Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

Abstract

Objectives: The objective of this article is to update previous evidence-based recommendations for evaluation and management of individuals with solid pulmonary nodules and to generate new recommendations for those with nonsolid nodules.

Methods: We updated prior literature reviews, synthesized evidence, and formulated recommendations by using the methods described in the "Methodology for Development of Guidelines for Lung Cancer" in the American College of Chest Physicians Lung Cancer Guidelines, 3rd ed.

Results: We formulated recommendations for evaluating solid pulmonary nodules that measure > 8 mm in diameter, solid nodules that measure ≤ 8 mm in diameter, and subsolid nodules. The recommendations stress the value of assessing the probability of malignancy, the utility of imaging tests, the need to weigh the benefits and harms of different management strategies (nonsurgical biopsy, surgical resection, and surveillance with chest CT imaging), and the importance of eliciting patient preferences.

Conclusions: Individuals with pulmonary nodules should be evaluated and managed by estimating the probability of malignancy, performing imaging tests to better characterize the lesions, evaluating the risks associated with various management alternatives, and eliciting their preferences for management.

Figure 1.

[Sections 4.0, 4.3] Management algorithm for individuals with solid nodules measuring 8 to 30 mm in diameter. Branches indicate steps in the algorithm following nonsurgical biopsy. *Among individuals at high risk for surgical complications, we recommend either CT scan surveillance (when the clinical probability of malignancy is low to moderate) or nonsurgical biopsy (when the clinical probability of malignancy is moderate to high). RFA = radiofrequency ablation; SBRT = stereotactic body radiotherapy.

Figure 2.

[Section 4.0] Factors that influence choice between evaluation and management alternatives for indeterminate, solid nodules ≥ 8 to 30 mm in diameter.

Figure 3.

[Section 4.1] Assessment of the probability of malignancy.

Figure 4.

[Section 4.3] Balance sheet of pros and cons of alternatives for evaluation and management of pulmonary nodule.

Figure 5.

[Section 4.6.2] EBUS-TBB compared with TBB guided by fluoroscopy for patients with peripheral lung nodules.

Figure 6.

[Section 5.2] Management algorithm for individuals with solid nodules measuring < 8 mm in diameter. F/U =follow-up.