Pulmonary nodule medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Overview

The optimal management approach of solitary pulmonary nodule mainly depends on the nodule size and growth. Other parameters, such as location and distribution may also be helpful. Surgical resection is often recommended among patients with a malignant likelihood of solitary pulmonary nodule. On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance.

Medical Therapy

  • The optimal management approach of solitary pulmonary nodule mainly depends on the nodule size and growth.
  • Other parameters, such as location and distribution may also be helpful.
  • The solitary pulmonary nodule risk assessment is useful to determine the likelihood of malignancy and prompt treatment.
  • Surgical resection is often recommended among patients with a malignant likelihood of solitary pulmonary nodule.
  • On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance.

Management Strategies

The algorithm below summarizes the different management strategies for patients with pulmonary nodule:

Solid solitary pulmonary nodule
< 8mm
 
Solid solitary pulmonary nodule
> 8mm
 
 
 
Subsolid/part-solid nodule
 
 
 
Multiple
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-enhanced CT scan (NECT)
*Frequency depends on individual risk assesment
 
Malignancy risk assessment
 
< 5mm
 
> 5mm
 
Each nodule should be assessed individually*
CT surveillance and biopsy accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intermediate Risk
Positron emission tomography
If positive, request biopsy or surgical excision
If negative, serial CT scans*

High Risk
Biopsy
or
Surgical excision
 
CT Surveillance
Every 3 months
 
No additional work-up
 
 
 
 
 
 

Follow-Up and Surveillance

  • Guideline treatment and management recommendations for solitary pulmonary nodule include:
  • American College of Chest Physicians (ACCP) guidelines
  • Fleischner Society guidelines
  • The table below summarizes the follow-up and surveillance recommendations for solitary pulmonary nodule according to the Fleischner Society guidelines.
Recommendations for Follow-up and Management of Nodules <8 mm
Detected Incidentally at Non-screening CT
Nodule Size (mm) Low risk patients High risk patients
Less than or equal to 4 No follow-up needed Follow-up at 12 months. If no change, no further imaging needed
> 4 - 6 Follow-up at 12 months. If no change, no further imaging needed Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change
> 6 - 8 Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change. Initial follow-up CT at 3 - 6 months and then at 9 -12 and 24 months if no change
> 8 Follow-up CTs at around 3, 9, and 24 months. Dynamic contrast enhanced CT, PET, and/or biopsy Same at for low risk patients
Note: Newly detected indeterminate nodule in persons 35 years of age or older.[1]
* Low risk patients: Minimal or absent history of smoking and of other known risk factors.
* High risk patients: History of smoking or of other known risk factors.

References

  1. Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society. Radiology 2005 237: 395-400.

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