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The imaging manifestations of lung cancer

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The Imaging Manifestations of Lung Cancer
Tan-Lucien H. Mohammed, MD,* Charles S. White, MD and Robert D. Pugatch, MD

Imaging plays an integral role in diagnosing, staging, and following patients with lung
cancer. Many lung neoplasms are detected on chest radiographs, but the majority of
patients have advanced stage disease at the time of presentation. There is a wide spectrum
of radiologic manifestations of lung cancer, and recognition of these findings is essential
for patient management. As we continue to understand more about tumor biology, new
imaging techniques likely will emerge. Nevertheless, the chest radiograph and CT remain
important tools in establishing the diagnosis of lung cancer.
Semin Roentgenol 40:98-108 2005 Elsevier Inc. All rights reserved.

L ung cancer is the leading cause of cancer-related deaths

in the world, with approximately 172,000 new cases oc-
curring this year in the United States alone.1-3 The dismal
prognosis of lung cancer is directly associated with its de-
layed presentation. Signs and symptoms are rarely present
until the malignancy has become advanced and possibly un-
resectable. The most favorable prognoses are those found in
patients with stage IA (T1N0M0) disease. These patients have
a 61 to 75% 5-year survival following surgical resection.4,5
Nevertheless, approximately one-half of all lung cancers have
extrapulmonary spread at the time of diagnosis. As a result,
the average patient with a diagnosis of lung cancer has a
5-year survival of 10 to 15%.6
Therefore, a prompt and accurate diagnosis of lung cancer
is essential to providing the patient with a potential for cancer
cure.7 Noninvasive testing for lung cancer most frequently
includes chest radiography, CT scan, MR imaging, or PET
scanning. The first two of these modalities and their pitfalls
are considered in this article.
Nodules and Masses
Lung cancer may manifest either peripherally or centrally. By
definition, a solitary pulmonary nodule (SPN) is any intrapa-
renchymal lesion that is 3 cm in diameter and is not asso-
ciated with adenopathy or atelectasis.8 Lung lesions 3 cm in
size are defined as lung masses. One in 500 chest radiographs
demonstrates a lung nodule. Nearly 90% of these are inci-
*Section of Thoracic Imaging, Department of Diagnostic Radiology, The
Cleveland Clinic Foundation, Cleveland, OH.
Section of Thoracic Imaging, Department of Diagnostic Radiology, Univer-
sity of Maryland Medical Center, Baltimore, MD.
Address reprint requests to Charles S. White, MD, Department of Diagnostic
Radiology, 22 S. Greene Street, Baltimore, MD 21201. E-mail:
cwhite@umm.edu
dental and are found unexpectedly on radiographs obtained
for unrelated diagnostic work-ups. Annually, more than
150,000 patients in the United States present with a SPN.
This number has increased further due to incidental findings
of lung nodules on thoracic CT.7 Most peripheral lung can-
cers are adenocarcinomas, although the other major cell
types occasionally occur peripherally.
When a new intrathoracic nodule is encountered, a myriad
of diagnoses should be considered including neoplastic, in-
fectious, inflammatory, vascular, traumatic causes and,
rarely, congenital lesions.9 Other benign etiologies include
intrapulmonary lymph nodes, plasma cell granulomas, rheu-
matoid nodules, and sarcoidosis. Although most pulmonary
nodules are benign, primary lung cancer may be found in
approximately 35% of pulmonary nodules.10 Solitary metas-
tases account for an additional 23%.11-13 Clinical character-
istics such as tobacco usage, prior history of cancer, and older
age all increase the probability that a pulmonary lesion is
malignant.14 Imaging characteristics (as noted below) can
also influence the probability of malignancy. Overall, all pul-
monary nodules should be considered malignant until
proven otherwise.15
When lung cancer arises centrally, common manifesta-
tions are a hilar mass or secondary lobar atelectasis due to
obstruction of a main bronchus. The extent of postobstruc-
tive atelectasis depends on the completeness of bronchial
occlusion and the degree to which collateral air drift allows
aeration of the distal lung. Clinically, a postobstructive pneu-
monia occurs in a minority of patients. Most frequently, cen-
tral lung cancer is of squamous or small-cell histological
types.
Chest Radiography
Chest radiography plays a critical role in the initial evaluation
and subsequent diagnosis of lung cancer. Chest radiographs

98 0037-198X/05/$-see front matter 2005 Elsevier Inc. All rights reserved.

doi:10.1053/j.ro.2005.01.002
Imaging manifestations of lung cancer 99

Figure 1 Seventy-one-year-old man with a cavitary lung cancer and idiopathic pulmonary fibrosis (IPF). (A) Chest
radiograph shows a left mid-lung cavitary lesion with a shaggy relatively thick wall and coarse reticular opacities
predominantly involving the peripheral and basal aspects of both lungs. (B) Unenhanced chest CT (lung window)
shows the thick-walled cavitary lesion communicating with a central bronchus and peripheral reticular opacities with
honeycombing.

are easily accessible, quickly obtained, relatively inexpensive

and can be assessed by both the clinician and the radiologist.7
In the asymptomatic patient, an abnormality on the chest
radiograph may be the first clue to the presence of lung
cancer. In symptomatic patients, a chest radiograph may of-
ten strongly support a suspicion of lung carcinoma. For pa-
tients presenting with either nonspecific systemic complaints
or symptoms suggestive of metastatic disease, the chest ra-
diograph can help in focusing attention quickly to the lung as
a potential primary site. Nearly all lung cancer is found on
chest radiographs or incidentally on CT.
Once a pulmonary lesion is encountered, an important
next step is comparison with old radiographs. Benign lesions
typically have a prolonged doubling time of 16 months.16
Doubling times of malignant nodules have been calculated
from 40 to 360 days.17 Conventionally, growth stability over
a 2-year interval is considered a reliable indicator for benign
disease.6,18 CT is more sensitive in detecting changes in size of
an SPN than chest radiographs, especially for small nodules,
because doubling in tumor volume may result in a change in
diameter of only a few millimeters.
Characteristics of the nodule on chest radiography may be
valuable. The presence of a spiculated margin, often termed a
corona radiata, indicates a high likelihood of a malignant
lesion, although a benign process such as a round pneumonia
or scar may also manifest this sign. Cavitation may occur
within nodules and masses. In malignant lesions, cavitation
typically is thick-walled and irregular (Fig. 1).
Detection of calcification in a pulmonary lesion is particu-
larly important, because certain patterns of calcification are
associated with a very high likelihood that the nodule is
benign. Organized patterns of calcification, such as pop- Figure 2 Forty-eight-year-old man with a pulmonary hamartoma.
corn type (often seen in hamartomas), lamellar concentric Chest radiograph demonstrates a left mid-lung nodule containing a
rings of calcium, central calcification, or homogeneous dense dense popcorn pattern of calcification (arrow).
100
Figure 3 Fifty-four-year-old man with squamous cell carcinoma. Posteroanterior (A) and lateral (B) chest radiographs
show homogeneous opacity obscuring the left hilum that obscures the upper left heart border (A) (arrows) and forms
a band of opacity anteriorly on the lateral radiograph (B) (arrows) consistent with left upper lobe collapse. There is mild
compensatory ipsilateral shift of the mediastinum.
calcification all carry an extremely low likelihood of malig-
nancy (Fig. 2). Not all nodules that contain calcification are
benign. Certain patterns of calcification are considered radio-
logically indeterminate, meaning that they neither increase
nor decrease the likelihood of malignancy compared with a
noncalcified nodule. These indeterminate patterns include
stippled fine calcification and eccentric calcification.
Radiographic manifestations of central lesions are a hilar or
perihilar mass with or without distal lung collapse (Fig. 3). In
some instances, the hilar mass may be distinguished from
associated collapse, particularly in the right upper lobe where
the normal upward movement of the minor fissure in benign
atelectasis is incomplete due to a central bulge created by the
tumor (Fig. 4). The resulting sigmoid-shaped appearance of
the lateral margin of the collapsed right upper lobe and the
associated hilar mass is termed the S sign of Golden.
If the abnormality is new, or if older radiographs are un-
available, CT has proven helpful to further characterize pul-
monary lesions. CT can often supplement the chest radio-
graphs by detecting mediastinal lymph node metastases and
chest wall and mediastinal invasion that provide more accu-
rate staging of the tumor.
Computed Tomography
For all newly discovered or indeterminate pulmonary le-
sions, a CT is warranted. CT offers ideal imaging for localiza-
tion and characterization of a nodule. The ability of CT scan-
ning to evaluate the entire thorax at the time of nodule
assessment is of further benefit. The recent advent of multi-
slice scanners has led to advances in image resolution with a
T.L. Mohammed, C.S. White, and R.D. Pugatch
substantial reduction in both tube loading and scanning time
as up to 64 slices can be acquired simultaneously. Less respi-
ratory motion artifact occurs with multislice scanners due to
their shorter scanning times. The role of IV contrast in the
evaluation of SPNs is evolving. In routine practice, IV con-
trast is not considered necessary for detecting pulmonary
nodules, since nodules inherently stand out from surround-
ing aerated lung parenchyma. However, for characterization
of nodules, contrast enhancement may be useful (see below).
In addition, mediastinal lymphadenopathy, metastasis to the
adrenal glands, liver, or bone and additional pulmonary le-
sions that may not be visible on chest radiography may be
more apparent on CT. Chest CT can also help in assessing the
chest wall, mediastinum, or diaphragm for invasion.
Many SPNs have a characteristic benign appearance on
CT. For example, a nodule containing a fat density can be
classified as a hamartoma (Fig. 5). Arteriovenous fistulas
demonstrate the presence of a feeding artery and a draining
vein as well as contrast enhancement on CT. A dense comet
tail sign on CT suggests rounded atelectasis (Fig. 6). A nod-
ular density within a cavity suggests a fungal etiology. Pul-
monary infarcts may be characterized on CT as a wedge-
shaped density abutting the pleura and containing air
bronchograms.7
As on chest radiography, nodules on CT that are ill-de-
fined or have irregular or spiculated margins suggest malig-
nancy (Fig. 7). In fact, 84 to 90% of spiculated nodules are
malignant.19,20 Lung nodule size is also a good indicator of
the likelihood of malignancy. If a nodule is found to measure
more than 2 cm in size, it has a greater likelihood of being
malignant, compared with a 50% rate of malignancy in all
Imaging manifestations of lung cancer
Figure 4 Forty-eight-year-old woman with squamous cell carcinoma. (A) PA chest radiograph reveals right upper lobe
atelectasis with abnormal convexity at the right hilum (arrow). (B) Contrast-enhanced chest CT (mediastinal window)
demonstrates a central endobronchial tumor obstructing the right upper lobe bronchus with associated right upper
lobe atelectasis (arrow).
nodules less than 2 cm.21 A lesion found to be greater than 3
cm in size has a very high incidence of malignancy and is
termed a mass. Air bronchograms and pseudocavitation are
characteristics seen on CT imaging that are more common in
malignant (30%) than benign (5%) lesions.19 Cavitation of a
nodule is also consistent with malignancy; however, infec-
tious and inflammatory etiologies may have similar presen-
tations. In these situations, wall thickness can aid in deter-
mining the probability that an SPN is benign or malignant
(Fig. 1).
As CT technology has improved, smaller lung nodules are
now more easily detected. Many of these are benign, such as
granulomas or intrapulmonary lymph nodes.22 Most typi-
cally, intrapulmonary lymph nodes are 1 to 2 mm in diameter
and are located in the posterior basal subpleural portions of
the lungs. These small nodules are generally indeterminate
by imaging criteria, and they are too small to be imaged with
PET or sampled by percutaneous biopsy. This dilemma is
discussed in more detail in the article on lung cancer screen-
ing.
While CT can be extremely specific for certain benign
lesions, many abnormalities remain indeterminate and
lung cancer cannot be excluded. For those SPNs with in-
determinant morphology, IV contrast enhancement with
helical CT imaging may be a helpful adjunct. Swensen and
coworkers found nodules enhancing to 20 Hounsfield
Units to be a predictive feature of malignancy while con-
trast enhancement 15 Hounsfield Units was characteris-
101
tic of a benign lesion with a sensitivity of 98%, specificity
of 73%, and 85% of accuracy.23
In the setting of an indeterminate nodule, options include
follow-up with serial CT scanning, PET scanning, or an in-
vasive procedure such as bronchoscopy, transthoracic needle
biopsy, or surgery.
Pitfalls of Lung Cancer Imaging
Over- and underdiagnosis of lung cancer remains a serious
problem by both chest radiography and CT. Overdiagnosis
may lead to unnecessary diagnostic testing and invasive pro-
cedures. Underdiagnosis may lead to missed lung cancer, a
lethal outcome, and medicolegal action.
Of more than 100,000 medicolegal cases collected from
1985 to 1995 by a large data-sharing organization and en-
compassing all medical specialties, actions involving malig-
nant neoplasms of the bronchus or lung were the sixth most
common. Among radiologists, errors in diagnosis of lung
cancer were the second most common cause for litigation,
after malignant neoplasms of the female breast. Approxi-
mately 90% of the alleged errors in diagnosis of lung cancer
occurred on chest radiographs, 5% on CT scans, and 5% on
other studies. Forty-five percent resulted in indemnity pay-
ments, which averaged $150,000 (Lori Bartholomew, Physi-
cian Insurers Association of America, personal communica-
tion).
102
Figure 5 Thirty-eight-year-old man with a pulmonary hamartoma. CT
scan demonstrates a right middle lobe nodule with extensive popcorn
calcification and intervening areas of fat attenuation (arrow).
Figure 6 Fifty-two-year-old woman with round atelectasis. (A) Unenhanced chest CT (lung window) shows a subpleu-
ral mass with infolding of adjacent strands of lung, termed the comet-tail sign (arrow). (B) Unenhanced chest CT
(mediastinal window) window reveals pleural thickening adjacent to the pleural mass (arrow).
T.L. Mohammed, C.S. White, and R.D. Pugatch
Etiologies of Missed Lung Cancer
A conventional classification of factors that contribute to
missed lung cancer include those arising from observer error,
lesion characteristics, or technical considerations.24
Observer error is probably the most important factor.
Kundel and coworkers described three types of observer er-
ror.25 A scanning error is defined by nonfixation of a nodule
during the 350 msec that a lesion is focused on the fovea. A
recognition error results if a lesion is scanned adequately but
is not detected. A decision-making error is caused by incor-
rect interpretation of a recognized abnormality as normal
(Fig. 8). Among 20 errors by four observers who interpreted
36 chest radiographs with simulated nodules, scanning er-
rors, recognition errors, and decision-making errors ac-
counted for 30, 25, and 45%, respectively, of observer errors.
Satisfaction-of-search error, or tunnel vision, is a separate
observer error that may contribute to missed lung cancer. In
this situation, the radiologist is distracted by important but
unrelated radiographic abnormalities, leading to failure to
diagnose a lung cancer (Fig. 9). One study demonstrated
reduced nodule detection on radiographs when other major
abnormalities were present, confirming the importance of
satisfaction of search error.26
Lesion characteristics are important determinants of the
likelihood of diagnosing an early lung cancer. The size of a
lesion is of great importance (Fig. 10). The smallest lesion
that can be visualized on chest radiographs, even in retro-
spect, is 4 mm. Studies using simulated nodules of 1 cm on
chest radiographs have demonstrated a false-negative error
Imaging manifestations of lung cancer 103

Figure 7 Fifty-one-year-old man with COPD and a peripheral ade-
nocarcinoma. Unenhanced CT (lung window) shows a spiculated
nodule in the right upper lobe and saber-sheath deformity of the
trachea.
rate ranging from 40 to 87%. In a retrospective study of
overlooked lung cancer by Austin and coworkers, 31% of
overlooked lesions were greater than 2 cm in diameter.27
Thus, it is clear that size is not the only lesion characteristic
that affects detection of lung nodules.
Lesion conspicuity is of crucial importance in the detect-
ability of lung cancer.28 Conspicuity refers to the extent to
which a lesion is distinguishable from adjacent opacities that
may impair its visibility (or more simply, the extent to which
it stands out) (Fig. 10). The term encompasses both the den-
sity of the nodule itself and the structures that reduce visibil-
ity such as ribs, clavicles, or blood vessels that project adja-
cent to or over the nodule. Although lesion conspicuity is a
useful concept, a rigorous definition remains elusive.
Technical considerations may have a role in failure to di-
agnose lung cancer. An anteroposterior examination may be
a contributing factor particularly if portable technique is
used. In a study by Latief and coworkers, the mean diameter
of overlooked lung cancer on anteroposterior radiographs
was 2.3 cm.29 Patient motion or a suboptimal inspiratory
effort increases the likelihood that a lung lesion will be over-
looked. Other factors such as film contrast, density, and kvp
affect the detectability of a lesion. In general, wide-latitude,
low-contrast technique (130 to 140 kvp) is preferred because
it provides more uniform film exposure than low kvp tech-
nique. The use of digital radiography decreases the variability
of the image appearance.30 As compared with film-screen
radiography, digital radiography leads to similar effectiveness
of nodule detection and permits the use of computer-aided
detection (CAD).
Definition of
Malpractice in Missed Lung Cancer
In general, negligence is the legal criterion that is used to
decide whether malpractice has occurred in cases of missed
lung cancer. Negligence can be shown if a radiologist
breaches the standard of care (that exercised by a reasonably

Figure 8 Seventy-four-year-old man with missed lung cancer due to decision-making error. (A) An indistinct focal
opacity is visible in the left upper lobe (arrow). (B) Coronal reconstruction of unenhanced chest CT (lung window)
demonstrates an irregular nodular lesion in the posterior aspect of the right upper lobe nodule. The nodule was
presumably overlooked prospectively due to its small size and/or being mistaken for the first left costochrondal
junction.
104
Figure 9 Fifty-five-year-old man with missed lung cancer. (A) PA chest radiograph shows a pacemaker obscuring a
substantial portion of the left mid-lung. (B) Detailed view shows a partially hidden lung mass projecting medial to the
pacemaker (arrow). Satisfaction-of-search error likely contributed to failure to detect this lesion.
prudent physician) by failing to diagnose a lung cancer, and
that this failure to diagnose is a proximate cause of substantial
injury to the patient. Although it is possible to breach the
standard of care and not be found liable because of a lack of
proximate cause or substantial injury, it is far easier to argue
that the standard of care was not breached. Unfortunately,
even this defense is not straightforward.
Plaintiff attorneys routinely argue that any missed lung
cancer constitutes malpractice, but compelling evidence in
the radiologic literature suggests that overlooked lung cancer
does not necessarily indicate negligence. Muhm and cowork-
ers used chest radiographs to screen for early lung cancer at
4-month intervals in a large cohort of men who were heavy
smokers.31 Of 50 peripheral lung cancers that were diag-
nosed, 45 (90%) were visible in retrospect on a radiograph 4
months earlier. Four cancers (8%) were visible in retrospect 2
years before diagnosis, and one of these was visible 53
months earlier. Twelve (75%) of 16 perihilar lesions were
also visible on prior examinations. In this study, failure to
diagnose lesions occurred despite a high level of suspicion on
the part of at least two interpreters. It is clear that the expec-
tation that radiologists can or should be able to diagnose all
lung cancers is unreasonable.
Because there is no rigorous definition as to what consti-
tutes standard of care in the diagnosis of early lung cancer,
the final decision typically relies on the ability of the experts
of each of the contesting parties to persuade the judge or jury
that their definition is correct. The conspicuity of a lesion (as
defined previously) probably is the single most important
factor in determining whether the standard of care has been
breached. A lesion of high conspicuity (ie, an obvious lesion)
T.L. Mohammed, C.S. White, and R.D. Pugatch
is far more likely to be associated with an adverse legal out-
come.28
Strategies to Reduce Missed Lung Cancer
Complete elimination of the missed lung cancer is an unre-
alistic goal, but an appropriate goal would be to substantially
reduce the rate of overlooked lung cancer, especially among
lesions of high conspicuity. Several methods of error rate
reduction have been suggested. In a previous study of lung
cancer litigation by the Physician Insurers Association of
America, an organization of liability companies owned or
directed by physicians and dentists, a major factor in the
occurrence of overlooked lung cancer was failure to compare
the radiograph on which misdiagnosis was alleged with per-
tinent prior examinations. Similarly, in a study of missed
bronchogenic cancer, failure to compare with one or a se-
quence of prior radiographs was the most common cause of
interpretive error.27 A separate approach to decreasing error
would be to emphasize the need to avoid satisfaction of
search error, since it appears to be an important contributor
to the failure to diagnose cancer in the presence of unrelated
major findings.
CAD-based strategies may also be valuable to reduce
missed lung cancer on chest radiography if digital radiogra-
phy techniques are used. Most lung CAD has been directed
toward CT imaging but at least one radiographic CAD system
has been granted FDA approval.
Missed Lung Cancer on CT
The rapid development of CT scanning and, in particular,
multislice technology has led to the possibility that errors in
Imaging manifestations of lung cancer 105

Figure 10 Forty-nine-year-old man with a missed lung cancer. (A) PA chest radiograph shows a subtle left mid-lung
nodule (arrow). (B) Contrast-enhanced chest CT (lung window) reveals a 1.2-cm nodule in the lingua (arrow). Small
lesion size and low conspicuity evidently played a role in overlooking this lesion.

lung cancer diagnosis will occur on CT. Pitfalls in CT diag-
nosis of lung cancer may be classified as resulting from mis-
interpretation of a normal structure or benign nodule as lung
cancer (false-positive diagnosis), incorrect interpretation of a
lung cancer as a benign process (false-negative diagnosis), or
failure to visualize and/or describe a lesion that represents
lung cancer (missed lung cancer).32
On CT, normal structures can be misinterpreted as repre-
senting a pulmonary nodule because of partial volume arti-
fact or lack of awareness of normal anatomic structures. The
best example of this phenomenon is the misperception of the
lowermost portion of the first costochondral junction as a
pulmonary nodule. Review of the images in the cine mode on
a workstation and off-axial reconstructions can address this
difficulty. Granuloma, hamartoma, round pneumonia, he-
matoma, or arteriovenous malformation also can mimic a
lung cancer nodule.
A second category of pitfall is an atypical lesion that rep-
resents lung cancer. As on chest radiography, lung carcinoma
on CT can assume many different forms. An airspace or

Figure 11 Fifty-two-year-old woman with atypical lung cancer. (A) Contrast-enhanced chest CT (lung window) dem-
onstrates a dense area of consolidation in the right lower lobe that was thought to represent pneumonia. (B) Contrast-
enhanced chest CT (mediastinal window) obtained 5 months later shows marked progression of pulmonary involve-
ment. Bronchoscopy revealed brochioloalveolar carcinoma.
106 T.L. Mohammed, C.S. White, and R.D. Pugatch

Figure 12 Fifty-year-old woman with missed lung cancer on CT. (A) Contrast-enhanced chest CT (lung window) shows
a vague nodular density of mixed attenuation that was interpreted as an area of atelectasis (arrow). (B) Contrast-
enhanced chest CT (lung window) obtained 6 months later at the same level demonstrates interval development of a
cavitary nodule that was subsequently diagnosed as squamous cell carcinoma.

ground-glass pattern or ill-defined area of consolidation is a nosed on the prevalence screening study were missed initially
well-described manifestation of lung cancer, particularly and detected retrospectively on the follow-up incidence
bronchioloalveolar cell or adenocarcinoma (Fig. 11). Calcifi- scan.38 The authors do not state the proportion of these nod-
cation, while often associated with benign conditions, can ules that eventually proved to be malignant.
also occur in lung cancer. In one study, calcification was Missed lung cancer on screening CT has been more often
identified on CT in 19% of patients with lung cancer, most reported as peripheral and at an earlier stage as compared
often in larger masses.33 Thin-walled cavities (4 mm or less) with the routine clinical settings.39,40 Li and coworkers inves-
may be malignant in up to 6% of cases.34 Other atypical tigated 32 lung cancers overlooked on 39 low-dose CT scans
manifestations of lung cancer include a cystic appearance and concluded that 23 errors were caused by detection fail-
mimicking a bronchogenic cyst and an air-crescent sign.
Perhaps the most challenging and clinically relevant pitfall
is missed lung cancer on CT. In a phantom study, Naidich
and coworkers used an experimental model to assess nodule
detection in which simulated nodules ranging from 1 to 7
mm were electronically inserted into computerized data
sets.35 The average detection rates were 91, 82, 48, and 1%
for nodules smaller than 7, 4.5, 3, and, 1.5 mm, respectively.
Nodules that were peripherally located and dense were more
likely to be detected.
CT-related missed lung cancer can occur in either the rou-
tine clinical setting or the course of a routine screening pro-
tocol (Fig. 12). In either instance, misses can be ascribed to
either lack of detection or, in some cases, misidentification of
the lesion as a normal or benign structure such as a vessel.
This phenomenon can be particularly problematic in the set-
ting of underlying lung disease such as pulmonary fibrosis.
The relatively large diameter of the average missed lesion on
CT (1 cm) in some of the series is notable.
Earlier series of missed lung cancer on CT, reported in the
routine clinical setting, have described a mixture of central
and peripheral lesions.36,37 In one report, two-thirds of over-
looked lesions were endobronchial (Fig. 13). Major distract-
ing findings (eg, aortic aneurysm, old tuberculous changes) Figure 13 Fifty-five-year-old woman with a missed endobronchial
were present on the scan in nearly half the patients. lung cancer. Contrast-enhanced chest CT (mediastinal window) ob-
In the more recent screening studies, overlooked small tained for assessment of pulmonary embolism demonstrates occlu-
nodules are one of the main areas of difficulty. In the study of sion of the superior segment of the left lower lobe bronchus by a
Swensen and coworkers, 26% of all nodules ultimately diag- small squamous cell carcinoma (arrow).
Imaging manifestations of lung cancer
Figure 14 Seventy-four-year-old man with pulmonary fibrosis and a
missed lung cancer. Contrast-enhanced chest CT (lung window)
shows peripheral reticular opacities and honeycombing and an ir-
regular nodule in the right upper lobe that was not initially recog-
nized as lung cancer.
ure and 16 were due to misidentification.39 The detection
failures averaged nearly 10 mm in diameter and 91% dem-
onstrated a significant component of ground-glass opacity.
The misidentified lesions had a mean diameter of nearly 16
mm and often occurred in the background of significant un-
derlying disease such as emphysema, fibrosis, or tuberculosis
(Fig. 14). The vast majority (88%) of lesions were Stage 1A.
To date, the CT scans in the missed lung cancer studies have
been acquired with 10-mm-thick slices. The effect of using a
thinner CT collimation, as is now often done, is unknown.
Medicolegal consequences of missing lung cancer on CT
are well-documented. From 1996 to 2001, eight cases were
filed alleging missed lung cancer on CT, as reported to a large
not-for-profit consortium that monitors insurance claims
(Lori Bartholomew, PIAA, personal communication). This
represented slightly less than 10% of all cases filed alleging
failure to detect lung cancer during that time. A recent com-
mentary described a lawsuit filed on behalf of a patient with
advanced lung cancer whose 8-mm left lower lobe lung le-
sion had earlier been overlooked on a lung cancer screening
CT scan.41 A $1,000,000 settlement was agreed to, with the
radiologist assuming 90% of the responsibility.
Indirect evidence suggests that CAD may be valuable in a
second-reader function for assessing lung nodules on CT. In
a subgroup of 38 lung nodules overlooked on initial inter-
pretation during a low-dose screening CT program, 32 (84%)
were detected by an automated lung nodule detection pro-
gram.42
Conclusion
Chest radiography and CT remain critical to the imaging
analysis of lung cancer. However, each technique is associ-
ated with pitfalls of lung cancer diagnosis and their medico-
legal ramifications.
107
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