radiographic presentation of lung cancer

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Pediatric Care
Diseases and Conditions

Lung Cancer

Lung cancer usually forms in the cells lining air passages within the lungs. The two main types of lung cancer are called small-cell lung cancer and non-small-cell lung cancer.

Lung cancer is usually first detected by a radiologist on an imaging test. This may include a CT scan of your chest, a PET/CT or a chest x-ray. Sometimes the diagnosis is made via a bronchoscopy (where a lung doctor looks at your lung airways with a small camera) or a lab test looking at the cells in your sputum/spit. Most cases of suspected lung cancer will be confirmed with some sort of biopsy. This biopsy can be done via a bronchoscopy or by a radiologist using CT imaging guidance. Sometimes an endobronchial ultrasound is performed to view and sample lymph nodes in the central chest (mediastinum).

If you are diagnosed with lung cancer you may also have an MRI or CT scan of your brain. Treatment options depend on the extent of the disease and include surgery, radiation therapy and systemic therapy (chemotherapy, targeted therapy, or immunotherapy) or a combination thereof.

What is lung cancer?

How is lung cancer diagnosed and evaluated, how is lung cancer treated, which test, procedure or treatment is best for me.

Lung cancer forms in tissues of the lung, usually in the cells lining air passages.

Lung cancer is the leading cause of cancer deaths in the United States and worldwide. Approximately 85 percent of lung cancer tumors occur in current or former cigarette smokers. It is estimated that there are more than 94 million current and former smokers in the United States, many of whom are at high risk of developing the disease.

Besides cigarette smoking, other risk factors of lung cancer can include:

Exposure to second hand smoke
Exposure to asbestos or radon gas

Typical symptoms of lung cancer depend on the location and extent of the cancer but can include:

Shortness of breath
Chronic coughing
Coughing up blood
Chronic shoulder pain
Voice hoarseness
Difficulty swallowing
Unexplained weight loss
Unusual bone pain

In most cases of early lung cancer, there are no symptoms, and the cancer may be discovered on imaging tests performed for unrelated reasons. If the lung cancer has spread to the brain, you may also experience blurred vision, seizures, headaches and/or symptoms of stroke.

There are two main types of lung cancer, each of which has different microscopic appearances:

Small-cell lung cancer (SCLC) is usually found in active or former cigarette smokers. Although SCLC is a less common type of lung cancer, it is a more aggressive tumor that is more likely to spread to other body sites.
Non-small-cell lung cancer (NSCLC) tends to grow more slowly and takes longer to spread beyond the lung.

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Your primary doctor will begin by asking you about your medical history, risk factors and symptoms. You will also undergo a physical exam.

Before there are even symptoms of the disease, eligible patients undergo regular lung cancer screening in which one or more of the following imaging tests may be performed:

Low-dose computed tomography (LDCT) : CT scanning combines special x-ray equipment with sophisticated computers to produce multiple, cross-sectional images or pictures of the inside of the body. LDCT produces images of sufficient quality that may detect many lung diseases and abnormalities using up to 90 percent less ionizing radiation than a standard chest CT scan .
Chest x-ray : An x-ray exam will allow your doctor to see your lungs, heart and blood vessels and is often the first imaging test performed when there are symptoms of lung cancer. This noninvasive medical test provides views from the back to the front as well as from the side.
Sputum Cytology : This diagnostic test examines a sample of sputum (coughed-up mucus) under a microscope to determine whether abnormal cells are present.

Other imaging tests that may be performed to evaluate the extent of lung cancer include:

CT of the chest : A CT scan may be done to see finer details within the lungs and detect tumors that may be more difficult to see on a routine x-ray. It also is used to perform a detailed assessment of abnormalities that are detected but not fully evaluated with LDCT. CT is the main imaging test for the assessment of lung cancer. A CT scan of the abdomen and pelvis may also be performed.
PET/CT Scan : This is a test that uses both PET and CT and a small amount of radioactive material (fluorodeoxyglucose or FDG) to help determine the extent of lung cancer after it has been diagnosed and to assess the lung cancer after treatment.
Bronchoscopy : A visual inspection of the inside of the airways (trachea and the bronchial tree) of the lungs, using a rigid or flexible tube.
Endobronchial ultrasound: An ultrasound probe is used during bronchoscopy to visualize and sample lymph nodes.
MRI of the brain: In more advanced stages of lung cancer, an MRI of the brain is performed to evaluate for potential tumor spread to the brain.
MRI of the chest : MRI of the chest is uncommonly used in lung cancer. It gives detailed pictures of the mediastinum , chest wall, pleura, heart and blood vessels. It can assess characteristics of tumors, including cancer of the lungs or other tissues, which are not fully assessed with other imaging modalities (typically CT) or when there are contraindications to the use of standard imaging tests.

If an area of concern is suspected to be benign by these exams, no further steps may be needed. Your doctor may want to monitor the area at future visits to check if the tumor has changed, grown or dissolved.

If these tests suggest that the abnormal cells in question are lung cancer, a biopsy may be necessary. A lung biopsy is the removal of lung tissue in order to examine it for the presence of abnormal cells. Biopsies are performed in several different ways. Some biopsies involve removing a small amount of tissue with a needle while others involve surgically removing an entire lump, or nodule, that is suspicious.

Often, the tissue is removed by placing a needle through the skin to the area of abnormality, a procedure called needle biopsy of the lung . This procedure involves removing several small samples from your lung(s) and is extremely safe and effective.

About one-third of lung cancer patients are diagnosed with localized disease that may be treated by either surgical resection or, if the patient is not a candidate for full surgical resection or desires a non-invasive approach, with radiation therapy. Very early stage disease can be treated with stereotactic body radiation therapy (SBRT) as an alternative to surgery in elderly or frail people or people who refuse surgery. Another third of patients have disease that has already spread to the lymph nodes. In these cases, radiation therapy along with chemotherapy is used and occasionally surgery is performed. The remaining third of patients may have tumors that have already spread to other parts of the body via the blood stream and are typically treated with chemotherapy and sometimes with radiation therapy for the relief of symptoms.

It is important to choose an overall treatment plan that is appropriate and customized for an individual patient. After diagnosis, treatment planning for lung cancer often involves consultations with doctors from different specialties including diagnostic radiology, thoracic surgery, radiation oncology, and medical oncology. The type of treatment chosen determines which of the doctors will treat the patient.

Lobectomy , the removal of an entire lobe of the lung, is an accepted procedure for removing lung cancer when the lungs are functioning well. The mortality risk is less than three percent to four percent and tends to be highest in older patients. There are three lobes on the right (upper, middle and lower) and two on the left (upper and lower).
Sublobar resection may be referred to as either a "wedge resection" or a "segmentectomy." If lung function prohibits lobectomy, or a tumor is very small, sublobar resection may be performed in which a small cancer confined to a limited area may be removed with a small portion of surrounding lung tissue. Sublobar resection carries a higher risk for recurrence than lobectomy. Sublobar resections are associated with less loss of lung function when compared to lobectomy, as a smaller portion of lung is removed. They carry an operative mortality risk of 1.4 percent. Not all small tumors can be removed by sublobar resections. Usually, these are deep in the middle of the lobe.
Pneumonectomy: If the entire lung must be taken out by "pneumonectomy", the expected mortality rate is higher (5–8 percent) with the oldest patients being at highest risk. This happens when tumors are very large or are very close to the large blood vessels (pulmonary artery or vein) of the chest or the mainstem bronchi.
Mediastinoscopy: A mediastinoscopy is performed through a small incision in the lower neck above the breast bone (sternum) and is used to sample the lymph nodes in the central chest (mediastinum). An alternative to mediastinoscopy is an endobronchial ultrasound (EBUS).
As primary treatment
Before surgery to shrink the tumor
After surgery to eliminate any cancer cells that remain in the treated area
To treat lung cancer that has spread to the brain or other areas of the body

Besides attacking the tumor, radiotherapy can help to relieve some of the symptoms the tumor causes such as shortness of breath. When used as an initial treatment instead of surgery, radiotherapy may be given alone or combined with chemotherapy. Today, many patients who have a small localized lung cancer, but who are not candidates for surgery, are being treated with a radiation treatment technique known as stereotactic body radiation therapy (SBRT). Patients who are poor candidates for surgery include the elderly, patients with chronic heart failure, and patients receiving a blood thinning drug that puts them at risk of surgical bleeding. SBRT involves treatment with many small, focused radiation beams or an arc of radiation therapy delivered while tracking the lung tumor along with its movement during breathing, typically in three to five treatments. This treatment delivers very high doses of radiation therapy to the tumor in patients where surgery is not an option or might produce a suboptimal outcome such as in the case of sublobar resection. SBRT is primarily used in the setting of early stage, localized disease. See the Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT) page for more information on SBRT.

Radiation therapy is typically delivered by the external beam technique, which aims a beam of x-rays directly at the tumor. Treatment is given in a series of sessions, or fractions, usually over six to seven weeks for conventional treatments, and over one to five treatments for patients that can be treated with SBRT. For more detailed information see the External Beam Therapy (EBT) page . Three-dimensional conformal radiation therapy and intensity-modulated radiation therapy (IMRT) and SBRT are radiation techniques based on a 3-D image or 4-D image of the tumor taken with a chest CT scan. This image serves as the target for a high-energy radiation beam that can change in shape and size to match the tumor. These methods minimize radiation exposure of nearby normal lung tissue and other critical structures such as the heart and spinal cord. Because your lungs move (with breathing), your doctor may also use image-guided radiation therapy (IGRT) and four-dimensional computed tomography (4D CT), which allows the radiation oncologist to obtain information on how your tumor moves while you breathe, to improve the precision and accuracy of the delivery of treatment. See the Intensity-Modulated Radiation Therapy (IMRT) page and the Image-Guided Radiation Therapy (IGRT) page for more information.

In brachytherapy , radiation is delivered directly to the site of disease. This is usually achieved either through a surgical procedure where, after resection of the primary tumor, radioactive seeds are sutured to the edge of the surgical resection. Also, in the setting of an obstructive tumor within an airway, radiation is delivered to the site of obstruction through a plastic tube that is temporarily inserted into the airway. This may help to relieve severe symptoms but does not cure the cancer. Not all centers perform brachytherapy for lung cancers and not all cancers are appropriately treated with brachytherapy.

Chemotherapy involves drugs that are toxic to cancer cells. The drugs are usually given by direct injection into an arm vein or through a catheter placed in a large central vein. See the Vascular Access Procedures page for more information.

In non-small cell lung cancer, chemotherapy is often given after surgery to eliminate microscopic disease. Chemotherapy also may slow tumor growth and relieve symptoms in patients who cannot have surgery. This treatment is used in all stages of lung cancer and can prolong life even in elderly persons as long as they are in good general health. Some chemotherapy drugs increase damage done to tumors by the radiation treatment of cancer cells. Others keep the tumor cells at a stage where they are most susceptible to radiation treatment or impair the ability of cancer cells to repair themselves after a course of radiation therapy. A combination of chemotherapy given during a course of radiotherapy is more effective than radiotherapy alone but has more side effects.

If chemotherapy is used, it is often to increase the effectiveness of surgery or radiotherapy. Different drugs may be used to treat NSCLC and SCLC. Plus, different types of chemotherapy may be used for different types of non-small cell lung cancer.

Chemotherapy may cause significant side effects, such as nausea or vomiting and damage to the white blood cells that are needed to combat infection, but there now are effective ways to at least partially counter and treat most of these effects. Every chemotherapy drug is different and has a different set of side effects.

Chemotherapy is the mainstay of the treatment for small cell lung cancer (SCLC). Radiation therapy is often used along with chemotherapy to treat lung tumors that have not spread beyond the chest or other organs. Surgery is not commonly used in SCLC due to the tendency of SCLC to spread quickly beyond the local area. While surgery is seldom used to treat patients with SCLC, it is occasionally used to obtain tissue samples for microscopic study to determine the type of lung cancer present. For small cell lung cancer, after treatment directed to the disease in the chest, the radiation oncologist may suggest radiation therapy directed at the brain even though no cancer has been found there. This is called prophylactic cranial irradiation and is given to prevent lung cancer metastases from forming at this vital site. In SCLC that has spread beyond the chest, radiation therapy can be recommended after chemotherapy as "consolidation" to the bulky areas of tumor or to the brain (PCI). It can also be used in SCLC to alleviate symptoms caused by tumor.

Targeted agents: Newer biologic agents, which may have fewer side effects than traditional chemotherapy – and in some instances may be just as effective – are being used in appropriate circumstances. Targeted therapies, newer drugs that work differently than regular chemotherapy, are designed to target mutations within NSCLC cells and inhibit growth. They may be used alone or in conjunction with regular chemotherapy.
Immunotherapy uses drugs that boost the patient's immune system to help control cancer. Some studies, but not all, have shown better survival rates when these drugs are given after surgery.

It is extremely important to remember that "inoperable" does not mean "incurable" when it comes to lung cancer. In fact, an increasing number of patients are being treated with a non-surgical approach across all stages of this disease. The effectiveness of the treatment depends on the stage of disease. In early stage inoperable disease treated with radiotherapy alone, control of disease is the norm. In more advanced disease, a combination of chemotherapy and radiation is delivered with curative intent. Cure rates are lower but still possible even with disease spread to the lymph nodes within the chest. Your physicians will often propose a combination of surgery, systemic therapy and/or radiation therapy as appropriate.

See the Lung Cancer Treatment page for more information.

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This page was reviewed on July 15, 2023

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5 Variable Imaging Presentations of Lung Cancer

10.1055/b-0038-149809 5 Variable Imaging Presentations of Lung Cancer Mark S. Parker Summary This chapter reviews the most common location and imaging characteristics of missed lung cancers as well as the variable imaging presentations of lung cancers. The newly revised classification system for adenocarcinoma of the lung is also discussed. Illustrative examples of adenocarcinoma in situ, minimally invasive adenocarcinoma, and invasive adenocarcinoma are provided. The concept of malignancy rate based on lesion morphology and doubling times is also presented. Keywords: missed lung cancers, adenocarcinoma, classification, atypical adenomatous hyperplasia, minimally invasive adenocarcinoma, adenocarcinoma in situ, invasive adenocarcinoma, lepidic, mucinous, solid, subsolid, ground glass, doubling time 5.1 Introduction On conventional chest radiography, the variable manifestations of lung cancer may be broadly characterized as indirect or direct. Indirect radiographic manifestations include atelectasis, often related to an endobronchial lesion or extrinsic compression of the airway by adjacent lymphadenopathy and nonresolving pneumonia-airspace disease. Direct radiographic manifestations of lung cancer may include a nodule(s) (< 3.0 cm diameter), mass (≥ 3.0 cm diameter), and parenchymal consolidation (▶ Table 5.1 ). Table 5.1 Variable radiographic manifestations of lung cancer Indirect signs Direct signs Atelectasis Nodule Nonresolving pneumonia-airspace disease Mass Focal consolidation 5.2 Location and Imaging Characteristic of Missed Lung Cancers As stressed earlier, conventional radiography is not the optimal screening tool for the early detection of lung cancer. Austin et al reported the vast majority of missed bronchogenic cancers on retrospective review occur in an upper lobe (81%) (3 upper lobe: 2 lower lobe), and in the right upper lobe in particular (56%) (3 RUL: 2 LUL). More missed lung cancers occurred in women (67%) than in men (33%). Other problematic radiographic regions where missed lung cancers occurred included the perihilar and paraspinal regions (▶ Fig. 5.1 ). The mean diameter of the missed lung cancer was 1.6 ± 0.8 cm (range: 0.6–3.4 cm). Shah et al revisited this topic in 2003 and again found that most missed potentially resectable primary lung cancers were located in the upper lobes (right: 45%; left: 28%; total: 72%), especially the apical and posterior segments or subsegments (60%). The clavicle obscured visualization of 22% of the missed cancers. The missed cancers had a median diameter of 1.9 cm. The high percentage (54–90%) and large average size (1.3–1.6 cm) of missed primary lung cancers on conventional chest radiographs have been reported in numerous additional studies. Potential contributing causes for failed radiographic detection include obscuration of the lesion from superimposed intrathoracic and extrathoracic structures such as the ribs, clavicles, hilar vessels, and the heart. Fig. 5.1 (a) Most frequent location of missed primary lung cancers on posteroanterior (PA) and (b) lateral chest X-ray. (Adapted with permission of Austin JH, Romney BM, Goldsmith LS. Missed bronchogenic carcinoma: radiographic findings in 27 patients with a potentially resectable lesion evident in retrospect. Radiology. 1992;182(1):115–122.) In 2002, Li et al reported 83 primary lung cancers were found during an annual low-dose computed tomography (LDCT) screen and confirmed at either biopsy or surgery. Thirty-two (38.6%) of these lung cancers were missed on 39 initial CT scans: 23 scans due to detection errors and 16 scans from interpretation errors. All of the missed lung cancers were intrapulmonary. Of these missed cancers, 88% were stage IA. All detection error cases involved adenocarcinomas. Eighty-five percent were well-differentiated lesions and 55% were in nonsmoking women. The mean size of missed cancers in this patient population was 9.8 mm. The mean size of missed lung cancers due to interpretation error was 15.9 mm. Ninety-one percent of the missed nodules in the detection error group were ground glass. In the detection error group, 83% of the missed lung cancers overlapped with or were obscured by similar-appearing adjacent normal structures such as pulmonary vessels. In all, 87.5% of CT scans with interpretation errors were associated with a background of concomitant complex disease. Most missed cancers tended to be central or endobronchial, adjacent to scars or vessels and of low attenuation. On LDCT, lung cancers may have a variable appearance. Lesions may appear as well-defined, solid noncalcified nodules, subsolid pure ground-glass, and as part-solid nodules. Additional morphologic features may include lobulation, concave notching, desmoplasia, pleural retraction, internal lucencies, and pericystic nodularity. These varying morphologic appearances will be illustrated in the remainder of this textbook. 5.3 Revised Adenocarcinoma Classification Non–small cell lung cancers (NSCLC) account for about 85% of all newly diagnosed lung cancers. Adenocarcinoma is the most common variety. The prevalence of adenocarcinoma is increasing and it presents more frequently in asymptomatic women, and often in nonsmokers. Recently, the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) introduced new terminology and diagnostic criteria to better reflect our understanding of the heterogeneous pathology, imaging features, and clinical behavior of peripheral lung adenocarcinomas (formerly known as bronchioloalveolar cell carcinoma). The new classification system clearly distinguishes between preinvasive, minimally invasive, and frankly invasive lung lesions (▶ Table 5.2 ). Table 5.2 New classification schema for lung adenocarcinoma (formerly bronchioloalveolar cell carcinoma) Pre-invasive lesions Minimally invasive lesions Invasive adenocarcinoma Invasive adenocarcinoma variants Atypical adenomatous hyperplasia (AAH) Minimally invasive adenocarcinomas (MIA; e.g., mucinous, nonmucinous, or mixed) Acinar predominant Invasive mucinous adenocarcinoma Adenocarcinoma in situ (AIS; e.g., mucinous, nonmucinous, or mixed) Papillary predominant Colloid, fetal, and enteric Micropapillary predominant Solid predominant with mucin production Lepidic predominant adenocarcinoma The imaging spectrum of these precancerous and cancerous lesions ranges from pure ground-glass nodules to part-solid nodules to solid nodules and masses (▶ Fig. 5.2 ). A pure ground-glass nodule manifests as a focal area of increased attenuation that does not obscure visualization of the underlying lung parenchyma (e.g., bronchovascular bundles; ▶ Fig. 5.3 a ; ▶ Fig. 5.4 ). A subsolid nodule is an opacity that is less dense than solid and is further subdivided into part solid and pure ground glass (▶ Fig. 5.2 ). A part-solid nodule contains both solid high-attenuation elements and ground glass (▶ Fig. 5.5 ). A solid nodule manifests as a focal region of increased attenuation through which normal bronchovascular structures cannot be seen or are completely obscured (▶ Fig. 5.6 ). Fig. 5.2 Characterization of lung nodules on low-dose computed tomography (LDCT) using the new classification schema. Fig. 5.3 (a) Low-dose computed tomography (LDCT) scan of an asymptomatic woman smoker reveals a 5-mm pure ground-glass lesion in the lingula. Imaging features are consistent with atypical adenomatous hyperplasia. (b) The diagnosis was subsequently proven at biopsy. Fig. 5.4 Low-dose computed tomography (LDCT) screening examination shows a 25-mm pure ground-glass opacity in the anterior segment of the right upper lobe. Diagnosis: adenocarcinoma in situ (AIS). Fig. 5.5 Low-dose computed tomography (LDCT) screening examination shows a part-solid nodule with a small central component measuring less than 5 mm characteristic of minimally invasive adenocarcinoma (MIA) in the posterior basal segment of the right lower lobe Fig. 5.6 (a,b) Selected axial and (c) coronal low-dose computed tomography (LDCT) images of a 60-year-old woman with a 40-pack-year history of tobacco abuse reveals an unsuspected invasive adenocarcinoma in the superior segment of the right lower lobe. Note the (a,c) polylobulated solid morphology, (a,c) associated desmoplasia, and (b) internal air bronchograms. Noguchi et al demonstrated that those patients with ground-glass nodular opacities identified on screening LDCT have a better prognosis than patients with solid nodules. Histopathologically, the ground-glass opacities show a lepidic growth pattern. More specifically, the cancer cells use the normal pre-existing alveolar septa as a “scaffold,” growing along it without invading the stroma, pleura, or vessels. The lung cancer–screening literature also shows a higher rate of malignancy in incidental part-solid nodules compared to incidental solid nodules.

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radiographic presentation of lung cancer

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Advances in Radiation Oncology in Lung Cancer pp 67–83 Cite as

Role of Radiologic Imaging in Lung Cancer

Salome Kukava 2 &
George Tsivtsivadze 2
First Online: 19 July 2022

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Part of the book series: Medical Radiology ((Med Radiol Radiat Oncol))

Computed tomography (CT) of the chest is the cornerstone of the diagnosis and staging of lung cancer. The advantages of CT in imaging the thorax are its cross-sectional format, superior density resolution, and wide dynamic range. Today’s CT scanners combine fast acquisition, fast data reconstruction, and very high spatial resolution. The aim of the current chapter is to review the role of contrast-enhanced MDCT in the diagnosis and staging of lung cancer and characterization of solitary pulmonary nodules.

Computed tomography
Contrast-enhanced computed tomography
Lung cancer
Staging of lung cancer

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Abbreviations

Left lower lobe

Left upper lobe

Non-small cell lung cancer

Response evaluation criteria in solid tumors

Right lower lobe

Right middle lobe

Right upper lobe

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Kukava, S., Tsivtsivadze, G. (2022). Role of Radiologic Imaging in Lung Cancer. In: Jeremić, B. (eds) Advances in Radiation Oncology in Lung Cancer. Medical Radiology(). Springer, Cham. https://doi.org/10.1007/174_2022_302

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v.31(5); 2022 Dec

Trends in Imaging Patterns of Bronchogenic Carcinoma: Reality or a Statistical Variation? A Single-Center Cross-Sectional Analysis of Outcomes

Ravikanth reddy.

a Department of Radiology, St. John's Hospital, Kattappana, India

Sandeep Reddy

b Department of Radiology, St. John's Hospital, Bengaluru, India

Associated Data

The data that support the findings of this study are not publicly available as they may contain information that could compromise the privacy of the participants but are available from the corresponding author Ravikanth Reddy upon reasonable request.

Introduction

Bronchogenic carcinoma accounts for more cancer-related deaths than any other malignancy and is the most frequently diagnosed cancer in the world. Bronchogenic carcinoma is by far the leading cause of cancer death among both men and women, making up almost 25% of all cancer deaths. The objective of this study was to identify the changing trends, if any, in radiological patterns of bronchogenic carcinoma to document the various computed tomography (CT) appearances of bronchogenic carcinoma with histopathologic correlation.

This was a single-center cross-sectional study on 162 patients with clinical or radiological suspicion of bronchogenic carcinoma with histopathological confirmation of diagnosis.

There was a male preponderance with bronchogenic carcinoma and smoking being the most common risk factor. Squamous cell carcinoma followed by adenocarcinoma and small cell carcinoma is the most common histologic subtype. Squamous cell carcinoma was noted to be present predominantly in the peripheral location (55.5%), and adenocarcinoma was noted to be present predominantly in the central location (68.4%).

CT is the imaging modality of choice for evaluating bronchogenic carcinoma and provides for precise characterization of the size, extent, and staging of the carcinoma. Among 162 bronchogenic carcinoma cases evaluated in the current study, a definite changing trend in the radiological pattern of squamous cell carcinoma and adenocarcinoma was observed. Squamous cell carcinoma was predominantly noted to be a peripheral tumor, and adenocarcinoma is predominantly noted to be a central tumor. Surveillance or restaging scans are recommended, considering the high mortality rate in patients with bronchogenic carcinoma.

Bronchogenic carcinoma is the leading cause of cancer death among both men and women, making up almost 25% of all cancer deaths.
Squamous cell carcinoma followed by adenocarcinoma is the most common histologic subtype.
Squamous cell carcinoma was noted predominantly in the peripheral location, and adenocarcinoma was noted predominantly in the central location.

Bronchogenic carcinoma accounts for more cancer-related deaths than any other malignancy and is the most frequently diagnosed cancer in the world [ 1 ]. Bronchogenic carcinoma is by far the leading cause of cancer death among both men and women, making up almost 25% of all cancer deaths [ 2 ]. The incidence in males has risen rapidly with each decade since the 1930s through the 1960s [ 3 ]. In women, the recent overall increase in incidence of bronchogenic carcinoma was mainly due to an increase in adenocarcinoma, which has been the predominant cell type in women [ 4 ]. Overall, the chance that a male will develop bronchogenic carcinoma in his lifetime is about 1 in 15; for a female, the risk is about 1 in 17 [ 5 ]. These numbers include both smokers and nonsmokers. For smokers, the risk is much higher, while for nonsmokers, the risk is lower [ 6 ]. Most people diagnosed with bronchogenic carcinoma are aged 65 or older; a very small number of people diagnosed are younger than 45 years of age [ 7 ]. The average age of patients when diagnosed with bronchogenic carcinoma is about 57 years [ 8 ]. Each year, more people die of bronchogenic carcinoma than of colon, breast, and prostate cancers combined [ 9 ]. Statistics on survival in people with bronchogenic carcinoma vary depending on the stage (extent of spread) of the cancer when it is diagnosed. Early diagnosis and prevention of bronchogenic carcinoma thus assumes a major public health issue in the current times.

Radiomics is an emerging method based on algorithms for data characterization, which allows the extraction of many features from medical images. By exploiting the information provided by such features, radiomic approaches aim to uncover and quantitatively describe tumor patterns and characteristics otherwise not observable through traditional algorithms for image analysis. Radiomics has shown a good ability to be considered as a potential new biomarker at different steps of patient care in the management of bronchogenic carcinoma from screening to treatment and follow-up [ 10 ]. Artificial intelligence (AI) refers to the use of a computer to simulate intelligent behavior with or without minor human intervention. In the case of bronchogenic carcinoma screening, machine learning, which is a branch of AI, provides algorithms as an aid for radiologists. Such techniques could serve as a computer-aided diagnosis for identifying candidate nodules and retrieving as much diagnostically relevant information as possible [ 11 ].

Imaging has a crucial role to play in the management of patients with bronchogenic carcinoma which ranges from staging in advanced disease to screening in high-risk individuals. Computed tomography (CT), in particular, is the imaging modality of choice for staging of bronchogenic carcinoma by evaluating the extent of mediastinal invasion and lymph nodal involvement [ 12 ]. The present study is aimed at evaluating the CT imaging characteristics of bronchogenic carcinoma with histopathological correlation (Table (Table1). 1 ). The purpose of this study was to identify the changing trends, if any, in radiographic patterns of bronchogenic carcinoma to document the various CT appearances of bronchogenic carcinoma with histopathologic correlation.

Comparison of location among different histopathological subtypes of bronchogenic carcinoma

Materials and Methods

This was a single-center, cross-sectional study on 162 patients with clinical or radiological suspicion of bronchogenic carcinoma referred to a tertiary care hospital in South India between December 26, 2019, and January 25, 2021. The current cross-sectional study is reported in line with the Standards for Reporting of Diagnostic Accuracy Studies guidelines for diagnostic accuracy studies.

Patient Selection

Patients with clinical or radiological suspicion of bronchogenic carcinoma were evaluated on CT. 162 patients with a confirmed histopathological diagnosis of bronchogenic carcinoma were included in the study. Mean age of the study population composed of 12 females and 150 males was noted to be 62.5 years, with age selection criteria ranging between 45 and 90 years.

Imaging Technique of Chest CT

The chest CT was obtained on a GE (General Electric Medical Systems, Milwaukee, WI, USA) 16-slice MDCT machine. CT scans were performed in caudocranial scanning direction from the level of lung apices to the diaphragm and routinely included the adrenals, at 120 kVp and 50–210 mAs, depending on their weight, using 16 × 1.25 collimation, 0.5 s rotation time reconstructed at 1.25-mm slices with 1.25 mm increment. Patients were instructed to hold their breath if clinically possible. Images were reconstructed using a moderately soft reconstruction filter (“DETAIL”) at the mediastinal window and a sharp reconstruction filter (“LUNG”) at the lung window settings. If a mass or nodule was identified, additional 5-mm collimation sections were obtained through the lesion. 60–70 mL of nonionic, water-soluble contrast media (Omnipaque) of strength 300 mgI/mL IV contrast were used in all the patients, except in patients with renal failure and with a past history of contrast-related allergic reaction. Five-millimeter sections at the level of hila were included on post-contrast CT images. The CT images were viewed in the lung window for evaluating the primary mediastinal window for local staging and lymphadenopathy and the bone window for ruling out distant metastases.

Image Analysis

Analysis of CT findings was made based on the site of the mass lesion − left/right, size >3 cm, 2–3 cm, 1–2 cm, or <1 cm; peripheral/central location; segmental/lobar distribution; contour of the mass lesion − smooth, lobulated, or spiculated; the presence of air bronchogram, calcification, or cavitation within the mass lesion; enhancement pattern; and the presence of satellite lesions in close proximity to the mass lesion.

CT evaluation of central tumors was based on findings such as bronchial abnormality − peribronchial thickening, luminal narrowing, extrinsic compression, or endobronchial lesion; obstructive pneumonitis; and the presence of collapse. Criteria to interpret chest wall invasion included soft tissue mass, bone destruction, obliteration of extrapleural fat plane, pleural thickening, degree of contact with the pleura exceeding 3 cm. Criteria to interpret direct mediastinal invasion include circumferential contact with the aorta exceeding 90°, a visible mediastinal fat plane between the mass and vascular structures of the mediastinum, and broad base of the mass lesion making greater than 3 cm contact with the mediastinum. TNM staging was done based on CT findings such as nodal status and mediastinal nodal involvement, distant metastases to the adrenals, bone, brain, liver, and the presence of satellite nodules. Comparison was made between CT findings and histopathological reports based on samples obtained on FNACs and bronchoscopy-based lung biopsies.

Data Analysis and Statistics

This is a descriptive analysis using numbers and percentages for categorical variables in patients with bronchogenic carcinoma. Statistical analyses were conducted using SPSS Statistical Package (version 20.0), IBM SPSS Statistics for Windows, V.20.0, IBM Corp., Armonk, NY, USA.

Ethical Considerations

All examinations performed in studies involving human participants were in accordance with the ethical standards of the Institutional Ethics Committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all patients prior to their enrollment in this study.

The mean age of the study population comprising 12 females and 150 males was 62.5 years with age selection criteria ranging between 45 and 90 years. All nonsmoker individuals in this study were females, and all male individuals were smokers.

Based on laterality, the right lung was commonly involved, followed by the left lung. Based on the location, the upper lobe of the lung was most commonly involved.

Among 162 patients with bronchogenic carcinoma, a majority of the lesions were greater than 3 cm which demonstrated predominantly heterogenous contrast enhancement. Nodules with spiculated margins were encountered in 104 cases (64.1%), lobulated margins in 55 cases (33.9%), and smooth margins in 3 cases (1.8%). Calcifications were noted in 32 (19.7%) patients with punctate calcifications observed in 22 patients. Calcifications were frequently reported in central tumors (56.1%) as compared to peripheral tumors and also in squamous cell carcinoma subtype of bronchogenic carcinoma (42.3%). Among 28 centrally obstructing tumors causing segmental lung collapse, 16 cases demonstrated dilated fluid-filled bronchi, suggestive of positive “mucous bronchogram” sign.

On staging CT, mediastinal nodal involvement was observed in 133 (82%) patients, mediastinal invasion was observed in 55 (33.9%) patients, and vascular invasion was observed in 102 (62.9%) patients; extrathoracic metastases were observed in 99 patients (61.1%) with the most common sites of involvement being the bone (27.3%), followed by the liver (19.7%) and adrenals (9.1%) (Table (Table2). 2 ). Most patients included in the current study were already having advanced stage of bronchogenic carcinoma at the time of presentation, with small cell carcinoma as the predominant histopathological subtype (extensive stage 82.3%) as compared to non-small cell carcinoma (stage IIIb 42.7% and stage IV 47.1%) (Fig. (Fig.1 1 ).

An external file that holds a picture, illustration, etc.
Object name is mpp-0031-0480-g01.jpg

Axial contrast-enhanced CT image of chest demonstrating extensive peripheral consolidation with numerous air bronchograms in a case of bronchoalveolar carcinoma of left lung.

Frequency correlation based on imaging features in patients with bronchogenic carcinoma

Most studies undertaken in the Indian subcontinent have reported the commonest cell type to be squamous cell carcinoma, accounting for 34–73% of total cases of lung cancer [ 13 ]. The most common subtype of bronchogenic carcinoma noted in the current study was squamous cell carcinoma, accounting for 45.6%, followed by adenocarcinoma, accounting for 38 cases (23.4%). However, adenocarcinoma was the predominant histopathological subtype in females, especially in young women, and squamous cell carcinoma in males according to most of the published literature [ 14 ]. Chronic inflammation of the lung parenchyma causing gradual progression from epithelial dysplasia to metaplasia to carcinoma in situ relates to pathophysiology of adenocarcinoma. As much of the respiratory epithelium is located at the periphery of the lung parenchyma, statistically, adenocarcinoma has more propensity for peripheral location of the lung than for the central location [ 15 ]. However, in the current study, adenocarcinoma was more frequently encountered in a central location than in a peripheral location which reflects a changing trend in the pattern of bronchogenic carcinoma. The occurrence of adenocarcinoma predominantly in the central location was compared with a study by Sharma et al. [ 16 ] using the χ 2 test and proved to be statistically significant ( p value <0.05). Moreover, the occurrence of squamous cell carcinoma predominantly in the peripheral location was compared with a study by Sharma et al. [ 16 ] using the χ 2 test and proved to be statistically significant ( p value <0.05). Quinn et al. [ 17 ] found a relative increase in the frequency of adenocarcinoma among lung cancers. Conclusions drawn from their study showed a relative decrease in peripheral tumors and an increase in central tumors. A study performed in India concluded that adenocarcinoma is the most common central tumor and also the most common histological subtype [ 18 ]; they attributed the findings to an increasing trend of bronchogenic carcinoma in females and nonsmokers and an additional reason being the inclusion of large cell carcinoma under the subtype of adenocarcinoma.

The recent relative increase in the central location of adenocarcinoma and change in histopathological subtypes of bronchogenic carcinoma may be attributed to changes in lifestyle patterns with cigarette smoking showing high association with central location of adenocarcinoma [ 19 ]. Also, lowering of nicotine content in cigarette leads users to inhale deeper puffs containing larger volumes to maintain similar blood nicotine levels [ 20 ]. Additionally, the increased use of immunohistochemistry techniques for antibodies to carcinoembryonic antigen and mucin staining has led to enhanced recognition of adenocarcinoma. Finally, the inclusion of the large cell carcinoma with mucus production under the poorly differentiated adenocarcinoma subtype of bronchogenic carcinoma has accounted for the relative increase in central location of adenocarcinoma. Although the net effect of these reasons may be modest, in reality, there might be an actual statistical variation that has led to a proportional increase in centrally located adenocarcinomas, reflecting the changing trend.

The high incidence of liver metastases encountered in the current study is related partly to the high incidence of adenocarcinoma that tends to metastasize to the liver as compared to small cell carcinoma. Our findings correlate with those of Chhajed et al. [ 18 ] who reported a 23.3% incidence of liver metastases with adenocarcinoma constituting the commonest histopathological subtype (35.5%). Extrathoracic metastases were reported at the time of presentation in advanced stages of small cell carcinoma and adenocarcinoma, correlating with the findings reported in the literature [ 21 ].

In the current study, pleural effusions were commonly reported in patients with adenocarcinoma, followed by bronchoalveolar carcinoma, correlating with the findings from the literature [ 22 ]. Cavitations were frequently reported in squamous cell carcinoma, and pseudo-cavitations were commonly reported in adenocarcinomas and bronchioloalveolar carcinoma, correlating with the findings from the literature [ 23 ].

The principle of radiomics lies in the extraction of radiomic features which is a process to convert conventional images to minable data by extracting high-dimensional quantitative semantic and/or agnostic features [ 24 ]. Semantic features are defined as those which are commonly used for the region of interest description by human observers [ 25 ]. Agnostic features are those extracted by a computational process for assessment of region of interest heterogeneity [ 26 ]. In general, there are three types of such features. The first-order features describe the distribution of all the voxel (3-dimensional pixel) values in the CT images. These are histogram-based properties detailing the mean, median, maximum, and minimum values of the voxel intensities on the images. The second-order features are textural features, which are obtained by calculating the spatial relationship between voxels. Finally, the higher order features are derived using mathematical-based formula features or deep convolutional neural network. The standard radiomic process includes data acquisition, image reconstruction, image segmentation, image preprocessing, feature extraction, feature selection, machine learning, and model evaluation. Radiomics and AI have been shown to have utility across the bronchogenic carcinoma care continuum including risk prediction, early detection, diagnosis, prognosis, and treatment response.

Since 2002, the National Lung Screening Trial (NLST) has included participants with a high risk of bronchogenic carcinoma [ 27 ]. Low-dose helical CT compared with traditional chest radiography was applied for bronchogenic carcinoma screening. Accordingly, improving the present methods to detect nodules and discriminate bronchogenic carcinoma from benign nodules is now urgent. In 2014, Lung CT Screening Reporting and Data System was first proposed as a tool for standardizing bronchogenic carcinoma screening [ 28 ]. CT reporting and management were based on the traditional radiologist's lexicon such as size, calcification, and tumor density. However, when implemented in clinical work, controversies such as decreased sensitivity and increased interobserver variability arose. As a result of interdisciplinary efforts, radiomics and AI were chosen for compensation.

Although pathologic staging remains the most important prognostic factor for lung cancer survival, there is marked variability in patient outcomes and survival among patients with the same stage of disease, suggesting that other factors contribute to lung cancer survival, progression, and recurrence. Radiomic studies have shown that image-based classifiers have the potential to complement staging and improve prognostication of lung cancer. Aerts et al. [ 29 ] analyzed NSCLC and validated a CT radiomic signature that had better prognostic performance than TNM staging and volume with a high concordance index.

Early assessment of a therapeutic efficacy and predicting treatment outcomes would aid in decision support for which treatment has the potential to have optimal benefit for the individual patient. This could eliminate unnecessary treatments, reduce costs and side effects, and increase patient survival. Studies have also investigated the utility of radiomics for treatment responses to chemotherapy or radiation therapy [ 30 ].

This study has a few limitations. External validity may be limited in the current study due to its single-center setup. The second limitation is the relatively small number of cases. A third limitation is that many patients with advanced stage of disease were included in the study.

Conclusions

CT is the imaging modality of choice for evaluating bronchogenic carcinoma as it provides precise characterization of the size, extent, and staging. In the current study, squamous cell carcinoma was predominantly found to be a peripheral tumor, and adenocarcinoma was predominantly noted to be a central tumor. This study demonstrates that the changes in imaging patterns will have a significant impact on the management of bronchogenic carcinoma and suggests the need to prioritize strategies based on multidisciplinary teams, while the rising prominence of adenocarcinomas also has treatment implications. Furthermore, evidence from computer-derived features from CT through radiomics, AI, and deep learning technologies can identify extensive characteristics of bronchogenic carcinoma, such as nodule detection and malignant lesion discrimination. Larger prospective studies are needed to ascertain whether the relative increase in the number of cases of centrally located adenocarcinoma is merely a statistical variation or a reality reflecting the changing trend. Extended intervals between surveillance or restaging scans are also recommended, given the high risk of mortality in patients with bronchogenic carcinoma.

Statement of Ethics

The authors certify that they obtained all appropriate patient consent forms. Patients gave their consent for their images and other clinical information to be published. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but that anonymity cannot be guaranteed.

Conflict of Interest Statement

The authors have no conflicts of interest to disclose.

Funding Sources

Author contributions.

Ravikanth Reddy contributed to conception, design of the study, and drafted and critically revised the manuscript. Sandeep Reddy contributed to image acquisition and analysis and revised the manuscript. All authors gave final approval.

Data Availability Statement

Acknowledgment.

We thank Mrs. Mani Sabbavarapu for her assistance in proofreading and language editing.

Funding Statement

Lung cancer (staging - IASLC 8th edition)

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Citation, DOI, disclosures and article data

At the time the article was created Yuranga Weerakkody had no recorded disclosures.

At the time the article was last revised Yuranga Weerakkody had no financial relationships to ineligible companies to disclose.

NSCLC staging
IASLC 8th edition lung cancer staging
Non small cell lung cancer staging
Lung cancer staging
Lung cancer TNM
Staging of non small cell lung cancer
TNM staging of lung cancer
Non-small cell lung cancer staging
Small cell lung cancer staging

The IASLC (International Association for the Study of Lung Cancer) 8 th edition lung cancer staging system was introduced in 2016 and supersedes the IASLC 7 th edition . It is a TNM staging system .

Standard-of-care lung cancer staging ideally should be performed in a multidisciplinary meeting using the information provided both from CT and FDG-PET-CT with further inputs from the histopathologic findings (pathological staging). The National Comprehensive Cancer Network (NCCN) guidelines recommend that FDG-PET-CT should be offered to all patients with non-small cell lung cancer (NSCLC) and that PET-positive findings for mediastinal nodes and/or distant disease require histopathological or other radiological confirmation 4 .

The revised 9 th edition of the TNM system for lung cancer is scheduled for 2024 6 .

T: primary tumor

Tx: primary tumor cannot be assessed or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy

T0: no evidence of a primary tumor

Tis: carcinoma in situ - tumor measuring 3 cm or less and has no invasive component at histopathology

T1: tumor measuring 3 cm or less in greatest dimension surrounded by lung or visceral pleura without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e. not in the main bronchus)

T1a(mi): minimally invasive adenocarcinoma

tumor has an invasive component measuring 5 mm or less at histopathology

T1a ss: superficial spreading tumor in central airways (spreading tumor of any size but confined to the tracheal or bronchial wall)

T1a: tumor ≤1 cm in greatest dimension

T1b: tumor >1 cm but ≤2 cm in greatest dimension

T1c: tumor >2 cm but ≤3 cm in greatest dimension

T2: tumor >3 cm but ≤5 cm or tumor with any of the following features:

involves the main bronchus regardless of distance from the carina but without the involvement of the carina

invades visceral pleura

associated with atelectasis or obstructive pneumonitis that extends to the hilar region (involving part or all of the lung)

T2a: tumor >3 cm but ≤4 cm in greatest dimension

T2b: tumor >4 cm but ≤5 cm in greatest dimension

T3: tumor >5 cm but ≤7 cm in greatest dimension or associated with separate tumor nodule(s) in the same lobe as the primary tumor or directly invades any of the following structures:

chest wall (including the parietal pleura and superior sulcus )

phrenic nerve

parietal pericardium

>7 cm in greatest dimension or

associated with separate tumor nodule(s) in a different ipsilateral lobe than that of the primary tumor

invades any of the following structures

mediastinum

great vessels

recurrent laryngeal nerve

vertebral body

It is recommended that solid and non-solid lesions should be measured on the image that shows the greatest tumor dimension (on axial, coronal, or sagittal planes). Although those lesions that are part solid should be measured on both their largest average diameter and the largest diameter of the solid component, only the solid component measurement is to be used for staging 3 . The solid component of subsolid lesions should be measured on a lung or intermediate window rather than mediastinal window 3 .

For those centrally located lung tumors associated with peripheral post-obstructive atelectasis, FDG-PET-CT is useful in further delineating the real tumor size and, leading to a more precise T staging and a smaller targeted volume in radiation treatment planning.

N: regional lymph node involvement

Nx: regional lymph nodes cannot be assessed

N0: no regional lymph node metastasis

N1: metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes , including involvement by direct extension

N2: metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)

N3: metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene , or supraclavicular lymph node(s)

Please note that there has been no change in nodal involvement staging since the 7 th edition of the IASLC.

PET-CT plays an important role in staging nodal disease. FDG uptake higher than the blood pool is suspicious, and uptake higher than the liver is highly concerning for nodal metastases. Endobronchial biopsy of an FDG-avid node is recommended to confirm the highest pathologic stage of disease 4 .

M: distant metastasis

M0: no distant metastasis

M1: distant metastasis present

M1a: separate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial nodule(s) or malignant pleural or pericardial effusions

M1b: single extrathoracic metastasis, involving a single organ or a single distant (nonregional) node

a single extrathoracic metastasis has a better survival and different treatment choices, which is why it has now been staged separately

M1c: multiple extrathoracic metastases in one or more organs

NB: The MX category is no longer used, it was removed in the 6 th edition of the TNM system, if presence of metastases is not known the cancer is assigned M0 5 .

There is a recommendation that the number of metastatic lesions, the larger diameter of individual metastatic deposits, and the number of involved organs should be stated in the radiological report 3 . However, note that the site of the metastasis by itself is not a prognostic factor 4 .

FDG PET-CT has a higher diagnostic value for the diagnosis of bone metastases compared to other methods. Therefore, bone scintigraphy is not recommended for staging purposes 4 .

Histologic diagnosis is recommended when the adrenal gland is the only site of metastatic disease, given the risk of a false-positive 4 .

Stage groupings

TNM equivalent: T is , N0, M0

TNM equivalent: T1, N0, M0

5-year survival: up to 92%

TNM equivalent: T2a, N0, M0

5-year survival: 68%

TNM equivalent: T2b, N0, M0

5-year survival: 60%

TNM equivalent: T1/T2, N1, M0 or T3, N0, M0

5-year survival: 53%

TNM equivalent: T1/T2, N2, M0 or T3/T4, N1, M0 or T4, N0, M0

5-year survival: 36%

TNM equivalent: T1/T2, N3, M0 or T3/T4, N2, M0

5-year survival: 26%

TNM equivalent: T3/T4, N3, M0

5-year survival: 13%

TNM equivalent: any T, any N with M1a/M1b

5-year survival: 10%

TNM equivalent: any T, any N with M1c

5-year survival: 0%

Quiz questions

1. Detterbeck F, Boffa D, Kim A, Tanoue L. The Eighth Edition Lung Cancer Stage Classification. Chest. 2017;151(1):193-203. doi:10.1016/j.chest.2016.10.010 - Pubmed
2. Goldstraw P, Chansky K, Crowley J et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. J Thorac Oncol. 2016;11(1):39-51. doi:10.1016/j.jtho.2015.09.009 - Pubmed
3. Carter B, Lichtenberger J, Benveniste M et al. Revisions to the TNM Staging of Lung Cancer: Rationale, Significance, and Clinical Application. Radiographics. 2018;38(2):374-91. doi:10.1148/rg.2018170081 - Pubmed
4. Kandathil A, Kay F, Butt Y, Wachsmann J, Subramaniam R. Role of FDG PET/CT in the Eighth Edition of TNM Staging of Non-Small Cell Lung Cancer. Radiographics. 2018;38(7):2134-49. doi:10.1148/rg.2018180060 - Pubmed
5. Amin M, Greene F, Edge S et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to Build a Bridge from a Population-Based to a More "Personalized" Approach to Cancer Staging. CA Cancer J Clin. 2017;67(2):93-9. doi:10.3322/caac.21388 - Pubmed
6. Rami-Porta R. Future Perspectives on the TNM Staging for Lung Cancer. Cancers (Basel). 2021;13(8):1940. doi:10.3390/cancers13081940 - Pubmed

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Radiographic imaging of bronchioloalveolar carcinoma: screening, patterns of presentation and response assessment

Affiliation.

1 University of California Davis Cancer Center, Sacramento, CA, USA. [email protected]
PMID: 17409997

Bronchioloalveolar carcinoma (BAC) is a previously uncommon subset of adenocarcinoma with unique epidemiology, pathology, radiographic presentation, clinical features, and natural history compared with other non-small cell lung cancer (NSCLC) subtypes. Classically, BAC demonstrates a relatively slow growth pattern and indolent clinical course. However, in a subset of patients, rapid growth and death from bilateral diffuse consolidative disease occurs within months of diagnosis or recurrence. Recent data suggest that the incidence of BAC is increasing, notably in younger nonsmoking women. The initial radiographic presentation of BAC varies considerably, from single ground glass opacities (GGOs) or nodules of mixed ground glass and solid attenuation to diffuse consolidative or bilateral multinodular disease. The rising incidence of BAC is also reflected in recent lung cancer screening studies employing helical computed tomography (CT), where the differential diagnosis of GGOs includes not only BAC and overt adenocarcinoma, but inflammatory disease, focal fibrosis, and atypical adenomatous hyperplasia. Because advanced-stage BAC presents as measurable mass lesions in fewer than 50% of cases, determination of radiographic response to therapy by standard criteria is often difficult. Here, we review current data regarding the radiographic imaging of BAC: its radiographic presentations in asymptomatic early-stage and in advanced-stage disease, the functional imaging characteristics of BAC, and challenges of response assessment, including evolving opportunities for computer-assisted image analysis.

Publication types

Comparative Study
Research Support, Non-U.S. Gov't
Adenocarcinoma, Bronchiolo-Alveolar / diagnosis
Adenocarcinoma, Bronchiolo-Alveolar / diagnostic imaging*
Adenocarcinoma, Bronchiolo-Alveolar / therapy
Antineoplastic Combined Chemotherapy Protocols / therapeutic use
Carcinoma, Non-Small-Cell Lung / diagnosis
Carcinoma, Non-Small-Cell Lung / diagnostic imaging*
Carcinoma, Non-Small-Cell Lung / therapy
Combined Modality Therapy
Diagnosis, Differential
Follow-Up Studies
Lung Neoplasms / diagnosis
Lung Neoplasms / diagnostic imaging*
Lung Neoplasms / therapy
Mass Screening / methods
Neoplasm Recurrence, Local / diagnostic imaging*
Neoplasm Recurrence, Local / pathology
Neoplasm Staging
Pneumonectomy / methods
Positron-Emission Tomography
Sensitivity and Specificity
Tomography, Spiral Computed*
Treatment Outcome

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Objective: The present expert review aims to describe the use of radiological imaging modalities for the diagnosis of lung cancer. Methods: Some papers were selected from the international literature, by using mainly Pubmed as a source. Results: Chest x-ray (CXR) is the first investigation performed during the workup of suspected lung cancer.
Role of Radiologic Imaging in Lung Cancer
Abstract. Computed tomography (CT) of the chest is the cornerstone of the diagnosis and staging of lung cancer. The advantages of CT in imaging the thorax are its cross-sectional format, superior density resolution, and wide dynamic range. Today's CT scanners combine fast acquisition, fast data reconstruction, and very high spatial resolution.
The radiologic appearance of lung cancer
A solitary pulmonary nodule (SPN) is the most common radiographic presentation of lung cancer. The imaging characteristics of solitary pulmonary nodules are described and illustrated. The appearance and implications of extension of lung cancer to the pleura are explored. Finally, the contribution of various thoracic imaging modalities to the ...
Radiographic Imaging of Bronchioloalveolar Carcinoma: Screening
Overdiagnosis refers to a lung cancer that would not lead to an individual's death because of slow growth rate and competing age-related risks for death. In the original Mayo Lung Project, Fontana et al32 observed 206 lung cancers in the screened group, but only 160 cancers in the control group. They found a signiﬁcantly better 5-year ...
Trends in Imaging Patterns of Bronchogenic Carcinoma: Reality or a
Introduction. Bronchogenic carcinoma accounts for more cancer-related deaths than any other malignancy and is the most frequently diagnosed cancer in the world [].Bronchogenic carcinoma is by far the leading cause of cancer death among both men and women, making up almost 25% of all cancer deaths [].The incidence in males has risen rapidly with each decade since the 1930s through the 1960s [].
Clinical and chest radiographic features of missed lung cancer and
Chest X-ray sensitivity and lung cancer outcomes: a retrospective observational study. ... (NSCLC) in young adults, age <50, is associated with late stage at presentation and a very poor prognosis in patients that do not have a targeted therapy option: a real-world study. Cancers (Basel), 14 (2022), p. 6056, 10.3390/cancers14246056.
Lung cancer (staging
The IASLC (International Association for the Study of Lung Cancer) 8th edition lung cancer staging system was introduced in 2016 and supersedes the IASLC 7 th edition . It is a TNM staging system. Standard-of-care lung cancer staging ideally should be performed in a multidisciplinary meeting using the information provided both from CT and FDG ...
Radiographic imaging of bronchioloalveolar carcinoma: screening
Bronchioloalveolar carcinoma (BAC) is a previously uncommon subset of adenocarcinoma with unique epidemiology, pathology, radiographic presentation, clinical features, and natural history compared with other non-small cell lung cancer (NSCLC) subtypes. Classically, BAC demonstrates a relatively slow growth pattern and indolent clinical course.
Electronics
Lung cancer, a prevalent and life-threatening condition, necessitates early detection for effective intervention. Considering the recent advancements in deep learning techniques, particularly in medical image analysis, which offer unparalleled accuracy and efficiency, in this paper, we propose a method for the automated identification of cancerous cells in lung tissue images. We explore ...
Imidex Hires Wes Bolsen as CEO to Commercialize FDA-Cleared
Imidex's AI-powered software VisiRad™ XR was built on one of the largest chest X-Ray databases in the world and is one of the only products to hold an FDA 510(k) clearance to detect lung nodules ...