, an incidentaloma
is a tumor
) found by coincidence (incidental
) without clinical symptoms
or suspicion. It is a common problem: up to 7% of all patients over 60 may harbor a benign growth, often of the adrenal gland
, which is detected when diagnostic imaging
is used for the analysis of unrelated symptoms. With the increase of "whole-body CT scanning
" as part of health screening programs, the chance of finding incidentalomas is expected to increase. 37% of patients receiving whole-body CT scan
may have abnormal findings that need further evaluation.
When faced with an unexpected finding on diagnostic imaging, the clinician faces the challenge to prove that the lesion is indeed harmless. Often, some other tests are required to determine the exact nature of an incidentaloma.
In adrenal gland tumors, a dexamethasone
suppression test is often used to detect cortisol
excess, and metanephrines
for excess of these hormones. Tumors under 3 cm are generally considered benign and are only treated if there are grounds for a diagnosis of Cushing's syndrome
Hormonal evaluation includes:
- 1-mg overnight dexamethasone suppression test
- 24-hour urinary specimen for measurement of fractionated metanephrines and catecholamines
- plasma aldosterone concentration and plasma renin activity if hypertension is present
On CT scan, benign adenomas typically are low radiographic density (due to fat content) and rapid washout of contrast medium (50% or more of the contrast medium washes out at 10 minutes). If the hormonal evaluation is negative and imaging suggests benign, followup should be considered with imaging at 6, 12, and 24 months and repeat hormonal evaluation yearly for 4 years
Most renal cell cancers are now found incidentally. Tumors less than 3 cm in diameter less frequently have aggressive histology
Autopsy series have suggested that pituitary incidentalomas may be quite common. It has been estimated that perhaps 10% of the adult population may harbor such endocrinologically inert lesions. When encountering such a lesion, long term surveillance has been recommended. Also baseline pituitary hormonal function needs to be checked, including measurements of serum levels of TSH
(as a test of growth hormone
activity), adrenal function (i.e. 24 hours urine corticol,dexamethasone suppression test). teststerone in men and estradial in amenorrheic women.
masses may be found in 9% of patients undergoing bilateral carotid duplex ultrasonography.
Some experts recommend that nodules > 1 cm (unless the TSH is suppressed) or those with ultrasonographic features of malignancy should be biopsied by fine needle aspiration. Computed tomography is inferior to ultrasound for evaluating thyroid nodules. Ultrasonographic markers of malignancy are:
- solid hypoechoic appearance
- irregular or blurred margins
- intranodular vascular pattern
- Irregular margins
- intranodular vascular spots
masses may be found in 0.1% of patients undergoing bilateral carotid duplex ultrasonography.
Studies of whole body screening computed tomography
find abnormalities in the lungs of 14% of patients.
Clinical practice guidelines
by the American College of Chest Physicians
advise on the evaluation of the solitary pulmonary nodule
Other organs that can harbor incidentalomas include the liver
(often a hemangioma
The concept of the incidentaloma has been criticized, as such lesions do not have much in common other than the history of an incidental identification and the assumption that they are clinically inert. It has been proposed just to say that such lesions have been "incidentally found." The underlying pathology shows no unifying histological concept.