Today’s cases: November 30th, 2015

Firstly, before this week’s cases, I have a few homework assignments:

Q1. Types of lung cancer, which is most common?

There are two major types of lung cancer, non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Staging lung cancer is based on whether the cancer is local or has spread from the lungs to the lymph nodes or other organs.

Non-Small Cell Lung Cancer

Non–small cell lung cancer. Bronchoscopy. A large

Non–small cell lung cancer. Bronchoscopy. A large central lesion was diagnosed as non–small cell carcinoma.

Non–small cell lung cancer. CT scan shows cavitati

Non–small cell lung cancer. CT scan shows cavitation and air-fluid level.

Non-small cell lung cancer accounts for about 85 percent of lung cancers. Among them are these types of tumors:

  1. Adenocarcinoma is the most common form of lung cancer in the United States among both men and women. 2. Squamous cell carcinoma (which is also called epidermoid carcinoma) forms in the lining of the bronchial tubes. 3. Large cell carcinomas refer to non-small cell lung cancers that are neither adenocarcinomas nor epidermoid cancers.

Stage I: The cancer is located only in the lungs and has not spread to any lymph nodes.

Stage II: The cancer is in the lung and nearby lymph nodes.

Stage III: Cancer is found in the lung and in the lymph nodes in the middle of the chest, also described as locally advanced disease. Stage III has two subtypes:

If the cancer has spread only to lymph nodes on the same side of the chest where the cancer started, it is called stage IIIA. If the cancer has spread to the lymph nodes on the opposite side of the chest, or above the collar bone, it is called stage IIIB. Stage IV: This is the most advanced stage of lung cancer, and is also described as advanced disease. This is when the cancer has spread to both lungs, to fluid in the area around the lungs, or to another part of the body, such as the liver or other organs.

Small Cell Lung Cancer

Small cell lung cancer accounts for the remaining 15 percent of lung cancers in the United States. Small cell lung cancer results from smoking even more so than non-small cell lung cancer, and grows more rapidly and spreads to other parts of the body earlier than non-small cell lung cancer. It is also more responsive to chemotherapy.

Lung cancer, small cell. Contrast-enhanced CT scan

Lung cancer, small cell. Contrast-enhanced CT scan of the chest shows a large left lung and a hilar mass, with invasion of the left pulmonary artery.

Stages of Small Cell Lung Cancer

Limited stage: In this stage, cancer is found on one side of the chest, involving just one part of the lung and nearby lymph nodes.

Extensive stage: In this stage, cancer has spread to other regions of the chest or other parts of the body.

Lung cancer, small cell. Contrast-enhanced MRI of

Lung cancer, small cell. Contrast-enhanced MRI of the brain in a patient with known small-cell lung cancer (SCLC). Axial section at the level of lateral ventricles shows at least 2 ring-enhancing metastatic lesions in the periventricular region. The brain is one of the predominant sites for SCLC metastasis.

More recently, the American Joint Commission on Cancer implemented a more detailed staging system in which the stages of small cell lung cancer are described using Roman numerals and letters (for example, Stage IIA). This is the same method that is used for non-small cell lung cancer in describing the growth and spread of the cancer.

Q2: What type of primary lung cancers can result in a cavity?

A: Squamous-cell carcinoma is the most common histological type of lung cancer to cavitate (82% of cavitary primary lung cancer, Figure 1), followed by adenocarcinoma (Figure 2) and large cell carcinoma.[4,9]

Q3: What are possible bacterial causes of lung cavities?

Tuberculosis, periodontal disease and necrotizing pneumonia are bacterial causes of lung cavities. Also – cryptococcus, which makes a fungus ball (aspergilloma) Comes from pigeon droppings.

1. 73 yo male, lung cancer chemotherapy follow-up,  pt. now off chemo, lung primary metastasis and has made a hole, lymph nodes look worrisome (under 1cm size is normal), cavity noticed and getting larger,

This pt likely has squamous-cell carcinoma (type on non-small cell lung cancer)

Above: Thick-walled cavities in a 66-year-old man with squamous cell carcinoma of the lung

Usually present as obstructive lesions of the bronchus leading to infection. Occasionally cavitates (10% at presentation) – this will occur when the central part of the tumour undergoes necrosis. On x-ray this may have the appearances of an abscess, or a TB cavity, but on CT, you will clearly be able to see the jagged edge of the cavity, and possible infiltration of other structures (such as the pleura) and thus the cavity can be differentiated.


2. 50 yo male, presented with a headache, pansinusitis probably due to fenestration of basilar artery (often mistaken for a dissection)

Pansinusitis: Inflammation of all the accessory sinuses of the nose on one or both sides. – ethmoid sinus, spenoid sinus, maxillary sinus

CT examination: Unenhanced, coronal scans: The mucosa of the ethmoid cells (double arrow) and of both maxillar sinuses (arrows) is swollen in the upper picture. (=> picture)

In the lower picture, the mucosa of both the dorsal ethmoid cells and the sphenoid sinus is swollen. The pictures unambiguously prove pansinusitis.

Basilar artery fenestration (or more simply, basilar fenestration) is the most common intracranial arterial fenestration. It refers to duplication of a portion of the artery.


3. 67 yo male, hydrocephalus following clipping of aneurysm (a secondary change of an aneurysm/hemorrhage)

Below: Noncontrast head CT (left) demonstrates mildly dilated lateral and third ventricles (asterisks). T2 weighted MRI shows that reason for that is a right cerebellar mass (black arrow) causing mass effect on and obliteration of the fourth ventricle (white arrow).


Hydrocephalus is a condition in which there is either an obstruction to the flow of CSF within the ventricular system or subarachnoid space (noncommunicating hydrocephalus) either due to intraventricular mass lesions or to external compression or a problem with reabsorption of CSF (communicating hydrocephalus).


4. 37 yo male, dizzyness, problem in the region of the pons – cavernous hemangioma, it was most probably capillary telangiectasiae

CNS capillary telangiectasiae(s) are small, asymptomatic low flow vascular lesions of the brain.

Cavernous hemangioma, also called cavernous angioma, or cavernoma (often when referring to presence in the brain [citation needed]), is a type of blood vessel malformation or hemangioma, where a collection of dilated blood vessels form a tumor.

The pterion is the region where the frontal, parietal, temporal, and sphenoid join together. It is located on the side of the skull, just behind the temple.

Midbrain cavernoma (Axial T2):

Below: Pontine hemorrhage – cavernous malformation of the pons

Capillary telangiectasia Radiology MRI CT

When looking at the brain, I have the tendency to think everything I see is a tumor BUT – that is a rare case – so

1st – Think of vascular disease, hemorrhage

2nd- Infections, cysts (many types – tumor making, congenital)

3rd—last? – tumors

Diagnostic Imaging: Brain, Second Edition


5. 51 yo male, cervical canal stenosis C5,6 (the abnormal narrowing of a passage in the body), due to generative change, we need to know the difference – herniation vs. bulging

Bulging discs are still contained within the annulus fibrosis. Herniated disc extend outside the annulus.

A herniated disc is a traumatic focused injury to the disc, which results in a portion of the nucleus, or inside material, pushing out into a nerve.

A herniated disc is “non-contained,” which means a tear or rupture is present. A portion of the gel-like nucleus pulposus has leaked into the spinal canal. A herniated disc might have begun as a bulging disc, but created so much pressure on the outer wall of the disc that a rupture occurred.


6. 53 yo male, stenosis of ICA – CCA (cervical segment), temporal arachnoid cyst (fluid collection) – sometimes compresses normal brain, can cause syncope

Arachnoid cysts are cerebrospinal fluid covered by arachnoidal cells and collagen that may develop between the surface of the brain and the cranial base or on the arachnoid membrane, one of the three membranes that cover the brain and the spinal cord.

Lateral carotid angiogram shows that the cervical carotid artery (CCA) is narrowed, but it has a smooth outline. The supraclinoid internal carotid artery (ICA) is occluded. Note the enlarged ophthalmic artery (Opthal A.), which functions as a major collateral.

Axial CT showing a typical arachnoid cyst left temporal

Arachnoid cyst.jpg

7. 51 yo female, mamography, mass on left since last year, benign calcification b/c clear and large, know breast mass vs fat…

  • if distribution of calcification is diffuse = benign
  • In terms of Form, microcalcifications come in many shapes. They can be round, linear, coarse, granular (fine), monomorphic (all the same basic shape), or pleomorphic (many different shapes), or clustered.In Size, microcalfications are described as either large or small, or when in clusters whether the sizes of microcalcifications are homogeneous or not.The Density of microcalcifications may be high, low, or variable. And if in a cluster, the homogeneous or non-homogeneous nature of the density is noted.The Distribution refers to the overall placements of the microcalcifications within the breast image. Microcalfications can be in single clusters or multifocal, unilateral or bilateral, diffuse, segmental, linear, or regional.





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