Radiology of lung cancer (investigations and staging)

Question 1

What are the steps of a systematic review of a CXR? (8)

Answer 1

Name/marker/rotation/penetration
Lines/metal work
Heart
Mediastinum
Lungs
Bones
Diaphragm
Soft tissue

Question 2

What do you look at with the heart on a CXR?

Answer 2

Distortion
Enlargement

Question 3

What do you look at with the mediastinum on a CXR?

Answer 3

Structures beneath the heart
Central airways
Hilar vascular structures should be crisply defined
Widening of mediastinum
Trachea should be central

Question 4

What do you look at with the lungs on a CXR?

Answer 4

Compare zones
Look for abnormalities
Lung collapse
Mass
Look between ribs for lung detail
Look “behind” the heart

Question 5

What to look at with bones on a CXR?

Answer 5

Costophrenic angles
Fractures

Question 6

What are the major review sections on a CXR?

Answer 6

Hila
Lung apices
Behind the heart
Behind the diaphragm

Question 7

What is the next step after CXR in investigation?

Answer 7

CT scan

Question 8

What to look at on a CT?

Answer 8

Size
Shape
Atelectasis
Border
Density
Solid or non-solid
Dynamic contrast enhancement >25HU
Growth

Question 9

What is the difference between a pulmonary nodule and pulmonary mass?

Answer 9

Pulmonary mass is over 3cm with no mediastinal adenopathy or atelectasis.
Pulmonary nodule is less than 3cm no mediastinal adenopathy or atelectasis.

Question 10

What are solitary pulmonary nodule/mass?

Answer 10

Lung cancer
Metastasis - Breast, renal, seminoma, sarcoma
Benign lung neoplasm - Carcinoid, hamartoma
Infection - Bacterial, TB, fungal
Vascular haematoma

Question 11

How can tumours be staged?

Answer 11

Clinical history/examination
Performance status
Pulmonary function
TNM

Question 12

What does the T stand for in TNM?

Answer 12

T = size of tumour

Question 13

What does staging TX and T0 stand for?

Answer 13

TX= primary tumour cannot be assessed
T0 = No evidence of primary tumour

Question 14

What does stage T1 mean?

Answer 14

T1 = <3cm surrounded by lung/visceral pleura not involved with main bronchus.

T1a = <=1cm
T1b = <=2cm
T1c = <=3cm

Question 15

What does stage T2 mean?

Answer 15

T2 = 3-5cm or involved with:
- Main bronchus/carina
- Invades visceral pleura
- Associated with atelectasis, obstructive pneumonitis that extends to hilar region involving part/all of the lung.

T2a = 3-4cm
T2b = 4-5cm

Question 16

What does stage T3 mean?

Answer 16

T3 = 5-7cm or invading any of:
- Chest wall
- Phrenic nerve
- Parietal pericardium
Or separate tumour nodules in same lobe as primary.

Question 17

What does stage T4 mean?

Answer 17

> 7cm or invades any of:
- Diaphragm
- Mediastinum
- Heart
- Great vessels
- Trachea
- Recurrent laryngeal nerve
- Oesophagus
- Vertebral body
- Carina
- Separate tumour nodules in a different ipsilateral lobe.

Question 18

What does the N stand for in TNM staging?

Answer 18

Lymph node involvement

Question 19

What does stage N0 mean?

Answer 19

No regional lymph node metastases

Question 20

What does stage N1 mean?

Answer 20

Ipsilateral peribranchial, hilar or intrapulmonary nodes including by direct extension

Question 21

What does stage N2 mean?

Answer 21

Ipsilateral mediastinal, subcarinal

Question 22

What does stage N3 mean?

Answer 22

Contralateral mediastinal, contralateral hilar, scalene or supraclavicular

Question 23

What does the M stand for in TNM staging?

Answer 23

Metastasis

Question 24

What does M1 mean and subcategories?

Answer 24

M1 = distant metastasis

M1a
- Separate tumour nodules in contralateral lobes
- Tumour with pleural or pericardial nodules or malignant pleural or pericardial effusion
M1b
- Single distant metastasis
M1c
- Multiple distant metastasis

Question 25

What does PET-CT scans show?

Answer 25

Whole body staging in a single study excluding cerebral disease.
Discloses metastases and other pathology (unexpected metastasis 10-20%).
Excludes metastases where structural imaging abnormal.
Non invasive

Question 26

What are the methods of tissue diagnosis?

Answer 26

Bronchoscopy
EBUS
Percutaneous image guided biopsy
- Fluoroscopy/CT/US guided