Chest
Volume 143, Issue 5, Supplement, May 2013, Pages e93S-e120S
Journal home page for Chest

Evaluation of Individuals With Pulmonary Nodules: When Is It Lung Cancer?: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.12-2351Get rights and content

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.

Methods

We updated prior literature reviews, synthesized evidence, and formulated recommendations by using the methods described in the “Methodology for Development of Guidelines for Lung Cancer” in the American College of Chest Physicians Lung Cancer Guidelines, 3rd ed.

Results

We formulated recommendations for evaluating solid pulmonary nodules that measure > 8 mm in diameter, solid nodules that measure ≤ 8 mm in diameter, and subsolid nodules. The recommendations stress the value of assessing the probability of malignancy, the utility of imaging tests, the need to weigh the benefits and harms of different management strategies (nonsurgical biopsy, surgical resection, and surveillance with chest CT imaging), and the importance of eliciting patient preferences.

Conclusions

Individuals with pulmonary nodules should be evaluated and managed by estimating the probability of malignancy, performing imaging tests to better characterize the lesions, evaluating the risks associated with various management alternatives, and eliciting their preferences for management.

Section snippets

General Approach

2.3.1. 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 (Grade 1C).

2.3.2. 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 (Grade 2C).

Remark: This recommendation applies only to solid nodules. For guidance about follow-up of subsolid nodules, see Recommendations 6.5.1 to

Methods

To update previously published guidelines for evaluation of individuals with pulmonary nodules,6 we repeated prior searches of Medline for studies of chest CT imaging, PET imaging, and transthoracic needle biopsy (TTNB) and performed new searches for studies of subsolid nodules, bronchoscopy, surgical complications, and methods to detect nodule growth (Appendix S1). All searches were performed in October 2011 and subsequently updated through May 2012. We identified additional articles by

Anatomic Imaging

Pulmonary nodule diagnosis begins with imaging studies. Recent attention has focused on studies of computer-assisted detection, computer-assisted diagnosis, volumetric measurement of growth, and functional imaging, as described in this section.

Suitability for Surgery or Other Curative-Intent Treatment

Before embarking on a potentially inconvenient, risky, and expensive evaluation, it is important to establish the individual's suitability and desire for curative treatment. Although therapeutic lobectomy frequently is contraindicated in individuals with advanced comorbid conditions, relatively few individuals will be excluded from consideration for sublobar resection or other less-invasive treatments (see Brunelli et al25 “Physiologic Evaluation of the Patient With Lung Cancer Being Considered

Solid Nodules Measuring > 8 mm in Diameter

Among individuals with a solid nodule measuring > 8 mm in diameter (either solitary or dominant), steps in the evaluation include estimating the probability of cancer; further characterizing the lesion with CT scan, PET scan, or another functional imaging test; and choosing among nonsurgical biopsy, surgical resection, and active surveillance with serial CT scans (Figs 1, 2).

Solid Nodules Measuring ≤ 8 mm in Diameter

On the basis of observations from lung cancer screening trials, the attenuation of nodules may be characterized as solid or subsolid. Subsolid nodules can be further classified as part-solid or pure ground glass (defined as focal densities in which underlying lung morphology is preserved). Part-solid and ground glass nodules are discussed subsequently. Solid nodules are the most frequently encountered type but least likely to be malignant among the three types.119, 120

Small, solid nodules can

Subsolid Nodules

In this section, we make recommendations for evaluation and management of asymptomatic individuals with focal, rounded opacities that are subsolid, that is, either nonsolid (pure ground glass) or part solid (with a solid component but > 50% ground glass). Recommendations are predicated on several competing considerations, including the relatively high prevalence of premalignant and malignant disease, uncertainty about the sensitivity of PET scan and needle biopsy, challenges associated with

Individuals With One or More Additional Nodules Detected During Nodule Evaluation

In individuals with known or suspected lung cancer, CT scan will frequently identify one or more additional nodules. Most of these additional nodules are benign. A study from Japan showed that 10% of patients with suspected lung cancer had a second nodule detected during subsequent evaluation, and 60% of these were benign at surgery.178 In another study, CT scan detected a second indeterminate nodule in 16% of patients with clinically operable stage I to IIIA non-small cell lung cancer.179 The

Conclusions and Recommendations for Research

The pulmonary nodule is increasingly common and remains a vexing problem. Individuals with solid nodules measuring > 8 mm should be managed by reviewing old imaging studies; estimating the probability of malignancy; performing imaging tests to better characterize the nodule; evaluating the risks associated with various management alternatives; and eliciting patient preferences for CT scan surveillance, nonsurgical biopsy, or surgical diagnosis. Solid nodules measuring ≤ 8 mm are infrequently

Acknowledgments

Author contributions: Dr Gould had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Gould: contributed to the conception and design, acquisition of data, analysis and interpretation of data, formulation and approval of the recommendations, drafting of the manuscript, revision of the manuscript for important intellectual content, and final approval of the article.

Dr Donington: contributed to the conception

References (183)

  • GJ Herder et al.

    Clinical prediction model to characterize pulmonary nodules: validation and added value of 18F-fluorodeoxyglucose positron emission tomography

    Chest

    (2005)
  • JM Isbell et al.

    Existing general population models inaccurately predict lung cancer risk in patients referred for surgical evaluation

    Ann Thorac Surg

    (2011)
  • MC Tammemagi et al.

    Prediction of true positive lung cancers in individuals with abnormal suspicious chest radiographs: a prostate, lung, colorectal, and ovarian cancer screening trial study

    J Thorac Oncol

    (2009)
  • MM Wahidi et al.

    Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition)

    Chest

    (2007)
  • H Mizugaki et al.

    Combining transbronchial biopsy using endobronchial ultrasonography with a guide sheath and positron emission tomography for the diagnosis of small peripheral pulmonary lesions

    Lung Cancer

    (2010)
  • T Mori et al.

    Diffusion-weighted magnetic resonance imaging for diagnosing malignant pulmonary nodules/masses: comparison with positron emission tomography

    J Thorac Oncol

    (2008)
  • T Berghmans et al.

    European Lung Cancer Working Party for the IASLC Lung Cancer Staging Project. Primary tumor standardized uptake value (SUVmax) measured on fluorodeoxyglucose positron emission tomography (FDG-PET) is of prognostic value for survival in non-small cell lung cancer (NSCLC): a systematic review and meta-analysis (MA) by the European Lung Cancer Working Party for the IASLC Lung Cancer Staging Project

    J Thorac Oncol

    (2008)
  • RS Wiener et al.

    “What do you mean, a spot?”: A qualitative analysis of patients' reactions to discussions with their doctors about pulmonary nodules

    Chest

    (2013)
  • GA Silvestri et al.

    Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

    Chest

    (2013)
  • RS Wiener et al.

    “What do you mean, a spot?”: A qualitative analysis of patients' reactions to discussions with their doctors about pulmonary nodules

    Chest

    (2013)
  • DM Geddes

    The natural history of lung cancer: a review based on rates of tumour growth

    Br J Dis Chest

    (1979)
  • N O'Rourke et al.

    Lung cancer treatment waiting times and tumour growth

    Clin Oncol (R Coll Radiol)

    (2000)
  • DE Ost et al.

    Clinical and organizational factors in the initial evaluation of patients with lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

    Chest

    (2013)
  • RJ Korst et al.

    The utility of automated volumetric growth analysis in a dedicated pulmonary nodule clinic

    J Thorac Cardiovasc Surg

    (2011)
  • PJ Nietert et al.

    Imprecision in automated volume measurements of pulmonary nodules and its effect on the level of uncertainty in volume doubling time estimation

    Chest

    (2009)
  • RM Lindell et al.

    5-year lung cancer screening experience: growth curves of 18 lung cancers compared to histologic type, CT attenuation, stage, survival, and size

    Chest

    (2009)
  • N Kothary et al.

    Computed tomography-guided percutaneous needle biopsy of pulmonary nodules: impact of nodule size on diagnostic accuracy

    Clin Lung Cancer

    (2009)
  • YL Ng et al.

    CT-guided percutaneous fine-needle aspiration biopsy of pulmonary nodules measuring 10 mm or less

    Clin Radiol

    (2008)
  • B Chakrabarti et al.

    Risk assessment of pneumothorax and pulmonary haemorrhage complicating percutaneous co-axial cutting needle lung biopsy

    Respir Med

    (2009)
  • MD Guimarães et al.

    Predictive complication factors for CT-guided fine needle aspiration biopsy of pulmonary lesions

    Clinics (Sao Paulo)

    (2010)
  • MP Rivera et al.

    Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

    Chest

    (2007)
  • DP Naidich et al.

    Solitary pulmonary nodules. CT-bronchoscopic correlation

    Chest

    (1988)
  • S Bandoh et al.

    Diagnostic accuracy and safety of flexible bronchoscopy with multiplanar reconstruction images and ultrafast Papanicolaou stain: evaluating solitary pulmonary nodules

    Chest

    (2003)
  • WJ Tuddenham

    Glossary of terms for thoracic radiology: recommendations of the Nomenclature Committee of the Fleischner Society

    AJR Am J Roentgenol

    (1984)
  • WJ Tuddenham

    Glossary of terms for thoracic radiology: recommendations of the Nomenclature Committee of the Fleischner Society

    AJR Am J Roentgenol

    (1984)
  • HJ Schünemann et al.

    Grading quality of evidence and strength of recommendations for diagnostic tests and strategies [published correction in BMJ. 2008;336(7654)]

    BMJ

    (2008)
  • CA Good

    Management of patient with solitary mass in lung

    Chic Med Soc Bull

    (1953)
  • CV Zwirewich et al.

    Solitary pulmonary nodule: high-resolution CT and radiologic-pathologic correlation

    Radiology

    (1991)
  • SS Siegelman et al.

    Pulmonary hamartoma: CT findings

    Radiology

    (1986)
  • SS Siegelman et al.

    Solitary pulmonary nodules: CT assessment

    Radiology

    (1986)
  • EA Zerhouni et al.

    CT of the pulmonary nodule: a cooperative study

    Radiology

    (1986)
  • CV Zwirewich et al.

    Solitary pulmonary nodule: high-resolution CT and radiologic-pathologic correlation

    Radiology

    (1991)
  • JH Woodring et al.

    Significance of wall thickness in solitary cavities of the lung: a follow-up study

    AJR Am J Roentgenol

    (1983)
  • JH Woodring et al.

    Significance of wall thickness in solitary cavities of the lung: a follow-up study

    AJR Am J Roentgenol

    (1983)
  • SW Harders et al.

    High resolution spiral CT for determining the malignant potential of solitary pulmonary nodules: refining and testing the test

    Acta Radiol

    (2011)
  • S Diederich et al.

    Resolving small pulmonary nodules: CT features

    Eur Radiol

    (2005)
  • K Mori et al.

    Development of a novel computer-aided diagnosis system for automatic discrimination of malignant from benign solitary pulmonary nodules on thin-section dynamic computed tomography

    J Comput Assist Tomogr

    (2005)
  • A Berrington de González et al.

    Projected cancer risks from computed tomographic scans performed in the United States in 2007

    Arch Intern Med

    (2009)
  • R Smith-Bindman et al.

    Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer

    Arch Intern Med

    (2009)
  • JR Mayo et al.

    Radiation exposure at chest CT: a statement of the Fleischner Society

    Radiology

    (2003)
  • Cited by (1046)

    View all citing articles on Scopus

    COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

    Disclaimer: American College of Chest Physicians guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

    Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

    View full text