Lung cancer

Dr. ASHISH K GUPTA
PG II YEAR
RADIODIAGNOSIS
SLIMS

 Lung cancer, or frequently, if somewhat
incorrectly, known as bronchogenic
carcinoma,
 The most common cause of cancer in men,
and the 6th most frequent cancer in women
worldwide.
 It is the leading cause of cancer mortality
worldwide in both men and women and
accounts for approximately 20% of all cancer
deaths

Epidemiology
 Lung cancer is the most common fatal malignancy
worldwide both in male and female.
 The major risk factor is CIGARETTE SMOKING
which is implicated in 90% of cases and increase
the risk of lung cancer 20-30 times.
Other risk factors:
 asbestos: 5x increased risk
 occupational exposure: uranium, radon, arsenic,
chromium
 diffuse lung fibrosis: 10x increased risk
 chronic obstructive pulmonary disease

Clinical presentation
 Patients with lung cancer may be asymptomatic in up
to 50% of cases.
 Cough and dypnoea are rather non-specific
symptoms that are common amongst those with lung
cancer.
 Central tumours may result in haemoptysis and
peripheral lesions with pleuritic chest pain.
 Pneumonia, pleural effusion, wheeze,
lymphadenopathy are not uncommon. Other
symptoms may be secondary to metastases (brain,
liver, bone) or to paraneoplastic syndromes.

Pathology
 The term bronchogenic carcinoma is
somewhat loosely used to refer to primary
malignancies of the lung
 associated with inhaled carcinogens and
includes four main histological subtypes.
 These are broadly divided into non small-
cell carcinoma and small cell carcinoma as
they are differ clinically in terms of
presentation, treatment and prognosis:

NON SMALL-CELL LUNG
CANCER (NSCLC) (80%)
 Adenocarcinoma (35%)
 Most common cell type overall
 Most common in women
 Most common cell type in non-smokers but still most patients
are smokers
 Peripheral
 Squamous cell carcinoma (30%)
 Strongly associated with smoking
 Most common carcinoma to cavitate
 Poor prognosis
 Large-cell carcinoma (15%)
 Peripherally located
 Very large, usually more than 4 cm

SMALL CELL
CARCINOMA (20%)
 Almost always in smokers
 Metastasises early
 Most common primary lung malignancy
to cause paraneoplastic
syndromesand SVC obstruction
 Worst prognosis
Other malignant pulmonary neoplasms
include lymphoma and sarcoma (rare)

Non-small cell lung cancer
(NSCLC) staging
 Non-small cell lung cancer (NSCLC)
staging can be accomplished both by
the TNM system, or by the AJCC
staging system.

TNM system
 Primary tumour (T)
 Tx: malignant cells on cytology but no
tumour found on bronchoscopy or imaging.
 Tis: carcinoma in situ
 T1
 tumour size equal or less than 3cm
 not involving the main bronchus
○ T1a: smaller than 2 cm in longest dimension
○ T1b: larger than 2 cm but smaller or equal to 3
cm

Stage T1 tumors. (a) Chest CT scan shows a left lower lobe nodule (arrow)
measuring less than 2 cm in size, a finding that is consistent with a stage
T1a tumor (≤2 cm). (b) Chest CT scan obtained in a different patient shows
a right upper lobe nodule (arrow) measuring 2.9 cm in size, a finding that
is consistent with a stage T1b tumor (>2 cm but ≤3 cm).

T2:
 Tumour size more than 3cm but
less/equal to 7cm or
 Involving the main bronchus but >2 cm
from carina
 Visceral pleural involvement
 Lobar atelectasis extending to the hilum
but not collapse of the entire lung
 T2a: larger than 3 cm but smaller than 5 cm
 T2b: larger than 5 cm but smaller than 7 cm

Stage T2 tumors. (a) Chest CT scan shows a centrally located lung nodule (arrow)
causing airway obstruction, with atelectasis or postobstructive pneumonia that
does not, however, involve the entire lung. (b) Chest CT scan obtained in a
different patient shows a mass in the right lung (arrow) measuring 4.8 cm, a
finding that is consistent with a stage T2a tumor (>3 cm but ≤5 cm). (c) Coronal
chest CT scan obtained in a third patient shows a nodule in the bronchus
intermedius (arrow). The nodule is 4 cm from the carina (an endobronchial lesion
> 2 cm from the carina is considered stage T2

T3
 Tumour size more than 7 cm or
 tumour <2 cm from carina but not involving
trachea or carina
 Involvement of the chest wall, including
pancoast tumour, diaphragm, phrenic
nerve, mediastinal pleura or parietal
pericardium
 Separate tumour nodule(s) in the same
lobe
 Atelectasis or post obstructive pneumonitis
of entire lung

Stage T3 tumors.
(a) Chest CT scan shows an irregular mass in the left upper lobe with
suspicious local extension to the mediastinal pleura (arrow).
(b) Chest CT scan obtained in a different patient shows an endobronchial
mass (arrow) less than 2 cm from the carina.
(c) Chest CT scan obtained in a third patient shows a left lower lobe mass
over 7 cm in diameter (arrow).

Stage T3 tumors. Chest CT scan shows a primary mass
(arrow) with satellite nodules (arrowheads) in the right
lower lobe.

T4
 any size tumour with:
 involvement of the trachea, oesophagus,
recurrent laryngeal nerve vertebra, great
vessels or heart
 separate tumour nodules in the same
lung but not in the same lobe

Stage T4 tumors. Chest CT scan shows a primary lung
tumor in the right upper lobe (long arrow) with a smaller
separate nodule in the right lower lobe (short arrow).

Stage T4 tumors. Chest CT scan shows a right upper
lobe mass (arrow) with mediastinal and carinal
invasion, ipsilateral loculated pleural effusion, and
thickening and enhancement of the pleura.

Nodal status (N)
 Nx: regional nodes cannot be assessed
 N0: no regional nodal metastases
 N1: ipsilateral peribronchial, hilar or
intrapulmonary nodes, including direct
invasion
 N2: ipsilateral mediastinal or subcarinal
nodes
 N3: contralateral nodal involvement ;
ipsilateral or contralateral scalene or
supraclavicular nodal involvement

Stage N1 lymph nodes.
(a) Chest CT scan shows an enlarged right hilar lymph node (level 10) (arrow)
measuring 15 mm in the short axis.
(b) Chest CT scan shows a left lower lobe mass and an ipsilateral enlarged
interlobar lymph node (level 11) (arrow) measuring 11 mm in the short axis

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 )

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).

Distant metastasis (M)
 Mx: distant metastases cannot be
assessed
 M0: no distant metastases
 M1: distant metastases present
 M1a: presence of a malignant pleural or
pericardial effusion, pleural dissemination, or
pericardial disease, and metastasis in
opposite lung
 M1b: extrathoracic metastases

Metastatic disease as seen at
conventional imaging. (a) Axial contrast
material–enhanced T1-weighted MR
image of the brain obtained in a
patient with known primary lung
cancer shows a ring-enhancing lesion
with surrounding edema in the right
occipital pole (arrow), a finding that is
consistent with metastasis. (b)
Abdominal CT scan obtained in a
different patient shows multiple
enhancing hepatic masses (arrows)
and a right adrenal mass (arrowhead),
findings that are consistent with
metastatic disease. (c) Technetium-
99m methylene diphosphonate nuclear
bone scintigrams obtained in a third
patient with lung cancer show
multifocal areas of abnormal
radiotracer uptake in the axial and
appendicular skeleton, findings that
are consistent with metastases

Types of bone metastases in lung cancer. (a)
Blastic; (b) Lytic; (c)
Mixed; (d) Bone marrow.

AJCC staging system
stage 0
TNM equivalent: carcinoma in stiu
resectable: yes
stage I
TNM equivalent: T1 or T2, N0, M0
resectable: yes
5 year survival: 47%
stage IIa
TNM equivalent: T1, N1, M0
resectable: yes
stage IIb
TNM equivalent: T2, N1, M0 or T3, N0, M0
resectable: yes
5 year survival: 26%
stage IIIa
TNM equivalent: T1 or 2, N2, M0 or T3, N1 or 2, M0
resectable: yes
--------------- accepted cut off between resectable and non resectable ----------
stage IIIb
TNM equivalent: T1, 2 or 3, N3, M0 or T4, N0, 1, 2 or 3, M0
resectable: no
5 year survival: 8%
stage IV
TNM equivalent: any T, any N with M1
resectable: no
5 year survival: 2%

PET/CT
 PET/CT is a hybrid imaging technique that
provides anatomical information of the CT
and metabolic information of the PET,
 allowing to visualize both individually or
fused in 3D or bidimensional slices.
 The most commonly used radiotracer is
F18-FDG,
 which allows detecting primary tumors as
well as metastasis that consume glucose,
corresponding to the majority of the
malignant pulmonary lesions.

Partially necrotic left pulmonary tumor with rib involvement. Transthoracic
needle biopsy has to be directed to periphery of tumor for viable sample.
There are two metastases in infraclavicular node and muscular location
(arrows),both of them negative in CT.

 As each subtype has a different
radiographic appearance, demographic,
and prognosis:
 squamous cell carcinoma of the lung
 adenocarcinoma of the lung
 large cell carcinoma of the lung
 small cell carcinoma of the lung

Squamous cell
carcinoma (SCC)
 Squamous cell carcinoma (SCC) is
one of the non-small cell carcinomas of
the lung, overtaken by adenocarinoma
of the lung as the most
commonly encountered lung cancer.

Epidemiology
 Squamous cell carcinoma accounts for ~30-35%
of all lung cancers and in most instances are due
to HEAVY SMOKING .
 In general, squamous carcinomas are
encountered more frequently in male smokers,
and adenocarcinoma in female smokers.

 depends on the location of the tumour
 A chronic cough and haemoptysis may be
present.
 More peripheral tumours, (e.g. Pancoast tumour)
 Metastatic disease may be the first sign of
malignancy (e.g. cerebral metastasis,pathological
fracture, etc).

Pathology
 known to arise centrally (66-90%), the incidence of
peripherally located SCC is increasing .
 Macroscopically these tumours tend to be off-white in
colour, arising from, and extending into a bronchus.
 They invade the surrounding lung parenchyma and can
extend into the chest wall.
 Larger tumours have a tendency to undergo central
necrosis.
 Four subtypes are recognised :
 papillary
 clear cell
 small cell (not to be confused with small cell lung cancer)
 basaloid

Metastases
Most common sites of metastatic disease
are :
 Regional lymph nodes
 Adrenal glands (see adrenal gland
tumours)
 Brain (see cerebral metastases)
 Bone (see skeletal metastases)
 Liver (see liver metastases)

Radiographic features
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,

(a) and bronchogram (b) show the characteristic growth pattern of these tumors
in a patient with a squamous cell carcinoma of the night main stem bronchus.
Note the irregular narrowing (arrow) of to bronchial lumen, which may result in
postobstructive pneumonia or atelcısis

Squamous cell carcinoma in a 57-year-old man.
PA (a) and lateral (b) chest radiographs demonstrate a complete consolidation
of the right upper lobe. At bronchoscopy, an endobronchial tumor of the r ı t
main stem bronchus was identified.

Squamous cell carcinoma in a 63-year-old woman with dysphagia and weight
loss. (a) Frontal chest radiograph demonstrates opacification of the left
hemithorax and ipsilateral mediastinal shift consistent with complete atelectasis of
the left lung. Lack of visualization of the left main stem bronchus suggests central
occlusion. (b) Contrast-enhanced chest CT scan (mediastinal window)
demonstrates a softtissue mass (in), which narrowed and obstructed the left main
stem bronchus, left lung atebectasis, and left pleural effusion. At bronchoscopy, a
circumferential, friable obstructing endobronchial lesion was found.

Squamous cell carcinoma in a 62-year-old man with left shoulder pain. (a, b) Thin-
section chest CT scans (lung window) show an endobronchial nodule (arrow in a) within
the right lower lobe bronchus.
There is involvement of the adjacent lung parenchyma with associated volume loss of
the night lower lobe.
Note the bobulated mass (arrowhead in b) that displaces the major fissure. (C) Gross
specimen of the resected right lower lobe shows the endobronchial component of the
tumor

Squamous cell carcinoma in a 72-year-old man
with left arm pain, chest pain, and increasing dyspnea.
(a) PA chest radiograph demonstrates a large rounded cavitary
mass with an air-fluid level in the superior segment of the left lower lobe. Note the
nodular, irregular contour of the inner wall of the cavity. (b) Contrast-enhanced chest CT
scan (mediastinal window) demonstrates the air-fluid level within the lesion and the
irregular aspect of its inner wall.

CT
 Cavitation is a frequent finding in primary lung
SCC but can also be encountered in metastatic
SCC.
 Cavitation is secondary to tumoral necrosis.
 SCC can have a central scar with peripheral
growth of tumor.

Differential diagnosis
 The differential diagnosis depends on
the location and appearance of the
mass.
 hilar mass (unilateral): differential for a
hilar mass
 solitary pulmonary nodule: differential for
a solitary pulmonary nodule
 pleural effusion: differential for a pleural
effusion

Adenocarcinoma of the
lung
 one of the non-small cell carcinomas of
the lung
 a malignant tumour with glandular
differentiation or mucin production.
 Tumour exhibits various patterns and
degrees of differentiation, including
lepidic, acinar, papillary, micropapillary
and solid with mucin formation

Epidemiology
 It is now considered the most common
histological subtype in terms of
prevalence.
 Clinical presentation
 Early symptoms are fatigue with mild
dyspnoea followed by chronic cough
and haemoptysis at a later stage.

 Radiographic features
 A lung nodule is a rounded or irregular
region of increased attenuation
measuring less than 3 cm.
 The amount of attenuation can further
classify the nodules as either ground
glass, sub-solid or solid.

Adenocancinoma in an asymptomatic 58-year-old male smoker with a radiographic
abnormalitfound incidentally on a preoperativeradiograph obtained before cataract
surgery.
(a) Posteroantenior (PA) chest radiograph shows alobulated 1.5-cm solitary nodule
(arrow) in theright upper lobe overlying the first anterior rib

(b) Chest computed tomographic (CT) scan (lungwindow) shows large bullae
surrounding a wellmarginated,lobulated soft-tissue nodule.

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

Right lung adenocarcinoma. There is one liver
metastases (arrow) that is not visible in
contrasted CT.

Large cell carcinoma of the
lung
 Large cell carcinoma of the
lung is one of the histological type
of non-small cell carcinomas of the lung.
Epidemiology
 It is thought to account for approximately
10% of bronchogenic carcinoma .
 Patient presents with dyspnea, chronic
cough and haemoptysis.

 Large cell carcinoma of the lung typically
presents as a large peripheral mass of
solid attenuation and irregular margin.
 Focal necrosis can be present.
 Other characteristics include rapid
growth and early metastasis.

large cell carcinoma in a 61-year-old woman with blood-streaked
sputum and weight loss. (a) PA chest radiograph demonstrates a large
peripheral mass of the left upper lobe,
which abuts the pleural surface and has a bobubated contour.

large cell carcinoma in a
57-year-old man with weight loss, orthopnea, and a painful palpable mass of the
anterior chest wall on the
left side. (a) Contrast-enhanced chest CT scan (mediastinal window) demonstrates
a large mass of heterogeneoUs
attenuation, which produces mass effect on the mediastinal structures.

Small cell lung cancer
(SCLC)
 Also known as oat cell lung cancer is a subtype of
bronchogenic carcinoma .
 Rapidly grow,
 Are highly malignant,
 Widely metastasise and show initial response to
chemotherapy and radiotherapy.
 Sclcs have a very poor prognosis and are usually
unresectable.
Epidemiology
 Small cell lung cancers represent 15-20% of lung
cancers and is strongly associated with cigarette
smoking.

 Clinical presentation can significanctly vary and can present in the
following ways.
 constitutional
 fever
 weight loss
 malaise
 primary tumour
 cough
 haemoptysis
 dyspnoea
 local invasion
 dysphagia (oesophageal compression)
 hoarseness (recurrent laryngeal nerve palsy)
 stridor (airway compression)
 SVC obstruction
 rib erosion
 metastatic spread (affecting ~70% of patients are presentation)
 bone pain (bone metastases)
 focal neurological deficit (CNS involvement)
 right upper quadrant pain (liver metastases)
 paraneoplastic syndromes

 Pathology
 It arises from the bronchial mucosa.
 Local invasion occurs in the submucosa with subsequent
invasion of peribronchial connective tissue.
 Cells are small, oval, with scant cytoplasm and a high
mitotic count.
 It is the most common lung cancer subtype to produce
necrosis, superior vena cava (SVC) infiltration/SVC
obstruction, and paraneoplastic syndromes.
Location
 Approximately 90-95% of SCLCs occur centrally, and
usually arising in a lobar or main bronchus .

 located centrally in the vast majority of cases
(90%). They arise from main-stem of lobar
bronchi, and thus appear as hilar or perihilar
masses .
 They frequently have mediastinal lymph node
involvement at presentation.
Plain film
 seen as a hilar/perihilar mass usually with
mediastinal widening due to lymph node
enlargement.

 CT
 On CT mediastinal involvement may appear
similar to lymphoma, with numerous enlarged
nodes.
 Direct infiltration of adjacent structures is more
common.
 Small cell carcinoma of the lung is the most
common cause of SVC obstruction, due to both
compression/thrombosis and/or direct infiltration .
 Necrosis and haemorrhage are both common.
 CT is able to stage small cell cell lung cancer.

Small cell carcinoma in a 41-year-old woman with persistent cough and weight
loss.
(a) PA chest radiograph shows a lobulated right hilar mass. (b) Frontal linear
chest tomogram shows smooth
narrowing of the bronchus intermedius due to extrinsic compression by the hilar
mass, which represented
lymph node metastases from small cell carcinoma.

Small cell carcinoma in a 72-year-old man with a history of dyspnea.
(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.

Differential diagnosis
 Imaging imaging differential considerations
include
 non small-cell lung cancer
 squamous cell carcinoma of the lung
 adenocarcinoma of the lung
 undifferentiated large-cell carcinoma of the lung
 lymphoma
 pulmonary sarcoma (rare)
 pulmonary metastases
 benign lung lesions

Paraneoplastic
Syndromes
 Various paraneoplastic syndromes can
arise in the setting of lung cancer:
 ENDOCRINE
 SIADH causing hyponatraemia: small-cell sub
type
 ACTH secretion (Cushing syndrome): carcinoid
and small-cell sub type
 PTHrp causing hypercalcaemia: squamous cell
carcinoma
 Carcinoid syndrome
 Gynaecomastia

NEUROLOGICAL
 Polyneuropathy
 Myelopathy
 Cerebellar degeneration
 Lambert-eaton myasthenia syndrome

OTHER
 Finger clubbing
 Hypertrophic pulmonary osteoarthropathy
(HPOA): squamous cell carcinoma subtype
 Nephrotic syndrome
 Polymyositis
 Dermatomyositis
 Eosinophilia
 Acanthosis nigricans
 Thrombophlebitis: adenocarcinoma
subtype

case
Pt came to orthopedics department with
trauma , and was referred for PAC and
consequently chest radiograph was
taken
Pt gave history of smoking last 10-15
years but was asymptomatic.

Chest radiograph
Findings reveals :-
9999 Left upper lobe
homogeneous opacity
with minimal hilar
enlargement measuring
approx 3 x 3.4 cm
Another nodular
homogeneous opacity
noted in the right upper
lobe measuring 1.5 cm.

CT findings reveals :-
A central cavitary mass lesion measuring 3.1 x 3.4 cm with thin
walls measuring 0.4 -0.5 cm and spiculated margins and chunky
calcification in the inferior wall of cavity with CT densitometric
value of 110 - 140 HU in left upper lobe posterior segment.

Another solitary lesion measuring 2.5 cm with central
hyperdense focal calcification noted in the right upper
lobe .

Associated findings:- A cystic lesion noted
in the right lobe of liver

Lung cancer

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