Fleischner

Society 2017 pulmonary nodule guidelines

Management recommendations for incidentally detected pulmonary nodules on CT, organized by nodule type (solid, subsolid) and size, for patients 35 and older without known cancer or immunosuppression.

vigenteFleischner Society2017CT

Fonte primária 10 categorias

solid-single-<6Solid single nodule, under 6 mm solid-single-6to8Solid single nodule, 6 to 8 mm solid-single->8Solid single nodule, over 8 mm solid-multiple-<6Solid multiple nodules, under 6 mm solid-multiple->=6Solid multiple nodules, 6 mm or larger ggn-single-<6Ground glass single nodule, under 6 mm ggn-single->=6Ground glass single nodule, 6 mm or larger partsolid-single-<6Part solid single nodule, under 6 mm partsolid-single->=6Part solid single nodule, 6 mm or larger subsolid-multipleMultiple subsolid nodules

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Categorias

Reescritas a partir da fonte e citadas

solid-single-<6

1 de 10

Solid single nodule, under 6 mm

Single solid nodule under 6 mm (under ~100 mm3); recommendation differs by patient risk.

CondutaLow risk: no routine follow-up. High risk: optional CT at 12 months. The guideline notes that nodules under 6 mm generally need no routine follow-up, but selected high-risk patients with suspicious morphology and/or upper-lobe location may warrant a 12-month follow-up.

RiscoAverage malignancy risk is under 1% even in high-risk patients; suspicious morphology and/or upper-lobe location can raise the estimated risk into the 1%-5% range.

verificadoGuidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017Fleischner 2017 Table 1, Section A (Solid Nodules), Single, <6 mm row

solid-single-6to8

2 de 10

Solid single nodule, 6 to 8 mm

Single solid noncalcified nodule with mean diameter 6-8 mm (approximately 100-250 mm3); follow-up intensity depends on clinical risk and morphology.

CondutaLow risk: CT at 6-12 months, then consider CT at 18-24 months if morphology is suspicious or stability is uncertain. High risk: CT at 6-12 months and again at 18-24 months.

RiscoThe guideline estimates an average malignancy risk of approximately 0.5%-2.0% for solitary solid nodules in this size band; individual risk varies with morphology and patient factors.

verificadoGuidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017Fleischner 2017 Table 1, Section A (Solid Nodules), Single, 6-8 mm row

solid-single->8

3 de 10

Solid single nodule, over 8 mm

Single solid nodule larger than 8 mm (over ~250 mm3); same management for low and high risk.

CondutaConsider CT at 3 months, PET/CT, or tissue sampling (applies to both low- and high-risk single nodules).

RiscoThe guideline cites an average malignancy risk of approximately 3% for an 8-mm solitary nodule, while emphasizing that risk may be substantially higher according to size, morphology, location, and clinical factors.

verificadoGuidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017Fleischner 2017 Table 1, Section A (Solid Nodules), Single, >8 mm row

solid-multiple-<6

4 de 10

Solid multiple nodules, under 6 mm

Multiple solid nodules with the largest under 6 mm; recommendation differs by patient risk. Use the most suspicious nodule to guide management.

CondutaLow risk: no routine follow-up. High risk: optional CT at 12 months.

RiscoMost multiple solid nodules under 6 mm are benign healed granulomas or intrapulmonary lymph nodes; the guideline does not publish a per-row malignancy probability.

verificadoGuidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017Fleischner 2017 Table 1, Section A (Solid Nodules), Multiple, <6 mm row

solid-multiple->=6

5 de 10

Solid multiple nodules, 6 mm or larger

Multiple solid nodules with at least one in the 6-8 mm or >8 mm band. Use the most suspicious nodule to guide management; intervals may vary with size and risk.

CondutaCT at 3-6 months. At 18-24 months, CT is optional for low-risk patients and recommended for high-risk patients. If one nodule is larger or more suspicious, use its corresponding solitary-nodule pathway to guide management.

RiscoNo per-row malignancy percentage is given. The most suspicious nodule, which may not be the largest, drives risk assessment; multiplicity and the distribution and morphology of all nodules remain clinically relevant.

verificadoGuidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017Fleischner 2017 Table 1, Section A (Solid Nodules), Multiple, 6-8 mm and >8 mm columns

ggn-single-<6

6 de 10

Ground glass single nodule, under 6 mm

Single pure ground-glass nodule under 6 mm.

CondutaNo routine follow-up. In selected patients with a nodule close to 6 mm, suspicious morphology, or other risk factors, optional CT at approximately 2 and 4 years may be considered.

RiscoThe guideline cites data in which up to 10% of these nodules grew and nearly 1% progressed to adenocarcinoma over many years, supporting conservative management for most patients.

verificadoGuidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Ground glass, <6 mm column

ggn-single->=6

7 de 10

Ground glass single nodule, 6 mm or larger

Single pure ground-glass nodule 6 mm or larger.

CondutaCT at 6-12 months to confirm persistence, then CT every 2 years out to 5 years. If a solid component or growth develops, consider resection.

RiscoPersistent pure ground-glass nodules can represent indolent adenocarcinoma-spectrum lesions; the guideline notes that growth commonly requires 3-4 years to establish and does not provide a single per-row malignancy percentage.

partsolid-single-<6

8 de 10

Part solid single nodule, under 6 mm

Single apparent part-solid nodule under 6 mm. A discrete solid component cannot be measured reliably at this size, so the guideline treats it like a pure ground-glass nodule of the same size.

CondutaNo routine follow-up. Optional longer-term CT may be considered in selected patients when the nodule is close to 6 mm or has suspicious morphology or other risk factors.

RiscoThe guideline does not publish a separate malignancy probability for apparent part-solid nodules under 6 mm because a true solid component is not reliably defined at this size.

verificadoGuidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017MacMahon et al. 2017, Recommendation 4 (solitary part-solid nodules), first paragraph; Table 1 Section B, <6 mm column

partsolid-single->=6

9 de 10

Part solid single nodule, 6 mm or larger

Single part-solid nodule 6 mm or larger. The guideline notes part-solid nodules are generally not defined as such below 6 mm, and persistent part-solid nodules with a solid component of 6 mm or more should be regarded as highly suspicious.

CondutaCT at 3-6 months to confirm persistence. If unchanged and the solid component stays under 6 mm, annual CT for at least 5 years. If the solid component is 6 mm or larger, grows, exceeds 8 mm, or morphology is particularly suspicious, consider PET/CT, biopsy, or resection.

RiscoPart-solid nodules have a high likelihood of malignancy. A persistent solid component under 6 mm more often represents adenocarcinoma in situ or minimally invasive adenocarcinoma; a component 6 mm or larger is highly suspicious for invasive disease.

subsolid-multiple

10 de 10

Multiple subsolid nodules

Multiple subsolid nodules (ground-glass and/or part-solid). Multiple sub-6 mm pure ground-glass nodules are usually benign.

CondutaUnder 6 mm: CT at 3-6 months; if stable, consider CT at 2 and 4 years. 6 mm or larger: CT at 3-6 months, with subsequent management based on the most suspicious nodule(s).

RiscoMultiple tiny subsolid nodules may be infectious or inflammatory. If persistent, they may represent atypical adenomatous hyperplasia or adenocarcinoma in situ; when at least one lesion is 6 mm or larger, more than one suspicious lesion increases the overall likelihood of cancer.

verificadoGuidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017Fleischner 2017 Table 1, Section B (Subsolid Nodules), Multiple row

Lógica de decisão estruturada

Use the matching outcome_code for cited management and risk text. Do not apply this incidental-nodule algorithm to screening CT, known primary cancer, or immunosuppression.

{
  "applicability": {
    "use_for": "Incidentally detected pulmonary nodules on CT in adults age 35 years or older.",
    "exclude": [
      "lung_cancer_screening",
      "known_primary_cancer",
      "immunosuppression"
    ],
    "screening_alternative": "lung-rads-2022"
  },
  "measurement": {
    "technique": "Average the long and short axes on the plane showing the greatest dimensions and round to the nearest whole millimeter.",
    "thin_section_ct_mm_max": 1.5,
    "diameter_bands_mm": [
      "<6",
      "6-8",
      ">8"
    ],
    "equivalent_volume_thresholds_mm3": [
      100,
      250
    ],
    "compare_with": "earliest and most recent available prior CT"
  },
  "axes": {
    "attenuation": [
      "solid",
      "pure_ground_glass",
      "part_solid"
    ],
    "count": [
      "single",
      "multiple"
    ],
    "total_mean_diameter_mm": [
      "<6",
      "6-8",
      ">8"
    ],
    "solid_component_mm": [
      "<6",
      "6-8",
      ">8"
    ],
    "patient_risk_for_solid_nodules": [
      "low",
      "high"
    ]
  },
  "cells": [
    {
      "outcome_code": "solid-single-<6",
      "when": {
        "attenuation": "solid",
        "count": "single",
        "total_mean_diameter_mm": "<6"
      },
      "management_varies_by": "patient_risk_for_solid_nodules"
    },
    {
      "outcome_code": "solid-single-6to8",
      "when": {
        "attenuation": "solid",
        "count": "single",
        "total_mean_diameter_mm": "6-8"
      },
      "management_varies_by": "patient_risk_for_solid_nodules"
    },
    {
      "outcome_code": "solid-single->8",
      "when": {
        "attenuation": "solid",
        "count": "single",
        "total_mean_diameter_mm": ">8"
      }
    },
    {
      "outcome_code": "solid-multiple-<6",
      "when": {
        "attenuation": "solid",
        "count": "multiple",
        "largest_total_mean_diameter_mm": "<6"
      },
      "management_varies_by": "patient_risk_for_solid_nodules"
    },
    {
      "outcome_code": "solid-multiple->=6",
      "when": {
        "attenuation": "solid",
        "count": "multiple",
        "largest_total_mean_diameter_mm": ">=6"
      },
      "governing_lesion": "most_suspicious_not_necessarily_largest"
    },
    {
      "outcome_code": "ggn-single-<6",
      "when": {
        "attenuation": "pure_ground_glass",
        "count": "single",
        "total_mean_diameter_mm": "<6"
      }
    },
    {
      "outcome_code": "ggn-single->=6",
      "when": {
        "attenuation": "pure_ground_glass",
        "count": "single",
        "total_mean_diameter_mm": ">=6"
      }
    },
    {
      "outcome_code": "partsolid-single-<6",
      "when": {
        "attenuation": "part_solid",
        "count": "single",
        "total_mean_diameter_mm": "<6"
      },
      "caveat": "A discrete solid component is unreliable at this size; manage like a pure ground-glass nodule."
    },
    {
      "outcome_code": "partsolid-single->=6",
      "when": {
        "attenuation": "part_solid",
        "count": "single",
        "total_mean_diameter_mm": ">=6"
      },
      "escalation_axes": [
        "solid_component_mm",
        "growth",
        "lobulated_or_cystic_morphology"
      ]
    },
    {
      "outcome_code": "subsolid-multiple",
      "when": {
        "attenuation": [
          "pure_ground_glass",
          "part_solid"
        ],
        "count": "multiple"
      },
      "branches": [
        "all_under_6mm",
        "at_least_one_6mm_or_larger"
      ],
      "governing_lesion": "most_suspicious_not_necessarily_largest"
    }
  ],
  "modifiers_and_overrides": [
    {
      "if": "perifissural_or_juxtapleural morphology consistent with an intrapulmonary lymph node",
      "then": "no routine follow-up even when mean diameter exceeds 6 mm"
    },
    {
      "if": "solid nodule under 6 mm with suspicious morphology or upper-lobe location",
      "then": "consider the optional 12-month CT branch"
    },
    {
      "if": "part-solid solid component is 6 mm or larger",
      "then": "highly suspicious; short-term CT to confirm persistence and consider diagnostic evaluation"
    },
    {
      "if": "part-solid morphology is lobulated/cystic, solid component grows, or solid component exceeds 8 mm",
      "then": "consider PET/CT, biopsy, or resection"
    },
    {
      "if": "clinical infection or immunocompromise",
      "then": "the guideline is not directly applicable; individualized short-term evaluation may be appropriate"
    }
  ],
  "solid_nodule_risk_context": {
    "low": "Estimated cancer risk below 5%; typically younger age, less smoking, smaller size, regular margins, and non-upper-lobe location.",
    "high": "Combines ACCP intermediate and high risk; factors include older age, heavy smoking, larger size, irregular/spiculated margins, upper-lobe location, carcinogen exposure, emphysema/fibrosis, and family history.",
    "subsolid_note": "Subsolid recommendations are independent of the customary low/high clinical-risk split."
  },
  "source_locator": "MacMahon et al. Radiology 2017, Table 1 and Recommendations 1-5; General Recommendations; Risk Factors for Malignancy; Perifissural Nodules."
}

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