Tumours Flashcards
@# 7. Which of the following has the greatest incidence of metastases to the lung?
A. Choriocarcinoma
B. Hypernephroma
C. Ewing’s sarcoma
D. Rhabdomyosarcoma
E. Testicular seminoma
A. Choriocarcinoma
In order of decreasing frequency, pulmonary metastases arise from choriocarcinoma, hypernephroma/Wilms’ tumor, Ewing’s/rhabdomyosarcoma and testicular tumors.
- Which of the following is the strongest feature to support a diagnosis of a hamartoma on investigation of a pulmonary mass?
A. A smooth, lobulated contour
B. Chondroid calcification
C. Slow growth
D. The presence of an extra-adrenal paraganglioma
E. Cavitation
B. Chondroid calcification
Calcification occurs in approximately 20% of cases and is almost pathognomonic if of the chondroid ‘popcorn’ type.
- Which of the following features most favours Hodgkin’s rather than non-Hodgkin’s lymphoma?
A. Posterior mediastinal nodes
B. Para-aortic lymphadenopathy
C. Mesenteric adenopathy
D. Contiguous spread
E. Hepatomegaly
D. Contiguous spread
Contiguous spread is a feature of Hodgkin’s disease, compared with non-contiguous spread in non-Hodgkin’s disease. Other differences include greater thoracic involvement and less abdominal involvement in Hodgkin’s disease.
- Which of the following indicates T3 rather than T4 lung cancer?
A. Invasion of the oesophagus
B. Invasion of the trachea
C. Invasion of the pericardium
D. Malignant pleural effusion
E. Invasion of the vertebral body
C. Invasion of the pericardium
T3 disease features include a tumour of any size less than 2cm from the carina, invasion of the parietal pleura, chest wall, diaphragm, mediastinal pleura, pericardium, pleural effusion or satellite nodule in the same lobe. T4 disease is characterised by invasion of the heart, great vessels, trachea, oesophagus, vertebral body, carina or the presence of a malignant pleural effusion. The TNM staging system was updated in 2009 (AJR, 2010).
- A 47-year-old female Caucasian smoker presents with persistent cough and haemoptysis. CT shows a 2.2cm soft tissue mass in the left lower lobe with coarse calcific foci and no mediastinal, hilar or axillary lymphadenopathy. A small endobronchial lesion is also seen in the left lower lobe bronchus. What is the most likely diagnosis?
A. Bronchogenic carcinoma
B. Pulmonary TB
C. Lymphoma
D. Fibrosing mediastinits
E. Bronchial carcinoid
E. Bronchial carcinoid
A typical carcinoid is a small mass (< 2.5cm) with no associated lymphadenopathy. Calcifications are seen in up to 26% of cases on CT. The iceberg phenomenon is the presence of a small endobronchial component associated with a larger extrabronchial component
- A 48-year-old male smoker with a pulmonary mass on CXR is investigated with CT. This shows a well-defined right upper lobe lesion measuring 3cm with attenuation of -156 Hounsfield Units (HU). Which is the most likely diagnosis?
A. Tuberculoma
B. Mestastasis from colorectal cancer
C. Histoplasmosis
D. Hamartoma
E. Pulmonary AVM
D. Hamartoma
Hamartomas are usually well-defined solitary lesions < 4cm. The presence of fat in the lesion is a diagnostic feature, although may not be present in a hamartomatous nodule in up to 1⁄3 of cases. The lesions may grow slowly over time.
- Which of the following features is most likely to indicate malignancy in a solitary pulmonary nodule?
A. Size > 3cm
B. Malignant growth rate
C. Spiculated margin
D. Age > 70
E. Smoking
C. Spiculated margin
In order of decreasing likelihood, the following are features suggestive of malignancy in an indeterminate pulmonary nodule:
• Spiculated margin
• Size > 3cm
• Age > 70 years
• Malignant growth rate
• Smoker
• Upper lobe location
- Which of the following features is most likely to indicate a benign solitary pulmonary nodule?
A. Age 30-39
B. Upper lobe location
C. Size < 1cm
D. Smooth margin
E. Age > 70
A. Age 30-39
Benign growth rate, benign calcification, age < 39 and a non-smoking history are the features most likely to favour a benign nodule.
- A 53-year-old male smoker is under evaluation for a thoracic aortic aneurysm. Whilst reviewing pre- and postcontrast CT images of the chest, a 2.4 cm lesion is seen in the left lower lobe, with a mural nodule. Which of the following features most favours a diagnosis of cavitating lung cancer rather than an intracavitatory apergilloma?
A. Size of lesion
B. Contrast enhancement > 10HU
C. Wall thickness
D. Adjacent bronchiectasis
E. Volume loss in involved lobe
B. Contrast enhancement > 10HU
Degree of contrast enhancement is much higher in cavitating lung tumours. Adjacent bronchiectasis is more often seen in aspergillomas.
@# 49. Which of the following is most likely to present as a haemorrhagic rather than a calcified pulmonary metastases?
A. Breast cancer
B. Chondrosarcoma
C. Testicular cancer
D. Choriocarcinoma
E. Mucinous adenocarcinoma of the colon
D. Choriocarcinoma
Choriocarcinoma, renal carcinoma, and melanoma are causes of haemorrhagic pulmonary metastases.
13) A 76-year-old female presents with hemoptysis and cough. A chest radiograph shows a mass in the right upper lobe that contains a crescent of air. Which feature on CT would make a cavitating malignancy more likely than aspergilloma?
a. thin cavity wall
b. high-density central mass
c. enhancing central mass
d. calcification
e. adjacent bronchiectasis
c. enhancing central mass
Aspergilloma appears as a solid mass in a thin-walled cavity, which lies in a dependent position and is mobile. A crescent-shaped airspace is typical. It may calcify and be associated with pleural thickening. In contrast, cavitating malignancy often has irregular thick-walled margins with a central mass that often enhances, and is fixed and nonmobile. Calcification may occur in relation to malignancy but is usually adjacent to, rather than in, the lesion and is usually seen with a scar carcinoma. Neither causes high-density lesions. Adjacent bronchiectasis is more often seen when there has been previous infection such as tuberculosis, producing a cavity in which an aspergilloma develops.
31) An 80-year-old man presents with hemoptysis and a mass on chest radiograph. A biopsy shows non-small-cell lung cancer. CT of chest shows a 4 cm, right middle lobe mass with pleural tethering but no chest wall invasion. Lymph nodes are seen at the right hilum (17 mm short axis), in the subcarinal space (20 mm short axis) and in the aortopulmonary space (8 mm short axis). No other abnormalities are seen. What is the TNM stage?
a. T2 N1 M0
b. T2 N2 M0
c. T2 N3 M0
d. T3 N1 M0
e. T3 N2 M0
b. T2 N2 M0
The T stage is T2, as the lesion is over 3cm but there is no chest wall or mediastinal invasion or other associated feature. The nodes at the right hilum (N1) and in the subcarinal space (N2) are significantly enlarged, whereas the node in the aortopulmonary space (N3) is not (,10mm short axis), hence the N stage is N2.
32) A 48-year-old female with known lung cancer undergoes an 18FDG PET/CT scan. The tumor is highly FDG avid. Several areas of moderate uptake are noted on the study. Which of the following findings is of concern with regard to metastatic disease?
a. diffuse thyroid uptake
b. symmetrical nasopharyngeal tonsil uptake
c. diffuse uptake in caecal wall
d. focal paravertebral muscle uptake
e. focal uterine cavity uptake
d. focal paravertebral muscle uptake
FDG uptake occurs at many sites due to physiological uptake. Muscle uptake is variable, but usually occurs throughout a muscle when physiological. Focal muscle uptake is of concern, although benign causes are not uncommon. Diffuse thyroid uptake is usually physiological, but may indicate thyroiditis, whereas focal thyroid uptake may be malignant in 20–50% of cases. Tonsillar uptake if diffuse and symmetrical is likely to be benign, but asymmetrical or focal uptake requires further assessment. Caecal uptake, if diffuse, is probably due to lymphoid uptake, but, again, focal uptake must be assessed further. FDG uptake in the uterine cavity is usually due to menstruation.
50) A 56-year-old male presents with wheezing, cough and recurrent chest infections. A chest radiograph shows right middle lobe consolidation. CT of the chest shows a 3 cm mass arising within the right middle lobe bronchus with distal collapse and consolidation. Which feature of the mass would make hamartoma more likely than carcinoid?
a. central location
b. presence of calcification
c. cavitation
d. presence of fat
e. prominent enhancement
d. presence of fat
Hamartomas are usually seen in the periphery of the lungs (two-thirds) with 10% being endobronchial. Calcification is seen in 15%, often popcorn type. Cavitation is rare but fat is seen in 50%. Carcinoids are usually located centrally and are endobronchial. Calcification is seen in one-third and they rarely cavitate. They do not contain fat and show prominent enhancement following contrast, as they are vascular.
61) A 44-year-old male presents with a solitary pulmonary nodule on a chest radiograph performed for a suspected chest infection. CT shows this to be 20 mm in diameter with a central cavity and smooth internal walls. No additional findings are seen. Which investigation should be arranged?
a. none; findings are entirely benign
b. CT enhancement study
c. interval volumetric CT
d. contrast MRI
e. 18FDG PET/CT scan
e. 18FDG PET/CT scan
Although the imaging features suggest a benign nodule, malignancy cannot be excluded and further investigation is warranted.
CT enhancement studies may be helpful in solid nodules, but are of less value when a nodule is cavitating.
An 18FDG PET/CT scan has both high sensitivity and specificity in assessing solitary pulmonary nodules, with accuracy over 90%.
In particular there is a high specificity for a lesion that shows no FDG uptake being benign.
Follow-up is still recommended to ensure no growth and exclude a very low-grade tumor.
Interval CT may be considered an option, but in a young patient, unless there are exceptional circumstances, aiming to characterize the lesion is considered more appropriate.
MRI is of no proven value in the evaluation of lung nodules.
68) A 16-year-old male presents with sudden shortness of breath. A chest radiograph shows multiple, bilateral nodules measuring up to 3 cm, some of which are calcified. There is a moderate left pneumothorax. The patient has been undergoing treatment for a malignant tumor. What is the most likely diagnosis?
a. metastases secondary to Wilms’ tumor
b. metastases secondary to osteosarcoma
c. metastases secondary to testicular tumor
d. abscesses secondary to immunosuppression
e. varicella pneumonia secondary to immunosuppression
b. metastases secondary to osteosarcoma
Osteosarcoma pulmonary metastases are uncommon (seen in 2% ofcases) and present as multiple masses which may calcify. There is a high incidence of associated pneumothorax.
Wilms’ tumors may also produce multiple pulmonary masses and may be associated with pneumothorax, but are not known to calcify.
Testicular tumors may produce calcified lung metastases, but are not associated with pneumothorax.
Varicella pneumonia shows patchy consolidation in the acute phase, with multiple, small, calcified nodules in the chronic phase.
Abscesses may present as multiple masses but rarely calcify and often cavitate.
69) A 64-year-old male presents with worsening shortness of breath and hemoptysis. A chest radiograph shows a right hilar mass with extensive reticulation in the ipsilateral lung, with Kerley A and B lines and reduced lung volumes. The left lung is clear. CT of the chest demonstrates the right hilar mass, and a thickened parenchymal polygonal network within the mid and lower zones of the ipsilateral lung. Beaded thickening of the interlobular septa is also noted. What is the most likely diagnosis?
a. lymphangitis carcinomatosis
b. idiopathic pulmonary fibrosis
c. extrinsic allergic alveolitis
d. histiocytosis
e. sarcoidosis
a. lymphangitis carcinomatosis
Lymphangitis carcinomatosis is tumor cell accumulation within connective tissue, causing lymphatic obstruction. This leads to interstitial edema. The chest radiograph may be normal, but there is often reticulonodular change with Kerley A and B lines. An ipsilateral hilar or mediastinal mass may be seen. Pulmonary fibrosis has a peripheral predominance and tends to be bilateral. Extrinsic allergic alveolitis and histiocytosis tend to be bilateral. Sarcoidosis usually produces a more nodular pattern and there is predominance in the upper lobes. Polygonal structures on CTare uncommon in sarcoidosis.
77) Which of the following descriptions would be most suggestive of a pulmonary hamartoma on imaging?
a. round, 2 cm, soft-tissue mass with no calcification or fat, in a central location
b. irregular, 8 cm mass with cavitation and associated effusion
c. multiple lesions of 1–3 cm with calcification, throughout lungs
d. lobulated, 3 cm mass with calcification and fat, in a peripheral location
e. peripheral, 5 cm lesion with no calcification, and band-like opacity connecting it to the hilum
d. lobulated, 3 cm mass with calcification and fat, in a peripheral location
Hamartomas are seen in 0.25% of the population and are the commonest benign lung tumor. Two-thirds are found peripherally. They are rarely multiple or cavitatory. Fifteen per cent calcify (classically popcorn) and 50% contain fat.
Option (a) is more typical of carcinoid,
while (c) is suggestive of multiple granulomas, probably secondary to chickenpox.
Option (e) is characteristic of pulmonary arteriovenous malformation.
83) In thoracic lymphoma, which feature would favor non-Hodgkin’s lymphoma over Hodgkin’s disease?
a. predominantly anterior mediastinal lymph nodal involvement
b. predominantly middle mediastinal lymph nodal involvement
c. predominantly posterior mediastinal lymph nodal involvement
d. nodal calcification
e. mass larger than 5 cm
c. predominantly posterior mediastinal lymph nodal involvement
Mediastinal nodal involvement is generally more suggestive of Hodgkin’s disease, but disease is usually seen in the middle and anterior mediastinum. Posterior mediastinal involvement, with little or no anterior or middle mediastinal involvement, suggests non-Hodgkin’s lymphoma as a more likely diagnosis. Calcification can occur in either condition, nearly always post-therapy. The size of the lymph node masses is not discriminatory.
@# 5- A 24-year-old asymptomatic man has a CXR for insurance purposes. The report describes a solitary 2 cm nodule. A subsequent CT is arranged. Which of the following of the features favor a diagnosis of carcinoid over hamartoma?
(a) Avid 18FDG-PET uptake
(b) Calcification
(c) Central location
(d) Hounsfield value of —30
(e) Solitary lesion
(c) Central location
Pulmonary carcinoids represent < 4% of all lung tumors and approximately 15% of all carcinoid tumors within the body. They can be typical (type 1; local tumor; 90%) or atypical (type 2; metastasizes to local LNs, rarely to liver), 80% are centrally located.
They rarely cause carcinoid syndrome, often enhance strongly, 1/3 contain calcification, and they typically have no uptake at PET.
Hamartomas are well circumscribed solitary nodules; 90% are peripheral. They are benign tumors composed of cartilage, connective tissue, muscle, fat, and bone.
Fat attenuation at CT is described as pathognomonic, pompom’ calcification is also diagnostic but is seen in only 20%
17- You are asked to review a follow up CT for a patient with a metastatic carcinoma in a clinical trial. The initial CT showed 2 pulmonary lesions, measuring 6 and 4 respectively. The current CT shows 3 lesions, each measuring 2 cm. How should you classify the response?
(a) Complete response
(b) Mixed response
(c) Partial response
(d) Stable disease
(e) Progressive disease
(e) Progressive disease
The development of any new lesion, or an increase in the overall size of lesions by 20% or more, indicates progressive disease. There is no ‘mixed response’ category in the RECIST system.
6- A 38-year-old non-smoker presents with pleuritic chest pain, shortness of breath and a raised D-Dimer. A CT pulmonary angiogram is performance which shows no pulmonary emboli- There is a solitary 7 mm, well circumscribed nodule in the right upper lobe- What should you recommended?
(a) No follow—up
(b) CT at 6—12 months
(c) CT at 3, 9, and 24 months
(d) CT 6—12 at months, then 1 8—24 months
(e) PET-CT or biopsy of nodule
(b) CT at 6—12 months
The Fleischer society guidelines were published in 2005 and relate to the management of incidentally detected new lung nodules. They do not apply to patients < 35 yrs. (as the risk of lung cancer is minimal below this age), with underlying malignancy, or with unexplained fever. Low risk patients are defined as having a minimal or absent history of smoking and of other known risk factors (e.g. family history, asbestos/ radon exposure). NB non-or partly solid (e.g. groundglass nodules) may require longer follow-up to rule out adenocarcinoma.
@# 38- A 40-year-old Woman presents hemoptysis- CXR shows multiple cavitating lesions in both lungs- Needle biopsy confirms the lesions are metastatic. Which of the following is the least likely cause?
(a) Squamous cell carcinoma of the larynx
(b) Adenocarcinoma of the cervix
(c) Transitional cell carcinoma of the bladder
(d) Adenocarcinoma of the colon
(e) Giant cell tumor of the distal femur
(e) Giant cell tumor of the distal femur
The differential diagnosis for cavitating metastases also includes melanoma. Giant cell tumor metastases may calcify.
7 A 64 year old woman presents with dyspnoea. CXR shows reticulonodular opacities and coarsened bronchovascular marking only within the right lower zone. HRCT shows focal RLL thickening of peribronchovascular interstitium, interlobular septa and fissures with preservation of normal parenchymal architecture.
What is the most likely underlying cancer?
(a) Bronchogenic
(b) Cervical
(c) Gastric
(d) Ovarian
(e) Thyroid
(a) Bronchogenic
The findings described are consistent with lymphangitis carcinomatosis. Although the appearance of LC on HRCT scans is nonspecific, the features in a symptomatic patient with history of malignancy is highly suggestive. A number of primary tumours are associated with this finding within the lung, including cervix, colon, stomach, breast, pancreatic, thyroid and larynx. Focal, unilateral disease is particularly associated with underlying bronchogenic carcinoma (breast cancer can also produce this pattern).
8 After squamous cell carcinoma, which is the next most common tumour of the trachea?
(a) Adenoid cystic carcinoma
(b) Muco-epidermoid tumour
(c) Carcinoid
(d) Squamous cell papilloma
(e) Lymphoma
(a) Adenoid cystic carcinoma
More than 90% of tracheal neoplasms are malignant, with adenoid cystic carcinomas second most common. Squamous cell papillomas, related to human papilloma virus infection, are the most common benign lesions.
14 A 63 year old smoker presents with pain in the right arm. On examination there is wasting of the small muscles in the right hand, ptosis and miosis of the right eye. CXR shows right apical pleural thickening and an associated mass. What is the most likely tumour type?
(a) Large cell
(b) Mesothelioma
(c) Oat cell
(d) Reed-Sternberg cell
(e) Squamous cell
(e) Squamous cell
The lesion described is that of a Pancoast tumour. This is a superior sulcus tumour that is most commonly due to a primary lung tumour, but can result from breast cancer, myeloma, mesothelioma, lymphoma, or metastases. Overall 3% of bronchogenic cancers present this way, the commonest being squamous cell; adenocarcinoma is the second commonest. Symptoms result from local involvement of the brachia! plexus (arm pain, hand muscle wasting) and the sympathetic chain (Homer’s syndrome: ipsilateral enophthalmos, ptosis, miosis and anhidrosis).
@#1 17 A 25 year old woman has a CXR for insurance purposes. There is a 2 cm well-circumscribed lesion in the periphery of the RLL. The subsequent CT demonstrates fat and calcification within the lesion; no other lesions are identified. What two further conditions, if present, would make the diagnosis part of Carney’s triad?
(a) Atrial myxoma and extra-adrenal paraganglioma
(b) Atrial myxoma and pituitary adenoma
(c) Breast fibroadenoma and pituitary adenoma
(d) Gastric leiomyosarcoma and breast fibroadenoma
(e) Gastric leiomyosarcoma and extra-adrenal paraganglioma
(e) Gastric leiomyosarcoma and extra-adrenal paraganglioma
Pulmonary hamartomas, gastric leiomyosarcomas (GISTs) and functioning extra-adrenal paragangliomas make up this rare triad. Almost all patients are female (80%) aged 10-30 years. Pituitary adenomas, cardiac myxomas, along with myxoid fibroadenomas of the breast and testicular tumours are associated with the autosomal dominant Carney complex.
@# 26 A 64 year old man undergoes nephrectomy for a right renal tumour. A year later he presents with haemoptysis. CT of the chest shows 3 lesions in the right hemithorax measuring 20 x 10 mm, 20 x 12 mm and 10 x 10 mm. Biopsy confirms these are metastases. After a course of chemotherapy, the lesions measure 18 x 8 mm, 17 x 10 mm and 10 x 8
mm. By RECIST criteria the status of the disease is?
(a) Stable disease
(b) Partial response
(c) Good response
(d) Excellent response
(e) No response
(a) Stable disease
Baseline is defined as the sum of the long diameters of the target lesions where up 2 target lesions per organ and 5 overall can be used. Partial response involves a decrease of 30% or more in the sum of the long diameters. Complete response implies the disappearance of all lesions. Disease progression involves an increase in the sum of the long diameters of 20%. Good response, no response and excellent response are not part of the RECIST criteria.
@#1 34 A 50 year old woman with a history of scleroderma and a 30 pack per year smoking history presents with a cough. CXR shows a 1.2 cm peripheral nodule in the right lower lobe. CT confirms the nodule is solitary and is of mixed attenuation with a ground glass appearance. There is no mediastinal lymphadenopathy. Repeat interval CT at 6 weeks, after treatment with antibiotics, shows the lesion has remained stable in size but there is some evidence of cavitation. 18FDGPET is performed and found to be negative. The likeliest diagnosis is?
(a) Bronchoalveolar carcinoma
(b) Squamous cell carcinoma
(c) Atypical infection
(d) Carcinoid
(e) Adenocarcinoma
(a) Bronchoalveolar carcinoma
BAC is a slow growing peripheral tumour associated with chronic lung disease and ground glass appearance on HRCT. It can cavitate and is PET negative in 55%.
36 A 58 year old man undergoes an uncomplicated pneumonectomy for lung cancer. Which of the following signs on CXR is considered abnormal?
(a) Opacification of 1/3 of the pneumonectomy hemithorax within 24 hours
(b) Depression of the hemidiaphragm on the pneumonectomy side
(c) Apical herniation of the unaffected lung to the pneumonectomy side
(d) Shift of the mediastinum to the pneumonectomy side
(e) Opacification of 2/3 of the hemithorax on the pneumonectomy side within 7 days
(b) Depression of the hemidiaphragm on the pneumonectomy side
Ipsilateral mediastinal shift and elevation of the hemidiaphragm are normally seen after pneumonectomy. Depressions of the hemidiaphragm or contralateral mediastinal shift are abnormal and may indicate haemorrhage, empyema or a bronchopleural fistula.
40 A 50 year old man is found to have a 3.5 cm round, welldefined, right lower lobe nodule on CXR. CT examination shows the lesion is solitary and contains areas of fat. The likeliest diagnosis is?
(a) Carcinoid
(b) Bronchoalveolar carcinoma
(c) Pulmonary teratoma
(d) Pulmonary hamartoma
(e) Pulmonary lipoma
(d) Pulmonary hamartoma
Fat in a round well defined pulmonary lesion measuring up to 4 cm is virtually diagnostic of pulmonary hamartoma. Calcification, classically in a “popcorn” distribution, is seen in 15-20%.
@#1 60 A 57 year old man with biopsy proven lung cancer attends for a PET-CT study. This demonstrates a 4 cm tumour in the left lower lobe, not abutting the pleural surface. There are enlarged, PET positive nodes in the left hilar, sub-carinal and cervical nodes. How would you stage this tumour?
(a) T3 N3 MO
(b) T2 N2 MO
(c) T2 N3 MO
(d) T2 N2 M1
(e) T2 N3 M1
(d) T2 N2 M1
T2 lesions are those greater than 3 cm not invading the parietal pleura and more than 2 cm away from the carina. N1 nodes are hilar, N2 nodes include ipsilateral mediastinum and sub-carinal, N3 nodes are supraclavicular and contralateral mediastinum. Nodes outside these regions are considered to be M1.
@#1 4. In an investigation for lung malignancy, all of the following may produce a false positive result on a PET-CT except:
a. Pulmonary hamartoma
b. Intralobar sequestration
c. Tuberculosis
d. Pneumonia
e. Scarring
b. Intralobar sequestration
Active tuberculosis, consolidation, atypical pulmonary hamartomas and scars may cause false positive results. Uncomplicated sequestration will not demonstrate FDG uptake.
@# 17. The staging chest CT of a 40 year old man with a known primary malignancy demonstrates cavitating pulmonary metastases. The least likely type of primary lesion would be:
a. Squamous cell carcinoma
b. Malignant melanoma
c. Renal cell cancer
d. Sarcomas
e. Colonic carcinoma
- c. Renal cell cancer
- A 55 year old man has a repeat chest radiograph which demonstrates a persistent patch of consolidation four months after a previous radiograph. Bronchioloalveolar carcinoma (BAC) is suspected. Which of the following makes the diagnosis less likely?
a. Low attenuation consolidation
b. Negative PET-CT
c. Central location
d. Long history of smoking
e. Associated cavitation
- c. Central location
BAC can present in a local form as a mass, usually peripheral, subpleural in location or as diffuse persistent/progressive consolidation in patients with a history of smoking. The area of consolidation is often of low attenuation on CT due to copious mucin production. It is the second most common type of malignancy associated with cavitation.
- A 62 year old man presents with right shoulder pain which radiates down his arm. A plain radiograph confirms the presence of a right apical mass with destruction of surrounding ribs. CT-guided biopsy is performed & is likely to reveal:
a. Large cell lung cancer
b. Squamous cell cancer
c. Small cell lung cancer
d. Adenocarcinoma
e. Carcinoid
- b. Squamous cell cancer
The case describes a Pancoast tumour for which squamous is the most common cell type.
- A 60 year old female underwent a right pneumonectomy for bronchogenic carcinoma. Which feature on plain chest radiograph would be a cause of worry seven days after surgery?
a. A sequential increase in the fluid level
b. Shift of the previously central trachea to the right
c. Shift of the previously central trachea to the left
d. Elevation of the right hemi-diaphragm
e. Shift of the cardiac silhouette to the right
- c. Shift of the previously central trachea to the left
All the other changes are expected changes at this stage following a pneumonectomy. However, contralateral shift of the trachea may be indicative of a post-surgical bronchopleural fistula.
@#e 38. A 68 year old miner develops an irregular opacity in the upper zone on plain chest radiograph. Which imaging feature would be more in favour of malignancy than progressive massive fibrosis (PMF)?
a. Peripheral enhancement on contrast-enhanced MR
b. Peripheral location on axial images
c. Presence of calcification
d. High signal on T2-weighted images
e. Avid lesion on PET-CT
d. High signal on T2-weighted images
PMF has a peripheral location which moves towards the hilum on follow-up imaging.
Calcification and cavitation may also be seen.
PMF lesions can be FDG-avid on PET-CT.
However, high signal in a mass on T2-weighted images is strongly suspicious for malignancy.
- The plain chest radiograph of a 52 year old male presenting with cough and haemoptysis reveals a veil-like opacity over the left upper zone. CT reveals an endobronchial lesion in the left upper lobe bronchus causing lobar collapse. Bronchoscopic biopsy is least likely to reveal:
a. Squamous cell carcinoma
b. Carcinoid
c. Lymphoma
d. Metastatic renal cell cancer
e. Bronchioloalveolar carcinoma
- e. Bronchioloalveolar carcinoma
BAC usually presents as a peripheral, subpleural mass or persistent patch of consolidation. All the others can present as endobronchial lesions.
- A 60 year old man presents with a 6 month history of shortness of breath, wheeze and a recent episode of haemoptysis. Plain chest radiograph reveals partial right middle and lower lobe collapse. This is further confirmed on CT which also suggests an endobronchial lesion in the bronchus intermedius. It is FDG-avid on PET-CT scan. Bronchoscopy reveals a smooth submucosal lesion. The histopathology of the lesion is most likely to be:
a. Mucoepidermoid carcinoma
b. Atypical carcinoid
c. Renal cell carcinoma metastasis
d. Adenoid cystic carcinoma
e. Squamous cell papilloma
- d. Adenoid cystic carcinoma
Adenoid cystic carcinoma is the second most common malignancy of the central airways after squamous cell cancer and often presents as an endoluminal mass with an intact mucosa. Mucoepidermoid carcinoma is rare. Benign tumours are mostly of mesenchymal origin and are rare. Carcinoids in these locations are usually of the typical type.
- A 59 year old male presents with left shoulder pain and tingling in his fingers. Plain chest radiograph reveals the presence of a left apical mass with some rib destruction. CT confirms the presence of a superior sulcus tumour at the left apex with no evidence of nodal or distant metastasis. The patient is referred for a MR scan to assess resectability. Which of the following is appropriate?
a. Coronal T1-weighted images are best to identify involvement of the brachial plexus
b. T2-weighted images are vital to assess resectability and should be performed first
c. Axial images are best to assess spinal canal and foraminal involvement
d. Use of intravenous contrast is necessary to identify the subclavian vessels and their relation to the brachial plexus and the tumour
e. Imaging is usually performed using a body coil
- c. Axial images are best to assess spinal canal and foraminal involvement
Sagittal and axial images are the most important acquisitions to assess the local extent and involvement of vital neurovascular structures by the tumour, with coronal imaging adding very little further information. T1-weighted images are the most important to assess resectability and should be acquired first. The subclavian vessels can be seen quite clearly as flow voids even without contrast. Gadolinium is usually given to assess for vascular invasion and following adjuvant therapy. Imaging is performed using a neck coil to improve resolution for identifying small local structures.
@# 59. A 60 year old man presents with progressive breathlessness. The plain chest radiograph reveals reticular shadowing in the right lower zone, but is otherwise unremarkable. HRCT demonstrates the presence of beaded thickening of the interlobular septae forming a polygonal reticular network in the right lower lobe with central dots within. There is also a small pleural effusion. Which of the following is the most likely cause?
a. Sarcoidosis
b. Bronchogenic carcinoma
c. Heart failure
d. Extrinsic allergic alveolitis
e. Fibrosing alveolitis
- b. Bronchogenic carcinoma
The changes described indicate lymphangitis carcinomatosis.
Whilst similar appearances are seen in sarcoidosis, the changes are usually in the upper lobe and pleural effusion is rare.
In heart failure, the interlobar septal thickening is usually smooth and usually bilateral.
In EAA, pleural effusion is rare and changes are more bronchocentric and bilateral. The polygonal structure is usually distorted in both EAA and cryptogenic fibrosis, where changes are again subpleural.
QUESTION 4 An 80-year-old lifelong male smoker presents with a cough and wheeze. A CXR demonstrates right middle lobe airspace opacification with bulging of the central oblique and horizontal fissures. The radiographic appearances fail to resolve 4 weeks later, after an appropriate course of antibiotics. CT evaluation demonstrates a large cavitating centrally placed mass. Which one of the following diagnoses is the most likely?
A Adenocarcinoma
B Large cell carcinoma
C Lymphoma
D Small cell carcinoma
E Squamous cell carcinoma
E Squamous cell carcinoma
In lung cancer, the radiological pattern of disease varies with the cell type. Squamous cell tumours are the most common tumour to cavitate and those most frequently associated with collapse/consolidation of the lung due to their predominantly central location.
QUESTION 5 You are reviewing a contrast-enhanced CT chest for a suspected central bronchogenic carcinoma of the lung. You determine that the tumour is greater than 3 cm in its longest dimension, invades the mediastinal pleura but does not invade any mediastinal structures. There is an associated pleural effusion but you are informed by the clinical team that multiple cytopathological examinations reveal no tumour cells. What would be your proposed T staging?
A TX
B T1
C T2
D T3
E T4
D T3
T3 and T4 tumours can be of any size. However, if the tumour extends into the chest wall, diaphragm or the mediastinal pleura or pericardium (without involving the heart or mediastinal structures) it is a T3 tumour.
QUESTION 30 A previously fit and well 70-year-old man has a routine CXR prior to a left hip replacement. An incidental right hilar mass is noted with associated right middle lobe collapse and bulging of the oblique and horizontal fissures. Cavitation is seen within the mass and mediastinal lymphadenopathy is demonstrated on the subsequent CT examination. No calcification is demonstrated within the mass. What is the most likely diagnosis?
A Arteriovenous malformation
B Aspergilloma
C Empyema
D Sarcoidosis
E Squamous cell carcinoma
E Squamous cell carcinoma
Squamous cell carcinoma of the lung is the most common bronchogenic carcinoma to demonstrate cavitation.
QUESTION 31 A 50-year-old female patient with Cushing’s syndrome presents with a wheeze and nonresolving left lower lobe consolidation. CT reveals a calcified polypoid tumour lying external to the left main bronchus, with a smaller intraluminal component causing partial left lower lobe obstruction. Marked enhancement is seen after the administration of contrast medium. What is the most likely diagnosis?
A Bronchial carcinoid
B Bronchial chondroma
C Bronchial fibroma
D Bronchial haemangioma
E Bronchial hamartoma
A Bronchial carcinoid
Most bronchial carcinoids arise in the central airways and are often seen with collapse/consolidation of distal lung, due to bronchial obstruction.
@# QUESTION 32 A middle-aged man has recently had a CT abdomen performed for chronic lower left abdominal pain. Whilst mild sigmoid diverticular disease was present, it was also noted that there was significant para-aortic lymphadenopathy. Lymphoma was the suspected diagnosis and a chest CT was performed, prior to biopsy. “Which additional CT finding is most likely to suggest a diagnosis of non-Hodgkin’s lymphoma rather than Hodgkin’s disease?
A Isolated pulmonary consolidation
B Paramediastinal interstitial fibrosis
C Peripheral subpleural masses with a pleural effusion
D Peripheral subpleural masses without a pleural effusion
E Pulmonary consolidation with mediastinal lymphadenopathy
A Isolated pulmonary consolidation
At presentation, Hodgkin’s disease most commonly has lung parenchymal disease accompanied by intrathoracic adenopathy,
whereas isolated lung involvement is not uncommon in non-Hodgkin’s lymphoma.
Pleural effusions (unilateral) are common in both types of lymphoma, as are peripheral subpleural masses.
Consolidation with air bronchograms can also be seen in both diseases.
QUESTION 33 A confused 70-year-old man with a history of cough and some shortness of breath attends your Radiology Department for a CXR. It is noted that there are multiple discrete, spherical and well-defined pulmonary nodules with a peripheral distribution. Some calcification is noted within some of these nodules but cavitation is not evident. The accompanying nurse from the care home tells you that he has a ‘growth’ somewhere but is not sure what this is. What is the most likely primaiy tumour?
A Adenocarcinoma of the colon
B Anaplastic thyroid carcinoma
C Chondrosarcoma of the femur
D Invasive ductal carcinoma of the breast
E Squamous cell carcinoma of the oesophagus
C Chondrosarcoma of the femur
Calcified lung metastases rarely occur, except in osteosarcoma and chondrosarcoma. Even if a primary tumour displays calcification (eg breast or colonic carcinoma), the pulmonary metastases will rarely demonstrate calcification.
- A 73-year-old patient is involved in a road traffic accident (RTA) and sustains a head injury. He is intubated at the scene due to a low Glasgow Coma Scale (GCS). The patient is transferred for a CT chest as he is hypoxic. On reviewing the CT scan you note widespread emphysema, consistent with the history of smoking. He has a narrowing of the trachea, immediately inferior to the distal margin of the endotracheal (ET) tube. This narrowing is caused by an endoluminal mass associated with a circumferential area of soft tissue that extends into the paratracheal space. There is no pneumomediastinum and no other lung injury is seen. What is the most likely cause?
A. Post-intubation stenosis.
B. Tracheal papilloma.
C. Non small cell lung cancer.
D. Adenoid cystic carcinoma.
E. Squamous cell carcinoma.
- E. Squamous cell carcinoma.
Tracheal malignancies make up 1–2% of all adult intrathoracic tumours and as such are uncommon. Malignant lesions make up 90% of all tracheal malignancies. Of these, squamous cell carcinomas are the most common, presenting in elderly patients with a history of smoking.
Adenoid cystic carcinoma is the next most common, presenting in a younger age group and associated with a better prognosis. Benign lesions account for less than 10%. Non small cell lung cancer (NSCLC) would be the leading differential diagnosis if this lesion was found endobronchially, but not in the trachea. NSCLC can cause tracheal narrowing, but as an extrinsic lesion. The history is too brief for post-intubation stenosis to be considered and this is not associated with a soft tissue mass.
@# 17. A 34-year-old woman presents with a 4-month history of gradually increasing dyspnoea and cough. A CXR and subsequent CT scan show multiple cavitating lung lesions. On the CT scan, some of these lesions are noted to have surrounding ground-glass attenuation. No other abnormality is seen. Which of the following diagnoses are the fi ndings most compatible with?
A. Rheumatoid lung.
B. Lung abscesses.
C. Eosinophilic granuloma.
D. Churg–Strauss syndrome.
E. Melanoma metastases.
- E. Melanoma metastases.
The GGO surrounding a nodule is known as the ‘halo’ sign and represents perilesional haemorrhage. The differential diagnosis given rests on the presence of this feature and cavitation.
Melanoma metastases can both cavitate and produce perilesional haemorrhage.
The halo sign may also be seen in other conditions with perilesional haemorrhage or cellular infiltration and is usually best seen on HRCT. These diagnoses include bronchoalveolar carcinoma, haemorrhagic metastases, Wegener’s granulomatosis, and angio-invasive infections, such as invasive aspergillosis.
Alternative correct answers would be Wegener’s granulomatosis, lymphoma, bronchoalveolar carcinoma, and squamous cell carcinoma as these can produce both cavitating nodules and the halo sign.
Rheumatoid lung, eosinophilic granuloma, and lung abscesses are associated with cavitating nodules but not the halo sign.
Churg–Strauss syndrome is not associated with the halo sign and cavitation is rare.
- You are taking the respiratory multidisciplinary team meeting. A respiratory physician has asked you to present two patients, both with incidentally detected solitary pulmonary nodules. Patient A is a 64-year-old male patient. He is a non-smoker. The lesion is 7 mm in diameter and smooth. Patient B is also a 64-year-old male, who smokes 30 cigarettes per day. His lesion is 5 mm in diameter. What follow-up would you recommend for these patients?
A. Urgent positron emission tomography (PET) scan for both. Reassess with result.
B. CT within 6 months for Patient A. If unchanged repeat within 12 months. PET scan for Patient B and reassess with result.
C. CT scan within 12 months for Patient A. If unchanged further CT within a further 12 months. Serial 6 monthly CT scans for Patient B for 2 years.
D. CT scan within 12 months for both. If unchanged, both need a follow-up CT within a further 12 months.
E. Follow-up CT at 12 months for both. If unchanged, no further follow-up.
- D. CT scan within 12 months for both. If unchanged, both need a follow-up CT within a further 12 months.
Due to the rapid rise in the detection of solitary pulmonary nodules (SPNs) on CT, the Fleischner Society released guidelines on the follow-up of SPNs. For SPNs below 1 cm in diameter, PET is less reliable due to the small volume of tissue being examined. These guidelines simply use the size of the lesion and knowledge of the patient’s relative risk (smoker versus nonsmoker) to guide follow-up. Whilst Patient B’s lesion is smaller, it requires the same follow-up as the larger lesion found in Patient A because of his increased risk. Lesions less than 4mm in lowrisk patients do not require any follow-up; these lesions require a single CT within 12 months in high-risk patients.
- A 64-year-old smoker is referred by his GP for persisting consolidation which has failed to resolve despite multiple antibiotic therapies. Of note he has been apyrexic and inflammatory markers have not been particularly raised. The respiratory team request a CT of chest, which shows GGO and consolidation of almost the entire left lower lobe, delineated by the major fissure, which is not displaced. Air bronchograms are present, but there is no significant loss of volume or expansion of the lobe and no mediastinal or hilar adenopathy. No mass obstructing the left lower lobe bronchus (either endoluminal or extrinsic) is demonstrated and the bronchoscopy findings corroborate this (results from washings not yet available). A PET-CT is normal. What is the most likely pathology?
A. Carcinoid tumour.
B. Bronchioloalveolar carcinoma.
C. Small cell carcinoma.
D. Tuberculosis (TB).
E. Klebsiella pneumonia.
- B. Bronchioloalveolar carcinoma.
In this disease, the tumour spreads along the alveolar septa without invading alveolar walls. The air in the alveoli is replaced by tumour cells, producing consolidation and GGO.
Mediastinal lymphadenopathy is rare;
pleural effusion is common.
Diagnosis is made by sputum/bronchial washing cytology or lung biopsy. It mimics other causes of air-space opacification such as pneumonia, haemorrhage, oedema etc.
Disseminated adenocarcinoma, choriocarcinoma, or lymphoma might produce identical CT findings.
PET-CT is often negative in the case of both bronchioloalveolar carcinoma and carcinoid tumours of the lung.
Carcinoid is in the form of a focal mass, not diffuse consolidation.
Klebsiella pneumonia classically produces enlargement of the involved lobe, bulging of the fissures with the propensity for cavitation, and abscess formation. One would expect pyrexia and raised inflammatory markers, and consolidation usually produces some abnormality on PET-CT.
Small cell carcinoma is usually positive on PET-CT. TB is usually PET positive and has a predilection for the upper lobes, or apical segments of the lower lobes if the latter are involved.
- A 72-year-old female patient presents with a diagnosis lung malignancy obtained from bronchial washings. The CT shows a 4cm lesion in the right upper lobe with ipsilateral hilar and mediastinal lymphadenopathy in the 4R station. There is no chest wall invasion and the lung lesion is surrounded on all sides by lung parenchyma. There is currently no evidence of infradiaphragmatic disease. What is the TNM stage of this small cell lung cancer?
A. T2a N1 M0.
B. T2b N1 M0.
C. T1b N2 M0.
D. T2a N2 M0.
E. None of these.
- E. None of these.
The TNM staging of lung cancer is not commonly used for staging small cell lung cancer. This cell type is particularly aggressive and often has occult metastases at the time of malignancy. The mainstay of treatment is with chemoradiotherapy, with imaging only used to stage disease as intrathoracic (limited or extensive) or extrathoracic.
@# 34. A 68-year-old patient has a CXR carried out due to a recurrent chest infection. The patient is a smoker. The CXR shows a solitary pulmonary nodule. A CT is carried out which demonstrates a 2.8-cm lesion in the right lower lobe as noted on CXR. This lesion is spiculated. There is a second lesion noted in the right lower lobe that is 1.2 cm in size and was not visible on the CXR. There is a 0.8-cm ipsilateral peribronchial lymph node identified. There are no evident metastases. A PET-CT is carried out which shows an SUV max of 8 in both pulmonary lesions. There is no uptake in the lymph node. No metastases are identified. A biopsy confirms non-small cell lung cancer. Based on the available imaging, what is the stage of this lesion?
A. Stage 1A.
B. Stage 1B.
C. Stage 2A.
D. Stage 2B.
E. Stage 3A.
- D. Stage 2B.
The TNM definitions, on which the staging system is based, were recently updated in 2010. In this update, the nodal classifications were not changed, but the T staging was updated, as was M staging. Sub-classifications were added to T1,
with lesions <2 cm being T1a
and lesions between 2 and 3 cm being T1b.
Lesions between 3 and 5 cm are T2a
and between 5 and 7 cm are T2b.
Lesions over 7 cm are T3, as are synchronous lesions within the primary lobe, as in this case.
Multiple lesions within the primary lobe were formerly T4.
In this question, the lymph node is not enlarged by size criteria and is not FDG avid on PET. While this may yet still be involved, on imaging findings alone, this lesion should be classed as N0.
The absence of metastases is obviously M0. Thus this patient is T3 N0 M0, which corresponds to stage 2b.
T2b N1 tumours are also in this stage.
Stage 2a lesions are T2a N1 or T2b N0.
Stage 3a lesions are T3 or less with N2 disease or T3 N1 lesions.
- You are attending a lecture on lung cancer, but unfortunately you arrive late so you have missed the introduction. The lecturer is describing a subtype of lung cancer. The description is of a tumour that comprises 30% of all lung cancers. It typically occurs peripherally, but can be central. This tumour can cavitate, but this occurs in only 4% of cases. Hilar and/or mediastinal involvement is seen in over half of cases on plain film radiography. What subtype of lung cancer is being described?
A. Adenocarcinoma.
B. Bronchoalveolar carcinoma.
C. Squamous cell carcinoma.
D. Small cell carcinoma.
E. Giant cell carcinoma.
- A. Adenocarcinoma.
These are all classical features of adenocarcinoma.
Bronchoalveolar carcinoma is a subtype of adenocarcinoma. This comprises 2–10% of lung cancers.
There are three subtypes: a solitary nodule (41%), multifocal nodules (36%), and peripheral consolidation (23%).
Squamous cell carcinoma is only slightly less prevalent than adenocarcinoma. It cavitates in 86% of cases and typically occurs centrally.
Small cell carcinoma comprises 18% of lung cancers. It usually presents on plain film radiography as hilar and/or mediastinal adenopathy. CT often detects lung opacities.
Giant cell carcinoma is a poorly differentiated subtype of NSCLC that is capable of rapid growth and early metastasis.
- A 50-year-old female is found to have a solitary pulmonary nodule on imaging. Which of the following features suggests that it is benign?
A. Irregular, spiculated margin.
B. Central ‘popcorn’ calcification.
C. Doubling time of 180 days.
D. Contrast enhancement of 25 Hounsfield units(HU).
E. SUV of 8 on PET-CT.
- B. Central ’popcorn’ calcification.
Irregular or spiculated margin, eccentric or stippled calcification, doubling time of 20–400 days, contrast enhancement of more than 15 HU, and high uptake (SUV > 2.5) on PET-CT are all features associated with a malignant lesion. Diffuse, central nodular, and popcorn-like calcification, doubling time of more than 400 days, contrast enhancement of less than 15 HU, and low uptake (SUV < 2.5) on PET-CT are associated with benign lesions.
- A 47-year-old male patient is referred to the respiratory physicians with a 1-year history of wheeze. He is a non-smoker. A CXR reveals subtle narrowing of the bronchus intermedius. A CT scan reveals a lesion with an endobronchial component, which narrows the airway significantly. The lesion also has an extraluminal component, which is 2 cm in diameter and has smooth margins. The lesion displays stippled calcification and no cavitation. Following contrast enhancement, the lesion enhances avidly in the arterial phase. You formulate a differential diagnosis based on these imaging features. The patient is not keen for intervention. Based on your suspicions, what would be the least invasive means of follow-up imaging to help achieve a diagnosis?
A. PET-CT.
B. Bronchoscopy and biopsy.
C. Indium-111 octreotide single photon emission computed tomography (SPECT) CT.
D. MRI using T2WI and short tau inversion recovery (STIR) coronal imaging.
E. Bronchial angiography.
- C. Indium-111 octreotide SPECT–CT.
The imaging features allude to the diagnosis of bronchial carcinoid. This tends to occur in younger patients than bronchogenic carcinoma does, and is not associated with smoking. Whilst carcinoid tumours can present as a peripheral nodule, they are more typically central, hilar, perihilar, or endobronchial, as in this case. Classical features are of a smooth nodule, narrowing or compressing the bronchus, or of an endobronchial lesion. Both commonly have stippled calcification and demonstrate avid enhancement. Carcinoid tumours in this location are classed as either typical or atypical based on pathology. All the imaging options are valid. The degree of enhancement can simulate a pulmonary vascular malformation, which can be assessed with angiography, although MR angiography would be less invasive in this case. The definitive tissue diagnosis is commonly reached with bronchoscopy, but this can be associated with massive haemorrhage because of the vascular nature of this tumour. As such radiolabelled imaging, which is sensitive in 86% of patients, is a less invasive option. FDG PET is often negative in cases of carcinoid because of the low metabolic activity of this tumour. MRI characteristics of bronchial carcinoid have been well described, but will be unlikely to significantly progress the diagnostic pathway in this case.
@# (GU) 67. A 48-year-old women presents with shortness of breath and undergoes an HRCT of the chest to assess interstitial changes seen on plain film. She has emigrated from Eastern Europe and knows that she had a gynaecological cancer that was treated there, but is unsure of her treatment. The HRCT reveals unilateral thickened interlobular septa, perilymphatic nodules, and ipsilateral hilar adenopathy. What is the most likely underlying diagnosis?
A. Cervical carcinoma.
B. Ovarian epithelial carcinoma.
C. Endometrial carcinoma.
D. Leiomyosarcoma of the uterus.
E. Vaginal carcinoma.
- A. Cervical carcinoma.
This patient has developed lymphangitis carcinomatosis. In 50% of cases the septal thickening is focal or unilateral and this is useful in distinguishing lymphangitis from other causes of septal thickening, such as pulmonary oedema or sarcoidosis. Hilar adenopathy is present in 50% and pleural effusion in 30–50%. The interlobular septal thickening can be smooth (as in pulmonary oedema and alveolar proteinosis) or nodular (also found in sarcoidosis and silicosis). Lymphangitis carcinomatosis usually occurs secondary to the spread of (adeno-) carcinoma, most commonly bronchogenic, breast, and stomach. The mnemonic Certain Cancers Spread By Plugging The Lymphatics (Cervix Colon Stomach Breast Pancreas Thyroid Larynx) is useful. Lymphangitis carcinomatosis is occasionally associated with cervical carcinoma and certainly more so than with the other options presented.
@#1 26 A patient is awaiting investigation and treatment of a superficial neck mass, suspicious for non- Hodgkin’s lymphoma. Their chest radiograph shows bilateral hilar lymphadenopathy. When is the best time to perform PET CT in view of gaining a histological diagnosis and commencing treatment?
a Wait 1 week after neck dissection
b Wait 4 weeks after neck dissection
C Wait 4-6/52 after start of chemotherapy
d Within 1 week of commencing chemotherapy
e Wait 4-6 weeks after starting radiotherapy
26 Answer C: Wait 4-6/52 after start of chemotherapy
Performing PET imaging after a procedure will produce inaccurate results as traumatised tissues have an increased metabolism and will mask any adjacent uptake due to pathology. Imaging should ideally wait six weeks post surgery, one week post biopsy, six weeks post chemotherapy and six months post radiation to avoid false positive uptake. However, some tumours such as GIST can show reduced metabolic activity and hence reduced uptake as soon as 24 hours following commencement of chemotherapy where conventional imaging will appear no different for weeks.
28 A patient with a lung cancer measuring 3.5 cm in their right upper lobe 4 cm from the mediastinal structures with 1cm nodes in the right hilum and a 3-mm nodule in the right lower lobe underwent PET CT for further staging following a standard CT. The primary tumour is avid and further uptake of over 2.5 SUV is seen in the nodes of ipsilateral hilum. Further uptake is seen bilaterally in the supraclavicular region in a linear distribution although no associated soft tissue mass is seen on the corresponding diagnostic CT. The small nodule in the right lower lobe is not well visualised on PET and no uptake is seen related to it. What is the most likely TNM staging based on the PET scan?
a T1N2MO
b T2N1Mx
c T2N1M1
d T1N2Mx
e T1N1MO
28 Answer B: T2N1Mx
The satellite nodule would upstage this to M1 if positive but is too small to exclude this on PET, therefore metastatic disease cannot be accurately assessed and this should be mentioned in the report. The supraclavicular uptake sounds typical of brown fat uptake and providing there is no correlating soft tissue mass should be reported as such.
31 A 32-year-old man developed a low-grade fever and weight loss. He was previously well and had never smoked. CT shows lymphadenopathy on both sides of the diaphragm and a sample taken at mediastinoscopy showed Reed-Sternberg cells. There were no further positive findings in the rest of the thorax or abdomen. Where in the thorax is the lymphadenopathy most likely?
a Anterior mediastinum
b Middle mediastinum
C Posterior mediastinum
d Superior mediastinum
e Hilar nodes
31 Answer A: Anterior mediastinum
The Reed-Sternberg cell, although not common, is characteristic of Hodgkin’s disease (which affects T-cells). The nodular sclerosing subtype is the most common and carries a relatively good prognosis. There is a bimodal distribution with peaks in the 25-30 and 75-80 age groups. Anterior mediastinal and retrosternal nodes are more commonly involved. The presence of a pleural effusion is not of prognostic significance.
32 A 64-year-old non-smoker presents to his GP with progressive dyspnoea. His chest radiograph demonstrates a peripheral lung mass. What is the most likely histological type of carcinoma?
a Squamous cell carcinoma
b Small cell lung carcinoma
C Bronchoalveolar cell carcinoma
d Large cell carcinoma
e Adenocarcinoma
32 Answer E: Adenocarcinoma
This is simply a question of incidence. It is the most common type of lung carcinoma and is also the most common in non-smokers.
@#1 43 A 50-year-old man was admitted feeling unwell and multiple ill-defined nodules of varying sizes within both lungs were visible on his chest radiograph. These were suspected to be lung metastases. What is the most likely primary tumour?
a Testicular teratoma
b Renal cell carcinoma
c Thyroid carcinoma
d Melanoma
e Pancreatic carcinoma
43 Answer B: Renal cell carcinoma
All these tumours except pancreatic carcinoma often metastasise to the chest but renal cell carcinoma is both the most common and the most likely to present with lung metastases already present.
@#1 (Ped) 40 A 10-year-old child is diagnosed with non-Hodgkin’s lymphoma (NHL). He is found to have two single extranodal tumours on opposite sides of the diaphragm. What stage of disease does he have?
aI
b II
C III
d IV
eV
40 Answer C: III
The St Jude classification is used to stage NHL. There are four stages:
I Single extranodal tumour/single anatomic area
II
(a) Single extranodal tumour + regional nodes
(b) Two or more nodal areas on same side of diaphragm
(c) Two extranodal tumours +/nodes on same side of diaphragm
(d) Primary gastrointestinal tumour +/nodes
III
(a) Two extranodal tumours on opposite sides of diaphragm
(b) Two or more nodal areas on both sides of diaphragm
(c) Primary intrathoracic tumours
(d) Extensive primary intra-abdominal disease
(e) Paraspinal/epidural tumour
IV
Any of above + CNS/bone marrow involvement
44 A 30-year-old male presented with night sweats and weight loss. A chest radiograph revealed widening of the right paratracheal space and a CT demonstrated extensive lymphadenopathy within the thorax but no subdiaphragmatic involvement. In view of a likely diagnosis of lymphoma, what would make non-Hodgkin’s lymphoma more likely than Hodgkin’s lymphoma?
a Abnormal T-cells on lymph node biopsy
b Incidence
c Pleural effusion
d Normal chest radiograph six months previously
e Involvement of principally the hilar and subcarinal lymph nodes
44 Answer B: Incidence
Non-Hodgkin’s lymphoma is approximately eight times more common than Hodgkin’s lymphoma. Hodgkin’s lymphoma is a disease solely of T-cells as opposed to non-Hodgkin’s lymphoma which can involve T or B cells. Adenopathy most commonly involves the anterior mediastinal nodes. Pleural effusion is nondiscriminatory.
46 A 54-year-old female presented with progressive dyspnoea and diffuse pulmonary opacities on her chest radiograph. An HRCT revealed interlobular septal thickening bibasally. What further findings would suggest a diagnosis of lymphangitis carcinomatosis rather than cardiogenic pulmonary oedema?
a Nodular interlobular septal thickening
b Pleural fluid
C Ground-glass opacification
d Centrilobular nodules
e Mediastinal lymphadenopathy
46 Answer A: Nodular interlobular septal thickening
In lymphangitis carcinomatosis the interlobular septal thickening is caused by tumour infiltration and is more often irregular or nodular in appearance. The remaining features would not be unusual in either condition.
@# (Ped)46 A 12-year-old girl with known osteosarcoma of the proximal femur presents with acute shortness of breath. What is the most likely finding on CXR?
a Bilateral hilar lymphadenopathy
b Pneumothorax
C Coarsened bronchovascular markings with reticular opacities
d Bilateral lower lobe atelectasis
e Multiple cavitating nodules
46 Answer B: Pneumothorax
The rupture of subpleural metastatic nodules into the pleural space can cause spontaneous pneumothorax. Cavitating metastases classically occur in squamous cell carcinoma. Osteosarcoma lung metastases can calcify.
31 A 32-year-old man developed a low-grade fever and weight loss. He was previously well and had never smoked. CT shows lymphadenopathy on both sides of the diaphragm and a sample taken at mediastinoscopy showed Reed Sternberg cells. There were no further positive findings in the rest of the thorax or abdomen. What is the Ann Arbor stage of this disease?
a Stage I
b Stage II
C Stage III
d Stage IV A
e Stage IV B
31 Answer C: Stage III
Ann Arbor classification is most commonly used. In stage I disease, there is involvement of one or two contiguous regions on the same side of the diaphragm. In stage II disease, more than two contiguous regions are involved on the same side of the diaphragm. When there is disease on both sides of the diaphragm, it is classed as stage III. Stage IV disease indicates organ involvement. The thymus and spleen are considered a `lymph node’ in staging.
34 A 75-year-old gentleman who had worked in the construction industry had a chest radiograph prior to an elective cholecystectomy Multiple calcified pleural plaques were visible bilaterally with basal interstitial shadowing. There was also an ill-defined mass in the left lung. What is the most likely aetiology of the pulmonary tumour?
a Small cell carcinoma
b Bronchoalveolar cell carcinoma
C Squamous cell carcinoma
d Large cell carcinoma
e Aspergilloma
34 Answer B: Bronchoalveolar cell carcinoma
Lung carcinoma is more frequent in individuals with asbestos exposure (20-25% life time risk) and bronchoalveolar carcinoma is the most common subtype. Smoking further increases the risk. The risk of malignant mesothelioma is 10% over the lifetime of an asbestos worker, with a 20- to 40-year latency period.
36 A 55-year-old man presented with a persistent cough and wheeze. CT of his thorax showed a solitary 2 cm endobronchial polypoidal mass that enhanced vividly in the late arterial phase. There were no other positive findings and a PET scan showed no uptake in this lesion. What is the most likely diagnosis?
a Squamous cell carcinoma
b Rheumatoid nodule
c Carcinoid
d Metastatic nasopharyngeal carcinoma
e Bronchogenic cyst
36 Answer C: Carcinoid
Pulmonary carcinoid is a slow-growing low-grade malignant vascular tumour. It is often centrally located (70-90%). Up to one-third of these calcify but cavitation is rare. Pulmonary carcinoid rarely results in the carcinoid syndrome. It commonly shows no tracer uptake on PET imaging. It is occasionally associated with MEN type I.
@#1 37 A 78-year-old female patient had a chest radiograph that showed multiple pulmonary nodules of varying sizes in both lungs, without zonal predilection which were thought to be metastases. What is the most likely site of an underlying primary tumour?
a Breast
b Colon
c Bone
d Pancreas
e Ovary
37 Answer A: Breast
44 A 44-year-old male presented with haemoptysis and a chest radiograph was performed. A 1-cm soft-tissue-density nodule was identified projected over the right upper zone. What additional finding is most likely to suggest a malignant aetiology?
a Calcification within the nodule
b Multiple small satellite nodules surrounding the dominant nodule
C Bihilar lymphadenopathy
d Linear densities radiating from the edge of the lesion into the surrounding lung
e The presence d -a feeding and draining vessel emanating from the hilar aspect of the nodule
44 Answer D. Linear densities radiating from the edge of the lesion into the surrounding lung
Although not specific for malignancy, a spiculated margin is highly suspicious. This represents reoriented connective tissue drawn into the tumour by the cicatrising nature of many malignant tumours.
There are benign processes that can cause this appearance such as lipoid pneumonias and tuberculomas, but the remaining features are more likely to suggest a benign aetiology.
45 A 50-year-old male smoker was investigated for haemoptysis and a bronchocentric 3-cm soft tissue lesion was seen 1 cm from the carina in the left upper lobe. The maximum visible nodes were 14mm in the left hilum, a 13-mm subcarinal node in the central mediastinum and a 9-mm right hilar node. There was no further parenchymal lesion or effusion and no distant lesions were visible. What is the appropriate TNM staging?
a T2, N1, MO
b T2, N2, M0
c T2, N3, MO
d T3, N2, M0
e T3, N3, MO
45 Answer D: T3, N2, MO
The current TNM staging system is set to change in January 2010, but this answer remains correct according to the proposed revisions for the 7th edition. The new staging provides a more comprehensive breakdown of tumour size and a change in the classification of separate tumour nodules.
49 A 56-year-old female with a history of breast carcinoma presented with chest pain that was atypical for cardiac pain and she was afebrile. A chest radiograph demonstrated right upper lobe opacification adjacent to the mediastinum with a very well-defined lateral border and elevation of the right hilum. What is the most likely explanation for these findings?
a Right upper lobe pneumonia
b Lymphangitis carcinomatosis
C Scleroderma
d Radiation pneumonitis
e Chemotherapy-induced lung disease
49 Answer D: Radiation pneumonitis
The location and well-defined margin are typical of post-radiation damage to the lung. Breast cancer is routinely treated with radiotherapy.
30 A pre-employment screening chest radiograph on a 40-year-old female revealed a solitary mass in the periphery of the right upper zone. This was of fat density and `popcorn’ calcification was visible. The radiograph was otherwise normal and the patient was asymptomatic. What is the most likely diagnosis?
a Pancoast tumour
b Pulmonary hamartoma
C Tuberculoma
d Pulmonary nocardia
e Sarcoid
30 Answer B: Pulmonary hamartoma
Pulmonary hamartoma is the most common benign tumour of the lung. It is often asymptomatic and picked up incidentally on routine screening. They can be symptomatic if centrally located but the majority are peripheral. Popcorn calcification is visible in approximately 20% and fat density in half.
@# 31 A 32-year-old man developed a low-grade fever and weight loss and was found to have Hodgkin’s lymphoma with lymphadenopathy in both thorax and abdomen. Involvement of which extra-nodal site is associated with the worst prognosis?
a Pleural effusion
b Spleen
c Thymus
d Bone
e Small intestine
31 Answer E: Small intestine.
@# 36 A 55-year-old man presented with a persistent cough and wheeze. CT of his thorax showed a solitary 2-cm endobronchial polypoidal mass that enhanced vividly in the late arterial phase. There were no other positive findings and a PET scan showed no uptake in this lesion. From which artery is the blood supply to this lesion most likely to be derived?
a Pulmonary artery
b Bronchial artery
c Adjacent intercostal artery
d Internal mammary artery
e Inferior thyroid artery
36 Answer B: Bronchial artery
Pulmonary carcinoid is a slow-growing low-grade malignant vascular tumour supplied by the bronchial circulation.
(Ped) 37 A 10-year-old boy presents with a mass in the posterior triangle of the neck, night sweats and significant weight loss. The mass is biopsied under ultrasound guidance and found to be Hodgkin’s lymphoma. A staging CT shows abnormal lymph nodes within the right axilla and left cervical chain. Which of the following would be the appropriate staging?
a Stage 1A
b Stage 2A
C Stage 2B
d Stage 3A
e Stage 3B
37 Answer C: Stage 2B
The staging system for Hodgkin’s lymphoma is:
Stage 1: One group of lymph nodes involved.
Stage 2: Two or more groups of lymph nodes involved on one side of the diaphragm.
Stage 3: Lymph nodes involved on both sides of the diaphragm. The spleen may be involved.
Stage 4: Spread beyond lymph nodes to, for example, liver, lungs or bone marrow.
A: No systemic symptoms B: Night sweats, weight loss >10% or fever.
41 A 35-year-old female presented with a persistent cough and a chest radiograph was performed. This demonstrated a 2.5-cm mass in the periphery of the right lung and a subsequent CT was performed which confirmed a 2.5-cm lobulated mass in the right lower lobe with a heterogeneous appearance. A focus of low attenuation with the lesion had a density of -100 HU. What is the most appropriate course of action?
a Proceed to a staging abdominal and pelvic CT. The most likely diagnosis is metastatic adenocarcinoma
b Proceed to abdominal CT. The most likely diagnosis is a primary bronchogenic carcinoma
c Advise no further investigations necessary. The most likely diagnosis is a pulmonary hamartoma
d Advise exclusion of granulomatous disease by clinical means
e Advise review of the clinical history for evidence of hydrocarbon inhalation. The most likely diagnosis is lipoid pneumonia
41 Answer C: Advise no further investigations necessary.
The most likely diagnosis is a pulmonary hamartoma The presence of fat attenuation in a lung mass is diagnostic of a pulmonary hamartoma. Chondroid (‘popcorn’) calcification is another diagnostic feature.
42 A 69-year-old female smoker presented with dyspnoea and weight loss. A chest radiograph showed reticular densities, Kerley lines and hilar lymphadenopathy with a normal heart size. Interlobular septal thickening with nodular pattern and a right-sided pleural effusion were visible on a subsequent CT. What is the most likely diagnosis?
a Usual interstitial pneumonia
b Sarcoidosis
C Lymphangitis carcinomatosis
d Lymphoid interstitial pneumonia
e Left ventricular failure
42 Answer C: Lymphangitis carcinomatosis
Pleural involvement in usual interstitial pneumonia (UIP) and sarcoidosis is unusual. In lymphoid interstitial pneumonia (LIP) there would almost certainly be centrilobular nodules and usually cysts. It would be unusual to see Kerley A and B lines in UIP, sarcoidosis or LIP. The normal heart size, nodular appearance to the septa and lymphadenopathy all make lymphangitis carcinomatosis more likely than LVE
@# 43 An 18-year-old male was investigated for lethargy and haemoptysis. A chest radiograph revealed multiple lung nodules, which contained small irregular calcifications. Assuming these lesions to be metastases, what it the most likely underlying primary tumour?
a Pancreas
b Renal
C Prostate
d Testis
e Lung
43 Answer D: Testis
Other primary malignancies causing calcification within metastases include breast, colon (mucinous adenocarcinoma), osteosarcoma and ovarian.
44 A 56-year-old female with cough and dyspnoea was noted to have a calcified lung nodule on chest radiography. What pattern of calcification would make malignancy more likely?
a Completely calcified lesion
b Multiple small foci of calcification
C Concentric calcification
d Central calcification
e Popcorn calcification
44 Answer B: Multiple small foci of calcification
Particularly adenocarcinomas that produce mucin can demonstrate multiple small foci of calcification.
Popcorn calcification is diagnostic of a pulmonary hamartoma,
complete or central calcification is seen in healed granulomas
and concentric calcification is also indicative of granulomas.
- A 55-year-old woman presents with left-sided ptosis and shoulder pain. The chest radiograph shows a mass in the left lung apex. CT confirms a large superior sulcus tumour eroding through the posterior chest wall and rib.
What is the most likely diagnosis?
(a) Adenocarcinoma
(b) Squamous cell carcinoma
(c) Small cell undifferentiated carcinoma
(d) Undifferentiated large cell carcinoma
(e) Scar carcinoma
- (b) Squamous cell carcinoma
Superior sulcal tumours are frequently squamous cell carcinomas. They may lead to atrophy of muscles secondary to brachial plexus involvement or/and Horner’s syndrome secondary to involvement of sympathetic chain and stellate ganglion
- A 64-year-old non-smoker presents with right chest pain and cough. CT shows a 3 cm spiculated mass in the right upper lobe, abutting the lateral chest wall. The likely histology is expected to be?
(a) Adenocarcinoma
(b) Squamous cell carcinoma
(c) Small cell undifferentiated carcinoma
(d) Undifferentiated large cell carcinoma
(e) Oat cell cancer
- (a) Adenocarcinoma
Adenocarcinoma is the most common type associated with non-smokers and is usually seen in the periphery.
Squamous cell carcinoma, small cell undifferentiated type and undifferentiated large cell cancers are strongly associated with smoking.
- A 35-year-old male smoker with cough shows a 3 cm mass in the right upper lobe. CT confirms the well-defined lesion with smooth margins and calcification an identifies few non-specific lymph nodes in mediastinum. PET–CT shows minimaluptake with SUV < 1.5. What is the most likely diagnosis?
(a) Hamartoma
(b) Consolidation
(c) Bronchogenic carcinoma
(d) Metastasis
(e) Scarring
- (a) Hamartoma
This is the most common benign tumour of the lung. It commonly contains calcification and fat (diagnostic). On a PET scan, hamartomas usually show poor uptake while the other listed conditions may show high uptake on PET.
- A 55-year-old man had a left pneumonectomy for bronchogenic carcinoma. 10 days later, a chest radiograph shows that approximately 50% of the pneumonectomy space is filled with fluid and there is an air-fluid level. What is the most likely diagnosis?
(a) Bronchopleural fistula
(b) Empyema
(c) Normal evolution of pneumonectomy space
(d) Chylothorax
(e) Post-pneumonectomy syndrome
- (c) Normal evolution of pneumonectomy space
After 7–10 days, approximately half to two-thirds of the pneumonectomy space fills up with fluid.
Complete filling with fluid is seen in 2–4 months.
A small amount of air may be seen indefinitely.
Post-pneumonectomy syndrome is seen after 1 year.
Bronchopleural fistula should be considered if there is persistent pneumothorax or if the air–fluid level drops by > 2 cm or there is reappearance of air in a previously opacified pneumonectomy space.
- A 46-year-old woman with a history of breast cancer presents with persistent cough. The chest radiograph shows reticular shadowing in the left lower zone. HRCT shows diffuse septal thickening and nodularity in the left lower lobe.
What is the most likely diagnosis?
(a) Heart failure
(b) Lymphangitic carcinomatosis
(c) Sarcoidosis
(d) Amyloidosis
(e) Respiratory bronchiolitis
- (b) Lymphangitic carcinomatosis
Given the history of malignancy, septal thickening with septal nodularity is suggestive/suspicious of lymphangitic carcinomatosis.
@# 43. A 62-year-old man with known primary malignancy presents with haemoptysis. Chest radiograph shows a cavitating lesion in the left mid zone. Which is the least likely diagnosis?
(a) Carcinoma of the colon
(b) Melanoma
(c) Transitional cell carcinoma of the bladder
(d) Carcinoma of the prostate
(e) Squamous cell carcinoma of the lung
- (d) Carcinoma of the prostate
The rest of the tumours are all common causes of cavitating metastatic lesions.
- A 36-year-old man presents with cough and haemoptysis. The chest radiograph demonstrates a 4 cm mass lesion in right upper lobe with calcifications. CT-guided biopsy shows that the lesion is malignant. What is the most unlikely primary?
(a) Osteosarcoma femur
(b) Thyroid carcinoma
(c) Testicular primary
(d) Carcinoma colon
(e) Lymphoma
- (e) Lymphoma
Lymphoma lesions do not usually show calcifications unless there is a history of treatment with radiation. The rest of the tumours listed can present with calcifying lung metastatic deposits.
- When a solitary pulmonary nodule is seen on computed tomography (CT), which of the following radiological features suggested it is benign? (T/F)
(a) Amorphous calcification within the nodule.
(b) Air bronchograms within the nodule.
(c) CT attenuation of – 10 Hounsfield units (HU).
(d) Lobulated outline of the nodule.
(e) Enhancement of the nodule by less than 15 HU following intravenous contrast.
Answers:
(a) Not correct
(b) Not correct
(c) Correct
(d) Not correct
(e) Correct
Explanation:
Popcorn type calcification indicated benignity and is typical of hamartoma.
Amorphous calcification is seen in upto7% of lung carcinomas.
Air bronchograms may be seen within a tumour mainly bronchoalveolar carcinoma.
Lobulated outline and corona radiate on CT are typical of carcinoma
- The following statements regarding pulmonary hamartomas are correct: (T/F)
(a) 5-10% undergo malignant transformation.
(b) Calcification is seen in 30-35%
(c) 80% are located endobronchially.
(d) Central fat density is identified on Ct imaging.
(e) 95% are identified in patients over 40 years.
Answers:
(a) Not correct
(b) Correct
(c) Not correct
(d) Correct
(e) Correct
Explanations:
Pulmonary hamartomas are purely benign lesions with 90% presenting as intrapulmonary lesions within 2 cm of the pleura. Less than 10% of lesions are endobronchial.
- Which of the following are correct regarding squamous cell carcinoma (SCC) at the lung: (T/F)
(a) Is the commonest long tumour to cavitate.
(b) Has the highest incidence of distant metastases.
(c) Is the most likely cell type to cause a Pancoast tumour.
(d) Is the most likely cell type to cause superior venous obstruction.
(e) Is most often centrally located.
Answers:
(a) Correct
(b) Not correct
(c) Correct
(d) Not correct
(e) Correct
Explanation:
Lung SCC has lowest chances of distant metastasis.
Small cell carcinoma is most likely to cause superior venous obstruction.
@# 42. Which of the following are correct concerning lymphoma: (T/F)
(a) Lymph node calcification occurs.
(b) Hodgkin’s disease is more common in the chest than non-Hodgkin’s disease.
(c) Posterior mediastinal lymph nodes favour lymphoma rather than Sarcoidosis.
(d) Intrapulmonary lymphoma can present with massive pneumonia – like lobar infiltrates.
(e) Miliary nodules can be the presenting appearance on chest X-Ray.
Answers:
(a) Correct
(b) Correct
(c) Not correct
(d) Correct
(e) Correct
Explanation:
In lymphoma anterior mediastinal lymph nodes are seen.
- The following statements regarding alveolar cell carcinoma are correct: (T/F)
(a) Air bronchograms are a feature of both forms.
(b) Growth is rapid.
(c) It is associated with underlying pre-existing lung fibrosis.
(d) The diffuse pneumonic form is commoner than the local mass form.
(e) It is usually located subpleurally.
Answers:
(a) Correct
(b) Not correct
(c) Correct
(d) Not correct
(e) Correct
Explanation:
Doubling time of alveolar cell carcinoma is longer than 18 months, thus slow growing.
Local mass form is more common. Pneumonic form accounts for 10% - 40 %.?
@#1 48. The following statements regarding lymphangitis carcinomatosis are correct: (T/F)
(a) Chest X-Ray appearances are of multiple reticulonodular opacities.
(b) It is associated with gastric cancer.
(c) Kerley A and B lines are seen.
(d) Radiological changes usually precede symptom onset.
(e) Hilar adenopathy is seen in 80-90%
Answers:
(a) Correct
(b) Correct
(c) Correct
(d) Not correct
(e) Not correct
Explanation:
Lymphangitis carcinomatosis presents with shortness of breath before radiological changes.
Hilar adenopathy is seen in 20% - 50%.
