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2017 Fleischner Society Pulmonary Nodule Follow-Up Guidelines and Recommendations
for Solid, Subsolid and Ground-Glass Lung Nodules



In 51% of cases, physicians fail to obtain the indicated follow-up exams.
Pulmonary Nodule Size Lung Nodule Type Single vs. Multiple Low Risk Patient High Risk Patient
< 6mm
(< 100mm3)		 Solid Solitary

No Follow-Up

If suspicious morphology or upper lobe location, consider 12-month follow-up.
 Optional CT in 12 months
Multiple

No Follow-Up

If suspicious morphology or upper lobe location, consider 12-month follow-up.
 Optional CT in 12 months
Part-Solid
(Subsolid)
 Solitary No Follow-Up
Multiple CT in 3 to 6 months. If unchanged, consider CT at 2 and 4 years.
Ground-Glass Solitary

No Follow-Up

If suspicious, consider follow-up at 2 and 4 years.  If grows or increasingly solid, consider resection.
Multiple CT in 3 to 6 months.  If unchanged, consider CT in 2 and 4 years.
6 to 8mm
(100-250mm3)		 Solid Solitary CT in 6 to 12 months, then consider CT in 18 to 24 months. CT in 6 to 12 months, then obtain CT in 18 to 24 months.
Multiple CT in 3 to 6 months, then consider CT in 18 to 24 months CT in 3 to 6 months, then obtain CT in 18 to 24 months
Part-Solid
(Subsolid)
 Solitary CT in 3 to 6 months to confirm persistance.  If unchanged and solid component below 6mm, CT annually for 5 years. 
Persistent part-solid nodules containing a solid componment > 6mm are highly suspicious.
Multiple CT in 3 to 6 months.  Then management based on most suspicious nodule(s).
Ground-Glass Solitary CT in 6 to 12 months to confirm persistence, then CT every 2 years until 5 years.
If grows or increasingly solid, consider resection.
Multiple CT at 3 to 6 months.  Then management based on most suspicious nodule(s).
> 8mm
(> 250mm3)		 Solid Solitary In 3 months consider either CT, Biopsy, or PET-CT (however, negative PET-CT does not exclude low-grade malignancy, FDG uptake may be underestimated in small nodules < 1cm, or those close to diaphragm)
Multiple CT in 3 to 6 months, then consider CT at 18 to 24 months CT in 3 to 6 months, then obtain CT at 18 to 24 months
Part-Solid
(Subsolid)
 Solitary CT in 3 to 6 months to confirm persistance.  If unchanged and solid component below 6mm, CT annually for 5 years.
Persistent part-solid nodules containing a solid componment > 6mm are highly suspicious.
Multiple CT at 3 to 6 months.  Then management based on most suspicious nodule(s).
Ground-Glass Solitary CT in 6 to 12 months to confirm persistence, then CT every 2 years until 5 years.
If grows or increasingly solid, consider resection.
Multiple CT at 3 to 6 months.  Then management based on most suspicious nodule(s).


Fleischner Society Recommendations and this table do NOT apply to:
Diameter of lung nodule is the average of the short and long axes, rounded to the whole millimeter.

Lung Cancer Risk Factors:
  • Tobacco use.
  • Family history of lung cancer.
  • Upper pulmonary lobe location of nodule.
  • Presence of emphysema.
  • Pulmonary fibrosis.
  • Older Age.
  • Female gender.
Don't let this happen to Your Patient:
 Lung nodule was seen and appropriate follow-up was recommended, but follow-up imaging was not obtained, leading to progression of cancer. Lost Souls Radiology Recommendation Tracker helps to prevent patients being lost to follow-up.


2017 Fleischner Society Lung Nodule Follow-Up Guidelines for Solid, Subsolid and Ground-glass Pulmonary Nodules

References

  • H MacMahon, DP Naidich, JM Goo, KS Lee, ANC Leung, JR Mayo, AC Mehta, Y Ohno, CA Powell, M Prokop, GD Rubin, CM Schaefer-Prokop, WD Travis, PE Van Schil, AA Bankier. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology 2017, DOI: http://dx.doi.org/10.1148/radiol.2017161659
  • McWilliams, A.; Tammemagi, M. C.; Mayo, J. R.; Roberts, H.; Liu, G.; Soghrati, K.; Yasufuku, K.; Martel, S.; Laberge, F.; Gingras, M.; Atkar-Khattra, S.; Berg, C. D.; Evans, K.; Finley, R.; Yee, J.; English, J.; Nasute, P.; Goffin, J.; Puksa, S.; Stewart, L.; Tsai, S.; Johnston, M. R.; Manos, D.; Nicholas, G.; Goss, G. D.; Seely, J. M.; Amjadi, K.; Tremblay, A.; Burrowes, P.; MacEachern, P.; Bhatia, R.; Tsao, M.-S. & Lam, S. Probability of Cancer in Pulmonary Nodules Detected on First Screening CT New England Journal of Medicine, 2013, 369, 910-919