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Imaging of the Patient with Non–Small Cell Lung Cancer¹

¹ From the Division of Diagnostic Imaging, Department of Diagnostic Radiology (R.F.M.), Department of Thoracic and Cardiovascular Surgery (S.S.S.), Division of Radiation Oncology (C.W.S.), and Division of Cancer Medicine (D.J.S.), University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030. Received June 2, 2004; revision requested August 12; revision received October 27; accepted December 15. Address correspondence to R.F.M. (e-mail: rmunden{at}di.mdacc.tmc.edu).

View larger version (76K): [in a new window]   Figure 1. Transverse CT image in a 62-year-old woman with a central tumor in the left upper lobe and atelectasis (T3 tumor) shows tumor (T) occluding (arrow) the left upper lobe bronchus and surrounding the pulmonary artery. At surgery, the tumor was invading the pericardium and required intrapericardial pneumonectomy. At 1-year after surgery, there was no local recurrence, but the patient developed distant metastasis.

View larger version (138K): [in a new window]   Figure 2. Transverse CT image in a 51-year-old woman with squamous cell carcinoma of the left lower lobe shows large left lower lobe mass (M) invading the left atrium (arrows). Patient underwent left pneumonectomy and left atrial resection and reconstruction. Patient was alive at 1 year, with evidence of small contralateral lung metastasis.

View larger version (145K): [in a new window]   Figure 3a. Images in a 58-year-old man with NSCLC of the right upper lobe. (a) Transverse CT image of the lower neck shows a small lymph node (arrow) along the left internal jugular vein that could easily be overlooked. (b) Fused PET/CT image shows increased activity of the lymph node (arrow), indicative of metastatic disease.

View larger version (86K): [in a new window]   Figure 3b. Images in a 58-year-old man with NSCLC of the right upper lobe. (a) Transverse CT image of the lower neck shows a small lymph node (arrow) along the left internal jugular vein that could easily be overlooked. (b) Fused PET/CT image shows increased activity of the lymph node (arrow), indicative of metastatic disease.

View larger version (94K): [in a new window]   Figure 4a. Images in a 64-year-old woman with adenocarcinoma of the left upper lobe treated with chemoradiation. Follow-up CT results could not exclude persistent tumor. (a) Transverse CT image shows a masslike appearance (arrows) to the radiation fibrosis in the left upper lobe that was concerning for recurrent tumor. The air bronchograms typically seen in radiation fibrosis are not evident. (b) Coronal CT reconstruction shows the extent of the mass (arrow) above the aortic arch (A). (c) Coronal fused PET/CT image obtained to evaluate the mass shows no increased FDG uptake (arrow), indicating no malignancy. Follow-up imaging for 9 months continued to show no increased FDG uptake within the mass, thus confirming stable radiation fibrosis. A = aortic arch.

View larger version (87K): [in a new window]   Figure 4b. Images in a 64-year-old woman with adenocarcinoma of the left upper lobe treated with chemoradiation. Follow-up CT results could not exclude persistent tumor. (a) Transverse CT image shows a masslike appearance (arrows) to the radiation fibrosis in the left upper lobe that was concerning for recurrent tumor. The air bronchograms typically seen in radiation fibrosis are not evident. (b) Coronal CT reconstruction shows the extent of the mass (arrow) above the aortic arch (A). (c) Coronal fused PET/CT image obtained to evaluate the mass shows no increased FDG uptake (arrow), indicating no malignancy. Follow-up imaging for 9 months continued to show no increased FDG uptake within the mass, thus confirming stable radiation fibrosis. A = aortic arch.

View larger version (100K): [in a new window]   Figure 4c. Images in a 64-year-old woman with adenocarcinoma of the left upper lobe treated with chemoradiation. Follow-up CT results could not exclude persistent tumor. (a) Transverse CT image shows a masslike appearance (arrows) to the radiation fibrosis in the left upper lobe that was concerning for recurrent tumor. The air bronchograms typically seen in radiation fibrosis are not evident. (b) Coronal CT reconstruction shows the extent of the mass (arrow) above the aortic arch (A). (c) Coronal fused PET/CT image obtained to evaluate the mass shows no increased FDG uptake (arrow), indicating no malignancy. Follow-up imaging for 9 months continued to show no increased FDG uptake within the mass, thus confirming stable radiation fibrosis. A = aortic arch.

View larger version (77K): [in a new window]   Figure 5a. Transverse CT images in a 36-year-old man with a right lower lobe moderately differentiated squamous cell carcinoma. The patient underwent chemo- and radiation therapy. (a) Mediastinal (window: width, 599 HU; level, 55 HU) image shows a right lower lobe mass (M) occluding the bronchus intermedius. (b) Lung (window: width, 1500; level, –600) image at baseline shows minimal surrounding pulmonary opacities (arrows). M = mass. (c) Image obtained at 8-month follow-up shows scattered nodules (arrowheads) and poorly defined opacities in the right lower lobe. Note the sharp demarcation (arrows) of the irradiated lung from normal lung and that the nodules and opacities are within the demarcated area of irradiation. These nodules should not be confused for metastatic nodules because they are within the radiation field. (d) Image obtained at 14 months shows well-organized radiation fibrosis with sharp demarcation (arrows) between fibrosis and normal lung. Nodules are no longer evident and there are no metastatic nodules.

View larger version (107K): [in a new window]   Figure 5b. Transverse CT images in a 36-year-old man with a right lower lobe moderately differentiated squamous cell carcinoma. The patient underwent chemo- and radiation therapy. (a) Mediastinal (window: width, 599 HU; level, 55 HU) image shows a right lower lobe mass (M) occluding the bronchus intermedius. (b) Lung (window: width, 1500; level, –600) image at baseline shows minimal surrounding pulmonary opacities (arrows). M = mass. (c) Image obtained at 8-month follow-up shows scattered nodules (arrowheads) and poorly defined opacities in the right lower lobe. Note the sharp demarcation (arrows) of the irradiated lung from normal lung and that the nodules and opacities are within the demarcated area of irradiation. These nodules should not be confused for metastatic nodules because they are within the radiation field. (d) Image obtained at 14 months shows well-organized radiation fibrosis with sharp demarcation (arrows) between fibrosis and normal lung. Nodules are no longer evident and there are no metastatic nodules.

View larger version (122K): [in a new window]   Figure 5c. Transverse CT images in a 36-year-old man with a right lower lobe moderately differentiated squamous cell carcinoma. The patient underwent chemo- and radiation therapy. (a) Mediastinal (window: width, 599 HU; level, 55 HU) image shows a right lower lobe mass (M) occluding the bronchus intermedius. (b) Lung (window: width, 1500; level, –600) image at baseline shows minimal surrounding pulmonary opacities (arrows). M = mass. (c) Image obtained at 8-month follow-up shows scattered nodules (arrowheads) and poorly defined opacities in the right lower lobe. Note the sharp demarcation (arrows) of the irradiated lung from normal lung and that the nodules and opacities are within the demarcated area of irradiation. These nodules should not be confused for metastatic nodules because they are within the radiation field. (d) Image obtained at 14 months shows well-organized radiation fibrosis with sharp demarcation (arrows) between fibrosis and normal lung. Nodules are no longer evident and there are no metastatic nodules.

View larger version (110K): [in a new window]   Figure 5d. Transverse CT images in a 36-year-old man with a right lower lobe moderately differentiated squamous cell carcinoma. The patient underwent chemo- and radiation therapy. (a) Mediastinal (window: width, 599 HU; level, 55 HU) image shows a right lower lobe mass (M) occluding the bronchus intermedius. (b) Lung (window: width, 1500; level, –600) image at baseline shows minimal surrounding pulmonary opacities (arrows). M = mass. (c) Image obtained at 8-month follow-up shows scattered nodules (arrowheads) and poorly defined opacities in the right lower lobe. Note the sharp demarcation (arrows) of the irradiated lung from normal lung and that the nodules and opacities are within the demarcated area of irradiation. These nodules should not be confused for metastatic nodules because they are within the radiation field. (d) Image obtained at 14 months shows well-organized radiation fibrosis with sharp demarcation (arrows) between fibrosis and normal lung. Nodules are no longer evident and there are no metastatic nodules.

View larger version (120K): [in a new window]   Figure 6a. Transverse CT images in a 72-year-old woman with adenocarcinoma of the right upper lobe who underwent radiation therapy. (a) Image obtained 11 months after completion of therapy shows radiation fibrosis (white arrows). Note patency of the air bronchograms (black arrows). (b) Image obtained 1 month later shows filling in of the air bronchograms with soft-tissue opacity (arrows) indicating recurrent tumor.

View larger version (116K): [in a new window]   Figure 6b. Transverse CT images in a 72-year-old woman with adenocarcinoma of the right upper lobe who underwent radiation therapy. (a) Image obtained 11 months after completion of therapy shows radiation fibrosis (white arrows). Note patency of the air bronchograms (black arrows). (b) Image obtained 1 month later shows filling in of the air bronchograms with soft-tissue opacity (arrows) indicating recurrent tumor.

View larger version (175K): [in a new window]   Figure 7a. Transverse CT images in a 53-year-old woman with adenocarcinoma of the right upper lobe who was not a candidate for surgery because of comorbid disease. Three-dimensional conformal radiation therapy was performed. (a) Baseline image shows a lobulated lesion (arrows) of the right upper lobe. (b) Image obtained 37 months after completion of radiation therapy shows an atypical pattern of radiation fibrosis of a small nodule (arrow) associated with a linear scar. Without prior knowledge of treatment, this could be misinterpreted as a pulmonary nodule arising from a scar.

View larger version (162K): [in a new window]   Figure 7b. Transverse CT images in a 53-year-old woman with adenocarcinoma of the right upper lobe who was not a candidate for surgery because of comorbid disease. Three-dimensional conformal radiation therapy was performed. (a) Baseline image shows a lobulated lesion (arrows) of the right upper lobe. (b) Image obtained 37 months after completion of radiation therapy shows an atypical pattern of radiation fibrosis of a small nodule (arrow) associated with a linear scar. Without prior knowledge of treatment, this could be misinterpreted as a pulmonary nodule arising from a scar.

View larger version (132K): [in a new window]   Figure 8a. Transverse CT images in a 63-year-old man who underwent left lower lobectomy for adenocarcinoma of the left lower lobe. (a) Image obtained 4 months after surgery reveals a right lower lobe lesion confirmed as metastatic disease at biopsy. Baseline measurement is 16.7 mm. (b) Image obtained after completion of first course of chemotherapy shows interval growth. The lesion measures 25.4 mm. According to RECIST criteria, this is 52% growth and compatible with progressive disease.

View larger version (129K): [in a new window]   Figure 8b. Transverse CT images in a 63-year-old man who underwent left lower lobectomy for adenocarcinoma of the left lower lobe. (a) Image obtained 4 months after surgery reveals a right lower lobe lesion confirmed as metastatic disease at biopsy. Baseline measurement is 16.7 mm. (b) Image obtained after completion of first course of chemotherapy shows interval growth. The lesion measures 25.4 mm. According to RECIST criteria, this is 52% growth and compatible with progressive disease.

View larger version (131K): [in a new window]   Figure 9a. Transverse CT images in a 66-year-old man previously treated for adenocarcinoma of the left upper lobe with new metastatic disease in the right upper lobe. The right upper lobe tumor can be used as a RECIST target lesion to assess response to treatment. (a) Note the lobulated contour (arrow) of the tumor. (b) If one radiologist does not include the small lobule in the measurement, the largest dimension of the tumor is 18.4 mm. (c) If another radiologist measures the same tumor but includes the small projection, the largest dimension is 24.4 mm. This increase in size could be interpreted as progressive disease (33% increase), even though there is no difference. Therefore, a lesion that is not changed on follow-up images may be stable, but interobserver errors in measuring could indicate a change that would result in alteration of treatment.

View larger version (128K): [in a new window]   Figure 9b. Transverse CT images in a 66-year-old man previously treated for adenocarcinoma of the left upper lobe with new metastatic disease in the right upper lobe. The right upper lobe tumor can be used as a RECIST target lesion to assess response to treatment. (a) Note the lobulated contour (arrow) of the tumor. (b) If one radiologist does not include the small lobule in the measurement, the largest dimension of the tumor is 18.4 mm. (c) If another radiologist measures the same tumor but includes the small projection, the largest dimension is 24.4 mm. This increase in size could be interpreted as progressive disease (33% increase), even though there is no difference. Therefore, a lesion that is not changed on follow-up images may be stable, but interobserver errors in measuring could indicate a change that would result in alteration of treatment.

View larger version (129K): [in a new window]   Figure 9c. Transverse CT images in a 66-year-old man previously treated for adenocarcinoma of the left upper lobe with new metastatic disease in the right upper lobe. The right upper lobe tumor can be used as a RECIST target lesion to assess response to treatment. (a) Note the lobulated contour (arrow) of the tumor. (b) If one radiologist does not include the small lobule in the measurement, the largest dimension of the tumor is 18.4 mm. (c) If another radiologist measures the same tumor but includes the small projection, the largest dimension is 24.4 mm. This increase in size could be interpreted as progressive disease (33% increase), even though there is no difference. Therefore, a lesion that is not changed on follow-up images may be stable, but interobserver errors in measuring could indicate a change that would result in alteration of treatment.

View larger version (113K): [in a new window]   Figure 10a. Multidisciplinary care of a 44-year-old man with left upper lobe poorly differentiated NSCLC. (a) Transverse CT image at baseline shows a large left upper lobe mass (m) with an adjacent satellite lesion (arrow). (b) Transverse CT image at baseline also reveals a small indeterminate nodule in the right upper lobe (arrow). (c) PET image demonstrates a hypermetabolic mass (m) of the left upper lobe and increased activity in a nodule of the right upper lobe nodule (arrow). Transthoracic needle biopsy of the right upper lobe nodule was positive for poorly differentiated NSCLC. (d) Transverse CT image after induction chemotherapy reveals decrease in left upper lobe mass (m) and resolution of the adjacent satellite nodule. There also is no longer evidence of the right upper lobe nodule. (e) PET image after induction chemotherapy shows the left upper lobe hypermetabolic mass (m) and resolution of activity in the right upper lobe. The patient underwent resection of the left upper lobe mass and radiation therapy in the left upper chest. At a recent follow-up 24 months after initiation of induction chemotherapy, the patient remains free of disease.

View larger version (125K): [in a new window]   Figure 10b. Multidisciplinary care of a 44-year-old man with left upper lobe poorly differentiated NSCLC. (a) Transverse CT image at baseline shows a large left upper lobe mass (m) with an adjacent satellite lesion (arrow). (b) Transverse CT image at baseline also reveals a small indeterminate nodule in the right upper lobe (arrow). (c) PET image demonstrates a hypermetabolic mass (m) of the left upper lobe and increased activity in a nodule of the right upper lobe nodule (arrow). Transthoracic needle biopsy of the right upper lobe nodule was positive for poorly differentiated NSCLC. (d) Transverse CT image after induction chemotherapy reveals decrease in left upper lobe mass (m) and resolution of the adjacent satellite nodule. There also is no longer evidence of the right upper lobe nodule. (e) PET image after induction chemotherapy shows the left upper lobe hypermetabolic mass (m) and resolution of activity in the right upper lobe. The patient underwent resection of the left upper lobe mass and radiation therapy in the left upper chest. At a recent follow-up 24 months after initiation of induction chemotherapy, the patient remains free of disease.

View larger version (76K): [in a new window]   Figure 10c. Multidisciplinary care of a 44-year-old man with left upper lobe poorly differentiated NSCLC. (a) Transverse CT image at baseline shows a large left upper lobe mass (m) with an adjacent satellite lesion (arrow). (b) Transverse CT image at baseline also reveals a small indeterminate nodule in the right upper lobe (arrow). (c) PET image demonstrates a hypermetabolic mass (m) of the left upper lobe and increased activity in a nodule of the right upper lobe nodule (arrow). Transthoracic needle biopsy of the right upper lobe nodule was positive for poorly differentiated NSCLC. (d) Transverse CT image after induction chemotherapy reveals decrease in left upper lobe mass (m) and resolution of the adjacent satellite nodule. There also is no longer evidence of the right upper lobe nodule. (e) PET image after induction chemotherapy shows the left upper lobe hypermetabolic mass (m) and resolution of activity in the right upper lobe. The patient underwent resection of the left upper lobe mass and radiation therapy in the left upper chest. At a recent follow-up 24 months after initiation of induction chemotherapy, the patient remains free of disease.

View larger version (108K): [in a new window]   Figure 10d. Multidisciplinary care of a 44-year-old man with left upper lobe poorly differentiated NSCLC. (a) Transverse CT image at baseline shows a large left upper lobe mass (m) with an adjacent satellite lesion (arrow). (b) Transverse CT image at baseline also reveals a small indeterminate nodule in the right upper lobe (arrow). (c) PET image demonstrates a hypermetabolic mass (m) of the left upper lobe and increased activity in a nodule of the right upper lobe nodule (arrow). Transthoracic needle biopsy of the right upper lobe nodule was positive for poorly differentiated NSCLC. (d) Transverse CT image after induction chemotherapy reveals decrease in left upper lobe mass (m) and resolution of the adjacent satellite nodule. There also is no longer evidence of the right upper lobe nodule. (e) PET image after induction chemotherapy shows the left upper lobe hypermetabolic mass (m) and resolution of activity in the right upper lobe. The patient underwent resection of the left upper lobe mass and radiation therapy in the left upper chest. At a recent follow-up 24 months after initiation of induction chemotherapy, the patient remains free of disease.

View larger version (94K): [in a new window]   Figure 10e. Multidisciplinary care of a 44-year-old man with left upper lobe poorly differentiated NSCLC. (a) Transverse CT image at baseline shows a large left upper lobe mass (m) with an adjacent satellite lesion (arrow). (b) Transverse CT image at baseline also reveals a small indeterminate nodule in the right upper lobe (arrow). (c) PET image demonstrates a hypermetabolic mass (m) of the left upper lobe and increased activity in a nodule of the right upper lobe nodule (arrow). Transthoracic needle biopsy of the right upper lobe nodule was positive for poorly differentiated NSCLC. (d) Transverse CT image after induction chemotherapy reveals decrease in left upper lobe mass (m) and resolution of the adjacent satellite nodule. There also is no longer evidence of the right upper lobe nodule. (e) PET image after induction chemotherapy shows the left upper lobe hypermetabolic mass (m) and resolution of activity in the right upper lobe. The patient underwent resection of the left upper lobe mass and radiation therapy in the left upper chest. At a recent follow-up 24 months after initiation of induction chemotherapy, the patient remains free of disease.