lung carcinoma , classification and TNM staging , radiological finding,

1. Dr. ASHISH K GUPTA
PG II YEAR
RADIODIAGNOSIS
SLIMS

2.  Lung cancer, or frequently, if somewhat
incorrectly, known as bronchogenic
carcinoma,
 The most common cause of cancer in
men, and the 6th most frequent cancer in
women worldwide.
 It is the leading cause of cancer
mortality worldwide in both men and
women and accounts for approximately
20% of all cancer deaths

3. Epidemiology
 Lung cancer is the most common fatal malignancy
worldwide both in male and female. The major risk
factor is CIGARETTE SMOKING which is
implicated in 90% of cases and increase the risk
of lung cancer 20-30 times.
Other risk factors:
 asbestos: 5x increased risk
 occupational exposure: uranium, radon, arsenic,
chromium
 diffuse lung fibrosis: 10x increased risk
 chronic obstructive pulmonary disease

4. Clinical presentation
 Patients with lung cancer may be asymptomatic in up
to 50% of cases.
 Cough and dypnoea are rather non-specific
symptoms that are common amongst those with lung
cancer.
 Central tumours may result in haemoptysis and
peripheral lesions with pleuritic chest pain.
 Pneumonia, pleural effusion, wheeze,
lymphadenopathy are not uncommon. Other
symptoms may be secondary to metastases (brain,
liver, bone) or to paraneoplastic syndromes.

5. OTHER
 Finger clubbing
 Hypertrophic pulmonary osteoarthropathy
(HPOA): squamous cell carcinoma subtype
 Nephrotic syndrome
 Polymyositis
 Dermatomyositis
 Eosinophilia
 Acanthosis nigricans
 Thrombophlebitis: adenocarcinoma subtype

6. Pathology
 The term bronchogenic carcinoma is
somewhat loosely used to refer to primary
malignancies of the lung that are
associated with inhaled carcinogens and
includes four main histological subtypes.
 These are broadly divided into non small-
cell carcinoma and small cell carcinoma as
they are differ clinically in terms of
presentation, treatment and prognosis:

7. NON SMALL-CELL LUNG
CANCER (NSCLC) (80%)
 Adenocarcinoma (35%)
 Most common cell type overall
 Most common in women
 Most common cell type in non-smokers but still most patients
are smokers
 Peripheral
 Squamous cell carcinoma (30%)
 Strongly associated with smoking
 Most common carcinoma to cavitate
 Poor prognosis
 Large-cell carcinoma (15%)
 Peripherally located
 Very large, usually more than 4 cm

8. SMALL CELL
CARCINOMA (20%)
 Almost always in smokers
 Metastasises early
 Most common primary lung malignancy
to cause paraneoplastic
syndromesand SVC obstruction
 Worst prognosis
Other malignant pulmonary neoplasms
include lymphoma and sarcoma (rare)

9. Non-small cell lung cancer
(NSCLC) staging
 Non-small cell lung cancer (NSCLC)
staging can be accomplished both by
the TNM system, or by the AJCC
staging system.

10. TNM system
 Primary tumour (T)
 Tx: malignant cells on cytology but no
tumour found on bronchoscopy or imaging.
 Tis: carcinoma in situ
 T1
 tumour size equal or less than 3cm
 ​​not involving the main bronchus
○ T1a: smaller than 2 cm in longest dimension
○ T1b: larger than 2 cm but smaller or equal to 3
cm

11. Stage T1 tumors. (a) Chest CT scan shows a left lower lobe nodule (arrow)
measuring less than 2 cm in size, a finding that is consistent with a stage
T1a tumor (≤2 cm). (b) Chest CT scan obtained in a different patient shows
a right upper lobe nodule (arrow) measuring 2.9 cm in size, a finding that
is consistent with a stage T1b tumor (>2 cm but ≤3 cm).

12.  T2:
 Tumour size more than 3cm but less/equal
to 7cm or
 Involving the main bronchus but >2 cm
from carina
 Visceral pleural involvement
 Lobar atelectasis extending to the hilum
but not collapse of the entire lung
 T2a: larger than 3 cm but smaller than 5 cm
 T2b: larger than 5 cm but smaller than 7 cm

13. Stage T2 tumors. (a) Chest CT scan shows a centrally located lung nodule (arrow)
causing airway obstruction, with atelectasis or postobstructive pneumonia that
does not, however, involve the entire lung. (b) Chest CT scan obtained in a
different patient shows a mass in the right lung (arrow) measuring 4.8 cm, a
finding that is consistent with a stage T2a tumor (>3 cm but ≤5 cm). (c) Coronal
chest CT scan obtained in a third patient shows a nodule in the bronchus
intermedius (arrow). The nodule is 4 cm from the carina (an endobronchial lesion
> 2 cm from the carina is considered stage T2

14.  T3
 Tumour size more than 7 cm or
 tumour <2 cm from carina but not involving
trachea or carina
 Involvement of the chest wall, including
pancoast tumour, diaphragm, phrenic nerve,
mediastinal pleura or parietal pericardium
 Separate tumour nodule(s) in the same lobe
 Atelectasis or post obstructive pneumonitis of
entire lung

15. Stage T3 tumors.
(a) Chest CT scan shows an irregular mass in the left upper lobe with
suspicious local extension to the mediastinal pleura (arrow).
(b) Chest CT scan obtained in a different patient shows an endobronchial
mass (arrow) less than 2 cm from the carina.
(c) Chest CT scan obtained in a third patient shows a left lower lobe mass
over 7 cm in diameter (arrow).

16. Stage T3 tumors. Chest CT scan shows a primary mass
(arrow) with satellite nodules (arrowheads) in the right
lower lobe.

17.  T4
 any size tumour with:
 involvement of the trachea, oesophagus,
recurrent laryngeal nerve vertebra, great
vessels or heart
 separate tumour nodules in the same
lung but not in the same lobe

18. Stage T4 tumors. Chest CT scan shows a primary lung
tumor in the right upper lobe (long arrow) with a smaller
separate nodule in the right lower lobe (short arrow).

19. Stage T4 tumors. Chest CT scan shows a right upper
lobe mass (arrow) with mediastinal and carinal
invasion, ipsilateral loculated pleural effusion, and
thickening and enhancement of the pleura.

20.  Nodal status (N)
 Nx: regional nodes cannot be assessed
 N0: no regional nodal metastases
 N1: ipsilateral peribronchial, hilar or
intrapulmonary nodes, including direct
invasion
 N2: ipsilateral mediastinal or subcarinal
nodes
 N3: contralateral nodal involvement ;
ipsilateral or contralateral scalene or
supraclavicular nodal involvement

21. Stage N1 lymph nodes. (a) Chest CT scan obtained in a patient with right-sided
lung cancer shows an enlarged right hilar lymph node (level 10) (arrow)
measuring 15 mm in the short axis. (b) Chest CT scan obtained in a different
patient shows a left lower lobe mass and an ipsilateral enlarged interlobar lymph
node (level 11) (arrow) measuring 11 mm in the short axis

22. Stage N2 lymph nodes. (a) Chest CT scan shows an enlarged (1.6-cm) right upper
paratracheal lymph node (level 2) (arrowhead). (b) Chest CT scan obtained in a
different patient shows an enlarged (1.5-cm) right lower paratracheal lymph node
(level 4) (arrowhead). (c) Chest CT scan obtained in a third patient shows a right
lower lobe mass (white arrow) with an enlarged (1.6-cm) subcarinal lymph node
(level 7) (black arrow )

23. Stage N3 lymph nodes. (a) Axial PET/CT image of the chest shows a primary
mass in the left lung (arrow) and a right lower paratracheal lymph node
(arrowhead), both of which demonstrate intense radiotracer uptake.
Metastatic involvement of the lymph node was confirmed at
mediastinoscopic resection. (b) Chest CT scan obtained at the lung apex in
a different patient shows enlarged bilateral supraclavicular lymph nodes
(arrows).

24.  Distant metastasis (M)
 Mx: distant metastases cannot be
assessed
 M0: no distant metastases
 M1: distant metastases present
 M1a: presence of a malignant pleural or
pericardial effusion, pleural dissemination, or
pericardial disease, and metastasis in
opposite lung
 M1b: extrathoracic metastases

25. Metastatic disease as seen at
conventional imaging. (a) Axial contrast
material–enhanced T1-weighted MR
image of the brain obtained in a
patient with known primary lung
cancer shows a ring-enhancing lesion
with surrounding edema in the right
occipital pole (arrow), a finding that is
consistent with metastasis. (b)
Abdominal CT scan obtained in a
different patient shows multiple
enhancing hepatic masses (arrows)
and a right adrenal mass (arrowhead),
findings that are consistent with
metastatic disease. (c) Technetium-
99m methylene diphosphonate nuclear
bone scintigrams obtained in a third
patient with lung cancer show
multifocal areas of abnormal
radiotracer uptake in the axial and
appendicular skeleton, findings that
are consistent with metastases

26.  AJCC staging system
 stage 0
 TNM equivalent: carcinoma in stiu
 resectable: yes
 stage I
 TNM equivalent: T1 or T2, N0, M0
 resectable: yes
 5 year survival: 47%
 stage IIa
 TNM equivalent: T1, N1, M0
 resectable: yes
 stage IIb
 TNM equivalent: T2, N1, M0 or T3, N0, M0
 resectable: yes
 5 year survival: 26%
 stage IIIa
 TNM equivalent: T1 or 2, N2, M0 or T3, N1 or 2, M0
 resectable: yes
 --------------- accepted cut off between resectable and non resectable ----------
 stage IIIb
 TNM equivalent: T1, 2 or 3, N3, M0 or T4, N0, 1, 2 or 3, M0
 resectable: no
 5 year survival: 8%
 stage IV
 TNM equivalent: any T, any N with M1
 resectable: no

27.  As each subtype has a different
radiographic appearance, demographic,
and prognosis:
 squamous cell carcinoma of the lung
 adenocarcinoma of the lung
 large cell carcinoma of the lung
 small cell carcinoma of the lung

28. Squamous cell
carcinoma (SCC)
 Squamous cell carcinoma (SCC) is
one of the non-small cell carcinomas of
the lung, overtaken by adenocarinoma
of the lung as the most
commonly encountered lung cancer.

29. Epidemiology
 Squamous cell carcinoma accounts for ~30-35%
of all lung cancers and in most instances are due
to HEAVY SMOKING .
 In general, squamous carcinomas are
encountered more frequently in male smokers,
and adenocarcinoma in female smokers.

30. Clinical presentation
 Clinical presentation depends on the location of the
tumour and is largely independent of histology.
 Central tumours with invasion and obstruction of
bronchi typically result in distal collapse which may
have superimposed infection. A chronic cough
and haemoptysis may be present.
 More peripheral tumours, if not found incidentally on
imaging, usually present when larger, invading into
chest wall (e.g. Pancoast tumour)
 Metastatic disease may be the first sign of malignancy
(e.g. cerebral metastasis,pathological fracture, etc).

31. Pathology
 Although squamous cell carcinoma of the lung is
traditionally known to arise centrally (66-90%), the
incidence of peripherally located SCC is increasing .
 Macroscopically these tumours tend to be off-white in
colour, arising from, and extending into a bronchus. They
invade the surrounding lung parenchyma and can extend
into the chest wall. Larger tumours have a tendency to
undergo central necrosis.
 Four subtypes are recognised :
 papillary
 clear cell
 small cell (not to be confused with small cell lung cancer)
 basaloid

32. Metastases
Most common sites of metastatic disease
are :
 Regional lymph nodes
 Adrenal glands (see adrenal gland
tumours)
 Brain (see cerebral metastases)
 Bone (see skeletal metastases)
 Liver (see liver metastases)

33. Radiographic features
 Chest radiograph
 The appearance depends on the location of the
lesion..When the right upper lobe is collapsed and
a hilar mass is present, this is known as
the Golden S sign.
 A more peripheral location may appear as a
rounded or spiculated mass. Cavitation may be
seen as an air-fluid level.
 A pleural effusion may also be seen, and although
it is associated with a poor prognosis,

34. (a) and bronchogram (b) show the characteristic growth pattern of these tumors
in a patient with a squamous cell carcinoma of the night main stem bronchus.
Note the irregular narrowing (arrow) of to bronchial lumen, which may result in
postobstructive pneumonia or atelcısis

35. Squamous cell carcinoma in a 57-year-old man.
PA (a) and lateral (b) chest radiographs demonstrate a complete consolidation
of the right upper lobe. At bronchoscopy, an endobronchial tumor of the r ı t
main stem bronchus was identified.

36. Squamous cell carcinoma in a 63-year-old woman with dysphagia and weight
loss. (a) Frontal chest radiograph demonstrates opacification of the left
hemithorax and ipsilateral mediastinal shift consistent with complete atelectasis of
the left lung. Lack of visualization of the left main stem bronchus suggests central
occlusion. (b) Contrast-enhanced chest CT scan (mediastinal window)
demonstrates a softtissue mass (in), which narrowed and obstructed the left main
stem bronchus, left lung atebectasis, and left pleural effusion. At bronchoscopy, a
circumferential, friable obstructing endobronchial lesion was found.

37. Squamous cell carcinoma in a 62-year-old man with left shoulder pain. (a, b) Thin-
section chest CT scans (lung window) show an endobronchial nodule (arrow in a) within
the right lower lobe bronchus.
There is involvement of the adjacent lung parenchyma with associated volume loss of
the night lower lobe.
Note the bobulated mass (arrowhead in b) that displaces the major fissure. (C) Gross
specimen of the resected right lower lobe shows the endobronchial component of the
tumor

38. Squamous cell carcinoma in a 72-year-old man
with left arm pain, chest pain, and increasing dyspnea.
(a) PA chest radiograph demonstrates a large rounded cavitary
mass with an air-fluid level in the superior segment of the left lower lobe. Note the
nodular, irregular contour of the inner wall of the cavity. (b) Contrast-enhanced chest CT
scan (mediastinal window) demonstrates the air-fluid level within the lesion and the
irregular aspect of its inner wall.

39.  CT
 Cavitation is a frequent finding in primary lung
SCC but can also be encountered in metastatic
SCC. Cavitation is secondary to tumoral necrosis.
In other instances, SCC can have a central scar
with peripheral growth of tumor.

40.  Differential diagnosis
 The differential diagnosis depends on the
location and appearance of the mass.
 hilar mass (unilateral): differential for a hilar
mass
 solitary pulmonary nodule: differential for a
solitary pulmonary nodule
 pleural effusion: differential for a pleural
effusion

41. Adenocarcinoma of the
lung
 Adenocarcinoma of the lung is one of
the non-small cell carcinomas of the
lung and is a malignant tumour with
glandular differentiation or mucin
production.
 Tumour exhibits various patterns and
degrees of differentiation, including
lepidic, acinar, papillary, micropapillary
and solid with mucin formation

42.  Epidemiology
 It is now considered the most common
histological subtype in terms of
prevalence.
 Clinical presentation
 Early symptoms are fatigue with mild
dyspnoea followed by chronic cough
and haemoptysis at a later stage.

43.  Radiographic features
 Sometimes it is impossible to
radiographically distinguish between
other histological lung cancer types.
 A lung nodule is a rounded or irregular
region of increased attenuation
measuring less than 3 cm. The amount
of attenuation can further classify the
nodules as either ground glass, sub-
solid or solid.

44. Adenocancinoma in an asymptomatic 58-year-old male smoker with a radiographic
abnormalitfound incidentally on a preoperativeradiograph obtained before cataract
surgery.
(a) Posteroantenior (PA) chest radiograph shows alobulated 1.5-cm solitary nodule
(arrow) in theright upper lobe overlying the first anterior rib

45. (b) Chest computed tomographic (CT) scan (lungwindow) shows large bullae
surrounding a wellmarginated,lobulated soft-tissue nodule.

46. Adenocarcinoma in a 41-year-old man with right shoulder pain for several
months. (a) Apical brdotic
chest radiograph demonstrates a right apical mass with poorly marginated
borders. (b) Chest CT scan
(lung window) shows a homogeneous peripheral right upper lobe mass with
irregular borders. There is tumon
involvement of a posterior rib (arrow).

47. Large cell carcinoma of the
lung
 Large cell carcinoma of the
lung is one of the histological type
of non-small cell carcinomas of the lung.
Epidemiology
 It is thought to account for approximately
10% of bronchogenic carcinoma .
Clinical presentation
 Patient presents with dyspnea, chronic
cough and haemoptysis.

48.  Radiographic features
 Large cell carcinoma of the lung typically
presents as a large peripheral mass of
solid attenuation and irregular margin.
Focal necrosis can be present. Other
characteristics include rapid growth and
early metastasis.

49. large cell carcinoma in a 61-year-old woman with blood-streaked
sputum and weight loss. (a) PA chest radiograph demonstrates a large
peripheral mass of the left upper lobe,
which abuts the pleural surface and has a bobubated contour. (b) Cut surface
of the gross specimen demonstrates
a 7-cm tumor that extends to the pleural surface.

50. large cell carcinoma in a
57-year-old man with weight loss, orthopnea, and a painful palpable mass of the
anterior chest wall on the
left side. (a) Contrast-enhanced chest CT scan (mediastinal window) demonstrates
a large mass of heterogeneoUs
attenuation, which produces mass effect on the mediastinal structures. (b) Cut
surface of the neoplasm
shows a large central area of necrosis,

51. Small cell lung cancer
(SCLC)
 Small cell lung cancer (SCLC) (also known as oat cell
lung cancer) is a subtype of bronchogenic carcinoma and
considered separate from non small-cell lung cancer
(NSCLC) as it has unique presentation, imaging
appearances, treatment, and prognosis.
 Small cell lung cancers rapidly grow, are highly malignant,
widely metastasise and show initial response to
chemotherapy and radiotherapy.
 SCLCs have a very poor prognosis and are usually
unresectable.
Epidemiology
 Small cell lung cancers represent 15-20% of lung
cancers and is strongly associated with cigarette
smoking.

52. Clinical presentation
 Clinical presentation can significanctly vary and can present in the following ways.
 constitutional
 fever
 weight loss
 malaise
 primary tumour
 cough
 haemoptysis
 dyspnoea
 local invasion
 dysphagia (oesophageal compression)
 hoarseness (recurrent laryngeal nerve palsy)
 stridor (airway compression)
 SVC obstruction
 rib erosion
 metastatic spread (affecting ~70% of patients are presentation)
 bone pain (bone metastases)
 focal neurological deficit (CNS involvement)
 right upper quadrant pain (liver metastases)
 paraneoplastic syndromes

53.  Pathology
 Small cell carcinoma is considered a neuroendocrine
tumour of the lung. It arises from the bronchial
mucosa. Local invasion occurs in the submucosa with
subsequent invasion of peribronchial connective
tissue. Cells are small, oval, with scant cytoplasm and
a high mitotic count.
 It is the most common lung cancer subtype to
produce necrosis, superior vena cava (SVC)
infiltration/SVC obstruction, and paraneoplastic
syndromes.
Location
 Approximately 90-95% of SCLCs occur centrally, and
usually arising in a lobar or main bronchus .

54. Radiographic features
 Small cell cell tumours are located centrally in the
vast majority of cases (90%). They arise from main-
stem of lobar bronchi, and thus appear as hilar or
perihilar masses . They frequently have mediastinal
lymph node involvement at presentation.
Plain film
 Appearances on chest x-rays are non-specific. They
may be seen as a hilar/perihilar mass usually with
mediastinal widening due to lymph node
enlargement 2. In fact, the mediastinal involvement is
often the most striking feature and the primary mass
may be inapparent.

55.  CT
 On CT mediastinal involvement may appear
similar to lymphoma, with numerous enlarged
nodes. Direct infiltration of adjacent structures
is more common. Small cell carcinoma of the
lung is the most common cause of SVC
obstruction, due to both
compression/thrombosis and/or direct
infiltration .
 Necrosis and haemorrhage are both common.
Only rarely do small cell carcinomas present
as a solitary pulmonary nodule.
 CT is able to stage small cell cell lung cancer.

56. Small cell carcinoma in a 41-year-old woman with persistent cough and weight
loss.
(a) PA chest radiograph shows a lobulated right hilar mass. (b) Frontal linear
chest tomogram shows smooth
narrowing of the bronchus intermedius due to extrinsic compression by the hilar
mass, which represented
lymph node metastases from small cell carcinoma.

57. Small cell carcinoma in a 72-year-old man with a history of dyspnea.
(a) Chest CT scan demonstrates a spiculated nodule in the right upper lobe.
(b) Contrast enhanced chest CT scan (mediastinal window) shows massive
mediastinal lymphadenopathy secondary to lymph node metastases.

58.  Differential diagnosis
 Imaging imaging differential considerations
include
 non small-cell lung cancer
 squamous cell carcinoma of the lung
 adenocarcinoma of the lung
 undifferentiated large-cell carcinoma of the lung
 lymphoma
 pulmonary sarcoma (rare)
 pulmonary metastases
 benign lung lesions

59. Paraneoplastic Syndromes
 Various paraneoplastic syndromes can
arise in the setting of lung cancer:
 ENDOCRINE
 SIADH causing hyponatraemia: small-cell sub
type
 ACTH secretion (Cushing syndrome): carcinoid
and small-cell sub type
 PTHrp causing hypercalcaemia: squamous cell
carcinoma
 carcinoid syndrome
 gynaecomastia

60. NEUROLOGICAL
 polyneuropathy
 myelopathy
 cerebellar degeneration
 Lambert-Eaton myasthenia syndrome

61. case
Pt came to ortho department for trauma
.then was reffered for PAC and
conciquently chest radiograph was taken
Pt gave history of smoking last 10-15
years but was asymptomatic.

62. Chest radiograph
Findings reveals :- left
upper lobe
homogeneous opacity
with minimal hilar
enlargement measuring
approx 3 x 3.4 cm
Another noduler
homogeneous opacity
noted in the right upper
lobe measuring 1.5 cm.

63. Ct findings reveals:-
A central cavitary mass lesion measuring 3.1 x 3.4 cm with thin
walls measuring 0.4 -0.5 cm and spiculated margins and chunky
calcification in the inferior wall of cavity with ct dencitometric value
of 110 - 140 HU in left upper lobe posterior segment.

65. Another solitary lesion measuring 2.5 cm with central hyperdense focal
calcification noted in the right upper lobe .

66. Associated findings:- A cystic lesion noted
in the right lobe of liver