LUNG CANCERDr. ASHISH K GUPTA

PG II YEARRADIODIAGNOSIS

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.

OTHER Finger clubbing Hypertrophic pulmonary osteoarthropathy

(HPOA): squamous cell carcinoma subtype Nephrotic syndrome Polymyositis  Dermatomyositis  Eosinophilia Acanthosis nigricans Thrombophlebitis: adenocarcinoma subtype

Pathology

The term bronchogenic carcinoma is somewhat loosely used to refer to primary malignancies of the lung that are 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 overallMost common in womenMost common cell type in non-smokers but still most patients are

smokersPeripheral

Squamous cell carcinoma (30%)Strongly associated with smokingMost common carcinoma to cavitatePoor 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 prognosisOther 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 cmT2b: 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 obtained in a patient with right-sided lung cancer shows an enlarged right hilar lymph node (level 10) (arrow) measuring 15 mm in the short axis. (b) Chest CT scan obtained in a different patient 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

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%

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.

Clinical presentation

Clinical presentation depends on the location of the tumour and is largely independent of histology. 

Central tumours with invasion and obstruction of bronchi typically result in distal collapse which may have superimposed infection. A chronic cough and haemoptysis may be present. 

More peripheral tumours, if not found incidentally on imaging, usually present when larger, invading into chest wall (e.g. Pancoast tumour) 

Metastatic disease may be the first sign of malignancy (e.g. cerebral metastasis,pathological fracture, etc). 

Pathology

Although squamous cell carcinoma of the lung is traditionally 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

MetastasesMost 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 manwith left arm pain, chest pain, and increasing dyspnea.(a) PA chest radiograph demonstrates a large rounded cavitarymass 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. In other instances, 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 Adenocarcinoma of the lung is one of

the non-small cell carcinomas of the lung and is 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 Sometimes it is impossible to

radiographically distinguish between other histological lung cancer types.

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 brdoticchest 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 tumoninvolvement of a posterior rib (arrow).

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 .Clinical presentation Patient presents with dyspnea, chronic

cough and haemoptysis.

Radiographic features 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-streakedsputum 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. (b) Cut surface of the gross specimen demonstratesa 7-cm tumor that extends to the pleural surface.

large cell carcinoma in a57-year-old man with weight loss, orthopnea, and a painful palpable mass of the anterior chest wall on theleft side. (a) Contrast-enhanced chest CT scan (mediastinal window) demonstrates a large mass of heterogeneoUsattenuation, which produces mass effect on the mediastinal structures. (b) Cut surface of the neoplasmshows a large central area of necrosis,

Small cell lung cancer (SCLC)

Small cell lung cancer (SCLC) (also known as oat cell lung cancer) is a subtype of bronchogenic carcinoma and considered separate from non small-cell lung cancer (NSCLC) as it has unique presentation, imaging appearances, treatment, and prognosis. 

Small cell lung cancers 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

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 Small cell carcinoma is considered a neuroendocrine

tumour of the lung. 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 .

Radiographic features

Small cell cell tumours are 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 Appearances on chest x-rays are non-specific. They

may be seen as a hilar/perihilar mass usually with mediastinal widening due to lymph node enlargement 2. In fact, the mediastinal involvement is often the most striking feature and the primary mass may be inapparent.

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. Only rarely do small cell carcinomas present as a solitary pulmonary nodule.

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 smoothnarrowing of the bronchus intermedius due to extrinsic compression by the hilar mass, which representedlymph 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 lungadenocarcinoma of the lungundifferentiated 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:

ENDOCRINESIADH causing hyponatraemia: small-cell sub

typeACTH secretion (Cushing syndrome): carcinoid

and small-cell sub typePTHrp causing hypercalcaemia: squamous cell

carcinomacarcinoid syndromegynaecomastia

NEUROLOGICAL polyneuropathy myelopathy cerebellar degeneration Lambert-Eaton myasthenia syndrome

casePt came to ortho department for trauma .then was reffered for PAC and conciquently chest radiograph was takenPt gave history of smoking last 10-15 years but was asymptomatic.

Chest radiographFindings reveals :- left upper lobe homogeneous opacity with minimal hilar enlargement measuring approx 3 x 3.4 cmAnother noduler 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 dencitometric 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