Lung cancer radiology

Question 1

what is the order for the systematic review of the lungs in a chest x ray?

Answer 1

1. name/ marker/ rotation (gap between clavicles and spinous processes)/ penetration
2. lines/metal work
3. heart
4. mediastinum
5. lungs
   - upper zone
   - middle zone
   - lower zone
6. bones
7. diaphragm
8. soft tissues

Question 2

when looking at the mediastinum in a chest x-ray what is normal?

Answer 2

• hilar vascular structures should be crisply defined
• no widening of mediastinum
• trachea is central

Question 3

when looking at the lungs in a chest x-ray what is normal?

Answer 3

• compare upper, middle and lower zones to check they are consistent and normal
• look between ribs for lung detail
• look “behind” heart

Question 4

why might the whole lung appear opaque in lung cancer?

Answer 4

if the tumour blocks a main bronchus, preventing air entering the lung

Question 5

why might a lobe of a lung appear opaque in lung cancer?

Answer 5

if the cancer is blocking one of the secondary bronchi

Question 6

what are the areas that must be carefully reviewed for lung cancer?

Answer 6

Hila
lung apices
behind the heart
behind the diaphragm

Question 7

what are the important steps to do to prevent misdiagnosing lung cancer?

Answer 7

• always compare with previous imaging

- confirm lesion is intrapulmonary

Question 8

what is the step after a chest x-ray if lung cancer is suspected?

Answer 8

CT scan

Question 9

what is a CT scan used to do after a chest xray?

Answer 9

evaluate:

• size
• shape
• atelectasis (collapsed lung, alveoli collapse, not pneumothorax)
• border
• density
• solid or non-solid
• growth
• for dynamic contrast enhancement

Question 10

what is a pulmonary mass?

Answer 10

an opacity in lung over 3cm with no mediastinal adenopathy (enlargement of the mediastinal lymph nodes) or atelectasis

Question 11

what is a pulmonary nodule?

Answer 11

an opacity in the lung up to 3cm with no mediastinal adenopathy or atelectasis

Question 12

what is mediastinal adenopathy?

Answer 12

invasion of a cancer in to the mediastinal lymph nodes

Question 13

what are the possible diagnoses for a solitary pulmonary nodule or mass?

Answer 13

• lung cancer
• metastasis
• benign lung neoplasm
• infection
• vascular haematoma

Question 14

what will help distinguish a pulmonary nodule/mass caused by lung cancer from other causes?

Answer 14

age and smoking history

Question 15

what will help distinguish a pulmonary nodule/mass caused by metastasis from other causes?

Answer 15

previous history of breast, renal, seminoma, sarcoma

Question 16

give an example of a benign lung neoplasm?

Answer 16

carcinoid hamartoma

Question 17

what infections may cause a solitary pulmonary nodule/mass?

Answer 17

tuberculosis or fungal infection

Question 18

what is the T part of the TNM staging system for cancer?

Answer 18

how big it is and how far it spread/ size and position of the tumour

Question 19

what is the N part of the TNM staging system for cancer?

Answer 19

whether cancer cells have spread into the lymph nodes

Question 20

what is the M part of the TNM staging system for cancer?

Answer 20

whether the tumour has spread anywhere else in the body ie metastases

Question 21

what investigations are used to determine the T stage of lung cancer?

Answer 21

CT
PET-CT
bronchoscopy

Question 22

what investigations are used to determine the N stage of lung cancer?

Answer 22

PET-CT
mediastinoscopy
CT
EBUS/EUS

Question 23

what is EBUS?

Answer 23

endobronchiol ultrasound, A special endoscope fitted with an ultrasound processor and a fine-gauge aspiration needle is guided through the patient’s trachea

Question 24

what investigations are used to determine the m stage of lung cancer?

Answer 24

PET-CT
CT
bone scan

Question 25

what does TX mean in the TNM cancer staging system?

Answer 25

primary tumour cannot be assessed

Question 26

what does T0 mean in the TNM cancer staging system?

Answer 26

no evidence of primary tumour

Question 27

what does Tis mean in the TNM cancer staging system?

Answer 27

carcinoma in situ

Question 28

what does a T1 cancer look like?

Answer 28

tumour ≤3cm in greatest diameter, surrounded by lung or visceral pleura, no bronchoscopic evidence of involvement of the main bronchus

Question 29

what is a T1a tumour?

Answer 29

minimally invasive adenocarcinoma ≤1cm

Question 30

what is a T1b tumour?

Answer 30

minimally invasive adenocarcinoma ≤2cm

Question 31

what is a T1c tumour?

Answer 31

minimally invasive adenocarcinoma ≤3cm

Question 32

what is a T2 tumour?

Answer 32

a tumour >3cm but <5cm

Question 33

which features make a tumour a T2a tumour?

Answer 33

any one of: 1. Involves main bronchus, but not carina 2. Invades visceral pleura 3. Associated with atelectasis or obstructive pneumonitis that extends to the hilar region involving part or all the lung

Question 34

what size is a T2a tumour?

Answer 34

>3 cm but <4cm

Question 35

what size is a T2b tumour?

Answer 35

>4cm but <5cm

Question 36

what are the features of a T3 tumour?

Answer 36

tumour >5cm but <7cm or one that directly invades any of the following: chest wall phrenic nerve parietal pericardium or seperate tumour nodule(s) in the same lobe as the primary

Question 37

what is a T4 tumour?

Answer 37

``` a tumour that is >7cm or invades any of the following: Diaphragm mediastinum heart great vessels trachea recurrent laryngeal nerve esophagus vertebral body carina ``` or has seperate nodule(s) in a different ipsilateral lobe

Question 38

what does N0 mean?

Answer 38

no regional lymph node metastases

Question 39

what does N1 mean?

Answer 39

ipsilateral peribronchial, hilar or intrapulmonary nodes including direct extension (local invasion)

Question 40

what does N2 mean?

Answer 40

N2 Ipsilateral mediastinal, subcarinal

Question 41

what does N3 mean?

Answer 41

Contralateral mediastinal, contralateral hilar, scalene or supraclavicular

Question 42

what does M0 mean?

Answer 42

no distance metastasis

Question 43

what does M1a mean?

Answer 43

- separate tumour nodule in a contralateral lobe | - tumour with peural or pericardial nodulels or malignant pleural or pericardial effusion

Question 44

what does M1b mean?

Answer 44

single distant metastasis

Question 45

what does M1c mean?

Answer 45

multiple distant metastases

Question 46

what is a the function of PET/CT scanning in staging?

Answer 46

very useful tool as it performs whole body staging in a single study excluding cerebral disease

Question 47

what are the limitations of PET CT?

Answer 47

all tests have false negative or false positive results | costly

Question 48

what are the tissue diagnosis techniques?

Answer 48

- Bronchoscopy and EBUS - Percutaneous image guided biopsy ,fluoroscopy/CT/US guided - Mediastinoscopy to sample mediastinal nodes - Mediastinotomy for anterior mediastinal nodes - VATS (Video-assisted thoracoscopic surgery) - explorative thoracotomy