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Leon
Legaspi
Liao
Lim, AP
Lim, PJ
Lim, RD
Liquete
Llamas, KN
Llamas, MT
Lo
A.C 49 y/o male
CC: Difficulty of breathing
6 months PTC
5 months PTC
1 month PTC
Personal History:
(+) Smoking
(+) Alcoholic drinker
Pertinent Physical Examination:
Tachypneic
Hyposthenic
Dullness on the right upper lobe
No rales
Histopath findings:
Non-small cell carcinoma
Histopathology – Non small cell CA
Bronchogenic
Carcinoma
Bronchogenic Carcinoma
• Most frequently diagnosed major cancer in
the world
• Most common cause of mortality
worldwide
• Largely due to carcinogenic effect of
cigarette smoking
• Occurs most often between 40 and 70
years (peak incidence of 50’s and 60’s)
Bronchogenic Carcinoma
• Arises by a stepwise accumulation of
genetic abnormalities that transform
benign bronchial epithelium to neoplastic
tissues
• Unlike many other cancers, the major
environmental insult that inflicts genetic
damage is known
Bronchogenic Carcinoma
• Etiology
– Tobacco smoking
– Industrial hazards (radiation, uranium,
asbestos)
– Air pollution (radon)
• Genetic predisposition
– Inherited mutations to rb and p53 genes
– 1st degree relatives of lung cancer probands
Bronchogenic Carcinoma
• Arises most often in and about the hilus of
the lung
• About ¾ of the lesions take their origin
from first-order, second-order, and third
order bronchi
Bronchogenic Carcinoma
• Tumor classification (WHO)
– Important for consistency in treatment
– Provides a basis for epidemiologic and biological
studies
Kumar, et. al. (2005). Robbins and Cotran Pathologic Basis of Disease. 7th ed. Elsevier: China. pg. 759
Bronchogenic Carcinoma
• Relative proportion of • For clinical use (on
major categories: the basis of likelihood
– Squamous cell of metastasis and
carcinoma (24-40%) response to
– Adenocarcinoma treatment):
(25-40%) – Small cell carcinoma
– Small cell carcinoma (metastatic; high initial
(20-25%) response to chemo)
– Large cell carcinoma – Non-small cell
(10-15%) carcinoma ( less
metastatic and
responsive)
Bronchogenic Carcinoma
• TNM International Staging System
– Used for NSCC particularly in preparing
patients for curative attempts with surgery or
radiotherapy
– Provides useful prognostic information
Radiologic signs of Bronchogenic
Carcinoma
• Atelectasis
– Segmental
– Lobar
• Unilateral hilar enlargement
• Overinflation, obstructive
• Mediastinal mass
• Apical pulmonary opacity
• Cavitation
• Segmental consolidation
• Parenchymal mass
• Mucoid impactation
• Poorly defined, irregular, non-homogenous density
Atelectasis
• a state of incomplete expansion of a lung
or any portion of it
• loss of lung volume – lung collapse
• there is a decrease or absence of air in
the alveoli
• It is always a secondary lesion and is
therefore a sign of disease rather than a
disease in itself. Its causes can be
grouped into six general categories
Causes:
2. Bronchial obstruction (resorption atelectasis)
– Intrinsic
– Extrinsic
3. Space-occupying process
− pneumothorax, pleural fluid, diaphragmatic
elevation, herniation of abdominal viscera into the
thorax, and large intrathoracic tumors
4. Paralysis or paresis resulting in inability to
expand a lung completely
1. Restriction of motion as a result of pleural
disease or injury.
• chronic constrictive pleuritis - causes a ↓ in volume of
one hemithorax
• pleural infections and thoracic or upper-abdominal
trauma
2. Adhesive atelectasis - non-obstructive
airlessness in patients with inactivation,
decrease, or loss of surfactant.
3. Cicatrization atelectasis - volume loss found in
patients with local or general pulmonary fibrosis
Radiographic signs of Atelectasis
• Direct Signs ( due to lobar volume loss)
– Displacement of interlobular fissures
– air bronchograms
• Indirect Signs
– Diaphragmatic elevation:
– Juxtaphrenic Peak (upper lobe atelectasis)
– Mediastinal shift
– Compensatory overinflation of normal lung
– Hilar displacement
– Reorientation of hilum or bronchi
– ULA
– LLA
– Approximation of the ribs
– Flat waist sign
– Increased lung opacity
– Absence of air bronchograms
– Absence of air bronchograms suggests central
bronchial obstruction
– Mucus bronchograms
– Shifting granuloma sign
Radiologic sign of bronchogenic
carcinoma
• Atelectasis - may be segmental or lobar
minor fissure
is elevated,
indicating
that there is
some
atelectasis.
A: The mass obscures the upper
cardiac border and aorta and
fades off into the lung superiorly.
There is some mediastinal shift to
the left and elevation of the left
hemidiaphragm.
B: Arrows point to the displaced
fissure, with the partially
atelectatic upper lobe anterior to it
• most readily seen in the right upper lobe
– Atelectasis results in elevation and concavity
of the secondary interlobar fissure laterally.
– A convexity medially with greater opacity
represents the tumor mass.
• the inferior margin of the lobe resembles the
reversed letter S (Golden's sign).
Hilar Enlargement
Overinflation
(+) consolidation at
the right base with
small bilateral
pleural effusions
Segmental
consolidation
Perihilar
consolidation
Parenchymal Mass
• Right upper lobe
– Tumor enlargment
– Golden’s sign
• Middle lobe atelectasis
• Elevation of right hemidiaphragm
Radiologic signs of Metastasis
Pleural Effusion
• Normally, the pleura cannot be seen on
chest radiographs
– Exceptions:
• where the lungs contact each other at the junction
lines
• where the visceral pleura infolds to form the
fissures.
Pleural Effusion
• most common clinical manifestation of pleural
pathology.
• A mismatch between the rates of inflow and
outflow of fluid in the pleural space leads to a
pleural effusion.
• Mechanisms in the formation of pleural
effusions:
– (1) increased capillary hydrostatic osmotic pressure,
– (2) decreased colloid osmotic pressure
– (3) increased microvascular permeability
– (4) decreased lymphatic pleural drainage
– (5) decreased pleural surface pressure
– (6) transdiaphragmatic passage of peritoneal fluid
Pleural Effusion
• Pleural effusion together with a visible
pulmonary tumor mass
– indicates involvement of the pleura by direct
extension or as the result of metastasis.
Radiographic Features of
Pleural Effusion
• depends on the patient's position and mobility of
the pleural fluid
• lateral decubitus chest radiograph
– most sensitive radiographic projection for identifying
pleural fluid
– detect as little as 5 mL of pleural fluid
• PA chest radiograph
– accumulation of at least 200 mL of pleural fluid is
needed to cause blunting of the lateral costophrenic
angles
Pleural Effusion
• AP chest radiograph
– A homogeneous left-
sided inferior opacity
with concave upper
margin, higher
laterally than medially
Pleural Effusion
• Left lateral decubitus
view
– reveals free-flowing
pleural effusion as a
uniform band of soft-
tissue density along
the chest wall
Computed Tomography of Pleural
Effusion
• CT signs to aid in distinguishing between
pleural effusion and ascites in the
peritoneal cavity
– diaphragm sign
– the displaced crus sign
– interface sign
– the bare-area sign
• Diaphragm sign
– ascites - inside the dome of the diaphragm
– pleural fluid outside the dome
• Location of the diaphragm
– readily identified in ascites
– may not be identified in pleural effusion
• Displaced crus sign
– anterolateral displacement of the
diaphragmatic crus, when pleural fluid collects
between the crus and the spine
– ascitic fluid would result in the opposite
displacement of the diaphragmatic crus