Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 38

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Endocrinology & Metabolism
journal homepage: www.elsevier.com/locate/beem

Incidentalomas A disease of modern imaging

technologyq
Jennifer Wagner, PhD a, David C. Aron, MD, MS b, c, d, *
a

Midwest-Mountain Veterans Engineering Resource Center, VA Nebraska Western Iowa Health care System, Omaha, NE, USA
VA HSR&D Quality Enhancement Research Initiative Center for Implementation Practice & Research Support (CIPRS),
Louis Stokes Cleveland, USA
c
Dept. of Veterans Affairs Medical Center 14(W), 10701 East Boulevard, Cleveland, OH 44106, USA
d
Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine, Cleveland OH 44106, USA
b

Keywords:
imaging technology
magnetic resonance imaging
CT scanning
unintended consequences
social studies of medicine

The evolution of new diagnostic techniques has revolutionized the

practice of medicine and in fact, the nature of medicine itself.
Technology has also expanded the visual eld of medicine: the
naked eye was assisted by the light microscope and then electron
microscope to see smaller and smaller features while radiology has
permitted non-invasive identication of internal structures.
However, there are unintended consequences one of which is the
discovery of an anomaly during the course of looking for something else incidental ndings and incidentalomas. Technology in
general and imaging specically offer much in service to physicians and their patients. However, it behoves physicians to ensure
that technology supplements but does not replace good clinical
judgment. This essay aims to put the issue of incidental ndings
related to advancing technology (especially imaging technology)
into a broader context.
Published by Elsevier Ltd.

In his famous book on diseases of the pituitary gland, written in 1912, Cushing described Minnie
G, a patient thought to have a peculiar polyglandular syndrome now known to be the syndrome that
bears Cushings name.1 Although within two decades such patients were thought to have basophilic
adenomas of the pituitary, surgical exploration was the only reliable technique to conrm anatomic

q The views expressed are those of the author and do not represent the views of any agency.
* Corresponding author. Dept. of Veterans Affairs Medical Center 14(W), 10701 East Boulevard, Cleveland, OH 44106, USA.
Tel.: 1 216 421 3098.
E-mail address: David.Aron@va.gov (D.C. Aron).
1521-690X/$ see front matter Published by Elsevier Ltd.
doi:10.1016/j.beem.2011.08.006

J. Wagner, D.C. Aron / Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 38

diagnosis in the living patient. Preoperative identication of the disease relied almost exclusively on
the physicians bedside skills and clinical acumen for diagnosis. Neuroradiology was in its infancy. A
century later, the evolution of new diagnostic techniques has revolutionized the practice of medicine
and in fact, the nature of medicine itself.
To quote Carl Mitcham, philosopher of technology: Medicine is increasingly dened by the type
and character of its instruments (from stethoscope to high-tech imaging devices) and the construction
of special humanartifact interactions (synthetic drugs, prosthetic devices). Indeed, the physicianpatient relationship, medical knowledge, and the concept of health are all affected by technological
change.2 (p.2477) Technology enables direct interventions so that medicine has changed from
assisting the healing capacity of nature (and calling upon the power of nature) to controlling and
manipulating bodily healing itself.3,4 An intensication of this process, termed biomedicalization by
the sociologist Adele Clarke and her colleagues, involves increasingly complex processes and expansion
of mechanical technologies to biotechnologies, especially those based upon genetics.5 Technology has
also expanded the visual eld of medicine: the naked eye was assisted by the light microscope and
then electron microscope to see smaller and smaller features while radiology has permitted noninvasive identication of internal structures. Now, preclinical or subclinical disease is being found
owing to the extensive use of sophisticated technology; risk itself has been transformed into disease.6
This is further complicated by the discovery of an anomaly during the course of looking for something
else incidental ndings and incidentalomas. The aim of this essay is to put the issue of incidental
ndings related to advancing technology (especially imaging technology) into a broader context.
Fueled by modern scientic advancements, Western culture holds to a belief in inevitable progress
and that technological advancement is a major part of that progress. Bjorn Hofman, who has written
extensively on technology in medicine, wrote that technology has become the bias of our culture.4
Technology has changed everything about human life: the way we travel, work, communicate, and
enjoy leisure have all changed markedly in the last generation. Technology also appeals to Western
ideals of freedom and choice as well as the penchant for novelty, innovation, and action. In Western
society, new is better and nothing reects new as well as the latest technology.
Corresponding to the rise of technology throughout society is a parallel in health care, a technological mandate.4 Medical professionals dont attract patients with promises of conventional
treatments. Rather, we look for products and services that are described as state-of-the-art, the
latest, or novel. A critic of technology, Neil Postman pointed to an American character that embraces
technological innovation which itself has become synonymous with progress and made technology the
foundation of the medical profession.7 This has contributed to a medical arms race in which different
health care systems, hospitals, and physician practices compete in the marketplace based on their use
of the latest technique. The amount of technology in a given hospital is a factor in the US News and
World Report Best Hospitals ranking methodology. The results of this rise in the use of medical
technology means tests are more precise, surgeries less invasive, information more available, diagnostics more reliable, and treatments more targeted than in the past. How many of us would forgo
these advances to live in earlier and simpler times?
Hofman provided an analytic framework highlighting medical technologys ve major features. He
characterized technology in medicine as: interventive, expansive, dening disease, generalizing, and
liberating.3 By providing the basic phenomena to be studied and manipulated in medicine, technology
strongly inuences the concept of disease, and hence medical action. It denes what is diagnosed and
what is treated. As a general method for diagnosis and treatment with its ability to generate reproducible results, technology has contributed to making medicine more scientic. Finally, technology has
made medical knowledge independent from the subjective experience of the patient. (It is arguable
how liberating this is, since the patient experience is central to dis-ease, if not disease). However,
despite remarkable technologic advancement, the practice of endocrinology and of medicine in general
continues to involve uncertainty and this uncertainty along with faith in technology as well as other
factors have contributed to increasing use of technology and technological development.
Imaging has become central to medical practice as it has to society. Recent improvement in image
quality8 combined with visualization as a cultural preference9 have contributed to a belief that imaging
is a superior diagnostic method for acquiring knowledge about the body.10 Expectations for medical
technology in general and imaging in particular are high among ordinary people as well as medical

J. Wagner, D.C. Aron / Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 38

professionals and the health care marketplace promotes the expectations. Illes et al. wrote that our
society equates innovative medical technology with better care and supports market-based
approaches to a range of services that emphasize consumer choice and responsibility.11 Full body
scans and a variety of specialized imaging procedures are widely advertised and require no physician
referral. Two typical web sites are shown in Fig. 1. It then comes as no surprise that patient requests and
self-referrals are becoming increasingly commonplace. Kolber et al. surveyed patients seeking whole
body scans.12 Only 20% of those surveyed heard about the scan from a physician. These patients had
high expectations of the whole body scan in terms of personal benet. Similarly, patients have high
expectations for their physicians to order such imaging. For example, in a survey of radiologists from
Norway, among the most common reasons cited for unnecessary testing was increased patient
demands for certain knowledge about their own.body.13
Aside from societal norms, many factors have contributed to the rise of technology in health care.
The Internet has played a role in putting information literally at ones ngertips. This has affected the
way that patients view their role in health care. Suddenly, patients can access virtually innite although
frequently incomplete or inaccurate information about medical conditions and treatments while in the
comfort of their living rooms. Potential patients can use symptom checkers to enter their symptoms

Fig. 1. Screen shots of web sites related to imaging services. Upper Panel: www.scandirectory.com/content/body_scan.asp Lower
Panel: http://www.completebodyscan.com/. (Accessed 8/8/11. Note: authors are not in any way afliated with these companies.)

J. Wagner, D.C. Aron / Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 38

and get a preview of possible diagnoses. Then, because pharmaceutical commercials are streamed into
homes via television (in the United States at least) and Internet advertising, instead of turning to
physicians for advice on medications, patients offer their needs assessment to physicians and ask for
specic medications: Ask your doctor if XXX is right for you. Instead of being viewed solely as the
expert who directs care, physicians are also viewed as the avenue to an anonymously recommended,
patient-dened course of action. Moreover, just as patients dont always feel that providers are taking
their complaints seriously if they dont leave with a prescription, there is a tendency to equate laboratory work and body scans with quality care.14
Images have assumed an especially privileged role in medical technology. When testing is not
ordered, the assumption often is not that it is not indicated, but rather that nances are somehow
involved.9,10 The recent focus on improved cameras and picture viewing capabilities in the home shows
similar bias toward video innovations in production of the body as anatomical pictures.9,10 The
cultural inuences even go as far as affecting the name MRI. What was once referred to as nuclear
magnetic resonance now includes the word imaging in its name.9,10 (Hofmann) traces this to many
characteristics that are implicit in technology: it satises our natural curiosity and ability to address the
ambiguous and uncertain.4 Physicians are inevitably drawn into the process. Medical technology has
grown from being a tool to becoming a companion and, in some cases, the master of physician.4
For all the countless positive changes technology has brought to our society, no technology is
without unintended consequences, sometimes positive and sometimes negative. In some cases, these
unintended consequences are foreseeable, though not desirable or predictable. For example, nuclear
power plants bring the risk of plant meltdowns and man-made dams allow oods to be more
destructive when they do occur. While foreseeable, these are not the intended outcomes. The risks
would not exist without the technology. In other cases, potential effects come in the form of less
foreseeable consequences. The Fukushima nuclear power plant was designed to withstand a major
earthquake, but not the tsunami that could be triggered by the earthquake. Aspirin, rst used as a pain
reliever, has since been found to have other therapeutic uses, e.g., prevention and treatment of
myocardial infarction. This is a positive development for many individuals with certain heart and blood
conditions. However, negative consequences are also possible. For example, the development of
antimicrobial resistance to antibiotics has followed their widespread and often benecial use.
Advances in diagnostic tests in general and imaging in particular are no exception to the rule.
While patients believe that more testing is better, there are times where the ndings can have
negative effects. Gilbert Welch called attention to the mid-course review of Healthy People 2010.15
While the data from 2001 to 2002 showed a slight increase in life expectancy as compared with
19992000, there was a decrease in expected years free of selected chronic disease of 1.2 years for
women and 1.3 for men. Welch posits that this counter-intuitive nding is due to modern diagnostic
practices: Americans are more likely to be told that they have a chronic disease. While the amount of
money spent on personal health care in America doubled from 1998 to 2008 ($1 trillion to $2 trillion),
the life expectancy grew by only 1.2 years (from 76.7 to 77.9 [2007] years). Disease is now diagnosed
based on laboratory tests in the absence of clinical signs and symptoms. Moreover, the state of
increased risk for a disease has become a disease itself, e.g., hypercholesterolemia. Furthermore, the
very tests meant to improve patients health might actually cause harm, for example from exposure to
radiation from multiple CT scans.12,16 Although medical technology has brought great advances to the
certainty in diagnostic abilities, it has also given rise to new areas of uncertainty. These are most
evident in the case of incidental ndings in imaging studies.
Human abnormalities are prevalent. So-called abnormalities are so common on MRI of the spine
as to be viewed as normal variants possibly related to aging.1719 In a cross-sectional study, 36% of
asymptomatic persons aged 60 years or older had a herniated disc, 21% had spinal stenosis, and more
than 90% had a degenerated or bulging disc.20 A prospective study found that among patients with
lumbar imaging abnormalities before the onset of low back pain, 84% had unchanged or improved
ndings after symptoms developed.21 Thus, there may be little correlation between abnormalities
and symptoms attributed to those abnormalities. The abnormalities might be considered incidental
ndings.
An incidentaloma is dened as an unsuspected nding (typically a mass lesion) discovered in the
course of looking for something else. Incidental ndings are very common. Furtado et al. (2005)

J. Wagner, D.C. Aron / Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 38

reported that 86% of 1192 patients receiving a whole body CT scan had some type of nding.22 While
most of these were benign, 37% of patients were referred for some type of follow-up treatment.
Similarly, Morin et al. looked at abnormalities during whole body MRI scans; 59.2% of those identied
were categorized as low clinical signicance.23 Incidentalomas have also become an issue in clinical
research studies. A review of recent studies indicates that, depending on technology being used,
roughly one-third of participants can be expected to present with an incidental nding.2325 What, if
anything, can ethically be withheld from the participant? The risk that an incidental nding might be
identied? The fact that an incidental nding was in fact identied in a given participant? Are our
patients different from research subjects? One thinks not.26,27
As the latest technology identies new diseases (or the potential for diseases), clinicians are faced
with the dilemma as to whether or not to treat. There are many conditions or diseases that were
previously undetectable, but with new technology, present themselves on lms (or digitized screens)
or in test tubes. In these cases, new technology is actually adding uncertainty to the diagnostic and
treatment process. Consider the case of adrenal incidentalomas. Adrenal carcinoma is mercifully quite
rare. However, the frequency of adrenal carcinoma in incidentalomas is relatively high. Yet so far, all the
surgeries done for adrenal incidentalomas large enough for the diagnosis of adrenal carcinoma to be
considered have not reduced the mortality rate from adrenal carcinoma. This raises the question of
whether all lesions that have histologic features of adrenal carcinoma behave like those diagnosed
clinically.28,29 Nevertheless, once identied, there are pressures to relieve the uncertainty as to their
signicance.
The term incidentaloma has moved from professional jargon to the popular press. In a commentary
in the New York Times, a case is presented of a patient who retrospectively was deemed low risk with
regard to diseases associated with the serendipitously discovered mass.30 Many people then submitted
comments relaying similar situations. However, additional testing following discovery of incidentaloma may result in further expense and harm as false-positive results are pursued, producing the
cascade effect described by Mold and Stein as a chain of events (which) tends to proceed with
increasing momentum, so that the further it progresses the more difcult it is to stop.31 This is a form
of technological iatrogenesis, a term that Palmieri, Peterson, and Ford posited that needs to be included
in a list that previously only contained clinical, social, and cultural, to describe adverse outcomes
relating to medical interventions (or failure to intervene).32 Much has been made of the distancing
between physician and patient brought about through technology, the atrophy of clinical diagnostic
skills, and the lost art of taking a good history (see R.L. Sanders33 for an extended discussion). Even
were these not true, subjecting patients to unnecessary testing and treatment carries its own set of
risks. Technology in general and imaging specically offer much in service to physicians and their
patients. However, it behoves physicians to ensure that technology supplements but does not replace
good clinical judgment.
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