Solid Indeterminate Pulmonary Nodules Less Than or Equal to 250 mm³: Application of the Updated Fleischner Society Guidelines in Clinical Practice

Abstract

Background The latest version of the Fleischner Society guidelines for management of incidental pulmonary nodules was published in 2017. The main purpose of these guidelines is to reduce the number of unnecessary computed tomography (CT) examinations during the follow-up of small indeterminate nodules. Objective The present study aimed to evaluate the performance of these guidelines for management of solid indeterminate pulmonary nodules (SIPNs) ≤ 250 mm3. Materials and Methods During a 7-year period, we retrospectively reviewed the chest CT scans of 672 consecutive patients with SIPNs. The study sample was selected according to the following inclusion criteria: solitary SIPN; diameter ≥ 3 mm; volume ≤ 250 mm3; two or more CT scans performed with the same scanner and same acquisition/reconstruction protocol; thin-section 1-mm images in DICOM format; histologic diagnosis or follow-up ≥ 2 years; and no oncological history. Applying these criteria, a total of 27 patients with single SIPNs ≤ 250 mm3 were enrolled. For each SIPN, the volume and doubling time were calculated using semiautomatic software throughout the follow-up period. For each SIPN, we applied the Fleischner Society guidelines, and the recommended management was compared to what was actually done. Results A significant volumetric increase was detected in 5/27 (18.5%) SIPNs; all growing nodules were observed in high-risk patients. In these SIPNs, a histologic diagnosis of malignancy was obtained. Applying the Fleischner Society recommendations, all five malignant nodules would have been identified. None of the SIPNs < 100 mm3 in low-risk patients showed significant growth during the follow-up period. The application of the new guidelines would have led to a significant reduction in follow-up CT examinations (Hodges-Lehmann median difference, -2 CT scans; p = 0.0001). Conclusion The application of the updated Fleischner Society guidelines has been shown to be effective in the management of SIPNs ≤ 250 mm3 with a significant reduction in radiation dose.

What’s New on Quantitative CT Analysis as a Tool to Predict Growth in Persistent Pulmonary Subsolid Nodules? A Literature Review

“…Among quantitative CT methods, those related to thoracic imaging are the most studied [20,22,23,[31][32][33][34][35][36][37][38][39][40][41][42][43]. In particular, the applications related to the classification and management of lung nodules are the most well-known and are used in both clinical practice and lung cancer screening programs [20,22,23,[31][32][33][34].…”

“…Among the radiological diagnostic methods applied in the thoracic field, CT is the most widely used for quantitative analysis [21]. While the effectiveness of quantitative CT applications for predicting malignancy in solid nodules is well established and widely described in the literature [22,23], those related to SSN growth prediction are much more recent and, therefore, less well-known.…”

Quantitative CT Analysis for Predicting the Behavior of Part-Solid Nodules with Solid Components Less than 6 mm: Size, Density and Shape Descriptors

“…Methods for the quantitative analysis of medical CT images are constantly expanding, and the applications of such methods in the thoracic field are increasing [4,5,9,14,[17][18][19][20][21][22]28,[30][31][32][33][34].…”

“…Lung nodules represent a common finding on chest computed tomography (CT), and their incidence is steadily increasing [1][2][3]. With improvements in temporal and spatial resolution, multidetector CT (MDCT) scanners are now able to detect a larger number of nodules, especially small nodules and subsolid nodules (SSNs) [1, [3][4][5].…”

Solid Indeterminate Pulmonary Nodules of Less Than 300 mm3: Application of Different Volume Doubling Time Cut-offs in Clinical Practice

“…Pulmonary nodules are a frequent incidental finding in clinical practice [1,2,3]. In fact, with the introduction and broad availability of multidetector row computed tomography (MDCT) scanners and thin-section CT images, an increasing number of pulmonary nodules are being detected, especially those of small size [4].…”