Fundamentals of Oncologic PET-CT Reporting

Over the past 15 years, from the inception of hybrid imaging and introduction of PET-CT to the armamentarium of medical diagnostic departments, numerous styles of reporting have been employed. The type of reporting is mostly derived by the organizational structure of the imaging department. Institutions with separate Radiology and Nuclear Medicine departments usually generate two separate reports. The PET portion of the interpretation is made in the light of anatomical landmarks provided by the CT portion of the study. A separate CT report is also generated. In many instances, a third report is created fusing the separate PET and CT reports. The downsides to this system are the inefficiency of interpretation and the potential confusion for referring physicians when the separate PET and CT reports don't completely match. Needless to say, CT also provides much more information than simple anatomical landmarks, many of which may be crucial to the management of the patient. The more appropriate method of interpretation is for the PET and CT portions of the examination to be interpreted by a dual trained and credentialed imager, creating a single, comprehensive report encompassing both PET and CT findings in the body of the report. In the impression of the report, both sets of findings are correlated and appropriate conclusions and recommendations are made. There are two main downsides to this " perfect " reporting system. Dual trained imagers are not that abundant in the imaging community and healthcare payers may be more likely to decrease the payment to a single reimbursement for the entire examination. The following is the authors' recommendation of reporting a PET-CT study: 1. Patient demographics including name, last name, date of birth, medical record number, inpatient / outpatient status, study-accession number. 2. Study related data including date of service, time of service, location of service 3. Comparison: Any related comparative studies including prior PET-CT, CT, Ultrasound, MR, etc. Preferably with mention of date and technique (with contrast or without oral and/or IV contrast) 4. Indication: Common indications include initial staging, response to treatment and assessment for recurrence. Indications such as detection of the primary focus of cancer of unknown origin haven't been widely used yet. 5. History: Brief relevant history, including the histological subtype of malignancy, if known, any applied treatment (surgery, radiation, chemotherapy, etc) with documentation of time and duration, and any relevant tumor markers. Recently, in California, a new regulation has created …