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Correspondence |

Management of Subsolid NodulesManagement of Subsolid Nodules FREE TO VIEW

Ryutaro Kakinuma, MD, PhD; Kazuto Ashizawa, MD, PhD; Yoko Kusunoki, MD; Takeshi Kobayashi, MD; Tetsuro Kondo, MD; Tohru Nakagawa, MD; Masayuki Hatakeyama, MD; Yuichiro Maruyama, MD
Author and Funding Information

From the National Cancer Center Research Center for Cancer Prevention and Screening (Dr Kakinuma); the Department of Clinical Oncology (Dr Ashizawa), Nagasaki University Graduate School of Biomedical Science; the Hanwa Intelligent Medical Center (Dr Kusunoki); the Ishikawa Prefectural Central Hospital (Dr Kobayashi); the Kanagawa Cancer Center (Dr Kondo); the Hitachi Health Care Center (Dr Nakagawa); the Tokyo Anti-Tuberculosis Association (Dr Hatakeyama); and the Komoro Kousei General Hospital (Dr Maruyama).

Correspondence to: Ryutaro Kakinuma, MD, PhD, National Cancer Center Research Center for Cancer Prevention and Screening, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045; e-mail: rkaki@ncc.go.jp


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(5):1741-1742. doi:10.1378/chest.13-1314
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Published online
To the Editor:

We recently read with great interest the article by Gould et al1 in the American College of Chest Physicians lung cancer guidelines in CHEST (May 2013), and we certainly appreciate the authors’ hard work and diligent efforts in presenting the guidelines. However, we were surprised to see several inconsistencies between the article and a statement from the Fleischner Society by Naidich et al,2 published in the January 2013 issue of Radiology, regarding subsolid nodules.

First, with respect to the definition of nodule size, the guidelines used the term “diameter,” whereas the statement referred to the “average” of the long and short axial dimensions. Some interobserver variability is inherent in the measurement of pulmonary nodules even when the same measurement method is used. If the measurement methods differ (ie, one observer measures the nodule size based on the diameter and another observer uses the average of the long and short dimensions), the interobserver variability is likely to be greater than if the same measurement method were used by the same two observers.

Second, the descriptions in the guidelines regarding “part-solid nodule” and “solid component” are confusing. Which measurement should observers perform when measuring the diameter of a part-solid nodule? Did the authors mean the diameter of the entire part-solid nodule (measurement A) or the diameter of the solid component in the part-solid nodule (measurement B)? It is unclear whether each of the descriptions for part-solid nodules (≤ 8 mm, > 8 mm, and > 15 mm) referred to measurement A (entire part-solid nodule) or measurement B (solid component only). In fact, the authors stated in their first remark to recommendation 6.5.4 that “PET should not be used to characterize part-solid lesions in which the solid component measures ≤ 8 mm.”1

Next, as for evaluating solid components on CT images, the statement recommended that “the solid component should be evaluated with narrow and/or mediastinal windows,” and the ground-glass component should be measured using “wide and/or lung windows.”2 The guidelines did not provide any instructions, however, regarding how each component should be measured on CT images. Whether a solid component is measured using the lung field settings or the mediastinal settings could also affect interobserver variability.

Finally, the statement recommended an “initial follow-up CT at 3 months to confirm persistence”2 of a part-solid nodule, but the guidelines recommended proceeding “directly to further evaluation with PET, nonsurgical biopsy, and/or surgical resection”1 for a part-solid nodule “measuring > 15 mm in diameter.” The statement cited one study that reported a part-solid nodule with “a larger size of the solid component” could potentially have disappeared at follow-up,3 so the statement “strongly advised that at least one follow-up CT scan be obtained in 3 months to confirm persistence.”2

Acknowledgments

Other contributions: This work was performed by the Pulmonary Nodule Management Committee of the Japanese Society of CT Screening. All authors are the members of the Committee.

Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2013;143(5_suppl):e93S-e120S.
 
Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317. [CrossRef] [PubMed]
 
Lee SM, Park CM, Goo JM, et al. Transient part-solid nodules detected at screening thin-section CT for lung cancer: comparison with persistent part-solid nodules. Radiology. 2010;255(1):242-251. [CrossRef] [PubMed]
 

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References

Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2013;143(5_suppl):e93S-e120S.
 
Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317. [CrossRef] [PubMed]
 
Lee SM, Park CM, Goo JM, et al. Transient part-solid nodules detected at screening thin-section CT for lung cancer: comparison with persistent part-solid nodules. Radiology. 2010;255(1):242-251. [CrossRef] [PubMed]
 
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