1. L. Romano, A. Pinto (eds.), Errors in Radiology, © Springer-Verlag Italia 2012 19
Errors in the Diagnosis of Lung Neoplasms
Luigia Romano, Antonio Pinto, and Carlo Muzj
3
L. Romano ( )
Department of Diagnostic Radiological Imaging, “A. Cardarelli” Hospital,
Naples, Italy
3.1 Introduction
Imaging diagnosis of lung cancer frequently occurs in the context of screen-
ing. In other cases, nodules may be detected on a routine CT scan or chest
radiograph in asymptomatic patients. These tumors, which tend to be smaller
at diagnosis, are referred to as central or peripheral as they have not spread
beyond their local confines. While the features of the lesions’ borders can be
suggestive of malignancy, they are not diagnostic. However, the presence of
spiculation is thought to indicate a higher likelihood of malignancy [1] where-
as clearly defined edges [2] may indicate an inflammatory process. Cavitation,
frequently an indication of long-standing or advanced lung cancer, is most
commonly seen in squamous cell lung cancer [3].
The diagnosis of a subtle lung cancer at chest radiography remains a for-
midable challenge. Several investigators [4-8] have described the substantial
pitfalls of interpretation created by overlapping structures and by the small
size and low conspicuity typical of many lesions. Notwithstanding the diffi-
culty in making the diagnosis, missed lung cancer is the second-leading cause
of malpractice claims against radiologists [9].
Chest images contain a range of perceptual ambiguities that contribute to a
significant error rate in diagnosis [10]. Indeed, is not unusual to retrospective-
ly discover significant radiological abnormalities in patients who are later diag-
nosed with lung cancer [8]. The term missed cancer can refer to a lesion that
was detected but misinterpreted by the radiologist [6]. The failure to detect a
lung cancer, under any conditions, would be considered as negligence.

2. 3.2 Misdiagnosis of Lung Cancer on Chest Radiograph
The chest radiograph is a two-dimensional projection of a complex array of
three-dimensional structures. Each of these structures, i.e., the pulmonary ves-
sels, bones, and parts of the mediastinum, may project over the lung and there-
by partly or totally obscure pulmonary lesions at chest radiography. Some lung
nodules are small or inconspicuous because of ill-defined margination or low
opacity. Consequently, a radiologist may fail to detect the lesion or may dis-
count it as a benign structure.
Most overlooked lung neoplasms on chest radiographs are solitary pul-
monary nodules. Missed cancer usually has a substantial upper lobe predilec-
tion [4, 11]. This predominance probably reflects the tendency of bron-
chogenic carcinoma to involve the upper lobes more frequently than other
regions [4]. The perihilar regions are less common sites of overlooked lung
cancer. Radiologist-missed lung cancers on chest radiographs have been
reported to share the following characteristics: (a) most missed nodular can-
cers are visually subtle, but they are not always very small (median diameter,
16–20 mm); (b) missed cancers are located predominantly in the upper lobes;
(c) superposing structures and distracting lesions are frequently present; and
(d) image quality is commonly poor [4, 5, 9, 11]. The findings in the radiolo-
gist-missed cancer series that served as the basis for those conclusions were
similar to those reported in previous studies [5, 7], although image quality was
generally high.
The role of the lateral chest radiograph in the detection of lung cancer has
been discussed for over 30 years [12, 13]. In the series by Shah et al. [7], only
the lateral chest radiograph revealed the lung neoplasm retrospectively in two
patients (5%) and the cancer was better seen on the lateral radiograph than on
the frontal projection in one other patient (2%) in the same series. These
results are comparable to those of other series, in which the detection rate for
lung cancer on the lateral radiograph vs. the frontal chest radiograph was
2–4% [14, 15].
Lung cancer nodules are frequently missed on chest radiographs by radiolo-
gists in clinical practice, with reported error rates of 20–90% [14, 16] (Fig. 3.1).
Even in observer performance studies, in which the participating radiologists
are aware that many lung cancers are included, up to 40% of previously missed
cancers remain undetected [17]. In one classic study [14] of lung cancer
detected during the Mayo Lung Screening Project, 45 (90%) of 50 peripheral
and 12 (75%) of 16 central lung lesions were visible in retrospect on films
obtained 4 months prior to the radiograph on which the diagnosis was estab-
lished (Fig. 3.2a, b). In several clinical series of missed lung cancer, in which
the numbers of patients ranged from 27 to 40, the median diameter of such
lesions was fairly large (> 1.5 cm) [4-7]. Missed tumors were attributed to
multiple factors, including failure of perceptual analysis by the radiologist,
lack of comparison with previous radiographs, inadequate awareness of clini-
cal information, and deficiencies in film quality [6, 7].
20 L.Romano et al.

3. 3.3 Source of Errors in Chest Film Interpretation
There are many sources of error in the radiographic diagnosis of lung cancer:
image quality, lesion detection, lesion recognition, and communication of the
radiological findings to the referring physician [18]. Lesion size is an impor-
tant factor influencing detectability on chest radiographs; according to some
reports, only 50% of 1-cm lesions are detected [19]. Lesion shape may also
influence detectability, as sharply marginated lesions are found more easily
than spiculated or poorly defined cancers.
In addition, technical features play an important role in the failure to diag-
nose lung cancer [19]. On chest radiography, film contrast, density, and kVP
3 Errors in the Diagnosis of Lung Neoplasms 21
Fig.3.2 a Coronal reformatting CT image shows an irregular rounded nodule with a poorly defined
border, localized at the right upper pulmonary lobe (white arrow). Biopsy revealed a poorly dif-
ferentiated cancer. b A lung nodule was visible (white arrow) retrospectively on the X-ray film ob-
tained 4 months previously
a b
Fig.3.1 Missed cancer of the
middle pulmonary right field:
a subtle low-density small nodule
(white arrow) is partially hidden
by the superposing ribs

4. all influence lesion detection [9]. Manning et al. [20] reported that the major-
ity of errors related to lung cancer missed on the posteroanterior chest radi-
ograph were failures of decision rather than of detection, supporting the idea
that the complexity of the visual information in chest imaging makes it diffi-
cult for observers to discriminate between normal anatomic structures and
nodular pathological features, even when such features have been made visu-
ally obvious by the imaging process.
A missed diagnosis of a lung neoplasm can also be due to observer error.
In the study of Kundel et al. [21] three types of observer error were described:
scanning error (failure of the radiologist to fixate on the area of the lesion),
recognition error, and decision-making error, which in the authors’ series was
the most common [21]. A decision-making error is due to the incorrect inter-
pretation of a malignant lesion as a normal structure after detection. Another
form of observer error that may contribute to lesions being overlooked (includ-
ing lung cancer) is the satisfaction of search (SOS) error [10], in which an
abnormality is missed because another abnormality has been detected and fur-
ther image interpretation subsequently discontinued. Sources of error in inter-
pretation include the patient’s clinical history, the presence or absence of pre-
vious studies, the index of suspicion, the presence of an abnormality, the read-
ing room environment, and the level of interpreter vigilance.
In case of evidence of a suspected lung neoplasm on chest plain film, it is
important that the radiologist suggests the next appropriate imaging procedure
(Fig. 3.3a, b). Indeed, the failure to do so is another cause of malpractice
claims against radiologists. These recommendations or suggestions for addi-
tional radiologic procedures must be appropriate and add meaningful informa-
tion to clarify, confirm, or rule out the initial impression. The American
22 L.Romano et al.
Fig.3.3 a A chest X-ray film shows a poorly marginated opacity (white arrow) of the right lung in
an asymptomatic smoker. b The axial CT image shows the irregular infiltrating edge of the nod-
ule (white arrow) with distortion of the adjacent small vessels
a b

5. College of Radiology “Practice Guideline for Communication of Diagnostic
Imaging Findings” [22] states that “follow-up or additional diagnostic studies
to clarify or confirm the impression should be suggested when appropriate.”
3.4 Errors in the Diagnosis of Lung Cancer on Chest
Computed Tomography
The number of lung cancers missed at CT, as cited in the literature, has been
limited probably because it is difficult to identify the missed cases among the
many routine CT examinations performed in most medical centers [23, 24].
Gurney [23] reported that nine lung cancers missed at CT were identified from
a monthly tumor registry that was maintained for about 10 years; five of these
tumors were peripheral lung cancers < 3 mm in diameter, which was consid-
ered as the threshold size for detectability. White et al. [24] reported 14 lung
cancers overlooked at CT from about 37,500 chest CT scans at more than three
institutions; the most common characteristic among these cases was an endo-
bronchial location.
A more recent study of seven lung cancers missed at low-dose CT was
reported on by Kakinuma et al. [25], based on 5,418 lung cancer CT screening
studies performed over a period of more than 3 years. In the study by Li et al.
[26], 83 primary lung cancers were found during an annual low-dose CT
screening program and confirmed histopathologically at either surgery or
biopsy. Of these lung cancers, 32 were missed on 39 CT scans: on 23 scans
owing to detection errors and on 16 scans owing to interpretation errors
(Fig. 3.4a-d). In their interpretation error cases, 88% of the missed cancers, or
the features of these tumors, mimicked benign lesions and/or were associated
with underlying lung disease. Missed cancers with linear, triangular, and irreg-
ular patterns, similar to the patterns of benign lesions, were common findings,
and the underlying lung diseases were due to other abnormalities, such as
residual tuberculosis (including pleural thickening) or residual or new inflam-
matory lesions, emphysema, or lung fibrosis [26].
Due to improvements in CT imaging technology, the detection of small pul-
monary nodules has improved. The ability to detect small nodules is of para-
mount importance in finding early-stage lung cancer. However, nodules < 1 cm
in diameter often pose a dilemma, for both clinicians and patients, as they may
be difficult to biopsy and can easily be confused with normal anatomic struc-
tures within the lung.
3.5 Conclusions
Lung cancer is the most frequently occurring cancer in the world; in the USA
it is the second most commonly diagnosed cancer. Accurate imaging-based
staging can have a significant impact on appropriate treatment and surgical
3 Errors in the Diagnosis of Lung Neoplasms 23

6. options. The failure to detect, identify, or describe an abnormality that on a
plain chest radiograph is subsequently shown to be lung cancer has potential-
ly very serious consequences in medical malpractice litigation.
Multiple strategies have been recommended to reduce the rate of missed
lung cancer. These include scrupulous comparison of the current radiographic
study with the results of previous examinations, avoidance of distracting find-
ings leading to SOS errors, and the double reading of images. Each of these
approaches has drawbacks related to workflow and the limitations of human
perception. Computer-aided detection (CAD) systems are increasingly being
introduced as a “second reader” to assist in the evaluation of images of com-
plex anatomic structure, and they can mark many visually subtle lung cancers
that may be missed by radiologists. Although false-positive detections are
numerous and potentially distracting, the majority of them are clearly due to
superposing anatomic structures. Accordingly, the reduction of false-positives
should be a priority in the development of CAD programs.
24 L.Romano et al.
Fig.3.4 a Admission radiograph from a young male with chest pain, hemoptysis, and breathless-
ness: the right pulmonary artery is enlarged. b Axial CT scan obtained during the arterial phase
shows a typical filling defect of the right pulmonary artery (white arrow) due to a thromboembolism.
c,dAfter 2 weeks of anticoagulant therapy, the axial CT scan obtained during the portal phase demon-
strates contrast enhancement of the embolus (white arrow): the filling defect of the right pulmonary
artery is due to hilar cancer
c d
a b

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