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Sample, Sammy G
ST0001
PET Evaluation Form
1234567890
Study date
MM/DD/YYYY
Radiologist
Radiologist NPI
PET scan performed at outside institution
PET scan performed at outside institution
No
Yes
Date of baseline CT
Date of baseline CT
MM/DD/YYYY
Date of most recent comparative study
Date of most recent comparative study
MM/DD/YYYY
Are there any nodules noted in the CT scan?
Are there any nodules noted in the CT scan?
No
Yes
Are non-calcified nodules noted, all less than 6 mm?
Are non-calcified nodules noted, all less than 6 mm?
No
Yes
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
SUV
SUV
SUV
SUV
SUV
SUV
SUV
SUV
SUV
SUV
SUV
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
Spiculated
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
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
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
PET details - lung and nodules
PET details - lymph nodes
Other clinically significant ancillary finding?
Other clinically significant ancillary finding?
No
Yes
Organ/Location
-
Breast
Abdomen
Head
Neck
Describe
Organ/Location
-
Breast
Abdomen
Head
Neck
Describe
Comments
Any other findings
Follow-Up
Follow-up
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
VAT
Resection
When
MM/DD/YYYY
Now
1 month
3 months
6 months
1 year
Other
Impression
Nodules
No evidence of abnormal uptake. Follow-up as recommended above.
Uptake as described above. Follow-up as recommended above.
Nodule(s) unchanged, as described above. Follow-up as recommended above.
Other findings
No other abnormalities.
Other abnormalities and suggested follow-up as described above.
Diffuse abnormalities.
Impression remarks
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