Clinical Radiology 75 (2020) 423e432

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Clinical Radiology
journal homepage: www.clinicalradiologyonline.net

Review

The role of imaging in malignant pleural

mesothelioma: an update after the 2018 BTS
guidelines
S. Sinha a, A.J. Swift a, b, M.A. Kamil a, S. Matthews a, M.J. Bull a, P. Fisher c,
D. De Fonseka d, S. Saha d, J.G. Edwards e, C.S. Johns a, *
a
Department of Radiology, Sheffield Teaching Hospitals, Sheffield, UK
b
Academic Unit of Radiology, The University of Sheffield, Sheffield, UK
c
Department of Oncology, Sheffield Teaching Hospitals, Sheffield, UK
d
Department of Respiratory Medicine, Sheffield Teaching Hospitals, Sheffield, UK
e
Department of Thoracic Surgery, Sheffield Teaching Hospitals, Sheffield, UK

art icl e i nformat ion

Malignant pleural mesothelioma (MPM) is a primary malignancy of the pleura and is associ-
Article history: ated with a poor outcome. The symptoms and signs of malignant mesothelioma present late in
Received 17 June 2019 the natural history of the disease and are non-specific, making the diagnosis challenging and
Accepted 4 December 2019 imaging key. In 2018, the British Thoracic Society (BTS) updated the guideline on diagnosis,
staging, and follow-up of patients with MPM. These recommendations are discussed in this
review of the current literature on imaging of MPM. It is estimated MPM will continue to cause
serious morbidity and mortality in the UK late into the 21st century, and internationally,
people continue to be exposed to asbestos. We aim to update the reader on current and future
imaging strategies, which could aid early diagnosis of pleural malignancy and provide an
update on staging and assessment of tumour response.
Crown Copyright Ó 2019 Published by Elsevier Ltd on behalf of The Royal College of
Radiologists. All rights reserved.

Introduction 7%.2 There are four histopathological subtypes of MPM:

Malignant pleural mesothelioma (MPM) is a cancer of
the mesothelial cells lining the pleural surface of the lung.1
Although not a common form of malignancy, MPM was
reported in nearly 7,000 patients in the UK between 2014
and 2016 (84% were men).2 The number of deaths from
MPM is estimated to reach 90,000 by 2050 and the number
of UK cases is predicted to peak by 2025.2,3 MPM has a
universally poor outcome, with a 3-year survival of only
epithelioid, sarcomatoid, mixed, and desmoplastic. Of these
pathological subtypes, sarcomatoid has the worst median
survival of 4 months; the epithelioid subtype has the best
prognosis with a median survival of 13 months.4
The causative link between asbestos and malignant
pleural mesothelioma was identified in the 1960s.5 Expo-
sure is either through the person’s occupation, as with the
majority, or passive exposure from washing the clothes of
individuals who work with asbestos. The lifetime risk of

* Guarantor and correspondent: C. S. Johns, Radiology Department, Northern General Hospital, Sheffield S5 7AU, UK. Tel.: +0114 2715964.
E-mail address: c.johns@sheffield.ac.uk (C.S. Johns).

https://doi.org/10.1016/j.crad.2019.12.001
0009-9260/Crown Copyright Ó 2019 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. All rights reserved.
424 S. Sinha et al. / Clinical Radiology 75 (2020) 423e432

developing MPM is dependent upon the duration and de-
gree of exposure to all forms of the naturally occurring sil-
icate mineral, including the more common forms used in
industry such as chrysolite (white asbestos) and amphibole
(blue and brown asbestos).1,6 Asbestos exposure is also
associated with a number of benign and malignant pleural
and pulmonary diseases, including asbestosis, pleural
effusion, pleural thickening, pleural plaques, round atelec-
tasis, and lung cancer.7 These are shown in Fig 1.
The high incidence of mesothelioma in exposed in-
dividuals has led to interest in screening at-risk patients
with blood tests, breath tests, and low-dose computed to-
mography (CT). This remains a controversial debate,
hampered by a low incidence even in high-risk populations,
subtle imaging findings, and a lack of curative therapy.8e11
Routine screening of asymptomatic patients by radiog-
raphy with established asbestos-related pleural plaques is
not advised. Plaques are an identifier of asbestos exposure,
but are not pre-malignant. A large-scale pilot screening
programme designed to examine the association between
pleural plaques and the risk of pleural mesothelioma in
former asbestos-exposed workers concluded that, although
pleural plaques may be an independent risk factor for me-
sothelioma, specific screening for pleural mesothelioma
could not be recommended due to the frequency and
prognosis of pleural mesothelioma.12
Metastatic pleural disease (frequently from lung and
breast cancer) is more common than mesothelioma,13 but
the most common primary malignancy of the pleura is
MPM. It most frequently affects the right hemithorax (ratio
1.6:1 right to left), likely due to the higher surface area and
different lymphatic drainage.1 Due to the latency period
from exposure to the development of pleural malignancy of
between 20 and 50 years, the highest incidence of MPM
effects patients aged 70e84 years.4,14 The mainstay of
treatment of mesothelioma lies with systemic chemo-
therapy, although there may be a role for surgery in certain
patients with surgically resectable disease.15 Imaging is
crucial in the decision regarding suitability for surgery.
The British Thoracic Society (BTS) diagnostic
pathway
Malignant pleural mesothelioma is challenging to di-
agnose as there are no clinical features that are specific to
the disease. Shortness of breath, chest discomfort, cough,
loss of weight and appetite, fatigue, and finger clubbing are
the key clinical features of mesothelioma, but also occur in
patients with benign and malignant lung and pleural
diseases.1,16,17
The BTS published guidelines for the investigation and
management of mesothelioma in 2018; the guidance on
imaging is summarised in Table 1.18 In the guideline, the
first line imaging technique for all patients with clinical
features suggestive of MPM is a chest radiograph. Those
with suspicious radiographic features should be urgently
referred for further investigation, and further imaging may
be considered in patients with persistent symptoms with
prior asbestos exposure. The second-line investigation of
MPM is contrast-enhanced CT of the thorax (with the
contrast medium in the venous phase). Integrated positron-
emission tomography (PET)-CT is recommended, but with
caution due to high numbers of false positives after talc
pleurodesis,19 and magnetic resonance imaging (MRI) is
currently only recommended when differentiating the

Figure 1 Benign complications of asbestos exposure. (a) A patient with benign calcified pleural plaques, demonstrated as “holly-leaf” regions of
calcification, easily identified on the unenhanced thoracic CT image. (b) A benign asbestos-related effusion, with no pleural nodularity. (c) A
prone unenhanced high-resolution CT image of a patient with asbestosis, note the mild sub-pleural reticulation in areas away from the pleural
plaques. (d) Rounded atelectasis in a patient with diffuse pleural thickening from asbestos exposure.
 S. Sinha et al. / Clinical Radiology 75 (2020) 423e432
Table 1
A summary of the imaging recommendations in the 2018 BTS guideline.
Offer all patients with clinical features of mesothelioma an urgent chest
radiograph
Consider referral for further investigation in patients with persistent
symptoms and history of asbestos exposure despite normal chest X-
ray
All patients with radiographic or clinical features of MPM should be
referred to a specialist centre (2-week wait suspected cancer pathway)
Contrast-enhanced CT (optimised for the pleura) is the first-line cross-
sectional imaging modality
Staging of MPM should be recorded according to version 8 of the IASLC
staging proposal
MRI should be considered in patients where differentiating T stage will
affect management (i.e. chest wall invasion)
PET-CT should be considered in patients where excluding distant
metastasis will change management
Do not rely on cytology alone to make a diagnosis of MPM unless a biopsy
is not possible or not required to determine management due to
patient wishes or poor performance status
MPM, malignant pleural mesothelioma; CT, computed tomography; PET-CT,
venous phase). Integrated positron-emission tomography; MRI, magnetic
resonance imaging; IASLC, International Association for the Study of Lung
Cancer.
depth of invasion will alter management, such as the suit-
ability for surgical treatment.
Ultimately, tissue is required to confirm MPM. The
easiest method is pleural aspiration, but the diagnostic yield
from pleural aspiration and cytology alone is low (reported
as 16e73% sensitive).20e22 A pleural biopsy is usually
required to first confirm the diagnosis and the histological
subtype of MPM. Guidance by ultrasound or CT allows for
percutaneous biopsies,23 which may be improved with the
addition of PET,24 but other more invasive methods, such as
medical thoracoscopy and video-assisted thoracoscopic
surgery (VATS), have higher diagnostic rates (with sensi-
tivity reaching 94e100%).25,26
Chest radiography
Chest radiography is insensitive and non-specific for the
diagnosis of MPM,27 but recommended as the first-line im-
aging test because of the relatively low dose of ionising ra-
diation and easy availability. A unilateral pleural effusion is
the commonest feature, reported in 94% of cases of pleural
malignancy.15 The typical feature of mesothelioma is diffuse
pleural thickening, which eventually encases the pleural
surface causing volume loss, with spread along the inter-
lobar fissures,28 although these are late findings (Fig 2).
Pleural plaques, often seen on the mediastinal or diaphrag-
matic pleura, indicate prior asbestos exposure, but are not a
pre-malignant disease.29 In patients with persistent symp-
toms and history of asbestos exposure despite normal chest
radiography, further imaging may be considered.
CT
Contrast-enhanced CT of the thorax is the initial cross-
sectional imaging method to evaluate patients with sus-
pected MPM. Unlike in other thoracic oncology settings,
which time the contrast medium bolus to the arterial phase,
425
the contrast medium bolus timed at optimal enhancement
of the pleura (this varies between centres, but is typically
100 ml iodinated contrast medium with around 45e70
seconds delay). Fig 3 demonstrates the difference in
appearance between an arterial and venous phase image of
a pleural mass. The images are normally reviewed with a
soft-tissue window and level, but “liver” setting may help to
highlight regions of abnormal pleura. Again, the typical
features of malignant pleural disease include unilateral
pleural thickening and ipsilateral pleural effusion.30,31
The features of mesothelioma identifiable on CT are
shown in Fig 4, and include pleural enhancement, pleural
thickness >1 cm (sensitivity 35e47% and specificity
64e94%), pleural nodularity (sensitivity 37e48% and spec-
ificity 86e97%), mediastinal pleural involvement (sensi-
tivity 70e74% and specificity 83e93%), nodular or irregular
thickening of inter-lobar fissure(s) (sensitivity 10% and
specificity 100%) and infiltration of the chest wall or dia-
phragm (sensitivity 17e29% and specificity 100%).32e38 The
above features are present relatively late in the disease.
Although not as specific to malignancy, subtle nodular
pleural thickening of the mediastinal or fissural pleura,
particularly in the presence of a unilateral pleural effusion
or pleural plaques should raise the suspicion for early ma-
lignancy.29,34,39 A number of features may also indicate
benign disease, such as the split pleura sign in which both
the visceral and parietal pleura are thickened and enhance
with the pleural effusion between them (Fig 5), and sub-
pleural oedema, in which the extrapleural fat is high density
due to oedema.40,41
Although the visceral pleura lymphatics drain in the
same pattern as the lung, the parietal lymphatics drain
through different pathways.42 The parietal pleura drains to
internal mammary, pericardial, retrocrural, epigastric, sub-
pleural, and paraspinal lymph nodes.43 These different
lymph node stations should be scrutinised when staging
patients with mesothelioma. Fig 6 provides examples of
these nodal stations in patients with advanced
mesothelioma.
Differentiating metastatic pleural disease from MPM is
difficult. Pleural metastases from a primary malignancy of
the lung, breast, ovary, stomach, and lymphoma are more
common than malignant pleural mesothelioma. Therefore,
the CT images should be scrutinised to exclude an alterna-
tive primary. The cross-sectional imaging features of met-
astatic pleural disease are otherwise similar to MPM,31,35
although the absence of pleural plaques, another primary
(particularly lung) or mediastinal or hilar lymph node
enlargement would suggest mesothelioma is less likely.38
PET
Integrated PET-CT is recommended as an add-on test for
the detection of nodal disease and extra-thoracic spread in
potential surgically operable patients. 2-[18F]-fluoro-2-
deoxy-D-glucose (FDG) is a glucose analogue bound to 18-
fluorine, a positron emitter. Three-dimensional (3D) im-
ages of the uptake of FDG can be produced, allowing for
426 S. Sinha et al. / Clinical Radiology 75 (2020) 423e432
Figure 2 The spectrum of chest radiograph findings in mesothelioma. (a) Chest radiograph shows a small loculated right pleural effusion. (b)
Chest radiograph shows extensive circumferential right pleural thickening with associated volume loss of the right hemithorax.
Figure 3 The difference in pleural mass enhancement between an
arterial and a venous CT of the chest. Pleural thickening is much more
pronounced in the venous phase scan.
qualitative and quantitative assessment of tissue glucose
uptake and, therefore, an assessment of metabolic activity.
A standardised uptake value (SUV) of 2 can reliably differ-
entiate benign from malignant disease with a sensitivity of
88e100% and specificity of 88e92%,44 but due to the risk of
false positives, PET-CT should be avoided in patients who
have undergone previous talc pleurodesis (Fig 7) or in
populations with a high prevalence of tuberculosis.19 Tu-
mours with low proliferation rates or early disease can also
produce false negatives.45
Although currently only recommended for nodal and
metastatic staging in mesothelioma, PET-CT may be useful
in the diagnostic and prognostic assessment of MPM pa-
tients, likely reflecting tumour aggressiveness.46 Due to its
representation of the metabolic activity of tissues, PET may
potentially increase the diagnostic accuracy of pleural bi-
opsy,24 and a reduction in SUV may be a marker of early
response to chemotherapy, although talc therapy will
significantly affect its utility in this regard.46e49
MRI
The BTS recommend thoracic MRI when differentiating T
stage will alter management, i.e., in decisions regarding
suitability for surgical resection.50 The advantage of MRI
over CT and PET is excellent soft-tissue contrast: MRI is
significantly more accurate than CT at identifying invasion
of the endo-thoracic fascia, chest wall, diaphragm, and
mediastinal fat.50 MRI has a sensitivity and specificity of
87.5% for T2 disease and for T3 disease a specificity of 91%
and sensitivity of 100%.50 Often, MRI will upstage the pa-
tient over CT identifying local invasion51; however, diag-
nostic CT has better spatial resolution, exhibits fewer issues
with respiratory and cardiac motion artefact and is superior
to MRI in determining nodal stage. The biggest limitations
to MRI are long acquisition times, low proton density, and
susceptibility artefacts from airetissue interfaces. Im-
provements in MRI hardware and parallel imaging and view
sharing techniques have significantly reduced these limi-
tations.52e54 A large volume of the literature in imaging
mesothelioma on CT and MRI is now dated, so it would be
interesting to update a comparison between CT and MRI
after improvements in both CT thin section capabilities and
improving MRI technologies.
The characteristic MRI features of malignant pleural
disease are: heterogeneous high signal on T2 weighted MRI
sequences, iso-intense or slightly hyperintense to adjacent
muscle on T1 and avid enhancement with gadolinium
(Fig 8). Combined with a pleural thickness >1 cm, this is
very accurate for differentiating malignant from benign
pleural disease (sensitivity 100% and specificity 95%).55,56
Diffusion-weighted MRI (DWI) creates images based on
the diffusion of water molecules, through a quantifiable
measurement called the apparent diffusion coefficient
 S. Sinha et al. / Clinical Radiology 75 (2020) 423e432 427

Figure 4 CT features of mesothelioma. A panel of representative contrast enhanced CT images of patients with mesothelioma at presentation. (a)
A patient with a small pleural effusion with visceral and parietal pleural thickening (arrowhead) that involves the anterior mediastinal pleura
(arrow). (b) Focal pleural thickening (arrow) with evidence of invasion through the chest wall. (c) A patient with mesothelioma with local
invasion through the diaphragm and the chest wall. Note the calcification from previous talc pleurodesis (arrow). (d) A subtler case of meso-
thelioma with nodular pleural thickening along the mediastinal pleura (arrow).

(ADC). There is restricted diffusion (low ADC) in malignant
pleural disease, due to hypercellularity and hyper-
vascularity and less restriction (higher ADC value) in
benign, necrotic, or inflammatory pleural lesions.57 DWI
ADC alone can differentiate benign from a malignant pleural
disease, with a sensitivity of 71.4% and specificity of 100%.
Using both DWI and dynamic contrast-enhanced (DCE) MRI
the diagnostic accuracy for mesothelioma can be increased
to 94%.58 Pleural pointillism or heterogeneity of restricted
diffusion on high-b-value DWI images (1000 s/mm2) can
similarly differentiate malignant pleural disease from
benign disease. This method performed substantially better
than mediastinal pleural thickness and shrinking lung, and
may reduce the number of unnecessary invasive procedures
for malignant pleural mesothelioma, especially in those
with poor prognosis. The main advantage of pointillism is
simplicity of reporting, but its disadvantage is greater
subjectivity.59
The cross-sectional imaging features of pleural malig-
nancy described above are indicative of late-stage disease.
Current imaging methods are limited in the detection of
early pleural malignancy, resulting in poor survival rates
amongst these patients. An imaging-based solution could
prevent many patients from undergoing invasive proced-
ures as part of diagnosis and staging, limiting such pro-
cedures to those patients who are predicted to have a better
prognosis. Furthermore, the majority of imaging features
are morphological, resulting in interobserver variability.
There is significant interest in all areas of radiology to in-
crease quantitative and semi-quantitative metrics to
address this short coming, for example measurements of
gadolinium enhancement to infer tumour angiogenesis and
ADC to infer cellularity.60
Ultrasound
Although not suitable to directly diagnose mesotheli-
oma, ultrasound is often used for image-guided pleural
aspiration or percutaneous biopsy of a pleural mass. The
428 S. Sinha et al. / Clinical Radiology 75 (2020) 423e432

imaging features suggesting malignant pleural disease

mirror those findings on other techniques, i.e. pleural
thickening >1cm (sensitivity of 42% and specificity of 95%)
and nodularity (sensitivity 42% and specificity of 100%).37,61
The reported diagnostic yield from cytology on a pleural
aspirate sample is variable with sensitivity ranging from
16% to 73%.20,21 Where the diagnosis from pleural aspiration
is negative or inconclusive, the BTS guidelines recommend
thoracoscopy. If thoracoscopy is not suitable for the patient
and/or contrast-enhanced CT shows pleural thickening, an
image-guided pleural biopsy (CT or ultrasound) has a high
yield (sensitivity rates reported up to 94% and many studies
suggesting 100% specificity), with low complication
rates.23,26,62,63 The biopsy site can be correlated to a pleural
site demonstrating high FDG uptake to increase diagnostic
yield, if PET/CT has been undertaken.24

Staging MPM

The tumourenodeemetastasis (TNM) system for staging

Figure 5 The split pleura sign of chronic empyema. The visceral and
parietal pleura both enhance due to neovascularity in chronic
empyema.
of MPM was updated in 2016 based on recommendations by
the International Association for the Study of Lung Cancer
(IASLC) and is used to predict patient survival.64e66 The
TNM staging system assesses the local invasion of the
tumour (T), nodal involvement (N) and metastatic disease

Figure 6 Nodal stations in mesothelioma. Typical nodal stations in a patient with malignant mesothelioma. Right and left paratracheal (a),
axillary (b), aorto-pulmonary window (c, arrow), internal mammary (c, arrowhead), precardiac (d), subpleural (e) and coeliac (f) node stations.
 S. Sinha et al. / Clinical Radiology 75 (2020) 423e432 429

Figure 7 PET-CT in malignant mesothelioma. Coronal maximum intensity projection images from FDG PET-CT in two patients. (a) The patient
has malignant mesothelioma of the left lung. (b) The patient on the right has lung cancer I in the right lung and pleural uptake in the left lung
due to talc pleurodesis. Note the challenges of differentiating mesothelioma from talc.

Figure 8 MRI in mesothelioma. (a) Fat-saturated T1 imaging shows nodular pleural thickening. (b) The DWI image shows focal areas of
restricted diffusion (high signal) along the pleura, which is confirmed as a low ADC (low signal) on the ADC map (c).

(M) and is summarised in Table 2. This staging is based on
surgical staging, and hence, is difficult to transfer accurately
to radiological staging.
TNM 8 differs from the seventh edition in two key as-
pects. Firstly, the clinical and pathological T1a and T1b were
combined into a single T1 category. Second, hilar and ipsi-
lateral nodes have been merged and categorised as N1 and
contralateral nodes reclassified as N2. N3 has been removed
from TNM version 8.
Despite its role as the initial diagnostic test for MPM, CT
is limited for staging. CT is particularly challenging in the
assessment of depth of invasion, often under estimating the
T stage,67 a key requirement for assessment of suitability for
surgery. Further, identifying mediastinal nodes on CT is
difficult (sensitivity 60% and specificity 70%) as adjacent
pleural thickening obscures the lymphadenopathy.4,29,34,68
PET/CT performs better for the detection of nodal dis-
ease,69 but the reference standard for staging mesothelioma
remains postoperative histological staging and media-
stinoscopic sampling of lymph nodes. CT TNM staging is
associated with interobserver variability making it is sub-
optimal in predicting prognosis in patients with MPM.70,71
As such, there is increasing interest in moving towards
tumour volume in the assessment of staging.66,72 The North
American Multi-centre Volumetric CT Study for Clinical
Staging of Malignant Pleural Mesothelioma found poor
correlation of T staging between two reporting radiologists,
but good correlation for tumour volume measurements.
The tumour volume also correlated significantly with
pathological T stage, pathological N stage, as well as with
overall survival.71
Radiological assessment of tumour response
to treatment
The treatment of MPM involves a multimodality
approach of surgery, radiotherapy, and chemotherapy, and
there is a paucity of data assessing the role of imaging in the
follow-up of MPM. Assessing the response to treatment
using standard RECIST criteria that require bidimensional
measurements is not practical and often not feasible in
monitoring mesothelioma. The recent BTS guidelines
recommend the modified Response Evaluation Criteria In
Solid Tumours (mRECIST) criteria to assess treatment
response based upon tumour thickness on CT. The revised
mRECIST criteria is based on measuring tumour thickness
on CT perpendicular to the chest wall or mediastinum in
430 S. Sinha et al. / Clinical Radiology 75 (2020) 423e432

Figure 9 A demonstration of mRECIST calculation. The solid white line shows the measurement of pleural thickening at three representative
levels in the thorax at baseline (top row) and at follow-up (bottom row), showing disease progression.

two positions at three levels in the thorax.73 Fig 9 demon-

Table 2 strates an mRECIST case in a follow-up patient with meso-
The 8th the International Association for the Study of Lung Cancer (IASLC) thelioma. The six measurements are combined into a single
TNM staging for malignant pleural mesothelioma.78 unidimensional value, which can be serially monitored.
Primary tumour (T) Despite this recommendation, it is noted that non-spherical
TX - Primary tumour cannot be assessed tumour growth will potentially limit the usefulness of
T0 - No evidence of primary tumour
mRECIST in MPM,67 although other quantitative methods
T1 - Tumour limited to ipsilateral parietal and/or visceral pleura
T2 - Tumour involving each of the ipsilateral pleural surfaces plus:
for the assessment of response to treatment of MPM are not
currently recommended for everyday practice.
 involvement of the diaphragm, or Tumour volume measurement is a quantitative method
 extension into the underlying pulmonary parenchyma shown to be useful in assessing response to treatment, but
T3 - Locally advanced but potentially resectable, involving all of the
is time-consuming to perform.18 A reduction in tumour
ipsilateral pleural surfaces plus:
volume on CT post-treatment for MPM is associated with an
 involving the endo-thoracic fascia, or improved survival rate,74 and this is also the case for tumour
 extends into the mediastinal fat/chest wall soft tissues, or volume on MRI.75 Functional imaging techniques using MRI,
 involves the pericardium such as DWI and DCE MRI, have the potential to act as a
T4 - Locally advanced, unresectable tumour. Involves all the ipsilateral
pleural surfaces plus:
quantitative method of assessing tumour response to
treatment. These techniques are reflective of underlying
 diffuse extension or multifocal masses in the chest wall,  rib tumour pathophysiology such as tissue cellularity and
destruction, or micro-vessel density.60,76,77
 direct extension into the peritoneum across the diaphragm, or
 extension into the contralateral pleura, mediastinal organs or spine,
or
Conclusion
 extends through the internal surface of the pericardium  pericar-
dial effusion, or involves the myocardium
Regional lymph nodes (N) The clinical features of malignant pleural mesothelioma
NX - Regional lymph nodes cannot be assessed are non-specific and patients often present with advanced
N0 - No regional lymph node metastases
disease, so overall survival is poor. Non-invasive tests are
N1 - Ipsilateral bronchopulmonary, hilar or mediastinal lymph nodes
involved
relatively limited in the diagnosis of mesothelioma and
N2 - Contralateral mediastinal, ipsilateral or contralateral supraclavicular little has changed since the previous clinical radiology re-
lymph nodes involved view in 2009,42 despite the publication of BTS guidelines. In
Distant metastasis (M) order to improve rates of survival early diagnosis is required
M0 - No distant metastasis
and novel methodologies for non-invasive imaging offer
M1 - Distant metastasis present
some potential.
 S. Sinha et al. / Clinical Radiology 75 (2020) 423e432
The mainstay of imaging rests with contrast enhanced
CT. The diagnosis and staging are based on CT and immu-
nohistological findings. It is unclear if novel methodologies
such as MRI and PET can add value, particularly in patients
with atypical or equivocal CT signs and in follow-up, and
their roles are yet to be fully validated prospectively.
Declaration of interest
The authors declare no conflict of interest.
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