Comparison of Fleischner, Lung-RADS and ACCP guideline management of SN detected within or outside of screening
| Fleischner | ACCP | Lung-RADS | |||
|---|---|---|---|---|---|
| Low risk | High risk | Low risk | High risk | ||
| Baseline scan | |||||
| No nodules or nodules with benign features | No follow-up | No follow-up | Not specified | Category 1 (negative): return to annual screening at 12 months | |
| <4 mm | Interval CT at 12 months | Optional follow-up | Interval CT at 12 months then discharge if stable | Category 2 (benign): return to annual screening at 12 months | |
| 4–6 mm | Interval CT at 12 months | Interval CT at 6–12 and 18–24 months | Interval CT at 12 months then discharge if stable | Interval CT at 6–12 and 18–24 months and discharge at 24 months if stable | |
| 6–8 mm | Interval CT at 6–12 and 18–24 months | 3–6, 9–12 and 24 months | Interval CT at 6–12 and 18–24 months and discharge at 24 months if stable | Interval CT at 3–6, 9–12 and 24 months and discharge at 24 months if stable | Category 3 (probably benign): interval CT at 6 months |
| 8–15 mm | Interval CT at 3, 9, 24 months, dynamic CT chest, PET-CT±histology |
Risk<5%: perform CT surveillance at 3–6, 9–12 and 18–24 months If non-FDG avid/ non-enhancing on contrast CT and risk <40% or negative biopsy: perform CT surveillance at 3–6, 9–12 and 18–24 months Risk 5%–65%: perform PET and consider biopsy/resection Risk >65%: PET not required favour histological confirmation, with surgical resection | Category 4A (suspicious): PET-CT: interval CT at 3 months | ||
| >15 mm | Category 4B (suspicious): perform standard CT with or without contrast; PET-CT; histology | ||||
| Interval scan | |||||
| <4 mm (new) | Discharge if resolved or at 12 months if no growth | If there is clear evidence of growth (VDT<400 days is suggestive of malignancy), favour surgical resection If no growth or decrease in size, follow-up for 2 years or until nodule disappears | Category 2 (benign): return to annual screening at 12 months | ||
| 4–6 mm (new) | Discharge if resolved or at 1 year if no growth | Discharge if resolved or at 18–24 months if no growth | Category 3 (probably benign): interval CT at 6 months | ||
| <8 mm (new/growing) | Discharge if resolved or at 24 months if no growth | Discharge if resolved or at 24 months if no growth | Category 4A (suspicious): interval CT at 3 months | ||
| >8 mm (new/growing) | Perform PET-CT±histology Discharge if resolved or at 24 months if no growth | Category 4B (suspicious): perform standard CT with or without contrast; PET-CT; histology | |||
N.B. Lung-RADS is for CT screening scans only.
ACCP, American College of Chest Physicians; PET, positron emission tomography; RADS, Reporting and Data System; SN, solid nodules.