Oncology PET/CT Interpretation Report

Patient: [name; MRN; DOB; sex]

Exam: [exam name with tracer; anatomic coverage]

Date/Time: [exam date and time]

Referring Clinician: [name; service]

Interpreting Physician: [name; credentials]

Clinical Information

[Indication and clinical question] (State the operational intent: [initial staging / restaging / response assessment / clarification of indeterminate finding]. Specify the clinical question to be answered.) [Known or suspected malignancy] (Name primary cancer, site, and histology when available.) [Staging and therapy context] (Include relevant stage if provided; summarize pertinent therapy details such as surgery, radiation, or systemic therapy with dates; specify time since last treatment only if explicitly stated.) (If clinical history is limited, state what was provided and note that no additional details were available.)

Comparison

• [Prior PET/CT studies with dates] (List in reverse chronological order; note if images vs report-only available.)
• [Other relevant imaging with dates] (CT, MRI, or other modalities if clinically pertinent.)
• [Primary comparator study] (Identify which prior is used for response comparisons when multiple priors exist.)

Technique

Tracer/Dose: [tracer name; administered activity; uptake time in minutes]

Patient Parameters: [weight; blood glucose at injection]

Coverage/Position: [anatomic coverage; patient position; arms position]

CT Component: [low-dose attenuation correction / diagnostic-quality CT]; [IV contrast use]; [oral contrast use]

SUV Method: [SUVmax / SULpeak]; [normalization method]

(If critical parameters affecting SUV comparability are unknown—dose, uptake time, blood glucose, or weight—state which are missing and note that this limits quantitative comparison.)

Findings

[Study quality and limitations] (Describe artifacts or limitations affecting interpretation: motion, misregistration, infiltration, hyperglycemia, brown fat activation, limited coverage.)

Primary tumor or tumor bed:

• [Location and CT correlate]
• [Metabolic activity with SUV when appropriate]
• [Local invasion or treatment effect features]
• [Interval change vs primary comparator]

Regional nodal disease:

• [Nodal station/region]: [size]; [uptake characterization]; [interval change]
• (Add additional nodal regions as applicable.)

Distant metastatic disease:

• Lungs/Pleura: [lesion locations, sizes, uptake, interval change]
• Liver: [lesion locations, sizes, uptake, interval change]
• Adrenals/Spleen/Peritoneum: [findings]
• Bone/Marrow: [sites, pattern, uptake, interval change]
• Brain: [findings if covered] (Note limitations from high physiologic uptake.)
• Other sites: [site-specific findings]

Target lesions for response: (If applicable. Maintain stable lesion IDs across serial exams. Explicitly state if the hottest lesion changes between scans.)

• [Lesion ID]: [site]; [CT size]; [PET metric and value]; [comparator value and % change]; [response descriptor]
• (Add or retire targets per accepted criteria; document rationale.)

Clinically significant non-oncologic CT findings:

• [Finding with significance and recommendation if needed] (Do not bury actionable items in Impression only.)

Impression

• Overall conclusion: [one-line summary prioritizing management impact—metabolically active malignancy present/absent, suspicion for progression, or overall response category]
• Response assessment: [framework: PERCIST / Deauville-Lugano / none]; [category: complete metabolic response / partial metabolic response / stable metabolic disease / progressive metabolic disease] (For lymphoma, state Deauville score with corresponding category. Qualify if technique differences limit SUV comparability. For immunotherapy, distinguish unconfirmed vs confirmed progression when appropriate.)
• Staging: [TNM or Ann Arbor/Lugano stage if determinable] (State uncertainty if required determinants are absent.)
• Key disease sites: [primary tumor status; regional nodes; dominant metastatic sites; new lesions]
• Recommendations: [biopsy correlation, targeted imaging, follow-up interval] (Only when clinically useful.)
• Critical results communication: [who notified; when; method] (If applicable.)

(Label indeterminate lesions as indeterminate with management-oriented guidance. Do not assign a response category without an appropriate comparator and context. Do not declare complete response if coverage is incomplete or suspicious new lesions are unevaluated.)