C a r d i o p u l m o n a r y I m a g i n g • R ev i ew

Carter et al.
Screening for Lung Cancer

Cardiopulmonary Imaging
Review

Screening for Lung Cancer: Lexicon

FOCUS ON:

for Communicating With Health

Care Providers
Brett W. Carter 1 OBJECTIVE. The effectiveness of lung cancer screening with low-dose CT (LDCT) has
John P. Lichtenberger III2 been shown by multiple clinical trials, particularly the National Lung Screening Trial. Accu-
Carol C. Wu1 rate communication of LDCT results to health care providers is critical to optimal patient care.
Reginald F. Munden 3 CONCLUSION. The Lung CT Screening Reporting and Data System (Lung-RADS), a
structured decision-oriented reporting system designed to minimize the rate of false-positive
Carter BW, Lichtenberger JP III, Wu CC, results and developed by the American College of Radiology, is recommended for use with
­Munden RF all LDCT examinations.
American Journal of Roentgenology 2018.210:473-479.

ung cancer remains the leading Centers for Medicare & Medicaid Services

L cause of cancer-related mortality

Keywords: CT, low-dose screening, lung cancer,
lung cancer screening
doi.org/10.2214/AJR.17.18865
Received August 4, 2017; accepted without revision
August 10, 2017.
1
Department of Diagnostic Radiology, The University of
Texas MD Anderson Cancer Center, 1515 Holcombe Blvd,
Unit 1478, Houston, TX 77030. Address correspondence
to B. W. Carter (bcarter2@mdanderson.org).
2
Department of Radiology and Radiological Sciences,
Uniformed Services University of the Health Sciences,
Bethesda, MD.
3
Department of Radiology, Wake Forest University
School of Medicine, Winston-Salem, NC.
This article is available for credit.
AJR 2018; 210:473–479
0361–803X/18/2103–473
© American Roentgen Ray Society
in the United States, and the
overall 5-year survival remains
low at 17% [1]. The effectiveness of lung can-
cer screening with low-dose CT (LDCT) has
been shown by multiple studies, including the
International Early Lung Cancer Action Proj-
ect (I-ELCAP) and the National Lung Screen-
ing Trial (NLST), both of which included pa-
tients who had no symptoms and were at high
risk of developing lung cancer. I-ELCAP
showed that LDCT could reliably detect ma-
lignant disease 4 times more frequently than
chest radiography [1]. In 2011, the National
Cancer Institute’s NLST found that patients
55–74 years old with a 30-pack-year history
of smoking who were current or former
smokers (i.e., had quit < 15 years earlier) and
had no symptoms who underwent screening
with LDCT had a 20% reduction in lung can-
cer–specific mortality compared with those
screened with chest radiography [2].
On the basis of these results, multiple non-
profit, professional, and federal organizations
have recommended annual LDCT screen-
ing for lung cancer in high-risk patients in-
cluding the National Comprehensive Cancer
Network, the U.S. Preventive Services Task
Force (USPSTF), the American Society of
Clinical Oncology, and the American Can-
cer Society [3–10]. In 2013, the USPSTF rec-
ommended annual screening with LDCT for
adults 55–80 years old who have a 30-pack-
year smoking history and currently smoke or
have quit within the past 15 years [3]. The
proposed similar eligibility criteria but use
a narrower patient age range of 55–77 years
[11]. With the growing awareness and utili-
zation of lung cancer screening with LDCT,
it is necessary for radiologists to educate
health care providers about the risks and
benefits, eligibility criteria, the detailed pro-
cess of LDCT screening, and the availability
of high-quality screening centers [12]. This
role of the radiologist is especially critical
given that most primary care providers rec-
ommend chest radiography over LDCT for
the purpose of lung cancer screening, the for-
mer of which has not been shown to reduce
lung cancer–specific mortality [13].
The American College of Radiology
(ACR) has recommended that all lung cancer
screening programs use structured reporting
for the clinical reporting of LDCT examina-
tions and introduced the Lung CT Screening
Reporting and Data System (Lung-RADS) in
2014 to standardize the reporting and man-
agement of patients undergoing screening
with LDCT and to facilitate data collection
and monitoring of patient outcomes [14]. In
this system, a specific Lung-RADS catego-
ry is assigned to each LDCT examination on
the basis of the presence or absence of ab-
normalities and the specific imaging find-
ings encountered. Each category estimates
the likelihood of malignancy for the domi-
nant finding and offers specific recommen-
dations regarding management.
The purpose of this article is to present the es-
sential lexicon of lung cancer screening as it

AJR:210, March 2018 473


pertains to LDCT—that is, Lung-RADS—
and to illustrate the utilization of Lung-RADS
categories and recommendations regarding
patient management.
Communication of Screening Results
Accurate communication of LDCT re-
sults is one of the most important functions
of a successful lung cancer screening pro-
gram because it guides health care provid-
ers toward appropriate patient management
and facilitates patient care from a team-
based approach. The ACR has recommend-
ed that standardized or structured report-
ing, in which the information contained in a
clinical report follows a predefined format,
be used in lung cancer screening programs
when reporting results to the referring pro-
vider, patient, and other health care providers
involved in the clinical management of the
patient. Compared with free-form clinical ra-
diology reports, structured reporting has sev-
American Journal of Roentgenology 2018.210:473-479.
eral advantages including the uniform deliv-
ery of important clinical information, clear
identification of patients with imaging find-
ings that may require management in a mul-
tidisciplinary setting, and the potential for
enhanced data mining [15]. For the purpos-
es of lung cancer screening, LDCT studies
should include specific types of informa-
tion, including scanning technique, relevant
comparison examinations, imaging findings,
overall study impression, Lung-RADS cate-
gory, and recommendations for clinical man-
agement. For pulmonary nodules, specific
information such as location, size, attenu-
ation, morphology, margins, and behavior
should be included [15].
Professional organizations such as the
ACR, the American College of Chest Phy-
sicians (ACCP), and the American Thoracic
Society (ATS) have recommended that lung
cancer screening programs use a structured
reporting system such as Lung-RADS and
that programs collect data regarding com-
pliance with the system used [16, 17]. Addi-
tionally, the ACCP and ATS suggest that the
selected structured reporting system be used
for 90% or more of the LDCT reports [17].
Lung-RADS
Development and Utilization
The utilization of standardized report-
ing of imaging findings and management
recommendations for LDCT examinations
performed for the purposes of lung cancer
screening is a relatively recent development.
Lung-RADS was developed by the ACR
474 AJR:210, March 2018
Carter et al.
Lung Cancer Screening Committee sub-
group and modeled after BI-RADS for breast
cancer screening. Lung-RADS features spe-
cific assessment categories and management
recommendations for pulmonary nodules
identified on lung cancer screening LDCT
examinations, as well as other significant ab-
normalities involving the lungs, cardiovas-
cular system, and other structures. The first
and current version of Lung-RADS was pub-
lished in April 2014, with the stated goals of
reducing potential confusion regarding the
interpretation and reporting of LDCT stud-
ies performed for lung cancer screening pur-
poses and facilitating outcomes monitoring.
Lung-RADS should be used only when in-
terpreting and reporting LDCT studies per-
formed for the purposes of lung cancer
screening, and assessment categories and
management recommendations should not
be used for abnormalities identified on other
types of CT studies or on other imaging mo-
dalities such as PET/CT or MRI.
Significant Findings
The presence or absence of pulmonary
nodules and specific imaging features of
these lesions are the most important features
to report on LDCT examinations performed
for lung cancer screening. Pulmonary nod-
ules identified should be characterized in
further detail by location (pulmonary lobe or
segment or bronchus), size, attenuation, com-
position (solid, nonsolid, or part-solid), and
TABLE 1: Lung CT Screening Reporting and Data System (Lung-RADS)
­Categories for Pulmonary Nodules by Nodule Type and Size
Pulmonary Nodule Type and Size on Lung-RADS
Baseline LDCT Category
Solid pulmonary nodules
< 6 mm
≥ 6 mm to < 8 mm
≥ 8 mm to < 15 mm
≥ 8 mm
Part-solid pulmonary nodules
< 6 mm total diameter
≥ 6 mm total diameter with a solid
component < 6 mm
≥ 6 mm with a solid component ≥ 6 mm
to < 8 mm
Solid component ≥ 8 mm
Nonsolid pulmonary nodules
< 20 mm
≥ 20 mm
Note—LDCT = low-dose CT, NA = not applicable.
benign features such as internal fat or specif-
ic patterns of calcification (complete, central,
popcorn, or concentric rings) or features con-
cerning for malignancy (spiculation, ground-
glass nodule that doubles in size over 1 year,
or associated enlarged lymph nodes). Any
change in size or in other imaging features
of pulmonary nodules between LDCT stud-
ies should be noted.
Pulmonary nodules and other lung lesions
should be measured on lung windows with
size reported as the average diameter round-
ed to the nearest whole number. A single di-
ameter measurement can be used only for
round pulmonary nodules. In Lung-RADS,
specific size cut points apply to pulmonary
nodules at initial detection and those that
grow and reach a higher size category on sub-
sequent LDCT examinations. Growth is de-
fined as an increase in size of more than 1.5
mm. The overall Lung-RADS category giv-
en to each case is coded between 0 and 4 and
is based on the pulmonary nodule with the
highest degree of clinical suspicion. LDCT
studies with Lung-RADS category 1 or 2 are
considered negative screens and those with
Lung-RADS category 3 or 4 are considered
positive screens.
Lung-RADS Assessment Categories
For each LDCT examination, an overall
Lung-RADS assessment category is provid-
ed as a two-part alphanumeric score includ-
ing category (part 1) and modifier (part 2).
Size on Follow-Up LDCT
2 New < 4 mm
3 New 4 mm to < 6 mm
4A Growing < 8 mm or new 6 mm to < 8 mm
4B New or growing ≥ 8 mm
2 NA
3 New < 6 mm total diameter
4A ≥ 6 mm with a new or growing < 4 mm solid
component
4B New or growing ≥ 4 mm solid component
2 ≥ 20 mm and unchanged or slowly growing
3 New ≥ 20 mm

The category classifies pulmonary nodules
as 0–4 as determined by imaging features
such as size, composition, and morphology
and by LDCT time point (baseline or sub-
sequent follow-up) (Table 1). The modifi-
er considers other types of information that
are potentially clinically significant and uses
modifiers X, C, and S.
Lung-RADS category 0 represents an in-
complete assessment due to either subopti-
mal imaging technique or the existence of
other studies that could be used for compari-
son purposes but are not available at the time
of interpretation. For LDCT studies without
pulmonary nodules or with definitely benign
pulmonary nodules, Lung-RADS category 1
is used and denotes a low probability of ma-
lignancy (< 1%).
LDCT scans with pulmonary nodules that
are not definitely benign may be classified as
Lung-RADS category 2, 3, 4A, 4B, or 4X on
the basis of size, composition (solid, nonsol-
American Journal of Roentgenology 2018.210:473-479.
id, or part-solid), and behavior. Lung-RADS
category 2 includes nodules with a benign ap-
pearance or behavior and is associated with
a low likelihood of malignancy (< 1%). Pul-
monary nodules that are probably benign are
designated Lung-RADS category 3, which is
associated with a 1–2% probability of malig-
nancy. Pulmonary nodules that are suspicious
for malignancy are classified as Lung-RADS
category 4, which is subdivided into A and B
components, with a probability of malignancy
of 5–15% for 4A and greater than 15% for 4B.
The X, C, and S modifiers can be add-
ed to categories 0–4 if other potentially
significant findings are identified. The overall
Lung-RADS assessment score consists of the
category number and any modifier. Addition-
al imaging features that increase the suspi-
cion for malignancy of Lung-RADS category
3 or 4 pulmonary nodules including spicula-
tion, rapid growth, or associated lymph node
enlargement are denoted by the X modifier.
For these LDCT examinations, the overall
assessment score is denoted as 4X and is as-
sociated with a probability of malignancy of
greater than 15%. The C modifier indicates
a history of lung cancer, and the S modifier
reflects the presence of clinically significant
or potentially clinically significant findings
involving the lungs, such as emphysema; the
cardiovascular system, such as coronary ar-
tery calcification; and other structures.
Patient Management
Each Lung-RADS category includes spe-
cific recommendations regarding patient
AJR:210, March 2018 475
Screening for Lung Cancer
management. For Lung-RADS categories 1
and 2, annual screening with LDCT is rec-
ommended. For Lung-RADS category 3,
6-month follow-up LDCT is recommend-
ed. For Lung-RADS category 4A, 3-month
follow-up LDCT or investigation with FDG
PET/CT (when an 8-mm solid component is
present) is recommended. For Lung-RADS
categories 4B and 4X, diagnostic chest CT
with or without IV contrast material, FDG
PET/CT, or tissue sampling may be con-
sidered. Once a diagnosis of lung cancer is
made, additional examinations may be per-
formed to evaluate, stage, and restage lung
cancer; however, these examinations are not
considered lung cancer screening.
When an S modifier is used to denote other
clinically significant or potentially clinically
significant findings, specific management re-
garding the abnormality may be suggested.
For example, referral to pulmonology may be
recommended for patients with emphysema.
Utility in Practice
Pinsky and colleagues [18] applied
Lung-RADS to the NLST population and
showed that its use may significantly re-
duce the false-positive result rate with some
corresponding decrease in sensitivity com-
pared with the NLST algorithm. McKee
et al. [19] evaluated the effect of applying
Lung-RADS to the frequency of positive and
false-negative findings in a clinical lung can-
cer screening program. They found that using
Lung-RADS increased the positive predic-
tive value by a factor of 2.5, to 17.3%, with-
out increasing the number of examinations
with false-negative results [19]. Chung and
colleagues [20] recently evaluated the added
value of Lung-RADS category 4X over cat-
egories 3, 4A, and 4B for differentiating be-
tween benign and malignant subsolid pulmo-
nary nodules and found that its inclusion is of
added value and results in high malignancy
rates in the hands of experienced radiologists.
Case-Based Approach to Lung-RADS
Case 1
A screening LDCT examination of a
63-year-old man shows a 7-mm solid nod-
ule in the right upper lobe (arrow in Fig. 1).
Although solid nodules measuring 6 mm or
larger but less than 8 mm at baseline LDCT
are typically assigned Lung-RADS category
2, in this case, the baseline LDCT for this
patient (not shown) was negative, indicat-
ing that this nodule is new. New solid nod-
ules measuring between 6 mm and less than
8 mm are classified as Lung-RADS catego-
ry 4A. Management options for this catego-
ry include follow-up LDCT in 3 months and
PET/CT when there is a solid component that
is 8 mm or larger.
Case 2
A baseline screening LDCT examination
of a 61-year-old woman shows a 6 × 3 mm
(average = 4.5 mm, rounded to 5 mm) sol-
id nodule in the right upper lobe (arrow in
Fig. 2A). On the basis of the size and com-
position of this nodule, Lung-RADS catego-
ry 2 was assigned and follow-up LDCT was
performed 12 months later. Follow-up LDCT
shows interval increase in the size of this
nodule (arrow in Fig. 2B), now measuring 9 ×
6 mm (average = 7.5 mm, rounded to 8 mm).
On the basis of the increase in the size of the
nodule, Lung-RADS category 4A was as-
signed at follow-up LDCT. In Lung-RADS,
growth is defined as an increase in size of
greater than 1.5 mm, and growing solid nod-
ules measuring less than 8 mm are classified
as Lung-RADS category 4A.
Case 3
A baseline screening LDCT examination
of a 76-year-old man shows a part-solid nod-
ule in the right upper lobe measuring 17 × 12
mm (average = 14.5 mm, rounded to 15 mm)
with a 7-mm solid component (arrow in Fig.
3). On the basis of the size and composition
of the nodule, Lung-RADS category 4A was
assigned. The probability of malignancy in
this case is between 5% and 15%, and follow-
up LDCT in 3 months is the management for
this patient because the size of the solid com-
ponent (7 mm) does not meet the cutoff for
FDG PET/CT.
Case 4
A screening LDCT examination of a
56-year-old woman shows a new masslike
opacity in the middle lobe measuring 27 × 24
mm (average = 25.5 mm, rounded to 26 mm)
(arrow in Fig. 4A). According to size criteria,
this lesion was classified as Lung-RADS cat-
egory 4B. Given the rapidity of development
and history of bronchiectasis in this region,
an infectious or inflammatory process was
favored as the etiology, although a primary
lung neoplasm could not be excluded, and
follow-up LDCT was recommended. Follow-
up LDCT shows a marked interval decrease
in the opacity with only residual opacity (ar-
row in Fig. 4B) remaining; this finding sug-
gests an infectious or inflammatory cause.

The Lung-RADS category at follow-up was
2 based on the appearance of other nodules.
Case 5
A baseline screening LDCT examinations
of a 67-year-old man shows a solid mass
measuring 35 mm in the left lower lobe ad-
jacent to the left interlobar fissure (arrow in
Fig. 5). Solid nodules measuring 15 mm or
larger are classified as Lung-RADS 4B, and
management options include chest CT with
or without contrast material, PET/CT, or tis-
sue sampling. CT-guided biopsy of the mass
was subsequently performed and revealed
primary adenocarcinoma of the lung.
Case 6
A baseline screening LDCT examination
of a 73-year-old man shows a solid endo-
bronchial nodule in the posterior right main
bronchus (arrow in Fig. 6). A bronchoscop-
ic biopsy was subsequently performed and
American Journal of Roentgenology 2018.210:473-479.
revealed non–small cell lung cancer. Endo-
bronchial nodules are typically classified as
Lung-RADS category 4A lesions.
Case 7
A baseline screening LDCT examina-
tion of a 67-year-old woman shows a nonsol-
id nodule in the right lower lobe measuring
11 × 7 mm (average = 9 mm) (Fig. 7). For
this case, Lung-RADS category 2 was as-
signed, and follow-up LDCT in 12 months
was scheduled. Nonsolid nodules measuring
less than 20 mm at baseline or nonsolid nod-
ules measuring 20 mm or larger that are un-
changed or slowly growing are classified as
Lung-RADS category 2.
Case 8
A baseline screening LDCT examination of
a 62-year-old woman shows a nonsolid nod-
ule in the left lower lobe (arrow in Fig. 8A)
measuring 12 × 10 mm (average = 11 mm).
Lung-RADS category 2 was assigned. Follow-
up LDCT 12 months later shows interval de-
velopment of a solid component measuring 7
mm (arrow in Fig. 8B). Part-solid nodules with
new or growing solid components measuring
4 mm or larger are classified as Lung-RADS
category 4B. CT-guided biopsy of this nodule
was subsequently performed and revealed pri-
mary adenocarcinoma of the lung.
Case 9
A baseline screening LDCT examina-
tion of a 63-year-old woman shows a nonsol-
id nodule measuring 18 × 17 mm (average =
476 AJR:210, March 2018
Carter et al.
17.5 mm, rounded to 18 mm) in the right up-
per lobe (arrow in Fig. 9A). Nonsolid nodules
measuring less than 20 mm are classified as
Lung-RADS 2 and are associated with a low
probability of malignancy, less than 1%. Fol-
low-up LDCT shows an interval increase in
the size of this lesion measuring 23 × 21 mm
(average = 22 mm) (arrow in Fig. 9B). Giv-
en the interval change in the size of this le-
sion, Lung-RADS category 3 was assigned.
Although tissue sampling was not recom-
mended, subsequent CT-guided biopsy was
performed and revealed primary adenocarci-
noma of the lung.
Case 10
A baseline screening LDCT examination
of a 73-year-old man shows a 25-mm solid
nodule with spiculated margins in the right
upper lobe (arrow in Fig. 10A). A baseline
screening LDCT examination of a different
patient, a 58-year-old man, shows a 22-mm
spiculated nodule that contacts the adjacent
pleural surface (Fig. 10B). On the basis of
the size and composition of these nodules,
Lung-RADS category 4B would normally be
assigned; however, the presence of spiculation
increased the clinical concern for malignancy,
and Lung-RADS category 4X was assigned.
Limitations and Future Directions
Although Lung-RADS may reduce the
false-positive rate of LDCT examinations and
improve the cost-effectiveness of lung can-
cer screening, several limitations have been
described. Lung-RADS has never been used
in a prospective manner as part of a clini-
cal trial. Additionally, the reproducibility of
Lung-RADS is uncertain. Han and colleagues
[21] evaluated possible variability in the inter-
pretations of LDCT scans by thoracic radiolo-
gists using Lung-RADS on difficult-to-classi-
fy scenarios. They discovered large variability
in the interpretations of the Lung-RADS cat-
egories, with high frequencies of disagree-
ment in some specific scenarios. Several spe-
cific clinical scenarios are not addressed by
Lung-RADS. For instance, in some patients,
screening LDCT may show isolated hilar and
mediastinal lymphadenopathy or pleural effu-
sion in the absence of pulmonary nodules or
other lung lesions [22]. Chung et al. [23] quan-
tified and compared the malignancy rates for
Lung-RADS categories 2 and 4B subsolid
nodules. They found that malignancy proba-
bilities for Lung-RADS 2 and 4B lesions gen-
erally matched malignancy risks in subsolid
pulmonary nodules but noted that the upgrade
of highly suspicious Lung-RADS 2 subsolid
nodules to Lung-RADS 4X might be benefi-
cial and should be considered in future ver-
sions of Lung-RADS.
Conclusion
Standardized reporting of findings on
LDCT examinations with the associated
management recommendations is a critical
component of any lung cancer screening pro-
gram. It is imperative that radiologists under-
stand and appropriately apply Lung-RADS
to ensure that patients at high risk of devel-
oping lung cancer receive uniform and qual-
ity care during their baseline and follow-up
LDCT examinations.
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Fig. 1—Screening low-dose CT (LDCT) image of
63-year-old man shows 7-mm solid nodule in right
upper lobe (arrow). Although solid nodules measuring
6 mm or larger but less than 8 mm at baseline LDCT
are typically assigned Lung CT Screening Reporting
and Data System (Lung-RADS) category 2, in this
case, baseline LDCT for this patient (not shown) was
negative, indicating that this nodule is new and is
consistent with Lung-RADS category 4A.
A B
Fig. 2—61-year-old woman.
A, Baseline screening low-dose CT (LDCT) image shows 6 × 3 mm (average = 4.5 mm, rounded to 5 mm) solid
nodule in right upper lobe (arrow). On basis of size and composition of this nodule, Lung CT Screening Reporting
and Data System (Lung-RADS) category 2 was assigned, and follow-up LDCT was performed 12 months later.
B, Follow-up LDCT image obtained 12 months after A shows interval increase in size of nodule (arrow), which
now measures 9 × 6 mm (average = 7.5 mm, rounded to 8 mm); Lung-RADS category 4A was assigned.

AJR:210, March 2018 477

 Carter et al.

Fig. 3—Baseline screening low-dose CT image of
76-year-old man shows part-solid nodule in right
upper lobe measuring 17 × 12 mm (average = 14.5
mm, rounded to 15 mm) with 7-mm solid component
(arrow). On basis of size and composition of nodule,
Lung CT Screening Reporting and Data System
category 4A was assigned.
American Journal of Roentgenology 2018.210:473-479.
A B
Fig. 4—56-year-old woman.
A, Screening low-dose CT (LDCT) image shows new masslike opacity (arrow) in middle lobe measuring 27 ×
24 mm (average = 25.5 mm, rounded to 26 mm). According to size criteria, this lesion was classified as Lung CT
Screening Reporting and Data System (Lung-RADS) category 4B.
B, Follow-up LDCT image obtained 3 months after A shows marked interval decrease in opacity with only
residual opacity remaining (arrow); this change suggests infectious or inflammatory cause. Lung-RADS
category assigned at follow-up was 2 on basis of appearance of other nodules.

Fig. 5—Baseline screening low-dose CT image of
67-year-old man shows solid mass measuring 35 mm
in left lower lobe adjacent to left interlobar fissure
(arrow); this finding is consistent with Lung CT
Screening Reporting and Data System category 4B.
Fig. 6—Baseline screening low-dose CT image of
73-year-old man shows solid endobronchial nodule in
posterior right main bronchus (arrow). Bronchoscopic
biopsy subsequently was performed and revealed
non–small cell lung cancer. Endobronchial nodules
are typically classified as Lung CT Screening
Reporting and Data System category 4A lesions.
Fig. 7—Baseline screening low-dose CT (LDCT)
image of 67-year-old woman shows nonsolid nodule
(arrow) in right lower lobe measuring 11 × 7 mm
(average = 9 mm). For this case, Lung CT Screening
Reporting and Data System category 2 was assigned,
and follow-up LDCT in 12 months was scheduled.

478 AJR:210, March 2018

 Screening for Lung Cancer

Fig. 8—62-year-old woman.

A, Baseline screening low-dose CT (LDCT) image
shows nonsolid nodule in left lower lobe measuring
12 × 10 mm (average = 11 mm) (arrow). Lung CT
Screening Reporting and Data System (Lung-RADS)
category 2 was assigned.
B, Follow-up LDCT image obtained 12 months after
A shows interval development of solid component
measuring 7 mm (arrow) consistent with Lung-RADS
category 4B.

A B

Fig. 9—63-year-old woman.

A, Baseline screening low-dose CT (LDCT) image
shows nonsolid nodule measuring 18 × 17 mm
(average = 17.5 mm, rounded to 18 mm) in right upper
lobe (arrow) consistent with Lung CT Screening
Reporting and Data System (Lung-RADS) category 2.
American Journal of Roentgenology 2018.210:473-479.

B, Follow-up LDCT image obtained 12 months after A

shows interval increase in size of this lesion (arrow),
which measures 23 × 21 mm (average = 22 mm). Given
interval change in size of this lesion, Lung-RADS
category 3 was assigned.

A B

Fig. 10—Baseline low-dose CT (LDCT) images show

findings assigned Lung CT Screening Reporting and
Data System (Lung-RADS) category 4X.
A, Baseline screening LDCT image of 73-year-old man
shows 25-mm solid nodule with spiculated margins in
right upper lobe (arrow).
B, Baseline screening LDCT image of 58-year-old
man shows 22-mm spiculated nodule (arrow) that
contacts adjacent pleural surface. On basis of
size and composition of nodules shown in A and
B, Lung-RADS category 4B would normally be
assigned; however, presence of spiculation increased
clinical concern for malignancy in both cases, and
Lung-RADS category 4X was assigned.
A B

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