ORIGINAL ARTICLE

Incidental findings in patients with multiple injuries: How to proceed? Miriam Ruesseler, MD, Anna Schill, MD, Thomas Lehnert, MD, Hendrik Wyen, MD, Sebastian Wutzler, MD, Ingo Marzi, MD, and Felix Walcher, MD, Frankfurt, Germany

Multislice computed tomography (MSCT) is the diagnostic criterion standard for the initial evaluation of patients with suspected multiple injuries. Besides scanning for injuries directly related to the initial trauma, MSCT scans can reveal pathologies unrelated to the trauma of clinical relevance. The aim of the present study was to determine the frequency and follow-up course of incidental findings in patients with multiple injuries. METHODS: This is a retrospective analysis of prospectively collected data on 2,242 patients with suspected multiple injuries at a Level I trauma center from 2006 to 2010. The MSCT reports were retrospectively reviewed regarding abnormal findings not related to trauma. These incidental findings were classified on a four-point level scoring system with respect to clinical importance and urgency for further diagnostic and therapeutic procedures. RESULTS: During initial trauma center evaluation in the emergency department, 2,246 patients met our inclusion criteria. A total of 2,036 patients (90.7%) underwent MSCT; 1,142 (50.9%) of the patients had one or more incidental findings. A total of 2,844 incidental findings were detected. Overall, 349 tumor findings were noted (12.3% of all incidental findings); 113 findings were suspicious for malignant processes or metastasis. According to our classification, 168 (5.9%) of the incidental findings required urgent follow-up (Level 4), and 527 (18.5%) of the incidental findings required a follow-up before discharge (Level 3). CONCLUSION: MSCT in patients with multiple injuries reveals one or more incidental findings in more than one of two patients. A scoring system classifying for relevance of incidental findings was introduced and could be applied in routine trauma care in the future. (J Trauma Acute Care Surg. 2013;75: 848Y853. Copyright * 2013 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. KEY WORDS: Incidental findings; multiple trauma; MSCT; emergency department. BACKGROUND:

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uring the past decades, the use of computed tomography (CT) has grown rapidly as a consequence of its recognized clinical value in nearly all areas of medicine. The introduction of multislice CT (MSCT), with its revolutionary reduction in scan time, has made this imaging technology available for the early assessment of trauma patients.1Y3 A significant survival benefit for severely injured patients receiving whole-body CT scans has been shown by Huber-Wagner et al.4 However, there is an ongoing debate about the benefits in relation to the risk of radiation exposure and inappropriate use of limited resources.1,5 The potential benefits of liberal MSCT imaging in trauma patients must be weighed against the risks of radiation exposure and contrast mediumYinduced nephropathy.6Y9 The risk of radiation exposure especially is a controversial, frequently discussed topic.10,11 The estimated lifetime mortality risk attributable to cancer from whole-body CT examination is 0.1%, with the potential rates as great as almost 2% with annual scans.7 Submitted: May 11, 2013, Revised: August 1, 2013, Accepted: August 1, 2013. From the Departments of Trauma, Hand and Reconstructive Surgery (M.R., A.S., H.W., S.W., I.M., F.W.) and Interventional and Diagnostic Radiology (T.L.) Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany. Parts of the study were presented as short communication at the 13th European Congress of Trauma and Emergency Surgery, May 2012, in Basel, Switzerland. Address for reprints: Miriam Ruesseler, MD, Department of Trauma Surgery, Johann Wolfgang Goethe-University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; email: [email protected] DOI: 10.1097/TA.0b013e3182a925b9

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Besides providing information on acute trauma-related injuries, MSCT scans could also reveal pathologies not related to trauma, which may require further investigations.12,13 The diagnosis and correct treatment of incidental findings could have a great impact on the patient’s future health and wellbeing. However, incidental findings are challenging for trauma surgeons and emergency physicians who need to decide on their clinical importance and management in addition to the acute and urgently necessary trauma treatment. Different studies show a high number of incidental findings in imaging diagnostic tests, especially in CT studies.12Y14 A large number of these findings are clinically significant and require additional evaluation on a more or less urgent basis. Irrespective of the need for additional care, every patient has to be informed about any such findings. In the literature, medium-to-high numbers of incidental findings are described for many medical disciplines, various imaging modalities, and different CT imaging methods such as CT coronary angiography or CT colonoscopy.15,16 There are only a limited number of studies describing the incidence of incidental findings in trauma management. Most studies focus on determined scan areas such as the abdomen or pelvis17,18 and exclude children or patients who did not have a complete trauma scan.13,17 Some provide a classification for incidental findings, but only a few provide guidance for follow-up.12,13 Barrett et al.13 in 2008, in a study with 3,092 trauma patients, stated that 32% (990) of the patients had J Trauma Acute Care Surg Volume 75, Number 5

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potentially relevant findings, which needed further evaluation or close follow-up. However, there is a consistently poor quality of documentation of incidental findings and an inadequate management or referral system for these lesions.12,19 In the current literature, there is an ongoing debate on incidental findings in CT scans, but there are only a few recommendations available for use during the daily routine.14,15,20 The aims of the present study were to determine the frequency and clinical importance of incidental findings in seriously injured patients at a Level I trauma center and to provide a simple and applicable tool regarding follow-up.

PATIENTS AND METHODS Study Design and Setting A retrospective analysis of prospectively collected data on trauma patients admitted to the emergency department (ED) was performed at a Level I trauma center. The documentation during trauma management after admission was performed by a documentation assistant, who was not involved in the treatment of the trauma patient. The collected data are processed by the Microsoft AccessYbased system, TraumaWatch, which has been in use in our department since April 2002.21 This system is composed of an extended version of the data collected in the Trauma Registry of the German Society for Trauma Surgery (DGU),22 with a more detailed description of the out-of-hospital phase, ED phase, intensive care unit stay, and final outcomes. Demographic data including age, sex, type and mechanism of injury, as well as outcome were recorded.

Data Collection and Processing All trauma patients admitted in our hospital’s ED trauma room with suspected severe multiple injuries between January 1, 2006, and December 31, 2010, were included. There was no age limitation. Patients excluded from the study were those with incomplete TraumaWatch documentation. Patients received whole-body CT or nonYwhole-body CT during trauma room diagnostics, as indicated by the 2006 Whitebook for the treatment of the severely injured, among other authorities.4,23 A whole-body CT is an unenhanced CT of the head and neck, followed by contrast-enhanced CT of the chest, abdomen, and pelvis, including the complete spine.4 A nonYwhole-body CT was focused on specific body parts. All CT studies were interpreted directly by a board-certified radiologist and a trauma surgeon and were reviewed by another radiologist within 24 hours after the CT scan. We reviewed the reports of all of these CT scans and searched for incidental findings. An incidental finding was defined as an abnormal finding not related to trauma seen on MSCT that could potentially pose danger to the patient’s present or future health.13 Recommendations made by the radiologist for further management were also noted. On the basis of preexisting classifications,12,13,15 we developed a more precise and clinically applicable management tool that leans toward actual guidelines, reviews, and guiding articles (Table 1). Incidental findings were divided into four categories based on their clinical importance. The classification

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should help to determine the clinical importance and assist clinicians in managing their patients. Level 1 includes minor degenerative and nondegenerative findings that do not require any further evaluation, initiation of therapy, or follow-up. Level 2 includes findings that do not require urgent initiation of further evaluation/therapy. However, a follow-up within a year should be performed. The patient should be informed, and the findings should be described in the physician referral. Level 3 includes findings with potentially severe impact on patients’ health, which necessitate additional evaluation and close follow-up within 3 months. This might be initiated during the hospital stay but can also be performed in an ambulatory setting. Level 4 includes all findings that require an urgent initiation of further evaluation and therapy before hospital discharge. To develop a tool that makes it easy to get to know the clinical significance as well as the appropriate management of an incidental finding, all types of incidental findings that were detected in our patient population were sorted according to their level by scanning area and organ system. The classification of findings into our scoring system was performed following current guidelines, reviews, and guiding articles.20,24,25 For each type of finding, we reviewed currently available articles and guidelines to determine the recommended management and clinical importance of incidental findings in CT scans as well as on diseases and disorders diagnosed with CT scans.20,24,26 For those incidental findings, where no guidelines were available concerning the further management when first detected by CT scan, we reviewed common management guidelines, although they did not differentiate between diagnoses given because of a CT scan or other diagnostic instruments. For all findings that were not sufficiently well described in the written radiologist’s report to be leveled according to the guidelines as well as those where malignancy could not be excluded, the original images were reviewed and were additionally reevaluated by a radiologist. The statistic interdependence of the variables age and number of incidental findings were calculated by the JonckheereTerpstra test. The data were analyzed using Microsoft Excel for

TABLE 1. Scoring System for Incidental Findings Scoring System Level 1 Findings that do not require any further evaluation, initiation of therapy, or any follow-up except for clinical symptoms. Level 2 Findings that do not require urgent initiation of further evaluation/therapy. However, a regular follow-up (e.g., annually) should be performed. Level 3 Findings with potentially serious results that necessitate further evaluation and close follow-up. This might be initiated during the hospital stay but can also be performed ambulatory within a 3-month period. Level 4 Findings that require an urgent initiation of further evaluation and therapy before hospital discharge.

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Figure 1. Study protocol.

Windows (Microsoft Corporation, Redmond, WA) SPSS version 17.0 (IBM, Armonk, NY).

RESULTS During the study period, 2,289 patients experiencing multiple injuries were presented to our trauma center (Fig. 1), with 1,632 males (71.3%) and having a mean age of 41 years. Only 47 were excluded because of missing data. Therefore, 2,242 patients met our inclusion criteria (Fig. 1). The mean (SD) Injury Severity Score (ISS) of the study population was 17.13 (14.97) points. Within the trauma room diagnostics, 2,036 patients received a CT scan, of whom 1,812 patients (81%) received a whole-body CT. In 206 patients, no CT scan was performed, and of these, 104 (50.5%) were children younger than 18 years. In our study, a total of 1,142 patients (50.9%) had incidental findings on a CT scan. Of these, 701 patients (61%) had more than one incidental finding; the total number in any individual patient ranged from 1 to 12. A total of 2,844 incidental findings were detected.

The rate of incidental findings of all levels grew with the age of the patients (Table 2). The Jonckheere-Terpstra test confirmed that the two variables, age and number of incidental findings, are statistically interdependent. With a p = 0.002, a significant trend of an increase of incidental findings with age is determined (J = 1,437,049, z = 3.16, p = 0.002, > = 0.05). A total of 1,621 incidental findings (56.9%) were scored Level 1; 1,223 findings (43%) were scored Level 2, 3, or 4. Of the Level 1 and 2 findings, 754 (35.1%) could be referred to as degenerative changes. There were a total of 168 Level 4 findings in 145 patients (6.5%), and the mean age in this group was 60 years. The average ISS of patients with Level 4 findings was 19.8 points. Of the Level 4 findings, 54.8% were observed in patients older than 65 years, and only 10.1% of Level 4 findings were detected in patients younger than 25 years. We did not find any significant differences regarding sex in terms of the number of findings in each level. Of the patients found to have Level 4 findings, 143 (98.6%) were kept in hospital after the trauma room diagnostics. Eleven Level 4 patients with indication for admission were transferred to other hospitals after the initial trauma room treatment. Twentyfour patients (16.6%) with Level 4 findings died during their hospital stay because of traumatic injuries, with an overall death rate of 1:6 in patients with Level 4 findings and 1:11 in all 2,289 patients presented at the ED. In all levels, a total of 349 tumor findings were noted, and 102 of these were considered benign (e.g., meningioma, myoma, cholesteatoma). Of all tumor findings, 69 were lymphadenopathies with lymph nodules greater than 1 cm. In 115 Level 4 findings, malignant processes or metastasis could not be excluded (Table 3), and 68 of these findings (59.1%) were detected in male patients. The mean age in this group was 62 years. In male patients, there were conspicuously more lesions of the lung, skeleton, and suspect lymphadenopathy. In younger patients, there were more suspicious findings related to the adrenal gland and uterus/adnexa.

DISCUSSION Our results show a high frequency of incidental findings in patients with suspected severe multiple injuries. Some 50.9% of the patients have nonYtrauma-related findings according to

TABLE 2. Distribution of IF No. patients No. IF 0Y25 y 26Y45 y 46Y65 y 965 y

IF Level 1

IF Level 2

IF Level 3

IF Level 4

Total

920* 1,621 (100%) 152 (9.4%) 331 (20.4%) 459 (28.3%) 679 (41.9%)

400* 528 (100%) 24 (4.5%) 71 (13.4%) 141 (26.7%) 292 (55.3%)

416* 527 (100%) 48 (9.1%) 113 (21.4%) 141 (26.7%) 225 (42.7%)

145* 168 (100%) 17 (10.1%) 26 (15.5%) 33 (19.6%) 92 (54.8%)

1,142* 2,844 (100%) 241 (8.5%) 541 (19%) 774 (27.2%) 1,288 (45.3%)

*One patient can have more than one IF. Number of IF sorted by scoring level and age group. IF, incidental findings.

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TABLE 3. Level 4 Findings for Which Malignancy Cannot be Excluded n Adrenal gland, e.g., ‘‘tumorous lesion of adrenal gland, 3.1  2.6 cm’’ Thyroid gland, e.g., ‘‘knotty changes of thyroid gland, density inhomogeneous, small cystic changes 3.1  2.3 cm’’ Bones/skeleton, e.g., ‘‘tumorous ilium 3.7  4.4 cm, suspected chondrosarcoma’’ Suspect lymphadenopathy e.g., ‘‘solitary hilum lymph knot, 2.2 cm’’ GIT (including esophagus), e.g., ‘‘contrast-enhanced tumor at stomach entrance, 3.4  2.3 cm’’ Pancreas, e.g., ’’suspect for tumor of pancreas tail’’ Gallbladder, ‘‘neoplasm of gallbladder’’ Liver, e.g., ‘‘inhomogeneous cystic lesionVsuspicious for malignancy’’ Brain and head, e.g., ‘‘suspect for astrocytoma’’ Bladder, e.g., ‘‘tumor on the superior surface of the urinary bladder suspect for carcinoma’’ Prostate, e.g., ‘‘suspect for carcinoma of the prostate gland’’ Uterus and adnexa, e.g., ‘‘inhomogeneous contrast-enhanced uterus with multiple ovarian cysts, partially hemorrhaged’’ Female breast, e.g., ‘‘knotty changes of the breast’’ Kidney, e.g., ‘‘cystic tumor, impression of ureter’’ Mediastinal cavity, e.g., ‘‘increase in density suspect for lymphoma’’ Lung, e.g., ‘‘pulmonary mass right upper lobe 3.3  2.0 cm’’ Total

Mean Age, y

Age Range, y

Sex Ratio, M/F

4 2

44 56

29Y67 45Y66

1:1 1:1

9 14 8

73 59 59

18Y96 16Y85 10Y83

3.5:1 6:1 1:1

8 1 6 8 5 4 8

76 67 60 56 75 80 45

52Y93 67 29Y83 6Y70 58Y87 67Y96 20Y83

5 8 1 24 115

56 64 37 61 62

41Y81 32Y86 37 18Y89 6Y96

1:3 1:0 1:1 1:1.6 4:1 4:0 0:8 0:6 1.6:1 1:0 3.8:1 1.45:1

Level 4 findings with possible malignancy sorted by anatomic region with examples from radiology reports. GIT, gastrointestinal tract

the trauma scan. Most findings did not require immediate initiation of further diagnosis before hospital discharge. However, a significant proportion (43%) had incidental findings, which were clinically important, and adequate follow-up and treatment were necessary. Therefore, the frequency and relevance of incidental findings should not be underestimated. The greater proportion of incidental findings were seen on abdominal and pelvic CT scans, and these results are consistent with similar studies in the literature. Barrett et al.13 detected incidental findings in 53% of trauma patients who received CT scans, of whom 32% required urgent evaluation, while Devine et al.17 observed incidental findings from CT scans in 72% of 922 trauma patients. Not surprisingly, there were more findings in older patients. Since our population is becoming older, with elderly patients being more active in daily living and by these more often experiencing severe injuries,27 this will probably increase the detection of incidental findings. Approximately 45% of the incidental findings were detected in the group of patients older than 65 years. Nevertheless, 27.5% of these were found in patients younger than 45 years, and in particular, this age group constituted 29.4% of all Level 3 and 4 incidental findings. It is important to weigh the benefits and potentially harmful effects when considering requesting for a CT scan. Potential damage caused by radiation or kidney failure from contrast enhancement reagents has to be considered. The indication for CT scan should be carefully assessed. In the case of trauma scans, it has been shown that MSCT has a marked benefit for the survival of trauma patients.4 Even in young patients, who are at greater risk of developing long-term neoplastic effects, the benefits from high sensitivity, early, detection and fewer missed injuries might surpass the long-term risk of

neoplasms and cancer mortality after radiation exposure and therefore should be considered.28,29 Which roles are incidental findings playing in the discussion of balancing the risks and benefits of trauma scans? On the one hand, the benefits may even be greater when incidental findings were consequently considered in the management of trauma patients. In our study, we found 527 Level 3 (20% of the patients) and 168 Level 4 (7.1% of the patients) (Table 2) incidental findings, which needed contemporary follow-up or treatment. This is consistent with a study by Van Vugt et al.,30 who described incidental findings with high clinical relevance in 6.6% of their patient population; in 23.4% of the patients, incidental findings were of moderate relevance. Especially in those patients, an additional benefit of the CT scan by detecting and treating the incidental findings might exist. As the aim of the present study was to analyze the frequency and relevance of incidental findings, a further follow-up and the clinical consequences for the patients will be part of further research. However, we already identified that less than 30% of all Level 4 findings had a further follow-up during their hospital stay. Incidental findings increase the challenge and workload for clinicians, especially in the busy working atmosphere of the ED. The treatment of trauma patients is very complex, and the management of traumatic injuries is prioritized. Within the circumstances of trauma management, there are many incidental findings that are not important during the initial trauma care but still might be important for the patient’s future health. Therefore, the clinical relevance of an incidental finding has to be weighed against the patient’s actual injuries and also against the patient’s future health. Furthermore, clinicians working at the ED and treating trauma patients may not be confident in the treatment of

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an incidental finding since these diagnoses are usually undertaken by other departments. Early identification and treatment of incidental findings not only increase patients’survival but also decrease morbidity.31Y33 Moreover, knowledge of the presence of any finding might be helpful for the patient’s primary care physician or other health care providers. In contrast, the consequent follow-up and treatment of incidental findings in trauma patients could lead to unnecessary, costly, invasive procedures and, often, further exposure to radiation.34 It might also cause additional anxiety to the patients, without benefit.19 Furthermore, the health care system will be burdened with an additional workload for inconsequential abnormalities. Questions must be raised on how to most effectively deal with the incidental findings. Thus, further diagnostics and initiation of treatment need to be practicable in the daily routine of the trauma patient care. The establishment of a clear communication or notification system between the radiology department and ED is important. In addition, a precise description of the findings in the radiologist’s report and, if applicable, additional advice from radiology on how to proceed with an incidental finding can simplify the management. The lack of communication of incidental findings discovered on MSCT evaluation in trauma patients also presents a potential medicolegal concern. Physicians are responsible for the results of the diagnostics ordered and are obliged to inform patients of these results.13 Paluska et al.12 revealed in their study a significantly high rate of poor documentation of both incidental findings and the subsequent management or referral. For quality improvement, results should be communicated to patients and their physicians to ensure further evaluation. Preexisting knowledge needs to be determined, and a plan for further evaluation should be formulated before discharge or as an outpatient. In our study, we were able to develop a scoring system, classifying the actual relevance of each incidental finding, applicable in the daily routine of patient care. Further work should develop a matching algorithm regarding the required further diagnostics and treatment for incidental findings, applying an interdisciplinary approach with the corresponding medical disciplines. Such a feature might be introduced in the trauma documentation sets. Study limitations include the retrospective design at a single Level 1 trauma center, and therefore, this may not be applicable to all hospitals. There are regional differences in patient populations and therefore different health risk factors that increase the likelihood for cancer as well as cardiovascular and cerebrovascular diseases. We were not able to determine retrospectively whether the incidental findings were communicated to patients or family doctors and if any follow-up or treatment was performed. We did not follow up on patients with suspicious findings for malignancy and do not know how many finally turned out to be malignant. Conversely, we do not know how many of the patients already had knowledge about the existence of lesions and diseases before the trauma scan. Therefore, we cannot completely determine the actual benefit. The number of incidental findings that have been reported either to the patients or to their family doctors as well as an evaluation of urgent initiation and treatment of Level 4 852

findings should be evaluated in a prospective study, for example, by applying the algorithm proposed in this article.

CONCLUSION In conclusion, we were able to demonstrate a significant number of incidental findings in our patient population, which need careful consideration for further investigations. Furthermore, we were able to introduce a scoring system, classifying the actual relevance of each incidental finding, applicable in the daily routine of patient care. The consequent handling of incidental findings may add an extra burden for trauma surgeons and emergency physicians but should lead to improvements in health care for the patients. Especially in trauma patients, the reviewing radiologist should pay attention to both the presence of traumatic injuries and the incidental findings and communicate both to the ordering physician. AUTHORSHIP M.R. and A.S. had full access to all the data in the study and contributed to all parts of the study. H.W. and S.W. contributed to the study design, data collection, and interpretation. T.L. contributed to the data analysis. F.W. und I.M. contributed to the study design, data analysis, and data interpretation. All authors contributed to the writing and critical revision of the manuscript.

DISCLOSURE The authors declare no conflicts of interest.

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Incidental findings in patients with multiple injuries: how to proceed?

Multislice computed tomography (MSCT) is the diagnostic criterion standard for the initial evaluation of patients with suspected multiple injuries. Be...
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