Pulmonary nodule medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Solitary pulmonary nodule}} | {{Solitary pulmonary nodule}} | ||
{{CMG}} | {{CMG}}{{AE}}{{MV}} | ||
==Overview== | ==Overview== | ||
The optimal management approach of solitary pulmonary nodule mainly depends on the nodule size and growth. Other parameters, such as location and distribution may also be helpful. [[Surgical resection]] is often recommended among [[Patient|patients]] with a [[malignant]] likelihood of solitary pulmonary nodule. On the other hand, solitary pulmonary nodules with [[benign]] features are eligible for periodic [[Computed tomography|CT]] surveillance. | |||
==Medical Therapy== | ==Medical Therapy== | ||
{| | *The optimal management approach of solitary pulmonary nodule mainly depends on the nodule size and growth. | ||
!Nodule Size (mm) | *Other parameters, such as location and distribution may also be helpful. | ||
!'''Low risk''' patients | *The solitary pulmonary nodule risk assessment is useful to determine the likelihood of [[Cancer|malignancy]] and prompt treatment. | ||
!'''High risk''' patients | *[[Surgical resection]] is often recommended among [[Patient|patients]] with a [[malignant]] likelihood of solitary pulmonary nodule. | ||
*On the other hand, solitary pulmonary nodules with [[benign]] features are eligible for periodic [[Computed tomography|CT]] surveillance. | |||
===Management Strategies=== | |||
The algorithm below summarizes the different management strategies for [[Patient|patients]] with pulmonary nodule: | |||
{{familytree/start |summary=PE diagnosis Algorithm.}} | |||
{{familytree | A01 |-| A02 |-|-|-| A03 |-|-|-| A04 | | |A01=<div style="width: 10em; padding:1em;">'''Solid solitary pulmonary nodule'''<br> < 8mm</div>|A02=<div style="width: 10em; padding:1em;">'''Solid solitary pulmonary nodule'''<br> > 8mm</div>|A03=<div style="width: 10em; padding:1em;">'''Subsolid/part-solid nodule'''</div>|A04=<div style="width: 10em; padding:1em;">'''Multiple'''</div>}} | |||
{{familytree | |!| | | |!| | | |,|-|^|-|.| | | |!| | | }} | |||
{{familytree | |!| | | |!| | | |!| | | |!| | | |!|}} | |||
{{familytree | B01 | | B02 | | B03 | | B04 | | B05| | |B01='''[[Solitary pulmonary nodule CT|'''Non-enhanced CT scan (NECT)''']]<br><SMALL>*Frequency depends on individual risk assesment</SMALL>|B02=[[Solitary pulmonary nodule evaluation of solitary pulmonary nodule#Malignancy risk assessment|'''Malignancy risk assessment''']]|B03= '''< 5mm'''|B04= '''> 5mm'''|B05='''Each nodule should be assessed individually*'''<br><SMALL>CT surveillance and biopsy accordingly</SMALL> }} | |||
{{familytree | | | | | |!| | | |!| | | |!| | | | | | }} | |||
{{familytree | | | | | C01 | | C02 | | C03 | | | | | | |C01=''' Intermediate Risk'''<br>[[Solitary pulmonary nodule other imaging findings|'''Positron emission tomography''']]<br><SMALL>If positive, request biopsy or surgical excision<br> If negative, serial CT scans* </SMALL> <br>'''High Risk'''<br>[[Solitary pulmonary nodule biopsy|'''Biopsy''']]<br>or<br>[[Solitary pulmonary nodule surgery|'''Surgical excision''']]|C02=[[Solitary pulmonary nodule CT #CT surveillance|'''CT Surveillance''']]<br> Every 3 months|C03='''No additional work-up'''}} | |||
{{familytree/end}} | |||
==Follow-Up and Surveillance== | |||
*[[Medical guideline|Guideline]] treatment and management recommendations for solitary pulmonary nodule include: | |||
:*[[American College of Chest Physicians|American College of Chest Physicians (ACCP)]] [[Medical guideline|guidelines]] | |||
:*Fleischner Society [[Medical guideline|guideline]] | |||
*The table below summarizes the follow-up and surveillance recommendations for solitary pulmonary nodule according to the Fleischner Society [[Medical guideline|guideline]]: | |||
{|style="border: 5px; font-size: 90%; margin: 5px; width: 1000px" align=center | |||
!style="padding: 5px 5px; background: #4479BA; font-weight: bold; text-align:center;" colspan="3"|{{fontcolor|#FFF|'''Recommendations for Follow-up and Management of Nodules <8 mm <br> Detected Incidentally at Non-screening CT'''}} | |||
|+ | |||
!style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Nodule Size (mm)}} | |||
!style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|'''Low risk''' patients}} | |||
!style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|'''High risk''' patients}} | |||
|- | |- | ||
| | |style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|≤ 4 | ||
|No follow-up needed | |style="padding: 5px 5px; background: #F5F5F5;"| | ||
|Follow-up at 12 months | * No follow-up needed | ||
|style="padding: 5px 5px; background: #F5F5F5;"| | |||
* Follow-up at 12 months | |||
* If no change, no further [[imaging]] needed | |||
|- | |- | ||
|>4 - 6 | |style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|> 4 - 6 | ||
|Follow-up at 12 months | |style="padding: 5px 5px; background: #F5F5F5;"| | ||
|Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change | * Follow-up at 12 months | ||
* If no change, no further [[imaging]] needed | |||
|style="padding: 5px 5px; background: #F5F5F5;"| | |||
* Initial follow-up [[Computed tomography|CT]] at 6 -12 months and then at 18 - 24 months if no change | |||
|- | |- | ||
|>6 - 8 | |style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|> 6 - 8 | ||
|Initial follow-up CT at 6 -12 months and then at 18 - 24 months if no change | |style="padding: 5px 5px; background: #F5F5F5;"| | ||
|Initial follow-up CT at 3 - 6 months and then at 9 -12 and 24 months if no change | * Initial follow-up [[Computed tomography|CT]] at 6 -12 months and then at 18 - 24 months if no change | ||
|style="padding: 5px 5px; background: #F5F5F5;"| | |||
* Initial follow-up [[Computed tomography|CT]] at 3 - 6 months and then at 9 -12 and 24 months if no change | |||
|- | |- | ||
|>8 | |style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|> 8 | ||
|Follow-up | |style="padding: 5px 5px; background: #F5F5F5;"| | ||
|Same at for low risk patients | * Follow-up [[Computed tomography|CT]] at around 3, 9, and 24 months | ||
* Dynamic [[Contrast medium|contrast]] enhanced [[Computed tomography|CT]], [[Positron emission tomography|PET]], and/or [[biopsy]] | |||
|style="padding: 5px 5px; background: #F5F5F5;"| | |||
* Same at for low risk [[Patient|patients]] | |||
|} | |} | ||
:<SMALL>Note: Newly detected indeterminate nodule in persons 35 years of age or older.<ref>Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. [http://radiology.rsnajnls.org/cgi/content/abstract/237/2/395 Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society.] Radiology 2005 237: 395-400.</ref><br>* '''Low risk patients''': Minimal or absent history of [[smoking]] and of other known [[Risk factor|risk factors]]<br>* '''High risk patients''': History of [[smoking]] or of other known [[Risk factor|risk factors]]</SMALL> | |||
Note: Newly detected indeterminate nodule in persons 35 years of age or older.<ref>Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. [http://radiology.rsnajnls.org/cgi/content/abstract/237/2/395 Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society.] Radiology 2005 237: 395-400.</ref> | |||
* '''Low risk patients''': Minimal or absent history of smoking and of other known risk factors | |||
* '''High risk patients''': History of smoking or of other known risk factors | |||
==References== | ==References== | ||
Latest revision as of 02:58, 2 July 2019
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Risk calculators and risk factors for Pulmonary nodule medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]
Overview
The optimal management approach of solitary pulmonary nodule mainly depends on the nodule size and growth. Other parameters, such as location and distribution may also be helpful. Surgical resection is often recommended among patients with a malignant likelihood of solitary pulmonary nodule. On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance.
Medical Therapy
- The optimal management approach of solitary pulmonary nodule mainly depends on the nodule size and growth.
- Other parameters, such as location and distribution may also be helpful.
- The solitary pulmonary nodule risk assessment is useful to determine the likelihood of malignancy and prompt treatment.
- Surgical resection is often recommended among patients with a malignant likelihood of solitary pulmonary nodule.
- On the other hand, solitary pulmonary nodules with benign features are eligible for periodic CT surveillance.
Management Strategies
The algorithm below summarizes the different management strategies for patients with pulmonary nodule:
Solid solitary pulmonary nodule < 8mm | Solid solitary pulmonary nodule > 8mm | Subsolid/part-solid nodule | Multiple | ||||||||||||||||||||||||||||||||||||||
| Non-enhanced CT scan (NECT) *Frequency depends on individual risk assesment | Malignancy risk assessment | < 5mm | > 5mm | Each nodule should be assessed individually* CT surveillance and biopsy accordingly | |||||||||||||||||||||||||||||||||||||
| Intermediate Risk Positron emission tomography If positive, request biopsy or surgical excision If negative, serial CT scans* High Risk Biopsy or Surgical excision | CT Surveillance Every 3 months | No additional work-up | |||||||||||||||||||||||||||||||||||||||
Follow-Up and Surveillance
- Guideline treatment and management recommendations for solitary pulmonary nodule include:
- American College of Chest Physicians (ACCP) guidelines
- Fleischner Society guideline
- The table below summarizes the follow-up and surveillance recommendations for solitary pulmonary nodule according to the Fleischner Society guideline:
| Recommendations for Follow-up and Management of Nodules <8 mm Detected Incidentally at Non-screening CT |
||
|---|---|---|
| Nodule Size (mm) | Low risk patients | High risk patients |
| ≤ 4 |
|
|
| > 4 - 6 |
|
|
| > 6 - 8 |
|
|
| > 8 |
| |
- Note: Newly detected indeterminate nodule in persons 35 years of age or older.[1]
* Low risk patients: Minimal or absent history of smoking and of other known risk factors
* High risk patients: History of smoking or of other known risk factors
References
- ↑ Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society. Radiology 2005 237: 395-400.