Pulmonary Nodules:​Common

Questions and Answers

Robert C. Langan, MD, St. Luke’s Hospital Family Medicine Residency/Sacred Heart Campus,
Allentown, Pennsylvania;​Temple University School of Medicine, Philadelphia, Pennsylvania
Andrew J. Goodbred, MD, St. Luke’s Hospital Family Medicine Residency/Anderson Campus,
Easton, Pennsylvania;​Temple University School of Medicine, Philadelphia, Pennsylvania

Pulmonary nodules are often incidentally discovered on chest imaging or from dedicated lung cancer
screening. Screening adults 50 to 80 years of age who have a 20-pack-year smoking history and currently
smoke or have quit smoking within the past 15 years with low-dose computed tomography is associated
with a decrease in cancer-associated mortality. Once a nodule is detected, specific radiographic and
clinical features can be used in validated risk stratification models to assess the probability of malig-
nancy and guide management. Solid pulmonary nodules less than 6 mm warrant surveillance imaging
in patients at high risk, and nodules between 6 and 8 mm should be reassessed within 12 months, with
the recommended interval varying by the risk of malignancy and an allowance for patient-physician
decision-making. A functional assessment with positron emission tomography/computed tomography,
nonsurgical biopsy, and resection should be considered for solid nodules 8 mm or greater and a high
risk of malignancy. Subsolid nodules have a higher risk of cancer and should be followed with sur-
veillance imaging for longer. Direct physician-patient communication, clinical decision support within
electronic health records, and guideline-based management algorithms included in radiology reports
are associated with increased compliance with existing guidelines. (Am Fam Physician. 2023;​107(3):​
282-291. Copyright © 2023 American Academy of Family Physicians.)

The incidental discovery of pulmonary nod- than 3 cm in diameter), or who are immunocom-
ules on imaging studies of the chest or through promised should be referred to a pulmonologist
dedicated screening programs for the detection for further workup.7
of lung cancer is common. It is estimated that
1.57 million nodules are detected incidentally What Nodule and Patient
every year, 5% of which are malignant.1 The Characteristics Suggest a Malignant
incidence of pulmonary nodules in lung cancer Cause?
screening programs has been reported at approx- The risk of malignancy is higher in solid nodules
imately 27%, with 1.1% of patients diagnosed with that are large, have irregular borders, have asym-
lung cancer. 2 Guidelines have been published metric calcifications, have a volume doubling time
to aid physicians in managing these nodules.3-5 between one month and one year, or are in the
Examples of benign causes of pulmonary nodules upper lung lobes. Subsolid nodules are more likely
are listed in Table 1.6 All patients with a pulmo- to be cancerous than solid nodules. Increasing age
nary nodule and a history of malignancy, with and history of cigarette smoking are associated with
multiple nodules but no dominant nodule, with a higher risk of lung cancer.
any pulmonary mass (i.e., lung opacity of greater
EVIDENCE SUMMARY
Malignancy is more common in solid nodules
CME This clinical content conforms to AAFP cri- that are 6 mm or greater in diameter. 3 Other
teria for CME. See CME Quiz on page 226.
nodule characteristics associated with cancer
Author disclosure:​ No relevant financial
include location in the upper lung lobes, irreg-
relationships.
ular or spiculated borders, ground-glass appear-
Patient information:​A handout on this topic,
written by the authors of this article, is available
ance, or punctate or eccentric calcifications7
with the online version of this article. (Figure 18). Nodules with a volume doubling time
of more than 30 days to less than 400 days are

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 PULMONARY NODULES

also associated with malignancy because nodules that grow less common than solid nodules (21% vs. 79% in one lung
rapidly over days to weeks are more likely to be infectious cancer screening study), part-solid nodules are associated
or inflammatory, and aggressive cancers can double in with a higher risk of slow-growing cancer.9 Increasing age,
volume every three to four months (Table 2).7 Significant greater than 20-pack-year smoking history among current
growth found on follow-up imaging is presumptive evidence smokers or those who have quit within the past 15 years,
of malignancy and requires consultation with a pulmonary a family history of lung cancer, and exposure to asbestos,
subspecialist or more frequent monitoring. Subsolid nodules uranium, or radium are associated with an increased risk of
include pure ground-glass and part-solid nodules. Although pulmonary malignancy.3

What Is the Evidence for Screening

TABLE 1 Asymptomatic People for Lung Cancer?
The U.S. Preventive Services Task Force (USPSTF) recom-
Benign Causes of Pulmonary Nodules mends annual screening for lung cancer with low-dose com-
Category Examples puted tomography (CT) in adults 50 to 80 years of age who
Benign Chondroma
have a 20-pack-year smoking history and currently smoke or
tumor quit smoking within the past 15 years. Screening should be
Hamartoma
discontinued once a person has not smoked for 15 years or
Lipoma
develops a health problem that substantially limits life expec-
Congenital Arteriovenous malformation tancy or a willingness to have curative lung surgery (USPSTF
Bronchogenic cyst Grade B recommendation).10
Immune- Rheumatoid arthritis EVIDENCE SUMMARY
mediated Sarcoidosis
disease The National Lung Screening Trial compared annual low-
dose CT to chest radiography for three consecutive years in
Infectious Infectious granuloma* patients at high risk (defined as 55 to 74 years of age with
Coccidioidomycosis at least a 30-pack-year smoking history who were current
Histoplasmosis smokers or had quit within the previous 15 years). After 6.5
Mycobacterium tuberculosis years of follow-up, there was a 20% reduction in lung cancer–
Lung abscess related mortality and a 6.7% decrease in overall mortality
in the low-dose CT group.11 A more recent meta-analysis of
Other Amyloidosis
more than 96,000 people that included the National Lung
Endoparenchymal lymph node Screening Trial data demonstrated that screening people at
*—Healed infectious granulomas are the most common type of high risk with low-dose CT decreased lung cancer–related
benign pulmonary nodule. mortality by 1.8% to 2.2% over five to 10 years but did not
Information from reference 6. change overall mortality.12 In 2014, the USPSTF recom-
mended the use of low-dose CT for lung cancer screening

FIGURE 1

Benign Malignant

Diffuse Central Popcorn Concentric Ground-glass Eccentric

Patterns of appearance that suggest benign or malignant pulmonary nodules.

Illustration by Dave Klemm
Reprinted with permission from Kikano GE, Fabien A, Schilz R. Evaluation of the solitary pulmonary nodule. Am Fam Physician. 2015;​92(12):​1085.

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 PULMONARY NODULES

in people at high risk13;​this recommendation was updated Referral to pulmonology, interventional radiology, or tho-
in 2021 based on data from additional studies and screening racic surgery for lung biopsy should be considered for solid
models showing benefits for a larger age range (50 to 80 years nodules 15 mm or greater or new or growing nodules 8 mm
of age) and shorter smoking history (20-pack-year smok- or greater. Referral should also be considered for subsolid
ing history) and is endorsed by the American Academy of nodules if the solid component is 8 mm or greater or 4 mm
Family Physicians.10,14 Screening patients at high risk of lung or greater and is new or growing. The presence of additional
cancer with low-dose CT is also recommended by the Amer- features of malignancy, such as spiculation, doubling of nod-
ican College of Chest Physicians (CHEST) and the American ule size in one year, or lymphadenopathy, may also indicate
Cancer Society, with screening starting at 55 years of age for a nodule that requires biopsy.5 Lung-RADS scoring may
patients with a 30-pack-year smoking history who currently decrease the number of subsequent unnecessary diagnos-
smoke or have quit within the past 15 years.15,16 tic procedures when used as part of a lung cancer screening
program.19
What Is the Recommended Management
of a Nodule Identified During Lung Cancer What Tools Help Physicians Risk Stratify
Screening? Incidentally Discovered Pulmonary Nodules?
Repeat low-dose CT is recommended for benign or probably Validated risk calculators estimate the chance of malignancy
benign nodules;​the screening interval depends on the mor- for incidentally discovered pulmonary nodules. All calculators
phology and size of the initial lesion. Additional imaging or use history and nodule characteristics found on low-dose CT;​
referral for biopsy should be considered for patients with very some calculators use the results of PET/CT.
suspicious large solid nodules (15 mm and greater or 8 mm
and greater that are new or growing) and subsolid nodules EVIDENCE SUMMARY
with large solid components (8 mm or greater or 4 mm and Although many incidentally discovered lung nodules are
greater that are new or growing). found on CT, nodules may also be found on plain radiog-
raphy. CHEST recommends that unless nodules can be
EVIDENCE SUMMARY clearly classified as benign (e.g., due to a benign pattern of
The American College of Radiology Lung-RADS score pro- calcification), chest CT with thin sections is recommended
vides management recommendations for pulmonary nod- due to its better sensitivity and specificity for detecting lung
ules found during lung cancer screening and is
recommended by pulmonary societies3,5,15 (Table
35). Patients with a negative screening result or TABLE 2
benign-appearing nodules should continue rou-
tine annual low-dose CT screening. Probably Radiographic Features of Pulmonary Nodules Sug-
benign lesions should be reimaged with low-dose gesting Benign or Malignant Etiology
CT in six months. Suspicious lesions should be Feature Suggests benign etiology Suggests malignant etiology
reimaged with low-dose CT in three months. Appearance Concentric, central, Eccentric calcifica-
Positron emission tomography/CT (PET/CT) diffuse, or popcorn-​ tions, noncalcified, or
imaging is used to assess the metabolic activity like calcifications ground-glass
of a nodule. Although malignant nodules may be
Border Smooth Spiculated (higher risk) or
more metabolically active, some inflammatory irregular
and infectious nodules also may have high uptake
on PET/CT 7;​ the reported sensitivity is 89% Density Solid Subsolid
and specificity is 75% for detecting lung cancer.17 Location Perifissural, subpleural Upper lobes
The Lung-RADS guidelines state that PET/CT
may be used in evaluating suspicious or very sus- Multiple Dominant nodule No dominant nodule
picious lesions with a solid component of 8 mm nodules present present
or greater. Physicians should be mindful of the
5
Size < 6 mm ≥ 6 mm
cumulative dose of radiation to which a patient
is exposed in screening and follow-up studies, Volume dou- Less than 30 days or Between 30 and 400 days
bling time greater than 400 days
which ranges from low-dose CT (1.5 mSv), to
CT of the chest (6.1 mSv), to full-body PET/CT Information from reference 7.
(22.7 mSv).18

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 PULMONARY NODULES

malignancy compared with plain radiography, and its ability of malignancy can be classified as high risk (greater than
to provide additional information such as size and attenua- 65%), intermediate risk (5% to 65%), and low risk (less than
tion characteristics of any lesions.4 5%).4 Validated risk prediction models have been developed
Guidelines from the Fleischner Society and CHEST and have online tools to help with their implementation into
recommend using malignancy risk prediction models for practice (Table 420-24). Physicians should choose a calculator
patients with incidentally discovered pulmonary nodules that best represents the characteristics of the patient being
to help determine management.3,4 Individual patient risk assessed.7 Note that although the accuracy of these tools has

TABLE 3

American College of Radiology Lung-RADS Scoring and Management Recommendations

Category descriptor Lung-RADS Findings Management

Incomplete 0 Prior chest CT examination being located for comparison Comparison to prior
Estimated popula- (see note 9) chest CT
tion prevalence: ~ 1%
Part or all of lungs cannot be evaluated Additional lung can-
cer screening CT
imaging needed

Findings suggestive of an inflammatory or infectious process 1- to 3-month LDCT

(see note 10)

Negative 1 No lung nodules OR 12-month screening

Estimated popula- Nodule with benign features: complete, central, popcorn, or LDCT
tion prevalence: 39% concentric calcifications OR fat-containing

Benign 2 Juxtapleural nodule: < 10 mm mean diameter at baseline or 12-month screening

Based on imaging new AND solid, smooth margins; and oval, lentiform, or triangu- LDCT
features or indolent lar shape
behavior Solid nodule: < 6 mm at baseline OR new < 4 mm
Estimated popula- Part-solid nodule: < 6 mm total mean diameter at baseline
tion prevalence: 45% Nonsolid nodule (ground-glass nodule): < 30 mm at baseline,
new or growing OR ≥ 30 mm stable or slow-growing (see note 7)
Airway nodule, subsegmental at baseline, new, or stable (see
note 11)
Category 3 nodule that is stable or decreased in size at 6-month
follow-up CT, OR category 3 or 4A nodules that resolve on
follow-up, OR category 4B findings proven to be benign in
etiology following appropriate diagnostic workup

Probably benign 3 Solid nodule: ≥ 6 to < 8 mm at baseline OR new 4 to < 6 mm 6-month LDCT
Based on imaging Part-solid nodule: ≥ 6 mm total mean diameter with solid
features or behavior component < 6 mm at baseline OR new < 6 mm in total mean
diameter
Estimated popula-
tion prevalence: 9% Nonsolid nodule (ground-glass nodule): ≥ 30 mm at baseline or
new
Atypical pulmonary cyst: (see note 12) growing cystic compo-
nent (mean diameter) of a thick-walled cyst
Category 4A nodule that is stable or decreased in size at
3-month follow-up CT (excluding airway nodules)
continues

CT = computed tomography;​LDCT = low-dose chest CT; PET/CT = positron emission tomography/computed tomography.

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 PULMONARY NODULES

TABLE 3 (continued)

American College of Radiology Lung-RADS Scoring and Management Recommendations

Category descriptor Lung-RADS Findings Management

Suspicious 4A Solid nodule: ≥ 8 to < 15 mm at baseline OR growing < 8 mm 3-month LDCT;

Estimated popula- OR new 6 to < 8 mm PET/CT may be
tion prevalence: 4% Part-solid nodule: ≥ 6 mm with solid component ≥ 6 to < 8 mm considered if there
at baseline OR new or growing < 4 mm solid component is a ≥ 8 mm solid
nodule or solid
Airway nodule, segmental or more proximal at baseline or new component
(see note 11)
Atypical pulmonary cyst: (see note 12) thick-walled cyst OR
multilocular cyst at baseline OR thin- or thick-walled cyst that
becomes multilocular

Very suspicious 4B Airway nodule, segmental or more proximal, and stable or Referral for further
Estimated popula- growing (see note 11) clinical evaluation
tion prevalence 2%
Solid nodule: ≥ 15 mm at baseline OR new or growing ≥ 8 mm Diagnostic chest
Part-solid nodule: solid component ≥ 8 mm at baseline OR new CT with or without
or growing ≥ 4 mm solid component contrast; PET/CT
may be considered
Atypical pulmonary cyst: (see note 12) thick-walled cyst with if there is a ≥ 8 mm
growing wall thickness/nodularity OR growing multilocu- solid nodule or solid
lar cyst (mean diameter) OR multilocular cyst with increased component; tissue
loculation or new/increased/opacity (nodular, ground glass, or sampling; and/or
consolidation) referral for further
Slow-growing solid or part-solid nodule that demonstrates clinical evaluation
growth over multiple screening exams (see note 8) Management
depends on
Estimated popula- 4X Category 3 or 4 nodules with additional features or imaging evaluation, patient
tion prevalence < 1% findings that increase suspicion for lung cancer (see note 14)w preference, and the
probability of malig-
nancy (see note 13)

Significant or poten- S Modifier: may add to category 0-4 for clinically significant As appropriate to
tially significant or potentially clinically significant findings unrelated to lung the specific finding
Estimated popula- cancer (see note 15)
tion prevalence 10%

CT = computed tomography;​LDCT = low-dose chest CT; PET/CT = positron emission tomography/computed tomography.
Notes:
1. Lung-RADS Category: Each exam should be coded 0-4 based on the nodule with the highest degree of suspicion.
2. Lung-RADS Management: The timing of follow-up imaging is from the date of the exam being interpreted. For example, 12-month screening
LDCT for Lung-RADS 2 is from the date of the current exam. Also note that management of category 3 and 4A nodules follows a stepped
approach based on follow-up stability or decrease in size. If nodules resolve on follow-up, reclassify according to the most concerning finding.
3. Practice Audit Definitions: A negative screen is defined as categories 1 and 2; a positive screen is defined as categories 3 and 4. A negative
screen does not mean that an individual does not have lung cancer.
4. Nodule Measurement: To calculate nodule mean diameter, measure both the long and short axis to one decimal point in mm, and report
mean nodule diameter to one decimal point. The long and short axis measurements may be in any plane to reflect the true size of the nodule.
Volumes, if obtained, should be reported to the nearest whole number in mm3.
5. Size Thresholds: Apply to nodules at first detection and that enlarge, reaching a higher size category. When a nodule crosses a new size threshold for
other Lung-RADS categories, even if not meeting the definition of growth, the nodule should be reclassified based on size and managed accordingly.
6. Growth: An increase in mean diameter size of > 1.5 mm within a 12-month interval.
7. Slow-Growing–Non-Solid (Ground-Glass) Nodules: A ground-glass nodule (GGN) that demonstrates growth over multiple screening exams
but does not meet the > 1.5 mm threshold increase in size for any 12-month interval may be classified as Lung-RADS 2 until the nodule meets
findings criteria of another category, such as developing a solid component (then manage per part-solid nodule criteria).
continues

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 PULMONARY NODULES

TABLE 3 (continued)

American College of Radiology Lung-RADS Scoring and Management Recommendations

8. Slow-Growing-Solid or Part-Solid Nodules: A solid or part-solid nodule that demonstrates growth over multiple screening exams but does not
meet the > 1.5 mm threshold increase in size for any 12-month interval is suspicious and may be classified as a Lung-RADS 4B. Slow-growing
nodules may not have increased metabolic activity on PET/CT; therefore, biopsy, if feasible, or surgical evaluation may be the most appropriate
management recommendation.
9. Prior Exams: If waiting on prior exams (either a prior screening or diagnostic CT), the Lung-RADS 0 category is temporary until the comparison
study is available and a new Lung-RADS category is assigned.
10. Suspected Infectious or Inflammatory Findings:
a. Lung-RADS 0 with 1-3 month follow-up LDCT may be recommended for pulmonary findings suggesting an indeterminate infectious or
inflammatory process. Such findings may include segmental or lobar consolidation, multiple new nodules (more than six), large solid nod-
ules (≥ 8 mm) appearing in a short interval, and new nodules in certain clinical contexts (e.g., immunocompromised patient). At 1-3 month
follow-up, a new Lung-RADS classification and management recommendation should be provided based on the most suspicious nodule.
b. New solid or part-solid nodules with imaging features more concerning for malignancy than an infectious or inflammatory process meeting
Lung-RADS 4B size criteria may be classified as such with appropriate diagnostic and/or clinical evaluation.
c. Some findings indicative of an infection or infectious process may not warrant short-term follow-up (e.g., tree-in-bud nodules or new < 3
cm ground glass nodules). These nodules may be evaluated using existing size criteria with a Lung-RADS classification and management
recommendation based on the most suspicious finding.
11. Airway Nodules:
a. Endotracheal or endobronchial abnormalities that are segmental or more proximal are classified as Lung-RADS 4A.
b. Subsegmental and/or multiple tubular endobronchial abnormalities favor an infectious process; if no underlying obstructive nodule is iden-
tified, these findings may be classified as Lung-RADS 0 (likely infectious or inflammatory) or 2 (benign).
c. The presence of air in segmental or more proximal airway abnormalities often favors secretions; if no underlying soft tissue nodule is iden-
tified, these findings may be classified as Lung-RADS 2.
d. Segmental or more proximal airway nodules that are stable or growing on 3-month follow-up CT are upgraded to Lung-RADS 4B with
management recommendation for further clinical evaluation (typically bronchoscopy).
12. Atypical Pulmonary Cysts:
a. Thin-walled Cyst: Unilocular with uniform wall thickness < 2 mm. Thin-walled cysts are considered benign and are not classified or managed
in Lung-RADS.
b. Thick-walled Cyst: Unilocular with uniform wall thickness, asymmetric wall thickening, or nodular wall thickening ≥ 2 mm (cystic component
is the dominant feature); manage as an atypical pulmonary cyst.
c. Multilocular Cyst: Thick- or thin-walled cyst with internal septations. Manage as an atypical pulmonary cyst.
d. Cavitary Nodule: Wall thickening is the dominant feature; manage as a solid nodule (total mean diameter).
e. Cyst with an Associated Nodule: Any cyst with adjacent internal (endophytic) or external (exophytic) nodule (solid, part-solid, or ground-
glass). Management is based upon Lung-RADS criteria for the most concerning feature.
f. G rowth: > 1.5 mm increase in nodule size (mean diameter), wall thickness, and/or size of the cystic component (mean diameter) occurring
within a 12-month interval.
g. Fluid-containing cysts may represent an infectious process and are not classified in Lung-RADS unless other concerning features are
identified.
h. Multiple cysts may indicate an alternative diagnosis such as Langerhans cell histiocytosis (LCH) or lymphangioleiomyomatosis (LAM) and are
not classified in Lung-RADS unless other concerning features are identified. (Reference: Seaman DM, Meyer CA, Gilman MD, McCormack
FX. Diffuse Cystic Lung Disease at High-Resolution CT. AJR 2011;196: 1305-1311)
1 3. 
Category 4B: Management is predicated on clinical evaluation (comorbidities), patient preference, and risk of malignancy. Radiologists
are encouraged to use the McWilliams, et. al. Assessment Tool when making recommendations (https://brocku.ca/lung​cancer-​screening-​
and-risk-prediction/risk-calculators/).
14. Category 4X: Category 3 or 4 nodules with additional imaging findings that increase the suspicion of lung cancer, such as spiculation, lymph-
adenopathy, frank metastatic disease, a GGN that doubles in size in 1 year, etc. 4X is a distinct Lung-RADS category; X should not be used as a
modifier.
15. E xam Modifier: An S modifier may be added to Lung-RADS categories 0-4 for clinically significant or potentially clinically significant findings
unrelated to lung cancer.
a. Management should adhere to available ACR Incidental Findings management recommendations (https://www.acr.org/Clinical-Resources/
Incidental-Findings). The ACR Lung Cancer Screening CT Incidental Findings Quick Reference Guide summarizes common findings and
management (https://www.acr.org/-/media/ACR/Files/Lung-Cancer-Screening-Resources/LCS-Incidental-Findings-Quick-Guide.pdf).
b. Findings that are already known, and have been or are in the process of clinical evaluation DO NOT require an S modifier. Any evidence of a
concerning change in a known significant or potentially significant finding that is unexpected warrants renewed use of the S modifier.
16. Lung Cancer Diagnosis: Once a patient is diagnosed with lung cancer, further management (including additional imaging, such as PET/CT) may
be performed for purposes of lung cancer staging; this is no longer considered screening.
Additional resources available at: https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/Lung-Rads
Reprinted with permission from American College of Radiology. Lung-RADS 2022. November 2022. Accessed January 23, 2023. https://​w ww.acr.
org/-/media/ACR/Files/RADS/Lung-RADS/Lung-RADS-2022.pdf.

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 PULMONARY NODULES

been established, their clinical usefulness has not been veri- (high, which combines the intermediate- and high-risk
fied and may not add much beyond the clinical expertise and groups; or low).3 High-risk factors include older age, sig-
interpretation provided by specialists or radiologists.7 nificant smoking history, larger nodule size, irregular or
spiculated borders, or upper lobe location. Low-risk factors
What Is the Recommended Management include young age, less smoking, smaller nodule size, regular
of an Incidentally Detected Solid Pulmonary margins, and location not in the upper lobes. Patients at low
Nodule? risk with small nodules (less than 6 mm) do not require fur-
The Fleischner Society and CHEST recommend no follow-up ther surveillance. Repeat CT at 12 months may be considered
for small, low-risk nodules and scheduled follow-up with CT in patients at high risk. Short-interval imaging with CT in
for medium-sized nodules. The Fleischner Society recom- six to 12 months is recommended for medium-sized nodules
mends short-term CT follow-up, PET/CT, or tissue sampling (6 to 8 mm) regardless of the risk category, followed by more
for large nodules, whereas CHEST recommends management frequent surveillance. For large nodules (greater than 8 mm),
based on the risk of malignancy. physicians should consider CT in three months, PET/CT, or
referral for tissue sampling.
EVIDENCE SUMMARY The CHEST guideline makes similar recommendations for
Management of solid pulmonary nodules varies among small and medium-sized nodules.4 However, for large nod-
guidelines (Table 5).3,4 The Fleischner Society recommends ules, management differs based on the risk of malignancy,
follow-up be performed based on nodule size (less than which includes the use of risk prediction models. Patients
6 mm, 6 to 8 mm, greater than 8 mm) and risk assessment at low risk (less than 5%) may be followed with low-dose

TABLE 4

Validated Risk Prediction Models for Pulmonary Nodules

U.S. Department of
Characteristic Mayo Clinic Veterans Affairs Herder Cleveland Clinic PanCan (Brock University)

Population Incidental Incidental nodule Incidental Incidental nodules Nodules detected during
characteristic nodule on chest on chest radiog- nodule on chest referred for biopsy lung cancer screening
radiography raphy confirmed radiography or lung resection
with CT with PET/CT
performed

Components Age Age Age Age Age

of model Extrathoracic Nodule diameter Extrathoracic Presence of Presence of emphysema
cancer ≥ 5 years Smoking history cancer ≥ 5 years emphysema Family history of lung
ago ago PET/CT results cancer
Time since quit-
Nodule diameter ting smoking PET/CT results History of nonlung Location
Smoking history Nodule diameter cancer Nodule count
Spiculation Smoking history Smoking history Nodule size
Upper lobe Spiculation Solid and irregular Nodule type
location Upper lobe edges
Patient sex
location Upper lobe location

Website https://​reference. Available in http://​w ww. Available in original https://​w ww.uptodate.

medscape. original arti- nucmed.com/ article24: https://​ com/contents/calculator-
com/calculator/ cle23: https://​ nucmed/spn_ journal.chestnet. solitary-pulmonary-
solitary- journal.chestnet. risk_calculator. org/article/S0012-​ nodule-malignancy-
pulmonary- org/article/ aspx 3692(19)​30689-0/​ risk-in-adults-brock-
nodule-risk S0012-​3692(15)​ fulltext university-cancer-
48320-​5/fulltext prediction-equation

CT = computed tomography;​PET/CT = positron emission tomography/computed tomography.

Information from references 20-24.

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 PULMONARY NODULES
TABLE 5

Comparison of Guidelines for the Management of Incidental Solid Pulmonary Nodules

Nodule size* Assigned risk† American College of Chest Physicians Fleischner Society

Small High risk ≤ 4 mm:​CT at 12 months (if stable, no further follow-up) Optional:​ follow-up
(< 6 mm) > 4 to 6 mm:​CT at six to 12 months (if stable, repeat CT at 18 to 24 CT in 12 months
months)
Low risk ≤ 4 mm:​patient discussion, with option for follow-up No follow-up
> 4 to 6 mm:​follow-up CT at 12 months (if stable, no further follow-up)

Medium High risk CT at three to six months (if stable, then nine to 12 months and 24 CT in six to 12 months,
(6 to 8 mm) months) then repeat CT in 18
to 24 months
Low risk CT at six to 12 months (if stable, follow-up at 18 to 24 months) CT in six to 12 months,
then consider repeat
CT at 18 to 24 months

Large High/low risk ≥ 8 mm:​calculate probability of malignancy:​ Consider follow-up

(> 8 mm) Pretest probability < 5%:​surveillance CT in three months CT at three months,
PET/CT, or tissue
Pretest probability 5% to 65%:​PET/CT with plan for continued sur- sampling
veillance, nonsurgical biopsy, or surgical biopsy/resection
Pretest probability > 65%:​surgical biopsy or resection after staging

CT = computed tomography;​PET/CT = positron emission tomography/computed tomography.

*—The Fleischner Society adds volume criteria for nodule size:​small < 100 mm3;​medium = 100 to 250 mm3;​large > 250 mm3.
†—The American College of Chest Physicians recommends the use of clinical judgement or a validated risk prediction model (Table 4) to assign the
personal risk of malignancy as high (> 65%), intermediate (5% to 65%), or low (< 5%). The Fleischner Society recommends characterizing personal
risk of malignancy as high risk using any of the following:​older age, significant smoking history, larger nodule size, irregular or spiculated borders,
or upper lobe location;​vs. low risk using any of the following:​young age, less smoking, smaller nodule size, regular margins, and location not in
the upper lobes.
Information from references 3 and 4.

CT in three months. Patients with an intermediate risk of intermediate-sized (6 to 8 mm) subsolid nodules, and larger
malignancy (5% to 65%) may be offered PET/CT to define (greater than 8 mm) subsolid nodules are managed similarly
the risk of malignancy further or determine the need for a to large solid nodules.
biopsy. Peripherally located nodules are often more acces-
sible by CT-guided transthoracic needle biopsies, whereas EVIDENCE SUMMARY
bronchoscopy may more easily reach nodules nearer to an CHEST and Fleischner Society guidelines do not recom-
airway.7 In one meta-analysis, transthoracic needle biopsies mend further imaging for small subsolid pulmonary nod-
had a higher diagnostic yield than bronchoscopy (93% vs. ules. Larger ground-glass nodules should be followed with
75%) but were also associated with a higher risk of bleeding repeat CT at six to 12 months, then periodically for the next
and pneumothorax.25 Technological advances in bronchos- few years (Table 6).3,4 CHEST recommends that part-solid,
copy have improved diagnostic yield with similarly low com- 6 to 8 mm nodules be reimaged with CT at three, 12, and
plication rates.26 24 months, then annually for five years. Nodules greater
When the risk of malignancy is high (greater than 65%), than 8 mm should have follow-up CT at three months with
surgical resection is recommended for patients who can tol- PET/CT, biopsy, or resection if the nodule persists. The
erate the procedure.7 Nonsurgical options, including biopsy, Fleischner Society recommends repeat CT in three to six
stereotactic radiotherapy, or ablative therapies, may be con- months for part-solid nodules 6 mm or greater, then annu-
sidered for patients at very high risk of death from the resec- ally for five years.
tion procedure.
What Factors Are Associated With Improved
What Is the Recommended Management Adherence to These Guidelines?
for Incidentally Detected Subsolid Nodules? Adherence to guidelines is improved with high-quality
Small subsolid nodules (5 mm or less per CHEST, less than physician-patient communication, clinical decision sup-
6 mm per the Fleischner Society) do not require further imag- port tools, and radiology reports that include guideline
ing. Regular surveillance imaging with CT is recommended for templates.

March 2023 ◆ Volume 107, Number 3 www.aafp.org/afp American Family Physician 289

 PULMONARY NODULES
SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comment

Annual lung cancer screening with low-dose computed tomog- B U.S. Preventive Services Task Force
raphy is recommended in adults 50 to 80 years of age who have recommendation based on reduction in
a 20-pack-year smoking history and currently smoke or have quit cancer-associated mortality
within the past 15 years.10

Chest computed tomography with thin sections should be ordered C Guideline recommendations from the
for patients with pulmonary nodules detected on chest radiogra- American College of Chest Physicians
phy that cannot be clearly classified as benign.4

A validated clinical decision tool should be used in patients with C Guideline recommendations from the
pulmonary nodules to determine the probability of malignancy American College of Chest Physicians and
(high risk, greater than 65%;​intermediate risk, 5% to 65%;​and low Fleischner Society
risk, less than 5%) and guide management. 3,4

Direct communication with patients, clinical decision support C Several small studies demonstrated
within electronic health records, and guideline-based manage- improved adherence to guidelines but
ment algorithms included in radiology reports improve compliance did not discuss improvements in specific
with guidelines for the management of pulmonary nodules. 28-30 patient-oriented outcomes

A = consistent, good-quality patient-oriented evidence;​ B = inconsistent or limited-quality patient-oriented evidence;​ C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://​w ww.aafp.
org/afpsort.

TABLE 6

Comparison of Guidelines for the Management of Incidental Subsolid Pulmonary Nodules

Nodule size American College of Chest Physicians Fleischner Society

Small ≤ 5 mm:​no follow-up < 6 mm:​no routine follow-up for ground-glass

or part-solid nodules

Large > 5 mm ≥ 6 mm
Ground-glass:​ Ground-glass:​
CT at 12 months, then annual CT for three years CT at six to 12 months, then every two to
Part-solid nodule:​ five years

≤ 8 mm solid component:​CT at three, 12, and 24 months, Subsolid nodule:​

then annually for five years CT at three to six months, then annually
> 8 mm solid component:​CT at three months, further eval- for five years
uation with PET/CT, biopsy, or resection if nodule persists

CT = computed tomography;​PET/CT = positron emission tomography/computed tomography.

Information from references 3 and 4.

EVIDENCE SUMMARY during inpatient care or preoperative visits are associated

In one study, only 55% of patients with pulmonary nodules with subsequent nonadherence to published guidelines.27
of any type diagnosed outside of a lung cancer screening
program received appropriate, guideline-based care.27 Direct This article updates previous articles on this topic by Kikano,
physician-patient communication, clinical decision support et al.,8 and Albert and Russell. 31
within electronic health records, and guideline-based man- Data Sources:​A PubMed search was completed using the key
terms solitary pulmonary nodule, diagnosis, management,
agement algorithms included in radiology reports are all
and lung cancer screening. Also searched were the Agency for
associated with increased compliance with guidelines.28-30 Healthcare Research and Quality evidence reports, Clinical Evi-
Conversely, inappropriate or incomplete radiology reports, dence, the Cochrane database, Essential Evidence Plus, U.S. Pre-
receiving care at multiple facilities, and incidental detection ventive Services Task Force, and the Institute for Clinical Systems

290  American Family Physician www.aafp.org/afp Volume 107, Number 3 ◆ March 2023
 PULMONARY NODULES

Improvement. Search dates:​March 4, 2022 to July 15, 2022, 1 3. Moyer VA;​U.S. Preventive Services Task Force. Screening for lung can-
August 20, 2022, and January 23, 2023. cer:​U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med. 2014;​160(5):​330-338.

14. American Academy of Family Physicians. Clinical preventive ser-
The Authors vice recommendation:​lung cancer. 2021. Accessed March 4,
2022. https://​w ww.aafp.org/family-physician/patient-care/clinical-
ROBERT C. LANGAN, MD, FAAFP, is the program director at recommendations/all-clinical-recommendations/lung-cancer.html
St. Luke’s Hospital Family Medicine Residency/Sacred Heart
15. Mazzone PJ, Silvestri GA, Patel S, et al. Screening for lung cancer:​
Campus, Allentown, Pa., and an adjunct professor in the CHEST guideline and expert panel report. Chest. 2018;​153(4):​954-985.
Department of Family and Community Medicine at Temple 16. Wender R, Fontham ETH, Barrera E Jr., et al. American Cancer Society
University School of Medicine, Philadelphia, Pa. lung cancer screening guidelines. CA Cancer J Clin. 2013;​63(2):​107-117.
17. Deppen SA, Blume JD, Kensinger CD, et al. Accuracy of FDG-PET to
ANDREW J. GOODBRED, MD, FAAFP, is the associate diagnose lung cancer in areas with infectious lung disease:​a meta-
program director at St. Luke’s Hospital Family Medicine analysis. JAMA. 2014;​312(12):​1 227-1236.
Residency/Anderson Campus, Easton, Pa., and an adjunct 18. American College of Radiology. Radiation dose to adults from com-
associate professor in the Department of Family and Com- mon imaging examinations. Accessed August 3, 2022. https://​w ww.
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Reference-Card.pdf
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