Management of small (3-5-mm) pulmonary nodules at chest CT: Global survey of thoracic radiologists

Purpose: To prospectively determine management strategies used by international thoracic radiologists in evaluation of small (3-5-mm) pulmonary nodules at chest computed tomography (CT). Materials and Methods: Institutional review board exemption was granted for this study, which included consenting participants. An electronic survey was sent to members of major thoracic radiology societies in North America, Europe, and Asia. The main part of the survey consisted of four management questions with clinical scenarios. Associations between recommendations and years of experience, location in a region endemic for granulomatous disease, country, and practice type were assessed. Univariate analysis was performed to determine differences in follow-up recommendations on the basis of patient characteristics, percentage of chest CT scans obtained at follow-up, years of experience in radiology, and professional society affiliation of respondents. Differences in categorical variables were examined by using Pearson χ² and Fisher exact tests. Results: Two hundred two (25%) of approximately 800 online surveys were completed. Surveys from respondents from the United States comprised 61% of completed surveys. Median experience of respondents was 11-20 years. Fifty-two percent practice in an area endemic for granulomatous disease. Only 35% of practices have a policy in place for nodule management. In scenarios in which patients had a low likelihood of malignancy, respondents' preferential recommendation was short-term CT follow-up (3-6 months) rather than intermediate-term CT follow-up (12 months) for patients older than 40 years compared with their recommendation in patients younger than 40 years, in whom recommendations for short- or intermediate-term follow-up were roughly equal. In scenarios in which patients had a high risk of malignancy, follow-up was also strongly favored instead of biopsy, with short-term follow-up more commonly advocated. Location in an area endemic for granulomatous disease and years of experience also influenced recommendations. Conclusion: Globally, the most common recommendation for CT evaluation of nodules is short-term follow-up, with a tendency toward less aggressiveness in scenarios in which patients had lower risk of malignancy and increased aggressiveness in scenarios in which patients had higher risk of malignancy.