Lung cancer screening using low dose CT scan reduces lung cancer specific and overall mortality in high risk patients. A significant limitation of lung cancer screening is the false positive rates. The American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS)was designed to standardize reporting of low dose lung cancer screening scans and also to decrease the false positive rates without significantly compromising on the sensitivity. Implementing Lung-RADS can also improve cost effectiveness. Lung-RADS, however, has never been studied in a prospective fashion. Lung-RADS does not have a specific reporting category for patients with isolated hilar and mediastinal adenopathy or pleural effusion in the absence of lung nodules. We report four such cases in our lung cancer screening program. We believe that this is a significant limitation of Lung-RADS and should be revised in its new version.