Imaging of

Lung
Tumors

Roshan Valentine
Outline
• Introduction • Rare primary malignant
neoplasms
• Carcinoma bronchus • Benign pulmonary
- pathology, symptoms
tumors
- radiological features
- diagnostic imaging • Intrathoracic lymphoma
- staging and leukemia
- assessing treatment • Metastatic lung disease
• Evaluation of solitary
pulmonary nodule
Introduction

• A wide variety of neoplasms arise in the lungs

• Many are overtly malignant, others are definitely benign

• Some fall in between these two extremes

 Introduction
• Lung cancer is the most common cause of cancer death in developed

countries.

• The prognosis is poor, with less than 15% of patients surviving

5 years after diagnosis. The poor prognosis is attributable to lack of

efficient diagnostic methods for early detection and lack of successful

treatment for metastatic disease.

 Introduction

• 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.
 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
 Clinical features

• Cough, wheeze, sputum production, breathlessness, chest

discomfort, hemoptysis

• Asymptomatic(20%)

• Finger clubbing, SVC obstruction, Horner’s syndrome,

chest wall pain, dysphagia, pericardial tamponade

• Abnormal CXR in asymptomatic patients

• Paraneoplastic syndromes
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

 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

Airway obstruction
Airway obstruction
Bronchocele
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

 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
Peripheral mass
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

Mediastinal involvement
Mediastinal involvement
 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
Staging
T1
T2
T3
T4
N
o
d
al
st
a
g
I
n
g
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

 Alveolar cell carcinoma

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

Alveolar cell carcinoma
Rare primary malignant neoplasms

Pulmonary Kaposi’s sarcoma

• AIDS

• Segmental or lobar consolidation

• Multiple nodular and linear opacities

• Pleural effusions

• Hilar and mediastinal lymphadenopathy

Rare primary malignant neoplasms

Pulmonary artery angiosarcoma

• Hilar mass

• Signs of pulmonary embolism and pulmonary artery

hypertension
 Rare primary malignant neoplasms

• 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
 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

 Metastatic lung disease

• Cavitation – Squamous carcinomas and sarcomas

• Calcification – Osteosarcoma, chondrosarcoma, mucinous

adenocarcinoma

• Endobronchial metastases – Ca kidney, breast, colon

Metastatic lung disease
 Metastatic lung disease

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

Metastatic lung disease
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

Solitary pulmonary nodule

Causes
• Bronchial carcinoma • Bronchocele
• Bronchial carcinoid • Fungus ball
• Granuloma • Massive fibrosis in coal
• Hamartoma workers
• Metastases • Bronchogenic cyst
• Chronic pneumonia or • Sequestration
abscess • AVM
• Hydatid cyst • Pulmonary infarct
• Pulmonary hematoma • Round atelectasis
 Solitary pulmonary nodule

Mimics

• Extrathoracic artefacts

• Cutaneous masses

• Bony lesions

• Pleural tumors or plaques

• Encysted pleural fluid

• Pulmonary vessels
 Solitary pulmonary nodule

Factors to differentiate
• Size
• Calcification
• Enhancement
• Growth rates
• Shape
• Margin
SIZE
• >3cm : Malignant unless proved otherwise
Calcification
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

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