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Pulmonary nodules

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Updated 2023 ACR guidelines for the evaluation of incidentally detected indeterminate pulmonary nodules.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of pulmonary nodules are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2023), the Fleischner Society (FS 2017,2013), the British Thoracic Society (BTS 2015), and the American College of Chest Physicians (ACCP 2013). ...
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Classification and risk stratification

Malignancy risk assessment: as per BTS 2015 guidelines, use composite prediction models based on clinical and radiological factors to estimate the probability of malignancy of a pulmonary nodule (≥ 8 mm or ≥ 300 mm³).
B
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Diagnostic investigations

CT, indications: as per BTS 2015 guidelines, use a maximum section thickness of 1.25 mm when obtaining CT involving the chest where nodule detection is of potential importance.
B
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  • CT (technical considerations)

  • PET-CT

  • Other imaging techniques

  • Laboratory markers

Diagnostic procedures

Bronchoscopy
As per BTS 2015 guidelines:
Consider performing bronchoscopy in the evaluation of pulmonary nodules with bronchus sign present on CT.
C
Consider augmenting yield from bronchoscopy using either radial endobronchial ultrasound, fluoroscopy or electromagnetic navigation.
C

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  • Lung biopsy

Medical management

ICSs: as per BTS 2015 guidelines, do not use ICSs in the management of indeterminate pulmonary nodules.
D

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  • Antibiotics

Therapeutic procedures

Radiotherapy and radiofrequency ablation
As per BTS 2015 guidelines:
Consider offering stereotactic ablative body radiotherapy or radiofrequency ablation, if technically suitable, in patients unfit for surgery having pulmonary nodules with a high probability of malignancy where biopsy is nondiagnostic or not possible.
C
Consider offering conventional radical radiotherapy, if not suitable for stereotactic ablative body radiotherapy or radiofrequency ablation, in patients unfit for surgery having pulmonary nodules with a high probability of malignancy where biopsy is nondiagnostic or not possible.
C

Surgical interventions

Surgical resection, indications: as per BTS 2015 guidelines, discuss the options of observation with repeat CT, CT-guided biopsy, or resection/non-surgical treatment with the patient with an approximate risk of malignancy of > 10%, taking into account factors such as age, comorbidities, and risk of surgery.
B
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  • Surgical resection (technical considerations)

Specific circumstances

Patients with incidental nodules: as per BTS 2015 guidelines, use the same diagnostic approach for nodules detected incidentally as those detected through screening.
B

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  • Patients with current or previous malignancy

Patient education

General counseling: as per BTS 2015 guidelines, provide patients and carers with accurate and understandable information about the probability of malignancy of the pulmonary nodule.
B
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Follow-up and surveillance

Follow-up imaging, general principles: as per BTS 2015 guidelines, offer CT surveillance in patients with nodules ≥ 5 mm to < 8 mm maximum diameter or ≥ 80 mm³ to < 300 mm³.
B
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  • Follow-up imaging, solid nodules

  • Follow-up imaging, subsolid nodules

  • Follow-up imaging, nonsolid nodules

  • Follow-up imaging, nodules with benign features