Radiological staging of lung cancer Shukri Loutfi,MD,FRCR Consultant Thoracic Radiologist KAMC-Riyadh
Bronchogenic Carcinoma Accounts for 14% of new cancer diagnoses in 2012. Estimated to kill ~150,000 people in the US in 2013. Responsible for 28% of cancer related deaths in the US. Exceeds the mortality from breast,prostate,colon and pancreatic cancers combined. Klingerman,S.Radiol Clin N Am 52 (2014) 69-83
Bronchogenic Carcinoma Non-small cell lung cancer (NSCLC),(85%) Adenocarcinoma (35-40%) Squamous cell carcinoma (25-30%) Large cell carcinoma (10-15%) Small cell lung cancer (SCLC), (15%).
Purpose of Lung Cancer Staging Staging of any tumor is done to Define the extent of disease. To determine prognosis. To select proper treatment. Curative therapy: Surgery Radiotherapy RFA Palliative care: in more advanced disease.
The Role of Radiologist in Lung Cancer
Chest Radiographs Usually the 1 st imaging modality. Detection of Lung cancer depends on; Size, location, technique (PA and/or lateral view, dual-energy). Define intra or extra-pulmonary location. Determine next imaging modality.
Chest Radiographs
Chest Radiographs Golden S Sign Luftsichel sign
Dual-energy Radiography
Hilar overlay sign
Lung Cancer Staging Computed Tomography PET or PET/CT Radio-isotope scan MRI
Lung Cancer Staging
Computed Tomography Technique: Anatomical coverage: Base of neck to the inferior border of the liver covering the adrenal glands. +/-Contrast administration*. 80-100 cc of Low/Iso-osmolar Contrast at 3-4 ml/sec flow rate. Slice thickness of 2.5-5 mm with 1:1 pitch. Multi-planar Reformation. *Patz and colleague; IV contrast administration altered radiological staging in 4% of patients.
T-Descriptor I. Size of the primary neoplasm. II. Invasion of adjacent structures. III. Relationship to tracheo-bronchial tree. IV. Presence of ipsilateral tumoral nodules.
T-Descriptor (Size) The radiology reports most include the longest dimension of the primary tumor so the size component of T-Staging is performed by the reader.
T-Descriptor (Size)
T-Descriptor (Size)
T-Descriptor(Local invasion)
T-Descriptor(Local invasion) Chest wall invasion by CT Sensitivity 38-87% Specificity 40-90% Can be mimicked by pleural inflammation and thickening. The most reliable sign. Rib/vertebral destruction. Mediastinal Invasion I. 3cm contact. II. III. Loss of fat planes. 90 degrees encasement of the Aorta
T-Descriptor(Local invasion)
T-Descriptor(Local invasion)
T-Descriptor(Local invasion) MR has utility in the evaluation of mediastinal invasion (pericardial and myocardial ) and Pancoast tumor.
T-Descriptor (Tracheo-bronchial invasion)
T-Descriptor (Tracheo-bronchial invasion)
T-Descriptor (additional Ipsilateral Pulmonary nodules) Radiologists play important role in the identification of additional pulmonary nodules via pre-operative studies. Nodules in the same lobe T3. Nodules in different lobe T4.
T1 Disease T1a T1b
T2 Disease Subtotal lung collapse 4.8 cm mass > 2 cm from the carina
T3 Disease > 7 cm diameter <2 cm from carina Same lobe additional nodules
T4 Disease
Evaluation of Primary Tumor (the T Factor) CT is the main modality. T1 and T2 lesions distinction ;based on size and rarely impacts the choice of therapy. Cannot reliably determine the presence of parietal pleural invasion. Features such as discrete bone destruction. MRI: Problem solving. Superior to CT for neural foramina, spinal canal, and brachial plexus involvement in superior sulcus tumors. Useful in chest wall/pericardial invasion. ACR Appropriateness Criteria non-invasive clinical staging of bronchogenic carcinoma.
N-Descriptor
J Thorac Oncol 2007;2(7): 603-12 N-Descriptor
N-Descriptor A short axis greater than 10 mm is widely accepted as the reference for enlarged thoracic lymph nodes. Prevalence of malignancy influenced by size: 30% in LNs with diameter 10-15 mm and 67% in LNs with diameter > 15 mm. PET-CT is superior to CT for mediastinal lymph node staging. PPV, NPV and accuracy are 78%,91%and 87%, respectively.* False positive results from inflammatory /infectious lymphadenopathy or residual brown fat. False negative results when tumor load is low (Micrometastes). Important Changes in the 7 th edition of the TNM staging system. Moving the division between right and left paratracheal lymph nodes (Stations 2-4) from the midline to the left lateral border of the trachea. *De Wever et al.eur Respir J 2009;33:201-12
Courtesy of Mustafa Altinyay,MD N-Descriptor
Brown Fat
M-Descriptor
M-Descriptor PET-CT is the best imaging modality for evaluation of metastatic disease except for the brain (MRI is superior). Pleural involvement Pleural thickening and enhancement. Discrete pleural nodules. Increased FDG-PET activity. Thoracocentesis or thoracoscopic biopsy.
ACR Appropriateness Criteria non-invasive clinical staging of bronchogenic carcinoma.
Reporting (RECIST 1.1 Criteria) Presented in January 2009 by RECIST working group Measurable lesions Lesions > 10 mm in longest diameter on CT or MRI. Lesions 20 mm in longest diameter on Chest radiographs. Non-Measurable lesions Lesions < 10 mm. Skeletal metastases without soft tissue component. Ascites. Pleural/pericardial effusion. Lymphangitic Spread. Lemptomeningeal spread. Lesions in irradiated area. Organomegaly. http://www.recist.com/
Measurable lesions
Non-Measurable lesions
Reporting (RECIST 1.1 Criteria) Selection of Target lesions based on size and suitability for accurate repeated measurements. Target lesions are two per organ and five maximum in total RECIST 1.0 RECIST 1.1
Reporting (RECIST 1.1 Criteria) It is possible to record multiple nontarget lesions involving the same organ as a single item on the case record form (e.g. multiple enlarged pelvic lymph nodes or multiple liver metastases.
Reporting (RECIST 1.1 Criteria) Lymph nodes with a short axis of 15 mm are considered measurable and assessable as target lesions. Lymph nodes with a short axis of < 10 mm are defined as nonpathologic. All other pathologic nodes with a short axis of 10 mm but < 15 mm should be considered nontarget lesions
Reporting (RECIST 1.1 Criteria) The sum of the longest diameters of all target lesions is recorded and used for objective tumor response assessment Nishino M et al. AJR 2010;195:281-289
Reporting (RECIST 1.1 Criteria)
Reporting (RECIST 1.1 Criteria) Assessment of progressive disease Partial response Stable disease Progressive disease
Reporting (RECIST 1.1 Criteria) Paradoxical increase in tumor size in response to therapy due to hemorrhage or necrosis Observed in targeted anticancer therapy using antiangiogenesis agents or tyrosine kinase inhibitors. MRI or PET-CT can be used to confirm the presence of intralesional changes and metabolic response. Radiologists must be aware of this phenomenon to avoid misinterpretation and to prompt appropriate further evaluation by MRI or PET/CT.
Reporting (RECIST 1.1 Criteria) Paradoxical increase in size of target lesions after targeted therapy in 69-year-old woman with melanoma
The Role of Radiologist in Lung Cancer