How I Do It: Management of Pleural-attached Pulmonary Nodules in Low-Dose CT Screening for Lung Cancer

Lung cancer is the leading cause of cancer deaths globally. In various trials, the ability of low-dose CT screening to diagnose early lung cancers leads to high cure rates. It is widely accepted that the potential benefits of low-dose CT screening for lung cancer outweigh the harms. The ability to reliably predict the benignity of nodules, especially at the baseline round, further reduces the potential for harm. Pleural-attached nodules are an important subgroup that represents nodules attached (distance from any pleural surface, 0 mm) to any pleural surfaces (fissural, costal, mediastinal, and diaphragmatic). Pleural-attached solid nodules less than 10 mm in average diameter with smooth margins and triangular, lentiform, oval, or semicircular shapes have a high likelihood of benignity. The 2019 Lung CT Screening Reporting and Data System (Lung-RADS) version 1.1 assigned pleural-attached nodules with these features to categories 3 (probably benign, recommend follow-up in 6 months) or 4 (suspicious for malignancy, recommend follow-up in 3 months or PET/CT). However, Lung-RADS version 2022 now recommends annual follow-up rather than short-term follow-up. These changes downgrade these nodules to category 2 (benign) and limits additional workup. This review article summarizes the terminology used to describe these nodules, characteristics for determining benignity, and the accuracy of the evidence used to make these recommendations.