Fleischner Society pulmonary nodule recommendations

The Fleischner society pulmonary nodule recommendations are for the follow-up and management of pulmonary nodules smaller than 8 mm detected incidentally in patients >35 years on non-screening CT.

Solid nodules

Nodule size: less than or equal to≤ 4 mm

• low risk patients: no follow-up needed
• high risk patients: follow-up at 12 months and if no change, no further imaging needed

Nodule size: > 4-6 mm

• low risk patients: follow-up at 12 months and if no change, no further imaging needed
• high risk patients: initial follow-up CT at 6-12 months and then at 18-24 months if no change

Nodule size: > 6;6-8 mm

• low risk patients: initial follow-up CT at 6-12 months and then at 18-24 months if no change
• high risk patients: initial follow-up CT at 3-6 months and then at 9-12 and 24 months if no change

Nodule size: > 8;8 mm

• either low or high risk patients
  • follow-up CTs at around 3, 9, and 24 months
  • dynamic contrast enhanced CT, PET, and/or biopsy 

Note: newly detected indeterminate nodule in persons 35 years of age or older.

• low risk patients: minimal or absent history of smoking and or other known risk factors
• high risk patients: history of smoking or of other known risk factors (e.g. first degree relative with lung cancer, or exposure to asbestos, radon, uranium)
• if a nodule up to 8 mm is partly solid or is ground glass further follow up is required after 24 months to exclude possible slow growing adenocarcinoma (BAC) 

Sub solid nodules

Solitary pure ground-glass nodules ²

• nodule size ≤ 5mm
  • no CT follow up required
• nodule size > 5mm
  • follow up CT at 3 months, then annual CT for at least 3 years

Solitary part-solid nodules ²

• initial follow-up CT at 3 months
• if persistent and solid component <5mm
  • annual CT for at least 3 years
• if persistent and solid component ≥ 5mm
  • biopsy or surgical resection

Multiple subsolid nodules

• pure ground glass nodules ≤ 5mm
  • CT at 2 and 4 years
• pure ground glass nodules >5mm, without a dominant lesion(s)
  • initial follow-up CT at 3 months, than annual CT for at least 3 years
• dominant nodule(s) with part-solid or solid component
  • initial follow-up CT at 3 months
  • if persistent, biopsy or surgical resection (especially if has >5mm solid component).

See also

• incidental lung nodules
• British thoracic society guidelines for pulmonary nodules (2015)