Teaching File: Tumors of the Lung

Teaching File: Solitary Pulmonary Nodule (SPN)

Teaching File: Bronchial Carcinoma

Strategies of investigations
Tumor patterns
Tumor staging
Chest wall infiltration
Mediastinal infiltration
Infiltration of great vessels
Metastases to regional lymphnodes
Distant metastases
Therapy induced patterns

Teaching File: Other Tumors

Teaching File: Metastases

Index (in German)

Teaching File: Solitary Pulmonary Nodule (SPN)


Textbook (in German)

Rapid measurement of densities in a nodule: window width is turned down to 2, i.e. black and white image results. The center value is changed to a value where a first pixel in the area of interest brighten up or the last disappears. This center value represents the maximal density value in the nodule.

Rounded density in upper lung field. The patient had a bronchoscopy with tissue sampling from this area the previous day. Three days later the assumed nodule has nearly disappeared. It represented a biopsy-induced hematoma.

CT of adenomatous carcinoma with a speck of calcification in the anterior segment of the right upper lobe. Central calcifications are said to be characteristic of granulomas and peripheral calcifications for carcinomas. Reasoning: carcinomas that develop in a calcified scar will push the scar with its calcification to the periphery. Nevertheless it has been shown that carcinomas may show all patterns of calcification.

Bronchial carcinoma in anterior segment of left upper lobe with slight eccentric calcification. The pattern of calcification cannot be used as a definite diagnostic tool. It is only illustrative. Diagnoses that are relevant to therapy stem from histology or cytology.


Teaching File: Bronchial Carcinoma


Textbook (in German)

Strategies of investigations

Textbook (in German)

The so-called "double window technique" should not be utilized as the blurred borders of the two windows may obliterate small pathologies.

Retrocardial mass. Round structure in the shadow of the left heart. Such finding may easily be overlooked. CT shows the relation of the mass to chest wall, ribs, and aorta better than the lateral view, which is not presented.

Transthoracic puncture of a pleural mass, guided by CT. To avoid central necrotic areas that would be useless for histology or cytology, it is advisable to puncture the periphery of a mass. In 30% of transthoracic punctures a pneumothorax may occur. Only 25% of these cases need therapy. Positioning the patient on the puncture side after the procedure may reduce the occurrence of pneumothoraces. In any case an expiratory film is required to exclude complications 2-3 hours after puncture.

Transbronchial biopsy in the 6. segment of the right lower lobe.

Transthoracic puncture of a paramediastinal mass in the left upper lung field. The needle passes through the paravertebral soft tissue to avoid a lesion of the pleura.

Pancoast tumor in the apex of the left lung. The mass is hardly visible on the chest film (upper image). Coronal MRI depicts the tumor and its infiltration of the apex of the lung.


Tumor patterns

Adenocarcinoma in lower lobe. Macroanatomic slice. The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however: http://www-medlib.med.utah.edu/WebPath/ORGAN.html

Squamous cell carcinoma with subtotal occlusion of the right main bronchus. The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however: http://www-medlib.med.utah.edu/WebPath/ORGAN.html

Natural history of a bronchial carcinoma. Cranial to the right hilum there is a mass that was overlooked: 2 months later marked growth of the central carcinoma was observed.

Gross pathologic specimen of a lung with a large bronchial carcinoma in the lower lobe. There is a dependent atelectasis dorsal and caudal of the mass.

Signs of malignancy in CT are mostly the same as in chest film: spiculae ("burst") and pleural finger (poststenotic dystelectasis or lymphangitis, sometimes with a reaction of local thickening of the pleura).

CT of a bronchial carcinoma in the anterior segment of the left upper lobe. There are fine lines (pleural fingers) to the pleura, which shows some thickening in this area.

Central bronchial carcinoma on the right.

Wide spread Adenocarcinoma.

Disseminated Adenocarcinoma. Most foci have central necrosis.

P.a. and lateral chest films show diffusely infiltrating Adenocarcinoma.

Chest x-ray with Adenocarcinoma. Diffuse alveolar consolidations on the left side.

Chest x-ray with bronchial carcinoma in left upper lobe (arrows). Enlarged lymphnodes in the left hilum (arrowheads).

Chest films p.a. and lateral with big peripheral bronchial carcinoma in the posterior segment of the left upper lobe.

Chest films p.a. and lateral with central bronchial carcinoma on the left. The enlarged right hilum is well seen on the p.a. film. If a mass superimposes the hili on the lateral film the tumor is sometimes hardly visible.

Chest films p.a. and lateral with central bronchial carcinoma on the right.

Bronchial carcinoma in the posterior segment of the right upper lobe with cavitation.

Periostal thickening at the distal femur in a Patient with bronchial carcinoma. Mostly these paraneoplasias are discovered in the nuclear bone scan in the search for bone metastases. Often, the patients suffer from arthralgia (Pièrre-Marie-Bamberger-Syndrom).

Metastatic lymphangiosis. Bronchial carcinoma on the right with right upper lobe atelectasis.

Atelectasis and tumor. In MRI there is a big mass in the left upper lobe. Cranial to this mass there is an area of increased signal intensity. This might well be an atelectasis. In the axial plane the differentiation of atelectasis and tumor is not possible. Neither MRI nor CT can differentiate the entities regularly and with confidence.

Atelectasis and tumor. Contrast medium enhanced CT, scans from caudal to cranial. The area that belongs to the tumor is not as dense as the perfused atelectatic tissue. Though near the hilum, no big vessels are visible.

Squamous cell carcinoma with cavitation in the anterior segment of the left upper lobe with draining bronchus. This might well be cavitating tuberculosis. Radiological signs of a carcinoma would include contralateral hilar lymphnode enlargement or distant metastases.

Development of a squamous cell carcinoma in chest film and CT. Radiological, the differentiation from tuberculosis is not possible.


Tumor staging (descriptor T)

Textbook (in German) on TNM staging

Bronchial carcinoma in segment 6. TNM: T2 (tumor diameter > 3 cm).

T1N2 of bronchial carcinoma near descending aorta, < 3cm (stage: T1), in posterior segment of left upper lobe. Ipsilateral in the aortopulmonary window there are enlarged mediastinal lymphnodes, > 10 mm in short diameter. The descriptor for these nodes is therefore N2.

T2 Bronchial carcinoma in left 6. segment > 3 cm (i.e. stage: T2).

Endoluminal tumor growth in the bronchus intermedius, > 2 cm from the carina.


Chest wall infiltration

Textbook (in German) on the subject

Right dorsal mass, adjacent to the pleura. Subpleural fat (fat lamella) is still visible. Probability of infiltration of the chest wall is therefore low.

Right bronchial carcinoma with extension to the pleura. There is no pleura fat lamella discernable. Infiltration of at least the pleura (T3) can be assumed.

Infiltration of the chest wall. Mass lesion in the left upper lobe at the lateral chest wall. The tumor has completely destroyed the 2. and 3. rib.

Bronchial carcinoma of T3 in the right upper lobe. There is no peripleural fat lamella to be seen. The mass contacts the chest wall over a distance of more than 3-cm. Chest wall infiltration is most probable.

Chest wall infiltration (T3). MRI of a left bronchial carcinoma that has infiltrated the musculature of the chest wall with soft tissue enlargement.

Pancoast tumor with destruction of ribs.

Pancoast tumor of the right apex of the lung. The chest x-ray shows a homogeneous density apicolateral.

Pancoast tumor and atelectasis in the left apex of the lung. The sagittal MR image shows the nerves and vessels of the superior sulcus surrounded by fat; most likely they are not infiltrated. This exam demonstrates the superiority of MRI to solve this question.

Sagittal MTI of a mass in the left apex. The signal void vena anonyma shows no surrounding perivascular fat with hyperintense signal. An infiltration of the vessel is therefore most probable and the tumor is inoperable.


Infiltration of the mediastinum

Diffuse infiltration of the mediastinum (T4) by a left side central bronchial carcinoma. Bronchi and vessels of the lower lobe are enclosed.

T4 tumor: extensive bronchial carcinoma with continuous infiltration into the mediastinum. The vena cava cannot be delineated. The mass contacts the right lateral wall of the Trachea.

Mass in left upper lobe with mediastinal infiltration. Tumor fingers reach the wall of the aorta. An infiltration of the aorta can be discussed, but is not likely because of the small area of contact. Prior to surgery MRI should clarify this situation.

MRI of right side bronchial carcinoma with small extensions into the mediastinal fat (T4).

T4 because of pericardial effusion. The intrapericardial fluid has a thickness of up to 10 mm.


Infiltration of great vessels

Textbook (in German)

Cavography. A mediastinal mass compresses the cava superior from medial.

Compression of a segmental artery of upper lobe by a mass (arrow). This angiography of the pulmonary artery does not help with TNM staging.

Left side bronchial carcinoma with infiltration of the mediastinum. The mass contacts more than 50% of the circumference of the aorta. There is no perivascular fat lamella. Though the aorta is more resistant to infiltration then other vessels, tumor infiltration is likely.

Vessel infiltration? MRI of a mass in left upper lobe. The mass abuts the aortic arch. Between mass and aorta a fat lamella is visible (arrow) but interrupted for a short distance (arrowhead). This might indicate vessel infiltration. A more reliable sign would be irregular contours of the lumen of the vessel. Infiltration into the aortic wall is not as frequent as into venous walls.

The perivascular fat lamella parts mass, aorta descendens and aortic arch.

Phlebography of vena cava superior and veins of the right shoulder in bronchial carcinoma. The mass narrows the lumen of the brachiocephalic vein from caudal (arrow). Angiography does not allow a decision on wether there is compression or also infiltration of the vessel.

Mediastinal Infiltration (lower part of the image) by a right sided bronchial carcinoma. The mass has infiltrated the vena cava superior (therefore descriptor T4). Cranial (upper part of image) there is a thrombus like extension of tumor into the lumen.

MRI of bronchial carcinoma left upper lobe. The carcinoma abuts the aortic arch. There is no perivascular fat lamella. The inner contour of the aortic lumen shows irregularities. A tumor infiltration is most likely (the descriptor is T4).

T4N3 Tumor. CT of a central bronchial carcinoma that infiltrates into the mediastinum (T4). It is also a T4 tumor because it infiltrates the cava superior, which is seen only as a dash like contour. Contralateral in the aortopulmonary window there are multiple lymphnodes, enlarged more than 10 mm in short diameter. This denominates it a N3 tumor.

Transverse MRI and frontal MRI of a tumor that infiltrates the aorta descendens.

Tumor infiltration of the veins of the lung and further into the left atrium.

Pancoast tumor in transverse and sagittal MRI. The tumor has infiltrated around the subclavian artery (double arrow). This shows inoperability.


Metastases to regional lymphnodes (descriptor: N)

Textbook (in German)

The crescent shaped density at the back of the ascending aorta is formed by a plica of the pericardium. This should not be mistaken for a lymphnode.

Stage N1. Bronchial carcinoma in middle lobe. Beaded structures from the mass to the hilum represent lymphnode metastases along the lymphatic vessels from the tumor to the hilum. This describes the Lymphnode status as N1.

Stage N1. Bronchial carcinoma in lower lobe (not visualized in this slice). Ventral of the lower lobe artery, which is enhanced by contrast medium there is an enlarged lymphnode. It is situated on the draining path from the tumor to the hilum and represents a local metastasis.

Stage T3N2. Bronchial carcinoma in the anterior segment of the left upper lobe of more than 3 cm. It shows radiating structures towards the aorta (i.e. T3) but it clearly separated from the vessel (i.e. not T4). In the aortopulmonary window, between aorta ascendens, aorta descendens and Trachea there are lymphnodes with a short diameter of more than 10 mm. Therefore the description of the tumor is T3N2. Vc: vena cava superior.

Stage N2: Subcarinal lymphnode metastases belong to the same side as the tumor.

Stage N3: CT of a right peripheral bronchial carcinoma (not shown in this slice) with pretracheal retrocaval lymphnodes (L). The Lymphnodes reach across the midline. Therefore it is no longer described as N2 but N3 lymphnode status. Aa: aorta ascendens; T: Trachea; C: vena cava superior.

N3 description of a left bronchial carcinoma in the anterior segment of the upper lobe. On the contralateral paratracheal side there is an enlarged lymphnode. On the same side as the tumor this would be a N2 lymphnode metastasis.

N3 description (stage) of a bronchial carcinoma in the posterior segment of the left upper lobe with close contact to the descending Aorta (infiltration?). Two enlarged lymphnodes in the aortopulmonary window would denominate the nodes as N2 - but there is third pretracheal retrocaval node on the other side. This describes the lymphnode situation as N3.

N3 stage of a bronchial carcinoma (not showed on this slice). On both sides of the mediastinum there are enlarged lymphnodes.


Distant metastases (descriptor: M)

Textbook (in German)

Lymphangiosis carcinomatosa of a bronchial carcinoma in the posterior segment of the right upper lobe. Characteristic polygonal pattern by tumor cell infiltration of the lymph vessels in the interstitium of the secondary lobulus.

Lymphangiosis carcinomatosa in chest x-ray p.a. and lateral. Radiating pattern from the hili into the periphery.

Lymphangiosis carcinomatosa. Diffuse broom like linear pattern hilufugal into the periphery. Right lower lobe atelectasis. Effusion on the left.

Lymphangiosis carcinomatosa. The walls of the secondary lobulus are thickened by infiltration of tumor cells. The lobuli have a polygonal shape (arrows).

Lymphangiosis carcinomatosa.

Lymphangiosis carcinomatosa. Right bronchial carcinoma with atelectasis of right upper lobe.

Pulmonary metastases of a bronchial carcinoma (A) and (B).

Multiple metastases into liver and spleen by bronchial carcinoma

Metastases in kidneys and liver by bronchial carcinoma. CT pre- and post intravenous contrast medium application in arterial and parenchymal phase. The liver metastases are visible in the pre-contrast scan. The deposit in the dorsal part of the right kidney only shows up after contrast medium. It is best visible in the parenchymal phase.

Renal metastasis of a bronchial carcinoma. This deposit also shows up only after intravenous contrast medium application. CT scans of precontrast, arterial and parenchymal phase.

Pericardial metastasis with pericardial effusion. CT-guided pericardial drainage.

Metastasis in the root of the right lateral arch of the posterior elements of the 5. vertebral body of the thoracic spine. Sign of blinking owl: the eye on the side of the pathology (destroyed root of the arch) seems closed.

Bone metastasis of a bronchial carcinoma into the tibia.

Bone metastasis of a bronchial carcinoma into the proximal radius.

Recurrent bronchial carcinoma in the left middle lung field with cavitation. Obliteration of the left lateral costophrenic sinus.


Therapy induced patterns

Follow up after pneumonectomy because of a right central bronchial carcinoma. Postoperatively fluid fills the hemithorax. The first film in upright position shows a fluid level (seropneumothorax). Some weeks later the right hemithorax shows a homogenous density because it is completely fluid filled.

Complications of chemotherapy. Right small cell bronchial carcinoma. Enlarged right hilum. After chemotherapy the tumor formation is reduced. There is new infiltration of tuberculosis in the right upper lobe.

Small cell bronchial carcinoma after chemotherapy and radiation. Nevertheless progressive upper venous congestion because of tumor compression of the vena cava superior (arrows, and CT). Under fluoroscopy the stenosis is marked externally (small arrows) and dilated with a balloon. Than 2 Z-stents are placed, partly overlapping. The patient improved markedly.

Adenoidcystic carcinoma.



Teaching File: Other Tumors


Textbook (in German)

Chondroma perihilar right.

Mycosis fungoides, pulmonary involvement. Mycosis fungoides is a low differentiated T-cell-lymphoma. In stage IV lymphnodes and/or visceral organs are involved.

Chronic lymphatic leukemia. CT shows bilateral infiltration of lung parenchyma.

Aggressive neurofibromatosis. CT shows destruction of a rib.



Teaching File: Metastases


Textbook (in German)

gross pathologic specimen showing metastases of the lung.

Suspected pulmonary nodule. Close inspection of the soft tissue of the chest shows multiple cutaneous nodules. They may mimic pulmonary nodules if projected into the lung fields.

Pulmonary metastases do not present as well in MRI as in CT. With ECG- and respiration triggered T2 sequences an accuracy of 95% has been achieved recently.

Peripheral calcification. In CT sharp contours and bone like density values.

Diffuse, small, miliary Metastases.

Lung metastasis of an osteosarcoma in right upper lobe.

Profuse metastases of a salivary gland carcinoma.

Natural history of a metastasis of colon carcinoma over a period of 24 months.

Metastases of an extragonadal mediastinal germ cell carcinoma.

Metastases of a carcinoma of the oropharynx.

Lymphangiosis carcinomatosa in carcinoma of the breast. ©Dr. Lund, Hamburg

Metastasis of a renal cell carcinoma at the ventral chest wall.

Recurrent malignant histiozytoma with multiple pulmonary nodules. Usually, it grows in the chest wall, rarely in the lung.


Index Teaching File

The Lung in the Web


Diary (in German)

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