thank you grainger and allison

1. TUMOURS OF THE LUNGS
Dr. Nikhil Murkey

2. INTRODUCTION
 Commonest fatal malignancy in adults.
 Between 40-70 yrs.
 Risk factors
 Cigarettes
 Atmospheric pollution
 Asbestos exposure
 Radioactive and industrial chemicals
 Miners (nickel, arsenic, chromates, etc.)

3. PATHOLOGY
Most carcinomas fall into one of the following four
categories
 Squamous cell carcinoma
 Adenocarcinoma
 Large cell carcinoma
 Small (oat) cell carcinoma
 Other rare tumours are clear cell, basal cell
carcinosarcoma, etc.

4. CLINICAL PRESENTATION
When present as…
 Asymptomatic
 Recurrent pneumonia
 Cough, wheeze, hemoptysis
 Paraneoplastic syndromes
lobectomy or pneumectomy may be curative

5. CLINICAL PRESENTATION
When presentation includes…
 Hoarseness
 Chest pain
 Brachial plexus neuropathy
 Horner’s syndrome
 SVC obstruction
 Dysphagia
 Features of cardiac tamponade
it indicates invasion of mediastinum or chest wall and
a poorer prognosis.

6. IMAGING TECHNIQUES
 Chest X-ray
 CT
 MRI
 PET
 PET-CT

7. IMAGING FEATURES (PERIPHERAL)
Tumour shape and margins
 Generally are spherical or oval.
 Lobulation
 Corona radiata
 Tail between the mass and the pleura
 Usually have well defined edges, but some
peripheral cancers like adenocarcinoma and
bronchiolo-alveolar cell carcinoma have ill defined
edges similar to pneumonia.

8. Bronchial carcinoma in the left lower lobe
showing typical rounded, slightly lobular
configuration. The mass shows a notch
posteriorly

9. CT demonstrating a second primary bronchogenic carcinoma
in the right lung in a patient who had undergone a previous left
pneumonectomy 7 years earlier. The new tumour has
spiculated edges infiltrating into the adjacent lung (corona
radiata).

10. Squamous cell carcinoma resembling
pneumonia. The entire opacity seen on
this radiograph is due to the
carcinoma itself

11. IMAGING FEATURES (PERIPHERAL)
Cavitation
 Best demonstrated by CT
 Squamous cell carcinoma most likely to cavitate
 Cavity wall is usually 8 mm thick or greater
 Fluid levels are common.

12. EXAMPLES OF NEOPLASTIC CAVITATION ON CHEST
RADIOGRAPHY.
(A) The cavity is eccentric (large cell undifferentiated
carcinoma).
(B) The inner wall of the cavity is irregular and an air–
fluid level is present (squamous cell carcinoma).
(C) The cavity wall is very thin (squamous cell
carcinoma).

13. CT showing cavitating squamous cell carcinoma.
The wall of the cavity is variable in thickness.

14. IMAGING FEATURES (PERIPHERAL)
Other findings
 Air bronchograms
 Bubble like lucencies or pseudocavitation
 Bronchocele, mucocele, mucoid impaction
 Ground glass attenuation of nodules or purely
ground glass opacities.

15. Apical bronchiolo-alveolar cell
carcinoma of the left upper lobe with
ground-glass attenuation margins.

16. IMAGING FEATURES (CENTRAL)
 Cardinal imaging signs of a central tumour are
collapse or consolidation of the lung beyond the
tumour.
 Golden S sign
 Recurrent or persistent pneumonia and loss of
volume of the lung without air bronchogram
 Drowned lobe
 Mucus filled dilated bronchi in the collapsed lobe on
CT scan

17. (A) Collapse of a lobe around a central mass.
(B) The middle lobe has undergone collapse, but there is a central
mass causing the central portion of both the oblique and horizontal
fissures to bulge outwards (arrows).

18. Fluid-filled dilated
bronchi beyond a
central obstructing
carcinoma are visible
in this collapsed and
consolidated left
lower lobe.

19. IMAGING FEATURES (BOTH)
Hilar enlargement
 Common presenting feature
 Likely causes are the mass, lymphadenopathy
consolidated lung or a combination of these
 More lobular the shape, the more likely that
metastatic lymphadenopathy is present
 Increased density of the hilum owing to summation
of the density of the hilum and the mass

20.  Dense hilum.
The right hilum
is dense owing
to a mass
superimposed
directly over it.
The mass
proved to be a
squamous cell
carcinoma.

21. RADIOGRAPHIC PATTERN OF EACH CELL TYPE
 Early and massive lymphadenopathy and direct
mediastinal invasion are associated with small cell and
large cell carcinomas
 A mass in and around hilum is characteristic of small cell
carcinoma
 Peripheral nodule is very common on adenocarcinoma
and large cell tumour
 Most adenocarcinomas and small cell tumours are small
(<4 cm)
 Squamous cell carcinoma attain great size and cavitate
more frequently
 Collapse and consolidation beyond the tumour is the
most common feature seen with squamous cell
carcinoma
 Pleural effusion (with dyspnoea) is a feature of
adenocarcinoma

22. Massive
mediastinal
adenopathy in a
patient with
small (oat) cell
carcinoma of
the bronchus.
The primary
carcinoma is
not visible
because it lies
centrally in the
bronchial tree.

23. RADIOGRAPHIC PATTERN OF EACH CELL TYPE
 Bronchiolo-alveolar carcinomas present as
peripheral pulmonary opacities
 Bubble like lucencies, air containing cystic
lucencies, air bronchograms and cavitation may be
seen
 It may also present as a patch of pneumonia in one
or more lobes.
 Focal ground glass opacities

24. Bronchiolo-alveolar
carcinoma
occupying the right
lower lobe. The
appearance is
identical to
consolidation with
partial collapse. Air
bronchograms are
present.

25. (A) Bronchiolo-alveolar carcinoma with widespread lung
involvement. The appearance closely resembles
bronchopneumonia or pulmonary oedema.
(B) CT of a similar case showing the typical airspace filling
with an obvious air bronchogram.

26. TREATMENT AND STAGING NSCLC
Stage Description Treatment Options
Stage I a/b Tumor of any size is found only in the Surgery
lung
Stage II a/b Tumor has spread to lymph nodes Surgery
associated with the lung
Stage III a Tumor has spread to the lymph nodes Chemotherapy followed
in the tracheal area, including chest by radiation or surgery
wall and diaphragm
Stage III b Tumor has spread to the lymph nodes Combination of
on the opposite lung or in the neck chemotherapy and
radiation
Stage IV Tumor has spread beyond the chest Chemotherapy and/or
palliative (maintenance)
care

27. SCLC
 Limited Stage
Defined as tumor involvement of one lung, the
mediastinum and ipsilateral and/or contralateral
supraclavicular lymph nodes or disease that can be
encompassed in a single radiotherapy port.
 Extensive Stage
Defined as tumor that has spread beyond one lung,
mediastinum, and supraclavicular lymph nodes.
Common distant sites of metastases are the
adrenals, bone, liver, bone marrow, and brain.

28. MEDIASTINAL INVASION
 Plain radiographic evidence relies on demonstrating
phrenic nerve palsy
 Major CT AND MRI signs of mediastinal invasion relies
on demonstration of the tumour deep within the
mediastinal fat
 Glazer et al showed that
A. Presence of less than 3 cm of contact with the mediastinum
B. Less than 90 degrees of circumferential contact with the
aorta
C. A visible mediastinal fat plane between the tumour and any
vital mediastinal organ
indicates a very high probability of resectability and
most of the patient with these descriptions had no
mediastinal invasion on surgery.

29. (A) Extensive deep mediastinal invasion by
primary bronchial carcinoma.
(B) On lung windows there are pulmonary
metastases

30. CHEST WALL INVASION
 Diagnosis of chest wall involvement unreliable on
CT unless bone destruction or a large soft tissue
mass is seen
 Local chest pain is the most specific indicator for
involvement of parietal pleura or chest wall
 MRI is better than CT in demonstrating chest wall
and diaphragmatic involvement
 MRI is the modality of choice for demonstrating
Pancoast’s tumour
 Transthoracic ultrasound can diagnose chest wall
invasion with a high degree of accuracy
 99mTc radionuclide skeletal scintigraphy is sensitive
to assess bone invasion

31. CHEST WALL INVASION BY A PANCOAST'S TUMOUR.
Involvement of the soft tissues of the chest wall is
appreciated on the
(A) coronal T1- and
(B) T2-weighted MRI images.
(C) This example from a different patient shows the better
demonstration of bone involvement (arrows) on CT.

32. INTRATHORACIC LYMPH NODE METASTASES
 Lung cancer normally spread to ipsilateral hilar lymph nodes,
then to the ipsilateral mediastinal lymph nodes, and then to
the contralateral mediastinal and supraclavicular lymph nodes
 Skip metastases to mediastinal lymph node may occur
 Node with a short axis size of more than 10 mm is considered
enlarged
 There is no measurement above which all nodes can be
assumed to be malignant or below which all can be
considered benign
 The predictive value of nodal metastatic disease may be
improved by ensuring that the nodes draining the tumour are
larger than the nodes elsewhere in the mediastinum
 STIR imaging produces sufficient difference between normal
and pathological nodal tissue to detect metastases with 93%
sensitivity and 87% specificity

33. INTRATHORACIC LYMPH NODE METASTASES
 Endoscopic ultrasound can be used to assess the
size and morphology of, and to guide fine needle
aspiration of aortopulmonary, subcarinal and
posterior mediastinal nodes, achieving greater
sensitivity and specificity than CT and PET in some
series
 PET imaging has consistently demonstrated greater
accuracy than CT and MRI in detecting nodal
metastases, and accuracy increases on using PET-
CT

34. There are several
enlarged nodes in
the right
paratracheal area.
The largest
measured 16 mm
in its short axis
diameter (arrow).
The primary
tumour was a
bronchial
carcinoma in the
right lung.

35. The largest of the right
paratracheal nodes
(arrow) is 17 mm in its
short axis diameter. This
node proved to be free of
malignant tumour at
thoracotomy. The
enlargement was due to
reactive hyperplasia.
None of the hilar or
mediastinal nodes in this
patient was involved by
tumour. The primary
tumour can be seen in the
right lung. It shows
extensive contact with the
right chest wall, but no
definite evidence of
invasion of the chest wall
on CT. At surgery there
was invasion of the soft
tissues of the chest wall
but no spread to the ribs

36. Cavitating
bronchogenic
carcinoma. There is
preservation of the
extrapleural fat plane
at the point of
contact with the
chest wall. Although
the pleura may be
involved the chest
wall is likely to be
otherwise spared.

37. RECURRENT MALIGNANT RIGHT HILAR LYMPH
NODES FROM A SMALL PERIPHERAL NON-SMALL
CELL LUNG CANCER.
(A) CT demonstrates nodes at the right hilum.
(B) The PET–CT image confirms high FDG uptake in
keeping with malignant involvement.

38. PLEURAL INVOLVEMENT
 Occur d/t direct spread, lymphatic involvement or
tumour emboli.
 Pleural effusion in association with a primary lung
cancer designated the tumour as being T4
 Some adenocarcinomas present as lobular pleural
thickening indistinguishable from malignant
mesothelioma.

39. PULMONARY SARCOMA AND OTHER PRIMARY
MALIGNANT NEOPLASMS
 There are many other neoplasms that involve the
lung like fibrosarcoma, leiomyosarcoma,
carcinosarcoma, etc. but they all present as solitary
pulmonary nodule or a tracheal or endobronchial
mass
 Kaposi’s sarcoma is another important neoplasm
caused due to the AIDS epidemic.

40. KAPOSI’S SARCOMA
 Rare in absence of cutaneous involvement
 Can involves both the parenchyma and the
tracheobronchial tree
 May be focal or widespread (commoner)
 Perihilar linear, rounded or reticulonodular
shadowing is seen
 Frequently associated with lymphadenopathy
 Pleural involvement in the form of b/l pleural
effusion common feature

41. KAPOSI'S SARCOMA IN TWO PATIENTS WITH
AIDS.
(A) Plain chest radiograph showing extensive pulmonary shadowing consisting of a
mixture of ill-defined rounded and bandlike shadows maximal in the perihilar
regions and lower zones.
(B) CT showing the peribronchial distribution of the ill-defined pulmonary nodules.
There is interlobular septal thickening, a feature that is also frequently identified
on the chest radiograph.

42. TUMOURS OF THE TRACHEA
 Squamous cell carcinoma
 Adenoid cystic carcinoma (cylindroma)
 Mucoepidermoid carcinoma
 Others
Present as either
 Mural nodule with lobular or irregular wall
 Stenotic lesion
 Paratracheal mass (adenoid cystic carcinoma)

43. Adenoid cystic
carcinoma of the
trachea. There is
irregular polypoid
tumour within the
tracheal lumen.

44. BENIGN PULMONARY TUMOURS
Bronchial carcinoids
 Typical or central
 Atypical or peripheral
 They can invade locally and may metastasize
 Atypical carcinoids have a poorer prognosis
 Even small tumours can produce enough ACTH to
cause Cushing’s syndrome
 Central masses show “iceberg” phenomenon
 Central tumours can cause bronchial obstruction
and peripheral masses mimic bronchial carcinoma
so removed surgically

45. CARCINOIDS
A small tumour is
completely
occluding the right
main bronchus and
causing extensive
collapse in the right
lung. The
endoluminal
component is well
seen (arrows), but
there is poor
differentiation of the
tumour from
adjacent collapsed
lung

46. A well-defined perihilar carcinoid tumour (arrows)
is demonstrated anterior to the artery to the right
lower lobe. On lung windows there is only a small
band of atelectasis in the middle lobe

47. A small peripheral
carcinoid tumour
indistinguishable from
a number of other
causes of a solitary
pulmonary nodule.

48. BENIGN PULMONARY TUMOURS
Pulmonary hamartoma
 Masses of cartilage with clefts lined by bronchial
epithelium and contain large collection of fat
 Occasionally multiple
 Carney’s syndrome: triad of pulmonary chondroma,
gastric epitheloid leiomyosarcoma and extra-adrenal
paragangliomas
 90% peripheral, 10% central
 Central tumours cause bronchial obstruction
 peripheral tumours on chest radiographs appear
spherical or slightly lobulated, usually less than 4 cm,
with normal surrounding lung with spotty, linear or
popcorn calcification
 On CT it shows characteristic central fat density

49. Round, completely smooth, hamartoma in a 57 year
old asymptomatic man. There is typical coarse
popcorn calcification in this lesion which is unusually
large.

50. BENIGN LYMPHOPROLIFERATIVE DISORDERS
 Lymphocytic interstitial pneumonia
 Diffuse infiltration of pulmonary parenchyma by plasma
cells and lymphocytes
 Commonly associated with underlying immunological
disorders like Sjogren’s syndrome and AIDS
 Bilateral ground glass opacification and cysts
 Follicular bronchiolitis
 Hyperplasia of MALT in the airways
 Reticular or reticulonodular shadowing with centrilobular
nodules and ground glass opacity, bronchial wall
thickening, bronchial dilatation, interlobular septal
thickening and peribronchovascular airspace
consolidation is seen

51. MALIGNANT LYMPHOPROLIFERATIVE DISORDER
 Lymphoma
 Hodgkin's lymphoma commoner than non-Hodgkin’s lymphoma
 May appear as one or more areas of pulmonary consolidation, s
multiple pulmonary nodules or as miliary nodules and
reticulonodular shadowing resembling lymphangitic carcinomatosa.
 The pulmonary opacities radiate outside from the hila
 Very rapid increase in the size of the lymphomatous deposits so
that it gets confused with pneumonia has been seen in high grade
non-Hodgkin’s lymphoma.
 Non- Hodgkin’s lymphoma of MALT type are most frequently
encountered primary lymphomas of the lung and appear as solitary
or multiple areas of consolidation with no lobar predilection and
with prominent air bronchograms. A few of such lesions may show
calcification but cavitation does not occur.
 Pleural effusions are common except in MALT type lymphoma

52. Primary pulmonary lymphoma. This appearance
had been very slowly progressive over several
years.

53. Pulmonary
involvement by
lymphocytic
lymphoma showing
multiple pulmonary
masses

54. Pulmonary
involvement by non-
Hodgkin's lymphoma
showing an
appearance closely
resembling
lymphangitic
carcinomatosa with
widespread nodules
and thickened septal
lines.

55. MALIGNANT LYMPHOPROLIFERATIVE DISORDER
 Leukemia
 Pulmonary infiltration of lungs at autopsy is found in two-
thirds of the patients with leukemia
 Usually asymptomatic
 Imaging features include diffuse bilateral reticulations and
patterns resembling interstitial edema, lymphangitic
carcinomatosis, small nodules, ground glass opacification or
consolidation
 Mediastinal lymphadenopathy with pleural effusion may be
present
 Pleural thickening due to a chloroma formation is also seen
rarely
 Patients with leukostasis, which is seen when the WBC count
is extremely high, present with dyspnea.
 Chest radiographs of such patients may be normal or show
air space shadowing d/t pulmonary edema.

56. PULMONARY METASTASES
Arise usually from
 Breast
 GIT
 Kidneys
 Testes
 Head and neck tumours
 Bone and soft tissue sarcomas

57. PULMONARY METASTASES
Presentation
 One or more discreet, spherical and well defined
pulmonary nodules, but can be irregular
(adenocarcinomas) and show cavitation (squamous
cell carcinomas)
 Calcification unusual except in case of
osteosarcoma and chondrosarcoma
 Rate of growth is variable (explosive in
choriocarcinomas and osteosarcomas and
extremely slow in thyroid carcinomas)

58. PULMONARY METASTASES
Techniques for diagnosing metastases
 High kV films ( above 1 cm )
 Sensitivity increased by CT, but specificity
decreases especially in nodules below 6 mm
 When calcification can be identified, metastases
can be excluded except for osteosarcoma and
chondrosarcoma

59. PULMONARY METASTASES
Use of CT to detect pulmonary metastases is for
A. Investigation of a patient with normal chest radiograph
in whom likelihood of metastases is high and in whom
the demonstration of the presence of metastases
would alter the management
B. Investigation of patients who are being considered for
surgical resection of a known pulmonary metastases to
look for further occult lesions
C. Distinction of solitary from multiple pulmonary nodules
in a patient with an extrathoracic primary tumour in
whom the diagnostic question is metastasis vs. primary
bronchial carcinoma
 PET is useful for detecting of thoracic metastases, but
weakness of PET is the limited sensitivity for nodules
less than 10 mm.

60. Multiple, well-
defined spherical
nodules in the
lungs. Rib
metastases with
associated soft
tissue swelling are
also present
(arrows). In this
case the primary
tumour was a
synovial cell
carcinoma.

61. CT demonstrating a single peripheral metastasis
(arrow). There were multiple lesions at other levels.
The volume loss and scarring in the left lung is
secondary to previous resection of the primary
bronchogenic carcinoma.

62. Irregular
pulmonary
metastases due
to metastatic
adenocarcinoma
from an
unknown
primary. The
nodules are
irregular in
outline. A large
left pleural
effusion is also
present

63. LYMPHANGITIC CARCINOMATOSIS
 Permeation of pulmonary lymphatics and/or adjacent
interstitial tissue by neoplastic cells
 Most common tumours that spread by this manner are
 Bronchus
 Breast
 Stomach
 Prostate
 May also develop secondary to blood borne emboli
lodging in pulmonary arteries, direct extension from hilar
lymph node, from pleura into adjacent interlobular septa
or from a primary carcinoma of the lung into adjacent
peribrochovascular interstitium

64. LYMPHANGITIC CARCINOMATOSIS
 Radiological features:
 Fine reticulonodular shadowing and/or thickened
septal lines
 Subpleural edema visible as thickening of fissures
 Pleural effusion
 HRCT shows nonuniform, often nodular thickening
of the interlobular septa and irregular thickening of
the brochovascular bundles in the central positions
of the lungs
 Nodular shadows may be seen scattered
throughout the parenchyma

65. Unilateral
lymphangitic
carcinomatosis
due to carcinoma
of the bronchus,
showing thickened
septal lines and
nodules confined
to the right lung

66. Bilateral
lymphangitic
carcinomatosis
showing bilateral
thickened septal
lines together with
widespread
nodulation of the
lungs. The primary
tumour in this 71
year old woman was
presumed to be a
bronchial carcinoma
(a diagnosis based
on sputum
cytology).

67. High-resolution CT of lymphangitic carcinomatosis.
Note the variable thickening of the interlobular septa and the
enlargement of the bronchovascular bundle in the centre of the
secondary pulmonary lobules.
The polygonal shape of the walls (septa) of the secondary pulmonary
lobules is particularly well shown anteriorly.
The pulmonary nodule is due to a discrete metastasis, a relatively
frequent finding in this condition.

68. UNUSUAL PATTERNS OF METASTATIC CANCER
Endobronchial metastasis:
 Airway obstruction is the dominant feature
 Melanoma
 Renal
 Colorectal
 Breast
Miliary metastases:
 Thyroid
 Renal
 Bone sarcomas
 Choricarcinoma
Tumour emboli:
 Pattern of pulmonary arterial hypertension
 Hepatoma
 Breast carcinoma
 Kidney
 Stomach
 Prostate
 Choriocarcinoma

69. SOLITARY PULMONARY NODULE
 Defined as a solitary circumscribed pulmonary
opacity with no associated pulmonary, pleural or
mediastinal abnormality measuring less than 3 cm
in diameter
 Only 1% of solitary masses under the age of 35 will
ne malignant

70. CAUSE OF SPN
 Bronchial carcinoma
 Carcinoid
 Granuloma
 Hamartoma
 Metastasis
 Chronic pneumonia or abscess
 Hydatid cyst
 Pulmonary hematoma
 Bronchocele
 Fungus ball
 Massive fibrosis in coal workers
 Bronchogenic cyst
 Sequestration
 Atriovenous malformation
 Pulmonary infarct
 Round atelectasis

71. SIMULANTS OF A SPN
 Extrathoracic artifacts
 Cutaneous masses
 Pleural tumours or plaques
 Encysted pleural fluid
 Pulmonary vessels

72. EVALUATION OF SPN
Rate of growth
 Benign lesions have a doubling time of either less
than 1 month or greater than 18 months
 Malignant lesions have a doubling time between 1
and 18 months
 Exception in bronchiolo-alveolar cell carcinoma
which may be very slow growing with larger
doubling time
 A mass which has not grown over 2 yrs. is
considered benign.

73. EVALUATION OF SPN
Attenuation and enhancement
 A dense central nidus or diffuse calcification are
good indicators of benignity
 If the calcification is in only a part of tumour or
granular in nature then further evaluation is
necessary by CECT
 A complete lack of enhancement (<15 HU)
following CECT is indicative of benignity
 Nodules of ground glass attenuation are likely to be
malignancy, most likely bronchiolo-alveolar cell
carcinoma
Size and margins are not very reliable indicators of
whether the lesion is benign or malignant

74. Calcified infectious
granuloma engulfed
by lung cancer.
CT shows a cluster of
densely calcified small
nodules almost at the
centre of a small
carcinoma.

75. Tumour calcification. Large bronchial carcinoma in left
lower lobe showing extensive amorphous and cloud-
like calcification.
Initial examination; no treatment had been given.

76. Contrast-enhanced CT for the evaluation of a
solitary pulmonary nodule. There is differential
enhancement in this lesion that was due to a
primary adenocarcinoma

77. TO SUMMARIZE…
 When u see a SPN, first confirm its intrapulmonary
location by taking a lateral radiograph or performing
a CT scan
 Diffuse calcification, completely absent
enhancement on contrast CT and no growth for 2
years signifies that the lesion is benign
 If it does not show any of the following
characteristics then we assume it to of malignant
etiology (it can be either an active granuloma or
malignancy).
 Next step to be undertaken is a CT guided biopsy
(core biopsy not FNAC)

79. Thank you…