Radiologists Differ on Follow-Up Guidance of Incidental Cysts

A lack of uniformity in the best way to approach incidental cysts is leading to wide variation in follow-up imaging guidance, some of which is causing problems.

In a single-center study published June 23 in the Journal of the American College of Radiology, a team of investigators from Brigham and Women’s Hospital said that while an increase in cross-sectional imaging has led to the detection of more incidental pancreatic cysts, radiologists differ on the next steps.

Greater identification is beneficial since these cysts are largely difficult-to distinguish, but there is no agreed upon set of guidelines for providers to use. This lack of consistency has led to much discussion, but little consensus to date.

To determine the impact of having no specified guidelines, the team, led by Neena Kapoor, M.D., a radiologist with Brigham and Women’s, examined 2,872 reports that included imaging recommendations for small focal cystic pancreatic lesions (FCPLs). From their analysis, they found there is wide variation among abdominal imaging providers on follow-up recommendations.

“Our work adds to the growing body of literature showing that there is inter-radiologist variation in recommendations for follow-up imaging, which may impact quality and patient experience of care, as well as downstream imaging costs,” the team said.

Overall, the team examined abdominal CTs and MRIs captured between July 2016 and June 2018. They focused on reports that had pancreatic cysts of less than 1.5 cm, ultimately identifying 708. Most patients – 60 percent – were women, and nearly as many – 59.3 percent – had only one cyst.

Based on their analysis, the team identified a 24.7-percent follow-up recommendation rate, confirming findings from previous studies. But, at the same time, they saw little consistency within providers from their institution. Among individual providers, follow-up recommendation rates of abdominal imagers in their department ranged from 25.3 percent to 85.3 percent. More consistent recommendation behavior came from providers in emergency and oncology imaging.

“The reasons for this variation are likely multi-factorial and at least partly reflect lack of agreement among various specialties on this topic, as reflected in the differences between the various professional society guidelines regarding the imaging management of pancreatic cysts,” they said. “In addition to differences in guidelines, evidence suggests that expert clinicians can often disagree with some of the specific recommendations embedded in guidelines.”

Kapoor’s team also saw that follow-up rates were someone lower among older patients while providers were more likely to suggest follow-up imaging on findings linked to main duct dilation and separation.

The team did note that, as a single-institution study, their findings could be specific to their facility. But, the discrepancy in follow-up recommendations was so great, additional research is warranted.

“There is significant inter-radiologist variation in follow-up recommendations for small pancreatic cysts, even after adjusting for various patient- and cyst-specific imaging features,” the team concluded. “Further research is needed to determine which targeted interventions can lead to decreases in unwarranted variation in radiologist recommendations, which may ultimately improve patient care and outcomes.”

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