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Let's talk about reporting considerations

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for your lung cancer screening CT exams.

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We're gonna talk about structured reports from the

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radiologist's perspective, things that you can do

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to ensure high quality reports with the right information

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that's easily translatable to our referring physicians,

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nurse coordinators and navigators as well as the patients.

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We're gonna talk about the advantages of patient

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specific letters in lay language

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that is more translatable at the patient level

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that can be performed in addition

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to doing your structured reporting as well as the importance

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of patient tracking tools, which use the information

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that you create in your structured reports to help uh,

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manage the downstream testing and follow the patients.

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In the work I'm doing with the American Cancer Society's

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National Lung Cancer Roundtable,

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we're putting together a toolkit to help practices implement

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and improve their early detection programs,

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including lung cancer screening at incent pulmonary nodules.

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And one of the elements that we put together has to do

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with the radiology report, having the right information,

1:06

inconsistent structure in good format in a way

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that is translatable

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and usable to those who consume our product, which they see

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as the radiology report.

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We of course know there's so much behind the report,

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including the quality

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of the exams we performed in all the work, the radiologists,

1:22

the radiology technologists

1:24

and our medical physicists do to make that happen.

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But it comes down in terms of translating what we're seeing

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to our radiology report.

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Whether you're using a structured template in a reporting

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system, free text

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or a hybrid for generating radiology report,

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there are some standard elements that are important

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to include in a lung cancer screening CT report.

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Of course, we always want to make sure

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that the exam has the correct header or name

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and is clearly indicated to be a lung cancer screening CT

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with the date that it was acquired.

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And this makes it easy to recognize this

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as a lung cancer screening CT as opposed to another type

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of chest CT a patient might have had such

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as a pulmonary embolism CT or a HR CT of the chest.

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And it also is important to make the date very clear so

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that people can compare

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how long ago it was from the last screen.

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In terms of tracking patients into the future.

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By having elements in a structured template,

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you can then put these into

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and extract them into tracking tools

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that can help manage your lung cancer screening patients.

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So making sure they're coming back for annual exams

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and short-term followup exams.

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So structure can help you if you're in a system

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where you can integrate

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that information into patient tracking.

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The reason for the exam lung cancer screening should be

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specifically stated as lung cancer screening.

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Uh, we often see people putting in other patient

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diagnoses into the reason for exam

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and that can create challenges with insurance coverage

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and reimbursement with patients

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and your staff often having to go back

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and forth many times to clarify.

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This is indeed a CT done specifically

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for lung cancer screening.

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Not done because the patient also has COPD

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or also has heart disease

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or also has a remote history

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of another cancer like a melanoma that's under surveillance

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but is irrelevant to the fact

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that this patient is here today

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for a lung cancer screening exam.

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So I like to say keep it simple lung cancer screening

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and don't add in all the other patient medical issues

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that might be on their problem list.

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This makes it very clear

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for insurance companies if they're making you jump

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through preauthorization, but importantly for reimbursement

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after your report is completed, it's important to give uh,

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information on whether there is a comparison exam

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and how far back you're going to look at the exam.

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We wanna know this to determine

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how long nodules have been stable over time.

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And so it's important for you as the radiologist not only

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to look at the last CT

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but look at other cts, the oldest cts if possible,

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to determine how long a nodule has been there and stable.

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The longer a nodule has been stable, the more likely it is

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to be benign and don't just look for chest cts.

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Sometimes our systems are automatically set up

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to pull the comparison chest cts to the top

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of your comparison list or the top of your reporting system.

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But sometimes that might miss other important exams like an

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abdomen CT or a neck CT or a shoulder ct.

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Other CT exams that might include part

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of the lungs can be a very important comparison.

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So I always say don't just look at the comparison chest cts,

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but there may be other exams,

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particularly if you don't have a comparison chest ct.

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That can be very important in looking at nodule stability.

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And stability is our most important criteria

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for benign nodules or benign behaving nodules.

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So we always put at the top of our report,

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so we've got exam name

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and date, specify lung screening, CT with date, reason

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for exam, keep it simple lung cancer screening

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and comparison chest cts

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and other cts that might include a portion of the lung.

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Make it very clear

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how far back you're able to go with comparison.

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The third section really getting to the meat

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of reporting is the findings

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and the following element should be reported

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for each nodule in long rads.

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We recommend reporting up to the sixth largest

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or most suspicious nodules by their morphology or growth.

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And so we recommend having a section in your report

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that is specifically for lung where you put these findings.

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It's important to report the nodule size.

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Uh, we usually do that in mean diameter in millimeters

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as recommended by lung rats orally.

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You can also report lung volume if you're using

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volumetric software.

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There's really no evidence that reporting

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by volume versus reporting a managed

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by millimeters changes patient outcome.

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We know the volume can give us a more precise measurement,

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but there's no evidence that that increase in precision

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of nodule size measurement actually changes patient outcomes

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long term in lung cancer screening.

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And so there are some countries

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where volume measurement is very common, such as in the uh,

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region where the Dutch Belgian Nelson trial was performed.

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But I would say in most of the world we're using millimeters

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and mean diameter.

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Following size is consistency.

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Where is it on the solid part, solid nonsolid continuum

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or is it cystic?

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What lobe is it in?

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You can spell it out in full like right upper lobe

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or just use abbreviations.

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Image number and series number on which the nodule is found

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are gonna be very helpful to you.

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Perhaps a little extra time

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to document when you're reading the exam today,

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but they'll be very happy

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that you have it when next year's annual screening exam

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comes around and you're trying to find those nodules

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and compare them side by side.

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And then comparison CT if you have comparisons,

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comment if the nodule is unchanged, if it's increased

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or decreased and give the prior size.

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That way we know the directionality of the growth pattern.

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If there are any unique features

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that might be helpful in reading future exams,

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you might wanna include that again to help you

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and your, your fellow radiology practitioners

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and physicians in your department and your program.

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Being able to find the nodules if they wanna look at it

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and do those comparisons.

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Some of those unique features might be whether it's

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central or peripheral.

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The ones that are out along the lung edge are pretty easy

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to see because there's not a lot of blood vessels out there.

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But the further you get to the center of the lung,

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the closer they get to vessels and vessels in cross-section.

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And so sometimes your left scratch in your head,

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which little.is it that my colleagues saw last time?

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And if you put the series

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and image number, it can be helpful.

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I also help it find useful when reading the exams

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to put a small arrow pointing to these small nodules so

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that next time around it's very easy

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and quick for uh, myself

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or my radiology colleagues in our group

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to quickly get to those nodules.

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So we've got size, consistency, lobe

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series and image number

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and then growth for comparison,

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increase, decrease or unchanged.

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And lastly, those unique features which can help you find

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noles a few comments.

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I really recommend putting one nodule on

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each row of the report.

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That way you don't have a free text paragraph that kind of

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mixes one nodule with a comma

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to the next nodule to the next nodule.

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So clarity, easy to see the information in the report.

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So recommend one nodule per row.

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With this information, I'll show you some examples.

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If you have specifically benign nodules,

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it's probably a good idea to call them out

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so they're not confusing to others particularly uh,

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non radiologists who might be looking at the report

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and looking at the images.

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We know there are parts of the country

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that have endemic fungal infections.

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So histoplasmosis in our Midwestern histoplasmosis belt in

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the south, we have coccidia, mycosis, and cryptococcus.

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So where you have endemic fungus, you're gonna see more

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of these benign nodules and important to call them out.

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Specifically there are specific benign features

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of lesions like hematomas with fat or fat and calcium.

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Again, calling them out and reporting them important

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but not on your list of the noncalcified nodules

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that you're going to follow over time.

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And then lastly, if you have issues with exam quality

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that impact interpretation, just be honest and mention them.

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Did the patient take a great breath in

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and out during the examination causing respiratory motion

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artifact that maybe wasn't caught

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by the imaging technologist at the time and repeated?

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So if there are exam quality issues, put it in your report.

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If it requires a callback, bring the patient back to repeat

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that portion of the exam.

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So let's look at a couple examples of

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how this might look in your radiology reports.

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Up top is an example for what might be a first time exam.

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And on the bottom is if you have a comparison exam note

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we've covered the series number.

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There are the following noncalcified novel as described

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below on series two and it applies to all the list below.

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We have each nodule by load, its density solid

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or ground glass and its image number.

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So for each of the nodules we're providing the same detail.

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And then I mentioned extra features like per fist

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or juxta, plural.

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These are nodules which are defined

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as benign intra pulmonary lymph nodes.

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And so adding these extra features can be helpful in both

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conveying the significance of the nodules

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as well as locating them.

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And then if you have a comparison exam,

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say if it's changed or not.

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So for this first nodule solid 11 millimeters, the next time

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around it was previously seven millimeters.

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On that first report we looked at above the left lower lobe,

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ground glass, eight millimeter nodule unchanged,

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and the right middle lobe peri fist nodule.

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You could say it's unchanged or not,

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but either way it's a benign pulmonary lymph node.

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So these are examples of

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what your reports can look like consistent and clear.

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Easy to find the information for you today

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and easy to find it for you in the future.

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When reporting examinations, sometimes you can use

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external reporting tools or knowle detection

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and management tools to help do this for you.

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And we'll talk about that a little bit.

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So if you're using some tool like PowerScribe

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to do your reporting, you can create structured fields

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to put that information with pick lists.

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So here's an example that I built in our PowerScribe

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reporting software where if you're not using any automatic

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importing from a software tool that's detecting

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and measuring your nodules for you, you have discrete fields

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for each one diameter type in

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or speech the nodule a size pick

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for the low, but just a pick list.

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Just click on the one and then pick.

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And similarly a pick list for density

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and enter the image number.

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And you can do this for each of the up

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to six total nodules that you have.

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And then similarly, you can create standard

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fields for your impression.

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I highly recommend this instead of allowing the kind

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of variability amongst different radiologists is about

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how they want to report their lung reds

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or what kind of sentence structure they use.

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Again, it makes it very easy for the referring physicians

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to always have the same structure.

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And if you're doing uh, quality control

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and quality improvement

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and looking at your data makes the information easy to find

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as well as to extract it if you're using any tools

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to extract information outta your radiology reports.

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So in our radiology impression it looks something like this

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lung ran category.

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It's a pick list where you pick your lung ran

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category zero one up to four x.

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You'll note each of them has a version with

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and without the S modifier.

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That is a specific category in lung rats

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to add the S modifier.

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And that will feed into the next uh, impression finding,

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which is about those S modifiers for significant

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or potentially significant findings.

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And we simply have a pick list for those as well.

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We can click none if there are none.

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It makes it very clear that there aren't any.

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But then we can also have our pick list for other findings

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that may be significant.

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So you can see here we have in our pick list moderate

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coronary calcification, severe calcification, moderate

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or severe emphysema, osteoporosis, uh,

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mild fibrotic interstitial lung disease, important to detect

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as it can progress over time.

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Respiratory bronchitis.

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A common finding in individuals who smoke cigarettes

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with inflammation around their small airways.

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Usually upper low predominant

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as some fuzzy central lobular nodules or a dilated aorta.

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Ascending dilatation is the one that we see the most.

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You can build a pick list with the things

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that you think are most important to your practice.

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If there are several potential

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or significant cental findings, we basically copy paste this

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and add to the pick list findings represented

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or we add additional ones if they're not on the list.

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So we built this for convenience

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and consistency of reporting.

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We also include in reports,

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and we recommend that you do this

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to include a link to lung rads.

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You might be familiar with it in your radiology practice,

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but you're referring physicians

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and your patients may have no idea

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what this lung RADS radiology speak is that we're using.

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We include a link to the Lung Rad resources,

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which gets us right to the interpretation table if you're

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referring physicians are interested in looking at it

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or want to be reminded of it.

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And then we have a definition of what each term is.

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So if you're referring physician or a patient

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or a nurse navigator coordinator in the program,

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you can see what they mean.

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So category one negative screen,

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No nodules and

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or definitely benign nodules continue

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screening in 12 months.

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And so on up the ladder.

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Category four B positive, screen suspicious,

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recommend multidisciplinary consultation

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and additional imaging, which could be a CT chest

15:05

with contrast or a PET CT at the solid component is eight

15:09

millimeters or larger and or tissue sampling.

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So it sets the stage for the result, whether it's positive

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or negative, and what the next steps are very clearly.

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And it's very clear for people to see in long reds

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how it escalates with each finding category

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and where they're finding fits in

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for their particular patient.

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Is it a three? Is it a one? Is it a four B? And so on.