The Fleischner Society Guidelines for management of solid nodules were published in 2005, and separate guidelines for subsolid nodules were issued in 2013. Since then, new information has become available; therefore, the guidelines have been revised to reflect current thinking on nodule management. The revised guidelines incorporate several substantive changes that reflect current thinking on the management of small nodules. The minimum threshold size for routine follow-up has been increased, and recommended follow-up intervals are now given as a range rather than as a precise time period to give radiologists, clinicians, and patients greater discretion to accommodate individual risk factors and preferences. The guidelines for solid and subsolid nodules have been combined in one simplified table, and specific recommendations have been included for multiple nodules. These guidelines represent the consensus of the Fleischner Society, and as such, they incorporate the opinions of a multidisciplinary international group of thoracic radiologists, pulmonologists, surgeons, pathologists, and other specialists. Changes from the previous guidelines issued by the Fleischner Society are based on new data and accumulated experience. Table. These are followed by graded ratings of each recommendation using the American College of Chest Physicians recommendations for evidence grading in clinical guidelines (9). Additional explanations are provided regarding the rationale for each recommendation, which is based on the consensus of a multidisciplinary team and a systematic review of the literature, further details of which are included in Appendix E1 [online]. 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. This criterion is necessarily arbitrary, and we recognize that a higher threshold may be considered appropriate in some environments and that this threshold will ultimately depend on social and economic factors. Several general considerations regarding technical aspects of using these recommendations are also presented. Finally, in Appendix E1 (online), additional information regarding methods and risk factors is given. detected at CT in adult patients who are at least 35 years old. Separate guidelines have been issued for lung cancer screening, such as those from the American College of Radiology (ACR), and we support the use of those guidelines when interpreting the results of CT screening (8). Specific recommendations are provided for patients with multiple solid and subsolid nodules, and several other commonly encountered clinical situations are addressed.These guidelines are not intended for use in patients with known primary cancers who are at risk for metastases, nor are they intended for use in immunocompromised patients who are at risk for infection; in these patients, treatment should be based on the specific clinical situation. Also, because lung cancer is rare in children and adults younger than 35 years, these guidelines are no...

BACKGROUND Major issues in the implementation of screening for lung cancer by means of low-dose computed tomography (CT) are the definition of a positive result and the management of lung nodules detected on the scans. We conducted a population-based prospective study to determine factors predicting the probability that lung nodules detected on the first screening low-dose CT scans are malignant or will be found to be malignant on follow-up. METHODS We analyzed data from two cohorts of participants undergoing low-dose CT screening. The development data set included participants in the Pan-Canadian Early Detection of Lung Cancer Study (PanCan). The validation data set included participants involved in chemoprevention trials at the British Columbia Cancer Agency (BCCA), sponsored by the U.S. National Cancer Institute. The final outcomes of all nodules of any size that were detected on baseline low-dose CT scans were tracked. Parsimonious and fuller multivariable logistic-regression models were prepared to estimate the probability of lung cancer. RESULTS In the PanCan data set, 1871 persons had 7008 nodules, of which 102 were malignant, and in the BCCA data set, 1090 persons had 5021 nodules, of which 42 were malignant. Among persons with nodules, the rates of cancer in the two data sets were 5.5% and 3.7%, respectively. Predictors of cancer in the model included older age, female sex, family history of lung cancer, emphysema, larger nodule size, location of the nodule in the upper lobe, part-solid nodule type, lower nodule count, and spiculation. Our final parsimonious and full models showed excellent discrimination and calibration, with areas under the receiver-operating-characteristic curve of more than 0.90, even for nodules that were 10 mm or smaller in the validation set. CONCLUSIONS Predictive tools based on patient and nodule characteristics can be used to accurately estimate the probability that lung nodules detected on baseline screening low-dose CT scans are malignant. (Funded by the Terry Fox Research Institute and others; ClinicalTrials.gov number, NCT00751660.)

BACKGROUND The major sites of obstruction in chronic obstructive pulmonary disease (COPD) are small airways (<2 mm in diameter). We wanted to determine whether there was a relationship between small-airway obstruction and emphysematous destruction in COPD. METHODS We used multidetector computed tomography (CT) to compare the number of airways measuring 2.0 to 2.5 mm in 78 patients who had various stages of COPD, as judged by scoring on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) scale, in isolated lungs removed from patients with COPD who underwent lung transplantation, and in donor (control) lungs. MicroCT was used to measure the extent of emphysema (mean linear intercept), the number of terminal bronchioles per milliliter of lung volume, and the minimum diameters and cross-sectional areas of terminal bronchioles. RESULTS On multidetector CT, in samples from patients with COPD, as compared with control samples, the number of airways measuring 2.0 to 2.5 mm in diameter was reduced in patients with GOLD stage 1 disease (P = 0.001), GOLD stage 2 disease (P = 0.02), and GOLD stage 3 or 4 disease (P<0.001). MicroCT of isolated samples of lungs removed from patients with GOLD stage 4 disease showed a reduction of 81 to 99.7% in the total cross-sectional area of terminal bronchioles and a reduction of 72 to 89% in the number of terminal bronchioles (P<0.001). A comparison of the number of terminal bronchioles and dimensions at different levels of emphysematous destruction (i.e., an increasing value for the mean linear intercept) showed that the narrowing and loss of terminal bronchioles preceded emphysematous destruction in COPD (P<0.001). CONCLUSIONS These results show that narrowing and disappearance of small conducting airways before the onset of emphysematous destruction can explain the increased peripheral airway resistance reported in COPD. (Funded by the National Heart, Lung, and Blood Institute and others.)

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The MSCT can provide detailed information on the shape of the aortic annulus and the relation between the annulus and the ostia of the coronary arteries. Thereby, MSCT may be helpful for avoiding paravalvular leakage and coronary occlusion and may facilitate the selection of candidates for transcatheter aortic valve replacement.

For effective clinical management of cystic fibrosis (CF) lung disease it is important to closely monitor the start and progression of lung damage. The aim of this study was to investigate the ability of high-resolution computed tomography (HRCT) scoring systems and pulmonary function tests (PFT) to detect changes in lung disease.CF children (n=48) had two HRCT scans in combination with two PFT 2 yrs apart. Their scans were scored using five scoring systems (Castile, Brody, Helbich, Santamaria and Bhalla). "Sensitivity" was defined as the ability to detect disease progression.In this group of children, HRCT scores worsened. PFT remained unchanged or improved. Of the HRCT parameters, mucous plugging and the severity, extent and peripheral extension of bronchiectasis worsened significantly. Relationships between changes in HRCT scores and PFT were weak. Substantial structural lung damage was evident in some children who had normal lung function.These data show that high-resolution computed tomography is more sensitive than pulmonary function tests in the detection of early and progressive lung disease, and suggest that high-resolution computed tomography may be useful in the follow up of cystic fibrosis children and as an outcome measure in studies that aim to reduce lung damage. Eur Respir J 2004; 23: 93-97.

In this study, US was more sensitive than supine chest radiography and as sensitive as CT in the detection of traumatic pneumothoraces.

The accuracies of chest radiography and computed tomography (CT) in the prediction of specific diagnoses in 118 consecutive patients with chronic diffuse infiltrative lung disease (DILD) were compared. The radiographs and CT scans were independently assessed by three observers without knowledge of clinical or pathologic data. The observers listed the three most likely diagnoses in order of probability and recorded the degree of confidence they felt in their first-choice diagnosis on a three-point scale. Confidence level 1 (definite) was reached with 23% of radiographic and 49% of CT scan readings, and the correct diagnosis was made with 77% and 93% of those readings, respectively (P less than .001). The correct first-choice diagnosis regardless of the level of confidence was made with 57% of radiographic and 76% of CT scan readings (P less than .001). The CT scan interpretations were most accurate in silicosis (93%), usual interstitial pneumonia (89%), lymphangitic carcinomatosis (85%), and sarcoidosis (77%). Observers correctly predicted whether a transbronchial or open lung biopsy was indicated with 65% of radiographs and 87% of CT scans (P less than .001). It is recommended that CT be performed before lung biopsy in all patients with chronic DILD.