Bronchogenic carcinoma

Dr / Hytham Nafady

Pathology

Symptoms of local chest disease:• Cough.• Hemoptysis.

Symptoms of chest wall invasion:• Chest pain.

Symptoms of mediastinal invasion:• e.g. superior vena cava syndrome (dilated anterior chest wall veins).

Symptoms of distant metastases:

Constitutional symptoms:• Weight loss.• Malaise.• Weakness.

Paraneoplastic syndromes:

CP

Causes of hemoptysis

Paraneoplastic syndromes

• Migratory thrombophlebitis.• Cerebellar degeneration.• Eaton Lambert syndrome.• Hypertrophic osteoarthropathy.• Hypocalcemia (ectopic PTH).• Hypercalcemia (ectopic cacitonin).• Ectopic ACTH• SIADH

Radiological manifestations of BC

1. Hilar enlargement & increased density.

2. Bronchial obstruction.

3. Pulmonary mass lesion.

4. Pulmonary nodule.

5. Mediastinal involvement.

6. Pleural effusion.

7. Chest wall involvement.

8. Bone involvement.

9. Metastases.

Hilar enlargement

Normal hilum

Contents of the hilum

Contents of the hilum

Bronchi Bronchi Pulmonary arteriesPulmonary arteries Pulmonary veinsPulmonary veins Lymph NodesLymph Nodes

DD of hilar enlargement

DD of hilar lymphadenopathy

Pulmonary plethora

• Infant with VSD.

• Cardiomegagly , prominent pulmonary conus & Pulmonary plethora are suggestive of left to right shunt

Pulmonary hypertension

• Prominent main pulmonary artery segment (MPA), which appears to be aneurysmally dilated.

• Right pulmonary artery (RPA) is also enlarged. • Enlargement of right pulmonary artery differentiates it from the post

stenotic dilatation of main pulmonary artery in pulmonary stenosis. • In post stenotic dilatation, even though the left pulmonary artery which is

in line with the main pulmonary artery may be dilated, the right pulmonary artery which does not have the effect of the jet and eddy currents, is not dilated.

• This X-ray also shows a prominent right atrial contour, indicating right atrial dilatation as a consequence of pulmonary hypertension and right ventricular hypertrophy.

• The end on views of blood vessels seen through the right pulmonary artery shadow are tiny, indicating that the RPA dilatation is unlikely to be due to increased pulmonary blood flow. Large end on vessels are a feature of pulmonary hypertension due to excessive left to right shunt causing increased pulmonary blood flow. In this case, the absence of them would make one think that the severe pulmonary hypertension is probably primary.

• The right ventricular systolic pressure and hence the pulmonary artery systolic pressure estimated by continuous wave Doppler interrogation of the tricuspid regurgitation jet was over 110 mm Hg.

Bronchial obstruction

Bronchial tapering

Bronchial cut off sign

Bronchial cut off sign

Bronchial cut off

Endobronchial mass

Effects of bronchial obstruction

Obstructive collapse

2ry pneumonia

Criteria of 2ry pneumonia:1. Consolidation collapse.2. Consolidation with no air bronchogram.3. Consolidation with hilar mass.4. Consolidation confined to one lobe for

more than 2 weeks without resolution or spread to other lobes.

5. Unresolved pneumonia (for more than 8 weeks after proper antibiotic therapy).

Golden S sign

Golden S sign

Bronchocele (mucoid impaction)

• Branching tubular opacities giving finger in glove appearance.

Pulmonary mass lesion

> 3 cm.

Pulmonary nodule Criteria of malignancy

Size Large pulmonary nodule (>2cm).Enlarging (doubling time 1-18 months)

Margin Spiculated.Lobultated.Poorly defined.

Calcification Usually no calcification.Stippled or eccentric calcification (engulfment of calcified granuloma).

Cavitation Thick walled eccentric cavitation with irregular inner margin.

Air bronchogram

Broncho-alveolar carcinoma.

• Corona radiata sign• Fine linear strands

extending 4-5 mm outward

• Spiculated on CXRs• 84 – 90% are

malignant

Spiculated margin

• Corona radiata sign• Fine linear strands

extending 4-5 mm outward

• Spiculated on CXRs• 84 – 90% are

malignant

Spiculated margin

• Scalloped border• Intermediate

probability of cancer• Smooth border

suggestive of benign diagnosis

Lobulated margin

• Scalloped border• Intermediate

probability of cancer• Smooth border

suggestive of benign diagnosis

Lobulated margin

Illdefined margin

Air bronchogram

Calcification

Mediastinal involvement

• Mediastinal lymph node enlargement.

• Involvement of mediastinal structures.

Mediastinal LN enlargement

Upper right paratracheal LN:

Convexity of the SVC interface.Thickening of the right paratracheal strip.

Lower right paratracheal:

Enlargement of the azygos arch.

Upper left paratracheal LN:

Convexity of the left subclavian artery interface.

Aorto-pulmonary LN:

Convexity of the aorto-pulmonary window.

Subcarinal LN: Convexity of the superior extent of azygo-esophageal recess.

Widening of the carina.

Paraoesophageal LN:

Thickening of the posterior tracheal band on lateral film.

Mediastinal lymph node metastases

Esophagus Esophageal compression or invasion.

Phrenic nerve Diaphragmatic paralysis

Recurrent laryngeal N. Vocal cord paralysis.

SVC Dilated neck & anterior chest wall veins.

Pulmonary artery Pulmonary oligemia.

Pericardium Pericardial effusion.

Pulmonary vein Tumoral thrombosis

Bronchogenic carcinoma with tumoral thrombosis of the left superior pulmonary vein

Phrenic nerve palsy

Phrenic nerve palsy

SVC syndrome

SVC obstruction

Azygos arch

Bronchogenic carcinoma with invasion of the intrapericardial portion of the left pulmonary

artery

Pleural effusion

Pathology:

• Direct spread.

• Lymphatic obstruction.

• 2ry pneumonia.

Radiolgical criteria:

Pleural effusion without mediastinal shift due to underlying obstructive collapse

Chest wall invasion C.P:Focal chest pain.Radiological manifestations:CXR:Bone destruction.Chest wall mass.CT:Area of contact >Obtuse angleMRI:• Parietal tumoral signal intensity on T1 (T2 WIs has no value)• Parietal enhancement.• Interruption of the extrapleural fat.In superior sulcus tumor:• Invasion of the subclavian vessels.• Invasion of the brachial plexus.

Bone involvement

Direct bone invasion.• Rib or vertebral body destruction.Hematogenous metastases:• Usually osteolytic metastases.Hypertrophic osteoarthropathy:• Involving the wrist, hand, ankle & foot.• The involved bone show solid periosteal

reaction.

Metastases LLBB: Lung, liver, bone & brain.Adrenal gland.

BAC

Thank you