Incidentalomas are increasingly common findings on radiologic studies, causing worry for physicians and patients. Physicians should consider the risk of discovering incidentalomas when contemplating imaging. Patients may assume that incidentalomas are cancer, and may not be aware of the radiation risks associated with repeat imaging. Once incidentalomas are detected, appropriate management is dependent on an informed patient’s wishes and the clinical situation. Guidelines are provided for the initial management of eight incidentalomas (pituitary, thyroid, pulmonary, hepatic, pancreatic, adrenal, renal, and ovarian). Patients presenting with pituitary incidentalomas should undergo pituitary-specific magnetic resonance imaging if the lesion is 1 cm or larger, or if it abuts the optic chiasm. Thyroid incidentalomas are ubiquitous, but nodules larger than 1 to 2 cm are of greater concern. Worrisome pulmonary incidentalomas are those larger than 8 mm or those with irregular borders, eccentric calcifications, or low density. However, current guidelines recommend that even pulmonary incidentalomas as small as 4 mm be followed. Solid hepatic incidentalomas 5 mm or larger should be monitored closely, and multiphasic scanning is helpful. Pancreatic cystic neoplasms have malignant potential, and surgery is recommended for pancreatic cysts larger than 3 cm with suspicious features. Adrenal lesions larger than 4 cm are usually biopsied. The Bosniak classification is a well-accepted means of triaging renal incidentalomas. Lesions at category IIF or greater require serial monitoring or surgery. Benign or probably benign ovarian cysts 3 cm or smaller in premenopausal women or 1 cm or smaller in postmenopausal women do not require follow-up. Ovarian cysts with thickened walls or septa, or solid components with blood flow, should be managed closely.



Advanced imaging studies show tremendous details of pathology. They can also show incidental findings that are of unclear significance. Family physicians are often the ones to explain these incidentalomas to patients. Further workup of incidentalomas may cause harm. According to an expert panel of the American College of Radiology (ACR), although most incidental findings prove to be benign, their discovery often leads to a cascade of testing that is costly, provokes anxiety, exposes patients to radiation unnecessarily, and may even cause morbidity.1 The goal of this review is to provide guidelines on initial management of incidentalomas. Available guidelines are from specialty societies and based on expert opinion, and do not always agree.This article summarizes the mechanisms, clinical features, follow-up, treatment and prognosis of relapsed PCNSL, aiming to provide evidence for further understanding and designing better treatment strategies.

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