Radiology of Lung Cancer and Staging Flashcards
How many lung cancer patients present with advanced disease?
2/3
What is the first investigation carried out in the diagnosis of lung cancer?
Chest X-ray
What is the systematic approach to X-rays?
- Name/marker/rotation/penetration
- Lines/metal work
- Heart
- Mediastinum
- Lungs -zones (upper, middle, lower)
- Bones
- Diaphragm
- Soft tissue
How should the mediastinum look on an X-ray?
- Hilar vascular structures should be crisply defined
- No widening of mediastinum
- Trachea should be central
What should be examined in relation to the lungs on an X-ray
- Compare upper, mid and lower areas
- Look between ribs for lung detail
- Remember to look behind the heart
What can a small tumour within a main airway cause?
A collapse of the peripheral lung
What should doctors be aware of?
Lobar collapse which fails to resolve in 2 to 3 weeks in a smoker of age >45
What should you be aware of with lesions?
- They are often more subtle than tumours
- Beware of lesions behind the heart and hila
- Compare with previous films
- Always look at review areas
What areas are considered review areas?
- Hila
- Lung apices
- Behind the heart
- Behind the diaphragm
After confirming a lesion is intrapulmonary what is the nest test to run?
CT scan
What are you looking for with a CT?
Evaluate
- Size
- Shape
- Atelectasis
- Border
- Density
- Solid vs non solid
- Dynamic contrast enhancement >25 HU
- Growth
Pulmonary mass
An opacity in lung over 3cm with no mediastinal adenopathy or atelectasis
Pulmonary nodule
An opacity in lung up to 3cm with no mediastinal adenopathy or atelectasis
What can pulmonary masses/nodules in the lung mean?
- Lung cancer
- Metastasis
- Benign lung neoplasm
- Infection bacterial, tuberculosis or fungal
- Vascular haematoma
When diagnosing based on scans what should you bear in mind?
- Clinical history
- Compare with previous films
What is CT useful for?
To characterise
What is considered in the of staging lung cancer?
- Clinical history/examination
- Performance status
- Pulmonary function
- TMN International system for staging of Lung Cancer
What does TNM stand for?
- T: Tumour
- N: Nodes
- M: Metastases
TNM staging: Tumour
- How big it is and how far has it spread
- Size and position of tumour
TNM staging: Nodes
-Whether cancer cells have spread into the lymph nodes
TNM staging: Metastasis
-Whether the tumour has spread anywhere else in the body
What tests are used in evaluating T?
- CT
- PET-CT
- Bronchoscopy
What tests are used in evaluating N?
- PET-CT
- Mediastinoscopy
- CT
- EBUS/EUS
What tests are used in evaluating M?
- PET-CT
- CT
- Bone scan
What is FDG PET?
- Functional imaging
- Nuclear medicine technique
- Clinical use for lung cancer staging from 1994
- Labelled glucose analogue 18F-FDG
- Expensive
- Limited availability in the UK
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
Tis
Carcinoma in situ
What is PET/CT used for in T staging?
Assessing chest wall or mediastinal invasion
How many patients present with metastases?
1/3
What are common sites of metastasis?
- Cerebral
- Skeletal
- Adrenal
- Liver
What role does PET/CT play in staging?
- Performs whole body staging in single study excluding cerebral disease
- Discloses metastases and other pathology not detected by other means
- Excludes metastases where structural imaging abnormal
- Non invasive
What are limitations o PET CT?
- Expensive
- Can produce false negatives
- Can produce false positives
What tests can be performed for tissue diagnosis?
- Bronchoscopy and EBUS
- Percutaneous image guided biopsy, fluoroscopy/CT/US guided
- Mediastinoscopy to sample mediastinal nodes
- Mediastinotomy for anterior mediastinal nodes
- VATS
- Explorative thoracotomy
