(no consultations)
- 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
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.
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.
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.
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.
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.
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.
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)
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)
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. 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.
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.
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.
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.
(no consultations)
7.4.07