Hitzeman Nathan, Cotton Erin
Sutter Medical Center, Sacramento, CA, USA.
Am Fam Physician. 2014 Dec 1;90(11):784-9.
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.
偶发瘤在影像学检查中越来越常见，这让医生和患者都感到担忧。医生在考虑进行影像学检查时应考虑发现偶发瘤的风险。患者可能会认为偶发瘤就是癌症，并且可能没有意识到重复影像学检查所带来的辐射风险。一旦检测到偶发瘤，恰当的处理取决于患者的知情意愿和临床情况。本文为八种偶发瘤（垂体、甲状腺、肺、肝、胰腺、肾上腺、肾和卵巢）的初始处理提供了指导原则。出现垂体偶发瘤的患者，如果病变直径达到或超过1厘米，或者病变紧邻视交叉，则应接受垂体特异性磁共振成像检查。甲状腺偶发瘤很常见，但直径大于1至2厘米的结节更值得关注。令人担忧的肺部偶发瘤是指直径大于8毫米或边界不规则、有偏心钙化或低密度的瘤体。然而，目前的指导原则建议，即使是小至4毫米的肺部偶发瘤也应进行随访。直径5毫米或更大的实性肝脏偶发瘤应密切监测，多期扫描有助于诊断。胰腺囊性肿瘤具有恶变潜能，对于直径大于3厘米且有可疑特征的胰腺囊肿，建议进行手术治疗。直径大于4厘米的肾上腺病变通常需进行活检。博斯尼亚克分类法是一种广泛接受的对肾脏偶发瘤进行分类的方法。IIF级或更高级别的病变需要进行连续监测或手术。绝经前女性直径3厘米或更小、绝经后女性直径1厘米或更小的良性或可能为良性的卵巢囊肿无需随访。壁或间隔增厚、或有血流的实性成分的卵巢囊肿应密切处理。
