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doi:10.1378/chest.07-1353
(Chest. 2007; 132:108S-130)
© 2007 American College of Chest Physicians
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Evaluation of Patients With Pulmonary Nodules: When Is It Lung Cancer?*

ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

Michael K. Gould, MD, FCCP; James Fletcher, MD; Mark D. Iannettoni, MD, FCCP; William R. Lynch, MD; David E. Midthun, MD, FCCP; David P. Naidich, MD, FCCP and David E. Ost, MD, FCCP

* From the VA Palo Alto Health Care System and the Department of Medicine (Dr. Gould), Stanford School of Medicine, Stanford, CA; the Department of Radiology (Dr. Fletcher), Indiana University School of Medicine, Indianapolis, IN; the Department of Cardiothoracic Surgery (Drs. Iannettoni and Lynch), University of Iowa Carver College of Medicine, Iowa City, IA; the Department of Medicine (Dr. Midthun), Mayo School of Medicine, Rochester, MN; and the Departments of Radiology (Dr. Naidich) and Medicine (Dr. Ost), New York University Medical Center, New York, NY.

Correspondence to: Michael K. Gould, MD, FCCP, VA Palo Alto Health Care System, 3801 Miranda Ave (111P), Palo Alto, CA 94304; e-mail: gould{at}stanford.edu

Background: Pulmonary nodules are spherical radiographic opacities that measure up to 30 mm in diameter. Nodules are extremely common in clinical practice and challenging to manage, especially small, "subcentimeter" nodules. Identification of malignant nodules is important because they represent a potentially curable form of lung cancer.

Methods: We developed evidence-based clinical practice guidelines based on a systematic literature review and discussion with a large, multidisciplinary group of clinical experts and other stakeholders.

Results: We generated a list of 29 recommendations for managing the solitary pulmonary nodule (SPN) that measures at least 8 to 10 mm in diameter; small, subcentimeter nodules that measure < 8 mm to 10 mm in diameter; and multiple nodules when they are detected incidentally during evaluation of the SPN. Recommendations stress the value of risk factor assessment, the utility of imaging tests (especially old films), the need to weigh the risks and benefits of various management strategies (biopsy, surgery, and observation with serial imaging tests), and the importance of eliciting patient preferences.

Conclusion: Patients with pulmonary nodules should be evaluated by estimation of the probability of malignancy, performance of imaging tests to characterize the lesion(s) better, evaluation of the risks associated with various management alternatives, and elicitation of patient preferences for treatment.

Key Words: emission CT • granulomas • lung metastasis • lung neoplasms • needle biopsy • pulmonary coin lesion • radiograph CT • thoracic radiography • thoracic surgery






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