Radiology of Lung Cancer and Staging

Question 1

When looking at a chest x-ray, what systematic things should you always look at?

Answer 1

Name/marker/rotation/ penetration

Lines/metal work

Heart

Mediastinum

Lungs
Zones (upper/middle/lower)

Bones

Diaphragm

Soft Tissues

Question 2

What would we expect to see in a chest x-ray regarding the mediastinum?

Answer 2

1. Hilar vascular structures should be crisply defined
2. No widening of mediastinum
3. Trachea should be central

Question 3

What do you need to pay attention to when looking at the lungs of a chest x-ray?

Answer 3

Look between ribs for lung detail
Remember to look “behind” the heart
Compare zones of the heart

Question 4

If one of the lungs is completely white in a chest x-ray, what is this called?

Answer 4

Hemithorax

Question 5

What should we look out for in smokers>45 regarding lung cancer?

Answer 5

Lobar collapse which doesn’t resolve in 2-3 weeks

Question 6

Lung cancer can be difficult to spot on a chest x-ray so what should we look out for?

Answer 6

Lesions often more subtle- beware of lesions behind the heart and hila
Compare with previous films
Always look at review areas

Question 7

Which areas of a chest x-ray should be reviewed?

Answer 7

Hila
Lung apices
Behind the heart
Behind the diaphragm

Question 8

Define pulmonary nodule.

Answer 8

An opacity in lung up to 3cm with no mediastinal adenopathy or atelectasis

Question 9

Define opacity

Answer 9

Lacking transparency

Question 10

Define adenopathy

Answer 10

Large or swollen lymph glands

Question 11

Define atelectasis.

Answer 11

Partial collapse of the lung.

Question 12

Define pulmonary mass.

Answer 12

Pulmonary mass is an opacity in lung over 3cm with no mediastinal adenopathy or atelectasis

Question 13

Give two examples of benign lung neoplasms.

Answer 13

Carcinoid
Hamartoma

Question 14

In the staging for lung cancer, what two things are usually done first?

Answer 14

History
Chest X-ray

Question 15

Which type of radiology is useful for staging lung cancer?

Answer 15

CT

Question 16

Describe what the first part (T) of TMC staging is looking at.

Answer 16

Size and position of the tumour
How big and if it has spread

Question 17

Describe what the second part (M) of TMC staging is looking at.

Answer 17

Whether or not the cancer has spread to the lymph nodes

Question 18

Describe what the third part (C) of TMC staging is looking at.

Answer 18

Whether the cancer has spread anywhere else (metastases).

Question 19

Which investigations can be carried out for stage one (T) of TMC screening?

Answer 19

CT
PET-CT
Bronchoscopy

Question 20

Which investigations can be carried out for stage two (M) of TMC screening?

Answer 20

PET-CT
CT
Mediastinoscopy
EBUS/EUS

Question 21

Which investigations can be carried out for stage three (C) of TMC screening?

Answer 21

PET-CT
CT
Bone scan

Question 22

In the staging of lung cancer, what two parts are important to consider?

Answer 22

Performance status
Pulmonary function

Question 23

What does FDG stand for?

Answer 23

Fludeoxyglucose (18F)

Question 24

What is FDG?

Answer 24

Labelled glucose analogue
Radiotracer

Question 25

What are some of the disadvantages of FDG PET scans?

Answer 25

Expensive Limited availability in the UK

Question 26

Describe the classification for a T1 tumour.

Answer 26

Tumour ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of involvement of the main bronchus

Question 27

Describe the classification of a T2 tumour.

Answer 27

Tumour >3 cm but 5 cm OR A tumour with any of the following: -Involves main bronchus, but not carina -Invades visceral pleura -Associated with atelectasis or obstructive pneumonitis that extends to the hilar region involving part or all the lung

Question 28

Describe the classification of a T3 tumour.

Answer 28

Tumour >5 cm but <7cm OR A tumour which invades any of the following- -chest wall (including superior sulcus tumors) -phrenic nerve -parietal pericardium -separate tumour nodule(s) in the same lobe as the primary

Question 29

Describe the classification of a T4 tumour.

Answer 29

Tumour >7cm OR A tumour which invades any of the following- -diaphragm -mediastinum -heart -great vessels -trachea -recurrent laryngeal nerve -oesophagus -vertebral body -carina

Question 30

In which classification of cancer would there be separate tumour nodule(s) in a different ipsilateral lobe?

Answer 30

T4

Question 31

What can PET scans be useful for?

Answer 31

Assessing chest wall or mediastinal invasion

Question 32

In regards the the TMC screening, what does N0 mean?

Answer 32

No regional lymph node metastases

Question 33

In regards the the TMC screening, what does N1 mean?

Answer 33

Ipsilateral peribronchial , hilar or intrapulmonary nodes including by direct extension

Question 34

In regards the the TMC screening, what does N2 mean?

Answer 34

Ipsilateral mediastinal or subcarinal nodes

Question 35

In regards the the TMC screening, what does N3 mean?

Answer 35

Contralateral mediastinal nodes, contralateral hilar, scalene or supraclavicular

Question 36

How does size of a lymph node relate to the likelihood of it metastasising?

Answer 36

The bigger the lymph node it, the more likely it'll metastasise.

Question 37

In regards to TMC screening, what does M0 mean?

Answer 37

No distant metastasis

Question 38

In regards to TMC screening, what does M1 mean?

Answer 38

Distant metastasis

Question 39

List some benefits of CT PET

Answer 39

Whole body staging at once Non invasive Can diagnose metastases

Question 40

Discuss some negatives of PET CT scans.

Answer 40

Cost False negatives False positives

Question 41

What type of investigation is carried out if the patient has a central tumour or central node disease?

Answer 41

A bronchoscopy and/or an EBUS

Question 42

What is mediastinoscopy used for?

Answer 42

Used to sample mediastinal nodes

Question 43

What is mediastinotomy used for?

Answer 43

Used to sample anterior mediastinal nodes