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Missing Image & CT Evaluation
Incomplete Form
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Enrollment
Sample, Sammy G
ST0001
CT Evaluation Form
1234567890
Scan
Nodules
Emphysema/Coronary Calcifications
Other Abnormalities
Impression & Follow Up
Scan information
CT study date
MM/DD/YYYY
Signing radiologist
—
Radiologist
Clinical information
Include in impression
CT scan performed at outside institution
Type of exam
Baseline
Annual repeat
Follow-up (not annual repeat)
Only select Baseline if there is no prior CT or there is a prior CT scan more than 3 years ago
CT protocol
Low-Dose CT
Standard CT
Limited CT
Reconstructed slice thickness (mm)
-
0.5
0.625
0.75
0.8
1.0
Other
Specify
CDTI (vol)
DLP
Size-specific dose estimates (SSDE)
Baseline CT
MM/DD/YYYY
0
months since baseline
Most recent comparative study
MM/DD/YYYY
Prior scans
Nodules
READ before completing the Nodule Grid
BASELINE: Include all nodules >= 6.0 mm in average diameter. Others are OPTIONAL.
ANNUAL REPEAT: include all NEW nodules >= 3.0 mm in average diameter.
For BASELINE CT, all nodules are new unless there is a CT more than 3 years earlier.
For BASELINE CT, the nodules will automatically be sorted with the largest non-calcified nodules with a solid component coming first.
Note: hilar masses and focal consolidation should be included in the nodule grid.
The same nodule ID will be used on all subsequent CT and other forms. NEW nodules, even if LARGER, must follow nodules already listed.
For nodules recommended for biopsy or antibiotics, list the reason in the comments field in the corresponding column.
If no nodules were detected, you may skip this section.
Add nodule
Add nodule
Nodule ID
Nodule 1
Nodule 2
Nodule 3
Nodule 4
Nodule 5
Nodule 6
Nodule 7
Nodule 8
Nodule 9
Nodule 10
Is it new?
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
Nodule seen in series
Nodule seen in images
-
-
-
-
-
-
-
-
-
-
Nodule status
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
-
Solid
Part-solid
Nonsolid
Other (see comment)
Length (mm)
Maximum width (mm)
Mean diameter (mm)
-
-
-
-
-
-
-
-
-
-
Height (mm)
Volume (mm
3
)
Calculate
Manually entered
Calculate
Manually entered
Calculate
Manually entered
Calculate
Manually entered
Calculate
Manually entered
Calculate
Manually entered
Calculate
Manually entered
Calculate
Manually entered
Calculate
Manually entered
Calculate
Manually entered
Solid comp. of part-solid
x
x
x
x
x
x
x
x
x
x
Solid mean diameter(mm)
-
-
-
-
-
-
-
-
-
-
Smooth edges
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Calcifications
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Index Nodule
Spiculated
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Distance from the costal pleura (mm)?
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Comment
Pathologic diagnosis
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
AIS
MIA
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
Add nodule
Additional non-calcified nodules
Additional calcified nodules
Emphysema/Coronary Calcifications
Emphysema
Not visible
None
Mild
Moderate
Severe
Coronary calcifications
None
Mild
Moderate
Severe
Coronary Artery Calcifications Score
Left main
-
None
Minimal < ⅓
Moderate
Extensive > ⅔
LAD
-
None
Minimal < ⅓
Moderate
Extensive > ⅔
Circumflex
-
None
Minimal < ⅓
Moderate
Extensive > ⅔
RCA
-
None
Minimal < ⅓
Moderate
Extensive > ⅔
Visual
CAC
score
Other Abnormalities
Pulmonary
RUL
RML
RLL
LUL
LLL
Cysts
Yes
Blebs/Bullae
Yes
Regional or diffuse consolidation
(focal - put in nodule grid)
Yes
Scarring
Yes
Apical
Unilateral
Bilateral
Bronchiectasis
Yes
Small airways disease
Yes
Post-surgical findings
(i.e. bronchial resection margin)
N/A
Normal
Abnormal
Not visible
Right
Left
Early and Late Findings of Interstitial Lung Disease
Traction bronchiectasis in a peripheral location
Yes
Peripheral ground-glass opacities
Yes
Reticulations
Yes
Honeycombing
Yes
Additional comments on pulmonary abnormalities
Include in impression
Pleural or pleural-related
Pleural thickening/plaques
Yes
Right
Left
Calcification
Rounded atelectasis
Yes
RUL
RML
RLL
LUL
LLL
Pleural effusion
Yes
Right
-
None
Small
Moderate
Large
Left
-
None
Small
Moderate
Large
Pleural tumor
Yes
Additional comments on pleural abnormalities
Include in impression
Cardiac and aortic
Aortic calcifications
-
None
Minimal < ⅓
Moderate
Extensive > ⅔
Pericardial effusion severity
-
None
Minimal
Moderate
Extensive
Pulmonary artery width (mm)
Ascending aorta width (mm)
Pulmonary artery/aorta ratio
(calculated)
Additional comments on cardiac abnormalities
Include in impression
Neck and mediastinal
Thyroid
Yes
Calcification
Cyst/nodule < 15 mm
Mass
Other
Thymus
(report if ovoid > 7 mm or if thymic shape with width > 1.3cm)
Yes
Calcification
Cyst
Mass
Other
Lymph Nodes
(w/o central fat)
Any enlarged or growing hilar or mediastinal lymph nodes
(short axis > 10mm)
(any size for para-esophageal)
Yes
Level
8
th
edition classification: CHEST 2017; 151: 193-203
N1: Low cervical, supraclavicular, and sternal notch nodes
N2R: Upper paratracheal (right)
N2L: Upper paratracheal (left)
N3A: Prevascular
N3P: Retrotracheal
N4R: Lower paratracheal (right)
N4L: Lower paratracheal (left)
N5: Subaortic
N6: Para-aortic (ascending aorta or phrenic)
N7: Subcarinal
N8: Paraesophageal (below carina)
N9: Pulmonary ligament
N10: Hilar
N11: Interlobar
N12: Lobar
N13: Segmental
N14: Subsegmental
Any calcified hilar or mediastinal lymph nodes
Yes
Abnormal axillary lymph nodes
Yes
Right
Left
Other Vascular Abnormalities
Yes
Aorta
Pulmonary arteries
Other
Esophageal
Yes
Air-fluid level
Wall thickening
Mass
Other
Hiatal Hernia
Yes
Other Mediastinal Masses
Yes
Calcification
Cyst
Mass
Other
Additional comments on neck and mediastinal abnormalities
Include in impression
Breast
Right Breast
Yes
Calcification
Cyst
Mass
Other
Right Breast Density Classification (BI-RADS)
-
1 - Almost entirely fatty
2 - Scattered areas of fibroglandular density
3 - Heterogeneously dense
4 - Extremely dense
Left Breast
Yes
Calcification
Cyst
Mass
Other
Left Breast Density Classification (BI-RADS)
-
1 - Almost entirely fatty
2 - Scattered areas of fibroglandular density
3 - Heterogeneously dense
4 - Extremely dense
Additional comments on breast abnormalities
Include in impression
Bone
Specify bone abnormalities
Include in impression
Abdominal
Gallbladder
Yes
Cholecystectomy
Stones
Sludge
Other
Spleen
Yes
Calcification
Cyst
Mass
Other
Liver
Yes
Calcification
Cyst
Mass
HU < 40
Other
Pancreas
Yes
Calcification
Cyst
Mass
Other
Adrenals
Yes
Calcification
Cyst
Mass
Other
Kidneys
Yes
Calcification
Cyst
Mass
Other
Additional comments on abdominal abnormalities
Include in impression
Impression
Annual repeat and follow-up CT scans should utilize the same low-dose protocol used for baseline low-dose CT scans.
Nodules
No evidence of nodules. Follow-up as recommended.
Nodule(s) as described. Consistent with old granulomatous disease. Follow-up as recommended.
Nodule(s) unchanged, as described. Follow-up as recommended.
Nodule(s) as described. Follow-up as recommended.
Other Findings
No other significant abnormalities.
Other abnormalities and suggested follow-up as described above.
Impression remarks
Follow Up
Follow up approach:
Lung-RADS
I-ELCAP
Options
select one or more
LDCT follow up:
Annual repeat
Now
1 month
3 months
6 months
Other
Approximate follow-up date:
MM/DD/YYYY
Other follow up:
Antibiotics
Contrast CT
PET
Percutaneous biopsy
Bronchoscpy
Pulmonary consultation
Refer to tumor board
No other further follow-up
Other
Specify
Lung-RADS
Category
Not applicable
0 (incomplete)
1 (negative)
2 (benign appearance or behavior)
3 (probably benign)
4A (suspicious)
4B (suspicious)
4X (suspicious)
Modifiers
S - clinically significant or potentially clinically significant findings (non lung cancer)
C - prior diagnosis of lung cancer who return to screening
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