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CARCINOMA LUNG WITH
METASTASIS– E poster
Submitted by – Dr Anisha.K.A
Junior Resident
Dr. Deepa. S , Asst Prof
Dr. Abhilash Babu TG, HoD
Department of Radiodiagnosis
Govt Medical College Thrissur
Clinical presentation
66 year Old gentleman who is a chronic smoker , alcoholic and known case of hypertension and Diabetes mellitus on
treatment presented with history of seizures 2 episodes in a week and occasional cough. No history of fever, hamoptysis.
Patient was evaluated in a private hospital initially and undergone plain CT Brain which showed multiple areas of
intracerebral haemorrhage of varying sizes with surrounding oedema in left frontal, parietal, occipital lobe, left posterior
periventricular white matter, right parietal,temporal lobe,right superior cerebellar hemisphere possibly haemorrhagic
metastasis followed by MRI Brain (plain+contrast) with spectroscopy which showed multiple well defined round T2
heterogenously hyperintense mass lesions in bilateral cerebral hemispheres, right cerebellum showing diffusion
restriction, haemorrhage , heterogenous post contrast enhancement, perilesional oedema suggestive of multiple
haemorrhagic brain metastasis. Spectroscopy from the lesion in right frontal lobe shows choline peak.
And patient was referred to neurosurgery department GMC Thrissur; for further evaluation to department of
radiodiagnosis and CECT thorax +abdomen was done.
Plain CT thorax abdomen
On plain CT thorax – a mildly lobulated soft tissue
density lesion noted in anterior segment of left
upper lobe. Hypodense lesion noted in subcarinal
region and prevascular space possibly
lymphnode. An exophytic mass noted in
interpolar region of right kidney. A nodule noted
in posterior para renal space.
Contrast CT
- A lobulated enhancing soft tissue density lesion
measuring 2.8x 2.3x 2.8cm in the anterior
segment of left upper lobe possibly neoplastic.
Heterogeneously enhancing hypodense lesion
measuring 3.7 x2.9 cm in the subcarinal region
with predominant peripheral enhancement and
central non enhancing areas (necrotic lymph
node);Similar heterogeneously enhancing lymph
node in prevascular space likely mediastinal
lymphnode mass.
- Heterogeneously enhancing lymph node
measuring 1.9 x1.6 cm in left axillary region
- Small exophytic enhancing mass measuring 1.5
x1 cm seen arising from lateral cortex of
interpolar region of right kidney extending to
perinephric space likely primary renal neoplasm.
- Well defined enhancing nodular lesion
measuring 9.7 x 7 mm in posterior para renal
space ? lymph node.
- Few hypoenhancing hypodense lesion in head
of pancreas? pancreatic metastasis
- Bilateral renal calculi on right side measuring 5
mm in lower calyx and Left side measuring 6.5
mm in lower calyx
Conclusion
 A Lobulated enhancing soft tissue density lesion in anterior segment of left upper lobe as described
possibly neoplastic suggested HPR correlation.
 Heterogeneously enhancing hypodense lesion in subcarinal, prevascular region as described likely
mediastinal lymph node mass
 Exophytic enhancing mass in right kidney as described likely primary renal neoplasm
 Hypoenhancing hypodense lesion in head of pancreas as described ? metastasis to pancreas
• Patient was admitted in neurosurgery department ,was given supportive measures due to extensive metastasis and
succumbed to his illness.
Discussion
• Lung cancer is the leading cause of cancer mortality worldwide; accounting for ~20% of all cancer deaths.
• Risk factors: The major risk factor is tobacco smoking, which is implicated in 90% of cases, Asbestos exposure, diffuse
lung fibrosis, chronic obstructive pulmonary disease are other risk factors.
• The predominant cell types are small cell lung cancer(SCLC) and non-small cell lung cancer (NSCLC).NSCLC
is divided into three main subtypes, squamous cell carcinoma, adenocarcinoma and large cell cancer.
• The chest radiograph will remain the initial investigation in all patients suspected of lung cancer. The
mainstay of staging investigation for a patient with suspected lung cancer is contrast enhanced CT
supplemented by FDG-PET-CT and MR when required. Staging the intrathoracic extent of lung cancer is a
multidisciplinary process utilising imaging, bronchoscopy and biopsy. The thoracic imaging features of
bronchial carcinoma are discussed under three headings: peripheral tumours, central tumours (arising in a
large bronchus at or close to the hilum) and staging intrathoracic spread of bronchial carcinoma.
• Peripheral tumours: Tumours at the lung apex (Pancoast’s tumours, superior sulcus tumours) may
resemble apical pleural thickening; however, the majority of peripheral lung cancers are approximately
spherical or oval in shape. Cavitation, Air bronchograms and bubble-like lucencies or pseudocavitation
may be seen within lung cancers, in particular with adenocarcinoma. Calcification rarely seen.
• Central tumours :collapse/consolidation of the lung beyond the tumour and the presence of hilar
enlargement.
• Staging Intrathoracic Spread of Bronchial Carcinoma: Hilar Enlargement, Mediastinal Invasion, Chest Wall Invasion, Pleural
Involvement.
The essential points to establish when staging the intrathoracic extent of non-small cell cancers are: (A)whether the
tumour has spread to hilar or mediastinal nodes; (B) if it has, which nodal groups are involved; (C)whether the tumour
has invaded the chest wall or mediastinum; and (D) if it has, whether it is still potentially curable surgically. If chest
radiography and CT + PET show no evidence of spread beyond the lung (other than to ipsilateral hilarnodes) in a
patient who is suitable for surgery, and in whom bronchoscopy shows the tumour to be resectable then that patient
should be offered surgical resection
without further preoperative invasive procedures. Spread to ipsilateral nodes, has a significantly adverse effect on
prognosis and even if surgery is undertaken, it is performed with the understanding that 5-year survival rates are poor.
For lung cancers that have invaded the mediastinum or chest wall, it is not resectable for possible cure, the prognosis
will be poorer.
Extrathoracic Staging of Lung Cancer: Lung cancer is commonly associated with widespread haematogenous
dissemination at the time of presentation. Sites of spread include the adrenal glands, bones ,brain, liver and more
distant lymph nodes.
Adenocarcinoma of the lung is the most common histologic type of lung cancer. Early symptoms are fatigue with mild
dyspnea followed by a chronic cough and haemoptysis at a later stage. In CT Nodules appear either as ground glass,
subsolid or solid. Fleischner Society guidelines provide recommendations for the imaging follow-up of both ground glass
and solid nodules .
Squamous cell carcinoma is one of the non-small cell carcinomas of the lung second only to adenocarcinoma of the
lung associated with heavy smoking. Central tumors with invasion and obstruction of bronchi typically result in
distal collapse which may have superimposed infection. Chronic cough, haemoptysis may be present. More peripheral
tumors, if not found incidentally on imaging, usually present when larger, invading into chest wall (e.g. Pancoast
tumor). Metastatic disease may be the first sign of malignancy (e.g. cerebral metastasis pathological fracture etc). The
most common sites of metastasis are regional lymph nodes, adrenal glands, brain, bone, and liver . In CT Central tumors
often result in intraluminal obstruction and cause lung collapse and/or obstructive pneumonitis. Peripheral tumors may
be seen as a solid nodule/mass with or without an irregular border .Cavitation is a frequent finding in primary lung
squamous cell carcinoma.When squamous cell carcinoma presents as a peripheral solid nodule, follow-up is as per
the Fleischner Society guidelines. Survival depend on stage of disease.
• Large cell lung cancer is one of the histological types of non-small cell carcinomas of the
lung diagnosed only on resection. Patients present with dyspnea, chronic cough, and hemoptysis. In
CT Large cell lung cancer is typically seen as a large peripheral mass of solid attenuation and irregular
margin. Large cell neuroendocrine tumor has a more aggressive pattern and is associated with a
poorer prognosis.
• Small cell lung cancer (SCLC), also known as oat cell lung cancer are neuroendocrine tumors of the
lung that rapidly grow, are highly malignant, widely metastasize, and, despite showing an initial
response to chemotherapy and radiotherapy, have a poor prognosis and are usually unresectable.
Clinical features can be fever, weight loss, haemoptysis, dysphagia, hoarseness, bone pain, right
upper quadrant pain. On CT, mediastinal involvement may appear similar to lymphoma, with
numerous enlarged nodes. Direct infiltration of adjacent structures is common. Small cell carcinoma
of the lung is the most common cause of SVC obstruction, Small cell lung cancers are usually
characterized as a mass lesion, where necrosis and hemorrhage are both common. Only rarely
present as a solitary pulmonary nodule. These patients are usually managed with aggressive
chemoradiation therapy and, a few, with lobectomy associated with mediastinal lymph node
dissection. Surgical excision is commonly not recommended beyond these early stages, as studies
have shown that any nodal involvement (N1–3 disease) will not benefit from excisional treatment.
Brain metastases are found in up to a quarter of patients at presentation. Advanced disease (stage IV)
is managed only with chemotherapy, primarily for palliation and symptom control.
• The IASLC (International Association for the Study of Lung Cancer) 8th
edition lung cancer
staging system was introduced in 2016 It is a TNM staging system. Standard-of-care lung cancer
staging ideally should be performed in a multidisciplinary meeting using the information provided
both from CT and FDG-PET-CT with further inputs from the histopathologic findings (pathological
staging).
Review of literature
• Grainger and Allisons diagnostic radiology. Pulmonary neoplasms 2020;15(4):320–346
• Detterbeck F, Boffa D, Kim A, Tanoue L. The Eighth Edition Lung Cancer Stage Classification. Chest.
2017;151(1):193-203
• Goldstraw P, Chansky K, Crowley J et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of
the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. J
Thorac Oncol. 2016;11(1):39-51.
• Fauci A, Braunwald E, Kasper D et al. Harrison's Principles of Internal Medicine, 17th Edition. (2008) ISBN:
0071466339
• Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott Williams & Wilkins. (2007)
ISBN:0781761352
• Rosado-de-Christenson M, Templeton P, Moran C. Bronchogenic Carcinoma: Radiologic-Pathologic
Correlation. Radiographics. 1994;14(2):429-46
Thank you

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Carcinoma lung clinical and radiology ct

  • 1. CARCINOMA LUNG WITH METASTASIS– E poster Submitted by – Dr Anisha.K.A Junior Resident Dr. Deepa. S , Asst Prof Dr. Abhilash Babu TG, HoD Department of Radiodiagnosis Govt Medical College Thrissur
  • 2. Clinical presentation 66 year Old gentleman who is a chronic smoker , alcoholic and known case of hypertension and Diabetes mellitus on treatment presented with history of seizures 2 episodes in a week and occasional cough. No history of fever, hamoptysis. Patient was evaluated in a private hospital initially and undergone plain CT Brain which showed multiple areas of intracerebral haemorrhage of varying sizes with surrounding oedema in left frontal, parietal, occipital lobe, left posterior periventricular white matter, right parietal,temporal lobe,right superior cerebellar hemisphere possibly haemorrhagic metastasis followed by MRI Brain (plain+contrast) with spectroscopy which showed multiple well defined round T2 heterogenously hyperintense mass lesions in bilateral cerebral hemispheres, right cerebellum showing diffusion restriction, haemorrhage , heterogenous post contrast enhancement, perilesional oedema suggestive of multiple haemorrhagic brain metastasis. Spectroscopy from the lesion in right frontal lobe shows choline peak. And patient was referred to neurosurgery department GMC Thrissur; for further evaluation to department of radiodiagnosis and CECT thorax +abdomen was done.
  • 3. Plain CT thorax abdomen On plain CT thorax – a mildly lobulated soft tissue density lesion noted in anterior segment of left upper lobe. Hypodense lesion noted in subcarinal region and prevascular space possibly lymphnode. An exophytic mass noted in interpolar region of right kidney. A nodule noted in posterior para renal space.
  • 4. Contrast CT - A lobulated enhancing soft tissue density lesion measuring 2.8x 2.3x 2.8cm in the anterior segment of left upper lobe possibly neoplastic. Heterogeneously enhancing hypodense lesion measuring 3.7 x2.9 cm in the subcarinal region with predominant peripheral enhancement and central non enhancing areas (necrotic lymph node);Similar heterogeneously enhancing lymph node in prevascular space likely mediastinal lymphnode mass. - Heterogeneously enhancing lymph node measuring 1.9 x1.6 cm in left axillary region - Small exophytic enhancing mass measuring 1.5 x1 cm seen arising from lateral cortex of interpolar region of right kidney extending to perinephric space likely primary renal neoplasm. - Well defined enhancing nodular lesion measuring 9.7 x 7 mm in posterior para renal space ? lymph node. - Few hypoenhancing hypodense lesion in head of pancreas? pancreatic metastasis - Bilateral renal calculi on right side measuring 5 mm in lower calyx and Left side measuring 6.5 mm in lower calyx
  • 5. Conclusion  A Lobulated enhancing soft tissue density lesion in anterior segment of left upper lobe as described possibly neoplastic suggested HPR correlation.  Heterogeneously enhancing hypodense lesion in subcarinal, prevascular region as described likely mediastinal lymph node mass  Exophytic enhancing mass in right kidney as described likely primary renal neoplasm  Hypoenhancing hypodense lesion in head of pancreas as described ? metastasis to pancreas • Patient was admitted in neurosurgery department ,was given supportive measures due to extensive metastasis and succumbed to his illness.
  • 6. Discussion • Lung cancer is the leading cause of cancer mortality worldwide; accounting for ~20% of all cancer deaths. • Risk factors: The major risk factor is tobacco smoking, which is implicated in 90% of cases, Asbestos exposure, diffuse lung fibrosis, chronic obstructive pulmonary disease are other risk factors. • The predominant cell types are small cell lung cancer(SCLC) and non-small cell lung cancer (NSCLC).NSCLC is divided into three main subtypes, squamous cell carcinoma, adenocarcinoma and large cell cancer. • The chest radiograph will remain the initial investigation in all patients suspected of lung cancer. The mainstay of staging investigation for a patient with suspected lung cancer is contrast enhanced CT supplemented by FDG-PET-CT and MR when required. Staging the intrathoracic extent of lung cancer is a multidisciplinary process utilising imaging, bronchoscopy and biopsy. The thoracic imaging features of bronchial carcinoma are discussed under three headings: peripheral tumours, central tumours (arising in a large bronchus at or close to the hilum) and staging intrathoracic spread of bronchial carcinoma. • Peripheral tumours: Tumours at the lung apex (Pancoast’s tumours, superior sulcus tumours) may resemble apical pleural thickening; however, the majority of peripheral lung cancers are approximately spherical or oval in shape. Cavitation, Air bronchograms and bubble-like lucencies or pseudocavitation may be seen within lung cancers, in particular with adenocarcinoma. Calcification rarely seen. • Central tumours :collapse/consolidation of the lung beyond the tumour and the presence of hilar enlargement. • Staging Intrathoracic Spread of Bronchial Carcinoma: Hilar Enlargement, Mediastinal Invasion, Chest Wall Invasion, Pleural Involvement.
  • 7. The essential points to establish when staging the intrathoracic extent of non-small cell cancers are: (A)whether the tumour has spread to hilar or mediastinal nodes; (B) if it has, which nodal groups are involved; (C)whether the tumour has invaded the chest wall or mediastinum; and (D) if it has, whether it is still potentially curable surgically. If chest radiography and CT + PET show no evidence of spread beyond the lung (other than to ipsilateral hilarnodes) in a patient who is suitable for surgery, and in whom bronchoscopy shows the tumour to be resectable then that patient should be offered surgical resection without further preoperative invasive procedures. Spread to ipsilateral nodes, has a significantly adverse effect on prognosis and even if surgery is undertaken, it is performed with the understanding that 5-year survival rates are poor. For lung cancers that have invaded the mediastinum or chest wall, it is not resectable for possible cure, the prognosis will be poorer. Extrathoracic Staging of Lung Cancer: Lung cancer is commonly associated with widespread haematogenous dissemination at the time of presentation. Sites of spread include the adrenal glands, bones ,brain, liver and more distant lymph nodes. Adenocarcinoma of the lung is the most common histologic type of lung cancer. Early symptoms are fatigue with mild dyspnea followed by a chronic cough and haemoptysis at a later stage. In CT Nodules appear either as ground glass, subsolid or solid. Fleischner Society guidelines provide recommendations for the imaging follow-up of both ground glass and solid nodules . Squamous cell carcinoma is one of the non-small cell carcinomas of the lung second only to adenocarcinoma of the lung associated with heavy smoking. Central tumors with invasion and obstruction of bronchi typically result in distal collapse which may have superimposed infection. Chronic cough, haemoptysis may be present. More peripheral tumors, if not found incidentally on imaging, usually present when larger, invading into chest wall (e.g. Pancoast tumor). Metastatic disease may be the first sign of malignancy (e.g. cerebral metastasis pathological fracture etc). The most common sites of metastasis are regional lymph nodes, adrenal glands, brain, bone, and liver . In CT Central tumors often result in intraluminal obstruction and cause lung collapse and/or obstructive pneumonitis. Peripheral tumors may be seen as a solid nodule/mass with or without an irregular border .Cavitation is a frequent finding in primary lung squamous cell carcinoma.When squamous cell carcinoma presents as a peripheral solid nodule, follow-up is as per the Fleischner Society guidelines. Survival depend on stage of disease.
  • 8. • Large cell lung cancer is one of the histological types of non-small cell carcinomas of the lung diagnosed only on resection. Patients present with dyspnea, chronic cough, and hemoptysis. In CT Large cell lung cancer is typically seen as a large peripheral mass of solid attenuation and irregular margin. Large cell neuroendocrine tumor has a more aggressive pattern and is associated with a poorer prognosis. • Small cell lung cancer (SCLC), also known as oat cell lung cancer are neuroendocrine tumors of the lung that rapidly grow, are highly malignant, widely metastasize, and, despite showing an initial response to chemotherapy and radiotherapy, have a poor prognosis and are usually unresectable. Clinical features can be fever, weight loss, haemoptysis, dysphagia, hoarseness, bone pain, right upper quadrant pain. On CT, mediastinal involvement may appear similar to lymphoma, with numerous enlarged nodes. Direct infiltration of adjacent structures is common. Small cell carcinoma of the lung is the most common cause of SVC obstruction, Small cell lung cancers are usually characterized as a mass lesion, where necrosis and hemorrhage are both common. Only rarely present as a solitary pulmonary nodule. These patients are usually managed with aggressive chemoradiation therapy and, a few, with lobectomy associated with mediastinal lymph node dissection. Surgical excision is commonly not recommended beyond these early stages, as studies have shown that any nodal involvement (N1–3 disease) will not benefit from excisional treatment. Brain metastases are found in up to a quarter of patients at presentation. Advanced disease (stage IV) is managed only with chemotherapy, primarily for palliation and symptom control. • The IASLC (International Association for the Study of Lung Cancer) 8th edition lung cancer staging system was introduced in 2016 It is a TNM staging system. Standard-of-care lung cancer staging ideally should be performed in a multidisciplinary meeting using the information provided both from CT and FDG-PET-CT with further inputs from the histopathologic findings (pathological staging).
  • 9. Review of literature • Grainger and Allisons diagnostic radiology. Pulmonary neoplasms 2020;15(4):320–346 • Detterbeck F, Boffa D, Kim A, Tanoue L. The Eighth Edition Lung Cancer Stage Classification. Chest. 2017;151(1):193-203 • Goldstraw P, Chansky K, Crowley J et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. J Thorac Oncol. 2016;11(1):39-51. • Fauci A, Braunwald E, Kasper D et al. Harrison's Principles of Internal Medicine, 17th Edition. (2008) ISBN: 0071466339 • Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott Williams & Wilkins. (2007) ISBN:0781761352 • Rosado-de-Christenson M, Templeton P, Moran C. Bronchogenic Carcinoma: Radiologic-Pathologic Correlation. Radiographics. 1994;14(2):429-46