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EMGuideWire's Radiology Reading Room: Lung Cancer

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Lung Cancer Case Studies
Danielle Aument, PA & Oriane Longerstaey, MD
Departments of Cardiac Surgery & Emergency Medicine
...

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Disclosures
• This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Prog...

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Process
• Many are providing cases and these slides are shared with all contributors.
• Contributors from many Carolinas M...

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EMGuideWire's Radiology Reading Room: Lung Cancer

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Lung Cancer and is brought to you by Oriane Longerstaey, MD and Danielle Aument, PA. Special Guest Editors are Jeffrey Hagen, MD and Jaspal Singh, MD.

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Lung Cancer and is brought to you by Oriane Longerstaey, MD and Danielle Aument, PA. Special Guest Editors are Jeffrey Hagen, MD and Jaspal Singh, MD.

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EMGuideWire's Radiology Reading Room: Lung Cancer

  1. 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. 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. 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. 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. It’s All About The Anatomy!
  6. 6. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  7. 7. Routine Preoperative CXR.
  8. 8. CXR Findings Can Be Subtle! Routine Preoperative CXR. Pulmonary Nodule
  9. 9. Pulmonary Nodule Routine Preoperative CXR.
  10. 10. Evaluation Of Pulmonary Nodules
  11. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 25. 81-Year-Old With Cough And Fever
  26. 26. 81-Year-Old With Cough And Fever RUL Density
  27. 27. 81-Year-Old With Cough And Fever Chest CT Suggests Bronchogenic Carcinoma
  28. 28. 63-Year-Old Male Sharp Right Sided Chest Pain
  29. 29. 63-Year-Old Male Sharp Right Sided Chest Pain Right Upper Lobe Pleural Based Mass
  30. 30. Right Upper Lobe Pleural Based Mass 63-Year-Old Male With Sharp Right Sided Chest Pain.
  31. 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. 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. 33. 79 Year Old Male Smoker Presents With Cough And Two Weeks Of Right Sided Chest. The Lateral View Is Helpful
  34. 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. 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. 36. Right Lung Mass + Effusion + Metastasis To The Chest Wall [*]. * * Pathology Non-Small Cell Lung Cancer
  37. 37. Metastatic Disease Involving The Lungs • Breast • Colon • Melanoma • Gynecologic malignancies • Kidney • Testes
  38. 38. 60-Year-Old With Metastatic Ovarian Cancer.
  39. 39. 60-Year-Old With Metastatic Ovarian Cancer. Metastases To RUL + Bilateral Malignant Left Pleural Effusions.
  40. 40. 70-Year Old With Ovarian Cancer Receiving Chemotherapy Presents With Fever.
  41. 41. 70-Year Old With Ovarian Cancer Receiving Chemotherapy Presents With Fever. Diffuse Metastatic Disease
  42. 42. 70-Year Old With Ovarian Cancer Receiving Chemotherapy Presents With Fever. Diffuse Metastatic Disease
  43. 43. 65 Year Old With Renal Cell Carcinoma Presents With Three Weeks Of Progressive Dyspnea.
  44. 44. Left Upper Lobe Metastasis 65 Year Old With Renal Cell Carcinoma Presents With Three Weeks Of Progressive Dyspnea.
  45. 45. Left Upper Lobe Metastasis 65 Year Old With Renal Cell Carcinoma Presents With Three Weeks Of Progressive Dyspnea.
  46. 46. 75-Year-Old With Metastatic Melanoma – CXR Today
  47. 47. 75-Year-Old With Metastatic Melanoma – CXR Today Multiple New Metastases
  48. 48. Metastatic Round Cell Cancer * * * * *
  49. 49. 30-Year-Old With One Month Of Shortness Of Breath
  50. 50. 30-Year-Old With One Month Of Shortness Of Breath
  51. 51. But What Is This Density? Is It An Effusion? 30-Year-Old With One Month Of Shortness Of Breath
  52. 52. 30-Year-Old With One Month Of Shortness Of Breath. Subsequently Diagnosed With Testicular Cancer. Large Pleural-Based Mass
  53. 53. 67-Year-Old With History Of Uterine Cancer. She Is Now Short Of Breath
  54. 54. Uterine Cancer Metastases – Entire Left Hemithorax + Right Lung Lesion 67-Year-Old With History Of Uterine Cancer. She Is Now Short Of Breath
  55. 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. 56. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling.
  57. 57. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling. What Is This?
  58. 58. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling. Lung Mass Compressed Superior Vena Cava Superior Vena Cava Syndrome
  59. 59. 43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling. Lung Mass Compressed Superior Vena Cava Biopsy = Melanoma.
  60. 60. 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.
  61. 61. 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%
  62. 62. 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
  63. 63. 68 Year Old With A History Of Breast Cancer Presents With Dyspnea Today One Year Ago
  64. 64. 68 Year Old With A History Of Breast Cancer Presents With Dyspnea Malignant Pleural Effusion
  65. 65. 63-Year-Old With Metastatic Breast Cancer
  66. 66. 63-Year-Old With Metastatic Renal Cell Cancer Malignant Left Pleural Effusion
  67. 67. 55-Year-Old With A Past History Lung Cancer Presents With Increasing Shortness Of Breath
  68. 68. 55-Year-Old With A Past History Lung Cancer Presents With Increasing Shortness Of Breath Prior CXR: Right Hilar Mass + RUL Density RUL Density
  69. 69. 55-Year-Old With A Past History Lung Cancer Presents With Increasing Shortness Of Breath
  70. 70. 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
  71. 71. 72-Year-Old With Metastatic Breast Cancer
  72. 72. 72-Year-Old With Metastatic Breast Cancer Malignant Right Pleural Effusion
  73. 73. Lung Mass With Malignant Effusion
  74. 74. Lung Mass After Effusion Drainage
  75. 75. 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.
  76. 76. 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
  77. 77. 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
  78. 78. 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
  79. 79. Treatment Options for Malignant Pulmonary Nodules
  80. 80. 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
  81. 81. 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.
  82. 82. Surgical Options • Approach to surgery: • Open thoracotomy • Video Assisted Thoracoscopic Surgery (VATS) • Robotic Assisted Thoracoscopic Surgery • Types of resections: • Wedge resection • Segmentectomy • Lobectomy • Pneumonectomy
  83. 83. 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.
  84. 84. 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!

Editor's Notes

  • Size plays a predominant role in the T category; as well as invasion into adjacent mediastinal or peripheral structures
    N category yis determined by the location of involved nodes
    M category depends on location and extend of metastasis
    In all of these categories if it’s either bigger, if there’s more, or if it is further away from the primary tumor, then it is higher in the category and carries a worse prognosis

  • - Once you get to the M category, if there is any metastasis, the cancer is considered stage IV
  • In 2013, the American College of Chest Physicians cam eout with the 3rd edition of evidence-based clinical practice guidelines for diagnosis and management of lung cancer; in this article they made this statement: “individual with pulmonary nodules should be evaluated and managed by estimating the probability of malignancy, performing imaging tests to better charactewrize the lesions, evaluating the risks associated with various management alternatives, and eliciting their preference sfor management”
    Basically, they are saying that the treatment of these patients involves several factors and requires deliberate and comprehensive patient education and patient involvement in the decision making process.

    It is important to remember that the treatments for these types of cancer are not black and white. Literature is always changing and patient preferences and values highly impact the decisions made

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