Pulmonary nodule medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Overview

The optimal management approach of solitary pulmonary nodule mainly depends on the nodule size and growth. Other parameters, such as location and distribution may also be helpful. Surgical resection is often recommended among patients with a malignant likelihood of solitary pulmonary nodule. On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance.

Medical Therapy

The optimal management approach of solitary pulmonary nodule mainly depends on the nodule size and growth.
Other parameters, such as location and distribution may also be helpful.
The solitary pulmonary nodule risk assessment is useful to determine the likelihood of malignancy and prompt treatment.
Surgical resection is often recommended among patients with a malignant likelihood of solitary pulmonary nodule.
On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance.

Management Strategies

The algorithm below summarizes the different management strategies for patients with pulmonary nodule:

Solid solitary pulmonary nodule
< 8mm

Solid solitary pulmonary nodule
> 8mm

Subsolid/part-solid nodule

Multiple

Non-enhanced CT scan (NECT)
*Frequency depends on individual risk assesment

Malignancy risk assessment

< 5mm

> 5mm

Each nodule should be assessed individually*
CT surveillance and biopsy accordingly

Intermediate Risk
Positron emission tomography
If positive, request biopsy or surgical excision
If negative, serial CT scans*
High Risk
Biopsy
or
Surgical excision

CT Surveillance
Every 3 months

No additional work-up

Follow-Up and Surveillance

Guideline treatment and management recommendations for solitary pulmonary nodule include:

American College of Chest Physicians (ACCP) guidelines
Fleischner Society guideline

The table below summarizes the follow-up and surveillance recommendations for solitary pulmonary nodule according to the Fleischner Society guideline:


Recommendations for Follow-up and Management of Nodules <8 mm Detected Incidentally at Non-screening CT
Nodule Size (mm)	Low risk patients	High risk patients
≤ 4	No follow-up needed	Follow-up at 12 months If no change, no further imaging needed
> 4 – 6	Follow-up at 12 months If no change, no further imaging needed	Initial follow-up CT at 6 -12 months and then at 18 – 24 months if no change
> 6 – 8	Initial follow-up CT at 6 -12 months and then at 18 – 24 months if no change	Initial follow-up CT at 3 – 6 months and then at 9 -12 and 24 months if no change
> 8	Follow-up CT at around 3, 9, and 24 months Dynamic contrast enhanced CT, PET, and/or biopsy	Same at for low risk patients

Note: Newly detected indeterminate nodule in persons 35 years of age or older.^[1]
* Low risk patients: Minimal or absent history of smoking and of other known risk factors
* High risk patients: History of smoking or of other known risk factors

References

↑ Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society. Radiology 2005 237: 395-400.

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[1] Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society. Radiology 2005 237: 395-400.

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