Imaging Pearls ❯ Chest ❯ Lung Cancer
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- OBJECTIVE. The purpose of this study was to evaluate the superiority of either of two protocols for combined contrast-enhanced thoracic and abdominal CT of patients with lung cancer by comparing contrast enhancement, contrast-related artifacts, image quality, and radiation dose.
CONCLUSION. A single 60-second delayed acquisition for thoracic and abdominal contrast-enhanced CT is associated with less contrast artifact and affords better visualization of lymph nodes at a lower radiation dose while acceptable vascular and hepatic contrast enhancement is maintained.
Best Protocol for Combined Contrast-Enhanced Thoracic and Abdominal CT for Lung Cancer: A Single-Institution Randomized Crossover Clinical Trial Elena García-Garrigós et al. AJR 2018; 210:1226–1234 - “Protocol A consisted of two acquisitions: one 35-second delayed CT acquisition for the chest followed by a 70-second delayed abdominal acquisition. Protocol B was a single 60-second delayed acquisition covering the chest and the abdomen. Attenuation and noise of the aorta, pulmonary artery, and liver were measured. Contrast-related artifacts, mediastinal lymph node visualization, liver enhancement, and noise were visually scored. Dose-length product was recorded."
Best Protocol for Combined Contrast-Enhanced Thoracic and Abdominal CT for Lung Cancer: A Single-Institution Randomized Crossover Clinical Trial Elena García-Garrigós et al. AJR 2018; 210:1226–1234 - “For patients with lung cancer, a single 60-second delayed acquisition for contrast- enhanced CT of the chest and abdomen is preferable to two separate acquisitions. It decreases contrast-related perivenous artifact, facilitates evaluation of mediastinal lymph node stations and pleural lesions, and improves tumor delineation. These benefits are achieved while the same abdominal enhancement and quality are maintained at lower but acceptable thoracic vascular enhancement and a lower radiation dose."
Best Protocol for Combined Contrast-Enhanced Thoracic and Abdominal CT for Lung Cancer: A Single-Institution Randomized Crossover Clinical Trial Elena García-Garrigós et al. AJR 2018; 210:1226–1234
- “TRO was associated with slightly higher yield of PE and AD, specifically in the emergency department. This benefit comes with higher nondiagnostic image quality, radiation, and contrast doses. Although TRO may be of value in selected patients, its indiscriminate use is not warranted. The appropriate use of TRO needs to be further defined.”
Triple Rule Out Versus Coronary CT Angiography in Patients With Acute Chest Pain Burris II, AC et al. J Am Coll Cardiol Img 2015;8:817–25
- “PET/CT has a high specificity, but low sensitivity for detecting LN metastasis in patients with NSCLC. Tb might be one of the main reasons for lower sensitivity of PET/CT in several countries. The primary clinicians of lung cancer should be aware of the possibility of hidden metastatic LNs in bilateral FDG uptake of mediastinal and hilar LNs, especially in the Tb endemic countries.”
Update on nodal staging in non-small cell lung cancer with integrated positron emission tomography/computed tomography: a meta-analysis. Pak K et al. Ann Nucl Med. 2015 Jun;29(5):409-19 - “Appropriate imaging modalities for screening, staging, and surveillance of patients with suspected and documented metastatic disease to bone include (99m)Tc bone scanning, MRI, CT, radiography, and 2-[(18)F]fluoro-2-deoxyglucose-PET. Clinical scenarios reviewed include asymptomatic stage 1 breast carcinoma, symptomatic stage 2 breast carcinoma, abnormal bone scan results with breast carcinoma, pathologic fracture with known metastatic breast carcinoma, asymptomatic well-differentiated and poorly differentiated prostate carcinoma, vertebral fracture with history of malignancy, non-small-cell lung carcinoma staging, symptomatic multiple myeloma, osteosarcoma staging and surveillance, and suspected bone metastasis in a pregnant patient. No single imaging modality is consistently best for the assessment of metastatic bone disease across all tumor types and clinical situations. In some cases, no imaging is indicated.”
ACR appropriateness criteria on metastatic bone disease. Roberts CC et al. J Am Coll Radiol. 2010 Jun;7(6):400-9 - “No single imaging modality is consistently best for the assessment of metastatic bone disease across all tumor types and clinical situations. In some cases, no imaging is indicated.”
ACR appropriateness criteria on metastatic bone disease. Roberts CC et al. J Am Coll Radiol. 2010 Jun;7(6):400-9 - “Skeletal metastases are the most common malignant tumor in bone. Certain types of cancer (e.g., of the prostate or breast) are particularly likely to give rise to skeletal metastases, with prevalences of up to 70%. The diagnosis of skeletal metastases has a major impact on the overall treatment strategy and is an important determinant of the course of illness and the quality of life. The goal of diagnostic imaging is to detect skeletal metastases early, whenever they are suspected on the basis of clinical or laboratory findings or in patients who are at high risk. Other important issues include assessment of the risk of fracture and the response to treatment.”
The Diagnostic Imaging of Bone Metastases Heindel W et al. Dtsch Arztebl Int. 2014 Oct; 111(44): 741–747.
- Lung Cancer is the number 1 cause of cancer related deaths
- In 2011 (the most recent year numbers are available from the CDC)
- 207,339 people in the United States were diagnosed with lung cancer, including 110,322 men and 97,017 women.
- 156,953 people in the United States died from lung cancer, including 86,736 men and 70,217 women. - Lung Cancer and Smoking
(NCI database)
- Cigarette smoking causes an estimated 443,000 deaths each year, including approximately 49,000 deaths due to exposure to secondhand smoke.
- Lung cancer is the leading cause of cancer death among both men and women in the United States, and 90 percent of lung cancer deaths among men and approximately 80 percent of lung cancer deaths among women are due to smoking. - Lung Cancer and Smoking
(NCI database)
- Smoking causes many other types of cancer, including cancers of the throat, mouth, nasal cavity, esophagus, stomach, pancreas, kidney, bladder, and cervix, and acute myeloid leukemia.
- People who smoke are up to six times more likely to suffer a heart attack than nonsmokers, and the risk increases with the number of cigarettes smoked. Smoking also causes most cases of chronic lung disease.
- People who quit smoking, regardless of their age, are less likely than those who continue to smoke to die from smoking-related illness:
- Quitting at age 30: Studies have shown that smokers who quit at about age 30 reduce their chance of dying prematurely from smoking-related diseases by more than 90 percent
- Quitting at age 50: People who quit at about age 50 reduce their risk of dying prematurely by 50 percent compared with those who continue to smoke
- Quitting at age 60: Even people who quit at about age 60 or older live longer than those who continue to smoke
- Lymphangitic Carcinoma: Differential Diagnosis
- Pulmonary edema
- Idiopathic pulmonary fibrosis
- Scleroderma
- Lymphoma
- Drug reaction
- Asbestosis
- Hypersensitivity pneumonitis - Lymphangitic Carcinoma: Source of Tumor
- Breast cancer
- Gastric cancer
- Pancreatic cancer
- Lung cancer
- Prostate cancer - Lymphangitic Carcinoma: facts
- Spread may be via lymphatics as in lymphoma or hematogenous spread from small pulmonary artery branches to the lymphatics
- Lymphangitic spread means stage IV disease
- Pathology is interstitial thickening of interlobular septa due to tumor spread, desmoplastic response and dilated lymphatics
- Lymphangitic Carcinoma: Differential Diagnosis
- Pulmonary edema
- Idiopathic pulmonary fibrosis
- Scleroderma
- Lymphoma
- Drug reaction
- Asbestosis
- Hypersensitivity pneumonitis - Lymphangitic Carcinoma: Source of Tumor
- Breast cancer
- Gastric cancer
- Pancreatic cancer
- Lung cancer
- Prostate cancer - Lymphangitic Carcinoma: facts
- Spread may be via lymphatics as in lymphoma or hematogenous spread from small pulmonary artery branches to the lymphatics
- Lymphangitic spread means stage IV disease
- Pathology is interstitial thickening of interlobular septa due to tumor spread, desmoplastic response and dilated lymphatics - “ Perfusion CT can depict therapy induced changes in patients with lung adenocarcinoma and can identify response to treatment on the whole tumor mass.”
Whole Tumor Perfusion CT in Patients with Advanced Lung Adenocarcinoma Treated with Conventional and Antiangiogenetic Chemotherapy: Initial Experience
Fraioli F et al.
Radiology 2011; 259:574-582 - “ Perfusion CT imaging may allow evaluation of lung cancer angiogenesis demonstrating alterations in vascularity following treatment.”
Whole Tumor Perfusion CT in Patients with Advanced Lung Adenocarcinoma Treated with Conventional and Antiangiogenetic Chemotherapy: Initial Experience
Fraioli F et al.
Radiology 2011; 259:574-582 - Bronchioalveolar Carcinoma (BAC): CT Appearance
- Ground glass nodule
- Single mass
- Diffuse consolidation
- Multinodular forms - Bronchioalveolar Carcinoma (BAC): Facts
- Up to 6% of all primary lung cancers
- Male to female ratio is 1:1
- Subtype of well differentiated adenocarcinoma
- Presents with cough, hemoptysis or as an incidental finding "In 2009 a new TNM staging system was published by the International Union Against Cancer and the American Joint Committee on Cancer. The new edition will encompass no-small cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoids."
A Radiologic Review of the New TNM Classification for Lung Cancer
Kligermn S, Abbott G
AJR 2010; 194:562-573"Non-small cell lung cancer with higher perfusion is more sensitive to chemoradiation therapy than that with lower perfusion. After chemoradiation therapy, findings at perfusion CT are a significant predictor of early tumor response and overall survival among patients with non-small cell lung cancer."
Tumor Response in Patients With Advanced Non-Small Cell Lung Cancer: Perfusion CT Evaluation of Chemotherapy and Radiation Therapy
Wang J et al.
AJR 2009; 193:1090-1096- How can you measure tumor response to therapy?
- RECIST criteria (size)
- Tumor volume
- Perfusion CT imaging
- PET/CT activity - “ In 2009 a new TNM staging system was published by the International Union Against Cancer and the American Joint Committee on Cancer. The new edition will encompass no-small cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoids.”
A Radiologic Review of the New TNM Classification for Lung Cancer
Kligermn S, Abbott G
AJR 2010; 194:562-573