Toggle navigation
Home
Case Review
Reports
Enrollment
Activity
Participant Follow-up
Missing Image & CT Evaluation
Incomplete Form
Inactive
Matching Report
Work List
Logout
Sample, Sammy G
ST0001
Intervention and Surgical Treatment Form
1234567890
Treatment
Nodules
Emphysema/Coronary Calcifications
Other Abnormalities
Follow-Up
Treatment
Clinical TNM status
(8th edition)
T status
-
T0
Tis
T1a mi
T1a SS
T1a
T1b
T1c
T2 Visc Pl
T2 Centr
T2a
T2b
T3
T3 Inv
T3 Satell
T4
T4 Inv
T4 Ipsi Nod
TX
N status
-
N0
N1
N2
N3
NX
M status
-
M0
M1a Pl Dissem
M1a Contr Nod
M1b Single
M1c Multi
MX
Not applicable (specify)
Specify
Clinical staging based on
only CT
only PET
both
other (specify)
Specify
Have you had a pulmonary function test?
No
Yes
FEV1 (L/s)
FVC (L)
FEV1/FVC
%
Diffusion capacity (mL/min/mm Hg)
Referring physician
Referring physician's phone
Referring physician's fax
Treating physician
Treating physician's phone
Treating physician's fax
Lesion site
-
LUL
LLL
RUL
RML
RLL
Endobronchial
Mediastinum
Pleura
Other (specify)
If multiple sites, select other and specify
Specify
Indication for treatment
-
First Lung Cancer
Recurrence
New Primary Lung Cancer
Other (specify)
Specify/Comments
Treatment option
-
Surgery
Radiation Therapy
Chemotherapy
Watchful Waiting
Other
Treatment
start
date
MM/DD/YYYY
Specify
Surgical Treatment Information
Was mediastinoscopy performed?
No
Yes
Add information to the
Lymph node status
grid below.
These should be in addition to any nodes resected during surgery, if performed.
Procedure date
MM/DD/YYYY
Specimen ID
Location of procedure
Physician
Physician's phone
Physician's fax
Resection
Was resection performed?
No
Yes
Refused
Aborted due to positive mediastinoscopy or other reasons
?
If no or refused, give date
MM/DD/YYYY
If no or refused, give reason
Location of procedure
Type of surgery
VAT
Thoracotomy
Robotic-assisted
Other
Other (specify)
Extent of surgery
-
Wedge resection
Segmentectomy
Lobectomy
Bilobectomy
Pneumonectomy
Other (specify)
Extent (specify)
Was there a conversion of VATS to open?
No
Yes
Comments
For all resections, please fill out the following questions on the resection margin.
Distance to the resection margin (mm):
Method of margin measurement:
Gross
Micro
Which margin?
Staple Line
Bronchial
Parenchymal
Vascular
Other
Margin comments
Margin measured with staples:
Removed
Intact
Unknown
If initial margin positive, was additional margin sent?
No
Yes
N/A
Additional specimens sent?
Specimen ID
Additional surgery for same lesion?
No
Yes
Date
MM/DD/YYYY
Comments
Discharge date
MM/DD/YYYY
Readmit within 30 days of discharge?
No
Yes
Discharge location?
Home
Other hospital
Extended Care / Transitional Care Unit / Rehab
Nursing home
Hospice
Other
Complications during surgery?
No
Yes
Comments
Complications during hospital stay?
No
Yes
Comments
Discharged with home O₂?
No
Yes
Discharged with chest tube?
No
Yes
Date of chest tube removal
MM/DD/YYYY
60-day vital status
Reviewed for QA?
No
Yes
Specify
Pathology tumor size (mm)
Length
Width
Height
Not applicable (specify)
Specify
Invasion of other structures
No
Yes
Location
Major vascular
Pleura
Angiolymphatic
Other (specify)
Specify
T Staging
T2 Visc Pl:
Visceral Pleura
T2 Cen:
Main bronchus (not carina)
Atelectasis to hilum
T3 Inv:
Chest wall
Pericardium
Phrenic nerve
T4 Inv:
Mediastinum
Diaphragm
Heart
Great vessels
Recurrent laryngeal nerve
Carina
Trachea
Esophagus
Spine
Adenocarcinoma Histology (Predominant)
—
Adenocarcinoma NOS
Adenocarcinoma in situ, nonmucinous
Adenocarcinoma in situ, mucinous
Adenocarcinoma in situ, indeterminate mucinous/nonmucinous
Minimally invasive adenocarcinoma, nonmucinous
Minimally invasive adenocarcinoma, mucinous
Minimally invasive adenocarcinoma, Mixed nonmucinous and mucinous
Minimally invasive adenocarcinoma, indeterminate mucinous/nonmucinous
Invasive adenocarcinoma, Lepidic predominant adenocarcinoma
Invasive adenocarcinoma, Acinar predominant adenocarcinoma
Invasive adenocarcinoma, Papillary predominant adenocarcinoma
Invasive adenocarcinoma, Micropapillary predominant adenocarcinoma
Invasive adenocarcinoma, Solid predominant adenocarcinoma
Invasive adenocarcinoma, multiple predominant patterns
Invasive adenocarcinoma, Predominant subtype cannot be determined
Invasive mucinous adenocarcinoma
Mixed invasive mucinous and nonmucinous adenocarcinoma
Fetal adenocarcinoma
Enteric adenocarcinoma
Colloid adenocarcinoma
Signet ring features
Clear cell features
NSLC, favor adenocarcinoma
Predominant features
solid
acinar
papillary
micropapillary
Lepidic /bronchioloalveolar
other (specify)
Percentages
Secondary / Other features
solid
acinar
papillary
micropapillary
Lepidic /bronchioloalveolar
other (specify)
Percentages
Lymph nodes status (N)
AJCC Levels
Node
N1
N2R
N2L
N3
N4R
N4L
N5
N6
N7
N8
N9
Resected
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Number
resected
N1 Number resected
N2R Number resected
N2L Number resected
N3 Number resected
N4R Number resected
N4L Number resected
N5 Number resected
N6 Number resected
N7 Number resected
N8 Number resected
N9 Number resected
Number
positive
N1 number positive
N2R number positive
N2L number positive
N3 number positive
N4R number positive
N4L number positive
N5 number positive
N6 number positive
N7 number positive
N8 number positive
N9 number positive
Node
N10R
N10L
N11R
N11L
N12R
N12L
N13R
N13L
N14R
N14L
Peribronchial
lymph nodes
Location
unspecified
Resected
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Number
resected
N10R number positive
N10L number positive
N11R number positive
N11L number positive
N12R number positive
N12L number positive
N13R number positive
N13L number positive
N14R number positive
N14L number positive
Peribronchial lymph nodes
Location unspecified
Number
positive
N10R number positive
N10L number positive
N11R number positive
N11L number positive
N12R number positive
N12L number positive
N13R number positive
N13L number positive
N14R number positive
N14L number positive
Peribronchial lymph nodes
Location unspecified
Specify location
Additional lesions
No
Yes
Number
Lesion
Location
Length
(mm)
Width
(mm)
Height
(mm)
Pathologic diagnosis
Specify
Seen on CT
1
-
LUL
LLL
RUL
RML
RLL
Length
Width
Height
Pathological diagnosis
-
AAH
Atyp bronch prolif
BAC
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Multifocal (specify)
Other (specify)
Seen on CT
No
Yes
?
2
-
LUL
LLL
RUL
RML
RLL
Length
Width
Height
Pathological diagnosis
-
AAH
Atyp bronch prolif
BAC
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Multifocal (specify)
Other (specify)
Seen on CT
No
Yes
?
3
-
LUL
LLL
RUL
RML
RLL
Length
Width
Height
Pathological diagnosis
-
AAH
Atyp bronch prolif
BAC
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Multifocal (specify)
Other (specify)
Seen on CT
No
Yes
?
4
-
LUL
LLL
RUL
RML
RLL
Length
Width
Height
Pathological diagnosis
-
AAH
Atyp bronch prolif
BAC
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Multifocal (specify)
Other (specify)
Seen on CT
No
Yes
?
T3 Satell
Yes
T4 Ipsi Nod
Yes
Evidence of metastasis
No
Yes
Specify
M staging (8th edition)
-
M0
M1a Pl Dissem
M1a Contr Nod
M1b Single
M1c Multi
MX
Post-surgical TNM status (8th Edition)
-
T0
Tis
T1a mi
T1a SS
T1a
T1b
T1c
T2 Visc Pl
T2 Centr
T2a
T2b
T3
T3 Inv
T3 Satell
T4
T4 Inv
T4 Ipsi Nod
TX
N Status
-
N0
N1
N2
N3
NX
M Status
-
M0
M1a Pl Dissem
M1a Contr Nod
M1b Single
M1c Multi
MX
not applicable
Specify
Other findings / comments
Radiation Treatment Information
Radiation oncologist name
First date of treatment
MM/DD/YYYY
Last date of treatment
MM/DD/YYYY
Total dose of radiation
cGy
Dose per fraction of radiation
cGy
Number of fractions
Frequency of radiation
daily
every other day
weekly
other
Specify
Lesion site
-
LUL
LLL
RUL
RML
RLL
Endobronchial
Mediastinum
Pleura
Other (specify)
Specify
Size of gross tumor volume
cc
Size of internal target volume
cc
Size of planning target volume
cc
Radiation dose delivery
3D-CRT
IMRT
VMAT
conformal arc
cyberknife
tomotherapy
protons based
other (specify)
Specify
Tumor motion control
none
4D-simulation and ITV
gated radiation
breath hold
other (specify)
Specify
SBRT
No
Yes
Patient positioning
alphacradle
stereotactic body frame
other (specify)
Specify
Treatment verification
kv images
cone beam CT
other (specify)
Specify
V20 of ipsilateral lung (percentage)
V20 of total lung (percentage)
V30 of chest wall (cc)
Maximum Esophageal Dose
Maximum Distal Bronchus Dose
Maximum Mainstem Bronchus Dose
D95 of PTV (in Gray)
Brachial plexus max [32 Gy]
Heart/pericardium receiving 32Gy [15cc]
Max skin dose < 32Gy
Ration of Rx isodose vol to PTV < 1.5
V100 %
Dmax %
D2cm max%
V30 to rib
Highest dose to rib
Was the entire dose delivered to the participant?
No
Yes
Specify
Were there any unplanned interruptions or incomplete fractions?
No
Yes
Specify
Side effects
none
minimal
marked
Comments
Check all that apply
Fatigue
Tightness in chest
Chest wall pain
Cough
Shortness of breath
Dyspnea
Decreased appetite/weight loss
Nausea/vomiting
Diarrhea
Other
Specify
Chemotherapy Treatment Information
Treating physician name
First date of treatment
MM/DD/YYYY
Last date of treatment
MM/DD/YYYY
Frequency of chemotherapy
daily
every other day
weekly
other
Specify
Lesion Site
-
LUL
LLL
RUL
RML
RLL
Endobronchial
Mediastinum
Pleura
Other (specify)
Specify
Describe treatment
Subsequent treatments
Drugs used
Number of rounds
Was the entire dose delivered to the participant?
No
Yes
Specify
Were there complications associated with treatment?
No
Yes
Specify
Side effects
none
minimal
marked
Comments
Check all that apply
Fatigue
Tightness in chest
Chest wall pain
Cough
Shortness of breath
Dyspnea
Decreased appetite/weight loss
Nausea/vomiting
Diarrhea
Other
Specify
Nodules
Baseline CT
MM/DD/YYYY
Most recent CT
MM/DD/YYYY
Total number of non-calcified nodules
(parenchymal and endobronchial)
Update the Nodule Status, Action, and Pathologic Diagnosis for each of the nodules affected by this procedure.
Enter any pathologic details given in the surgical pathology report in the Surgical Pathology Details field.
Update the Follow-up section.
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?
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
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
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
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
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
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
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
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
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
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
Endobronchial?
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Endobronchial?
-
No
Trachea
Rt. Main
Lt. Main
BI
RUL
RML
RLL
LUL
LLL
Most likely location?
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Most likely location?
-
Endobr
LUL
LLL
RUL
RML
RLL
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in series
Nodule seen in images
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule seen in image (Low)
-
Nodule seen in image (High)
Nodule status
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
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
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
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
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
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
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
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
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
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
Nodule consistency
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Nodule consistency
-
Solid
Part-solid
Nonsolid
Other (see comment)
Length (mm)
length (mm)
length (mm)
length (mm)
length (mm)
length (mm)
length (mm)
length (mm)
length (mm)
length (mm)
length (mm)
Maximum width (mm)
Maximum width
Maximum width
Maximum width
Maximum width
Maximum width
Maximum width
Maximum width
Maximum width
Maximum width
Maximum width
Mean diameter (mm)
-
-
-
-
-
-
-
-
-
-
Height (mm)
Height
Height
Height
Height
Height
Height
Height
Height
Height
Height
Volume (mm
3
)
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Volume
Calculate
Manually entered
Solid comp. of part-solid
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
Solid comp. length
x
Solid comp. width
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
Index nodule
Index nodule
Index nodule
Index nodule
Index nodule
Index nodule
Index nodule
Index nodule
Index nodule
Index nodule
Spiculated
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Distance from the costal pleura (mm)?
Distance
Distance
Distance
Distance
Distance
Distance
Distance
Distance
Distance
Distance
Action
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Action
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
Resection
Comment
Comment
Comment
Comment
Comment
Comment
Comment
Comment
Comment
Comment
Comment
Pathologic diagnosis
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
Add nodule
Small non-calcified nodules are present
Small calcified nodules are present
Surgical pathology details
Emphysema/Coronary Calcifications
Emphysema
Not visible
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
Pulmonary artery width (mm)
Ascending aorta width (mm)
Pulmonary artery/aorta ratio
(calculated)
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
RUL
RML
RLL
LUL
LLL
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 aorta
Aortic calcifications
-
None
Minimal < ⅓
Moderate
Extensive > ⅔
Pericardial effusion severity
-
None
Minimal
Moderate
Extensive
Additional comments on cardiac abnormalities
Include in impression
Neck and mediastinal
Thyroid
Yes
Calcification
Cyst/nodule < 15 mm
Mass
Other
Specify
Thymus
(report if ovoid > 7 mm or if thymic shape with width > 1.3cm)
Yes
Calcification
Cyst
Mass
Other
Specify
Lymph Nodes
(w/o central fat)
Any enlarged or growing hilar or mediastinal lymph nodes
(short axis > 10mm)
(any size for para-esophageal)
View lymph node chart
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
Specify
Other Vascular Abnormalities
Yes
Aorta
Pulmonary arteries
Other
Specify
Esophageal
Yes
Air-fluid level
Wall thickening
Mass
Other
Specify
Hiatal Hernia
Yes
Specify
Other Mediastinal Masses
Yes
Calcification
Cyst
Mass
Other
Specify
Additional comments on neck and mediastinal abnormalities
Include in impression
Breast
Right Breast
Yes
Calcification
Cyst
Mass
Other
Specify
Right Breast Density Classification (BI-RADS)
Right Breast Density Classification
-
1 - Almost entirely fatty
2 - Scattered areas of fibroglandular density
3 - Heterogeneously dense
4 - Extremely dense
Left Breast
Yes
Calcification
Cyst
Mass
Other
Specify
Left Breast Density Classification (BI-RADS)
Left Breast Density Classification
-
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
Specify
Spleen
Yes
Calcification
Cyst
Mass
Other
Specify
Liver
Yes
Calcification
Cyst
Mass
HU < 40
Other
Specify
Pancreas
Yes
Calcification
Cyst
Mass
Other
Specify
Adrenals
Yes
Calcification
Cyst
Mass
Other
Specify
Kidneys
Yes
Calcification
Cyst
Mass
Other
Specify
Additional comments on abdominal abnormalities
Include in impression
Follow-Up
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
Bronchoscopy
Pulmonary consultation
Refer to tumor board
No other further follow-up
Other
Specify
Save for Later
Submit
Delete
×
Warning
Are you certain you want to delete this form?