Vol. 47, No. 4, 2008
Chest Radiographic Findings in Bronchogenic Carcinoma in Pakistani Population
Muhammad Imran Suliman,1 Basharat Ali,1 Hamid Majeed,1 Fayyaz Qureshi2
Bahawal Victoria Hospital Bahawalpur,1 Women Medical College Abbotabad2
Objectives: To observe the common radiographic findings in histologically confirmed cases of bronchogenic carcinoma.
Patients and Methods: This descriptive study comprised of 35 consecutive histopathologically / cytological confirmed cases of bronchogenic carcinoma that were admitted from January 2000 to April 2003 in Bahawal Victoria hospital Bahawalpur. Plain chest radiographs were obtained in all cases. Two radiologists blinded to the cell types were asked to interpret the radiographs.
Results: Hilar mass was the major manifestation in 62.8% cases. Chest radiographs showed 7 different types of lesions in four cell varieties in 35 cases, these included hilar mass in 62% cases of squamous cell carcinoma. Cavitation and rib erosion were found exclusively in squamous cell type carcinoma. In small cell carcinomas, hilar involvement was present in 83.3% cases. Half of large cell carcinomas and one case of adenocarcinoma presented with a peripheral mass. Hilar mass was seen in 50% cases with adenocarcinoma. Wide mediastinum was seen only in cases with small cell carcinoma.
Conclusion: The chest radiograph findings in brochogenic carcinoma has more or less a standard patterns which can help the physician in better suspicion and diagnosis.
Key words: Radiography, bronchogenic carcinoma, adenocarcinoma, squamous cell lung cancer
Dr. Muhammad Imran Suliman
Women Medical College, Abbottabad.
Chest radiographs have specific picture in almost all cases with pulmonary neoplasms presenting to a tertiary care unit.1 Common early appearance include a hilum bulging out slightly in cases of a tumor arising from the main central airways.2 A peripheral tumor manifests generally as a rounded or ovoid shadow. Central necrosis in a tumor may give a cavitatory lesion on a radiographic image and this is principally seen in squamous cell variety. Cavitation can never be attributed to small cell carcinoma.3 Moreover squamous cell carcinoma commonly leads to segmental or lobar collapse due to their frequent central location.4 Similarly, small cell carcinoma generally presents with bulky hila and mediastinal lymph node masses.5,6
We carried out this study to evaluate the radiographic findings in histologically confirmed cases of bronchogenic carcinoma in our local population.
This study was done to see the chest radiographic patterns in 35 consecutive cases of lung cancer with established cell types. All the patients were admitted from January 2000 to April 2003 in different medical units of Bahawal Victoria hospital, Bahawalpur.
Chest radiographs (posteroanterior view only) taken within a month before going for histopathology were taken as standard. Radiograph findings were taken from a senior radiologist who was unaware of the cell type. Particular abnormalities like hilar mass, collapse lung/post obstructive consolidation, cavitation, rib erosion, wide mediastinum, pleural effusion and peripheral mass on the chest X-rays were assessed. Subsequently another radiologist was also asked to give his findings on the X-ray films. The reports of two radiologists were than merged and correlated with the cell type of the tumor.
Six different morphologic patterns on chest radiographs were seen in 35 patients having non-small cell bronchogenic carcinoma. Hilar mass was seen in majority 17 (58.6%) of the cases followed by post obstructive consolidation/collapse lung in 5 cases (17.2%). Out of 21 cases of squamous cell carcinoma 62% manifested as a hilar mass. Cavitation and rib erosion were found exclusively in cases with squamous cell carcinoma. Hilar mass was seen in 2 cases (50%) with adenocarcinoma. Only one case had pleural effusion. Two cases (50%) of large cell carcinomas and one of adenocarcinoma presented with a peripheral mass. Of 6 cases with small cell carcinomas, 5 presented as a hilar mass, and 1 had wide mediastinum.
Chest radiography, being an easily available investigation, is frequently the initial tool to diagnose bronchogenic carcinoma.7 Often a spicular mass clearly suggests lung cancer, but one can deduce its possibility from findings like an un-resolving consolidation or collapsed lung. In most circumstances, need for additional imaging becomes indispensable.8
In the present study, the commonest chest X-ray finding in cases with bronchogenic carcinoma was a hilar mass seen in 63% cases. Similar findings were reported by others.9, 10
Squamous cell carcinoma often presents as a central lesion which invades the hilum and mediastinum.11,12 In the present study hilar mass was seen in 62% cases of squamous cell carcinoma.
Cavitation occurs in 82% of cases with squamous cell carcinoma 13 but in the present study it was seen in only 5.7% cases.
Adenocarcinoma of the lung often presents as a peripherally located lesion on chest radiographs11 Mayo clinic study reported its peripheral location in 72% of cases4 while Daniel et al14 found the peripheral tumor in only 49% cases and reported that there is no statistically significant difference between adenocarcinoma and squamous cell carcinoma presenting as a peripheral or central mass.14 Hollings observed that 51% cases in his study presented with either hilar or hilar and mediastinal masses.15 In the present study half of the cases with adenocarcinoma appeared as hilar masses.
Small cell carcinoma commonly manifests as a hilar mass, but this classic presentation is because of hilar and mediastinal nodal metastases while the main tumor remains occult.11,16 In our study 83.3% cases of small cell carcinomas presented as a hilar mass and the rest with widening of mediastinum.
Large cell carcinoma is usually considered as a peripheral mass.11 In our study it was true in 50% cases.4 We found pleural effusion in 2.8% cases with bronchogenic carcinoma as compared to 4% of the Mayo clinic results, while other report showed pleural effusion in 24% cases.14 According to Sharma, isolated pleural effusion was present in 3.8% cases of squamous cell carcinoma, 22% cases of adenocarcinoma and in 4% cases of small cell lung cancers.12 In our study pleural effusion was seen in one case only that had adenocarcinoma.
Larger studies are required to confirm our findings that characteristic radiological patterns are found in specific bronchogenic carcinoma.
1. Fergusson RJ, Gregor A, Dodds R. Management of lung cancer in South-East Scotland. Thorax 1996; 51:569.
2. Weiss W, Boucot KR. The Philadelphia pulmonary neoplasm research project: early roentgenographic appearance of bronchogenic carcinoma. Arch Intern Med 1974; 134:306.
3. Byrd RB, Carr DT, Miller WE. Radiographic abnormalities in carcinoma of the lung as related to histological cell type. Thorax 1969; 24: 574.
4. Byrd RB, Miller WE, Carr DT, Payne WS, Woolner LB. The roentgenographic appearance of squamous cell carcinoma of the bronchus. Mayo Clin Proc 1968; 43:327–32.
5. Forster BB, Muller NL, Miller RR, Nelems B, Evans KG. Neuroendocrine carcinomas of the lung: clinical, radiologic, and pathologic correlation. Radiology 1989; 170:441–5.
6. Pearlberg JL, Sandler MA, Lewis JW Jr, Beute GH, Alpern MB. Small-cell bronchogenic carcinoma: CT evaluation. Am J Roentgenol 1988; 150:265–8.
7. Legmann P. Imaging and lung disease: uses and interpretation. Tuber Lung Dis. 1993; 74:147-58.
8. Hyer JD, Silvestri G. Diagnosis and staging of lung cancer. Clin Chest Med 2000; 21:95-106.
9. Chaudhary K, Rasul S, Iqbal Z, Qureshi S, Haq M, Hussain G et al. Fiberoptic bronchoscopy-role in the diagnosis of bronchogenic carcinoma. Biomedica 1998; 14: 32-6.
10. Martinez ME, Aparicio UJ, Sanchis AJ, de Diego DA, Martinez FM, Cases VE, et al. Fiber bronchoscopy in lung cancer: relationship between radiology, endoscopy, histology and diagnostic value in a series of 1801 cases. Arch Bronconeumol.1994; 30:291-6.
11. Sider L. Radiographic manifestations of primary bronchogenic carcinoma. Radiol Clin North Am. 1990; 28:583-97.
12. Sharma CP, Behera D, Aggarwal AN, Gupta D, Jindal SK. Radiographic patterns in lung cancer. Indian J Chest Dis Allied Sci. 2002; 44:25-30.
13. Chaudhuri MR. Primary pulmonary cavitating carcinomas. Thorax 1973; 28:354-66.
14. Daniel Q, Adriane G, Steven B. The changing radiographic presentation of bronchogenic carcinoma with reference to cell types. Chest 1996; 110:1474-9.
15. Hollings, Shaw P. Diagnostic imaging of lung cancer. Eur Respir J 2002; 19: 722–42.
16. Armstrong P. Neoplasms of the lungs, airways and pleura. In: Armstrong P, Wilson AG, Dee P, Hansell DM, editors. Imaging of Diseases of the Chest. 3rd ed. London: Mosby (Harcourt); 2000.p.305–401.