As proponents of raising the awareness of the potential consequences of overdiagnosis, we are pleased to see Dr. Fitzgerald’s acknowledgement of the challenges that the diagnosis of intracranial aneurysms presents. We further agree that language serves as the foundation of radiology. In contradistinction to Dr. Fitzgerald, we believe that altering the nomenclature of intracranial aneurysms represents the most viable option available to mitigate both the stigma and potential interventions sought by patients presenting with intracranial aneurysms.
Guidelines for nomenclature exist to more accurately characterize a given process. For example, a multi-organizational consensus statement on spine nomenclature recently recharacterized terminology related to lumbar spine pathology . The need to further clarify terms like “bulge” and “herniation” naturally places current spine reports at odds with those adhering to older guidelines. However, choosing not to adopt these new guidelines to prevent confusion ignores the rationale behind the impetus for change—providing a more accurate description of a given process.
Likewise, an interdisciplinary 2002 consensus statement opted to rename the superficial femoral vein as simply the femoral vein . The original nomenclature derived from classical anatomic descriptors: the common femoral vein bifurcated into deep and superficial branches; hence, they were termed as such. However, this generated confusion as the “superficial femoral vein” represents part of the deep venous system. Although this nomenclature represented a classic medical school test question, the ambiguity present in the name could potentially affect patient care, as incomplete understanding could lead to undertreatment of deep venous thrombosis. The need to mitigate this confusion led to the change in nomenclature.
Breast cancer presents a close parallel to aneurysms. Both are complex, heterogeneous entities with a wide variety of potential outcomes that are associated with certain diagnostic features. The nomenclature for breast cancer includes ductal carcinoma in situ (DCIS), which is distinguished by its unique histology and lower risk . When patients consult online resources about DCIS, they are generally reassured that DCIS is less dangerous than invasive breast cancer. In addition, the designation of DCIS as a distinct entity has spurred research into its specific pathology.
As an alternative to changing the nomenclature of aneurysms, Dr. Fitzgerald suggests merely including a statement regarding the risk of rupture. However, that statistic is meaningless by itself. Risk of rupture must always be weighed against consequences of rupture, risk of treatment, and benefits of treatment. That is a complex discussion best left to the patients and the referring physicians. Dr. Fitzgerald also suggests not reporting small aneurysms at all, effectively ending such a discussion before it can start. But why should the management of small aneurysms be settled by the radiologist, rather than by the patient?
Given the potential cascade of interventions spawned by the diagnosis of an intracranial aneurysm, both our lexicon and our measurements should reflect the significance of the finding. We therefore proposed the term “vascular outpouching of indeterminate relevance” as a potential solution to allow the radiologist to convey the significance of these sorts of vascular findings through verbiage as well as via a millimeter measurement. Like any nomenclature system, acceptance takes time and the supporting literature will be sparse. However, should radiologists choose to adopt this term, the body of literature will grow, which will prompt further debate and refinement regarding the subject. These steps serve as the precursors to a more formal consensus statement and the more widespread acceptance associated with these statements.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
References
1. Fardon D.F., Williams A.L., Dohring E.J., et. al.: Lumbar disc nomenclature: version 2.0. Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J 2014; 14: pp. 2525-2545.
2. Caggiati A., Bergan J.J., Gloviczki P., et. al.: Nomenclature of the veins of the lower limbs: an international disciplinary consensus statement. J Vasc Surg 2002; 36: pp. 416-422.
3. Feig S.A.: Overdiagnosis of breast cancer at screening is clinically insignificant. Acad Radiol 2015; 22: pp. 961-966. Epub 2015 Mar 18
4. Well C.J., O’Donoghue C., Ojeda-Fournier H., et. al.: Evolving paradigm for imaging, diagnosis, and management of DCIS. J Am Coll Radiol 2013; 10: pp. 918-923.