1. Chest p56-63 (Lung Cancer, Other Tumours) Flashcards
Solitary pulmonary nodule - definition (3)
Round or oval lesion <3cm in diameter (>3cm = mass).
Surrounded by normal lung parenchyma.
No associated adenopathy or pleural effusion.
Classic benign calcification patterns (4)
Solid/diffuse.
Laminated.
Central.
Popcorn.
Benign pulmonary nodule features (3)
Presence of fat.
Rapid doubling time (<1 month).
Slow doubling time (>16 months)
Suspicious pulmonary nodule features (3)
Spiculated margins (corona Radiata sign).
Air bronchograms through the nodule (usually adenocarcinoma in situ).
Part solid/part ground glass lesions.
Solid vs ground glass nodules - suspicion (3)
Part solid/part ground glass is most sus.
Only ground glass is intermediate.
Totally solid is least sus.
when to use PET for SPNs
Can be used for SPNs >1cm.
Hot on PET - DDx (2)
Cancer is supposed to be hot (SUV > 2.5).
Infectious or granulomatous nodules can also be hot.
Ground glass nodules - PET findings (2)
Cold suggests cancer.
Hot suggests infection.
Lung cancer risk factors (5)
Being >30YO,
Exposure to arsenic, nickel, asbestos, chromium, beryllium, radon),
Lung fibrosis,
COPD,
FHx
Lung cancer - Types (4)
Squamous,
Small cell,
Large cell,
Adenocarcinoma
Squamous cell Ca - features (5)
Usually centrally located.
Strong smoking association.
Cavitation is common.
Ectopic PTH production.
Good prognosis, late to metastasize
Small cell Ca - features (5)
Usually central (common near main/lobar bronchi).
May only get central lymphadenopathy.
Paraneoplastic syndromes - SIADH and ectopic ACTH.
Poor prognosis.
Lambert Eaton - proximal weakness due to abnormal acetylcholine release at NMJ
Large cell Ca - features (2)
Peripheral and large (>4cm).
Poor prognosis.
Adenocarcinoma - features (3)
Usually peripheral, often upper lobes.
Commonest subtype and commonest to present as solitary pulmonary nodule.
Associated with lung fibrosis.
BAC (Broncho-Alveolar Carcinoma) - definition
Subtype of adenocarcinoma
Atypical adenomatous hyperplasia of the lung (AAH) - definition
Precursor to Adenocarcinoma of lung
Adenocarcinoma in Situ (ACIS) - features (2)
<3cm.
Multiple subtypes, commonest is non-mucinous.
Minimally invasive adenocarcinoma (MIA) (5)
<3cm with <5mm of stromal invasion (>5mm = lepidic predominant adenocarcinoma).
Usually ground glass.
Usually COLD on pet.
Fried egg sign (ground glass around nodule).
Pseudocavitation (bubble like lucencies).
Part solid nodules - malignancy predictor
Larger the solid part, the more likely to be malignant.
Staging threshold for unresectable lung cancer
3B (Implies N3 or T4 disease)
Lung cancer staging - multicentric tumours (3)
T3 - 2 lesions in same lobe
T4 - 2 lesions in different lobes (same lung)
M1a - 2 lesions in different lungs
Non-resectable features of lung Ca (4)
Supraclavicular or Scalene nodes.
Contralateral mediastinal or hilar nodes.
Tumour in same lung but different lobes.
Malignant pleural effusion.
Radiation changes - features (3)
Varied appearance, based on volume of lung involved, time involved and whether chemo also given.
Early (1-3 months): Homogenous or patchy ground glass opacities.
Late: Dense consolidation, traction bronchiectasis and volume loss
Bronchopulmonary fistula - features (4)
Uncommon complication of pneumonectomy.
Normally: Empty space will fill with fluid.
Fistula: Empty space fills with air over time.
Can confirm with xenon NM test, shows xenon in the pneumonectomy space.
Mets to the lungs - types (3)
Direct invasion,
Haematogenous,
Lymphangetic Carcinomatosis (LC)
Direct invasion mets - sources (4)
Cancer of the mediastinum, pleura or chest wall.
Commonly oesophageal carcinoma, lymphoma or malignant germ cell tumour.
Rarely mets to the pleura which directly invade lung.
Even rarer - mesothelioma invading the lung.
Haematogenous mets - features (4)
Tends to be multiple, random distribution, favouring lower lobes.
Nodules smoother than primary neoplasm.
Squamous mets can cavitate.
Cannonball mets typically from renal cell or choriocarcinoma (testis)
Haematogenous mets - sources (5)
Breast,
Kidney,
Thyroid,
Colon,
Head and neck squamous Ca.
Feeding vessel sign (2)
Prominent vessel heading into a nodule. Suggests haematogenous origin.
Either due to mets or septic emboli.
Lymphagetic carcinomatosis (LC) - sources (5)
Commonest is bronchogenic carcinoma invading lymphatics.
Non-lung common causes include:
- Breast
- Stomach
- Pancreas
- Prostate
Lymphangetic carcinomatosis (LC) - features (2)
Nodular thickening of interlobular septa and sub-pleural interstitium.
Thickening does NOT distort the pulmonary lobule, unlike fibrosis.
Carcinoid - classification (4)
By distribution:
- peripheral pulmonary
- bronchial
By histologic type:
- typical
- atypical
Typical carcinoid - trivia (2)
Slow growing, locally invasive (10% met to nodes).
No smoking association.
Typical carcinoid - features (5)
Occur centrally within a bronchus and cause obstructive symptoms.
Can cause haemoptysis, as they’re highly vascular.
Localised by Octreotide scan.
Pulmonary tumours cause carcinoid syndrome w/flushing.
Valvular degeneration occurs on left side (GI carcinoid tumours cause right sided valve degeneration)
Atypical carcinoids (2)
Rarer, seen in older people.
More likely to be a mass.
Adenoid cystic (cylindroma) (3)
Commonest bronchial gland tumour.
NOT associated with smoking.
Usually main or lobar bronchus.
Pulmonary lymphoma - types (4)
Primary,
Secondary,
PTLD,
AIDS related.
Pulmonary lymphoma - imaging (3)
Radiographic pattern varies.
Lymphangitic spread (uncommon),
Perihilar airspace opacities,
Mediastinal adenopathy
Primary pulmonary lymphoma - features (3)
Rare, usually non-hodgkin.
Defined as lack of extrathoracic involvement for 3 months.
80% are low grade MALToma
Secondary pulmonary lymphoma - features (4)
More common than primary. Pulmonary involvement of systemic lymphoma.
NHL is more common than HL (80-90% lymphoma vs 10-20%)
But NHL is less likely to involve the lungs. (45% intrathoracic, 25% parenchymal disease, vs 85% intrathoracic and 40% parenchymal)
HL affects nodes and parenchyma, NHL can just affects parenchyma.
PTLD (Post transplant lung disease) - features (4)
Usually within a year of solid organ or stem cell transplant.
Late presentations (>1 year) are more agressive.
B Cell lymphoma, with relationship with EB virus.
Can get nodal and extra-nodal disease.
PTLD - imaging (4)
Typically:
Well defined pulmonary nodules/mass,
Patchy airspace consolidation,
Halo sign and
interlobular septal thickening
AIDS Related Pulmonary Lymphoma (ARL) - Features (4)
Second most common lung tumour in AIDS (behind Kaposi),
Almost all high grade NHL.
Relationship with EBV.
Seen in CD4 <100.
Aids related lymphoma- imaging (2)
Commonest: Multiple, peripheral nodules ranging 1-5cm.
Extranodal locations are common (CNS, bone marrow, lung, liver, bowel)
AIDS pt with lung nodules, pleural effusion and lymphadenopathy
Lymphoma
Kaposi sarcoma - imaging (3)
Favours tracheobronchial mucosa and perihilar lung.
Flame shaped.
Bloody pleural effusion is common (50%)
Kaposi sarcoma - trivia (5)
Commonest lung tumour in AIDS (requires CD4 <200),
Most common hepatic neoplasm in AIDS,
Buzzword - flame shaped opacities.
Slow growth & asymptomatic, despite lungs looking terrible.
Thallium positive, gallium negative.
Hamartoma - imaging/features (4)
Macroscopic fat and popcorn calcifications.
Usually incidental.
Can cause problems if endobronchial (2%)
Can be hot on PET, still benign.
Hamartoma - trivia
Commonest benign lung mass.
Thallium vs Gallium
Kaposi - Thallium positive, Gallium negative
Lymphoma - Gallium positive, Thallium negative
