New developments in the imaging of lung cancer

Abstract

Radiological and nuclear medicine methods play a fundamental role in the diagnosis and staging of patients with lung cancer. Imaging is essential in the detection, characterisation, staging and follow-up of lung cancer. Due to the increasing evidence, low-dose chest computed tomography (CT) screening for the early detection of lung cancer is being introduced to the clinical routine in several countries. Radiomics and radiogenomics are emerging fields reliant on artificial intelligence to improve diagnosis and personalised risk stratification. Ultrasound- and CT-guided interventions are minimally invasive methods for the diagnosis and treatment of pulmonary malignancies. In this review, we put more emphasis on the new developments in the imaging of lung cancer.

FIGURE 1

Images of a 73-year-old female patient admitted to hospital for secondary hypertension workup and management. a) A routine chest radiograph showed a right basal pulmonary nodule, which was misdiagnosed as the right nipple, but b) computed tomography (CT) and c) CT-guided biopsy confirmed the presence of a carcinoid tumour. In addition, a) chest radiography and CT (not shown) confirmed an aberrant right subclavian artery, known clinically as arteria lusoria, which is the most common embryological abnormality of the aortic arch. Images courtesy of the Medical Imaging Centre, Semmelweis University, Budapest, Hungary.

FIGURE 2

Computed tomography (CT) scans of a growing part-solid nodule. a) In 2014. b) Axial and c) coronal views from 3 years later, in 2017. The 70-year-old female smoker patient was investigated due to cough. Positron emission tomography/CT did not show fluorodeoxyglucose uptake in the lesion. Biopsy confirmed adenocarcinoma. Images courtesy of the Medical Imaging Centre, Semmelweis University, Budapest, Hungary.

FIGURE 3

Low-field magnetic resonance imaging (0.55 T) images (T2 FBLADE sequence). a) Axial and b) coronal views of a metastatic lung nodule in the right upper lobe (S3 segment), and c) axial view of another metastatic pulmonary lesion in the right upper lobe and a growing mediastinal lymph node, in a young female pregnant patient with metastatic breast cancer. Images courtesy of the National Institute of Oncology, Budapest, Hungary.

FIGURE 4

a) A fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/computed tomography (CT) image in three sectional planes of an 82-year-old smoker. In the left upper lobe, a pulmonary mass with a hypermetabolic border (maximum standardised uptake value 13.6) and a necrotic centre comes into view. Staging remained without evidence of mediastinal or extrathoracic metastasis. b) The maximum intensity projection (MIP) shows an overview of the entire PET scan. Information about the distribution of FDG uptake assisted CT-guided puncture, which was taken from the marginal area of the pulmonary mass and confirmed a pulmonary squamous cell carcinoma.

FIGURE 5

Positron emission tomography (PET)/computed tomography (CT) of a 56-year-old smoker who presented with a chronic dry cough. In the left lower lobe of the lung, a) CT showed a solid compaction (23 mm) close to the hilus, which in b) fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) PET/CT showed only a slightly increased uptake (maximum standardised uptake value (SUV_max) 3.2) and was not considered to be malignant. c) Somatostatin receptor expression was significantly increased in the gallium-68 dodecane tetraacetic acid-conjugated octreotide (⁶⁸Ga-DOTATOC) PET/CT at this site (SUV_max 43). Left lower lobe resection revealed a typical carcinoid.

FIGURE 6

Low-dose computed tomography screening of a 77-year-old female smoker, which confirmed a tumour-suspicious speculated solid lesion in the right upper lobe. Image courtesy of the National Institute of Oncology, Budapest, Hungary.

FIGURE 7

a) Algorithm for management of solid pulmonary nodules (PNs) based on British Thoracic Society guidelines. Reproduced and modified from [102] with permission. b) Algorithm for management of sub-solid PNs based on Fleischner Society guidelines. Information from [27]. PET: positron emission tomography; CT: computed tomography; GGO: ground-glass opacity; PSN: part-solid nodules.

FIGURE 8

Computed tomography (CT)-guided transthoracic lung biopsy performed in the 82-year-old lung cancer patient shown in figure 4. Biopsy location was additionally guided by positron emission tomography/CT. In the case of this central tumour far from the chest wall, bronchoscopic tissue sampling would also have been feasible.