Oncology services see pulmonary nodules referred from every direction, and a large proportion of the work is deciding which ones need anything at all. This clinical practice review sets out the structure.
Two questions come before any risk model. Is the nodule solid or subsolid — and if subsolid, part-solid or pure ground-glass, because the pathways differ. And is there previous imaging to compare against, since the single most informative thing about a nodule is whether it was there before and whether it has changed. A solid nodule stable for two years is considered benign; that rule does not transfer to subsolid nodules, which grow slowly and need a longer period of stability before the same conclusion is safe. Subsolid nodules also carry a higher risk of malignancy, and the development or enlargement of a solid component within one is the change that matters most.
Beyond that the pathway follows risk: CT surveillance for low-risk nodules, PET-CT and/or biopsy for intermediate risk, surgical resection for selected high-risk ones, with prediction models available to place solid nodules on that scale. Biopsy is by transthoracic needle or navigational bronchoscopy. The review frames the whole exercise as a balance between diagnosing cancer promptly and not subjecting people with benign disease to invasive procedures — which is the judgement the referring clinician is implicitly asking the service to make.
- Establish solid versus subsolid before applying any surveillance interval
- Find and compare prior imaging; it is the highest-yield step available
- Do not apply the two-year stability rule to subsolid nodules
- In a subsolid nodule, a new or growing solid component is the decisive change
- Use a prediction model for solid nodules rather than size alone
Why it matters
The reassurance rule that works for solid nodules gives false reassurance for the subsolid ones, which are the more likely to be malignant.
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