Fleischner Calculator: Management of Incidental Pulmonary Nodules Detected on CT

Guidelines From the Fleischner Society (2017)

Fleischner

How many nodules have you identified?

Solitary nodule

Multiple nodules

How is the composition of the nodule?

Solid

Part-solid

Groundglass

Attention: Use the most suspicious nodule to guide management. Follow-up intervals may vary according to size and risk.

Are there any solid nodules?

Yes, there are solid nodules.

No, all nodules are subsolid (i.e., part-solid or ground glass).

How is the clinical risk of the patient for malignancy?

Low risk

High risk

See below for factors related to risk for malignancy.

Attention: For part-solid nodules, measurements should be based on the solid component.

Long-axis diameter of the largest nodule (mm)

Short-axis diameter of the largest nodule (mm)

Calculated mean diameter

Recommendation:

No routine follow-up is needed.

Nodules <6 mm do not require routine follow-up in low-risk patients.

Recommendation:

No routine follow-up is needed.

In certain suspicious ground glass nodules smaller than 6 mm, consider follow-up at 2 and 4 years.

Recommendation:

No routine follow-up is needed.

In practice, part-solid nodules cannot be defined as such until their diameter is at least 6 mm. Nodules smaller than 6 mm do not usually require follow-up.

Recommendation:

CT at 6–12 months, then consider CT at 18–24 months

Recommendation:

CT at 6–12 months, then CT at 18–24 months

Recommendation:

CT at 3–6 months, then consider CT at 18–24 months

Recommendation:

CT at 3–6 months, then at 18–24 months

Recommendation:

Optional CT at 12 months.

Recommendation:

CT at 3-6 months, if stable consider CT and 2 and 4 years.

Multiple <6 mm pure ground-glass nodules are usually benign but consider follow-up in selected patients at high risk at 2 and 4 years.

Recommendation:

CT at 6–12 months to confirm persistence, then CT every 2 years until 5 years.

If solid component(s) or growth develops, consider resection.

Recommendation:

CT at 3–6 months to confirm persistence. If the nodule is unchanged and solid component remains,6 mm, annual CT should be performed for 5 years.

Persistent part-solid nodules with solid components smaller than 6 mm should be considered highly suspicious.

Recommendation:

CT at 3–6 months. Subsequent management based on the most suspicious nodule(s).

Recommendation:

Consider CT at 3 months, PET/CT, or tissue sampling.

Solid nodules larger than 8mm in diameter need CT, PET/CT, or tissue sampling irrespective of patient's clinical risk status.

Reference:

GuidelineMacMahon, H., Naidich, D. P., Goo, J. M., Lee, K. S., Leung, A. N. C., Mayo, J. R., Mehta, A. C., Ohno, Y., Powell, C. A., Prokop, M., Rubin, G. D., Schaefer-Prokop, C. M., Travis, W. D., Van Schil, P. E., & Bankier, A. A. (2017). Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology, 284(1), 228–243. https://doi.org/10.1148/radiol.2017161659

More about this calculator:

The Fleischner Society's 2017 guidelines for managing incidental pulmonary nodules found on CT scans offer an updated and detailed approach for clinicians. Building on the previous guidelines from 2005 and 2013, these revisions incorporate new research and clinical insights to refine the recommendations. Significant changes include raising the minimum threshold size for routine follow-up and providing flexible follow-up intervals instead of fixed periods, allowing adjustments based on individual patient risk factors and preferences. The guidelines also consolidate recommendations for both solid and subsolid nodules into a single, simplified table and include specific advice for managing multiple nodules.

This updated approach not only aims to improve clinical outcomes but also emphasizes the importance of minimizing unnecessary follow-up examinations and associated healthcare costs. By providing a range of follow-up intervals and increasing the minimum threshold size for follow-up, the guidelines help reduce patient anxiety and exposure to radiation. These advancements underscore the commitment to a patient-centered approach, ensuring that each case is handled with the most appropriate level of care based on the latest evidence and expert consensus.

To support the implementation of these guidelines, we have developed this calculator to assisst radiologists and clinicians determine the best management strategies for patients with incidental lung nodules, thereby improving decision-making and patient care.

Related Calculators:

Lung-RADS 2022

Based on the most recently updated guideline

Fleischner Calculator: Management of Incidental Pulmonary Nodules Detected on CT

Attention: Use the most suspicious nodule to guide management. Follow-up intervals may vary according to size and risk.

Attention: For part-solid nodules, measurements should be based on the solid component.

Recommendation:

No routine follow-up is needed.

Nodules <6 mm do not require routine follow-up in low-risk patients.

Recommendation:

No routine follow-up is needed.

In certain suspicious ground glass nodules smaller than 6 mm, consider follow-up at 2 and 4 years.

Recommendation:

No routine follow-up is needed.

In practice, part-solid nodules cannot be defined as such until their diameter is at least 6 mm. Nodules smaller than 6 mm do not usually require follow-up.

Recommendation:

CT at 6–12 months, then consider CT at 18–24 months

Recommendation:

CT at 6–12 months, then CT at 18–24 months

Recommendation:

CT at 3–6 months, then consider CT at 18–24 months

Recommendation:

CT at 3–6 months, then at 18–24 months

Recommendation:

Optional CT at 12 months.

Recommendation:

CT at 3-6 months, if stable consider CT and 2 and 4 years.

Multiple <6 mm pure ground-glass nodules are usually benign but consider follow-up in selected patients at high risk at 2 and 4 years.

Recommendation:

CT at 6–12 months to confirm persistence, then CT every 2 years until 5 years.

If solid component(s) or growth develops, consider resection.

Recommendation:

CT at 3–6 months to confirm persistence. If the nodule is unchanged and solid component remains,6 mm, annual CT should be performed for 5 years.

Persistent part-solid nodules with solid components smaller than 6 mm should be considered highly suspicious.

Recommendation:

CT at 3–6 months. Subsequent management based on the most suspicious nodule(s).

Recommendation:

Consider CT at 3 months, PET/CT, or tissue sampling.

Solid nodules larger than 8mm in diameter need CT, PET/CT, or tissue sampling irrespective of patient's clinical risk status.

Reference:

More about this calculator:

Related Calculators:

Lung-RADS 2022

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