Management of pulmonary nodules according to the 2015 British Thoracic Society guidelines: Key messages for clinical practice

Abstract

The British Thoracic Society guideline on the investigation and management of pulmonary nodules is based on a comprehensive and systematic review of the literature on pulmonary nodules. Recent evidence has suggested that significant changes to existing guidelines are necessary. The use of 2 malignancy prediction calculators to better characterize the risk of malignancy was firmly supported by evidence, as were the recommendations for a higher nodule size threshold for follow up (≥5 mm or ≥80 mm3) and a reduction of the follow up period to 1 year for solid pulmonary nodules. Although caution is required where there is a history of cancer, both of these recommendations will reduce the number of follow up computed tomographies, thereby improving cost effectiveness and pressure on imaging services. Recent evidence has also confirmed the superiority of volumetry as the preferred measurement method and clarified the management of nodules with extended volume doubling times. Acknowledging the good prognosis of subsolid nodules, there are recommendations for less aggressive options in their management. The guidelines recommend ordinal scale reporting for positron emission tomography-computed tomography to facilitate incorporation into risk models. There are recommendations on when biopsy is most helpful, the threshold for treatment without histological confirmation, and surgical and nonsurgical treatment. The guideline also provides evidence based recommendations about the information that people need and that should be provided for them. The complexity of managing pulmonary nodules is made more accessible by 4 management algorithms. In the real world, it is surprising how easy these are to follow and how they seem to follow an intuitive approach.