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).