Pulmonary Nodule · Surveillance vs Wedge/Lobectomy + Approach

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Solid/subsolid + size + risk
   Composition (solid/subsolid) + size + risk? (Fleischner 2017 applies to incidental nodules in those ≥35 years without known malignancy.)
   • Solid <6 mm (low-risk) → Solid <6 mm → generally no follow-up
   • Solid 6–8 mm or subsolid ≥6 mm (intermediate) → Intermediate → serial CT surveillance
   • Solid >8 mm or persistent part-solid with solid component ≥6 mm / growing / high-risk → >8 mm/growing → surgery after work-up
2. [End] Solid <6 mm → generally no follow-up
   Solid <6 mm (low-risk) → generally no routine follow-up needed; high-risk patients may have a single 12-month CT (Fleischner 2017).
3. [End] Intermediate → serial CT surveillance
   Solid 6–8 mm → CT at 6–12 months then 18–24 months; subsolid GGN ≥6 mm → CT at 6–12 months then periodically to 5 years; escalate evaluation for a growing part-solid component.
4. [Decision] >8 mm/growing → surgery after work-up
   Extent of resection? (Solid >8 mm or persistent part-solid with solid component ≥6 mm or growing/high-risk → manage after PET/CT and biopsy evaluation.)
   • Peripheral small nodule ≤2 cm (especially pure/part GGO or limited lung reserve) → ≤2 cm peripheral → wedge/segmentectomy
   • Confirmed/highly suspected NSCLC, larger/solid/central, lung function tolerates → NSCLC → lobectomy
5. [End] ≤2 cm peripheral → wedge/segmentectomy
   Peripheral small nodule (≤2 cm, especially pure/part GGO or poor lung reserve) → wedge resection or segmentectomy (JCOG0802/CALGB140503 support ≤2 cm peripheral segmentectomy); both diagnostic and therapeutic, VATS preferred.
6. [End] NSCLC → lobectomy
   Confirmed/highly suspected NSCLC, larger/solid/central, lung function tolerates → lobectomy + mediastinal lymph node dissection (the standard); VATS/robotic preferred.

Source guidelines & references

• Pulmonary nodule management (Fleischner 2017 incidental nodules; ACR Lung-RADS; NCCN/JCOG0802)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways