Incidentaloma

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In medicine, an incidentaloma is a tumor (-oma) found by coincidence (incidentally) without clinical symptoms or suspicion. Like other types of incidental findings, it is found during the course of examination and imaging for other reasons. 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] As many incidentally found lesions may never cause disease, there is a risk of overdiagnosis.

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[edit]

Incidental adrenal masses on imaging are common (0.6 to 1.3% of all abdominal CT). Differential diagnosis include adenoma, myelolipoma, cyst, lipoma, pheochromocytoma, adrenal cancer, metastatic cancer, hyperplasia, and tuberculosis.[2] Some of these lesions are easily identified by radiographic appearance; however, it is often adenoma vs. cancer/metastasis that is most difficult to distinguish. Thus, clinical guidelines have been developed to aid in diagnosis and decision-making.[3]

The first considerations are size and radiographic appearance of the mass. Suspicious adrenal masses or those ≥4 cm are recommended for complete removal by adrenalectomy. Masses <4 cm may also be recommended for removal if they are found to be hormonally active, but are otherwise recommended for observation.[4] All adrenal masses should receive hormonal evaluation. Hormonal evaluation includes:[5]

  • 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 lesion, follow up should be considered. Imaging at 6, 12, and 24 months and repeat hormonal evaluation yearly for 4 years is often recommended,[5] but there exists controversy about harm/benefit of such screening as there is a high subsequent false-positive rate (about 50:1) and overall low incidence of adrenal carcinoma.[6]

Renal incidentaloma[edit]

Most renal cell carcinomas are now found incidentally.[7] Tumors less than 3 cm in diameter less frequently have aggressive histology.[8]

Pituitary incidentaloma[edit]

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.[9] When encountering such a lesion, long term surveillance has been recommended.[10] 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[edit]

Incidental thyroid masses may be found in 9% of patients undergoing bilateral carotid duplex ultrasonography.[11]

Some experts[12] 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.[13] Ultrasonographic markers of malignancy are:[14]

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

Parathyroid incidentaloma[edit]

Incidental parathyroid masses may be found in 0.1% of patients undergoing bilateral carotid duplex ultrasonography.[11]

Pulmonary nodule[edit]

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.[15]

Lumbosacral Spine[edit]

The increasing use of MRI, often during diagnostic work-up for back or lower extremity pain, has led to a significant increase in the number of incidental findings that are most often clinically inconsequential. The most common include:[16]

In some cases, the above findings may actually be significant findings and associated with symptoms or disease.

Others[edit]

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

Scientific criticism[edit]

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

References[edit]

  1. ^ a b Furtado CD, Aguirre DA, Sirlin CB, et al. (2005). "Whole-body CT screening: spectrum of findings and recommendations in 1192 patients". Radiology 237 (2): 385–94. doi:10.1148/radiol.2372041741. PMID 16170016. 
  2. ^ Cook DM (December 1997). "Adrenal mass". Endocrinol. Metab. Clin. North Am. 26 (4): 829–52. PMID 9429862. 
  3. ^ "2009 AACE/AAES Guidelines, Adrenal incidentaloma". 
  4. ^ Grumbach MM, Biller BM, Braunstein GD, et al. (2003). "Management of the clinically inapparent adrenal mass ("incidentaloma")". Ann. Intern. Med. 138 (5): 424–9. doi:10.7326/0003-4819-138-5-200303040-00013. PMID 12614096. 
  5. ^ a b Young WF (2007). "Clinical practice. The incidentally discovered adrenal mass". N. Engl. J. Med. 356 (6): 601–10. doi:10.1056/NEJMcp065470. PMID 17287480. 
  6. ^ Cawood TJ, Hunt PJ, O'Shea D, Cole D, Soule S (October 2009). "Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink?". Eur. J. Endocrinol. 161 (4): 513–27. doi:10.1530/EJE-09-0234. PMID 19439510. 
  7. ^ Reddan DN, Raj GV, Polascik TJ (2001). "Management of small renal tumors: an overview". Am. J. Med. 110 (7): 558–62. doi:10.1016/S0002-9343(01)00650-7. PMID 11343669. 
  8. ^ Remzi M, Ozsoy M, Klingler HC, et al. (2006). "Are small renal tumors harmless? Analysis of histopathological features according to tumors 4 cm or less in diameter". J. Urol. 176 (3): 896–9. doi:10.1016/j.juro.2006.04.047. PMID 16890647. 
  9. ^ Hall WA, Luciano MG, Doppman JL, Patronas NJ, Oldfield EH (1994). "Pituitary magnetic resonance imaging in normal human volunteers: occult adenomas in the general population". Ann. Intern. Med. 120 (10): 817–20. doi:10.7326/0003-4819-120-10-199405150-00001. PMID 8154641. 
  10. ^ Molitch ME (1997). "Pituitary incidentalomas". Endocrinol. Metab. Clin. North Am. 26 (4): 725–40. doi:10.1016/S0889-8529(05)70279-6. PMID 9429857. 
  11. ^ a b Steele SR, Martin MJ, Mullenix PS, Azarow KS, Andersen CA (2005). "The significance of incidental thyroid abnormalities identified during carotid duplex ultrasonography". Archives of surgery (Chicago, Ill. : 1960) 140 (10): 981–5. doi:10.1001/archsurg.140.10.981. PMID 16230549. 
  12. ^ Castro MR, Gharib H (2005). "Continuing controversies in the management of thyroid nodules". Ann. Intern. Med. 142 (11): 926–31. doi:10.7326/0003-4819-142-11-200506070-00011. PMID 15941700. 
  13. ^ Shetty SK, Maher MM, Hahn PF, Halpern EF, Aquino SL (2006). "Significance of incidental thyroid lesions detected on CT: correlation among CT, sonography, and pathology". AJR. American journal of roentgenology 187 (5): 1349–56. doi:10.2214/AJR.05.0468. PMID 17056928. 
  14. ^ Papini E, Guglielmi R, Bianchini A, et al. (2002). "Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features". J. Clin. Endocrinol. Metab. 87 (5): 1941–6. doi:10.1210/jc.87.5.1941. PMID 11994321. 
  15. ^ Gould MK, Fletcher J, Iannettoni MD, et al. (2007). "Evaluation of Patients With Pulmonary Nodules: When Is It Lung Cancer?: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)". Chest 132 (3_suppl): 108S–130S. doi:10.1378/chest.07-1353. PMID 17873164. 
  16. ^ Park HJ, Jeon YH, Rho MH, et al. (May 2011). "Incidental findings of the lumbar spine at MRI during herniated intervertebral disk disease evaluation". AJR Am J Roentgenol 196 (5): 1151–5. doi:10.2214/AJR.10.5457. PMID 21512084. 
  17. ^ Mirilas P, Skandalakis JE (2002). "Benign anatomical mistakes: incidentaloma". The American surgeon 68 (11): 1026–8. PMID 12455801.