Incidental imaging finding


In medical or research imaging, an incidental finding is an unanticipated finding which is not related to the original diagnostic inquiry. As with other types of incidental findings, they may represent a diagnostic, ethical, and philosophical dilemma because the significance is unclear. While some coincidental findings may lead to beneficial diagnoses, others may lead to overdiagnosis in the form of unnecessary testing and treatment, i.e. the "cascade effect."
Incidental findings are common in imaging. For instance, around 1 in every 3 cardiac MRIs result in an incidental finding. Incidence is similar for chest CTs.
As the use of medical imaging increases, the chance of detecting incidental findings is expected to increase.

Adrenal

Incidental adrenal masses on imaging are common. Differential diagnosis include adenoma, myelolipoma, cyst, lipoma, pheochromocytoma, adrenal cancer, metastatic cancer, hyperplasia, and tuberculosis. 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. Although adrenal incidentalomas are common, they are not commonly cancerous - less than 1% of all adrenal incidentalomas are malignant.
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. All adrenal masses should receive hormonal evaluation. Hormonal evaluation includes:
On CT scan, benign adenomas typically are of low radiodensity. A radiodensity equal to or below 10 Hounsfield units is considered diagnostic of an adenoma. An adenoma also shows rapid radiocontrast washout. If the hormonal evaluation is negative and imaging suggests benign lesion, follow up may be considered. Imaging at 6, 12, and 24 months and repeat hormonal evaluation yearly for 4 years is often recommended, but there exists controversy about harm/benefit of such screening as there is a high subsequent false-positive rate and overall low incidence of adrenal carcinoma.

Brain

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, adrenal function, testosterone in men, and estradiol in amenorrheic women.

Thyroid and parathyroid

Incidental thyroid masses may be found in 9% of patients undergoing bilateral carotid duplex ultrasonography.
Some experts recommend that nodules > 1 cm 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:
Incidental parathyroid masses may be found in 0.1% of patients undergoing bilateral carotid duplex ultrasonography.
The American College of Radiology recommends the following workup for thyroid nodules as incidental imaging findings on CT, MRI or PET-CT:
FeaturesWorkup

Very likely ultrasonography
Multiple nodulesLikely ultrasonography
Solitary nodule in person younger than 35 years old
  • Likely ultrasonography if at least 1 cm large in adults, or for any size in children.
  • None needed if less than 1 cm in adults
    • Solitary nodule in person at least 35 years old
  • Likely ultrasonography if at least 1.5 cm large
  • None needed if less than 1.5 cm

    • Pulmonary

    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.

    Kidney

    Most renal cell carcinomas are now found incidentally. Tumors less than 3 cm in diameter less frequently have aggressive histology.
    A CT scan is the first choice modality for workup of solid masses in the kidneys. Nevertheless, hemorrhagic cysts can resemble renal cell carcinomas on CT, but they are easily distinguished with Doppler ultrasonography. In renal cell carcinomas, Doppler US often shows vessels with high velocities caused by neovascularization and arteriovenous shunting. Some renal cell carcinomas are hypovascular and not distinguishable with Doppler US. Therefore, renal tumors without a Doppler signal, which are not obvious simple cysts on US and CT, should be further investigated with contrast-enhanced ultrasound, as this is more sensitive than both Doppler US and CT for the detection of hypovascular tumors.

    Spinal

    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:
    Sometimes normally asymptomatic findings can present with symptoms and these cases when identified cannot then be considered as incidentalomas.

    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.