Radiologic Management of Pulmonary Nodules and Masses

Variant: 1 Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.

Procedure	Appropriateness Category
Follow-up imaging only	May Be Appropriate
Percutaneous lung biopsy	May Be Appropriate (Disagreement)
Endobronchial ultrasound and biopsy	Usually Not Appropriate
Percutaneous ablation lung	Usually Not Appropriate
Stereotactic body radiotherapy	Usually Not Appropriate
Surgical management	Usually Not Appropriate
Fiducial marker and surgical management	Usually Not Appropriate

Variant: 2 Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.

Procedure	Appropriateness Category
Percutaneous lung biopsy	Usually Appropriate
Endobronchial ultrasound and biopsy	Usually Appropriate
Fiducial marker and surgical management	Usually Not Appropriate
Follow-up imaging only	Usually Not Appropriate
Stereotactic body radiotherapy	Usually Not Appropriate
Surgical management	Usually Not Appropriate
Percutaneous ablation lung	Usually Not Appropriate

Variant: 3 Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.

Procedure	Appropriateness Category
Endobronchial ultrasound and biopsy	Usually Appropriate
Percutaneous lung biopsy	May Be Appropriate
Follow-up imaging only	May Be Appropriate
Surgical management	Usually Not Appropriate
Fiducial marker and surgical management	Usually Not Appropriate
Percutaneous ablation lung	Usually Not Appropriate
Stereotactic body radiotherapy	Usually Not Appropriate

Variant: 4 Adult. Serially, enlarging solitary solid pulmonary nodule in the periphery of the lung, now 1 to 3 cm in diameter. High risk of poor surgical outcome. Next step.

Procedure	Appropriateness Category
Percutaneous lung biopsy	Usually Appropriate
Stereotactic body radiotherapy	May Be Appropriate
Endobronchial ultrasound and biopsy	May Be Appropriate
Follow-up imaging only	May Be Appropriate
Percutaneous ablation lung	May Be Appropriate
Fiducial marker and surgical management	Usually Not Appropriate
Surgical management	Usually Not Appropriate

Variant: 5 Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.

Procedure	Appropriateness Category
Percutaneous lung biopsy	Usually Appropriate
Endobronchial ultrasound and biopsy	May Be Appropriate
Fiducial marker and surgical management	May Be Appropriate (Disagreement)
Follow-up imaging only	May Be Appropriate
Surgical management	May Be Appropriate (Disagreement)
Percutaneous ablation lung	Usually Not Appropriate
Stereotactic body radiotherapy	Usually Not Appropriate

Variant: 6 Adult. 1 to 3 cm solitary ground glass pulmonary nodule which has persisted on short interval follow-up. Findings suspicious for primary lung adenocarcinoma. Next step.

Procedure	Appropriateness Category
Percutaneous lung biopsy	Usually Appropriate
Endobronchial ultrasound and biopsy	May Be Appropriate
Fiducial marker and surgical management	May Be Appropriate
Follow-up imaging only	May Be Appropriate
Percutaneous ablation lung	Usually Not Appropriate
Stereotactic body radiotherapy	Usually Not Appropriate
Surgical management	Usually Not Appropriate

Panel Members

Osmanuddin Ahmed, MD^a; Shenise Gilyard, MD^b; Charles Y. Kim, MD^c; Anupama Chundury, MD^d; Edwin F. Donnelly, MD, PhD^e; Erica M. Knavel Koepsel, MD^f; Jules Lin, MD^g; Mina S. Makary, MD^h; Parth Mehta, MDⁱ; Eric J. Monroe, MD^j; Matthew J. Scheidt, MD^k; Elliot Servais, MD^l; Nicholas Fidelman, MD^m.

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.
A. Endobronchial ultrasound and biopsy

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.
B. Fiducial marker and surgical management

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.
C. Follow-up imaging only

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.
D. Percutaneous ablation lung

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.
E. Percutaneous lung biopsy

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.
F. Stereotactic body radiotherapy

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.
G. Surgical management

Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.

Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.
A. Endobronchial ultrasound and biopsy

Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.
B. Fiducial marker and surgical management

Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.
C. Follow-up imaging only

Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.
D. Percutaneous ablation lung

Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.
E. Percutaneous lung biopsy

Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.
F. Stereotactic body radiotherapy

Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.
G. Surgical management

Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.

Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.
A. Endobronchial ultrasound and biopsy

Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.
B. Fiducial marker and surgical management

Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.
C. Follow-up imaging only

Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.
D. Percutaneous ablation lung

Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.
E. Percutaneous lung biopsy

Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.
F. Stereotactic body radiotherapy

Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.
G. Surgical management

Variant 4: Adult. Serially, enlarging solitary solid pulmonary nodule in the periphery of the lung, now 1 to 3 cm in diameter. High risk of poor surgical outcome. Next step.

Variant 4: Adult. Serially, enlarging solitary solid pulmonary nodule in the periphery of the lung, now 1 to 3 cm in diameter. High risk of poor surgical outcome. Next step.
A. Endobronchial ultrasound and biopsy

Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.

Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.
A. Endobronchial ultrasound and biopsy

Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.
B. Fiducial marker and surgical management

Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.
C. Follow-up imaging only

Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.
D. Percutaneous ablation lung

Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.
E. Percutaneous lung biopsy

Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.
F. Stereotactic body radiotherapy

Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.
G. Surgical management

Variant 6: Adult. 1 to 3 cm solitary ground glass pulmonary nodule which has persisted on short interval follow-up. Findings suspicious for primary lung adenocarcinoma. Next step.

Variant 6: Adult. 1 to 3 cm solitary ground glass pulmonary nodule which has persisted on short interval follow-up. Findings suspicious for primary lung adenocarcinoma. Next step.
A. Endobronchial ultrasound and biopsy

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.