New Guidelines For Management Of Incidental Pulmonary Nodules Detected On CT Images

It is not uncommon for to receive inquiries from potential medical malpractice victims who question whether an incidental lung nodule finding on a chest CT that was not subsequently clinically investigated caused a delay in diagnose of a serious treatable medical condition that caused them harm.

An article appearing in JAMA Clinical Guidelines Synopsis on November 8, 2018 entitled “Incidental Pulmonary Nodules Detected on CT Images” summarized the problem as follows: “An incidental lung nodule on CT scan can create uncertainty for clinicians and anxiety for patients and families, given that lung cancer is the leading cause of cancer mortality in the United States. Incidental lung nodules are not uncommon. A systematic review of CT screening lung cancer trials noted that a lung nodule was detected in up to 51% of study participants. More than 95% of detected nodules are benign and have a wide variety of causes, including infections, granulomatous disease, hamartomas, arteriovenous malformations, round atelectasis, and lymph nodes.”

High-Risk Nodules

High-risk lung nodules are defined by the American College of Chest Physicians as nodules with an estimated cancer risk of at least 65%. High-risk patient factors include older age and heavy smoking, while high-risk nodule features include larger nodule size, irregular or spiculated margins, and upper lobe location.

Low-Risk And Intermediate-Risk Nodules

Low-risk nodules are defined as having an estimated risk of cancer of less than 5% and are associated with young age and less smoking, along with smaller size, regular margins, and location in an area other than the upper lobe.

Nodules at intermediate risk have mixed low- and high-risk characteristics, which may include other higher-risk factors such as emphysema and pulmonary fibrosis, positive family history, and known exposure to inhaled carcinogens. For the purposes of the Fleischner recommendation table, nodules with intermediate-risk estimations of 5% to 65% were combined with the high-risk category.

Fleischner Recommendation Table

The Fleischner Society is an international multidisciplinary society that publishes standards, guidelines, and consensus statements on the diagnosis and treatment of chest diseases. In 2017, the Society published updated guidelines for the management of incidental pulmonary nodules detected on CT images in adults aged 35 years or older. The new guidelines offer more precise recommendations based on patient risk, the number of nodules (single vs multiple), and the subtyping of subsolid nodules (GGN vs partly solid); discuss additional risk factors for malignancy; and add flexibility regarding follow-up imaging.

Major recommendations and ratings:

– Prior imaging studies should always be reviewed whenever available (grade 1A; strong recommendation; high-quality evidence); – Solid nodules <6 mm do not require routine follow-up in low-risk patients (grade 1C; strong recommendation); - For pure ground-glass nodules (GGNs) <6 mm, no routine follow-up is recommended (grade 1B; strong recommendation); - Some solid nodules <6 mm with suspicious morphology, upper lobe location, or both may pose higher risk and warrant follow-up at 12 months (grade 2A; weak recommendation); - For solitary solid noncalcified nodules measuring 6 to 8 mm in patients at high risk, an initial follow-up examination is recommended at 6 to 12 months and again at 18 to 24 months (grade 1B; strong recommendation; moderate-quality evidence); - For solitary solid noncalcified nodules >8 mm in diameter, consider 3-month follow-up, workup with combined positron emission tomography (PET) and CT, tissue sampling, or a combination thereof (grade 1A; strong recommendation; high-quality evidence).


If you or a family member may be the victim of lung cancer misdiagnosis in the United States that may be due to medical malpractce, you should promptly consult with a medical malpractice attorney in your state who may investigate your cancer misdiagnosis malpractice claim for you and represent you or your family member in a medical malpractice case, if appropriate.

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This entry was posted on Sunday, November 25th, 2018 at 5:23 am. Both comments and pings are currently closed.

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