PPT explaining the presentation of various benign and malignant lesions of lung

1. Imaging of
Lung
Tumors
Roshan Valentine

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

3. 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

4. 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.

5. 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.

6. 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

7. 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

8. 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

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

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

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

12. Hilar enlargement

13. 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

14. 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

15. Airway obstruction

16. Airway obstruction
Bronchocele

17. 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

18. 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

19. Peripheral mass

20. Peripheral mass

21. Pancoast tumor

22. 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

23. Mediastinal involvement

24. Mediastinal involvement

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

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

27. 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

28. 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

29. Diagnostic imaging

30. 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

32. Staging

33. Staging

34. T1

35. T2

36. T3

37. T4

38. N
o
d
al
st
a
g
I
n
g

39. N1

40. N2

41. N3

42. 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

43. 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

44. Alveolar cell carcinoma

45. Rare primary malignant neoplasms
Pulmonary Kaposi’s sarcoma
• AIDS
• Segmental or lobar consolidation
• Multiple nodular and linear opacities
• Pleural effusions
• Hilar and mediastinal lymphadenopathy

46. Rare primary malignant neoplasms
Pulmonary artery angiosarcoma
• Hilar mass
• Signs of pulmonary embolism and pulmonary artery
hypertension

47. 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

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

49. 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

50. Bronchial carcinoid

51. 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

52. 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

53. Pulmonary hamartoma

54. 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

55. 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

56. Hodgkin’s disease

57. 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

58. Non – Hodgkin’s disease

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

60. 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

61. Lymphomatoid granulomatosis

62. 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

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

64. Metastatic lung disease
• Cavitation – Squamous carcinomas and sarcomas
• Calcification – Osteosarcoma, chondrosarcoma, mucinous
adenocarcinoma
• Endobronchial metastases – Ca kidney, breast, colon

65. Metastatic lung disease

66. 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

67. Metastatic lung disease
Lymphangitis carcinomatosa

68. 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

69. Solitary pulmonary nodule
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

70. Solitary pulmonary nodule
Mimics
• Extrathoracic artefacts
• Cutaneous masses
• Bony lesions
• Pleural tumors or plaques
• Encysted pleural fluid
• Pulmonary vessels

71. Solitary pulmonary nodule
Factors to differentiate
• Size
• Calcification
• Enhancement
• Growth rates
• Shape
• Margin

72. SIZE
• >3cm : Malignant unless proved otherwise

73. Calcification

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

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

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

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

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