Fleischner · Tórax

Fleischner Society 2017 pulmonary nodule guidelines

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Management recommendations for incidentally detected pulmonary nodules on CT, organized by nodule type (solid, subsolid) and size, for patients 35 and older without known cancer or immunosuppression.

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Escala de categorias

solid-single-<6 solid-single-6to8 solid-single->8 solid-multiple-<6 solid-multiple->=6 ggn-single-<6 ggn-single->=6 partsolid-single-<6 partsolid-single->=6 subsolid-multiple

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Procedência e vigência

Órgão emissor: Fleischner Society
Versão: 2017
Ano: 2017
Família: algoritmo
Tipo de lógica: matrix
Modalidade: CT
Fonte primária: Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 · doi:10.1148/radiol.2017161659
Última verificação: 2026-07-24
Última checagem: 2026-08-12

Lógica de decisão

Forma estruturada (matrix). Uma futura calculadora a lê; as categorias abaixo são a superfície legível.

Use the matching outcome_code for cited management and risk text. Do not apply this incidental-nodule algorithm to screening CT, known primary cancer, or immunosuppression.

Mostrar a lógica estruturada (JSON)

{
  "applicability": {
    "use_for": "Incidentally detected pulmonary nodules on CT in adults age 35 years or older.",
    "exclude": [
      "lung_cancer_screening",
      "known_primary_cancer",
      "immunosuppression"
    ],
    "screening_alternative": "lung-rads-2022"
  },
  "measurement": {
    "technique": "Average the long and short axes on the plane showing the greatest dimensions and round to the nearest whole millimeter.",
    "thin_section_ct_mm_max": 1.5,
    "diameter_bands_mm": [
      "<6",
      "6-8",
      ">8"
    ],
    "equivalent_volume_thresholds_mm3": [
      100,
      250
    ],
    "compare_with": "earliest and most recent available prior CT"
  },
  "axes": {
    "attenuation": [
      "solid",
      "pure_ground_glass",
      "part_solid"
    ],
    "count": [
      "single",
      "multiple"
    ],
    "total_mean_diameter_mm": [
      "<6",
      "6-8",
      ">8"
    ],
    "solid_component_mm": [
      "<6",
      "6-8",
      ">8"
    ],
    "patient_risk_for_solid_nodules": [
      "low",
      "high"
    ]
  },
  "cells": [
    {
      "outcome_code": "solid-single-<6",
      "when": {
        "attenuation": "solid",
        "count": "single",
        "total_mean_diameter_mm": "<6"
      },
      "management_varies_by": "patient_risk_for_solid_nodules"
    },
    {
      "outcome_code": "solid-single-6to8",
      "when": {
        "attenuation": "solid",
        "count": "single",
        "total_mean_diameter_mm": "6-8"
      },
      "management_varies_by": "patient_risk_for_solid_nodules"
    },
    {
      "outcome_code": "solid-single->8",
      "when": {
        "attenuation": "solid",
        "count": "single",
        "total_mean_diameter_mm": ">8"
      }
    },
    {
      "outcome_code": "solid-multiple-<6",
      "when": {
        "attenuation": "solid",
        "count": "multiple",
        "largest_total_mean_diameter_mm": "<6"
      },
      "management_varies_by": "patient_risk_for_solid_nodules"
    },
    {
      "outcome_code": "solid-multiple->=6",
      "when": {
        "attenuation": "solid",
        "count": "multiple",
        "largest_total_mean_diameter_mm": ">=6"
      },
      "governing_lesion": "most_suspicious_not_necessarily_largest"
    },
    {
      "outcome_code": "ggn-single-<6",
      "when": {
        "attenuation": "pure_ground_glass",
        "count": "single",
        "total_mean_diameter_mm": "<6"
      }
    },
    {
      "outcome_code": "ggn-single->=6",
      "when": {
        "attenuation": "pure_ground_glass",
        "count": "single",
        "total_mean_diameter_mm": ">=6"
      }
    },
    {
      "outcome_code": "partsolid-single-<6",
      "when": {
        "attenuation": "part_solid",
        "count": "single",
        "total_mean_diameter_mm": "<6"
      },
      "caveat": "A discrete solid component is unreliable at this size; manage like a pure ground-glass nodule."
    },
    {
      "outcome_code": "partsolid-single->=6",
      "when": {
        "attenuation": "part_solid",
        "count": "single",
        "total_mean_diameter_mm": ">=6"
      },
      "escalation_axes": [
        "solid_component_mm",
        "growth",
        "lobulated_or_cystic_morphology"
      ]
    },
    {
      "outcome_code": "subsolid-multiple",
      "when": {
        "attenuation": [
          "pure_ground_glass",
          "part_solid"
        ],
        "count": "multiple"
      },
      "branches": [
        "all_under_6mm",
        "at_least_one_6mm_or_larger"
      ],
      "governing_lesion": "most_suspicious_not_necessarily_largest"
    }
  ],
  "modifiers_and_overrides": [
    {
      "if": "perifissural_or_juxtapleural morphology consistent with an intrapulmonary lymph node",
      "then": "no routine follow-up even when mean diameter exceeds 6 mm"
    },
    {
      "if": "solid nodule under 6 mm with suspicious morphology or upper-lobe location",
      "then": "consider the optional 12-month CT branch"
    },
    {
      "if": "part-solid solid component is 6 mm or larger",
      "then": "highly suspicious; short-term CT to confirm persistence and consider diagnostic evaluation"
    },
    {
      "if": "part-solid morphology is lobulated/cystic, solid component grows, or solid component exceeds 8 mm",
      "then": "consider PET/CT, biopsy, or resection"
    },
    {
      "if": "clinical infection or immunocompromise",
      "then": "the guideline is not directly applicable; individualized short-term evaluation may be appropriate"
    }
  ],
  "solid_nodule_risk_context": {
    "low": "Estimated cancer risk below 5%; typically younger age, less smoking, smaller size, regular margins, and non-upper-lobe location.",
    "high": "Combines ACCP intermediate and high risk; factors include older age, heavy smoking, larger size, irregular/spiculated margins, upper-lobe location, carcinogen exposure, emphysema/fibrosis, and family history.",
    "subsolid_note": "Subsolid recommendations are independent of the customary low/high clinical-risk split."
  },
  "source_locator": "MacMahon et al. Radiology 2017, Table 1 and Recommendations 1-5; General Recommendations; Risk Factors for Malignancy; Perifissural Nodules."
}

Categorias num relance

Cat.	Significado	Conduta	Risco	Fonte
solid-single-<6	Solid single nodule, under 6 mm Single solid nodule under 6 mm (under ~100 mm3); recommendation differs by patient risk.	Low risk: no routine follow-up. High risk: optional CT at 12 months. The guideline notes that nodules under 6 mm generally need no routine follow-up, but selected high-risk patients with suspicious morphology and/or upper-lobe location may warrant a 12-month follow-up.	Average malignancy risk is under 1% even in high-risk patients; suspicious morphology and/or upper-lobe location can raise the estimated risk into the 1%-5% range.	okfonte Fleischner 2017 Table 1, Section A (Solid Nodules), Single, <6 mm row
solid-single-6to8	Solid single nodule, 6 to 8 mm Single solid noncalcified nodule with mean diameter 6-8 mm (approximately 100-250 mm3); follow-up intensity depends on clinical risk and morphology.	Low risk: CT at 6-12 months, then consider CT at 18-24 months if morphology is suspicious or stability is uncertain. High risk: CT at 6-12 months and again at 18-24 months.	The guideline estimates an average malignancy risk of approximately 0.5%-2.0% for solitary solid nodules in this size band; individual risk varies with morphology and patient factors.	okfonte Fleischner 2017 Table 1, Section A (Solid Nodules), Single, 6-8 mm row
solid-single->8	Solid single nodule, over 8 mm Single solid nodule larger than 8 mm (over ~250 mm3); same management for low and high risk.	Consider CT at 3 months, PET/CT, or tissue sampling (applies to both low- and high-risk single nodules).	The guideline cites an average malignancy risk of approximately 3% for an 8-mm solitary nodule, while emphasizing that risk may be substantially higher according to size, morphology, location, and clinical factors.	okfonte Fleischner 2017 Table 1, Section A (Solid Nodules), Single, >8 mm row
solid-multiple-<6	Solid multiple nodules, under 6 mm Multiple solid nodules with the largest under 6 mm; recommendation differs by patient risk. Use the most suspicious nodule to guide management.	Low risk: no routine follow-up. High risk: optional CT at 12 months.	Most multiple solid nodules under 6 mm are benign healed granulomas or intrapulmonary lymph nodes; the guideline does not publish a per-row malignancy probability.	okfonte Fleischner 2017 Table 1, Section A (Solid Nodules), Multiple, <6 mm row
solid-multiple->=6	Solid multiple nodules, 6 mm or larger Multiple solid nodules with at least one in the 6-8 mm or >8 mm band. Use the most suspicious nodule to guide management; intervals may vary with size and risk.	CT at 3-6 months. At 18-24 months, CT is optional for low-risk patients and recommended for high-risk patients. If one nodule is larger or more suspicious, use its corresponding solitary-nodule pathway to guide management.	No per-row malignancy percentage is given. The most suspicious nodule, which may not be the largest, drives risk assessment; multiplicity and the distribution and morphology of all nodules remain clinically relevant.	okfonte Fleischner 2017 Table 1, Section A (Solid Nodules), Multiple, 6-8 mm and >8 mm columns
ggn-single-<6	Ground glass single nodule, under 6 mm Single pure ground-glass nodule under 6 mm.	No routine follow-up. In selected patients with a nodule close to 6 mm, suspicious morphology, or other risk factors, optional CT at approximately 2 and 4 years may be considered.	The guideline cites data in which up to 10% of these nodules grew and nearly 1% progressed to adenocarcinoma over many years, supporting conservative management for most patients.	okfonte Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Ground glass, <6 mm column
ggn-single->=6	Ground glass single nodule, 6 mm or larger Single pure ground-glass nodule 6 mm or larger.	CT at 6-12 months to confirm persistence, then CT every 2 years out to 5 years. If a solid component or growth develops, consider resection.	Persistent pure ground-glass nodules can represent indolent adenocarcinoma-spectrum lesions; the guideline notes that growth commonly requires 3-4 years to establish and does not provide a single per-row malignancy percentage.	okfonte Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Ground glass, >=6 mm column
partsolid-single-<6	Part solid single nodule, under 6 mm Single apparent part-solid nodule under 6 mm. A discrete solid component cannot be measured reliably at this size, so the guideline treats it like a pure ground-glass nodule of the same size.	No routine follow-up. Optional longer-term CT may be considered in selected patients when the nodule is close to 6 mm or has suspicious morphology or other risk factors.	The guideline does not publish a separate malignancy probability for apparent part-solid nodules under 6 mm because a true solid component is not reliably defined at this size.	okfonte MacMahon et al. 2017, Recommendation 4 (solitary part-solid nodules), first paragraph; Table 1 Section B, <6 mm column
partsolid-single->=6	Part solid single nodule, 6 mm or larger Single part-solid nodule 6 mm or larger. The guideline notes part-solid nodules are generally not defined as such below 6 mm, and persistent part-solid nodules with a solid component of 6 mm or more should be regarded as highly suspicious.	CT at 3-6 months to confirm persistence. If unchanged and the solid component stays under 6 mm, annual CT for at least 5 years. If the solid component is 6 mm or larger, grows, exceeds 8 mm, or morphology is particularly suspicious, consider PET/CT, biopsy, or resection.	Part-solid nodules have a high likelihood of malignancy. A persistent solid component under 6 mm more often represents adenocarcinoma in situ or minimally invasive adenocarcinoma; a component 6 mm or larger is highly suspicious for invasive disease.	okfonte Fleischner 2017 Table 1, Section B (Subsolid Nodules), Single, Part solid, >=6 mm column
subsolid-multiple	Multiple subsolid nodules Multiple subsolid nodules (ground-glass and/or part-solid). Multiple sub-6 mm pure ground-glass nodules are usually benign.	Under 6 mm: CT at 3-6 months; if stable, consider CT at 2 and 4 years. 6 mm or larger: CT at 3-6 months, with subsequent management based on the most suspicious nodule(s).	Multiple tiny subsolid nodules may be infectious or inflammatory. If persistent, they may represent atypical adenomatous hyperplasia or adenocarcinoma in situ; when at least one lesion is 6 mm or larger, more than one suspicious lesion increases the overall likelihood of cancer.	okfonte Fleischner 2017 Table 1, Section B (Subsolid Nodules), Multiple row

Referências cruzadas

fronteira compartilhadaLung-RADS. Lung CT Screening Reporting and Data SystemFleischner governs incidental nodules, Lung-RADS governs screening detected nodules.

Histórico de versões

Data	Evento	Detalhe	Situação
2017-07-01	revised	Fleischner Society 2017 guidelines published, updating the 2005 recommendations. evidência	confirmado

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