Pulmonary nodule on x-ray: An algorithmic approach

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Applied Evidence

Pulmonary nodule on x-ray: An algorithmic approach

J Fam Pract. 2016 February;65(2):103-107,110-111

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References

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Patients with no risk factors for malignancy. The frequency of surveillance CT is determined by the size of the nodule. Nodules ≤4 mm do not need to be followed. For nodules >4 mm to 6 mm, a repeat CT in 12 months is recommended with no follow-up if stable. For nodules >6 to <8 mm, repeat CT is recommended at 6 to 12 months, and again between 18 and 24 months if unchanged.¹Patients with one or more risk factors for malignancy. Nodules ≤4 mm should be reevaluated at 12 months in patients with one or more risk factors; no additional follow-up is needed if unchanged. For nodules >4 mm to 6 mm, CT should be repeated between 6 and 12 months and again between 18 and 24 months. Nodules >6 mm to <8 mm should be followed initially between 3 to 6 months, then between 9 and 12 months and again at 24 months if unchanged.¹

Subsolid nodules have a high prevalence of premalignant and malignant disease.

Subsolid nodules require a different approach

Subsolid nodules have a high prevalence of premalignant and malignant disease (adenocarcinoma in situ, minimally invasive adenocarcinoma, and adenocarcinoma). Studies have reported subsolid nodule malignancy rates ranging from 20% to 75%.^11-15 This wide range may be a function of different nodule sizes or rates of biopsy. The prevalence increases even further in nodules with a part solid component.

These factors, plus challenges in measuring serial growth on CT and the uncertain prognosis of untreated premalignant disease, make it necessary to have separate guidelines for managing subsolid nodules. The Fleischner Society, National Comprehensive Cancer Network, and the American College of Radiology (LungRads) each have differing recommendations on the frequency of follow-up for different-sized subsolid nodules. Newer studies favor a more conservative approach.¹⁶ Here we describe the current ACCP guidelines for managing subsolid nodules (ALGORITHM 3).¹

GGNs. In an individual with a pure GGN ≤5 mm in diameter, no further evaluation is recommended. In an individual with a pure GGN >5 mm in diameter, annual surveillance with chest CT for at least 3 years is recommended.¹

Part solid nodules. In an individual with a part solid nodule ≤8 mm, conduct CT surveillance at 3, 12, and 24 months and then annually for an additional one to 3 years. In a patient with a part solid nodule >8 mm to 15 mm, repeat chest CT at 3 months followed by a PET scan, nonsurgical biopsy, and/or surgical resection if the nodule persists. A patient with a part solid nodule >15 mm should undergo a PET scan, nonsurgical biopsy, and/or surgical resection.

CASE 2 › Ms. G is seen in the office by her FP, and they discuss management options. A repeat CT is done in 3 months and shows a persistent, unchanged nodule. Ms. G opts for a transthoracic biopsy, which reveals adenocarcinoma. Following a PET scan, which shows no evidence of metastasis, curative surgical wedge resection is done.

Multiple subsolid nodules. In a patient who has a dominant nodule and one or more additional nodules, each nodule should be evaluated individually, according to recommendations from the Fleischner Society (the ACCP currently does not have guidelines for managing multiple subsolid nodules). An individual with multiple GGNs that all measure ≤5 mm should receive CT exams at 2 and 4 years.¹³ A patient with multiple GGNs that include at least one nodule >5 mm but no dominant nodule should undergo follow-up CT at 3 months and annual CT surveillance for at least 3 years.¹³

CORRESPONDENCE
Samina Yunus, MD, MPH, Cleveland Clinic, Family Medicine, 551 East Washington Street, Chagrin Falls, OH 44022; yunuss@ccf.org.