Example reporting template

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 nodules*]. 

COMPARISON: [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 | cavitation ]
			Calcification: [none* | benign pattern | indeterminate] {only if Composition = calcified}
		Location: {lung/lobe/segment}
		Image location: series # image #

		
Other lung findings: [ ]		
		

Airway: [Unremarkable.]

Pleura: [No pleural effusion, thickening or pneumothorax.]

Thoracic aorta and great vessels:  [<Normal in diameter.>]

Pulmonary arteries: [<Normal.>]

Heart and pericardium: [<Unremarkable.>]

Lymph nodes: [<No enlarged thoracic lymph nodes.>]

Thoracic spine: [Unremarkable, with normal thoracic vertebral body heights.]

Chest wall: [Unremarkable.]

Visualized upper abdomen: [Unremarkable.]


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