How Do You Solve a Problem Like Incidentalomas?

Leonard Berlin, MD, FACR


Appl Radiol. 2013;42(2):10-12. 

In This Article

Standard of Care

The standard of care to which physicians must adhere is defined as conduct that is "usual and customary in the local or national community, under the same or similar circumstances."[19] In formulating how radiologists should conduct themselves when they observe an incidentaloma, we must attempt to discover, usually by consulting the published scientific literature, whether there is a "usual and customary manner" in which other radiologists and medical facilities deal with incidentalomas. A perusal of medical literature reveals that there is no clear-cut unanimity on this issue. A recent report describing how radiologists at 3 major academic centers—Johns Hopkins University, New York University, and Stanford University—manage incidentalomas disclosed that there is anything but a consensus among them. The rate of agreement as to whether to report an incidentaloma seen on a CT scan ranged from 30% to 85%.[20] Not only was there lack of agreement among the academic institutions but also among radiologists in the same institution. A report from the University of Pittsburg disclosed that even when incidental findings that were not considered important enough to require medical follow up were discovered, patient notification was nevertheless almost always carried out because of "medico-legal concerns."[21]

Other articles have focused on the ethical issue of whether physicians who discover an incidentaloma on imaging studies of volunteers involved in research studies should or should not divulge that information to the volunteer. Not surprisingly, there was no consensus.[22,23]

The results of a recent retrospective study of patients diagnosed with renal cell carcinoma in Iceland between 1971 and 2005 could well have major impact in determining the standard of care relative to the reporting of incidentalomas. In 28% of patients, the carcinoma was discovered as an incidental finding on a CT or ultrasound performed for reasons unrelated to the renal carcinoma. These patients had a statistically significant better survival rate than those whose carcinomas were found after they had exhibited symptoms or laboratory abnormalities. The authors concluded that incidental detection affects survival favorably—indeed, to a much greater extent than can be explained simply by differences in stage, grade, or demographics compared to those with symptoms.[24]

In an editorial titled, "Incidentally, It's Still Cancer," a surgeon-researcher opined:

"The most important take-home point is that malignancy does occur in small tumors and also can be evident ultimately in presumably benign lesions. Physicians should be applauded for endorsing an aggressive surgical stance against the disease. After all, it's cancer we are dealing with here."[25]