an opacity completely stable in size for than 2 years is considered
benign
in patient under the age of 35, particularly a nonsmoker without a history of malignancy, an SPN is invariably a
granuloma, hamartoma or an inflammatory lesion
SPNs in a patient over 35 years of age should never be followed radiographically without tissue confirmation unless benign patterns are seen such as
calcification or the presence of intralesional fat or there has been radiographically documented lack of growth over a minimum of 2 years
An SPN that arises more than 2 years after the diagnosis of an extrathoracic malignancy and proves to be malignant is almost always a
primary lung tumor rather than a metastasis
exceptions to the rule in which SPNs of more than 2 years after an extrathoracic malignancy diagnosis has been made is almost alwats a primary lung tumor except for what extrathoracic malignancies
breast and melanoma
lung cancer presenting as a solid SPN has a doubling time of approximately
180 days
some benign lesions that may exhibit a growth rate similar to that of malignant lesions
hamartomas and histoplasmosis
malignant SPNs that may have a doubling time of greater than 2 years
well-differentiated adenocarcinoma and carcinoid tumors
Altho size does not reliably discriminate benign from malignant SPNs, the larger the lesion, the greater the likelihood its
Malignant
Masses exceeding __ cm in diameter are usually malignant
4 cm
Malignancies that may have a perfectly smooth margin
Carcinoid tumor, adenocarcinoma, solitary metastasis
Benign lesions that have a spiculated border include
Lipoid pneumonia, organizing pneumonia, tuberculomas, mass lesions of progressive massive fibrosis in complicated silicosis
Presence of small “satellite” nodules around the periphery of a dominant nodule is strongly suggestive of
Benign disease such as granulomatous infection
Presence of a halo of ggo encircling an SPN in an immunocompromised, neutropenic patient should suggest diagnosis of
Invasive fungal disease
An area of pleural thickening with a “comet” tail of bronchi and vessels entering the hilar aspect of mass and associated lobar volume loss is characteristic of
Rounded atelectasis
Probably the single most important factor in characterizing the lesion as benign or indeterminate
Density
Complete, central or peripheral rim-like calcification within an SPN is specific for a
Healed granuloma from tuberculosis or histoplasmosis
Concentric or laminated calcification indicates a
Granuloma
a bronchogenic carcinoma that arises in an area of previous granulomatous infection may engulf a preexisting calcified granuloma as it enlarges. In thi situation, the calcification will be
eccentric
Identification of fat within an SPN is diagnostic of a
pulmonary hamartoma
majority of subsolid nodules that persist beyond 3 months reflect
adenocarcinoma
majority of pure ground glass nodules are
benign
ground glass nodules <6mm in diameter almost invariably reflect
atypical adenomatous hyperplasia or focal fibrosis
pure ground glass nodules >6mm may reflect malignancy, the minority that are malignant represent
indolent lepidic-predominant adenocarcinoma
cystic lesions with wall thickening or nodularity that are malignant are usually
adenocarcinoma
demonstration of an air bronchogram or bubbly lucencies within an SPN is highly suspicious for
adenocarcinoma
all malignant lesions virtually demonstrates an increase in attenuation of greater than ___HU
15 HU after contrast administration
if SPN is <6 mm in low risk patients, what is the management
no follow up needed
if SPN is >6 mm in low risk patients, what is the management
optional follow-up, at 12th month
if SPN is 6-8 mm in low risk patients, what is the management
CT @ 6-12 months, consider @ 18-24 months
if SPN is 6-8 mm in high risk patients, what is the management
follow up CT @ 6-12 months, then @ 18-24 months
if SPN is >8mm in low risk patients, what is the management
consider CT @ 3 months, PET/CT or biopsy
if SPN is >8 mm in high risk patients, what is the management
consider CT @ 3months, PET/CT or biopsy
if SPN is subsolid <6 mm, what is the management
no follow up needed, ff up @2 and 4 years if suspicious
ground glass > or = to 6mm, what is the management
CT @ 6-12 months then every 2 years x 5 years; if solid component or growth, consider resection
part solid nodule > or = to 6 mm
ff up CT @3-6 months, if stable and solid component <6 mm, annual CT x 5 years; persistent part-solid nodules highly suspicious- PET CT for solid component >6 mm
a doubling time of SPN of less than 30 days or greater than 2 years represent a benign or malignant lesion?
benign
because most SPNs are peripherally situated in the lung, what is the procedure of choice for tissue sampling?
transthoracic needle biospy
peripheral lesions that are too small for successful TNB can be sampled with
video-assisted thoracoscopic surgery (VATS)
SPNs that are centrally situated with a large bronchus entering the lesion should undergo
transbronchoscopic biopsy
Majority of carcinoid tumors are located where, which present with wheezing, atelectasis or obstructive pneumonitis
central endobronchial lesions
reflects a benign neoplasm composed of an abnormal arrangement of the mesenchymal and epithelial elements found in normal lung
pulmonary hamartoma
pulmonary hamartomas are usually seen at what age
4th to 5th decades of life
a confident diagnosis of hamartoma can be made when HRCT shows a nodule or mass demonstrating a smooth lobulated border and containing focal fat
a smooth lobulated border and containing focal fat
calcification in hamartoma if present, demonstrates what pattern
popcorn like
low grade B-cell lymphomas that present in adults in therir 50s. most common radiographic finding is an SPN or focal airspace opacity
non-hodgkin lymphoma
classified as an adenoma and typically affects females and presents as a solitary, smoothly marginated juxtapleural nodule that enhances densely due to its vascular nature
sclerosing pneumocytoma (hemangioma)
characterized histologically by myofibroblasts which are spindle cells admixed with chronic inflammation–containing plasma cells. these lesions appear as smoothly marginated SPNs in children and young adults
inflammatory myofibroblastic tumor (plasma cell granuloma, inflammatory pseudotumor)
true or false, in lipoid pneumonia, spiculated appearance is not uncommon, as the oild may produce a chronic inflammatory reaction in the surrounding lung that leads to fibrosis
true
fluid-filled cystic lesions of the lung that can produce and SPN
bronchogenic cyst
90% of the bronchogenic cysts can be found in the
middle mediastinum
appears on CT as an intraparenchymal air-fluid levle wihin a thin-walled localized air collection (usually in the upper lobe) with typical bullous changes in other portions of lung
bronchogenic cyst
a recent history of lower respiratory tract infection in this mass-like lung lesion will be present
focal organizing pneumonia
hematoma or traumatic lung cyst can present as
round opacities often containing air or an air/fluid level
99% of malignant epithelial neoplasms of lungs arise from the
bronchi
bronchogenic carcinoma are subdivided in the four main histologic subtypes
adenocarcinoma, squamous cell carcinoma, small cell carcinoma and large cell carcinoma
most common type of lung cancer, accounting for approximately 43% of all lung carcinomas. it has the weakest association with smoking and most common subtype of nonsmokers
adenocarcinoma
adenocarcinomas are usually found in
upper lobes, 1/4 of cases are in the central portions of lungs
arises from bronchiolar or alveolar epithelium and have an irregular or spiculated appearance where they invade adjacent lung producing an irregularly marginated pulmonary nodule or mass
adenocarcinoma
the presence of ground glass densities in adenocarcinoma presenting as an SPN represents
lepidic growth of tumor cells along the alveolar walls
solid (soft tissue component) in adenocarcinoma reflects
invasive tumor
second most common subtype of lung cancer, accounting for approximately 23% of all cases. this tumor arises centrally within a lobar or segmental bronchus
squamous cell carcinoma
these tumors are polypoid masses that grow into the bronchial lumen while simultaneously invading the bronchial wall
squamous cell carcinoma
common radiographic findings include a hilar mass with or without obstructive pneumonitis or atelectasis. central necrosis is common in large tumors; cavitation may be seen if communication has occurred between the central portion of mass and the bronchial lumen
squamous cell carcinoma
presence of keratin pearls and intercellular bridges are specific for what tumor
squamous cell carcinoma
treatment for adenocarcinoma
stage I-II surgery, stage III-IV XRT/chemo
treatment for squamous cell carcinoma
stage I-II surgery, stage III-IV- XRT/chemo
treatment of small cell carcinoma
chemotherapy
treatment for large cell carcinoma or carcinoid tumor
variable
type of neuroendocrine tumor of the lung, accounts for 13% of bronchogenic carcinomas and arises centrally within the main or lobar bronchi
small cell carcinoma
these tumors are most malignant neoplasms arising from bronchial neuroendocrine (kulchitsky) cells and are alternatively referred as kulchitsky cell cancers of KCC-3
small cell carcinoma
typical carcinoid tumors (small cell ca) that represent least malignant type
KCC-1
atypical carcinoid tumors (small cell ca) that represent intermediate in aggressiveness
KCC-2
exhibits a small endobronchial component invading the bronchial wall and peribronchial tissues early in the course of the disease. this produces a hilar or mediastinal mass with extrinsic bronchial compression and obstruction. Invasuin of the submucosal and peribronchial lymphatics leads to local lymph node enlargement and hematogeneous dissemination
small cell carcinoma
diagnosed when a non small cell lung cancer lacks the histologic characteristics of squamous cell carcinoma or adenocarcinoma. tumors tend to arise peripherally as a solitary mass and is often large at the time of presentation
large cell carcinoma
in addition to cigarette smoke, well-recognized risk factors for the development of lung cancer include
COPD, emphysema, asbestos exposure, previous Hodgkin lymphoma, radon exposure and diffuse interstitial or localized lung fibrosis
carcinogens in cigarette smoke produce
cellular atypia and squamous metaplasia of bronchiolar epithelium, that may precede malignant transformation
two histologic subtypes with the strongest association with cigarette smoking in men
small cell carcinoma and squamous cell carcinoma
subtype that is associated with cigarette smoking in women
all histologic subtypes
patients previously treated for mediastinal hodgkin disease with radiation, chemotherapy or a combination of two have an eightfold increase in lung cancer begining how many years after tx
10 years
diffuse interstitial fibrosis in patients with usual interstitial pneumonitis due to scleroderma, rheumatoid lung disease or idiopathic pulmonary fibrosis has been associated with an increased incidence of what type of bronchogenic ca
adenocarcinoma
most common radiographic finding in lung cancer
an SPN (size between 2mm and 3 cm) or lung mass (3 cm or larger), and a hilar mass with or without bronchial obstruction
marked mediastinal nodal enlargement producing a lobulated mediastinal contour is characteristic of
small cell carcinoma
most common finding if there is obstruction of bronchial lumen by the endobronchial component of a tumor
resorptive atelectasis or obstructive pneumonitis of lung distal to the obstructing lesion
ocassionally, lung mass producing the lobar atelectasis creates a central convexity in the normally concave contour of the collapsed lobe, producing the
S sign of Golden
walls of cavitating neoplasms tend to be ____ than those of cavitary inflammatory lesions
thicker and more nodular
a peripheral neoplasm arising in that portion of the lung apex, indented superiorly by the subclavian artery
pancoast (superior sulcus) tumor
presents with arm pain and muscular atrophy attributable to brachial plexus involvement, Horner syndrome from involvement of sympathetic change and shoulder pain from chest wall invasion
pancoast tumor
most common cause of SVC syndrome
lung cancer
represents invasion of the lymphatic changgels of the lung by tumor
lymphangitic carcinomatosis
pathophysiology of lymphangitic carcinomatosis
invasion of lymphatics or neoplastic involvement of the hilar and mediastinal nodes, leads to retrograde (centrifugal) lymphatic flow with dilatation of lymphatic channels, interstitial deposits of tumor and fibrosis
appears as smooth or beaded thickening of the interlobular septa and bronchovascular interstitium
lymphangitic carcinomatosis
current theshold for lung cancer detection appears to be a lesion size of
> or equal to 8mm
Tumor invasion of mediastinum with involvement of heart, great vessels, trachea, carina, esophagus, diaphragm, or recurrent laryngeal nerve precludes
Resection
True or false, localized invasion of the pericardium does not prevent resection
True
True or false: tumors that involve a main bronchus are resectable regardless of their distance from the carina
True
True or false: malignant pleural or pericardial thickening, nodularity or effusion is M1a disease and precludes curative resection
True
Features that strongly suggests pleural invasion
Pleural thickening >1cm, lobulated pleural thickening or circumferential pleural thickening
True or false: contralateral hilar/mediastinal or supraclavicular nodal disease is unresectable
True
Lung Parenchymal involvement in what type of lymphoma is 2-3x more common
Hodgkin disease
Most cases of primary pulmonary non hodgkin lymphoma arise from
BALT and represent low grade B-cell lymphomas
BALT lymphomas are also termed as _____ and have been associated with autoimmune diseases, in particular Sjögren syndome and RA
Extranodal marginal zone lymphomasp
Presents a T-cell rich primary pulmonary B cell lymphoma associated with epstein-barr virus
Lymphomatoid granulomatosis
Radiographic features of lymphomatoid granulomatosis
Multiple nodular opacities with a lower lobe predilection. Cavitation as a result of vascular invasion is common
Related inflammatory conditions associated with autoimmune and immunologic diseases including Sjögren syndrome,RA, myasthenia gravis and immunocompromised states including common variable munodeficiency and HIV infection
Follicular bronchiolitis, lymphocytic interstitial pneumonitis and nodular lymphoid hyperplasia
Ct findings in follicular bronchiolitis, LIP and nodular lymphoid hyperplasia
Diffuse ground-glass opacity, poorly defined centrilobular nodules, interlobular septal thickening, and thin-walled cysts
Represents a specrrum of entities ranging from benign polyclonal lymphoid proliferation to aggressive non-hodgkin lymphoma that develop in a small percentage of transplant patients with lung transplant recipients most commonly affected
Posttransplant lymphoproliferative disorder
Infection with what virus is responsible for most cases of posttransplant lymphoproliferative disorder
EBV
Parenchymal imvolvement in leukemia usually takes the form of
Interstitial infiltration by leukemic cells, with resultant peribronchial cuffing and reticulonodular opacities
An unusual pulmonary manifestation of leukemia is _____, which is seen in acute leukemia or those in blast crisis in whom the peripheral white blood cell count exceeds 100,000 to 200,000/cm3
Pulmonary leukocytosis
Ct findings in Kaposi sarcoma
Typical peribronchovascular location of the opacities and may demonstrate air bronchograms traversing mass-like areas of confluent disease
The mass-like opacities in kaposi sarcoma often parallel the long axis of bronchovascular structures and have been described as
Flame shaped
Rare malignant lung tumor affecting children and young adults. These tumors tend to be extremely large at presentation
Pulmonary blastoma
Preneoplastic proliferation of neuroendocrine cells found in the mucosa of small airways. Affected patients are middle-aged women that present either with asymptomatic small lung nodules that simulate metastatic disease or with symptoms of cough, dyspnea and wheezing diagnosed as
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia
Ct findings in diffuse idiopathic pulmonary neuroendocrine cell hyperplasia
Mosaic lung attenuation and air trapping ate typically seen on inspiratpry and expiratory ct
most common benign tracheal tumors in adults
chondroma, fibroma, squamous cell papilloma, hemangioma, granular cell tumor
sessile or pedunculated fibrous masses arising in the cervical trachea
fibromas
hemangiomas are seen in the cervical trachea almost exclusively in what age group
infants and young children
neoplasm that arises from the neural elements in the tracheal or bronchial wall. usually involve the cervical trachea or main bronchi but can arise in smaller bronchi
granular cell tumor
intratracheal thyroid tissue is likewise goitrous and most commonly found in what portion of the trachea
posterolateral wall of cervical trachea
presence of a small intraluminal and large extraluminal soft tissue component has given rise to the descriptive term “iceberg tumor”
carcinoid tumor
benign neoplasm comprised of disorganized epithelial and mesenchymal elements normally found in the bronchus or lung
pulmonary hamartoma
presents as pedunculated lesions in the bronchus with fatty centers covered by fibrous tissue that contain little cartilage
endobronchial hamartomas
transpleural spread of tumor can be seen in cases of
invasive thymoma
most common mediastinal malignancies to invade the lung are
esophageal carcinoma, lymphoma, malignant germ cell tumors or any malignancy metastasizing to mediastinal or hilar lymph nodes
difference in radiologic appearance of pulmonary metastasis from primary bronchogenic carcinoma
mets- smooth in contour
primary lung ca- lobulated or spiculated
nodular pulmonary metastases are usually smooth or lobulated lesions that are found in greater numbers in what portion of the lungs due to the greater pulmonary blood flow to these regions
periphery
the demonstration of calcification within multiple pulmonary nodules in the abscence of a history of a primary bone forming neoplasm such as osteogenic sarcoma or chondrosarcoma is diagnostic of
granulomatous disease
most common cause of unilateral lymphangitic carcinomatosis
bronchogenic carcinoma
MC extrathoracic malignancies to produce lymphangitic carcinomatosis are
breast, stomach, pancreas, and prostate
common causes of pulmonary arterial emboli due to their possible invasion of hepatic veins and renal veins, gaining access to the right heart and pulmonary vasculature
HCC and renal cell CA
