In this presentation our agenda is Brief introduction Radiological Modalities Radiological Features Radiological Imaging Of Complications of lung cancer. I followed Dahnert and try to describe all findings in lung cancer. Hope it will prove an atlas in Lung cancer imaging.

1. DR. Muhammad Bin Zulfiqar
PGR IV New Radiology Department
SHL/SIMS
radiombz@gmail.com

2. 2
 Brief introduction
 Radiological Modalities
 Radiological Features
 Radiological Imaging Of Complications
Agenda

3. 3
 Bronchogenic carcinoma is a malignant neoplasm of the
lung arising from the epithelium of the bronchus or
bronchiole.
Definition

4. 4
 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
Lung Cancer Demographics

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

6.  Atypical adenomatous hyperplasia
 Squamous dysplasia / carcinoma in situ
 Diffuse idiopathic pulmonary neuroendocrine cell
hyperplasia
Preinvasive Lesions

7. 7
 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%
Classification
Continued

8. 8
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.
Classification

9.  Central tumors
• Cough
• Wheezing
• Hemoptysis
• Pneumonia
 Extrapulmonary invasion
• Pain
• Pancoast syndrome
• SVC Syndrome
 Metastases
 Paraneoplastic syndromes
 Asymptomatic 10%
Clinical Features

10. 10
 PLAIN CHEST RADIOGRAPH
 BRONCHOGRAPHY (Obsolete)
 COMPUTED TOMOGRAPHY
 MAGNETIC RESONANCE IMAGING
 BARIUM STUDIES
 ULTRASONOGRAPHY
 POSITRON EMMISION TOMOGRAPHY
 ANGIOGRAPHY
Imaging Modalities

11.  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)
Presentations of Lung Tumor
Continued

12.  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
Presentations of Lung Tumor
Continued

13.  Persistent peripheral infiltrate
 NO air bronchogram
 Pleural effusion
 Chest wall invasion:
 Involvement of main pulmonary artery (18%); lobar
 Calcification in 7% on CT
Presentations of Lung Tumor

14.  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.
Solitary Pulmonary Nodule / Mass

15.  A focal opacity (solitary pulmonary nodule) is visible
with speculated margins

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

17.  Bronchial carcinoma in the left lower
lobe showing typical rounded,
slightly lobular configuration. The
mass shows a notch posteriorly
Mass

18.  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
Ground glass haze

19.  Bronchoalveolar Carcinoma--- as ground glass haze in
left lower lobe and lingula

20.  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)
Consolidation

22.  Air space infiltration involving almost all left lung
zones and right mid zone
Continued

23.  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 of bronchoalveolar carcinoma, the patient
condition did not permit for this.

24.  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
of bronchoalveolar carcinoma, the
patient condition did not permit for
this.

25.  CT angiogram sign. A
patient with bronchoalveolar
carcinoma. Enhancing
pulmonary vessels in a low-
attenuating mass are seen.
CT Angiogram Sign

26.  CT angiogram sign. Another
patient with bronchoalveolar
carcinoma. Enhancing
pulmonary vessels in a low-
attenuating mass are seen.
CT Angiogram Sign

27.  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.
cavitation

28.  The cavity is eccentric (large cell undifferentiated
carcinoma). (B) The inner wall of the cavity is irregular
(squamous cell carcinoma).

29.  The cavity wall may be very
thin (squamous cell
carcinoma).

30.  Cavitating mass in the left
mid-zone and there is
bulging of the
aortopulmonary window,
indicating lymph node
enlargement.
30

31.  Irregular opacity in left
mid-zone with central air
density due to cavitation
and inferior horizontal
margin due to air-fluid
level.
31

32.  FIGURE 15-14 ■ CT showing a cavitating squamous
cell carcinoma in the left lung. The wall of the cavity
is variable in thickness.

33.  Bronchial carcinoma in the posterior segment of the
right upper lobe with cavitation.

34.  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.

35.  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.
Central Mass

36.  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 region and left hilum with almost complete
obliteration of left lower lobe bronchus with left lower lobe collapse.
 There is a tiny left pleural effusion and bilateral enhancing adrenal lesions.
 Enhancing right adrenal mass.

37.  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.

38.  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)
Unilateral Hilar Mass

39.  Chest X-ray shows a
dense left hilum, but
no definite mass.
39

40.  Chest X-ray shows
the primary tumour
is at the left hilum.
40

41.  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.

42.  Recurrent malignant left
hilar lymph nodes from a
small peripheral non-
small 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.

43.  Anterior+ middle mediastinal widening
 Might suggests small cell carcinoma)
Mediastinal Widening

44.  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.

45.  The CT confirms the presence of mass in both the
anterior and the middle mediastinum.

46. 46
 F-18 FDG PET imaging has been shown to be an accurate, non-
invasive 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.
PET-CT

47. 47
 PET scan showing abnormal uptake of FDG in a tumour
nodule in the right upper lobe(arrow) & in two superior
mediastinal lymph nodes(arrowheads).

48. 48
 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.

49. 49
 (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.

50. 50
 Carcinoma of the bronchus.
Barium Swallow shows extrinsic
compression of the mid-esophagus
by enlarged subcarinal lymph
nodes.

51.  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)
Segmental I lobar I lung atelectasis

52.  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).

53.  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.

54.  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
airways—the CT mucous
bronchogram sign.

55.  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.

56.  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.

57.  FIGURE 15-18 ■ Fluid-filled dilated bronchi beyond a
central obstructing carcinoma are visible in this collapsed
and consolidated right lower lobe.

58.  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)
Golden S sign

59.  Golden’s 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.

60. ‘Golden S sign.‘ Collapsed right upper lobe with mass at right hilum.
60

61.  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
Golden’s S sign.

62.  Left upper lobe collapse due to bronchial carcinoma.
 Carcinoma has caused rat tail like narrowing of left upper
main bronchus
Rat tail termination of bronchus

63.  Mucoid impaction of segmental / lobar bronchus (due
to endobronchial obstruction) or from external
compression on bronchus.
Mucoid Impaction

64.  Bronchocele with typical
gloved-finger branching
pattern
64

65. Bronchocele due to carcinoma of the bronchus.
CT shows dilated, fluid-filled bronchi in the
lingula, secondary to carcinoma at the left
hilum.
65

66.  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.

67.  local hyperaeration (due to
check-valve 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.
Local Hyperaeration

68.  persistent peripheral infiltrate (30%) = post obstructive
pneumonitis
Persistent peripheral infiltrates

69.  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

70.  The bronchial cut off sign refers to the abrupt
truncation of a bronchus from obstruction, which may
be due to cancer, mucous plugging, trauma or foreign
bodies. Typically, there is associated distal lobar
collapse.
Bronchial cut off sign

71.  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

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

73.  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.
Malignant Pleural effusion

74.  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.

75. 75
 Large left pleural effusion
due to carcinoma of
bronchus.
There is a large echo-free
effusion above the left
hemidiaphragm
(arrowheads) and spleen
(s).

76. 76
 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.

77.  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.

78.  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%)
Chest Wall Invasion

79.  FIGURE 15-22 ■ Chest wall invasion by a Pancoast’s
tumour. Involvement of the soft tissues of the chest wall
appreciated on the (A) axial T1-, (B) coronal T2-weighted
MRI

80.  FIGURE 15-22 ■ Chest wall invasion by a Pancoast’s
tumour. Involvement of the soft tissues of the chest wall
and the left second rib is appreciated.

81.  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 close-up 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.

82.  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

83.  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.
Involvement of Main Arteries

84.  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.

85.  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.

86.  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)
Calcifications

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

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

89. Benign calcification patterns

90. Feeding Vessel Sign
 Feeding vessel sign. A
patient with bronchial
carcinoma. Pulmonary
artery leading directly to
the mass is seen.

91.  Bronchial cuff sign = focal / circumferential thickening
of bronchial wall imaged end-on (early sign)
Bronchial Cuff Sign

92. 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

93. 93
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

94. 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.
94

95. 95
TNM STAGING
T1 <3cm in diameter, sorrounded by lung/visceral pleura
T2 >3cm in diameter/invasion of visceral pleura/lobar
atelectasis/obstructive pneumonitis/at least 2cm from
the carina.
T3 Tumour of any size; less than 2cm from the carina/
invasion of parietal pleura, chest wall, diaphragm,
mediastinal pleura, pericardium.
T4 Invasion of the heart, great vessels, trachea, esophagus,
vertebral body, carina/ malignant effusion
N1 Peribronchial / ipsilateral hilar nodes
N2 Ipsilateral mediastinal nodes.
N3 Contralateral hilar/ mediastinal nodes
M0 No metastases
M1 Distant metastases present.

96. 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.
96

97. 97
CHEST
RADIOGRAPHY
1st line investigation; cheap
and readily available; can
depict most of the features
of overt lung cancer and its
complications.
COMPUTED
TOMOGRAPHY
The gold standard in
diagnosis and staging of
lung cancer; gives cross-
sectional imaging with
better representation of
anatomy; clearly depicts
mediastinal adenopathy
and involvement of
adjacent structures.

98. MAGNETIC
RESONANCE IMAGING
Excellent soft tissue
resolution; clearly depicts
vascular invasion better than
CT; imaging modality of
choice for assessing Pancoast
tumours; of importance in
cases where CT findings are
indeterminate or equivocal.
POSITRON EMISSION
TOMOGRAPHY
Provides excellent depiction of
functional status of suspicious
lung masses; helps to sort out
status of nodal enlargement
coexisting with lung cancer.
98

99. 99
LOCAL COMPLICATIONS:
• Superior Vena Cava Syndrome
• Intractable Hemoptysis
DISTANT COMPLICATIONS:
• Metastases
PARANEOPLASTIC SYNDROMES:
• Hypertrophic Osteoarthropathy
RADIOLOGY OF COMPLICATIONS

100. 100
 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.
SVC SYNDROME

101. 101
 Lung cancer is the leading malignant cause of SVC
syndrome, with non–small 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.
SVC SYNDROME

102. 102
 Swelling of the face, arms, or chest wall
 Difficulty breathing (dyspnoea)
 Widening of the veins in the neck and chest
SVC SYNDROME

103. 103
 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.

104. 104
 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.

105. 105
 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%.
INTRACTABLE HEMOPTYSIS

106.  Reports of neurological damage following
bronchial angiography indicate care in avoiding
obstruction of the artery of Adamkiewicz.
106

107. Angiographic image
showing blood ejecting
from a ruptured bronchial
artery branch (arrow)
Selective embolization of
the feeding artery obtained
with gel foam.
107

108. 108
 Aka Bamberger-Marie syndrome
 Hypertrophic osteoarthropathy is a paraneoplastic
syndrome most often found in non-small cell lung cancer.
HYPERTROPHIC OSTEOARTHROPATHY

109. 109
 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.
HYPERTROPHIC OSTEOARTHROPATHY

110. 110
 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.
HYPERTROPHIC OSTEOARTHROPATHY

111. 111
 Radiograph showing thickened, columnar
diaphyses and erosion of the terminal phalangeal
tufts in Hypertrophic Osteoarthropathy

112. 112
 Bone scintigraphy showing
periosteal proliferation along
the margins of the shafts of
the tibias, radii, ulnae and
pelvic bones.

113. 113
 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.
DISTANT METASTASES

114. 114
 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.
DISTANT METASTASES

115. 115
 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.
LIVER METASTASES

116. 116
Computed tomographic (CT) scan of the abdomen
showed multiple hepatic metastases (arrows).

117. 117
Gadolinium-enhanced 3D LAVA (Liver Acquisition with Volume
Acceleration). Hypovascular metastases are best depicted on portal
venous phase images.

118. 118
 Adrenal metastases are common and often solitary.
 They must be differentiated from adrenal adenomas,
which occur in 1% of the adult population.
ADRENAL METASTASES

119. 119
 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.
ADRENAL METASTASES

120. 120
Sonogram showing a 6-cm right adrenal metastasis
of lung cancer.

121. 121
 Adrenal metastasis from small cell lung
cancer

122. 122
 Coronal PET/CT image
demonstrating intense FDG
uptake in the primary left upper
lobe lung carcinoma (curved arrow)
and in the adrenal metastases
(arrows)

123. 123
 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.
BONE METASTASES

124. 124
 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.
BONE METASTASES

125. 125
Bone Metastasis from Primary Lung
Cancer :Lytic lesion of humerus with a
pathological fracture.

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

127. 127
FDG PET images demonstrate
bone metastases (arrows).

128. 128
Isotope bone scan. Hot spots due to bony metastases.

129. 129
 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.
BRAIN METASTASES

130. 130
 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.
BRAIN METASTASES

131. 131
Non small cell lung cancer with hemorrhagic brain metastasis
(A) Pre-operative non-contrast enhanced computed
tomography (CT). (B) Pre-operative contrast-enhanced CT.

132. 132
Contrast-enhanced CT scans of the same patient
showing multiple enhancing cerebral metastases of lung
cancer in the left cerebral hemisphere.

133. 133
DIFFERENTIAL DIAGNOSES
 Pulmonary metastases Pulmonary AV malformation

134. 134
DIFFERENTIAL DIAGNOSES
 Pulmonary tuberculosis  Pulmonary hamartoma

135. THANK YOU