lung tumor radiology
TRANSCRIPT
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Imaging of Lung
Tumors
Roshan Valentine
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Outline • Introduction
• Carcinoma bronchus - pathology, symptoms - radiological features - diagnostic imaging - staging - assessing treatment
• Rare primary malignant neoplasms• Benign pulmonary
tumors• Intrathoracic lymphoma
and leukemia• Metastatic lung disease• Evaluation of solitary
pulmonary nodule
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Introduction
• A wide variety of neoplasms arise in the lungs
• Many are overtly malignant, others are definitely benign
• Some fall in between these two extremes
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Introduction• Lung cancer is the most common cause of cancer death in
developed countries.
• The prognosis is poor, with less than 15% of patients surviving
5 years after diagnosis. The poor prognosis is attributable to lack of
efficient diagnostic methods for early detection and lack of
successful treatment for metastatic disease.
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Introduction
• The usefulness of the various imaging examinations largely depends on the clinical findings at the time of presentation and also on the stage of the disease
• Many imaging modalities are used to further evaluate the findings seen on the previous imaging and to determine the stage of the disease.
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Bronchial carcinoma• Most common cause of cancer in men
• 6th most frequent cancer in women
• Leading cause of cancer mortality worldwide – 20%
• In India, approximately 63,000 new lung cancer cases are reported each year.
• Major risk factor is cigarette smoking which is implicated in 90% of cases.
• Other risk factors include radon, asbestos, uranium, arsenic, chromium
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Pathology
• NSCLC(80%)• Squamous(35%)
• Smoking , cavitate , poor prognosis• Adeno (30%)
• Women , non-smokers, peripheral• Large cell (15%)
• SCLC (20%)• Smoking, metastasises early, paraneoplastic syndromes and SVC
obstruction• Worst prognosis
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Clinical features
• Cough, wheeze, sputum production, breathlessness, chest discomfort, hemoptysis
• Asymptomatic(20%)
• Finger clubbing, SVC obstruction, Horner’s syndrome, chest wall pain, dysphagia, pericardial tamponade
• Abnormal CXR in asymptomatic patients
• Paraneoplastic syndromes
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Radiological features
• Reflect pathology
• Depend on size, site, histology
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Radiological features
1. Hilar enlargement
2. Airway obstruction
3. Peripheral mass
4. Mediastinal involvement
5. Pleural involvement
6. Bone involvement
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Hilar enlargement
• Enlargement or increased density- 1 central tumor
• Peripheral tumors - Bronchopulmonary lymph nodes
• Extensive hilar and mediastinal lymphadenopathy - small
cell tumors
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Hilar enlargement
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Airway obstruction
• Collapse – segmental / lobar / entire lung• Consolidation – infection distal to obstruction prior to
collapse – absent air bronchogram
• Mucocele or bronchocele due to mucoid impaction
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Airway obstruction
Central mass
• Shape of the collapsed or consolidated lobe may be altered
because of the bulk of the underlying tumor
• Fissure in the region of the mass is unable to move in the
usual manner , and fissure may show a bulge – Golden S sign
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Airway obstruction
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Airway obstruction Bronchocele
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Peripheral mass
• Common presentation of lung Ca• Larger; poorly defined, lobulated, umbilicated or spiculated
margins (Corona radiata)• Satellite opacities – more in benign than malignant • Calcification – diffuse or central • Doubling time – 1-18 months ; >2 yrs – benign
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Peripheral mass• Cavitation – central necrosis or abscess formation
• Malignant cavities – thick walled, irregular nodular
inner margin
• Pancoast/ superior sulcus tumors – lung apex – tendency to invade
ribs, spine, brachial plexus, and inferior cervical sympathetic
ganglia
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Peripheral mass
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Peripheral mass
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Pancoast tumor
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Mediastinal involvement
• Lymph nodes : SCLC, mediastinal widening, lobulated outline
• Esophagus : compression or invasion - barium swallow
• Phrenic nerve : elevated hemidiaphragm, paradoxical movement on fluoroscopy
• SVC : obstruction on dynamically enhanced CT/MRI
• Pericardial invasion : pericarditis or pericardial effusion
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Mediastinal involvement
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Mediastinal involvement
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Pleural involvement
• Pleural effusion : direct spread, lymphatic obstruction,
obstructive pneumonitis, sympathetic response
• Spontaneous pneumothorax : cavitating subpleural tumor
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Bone involvement
• Direct invasion : peripheral carcinomas-ribs / spine
• Hematogenous : lytic, identified earliest by isotope bone scan
• Hypertrophic osteoarthropathy – well defined periosteal new
bone formation
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Diagnostic imaging
• The prognosis and treatment of lung cancer depends
on the general condition of the patient and on the histology
of the tumor and its extent at the time of presentation
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Diagnostic imaging
• SCLC – metastasise early, disseminated at presentation, chemosensitive
• NSCLC – metastasise later, esp. squamous
• Central tumors – sputum cytology, bronchoscopic biopsies or washings
• Peripheral tumors – percutaneous biopsy with fluoroscopic,
CT or USG guidance
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Diagnostic imaging
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Staging
Purposes
• Identify patients with NSCLC who will benefit from surgery
• To avoid surgery in those who will not benefit
• To provide accurate data for assessing and
comparing different methods of treatment
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Staging
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Staging
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T1
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T2
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T3
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T4
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Nodal stagIng
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N1
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N2
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N3
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Alveolar cell carcinoma
• Bronchiolar or bronchio-alveolar Ca
• Subtype of adeno Ca
• Peripherally, probably from type II pneumocytes
• Not associated with smoking
• May be associated with diffuse pulmonary fibrosis and pulmonary scars
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Alveolar cell carcinoma
Two patterns:
• Focal form – solitary peripheral mass, air bronchograms often visible, may spread via airways to progress to diffuse pattern
• Diffuse form – multiple acinar shadows, with areas of confluence
CT : ground glass opacification, small nodular opacities, frank consolidation, thickened interlobular septa
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Alveolar cell carcinoma
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Rare primary malignant neoplasms
Pulmonary Kaposi’s sarcoma • AIDS• Segmental or lobar consolidation• Multiple nodular and linear opacities• Pleural effusions• Hilar and mediastinal lymphadenopathy
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Rare primary malignant neoplasms
Pulmonary artery angiosarcoma• Hilar mass• Signs of pulmonary embolism and pulmonary artery
hypertension
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Rare primary malignant neoplasms
• Fibrosarcoma• Leiomyosarcoma• Carcinosarcoma• Pulmonary blastoma • Malignant hemangiopericytoma
Often present as solitary pulmonary mass radiologically indistinguishable from a carcinoma of the lung
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Benign pulmonary tumors
• Bronchial carcinoid
• Pulmonary hamartoma• Bronchial chondroma
• Pulmonary fibroma
• Pulmonary myxoma
• Plasma cell granuloma
• Bronchial papilloma
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Bronchial carcinoid
• Neuroendocrine tumors derived from APUD cells
• Typical(90%) and atypical
• 80% arise in lobar or segmental bronchi
• Cause bronchial obstruction, collapse, recurrent segmental pneumonia, bronchiectasis, abscess formation.
• Peripheral carcinoids –well circumscribed round or ovoid solitary nodules
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Bronchial carcinoid
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Pulmonary hamartoma
• Consists of abnormal arrangement of tissues normally found in
the organ concerned
• Large cartilaginous component, and appreciable fatty component
• Solitary nodule in an asymptomatic adult
• Rare in childhood
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Pulmonary hamartoma
• Peripheral
• Well circumscribed nodules
• Do not cavitate
• Low density within denotes fat
• 30% show calcification on x-ray with popcorn appearance
• Grow slowly on serial films
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Pulmonary hamartoma
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Intrathoracic lymphoma and leukemia
Hodgkin’s disease • MC lymphoma
• Usually arises in lymph nodes – hilar or mediastinal node enlargement on CXR
• Lymphadenopathy – frequently bilateral, asymmetrical, involves anterior
mediastinal glands
• CT – Paraspinal and retrosternal nodes
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Hodgkin’s disease • Involves lung parenchyma in 30%
• Pulmonary infiltrate may appear as solitary areas of consolidation,
larger confluent areas or miliary nodules
• Pulmonary opacities may have an air bronchogram and may cavitate
• Pleural effusion due to lymphatic obstruction, pleural plaques may
be seen
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Hodgkin’s disease
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Non – Hodgkin’s disease
• Radiologic manifestations are similar to Hodgkin’s disease
• Progression of disease is less orderly
• Pulmonary and pleural involvement precedes mediastinal disease
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Non – Hodgkin’s disease
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Pseudolymphoma
• Tumor like condition which behaves benignly
• Focal
• Solitary or multiple areas of pulmonary consolidation
• Air bronchogram, cavitation may occur
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Lymphomatoid granulomatosis
• Angiocentric, angiodestructive lymphoreticular, proliferative and
granulomatous disease predominantly involving the lungs
• A T-cell non-Hodgkin’s lymphoma
• Multiple ill defined nodules resembling metastases
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Lymphomatoid granulomatosis
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Leukemia
• Radiographic abnormalitites are due to the complications of the disease
• Mediastinal lymph node enlargement, pleural effusion, pulmonary
infiltrates
• More common in lymphatic than myeloid leukemia
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Metastatic lung disease
• Hematogenous > lymphatic > Endobronchial
• Primaries – breast, skeleton, urogenital system, colon, melanoma
• Bilateral ,basal predominance, often peripheral and subpleural
• Spherical, well defined margins
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Metastatic lung disease
• Cavitation – Squamous carcinomas and sarcomas
• Calcification – Osteosarcoma, chondrosarcoma, mucinous
adenocarcinoma
• Endobronchial metastases – Ca kidney, breast, colon
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Metastatic lung disease
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Metastatic lung disease
Lymphangitis carcinomatosa
• Hematogenous metastases occluding peripheral pulmonary lymphatics
• Lung, breast, stomach, pancreas, cervix and prostate
• CXR - Coarse, linear, reticular and nodular basal shadowing, pleural effusions and hilar lymphadenopathy
• HRCT – Nodular thickening of interlobular septa, thickening of centrilobular bronchovascular bundles
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Metastatic lung disease Lymphangitis carcinomatosa
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Solitary pulmonary nodule
• Defined as a solitary circumscribed pulmonary opacity 3 cm in diameter with no associated pulmonary, pleural or mediastinal abnormality
• 40% of SPNs are malignant
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Solitary pulmonary nodule
Causes• Bronchial carcinoma• Bronchial carcinoid• Granuloma• Hamartoma• Metastases• Chronic pneumonia or
abscess• Hydatid cyst• Pulmonary hematoma
• Bronchocele• Fungus ball• Massive fibrosis in coal workers• Bronchogenic cyst• Sequestration• AVM• Pulmonary infarct• Round atelectasis
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Solitary pulmonary nodule
Mimics
• Extrathoracic artefacts
• Cutaneous masses
• Bony lesions
• Pleural tumors or plaques
• Encysted pleural fluid
• Pulmonary vessels
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Solitary pulmonary nodule
Factors to differentiate• Size• Calcification• Enhancement• Growth rates• Shape• Margin
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SIZE• >3cm : Malignant unless proved otherwise
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Calcification
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Enhancement on ct• Post contrast : > 20HU s/o malignancy
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GrowthW.r.t Doubling time of the lesion• Malignant : 1-6months• Benign : > 18months
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Shape• Polygonal shape • Three-dimensional ratio > 1.78 - sign of benignity
A
B
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margin
• Corona radiata sign - highly associated with malignancy • Lobulated or scalloped margins - intermediate
probability• Smooth margins - more likely benign
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Air Bronchogram sign
• A/w malignancy
• Bronchoalveolar ca and adenocarcinoma
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