Fleischner Criteria Calculator for Incidental Pulmonary Nodules

Management of incidental pulmonary nodules detected on CT based on the 2017 Fleischner Criteria guidelines from the Fleischner Society

Fleischner
How many nodules have you identified?
How is the composition of the nodule?
Attention: Use the most suspicious nodule to guide management. Follow-up intervals may vary according to size and risk.
Are there any solid nodules?
How is the clinical risk of the patient for malignancy?
See below for factors related to risk for malignancy.
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.
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Reference:

  1. 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

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More about the Fleischner Criteria Calculator for incidental pulmonary nodules:

The Fleischner Criteria provide a standardized approach for the management of incidentally detected pulmonary nodules on CT scans in adults aged 35 years and older. These guidelines are designed to assist clinicians in determining appropriate follow-up and management strategies based on nodule characteristics and patient risk factors.

Key Principles:
  • Patient Population: Adults ≥35 years old with incidentally detected pulmonary nodules on CT imaging.
  • Exclusions: The guidelines do not apply to patients with known malignancy, immunocompromised status, or those undergoing lung cancer screening.
  • Nodule Assessment: Nodules are categorized based on size, consistency (solid, subsolid), and number (single, multiple).
  • Risk Stratification: Patients are stratified into low-risk and high-risk categories based on factors such as smoking history and exposure to carcinogens.
Fleischner Management Recommendations:

Solid Nodules:

  • <6 mm: No routine follow-up for low-risk patients; optional CT at 12 months for high-risk patients.
  • 6–8 mm: CT at 6–12 months; consider CT at 18–24 months if stable.
  • >8 mm: Consider CT at 3 months, PET/CT, or tissue sampling.

Subsolid Nodules:

  • Pure Ground-Glass <6 mm: No routine follow-up.
  • Pure Ground-Glass ≥6 mm: CT at 6–12 months to confirm persistence; if persistent, CT every 2 years until 5 years.
  • Part-Solid <6 mm: No routine follow-up.
  • Part-Solid ≥6 mm: CT at 3–6 months; if stable, annual CT for 5 years.

Multiple Nodules: Management is based on the most suspicious nodule, considering size, consistency, and patient risk factors.

Clinical Application:

By adhering to the Fleischner Society Guidelines, clinicians can make informed decisions regarding the management of incidental pulmonary nodules, balancing the risks of unnecessary interventions against the need for early detection of malignancy. These guidelines promote consistency in care and help reduce variability in clinical practice.

For detailed information and resources on the Fleischner Society Guidelines, please refer to the references listed above.

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  1. Fleischner Criteria Calculator for Incidental Pulmonary Nodules
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    1. More about the Fleischner Criteria Calculator for incidental pulmonary nodules:
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      2. Fleischner Management Recommendations:
      3. Clinical Application:

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