ER Division Incidentaloma

Practice Guidelines
CONTENTS

A. Pulmonary Nodules
i. Solid
ii. Subsolid/Groundglass
B. Liver Lesions
C. Gallbladder Findings
D. Pancreatic Cysts
E. Splenic Lesions
F. Adrenal Nodules
G. Renal Masses
i. Solid
ii. Cystic
H. Lymph Nodes
I. Adnexal Cysts
i. CT
ii. US
J. Thyroid Nodules by CT
K. Additional findings that may benefit from standardized reporting
a. testicular microlithiasis
b. no IUP w/ positive beta
c. subchorionic Bleed
d. first trimester pregnancy evaluation: SRU criteria

Solid Pulmonary Nodules

Fleischner Guidelines (MACRO: Incidental pulmonary nodule solid)

SIZE*
4 mm
>4 to 6 mm
>6 to 8 mm
>8 mm

LOW RISK

HIGH RISK

No follow-up needed.
Single follow-up in 12 months. Discontinue if stable.
Single follow-up in 12 months. Discontinue if
Initial follow-up in 6-12 months, then 18-24 months
stable.
if stable.
Initial follow-up in 6-12 months, then 18-24
Initial follow-up in 3-6 months, then 9-12 months
months if stable.
and again at 24 months if stable.
One of more of the following: serial follow-up at 3, 9, and 24 months; PET; biopsy.

NOTES
Guidelines are intended for newly detected indeterminate nodules in persons age 35 or older without a history
of cancer.
*Size is the average of length and width.
Low risk: minimal/absent smoking history. No other known risk factors.
High risk: smoking or other known risk factors.
Nodules in patients with a history of cancer should be evaluated per clinical protocol pertaining to the
patients cancer type and treatment history.
For larger solid nodules, beware for PET: carcinoids and low grade adenocarcinomas may not be metabolically
active. Consider phrasing: PET or 3 month follow-up if biopsy is not elected.

Subsolid Pulmonary Nodules

New Fleischner Recommendations

Nodule Type
Solitary Pure GGN

Recommendations

Remarks

MACRO: Incidental pulmonary nodule pure groundglass

5 mm

No follow-up needed.

Use 1-mm slices to ensure purely

GGN.

>5mm

Initial follow-up at 3 months, then annually

for at least 3 years if persistent.

FDG-PET not generally advised.

Solitary Subsolid Nodule

Solid portion <5 mm
Solid portion 5 mm

MACRO: Incidental pulmonary nodule subsolid

Initial follow-up at 3 months, then annually
for at least 3 years if persistent.
Initial follow-up at 3 months. Surgical
resection or biopsy if persistent.

Consider PET for staging purposes if

solid portion 10 mm.

Multiple Subsolid Nodules

Pure GGNs 5 mm

Pure GGNs >5 mm without

dominant nodule
Dominant nodule with solid
component

Follow-up CT at 2 and 4 years.

Initial follow-up at 3 months, then annually

for at least 3 years if persistent.
Initial follow-up at 3 months. Surgical
resection or biopsy if persistent.

Consider non-neoplastic etiologies

such as ILD (hypersensitivity
pneumonitis, respiratory bronchiolitis
in smokers.) Look for a centrilobular
pattern in these conditions.
FDG-PET not generally advised.

NOTES

No distinction between high and low risk.

Transbronchial needle biopsy generally not advised for pure ground glass nodules due to low diagnostic yield.
The solid component of a subsolid nodule may be targeted for percutaneous biopsy if of adequate size (>8mm).
Subsolid adenocarcinomas may not be metabolically active on PET; PET can be used for staging but should not
be used to exclude adenocarcinoma in cases of subsolid (or pure ground glass) lesions.
Evaluate morphology using 1-mm axial slices.
Measurements based on average of length and width.
Always compare to earliest exam to detect slow growth.
Bronchoalveolar cell carcinoma. Preferred terms: adenocarcinoma in situ (pure ground glass lesion <3 cm),
minimally invasive adenocarcinoma (solid component <5 mm), or invasive adenocarcinoma (solid component
>5mm).
Differential for a persistent ground glass nodule includes focal fibrosis, atypical adenomatous hyperplasia, and
adenocarcinoma in situ.

Incidental Liver Masses (CT)

Source: JACR White Paper 2010

Incidental Gallbladder Findings

Gallstones

Asymptomatic no action.
Symptomatic consider ultrasound.

Wall Calcification

Diffuse (porcelain gallbladder) no specific recommendation. Lower risk for cancer than historically thought.
Focal no specific recommendation. Higher risk for cancer than diffuse, still low overall.

Hyperattenuating Contents

Caused by concentrated bile, sludge, noncalcified stones, vicarious contrast excretion.

No action.

Wall Thickening

Diffuse, asymptomatic no action.

Focal > 3 mm, potential polyp or mass consider ultrasound. MACRO: Incidental Gallbladder Polyp
o Polyp 6 mm no action.
o Polyp 7-9 mm annual ultrasound.
o Polyp 10 mm surgical consultation.

Distention

Defined as transverse diameter > 4 cm and longitudinal diameter > 9 cm.

Asymptomatic no action. Likely secondary to fasting state.
Symptomatic clinical action ultrasound.

Source: JACR White Paper 2013

Pancreatic Cysts (CT/US)

Basic Differential by Morphology

Unilocular: lymphoepithelial cyst, pseudocyst, mucinous cystic neoplasm (MCN), small IPMN, small serous
cystadenoma
Microcystic: lymphoepithelial cyst, serous cystadenoma
Macrocystic: MCN, IPMN, oligocystic serous tumor
Cyst w/ solid component: serous cystadenoma (spongy architecture mimics solid), SPEN, islet cell tumor

Red Flags for Malignancy

Symptomatic patient: hyperamylasemia, weight loss, epigastric pain, jaundice, recent onset diabetes
Mucinous features: macrocystic, peripheral calcs, tail position, middle-aged woman
Dilated CBD
Involvement of main pancreatic duct
Lymphadenopathy
Mural nodules

Management of an Incidental Cyst in an Asymptomatic Patient

<2 cm cyst (MACRO: Incidental pancreatic cyst less than 2 cm)

o Avoid characterization unless absolutely characteristic.
o Follow-up pancreas protocol MRI/MRCP in one year.
Stable benign, no follow-up.
Enlarging continue annual surveillance.
2-3 cm cyst (MACRO: Incidental pancreatic cyst greater than 2 cm)
o Initial characterization with pancreas protocol MRI/MRCP.
Uncharacterized continue annual surveillance.
Probable side branch IPMN follow-up every 6 months for 2 years, then yearly if stable.
Probable serous cystadenoma follow-up every 2 years.
>3 cm cyst
o Characterization with pancreas protocol MRI/MRCP.
Uncharacterized consider cyst aspiration and/or surgical resection.
Probable serous cystadenoma consider resection when 4 cm.
Other cystic neoplasm consider cyst aspiration and/or consider resection.

Source: JACR White Paper 2010

Incidental Splenic Lesions (MACRO: Incidental splenic lesion)

Benign Features

Homogeneous
Attenuation < 20 HU
Nonenhancing
Smooth margins
Hemangioma pattern

Indeterminate Features

Heterogeneous
Attenuation > 20 HU
Enhancing
Smooth margins

Heterogeneous
Enhancing
Irregular margins
Necrotic
Invasive

No Follow-up Needed

Cyst
Classic hemangioma (same pattern as liver, uncommon in spleen)
Not suspicious, stable x1 year

Follow-up Imaging (MRI in 6 + 12 months)

No known cancer, indeterminate features

Known cancer, lesion <1 cm

Further Workup (PET, MR, Biopsy)

Substantial growth
Suspicious features
Known cancer, lesion 1 cm.

Source: JACR White Paper 2013

Suspicious Features

Adrenal Nodules (< 1 cm, no F/U)

Keys for ED practice (most commonly encountered):

MACRO: Incidental Adrenal is a decision tree macro.

If there is prior imaging, no cancer history, lesion indeterminate, but stable 1 yr, presumed benign.
Adrenal nodules 1 cm but < 4 cm: No priors. No cancer history. Presumed benign. Recommend
imaging follow-up in 12 months with MRI.
Adrenal Nodules < 1 cm: presumed benign.
MACRO: Incidental adrenal adenoma. If benign adenoma white paper recommended impression:
Findings consistent with a benign adenoma. If there are clinical signs or symptoms of adrenal
hyperfunction, biochemical evaluation may be appropriate.

Source: JACR White Paper 2010 Berland et al.

Solid Renal Masses

Management in the General Population*

Size

Probable Diagnosis

Recommendation

<1 cm

RCC, AML, oncocytoma

Observe until 1 cm
CT/MR at 3-6 months, 12
months, then yearly.

1-3 cm

RCC (if no detectable fat)

Surgery

>3 cm

RCC (if no detectable fat)

Surgery

Comments
Thin (<3 mm) sections help confirm
enhancement.
For hyperdense, homogeneously enhancing
masses as CT, consider MRI and percutaneous
biopsy to diagnose fat-poor AML
Fat-poor AML and oncocytoma still may be
found at surgery

* Imaging observation may be appropriate in patients with limited life expectancy or poor
surgical candidates.

Source: JACR White Paper 2010

Renal Cysts

Bosniak Classification (CT/MR, not US)

Category 1

~0% malignant

Hairline or imperceptible wall

No septa, calcification, nodule, or enhancement
Fluid signal/attenuation
Benign, no follow-up.

Category 2

~0% malignant

Few hairline septa, with or without perceived enhancement

Fine calcification or short segment of slightly thickened calcification along wall or septa
Hemorrhagic/proteinaceous cyst 3 cm
Benign, no follow-up.

Category 2F (MACRO: incidental renal bosniak)

~25% malignant

Multiple hairline septa, with or without perceived enhancement

Minimally thickened wall or septa
Thick or nodular calcification
No enhancement
Intrarenal hemorrhagic/proteinaceous cyst >3 cm
CT/MR at 6 and 12 months, then yearly for 5 years.

Category 3

~50% malignant

Thickened irregular or smooth walls or septa, with measurable enhancement

Surgery*

Category 4
~99% malignant
Enhancing soft tissue components adjacent to or separate from walls or septa
Surgery*

* Imaging observation may be appropriate in patients with limited life expectancy or poor
surgical candidates.

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Source: JACR White Paper 2010

Incidental Lymph Nodes

Benign Features

Short axis <1 cm in retroperitoneum

Oblong/reniform shape, fatty hilum
Normal enhancement
Normal number

Suspicious Features

Short axis 1 cm in retroperitoneum

Round or indistinct hilum
Necrotic or hypervascular
Abnormal number:
3 nodes at 1 nodal station
2 nodes at 2 nodal stations

No Follow-up Needed

Benign features
Suspicious features but stable x1 year

Follow-up Imaging (CT/MR in 3 months)

No known malignancy and clinical/laboratory data suggest benign process.

Further Workup (PET, EUS, Biopsy, MIBG, etc.)

Imaging progression
Known malignancy
No known malignancy but clinical/laboratory data suggest lymphoproliferative disorder

Source: JACR White Paper 2013

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Incidental Adnexal Cyst (CT)

Benign-Appearing Cyst (MACRO: Incidental Ovarian cyst CT (benign appearing))

All of the following: round or oval, regular wall, uniform fluid or layering blood if premenopausal, <10 cm overall.

Premenopausal (in absence of last known menstrual period, 50 yoa used for
arbitrary designation of menopause)

5 cm benign, no follow-up.
>5 cm US in 6-12 weeks.

Early Postmenopausal (If unknown menstrual status, this is 50-55 yoa)

3 cm benign, no follow-up.
>3 to 5 cm US in 6-12 months.
>5 cm US now.

Late Postmenopausal (if unknown menstrual status, this is > 55 yoa)

3 cm benign, no follow-up. *Option to lower threshold to 1 cm to increase sensitivity for neoplasm.

>3 cm US now.

Probably Benign Cyst

Benign features except: angulated margins, not round or oval, poorly imaged (streak artifact, noise), etc.

Premenopausal (< 50 years old)

3 cm benign, no follow-up.
>3 to 5 cm US in 6-12 weeks.
>5 cm US now.

Early Postmenopausal (50-55 years old)

3 cm benign, no follow-up.
>3 cm US now.

Late Postmenopausal (>55 years old)

1 cm benign, no follow-up.
>1 cm US now.

Other Features
Solid component, mural nodule, septations, nonsimple fluid, layering blood if postmenopausal.

Diagnostic features appropriate clinical/surgical management.

Nonspecific features US
Source: JACR White Paper 2013

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Adnexal Cysts (US) (MACRO: Incidental ovarian cyst sonography)

*If menopausal status is unknown: <50 is premenopausal, 50-55 is early postmenopausal, and >55 is late post-menopausal
Simple Cyst (ovarian or extraovarian)

Premenopausal (<50 years old)

o
o
o
o

3 cm normal, no follow-up. Optional whether to mention.

5 cm no follow-up.
>5 to 7 cm annual follow-up US.
>7 cm follow-up MRI (contrast enhanced).

Postmenopausal (>55 years old)

o
o
o

1 cm no follow-up. Considered clinically unimportant.

>1 to 7 cm annual follow-up US.
>7 cm Surgical consultation and/or MRI (contrast enhanced).

Hemorrhagic Cyst

Premenopausal (< 50 years old)

o
o
o

Early Postmenopausal (50-55 years old)

o

3 cm no follow-up. Optional whether to mention.

5 cm no follow-up.
>5 cm follow-up US in 6-12 weeks.
Any size follow-up US in 6-12 weeks.

Late Postmenopausal (>55 years old)

o

Any size Surgical consultation.

Suspected Endometriomas (any age)

Initial follow-up US in 6-12 weeks (to distinguish from hemorrhagic cysts, which should involute).
Annual US thereafter if not surgically removed.

Dermoid (any age)

Annual US if not surgically removed.

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Thyroid Nodules Seen by CT

Background: Present in up to 16% of all Chest CTs. <10% of these may be malignant.

Suspicious CT or MR Findings: Proceed to Thyroid US.

Abnormal lymph nodes and/or local tissue invasion by thyroid nodule.

Abnormal node features: calcifications, cystic components, and/or increased
enhancement.
o Nodal enlargement (less specific): ispilateral nodes > 1.5 cm short axis, proceed
to Thyroid US.

o
o

General population (thyroid nodules without suspicious features): MACRO:

Incidental thyroid nodule
o Age < 35 yrs: Solitary or few Thyroid Nodules < 1 cm : Ignore
o Age < 35 yrs: Solitary or few Thyroid Nodules 1 cm : Non-emergent Thyroid US
Follow-Up
o Age 35 yrs: Solitary or few Thyroid Nodules < 1.5 cm : Ignore
o Age 35 yrs: Solitary or few Thyroid Nodules 1.5 cm : Non-emergent Thyroid
US Follow-Up
In patients with limited life expectancy or serious co-morbidities that increase risk
of treatment no further evaluation is appropriate.
Multinodular Goiter: [MACRO: Incidental thyroid goiter] Controversial. If we see any
individual nodule in the goiter that meets the above criteria or if this is previously
unknown and the gland is not entirely seen Thyroid US follow-up.

Source: JACR 2014 Hoang et al. This would be compatible with ATA 2006 and NCCN 2010 guidelines. Summarized in
Ahmed S et al. Incidental Nodules on Chest CT: Review of the Literature and Management Suggestions. AJR Nov 2010, Vol
195, Number 5.

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Additional Findings: Standardized Reporting

MACRO: Incidental testicular microlithiasis: Findings of testicular microlithiasis, which may be associated with
slight increased risk for testicular neoplasms. As such, patient education regarding self-examination and annual followup sonography should be considered.

MACRO: Incidental ectopic not excluded: No intrauterine pregnancy. In the setting of positive Beta HcG,
considerations include a missed abortion or an unseen ectopic. Serial Beta HCG and sonographic follow-up should be
obtained based on clinical factors.

(SRU based) MACRO: Incidental Failed first trimester pregnancy: Given [pick list with below options]
findings are diagnostic of pregnancy failure.

CRL of 7 mm with no fetal heartbeat

mean gestational sac diameter 25 mm with no visible embryo
absence of an embryo with heartbeat greater than 2 weeks after the prior scan showed a GS without a YS
absence of an embryo with heartbeat 11 days after a scan that showed GS with a YS

(SRU based) MACRO: Possible first trimester pregnancy failure: Given [pick list with below options] findings
are suspicious for but not diagnostic of pregnancy failure. Two week sonographic follow-up recommended.

CRL of < 7 mm and no heartbeat

mean gestational sac diameter of 16-24 mm and no embryo
empty amnion
small gestational sac in relation to the size of the embryo (< 5 mm difference between MSD and CRL)
absence of embryo with heartbeat 7-13 days after a scan that showed a GS without YS
absence of embryo with heartbeat 7-10 days after a scan that showed GS with YS findings

Subchorionic Hemorrhage (SCH):

Risk of spontaneous abortion ~ doubles with large vs. small/moderate size SCH.
Greater circumferential involvement of the gestational sac increases risk of spontaneous abortion.
Retroplacental involvement increases risk of poor fetal outcomes.
Maternal age > 35 yrs increases risk of spontaneous abortion.
Fetal age > 8 weeks increases risk of spontaneous abortion.

Size of hematoma is described by % of chorionic sac circumference elevated:

o Small is <
o Moderate is to
o Large is >
Volume of hematoma can be described. Compare to GS size.
Location of hematoma in uterus (adjacent to internal os, retroplacental, other)

*Source: Variety of papers, most significantly Bennett et al. Radiology 1996.