Table of contents
Pulmonary nodules
What's new
Updated 2024 AATS guidelines for the management and surveillance of 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 Association for Thoracic Surgery (AATS 2024), 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
Definitions: as per AATS 2024 guidelines, define a subsolid lung nodule as a CT-identified focal ground-glass opacity with variable solid components within which underlying pulmonary vessels or bronchial structures remain visible.
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Malignancy risk assessment
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.
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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.
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Consider augmenting yield from bronchoscopy using either radial endobronchial ultrasound, fluoroscopy or electromagnetic navigation.
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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.
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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.
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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.
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Surgical interventions
Surgical resection, indications: as per AATS 2024 guidelines, consider performing sublobar resection (wedge resection or segmentectomy) of peripheral subsolid lesions < 20 mm in patients medically suitable for and amenable to surgery.
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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.
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Patients with current or previous malignancy
Patient education
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.
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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