DR. Muhammad Bin ZulfiqarPGR IV New Radiology DepartmentSHL/SIMSradiombz@gmail.com

RADIOLOGICAL IMAGING IN LUNG CANCER

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Brief introduction Radiological Modalities Radiological Features Radiological Imaging Of Complications

Agenda

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Bronchogenic carcinoma is a malignant neoplasm of the lung arising from the epithelium of the bronchus or bronchiole.

Definition

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Most common cancer in males world-wide Leading cause of cancer mortality in women

and men (United States) Mortality rates in women began increasing in

1935 and surpassed breast cancer in 1987

Lung Cancer Demographics

Cigarette smoking Radon gas Industrial exposure e.g. asbestos, arsenic,

uranium Concomitant disease e.g. Chronic pulmonary

scar and fibrosis

Risk Factors

Atypical adenomatous hyperplasia Squamous dysplasia / carcinoma in situ Diffuse idiopathic pulmonary neuroendocrine

cell hyperplasia

Preinvasive Lesions

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According to anatomy:• Central lung cancer, mostly is squamous cell carcinoma

and small cell carcinoma.• Peripheral lung cancer, mostly is adenocarcinoma and

large cell carcinoma. According to histology:• Small cell lung cancer(SCLC) 20%• Non-small cell lung cancer(NSCLC)• Adenocarcinoma 30-40• Squamous cell carcinoma 30-40% • Large cell Undifferentiated carcinoma 10%

Classification

Continued

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According to Pathology:• Squamous cell carcinoma: Most common subtype. Arises

from altered bronchial epithelium and growth in situ. Related to cigarette smoking. Cavitation can occur. Strongly associated with smoking.

• Adenocarcinoma: Arises from the submucosal glands, located in peripheral airways and alveoli. Commonest subtype in women & non-smokers.

• Large-cell carcinoma: Located peripherally. They can be quite large. Strongly associated with smoking.

• Small Cell Lung Cancer: Derived from neuroendocrine cells. May be related to paraneoplastic syndromes.

Classification

Central tumors• Cough• Wheezing• Hemoptysis• Pneumonia

Extrapulmonary invasion• Pain• Pancoast syndrome• SVC Syndrome

Metastases Paraneoplastic syndromes Asymptomatic 10%

Clinical Features

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PLAIN CHEST RADIOGRAPH BRONCHOGRAPHY (Obsolete) COMPUTED TOMOGRAPHY MAGNETIC RESONANCE IMAGING BARIUM STUDIES ULTRASONOGRAPHY POSITRON EMMISION TOMOGRAPHY ANGIOGRAPHY

Imaging Modalities

Solitary peripheral nodule / mass with corona radiata I pleural tail sign / satellite lesion

Ground glass haze Consolidation Cavitation Central mass: common in small cell carcinoma Unilateral hilar enlargement (secondary to primary

tumor / enlarged lymph nodes) Anterior+ middle mediastinal widening (suggests

small cell carcinoma)

Presentations of Lung Tumor

Continued

Segmental / lobar / lung atelectasis Reverse S sign of Golden" on PA CXR Rat tail termination of bronchus Bronchial cuff sign Bronchial cut of sign Local hyperaeration Mucoid impaction of segmental I lobar

bronchus

Presentations of Lung Tumor

Continued

Persistent peripheral infiltrate NO air bronchogram Pleural effusion Chest wall invasion: Involvement of main pulmonary artery (18%);

lobar Calcification in 7% on CT

Presentations of Lung Tumor

A solitary pulmonary nodule is defined as a discrete, well-marginated, rounded opacity less than or equal to 3 cm in diameter that is completely surrounded by lung parenchyma, does not touch the hilum or mediastinum, and is not associated with adenopathy, atelectasis, or pleural effusion. 

Lesions larger than 3 cm are considered masses and are treated as malignancies until proven otherwise.

Solitary Pulmonary Nodule / Mass

A focal opacity (solitary pulmonary nodule) is visible with speculated margins

Corona radiata sign in a malignant lesion with spiculation at the margin.

Bronchial carcinoma in the left lower lobe showing typical rounded, slightly lobular configuration. The mass shows a notch posteriorly

Mass

Early stage (due to lepedic growth pattern along alveolar septa with relative lack of acinar filling)

ground-glass haziness bubble-like hyperlucencies / pseudocavitation airway dilatation Lesion persists / progresses within 6-8 weeks

Ground glass haze

Bronchoalveolar Carcinoma--- as ground glass haze in left lower lobe and lingula

acinar airspace consolidation+ air bronchogram+ poorly marginated borders

Airspace consolidation may affect both lungs (mucus secretion)

±Cavitation within consolidation "CT angiogram sign" = low-attenuation

consolidation does not obscure vessels (mucin-producing subtype)

Consolidation

Air space infiltration involving almost all left lung zones and right mid zone

Continued

CT confirms extensive airspace opacities with numerous air-bronchograms. No pleural effusions or significant adenopathy.

Sputum, right and left main bronchus lavage were positive for malignant cells consistent of carcinoma, thought true cut biopsy was suggested by the pathologist to confirm the diagnosis of bronchoalveolar carcinoma, the patient condition did not permit for this.

CT confirms extensive airspace opacities with numerous air-bronchograms. No pleural effusions or significant adenopathy.

Sputum, right and left main bronchus lavage were positive for malignant cells consistent of carcinoma, thought true cut biopsy was suggested by the pathologist to confirm the diagnosis of bronchoalveolar carcinoma, the patient condition did not permit for this.

CT angiogram sign. A patient with bronchoalveolar carcinoma. Enhancing pulmonary vessels in a low-attenuating mass are seen.

CT Angiogram Sign

CT angiogram sign. Another patient with bronchoalveolar carcinoma. Enhancing pulmonary vessels in a low-attenuating mass are seen.

CT Angiogram Sign

Cavitation (16%): Usually thick-walled (> 5 mm) with irregular

inner surface (nodular internal margin); Secondary to squamous cell carcinoma in 4 /

5th, Followed by bronchoalveolar carcinoma A maximum wall thickness <4 mm is

unlikely to be malignant, but rare cases do exist with thin walls simulating bullae.

cavitation

The cavity is eccentric (large cell undifferentiated carcinoma). (B) The inner wall of the cavity is irregular (squamous cell carcinoma).

The cavity wall may be very thin (squamous cell carcinoma).

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Cavitating mass in the left mid-zone and there is bulging of the aortopulmonary window, indicating lymph node enlargement.

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Irregular opacity in left mid-zone with central air density due to cavitation and inferior horizontal margin due to air-fluid level.

FIGURE 15-14 ■ CT showing a cavitating squamous cell carcinoma in the left lung. The wall of the cavity is variable in thickness.

Bronchial carcinoma in the posterior segment of the right upper lobe with cavitation.

Cavitating bronchogenic carcinoma. There is preservation of the extrapleural fat plane at the point of contact with the chest wall. Although the pleura may be involved, the chest wall is likely to be otherwise spared.

central mass (38%): common in small cell carcinoma

Central tumours may be visible on the chest radiograph as an abnormal convexity or density in the hilar region.

Central Mass

CT scoutogram demonstrates bulkiness of the left hilum with collapse of the left lower lobe and a small pleural effusion. 

CT though the chest with contrast demonstrates numerous necrotic lymph nodes in the sub carinal region and left hilum with almost complete obliteration of left lower lobe bronchus with left lower lobe collapse. 

There is a tiny left pleural effusion and bilateral enhancing adrenal lesions. Enhancing right adrenal mass. 

Axial and coronal images of the CT demonstrating extensive mediastinal mass with compression of the SVC. The mass also was compressing the trachea and proximal airways.

Unilateral hilar enlargement (secondary to primary tumor / enlarged lymph nodes)• Calcified enlarged nodes frequently benign• Nodes in short axis diameter:• 0-10 mm normal (micrometastases)• >10 mm (65% sensitive + specific for tumor)• 20-40 mm (37% not involved by tumor)

PET (89% sensitive, 99% specific)

Unilateral Hilar Mass

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Chest X-ray shows a dense left hilum, but no definite mass.

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Chest X-ray shows the primary tumour is at the left hilum.

Dense hilum. (A) The left hilum is dense, owing to a mass superimposed directly over it. (B) Corresponding axial CT image demonstrates the mass lying behind the left hilum. The mass proved to be a squamous cell carcinoma.

Recurrent malignant left hilar lymph nodes from a small peripheral non-small cell lung cancer. (A) CT demonstrates nodes at the left hilum. (B) The PET/CT image confirms high FDG uptake in keeping with malignant involvement.

Anterior+ middle mediastinal widening Might suggests small cell carcinoma)

Mediastinal Widening

A patient with a small cell lung carcinoma. On the PA film there is a lobulated paratracheal stripe on the right.

On the lateral radiograph there is a density overlying the ascending aorta and filling the retrosternal space.

These findings indicate a mass in the anterior as well as in the middle mediastinum.

The CT confirms the presence of mass in both the anterior and the middle mediastinum.

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F-18 FDG PET imaging has been shown to be an accurate, non-invasive imaging test for the assessment of pulmonary nodules and larger mass lesions

96 % sensitive, 93 % specific. Several studies have shown that PET is more accurate

than CT for the staging of NSCLC. PET appears to be more accurate than CT in detecting

metastatic mediastinal lymphadenopathy. Detection of unsuspected metastatic disease by PET may

permit reduction in the number of thoracotomies performed for non-resectable disease.

PET-CT

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PET scan showing abnormal uptake of FDG in a tumour nodule in the right upper lobe(arrow) & in two superior mediastinal lymph nodes(arrowheads).

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Unresectable lung cancer. FDG-PET scan shows large primary tumour with metastases in lymph nodes, bone, & right adrenal.

PET is also very useful in clarifying those cases in which occurenct of benign nodal enlargement coexists with a malignant lung lesion.

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(C)Contrast enhanced CT demonstrated enlarged lymph nodes (> 1 cm in short axis; arrowheads) in ipsi- and contra-lateral mediastinal nodal stations .(D)PET-CT showed high metabolic activity of the parenchymal lesion but no nodal [18F]-2-FDG uptake.

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Carcinoma of the bronchus. Barium Swallow shows extrinsic compression of the mid-esophagus by enlarged subcarinal lymph nodes.

Segmental I lobar I lung atelectasis (37%) secondary to airway obstruction (particularly in squamous cell carcinoma):

Post obstructive lung enhances to a greater extent than tumor on CECT

Distal lung atelectasis has a higher signal intensity than the central mass in 77% on T2WI (due to accumulation of secretions in obstructed lung)

Segmental I lobar I lung atelectasis

Total left lung collapse. (A) Frontal and (B) lateral chest radiographs. The cause of the collapse is a bronchogenic carcinoma; the endobronchial component is visible as an abrupt cutoff of the left main bronchus. Note the marked displacement of the right lung anteriorly and posteriorly across the midline (arrows). Note the marked anterior hyperlucency of the thorax on the lateral view (B).

CT of right upper lobe collapse due to bronchogenic carcinoma. Note how the attenuation of the necrotic tumour is lower than the adjacent collapsed lung which enhances with intravenous contrast medium.

Contrast enhanced CT sections of whole lung collapse due to a squamous cell carcinoma in the left main bronchus (arrow in A). There is also a left pleural effusion and a small pericardial effusion. Note the low attenuation areas relative to the densely enhancing left lower lobe parenchyma (B) which represent mucus filled airways—the CT mucous bronchogram sign.

Intravenous contrast enhanced CT demonstrating right middle lobe collapse (A). Image from a CT PET study at the same level (B) shows increased uptake of radioisotope within the collapse. A targeted ultrasound guided biopsy was performed and bronchogenic carcinoma confirmed.

FIGURE 14-18 ■ Tight right upper lobe collapse. Note how the collapsed lobe (due to a central bronchogenic carcinoma) results in increased right paramediastinal density.

FIGURE 15-18 ■ Fluid-filled dilated bronchi beyond a central obstructing carcinoma are visible in this collapsed and consolidated right lower lobe.

Reverse S sign of Golden" on PA CXR =combination of

RUL collapse (inferiorly concave margin of lateral portion of minor fissure, which moved superiorly and medially with compensatory expansion of RML) + bulge of central tumor (inferiorly convex margin of medial portion of minor fissure)

Golden S sign

Golden’s S sign. A right upper lobe collapse demonstrating peripheral concavity and central convexity (arrows) due to an underlying bronchogenic carcinoma resulting in a reverse S shape.

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‘Golden S sign.‘ Collapsed right upper lobe with mass at right hilum.

CT of a collapsed right upper lobe due to a squamous cell carcinoma. Note the peripheral air bronchograms (arrow) in (A) despite a central obstructing mass with amorphous calcification (B). There is a convex border of the collapsed lobe (arrows) (B) which is the CT equivalent of Golden’s S sign.

Left upper lobe collapse due to bronchial carcinoma. Carcinoma has caused rat tail like narrowing of left upper main

bronchus

Rat tail termination of bronchus

Mucoid impaction of segmental / lobar bronchus (due to endobronchial obstruction) or from external compression on bronchus.

Mucoid Impaction

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Bronchocele with typical gloved-finger branching pattern

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Bronchocele due to carcinoma of the bronchus. CT shows dilated, fluid-filled bronchi in the lingula, secondary to carcinoma at the left hilum.

Bronchocele due to carcinoma of the bronchus. CT shows dilated, fluid-filled bronchi in the right middle lobe, secondary to carcinoma at the right hilum.

local hyperaeration (due to check-valve type endobronchial obstruction, best on expiratory view)

CT shows dilated, fluid-filled bronchi in the right middle lobe, secondary to carcinoma at the right hilum.

Local hyperaeration also seen.

Local Hyperaeration

persistent peripheral infiltrate (30%) = post obstructive pneumonitis

Persistent peripheral infiltrates

Chest CT shows airspace disease in the left lower lobe with air bronchogram and ill-defined nodules in both lungs.

This was refractory to treatment.

Biopsy suggested bronchoalveolar carcinoma

The bronchial cut off sign refers to the abrupt truncation of a bronchus from obstruction, which may be due to cancer, mucous plugging, trauma or foreign bodies. Typically, there is associated distal lobar collapse. 

Bronchial cut off sign

CT scout film shows abrupt cut off of right main bronchus with collapse of right lung and mediastinal shift. CT shows a mass arising and obliterating the right main bronchus

PA chest radiograph shows abrupt cut off of left main bronchus with collapse.

pleural effusion (8-15%): Usually unilateral most commonly due to adenocarcinoma Second leading cause of exudative pleural effusions. Frequent seen in patients with age>45 Ys, manifestated

by chest pain, hemoptysis and emaciate. Bloody and massive pleural effusion is the typical clinical

picture. Significantly high LDH and CEA level(>20ug/L) in pleural fluid.

Pleural fluid cytology, needle biopsy, thoracoscopy or open pleural biopsy has its greatest utility in establishing the diagnosis of malignant pleural effusions.

Malignant Pleural effusion

CXR shows complete opacification of the right hemithorax, which is due to a combination of complete collapse of the right lung and a large malignant pleural effusion. The right lung had collapsed due to a large tumour obstructing the right main bronchus (note the abrupt cut-off in the bronchus, arrow). The resultant volume loss in the right hemithorax has resulted in shift of the trachea to the right. There are multiple large metastases in the left lung.

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Large left pleural effusion due to carcinoma of bronchus.There is a large echo-free effusion above the left hemidiaphragm (arrowheads) and spleen (s).

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Contrast enhanced computed tomography: Necrotic mass in the right lower lobe (short arrow) with pleural (p) and pericardial (pc) effusions which were confirmed to be malignant.

Axial CT images show a large mass (stars) in the left lower lobe with a large left pleural effusion with focal pleural thickening (arrowheads). The lung mass is better seen on a post-thoracentesis image. Transbronchial biopsy revealed adenocarcioma and pleural fluid cytology confirmed the presence of malignant cells. Based on the new staging system, this patient has at least M1a disease.

Localized chest wall pain = most sensitive predictor

Tumor interdigitating with chest wall musculature on T2WI

Obliteration of high-intensity extra thoracic fat on TlWI

Bone erosion of ribs I spine (9%)

Chest Wall Invasion

FIGURE 15-22 ■ Chest wall invasion by a Pancoast’s tumour. Involvement of the soft tissues of the chest wall appreciated on the (A) axial T1-, (B) coronal T2-weighted MRI

FIGURE 15-22 ■ Chest wall invasion by a Pancoast’s tumour. Involvement of the soft tissues of the chest wall and the left second rib is appreciated.

Frontal chest radiograph demonstrates a mass in the left lung apex (white arrow in left image). There is associated destruction of the left 2nd and 3rd ribs posteriorly (white circle). The close-up photo of the left apex shows the rib destruction (white arrow) more clearly. The combination of an apical mass with rib destruction is characteristic for a Pancoast Tumor.

Bronchial neoplasms in contact with the thoracic wall may invade ribs and adjacent vertebrae and engulf destroyed pieces of bone and thus mimic intratumoral calcification as in this pancoast tumor

Involvement of main pulmonary artery (18%); lobar +segmental arteries (53%) may result in additional peripheral radiopacity (due to lung infarct)

Aorta may also be invaded.

Involvement of Main Arteries

FIGURE 15-21 ■ MRI of a left lower lobe tumour that has directly invaded the aortic wall, which has altered signal adjacent to the tumour.

Well-defined enhanced central left lung mass is seen with mediastinal invasion. Mass encases left main bronchus, left upper bronchus and also left main pulmonary artery. Filling defect is noted in the encased artery favouring a complicating thrombosis. Multiple low attenuation enlarged mediastinal lymphadenopathy. 

Calcification in 7% on CT (histologically in 14%) usually eccentric / finely stippled

a) Preexisting focus of calcium engulfed by tumorb) Dystrophic calcium within tumor necrosisc) Calcium deposit from secretory function of

carcinoma ( e.g. mucinous adenocarcinoma)

Calcifications

Calcified infectious granuloma engulfed by lung cancer. CT shows a cluster of densely calcified small nodules almost at the centre of a small carcinoma.

Tumour calcification. Large bronchial carcinoma invading the mediastinum demonstrates coarse and cloud-like calcification.

Benign calcification patterns

Feeding Vessel Sign

Feeding vessel sign. A patient with bronchial carcinoma. Pulmonary artery leading directly to the mass is seen.

Bronchial cuff sign = focal / circumferential thickening of bronchial wall imaged end-on (early sign)

Bronchial Cuff Sign

ANGIOGRAPHY

This is mainly carried out to assess the vascularity of a diagnosed tumour and also for pre-operative embolisation to reduce tumour bulk/ reduce intra-op bleeding.

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A left inferior phrenic arteriogram shows the vessel accounting for systemic arterial supply to the tumour through hypertrophied pleural collateral channels. Polyvinyl alcohol embolisation was carried out with good clinical results

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STAGING OF BRONCHOGENIC CARCINOMA

Staging is done using the lung cancer TNM staging system.

T= Tumour size

N= Level of nodal involvement

M= Presence or absence of metastases.

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TNM STAGINGT1 <3cm in diameter, sorrounded by lung/visceral

pleuraT2 >3cm in diameter/invasion of visceral

pleura/lobar atelectasis/obstructive pneumonitis/at least 2cm from the carina.

T3 Tumour of any size; less than 2cm from the carina/ invasion of parietal pleura, chest wall, diaphragm, mediastinal pleura, pericardium.

T4 Invasion of the heart, great vessels, trachea, esophagus, vertebral body, carina/ malignant effusion

N1 Peribronchial / ipsilateral hilar nodesN2 Ipsilateral mediastinal nodes.N3 Contralateral hilar/ mediastinal nodesM0 No metastasesM1 Distant metastases present.

CONCLUSION / SUMMARY

Lung cancer is an extremely prevalent disease that most radiologists will encounter on a frequent basis.

Familiarity with the various manifestations of lung cancer on the different imaging modalities may help suggest the initial diagnosis, especially in an older patient with a history of cigarette smoking.

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CHEST RADIOGRAPHY

1st line investigation; cheap and readily available; can depict most of the features of overt lung cancer and its complications.

COMPUTED TOMOGRAPHY

The gold standard in diagnosis and staging of lung cancer; gives cross-sectional imaging with better representation of anatomy; clearly depicts mediastinal adenopathy and involvement of adjacent structures.

MAGNETIC RESONANCE IMAGING

Excellent soft tissue resolution; clearly depicts vascular invasion better than CT; imaging modality of choice for assessing Pancoast tumours; of importance in cases where CT findings are indeterminate or equivocal.

POSITRON EMISSION TOMOGRAPHY

Provides excellent depiction of functional status of suspicious lung masses; helps to sort out status of nodal enlargement coexisting with lung cancer.

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LOCAL COMPLICATIONS:• Superior Vena Cava Syndrome• Intractable Hemoptysis

DISTANT COMPLICATIONS:• Metastases

PARANEOPLASTIC SYNDROMES:• Hypertrophic Osteoarthropathy

RADIOLOGY OF COMPLICATIONS

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SVC (Superior Vena Cava) Syndrome is a set of symptoms that result when blood flow through the superior vena cava is obstructed by extrinsic compression or by tumour invasion.

SVC SYNDROME

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Lung cancer is the leading malignant cause of SVC syndrome, with non–small cell lung cancer accounting for about 50% of the cases and SCLC accounting for about 25% of cases occurring in malignancy.

This syndrome is a complication that occurs in 2% to 4% of people living with lung cancer, and in some cases is the first symptom that leads to the diagnosis.

SVC SYNDROME

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Swelling of the face, arms, or chest wall

Difficulty breathing (dyspnoea)

Widening of the veins in the neck and chest

SVC SYNDROME

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Axial and coronal images of the CT demonstrating extensive mediastinal mass with compression of the SVC. The mass also was compressing the trachea and proximal airways.

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Stenting of superior vena cava is a well-known but not so commonly used technique to alleviate this syndrome.

The catheter wire is placed in the vena cava stenotic segment. The stent is delivered and the stenosis is solved.

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Bronchial artery angiography with embolization has become a mainstay in the treatment of intractable hemoptysis in some patients with lung cancer.

Major complications are rare and immediate clinical success defined as cessation of hemorrhage ranges in most series from 85% to 100%, although recurrence of hemorrhage ranges from 10% to 33%.

INTRACTABLE HEMOPTYSIS

Reports of neurological damage following bronchial angiography indicate care in avoiding obstruction of the artery of Adamkiewicz.

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Angiographic image showing blood ejecting from a ruptured bronchial artery branch (arrow)

Selective embolization of the feeding artery obtained with gel foam.

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Aka Bamberger-Marie syndrome Hypertrophic osteoarthropathy is a paraneoplastic

syndrome most often found in non-small cell lung cancer.

HYPERTROPHIC OSTEOARTHROPATHY

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It is a medical condition combining clubbing and periostitis of the long bones of the upper and lower extremities.

Distal expansion of the long bones as well as painful, swollen joints and synovial villous proliferation are often seen.

HYPERTROPHIC OSTEOARTHROPATHY

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Diagnosis is confirmed by the characteristic bone changes on plain radiograph and periostitis on bone scintigram.

The syndrome generally resolves dramatically with treatment of the underlying malignancy.

HYPERTROPHIC OSTEOARTHROPATHY

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Radiograph showing thickened, columnar diaphyses and erosion of the terminal phalangeal tufts in Hypertrophic Osteoarthropathy

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Bone scintigraphy showing periosteal proliferation along the margins of the shafts of the tibias, radii, ulnae and pelvic bones.

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Small cell> Adeno > Large> Squamous Lung cancer spread (metastatases) is sadly too

common. Nearly 40% of people with lung cancer have

metastases to a distant region of the body at the time of diagnosis.

DISTANT METASTASES

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Lung cancer can spread to any region of the body, but most commonly spreads to the liver, the lymph nodes, the brain, the bones, and the adrenal glands.

DISTANT METASTASES

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The staging CT scan of the thorax is usually extended to include the liver and adrenal glands.

CT scanning has a sensitivity of about 85% in the detection of liver metastases. Similar rates may be obtained with MRI and ultrasonography performed by experienced imagers.

LIVER METASTASES

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Computed tomographic (CT) scan of the abdomen showed multiple hepatic metastases (arrows).

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Gadolinium-enhanced 3D LAVA (Liver Acquisition with Volume Acceleration). Hypovascular metastases are best depicted on portal venous phase images.

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Adrenal metastases are common and often solitary.

They must be differentiated from adrenal adenomas, which occur in 1% of the adult population.

ADRENAL METASTASES

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Lesions smaller than 1 cm are usually benign. Metastases are usually larger than 3 cm; on non-

enhanced CT scans, they have an attenuation coefficient of 10 HU or higher.

Adenomas and metastases can also be distinguished by using MRI and PET scanning.

ADRENAL METASTASES

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Sonogram showing a 6-cm right adrenal metastasis of lung cancer.

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Adrenal metastasis from small cell lung cancer

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Coronal PET/CT image demonstrating intense FDG uptake in the primary left upper lobe lung carcinoma (curved arrow) and in the adrenal metastases (arrows)

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Osteolytic (70%) Osteoblastic (30%) Technetium-99m (99m Tc) radionuclide bone

scanning is indicated in patients with bone pain or local tenderness.

The test has a 95% sensitivity for the detection of metastases but a high false-positive rate because of degenerative disease and trauma.

BONE METASTASES

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The assessment of these metastases requires comparison of the bone scans with plain radiographs.

Vertebrae(70%), Pelvis(40%), Femora(25%) Plain radiographs typically show destructive lytic

lesions ± pathological fractures. Similar features are seen on CT scans.

BONE METASTASES

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Bone Metastasis from Primary Lung Cancer :Lytic lesion of humerus with a pathological fracture.

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Bone Metastasis from Primary Lung Cancer expansile lytic rib lesions (arrows).

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FDG PET images demonstrate bone metastases (arrows).

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Isotope bone scan. Hot spots due to bony metastases.

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SCLC and adenocarcinoma are the most common sources of cerebral metastases.

MRI is superior to CT, especially in the depiction of the posterior fossa and the area adjacent to the skull base.

BRAIN METASTASES

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However, the brain is not routinely imaged in asymptomatic patients with NSCLC, because the incidence of silent cerebral metastases is only 2-4%.

Brain metastases are typically hemorrhagic and occur at the grey-white mater junction of the brain.

BRAIN METASTASES

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Non small cell lung cancer with hemorrhagic brain metastasis (A) Pre-operative non-contrast enhanced computed tomography (CT). (B) Pre-operative contrast-enhanced CT.

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Contrast-enhanced CT scans of the same patient showing multiple enhancing cerebral metastases of lung cancer in the left cerebral hemisphere.

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DIFFERENTIAL DIAGNOSES

Pulmonary metastases Pulmonary AV malformation

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DIFFERENTIAL DIAGNOSES

Pulmonary tuberculosis

Pulmonary hamartoma

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