Dr Muhammad Shoyab

HMO (Radiology & Imaging)

DMCH

Tuesday 02 July 2013

 Commonest neoplasm

 Leading cause of cancer-related deaths

Robbins
 2nd most common negligence litigation against
radiologists
 90% of tumors were visible on previous radiographs

(mostly CXR)

 30% were >2 cm

 Many misses despite two independent readers

 Radiologist is fined in 50% cases

Gurney
 Changing demographics
 Declining male predominance (2:1)

 No more limited to smokers

 No more limited to elderly adults (>50 yrs)

Gurney
 Eagle’s eye detection (screening)

 Staging
 Resectable or Not
 Lobectomy or Pneumonectomy

 Histological typing confirmed only by biopsy

Asst
NON-SMALL CELL CARCINOMA SMALL CELL CARCINOMA
SYN : BRONCHOGENIC CA (85%) (15%)

 50% are found  80% metastasise

localised at diagnosis before diagnosis
(fastest growth)

 Usually resectable  <10% are resectable

 Worse prognosis

AJCC
 Small Cell Carcinoma  Carcinoid (2%)
(15%)  Lymphoma
 Non-Small Cell Carcinoma  Mesenchymal Tumours
(85%)  Miscellaneous
 Adenocarcinoma (40%)  Hamartoma
▪ Bronchioloalveolar Carcinoma  Haemangioma
(2-5%)
 Clear Cell Tumour
 Squamous Cell Carcinoma
 Germ Cell Tumour
(30%)
 Large Cell Carcinoma (15%)

Haaga
Fastest growing lung cancer
80% metastasise before diagnosis
<10% treatable by resection

Gurney | AJCC
 Large mediastinal ± hilar
(85%) lymphadenopathy

Gurney | Haaga
 Large mediastinal ± hilar
(85%) lymphadenopathy
 Small central / proximal
airway mass
 Often (~90%) not visible
 SPN without L/N <5%

Gurney | Haaga
 Large mediastinal ± hilar
(85%) lymphadenopathy
 Small central / proximal
airway mass
 Often (~90%) not visible
 SPN without L/N <5%
 Mass effect + invasion
 SVC involvement 10%

Gurney | Haaga
 Large mediastinal ± hilar
(85%) lymphadenopathy
 Small central / proximal
airway mass
 Often (~90%) not visible
 SPN without L/N <5%
 Mass effect + invasion
 SVC involvement 10%
 Lung / lobar collapse /
consolidation

Gurney | Haaga | CXR WHO

 Large mediastinal ± hilar
(85%) lymphadenopathy
 Small central / proximal
airway mass
 Often (~90%) not visible
 SPN without L/N <5%
 Mass effect + invasion
 SVC involvement 10%
 Lung / lobar collapse /
consolidation
 Phrenic nerve palsy
Gurney | Haaga | CXR WHO
 Large mediastinal ± hilar  Pleural effusion (5-40%)
(85%) lymphadenopathy suggests extensive disease
 Small central / proximal
airway mass
 Often (~90%) not visible
 SPN without L/N <5%
 Mass effect + invasion
 SVC involvement 10%
 Lung / lobar collapse /
consolidation
 Phrenic nerve palsy
Gurney | Haaga
 Large mediastinal ± hilar  Pleural effusion (5-40%)
(85%) lymphadenopathy suggests extensive disease
 Small central / proximal  Metastatic lesions (80%)
airway mass suggests extensive disease
 Often (~90%) not visible
 SPN without L/N <5%
 Mass effect + invasion
 SVC involvement 10%
 Lung / lobar collapse /
consolidation
 Phrenic nerve palsy
Gurney | Haaga
 Large mediastinal ± hilar  Pleural effusion (5-40%)
(85%) lymphadenopathy suggests extensive disease
 Small central / proximal  Metastatic lesions (80%)
airway mass suggests extensive disease
 Often (~90%) not visible
 Cavitation distinctly rare
 SPN without L/N <5%
 Mass effect + invasion
 SVC involvement 10%
 Lung / lobar collapse /
consolidation
 Phrenic nerve palsy
Gurney | Haaga
 Large mediastinal ± hilar  Pleural effusion (5-40%)
(85%) lymphadenopathy suggests extensive disease
 Small central / proximal  Metastatic lesions (80%)
airway mass suggests extensive disease
 Often (~90%) not visible
 Cavitation distinctly rare
 SPN without L/N <5%
 Extensive necrosis
 Mass effect + invasion
 SVC involvement 10%
 Lung / lobar collapse /
consolidation
 Phrenic nerve palsy
Gurney | Haaga
 Oat cell carcinoma

 Kulchitsky cell tumor

 Neuroendocrine tumor
(grade-III)

Gurney
 Eaton-Lambert syndrome
 Limbic encephalitis
 Cerebellar degeneration
 Dermatomyositis / polymyositis
 Syndrome of inappropriate antidiuretic hormone
 Ectopic ACTH causing Cushing syndrome
 Hypercalcemic hyperparathyroidism Gurney
Also known as bronchogenic carcinoma
85% of Lung Cancers
Usually resectable

Gurney | AJCC
 Adenocarcinoma (40%)
 Types A-C : Bronchioloalveolar Carcinoma (2-5%)
 Types D-F : Poorly differentiated / tubular /
papillary adenocarcinoma

 Squamous Cell Carcinoma (30%)

 Large Cell Carcinoma (15%)

Gurney | Haaga
 Solitary pulmonary
nodule
 Usually upper lobes

Gurney
 Solitary pulmonary
nodule
 Usually upper lobes

 Mediastinal / Hilar
Lymphadenopathy ±

Gurney
 Solitary pulmonary
nodule
 Usually upper lobes

 Mediastinal / Hilar
Lymphadenopathy ±

 Lobar collapse

Gurney
 Solitary pulmonary  Unresolved / recurrent
nodule consolidation in same
 Usually upper lobes lobe

 Mediastinal / Hilar
Lymphadenopathy ±

 Lobar collapse

Gurney
 Solitary pulmonary  Unresolved / recurrent
nodule consolidation in same
 Usually upper lobes lobe

 Mediastinal / Hilar  May be false –ve on PET,

Lymphadenopathy ± sputum for malignant
cells
 Lobar collapse

Gurney
 Adenocarcinoma (40%)
 Types A-C : Bronchioloalveolar Carcinoma (2-5%)
 Types D-F : Poorly differentiated / tubular /
papillary adenocarcinoma

 Squamous Cell Carcinoma (30%)

 Large Cell Carcinoma (15%)

Gurney | Haaga
 40% of lung cancers

 Occurs in women and non-

smokers

 Worse prognosis than

squamous cell carcinoma

 Solitary pulmonary
nodule
 Peripheral

Gurney | Haaga
 40% of lung cancers

 Occurs in women and non-

smokers

 Worse prognosis than

squamous cell carcinoma

 Solitary pulmonary
nodule
 Peripheral
 Soft tissue density
Gurney | Haaga
 40% of lung cancers  Lymphadenopathy / Lobar
collapse ±
 Occurs in women and non-
smokers

 Worse prognosis than

squamous cell carcinoma

 Solitary pulmonary
nodule
 Peripheral
 Soft tissue density
Gurney | Haaga
 2-5% of lung cancers
 A-C types of adenocarcinoma
 Synonym : Alveolar cell carcinoma
 Slow growing (may not change in
size for >2 years)
 No relation with smoking

 Ground-glass opacity /
consolidation ± peripheral
nodule not responding to
antibiotics

 Cavitation / calcification : Rare Gurney | Haaga

 30% of lung cancers
 Slow growing
 Late metastasis

 Solitary pulmonary
nodule
 2/3 central

Gurney | Haaga
 30% of lung cancers
 Slow growing
 Late metastasis

 Solitary pulmonary
nodule
 2/3 central

 Lymphadenopathy /
Lobar collapse ±

Gurney | Haaga
 30% of lung cancers
 Slow growing
 Late metastasis

 Solitary pulmonary
nodule
 2/3 central

 Lymphadenopathy /
Lobar collapse ±

 1/3 peripheral SPN

Gurney | Haaga
 30% of lung cancers  Cavitation (mostly in
 Slow growing peripheral lesions)
 Late metastasis
 Thick (>15 mm), irregular
walls
 Solitary pulmonary  Minimal fluid level
nodule
 2/3 central

 Lymphadenopathy /
Lobar collapse ±

 1/3 peripheral SPN

Gurney | Haaga
 15% of lung cancers
 Rapidly growing

 Peripheral mass

Gurney | Haaga
 15% of lung cancers
 Rapidly growing

 Peripheral mass

 >4 cm at diagnosis

Gurney | Haaga
 15% of lung cancers
 Rapidly growing

 Peripheral mass

 >4 cm at diagnosis

 Lymphadenopathy /
Lobar collapse ±

Gurney | Haaga
 15% of lung cancers
 Rapidly growing

 Peripheral mass

 >4 cm at diagnosis

 Lymphadenopathy /
Lobar collapse ±

 Cavitation uncommon
Gurney | Haaga
 Hypercalcaemia

Gurney
 Hypercalcaemia

 Clubbing
 Hypercalcaemia

 Clubbing

 Hypertrophic pulmonary
osteoarthropathy
NON-SMALL CELL CARCINOMA SMALL CELL CARCINOMA
 Solitary pulmonary nodule  Mediastinal ± hilar (85%) mass

 Lobar collapse  Lobar / Lung Collapse

 Cavitation may be present (in  Cavitation distinctly rare

peripheral sq. cell carcinoma)
 Mass effect + invasion

 Phrenic nerve palsy

Gurney
 Small Cell Carcinoma  Carcinoid (2%)
(15%)  Lymphoma
 Non-Small Cell Carcinoma  Mesenchymal Tumours
(85%)  Miscellaneous
 Adenocarcinoma (40%)  Hamartoma
▪ Bronchioloalveolar Carcinoma  Haemangioma
(2-5%)
 Clear Cell Tumour
 Squamous Cell Carcinoma
 Germ Cell Tumour
(30%)
 Large Cell Carcinoma (15%)

Haaga
 Malignant lesion ± benign
tumorlets
 Neuroendocrine tumour
(grades I & II)
 60-80% occur in never-
smokers

Gurney | Haaga | M&N

 Malignant lesion ± benign  80% are central lesions
tumorlets  Located at bronchial
 Neuroendocrine tumour
branching points
(grades I & II)
 60-80% occur in never-
smokers

Gurney | Haaga | M&N

 Malignant lesion ± benign
tumorlets
 Neuroendocrine tumour
(grades I & II)
 60-80% occur in never-
smokers
 80% are central lesions
 Located at bronchial
branching points
 May have central
calcification
Gurney | Haaga | M&N
 Malignant lesion ± benign
tumorlets
 Neuroendocrine tumour
(grades I & II)
 60-80% occur in never-
smokers
 80% are central lesions
 Located at bronchial
branching points
 May have central
calcification
 Striking contrast
enhancement
Gurney | Haaga | M&N
 Malignant lesion ± benign
tumorlets
 Neuroendocrine tumour
(grades I & II)
 60-80% occur in never-
smokers
 80% are central lesions
 Located at bronchial
branching points
 May have central
calcification
 Striking contrast
enhancement
 Lymphadenopathy
uncommon
Gurney | Haaga | M&N
 Malignant lesion ± benign
tumorlets
 Neuroendocrine tumour
(grades I & II)
 60-80% occur in never-
smokers
 80% are central lesions
 Located at bronchial
branching points
 May have central
calcification
 Striking contrast
enhancement
 Lymphadenopathy
uncommon
 Octreotide (somatostatin
analog) uptake +ve
Gurney | Haaga | M&N
 90% are peripheral
lesions

Gurney | Springer | CXR Clinical Practice | CXR WHO

 90% are peripheral
lesions
 50% have fat content
— confirmatory

Gurney | Springer | CXR Clinical Practice | CXR WHO

 90% are peripheral
lesions
 50% have fat content
— confirmatory
 Popcorn calcification in
1/3 (virtually diagnostic)

Gurney | Springer | CXR Clinical Practice | CXR WHO

 90% are peripheral
lesions
 50% have fat content
— confirmatory
 Popcorn calcification in
1/3 (virtually diagnostic)
↑ Size = ↑ Calcification

Gurney | Springer | CXR Clinical Practice | CXR WHO

 90% are peripheral
lesions
 50% have fat content
— confirmatory
 Popcorn calcification in
1/3
 No FDG uptake

Gurney
Most common (50%) site of metastasis
Haematogenous & Lymphangitic Patterns
 Multiple pulmonary
nodules
 Multiple pulmonary
nodules
 Variable sizes
 Multiple pulmonary
nodules
 Variable sizes
 Predominantly :
 Bases
 Outer 1/3
 Lower lobes
 Multiple pulmonary
nodules
 Variable sizes
 Predominantly :
 Bases
 Outer 1/3
 Lower lobes
 Feeding vessel may be seen
 Multiple pulmonary
nodules
 Variable sizes
 Predominantly :
 Bases
 Outer 1/3
 Lower lobes
 Feeding vessel may be seen
 Lung architecture distorted
(hilic growth)
 Irregular, nodular, beaded
septal thickening (upto 10
mm) ± fissure /
bronchovascular thickening
 Irregular, nodular, beaded
septal thickening (upto 10
mm) ± fissure /
bronchovascular thickening
 Predominantly :
 Basilar
 Right lung
 Irregular, nodular, beaded
septal thickening (upto 10
mm) ± fissure /
bronchovascular thickening
 Predominantly :
 Basilar
 Right lung
 Spares entire lobe / lung in
50% cases
 Irregular, nodular, beaded
septal thickening (upto 10
mm) ± fissure /
bronchovascular thickening
 Predominantly :
 Basilar
 Right lung
 Spares entire lobe / lung in
50% cases
 CXR may be normal or
reticulonodular
 Irregular, nodular, beaded  Unilateral : lung source
septal thickening (upto 10
mm) ± fissure /
bronchovascular thickening
 Predominantly :
 Basilar
 Right lung
 Spares entire lobe / lung in
50% cases
 CXR may be normal or
reticulonodular
 Irregular, nodular, beaded  Unilateral : lung source
septal thickening (upto 10  Bilateral (asymmetrical) :
mm) ± fissure / extrapulmonary sources
bronchovascular thickening
 Predominantly :
 Basilar
 Right lung
 Spares entire lobe / lung in
50% cases
 CXR may be normal or
reticulonodular
 Irregular, nodular, beaded  Unilateral : lung source
septal thickening (upto 10  Bilateral (asymmetrical) :
mm) ± fissure / extrapulmonary sources
bronchovascular thickening  Lung architecture
 Predominantly : preserved (lipidic growth)
 Basilar
 Right lung
 Spares entire lobe / lung in
50% cases
 CXR may be normal or
reticulonodular
 Irregular, nodular, beaded  Unilateral : lung source
septal thickening (upto 10  Bilateral (asymmetrical) :
mm) ± fissure / extrapulmonary sources
bronchovascular thickening  Lung architecture
 Predominantly : preserved (lipidic growth)
 Basilar  Typical of adenocarcinomas
 Right lung
 Spares entire lobe / lung in
50% cases
 CXR may be normal or
reticulonodular
 Irregular, nodular, beaded  Unilateral : lung source
septal thickening (upto 10  Bilateral (asymmetrical) :
mm) ± fissure / extrapulmonary sources
bronchovascular thickening  Lung architecture
 Predominantly : preserved (lipidic growth)
 Basilar  Typical of adenocarcinomas
 Right lung  Makes any tumour end-
 Spares entire lobe / lung in stage (IV)  unresectable,
50% cases poor prognosis
 CXR may be normal or
reticulonodular
 • Size.
T • Location.
• Extent of the lesion

N • Regional lymph node involvement.

M • Metastases
 Involving heart / great vessels / rec laryngeal nerve /
trachea / carina / esophagus / vertebral body

SVC
ESO
LPA
 Involving heart / great vessels / rec laryngeal nerve /
trachea / carina / esophagus / vertebral body, OR
 Separate nodule in another lobe (SAME lung)

SVC
ESO
LPA
 Involving heart / great vessels / rec laryngeal nerve /
trachea / carina / esophagus / vertebral body, OR
 Separate nodule in another lobe (SAME lung) , OR
 Lymphangitic / vascular spread

SVC
ESO
LPA
 Involving chest wall / diaphragm / phrenic nerve
 Involving chest wall / diaphragm / phrenic nerve, OR
 Involving main bronchus <2 cm distal to carina
 Involving chest wall / diaphragm / phrenic nerve, OR
 Involving main bronchus <2 cm distal to carina , OR
 Atelectasis / obstructive pneumonitis involving entire
lung
 Involving chest wall / diaphragm / phrenic nerve, OR
 Involving main bronchus <2 cm distal to carina , OR
 Atelectasis / obstructive pneumonitis involving entire
lung, OR
 Larger than 7 cm
 Involving main bronchus >2 cm distal to carina
 Involving main bronchus >2 cm distal to carina, OR
 Atelectasis / obstructive pneumonitis Not involving
entire lung
 Involving main bronchus >2 cm distal to carina, OR
 Atelectasis / obstructive pneumonitis Not involving
entire lung, OR
 >3 cm [2a : 3-5 cm, 2b : 5-7 cm]
SPN upto 3 cm [1a : upto 2 cm, 1b : 2-3 cm]
 N0 – No nodes
 N0 – No nodes
 N1 – Ipsilateral hilar
nodes
 N0 – No nodes
 N1 – Ipsilateral hilar
nodes
 N2 – Ipsilateral
mediastinal nodes
 N0 – No nodes
 N1 – Ipsilateral hilar
nodes
 N2 – Ipsilateral
mediastinal nodes
 N3 – Ipsilateral
supraclavicular nodes
and beyond (i.e.
Contralateral
mediastinal / hilar LN
OR lateral scalene)
 M0 – No mets
 M0 – No mets

 M1a – Separate nodule

in OPPOSITE lung, OR
pleural / pericardial
effusion
 M0 – No mets

 M1a – Separate nodule

in OPPOSITE lung, OR
pleural / pericardial
effusion

 M1b – Distant
metastasis
Benign or Malignant?
 <3 cm : Nodule

 >3 cm : Mass (most likely not benign)

SOLITARY MULTIPLE

 Granuloma  Sarcoidosis
 Bronchogenic (non-small  Metastases
cell) carcinoma  Lymphoma
 Hamartoma  Rheumatoid nodules
 Solitary metastasis  Amyloidosis
 Carcinoid

Gurney
 Smooth : may be benign
 Smooth : may be benign

 Irregular, spiculated, sun’s ray appearance : likely to be

malignant
 Usually indicates benignness
 Central : benign
 Central : benign
 Laminated : benign
 Central : benign
 Laminated : benign
 Diffuse : benign
 Central : benign
 Laminated : benign
 Diffuse : benign
 Popcorn : benign
 Central : benign
 Laminated : benign
 Diffuse : benign
 Popcorn : benign
 Stippled : may be malignant
 Central : benign
 Laminated : benign
 Diffuse : benign
 Popcorn : benign
 Stippled : may be malignant
 Eccentric : may be malignant
 Heterogeneous : most likely (68%) malignant

 >20 HU enhancement : most likely malignant

 <15 HU enhancement : possibly benign

CENTRAL LESIONS PERIPHERAL LESIONS
 Small Cell Carcinoma  Adenocarcinoma

 Lymphoma  Large Cell Carcinoma

 Carcinoid (80%)  Hamartoma (90%)

 Squamous Cell
Carcinoma (2/3)
Haaga
LOBAR ENTIRE LUNG
 Small Cell Carcinoma  Small cell carcinoma

 Non-small cell carcinoma

 Squamous cell carcinoma (peripheral type)
SMOKERS PREDOMINANT UNRELATED WITH SMOKING

 Small cell carcinoma  Adenocarcinoma

 Squamous cell carcinoma  Bronchioloalveolar

carcinoma

 Carcinoid
FAST GROWTH SLOW GROWTH

 Small cell carcinoma  Bronchioloalveolar

(fastest) carcinoma

 Large cell carcinoma  Carcinoid