This guideline is based on a comprehensive review of the
literature on pulmonary nodules and expert opinion. Although the
management pathway for the majority of
nodules detected is straightforward it is sometimes more complex and
this is helped
by the inclusion of detailed and
specific recommendations and the 4 management algorithms below. The
Guideline Development
Group (GDG) wanted to highlight the new
research evidence which has led to significant changes in management
recommendations
from previously published guidelines.
These include the use of two malignancy prediction calculators (section
‘Initial assessment
of the probability of malignancy in
pulmonary nodules’, algorithm 1) to better characterise risk of
malignancy. There are
recommendations for a higher nodule
size threshold for follow-up (≥5 mm or ≥80 mm3) and a
reduction of the follow-up period to 1 year for solid pulmonary nodules;
both of these will reduce the number of follow-up
CT scans (sections ‘Initial assessment
of the probability of malignancy in pulmonary nodules’ and ‘Imaging
follow-up’, algorithms
1 and 2). Volumetry is recommended as
the preferred measurement method and there are recommendations for the
management of
nodules with extended volume doubling
times (section ‘Imaging follow-up’, algorithm 2). Acknowledging the good
prognosis of
sub-solid nodules (SSNs), there are
recommendations for less aggressive options for their management
(section ‘Management
of SSNs’, algorithm 3).
The guidelines provide more
clarity in the use of further imaging, with ordinal scale reporting for
PET-CT recommended to
facilitate incorporation into risk
models (section ‘Further imaging in management of pulmonary nodules’)
and more clarity
about the place of biopsy (section
‘Non-imaging tests and non-surgical biopsy’, algorithm 4). There are
recommendations for
the threshold for treatment without
histological confirmation (sections ‘Surgical excision biopsy’ and
‘Non-surgical treatment
without pathological confirmation of
malignancy’, algorithm 4).
Finally, and possibly most
importantly, there are evidence-based recommendations about the
information that people need and
which should be provided. This document
is intended to be used both as a summary in the day to day management
of a person
with a pulmonary nodule and a
comprehensive reference text.
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