BRANT: Chapter 13 - PULMONARY NEOPLASMS AND NEOPLASTIC-LIKE CONDITIONS Flashcards
T/F: An opacity completely stable in size for more than 2 years is considered benign and obviates further evaluation.
True
T/F: SPNs in a patient over 35 years of age should never be followed radiographically without tissue confirmation unless a benign pattern of calcification or the presence of intralesional fat is identified on radiographs or thin-section CT or there has been radiographically documented lack of growth over a minimum of 1 year.
False
T/F: SPNs in a patient over 35 years of age should never be followed radiographically without tissue confirmation unless a benign pattern of calcification or the presence of intralesional fat is identified on radiographs or thin-section CT or there has been radiographically documented lack of growth over a minimum of 2 years.
T/F: An SPN that arises more than 2 years after the diagnosis of an extrathoracic malignancy and proves to be malignant is almost always a metastasis rather than a primary lung tumor.
False
An SPN that arises more than 2 years after the diagnosis of an extrathoracic malignancy and proves to be malignant is almost always a PRIMARY LUNG TUMOR rather than a metastasis;
2 carcinomas that are exception to the rule: An SPN that arises more than 2 years after the diagnosis of an extrathoracic malignancy and proves to be malignant is almost always a primary lung tumor rather than a metastasis;
Breast CA and melanoma
- Term that refers to the time it takes for a nodule to double its volume.
- For a sphere, this corresponds to a ____% increase in diameter.
Doubling time
26%
Studies have shown that lung cancer presenting as a solid SPN has a doubling time of approximately ____
Therefore, a doubling time of less than ____ or ____ reliably characterizes a solid lesion as benign
180 days
1 month or greater than 2 years
Masses exceeding ____ cm in diameter are usually malignant
4
However, the converse does not hold true; many pulmonary malignancies are less than 2 cm in diameter at the time of diagnosis, particularly if detected by screening chest CT.
Nodules ____ in diameter have a less than 1% likelihood of malignancy even in high-risk patients, and, therefore, most radiologists will not recommend evaluation of such lesions unless there is a very high clinical likelihood of malignancy.
<6 mm
The term ____ has been used to describe this appearance, in which linear densities radiate from the edge of a nodule into the adjacent lung.
Corona radiata
A peripherally situated pulmonary nodule may contact the costal pleura or interlobar fissure via a linear opacity known as a ____, which reflects pleural retraction associated with fibrosis related to the lesion and is not specific for malignancy.
“Pleural tail”
T/F: The presence of small “satellite” nodules around the periphery of a dominant nodule is strongly suggestive of benign disease, particularly granulomatous infection.
True
A nodule or mass adjacent to an area of pleural thickening with a “comet tail” of bronchi and vessels entering the hilar aspect of the mass and associated lobar volume loss is characteristic of ____
Rounded atelectasis
Diagnosis
Arteriovenous malformation
It is probably the single most important factor in characterizing the lesion as benign or indeterminate.
Density
Identify the five patterns of calcification that when present in a solid nodule that is smooth or lobulated reliably indicates benignity.
Complete
Central
Peripheral rim-like
Concentric or laminated
Popcorn
Complete, central, or peripheral rim-like: healed granuloma from tuberculosis or histoplasmosis.
Concentric or laminated calcification: granuloma and allows confident exclusion of neoplasm.
Popcorn calcification: pulmonary hamartoma
Popcorn calcification within a nodule is diagnostic of a ____ in which the cartilaginous component has calcified.
Pulmonary hamartoma
Location of calcification:
a. Granuloma
b. Bronchogenic CA that enguled a calcified granuloma
a. Central
b. Eccentric
Diagnosis
Pulmonary hamartoma
CT features diagnostic of pulmonary hamartoma:
1. Popcorn calcification
2. Fat within an SPN
As a rule, hamartomas that contain calcium also contain fat.
T/F: Majority of subsolid nodules that persist beyond 3 months reflect adenocarcinoma.
True
T/F: Majority of pure ground-glass attenuation nodules are malignant.
False
Majority of pure ground-glass attenuation nodules are BENIGN.
Benign or malignant
Malignant
(Adenocarcinoma)
Some lung cancers can present on CT as cystic lesions with wall thickening or nodularity. The majority of these lesions prove to be adenocarcinoma.
T/F: Virtually all malignant lesions demonstrating an increase in attenuation of greater than 15 H after contrast administration
True
Therefore, lack of significant (i.e., >15 H) enhancement of a solid nodule 6 to 30 mm in diameter following intravenous iodinated contrast administration effectively excludes malignancy (sensitivity = 98%).
Management decision based on Fleischner Guidelines 2017:
a. Low risk patient with solid nodule of size 6-8 mm (100-250mm3)
b. High risk patient with solid nodule of size 6-8 mm (100-250mm3)
a. CT at 6-12 months, consider at 18-24 months
b. Follow-up CT at 6-12 months, then 18-24 months
When measuring a solid or subsolid nodule on CT at baseline or follow-up, the average diameter of two measurements (the largest diameter and a second perpendicular to the largest) in any of the axial, sagittal, or coronal planes rounded to the nearest millimeter obtained should be recorded for lesions <10 mm in diameter; for lesions ≥10 mm, bidimensional measurements should be given. For subsolid lesions with a solid component, a single largest diameter of the solid component should also be measured.
Management decision based on Fleischner Guidelines 2017:
a. Ground-glass at least 6 mm (>100 mm3)
b. Subsolid <6 mm (<100 mm3)
c. Part-solid nodule at least 6 mm (>100 mm3)
See below
When measuring a solid or subsolid nodule on CT at baseline or follow-up, the average diameter of two measurements (the largest diameter and a second perpendicular to the largest) in any of the axial, sagittal, or coronal planes rounded to the nearest millimeter obtained should be recorded for lesions <10 mm in diameter; for lesions ≥10 mm, bidimensional measurements should be given. For subsolid lesions with a solid component, a single largest diameter of the solid component should also be measured.
This benign epithelial tumor is classified as an adenoma and typically affects females and presents as a solitary, smoothly marginated juxtapleural nodule that enhances densely due to its vascular nature. The lesion may contain foci of low attenuation and may be calcified on thin-section CT analysis.
Sclerosing pneumocytoma (hemangioma)
It is the most common type of lung cancer, accounting for approximately 43% of all lung carcinomas. It has the weakest association with smoking and is the most common subtype of lung cancer in nonsmokers
Adenocarcinoma
Arise from bronchiolar or alveolar epithelium
Most often develop in the upper lobes as SPNs, or sometimes, in the central portions of the lungs in about one-fourth of cases
It is the second most common subtype of lung cancer accounting for approximately 23% of all cases. This tumor arises centrally within a lobar or segmental bronchus.
Squamous cell carcinoma
Grossly, these tumors are polypoid masses that grow into the bronchial lumen while simultaneously invading the bronchial wall. The central location and endobronchial component of the tumor account for the presenting symptoms of cough and hemoptysis and for the common radiographic findings of a hilar mass with or without obstructive pneumonitis or atelectasis.
The most malignant neoplasms arising from bronchial neuroendocrine (Kulchitsky) cells and are alternatively referred to as Kulchitsky cell cancers or KCC-3, and arises centrally within the main or lobar bronchi
Small cell carcinoma
T/F: Large cell carcinoma and squamous cell carcinoma are the two histologic subtypes, with the strongest association with cigarette smoking in men
False
SMALL cell carcinoma and squamous cell carcinoma are the two histologic subtypes, with the strongest association with cigarette smoking in men
Risk for lung CA:
a. Asbestos exposure
b. Asbestos + Smoking
a. 4x
b. 40-50x
The edge characteristics of an SPN are best appreciated on thin-section (i.e., ____ mm) CT images through the lesion.
≤1.5
T/F: The volume doubling time (equivalent to a 26% increase in diameter) for a malignant nodule usually ranges from 1 month (some squamous cell and large cell carcinomas) to nearly 5 years (preinvasive or minimally invasive adenocarcinoma).
True
79/F. Diagnosis
Pancoast or superior sulcus tumor
Apical soft tissue thickening exceeding 5 mm, asymmetric thickness of biapical opacities exceeding 5 mm, enlargement on serial radiographs, or evidence of rib destruction should prompt further evaluation with CT or MR.
Most common cause of SVC syndrome
Lung cancer
It represents invasion of the lymphatic channels of the lung by tumor
Lymphangitic carcinomatosis
High risk patients for lung ca are of what age and how many pack years of smoking?
55 to 75
30-py of cigarrete smoking
This is the most accurate noninvasive imaging method of detecting lymph node metastases in patients with lung cancer
FDG-PET/CT
Lung ca stage representing T1–T2N2 disease (i.e., tumor <5 cm with ipsilateral mediastinal nodal involvement), a T3 lesion with ipsilateral N1 nodal disease, or a T4 lesion associated with no nodal (N0) or ipsilateral hilar nodal involvement (N1).
Stage IIIa
Lung ca stage representing T1–T2N3 disease (contralateral hilar, mediastinal, scalene, or supraclavicular nodal involvement) or T3T4N2 disease.
Stage IIIb
TNM classification if the tumor is 4 cm with contralateral hilar nodal involvement without distant mets
T2N3M0
T/F: Localized invasion of the pericardium (T3 tumor) does not prevent resection.
True
Tumor invasion of the mediastinum with involvement of the heart, great vessels, trachea, carina, esophagus, diaphragm, or recurrent laryngeal nerve (T4 tumor) precludes resection.
Divides 1R and 1L station
Midline of trachea
Posterior border of 3A station
Landmark that distinguishes:
a. 2R and 4R
b. 2L and 4L
a. Intersection of the caudal margin of L brachiocephalic vein with trachea
b. Superior margin of aortic arch
What station is the pulmonary ligament nodes?
9
Most common primary tracheal malignancy, accounting for at least 50% of all malignant tracheal neoplasms
SCCA
Majority of SCCA arise in this part of the trachea
Distal trachea, within 3-4 cm of the tracheal carina
Next: cervical trachea
Cut-off size that suggests whether a tracheal mass is likely to be malignant vs benign
2 cm
Masses >2 cm in diameter are likely to be malignant, while those <2 cm are more likely benign.
Most common types of thyroid CA to invade the trachea
a. Papillary CA
b. Follicular CA
c. Anaplastic CA
d. A and B only
e. All of the above
d. A and B only
T/F: The most common extrathoracic malignancies to produce LC are carcinomas of the breast, stomach, pancreas, and prostate.
True
Diagnosis
Pulmonary metastases
