lung ca radiology

1. )
March,2023
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2. Outline
 Introduction
 Imaging
 Staging
 Histologic classification and imaging feature
 Mechanisms of lung metastases
 Manifestations of metastatic Lung tumors
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3. Introduction
 Pulmonary neoplasms are a heterogeneous group of
lesions with variable morphologic and imaging features.
 The most common neoplasm of the lung is metastatic
disease
 Most patients (80% to 90%) with multiple
metastases have a history of neoplasm.
 Among cases of multiple nodules detected with CT,
73% were reported to be pulmonary metastases.
 A major challenge is the differentiating various tumor-
like nonneoplastic infectious from pulmonary neoplasia.
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4. Cont…
 Metastases, the most common pulmonary
manifestation are:-
 multifocal lung nodules or masses that
 typically exhibit spherical shapes,
 well-defined borders, and
 a basilar-predominant distribution.
 Atypical manifestations of metastatic disease include
solitary nodule, cavitation, and calcification.
 Lymphangitic carcinomatosis with patchy reticular
opacities that represent interlobular septal thickening.
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5. Cont…
 Lung cancers are primary malignant lung neoplasms that
comprise a wide range of histologic cell types, including
 Adenocarcinoma,
 Squamous cell carcinoma,
 Small cell carcinoma,
 Large cell carcinoma, and
 Neoplasms of mixed histology.
 Lung cancer is associated with cigarette smoking.
 Other carcinogens include asbestos, arsenic, pesticides, and
polycyclic aromatic hydrocarbons.
 Age and Genetics.
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6. Imaging Modality
 X-ray
Chest CT
FDG PET or PET/CT
MRI
ROLE
 Detects tumor
characteristics
 Staging
 Pre op assessment
 Restages disease extent
after therapy
 Follow up
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7. Imaging Features
 Peripheral lung cancer often
manifests as a solitary
pulmonary nodule, mass, or
consolidation.
 Such lesions may invade
extrapulmonary
structures including the
chest wall, diaphragm,
and mediastinum.
 Central lung cancer often
manifests as a, which may be
obscured by surrounding
pneumonia &/or hilar or
perihilar mass, atelectasis.
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8. Cont…
 Advanced lung cancer may
manifest with extensive
intrathoracic LNP and
may mimic lymphoma and
metastatic disease.
 Cavitations , Reverse
golden S sign PA cxr,
pleural tail sign,mucoid
impaction and rat tail
termination of bronchus.
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9. Staging
 Lung cancer is staged using a TNM classification,
which is based on a combination of findings:
 The location and morphologic characteristics of the
primary tumor (T);
 The presence or absence of hilar, mediastinal, or other
lymphadenopathy (N);
 The presence or absence of distant metastases (M).
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10. Staging
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11. Cont…
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14. HISTOLOGICAL CLASSIFICATION
 In 2015, the World Health Organization (WHO) published a revised
classification of lung tumors
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15. 1. ADENOCARCINOMA
 Is a malignant epithelial lung tumor characterized by
glandular differentiation, pneumocyte marker
expression, or mucin production.
 Range from preinvasive to invasive lesions.
 Commonest type 40-50%
 Early metastasis is common than SCC.
 75% solitary peripheral lung nodule.
 Associated with lung fibrosis and genetic abnormality.
 Less associated with cigarette smoking.
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16. Imaging
 CXR
 Solitary nodule/mass,
consolidation
 Multifocal nodules, masses,
consolidations
 Central lesion: Post obstructive
atelectasis/pneumonia
 Local invasion, lymphadenopathy,
pleural effusion
 CT
 Solid or subsolid nodule or mass
 Irregular, lobular, or spiculated
borders
 Local invasion, lymphadenopathy,
metastases
 Pleural effusion, nodular pleural
thickening
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18. Types of adenocarcinoma

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19. AAH AIS MIA
LPA IMA
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20. 2. Squamous Cell Carcinoma
 it currently accounts for about 20% of cases.
 It is strongly associated with cigarette smoking.
 Rapidly growth and late metastasis.
 65% Central involving main, Lobar and segmental
bronchus.
 30% peripheral solitary nodule.
 Patient C/P obstructive symptom.
 Sputum cytology can +ve before radiologically visible.
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21. Imaging
 Radiography
 Central hilar/perihilar mass
 Bronchial obstruction with post obstructive
 atelectasis/pneumonia
 Mediastinal/hilar lymphadenopathy
 Peripheral lung nodule or mass
 CT
 Central nodule/mass ± post obstructive effects
 Assessment of lymphadenopathy, local invasion
 Peripheral nodule/mass, assessment of morphologic features,
local invasion.
 MR: Complementary to CT, assessment of brachial plexus,
mediastinum, chest wall
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23. Cont…
 Squamous cell carcinoma with a cavitary lung mass
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24. 3. NEUROENDOCRINE TUMORS
 It includes ;- high-grade tumors (SCLC and LCNEC),
 intermediate-grade ..atypical carcinoid tumor,
 low-grade…. typical carcinoid tumor, and
 preinvasive diffuse idiopathic pulmonary neuroendocrine cell hyperplasia
(DIPNECH)
 Accounts 20% to 25% of invasive lung malignancies.
 The commonest is small cell lung carcinoma (SCLC) 15% to 20% .
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25. I. Small Cell Carcinoma
 Highly malignant neuroendocrine lung cancer thought to
arise from Kulchitsky cells.
 Strongly associated with cigarette smoking.
 Rapidly growth and early metastasis.
 Central lung CA that associated peribronchial invasion.
 Associated with SVC and parapneoplastic syndrome.
 Worst prognosis.
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26. Imaging
 Radiography
 Large central/mediastinal mass
 Hilar mass ± post obstructive effects
 Elevated hemidiaphragm from phrenic nerve involvement
 Solitary nodule or mass
 CT
 Large hilar/mediastinal mass/lymphadenopathy
 Encasement/invasion of mediastinal structures
 Bronchial encasement/obstruction & post obstructive effects
 Metastases to adrenal gland, liver, skeleton
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27. Cont…
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29. 2. Large Cell Neuroendocrine Carcinoma
 LCNEC was formerly classified as a subtype of LCC.
 It is high-grade NEC.
 Has a poor prognosis.
 It is strongly associated with smoking.
 Mostly founded at periphery.
 Large size 1-9cm.
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30. IMAGING
Radiography
 Peripheral nodule or mass
 Associated mediastinal &/or hilar lymphadenopathy
CT
 Nodule or mass with spiculated or well-defined margins
 Heterogeneous or homogeneous enhancement
 Dystrophic calcification in 20% of cases
 Metastasis: Brain, bone, and liver
FDG PET/CT
 Tumors typically demonstrate increased FDG uptake
 Superior to PET or CT alone in staging of disease
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33. 3. Carcinoid Tumors
 About 20-30% of all lesions arise from the respiratory
tract.
 It accounts 1-2% of all primary lung cancers.
 are classified based on mitotic activity:-
 Typical (low grade) and
 Atypical (intermediate grade).
 Typical carcinoids:-more common,80% in bronchial wall.
 Atypical carcinoid account for 10-16% of all carcinoids,
 are more aggressive than typical carcinoids, and
 are more strongly associated with metastases to lymph nodes
(57% versus 13%).
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34. Imaging
Radiography
 Central hilar or perihilar nodule or mass
 Solitary peripheral lung nodule
 Post obstructive atelectasis, pneumonia
CT
 Avidly enhancing central nodule or mass
 Calcification/ossification in 30%
 Endobronchial, partially endobronchial, abutting bronchus,
peripheral
 Post obstructive effects: Atelectasis, consolidation
bronchiectasis
Nuclear medicine
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36. 5. MESENCHYMAL TUMORS
 Pulmonary Hamartoma:-
 commonest benign lung tumor accounts 75%.
 Age above 50yr M=2F
 Composed at least 2 mesenchymal element.
 On imaging: Above 85% present as solitary nodule
 5-15% Endobronchial nodule
 Well-defined,rounded margin often lobulated.
 30% calcified (pop corn)
 Slow growth (0.5-5mm/yr).
 Malignancy transformation and recurrence is rare.
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38. Distant Mets and RX of lung Ca
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39. METASTATIC LUNG CA
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40. MECHANISMS OF SPREAD
 Direct extension from the primary tumor; most
common with thyroid tumors, esophageal carcinoma,
thymoma and thymic malignancies, lymphoma, and
malignant germ cell tumors.
 Hematogenous spread
 Lymphatic (lymphangitic) spread; carcinomas of the
breast, stomach, pancrease, prostate, cervix, and thyroid.
 Spread within the pleural space; thymoma, lung
carcinoma
 Endobronchial (aerogenous) spread; uncommon,
except in patients with invasive mucinous adenocarcinoma.
It is also occur in patients with tracheobronchial
papillomatosis.
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41. MANIFESTATIONS OF METASTASTIC TUMOR
1.Lung Nodules
 are the most common thoracic
manifestation.
 In most cases, they are
hematogenous in origin.
 predominate in the lung bases.
 CXR
○ Multiple well-defined lung
nodules/masses
○ Variably sized: Miliary to
"cannonball"
○ comm0n site lung bases and
periphery.
CT:- with thin slice can visualized
as small as 1-2mm.
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42. ‘feeding vessel sign’
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43. 2. Multiple Nodules
 Are often vary in size.
 Occasionally, the same size.
 they tend to be distributed
throughout the lung.
 Large nodular mets called
‘Cannon ball”mets.
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44. 3. Solitary Nodule
 About 5% to 10% of solitary metastases.
 Many patients who appear to have a solitary metastasis
visible on CXR are may have multiple pulmonary
nodules on CT.
 It has more likely a smooth margin than is primary lung
carcinoma .
 In a patient with a known extra thoracic tumor and a
solitary nodule detected radiographically, the likelihood
that the nodule is a metastasis (as opposed to primary
lung cancer) varies with the cell type of the primary
tumor.
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45. Cont…
 Patients with carcinomas of the head and neck,
bladder, breast, cervix, bile ducts, esophagus, ovary,
prostate, or stomach are more likely to have primary
lung carcinoma than lung metastasis (ratio, 8:1 for
patients with head and neck cancers; 3:1 for patients with
other types of cancer)
 Patients with carcinomas of the salivary glands,
adrenal, colon, parotid gland, kidney, thyroid gland,
thymus, or uterus have fairly even odds (ratio, 1:1).
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46. Cont
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47. 4.Hemorrhage around Metastatic Nodules
 If a tumor are surrounded by
hemorrhage appear CT halo
sign or ill-defined fuzzy
margins.
 Is not a specific finding.
 Angiosarcomas and
choriocarcinomas are the
most representative causes
of hemorrhagic metastases.
 Cause is Fragility of the
neovascular tissue that
leads to a rupture of the
vessel.
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48. 5. Dilated Vessels within a Mass
 Are engorged tumor vessels that
suggest the hypervascular
nature of the metastatic nodule.
 Seen in cases of a metastasis
from a sarcoma such as an
alveolar soft-part sarcoma or a
leiomyosarcoma.
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49. 6. Cavitation
 is not as common as with primary lung carcinoma, but it
occurs in about 5% of cases.
 It may be seen even with small nodules
 The likelihood of cavitation varies with histology.
 Cavitation is most common with squamous cell tumors (70
%) and transitional cell tumors but also may be seen in
adenocarcinomas, particularly from the colon, and in some
sarcomas.
 A pneumothorax or hemopnemothorax can be complicated.
 Chemotherapy is known to induce cavitations.
 The exact mechanism of cavitation is usually difficult to
determine
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50. 1/28/2024 53

51. Cont…
Cavitary nodule in
metastatic transitional
cell carcinoma. Even
though the nodule is very
small , a distinct cavity is
visible
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52. 8. Calcification
 Occurs most commonly with osteogenic sarcoma,
chondrosarcoma, synovial sarcoma, thyroid carcinoma, and
mucinous adenocarcinoma.
 Calcification may be dense, particularly with osteogenic
sarcoma
 may persist following successful chemotherapy despite
resolution of the tumor.
 Several mechanisms are responsible for calcification.
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54. Benign Metastasizing Tumor
 Benign tumors in an extrapulmonary site rarely metastasize
to the lung.
 These tumors are histologically benign.
 originate from a leiomyoma of the uterus , a hydatidiform
mole,GCT, chondroblastoma, a pleomorphic adenoma of
the salivary gland, or a meningioma
 usually show very slow growth.
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55. Sterilized Metastasis
 A metastatic nodule persists after adequate chemotherapy
with its size unchanged or slightly diminished
 Except for the stable appearance of their size, these
“sterilized” nodules are radiologically indistinguishable
from a residual viable tumor.
 Metastases from a choriocarcinoma, testicular Cancer,
after chemotherapy are common causes of sterilized
metastases.
 Biologic markers
 PET has capability to help evaluate biologic activity.
 Some germ cell tumors convert to a benign mature teratoma
after chemotherapy and result in persistence of the masses.
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56. 2. Lymphangitic Spread of Tumor
 is refers to tumor growth in the lymphatic system of the lungs.
 It occurs most commonly in breast, lung, stomach, pancreas,
prostate, cervix, or thyroid and in patients with metastatic
adenocarcinoma from an unknown primary site.
 About 80% of cases are due to adenocarcinoma.
 Symptoms of shortness of breath are common and can predate
radiographic abnormalities.
 On CXR appear as reticular or reticulonodular opacities,
asymmetric Kerley’s lines, hilar and mediastinal
lymphadenopathy, and pleural effusion. In some patients, the
chest radiograph is normal.
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57. Cont…
Coned-down
radiograph showing
the right lower lobe
demonstrates an
abnormal reticular
pattern and a right
pleural effusion.
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58. Cont…
 On HRCT typically shows :
smooth thickening of the
interlobular septa,
smooth thickening of the
peribronchovascular
interstitium the perihilar lung
(i.e. “peribronchial cuffing”), and
smooth subpleural
interstitial thickening (i.e.
thickening of the fissures).
Less often,nodular thickening
of these structures is visible .
This pattern of nodules is
termed “perilymphatic”
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59. Cont…
 In about 50% of patients, it appear focal, unilateral, or
asymmetrical rather than diffuse on CT.
 Hilar lymphadenopathy is visible on CT in only 50% of
patients with lymphangitic spread.
 Lymph node enlargement can be symmetrical or
asymmetrical. Pleural effusion is common.
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60. 3. Airway Metastases
 Locally spread from adjacent mediastinal structures (e.g.,
esophagus), lung, or lymph node metastases or because of
hematogenous spread.
 It commonly occurs in tracheobronchial papillomatosis and
invasive mucinous adenocarcinoma.
 May present airway obstruction and atelectasis.
 If some patients, airway obstruction may be the first
manifestation of the extrathoracic neoplasm.
 CXR/CT show a tapered narrowing of AW lumen (rat tail
appearance).
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61. Cont…
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62. Cont…
Invasive mucinous
adenocarcinoma. Patchy
areas of consolidation and
centrilobular nodules are
visible.
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63. Cont…
Polypoid endobronchial
mass in metastatic
melanoma
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64. Air-Space Pattern
metastases from an adenocarcinoma
of the GIT Lepidic growth
air-space nodules, consolidation
containing an air bronchogram,
focal or extensive ground-glass
opacities, and nodules with CT halo
signs
The diagnosis of a
bronchioloalveolar carcinoma
cannot be made with confidence if
an extrapulmonary
adenocarcinoma has not been
ruled out
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65. 4. Lymph Node Metastases
 Are uncommon, occurring in less than 3% of cases.
 Spread via the thoracic duct. Spread to LN from hematogenous
spread lung mets.
 The extrathoracic tumors most likely to metastasize to the
mediastinum and hila are carcinomas of the head and neck
(including thyroid tumors), GUT (e.g., renal and testicular
carcinoma), breast, and melanoma.
 Enlarged LN may be unilateral or bilateral and symmetric or
asymmetric.
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66. Cont…
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67.  Necrotic, rim-enhancing, or low-attenuation lymph nodes
common in testicular carcinoma, renal cell carcinoma, breast
cancer, and lung cancer.
 Most metastatic tumors result in lymph node enlargement without
distinguishing characteristics
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68. Cont…
Enhancing lymph node
metastasis with
metastatic
paraganglioma. A left
paraaortic lymph node is
densely enhancing
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69. Cont…
Calcified lymph nodes
following treatment of
metastatic gastric cancer.
Multiple densely
calcified axillary and
mediastinal nodes are
visible
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70. Cont…
Necrotic lymph node in
metastatic renal cell
carcinoma. An enlarged
pretracheal lymph node
shows a low-attenuation
center and rim
enhancement
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71. Cont…
Internal mammary
lymph node metastasis
in breast cancer. An
enlarged node is
visible on the right
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72. 4. Pleural Metastases
 may result from local spread, hematogenous spread, or
lymphatic spread.
 It is most common with adenocarcinoma
 CXR usually show pleural effusion or pleural thickening,
which may be lobulated, nodular, or concentric (i.e.,
surrounding the lung).
 CT may show pleural effusion with or without pleural
thickening, pleural masses and nodular pleural thickening
, or concentric pleural thickening.
 Nodular pleural thickening or pleural masses in a patient
with known malignancy strongly suggest pleural
metastasis.
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73. Cont’d…
Metastatic colon carcinoma with
paracardiac lymph node
enlargement and malignant
pleural effusion. Paracardiac
lymph node enlargement is
present.
Multiple pleural nodules are
highly suggestive of pleural
metastases
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74. Spontaneous Pneumothorax
 May result from metastases
involving the visceral pleural
surface.
 The pleural metastases may
appear necrotic or cavitary, or
solid, with pneumothorax
presumably resulting from
other mechanisms of pleural
disruption or airway
obstruction with air trapping.
 Pneumothorax is most
typical of metastatic
sarcoma and may be the first
symptom of metastasis.
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Metastatic melanoma with pneumothorax.
A solid-appearing metastasis

75. References
• Radiographic
• Radiology assistance
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76. Thank you!!!
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