Radiology of Lung Cancer

Question 1

What is the approach to a systematic review of the lungs on a CXR?

Answer 1

1. Name/marker/rotation/penetration
2. Lines/metal work
3. Heart
4. Mediastinum
5. Lung zones
6. Bones
7. Diaphragm
8. Soft tissue

Question 2

What to look for in the mediastinum on a CXR?

Answer 2

Hilar structures crisply defined
No widening of structure
Central trachea

Question 3

What to look for in the lungs on a CXR?

Answer 3

Compare upper, mid and lower zones
Look between ribs for lung detail
Remember to look “behind” heart

Question 4

Why might the whole lung look opaque on a CXR?

Answer 4

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

Question 5

Why might a lobe of the lung look opaque on a CXR?

Answer 5

If the tumour is blocking one of the secondary bronchi

Question 6

What are the areas that must be carefully reviewed on CXR 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

Compare CXR 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

Carry out CT

Question 9

What is the CT scan to show after a CXR?

Answer 9

Size
Shape
Atelectasis (collapse)
Border 
Density
Solid or not solid 
Growth 
For dynamic contrast enhancement

Question 10

What is a pulmonary mass?

Answer 10

An opacity in the lung > 3cm with no mediastinal adenopathy (swollen 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 will help distinguish a pulmonary nodule/mass caused by lung cancer from other causes?

Answer 13

Age and smoking history

Question 14

What will help distinguish a pulmonary nodule/mass caused by metastases or from other causes?

Answer 14

Previous history of breast, renal, seminoma, sarcoma

Question 15

What infections may cause a solitary pulmonary nodule/mass?

Answer 15

Bacterial, TB or fungal

Question 16

Give an example of a benign lung neoplasm

Answer 16

Carcinoid, hamartoma

Question 17

What does the T describe in the TNM staging?

Answer 17

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

Question 18

What does the N describe in the TNM staging?

Answer 18

Whether the cancer cells have spread into the lymph nodes

Question 19

What does the M describe in the TNM staging?

Answer 19

Any metastases present?

Question 20

What investigation are used to determine T in TNM staging?

Answer 20

CT
PET-CT
Bronchoscopy

Question 21

What investigation are used to determine N in TNM staging?

Answer 21

CT
PET-CT
Mediastinoscopy
EBUS

Question 22

What investigation are used to determine M in TNM staging?

Answer 22

CT
PET-CT
Bone scan

Question 23

Define Tx, T0, Tis

Answer 23

Tx - primary tumour cannot be assessed
T0 - no evidence of primary tumour
Tis - carcinoma in situ

Question 24

Describe T1 tumour

Answer 24

<= 3cm
Surrounded by lung or visceral pleura
No involvement with main bronchus

Question 25

Size of T1a tumour

Answer 25

Minimally invasive adenocarcinoma | <= 1cm

Question 26

Size of T1b tumour

Answer 26

< 2cm

Question 27

Size of T1c tumour

Answer 27

<= 3cm

Question 28

Describe T2 tumour

Answer 28

``` > 3cm but under 5 cm Or one that: Involves main bronchus Invades visceral pleura Associated with atelectasis or obstructive pneumonitis ```

Question 29

Size of T2a tumour

Answer 29

> 3cm but < 4cm

Question 30

Size of T2b tumour

Answer 30

> 4cm but < 5cm

Question 31

Describe T3 tumour

Answer 31

``` > 5cm but < 7cm Or one that directly invades: -Chest wall -Phrenic nerve -Parietal periardium ```

Question 32

Describe T4 tumour

Answer 32

``` > 7cm or invades: Diaphragm Mediastinum Heart Great vessels Trachea Recurrent laryngeal nerve Oesophagus Vertebral body Carina ```

Question 33

What do PET/CT scans do in T staging?

Answer 33

Assess chest wall invasion or mediastinal invasion

Question 34

Define N0

Answer 34

No lymph nodes

Question 35

Define N1

Answer 35

Ipsilateral perobronchial, hilar or intrapulmonary nodes

Question 36

Define N2

Answer 36

Ispilateral mediastinal, subcarinal

Question 37

Define N3

Answer 37

Contralateral mediastinal, contralateral hilar, scalene or supraclavicular

Question 38

Where are common places for metastases?

Answer 38

Cerebral Skeletal Adrenal Liver

Question 39

Define M0

Answer 39

No metastases

Question 40

Define M1

Answer 40

Distant metastases

Question 41

Define M1a

Answer 41

Separate tumour nodule in contralateral lobe | Tumour with pleural or pericardial nodules or malignant pleural or pericardial effusion

Question 42

Define M1b

Answer 42

Single distant metastases

Question 43

Define M1c

Answer 43

Multiple distant metastases

Question 44

What are the limitation of PET CT

Answer 44

All tests have: False negative results False positive results Cost

Question 45

What tests are carried out for tissue diagnosis?

Answer 45

Bronchoscopy and EBUS | Percutaneous image guided biopsy

Question 46

What determines stage IV lung cancer?

Answer 46

Any T Any N M1