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“It is difficult to make the asymptomatic patient feel better.”

Generations of surgeons have been trained to keep Stanley Hoerr's famous dictum in mind. Physicians are now faced with helping the asymptomatic patient deal with findings uncovered in their routine medical care—findings that may or may not affect their future well-being and are often a source of great concern. Before the introduction of cross-sectional imaging with computed tomographic scanning and magnetic resonance imaging, incidental clinical findings were almost exclusively limited to those discovered in the course of operative procedures to remedy other conditions.

For the practicing clinician, what to do about managing incidentalomas has become an everyday problem. Imaging reports commonly contain reference to incidental findings with advice recommending “clinical correlation,” follow-up imaging, or biopsy. We are all sensitive to the concern that the evaluation of some incidental findings has led to unnecessary testing, increased anxiety for the patient, increased cost of medical care, and sometimes significant complications from attempts to exonerate innocent incidental lesions. The liability climate in the United States has magnified the problem because of the significant issue of lawsuits for failure to diagnose problems that led to adverse outcomes. The National Institutes of Health and the “imaging industry” are both expanding research funding for imaging techniques in the hope that this will minimize unnecessary additional testing by developing more specific and sensitive imaging.

Autopsy studies have shown that occult, clinically insignificant thyroid cancers are common. The incidence of thyroid cancer has more than doubled in the last 30 years without any rise in the mortality rate. This phenomenon is believed to be attributable to increased detection of thyroid masses by modern imaging. Prinz and Chen examine the practical dilemma of managing occult thyroid lesions. Fortunately, the sensitivity of modern imaging has allowed accurate histological characterization of clinically inapparent nodules by percutaneous image-guided fine needle aspiration and allowed clinicians to chart a safe course for managing patients. A diagnostic and therapeutic algorithm is presented.

Unexpected ovarian masses are as often discovered incidentally at operation for nongynecologic conditions as they are by imaging. This creates a more immediate problem for the surgeon since the luxury of further imaging is precluded. Caceres and Chi review the differential diagnosis with particular emphasis on intraoperative frozen section and the need for caution before proceeding with radical ablative surgery, especially in women of childbearing age. Although a second procedure may be necessary, certainty of diagnosis with a full staging evaluation ultimately is optimal care. The preservation of reproductive function in patients with infectious, benign cystic or hemorrhagic, and certain malignancies is emphasized.

Pulmonary nodules are among the most common incidentalomas and usually require further characterization. Although granulomas and other benign lesions are common, the possibility of malignancy is always high in the differential. Specific imaging findings are reviewed in detail Virtually all solitary pulmonary nodules require histologic evaluation. The optimal evaluation, methods of biopsy, and indications for surgery are presented by Ryder and Ng.

One of the remarkable successes of body scanning has been the early diagnosis of renal cell carcinoma. Incidentally discovered cancers now account for 50% of newly diagnosed renal cancer cases, with an attendant reduction in tumor size, lower nuclear grade, and increased options for less radical surgery. Aragona, Wotkowicz, and Libertino outline the role of innovative, less invasive procedures and the quandary of managing small incidentally discovered renal lesions in elderly and poor risk patients. The role of percutaneous biopsy, especially when the suspicion of the mass being metastatic or nonrenal in origin, is reviewed. The role of watchful waiting with risk analysis is presented. Ultimately the benefit of incidentally finding renal cancer, with improved cure rates and less drastic surgery, is a unique result of modern imaging.

Continuing and expected improvements in imaging techniques will undoubtedly result in changes to how we manage these incidental findings. We are likely to find even more incidentalomas, which will be managed surgically, medically, or expectantly.