1. Myndrannsóknir á lungum Lungnakrabbamein Jørgen Albrechtsen, röntgenlæknir

2. Lung cancer Non-small cell lung cancer (NSCLC) 75% (Similar prognosis and managed in a similar way) – Adenocarcinoma – Squamous cell carcinoma – Large cell cancer Small cell lung cancer (Surgery an option in fewer than 5%) Lung cancer staging relies on the TNM system designed jointly by the UICC (Union Internationale Contre le Cancer) and the AJCC (American Joint Committee on Cancer). The system is based on the spread of the primary tumor (T), the extent of lymph node involvement (N), and the presence or absence of metastases (M). In SCLC staging is more an issue of identifying patients with localized vs metastatic disease.

3. Staging of lung cancer

4. NSCLC staging: Primary tumor (T) T1: < 3cm, surrounded by lung or pleura, and not located in the main stem bronchus T2: > 3cm, or involving the main stem bronchus, 2 cm or more from the carina, or tumor invading the visceral pleura, or tumor with incomplete lung expansion or obstructive lung infection that does not involve the entire lung T3: Any size that directly invades the chest wall, diaphragm, pleura, or pericardium, or tumor that involves the main stem bronchus less than 2 centimeters (< 2 cm) from the carina, or associated with complete lung collapse or obstructive lung infection involving the entire lung T4: Any size that invades the heart, great vessels, trachea, esophagus, vertebral body, or carina, or separate tumor nodules in the same lung lobe, or associated with a malignant pleural effusion

5. Lung nodulus Benign Malign Pattern of calcification Shape Sharpness of contour Degree of calcification Size

6. Lung cancer

7. Fluid in the horizontal fissure

8. Lung cancer: Pancoast´s tumor A cancer in the inlet of the thorax is called a Pancoast´s tumor. It may infiltrate the nerves of the brachial plexus causing radiculating pain of the shoulder and arm. It also may cause Horners syndrom*) by growing into the sympathetic nerve pathway along the great vessels of the thoracic inlet. *) Horners syndrom: 1.Pupil constriction Ptosis Loss og sweating on the forhead

9. Lung cancer: Pancoast´s tumor MPR images are very important to identify thoracic wall infiltration. “Dirty fat” in the extrapleural space indicates cancer infiltration. MPR- and 3D images makes it possible to follow the contrast filled vessels.

10. NSCLC staging: Lymph nodes (N) Short axis diameter > 10mm – N1: Hilar lymph nodes – N2: Ipsilateral mediastinal lymph nodes – N3: Contra lateral mediastinal lymph nodes

11. Lymph nodes Mediastinal and hilar lymph nodes are often seen. They are oval, sharply delineated from mediastinal fat and may demonstrate a “hilum fat sign” 10 mm In general lymphnodes smaller than 10 mm across are considered normal. According to the “American thoracic society” they may be as large as 15 mm in the aortopulmonal window, 10 mm hilar and subcarinal, 7 mm para-aortic and 6 mm in the anterior mediastinum. If more than 3 lymph nodes are seen in the aortopulmonal window abnormallities should be considered (infection, metastasis or lymphoma) Subcarinal lymph node Esophagus Para-aortic lymph nodes Metastases Hilar lymph node Aortopulmonar window

12. Staging Pericardium Esophagus

13. PET/CT PET CT PET is superior to CT in the assessment of mediastinal nodal metastases. In patients with N2 disease, PET had a sensitivity of 83% and a specificity of 94%, compared with a sensitivity of 63% and a specificity of 73% with CT. The superiority of PET is even more marked in the assessment of hilar nodes, for which it has a 73% sensitivity and a 76% specificity, compared with an 18% sensitivity and an 86% specificity with CT. CT PET

14. Cyclotron FDG (2- 18 fluoro-deoxy-D-glucose) –Synthesizer PET/CT PET: Possitron Emission Tomography IsotopHalf-life Cabon-11 20 min Nitrogen-13 10 min Oxygen-15 2 min Flourin-18 70 min (Molybdenenum-99 66 hours)

15. Distant metastases (M) Lung. Liver. Adrenal glands. Bone. Brain. – NSCLC 50% of patients with metastases – lowest in squamous cell cancer. Adenocarcinoma tent to metastasize to the brain and adrenals early in its course. – SCLC: 80% at presentation

16. Lung metastasis Pulmonary metastases are not visible in conventional x-ray unless they are larger than 5 to 6 mm. In CT they can be detected at 1 to 2 mm. The correct windowsetting is essential: Small focal lesions do not appear on soft-tissue windows, or may be mistaken for normal vessels. Lungwindow should always be used for examining lung parenchyma!

17. Metastases CT

18. Bonescann

19. Metastases

20. Metastasis MRI

21. Ultrasound metastasis vs. cysts Acoustic enhancement behind cysts

22. Case

23. Nodule

24. Pulmonary nodule Single intraparenchymal lesion < 3cm and not associated with atelectasis or lymphadenopathy (Lesion >3cm = mass is considered malignant until otherwise proven)

25. Pulmonary nodules (Size) Likelihood of malignancy – 0.2% for <3mm – 0.9% for 4-7mm – 18% for 8-20mm – 50% for >20mm MidthunDE, Swensen SJ, Jett JR, Hartman TE. Evaluation of nodules detected by screening for lung cancer with low dose spiral computed tomography. Lung Cancer2003;41(suppl 2):S40. Size <4mm 4-7mm 8-20mm >20mm Total 2038 1034 268 16 Malignancy 0% 1% 15% 75%

26. Pulmonary nodules Older recommendations for small nodules was: CT-follow-up 3, 6, 12, 18 and 24 month <1% of nodules <5mm are malignant 51% of all smokers >50years have small pulmonary nodules The probability of a 8mm nodule turning into lethal cancer is 10 – 20% MacMahorn et al: Guidelines for management of small pulmonary nodules detected on CT scans: A Statement from the Fleischner society. Radiology Nov 2005, 237; 395-400

27. Recommendation for follow up Nodule size *) Low-risk patientHigh-risk patient <4mmNo follow-upFollow-up CT at 12month; if unchanged, no further follow-up 4-6mmFollow-up CT at 12month; if unchanged, no further follow-up Initial follow-up CT at 6 to 12month then at 18 to 24 month if no change 6-8mmInitial follow-up CT at 6 to 12month then at 18 to 24 month if no change Initial follow-up CT at 3 to 6month then at 9 to 12 and 24 month if no change >8mmFollow –up CT at around 3, 9, 24 month, dynamic contrast enhanced CT, PET and/or biopsy Same as low-risk patient *) Average of length and with