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Examenul radiologic are rol att n diagnostic ct i n depistarea cancerului pulmonar, simptomatologia clinic fiind foarte
srac sau lipsind cu desvrire n perioada de nceput, iar cnd apare, tumora a depit de mult limitele operabilitii.
Varieti:
- carcinom epidermoid: cel mai frecvent (40%). Poate fi periferic sau central, cu un burjon endobronic. Aceste tumori sunt
adesea necrozate.
- adenocarcinom (20%). Poate fi central sau mai frecvent periferic, cteodat dezvoltat pe o cicatrice. Diferena ntre un
adenocarcinom primitiv i metastaza pulmonar a unui adenocarcinom extratoracic poate fi dificil.
- carcinom anaplazic cu celule mici (20%). Sunt cel mai frecvent centrale. Este o tumor cu evoluie i extensie ganglionar
mediastinal i metastatic rapid.
- carcinomul cu celule mari formeaz un grup heterogen
- carcinom bronhiolo-alveolar este un subtip de adenocarcinom; tumori periferice dezvoltate la nivelul bronhiolelor
terminale sau alveolelor.
- tumori mixte au o compoziie histologic variat
RX of SCLC
Conventional radiography is not helpful in finding early disease. When the mass or mass effect is visible on a radiograph,
the disease is almost invariably in an advanced stage. Although some institutions use low-dose CT to detect early nonsmall cell lung
cancer (NSCLC), it is probably not effective in evaluating SCLC.
Chest radiographs may show unilateral hilar enlargement, increased hilar opacity, a perihilar mass, mediastinal
mass, or a combination of these. Less commonly, small cell lung cancer (SCLC) may appear as a solitary
pulmonary nodule. (See the images below.)[7]
Compression of the bronchi is relatively common in SCLC because of the central location of the tumor in most cases. About 30-50%
of SCLCs show evidence of obstructive pneumonitis on the initial presentation. SCLC can appear as segmental or lobar atelectasis
with or without an obvious hilar mass. The S sign of Golden is seen when a collapsed upper lobe forms a meniscus concave toward the
hilum and when an enlarged hilar mass forms the convex meniscus of the S. Occasionally, endobronchial growth or bronchial
compression may be appreciated as a bronchial cutoff or filling defect.
Thickening of the right paratracheal stripe may be an indication of right paratracheal lymphadenopathy. With massive subcarinal
lymphadenopathy, widening of the carinal angle may occasionally be observed. Subtle changes of hilar asymmetry, increased opacity,
a convex or lobulated outer hilar border, or any change from a previous radiograph should be viewed with suspicion.
Involvement of pleura or pericardium may result in pleural or pericardial effusions.
Rarely, involvement of a pulmonary artery may result in compression of the artery with oligemia in the area of distribution. Invasion
of pulmonary artery may result in pulmonary metastatic lesions.
Large mediastinal masses may lead to lymphatic obstruction, which may result in reticulonodular opacities in the lung.
Lateral views are complementary to the frontal views and help in assessing the mediastinal abnormalities, especially in the retrosternal
and hilar regions. Paratracheal masses and thickening of the posterior wall of the bronchus intermedius may be seen on the lateral
view.
The degree of confidence in radiography is low, because a bulky mediastinal mass may also be seen in a variety of conditions other
than small cell lung cancer.
Contrast-enhanced CT
Contrast-enhanced CT is routinely used to further evaluate any suspicious abnormality noted on radiographs. This
examination is also routinely used to determine the stage of a known SCLC, to follow up patients after treatment,
and to evaluate distant metastatic disease.
Contrast-enhanced CT can sometimes be used:
- To differentiate a tumor mass from the adjacent collapsed lung or pneumonitis, which usually enhances more than the tumor
- Sometimes, air bronchograms are observed.
- Three-dimensional (3D) images in detecting invasion of adjacent organs.
- Chest-wall invasion can be demonstrated with evidence of rib destruction (the most specific finding), pleural thickening, and
obliteration of the extrapleural fat line. An obtuse angle of the mass with the chest wall may also suggest invasion. Pain in the chest
wall is a more specific sign of involvement.
- Signs of mediastinal invasion: contact with the mediastinum of more than 3 cm, contact with aorta of more than
90, invasion of the mediastinal fat, and pleural or pericardial thickening are considered.
- CT scans can also show endobronchial growth and the degree of compression of the bronchi or vessels.
-The size of lymph nodes is generally estimated for staging purposes by measuring the short axis of the lymph nodes. Compared
with the long axis, the short axis is a more accurate predictor of the volume. For practical purposes, a short-axis measurement greater
than 1 cm is generally considered abnormal in the chest. However, some have observed different measurements in different groups of
patients.
- CT of the chest routinely includes imaging of the adrenal glands, which are common sites for of small cell lung cancer metastases. A
lesion with an attenuation value less than 10 HU (Hounsfield units) on a nonenhanced CT scan most likely represents an adenoma
(90% accuracy).
- CT of the abdomen and pelvis is also generally indicated in staging of small cell lung cancer to rule out metastases to the liver,
nodes, or other organs.
- CT of the head helps in ruling out brain metastasis, which is also common in small cell lung cancer.[2]
-CT is also routinely used to follow up patients with small cell lung cancer after irradiation and chemotherapy.
Degree of confidence
CT scanning is reasonably accurate in depicting suspicious or indeterminate masses and for staging small cell lung cancers.
False positives/negatives
With CT scanning, criteria based on the size of the lymph nodes are used for staging the disease. This method has inherent limitations.
False-positive findings are due to enlarged benign reactive nodes, and false-negative findings are due to microscopically involved
normal-sized metastatic nodes.
MRI
Although most centers do not routinely use MRI to evaluate the primary lesion in the chest, it may provide useful
information in problematic cases of mediastinal invasion. MRI does have a role in ruling out brain metastatic
lesions and in differentiating questionable adrenal masses. In pregnant patients, MRI can also be used instead of
CT scanning, to avoid the potential effects of ionizing radiation.[6]
Gadolinium-enhanced MRI may also be helpful because the lung enhances rapidly, whereas the tumor usually
enhances relatively slowly. MRI is also good for detecting nodes in the aortopulmonary window or for detecting
subcarinal nodes, because it can provide images in the sagittal and coronal planes. With chemical shift imaging,
MRI is reliable in differentiating adrenal adenomas from possible metastasis because it shows decreases in signal
intensity on out-of-phase images as compared with in-phase images.
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine
[MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been
linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD).
For more information, see the eMedicine topic Nephrogenic Systemic Fibrosis.
NSF/NFD has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based
contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease.
Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the
skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands,
legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see Medscape.
Degree of confidence
MRI may be more sensitive than CT scanning for the assessment of mediastinal, vascular, or chest wall invasion. MRI is considered
superior to CT scanning for detecting brain metastatic lesions and for evaluating the adrenal masses.[2]
False positives/negatives
Because of the relatively low spatial resolution of MRI compared with that of CT, a cluster of small lymph nodes may occasionally be
mistaken for a single enlarged node. This observation can lead to a false-positive finding. Also, calcifications may be missed on MRIs.
Lung cancer, small cell. Contrast-enhanced CT scan of the chest shows a large left lung and a hilar mass, with invasion of the left
pulmonary artery.
Lung cancer, small cell. Contrast-enhanced CT scan of the abdomen. Axial section through the liver shows multiple hypoattenuating
areas in the liver. Poorly defined margins, attenuation greater than that of water, and scattered distribution in a patient with known lung
cancer is most consistent with metastatic disease.
Lung cancer, small cell. Nonenhanced CT scan of the abdomen at the level of adrenal gland shows a large adrenal mass on the left
side. The high attenuation values on this image and the large size of the adrenal mass suggest a malignant lesion. The adrenal glands
are a common site for metastatic small-cell lung cancer.
Lung cancer, small cell. CT scan of the chest at the level of hila shows a large hilar tumor on the right side, with loculated pleural
effusion. Nodular thickening of the pleura suggests pleural metastasis. The tumor mass is difficult to differentiate from the adjacent
atelectatic lung.
Lung cancer, small cell. Contrast-enhanced MRI of the brain in a patient with known small-cell lung cancer (SCLC). Axial section at
the level of lateral ventricles shows at least 2 ring-enhancing metastatic lesions in the periventricular region. The brain is one of the
predominant sites for SCLC metastasis.
A 50yr-old female with irregular cavitating squamous cell carcinoma in the right upper lobe (arrows).
a) Collapse of the left lung with mediastinal shift and a right middle
zone nodule (arrow). b) Perihilar low attenuation adenocarcinoma
(arrows) with distal enhancing collapsed lung in same patient.
Nonsmall cell lung cancer. Bronchoscopy. A large central lesion was diagnosed as nonsmall cell carcinoma.
Nonsmall cell lung cancer. Left pleural effusion and volume loss secondary to nonsmall cell carcinoma of the left lower lobe. The
pleural effusion was sampled and found to be malignant; therefore, the lesion is inoperable.
Nonsmall cell lung cancer. A cavitating right lower lobe squamous cell carcinoma.
Nonsmall cell lung cancer. CT scan shows cavitation and air-fluid level.
Nonsmall cell lung cancer. Patient has right lower lobe opacity. This is not well circumscribed and was found to be a squamous cell
carcinoma.
Nonsmall cell lung cancer. Right upper lobe lesion diagnosed as adenocarcinoma on percutaneous biopsy.
Nonsmall cell lung cancer. Right upper lobe collapse with the S sign of Golden secondary to underlying nonsmall cell carcinoma
of the bronchus.
Nonsmall cell lung cancer. Comparative characteristics of the primary tumor are shown in the vertical columns. Horizontal columns
refer to lymph node involvement. The different stages are color coded and can be found at the intersection of appropriately matched
horizontal and vertical columns. Stages with unique characteristics, such as stages 0 and IV, are defined in separate boxes. Courtesy of
Lababede et al (Chest 1999; 115(1): 233-5).
Nonsmall cell cancer requires meticulous staging, because the treatment and prognosis vary widely depending on the stage.
In nonsmall cell lung cancer, surgical resection offers patients the best chance for survival.
- Surgery may be curative for stage I and stage II disease; however, only a minority of patients (20-25%) have disease at these
stages. - - Patients with stage IIIA disease may be candidates for surgical resection.
- In patients with stage IIIB disease, the tumors usually are considered unresectable.
- Patients with stage IV disease have distant metastases and are offered nonsurgical treatment, with the exception of rare cases
of resectable solitary metastasis in a patient who also has a resectable primary lesion.
Most patients with stage I and stage II disease require preoperative or intraoperative mediastinal dissection for accurate staging prior
to lung resection. The overall surgical mortality rate following lung resection is 3.7%. The mortality rate is higher (6-9%) in patients
requiring pneumonectomy and in patients older than 70 years. The overall 5-five year survival rate may depend on whether the tumor
is stage T1 or stage T2. The overall 5- and 10-year survival rates are 75% and 67%, respectively, in patients who undergo resection for
stage I disease.
Patients with stage IA (T1 N0) disease have a significantly higher survival rate (82% at 5 y) compared with those with stage IB (T2
N0) disease (68% at 5 y and 60% at 10 y).[5]
Patients with stage IIA (T1 N1) tumors have a survival rate of approximately 50% at 5 years, whereas patients with stage IIB (T2 N1
and T3 N0) tumors have a 40% survival rate.
Patients with stage IIIA (T1 or T2 N2) tumors have been reported to have a 5-year survival rate of 29%. The 5-year survival rate in
patients with complete resection of stage IIIB tumors is 49% in T3 N0 disease, 27% in T3 N1 disease, and 15% in T3 N2 tumors. For
patients with stage IV disease, the median survival is 8.5-21 weeks, and the 1-year survival rate is 10%.
The overall 5-year survival rate is grim because most patients with nonsmall cell lung cancer present with locally advanced or
metastatic disease. Approximately 65-80% of patients present with unresectable disease. At present, the National Cancer Institute
and other medical associations and regulatory bodies do not recommend early screening for lung cancer as part of a periodic health
examination.
A number of studies are currently under way to find improved treatments for non-small cell lung cancer.[6, 7, 8]
Preferred examination
In a malignancy such as bronchogenic carcinoma, early detection can lead to surgical resection of the lesion and cure. Unfortunately,
to date, the use of radiologic modalities has not proven successful in reducing mortality rates. For screening of nonsmall cell
carcinoma of the lung, chest radiography may result in improved survival, although a mortality benefit has not been confirmed. On the
basis of results from the Mayo Lung Project and a Czechoslovakian study, the American Cancer Society does not recommend routine
mass screening for the detection of lung cancer.
However, early stage detection, resectability, and survival improve with chest radiographic screening in high-risk populations.
Studies have shown that low-dose helical CT scan of the thorax may detect lesions at an earlier stage and, therefore, may potentially
improve resectability, survival, and mortality rates.
Limitations of techniques
Chest radiography remains the primary means of radiographic assessment of lung carcinoma. However, 12-30% of lung cancers are
missed on chest radiographs.[9] A nodule smaller than 2-3 mm may not be detected by using chest radiographs, and overlapping soft
tissue opacities may hide small endobronchial lesions. Chest radiographs depict indirect signs of endobronchial lesions such as
obstructive pneumonia or atelectasis. These signs may well be secondary to benign tumors or mucus plugging or a foreign body. In a
solitary lung nodule, probability of malignancy is approximately 40% overall; therefore, a nodule identified on a chest x-ray requires
further diagnostic workup to exclude lung cancer.
The advantage of CT scanning in nonsmall cell lung cancer is that it can be used to distinguish tumor from surrounding atelectatic
lung. CT scans may be helpful in demonstrating superior vena cava compression, pericardial effusion, and lymphangitic dissemination
in several other conditions. A major limitation of CT scanning is the inability to distinguish invasion from simple approximation to
adjacent structures.
In staging of nonsmall cell carcinoma, CT has several limitations. Normal-sized mediastinal lymph nodes may contain microscopic
metastatic deposits that are subsequently identified on thoracotomy in as many as 20% of patients. Similarly, enlarged inflammatory
nodes may be falsely characterized as metastases in as many as 20% of patients.
The sensitivity and specificity of CT in detecting metastatic mediastinal lymph node involvement is in the range of 70-80%. CT
scanning may have further limitations in distinguishing stage IIIA disease from stage IIIB disease. In a peripheral TI lesion, CT
probably does not contribute, because chest radiography appears to be sufficient. CT is also limited in evaluating the extent of
endobronchial abnormalities. CT may also be limited in evaluating and staging apical lung tumors.
For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education
articles Lung Cancer, Bronchoscopy, Understanding Lung Cancer Medications, and Non-Small-Cell Lung Cancer.
On chest radiography, the findings of nonsmall cell lung carcinomas are varied and
considered in the differential diagnosis of many disorders. The most common findings are described below.
Bronchial stenosis
Bronchial stenosis and poststenotic changes are common, because most nonsmall cell carcinomas demonstrate intraluminal growth.
Narrowing of the main bronchi or a complete cutoff can be identified on chest radiographs.
An endobronchial lesion commonly leads to partial or complete atelectasis and is the most common sign of bronchogenic carcinoma.
Complete endobronchial obstruction can sometimes produce distal mucoid impaction, which may be visible on plain radiographs as a
tubular or branching opacity.
Atelectasis of a segment, a lobe, or an entire lung may occur.
Radiographic signs include patchy irregular or homogeneous opacities in a lobar or segmental distribution. A loss of lung volume may
be seen, as well as displacement of interlobar fissures, the mediastinum, the diaphragm, and the ribs.
Postobstructive pneumonia may be identified in a segmental or lobar distribution. In patients with recurrent pneumonia, bronchogenic
carcinoma is suggested unless proven otherwise.
Regional hyperlucency
An endobronchial lesion reduces the ventilation despite normal or increased air volume. As a result, hypoxic vasoconstriction reduces
perfusion, and attenuation is seen as hyperlucency on chest radiography. In partially atelectatic areas of the lung, hyperlucency rather
than opacity may be evident.
Hilar mass
Central bronchogenic carcinomas manifest added opacity in the hilar region.
In the early stage, the tumor may fill the lateral concavity of the hilar shadow, and in the advanced stage, all hilar structures are
obliterated.
Infiltration of lymphatics with bronchogenic carcinomas may be demonstrated as linear opacities radiating from the hilar mass into the
lung periphery.
A solitary pulmonary nodule may be relatively well marginated and appears as a rounded lung opacity.
Reportedly, a solitary pulmonary nodule is benign in as many as 60% of patients in some series. All patterns of calcification except
eccentric or scattered punctate (stippled) calcification are associated with a benign lesion.
Procuring and identifying the lesion on previous chest radiographs is extremely important. This may help establish the doubling time
interval for the nodule. A doubling time of 30-365 days commonly is associated with a malignancy.
Other possible signs of malignancy include the following:
Diameter more than 3 cm
Ill-defined or spiculated margin
Rigler notch sign (a notch on the nodule corresponding to the vascular supply)
Radial striated markings at the nodular margin (termed corona radiata)
Thick-walled cavity
Eccentric calcification
Nonresolving pneumonia
An ill-defined homogeneous or patchy consolidation in a segmental or nonsegmental distribution may be an indication of
bronchogenic carcinoma. Patients with these findings often are treated initially for pneumonia; the lack of response to antibiotic
therapy suggests the diagnosis of a malignancy.
The opacity may contain air bronchograms and air alveolograms. This presentation is often seen with adenocarcinoma and
bronchoalveolar carcinoma.
Indirect signs of involvement of contiguous structures also may be found. Bronchogenic carcinoma may involve the surrounding
thoracic structures, which often indicates that the tumor is not resectable. Findings include the following:
Osteolytic lesions and pathologic fractures of rib and vertebra
Phrenic nerve involvement causing diaphragmatic paralysis and exhibiting ipsilateral elevation of involved diaphragm
Pleural effusion secondary to visceral pleural involvement or lymphatic obstruction (confirm the presence of a malignant
effusion using thoracentesis)
Intervention
Percutaneous transthoracic needle biopsy (PTNA) is used for the diagnosis of lung cancer. Chest radiographs are recommended at 1and 4-hour intervals after the biopsy is performed, unless the patient appears to be hypoxemic or unstable, in which case chest
radiography should be performed immediately.
A small or asymptomatic pneumothorax may be followed at an interval of 2-4 hours with repeat chest radiography. If the
pneumothorax remains stable and patient is asymptomatic, chest tube drainage is not required. In an enlarging pneumothorax (15-30%
pneumothorax) or a symptomatic patient, a pneumothorax drainage catheter should be placed and connected to a Heimlich valve or
Pleurovac system.
Computed Tomography
CT scanning of the thorax plays multiple roles in evaluation of patients with bronchogenic carcinoma. These include lung cancer
screening, evaluation of a solitary pulmonary nodule, and staging.
A few trials have used low-dose helical CT to screen patients at risk for lung cancer. CT has depicted noncalcified nodules, although a
small number have been found to be malignant.
CT densitometry
CT densitometry is useful in detecting the presence and distribution of calcification and fat within solitary nodules.
CT scan is more sensitive than chest radiography for detecting the presence of calcification. Approximately one third of indeterminate
nodules found on chest radiography can be demonstrated to have calcium on CT scans. CT numbers can be obtained by placing a
cursor over the lesion; a value of more than 200 HU indicates calcification.
The presence of fat, detected either from direct visualization or from CT numbers ranging from 40 to 120 HU, is diagnostic of
hamartoma.
Contrast-enhanced CT
Enhanced scans may help in distinguishing between malignant and benign lesions. Malignant lesions enhance to a greater degree than
do benign lesions after the administration of a contrast material; however, active granulomas or other infectious lesions can also
enhance.
A measurement of CT numbers during enhancement is useful. An increase of 20 HU or more indicates a sensitivity for lung cancer of
98% and a specificity of 73%.[10] Contrast enhancement may be used in patients who do not have characteristic findings of either
malignant or benign lesions. The nonenhancing nodules may be monitored as long as other features suggesting malignancy are not
present.
CT scans are useful in assessing local invasion of the chest wall, mediastinum, mainstem bronchus, central veins, and arteries. Signs of
chest wall invasion include bone destruction, tumor extension into the chest wall, pleural thickening, and loss of extrapleural fat plane.
Identification of mediastinal invasion with CT usually is unreliable. In addition, minimal mediastinal fat invasion may be resectable in
many cases. Tumor invasion of the central arteries and veins may be identified by using CT, which indicates that a pneumonectomy is
required. Tumor invasion of the mainstem bronchus can also be visualized on CT scans. This is a useful finding for planning the
surgical procedure.
CT is a useful radiologic modality for noninvasive anatomic evaluation of the hila and mediastinum. The indication of metastasis
primarily is based on size criteria. A lymph node with a short-axis diameter of more than 1 cm is defined as enlarged. Although the
probability of metastasis increases with increasing lymph node size, CT scanning is not helpful in differentiating a metastasis from a
benign lesion.
Microscopic metastases
Normal-sized lymph nodes have been reported in 7-33% of patients undergoing CT staging. In addition, controversy exists over
whether the short-axis or the long-axis diameters should be used in imaging. Another limitation may be interobserver variability in the
interpretation of imaging studies. Despite the limitations, CT provides useful staging information to the surgeon. Noting enlargement
in a specific location may help surgeons in planning procedures, including mediastinoscopy, mediastinotomy, or percutaneous needle
aspiration biopsy.
CT is useful in demonstrating extrathoracic metastases. Distant metastases demonstrated with CT include metastases to the adrenal
glands, brain, bones, liver, and soft tissues.
Chest CT should include the upper abdomen to assess the liver, upper abdominal lymph nodes, and adrenal glands. However, on
needle biopsy, most adrenal masses are shown to be adenomas rather than metastases.
Degree of confidence
On contrast-enhanced CT scans, increased attenuation of 20 HU or more is 98% sensitive and 73% specific for lung cancer.[10]
CT scans are used extensively for staging nonsmall cell lung cancer; however, CT staging leads to either overestimated or
underestimated staging in approximately 40% of patients.
MRI is an imaging modality with several advantages, including a lack of ionizing radiation, the ability to image vascular structures
without contrast media, the ability to image in any plane, and superior contrast resolution. MRI is not useful as an initial imaging tool,
but it may be superior to CT in the evaluation of local invasion and detection of hilar lymphadenopathy.
In particular, MRI is useful in the evaluation of superior sulcus tumors. Invasion of the brachial plexus, subclavian vessels, and
adjacent vertebral bodies can be demonstrated with MRI. Compared with other techniques, MRI may be slightly more accurate in
detecting extranodal tumor extension into the mediastinum.
The multiplanar capability of MRI enables a more accurate evaluation of hilar lymph nodes, aortopulmonary window lymph nodes,
and subcarinal region lymph nodes than does CT scanning.
In addition, MRI can be helpful in identifying the relationship of the tumor to the central pulmonary artery, aorta, carina, and main
bronchi.
Degree of confidence
MRI depends on size criteria for the detection of mediastinal metastases. MRI is limited in detecting small lymph nodes containing
microscopic deposits. MRI can be used as an imaging modality for apical or superior sulcus lung tumors. MRI is superior in detecting
invasion of the chest wall, vertebral body, subclavian vessels, and brachial plexus. For the detection of chest wall invasion, a
sensitivity of approximately 90% and a specificity of 96-100% has been reported.
MRI is not able to depict calcification. Blood vessels with low flow may be misdiagnosed as lymph nodes or masses. Respiratory or
other motion may cause blurring of images, leading to a missed diagnosis of lymphadenopathy.
Nuclear Imaging
In patients who have biochemical or physical evidence of bone metastasis, a bone scan is required as part of the preoperative workup.
A routine bone scan is usually not recommended in asymptomatic patients.
PET can be used to determine the metabolic activity rather than the morphologic features of the lesions. Bronchogenic carcinoma is
associated with an increased rate of glucose metabolism. PET uses deoxyglucose linked to fluorine 18 (a positron emitter). The agent,
2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG), competes with glucose for transport into the cells and after phosphorylation
accumulates in tumor cells. Lung tumor cells have increased glucose metabolism; however, this is not specific for tumors and may
occur in infectious or inflammatory processes.
FDG-PET scan has been used to differentiate benign from malignant pulmonary nodules. PET scans also may be useful in detecting
distant metastases when whole-body imaging is performed. Because of the false-positive rate, invasive staging procedures may still be
required before potentially curative surgical management is denied.[11]
Degree of confidence
PET imaging has higher sensitivity, specificity, and accuracy than does CT scanning in staging mediastinal disease. Published studies
have demonstrated a sensitivity of 80%, an overall specificity of 92%, and an accuracy of 92%, with a positive predictive value of
90% and a negative predictive value of 93%.
False positives/negatives
False-negative studies can occur in patients with carcinoid syndrome, bronchoalveolar carcinomas, and bronchogenic carcinoma
measuring less than 10 mm. False-positive findings are known to occur in infectious or inflammatory disorders such as tuberculosis,
histoplasmosis, and rheumatoid nodules.
Metastazele bronho-pulmonare
Mijlocul de diagnostic: radiografie standard i/sau CT. O radiografie toracic normal nu permite eliminarea diagnosticului;
nodulii de talie mic (cu diam sub 6mm), o limfangit localizat, o form embolic pot scpa i n acest caz CT este util.
(cancerul tiroidian cu metastaze pulmonare cu imagine toracic normal).
Forme radiologice Aspectele observate sunt n funcie de calea de diseminare: hematogen, limfatic, bronhogen.
A. Forma nodular: este cea mai frecvent; nodulii sunt variabili ca numr i dimensiune; pot fi unici, dar frecvent multipli,
aprnd ca opaciti diseminate n ambele arii pulmonare predominant la baze i la periferie. Aceast distribuie poate fi
modificat de condiiile anatomice locale de vascularizaie (emfizemul pulmonar). Sunt n general rotunde, omogene,
nete. Pot fi ntlnite forme atipice: contururile pot fi difuze printr-o hemoragie perimetastatic; contururi spiculiforme
simulnd un cancer bronho-pulmonar primitiv; leziuni excavate (4% din cazuri), n metastazele epidermoide ORL,
genitale sau n curs de chimioterapie. Excavaia realizeaz cteodat un aspect pseudochistic care explic posibilitatea
unui pneumotorax revelator; cteodat exist calcificri n metastaze de osteosarcom, cancer colic sau tiroidian; aspect
particular disembrioame testiculare cu metastaze nodulare stabile i dup chimioterapie (sterile).CT este metoda cea
mai sensibil pentru detectarea metastazelor. Detecteaz metastaze cu diametrul de la 2 la 3mm.
B. Forma infiltrant
1. Limfangita carcinomatoas- reprezint a 2-a mare form de metastazare. Este o form dramatic pentru pacient.
Radiologic: sindrom interstiial bilateral cu opaciti liniare mai mult sau puin groase, reticulo-nodulare i contur difuz
perihilar; mrirea progresiv a acestor imagini se acompaniaz rapid de o pierdere a volumului pulmonar, epanament
pleural frecvent i adenopatii hilare sau mediastinale.
2. Forma microembolic: radiografia normal n 25% din cazuri; aspect compatibil cu infarctul pulmonar n 50% din cazuri:
cteodat hipertransparen localizat.
3. Forme endobronice: puin frecvente (2% din metastaze) metastazare pe cale limfatic n submucoas spre caren i
trahee; semnele radiologice sunt ale cancerului central (opacitate hilar cu sau fr tulburri de ventilaie), dg fiind
endoscopic.
4. Forme bronhogene n carcinomul bronhiolo-alveolar cu expresie pneumonic, posibilitatea de propagare spre alte teritorii
segmentare sau lobare homo sau contralaterale este frecvent pe cale endo-aerian; aspectul radiologic este de
condensare alveolar pseudopneumonic cu bronhogram.
Tumorile benigne
Tumorile benigne reprezint 5-10% din tumorile pulmonare. Radiologic: opacitate unic, excepional multipl; vorbim de nodul dac
diametrul este inferior 3cm.
1. Argumente pentru benignitate
Pentru nodulii unici factorii de apreciere sunt:
- contextul clinic: vrsta pacientului: benignitatea este regula sub 30 ani (90%), reducndu-se la 45% peste 50ani; i disprnd
peste 80 ani; semnele asociate cu antecedentele de neoplazie cresc probabilitatea malignitii unui nodul.
-dimensiuni: 80% din nodulii benigni au mai puin de 2cm diametru;
- conturul: net i regulat orienteaz spre benignitate; n mai puin de 30% din cazuri este vorba de o leziune malign, n
general metastatic; invers conturul difuz i cu spiculi este evocator pentru malignitate dar se poate ntlni n 30% din
cazuri n leziunile benigne;
- structura - imaginea mixt se poate ntlni att n leziunile benigne ct i n cele maligne: leziunile benigne au un inel subire
i net; leziunile maligne au inel gros i neregulat; - calcificrile detectarea lor este un argument n favoarea benignitii;
- reinem: nidus central calcificat; calcificri lamelare i/sau concentrice, o impregnare calcic difuz; calcificri pop
corn. Leziunile maligne se pot calcifica- 14% din cazuri. CT este mult mai sensibil n detectarea calcificrilor.
- aprecierea n dinamic. Absena creterii timp de doi ani este un argument clasic n favoarea benignitii dar nu este absolut
i impune un grad de pruden. Adenocarcinoamele pot fi stabile n timp mai muli ani. Autorii americani susin c
din existena natural a unui cancer pulmonar s-a scurs n momentul n care el devine detectabil radiologic Fraser.
Carcinoamele bronice au de obicei un timp de dedublare ntre 1 i 18 luni. De aceea compararea cu radiografiile
anterioare poate fi util i o mas sau un nodul care nu i-a modificat aspectul ntr-un interval de 2 ani este aproape
sigur benign.
2. Orientarea etiologic
Dou tumori au caracteristici imagistice evocatoare pentru diagnostic: hamartomul: opaciate rotund de talie mic, sub
2,5cm, cu contur net i regulat, adesea boselat. n mai puin de 20% din cazuri exist calcificri; lipomul aspect
caracteristic CT ( mas omogen, bine delimitat, cu densiti de grsime).
Types
1. Hamaratomas make up 75 percent of benign lung tumors, the most common type found. They can occur in children, but the
majority of these are found in adults and are located on the edges of the lungs.
2. Bronchial adenomas account for half of all benign pulmonary tumors. This term also includes characinoid tumors and
mucoepidermoid carcinomas, both of which are actually low-level malignant lung tumors.
3. Mucous gland adenomas are the third main type of benign lung tumor. They're completely malignancy-free, found in the main or
smaller bronchi.
Identification
Regardless of type, most benign lung tumors arise on the lung's outer periphery. These non-life-threatening nodules can also be
found within the lungs' centrally located tracheobronchal tree.
The most common type of benign lung tumor, hamaratomas, occur on the lungs' periphery and are generally made up of fat, cartilage
and epithelial cell tissue. They are firm and marble-like growths.
Bronchial adenomas sprout from mucous glands and tracheal (or windpipe) ducts and are identified by their ability to spread very
slowly, since they are low-grade malignant tumors.
Found in both the main and local bronchi, mucous gland adenomas are column-like in appearance and are sometimes shaped like
small mushrooms.
Time Frame
The average patient diagnosed with benign lung tumors is 45 to 50 years old, and the incidence of the hamaratoma benign lung
tumor peaks in patients from 50 to 60.
Meanwhile, a mere 6 percent of common benign tumors of the lung have been found in patients younger than 30. These cases are also
very rare among children and adolescents.
Considerations
Doctors can opt to perform surgery to remove benign lung tumors, and do so primarily to ensure there are no potentially
harmful lesions on the lungs. Cancer-free lung masses are also frequently removed in cases where they provoke troublesome
symptoms, such as pneumonia or collapsing lung tissue.
Warning
Detecting the symptoms of benign lung tumors are key in leading to their diagnosis and removal. Symptoms include a range of
behaviors such as persistent coughing and wheezing, shortness of breath, coughing up of blood, fever or a rattling sound in the lungs.
Although non-cancerous tumors of the lung generally don't endanger a patient's health, some can obstruct the lungs, facilitating
pneumonia, lung tissue collapse and difficulty breathing.
Hemangiopericitoma
Hamartoma
Hamartoma