Lung Cancer

Question 1

Describe T staging for Lung cancer TNM8

Answer 1

Tx: Cannot be assessed, not visualized on imaging
T0: No evidence of primary tumour
Tis: Carcinoma in situ
T1: < or equal to 3cm, surrounded by lung visceral pleura, not involving main bronchus
T1a(mi): minimally invasive carcinoma
T1a: <or equal to 1cm
T1b: >1cm, less than or equal to 2cm
T1c: >2cm but less than or equal to 3cm.

T2: >3cm but less than or equal to 5cm. Involvement of the main bronchus without carina, regardless of distance from it, or invasion of the visceral pleura, or atelectasis, or post obstructive pneumonitis extending to the hilum
T2a: >3cm but <or equal to 4cm
T2b: >4cm but <or equal to 5cm

T3: Tumor size >5cm to 7cm or pancoast that involves thoracic nerve roots T1 and T2 only.
Tumor of any size that
* invades the chest wall
* invades the pericardium
* invades the phrenic nerve
* shows one or more satellite nodules in the same lung lobe

T4: Tumor size >7cm or Pancoast tumor that involves C8 or higher nerve roots, brachial plexus, subclavian vessels or spine
Tumor of any size that
* invades mediastinal fat or mediastinal structures
* invades the diaphragm
* involves the carina
* shows one or more satellite nodules in another lobe on the ipsilateral side

[https://radiologyassistant.nl/chest/lung-cancer/tnm-classification-8th-

Question 2

Describe N staging for TNM8

Answer 2

N1 - Nodes
N1-nodes are ipsilateral nodes within the lung up to hilar nodes.
N1 alters the prognosis but not the management.
N2-nodes represent ipsilateral mediastinal or subcarinal lymphadenopathy.
N3 - Nodes
N3-nodes represent contralateral mediastinal or contralateral hilar lymphadenopathy or scalene or supraclavicular nodes.

Question 3

Describe N staging for tumours in the right lung

Answer 3

N1
Ipsilateral peribronchial and/or hilar lymph nodes 10R-14R

N2
Ipsilateral mediastinal and/or subcarinal lymph nodes 2R, 3aR, 3p, 4R, 7, 8R, 9R

N3
Contralateral mediastinal and/or hilar, as well as any supraclavicular lymph nodes 1, 2L, 3aL, 4L, 5, 6, 8L, 9L, 10L-14L

Question 4

Describe N staging for tumours in the left lung

Answer 4

N1
Ipsilateral peribronchial and/or hilar lymph nodes 10L-14L

N2
Ipsilateral mediastinal and/or subcarinal lymph nodes 2L, 3aL, 4L, 5, 6, 7, 8L, 9L

N3
Contralateral mediastinal and/or hilar, as well as any supraclavicular lymph nodes 1, 2R, 3aR, 3pR, 4R, 8R, 9R, 10-14R

Question 5

Describe M staging for TNM8

Answer 5

A distinction is made between regional metastatic disease (M1a) and solitary (M1b) or multiple (M1c) distant metastatic disease:

M0: No distant metastases
M1: Distant metastases
M1a: Regional metastatic disease defined as malignant pleural or pericardial effusion/nodules, as well as contralateral or bilateral pulmonary nodules.
M1b: solitary extrathoracic metastasis
M1c: Multiple extrathoracic metastases, either in a single organ or in multiple organ

Question 6

Discuss synopsis of recommendations for selection of patients for radical treatment

Answer 6

Ensure a CT scan that is <4 weeks old is available
at the time of radical treatment of borderline
lesions

Arrange a CT scan of the chest, lower neck and
upper abdomen with intravenous contrast

Ensure positron emission tomography (PET)-CT
scanning is available for all patients being considered for radical treatment.

Offer radical treatment without further mediastinal lymph node sampling if there is no significant
uptake in normal sized mediastinal lymph nodes on PET-CT scanning

Consider MRI or CT scanning of the head in
patients selected for radical treatment, especially in stage III disease

Confirm negative results obtained by TBNA
and EBUS/EUS-guided TBNA by mediastinoscopy
and lymph node biopsy where clinically appropriate.

Question 7

Describe the radiological findings for sarcoidosis

Answer 7

Common findings:
Small nodules in a perilymphatic distribution (i.e. along subpleural surface and fissures, along interlobular septa and the peribronchovascular bundle).
Upper and middle zone predominance.
Lymphadenopathy in left hilus, right hilus and paratracheal (1-2-3 sign). Often with calcifications.

Uncommon findings:
Conglomerate masses in a perihilar location.
Larger nodules (> 1cm in diameter, in Grouped nodules or coalescent nodlues surrounded by multiple satellite nodules (Galaxy sign)
Nodules so small and dense that they appear as ground glass or even as consolidations (alveolar sarcoidosis)

Fibrosis in Sarcoidosis.
Progressive fibrosis in sarcoidosis may lead to peribronchovascular (perihilar) conglomerate masses of fibrous tissue.
The typical location is posteriorly in the upper lobes, leading to volume loss of the upper lobes with displacement of the interlobar fissure.

Other diseases that commonly result in this appearance are:
Silicosis
Tuberculosis
Talcosis

Question 8

what is loefgrens syndrome

Answer 8

Loefgren’s syndrome, an acute presentation of sarcoidosis, consists of arthritis, erythema nodosum, bilateral hilar adenopathy and occurs in 9-34% of patients.

Question 9

What are the radiological definitions for bronchiectasis

Answer 9

1. lack of tapering, defined as an unchanged airway diameter for 2 cm after branching
2. The diameter of the airway exceeds that of the accompanying artery, also quantified by computing the airway–artery ratio (AA ratio)
3. visibility of airways within 1 cm of the costal pleura or the mediastinal pleura indicates bronchiectasis