LUNG CANCER XRAYS

1. CHEST X-RAY
LUNG CANCER

2. Lung cancer - Mass
•Image shows a very large rounded mass filling the upper zone of the right lung
•Whenever there is an abnormal area of shadowing (increased
density/whiteness) in the lungs, the diagnosis of infection or cancer should be
considered likely causes

3. Lung cancer - consolidation
•This X-ray shows an area of air-space shadowing (consolidation)
•This appearance can be due to either infection or cancer - an X-ray cannot
determine the difference
•Further investigation with CT and bronchoscopy found a primary lung
malignancy in this case

4. Hilar mass and effusion
•The right hilum is grossly abnormal in this image - compare with the left side where
the normal vascular structures of the hilum are clearly defined
•The mediastinum is widened due to enlargement of lymph nodes immediately to the
right of the trachea - the right paratracheal stripe is no longer visible
•Blunting of the right costophrenic angle and formation of a ‘meniscus’ are typical
features of a pleural effusion
•Lung cancer was confirmed following bronchoscopy and biopsy

5. Cavitated lung mass
•Lung cancers may initially form a solid mass and then cavitate internally due to
cell necrosis
•Squamous cell lung cancer is the cell type most likely to cavitate - as was
confirmed in this patient following biopsy
•Lung cavities can be caused by diseases other than cancer - such as infection
or vasculitis

6. Cavitated lung mass - Coronal plane CT
•(Same patient as image above)
•CT clearly shows formation of cavities within the mass

7. Right upper lobe collapse
•Dense shadowing at the right upper zone is due to collapse of the right upper lobe
•The horizontal fissure (white dotted line) is raised from its normal position (red
line) because of volume loss of the collapsed right upper lobe
•The contour of the obstructing mass is visible and it causes the horizontal fissure
to appear S-shaped
•This is the 'Golden S' sign - a sign highly predictive of lung cancer obstructing the
right upper lobe bronchus

8. Left upper lobe collapse
•There is a veil-like appearance of the left lung
•The aortic knuckle remains well-defined due to the adjacent left lower lobe which
remains full of air and interposes the collapsed upper lobe and the aortic arch
•The left heart border is obscured and the left hemidiaphragm is raised indicating lung
volume loss
•These are the typical appearance of left upper lobe collapse
•A mass which is just visible at the left hilum is causing collapse of the left upper lobe

9. Phrenic nerve palsy - Image 1
•As lung cancers grow there is an increasing risk of complications due to
invasion of surrounding tissues
•This image shows a small mass (nodule) near the right hilum
•Note the normal position of the right hemi-diaphragm

10. Phrenic nerve palsy - Image 2
•The patient was not suitable for surgery and other treatment eventually failed
- the mass continued to grow
•This image (18 months after the image above) shows the mass has reached
the hilum and right heart border
•The raised position of the right hemidiaphragm indicates phrenic nerve palsy -
paralysis of the diaphragm due to invasion or compression of the phrenic
nerve

11. Bone destruction
•This close up image of a chest X-ray shows a large mass of the right upper
zone due to a lung cancer
•Large gaps in the right 3rd rib (orange) and 4th rib (red) are due to direct
invasion of the cancer into the chest wall with bone destruction
•This patient presented with increasing shoulder pain and had no respiratory
symptoms other than a long-standing smoking related cough

12. Malignant lung nodule pre-treatment
•Chest X-rays are often used to monitor response to treatment for lung cancer
•This image shows a large rounded nodule in the right mid-zone

13. Malignant lung nodule pre-treatment -
detail
•A close-up view shows it has a spiculated edge - a feature associated with
malignant lesions
•Lung cancer was diagnosed following biopsy and radiotherapy treatment was
started

14. Post-radiotherapy
•The nodule is much smaller after treatment with stereotactic radiotherapy

15. Lung cancer progression - Pre-treatment
•This long term smoker presented with a cough and finger clubbing
•A large lobulated mass is seen in the region of the right lung hilum - proven
to be a cancer following biopsy
•CT showed it was non-operable and chemotherapy was offered

16. Lung cancer - 3 months post-
chemotherapy
•The mass can no longer be seen clearly indicating a good response to
treatment
•The raised position of the right hemi-diaphragm is a sinister feature and implies
injury or invasion of the phrenic nerve leading to phrenic nerve palsy

17. Lung cancer - 4 months after chemotherapy
•The mass has recurred
•Consolidation seen distal to the mass (asterisks) may be due to disease infiltration,
lymphangitis or possibly infection
•This consolidation is demarcated inferiorly by the horizontal fissure indicating it is
mainly in the right upper lobe
•The right hemi-diaphragm is higher than on the previous image indicating
increasing volume loss of the right lung
•Blunting of the right costophrenic angle indicates a pleural effusion
•Bulging of the left mediastinal contour indicates progression of disease through the
mediastinum to the contralateral side

18. Lung cancer - Disease progression
•Another month later the mass has again increased in size
•The horizontal fissure is displaced superiorly - indicating the right upper lobe
has lost volume due to occlusion of airways
•Increased density (whiteness) under the level of the diaphragm indicates the
presence of pleural fluid – this is the typical appearance of a subpulmonic
effusion (fluid located between the lung base and hemidiaphragm)

19. Lung cancer - Disease progression
•After a further month the mass and effusion have again increased in size
•There is now a contralateral pleural effusion

20. Metastases (from lung to lung)
•This image shows a large right middle zone lung mass (found to be a cancer
on biopsy) with several nodules (metastases) elsewhere in both lungs
(arrowheads)

21. Metastases (from lung to bone)
•A right upper zone lung cancer has spread to the right 6th rib which appears
expanded

22. Metastases (from lung to bone) - CT
•(Same patient as image above)
•This coronal plane CT image shows the abnormally expanded bone of the sixth rib

23. Metastases (to lung) - Cholangiocarcinoma
•Lungs are a common site of metastatic disease from other parts of the body
•Appearances of metastases are highly varied
•Image shows numerous small lung nodules scattered throughout both lungs
•This patient had a metastatic cholangiocarcinoma
•Metastases from other cancers - such as breast or thyroid cancer - can have
similar appearances

24. Metastases (to lung) - Renal cell carcinoma
•This image shows numerous lung nodules of varied sizes scattered throughout
both lungs
•This patient had renal cell carcinoma which is often said to give rise to ‘canon-
ball’ metastases in the lungs - a descriptive term referring to their appearance -
big and round

25. Mass behind heart
•At first glance this chest X-ray may appear normal
•On closer inspection a large, round mass is seen in the left lower zone,
obscured by the heart
•This is a lung cancer located in the left lung behind the heart
•The dotted line indicates the level of the CT image - see below

26. Mass behind heart - CT
•The CT shows the position of the mass behind the heart

27. Mass below diaphragm
•A systematic review of this X-ray shows a nodule (small mass) in the right lower
zone, obscured by the soft tissues of the upper abdomen
•Don’t forget that the lung passes below the level of the dome-shaped
diaphragm

28. Mass below diaphragm (detail)
•A closer look at the area shows it is a spiculated and cavitating lesion
•The dotted line indicates the level of the CT image - see below

29. Mass below diaphragm
•The CT shows the nodule behind the dome of the diaphragm
•It has a spiculated edge, it contains a cavity, and it makes contact with the
pleural surface