Radiology of lung cancer and staging Flashcards
what should be the systematic review when considering CXR?
- name, marker, rotation, penetration
- lines /metal work
- heart
- mediastinum
- lungs (zones: upper/ middle/ lower)
- bones
- diaphragm
- soft tissues
what do you look for in CXR when checking the mediastinum?
- trachea should be central
- no widening of mediastinum
- hilar vascular structures should be crisply defined
where do you look for in CXR when checking the lungs?
- compare upper, mid and lower zones
- look between ribs for lung detail
- remember to look “behind” the heart
what possibly causes a lobar collapse which fails to resolve in 2 to 3 weeks in a smoker of age > 45?
central lung cancer
what do lesions in the review areas often indicate?
lung cancer
where do you look for in CXR when checking review areas?
- hila
- lung apices
- behind the heart
- behind the diaphragm
what is the angle between the ribs and the diaphragm called?
costophrenic angle
what is the typical clinical history for lung cancer?
increasing SOB in smoker, history of pulmonary fibrosis, recent haemoptyis
what do you always have to do when examining a patient’s cxr? (HINT: previous cxr)
always compare with previous imaging
why would you sometimes complete PA cxr with sagittal view?
confirm lesion is intrapulmonary
what is the 2nd step after cxr?
CT
what does a CT enable us to tell about a lesion?
-evaluate size, shape atelectasis, border, density, solid or non solid, dynamic, contrast enhancement > 25 HU, growth
what is a pulmonary mass?
pulmonary mass is an opacity in lung over 3cm with no mediastinal adenopathy or atelectasis
what is a pulmonary nodule?
pulmonar nodule is an opacity in lung up to 3cm with no mediastinal adenopathy or atelectasis
what might a solitary pulmonary nodule or mass suggest?
- lung cancer (if old and smoking history)
- metastasis (if previous history of breast, renal, seminoma, sarcoma)
- benign lung neoplasm (e.g.: carcinoid, hamartoma)
- infection bacterial, tuberculosis or fungal
- vascular haematoma, AVM
how do you assess stage of lung cancer?
- clinical history/ examination
- performance status
- pulmonary function
- TNM international system for staging lung cancer
what is TNM staging?
T: how big, how far-spread, size, position
N: have cancer cells spread into lymph nodes?
M: presence of distant metastasis?
what analogue is labelled in a FDG PET?
labelled glucose analogue 18F-FDG
what does Tx mean?
primary tumour cannot be assessed
what does T0 mean?
no evidence of primary tumour
what does Tis mean?
carcinoma in situ
what does T1 mean?
tumour <3cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of involvement of the main bronchus
what does T1a mean?
minimally invasive adenocarcinoma, tumour <1cm in greatest dimension
what does T1b mean?
tumour <2cm
what does T1c mean?
tumour <3cm
what does T2 mean?
tumour >3cm or any tumour with the following features:
- 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
what does T2a mean?
between 3 and 4cm
what does T2b mean?
between 4 and 5cm
what does T3 mean?
between 5 and 7 or one that directly invades any of the following:
- chest wall (including superior sulcus tumours)
- phrenic nerve
- parietal pericardium
or separate tumour nodules in the same lobe as the primary
what does T4 mean?
> 7cm or invades any of the following: - diaphragm - mediastinum - heart - great vessels - trachea - recurrent laryngeal nerve - oesophagus - vertebral body - carina or separate tumour nodule in a different ipsilateral lobe
what does N0 mean?
no regional lymph node metastases
what does N1 mean?
ipsilateral peribronchial, hilar or intrapulmonary nodes including by direct extension
what does N2 mean?
ipsilateral mediastinal, subcarinal
what does N3 mean?
contralateral mediastinal, contralateral hilar, scalene or supraclavicular
where do pulmonary tumours metastasise?
brain, skeleton, adrenal glands, liver
what fraction of patients have metastasised lung cancer?
1/3
what does M0 mean?
no distant metastasis
what does M1 mean?
distant metastasis
what does M1a mean?
- separate tumour nodule(s) in a contralateral lobe
- tumour with pleural or pericardial nodules or malignant pleural or pericardial effusion
what does M1b mean?
single distant metastasis
what does M1c mean?
multiple distant metastasis
how can PET/CT help in staging?
- performs whole body staging in a single study excluding cerebral disease
- discloses metastases and other pathology not detected by other means (unexpected metastases in 10-20% cases)
- excludes metastases where structural imaging abnormal
- non invasive
how can you diagnose tissue?
- using bronchoscopy and EBUS
- percutaneous image guided biopsy, fluoroscopy/CT/US guided
- mediastinoscopy to sample mediastinal nodes
- mediastinotomy for anterior mediastinal nodes
- VATS
- explorative thoracotomy
