Example reporting template

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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