Chest Imaging_2.lung ca misses shanghai_by Dr. Gerald F. Abbott

3rd Seed Program / Shanghai 2015 3rd Seed Program / Shanghai 2015

Lung CancerLung CancerMisses and MimicsMisses and Mimics

Gerald F. Abbott MD Gerald F. Abbott MD Harvard Medical SchoolHarvard Medical SchoolMassachusetts General HospitalMassachusetts General Hospital

Lung CancerLung CancerUSAUSA

Most common cause Most common cause

of of cancer deathcancer death

A leading cause of A leading cause of

medical malpractice claimsmedical malpractice claims

in the USAin the USA

Lung CancerLung CancerUSAUSA

2013 Chest radiology lawsuits:

78% Errors in diagnosis

42% Failure to diagnosis lung cancer

61% Settled in favor of plaintiff

Mean payment $277,230. USD / 1,720,000. Chinese Yuan

3 Malpractice Cases3 Malpractice CasesAll settled out of CourtAll settled out of Court

MissedMissed Missed Missed Misinterpreted Misinterpreted

3 Malpractice Cases3 Malpractice CasesAll settled out of CourtAll settled out of Court

MissedMissed Missed Missed Misinterpreted Misinterpreted

Missed Lung CancerMissed Lung CancerLocationLocation

Most “misses” in upper lobes,Most “misses” in upper lobes,

perihilar, paraspinal regionsperihilar, paraspinal regions

Lung cancer occurs in Lung cancer occurs in

Upper lobes > Lower lobes 3:2Upper lobes > Lower lobes 3:2

RUL > LUL 3:2RUL > LUL 3:2

Anatomic structures overlap lesionsAnatomic structures overlap lesions

Austin. Radiology 1992. Shah, Austin et al. Radiology 2003.Austin. Radiology 1992. Shah, Austin et al. Radiology 2003.

Missed Lung CancerMissed Lung CancerOverlapping anatomic structuresOverlapping anatomic structures

Danger zones: Danger zones:

Apical, Perihilar, Paraspinal regionsApical, Perihilar, Paraspinal regions

Austin. Radiology 1992. Shah, Austin et al. Radiology 2003.Austin. Radiology 1992. Shah, Austin et al. Radiology 2003.

Missed Lung CancerMissed Lung CancerChest RadiographyChest Radiography

Peripheral nodules with indistinct bordersPeripheral nodules with indistinct borders

Nodular opacities obscured by overlapping structuresNodular opacities obscured by overlapping structures

Case 1Case 1 Case 2Case 2


Peripheral nodules with indistinct bordersPeripheral nodules with indistinct borders

Nodular opacities obscured by overlapping structuresNodular opacities obscured by overlapping structures

Case 1Case 1 Case 2Case 2

Chest RadiographyChest Radiography““Blind Spots”Blind Spots”Upper lung zones / Apical regionsUpper lung zones / Apical regions

Paramediastinal / Hila / Retrocardiac / Inferior lower lobesParamediastinal / Hila / Retrocardiac / Inferior lower lobes


Paramediastinal / Paramediastinal / Hila Hila / Retrocardiac / Inferior lower lobes/ Retrocardiac / Inferior lower lobes


Paramediastinal Paramediastinal / Hila / Hila / Retrocardiac / Inferior lower lobes/ Retrocardiac / Inferior lower lobes


Paramediastinal / Paramediastinal / HilaHila / Retrocardiac / Inferior lower lobes / Retrocardiac / Inferior lower lobes


Paramediastinal / Hila / Retrocardiac / Inferior lower lobesParamediastinal / Hila / Retrocardiac / Inferior lower lobes


Paramediastinal / Hila / Paramediastinal / Hila / RetrocardiacRetrocardiac / Inferior lower lobes / Inferior lower lobes


Paramediastinal / Hila / Paramediastinal / Hila / RetrocardiacRetrocardiac / Inferior lower lobes / Inferior lower lobes

54-year old man with cough54-year old man with cough

CXR Report: CXR Report: “scarring at right lung base”“scarring at right lung base”

54-year old man with cough54-year old man with cough

Displaced fissures = Sign of AtelectasisDisplaced fissures = Sign of Atelectasis””

Minor Minor fissurefissure Major Major

fissurefissure

Complete RLL AtelectasisComplete RLL AtelectasisLung cancer Lung cancer


fissurefissure Major Major fissurefissure

Complete RLL AtelectasisComplete RLL AtelectasisLung cancer Lung cancer


fissurefissure TumorTumor AtelectasisAtelectasis

Chest RadiographyChest Radiography““Blind Spots”Blind Spots”

History:History:

““Cough, fever”Cough, fever”

Blind SpotsInferior lower lobes

Blind SpotsInferior lower lobes

Caudal extent of lung at L1

Common cognitive errorCommon cognitive error

Obvious abnormality attracts the viewer’s attentionObvious abnormality attracts the viewer’s attention

Lowers vigilance for more subtle abnormalitiesLowers vigilance for more subtle abnormalities

Greater error rate with multiple abnormalitiesGreater error rate with multiple abnormalities

Satisfaction of Search Satisfaction of Search

ErrorError

Chest RadiographyChest Radiography

Common cognitive errorCommon cognitive error

Obvious abnormality attracts the viewer’s attentionObvious abnormality attracts the viewer’s attention

Lowers vigilance for more subtle abnormalitiesLowers vigilance for more subtle abnormalities

Greater error rate with multiple abnormalitiesGreater error rate with multiple abnormalities

Satisfaction of Search Satisfaction of Search

ErrorError

Chest RadiographyChest Radiography


Lesion characteristics:Lesion characteristics:

Size, shape and densitySize, shape and density

Mean diameter Mean diameter 1.3 to 1.6 cm1.3 to 1.6 cm

ConspicuityConspicuity = Obviousness = Obviousness

(influenced by density, shape, (influenced by density, shape,

margin characteristics)margin characteristics)

Missed Lung CancerMissed Lung CancerFactorsFactors

Rate of error: 10-50% Rate of error: 10-50%

Poor image qualityPoor image quality

Poor viewing conditionsPoor viewing conditions

Poor lesion conspicuity Poor lesion conspicuity

Superimposition of normal structuresSuperimposition of normal structures

(e.g. clavicles, ribs, blood vessels, hila, mediastinal structures)(e.g. clavicles, ribs, blood vessels, hila, mediastinal structures)

Observer ErrorsObserver ErrorsSearch error Search error

Failed to look at lesionFailed to look at lesion

Observer ErrorsObserver ErrorsSearch error Search error

Failed to look at lesionFailed to look at lesion

RecognitionRecognition

Looked at lesionLooked at lesion

Failed to fixate on itFailed to fixate on it

Decision-makingDecision-making

Detected, but misinterpretedDetected, but misinterpreted

Lung cancer Lung cancer called “pneumonia”called “pneumonia”

Decision-making errorDecision-making error

Detected, but misinterpretedDetected, but misinterpreted

Decision-making ErrorDecision-making ErrorRemedyRemedy

Know the Know the

imaging features imaging features

of Lung Cancerof Lung Cancer

Lung CancerImaging Features

Nodule / Mass (>3 cm)

Bronchial wall thickening

Endobronchial nodule

Consolidation

Atelectasis

Post obstructive consolidation

Mucoid impaction

Advanced lung cancer:

Extrapulmonary / Lymphadenopathy / Multifocal

Adenocarcinoma / Large cell carcinomaPeripheral lesion

Solitary pulmonary nodule or mass

Squamous cell / Small cell caCentral lesion

Bronchial wall thickening, nodularity


Hilar mass, atelectasis, consolidation

Lung Cancer cell typesLung Cancer cell typesImaging ManifestationsImaging Manifestations

Adenocarcinoma Large cell carcinomaPeripheral lesion

Solitary pulmonary nodule or mass

Squamous cell / Small cell caCentral lesion

Bronchial wall thickening, nodularity


Hilar mass, atelectasis, consolidation

Lung Cancer cell typesLung Cancer cell typesImaging ManifestationsImaging Manifestations

2011: RevisedClassification

Spectrum of AdenocarcinomaGround-glass w/wo solid component (“subsolid” )

Adenocarcinoma in situ

Ground-glass nodule

Minimally invasive adenocarcinoma

Ground-glass + solid component

Invasive adenocarcinoma

Ground-glass with increasing solid component

LepidicDefinition

Le-pid-ic adj. Scales or a scaly covering layer.

Adenocarcinoma in situ (AIS)

Pulmonary AdenocarcinomaPulmonary AdenocarcinomaHistologic SpectrumHistologic Spectrum

Progression fromProgression fromin situ in situ carcinoma carcinoma to to Invasive carcinomaInvasive carcinoma

Pure lepidicPure lepidic Predominantly lepidic Predominantly lepidic Ground glassGround glass Ground glass + Solid Ground glass + Solid

Subsolid NodulesMalignancy Rate of Subsolid > Solid

Subsolid 34%

Pure GGO 18%

Part solid 63%

Solid 7%

Henschke AJR 2002

Low attenuation (Ground glass)Low attenuation (Ground glass)

Small sizeSmall size

Missed Lung CancerMissed Lung Cancer

CTCT


CTCT

White. Radiology 1996White. Radiology 1996

Kakinuma. Radiology 1999Kakinuma. Radiology 1999

Rusinek. Radiology 1998Rusinek. Radiology 1998

Ko. Radiology 2003Ko. Radiology 2003

Peldschus. Chest 2005Peldschus. Chest 2005

Central lesions Central lesions

Endobronchial tumorsEndobronchial tumors

Adjacent to scarringAdjacent to scarring

Adjacent to vesselsAdjacent to vessels

Low attenuation (GGO)Low attenuation (GGO)

Smalll sizeSmalll size


CTCTCentral lesions Central lesions

Endobronchial tumorsEndobronchial tumors

Adjacent to scarringAdjacent to scarring

Adjacent to vesselsAdjacent to vessels

Low attenuation (GGO)Low attenuation (GGO)

Smalll sizeSmalll size

White. Radiology 1996White. Radiology 1996

Kakinuma. Radiology 1999Kakinuma. Radiology 1999

Rusinek. Radiology 1998Rusinek. Radiology 1998

Ko. Radiology 2003Ko. Radiology 2003

Peldschus. Chest 2005Peldschus. Chest 2005

Mixture of cell types

Histology = heterogeneous

HistologicHistologicheterogeneityheterogeneity

Lobulated Lobulated contourscontours

Pulmonary Adenocarcinoma

Adenocarcinoma Serial CTsLung Cancer Screening Trial

BaselineScreen

12 months 15 months 19 months

Growth + Increasing Lobulation

6 months later


CTCTEndobronchial tumorsEndobronchial tumors

Lung Cancer MimicsLung Cancer MimicsIntrapulmonary lymph nodesIntrapulmonary lymph nodes

Infection (Fungal, Bacterial, TB)Infection (Fungal, Bacterial, TB)

Other tumors (hamartoma, carcinoid, lymphoma, metastases)Other tumors (hamartoma, carcinoid, lymphoma, metastases)

Granulomatosis with polyangiitis (WG)Granulomatosis with polyangiitis (WG)

Inflammatory myofibroblastic tumorInflammatory myofibroblastic tumor

Rounded atelectasisRounded atelectasis

Focal organizing pneumoniaFocal organizing pneumonia

Lipoid pneumoniaLipoid pneumonia

Nodular fibrosisNodular fibrosis

AmyloidAmyloid

Rounded atelectasisRounded atelectasis

Lung Cancer MimicsLung Cancer MimicsIntrapulmonary Lymph NodesIntrapulmonary Lymph Nodes

More detected with thin-section CTMore detected with thin-section CT

Below level of carinaBelow level of carina

Occur along pleura, fissuresOccur along pleura, fissures

Some occur 1-8 mm from pleuraSome occur 1-8 mm from pleura

<10 mm / Triangular or ovoid shape<10 mm / Triangular or ovoid shape

1-3 interlobular septa extend from IPLN1-3 interlobular septa extend from IPLN

Wang et al. Clinical Imaging 2013.Wang et al. Clinical Imaging 2013.

Lung Cancer MimicsLung Cancer MimicsFocal Organizing PneumoniaFocal Organizing PneumoniaNodular FibrosisNodular Fibrosis

Delayed resolution of pneumonia. Delayed resolution of pneumonia.

Solitary form of COP. Resolves in 6-8 wksSolitary form of COP. Resolves in 6-8 wks

Focal scarring.Focal scarring.

Does not resolve.Does not resolve.

Lung Cancer MimicsLung Cancer MimicsInfectionInfection

TB TB Fungal disease Fungal disease Lung abscess Lung abscess

BlastomycosisBlastomycosis

Lung Cancer MimicsLung Cancer MimicsInfectionInfection

TB TB Fungal disease Fungal disease Lung abscess Lung abscess

CoccidioidomycosisCoccidioidomycosis Coccidioidomycosis Coccidioidomycosis

Lung Cancer MimicsLung Cancer MimicsOther TumorsOther Tumors

CarcinoidCarcinoid Hamartoma Hamartoma Solitary metastasis Solitary metastasis

May see fat May see fat (59%) /calcification (59%) /calcification (25%)(25%)

MelanomaMelanoma

Synovial sarcomaSynovial sarcoma

3rd Seed Program / Shanghai 2015 3rd Seed Program / Shanghai 2015

Lung CancerLung CancerMisses and MimicsMisses and Mimics

Gerald F. Abbott MD Gerald F. Abbott MD Harvard Medical SchoolHarvard Medical SchoolMassachusetts General HospitalMassachusetts General Hospital

Date post:	18-Aug-2015
Category:	Health & Medicine
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Chest Imaging_2.lung ca misses shanghai_by Dr. Gerald F. Abbott

Health & Medicine