The Fleischner Society developed guidelines for managing a patient with a small pulmonary nodule detected on a CT scan.
Patient selection:
(1) age > 35 years
(2) incidental nodule found on CT scan of the chest
Parameters:
(1) length of the lesion in mm
(2) wideth of the lesion in mm
(3) low vs high risk patient
size of the lesion in mm =
= ((length) + (width)) / 2
High risk patients:
(1) history of smoking (other than minimal)
(2) history of lung cancer in a first degree relative
(3) exposure to asbestos
(4) exposure to uranium
(5) exposure to radon
Size in mm
Management of a Low Risk Patient
<= 4 mm
No follow-up.
4.1 to 6 mm
Follow-up CT at 12 months. If unchanged then no further follow-up.
6.1 to 8 mm
Follow-up CT at 6-12 months. If no change then follow-up at 18-24 months.
> 8 mm
Follow-up at 3, 9 and 24 months (see note).
where:
• Follow-up for a nodule > 8 mm may include dynamic contrast-enhanced CT, PET and/or biopsy.
Size in mm
Management of a High Risk Patient
<= 4 mm
Follow-up CT at 12 months. If unchanged then no further follow-up (see below).
4.1 to 6 mm
Follow-up CT at 6-12 months. If no change then follow-up at 18-24 months (see below).
6.1 to 8 mm
Follow-up CT at 3-6 months. If no change then follow-up at 9-12 months and at 24 months (see below).
> 8 mm
Follow-up at 3, 9 and 24 months (as above).
where:
• The recommendations for a high risk patient in the first and second categories is the same as the second and third categories for a low risk patient respectively.
• A high risk patient with a nonsolid ground glass or partly solid nodule should have a longer follow-up to exclude an indolent adenocarcinoma.
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