Lung nodules

Does your patient wish to be referred?

Minimum referral criteria

Does your patient meet the minimum referral criteria?

Category 1

Appointment within 30 days is desirable

Lung nodules are traditionally defined as ≤30 mm in diameter. This section is relevant to both screening detected and incidental (scan performed for a different reason) lung nodules.

Any one of the following:

	Solid	Part Solid	Non-solid (Ground glass)
National Lung Cancer Screening Program	High Risk (Cat 5) or Very High Risk (Cat 6) nodules Calculated risk of malignancy >30%
Nodule Size^[1]	>8 mm	Solid component >8 mm
Nodule volume^[2]	≥268 mm³	Solid component ≥268 mm³
Change from previous scans (within 24 months)	Progressive growth over 3 or more scans Increase in size of >1.5 mm or volume of >25%	Progressive growth over 3 or more scans Solid component ≥4 mm or ≥34 mm³ which is new or growing	Doubling in size within 12 months
Other features	Growing nodule within a larger airway (segmental or more proximal) Progressive atypical cyst compared to previous scan(s) Regional lymphadenopathy Frank metastatic disease with no other obvious source

^[1]Dimensions are average of long and short axes, rounded to the nearest millimetre. Where only the largest diameter is provided in the imaging Report, this measurement can be considered

^[2]Volume calculated from radiology volumetric software.

Category 2

Appointment within 90 days is desirable

Any one of the following:

	Solid	Part Solid	Non-solid (Ground glass)
National Lung Cancer Screening Program	Moderate Risk (Cat 4) nodules where community follow up is not possible or where additional clinical risk factors are present.
Nodule Size^[1]	6–8 mm	Solid component 6–8 mm	≥30 mm
Nodule volume^[2]	≥113 to <268 mm³	Solid component 113 to <268 mm³
Change from previous scans (within 24 months)	Nodule 4 to <8 mm (113 to <268 mm³) which is new or growing	Solid component of nodule <4 mm (<34 mm³) which is new or growing	Doubling in size within 12 months
Other features	Nodule within a larger airway (segmental or more proximal) Atypical pulmonary cyst (multilocular or thick walled) Personal history of cancer – Request for Advice is available, if required, for small nodules that do not meet standard criteria.

^[1]Dimensions are average of long and short axes, rounded to the nearest millimetre. Where only the largest diameter is provided in the imaging Report, this measurement can be considered as a surrogate for the average.

^[2]Volume calculated from radiology volumetric software.

Category 3

Appointment within 365 days is desirable

There are no Category 3 criteria. Support for managing nodules <6 mm (that do not meet criteria for change from previous scans above) can be obtained by Request for Advice, if required.

If your patient does not meet the minimum referral criteria

Consider other treatment pathways or an alternative diagnosis.

If you still need to refer your patient:

Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
Please note that your referral may not be accepted or may be redirected to another service

Other important information for referring practitioners

Not an exhaustive list

Refer to HealthPathways or local guidelines
National Lung Cancer Screening Program:
Fleischer Society Guidelines 2017 | Timing for Follow-Up CT scans for incidental Lung Nodules^[1]

Type		Risk^[2]	<6 mm	6-8 mm (≥6 for subsolid)
Solid	Single	Low	None	6-12 months then consider at 18-24 months
	Single	High	12 months(optional)	6-12 months then at 18-24 months
	Multiple	Low	None	3-6 months then consider at 18-24 months
	Multiple	High	12 months (optional)	3-6 months then at 18-24 months
Non-solid			No routine follow-up	6-12 months then 2-yearly for 5 yrs
Part-solid			No routine follow-up	3-6 months then yearly for 5 yrs
Multiple			3-6 months then annual for 5 years	6-12 months then based on most suspicious

^[1]Not intended for patients <35 years, lung cancer screening, history of cancer or immunocompromised

^[2]High-risk factors include older age, heavy smoking, irregular or spiculated margins, and upper lobe location.

Nodules that do not require referral include:
- Nodules with diffuse, central, laminated or popcorn patterns of calcification or macroscopic fat
- Juxtapleural (perifissural) nodules with characteristic triangular morphology < 10 mm diameter
- Solid nodules stable for at least 2 years
- Non-solid, part solid and atypical pulmonary cysts stable for at least 5 years
Review of previous imaging is very important to determine if nodules are new, enlarging, stable or decreased.
Follow up imaging of nodules should be performed at the same radiology service and on the same equipment, if possible.

Referral requirements

A referral may be rejected without the following information.

Essential referral information

Chest imaging and details of radiology provider
Details and pathology results (if available) of previous malignancies
NLCSP screening report, if applicable
Patient characteristics which influence risk of malignancy:
- Personal history of cancers
- Patient history, symptoms, and indication for CT (if CT performed for respiratory (infective) symptoms, consider short interval repeat CT depending on radiological likelihood of malignancy (e.g., 8–12 weeks)
- Detailed smoking history including tobacco, marijuana, electronic cigarettes, and illicit drugs
- Family history of lung cancer
- Ethnicity
- Occupational exposures
- Known underlying lung disease, for example, COPD, Interstitial lung disease
- Medications, for example, anticoagulation, immunosuppressive drugs

Additional Referral Information (Useful for processing the referral)

Historical imaging (if available)
FBC, ELFT and any other relevant pathology results

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

Clinical Modifiers (where relevant)

Impact on employment
Impact on education
Impact on home
Impact on activities of daily living
Impact on ability to care for others
Impact on personal frailty or safety
Identifies as Aboriginal and/or Torres Strait Islander

Reason for Referral (essential)

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can’t order, or the patient can’t afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Clinical Information (essential)

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use