PULMONARY NEOPLASMS
THE SOLITARY PULMONARY NODULE
• One must determine whether a focal opacity seen on the chest radiograph
is real or artifactual.
• E orts should be made to ascertain whether it is truly intrathoracic, which
should begin with a careful review of a lateral radiograph to localize the
opacity.
• Densities seen on only a single view may re ect arti- facts, skin, chest wall
or pleural lesions, or true intrapulmo- nary nodules.
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• Often a limited chest CT focused on the area in question on the chest
radiograph is necessary to de nitively delineate the location and nature of
a focal nodular radiographic opacity.
• Comparison chest radiographs, when available, should be reviewed to
determine whether nodular opacities were evident previously.
• An opacity completely stable in size for more than 2 years is considered
benign and further evaluation is unnecessary.
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• If there is any concern that a nodule previously seen has enlarged, a chest
CT should be obtained for further characterization.
• Once a new or enlarging SPN has been identi ed, the radi- ologist should
initiate a series of investigations to determine whether the nodule has
features that are de nitely benign, highly suspicious for malignancy, or
lacking clear benign or malignant features and therefore indeterminate.
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CLINICAL FACTORS
• In a patient younger than 35 years, particularly a nonsmoker without a
history of malignancy, an SPN is invariably a granuloma, hamartoma, or
in ammatory lesion.
• Patients older than 35 years, particularly those who are current or recent
cigarette smokers, have a signi cant incidence of malignant SPNs
• Alternatively, if the patient is from an area where histoplasmosis or
tuberculosis is endemic, the likelihood of a granuloma is greater.
• The nding of an SPN in a patient with an extrathoracic malignancy raises
the possibility of a solitary pul- monary metastasis
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GROWTH PATTERN
• The growth rate of an SPN is usu- ally expressed as the doubling time, or
the time it takes for a nodule to double its volume.
• Although some benign lesions (mostly hamartomas and histoplasmomas)
may exhibit a growth rate similar to that of malignant lesions, the absence
of growth or an extraordinarily slow or rapid rate of growth of a solid
nodule is reliable evidence that an SPN is benign.
• Therefore, a doubling time of less than 1 month or greater than 2 years
reliably characterizes a solid lesion as benign.
ALGORITHM FOR IMAGING EVALUATION OF AN
SPN
SIZE
• Although size does not reliably discriminate benign from malignant SPNs,
the larger the lesion, the greater the likelihood of malignancy.
• Masses exceeding 4 cm in diameter are usually malignant.
BORDER/MARGIN CHARACTERISTICS
• A round, smooth nodule is most likely a granuloma or hamartoma,
although a rare primary pulmonary malignancy such as a carcinoid tumor,
adenocarcinoma, or a solitary metastasis may have a perfectly smooth
margin.
• A notched or lobulated contour may be seen in hamartomas, but
malignant lesions including carcinoid tumors and some bronchogenic
carcinomas will have a lobulated border.
• A spiculated margin is highly suspicious for malignancy
DENSITY
• The internal density of an SPN is probably the single most important
factor in characterizing the lesion as benign or indeterminate.
• In general, lesions that are calci ed are benign.
• Complete or central calci cation within an SPN is speci c for a healed
granuloma.
• Concentric or laminated calci cation indicates a granuloma.
• Popcorn calci cation within a nodule is diagnostic of a pul- monary
hamartoma in which the cartilaginous component has calci ed.
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• The identi cation of fat within an SPN is diagnostic of a pulmonary
hamartoma.
• Air bronchogram or bubbly lucencies within an SPN is highly suspicious
for adenocarcinoma, particularly bronchioloalveolar cell subtypes.
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CONTRAST-ENHANCED CT
• Virtually all malignant lesions demonstrate an increase in attenuation of
greater than 15 H after contrast administration.
• Therefore, lack of signi cant (>15 H) enhancement of a solid nodule 6 to
30 mm in diameter after IV iodinated contrast e ectively excludes
malignancy.
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CONTRAST CT
BRONCHOGENIC CARCINOMA
• Adenocarcinoma is the most common type of lung cancer, accounting
for approximately one-third of all bronchogenic carcinomas.
• It is the most common subtype of lung cancer in nonsmokers.
• These tumors arise from the bronchiolar or alveolar epithelium and have
an irregular or spiculated appearance where they invade adjacent lung.
• Fibrosis in and about the tumor is common.
• These gross features usually produce an ill-de ned pulmonary nodule or
mass on chest radiographs
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ADENOCARCINOMA
SQUAMOUS CELL CARCINOMA
• The second most common subtype of bronchogenic carcinoma,
accounting for approximately one-fourth of all cases
• This tumor arises centrally within a lobar or segmental bronchus.
• Grossly, these tumors are polypoid masses that grow into the bronchial
lumen while simultaneously invading the bronchial wall.
• Central necrosis is common in large tumors; cavitation may be seen if
communication has occurred between the central portion of the mass and
the bronchial lumen
SQUAMOUS CELL CARCINOMA
SMALL CELL CARCINOMA
• Accounts for 25% of bronchogenic carcinomas and arises centrally within
main or lobar bronchi.
• Small cell carcinomas exhibit a small endo- bronchial component,
invading the bronchial wall and peribronchial tissues early in the course of
disease.
• This produces a hilar or mediastinal mass with extrinsic bronchial
compression and obstruction
• Invasion of the submucosal and peribronchial lymphatics leads to local
lymph node enlargemen
SMALL CELL CARCINOMA
LARGE CELL CARCINOMA
• Accounts for 15% of bronchogenic carcinomas and is occasionally
diagnosed when a non-small cell bronchogenic carcinoma lacks the
histologic characteristics of squamous cell carcinoma or adenocarcinoma.
• This tumor tends to arise peripherally as a solitary mass and is often large
at the time of presentation
• It is similar to adenocarcinoma in its radiologic characteristics (except for
its large size) and behavior.
ADENOCARCINOMA
LEPIDIC PREDOMINANT ADENOCARCINOMA
SQUAMOUS CELL CARCINOMA
SMALL CELL CARCINOMA
SMALL CELL CARCINOMA
LARGE CELL CARCINOMA
CARCINOID TUMOR
• Carcinoid tumors originate from neuroendocrine cells in the bronchial wall.
• Typical carcinoid tumors occur most commonly in patients 40 to 60 years
of age (mean age, 45 to 55).
• Approximately 80% of typical carcinoid tumors occur centrally, in the
main, lobar, or segmental bronchi.
• These tumors are highly vascular, and hemoptysis is a common presenting
complaint.
• Nearly half of typical carcinoid tumors are associated with radiographic ndings
of bronchial obstruction, primarily atelectasis or consolidation, typically limited to
a lobe or segment.
• Central tumors, with or without ndings of obstruction, may be visible as discrete
mass lesions in or near the hila.
• In many cases, these tumors have a large endobronchial component and appear
on CT as intraluminal masses with a convex margin pointing toward the hilum.
• Because they are highly vascular, dense enhancement may be seen on CT
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CARCINOID TUMOR
PULMONARY HAMARTOMA
•
PULMONARY HAMARTOMA WITH AREAS OF FAT
ATTENUATION
HEMATOGENOUS METASTASES
• May be seen with any tumor that gains access to the SVC, inferior vena
cava, or thoracic duct, because the PA is the nal common pathway for
these channels.
• Pulmonary nodules are the most common manifestation of hematogenous
metastases to the lung.
• They are most commonly seen in carcinomas of the lung, breast, kidney,
thyroid, colon, uterus, and head and neck.
• Carcinomas of the rectosigmoid colon, osteogenic sarcoma, renal cell car-
cinoma, and melanoma are more likely to result in solitary pulmonary
metastases. fi
• Nodular pulmonary metastases are usually smooth or lobulated lesions
that are found in greater numbers in the peripheral portions of the lower
lobes because of the greater pulmonary blood ow to these regions.
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MULTINODULAR PULMONARY METASTASES
