Multicentre analysis of incidental findings on low-resolution CT attenuation correction images: an extended study

Coward, Joanne; Lawson, Richard; Kane, Tom; Elias, Mark; Howes, Andrea; Birchall, J. D.; Hogg, Peter

doi:10.1259/bjr.20150555

Cited by 14 publications

(11 citation statements)

References 4 publications

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“…18 Two years later, adding a further 1672 patients, the same research group concluded that routine reporting of CTAC images is not beneficial due to a low positive predictive value over a 2-year period of 12%. 24 Conversely, the detrimental impact of incidental findings on clinical outcome has been documented by a recent study that retrospectively identified 135 patients (12%) with incidental findings in CTAC. 25 Although these findings did not significantly increase all-cause mortality, they were associated with a significantly higher cancer-specific mortality-indicating that patients with incidental findings may more often end up with lethal cancer.…”

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confidence: 99%

Extracardiac findings on computed tomography attenuation correction: Is it worth paying extra attention?

Benz

Fuchs

2018

Journal of Nuclear Cardiology

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Due to the profound impact of attenuation artifacts on diagnostic accuracy, especially specificity, 1 several methods like computed tomography attenuation correction (CTAC), 2 prone myocardial perfusion image (MPI) acquisition, 3 or external radionuclide sources like 153 Gd 4 have been developed. CTAC has evolved as the most common standard used, since it not only improves diagnostic accuracy and outcome prediction by reducing attenuation artifacts 1,5,6 but also enables the evaluation of coronary calcium scoring, 7 offering substantial added diagnostic and prognostic value. 8,9 Furthermore, the application of a CTAC can discriminate defects caused by left bundle branch block from real perfusion defects in SPECT MPI 10 and allows diagnosis of pulmonary hypertension by determining the diameter of the main pulmonary artery in CTAC. 11 Moreover, incidental findings can be found in CTAC with a high prevalence. 12,13 These early results on incidental findings in CTAC have recently been confirmed by a systematic review and meta-analysis demonstrating a prevalence of 44% incidental extracardiac findings, 16% major incidental extracardiac findings, and 0.7% previously unknown malignancies. 14 Although most of these findings might be negligible, some are of clinical relevance. In fact, it is recommended by the EANM procedural guidelines for radionuclide MPI with SPECT and SPECT/CT that noncontrast-enhanced CT scans for AC and also scouts should be additionally screened by a physician fully trained in CT readings. 15 Accordingly, the review of all visible non-cardiovascular structures is recommended by the Society of Cardiovascular Computed Tomography in patients undergoing non-contrast calcium scoring and coronary CT angiography. 16 Despite these recommendations, the field still remains controversial. Considering the high prevalence of these findings, concerns are reported about increased cost and radiation exposure due to follow-up scans, morbidity of biopsy or resection, and anxiety of both the patient and the physician about a non-significant pathology. In addition, only a minority of incidental findings that seem clinically significant in CTAC might actually be detrimental to patient outcome. 17 Hence, considering doubtful clinical relevance, the debate is ongoing whether it is worth paying extra attention to extracardiac findings.In the current issue of the Journal of Nuclear Cardiology, Zadro et al. investigated the prevalence of extracardiac findings on CTAC for MPI by SPECT and evaluated the prognostic outcome. The authors retrospectively screened 1506 patients who underwent MPI SPECT and low-dose CTAC. Extracardiac findings of CTAC were captured and classified as major or minor abnormalities. The prevalence of minor and major extracardiac findings was high, which were found in 830 (55.1%) and 212 (14.1%) patients, respectively, whereas 464 (30.8%) patients had no abnormality. Aneurysm of the aorta (33.8%), liver cirrhosis (27.2%), non cystic hypodense lesions of the liver (18.5%), and suspicious nodules in the ...

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Section: See Related Article Pp 1574-1583mentioning

confidence: 99%

Extracardiac findings on computed tomography attenuation correction: Is it worth paying extra attention?

Benz

Fuchs

2018

Journal of Nuclear Cardiology

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“…A 2-y multicenter study that took place in 4 nuclear medicine departments in the United Kingdom was granted local approval from each participating hospital and ethical approval from the University of Salford, following advice from the Health Research Authority (26). Positive findings were identified on the attenuation-correction CT images of 962 (28%) of 3,485 patients undergoing SPECT/CT MPI.…”

Section: Diagnostic-value Considerationsmentioning

confidence: 99%

The Clinical Dilemma of Incidental Findings on the Low-Resolution CT Images from SPECT/CT MPI Studies

Coward

Nightingale

Hogg

2016

J. Nucl. Med. Technol.

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CE credit: For CE credit, you can access the test for this article, as well as additional JNMT CE tests, online at https://www.snmmilearningcenter.org. Complete the test online no later than September 2019. Your online test will be scored immediately. You may make 3 attempts to pass the test and must answer 80% of the questions correctly to receive 1.0 CEH (Continuing Education Hour) credit. SNMMI members will have their CEH credit added to their VOICE transcript automatically; nonmembers will be able to print out a CE certificate upon successfully completing the test. The online test is free to SNMMI members; nonmembers must pay $15.00 by credit card when logging onto the website to take the test.Incidental findings are common in medical imaging. There is a particularly high prevalence of incidental findings within the thorax, the most frequent being pulmonary nodules. Although pulmonary nodules have the potential to be malignant, most are benign, resulting in a high number of false-positive findings. Low-resolution CT images produced for attenuation correction of SPECT images are essentially a by-product of the imaging process. The high number of false-positive incidental findings detected on these attenuation-correction images causes a reporting dilemma. Early detection of cancer can be beneficial, but falsepositive findings and overdiagnosis can be detrimental to the patient. Attenuation-correction CT images are not of diagnostic quality, and further diagnostic tests are usually necessary for a definitive diagnosis to be reached. Given the high number of falsepositive findings, the psychologic effect on the patient should be considered. This review recommends caution when the findings on attenuation-correction CT images are routinely reported. Medi cal imaging uses a range of modalities that yield both anatomic and functional information (1). Visual correlation of images acquired using separate modalities can provide more information than images from a single modality alone, though there is an inevitable risk of misregistration between images that have been acquired during different imaging sessions. The development of hybrid imaging has led to the integration of two modalities in one machine, allowing coregistration of images that have been acquired in a single session (1,2). This allows direct correlation of anatomic and functional information, increasing sensitivity and specificity while adding clarity to indeterminate cases (3). SPECT/CT offers an excellent example of hybrid imaging, combining the functional ability of SPECT with the anatomic ability of CT.The strength of SPECT lies in gaining pathophysiologic detail in a minimally invasive way (4). Pathologic processes can be identified by uptake of radiopharmaceuticals, but the precise location is often difficult to ascertain because of low image resolution and a lack of anatomic landmarks. Moreover, uptake on some scans is often nonspecific, revealing abnormalities but not their specific cause. CT can provide a useful means of localization, also enabl...

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“…Incidental findings of potential clinical significance have been reported in 2-33% of SPECT-CT MPI studies. [6][7][8][9] These may or may not prove to actually be clinically significant after further evaluation. The majority are found not to be of clinical consequence -such as benign liver cysts.…”

Section: Text Introductionmentioning

confidence: 99%

“…New primary lung cancers first detected as incidental pulmonary nodules on CTAC in MPI have been described in published reviews and a case report. [6][7][8][9][10] Despite this, SPECT-CT incidental findings continue to…”

Section: Text Introductionmentioning

confidence: 99%

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Primary Thoracic Cancers Incidentally Detected on CT Attenuation Correction Images During Myocardial Perfusion Scintigraphy

Delaney

Fong

Lee

2018

Clinical Lung Cancer

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Introduction: Incidental findings on CT attenuation correction images undertaken as part of myocardial perfusion scintigraphy may represent undiagnosed malignancy, but their routine review and reporting remains controversial. Methods: We present a series of 10 primary thoracic cancers incidentally detected in this way. They were identified as part of a retrospective review of incidental CT attenuation correction findings in 3122 consecutive myocardial perfusion studies over a forty-month period. Results: The nature and location within the thorax of the incidental findings which represented undiagnosed malignancy was varied. Early detection allowed curative surgical treatment to be undertaken in four cases, with no recurrence or metastasis at one year in these patients. The rate of new primary cancer detection was similar to previous studies. Conclusions: This series highlights the need for mandatory review and reporting with appropriate further investigation of incidental CT attenuation correction findings, and the potential of this to impact patient outcomes. The importance of clear communication between the nuclear medicine department and the treating medical team, to both avoid unnecessary delay in urgent cases clearly suspicious for malignancy and to ensure that appropriate follow-up of potentially important non-urgent findings is not missed, cannot be over-emphasised.

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Multicentre analysis of incidental findings on low-resolution CT attenuation correction images: an extended study

Cited by 14 publications

References 4 publications

Extracardiac findings on computed tomography attenuation correction: Is it worth paying extra attention?

Extracardiac findings on computed tomography attenuation correction: Is it worth paying extra attention?

The Clinical Dilemma of Incidental Findings on the Low-Resolution CT Images from SPECT/CT MPI Studies

Primary Thoracic Cancers Incidentally Detected on CT Attenuation Correction Images During Myocardial Perfusion Scintigraphy

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