Incidentaloma

In medicine, an incidentaloma is a tumor (-oma) 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.^[1]

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.

Adrenal incidentaloma

In incidental findings of adrenal gland tumors, a dexamethasone suppression test is often used to detect cortisol excess, and metanephrines or catecholamines 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 or pheochromocytoma.^[2] Hormonal evaluation includes:^[3]

• 1-mg overnight dexamethasone suppression test
• 24-hour urinary specimen for measurement of fractionated metanephrines and catecholamines
• Blood plasma aldosterone concentration and plasma renin activity, if hypertension is present

On CT scan, benign adenomas typically are of low radiographic density (due to fat content) and show 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^[3]

Renal incidentaloma

Most renal cell carcinomas are now found incidentally.^[4] Tumors less than 3 cm in diameter less frequently have aggressive histology.^[5]

Pituitary incidentaloma

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.^[6] When encountering such a lesion, long term surveillance has been recommended.^[7] Also, a baseline pituitary hormonal function test should be done, including measurements of serum levels of TSH, prolactin, IGF-1 (as a test of growth hormone activity), adrenal function (i.e. 24 hour urine cortisol, dexamethasone suppression test), testosterone in men, and estradiol in amenorrheic women.

Thyroid incidentaloma

Incidental thyroid masses may be found in 9% of patients undergoing bilateral carotid duplex ultrasonography.^[8]

Some experts^[9] 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.^[10] Ultrasonographic markers of malignancy are:^[11]

• solid hypoechoic appearance
• irregular or blurred margins
• intranodular vascular spots or pattern
• microcalcifications

Parathyroid incidentaloma

Incidental parathyroid masses may be found in 0.1% of patients undergoing bilateral carotid duplex ultrasonography.^[8]

Pulmonary nodule

Studies of whole body screening computed tomography find abnormalities in the lungs of 14% of patients.^[1] Clinical practice guidelines by the American College of Chest Physicians advise on the evaluation of the solitary pulmonary nodule.^[12]

Others

Other organs that can harbor incidentalomas include the liver (often a hemangioma).

Scientific criticism

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."^[13] The underlying pathology shows no unifying histological concept.

See also

• Overdiagnosis — Some incidentalomas represent overdiagnosis of a very slowly growing cancer that would never cause the patient any harm

References