Lung Cancer Screening CT Report (Lung-RADS)

Exam: Low-Dose CT Chest for Lung Cancer Screening (Lung-RADS)

Patient: [name, MRN, DOB, sex]

Accession: [number]

Exam Date: [date/time]

Facility: [site]

Interpreting Radiologist: [name]

Ordering Clinician: [name]

Study Type: [Baseline / Annual / Short-interval follow-up / Completion exam]

Clinical Information

Indication: Lung cancer screening in asymptomatic high-risk patient. (If patient is symptomatic, state the symptoms and note that the exam may function as diagnostic rather than screening.)

Smoking History: [Current / Former / Never smoker; pack-years; years since quitting if former] (If not provided, document as "not provided" rather than leaving blank.)

Comparison: [Prior exam modality and date(s) / None available / Prior exams exist but not available for comparison]

Technique

Protocol: Non-contrast low-dose chest CT, screening protocol

Coverage: Lung apices through lung bases [include upper abdomen/adrenals if standard for program]

Reconstructions: [axial slice thickness; coronal/sagittal reformats; MIP if used]

Dose: CTDIvol [value] mGy; DLP [value] mGy·cm

Limitations: [motion artifact / incomplete inspiration / body habitus / metal artifact / None]

Findings

Pulmonary Nodules: [Nodules present / No pulmonary nodules detected]

(If present, characterize each category-relevant nodule using the format below. Record mean diameter in mm per Lung-RADS v2022. For part-solid nodules, also report mean diameter of solid component. Designate the category-determining lesion.)

• Lesion [ID]: [solid / part-solid / ground-glass / airway nodule / atypical cyst]; Location: [lobe, laterality]; Mean diameter: [mm]; Change since prior: [new / stable / increased / decreased / resolved]; Morphology: [margins, calcification, cavitation as relevant]; Reference: [series/image]
• (Repeat for each category-relevant nodule. Very small stable nodules not affecting categorization may be summarized collectively.)

Other Findings: [Clinically meaningful findings in airways, lung parenchyma, pleura, mediastinum/hila/lymph nodes, heart/great vessels, upper abdomen, and chest wall/musculoskeletal structures as applicable] (Include only abnormalities; omit normal structures.)

Impression

Lung-RADS: [Category 0 / 1 / 2 / 3 / 4A / 4B / 4X] based on [specific lesion reference]. Modifier: [S] (Include S modifier only if clinically significant incidental finding requires separate management; otherwise omit.)

Key Finding(s): [Brief summary of the finding(s) driving the category assignment]

Recommendation: [Single explicit management directive matching the assigned category; specify modality and timing in months] (Align with Lung-RADS v2022: screening LDCT at 12 months, short-interval LDCT at 3 or 6 months, diagnostic chest CT, PET/CT, tissue sampling, or specialty referral.)

Incidental Findings: [Each actionable incidental finding with specific management recommendation or referral] (Include only if S modifier applied; otherwise omit this field.)

Communication: [Direct communication for urgent or unexpected actionable findings: date/time, recipient, method] (Document per local policy if applicable; omit if not required.)

(Do not infer eligibility-related facts. If smoking history, symptoms, or prior imaging details are unavailable, state "not provided." Imaging-based inferences are acceptable when supported by CT findings with brief rationale.)