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 nodules*].  
+
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:  
+
    Nodule:  
Size: [# x # cm] {if size > 3cm, it's a "mass" and needs staging info}
+
Size: [# x # cm]
Composition: [ solid | ground-glass | mixed | calcified | fatty | enhancing | cavitation ]
+
            {if size > 3cm, it's a "mass" and needs staging info}
Calcification: [none* | benign pattern | indeterminate] {only if Composition = calcified}
+
Composition: [ solid | ground-glass | mixed | calcified | fatty | enhancing | cavitary ]
Location: {lung/lobe/segment}
+
Calcification: [none* | benign pattern | indeterminate]  
Image location: series # image #
+
            {only if Composition = calcified}
 
+
Location: [ ]  {lung/lobe/segment}
+
Image location: series [#] image [#]
 +
 
Other lung findings: [ ]
 
Other lung findings: [ ]
 
 
 +
Airway: [Normal*]
  
Airway: [Unremarkable.]
+
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: [<Normal.>]
+
Pulmonary arteries: [Normal*]
  
Heart and pericardium: [<Unremarkable.>]
+
Heart and pericardium: [Normal*]
  
Lymph nodes: [<No enlarged thoracic lymph nodes.>]
+
Lymph nodes: [No enlarged thoracic lymph nodes*]
  
Thoracic spine: [Unremarkable, with normal thoracic vertebral body heights.]
+
Thoracic spine: [Normal*]
  
Chest wall: [Unremarkable.]
+
Chest wall: [Normal*]
  
Visualized upper abdomen: [Unremarkable.]
+
Visualized upper abdomen: [Normal*]
  
  
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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     High-Risk Patient
+
Nodule    Low-Risk Patient       High-Risk Patient
 
  Size
 
  Size
< 4 mm   no follow up needed     follow up CT at 12 months
+
< 4 mm     no follow up needed   follow up CT at 12 months
                                if unchanged, no follow up
+
                                  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   contrast enhanced CT, PET and/or biopsy, OR
+
> 8 mm     contrast enhanced CT, PET and/or biopsy, OR
        watchful waiting: follow up CT at 3, 9 & 24 months
+
          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