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 Table of Contents  
REVIEW ARTICLE
Year : 2014  |  Volume : 19  |  Issue : 2  |  Page : 100-105

What clinician's need to know about imaging features in lung cancer?


Department of Radiodiagnosis and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication11-Aug-2014

Correspondence Address:
Binit Sureka
Department of Radiodiagnosis and Imaging, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.138428

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  Abstract 

Bronchogenic carcinoma is one of the most common cancers both in males and females worldwide. Lung malignancies can present with manifestations involving any organ system and also mimic like benign nodules or infective consolidation. Present review highlights spectrum of typical presentations and imaging features of lung malignancies.

Keywords: Bronchogenic, carcinoma, malignancy


How to cite this article:
Sureka B, Mittal MK, Mittal A, Sinha M, Thukral BB. What clinician's need to know about imaging features in lung cancer?. J Mahatma Gandhi Inst Med Sci 2014;19:100-5

How to cite this URL:
Sureka B, Mittal MK, Mittal A, Sinha M, Thukral BB. What clinician's need to know about imaging features in lung cancer?. J Mahatma Gandhi Inst Med Sci [serial online] 2014 [cited 2019 Mar 25];19:100-5. Available from: http://www.jmgims.co.in/text.asp?2014/19/2/100/138428


  Introduction Top


Lung cancer is the most common cause of cancer-related death in men and women and is responsible for 1.3 million deaths worldwide annually. In 2013, American Cancer Society's estimates for lung cancer in the United States are about 228,190 new cases of lung cancer (118,080 in men and 110,110 in women) and an estimated 159,480 deaths from lung cancer (87,260 in men and 72,220 among women), accounting for about 27% of all cancer deaths. [1] Overall, the chance that a man will develop lung cancer in his lifetime is about 1 in 13; for a woman, the risk is about 1 in 16. The incidence of developing a lung cancer is much higher for smokers. [1],[2] In India, lung cancer was initially thought to be extremely rare but today, according to Indian Cancer Registry, approximately 63,000 new lung cancer cases are reported each year. The major risk factor for developing lung cancer is tobacco use. However, a significant number of patients with lung cancer have no history of smoking. [3] In India, there were 51,000 deaths due to lung cancer in 2008 (Globocan Report, 2008). Exact estimates of current cancer deaths due to lung cancer are not available yet, despite Indian national cancer registry being started in 1981. Actual figures regarding the magnitude of lung cancer, therefore, may be larger. [4]


  Radiological Features Top


The role of imaging lies in (i) making the diagnosis, (ii) staging the tumor, and (iii) assessing treatment response. Initial step lies in differentiating pulmonary lesions from pleural lesions. Pulmonary lesions usually have acute angles with the chest wall and engulf the pulmonary vasculature, whereas pleural-based lesions make obtuse angles, displace the pulmonary vasculature, and change its location on respiration. Extrapleural masses displace the extrapleural fat inward and cause rib erosion. Mediastinal masses have their medial margins merging with the mediastinum, may extend into the bilateral hemi thoraces, and lack air bronchogram. Metastasis to the lungs from distant primary can present as multiple nodules of variable sizes. Cavitating metastatic nodules are seen in squamous cell carcinomas and sarcomas. Calcific metastatic nodules are seen from sarcomas and mucinous adenocarcinoma.

Pathologically, there are four types of lung cancer-Squamous cell, adenocarcinoma, large cell, and small (oat) cell carcinoma. During the past 4 decades, there has been a worldwide decrease in squamous cell cancer and a sharp rise in adenocarcinoma. [5] Squamous cell carcinoma is a slow growing, central, and late metastasizing tumor. Adenocarcinoma arises peripherally and is associated with mediastinal lymphadenopathy and distant metastases at presentation. Bronchoalveolar carcinoma (BAC) is a well-differentiated subtype of adenocarcinoma which has a better prognosis. Cavitation is more common in squamous cell carcinoma [Figure 1]. Extensive hilar and mediastinal lymphadenopathy is more common in small cell carcinoma.

Nodules suspicious for malignancy are usually larger than 3 cm, peripheral margins which show irregularity, speculation, lobulation, and notching, presence of pleural tag, amorphous calcification, feeding vessel sign, positive bronchus sign-narrowing of a peripheral bronchus, doubling time of 1-18 months-26% increase in nodule diameter, thick irregular cavity with maximum thickness greater than 16 mm.
Figure 1: Squamous cell carcinoma with D1 vertebral metastases in 35-year-old male (a) Axial contrast-enhanced computed tomography scan showing destruction of D1 vertebra (arrowhead) with soft tissue component and (b) computed tomography section showing malignant necrotic right lung mass (arrow) with chest wall invasion

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Feature of pneumonia suspicious for lung cancer on imaging are as follows:

  • Golden S sign
  • Round or oval shape of the opacity
  • Pneumonia in the common bronchial territory
  • Pneumonia unchanged for more than 2 weeks
  • Pneumonia recurring at same site
  • Expansion of the consolidated lobe
  • Dilated fluid-filled bronchi
  • Visible stenosis of the supplying bronchus
  • Expanded lobe with fluid bronchogram sign [Figure 2].


Features of mediastinal invasion are loss of fat planes with the mediastinum, contact of more than 3 cm with the mediastinum, contact of more than 90° with the aorta, and invasion of mediastinal structures [Figure 3] and [Figure 4]. Elevation of hemidiaphragm is an indirect sign of mediastinal invasion on chest X-ray due to involvement of phrenic nerve. [6] Findings of chest wall invasion are obtuse angle of contact with the chest wall and tumor, obliteration of extrapleural fat plane, pleural thickening, presence of extrapleural soft tissue component and rib destruction [Figure 5]. [7] Pleural involvement is suggested by presence of pleural effusion, nodular pleural deposits, and sometimes spontaneous pneumothorax. For lymph node staging, midline nodes such as prevascular and subcarinal nodes are considered ipsilateral lymph nodes. Contralateral (N3) or gross ipsilateral (N2) lymph nodal involvement precludes surgery.
Figure 2: Central lung cancer with fluid bronchogram sign in 45-year-old male (a) Chest radiograph showing inhomogeneous opacity (arrow) right lower zone silhouetting the right hemidiaphragm, (b) axial contrast-enhanced computed tomography showing malignant necrotic mass (arrowhead) causing collapse of right lower lobe, and (c) computed tomography section distal level showing collapsed lobe with mucus filled bronchi (arrows)

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Figure 3: Central lung cancer invading into left atrial appendage in 56-year-old male (a) Axial contrast-enhanced computed tomography scan showing heterogeneous malignant lung mass (arrow) and (b) computed tomography section showing invasion into left atrial appendage (arrowhead)

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Figure 4: Squamous cell carcinoma invading superior vena cava (SVC) in 42-year-old male Axial contrast-enhanced computed tomography scan showing central lung mass invading superior vena cava (arrow)

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Figure 5: Peripheral lung cancer with chest wall invasion in 40-year-old male (a) Chest radiograph showing erosion of right third posterior rib (arrowhead) with adjacent soft tissue opacity (arrow) and (b) axial contrast-enhanced computed tomography scan showing heterogeneously enhancing soft tissue causing chest wall invasion with destruction of rib (arrow)

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Pancoast tumors are apical lung cancers with extrathoracic extension also known as superior sulcus tumors. On chest radiographs, superior sulcus tumors appear as an apical lung mass or pleural thickening. Magnetic resonance imaging is useful to diagnose invasion of chest wall, brachial plexus, neural foramina, and subclavian vessels [Figure 6]. [8]
Figure 6: Pancoast tumor in 53-year-old male Coronal reconstructed contrast-enhanced computed tomography scan showing heterogeneously enhancing necrotic mass lesion (arrow) in right side of lung causing destruction of rib with extrathoracic extension

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BAC occurs in two distinct forms solitary pulmonary nodule or in pneumonic form. Nodules may be solid or show ground glass opacity. Bubble like cystic lucencies, stretching with narrowing of bronchi, crazy paving, and computed tomography (CT) angiogram sign are features suggestive of this type of malignancy [Figure 7]. In 2011, new classification system has replaced BAC with four new terms: (a) Adenocarcinoma in situ-which at CT is usually nonsolid; (b) minimally invasive adenocarcinoma-which at CT is mainly nonsolid but may have a central solid component of up to approximately 5 mm; (c) lepidic predominant nonmucinous adenocarcinoma-which at CT is usually part solid, but may be nonsolid or occasionally have cystic components; and (d) invasive mucinous adenocarcinoma-which at CT varies widely from solid to mostly solid to part solid to nonsolid and may be single or multiple. [9]
Figure 7: Lung mass with computed tomography angiogram sign in 40-year-old male Axial contrast-enhanced computed tomography scan showing mass-like consolidation with enhancing vessels (arrow) within giving computed tomography angiogram sign

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Lymphangitis carcinomatosis represents infiltration of pulmonary lymphatics by tumor cells. On X-ray, reticulonodular opacities are seen in lung fields. High-resolution Computed Tomography (HRCT) scan shows nonuniform, nodular thickening of interlobular septa, and bronchovascular bundles [Figure 8].

Liver, bones, brain [Figure 9], and adrenals [Figure 10] are the most common site of metastases in lung cancer. Imaging protocol for evaluation of lung cancer should include scans of upper abdomen for assessment of liver and adrenals. Hematogenous metastases to the bone are usually osteolytic and painful [Figure 11] and [Figure 12]. Atypical sites of metastases include cutaneous, intramuscular, and intraperitoneal region [Figure 13] and [Figure 14]. Cutaneous metastasis is not a common presentation of bronchogenic carcinoma and generally portends a poor prognosis. [10] Rarely, lung cancer can occur in a preexisting interstitial lung disease [Figure 15], pneumoconiosis, connective tissue disorders, and sarcoidosis.
Figure 8: Squamous cell carcinoma lung with lymphangitis carcinomatosis in 65-year-old male (a) Chest radiograph showing inhomogeneous opacity right upper zone (black arrowhead) with reticulonodular opacities bilateral lungs (arrow) and opacity in right lower zone (white arrowhead), (b) axial contrast-enhanced computed tomography scan showing malignant necrotic mass (arrow) in right upper lobe, (c) computed tomography section showing rib metastasis (arrowhead) in lower sections corresponding to opacity in right lower zone on chest radiograph, and (d) computed tomography lung window showing irregular nodular interstitial thickening bilateral lungs (arrows)

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Figure 9: Lung cancer with brain metastasis in 55-year-old male (a) Axial contrast-enhanced computed tomography scan showing central right lung mass (arrowhead) and (b) computed tomography head showing cerebellar metastasis (arrowhead) with perilesional edema

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Figure 10: Bronchoalveolar carcinoma with bilateral adrenal metastases in 43-year-old male (a) Axial contrast-enhanced computed tomography scan showing mass-like consolidation (arrow) left upper lobe and (b) computed tomography scan lower sections showing bilateral adrenal masses (arrowheads)

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Figure 11: Lung cancer with rib metastases in 64-year-old female (a) Axial computed tomography scan showing necrotic malignant mass right upper lobe (arrow) with necrotic mediastinal Lymphadenopathy (arrowhead) and (b) computed tomography scan showing destruction of rib with soft tissue (arrowhead) and old tubercular changes right upper lobe (arrow)

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Figure 12: Small cell lung cancer presenting as osteomyelitis in 55-year-old male (a and b) Radiograph anterior posterior and lateral view right leg showing lytic lesions in tibia (arrows) with soft tissue, (c) chest radiograph showing inhomogeneous opacity left lung (arrow), and (d) computed tomography scan showing necrotic left lung mass (arrowhead) with mediastinal invasion

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Figure 13: Adenocarcinoma lung with subcutaneous and peritoneal metastases in a 62-year-old male (a) Chest radiograph showing inhomogeneous suspicious opacity left upper zone (arrow), (b) axial contrast-enhanced computed tomography scan showing necrotic malignant mass (arrow) with encasement vessels, (c) computed tomography scan lung window showing adjacent interstitial thickening (arrowhead) suggestive of lymphangitis carcinomatosis, and (d-f) axial computed tomography scan showing right adrenal (arrow), subcutaneous, and intraperitoneal metastases (arrowheads)

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Figure 14: Small cell lung carcinoma with renal and intramuscular metastases in 60-year-old female (a) Axial contrast-enhanced computed tomography scan showing necrotic malignant central lung mass (arrowhead) with ipsilateral pulmonary metastasis (arrow), (b) computed tomography scan lower section showing right renal metastasis (arrow) with necrotic retroperitoneal lymph node, and (c) computed tomography scan lower section showing subcutaneous and intramuscular metastases (arrowheads)

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Figure 15: Adenocarcinoma with interstitial lung disease in 60-year-old male (a) Chest radiograph showing mass like opacity left lower zone (arrow) with increased reticular markings lower zones bilaterally and (b) axial computed tomography lung window showing mass (arrow) with spiculated margins and changes of bilateral early interstitial lung disease (arrowhead)

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Primary treatment of nonsmall cell lung cancer is surgery with adjuvant chemotherapy and/or radiotherapy. Surgery is done for stage 1 and 2 cancers. T3 tumors are also suitable for surgery if there is no lymphadenopathy or metastasis. Small cell lung carcinomas are treated with radiotherapy or radiofrequency ablation if the patient is unfit for surgery. [11] With the advent of targeted therapies, the latest classification recommends that pathologists minimize the use of the term nonsmall cell lung cancer to better inform the treatment decision of medical oncologists. Pemetrexed in combination with cisplatin is indicated for advanced stage nonsquamous nonsmall cell carcinoma, while bevacizumab is contraindicated in squamous cell carcinoma because of its association with fatal hemorrhage in patients with squamous cell histology. [12]

 
  References Top

1.American Cancer Society. 2010 Cancer facts and figures. Atlanta: American Cancer Society; 2013  Back to cited text no. 1
    
2.Kligerman S, White C. Epidemiology of lung cancer in women: Risk factors, survival, and screening. AJR Am J Roentgenol 2011;196:287-95.  Back to cited text no. 2
    
3.Noronha V, Dikshit R, Raut N, Joshi A, Pramesh CS, George K, et al. Epidemiology of lung cancer in India: Focus on the differences between non-smokers and smokers: A single-centre experience. Indian J Cancer 2012;49:74-81.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Mohapatra PR. Optimizing the management of lung cancer: Role of the pulmonologist in India. Lung India 2013;30:173-4.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Gabrielson E. Worldwide trends in lung cancer pathology. Respirology 2006;11:533-8.  Back to cited text no. 5
[PUBMED]    
6.Glazer HS, Kaiser LR, Anderson DJ, Molina PL, Emami B, Roper CL, et al. Indeterminate mediastinal invasion in bronchogenic carcinoma: CT evaluation. Radiology 1989;173:37-42.  Back to cited text no. 6
    
7.Ratto GB, Piacenza G, Frola C, Musante F, Serrano I, Giua R, et al. Chest wall involvement by lung cancer: Computed tomographic detection and results of operation. Ann Thorac Surg 1991;51:182-8.  Back to cited text no. 7
    
8.Freundlich IM, Chasen MH, Varma DG. Magnetic resonance imaging of pulmonary apical tumors. J Thorac Imaging 1996;11:210-22.  Back to cited text no. 8
    
9.Austin JH, Garg K, Aberle D, Yankelevitz D, Kuriyama K, Lee HJ, et al. Radiologic implications of the 2011 classification of adenocarcinoma of the lung. Radiology 2013;266:62-71.  Back to cited text no. 9
    
10.Aggarwal A, Jhamb R. Subcutaneous nodules and bronchogenic carcinoma-an atypical presentation. J Human Dis 2011;1:1-3.  Back to cited text no. 10
    
11.Lanuti M, Sharma A, Digumarthy SR, Wright CD, Donahue DM, Wain JC, et al. Radiofrequency ablation for treatment of medically inoperable stage I non-small cell lung cancer. J Thorac Cardiovasc Surg 2009;137:160-6.  Back to cited text no. 11
    
12.Galvin JR, Franks TJ. Lung cancer diagnosis: Radiologic imaging, histology, and genetics. Radiology 2013;268:9-11.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]


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