Fleischner Society Guidelines, 2013 Update: Frequent CT follow-up recommended for subsolid pulmonary 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 incidentally-detected, solitary, pure ground-glass nodules (GGNs) > 5 mm on computed tomography (CT), initial follow-up is recommended at 3 months, followed by annual CT surveillance. Nodules ≤ 5 mm require no follow-up.

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

3. In patients with incidentally-detected multiple pure GGNs > 5 mm without a dominant lesion, follow-up at 3 months with annual CT surveillance is recommended.

4. Solitary part-solid or multiple nodules with a dominant lesion require extended follow-up.

Original Date of Publication: January 2013

Study Rundown:

The original Fleischner Society Guidelines for pulmonary nodules published in 2005 provided guidance for follow-up of solitary pulmonary nodules found incidentally on CT. However, they did not provide specific considerations for a special subset of subsolid 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 guideline from the Fleischner Society was to provide recommendations for imaging follow-up of this unique subset of nodules. The position statement provided six recommendations for the management of subsolid pulmonary nodules found on CT, detailed in the schematic 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 in size. For subsolid nodules greater than 5 mm or for any solitary nodules with both subsolid and solid components, more frequent CT imaging follow-up is required starting at 3 months, followed by yearly CT surveillance for three years. The remaining three recommendations are related to multiple subsolid nodules. For patients with multiple subsolid nodules which are smaller than 5 mm in size, CT follow-up is recommended only 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 surveillance for three years. Finally, in patients with a dominant lesion which contains both subsolid and solid components, increased frequency of follow-up is recommended starting at 3 months, with recommendation for surgical biopsy or resection if the lesion persists and especially if it features a solid component > 5 mm. In addition to the six recommendations, the position statement highlights the importance of using contiguous thin sections (i.e. 1 mm slices) with mediastinal and lung windows to determine the presence of a non-solid component of pulmonary nodules. Additionally, the position statement clarified the use of position emission tomography (PET) in this subgroup as valuable only in the assessment of nodules with both solid and non-solid components greater than 10 mm in size. The recommendations are strengthened by the grading of each specific recommendation based on the quality of the evidence. The updated Fleischner Society Guidelines provide expert opinion based on currently available evidence and has been widely adopted as the imaging follow-up recommendation plan 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 at CT: A Statement from the Fleischner Society. Radiology. 2013 Jan 1;266(1):304–17.

Additional Review:

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

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