As unusual as a term in medical science can be, an incidentaloma is exactly what it sounds like—a tumor that is found completely by coincidence while looking for something else. It has no signs or symptoms and generally is found during a scanning or x-ray procedure and reported by the radiologist. It comes as a completely “incidental” finding and often causes a significant quandary both in clinical and insurance medicine.
The boom in scanning and x-ray procedures has caused an incredible increase in finding growths (or tumors) that were completely unsuspected clinically. The advances in technology with better resolution and graphic imaging have also increased what can be seen from previous decades when these findings would have been missed or undetected.
The estimate is that more than one in 20 patients over age 60 may harbor these growths. The question to answer is whether they are no more than benign findings which have no effect whatsoever on day-to-day life, or whether they are pre-malignant growths that need further investigation and will result in increased early mortality.
The largest culprit is perhaps whole body CT scanning, which has been marketed by health screening programs as a way to detect disease before it produces clinical findings. Rather than looking for disease in a suspected organ or localizing to a patient complaint, the scan provides findings with no clinical correlating information for the radiologist. As such, the radiologist reading the scan is left to wonder whether the finding has any significance at all, or whether it is part of anatomic anomalies we all have. The infamous phrase “cannot rule in or rule out” a growth or pathology has many time exposed patients to additional x-rays, radiation and testing that turns into a search for what essentially may be nothing.
Of incidentalomas that sometimes produce significant health findings, adrenal growths are the most common. On top of the adrenal glands at the superior poles of the kidneys, the growths can be benign adenomas or tumors that may cause an increase in hormones that cause excess cortisone production or hypertension. Generally speaking, there ought to be symptoms that correlate to disease. However, the presence of such a growth often produces the need for follow-up scanning and procedures to check for growth or expansion. Thus, no clean bill of health when they are detected.
Brain scans even with no signs or symptoms of disease may show meningiomas or pituitary adenomas. When a meningioma remains stable in size, it is not commonly a worry. However, pituitary adenomas may secrete hormones that are endocrinologically active on many biological axes in the body and should be monitored. This is done more often with hormone and blood screening tests than by repeated x-rays.
Thyroid, parathyroid and kidney incidentalomas also are relatively common sites of findings, but perhaps the most concerning from both a clinical and insurance point of view are pulmonary nodules. The solitary pulmonary nodule, if it proliferates, can be a finding of early and perhaps treatable cancer, and the American College of Chest Physicians has a complete protocol of how to evaluate a newly found nodule along with testing criteria. Depending on size, density, location and change in proportion, the probability of serious pathology varies, but this finding is uniformly taken seriously by the physician, rather than being dismissed as a benign situation.
In clinical medicine, how far to pursue an incidentaloma is still a matter of debate. The costs both to the patient and to the health care system can be staggering, as is the amount of radiation a person can be exposed to following up on a lesion that may have no clinical or pathological significance. In insurance, underwriters will often want to have some resolution on whether such a growth can have a significant effect on mortality before proceeding with an offer.
Most scientific and fiscally responsible medicine and underwriting involves thorough and risk-based assessment of the probability of a finding being of pathological significance against the high likelihood that the growth found is no more than an anatomical variation in a healthy body. Both common sense and the words of the famed physician Hippocrates “above all do no harm” contribute to the degree of work-up and the decision to leave an “incidental” finding be, especially when the odds overwhelmingly favor it being nothing more than that.
