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Lung-RADS assessment categories for lung cancer screening

Lung-RADS assessment categories for lung cancer screening
Category descriptor Lung-RADS score Findings Management Risk of malignancy (%) Estimated population prevalence (%)
Incomplete 0 Prior chest CT examination(s) being located for comparison Additional lung cancer screening CT images and/or comparison to prior chest CT examinations is needed. NA 1
Part or all of lungs cannot be evaluated

Negative

No nodules and definitely benign nodules 		1 No lung nodules Continue annual screening with LDCT in 12 months. <1 90
Nodule(s) with specific calcifications: complete, central, popcorn, concentric rings and fat containing nodules

Benign appearance or behavior

Nodules with a very low likelihood of becoming a clinically active cancer due to size or lack of growth 		2 Perifissural nodule(s): (refer to important note 11)
  • <10 mm (<523.6 mm3)
Continue annual screening with LDCT in 12 months. <1 90
Solid nodule(s):
  • <6 mm (<113.1 mm3)
  • New <4 mm (<33.5 mm3)
Part solid nodule(s):
  • <6 mm total diameter (<113.1 mm3) on baseline screening
Non solid nodule(s) (GGN):
  • <30 mm (<14137.2 mm3)
  • OR
  • ≥30 mm (≥14137.2 mm3) and unchanged or slowly growing
Category 3 or 4 nodules unchanged for ≥3 months

Probably benign

Probably benign finding(s) – short term follow up suggested; includes nodules with a low likelihood of becoming a clinically active cancer 		3 Solid nodule(s):
  • ≥6 to <8 mm (≥113.1 to <268.1 mm3) at baseline
  • OR
  • New 4 mm to <6 mm (33.5 to <113.1 mm3)
6 month LDCT. 1 to 2 5
Part solid nodule(s):
  • ≥6 mm total diameter (≥113.1 mm3) with solid component <6 mm (<113.1 mm3)
  • OR
  • New <6 mm total diameter (<113.1 mm3)
Non solid nodule(s) (GGN):
  • ≥30 mm (≥14137.2 mm3) on baseline CT or new

Suspicious

Findings for which additional diagnostic testing is recommended 		4A Solid nodule(s):
  • ≥8 to <15 mm (≥268.1 to <1767.1 mm3) at baseline
  • OR
  • Growing <8 mm (<268.1 mm3)
  • OR
  • New 6 to <8 mm (113.1 to <268.1 mm3)
3 month LDCT; PET/CT may be used when there is a ≥8 mm (≥268.1 mm3) solid component. 5 to 15 2
Part solid nodule(s):
  • ≥6 mm (≥113.1 mm3) with solid component ≥6 mm to <8 mm (≥113.1 to <268.1 mm3)
  • OR
  • With a new or growing <4 mm (<33.5 mm3) solid component
Endobronchial nodule

Very suspicious

Findings for which additional diagnostic testing and/or tissue sampling is recommended 		4B Solid nodule(s):
  • ≥15 mm (≥1767.1 mm3
  • OR
  • New or growing, and ≥8 mm (≥268.1 mm3)

Chest CT with or without contrast, PET/CT and/or tissue sampling depending on the probability of malignancy and comorbidities*. PET/CT may be used when there is a ≥8 mm (≥268.1 mm3) solid component.

For new large nodules that develop on an annual repeat screening CT, a 1 month LDCT may be recommended to address potentially infectious or inflammatory conditions. 		>15 2
Part solid nodule(s) with:
  • A solid component ≥8 mm (≥268.1 mm3)
  • OR
  • A new or growing ≥4 mm (≥33.5 mm3) solid component
4X Category 3 or 4 nodules with additional features or imaging findings that increases the suspicion of malignancy

Other

Clinically significant or potentially clinically significant findings (non lung cancer) 		S Modifier – may add on to category 0 to 4 coding As appropriate to the specific finding. NA 10
IMPORTANT NOTES FOR USE:
  1. Negative screen: does not mean that an individual does not have lung cancer.
  2. Size: to calculate nodule mean diameter, measure both the long and short axis to one decimal point, and report nodule mean diameter to one decimal point.
  3. Size thresholds: apply to nodules at first detection, and that grow and reach a higher size category.
  4. Growth: an increase in size of >1.5 mm (>1.8 mm3).
  5. Exam category: each exam should be coded 0 to 4 based on the nodule(s) with the highest degree of suspicion.
  6. Exam modifiers: S modifier may be added to the 0 to 4 category.
  7. Lung cancer diagnosis: once a patient is diagnosed with lung cancer, further management (including additional imaging such as PET/CT) may be performed for purposes of lung cancer staging; this is no longer screening.
  8. Practice audit definitions: a negative screen is defined as categories 1 and 2; a positive screen is defined as categories 3 and 4.
  9. Category 4B management: this is predicated on the probability of malignancy based on patient evaluation, patient preference and risk of malignancy; radiologists are encouraged to use the McWilliams et al assessment tool when making recommendations.
  10. Category 4X: nodules with additional imaging findings that increase the suspicion of lung cancer, such as speculation, GGN that doubles in size in 1 year, enlarged lymph nodes, etc.
  11. Solid nodules with smooth margins, an oval, lentiform or triangular shape, and maximum diameter <10 mm or 523.6 mm3 (perifissural nodules) should be classified as category 2.
  12. Category 3 and 4A nodules that are unchanged on interval CT should be coded as category 2, and individuals returned to screening in 12 months.
Lung-RADS: lung imaging reporting and data system; CT: computed tomography; NA: not applicable; LDCT: low-dose computed tomography; GGN: ground-glass density nodule; PET: positron emission tomography.
* Link to Lung-RADS calculator: https://brocku.ca/lung-cancer-screening-and-risk-prediction/risk-calculators/.
Reproduced from: American College of Radiology, (Lung-RADS™ Version 1.1 Assessment Categories). Copyright © 2019 American College of Radiology. Available at: https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/Lung-Rads (Accessed on June 28, 2018). Reproduced under the terms of the Creative Commons Attribution License.
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