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ALL / Respiratory Medicine

Solitary lung nodule

Solitary lung nodule

BTS pathway for solid pulmonary nodules - nodule volume should be assessed using semi-automated volumetry where possible.
  • < 80 mm3 or < 5 mm → discharge
    • exceptions include a history of malignancy or a new nodule compared with CT performed within the previous 2 years
  • obvious benign features → discharge
    • diffuse, central, laminated or popcorn calcification
    • macroscopic fat
    • a typical perifissural or subpleural nodule < 10 mm
  • 80 to < 300 mm3 or 5 to < 8 mm → CT surveillance
    • if only diameter is available and the nodule is 5 to < 6 mm: CT at 1 year
    • if ≥ 80 mm3 or ≥ 6 mm: CT at 3 months and 1 year
  • ≥ 300 mm3 or ≥ 8 mm → calculate the probability of malignancy using the Brock model
    • Brock risk < 10% → CT surveillance
    • Brock risk ≥ 10% → PET-CT, provided the nodule is above the local PET-CT detection threshold, followed by calculation of the Herder risk
    • Herder risk < 10% → CT surveillance
    • Herder risk 10–70% → consider image-guided biopsy; excision biopsy or continued CT surveillance may also be appropriate depending on clinical risk and patient preference
    • Herder risk > 70% → offer definitive treatment, with or without prior biopsy

During CT surveillance:
  • use low-dose CT and semi-automated volumetry where possible
  • an increase in volume of ≥ 25% indicates significant growth
  • volume doubling time < 400 days → investigate further and consider definitive treatment
  • volume doubling time 400–600 days → consider biopsy or continued surveillance
  • volume doubling time > 600 days → consider discharge or longer-term surveillance
  • discharge if stable at 1 year using volumetry, or at 2 years if assessed using diameter
+PassMedicine Notes
BTS pathway for solid pulmonary nodules - nodule volume should be assessed using semi-automated volumetry where possible.
  • < 80 mm3 or < 5 mm → discharge
    • exceptions include a history of malignancy or a new nodule compared with CT performed within the previous 2 years
  • obvious benign features → discharge
    • diffuse, central, laminated or popcorn calcification
    • macroscopic fat
    • a typical perifissural or subpleural nodule < 10 mm
  • 80 to < 300 mm3 or 5 to < 8 mm → CT surveillance
    • if only diameter is available and the nodule is 5 to < 6 mm: CT at 1 year
    • if ≥ 80 mm3 or ≥ 6 mm: CT at 3 months and 1 year
  • ≥ 300 mm3 or ≥ 8 mm → calculate the probability of malignancy using the Brock model
    • Brock risk < 10% → CT surveillance
    • Brock risk ≥ 10% → PET-CT, provided the nodule is above the local PET-CT detection threshold, followed by calculation of the Herder risk
    • Herder risk < 10% → CT surveillance
    • Herder risk 10–70% → consider image-guided biopsy; excision biopsy or continued CT surveillance may also be appropriate depending on clinical risk and patient preference
    • Herder risk > 70% → offer definitive treatment, with or without prior biopsy
During CT surveillance:
  • use low-dose CT and semi-automated volumetry where possible
  • an increase in volume of ≥ 25% indicates significant growth
  • volume doubling time < 400 days → investigate further and consider definitive treatment
  • volume doubling time 400–600 days → consider biopsy or continued surveillance
  • volume doubling time > 600 days → consider discharge or longer-term surveillance
  • discharge if stable at 1 year using volumetry, or at 2 years if assessed using diameter


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