[abananarest]

This is the kind of stuff I try to unsee when Im reading bc it turns into 10 min of me looking stuff up and some hedgey differential. Lol.

But yea, when I was in training a lot of my attendings would just favor atypical hemang or some other benign thing. Especially in the absence of known malignancy.

[smfst7_929]

Thi is why some radiologists are slow enough that time seems to stop around them.  In my old group, I literally saw a guy spend an hour on a runoff study.  I’m sure all the incidentalomas seen on the runoff patient population cohort make his head spin.  Lot of OCD people out there in RADS who let perfection get in the way of just doing an overall good job. If you’re unsure, recommend followup and let that be that.  If every radiologist wasted time on stuff like this, we would be in such a critical shortage of radiologists that it would be national news.  So in a sense, you are doing the right thing by the patient and by the medical system in general by just recommending follow-up on unusual or atypical cases. 

[Unknown Member]

Quote from sartoriusBIG

 In my old group, I literally saw a guy spend an hour on a runoff study.  I’m sure all the incidentalomas seen on the runoff patient population cohort make his head spin.  Lot of OCD people out there in RADS who let perfection get in the way of just doing an overall good job. 

Rvu comp system was made for guys like this.

[ravanderheijden_47]

Quote from sartoriusBIG

Thi is why some radiologists are slow enough that time seems to stop around them.  In my old group, I literally saw a guy spend an hour on a runoff study.  I’m sure all the incidentalomas seen on the runoff patient population cohort make his head spin.  Lot of OCD people out there in RADS who let perfection get in the way of just doing an overall good job. If you’re unsure, recommend followup and let that be that.  If every radiologist wasted time on stuff like this, we would be in such a critical shortage of radiologists that it would be national news.  So in a sense, you are doing the right thing by the patient and by the medical system in general by just recommending follow-up on unusual or atypical cases. 

Forgiving my lack of experience, in your estimation would you consider this an ‘unusual’ case?

[Unknown Member]

It is atypical. Likely hemangioma but may be other benign fibro-osseous lesion. Consider 6 month follow up, next case.
 
Any rads resident has seen all types of atypical vertebral and liver hemangiomas.

[alex.nieto_484]

I would say something along the lines of “Nonspecific but likely benign based on lack of aggressive features. If clinically indicated follow-up to establish stability can be obtained in 3-6 months”.

[abananarest]

Quote from sartoriusBIG

Thi is why some radiologists are slow enough that time seems to stop around them.  In my old group, I literally saw a guy spend an hour on a runoff study.  I’m sure all the incidentalomas seen on the runoff patient population cohort make his head spin.  Lot of OCD people out there in RADS who let perfection get in the way of just doing an overall good job. If you’re unsure, recommend followup and let that be that.  If every radiologist wasted time on stuff like this, we would be in such a critical shortage of radiologists that it would be national news.  So in a sense, you are doing the right thing by the patient and by the medical system in general by just recommending follow-up on unusual or atypical cases. 

Yep agreed. Gotta know when to just let things go.

[Unknown Member]

Good discussion. Agree with most comments.
Also, depends on my spidey sense that day.

[reza800p_368]

Lots of OCDs in RADs. Many join academics but with increasing expectations at academics, they have a hard time adjusting.

[richarnp4215]

Follow it.

[ravanderheijden_47]

Thanks everyone

[Unknown Member]

NickF I think you can take solace in that your question is a good one, and it is an issue we all deal with. In fact, the closer you look at marrow on mri or ct, the more ditzels you will come across. There is a point where you blow them off vs follow them; with the threshold irrationally fluctuating depending on the time of day, coffee imbibed, other cases seen that day etc. If you recently missed a met, you will more likely follow it and visa versa.

[mgmacielendocrino_912]

Very common to see this if you read spine MRIs regularly. It’s probably atypical H but you have to recommend follow up (in few months) bc Mets can look similar.

[btomba_77]

Agree with follow –
 
As my mentor Mark Robbin would say “If you can’t name it you can’t ignore it.”
 
 
So for me it would get a short term follow-up in 4-6 months unless patient had history of malignancy and therapy/surgical options depended on knowing.

[Unknown Member]

The vast majority are nothing. Is there any published study on the incidence of malignancy in a solitary nonspecific marrow lesion such as this, stratified by age and history of primary tumor?

[benoit.elens]

These are fairly common and this will generate a lot of follow-ups.  You guys follow all of them?  Often times, see them concurrently with normal-appearing hemangiomas which increases confidence that they are likely benign.  Maybe I should start following all to mitigate risk?

[bluepn4078]

Agree with above, once I start seeing these alongside more typical hemangiomas, I just say typical and presumed atypical hemangiomas, but I suppose in this day and age of cya, an easy 3-6 month follow up and thank you for the rvus will suffice.

[22002469]

Fairly common but a decent % of the time we can get out of a follow up with a prior MR (or CT abd/pelvis) and prove it was there before. Agree if other classic hemangiomas and one atypical Im more likely to let it go too.

If its truly just a T1 dark/T2 bright blob with no other clues youll certainly end up being OK most of the time if you ignore, but probably should short-term follow it at least once.

[benoit.elens]

Useful thread, I am a bit lax on CYA game to be honest and definitely learned something here.

[Unknown Member]

Is there any evidence that the simultaneous presence of typical hemangiomas would increase the likelihood of an atypical hemangioma? I mean, are they associated?

[xavierpanchana_510]

Surprised so many of you follow these. I don’t even mention half of them.

[22002469]

Generally speaking if someone has 1 hemangioma, they will often (not always of course) have a few. I presume this is true of typical and atypical, I see them simultaneously all the time. 
 
So if you have 4 lesions and 3 are clearly typical hemangiomas and the 4th is one of these indeterminate “probable” atypical hemangioma, I think it’s reasonable to sway even more towards benign hemangioma. Of course none of this is certain, someone could have 3 typical hemangiomas and still get an early met.
 
But we’re talking probabilities here. If it’s a single solitary lesion, maybe its 97-98%+ benign. If its the 4th and the other 3 are obviously hemangiomas, maybe its 99+% benign (numbers made up of course).
 
At some point anything else becomes unlikely enough it starts to make sense to let it go when entirely incidental.
 
I don’t think there are hard and fast rules but people use their experience as well. When in doubt, I would short term follow once after doing a search for prior MR and CTs. 

 

[benoit.elens]

Do atypical hemangiomas on MRI have a similar appearance to typical on CT?

[22002469]

Sometimes yes, sometimes no.

If classic hemangioma look on CT youre all set.

Even if not classic but something similar size and same location on a CT from a year or more ago, also no need to follow.

Can avoid following most of these if you are paying attention and tend to get patients with prior imaging.

[22002469]

Indeterminate but likely benign, favor fat poor hemangioma.
 
In the absence of a history of malignancy, options are CT (confirm corduroy appearance) or short term follow up MRI 3-4 months. Young female probably just a f/u MRI OK.
 
Incorrect conclusions would be:
— Entirely ignoring/doing nothing
— Doing a full onc workup/biopsy.