MTE 27.02 Pulmonary Nodule Guidelines: How Do We Decide Between the IELCAP, ACCP, NCCN, Fleischner Society, BTS, and Lung-RADS?

Abstract

In the era of multidetector CT and lung cancer screening with low-dose CT, there are increasing number of incidentally or screen detected pulmonary nodules. Because a pulmonary nodule is an important finding of lung cancer, how to manage these nodules has become an essential issue in dealing with lung cancer, which explains why many guidelines on this topic are available. In this talk, overview of several well-established guidelines or protocols of International Early Lung Cancer Action Program (IELCAP), the American College of Chest Physicians (ACCP), National Comprehensive Cancer Network (NCCN), Fleischner Society, British Thoracic Society (BTS), and Lung CT screening Reporting and Data System (Lung-RADS) will be introduced. Nodule management protocols are different whether nodules are detected at screening programs or incidentally. Screening programs target high-risk subjects who need consistent monitoring, whereas incidentally detected lung nodules represent a different population that needs a varied clinical management. ACCP, BTS, and Fleischner Society guidelines deal with incidental nodules, while IELCAP and Lung-RADS are protocols for screening programs. NCCN guidelines state both issues with separate algorithms. Most pulmonary nodule guidelines have common components: risk factor assessment, nodule size, and nodule consistency. Baseline and annual repeat protocols are different at screening programs. Risk factors include age, smoking history, family history, previous cancer history, occupation exposure, etc. Nodules smaller than certain thresholds (NCCN, < 4 mm; ACCP and BTS, < 5 mm; Fleischner, IELCAP, and Lung-RADS, < 6 mm) do not require routine follow-up. The management for larger nodules varies with guidelines, but 8 mm and/or 15 mm are frequently recommended thresholds for more workups. Nodules can be classified into solid, part-solid, and pure ground-glass nodule according to their consistency. Because the likelihood of malignancy and growth rates are quite different depending on the nodule consistency, this classification is important in nodule management. Nodule volumetry and risk-prediction models such as the Brock University tool, currently employed in BTS guidelines, may be used more frequently in future guidelines. While the Fleischner Society, IELCAP, and Lung-RADS guidelines are relatively straightforward focused on the initial workup, ACCP, NCCN, and BTS guidelines also deal with the further workup and treatment. Some studies have shown that there is high awareness and adoption of these guidelines, but there are varying degrees of conformance with these recommendations. With the accumulation of large data, these guidelines will be more meticulous and evidence-based. Computerized tools that can assess both clinical and radiologic information will facilitate handling the issue of nodule management. 1. I-ELCAP protocol documents at http://www.ielcap.org/protocols Gould MK, 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 May;143(5 Suppl):e93S-e120S. 2. NCCN guidelines at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp. 3. Callister ME, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015 Aug;70 Suppl 2:ii1-ii54. 4. MacMahon H, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017 Jul;284(1):228-243. Lung-RADS at https://www.acr.org/Quality-Safety/Resources/LungRADS. guidelines, lung cancer, lung nodule management