Chapter

Radiological Diagnosis
and Staging of Lung Cancer 11
Simon Padley

Contents more deaths; in some Scandinavian countries female

lung cancer deaths surpass those in males.
11.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . 127
Smoking tobacco significantly increases the likeli-
11.2 Presentation and Diagnosis . . . . . . . . . . . . . . 127 hood of developing lung cancer, the relative risk in-
11.2.1 Symptoms . . . . . . . . . . . . . . . . . . 127 creasing 20- to 30-fold in smokers as compared to non-
11.2.2 Chest Radiography . . . . . . . . . . . . . 128 smokers. Passive smokers are also at an approximately
11.2.3 Computed Tomography . . . . . . . . . . 128 24% increased risk of developing lung cancer [2]. Other
11.2.4 Adenocarcinoma . . . . . . . . . . . . . . 129 risk factors for developing lung cancer include occupa-
11.2.5 Squamous Cell Carcinoma . . . . . . . . 130
11.2.6 Large-Cell Carcinoma . . . . . . . . . . . 130 tional exposure to asbestos and several other carcino-
11.2.7 Small-Cell Lung Cancer . . . . . . . . . . 130 gens, pulmonary fibrosis, and radiotherapy.
11.2.8 Subsequent Patient Investigation . . . . 130 Late presentation is one of the factors that has im-
11.2.9 Biopsy . . . . . . . . . . . . . . . . . . . . 130 paired significant improvements in survival rates over
11.2.10 Positron Emission Tomography . . . . . 131 the past 30 years, despite advances in detection meth-
ods and treatments. Median survival from diagnosis has
11.3 Staging . . . . . . . . . . . . . . . . . . . . . . . . . . 131
11.3.1 Staging of NSCLC . . . . . . . . . . . . . 131 remained at 6±12 months, and overall 5-year survival is
11.3.1.1 The International Staging System . . . . 131 approximately 5% [3]. No study has described definite
11.3.1.2 Staging of the Primary Tumor . . . . . . 132 benefit from screening for lung cancer. Recent large
11.3.1.3 Chest-Wall Invasion . . . . . . . . . . . . 133 computed tomography (CT) studies have demonstrated
11.3.1.4 Nodal Staging . . . . . . . . . . . . . . . . 137 increased lung cancer detection in at-risk populations,
11.3.1.5 Detection of Nodal Enlargement . . . . . 137
11.3.1.6 Extrathoracic Staging . . . . . . . . . . . 138 but many questions remain unanswered. Most impor-
11.3.1.7 Liver Metastases . . . . . . . . . . . . . . 138 tantly, there is no current evidence that screening con-
11.3.1.8 Adrenal Metastases . . . . . . . . . . . . . 138 fers a disease-specific survival benefit. In an effort to
11.3.1.9 Brain Metastases . . . . . . . . . . . . . . 138 provide definitive evidence, a large-scale trial, the Na-
11.3.1.10 Bone Metastases . . . . . . . . . . . . . . 139 tional Lung Cancer Screening Trial (USA), is currently
11.3.1.11 Lung Metastases . . . . . . . . . . . . . . 140 underway. This will study the overall and comparative
11.3.2 Staging of SCLC . . . . . . . . . . . . . . 140
utility of chest radiography and spiral CT for lung can-
11.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 141 cer screening and has recruited 50,000 patients. This
trial commenced in 2002 and is due to continue until
2009, after which the findings will be reported.

11.1 Epidemiology
Lung cancer is the most frequently encountered malig-
nancy worldwide, with 1.2 million new cases annually,
causing 17.8% of all cancer deaths [1]. Four major cell
types exist, accounting for 95% of lung cancers. The
first three are squamous cell carcinoma (SCC), adeno-
carcinoma, and large-cell carcinoma, which are collec-
tively known as non-small-cell lung cancer (NSCLC).
The fourth major cell type, small-cell lung cancer
(SCLC), is grouped separately. Currently there is a 3:1
male to female predominance. In women, breast cancer
is currently more common, but lung cancer causes
11.2 Presentation and Diagnosis
11.2.1 Symptoms
Overall, approximately 10% of patients with lung cancer
are asymptomatic at presentation [4, 5], the diagnosis
usually arising incidentally from a radiograph underta-
ken for other reasons. In symptomatic patients the un-
derlying disease may cause cough, hemoptysis or pain.
Mediastinal invasion can lead to symptoms of hoarse-
ness, Horner's syndrome, phrenic nerve paralysis, dys-
128 III. Clinical Evaluation of Lung Cancer
phagia, and superior vena cava obstruction [6]. Large
pleural effusions may cause breathlessness. In addition,
symptoms may be constitutional (e.g., malaise, weight
loss) or directly related to metastatic deposits (e.g., pain
from skeletal metastases). Other manifestations include
paraneoplastic phenomena such as hypertrophic os-
teoarthropathy, Lambert Eaton Syndrome, and inap-
propriate antidiuretic hormone secretion.
Symptoms are often nonspecific, but their first-line
investigation often includes chest radiography, which
may identify the presence of the tumor. Cross-sectional
imaging with CT is then usually undertaken to confirm
the nature of the mass.
11.2.2 Chest Radiography
It is rare that a lung cancer is identified on chest radio-
graphy unless it is greater than 1 cm in diameter [7±
11]. Furthermore, it has been reported that 85% of
missed lung cancers are peripheral, < 2 cm in size, of
low contrast density, and are in areas of anatomical
overlap (e.g., between the ribs and clavicle) [12].
Although small lung cancers (< 1 cm) are difficult to de-
tect, optimal viewing conditions and systematic analysis
with particular attention to review areas (apices, retro-
cardiac, hilar, and diaphragmatic areas) have been
found to aid detection [13]. Once a suspicious lesion is
identified it is important to undertake comparison with
any previous radiographs. If the lesion was present pre-
viously but is unchanged over a 2-year interval it can
be presumed to be benign [14, 15]. In circumstances
where no old films are available, CT is usually employed
to characterize the lesion further [16].
11.2.3 Computed Tomography
CT is useful in further classification of nodules identi-
fied on chest radiography. Lung cancers on CT typically
appear as soft-tissue-density mass lesions within the
lung parenchyma, but occasionally they may appear as
focal ground-glass opacities (especially in adenocarci-
noma). Other imaging findings include:
1. Air bronchograms (typically in adenocarcinoma).
2. Calcification (rarely seen on chest radiography, seen
in up to 10% of cases on CT) is found predominant-
ly in tumors greater than 5 cm in diameter, but
amorphous or cloud-like calcification may be seen in
small peripheral tumors [17]. Cancers may engulf a
preexisting calcified focus.
3. Cavitation, most typically a feature of SCC [18, 19],
is normally eccentric and can occur in tumors of
any size. The cavity is normally thick-walled and
may contain fluids and necrotic tumor fragments. In
rare cases an air-crescent may be seen within the
cavity outlining the tumor mass [20].
4. Nodules (£ 3 cm) that contain mixed soft-tissue and
ground-glass densities carry greater risk of malig-
nancy than purely solid nodules and are more com-
monly associated with bronchioalveolar cell carcino-
ma (BAC) [21]. The histology of mixed nodules was
found to differ from that of purely solid nodules,
and is more commonly associated with BAC histol-
ogy [21].
Other findings on chest radiography and CT that raise
the suspicion of malignancy include:
1. The radiographic `S' sign of Golden (seen as a
bulging fissure deviated around a central tumor
mass, typically in the right upper zone), which im-
plies a proximal lung tumor causing distal lung col-
lapse.
2. Large lesions. The likelihood of malignancy of a le-
sion identified on CT is increased with increasing
size (up to 80% of nodules with a diameter greater
than 2 cm are malignant [22, 23].
3. Localized consolidation confined to one lobe that
persists for longer than 2 weeks or recurs in the
same lobe, especially if there is no associated loss of
volume or air bronchograms. It is generally held that
complete resolution of a consolidation excludes an
underlying obstructing mass.
4. Consolidation confined to one lobe in a patient > 35
years old associated with volume loss, mucus-filled
bronchi ,and absence of air bronchograms. Mucus-
filled dilated airways seen within collapsed lobes
(better appreciated on postcontrast images) should
prompt the search for a centrally obstructing tumor
[17]. Careful analysis of CT images may reveal an
endobronchial mass.
5. Unilateral hilar enlargement. This may be the only
radiographic feature of a lung malignancy [24±28]
and may reflect a proximal tumor, lymphadenopathy,
consolidated lung, or a combination of all three. CT
scanning is useful in this scenario to differentiate
these from vascular causes (e.g., poststenotic dilata-
tion of the pulmonary artery).
6. Lesion margins. The tumor margin may be lobu-
lated, which is thought to reflect differential growth
rates within the tumor. Alternatively, the tumor may
be spiculated due to local extension or incitement of
a fibrotic response in the surrounding lung.
Although prominent spiculation significantly in-
creases the likelihood of a solitary pulmonary nod-
ule being malignant, it is not highly specific [17].
7. Differential enhancement. Several studies have exam-
ined the enhancement characteristics of benign and
malignant lung masses. Nodules that fail to enhance
to £ 15 Hounsfield Units (HU) after a standard dose
of intravenous contrast, were found to be benign
[29]. Despite this test having a high sensitivity for
S. Padley Chapter 11 Radiological Diagnosis and Staging of Lung Cancer 129

benign lesions, it is not highly specific for excluding

malignancy.

Signs associated with benignity include:

1. The presence of fat (±40 HU to ±120 HU) within a le-
sion. The presence of fat or calcification, or a combi-
nation of the two was shown to correctly identify 30/
46 hamartomas (benign tumors) in one series [30].
2. Calcification in soft-tissue lung lesions. This should
be interpreted with caution in masses > 3 cm, how-
ever, as the tumor may engulf granulomata leading
to an eccentric pattern of calcification within the
mass.
3. The enhancing rim sign. A homogenously low-den-
sity, centered nodule that has a minimal enhancing
rim (< 15 HU) has been associated with an increased
probability of benignity [31].

Using imaging to differentiate between histological vari-

Fig. 11.1. Computed tomography (CT) section (imaged on lung
eties of lung cancer is not often rewarding, but some window settings) demonstrating a predominantly ground-glass
features may aid in the differential diagnosis. mass in the posterior right lung. Histological analysis revealed
this to be a bronchoalveolar cell carcinoma

11.2.4 Adenocarcinoma
Adenocarcinoma tends to present as smoothly margi-
nated round or oval nodules or mass in the periphery
of the lung [17], but in up to 35% of cases may present
as a pulmonary mass with associated mediastinal nodal
enlargement [32]. Lesions rarely calcify [16] or cavitate
[33]. BAC is a subtype of adenocarcinoma that may
present as solitary or multiple lesions [34], but most
(60%) usually manifest as a well-circumscribed nodule
in the lung periphery. BAC may have multiple peripher-
al focal areas of low-attenuation cystic spaces or air
bronchograms within it (Fig. 11.1) [16]. Multifocal BAC
may manifest as multiple well-defined nodules of vary-
ing size or multiple poorly defined or ground-glass
opacities that coalesce and resemble pneumonia or reti-
culonodular opacities. Other features include pleural ef-
fusions, atelectasis, and (rarely) pneumothorax.

Fig. 11.2. A Large peripheral squamous cell tumor in the poste- postpneumonectomy showing recurrence at the site of the
rior aspect of the right lung. B Follow-up scan taken 1 year original tumor, with invasion into the adjacent vertebral body
130 III. Clinical Evaluation of Lung Cancer
11.2.5 Squamous Cell Carcinoma
SCC is relatively slow growing and commonly arises
from lobar or segmental bronchi, causing occlusion of a
central lumen of the bronchus and distal collapse. Thus
it may present with the same radiological features as an
episode of infective pneumonia. Alternatively, there may
be hemoptysis or signs related to invasion of adjacent
structures, such as recurrent laryngeal nerve palsy [17].
Peripheral tumors may be asymptomatic until they have
grown to a substantial size (Fig. 11.2 A) when they may
also cavitate in up to 20% of cases [33].
11.2.6 Large-Cell Carcinoma
Large-cell carcinoma typically presents as large periph-
eral masses with irregular margins. Cavitation and cal-
cification are rare [16].
11.2.7 Small-Cell Lung Cancer
SCLC most commonly arises from the main airways,
but is associated with rapid invasion into vascular and
lymphatic tissues, resulting in a high rate of metastatic
lymph node involvement. Even though the primary le-
sion may be small and unidentified on chest radiogra-
phy there may be bulky hilar and mediastinal lymph
node enlargement.
11.2.8 Subsequent Patient Investigation
After an initial working diagnosis of a lung carcinoma,
further work will be required for confirmation of the
diagnosis and to establish disease stage. If the imaging
features of the lesion suggest a low likelihood of malig-
nancy, follow-up scanning may be performed to detect
changes in lesion characteristics and to confirm lack of
interval change. Whilst it may be sufficient to under-
take serial chest radiographs, in some cases it is more
usual to employ CT for this purpose. Accurate assess-
ment of growth allows calculation of tumor doubling
time. The doubling time is calculated from the increase
in tumor volume over a known period. A 25% increase
in diameter is approximately equivalent to a doubling
in volume [17]. It is generally accepted that doubling
times in lung cancer range from 30 to 490 days, but ow-
ing to this wide range, considerable overlap exists be-
tween the doubling times of benign and malignant nod-
ules. Very rapid nodule doubling times (< 7 days)
should suggest an infective etiology. However, this
method of analysis is not without its own problems.
One study of the reliability of observer measure-
ments of nodule size on CT using electronic calipers
suggested that measurements may be so variable be-
tween multiple observations by single or multiple ob-
servers that results are misleading and could lead to un-
necessary invasive investigations or to malignant
growth being missed [35]. However, the advent of mul-
tidetector CT (MDCT) scanners with automated volume
analysis software has been shown to more accurately as-
sess nodule size [36]. Overall, it is generally held that
stability or regression in the size of a nodule with no
significant changes in overall morphology for a period
of 2 years is required to confirm a nonmalignant etiol-
ogy [37].
11.2.9 Biopsy
In cases where the probability of malignancy is high,
early histological confirmation may become the pre-
ferred course of action. In practice, a tissue diagnosis is
obtained, where feasible, to help guide further treat-
ment. Sputum cytology is often performed but has
varying yields. Only 1.9% cases were diagnostic in one
series of patients in whom a diagnosis of lung cancer
was established by other means [13], whereas in a
further series (of high-risk patients screened for lung
cancer with chest radiograph or CT and sputum cytol-
ogy), sputum cytology detected cancer cells in all 251
patients studied, many of whom had no evidence of
lung cancer on imaging at that time [38]. If a pleural ef-
fusion is present then thoracocentesis should be per-
formed. In patients with a possible extrathoracic metas-
tasis, biopsy of that lesion is of the greatest prognostic
value.
Staging using CT can be of great utility for biopsy
planning and may help to predict the likelihood of ob-
taining a positive tissue diagnosis by any particular
method. CT is an invaluable guide to the bronchosco-
pist, with successful biopsy sampling being more likely
if one or more of the following CT features are present:
ill-defined lesion margins, endobronchial soft-tissue
component, a large airway leading directly to the lesion,
and the lesion lying < 4 cm from the nearest lobar
bronchus [39].
Percutaneous biopsy sampling can be performed un-
der CT or ultrasound guidance, and is the preferred
method in peripheral lesions. Percutaneous biopsy sam-
pling is relatively contraindicated in patients with a sin-
gle lung. Other relative contraindications include bleed-
ing diathesis, vascular malformations, severe obstruc-
tive lung disease, pulmonary arterial hypertension, and
an inability to cooperate. Potential complications in-
clude hemoptysis, pneumothorax, air embolus, and tu-
mor implantation. Hemoptysis occurring as a result of
focal pulmonary hemorrhage occurs in approximately
S. Padley
10% of cases, and major bleeding is the commonest
cause of death as a complication of lung biopsy [40]. To
reduce this risk, bleeding diatheses should be corrected,
major vessels should be avoided, and perihilar lesions
carefully assessed for vascular anatomy prior to biopsy
procedures. To reduce the incidence of pneumothorax,
reported in 17.9±44% of case series [40], the coaxial
biopsy technique and avoidance of interlobar fissures is
preferred to reduce the number of pleural surfaces
punctured. Tumor implantation and dissemination as a
result of percutaneous biopsy sampling are very rare.
11.2.10 Positron Emission Tomography
Positron emission tomography (PET) has made a signif-
icant contribution to range of tools available to assess
possible lung cancer. A full description of PET is be-
yond the scope of this chapter. However in brief, fluo-
rine-18 (18F) is attached to deoxyglucose to produce
fluorodeoxyglucose (FDG). This is used to assess cellu-
lar glucose metabolism. Tumor cells and inflammatory
processes are characterized by a higher than normal
level of glucose metabolism. The amount of FDG
trapped within tumor cells can be identified by imaging
18
F decay using a PET camera. Detection is most com-
monly measured semiquantitatively using a standard
uptake value (SUV). This is the ratio of tracer uptake
by the lesion corrected for body weight and serum glu-
cose and compared with background. Lesions with SUV
values greater than 2.5 are generally regarded as malig-
nant [41]. The use of PET in Europe has increased dra-
matically in the past 5 years, but remains limited by
lack of availability. To help assess whether a detected
lung nodule is benign or malignant, PET can be used to
assess metabolic activity and thus help gauge whether
further action is required. Those lesions that appear to
be metabolically inert are probably benign and may be
followed up radiologically. However, caveats to this ex-
ist. Although the sensitivity of PET in detecting primary
NSCLC is generally reported as 95% for lesions ³ 3 cm
[42, 43], the spatial resolution of PET does not allow
such high sensitivities for lesions < 1 cm [44]. In a re-
cent study of 136 nodules, 20 were < 1 cm in diameter;
all were negative on PET despite 8 being malignant on
final histology [45]. False-negative results have been re-
ported most commonly in BAC and carcinoid tumors,
which are histologically relatively well differentiated. In
contrast, false-positive results may be seen in several in-
fective and inflammatory conditions, notably in tuber-
culosis, sarcoidosis, histoplasmosis, and rheumatoid
nodules. Furthermore, the serum glucose concentration
at the time of scanning is an important factor in image
quality and if raised, causes reduced FDG uptake into
tumor cells, resulting in reduced tumor conspicuity
[46].
Chapter 11 Radiological Diagnosis and Staging of Lung Cancer 131
A less widely employed nuclear medicine technique
relies on the fact that most malignant lung tumor cells
express somatostatin receptors. The radionuclide 99mTc
depreotide, which binds to somatostatin receptors, can
help in the differentiation of cancerous from benign
lung nodules. In one study of 114 patients, 85 out of 88
malignant nodules and 19 out of 26 benign lesions were
correctly identified [47]. At present no comparative
studies of PET and somatostatin receptor radionucleo-
tides have been published.
11.3 Staging
11.3.1 Staging of NSCLC
Lung cancer staging provides information about the an-
atomical extent and histological nature of disease, which
helps to optimize therapy, informs on prognosis, and
allows assessment for possible resection. In those in
whom surgery is not deemed appropriate, assessment of
disease burden aids the oncologist to plan radiotherapy
and chemotherapeutic regimens and assists in the as-
sessment of response to therapy.
11.3.1.1 The International Staging System
The current staging system for NSCLC is based on the
Tumor, Nodal, Metastasis (TNM) classification (Ta-
bles 11.1 and 11.2) [48]. Stage I tumors are confined to
the lung parenchyma (Fig. 11.3). They do not breach
the parietal pleura and are not associated with meta-
static spread. IA tumors are £ 3 cm in size; five-year
survival in this group ranges from 61 to 67%. IB tumors
are > 3 cm in size; five-year survival in this group
ranges from 38 to 57%.
Stage II tumors are divided into those that are
£ 3 cm in size but are associated with metastasis to ipsi-
lateral hilar nodes (IIA) and those that are > 3cm and
are either associated with metastasis to ipsilateral hilar
nodes or have invaded the adjacent mediastinum, dia-
phragm, or chest wall (IIB). Stage IIB may extend along
main bronchi for up to 2 cm from the carina and re-
main suitable for surgical resection. For stage IIA dis-
ease, 5-year survival is 34±55%, whereas for stage IIB
disease it is 22±24% for clinically staged disease or 38±
39% for pathologically staged disease. It can be seen,
therefore, that clinical staging tends to underestimate
the stage of disease as compared to pathological stag-
ing.
Stage III tumors include those patients with extensive
but resectable disease (IIIA) and those with disease
deemed irresectable by conventional surgical techniques
(IIIB). Tumors that are classified as IIIA include tumors
that have N2 nodal spread with no distant metastases
132 III. Clinical Evaluation of Lung Cancer
Table 11.1. The Tumor, Nodal, Metastasis (TNM) Classification
of tumor extent
Primary tumor (T)
Tx Primary tumor cannot be assessed
Or
Tumor cells identified on bronchial washings but not
visible on imaging or bronchoscopy
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor 3 cm in greatest dimension, surrounded by lung
or visceral pleura without bronchoscopic evidence of
invasion more proximal than the lobar bronchus (i.e.,
not in the main bronchus)
T2 Tumor with any of the following features of size or ex-
tent: < 3 cm in greatest dimension; involves the main
bronchus, 2 cm distal to the carina; invades the viscer-
al pleura; associated with atelectasis or obstructive
pneumonitis that extends to the hilar region but does
not involve the entire lung
T3 Tumor of any size that directly invades any of the fol-
lowing: chest wall (including superior sulcus tumor),
diaphragm, mediastinal pleura, parietal pericardium;
tumor in the main bronchus < 2 cm distal to the carina,
but without involvement of the carina; associated at-
electasis or obstructive pneumonitis of the entire lung
T4 Tumor of any size that invades any of the following:
mediastinum, heart, great vessels, trachea, esophagus,
vertebral body, carina; tumor with a malignant pleural
or pericardial effusion (provided that evidence for ma-
lignancy as the cause of effusion is cytopathologically
confirmed), or satellite tumor nodule(s) within the ipsi-
lateral primary-tumor lobe of the lung
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph nodes
N1 Metastases to ipsilateral peribronchial and/or ipsilateral
hilar lymph nodes, and intrapulmonary nodes invaded
by the most distant extension of the primary tumor
N2 Metastases to ipsilateral mediastinal and/or subcarinal
lymph nodes(s)
N3 Metastases to contralateral mediastinal, contralateral hi-
lar, ipsilateral or contralateral scalene, or supraclavicu-
lar lymph node(s)
Distant metastases (M)
MX Distant metastases cannot be assessed
M0 No distant metastases
M1 Distant metastases are present
Table 11.2. Staging with respect to TNM grouping
Stage: Definition (via TNM grouping):
IA T1 N0 M0
IB T2 N0 M0
IIA T1 N1 M0
IIB T2 N1 M0 or T3 N0 M0
IIIA T3 N1 M0 or T1 N2 M0 or T2 N2 M0 or T3 N2 M0
IIIB T4 N0 M0 or T4 NI M0 or T4 N2 M0 or T1 N3 M0
or T2 N3 M0 or T3 N3 M0 or T4 N3 M0
IV Any T, any N, M1
and those T3 tumors where spread is only to hilar nodes.
Stage IIIB tumors include any T4 tumor or any N3 nodes
(Fig. 11.4). Although not usually surgical candidates,
stage IIIB tumors may be considered for extended proce-
dures after neoadjuvant chemotherapy [49]. Five-year
survival for patients with stage IIIA tumors ranges from
9 to 13% for clinically staged disease or from 23 to 25%
for pathologically staged disease; that for stage IIIB tu-
mors is 1±8% for clinically staged disease.
Stage IV represents all tumors with M1 disease
(Fig. 11.5). Five-year survival in this group is 1%.
11.3.1.2 Staging of the Primary Tumor
CT is the most commonly used tool in evaluation of the
primary tumor. Defining the primary tumor in terms of
T staging enables prediction of resectability. This defini-
tion may not be straightforward, as distinction from
the adjacent collapsed lung may be impossible and thus
lead to an overestimation of tumor size. Differentiation
of central lung cancer from distal collapse can some-
times be achieved on CT using bolus contrast enhance-
ment. The collapsed lung tends to enhance to a greater
extent than the adjacent tumor. This difference in en-
hancement is most marked 40 s to 2 min postinjection
of the contrast medium [50]. Despite this, contrast dif-
ferences between the tumor and the adjacent lung are
not always readily identifiable [50±52]. T1 and T2 tu-
mors are most amenable to surgical resection using
standard techniques. T3 tumors that involve the chest
wall or mediastinum to a limited extent may also be
candidates for surgical resection, albeit with more com-
plex techniques. T4 tumors are irresectable.
Chest radiography is of little use when assessing me-
diastinal invasion. However, phrenic nerve involvement
may be inferred by the presence of ªnewº diaphrag-
matic elevation. Imaging of diaphragmatic movement
with ultrasound or fluoroscopy can produce similar in-
formation [53]. Noninvasive assessment of an extensive
mediastinal tumor is usually provided by CT. Borderline
invasion by less extensive disease is unreliable [54].
Historically, Glazer et al. described three features
that predicted resectability: (1) less than 3 cm of medi-
astinal contact, (2) intact fat plane between the tumor
and mediastinum, and (3) < 908 circumferential contact
with the aorta [55]. The utility of these described crite-
ria can, however, be limited. For example, loss of fat
plane identified on CT may be due to motion artifact,
inflammation, or tumor infiltration. Newer, faster,
MDCT scanners can reduce the effect of motion artifact
and partial volume averaging, improving radiological
accuracy. However, no reliable method of noninvasive
differentiation of local inflammatory reaction from di-
rect malignant invasion has yet been developed. Thus,
without clear evidence of invasion tumors tend to be
understaged to prevent denying the patient the chance
of a curative resection [56].
S. Padley
Fig. 11.3. T2 N0 M0 tumor. CT sections (with lung and mediastinal window settings, A and B, respectively) demonstrate a large
(> 3 cm) solid spiculated mass in the left upper lobe
Fig. 11.4. CT section demonstrating a small peripheral (T1) tu-
mor with large hilar and mediastinal (N3) nodal enlargement
Magnetic resonance imaging (MRI) may be em-
ployed to clarify issues regarding invasion of local
structures. The integrity of the mediastinal or extra-
pleural fat stripe allows more accurate assessment of tu-
mor transgression [57]; in addition, MRI may demon-
strate endoluminal tumor extension and infiltration of
the pericardium and heart (T4) better than CT. The ar-
guments regarding the superior capability of MRI for
multiplanar imaging have now been largely superseded
by MDCT (Fig. 11.6) [58]. However, in one recent study
Chapter 11 Radiological Diagnosis and Staging of Lung Cancer 133
contrast-enhanced magnetic resonance angiography was
shown to demonstrate mediastinal and hilar invasion
with a sensitivity of up to 90%, a specificity of up to
87%, and an accuracy of up to 88%, values that are
higher than those for CT and standard T1-weighted
MRI [59]. Another comparison of the two modalities
(CT and MRI) showed no significant differences in their
sensitivities or specificities other than superior MRI as-
sessment of myocardial invasion and extension of tu-
mor into the left atrium via the pulmonary veins.
Therefore, these authors did not recommend routine
use of MRI in patients who initially present for evalua-
tion for mediastinal dissemination [57]. At present, the
role of MRI in the investigation of mediastinal invasion
remains one of a problem-solving tool in selected cases
[60].
Current PET scanners do not offer the anatomical
detail provided by CT and MRI; however, they do allow
accurate identification of involved nodes or direct medi-
astinal extension, especially when undertaken as part of
a combined CT/PET study (Fig. 11.7). PET can also be
used to confirm direct invasion of a tumor into the left
recurrent laryngeal nerve, as in these circumstances it
can reveal increased uptake in the internal laryngeal
muscles on the right side, owing to their compensatory
increased use [61].
11.3.1.3 Chest-Wall Invasion
Local chest-wall invasion is not an absolute contraindi-
cation to surgery, but it does require alteration of surgi-
cal technique. Currently, local chest-wall pain remains a
more specific a marker of chest-wall invasion than any
134 III. Clinical Evaluation of Lung Cancer
Fig. 11.5. A CT section demonstrating a right hilar (T3) tumor.
B CT section through the liver (of the same patient) revealing a
low-density deposit consistent with a metastasis (stage 4 dis-
imaging test [62]. Chest radiography is relatively insen-
sitive in the detection of chest-wall invasion. Although
advanced rib destruction can be identified, more subtle
changes are not.
CT can be used to detect cortical bone destruction,
but is not as sensitive as radionuclide bone scanning
for this purpose (Fig. 11.8). Chest wall soft-tissue in-
volvement is identified on CT by the presence tumor
extending through the intercostal muscles, beyond the
ease). C A large soft-tissue mass (in another patient) at the lev-
el of the right hilum encasing vessels and extending into the
mediastinum at that level (stage 4 tumor)
line of the ribs or into the extrapleural fat. More subtle
invasion is less confidently assessed [62±64]. Described
signs of pleural invasion on CT include: an obtuse angle
of contact between the tumor and chest wall, oblitera-
tion of extrapleural fat, pleural thickening, and the
presence of extrapleural soft tissue. Once again the
presence of inflammatory changes causing false-positive
signs reduces the specificity of this method. However,
obliteration of the extrapleural fat with a large degree
S. Padley
Fig. 11.6. Right upper lobe tumor. CT transverse (A) and coro-
nal sections (B) with multiplanar reformation on mediastinal
(A) and lung window settings (B) demonstrating a tumour
mass in the right upper lobe abutting the mediastinum and
Fig. 11.7. B Coronal positron emission tomography (PET) image
demonstrating a focus of tracer uptake in the right upper lobe
(note normal uptake in the heart). B PET-CT image of the
same patient at the same level, highlighting the improved ana-
of pleural contact and extensive pleural thickening have
been described as CT signs that make pleural invasion
very likely [65].
Techniques such as diagnostic pneumothorax, which
have also been used in the assessment of mediastinal
invasion, have been utilized in attempts to improve the
accuracy of differentiation between visceral and parietal
invasion and have shown some benefit but have not
Chapter 11 Radiological Diagnosis and Staging of Lung Cancer 135
encasing the azygos and superior pulmonary veins. Inspection
of the right upper lobe bronchus on the coronal section shown
in B reveals a soft tissue nodule within its wall, consistent with
an endobronchial metastasis
tomical resolution with this technique. B PET-CT image of an-
other patient with a left upper lobe tumor. A second focus of
tracer uptake is identified at the left hilum, consistent with the
tumor involving lymph nodes at this site
gained general acceptance. Furthermore, use of dynamic
expiratory MDCT (viewed on cine loop) has been re-
ported to be 100% accurate for chest-wall and mediasti-
nal fixation when compared to pathological examina-
tion, but has likewise not become a common technique
[66].
There are similar difficulties in the differentiation
between benign and malignant pleural adhesion using
136 III. Clinical Evaluation of Lung Cancer
Fig. 11.8. A A bone scan image demonstrating tracer uptake in
the right third and fourth ribs. B, C CT sections demonstrating
chest-wall invasion in the same patient, with destruction of the
both CT and MRI [57]. However, in one study of 34 pa-
tients, the presence of low-intensity material (identical
signal to the tumor) encroaching into the high-intensity
extrapleural fat (on T1-weighted images) identified in-
vasion with 85% sensitivity and 100% specificity [67].
Assessment of superior sulcus tumors with MRI has
been shown to be superior to CT, which suffers from
considerable image degradation from shoulder streak
artifact. Older studies in which MRI was found to have
a 94% correlation with surgical and clinical findings
and CT had an accuracy of 63% are now outdated due
to the advent of MDCT [68]. MRI reliably diagnoses
chest-wall invasion and extension into the root of the
neck, with the added benefit of visualization of vascular
and neural structures.
Several reports, mainly from Japan, have demon-
strated that ultrasound can be used to assess chest-wall
invasion. Disruption of the continuous pleural line has
been thought to represent a useful sign of invasion, with
adjacent ribs. D Coronal magnetic resonance imaging section
from another patient demonstrating local chest-wall invasion
from a superior sulcus tumor
lack of movement of the tumor during respiration im-
plying adherence. In one report this technique was su-
perior to CT, with > 95% sensitivity and specificity for
invasion [69]. Another report suggested that biopsy
sampling was necessary for optimal accuracy [70].
A recent study of PET reported 100% sensitivity,
71% specificity, and a negative predictive value of 100%
in detecting malignant pleural disease, whereas CT was
found to be indeterminate in 71% of cases but had
100% specificity and negative predictive value [71]. In a
further study examining lone pleural effusion, PET was
found to have 95% sensitivity for detecting malignancy
[72], whereas it is known that thoracocentesis may not
prove malignancy in up to 40% of patients with truly
malignant effusions [73].
S. Padley
11.3.1.4 Nodal Staging
Lung cancers normally spread to the ipsilateral hilar
nodes, then ipsilateral mediastinal, contralateral medi-
astinal, and supraclavicular nodes. Although nodal
spread is most often sequential, metastases to the medi-
astinal nodes in the absence of hilar nodes is seen in
33% of cases [74].
11.3.1.5 Detection of Nodal Enlargement
Chest radiography is generally insensitive for nodal
staging. However, the presence of enlarged hilar or
paratracheal nodes has been shown to be specific (92%)
for N2-N3 disease [57].
In a recent study, it was found that use of ultrasound
(with or without fine-needle aspiration, FNA) had three
times the sensitivity of clinical palpation for the detec-
tion of involved supraclavicular nodes. The detection of
these nodes establishes an N3 nodal stage, placing the
patient in an inoperable category (Fig. 11.9). Previous
studies have reported a prevalence of 12% for involved
supraclavicular nodes when evaluated by palpation
alone; on postmortem, however, their presence has been
reported in up to 37.5% of cases [75]. Thus routine use
of ultrasound and FNA to detect supraclavicular adeno-
pathy has been suggested as a method to improve the
accuracy of preoperative staging and reduce the overall
number of staging investigations required.
Lymph node assessment on CT is achieved primarily
by measuring lymph node size. Currently, the short-axis
diameter is considered the most useful predictor of me-
tastatic nodal involvement [76, 77]. However, the use of
size as a discriminator of metastatic lymph node in-
volvement has several pitfalls. Firstly, there is a normal
variation of lymph node size throughout the mediasti-
num; thus, standardization of an upper limit of normal
is inherently inaccurate. Secondly, the diameter of indi-
vidual nodes varies with orientation to scan plane.
Furthermore, the presence of enlargement is not diag-
nostic of metastasis and may be due to reactive hyper-
plasia, infection, or coincidental inflammatory condi-
tions. In addition, normal-sized nodes do not preclude
the presence of metastases, especially in cases of adeno-
carcinoma where up to 25% of resected normal-sized
nodes have been demonstrated to contain metastases
[78]. Despite these problems the use of lymph node size
as a staging tool is standard CT practice. A 1-cm short-
axis diameter is used as the upper limit of normal and
has been found to be associated with 64% sensitivity
and 62% specificity for detecting malignancy based on
a station-by-station surgical/radiological correlation
[79]. The negative predictive value of this measurement
is in the order of 85%.
The accuracy of MRI, despite its improved contrast
resolution, is limited by the same constraints of overlap
of features of benign and malignant causes of node en-
largement. Although it is generally felt that an MRI sig-
Chapter 11 Radiological Diagnosis and Staging of Lung Cancer 137
Fig. 11.9. Right supraclavicular lymphadenopathy. CT section
demonstrating (arrows) a lymph node mass in the right supra-
clavicular fossa
nal within nodes is not a useful predictor of involve-
ment, a recent study has reported that short-tau inver-
sion-recovery imaging produces a sufficient signal dif-
ference between normal and pathological nodal tissue
to detect metastases with 93% sensitivity and 87% spec-
ificity [80]. The previously cited advantage of MRI over
CT in nodal detection due to the ability to distinguish
small nodes from vessels without the use of intravenous
contrast medium has been effectively negated by the
advent of MDCT.
Many studies have examined the efficacy of PET in
nodal staging of lung cancer. In a meta-analysis of 29
studies encompassing 2,226 patients, PET was found to
have a mean sensitivity of 79% and mean specificity of
91% for malignant nodal involvement [80]. Accuracy
for mediastinal lymph node staging has been reported
as 85±96% [81, 82]. It has also been suggested that
whole-body PET demonstrates all lymph node stations
and so may obviate the need for mediastinoscopy in
some cases. This is because the negative predictive val-
ue of PET for N3 disease is identical to that for medias-
tinoscopy (96%) [83]. Thus, patients with a negative
PET result could proceed directly to surgical resection,
whereas those with a positive PET result should under-
go mediastinal lymph node sampling [84].
One study comparing conventional workup and con-
ventional workup with the addition of PET in 188 pa-
tients demonstrated that significantly more patients in
the non-PET group underwent a ªfutileº thoracotomy.
Futile thoracotomy was defined as thoracotomy for be-
nign stage IIIA-N2 disease or stage III disease, or pa-
tients with recurrence or death within 1 year of surgery.
In this study, 42% of the conventional workup group
underwent a futile thoracotomy, compared with only
21% in the PET group. In most cases, PET detected N2
and N3 disease that was otherwise not apparent [85]. A
138 III. Clinical Evaluation of Lung Cancer
further large meta-analysis of PET, CT, and endoscopic
ultrasound (EUS) has shown that the sensitivity and
specificity of PET for mediastinal staging is greater
than for the other two modalities [86]. However, an-
other study showed PET to be inferior to EUS with
FNA [87].
EUS is a relatively new technique that visualizes aor-
topulmonary, subcarinal, and posterior mediastinal
nodes. Anterior mediastinal and paratracheal nodes are
not as well demonstrated due to the presence of air in
the trachea. Endosonographic features of neoplastic in-
volvement include round rather than oval nodal shape,
sharp nodal borders, and inhomogeneous hypoechoic
internal echo texture [88]. EUS also allows FNA to be
performed through the endoscope, and can also assess
the operability of the primary tumor and of nodal me-
tastases. In one study the sensitivity of EUS was found
to be similar to that of PET but its specificity was far
greater (100% for EUS and 72% for PET) [87].
At the present time mediastinoscopy and mediasti-
notomy remain the most widely employed techniques
for mediastinal lymph node sampling. They have a high
sensitivity and specificity for detecting malignant dis-
ease and, although invasive, are indicated prior to tho-
racotomy when other forms of imaging suggest nodal
involvement.
11.3.1.6 Extrathoracic Staging
Lung cancer is commonly associated with widespread
hematogenous dissemination at the time of presenta-
tion. Detection of metastatic disease precludes surgical
resection of the primary tumor. Disease quantification
at extrathoracic sites is useful to assess the response to
therapy on sequential scans. Currently, there is a lack of
consensus regarding whether or not to perform extra-
thoracic screening in patients who otherwise have po-
tentially operable disease. The frequency of extratho-
racic occult metastases in one study was reported as
18% overall [89]. However, the accuracy of the imaging
modality in question, the effectiveness of laboratory
and clinical screening at excluding disseminated dis-
ease, and the requirement for further confirmatory tests
that have repercussions on economic and logistic con-
siderations are all factors that influence practice.
Some staging protocols take into account the histo-
logical type of the tumor. At presentation, SCLC is com-
monly widely disseminated, whereas SCC is less likely
to have detectable metastases than any other histology
for any given TN stage [90±92].
Most patients with lung cancer in the UK have initial
staging with contrast-enhanced CT of the thorax, which
is routinely continued down to include the liver and
adrenals. If suspicious lesions are seen at the time of
scanning a delayed-phase scan may be performed. If
identified later, the patient may return for a further CT
or MRI characterization.
11.3.1.7 Liver Metastases
Up to 12% of patients with lung cancer have been re-
ported to have asymptomatic liver metastases at initial
work-up [93]. Whilst clinical assessment and laboratory
tests are known to have a low positive predictive value
for liver metastases, deposits are usually detected on
contrast-enhanced CT (Fig. 11.5). CT detects colorectal
tumor metastases in the liver with an accuracy of 85%
when compared with postmortem studies. Conventional
ultrasound is significantly less sensitive than CT for de-
tection of hepatic deposits. MRI is at least as good (and
probably better) than CT, but the cost and limited ac-
cess to MRI tend to confine its role to characterization
of previously identified lesions.
11.3.1.8 Adrenal Metastases
Incidental nonfunctioning adenomas of the adrenal
glands are present in 2±10% of the adult population.
Adrenal metastases were present in 6.9% of patients
with NSCLC in one meta-analysis [94]. Thus, in patients
with NSCLC the presence of a small (< 3 cm) solitary
adrenal nodule presents a reasonably commonplace di-
agnostic difficulty. Overall incidental adrenal masses
have been shown to be more commonly due to adeno-
ma than metastasis with ratio of 68% (17/25) to 32%
(8/25) [95]. However, for lesions > 3 cm in size the con-
verse is true. Adenomas are normally well circum-
scribed, homogenous, and have a density of £ 10 Houns-
field Units (HU) on unenhanced CT owing to high lipid
content. Following administration of intravenous con-
trast they display little enhancement. Several useful al-
gorithms for characterization of incidental adrenal
masses have been developed (Fig. 11.10).
When CT has failed to characterize an adrenal nod-
ule, then MRI may be undertaken and can be used to
characterize a nodule as an adenoma on the basis of
signal characteristics that reflect high adenoma lipid
content. In one study this technique was demonstrated
to have 100% sensitivity and 81% specificity [96].
PET has been shown to have high sensitivity (100%)
and specificity (80±100%) for adrenal metastases of
more than 1 cm in size. Adrenal masses smaller than
1 cm are not reliably assessed with this technique. In
addition, some PET-positive benign adrenal adenomas
have also been reported [97].
11.3.1.9 Brain Metastases
Brain metastases are more frequent when the primary
tumor is greater than 3 cm in diameter [98]. Isolated
central nervous system metastases are uncommon in
NSCLC and are generally associated with abnormal neu-
rological examination [99, 100]. Truly asymptomatic
brain metastases are thought to occur in 2.7±9.7% pa-
tients [16] and are more common with SCLC and ade-
nocarcinoma than with SCC [95, 101, 102]. MRI is more
S. Padley Chapter 11 Radiological Diagnosis and Staging of Lung Cancer 139

Fig. 11.10. Diagnostic flow diagram outlining a proposed sys- from Dunnick and Korobkin 2002 [109]. HU Hounsfield units,
tem for management of incidental adrenal masses. Adapted MRI magnetic resonance imaging

sensitive than CT for the detection of brain metastases

and is the modality of choice for brain imaging when
available (Fig. 11.11).
Screening for brain metastases is contentious. One
study compared a standardized clinical neurological ex-
amination with CT of the brain and concluded that CT
was not indicated in patients with a normal clinical ex-
amination [103]. In a further study, gadolinium-en-
hanced MRI detected occult brain metastases in 6 out
of 29 patients with lung tumors greater than 3 cm in di-
ameter on CT [98]. These MRI findings were deemed to
have altered the treatment and follow-up, and this study
suggests that for primary tumors of more than 3 cm in
diameter (especially if adenocarcinoma or large-cell car-
cinoma) MRI of the brain may be indicated as part of
the routine staging. PET imaging does not alter this
conclusion since normal brain has substantial metabolic
activity, and focal abnormal cerebral accumulation of
labeled glucose due to metastasis is unreliable, with a
sensitivity of only 60%. Thus, it should not replace tra-
ditional imaging modalities for this purpose.

11.3.1.10 Bone Metastases

The frequency of otherwise occult bony metastases de-
tected on initial work-up is reported to be between 3.4
and 15% (Figs. 11.12 and 11.13) [93]. In patients with
symptomatic disease, a radionuclide bone scan (which
detects osteoblastic activity) is often utilized as an ini-
Fig. 11.11. Brain metastases. Contrast-enhanced CT section
demonstrating two metastases in the right cerebral hemisphere.
Note the halo of low attenuation around the lower of the two
metastases, consistent with vasogenic edema
140 III. Clinical Evaluation of Lung Cancer
Fig. 11.12. Bone metastasis. CT section showing destruction of
vertebral body and replacement of normal bone with tumor
Fig. 11.13. Lung metastasis. CT section through the base of the
lungs demonstrating a small nodule at the right base, consis-
tent with a metastasis
tial investigation. Although it is 95% sensitive, false
positives from coexistent degenerative disease occur in
many cases. Plain film radiography is then suggested to
differentiate degenerative from metastatic disease. Meta-
static bone disease on plain radiography most com-
monly manifests as lytic lesions. However, significant
loss of bone is required before plain radiography de-
tects these metastases.
Screening for asymptomatic bony metastases with
radionuclide scintigraphy is not currently recommended
owing to its high false-positive rate. Whole-body MRI
could also be employed as a staging tool, but despite in-
teresting studies of the potential for whole-body MRI to
replace scintigraphy having been published, this tech-
nique is not yet widely employed.
PET has been found to be 92% sensitive and 99% spe-
cific for bone metastases compared to bone scintigraphy
(which has a specificity of 50% and sensitivity of 92%).
However, as standard CT and PET studies do not include
the lower limbs, they do not provide a full skeletal survey.
Some would argue that if PET replaced radionuclide bone
scanning, whole-body studies would be required [84].
However, isolated metastases below the knees are dis-
tinctly uncommon and distal metastases are usually part
of more widely disseminated disease.
11.3.1.11 Lung Metastases
These are not common at presentation but are seen in ap-
proximately 20% of cases at postmortem. However, in one
retrospective study it was found that at presentation, up
to 52% of patients with lung cancer had multiple lung
nodules, which in most patients (78%) numbered greater
than 50. The size also varied from 2 mm to 30 mm (80%
were < 10 mm). The primary associated histology was
pulmonary adenocarcinoma and the survival rate was
commensurate with stage IV disease [104].
As pulmonary metastases indicate stage IV disease
and render the patient inoperable, preoperative detec-
tion is important. In these days of MDCT, nodule detec-
tion is usually not problematic. More frequently the
problem is accurate assessment of the nature of a possi-
ble metastatic nodule. Characteristic benign calcifica-
tion within such a lesion is the exception. Most lesions
are of soft-tissue density and studies that have tried to
further evaluate these lesions have lead to inconsistent
results. PET scanning may be useful to assess the likeli-
hood of metastatic malignancy or a second primary in
indeterminate cases.
11.3.2 Staging of SCLC
SCLC is normally regarded as a systemic disease. At the
time of presentation surgical resection is viable in less
than 5% of cases, as up to 80% cases have already metas-
tasized [105, 106]. Classification is based on a two-stage
system proposed by the Veteran's Administration Lung
Cancer Study Group, which divides patients into limited
and extensive disease groups [105]. Patients with lim-
ited-stage disease are conferred a survival advantage.
Limited disease is defined as that which is confined to
one hemithorax (but including ipsilateral and contralat-
eral mediastinal, and supraclavicular nodes). To assess
disease stage in these patients chest radiography is sup-
plemented with CT of the chest, liver and adrenals, and
brain. Bone scintigraphy and bone marrow aspiration
to evaluate medullary disease are also performed. Liver
and bone metastases are present in up to 30% of patients
and brain metastases in up to 15% of patients. The use of
PET has not been extensively examined in SCLC. In one
S. Padley
series, apparently limited disease was upstaged to exten-
sive disease in 7 out of 24 patients [107].
Extensive disease is that which extends outside the
boundaries of a single radiotherapy field. MRI of the
brain, body, spine, abdomen, and pelvis has been
shown to compare favorably to conventional techniques
for the detection of extensive disease. In addition, it has
been found to delineate bone metastases not detected
by bone marrow aspiration or bone scintigraphy. The
disadvantage of whole-body MRI, however, remains the
length of acquisition time and cost.
Isolated bone metastases are uncommon. When
other extrathoracic metastases are found then radionu-
clide bone scanning or bone marrow aspiration or MRI
are indicated [16].
Central nervous system metastases are common at
presentation and are a common site of disease. Routine
CT evaluation of the brain is indicated as approximately
5% of patients with brain metastases are asymptomatic,
and aggressive treatment with chemotherapy and radio-
therapy can improve prognosis and decrease morbidity
if the brain is the only site of extrathoracic disease
[106].
An alternative approach, to avoid an exhaustive
search for extensive disease, is to allow clinical symp-
toms to direct imaging, terminating on the discovery of
extensive disease.
11.4 Conclusion
The diagnosis and staging of lung cancer is a multi-
phase process. The initial diagnosis may arise following
investigation of associated clinical symptoms or, as is
often the case, may be an incidental finding on chest
radiography performed for another reason. Once de-
tected, the tumor should be graded according to the
TNM system and then staged using the International
Staging System.
Currently, the British Thoracic Society and Society
of Cardiothoracic Surgeons of Great Britain and Ireland
Working Party [108] guidelines for preoperative suit-
ability assessment for patients with lung cancer are:
1. All patients being considered for surgery should have
a plain chest radiograph and a CT scan of the thorax
including the liver and adrenal glands.
2. Confirmatory diagnostic percutaneous needle biopsy
in patients presenting with peripheral lesions is not
mandatory in patients who are otherwise fit, particu-
larly if there are previous chest radiographs showing
no evidence of a lesion.
3. Patients with mediastinal nodes with a short-axis di-
ameter greater than 1 cm in short axis diameter on
the CT scan should undergo biopsy sampling by
staging mediastinoscopy, anterior mediastinotomy,
or needle biopsy, as appropriate.
Chapter 11 Radiological Diagnosis and Staging of Lung Cancer 141
To this approach could be added MRI scanning in cases
of superior sulcus tumor, and PET scanning to help as-
sess nodal staging in difficult cases and to help differ-
entiate cancer from an adjacent collapsed/consolidated
lung. PET also has a role to play in the more difficult is-
sue of detecting important asymptomatic metastases
that, if discovered, would divert patients from a futile
attempt at curative surgery.
Key Points
l The diagnosis of lung cancer may occur during
coordinated investigation of symptoms or inci-
dentally on imaging performed for other reasons.
l Once identified the tumor should be staged using
the TNM system.
l Currently diagnosis and staging rely predomi-
nantly on chest radiography and computed tomo-
graphy (CT) scanning.
l Use of positron emission tomography for staging
disease is increasing in concert with availability.
l Use of magnetic resonance imaging remains con-
fined to problem-solving in cases of uncertainty
on CT (e.g., superior sulcus tumors).
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