Based on our experience, we believe that particular caution should be exercised in reporting Lung-RADS 1 category for patients with adenopathy/pleural effusion with no lung nodules, as a majority of the lung cancer screening scans will be ordered by PCPs who may not necessarily have expertise in interpreting CT scans of the chest and may not have time to look at scans in their busy practices and may rely on the radiologist's final interpretation of the scans, which, as in our cases, will be rightfully reported as Lung-RADS 1 (benign). Lung-RADS has the potential to significantly decrease the false-positive results in patients undergoing LDCT for lung cancer screening. In the long run, it may be more cost-effective than the NLST protocol. However, as with any new system, an ongoing evaluation of the performance of Lung-RADS should be conducted so that the sensitivity and mortality benefit seen in the NLST trial is not compromised. As prospective performance characteristics of Lung-RADS become available, it is expected that it will be revised, similar to the process the ACR has used to revise the Breast Imaging Reporting and Data System classification scheme for breast cancer screening, which is now in its fifth edition. We strongly believe, based on our experience with these four cases, that the new version of Lung-RADS, version 2.0, should incorporate these shortcomings and have a separate category for findings that are highly suspicious for malignancy but do not have an accompanying lung nodule.