British Thoracic Society guidelines for pulmonary nodules

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British Thoracic Society guidelines for pulmonary nodules were published in August 2015 for the management of pulmonary nodules seen on CT. In the United Kingdom, they supersede the Fleischner Society guidelines.

They are based initially on identifying whether the nodule is solid or subsolid and then evaluating its size. The guidelines now emphasize size assessment based on volume rather than diameter, particularly when considering discharging patient from follow-up.

Each lung nodule is assessed individually. The Brock and Herder risk models are used to stratify patients to determine appropriate follow-up and management.

Solid nodules

Nodule size: <5 mm diameter or <80 mmvolume
  • discharge
Nodule size: 5-6 mm diameter
  • CT at 1 year from baseline
Appearance on repeat CT 1 year from baseline
  • stable on basis of 2D diameter
    • CT 2 years from baseline with volume assessment; manage as per volume class (see below)
  • stable on volumetry
    • discharge
  • volume doubling time >600 days
    • discharge or CT surveillance depending on patient preference
  • volume doubling time 400-600 days
    • consider biopsy or further CT surveillance based on patient preference
  • volume doubling time ≤400 days
    • further workup and consideration of definitive management
Nodule size: >6 mm diameter or ≥80 mm volume
  • repeat CT at 3 months from baseline
Appearance on repeat CT at 3 months
  • volume doubling time ≤400 days
    • further work up and consideration of definitive management
  • volume doubling time >400 days
    • CT surveillance as for 5-6 mm solid nodules
Nodule size: ≥8 mm diameter or ≥300 mm volume
  • low risk of malignancy
    • <10% based on Brock model
    • CT surveillance as for 5-6 mm solid nodules
  • higher risk of malignancy
    • ≥10% based on Brock model
    • PET-CT with risk assessment using Herder model
      • <10% risk of malignancy
        • CT surveillance as for 5-6 mm solid nodules
      • 10-70% risk of malignancy
        • consider image-guided biopsy
      • >70% risk of malignancy
        • consider excision or non-surgical treatment
        • +/- image guided biopsy

Subsolid nodules

These include nodules with a partly solid or partly ground glass component.

Nodule size: <5 mm diameter or <80 mmvolume

  • discharge

Nodule size: ≥5 mm diameter or ≥80 mm volume
  • if there is previous imaging
    • nodules stable for 4 years are discharged
    • nodules stable for less than 4 years undergo further surveillance and malignancy risk assessment
  • if no previous imaging is available
    • repeat thin section CT at 3 months (see below)
Appearance on repeat CT at 3 months: if resolved
  • discharge
Appearance on repeat CT at 3 months: if stable
  • low risk of malignancy
    • <10% based on Brock model or morphology
    • repeat thin section CT at 1, 2 and 4 years from baseline
  • higher risk of malignancy
    • ≥10% based on Brock model or morphology
    • discuss options with the patient
      • surveillance thin section CT at 1, 2 and 4 years
      • image guided biopsy
      • resection or non-surgical treatment
Appearance on repeat CT at 3 months: growth/altered morphology
  • favor resection or non-surgical therapy
  • offer repeat CT at 1, 2 and 4 years from baseline if the patient does not want resection/therapy

See also