RADIOLOGICAL IMAGING OF PULMONARY NEOPLASM'S

DR. PANKAJ KAIRA JR 1 RADIODIAGNOSIS

SRMSIMS BAREILLY

A wide variety of neoplasms may arise in the lungs

While many lung tumors are malignant, others are benign , some fall between these two extremes (both clinically & histologically)

Carcinoma of bronchus is by far the most commonest and most important primary tumor of the lung

VARIOUS TYPES BRONCHOGENIC CARCINOMA PULMONARY SARCOMA BENIGN PULMONARY TUMORS - bronchial

carcinoids , pulmonary hamartoma MALIGNANT LYMPHOPROLIFERATIVE

DISORDERS – lymphoma , leukemia METASTASIS SOLITARY PULMONARY NODULE - evaluation

BRONCHOGENIC CARINOMA Commonly known as lung carcinoma A highly malignant primary lung tumor that has a

very poor prognosis Arises from respiratory epithelium ; bronchus ,

bronchiole or alveoli. Commonest fatal malignancy in adult males in the

western world Its more common in men than in women , but the

incidence in women is rising Responsible for 1.38 million deaths annually, as of

2008 Overall 5 yr survival is <15% Most cases 40-70 yrs age ; unusual below 30 yrs.

CAUSES- Tobacco smoke - most important causative agent

(20-30 fold , increased risk ; proportional to dose). Polycyclic aromatic hydrocarbons , Nitrosamines carcinogens in cigarette smoke.- Passive smoking- Atmospheric pollution – vehicles, industries,

power plants- Exposure to asbestos, nickel, arsenic , chromates,

nickel, mustard gas- Radon gas – natural gas produced by decay of

uranium- Radiotherapy

CLINICAL FEATURES 20 % asymptomatic presentation

; found incidentally on routine CXR

Bronchogenic carcinoma may present with a VARIETY CLINICAL MANIFESTATIONS :

RESPIRATORY SYMPTOMS: cough, hemoptysis, wheeze, dyspnoea

SYSTEMIC SYMPTOMS: weight loss, fever, clubbing, fatigue

LOCAL COMPRESSION SYMPTOMS: chest pain, bone pain, superior venacava obstruction, difficulty swallowing

Nodule found on routine chest radiograph

CLINICAL MANIFESTATIONS Due to primary lesions:

o cough with/without

sputum

o weight loss

o pneumonia

o dyspnoea

o fever

o hemoptysis

Due to local extension:

o chest pain

o hoarseness

o superior vena cava syndrome

o horner’s syndrome

o dysphagia

o pericardial effusion

o pleural effusion

o diaphragm paralysis

CONTD…Regional spread to hilar and mediastinal nodes may cause :

Dysphagia due to esophageal compression Hoarseness due to recurrent laryngeal nerve compression Horner’s syndrome due to sympathetic nerve involvement And, elevation of the hemidiaphragm from phrenic nerve

compression.

Extrapulmonary manifestations : Include – o metastasis to other organs, such as brain, central nervous

system, skeleton system, liver, adrenal glands and lymph nodes.

PARANEOPLASTIC SYNDROMES Paraneoplastic syndromes are common in lung cancer patients and may be the first manifestation of the disease or its recurrence.

The extent of paraneoplastic syndromes is unrelated to the size of the primary tumour. Lung cancer and small-cell lung cancer (SCLC) in particular is the most common cancer

to be associated with para neoplastic syndromes. However, some paraneoplastic syndromes are more often found in non-small-cell lung

cancer (NSCLC). For example hypertrophic pulmonary osteoarthropathy has most often been described in association NSCLC

EXAMPLE - 1) Hypertrophic Pulmonary Osteoarthropathy, 2) Hypercalcemia, 3) Inappropriate Antidiuretic Hormone Secretion Syndrome (SIADH) 4) Peripheral Neuropathies,and 5) Cushing’s Syndrome

Many of the lung cancer symptoms are non-specific Cancer is already spread beyond the original site by

the time its suspected Small cell> Adeno > Large> Squamous Common sites of spread :- Brain- Bone - Adrenals- Opposite lung- Liver- Pericardium- Kidneys

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Computed tomographic (CT) scan of the abdomen showed multiple hepatic metastases (arrows).

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Adrenal metastases are common and often solitary. They must be differentiated from adrenal adenomas, which occur in

1% of the adult population.. Lesions smaller than 1 cm are usually benign. Metastases are usually larger than 3 cm; on non-enhanced CT scans,

they have an attenuation coefficient of 10 HU or higher. Adenomas and metastases can also be distinguished by using MRI

and PET scanning.

ADRENAL METASTASES

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Osteolytic (70%) Osteoblastic (30%) Technetium-99m (99m Tc) radionuclide bone

scanning is indicated in patients with bone pain or local tenderness.

The test has a 95% sensitivity for the detection of metastases but a high false-positive rate because of degenerative disease and trauma.

The assessment of these metastases requires comparison of the bone scans with plain radiographs.

Vertebrae(70%), Pelvis(40%), Femora(25%) Plain radiographs typically show

destructive lytic lesions ± pathological fractures.

Similar features are seen on CT scans.

BONE METASTASES

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FDG PET images demonstrate bone metastases (arrows).

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Isotope bone scan. Hot spots due to bony metastases.

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SCLC and adenocarcinoma are the most common sources of cerebral metastases.

MRI is superior to CT, especially in the depiction of the posterior fossa and the area adjacent to the skull base.

However, the brain is not routinely imaged in asymptomatic patients with NSCLC, because the incidence of silent cerebral metastases is only 2-4%.

Brain metastases are typically hemorrhagic and occur at the grey-white mater junction of the brain.

BRAIN METASTASES

CLASSIFICATION OF LUNG CARCINOMA

Broadly classified into 2 types-Based on microscopic appearance of tumor

cells

Non- small cell Lung carcinoma

(80%)

Adenocarcinoma

30-40%Squamous cell

Ca 30%Large cell Ca

10-15%Mixtures of

different types of NSCC

Small cell Lung carcinoma (20%)

ADENOCARCINOMA ~ 30-40% ; most common subtype

composed of malignant glandular epithelium, varying in degree of differentiation.

Most common cell type in non-smokers. smaller than other bronchogenic carcinomas. located in lung periphery Radiologic feature – peripheral nodule /

peripheral mass 5 yr survival = 17%

BRONCHOALVEOLAR CARCINOMA : is a type of adenocarcinoma ; m/c in women and non-smokers

arises from epithelium of terminal bronchiole or alveolus

almost always peripheral ; may present as pneumonia like consolidation ,as a solitary nodule or forms multiple colaescing nodules.

• Chest x-ray –WIDESPREAD LUNG INVOLVEMENT

CT scan– TYPICAL AIRSPACE FILLING WITH AN AIRBRONCHOGRAM

SQUAMOUS CELL CARCIMONA ~ 30-35% ; second most common subtype*

composed of malignant squamous cells that vary in degree of differentiation from tumor to tumor

m/c in men closely related to smoking Radiological feature – hilar or perihilar

mass, cavitating lung mass, peripheral nodule, atelectasis or obstructive pneumonitis distal to obstructed bronchus.

Most common carcinoma to cavitate 5 yr survival =15%**

HILAR CAITATING MASS - due to squamous cell carcinoma

SMALL (OAT) CELL CARCINOMA ~ 20-25%

composed of small cells that resemble lymphocytes

strongly related to smoking very aggressive metastasizes early radiologic feature – hilar mass /

mediastinal mass 5 yr survival = 5 % ; worst prognosis Staged in two groups- a) limited stage disease b) extensive stage disease

RADIOGRAPHIC FEATURES- Typically central in location, 75- 90% cases Hilar or a perihilar mass Massive adenopathy, often bilateral Associated lobar collapse Primary tumor may not be readily evident because it is obscured by the extensive adenopathy. And in such cases, CT SCAN may prove advantageous

PANCOAST TUMOR Also known as superior sulcus tumor.

CLINICAL FEATURES may include - chest pain - horner’s syndrome - bone destruction - atrophy of hand muscles

RADIOLOGICALLY- Usually appears as – an apical mass - asymmetrical pleural thickening with irregularity that occasionally is associated with rib destruction Apical thickening which is usually bilateral, may be a normal finding, commonly

seen in older patients. However, irregular apical thickening, that is 5mm or greater than that on the opposite side should be considered with suspicion.

INVASION OF – chest wall, brachial plexus, vertebral bodies, spinal canal, subclavian artery

MRI Is the preferred modality because of its ability to visualize

structures at the apex of the thorax It is usually useful in determining certain parameters of

resection of the tumor such as invasion of the vertebral bodies, involvement of the subclavian artery and brachial plexus.

Coronal and sagittal images are particularly helpful

CT scan may be helpful when extensive mediastinal invasion is present But the value of CT in determining chest wall invasion is

somewhat limited, and here MRI may have a slight advantage.

LARGE CELL CARCINOMA ~ 15-20% composed of large, undifferentiated malignant

cells Radiologic feature – large peripheral mass 5 yr survival = 11%

IMAGING • CXR – commonly useful to suspect lung cancer in asymptomatic or

non-specific cases• Next investigation that comes in use is CT / computed tomography• The diagnosis is confirmed with a biopsy which is usually performed

by  bronchoscopy or CT-guidance• Immunostaining used to categorize the subtype on which prognosis

depends• PET imaging with FDG (fluorodeoxyglucose) is increasingly used for

staging• Sensitivity of PET in one study = 79% , specificity = 91% ; whereas the sensitivity of CT 60% , specificity = 70% • Fused PET-CT imaging provides registration of FDG metabolic

activity with the anatomical detail of CT .

LUNG CARCINOMA CAN BE DISCUSSED as:

1) CENTRAL TUMORS 2) PERIPHERAL TUMORS

PERIPHERAL TUMORS Approximately 40% of the bronchial carcinomas arise beyond

the segmental bronchi In 30% a peripheral mass is the sole radiographic finding

A. Tumor shape and size

B. Cavitation

C. Calcification

D. Presence of air bronchograms

E. Ground glass attenuation

TUMOR SHAPE AND SIZE- Tumor at lung apex may appear as pleural thickening. Majority of peripheral tumors may be spherical or oval CORONA RADIATA - numerous strands radiating from the nodule into

surrounding lung Peripheral line shadow or ‘TAIL’ SIGN - linear opacity that extends from

a peripheral nodule to the visceral pleura

CAVITATION-• Best demonstrated on CT SCAN• Most commonly seen in squamous cell type of lung carcinoma.• Cavities with a greatest wall thickness less than 5 mm are almost

always BENIGN whereas most of those with a maximal wall thickness greater than 15 mm are MALIGNANT

EXAMPLE OF A THICK WALLED CAVITY

BENIGN CALCIFICATION PATTERNS

A SOLID CALCIFIED SOLITARY PULMONARY NODULE

SPECKLED OR PUNCTATE CALCIFICATIONS

ECCENTRIC CALCIFICATION

CENTRAL TUMORS Cardinal imaging signs of a central tumor are – A) collapse / consolidation B) hilar enlargement

A) Collapse /consolidation: - Obstruction of major bronchus often leads to a consequent pulmonary opacity and secondary infection may occur beyond the obstruction. Example: Non-resolving pneumonia

“The presence of pneumonia in at-risk patient, confined to one lobe that persists unchanged for longer than 2-3 weeks, OR a pneumonia that recurs in the same lobe which shows loss of volume and no air bronchograms.”

A simple pneumonia often clears or spreads to other segments within a few weeks of treatment with antibiotics

Early stage (due to lepedic growth pattern along alveolar septa with relative lack of acinar filling)

ground-glass haziness bubble-like hyperlucencies / pseudocavitation airway dilatation Lesion persists / progresses within 6-8 weeks

GROUND GLASS HAZE

Bronchoalveolar Carcinoma--- as ground glass haze in left lower lobe and lingula

acinar airspace consolidation+ air bronchogram+ poorly marginated borders

Airspace consolidation may affect both lungs (mucus secretion)

±Cavitation within consolidation "CT angiogram sign" = low-attenuation

consolidation does not obscure vessels (mucin-producing subtype)

CONSOLIDATION

Air space infiltration involving almost all left lung zones and right mid zone

Continued

CT confirms extensive airspace opacities with numerous air-bronchograms. No pleural effusions or significant adenopathy.

Sputum, right and left main bronchus lavage were positive for malignant cells consistent of carcinoma, thought true cut biopsy was suggested by the pathologist to confirm the diagnosis of bronchoalveolar carcinoma, the patient condition did not permit for this.

CT ANGIOGRAM SIGN

CT angiogram sign. A patient with bronchoalveolar carcinoma. Enhancing pulmonary vessels in a low-attenuating mass are seen.

The cavity is eccentric (large cell undifferentiated carcinoma).

(B) The inner wall of the cavity is irregular (squamous cell carcinoma).

The cavity wall may be very thin (squamous cell carcinoma).

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Cavitating mass in the left mid-zone and there is bulging of the aortopulmonary window, indicating lymph node enlargement.

Irregular opacity in left mid-zone with central air density due to cavitation and inferior horizontal margin due to air-fluid level.

CT showing a cavitating squamous cell carcinoma in the left lung.

The wall of the cavity is variable in thickness.

Bronchial carcinoma in the posterior segment of the right upper lobe with cavitation.

GOLDEN ‘S’ SIGN- The Golden S sign is created by a central mass and should

raise suspicion of a central neoplasm, such as primary bronchial carcinoma.

CT image of chest demonstrates a convexity with collapse of RUL

Collapsed right upper lobe with a convex bulge along the lower aspect of the collapsed lung (white arrows) producing a Golden 'S' sign

B) Hilar enlargement- - common presenting feature in patients with bronchial carcinoma - may reflect proximal tumor, lymphadenopathy, consolidated lung

Early, massive hilar or mediastinal lymphadenopathy and invasion – well seen in –

1) Small cell Ca.2) Large cell Ca

Bronchocele due to carcinoma of the bronchus. CT shows dilated, fluid-filled bronchi in the lingula, secondary to carcinoma at the left hilum.

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Bronchocele due to carcinoma of the bronchus. CT shows dilated, fluid-filled bronchi in the right middle lobe, secondary to carcinoma at the right hilum.

The bronchial cut off sign refers to the abrupt truncation of a bronchus from obstruction, which may be due to cancer, mucous plugging, trauma or foreign bodies. Typically, there is associated distal lobar collapse. 

BRONCHIAL CUT OFF SIGN

CT scout film shows abrupt cut off of right main bronchus with collapse of right lung and mediastinal shift. CT shows a mass arising and obliterating the right main bronchus

PA chest radiograph shows abrupt cut off of left main bronchus with collapse.

Pleural effusion (8-15%): Usually unilateral Most commonly due to adenocarcinoma Second leading cause of exudative pleural effusions. Frequent seen in patients with age>45 Ys,

manifestated by chest pain, hemoptysis and emaciate.

Bloody and massive pleural effusion is the typical clinical picture. Significantly high LDH and CEA level(>20ug/L) in pleural fluid.

Pleural fluid cytology, needle biopsy, thoracoscopy or open pleural biopsy has its greatest utility in establishing the diagnosis of malignant pleural effusions.

MALIGNANT PLEURAL EFFUSION

CXR shows complete opacification of the right hemithorax, which is due to a combination of complete collapse of the right lung and a large malignant pleural effusion. The right lung had collapsed due to a large tumour obstructing the right main bronchus (note the abrupt cut-off in the bronchus, arrow). The resultant volume loss in the right hemithorax has resulted in shift of the trachea to the right. There are multiple large metastases in the left lung.

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Contrast enhanced computed tomography: Necrotic mass in the right lower lobe (short arrow) with pleural (p) and pericardial (pc) effusions which were confirmed to be malignant.

Axial CT images show a large mass (stars) in the left lower lobe with a large left pleural effusion with focal pleural thickening (arrowheads). The lung mass is better seen on a post-thoracentesis image. Transbronchial biopsy revealed adenocarcioma and pleural fluid cytology confirmed the presence of malignant cells. Based on the new staging system, this patient has at least M1a disease.

• Cranial to the right hilum there is a mass that was overlooked.

• 2 months later marked growth of the central carcinoma was observed.

Obstruction of a major bronchus often leads to atelectasis and retention of secretions = consequent pulmonary opacity

To differentiate :• Shape of collapsed /consolidated

lobe may be altered due to bulk of underlying tumor

• At- risk patient; pneumonia confined to one lobe (or more) that persists unchanged for >2-3 wks

Pneumonia that recurs in same lobe , particularly if the lobe shows loss of volume or no air – bronchogramsSimple pneumonia clears out or spreads to other segments within few weeks. SCC resembling pneumonia

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F-18 FDG PET imaging has been shown to be an accurate, non-invasive imaging test for the assessment of pulmonary nodules and larger mass lesions

96 % sensitive, 93 % specific. Several studies have shown that PET is more accurate

than CT for the staging of NSCLC. PET appears to be more accurate than CT in detecting

metastatic mediastinal lymphadenopathy. Detection of unsuspected metastatic disease by PET

may permit reduction in the number of thoracotomies performed for non-resectable disease.

PET-CT

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PET scan showing abnormal uptake of FDG in a tumour nodule in the right upper lobe(arrow) & in two superior mediastinal lymph nodes(arrowheads).

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Unresectable lung cancer. FDG-PET scan shows large primary tumour with metastases in lymph nodes, bone, & right adrenal.

PET is also very useful in clarifying those cases in which occurence of benign nodal enlargement coexists with a malignant lung lesion.

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(C)Contrast enhanced CT demonstrated enlarged lymph nodes (> 1 cm in short axis; arrowheads) in ipsi- and contra-lateral mediastinal nodal stations .(D)PET-CT showed high metabolic activity of the parenchymal lesion but no nodal [18F]-2-FDG uptake.

PULMONARY SARCOMA

Primary pulmonary sarcomas (fibromyosarcoma, leiomyosarcoma) are rare

Majority are metastatic sarcomas (from extrathoracic primary tumor ) Extensive pulmonary shadowing

consisting of a mixture of ill – defined rounded & band like shadows maximal in the perihilar regions & lower zones

Mediastinal angiosarcoma in a 38-year-old man, (a) PA chest radiograph shows a mediastinal contour abnormality (arrows), (b) CT+C shows a large, homogeneous mediastinal mass (arrows) abutting the aorta (A) and superior vena cava (S), at exploratory thoracotomy, the mass did not arise from or involve the aorta and heart, and resection was performed, location in the anterior mediastinum and absence of an obvious vascular origin are typical of angiosarcomas

Pulmonary leiomyosarcoma in a 62-year-old woman, (a) CT+C shows a large, heterogeneous lung mass that extends into the azygoesophageal recess and compresses and displaces the left atrium (LA), note the origin in the lung, the large size, and the heterogeneous attenuation, common features of leiomyosarcoma, (b) T1+C fat-saturated shows that the mass is heterogeneous, diffuse enhancement surrounds well-circumscribed areas of low signal intensity (arrows), which are consistent with cystic spaces, (c) Axial fast spin-echo T2-weighted MR image shows a fluid-fluid level (arrow), which is consistent with blood products within a cystic space

Rhabdomyosarcoma in a 42-year-old man, (a) PA chest radiograph shows a well-circumscribed mass in the right hemithorax that arises from the mediastinum, note the small right pleural effusion and the surgical clips from incisional biopsy, (b) CT+C shows that the mass is large and compresses the superior vena cava (arrow), note the heterogeneous attenuation within the mass, which is consistent with necrosis

Ewing sarcoma in a 9-year-old boy, (a) PA chest radiograph shows a large mass within the left hemithorax that extends into the right hemithorax, (b) Nonenhanced CT shows that the mass is large and heterogeneous, there is destruction and inward displacement of a left rib (long arrow), rib destruction is typical but may not be extensive, note the local invasion into the subcutaneous tissues (short arrow). (c-e) Axial fast spin-echo T2 (c), coronal T1-weighted (d), and coronal T1+C  (e) show focal areas of high signal intensity and heterogeneous enhancement, findings consistent with necrosis and hemorrhage, note the marked displacement of mediastinal structures into the right hemithorax. LV = left ventricle

Primitive neuroectodermal tumor in a 44-year-old man,  (a) PAchest radiograph shows a large, right-sided chest mass,

(b) Nonenhanced CT scan shows that the mass is heterogeneous, note the absence of rib destruction, Primitive neuroectodermal tumors are typically located in the chest wall and demonstrate rib destruction less commonly than does Ewing sarcoma .

Chest wall chondrosarcoma in a 62-year-old man, nonenhanced CT shows a large mass that arises from the costochondral junction, the mass extends into the subcutaneous tissue and compresses and displaces the heart, note the focal punctate and linear calcifications, anterior location, origin from the costochondral arches, and chondroid calcification are characteristic of chondrosarcomas of the chest wall

Osteosarcoma in a 43-year-old man, CT+C shows a left-sided chest wall mass with an osteoid matrix (arrow), a finding characteristic of chest wall osteosarcoma

Pulmonary synovial sarcoma in a 63-year-old man with pneumonia. (a) PA chest radiograph shows a mass in the right cardiophrenic angle (arrows) and heterogeneous areas of increased opacity in the middle and right lower lobes, findings consistent with pneumonia, (b) CT+C shows that the mass is heterogeneous, areas of low attenuation within the mass are consistent with extensive necrosis, note the small right pleural effusion

Neurofibrosarcoma in a 33-year-old woman with type 1 neurofibromatosis, (a) Nonenhanced CT scan shows a large, homogeneous mass in the left axilla (arrows), note the absence of rib destruction, (b, c) Coronal T1 (b) and fat-saturated T2 (c) show that the mass (M) is well circumscribed with low signal intensity on the T1 (b) and high signal intensity on the T2 (c), note the small neurofibroma with similar signal intensity in the lower lateral aspect of the left hemithorax (arrow), the patient presented with pain in the region of the left axillary mass; because the characteristic appearance of a neurofibroma on T2 (the target sign) was absent, biopsy was performed

BENIGN PULMONARY TUMORS BRONCHIAL CARCINOIDS PULMONARY HAMARTOMA OTHERS – FIBROMA, CHONDROMA, LIPOMA,

HAEMANGIOMA, NEUROGENIC TUMOURS

BRONCHIAL CARCINOIDS Neuroendocrine tumors ; constitute <5% pulmonary tumors May be : TYPICAL : arise in central airways ATYPICAL : arise in lung periphery S/S - wheeze, pneumonia, hemoptysis Even if small , they may secrete ACTH in sufficient quantities

to cause CUSHING’S SYNDROME

Radiographic appearances: Central lesion – partial or complete bronchial obstruction

resulting in atelectasis with or without pneumonia Peripheral lesion – present as solitary spherical or lobular

nodule , 2-4 cm in diameter , with a well – defined smooth edge .

CT – calcification seen in 1/3rd patients

A small tumor completely occluding the right main bronchus and causing extensive collapse in right lung. The endoluminal component is well seen .There is poor differentiation of the tumor from adjacent collapsed lung

Well defined perihilar carcinoid tumor demonstrated anterior to the artery to the right lower lobe

A small peripheral carcinoid tumor indistinguishable from a number of other causes of SPN

 Asymmetry of the bronchovascular bundles in the apex of the upper lobe , these are due to a small subtle hyperattenuating peripheral solitary pulmonary nodule immediately adjacent to the apical segmental bronchus of the right upper lobe , this finding is consistent with a primary bronchial carcinoid tumor

HAMARTOMAS Most common benign tumor of

the lung. Composed of abnormal

arrangement of tissues ; cartilage, connective tissue, muscle, fat, and bone

Discovered incidentally Well-circumscribed nodules or

masses (usually small) with either smooth or lobulated margins

Approximately 60% have fat and approximately 20-30% have calcification / ossification (pop-corn like calcification)

Cavitation is not seen On CT scan fat can be

recognized by comparing it to subcutaneous fat and will typically have a Hounsfield measurement of -40 to -120HU

MALIGNANT LYMPHOPROLIFERATIVE DISORDERS

Radiographic appearances –

One or more areas of pulmonary consolidation resembling pneumonia

Multiple pulmonary nodules

Miliary nodulation or reticulonodular shadowing resemblibg lymphangitis carcinomatosa

LYMPHOMA

LEUKAEMIA

Imaging features – Diffuse bilateral reticulation & patterns

resembling interstitial oedema , lymphangitic carcinomatosis , small nodules , ground glass opacification & consolidation

Hilar / mediastinal lymphadenopathy Pleural effusion – common

METASTASIS Pulmonary metastases

are usually from breast, GIT, kidneys, testes, head & neck tumours.

Sign – one / more discrete pulmonary nodules usually in the outer portions of lungs

Nodules are characteristically round & well defined

They may be of any shape &have a irregular edge - adenocarcinoma

Irregular pulmonary metastasis – occur In adenocarcinoma .Nodules are irregular in outline . A large left pleural effusion is also seen

Metastases :a) Pathways of metastatic spread from a

primary extrathoracic site to lungsb) Neoplasms with rich vascular supplyc) Neoplasms with lymphatic

disseminationd) Other neoplasms with high propensity

to localize in lunge) Calcified Metastasesf) Giant Metastasesg) Sterile Metastases

a) Pathways of metastatic spread from a primary extrathoracic site to lungs :

1-Spread via pulmonary arteries2-Lymphatic spread (celiac nodes → posterior mediastinal nodes

+ paraesophageal nodes) and in lung parenchyma3-Direct extension4-Endobronchial spread

b) Neoplasms with rich vascular supply draining into systemic venous system :

1-Renal cell carcinoma2-Sarcomas3-Trophoblastic tumors4-Testis5-Thyroid

c) Neoplasms with lymphatic dissemination :1-Breast (usually unilateral)2-Stomach (usually bilateral)3-Pancreas4-Larynx5-Cervixd) Other neoplasms with high propensity to

localize in lung :1-Colon2-Melanoma3-Sarcoma

e) Calcified Metastases :-Calcifications in lung metastases are observed in :

1-Bone Tumor Metastases :a) Osteosarcomab) Chondrosarcoma

2-Mucinous Tumors :a) Ovarianb) Thyroidc) Pancreasd) Colone) Stomach

3-Metastases After Chemotherapy

f) Giant Metastases : Cannon Ball1-Head and neck cancer2-Testicular and ovarian cancer3-Soft tissue cancer4-Breast cancer5-Renal cancer6-Colon cancer

Multiple subcentimeter calcified pulmonary nodules (mets , red arrows) , pleural effusion (blue arrows)

SOLITARY PULMONARY NODULE A solitary pulmonary nodule is

defined as a discrete, well-marginated, rounded opacity less than or equal to 3 cm in diameter that is completely surrounded by lung parenchyma, does not touch the hilum or mediastinum, and is not associated with adenopathy, atelectasis, or pleural effusion.

Lesions larger than 3 cm are considered masses and are treated as malignancies until proven otherwise.

Most are benign, upto 40% of SPN’s may be malignant

DIFFERENTIALS OF SPN Bronchial carcinoma Bronchial carcinoid Granuloma Hamartoma Metastasis Chronic pneumonia or abscess Hydatid cyst Pulmonary haematoma Bronchocele

Fungus ball Massive fibrosis in coal workers Bronchogenic cyst Sequestration Atriovenous malformation Pulmonary infarct Round atelectasis

PSEUDOTUMOR Sharply marginated collection of pleural fluid - Either within an interlobar pulmonary fissure, or - In a subpleural location adjacent to a fissure.

Imaging : located along course of interlobar fissures Lenticular or biconvex contour

Most occour in minor/horizontal fissure

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CHEST RADIOGRAPHY 1st line investigation; cheap and readily available; can depict most of the features of overt lung cancer and its complications.

COMPUTED TOMOGRAPHY The gold standard in diagnosis and staging of lung cancer; gives cross-sectional imaging with better representation of anatomy; clearly depicts mediastinal adenopathy and involvement of adjacent structures.

MAGNETIC RESONANCE IMAGING

Excellent soft tissue resolution; clearly depicts vascular invasion better than CT; imaging modality of choice for assessing Pancoast tumours; of importance in cases where CT findings are indeterminate or equivocal.

POSITRON EMISSION TOMOGRAPHY

Provides excellent depiction of functional status of suspicious lung masses; helps to sort out status of nodal enlargement coexisting with lung cancer.

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