Guideline on Management of Solitary Pulmonary Nodule

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Observación con TC de baja radiación, siempre que no se detecte crecimiento. Los números y letras entre paréntesis hacen referencia a los apartados del texto en que son comentados." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos J. Álvarez Martínez, Gorka Bastarrika Alemañ, Carlos Disdier Vicente, Alberto Fernández Villar, Jesús R. Hernández Hernández, Antonio Maldonado Suárez, Nicolás Moreno Mata, Antoni Rosell Gratacós" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Carlos J." "apellidos" => "Álvarez Martínez" ] 1 => array:2 [ "nombre" => "Gorka" "apellidos" => "Bastarrika Alemañ" ] 2 => array:2 [ "nombre" => "Carlos" "apellidos" => "Disdier Vicente" ] 3 => array:2 [ "nombre" => "Alberto" "apellidos" => "Fernández Villar" ] 4 => array:2 [ "nombre" => "Jesús R." 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Álvarez Martínez, Gorka Bastarrika Alemañ, Carlos Disdier Vicente, Alberto Fernández Villar, Jesús R. Hernández Hernández, Antonio Maldonado Suárez, Nicolás Moreno Mata, Antoni Rosell Gratacós" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Carlos J." "apellidos" => "Álvarez Martínez" "email" => array:2 [ 0 => "carlosjose.alvarez@salud.madrid.org" 1 => "cam02m@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Gorka" "apellidos" => "Bastarrika Alemañ" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Carlos" "apellidos" => "Disdier Vicente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "Alberto" "apellidos" => "Fernández Villar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 4 => array:3 [ "nombre" => "Jesús R." "apellidos" => "Hernández Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 5 => array:3 [ "nombre" => "Antonio" "apellidos" => "Maldonado Suárez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] 6 => array:3 [ "nombre" => "Nicolás" "apellidos" => "Moreno Mata" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] 7 => array:3 [ "nombre" => "Antoni" "apellidos" => "Rosell Gratacós" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] ] "afiliaciones" => array:9 [ 0 => array:3 [ "entidad" => "Servico de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain, CIBERES" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiothoracic Imaging Division, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Valladolid, Valladolid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Neumología, Hospital de Vigo, Vigo, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Neumología, Complejo Asistencial de Ávila, Hospital de Ávila, Ávila, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario Quirón, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Cirugía Torácica, Hospital Virgen Rocío, Sevilla, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario de Bellvitge, Barcelona, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Normativa sobre el manejo del nódulo pulmonar solitario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2863 "Ancho" => 2169 "Tamanyo" => 325717 ] ] "descripcion" => array:1 [ "en" => "Algorithm for the management of PN>8mm: clinical setting with difficult access to PET-CT or preference for cytohistological study of SPN. FB: fiberoptic bronchoscopy and guided biopsy; m: months; SPN: solitary pulmonary nodule; PET-CT: positron emission tomography with computed tomography; PM: probability of malignancy; CT: chest computed tomography, including thin sections. Follow-up with low-radiation CT, provided no growth is detected. Numbers and letters in brackets refer to the sections in the text where they are discussed." ] ] ] "textoCompleto" => "ObjectivesThe aim of these guidelines is to facilitate decision making in the treatment of patients with a solitary pulmonary nodule (SPN).<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> These guidelines are not intended to be rigid, since the treatment of SPN is an example of how estimation of the probability of malignancy (PM), access to the various diagnostic and therapeutic techniques and patient preferences work together to mold the optimal decision. This process should be individualized in the clinical setting and for each particular situation. Since accessibility to some diagnostic techniques may vary, depending on the setting, a general strategic algorithm is proposed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>) with two alternatives, depending on the degree of accessibility to positron emission tomography (PET) (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 2 and 3</a>). The recommendations have been graded according to strength (strong 1, weak 2) based on the relationship between the foreseeable benefits and the risks for the patient; and the quality of the scientific evidence, as high (A), moderate (B), low (C) or very low (D), according the GRADE system.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> A summary of these recommendations<a class="elsevierStyleCrossRefs" href="#bib0010">2,4,6</a> is given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The extended version of these recommendations is available as an online supplement, along with additional tables and figures (S) (Appendix 1).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Introduction: Concept and EtiologySPN is defined as a single, spherical, distinct, radiological opacity with a long axis of ≤30mm, primarily surrounded by aerated lung and without associated atelectasis, hilar enlargement or pleural effusion.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> SPNs may be observed on chest X-ray or chest computed tomography (CT) performed to study other diseases or for diagnostic screening for lung cancer (LC).<a class="elsevierStyleCrossRefs" href="#bib0015">3,6,7</a> Millimetric nodules (≤8mm in diameter)<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,6</a> and subsolid nodules (SSNs)<a class="elsevierStyleCrossRefs" href="#bib0010">2,5</a> (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 4</a>), requiring different management,<a class="elsevierStyleCrossRefs" href="#bib0025">5–7</a> may be detected on CT (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>). SSNs include both ground glass nodules and partially solid nodules that combine a ground glass component with a solid component.<a class="elsevierStyleCrossRefs" href="#bib0010">2,5–7</a><elsevierMultimedia ident="fig0025"></elsevierMultimedia>Nodules are estimated to occur at a rate of 1 or 2 per 1000 X-rays.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3,8</a> The prevalence of nodules on CTs performed in adult smokers for LC screening is very high, between 20% and 50%, and are generally less than 10mm in size; the incidence in successive annual CTs is 10%.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3,6,7</a>When evaluating SPNs with CT, other small nodules are often found. When they are few or one is clearly dominant, they should be considered as independent SPNs, since, even if the situation is LC, accompanying subcentimeter nodules are commonly benign.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,6,7</a> Moreover, in up to 20% of cases, the malignant nodule is not the largest.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>SPN is the radiological manifestation of many diseases<a class="elsevierStyleCrossRef" href="#bib0015">3</a> (online Appendix–Table 1S). However, most nodules are caused by pulmonary malignancies, granulomas and hamartomas.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The prevalence of malignancy varies between series<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a>: from between 5% and 70%, depending on whether the figures are retrieved from health checks or studies of diagnostic techniques, and to a lesser extent in SPNs detected in LC screening programs, where the prevalence is 1%–10%, depending on nodule size.<a class="elsevierStyleCrossRefs" href="#bib0015">3,7</a> The PM of SPNs increases notably in patients with previous tumor disease.<a class="elsevierStyleCrossRefs" href="#bib0015">3,10</a>Most malignant SPNs are LC, most frequently adenocarcinomas and large cell carcinomas.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> In malignant SSN, the most common strains are in the adenocarcinoma spectrum,<a class="elsevierStyleCrossRefs" href="#bib0025">5,11,12</a> ranging between atypical adenomatous hyperplasia in the smallest nodules, adenocarcinoma in situ, minimally invasive adenocarcinoma and invasive adenocarcinomas, if a solid component is present, particularly in mucinous nodules and those with lepidic growth.<a class="elsevierStyleCrossRefs" href="#bib0025">5,11,12</a>Diagnostic Techniques in the Study of Solitary Pulmonary NoduleChest Computed TomographyThis technique is vastly superior to standard X-ray in the evaluation of SPNs.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> It can detect other nodules and mediastinal lymphadenopathies, diagnose pseudonodules (extraparenchymal lesions) and help in planning nodule biopsy or aspiration. In some cases, it can provide a specific diagnosis, such as arteriovenous malformations, mycetomas, rounded atelectasis or hamartomas. Accordingly, CT is essential as the index examination for the study of SPNs.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Nodule enhancement or contrast material uptake showed a sensitivity of 98% for malignancy with a cutoff of >15 Hounsfield units (HU) and a specificity of 58%.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> This is applicable to spherical, homogeneous SPNs>8mm, without fat, calcium cavitation or necrosis. This may be valuable in centers with expertise in this technique, but due to the introduction of PET its use has not become widespread.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Positron Emission TomographyOne of the major indications for PET-CT with 18F-deoxy-d-glucose is the study of SPNs. Mean sensitivity for solid SPNs>10–15mm is 0.93 (confidence interval [CI] 0.90–0.95), and mean specificity is 0.8 (CI 0.74–0.85).<a class="elsevierStyleCrossRefs" href="#bib0010">2,14,15</a> False negatives on PET-CT are associated with defective technique, tumor diameter<7mm, carcinoid tumors, subsolid nodules and some adenocarcinomas, particularly in situ, minimally invasive, lepidic growth, or mucinous adenocarcinomas.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> False positives are more common and include inflammatory and infectious lesions, such as granulomas, tuberculosis, mycosis or pneumonias.<a class="elsevierStyleCrossRefs" href="#bib0010">2,16</a>PET-CT is of most use in SPNs>8mm with intermediary PM: a negative study greatly reduces PM.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> In a positive PET-CT, a greater standardized uptake value (SUV) indicates greater tumor aggressivity and a poorer prognosis for the patient, although its reduced specificity, and thus the chance of a false positive, must be taken into account.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> It can also help select the most efficient and accessible site for biopsy and help, if necessary, in planning radiation therapy.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> PET-CT contributes to cancer staging<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> by evaluating mediastinal and systemic metastasis, and is recommended in many LC management guidelines.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18,20</a> In these recommendations, PET-CT is used in two ways: as a tool for characterizing the SPN and as a staging technique in SPNs with high PM.Cytohistological Sampling of Solitary Pulmonary NoduleComputed Tomography, Radioscopy or Ultrasound-Guided Fine Needle Transthoracic AspirationAn analysis of the literature on 48 studies shows good sensitivity, 86% (CI 84%–88%), for the diagnosis of malignancy and very good specificity, 99% (CI 98%–99%).<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In SPNs smaller than 15mm, sensitivity is lower, at 70%–82%.<a class="elsevierStyleCrossRefs" href="#bib0010">2,22</a> In benign disease, specificity is also lower.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> The mean rate of pneumothorax was 15%, of which 7% required drainage.<a class="elsevierStyleCrossRefs" href="#bib0010">2,21,23</a> Transthoracic aspiration is contraindicated in cases of poor patient collaboration, very compromised respiratory function or single lung or hemorrhagic diathesis, and in the presence of emphysema or extensive bullae in the region of the nodule. Between 4% and 50% of the results do not provide a diagnosis, and up to 20% are false negatives.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> If PM is high, the rate of true negatives is the same as that of false negatives, so it is not useful for excluding malignancy.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Fiberoptic Bronchoscopy and Associated TechniquesIn LC, the diagnostic yield of CT-guided transbronchial aspiration (TBA) to target the nodule ranges, according to the series, from 20% to 80%, and is lower in SPNs smaller than 20mm, where the mean yield is 30%.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> In benign SPNs, the yield is 10%. This technique is more effective in larger central nodules (>20mm) using an air bronchogram.<a class="elsevierStyleCrossRefs" href="#bib0010">2,24</a> There is little risk of TBA: pneumothorax, 2%,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and more rarely, hemoptysis or hematomas. Although the diagnostic yield for SPNs is less than that obtained with transthoracic fine needle aspiration-biopsy (FNAB), an endobronchial examination can be carried out before planning LC surgery.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Ultra-fine bronchoscopies for better access to lesions, guide sheaths for positioning the forceps, radial probe ultrasound endobronchoscopy, electromagnetic navigation bronchoscopy and navigation bronchoscopy are all under evaluation, being techniques that allow the forceps to be guided toward the nodule, thus improving yield.<a class="elsevierStyleCrossRefs" href="#bib0010">2,26</a> These techniques have been compared in a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0130">26</a>: the combined yield was 70%, better than in previous radioscopy-guided series, and the yields of the individual techniques ranged from 68.5% to 73%, although wide variability and heterogeneity were observed among the studies. The yield was lower in SPNs<20mm, 61% versus 80% in >20mm. Combining techniques may improve the yield somewhat.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> As can be seen from these data, no technique in particular outperforms others in terms of yield, and the recommendation is that each center should use the techniques for which both equipment and expertise are available.Video-assisted Thoracoscopy and ThoracotomySPNs can be resected using these techniques.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> If the SPNs are small or located deep in the parenchyma, they can be previously dyed or marked with a hookwire, generally with CT-guided transthoracic puncture. The risks of video-assisted thoracoscopy are low and mortality is very rare (less than 1%), morbidity is low, and the diagnostic yield is good, similar to thoracotomy but with lower mortality.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> When the SPN is LC, if the clinical situation of the patient permits, anatomical resection is indicated: in general, lobectomy and mediastinal node dissection are recommended.<a class="elsevierStyleCrossRefs" href="#bib0010">2,20,27</a>Estimation of the Probability of MalignancyMalignant SPNs differ from benign SPNs in certain clinical and radiological aspects, described in more detail in the extended version of these guidelines (see online supplement). The factors most closely associated with malignancy are the size of the SPN, margin features, density, patient age, accumulated tobacco consumption, existence of other malignancy and detection of growth.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3,6,7,10,28-30</a> Central, laminar or total calcification of the SPN is considered a good criterion for benignancy,<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> as is radiological stability for more than 24 months, implying a doubling time of over 730 days. This criterion is not valid for SSN, for which the observation must be extended to at least 3 years.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3,5</a>Most clinicians estimate PM intuitively, but several SPN models and classification rules have been proposed<a class="elsevierStyleCrossRefs" href="#bib0035">7,28–32</a> and there are even calculators available online (online Appendix–Table 2S) or as a smartphone application (Medcalc medical calculator). Table 2S of the online Appendix gives a set of formulas obtained from different logistical models and Figure 1S is a valid nomogram for SPNs in chest X-ray.This estimation of PM guides the subsequent diagnostic process.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,31</a> Logically, when predicting malignancy, the results of all the examination techniques are reviewed, including the PET-CT results,<a class="elsevierStyleCrossRefs" href="#bib0155">31,32</a> the biopsy or aspiration results and the evaluation of growth, if suitable images are available.Along with PM, the foreseeable benefits and risks of the treatment must be assessed. There is a threshold PM indicating observation, i.e., any PM for which the most reasonable option is prospective observation of the stability or growth of the SPN; and a threshold for surgery, for which surgery is clearly recommended since the probability of early stage cancer is high. These thresholds depend on the expected benefits; for example, probability of cure or treatment response in cases of malignant disease, the surgical risks, that may vary between patients and the personal attitude and preference of the patient.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Sequential Evaluation of the Solitary Pulmonary NoduleThe aim of evaluating an SPN is to diagnose and treat SPNs that represent active disease, in particular LC, since 5-year survival is 70%–80% in early stage disease.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Another aim is to avoid submitting patients with granulomas, hamartomas and other benign lesions to costly and risky treatments. There is no singly accepted procedure. The key elements for evaluation are estimation of the probability of malignancy, accessibility to different diagnostic tests and the expertise of clinicians in these techniques, and the preferences of the patient.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a><a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 1–3</a> show the proposed sequential evaluation of SPN: <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a> describes the initial classification by SPN size, density and solidity or subsolidity, separating patients who require individualized management and those who can be diagnosed from the outset. <a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 2 and 3</a> describe the proposed strategy for indeterminate solid SPNs>8mm, depending on whether access to PET-CT is easy (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 2</a>) or more difficult (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 3</a>).Clinical and Initial Radiological Evaluation (1)The initial examination comprises history, examination and the evaluation of the radiological features, along with comparison with all available prior X-rays<a class="elsevierStyleCrossRefs" href="#bib0010">2,31</a>: grade of recommendation, 1C.If there is no evidence of stability for >2 years or benign calcification, CT with thin sections through the nodule of interest is indicated<a class="elsevierStyleCrossRef" href="#bib0010">2</a>: grade of recommendation, 1B.Some nodules can be classified in this phase as benign if they are seen to be stable for more than 2 years or from their features on CT<a class="elsevierStyleCrossRefs" href="#bib0010">2,31</a>: grade of recommendation, 2C.In indeterminate SPNs, surveillance will continue, depending on the patient characteristics and the radiological features of the nodule.Patients in Special Situations (2)A patient's situation may be considered special because of a change in the etiological frequency or the PM of the SPN, or because the procedure is limited to non-invasive techniques due to surgical risks.Patients with prior or concomitant malignant disease. The PM of pulmonary nodules, whether single or multiple, increases greatly in these patients,<a class="elsevierStyleCrossRefs" href="#bib0015">3,10</a> even if they are small.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The possibility of metastasis is even greater if the SPNs were not previously present. Nevertheless, when the SPNs are subcentimetric, up to one-third are benign, so the diagnosis must be confirmed with biopsy, aspiration or video-assisted thoracoscopy before denying potentially curative treatments: grade of recommendation, 2C.<a class="elsevierStyleCrossRefs" href="#bib0010">2,10</a> SPNs in immunocompromised patients will require individualized evaluation, and biopsy or aspiration is preferred.<a class="elsevierStyleCrossRef" href="#bib0165">33</a>In inoperable patients, the evaluation of SPN is limited. Biopsy or aspiration is indicated in cases with high PM or positive results on PET, for guiding chemotherapy or radiation therapy if treatment of LC is required: grade of recommendation, 2C.Solitary Pulmonary Nodule>8mm (3) (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 2 and 3</a>)The first step is to classify the patient according to the estimated PM: low (¿5%), intermediate or high (>65%)<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,29,31</a>: grade of recommendation, 1C.Low Probability of Malignancy (3, 1)Low PM is that estimated at less than 5%.<a class="elsevierStyleCrossRefs" href="#bib0010">2,31</a> This includes SPNs that are still small (<10–15mm), with distinct margins, younger patients (<40 years), low total tobacco consumption and, of course, no extrapulmonary malignant disease.<a class="elsevierStyleCrossRefs" href="#bib0010">2,28–32,34</a> In these cases, radiological observation is recommended<a class="elsevierStyleCrossRefs" href="#bib0010">2,31</a>: grade of recommendation, 2C.Also included are SPNs with intermediate PM and negative PET-CT or those evaluated with FNAB showing non-malignancy<a class="elsevierStyleCrossRef" href="#bib0010">2</a>: grade of recommendation, 2C.Intermediate Probability of Malignancy (3, 2)A PM of between 5% and 65% is considered intermediate.<a class="elsevierStyleCrossRefs" href="#bib0010">2,28–32,34</a> In these cases, PET-CT, being non-invasive, low risk and of high discriminatory power, is recommended (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 2</a>): grade of recommendation, 1B. A negative result reduces the PM considerably, and observation may be recommended; a positive result increases PM and classifies it as high.<a class="elsevierStyleCrossRefs" href="#bib0010">2,31</a>Depending on accessibility and wait times for performing PET-CT, an alternative procedure is CT-guided FNAB or fiberoptic bronchoscopy (FB)-TBA guided by radioscopy, ultrasound endoscopy or electromagnetic or virtual navigation (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 3</a>): grade of recommendation, 2C. The biopsy option is particularly advisable when the clinical PM and findings on imaging tests are discordant, when etiologies requiring specific medical treatment (e.g., tuberculosis) are suspected or if the patient is adverse to surgery<a class="elsevierStyleCrossRef" href="#bib0010">2</a>: grade of recommendation, 2C.Repeating biopsy or aspiration techniques in case of initial negativity is only recommended when the PM of the SPN is high and diagnosis prior to surgery is considered necessary, or when surgery is contraindicated.If the result is negative, PET-CT would be recommended (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 3</a>): grade of recommendation, 1B. If no PET-CT is available, the alternative would be monitoring with CT, particularly if the FNAB was negative, or surgery.High Probability of Malignancy (3, 3)PM is high in patients over 50 years of age, with a history of smoking or radiological features of malignancy: SPN>15mm, speculated margins or heterogeneous density. SPNs that are hypermetabolic on PET-CT, those that have increased in size or changed shape and those with a cytology or lung biopsy suggestive of malignancy are also of high PM.<a class="elsevierStyleCrossRefs" href="#bib0010">2,28–32,34</a>In these cases, some authors recommend direct diagnostic-therapeutic surgery and others prefer biopsy techniques.<a class="elsevierStyleCrossRefs" href="#bib0010">2,31</a> In the population selected by this algorithm, when patients with other cancers have been excluded, most SPNs are lung cancers. Thus, the recommendation is that they are managed as such,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> with PET-CT being recommended as a method for staging<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a>: grade of recommendation, 2C.Pre-surgery histological diagnosis can be determined using FB-TBA, a technique that also allows an evaluation of the bronchial tree before undertaking surgery, or by FNAB. A negative result does not sufficiently reduce the PM to preclude resection of the SPN. The efficacy of attempting pre-surgical diagnosis of SPN with high PM, at clinical stage I or II with CT and PET-CT, provided the patient is operable, has not been investigated. For this reason, this is offered as an option in the algorithm (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 2</a>), although pre-surgical evaluation with FB is a standard practice: grade of recommendation, 2C.If PET-CT reveals mediastinal or extrathoracic uptakes suggestive of metastasis, these should be evaluated before resection surgery.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> If the SPN with high PM is negative on PET-CT, the PM is not sufficiently reduced to recommend observation,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and resection via video-assisted thoracoscopy is recommended: grade of recommendation, 2C. Lower uptake, however, suggests a better prognosis and less probability of dissemination, something that can be taken into account if the patient has a strong objection to surgery.<a class="elsevierStyleCrossRefs" href="#bib0015">3,31</a>In the proposed strategy, the evaluation of an SPN with high PM should conclude with a specific diagnosis or diagnostic-therapeutic resection (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 2 and 3</a>).Solitary Pulmonary Nodule <8mm (4)The prevalence of these SPNs is very high in CT studies, and PM is low, unless there is a history of previous or concomitant metastasizing tumor.<a class="elsevierStyleCrossRefs" href="#bib0010">2,6</a> They are difficult to access for obtaining biopsies and PET-CT and dynamic CT have very low sensitivity.<a class="elsevierStyleCrossRefs" href="#bib0010">2,6</a> An observation strategy following the recommendations of the Fleischner Society<a class="elsevierStyleCrossRef" href="#bib0030">6</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>) is proposed, taking into consideration asymptomatic patients without concomitant malignant disease: grade of recommendation, 2C.Follow-up is performed with low-dose, non-contrast CT<a class="elsevierStyleCrossRef" href="#bib0030">6</a>: grade of recommendation, 1C. Again, the patient must be informed and his/her preferences must be taken into consideration.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Subsolid Pulmonary Nodule (5)These are ground-glass nodules, pure or with a solid component<a class="elsevierStyleCrossRef" href="#bib0025">5</a> (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 4</a>). Determination of a subsolid nodule requires thin sections, preferably of 1mm, since small solid SPNs in 5-mm CT slices may appear as ground glass.<a class="elsevierStyleCrossRefs" href="#bib0010">2,5</a>SSNs are difficult to access for biopsy or aspiration and the sensitivity of PET-CT is low.<a class="elsevierStyleCrossRefs" href="#bib0025">5,35</a> On the other hand, their PM is relatively high, 15% or more in the case of ground-glass SPN and over 50% for a mixed nodule.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> It is also more difficult to establish changes in size or volume of these lesions during surveillance, and malignancies that appear in this form may be indolent for an extended period, for which reason the period of observation must be longer,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> i.e., at least 3 years.As many benign etiologies are acute or subacute processes, an initial observation strategy with CT at 3 months is proposed, since some SPNs can disappear. If they persist, the strategy will be determined by the size of the SPN, if they have a solid component and if they are single or multiple (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists in detail the recommendations as proposed by the Fleischner Society.<a class="elsevierStyleCrossRef" href="#bib0025">5</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Final Possibilities After Evaluation<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">A.Diagnosis of benignancy: Patients with a specific diagnosis on CT, such as hamartomas, arteriovenous malformations, cystic lesions, rounded atelectasis, mycetomas, pseudonodules or calcified nodules, or who have criteria for benignancy, e.g., documented stability for at least 2 years, in the case of solid nodules, or at least 3 years for subsolid nodules<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>: grade of recommendation, 2C.</li><li class="elsevierStyleListItem" id="lsti0010">B.Radiological observation: Indicated in SPNs with low PM, or with intermediate PM when PET-CT is negative, grade of recommendation, 2C. This may also be indicated in undiagnosed SPNs if the risk of surgery is very high or if the patient refuses surgery: grade of recommendation, 2C.For SPN>8mm with low PM, CT monitoring is recommended at 3–6 months, again at 9–12 months and again at 24 months.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> There are specific strategies for SPN≤8mm and SSN<a class="elsevierStyleCrossRefs" href="#bib0010">2,5,6</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>): grade of recommendation, 2C. Surveillance CTs must be performed with low-dose and non-contrast: grade of recommendation, 1C.</li><li class="elsevierStyleListItem" id="lsti0015">C.Diagnostic-therapeutic surgery: Operable patients with undiagnosed SPN and PM greater than low should be offered resection: grade of recommendation, 2C. Although video-assisted thoracoscopy is the method of choice (grade of recommendation, 1C), each surgical team will decide on the best approach. Intraoperative biopsy is recommended for completing appropriate resection in the case of LC: grade of recommendation, 1C.</li><li class="elsevierStyleListItem" id="lsti0020">D.Specific diagnosis: This is the etiological diagnosis of SPN. If LC is diagnosed, specific local staging and treatment protocols will be applied.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>The algorithm cannot be completed without re-emphasizing that the optimal decision must include the opinion and the preferences of the appropriately informed patient<a class="elsevierStyleCrossRef" href="#bib0010">2</a>: grade of recommendation, 1C.</li></ul>Conflict of InterestsThe authors state that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres349284" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec330945" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres349283" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec330946" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Objectives" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Introduction: Concept and Etiology" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Diagnostic Techniques in the Study of Solitary Pulmonary Nodule" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Chest Computed Tomography" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Positron Emission Tomography" ] 2 => array:3 [ "identificador" => "sec0030" "titulo" => "Cytohistological Sampling of Solitary Pulmonary Nodule" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Computed Tomography, Radioscopy or Ultrasound-Guided Fine Needle Transthoracic Aspiration" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Fiberoptic Bronchoscopy and Associated Techniques" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Video-assisted Thoracoscopy and Thoracotomy" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Estimation of the Probability of Malignancy" ] 8 => array:3 [ "identificador" => "sec0055" "titulo" => "Sequential Evaluation of the Solitary Pulmonary Nodule" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Clinical and Initial Radiological Evaluation (1)" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Patients in Special Situations (2)" ] 2 => array:3 [ "identificador" => "sec0070" "titulo" => "Solitary Pulmonary Nodule >8 mm (3) (Figs. 2 and 3)" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Low Probability of Malignancy (3, 1)" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Intermediate Probability of Malignancy (3, 2)" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "High Probability of Malignancy (3, 3)" ] ] ] 3 => array:2 [ "identificador" => "sec0090" "titulo" => "Solitary Pulmonary Nodule <8 mm (4)" ] 4 => array:2 [ "identificador" => "sec0095" "titulo" => "Subsolid Pulmonary Nodule (5)" ] ] ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Final Possibilities After Evaluation" ] 10 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflict of Interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-10-03" "fechaAceptado" => "2014-01-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec330945" "palabras" => array:4 [ 0 => "Solitary pulmonary nodule" 1 => "Subsolid nodule" 2 => "Subcentimeter nodule" 3 => "Lung cancer" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec330946" "palabras" => array:4 [ 0 => "Nódulo pulmonar solitario" 1 => "Nódulo subsólido" 2 => "Nódulo subcentimétrico" 3 => "Cáncer de pulmón" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The aim of the proposed recommendations is to be a tool to facilitate decision-making in patients with a solitary pulmonary nodule (SPN). For an optimal decision, accessibility to the different diagnostics techniques and patient preferences need to be incorporated.The first assessment, which includes a chest computed tomography scan, separates a group of patients with extrapulmonary neoplasm or a high surgical risk who require individualized management. Another two groups of patients are patients with SPN up to 8mm and those who have a subsolid SPN, for which specific recommendations are established.SPNs larger than 8mm are classified according to their probability of malignancy into low (less than 5%), where observation is recommended, high (higher than 65%), which are managed with a presumptive diagnosis of localized stage carcinoma, and intermediate, where positron emission tomography-computed tomography has high yield for reclassifying them into high or low probability. In cases of intermediate or high probability of malignancy, transbronchial needle aspiration or biopsy of the nodule may be an option.Radiologic observation with low radiation computed tomography without contrast is recommended in SPN with low probability of malignancy, and resection with videothoracoscopy in undiagnosed cases with intermediate or high probability of malignancy." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Las recomendaciones que se proponen pretenden ser un instrumento que facilite la toma de decisiones en pacientes con nódulo pulmonar solitario (NPS). Para una decisión óptima hay que incorporar la accesibilidad a las distintas técnicas diagnósticas y las preferencias del paciente.La primera valoración, que incluye la tomografía computarizada torácica, separa a un grupo de pacientes con neoplasia extrapulmonar o muy alto riesgo quirúrgico que requieren manejo individualizado. Otros 2 grupos son los pacientes con NPS de hasta 8mm y los que tienen NPS subsólido, para los que se establecen recomendaciones específicas.Los NPS mayores de 8mm se clasifican según su probabilidad de malignidad en baja (menor del 5%) donde se recomienda observación, alta (mayor del 65%) que se manejan con el diagnóstico de presunción de carcinoma en estadio localizado, e intermedia, donde la tomografía de emisión de positrones tiene gran rendimiento para reclasificarlos en alta o baja probabilidad. En los casos de probabilidad de malignidad intermedia o alta puede ser una opción la punción o biopsia transbronquial del nódulo.Se recomienda la observación radiológica con tomografía computarizada de baja radiación y sin contraste en el NPS con baja probabilidad de malignidad, y la resección con videotoracoscopia en los casos no diagnosticados y con probabilidad de malignidad intermedia o alta." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Álvarez Martínez CJ, Bastarrika Alemañ G, Disdier Vicente C, Fernández Villar A, Hernández Hernández JR, Maldonado Suárez A, et al. Normativa sobre el manejo del nódulo pulmonar solitario. Arch Bronconeumol. 2014;50:285–293." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are Supplementary data to this article:<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0115" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3081 "Ancho" => 2501 "Tamanyo" => 453828 ] ] "descripcion" => array:1 [ "en" => "Algorithm for the management of PN: initial classification and observation of SPN≤8mm and subsolid SPN. m: months, PN: pulmonary nodule; SPN: solitary pulmonary nodule; CT: computed tomography, including thin sections. Follow-up with low-radiation CT, provided no growth is detected. Numbers and letters in brackets refer to the sections in the text where they are discussed." ] ] 1 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2971 "Ancho" => 2169 "Tamanyo" => 310600 ] ] "descripcion" => array:1 [ "en" => "Algorithm for the management of PN>8mm: clinical setting with easy access to PET-CT. m: months, PN: pulmonary nodule; SPN: solitary pulmonary nodule; PET-CT: positron emission tomography with computed tomography; PM: probability of malignancy; CT: chest computed tomography, including thin sections. Follow-up with low-radiation CT, provided no growth is detected. Numbers and letters in brackets refer to the sections in the text where they are discussed." ] ] 2 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2863 "Ancho" => 2169 "Tamanyo" => 325717 ] ] "descripcion" => array:1 [ "en" => "Algorithm for the management of PN>8mm: clinical setting with difficult access to PET-CT or preference for cytohistological study of SPN. FB: fiberoptic bronchoscopy and guided biopsy; m: months; SPN: solitary pulmonary nodule; PET-CT: positron emission tomography with computed tomography; PM: probability of malignancy; CT: chest computed tomography, including thin sections. Follow-up with low-radiation CT, provided no growth is detected. Numbers and letters in brackets refer to the sections in the text where they are discussed." ] ] 3 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1760 "Ancho" => 1584 "Tamanyo" => 288112 ] ] "descripcion" => array:1 [ "en" => "Mixed subsolid solitary pulmonary nodule in the left upper lobe. Chest computed tomography with 2mm thin sections in a patient with a solitary pulmonary nodule in the left upper lobe. Axial slice (A) in upper lobes and coronal (B) and sagittal (C) reconstructions in the left upper lobe. An 18-mm ground-glass solitary pulmonary nodule is observed, with a 7-mm solid component in the interior. Resection by video-assisted thoracoscopy revealed adenocarcinoma." ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "FB: fibroscopy; PN: pulmonary nodule; SPN: solitary pulmonary nodule; PET: positron emission tomography; PM: probability of malignancy; CT: computed tomography." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Grade<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPN initial evaluation</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">All decisions on the management of an SPN must include the opinion and preferences of the appropriately informed patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate stability or growth in previous radiological studies if available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stability for more than 2 years in solid SPN and benign calcification indicate benignancy and do not require further evaluation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT, with thin sections through lesion of interest, is essential for the initial evaluation of indeterminate SPN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPN in patients with previous or concomitant malignancy require individualized management and evaluation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPNs in inoperable patients require individualized management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPNs will be classified as solid nodules>8 mm, solid nodules≤8mm and subsolid nodules \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Solid nodules>8mm</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Should be classified according to PM: low (<5%), intermediate or high (>65%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPN with low PM: radiological observation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Radiological observation: low-radiation CT without contrast at 3–6, 9–12 and 24 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPN with intermediate PM: PET-CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative PET-CT: radiological observation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPNs with intermediate PM: biopsy-aspiration is an acceptable alternative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No histological diagnosis: PET-CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biopsy or aspiration is advisable in case of discordance between clinical PM and imaging tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspected etiology requiring medical treatment (e.g. tuberculosis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients refusing or objecting to diagnostic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPN with high PM: management according to presumed diagnosis of early stage carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPN with high PM: FB with bronchial examination and transbronchial biopsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2D \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Non-diagnosed SPN with PM greater than low in operable patients: SPN resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommended technique: video-assisted thoracoscopy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interoperative biopsy to establish type of resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subcentimeter PNs associated with SPN should not be contraindication for curative carcinoma surgery unless there is confirmation of metastasis. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPN<8mm</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Observation strategy following recommendations of the Fleischner Society (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low-dose, non-contrast CT surveillance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subsolid SPNs</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention according to recommendations of the Fleischner Society (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1B to 2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low-dose, non-contrast CT surveillance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab521250.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Grade of recommendation by strength (strong 1, or weak 2) and quality of scientific evidence as high (A), moderate (B), low (C) or very low (D), according to the GRADE system." ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for the Management of Solitary Pulmonary Nodule." ] ] 5 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "PN: pulmonary nodule; SPN: solitary pulmonary nodule; PET: positron emission tomography; CT: computed tomography. The grade of recommendation is that proposed by the Fleischner Society,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> based on the GRADE system. The recommendations of the American College of Chest Physicians<a class="elsevierStyleCrossRef" href="#bib0010">2</a> reduce the strength of the recommendation by one grade. The CT for evaluation must be fine slice and follow-up low-dose CT." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Grade of Recommendation<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ground-glass SPN</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT at 3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Annual CTFollow-up >3 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Partially solid SPN (solid part)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT at 3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Annual CTFollow-up >3 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT at 3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biopsy, resection, PET-CT if solid part >10mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple ground-glass PN</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider non-malignant causes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT at 2 and 4 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT at 3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Annual CTFollow-up >3 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple PN with solid component \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CT 3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biopsy, resection, especially if solid part >5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1C \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab521251.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Grade of recommendation by strength (strong 1, or weak 2) and quality of scientific evidence as high (A), moderate (B), low (C) or very low (D), according to the GRADE system." ] ] ] "descripcion" => array:1 [ "en" => "Management of Subsolid Nodules." ] ] 6 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc2.doc" "ficheroTamanyo" => 44032 ] ] 7 => array:6 [ "identificador" => "fig0005" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "mmc1.jpeg" "Alto" => 2147 "Ancho" => 1583 "Tamanyo" => 234972 ] ] "descripcion" => array:1 [ "en" => "Figure 1S Nomogram for estimating the probability of malignancy of a solitary pulmonary nodule on the basis of patient age, size and distinct or indistinct borders on the standard chest X-ray. Based on Álvarez-Martínez.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Decision making in patients with pulmonary nodules" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.E. Ost" 1 => "M.K. Gould" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201104-0679CI" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2012" "volumen" => "185" "paginaInicial" => "363" "paginaFinal" => "372" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21980032" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.K. Gould" 1 => "J. Donington" 2 => "W.R. Lynch" 3 => "P.J. Mazzone" 4 => "D.E. Midthun" 5 => "D.P. Naidich" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.12-2351" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2013" "volumen" => "143" "paginaInicial" => "e93S" "paginaFinal" => "e120S" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23649456" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A practical algorithmic approach to the diagnosis and management of solitary pulmonary nodules. Part 1: Radiologic characteristics and imaging modalities" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V.K. Patel" 1 => "S.K. Naik" 2 => "D.P. Naidich" 3 => "W.D. Travis" 4 => "J.A. Weingarten" 5 => "R. Lazzaro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.12-0960" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2013" "volumen" => "143" "paginaInicial" => "825" "paginaFinal" => "839" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23460160" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An official ATS statement: grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.J. Schunemann" 1 => "R. Jaeschke" 2 => "D.J. Cook" 3 => "W.F. Bria" 4 => "A.A. El-Solh" 5 => "A. Ernst" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200602-197ST" "Revista" => array:7 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2006" "volumen" => "174" "paginaInicial" => "605" "paginaFinal" => "614" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16931644" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1699258X11003470" "estado" => "S300" "issn" => "1699258X" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.P. Naidich" 1 => "A.A. Bankier" 2 => "H. MacMahon" 3 => "C.M. Schaefer-Prokop" 4 => "M. Pistolesi" 5 => "J.M. Goo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.12120628" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2013" "volumen" => "266" "paginaInicial" => "304" "paginaFinal" => "317" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23070270" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. MacMahon" 1 => "J.H. Austin" 2 => "G. Gamsu" 3 => "C.J. Herold" 4 => "J.R. Jett" 5 => "D.P. Naidich" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.2372041887" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2005" "volumen" => "237" "paginaInicial" => "395" "paginaFinal" => "400" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16244247" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Probability of cancer in pulmonary nodules detected on first screening CT" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. McWilliams" 1 => "M.C. Tammemagi" 2 => "J.R. Mayo" 3 => "H. Roberts" 4 => "G. Liu" 5 => "K. Soghrati" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1214726" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2013" "volumen" => "369" "paginaInicial" => "910" "paginaFinal" => "919" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24004118" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice. The solitary pulmonary nodule" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Ost" 1 => "A.M. Fein" 2 => "S.H. Feinsilver" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMcp012290" "Revista" => array:6 [ "tituloSerie" => "New Engl J Med" "fecha" => "2003" "volumen" => "348" "paginaInicial" => "2535" "paginaFinal" => "2542" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12815140" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estimating the probability of malignancy in solitary pulmonary nodules. A Bayesian approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.R. Cummings" 1 => "G.A. Lillington" 2 => "R.J. Richard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/arrd.1986.134.3.449" "Revista" => array:6 [ "tituloSerie" => "Am Rev Respir Dis" "fecha" => "1986" "volumen" => "134" "paginaInicial" => "449" "paginaFinal" => "452" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3752700" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relationship between a history of antecedent cancer and the probability of malignancy for a solitary pulmonary nodule" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.M. Mery" 1 => "A.N. Pappas" 2 => "R. Bueno" 3 => "S.J. Mentzer" 4 => "J.M. Lukanich" 5 => "D.J. Sugarbaker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2004" "volumen" => "125" "paginaInicial" => "2175" "paginaFinal" => "2181" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15189939" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiologic implications of the 2011 classification of adenocarcinoma of the lung" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.H. Austin" 1 => "K. Garg" 2 => "D. Aberle" 3 => "D. Yankelevitz" 4 => "K. Kuriyama" 5 => "H.J. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.12120240" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2013" "volumen" => "266" "paginaInicial" => "62" "paginaFinal" => "71" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23070271" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Classification of Lung Adenocarcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.D. Travis" 1 => "E. Brambilla" 2 => "M. Noguchi" 3 => "A.G. Nicholson" 4 => "K.R. Geisinger" 5 => "Y. Yatabe" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/JTO.0b013e318206a221" "Revista" => array:6 [ "tituloSerie" => "J Thorac Oncol" "fecha" => "2011" "volumen" => "6" "paginaInicial" => "244" "paginaFinal" => "285" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21252716" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung nodule enhancement at CT: multicenter study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.J. Swensen" 1 => "R.W. Viggiano" 2 => "D.E. Midthun" 3 => "N.L. Muller" 4 => "A. Sherrick" 5 => "K. Yamashita" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiology.214.1.r00ja1473" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2000" "volumen" => "214" "paginaInicial" => "73" "paginaFinal" => "80" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10644104" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Revisión sistemática de la eficacia diagnóstica de la tomografía por emisión de positrones en el nódulo pulmonar solitario" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Pozo Rodríguez" 1 => "C. Álvarez-Martínez" 2 => "C. Melero-Moreno" 3 => "M.A. Pozo-García" 4 => "W. Martín-Roncero" 5 => "I. Martín-García" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "MBE Neumol" "fecha" => "2004" ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.K. Gould" 1 => "C.C. Maclean" 2 => "W.G. Kuschner" 3 => "C.E. Rydzak" 4 => "D.K. Owens" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Med Assoc" "fecha" => "2001" "volumen" => "285" "paginaInicial" => "914" "paginaFinal" => "924" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Accuracy of FDG-PET to diagnose lung cancer in a region of endemic granulomatous disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Deppen" 1 => "J.B. Putnam Jr." 2 => "G. Andrade" 3 => "T. Speroff" 4 => "J.C. Nesbitt" 5 => "E.S. Lambright" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2011.02.052" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2011" "volumen" => "92" "paginaInicial" => "428" "paginaFinal" => "432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21592456" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.A. Silvestri" 1 => "A.V. Gonzalez" 2 => "M.A. Jantz" 3 => "M.L. Margolis" 4 => "M.K. Gould" 5 => "L.T. Tanoue" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.12-2355" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2013" "volumen" => "143" "paginaInicial" => "e211S" "paginaFinal" => "e250S" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23649440" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines on the radical management of patients with lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Lim" 1 => "D. Baldwin" 2 => "M. Beckles" 3 => "J. Duffy" 4 => "J. Entwisle" 5 => "C. Faivre-Finn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2010.145938" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65 Suppl. 3" "paginaInicial" => "iii1" "paginaFinal" => "iii27" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20940263" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of PET and PET/CT for radiation therapy planning: IAEA expert report 2006-2007" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. MacManus" 1 => "U. Nestle" 2 => "K.E. Rosenzweig" 3 => "I. Carrio" 4 => "C. Messa" 5 => "O. Belohlavek" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.radonc.2008.11.008" "Revista" => array:6 [ "tituloSerie" => "Radiother Oncol" "fecha" => "2009" "volumen" => "91" "paginaInicial" => "85" "paginaFinal" => "94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19100641" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SEPAR guidelines for lung cancer staging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Sanchez de Cos" 1 => "J.H. Hernandez" 2 => "M.F. Jimenez" 3 => "S.P. Sanchez" 4 => "A.R. Gratacos" 5 => "R.R. Porta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2011.06.013" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2011" "volumen" => "47" "paginaInicial" => "454" "paginaFinal" => "465" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21824707" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transthoracic needle aspiration biopsy for the diagnosis of localised pulmonary lesions: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y. Lacasse" 1 => "E. Wong" 2 => "G.H. Guyatt" 3 => "D.J. Cook" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "1999" "volumen" => "54" "paginaInicial" => "884" "paginaFinal" => "893" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10491450" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "CT-guided percutaneous fine-needle aspiration biopsy of pulmonary nodules measuring 10mm or less" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.L. Ng" 1 => "D. Patsios" 2 => "H. Roberts" 3 => "A. Walsham" 4 => "N.S. Paul" 5 => "T. Chung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.crad.2007.09.003" "Revista" => array:6 [ "tituloSerie" => "Clin Radiol" "fecha" => "2008" "volumen" => "63" "paginaInicial" => "272" "paginaFinal" => "277" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18275867" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.S. Wiener" 1 => "L.M. Schwartz" 2 => "S. Woloshin" 3 => "H.G. Welch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7326/0003-4819-155-3-201108020-00003" "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2011" "volumen" => "155" "paginaInicial" => "137" "paginaFinal" => "144" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21810706" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multivariate study of predictive factors for clearly defined lung lesions without visible endobronchial lesions in transbronchial biopsy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Botana-Rial" 1 => "M. Núñez-Delgado" 2 => "A. Pallarés-Sanmartín" 3 => "V. Leiro-Fernández" 4 => "M. Torres-Durán" 5 => "C. Represas-Represas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00464-010-1080-4" "Revista" => array:6 [ "tituloSerie" => "Surg Endosc" "fecha" => "2010" "volumen" => "24" "paginaInicial" => "3031" "paginaFinal" => "3036" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20499106" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Value of flexible bronchoscopy in the pre-operative work-up of solitary pulmonary nodules" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Schwarz" 1 => "N. Schonfeld" 2 => "R.C. Bittner" 3 => "T. Mairinger" 4 => "H. Russmann" 5 => "T.T. Bauer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00018612" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2013" "volumen" => "41" "paginaInicial" => "177" "paginaFinal" => "182" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22496316" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.S. Wang Memoli" 1 => "P.J. Nietert" 2 => "G.A. Silvestri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.11-1764" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2012" "volumen" => "142" "paginaInicial" => "385" "paginaFinal" => "393" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21980059" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Falcoz PE, Brunelli A, Dahan M, Decaluwe HM, Raemdonck D, Rocco G, et al. Database report silver book 2013. European Society of Thoracic Surgeon. 2013 accessed 03.03.14]. Available from: <a id="intr0015" class="elsevierStyleInterRef" href="http://www.ests.org/_userfiles/pages/files/database%202013.pdf">http://www.ests.org/_userfiles/pages/files/database%202013.pdf</a>" ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.J. Swensen" 1 => "M.D. Silverstein" 2 => "D.M. Ilstrup" 3 => "C.D. Schleck" 4 => "E.S. Edell" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Intern Med" "fecha" => "1997" "volumen" => "157" "paginaInicial" => "849" "paginaFinal" => "855" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9129544" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.K. Gould" 1 => "L. Ananth" 2 => "P.G. Barnett" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.06-1261" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2007" "volumen" => "131" "paginaInicial" => "383" "paginaFinal" => "388" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17296637" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Determinación de un modelo predictivo de la probabilidad de malignidad en el nódulo pulmonar solitario y verificación de la bondad predictiva del modelo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.J. Álvarez-Martínez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2000" "editorial" => "Universidad Complutense" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A practical algorithmic approach to the diagnosis and management of solitary pulmonary nodules. Part 2: Pretest probability and algorithm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V.K. Patel" 1 => "S.K. Naik" 2 => "D.P. Naidich" 3 => "W.D. Travis" 4 => "J.A. Weingarten" 5 => "R. Lazzaro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.12-1487" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2013" "volumen" => "143" "paginaInicial" => "840" "paginaFinal" => "846" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23460161" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical prediction model to characterize pulmonary nodules: validation and added value of 18F-fluorodeoxyglucose positron emission tomography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.J. Herder" 1 => "H. van Tinteren" 2 => "R.P. Golding" 3 => "P.J. Kostense" 4 => "E.F. Comans" 5 => "E.F. Smit" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.128.4.2490" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2005" "volumen" => "128" "paginaInicial" => "2490" "paginaFinal" => "2496" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16236914" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "I manage pulmonary nodular lesions and nodular infiltrates in patients with hematologic malignancies or undergoing hematopoietic cell transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.R. Wingard" 1 => "J.W. Hiemenz" 2 => "Jantz M.A. How" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1182/blood-2012-02-378976" "Revista" => array:6 [ "tituloSerie" => "Blood" "fecha" => "2012" "volumen" => "120" "paginaInicial" => "1791" "paginaFinal" => "1800" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22692506" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Validation of two models to estimate the probability of malignancy in patients with solitary pulmonary nodules" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.M. Schultz" 1 => "G.D. Sanders" 2 => "P.R. Trotter" 3 => "E.F. Patz Jr." 4 => "G.A. Silvestri" 5 => "D.K. 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Recommendations of SEPAR

Guideline on Management of Solitary Pulmonary Nodule

Normativa sobre el manejo del nódulo pulmonar solitario

Carlos J. Álvarez Martíneza,

Corresponding author

carlosjose.alvarez@salud.madrid.org
cam02m@gmail.com

Corresponding author.

, Gorka Bastarrika Alemañb,c, Carlos Disdier Vicented, Alberto Fernández Villare, Jesús R. Hernández Hernándezf, Antonio Maldonado Suárezg, Nicolás Moreno Matah, Antoni Rosell Gratacósi

a Servico de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain, CIBERES

b Cardiothoracic Imaging Division, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada

c Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, Spain

d Servicio de Neumología, Hospital Universitario Valladolid, Valladolid, Spain

e Servicio de Neumología, Hospital de Vigo, Vigo, Spain

f Servicio de Neumología, Complejo Asistencial de Ávila, Hospital de Ávila, Ávila, Spain

g Servicio de Medicina Nuclear, Hospital Universitario Quirón, Madrid, Spain

h Servicio de Cirugía Torácica, Hospital Virgen Rocío, Sevilla, Spain

i Servicio de Neumología, Hospital Universitario de Bellvitge, Barcelona, Spain

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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the management of PN<span class="elsevierStyleMonospace">&#62;</span>8<span class="elsevierStyleHsp" style=""></span>mm&#58; clinical setting with difficult access to PET-CT or preference for cytohistological study of SPN&#46; FB&#58; fiberoptic bronchoscopy and guided biopsy&#59; m&#58; months&#59; SPN&#58; solitary pulmonary nodule&#59; PET-CT&#58; positron emission tomography with computed tomography&#59; PM&#58; probability of malignancy&#59; CT&#58; chest computed tomography&#44; including thin sections&#46; Follow-up with low-radiation CT&#44; provided no growth is detected&#46; Numbers and letters in brackets refer to the sections in the text where they are discussed&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Objectives</span><p id="par0005" class="elsevierStylePara elsevierViewall">The aim of these guidelines is to facilitate decision making in the treatment of patients with a solitary pulmonary nodule &#40;SPN&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> These guidelines are not intended to be rigid&#44; since the treatment of SPN is an example of how estimation of the probability of malignancy &#40;PM&#41;&#44; access to the various diagnostic and therapeutic techniques and patient preferences work together to mold the optimal decision&#46; This process should be individualized in the clinical setting and for each particular situation&#46; Since accessibility to some diagnostic techniques may vary&#44; depending on the setting&#44; a general strategic algorithm is proposed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>&#41; with two alternatives&#44; depending on the degree of accessibility to positron emission tomography &#40;PET&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 2 and 3</a>&#41;&#46; The recommendations have been graded according to strength &#40;strong 1&#44; weak 2&#41; based on the relationship between the foreseeable benefits and the risks for the patient&#59; and the quality of the scientific evidence&#44; as high &#40;A&#41;&#44; moderate &#40;B&#41;&#44; low &#40;C&#41; or very low &#40;D&#41;&#44; according the GRADE system&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> A summary of these recommendations<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;6</span></a> is given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The extended version of these recommendations is available as an online supplement&#44; along with additional tables and figures &#40;S&#41; &#40;Appendix 1&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction&#58; Concept and Etiology</span><p id="par0010" class="elsevierStylePara elsevierViewall">SPN is defined as a single&#44; spherical&#44; distinct&#44; radiological opacity with a long axis of &#8804;30<span class="elsevierStyleHsp" style=""></span>mm&#44; primarily surrounded by aerated lung and without associated atelectasis&#44; hilar enlargement or pleural effusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> SPNs may be observed on chest X-ray or chest computed tomography &#40;CT&#41; performed to study other diseases or for diagnostic screening for lung cancer &#40;LC&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6&#44;7</span></a> Millimetric nodules &#40;&#8804;8<span class="elsevierStyleHsp" style=""></span>mm in diameter&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;6</span></a> and subsolid nodules &#40;SSNs&#41;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 4</a>&#41;&#44; requiring different management&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> may be detected on CT &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>&#41;&#46; SSNs include both ground glass nodules and partially solid nodules that combine a ground glass component with a solid component&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#8211;7</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Nodules are estimated to occur at a rate of 1 or 2 per 1000 X-rays&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;8</span></a> The prevalence of nodules on CTs performed in adult smokers for LC screening is very high&#44; between 20&#37; and 50&#37;&#44; and are generally less than 10<span class="elsevierStyleHsp" style=""></span>mm in size&#59; the incidence in successive annual CTs is 10&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">When evaluating SPNs with CT&#44; other small nodules are often found&#46; When they are few or one is clearly dominant&#44; they should be considered as independent SPNs&#44; since&#44; even if the situation is LC&#44; accompanying subcentimeter nodules are commonly benign&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;6&#44;7</span></a> Moreover&#44; in up to 20&#37; of cases&#44; the malignant nodule is not the largest&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">SPN is the radiological manifestation of many diseases<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;online Appendix&#8211;Table 1S&#41;&#46; However&#44; most nodules are caused by pulmonary malignancies&#44; granulomas and hamartomas&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The prevalence of malignancy varies between series<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a>&#58; from between 5&#37; and 70&#37;&#44; depending on whether the figures are retrieved from health checks or studies of diagnostic techniques&#44; and to a lesser extent in SPNs detected in LC screening programs&#44; where the prevalence is 1&#37;&#8211;10&#37;&#44; depending on nodule size&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7</span></a> The PM of SPNs increases notably in patients with previous tumor disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Most malignant SPNs are LC&#44; most frequently adenocarcinomas and large cell carcinomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> In malignant SSN&#44; the most common strains are in the adenocarcinoma spectrum&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;11&#44;12</span></a> ranging between atypical adenomatous hyperplasia in the smallest nodules&#44; adenocarcinoma in situ&#44; minimally invasive adenocarcinoma and invasive adenocarcinomas&#44; if a solid component is present&#44; particularly in mucinous nodules and those with lepidic growth&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;11&#44;12</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnostic Techniques in the Study of Solitary Pulmonary Nodule</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Chest Computed Tomography</span><p id="par0035" class="elsevierStylePara elsevierViewall">This technique is vastly superior to standard X-ray in the evaluation of SPNs&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> It can detect other nodules and mediastinal lymphadenopathies&#44; diagnose pseudonodules &#40;extraparenchymal lesions&#41; and help in planning nodule biopsy or aspiration&#46; In some cases&#44; it can provide a specific diagnosis&#44; such as arteriovenous malformations&#44; mycetomas&#44; rounded atelectasis or hamartomas&#46; Accordingly&#44; CT is essential as the index examination for the study of SPNs&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nodule enhancement or contrast material uptake</span> showed a sensitivity of 98&#37; for malignancy with a cutoff of &#62;15 Hounsfield units &#40;HU&#41; and a specificity of 58&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This is applicable to spherical&#44; homogeneous SPNs&#62;8<span class="elsevierStyleHsp" style=""></span>mm&#44; without fat&#44; calcium cavitation or necrosis&#46; This may be valuable in centers with expertise in this technique&#44; but due to the introduction of PET its use has not become widespread&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Positron Emission Tomography</span><p id="par0045" class="elsevierStylePara elsevierViewall">One of the major indications for PET-CT with <span class="elsevierStyleSup">18</span>F-deoxy-<span class="elsevierStyleSmallCaps">d</span>-glucose is the study of SPNs&#46; Mean sensitivity for solid SPNs&#62;10&#8211;15<span class="elsevierStyleHsp" style=""></span>mm is 0&#46;93 &#40;confidence interval &#91;CI&#93; 0&#46;90&#8211;0&#46;95&#41;&#44; and mean specificity is 0&#46;8 &#40;CI 0&#46;74&#8211;0&#46;85&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;14&#44;15</span></a> False negatives on PET-CT are associated with defective technique&#44; tumor diameter<span class="elsevierStyleMonospace">&#60;</span>7<span class="elsevierStyleHsp" style=""></span>mm&#44; carcinoid tumors&#44; subsolid nodules and some adenocarcinomas&#44; particularly in situ&#44; minimally invasive&#44; lepidic growth&#44; or mucinous adenocarcinomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> False positives are more common and include inflammatory and infectious lesions&#44; such as granulomas&#44; tuberculosis&#44; mycosis or pneumonias&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">PET-CT is of most use in SPNs&#62;8<span class="elsevierStyleHsp" style=""></span>mm with intermediary PM&#58; a negative study greatly reduces PM&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In a positive PET-CT&#44; a greater standardized uptake value &#40;SUV&#41; indicates greater tumor aggressivity and a poorer prognosis for the patient&#44; although its reduced specificity&#44; and thus the chance of a false positive&#44; must be taken into account&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> It can also help select the most efficient and accessible site for biopsy and help&#44; if necessary&#44; in planning radiation therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> PET-CT contributes to cancer staging<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> by evaluating mediastinal and systemic metastasis&#44; and is recommended in many LC management guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18&#44;20</span></a> In these recommendations&#44; PET-CT is used in two ways&#58; as a tool for characterizing the SPN and as a staging technique in SPNs with high PM&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Cytohistological Sampling of Solitary Pulmonary Nodule</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Computed Tomography&#44; Radioscopy or Ultrasound-Guided Fine Needle Transthoracic Aspiration</span><p id="par0055" class="elsevierStylePara elsevierViewall">An analysis of the literature on 48 studies shows good sensitivity&#44; 86&#37; &#40;CI 84&#37;&#8211;88&#37;&#41;&#44; for the diagnosis of malignancy and very good specificity&#44; 99&#37; &#40;CI 98&#37;&#8211;99&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In SPNs smaller than 15<span class="elsevierStyleHsp" style=""></span>mm&#44; sensitivity is lower&#44; at 70&#37;&#8211;82&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;22</span></a> In benign disease&#44; specificity is also lower&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The mean rate of pneumothorax was 15&#37;&#44; of which 7&#37; required drainage&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;21&#44;23</span></a> Transthoracic aspiration is contraindicated in cases of poor patient collaboration&#44; very compromised respiratory function or single lung or hemorrhagic diathesis&#44; and in the presence of emphysema or extensive bullae in the region of the nodule&#46; Between 4&#37; and 50&#37; of the results do not provide a diagnosis&#44; and up to 20&#37; are false negatives&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> If PM is high&#44; the rate of true negatives is the same as that of false negatives&#44; so it is not useful for excluding malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Fiberoptic Bronchoscopy and Associated Techniques</span><p id="par0060" class="elsevierStylePara elsevierViewall">In LC&#44; the diagnostic yield of CT-guided transbronchial aspiration &#40;TBA&#41; to target the nodule ranges&#44; according to the series&#44; from 20&#37; to 80&#37;&#44; and is lower in SPNs smaller than 20<span class="elsevierStyleHsp" style=""></span>mm&#44; where the mean yield is 30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In benign SPNs&#44; the yield is 10&#37;&#46; This technique is more effective in larger central nodules &#40;&#62;20<span class="elsevierStyleHsp" style=""></span>mm&#41; using an air bronchogram&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;24</span></a> There is little risk of TBA&#58; pneumothorax&#44; 2&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and more rarely&#44; hemoptysis or hematomas&#46; Although the diagnostic yield for SPNs is less than that obtained with transthoracic fine needle aspiration-biopsy &#40;FNAB&#41;&#44; an endobronchial examination can be carried out before planning LC surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Ultra-fine bronchoscopies for better access to lesions&#44; guide sheaths for positioning the forceps&#44; radial probe ultrasound endobronchoscopy&#44; electromagnetic navigation bronchoscopy and navigation bronchoscopy are all under evaluation&#44; being techniques that allow the forceps to be guided toward the nodule&#44; thus improving yield&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;26</span></a> These techniques have been compared in a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#58; the combined yield was 70&#37;&#44; better than in previous radioscopy-guided series&#44; and the yields of the individual techniques ranged from 68&#46;5&#37; to 73&#37;&#44; although wide variability and heterogeneity were observed among the studies&#46; The yield was lower in SPNs<span class="elsevierStyleMonospace">&#60;</span>20<span class="elsevierStyleHsp" style=""></span>mm&#44; 61&#37; versus 80&#37; in &#62;20<span class="elsevierStyleHsp" style=""></span>mm&#46; Combining techniques may improve the yield somewhat&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> As can be seen from these data&#44; no technique in particular outperforms others in terms of yield&#44; and the recommendation is that each center should use the techniques for which both equipment and expertise are available&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Video-assisted Thoracoscopy and Thoracotomy</span><p id="par0065" class="elsevierStylePara elsevierViewall">SPNs can be resected using these techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> If the SPNs are small or located deep in the parenchyma&#44; they can be previously dyed or marked with a hookwire&#44; generally with CT-guided transthoracic puncture&#46; The risks of video-assisted thoracoscopy are low and mortality is very rare &#40;less than 1&#37;&#41;&#44; morbidity is low&#44; and the diagnostic yield is good&#44; similar to thoracotomy but with lower mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> When the SPN is LC&#44; if the clinical situation of the patient permits&#44; anatomical resection is indicated&#58; in general&#44; lobectomy and mediastinal node dissection are recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;20&#44;27</span></a></p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Estimation of the Probability of Malignancy</span><p id="par0070" class="elsevierStylePara elsevierViewall">Malignant SPNs differ from benign SPNs in certain clinical and radiological aspects&#44; described in more detail in the extended version of these guidelines &#40;see online supplement&#41;&#46; The factors most closely associated with malignancy are the size of the SPN&#44; margin features&#44; density&#44; patient age&#44; accumulated tobacco consumption&#44; existence of other malignancy and detection of growth&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;6&#44;7&#44;10&#44;28-30</span></a> Central&#44; laminar or total calcification of the SPN is considered a good criterion for benignancy&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> as is radiological stability for more than 24 months&#44; implying a doubling time of over 730 days&#46; This criterion is not valid for SSN&#44; for which the observation must be extended to at least 3 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3&#44;5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Most clinicians estimate PM intuitively&#44; but several SPN models and classification rules have been proposed<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;28&#8211;32</span></a> and there are even calculators available online &#40;online Appendix&#8211;Table 2S&#41; or as a smartphone application &#40;Medcalc medical calculator&#41;&#46; Table 2S of the online Appendix gives a set of formulas obtained from different logistical models and Figure 1S is a valid nomogram for SPNs in chest X-ray&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">This estimation of PM guides the subsequent diagnostic process&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;31</span></a> Logically&#44; when predicting malignancy&#44; the results of all the examination techniques are reviewed&#44; including the PET-CT results&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> the biopsy or aspiration results and the evaluation of growth&#44; if suitable images are available&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Along with PM&#44; the foreseeable benefits and risks of the treatment must be assessed&#46; There is a threshold PM indicating observation&#44; i&#46;e&#46;&#44; any PM for which the most reasonable option is prospective observation of the stability or growth of the SPN&#59; and a threshold for surgery&#44; for which surgery is clearly recommended since the probability of early stage cancer is high&#46; These thresholds depend on the expected benefits&#59; for example&#44; probability of cure or treatment response in cases of malignant disease&#44; the surgical risks&#44; that may vary between patients and the personal attitude and preference of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Sequential Evaluation of the Solitary Pulmonary Nodule</span><p id="par0090" class="elsevierStylePara elsevierViewall">The aim of evaluating an SPN is to diagnose and treat SPNs that represent active disease&#44; in particular LC&#44; since 5-year survival is 70&#37;&#8211;80&#37; in early stage disease&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Another aim is to avoid submitting patients with granulomas&#44; hamartomas and other benign lesions to costly and risky treatments&#46; There is no singly accepted procedure&#46; The key elements for evaluation are estimation of the probability of malignancy&#44; accessibility to different diagnostic tests and the expertise of clinicians in these techniques&#44; and the preferences of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 1&#8211;3</a> show the proposed sequential evaluation of SPN&#58; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a> describes the initial classification by SPN size&#44; density and solidity or subsolidity&#44; separating patients who require individualized management and those who can be diagnosed from the outset&#46; <a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 2 and 3</a> describe the proposed strategy for indeterminate solid SPNs&#62;8<span class="elsevierStyleHsp" style=""></span>mm&#44; depending on whether access to PET-CT is easy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 2</a>&#41; or more difficult &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 3</a>&#41;&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Clinical and Initial Radiological Evaluation &#40;1&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The initial examination comprises history&#44; examination and the evaluation of the radiological features&#44; along with comparison with all available prior X-rays<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;31</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1C</span>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">If there is no evidence of stability for &#62;2 years or benign calcification&#44; CT with thin sections through the nodule of interest is indicated<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1B</span>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Some nodules can be classified in this phase as benign if they are seen to be stable for more than 2 years or from their features on CT<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;31</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C</span>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In indeterminate SPNs&#44; surveillance will continue&#44; depending on the patient characteristics and the radiological features of the nodule&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients in Special Situations &#40;2&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall">A patient&#39;s situation may be considered special because of a change in the etiological frequency or the PM of the SPN&#44; or because the procedure is limited to non-invasive techniques due to surgical risks&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Patients with prior or concomitant malignant disease&#46; The PM of pulmonary nodules&#44; whether single or multiple&#44; increases greatly in these patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10</span></a> even if they are small&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The possibility of metastasis is even greater if the SPNs were not previously present&#46; Nevertheless&#44; when the SPNs are subcentimetric&#44; up to one-third are benign&#44; so the diagnosis must be confirmed with biopsy&#44; aspiration or video-assisted thoracoscopy before denying potentially curative treatments&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;10</span></a> SPNs in immunocompromised patients will require individualized evaluation&#44; and biopsy or aspiration is preferred&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In inoperable patients&#44; the evaluation of SPN is limited&#46; Biopsy or aspiration is indicated in cases with high PM or positive results on PET&#44; for guiding chemotherapy or radiation therapy if treatment of LC is required&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Solitary Pulmonary Nodule<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#62;</span>8<span class="elsevierStyleHsp" style=""></span>mm &#40;3&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 2 and 3</a>&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">The first step is to classify the patient according to the estimated PM&#58; low &#40;¿5&#37;&#41;&#44; intermediate or high &#40;&#62;65&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;29&#44;31</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1C</span>&#46;</p><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Low Probability of Malignancy &#40;3&#44; 1&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Low PM is that estimated at less than 5&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;31</span></a> This includes SPNs that are still small &#40;&#60;10&#8211;15<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; with distinct margins&#44; younger patients &#40;&#60;40 years&#41;&#44; low total tobacco consumption and&#44; of course&#44; no extrapulmonary malignant disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;28&#8211;32&#44;34</span></a> In these cases&#44; radiological observation is recommended<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;31</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span></p><p id="par0145" class="elsevierStylePara elsevierViewall">Also included are SPNs with intermediate PM and negative PET-CT or those evaluated with FNAB showing non-malignancy<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Intermediate Probability of Malignancy &#40;3&#44; 2&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">A PM of between 5&#37; and 65&#37; is considered intermediate&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;28&#8211;32&#44;34</span></a> In these cases&#44; PET-CT&#44; being non-invasive&#44; low risk and of high discriminatory power&#44; is recommended &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 2</a>&#41;&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1B&#46;</span> A negative result reduces the PM considerably&#44; and observation may be recommended&#59; a positive result increases PM and classifies it as high&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;31</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Depending on accessibility and wait times for performing PET-CT&#44; an alternative procedure is CT-guided FNAB or fiberoptic bronchoscopy &#40;FB&#41;-TBA guided by radioscopy&#44; ultrasound endoscopy or electromagnetic or virtual navigation &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 3</a>&#41;&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span> The biopsy option is particularly advisable when the clinical PM and findings on imaging tests are discordant&#44; when etiologies requiring specific medical treatment &#40;e&#46;g&#46;&#44; tuberculosis&#41; are suspected or if the patient is adverse to surgery<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span></p><p id="par0160" class="elsevierStylePara elsevierViewall">Repeating biopsy or aspiration techniques in case of initial negativity is only recommended when the PM of the SPN is high and diagnosis prior to surgery is considered necessary&#44; or when surgery is contraindicated&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">If the result is negative&#44; PET-CT would be recommended &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 3</a>&#41;&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1B&#46;</span> If no PET-CT is available&#44; the alternative would be monitoring with CT&#44; particularly if the FNAB was negative&#44; or surgery&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">High Probability of Malignancy &#40;3&#44; 3&#41;</span><p id="par0170" class="elsevierStylePara elsevierViewall">PM is high in patients over 50 years of age&#44; with a history of smoking or radiological features of malignancy&#58; SPN<span class="elsevierStyleMonospace">&#62;</span>15<span class="elsevierStyleHsp" style=""></span>mm&#44; speculated margins or heterogeneous density&#46; SPNs that are hypermetabolic on PET-CT&#44; those that have increased in size or changed shape and those with a cytology or lung biopsy suggestive of malignancy are also of high PM&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;28&#8211;32&#44;34</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In these cases&#44; some authors recommend direct diagnostic-therapeutic surgery and others prefer biopsy techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;31</span></a> In the population selected by this algorithm&#44; when patients with other cancers have been excluded&#44; most SPNs are lung cancers&#46; Thus&#44; the recommendation is that they are managed as such&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> with PET-CT being recommended as a method for staging<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span></p><p id="par0180" class="elsevierStylePara elsevierViewall">Pre-surgery histological diagnosis can be determined using FB-TBA&#44; a technique that also allows an evaluation of the bronchial tree before undertaking surgery&#44; or by FNAB&#46; A negative result does not sufficiently reduce the PM to preclude resection of the SPN&#46; The efficacy of attempting pre-surgical diagnosis of SPN with high PM&#44; at clinical stage I or II with CT and PET-CT&#44; provided the patient is operable&#44; has not been investigated&#46; For this reason&#44; this is offered as an option in the algorithm &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 2</a>&#41;&#44; although pre-surgical evaluation with FB is a standard practice&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span></p><p id="par0185" class="elsevierStylePara elsevierViewall">If PET-CT reveals mediastinal or extrathoracic uptakes suggestive of metastasis&#44; these should be evaluated before resection surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> If the SPN with high PM is negative on PET-CT&#44; the PM is not sufficiently reduced to recommend observation&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and resection via video-assisted thoracoscopy is recommended&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span> Lower uptake&#44; however&#44; suggests a better prognosis and less probability of dissemination&#44; something that can be taken into account if the patient has a strong objection to surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;31</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In the proposed strategy&#44; the evaluation of an SPN with high PM should conclude with a specific diagnosis or diagnostic-therapeutic resection &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 2 and 3</a>&#41;&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Solitary Pulmonary Nodule &#60;8<span class="elsevierStyleHsp" style=""></span>mm &#40;4&#41;</span><p id="par0195" class="elsevierStylePara elsevierViewall">The prevalence of these SPNs is very high in CT studies&#44; and PM is low&#44; unless there is a history of previous or concomitant metastasizing tumor&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6</span></a> They are difficult to access for obtaining biopsies and PET-CT and dynamic CT have very low sensitivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6</span></a> An observation strategy following the recommendations of the Fleischner Society<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>&#41; is proposed&#44; taking into consideration asymptomatic patients without concomitant malignant disease&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span></p><p id="par0200" class="elsevierStylePara elsevierViewall">Follow-up is performed with low-dose&#44; non-contrast CT<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1C&#46;</span> Again&#44; the patient must be informed and his&#47;her preferences must be taken into consideration&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Subsolid Pulmonary Nodule &#40;5&#41;</span><p id="par0205" class="elsevierStylePara elsevierViewall">These are ground-glass nodules&#44; pure or with a solid component<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 4</a>&#41;&#46; Determination of a subsolid nodule requires thin sections&#44; preferably of 1<span class="elsevierStyleHsp" style=""></span>mm&#44; since small solid SPNs in 5-mm CT slices may appear as ground glass&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">SSNs are difficult to access for biopsy or aspiration and the sensitivity of PET-CT is low&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;35</span></a> On the other hand&#44; their PM is relatively high&#44; 15&#37; or more in the case of ground-glass SPN and over 50&#37; for a mixed nodule&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is also more difficult to establish changes in size or volume of these lesions during surveillance&#44; and malignancies that appear in this form may be indolent for an extended period&#44; for which reason the period of observation must be longer&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> i&#46;e&#46;&#44; at least 3 years&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">As many benign etiologies are acute or subacute processes&#44; an initial observation strategy with CT at 3 months is proposed&#44; since some SPNs can disappear&#46; If they persist&#44; the strategy will be determined by the size of the SPN&#44; if they have a solid component and if they are single or multiple &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists in detail the recommendations as proposed by the Fleischner Society&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Final Possibilities After Evaluation</span><p id="par0265" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">A&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diagnosis of benignancy&#58;</span> Patients with a specific diagnosis on CT&#44; such as hamartomas&#44; arteriovenous malformations&#44; cystic lesions&#44; rounded atelectasis&#44; mycetomas&#44; pseudonodules or calcified nodules&#44; or who have criteria for benignancy&#44; e&#46;g&#46;&#44; documented stability for at least 2 years&#44; in the case of solid nodules&#44; or at least 3 years for subsolid nodules<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">B&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Radiological observation&#58;</span> Indicated in SPNs with low PM&#44; or with intermediate PM when PET-CT is negative&#44; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span> This may also be indicated in undiagnosed SPNs if the risk of surgery is very high or if the patient refuses surgery&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C</span>&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">For SPN<span class="elsevierStyleMonospace">&#62;</span>8<span class="elsevierStyleHsp" style=""></span>mm with low PM&#44; CT monitoring is recommended at 3&#8211;6 months&#44; again at 9&#8211;12 months and again at 24 months&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> There are specific strategies for SPN&#8804;8<span class="elsevierStyleHsp" style=""></span>mm and SSN<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span> Surveillance CTs must be performed with low-dose and non-contrast&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1C&#46;</span></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">C&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diagnostic-therapeutic surgery&#58;</span> Operable patients with undiagnosed SPN and PM greater than low should be offered resection&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 2C&#46;</span> Although video-assisted thoracoscopy is the method of choice &#40;<span class="elsevierStyleItalic">grade of recommendation&#44; 1C</span>&#41;&#44; each surgical team will decide on the best approach&#46; Intraoperative biopsy is recommended for completing appropriate resection in the case of LC&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1C&#46;</span></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">D&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Specific diagnosis&#58;</span> This is the etiological diagnosis of SPN&#46; If LC is diagnosed&#44; specific local staging and treatment protocols will be applied&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">The algorithm cannot be completed without re-emphasizing that the optimal decision must include the opinion and the preferences of the appropriately informed patient<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58; <span class="elsevierStyleItalic">grade of recommendation&#44; 1C&#46;</span></p></li></ul></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of Interests</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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          "titulo" => "Introduction&#58; Concept and Etiology"
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          "titulo" => "Diagnostic Techniques in the Study of Solitary Pulmonary Nodule"
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              "titulo" => "Chest Computed Tomography"
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              "titulo" => "Positron Emission Tomography"
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              "titulo" => "Cytohistological Sampling of Solitary Pulmonary Nodule"
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                  "titulo" => "Computed Tomography&#44; Radioscopy or Ultrasound-Guided Fine Needle Transthoracic Aspiration"
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                  "titulo" => "Low Probability of Malignancy &#40;3&#44; 1&#41;"
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              "titulo" => "Solitary Pulmonary Nodule &#60;8 mm &#40;4&#41;"
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              "titulo" => "Subsolid Pulmonary Nodule &#40;5&#41;"
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          "titulo" => "Final Possibilities After Evaluation"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec330945"
          "palabras" => array:4 [
            0 => "Solitary pulmonary nodule"
            1 => "Subsolid nodule"
            2 => "Subcentimeter nodule"
            3 => "Lung cancer"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec330946"
          "palabras" => array:4 [
            0 => "N&#243;dulo pulmonar solitario"
            1 => "N&#243;dulo subs&#243;lido"
            2 => "N&#243;dulo subcentim&#233;trico"
            3 => "C&#225;ncer de pulm&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of the proposed recommendations is to be a tool to facilitate decision-making in patients with a solitary pulmonary nodule &#40;SPN&#41;&#46; For an optimal decision&#44; accessibility to the different diagnostics techniques and patient preferences need to be incorporated&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The first assessment&#44; which includes a chest computed tomography scan&#44; separates a group of patients with extrapulmonary neoplasm or a high surgical risk who require individualized management&#46; Another two groups of patients are patients with SPN up to 8<span class="elsevierStyleHsp" style=""></span>mm and those who have a subsolid SPN&#44; for which specific recommendations are established&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">SPNs larger than 8<span class="elsevierStyleHsp" style=""></span>mm are classified according to their probability of malignancy into low &#40;less than 5&#37;&#41;&#44; where observation is recommended&#44; high &#40;higher than 65&#37;&#41;&#44; which are managed with a presumptive diagnosis of localized stage carcinoma&#44; and intermediate&#44; where positron emission tomography-computed tomography has high yield for reclassifying them into high or low probability&#46; In cases of intermediate or high probability of malignancy&#44; transbronchial needle aspiration or biopsy of the nodule may be an option&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Radiologic observation with low radiation computed tomography without contrast is recommended in SPN with low probability of malignancy&#44; and resection with videothoracoscopy in undiagnosed cases with intermediate or high probability of malignancy&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las recomendaciones que se proponen pretenden ser un instrumento que facilite la toma de decisiones en pacientes con n&#243;dulo pulmonar solitario &#40;NPS&#41;&#46; Para una decisi&#243;n &#243;ptima hay que incorporar la accesibilidad a las distintas t&#233;cnicas diagn&#243;sticas y las preferencias del paciente&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La primera valoraci&#243;n&#44; que incluye la tomograf&#237;a computarizada tor&#225;cica&#44; separa a un grupo de pacientes con neoplasia extrapulmonar o muy alto riesgo quir&#250;rgico que requieren manejo individualizado&#46; Otros 2 grupos son los pacientes con NPS de hasta 8<span class="elsevierStyleHsp" style=""></span>mm y los que tienen NPS subs&#243;lido&#44; para los que se establecen recomendaciones espec&#237;ficas&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los NPS mayores de 8<span class="elsevierStyleHsp" style=""></span>mm se clasifican seg&#250;n su probabilidad de malignidad en baja &#40;menor del 5&#37;&#41; donde se recomienda observaci&#243;n&#44; alta &#40;mayor del 65&#37;&#41; que se manejan con el diagn&#243;stico de presunci&#243;n de carcinoma en estadio localizado&#44; e intermedia&#44; donde la tomograf&#237;a de emisi&#243;n de positrones tiene gran rendimiento para reclasificarlos en alta o baja probabilidad&#46; En los casos de probabilidad de malignidad intermedia o alta puede ser una opci&#243;n la punci&#243;n o biopsia transbronquial del n&#243;dulo&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se recomienda la observaci&#243;n radiol&#243;gica con tomograf&#237;a computarizada de baja radiaci&#243;n y sin contraste en el NPS con baja probabilidad de malignidad&#44; y la resecci&#243;n con videotoracoscopia en los casos no diagnosticados y con probabilidad de malignidad intermedia o alta&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; &#193;lvarez Mart&#237;nez CJ&#44; Bastarrika Alema&#241; G&#44; Disdier Vicente C&#44; Fern&#225;ndez Villar A&#44; Hern&#225;ndez Hern&#225;ndez JR&#44; Maldonado Su&#225;rez A&#44; et al&#46; Normativa sobre el manejo del n&#243;dulo pulmonar solitario&#46; Arch Bronconeumol&#46; 2014&#59;50&#58;285&#8211;293&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0260" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article&#58;<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0115"
          ]
        ]
      ]
    ]
    "multimedia" => array:8 [
      0 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3081
            "Ancho" => 2501
            "Tamanyo" => 453828
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the management of PN&#58; initial classification and observation of SPN&#8804;8<span class="elsevierStyleHsp" style=""></span>mm and subsolid SPN&#46; m&#58; months&#44; PN&#58; pulmonary nodule&#59; SPN&#58; solitary pulmonary nodule&#59; CT&#58; computed tomography&#44; including thin sections&#46; Follow-up with low-radiation CT&#44; provided no growth is detected&#46; Numbers and letters in brackets refer to the sections in the text where they are discussed&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2971
            "Ancho" => 2169
            "Tamanyo" => 310600
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the management of PN<span class="elsevierStyleMonospace">&#62;</span>8<span class="elsevierStyleHsp" style=""></span>mm&#58; clinical setting with easy access to PET-CT&#46; m&#58; months&#44; PN&#58; pulmonary nodule&#59; SPN&#58; solitary pulmonary nodule&#59; PET-CT&#58; positron emission tomography with computed tomography&#59; PM&#58; probability of malignancy&#59; CT&#58; chest computed tomography&#44; including thin sections&#46; Follow-up with low-radiation CT&#44; provided no growth is detected&#46; Numbers and letters in brackets refer to the sections in the text where they are discussed&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2863
            "Ancho" => 2169
            "Tamanyo" => 325717
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the management of PN<span class="elsevierStyleMonospace">&#62;</span>8<span class="elsevierStyleHsp" style=""></span>mm&#58; clinical setting with difficult access to PET-CT or preference for cytohistological study of SPN&#46; FB&#58; fiberoptic bronchoscopy and guided biopsy&#59; m&#58; months&#59; SPN&#58; solitary pulmonary nodule&#59; PET-CT&#58; positron emission tomography with computed tomography&#59; PM&#58; probability of malignancy&#59; CT&#58; chest computed tomography&#44; including thin sections&#46; Follow-up with low-radiation CT&#44; provided no growth is detected&#46; Numbers and letters in brackets refer to the sections in the text where they are discussed&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1760
            "Ancho" => 1584
            "Tamanyo" => 288112
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Mixed subsolid solitary pulmonary nodule in the left upper lobe&#46; Chest computed tomography with 2<span class="elsevierStyleHsp" style=""></span>mm thin sections in a patient with a solitary pulmonary nodule in the left upper lobe&#46; Axial slice &#40;A&#41; in upper lobes and coronal &#40;B&#41; and sagittal &#40;C&#41; reconstructions in the left upper lobe&#46; An 18-mm ground-glass solitary pulmonary nodule is observed&#44; with a 7-mm solid component in the interior&#46; Resection by video-assisted thoracoscopy revealed adenocarcinoma&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">FB&#58; fibroscopy&#59; PN&#58; pulmonary nodule&#59; SPN&#58; solitary pulmonary nodule&#59; PET&#58; positron emission tomography&#59; PM&#58; probability of malignancy&#59; CT&#58; computed tomography&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Grade<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">SPN initial evaluation</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">All decisions on the management of an SPN must include the opinion and preferences of the appropriately informed patient</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Evaluate stability or growth in previous radiological studies if available</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Stability for more than 2 years in solid SPN and benign calcification indicate benignancy and do not require further evaluation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">CT&#44; with thin sections through lesion of interest&#44; is essential for the initial evaluation of indeterminate SPN</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SPN in patients with previous or concomitant malignancy require individualized management and evaluation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SPNs in inoperable patients require individualized management</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SPNs will be classified as solid nodules<span class="elsevierStyleMonospace">&#62;</span>8 mm&#44; solid nodules&#8804;8</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mm and subsolid nodules</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Solid nodules&#62;8</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">mm</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Should be classified according to PM&#58; low &#40;&#60;5&#37;&#41;&#44; intermediate or high</span> &#40;&#62;65&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SPN with low PM&#58; radiological observation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Radiological observation&#58; low-radiation CT without contrast at 3&#8211;6&#44; 9&#8211;12 and 24 months</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SPN with intermediate PM&#58; PET-CT</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Negative PET-CT&#58; radiological observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SPNs with intermediate PM&#58; biopsy-aspiration is an acceptable alternative</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>No histological diagnosis&#58; PET-CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Biopsy or aspiration is advisable in case of</span> discordance between clinical PM and imaging tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Suspected etiology requiring medical treatment &#40;e&#46;g&#46; tuberculosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Patients refusing or objecting to diagnostic surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SPN with high PM&#58; management according to presumed diagnosis of early stage carcinoma</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SPN with high PM&#58; FB with bronchial examination and transbronchial biopsy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Non-diagnosed SPN with PM greater than low in operable patients&#58; SPN resection</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Recommended technique&#58; video-assisted thoracoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Interoperative biopsy to establish type of resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Subcentimeter PNs associated with SPN should not be contraindication for curative carcinoma surgery unless there is confirmation of metastasis&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">SPN&#60;8</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">mm</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Observation strategy following recommendations of the Fleischner Society</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Low-dose&#44; non-contrast CT surveillance</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Subsolid SPNs</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Intervention according to recommendations of the Fleischner Society</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1B to 2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Low-dose&#44; non-contrast CT surveillance</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Grade of recommendation by strength &#40;strong 1&#44; or weak 2&#41; and quality of scientific evidence as high &#40;A&#41;&#44; moderate &#40;B&#41;&#44; low &#40;C&#41; or very low &#40;D&#41;&#44; according to the GRADE system&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the Management of Solitary Pulmonary Nodule&#46;</p>"
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      5 => array:7 [
        "identificador" => "tbl0010"
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        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">PN&#58; pulmonary nodule&#59; SPN&#58; solitary pulmonary nodule&#59; PET&#58; positron emission tomography&#59; CT&#58; computed tomography&#46; The grade of recommendation is that proposed by the Fleischner Society&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> based on the GRADE system&#46; The recommendations of the <span class="elsevierStyleItalic">American College of Chest Physicians</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> reduce the strength of the recommendation by one grade&#46; The CT for evaluation must be fine slice and follow-up low-dose CT&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Grade of Recommendation<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Ground-glass SPN</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT at 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual CTFollow-up &#62;3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Partially solid SPN &#40;solid part&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT at 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual CTFollow-up &#62;3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT at 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Biopsy&#44; resection&#44; PET-CT if solid part &#62;10<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Multiple ground-glass PN</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consider non-malignant causes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT at 2 and 4 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">CT at 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Persistent&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual CTFollow-up &#62;3 years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1B&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Multiple PN with solid component&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistent&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                      "titulo" => "Decision making in patients with pulmonary nodules"
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                        "paginaFinal" => "372"
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                        "fecha" => "2013"
                        "volumen" => "143"
                        "paginaInicial" => "e93S"
                        "paginaFinal" => "e120S"
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                        "volumen" => "143"
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                    0 => array:2 [
                      "titulo" => "An official ATS statement&#58; grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2006"
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                        "paginaFinal" => "614"
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                      "titulo" => "Recommendations for the management of subsolid pulmonary nodules detected at CT&#58; a statement from the Fleischner Society"
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                          "etal" => true
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                            3 => "C&#46;J&#46; Herold"
                            4 => "J&#46;R&#46; Jett"
                            5 => "D&#46;P&#46; Naidich"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16244247"
                            "web" => "Medline"
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              "identificador" => "bib0035"
              "etiqueta" => "7"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probability of cancer in pulmonary nodules detected on first screening CT"
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                          "autores" => array:6 [
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                        "volumen" => "369"
                        "paginaInicial" => "910"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24004118"
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              "identificador" => "bib0040"
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                0 => array:2 [
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                      "titulo" => "Clinical practice&#46; The solitary pulmonary nodule"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Ost"
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                            2 => "S&#46;H&#46; Feinsilver"
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                        "fecha" => "2003"
                        "volumen" => "348"
                        "paginaInicial" => "2535"
                        "paginaFinal" => "2542"
                        "link" => array:1 [
                          0 => array:2 [
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              "identificador" => "bib0045"
              "etiqueta" => "9"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Estimating the probability of malignancy in solitary pulmonary nodules&#46; A Bayesian approach"
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                          "autores" => array:3 [
                            0 => "S&#46;R&#46; Cummings"
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                            2 => "R&#46;J&#46; Richard"
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                    0 => array:2 [
                      "doi" => "10.1164/arrd.1986.134.3.449"
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                        "tituloSerie" => "Am Rev Respir Dis"
                        "fecha" => "1986"
                        "volumen" => "134"
                        "paginaInicial" => "449"
                        "paginaFinal" => "452"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3752700"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0050"
              "etiqueta" => "10"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Relationship between a history of antecedent cancer and the probability of malignancy for a solitary pulmonary nodule"
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                          "etal" => true
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                            5 => "D&#46;J&#46; Sugarbaker"
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                    0 => array:1 [
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                        "tituloSerie" => "Chest"
                        "fecha" => "2004"
                        "volumen" => "125"
                        "paginaInicial" => "2175"
                        "paginaFinal" => "2181"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15189939"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0055"
              "etiqueta" => "11"
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                0 => array:2 [
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                      "titulo" => "Radiologic implications of the 2011 classification of adenocarcinoma of the lung"
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                            4 => "K&#46; Kuriyama"
                            5 => "H&#46;J&#46; Lee"
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                        "volumen" => "266"
                        "paginaInicial" => "62"
                        "paginaFinal" => "71"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23070271"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0060"
              "etiqueta" => "12"
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                    0 => array:2 [
                      "titulo" => "International Association for the Study of Lung Cancer&#47;American Thoracic Society&#47;European Respiratory Society International Multidisciplinary Classification of Lung Adenocarcinoma"
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                          "etal" => true
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                            5 => "Y&#46; Yatabe"
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                        "tituloSerie" => "J Thorac Oncol"
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                        "paginaInicial" => "244"
                        "paginaFinal" => "285"
                        "link" => array:1 [
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                            5 => "K&#46; Yamashita"
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                        "tituloSerie" => "Radiology"
                        "fecha" => "2000"
                        "volumen" => "214"
                        "paginaInicial" => "73"
                        "paginaFinal" => "80"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10644104"
                            "web" => "Medline"
                          ]
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                      ]
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              "etiqueta" => "14"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Revisi&#243;n sistem&#225;tica de la eficacia diagn&#243;stica de la tomograf&#237;a por emisi&#243;n de positrones en el n&#243;dulo pulmonar solitario"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46; Pozo Rodr&#237;guez"
                            1 => "C&#46; &#193;lvarez-Mart&#237;nez"
                            2 => "C&#46; Melero-Moreno"
                            3 => "M&#46;A&#46; Pozo-Garc&#237;a"
                            4 => "W&#46; Mart&#237;n-Roncero"
                            5 => "I&#46; Mart&#237;n-Garc&#237;a"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "MBE Neumol"
                        "fecha" => "2004"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46;K&#46; Gould"
                            1 => "C&#46;C&#46; Maclean"
                            2 => "W&#46;G&#46; Kuschner"
                            3 => "C&#46;E&#46; Rydzak"
                            4 => "D&#46;K&#46; Owens"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Med Assoc"
                        "fecha" => "2001"
                        "volumen" => "285"
                        "paginaInicial" => "914"
                        "paginaFinal" => "924"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Accuracy of FDG-PET to diagnose lung cancer in a region of endemic granulomatous disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Deppen"
                            1 => "J&#46;B&#46; Putnam Jr&#46;"
                            2 => "G&#46; Andrade"
                            3 => "T&#46; Speroff"
                            4 => "J&#46;C&#46; Nesbitt"
                            5 => "E&#46;S&#46; Lambright"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.athoracsur.2011.02.052"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Thorac Surg"
                        "fecha" => "2011"
                        "volumen" => "92"
                        "paginaInicial" => "428"
                        "paginaFinal" => "432"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21592456"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Methods for staging non-small cell lung cancer&#58; diagnosis and management of lung cancer&#44; 3rd ed&#58; American College of Chest Physicians evidence-based clinical practice guidelines"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "A&#46;V&#46; Gonzalez"
                            2 => "M&#46;A&#46; Jantz"
                            3 => "M&#46;L&#46; Margolis"
                            4 => "M&#46;K&#46; Gould"
                            5 => "L&#46;T&#46; Tanoue"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.12-2355"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2013"
                        "volumen" => "143"
                        "paginaInicial" => "e211S"
                        "paginaFinal" => "e250S"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23649440"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines on the radical management of patients with lung cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Lim"
                            1 => "D&#46; Baldwin"
                            2 => "M&#46; Beckles"
                            3 => "J&#46; Duffy"
                            4 => "J&#46; Entwisle"
                            5 => "C&#46; Faivre-Finn"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2010.145938"
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                        "tituloSerie" => "Thorax"
                        "fecha" => "2010"
                        "volumen" => "65 Suppl&#46; 3"
                        "paginaInicial" => "iii1"
                        "paginaFinal" => "iii27"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20940263"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Use of PET and PET&#47;CT for radiation therapy planning&#58; IAEA expert report 2006-2007"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; MacManus"
                            1 => "U&#46; Nestle"
                            2 => "K&#46;E&#46; Rosenzweig"
                            3 => "I&#46; Carrio"
                            4 => "C&#46; Messa"
                            5 => "O&#46; Belohlavek"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.radonc.2008.11.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiother Oncol"
                        "fecha" => "2009"
                        "volumen" => "91"
                        "paginaInicial" => "85"
                        "paginaFinal" => "94"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19100641"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SEPAR guidelines for lung cancer staging"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Sanchez de Cos"
                            1 => "J&#46;H&#46; Hernandez"
                            2 => "M&#46;F&#46; Jimenez"
                            3 => "S&#46;P&#46; Sanchez"
                            4 => "A&#46;R&#46; Gratacos"
                            5 => "R&#46;R&#46; Porta"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arbres.2011.06.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2011"
                        "volumen" => "47"
                        "paginaInicial" => "454"
                        "paginaFinal" => "465"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21824707"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Transthoracic needle aspiration biopsy for the diagnosis of localised pulmonary lesions&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Y&#46; Lacasse"
                            1 => "E&#46; Wong"
                            2 => "G&#46;H&#46; Guyatt"
                            3 => "D&#46;J&#46; Cook"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "1999"
                        "volumen" => "54"
                        "paginaInicial" => "884"
                        "paginaFinal" => "893"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10491450"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "CT-guided percutaneous fine-needle aspiration biopsy of pulmonary nodules measuring 10<span class="elsevierStyleHsp" style=""></span>mm or less"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Y&#46;L&#46; Ng"
                            1 => "D&#46; Patsios"
                            2 => "H&#46; Roberts"
                            3 => "A&#46; Walsham"
                            4 => "N&#46;S&#46; Paul"
                            5 => "T&#46; Chung"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.crad.2007.09.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Radiol"
                        "fecha" => "2008"
                        "volumen" => "63"
                        "paginaInicial" => "272"
                        "paginaFinal" => "277"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18275867"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule&#58; an analysis of discharge records"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46;S&#46; Wiener"
                            1 => "L&#46;M&#46; Schwartz"
                            2 => "S&#46; Woloshin"
                            3 => "H&#46;G&#46; Welch"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7326/0003-4819-155-3-201108020-00003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2011"
                        "volumen" => "155"
                        "paginaInicial" => "137"
                        "paginaFinal" => "144"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21810706"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multivariate study of predictive factors for clearly defined lung lesions without visible endobronchial lesions in transbronchial biopsy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Botana-Rial"
                            1 => "M&#46; N&#250;&#241;ez-Delgado"
                            2 => "A&#46; Pallar&#233;s-Sanmart&#237;n"
                            3 => "V&#46; Leiro-Fern&#225;ndez"
                            4 => "M&#46; Torres-Dur&#225;n"
                            5 => "C&#46; Represas-Represas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00464-010-1080-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Surg Endosc"
                        "fecha" => "2010"
                        "volumen" => "24"
                        "paginaInicial" => "3031"
                        "paginaFinal" => "3036"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20499106"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Value of flexible bronchoscopy in the pre-operative work-up of solitary pulmonary nodules"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Schwarz"
                            1 => "N&#46; Schonfeld"
                            2 => "R&#46;C&#46; Bittner"
                            3 => "T&#46; Mairinger"
                            4 => "H&#46; Russmann"
                            5 => "T&#46;T&#46; Bauer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00018612"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2013"
                        "volumen" => "41"
                        "paginaInicial" => "177"
                        "paginaFinal" => "182"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22496316"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;S&#46; Wang Memoli"
                            1 => "P&#46;J&#46; Nietert"
                            2 => "G&#46;A&#46; Silvestri"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.11-1764"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2012"
                        "volumen" => "142"
                        "paginaInicial" => "385"
                        "paginaFinal" => "393"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21980059"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Falcoz PE&#44; Brunelli A&#44; Dahan M&#44; Decaluwe HM&#44; Raemdonck D&#44; Rocco G&#44; et al&#46; Database report silver book 2013&#46; European Society of Thoracic Surgeon&#46; 2013 accessed 03&#46;03&#46;14&#93;&#46; Available from&#58; <a id="intr0015" class="elsevierStyleInterRef" href="http://www.ests.org/_userfiles/pages/files/database%202013.pdf">http&#58;&#47;&#47;www&#46;ests&#46;org&#47;&#95;userfiles&#47;pages&#47;files&#47;database&#37;202013&#46;pdf</a>"
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The probability of malignancy in solitary pulmonary nodules&#46; Application to small radiologically indeterminate nodules"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;J&#46; Swensen"
                            1 => "M&#46;D&#46; Silverstein"
                            2 => "D&#46;M&#46; Ilstrup"
                            3 => "C&#46;D&#46; Schleck"
                            4 => "E&#46;S&#46; Edell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "1997"
                        "volumen" => "157"
                        "paginaInicial" => "849"
                        "paginaFinal" => "855"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9129544"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;K&#46; Gould"
                            1 => "L&#46; Ananth"
                            2 => "P&#46;G&#46; Barnett"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.06-1261"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2007"
                        "volumen" => "131"
                        "paginaInicial" => "383"
                        "paginaFinal" => "388"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17296637"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Determinaci&#243;n de un modelo predictivo de la probabilidad de malignidad en el n&#243;dulo pulmonar solitario y verificaci&#243;n de la bondad predictiva del modelo"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46;J&#46; &#193;lvarez-Mart&#237;nez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2000"
                        "editorial" => "Universidad Complutense"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A practical algorithmic approach to the diagnosis and management of solitary pulmonary nodules&#46; Part 2&#58; Pretest probability and algorithm"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "V&#46;K&#46; Patel"
                            1 => "S&#46;K&#46; Naik"
                            2 => "D&#46;P&#46; Naidich"
                            3 => "W&#46;D&#46; Travis"
                            4 => "J&#46;A&#46; Weingarten"
                            5 => "R&#46; Lazzaro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.12-1487"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2013"
                        "volumen" => "143"
                        "paginaInicial" => "840"
                        "paginaFinal" => "846"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23460161"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
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              "referencia" => array:1 [
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                            2 => "R&#46;P&#46; Golding"
                            3 => "P&#46;J&#46; Kostense"
                            4 => "E&#46;F&#46; Comans"
                            5 => "E&#46;F&#46; Smit"
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                        "volumen" => "128"
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                    0 => array:2 [
                      "titulo" => "I manage pulmonary nodular lesions and nodular infiltrates in patients with hematologic malignancies or undergoing hematopoietic cell transplantation"
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                        "volumen" => "120"
                        "paginaInicial" => "1791"
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                        "link" => array:1 [
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                    0 => array:2 [
                      "titulo" => "Validation of two models to estimate the probability of malignancy in patients with solitary pulmonary nodules"
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                            0 => "E&#46;M&#46; Schultz"
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                            3 => "E&#46;F&#46; Patz Jr&#46;"
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                            5 => "D&#46;K&#46; Owens"
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                        "volumen" => "63"
                        "paginaInicial" => "335"
                        "paginaFinal" => "341"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17965070"
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                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Differentiation between malignancy and inflammation in pulmonary ground-glass nodules&#58; the feasibility of integrated &#40;18&#41;F-FDG PET&#47;CT"
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                        0 => array:2 [
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                            1 => "H&#46;J&#46; Lee"
                            2 => "W&#46;J&#46; Kang"
                            3 => "K&#46;G&#46; Kim"
                            4 => "J&#46;M&#46; Goo"
                            5 => "C&#46;M&#46; Park"
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                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
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                        "volumen" => "65"
                        "paginaInicial" => "180"
                        "paginaFinal" => "186"
                        "link" => array:1 [
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2014.05.007

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Year/Month	Html	Pdf	Total

2024 November	6	3	9
2024 October	306	65	371
2024 September	316	47	363
2024 August	228	56	284
2024 July	172	37	209
2024 June	142	47	189
2024 May	213	53	266
2024 April	113	39	152
2024 March	149	44	193
2024 February	97	55	152
2024 January	1	0	1
2023 November	1	2	3
2023 September	1	1	2
2023 August	1	2	3
2023 March	61	10	71
2023 February	391	85	476
2023 January	329	89	418
2022 December	304	85	389
2022 November	373	89	462
2022 October	291	93	384
2022 September	306	92	398
2022 August	289	98	387
2022 July	383	108	491
2022 June	390	113	503
2022 May	350	149	499
2022 April	418	133	551
2022 March	481	120	601
2022 February	527	97	624
2022 January	613	114	727
2021 December	385	102	487
2021 November	448	111	559
2021 October	438	153	591
2021 September	365	123	488
2021 August	335	92	427
2021 July	358	106	464
2021 June	458	139	597
2021 May	357	96	453
2021 April	781	173	954
2021 March	555	140	695
2021 February	309	67	376
2021 January	351	83	434
2020 December	369	82	451
2020 November	443	85	528
2020 October	361	90	451
2020 September	428	120	548
2020 August	328	92	420
2020 July	287	97	384
2020 June	285	87	372
2020 May	246	72	318
2020 April	235	72	307
2020 March	267	62	329
2020 February	290	81	371
2020 January	293	72	365
2019 December	271	50	321
2019 November	189	54	243
2019 October	161	39	200
2019 September	227	47	274
2019 August	160	45	205
2019 July	128	42	170
2019 June	112	42	154
2019 May	180	47	227
2019 April	148	97	245
2019 March	138	50	188
2019 February	122	39	161
2019 January	103	52	155
2018 December	118	46	164
2018 November	238	48	286
2018 October	230	45	275
2018 September	182	32	214
2018 June	1	0	1
2018 May	162	3	165
2018 April	246	15	261
2018 March	208	18	226
2018 February	141	16	157
2018 January	204	13	217
2017 December	176	14	190
2017 November	182	10	192
2017 October	116	20	136
2017 September	150	40	190
2017 August	120	35	155
2017 July	116	40	156
2017 June	152	59	211
2017 May	152	33	185
2017 April	142	37	179
2017 March	147	55	202
2017 February	142	30	172
2017 January	141	21	162
2016 December	190	29	219
2016 November	279	18	297
2016 October	290	35	325
2016 September	354	50	404
2016 August	310	49	359
2016 July	173	49	222
2016 May	6	0	6
2016 March	2	0	2
2016 February	5	0	5
2015 December	2	0	2
2015 October	211	3	214
2015 September	160	45	205
2015 August	203	45	248
2015 July	238	52	290
2015 June	157	49	206
2015 May	162	69	231
2015 April	159	42	201
2015 March	185	30	215
2015 February	165	16	181
2015 January	84	14	98
2014 December	70	25	95
2014 November	59	23	82
2014 October	65	26	91
2014 September	1	0	1
2014 August	1	1	2
2014 July	1	1	2

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