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    Fleischner Society Guidelines for Incidental Pulmonary Nodules

    Provides guidelines for management of solid and subsolid pulmonary nodules.
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    INSTRUCTIONS

    Use in patients ≥35 years old with incidental pulmonary nodules on CT imaging. Do not use for lung cancer screening or in patients with known primary cancer or immunosuppression. Use most suspicious nodule as guide to management. 

    When to Use
    Why Use

    • Patients ≥35 years old with incidental pulmonary nodules on CT scan.

    • Do not use for lung cancer screening or in patients with known primary cancer or immunosuppression.

    Incidental pulmonary nodules on imaging can be challenging to evaluate. These guidelines provide an accepted framework for management.

    Solid
    Subsolid
    Single
    Multiple

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    The Fleischner Society recommends that incidental nodules in patients <35 years old be managed on a case-by-case basis, as infectious causes are more likely than cancer (and therefore serial CT to monitor should be limited).

    Formula

    Choose the appropriate features. For nodule size, use the average of long and short axes and round to the nearest millimeter.

    Solid nodules:

    Size

    Single

    Multiple

    Low risk*

    High risk*

    Low risk*

    High risk*

    <6 mm (<100 mm3)

    No routine follow-up

    Optional CT at 12 months

    No routine follow-up

    Optional CT at 12 months

    6-8 mm (100-250 mm3)

    CT at 6-12 months, then consider CT at 18-24 months

    CT at 6-12 months, then CT at 18-24 months

    CT at 3-6 months, then consider CT at 18-24 months

    CT at 3-6 months, then at 18-24 months

    >8 mm (>250 mm3)

    Consider CT at 3 months, PET/CT, or tissue sampling

    Consider CT at 3 months, PET/CT, or tissue sampling

    CT at 3-6 months, then consider CT at 18-24 months

    CT at 3-6 months, then at 18-24 months

    Subsolid nodules:

    Size

    Single

    Multiple

    Ground glass

    Part solid

    <6 mm (<100 mm3)

    No routine follow-up

    No routine follow-up

    CT at 3-6 months. If stable, consider CT at 2 and 4 years

    ≥6 mm (≥100 mm3)

    CT at 6-12 months to confirm persistence, then CT every 2 years until 5 years

    CT at 3-6 months to confirm persistence. If unchanged and solid component remains <6 mm, annual CT should be performed for 5 years

    CT at 3-6 months. Subsequent management based on the most suspicious nodule(s)

    *Risk level is determined by clinical judgment, and all relevant risk factors should be considered, including:

    • Nodule size, morphology, location, multiplicity, growth rate, presence of emphysema, and evidence of fibrosis.

    • Age, race, sex, and family history of lung cancer.

    • Smoking status and exposure to other inhaled carcinogens.

    Dr. Heber MacMahon

    About the Creator

    Heber MacMahon, MB, BCh, is the section chief of thoracic radiology and a professor of radiology at the University of Chicago Medicine. He is also a leader in the University of Chicago Comprehensive Cancer Center's Advanced Imaging Program. Dr. MacMahon’s primary research is focused on thoracic diagnostic radiology, lung cancer detection, and computer-aided diagnosis.

    To view Dr. Heber MacMahon's publications, visit PubMed