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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| + | The "Lung Nodule CT" report template below is shown as an example, and has not been finalized or approved. | ||
| + | |||
| + | The [[report template guidelines]] explain the "markup" notation that has been defined for this effort. | ||
| + | |||
| + | |||
<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 | + | TECHNIQUE: [Low-dose helical CT was acquired without intravenous contrast |
| + | from lung apices to bases, and reconstructed at 2.5 mm every 1.25 mm, | ||
| + | and 1.25 mm every 0.625 mm.] (DFOV = [ ] cm) | ||
FINDINGS: | FINDINGS: | ||
| Line 13: | Line 21: | ||
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] | |
| − | + | 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 | + | 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> | ||
Latest revision as of 22:29, 11 June 2009
The "Lung Nodule CT" report template below is shown as an example, and has not been finalized or approved.
The report template guidelines explain the "markup" notation that has been defined for this effort.
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 without intravenous contrast
from lung apices to bases, and reconstructed at 2.5 mm every 1.25 mm,
and 1.25 mm every 0.625 mm.] (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