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Evaluation of the incidental subsolid pulmonary nodule in adults

Evaluation of the incidental subsolid pulmonary nodule in adults
Nodule type
and size (mm)
Recommendation Comments
Solitary pure ground-glass
<6 No routine follow-up. Consider CT at two and four years if patient is considered high risk for cancer.
≥6 CT at 6 to 12 months to confirm persistence. If unchanged, then CT every two years until five years. Growing nodules should undergo histologic sampling.* Histologic sampling requires resection as ground glass nodules are not amenable to needle biopsy.
Solitary part-solid
<6 No routine follow-up.

In practice, part-solid nodules <6 mm cannot be defined as such until ≥6 mm.  Consequently, these should be managed as a pure ground-glass nodule.

≥6 CT at three to six months to confirm persistence. If unchanged and solid component remains <6 mm, annual CT should be performed for five years. Nodules with solid component >8 mm or growing nodules should undergo histologic sampling.* For nodules with solid component ≤8 mm, histologic sampling requires resection as they are not amenable to needle biopsy.
Multiple
<6 CT at three to six months. If stable, no routine follow-up. Consider CT at two and four years if patient is considered high risk for cancer.
≥6 CT at three to six months. If stable, subsequent evaluation is based on the most suspicious nodule (largest nodule for pure ground-glass and largest solid component for part-solid).  
  1. Not applicable to patients age <35 years, in lung cancer screening, with immunosuppression, known pulmonary disease or symptoms or active primary cancer.
  2. Chest CT performed without contrast as contiguous 1 mm sections using low dose technique.
  3. Nodules unchanged for >5 years are benign.
CT: computed tomography.
* Growth is defined as >2 mm increase in overall size, increase in attenuation or appearance or enlargement of a solid component.
Adapted with permission from: MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT Images: From the Fleischner Society. Radiology 2017; 284:228. Copyright © 2017 Radiological Society of North America.
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