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DR.

Muhammad Bin Zulfiqar


PGR IV New Radiology Department
SHL/SIMS
radiombz@gmail.com

Agenda
Brief introduction
Radiological Modalities
Radiological Features
Radiological Imaging Of Complications

Definition

Bronchogenic carcinoma is a malignant neoplasm of the


lung arising from the epithelium of the bronchus or
bronchiole.

Lung Cancer Demographics

Most common cancer in males world-wide


Leading cause of cancer mortality in women and men
(United States)
Mortality rates in women began increasing in 1935
and surpassed breast cancer in 1987

Risk Factors

Cigarette smoking
Radon gas
Industrial exposure e.g. asbestos, arsenic, uranium
Concomitant disease e.g. Chronic pulmonary scar and
fibrosis

Preinvasive Lesions

Atypical adenomatous hyperplasia


Squamous dysplasia / carcinoma in situ
Diffuse idiopathic pulmonary neuroendocrine cell
hyperplasia

Classification

According to anatomy:

Central lung cancer, mostly is squamous cell carcinoma and small

cell carcinoma.
Peripheral lung cancer, mostly is adenocarcinoma and large cell
carcinoma.

According to histology:

Small cell lung cancer(SCLC) 20%


Non-small cell lung cancer(NSCLC)

Adenocarcinoma 30-40
Squamous cell carcinoma 30-40%
Large cell Undifferentiated carcinoma 10%

Continued

Classification
According to Pathology:

Squamous cell carcinoma: Most common subtype. Arises from

altered bronchial epithelium and growth in situ. Related to


cigarette smoking. Cavitation can occur. Strongly associated with
smoking.
Adenocarcinoma: Arises from the submucosal glands, located in
peripheral airways and alveoli. Commonest subtype in women &
non-smokers.
Large-cell carcinoma: Located peripherally. They can be quite
large. Strongly associated with smoking.
Small Cell Lung Cancer: Derived from neuroendocrine cells. May
be related to paraneoplastic syndromes.
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Clinical Features

Central tumors

Cough
Wheezing
Hemoptysis
Pneumonia

Extrapulmonary invasion

Pain
Pancoast syndrome
SVC Syndrome

Metastases
Paraneoplastic syndromes
Asymptomatic 10%

Imaging Modalities

PLAIN CHEST RADIOGRAPH


BRONCHOGRAPHY (Obsolete)
COMPUTED TOMOGRAPHY
MAGNETIC RESONANCE IMAGING
BARIUM STUDIES
ULTRASONOGRAPHY
POSITRON EMMISION TOMOGRAPHY
ANGIOGRAPHY
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Presentations of Lung
Tumor

Solitary peripheral nodule / mass with corona radiata I


pleural tail sign / satellite lesion
Ground glass haze
Consolidation
Cavitation
Central mass: common in small cell carcinoma
Unilateral hilar enlargement (secondary to primary
tumor / enlarged lymph nodes)
Anterior+ middle mediastinal widening (suggests small
cell carcinoma)
Continued

Presentations of Lung Tumor

Segmental / lobar / lung atelectasis


Reverse S sign of Golden" on PA CXR
Rat tail termination of bronchus
Bronchial cuff sign
Bronchial cut of sign
Local hyperaeration
Mucoid impaction of segmental I lobar bronchus
Continued

Presentations of Lung
Tumor

Persistent peripheral infiltrate


NO air bronchogram
Pleural effusion
Chest wall invasion:
Involvement of main pulmonary artery (18%); lobar
Calcification in 7% on CT

Solitary Pulmonary Nodule /


Mass

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.

A focal opacity (solitary pulmonary nodule) is visible


with speculated margins

Corona radiata sign in a malignant lesion with spiculation at the margin.

Mass

Bronchial carcinoma in the left lower


lobe showing typical rounded,
slightly lobular configuration. The
mass shows a notch posteriorly

Ground glass haze

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

Bronchoalveolar Carcinoma--- as ground glass haze in


left lower lobe and lingula

Consolidation

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)

Air space infiltration involving almost all left lung


zones and right mid zone

Continued

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 ofbronchoalveolar carcinoma, the patient
condition did not permit for this.

CT confirms extensive airspace


opacities with numerous airbronchograms. 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
ofbronchoalveolar carcinoma, the
patient condition did not permit for
this.

CT Angiogram Sign

CT angiogram sign. A
patient with bronchoalveolar
carcinoma. Enhancing
pulmonary vessels in a lowattenuating mass are seen.

CT Angiogram Sign

CT angiogram sign. Another


patient with bronchoalveolar
carcinoma. Enhancing
pulmonary vessels in a lowattenuating mass are seen.

cavitation

Cavitation (16%):

Usually thick-walled (> 5 mm) with irregular inner surface


(nodular internal margin);

Secondary to squamous cell carcinoma in 4 / 5th,

Followed by bronchoalveolar carcinoma

A maximum wall thickness <4 mm is unlikely to be


malignant, but rare cases do exist with thin walls
simulating bullae.

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).

Cavitating mass in the left


mid-zone and there is
bulging of the
aortopulmonary window,
indicating lymph node
enlargement.

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Irregular opacity in left


mid-zone with central air
density due to cavitation
and inferior horizontal
margin due to air-fluid
level.

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FIGURE 15-14 CT showing a cavitating squamous


cell carcinoma in the left lung. The wall of the cavity
is variable in thickness.

Bronchial carcinoma in the posterior segmentof the


right upper lobe with cavitation.

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.

Central Mass

central mass (38%): common in small cell carcinoma

Central tumours may be visible on the chest


radiograph as an abnormal convexity or density in
the hilar region.

CT scoutogram demonstrates bulkiness of the left hilum with collapse of


the left lower lobe and a small pleural effusion.
CT though the chest with contrast demonstrates numerous necrotic lymph
nodes in the sub carinal regionand left hilum with almost complete
obliteration of leftlower lobe bronchus with left lower lobe collapse.
There is a tiny left pleural effusion and bilateral enhancing adrenal lesions.
Enhancing right adrenal mass.

Axial and coronal images of the CT demonstrating extensive


mediastinal mass with compression of the SVC. The mass
also was compressing the trachea and proximal airways.

Unilateral Hilar Mass

Unilateral hilar enlargement (secondary to primary


tumor / enlarged lymph nodes)
Calcified enlarged nodes frequently benign
Nodes in short axis diameter:
0-10 mm normal (micrometastases)
>10 mm (65% sensitive + specific for tumor)
20-40 mm (37% not involved by tumor)

PET (89% sensitive, 99% specific)

Chest X-ray shows a


dense left hilum, but
no definite mass.

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Chest X-ray shows


the primary tumour
is at the left hilum.

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Dense hilum. (A) The left


hilum is dense, owing to a
mass superimposed directly
over it. (B) Corresponding
axial CT image
demonstrates the mass lying
behind the left hilum. The
mass proved to be a
squamous cell carcinoma.

Recurrent malignant left


hilar lymph nodes from a
small peripheral nonsmall cell lung cancer. (A)
CT demonstrates nodes at
the left hilum. (B) The
PET/CT image confirms
high FDG uptake in
keeping with malignant
involvement.

Mediastinal Widening

Anterior+ middle mediastinal widening

Might suggests small cell carcinoma)

A patient with a small cell lung carcinoma.


On the PA film there is a lobulated paratracheal stripe on the right.
On the lateral radiograph there is a density overlying the ascending aorta and filling the
retrosternal space.
These findings indicate a mass in the anterior as well as in the middle mediastinum.

The CT confirms the presence of mass in both the


anterior and the middle mediastinum.

PET-CT

F-18 FDG PET imaging has been shown to be an accurate, noninvasive 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.
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PET scan showing abnormal uptake of FDG in a tumour


nodule in the right upper lobe(arrow) & in two superior
mediastinal lymph nodes(arrowheads).
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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


occurenct of benign nodal enlargement coexists with a
malignant lung lesion.

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(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.
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Carcinoma of the bronchus.


Barium Swallow shows extrinsic
compression of the mid-esophagus
by enlarged subcarinal lymph
nodes.

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Segmental I lobar I lung


atelectasis

Segmental I lobar I lung atelectasis (37%) secondary to


airway obstruction (particularly in squamous cell
carcinoma):
Post obstructive lung enhances to a greater extent than
tumor on CECT
Distal lung atelectasis has a higher signal intensity
than the central mass in 77% on T2WI (due to
accumulation of secretions in obstructed lung)

Total left lung collapse. (A)


Frontal and (B) lateral chest
radiographs. The cause of the
collapse is a bronchogenic
carcinoma; the endobronchial
component is visible as an abrupt
cutoff of the left main bronchus.
Note the marked displacement of
the right lung anteriorly and
posteriorly across the midline
(arrows). Note the marked anterior
hyperlucency of the thorax on the
lateral view (B).

CT of right upper lobe collapse due to


bronchogenic carcinoma. Note how the
attenuation of the necrotic tumour is lower than
the adjacent collapsed lung which enhances with
intravenous contrast medium.

Contrast enhanced CT sections


of whole lung collapse due to a
squamous cell carcinoma in the
left main bronchus (arrow in
A). There is also a left pleural
effusion and a small
pericardial effusion. Note the
low attenuation areas relative
to the densely enhancing left
lower lobe parenchyma (B)
which represent mucus filled
airwaysthe CT mucous

bronchogram sign.

Intravenous contrast enhanced CT demonstrating right middle lobe


collapse (A). Image from a CT PET study at the same level (B) shows
increased uptake of radioisotope within the collapse. A targeted
ultrasound guided biopsy was performed and bronchogenic
carcinoma confirmed.

FIGURE 14-18 Tight right upper lobe collapse. Note how


the collapsed lobe (due to a central bronchogenic carcinoma)
results in increased right paramediastinal density.

FIGURE 15-18 Fluid-filled dilated bronchi beyond a


central obstructing carcinoma are visible in this collapsed
and consolidated right lower lobe.

Golden S sign

Reverse S sign of Golden" on PA CXR =combination


of

RUL collapse (inferiorly concave margin of lateral


portion of minor fissure, which moved superiorly
and medially with compensatory expansion of RML)
+ bulge of central tumor (inferiorly convex margin of
medial portion of minor fissure)

Goldens S sign. A right


upper lobe collapse
demonstrating peripheral
concavity and central
convexity (arrows) due to
an underlying
bronchogenic carcinoma
resulting in a reverse S
shape.

Golden S sign. Collapsed right upper lobe with mass at right hilum.

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CT of a collapsed right
upper lobe due to a
squamous cell carcinoma.
Note the peripheral air
bronchograms (arrow) in (A)
despite a central obstructing
mass with amorphous
calcification (B). There is a
convex border of the
collapsed lobe (arrows) (B)
which is the CT equivalent of
Goldens S sign.

Rat tail termination of


bronchus

Left upper lobe collapse due to bronchial carcinoma.


Carcinoma has caused rat tail like narrowing of left upper main bronchus

Mucoid Impaction

Mucoid impaction of segmental / lobar bronchus (due


to endobronchial obstruction) or from external
compression on bronchus.

Bronchocele with typical


gloved-finger branching
pattern

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Bronchocele due to carcinoma of the bronchus.


CT shows dilated, fluid-filled bronchi in the
lingula, secondary to carcinoma at the left
hilum.

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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.

Local Hyperaeration

local hyperaeration (due to checkvalve type endobronchial


obstruction, best on expiratory
view)

CT shows dilated, fluid-filled bronchi


in the right middle lobe, secondary to
carcinoma at the right hilum.

Local hyperaeration also seen.

Persistent peripheral
infiltrates

persistent peripheral infiltrate (30%) = post obstructive


pneumonitis

Chest CT shows airspace disease in


the left lower lobe with air
bronchogram and ill-defined
nodules in both lungs.

This was refractory to treatment.

Biopsy suggested bronchoalveolar


carcinoma

Bronchial cut off sign

Thebronchial cut off signrefers to the abrupt


truncation of abronchusfrom obstruction, whichmay
be due tocancer, mucous plugging, traumaor foreign
bodies. Typically, there is associateddistal
lobar collapse.

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

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

Malignant Pleural effusion

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.

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.

Large left pleural effusion


due to carcinoma of
bronchus.
There is a large echo-free
effusion above the left
hemidiaphragm
(arrowheads) and spleen
(s).

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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.
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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.

Chest Wall Invasion

Localized chest wall pain = most sensitive predictor

Tumor interdigitating with chest wall musculature on


T2WI

Obliteration of high-intensity extra thoracic fat on


TlWI

Bone erosion of ribs I spine (9%)

FIGURE 15-22 Chest wall invasion by a Pancoasts


tumour. Involvement of the soft tissues of the chest wall
appreciated on the (A) axial T1-, (B) coronal T2-weighted
MRI

FIGURE 15-22 Chest wall invasion by a Pancoasts


tumour. Involvement of the soft tissues of the chest wall
and the left second rib is appreciated.

Frontal chest radiograph demonstrates a mass in the left lung apex (white arrow in left image).
There is associated destruction of the left 2nd and 3rd ribs posteriorly (white circle). The closeup photo of the left apex shows the rib destruction (white arrow) more clearly. The combination
of an apical mass with rib destruction is characteristic for a Pancoast Tumor.

Bronchial neoplasms in contact with the thoracic wall may invade


ribs and adjacent vertebrae and engulf destroyed pieces of bone
and thus mimic intratumoral calcification as in this pancoast tumor

Involvement of Main Arteries

Involvement of main pulmonary artery (18%); lobar


+segmental arteries (53%) may result in additional
peripheral radiopacity (due to lung infarct)

Aorta may also be invaded.

FIGURE 15-21 MRI of a left lower lobe tumour that has


directly invaded the aortic wall, which has altered signal
adjacent to the tumour.

Well-defined enhanced central left lung mass is seen with


mediastinal invasion. Mass encases left main bronchus, left upper
bronchus and also left main pulmonary artery. Filling defect is
noted in the encased artery favouring a complicating thrombosis.
Multiple low attenuation enlarged mediastinal lymphadenopathy.

Calcifications

Calcification in 7% on CT (histologically in 14%)


usually eccentric / finely stippled

a)

Preexisting focus of calcium engulfed by tumor

b)

Dystrophic calcium within tumor necrosis

c)

Calcium deposit from secretory function of carcinoma


( e.g. mucinous adenocarcinoma)

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

Tumour calcification.
Large bronchial
carcinoma invading the
mediastinum
demonstrates coarse and
cloud-like calcification.

Benign calcification patterns

Feeding Vessel Sign

Feeding vessel sign. A


patient with bronchial
carcinoma. Pulmonary
artery leading directly to
the mass is seen.

Bronchial Cuff Sign

Bronchial cuff sign = focal / circumferential thickening


of bronchial wall imaged end-on (early sign)

ANGIOGRAPHY

This is mainly carried out to assess the


vascularity of a diagnosed tumour and also for
pre-operative embolisation to reduce tumour
bulk/ reduce intra-op bleeding.

92

A left inferior phrenic arteriogram shows the vessel


accounting for systemic arterial supply to the tumour
through hypertrophied pleural collateral channels.
Polyvinyl alcohol embolisation was carried out with good
clinical results

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STAGING OF BRONCHOGENIC CARCINOMA

Staging is done using the lung cancer TNM


staging system.

T= Tumour size

N= Level of nodal involvement

M= Presence or absence of metastases.

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TNM STAGING

T1

<3cm in diameter, sorrounded by lung/visceral pleura

T2

N1

>3cm in diameter/invasion of visceral pleura/lobar


atelectasis/obstructive pneumonitis/at least 2cm from
the carina.
Tumour of any size; less than 2cm from the carina/
invasion of parietal pleura, chest wall, diaphragm,
mediastinal pleura, pericardium.
Invasion of the heart, great vessels, trachea, esophagus,
vertebral body, carina/ malignant effusion
Peribronchial / ipsilateral hilar nodes

N2

Ipsilateral mediastinal nodes.

N3

Contralateral hilar/ mediastinal nodes

M0

No metastases

M1

Distant metastases present.

T3

T4

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CONCLUSION / SUMMARY

Lung cancer is an extremely prevalent disease


that most radiologists will encounter on a
frequent basis.

Familiarity with the various manifestations of


lung cancer on the different imaging modalities
may help suggest the initial diagnosis,
especially in an older patient with a history of
cigarette smoking.
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CHEST
RADIOGRAPHY
COMPUTED
TOMOGRAPHY

1st line investigation; cheap


and readily available; can
depict most of the features
of overt lung cancer and its
complications.
The gold standard in
diagnosis and staging of
lung cancer; gives crosssectional imaging with
better representation of
anatomy; clearly depicts
mediastinal adenopathy
and involvement of
adjacent structures.

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MAGNETIC RESONANCE Excellent soft tissue


resolution; clearly depicts
IMAGING

POSITRON EMISSION
TOMOGRAPHY

vascular invasion better than


CT; imaging modality of
choice for assessing Pancoast
tumours; of importance in
cases where CT findings are
indeterminate
or equivocal.
Provides excellent
depiction of
functional status of suspicious
lung masses; helps to sort out
status of nodal enlargement
coexisting with lung cancer.
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RADIOLOGY OF COMPLICATIONS
LOCAL COMPLICATIONS:
Superior Vena Cava Syndrome
Intractable Hemoptysis

DISTANT COMPLICATIONS:
Metastases

PARANEOPLASTIC SYNDROMES:
Hypertrophic Osteoarthropathy

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SVC SYNDROME

SVC (Superior Vena Cava) Syndrome is a set of symptoms


that result when blood flow through the superior vena
cava is obstructed by extrinsic compression or by tumour
invasion.

100

SVC SYNDROME

Lung cancer is the leading malignant cause of SVC


syndrome, with nonsmall cell lung cancer accounting for
about 50% of the cases and SCLC accounting for about
25% of cases occurring in malignancy.
This syndrome is a complication that occurs in 2% to 4% of
people living with lung cancer, and in some cases is the
first symptom that leads to the diagnosis.

101

SVC SYNDROME
Swelling

of the face, arms, or chest wall

Difficulty breathing (dyspnoea)

Widening

of the veins in the neck and chest

102

Axial and coronal images of the CT demonstrating extensive


mediastinal mass with compression of the SVC. The mass
also was compressing the trachea and proximal airways.

103

Stenting of superior vena cava is a well-known but not so commonly used technique to alleviate this syndrome.
The catheter wire is placed in the vena cava stenotic segment. The stent is delivered and the stenosis is solved.

104

INTRACTABLE HEMOPTYSIS

Bronchial artery angiography with embolization has


become a mainstay in the treatment of intractable
hemoptysis in some patients with lung cancer.

Major complications are rare and immediate clinical


success defined as cessation of hemorrhage ranges in most
series from 85% to 100%, although recurrence of
hemorrhage ranges from 10% to 33%.
105

Reports of neurological damage following


bronchial angiography indicate care in avoiding
obstruction of the artery of Adamkiewicz.

106

Angiographic image
showing blood ejecting
from a ruptured bronchial
artery branch (arrow)

Selective embolization of
the feeding artery obtained
with gel foam.
107

HYPERTROPHIC
OSTEOARTHROPATHY

Aka Bamberger-Marie syndrome

Hypertrophic osteoarthropathy is a paraneoplastic


syndrome most often found in non-small cell lung cancer.

108

HYPERTROPHIC
OSTEOARTHROPATHY

It is a medical condition combining clubbing and


periostitis of the long bones of the upper and lower
extremities.
Distal expansion of the long bones as well as painful,
swollen joints and synovial villous proliferation are often
seen.

109

HYPERTROPHIC
OSTEOARTHROPATHY

Diagnosis is confirmed by the characteristic bone changes


on plain radiograph and periostitis on bone scintigram.
The syndrome generally resolves dramatically with
treatment of the underlying malignancy.

110

Radiograph showing thickened, columnar


diaphyses and erosion of the terminal phalangeal
tufts in Hypertrophic Osteoarthropathy
111

Bone scintigraphy showing


periosteal proliferation along
the margins of the shafts of
the tibias, radii, ulnae and
pelvic bones.

112

DISTANT METASTASES

Small cell> Adeno > Large> Squamous

Lung cancer spread (metastatases) is sadly too common.

Nearly 40% of people with lung cancer have metastases to


a distant region of the body at the time of diagnosis.

113

DISTANT METASTASES

Lung cancer can spread to any region of the body, but most
commonly spreads to the liver, the lymph nodes, the brain,
the bones, and the adrenal glands.

114

LIVER METASTASES

The staging CT scan of the thorax is usually extended


to include the liver and adrenal glands.
CT scanning has a sensitivity of about 85% in the
detection of liver metastases. Similar rates may be
obtained with MRI and ultrasonography performed by
experienced imagers.

115

Computed tomographic (CT) scan of the abdomen


showed multiple hepatic metastases (arrows).
116

Gadolinium-enhanced 3D LAVA (Liver Acquisition with Volume Acceleration).


Hypovascular metastases are best depicted on portal venous phase images.
117

ADRENAL METASTASES

Adrenal metastases are common and often solitary.

They must be differentiated from adrenal adenomas,


which occur in 1% of the adult population.

118

ADRENAL METASTASES

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.

119

Sonogram showing a 6-cm right adrenal metastasis of


lung cancer.
120

Adrenal metastasis from small cell lung cancer


121

Coronal PET/CT image


demonstrating intense FDG
uptake in the primary left upper
lobe lung carcinoma (curved arrow)
and in the adrenal metastases
(arrows)

122

BONE METASTASES

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.

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BONE METASTASES

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.

124

Bone Metastasis from Primary Lung


Cancer :Lytic lesion of humerus with a
pathological fracture.

125

Bone Metastasis from Primary Lung Cancer expansile lytic rib lesions (arrows).
126

FDG PET images demonstrate


bone metastases (arrows).

127

Isotope bone scan. Hot spots due to bony metastases.


128

BRAIN METASTASES

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.

129

BRAIN METASTASES

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.

130

Non small cell lung cancer with hemorrhagic brain metastasis


(A) Pre-operative non-contrast enhanced computed
tomography (CT). (B) Pre-operative contrast-enhanced CT.
131

Contrast-enhanced CT scans of the same patient showing multiple


enhancing cerebral metastases of lung cancer in the left cerebral
hemisphere.
132

DIFFERENTIAL DIAGNOSES

Pulmonary metastases

Pulmonary AV malformation
133

DIFFERENTIAL DIAGNOSES

Pulmonary tuberculosis

Pulmonary hamartoma
134

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