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M.C. Callister
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P1.06 - Poster Session/ Screening and Early Detection (ID 218)
- Event: WCLC 2015
- Type: Poster
- Track: Screening and Early Detection
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.06-022 - The British Thoracic Society Guideline on the Investigation and Management of Pulmonary Nodules (2015) (ID 2328)
09:30 - 17:00 | Author(s): M.C. Callister
- Abstract
Background:
British Thoracic Society (BTS) Guidelines are aimed primarily at practitioners within the UK. They are National Health Service Evidence accredited which means they must adhere to robust guideline development methodology. The evidence base for this guideline comes mostly from countries outside the UK so the recommendations will have relevance to other countries healthcare systems.
Methods:
The recommendations are based on a comprehensive review of the literature on pulmonary nodules and expert opinion. A third of the 360 references cited were from 2012 onwards, reflecting the rapid expansion of the evidence base. The new evidence has resulted in important differences from guidelines previously published by the American College of Chest Physicians and the Fleischner Society.
Results:
There are four algorithms: initial approach to solid nodules; surveillance of solid nodules; management of sub-sold nodules; and pulmonary nodule treatment. Two malignancy prediction calculators are recommended to assess the risk of malignancy; one (the Brock University model) that performs best for smaller nodules and one that has the better accuracy for larger nodules following PET-CT (the Herder model). There are recommendations based on recent evidence from screening studies, for a higher nodule size threshold for follow up (≥5mm or ≥80mm[3]). This will reduce the number of follow up CTs which, in the UK at least, are not cost effective. Surveillance recommendations are also different from previous guidelines: people can be discharged after 1 year of stability if measured by semi-automated volumetry. Management is also dependent on the volume doubling time (VDT) with immediate further assessment for nodules that show a VDT of ≤400 days and either biopsy or further observation for nodules with VDTs of >400 to ≤600 days. People with nodules with a VDT >600 days have the option of discharge, if VDT is measured by volumetry. As in previous guidelines, a 3 month repaet CT is recommended for sub-solid nodules.After that, management is governed by risk assessment by the Brock tool (with the proviso that it may underestimate risk after the initial CT) and according to specific features that predict malignancy. Acknowledging the good prognosis of sub-solid nodules, there are recommendations for less aggressive options in their management. The guidelines provide more clarity in the use of further imaging, with ordinal scale reporting for PET-CT recommended to facilitate incorporation into the Herder risk model and more clarity about the place of biopsy and its influence on pre-test probability. Segmentectomy can be considered for primary diagnosis and treatment for nodules smaller than 2cm, and sub-lobar resection is recommended for pure ground glass nodules. Where fitness levels preclude surgery, non-surgical treatment with stereotactic ablative radiotherapy or radiofrequency ablation is recommended, even where biopsy is not possible, provided the probability of malignancy is high. Finally, there are evidence based recommendations about the information that people need that should be provided for them.
Conclusion:
The BTS guideline is intended to be used both as a summary in the day to day management of the person with a pulmonary nodule as well as a comprehensive reference text.
