Chest Film Reading, Lecture 11.

Dr/ ABD ALLAH NAZEER. MD.

Benign tumour of the lung.Benign lung tumour are a heterogenous group of neoplastic lesions originating from pulmonary structures.The term Benign may be misleading because these interface with lung function.(E. g.. Obstruction of a major bronchus may occur), depending upon tumour location.Benign tumours make up 2-5% of all primary lung tumours.The exact incidence is not known because these tumours are often asymptomatic and are only detected during autopathy.Reported series suggest that benign lung tumours affect men more frequently than women.The age range of patients affected is 17-77 years, with a mean age of 56 years for all types.

Benign lung tumors:Are not cancerous, so will not spread to other parts of the body , Grow slowly, or might even stop growing or shrink, Are usually not life-threatening , Usually do not need to be removed Can expand and push against nearby tissues but will not invade, destroy, or replace other tissues HamartomaThere are a number of different kinds of benign lung tumors, the most common being hamartomas. They account for about 55% of all benign lung tumors, and 8% of all lung tumors.Characteristics of lung hamartomas:About 80% are found in the peripheral, or outer, portion of the lung’s connective tissue. The remainder are found inside the bronchial tubes (the airways leading to the lungs). Deeper growths may be difficult to distinguish from cancerous nodules. Are made up of “normal” tissues such as cartilage, connective tissue, fat, and muscle but in abnormal amounts Are usually less than 4 centimeters in diameter Stay within a limited area and are not likely to press against nearby tissue Usually appear in chest X-rays as a coin-like round growth May look like fluffy wool or popcorn in about 15% of cases Are found more often in males than females, and between the ages of 50 and 70

PapillomaAnother type of benign lung tumor is called a papilloma. It grows in the bronchial tubes, sticking out from the surface area where it is attached. Papillomas are not very common and are divided into three types.Categories of pulmonary papillomas:SquamousOccur in both children and adults May appear as just one nodule or many Result from infection by human papilloma virus (HPV), the same virus that causes warts and certain sexually transmitted diseases GlandularNo cause has been identified Are less common than squamous papillomas Develop in larger airways than squamous papillomas Can occur in all ages but mostly adults Almost always appear as one nodule, centrally located Mixed squamous and glandularContain a mix of squamous and glandular papilloma tissue Only a small number of cases have been reported Has the potential to eventually turn cancerous because the squamous cells can change over time.

Alveolar Adenoma Alveolar adenomas are unusual neoplasms that are typically identified in the periphery of the lung. Originally described in 1986 by Yousem and these tumors have been identified in adults ranging in age from 39 to 74 years, usually as an asymptomatic solitary pulmonary nodule. Alveolar adenomas are soft, multicystic, and lobulated. No definite gender predilection has been identified.Solitary Fibrous Tumor of the Lung. Solitary fibrous tumors are

typically pleural-based tumors, but intrapulmonary examples have been described.50,51 Pulmonary SFTs are generally peripheral; they are sometimes on the pulmonary parenchymal side of the pleura but in some instances are completely separate from the pleura. They are firm and white with a whorled appearance. Solitary fibrous tumors may derive from submesothelial fibroblasts.Hemangiomas are a build-up of blood vessel cells in the skin or internal organs. Hemangiomas are a common type of birthmark, often occurring in the head, neck or trunk. They may appear red or bluish in colour. Most go away on their own. Those that interfere with vision, hearing or eating may require treatment.

Leiomyomas. Primary solitary pulmonary leiomyomas can be endobronchial or

parenchymal. Multiple smooth muscle tumors of the lung in women with history of uterine leiomyomas are more likely part of the entity of benign metastasizing leiomyoma.

Chondromas. Chondromas are tumors composed of hyaline or myxohyaline

cartilage without epithelial elements or other mesenchymal elements. Although these can represent isolated, sporadic tumors, such tumors with myxoid stroma in young women require examination for the Carney triad (gastric smooth muscle tumors, paraganglioma, chondromas).

Lipomas. These can be intraparenchymal or endobronchial, the latter being

more common.58 These tumors must be composed solely of adipose tissue; any component of lobulated cartilage or epithelial ingrowth on cleft like spaces raises the possibility of an adipose tissue–rich hamartoma.

Granular Cell Tumors. Benign tumor classifications included granular cell

myoblastoma (granular cell tumor), although these do not appear to be common benign lung tumors. In limited series of cases, these tumors occur in adults (average age, 40 years) with a male predominance. They are usually central tumors and therefore more likely to be symptomatic with cough, obstruction, or hemoptysis. They are often irregular and locally invasive and therefore can recur after conservative resection, but they do not metastasize.

Pulmonary hamartoma with "popcorn calcifications."

Pulmonary hamartoma with "popcorn calcifications."

Pulmonary hamartoma with "popcorn calcifications."

Respiratory papillomatosis. Endoluminal masses in respiratory papillomatosis seen on the axial computed tomography scan (black arrow) and on bronchoscopy (white arrow).

Coronal multiplanar reconstruction and the virtual bronchoscopic image showing extensive involvement of the distal trachea (arrow) and the right bronchus in a case of recurrent respiratory papillomatosis.

Airway involvement in Wegner’s granulomatosis. A: Axial computed tomography image shows cavitary lung nodules (large arrows); B: Coronal multiplanar reconstruction in lung window demonstrates irregular narrowing of the left main bronchus (small arrows).

Lung granuloma.

Alveolar adenoma.

Alveolar adenoma at the left inferior hilum.

Alveolar adenoma.

Bronchial mucous gland adenoma presenting as massive hemoptysis: A diagnostic dilemma.

Pulmonary capillary hemangiomas.

Pulmonary Sclerosing Hemangioma.

Sclerosing hemangioma of lung.

Solitary fibrousTumour of the pleura.

Solitary fibrousTumour of the pleura.

benign localized fibrous tumor originating from the mediastinal pleura.

Pulmonary Leiomyoma, CT scan showing multiple well-defined rounded bilateral lung nodules with no 18F-FDG uptake.

Pulmonary Leiomyoma, MR images show multiple well-defined rounded bilateral lung nodules

Solitary benign pulmonary leiomyoma.:

Osteochondromatosis of chest wall.:

chest wall chondrosarcoma.

CT show mediastinal lipoma compressing the lung.

CT scan showing a mass of fatty content in the dorsal region of the left thorax.

Mediastinal lipomatosis with cardiac intracavitary involvement.

Lung cancer, also known as carcinoma of the lung or

pulmonary carcinoma, is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung.Signs and symptoms which may suggest lung cancer

include: respiratory symptoms: coughing, coughing up blood, wheezing or shortness of breath systemic symptoms: weight loss, fever, clubbing of the fingernails, or fatigue symptoms due to the cancer mass pressing on adjacent structures: chest pain, bone pain, superior vena cava obstruction, difficulty swallowing If the cancer grows in the airways, it may obstruct airflow, causing breathing difficulties. The obstruction can lead to accumulation of secretions behind the blockage, and predispose to pneumonia.

T1a tumor.

Stage T2 tumors.

Stage T2 tumors.

Stage T3.—Tumors larger than 7 cm are now considered stage T3 tumors.

Stage T3 tumors. Chest CT scan shows a primary mass (arrow) with satellite nodules (arrowheads) in the right lower lobe

Stage T4 tumors. Chest CT scan shows a primary lung tumor in the right upper lobe (long arrow) with a smaller separate nodule in the right lower lobe (short arrow). In the 7th edition, this is considered stage T4 disease (stage M1 [metastatic] disease in the 6th edition).

Stage T4 tumors. Chest CT scan shows a right upper lobe mass (arrow) with mediastinal and carinalinvasion, ipsilateral loculated pleural effusion, and thickening and enhancement of the pleura. Note the tumor encasement and resultant narrowing of the right main-stem bronchus (arrowhead). The pleural thickening and enhancement, although nonspecific, are suggestive of metastatic pleural disease. In the 7th edition, proved pleural carcinomatosis is considered stage M1a disease.

Stage N1 lymph nodes. (a) Chest CT scan obtained in a patient with right-sided lung cancer shows an enlarged right hilar lymph node (level 10) (arrow) measuring 15 mm in the short axis. (b) Chest CT scan obtained in a different patient shows a left lower lobe mass and an ipsilateral enlarged interlobar lymph node (level 11) (arrow) measuring 11 mm.

Stage N2 lymph nodes. (a) Chest CT scan shows an enlarged (1.6-cm) right upper paratracheal lymph node (level 2) (arrowhead). (b) Chest CT scan obtained in a different patient shows an enlarged (1.5-cm) right lower paratracheal lymph node (level 4) (arrowhead). Like the lymph node in a, it is clearly to the right of the new border proposed by the IASLC (ie, the left lateral border of the trachea). (c) Chest CT scan obtained in a third patient shows a right lower lobe mass (white arrow) with an enlarged (1.6-cm) subcarinal lymph node (level 7) (black arrow).

Stage N3 lymph nodes. (a) Axial PET/CT image of the chest shows a primary mass in the left lung (arrow) and a right lower paratracheal lymph node (arrowhead), both of which demonstrate intense radiotracer uptake. Metastatic involvement of the lymph node was confirmed at mediastinoscopic resection. (b) Chest CT scan obtained at the lung apex in a different patient shows enlarged bilateral supraclavicular lymph nodes (arrows).

Small cell lung cancer. Chest CT scan (a) and corresponding PET/CT image (b) show a mass in the left lung (top arrow) with intense radiotracer uptake on the PET/CT image. The mass proved to be small cell lung cancer at pathologic analysis. Note the confluent ipsilateral prevascular (bottom arrow) and left paratracheal lymphadenopathy (N2), which shows intense uptake as well.

Chest wall and pleural invasion. Chest CT scans obtained with a soft-tissue window (a) and a bone window (b) show a right upper lobe mass measuring 4.9 cm in diameter, with a chest wall mass (arrow in a) and associated bone destruction of the adjacent posterior rib (arrow in b).

X-Ray and CT scan showing an intraparenchymal cavitating lung lesion adjacent to the anterior thoracic wall. Histology confirmed a large-cell NHL.

Pulmonary parenchymal lymphoma in a 41-year-old HIV-positive man.

Pleural metastasis. (a) Chest CT scan shows a right upper lobe mass (arrow) abutting the mediastinum, along with pleural thickening and effusion (arrowhead). (b) Axial FDG PET scan shows radiotracer uptake in the right upper lobe mass (arrow) and ipsilateral pleura (arrowhead)

Anterior, Middle and posterior mediastinal enlarged lymph nodes.

Pleural tumourssolitary fibrous tumour of the pleura (pleural fibroma)

• mesothelioma• localized mediastinal malignant mesothelioma

metastatic pleural disease, particularly from adenocarcinomas, e.g.• bronchogenic adenocarcinoma• breast cancer• ovarian cancer• prostate cancer• gastrointestinal adenocarcinoma• renal cell carcinoma

• lymphoma: pleural lymphoma• invasive thymoma

Lipoma loculated fluid (on plain film)

pleural effusion (pseudotumor)empyemahemothorax

mass related to ribs or chest wall, e.g. Ewing sarcoma of chest wall, Askin tumoursplenosisinfection including tuberculosis

Malignant mesothelioma: Axial contrast-enhanced CT scan showing homogeneously enhancing nodular pleural thickening (arrows) involving the mediastinal and costal pleura with volume loss changes in left hemithorax

Mesothelioma presenting as a pleural effusion: Axial contrast enhanced CT scan showing moderate left pleural effusion as loculated collection with thickening of pleura (arrows) in a case of mesothelioma

Benign solitary fibrous tumor: (A) Chest radiograph showing pleural-based opacity (arrow) in right hemithorax with peripheral obtuse margins; (B) axial contrast-enhanced CT scan showing heterogeneously enhancing pleural-based mass (arrowhead) proved to be benign fibrous pleural tumor

Pleural fibroma: (A) Chest radiograph showing lobulated pleural-based opacity (arrow) in right apical region; (B) axial contrast-enhanced CT scan showing heterogeneously enhancing peripheral mass lesion (arrow) in a biopsy-proven case of benign pleural fibroma

Malignant solitary fibrous tumor of pleura: Plain axial CT scan showing pleural-based soft tissue lesion with peripheral as well as internal calcification (arrow) abutting the liver

Pleural drop metastases in invasive thymoma: Axial contrast-enhanced CT image showing heterogeneously enhancing anterior mediastinal mass (arrowhead) with mild left pleural effusion and ipsilateral pleural implants (arrows)

Pleural metastases: Axial contrast-enhanced CT scan showing heterogeneously enhancing pleural-based mass lesion (arrow) in left hemithorax with extrathoracic extension in a case of metastatic adenocarcinoma

Pleural lymphoma: Axial contrast-enhanced CT scan showing heterogeneously enhancing lobulated mass lesion involving the diaphragmatic pleura (arrow) and invading the chest wall in a case of high-grade lymphoma

Spindle cell sarcoma of pleura: (A) Chest radiograph showing complete opacification of right hemithorax (arrowhead) with mediastinal shift to the left; (B) axial contrast-enhanced CT scan showing heterogeneously enhancing nodular pleural-based lesions with pleural effusion displacing the heart to the left

Askin tumor: (A) Chest radiograph showing inhomogeneous opacity (arrow) right hemithorax obscuring right hemidiaphragm without mediastinal shift; (B) axial contrast-enhanced CT scan showing heterogeneously enhancing nodular pleural-based lesions (arrows) involving the costal and mediastinal pleura with characteristic involvement of the sympathetic chain (arrowhead) in right paraspinal region

Loculated empyema: (A) Chest radiograph showing pleural-based opacity (arrow) with tapering obtuse margins in left hemithorax; (B) axial contrast-enhanced CT scan showing loculated collection (arrowhead) with peripherally enhancing thick walls

Calcified empyema: (A) Chest radiograph showing volume loss right hemithorax with veil-like calcified (arrow) pleural opacity; (B) axial contrast-enhanced CT scan showing evidence of calcified chronic empyema (arrow) with proliferation of extrapleural fat and crowding of ribs suggestive of volume loss in right hemithorax

Calcifying fibrous pseudotumor: (A) Chest radiograph showing pleural-based calcified opacity (arrowhead) left hemithorax with incomplete border sign; (B) plain axial CT scan image showing pleural-based calcified lesion (arrow) with no destruction of underlying ribs.

Thank You.