Lungtumorradiology BY dr harshil

Imaging of
Lung Tumors
DR HARSHIL KALARIA
CONSULTANT RADIOLOGIST
INFOCUS DIAGNOSTICS
@WWW.SLIDESHARE.COM/DR HARSHIL KALARIA@WWW.SLIDESHARE.COM/DR HARSHIL

Introduction
• Lung cancer, or frequently, if somewhat incorrectly, known as bronchogenic carcinoma is the
most common cause of cancer death in developed countries.
• The usefulness of the various imaging examinations
largely depends on the clinical findings at the time of
presentation and also on the stage of the disease
• Many imaging modalities are used to further evaluate the findings seen on the
previous imaging and to determine the stage of the disease.
@WWW.SLIDESHARE.COM/DR HARSHIL

Bronchial carcinoma
• Most common cause of cancer in men
• 6th most frequent cancer in women
• Leading cause of cancer mortality worldwide – 20%
• In India, approximately 63,000 new lung cancer cases are reported each year.
• Major risk factor is cigarette smoking which is implicated in 90% of cases.
• Other risk factors include radon, asbestos, uranium, arsenic, chromium

Pathology
• NSCLC(80%)
• Squamous(35%)
• Smoking , cavitate , poor prognosis
• Adeno (30%)
• Women , non-smokers, peripheral
• Large cell (15%)
• SCLC (20%)
• Smoking, metastasises early, paraneoplastic syndromes and SVC
obstruction
• Worst prognosis @WWW.SLIDESHARE.COM/DR HARSHIL

Clinical features
• Cough, wheeze, sputum production, breathlessness, chest
discomfort, hemoptysis
• Asymptomatic(20%)
• Abnormal CXR in asymptomatic patients
• Paraneoplastic syndromes
• Finger clubbing, SVC obstruction, Horner’s syndrome, chest wall pain, dysphagia,
pericardial tamponade, Hypertrophic pulmonary osteoarthropathy (HPOA): squamous cell
carcinoma subtype, Nephrotic syndrome, Polymyositis, Dermatomyositis, Eosinophilia,
Acanthosis nigricans
• Thrombophlebitis: adenocarcinoma subtype

Radiological features
• Reflect pathology
• Depend on size, site, histology

Radiological features
1. Hilar enlargement
2. Airway obstruction
3. Peripheral mass
4. Mediastinal involvement
5. Pleural involvement
6. Bone involvement

Hilar enlargement
• Enlargement or increased density- 1 central tumor
• Peripheral tumors - Bronchopulmonary lymph nodes
• Extensive hilar and mediastinal lymphadenopathy - small
cell tumors

Hilar enlargement

Airway obstruction
• Collapse – segmental / lobar / entire lung
• Consolidation – infection distal to obstruction prior to
collapse
– absent air bronchogram
• Mucocele or bronchocele due to mucoid impaction

Bronchial obstruction

Bronchial tapering

Bronchial cut off sign

Bronchial cut off

Endobronchial mass

Effects of bronchial obstruction

Obstructive collapse

2ry pneumonia
Criteria of 2ry pneumonia:
1. Consolidation collapse.
2. Consolidation with no air bronchogram.
3. Consolidation with hilar mass.
4. Consolidation confined to one lobe for
more than 2 weeks without resolution or
spread to other lobes.
5. Unresolved pneumonia (for more than 8
weeks after proper antibiotic therapy).

Bronchocele (mucoid impaction)
• Branching tubular opacities giving finger in
glove appearance.

Airway obstruction
Central mass
• Shape of the collapsed or consolidated lobe may be altered
because of the bulk of the underlying tumor
• Fissure in the region of the mass is unable to move in the
usual manner , and fissure may show a bulge – Golden S sign

Golden S sign

Peripheral mass
• Common presentation of lung Ca
• Larger; poorly defined, lobulated, umbilicated or
spiculated margins (Corona radiata)
• Satellite opacities – more in benign than malignant
• Calcification – diffuse or central
• Doubling time – 1-18 months ; >2 yrs – benign@WWW.SLIDESHARE.COM/DR HARSHIL

• Corona radiata sign
• Fine linear strands
extending 4-5 mm
outward
• Spiculated on CXRs
• 84 – 90% are
malignant
Spiculated margin

• Scalloped border
• Intermediate
probability of cancer
• Smooth border
suggestive of benign
diagnosis
Lobulated margin

Illdefined margin

Air bronchogram

Calcification

Peripheral mass
• Cavitation – central necrosis or abscess formation
• Malignant cavities – thick walled, irregular nodular
inner margin
• Pancoast/ superior sulcus tumors – lung apex – tendency to invade
ribs, spine, brachial plexus, and inferior cervical sympathetic
ganglia

Pulmonary nodule Criteria of malignancy
Size Large pulmonary nodule (>2cm).
Enlarging (doubling time 1-18 months)
Margin Spiculated.
Lobultated.
Poorly defined.
Calcification Usually no calcification.
Stippled or eccentric calcification
(engulfment of calcified granuloma).
Cavitation Thick walled eccentric cavitation with
irregular inner margin.
Air
bronchogram
Broncho-alveolar carcinoma.

Peripheral mass

Pancoast tumor

Mediastinal involvement
• Lymph nodes : SCLC, mediastinal widening, lobulated outline
• Esophagus : compression or invasion - barium swallow
• Phrenic nerve : elevated hemidiaphragm, paradoxical
movement on fluoroscopy
• SVC : obstruction on dynamically enhanced CT/MRI
• Pericardial invasion : pericarditis or pericardial effusion

N
o
d
al
st
a
g
I
n
g

Mediastinal LN enlargement
Upper right
paratracheal LN:
Convexity of the SVC interface.
Thickening of the right paratracheal strip.
Lower right
paratracheal:
Enlargement of the azygos arch.
Upper left
paratracheal LN:
Convexity of the left subclavian artery
interface.
Aorto-pulmonary
LN:
Convexity of the aorto-pulmonary window.
Subcarinal LN: Convexity of the superior extent of azygo-
esophageal recess.
Widening of the carina.
Paraoesophageal
LN:
Thickening of the posterior tracheal band on
lateral film.@WWW.SLIDESHARE.COM/DR HARSHIL

Mediastinal lymph node
metastases

Mediastinal involvement

Phrenic nerve palsy

SVC syndrome

Bronchogenic carcinoma with invasion of the
intrapericardial portion of the left pulmonary
artery

Pleural involvement
• Pleural effusion : direct spread, lymphatic obstruction, obstructive
pneumonitis, sympathetic response
• Spontaneous pneumothorax : cavitating subpleural tumor

Bone involvement
• Direct invasion : peripheral carcinomas-ribs / spine
• Hematogenous : lytic, identified earliest by isotope bone scan
• Hypertrophic osteoarthropathy – well defined periosteal new
bone formation

Diagnostic imaging
• The prognosis and treatment of lung cancer depends
on the general condition of the patient and on the histology
of the tumor and its extent at the time of presentation

Diagnostic imaging
• SCLC – metastasise early, disseminated at presentation, chemosensitive
• NSCLC – metastasise later, esp. squamous
• Central tumors – sputum cytology, bronchoscopic biopsies or washings
• Peripheral tumors – percutaneous biopsy with fluoroscopic,
CT or USG guidance

Diagnostic imaging

Staging
Purposes
• Identify patients with NSCLC who will benefit from surgery
• To avoid surgery in those who will not benefit
• To provide accurate data for assessing and
comparing different methods of treatment

Staging

T1

T3

T4

N1

N2

N3

Alveolar cell carcinoma
• Bronchiolar or bronchio-alveolar Ca
• Subtype of adeno Ca
• Peripherally, probably from type II pneumocytes
• Not associated with smoking
• May be associated with diffuse pulmonary fibrosis and pulmonary scars

Two patterns:
• Focal form – solitary peripheral mass, air bronchograms often
visible, may spread via airways to progress to diffuse pattern
•Diffuse form – multiple acinar shadows, with areas of confluence
CT : ground glass opacification, small nodular opacities, frank
consolidation, thickened interlobular septa

Rare primary malignant neoplasms
Pulmonary Kaposi’s sarcoma
• AIDS
• Segmental or lobar consolidation
• Multiple nodular and linear opacities
• Pleural effusions
• Hilar and mediastinal lymphadenopathy@WWW.SLIDESHARE.COM/DR HARSHIL

Pulmonary artery angiosarcoma
• Hilar mass
• Signs of pulmonary embolism and pulmonary artery
hypertension

• Fibrosarcoma
• Leiomyosarcoma
• Carcinosarcoma
• Pulmonary blastoma
• Malignant hemangiopericytoma
Often present as solitary pulmonary mass radiologically
indistinguishable from a carcinoma of the lung

Benign pulmonary tumors
• Bronchial carcinoid
• Pulmonary hamartoma
• Bronchial chondroma
• Pulmonary fibroma
• Pulmonary myxoma
• Plasma cell granuloma
• Bronchial papilloma

Thank you
@WWW.SLIDESHARE.COM/DR HARSHIL KALARIA

Bronchial carcinoid
• Neuroendocrine tumors derived from APUD cells
• Typical(90%) and atypical
• 80% arise in lobar or segmental bronchi
• Cause bronchial obstruction, collapse, recurrent segmental
pneumonia, bronchiectasis, abscess formation.
• Peripheral carcinoids –well circumscribed round or ovoid
solitary nodules

Bronchial carcinoid

Pulmonary hamartoma
• Consists of abnormal arrangement of tissues normally found in
the organ concerned
• Large cartilaginous component, and appreciable fatty component
• Solitary nodule in an asymptomatic adult
• Rare in childhood

Pulmonary hamartoma
• Peripheral
• Well circumscribed nodules
• Do not cavitate
• Low density within denotes fat
• 30% show calcification on x-ray with popcorn appearance
• Grow slowly on serial films

Pulmonary hamartoma

Intrathoracic lymphoma and leukemia
Hodgkin’s disease
• MC lymphoma
• Usually arises in lymph nodes – hilar or mediastinal node enlargement on CXR
• Lymphadenopathy – frequently bilateral, asymmetrical, involves anterior
mediastinal glands
• CT – Paraspinal and retrosternal nodes

Hodgkin’s disease
• Involves lung parenchyma in 30%
• Pulmonary infiltrate may appear as solitary areas of consolidation,
larger confluent areas or miliary nodules
• Pulmonary opacities may have an air bronchogram and may cavitate
• Pleural effusion due to lymphatic obstruction, pleural plaques may
be seen

Hodgkin’s disease

Non – Hodgkin’s disease
• Radiologic manifestations are similar to Hodgkin’s disease
• Progression of disease is less orderly
• Pulmonary and pleural involvement precedes mediastinal
disease

Non – Hodgkin’s disease

Pseudolymphoma
• Tumor like condition which behaves benignly
• Focal
• Solitary or multiple areas of pulmonary consolidation
• Air bronchogram, cavitation may occur

Lymphomatoid granulomatosis
• Angiocentric, angiodestructive lymphoreticular, proliferative and granulomatous
disease predominantly involving the lungs
• A T-cell non-Hodgkin’s lymphoma
• Multiple ill defined nodules resembling metastases

Lymphomatoid granulomatosis

Leukemia
• Radiographic abnormalitites are due to the complications of the disease
• Mediastinal lymph node enlargement, pleural effusion, pulmonary
infiltrates
• More common in lymphatic than myeloid leukemia

Metastatic lung disease
• Hematogenous > lymphatic > Endobronchial
• Primaries – breast, skeleton, urogenital system, colon,
melanoma
• Bilateral ,basal predominance, often peripheral and
subpleural
• Spherical, well defined margins

• Cavitation – Squamous carcinomas and sarcomas
• Calcification – Osteosarcoma, chondrosarcoma, mucinous
adenocarcinoma
• Endobronchial metastases – Ca kidney, breast, colon

Lymphangitis carcinomatosa
• Hematogenous metastases occluding peripheral pulmonary lymphatics
• Lung, breast, stomach, pancreas, cervix and prostate
• CXR - Coarse, linear, reticular and nodular basal shadowing,
pleural effusions and hilar lymphadenopathy
• HRCT – Nodular thickening of interlobular septa, thickening
of centrilobular bronchovascular bundles

Lymphangitis carcinomatosa

Solitary pulmonary nodule
• Defined as a solitary circumscribed pulmonary opacity
 3 cm in diameter with no associated pulmonary, pleural or
mediastinal
abnormality
• 40% of SPNs are malignant

Causes
• Bronchial carcinoma
• Bronchial carcinoid
• Granuloma
• Hamartoma
• Metastases
• Chronic pneumonia or
abscess
• Hydatid cyst
• Pulmonary hematoma
• Bronchocele
• Fungus ball
• Massive fibrosis in coal
workers
• Bronchogenic cyst
• Sequestration
• AVM
• Pulmonary infarct
• Round atelectasis@WWW.SLIDESHARE.COM/DR HARSHIL

Mimics
• Extrathoracic artefacts
• Cutaneous masses
• Bony lesions
• Pleural tumors or plaques
• Encysted pleural fluid
• Pulmonary vessels @WWW.SLIDESHARE.COM/DR HARSHIL

Factors to differentiate
• Size
• Calcification
• Enhancement
• Growth rates
• Shape
• Margin

SIZE
• >3cm : Malignant unless proved otherwise

Enhancement on ct
• Post contrast : > 20HU s/o malignancy

Growth
W.r.t Doubling time of the lesion
• Malignant : 1-6months
• Benign : > 18months

Shape
• Polygonal shape
• Three-dimensional ratio > 1.78 - sign of benignity
B
A

margin
• Corona radiata sign - highly associated with malignancy
• Lobulated or scalloped margins - intermediate
probability
• Smooth margins - more likely benign

Air Bronchogram sign
• A/w malignancy
• Bronchoalveolar ca and
adenocarcinoma

Esophagus Esophageal compression or invasion.
Phrenic nerve Diaphragmatic paralysis
Recurrent laryngeal N. Vocal cord paralysis.
SVC Dilated neck & anterior chest wall
veins.
Pulmonary artery Pulmonary oligemia.
Pericardium Pericardial effusion.
Pulmonary vein Tumoral thrombosis

Lungtumorradiology BY dr harshil

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