Download Imaging Bronchogenic Carcinoma

Imaging Bronchogenic
Carcinoma*
Edward F. Patz Jr, MD
Imaging plays an integral role in diagnosing, staging,
and following patients with lung cancer. Most lung
tumors are detected on chest radiographs, but unfortunately, the majority of patients have advanced
stage disease at presentation. There is a wide spectrum of radiologic manifestations of lung cancer, and
recognition of these findings is essential for patient
management. As we continue to understand more
about tumor biology, new imaging techniques should
emerge and have the potential to significantly improve our diagnostic capabilities.
(CHEST 2000; 117:90S–95S)
Key words: CT; diagnostic imaging; lung cancer; positron
emission tomography
Abbreviations: BAC ⫽ bronchioloalveolar cell carcinoma;
FDG ⫽ F-18-fluorodeoxyglucose; NSCLC ⫽ non-small cell lung
cancer; PET ⫽ positron emission tomography; SCLC ⫽ small
cell lung carcinoma
carcinoma, an uncommon disease at the
B ronchogenic
turn of the 20th century (only several hundred cases
reported before 1900), has become a major health problem heading into the new millennium. Approximately
172,000 new cases will occur this year in the United States
alone.1–3 The diagnosis of lung cancer has relied on
detection of cells in sputum or biopsy specimens and,
perhaps more importantly, on specific findings observed
on chest radiographs. The purpose of this review is to
describe the radiographic features of bronchogenic carcinoma for diagnosis and staging.
Diagnostic Evaluation
Lung cancer is often considered in the differential
diagnosis for a spectrum of thoracic radiographic abnormalities. When an abnormality is detected, an important
next step is comparison with old radiographs. Most consider a 2-year interval without change as good evidence for
benignancy.4,5 Occasionally, the lesion has a benign pattern of calcification (central, concentric, or stippled appearance), or clinical information suggests a specific diagnosis.
If no old radiographs are available, or if the abnormality
is new, CT may further characterize the lesion. While CT
is extremely specific for certain benign lesions, most
abnormalities remain indeterminate and lung cancer cannot be excluded. Patients may then proceed to an invasive
procedure for diagnosis.
Recently, a noninvasive test, positron emission tomog*From the Department of Radiology, Duke University Medical
Center, Durham, NC.
Correspondence to: Edward F. Patz, Jr, MD, Department of
Radiology, Box 3808, Duke University Medical Center, Durham,
NC 27710
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raphy (PET) imaging, has been used to evaluate pulmonary lesions. PET using F-18-fluorodeoxyglucose (FDG),
a d-glucose analog, is very accurate in differentiating
benign from malignant focal pulmonary lesions as small as
1 cm (sensitivity of 83 to 100%, and specificity of 80 to
100%)6 – 8 and may prove to be very cost-effective.9 Falsepositive studies (eg, increased FDG in benign lesions
including aspergillomas, abscesses, tuberculosis, and histoplasmomas6,8,10 –13) have been reported; however, when
no significant FDG activity is observed, the lesions are
invariably benign. These abnormalities can be followed;
invasive procedures are not necessary. Hypermetabolic
lesions are considered malignant until proven otherwise,
usually by tissue diagnosis.
Non-Small Cell Lung Carcinoma
Non-small cell lung carcinoma (NSCLC) accounts for
approximately 80% of all bronchogenic carcinomas, and is
typically classified into specific cell types. The most common types are adenocarcinoma, squamous cell carcinoma,
and large cell carcinoma, although a variety of other
unusual cell types have been classified according to the
World Health Organization.14
Adenocarcinoma: Adenocarcinoma accounts for 25 to
30% of NSCLC and is the most common type.15 It is
typically classified as acinar, papillary, solid, and bronchioloalveolar varieties. Adenocarcinoma typically presents as
a small (often ⬍ 4 cm), peripheral, round or oval, smoothly
marginated, solitary pulmonary nodule. Occasionally, a
more central location or spiculation and irregular margins
are noted. Some lesions distort surrounding vessels (corona radiata) or cause retraction of the adjacent pleura
(“pleuroparenchymal tail”), but these features also may be
seen with benign abnormalities.16 –18
Calcification is rarely seen in lung cancer on chest
radiographs; however, eccentric or amorphous calcification has been reported in up to 6% of cases at CT.
Calcification at times represents engulfment of a preexisting granuloma.19 –21
With peripheral adenocarcinoma, lymphadenopathy is
seen in 18% and 2% of hilar and mediastinal lymph nodes,
respectively.20,22 Central lesions, however, have hilar nodal
metastases in 40% of cases, and mediastinal lymph node
metastases in 27% of cases.17,20
Bronchioloalveolar cell carcinoma (BAC) is a peculiar
subtype of adenocarcinoma that may present with solitary
or multiple lesions.23 The chest radiographs of patients
with BAC most commonly demonstrate a well-circumscribed solitary nodule (60%) that may remain unchanged
in size over several years.17,24,25 BACs, like the majority of
adenocarcinomas, are usually peripherally located.26,27
Pseudocavitation, the presence of small focal low-attenuation regions within or surrounding the periphery of the
nodule and air bronchograms, is more commonly associated with these tumors than other cell types.
Multifocal BAC may present as follows: (1) multiple
well-defined nodular opacities of varying size, involving
one or both lungs (15%)16,17,24 –26,28 –30; (2) focal, poorly
defined opacities or multiple scattered opacities17 that may
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coalesce into lobar and rarely complete lung opacification,16 resembling pneumonia (10%); or (3) reticulonodular opacities resembling interstitial lung disease. Other
radiographic features include hilar and mediastinal metastases (18%), pleural effusions (1 to 10%), atelectasis (3%),
and rarely pneumothorax.16,26
pulmonary symptoms.23,30 Liver, bone marrow, adrenal
glands, and brain are frequent sites of metastatic disease.19,39
Staging Evaluation
NSCLC
Squamous Cell Carcinoma: Squamous cell carcinoma
has decreased in frequency and now comprises 25% of
lung cancers.15 These are usually slow growing, with late
metastasis predominately to the liver, adrenal glands,
kidneys, and bones.16,31 Tumors usually range in size from
1 to 10 cm. They are typically found in the central bronchi,
although one third occur beyond the segmental bronchi.16,17,22 Endobronchial neoplasm may result in postobstructive pneumonia and/or atelectasis in up to 50% of
cases,16,22,32 and the underlying mass may be observed.16,32
Mucoid impaction, bronchiectasis, and hyperinflation are
additional findings of a central obstructing neoplasm.16,17,33,34 Extension into the chest wall or mediastinum with bone destruction, superior vena cava syndrome,
and phrenic or recurrent laryngeal nerve paralysis have
been reported.16,23,30
Squamous cell carcinoma cavitates in 10 to 20% of
cases,16,22 particularly in large peripheral lesions
(30%).17,35 Cavity walls are usually thick and irregular,
ranging in size from 0.5 to 3 cm. Rarely, extensive necrosis
may result in a thin-walled cavity.16
Squamous cell carcinoma is the most common type to
prove Pancoast or superior sulcus tumors.16 Asymmetry of
⬎ 8 mm in apical pleural thickening may be an important
finding, especially when associated with chest wall pain,
brachial or laryngeal nerve paralysis, or bone destruction.16
Large Cell Carcinoma: Approximately 10 to 20% of all
lung cancers are large cell carcinomas.16,19,30 The majority
present as a large (average size ⬎ 7 cm), peripheral
mass,16,17,19,22,31,36,37 with poorly defined margins. Cavitation and calcification are uncommon (6%). Hilar and
mediastinal adenopathy are seen in 30% and 10% of cases,
respectively.16,17,19,22 Rapid growth with early lymphatic
and hematogenous metastases occurs frequently.37
Small Cell Lung Carcinoma
Twenty to 25% of all lung cancers are small cell lung
carcinoma (SCLC).19,30,38 They probably arise from neuroendocrine cells and contain neurosecretory granules and
may produce peptide hormones.23,30
The tumors are usually located centrally (75 to 90% of
cases),19,39 and mediastinal extension is common and often
extensive with encasement of mediastinal structures and
tracheobronchial compression.40,41 The less-commonly described peripheral SCLC is often associated with hilar
adenopathy,16,19,22,30 and atelectasis secondary to main
stem bronchus compression.17,19 Pleural effusions are
reported in 5 to 50% of cases.16,40 – 42
The primary lesion may be small or not even visible on
radiograph studies, but early extrathoracic metastases are
common and even present prior to the development of
When bronchogenic carcinoma has been diagnosed,
accurate staging becomes essential for therapeutic decision making and prognosis estimation. The new International System for Staging Lung Cancer using a TNM
system has provided a standardized method to describe
anatomic extent of disease.43– 48 Radiologic studies used in
conjunction with the International System for Staging
Lung Cancer include chest radiographs, CT, and occasionally MRI. The appropriate role of imaging in management
still requires definition, but the major indication is to
accurately differentiate stage I to IIIA (potentially resectable) from stage IIIB to IV (nonresectable) cancer.49 –51
Local Disease (Size and Extent; T Status): Radiologic
assessment of the size of primary lesions is usually done
using plain chest radiographs and, less commonly, CT or
MRI. Measurements may be inaccurate secondary to
ill-defined margins, change in rotation or degree of inspiration, window-setting differences on CT, or other factors,
but are generally valuable for purposes of tumor staging.
The extent of primary lesion can be suggested by plain
radiographs, CT, and MRI, but may not necessarily be
accurate in confirming chest wall or local mediastinal
invasion unless a chest wall mass, rib destruction, or gross
encasement of mediastinal structures is present.52–54 The
overall accuracy of CT in confirming invasion has been
reported to be 39 to 86%.12,54 –58 An advantage of MRI in
evaluating chest wall invasion is its superior soft-tissue
contrast resolution and multiplanar capability.59,60 MRI
has sensitivity (63 to 90%) and specificity (84 to 86%)
similar to CT,12,61,62 but is better than CT when findings
are equivocal.56,63 MRI is particularly useful in evaluation
of superior sulcus tumors, as CT is limited by its axial
format and streak artifacts from the shoulders. In this
setting, MRI can accurately assess the extent of local
invasion, including brachial plexus and subclavian vessel
involvement.56,59,61,64 – 66 Vertebral body marrow invasion, a
finding that would preclude resection, is also optimally
assessed by MRI.65
CT and MRI have similar accuracies in diagnosing
mediastinal involvement (56 to 89% and 50 to 93%,
respectively), although MRI has been shown by the
Radiologic Diagnostic Oncology Group trials to be slightly
better.56,61,67– 69 T1-weighted images optimally demonstrate tumor invasion of mediastinal fat, and mediastinal
involvement adjacent to a hilar mass is easier to determine
at MRI due to contrast between the neoplasm and flow
void in vessels.65,70
Nodal Disease (N Status): CT and occasionally MRI
are used to evaluate the hilar and mediastinal lymph
nodes. Size, unfortunately a nonspecific criterion, is the
only criterion used in attempting to distinguish normal
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from abnormal lymph nodes (short axis ⬎ 1 cm is considered
abnormal).71 Lymph node morphology and MRI signal characteristics are not useful in predicting lymph node metastases.12 Although CT and MRI are very accurate in demonstrating enlarged lymph nodes, the cause of enlargement may
be reactive hyperplasia, not metastasis, particularly if there is
a postobstructive pneumonia.64,72 The accuracy of CT and
MRI for detecting metastatic hilar (N1) disease is only 62 to
68% and 68 to 74%, respectively.67,73 This low accuracy of
radiographic staging of N1 metastatic disease, in most cases,
does not prevent surgical resection unless the patient is a
poor surgical candidate.12,72
The limitation of chest radiographs and CT/MRI, their
dependence on morphologic and anatomic findings, may
occasionally be overcome by FDG-PET imaging (Fig 1).6,7
PET has recently been demonstrated to be more accurate
than CT in diagnosing the presence of intrathoracic
metastatic nodal disease (81% and 52%, respectively).6,74
In another study, large nodes at CT were shown to be
nonmetastatic in 100% of patients when the nodes were
not FDG avid. In addition, the positive predictive value
for metastases was 100% for CT-detected small nodes that
had intense FDG uptake.75
Metastatic Disease (M Status): Common sites of metastases are lymph nodes as described above; brain and
CNS, bone, and adrenal gland metastases and metastases
to the contralateral lung are considered M1 disease.56
Initiating a radiologic investigation for metastatic disease is
often based on the clinical history, physical examination,
and blood indexes (CBC count, alkaline phosphatase, liver
Figure 1. Top, left: Posteroanterior chest radiograph of 66-year-old man who presented with a cough,
demonstrating an irregular 3.5-cm mass in the right base (arrow). Top, right: Coronal whole body PET
image demonstrates significant FDG uptake in the right lower lobe mass (arrow). In addition, there is
a smaller area of increased uptake in the right humerus and a second small area of abnormal uptake in
the right apex. The patient had no signs of bony or metastatic disease, although plain radiographs of the
right arm initiated from the PET study demonstrate a small lytic lesion in the right humerus consistent
with metastasis. Note is made of expected increased FDG activity in the left wrist at the injection site,
and in the kidneys and bladder from FDG excretion. Bottom, left: Axial CT image through the dome
of the liver demonstrates a small low attenuation area in the liver (arrow) and slight soft tissue fullness
in the right adrenal gland (arrow head). Bottom, right: Axial PET image at the same level demonstrates
significant FDG uptake in both the liver lesion (arrow) and adrenal mass (arrow head), consistent with
metastatic disease.
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function tests).49,76 Routine radiologic evaluation for occult metastases in the absence of clinical or laboratory
findings is not clearly indicated.49,50,56,76
Isolated CNS metastases are rare in patients with
NSCLC and are generally associated with an abnormal
neurologic examination.56,77 Asymptomatic brain metastases occur in 2.7 to 9.6% of patients usually with large cell
carcinomas and adenocarcinoma. The use of routine CT or
MRI of the CNS in asymptomatic patients with NSCLC is
controversial.77– 80
Patients with bone metastases are usually symptomatic
(pain) or have suggestive laboratory abnormalities (eg,
elevated alkaline phosphatase).80 Bone radiographs, radionuclide bone scanning with 99 technetium-methylene
diphosphonate or MRI are useful modalities for further
investigation.49 Occult skeletal metastases are rarely (up to
4%) detected by radionuclide 99 technetium-methylene
diphosphonate studies, but there is a high false-positive
rate (approximately 40%).76,77,79,80 Thus, routine radionuclide skeletal imaging should not be performed in
NSCLC.
Adrenal metastases do not produce reliable clinical and
laboratory findings; thus, upper abdominal imaging is
routinely performed, especially as part of thoracic CT
staging. Incidental nonfunctioning cortical adenomas occur in 3 to 5% of the population, and approximately 10%
of patients with NSCLC will have an adrenal mass at
CT.56,81,82 In the absence of other known extrathoracic
metastases, an adrenal mass is more likely benign. Attenuation values ⱕ 10 are virtually pathognomonic benign
adrenal enlargement.56,81 CT and MRI are similar in
detecting hepatic metastases, although isolated liver metastases are extremely uncommon and routine liver imaging is not usually suggested.50,83,84
SCLC
Radiologic staging of SCLC may help in determining
prognosis and in treatment planning.85 A two-stage classification proposed by the Veteran’s Administration Lung
Cancer Study Group separating patients into limited or
extensive disease groups has proven useful.86 Limited
disease is defined as tumor within a single radiotherapy
port (tumor confined to the thorax). Extensive disease
includes distant metastases and noncontiguous metastases
to the contralateral lung.48,86 Long-term survival occurs
primarily with limited disease and is rare with extensive
disease.86
Extensive disease is present at presentation in 60 to
80% of patients with SCLC.56,85,87,88 Metastases commonly
occur in the liver (22 to 28%), bone (30 to 38%), bone
marrow (17 to 25%), brain (8 to 15%), and retroperitoneal
lymph nodes (11%).85– 89 Conventional clinical and radiographic evaluation of extrathoracic metastatic disease usually includes bone marrow aspiration, radionuclide bone
scan, and CT or MRI of the brain and abdomen.56,85,90
MRI alone has recently been used as an accurate staging
modality for liver, adrenals, brain, and axial skeleton. Liver
function tests can be normal with hepatic metastases, and
25% of patients presenting with hepatic metastatic disease
will not have involvement of other organs.86 Abdominal
CT or ultrasound should be done routinely in the staging
evaluation of SCLC.86 MRI may be more sensitive than
contrast-enhanced CT in detecting hepatic metastases,
and similar to CT in evaluation of adrenal metastases.85
Isolated bone and bone marrow metastases are uncommon and are usually associated with involvement of other
organs.86,90 These patients often have no focal bone pain,
and alkaline phosphatase and peripheral blood findings
are usually normal.86,90 Consequently, if there are extrathoracic metastases, further evaluation should include a
radionuclide bone scan and bone marrow aspiration. MRI
may be more sensitive than bone scintigraphy in detecting
small and rapidly growing metastases with marrow infiltration.85,91
CNS metastases are common at presentation and as a
site of future disease.86 Routine CT or MRI evaluation of
the CNS is recommended, as approximately 5% of patients with cerebral metastases are asymptomatic.92 In
NSCLC, 2.7 to 9.6% are symptomatic and use of imaging
is controversial. Detection and treatment with aggressive
chemotherapy and radiotherapy can decrease morbidity
and improve prognosis if the brain is the only site of
extrathoracic disease.86
Conclusion
Current imaging for bronchogenic carcinoma makes
use of plain chest radiographs, CT, MRI, and nuclear
medicine. Most studies are designed to detect anatomic
abnormalities, leading to some problems in sensitivity and
especially specificity. In the future, imaging may be
directed more at tumor biology (molecular and genetic
targets), and perhaps then will have a greater impact on
this devastating disease.
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