Learning Radiology xray montage

Lung Masses
Bronchogenic Carcinoma

  • Incidence

        o      On routine survey, <5% are malignant nodules
    o      At surgery, 40% of nodules are ca, 40% granulomas

·       Causes of lung nodules-by frequency
o      Granulomas
    o      Bronchogenic ca
o      Hamartoma
    o      Metastases

·       Calcification of lung nodules

o      Laminated: TB granuloma

o      Central or target: histoplasmoma

o      Popcorn: hamartoma

·       Doubling time

o      If a lesion doubles in volume >6 weeks and <16 months, usually malignant

·       Cavitating nodules

o      Squamous cell most common
   o      Adenocarcinoma
o      Bronchoalveolar cell ca (rare)
o      Hodgkin's Disease (rare)

·       Mass with air bronchogram

o      Alveolar cell ca
o      Lymphoma
o      Pseudolymphoma
o      Inflammatory pseudotumor

·       Pulmonary nodules with pneumothorax

o      Osteosarcoma

o      Wilm's tumor

o      Eosinophilic granuloma

·       Types of bronchogenic carcinoma

o      Squamous cell ca (30-35%)

o      Adenocarcinoma (25-35%)

o      Small cell or oat cell (25%)

o      Large cell undifferentiated (10%)

·       Squamous cell ca

o      Central Location (2/3)

o      Atelectasis

o      "Reverse S sign of Golden"

o      Post-obstructive pneumonia

o      Mass

o      Peripheral location (1/3)

o      May cavitate

o      Most closely associated with smoking

Cavitating Bronchogenic Carcinoma, Squamous Cell

Cavitating Bronchogenic Carcinoma, Squamous Cell. There is a thick-walled cavity present in the right lung (red arrows) with spiculated outer margins (red arrows) and nodular inner margins (white arrows). There is associated lymphangitic spread (white circle. This was a squamous cell carcinoma, primary to the lung.

Cavitating Bronchogenic Carcinoma

Cavitating Bronchogenic Carcinoma, Squamous Cell. There is a thick-walled cavity present in the right lower lobe (white arrows) with a nodular inner margin to the cavity. An air-fluid level is present. This was a squamous cell carcinoma, primary to the lung.

·       Adenocarcinoma

o      Usually peripheral nodule

o      Found in scars

o      Solitary pulmonary nodule (52%)

o      Upper lobe distribution (69%)

·       Small cell undifferentiated=Oat Cell Carcinoma

o      Appearances

§       Mediastinal adenopathy

§       Hilar mass

§       Small or invisible lung nodule

o      High metastatic potential

o      Rapid growth

o      May be associated with

§       Hypoglycemia

§       Cushing's syndrome

§       Inappropriate secretion of ADH

§       Excessive gonadotropin secretion

·       Large cell undifferentiated (10%)

o      Large peripheral mass

o      Pleural involvement

·       Cell type by location

o      Central

§       Squamous cell

o      Peripheral

§       Adenocarcinoma

§       Large cell

·       Most common site: anterior segment RUL

o      Pancoast tumor=superior sulcus tumor (4%)

o      Squamous cell most often

o      SVC obstruction (5%)

§       Most often small cell

·       Associated clinical findings

o      Horner's syndrome

§       Pancoast tumor

o      Elevated hemidiaphragm

§       Phrenic nerve paralysis

o      Hoarseness

§       Recurrent laryngeal nerve (left>right)

o      SVC obstruction

§       Small cell ca

o      Pleural effusion (10%)

o      Dysphagia

o      Enlarged nodes

o      Esophageal invasion

·       Roentgenographic findings

o      Airway obstruction

§       Atelectasis most common sign

§       No air bronchogram

§       Also postobstructive pneumonia

o      Hilar enlargement

§       From either the carcinoma itself or nodes

§       Particularly common in oat cell, uncommon in adenoca

o      Mediastinal node enlargement

§       Particularly anaplastic ca

o      Cavitation

§       Common (2-16%)

§       Especially in squamous cell, mostly in upper lobes

§       Cavity is usually thick-walled with nodular inner margin

o      Pleural involvement

§       Common: 10%

§       Hemorrhagic effusion denotes direct tumor invasion

§       Effusion carries a poor prognosis even if no malignant cells are found

·       Metastases

o      Bone

§       Marrow: in 40% at time of presentation

§       Gross lesions in 10-35%

§       Most often in vertebra (70%), next in pelvis (40%), next femurs (25%)

§       Osteolytic mets (3/4)

§       Osteoblastic mets (1/4)

·       Especially in small cell and alveolar cell

o      Adrenals

§       In 37% pathologically at time of presentation

o      Brain

§       In 30% at autopsy

§       Multiple in 2/3

o      Kidney, GI tract, liver, contralateral lung

·       Prognosis

o      Mean survival time < 6 months

o      <10% overall 5 year survival

o      Survival by cell type at 40 months

§       Squamous cell (30%)

§       Large cell (16%)

§       Adenocarcinoma (15%)

§       Oat cell (1%)