American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Thoracic Nodules and Masses

Variant 1: Middle-aged patient (35–60 years old) with an incidental 1.5-cm lung nodule. The lesion was smooth. No associated adenopathy. No known risk factors for lung cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
FDG-PET/CT whole body Usually appropriate ☢☢☢☢ 10-30 mSv 7 n/a 0 0 0 0 0 0 0 0 0
Percutaneous lung biopsy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Middle-aged patient (35–60 years old) who had a CT pulmonary angiogram that was negative for pulmonary embolism but that demonstrated an incidental 1.5-cm lung nodule. The lesion was smooth. No associated adenopathy. Patient has a 70 pack/year smoking history and evidence of significant COPD on chest CT.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
FDG-PET/CT whole body Usually appropriate ☢☢☢☢ 10-30 mSv 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous lung biopsy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Middle-aged patient (35–60 years old) with a newly diagnosed colon carcinoma. Three pulmonary nodules, ranging up to 2 cm in diameter, noted on staging CT of the chest. At least 1 of the lesions demonstrates a lobulated appearance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
FDG-PET/CT whole body Usually appropriate ☢☢☢☢ 10-30 mSv 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous lung biopsy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Young adult patient (20–35 years old) with 1.0-cm smooth-walled noncalcified lung nodule seen on CT after minor motor vehicle trauma. No known risk factors for lung cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Follow-up imaging only Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous lung biopsy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 3 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Middle-aged patient (35–60 years old) with persistent 1.5-cm ground-glass nodule noted on an initial CT scan and a follow-up 3-month CT scan. No smoking history and no recent respiratory infection.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous lung biopsy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 5 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Elderly patient (>80 years old) with multifocal <2cm pure ground-glass opacities (no solid component) after chest CT recommended from an abnormal coronary CT examination. No smoking history and no recent respiratory infection.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Follow-up imaging only Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Percutaneous lung biopsy May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 3 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Middle-aged patient (35–60 years old) with a 2-cm smooth-walled lung nodule containing fatty elements by Hounsfield attenuation noted on CT. No prior imaging or risk factors for lung cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Conservative management (do nothing) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
Percutaneous lung biopsy Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Middle-aged patient (35–60 years old) with known multiple pulmonary nodules from metastatic cancer. All lesions but 1 have regressed on the current chemotherapy regimen.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous lung biopsy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 6 n/a 0 0 0 0 0 0 0 0 0
Bronchoscopic biopsy (repeat biopsy) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Elderly patient (>60 years old) with a positive purified protein derivative (tuberculin) test and abnormal chest radiograph. On CT scanning, bulky (up to 3 cm) mediastinal adenopathy is noted throughout the mediastinum (pretracheal, subcarinal, aortopulmonary window). The nodes do not demonstrate calcifications or necrosis. No associated pulmonary nodules.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic/bronchoscopic biopsy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous mediastinal biopsy May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Surgical mediastinal biopsy/resection May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 10: Elderly patient (>60 years old) with a long >30 pack/year smoking history meeting criteria for low-dose screening CT (LDCT). LDCT demonstrates a 2-cm pulmonary nodule in the lingula. There is mediastinal adenopathy (up to 2 cm) in the pretracheal and subcarinal regions as well as left perihilar (up to 2 cm) adenopathy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
FDG-PET/CT whole body Usually appropriate ☢☢☢☢ 10-30 mSv 8 n/a 0 0 0 0 0 0 0 0 0
Endoscopic/bronchoscopic mediastinal biopsy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous lung biopsy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Percutaneous mediastinal biopsy May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Surgical pulmonary nodule biopsy/resection Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 11: Middle-aged patient (35–60 years old) with shortness of breath presenting with bilateral hilar adenopathy measuring up to 2 cm, enlarging on serial 3-month imaging. Recent nondiagnostic bronchoscopic biopsy via TBNA. No intraparenchymal pulmonary nodules.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Bronchoscopic biopsy (repeat biopsy) Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body May be appropriate ☢☢☢☢ 10-30 mSv 5 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Surgical lung biopsy/resection May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Percutaneous lymph node biopsy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Variant 12: Middle-aged patient (35–60 years old) presenting with a 3-cm lobular mass involving the left pleura associated with rib erosion.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous lung biopsy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually appropriate ☢☢☢☢ 10-30 mSv 8 n/a 0 0 0 0 0 0 0 0 0
Surgical pleural biopsy/resection May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Follow-up imaging only Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Conservative management (do nothing) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.