THIS PRESENTATIONS GIVES DETAILS ON LUNG MASSES

1. BENIGN & MALIGNANT
LUNG NEOPLASTIC MASSES
•DR. NISHIT VIRADIA

2.  A wide variety of neoplasms may arise in the lungs
 While many lung tumors are malignant, others are
benign , some fall between these two extremes (both
clinically & histologically)
 Carcinoma of bronchus is by far the most commonest
and most important primary tumor of the lung

3. VARIOUS TYPES
 SOLITARY PULMONARY NODULE - evaluation
 BENIGN PULMONARY TUMORS
 BRONCHOGENIC CARCINOMA
 PULMONARY SARCOMA
 MALIGNANT LYMPHOPROLIFERATIVE
DISORDERS – lymphoma , leukemia
 METASTASIS

4. SOLITARY PULMONARY NODULE
 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.
 Most are benign, upto 40% of SPN’s may be
malignant

5. DIFFERENTIALS OF SPN
 Bronchial carcinoma
 Bronchial carcinoid
 Granuloma
 Hamartoma
 Metastasis
 Chronic pneumonia or abscess
 Hydatid cyst
 Pulmonary haematoma
 Bronchocele

6.  Fungus ball
 Massive fibrosis in coal workers
 Bronchogenic cyst
 Sequestration
 Atriovenous malformation
 Pulmonary infarct
 Round atelectasis

7. Solitary pulmonary nodule
Mimics
• Extrathoracic artifacts
• Cutaneous masses
• Bony lesions
• Pleural tumors or plaques
• Encysted pleural fluid
• Pulmonary vessels

8. Solitary pulmonary nodule
Factors to differentiate
• Size
• Shape
• Edge characteristic
• Calcification
• Enhancement
• Cavitation
• Growth rates

9. SIZE
• The size of the SPN is not a reliable indicator
of benignity, although the larger the nodule,
the more likely it is to be malignant.
• < 1 cm diameter the malignancy rate is35%
• For 1-2 cm, 50%
• For 2-3 cm 80%
• For > 3 cm 97%

10. Shape
• Lung carcinomas tend to be irregular in shape,
lobulated or notched.
• Lobulation and notching are signs that indicate
uneven growth and can be seen in a number of
lesions but more likely it in bronchogenic
carcinoma.
• Hamartomas and metastases are usually
round/oval and smooth with a non lobulated
edge.
• Scars or areas of atelectasis may appear linear or
angular.

11. Edge characteristic
• Irregularity, spiculation and lobulation s/o malignancy
• Benign lesions tend to have a smooth and sharply defined
edge.
• Only 20 percent of lesions with a smooth, sharp margin are
malignant.
• Malignancies that tend to have a sharp and smooth edge
include metastases and carcinoid tumors.
• The terms corona radiata and corona maligna or the
“sunburst appearance” have been used to describe the
presence of spiculation associated with a nodule or a mass.
• It reflects the presence of fibrosis surrounding the tumor,
particularly in patients with adenocarcinoma and
bronchioloalveolar carcinoma.

12. BENIGN CALCIFICATION PATTERNS

13. • Concentric (laminated) calcification is virtually
specific to tuberculous or fungal granulomas.
• Popcorn calcification consisting of overlapping,
randomly distributed, small rings of calcification
is seen only when there is cartilage in the nodule,
a feature seen in one third hamartomas and in
cartilage tumors
• Uniform calcification of a SPN is virtually
diagnostic of a calicfied granuloma and excludes
the diagnosis of bronchial carcinoma.

14. A SOLID CALCIFIED SOLITARY PULMONARYNODULE

15. SPECKLED OR PUNCTATE
CALCIFICATIONS
ECCENTRIC CALCIFICATION

17.  CAVITATION-
• Best demonstrated on CT SCAN
• Most commonly seen in squamous cell type of lung carcinoma.
• Cavities with a greatest wall thickness less than 5 mm are almost always
• BENIGN whereas most of those with a maximal wall thickness greater
than 15 mm are MALIGNANT
EXAMPLE OF A THICK WALLED CAVITY

18. AirBronchogram sign
• A/w
malignancy
• Bronchoalveolar
ca and
adenocarcinoma

19. Enhancement on ct
• Malignant nodule
Wash in more than 25 HU
Washout 5-31 HU (15 min delayed)

20. Growth
Doubling time of the lesion
• Malignant : 1-6months
• Benign : > 18months

22. BENIGN PULMONARY TUMORS
 PULMONARY HAMARTOMA
 OTHERS – FIBROMA, CHONDROMA, LIPOMA,
HAEMANGIOMA, NEUROGENIC TUMOURS

23. HAMARTOMAS
 Most common benign tumor of
the lung.
 Composed of abnormal
arrangement of tissues ;
cartilage, connective tissue,
muscle, fat, and bone
 Discovered incidentally
 Well-circumscribed nodules or
masses (usually small) with
either smooth or lobulated
margins
 Approximately 60% have fat and
approximately 20-30% have
calcification / ossification (pop-
corn like calcification)
 Cavitation is not seen
 On CT scan fat can be
recognized by comparing it to
subcutaneous fat and will
typically have a Hounsfield
measurement of -40 to - 120HU

26. BRONCHOGENIC CARINOMA
 Commonly known as lung carcinoma
 A highly malignant primary lung tumor that has a very
poor prognosis
 Arises from respiratory epithelium ; bronchus ,
bronchiole or alveoli.
 Commonest fatal malignancy in adult males in the
western world
 Its more common in men than in women , but the
incidence in women is rising
 Responsible for 1.38 million deaths annually, as of 2008
 Overall 5 yr survival is <15%
 Most cases 40-70 yrs age ; unusual below 30 yrs.

27. CAUSES
- Tobacco smoke - most important causative agent (20-
30 fold , increased risk ; proportional to dose).
Polycyclic aromatic hydrocarbons , Nitrosamines
carcinogens in cigarette smoke.
- Passive smoking
- Atmospheric pollution – vehicles, industries, power
plants
- Exposure to asbestos, nickel, arsenic , chromates,
nickel, mustard gas
- Radon gas – natural gas produced by decay of uranium
- Radiotherapy

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

29. CONTD…
Regional spread to hilar and mediastinal nodes may cause :
 Dysphagia due to esophageal compression
 Hoarseness due to recurrent laryngeal nerve compression
 Horner’s syndrome due to sympathetic nerve involvement
 And, elevation of the hemidiaphragm from phrenic nerve compression.
 Extrapulmonary manifestations :
Include –
o metastasis to other organs, such as brain, central nervous system,
skeleton system, liver, adrenal glands and lymph nodes.

30. CLASSIFICATION OF LUNG CARCINOMA
Broadly classified into 2 types-
Based on microscopic appearance of tumor cells
Non- small cell
Lung carcinoma
(80%)
Adenocarcinoma
30-40%
Squamous cell
Ca 30%
Large cell Ca
10-15%
Mixtures of
different types of
NSCC
Small cell Lung
carcinoma (20%)

31.  ADENOCARCINOMA ~ 30-40% ; most
common subtype
 composed of malignant glandular
epithelium, varying in degree of
differentiation.
 Most common cell type in non-smokers.
 smaller than other bronchogenic
carcinomas.
 located in lung periphery
 Radiologic feature – peripheral nodule /
peripheral mass
 5 yr survival = 17%
 BRONCHOALVEOLAR CARCINOMA : is a
type of adenocarcinoma ; m/c in women and
non-smokers
 arises from epithelium of terminal bronchiole
or alveolus
 almost always peripheral ; may present as
pneumonia like consolidation ,as a solitary
nodule or forms multiple colaescing
nodules.

32. • Chest x-ray –
WIDESPREAD LUNG INVOLVEMENT
CT scan–
TYPICAL AIRSPACE FILLING WITH AN
AIRBRONCHOGRAM

33.  SQUAMOUS CELL CARCIMONA ~ 30-
35% ; second most common subtype
 composed of malignant squamous cells that
vary in degree of differentiation from tumor
to tumor
 m/c in men
 closely related to smoking
 Radiological feature – hilar or perihilar
mass, cavitating lung mass, peripheral
nodule, atelectasis or obstructive
pneumonitis distal to obstructed bronchus.
 Most common carcinoma to cavitate
 5 yr survival =15%

34. HILAR CAVITATING MASS - due to squamous cell carcinoma

35.  SMALL (OAT) CELL CARCINOMA ~ 20-
25%
 composed of small cells that resemble
lymphocytes
 strongly related to smoking
 very aggressive
 metastasizes early
 radiologic feature – hilar mass /
mediastinal mass
 5 yr survival = 5 % ; worst prognosis
 Staged in two groups-
a) limited stage disease
b) extensive stage disease

36. RADIOGRAPHIC FEATURES-
 Typically central in location, 75- 90% cases
 Hilar or a perihilar mass
 Massive adenopathy, often bilateral
 Associated lobar collapse
Primary tumor may not be readily evident because it is
obscured by the extensive adenopathy. And in such cases, CT
SCAN may prove advantageous

37. PANCOAST TUMOR
 Also known as superior sulcus tumor.
 CLINICAL FEATURES
 may include - chest pain
- horner’s syndrome
- bone destruction
- atrophy of hand muscles
that
 RADIOLOGICALLY-
Usually appears as – an apical mass
- asymmetrical pleural thickening with irregularity
occasionally is associated with rib destruction
 Apical thickening which is usually bilateral, may be a normal finding, commonly
seen in older patients.
However, irregular apical thickening, that is 5mm or greater than that on
the opposite side should be considered with suspicion.
 INVASION OF – chest wall, brachial plexus, vertebral bodies, spinal canal,
subclavian artery

38.  MRI
 Is the preferred modality because of its ability to visualize structures at
the apex of the thorax
 It is usually useful in determining certain parameters of resection of
the tumor such as invasion of the vertebral bodies, involvement of the
subclavian artery and brachial plexus.
 Coronal and sagittal images are particularly helpful
 CT scan
 may be helpful when extensive mediastinal invasion is present
 But the value of CT in determining chest wall invasion is somewhat
limited, and here MRI may have a slight advantage.

43.  LARGE CELL CARCINOMA ~ 15-20%
 composed of large, undifferentiated malignant cells
 Radiologic feature – large peripheral mass
 5 yr survival = 11%

44. IMAGING
• CXR – commonly useful to suspect lung cancer in asymptomatic
or non- specific cases
• Next investigation that comes in use is CT / computed tomography
• The diagnosis is confirmed with a biopsy which is usually
performed by bronchoscopy or CT-guidance
• Immunostaining used to categorize the subtype on which prognosis
depends
• PET imaging with FDG (fluorodeoxyglucose) is increasingly used for
staging
• Sensitivity of PET in one study = 79% , specificity = 91% ;
whereas the sensitivity of CT 60% , specificity = 70%
• Fused PET-CT imaging provides registration of FDG metabolic
activity with the anatomical detail of CT .

46. LUNG CARCINOMA CAN BE DISCUSSED as:
1) CENTRAL TUMORS 2) PERIPHERAL
TUMORS

47. PERIPHERAL TUMORS
 Approximately 40% of the bronchial carcinomas arise beyond the
segmental bronchi
 In 30% a peripheral mass is the sole radiographic finding
A. Tumor shape and size
B. Cavitation
C. Calcification
D. Presence of air
bronchograms
E. Ground glass attenuation

48.  TUMOR SHAPE AND SIZE-
 Tumor at lung apex may appear as pleural thickening.
 Majority of peripheral tumors may be spherical or oval
 CORONA RADIATA - numerous strands radiating from the nodule into
surrounding lung
 Peripheral line shadow or ‘TAIL’ SIGN - linear opacity that extends from a
peripheral nodule to the visceral pleura

49. CAVITATION
• Cavitation may be seen in any type or size of lung cancers, however, it is
most common with squamous cell carcinoma.
• It develops due to central necrosis, liquefaction and emptying of the
contents in the airways.
• The cavity may contain fluid, air or air-fluid level.
• The malignant lung cavity is usually located eccentrically within the mass
resulting in unequal thickness of the cavity wall.
• The cavities walls usually, but not always, are at least 8 mm in thickness
and appear irregular and nodular in outline.
• Rarely, the cavity is seen as an air crescent, similar to the fungal ball. This
appearance is caused by the air around an intra-cavitory tumor.
• Air bronchogram or bubble like lucencies may also be identified in lung
cancers, especially in adenocarcinoma or bronchoalveolar carcinoma, on
thin section CT or HRCT.
• These lucencies are produced either due to small cavities or patent
bronchi within the tumor.

50. CALCIFICATION
• rarely seen in lung cancers(6-10 percent of bronchogenic).
• These represent either preexisting granulomatous
calcifications engulfed by the tumor or dystrophic
calcifications developed in the areas of tumor necrosis.
• The dystrophic tumor calcification is usually amorphous or
cloudy in appearance and located centrally while engulfed
calcifications tend to be located at the periphery of the
tumor.
• Tumor calcification may be seen in any type of
bronchogenic carcinoma and there is no predilection for
any specific histological subtype.
• Most lung cancers showing tumor calcifications are large in
size.

51. GROUND GLASS HAZE
• Ground glass opacities are sometimes seen
around the tumor and may represent adjacent
edema, inflammation or hemorrhage.
• Bronchoalveolar carcinomas may be seen as
purely ground glass small nodules.
• Lung cancers with higher (>50%) proportion of
ground glass opacity tend to grow slowly, have
lower chances of vascular or lymphatic
invasion and hence, have better prognosis

52.  Bronchoalveolar Carcinoma--- as ground glass
haze in left lower lobe and lingula

53. CENTRAL TUMORS
 Cardinal imaging signs of a central tumor are –
 A) collapse / consolidation
 B) hilar enlargement
A) Collapse /consolidation:
- Obstruction of major bronchus often leads to a consequent pulmonary opacity and
secondary infection may occur beyond the obstruction. Example: Non-resolving
pneumonia
“The presence of pneumonia in at-risk patient, confined to one lobe that
persists unchanged for longer than 2-3 weeks, OR a pneumonia that recursin
the same lobe which shows loss of volume and no air bronchograms.”
 A simple pneumonia often clears or spreads to other segments within afew
weeks of treatment with antibiotics

54.  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
CONSOLIDATION

55.  Air space infiltration involving almost all left lung
zones and right mid zone

56.  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.

57. CT ANGIOGRAM SIGN
CT angiogram sign. A patient with bronchoalveolar carcinoma. Enhancing
pulmonary vessels in a low-attenuating mass are seen.

58. Cavitating mass in the left mid-zone
and there is bulging of the
aortopulmonary window, indicating
lymph node enlargement.
Irregular opacity in left mid-zone with
central air density due to cavitation and
inferior horizontal margin due to air-fluid
level

59.  CT showing a cavitating squamous cell carcinoma
in the left lung.
The wall of the cavity is variable in thickness.

60.  Bronchial carcinoma in the posterior segment of
the right upper lobe with cavitation.

61. GOLDEN ‘S’ SIGN-
 The Golden S sign is created by a central mass and should raise
suspicion of a central neoplasm, such as primary bronchial carcinoma.
CT image of chest demonstrates a
convexity with collapse of RUL

62. Collapsed right upper lobe with a convex bulge along the lower
aspect of the collapsed lung (white arrows) producing a
Golden 'S' sign

64. B) Hilar enlargement-
- common presenting feature in patients with bronchial carcinoma
- may reflect proximal tumor, lymphadenopathy, consolidated lung
 Early, massive hilar or mediastinal lymphadenopathy and invasion –
well seen in –
1) Small cell Ca.
2) Large cell Ca

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

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.  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

68.  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

69.  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

70.  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.

71.  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.

72.  PARANEOPLASTIC SYNDROMES
Paraneoplastic syndromes are common in lung cancer patients and may be the first
manifestation of the disease or its recurrence.
 The extent of paraneoplastic syndromes is unrelated to the size of the primary tumour.
 Lung cancer and small-cell lung cancer (SCLC) in particular is the most common cancer
to be associated with para neoplastic syndromes.
 However, some paraneoplastic syndromes are more often found in non-small-cell lung
cancer (NSCLC). For example hypertrophic pulmonary osteoarthropathy has most often
been described in association NSCLC
EXAMPLE -
1) Hypertrophic Pulmonary Osteoarthropathy,
2) Hypercalcemia,
3) Inappropriate Antidiuretic Hormone Secretion Syndrome (SIADH)
4) Peripheral Neuropathies,and
5) Cushing’s Syndrome

73.  Many of the lung cancer symptoms are non-specific
 Cancer is already spread beyond the original site by the
time its suspected
 Small cell> Adeno > Large> Squamous
 Common sites of spread :
- Brain
- Bone
- Adrenals
- Opposite lung
- Liver
- Pericardium
- Kidneys

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

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

76.  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.
 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

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

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

79.  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.
 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

80.  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

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

82.  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 occurence of benign nodal
enlargement coexists with a malignant lung
lesion.

83.  Contrast enhanced CT demonstrated
enlarged lymph nodes (> 1 cm in short axis;
arrowheads) in ipsi- and contra-lateral
mediastinal nodal stations .
PET-CT showed high metabolic activity of the
parenchymal lesion but no nodal [18F]-2-FDG
uptake.

84. Bronchoalveolar Carcinoma
• It is a well differentiated subtype of adenocarcinoma characterized by slow growth
and better prognosis.
• It is not related to smoking.
• It presents in two distinct forms; as a solitary pulmonary nodule or in pneumonic
form. Solitary pulmonary nodule may be seen as solid nodule or ground glass
nodule . Mixed patterns may also be seen.
• Solid nodule tend to be subpleural and may have lobulated or spiculated margins.
This is indistinguishable from other types of cancers. Air bronchogram or bubbles
like cystic lucencies are common in solid nodules. Frank cavitation however, is
unusual.
• As the tumor grows slowly, the doubling time on radiographs may exceed 18
months, which is usually considered as upper limit for malignant lesions.
• The tumor also shows less or no uptake on PET scan for the same reason.
• Pneumonic form of bronchoalveolar carcinoma is results from characteristic lepidic
growth pattern of the tumor in which tumor cells use surrounding alveoli as a
scaffold for its growth. The tumors secret mucus and hence, clinically patients
present bronchorrhea
• The consolidation may be single or multifocal.

85. • Differentiation of bronchoalveolar carcinoma from
other causes of pneumonia may be difficult on
imaging.
• On CT, the peripheral location of pneumonia and
presence of solid nodule within are important
predictors of bronchoalveolar carcinoma over
pneumonia.53 When air bronchogram is seen, the
bronchi appear stretched and narrowed because of the
mass effect of bronchoalveolar carcinoma54.
• Pleural effusion and lymphadenopathy are infrequent
in bronchoalveolar carcinoma.

86. Lymphangitis Carcinomatosis
• This represents permeation of the pulmonary
lymphatics by tumor cells.
• Usual tumors to produce this are carcinomas of
lung, breast, GI tract, pancreas and prostate.
• Some tumors cause this by lymphatic spread to
hilar lymph nodes and then retrograde spread to
pulmonary lymphatics, while in other, it is caused
by harteries and then subsequent spread through
vessel walls into lymphatics of the lung.

87. • On chest radiographs,
• seen as reticulonodular opacities with thickened septal lines. It is
usually bilateral and symmetrical but may be unilateral, especially in
lung cancer.
• The hilar lymph nodes may or may not be enlarged.
• Subpleural bands and thickening of fissures due to subpleural
edema is a useful sign in the diagnosis of lymphangitis
carcinomatosis.
• Pleural effusion is also common.
• HRCT of the lungs is most sensitive investigation.
• It shows non uniform and nodular thickening of interlobular
• septa and brochovascular bundles.
• Patchy airspace opacities are also seen. The distribution and extent
of the abnormalities vary greatly

88. Lymphangitis carcinomatosis: HRCT of a woman with breast cancer
shows bilateral diffuse nodular peribronchovacular thickening
(arrows), nodular thickening of interlobular septa, fissure
and pleura with random nodules

89. BRONCHIAL CARCINOIDS
 Neuroendocrine tumors ; constitute <5% pulmonary tumors
 May be :
TYPICAL : arise in central airways
ATYPICAL : arise in lung periphery
 S/S - wheeze, pneumonia, hemoptysis
 Even if small , they may secrete ACTH in sufficient quantitiesto
cause CUSHING’S SYNDROME
 Radiographic appearances:
 Central lesion – partial or complete bronchial obstruction resulting
in atelectasis with or without pneumonia
 Peripheral lesion – present as solitary spherical or lobular nodule ,
2-4 cm in diameter , with a well – defined smooth edge .
 CT – calcification seen in 1/3rd patients

90. A small tumor completely occluding the right main bronchus and
causing extensive collapse in right lung. The endoluminal
component is well seen .There is poor differentiation of the tumor
from adjacent collapsed lung

91. Well defined perihilar carcinoid tumor demonstrated
anterior to the artery to the right lower lobe

92. A small peripheral carcinoid tumor indistinguishable
from a number of other causes of SPN

93. MALIGNANT LYMPHOPROLIFERATIVE DISORDERS
LYMPHOMA
 Radiographic
appearances –
 One or more areas of
pulmonary consolidation
resembling pneumonia
 Multiple pulmonary
nodules
 Miliary nodulation or
reticulonodular
shadowing resemblibg
lymphangitis
carcinomatosa

94. LEUKAEMIA
 Imaging features –
 Diffuse bilateral reticulation & patterns resembling
interstitial oedema , lymphangitic carcinomatosis ,
small nodules , ground glass opacification &
consolidation
 Hilar / mediastinal lymphadenopathy
 Pleural effusion – common

95. METASTASIS
 Pulmonary metastases
are usually from breast,
GIT, kidneys, testes, head
& neck tumours.
 Sign – one / more
discrete pulmonary
nodules usually in the
outer portions of lungs
 Nodules are
characteristically round &
well defined
 They may be of any
shape &have a irregular
edge - adenocarcinoma

96. Irregular pulmonary metastasis – occur In adenocarcinoma .
Nodules are irregular in outline . A large left pleural effusion is also seen

97. Metastases :
a)Pathways of metastatic spread from a
primary extrathoracic site to lungs
b) Neoplasms with rich vascular supply
c) Neoplasms with lymphatic dissemination
d)Other neoplasms with high propensity to
localize in lung
e) Calcified Metastases
f) Giant Metastases
g) Sterile Metastases

98. a) Pathways of metastatic spread from a primary
extrathoracic site to lungs :
1 Spread via pulmonary arteries
2 Lymphatic spread (celiac nodes → posterior mediastinal
nodes + paraesophageal nodes) and in lung parenchyma
3 Direct extension
4 Endobronchial spread
b) Neoplasms with rich vascular supply draining into
systemic venous system :
1-Renal cell carcinoma
2-Sarcomas
3-Trophoblastic tumors
4-Testis
5-Thyroid

99. c) Neoplasms with lymphatic dissemination :
1-Breast (usually unilateral)
2-Stomach (usually bilateral)
3-Pancreas
4-Larynx
5-Cervix
d) Other neoplasms with high propensity to
localize in lung :
1 Colon
2Melanoma
3-Sarcoma

100. e) Calcified Metastases :
-Calcifications in lung metastases are observed in :
1-Bone Tumor Metastases :
a) Osteosarcoma
b) Chondrosarcoma
2-Mucinous Tumors :
a) Ovarian
b) Thyroid
c) Pancreas
d) Colon
e) Stomach
3-Metastases After Chemotherapy

101. f) Giant Metastases : Cannon Ball
1 Head and neck cancer
2Testicular and ovarian cancer
3-Soft tissue cancer
4-Breast cancer
5-Renal cancer
6-Colon cancer

104. PSEUDOTUMOR
 Sharply marginated collection of pleural fluid
- Either within an interlobar pulmonary fissure, or -
In a subpleural location adjacent to a fissure.
 Imaging :
located along course of interlobar fissures
Lenticular or biconvex contour
 Most occour in minor/horizontal fissure

106. 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.

107. 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.