How Do You Solve a Problem Like Incidentalomas?

Leonard Berlin, MD, FACR


Appl Radiol. 2013;42(2):10-12. 

In This Article

Abstract and Introduction


How do you solve a problem like Maria Incidentalomas?

When I'm with her, I'm confused,

Out of focus and bemused.

(With apologies to) Oscar Hammerstein, Sound of Music, 1959


We know certain facts about incidentalomas. We know what they are: incidentally discovered masses or lesions, detected by computed tomography (CT), magnetic resonance imaging (MRI), or other imaging examinations performed for an unrelated reason.[1] We know why incidentalomas are increasing: The number of CT exams performed in the United States has increased geometrically over the decades, rising from 3 million annually in 1980 to close to 80 million annually currently, along with remarkable improvement in spatial and contrast resolution on newer-generation CT scanning equipment.[2] We know that up to 70% of persons undergoing screening CT colonography have at least one detectable incidentaloma.[3] We know incidentalomas are found in 34% of hemodynamically stable blunt trauma patients.[4] We know that 35% of patients undergoing CT for thoracolumbar blunt trauma injuries harbor incidentalomas.[5] We know that nodular incidentalomas are found in at least 25% of patients undergoing chest CT.[6] We know that incidentalomas occur in at least 40% of abdominal and pelvic CT exams obtained for research purposes.[7] We know incidentalomas are present in 49% of patients undergoing aortoiliac CT angiography prior to aortic valve repair.[8] We know that incidentalomas are found in up to 50% of the lungs on CT exams of the chest, up to 15% in the kidneys and liver on abdominal CTs, and up to 67% in the thyroid gland on neck ultrasound exams.[9] And we know that the chance that an incidentaloma found in any of these exams could represent a lethal carcinoma is < 1%.[9]

We also know that radiologists are increasingly facing a dilemma: If there is reasonable belief that the incidentaloma is of no clinical significance, then mentioning it in a radiologic report will lead to a cascade of costly tests, sometimes resulting in serious complications. However, if radiologists decide not to mention the incidentaloma, and, in the unlikely event it later turns out to have been an early carcinoma and the patient's health has been jeopardized, medical malpractice litigation could well ensue.

But what we do not know is: How do we solve the problem of incidentalomas?