Definition

Primary neoplasms of the lung and bronchial system.

Epidemiology

Most common cause of death from cancer More common in men than women Age 40–70 A fundamental distinction is made between small cell lung cancer (SCLC, 15–20% of cases) and nonsmall cell lung cancer (NSCLC, 80–85%) Adeno-carcinoma is the most common type of nonsmall cell lung cancer (40%, acinar, papillary, bronchioalveolar, solid, mucus-forming), followed by squamous cell carcinoma (30%), and large cell carcinoma (15%).

Etiology, pathophysiology, pathogenesis

Main risk factor is cigarette smoking; other factors include asbestos exposure.

Imaging Signs

Modality of choice

CT (including the adrenal region), PET (PET/CT) Chest radiographs are not used in staging.

Radiographic findings

Pulmonary focal lesion of variable size (1–10 cm) with ill-defined margins and spicules Larger focal lesions are often lobulated Lesions occur more often in the upper lobe than lower lobe Adenocarcinoma is usually peripheral Squamous cell carcinoma is usually central.

CT findings

Solid intrapulmonary mass of variable size; margins may be lobulated or spiculated Central necrosis occurs in squamous cell carcinoma Adenocarcinoma shows lesser density (ground-glass pattern) Peritumoral lymphangitis and/or pulmonary metastases may be present Adenocarcinoma may occur in three forms (peripheral solitary, multilocular, pneumonia-like consolidation).

MRI

More sensitive in detecting chest wall, plexus, or mediastinal involvement Can exclude brain metastases.

PET

FDG-PET is the modality of choice for N and M staging (except for adenocarcinoma, where 30% false-negative findings occur) MIBG-PET is used for tumors with neuroendocrine differentiation.

Pathognomonic findings

Spiculated nodule with or without hilar and mediastinal lymphomas.

Diagnostic steps in nonsmall cell lung cancer

Confirm diagnosis by imaging studies and histologic examination Exclude distant metastases Determine resectability.

Fig. 8.1 Peripheral bronchial carcinoma (large cell carcinoma) in a 45-year-old woman. The CT shows the spiculation clearly. It also shows isolated streaky densities consistent with a fingerlike pleural lesion or microatelectasis. Findings are almost pathognomonic for a peripheral bronchial carcinoma.

Clinical Aspects

Typical presentation

Cough Hemoptysis Dyspnea Chest pain.

Therapeutic options

– Circumscribed local tumor (stages I and II): Surgery with or without adjuvant chemotherapy.

– Locally advanced tumor (stage III): Combined radiation and chemotherapy or neoadjuvant multimodal therapy concepts.

– Stage IV (M1 with malignant pleural effusion): Palliative chemotherapy or, where indicated, palliative radiation therapy.

Course and prognosis

Five-year survival rate is about 10%, depending on the stage (stage Ia 75–80%, stage III b 5%) The slow-growing bronchioalveolar adenocarcinoma generally has a better prognosis.

What does the clinician want to know?

Staging Complications Monitoring treatment.

Staging

TNM classification

– T staging: T1 = Tumor diameter less than 3 cm without involvement of the main bronchus (intrapulmonary tumor) T2 = Tumor diameter greater than 3 cm with invasion of the main bronchus 2 cm distal to the carina, invasion of visceral pleura, or partial atelectasis or obstructive pneumonitis T3 = Tumor diameter greater than 7 cm with invasion of the chest wall, diaphragm, pericardium, mediastinal pleura, or main bronchus adjacent to the carina (distance to the carina < 2 cm, carina free of tumor) or complete collapse of one lung or a solitary tumor node in the same lobe T4 = Any tumor invading the mediastinum, heart, major vessels, trachea, esophagus, spine, or carina; or separate tumor node or nodes in another ipsilateral pulmonary lobe.

Fig. 8.2 Peripheral bronchial carcinoma (noncornified squamous cell carcinoma, nonsmall cell lung cancer) in a 69-year-old man. The plain chest radiographs show a large, relatively well-demarcated tumorous mass in the right posterior lower lobe. The radiographic morphology suggests an adenocarcinoma.

– N staging: N1 = intrapulmonary, ipsilateral peribronchial, or ipsilateral hilar lymph nodes N2 = ipsilateral mediastinal and/or subcarinal lymph nodes N3 = contralateral mediastinal or hilar lymph nodes, or ipsilateral or contralateral scalene or supraclavicular lymph nodes

Stages in nonsmall cell lung cancer.

Changes in the T categories (Goldstraw et al., 2007)

Differential Diagnosis

Tips and Pitfalls

N staging based on imaging morphology is unreliable—sensitivity is about 60%, specificity about 80%, negative predictive value about 55%, and positive predictive value about 80%.

Selected References

Gilman MD, Aquino SL. State-of-the-art FDG-PET imaging of lung cancer. Semin Roentgen-ol 2005; 40: 143–153

Goldstraw P et al. The IASLC lung cancer staging project: proposals for the revision of the TNM stage groupings in the forthcoming (7 th) edition of the TNM classification of malignant tumors. J Thorac Oncol 2007; 2: 706–714

Mohammed TH, White CS, Pugatch RD. The imaging manifestations of lung cancer. Semin Roentgenol 2005; 40: 98–108

Ravenel JG. Lung cancer staging. Semin Roentgenol 2004; 39: 373–385

Definition

Aggressive, rapidly growing primary neoplasm of the bronchial system.

Epidemiology

A fundamental distinction is made between small cell lung cancer (SCLC, 15–20% of cases) and nonsmall cell lung cancer (NSCLC, 80–85%) More common in men Age 40–70.

Etiology, pathophysiology, pathogenesis

Main risk factor is cigarette smoking.

Imaging Signs

Modality of choice

CT (including the adrenal region), PET (PET/CT) Chest radiographs are not used in staging.

Radiographic findings

Hilar or mediastinal mass A pulmonary focal lesion is the exception (< 10% of cases).

CT findings

Large mediastinal and hilar tumor with bronchial obstruction The mass may compress major vessels (vena cava, pulmonary artery) Obstructive atelectasis and/or pneumonitis.

MRI

Excludes brain metastases.

PET

FDG-PET is the modality of choice for staging (identifies disease as local or extended) MIBG-PET identifies neuroendocrine tumors.

Pathognomonic findings

Large mediastinal tumor involving the hilum.

Diagnostic steps in small cell lung cancer

Confirm diagnosis by imaging studies and histologic examination Determine stage of disease Limited program in extended disease.

Clinical Aspects

Typical presentation

Cough Hemoptysis Dyspnea Chest pain.

Therapeutic options

Local disease: Multimodal curative approach with surgery, chemotherapy, and radiation Extended disease: Palliative chemotherapy, with adjunctive radiation therapy where indicated.

Course and prognosis

With treatment, 5-year survival rate is 10–20% in local disease and 0–10% in extended disease.

What does the clinician want to know?

Staging Complications Monitoring treatment.

Fig. 8.3 Small cell bronchial carcinoma in a 40-year-old woman with back pain from spinal metastases.

a    The plain chest radiograph shows an extensive mediastinal tumor without signs of a pulmonary lesion.

b, c On CT the findings appear as a conglomerate of lymph nodes involving all mediastinal compartments. Associated pleural effusion on the left side. The central tracheo-bronchial system appears normal. Only repeated bronchoscopy demonstrated the shallow tumor in the right main bronchus.

Staging

Local disease: Tumor limited to mediastinum, hila, and supraclavicular region Extended disease: Extrathoracic manifestation or pulmonary metastases, malignant pleural effusion, axillary lymph node involvement.

Differential Diagnosis

Tips and Pitfalls

Primary site of small cell lung cancer is often unidentifiable on imaging studies.

Selected References

Gilman MD, Aquino SL. State-of-the-art FDG-PET imaging of lung cancer. Semin Roentgen-ol 2005; 40: 143–153

Irshad A, Ravenel JG. Imaging of small cell lung cancer. Curr Probl Diagn Radiol 2004; 33: 200–211

Definition

Epidemiology

Variant of adenocarcinoma 2–5% of all lung carcinomas More common in men than in women Peak age is about 50.

Etiology, pathophysiology, pathogenesis

Arises from type II pneumocytes and bronchiolar epithelium Not associated Scarring predisposes Spreads along the peripheral airways (bronchioloalveolar spread).

Imaging Signs

Modality of choice

CT.

Radiographic findings

Forms: Peripheral nodules or pneumonia-like infiltrate Solitary (80% of cases) or multilocular to disseminated (20%).

CT findings

– Broad morphologic spectrum: Peripheral nodule (ill-defined margins, lobulated or spiculated, satellite lesions) Consolidation of a relatively low density (mucinous subtype) with CT angiogram sign, air bronchogram, and bronchiolo-gram (“air bubbles” in 50% of cases) Multilocular, unilateral or bilateral, disseminated appearances.

– Density: Solid Ground-glass Mixed.

– Collateral findings: Peripheral halo Peritumoral lymphangitis (“crazy paving”) Peritumoral centrilobular nodules (bronchogenic spread) Pulmonary metastases or multicentric tumors Pleural effusion (30% of cases) Lymph-adenopathy (20%).

FDG-PET

High rate of false-negative findings.

Pathognomonic findings

Chronic, progressive lobar or multilobar infiltrate.

Clinical Aspects

Typical presentation

Incidental finding in nearly asymptomatic patients, or patients may have a cough with bronchorrhea and dyspnea.

Confirmation of the diagnosis

Bronchoalveolar lavage and transbronchial biopsy.

Therapeutic options

Tumor resection where findings are localized Radiation therapy and chemo-therapy are indicated for nonresectable tumors.

Course and prognosis

Prognosis is better than for other lung carcinomas due to the slow growth Resectable tumors have a 5-year survival rate of 75%.

Fig. 8.4 Bronchioalveolar carcinoma (alveolar cell carcinoma) in a 65-year-old man.

a The plain chest radiograph shows a pneumonia-like infiltrate on the right side involving primarily the apical segments of the lower lobe and the perihilar region.

b The area of the infiltrate is hypodense on CT so that the larger vessels are delineated in addition to an air bronchogram (CT angiogram sign). Mediastinal lymphadenopathy and isolated focal infiltrates are also seen on the left side (arrows).

Fig. 8.5 Bronchioalveolar carcinoma (alveolar cell carcinoma) in a 60-year-old woman.

a    The plain chest radiograph shows a pneumonia-like infiltrate in the right lower lobe and bilateral isolated, ill-defined focal opacities, more pronounced on the right than on the left.

b, c On CT the infiltrate appears partially as a homogeneously dense acinar shadow and partially as a less pronounced density resembling a ground-glass opacity. The CT angiogram sign (arrowhead) is prominent in both segments. The additional focal infiltrates in both lungs show a halo sign (arrows).

What does the clinician want to know?

Resectability (staging as in nonsmall cell lung cancer) Course.

Differential Diagnosis

Related posts:

Occupational Diseases Idiopathic Interstitial Pneumonia Collagen Diseases and Vasculitis Sequelae of Therapy Mediastinal Disorders Infections

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree