Chest imaging III: Nodular pulmonary disease. Ádám Domonkos Tárnoki, MD, PhD Assistant professor Department of Radiology, Semmelweis University 1

Transcription

1 Chest imaging III: Nodular pulmonary disease Ádám Domonkos Tárnoki, MD, PhD Assistant professor Department of Radiology, Semmelweis University 1

2 Pattern 2

3 Nodular pattern Several round opacity, typically 1 mm - 1 cm in diameter Forms: miliary (1-2 mm), small, medium or large, as the size of opacity increases When the nodular patterns are located in predominant distribution, may refer to specific differential diagnoses 3

4 The morphology of nodular pulmonary abnormalities Solitary lung nodules: Tuberculoma, bronchial carcinoma, metastasis, hamartoma, abscess, aspergilloma, adenoma, round atelectasis, AV shunt, bronchogenic cyst, sequestration, echinococcal cyst, infarction Multiple lung nodules can be cathegorized based on size: Miliary: TB, sarcoidosis, histiocytosis, silicosis, metastases Medium (sub-miliary): bronchogenic TB, metastases, peripheral Kaposi's sarcoma Large: metastases, Wegener's disease, lymphoma 4

5 Differentialdiagnosis of nodules Group Tumor Examples for some diseases metastases multiple primary tumor Kaposi's sarcoma Inflammation miliary tbc multiple lung abscess, septic embolism histoplasmosis, blastomycosis, candidiasis aspergillosis, varicella-zoster virus Connective tissue disorders and vasculitis Rheumatoid arthritis Wegener granulomatosis Pneumoconioses Vascular diseases Hypersensitive and idiopathic diseases silicosis pneumoconiosis of coal workers Multiplex AV malformations hemosiderosis sarcoidosis Langerhans cell histiocystosis hypersensitive pneumonitis 5

6 Multiple lung nodules (<3 cm) The secondary pulmonary lobule 6

7 Differentialdiagnosis of lung nodules Bronchiolar disease pulmonary edema vasculitis Webb HR: High resolution CT of the Lung sarcoidosis silicosis Lymphangiosis cc. Miliary tbc Miliary fungal infection Miliary viral infection metastases 7

8 Centrilobular nodular pattern Webb HR: High resolution CT of the Lung 8

9 Perilymphatic nodules Silicosis Sarcoidosis Lymphangitis job history upper lobe pseudo plaques calcified hilar lymph nodes Upper lobe Symmetric lymphadenopathy (BHL) Peribronchovascular nodules (irregular) nodular thickening of the interlobular septa pleural effusion 9

10 Differential diagnosis of the random distribution of the lung nodules Inflammatory tuberculosis Virus (CMV, flu, chickenpox) Fungi (blastomycosis, histoplasmosis) Metastases Thyroid cancer Adenocarcinoma 10

11 The solitary pulmonary nodules (<3 cm) Fleischner Radiology 2008 Round or oval, it is surrounded by the lung parenchyma Benign or malignant? 1. Density 2. Growth rate 3. Wind, shape 4. Cavitation 5. Air 6. Calcification 7. Size 11

12 The three types of lung nodules (<3 cm) Fleischner Radiology 2008 Solid nodule Partsolid (semisolid) nodule Clear ground glass (GG) (nonsolid) nodule 12

13 The solitary pulmonary nodules (<3 cm) Fleischner Radiology 2008 Round or oval, it is surrounded by the lung parenchyma Benign or malignant? 1. Density 2. Growth rate 3. Wind, shape 4. Cavitation 5. Air 6. Calcification 7. Size 13

14 The solitary pulmonary nodules (<3 cm) Volume doubling time (VDT): Volume doubling over time = 26% diameter increase Solid nodules VDT: days: most likely malignant VDT: <20 or >400 days: likely benign There is no growth in 2 years: the most reliable sign of benign behavior Subsolid nodules: they can grow very slowly! Hartmann I. ECR

15 The solitary pulmonary nodules (<3 cm) Fleischner Radiology 2008 Round or oval, it is surrounded by the lung parenchyma Benign or malignant? 1. Density 2. Growth rate 3. Wind, shape 4. Cavitation 5. Air 6. Calcification 7. Size 15

16 The solitary pulmonary nodules (<3 cm) Sharp, spherical: 20-30% malignant Lobulated, spiculated, irregular: % malignant Hartmann I. ECR

17 The solitary pulmonary nodules (<3 cm) Fleischner Radiology 2008 Round or oval, it is surrounded by the lung parenchyma Benign or malignant? 1. Density 2. Growth rate 3. Wind, shape 4. Cavitation 5. Air 6. Calcification 7. Size 17

18 The solitary pulmonary nodules (<3 cm) Especially squamous cell carcinoma Any size often eccentric Often thick, irregular wall (=> 5 mm) Air and / or liquefaction Often air-fluid level Hartmann I. ECR

19 The solitary pulmonary nodules (<3 cm) Fleischner Radiology 2008 Round or oval, it is surrounded by the lung parenchyma Benign or malignant? 1. Density 2. Growth rate 3. Wind, shape 4. Cavitation 5. Air 6. Calcification 7. Size 19

20 The solitary pulmonary nodules (<3 cm) air bronchogram Cyst-like hypodensities ("soap bubbles") Most commonly adenocarcinoma Hartmann I. ECR

21 The solitary pulmonary nodules (<3 cm) Fleischner Radiology 2008 Round or oval, it is surrounded by the lung parenchyma Benign or malignant? 1. Density 2. Growth rate 3. Wind, shape 4. Cavitation 5. Air 6. Calcification 7. Size 21

22 The solitary pulmonary nodules (<3 cm) Benign pattern Malignant pattern B. Ericsoussi Hartmann I. ECR

23 The solitary pulmonary nodules (<3 cm) Fleischner Radiology 2008 Round or oval, it is surrounded by the lung parenchyma Benign or malignant? 1. Density 2. Growth rate 3. Wind, shape 4. Cavitation 5. Air 6. Calcification 7. Size 23

24 Follow-up of lung nodules (Fleischner, Radiology 2017) 24

25 The solitary pulmonary nodules (<3 cm) Fleischner Radiology 2008 Round or oval, it is surrounded by the lung parenchyma Benign or malignant? 1. Density 2. Growth rate 3. Wind, shape 4. Cavitation 5. Air 6. Calcification 7. Size 25

26 Node detection: computed aided diagnosis (CAD) Computer-Diagnose (CAD): hilary nodules better than the peripheral Diagnosis by a radiologist (RAD): subpleural nodules better than the central CAD + RAD is better than 2 radiologists 26

27 Primary tumors Benign tumors (hamartoma, chondroma, lipoma): rare Semimalign (adenoma, hamartoma, carcinoid) X-ray: Round or lobulated node with well demarcated boundary, calcifications CT: small hilar lymphadenopathy, possible metastases Malignant bronchial carcinoma Central: in hilus area, unclear hilary extension Peripheral: in the lung parenchyma or along the thoracic wall Pancoast tumor: in the lung apex and grows transpleural through the chest wall, infiltrating the cervical sympathetic ganglia BAC (bronchoalveolar carcinoma) spreads into the alveoli, it is manifested by multinodular, infiltrative condensations in the peripheral pulmonary parenchyma, but can also appear in the form of round condensations 27

28 Carcinoid central lesion well circumscribed, round or oval ~ 2-5 cm homogeneous contrast enhancement Calcification (eccentric) 28

29 Bronchial carcinoma Adenocarcinoma Squamous cell Large cell Small cell SCLC NSCLC 29

30 Bronchioloalveolar carcinoma (BAC) 1-9% of the lung tumors Subtype of NSCLC (adenocarcinoma) 50% asymptomatic The terminal bronchioles, alveoli are affected Slowly progredient, "non-invasive" growth (the blood and lymph vessels, surrounding lung parenchyma are not affected) "lepidic" growth "Pre-invasive" malignant lesions (in situ carcinoma) invasive adenocarcinoma Non-smoker, women, Asia 30

31 Small growth (BAC) (alveolar collapse) 31 GGO PS PS PS S Vall d Hebron Hospital, Barcelona

32 IASLC/ATS/ERS classification of lung adenocarcinoma (2013) Preinvasiv lesions (formerly BAC) Atypical adenomatous hyperplasia (AAH) Adenocarcinoma In Situ (AIS) Minimally invasive lesions Minimally invasive Adenocarcinoma (MIA) Invasive ADC Predominantly lepidic ADC (LPA) Predominantly acinar Predominantly papillary Predominantly micropapillary Predominantly solid BAC stopped! Instead: AIS / MIA Instead of mucinous BAC: invasive mucinous ADC 32

33 IASLC/ATS/ERS classification of lung adenocarcinoma (2013) Takashima AJR Gandara J Tho Oncol 2006

34 CT and histopathological correlation in ADC Lederlin M Diagn Interv Imaging Lee HY AJR 2014

35 Lung cancer (mass: > 3cm): staging 5 yr survival Rami-Porta et al. Ann Thorac Cardiovasc Surg

36 Hematogenic spread: Metastases breast, prostate, kidney, thyroid, cervical, testicular, bone, melanoma, gastrointestinal and pancreatic tumors Lymphatic spread: breast, Bronchial carcinoma Lymphangitis carcinomatosa 36

37 DDD (detection, delineation, differentation) Nodules: >8-10 mm - to do! TNM Staging T: CT, MRI assessment of some cases (resectability) N: PET-CT M: PET-CT or MRI Staging CT-Screening has sence 37

38 CT-Screening of lung cancers (2017) Callister, Baldwin, Akram et al: British Thoracic Society guidelines for the investigation and management of pulmonary nodules: accredited by NICE Low dose CT Volumetry CAD? Double reporting? 38

39 CT-Screening of lung cancers (2017) Callister, Baldwin, Akram et al: British Thoracic Society guidelines for the investigation and management of pulmonary nodules: accredited by NICE ADVANTAGES There is 1 death associated death with radiation exposure versus 22 rescued patients fear-induced anxiety (2-6 months) smoking cessation Cost-effective: Screening + intensive smoking cessation + intervention DISADVANTAGES Overdiagnoses False positive cases Reduced by categorization of nodules Volumetry for an accurate assessment of growth Resection through benign disease Patz EF Jr et al. Overdiagnosis in low-dose computed tomography screening for lung cancer. JAMA Intern Med Feb 1;174(2): de Koning HJ et al. Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. Preventive Services Task Force. Ann Intern Med Mar 4;160(5):

40 Always look at the "hidden" areas on the x-ray film: Hilus Apex Behind the diaphragm and cardiac shadow

41 Summary Solitary/multiple lung nodules Multiple DD: localization: centrilobular, perilymphatic, random Solitary DD: solid, partsolid (semisolid), clear ground glass (GG) (nonsolid) nodules Density, growth rate, wind, shape, cavitation, air, calcification, size Nodules follow-up: Fleischner (2017) Primary tumors BAC! Lung cancer CT-Screening: preferred Staging (TNM): CT/MRT/PET-CT 41

42 THANK YOU FOR YOUR ATTENTION 42