Incidentaloma
Encyclopedia
In medicine
, an incidentaloma is a tumor
(-oma) found by coincidence (incidental) without clinical symptom
s 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.
is often used to detect cortisol
excess, and metanephrine
s or catecholamine
s for excess of these hormone
s. 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
.
Hormonal evaluation includes:
On CT scan, benign adenoma
s 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
s are now found incidentally. Tumors less than 3 cm in diameter less frequently have aggressive histology
.
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, 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.
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:
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
.
(often a hemangioma
).
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, an incidentaloma is a tumor
Tumor
A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
(-oma) found by coincidence (incidental) without clinical symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s 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
Adrenal gland
In mammals, the adrenal glands are endocrine glands that sit atop the kidneys; in humans, the right suprarenal gland is triangular shaped, while the left suprarenal gland is semilunar shaped...
, which is detected when diagnostic imaging
Radiology
Radiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualized within the human body. Radiologists use an array of imaging technologies to diagnose or treat diseases...
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.
Adrenal incidentaloma
In incidental findings of adrenal gland tumors, a dexamethasone suppression testDexamethasone suppression test
The dexamethasone suppression test is designed to diagnose and differentiate among the various types of Cushing's syndrome and other hypercortisol states.It has also been used in the research of depression.-Physiology:...
is often used to detect cortisol
Cortisol
Cortisol is a steroid hormone, more specifically a glucocorticoid, produced by the adrenal gland. It is released in response to stress and a low level of blood glucocorticoids. Its primary functions are to increase blood sugar through gluconeogenesis; suppress the immune system; and aid in fat,...
excess, and metanephrine
Metanephrine
Metanephrine is a metabolite of epinephrine created by action of catechol-O-methyl transferase on epinephrine. An article in the Journal of the American Medical Association, 2002, indicated that the measurement of plasma free metanephrines is the best tool in the diagnosis of pheochromocytoma, an...
s or catecholamine
Catecholamine
Catecholamines are molecules that have a catechol nucleus consisting of benzene with two hydroxyl side groups and a side-chain amine. They include dopamine, as well as the "fight-or-flight" hormones adrenaline and noradrenaline released by the adrenal medulla of the adrenal glands in response to...
s for excess of these hormone
Hormone
A hormone is a chemical released by a cell or a gland in one part of the body that sends out messages that affect cells in other parts of the organism. Only a small amount of hormone is required to alter cell metabolism. In essence, it is a chemical messenger that transports a signal from one...
s. Tumors under 3 cm are generally considered benign and are only treated if there are grounds for a diagnosis of Cushing's syndrome
Cushing's syndrome
Cushing's syndrome is a hormone disorder caused by high levels of cortisol in the blood. This can be caused by taking glucocorticoid drugs, or by tumors that produce cortisol or adrenocorticotropic hormone or CRH...
or pheochromocytoma
Pheochromocytoma
A pheochromocytoma or phaeochromocytoma is a neuroendocrine tumor of the medulla of the adrenal glands , or extra-adrenal chromaffin tissue that failed to involute after birth and secretes excessive amounts of catecholamines, usually noradrenaline , and adrenaline to a lesser extent...
.
Hormonal evaluation includes:
- 1-mg overnight dexamethasone suppression test
- 24-hour urinary specimen for measurement of fractionated metanephrines and catecholamines
- Blood plasmaBlood plasmaBlood plasma is the straw-colored liquid component of blood in which the blood cells in whole blood are normally suspended. It makes up about 55% of the total blood volume. It is the intravascular fluid part of extracellular fluid...
aldosteroneAldosteroneAldosterone is a hormone that increases the reabsorption of sodium ions and water and the release of potassium in the collecting ducts and distal convoluted tubule of the kidneys' functional unit, the nephron. This increases blood volume and, therefore, increases blood pressure. Drugs that...
concentration and plasma reninReninRenin , also known as an angiotensinogenase, is an enzyme that participates in the body's renin-angiotensin system -- also known as the Renin-Angiotensin-Aldosterone Axis -- that mediates extracellular volume , and arterial vasoconstriction...
activity, if hypertension is present
On CT scan, benign adenoma
Adenoma
An adenoma is a benign tumor of glandular origin. Adenomas can grow from many organs including the colon, adrenal glands, pituitary gland, thyroid, prostate, etc. Although these growths are benign, over time they may progress to become malignant, at which point they are called adenocarcinomas...
s typically are of low radiographic density (due to fat content) and show rapid washout of contrast medium
Contrast medium
A medical contrast medium is a substance used to enhance the contrast of structures or fluids within the body in medical imaging...
(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
Renal incidentaloma
Most renal cell carcinomaRenal cell carcinoma
Renal cell carcinoma is a kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products. RCC is the most common type of kidney cancer in adults, responsible for approximately 80% of cases...
s are now found incidentally. Tumors less than 3 cm in diameter less frequently have aggressive histology
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
.
Pituitary incidentaloma
AutopsyAutopsy
An autopsy—also known as a post-mortem examination, necropsy , autopsia cadaverum, or obduction—is a highly specialized surgical procedure that consists of a thorough examination of a corpse to determine the cause and manner of death and to evaluate any disease or injury that may be present...
series have suggested that pituitary
Pituitary gland
In vertebrate anatomy the pituitary gland, or hypophysis, is an endocrine gland about the size of a pea and weighing 0.5 g , in humans. It is a protrusion off the bottom of the hypothalamus at the base of the brain, and rests in a small, bony cavity covered by a dural fold...
incidentalomas may be quite common. It has been estimated that perhaps 10% of the adult population may harbor such endocrinologically
Endocrinology
Endocrinology is a branch of biology and medicine dealing with the endocrine system, its diseases, and its specific secretions called hormones, the integration of developmental events such as proliferation, growth, and differentiation and the coordination of...
inert
Inert
-Chemistry:In chemistry, the term inert is used to describe a substance that is not chemically reactive.The noble gases were previously known as inert gases because of their perceived lack of participation in any chemical reactions...
lesions. When encountering such a lesion, long term surveillance has been recommended. Also, a baseline pituitary hormonal function test should be done, including measurements of serum levels of TSH
TSH
TSH may refer to:* Tanzanian shilling, the currency of Tanzania* Thyroid-stimulating hormone, a hormone synthesized and secreted by thyrotrope cells* Tshiuetin Rail Transportation, a Canadian railway between Labrador and Quebec...
, prolactin
Prolactin
Prolactin also known as luteotropic hormone is a protein that in humans is encoded by the PRL gene.Prolactin is a peptide hormone discovered by Henry Friesen...
, IGF-1 (as a test of growth hormone
Growth hormone
Growth hormone is a peptide hormone that stimulates growth, cell reproduction and regeneration in humans and other animals. Growth hormone is a 191-amino acid, single-chain polypeptide that is synthesized, stored, and secreted by the somatotroph cells within the lateral wings of the anterior...
activity), adrenal function (i.e. 24 hour urine cortisol, dexamethasone suppression test), testosterone
Testosterone
Testosterone is a steroid hormone from the androgen group and is found in mammals, reptiles, birds, and other vertebrates. In mammals, testosterone is primarily secreted in the testes of males and the ovaries of females, although small amounts are also secreted by the adrenal glands...
in men, and estradiol
Estradiol
Estradiol is a sex hormone. Estradiol is abbreviated E2 as it has 2 hydroxyl groups in its molecular structure. Estrone has 1 and estriol has 3 . Estradiol is about 10 times as potent as estrone and about 80 times as potent as estriol in its estrogenic effect...
in amenorrheic women.
Thyroid incidentaloma
Incidental thyroidThyroid
The thyroid gland or simply, the thyroid , in vertebrate anatomy, is one of the largest endocrine glands. The thyroid gland is found in the neck, below the thyroid cartilage...
masses may be found in 9% of patients undergoing bilateral carotid duplex ultrasonography.
Some experts recommend that nodules > 1 cm (unless the TSH
Thyroid-stimulating hormone
Thyrotrophin-stimulating hormone is a peptide hormone synthesized and secreted by thyrotrope cells in the anterior pituitary gland, which regulates the endocrine function of the thyroid gland.- Physiology :...
is suppressed) or those with ultrasonographic features of malignancy should be biopsied by fine needle aspiration
Needle aspiration biopsy
Needle aspiration biopsy , may refer to fine needle aspiration cytology , fine needle aspiration biopsy and fine needle aspiration , is a diagnostic procedure sometimes used to investigate superficial lumps or masses...
. Computed tomography
Computed tomography
X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...
is inferior to ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
for evaluating thyroid nodules. Ultrasonographic markers of malignancy are:
- 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.Pulmonary nodule
Studies of whole body screening computed tomographyComputed tomography
X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...
find abnormalities in the lungs of 14% of patients.
Clinical practice guidelines by the American College of Chest Physicians
American College of Chest Physicians
The American College of Chest Physicians is a medical organization in the United States consisting of physicians and non-physician specialists in the field of chest medicine, which includes pulmonology, thoracic surgery, and critical care medicine....
advise on the evaluation of the solitary pulmonary nodule
Solitary pulmonary nodule
In radiology, a solitary pulmonary nodule or coin lesion is a mass in the lung smaller than 3 centimeters in diameter. It can be an incidental finding found in up to 0.2% of chest X-rays and around 1% of CT scans....
.
Others
Other organs that can harbor incidentalomas include the liverLiver
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
(often a hemangioma
Hemangioma
A hemangioma of infancy is a benign self-involuting tumor of endothelial cells, the cells that line blood vessels. It usually appears during the first weeks of life and sometimes resolves by age 10. In more severe case hemangioma may have permanency, if not treated by a physician...
).
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." The underlying pathology shows no unifying histological concept.See also
- OverdiagnosisOverdiagnosisOverdiagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's lifetime. Overdiagnosis is the least familiar side effect of testing for early forms of disease – and, arguably, the most important...
— Some incidentalomas represent overdiagnosis of a very slowly growing cancer that would never cause the patient any harm