Incidental Findings On Imaging: When Ignoring Them Is Malpractice

Three years later, you are diagnosed with kidney cancer — now Stage III, now requiring aggressive treatment, now with a dramatically different prognosis than it would have had if someone had acted on that finding three years ago.

This scenario — and variations of it involving the lungs, liver, lymph nodes, adrenal glands, thyroid, and other organs — happens thousands of times each year in the United States. It has a clinical name: an incidental finding, sometimes called an “incidentaloma.” And when a physician or hospital fails to act on it, the consequences can be devastating and legally actionable.

What Is an Incidental Finding?

An incidental finding is an unexpected abnormality discovered during a medical imaging study that was ordered for a different reason. The term “incidentaloma” is commonly used when the finding is a mass or lesion — a nodule on the lung found during a chest X-ray for a broken rib, a lesion on the liver spotted during an abdominal CT for appendicitis, a thyroid nodule noticed on an ultrasound of the neck.

Incidental findings are not rare. As imaging technology has become more sensitive and more widely used, incidental findings are identified in a substantial percentage of all imaging studies. The critical question is never whether the finding was expected. The critical question is whether the physician receiving that report took appropriate action.

The Standard of Care for Incidental Findings

The medical and radiological communities have developed specific evidence-based guidelines for the management of common incidental findings. These include:

• Lung nodules: The Fleischner Society guidelines provide detailed recommendations for the management of incidentally discovered pulmonary nodules based on size, patient risk factors, and nodule characteristics — specifying when CT follow-up is needed, how quickly, and when biopsy should be considered.
• Liver lesions: The American College of Radiology (ACR) LI-RADS system and other guidelines specify how to characterize incidental liver findings and what follow-up imaging or biopsy is required.
• Adrenal incidentalomas: Guidelines from endocrinology societies provide specific workup recommendations for adrenal masses discovered incidentally, including hormonal testing and size-based criteria for surgical consultation.
• Thyroid nodules: The American Thyroid Association and ACR TIRADS guidelines classify incidental thyroid nodules and specify which require ultrasound follow-up or fine needle aspiration.
• Renal masses: The ACR and urology guidelines provide criteria for evaluating incidental kidney findings and determining when biopsy, repeat imaging, or urologic consultation is indicated.

When a radiologist identifies a significant incidental finding, the standard of care requires that the finding be clearly communicated in the radiology report, often with a specific recommendation for follow-up. When the ordering physician receives that report, the standard of care requires that the finding be addressed — communicated to the patient, referred to an appropriate specialist, or scheduled for follow-up imaging on the timeline the guidelines specify.

Failure at any point in this chain — the radiologist who buries the finding in the last sentence of a lengthy report without flagging it, the primary care physician who never reads the report, the specialist who receives the referral and lets it sit — can result in a delayed cancer diagnosis that causes irreversible harm.

How Incidental Finding Failures Lead to Malpractice

The legal framework for these cases is the same as any delayed diagnosis malpractice claim: a physician departed from the standard of care, that departure caused a delay in diagnosis, and the delay caused harm that would not have occurred had the standard been met.

In incidental finding cases, we look at several specific failure patterns:

• Radiologist failure: Did the radiologist identify the finding but fail to give it appropriate prominence in the report? Did the report include a specific recommendation for follow-up that the ordering physician was obligated to act on?
• Communication breakdown: Was the abnormal finding communicated to the patient? Did the ordering physician have a system in place to track abnormal imaging results and ensure follow-up occurred?
• Physician failure to act: Did the ordering physician receive a report flagging an incidental finding and fail to order follow-up, refer to a specialist, or inform the patient?
• Hospital system failure: Did the hospital or medical practice lack adequate systems for tracking and following up on abnormal imaging results?

In Pennsylvania, medical malpractice cases based on delayed cancer diagnosis — including those arising from ignored incidental findings — have resulted in substantial recoveries for patients and families. The law does not require that the cancer be immediately apparent. It requires that the physician meet the standard of care in responding to what the imaging showed.

The Argument Against Acting on Incidental Findings — and Why It Fails

Some in the medical community have argued that incidental findings create unnecessary anxiety, lead to over-testing, and can sometimes cause harm through invasive follow-up procedures that turn out to be unnecessary. This argument — that physicians should be permitted to ignore or minimize incidental findings to avoid over-medicalization — has been used to justify inaction in cases where action was required.

The argument fails for a simple reason: medical guidelines exist precisely to distinguish between findings that require action and findings that can be safely observed or ignored. A physician who uses the theoretical concern about over-testing as a reason to do nothing about a 2-centimeter lung nodule in a 60-year-old smoker is not exercising clinical judgment. That physician is abandoning the patient.

The guidelines are not a burden. They are the standard of care. And they exist because the evidence shows that following them saves lives.

What to Do If You Believe an Incidental Finding Was Ignored

If you or a family member received an imaging study and were later diagnosed with a cancer or serious condition that may have been visible as an incidental finding on an earlier scan, here is what to do:

• Request copies of all imaging reports — not just the most recent ones. Radiology reports from prior CT scans, chest X-rays, MRIs, and ultrasounds will show what was seen and what follow-up, if any, was recommended.
• Request the actual imaging files, not just the reports. The images themselves can be reviewed by an independent radiologist to determine what was visible and when.
• Document all communication — or lack of it — from the ordering physician about the imaging results.
• Do not assume the statute of limitations has run. Pennsylvania’s discovery rule may toll the limitations period from when you knew or should have known about the negligence — which may be the date of your cancer diagnosis, not the date of the original scan.

About Lupetin & Unatin, LLC

Lupetin & Unatin is a boutique medical malpractice firm based in Pittsburgh, Pennsylvania, representing patients and families throughout the state. We have extensive experience handling delayed cancer diagnosis cases, including cases involving ignored or unfollowed incidental imaging findings. Our attorneys are Fellows of the American College of Trial Lawyers and have been recognized by Super Lawyers and Best Lawyers in America.

We handle all cases on a contingency fee basis — no fee unless we recover for you.