CHEST IMAGING 4 (TUMOURS) Flashcards
What are the 5 locations of chest tumours?
General
Location
Chest neoplasms are best categorized by their primary location:
- Lung tumors
- Pleural tumors
- Mediastinal tumors
- Tumors of the airway
- Chest wall tumors
4 malignant pulmonary neoplasms
Malignant tumors
• Bronchogenic carcinoma
• Lymphoma
• Metastases
• Sarcomas, rare
4 Low Grade Pulmonary Neoplastic Low-grade malignancies (previously bronchial adenoma)
Low-grade malignancies (previously bronchial adenoma)
• Carcinoid, 90%
• Adenoid cystic carcinoma (previously cylindroma, resembles salivary gland tumor), 6%
• Mucoepidermoid carcinoma, 3%
• Pleomorphic carcinoma, 1%
9 Benign Pulmonary Neoplasms
Benign tumors, rare
• Hamartoma
• Papilloma
• Leiomyoma
• Hemangioma
• Chemodectoma
• Pulmonary blastoma
• Chondroma
• Multiple pulmonary fibroleiomyomas
• Pseudolymphoma
Contraindications to Percut Lung bx:
- Severe COPD
- Pulmonary hypertension
- Coagulopathy
- Contralateral pneumonectomy
- Suspected echinococcal cysts
Rate of Tumour Seeding in Percut Bx
Tumor seeding is extremely uncommon (1 in 20,000).
True positive rate of Percut Bx
90%–95%
False positive cause of Percut bx
poor needle placement, necrotic tissue, and so on.
What is the technique for Percut lung bx?
Technique
1. Fluoroscopic or CT localization of nodule
2. Pass needle over superior border of rib to avoid intercostal vessels
3. Avoid traversing pulmonary veins and crossing fissure
4. Coaxial needle system:
• 19-gauge introducer needle
• 20-gauge core biopsy needle with 1–2-cm needle throw
5. Cytopathologist should be present to determine if sample is adequate and diagnostic.
6. CXR after procedure to determine presence of pneumothorax
What are the Complications of Percut lung bx?
- Pneumothorax, 25%; 5%–10% of patients require a chest tube (i.e., pneumothorax >25% or if patient is symptomatic)
- Hemoptysis
- Systemic air embolism: extremely rare but most serious complication, approximately 0.02%–0.7%
What is Bronchogenic Carcinoma?
Bronchogenic carcinoma refers broadly to any carcinoma of the bronchus.
What is the most common type of Bronchogenic Carcinoma?
Adenocarcinoma (40%)
What is the classification of Lung adenocarcinoma?
- Adenocarcinoma insitu
- Minimally invasive Adenocarcinoma
- Lepidic Predominant nonmucinous adenocarcinoma
- Invasive mucinous adenocarcinoma
What is Atypical Adenomatous hyperplasia? What does it typically look like?
Atypical adenomatous hyperplasia is one of the preinvasive lesions for adenocarcinoma of the lung:
• Typically a ground-glass nodule less than 5 mm in size
What are the different types of Bronchogenic Carcinoma?
Adenocarcinoma 40%
• in situ
• Minimally Invasive
• Lepidic Pred. Nonmucinous
• Invasive mucinous (previously mucinous bronchioloalveolar carcinoma)
Atypical adenomatous hyperplasia
SCC, 30%:
• Spindle cell carcinoma
Small cell carcinoma, 15%:
• Oat cell
• Intermediate cell type
• Combined oat cell carcinoma
Large cell carcinoma, 1%:
• Giant cell carcinoma
• Clear cell carcinoma
Adenosquamous tumor
What are the 4 risk factors for lung cancer?
Risk Factors for Bronchogenic Carcinoma
THE SHORT
- Smoking:
- Radiation, uranium mining
- Asbestos exposure
- Genetic predisposition (HLA-Bw44 associated?)
THE LONG
- Smoking: 98% of male patients and 87% of female patients with lung cancer smoke; 10% of heavy smokers will develop lung cancer. The strongest relationship between smoking and cancer has been established for SCC, followed by adenocarcinoma.
- Radiation, uranium mining
- Asbestos exposure
- Genetic predisposition (HLA-Bw44 associated?)
What are the rad findings of Lung cancer?
- Radiographic Spectrum/Primary Signs of Malignancy ( Fig. 1.32 )
- Mass (>6 cm) or nodule (<6 cm) with spiculated, irregular borders
- Unilateral enlargement of hilum: mediastinal widening, hilar prominence
- Cavitation
- Most common in ULs or superior segments of LLs
-
Wall thickness is indicative of malignancy
- < 4 mm: 95% of cavitated lesions are benign
- >15 mm: 85% of cavitated lesions are malignant
- Cavitation is most common in SCC
- Certain tumors may present as chronic ASD:
- adenocarcinoma,
- lymphoma
- Some air bronchograms are commonly seen by HRCT in adenocarcinoma.
What are the secondary signs of Lung cancer?
Secondary Signs of Malignancy ( Fig. 1.33 )
- Atelectasis (Golden inverted S sign in RUL, LUL collapse)
- Obstructive pneumonia
- Pleural effusion
- Interstitial patterns: lymphangitic tumor spread
- Hilar and mediastinal adenopathy
- Metastases to ipsilateral, contralateral lung
What are the typical locations of the following tumours?
What is the characteristic Appearance of:
- Adenocarcinoma
- Large cell
- SCC
- Small cell
- Adenocarcinoma -> Scar Carcinoma
- Large cell -> Large mass
- SCC -> Cavitatory
- Small cell -> Endocrine syndromes/activitiy
List the 5 paraneoplastic Syndromes of Lung cancer
- Metabolic
- Cushing syndrome (ACTH)
- Inappropriate antidiuresis (ADH)
- Carcinoid syndrome (serotonin, other vasoactive substances)
- Hypercalcemia (PTH, bone metastases)
- Hypoglycemia (insulin-like factor)
- Musculoskeletal
- Neuromyopathies
- Clubbing of fingers (HPO)
- Other
- Acanthosis nigricans
- Thrombophlebitis
- Anaemia
What is the incidence of paraneoplastic syndromes in bronchogenic carcinoma
Incidence: 2% of bronchogenic carcinoma
Radiation Pneumonitis
What is it?
When does it appear?
What is the min dose to get it?
Radiation Pneumonitis
- Radiation pneumonitis is the acute phase of radiation damage and usually appears 3 weeks after treatment.
- The minimum radiation dose to induce pneumonitis is 30 Gy.
- The acute phase is typically asymptomatic but may be associated with fever and cough.
- Fibrosis usually occurs after 6–12 months.
Radiographic Features
- Diffuse opacities in radiation port
- HRCT allows better assessment of extent than plain radiograph
RE: Lung cancer (staging - IASLC 8th edition)
What is the T1 stage split up into?
- Tx: primary tumour cannot be assessed or tumour proven by the presence of malignant cells in sputum or bronchial washings but not visualised by imaging or bronchoscopy
- T0: no evidence of a primary tumour
- Tis: carcinoma in situ - tumour measuring 3 cm or less and has no invasive component at histopathology
-
T1:
- tumour measuring 3 cm or less in greatest dimension surrounded by lung or visceral pleura without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e. not in the main bronchus)
-
T1a(mi):
- minimally invasive adenocarcinoma
- tumour has an invasive component measuring 5 mm or less at histopathology
- minimally invasive adenocarcinoma
-
T1a ss:
- superficial spreading tumour in central airways
- (spreading tumour of any size but confined to the tracheal or bronchial wall)
-
T1a:
- tumour ≤1 cm in greatest dimension
-
T1b:
- tumour >1 cm but ≤2 cm in greatest dimension
-
T1c:
- tumour >2 cm but ≤3 cm in greatest dimension
-
T1a(mi):
- tumour measuring 3 cm or less in greatest dimension surrounded by lung or visceral pleura without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e. not in the main bronchus)
https://radiologyassistant.nl/chest/lung-cancer/tnm-classification-8th-edition
Describe the features of a T2 cancer
- Tumor size >3cm to ≤5cm or
- Tumor of any size that
- invades the visceral pleura
- involves main bronchus, but not the carina
- shows an atelectasis or obstructive pneumonitis that extends to the hilum
- T2a= >3 to 4cm
- T2b= >4 to 5cm
Describe the Features of a T3 tumour
- T3: tumour >5 cm but ≤7 cm in greatest dimension or
- Pancoast tumour that involves T1 and T2 nerve roots only
- associated with separate tumour nodule(s) in the same lobe as the primary tumour or
- directly invades any of the following structures:
- chest wall (including the parietal pleura and superior sulcus)
- phrenic nerve
- parietal pericardium
https://radiologyassistant.nl/chest/lung-cancer/tnm-classification-8th-edition
Describe the features of a T4 tumour:
- Tumor size >7cm or
- Pancoast tumor that involves:
- C8 or higher nerve roots,
- brachial plexus,
- subclavian vessels or
- spine
- Tumor of any size that
- invades mediastinal fat or mediastinal structures
- invades the diaphragm
- involves the carina
- shows one or more satellite nodules in another lobe on the ipsilateral side
- Pancoast tumor that involves:
https://radiologyassistant.nl/chest/lung-cancer/tnm-classification-8th-edition
What Does Nx mean?
N: regional lymph node involvement
Nx: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension
N2: metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N3: metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
What does N0 Mean?
N: regional lymph node involvement
Nx: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension
N2: metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N3: metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
What does N1 mean?
N1: metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension
What does N2 Mean?
N2: metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
What does N3 mean?
N3:
- metastasis in:
- contralateral mediastinal,
- contralateral hilar,
- ipsilateral or contralateral scalene, or
- supra-clavicular lymph node(s)
Lable this diagram with the correct LN stations:
Regional Lymph Node Classification System
- Lymph node staging is done according to the American Thoracic Society mapping scheme.
- Supraclavicular nodes
- Low cervical, supraclavicular and sternal notch nodes
- Superior mediastinal nodes
- Upper Paratracheal: above the aortic arch, but below the clavicles.
- 3A. Pre-vascular: nodes not adjacent to the trachea like the nodes in station 2, but anterior to the vessels.
- 3P. Pre-vertebral: nodes not adjacent to the trachea, but behind the esophagus, which is prevertebral (3P).
- Inferior Mediastinal nodes
- Lower Paratracheal (including Azygos Nodes): below upper margin of aortic arch down to level of main bronchus.
- Aortic nodes
- Subaortic (A-P window): nodes lateral to ligamentum arteriosum. These nodes are not located between the aorta and the pulmonary trunk, but lateral to these vessels.
- Para-aortic (ascending aorta or phrenic): nodes lying anterior and lateral to the ascending aorta and the aortic arch.
- Subcarinal nodes
- Subcarinal.
- Inferior Mediastinal nodes
- Paraesophageal (below carina).
- Pulmonary Ligament: nodes lying within the pulmonary ligaments.
- Pulmonary nodes
- 10-14. N1-nodes: these are located outside of the mediastinum.
- The boundary between level 10 and level 4 is on the right the lower border of the azygos vein and on the left the upper border of the pulmonary artery (N1 vs. N2).
- There is an important separation to be made between level 1 and level 2/3 nodes, because it is N3-stage versus N2.
- The lower border of level 1 is the clavicles bilaterally and, in the midline, the upper border of the manubrium.
- The boundary between level 4R and 4L is the left lateral border of the trachea, and not the anatomic midline.
- Paracardial, internal mammarian, diaphragmatic, axillary and intercostal lymph nodes are not described in the IALSC lymph node map.
- Occasionally these can be present.
- It is proposed to regard these non-regional nodes as metastastic disease [2].
- CT is unrealiable in staging lymph nodes in patients with NSCLC regardless of the threshold size that is chosen.
- PET-CT is much more reliable in determining the N-status.
- False-positives occur in patients with sarcoid, tuberculosis and other infections.
- Because of the high negative predictive value, PET scanning should be performed in all patients considered for surgery.
What are the N1 Nodes?
Fig 1Lymph node stations in the N1 region (A, right side; B, left side). The location of each station is defined in relation to the bronchial structure as main bronchial (No. 10), interlobar (No. 11), lobar (No. 12), segmental bronchial (No. 13), and intrapulmonary (No. 14), regardless of the pleural reflection. For the right side, No. 11s(superior, between the upper and intermediate bronchi) and No. 11i (inferior, between the middle and lower bronchi) are distinguished.
The boundary between level 10 and level 4 is on the right the lower border of the azygos vein and on the left the upper border of the pulmonary artery (N1 vs. N2).
https://www.annalsthoracicsurgery.org/article/S0003-4975(00)01817-8/fulltext
What are the signs and accuracy of Chest wall invasion?
Chest Wall Invasion
Accuracy for detection of chest wall invasion by CT is 40%–60%.
Radiographic Features ( Fig. 1.37 )
- Reliable signs
- Soft tissue mass in chest wall
- Bone destruction
- Unreliable signs
- Obtuse angles at contact between tumor and pleura
- >3 cm of contact between tumor and pleura
- Pleural thickening
- Increased density of extrapleural fat
What is this sign?
What is the underlying pathogenesis?
What are the causes?
The Cheerio sign was defined as the CT finding of a nodule with a hypodense centre, resembling the ring-shaped Cheerios breakfast cereal.1
Pathologically, it is caused by peribronchiolar cellular proliferation around a patent airway.2
Common causes for Cheerio sign include:
- pulmonary Langerhans cell histiocytosis,
- lung adenocarcinoma, and
occasionally cavitary lesions of the lung, such as
- fungal infections,
- metastatic lung cancers,
- lymphoma,
- rheumatoid nodules and
- granulomatosis with polyangiitis.
It is commonly associated with invasive lepidic-predominant adenocarcinoma, as alveolar structures and bronchial patency are usually maintained in this cancer subtype.1
https://thorax.bmj.com/content/73/10/994
What are the typical characteristics of Large cell carcinoma?
Large Cell Carcinoma
- large (>70% are >4 cm at initial diagnosis)
- peripheral mass lesions.
- Overall uncommon tumor.
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8570
What type of tumor is this?
What are the clinical Findings?
What type of tumour are they histologically? (most commonly)
Pancoast Tumor (Superior Sulcus Tumor)
- Tumor located in the lung apex that has extended into the adjacent chest wall.
- Histologically, Pancoast tumors are often SCCs.
- Clinical Findings
- Horner syndrome
- Pain radiating into arm
- (invasion of pleura,
- bone,
- brachial plexus, or
- subclavian vessels)
Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 29403
What are the radiographic features of Pancoast tumours?
Apical mass
Chest wall invasion
Involvement of subclavian vessels
Brachial plexus involvement
Bone involvement: rib, vertebral body
What are the typical Rad Features of carcinoid tumours?
Radiographic Features
- PET negative
- 80% centrally located within main, lobar, segmental bronchi
- Segmental or lobar collapse (most common finding)
- Periodic exacerbation of atelectasis
- Endobronchial mass
- Very rarely located within the trachea (1%)
- Peripherally located carcinoid, 20%
- Pulmonary nodule
- May be enhanced with contrast medium
Case courtesy of Dr Chris O’Donnell, Radiopaedia.org, rID: 17594
OF the following which has the highers Mitosis per 10 high powered field?
Typical Carcinoid
Atypical Carcinoid
Large cell NET
Small Cell
Typical Carcinoid <2
Atypical Carcinoid 2-10
Large cell NET 10
Small Cell >50
Oout of the following which is usually peripheral and which is central?
Typical Carcinoid
Atypical Carcinoid
Large cell NET
Small Cell
Typical Carcinoid (central)
Atypical Carcinoid (central)
Large cell NET (PERIPHERAL)
Small Cell (+++ Central)
Which tumours are FDG avid?
Typical Carcinoid
Atypical Carcinoid
Large cell NET
Small Cell
Typical Carcinoid
Atypical Carcinoid
Large cell NET
Small Cell
What is this?
What percent are calcified?
What Cell origin are they?
Who are they more common in?
What are they composed of?
- Hamartomas are mesenchymal tumors
- most common benign tumors of the lung
-
composed of:
- cartilage (predominantly),
- connective tissue,
- muscle,
- fat, and
- epithelial tissue.
- 85% are identified as solitary pulmonary nodules,
- 5%–15% are endobronchial.
- They typically occur in individuals older than 50 years and are more common in men.
Case courtesy of Dr Ahmed Abdrabou, Radiopaedia.org, rID: 42249
What are the radiographic features of this tumour?
- Pulmonary hamartoma
- Radiographic Features
- Well-circumscribed, often lobulated pulmonary nodule
- Calcification identified in only 10% of hamartomas <3 cm but seen in approximately 75% of hamartomas ≥5 cm in size
- “Popcorn” calcification classically associated with hamartomas, but may also show stippled pattern
- Slow growth: 0.5–5 mm/year
- HRCT can show intralesional fat (65%)
Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 35749
What is the Carney Triad?
Who does it tend to occur in?
Carney Triad
Predominant in Young Women (<30 Years Old)
- Gastric smooth muscle tumors (epithelioid leiomyosarcoma)
- Functioning extra-adrenal paraganglioma
- Pulmonary chondromas
Carney triad is a rare syndrome defined by the coexistence of three tumours:
extra-adrenal paraganglioma
initially, only functioning extra-adrenal paragangliomas were included, but subsequent work includes non-functioning extra-adrenal paragangliomas 1
gastric gastrointestinal stromal tumours (GIST)
pulmonary chondroma
In most cases, only 2 of the 3 tumours are present at the time of diagnosis, with the most common combination being GIST and pulmonary chondromas. Although not considered part of the triad, there is an increased incidence of adrenocortical adenoma. It typically affects young people. No underlying genetic mutation has been identified.
What is this condition?
What is a complication?
Tracheobronchial Papillomatosis
Radiographic Features
- Multiple, well-demarcated nodules that can grow
- Cavitate with 2–3-mm-thick walls
- Air fluid levels may develop
- Risk of SCC 15 years after diagnosis
https://radiopaedia.org/cases/pulmonary-spread-of-tracheobronchial-papillomatosis
Multiple cavitating nodules and masses bilaterally with posterior and basal predilection. Numerous endoluminal tracheal soft-tissue lesions obstructing upper airways. Tracheostomy tube in place.
Findings are suggestive of pulmonary spread of tracheobronchial papillomatosis.
Case Discussion
Tracheobronchial papillomatosis is caused by human papilloma virus types 6 and 11. Less than 1% of patients with tracheobronchial papillomatosis have parenchymal extension. Juvenile onset type usually have a worse prognosis with higher incidence of pulmonary spread. Proposed mechanism of spread is associated with aerial dissemination of papilloma fragments facilitated by laryngeal and tracheal interventions.
What cell origin do pulmonary blastomas arise from?
What are the classifications?
Who are they predominate in?
- (primer) Pulmonary Blastoma
- Predominant in males, poor prognosis
- Radiographic Features
- Large peripheral mass that is well circumscribed
- May show pleural invasion and may metastasize
(Radiopedia) Pulmonary blastomas (PBs) comprise a rare group of lung tumours principally consisting of immature mesenchymal and epithelial structures that structurally mimic the embryonic lung.
Traditionally they were classified as
- well-differentiated fetal adenocarcinoma (WDFA) of lung - now considered removed from this category 4
- classic / biphasic pulmonary blastoma (CBPB)
- pleuropulmonary blastoma (PPB) - sometimes regarded as a separate entity,
https: //radiopaedia.org/articles/pulmonary-blastoma
https: //www.hindawi.com/journals/crim/2012/471613/
