Comparison of 10-year Survival Outcomes between CT Surveillance and Surgery for Ground-Glass Nodules

Background The debate over whether to manage pulmonary ground-glass nodules (GGNs) that increase in size during surveillance with continued follow-up or surgery poses challenges in clinical practice. Purpose To provide evidence-based insights into the long-term survival and appropriateness of surveillance for GGNs, particularly those that increase in size during follow-up. Materials and Methods In this prospective study, patients with GGNs detected at CT examinations between March 2005 and December 2013 were included at the National Cancer Center, China, and followed up until May 2024. The primary analysis compared overall survival (OS) between the surveillance and surgery groups among all individuals with GGNs, stable GGNs, and GGNs that increased in size. The secondary outcome was recurrence-free survival, confirmed with either pathologic findings or clinical-radiologic consensus. Cost and duration of surgery were also analyzed. Propensity score matching was used to balance baseline characteristics when comparing outcomes between groups. Multivariable Cox proportional hazard models were used to determine adjusted hazard ratios and 95% CIs. Results A total of 1003 GGNs in 684 individuals (median age, 56 years; IQR, 49-62 years; 434 female) were evaluated; among them, 40 individuals had dominant GGNs that developed solid components, whereas 644 individuals maintained their status as GGNs. Of these, 207 (32.1%) underwent surgery. There was no evidence of a difference observed in 10-year OS between surveillance and surgery groups (94.7% [95% CI: 92.2, 97.2] vs 97.6% [95% CI: 95.3, 100], respectively; <i>P</i> = .10). After multivariable adjustment, there was no evidence of an association between surgery and 10-year OS in those with GGNs (hazard ratio, 0.56 [95% CI: 0.18, 1.78]; <i>P</i> = .33), those with GGNs that increased in size (hazard ratio, 0.78 [95% CI: 0.15, 4.17]; <i>P</i> = .78), and those with stable GGNs (hazard ratio, 0.29 [95% CI: 0.03, 3.00]; <i>P</i> = .30). There was also no evidence of a difference observed in 7-year recurrence-free survival between 31 individuals with stable GGNs and 48 individuals with GGNs that increased in size (100% vs 100%, <i>P</i> > .99). There was no evidence that increased GGN size affected surgical cost ($8401.5 vs $8388.5, <i>P</i> = .79) or duration (2.0 vs 2.0 hours, <i>P</i> > .99). Conclusion For GGNs, there was no evidence of significant differences in long-term survival between surveillance and surgery or between stable and increased size during follow-up. Therefore, CT surveillance may be appropriate for GGNs until a solid component emerges. © RSNA, 2025 <i>Supplemental material is available for this article.</i> See also the editorial by Hammer in this issue.