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• W2133448114 abstract "As multidetector CT has come to play a more central role in medical care and as CT image quality has improved, there has been an increase in the frequency of detecting “incidental findings,” defined as findings that are unrelated to the clinical indication for the imaging examination performed. These “incidentalomas,” as they are also called, often confound physicians and patients with how to manage them. Although it is known that most incidental findings are likely benign and often have little or no clinical significance, the inclination to evaluate them is often driven by physician and patient unwillingness to accept uncertainty, even given the rare possibility of an important diagnosis. The evaluation and surveillance of incidental findings have also been cited as among the causes for the increased utilization of cross-sectional imaging. Indeed, incidental findings may be serious, and hence, when and how to evaluate them are unclear. The workup of incidentalomas has varied widely by physician and region, and some standardization is desirable in light of the current need to limit costs and reduce risk to patients. Subjecting a patient with an incidentaloma to unnecessary testing and treatment can result in a potentially injurious and expensive cascade of tests and procedures. With the participation of other radiologic organizations listed herein, the ACR formed the Incidental Findings Committee to derive a practical and medically appropriate approach to managing incidental findings on CT scans of the abdomen and pelvis. The committee has used a consensus method based on repeated reviews and revisions of this document and a collective review and interpretation of relevant literature. This white paper provides guidance developed by this committee for addressing incidental findings in the kidneys, liver, adrenal glands, and pancreas. As multidetector CT has come to play a more central role in medical care and as CT image quality has improved, there has been an increase in the frequency of detecting “incidental findings,” defined as findings that are unrelated to the clinical indication for the imaging examination performed. These “incidentalomas,” as they are also called, often confound physicians and patients with how to manage them. Although it is known that most incidental findings are likely benign and often have little or no clinical significance, the inclination to evaluate them is often driven by physician and patient unwillingness to accept uncertainty, even given the rare possibility of an important diagnosis. The evaluation and surveillance of incidental findings have also been cited as among the causes for the increased utilization of cross-sectional imaging. Indeed, incidental findings may be serious, and hence, when and how to evaluate them are unclear. The workup of incidentalomas has varied widely by physician and region, and some standardization is desirable in light of the current need to limit costs and reduce risk to patients. Subjecting a patient with an incidentaloma to unnecessary testing and treatment can result in a potentially injurious and expensive cascade of tests and procedures. With the participation of other radiologic organizations listed herein, the ACR formed the Incidental Findings Committee to derive a practical and medically appropriate approach to managing incidental findings on CT scans of the abdomen and pelvis. The committee has used a consensus method based on repeated reviews and revisions of this document and a collective review and interpretation of relevant literature. This white paper provides guidance developed by this committee for addressing incidental findings in the kidneys, liver, adrenal glands, and pancreas. ForewordThis white paper is meant not to comprehensively review the interpretation and management of solid masses in each organ system but to provide general guidance for managing incidentally discovered masses, appreciating that individual care will vary depending on each patient's specific circumstances; the clinical environment, available resources; and the judgment of the practitioner. Also, the term guidelines has not been used in this white paper to avoid the implication that this represents a component of the ACR Practice Guidelines and Technical Standards (which represent official ACR policy, having undergone a rigorous drafting and review process culminating in approval by the ACR Council), or the ACR Appropriateness Criteria® (which use a formal consensus-building approach using a modified Delphi technique). This white paper, which represents the collective experience of the Incidental Findings Committee, using a less formal process of repeated reviews and revisions of the draft document, does not represent official ACR policy. For these reasons, this white paper should not be used to establish the legal standard of care in any particular situation.IntroductionThe rapid increase in the utilization of cross-sectional imaging examinations over the past two decades, combined with the ongoing improvement in the spatial and contrast resolution of these studies, has led to a marked increase in the number of findings detected that are unrelated to the primary objectives of the examinations [1Pickhardt P.J. Hanson M.E. Vanness D.J. et al.Unsuspected extracolonic findings at screening CT colonography: clinical and economic impact.Radiology. 2008; 249: 151-159Crossref PubMed Scopus (161) Google Scholar, 2Bovio S. Cataldi A. Reimondo G. et al.Prevalence of adrenal incidentaloma in a contemporary computerized tomography series.J Endocrinol Invest. 2006; 29: 298-302PubMed Google Scholar, 3Wagner S.C. Morrison W.B. Carrino J.A. Schweitzer M.E. Nothnagel H. Picture archiving and communication system: effect on reporting of incidental findings.Radiology. 2002; 225: 500-505Crossref PubMed Scopus (43) Google Scholar, 4Yee J. Kumar N.N. Godara S. et al.Extracolonic abnormalities discovered incidentally at CT colonography in a male population.Radiology. 2005; 236: 519-526Crossref PubMed Scopus (147) Google Scholar]. An incidental finding, also known as an incidentaloma, may be defined as “an incidentally discovered mass or lesion, detected by CT, MRI, or other imaging modality performed for an unrelated reason” [5Incidentalomahttp://medical-dictionary.thefreedictionary.com/Incidental+findingGoogle Scholar]. Although such findings are incidental to the primary purpose of the study, one analysis suggested, “Some research and clinical activities are so prone to generating findings not intentionally sought that it is disingenuous to term them ‘unanticipated’ even if their precise nature cannot be anticipated in advance” [6Parker L.S. The future of incidental findings: should they be viewed as benefits?.J Law Med Ethics. 2008; 36: 341-351Crossref PubMed Scopus (49) Google Scholar]. More important than the definition is the action that each such finding invokes. So, we are asked to consider, “What is the responsible use of information that nobody asked for?” [7Fletcher R.H. Pignone M. Extracolonic findings with computed tomographic colonography: asset or liability?.Arch Intern Med. 2008; 168: 685-686Crossref PubMed Scopus (24) Google Scholar].The burden of extra costs with incidental findings on cross-sectional imaging has also raised concerns within the government and third-party payers as medical imaging utilization and expenditures have risen. A recent example of this was seen in the May 2009 CMS noncoverage decision regarding screening CT colonography [8Centers for Medicare and Medicaid Services. Decision memo for screening computed tomography colonography (CTC) for colorectal cancer (CAG-00396N). Baltimore, Md: Centers for Medicare and Medicaid Services.Google Scholar]. Although CT colonography focuses on detecting colorectal polyps to prevent colorectal carcinoma, an unenhanced, low–radiation dose CT scan of the lower chest, entire abdomen, and pelvis contains clinically significant incidental findings in 5% to 16% of asymptomatic patients [1Pickhardt P.J. Hanson M.E. Vanness D.J. et al.Unsuspected extracolonic findings at screening CT colonography: clinical and economic impact.Radiology. 2008; 249: 151-159Crossref PubMed Scopus (161) Google Scholar, 4Yee J. Kumar N.N. Godara S. et al.Extracolonic abnormalities discovered incidentally at CT colonography in a male population.Radiology. 2005; 236: 519-526Crossref PubMed Scopus (147) Google Scholar, 9Berland L.L. Incidental extracolonic findings on CT colonography: the impending deluge and its implications.J Am Coll Radiol. 2009; 6: 14-20Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 10Hara A.K. Johnson C.D. MacCarty R.L. Welch T.J. Incidental extracolonic findings at CT colonography.Radiology. 2000; 215: 353-357Crossref PubMed Scopus (309) Google Scholar, 11Hassan C. Pickhardt P.J. Laghi A. et al.Computed tomographic colonography to screen for colorectal cancer, extracolonic cancer, and aortic aneurysm: model simulation with cost-effectiveness analysis.Arch Intern Med. 2008; 168: 696-705Crossref PubMed Scopus (130) Google Scholar, 12Hellstrom M. Svensson M.H. Lasson A. Extracolonic and incidental findings on CT colonography (virtual colonoscopy).AJR Am J Roentgenol. 2004; 182: 631-638Crossref PubMed Scopus (128) Google Scholar, 13Xiong T. McEvoy K. Morton D.G. Halligan S. Lilford R.J. Resources and costs associated with incidental extracolonic findings from CT colonography: a study in a symptomatic population.Br J Radiol. 2006; 79: 948-961Crossref PubMed Scopus (49) Google Scholar, 14Xiong T. Richardson M. Woodroffe R. Halligan S. Morton D. Lilford R.J. Incidental lesions found on CT colonography: their nature and frequency.Br J Radiol. 2005; 78: 22-29Crossref PubMed Scopus (88) Google Scholar], with a higher frequency in symptomatic patients [9Berland L.L. Incidental extracolonic findings on CT colonography: the impending deluge and its implications.J Am Coll Radiol. 2009; 6: 14-20Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 10Hara A.K. Johnson C.D. MacCarty R.L. Welch T.J. Incidental extracolonic findings at CT colonography.Radiology. 2000; 215: 353-357Crossref PubMed Scopus (309) Google Scholar, 12Hellstrom M. Svensson M.H. Lasson A. Extracolonic and incidental findings on CT colonography (virtual colonoscopy).AJR Am J Roentgenol. 2004; 182: 631-638Crossref PubMed Scopus (128) Google Scholar, 13Xiong T. McEvoy K. Morton D.G. Halligan S. Lilford R.J. Resources and costs associated with incidental extracolonic findings from CT colonography: a study in a symptomatic population.Br J Radiol. 2006; 79: 948-961Crossref PubMed Scopus (49) Google Scholar, 14Xiong T. Richardson M. Woodroffe R. Halligan S. Morton D. Lilford R.J. Incidental lesions found on CT colonography: their nature and frequency.Br J Radiol. 2005; 78: 22-29Crossref PubMed Scopus (88) Google Scholar]. The noncoverage decision by CMS cited concern for the costs of evaluating extracolonic findings that are diagnostically indeterminate. Other existing or developing technologies may face this type of economic scrutiny as CMS and other third-party payers become more focused on cost containment.Although countless studies have been devoted to describing findings related to specific medical conditions, relatively little research has been devoted to understanding incidental findings. The most common reason to pursue incidental findings is to differentiate benign from potentially serious (including malignant) lesions. Although most incidental findings prove to be benign, their discovery often leads to a cascade of testing that is costly, provokes anxiety, exposes patients to radiation unnecessarily, and may even cause morbidity [15Casarella W.J. A patient's viewpoint on a current controversy.Radiology. 2002; 224: 927Crossref PubMed Scopus (46) Google Scholar]. Articles describing criteria for detecting, categorizing, reporting, and managing such findings have been inconsistent at best and leave many unanswered questions [1Pickhardt P.J. Hanson M.E. Vanness D.J. et al.Unsuspected extracolonic findings at screening CT colonography: clinical and economic impact.Radiology. 2008; 249: 151-159Crossref PubMed Scopus (161) Google Scholar, 9Berland L.L. Incidental extracolonic findings on CT colonography: the impending deluge and its implications.J Am Coll Radiol. 2009; 6: 14-20Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 10Hara A.K. Johnson C.D. MacCarty R.L. Welch T.J. Incidental extracolonic findings at CT colonography.Radiology. 2000; 215: 353-357Crossref PubMed Scopus (309) Google Scholar, 11Hassan C. Pickhardt P.J. Laghi A. et al.Computed tomographic colonography to screen for colorectal cancer, extracolonic cancer, and aortic aneurysm: model simulation with cost-effectiveness analysis.Arch Intern Med. 2008; 168: 696-705Crossref PubMed Scopus (130) Google Scholar, 12Hellstrom M. Svensson M.H. Lasson A. Extracolonic and incidental findings on CT colonography (virtual colonoscopy).AJR Am J Roentgenol. 2004; 182: 631-638Crossref PubMed Scopus (128) Google Scholar, 13Xiong T. McEvoy K. Morton D.G. Halligan S. Lilford R.J. Resources and costs associated with incidental extracolonic findings from CT colonography: a study in a symptomatic population.Br J Radiol. 2006; 79: 948-961Crossref PubMed Scopus (49) Google Scholar, 14Xiong T. Richardson M. Woodroffe R. Halligan S. Morton D. Lilford R.J. Incidental lesions found on CT colonography: their nature and frequency.Br J Radiol. 2005; 78: 22-29Crossref PubMed Scopus (88) Google Scholar].Project ObjectivesThe objectives of this project were: •to develop a consensus on sets of organ-specific imaging features for some commonly affected organ systems within the abdomen, which will lead to consistent definitions for, and identification of, incidental findings;•to develop medically appropriate approaches to managing incidental findings that are diagnostically indeterminate; and•to address the differences between unenhanced, low–radiation dose CT examinations and contrast-enhanced CT examinations using standard radiation doses for detecting and managing incidental findings.Potential Beneficial Outcomes of the ProjectBenefits anticipated from this effort included: •reducing risks to patients from additional unnecessary examinations, including the risks of radiation and risks associated with interventional procedures;•limiting the costs of managing incidental findings to patients and the health care system;•achieving greater consistency in recognizing, reporting, and managing incidental findings, as a component of formal quality improvement efforts;•providing guidance to radiologists who are concerned about the risk for litigation for missing incidental findings that later prove to be clinically important; and•helping focus research efforts to lead to an evidence-based approach to incidental findings.History of the ProjectBecause of the increasing recognition of the problems and opportunities of incidental findings, consideration of a formal approach to these issues began within the ACR in 2006. The Incidental Findings Committee was formed under the auspices of the Body Imaging Commission of the ACR. After several meetings and conference calls, the concepts and objectives described above were formulated. The initial intent was to develop guidelines analogous to those produced by the Fleischner Society on pulmonary nodules [16MacMahon H. Austin J.H. Gamsu G. et al.Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society.Radiology. 2005; 237: 395-400Crossref PubMed Scopus (1303) Google Scholar] and the consensus conferences of the Society of Radiologists in Ultrasound on thyroid nodules [17Frates M.C. Benson C.B. Charboneau J.W. et al.Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement.Radiology. 2005; 237: 794-800Crossref PubMed Scopus (955) Google Scholar] and carotid imaging [18Grant E.G. Benson C.B. Moneta G.L. et al.Carotid artery stenosis: gray-scale and Doppler US diagnosis—Society of Radiologists in Ultrasound Consensus Conference.Radiology. 2003; 229: 340-346Crossref PubMed Scopus (1052) Google Scholar].Because of the keen interest among groups both within and outside the ACR, the committee's participants were recruited from members of the ACR, all of who were also fellows or members of the Society of Computed Body Tomography and Magnetic Resonance, the Society of Gastrointestinal Radiologists, and the Society of Uroradiology. Contacts from other groups within the ACR, including the Colon Cancer Committee, the Appropriateness Criteria–Adrenal Panel and the Appropriateness Criteria–GI Panel (Liver Lesion Topic) also helped ensure the consistency of the guidance produced among these groups.Consensus ProcessExpert radiologists in relevant organ systems were recruited to participate in the Incidental Findings Committee and its subcommittees. We plan to further review and revise these recommendations periodically, on the basis of comments and new research. Although the scope of a project to address incidental findings on CT is large, the committee decided to develop guidance for a limited number of organ systems. Four subcommittees were established to address the largest number of incidental findings within the abdomen, in the kidneys, liver, adrenal glands, and pancreas. A fifth subcommittee was charged with attempting to ensure the use of common terminology and a common format. The committee elected to defer considering other incidental findings arising in the abdomen and pelvis, such as ovarian masses, splenic lesions, lymphadenopathy, and vascular abnormalities, including arterial stenoses, abdominal aortic aneurysms, and renal artery aneurysms. The membership of each subcommittee is listed in the Appendix.Each subcommittee was tasked to develop organ-specific guidance, which was initially formulated primarily by the subcommittee chairs. When this was complete, these subsections were distributed to the subcommittee members for further comments and discussion. Revisions of the entire document were then distributed to the subcommittee chairs, and multiple revisions ensued. Finally, the draft was distributed to the entire Incidental Findings Committee for additional review to achieve consensus and to arrive at a final manuscript. Reviews by other ACR committees were also integrated into drafts at appropriate points in the process. To facilitate rapidly formulating and clearly communicating this guidance, and to provide convenient graphic summaries for easy reference, the committee decided to express its recommendations in flowcharts and tables, buttressed with explanatory text.Elements of These Recommendations and FlowchartsCertain subspecialties within radiology have addressed inconsistencies of documentation by creating structured reporting, such as the Breast Imaging Reporting and Data System® classification [19D'Orsi C.J. Bassett L.W. Berg W.A. Breast Imaging Reporting and Data System: ACR BI-RADS-Mammography.4th ed. American College of Radiology, Reston, Va2003Google Scholar]. In an analogous way, Zalis et al [20Zalis M.E. Barish M.A. Choi J.R. et al.CT colonography reporting and data system: a consensus proposal.Radiology. 2005; 236: 3-9Crossref PubMed Scopus (498) Google Scholar], for the Working Group on Virtual Colonoscopy, proposed “C-RADS,” which includes an “E” classification system for extracolonic findings. Although this latter classification system has elements in common with these recommendations, it is not included with them here.In the flowcharts within this white paper, the algorithms use yellow boxes for steps that involve data to affect management, such as categorization, demographics, history, and the results of studies. Green boxes represent action steps, such as performing a study, following up, or intervening with a biopsy or surgery. Red boxes indicate that the evaluation process should stop, with no further action required, because the lesion can be concluded to be benign.Challenges of Addressing Incidental FindingsOne of the crucial obstacles to managing incidental findings cost-effectively is the unwillingness of many physicians to accept uncertainty even when the chance of a serious diagnosis is extremely unlikely. This unwillingness is in part driven by a paucity of data, the lack of clear-cut algorithms with regard to diagnostic and treatment strategies, fear of potential malpractice litigation, and the desire of patients and their families to adhere to the adage “better safe than sorry.” It may be difficult for physicians or patients to appreciate at an intellectual or emotional level that an incidental finding might not need to undergo further examinations or follow-up. Not only are further tests likely to yield a benign diagnosis, but such testing could even lead to morbidity [15Casarella W.J. A patient's viewpoint on a current controversy.Radiology. 2002; 224: 927Crossref PubMed Scopus (46) Google Scholar]. On the other hand, an incidental finding could represent a serendipitous discovery of a serious diagnosis, such as a large abdominal aortic aneurysm, and be potentially lifesaving; hence the conundrum. The discussion of cost is also burdened with strong opinions, with some believing that cost should be no obstacle to reaching a comfortable level of medical certainty for a positive or negative diagnosis [21Elstein A.S. On the origins and development of evidence-based medicine and medical decision making.Inflamm Res. 2004; 53: S184-S189PubMed Google Scholar, 22Wolf S.M. Lawrenz F.P. Nelson C.A. et al.Managing incidental findings in human subjects research: analysis and recommendations.J Law Med Ethics. 2008; 36: 219-248Crossref PubMed Scopus (551) Google Scholar]. Others might argue that medical resources should be best applied where they are known to be most effective. However, there is strong scientific validation for applying medical strategies that optimize results while minimizing costs and applying “evidence-based” reasoning to medical decisions [21Elstein A.S. On the origins and development of evidence-based medicine and medical decision making.Inflamm Res. 2004; 53: S184-S189PubMed Google Scholar].Unfortunately, information about the cost-effectiveness of pursuing incidental findings is largely lacking. Therefore, achieving a consensus of experts, supported by available literature, is a reasonable interim objective for this Incidental Findings Committee. However, there are several reasons to hypothesize that a group of specialty radiologists from academic institutions might be biased toward the overuse of imaging studies. For example, the culture of attempting to achieve diagnostic certainty noted above may be more intense in an academic environment, partly because of the higher intensity of illness seen there. Less experienced physicians in residency and fellowship may be more inclined to depend on imaging studies, with this inclination supported by attending physicians wanting to enhance the teaching experience. Also, academic institutions are more likely to have a broad array of advanced imaging technologies, the use of which is encouraged by the desire to perform research.Additionally, academic experts are intensely focused in their areas of interest and are keenly aware of the multitude of possible serious results from incidental findings, also potentially biasing their viewpoint. Therefore, in approaching incidental findings in this way, there is a risk that rather than the results of this project limiting the overuse of imaging, the detailed guidance generated from this project either might not affect such overutilization or could even increase it. Our goal was not necessarily to reduce utilization (although we believe this is needed) but rather to optimize utilization. In this way, only the appropriate incidental findings are evaluated further. These factors were considered in designing these recommendations, especially regarding the guidance on the length and frequency of follow-up studies for indeterminate lesions.Reporting ConsiderationsSome considerations are common to all organ systems. One universal principle is to refer to available prior relevant imaging examinations when interpreting incidental findings. Prior examinations need not be of precisely the same type or modality but are useful if they include the anatomic area in question, such as a chest CT scan that includes the upper abdomen. Also, the approach to incidental findings should be placed in the context of the individual patient's situation. As an extreme but common example, the need to report or pursue incidental findings may be unnecessary in patients with serious medical comorbidities or limited life expectancy.The wording of the radiology report is also controversial and could fall into 4 categories. This can be illustrated through the example of a renal mass that seems to be a simple cyst on an unenhanced CT scan. Such a lesion could be: 1Described as a “low-attenuation mass statistically likely to be a simple cyst” or a “low-attenuation mass likely to be benign;”2Reported as a “renal cyst.” This contains the specific, implicit recommendation to do nothing and limits the length of the radiology report but might be inaccurate in a small percentage of situations;3Not reported at all. Particularly in the case of small lesions, some would argue that such a finding is so common and innocuous that it does not rise to the level of an abnormality. Refraining from reporting would be analogous to a nonradiologist physician not mentioning an insignificant skin lesion on a physical examination report. Because many patients and some physicians become concerned about even minor findings, this would prevent any risk for further testing; or4Reported by stating that a definitive diagnosis cannot be made, but there are no features to suggest a malignant etiology, with one possible phrase being “indeterminate, no malignant features.” This would leave the workup to the discretion of the referring physician and perhaps the patient. However, such a report leaves the referrer in a quandary. This may lead to unnecessary testing, but it would essentially acknowledge the limits of the examination and acknowledge that there are no evidence-based data to allow specific recommendations.Option 1 was considered acceptable, but not necessarily preferred, by all members of the Incidental Findings Committee. However, the committee could not reach a consensus on all aspects of this subject, because various members preferred, while others raised objections to each of options 2, 3, and 4. Some members noted that reporting all incidental findings can be valuable if a patient has a follow-up examination and only the report is available.Scanning TechniquesIn the 4 organ-specific sections below (kidneys, liver, adrenal glands, and pancreas), comments apply to standard–radiation dose examinations, whether performed unenhanced or enhanced. However, low-dose unenhanced scans may be performed for CT colonography, identifying urinary tract calculi and other applications. We believe that incidental findings identified on such low–radiation dose, unenhanced scans require special considerations. These are separately addressed in an additional section following the 4 organ-specific sections.KidneysNature and Scope of the ProblemThe literature regarding the approach to renal masses detected on renal mass–protocol CT or MRI is replete with case series, retrospective analyses, and suggested clinical guidelines that have been long accepted and are widely adopted in clinical practice today [23Birnbaum B.A. Bosniak M.A. Megibow A.J. Lubat E. Gordon R.B. Observations on the growth of renal neoplasms.Radiology. 1990; 176: 695-701PubMed Google Scholar, 24Birnbaum B.A. Hindman N. Lee J. Babb J.S. Renal cyst pseudoenhancement: influence of multidetector CT reconstruction algorithm and scanner type in phantom model.Radiology. 2007; 244: 767-775Crossref PubMed Scopus (73) Google Scholar, 25Bosniak M. Problematic renal masses.in: RSNA categorical course in diagnostic radiology: genitourinary radiology Oak Brook, Ill: Radiological Society of North America. 1994: 183-191Google Scholar, 26Bosniak M.A. The current radiological approach to renal cysts.Radiology. 1986; 158: 1-10PubMed Google Scholar, 27Bosniak M.A. The small (less than or equal to 3.0 cm) renal parenchymal tumor: detection, diagnosis, and controversies.Radiology. 1991; 179: 307-317Crossref PubMed Scopus (290) Google Scholar, 28Bosniak M.A. Diagnosis and management of patients with complicated cystic lesions of the kidney.AJR Am J Roentgenol. 1997; 169: 819-821Crossref PubMed Scopus (144) Google Scholar, 29Bosniak M.A. Should we biopsy complex cystic renal masses (Bosniak category III)?.AJR Am J Roentgenol. 2003; 181: 1425-1426Crossref PubMed Scopus (5) Google Scholar, 30Bosniak M.A. Birnbaum B.A. Krinsky G.A. Waisman J. Small renal parenchymal neoplasms: further observations on growth.Radiology. 1995; 197: 589-597PubMed Google Scholar, 31Bosniak M.A. Megibow A.J. Hulnick D.H. Horii S. Raghavendra B.N. CT diagnosis of renal angiomyolipoma: the importance of detecting small amounts of fat.AJR Am J Roentgenol. 1988; 151: 497-501Crossref PubMed Scopus (241) Google Scholar, 32Bosniak M.A. Rofsky N.M. Problems in the detection and characterization of small renal masses.Radiology. 1996; 198: 638-641PubMed Google Scholar, 33Curry N.S. Cochran S.T. Bissada N.K. Cystic renal masses: accurate Bosniak classification requires adequate renal CT.AJR Am J Roentgenol. 2000; 175: 339-342Crossref PubMed Scopus (153) Google Scholar, 34Harisinghani M.G. Maher M.M. Gervais D.A. et al.Incidence of malignancy in complex cystic renal masses (Bosniak category III): should imaging-guided biopsy precede surgery?.AJR Am J Roentgenol. 2003; 180: 755-7" @default.
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• W2133448114 title "Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee" @default.
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