Guideline sources The following summarized guidelines for the evaluation and management of pulmonary nodules are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2023), the Fleischner Society (FS 2017; 2013), the British Thoracic Society (BTS 2015), and the American College of Chest Physicians (ACCP 2013). 1 2 3 4 5 Guidelines 1. Classification and risk stratification Malignancy risk assessment: As per BTS 2015 guidelines, use composite prediction models based on clinical and radiological factors to estimate the probability of malignancy of a pulmonary nodule ( 8 mm or 300 mm ). B Show 5 more As per ACCP 2013 guidelines, consider estimating the pretest probability of malignancy either qualitatively by using clinical judgment and/or quantitatively using a validated model in https://web.pathway.md/diseases/recsevD9WLB4j15O1 1/6 6/29/23, 11:36 PM Pulmonary nodules Pathway patients with a solid, indeterminate nodule > 8 mm in diameter. C 2. Diagnostic investigations Computed tomography, indications: As per BTS 2015 guidelines, use a maximum section thickness of 1.25 mm when obtaining CT involving the chest where nodule detection is of potential importance. B Show 5 more As per ACCP 2013 guidelines: Obtain chest CT (preferably with thin sections through the nodule) to characterize the nodule in patients with an indeterminate nodule identified on CXR. B Review prior imaging tests in patients with an indeterminate nodule visible on CXR and/or chest CT. B Computed tomography (technical considerations): obtain chest CT as the next imaging for evaluating incidentally detected indeterminate pulmonary nodules on CXR if there are no prior studies to confirm the nodule has been stable for 2 years. Do not obtain further evaluation if the nodule has been stable for 2 years. B Show 3 more Positron emission tomography-computed tomography: As per ACR 2023 guidelines, obtain FDG-positron emission tomography/CT whole body as the next imaging for evaluating incidentally detected indeterminate solid pulmonary nodules measuring > 8 mm on chest CT. B As per BTS 2015 guidelines, obtain positron emission tomography-CT in patients with a pulmonary nodule with an initial risk of malignancy of > 10% (Brock model) where the nodule size is greater than the local positron emission tomography-CT detection threshold. B Show 4 more As per ACCP 2013 guidelines: Consider obtaining functional imaging, preferably positron emission tomography, to characterize the nodule in patients with a solid, indeterminate nodule > 8 mm in diameter and low-to-moderate pretest probability of malignancy (5%-65%). C Avoid obtaining functional imaging to characterize the nodule in patients with a solid, indeterminate nodule > 8 mm in diameter and a high pretest probability of malignancy (> 65%). D Other imaging techniques: Do not obtain MRI, SPECT or dynamic contrast-enhanced CT to determine whether a nodule is malignant if positron emission tomography-CT is an available alternative. D Consider obtaining other imaging techniques such as C-arm cone beam CT and multiplanar reconstruction to improve diagnostic accuracy. C Laboratory markers: do not use biomarkers in the assessment of pulmonary nodules. D 3. Diagnostic procedures https://web.pathway.md/diseases/recsevD9WLB4j15O1 2/6 6/29/23, 11:36 PM Pulmonary nodules Pathway Bronchoscopy: Consider performing bronchoscopy in the evaluation of pulmonary nodules with bronchus sign present on CT. C Consider augmenting yield from bronchoscopy using either radial endobronchial ultrasound, fluoroscopy or electromagnetic navigation. C Lung biopsy: As per BTS 2015 guidelines, perform percutaneous lung biopsy when the results will alter the management plan. B Show 4 more As per ACCP 2013 guidelines: Consider performing non-surgical biopsy in patients with a solid, indeterminate nodule > 8 mm in diameter in the following circumstances: clinical pretest probability and findings on imaging tests are discordant low to moderate ( 10-60%) probability of malignancy suspected benign diagnosis requiring specific medical treatment fully informed patient desiring proof of a malignant diagnosis before surgery, especially when the risk of surgical complications is high. C Perform non-surgical biopsy and/or surgical resection in patients with a solid, indeterminate nodule showing clear evidence of malignant growth on serial imaging unless specifically contraindicated. B 4. Medical management Inhaled corticosteroids: do not use ICSs in the management of indeterminate pulmonary nodules. D Antibiotics: do not use antibiotics in the management of indeterminate pulmonary nodules. D 5. Therapeutic procedures Radiotherapy and radiofrequency ablation: Consider offering stereotactic ablative body radiotherapy or radiofrequency ablation, if technically suitable, in patients unfit for surgery having pulmonary nodules with a high probability of malignancy where biopsy is nondiagnostic or not possible. C Consider offering conventional radical radiotherapy, if not suitable for stereotactic ablative body radiotherapy or radiofrequency ablation, in patients unfit for surgery having pulmonary nodules with a high probability of malignancy where biopsy is nondiagnostic or not possible. C 6. Surgical interventions Surgical resection, indications: https://web.pathway.md/diseases/recsevD9WLB4j15O1 3/6 6/29/23, 11:36 PM Pulmonary nodules Pathway As per BTS 2015 guidelines, discuss the options of observation with repeat CT, CT-guided biopsy, or resection/non-surgical treatment with the patient with an approximate risk of malignancy of > 10%, taking into account factors such as age, comorbidities, and risk of surgery. B Show 5 more As per ACCP 2013 guidelines, discuss the risks and benefits of alternative management strategies and elicit patient preferences for management in patients with a solid, indeterminate nodule > 8 mm in diameter. B Show 2 more Surgical resection, technical considerations: As per BTS 2015 guidelines, perform surgical resection of pulmonary nodules preferentially by video-assisted thoracoscopic surgery rather than by an open approach. B Show 5 more As per ACCP 2013 guidelines, perform thoracoscopy to obtain a diagnostic wedge resection in patients with a solid, indeterminate nodule > 8 mm in diameter preferring surgical diagnosis. B 7. Specific circumstances Patients with incidental nodules: use the same diagnostic approach for nodules detected incidentally as those detected through screening. B Patients with current or previous malignancy: consider monitoring nodules below the threshold of < 5 mm maximum diameter or < 80 mm volume in patients with a history of previous or active cancer according to clinical judgment. C Show 2 more 8. Patient education General counseling: provide patients and carers with accurate and understandable information about the probability of malignancy of the pulmonary nodule. B Show 6 more 9. Follow-up and surveillance Follow-up imaging, general principles: As per BTS 2015 guidelines, offer CT surveillance in patients with nodules 5 mm to < 8 mm maximum diameter or 80 mm to < 300 mm . B Show 10 more As per ACCP 2013 guidelines, consider evaluating each nodule individually in patients with a dominant nodule and 1 additional small nodule. Avoid denying curative treatment unless there is histopathological confirmation of metastasis. C Follow-up imaging, solid nodules: https://web.pathway.md/diseases/recsevD9WLB4j15O1 4/6 6/29/23, 11:36 PM Pulmonary nodules Pathway As per FS 2017 guidelines, do not routinely follow-up patients with solid nodules < 6 mm at both low D and high risk D Show 6 more As per ACCP 2013 guidelines, avoid obtaining additional diagnostic evaluation in patients with a solid, indeterminate nodule being stable for at least 2 years. D Show 4 more Follow-up imaging, subsolid nodules: As per FS 2017 guidelines, do not routinely follow-up patients with: solitary pure ground-glass nodules < 6 mm D solitary part-solid nodules < 6 mm. D Show 4 more As per BTS 2015 guidelines, do not follow-up subsolid nodules < 5 mm in maximum diameter at baseline. D Show 4 more As per ACCP 2013 guidelines: Consider obtaining CT surveillance at approximately 3, 12, and 24 months followed by annual CT surveillance for an additional 1-3 years in patients with a subsolid nodule 8 mm in diameter. C Consider obtaining repeated chest CT at 3 months followed by further evaluation with positron emission tomography, non-surgical biopsy, and/or surgical resection for persisting nodules in patients with a subsolid nodule > 8 mm in diameter. C Follow-up imaging, nonsolid nodules: As per ACCP 2013 guidelines: Avoid obtaining further evaluation in patients with a non-solid (pure ground glass) nodule 5 mm in diameter. D Consider obtaining annual surveillance with chest CT for at least 3 years in patients with a non-solid (pure ground glass) nodule > 5 mm in diameter. C Follow-up imaging, nodules with benign features: As per BTS 2015 guidelines: Do not offer nodule follow-up or further investigation in patients with nodules with diffuse, central, laminated or popcorn pattern of calcification, or macroscopic fat. D Do not offer nodule follow-up or further investigation in patients with typical perifissural or subpleural nodules (homogeneous, smooth, solid nodules with a lentiform or triangular shape either within 1 cm of a fissure or the pleural surface and < 10 mm). D Clinical findings Past medical history Family history Bronchogenic cyst Lung cancer Coccidioidomycosis Granulomatosis with polyangiitis Histoplasmosis https://web.pathway.md/diseases/recsevD9WLB4j15O1 5/6 6/29/23, 11:36 PM Pulmonary nodules Pathway Lung metastasis Pulmonary AVM Pulmonary chondroma Pulmonary fibroma Pulmonary hamartoma Pulmonary hemangioma Rheumatoid arthritis Rib fracture Sarcoidosis Tuberculosis Social history Tobacco use References 1. Frank C Detterbeck, Sandra Zelman Lewis, Rebecca Diekemper et al. Executive Summary: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143 5 Suppl):7S 37S. Open 2. M E J Callister, D R Baldwin, A R Akram et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015 Aug;70 Suppl 2:ii1-ii54. Open 3. David P Naidich, Alexander A Bankier, Heber MacMahon et al. Recommendations for the management of subsolid pulmonary nodules detected at CT a statement from the Fleischner Society. Radiology. 2013 Jan;266 1 304 17. Open 4. Maria D. Martin, MDa, Travis S. Henry et al. ACR Appropriateness Criteria Incidentally Detected Indeterminate Pulmonary Nodule. ACR. 2023. Open 5. Heber MacMahon, David P Naidich, Jin Mo Goo et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017 Jul;284 1 228 243. Open 6. Postmus PE, Kerr KM, Oudkerk M et al. Early and locally advanced non-small-cell lung cancer NSCLC ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017 Jul 1;28(suppl_4):iv1-iv21. Open 7. No authors listed. Correction to the British Thoracic Society guidelines for the investigation and management of pulmonary nodules: accredited by NICE August 01, 2015. Thorax. 2015 Dec;70 12 1188. Open 8. Alexander A Bankier, Heber MacMahon, Jin Mo Goo et al. Recommendations for Measuring Pulmonary Nodules at CT A Statement from the Fleischner Society. Radiology. 2017 Nov;285 2 584 600. Open https://web.pathway.md/diseases/recsevD9WLB4j15O1 6/6