Due to the increasing use of imaging and lung cancer screening programs, the rate of detected pulmonary nodules has steadily increased over the past decade. Overall, the diagnosis and management of pulmonary nodules remain challenging. Moreover, no specific guidelines exist for the management of pulmonary nodules in patients with a history of previous malignancy. This study reflects the current management in a real-world setting in a specialized European center. In this retrospective single-center study, patients with a pulmonary nodule <3 cm referred to the Division of Pulmonology or the Department of Thoracic Surgery at the Medical University of Vienna, Austria, from November 2022 to July 2024, were analyzed. A subgroup analysis of patients with a history of previous malignancy was performed and compared to patients without previous malignancies. In total, 356 patients (48.5% male, median age 67 years [IQR 61-74], 53.7% with a history of previous cancer) with a pulmonary nodule (mean size of 14.8 mm) were enrolled. Bronchoscopy, computed tomography (CT)-guided biopsy, or surgery was performed in 13.2%, 7.3%, and 65.2% of the cases, respectively. The overall malignancy rate was 70.5%. Pulmonary nodules in patients with a prior malignancy were significantly larger ( < 0.001), showed a progression in size ( < 0.001), and were found to be malignant more frequently when compared to patients without previous cancer ( = 0.032). As most patients referred to a specialized center represent a selected group of high-risk patients, the majority of pulmonary nodules were found to be malignant. In patients with a history of previous malignancy, tissue sampling is warranted as the rate of malignancy is high.