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.  The initial guidelines for the management of solid nodules were released in 2005 ¹, and guidelines for the management of subsolid nodules were released in 2013 ². New revised 2017 recommendations for both solid and subsolid have since been released ⁴.

New2017 guidelines

Solid nodules

Solitary nodule size: <6 mm 

• low risk patients: no follow-up needed
• high risk patients: optional CT at 12 months

Solitary nodule size: 6-8 mm

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

Solitary nodule size: >8 mm

• either low or high risk patients
  • consider follow-up CT at 3 months, and/or CT-PET, and/or biopsy

Multiple nodules size: <6 mm

• low risk patients: no routine follow-up
• high risk patients: optional CT at 12 months

Multiple nodules size: 6-8 mm

• low risk patients: follow-up at 3-6 months, then consider further follow-up at 18-24 months
• high risk patients: follow-up at 3-6 months, then at 18-24 months if no change

Multiple nodules size: >8 mm

• low risk patients: follow-up at 3-6 months, then consider further follow-up at 18-24 months
• high risk patients: follow-up at 3-6 months, then at 18-24 months if no change

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-up is required after 24 months to exclude possible slow growing adenocarcinoma (BAC) 

Sub solidSubsolid nodules

Solitary pure ground-glass nodule

• nodule size <6mm
  • no CT follow up-up required
• nodule size ≥6mm
  • follow up CT at 6-12 months, then every 2 years until 5 years

Solitary part-solid nodule

• nodule size <6mm
  • no CT follow-up required
• nodule size ≥6mm
  • follow-up CT at 3-6 months
  • if unchanged, and solid component remains <6mm, then annual follow-up for 5 years

Multiple subsolid nodules

• nodule size <6mm
  • follow-up CT at 3-6 months
  • consider further follow-up at 2 and 4 years if stable
• nodule size ≥6mm
  • follow-up CT at 3-6 months
  • subsequent management based on the most suspicious nodule(s)

Old guidelines

Old guidelines have been left in place in this article in case previous reported follow up-up under them.

Solid nodules

Nodule size: ≤ 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: >6-8 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 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

• 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

• 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 then 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)