Q&A: Diagnosis Following A Typical Incidental Finding

With increasing utilization of cross-sectional imaging such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), the detection rates of incidental lesions have increased over time. While most incidental lesions can be left alone as they will have no clinical consequences, some are pathologies (eg, cancers, pseudoaneurysms) that could have an impact on patient outcomes. This is also true with the use of x-rays.

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In this article:
Evaluation following incidental findings
MCQ: clinical scenario
MCQ: answer
MCQ: explanation

Evaluation following incidental findings

In most cases, following the incidental finding of a previously unsuspected lesion, an algorithmic approach for evaluating the incidental lesion is available. The goal of the evaluation would be to select those that require further management from those that can be left alone because they are of no clinical significance.

Thus, diagnostic approach is to differentiate the vast majority of those that require no further evaluation from those that require further management, or referral for management. If the lesion does not demonstrate features characteristic of a specific diagnosis at detection, dedicated imaging is performed. Based on the imaging features, the lesion is left alone as having no clinical consequences or triaged for further management that includes surveillance imaging, biopsy, or treatment targeted toward the suspected diagnosis.

MCQ: clinical scenario

A 48 year old female teacher has an x-ray taken because of a recurrent dry cough. It is noted incidentally that there is sclerosis, destruction and fragmentation. On examination it is noted that she has decreased pain sensation over her shoulder joint and upper limb area.

These features are suggestive of:

a) juvenile rheumatoid arthritis
b) syringomyelia
c) epidermolysis bullosa
d) bronchial carcinoma
e) infectious mononucleosis

MCQ: answer

The correct answer is B

MCQ: explanation

Syringomyelia is a fluid-filled, gliosis-lined cavity within the spinal cord. Most lesions are between C2 and T9; however, they can descend further down or extend upward into the brainstem (syringobulbia). A syrinx can represent a focal dilation of the central canal, or it may lie separately, within the spinal cord parenchyma.

In syringomyelia, decreased pain sensation and impaired position sense contribute to the massive destruction of the shoulder.

A syrinx can be asymptomatic and discovered incidentally, as in this case, or on spinal cord imaging. Other patients present with progressive central cord deficits that can include a prominent central pain syndrome in a segmental distribution

Magnetic resonance imaging (MRI) will typically identify the intramedullary cavity; gadolinium administration will increase the sensitivity of finding an associated tumor. Surgical decompression with fenestration and/or shunt placement is recommended for patients with neurologic deterioration or intractable central pain. Neurologic deficits usually stabilize after intervention and sometimes improve.

Reference(s)
1). UpToDate: Disorders affecting the spinal cord. Accessed ..20. Available online: https://www.uptodate.com/contents/disorders-affecting-the-spinal-cord