. We aimed to quantify the prevalence with the detection of incidentalomas in patients with a which incidentalomas emerge on any type of imaging history of malignancy were included, but only within test and quantify the outcomes of incidentalomas further sensitivity analyses, because incidentalomas stratified by organ. We thus hoped to provide both in these patients could often represent metastases clinicians and policy makers with robust data in an (see Sensitivity analyses section below). Study designs easy-to-access and inclusive format to inform clinical beyond systematic reviews and meta-analyses were practice and guidelines. The availability of data from excluded. Further, systematic reviews and meta- diverse imaging modalities and diverse imaging areas analyses without explicit, systematic literature and organs in an umbrella review should provide searches and those that did not inform the prevalence a more comprehensive overview of the available or outcomes of incidentalomas were excluded (as evidence. consistent with previous umbrella reviews18 19). We also excluded studies that quantified non-imaging Methods incidentalomas (eg, surgical incidentalomas) and Protocol, registration, and study design conference abstracts (we were unable to complete The protocol for this umbrella review was developed and second level data extraction on conference abstracts). registered a priori (PROSPERO: CRD42017075679). We conducted an umbrella review of systematic Data extraction reviews and meta-analyses of observational studies We undertook data extraction on two levels. The first http://www.bmj.com/ describing the prevalence and outcomes of incidental level concerned extraction from included systematic imaging findings (incidentalomas). reviews and meta-analyses. The second level included the extraction of data from the primary studies within Search strategy and eligibility criteria the included systematic reviews and meta-analyses. Using a structured search strategy (appendix 1), we For first level extraction, we extracted PubMed ID, searched MEDLINE and EMBASE databases up to lead author’s name, publication year, study population, August 2017. Two authors (TM, SG) independently average age of population, number of studies included, undertook
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