Difference between revisions of "Example reporting template"
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(Created page with '<pre> PROCEDURE: CT CHEST NON CONTRAST - NODULE PROTOCOL {Used for nodules less than 10 mm; generally fewer than 6 nodules; not diffuse nodules; or for sarcoma metastasis screen...') |
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<pre> | <pre> | ||
| − | PROCEDURE: CT CHEST NON CONTRAST - NODULE PROTOCOL | + | PROCEDURE: CT CHEST NON-CONTRAST - NODULE PROTOCOL |
| − | {Used for nodules less than 10 mm; generally fewer than 6 nodules; not diffuse nodules; or for sarcoma metastasis screening.} | + | {Used for nodules less than 10 mm; generally fewer than 6 nodules; |
| + | not diffuse nodules; or for sarcoma metastasis screening.} | ||
| − | CLINICAL INDICATION: [Follow up lung | + | CLINICAL INDICATION: [Follow up lung nodule(s)*]. |
| − | COMPARISON: [None*]. | + | COMPARISON: [<date> | None*]. |
TECHNIQUE: [Low-dose helical CT was acquired from lung apices to bases, and reconstructed at 2.5 mm every 1.25 mm, and 1.25 mm every 0.625 mm, without intravenous contrast.] (DFOV = [ ] cm) | TECHNIQUE: [Low-dose helical CT was acquired from lung apices to bases, and reconstructed at 2.5 mm every 1.25 mm, and 1.25 mm every 0.625 mm, without intravenous contrast.] (DFOV = [ ] cm) | ||
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Nodules: | Nodules: | ||
| − | + | Nodule: | |
| − | + | Size: [# x # cm] | |
| − | + | {if size > 3cm, it's a "mass" and needs staging info} | |
| − | + | Composition: [ solid | ground-glass | mixed | calcified | fatty | enhancing | cavitary ] | |
| − | + | Calcification: [none* | benign pattern | indeterminate] | |
| − | + | {only if Composition = calcified} | |
| − | + | Location: [ ] {lung/lobe/segment} | |
| − | + | Image location: series [#] image [#] | |
| + | |||
Other lung findings: [ ] | Other lung findings: [ ] | ||
| + | Airway: [Normal*] | ||
| − | + | Pleura: [No pleural effusion, thickening or pneumothorax] | |
| − | |||
| − | Pleura: [No pleural effusion, thickening or pneumothorax | ||
Thoracic aorta and great vessels: [<Normal in diameter.>] | Thoracic aorta and great vessels: [<Normal in diameter.>] | ||
| − | Pulmonary arteries: [ | + | Pulmonary arteries: [Normal*] |
| − | Heart and pericardium: [ | + | Heart and pericardium: [Normal*] |
| − | Lymph nodes: [ | + | Lymph nodes: [No enlarged thoracic lymph nodes*] |
| − | Thoracic spine: [ | + | Thoracic spine: [Normal*] |
| − | Chest wall: [ | + | Chest wall: [Normal*] |
| − | Visualized upper abdomen: [ | + | Visualized upper abdomen: [Normal*] |
| Line 50: | Line 51: | ||
Recommendations for Follow-up and Management of Indeterminate Lung Nodules Detected Incidentally on Nonscreening CT (Adapted from the Fleischner Society Statement on CT of Small Pulmonary Nodules (Radiology 2005;237:395-400) | Recommendations for Follow-up and Management of Indeterminate Lung Nodules Detected Incidentally on Nonscreening CT (Adapted from the Fleischner Society Statement on CT of Small Pulmonary Nodules (Radiology 2005;237:395-400) | ||
| − | Nodule Low-Risk Patient | + | Nodule Low-Risk Patient High-Risk Patient |
Size | Size | ||
| − | < 4 mm | + | < 4 mm no follow up needed follow up CT at 12 months |
| − | + | if unchanged, no follow up | |
4-8 mm follow up CT at 6, 12 and 24 months | 4-8 mm follow up CT at 6, 12 and 24 months | ||
if no change, further follow up | if no change, further follow up | ||
| − | > 8 mm | + | > 8 mm contrast enhanced CT, PET and/or biopsy, OR |
| − | + | watchful waiting: follow up CT at 3, 9 & 24 months | |
Notes: diameter = average width; high risk is defined as a history of smoking or other know risk factors for lung cancer; low risk is defined as minimal or absent history of smoking or other known risk factors; caveat: nodules with a ground glass component may require longer follow up to exclude indolent adenocarcinoma | Notes: diameter = average width; high risk is defined as a history of smoking or other know risk factors for lung cancer; low risk is defined as minimal or absent history of smoking or other known risk factors; caveat: nodules with a ground glass component may require longer follow up to exclude indolent adenocarcinoma | ||
</pre> | </pre> | ||
Revision as of 14:40, 11 June 2009
PROCEDURE: CT CHEST NON-CONTRAST - NODULE PROTOCOL
{Used for nodules less than 10 mm; generally fewer than 6 nodules;
not diffuse nodules; or for sarcoma metastasis screening.}
CLINICAL INDICATION: [Follow up lung nodule(s)*].
COMPARISON: [<date> | None*].
TECHNIQUE: [Low-dose helical CT was acquired from lung apices to bases, and reconstructed at 2.5 mm every 1.25 mm, and 1.25 mm every 0.625 mm, without intravenous contrast.] (DFOV = [ ] cm)
FINDINGS:
Nodules:
Nodule:
Size: [# x # cm]
{if size > 3cm, it's a "mass" and needs staging info}
Composition: [ solid | ground-glass | mixed | calcified | fatty | enhancing | cavitary ]
Calcification: [none* | benign pattern | indeterminate]
{only if Composition = calcified}
Location: [ ] {lung/lobe/segment}
Image location: series [#] image [#]
Other lung findings: [ ]
Airway: [Normal*]
Pleura: [No pleural effusion, thickening or pneumothorax]
Thoracic aorta and great vessels: [<Normal in diameter.>]
Pulmonary arteries: [Normal*]
Heart and pericardium: [Normal*]
Lymph nodes: [No enlarged thoracic lymph nodes*]
Thoracic spine: [Normal*]
Chest wall: [Normal*]
Visualized upper abdomen: [Normal*]
IMPRESSION:
1. [< >].
Recommendations for Follow-up and Management of Indeterminate Lung Nodules Detected Incidentally on Nonscreening CT (Adapted from the Fleischner Society Statement on CT of Small Pulmonary Nodules (Radiology 2005;237:395-400)
Nodule Low-Risk Patient High-Risk Patient
Size
< 4 mm no follow up needed follow up CT at 12 months
if unchanged, no follow up
4-8 mm follow up CT at 6, 12 and 24 months
if no change, further follow up
> 8 mm contrast enhanced CT, PET and/or biopsy, OR
watchful waiting: follow up CT at 3, 9 & 24 months
Notes: diameter = average width; high risk is defined as a history of smoking or other know risk factors for lung cancer; low risk is defined as minimal or absent history of smoking or other known risk factors; caveat: nodules with a ground glass component may require longer follow up to exclude indolent adenocarcinoma