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The imaging manifestations of lung cancer

Article in Seminars in Roentgenology May 2005


DOI: 10.1053/j.ro.2005.01.002 Source: PubMed

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

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- substantial reduction in both tube loading and scanning time
nancy (Fig. 2). Not all nodules that contain calcification are as up to 64 slices can be acquired simultaneously. Less respi-
benign. Certain patterns of calcification are considered radio- ratory motion artifact occurs with multislice scanners due to
logically indeterminate, meaning that they neither increase their shorter scanning times. The role of IV contrast in the
nor decrease the likelihood of malignancy compared with a evaluation of SPNs is evolving. In routine practice, IV con-
noncalcified nodule. These indeterminate patterns include trast is not considered necessary for detecting pulmonary
stippled fine calcification and eccentric calcification. nodules, since nodules inherently stand out from surround-
Radiographic manifestations of central lesions are a hilar or ing aerated lung parenchyma. However, for characterization
perihilar mass with or without distal lung collapse (Fig. 3). In of nodules, contrast enhancement may be useful (see below).
some instances, the hilar mass may be distinguished from In addition, mediastinal lymphadenopathy, metastasis to the
associated collapse, particularly in the right upper lobe where adrenal glands, liver, or bone and additional pulmonary le-
the normal upward movement of the minor fissure in benign sions that may not be visible on chest radiography may be
atelectasis is incomplete due to a central bulge created by the more apparent on CT. Chest CT can also help in assessing the
tumor (Fig. 4). The resulting sigmoid-shaped appearance of chest wall, mediastinum, or diaphragm for invasion.
the lateral margin of the collapsed right upper lobe and the Many SPNs have a characteristic benign appearance on
associated hilar mass is termed the S sign of Golden. CT. For example, a nodule containing a fat density can be
If the abnormality is new, or if older radiographs are un- classified as a hamartoma (Fig. 5). Arteriovenous fistulas
available, CT has proven helpful to further characterize pul- demonstrate the presence of a feeding artery and a draining
monary lesions. CT can often supplement the chest radio- vein as well as contrast enhancement on CT. A dense comet
graphs by detecting mediastinal lymph node metastases and tail sign on CT suggests rounded atelectasis (Fig. 6). A nod-
chest wall and mediastinal invasion that provide more accu- ular density within a cavity suggests a fungal etiology. Pul-
rate staging of the tumor. monary infarcts may be characterized on CT as a wedge-
shaped density abutting the pleura and containing air
bronchograms.7
Computed Tomography As on chest radiography, nodules on CT that are ill-de-
For all newly discovered or indeterminate pulmonary le- fined or have irregular or spiculated margins suggest malig-
sions, a CT is warranted. CT offers ideal imaging for localiza- nancy (Fig. 7). In fact, 84 to 90% of spiculated nodules are
tion and characterization of a nodule. The ability of CT scan- malignant.19,20 Lung nodule size is also a good indicator of
ning to evaluate the entire thorax at the time of nodule the likelihood of malignancy. If a nodule is found to measure
assessment is of further benefit. The recent advent of multi- more than 2 cm in size, it has a greater likelihood of being
slice scanners has led to advances in image resolution with a malignant, compared with a 50% rate of malignancy in all
Imaging manifestations of lung cancer 101

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 tic of a benign lesion with a sensitivity of 98%, specificity
cm in size has a very high incidence of malignancy and is of 73%, and 85% of accuracy.23
termed a mass. Air bronchograms and pseudocavitation are In the setting of an indeterminate nodule, options include
characteristics seen on CT imaging that are more common in follow-up with serial CT scanning, PET scanning, or an in-
malignant (30%) than benign (5%) lesions.19 Cavitation of a vasive procedure such as bronchoscopy, transthoracic needle
nodule is also consistent with malignancy; however, infec- biopsy, or surgery.
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 Pitfalls of Lung Cancer Imaging
(Fig. 1).
As CT technology has improved, smaller lung nodules are Over- and underdiagnosis of lung cancer remains a serious
now more easily detected. Many of these are benign, such as problem by both chest radiography and CT. Overdiagnosis
granulomas or intrapulmonary lymph nodes.22 Most typi- may lead to unnecessary diagnostic testing and invasive pro-
cally, intrapulmonary lymph nodes are 1 to 2 mm in diameter cedures. Underdiagnosis may lead to missed lung cancer, a
and are located in the posterior basal subpleural portions of lethal outcome, and medicolegal action.
the lungs. These small nodules are generally indeterminate Of more than 100,000 medicolegal cases collected from
by imaging criteria, and they are too small to be imaged with 1985 to 1995 by a large data-sharing organization and en-
PET or sampled by percutaneous biopsy. This dilemma is compassing all medical specialties, actions involving malig-
discussed in more detail in the article on lung cancer screen- nant neoplasms of the bronchus or lung were the sixth most
ing. common. Among radiologists, errors in diagnosis of lung
While CT can be extremely specific for certain benign cancer were the second most common cause for litigation,
lesions, many abnormalities remain indeterminate and after malignant neoplasms of the female breast. Approxi-
lung cancer cannot be excluded. For those SPNs with in- mately 90% of the alleged errors in diagnosis of lung cancer
determinant morphology, IV contrast enhancement with occurred on chest radiographs, 5% on CT scans, and 5% on
helical CT imaging may be a helpful adjunct. Swensen and other studies. Forty-five percent resulted in indemnity pay-
coworkers found nodules enhancing to 20 Hounsfield ments, which averaged $150,000 (Lori Bartholomew, Physi-
Units to be a predictive feature of malignancy while con- cian Insurers Association of America, personal communica-
trast enhancement 15 Hounsfield Units was characteris- tion).
102 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
Figure 5 Thirty-eight-year-old man with a pulmonary hamartoma. CT abnormalities were present, confirming the importance of
scan demonstrates a right middle lobe nodule with extensive popcorn satisfaction of search error.26
calcification and intervening areas of fat attenuation (arrow).
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

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).
Imaging manifestations of lung cancer 103

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-
Figure 7 Fifty-one-year-old man with COPD and a peripheral ade-
nique. The use of digital radiography decreases the variability
nocarcinoma. Unenhanced CT (lung window) shows a spiculated
nodule in the right upper lobe and saber-sheath deformity of the of the image appearance.30 As compared with film-screen
trachea. radiography, digital radiography leads to similar effectiveness
of nodule detection and permits the use of computer-aided
detection (CAD).
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 Definition of
Thus, it is clear that size is not the only lesion characteristic Malpractice in Missed Lung Cancer
that affects detection of lung nodules. In general, negligence is the legal criterion that is used to
Lesion conspicuity is of crucial importance in the detect- decide whether malpractice has occurred in cases of missed
ability of lung cancer.28 Conspicuity refers to the extent to lung cancer. Negligence can be shown if a radiologist
which a lesion is distinguishable from adjacent opacities that 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 T.L. Mohammed, C.S. White, and R.D. Pugatch

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 is far more likely to be associated with an adverse legal out-
that this failure to diagnose is a proximate cause of substantial come.28
injury to the patient. Although it is possible to breach the
standard of care and not be found liable because of a lack of Strategies to Reduce Missed Lung Cancer
proximate cause or substantial injury, it is far easier to argue Complete elimination of the missed lung cancer is an unre-
that the standard of care was not breached. Unfortunately, alistic goal, but an appropriate goal would be to substantially
even this defense is not straightforward. reduce the rate of overlooked lung cancer, especially among
Plaintiff attorneys routinely argue that any missed lung lesions of high conspicuity. Several methods of error rate
cancer constitutes malpractice, but compelling evidence in reduction have been suggested. In a previous study of lung
the radiologic literature suggests that overlooked lung cancer cancer litigation by the Physician Insurers Association of
does not necessarily indicate negligence. Muhm and cowork- America, an organization of liability companies owned or
ers used chest radiographs to screen for early lung cancer at directed by physicians and dentists, a major factor in the
4-month intervals in a large cohort of men who were heavy occurrence of overlooked lung cancer was failure to compare
smokers.31 Of 50 peripheral lung cancers that were diag- the radiograph on which misdiagnosis was alleged with per-
nosed, 45 (90%) were visible in retrospect on a radiograph 4 tinent prior examinations. Similarly, in a study of missed
months earlier. Four cancers (8%) were visible in retrospect 2 bronchogenic cancer, failure to compare with one or a se-
years before diagnosis, and one of these was visible 53 quence of prior radiographs was the most common cause of
months earlier. Twelve (75%) of 16 perihilar lesions were interpretive error.27 A separate approach to decreasing error
also visible on prior examinations. In this study, failure to would be to emphasize the need to avoid satisfaction of
diagnose lesions occurred despite a high level of suspicion on search error, since it appears to be an important contributor
the part of at least two interpreters. It is clear that the expec- to the failure to diagnose cancer in the presence of unrelated
tation that radiologists can or should be able to diagnose all major findings.
lung cancers is unreasonable. CAD-based strategies may also be valuable to reduce
Because there is no rigorous definition as to what consti- missed lung cancer on chest radiography if digital radiogra-
tutes standard of care in the diagnosis of early lung cancer, phy techniques are used. Most lung CAD has been directed
the final decision typically relies on the ability of the experts toward CT imaging but at least one radiographic CAD system
of each of the contesting parties to persuade the judge or jury has been granted FDA approval.
that their definition is correct. The conspicuity of a lesion (as
defined previously) probably is the single most important Missed Lung Cancer on CT
factor in determining whether the standard of care has been The rapid development of CT scanning and, in particular,
breached. A lesion of high conspicuity (ie, an obvious lesion) 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- best example of this phenomenon is the misperception of the
nosis of lung cancer may be classified as resulting from mis- lowermost portion of the first costochondral junction as a
interpretation of a normal structure or benign nodule as lung pulmonary nodule. Review of the images in the cine mode on
cancer (false-positive diagnosis), incorrect interpretation of a a workstation and off-axial reconstructions can address this
lung cancer as a benign process (false-negative diagnosis), or difficulty. Granuloma, hamartoma, round pneumonia, he-
failure to visualize and/or describe a lesion that represents matoma, or arteriovenous malformation also can mimic a
lung cancer (missed lung cancer).32 lung cancer nodule.
On CT, normal structures can be misinterpreted as repre- A second category of pitfall is an atypical lesion that rep-
senting a pulmonary nodule because of partial volume arti- resents lung cancer. As on chest radiography, lung carcinoma
fact or lack of awareness of normal anatomic structures. The 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 107

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