Background and objectives The BTS published new guidelines for the investigation and management of pulmonary nodules in June 2015. These replace the Fleischner guidelines and are based on an improved evidence base produced predominantly from recent lung cancer screening trials.
The BTS guidelines suggest no radiological follow-up for nodules smaller than 5 mm or <80 mm3 and limit CT follow-up to 12 months when volumetric analysis is used. The guidelines recommend use of the Brock Model (full with spiculation) to estimate the probability of malignancy in nodules ≥8 mm. The Brock group also published a parsimonious model which requires fewer clinical variables to calculate risk with almost equivalent accuracy.
The objectives of this study are to establish the impact of the new guidance on the number of patients requiring radiological follow-up and the total number of scans recommended. We also studied any differences between the 2 Brock risk models.
Methods We retrospectively reviewed 99 consecutive patients who were reviewed for indeterminate lung nodules. Their follow-up recommendations were calculated using 3 methods: 1) Fleischner, 2) BTS guidelines using Brock (full), 3) BTS guidelines using Brock (parsimonious).
When using the Brock model we assumed worse case scenario if clinical information was not available (i.e. family history of lung cancer present). We assumed all nodules stayed stable in size and that volumetric analysis was performed.
Results 23% fewer patients (75 vs. 99) required surveillance when using the BTS guidelines with Brock models rather than Fleischner.
38% fewer CT scans (132 vs. 214) would be performed in total when using Brock (full) compared with Fleischner.
31/99 patients had nodules ≥8 mm. Using the Brock (full) model 9/31 would have PET-CT compared with 6/31 with the Brock (parsimonious) model.
Conclusion The new BTS guidelines will significantly reduce both the number of patients requiring radiological follow up for indeterminate nodules and also the total number of scans required overall.
Even assuming worst case scenario in terms of clinical risk factors there is very little difference between Brock (full) and Brock (parsimonious). This needs assessing in a larger population with clinical outcomes evaluated.
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