e-CASES: Guidelines from the Fleischner Society
Low-risk patients (Minimal or absent history of smoking and of other known risk factors.):
Less than or equal to 4 mm - No further investigation
4-6 mm - CT scanning at 12 months
6-8 mm - CT scanning at 6-12 months and 18-24 months
Greater than 8 mm - CT scanning at 3, 9, and 24 months; contrast-enhanced CT scanning; positron-emission tomography (PET) scanning; and/or biopsy
High-risk patients (History of smoking or of other known risk factors.)
Less than or equal to 4 mm - CT scanning at 12 months
4-6 mm - CT scanning at 6-12 months and 18-24 months
6-8 mm - CT scanning at 3–6 months, 9–12 months, and 24 months
Greater than 8 mm - Same as low-risk patients
The American College of Chest Physicians (ACCP) proposed new guidelines in 2007 for the management of solitary pulmonary nodules:
- Carefully calculate pretest probability for malignancy, either through experienced clinical judgment or through the use of a validated model.
- Previous chest radiographs should be reviewed to determine if the lesion has been stable over 2 years. If so, no further follow up is necessary, with the exception of pure ground-glass lesions on CT scans, which can be slower growing.
- For lesions with a benign pattern of calcification, further testing is not necessary.
- Management of indeterminate lesions greater than 8-10 mm depends on clinical probability of malignancy, as follows:
- Low probability: Serial CT scanning at 3, 6, 12, and 24 months
- Intermediate probability: 18-Fluorodeoxyglucose (FDG) PET scanning, contrast-enhanced CT scanning, transthoracic needle aspiration (TTNA), and/or transbronchial needle aspiration (TBNA)
- High probability: Surgical resection
- Subcentimeter lesions - Same as Fleischner Society, as listed above
- Any unequivocal growth noted during follow up = Definitive tissue diagnosis needed
Source : Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society - Radiology. 2005 Nov;237(2):395-400.