Tumors of the lung by Dr. Bom BC

1. Dr. Bom B. C.
MD Radiognosis
NAMS, Bir Hospital
RADIOLOGY OF LUNG
NEOPLASMS

2. Outline of presentation
 General overview of Lung neoplasm.
 Briefly about the pathology and clinical
presentations.
 Radiological feature of Malignant
neoplasms.
 Brief about the benign lung neoplasm.
 Summary.

3. LUNG NEOPLASMS :
OVERVIEW
 A wide variety of neoplasms may arise in the
lungs.
 While many lung tumors are overtly malignant
and others are definitely benign, some fall both
histologically and in their clinical behaviours
between these two extremes.
 Pulmonary tumors may be classified
histologically
or according to their presumed tissue of origin.

4.  However, it should be borne in mind that
histopathologists do not always agree on the
classification of an individual tumor.
 Carcinoma of the bronchus is by far the
commonest and most important primary tumor of
the lung.

5. EPIDEMIOLGY
 Lung cancer is a common malignancy.
 The American Cancer Society (ACS) estimates
that 224,210 new cases diagnosed in the United
States in 2014.
 Lung cancer incidence rates have declined since
the mid-1980s in men and late 1990s in women
as a result of reduced smoking prevalence.
 The number of new cases in men has been
decreasing at 1.9% per year (1992-2010) and at
1.2% (2005-2010) in woman.

6.  The annual mortality rate in men has decreased
since the 1990s, and in 2005-2010 this decrease
was 2.9% per year, whereas the rate in women,
after continuously increasing for several decades,
plateaued in 2004 and is now decreasing by 1.4%
per year (2004-2010).
 However, lung cancer remains the leading cause
of cancer-related deaths in both men and women
in the United States, and the ACS estimates that
in 2014 accounting for 28% of all cancer deaths
in men and 26% in women.

7. ETIOLOGY
1.Tobacco smoke (established in 1950 by Doll and
Hill the first large epidemiologic study)
 Cigarette smoking is now recognized as the
strongest risk factor for the development of lung
cancer; an estimated 85% to 90% of lung
cancers in men and 80% in women are
attributable to smoking.
 The risk increases with early age at initiation and
the length of time and number and type of
cigarettes smoked.
 Nearly all cases of squamous cell and small
cell carcinoma are related to cigarette
smoking.

8.  It has recently been reported that
adenocarcinomas are more strongly
associated with tobacco smoke exposure than
previously recognized.
 The change in smoking habits (use of filter tips,
decrease in tar yield) has been postulated to
account for the increase in incidence of
adenocarcinomas in cigarette smokers.
 Additionally, because adenocarcinomas are more
likely to be caused by other factors besides
smoking (e.g., passive smoke inhalation),
adenocarcinomas are the predominant cell type
in nonsmokers.

9. 2.Involuntary smoke exposure (passive
smoking)
 According to the International Agency for
Research on Cancer, involuntary smoking causes
lung cancer in never-smokers, with an excess
risk of 20% for women and 30% for men.
3.Environmental and occupational exposures to
particulate and chemical substances.
4.Exposure to the naturally occurring
radioactive gas radon ( both in homes and in
mines).

10. 5.Exposure to arsenic, chloromethyl ethers,
chromium, isopropyl oil, mustard gas,
nickel, chloroprene, vinyl chloride, and
various smelting byproducts such as lead
and copper.
6.Asbestos exposure ( duration,
concentration, fiber type)
7.Focal or diffuse pulmonary fibrosis
8.Ionizing radiation
9.Different gene mutations (e.g., p53, KRAS)

11. PATHOLOGY ;PULMONARY
NEOPLASMS

12. BENIGN NEOPLASMS

13. Most carcinomas of the lung fall into one of four
types
1. Squamous cell (or epidermoid ) carcinoma : 30-
35% of cases of primary lung cancer
2. Adenocarcinoma (including alveolar cell
carcinoma), 30-35%; of cases
3. Large cell undifferentiated : 15-20% of cases
4. Small (oat) cell carcinoma :20-25% of cas

14.  Some lung cancers do not fall neatly into one of
these categories and may have components that
resemble more than one type, for example
adeno-squamous carcinomas.
 Other rarer tumors are classified separately, for
example clear cell carcinoma, basal cell
carcinoma and carcinosarcorma.

15.  Approximately 50% of lung cancers arise centrally,
i.e. in or proximal to segmental bronchi.
 The tumor arises in the bronchial mucosa and
invades the bronchial wall.
 Tumor may grow around the bronchus and also into
the bronchial lumen.
 Obstruction of the lumen leads to collapse, and often
infection, in
the lung distal to the tumor.

16.  Tumors that arise peripherally appear as soft-
tissue nodules or irregular masses , and invade
the adjacent tissues.
 Signs of collapse or consolidation may occur, but
are less obvious than with central tumors.
 Both central and peripheral tumors may be
associated with hilar or mediastinal lymph node
enlargement, and this is also a potential cause of
central airway obstruction.

17.  The tumour may also undergo central necrosis
leading to cavitation.
 Peripheral tumors sometimes arise in pulmonary
scars, and there is evidence that pulmonary
fibrosis predisposes to neoplastic change.
 Although lung cancer usually presents as a single
primary tumor, synchronous tumors are not rare .
 Metastases from lung cancer may occur
anywhere in the body, but hilar, mediastinal and
supraclavicular lymph nodes are the commonest
sites followed by the liver, bones, brain, adrenal
glands and skin

18.  Squamous cell cancers tend to arise centrally,
grow
relatively slowly and cavitate more often than
other cell types.
 Adenocarcinomas usually arise peripherally,
sometimes in fibrotic lung, and cavitate less
often.
 Small cell tumors have the fastest rate of
growth and are usually disseminated at the
time of –presentation. They are usually central

19. CLINICAL PRESENTATION
 Respiratory symptoms such as cough, wheeze,
sputum production, breathlessness, chest
discomfort and hemoptysis are the commonest
presenting symptoms in patients with Lung
cancer, although approximately 20% of patients
are asymptomatic at presentation.
 Other presentations include - clubbing. superior
vencaval obstruction, Horner's syndrome, chest
pain, dysphagia and signs of pericardial
tamponade.

20.  An abnormal chest X-ray is a common
presentation in patients who are symptoms free
or who have non-specific symptoms.
 Patients may also present with symptoms of
metastatic
disease such as bone pain or signs of an
intracranial tumor or general debility.
 Pneumonia, particularly if it does not respond to
treatment, may be due to an underlying
neoplasm.

21.  A small number of patients present with
paraneoplastic syndromes such as
hypertrophic osteoarthropathy, endocrine
disturbance (e.g. inappropriate ADH
Secretion, Cushing's syndrome,
hypercalcemia), peripheral neuropathy and
recurrent peripheral venous thrombosis.

22. MALIGNANT NEOPLASMS OF THE LUNG ;
PREINVASIVE LESIONS
Atypical Adenomatous Hyperplasia (AAH)
 Is a localized proliferation of atypical type II
pneumocytes and/or Clara cells lining alveoli and
respiratory bronchioles, is typically less than 5 mm
in diameter.
 AAH is considered a precursor of
adenocarcinoma, based on a variety of molecular
findings that demonstrate a relationship to lung
adenocarcinoma.
 The frequency of AAH is unknown but has been
reported as an incidental finding in 2% to 3% of
patients without a primary lung cancer at postmortem
examination.

23.  However, AAH is most frequently diagnosed in
patients in primary non-small cell carcinoma,
especially adenocarcinoma
 In this regard, AAH occurs in the adjacent lung
parenchyma in 5% to 23% of resected lung
adenocarcinomas.
 It has also been reported that AAH lesions are not
significantly correlated with gender, age, smoking
status, familial history of malignancy, or preceding
malignancy.

24.  Radiologically, AAH manifests
as a small well-circumscribed
solitary or multifocal ground-
glass nodular opacity —usually
less than 1 cm but ranging in
size from a few millimeters to
approximately 2 cm—that
typically remains stable for
several months to years.
 Because AAH and
adenocarcinoma can have
similar radiologic manifestations,
computed tomography (CT)
differentiation is often difficult,
and resection is usually required

25. Adenocarcinoma In Situ
 A major change in the classification proposal for lung
adenocarcinoma by Travis et al. is the recognition of
adenocarcinoma in situ (AIS) as a preinvasive lesion.
 AIS was formerly classified as a
bronchioloalveolar cell carcinoma (BAC) according
to the 2004 WHO classification.
 AIS is a small (≤3 cm) localized adenocarcinoma
that has no stromal, vascular, or pleural invasion
and demonstrates lepidic growth.

26.  Lepidic predominant adenoca -
 predominance of bland pneumocytic type
neoplastic cells with growth along normal
structure eg. Alveoli
 Lepidic = scaly

27.  Radiologically,
nonmucinous AIS
typically manifests on
CT as a pure ground-
glass nodule (GGN) but
can occasionally
manifest as a part solid
(due to focal collapsed
alveoli or focal
thickened alveolar
septa) or solid nodule.
 Mucinous AIS can
manifest as a solid
nodule or
consolidation.

28. Diffuse Idiopathic Pulmonary
Neuroendocrine Cell Hyperplasia
(DIPNECH)
 DIPNECH, is a widespread proliferation of
pulmonary neuroendocrine cells or
neuroendocrine bodies within the epithelium of
the distal bronchi or terminal bronchioles.
 This proliferation can be confined to these
epithelium, or there can be extension beyond the
basement membrane, forming small localized or
diffuse aggregates called tumorlets (<0.5 cm in
diameter) or carcinoids .

29.  An important histologic feature occurring in a third
of patients is fibrous obliterative bronchiolitis and
peribronchiolar fibrosis of the involved airways.
 DIPNECH is regarded as a precursor lesion of
neuroendocrine lung tumors, specifically carcinoid
tumors.

30.  Radiologically,
DIPNECH manifests as
bronchial wall
thickening and a
mosaic attenuation
pattern (ground-glass
opacities and
hyperlucent areas) due
to air trapping.
 Solitary or multiple
nodules ranging in size
from 2 to 20 mm in
diameter are an
DIPNECH in a 63-year-old woman with a
chronic history of progressive cough and
dyspnea on minimal exertion. CT scan
shows multiple small bilateral pulmonary
nodules (arrows). Wedge resection
biopsy of the middle lobe revealed
carcinoid tumor (5 mm) and multiple
carcinoid tumorlets (<5 mm).

31. RADIOLOGICAL FEATURES
 The radiological features of lung cancer are a
reflection of the
Pathology.
 Depends upon
1. Size
2. Site
3. Behaviour

32. Hilar enlargement
 This is a common radiographic manifestation of
lung cancer.
 If the primary tumor is central this represents the
tumor itself.
 Occasionally hilar involvement is subtle and
presents as increased density of the hilum rather
than as enlargement .
 If tumour is peripheral, it represents metastasis to
lymph nodes and the primary tumour may or may
not be visible.
 True extent of nodal disease is best
demonstrated by CT/MRI.
 Extensive hilar and mediastinal

33. The left hilum is enlarged by
lymphadenopathy due to
adenocarcinoma. The primary
tumour is not visible.
Carcinoma of bronchus. Chest X-
ray shows a dense left hilum, but
no definite mass. Bronchoscopy
showed a squamous carcinoma in
the left main bronchus.

34. Chest X-ray shows
nodule in the left
midzone. Contrast-
enhanced CT on
lung window
confirms left lower
lobe mass, which
proved to be an
adenocarcinoma.;
CT on mediastinal
windows shows left
hilar
lymphadenopathy,
with
extensive
mediastinal
adenopathy
surrounding the
pulmonary arteries

35. `
Lymph Node Metastasis in Bronchogenic Carcinoma. Contrast-enhanced CT scan
through the mid lungs at the level of the middle lobe bronchi shows a right lower lobe
mass (M) with enlarged right hilar-interlobar (arrowheads) (Nl disease) and subacarinal
(curved arrow) (N2 disease) nodes. Axial PET-CT at same level shows marked
increased, FDG activity in the mass and nodes.Scan at the lung apices shows an
enlarged right supraclavicular node (arrow) (N3 disease). Fused axial PET-CT at same
level shows marked increased FDG
activity in the supraclavicular node (arrow). Biopsy of the supraclavicular node showed

36. Airway obstruction
 Bronchial narrowing due to tumor growth
eventually causes collapse of the lung distal to
the tumor.
 Depending on the location of the tumor,
segmental or lobar collapse or, less often,
collapse of an entire lung may be seen.
 Prior to collapse of a lobe or segment, infection
may develop distal to the bronchial obstruction ;
consequently, segmental or lobar consolidation
may be a manifestation of lung cancer, and as
this is secondary to bronchial occlusion an air
bronchogram is usually absent.

37.  As the primly tumor may be obscured by the
surrounding consolidation, the underlying
endobronchial lesions should be considered in
cases of segmental/lobar consolidation in cases
that do not resolve despite adequate treatment.
 Occassionly tumor arising in segmental or
subsegmental bronchi will lead to mucoid
impaction and devloplment of
bronchocele/mucocole.

38. Carcinoma of bronchus. (A) Chest X-ray
shows collapse of left lung. (B) Contrast-
enhanced CT on lung window confirms
collapsed left lung, shows small pleural
effusion and demonstrates tumor
extending into the left main bronchus. (C)
CT on mediastinal window demonstrates
tumor invading posterior wall of left atrium
(confirmed at surgery).

39. Fig: Bronchocele
secondary to
carcinoma of
bronchus, CT
demonstrating dilated
fluid filled bronchi in
the lingula , secondary
to carcimona at left
hilum

40. PERIPHERAL MASS
 A peripheral pulmonary mass in the chest x ray is
common presentation of lung cancer.
 If other features are present, such as hilar
enlargement or bony metastases, then the
malignant nature of the mass is easily
appreciated.
 Infrequently, however, a mass is the only
apparent abnormality and then the differential
diagnosis is more difficult.

41.  There are no radiological features that can
reliable differentiate between a benign and a
malignant pulmonary nodule or mass. However,
malignant tumors are usually larger than benign
lesions at the time of presentation.
 Furthermore , peripheral lung cancers tend to
have poorly defined, lobulated or umbilicated
margins or may appear spiculated.
 Satellite opacities around the main lesion are
more frequently seen with benign masses, but
may be associated with carcinomas.

42. Carcinoma of bronchus. A large, round
soft-tissue mass is present at the right
apex. Blunting of the right costophrenic
angle is due to a small pleural effusion.
Adenocarcinoma of bronchus. CT
shows spiculated, soft-tissue mass
with strands of tissue extending into
the adjacent lung parenchyma

43.  Diffusely or central calcification in a peripheral
pulmonary mass is very suggestive of a benign
lesion, but occasionally a calcified granuloma may
be engufled by a malignant mass
 Bronchial carcinoma have doubling time of
between 1-18 mths, so comparison to previous x -
ray is helpful and any mass or nodule that has been
static over 2 yr period is almost benign.

44. CAVITATION
 It is visible in about 10-15 % of peripheral
carcinoma on plain X rays and is better
demonstrated in CT.
 It is due to either central necrosis of the tumor or
abscess formation secondary to bronchial
obstruction and fluid level may be present within
the cavity.
 Typically malignant cavities are thick walled with
nodular irregular margin.

45. Squamous cell carcinoma of
bronchus. Chest X-ray shows a
cavitating mass with a fluid level
in the left mid zone.
Squamous cell carcinoma of
bronchus. CT Shows thick
walled cavitating mass with
spiculated outer surface and
nodular inner surface.

46.  Bronchial carcinoma arising at the lung apex
were formerly regarded as an entity distinct from
other lung cancers and were known as Pancoast
or Superior Sulcus tumors.
 Histologically they are similar to other lung
cancers, however due to location they have
tendency to invade ribs, spine, the brachial
plexus and inferior cervical sympathetic ganglia.

47.  The plain film may show an obvious mass with
associated bone destruction.
 Frequently only asymmetrical apical pleural
thickening is visible and full extent of tumor is
best demonstrated by CT/MRI.
 Bone involvement is often shown by CT.

48.  MRI is ideal for demonstrating the relationship of
the tumor to the brachial plexus and subclavian
vessels and for showing involvement of extra
pleural fat over the lung apex.
 However, for the purpose of percutaneous biopsy,
these tumors are often conveniently visualized by
USG from the supraclavicular fossa.

49. Superior Sulcus (Pancoast) Tumor.
Frontal radiograph shows a left apical
mass (arrowhead) with loss of the medial
left second rib (long arrow). B. CT scan
shows a nodule (arrowhead) with
extension to the pleura and destruction
o£ the left second rib (long arrow).
Diagnosis was non-small cell carcinoma.

50. Superior sulcus (Pancoast) tumor with chest wall invasion
and involvement of the brachial plexus. Coronal T1-
weighted MRI shows a mass (M) in the apex of the right
hemithorax, with invasion into the neck. The mass
surrounds the subclavian artery (*) and brachial plexus. R,
M R
*

51. Pancoast tumor. Chest X-ray shows
asymmetrical right apical pleural
thickening. CT shows large right apical
soft-tissue mass extending through chest
wall into apex of right axilla. Ultrasound
scan from right supraclavicular fossa
shows apical pulmonary mass of relatively
low echogenicity, and demonstrates the
easiest route of access for percutaneous

52. MEDIASTINAL INVOLVEMENT
 Enlargement of mediastinal lymph nodes is a
typical feature of small cell tumors, but occurs
with other bronchial carcinomas.
 The mediastinum appears widened and may
have a lobulated outline.
 In non-small cell tumors lymph node involvement
is less florid, and since its full extent may not be
appreciated on the chest X-ray it is best assessed
non-invasively by CT or MRI.

53. Signs of mediastinal invasion
 Loss of fat planes with the mediastinum with
contact of more than 3 cm with the mediastinum
 Contact of more than 900 with the aorta
 Involvement of major vessels, heart, carina,
trachea, esophagus or vertebra are the reliable
sign of mediastinal invasion i.e. T4 tumor

55.  Enlarged mediastinal
lymph nodes or
central tumors may
distort the
oesophagus.
 Barium swallow may,
therefore, be used to
assess the
mediastinum- and is
essential in patients
with dysphagia
 In these patients
oesophageal
compression or
invasion may be
demonstrated.
Carcinoma Bronchus. Chest X-ray shows
collapse and consolidation of right lower
lobe.
Barium swallow performed to investigate
dysphagia shows extrinsic compression of
mid oesophagus by enlarged subcarinal
lymph nodes.

56.  Mediastinal invasion may involve the phrenic
nerve and in patients with lung cancer elevation
of a hemidiaphragm suggests this complication or
may be due to pulmonary collapse or subphrenic
disease.
 Fluoroscopy or ultrasound scan of the diaphragm
may be used to determine if an elevated dome
moves paradoxically and is paralysed.

57.  Mediastinal spread of tumor may also cause
venecaval obstruction , and this may be
confirmed by superior vena cavography,
dynamically enhanced CT or MRI.
 Invasion of the pericardium by metastatic lymph
nodes or the primary tumor itself may result in
pericarditis and pericardial effusion.

58. Pleural involvement
 Pleural effusion may be due to direct spread of
the tumor but may also be the result of lymphatic
obstruction or be secondary to an obstructive
pneumonitis.
 Pleural effusion also occurs as a sympathetic
response to the tumour, in which case there is no
etiological or histological evidence of pleural
malignancy.
 Rarely, a cavitating subpleural tumour will cause
a spontaneous pneumothorax

59. Bone involvement
 Peripheral carcinomas may invade the ribs or
spine directly.
 Haematogenous metastases from lung to bone
are usually osteolytic .
 They are often painful, and are identified earliest
by isotope bone scan.
 Bone pain, particularly in the wrists, hands,
ankles and feet, may also be due to hypertrophic
ostcoarthropathy.
 Plain films - well defined periosteal new bone
formation.
 Isotope bone scan may he positive before

60. Superior sulcus tumor and shows
destruction of the first and second ribs .

61. DIAGNOSTIC IMAGNG AND
MANAGEMENT OF THE
CARCINOMA
Imaging makes an important contribution to
following three aspects for the management.
 Making Diagnosis.
 Staging the tumor.
 Assessing the treatment

62. MAKING THE DIAGNOSIS
 The prognosis and treatment of the lung cancer
depends upon the general condition of the
patient and on the histology of the tumor and its
extent at the time of presentation.
 Currently there are trial under way in both the
USA and Europe assessing the efficacy of low-
dose spiral CT in screening for lung cancer.
 Small cell tumors metastasize early and are
usually disseminated at the time of presentation.

63.  Non-small cell tumours metastasise later, the
natural
history of squamous cell carcinoma being longer
than that of adenocarcinoma and undifferentiated
large cell carcinoma.
 Moreover, small cell tumors are more sensitive to
chemotherapy than nonsmall cell tumors.
 Therefore, when planning treatment it is important
to know the histology of the tumor.

64.  Sputum cytology and bronchoscopic biopsies or
washings usually provide the cell type of central
tumors, but peripheral tumors may require
percutaneous biopsy.
 Can be done with fluoroscopic, CT or ultrasound
guidance
 Depending on the needle used the specimens
may be suitable for cytological or histological
evaluation.
 Obviously the either case, it is important to have

65.  Comparison with previous imaging is invaluable,
as a nodule that has not changed on the chest
radiograph over 2 years is likely to be benign.
 There may be features that confidently allow a
diagnosis of benign disease on the chest
radiograph or CT, for example a classical
appearance of infolded lung, or diffuse
calcification within the nodule.
 Recently developed strategies to differentiate
benign from malignant tumors include CT
densitometry and positron emission tomography
(PET) using18F-fluorodeoxyglucose ( FDG ).

66.  Compared to benign nodules, malignant nodules
show a greater degree of enhancement following
intravenous injection of iodinated contrast
medium, such that an increase in attenuation on
CT scanning of greater than 20 Hounsfield units
is very suggestive of malignancy.
 For nodules 2 cm in diameter or greater. PET
with FDG appears to be highly specific and
sensitive in identifying malignant lesions.
 However, if the possibility of lung cancer remains
the nodule should be closely monitored, biopsied
or excised.

67. RADIOLOGICAL FEATURES
Squamous cell carcinoma:
 They typically occur in central bronchi and
frequently manifest as postobstructive pneumonia
or atelectasis.
 Mucoid impaction, bronchiectasis, and
hyperinflation are uncommon radiologic
manifestations.
 Approximately one third of squamous cell
carcinomas occur beyond the segmental bronchi
and usually range in size from 1 to 10 cm.

68.  Squamous cell carcinomas are more likely to
cavitate than the other histologic cell types of lung
cancer.
 Cavitation occurs in 10% to 30% and is more
common in large peripheral masses and poorly
differentiated tumors.
 Cavitation is typically eccentric with thick
irregular walls, although thin walls may occur in
rare circumstances.
 Most squamous cell carcinomas grow slowly, and

69. Squamous cell lung cancer manifesting as a central endobronchial mass.,
Posteroanterior chest radiograph shows complete atelectasis of the left
upper lobe. Convexity in the lower portion of the atelectatic lung (arrow) is
the result of a central mass. B, CT confirms an endobronchial mass (M)
that occludes the left upper lobe bronchus and causes complete
atelectasis of the left upper lobe. Note the enlarged subcarinal node (*)
due to metastasis.
M
*

70. Squamous cell lung cancer manifesting as a peripheral mass.
Posteroanterior chest radiograph shows a mass in the right lower lobe and
infrahilar and paratracheal adenopathy (arrows). CT confirms the mass in
the right lower lobe and infrahilar adenopathy (arrow) and reveals variable
attenuation of the mass consistent with necrosis.

71. ADENOCARCINOMA
 Typically manifest radiologically as peripheral SPNs.
 Historically, nodules have been described as having soft
tissue attenuation and an irregular or spiculated margin as
a result of parenchymal invasion and an associated fibrotic
response .
 However, with the increasing use of CT, adenocarcinomas
manifesting as purely ground-glass or part-solid attenuation
are being detected with increasing frequency.
 Nonmucinous minimally invasive and lepidic-predominant
type typically manifest as solitary GGNs or part-solid
nodules (PSNs).
 Acinar-, papillary-, micropapillary-, or solid-predominant
patterns and invasive mucinous adenocarcinomas manifest
as solid nodules, although invasive mucinous

72. The high-resolution (HR)CT appearance of these
opacities has been reported to have a correlation with a
classification proposed by Noguchi et al., whereby small
(≤2 cm) peripheral adenocarcinomas are classified into
six types based on tumor growth patterns:
 Type A, localized BAC;
 Type B, localized BAC with foci of structural collapse of
alveoli;
 Type C, localized BAC with active fibroblastic
proliferation;
 Type D, poorly differentiated adenocarcinoma;
 Type E, tubular adenocarcinoma; and
 Type F, papillary adenocarcinoma with a compressive

74.  Lymphangitic carcinomatosis, although
uncommon at presentation, occurs more
frequently with adenocarcinomas and typically
manifests radiologically as thickening of
interlobular septa or multiple small pulmonary
nodules.
 Intrathoracic metastases to hilar and mediastinal
nodes are present in 18% to 40% and in 2% to
27% of patients, respectively, and tend to occur
more often with more centrally located
adenocarcinomas.

75. Adenocarcinoma of the lung manifesting as
lymphangitic carcinomatosis. Thin-section CT scan
shows thickening of bronchial walls and interlobular
septa in the left lung. Nodularity of the septa is
suggestive of malignancy.

76. Large cell carcinoma.
 These lesions make up 10% to 20% of all lung
cancers and include the variant large cell
neuroendocrine lung carcinoma (3% of lung
cancers in surgical series).
 Most are peripheral, poorly marginated masses
greater than 7 cm in diameter.
 Although growth is typically rapid, cavitation is
uncommon.
 Hilar and mediastinal adenopathy occurs in up to
one third of patients at presentation, and early
extrathoracic metastases are common.

77. Large cell lung cancer manifesting as a large mass. Left
Posteroanterior chest radiograph shows a large mass in the
right upper lobe. Right CT shows a well-circumscribed mass.
Note heterogeneous attenuation of the mass is consistent
with necrosis and nonenlarged paratracheal lymph nodes
(arrow).

78. SMALL CELL LUNG
CARCINOMA(SCLC)
 SCLCs comprise 13% to 15% of all lung cancers is
characterized histologically by small cells with scant
cytoplasm, marked nuclear atypia, high mitotic rate
(>10 mitoses/10 high-power field and extensive
necrosis.
 Two subtypes: pure SCLC (≈70%)&combined SCLC
(≈30%).
 The primary tumor is typically small, central in
location, and associated with marked hilar and
mediastinal adenopathy and distant metastases to
liver, bone marrow, adrenals, and brain.
 Pleural effusions occur in 5% to 40% of patients.
 Approximately 5% of SCLCs manifest as small,

79. SCLC in a 65-year-old man presenting with hoarseness caused by
involvement of the recurrent laryngeal nerve. Left Posteroanterior chest
radiograph shows a left upper lobe mass extending to the perihilar region
(arrows) and elevation of the left hemidiaphragm. Note diaphragmatic
paralysis is due to phrenic nerve involvement. Right CT reveals
mediastinal invasion with extension of the mass into the aortopulmonary
window (*) (the anatomic location of recurrent laryngeal nerve). Note
*
AA
DA

80. Staging the tumour
 Without treatment only about 40% of patients
with Lung cancer will survive 3 years from the
time of diagnosis.
 Currently the main hopes for curative treatment
lie with surgery for non-small cell cancer, and
chemotherapy for small cell tumor.
 The main purposes of accurate staging of lung
cancer arc:
1. To identify those patients with non-small cell
tumors who will benefit from surgery.
2. To avoid surgery in those who will not benefit
and
3. To provide accurate data for assessing and
comparing different methods of treatment.

90. ASSESSING TREATMENT
 Following chemotherapy for small cell cancer,
bulky mediastinal and hilar nodes and peripheral
lesions may show complete regression.
 Follow-up chest X-rays are required to detect
local recurrence, although recurrent disease is
often extrathoracic.
 These patients are also prone to opportunistic
infections.
 Following radiotherapy radiation pneumonitis and
pulmonary fibrosis may occur, and radiation
oesophagitis may be a consequence of
mediastinal irradiation.

91.  Mediastinal fibrosis
following radiotherapy
years previously.
 The sharp margins of
the fibrosis
correspond to the
edges of the radiation
field,

92. PULMONARY NEUROENDOCRINE
NEOPLASMS
 Four major types of neuroendocrine neoplasms
are recognized by the 2004 WHO Classification
of Tumors and are grouped into three histologic
grades.
 Typical carcinoid is characterized as low-grade
malignant neoplasm, atypical carcinoid as
intermediate grade, and large cell neuroendocrine
lung carcinoma and SCLC as high-grade
malignancies.

93. CARCINOID TUMORS.
 Primary pulmonary carcinoid tumors are low-grade
malignancies that constitute 1% to 2% of primary lung
tumors.
 They are classified histologically as typical (80%-
90%) or atypical (10%-20%) tumors depending on the
degree of cellular atypia.
 Typical carcinoid is a well-differentiated neoplasm
with neuroendocrine histologic features of 5 mm or
greater size with less than 2 mitoses per 10 HPF and
no necrosis, whereas atypical carcinoid has 2 to 10
mitoses per 10 HPF or necrosis.
 The most useful immunohistochemical markers for
identifying neuroendocrine neoplasms are
chromogranin, CD56, and synaptophysin; Ki-67 is
useful in differentiating typical carcinoid and atypical

94.  Typical carcinoid tumors occur with equal
frequency in men and women; the mean age at
diagnosis is 35 to 50 years.
 Tumors usually arise in lobar, segmental, or
proximal subsegmental bronchi and are generally
1 to 4 cm in size.
 Typical carcinoid tumors rarely metastasize to
regional nodes or beyond the thorax.
 Atypical carcinoid tumors are usually discovered
at a slightly older age (mean 53-60 years), are
often larger, and tend to occur more frequently in
the peripheral aspect of the lungs and are
aggressive to metastasize to LNs, Lung,

95.  Clinical manifestations depend on the histologic
type and location of the carcinoid tumor.
 Peripheral tumors are usually asymptomatic,
whereas central neoplasms can manifest as cough,
hemoptysis, or recurrent infection.
 Paraneoplastic manifestations such as carcinoid
syndrome (cutaneous flushing, bronchospasm,
chronic diarrhea, and valvular heart disease) and
Cushing’s syndrome are rare and more common
with atypical carcinoid tumors.
 Some 40% to 50% of patients with carcinoid
syndrome develop carcinoid heart disease,
characterized by right-sided heart failure caused by
fibrotic endocardial plaques.

96.  Carcinoid tumors most commonly manifest
radiographically or on CT as central endobronchial
masses with or without atelectasis or consolidation.
 A peripheral well-marginated pulmonary nodule is a
less common manifestation.
 The tumors are usually less than 3 cm in size,
although occasionally they may be as large as 10 cm
in diameter.
 Calcification is detected by CT in approximately
25% of carcinoid tumors.
 Hilar and mediastinal adenopathy and extrathoracic
metastases are uncommon ( Present in atypical type)
 In FDG PET scanning-Lower FDG uptake than
other malignancies

97. Typical carcinoid appearing as a central endobronchial
lesion. , Left Posteroanterior chest radiograph shows
complete atelectasis of right lower lobe (short arrows) with
compensatory hyperinflation of the left lung. Note
displacement of the anterior junction line (Long arrows).
Right, CT confirms atelectasis of the right lower lobe and
M

98. Other Lung Malignancy
 Sarcomatoid Carcinoma: poorly differentiated
carcinomas containing carcinomatous &
sarcomatous components.
 Molecular evidence supports the concept that these
are carcinomas of the lung with a clonal origin from
pluripotent stem cells capable of divergent
differentiation into carcinomatous and sarcomatous
components.
 They represent a clinicopathologic continuum, and
five subtypes are recognized: pleomorphic
carcinoma, spindle cell carcinoma, giant cell
carcinoma, carcinosarcoma, and pulmonary
blastoma

99. Carcinomas with spindle or giant
cells
 Sarcomatoid carcinomas of the lung (pleomorphic
carcinoma, spindle cell carcinoma, giant cell
carcinoma, carcinosarcoma) are rare, comprising
0.3% to 1% of malignant lung neoplasms.
 They are a heterogeneous group of NSCLCs
containing a sarcomalike component that
histogenetically may represent a malignant epithelial
neoplasm undergoing divergent tissue differentiation
originating from a single clone.
 Most patients are men, and mean age at presentation
is 65 years (range, 44-78 years).
 Most patients present with cough, dyspnea,
hemoptysis, chest pain, or weight loss.
 Although sarcomatoid carcinomas are usually
localized at presentation, distant metastases occur
frequently and the prognosis is poor.

100.  Radiologically these neoplasms can manifest
either as large peripheral masses or as polypoid
endobronchial lesions with atelectasis or
postobstructive pneumonia.
 Calcification & cavitation are uncommon, but
necrosis and hemorrhage - heterogeneous
attenuation on CT.
 Hilar or mediastinal adenopathy is uncommon.
 Pleural effusion can occur as a result of local
invasion.
 Metastases involve sites similar to those of lung
cancer (lung, liver, bones, adrenals, brain).

101. PULMONARY BLASTOMA.
 is a rare malignancy that makes up an estimated
0.25% to 0.5% of primary lung tumors.
 The tumor derives its name from its histologic
resemblance to fetal lung tissue.
 Pulmonary blastomas, however, are thought to
arise from primitive pluripotential stem cells and
may represent a variant of carcinosarcoma.

102.  Patients are often symptomatic at presentation;
cough, hemoptysis, and chest pain are frequent
manifestations.
 Pediatric age patients typically present with fever
and respiratory distress.
 The behavior of pulmonary blastomas is
aggressive and the outcome is poor due to
frequent relapses and metastases.

103.  Radiologically, pulmonary blastomas typically
manifest as large (range, 2.5-26 cm), well-
marginated masses located peripherally in the
lung.
 Multiple masses, cavitation, and calcification are
rare.
 Local invasion of the mediastinum and pleura
occurs in 8% and 25% of cases, respectively.
 Metastases to hilar and mediastinal lymph nodes
are present in 30% of resected cases.
 Extrathoracic metastases are common and have
a distribution similar to that of lung cancer.

104. Pulmonary blastoma manifesting as a large pulmonary mass. Left
Posteroanterior chest radiograph shows complete homogeneous
opacification of the left hemithorax and displacement of the
mediastinum to the right. Right CT reveals a large lung mass and
shows heterogeneous attenuation consistent with necrosis. There
is subcarinal adenopathy due to metastatic disease (*). Note the
*

105. LYMPHOMA
 Parenchymal involvement in Hodgkin disease is
two to three times more common than in non-
Hodgkin lymphoma.
 Parenchymal abnormalities in Hodgkin lymphoma
(30%).
 Usually produce linear and coarse reticulonodular
opacities that extend directly into the lung from
enlarged hilar nodes.
 Extensive areas of parenchymal involvement can
produce

106.  Atelectasis in Hodgkin disease is rarely caused by
extrinsic
nodal compression of the bronchi, but rather
develops from
an obstructing endobronchial tumor.
 Extension into the subpleural lymphatics may produce
subpleural plaques or masses that are visible only by
CT.
 While parenchymal involvement in Hodgkin disease
does not occur in the absence of hilar and mediastinal
nodal disease (excluding patients who have
undergone mediastinal irradiation), non Hodgkin
lymphoma may involve the parenchyma without

107.  The parenchymal involvement most often
appears as masses /airspace opacities the latter
may simulate lobar pneumonia.
 Coarse reticulonodular or tree-in-bud opacities
are uncommon, and rarely an SPN is the sole
manifestation of intrathoracic disease.
 Most cases of primary pulmonary non-Hodgkin
lymphoma arise from the BALT and represent
low·grade B cell lymphomas.

108. Primary Pulmonary Lymphoma. A. Chest radiograph shows a mass in
the right lower lobe (arrow). B. CT scan at lung windows through the
level of the right inferior pulmonary vein shows a lobulated mass in the
middle and right lower lobes (arrows) surrounding but not occluding the
basal segmental bronchi. Biopsy revealed non-Hodgkin B cell
lymphoma.

109. METASTATIC LUNG DISEASES
 Metastases most commonly reach the lung
haematogenously via the systemic veins and
pulmonary arteries.
 Commonest primary tumours of the breast,
skeleton and urogenital system –Approx. 80% of
pulmonary metastases.
 Lymphatic spread is less
common&endobronchial spread is rare, usually
being a manifestation of alveolar cell carcinoma.
 Approx. 3%; of asymptomatic pulmonary
nodules are metastasis.
 Commonest primary tumors producing
solitary metastases are carcinomas of the
colon , kidney and breast.

110.  Testicular tumors, bone sarcomas and
malignant melanoma in about 75% of cases
metastatic lung disease presents as multiple
pulmonary nodules.
 Metastases to the lung are usually bilateral,
affecting both
lungs equally, with a basal predominance.
 They are often peripheral and pleural based.
 Pulmonary metastases vary in size-a few mms to
several cms
 They tend to be spherical with a well-defined
margin.

111.  Cavitation may occur in metastases from any primary but
is more common in squamous carcinomas and sarcomas.
 Cavitation of a subpleural metastasis is a recognised
cause of spontaneous pneumothorax.
 Calcification is unusual in pulmonary metastases, being
most most often in osteogenie sarcoma and rarely in
chondrosarcoma and mucinous adenocarcinoma.
 Endobronchial metastases are rare, the commonest
primary tumours being carcinoma of kidney, breast and
large bowel. [ALSO SOLITARY]
 They may occlude the airway and cause segmental or
lobar collapse.

112. Left, P/A chest radiograph, Pulmonary metastases. Carcinoma of cervix.
Multiple cavitating
masses are present in both lungs.
Middle; P/A chest radiographs, Pulmonary metastasis, Osteogenic
sarcoma. .Densely calcified masses are present in both lungs
Right;. Pulmonary metastases. Soft-tissue sarcoma. CT shows subpleural
location of several of the metastases.

113. LYMPHANGITIS
CARCINOMATOSA
 Results from haematogenous metastases
invading and occluding peripheral pulmonary
lymphatics.
 The commonest primary sites are carcinoma of
the lung, breast, stomach, pancreas, cervix and
prostate.
 It is usually bilateral, but lung and breast cancer
may cause unilateral lymphangitis.
 The chest X-ray shows coarse, linear, reticular
and nodular shadowing, often with pleural
effusions and hilar lymphadenopathy.

114.  In the early stages of lung involvement the chest
X-ray may suggest lymphangitis but may not be
diagnostic.
 In these cases a high-resolution CT scan may be
undertaken to establish the diagnosis, when the
typical appearance is nodular thickening of the
interlobular septa and thickening of the
centrilobular bronchovascular bundles

115. Left; Posteroanterior chest radiographs, Unilateral lymphangitis
carcinomatosa. Carcinoma of the left lower lobe. There are several horizontal
septal lines in the periphery of the left lung.
Middle; Lymphangitis carcinomatosa. Carcinoma of cervix. Coarse reticular
shadowing is present throughout both lungs, and there is bilateral hilar
lymphadenopathy.
Right;Lymphangitis carcinomatosa. Breast cancer. High resolution CT
(HRCT) shows marked nodular thickening of the interlobular septa and

116. SQUAMOUS CELL PAPILLOMA
 Squamous cell papilloma is a mucosal lesion
caused by infection with human papilloma virus.
 This disease typically produces multiple laryngeal
masses in children born to women with venereal
warts (condylomata
acuminata).
 The trachea, bronchi and lungs may become
involved over time.
 These lesions usually regress by adolescence
and therefore are uncommon causes of a solitary
tracheal lesion in adults

117. PULMONATY HAMARTOMA
 Comprising of an abnormal arrangement of the
mesenchymal &epithelial elements found in normal
lung.
 Histologically, these lesions contain cartilage
surrounded
by fibrous connective tissue, with variable amounts of
fat.
smooth muscle, and seromucous glands;
calcification and ossification are seen in 30%.
 These tumors are seen most commonly in the fourth
and 1i£th decades of life.
 Approximately 90% of hamartomas arise within
the pulmonary parenchyma, accounting for
approximately 5% of all SPNs.

118.  Radiologically; a nodule smaller
than 2.5 an in
diameterdemonstrating a smooth or
lobulated border and containing
focal fat
 Calcification, when present, is in the
form of multiple clumps of calcium
throughout the lesion ("popcorn"
calcification)
 While hamartomas tend to grow
slowly.
 Rapid growth, pulmonary symptoms,
F
at

119. LEIOMYOMA,
FIBROMA,NEUROFIBROMA.
 Arising from the smooth muscle of the
airways/pulmonary
vessels, leiomyomas are rare neoplasms that
present as endobronchial/intrapulmonary lesions
with equal frequency.
 Radiographically, the parenchymal lesions are
sharply marginated, smooth or lobulated nodules
or masses.
 The histologic distinction of benign from
malignant
lesions is difficult.
 Similarly, fibromas (are sessile or pedunculated
fibrous

120. HEMANGIOPERICYTOMA
 is a connective tissue tumor that arises within the
lung from the pericyte, a cell associated with the
arteriolar and capillary endothelium.
 On chest radiographs, these lesions are seen as
SPNs and are indistinguishable from
bronchogenic carcinoma.

121. LIPOMAS:
 are rare intrapulmonary lesions that arise more
commonly within the tracheobronchial tree to
produce atelectasis.
 The demonstration of fat attenuation on CT is
diagnostic.
CHONDROMA
 Arises from the tracheal cartilage and produces a
well-circumscribed endoluminal mass.
 CT may demonstrate stippled cartilaginous
calcification
within the mass.

122. GRANULAR CELL TUMOR
(GRANULAR CELL
MYOBLASTOMA)
 Is a benign neoplasm arising from neural
dements in the central airways or parenchyma.
 The skin is the most common site for these
tumors.
 These tumors may present as SPNs but are more
commonly seen as endobronchial masses; half of
lung lesions present with obstructive pneumonitis
because of their endobronchial location

123. Granular Cell Tumor of Lung. CT scan at lung windows
through the lower lobes shows a smoothly bordered mass
(arrowhead) that narrows the anterior basal segmental
bronchus (arrow). Surgical lobectomy revealed a granular

124. SCLEROSING HEMANGIOMA.
 This is a benign epithelial neoplasm that typically
affects females and presents as a solitary,
smoothly marginated juxtapleural nodule that
enhances densely because of its vascular nature.
 The lesion may contain foci of low attenuation
and may be calcified on thin-section CT analysis.

125. INFLAMMATORY
MYOFIBROBLASLIC TUMOR
 Also known as plasma cell
granuloma/inflammatory pseudotumor
 Refers to a localized chronic inflammatory
response to an unknown agent in the lung.
 It is characterized histologically by an abundance
of
plasma cells.
 There are no distinguishing radiographic features.

126. BRONCHOGENIC CYST.
 Fluid filled cystic lesions of the lung may produce
an SPN.
 Intrapulmonary bronchogenic cysts are
uncommon causes of SPNs.
 90% of these lesions are found in the middle
mediastinum.
 The characteristic finding is a sharply marginated
cyst on CT or MR in a young patient, although
distinction from an infected bulla, solitary
echinococcal cyst, mucocele, or thin-walled lung

127.  Superinfection of a lung bulla may produce an
SPN or mass.
 In such patients, the radiographic or CT
appearance of an intraparenchymal air-fluid level
within a thin-walled localized air collection
(usually in an upper lobe), with typical bullous
changes in other portions of lung, usually allows
for the proper diagnosis

128. TO SUMMARIZE
 Lung malignancy is the most common cause of
morbidity and mortality in over 5th decades of life.
 The most common etiological agent being
tobacco smoking (Both active and passive).
 Making appropriate diagnosis, staging and
assessing the treatment are the three aspects of
the imaging for management of the lung
malignancy.

130. References
 Textbook of Radiology and Imaging- David
Sutton, Volume 1
 Fundamentals of Diagnostic Radiology, Bryants &
Helm 4th Edition
 CT and MRI of Whole Body, Haaga 6th Edition.

131. Carcinoid tumor
THANK YOU

132. NSCLC invading the left atrium. Double inversion recovery
contrast-enhanced single breath-hold coronal MRI shows an
enhancing right upper lobe mass (M) that extends via the
right superior pulmonary vein into the left atrium. A, aorta; LA,
left atrium; PA, right main pulmonary artery.
LA
PA
A
M