If incidental findings pass these 4 criteria, consider leaving off rad report

When radiologists discover harmless incidental findings, they are left with the complex, at times difficult choice of either including it in the radiology report or not mentioning it at all. If there is no clinical consequence and the radiologist is just going to recommend no further evaluation, it’s tempting to just leave it out of the report altogether. But what about the legal ramifications? What would one of their peers do in the same situation?

In an original article published by the Journal of the American College of Radiology, Pari V. Pandharipande, MD, MPH, Massachusetts General Hospital in Boston, and colleagues examined how they believe radiologists should react when facing such a dilemma.

“We consider the following question: if such an incidental finding has no known clinical consequence, does it merit mention in a radiology report?” the authors wrote. “We contend that the radiologist’s report should minimize the traditional descriptive catalog of findings and take a form similar to a consulting physician’s report, focusing on the clinical question. In the former, the radiologist, either passively or intentionally, displaces the responsibility of interpreting a finding’s importance to the referrer. In the latter, the radiologist shares responsibility for interpreting the finding’s importance in the context of the patient’s overall health.”

Pandharipande et al. highlighted that avoiding unnecessary follow-up imaging is a significant benefit of not disclosing harmless incidental findings. Even if the report recommends not following up on the finding, the referring physician could misunderstand that opinion and proceed by moving forward.

Using a Bosniak category 1 renal cyst as their example case, the authors listed four key criteria to be considered. If a radiologist can make it through this checklist, the authors said, perhaps not reporting the incidental finding is the way to go.

1. The cyst is not the reason for the examination.
2. The cyst has no meaningful anatomic or physiologic consequence.
3. The cyst has no excess malignant potential given known or suspected patient-level risk.
4. The cyst is not likely to indicate a nonmalignant disease

Pandharipande and colleagues acknowledged that these criteria do have limitations. For example, findings perceived as harmless may later become relevant. If a patient develops renal insufficiency  and CT reports from a decade ago reveal the patient had renal cysts present, the nephrologist may make assumptions about the radiologist’s thought process and exclude polycystic kidney disease as a possible diagnosis.

This is a rare circumstance, the authors explained, but it shows that radiologists must carefully consider their options.

“Even though this circumstance is unlikely, radiologists should have a low threshold for reporting cysts of potential clinical relevance,” the authors wrote.

The authors also discussed the medicolegal concerns radiologists may have with not disclosing harmless incidental findings.

“The failure to disclose an incidental imaging finding by itself is not sufficient to lead to legal liability,” the authors wrote. “To succeed in a medical malpractice claim of negligence, the patient alleging negligence must demonstrate that (1) a reasonable radiologist would have identified and reported the incidental finding, (2) failure to disclose the incidental finding caused the patient to suffer a legally compensable harm, and (3) the harm resulted in quantifiable damages. On the basis of these requirements, not reporting imaging findings that meet the criteria we recommend for nondisclosure is unlikely to lead to a successful legal claim.”

Of course, as Pandharipande pointed out, juries can always “differ on conclusions in individual cases.”