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BackgroundThe British Thoracic Society guidelines (2015) on the investigation and management of pulmonary nodules recommend the use of two risk prediction tools to assess the likelihood of malignancy in solid pulmonary nodules (Brock model following initial CT and the model described by Herder et al. following PET-CT). Management strategies are suggested on the basis of these risk assessments. The aim of this study was to assess the performance of this algorithm in patients with solid pulmonary nodules recruited from a UK teaching hospital.MethodPatients with solid pulmonary nodules (4–30 mm) were retrospectively identified from the lung cancer MDT and a nodule follow-up clinic (n = 221). All patients had a final diagnosis confirmed by histology or radiological stability on 2-year follow up.ResultsThe median age was 69 years. The prevalence of malignancy was 37.1% (29.9% primary lung cancer, 7.2% metastatic disease). 25 patients where PET-CT was recommended by the guideline but did not occur were excluded from subsequent analysis.Ten patients had nodules <5 mm and therefore would have been immediately discharged. All these nodules were benign.CT surveillance was recommended for 106 patients (37 with nodule <8 mm, 45 with malignant risk of <10% following initial CT, and 24 with malignant risk of <10% following PET-CT). 94% of these 106 patients had benign disease, 2% had primary lung cancer and 4% had metastatic disease.Surgical/non-surgical treatment was recommended for 58 patients where the malignant risk was >70% following PET-CT. 81% of these patients had primary lung cancer, 10% had metastatic disease and 9% were benign.For nodules with a malignant risk of between 10 and 70% following PET-CT, the guidelines recommend consideration of biopsy with alternatives of CT surveillance or surgical resection depending on patient preference and fitness. Of the 22 patients with nodules in this range, 36% were benign, 55% primary lung cancer and 9% metastatic disease.ConclusionThe solid nodule algorithm from the BTS guidelines shows good accuracy in discriminating benign from malignant nodules, recommending appropriate management in a high proportion of cases. Further studies should evaluate this and the other management algorithms with prospectively collected data.

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patients with 3 or more stations sampled varied from 0% to 26.6%. Furthermore, there was variability in the rate of inadequate sampling (2.4-7.6%), sensitivity (69.2-90.5%), negative predictive value (50-87.5%) and rate of surgical sampling of negative nodes (6.3-35.0%) across the EBUS centres. Discussion There is variability in practice in all parameters of EBUS practice examined in our Network, in the absence of agreed standards and protocols for mediastinal staging. Such protocols and standards have now been agreed and implemented across our Network and the EBUS sub-group is committed to ongoing data collection and publication to drive quality outcomes in this pivotal lung cancer service. Background Management of solitary pulmonary nodules (SPNs) depends critically on the pre-test probability of malignancy. Several quantitative prediction models have been developed using clinical and radiological criteria. Three models include CT criteria (Mayo, Veterans Association, Brock University) with a fourth model (Herder) incorporating FDG avidity on CT-PET scan in addition. These models have not been validated in a UK population, and the current study aimed to compare their performance in a population of patients recruited from a UK teaching hospital. S72Methods Patients with SPNs (4-30 mm) were retrospectively identified from the lung cancer MDT and a nodule follow-up clinic (n = 246). All patients had a final diagnosis confirmed by histology or radiological stability on a 2-year follow up. For each patient, the probability of the pulmonary nodule being malignant was calculated using the four models described. The models were used both in a restricted cohort of patients based on their respective exclusion criteria, and in the total cohort of patients. The accuracy of each model was assessed by calculating the area under the receiver operating characteristic (ROC) curve.Results The median age of the patient population was 69 years (range 32-94) and 50% were male. The prevalence of malignancy was 40.6% (33.3% primary lung cancer, 7.3% metastatic disease). Figure 1 shows the distribution of the probabilities of malignancy according to the four different models.The areas under the ROC curves for the cohorts restricted by respective exclusion criteria were (AUC, There was no statistical difference between the Mayo and Brock models, but both were significantly better than VA (AUC difference of 0.14 and 0.13 respectively, p ≤ 0.0001 for both). The Herder model performed significantly better than both Mayo and Brock models (AUC difference of 0.10 and 0.14 respectively, p ≤ 0.01). Conclusion Both the Mayo and the Brock models perform well in a UK population, but accuracy is improved by incorporating CT-PET findings using the Herder prediction model.95%