Difference between revisions of "Example reporting template"
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| Line 8: | Line 8: | ||
COMPARISON: [<date> | 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 17: | Line 19: | ||
Size: [# x # cm] | Size: [# x # cm] | ||
{if size > 3cm, it's a "mass" and needs staging info} | {if size > 3cm, it's a "mass" and needs staging info} | ||
| − | Composition: [ solid | ground-glass | mixed | calcified | fatty | enhancing | cavitary ] | + | Composition: [ solid | ground-glass | mixed | calcified |
| + | | fatty | enhancing | cavitary ] | ||
Calcification: [none* | benign pattern | indeterminate] | Calcification: [none* | benign pattern | indeterminate] | ||
{only if Composition = calcified} | {only if Composition = calcified} | ||
| Line 52: | Line 55: | ||
Detected Incidentally on Nonscreening CT | Detected Incidentally on Nonscreening CT | ||
| − | Adapted from the Fleischner Society Statement on CT of Small Pulmonary Nodules (Radiology 2005;237:395-400) | + | 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 | ||
Revision as of 15:17, 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 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