APPLICABILITY OF INTERNATIONAL GUIDELINES FOR THE MANAGEMENT OF PULMONARY NODULES IN UKRAINIAN CLINICAL PRACTICE

Abstract

Introduction. The increasing detection of pulmonary nodules due to the widespread use of chest imaging has created new challenges for radiologists regarding risk stratification, follow-up, and clinical decision-making. Several international guidelines, including those of the Fleischner Society, the American College of Chest Physicians (ACCP), the British Thoracic Society (BTS), Lung-RADS, and the European Society for Medical Oncology (ESMO), provide evidence-based recommendations for pulmonary nodule management. However, their implementation in routine clinical practice may be influenced by regional epidemiological characteristics, available imaging technologies, and healthcare system organization. In regions with a relatively high prevalence of infectious pulmonary diseases, including tuberculosis, the application of international recommendations may require regional adaptation to help reduce unnecessary invasive procedures while maintaining diagnostic accuracy. Therefore, evaluating the applicability of these guidelines under real-world clinical conditions remains an important issue in thoracic radiology.

Aim. To assess the applicability of current international guidelines for pulmonary nodule management (Fleischner Society, ACCP, BTS, Lung-RADS, and ESMO recommendations) in routine clinical practice based on a Ukrainian single-center cohort and to evaluate the role of digital chest radiography and multislice computed tomography in supporting regional adaptation of these recommendations.

Materials and methods. A retrospective single-center study included 148 patients with pulmonary nodules and mass lesions who underwent digital chest radiography and multislice computed tomography (MSCT). All included lesions underwent histopathological verification by surgery or biopsy. Imaging findings were compared with the recommendations of the Fleischner Society (2017), ACCP (2013), BTS (2015), Lung-RADS (version 2022), and ESMO regarding risk stratification, follow-up intervals, and diagnostic management. Particular attention was paid to the diagnostic performance of digital chest radiography, MSCT densitometry, volumetric assessment, and the applicability of low-dose follow-up protocols in routine clinical practice.

Results. The Fleischner Society, BTS, ACCP, Lung-RADS, and ESMO recommendations provided an appropriate framework for risk stratification and follow-up in most patients; however, several limitations became evident in the Ukrainian clinical setting. Benign granulomatous lesions frequently demonstrated imaging characteristics similar to those of malignant pulmonary nodules, increasing the risk of false-positive classification when recommendations were applied without consideration of regional epidemiology. Digital chest radiography demonstrated an overall sensitivity of 77.7% for the retrospective detection of histopathologically verified pulmonary lesions but showed limited performance for nodules ≤6 mm and subsolid lesions (sensitivity, 8.3%), supporting the need for MSCT in high-risk patients. MSCT densitometry demonstrated high diagnostic performance in differentiating benign from malignant lesions, with an optimal arterial-phase enhancement threshold of 22.5 HU (AUC=0.89). Volumetric assessment and volume doubling time (VDT) provided greater diagnostic value than a single morphological assessment.

Conclusions. International guidelines for pulmonary nodule management provide a reliable framework for diagnostic decision-making; however, their implementation in routine clinical practice should take into account regional epidemiological characteristics and local healthcare resources. The combination of digital chest radiography, multislice computed tomography, quantitative image analysis, and individualized follow-up strategies may improve diagnostic accuracy while supporting radiation safety and reducing unnecessary invasive procedures. The proposed approach may facilitate the practical adaptation of international recommendations to the Ukrainian healthcare setting.