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Abstract
Pulmonary subsolid nodules (SSNs) refer to the pulmonary pure ground-glass nodules and part-solid nodules. SSNs are frequently encountered in clinical settings, such as in screenings conducted with chest computed tomography. The main concern regarding pulmonary SSNs, particularly when they are persistent, has been a lung adenocarcinoma and the precursors to this condition. This review aims at describing the current understanding of the imaging features, histology, natural course, and to present the current management protocols based on the guidelines recently established by the Fleischner Society.
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References
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 | Fig. 1.Representative CT images of subsolid nodules. A. An 1-mm-thick section axial image of the left upper lobe shows a pure ground-glass nodule. There is a focal nodular area of increased lung attenuation through which the pulmonary vessels can be observed. B. An 1-mm-thick section axial image of the right upper lobe shows a part-solid nodule. This nodule presents with both ground-glass and solid components in which the underlying lung architecture cannot be visualized. |
 | Fig. 2.A transient subsolid nodule in a 43-year-old man. A. An initial 1-mm-thick section CT image shows a part-solid nodule in the left upper lobe. B. A follow-up 1-mm-thick section CT image acquired 1 month later shows resolution of the nodule, consistent with an infectious or inflammatory process. |
 | Fig. 3.A pure ground glass nodule with a bubble lucencies in a 65-year-old man. A. An 1-mm-thick section image of the lung window setting showed a 1.5 cm pure ground-glass nodule in the right upper lobe. B. The nodule had increased in size (to 2.0 cm) at the final follow-up 18 months after the initial CT. The nodule proved to be invasive adenocarcinoma. |
 | Fig. 4.Progression of a subsolid nodule during follow-up. Consecutive 1-mm-thick sections through left upper lobe section obtained at same anatomic level over a 3-year period (A: baseline, B: 3 years) show transformation of initial pure ground-glass nodule to a part-solid nodule, which subsequently proved to be adenocarcinoma in situ. |
Table 1.
Fleischner Society 2017 Guidelines for Management of Incidentally Detected Pulmonary Subsolid Nodules in Adults
| Nodule Type | Size∗ | Comments | |
|---|---|---|---|
| < 6 mm (< 100 mm3) | ≥ 6 mm (> 100 mm3) | ||
| Single | |||
| Ground glass | No routine follow-up | CT at 6–12 months to confirm persistence, then CT every 2 years until 5 years | In certain suspicious nodules < 6 mm, consider follow-up at 2 and 4 years. If solid component(s) or growth develops, consider resection |
| Part solid | No routine follow-up | CT at 3–6 months to confirm persistence. If unchanged and solid component remains, < 6 mm, annual CT should be performed for 5 years | In practice, part-solid nodules cannot be defined as such until ≥ 6 mm, and nodules < 6 mm do not usually require follow-up. Persistent part-solid nodules with solid components ≥ 6 mm should be considered highly suspicious |
| Multiple | CT at 3–6 months. If stable, consider CT at 2 and 4 years | CT at 3–6 months. Subsequent management based on the most suspicious nodule(s) | 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 |
Table 2.
Lung-Reporting and Data SystemTM Version 1.0 A Assessment Categories (Release date: April 28, 2014)
| Category | Category Descriptor | Category | Findings | Management | Probability of Malignancy | Estimated Population Prevalence |
|---|---|---|---|---|---|---|
| Incomplete | – | 0 | Prior chest CT examination(s) being located for comparison Part or all of lungs cannot be evaluated | Additional lung cancer screening CT images and/or comparison to prior chest CT examinations is needed | N/A | 1% |
| Negative | No nodules and definitely benign nodules | 1 |
No lung nodules Nodule(s) with specific calcifications: complete, central, popcorn, concentric rings and fat containing nodules |
Continue annual screening with LDCT in 12 months | < 1% | 90% |
| Benign appearance or behavior | Nodules with a very low 90% likelihood of becoming a clinically active cancer due to size or lack of growth | 2 |
Solid nodule(s): < 6 mm New < 4 mm Part solid nodule(s): < 6 mm total diameter on baseline screening Non solid nodule(s) (GGN): < 20 mm OR ≥ 20 mm and unchanged or slowly growing Category 3 or 4 nodules unchanged for ≥ 3 months |
|||
| Probably benign | Probably benign finding(s) – short term follow up suggested; includes nodules with a low likelihood of becoming a clinically active cancer | 3 |
Solid nodule(s): ≥ 6 to < 8 mm at baseline OR new 4 mm to < 6 mm Part solid nodule(s): ≥ 6 mm total diameter with solid component < 6 mm OR New < 6 mm total diameter Non solid nodule(s) (GGN) ≥ 20 mm on baseline CT or new |
6 month LDCT | 1–2% | 5% |
| Suspicious | Findings for which additional diagnostic testing and/or tissue sampling is recommended | 4A |
Solid nodule(s): ≥ 8 to < 15 mm at baseline OR Growing < 8 mm OR New 6 to < 8 mm Part solid nodule(s): ≥ 6 mm with solid component ≥ 6 mm to < 8 mm OR with a new or growing < 4 mm solid component Endobronchial nodule |
3 month LDCT; PET/CT may be used when there is a ≥ 8 mm solid component | 5–15% | 2% |
| 4B |
Solid nodule(s) ≥ 15 mm OR new or growing, and ≥ 8 mm Part solid nodule(s) with: A solid component ≥ 8 mm OR A new or growing ≥ 4 mm solid component |
Chest CT with or without contrast, PET/CT and/or tissue sampling depending on the ∗probability of malignancy and comorbidities. PET/CT may be used when there is a ≥ 8 mm solid component | > 15% | 2% | ||
| 4X | Category 3 or 4 nodules with additional features or imaging findings that increases the suspicion of malignancy | |||||
| Other | Clinically significant or potentially clinically significant findings (non lung cancer) | S | Modifier-may add on to category 0–4 coding | As appropriate to the specific finding | N/A | 10% |
| Prior lung cancer | Modifier for patients with a prior diagnosis of lung cancer who return to screening | C | Modifier-may add on to category 0–4 coding | – | – | – |
Neative screen: does not mean that an individual does not have lung cancer, Size: nodules should be measured on lung windows and reported as the average diameter rounded to the nearest whole number; for round nodules only a single diameter measurement is necessary, Size Thresholds: apply to nodules at first detection, and that grow and reach a higher size category, Growth: an increase in size of > 1.5 mm, Exam Category: each exam should be coded 0–4 based on the nodule(s) with the highest degree of suspicion, Exam Modifiers: S and C modifiers may be added to the 0–4 category, Lung Cancer Diagnosis: Once a patient is diagnosed with lung cancer, further management (including additional imaging such as PET/CT) may be performed for purposes of lung cancer staging; this is no longer screening, Practice audit definitions: a negative screen is defined as categories 1 and 2; a positive screen is defined as categories 3 and 4, Category 4B Management: this is predicated on the probability of malignancy based on patient evaluation, patient preference and risk of malignancy; radiologists are encouraged to use the McWilliams et al assessment tool when making recommendations, Category 4X: nodules with additional imaging findings that increase the suspicion of lung cancer, such as spiculation, GGN that doubles in size in 1 year, enlarged lymph nodes etc, nodules with features of an intrapulmonary lymph node should be managed by mean diameter and the 0–4 numerical category classification, Category 3 and 4A nodules that are unchanged on interval CT should be coded as category 2, and individuals returned to screening in 12 months.
∗ Link to McWilliams Lung Cancer Risk Calculator Upon request from the authors at https://brocku.ca/lung-cancer-screening-and-risk-prediction/risk-calculators/, At UptoDate http://www.uptodate.com/contents/calculator-solitary-pulmonary-nodule-malignancy-risk-brock-university-cancer-prediction-equation. GGN = ground-glassnodule, LDCT = low dose chest computed tomography, N/A = not available
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