The document summarizes updated guidelines from the Fleischner Society for the management of incidental pulmonary nodules detected on CT images. Key changes include combining the previous separate guidelines for solid and subsolid nodules into a single simplified table. The guidelines provide recommendations for follow up examinations based on nodule size, type, risk factors and number of nodules detected. The purpose is to reduce unnecessary follow ups while allowing discretion for managing risk. The guidelines represent an international consensus to help evaluate pulmonary nodules and determine appropriate clinical response.

1. Guidelines for Management of Incidental
Pulmonary Nodules Detected on CT
Images
Fleischner Society 2017

3.  The Fleischner Society Guidelines for management of
solid nodules were published in 2005.
 Separate guidelines for subsolid nodules were issued in
2013.
 The guidelines for solid and subsolid nodules have been
combined in one simplified table, and specific
recommendations have been included for multiple
nodules.

4.  The purpose of these recommendations is to reduce the
number of unnecessary follow-up examinations while
providing greater discretion to the radiologist, clinician,
and patient to make management decisions.
 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.

5.  Definition: the solitary pulmonary nodule is a single,
well-circumscribed, radiographic opacity that
measures up to 3 cm in diameter is surrounded
completely by aerated lung and doesn`t touch hilum
or mediastinum. There is no associated atelectasis,
adenopathy, or pleural effusion.
 All CT scans of the thorax in adults should be reconstructed
and archived with contiguous thin sections (<1.5 mm, typically
1.0 mm) to enable accurate characterization and measurement
of small pulmonary nodules

6. Differential Diagnosis
of Solitary Pulmonary
Nodules

7. Malignant
Bronchogenic carcinoma
 Adenocarcinoma
 Squamous cell carcinoma
 Large cell carcinoma
 Small cell carcinoma
Metastatic lesions
 Breast Head and neck
 Melanoma Colon
 Kidney Sarcoma
 Germ cell tumor Others
Pulmonary carcinoid

8. Benign
Infectious granuloma
 Tuberculosis
 Histoplasmosis
 Coccidioidomycosis
 Atypical mycobacteria
 Cryptococcosis
 Blastomycosis
Other infections
 Bacterial abscess
 Dirofilaria immitis
 Echinococcus cyst( hydatid cyst).
 Ascariasis
 Pneumocystis carinii
 Aspergilloma

9. Benign
Benign neoplasms
 Hamartoma
 Lipoma
 Fibroma
Vascular
 Arteriovenous malformation
 Pulmonary varix
Developmental
 Bronchogenic cyst
Inflammatory
 Granulomatosis with polyangiitis (Wegener's)
 Rheumatoid nodule

10. Benign
others
 Amyloidoma
 Rounded atelectasis
 Intrapulmonary lymph nodes
 Hematoma
 Pulmonary infarct
 Pseudotumor (loculated fluid)
 Mucoid impaction

11. Risk Factors for Malignancy:
General Considerations

12.  Nodule Size and Morphology(calcification&edge)
 Nodule Location
 Nodule Multiplicity
 Nodule Growth Rate
 Emphysema and Fibrosis
 Age, Sex, Race, and Family History
 Tobacco and Other Inhaled Carcinogens

13.  Nodule size has a clear relationship with risk of
malignancy, as discussed previously, and it is a
dominant factor in management.
 In these guidelines, nodules are further divided
into solid, ground-glass, and part-solid
categories.
Nodule Size and Morphology(calcification&edge)

14. Nodule Size and Morphology(calcification&edge)

15. Nodule Size and Morphology(calcification&edge)

16. Nodule Size and Morphology(calcification&edge)

17. Nodule Size and Morphology(calcification&edge)

18.  Lung cancers occur more frequently in the upper
lobes, with a predilection for the right lung.
 In the PanCan trial, upper lobe nodule location was
confirmed as a risk factor, with an odds ratio of
approximately 2.0.
Nodule Location

19.  An analysis of patients with multiple nodules in the
NELSON trial showed increased risk of primary
cancer as the total nodule count increased from 1 to 4
but decreased risk in patients with 5 or more nodules.
 In the PanCan trial, multiplicity of nodules was
associated with a reduced risk of cancer when
compared with risk associated with one nodule.
Nodule Multiplicity

20.  Volume doubling times for solid cancers are well
established (one volume doubling corresponds to a
26% increase in diameter), with a large majority of
times being in the 100–400 day range (20-400).
 For subsolid cancerous nodules, which represent
primary adenocarcinomas, more indolent growth is
the rule, with average doubling times on the order of
3–5 years.
Nodule Growth Rate

21.  The presence of emphysema on a CT image is an
independent risk factor for lung cancer.
 NLST found that emphysema- predominant COPD
phenotype and increasing severity of centrilobular
emphysema were associated with increased risk of
malignancy.
 Pulmonary fibrosis, particularly idiopathic pulmonary
fibrosis, is also an independent risk factor, with a
hazard ratio of approximately 4.2 compared with
emphysema alone.
Emphysema and Fibrosis

22.  An increase in risk associated with advancing age.
 Family history of lung cancer is a risk factor for both
smokers and those who never smoked.
 No significant difference between both genders except
incidence of adenocarcinoma in nonsmokers is
increasing, with female nonsmokers being affected
significantly more often than male nonsmokers.
 Race is also a factor, with a significantly higher
incidence of lung cancer in black men.
Age, Sex, Race, and Family History

23.  Cigarette smoking has been established as the major
risk factor for lung cancer with10 to 35 fold increased
risk, exposure to secondhand smoke is a proven.
 Other inhaled carcinogens that are known risk factors
for lung cancer include exposure to asbestos,
uranium, or radon.
Tobacco and Other Inhaled Carcinogens

34.  we recommend that risk be assigned according to the
categories proposed by the American College of
Chest Physicians (ACCP). Low risk, which
corresponds to an estimated risk of cancer of less
than 5%.
 To estimate high risk, we recommend combining the
ACCP intermediate-risk (5%–65% risk) and high-risk
(> 65% risk) categories.

37. Solitary Solid Nodule
<6 mm
<100mm³
Low risk
patients:
no
follow-up
needed
High risk
patients:
optional
CT at 12
months
6-8mm
100-250 mm³
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
> 8mm
>250 mm³
Low or High risk
consider follow-up CT
at 3 months, and/or
CT-PET, and/or biopsy
37

38. Solitary Subsolid Nodules
Pure ground glass
nodule
<6 mm
<100mm³
no CT follow-up
required
In certain suspicious
nodules , 6 mm, consider
follow-up at 2 and 4 years.
If solid component(s)
or growth develops,
consider resection.
≥6mm
≥100mm³
follow up CT at
6-12 months,
then every 2
years until 5
years
Solitary part-solid nodule
<6 mm
<100mm³
no CT follow-up
required
In certain suspicious
nodules , 6 mm, consider
follow-up at 2 and 4 years.
If solid component(s)
or growth develops,
consider resection.
≥6mm
≥100mm³
follow-up CT at 3-6 months
if unchanged, and solid
component remains <6mm,
then annual follow-up for 5
years
38

39. Multiple Solid Nodules
<6 mm
<100mm³
Low risk
patients:
no follow-
up needed
High risk
patients:
optional CT
at 12
months
≥6mm
≥100mm³
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
39

40. Multiple Subsolid Nodules
<6 mm
<100mm³
follow-up CT at 3-6 months
consider further follow-up at 2
and 4 years if stable
≥6mm
≥100mm³
follow-up CT at 3-6 months
subsequent management based on
the most suspicious nodule(s)
40

41. Thank you

42. Old guidelines