The 10 Pillars of Lung Cancer Screening

Teaching Points

  • The NLST was the first randomized controlled trial to report a significant reduction in disease-specific lung cancer mortality due to screening.
  • After a USPSTF grade B recommendation was issued in December 2013 and a positive coverage decision was granted by CMS in February 2015, millions of Americans at high risk became eligible for CT lung screening with no insurance co-payment.
  • In February 2015, CMS decided to cover annual LCS with low-dose CT for asymptomatic individuals aged 55–77 years with a high-risk tobacco smoking history. Specifically, reim  bursement covered those with a smoking history of at least 30 pack-years (1 pack-year equals smoking one pack per day for 1 year) who are currently smoking or who had quit less than 15 years ago.
  • Clear and concise communication of screening results is central to guiding providers toward the appropriate management pathway and to minimizing unnecessary workup.
  • Lung-RADS is a structured reporting system that defines what constitutes a positive screening test and links accepted nodule care pathways to the variety of nodules present on LCS images.
  • Source


  • The NLST was huge relative to prior investigations.  n = 53,454 whereas the largest prior was an order of magnitude smaller.
  • Perifissural location (meaning likely a subpleural node which is very common) is not part of the criteria.
  • Measurements are average of the longest axis and shortest axis on axial imaging.


  • In the findings section, the following descriptors should be provided for each nodule:
    • location (lobe, segment, with series or image number);
    • size, determined on lung window images and reported as the average diameter rounded to the nearest whole number;
    • attenuation (soft tissue, type of calcification, fat); morphology (solid, nonsolid and part solid [containing both solid and nonsolid components]);
    • margins (smooth, lobulated, spiculated).
  • Any interval change should be addressed in comparison with the findings from previous examinations, with particular attention to those from the baseline study.
  •  Lung-RADS defines growth as a greater than 1.5-mm increase in size to account for known interreader variability.


  • Category 0: Incomplete Data.
  • Category 1: No Nodule of benign nodules (calcified or fat containing).
    • Probability of malignancy < 1%.
    • Recommend follow-up low-dose CT in 12 months.
  • Category 2:  Benign appearance or behavior.  Solid Nodule up to 6 mm and non-solid nodule up to 20 mm.
    • Probability of malignancy < 1%.
    • Recommend follow-up low-dose CT in 12 months.
    • Notably: recommendations same as above
  • Category 3: Probably benign.
    • >= 6 to
    • 1%–2% probability that it will become clinically active cancer.
    • Recommend followup low-dose CT in 6 months.
      • Some category 3 nodules trigger direct physician-to-physician communication.
  • Category 4A: Suspicious for Malignancy.  All endobronchial Nodules.
    • Management includes additional diagnostic testing with low-dose CT in 3 months, contrast material–enhanced CT, PET/CT, and/or tissue sampling.
      • Category 4 and some category 3 nodules trigger direct physician-to-physician communication.
  • Category 4B: Suspicious for Malignancy.

Flow Chart: Solid


Flow Chart: Part-Solid


Flow Chart: Non-Solid


Synthesis Table

(PDF Linkage because of mice type on this image!)

LungRADS v 1.0 04 28 14.xlsx

Example Report Template



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