Subsolid Pulmonary Nodules
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Population Covered By The Guidance
This pathway provides guidance on the imaging surveillance of adult patients with subsolid pulmonary nodules.
This pathway is based on guidelines that do not apply to patients younger than 35 years, immunocompromised patients or patients with cancer.
Date reviewed: March 2017
Date of next review: August 2023
Published: November 2017
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Teaching Points
Teaching Points
- A pulmonary nodule is radiologically defined as an opacity
- Nodule size has a clear relationship with risk of malignancy,
- A subsolid nodule/ground glass nodule is defined as a focal area of slightly increased CT attenuation through which the normal lung parenchyma structures, airways, and vessels are visually preserved.
- Subsolid nodules are radiologically divided into pure ground glass nodules and part-solid ground glass nodules.
- Subsolid nodules tend to have a slow growth rate with volume doubling times (VDTs) ≥400 days and therefore longer total follow-up periods are recommended for subsolid nodules compared to solid nodules.
- This pathway presents an approach to the investigation and management of subsolid pulmonary nodules based on the current guidelines.
- Risk factors such as smoking history, familial history of lung cancer or exposure to carcinogenic agents are not considered in the current guidelines due to a lack of sufficient data.
- Several image-guided biopsy techniques are available and the choice depends on local expertise, availability, location of nodule and patient preferences
References
References
Date of literature search: February 2017
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Hansell DM, Bankier AA, MacMahon H, McLoud TC, Muller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008;246(3):697-722. (Guidelines). View the reference
- Cha MJ, Lee KS, Kim HS, Lee SW, Jeong CJ, Kim EY, et al. Improvement in imaging diagnosis technique and modalities for solitary pulmonary nodules: from ground-glass opacity nodules to part-solid and solid nodules Expert Rev Respir Med. 2016;10(3):261-78. (Review article). View the reference
- Naidich DP, Bankier AA, MacMahon H, Schaefer-Prokop CM, Pistolesi M, Goo JM, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-17. (Guidelines). View the reference
- Heuvelmans MA, Oudkerk M. Management of subsolid pulmonary nodules in CT lung cancer screening. J Thorac Dis. 2015;7(7):1103-6. (Review article). View the reference
- Scholten ET, de Jong PA, de Hoop B, van Klaveren R, van Amelsvoort-van de Vorst S, Oudkerk M, et al. Towards a close computed tomography monitoring approach for screen detected subsolid pulmonary nodules? Eur Respir J. 2015;45(3):765-73. (Level I evidence). View the reference
- MacMahon H, Naidich DP, Goo JM, Lee KS, Leung AN, Mayo JR, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017:1-16. (Guidelines). View the reference
- Suzuki K, Asamura H, Kusumoto M, Kondo H, Tsuchiya R. "Early" peripheral lung cancer: prognostic significance of ground glass opacity on thin-section computed tomographic scan. Ann Thorac Surg. 2002;74(5):1635-9. (Level II evidence). View the reference
- Vazquez M, Carter D, Brambilla E, Gazdar A, Noguchi M, Travis WD, et al. Solitary and multiple resected adenocarcinomas after CT screening for lung cancer: histopathologic features and their prognostic implications. Lung Cancer. 2009;64(2):148-54. (Level II/III evidence). View the reference
- Oh JY, Kwon SY, Yoon HI, Lee SM, Yim JJ, Lee JH, et al. Clinical significance of a solitary ground-glass opacity (GGO) lesion of the lung detected by chest CT. Lung Cancer. 2007;55(1):67-73. (Level II evidence). View the reference
- Henschke CI, Yankelevitz DF, Mirtcheva R, McGuinness G, McCauley D, Miettinen OS. CT screening for lung cancer: frequency and significance of part-solid and nonsolid nodules. AJR Am J Roentgenol. 2002;178(5):1053-7. (Level II evidence). View the reference
- Kim H, Park CM, Koh JM, Lee SM, Goo JM. Pulmonary subsolid nodules: what radiologists need to know about the imaging features and management strategy. Diagn Interv Radiol. 2014;20(1):47-57. (Review article). View the reference
- Park CM, Goo JM, Lee HJ, Lee CH, Chung DH, Chun EJ, et al. Focal interstitial fibrosis manifesting as nodular ground-glass opacity: thin-section CT findings. Eur Radiol. 2007;17(9):2325-31. (Level III evidence). View the reference
- Austin JH, Garg K, Aberle D, Yankelevitz D, Kuriyama K, Lee HJ, et al. Radiologic implications of the 2011 classification of adenocarcinoma of the lung. Radiology. 2013;266(1):62-71. (Review article). View the reference
- Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, et al. International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011;6(2):244-85. (Guidelines) View the reference
- Gould MK, Donington J, Lynch WR, Mazzone PJ, Midthun DE, Naidich DP, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e93S-120S. (Guidelines). View the reference
- MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400. (Guidelines). View the reference
- Shaham D, Guralnik L. The solitary pulmonary nodule: radiologic considerations. Semin Ultrasound CT MR. 2000;21(2):97-115. (Review article). View the reference
- Godoy MC, Naidich DP. Subsolid pulmonary nodules and the spectrum of peripheral adenocarcinomas of the lung: recommended interim guidelines for assessment and management. Radiology. 2009;253(3):606-22. (Review article). View the reference
- Lee SM, Park CM, Goo JM, Lee CH, Lee HJ, Kim KG, et al. Transient part-solid nodules detected at screening thin-section CT for lung cancer: comparison with persistent part-solid nodules. Radiology. 2010;255(1):242-51. (Level III evidence). View the reference
- Callister ME, Baldwin DR, Akram AR, Barnard S, Cane P, Draffan J, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015;70 Suppl 2:ii1-ii54. (Guidelines) View the reference
- Song YS, Park CM, Park SJ, Lee SM, Jeon YK, Goo JM. Volume and mass doubling times of persistent pulmonary subsolid nodules detected in patients without known malignancy. Radiology. 2014;273(1):276-84. (Level III evidence). View the reference
- Veronesi G, Travaini LL, Maisonneuve P, Rampinelli C, Bertolotti R, Spaggiari L, et al. Positron emission tomography in the diagnostic work-up of screening-detected lung nodules. Eur Respir J. 2015;45(2):501-10. (Review article). View the reference
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