Thoracic Imaging 2003 - Society of Thoracic Radiology

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SUGGESTED READING: Creasy JD, Chiles C, Routh WD, Dyer RB: Overview of traumatic injury of the thoracic aorta. Radiographics 1997; 17:27-45. Gaerte SC, Meyer CA, Winer-Muram HT, et al: Fat-containing lesions of the chest. Radiographics 2002;22: S61-S78. Jeung MY, Gasser B, Gangi A, et al: Imaging of cystic masses of the mediastinum. Radiographics 2002; 22: S79-S93. Proto AV: Conventional chest radiographs: Anatomic understanding of newer observations. Radiology 1992; 183: 593-603. Proto AV, Corcoran HL, Ball JB Jr; The left paratracheal reflection. Radiology 1989;171:625-628. Rossi SE, McAdams HP, Rosado-de-Christenson, et al; From the Archives of the AFIP: Fibrosing Mediastinitis. Radiographics 2001; 21: 737-757. 187 TUESDAY
Unusual Manifestations of Lung Cancer Michelle S. Ginsberg, M.D. Objective The common cell types of lung cancer have certain typical radiographic appearances which will be briefly discussed. However it is important to be familiar with the more unusual presentations as well. The purpose of this review is to suggest the correct diagnosis of bronchogenic carcinoma when the radiographic manifestations of a particular tumor are rare, mimic benign disease, or suggest disease of organs other than the lung. The appearance of missed lung cancer, and means of improving detection of these lesion will also be discussed. Adenocarcinoma Adenocarcinoma is the most common cell type of bronchogenic carcinoma and accounts for approximately 50% of cases. CT usually demonstrates a solitary peripheral pulmonary nodule. The nodule may be smooth or spiculated. Hilar and mediastinal lymph node involvement and distant metastases are frequently present at the time of diagnosis. Peripheral tumors may directly invade the pleura and grow circumferentially around the lung and mimic diffuse malignant mesothelioma. 1 Central tumors may directly invade mediastinal structures or via the pulmonary veins invade the left atrium. Bronchioloalveolar carcinoma Bronchioloalveolar carcinoma is considered a subtype of adenocarcinoma and commonly presents as a solitary nodule. 2 There may also be surrounding ground glass opacity. Cavitation an infrequent finding in adenocarcinoma may be seen in bronchioloalveolar carcinoma. 3 Although less common, consolidation and multiple small pulmonary nodules are other forms of presentations. 3 High-resolution CT may demonstrate air attenuation and pseudocavitation within the nodules corresponding to small bronchi and cystic spaces. 4 Unusual radiographic appearances include lobar atelectasis, expansile consolidation without air bronchograms, or elongated lobulated opacity resembling mucoid impaction. 5,6 Squamous cell carcinoma Squamous cell carcinoma most often presents as a central endobronchial obstructing lesion with associated atelectasis or post obstructive pneumonia. Less commonly approximately a third of these tumors may present as a solitary peripheral nodule with or without cavitation. 7 When the tumor cavitates, the inner wall is typically thick and irregular, and if secondarily infected may develop an air fluid level. Undifferentiated large cell carcinoma Undifferentiated large cell carcinoma usually presents as a large peripheral lesion, although a smaller proportion may also be centrally located. These tumors grow rapidly and metastasize early often presenting with hilar or mediastinal adnopathy. Giant-cell carcinoma is a subtype with multiple giant cells and a more aggressive behavior and poorer prognosis. Multiple primary carcinomas Synchronous lesions are defined as the presence of two tumors at the time of or closely following initial diagnosis. The incidence of synchronous multiple primary tumors is less than 3.5% of all lung cancer patients. 9 This number may even be higher depending on the cell type and how carefully further primary tumors are sought as well as the rigidity of the criteria used to define the tumors as primary lesions. Difference in cell type is an accepted criteria, however tumors of the same histologic type must be physically quite separate as well as separated by noncancerous lung tissue. 9,10 Metachronous lesions are defined as the second cancer appearing after a time interval, usually 12 months or more. These lesions compromise at least two thirds of multiple pulmonary neoplasms, and on average are recognized 4 to 5 years after the first primary. 10%-32% of patients surviving resection for lung cancer may develop a second primary tumor. 9 These lesions are regarded as multiple primary lesions only if they show unique histologic features. Squamous cell cancer is the most common histologic type of multiple carcinomas. Metastases The adrenal glands are one of the most common sites of metastases from lung cancer ranging from 5-10% of the time at presentation. In our experience we have also seen two cases of a mass within the adrenal gland that represented a collision tumor consistent of contiguous adrenal adenoma and metastasis. Lung cancer may present with unusual sites of metastases. For example the gallbladder an unusual site of metastatic disease in general can be the site of a lung metastasis. The kidneys, pancreas and small bowel may also be sites of metastases and may be radiographically indistinguishable from a primary tumor of that organ. Serosal and mesenteric implants may become quite large. Invasion with perforation of the adjacent bowl may result in a large mass with air within it having an appearance indistinguishable from an abscess. Muscle and subcutaneous tissues are other infrequent sites of metastases from bronchogenic cancer. Missed lung cancer A missed lung cancer is unusual by virtue of the fact that it was not detected. In contrast, most usual ones are detected when in "easy" areas of lungs on a chest radiograph or CT. Potentially resectable NSCLC lesions missed at chest radiography were characterized by predominantly peripheral (85%) and upper lobe (72%) locations and by apical and posterior segmental/subsegmental locations in an upper lobe (60%). The missed cancers had a median diameter of 1.9 cm. Most of these missed lesions (98%) were obscured by anatomic structures on the chest radiograph, most often by bones (ribs and clavicle). Only the lateral radiograph revealed the cancer retrospectively in 5% of patients. 11 Although chest CT is more sensitive for the detection of lung nodules than chest radiographs, the potential for missing small lung cancers at CT exists. A recent study by Li et al. evaluated 193 TUESDAY
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The Society of Thoracic Radiology T
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Dear Friends, Welcome to Miami Beac
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Continuing Medical Education Credit
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Warren B. Gefter, MD University of
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Ernest M. Scalzetti, MD SUNY Upstat
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Registration Hours Saturday, March
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Program Committee Ella A. Kazerooni
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Small Airway Disease Americana 3 Mo
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Benjamin Felson Memorial Lecture Am
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Session 2-B Concurrent Session Clin
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Workshops (choose 1) 1:00 - 1:45 D1
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Sunday
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March 2, 2003 General Session Sunda
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SUNDAY 46 One type of direct-readou
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CT-PET Imaging Suzanne Aquino, M.D.
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SUNDAY 58 an accompanying decreased
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SUNDAY 60 Radiofrequency Ablation i
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SUNDAY 62 17. Sewell PE, Vance RB.
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SUNDAY 64 cal ventilation will be r
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SUNDAY 66 radiologic, and histopath
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SUNDAY 68 application. The untreate
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SUNDAY 70 The Expanded Spectrum of
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SUNDAY 72 Hypersensitivity Pneumoni
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SUNDAY 74 Small Airway Diseases Mic
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SUNDAY 76 The “Head-cheese Sign
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SUNDAY 78 “Holes” in the Lung:
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SUNDAY 80 Pleural Effusions Gerald
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SUNDAY 82 Asbestos Related Pleural
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SUNDAY 84 Other Pleural Neoplasms S
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SUNDAY 86 Image-Guided Therapy of M
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Notes 88
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March 3, 2003 General Session 7:00
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Cardiac MRI: Established Indication
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Cardiac MRI: New Developments Gauth
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5. The volume of contrast medium re
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Acute Aortic Syndrome Ernest M. Sca
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as well as separation of the cusps
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Pulmonary Veins: Imaging for Radiof
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Imaging of Cardiopulmonary Support
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plied to the hollow fibers by an ex
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swelling of the entire leg, calf sw
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Multi-channel Pulmonary CTA: New Te
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terminate scintigrams, CT correctly
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CT Strucural and Functional Imaging
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curves (TDCs) are generated by manu
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7. Crawford T, Yoon C, Wolfson K, e
Page 93 and 94: 80. Fleischmann D, Rubin GD, Bankie
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Page 97 and 98: 129 MONDAY
Page 99 and 100: REFERENCES Bergin CJ, Rios G, King
Page 101 and 102: Notes 134
Page 103 and 104: March 4, 2003 General Session 7:00
Page 105 and 106: Adult Manifestations of Congenital
Page 107 and 108: will usually display the limbs of t
Page 109 and 110: Imaging of the Pericardium Paul L.
Page 111 and 112: Cardiomyopathy Martin J. Lipton, M.
Page 113 and 114: TUESDAY 150 Nuclear Cardiology Upda
Page 115 and 116: TUESDAY 152 ties. The predominant 1
Page 117 and 118: TUESDAY 154 Imaging protocols: Util
Page 119 and 120: Manpower Shortage in Radiology: Sol
Page 121 and 122: 159 TUESDAY
Page 127 and 128: NIBIB Update for Thoracic Radiology
Page 129 and 130: vertically along the right atrium t
Page 131 and 132: Multidetector Pediatric Chest CT: P
Page 133 and 134: The Spectrum of Pulmonary Infection
Page 135 and 136: Immune deficiency occurs frequently
Page 137 and 138: TUESDAY 180 The Internet and the Pr
Page 139 and 140: TUESDAY 182 Workshop A1: Lymphoma:
Page 141 and 142: TUESDAY 184 Digital Images: Camera
Page 143: TUESDAY 186 Analysis of Mediastinal
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Page 149 and 150: March 5, 2003 General Session Wedne
Page 151 and 152: WEDNESDAY 208 principle is that “
Page 153 and 154: WEDNESDAY 210 years and a current o
Page 155 and 156: WEDNESDAY 212 lesions generally mim
Page 157 and 158: WEDNESDAY 214 capable of studying t
Page 159 and 160: WEDNESDAY 216 Small T1 Lung Cancer:
Page 161 and 162: WEDNESDAY 218 REFERENCES Seely JM,
Page 163 and 164: WEDNESDAY 220 Therefore, radiologis
Page 165 and 166: WEDNESDAY 222 sectional area varies
Page 167 and 168: WEDNESDAY 224 Lung Cancer Staging A
Page 169 and 170: Metastatic Disease to Lung Gordon L
Page 171 and 172: Thoracic Metastates from Osteosarco
Page 173 and 174: STR tutorial: Use of MD CT reconstr
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Page 177 and 178: WEDNESDAY 236 Pulmonary Arterial Hy
Page 179 and 180: WEDNESDAY 238 pathological process,
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Page 183 and 184: THURSDAY 250 Pulmonary Tuberculosis
Page 185 and 186: THURSDAY 252 1. Clinical criteria:
Page 187 and 188: THURSDAY 254 AIDS patients are also
Page 189 and 190: THURSDAY 256 Viral Infection on HRC
Page 191 and 192: THURSDAY 258 Imaging of Coccidioido
Page 193 and 194: THURSDAY 260 from the laryngeal sur
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THURSDAY 262 Inflammatory Diseases
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Virtual Endoscopy in the Thorax: Pr
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Notes 269 THURSDAY
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SECOND LEVEL THIRD LEVEL
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