CASE 1 of CT imaging

Figures 2.1 to 2.6 are images of a patient considered operable by conventional staging with contrast enhanced CT of the chest and upper abdomen. This patient has multiple soft tissue metastases only identified by the PET component of the study and not seen on CT. Generally speaking, all patients with a diagnosis of small cell lung cancer are deemed inoperable, as this type represents a systemic disease process at the time of diagnosis. Still, treatment algorithms are changing, and some patients are considered forsurgery and radiotherapy as part of their management of the disease. On the other hand, non-small cell lung cancer may be operable depending on conditions such as tumor site and size, as well as the presence or absence of distant metastatic involvement. Surgery can be carried out with curative intent in those patients with limited stage disease, whereas palliative chemotherapy or radiotherapy is given to those considered inoperable. Stage IIIB and stage IV disease are considered inoperable, but controversy exists about the role of surgery in stage IIIA
disease (with involved mediastinal nodes N2). Some patients who are considered unsuitable for surgery due to other comorbidity may be considered for radical radiotherapy. To optimize patient outcome, it is necessary to obtain as much information as possible prior to deciding to follow a surgical pathway. It may be obvious from a plain chest X-ray that a tumor is inoperable. Features that make surgery unlikely include large tumors extending across the midline, bilateral lesions, malignant effusions, enlarged mediastinal nodes, or any evidence of pulmonary or osseous metastases. Over the last 20 years there has been a rapid growth in the
use of functional metabolic imaging in the diagnosis of lung cancer. Initially this was in the form of PET only but recently this has been superseded by the advent of fused PET/CT technology.
The use of PET and PET/CT has primarily been in the characterization of the solitary pulmonary nodule (SPN) and the preoperative staging of non-small cell lung cancer (NSCLC). Recently other applications for its utilization have been found in detecting recurrence and in the, evolving fields of radiotherapy planning and assessment of treatment response.
FIGURE 2.2. Axial image through the tumor.
FIGURE 2.1. Surgically resectable lung cancer using conventional staging