Lung Nodules

Question 1

Which lung lesions are most likely to be malignant?

Answer 1

Part solid (63%)
Ground glass (18%)
Solid (7%)

Question 2

Fleischer guidelines for SOLID lung nodules

Answer 2

SOLID NODULES
(a) Single
Low Risk:
- <6mm: no follow up
- 6-8mm: CT 6-12 months and then consider CT at 18-24 months
- >8mm: CT at 3 months, PET/CT or tissue sampling

High Risk

• < 6mm: optional CT at 12 months
• 6-8mm: CT 6-12 months and then CT at 18-24 months
• 8mm: consider CT at 3 months, PET/CT or tissue sampling

(b) Multiple
Low Risk
- <6mm: no follow up
- 6-8mm: CT 3-6 months and then consider CT at 18-24 months
- >8mm: CT at 3-6 months, PET/CT or tissue sampling

High Risk

• < 6mm: optional CT at 12 months
• 6-8mm: CT 3-6 wmonths and then CT at 18-24 months
• 8mm: consider CT at 3 months, PET/CT or tissue sampling

Question 3

Fleischner Guideline for SUBSOLID lung nodules

Answer 3

(a) Single
GROUND GLASS
- <6mm: no routine followup
- >6mm: CT at 6-12 months to confirm persistence, then CT every 2 years until 5 years

PART SOLID

• <6mm: no routine followup
• > 6mm: CT at 3-6 months to confirm persistence. If unchanged and solid component remains <6mm, annual CT should be performed for 5 years

(b) Multiple
- <6mm: CT at 3-6 months. If stable, consider CT at 2 and 4 years
- >6mm: CT at 3-6 months. Subsequent management based on the most suspicious nodule

Question 4

What is a ground glass nodule indicate?

Answer 4

Ground Glass Nodule

• Often atypical adenomatous hyperplasia or adenocarcinoma in situ - precursor for adenocarcinoma
• Solid + ground glass (sub solid) nodules however are suspicious for adenocarcinoma

Question 5

Subsolid nodules guidelines

Answer 5

• Includes ground glass and part solid nodules

- Follow up CT in 3 months for nodules >5mm or PET if solid component > 10mm

Question 6

Fleischner Guidelines

Answer 6

• Monitoring asymptomatic pulmonary nodules
• Does not apply to patients <35yo, those with known cancer and those who are immunosuppressed
• Ground glass need to be followed longer given their slower tumour doubling time - now recommended 5 years

Question 7

Risk factors for pulmonary nodules

Answer 7

Nodule Factors

• Size
• Margins (spiculated)
• Location - upper lobes more common
• Number of nodules - lower risk with >5 nodules

Patient Factors

• Age
• Smoking status: 30 pack year hx and quitting within 15 years
• Presence of emphysema and fibrosis

Question 8

High risk factors of nodules

Answer 8

• Older age
• Smoking history >30 pyh and cessation within 15 years
• Larger nodule size
• Spiculated margins
• Upper lobe location