Abstract
BACKGROUND. Lung-RADS recommends 3-month follow-up for category 4A nodules and downgrading to category 2 of all category 3 or 4 nodules that are unchanged for 3 months or longer, indicating benign behavior. This guidance may be problematic considering the potential for slow-growing cancers in that lack of nodule growth, particularly at short follow-up intervals, may provide false reassurance. OBJECTIVE. The purpose of this study was to evaluate the yield of short-term follow-up CT in showing growth among malignant nodules detected on lung cancer screening CT. METHODS. This retrospective study included 76 patients (53 women, 23 men; median age, 68 years) with a positive lung cancer screening CT result (Lung-RADS category ≥ 3) between June 2015 and May 2021 with a subsequent lung cancer diagnosis and at least one follow-up CT examination at least 3 months before diagnostic or therapeutic intervention. Semiautomated software was used for linear and volumetric nodule measurements. Diameter was defined as the mean of short- and long-axis measurements. For solid nodules, growth was defined as an at least 1.5-mm increase in mean diameter or an at least 25% increase in volume; part-solid nodules, an at least 1.5-mm increase in solid-component mean diameter or an at least 25% increase in volume; and ground-glass nodules, an at least 3-mm increase in mean diameter or development of a new solid component within the nodule. RESULTS. Median time to growth was 13 months by linear and 11 months by volumetric measurement. Frequency of growth at 3 months was 5% by linear and 7% by volumetric measurement. By linear measurement, median time to growth and frequency of growth at 3 months were 13 months and 7% (solid nodules), 18 months and 6% (part-solid nodules), not reached and 0% (ground-glass nodules), not reached and 0% (category 3 nodules), 13 months and 6% (category 4A nodule)s, 6 months and 11% (category 4B nodules), and 12 months and 10% (category 4X nodules). CONCLUSION. Malignant nodules manifest growth slowly on follow-up CT, and 3-month follow-up CT has very low yield. Stability at 3-month follow-up should not instill high confidence in benignancy, and downgrading all such nodules to Lung-RADS category 2 may be problematic. CLINICAL IMPACT. This study highlights the possibility of slow-growing malignancy and associated challenges in application of Lung-RADS to management of unchanged nodules on follow-up imaging.