SEMINAR PRESENTATION BY DR. (MRS.) E.

S OSHO RADIOLOGY DEPARTMENT OAUTHC

Question: Describe the radiological features of bronchogenic carcinoma

OUTLINE y Introduction: Definition /Descriptions Incidence/prevalence y Aetiology/risk factors y Types histology y Clinical presentation y Radiological investigation: Plan x-ray, USS, chest CT, MRI, PET, Angiography, bone scintigraphy y Radiological features / complications y Staging y Treatment y Prognosis .Differential diagnosis

INTRODUCTION Bronchogenic carcinoma = lung cancer = lung carcinoma = carcinoma of the bronchus. Carcinoma of the bronchus is the commonest fatal malignancy in adult males in the Western world. It is commoner in male than female M:F = 1.4:1, but the incidence in women in rising. Most cases occur between 40 and 70years, and it is unusual below30years of age.

Prevalence: In 1991 161,000 new cases, 143,000 death. Aetiology: The most important single aetiological factor is cigarette smoking (85%) and this is dose related. (No, Age of onset, depth of inhalation) passive smoking may account for 25% of lung cancers in non smokers.

Risk factors: Other factors include atmospheric pollution and certain occupations such as mining of Uranium, haematite and pitchblende. Working with gas retorts, chromates, nickel, asbestos, arsenic. Radon gas: May be the 2nd leading cause of lung cancer with up to 20,000 death per year.

Concomitant disease: Chronic pulmonary scar with pulmonary fibrosis may predispose to cancer. 45% of all peripheral cancers originate in scars. y Exposure to radioactivity is also a strong risk factor.

Types: Most carcinomas of the lung fall into one of four cell types namely: 1. Adenicarcinoma (50%) 2. Squamous cell carcinoma = epidermoid carcinoma (30-35%) 3. Small cell undifferentiated carcinoma (15%) 4. Large undifferentiated cell carcinoma (<5%)

y y y

However, some lung cancers do not fall neatly into one of these categories and may have components that resemble more than one type e.g. adenosquamous carcinomas. Other rare tumours are: Clear cell carcinoma Basal cell carcinoma Carcinosarcoma carcinoma

Adenocarcinoma (50%)

Most common cell type seen in women and non smokers

Intermediate malignant potential (slow growth, high incidence of early metastases)

Doubling time is 150-180days

Histology: Formation of glands /intracellular mucin Subtype: Bronchioloalveolar carcinoma Location: Almost invariably dev. In periphery, freq. found in scars (Tb, infarction, scleroderma, bronchiectasis) also in close relation to preexisting bullae.

Solitary peripheral subpleural mass (52%)/ alveolar infiltrate / multiple nodules. May invade pleura and grow circumferentially around the lung mimicking malignant mesothelioma. Upper lobe distribution (69%) Calcification in periphery of mass (1%) Smooth margin /spiculated margin due to desmoplastic reaction with retraction of pleura.

y y y

Carcinoma of bronchus. A large, round soft-tissue mass is softpresent 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 spiculated, softmass with strands of tissue extending into the adjacent lung parenchyma

Squamous cell carcinoma = epidermoid carcinoma (30-35%)

y Strongly

associated cigarette smoking

with

y Histology:

Mimics differentiation of the epidermis by producing keratin (epidermoid carcinoma), central necrosis is common.

y Histogenesis:

Chronic inflamation with squamous metaplasia, progression to dysplasia with carcinoma in situ. Positive sputum cytology common cell type diagnosed that is radiologically occult. from tumourelaborated parathyroid hormone like substance.

y Most

y Hypercalcemia

y Slowest

growth rate, lowest incidence of distant metastases. Doubling time is 90days (a) Central location within main / lobar/ segmental bronchus (2/3) y Large central mass cavitation y Distal atelectasis bulging fissue (due to mass) y Post obstructive pneumonia (All case of pneum. in adults ) y Airway obstruction with atelectasis (37%)

(b) Solitary peripheral nodule (1/3)

y Characteristic y Squamous

cavitation in (7-10%)

cell carcinoma in the most

common cell type to cavitate.

y Invasion

of chest wall (most common

cell type to cause pancoast tumor)

Squamous cell carcinoma of bronchus-natural history over bronchus3 years in a patient who declined treatment. (A) A small softsofttissue nodule is present in the left midzone

Eighteen months later the tumour has enlarged and cavitated, and there is bulging of the aortopulmonary cavitated, window, indicating lymph node enlargement

A further 6 months later, the tumour has further enlarged, and a fluid level is present in the cavity. Patchy consolidation is present in the left upper lobe.

Squamous carcinoma of the bronchus. CT shows a thick walled cavitation mass with a spiculated outer surface and nodular inner surface

Squamous cell bronchogenic Ca

Small undifferentiated carcinoma (15%)

Strongly associated with cigarette smoking. Rapid growth with high metastatic potential (early metastases in 6080% at time of diagnosis), it should be regarded as systemic disease regardless of stage, virtually never resectable.

Doubling time 30days

Pathology: Arises from bronchial mucosa with growth in submucosa and subsequent invasion of the peribronchial connective tissue. Smooth-appearing mucosal surface endoscopically Ectopic hormone, production: cushing synd, inappropriate secretion of ADH.

y Most

common 10 lung cancer superior (due vena to caval extrinsic

causing

obstruction compression,
y Location:

endoluminal central with

thrombosis / invasion). 90% lobar / mainstem bronchus (10 tumour rarely visualised)

y Typically

large hilar/perihilar mass often association with mediastinal widening (from adenopathy) necrosis + hemorrhage evaluation: CT Abd + head, bone scintigraphy, bilateral bone marrow biopses.

y Extensive y Staging

Small cell carcinoma of bronchus. Chest X-ray shows right upper lobe masses and extensive right paratracheal and right hilar lymphadenopathy. lymphadenopathy. Five months later, following chemotherapy the disease was in remission and the X-ray was normal. X-

4.

y y

y y y y

Large undifferentiated cell carcinoma (<5%) Strongly associated with smoking Intermediate malignant potential, rapid growth with early distant metastases Doubling time 120days Large bulky usually peripheral mass >6cm (50%) Location 60-80% arise in segmental bronchi

y y y

Central: Small cell carcinoma, squamous cell cancer (sputum cytology positive in 70%) arises in central airway often at points of bronchial bifurcation, infiltrates circumferentially, extends along bronchial tree. Peripheral: Adenocarcinoma, large cell carcinoma Upper lobe: Lower lobe = right lung: left lung = 3:2 Most common site is anterior segment of RUL]

Pancoast tumor (3%) = superior sulcus tumor, carcinoma.

y

frequently

squamous

cell

Atrophy of muscles of lpsilateral upper extremity due to lower brachial plexus involvement.

Horner synd (enophthalmos, miosis, ptosis, anhidrosis) due to sympathetic chain + stellate ganglion involvement

Pancoast tumour. T,-weighted coronal MRI shows precise tumour. T,extent of right apical mass with obliteration of the extrapleural fat where the mass invades the chest wall and enters the root of the neck.

Ultrasound scan from right supraclavicular fossa shows apical pulmonary mass of relatively low echogenicity, and echogenicity, demonstrates the easiest route of access for percutaneous biopsy.

y Apical y

pleural thickening / mass

soft tissue invasion / bone + sigittal MR images

destruction
y Coronal

improves evaluation
y SVC

obstruction (5%): often in

small cell carcinoma.

Pancoast tumour. (A) Chest X-ray shows asymmetrical tumour. Xright apical pleural thickening.

Clinical presentation
Asymptomatic

(10-50%)

usually

peripheral tumors

symptoms of central tumours Cough (75%),wheezing, pneumonia Hemoptysis (50%) dysphagia (2%)

Symptoms

of peripheral tumours:

Pleuritic / local chest pain, dyspnea, cough

Pancoast synd, SVC synd Hoarseness Symptoms of metastatic disease

(CNS, bone, liver, adrenal glands)

 Paraneoplastic

syndromes

Cachexia of malignancy Clubbing + hypertrophic osteoarthropathy Non bacterial thrombotic endocardits Migratory thrombophlebitis Ectopic secretion, hormone cushing synd, production: gynacomastia hypercalCemia, synd of inappropriate ADH acromegaly.

Radiological features y Solitary peripheral mass with corona radiata / pleural tail sign / satellite lession y Cavitation (16%): usually thickwalled with irregular inner surface, in 4/5 secondary to squamous cell carcinoma, followed by bronchioloalveolar carcinoma. y Central mass (38%): common in small cell carcinoma.

Unilateral hilar enlargement (20 to primary tumor/enlarged lymph nodes).

y y y y

Calcified enlarged nodes frequently benign Nodes in shot axis diameter PET (89% sensitive, 99% specific) Anterior and middle mediastinal widening (suggests small cell carcinoma).

y Segmental

/ lobar/ lung atelectasis (37%) secondary to airway obstruction (particularly in squamous cell carcinoma). lung enhances to a greater extent than tumor on CECT

y Postobstructive y Distal

lung atelectasis has a high signal intensity than the central mass 77% on T2WI (due to accumulation of secretions in obstructed lung)

S sign of golden on PA CXR = combination of RUL collapse (inf 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). y Rat tail termination of bronchus.
y (reverse)

S SIGN

GOLDENS

S SIGN

CTCT- SIGNE DE GOLDEN

y Bronchial

cuff sign = focal / circumferential thickening of bronchial wall imaged end-on (early sign) hyperaeration (due to check valve type endobronchial obstruction, best on expiratory view) imparction of segmental / lobar bronchus (due to endobronchial obstruction)

y Local

y Mucoid

y Persistent

peripheral infiltrate (30%) = postobstructive pneumonitis air bronchogram effusion (8-15%) most commonly due to adenocarcinoma.

y No

y Pleural

Chest wall invasion:

y

Localised chest wall pain most sensitive predictor Tumor interdigitation of with chest wall

musculature on T2WI
y

Obliteration

high

intensity

extrathoracic fat on T1WI

y

Bone erosion of ribs / spine (9%)

CT shows large right apical soft-tissue mass extending softthrough chest wall into apex of right axilla. axilla.

Involvement of main pulmonary artery (18%), lobar + segmental arteries (53%) may result in additional peripheral radiopacity (due to lung infart). y 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 fxn of carcinoma (e.g. mucinous adenocarcinoma)
y

Angiography:

Bronchiogenic carcinoma supplied by bronchial arteries

Distortion / stenosis/ occlusion of pulmonary arterial circulation

Complications
1.

Diaphragmatic elevation (phrenic Nn paralysis)

2.

Hoarseness (laryngeal nerve involvement, left > right)

3.

SVC obstruction (5%): lung cancer is cause of all SVC obstruction in 90%

A further 3 months later there is now complete collapse of the left upper lobe, and the left hemidiaphragm is elevated due to phrenic nerve involvement. involvement.

CT SCAN-SVC Obstruction SCAN-

SVC Obstruction

4. Pleural

effusion

(10%)

malignant, 5. Dysphagia:

parapneumonic, enlarged nodes,

lymphoobstructive esophageal invasion 6. Pericardial invasion: pericardial effusion, localised pericardial thickening / nodular masses.

Barium swallow performed to investigate dysphagia shows extrinsic compression of mid oesophagus by enlarged subcarinal lymph nodes.

CT on mediastinal window demonstrates tumour invading posterior wall of left atrium (confirmed at surgery).

TNM descriptions of non-small cell bronchial carcinoma (From Mountain 1997) Primary tumour (T) TX: Primary tumour cannot be assessed, or tumour proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging bronchoscopy T0: No evidence of primary tumour Tis: Carcinoma in situ.

T1:

T2:

Tumour <3 cm in greatest dimension surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e. not in the main bronchus) Tumour with any of the following features of size or extent: >3cm in greatest dimension, involves main bronchus >2cm distal to the carina; invades the visceral pleura; associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung.

T3: Tumour of any size that directly invades any of the following: chest wall (including superior sulcus tumours), diaphragm, mediastinal pleural, perietal pericardium, or tumour in the main bronchus <2cm distal to the carina, but without involvement of the carina, or associated atelectasis or obstructive pneumonitis of the entire lung.

T4: Tumour of any size that invades any of the following: mediastinum, heart, great vessels, traches, oesophagus, vertebral body, carina; or tumour with a malignant pleural or pericardial effusion, or with satellite tumour nodule(s) within the ipsilateral primary tumour lobe of the lung.

Regional lymph nodes (N) NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes involved by direct extension of the primary tumour. N2: Metastasis to ipsilateral mediastinal and/or subcarinal lymph node (s) N3: Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph nodes (s).

Distant metastasis (M) MX: M0: M1: Distant metastasis cannot be assessed No distant metastasis Distant metastasis present

Stages for international staging system for lung cancer (from Mountain 1986) 1986)
Stage I II IIIA Definition T1, N0, M0 T2, N0, M0 T1, N1, M0 T2, N1, M0 T3, N0, M0 T3, N1, M0 T1-3, N2, M0 Any T, N3, M0 T4, any N, M0 Any T, any N, M1

IIIB IV

Treatment 1. Surgical resection for non-small cell histologic types Unresectable: Involvement of heart, great vessels, trachea, esophagus, vertebral body, malignant pleural effusion. 2. Adjuvant chemotherapy + radiation therapy in extensive resectable disease 3. Chemotherapy for small cell carcinoma + radiation therapy for bulky disease, CNS metastases, spinal cord compression, SVC obstruction

Prognosis Mean survival time <6months. 10-15% overall 5 years survivals. Survival at 40months: squamous cell 30% > large cell 16% > adenocarcinoma 15% > oat cell 1%.

y y y y y y y y

DIFFERENTIAL DIAGNOSES Tuberculosis Sarcoidosis Metastatic Lung Dx Mesothelioma Pulmonary Arteriovenous Malformatn Hamartoma Allergic Bronchopulmonary Aspergillosis

Pulmonary arteriovenous malf. malf.

Cavitating tuberculosis

CannonCannon-ball Metastases

PULMONARY HAMARTOMA

Pulmonary hamartoma containing fat