Society management

Fleischner Society guidelines, 2013 update: Frequent CT follow-up recommended for subsolid lung nodules [Classics Series]

This study summary is an excerpt from the book 2 Minute Medicine’s The Classics in Medicine: Summaries of the Landmark Trials

1. In patients with solitary pure ground glass nodules (GGN) > 5 mm incidentally detected by computed tomography (CT), initial follow-up is recommended at 3 months, followed by annual CT surveillance. Nodules ≤ 5 mm do not require follow-up.

2. In patients with incidentally detected multiple pure GGNs ≤ 5 mm, follow-up CT scans at 2 and 4 years are recommended.

3. In patients with several pure GGNs > 5 mm accidentally detected without a dominant lesion, a 3-month follow-up with annual CT monitoring is recommended.

4. Solitary semi-solid or multiple nodules with a dominant lesion require prolonged follow-up.

Original publication date: January 2013

Summary of the study:

The original Fleischner Society guidelines for lung nodules published in 2005 provided guidance for follow-up of solitary lung nodules discovered incidentally on CT scan. However, they did not provide specific considerations for a special subset of subsolids or GGNs, nor the presence of multiple nodules. A previous study by Henschke et al. demonstrated that subsolid nodules have an increased risk of malignancy compared to pure solid nodules. The purpose of this landmark Fleischner Society guideline was to provide recommendations for the imaging follow-up of this unique subset of nodules. The position statement provided six recommendations for the management of subsolid lung nodules found on CT, detailed in the diagram on the following page. Three are related to solitary subsolid nodules. Specifically, the statement recommends no follow-up for solitary subsolid nodules less than 5 mm. For subsolid nodules greater than 5 mm or for any solitary nodule with both subsolid and solid components, more frequent CT imaging follow-up is required from 3 months, followed by annual CT surveillance for three years. The remaining three recommendations relate to multiple subsolid nodules. For patients with multiple subsolid nodules less than 5 mm in size, CT follow-up is only recommended at 2 and 4 years. Patients with multiple nodules as well as a dominant lesion (>5 mm) require more frequent follow-up starting at 3 months followed by annual CT monitoring for three years. Finally, in patients presenting with a dominant lesion containing both subsolid and solid components, an increased frequency of follow-up is recommended from 3 months, with the recommendation of a surgical biopsy or a resection if the lesion persists and above all if it has a solid component > 5 mm. In addition to the six recommendations, the position statement emphasizes the importance of using contiguous thin sections (i.e. 1 mm slices) with mediastinal and pulmonary windows to determine the presence of a component non-solid lung nodules. Additionally, the position statement clarified the use of positional emission tomography (PET) in this subgroup as being useful only in the evaluation of nodules with solid and non-solid components larger than 10 mm. of size. The recommendations are strengthened by ranking each specific recommendation according to the quality of the evidence. The updated Fleischner Society guidelines provide expert opinion based on currently available evidence and have been widely adopted as the blueprint for recommending follow-up imaging for the management of subsolid pulmonary nodules.

Click to read the study in Radiology

Naidich DP, Bankier AA, MacMahon H, Schaefer-Prokop CM, Pistolesi M, Goo JM, et al. Recommendations for the management of subsolid pulmonary nodules detected on CT scan: A statement from the Fleischner Society. Radiology. 2013 Jan 1;266(1):304–17.

Additional examination:

Henschke CI, Yankelevitz DF, Mirtcheva R, McGuinness G, McCauley D, Miettinen OS. CT Lung cancer screening. Am J Roentgenol. 2002 May 1;178(5):1053–7.

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