1. Lung Cancer Case Studies
Danielle Aument, PA & Oriane Longerstaey, MD
Departments of Cardiac Surgery & Emergency Medicine
Carolinas Medical Center
Atrium Health
Michael Gibbs, MD
Chest X-Ray Mastery Project™
Lead Editor
Jefferey Hagen, MD
Jaspal Singh, MD
Guest Editors

2. Disclosures
• This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
• The goal is to promote widespread mastery of CXR interpretation.
• There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
• Many are providing cases and these slides are shared with all contributors.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
disease state at hand: PRIMARY & METASTATIC LUNG CANCER.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. It’s All About The Anatomy!

6. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

7. Routine
Preoperative
CXR.

8. CXR Findings Can Be Subtle!
Routine
Preoperative
CXR.
Pulmonary
Nodule

9. Pulmonary Nodule
Routine Preoperative CXR.

10. Evaluation Of Pulmonary Nodules

11. Pulmonary Nodules
• Solid or subsolid lesions that is < 3cm, well defined, and completely
surrounded by pulmonary parenchyma.
• Lesions >3 cm are considered “masses.”
• Can represent benign or malignant disease.
• Annual incidence in the U.S. ∼1.6 million

12. Benign Pulmonary Nodules Malignant Pulmonary Nodules
Infectious – endemic fungi, mycobacteria,
Abscess forming bacteria (S. aureus)
Benign tumors – pulmonary hamartomas,
fibromas, pneumocytoma (pulmonary
sclerosing hemangioma)
Vascular – pulmonary AV malformations,
pulmonary infarcts, pulmonary
contusion/hematoma
Inflammatory – granulomatosis with
polyangiitis, RA, sarcoidosis, amyloidosis
Primary lung cancer
NSCLC – adenocarcinoma, squamous cell
carcinoma, large cell carcinoma, SCLC
Metastatic cancer
Malignant melanoma, sarcoma, carcinoma of
bronchus/colon/breast/kidney/testes/ovary
Carcinoid tumors

13. Risk Factors For Malignancy
• Increased age:
• 35-39 years of age – 3% risk
• >50 years of age - >50% risk of the nodule being malignant
• Other risk factors:
• SMOKING
• Exposure to cigarette smoke
• Emphysema
• Prior malignancy
• Asbestos exposure

14. Incidence Of Primary Lung Cancer
• Leading cause of cancer deaths worldwide in both men and women
• Non-small cell lung cancer (NSCLC) is 85% of lung cancers
• Small cell lung cancer (SCLC) is next most common
Primary Lung Cancer
Non-Small Cell Lung Cancer
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Small Cell Lung Cancer

15. Clinical Presentation
• Most patients present due to incidental findings on imaging or from
screening.
• ALWAYS suspect lung cancer in smoker with new onset cough or
hemoptysis
Most Common Symptoms
Cough 50-75%
Hemoptysis 25-50%
Dyspnea 25%
Chest Pain 20%

16. Initial Imaging
High-quality chest X-ray first:
CXR Findings Suggestive Of Cancer
New or enlarged focal lesion
Pleural effusion
Pleural nodularity
Enlarged hilar or paratracheal lymph nodes
Post-obstructive pneumonia

17. Initial Imaging
Size matters!
Pulmonary Nodule <8 mm Pulmonary Nodule >8 mm
• If the patient lacks other malignancy
risk factors, these can be monitored
with serial imaging.
• Frequency of imaging depends on
size (larger more frequent).
• The probability of malignancy must
be determined.
• Assess risk factors for lung cancer.

18. Probability Of Malignancy
The American College of Chest Physicians Clinical Practice Guideline
suggests using clinical judgment parameters or a validated model to
estimate the pretest probability of malignancy in indeterminant
nodules >8 mm.
Parameters
Patient age
Size and characteristics of nodule
Patient presentation
History of previous cancer

19. Mayo Clinic Predictive Model
Most commonly used model that uses 6 independent factors:
Smoking history
Older age
Nodule diameter
Upper lobe location
Spiculation present
Extra-thoracic cancer1
< 2% 2 – 20% > 70%
Very low post-
test probability
Lower post-test
probability
Higher post-test
probability
Watchful
waiting
Biopsy Surgical
intervention
1More than 5 years before nodule detection.

20. Lung Cancer Staging
Clinical Staging
• Multidisciplinary process
• Based on clinical, laboratory,
and radiographic data
Surgical-Pathologic Staging
• Clinical staging PLUS
• Histopathological data found
after biopsy

21. Radiologic Staging
Determine The Highest Radiographic Stage Prior To Biopsy  This Will Leads To A
Biopsy Technique That Optimizes Tissue Sampling For Diagnosis.
Computed Tomography:
• CT chest with contrast
• CT upper abdomen - liver, adrenal glands
• CT of other sites of possible metastasis
PET CT:
• Provides non-invasive assessment of tumor size, lymph node enlargement,
and metastasis (T, N, M)
• Deemed more accurate in detection of unsuspected pleural and extra-
thoracic metastases than conventional scanning (CT, bone scan, etc.)
MRI:
• Indicated for patients with suspected metastasis to the brain

22. Options For Biopsy
Cytopathologic Sampling
• Thoracentesis appropriate in patients with suspected malignant effusions
• Fine need aspiration appropriate distant metastatic tissue
Histopathologic Sampling: Endobronchial Ultrasound Directed Sampling (EBUS)
• Emerging as a common modality for NSCLC
• Efficient and effective for central lesions and mediastinal lymph nodes
• Results can be inconclusive
Surgical Sampling
• Highest quality tissue sample
• Can be curative in patients with lower clinical stage, peripheral disease

23. TNM Staging
• Staging is essential and provides insight into prognosis and treatment
options.
• 2018 8th Edition of the American Joint Commission on Cancer TNM
staging system for non-small cell lung cancer.
• Staging of primary lung malignancy based on TNM
• T: characteristics of primary tumor
• N: lymph node involvement
• M: metastasis status

24. For Additional Information On Lung
Cancer Staging And Treatment
Options, Please See the Appendix
That Is Included At The End Of This
Presentation.
Now Let’s Do Some More CXR Cases!

25. 81-Year-Old With
Cough And Fever

26. 81-Year-Old With
Cough And Fever
RUL Density

27. 81-Year-Old With
Cough And Fever
Chest CT Suggests Bronchogenic Carcinoma

28. 63-Year-Old Male
Sharp Right Sided
Chest Pain

29. 63-Year-Old Male
Sharp Right Sided
Chest Pain
Right Upper Lobe Pleural Based Mass

30. Right Upper Lobe Pleural Based Mass
63-Year-Old Male
With Sharp Right
Sided Chest Pain.

31. Right Upper Lobe Pleural Based Mass
Rib Destruction
The Likely
Cause Of Pain
63-Year-Old Male
With Sharp Right
Sided Chest Pain.

32. 79 Year Old Male
Smoker Presents
With Cough And
Two Weeks Of Right
Sided Chest Pain.
Chest X-Ray From Today: What Do You See?

33. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest.
The Lateral View Is Helpful

34. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest.
The Lateral View Is Helpful
This Looks Like A Round Mass

35. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest.
The Lateral View Is Helpful
This Looks Like A Round Mass
Is This Fluid, A Mass, Or Both?

36. Right Lung Mass + Effusion + Metastasis To The Chest Wall [*].
*
*
Pathology
Non-Small Cell Lung Cancer

37. Metastatic Disease Involving The Lungs
• Breast
• Colon
• Melanoma
• Gynecologic malignancies
• Kidney
• Testes

38. 60-Year-Old With
Metastatic Ovarian
Cancer.

39. 60-Year-Old With
Metastatic Ovarian
Cancer.
Metastases To RUL + Bilateral Malignant Left Pleural Effusions.

40. 70-Year Old With
Ovarian Cancer
Receiving
Chemotherapy
Presents With
Fever.

41. 70-Year Old With
Ovarian Cancer
Receiving
Chemotherapy
Presents With
Fever.
Diffuse Metastatic Disease

42. 70-Year Old With
Ovarian Cancer
Receiving
Chemotherapy
Presents With
Fever.
Diffuse Metastatic Disease

43. 65 Year Old With
Renal Cell
Carcinoma
Presents With
Three Weeks Of
Progressive
Dyspnea.

44. Left Upper Lobe Metastasis
65 Year Old With
Renal Cell
Carcinoma
Presents With
Three Weeks Of
Progressive
Dyspnea.

45. Left Upper Lobe Metastasis
65 Year Old With
Renal Cell
Carcinoma
Presents With
Three Weeks Of
Progressive
Dyspnea.

46. 75-Year-Old With Metastatic Melanoma – CXR Today

47. 75-Year-Old With Metastatic Melanoma – CXR Today
Multiple New Metastases

49. Metastatic Round Cell Cancer
*
*
*
*
*

50. 30-Year-Old With One Month Of Shortness Of Breath

51. 30-Year-Old With One Month Of Shortness Of Breath

52. But What Is This Density?
Is It An Effusion?
30-Year-Old With One Month Of Shortness Of Breath

53. 30-Year-Old With
One Month Of
Shortness Of
Breath.
Subsequently
Diagnosed With
Testicular Cancer.
Large Pleural-Based Mass

54. 67-Year-Old With
History Of
Uterine Cancer.
She Is Now Short
Of Breath

55. Uterine Cancer Metastases – Entire Left
Hemithorax + Right Lung Lesion
67-Year-Old With
History Of
Uterine Cancer.
She Is Now Short
Of Breath

56. Uterine Cancer Metastases – Entire Left
Hemithorax + Right Lung Lesion
67-Year-Old With
History Of
Uterine Cancer.
She Is Now Short
Of Breath

57. 43 Year Old With
3 Weeks Of
Progressive Right
Arm & Neck
Swelling.

58. 43 Year Old With
3 Weeks Of
Progressive Right
Arm & Neck
Swelling.
What Is
This?

59. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling.
Lung
Mass
Compressed
Superior
Vena Cava
Superior Vena Cava Syndrome

60. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling.
Lung
Mass
Compressed
Superior
Vena Cava
Biopsy = Melanoma.

63. Superior Vena Cava Syndrome
Anatomy And Physiology:
• Obstruction by the superior vena cava caused by either extrinsic
compression, i.e.: masses in the middle and anterior mediastinum
(tumor, infectious process, adenopathy, aortic aneurysm…), or
intrinsic obstruction, i.e.: thrombosis.
• Collateral flow to the inferior vena cave or azygous vein is established.
• Edema of the head, neck and upper extremities results.
• The severity of symptoms depends on the degree of obstruction and
the speed of onset.

65. Superior Vena Cava Syndrome
Etiologic Factors:
Overall
Thrombosis And Non-Malignant Causes
Increased use of catheters and pacemakers
35%
Malignant Causes
Non-small cell lung cancer
Small-cell lung cancer
Lymphoma
Metastatic
Cancer
50%
25%
10%
10%
65%

67. Superior Vena Cava Syndrome
Anatomic Swelling:
Edema Manifestations
Scalp/Face/Arms Physically striking but usually of little
consequence
Eyes Visual symptoms
Brain Headaches, confusion, encephalopathy
Larynx Stridor, hoarseness, airway obstruction

69. 68 Year Old With A History Of Breast Cancer Presents With Dyspnea
Today One Year Ago

70. 68 Year Old With
A History Of
Breast Cancer
Presents With
Dyspnea
Malignant Pleural Effusion

71. 63-Year-Old With
Metastatic Breast
Cancer

72. 63-Year-Old With
Metastatic Renal
Cell Cancer
Malignant Left Pleural Effusion

73. 55-Year-Old With A Past History Lung Cancer Presents With Increasing Shortness Of Breath

74. 55-Year-Old With A Past History Lung Cancer Presents With Increasing Shortness Of Breath
Prior CXR: Right Hilar Mass + RUL Density
RUL
Density

75. 55-Year-Old With A Past History Lung Cancer Presents With Increasing Shortness Of Breath

76. 55-Year-Old With A Past History Lung Cancer Presents With Increasing Shortness Of Breath
Current CXR: New Malignant Right Pleural Effusion
New (Malignant)
Pleural Effusion

77. 72-Year-Old With Metastatic Breast Cancer

78. 72-Year-Old With Metastatic Breast Cancer
Malignant Right Pleural Effusion

79. Lung Mass With Malignant Effusion

80. Lung Mass After Effusion Drainage

82. Light’s Criteria
Transudate Versus Exudate1,2
Pleural Fluid Protein/Plasma Protein >0.5
Pleural Fluid LDH/Plasma LDH >0.6
Pleural Fluid LDH >200 IU
1In patients with heart failure on diuretics, Light’s Criteria may misclassify a
transudate as an exudate up to 25% of the time.
2In heart failure patients, a serum protein 3.1 g/dl higher than the pleural fluid,
or a serum albumen 1.2 g/dl higher than the pleural fluid will help correctly
identify a transudate.

85. Malignant Effusions
• The second most common exudative effusions are those associated
with underlying malignancy
• The majority of malignant pleural effusions arise from lung cancer,
breast cancer, and lymphoma
• The presence of a malignant pleural effusion is associated with higher
mortality and significantly shorter survival

87. APPENDIX: Lung CancerTNM Staging
• Staging is essential and provides insight into prognosis and treatment
options.
• 2018 8th Edition of the American Joint Commission on Cancer TNM
staging system for non-small cell lung cancer.
• Staging of primary lung malignancy based on TNM
• T: characteristics of primary tumor
• N: lymph node involvement
• M: metastasis status

90. Staging Of SCLC
Most commonly classified in two stages: Limited and Extensive
Limited Stage Extensive Stage
• Tumor confined to ipsilateral hemithorax
• Regional nodes able to be included in a
single radiotherapy port
• Corresponds with TNM stages I through
IIIB
• Tumor extends beyond the ipsilateral
hemithorax
• Distant metastasis
• Malignant pericardial or pleural effusion
• Contralateral supraclavicular and/or
hilar involvement

91. Treatment Options for Malignant
Pulmonary Nodules

92. Small Cell Lung Cancer Treatment
• 90% of patients present with local and distant metastasis
• Very responsive to chemotherapy
Limited Stage Extensive Stage
• Combination chemotherapy and
radiation
• Rarely undergo surgery EXCEPT when
they have a single nodule without
metastasis or lymph node involvement
• Chemotherapy initially
• Radiation therapy may be beneficial in
patients with both a complete or partial
response to chemotherapy
Prognosis: 10-13% 5-year survival Prognosis: 1-3% 5-year survival

93. Non-Small Cell Lung Cancer Treatment
Surgical resection is the gold standard and can be curative1
I II III IV
• Complete surgical
resection when
possible
• Radiation in non-
surgical candidates
• Complete surgical
resection when
possible
• Post-op Adjuvant
chemotherapy may
improve survival
• Radiation in non-
surgical candidates
• Combination radiation
and chemotherapy
• Can be followed by
surgical therapy
• Systemic therapy or
palliation
• Chemotherapy,
immunotherapy
• Palliative surgery
and/or chemotherapy
1Patients may have ”resectable” cancer but may not be operative candidates due to poor pulmonary function and/or
comorbidities.

94. Surgical Options
• Approach to surgery:
• Open thoracotomy
• Video Assisted Thoracoscopic Surgery (VATS)
• Robotic Assisted Thoracoscopic Surgery
• Types of resections:
• Wedge resection
• Segmentectomy
• Lobectomy
• Pneumonectomy

95. Additional References
Moyer, V, A., U.S. Preventative Services Task Force. Screening for Lung Cancer: U.S. Preventative Services Task Force Recommendation
Statement. Annals of Internal Medicine, 160(5):330-338.
Tanner et al. (2017). Physician Assessment of Pretest Probability of Malignancy and Adherence with Guidelines for Pulmonary Nodule
Evaluation. Chest, 152(2): 263-270.
Neifield, J., Michaelis, L., Doppman, J. 1977. Suspected pulmonary metastases: correlation of chest x-ray, whole lung tomograms, and
operative findings. Cancer, 39(2): 383-387.
Gould. M., et al. 2013. Evaluation of individuals with pulmonary nodules: with is it lung cancer? Diagnosis and management of lung
cancer, 3rd et: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 243(5): e93-e120.
Allen, M., et al. 1993. Video-assisted thoracoscopic stapled wedge excision for indeterminate pulmonary nodules. Journal of Thoracic
and Cardiovascular Surgery, 106(6): 1048-1052.
Kumar, R., et al. 2004. 18F-FDG PET in evaluation of adrenal lesions in patients with lung cancer. Journal of Nuclear Medicine, 45(12):
1058-1062.
Swensen S. et al. 1999. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clinic Proceedings, 74(4): 319-
329.
McMahon H., et al. 2017. Guidelines for management of Incidental Pulmonary Nodules Detected on CT Images: From Fleischner
Society 2017. Radiology, 284(1): 228j-243.

96. If You Have Interesting Cases Of Lung Cancer, We Invite You
To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!