radiology of lung cancer (diagnosis and staging) Flashcards
steps of systematic review of CXR
name, marker, rotation, penetration
lines, metal work
heart
mediastinum
lungs - upper, middle and lower zones
bones
diaphragm
soft tissues
where do the lungs sit in relation to the diaphragm
they sit in front and behind the diaphragm and hemi-diaphragm?
review of mediastinum on CXR
hilar vascular structures should be crisply defined, compare height and difference between L and R
no widening of mediastinum
trachea should be central
look behind the heart
review of lungs on CXR
compare upper, mid and lower zones
look between ribs for lung detail
remeber to look behind the heart
compare L and R
what is the abnormality in this CXR
mass in the R lung
possible cavity of infection
- peripheral lung carcinoma
what is the abnormality in this CXR
whiteout of the L semi thorax
could be - total collapse of the lung, pneumonectomy, large pleural effusion
- central lung carcinoma which has lead to collapse, potential effusion also
if there is a concern about a central tumour which has caused collapse, a chest and abdominal CT would be done
what is the abnormality in this CXR
right upper lobe collapse
movement of the hilum
hyper-inflation of the lung - darker colour
BEWARE the lobar collapse which fails to resolve in 2-3wks in a smoker of age>45
what would be seen on a CXR if the lower of middle lobe collapses
lower - double heart border (triangle on both sides)
middle - loss of clear heart border
features of lung cancer on CXR
lesions often more subtle
beware of lesions behind the heart and hila
compare with previous films and always look at review areas
what are the review areas on a CXR
hila
lung apices
behind the heart
behind the diaphragm
what is the abnormality in this CXR
left middle zone abnormality
abnormality of the hilum - bulky
left hilar mass
what is the abnormality on this CXR
abnormality on the R
normal hilum position
rounded structure which is denser than the other side
what is the abnormality on this CXR
left lower zone abnormality
opacity behind the heart
cardiac area should be homogenous in density
mass behind the heart
what is the abnormality on this CXR
mass left costophrenic angle
what is the abnormality on this CXR
much denser on the R around apex
right apical/pancoast tumour
what is the abnormality on this CXR
tumour on R base
lacy like obacity (fibrosis) predominant in mid/lower zones and peripheries
clinical hx: increasing SOB in smoker, hx of pulmonary fibrosis, recent haemoptysis
what are the steps to take following a mass on CXR
always compare with previous imaging
confirm lesion is intrapulmonary
CT: evaluate size, shape, atelectasis, border, density, solid/non-solid, dynamic contrast enhancement >25 HU, growth
what is the abnormality on this CXR
rounded uniform opacity
previous breast cancer, mastectomy and then implant
look for evidence of metastasis
define pulmonary mass
an opacity in lung >3cm with no mediastinal adenopathy or atelectasis
define pulmonary nodule
opacity in lung up to 3cm with no mediastinal adenopathy or atelectasis
potential diagnosis for solitary pulmonary nodule or mass
lung cancer (age, smoking hx)
metastasis (prev hx of breast, renal, seminoma, sarcoma)
benign lung neoplasm e.g. carcinoid, hamartoma
infection (bacterial, TB, fungal)
vascular haematoma, AVM
multiple nodules/masses are much more likely to be mets
if an opacity is longstanding and unchanging is it likley to be malignant?
much less likely to be malignant
take note of clinical hx and compare to prev films
changes to lungs from TB
generally leads to scarring and calcifications in the upper zones
hila can be pulled up as a result of scarring
increased density can be a sign of infection
steps for staging lung cancer
clincal hx/examination
performance status
pulmonary function
TNM international system for staging lung cancer - tumour, nodes, mets, higher stage = poorer prognosis
TNM staging
T = how big is it, how far has it spread, is it infiltrating any additional structures (T1-4)
N = have cancer cells spread into the lymph nodes (N1-3)
M - whether the tumour has spread anywhere else in the body (M1A-C)
how is the T in TNM staged
CT, PET, bronchoscopy
how is the N in TNM staged
PET, mediastinoscopy (confirms malignancy in nodes), CT, EBUS/EUS
CT isn’t as useful for notes
PET will show the metabolic activity - useful for small nodes
how is the M in TNM staged
PET, CT, bone scan
FDG PET scan
functional imaging
used in lung cancer staging
labelled glucose analogue
expensive
limited availability in UK
PET scan
metabolic hot spots are matched to anatomical location
very metabolically active areas aren’t necessarily cancer, can also be infection
Tx/T0/Tis
Tx = 1y tumour cannot be assessed
T0 = no evidence of 1y tumour
Tis = carcinoma in situ
T1
tumous = 3cm in greatest dimension
surrounded by lung or visceral pleura
without bronchoscopic evidence of involvement of the main bronchus
T1a - minimally invasive adenocarcinoma tumous, = 1cm in greatest dimesion
T1b - = 2cm
T1c - = 3cm
T2
tumour >3cm but <5cm or tumour with any of the following features:
(T2 tumours with these features are classified T2a if = 5cm)
- involves main bronchus but not carina
- invades visceral pleura
- associated with atelectasis or obstructive pneumonitis that extends to hilar region involving part or all of the lung
T2a - >3cm but <4cm in greatest dimension
T2b - >4cm but <5cm in greatest dimension
T3
tumour >5cm but <7cm or one that directly invades any of the following:
- chest wall (including superior sulcus tumours)
- phrenic nerve
- parietal pericardium
or separate tumour nodule(s) in the same lobe as the 1y
T4
tumour >7cm or invades any of the following:
- diaphragm
- mediastinum
- heart
- great vessels
- trachea
- recurrent laryngeal nerve
- oesophagus
- vertebral body
- carina
separate tumour nodule(s) in a different ipsilateral lobe
how is PET/CT used in T staging
assessing chest wall or mediastinal invasion
N0
no regional lymph node metastasis
N1
ipsilateral peribronchal, hilar or intrapulmonary nodes including by direct extension
N2
ipsilateral mediastinal, subcarinal
N3
contralateral mediastinal, contralateral, hilar, scalene or supraclavicular
what proportion of patients present with mets
1/3
what are the scommon sites of mets in lung cancer
cerebral
skeletal
adrenal
liver
M0
no distant mets
M1 - distant mets
M1a (metastatic disease in thorax):
separate tumour nodule(s) in a contralateral lobe
tumour with pleural or pericardial nodules or malignant pleural or pericardial effusion
M1b - single distant mets
M1c - multiple distant mets
PET/CT in staging
performs whole body staging in a single study excluding cerebral disease (brain is normally metabolically active)
discloses mets and other pathology not deteceted by other means (unexpected mets in 10-20%)
excludes mets where structural imaging abnormal
non-invasive
how should cerebral disease be investigated
head CT w/ contrast
limitations of PET CT
all tests have false -ve and +ve results
cost
stage I cancer
T1 N0 M0
T2 N0 M0
stage II cancer
T1 N1 M0
T2 N1 M0
T3 N0 M0
Stage III cancer
T3 N1 M0
T3 N2 M0
T4 N0-2 M0
T1-4 N3 M0
Stage IV cancer
any T any N M1
1% 5YS
Tissue diagnosis
bronchoscopy and EBUS
percutaneous image guided biopsy,CT/US guided
mediastinoscopy - sample mediastinal nodes
mediastinotomy for anterior mediastinal nodes
VATS
explorative thoracotomy
