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
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
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
Chest RadiographyChest Radiography““Blind Spots”Blind Spots”Upper lung zones / Apical regionsUpper lung zones / Apical regions
Paramediastinal / Paramediastinal / Hila Hila / Retrocardiac / Inferior lower lobes/ Retrocardiac / Inferior lower lobes
Chest RadiographyChest Radiography““Blind Spots”Blind Spots”Upper lung zones / Apical regionsUpper lung zones / Apical regions
Paramediastinal Paramediastinal / Hila / Hila / Retrocardiac / Inferior lower lobes/ Retrocardiac / Inferior lower lobes
Chest RadiographyChest Radiography““Blind Spots”Blind Spots”Upper lung zones / Apical regionsUpper lung zones / Apical regions
Paramediastinal / Paramediastinal / HilaHila / Retrocardiac / Inferior lower lobes / Retrocardiac / Inferior lower lobes
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
Chest RadiographyChest Radiography““Blind Spots”Blind Spots”Upper lung zones / Apical regionsUpper lung zones / Apical regions
Paramediastinal / Hila / Paramediastinal / Hila / RetrocardiacRetrocardiac / Inferior lower lobes / Inferior lower lobes
Chest RadiographyChest Radiography““Blind Spots”Blind Spots”Upper lung zones / Apical regionsUpper lung zones / Apical regions
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
Minor Minor fissurefissure Major Major
fissurefissure Major Major fissurefissure
Complete RLL AtelectasisComplete RLL AtelectasisLung cancer Lung cancer
Minor Minor fissurefissure Major Major
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
Missed Lung CancerMissed Lung CancerChest 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
Endobronchial nodule
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
Endobronchial nodule
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
Missed Lung CancerMissed Lung Cancer
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
Missed Lung CancerMissed Lung Cancer
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
Missed Lung CancerMissed Lung Cancer
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