Radiological imaging of pulmonary neoplasms

1. RADIOLOGICAL IMAGING OF
PULMONARY NEOPLASM'S
DR. PANKAJ KAIRA
JR 1 RADIODIAGNOSIS
SRMSIMS BAREILLY

2.  A wide variety of neoplasms may arise in the lungs
 While many lung tumors are malignant, others are
benign , some fall between these two extremes (both
clinically & histologically)
 Carcinoma of bronchus is by far the most commonest
and most important primary tumor of the lung

3. VARIOUS TYPES
 BRONCHOGENIC CARCINOMA
 PULMONARY SARCOMA
 BENIGN PULMONARY TUMORS - bronchial
carcinoids , pulmonary hamartoma
 MALIGNANT LYMPHOPROLIFERATIVE
DISORDERS – lymphoma , leukemia
 METASTASIS
 SOLITARY PULMONARY NODULE - evaluation

4. BRONCHOGENIC CARINOMA
 Commonly known as lung carcinoma
 A highly malignant primary lung tumor that has a very
poor prognosis
 Arises from respiratory epithelium ; bronchus ,
bronchiole or alveoli.
 Commonest fatal malignancy in adult males in the
western world
 Its more common in men than in women , but the
incidence in women is rising
 Responsible for 1.38 million deaths annually, as of 2008
 Overall 5 yr survival is <15%
 Most cases 40-70 yrs age ; unusual below 30 yrs.

5. CAUSES
- Tobacco smoke - most important causative agent (20-
30 fold , increased risk ; proportional to dose).
Polycyclic aromatic hydrocarbons , Nitrosamines
carcinogens in cigarette smoke.
- Passive smoking
- Atmospheric pollution – vehicles, industries, power
plants
- Exposure to asbestos, nickel, arsenic , chromates,
nickel, mustard gas
- Radon gas – natural gas produced by decay of uranium
- Radiotherapy

6. CLINICAL FEATURES
 20 % asymptomatic presentation ;
found incidentally on routine CXR
Bronchogenic carcinoma may
present with a VARIETY CLINICAL
MANIFESTATIONS :
 RESPIRATORY SYMPTOMS:
cough, hemoptysis, wheeze,
dyspnoea
 SYSTEMIC SYMPTOMS: weight
loss, fever, clubbing, fatigue
 LOCAL COMPRESSION
SYMPTOMS: chest pain, bone pain,
superior venacava obstruction,
difficulty swallowing
Nodule found on routine chest
radiograph

7. CLINICAL MANIFESTATIONS
 Due to primary lesions:
o cough with/without
sputum
o weight loss
o pneumonia
o dyspnoea
o fever
o hemoptysis
 Due to local extension:
o chest pain
o hoarseness
o superior vena cava syndrome
o horner’s syndrome
o dysphagia
o pericardial effusion
o pleural effusion
o diaphragm paralysis

8. CONTD…
Regional spread to hilar and mediastinal nodes may cause :
 Dysphagia due to esophageal compression
 Hoarseness due to recurrent laryngeal nerve compression
 Horner’s syndrome due to sympathetic nerve involvement
 And, elevation of the hemidiaphragm from phrenic nerve compression.
 Extrapulmonary manifestations :
Include –
o metastasis to other organs, such as brain, central nervous system,
skeleton system, liver, adrenal glands and lymph nodes.

9.  PARANEOPLASTIC SYNDROMES
Paraneoplastic syndromes are common in lung cancer patients and may be the first
manifestation of the disease or its recurrence.
 The extent of paraneoplastic syndromes is unrelated to the size of the primary tumour.
 Lung cancer and small-cell lung cancer (SCLC) in particular is the most common cancer
to be associated with para neoplastic syndromes.
 However, some paraneoplastic syndromes are more often found in non-small-cell lung
cancer (NSCLC). For example hypertrophic pulmonary osteoarthropathy has most often
been described in association NSCLC
EXAMPLE -
1) Hypertrophic Pulmonary Osteoarthropathy,
2) Hypercalcemia,
3) Inappropriate Antidiuretic Hormone Secretion Syndrome (SIADH)
4) Peripheral Neuropathies,and
5) Cushing’s Syndrome

10.  Many of the lung cancer symptoms are non-specific
 Cancer is already spread beyond the original site by the
time its suspected
 Small cell> Adeno > Large> Squamous
 Common sites of spread :
- Brain
- Bone
- Adrenals
- Opposite lung
- Liver
- Pericardium
- Kidneys

11. 11
Computed tomographic (CT) scan of the abdomen showed multiple
hepatic metastases (arrows).

12. 12
 Adrenal metastases are common and often solitary.
 They must be differentiated from adrenal adenomas, which occur in 1% of
the adult population..
 Lesions smaller than 1 cm are usually benign.
 Metastases are usually larger than 3 cm; on non-enhanced CT scans, they
have an attenuation coefficient of 10 HU or higher.
 Adenomas and metastases can also be distinguished by using MRI and PET
scanning.
ADRENAL METASTASES

13. 13
 Osteolytic (70%) Osteoblastic (30%)
 Technetium-99m (99m Tc) radionuclide bone
scanning is indicated in patients with bone
pain or local tenderness.
 The test has a 95% sensitivity for the
detection of metastases but a high false-
positive rate because of degenerative disease
and trauma.
 The assessment of these metastases
requires comparison of the bone scans with
plain radiographs.
 Vertebrae(70%), Pelvis(40%), Femora(25%)
 Plain radiographs typically show destructive
lytic lesions ± pathological fractures.
 Similar features are seen on CT scans.
BONE METASTASES

14. 14
FDG PET images
demonstrate bone
metastases (arrows).

15. 15
Isotope bone scan. Hot spots due to
bony metastases.

16. 16
 SCLC and adenocarcinoma are the most common sources
of cerebral metastases.
 MRI is superior to CT, especially in the depiction of the
posterior fossa and the area adjacent to the skull base.
 However, the brain is not routinely imaged in asymptomatic
patients with NSCLC, because the incidence of silent
cerebral metastases is only 2-4%.
 Brain metastases are typically hemorrhagic and occur at
the grey-white mater junction of the brain.
BRAIN METASTASES

17. CLASSIFICATION OF LUNG CARCINOMA
Broadly classified into 2 types-
Based on microscopic appearance of tumor cells
Non- small cell
Lung carcinoma
(80%)
Adenocarcinoma
30-40%
Squamous cell
Ca 30%
Large cell Ca
10-15%
Mixtures of
different types of
NSCC
Small cell Lung
carcinoma (20%)

18.  ADENOCARCINOMA ~ 30-40% ; most
common subtype
 composed of malignant glandular
epithelium, varying in degree of
differentiation.
 Most common cell type in non-smokers.
 smaller than other bronchogenic
carcinomas.
 located in lung periphery
 Radiologic feature – peripheral nodule /
peripheral mass
 5 yr survival = 17%
 BRONCHOALVEOLAR CARCINOMA : is a
type of adenocarcinoma ; m/c in women and
non-smokers
 arises from epithelium of terminal bronchiole
or alveolus
 almost always peripheral ; may present as
pneumonia like consolidation ,as a solitary
nodule or forms multiple colaescing
nodules.

19. • Chest x-ray –
WIDESPREAD LUNG INVOLVEMENT
CT scan–
TYPICAL AIRSPACE FILLING WITH AN
AIRBRONCHOGRAM

20.  SQUAMOUS CELL CARCIMONA ~ 30-
35% ; second most common subtype*
 composed of malignant squamous cells that
vary in degree of differentiation from tumor
to tumor
 m/c in men
 closely related to smoking
 Radiological feature – hilar or perihilar
mass, cavitating lung mass, peripheral
nodule, atelectasis or obstructive
pneumonitis distal to obstructed bronchus.
 Most common carcinoma to cavitate
 5 yr survival =15%**

21. HILAR CAITATING MASS - due to squamous cell carcinoma

22.  SMALL (OAT) CELL CARCINOMA ~ 20-
25%
 composed of small cells that resemble
lymphocytes
 strongly related to smoking
 very aggressive
 metastasizes early
 radiologic feature – hilar mass /
mediastinal mass
 5 yr survival = 5 % ; worst prognosis
 Staged in two groups-
a) limited stage disease
b) extensive stage disease

23. RADIOGRAPHIC FEATURES-
 Typically central in location, 75- 90% cases
 Hilar or a perihilar mass
 Massive adenopathy, often bilateral
 Associated lobar collapse
Primary tumor may not be readily evident because it is
obscured by the extensive adenopathy. And in such cases, CT
SCAN may prove advantageous

24. PANCOAST TUMOR
 Also known as superior sulcus tumor.
 CLINICAL FEATURES
 may include - chest pain
- horner’s syndrome
- bone destruction
- atrophy of hand muscles
 RADIOLOGICALLY-
Usually appears as – an apical mass
- asymmetrical pleural thickening with irregularity that
occasionally is associated with rib destruction
 Apical thickening which is usually bilateral, may be a normal finding, commonly
seen in older patients.
However, irregular apical thickening, that is 5mm or greater than that on
the opposite side should be
considered with suspicion.
 INVASION OF – chest wall, brachial plexus, vertebral bodies, spinal canal,
subclavian artery

25.  MRI
 Is the preferred modality because of its ability to visualize structures at
the apex of the thorax
 It is usually useful in determining certain parameters of resection of
the tumor such as invasion of the vertebral bodies, involvement of the
subclavian artery and brachial plexus.
 Coronal and sagittal images are particularly helpful
 CT scan
 may be helpful when extensive mediastinal invasion is present
 But the value of CT in determining chest wall invasion is somewhat
limited, and
here MRI may have a slight advantage.

30.  LARGE CELL CARCINOMA ~ 15-20%
 composed of large, undifferentiated malignant cells
 Radiologic feature – large peripheral mass
 5 yr survival = 11%

31. IMAGING
• CXR – commonly useful to suspect lung cancer in asymptomatic or non-
specific cases
• Next investigation that comes in use is CT / computed tomography
• The diagnosis is confirmed with a biopsy which is usually performed by
bronchoscopy or CT-guidance
• Immunostaining used to categorize the subtype on which prognosis depends
• PET imaging with FDG (fluorodeoxyglucose) is increasingly used for staging
• Sensitivity of PET in one study = 79% , specificity = 91% ;
whereas the sensitivity of CT 60% , specificity = 70%
• Fused PET-CT imaging provides registration of FDG metabolic activity with
the anatomical detail of CT .

33. LUNG CARCINOMA CAN BE DISCUSSED as:
1) CENTRAL TUMORS 2) PERIPHERAL
TUMORS

34. PERIPHERAL TUMORS
 Approximately 40% of the bronchial carcinomas arise beyond the
segmental bronchi
 In 30% a peripheral mass is the sole radiographic finding
A. Tumor shape and size
B. Cavitation
C. Calcification
D. Presence of air
bronchograms
E. Ground glass attenuation

35.  TUMOR SHAPE AND SIZE-
 Tumor at lung apex may appear as pleural thickening.
 Majority of peripheral tumors may be spherical or oval
 CORONA RADIATA - numerous strands radiating from the nodule into
surrounding lung
 Peripheral line shadow or ‘TAIL’ SIGN - linear opacity that extends from a
peripheral nodule to the visceral pleura

36.  CAVITATION-
• Best demonstrated on CT SCAN
• Most commonly seen in squamous cell type of lung carcinoma.
• Cavities with a greatest wall thickness less than 5 mm are almost always
BENIGN whereas most of those with a maximal wall thickness greater than
15 mm are MALIGNANT
EXAMPLE OF A THICK WALLED CAVITY

37. BENIGN CALCIFICATION PATTERNS

38. A SOLID CALCIFIED SOLITARY PULMONARY NODULE

39. SPECKLED OR PUNCTATE
CALCIFICATIONS
ECCENTRIC CALCIFICATION

40. CENTRAL TUMORS
 Cardinal imaging signs of a central tumor are –
 A) collapse / consolidation
 B) hilar enlargement
A) Collapse /consolidation:
- Obstruction of major bronchus often leads to a consequent pulmonary opacity and
secondary infection may occur beyond the obstruction. Example: Non-resolving
pneumonia
“The presence of pneumonia in at-risk patient, confined to one lobe that
persists unchanged for longer than 2-3 weeks, OR a pneumonia that recurs in
the same lobe which shows loss of volume and no air bronchograms.”
 A simple pneumonia often clears or spreads to other segments within a few
weeks of treatment with antibiotics

41.  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

42.  Bronchoalveolar Carcinoma--- as ground glass
haze in left lower lobe and lingula

43.  acinar airspace consolidation+ air bronchogram+
poorly marginated borders
 Airspace consolidation may affect both lungs
(mucus secretion)
 ±Cavitation within consolidation
 "CT angiogram sign" = low-attenuation
consolidation does not obscure vessels (mucin-
producing subtype)
CONSOLIDATION

44.  Air space infiltration involving almost all left lung
zones and right mid zone
Continued

45.  CT confirms extensive airspace opacities with numerous air-
bronchograms. No pleural effusions or significant adenopathy.
 Sputum, right and left main bronchus lavage were positive for malignant
cells consistent of carcinoma, thought true cut biopsy was suggested by
the pathologist to confirm the diagnosis of bronchoalveolar carcinoma,
the patient condition did not permit for this.

46. CT ANGIOGRAM SIGN
CT angiogram sign. A patient with bronchoalveolar carcinoma. Enhancing
pulmonary vessels in a low-attenuating mass are seen.

47.  The cavity is eccentric (large cell undifferentiated carcinoma).
 (B) The inner wall of the cavity is irregular (squamous cell
carcinoma).
 The cavity wall may be very thin (squamous cell carcinoma).

48. Cavitating mass in the left mid-zone
and there is bulging of the
aortopulmonary window, indicating
lymph node enlargement.
48
Irregular opacity in left mid-zone with
central air density due to cavitation and
inferior horizontal margin due to air-fluid
level.

49.  CT showing a cavitating squamous cell carcinoma
in the left lung.
The wall of the cavity is variable in thickness.

50.  Bronchial carcinoma in the posterior segment of
the right upper lobe with cavitation.

51. GOLDEN ‘S’ SIGN-
 The Golden S sign is created by a central mass and should raise
suspicion of a central neoplasm, such as primary bronchial carcinoma.
CT image of chest demonstrates a
convexity with collapse of RUL

52. Collapsed right upper lobe with a convex bulge along the lower
aspect of the collapsed lung (white arrows) producing a
Golden 'S' sign

54. B) Hilar enlargement-
- common presenting feature in patients with bronchial carcinoma
- may reflect proximal tumor, lymphadenopathy, consolidated lung
 Early, massive hilar or mediastinal lymphadenopathy and invasion –
well seen in –
1) Small cell Ca.
2) Large cell Ca

55. Bronchocele due to carcinoma of the bronchus. CT
shows dilated, fluid-filled bronchi in the lingula,
secondary to carcinoma at the left hilum.
55

56.  Bronchocele due to carcinoma of the bronchus. CT
shows dilated, fluid-filled bronchi in the right middle
lobe, secondary to carcinoma at the right hilum.

57.  The bronchial cut off sign refers to the abrupt
truncation of a bronchus from obstruction,
which may be due to cancer, mucous plugging,
trauma or foreign bodies. Typically, there is
associated distal lobar collapse.
BRONCHIAL CUT OFF SIGN

58.  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

59.  PA chest radiograph shows abrupt cut off of left
main bronchus with collapse.

60.  Pleural effusion (8-15%): Usually unilateral
 Most commonly due to adenocarcinoma
 Second leading cause of exudative pleural
effusions.
 Frequent seen in patients with age>45 Ys,
manifestated by chest pain, hemoptysis and
emaciate.
 Bloody and massive pleural effusion is the typical
clinical picture. Significantly high LDH and CEA
level(>20ug/L) in pleural fluid.
 Pleural fluid cytology, needle biopsy, thoracoscopy
or open pleural biopsy has its greatest utility in
establishing the diagnosis of malignant pleural
effusions.
MALIGNANT PLEURAL EFFUSION

61.  CXR shows complete
opacification of the right
hemithorax, which is due to a
combination of complete
collapse of the right lung and
a large malignant pleural
effusion. The right lung had
collapsed due to a large
tumour obstructing the right
main bronchus (note the
abrupt cut-off in the bronchus,
arrow). The resultant volume
loss in the right hemithorax
has resulted in shift of the
trachea to the right. There are
multiple large metastases in
the left lung.

62. 62
 Contrast enhanced computed tomography:
Necrotic mass in the right lower lobe (short
arrow) with pleural (p) and pericardial (pc)
effusions which were confirmed to be malignant.

63.  Axial CT images show a large mass (stars) in the left lower lobe
with a large left pleural effusion with focal pleural thickening
(arrowheads). The lung mass is better seen on a post-
thoracentesis image. Transbronchial biopsy revealed
adenocarcioma and pleural fluid cytology confirmed the
presence of malignant cells. Based on the new staging system,
this patient has at least M1a disease.

64. • Cranial to the right hilum there is a mass that was overlooked.
• 2 months later marked growth of the central carcinoma was observed.

65. Obstruction of a major bronchus
often leads to atelectasis
and retention of secretions =
consequent
pulmonary opacity
To differentiate :
• Shape of collapsed /consolidated lobe
may be altered due to bulk of underlying
tumor
• At- risk patient; pneumonia confined to
one lobe (or more) that persists
unchanged for >2-3 wks
Pneumonia that recurs in same lobe ,
particularly if the lobe shows loss of volume
or no air – bronchograms
Simple pneumonia clears out or spreads to
other segments within few weeks.
SCC resembling pneumonia

66. 66
 F-18 FDG PET imaging has been shown to be an
accurate, non-invasive imaging test for the
assessment of pulmonary nodules and larger mass
lesions
 96 % sensitive, 93 % specific.
 Several studies have shown that PET is more
accurate than CT for the staging of NSCLC.
 PET appears to be more accurate than CT in
detecting metastatic mediastinal lymphadenopathy.
 Detection of unsuspected metastatic disease by
PET may permit reduction in the number of
thoracotomies performed for non-resectable
disease.
PET-CT

67. 67
 PET scan showing abnormal uptake of FDG in
a tumour nodule in the right upper lobe(arrow)
& in two superior mediastinal lymph
nodes(arrowheads).

68. 68
 Unresectable lung
cancer. FDG-PET
scan shows large
primary tumour with
metastases in lymph
nodes, bone, & right
adrenal.
PET is also very useful in clarifying those
cases in which occurence of benign nodal
enlargement coexists with a malignant lung
lesion.

69. 69
 (C)Contrast enhanced CT demonstrated
enlarged lymph nodes (> 1 cm in short axis;
arrowheads) in ipsi- and contra-lateral
mediastinal nodal stations .
(D)PET-CT showed high metabolic activity of the
parenchymal lesion but no nodal [18F]-2-FDG
uptake.

70. PULMONARY SARCOMA
 Primary pulmonary
sarcomas
(fibromyosarcoma,
leiomyosarcoma) are
rare
 Majority are
metastatic sarcomas
(from extrathoracic
primary tumor )
Extensive pulmonary shadowing consisting of
a mixture of ill – defined rounded & band like
shadows maximal in the perihilar regions &
lower zones

71. Mediastinal angiosarcoma in a 38-year-old man, (a) PA chest
radiograph shows a mediastinal contour abnormality (arrows),
(b) CT+C shows a large, homogeneous mediastinal mass (arrows)
abutting the aorta (A) and superior vena cava (S), at exploratory
thoracotomy, the mass did not arise from or involve the aorta and
heart, and resection was performed, location in the anterior
mediastinum and absence of an obvious vascular origin are typical of
angiosarcomas

72. Pulmonary leiomyosarcoma in a 62-year-old woman, (a) CT+C shows a
large, heterogeneous lung mass that extends into the azygoesophageal
recess and compresses and displaces the left atrium (LA), note the origin in
the lung, the large size, and the heterogeneous attenuation, common features
of leiomyosarcoma, (b) T1+C fat-saturated shows that the mass is
heterogeneous, diffuse enhancement surrounds well-circumscribed areas of
low signal intensity (arrows), which are consistent with cystic spaces, (c) Axial
fast spin-echo T2-weighted MR image shows a fluid-fluid level (arrow), which
is consistent with blood products within a cystic space

73. Rhabdomyosarcoma in a 42-year-old man, (a) PA chest radiograph
shows a well-circumscribed mass in the right hemithorax that arises
from the mediastinum, note the small right pleural effusion and the
surgical clips from incisional biopsy, (b) CT+C shows that the mass is
large and compresses the superior vena cava (arrow), note the
heterogeneous attenuation within the mass, which is consistent with
necrosis

74. Ewing sarcoma in a 9-year-old boy, (a) PA chest radiograph shows a large mass within
the left hemithorax that extends into the right hemithorax, (b) Nonenhanced CT shows
that the mass is large and heterogeneous, there is destruction and inward displacement
of a left rib (long arrow), rib destruction is typical but may not be extensive, note the local
invasion into the subcutaneous tissues (short arrow). (c-e) Axial fast spin-echo T2 (c),
coronal T1-weighted (d), and coronal T1+C (e) show focal areas of high signal intensity
and heterogeneous enhancement, findings consistent with necrosis and hemorrhage,
note the marked displacement of mediastinal structures into the right hemithorax. LV =
left ventricle

75. Primitive neuroectodermal tumor in a 44-year-old man,
(a) PAchest radiograph shows a large, right-sided chest mass,
(b) Nonenhanced CT scan shows that the mass is heterogeneous,
note the absence of rib destruction, Primitive neuroectodermal
tumors are typically located in the chest wall and demonstrate rib
destruction less commonly than does Ewing sarcoma .

76. Chest wall chondrosarcoma in a 62-year-old man, nonenhanced CT
shows a large mass that arises from the costochondral junction, the
mass extends into the subcutaneous tissue and compresses and
displaces the heart, note the focal punctate and linear calcifications,
anterior location, origin from the costochondral arches, and
chondroid calcification are characteristic of chondrosarcomas of the
chest wall

77. Osteosarcoma in a 43-year-old man, CT+C shows a left-sided
chest wall mass with an osteoid matrix (arrow), a finding
characteristic of chest wall osteosarcoma

78. Pulmonary synovial sarcoma in a 63-year-old man with
pneumonia. (a) PA chest radiograph shows a mass in the right
cardiophrenic angle (arrows) and heterogeneous areas of increased
opacity in the middle and right lower lobes, findings consistent with
pneumonia, (b) CT+C shows that the mass is heterogeneous, areas
of low attenuation within the mass are consistent with extensive
necrosis, note the small right pleural effusion

79. Neurofibrosarcoma in a 33-year-old woman with type 1 neurofibromatosis, (a)
Nonenhanced CT scan shows a large, homogeneous mass in the left axilla
(arrows), note the absence of rib destruction, (b, c) Coronal T1 (b) and fat-
saturated T2 (c) show that the mass (M) is well circumscribed with low signal
intensity on the T1 (b) and high signal intensity on the T2 (c), note the small
neurofibroma with similar signal intensity in the lower lateral aspect of the left
hemithorax (arrow), the patient presented with pain in the region of the left
axillary mass; because the characteristic appearance of a neurofibroma on T2
(the target sign) was absent, biopsy was performed

80. BENIGN PULMONARY TUMORS
 BRONCHIAL CARCINOIDS
 PULMONARY HAMARTOMA
 OTHERS – FIBROMA, CHONDROMA, LIPOMA,
HAEMANGIOMA, NEUROGENIC TUMOURS

81. BRONCHIAL CARCINOIDS
 Neuroendocrine tumors ; constitute <5% pulmonary tumors
 May be :
TYPICAL : arise in central airways
ATYPICAL : arise in lung periphery
 S/S - wheeze, pneumonia, hemoptysis
 Even if small , they may secrete ACTH in sufficient quantities to
cause CUSHING’S SYNDROME
 Radiographic appearances:
 Central lesion – partial or complete bronchial obstruction resulting
in atelectasis with or without pneumonia
 Peripheral lesion – present as solitary spherical or lobular nodule ,
2-4 cm in diameter , with a well – defined smooth edge .
 CT – calcification seen in 1/3rd patients

82. A small tumor completely occluding the right main bronchus and
causing extensive collapse in right lung. The endoluminal
component is well seen .There is poor differentiation of the tumor
from adjacent collapsed lung

83. Well defined perihilar carcinoid tumor demonstrated
anterior to the artery to the right lower lobe

84. A small peripheral carcinoid tumor indistinguishable
from a number of other causes of SPN

85. Asymmetry of the bronchovascular bundles in the apex of the upper lobe ,
these are due to a small subtle hyperattenuating peripheral solitary pulmonary
nodule immediately adjacent to the apical segmental bronchus of the right
upper lobe , this finding is consistent with a primary bronchial carcinoid tumor

86. HAMARTOMAS
 Most common benign tumor of
the lung.
 Composed of abnormal
arrangement of tissues ;
cartilage, connective tissue,
muscle, fat, and bone
 Discovered incidentally
 Well-circumscribed nodules or
masses (usually small) with
either smooth or lobulated
margins
 Approximately 60% have fat
and approximately 20-30%
have calcification / ossification
(pop-corn like calcification)
 Cavitation is not seen
 On CT scan fat can be
recognized by comparing it to
subcutaneous fat and will
typically have a Hounsfield
measurement of -40 to -
120HU

90. MALIGNANT LYMPHOPROLIFERATIVE DISORDERS
 Radiographic
appearances –
 One or more areas of
pulmonary consolidation
resembling pneumonia
 Multiple pulmonary
nodules
 Miliary nodulation or
reticulonodular
shadowing resemblibg
lymphangitis
carcinomatosa
LYMPHOMA

91. LEUKAEMIA
 Imaging features –
 Diffuse bilateral reticulation & patterns resembling
interstitial oedema , lymphangitic carcinomatosis ,
small nodules , ground glass opacification &
consolidation
 Hilar / mediastinal lymphadenopathy
 Pleural effusion – common

92. METASTASIS
 Pulmonary metastases
are usually from breast,
GIT, kidneys, testes, head
& neck tumours.
 Sign – one / more
discrete pulmonary
nodules usually in the
outer portions of lungs
 Nodules are
characteristically round &
well defined
 They may be of any
shape &have a irregular
edge - adenocarcinoma

93. Irregular pulmonary metastasis – occur In adenocarcinoma .
Nodules are irregular in outline . A large left pleural effusion is also seen

94. Metastases :
a) Pathways of metastatic spread from a
primary extrathoracic site to lungs
b) Neoplasms with rich vascular supply
c) Neoplasms with lymphatic dissemination
d) Other neoplasms with high propensity to
localize in lung
e) Calcified Metastases
f) Giant Metastases
g) Sterile Metastases

95. a) Pathways of metastatic spread from a primary
extrathoracic site to lungs :
1-Spread via pulmonary arteries
2-Lymphatic spread (celiac nodes → posterior mediastinal
nodes + paraesophageal nodes) and in lung parenchyma
3-Direct extension
4-Endobronchial spread
b) Neoplasms with rich vascular supply draining into
systemic venous system :
1-Renal cell carcinoma
2-Sarcomas
3-Trophoblastic tumors
4-Testis
5-Thyroid

96. c) Neoplasms with lymphatic dissemination :
1-Breast (usually unilateral)
2-Stomach (usually bilateral)
3-Pancreas
4-Larynx
5-Cervix
d) Other neoplasms with high propensity to
localize in lung :
1-Colon
2-Melanoma
3-Sarcoma

97. e) Calcified Metastases :
-Calcifications in lung metastases are observed in :
1-Bone Tumor Metastases :
a) Osteosarcoma
b) Chondrosarcoma
2-Mucinous Tumors :
a) Ovarian
b) Thyroid
c) Pancreas
d) Colon
e) Stomach
3-Metastases After Chemotherapy

98. f) Giant Metastases : Cannon Ball
1-Head and neck cancer
2-Testicular and ovarian cancer
3-Soft tissue cancer
4-Breast cancer
5-Renal cancer
6-Colon cancer

99. Multiple subcentimeter calcified pulmonary nodules
(mets , red arrows) , pleural effusion (blue arrows)

103. SOLITARY PULMONARY NODULE
 A solitary pulmonary nodule is
defined as a discrete, well-
marginated, rounded opacity less
than or equal to 3 cm in diameter that
is completely surrounded by lung
parenchyma, does not touch the
hilum or mediastinum, and is not
associated with adenopathy,
atelectasis, or pleural effusion.
 Lesions larger than 3 cm are
considered masses and are treated
as malignancies until proven
otherwise.
 Most are benign, upto 40% of SPN’s
may be malignant

104. DIFFERENTIALS OF SPN
 Bronchial carcinoma
 Bronchial carcinoid
 Granuloma
 Hamartoma
 Metastasis
 Chronic pneumonia or abscess
 Hydatid cyst
 Pulmonary haematoma
 Bronchocele

105.  Fungus ball
 Massive fibrosis in coal workers
 Bronchogenic cyst
 Sequestration
 Atriovenous malformation
 Pulmonary infarct
 Round atelectasis

107. PSEUDOTUMOR
 Sharply marginated collection of pleural fluid
- Either within an interlobar pulmonary fissure, or -
In a subpleural location adjacent to a fissure.
 Imaging :
located along course of interlobar fissures
Lenticular or biconvex contour
 Most occour in minor/horizontal fissure

109. 10
9
CHEST RADIOGRAPHY 1st line investigation; cheap and
readily available; can depict most of
the features of overt lung cancer and
its complications.
COMPUTED TOMOGRAPHY The gold standard in diagnosis and
staging of lung cancer; gives cross-
sectional imaging with better
representation of anatomy; clearly
depicts mediastinal adenopathy and
involvement of adjacent structures.

110. MAGNETIC RESONANCE
IMAGING
Excellent soft tissue resolution;
clearly depicts vascular invasion
better than CT; imaging modality of
choice for assessing Pancoast
tumours; of importance in cases
where CT findings are
indeterminate or equivocal.
POSITRON EMISSION
TOMOGRAPHY
Provides excellent depiction of
functional status of suspicious
lung masses; helps to sort out
status of nodal enlargement
coexisting with lung cancer.
110

111. THANK YOU