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Sample reports

A model report structure you can base documentation on

Below are four complete reports. The first two show the same patient: the baseline study and the first response assessment after treatment started — the essence of our work: we measure, then compare consistently by the same methodology. The third is a case in which cancer was suspected but not confirmed; the fourth — treatment ending in complete response. Each report has three layers: a structured organ-by-organ report, a RECIST 1.1 measurement table and clinically relevant conclusions — in a form ready for drug-programme, tumour-board and clinical-trial documentation.

Illustrative material — the report structure is real; all identifying data removed and case details modified.
REPORT · CT chest + abdomen + pelvis with contrast
3 anatomical regions · baseline study
EXAMPLE 01 · BASELINE

Pre-treatment staging — breast cancer

Female, 43 · initial workup · staging before treatment eligibility

CLINICAL DATAclinically a ~3 cm tumour of the right breast (upper quadrant) · BI-RADS 6 on referral · staging
01

Structured report

organ by organ · pathology highlighted
TECHNIQUE
Scope
CT of the chest, abdomen and pelvis before and after contrast administration
CHEST
Thyroid
not enlarged, heterogeneous; possible features of autoimmune thyroiditis — detailed assessment on ultrasound
Lungs
normally aerated; fibrotic/post-inflammatory changes at both lung bases; several focal lesions in both lungs suspicious for metastases, the largest up to 13 mm in segment 3 of the right lung and 14 mm in segment 6 of the left lung
Mediastinal lymph nodes
a suspicious lymph node in the anterior mediastinum near the sternum, 16 mm in short axis
Trachea and bronchi
patent
Pleural cavities
no effusion
Heart and mediastinum
normal
Esophagus
patent, thin-walled
Pulmonary trunk and arteries
patent
Thoracic aorta
normal
Chest wall
in the upper outer quadrant of the right breast an area of pathological enhancement 33 × 27 mm; multiple pathological right axillary lymph nodes up to 17 mm in short axis
ABDOMEN
Liver
a hypodense metastatic lesion 45 mm in segment 8; enlarged; with features of steatosis (unenhanced density ~40 HU)
Gallbladder
thin-walled; with a few calculi
Bile ducts
not dilated
Pancreas
normal size; homogeneous; no focal lesions; pancreatic duct not dilated
Spleen
not enlarged, no focal lesions
Adrenal glands
not enlarged
Kidneys and ureters
kidneys normally located, normal size; no hydronephrosis, no calculi, no focal lesions; symmetric excretion of contrast in the urographic phase; ureters not dilated
Urinary bladder
smooth outline, well distended
PELVIS
Reproductive organs
a fluid space with septa and calcifications in the region of the right adnexa, 54 × 43 mm — for further workup on MRI
Lymph nodes
retroperitoneal, mesenteric, inguinal and pelvic nodes not enlarged
Peritoneal cavity
a small amount of free fluid in the pelvis; no peritoneal implants
Bowel
walls not thickened, no pathological enhancement
Abdominal wall
no discernible lesions
Great vessels
patent
SKELETAL SYSTEM
Bones
disseminated lytic metastatic lesions in multiple bones within the scan range, the largest 30 mm in the sternum and 35 mm in the left iliac wing; degenerative changes of the thoracic, lumbar and sacral spine
02

Measurement table — RECIST 1.1

baseline · proposed target lesions
#Target lesion (proposed)LocationBaseline sizeMeasurement method
T1Right breast tumourupper outer quadrant33 mmlongest diameter
T2Liver metastasissegment 845 mmlongest diameter
T3Right lung lesionsegment 313 mmlongest diameter
T4Left lung lesionsegment 614 mmlongest diameter
T5Anterior mediastinal lymph nodeparasternal16 mmshort axis (node ≥ 15 mm)
Sum of target-lesion diameters (baseline SLD)121 mmreference point
NON-TARGET LESIONS (qualitative assessment on follow-up)
  • pathological right axillary lymph nodes (up to 17 mm in short axis)
  • disseminated lytic bone metastases (largest: sternum 30 mm, left iliac wing 35 mm)
  • remaining small focal lesions in both lungs
  • a small amount of free fluid in the pelvis
Baseline study — no response category is assigned; the sum of diameters (121 mm) is the reference point for subsequent assessments. Target-lesion selection per RECIST 1.1: max 5 lesions total, max 2 per organ; lymph nodes measurable at short axis ≥ 15 mm. The cystic adnexal lesion was not included in the RECIST assessment — it first requires characterisation on MRI.
03

Conclusions — clinically relevant information

copy-ready for the patient record
The picture corresponds to advanced right breast cancer with dissemination: right breast tumour 33 x 27 mm, metastatic right axillary lymph nodes up to 17 mm, a suspicious anterior mediastinal node 16 mm in short axis. Distant metastases to the lungs (largest 13 and 14 mm), liver (45 mm in segment 8) and skeleton (disseminated lytic lesions). Five target lesions defined per RECIST 1.1; baseline sum of diameters (SLD) 121 mm. A cystic right adnexal lesion 54 x 43 mm — requires characterisation on MRI. Additionally: heterogeneous thyroid (ultrasound suggested), hepatic steatosis, gallbladder calculi. Stage: cT2 N1 M1 — IV (TNM).
plain text, no formatting — ready to paste into the record
cT2 N1 M1 — stage IV (TNM)
RECIST Oncologic Teleradiology · sample documentoriginal: PDF with a qualified electronic signature · physician name and licence number
REPORT · CT chest + abdomen + pelvis with contrast · RESPONSE ASSESSMENT
comparison with baseline · same patient, same methodology
EXAMPLE 02 · RESPONSE ASSESSMENT

First treatment-response assessment

Same patient · breast cancer T2N1M1 histologically confirmed · on treatment within a drug programme · first study after therapy start

CLINICAL DATAbreast cancer T2N1M1 · drug programme · first response assessment · comparison with baseline (Example 01)
01

Structured report

with reference to the prior study
CHEST
Thyroid
not enlarged, heterogeneous; possible features of autoimmune thyroiditis — assessment on ultrasound
Lungs
normally aerated; fibrotic/post-inflammatory changes at both lung bases; reduction in size of metastatic lesions: to 8 mm (prev. 13 mm) in segment 3 of the right lung and to 10 mm (prev. 14 mm) in segment 6 of the left lung
Mediastinal lymph nodes
anterior mediastinal node near the sternum 9 mm (prev. 16 mm) in short axis
Trachea and bronchi
patent
Pleural cavities
no effusion
Heart and mediastinum
normal
Esophagus
patent, thin-walled
Pulmonary trunk and arteries
patent
Thoracic aorta
normal
Chest wall
in the upper outer quadrant of the right breast a hypodense area with calcifications 20 × 15 mm (prev. 33 × 27 mm); right axillary lymph nodes up to 11 mm (prev. 17 mm) in short axis
ABDOMEN
Liver
metastasis in segment 8 measuring 29 mm (prev. 45 mm); liver enlarged, with features of steatosis (unenhanced density ~40 HU)
Gallbladder
thin-walled; with a few calculi
Bile ducts
not dilated
Pancreas
normal size; homogeneous; no focal lesions; duct not dilated
Spleen
not enlarged, no focal lesions
Adrenal glands
not enlarged
Kidneys and ureters
no hydronephrosis, no calculi, no focal lesions; symmetric excretion of contrast; ureters not dilated
Urinary bladder
smooth outline, well distended
PELVIS
Reproductive organs
a fluid space with septa and calcifications in the region of the right adnexa 54 × 43 mm — unchanged compared with the prior study; per the provided MRI result benign in nature — for further observation
Lymph nodes
retroperitoneal, mesenteric, inguinal and pelvic nodes not enlarged
Peritoneal cavity
a small amount of free fluid in the pelvis; no peritoneal implants
Bowel
walls not thickened, no pathological enhancement
Abdominal wall
no discernible lesions
Great vessels
patent
SKELETAL SYSTEM
Bones
disseminated metastatic lesions have sclerosed (calcified) during treatment; no new lesions and no pathological fractures; degenerative changes of the thoracic, lumbar and sacral spine
02

Measurement table — RECIST 1.1

comparison with baseline · same lesions, same methodology
#Target lesionBaselineCurrentChange
T1Right breast tumour (upper outer quadrant)33 mm20 mm−13 mm · −39%
T2Liver metastasis (segment 8)45 mm29 mm−16 mm · −36%
T3Right lung lesion (segment 3)13 mm8 mm−5 mm · −38%
T4Left lung lesion (segment 6)14 mm10 mm−4 mm · −29%
T5Anterior mediastinal node (short axis)16 mm9 mm−7 mm · −44%
Sum of diameters (SLD)121 mm76 mm−45 mm · −37,2%
CATEGORY CALCULATION (RECIST 1.1)
  • SLD decrease: (76 − 121) / 121 = −37.2% → partial-response threshold ≤ −30% ✓
  • new lesions: none ✓ · non-target lesions: no progression ✓
  • → category: PR — partial response
New reference point (nadir): 76 mm. Progression on the next study is defined by an SLD increase of ≥ 20% relative to nadir and ≥ 5 mm in absolute terms (i.e. SLD ≥ 91 mm) or the appearance of a new lesion.
NON-TARGET LESIONS — qualitative assessment
  • right axillary lymph nodes: 11 mm (prev. 17 mm) — regression
  • bone metastases: sclerosis during treatment; no new lesions — the picture corresponds to a positive treatment response
  • right adnexal cystic lesion: stable; benign on MRI — outside RECIST assessment
Methodological note: sclerosis of bone lesions during treatment is a typical picture of healing and response, not progression — misreading it as “new sclerotic lesions” is one of the more common pitfalls in response assessment. Bone lesions in RECIST 1.1 remain non-target as a rule. Node T5 shrank below 10 mm in short axis (the normal-node criterion) but is still measured and included in the sum through the end of follow-up.
03

Conclusions — clinically relevant information

copy-ready for the patient record
Partial response to treatment (PR per RECIST 1.1) — sum of target-lesion diameters 121 mm -> 76 mm (-37.2%); compared with the baseline study, same lesions, same methodology. Regression of the right breast tumour, lung and liver metastases, and pathological mediastinal and right axillary lymph nodes. Sclerosis of bone metastases corresponds to a positive treatment response. No new metastatic lesions. New reference point (nadir): SLD 76 mm; progression at SLD >= 91 mm or on appearance of a new lesion. Right adnexal lesion stable, benign on MRI — outside the oncologic assessment.
plain text, no formatting — ready to paste into the record
PR — partial response · nadir SLD 76 mm
RECIST Oncologic Teleradiology · sample documentoriginal: PDF with a qualified electronic signature · physician name and licence number
REPORT · CT abdomen + pelvis with contrast
first-time study · no prior comparison
EXAMPLE 03 · BENIGN RESULT

Suspected renal tumour on ultrasound — CT verification

Male, 55 · left lumbar pain · ultrasound showed a ~30 mm lesion in the mid-portion of the left kidney

CLINICAL DATAleft lumbar pain · ultrasound: ~30 mm lesion in the mid-portion of the left kidney · suspected renal tumour
01

Structured report

organ by organ
SUPRADIAPHRAGMATIC / ABDOMEN
Lungs (supradiaphragmatic)
no focal lesions
Pleural cavities
no effusion
Liver
not enlarged; no focal lesions; homogeneous; normodense
Gallbladder
thin-walled; no calculi
Bile ducts
not dilated
Pancreas
normal size; homogeneous; no focal lesions; duct not dilated
Spleen
not enlarged, no focal lesions
Adrenal glands
not enlarged
URINARY SYSTEM — ANSWER TO THE CLINICAL QUESTION
Both kidneys
normally positioned; normal size; no hydronephrosis; no calculi; no lesions suspicious for malignancy; in the mid-portion of the left kidney a hypertrophied column of Bertin — a normal anatomical variant that can mimic a focal lesion on ultrasound
Ureters
not dilated
Urinary bladder
smooth outline, well distended
PELVIS
Prostate
measuring 43 × 37 mm, with heterogeneous intense enhancement and calcifications; correlation with PSA level advised
Lymph nodes
retroperitoneal, mesenteric, inguinal and pelvic nodes not enlarged
Peritoneal cavity
no effusion
Bowel
walls not thickened, no pathological enhancement
Abdominal wall
no discernible lesions
Great vessels
patent
SKELETAL SYSTEM — LIKELY SOURCE OF SYMPTOMS
Bones
no lesions suspicious for malignancy; degenerative changes of the lumbar and sacral spine; an L4/L5 intervertebral disc herniation with probable compression of the dural sac — detailed assessment on MRI
02

Measurement table

key dimensions and reference points
RECIST 1.1 — not applicable. RECIST response assessment applies to measurable malignant disease — no malignant lesions were found on this study, so no target lesions or response category are defined. Below are the dimensions of clinically relevant findings — for reliable comparison in the future.
StructureSizeCharacterManagement
Lesion described on ultrasound (left kidney)~30 mm (US)hypertrophied column of Bertin — anatomical variantno further oncologic workup
Prostate43 × 37 mmheterogeneous enhancement, calcificationscorrelation with PSA; urological assessment
L4/L5 intervertebral disc—herniation, probable compression of the dural sacMRI of the L-S spine
Methodological note: a hypertrophied column of Bertin is normal renal parenchyma bulging between the renal pyramids. On ultrasound it can be indistinguishable from a tumour — on contrast CT it enhances identically to the rest of the parenchyma, which resolves the doubt. It is one of the most common causes of a false-positive suspicion of a renal tumour on ultrasound.
03

Conclusions — clinically relevant information

copy-ready for the patient record
CT shows no left renal tumour — the lesion described on ultrasound corresponds to a hypertrophied column of Bertin (a normal renal anatomical variant). No features of malignancy within the scan range; RECIST assessment not applicable. Prostate 43 x 37 mm, with heterogeneous enhancement and calcifications — correlation with PSA level and urological assessment advised. An L4/L5 disc herniation with suspected compression of the dural sac — the likely source of the reported pain; further assessment on lumbosacral spine MRI advised.
plain text, no formatting — ready to paste into the record
No features of malignancy within the scan range
RECIST Oncologic Teleradiology · sample documentoriginal: PDF with a qualified electronic signature · physician name and licence number
REPORT · CT chest + abdomen + pelvis with contrast · RESPONSE ASSESSMENT
comparison with a pre-treatment study (provided by the patient)
EXAMPLE 04 · COMPLETE RESPONSE

Response to chemotherapy — seminoma

Male, 27 · right testicular seminoma · after right orchidectomy · on chemotherapy

CLINICAL DATAright testicular seminoma · after right orchidectomy · on chemotherapy · response assessment
01

Structured report

with reference to the prior study
CHEST
Thyroid
not enlarged, homogeneous
Lungs
normally aerated; no consolidations; no lesions suspicious for malignancy
Mediastinal lymph nodes
not enlarged
Trachea and bronchi
patent
Pleural cavities
no effusion
Heart and mediastinum
normal
Esophagus
patent, thin-walled
Pulmonary trunk and arteries
patent
Thoracic aorta
normal
Chest wall
no lesions
ABDOMEN
Liver
not enlarged; no focal lesions; homogeneous; normodense
Gallbladder
thin-walled; no calculi
Bile ducts
not dilated
Pancreas
normal size; homogeneous; no focal lesions; duct not dilated
Spleen
not enlarged, no focal lesions
Adrenal glands
not enlarged
Kidneys and ureters
normally located; no hydronephrosis; no calculi; no focal lesions; ureters not dilated
Urinary bladder
smooth outline, well distended
LYMPH NODES — ANSWER TO THE CLINICAL QUESTION
Retroperitoneal lymph nodes
previously pathological left para-aortic nodes now not enlarged: up to 8 mm in short axis (prev. 23 mm). Mesenteric, inguinal and pelvic nodes not enlarged
Prostate
measuring 33 × 30 mm, symmetric
Peritoneal cavity
no effusion
Bowel
walls not thickened, no pathological enhancement
Abdominal wall
no discernible lesions
Great vessels
patent
SKELETAL SYSTEM
Bones
no lesions suspicious for malignancy
02

Measurement table — RECIST 1.1

comparison with the pre-treatment study
#Target lesionPre-treatmentCurrentChange
T1Left para-aortic lymph nodes (short axis)23 mm8 mm−15 mm · −65%
Sum of diameters (SLD)23 mm8 mm−15 mm · −65%
CATEGORY CALCULATION (RECIST 1.1)
  • target node: short axis 8 mm < 10 mm → normal-node criterion met ✓
  • other target lesions: none ✓ · non-target lesions: resolved ✓ · new lesions: none ✓
  • → category: CR — complete response
Methodological note: in RECIST 1.1 complete response (CR) for lymph nodes does not require them to disappear entirely — a short-axis reduction below 10 mm is sufficient. The 8 mm node remains visible and is still measured, but meets the normal-node criterion. A CR requires confirmation on the next follow-up study.
03

Conclusions — clinically relevant information

copy-ready for the patient record
Complete response to treatment (CR per RECIST 1.1) — compared with the pre-treatment study. Complete regression of the previously enlarged left para-aortic lymph nodes: 23 mm -> 8 mm in short axis (nodal normality criterion < 10 mm met). No other target lesions, non-target lesions resolved, no new lesions. No features of recurrence or metastases within the scan range. Confirmation of response on the next follow-up study is advised, per the treatment protocol.
plain text, no formatting — ready to paste into the record
CR — complete response to treatment
RECIST Oncologic Teleradiology · sample documentoriginal: PDF with a qualified electronic signature · physician name and licence number

This report structure can work for your centre

A structured report, a RECIST table and conclusions ready for drug-programme documentation — in every study, for every patient, by the same methodology.

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