• Khan A, Davis SD, Goodman PC, Haramati LB, Leung AN, McLoud TC, Rosado de Christenson ML, Rozenshtein A, White CS, Kaiser LR, Expert Panel on Thoracic Imaging. Solitary pulmonary nodule. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 5 p. [30 references]

This is the current release of the guideline.

This guideline updates a previous version: Henschke CI, Yankelevitz D, Westcott J, Davis SD, Fleishon H, Gefter WB, McLoud TC, Pugatch RD, Sostman HD, Tocino I, White CS, Bode FR, Swensen SJ. Work-up of the solitary pulmonary nodule. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):607-9.

The appropriateness criteria are reviewed annually and updated by the panel as needed, depending on introduction of new and highly significant scientific evidence.

Solitary pulmonary nodule

Diagnosis

Oncology
Pulmonary Medicine
Radiology

Physicians

To evaluate the appropriateness of radiologic exam procedures for imaging and treatment decisions in the work-up of the solitary pulmonary nodule (SPN)

Patients with a solitary pulmonary nodule (SPN)

1. Computed tomography (CT)
   • High resolution
   • With contrast
2. Fine needle aspiration
3. Positron emission tomography (PET) scan
4. Watchful waiting with computed tomography follow-up

Utility of radiologic exam procedures in differential diagnosis

Searches of Electronic Databases

The guideline developer performed literature searches of peer-reviewed medical journals, and the major applicable articles were identified and collected.

The total number of source documents identified as the result of the literature search is not known.

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Systematic Review with Evidence Tables

One or two topic leaders within a panel assume the responsibility of developing an evidence table for each clinical condition, based on analysis of the current literature. These tables serve as a basis for developing a narrative specific to each clinical condition.

Expert Consensus (Delphi)

Since data available from existing scientific studies are usually insufficient for meta-analysis, broad-based consensus techniques are needed for reaching agreement in the formulation of the appropriateness criteria. The American College of Radiology (ACR) Appropriateness Criteria panels use a modified Delphi technique to arrive at consensus. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. These questionnaires are distributed to the participants along with the evidence table and narrative as developed by the topic leader(s). Questionnaires are completed by the participants in their own professional setting without influence of the other members. Voting is conducted using a scoring system from 1 to 9, indicating the least to the most appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted and opinions are unified to the highest degree possible. Eighty percent agreement is considered a consensus. This modified Delphi technique enables individual, unbiased expression, is economical, easy to understand, and relatively simple to conduct.

If consensus cannot be reached by this Delphi technique, the panel is convened and group consensus techniques are utilized. The strengths and weaknesses of each test or procedure are discussed and consensus reached whenever possible. If "No consensus" appears in the rating column, reasons for this decision are added to the comment sections.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

ACR Appropriateness Criteria®

Clinical Condition: Solitary Pulmonary Nodule, Noncalcified.

Variant 1: Nodule >1 cm, low clinical suspicion for cancer.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Nodule >1 cm, moderate to high clinical suspicion for cancer.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Nodule <1 cm, low clinical suspicion for cancer.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: Nodule <1 cm, moderate to high clinical suspicion for cancer.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

In view of the variety of diagnostic tests available and the variable accuracy of the different diagnostic techniques, no single algorithm for work-up is generally accepted. It has been found to vary from institution to institution. This is probably appropriate given the varying prevalence of lung disease in different parts of the country, varying skill levels of operators, and varying availability of equipment.

Abbreviations

• CT, computed tomography
• HRCT, high resolution computed tomography
• PET, positron emission tomography

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

Selection of appropriate radiologic imaging procedures for evaluation of patients with solitary pulmonary nodule

Not stated

An American College of Radiology (ACR) committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those exams generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

An implementation strategy was not provided.

Getting Better

Effectiveness

• Khan A, Davis SD, Goodman PC, Haramati LB, Leung AN, McLoud TC, Rosado de Christenson ML, Rozenshtein A, White CS, Kaiser LR, Expert Panel on Thoracic Imaging. Solitary pulmonary nodule. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 5 p. [30 references]

Not applicable: The guideline was not adapted from another source.

1995 Sep (revised 2005)

American College of Radiology - Medical Specialty Society

American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Thoracic Imaging

Panel Members: Arfa Khan, MD (Review author); Sheila D. Davis, MD (Panel chair); Philip C. Goodman, MD; Linda B. Haramati, MD; Ann N. Leung, MD; Theresa C. McLoud, MD; Melissa L. Rosado de Christenson, MD; Anna Rozenshtein, MD; Charles S. White, MD; Larry R. Kaiser MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Henschke CI, Yankelevitz D, Westcott J, Davis SD, Fleishon H, Gefter WB, McLoud TC, Pugatch RD, Sostman HD, Tocino I, White CS, Bode FR, Swensen SJ. Work-up of the solitary pulmonary nodule. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):607-9.

The appropriateness criteria are reviewed annually and updated by the panel as needed, depending on introduction of new and highly significant scientific evidence.

None available

This summary was completed by ECRI on March 25, 1999. The information was verified by the guideline developer on September 9, 1999. The summary was updated on February 12, 2002. The information was verified again by the guideline developer on March 25, 2002. This NGC summary was updated by ECRI on January 4, 2006. The updated information was verified by the guideline developer on January 19, 2006.