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Following the guidelines developed by the European Respiratory Society, the Fleischner Society and the International Association for the Study of Lung Cancer, recommendations for the management of GGNs have been updated ( 4, 15 ).

Another important point to consider is the value of size and texture in the prediction of malignancy in incidentally detected nodules. In this context, the recently published Lung CT Screening Guidelines of the European Respiratory Society, the Fleischner Society and the International Association for the Study of Lung Cancer ( 4 ) include no evidence-based recommendations for characterizing nodule size or texture, other than to indicate that nodule size is an important but not decisive factor in the decision whether to follow-up a detected nodule. Additional information to consider is the size of the nodule. A 14% to 31% risk of malignancy increases with doubling in size from 3 to 10 mm ( 30 ). This risk increases further with more significant increases in size (from 9 mm) ( 30 ). A high-risk classification is used for benign GGNs: a 6-mm GGN with a 10% to 80% likelihood of malignancy increases the likelihood of malignancy to a greater than 5% risk at 12 months. A completely solid nodule increases the likelihood of malignancy to more than 40% ( 30 ). Finally, nodule growth should be monitored with every CT. If the growth is stable, the risk of malignancy decreases; if the growth is decreasing, the risk of malignancy also decreases ( 30 ).

Conflicting data have been published regarding the value of CT during follow-up for incidentally detected pulmonary nodules ( 31, 32 ). According to a recent study conducted by Torsten Hagen in collaboration with the Fleischner Society, consolidation of preexisting ground-glass nodules (GGNs) is associated with a slightly elevated risk of lung cancer. This risk increases with the time between initial nodule appearance and consolidation, and decreases with consolidation size ( 30 ). Lung nodules often disappear on repeat CT after a few months; consolidation of ground-glass nodules is also a relatively common finding. Concerning the latter, the risk of malignancy decreases in follow-up CT examinations, with a drop in risk of around 20% to 40% in each follow-up visit. These results indicate that there is no need to repeat pulmonary surveillance after 6 months if consolidation is less than 1 cm in diameter and no ground-glass components in the solid nodule ( 30 ).

More than 3 decades of experience with testing of pulmonary nodules means the Fleischner Society has determined that there is no one ideal size for a pulmonary nodule on computed tomography (CT). Nodules varying from a few millimeters to several centimeters are readily diagnosed on CT images and this inflexibility of size limits treatment recommendations. The Fleischner Society guidelines recommend an initial size threshold of 1 cm for solid and 1.5 cm for subsolid nodules on CT scans (4). Size is the single most influential factor influencing the need for and efficacy of follow-up, and the recommended 1-cm threshold provides clear and consistent guidance on size thresholds. Until recently, the follow-up of solid nodules, whether they are benign or malignant, was based primarily on size. Size has become a less reliable measure of the progression of nodule growth, and a small or growing nodule may contain a small portion of tissue that warrants observation. Nodule size can be used to predict growth over time, but it is not a specific measure of time to growth. In addition, growing lesions that are increasing in size may contain a portion that is either stable or decreasing in size. The decision to treat any pulmonary nodule based on size alone is likely to result in missed diagnoses, inappropriate treatments, or overtreatment. As a result, the size threshold has been removed from the latest edition of the Fleischner Society guidelines. This change does not eliminate the clinical value of size as a predictor of growth over time (4). 5ec8ef588b

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