The Language of Reporting
FIGURES 1-4 ARE TYPES REPORTS. THEY NEED TO OPEN VERY LARGE (LIKE THE REFERNECES SECTION)…
Goals of Reporting:
Identifying abnormalities, reporting sizes and calculating SUV’s are the easy parts of PET/CT reading. The challenge and the real art of PET/CT reading are to meaningfully interpret these findings for the clinician.
Simply reporting that there are “several enlarged and moderately-avid nodes” without concluding with a meaningful interpretation of their significance is unhelpful and irresponsible.
The patient has been sent to us to answer a few simple questions:
Initial Exam:
- Is there active malignancy?
- What is the tumor burden and where is it located?
Follow Up Exam:
- What has happened in the interim (response to therapy)?
- Complete metabolic response? Partial? No change? Disease progression?
If these questions are not specifically answered in our report, we have simply not done our job.
Lawyers, Lawyers & Lawyers:
It would be naïve and a bit disingenuous to not acknowledge that balanced against
our noble goal of helping patients is a realistic need to also protect ourselves from excessive litigation.
Old, dumb joke:
Q: What’s a radiologist’s favorite plant?
A: The hedge.
While finding the proper balance between helping and hedging is often difficult, PETCTMD has worked very hard – with both clinicians and attorneys –to develop very precise reporting language that best finds this balance.
As we proceed throughout our teaching cases, we will suggest very specific reporting language that we believe achieves this goal.
Sample PET/CT Reports:
Until you develop your own reporting style, here are two sample reports (a negative report & a positive one) to give you a feel for the degree of specificity expected in a PET/CT report.
- Negative Report [Fig. 1]
- Positive Report [Fig. 2]
Patient & Technologist’s Sheets:
Detailed patient history is essential to accurate PET/CT interpretation. This includes not only the type of cancer the patient may have, but any recent treatments (surgery, chemotherapy, radiation) that may dramatically influence exam interpretation.
Depending on the center or hospital you might read for, access to patient history may be extremely limited. For this reason, our patients and our technologists each fill out a single page document, listing the information most relevant to PET/CT interpretation.
Not infrequently, these forms are the only patient history the radiologist will receive.
- Patient Questionnaire [Fig. 3]
- Technologist’s Data Sheet [Fig. 4]
