Bronchopulmonary Neoplasms

8 Bronchopulmonary Neoplasms


Nonsmall Cell Lung Cancer


Definition


Primary neoplasms of the lung and bronchial system.


image Epidemiology


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


image Etiology, pathophysiology, pathogenesis


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


Imaging Signs


image Modality of choice


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


image Radiographic findings


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


image CT findings


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


image MRI


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


image PET


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


image Pathognomonic findings


Spiculated nodule with or without hilar and mediastinal lymphomas.


image Diagnostic steps in nonsmall cell lung cancer


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


image


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


image Typical presentation


Cough image Hemoptysis image Dyspnea image Chest pain.


image 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.


image Course and prognosis


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


image What does the clinician want to know?


Staging image Complications image Monitoring treatment.


Staging


image TNM classification


T staging: T1 = Tumor diameter less than 3 cm without involvement of the main bronchus (intrapulmonary tumor) image 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 image 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 image 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.


image


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 image N2 = ipsilateral mediastinal and/or subcarinal lymph nodes image N3 = contralateral mediastinal or hilar lymph nodes, or ipsilateral or contralateral scalene or supraclavicular lymph nodes


M staging: M0 = No distant metastases image M1a = Separate tumor node or nodes on the contralateral lung, pleural nodes, or malignant pleural effusion image M1b = Distant metastases


image Stages in nonsmall cell lung cancer.


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















































6th edition T and M description


7th edition T and M


T1 (≤ 2 cm)


T1a


T1 (> 2–3 cm)


T1b


T1 (≤ 5 cm)


T2a


T2 (> 5–7 cm)


T2b


T2 (> 7 cm)


T3


T3 (invasion)


 


T4 (same lobe nodules)


 


T4 (extension)


T4


M1 (ipsilateral lung)


 


T4 (pleural effusion)


M1a


M1 (contralateral lung)


M1a


M1 (distant)


M1b


Differential Diagnosis
















Granuloma or tuberculoma


– Denser, more sharply demarcated, and rounder focal lesion


– Calcifications


– History and previous imaging studies


Hamartoma


– Asymptomatic incidental finding


– Popcorn calcifications


Carcinoid


– Carcinoids, adenoid cystic carcinomas, and mucoepidermoid carcinomas primarily involve the central airways


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


Small Cell Lung Cancer


Definition


Aggressive, rapidly growing primary neoplasm of the bronchial system.


image Epidemiology


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


image Etiology, pathophysiology, pathogenesis


Main risk factor is cigarette smoking.


Imaging Signs


image Modality of choice


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


image Radiographic findings


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


image CT findings


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


image MRI


Excludes brain metastases.


image PET


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


image Pathognomonic findings


Large mediastinal tumor involving the hilum.


image Diagnostic steps in small cell lung cancer


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


Clinical Aspects


image Typical presentation


Cough image Hemoptysis image Dyspnea image Chest pain.


image Therapeutic options


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


image Course and prognosis


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


image What does the clinician want to know?


Staging image Complications image Monitoring treatment.


image


image


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.


image Staging


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


Differential Diagnosis
















Lymphoma or lymph node metastases


– Usually no signs of obstruction such as atelectasis, compression of the vena cava, or invasion or obstruction of the pulmonary artery.


Benign lymphadenopathy


– Usually smaller lymph nodes that are distinguishable from each other


Nonsmall cell lung cancer


– Pulmonary focal lesion


– Fewer hilar and/or mediastinal lymph node metastases


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


Bronchioalveolar Carcinoma—Alveolar Cell Carcinoma


Definition


image Epidemiology


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


image Etiology, pathophysiology, pathogenesis


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


Imaging Signs


image Modality of choice


CT.


image Radiographic findings


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


image CT findings


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


Density: Solid image Ground-glass image Mixed.


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


image FDG-PET


High rate of false-negative findings.


image Pathognomonic findings


Chronic, progressive lobar or multilobar infiltrate.


Clinical Aspects


image Typical presentation


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


image Confirmation of the diagnosis


Bronchoalveolar lavage and transbronchial biopsy.


image Therapeutic options


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


image Course and prognosis


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


image


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).


image


image


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).


image What does the clinician want to know?


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


Differential Diagnosis




















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Feb 28, 2016 | Posted by in RESPIRATORY IMAGING | Comments Off on Bronchopulmonary Neoplasms

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Peripheral bronchial carcinoma


– No air bronchogram or bronchiologram


Pneumonia


– Symptoms of infection


– Responds to antibiotics


Cryptogenic organizing pneumonia


– Fluctuating picture


– Responds to steroids


Wegener granulomatosis


– Renal insufficiency


– Sinus involvement


Sarcoidosis