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More than 3 decades of experience with testing of pulmonary nodules means the Fleischner Society has determined that there is no one ideal size for a pulmonary nodule on computed tomography (CT). Nodules varying from a few millimeters to several centimeters are readily diagnosed on CT images and this inflexibility of size limits treatment recommendations. The Fleischner Society guidelines recommend an initial size threshold of 1 cm for solid and 1.5 cm for subsolid nodules on CT scans (4). Size is the single most influential factor influencing the need for and efficacy of follow-up, and the recommended 1-cm threshold provides clear and consistent guidance on size thresholds.
Until recently, the follow-up of solid nodules, whether they are benign or malignant, was based primarily on size. Size has become a less reliable measure of the progression of nodule growth, and a small or growing nodule may contain a small portion of tissue that warrants observation. Nodule size can be used to predict growth over time, but it is not a specific measure of time to growth. In addition, growing lesions that are increasing in size may contain a portion that is either stable or decreasing in size. The decision to treat any pulmonary nodule based on size alone is likely to result in missed diagnoses, inappropriate treatments, or overtreatment. As a result, the size threshold has been removed from the latest edition of the Fleischner Society guidelines. This change does not eliminate the clinical value of size as a predictor of growth over time (4).
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