1) Radiological evaluation plays an important role in staging and characterizing lung cancer. Imaging modalities like CT, MRI, and PET are used to determine the size, location, involvement of surrounding structures, and presence of metastases. 2) Key features examined on imaging include the side, lobe, level and number of primary tumors, invasion characteristics, and characteristics of involved lymph nodes. 3) Accurately determining the TNM stage guides treatment decisions between surgical, medical, and radiation oncologists. PET imaging can help differentiate tumor from atelectasis and detect occult metastases not seen on CT.

1. Radiological evaluation in cancer lung
DR KANHU CHARAN PATRO
MD,DNB(RADIATION ONCOLOGY),MBA,FICRO,FAROI(USA),PDCR,CEPC
HOD,RADIATION ONCOLOGY
Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam
drkcpatro@gmail.com /M- +91-9160470564
8/18/2023 2:49:35 AM 1

2. Ammunitions
• CXR
• CECT CHEST
• MRI
• PET
2

3. What to see?
3
• Side
• Lobe
• Invasion
Primary characteristics
• Level
• Number
• Malignant characteristics
Nodal characteristics
Staging

4. RADIATION ONCOLOGISTS PREVIEW
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5. SURGICAL
ONCOLOGISTS
PREVIEW
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6. MEDICAL ONCOLOGISTS
PREVIEW
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7. New staging
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8. 8

9. 9

10. 10

11. lung Primary
lesion
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12. 14
Imaging features:T1
T1: Tumor < 3 cm,
Not proximal to lobar bronchus
Surrounded by lung or visceral pleura
12

13. T1
13

14. 15
Imaging features:T2
T2: Tumor > 3 cm,
main bronchus > 2 cm from carina
Visceral pleura invasion
Atelectasis,consolidation not inv entire lung
14

15. T2
15

16. 16
Imaging features:T3
1. Any size with inv chestwall/med pleura/ parietal pericardium
/diaphragm
2. main bronchus inv <2cm from carina
3. Atelectasis,consolidation entire lung
Lesion abutting chest wall and
invading the visceral pleura,
Endobronch lesion at Lt.UL bronchus .
Left upper lobe collapse
Atelectasis ext to hilar region
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17. T3-IMAGING
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18. Imaging features:T4
1. Invasion of mediastinum, heart,
great vessels, trachea, esophagus,
vertebral body, carina
2. Satellite tumor nodules OTHER LOBE
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19. T4
19

20. Remember
• Same lobe extra nodule- T3
• Same lung extra nodule –T4
• Different lung extra nodule- M1
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21. NODAL STATIONS
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22. 22

23. 23

24. Lymph nodes
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25. Supraclavicular & upper paratracheal
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26. Prevertebral & prevascular
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27. Lower paratracheal
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28. Subaortic & para aortic
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29. Carinal, paraoesophageal & hilar
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30. 30

31. 31

32. 32

33. 33

34. 34

35. 35

36. 36

37. 37

38. 38

39. 39

40. 40

41. 41

42. 42

43. Remember
• Double digit lymph node level-N1
• Single digit lymph node level - N2[2-9]
• Opposite out side thoracic and – N3[1]
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44. N1-GROUP-10
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45. N1-HILAR-GROUP 10
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46. N2-UPPER PARATRACHEAL
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47. N2-MEDIASTINAL
Stage N2 lymph nodes. (a) Chest CT scan shows an enlarged (1.6-cm) right upper paratracheal
lymph node (level 2) (arrowhead). (b) Chest CT scan obtained in a different patient shows an
enlarged (1.5-cm) right lower paratracheal lymph node (level 4) (arrowhead). (c) Chest CT scan
obtained in a third patient shows a right lower lobe mass (white arrow) with an enlarged (1.6-
cm) subcarinal lymph node (level 7) (black arrow )
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48. N3
Stage N3 lymph nodes. (a) Axial PET/CT image of the chest shows a primary mass in the
left lung (arrow) and a right lower paratracheal lymph node (arrowhead), both of which
demonstrate intense radiotracer uptake. Metastatic involvement of the lymph node was
confirmed at mediastinoscopic resection. (b) Chest CT scan obtained at the lung apex in
a different patient shows enlarged bilateral supraclavicular lymph nodes (arrows).
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49. Characteristics of various histology
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50. Malignant nodule
• Corona radiata sign in a malignant lesion with
spiculation at the margin. 50

51. 51

52. • Calcification in 7% on CT (histologically in
14%) usually eccentric / finely stippled
a) Preexisting focus of calcium engulfed by
tumor
b) Dystrophic calcium within tumor necrosis
c) Calcium deposit from secretory function of
carcinoma ( e.g. mucinous adenocarcinoma)
Malignant Calcifications
52

53. Tumor calcification
Large bronchial
carcinoma invading
the mediastinum
demonstrates
coarse and cloud-
like calcification.
53

54. Alveolar cell carcinoma
• Bronchiolar or bronchio-alveolar Ca
• Subtype of adeno Ca
• Peripherally, probably from type II pneumocytes
• May be associated with diffuse pulmonary fibrosis and pulmonary scars
• CT : ground glass opacification, small nodular opacities, frank
consolidation, thickened interlobular septa
54

55. 55

56. • Early stage (due to lepedic growth pattern
along alveolar septa with relative lack of
acinar filling)
• Ground-glass haziness
• Bubble-like hyperlucencies / pseudocavitation
• Airway dilatation
• Lesion persists / progresses within 6-8 weeks
Ground glass haze
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57. Alveolar cell carcinoma
57

58. • local hyperaeration (due to
check-valve type
endobronchial obstruction,
best on expiratory view)
• CT shows dilated, fluid-filled
bronchi in the right middle
lobe, secondary to carcinoma
at the right hilum.
• Local hyperaeration also seen.
Local Hyperaeration
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59. Bronchocele-alveolar carcinoma
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60. Refers to vessels
appearing prominent during a
contrast enhanced CT as they
traverse an airless low
attenuation portion of
consolidated lung
CT Angiogram Sign
60

61. Small cell carcinoma
(a) Chest CT scan demonstrates a spiculated nodule in the right upper lobe.
(b) Contrast enhanced chest CT scan (mediastinal window) shows massive mediastinal
lymphadenopathy secondary to lymph node metastases. 61

62. LARGE CELL CARCINOMA
• Large peripheral mass of solid attenuation
and irregular margin.
• Focal necrosis can be present.
• Other characteristics include rapid growth
62

63. Large mass in large cell carcinoma
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64. ADENO-CARCINOMA LUNG
• Radiographic features
– Peripheral location
– Sometimes it is impossible to radiographically
distinguish between other histological lung cancer
types.
64

65. Adenocarcinoma
1. Adenocarcinoma in a 41-year-old man with right shoulder pain for several
months. (a) Apical fibrootic
2. chest radiograph demonstrates a right apical mass with poorly marginated
borders. (b) Chest CT scan
3. (lung window) shows a homogeneous peripheral right upper lobe mass with
irregular borders. There is tumor involvement of a posterior rib (arrow).
65

66. SQUAMOUS CELL CARCINOMA
• Chest radiograph
– The appearance depends on the location of the
lesion..When the right upper lobe is collapsed and a hilar
mass is present, this is known as the Golden S sign.
– A more peripheral location may appear as a rounded or
spiculated mass.
– Cavitation may be seen as an air-fluid level.
– A pleural effusion may also be seen, and although it is
associated with a poor prognosis,
66

67. • CT scout film shows abrupt cut off of right main
bronchus with collapse of right lung and
mediastinal shift. CT shows a mass arising and
obliterating the right main bronchus
Bronchial cut-off sign
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68. Cavitary lesion in squamous cell
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69. THE GOLDEN S SIGN
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70. • Left upper lobe collapse due to bronchial carcinoma.
• Carcinoma has caused rat tail like narrowing of left
upper main bronchus
Rat tail termination of bronchus
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71. Metastatic lung disease
feeding vessel sign
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72. TREE IN BUD SIGN-POST RADIATION
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73. NODULAR RADIATION PNEUMONITS
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74. GROUND GLASS PATTERN –POST RT
74
Ground-glass opacity (GGO) is a radiological
term indicating an area of hazy increased
lung opacity through which vessels and
bronchial structures may still be seen

75. RADIATION FIBROSIS
75

76. SCAR LIKE PATTERN-POST RT 5 YEAR
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77. SUSPICIOUS CONDITIONS
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78. Nodule in other lobe/satellite
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79. Atlectesis /Consolidation/tumor
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80. Intra and inter observer variation
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81. Rib and chest wall invasion
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82. Suspicious node
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83. WHEN IT IS UNCLEAR
THINK OF NUCLEAR
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84. 84

85. WHY PET
1. Morphological and functional
characterization of pulmonary nodules or
masses;
2. Differentiation tumor vs atelectasis
3. For tumor-node-metastasis (TNM) staging of
the mediastinum
4. Screening for metastases that might not be
detected by CT alone
5. For radiotherapy planning
85

86. Where is the Target?
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87. Suspicious satellite nodule
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88. Differentiating atelectsis and mass
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89. Suspicious chest wall invasion
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90. Rib and chest wall invasion-MRI
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91. Suspicious node
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92. Suspicious prevertebral node
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93. 93

94. PET-CT-WIN-WIN SITUATION
PARAMETER VOLUME
CHANNGE
T STAGE
UPSTAGING
1. PREVENTS TUMOR TISSUE MISSING
2. CHANGES TT FROM CURATIVE TO PALLLIATIVE
DOWN STAGING 1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
N STAGE UPSTAGING 1. PREVENTS TUMOR TISSUE MISSING
2. CHANGES TT FROM CURATIVE TO PALLLIATIVE
DOWN STAGING 1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
M STAGE UPSTAGING CURATIVE-TO PALLIATIVE
DOWN STAGING PALLIATIVE TO CURATIVE
94

95. 95
WHEN IT IS
SUSPICIOUS
PET IS
AUSPICIOUS

96. Bird’s eye view Eagle’s eye view
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97. 97