Evaluation Of Individuals With Pulmonary Nodules: When Is It Lung Cancer? Diagnosis And Management Of Lung Cancer

Publication Date: May 1, 2013
Last Updated: March 14, 2022

Recommendations

Anatomic Imaging

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. (1, C)
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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. (2, C)
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In the individual with an indeterminate nodule that is identifi ed by chest radiography, we recommend that CT of the chest should be performed (preferably with thin sections through the nodule) to help characterize the nodule. (1, C)
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Solid Nodules Measuring >8 mm in Diameter

In the individual with a solid, indeterminate nodule that measures >8 mm in diameter, we suggest that clinicians estimate the pretest probability of malignancy either qualitatively by using their clinical judgment and/or quantitatively by using a validated model. (2, C)
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In the individual with a solid, indeterminate nodule that measures >8 mm in diameter and low to moderate pretest probability of malignancy (5%-65%), we suggest that functional imaging, preferably with PET, should be performed to characterize the nodule. (2, C)
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In the individual with a solid, indeterminate nodule that measures >8 mm in diameter and a high pretest probability of malignancy (>65%), we suggest that functional imaging should not be performed to characterize the nodule. (2, C)
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In the individual with a solid, indeterminate nodule that measures >8 mm in diameter, we recommend that clinicians discuss the risks and benefits of alternative management strategies and elicit patient preferences for management. (1, C)
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In the individual with a solid, indeterminate nodule that measures >8 mm in diameter, we suggest surveillance with serial CT scans in the following circumstances:
• When the clinical probability of malignancy is very low ( <5%)
• When clinical probability is low (<30% to 40%) and the results of a functional imaging test are negative (ie, the lesion is not hypermetabolic by PET or does not enhance >15 HUs on dynamic contrast CT), resulting in a very-low post-test probability of malignancy
• When needle biopsy is nondiagnostic and the lesion is not hypermetabolic by PET
• When a fully informed patient prefers this nonaggressive management approach.
(2, C)
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In the individual with a solid, indeterminate nodule that measures >8 mm in diameter who undergoes surveillance, we suggest that serial CT scans should be performed at 3 to 6, 9 to 12, and 18 to 24 months, using thin sections and noncontrast, low-dose techniques. (2, C)
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In the individual with a solid, indeterminate nodule that shows clear evidence of malignant growth on serial imaging, we recommend nonsurgical biopsy and/or surgical resection unless specifically contraindicated. (1, C)
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In the individual with a solid, indeterminate nodule that measures >8 mm in diameter, we suggest nonsurgical biopsy in the following circumstances:

• When clinical pretest probability and findings on imaging tests are discordant
• When the probability of malignancy is low to moderate (~10% to 60%)
• When a benign diagnosis requiring specific medical treatment is suspected
• When a fully informed patient desires proof of a malignant diagnosis prior to surgery, especially when the risk of surgical complications is high.

(2, C)
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In the individual with a solid, indeterminate nodule that measures >8 mm in diameter, we suggest surgical diagnosis in the following circumstances:

• When the clinical probability of malignancy is high (>65%)
• When the nodule is intensely hypermetabolic by PET or markedly positive by another functional imaging test
• When nonsurgical biopsy is suspicious for malignancy
• When a fully informed patient prefers undergoing a defi nitive diagnostic procedure.

(2, C)
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In the individual with a solid, indeterminate nodule measuring ≥8 mm in diameter who chooses surgical diagnosis, we recommend thoracoscopy to obtain a diagnostic wedge resection. (1, C)
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Solid Nodules Measuring  ≤8 mm in Diameter

In the individual with a solid nodule that measures ≤8 mm in diameter and no risk factors for lung cancer, we suggest that the frequency and duration of CT surveillance be chosen according to the size of the nodule:

• Nodules measuring ≤4 mm in diameter need not be followed, but the patient should be informed about the potential benefi ts and harms of this approach.
• Nodules measuring >4 mm to 6 mm should be reevaluated at 12 months without the need for additional follow-up if unchanged.
• Nodules measuring >6 mm to 8 mm should be followed sometime between 6 and 12 months and then again at between 18 and 24 months if unchanged.

(2, C)
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In the individual with a solid nodule that measures ≤8 mm in diameter who has one or more risk factors for lung cancer, we suggest that the frequency and duration of CT surveillance be chosen according to the size of the nodule:

• Nodules measuring ≤4 mm in diameter should be reevaluated at 12 months without the need for additional follow-up if unchanged.
• Nodules measuring >4 mm to 6 mm should be followed sometime between 6 and 12 months and then again between 18 and 24 months if unchanged.
• Nodules measuring >6 mm to 8 mm should be followed initially sometime between 3 and 6 months, then subsequently between 9 and 12 months, and again at 24 months if unchanged.

(2, C)
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Subsolid Nodules

In the individual with a nonsolid (pure ground glass) nodule measuring ≤5 mm in diameter, we suggest no further evaluation. (2, C)
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In the individual with a nonsolid (pure ground glass) nodule measuring >5 mm in diameter, we suggest annual surveillance with chest CT for at least 3 years. (2, C)
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In the individual with a part-solid nodule measuring ≤8 mm in diameter, we suggest CT surveillance at approximately 3, 12, and 24 months, followed by annual CT surveillance for an additional 1 to 3 years. (2, C)
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In the individual with a part-solid nodule measuring >8 mm in diameter, we suggest repeat chest CT at 3 months, followed by further evaluation with PET, nonsurgical biopsy, and/or surgical resection for nodules that persist. (2, C)
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Individuals With One or More Additional Nodules Detected During Nodule Evaluation

In the individual with a dominant nodule and one or more additional small nodules, we suggest that each nodule be evaluated individually and curative treatment not be denied unless there is histopathological confirmation of metastasis. (2, C)
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Recommendation Grading

Overview

Title

Evaluation Of Individuals With Pulmonary Nodules: When Is It Lung Cancer? Diagnosis And Management Of Lung Cancer

Authoring Organization

Publication Month/Year

May 1, 2013

Last Updated Month/Year

January 9, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The objective of this article is to update previous evidence-based recommendations for evaluation and management of individuals with solid pulmonary nodules and to generate new recommendations for those with nonsolid nodules.

Target Patient Population

Patients with pulmonary nodules

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Operating and recovery room, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management

Diseases/Conditions (MeSH)

D008175 - Lung Neoplasms, D055613 - Multiple Pulmonary Nodules, D001706 - Biopsy, D003952 - Diagnostic Imaging

Keywords

lung cancer, imaging, CT imaging, nodules, biopsy

Methodology

Number of Source Documents
183
Literature Search Start Date
October 1, 2011
Literature Search End Date
May 1, 2012