Chest
Evaluation of Individuals With Pulmonary Nodules: When Is It Lung Cancer?: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Section snippets
General Approach
2.3.1. In the individual with an indeterminate nodule that is visible on chest radiography and/or chest CT, we recommend that prior imaging tests should be reviewed (Grade 1C).
2.3.2. In the individual with a solid, indeterminate nodule that has been stable for at least 2 years, we suggest that no additional diagnostic evaluation need be performed (Grade 2C).
Remark: This recommendation applies only to solid nodules. For guidance about follow-up of subsolid nodules, see Recommendations 6.5.1 to
Methods
To update previously published guidelines for evaluation of individuals with pulmonary nodules,6 we repeated prior searches of Medline for studies of chest CT imaging, PET imaging, and transthoracic needle biopsy (TTNB) and performed new searches for studies of subsolid nodules, bronchoscopy, surgical complications, and methods to detect nodule growth (Appendix S1). All searches were performed in October 2011 and subsequently updated through May 2012. We identified additional articles by
Anatomic Imaging
Pulmonary nodule diagnosis begins with imaging studies. Recent attention has focused on studies of computer-assisted detection, computer-assisted diagnosis, volumetric measurement of growth, and functional imaging, as described in this section.
Suitability for Surgery or Other Curative-Intent Treatment
Before embarking on a potentially inconvenient, risky, and expensive evaluation, it is important to establish the individual's suitability and desire for curative treatment. Although therapeutic lobectomy frequently is contraindicated in individuals with advanced comorbid conditions, relatively few individuals will be excluded from consideration for sublobar resection or other less-invasive treatments (see Brunelli et al25 “Physiologic Evaluation of the Patient With Lung Cancer Being Considered
Solid Nodules Measuring > 8 mm in Diameter
Among individuals with a solid nodule measuring > 8 mm in diameter (either solitary or dominant), steps in the evaluation include estimating the probability of cancer; further characterizing the lesion with CT scan, PET scan, or another functional imaging test; and choosing among nonsurgical biopsy, surgical resection, and active surveillance with serial CT scans (Figs 1, 2).
Solid Nodules Measuring ≤ 8 mm in Diameter
On the basis of observations from lung cancer screening trials, the attenuation of nodules may be characterized as solid or subsolid. Subsolid nodules can be further classified as part-solid or pure ground glass (defined as focal densities in which underlying lung morphology is preserved). Part-solid and ground glass nodules are discussed subsequently. Solid nodules are the most frequently encountered type but least likely to be malignant among the three types.119, 120
Small, solid nodules can
Subsolid Nodules
In this section, we make recommendations for evaluation and management of asymptomatic individuals with focal, rounded opacities that are subsolid, that is, either nonsolid (pure ground glass) or part solid (with a solid component but > 50% ground glass). Recommendations are predicated on several competing considerations, including the relatively high prevalence of premalignant and malignant disease, uncertainty about the sensitivity of PET scan and needle biopsy, challenges associated with
Individuals With One or More Additional Nodules Detected During Nodule Evaluation
In individuals with known or suspected lung cancer, CT scan will frequently identify one or more additional nodules. Most of these additional nodules are benign. A study from Japan showed that 10% of patients with suspected lung cancer had a second nodule detected during subsequent evaluation, and 60% of these were benign at surgery.178 In another study, CT scan detected a second indeterminate nodule in 16% of patients with clinically operable stage I to IIIA non-small cell lung cancer.179 The
Conclusions and Recommendations for Research
The pulmonary nodule is increasingly common and remains a vexing problem. Individuals with solid nodules measuring > 8 mm should be managed by reviewing old imaging studies; estimating the probability of malignancy; performing imaging tests to better characterize the nodule; evaluating the risks associated with various management alternatives; and eliciting patient preferences for CT scan surveillance, nonsurgical biopsy, or surgical diagnosis. Solid nodules measuring ≤ 8 mm are infrequently
Acknowledgments
Author contributions: Dr Gould had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Dr Gould: contributed to the conception and design, acquisition of data, analysis and interpretation of data, formulation and approval of the recommendations, drafting of the manuscript, revision of the manuscript for important intellectual content, and final approval of the article.
Dr Donington: contributed to the conception
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COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.
Disclaimer: American College of Chest Physicians guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.
Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.