Classification and Management of Incidentalomas

Introduction to Incidentalomas

Incidentalomas should be classified based on anatomical location, histological features, and risk stratification to guide appropriate management decisions, with the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) providing guidelines for classification and management 1

The American Cancer Society recommends the Traditional Classification system and the Modern Classification system for tumor classification, with the Traditional Classification system including Comedo, cribriform, micropapillary, papillary, and solid subtypes, and the Modern Classification system based primarily on nuclear grade and/or necrosis rather than architectural pattern 2
The International Neuroblastoma Pathology Classification (INPC) categorizes neuroblastomas into favorable or unfavorable histology groups, with four main categories based on Schwannian stroma development 3
The TNM AJC/UICC Classification is the most practical for treatment decision-making, with the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) providing guidelines for classification and management 4

The National Comprehensive Cancer Network (NCCN) recommends adequate tissue sampling, including surgical resection, incisional biopsy, or multiple tissue cores for diagnosis, and image-guided or excisional biopsy to confirm diagnosis for breast lesions 3
The European Society for Medical Oncology (ESMO) recommends site-specific imaging protocols, including endorectal ultrasound (ERUS) and MRI for T staging, and MRI for N staging for rectal tumors, and CT scan or high-resolution ultrasound for salivary gland tumors 5, 4

The Royal College of Pathologists recommends complete specimen examination with appropriate margins, including at least one section through the center of each lymph node, and reporting nuclear grade, presence/absence of necrosis, and architectural patterns for diagnosis 6, 2

The American College of Surgeons recommends complete surgical excision as the standard treatment for most solid incidentalomas, with margins depending on the specific diagnosis and risk stratification, and postoperative radiotherapy for high-grade tumors and incomplete resections 4, 6
The National Comprehensive Cancer Network (NCCN) recommends adjuvant therapy, including conformal radiotherapy based on WHO grade and extent of resection for ependymal tumors, and observation for confirmed benign incidentalomas or those with low malignant potential 7

The American Cancer Society recommends regular clinical examinations based on risk stratification, site-specific imaging protocols, and long-term follow-up for lesions with risk of late recurrence, with the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) providing guidelines for follow-up and prognosis 1
For patients with fat necrosis, the following guidelines are recommended: