BRANT: Chapter 13 - PULMONARY NEOPLASMS AND NEOPLASTIC-LIKE CONDITIONS

Question 1

T/F: An opacity completely stable in size for more than 2 years is considered benign and obviates further evaluation.

Answer 1

True

Question 2

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.

Answer 2

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.

Question 3

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.

Answer 3

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;

Question 4

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;

Answer 4

Breast CA and melanoma

Question 5

1. Term that refers to the time it takes for a nodule to double its volume.
2. For a sphere, this corresponds to a ____% increase in diameter.

Answer 5

Doubling time
26%

Question 6

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

Answer 6

180 days
1 month or greater than 2 years

Question 7

Masses exceeding ____ cm in diameter are usually malignant

Answer 7

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.

Question 8

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.

Answer 8

<6 mm

Question 9

The term ____ has been used to describe this appearance, in which linear densities radiate from the edge of a nodule into the adjacent lung.

Answer 9

Corona radiata

Question 10

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.

Answer 10

“Pleural tail”

Question 11

T/F: The presence of small “satellite” nodules around the periphery of a dominant nodule is strongly suggestive of benign disease, particularly granulomatous infection.

Answer 11

True

Question 12

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 ____

Answer 12

Rounded atelectasis

Question 12

Diagnosis

Answer 12

Arteriovenous malformation

Question 13

It is probably the single most important factor in characterizing the lesion as benign or indeterminate.

Answer 13

Density

Question 14

Identify the five patterns of calcification that when present in a solid nodule that is smooth or lobulated reliably indicates benignity.

Answer 14

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

Question 15

Popcorn calcification within a nodule is diagnostic of a ____ in which the cartilaginous component has calcified.

Answer 15

Pulmonary hamartoma

Question 16

Location of calcification:
a. Granuloma
b. Bronchogenic CA that enguled a calcified granuloma

Answer 16

a. Central
b. Eccentric

Question 17

Diagnosis

Answer 17

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.

Question 18

T/F: Majority of subsolid nodules that persist beyond 3 months reflect adenocarcinoma.

Answer 18

True

Question 19

T/F: Majority of pure ground-glass attenuation nodules are malignant.

Answer 19

False

Majority of pure ground-glass attenuation nodules are BENIGN.

Question 20

Benign or malignant

Answer 20

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.

Question 21

T/F: Virtually all malignant lesions demonstrating an increase in attenuation of greater than 15 H after contrast administration

Answer 21

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%).

Question 22

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)

Answer 22

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.

Question 23

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)

Answer 23

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.

Question 24

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.

Answer 24

Sclerosing pneumocytoma (hemangioma)

Question 25

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

Answer 25

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

Question 26

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.

Answer 26

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.

Question 27

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

Answer 27

Small cell carcinoma

Question 28

T/F: Large cell carcinoma and squamous cell carcinoma are the two histologic subtypes, with the strongest association with cigarette smoking in men

Answer 28

False

SMALL cell carcinoma and squamous cell carcinoma are the two histologic subtypes, with the strongest association with cigarette smoking in men

Question 29

Risk for lung CA:
a. Asbestos exposure
b. Asbestos + Smoking

Answer 29

a. 4x
b. 40-50x

Question 30

The edge characteristics of an SPN are best appreciated on thin-section (i.e., ____ mm) CT images through the lesion.

Answer 30

≤1.5

Question 31

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).

Answer 31

True

Question 32

79/F. Diagnosis

Answer 32

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.

Question 33

Most common cause of SVC syndrome

Answer 33

Lung cancer

Question 34

It represents invasion of the lymphatic channels of the lung by tumor

Answer 34

Lymphangitic carcinomatosis

Question 35

High risk patients for lung ca are of what age and how many pack years of smoking?

Answer 35

55 to 75
30-py of cigarrete smoking

Question 36

This is the most accurate noninvasive imaging method of detecting lymph node metastases in patients with lung cancer

Answer 36

FDG-PET/CT

Question 37

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).

Answer 37

Stage IIIa

Question 38

Lung ca stage representing T1–T2N3 disease (contralateral hilar, mediastinal, scalene, or supraclavicular nodal involvement) or T3T4N2 disease.

Answer 38

Stage IIIb

Question 39

TNM classification if the tumor is 4 cm with contralateral hilar nodal involvement without distant mets

Answer 39

T2N3M0

Question 40

T/F: Localized invasion of the pericardium (T3 tumor) does not prevent resection.

Answer 40

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.

Question 41

Divides 1R and 1L station

Answer 41

Midline of trachea

Question 42

Posterior border of 3A station

Answer 42

Question 43

Landmark that distinguishes:
a. 2R and 4R
b. 2L and 4L

Answer 43

a. Intersection of the caudal margin of L brachiocephalic vein with trachea
b. Superior margin of aortic arch

Question 44

What station is the pulmonary ligament nodes?

Answer 44

9

Question 45

Most common primary tracheal malignancy, accounting for at least 50% of all malignant tracheal neoplasms

Answer 45

SCCA

Question 46

Majority of SCCA arise in this part of the trachea

Answer 46

Distal trachea, within 3-4 cm of the tracheal carina

Next: cervical trachea

Question 47

Cut-off size that suggests whether a tracheal mass is likely to be malignant vs benign

Answer 47

2 cm

Masses >2 cm in diameter are likely to be malignant, while those <2 cm are more likely benign.

Question 48

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

Answer 48

d. A and B only

Question 49

T/F: The most common extrathoracic malignancies to produce LC are carcinomas of the breast, stomach, pancreas, and prostate.

Answer 49

True

Question 50

Diagnosis

Answer 50

Pulmonary metastases