The Daily Sign-Out

Incidentalomas revisited

Dr. Bruce Friedman posted a thoughtful blog on Lab Soft News recently concerning "incidentalomas" ("How to Avoid the Risks of a CT Incidentaloma").  This post happened to coincide with a new working committee at my hospital commissioned with developing a virtual clinic for following patients who have incidental lung nodules discovered.

Perhaps unlike other sites, there are widely disseminated radiographic recommendations for following lung nodules (Fleishner criteria).  Of interest, a recent article found that despite widespread awareness of these criteria, actual incorporation of these criteria into practice has been found wanting--only around 50% of radiology practices actually used these recommendations in reports.  One issue that we will be challenged with is how to track these patients across multiple different providers for appropriate follow-up.  One model we are considering is already in place: using a breast "navigator" to follow-up patients with abnormal mammograms.  This issue arose recently because of a series of patients presented at our Tumor Board who had incidental lung nodules identified but were not followed appropriately and then were re-discovered with inoperable advanced stage disease months later.

This idea also came up just today in a conversation I was having with a urologist colleague regarding renal incidentalomas treated with cryoablation.  I recently diagnosed an incidentally discovered 2.5-cm mass in an 80-year-old woman on CT-guided needle biopsy as an muscle-predominant angiomyolipoma (mini-case report on its way!).  For better or worse, the tumor was ablated probable before it was even grossed!  But, to return to Dr. Friedman's post, what if the patient was simply observed with serial imaging?  The urologist was unaware of any recommendations similar to the Fleishner criteria for lung nodules.  If you, dear reader, know of any please post them in a comment.

Finally, today's email brought a "Published Ahead of Print" article from Journal of Thoracic Oncology on-- mediastinal incidentalomas.  This is a prospective study of 88 patients in which mediastinal lymphadenopathy was found as an incidental finding on CT scans for indications other than staging.  The title is a bit deceptive but the scenario is common.  The finding of incidental mediastinal lymph nodes on CT were characterized by multiple Naruke stations involved, relative small sizes of nodes (median ranging from 6 to 14 mm for all nodes), and coexistence with hilar adenopathy.  In this study, sarcoidosis was diagnosed by EBUS-FNA in 22% of patients and 2 patients developed lung cancer 2 years after initial finding.

While I concur with the basic premise of the post (i.e. that one shouldn't jump into a full-blown diagnostic work-up of an incidental finding), I think we should also insist on developing evidence-based criteria for managing these types of findings such as, Fleishner criteria for lung nodules.

Disruptive Integration and Health Care

When Disruptive Integration Comes to Health Care

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Interesting article containing an interview with Dr. Jason Hwang co-author of The Innovator’s Prescription: A Disruptive Solution for Health Care (McGraw-Hill, 2009).

It got me thinking about niches where "disruptive innovation" may occur in laboratory medicine and pathology.  Please share any thoughts you may have--let's get a conversation started about this!

One area is lab testing for wellness or serial monitoring of chronic diseases managed on an outpatient basis.  The traditional hospital-based lab (like mine) just has not evolved to meet these needs.  Your lab may still be focused on inpatient lab testing.  Outreach efforts may want to incorporate marketing for these niches.

Another niche might be for outside or independent "second-opinion" diagnosis utilizing digitized slides either transmitted electronically or (so '90s!) dropped onto a CD-ROM.

Word!

Progress on integrated diagnostics for breast cancer

This will be the first in, hopefully, a series of blog entries that will chronicle my institution's effort to establish integrated diagnostic reporting for radiology-pathology testing for breast disease.

The lab admin director with whom I work is also enthusiastic about this project and we have talked informally about this for a couple of months while gathering information from various sources, especially from LabSoftNews.  The first person with whom we met was her counterpart in radiology.  This conversation was open-ended and basically explored our "visions" of what something like this might look like and then a rough idea of where we needed to go to get started.  Unfortunately, my counterpart in rads was on vacation for the following week but the plan was for me to meet with him as soon as he returned.  In the meantime, the lab and rads admin directors were planning to present to the hospital administration a list of necessary resources and a projection of revenue and value to the organization.

I am fortunate to be working with a radiologist, Dr. Jeff Mendell, who shares my enthusiam for pursuing this project.  We hope to build on an initiative that he started in December of 2008 where we began presenting a monthly breast radiology-pathology correlation conference.  After a few months, it was decided to make this part of a weekly tumor board, so once a month we devote one weekly conference to breast with rad-path correlation.  After meeting last week, we outlined five initial goals:

1. Perform "real-time" mammographic-ultrasound/pathologic biopsy correlation prior to final report.
2. Develop an integrated report combining radiographic findings, pathologic findings, an assessment of correlation, and recommendations for follow-up.
3. Identify the IS barriers to #2 since radiology and pathology currently report from different systems.
4. Discuss with our radiology and pathology colleagues.
5. Discuss with surgical, gynecologists, key internists, medical oncology, and radiation therapy colleagues to get additional ideas from end-users.
6. Identify measures of "success" of this effort.
7. Develop indicators to track outcomes.

The recent The Dark Daily audioconference on integrated diagnostics lacked objective measures for University of Kansas Medical Center's integrated diagnostics project.  I think it is fair to ask: what is the value of doing this?  Intuitively, it seems logical to pursue this in one form or another--but before an administration commits resources, one must be prepared to demonstrate what the tangible benefits will be.  We are currently working this out and I will blog on this at some point.  But, for now, we are looking at reducing out-migration of patients from our area, reducing patients lost to follow-up, reducing TAT from time of screening mammography to postbiopsy follow-up recommendation.

If anyone has their own experience, please share comments or email me offline and I will post as a blog.

Upcoming Audioconference: Integrated Breast Cancer Diagnostics

The Dark Report is presenting an audioconference on August 19, 2009 titled "Pathology and Radiology's Combined Future is Now at KU: How Integrated Breast Cancer Diagnostics are Improving Patient Care."

I am sponsoring this audioconference at my hospital.  The radiologists and I started a radiology-pathology monthly correlation conference last December as part of the radiology quality assurance process which has evolved into a monthly breast conference as part of our weekly Tumor Board Conference that now also attracts oncologists, surgeons, internists, nurses and others.  As I’m sure you are aware, the Dark Report, Dr. Bruce Friedman in LabSoftNews blog has written extensively on this for quite some time and, honestly, I thought it was so “out-there” that I was skeptical and dismissive.  My experience just with this conference and the fruitful, engaging, and instructive interaction with my colleagues opened my mind to the possibilites of integrating diagnostics, especially for breast and lung cancer diagnostics.

I'll be happy to share my summary and response to the audioconference.  Meanwhile, I encourage you pathologists to initiate a conversation with your radiology colleagues regarding integrated diagnostics.  We have much more in common that you might think--and this collaboration can really benefit our patients!