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The Fleischner Society 2017 and British Thoracic Society 2015 guidelines for managing pulmonary nodules: keep calm and carry on
  1. Arjun Nair1,
  2. Anand Devaraj2,
  3. Matthew E J Callister3,
  4. David R Baldwin4
  1. 1 Department of Radiology, University College London Hospital, London, UK
  2. 2 Department of Radiology, Royal Brompton Hospital, London, UK
  3. 3 Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  4. 4 Respiratory Medicine Unit, David Evans Research Centre, Nottingham University Hospitals, Nottingham, UK
  1. Correspondence to Dr Arjun Nair, Department of Radiology, University College London Hospital, London NW1 2BU, UK; arjun7764{at}

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Key messages

What is the key question?

  • How do the Fleischner recommendations for the management of incidental pulmonary nodules published in 2017 compare with the British Thoracic Society (BTS) recommendations published in 2015?

What is the bottom line?

  • The updated Fleischner Society recommendations are mostly similar to the 2015 BTS guideline, but the BTS goes further in its recommendations concerning the use of risk prediction models and volumetry, while the Fleischner guidelines go further in recommending a conservative approach to stable pure ground-glass nodules.

Why read on?

  • We discuss the areas where the two guidelines diverge—namely routes of presentation, solid nodule management and risk assessment—with reference to their rationale, relative merits and drawbacks, and offer pragmatic conclusions relevant to clinical practice about which guideline to adopt.


Pulmonary nodules are common, with a prevalence of 14%–36%,1–5 usually less in case series of nodules that are incidentally detected on thoracic CT scans performed for a variety of clinical indications. Clinical management of CT-detected pulmonary nodules was based initially on a statement made by the Fleischner Society in 2005.6 Three further guidelines and one statement have been published since 2013 incorporating emerging evidence. The Fleischner Society provided specific recommendations for subsolid nodule management in 2013.7 In the same year, the American College of Chest Physicians (ACCP) issued nodule guidance as part of its recommendations for the diagnosis and management of lung cancer.8 In 2015, the British Thoracic Society (BTS) published guidelines for nodule management, accompanied by a comprehensive evidence review.9 Most recently, the Fleischner Society updated their guidance for management and measurement of nodules, replacing both their 2005 and 2013 guidance.10 11 Clinician awareness of, and adherence to, such guidance has historically been poor, and remains so.12–16 Guidelines that differ in their recommendations are a potential source of confusion and thus risk increasing variation in clinical practice rather than achieving one of …

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  • Contributors All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be submitted, as per the ICMJE requirements.

  • Competing interests AN declares that he is a member of the Advisory Board for Aidence BV, The Netherlands, and he is part-funded by the UCLH Biomedical Research Centre (BRC), National Institute. DRB declares grants from AstraZeneca and Oncimmune, outside the submitted work. DRB and MEJC were coauthors of the British Thoracic Society guidelines for the investigation and management of pulmonary nodules published in 2015. AD has no competing interests to declare.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This article has been corrected since it was published Online First. The second author’s name was corrected.

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