From the Guidelines
The management of incidental pulmonary nodules (IPNs) involves a multidisciplinary approach, with initial assessment of nodule size, shape, and location.
Key Considerations
- For solid nodules ≥8mm, a low-dose computed tomography (LDCT) scan is recommended at 3,6, and 12 months to assess for growth, with consideration of positron emission tomography (PET) scan if significant growth is observed 1.
- For subsolid nodules, a follow-up LDCT scan is recommended at 6 and 12 months, with consideration of nodule resection if persistent or growing 1.
- The minimum threshold size for recommending follow-up is based on an estimated cancer risk in a nodule on the order of 1% or greater 1.
- CT Chest Without IV Contrast is the modality of choice to evaluate pulmonary nodules, with thin-section CT being 10 to 20 times more sensitive than standard radiography 1.
- Certain nodule characteristics suggestive of benign etiology, such as diffuse, central, laminated, or popcorn calcifications patterns, are better appreciated by CT and can avoid additional workup 1.
- Patient preferences and risk factors should be taken into account when making management decisions, with guidelines allowing flexibility to accommodate individual patient needs 1.
- Low-dose technique is recommended for CTs performed to follow lung nodules, with standardization of acquisition and reconstruction CT protocols to ensure accurate comparisons 1.
From the Research
Management Approach for Incidental Pulmonary Nodules
The management of incidental pulmonary nodules involves a multidisciplinary approach, with radiology playing a pivotal role 2. The following are key points to consider:
- The imaging evaluation of pulmonary nodules is a frequently encountered clinical circumstance, and advances in imaging modalities have improved detection and characterization 2.
- A set of criteria can define a benign nodule, including the lack of temporal change for 2 years or more, and certain benign imaging criteria, such as specific patterns of calcification or the presence of fat 2.
- For indeterminate pulmonary nodules, serial CT examinations through at least 2 years for solid nodules and 3 years for ground-glass nodules can demonstrate either benign biologic behavior or otherwise 2.
- The management of incidental pulmonary nodules can be optimized through a multidisciplinary approach, with a team of healthcare professionals working together to streamline care and improve adherence to recommendations 3.
Diagnostic Evaluation and Follow-up
The diagnostic evaluation of incidental pulmonary nodules should include:
- Consideration of any earlier imaging studies that may be available as an indication of possible growth over time 4.
- Assessment of nodule size, consistency, margin, and shape 5.
- Evaluation of localization, nodule number, presence or absence of growth, and volume doubling time 5.
- Follow-up CT scans at recommended intervals, such as 12 months for high-risk persons with nodules <4mm, and annual repeat scans for solid, smooth or attached indeterminate nodules between 5 and 10mm 5.
Guidelines and Recommendations
Guidelines for the management of incidental pulmonary nodules recommend:
- Preventing both over- and under-treatment 4.
- Providing further care by an interdisciplinary team if a tumor is suspected 4.
- Using a 10-step approach for routinely detected sub-centimeter non-calcified pulmonary nodules on a multi-detector CT in healthy persons 5.
- Implementing lung nodule programs, patient tracking software, artificial intelligence, and communication software to improve process management and achieve stage shift in lung cancer diagnosis 6.