Fleischner society pulmonary nodule recommendations

Radswiki et al.

The Fleischner society pulmonary nodule recommendations are for the follow-up and management of pulmonary nodules smaller than 8 mm detected incidentally in patients >35 years on non-screening CT.  The initial guidelines for the management of solid nodules were released in 2005 1, and guidelines for the management of subsolid nodules were released in 2013 2. New revised 2017 recommendations for both solid and subsolid have since been released 4.

Solid nodules
Solitary nodule size: <6 mm 
  • low risk patients: no follow-up needed
  • high risk patients: optional CT at 12 months
Solitary nodule size: 6-8 mm
  • low risk patients: follow-up at 6-12 months, then consider further follow-up at 18-24 months
  • high risk patients: initial follow-up CT at 6-12 months and then at 18-24 months if no change
Solitary nodule size: >8 mm
  • either low or high risk patients
    • consider follow-up CT at 3 months, and/or CT-PET, and/or biopsy
Multiple nodules size: <6 mm
  • low risk patients: no routine follow-up
  • high risk patients: optional CT at 12 months
Multiple nodules size: 6-8 mm
  • low risk patients: follow-up at 3-6 months, then consider further follow-up at 18-24 months
  • high risk patients: follow-up at 3-6 months, then at 18-24 months if no change
Multiple nodules size: >8 mm
  • low risk patients: follow-up at 3-6 months, then consider further follow-up at 18-24 months
  • high risk patients: follow-up at 3-6 months, then at 18-24 months if no change

Note: newly detected indeterminate nodule in persons 35 years of age or older.

  • low risk patients: minimal or absent history of smoking and or other known risk factors
  • high risk patients: history of smoking or of other known risk factors (e.g. first degree relative with lung cancer, or exposure to asbestos, radon, uranium)
  • if a nodule up to 8 mm is partly solid or is ground glass further follow-up is required after 24 months to exclude possible slow growing adenocarcinoma (BAC) 
Subsolid nodules
Solitary pure ground-glass nodule
  • nodule size <6mm
    • no CT follow-up required
  • nodule size ≥6mm
    • follow up CT at 6-12 months, then every 2 years until 5 years
Solitary part-solid nodule
  • nodule size <6mm
    • no CT follow-up required
  • nodule size ≥6mm
    • follow-up CT at 3-6 months
    • if unchanged, and solid component remains <6mm, then annual follow-up for 5 years
Multiple subsolid nodules
  • nodule size <6mm
    • follow-up CT at 3-6 months
    • consider further follow-up at 2 and 4 years if stable
  • nodule size ≥6mm
    • follow-up CT at 3-6 months
    • subsequent management based on the most suspicious nodule(s)

Old guidelines have been left in place in this article in case previous reported follow-up under them.

Solid nodules
Nodule size: ≤ 4 mm
  • low risk patients: no follow-up needed
  • high risk patients: follow-up at 12 months and if no change, no further imaging needed
Nodule size: 4-6 mm
  • low risk patients: follow-up at 12 months and if no change, no further imaging needed
  • high risk patients: initial follow-up CT at 6-12 months and then at 18-24 months if no change
Nodule size: >6-8 mm
  • low risk patients: initial follow-up CT at 6-12 months and then at 18-24 months if no change
  • high risk patients: initial follow-up CT at 3-6 months and then at 9-12 and 24 months if no change
Nodule size: >8 mm
  • either low or high risk patients
    • follow-up CTs at around 3, 9, and 24 months
    • dynamic contrast enhanced CT, PET, and/or biopsy 

Note: newly detected indeterminate nodule in persons 35 years of age or older.

  • low risk patients: minimal or absent history of smoking and or other known risk factors
  • high risk patients: history of smoking or of other known risk factors (e.g. first degree relative with lung cancer, or exposure to asbestos, radon, uranium)
  • if a nodule up to 8 mm is partly solid or is ground glass further follow up is required after 24 months to exclude possible slow growing adenocarcinoma (BAC) 
Sub solid nodules
Solitary pure ground-glass nodules
  • nodule size ≤ 5mm
    • no CT follow up required
  • nodule size > 5mm
    • follow up CT at 3 months, then annual CT for at least 3 years
Solitary part-solid nodules
  • initial follow-up CT at 3 months
  • if persistent and solid component <5mm
    • annual CT for at least 3 years
  • if persistent and solid component ≥ 5mm
    • biopsy or surgical resection
Multiple subsolid nodules
  • pure ground glass nodules ≤ 5mm
    • CT at 2 and 4 years
  • pure ground glass nodules >5mm, without a dominant lesion(s)
    • initial follow-up CT at 3 months then annual CT for at least 3 years
  • dominant nodule(s) with part-solid or solid component
    • initial follow-up CT at 3 months
    • if persistent, biopsy or surgical resection (especially if has >5mm solid component)
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Article information

rID: 13541
System: Chest
Section: Approach
Synonyms or Alternate Spellings:
  • Fleischner society recommonedations for pulmonary nodule assessment

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