What should be included in a radiology report for a suspected lung cancer case with a 2.5 cm mass in the left lower lobe?

Radiology Report Template for Suspected Lung Cancer with 2.5 cm Left Lower Lobe Mass

For a 2.5 cm mass in the left lower lobe with suspected lung cancer, your radiology report must include precise lesion characterization, TNM staging descriptors, assessment of mediastinal and hilar lymph nodes, evaluation for distant metastases, and explicit recommendations for tissue diagnosis and PET-CT staging. 1

Clinical Information Section

• Document patient age, smoking history (pack-years), and relevant cancer history 2, 3
• State the clinical indication (e.g., "suspected lung cancer," "abnormal chest radiograph") 4
• Include relevant symptoms if provided (cough, hemoptysis, weight loss, dyspnea) 5

Technical Parameters

• Specify CT technique: slice thickness (≤5 mm preferred), use of IV contrast, and imaging protocol 2
• State whether this is a contrast-enhanced study, as this aids in distinguishing vascular structures from lymph nodes 2

Findings Section - Primary Lesion Description

Location and Size

• Precise anatomic location: Left lower lobe with specific segment (e.g., superior segment, posterior basal segment) 2
• Three-dimensional measurements: Report in millimeters using long axis × short axis × craniocaudal dimension 2, 1
• For this 2.5 cm (25 mm) mass, document exact measurements (e.g., 25 × 22 × 24 mm) 1

Morphologic Characteristics (Critical for Risk Stratification)

• Margin characteristics: Specify if spiculated, lobulated, smooth, or irregular 6, 1
  • Spiculation is a high-risk feature that significantly increases malignancy probability 1
• Density: Solid, part-solid, or ground-glass 6
• Calcification pattern: Absent, diffuse, central, laminated, popcorn, or eccentric 6
• Relationship to pleura: Note pleural tags, pleural indentation, or chest wall invasion 2, 6
• Cavitation: Present or absent; if present, describe wall thickness 2

Airway Involvement

• Bronchial relationship: Document any segmental or lobar bronchial narrowing, cut-off, or endobronchial component 1
• Bronchial cut-off suggests endobronchial involvement and influences biopsy approach (favors bronchoscopy over percutaneous biopsy) 1

Enhancement Pattern (if contrast-enhanced)

• Describe enhancement characteristics: homogeneous, heterogeneous, minimal, or avid 2, 1
• Heterogeneous enhancement with minimal areas may suggest necrosis, concerning for malignancy 1

TNM Staging Descriptors

T Stage Assessment

• T1b: Tumor >2 cm but ≤3 cm 2
• For this 2.5 cm mass, classify as T1b (assuming no invasion beyond visceral pleura) 2
• Assess for features that would upstage:
  • Visceral pleural invasion (PL1/PL2) → T2a 2
  • Main bronchus involvement → T2 or T3 depending on distance from carina 2
  • Chest wall, diaphragm, or phrenic nerve invasion → T3 2
  • Mediastinal invasion → T4 2

N Stage Assessment (Lymph Node Evaluation)

• Mediastinal lymph nodes: Measure short-axis diameter of all visible nodes 2
  • Normal: <10 mm short axis 2
  • Enlarged: ≥10 mm short axis 2
• Specify nodal stations using International Association for the Study of Lung Cancer (IASLC) map:
  • N1: Hilar and intrapulmonary nodes (stations 10-14) 2
  • N2: Ipsilateral mediastinal nodes (stations 1-9) 2
  • N3: Contralateral mediastinal or supraclavicular nodes 2
• Describe pattern: Discrete enlarged nodes vs. mediastinal infiltration/matted nodes 2
• For a peripheral left lower lobe tumor with normal-sized mediastinal nodes, the probability of N2 disease is relatively low (radiographic group D), but tissue confirmation is still needed if nodes are borderline or if the patient is a surgical candidate 2

M Stage Assessment

• Intrathoracic metastases:
  • Separate tumor nodules in same lobe → T3 2
  • Separate nodules in different ipsilateral lobe → T4 2
  • Contralateral lung nodules → M1a 2
  • Pleural/pericardial nodules or malignant effusion → M1a 2
• Extrathoracic evaluation: State whether upper abdomen (liver, adrenals) is included in field of view 2

Additional Findings

• Atelectasis or obstructive pneumonitis: Describe extent (segmental, lobar, or entire lung) 2
• Pleural effusion: If present, note size and whether simple or complex 2
• Chest wall involvement: Assess for rib destruction or soft tissue extension 2
• Vascular involvement: Evaluate proximity to pulmonary vessels, aorta, or superior vena cava 2

Comparison to Prior Studies

• If available, document interval change in size, morphology, or associated findings 6, 4
• Calculate volume doubling time if prior imaging available (VDT <400 days indicates aggressive growth) 6

Impression Section (Use Active Voice)

Primary Finding

• State the most critical finding first: "There is a 2.5 cm spiculated mass in the left lower lobe, highly suspicious for primary lung malignancy" 1, 4
• Avoid hedging language like "likely" or "probably" when features are clearly concerning 4

Staging Summary

• Provide preliminary clinical stage based on imaging: "Clinical stage T1bN0M0 (stage IA3) pending pathologic confirmation" 2
• Explicitly state limitations: "Mediastinal lymph nodes are normal in size, but pathologic involvement cannot be excluded" 2

Risk Stratification

• For a 2.5 cm spiculated mass, state: "This lesion has high-risk features (size >8 mm, spiculation) with estimated malignancy probability >70%" 6, 1

Recommendations Section (Critical for Patient Management)

Immediate Next Steps

1. PET-CT for staging: "Whole-body FDG-PET/CT is recommended for both diagnosis and staging (ACR appropriateness rating 8/9)" 1

   • PET-CT distinguishes benign from malignant lesions and identifies occult metastases 1
   • Reduces futile thoracotomies by detecting unresectable disease 1

2. Tissue diagnosis:

   • If bronchial cut-off present: "Bronchoscopy with biopsy is preferred given segmental bronchial involvement" 1
   • If purely peripheral: "Percutaneous CT-guided biopsy or bronchoscopy with endobronchial ultrasound (EBUS) for tissue diagnosis" 1
   • State: "Tissue diagnosis is mandatory before definitive treatment" 7, 5

3. Mediastinal staging: "If mediastinal lymphadenopathy is identified on PET-CT, mediastinoscopy or EBUS-guided biopsy is required for pathologic N staging before surgical resection" 1

Multidisciplinary Management

• "Recommend presentation at multidisciplinary thoracic oncology tumor board for treatment planning" 1
• "Pulmonary function testing and cardiopulmonary assessment needed to determine surgical candidacy" 1

Surveillance is NOT Appropriate

• Explicitly state: "Surveillance imaging alone is inappropriate for a lesion of this size with high-risk features (ACR appropriateness rating 2/9)" 1

Critical Communication

• Direct communication required: For a suspected lung cancer, directly contact the referring physician by phone or secure messaging 4
• Document this communication in the report: "Critical finding communicated to Dr. [Name] on [date] at [time]" 4

Common Pitfalls to Avoid

Measurement Errors

• Do not measure obliquely; use true axial, coronal, or sagittal planes 6
• For part-solid nodules, measure both total diameter and solid component separately 6

Staging Errors

• Do not assume normal-sized lymph nodes exclude metastases; 20-25% of patients with central tumors have N2 disease despite normal-sized nodes 2
• Do not overlook pleural effusions; cytology-positive effusions upstage to M1a 2

Recommendation Errors

• Do not recommend "short-term follow-up" for a 2.5 cm spiculated mass; this delays diagnosis 1
• Do not recommend immediate surgery without tissue diagnosis and complete staging 1
• Do not omit PET-CT; it is essential for detecting occult metastases and preventing futile thoracotomies 1

Reporting Style Errors

• Avoid passive voice: Write "The mass invades the chest wall" not "Chest wall invasion is seen" 4
• Avoid uncertainty phrases like "cannot exclude malignancy" when features are clearly suspicious; instead state "highly suspicious for malignancy" 4
• Do not bury critical findings in the body; state them prominently in the impression 4