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Fleischner Society Recommendations for SPN Nodule Size
(average diam)Low-risk patient
(e.g. nonsmoker)High-risk patient
(e.g. smoker)
≤ 4 mm
no follow-up
CT at 12 months;
no further f/u if no change> 4-6 mm
CT at 12 months;
no further f/u if no change6-12 months; then
18-24 mo if no change> 6-8 mm
6-12 months; then
18-24 mo if no change3-6 months; then
9-12 & 24 mo if no change> 8 mm
Options: CT at approximately 3, 9, and 24 months,
PET, biopsy, and/or contrast-enhanced CT
MacMahon et al. Radiology 237:395, Nov 2005
- Fleischner Society Recommendations for SPN
- patients with known or suspected metastases:
use appropriate protocol for tumor, short term follow-up often appropriate
- young patients (< 35 years): consider a single low dose scan at 6-12 months
- elderly pts or patients with other conditions: follow-up may not be needed
- patients with fever: short term follow-up to exclude infection
- “ Lung nodules incidentally detected on abdominal CT were rarely malignant and were seen only in the setting of an underlying abdominal malignancy. Knowledge of such history is of critical importance to both the clinician and the radiologist.”
Clinical Significance of Lung Nodules Reported on Abdominal CT
Alpert JB et al.
AJR 2012;198: 793-799 - “ We have shown that only a small percentage of nodules reported on abdominal CT proved clinically significant and that all were seen in patients with a known or newly diagnosed malignancy.”
Clinical Significance of Lung Nodules Reported on Abdominal CT
Alpert JB et al.
AJR 2012;198: 793-799
- “ FDG PET showed no clear advantage for the staging of lung cancer with predominant GGO because of the low incidences of nodal and distant metastases.”
Is There a Role for FDG PET in the Management of Lung Cancer Manifesting Predominantly as Ground-Glass Opacity?
Kim TJ et al
AJR 2012; 198:83-88 - “ In summary, when CT shows a pulmonary nodule with predominant GGO, FDG PET frequently produces negative results. Furthermore, FDG PET is unlikely to detect lymph nodes or distant metastasis because of their low prevalence and, thus, does not appear to offer a clear advantage in patients with lung cancer manifesting as predominately GGO.”
Is There a Role for FDG PET in the Management of Lung Cancer Manifesting Predominantly as Ground-Glass Opacity?
Kim TJ et al
AJR 2012; 198:83-88
- Study limitations: VRT vs MIP
- Preset values set for
- VRT while real time adjustments are critical on a case by case basis VRT succes varies workstation to workstation while MIP has less variation
- Preset slab thickness for VRT may not be ideal Effect of Slab Thickness on the CT Detection of Pulmonary Nodules: Use of Sliding Thin-Slab Maximum Intensity Projection and Volume Rendering
Kawel N et al.
AJR 2009; 192; 1324-1329 "Our results show that the nodule detection rate using MIP is superior to that using VR independent of slab thickness."
Effect of Slab Thickness on the CT Detection of Pulmonary Nodules: Use of Sliding Thin-Slab Maximum Intensity Projection and Volume Rendering
Kawel N et al.
AJR 2009; 192; 1324-1329"MIP with a slab thickness of 8 mm is superior in the detection of pulmonary nodules to all other tested techniques."
Effect of Slab Thickness on the CT Detection of Pulmonary Nodules: Use of Sliding Thin-Slab Maximum Intensity Projection and Volume Rendering
Kawel N et al.
AJR 2009; 192; 1324-1329