A Decision Analysis of Follow-up and Treatment Algorithms for Nonsolid Pulmonary Nodules

• Published in: Radiology Vol. 290; no. 2; pp. 506 - 513
• Main Authors: Hammer, Mark M., Palazzo, Lauren L., Eckel, Andrew L., Barbosa, Eduardo M., Kong, Chung Yin
• Format: Journal Article
• Language: English
• Published: United States Radiological Society of North America 01.02.2019
• Subjects: Aged; Algorithms; Decision Making, Computer-Assisted; Female; Humans; Lung - diagnostic imaging; Lung Neoplasms - diagnostic imaging; Lung Neoplasms - mortality; Lung Neoplasms - therapy; Male; Middle Aged; Models, Statistical; Multiple Pulmonary Nodules - diagnostic imaging; Multiple Pulmonary Nodules - mortality; Multiple Pulmonary Nodules - therapy; Original Research; Tomography, X-Ray Computed
• ISSN: 0033-8419; 1527-1315; 1527-1315
• DOI: 10.1148/radiol.2018180867

Purpose To evaluate management strategies and treatment options for patients with ground-glass nodules (GGNs) by using decision-analysis models. Materials and Methods A simulation was developed for 1 000 000 hypothetical patients with GGNs undergoing follow-up per the Lung Imaging Reporting and Data System (Lung-RADS) recommendations. The initial age range was 55-75 years (mean, 64 years). Nodules could grow and develop solid components over time. Clinically significant malignancy rates were calibrated to data from the National Lung Screening Trial. Annual versus 3-year-interval follow-up of Lung-RADS category 2 nodules was compared, and different treatment strategies were tested (stereotactic body radiation therapy, surgery, and no therapy). Results Overall, 2.3% (22 584 of 1 000 000) of nodules were clinically significant malignancies; 6.3% (62 559 of 1 000 000) of nodules were treated. Only 30% (18 668 of 62 559) of Lung-RADS category 4B or 4X nodules were clinically significant malignancies. The risk of clinically significant malignancy for persistent nonsolid nodules after baseline was higher than Lung-RADS estimates for categories 2 and 3 (3% vs <1% and 1%-2%, respectively). Overall survival (OS) at 10 years was 72% (527 827 of 737 306; 95% confidence interval [CI]: 71%, 72%) with annual follow-up and 71% (526 507 of 737 306; 95% CI: 71%, 72%) with 3-year-interval follow-up (P < .01). At 10 years, OS among patients whose nodules progressed to Lung-RADS category 4B or 4X was 80% after radiation therapy (49 945 of 62 559; 95% CI: 80%, 80%), 79% after surgery (49 139 of 62 559; 95% CI: 78%, 79%), and 74% after no therapy (46 512 of 62 559; 95% CI: 74%, 75%) (P < .01). Conclusion Simulation modeling suggests that the follow-up interval for evaluating ground-glass nodules can be increased from 1 year to 3 years with minimal change in outcomes. Stereotactic body radiation therapy demonstrated the best outcomes compared with lobectomy and with no therapy for nonsolid nodules. © RSNA, 2018 Online supplemental material is available for this article.