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Imaging Sciences Interesting Cases

Case 60

Nate Johnson, MD

Clinical Presentation: A 67-year-old male presents to the emergency department with complaint of confusion and cough.

Imaging Findings:

Figure 1: Chest x-ray demonstrates a right upper lobe density with probable rib erosion suspicious for lung mass.
Figure 2: Axial CT image through the upper thorax demonstrates a right upper lobe mass that is eroding through the posterior rib.
Figure 3: Axial CT image demonstrates the same mass with extension into the spinal canal.
Figure 4: Axial CT image of the head with brain windows demonstrates a ring enhancing lesion in the right cerebral hemisphere with surrounding edema concerning for metastatic disease.

Diagnosis: Stage IV lung cancer with cerebral metastases

Discussion: It is important not only to detect but also to accurately stage bronchogenic carcinoma in order to correctly determine treatment and prognosis. While lung cancer can have a dim prognosis, there is a large spread of five-year mortality based on staging. A patient diagnosed with Stage 1A lung cancer has a 75% five-year survival. However a patient with Stage IV disease (as does our patient) has less than a 5% chance of survival at five years. A patient is considered to have unresectable disease if their stage is either IIIB or IV.

The staging of lung cancer is based on the familiar TNM system which relies on grading the 1) primary tumor, 2) lymph node involvement, and 3) metastases.

  • M1 - denotes the presence of metastatic disease.
  • M0 - designates absence of metastases

Nodal staging is as follows:

  • N0 - No lymph nodes involved
  • N1 - Ipsilateral hilar or bronchopulmonary nodes involved
  • N2 - Mediastinal nodes involved
  • N3 - Contralateral lymph nodes or scalene/supraclavicular nodal involvement

Primary tumor grading (T) is as follows:

  • Tis - Carcinoma in situ.
  • TX - Positive malignant cytologic findings without identifiable lesion.
  • T1 - Lesion <3cm surrounded by lung or visceral pleura -or- endobronchial variety distal to lobar bronchi.
  • T2 - Lesion >3cm - or - extends to the visceral pleura -or- causes atelectasis/obstruction - or - main bronchi tumors more than 2cm from the carina.
  • T3 - Direct extension into structures such as the diaphragm, pericardium parietal layer, mediastinal pleura or chest wall - or - endobronchial tumors within 2cm of the carina, without invasion - or - complete atelectasis of an entire lung - or - apical tumors.

    • References:

    1. Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest. 1997 Jun;111(6):1710-7. [PubMed]
    2. Mountain CF. A new international staging system for lung cancer. Chest. 1986 Apr;89(4 Suppl):225S-233S. [PubMed]
    3. Mountain CF. Expanded possibilities for surgical treatment of lung cancer. Survival in stage IIIa disease. Chest. 1990 May;97(5):1045-51. [PubMed]