Pancoast tumor differential diagnosis: Difference between revisions

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(/* The following table summarizes the differentiation of various lung tumors based on histological and topographical features:{{cite journal |vauthors=Erasmus JJ, Connolly JE, McAdams HP, Roggli VL |title=Solitary pulmonary nodules: Part I. Morphologic...)
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{{Pancoast tumor}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Pancoast_tumor]]
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==Overview==
==Overview==
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==Differential Diagnosis==
==Differential Diagnosis==
Pancoast tumor must be differentiated from other causes of [[mass]] located in the [[Apical|apical region]] of the [[chest]] which may present with [[pain]] in the [[Shoulder-joint|shoulder region]].The table below summarizes the findings that differentiate [[apical]] [[mass]] in the [[chest]] from the most common other [[conditions]] that cause [[hemoptysis]], [[cough]], [[dyspnea]], [[wheeze]], [[chest pain]], [[shoulder pain]], [[Weight loss|unexplained weight loss]], [[Loss of appetite|unexplained loss of appetite]], and [[fatigue]]<ref><nowiki>{{Small cell lung cancer [Internet]. BMJ Publishing Group Limited 2015 [updated 2014 Oct 29]. Available from: </nowiki>http://bestpractice.bmj.com/best-practice/monograph/1081/diagnosis/differential.html<nowiki>}}</nowiki></ref><ref name="pmid24455507">{{cite journal| author=Bhatt M, Kant S, Bhaskar R| title=Pulmonary tuberculosis as differential diagnosis of non-small cell lung cancer | journal=South Asian J Cancer | year= 2012 | volume= 1 | issue= 1 | pages= 36-42 | pmid=24455507 | doi=10.4103/2278-330X.96507 | pmc=PMC3876596 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24455507  }}</ref><ref name="pmid22242302">{{cite journal| author=Kamiya K, Yoshizu A, Misumi Y, Hida N, Okamoto H, Yoshida S| title=[Lung abscess which needed to be distinguished from lung cancer; report of a case]. | journal=Kyobu Geka | year= 2011 | volume= 64 | issue= 13 | pages= 1204-7 | pmid=22242302 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22242302  }} </ref><ref name="pmid24008649">{{cite journal| author=Matsuoka T, Uematsu H, Iwakiri S, Itoi K| title=[Chronic eosinophilic pneumonia presenting as a solitary nodule, suspicious of lung cancer;report of a case]. | journal=Kyobu Geka | year= 2013 | volume= 66 | issue= 10 | pages= 941-3 | pmid=24008649 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24008649  }} </ref><ref name="emedicine">{{cite web | last = Beeson | first = Michael S | title = Superior Vena Cava Syndrome | url=http://www.emedicine.com/emerg/topic561.htm | accessdate = 2008-03-24 }}</ref><ref name="wikibooks">Radiation Oncology/Palliation/SVC Syndrome. WikiBooks https://en.wikibooks.org/wiki/Radiation_Oncology/Palliation/SVC_Syndrome Accessed on January 13, 2016</ref><ref name="pmid18349457">{{cite journal |vauthors=Bruzzi JF, Komaki R, Walsh GL, Truong MT, Gladish GW, Munden RF, Erasmus JJ |title=Imaging of non-small cell lung cancer of the superior sulcus: part 1: anatomy, clinical manifestations, and management |journal=Radiographics |volume=28 |issue=2 |pages=551–60; quiz 620 |date= 2008 |pmid=18349457 |doi=10.1148/rg.282075709 |url=}}</ref><ref name="pmid24102007">{{cite journal |vauthors=Foroulis CN, Zarogoulidis P, Darwiche K, Katsikogiannis N, Machairiotis N, Karapantzos I, Tsakiridis K, Huang H, Zarogoulidis K |title=Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment |journal=J Thorac Dis |volume=5 Suppl 4 |issue= |pages=S342–58 |date=September 2013 |pmid=24102007 |pmc=3791502 |doi=10.3978/j.issn.2072-1439.2013.04.08 |url=}}</ref><ref name="pmid27429965">{{cite journal |vauthors=Marulli G, Battistella L, Mammana M, Calabrese F, Rea F |title=Superior sulcus tumors (Pancoast tumors) |journal=Ann Transl Med |volume=4 |issue=12 |pages=239 |date=June 2016 |pmid=27429965 |pmc=4930518 |doi=10.21037/atm.2016.06.16 |url=}}</ref><ref>[http://www.mountsinai.org/Other/Diseases/Thoracic%20outlet%20syndrome Thoracic outlet syndrome]
Pancoast tumor must be differentiated from other causes of [[mass]] located in the [[Apical|apical region]] of the [[chest]] which may present with [[pain]] in the [[Shoulder-joint|shoulder region]].The table below summarizes the findings that differentiate [[apical]] [[mass]] in the [[chest]] from the most common other [[conditions]] that cause [[hemoptysis]], [[cough]], [[dyspnea]], [[wheeze]], [[chest pain]], [[shoulder pain]], [[Weight loss|unexplained weight loss]], [[Loss of appetite|unexplained loss of appetite]], and [[fatigue]]
Mount Sinai Hospital, New York</ref><ref>Stepansky F, Hecht EM, Rivera R, Hirsh LE, Taouli B, Kaur M, Lee VS. Dynamic MR angiography of upper extremity vascular disease: pictorial review. Radiographics. 2008 Jan-Feb;28(1):e28. Epub 2007 Oct 29. PMID 17967936 </ref><ref name="radio">Superior Vena Cava Syndrome.Dr Amir Rezaee and Radswiki et al. Radiopedia http://radiopaedia.org/articles/superior-vena-cava-obstruction Accessed on January 13, 2016</ref>


{| {{table}} cellpadding="4" cellspacing="0" style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;"


| align="center" style="background:#f0f0f0;" |'''Condition/disease'''
=== '''The following table summarizes the differentiation of various lung tumors based on histological and topographical features:<ref><nowiki>{{Small cell lung cancer [Internet]. BMJ Publishing Group Limited 2015 [updated 2014 Oct 29]. Available from: </nowiki>http://bestpractice.bmj.com/best-practice/monograph/1081/diagnosis/differential.html<nowiki>}}</nowiki></ref><ref name="pmid24455507">{{cite journal| author=Bhatt M, Kant S, Bhaskar R| title=Pulmonary tuberculosis as differential diagnosis of non-small cell lung cancer | journal=South Asian J Cancer | year= 2012 | volume= 1 | issue= 1 | pages= 36-42 | pmid=24455507 | doi=10.4103/2278-330X.96507 | pmc=PMC3876596 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24455507  }}</ref><ref name="pmid22242302">{{cite journal| author=Kamiya K, Yoshizu A, Misumi Y, Hida N, Okamoto H, Yoshida S| title=[Lung abscess which needed to be distinguished from lung cancer; report of a case]. | journal=Kyobu Geka | year= 2011 | volume= 64 | issue= 13 | pages= 1204-7 | pmid=22242302 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22242302  }} </ref><ref name="pmid24008649">{{cite journal| author=Matsuoka T, Uematsu H, Iwakiri S, Itoi K| title=[Chronic eosinophilic pneumonia presenting as a solitary nodule, suspicious of lung cancer;report of a case]. | journal=Kyobu Geka | year= 2013 | volume= 66 | issue= 10 | pages= 941-3 | pmid=24008649 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24008649  }} </ref><ref name="emedicine">{{cite web | last = Beeson | first = Michael S | title = Superior Vena Cava Syndrome | url=http://www.emedicine.com/emerg/topic561.htm | accessdate = 2008-03-24 }}</ref><ref name="wikibooks">Radiation Oncology/Palliation/SVC Syndrome. WikiBooks https://en.wikibooks.org/wiki/Radiation_Oncology/Palliation/SVC_Syndrome Accessed on January 13, 2016</ref><ref name="pmid18349457">{{cite journal |vauthors=Bruzzi JF, Komaki R, Walsh GL, Truong MT, Gladish GW, Munden RF, Erasmus JJ |title=Imaging of non-small cell lung cancer of the superior sulcus: part 1: anatomy, clinical manifestations, and management |journal=Radiographics |volume=28 |issue=2 |pages=551–60; quiz 620 |date= 2008 |pmid=18349457 |doi=10.1148/rg.282075709 |url=}}</ref><ref name="pmid24102007">{{cite journal |vauthors=Foroulis CN, Zarogoulidis P, Darwiche K, Katsikogiannis N, Machairiotis N, Karapantzos I, Tsakiridis K, Huang H, Zarogoulidis K |title=Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment |journal=J Thorac Dis |volume=5 Suppl 4 |issue= |pages=S342–58 |date=September 2013 |pmid=24102007 |pmc=3791502 |doi=10.3978/j.issn.2072-1439.2013.04.08 |url=}}</ref><ref name="pmid27429965">{{cite journal |vauthors=Marulli G, Battistella L, Mammana M, Calabrese F, Rea F |title=Superior sulcus tumors (Pancoast tumors) |journal=Ann Transl Med |volume=4 |issue=12 |pages=239 |date=June 2016 |pmid=27429965 |pmc=4930518 |doi=10.21037/atm.2016.06.16 |url=}}</ref><ref>[http://www.mountsinai.org/Other/Diseases/Thoracic%20outlet%20syndrome Thoracic outlet syndrome]  
 
Mount Sinai Hospital, New York</ref><ref>Stepansky F, Hecht EM, Rivera R, Hirsh LE, Taouli B, Kaur M, Lee VS. Dynamic MR angiography of upper extremity vascular disease: pictorial review. Radiographics. 2008 Jan-Feb;28(1):e28. Epub 2007 Oct 29. PMID 17967936 </ref><ref name="radio">Superior Vena Cava Syndrome.Dr Amir Rezaee and Radswiki et al. Radiopedia http://radiopaedia.org/articles/superior-vena-cava-obstruction Accessed on January 13, 2016</ref>'''<ref name="pmid10682770">{{cite journal |vauthors=Erasmus JJ, Connolly JE, McAdams HP, Roggli VL |title=Solitary pulmonary nodules: Part I. Morphologic evaluation for differentiation of benign and malignant lesions |journal=Radiographics |volume=20 |issue=1 |pages=43–58 |date=2000 |pmid=10682770 |doi=10.1148/radiographics.20.1.g00ja0343 |url=}}</ref> ===
| align="center" style="background:#f0f0f0;" |'''Signs/symptoms'''
 
| align="center" style="background:#f0f0f0;" |'''Tests'''
|-
|Pancoast Tumor
|The most common [[symptoms]] of Pancoast tumor include [[cough]], [[hemoptysis]], [[dyspnea]], [[chest pain]], [[lack of appetite]], [[weight loss]], [[fatigue]]. [[Symptoms]] of [[Pancoast's syndrome]] resulting from Pancoast tumor include [[shoulder pain]] along the [[vertebral border of the scapula]], [[Horner's syndrome]] and [[weakness]] of [[hand]] [[muscles]]. Less common [[symptoms]] of [[Pancoast's syndrome]] include [[paraplegia]].
|'''[[Chest x-ray]]:''' Lordotic view on [[chest x-ray]] is helpful in visualizing Pancoast tumor because of its characteristic location in the [[Apical|apical portion]] of the [[lung]]. Findings on an [[x-ray]] suggestive of Pancoast tumor include [[opacity]] at the [[apex]] of the [[lung]] or in the superior sulcus area, the spread of the [[tumor]] can result in [[rib]] [[invasion]] that is observed as a [[bone]] destruction of [[posterior]] [[ribs]], [[vertebral body]] [[Infiltration (medical)|infiltration]], [[Enlargement of organs|enlargement]] of the [[mediastinum]]. '''[[CT scan]]''' is [[diagnostic]] of Pancoast tumor. [[CT scan]] has a limited ability to determine the extent of [[invasion]] of the [[primary tumor]] into adjoining structures when compared to [[MRI scan]]. [[Subclavian|Subclavian-vessel involvement]] is assessed by [[CT scanning|contrast CT scanning]]. '''[[MRI]]''' is helpful in the [[diagnosis]] of Pancoast tumor. [[MRI]] offers greater detail in the evaluation of [[chest wall]] [[invasion]], [[examination]] of [[vascular]] structures and [[Brachial plexus|brachial plexus involvement]] and resectability of the [[tumor]]. Other [[diagnostic]] studies for evaluating the spread of Pancoast tumor include [[Scintigraphy|bone scintigraphy]], [[PET scan]], [[Molecular|molecular tests]] and [[biopsy]].
|-
|[[Superior Vena Cava Syndrome]]
|[[Superior vena cava syndrome]] [[patients]] gradually develop [[symptoms]] as the [[malignancies]] increase in [[Size consistency|size]]. [[Symptoms]] occur when [[obstruction]] of [[Venous blood|venous blood flow]] back to the [[heart]] increases gradually,andd may worsen with [[Postural hypotension|postural changes]]. [[Symptoms]] are quite varied among [[benign]] and [[malignant]] [[superior vena cava syndrome]]. They can range from [[sub-clinical]] presentation to death. The most common [[symptoms]] include the following [[dyspnea]], [[cough]], [[swelling]] of the [[face]], [[neck]], [[trunk]], and [[Arm|arms]]. Less common [[symptoms]] include the following [[hoarseness]], [[chest pain]], problems [[swallowing]] and/or talking, [[coughing up blood]], [[headache]], [[Swallowing|lightheadedness]], decreased [[alertness]], [[Headache|dizziness]], [[lightheadedness|fainting]], sensation of [[decreased alertness|head]] or [[decreased alertness|ear]] "fullness", [[Vision|vision changes]].  
|On '''[[Chest X-ray|chest x-ray]]''', indirect [[signs]] such as [[Mediastinal widening|superior mediastinal widening]] and right [[hilar]] prominence may indicate the presence of a [[mediastinal mass]]. On enhanced '''[[CT scan]]''', findings include location and severity of the [[superior vena cava obstruction]], [[Thrombosis|superimposed thrombosis]], a [[mediastinal mass]] or [[lymphadenopathy]], [[Collateral circulation|collateral vessels]], and [[Lung mass|associated lung masses]]. [[CT scan]] is the [[imaging]] modality of choice. [[Doppler ultrasound|'''Doppler ultrasound''']] may be valuable in assessing the site and nature of the [[obstruction]] in [[superior vena cava syndrome]]. [[Venous|Venous patency]] and the presence of [[thrombi]] can also be assessed by using [[contrast]] and rapid scanning techniques. Other [[imaging]] finding is the [[Radionuclides|radionuclide]] [[technetium-99m]] [[venography]]. [[Invasive]] [[contrast]] [[venography]] may be useful on the [[etiology]] of [[obstruction]] and exact location of the obstruction, also helpful in the [[Surgery|surgical management]] of the [[Obstruction|obstructed]] [[vena cava]].
|-
| [[Thoracic outlet syndrome]]
|[[Arterial]] [[thoracic outlet syndrome]] can present with [[pallor]], [[Cold|sensation of cold]], [[pain]], and [[paresthesias]] of the [[fingers]] due to severe [[ischemia]].
 
[[Venous]] form (aka '''Paget-Schroetter syndrome''', '''Effort thrombosis''' and '''thoracic inlet syndrome''') presents with arm [[swelling]] and [[pain]].
|'''[[Chest radiography]]''' is helpful to evaluate presence of [[cervical]] or [[first rib]], [[Clavicle|clavicle deformity]], [[pulmonary]] [[disease]]. [[Duplex ultrasonography|Color flow duplex scanning]], [[nerve conduction studies]], [[electromyography]], or [[imaging studies]] are recommended to confirm or rule out a [[diagnosis]] of  [[Thoracic outlet syndrome|Thoracic outlet syndrome(]]TOS). '''[[Nerve conduction studies|Nerve conduction]] evaluation''' via root stimulation and F wave is the best direct approach to evaluation of [[neurologic]] TOS. '''[[CT scan]]''', [[MRI]], [[Arteriography]], while only rarely used to evaluate [[Thoracic outlet syndrome|thoracic outlet syndrome]], may be used if a [[surgery]] is being planned to correct an [[arterial]] [[Thoracic outlet syndrome|TOS]]. '''[[Arteriography]]''' is indicated in the presence of [[evidence]] of peripheral [[emboli]] in the [[upper extremity]], suspected [[subclavian]] [[stenosis]] or [[aneurysm]] (e.g., [[Bruits|bruit]] or abnormal [[supraclavicular]] pulsation), [[blood pressure]] differential greater than 20 mmHg, Obliteration of [[Radial artery|radial]] [[pulse]]. '''[[Venography]]''' indications include persistent or intermittent [[edema]] of the [[hand]] or [[arm]], [[Cyanosis|peripheral unilateral cyanosis]], [[Venous|prominent venous pattern]] over the [[arm]], [[shoulder]], or [[chest]]. '''[[Thermography]]''' indications are [[vasomotor]] or [[sudomotor]] [[instability]], [[Sensitivity|weather sensitivity]], cold limb in a shawl or [[C8|C8 distribution]]. [[Thermography]] may be one of the most sensitive tests to objectify the presence of [[thoracic outlet syndrome]], especially if it is felt to be [[sympathetic]] in [[origin]]
|-
|'''[[Cervical Disc Disease|Cervical Disk Disease]]'''
|With [[symptomatic]] [[degenerative]] [[disc disease]], [[chronic]] [[shoulder pain]] sometimes radiates to the [[arm]] that may be associated with sporadic [[tingling]] or [[weakness]] may also be evident. Similar [[pain]] may be felt or may increase with [[range of motion]] of [[shoulder joint]]. While the [[degeneration]] of the [[Disc disease|disc]] will likely progress as a natural part of the [[aging]] [[Process (anatomy)|process]], [[symptoms]] such as [[neck]] and [[shoulder pain]] often decrease over time.
|
|-
 
| '''[[Pneumonia]]/[[bronchitis]]'''||Typical [[symptoms]] include [[fever]], [[cough]], [[dyspnea]], and [[chest pain]]; [[Pneumonia|recurrent pneumonia]] or [[bronchitis]] in a [[Smoker's cough|smok]]<nowiki/>formerformer [[Smoking|smoker]] should raise the suspicion of [[lung cancer]]||'''[[Chest X-Ray]]''' is the first [[test]] performed; '''[[CT-scans|CT imaging]]''' can be helpful to evaluate [[pulmonary]] [[Mass|masses]] that might not be well visualised with [[chest x-ray]]; '''[[bronchoscopy]]''' can also be used to assess for endobronchial [[Lesion|lesions]] or to [[biopsy]] suspicious [[pulmonary]] [[Mass|masses]]
 
|-
 
| '''[[Carcinoid tumor]]'''||Often [[asymptomatic]] with normal [[physical examination]]; may cause [[cough]], [[dyspnea]], [[hemoptysis]], [[Wheezing|unilateral wheezing]], or [[Pneumonia|post-obstructive pneumonia]] if the [[tumor]] is endobronchial or compressing the [[Bronchi|central bronchi]]. ||'''[[CT-scans|CT chest:]]''' 80% of [[carcinoid tumors]] appear as an endobronchial [[nodule]] and 20% as a [[parenchymal]] [[nodule]], with smooth, rounded borders and is highly [[Vascularity|vascularized]]; '''[[bronchoscopy|flexible bronchoscopy]]''' shows raised, pink, [[vascular]], [[Lobule|lobulated]] [[lesions]]; '''endobronchial forceps [[biopsy]]''' is usually required for [[pathology]] to be [[diagnostic]]; [[Brushing|bronchial brushings]], [[Sputum|sputum specimens]], and lavage [[fluid]] rarely provide sufficient [[tissue]] for a conclusive [[diagnosis]]
 
|-
 
| '''[[Metastatic]] [[cancer]] from a non-thoracic primary site'''||[[Signs]] and [[symptoms]] depend on the location of the [[primary tumor]] and [[Disease|distant disease]] and may include [[pain]], [[weight loss]], [[malaise]], [[cough]], [[dyspnea]], [[clubbing]], or [[Wheezing|focal wheezing]]; [[Physical Examination|physical]] findings may be present depending on the location and extent of the [[disease]]||'''[[CT|CT chest]]''' shows one or multiple [[nodules]] of variable [[Size consistency|sizes]] from [[diffuse]] micronodular [[Opacity|opacities]] (miliary) to well-defined [[Mass|masses]], [[lesions]] are often irregular and in the periphery of the lower [[Lung|lung zones]]; '''[[CT]]/[[MRI]] [[head]], [[CT|CT abdomen and pelvis]]:''' extrapulmonary [[cancers]] that commonly [[metastasis]] to the [[lung]] include [[melanoma]], [[thyroid]] [[carcinoma]], [[esophageal cancer]]; [[ovarian cancer]]; [[sarcomas]]; and [[adenocarcinomas]] of the [[colon]], [[breast]], [[kidney]], and [[testis]]; '''[[Positron emission tomography|PET-FDG scan]]''' shows increased uptake in both primary and distant sites, certain [[metastatic]] [[lesions]], such as [[renal cell carcinoma]], have a lower probability of 18-fluorodeoxyglucose (FDG) uptake;  '''CT-guided transthoracic needle aspiration (TTNA)''' can reveal characteristic [[Malignant|malignant cells]], [[pneumothorax]] complicates 20% to 30% of TTNA procedures, the choice between [[bronchoscopy]] and TTNA is based on [[Lesion|lesion size]], location, [[risks]], and local expertise; '''[[biopsy]] during [[Bronchoscopy|flexible bronchoscopy]] and [[biopsy]]''' may show characteristic [[malignant]] [[cells]], [[bronchoscopy]] has a 100% yield for endobronchial [[lesions]] (which are extremely rare in [[metastatic]] deposits from other [[Primary tumor|primary tumors]])
 
|-
 
| '''[[Granuloma|Infectious granuloma]]'''||History may include travel to endemic areas, pet/animal exposures, and specific leisure activities (e.g., caving); may feature [[cough]], [[dyspnea]], [[hemoptysis]], [[weight loss]], [[fever]], [[joint aches]], [[skin lesions]], and [[night sweats]], or no [[symptoms]]; many possible [[causes]]: ''[[Histoplasma capsulatum]]'', ''[[Mycobacterium tuberculosis]]'', ''[[Coccidioides immitis]]'', ''[[Cryptococcus neoformans]]'', ''[[Aspergillus]]'', ''[[Pseudallescheria boydii]]'', ''Fusarium'' species, [[zygomycetes]], and others; non-specific [[skin]] [[Urine|findings]] may be seen in [[atypical mycobacteria]] and [[cryptococcosis]]; [[lymphadenopathy]] may be present with active [[disease]]||'''CT-guided TTNA''' can be used for [[diagnostic]] [[sampling]], [[pneumothorax]] complicates 20% to 30% of TTNA [[Procedure|procedures]], the choice between [[bronchoscopy]] and TTNA is based on [[lesion]] [[Size consistency|size]], [[Location parameter|location]], [[risks]], and local expertise; '''[[CT]] [[chest]]''' typically shows [[lesions]] <2 cm [[diameter]] and round with smooth borders, old [[granulomatous]] [[disease]] may feature [[central]], laminated, or [[diffuse]] [[calcification]] [[pattern]], [[mediastinal]] [[lymphadenopathy]] without [[Calcification|calcifications]] is sometimes present, [[nodules]] from angioinvasive [[fungi]] (e.g., [[Aspergillus]], [[Pseudallescheria boydii]], [[Fusarium|Fusarium species]], and [[zygomycetes]]) may demonstrate the "[[halo sign]]" (ground-glass [[opacity]] surrounding the [[nodule]]),  occasionally, [[Calcification|calcifications]] can be seen in the [[spleen]] or [[liver]]; '''[[fungal]] [[Serological testing|serologies]]:''' positive during active [[infection]]; '''[[Bronchoscopy|flexible bronchoscopy]] and [[biopsy]]''' can sometimes provide sample for identification and culture and [[sensitivity]] of [[Organisms|organism]]; '''[[PET scan|PET]]:''' usually negative (<2.5 standardised uptake values), may be positive in active [[infectious]] [[Process (anatomy)|processes]]
 
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| '''[[Sarcoidosis]]'''||[[Cough]], [[dyspnea]], [[fatigue]],  [[weight loss]], [[fever]], [[night sweats]], [[rash]], [[eye pain]], [[photophobia]], [[blurred vision]], and [[red eye]]; [[pulmonary]] [[examination]] is usually unrevealing; can affect any [[Organ (anatomy)|organ]], so [[Physical examination|physical findings]] depend on specific [[organs]] affected; [[skin lesions]] including [[maculopapular]] [[Eruption|eruptions]], [[subcutaneous]] [[nodular]] [[lesions]], and red-purple [[skin lesions]]||'''[[CT]] [[chest]]:''' [[mediastinal]] [[adenopathy]] often present with [[sarcoid]]. [[Sarcoid]] [[nodules]] have predilection for upper zones, although can be located throughout the [[lung]]; '''[[Bronchoscopy|flexible bronchoscopy]] and [[biopsy]]''' can demonstrate presence of non-caseating [[granulomas]]; '''[[CT-scans|CT-guided]]''' '''TTNA''' can provide access to material from some [[lesions]] inaccessible to [[Bronchoscopy|flexible bronchoscopy]]; '''[[Laboratory|laboratory markers]]:''' [[Angiotensin-converting enzyme|ACE elevation]] may be seen in [[sarcoidosis]] but is non-specific.
 
|-
 
| '''[[Rheumatoid arthritis]]'''||[[Arthralgias]], [[pain]], [[skin nodules]], [[pleural effusions]], [[pleuritis]], [[joint pain]], and [[deformity]]||'''[[CT]] [[chest]]''' typically shows [[lung]] [[nodule]] 3 mm to 7 cm, predominantly in peripheral upper and mid-[[lung]] zones, may show [[cavitation]]; '''[[Bronchoscopy|flexible bronchoscopy]] and [[biopsy]]''' shows [[Rheumatoid Arthritis|rheumatoid]] necrobiotic [[nodule]], necrobiotic [[nodules]] demonstrate a central zone of [[eosinophilic]] [[fibrinoid necrosis]] surrounded by palisading [[fibroblasts]], the [[nodule]] often centered on [[necrotic]] [[inflamed]] [[blood]] [[vessels]]; '''[[Laboratory medicine|laboratory markers]]:''' [[patients]] with [[lung]] [[nodules]] due to [[rheumatoid arthritis]] frequently have high levels of [[rheumatoid factor]], although [[seronegative]] cases have been reported.
 
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| '''[[Wegener's granulomatosis]]'''||[[Cough]], [[chest pain]], [[dyspnea]], [[hemoptysis]], [[rhinorrhoea]], [[epistaxis]], [[ear]]/[[sinus]] [[pain]], [[hoarseness]], [[fever]], [[fatigue]], [[anorexia]], [[weight loss]], [[palpable]] [[purpura]], [[painful]] [[ulcers]], [[uveitis]], [[upper airway]] [[inflammation]], and [[sinus]] [[pain]]||'''[[CT-scans|CT]] [[chest]] shows''' [[solitary]] or multiple [[lung]] [[nodules]], [[airways]] are frequently affected; '''[[Bronchoscopy|Flexible bronchoscopy]] or [[CT-scans|CT]]-guided TTNA''' may show [[Necrotizing|necrotising]] [[granulomatous]] [[inflammation]]; '''[[Laboratory medicine|laboratory markers]]:''' [[anti-neutrophil cytoplasmic antibody]] ([[ANCA]]), [[ANCA]] [[testing]] results depend on the extent and severity of the [[disease]].
 
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| '''[[Arteriovenous malformation]]'''||[[Dyspnea]] is uncommon, may cause [[hemoptysis]], [[pulmonary]] [[bruit]], [[Arteriovenous Fistula|arteriovenous communications]], or [[hemorrhagic]] [[telangiectasia]] in the [[skin]], [[mucous membranes]], and other [[organs]], [[cyanosis]] and [[finger clubbing]] may be present, [[Neurological illness|neurological]] [[symptoms]] from [[cerebral]] [[aneurysms]], [[cerebral]] [[emboli]]||'''[[CT-scans|CT]] [[chest]]''' shows round or oval [[nodule]](s) with feeding [[artery]] and draining [[vein]] often identified, most common in lower [[lobes]], multiple [[lesions]] in 30% of cases, usually round or oval, ranging from 1 cm to several cm in diameter; '''[[pulmonary]] [[angiography]]''' confirms presence and location of [[Arteriovenous malformation|AVMs]], identifies feeding [[arterial]] and [[venous]] structures, in cases of significant [[hemoptysis]], [[pulmonary]] [[angiogram]] is combined with [[bronchial]] [[artery]] [[embolisation]]; '''[[Arterial blood gas|ABG]] [[analysis]]''' may show decreased pO2 and decreased [[oxygen saturation]] when AV flow is severe., in cases of severe [[systemic]] [[Arteriovenous malformation|AVMs]], [[chronic]] [[hypoxemia]] may cause [[polycythemia]]
 
|-
 
| '''[[Amyloidosis]]'''||[[Weight loss]], [[paresthesias]], [[dyspnea]], and [[fatigue]] are the most common [[symptoms]] associated with [[amyloidosis]] and are common to all [[systemic]] forms; [[weight loss]] of >9 kg is common; small [[vessel]] involvement can cause [[jaw]] or [[limb]] [[claudication]], and rarely [[angina]]; [[amyloid]] [[purpura]] is present in about 1 in 6 [[patients]], typically [[Orbital cavity|peri-orbital]]; [[eyelid]] [[petechiae]] are common; [[hepatomegaly]] >5 cm below the right [[costal]] margin is seen in 10% of [[patients]] and [[splenomegaly]] is usually of modest degree.||'''[[CT]] [[chest]]''' shows [[lung]] involvement characterised by focal [[pulmonary]] [[nodules]], [[Tracheobronchial|tracheobronchial lesions]], or [[diffuse]] [[alveolar]] deposits; '''[[serum]] [[immunofixation]]''' shows presence of [[monoclonal]] [[protein]]; [[urine]] [[immunofixation]] shows presence of [[monoclonal]] [[protein]]; '''[[immunoglobulin]] free [[light chain]] [[Assays|assay]]''' shows [[abnormal]] kappa to [[Lambda (anatomy)|lambda]] [[ratio]].
 
|-
 
| '''[[Pulmonary tuberculosis]]'''||[[Cough]] longer than 2 to 3 weeks, discolored or [[Bloody sputum|bloody]] [[sputum]], [[night sweats]], [[weight loss]], [[loss of appetite]], and/or [[pleuritic]] [[chest]] [[pain]].||'''[[Chest X-ray|Chest x-ray]]:''' primary disease commonly presents as middle and lower [[lung]] zone infiltrates, [[ipsilateral]] [[adenopathy]], [[atelectasis]] from [[airway]] compression, and [[pleural effusion]] can be seen, reactivation-type (post-primary) [[pulmonary]] [[TB]] usually involves [[apical]] and/or [[posterior]] segment of right upper [[lobe]], apicoposterior segment of left upper [[lobe]], or superior segment of either lower [[lobe]], with or without [[cavitation]], as [[disease]] progresses it spreads to other segments/[[lobes]]; '''[[sputum]] [[Smear test|smear]]:''' positive for [[acid-fast bacilli]] ([[AFB]]), [[sputum]] may be spontaneously [[Expectorate|expectorated]] or induced, and at least 3 specimens should be collected (minimum 8 hours apart, including an early morning specimen, which is the best way to detect ''[[Mycobacterium tuberculosis]]'', [[organisms]] other than ''[[M. tuberculosis]]'', especially on-[[Mycobacteria|tuberculous mycobacteria]] (e.g., ''[[M. kansasii]]'' and ''M. avium'' , may be positive for [[AFB stain]]; '''[[Nucleic acid amplification technique|nucleic acid amplification tests]] [[NAAT|(NAAT)]]:''' positive for ''[[M. tuberculosis]]''  [[DNA]] or [[RNA]] [[amplification]] [[Test|tests]] for rapid [[diagnosis]], may be used on [[sputum]] or any [[sterile]] [[body]] [[fluid]].
 
|-
 
| '''[[Non-Hodgkin's lymphoma]] ([[NHL]])'''||Aggressive [[NHL]] may present with [[fever]], [[Night sweats|drenching night sweats]], [[malaise]], [[weight loss]], [[cough]], [[shortness of breath]], [[abdominal discomfort]], [[headache]], change in [[mental status]], [[dizziness]], [[ataxia]], [[pleural effusion]], [[lymphadenopathy]], [[pallor]], [[purpura]], [[jaundice]], [[hepatomegaly]], [[splenomegaly]], [[skin]] [[nodules]], and abnormal [[neurological]] [[examination]], low-grade [[NHL]] [[patients]] often minimally [[symptomatic]] or [[asymptomatic]].||'''[[Computed tomography|CT]] [[chest]]:''' frequently [[anterior]] [[mediastinum]], can determine if [[mass]] is [[cystic]] or [[solid]] and whether it contains [[calcium]] or [[fat]], [[contrast]] enhancement provides information concerning vascularisation of the [[mass]] and relationship to adjacent structures; '''FBC with differential:''' shows [[thrombocytopenia]], [[pancytopenia]]; '''[[Blood smear]]:''' shows [[nucleated]] [[red blood cells]], [[Platelets|giant platelets]]; '''[[Lymph nodes|lymph node]] [[biopsy]] with [[immunohistochemistry]]:''' shows characteristic [[cells]], preferably obtain [[Excisional biopsy|excisional]] or core [[biopsy]] to provide information on [[lymph node]] architecture; '''[[mediastinoscopy]]:''' used to sample [[mediastinal]] [[Lymph node|nodes]].
 
|-
 
| '''[[Hodgkin's lymphoma]]'''||Predominantly a [[disease]] of [[young adults]]; most [[patients]] present with a several-month history of persistent [[adenopathy]], most commonly of the [[cervical]] chain.||'''[[Chest x-ray|Plain chest x-ray:]]''' typically shows [[mediastinal]] [[mass]]/large [[mediastinal]] [[adenopathy]]; '''[[PET scan|PET scan:]]''' involved sites appear fluorodeoxyglucose (FDG)-avid (bright) with [[Positron emission tomography|PET imaging]]; '''[[lymph node]] [[biopsy]] with [[immunohistochemistry]]:''' the [[Hodgkin's]] [[cell]] can be a characteristic [[Reed-Sternberg cells|Reed-Sternberg cell]], or one of its variants, such as the lacunar [[cell]] in the [[nodular sclerosis]] subtype; in [[Nodular lymphocyte predominant Hodgkin lymphoma|nodular lymphocyte-predominant Hodgkin's lymphoma]], the characteristic [[cell]] is the [[lymphocytic]] and [[histiocytic]] (L&H) [[cell]], also referred to as a [[popcorn]] [[cell]].
 
|-
 
| '''[[Thymoma]]/[[Thymic carcinoma]]'''||Approximately 30% of [[patients]] with [[thymoma]] are [[asymptomatic]] at the time of [[diagnosis]]; may also present with [[cough]], [[chest pain]], [[signs]] of upper [[Airway constriction|airway congestion]], [[superior vena cava syndrome]], [[dysphagia]], or [[hoarseness]]; may have features of [[paraneoplastic syndromes]] associated with [[thymoma]] including [[myasthenia gravis]], [[polymyositis]], [[lupus erythematosus]], [[rheumatoid arthritis]], thyroiditis, and [[Sjogren's syndrome]]; about 30% of [[patients]] have [[symptoms]] suggestive of [[myasthenia gravis]] (e.g., [[ptosis]], [[double vision]])||'''[[Chest x-ray|Plain chest x-ray:]]''' in 50% of the [[patients]], [[thymomas]] are detected by chance with [[Chest radiography|plain-film chest radiography]]; [[CT]] [[chest]]: 90% occur in [[anterior mediastinum]]; '''[[Positron emission tomography|Positron emission tomography (PET):]]''' may be of value in determining [[malignancy]] and extramediastinal involvement; '''[[Biopsy|pre-operative biopsy]]:''' indicated if there are atypical features or if [[imaging]] suggests [[invasive]] [[tumor]] and [[patient]] is under consideration for [[Induction (biology)|induction therapy]]
 
|-
 
| '''[[Bronchogenic cyst]]'''||Usually [[Diagnosis|diagnosed]] in [[infancy]] and [[childhood]], although 50% are [[Diagnosis|diagnosed]] after 15 years of age; Approximately 50% of [[patients]] are [[asymptomatic]]; in [[Adult|adults]], [[chest pain]] (often [[pleuritic]]) and [[dysphagia]] (due to [[Esophageal|esophageal compression]]) are the most [[Symptoms|common symptoms]]; may also feature recurrent [[cough]] and [[chest]] [[infection]]/[[pneumonia]], [[superior vena cava syndrome]], [[tracheal compression]], and [[pneumothorax]]||'''[[Chest radiography|Two-view chest radiography:]]''' typically shows a sharply demarcated spherical mass of variable [[Size consistency|size]], most commonly located in the [[middle mediastinum]] around the [[carina]], can appear as a [[Solid tumors|solid tumor]] or show air-fluid level if [[cyst]] is [[infected]] or contains [[secretions]]; '''[[CT|CT chest:]]''' frequently [[middle mediastinum]], typically at level of the [[mediastinum]], [[Calcification|calcifications]] may also be seen; '''[[MRI]]:''' frequently [[middle mediastinum]], typically at level of the [[mediastinum]], T2-weighted [[images]] show a [[homogeneous]] [[mass]] of moderate-to-bright intensity, on T1-weighted [[images]], [[lesions]] may vary in [[intensity]] depending on [[protein]] content of the [[cyst]].
 
|-
 
| '''[[Tracheal tumors]]'''||Common [[symptoms]] include [[dyspnea]], [[cough]], [[hemoptysis]], [[wheeze]], and [[stridor]]; less commonly, [[hoarseness]] and [[dysphagia]] may be present||'''[[Chest radiograph|Plain chest radiographs]]''' are generally insensitive for detection of [[Tracheal bronchus|tracheal]] [[tumors]], clues that may indicate the presence of a [[Tracheal bronchus|tracheal]] [[tumour]] include abnormal [[calcification]], [[Tracheal bronchus|tracheal]] narrowing, [[Pneumonia|post-obstructive pneumonia]], and/or [[atelectasis]]; '''[[Helical CT scan|helical CT]]''' enables accurate calculation of [[tumor]] volumes and can help differentiate [[mucosal]] [[lesions]] from [[Submucosal|submucosal lesions]]; '''[[MRI]]''' can be useful in assessing [[extension]] into [[Tissue|surrounding tissue]] and [[vascular]] [[anatomy]]; '''[[bronchoscopy]]''' allows direct visualisation, opportunity for [[biopsy]], and potential for [[laser]] treatment.
 
|-
 
| '''[[Thyroid]] [[mass]]'''||[[Symptoms]] and [[signs]] depend on [[Size consistency|size]] of [[mass]]; may be visible/palpable as [[lump]] on anterior aspect of [[neck]]; may present with [[dysphagia]], [[hoarseness]], [[difficulty breathing]], and [[pain]] in [[neck]] or [[throat]]; may also be [[signs]] and [[symptoms]] of hyper- or [[hypothyroidism]] depending on the nature of the [[mass]].||'''[[Laboratory]] [[testing]]''' should include [[thyroid]] [[Function (biology)|function]] panel, with [[TSH]], free [[T4]], free [[T3]]; [[I-123 thyroid imaging|I-123 thyroid scan]] is ordered for [[patients]] with overt or [[subclinical]] [[hyperthyroidism]]  a hyperfunctioning (hot) [[Nodules|nodule]] is almost always [[benign]], most [[nodules]] are [[Hypofunctioning thyroid|hypofunctioning]] ([[cold]]) (most of these are [[benign]], but [[malignant]] [[nodules]] are also [[cold]]); '''[[ultrasound]] and [[doppler]]''' can be used to define [[Dimension|dimensions]] of [[Thyroid nodule|thyroid nodules]] and [[solid]]/[[cystic]] component(s), features suspicious of [[malignancy]] include [[Microcalcification|microcalcifications]], a more tall-than-wide shape, [[Vascularity|hypervascularity]], marked [[Echogenicity|hypoechogenicity]], or irregular margins, it can also [[Fine-needle aspiration|guide fine-needle aspiration]], which can reveal [[malignant]] [[cells]] or [[Cyst|cyst fluid]]; '''[[CT]] [[neck]]''' can evaluate [[cervical]] [[lymph]] [[Lymph node|nodes]] in cases of [[medullary]] [[thyroid]] [[cancer]], and extension of the [[scan]] into the [[chest]] can help evaluate a retrosternal [[thyroid]] [[mass]]
 
|}
=== '''The following table summarizes the differentiation of various lung tumors based on histological and topographical features:'''<ref name="pmid10682770">{{cite journal |vauthors=Erasmus JJ, Connolly JE, McAdams HP, Roggli VL |title=Solitary pulmonary nodules: Part I. Morphologic evaluation for differentiation of benign and malignant lesions |journal=Radiographics |volume=20 |issue=1 |pages=43–58 |date=2000 |pmid=10682770 |doi=10.1148/radiographics.20.1.g00ja0343 |url=}}</ref> ===
{| class="wikitable"
{| class="wikitable"
! colspan="11" |Abrevations:  
! colspan="11" |Abrevations:  
Line 107: Line 18:
MMP's: Mettaloprotineases matrix ;  GFAP: Glial fibrocilliary acid protein
MMP's: Mettaloprotineases matrix ;  GFAP: Glial fibrocilliary acid protein
|-
|-
! colspan="11" style="background:#4479BA; color: #FFFFFF;" align="center" + |Benign Lung Tumors<ref name="pmid23077446">{{cite journal |vauthors=Gümüştaş S, Inan N, Akansel G, Ciftçi E, Demirci A, Ozkara SK |title=Differentiation of malignant and benign lung lesions with diffusion-weighted MR imaging |journal=Radiol Oncol |volume=46 |issue=2 |pages=106–13 |date=June 2012 |pmid=23077446 |pmc=3472932 |doi=10.2478/v10019-012-0021-3 |url=}}</ref>
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" + |
|-
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" + |Benign lung tumor
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Risk/Epidemiology
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Risk/Epidemiology
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Pleuripotent cells
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Pleuripotent cells
Line 119: Line 28:
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Metastasis
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Metastasis
|-
|-
| colspan="3" style="background:#DCDCDC;" align="center" +  |'''Pancoast Tumor'''
| rowspan="3" style="background:#DCDCDC;" align="center" |'''Pancoast Tumor'''
| colspan="2" style="background:#DCDCDC;" align="center" |'''[[Squamous cell carcinoma of the lung|Squamous cell carcinoma (SCC)]]'''
|
|
*[[Asbestos]] [[Exposure assessment|exposure]] for prolonged period of time
*Cigarette smokers
*Exposure to [[gold]], [[nickel]]
* [[Arsenic]]  
*[[Smoking]]
*Men
 
|
|
* Columnar cells of bronchioles
* [[Epithelial cells]]
* [[Epithelial cells]]
* [[Neuroendocrine cells|Neuro endocrine cells]]
* Suprabasal bronchial cells
|
|
 
* Central
* Peripheral
* [[Bronchi]]
|
|
* White or grey lesions
* White or grey lesions
Line 141: Line 43:
* Intraluminal polypoid masses  
* Intraluminal polypoid masses  
* [[Infiltration (medical)|Infiltration]]  
* [[Infiltration (medical)|Infiltration]]  
* Peripheral distribution
 
* Gray-white central fibrosis
* [[Pleural]] puckering
* Anthracotic pigmentation
** [[Necrosis]]
** [[Cavitation]]
** [[Hemorrhage]]
* Lobulated or ill defined edges
|
|
* Exophytic
* Intra-epithelial 
* Without invasion
* Cells with clear [[cytoplasm]]
* Peripheral palisading of nuclei.
* Poor differentiation
|
|
* [[Keratin]]  
* [[Keratin]]  
Line 155: Line 57:
* [[CEA]]
* [[CEA]]
* [[Thyroid transcription factor-1]] ([[TTF-1]])  
* [[Thyroid transcription factor-1]] ([[TTF-1]])  
 
| rowspan="3" |
* [[CD56]]
'''[[Chest x-ray]]:''' Lordotic view on [[chest x-ray]] is helpful in visualizing Pancoast tumor because of its characteristic location in the [[Apical|apical portion]] of the [[lung]].
* [[Chromogranin]]
* [[Synaptophysin]]
* [[Cytokeratin]]
|'''[[Chest x-ray]]:''' Lordotic view on [[chest x-ray]] is helpful in visualizing Pancoast tumor because of its characteristic location in the [[Apical|apical portion]] of the [[lung]].  
* [[opacity]] at the [[apex]] of the [[lung]] or in the superior sulcus area, the spread of the [[tumor]] can result in [[rib]] [[invasion]] that is observed as a [[bone]] destruction of [[posterior]] [[ribs]], [[vertebral body]] [[Infiltration (medical)|infiltration]].
* [[opacity]] at the [[apex]] of the [[lung]] or in the superior sulcus area, the spread of the [[tumor]] can result in [[rib]] [[invasion]] that is observed as a [[bone]] destruction of [[posterior]] [[ribs]], [[vertebral body]] [[Infiltration (medical)|infiltration]].
* [[Enlargement of organs|enlargement]] of the [[mediastinum]].
* [[Enlargement of organs|Enlargement]] of the [[mediastinum]].
* '''[[CT scan]]''' is [[diagnostic]] of Pancoast tumor. [[CT scan]] has a limited ability to determine the extent of [[invasion]] of the [[primary tumor]] into adjoining structures when compared to [[MRI scan]]. [[Subclavian|Subclavian-vessel involvement]] is assessed by [[CT scanning|contrast CT scanning]].
* '''[[CT scan]]''' is [[diagnostic]] of Pancoast tumor. [[CT scan]] has a limited ability to determine the extent of [[invasion]] of the [[primary tumor]] into adjoining structures when compared to [[MRI scan]]. [[Subclavian|Subclavian-vessel involvement]] is assessed by [[CT scanning|contrast CT scanning]].
* '''[[MRI]]''' is helpful in the [[diagnosis]] of Pancoast tumor. [[MRI]] offers greater detail in the evaluation of [[chest wall]] [[invasion]], [[examination]] of [[vascular]] structures and [[Brachial plexus|brachial plexus involvement]] and resectability of the [[tumor]]. Other [[diagnostic]] studies for evaluating the spread of Pancoast tumor include [[Scintigraphy|bone scintigraphy]], [[PET scan]], [[Molecular|molecular tests]] and [[biopsy]].
* '''[[MRI]]''' is helpful in the [[diagnosis]] of Pancoast tumor. [[MRI]] offers greater detail in the evaluation of [[chest wall]] [[invasion]], [[examination]] of [[vascular]] structures and [[Brachial plexus|brachial plexus involvement]] and resectability of the [[tumor]]. Other [[diagnostic]] studies for evaluating the spread of Pancoast tumor include [[Scintigraphy|bone scintigraphy]], [[PET scan]], [[Molecular|molecular tests]] and [[biopsy]].
Line 169: Line 67:
* [[Breast]]
* [[Breast]]
* [[Bone]]
* [[Bone]]
* [[Bone marrow]]
|-
* Adrenal glands
| colspan="2" style="background:#DCDCDC;" align="center" |'''[[Small cell carcinoma]]'''
* Kidney
|
* [[Smoking]]
* [[Radon]] exposure
|
* Bronchial precursor cell
|
* Peripheral
|
* White-tan, soft, friable perihilar masses
* Extensive necrosis
* 5% peripheral coin lesions
|
* Sheet-like growth
* Nesting
* Trabeculae
* Peripheral palisading
* Rosette formation
* High mitotic rate
|
* [[CD56]]
* [[Chromogranin]]
* [[Synaptophysin]]
* [[TTF-1]]
|
* Bone marrow  
* Liver
|-
| colspan="2" style="background:#DCDCDC;" align="center" |'''[[Adenocarcinoma]]'''
|
* [[Smoking]]
|
* Columnar cells of bronchioles
|
* Peripheral
|
* Single or multiple lesions
* Different in size
* Peripheral distribution
* Gray-white central fibrosis
* [[Pleural]] puckering
* Anthracotic pigmentation
** [[Necrosis]]  
** [[Cavitation]]
** [[Hemorrhage]]
* Lobulated or ill defined edges
|
*Nuclear atypia
*Eccentrically placed nuclei
*Abundant [[cytoplasm]] with mucin [[Vacuole|vacuoles]]
*Often conspicuous [[nucleoli]]
*Lack of intercellular bridges.
*Different patterns, include: [[acinar]], lepidic, micropapillary, [[papillary]], and solid.
|
* Epithelial markers 
* [[CEA]]
* [[Cytokeratin|CK7]]
* [[TTF-1]]
|Aerogenous spread is characteristic
* [[Brain]]
* [[Bone]]
* [[Adrenal glands]]
* [[Liver]]
* [[Kidney]]
* Gastrointestinal Tract
* Gastrointestinal Tract
* [[Pleura]]
|-
* Abdominal [[Lymph node|lymph nodes]]
! colspan="11" style="background:#4479BA; color: #FFFFFF;" align="center" + |Benign Lung Tumors<ref name="pmid23077446">{{cite journal |vauthors=Gümüştaş S, Inan N, Akansel G, Ciftçi E, Demirci A, Ozkara SK |title=Differentiation of malignant and benign lung lesions with diffusion-weighted MR imaging |journal=Radiol Oncol |volume=46 |issue=2 |pages=106–13 |date=June 2012 |pmid=23077446 |pmc=3472932 |doi=10.2478/v10019-012-0021-3 |url=}}</ref>
* [[Pericardium]]
|-
|-
| rowspan="2" style="background:#DCDCDC;" align="center" + |'''[[Papilloma]]'''<ref name="pmid3969658">{{cite journal |vauthors=Maxwell RJ, Gibbons JR, O'Hara MD |title=Solitary squamous papilloma of the bronchus |journal=Thorax |volume=40 |issue=1 |pages=68–71 |date=January 1985 |pmid=3969658 |pmc=459982 |doi= |url=}}</ref>
| rowspan="2" style="background:#DCDCDC;" align="center" + |'''[[Papilloma]]'''<ref name="pmid3969658">{{cite journal |vauthors=Maxwell RJ, Gibbons JR, O'Hara MD |title=Solitary squamous papilloma of the bronchus |journal=Thorax |volume=40 |issue=1 |pages=68–71 |date=January 1985 |pmid=3969658 |pmc=459982 |doi= |url=}}</ref>

Latest revision as of 20:43, 19 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2]

Overview

Pancoast tumor must be differentiated from other causes of mass located in the apical region of the chest which may present with pain in the shoulder region. Differential diagnosis includes most common other conditions that cause hemoptysis, cough, dyspnea, wheeze, chest pain, shoulder pain, unexplained weight loss, unexplained loss of appetite, and fatigue such as superior vena cava syndrome, thoracic outlet syndrome, cervical disk disease, pneumonia/bronchitis, carcinoid tumor, infectious granuloma and thyroid mass.

Differential Diagnosis

Pancoast tumor must be differentiated from other causes of mass located in the apical region of the chest which may present with pain in the shoulder region.The table below summarizes the findings that differentiate apical mass in the chest from the most common other conditions that cause hemoptysis, cough, dyspnea, wheeze, chest pain, shoulder pain, unexplained weight loss, unexplained loss of appetite, and fatigue


The following table summarizes the differentiation of various lung tumors based on histological and topographical features:[1][2][3][4][5][6][7][8][9][10][11][12][13]

Abrevations:

HPV: human papillomavirus; CEA: Carcino embryogenic antigen; TTF1: Thyroid transcription factor-1; EMA: Epithelial membrane antigen; CK: Cyto keratin; CD: Cluster differentiation; NCAM: Neural Cell Differentiation Molecule;

MMP's: Mettaloprotineases matrix ; GFAP: Glial fibrocilliary acid protein

Risk/Epidemiology Pleuripotent cells Topography Gross Histology Immunohistochemistry Imaging Metastasis
Pancoast Tumor Squamous cell carcinoma (SCC)
  • Central
  • Exophytic
  • Intra-epithelial
  • Without invasion
  • Cells with clear cytoplasm
  • Peripheral palisading of nuclei.
  • Poor differentiation

Chest x-ray: Lordotic view on chest x-ray is helpful in visualizing Pancoast tumor because of its characteristic location in the apical portion of the lung.

Small cell carcinoma
  • Bronchial precursor cell
  • Peripheral
  • White-tan, soft, friable perihilar masses
  • Extensive necrosis
  • 5% peripheral coin lesions
  • Sheet-like growth
  • Nesting
  • Trabeculae
  • Peripheral palisading
  • Rosette formation
  • High mitotic rate
  • Bone marrow
  • Liver
Adenocarcinoma
  • Columnar cells of bronchioles
  • Peripheral
  • Single or multiple lesions
  • Different in size
  • Peripheral distribution
  • Gray-white central fibrosis
  • Pleural puckering
  • Anthracotic pigmentation
  • Lobulated or ill defined edges
  • Nuclear atypia
  • Eccentrically placed nuclei
  • Abundant cytoplasm with mucin vacuoles
  • Often conspicuous nucleoli
  • Lack of intercellular bridges.
  • Different patterns, include: acinar, lepidic, micropapillary, papillary, and solid.
 Aerogenous spread is characteristic
Benign Lung Tumors[14]
Papilloma[15] Squamous cell papilloma
  • HPV 6 and 11
  • Men
  • Median age of diagnosis is 54 years
  • Endobronchial
  • Cauliflower-like lesions
  • Tan-white soft to semifirm protrutions
  • Loose fibrovascular core
  • Stratified squamous epithelium
  • Acanthosis
  • Binucleate forms and perinuclear halos
  • Koilocytosis
  • N/A
  • Well circumscribed
  • Homogenous
  • Non-calcified
  • Solitary mass
  • N/A
Glandular papilloma
  • Rare
  • Mean age of diagnosis is 68 years
  • Endobronchial
  • White to tan endobronchial polyps that measure from 0.7-1.5 cm
  • N/A
  • Well circumscribed
  • Homogenous
  • Non-calcified
  • Solitary mass
  • N/A
Adenoma[16] Alveolar adenoma
  • Mean age of diagnosis is 53 years
  • Female predominance
  • All lung lobes
  • Lower lobes
  • Hilar
  • 0.7-6.0 cm
  • Well demarcated smooth
  • Lobulated, multicystic
  • Soft to firm
  • Pale yellow to tan cut surfaces
  • Well circumscribed
  • Homogenous
  • Non-calcified
  • Solitary mass
  • N/A
Papillary adenoma[17]
  • Mean age of diagnosis is 32 years
  • Male predominance
  • Bronchioloalveolar cell
  • No lobar predilection
  • Involves alveolar parenchyma
  • Well defined
  • Encapsulated
  • Soft, spongy to firm mass
  • Granular gray white/ brown
  • 1.0- 4.0 cm
  • Incidental finding
  • N/A
Mucinous cystadenoma
  • No sex predilection
  • Mean age of diagnosis is 52 years
  • Central
  • White-pink to tan
  • Smooth and shiny tumors
  • Gelatinous mucoid solid core
  • 0.7-7.5 cm
  • Numerous mucin-filled cystic spaces
  • Non-dilated microacini, glands, tubules and papillae
  • Coin lesion
  • Air-meniscus sign
  • N/A
Malignant Lung Tumors[18]
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Squamous cell carcinoma (SCC)[19] Papillary
  • Epithelial cells
  • Central
  • Exophytic
  • Intra-epithelial
  • Without invasion
Clear cell
Basaloid
  • Peripheral palisading of nuclei.
  • Poor differentiation
Small cell carcinoma[20]
  • Bronchial precursor cell
  • Peripheral
  • White-tan, soft, friable perihilar masses
  • Extensive necrosis
  • 5% peripheral coin lesions
  • Sheet-like growth
  • Nesting
  • Trabeculae
  • Peripheral palisading
  • Rosette formation
  • High mitotic rate
  • Bone marrow
  • Liver
Adenocarcinoma[21][22][23] Acinar adenocarcinoma
  • Columnar cells of bronchioles
  • Peripheral
  • Single or multiple lesions
  • Different in size
  • Peripheral distribution
  • Gray-white central fibrosis
  • Pleural puckering
  • Anthracotic pigmentation
  • Lobulated or ill defined edges
  • Irregular-shaped glands
  • Malignant cells:
    • Hyperchromatic nuclei
    • Fibroblastic stroma
  • Peripheral nodules under 4.0 cm in size
  • Central location as a hilar or perihilar mass
  • Rarely show cavitations.
  • Hilar adenopathy
  • Adenocarcinomas account for the majority of small peripheral cancers identified radiologically.
 Aerogenous spread is characteristic
  • Brain
  • Bone
  • Adrenal glands
  • Liver
  • Kidney
  • Gastrointestinal Tract
Papillary adenocarcinoma
Bronchio-alveolar carcinoma Non-mucinous
Mucinous
  • Low grade differentiation
  • Composed of:
    • Tall columnar cells
    • Basal nuclei
    • Pale cytoplasm resembling goblet cells
    • Varying amounts of cytoplasmic mucin
  • Cytologic atypia
Mixed non-mucinous and mucinous or indeterminate
  • Mixed type of cells
  • Low to high grade differentiated cells.
Solid adenocarcinoma with mucin production Fetal adenocarcinoma
Mucinous (“colloid”) carcinoma
Mucinous cystadenocarcinoma
Signet ring adenocarcinoma
  • Focal
  • Cells with nuclei displaced to sides
  • Components of other cells are present.
Clear cell adenocarcinoma
  • Clear cells with no nuclei
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Large cell carcinoma[24] Basaloid large cell carcinoma of the lung
  • Approximately 10% of lung cancers
  • Smoking
  • Soft, pink-tan tumor
  • Invasive growth pattern
  • Peripheral palisading
  • Small, monomorphic, cuboidal fusiform
  • Large, peripheral masses
Clear cell carcinoma of the lung
Lymphoepithelioma-like carcinoma of the lung
Large-cell lung carcinoma with rhabdoid phenotype
Mixed type
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Sarcomatoid carcinoma[25] Carcinosarcoma
  • Central or peripheral
  • Upper lobes
  • No specific imaging features 
Spindle cell carcinoma
  • Only spindle shaped tumor cells
  • Lymphoplasmacytic infiltrates
Giant cell carcinoma
Pleomorphic carcinoma
Pulmonary blastoma
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Carcinoid tumor[26] Typical carcinoid

Atypical carcinoid

  • Most common in males
  • Mean age of diagnosis 45
  • Atypical carcinoid is more commonly peripheral
  • Firm, well demarcated, tan to yellow tumors
  • Uniform polygonal cells
  • Nuclear atypia
  • Pleomorphism
  • The most common patterns are the organoid and trabecular
  • Highly vascularized fibrovascular stroma
  • Focal necrosis
Salivary gland tumors[27] Mucoepidermoid carcinoma
  • Most patients presents in the third and fourth decade
  • Constitutes of less than 1% tumor
  • No association with cigarette smoking or other risk factors
  • Primitive cells of tracheobronchial origin
  • Bronchial glands
  • Ranging in size from 0.5-6 cm
  • Soft, polypoid, and pink-tan in colour
  • High-grade lesions are infiltrative
  • Well-circumscribed oval or lobulated mass
  • Calcifications
  • Post-obstructive pneumonic infiltrates
Adenoid cystic carcinoma
  • Constitutes less than 1% of all lung tumors
  • Most commonly seen in fourth and fifth decades of life
  • Primitive cells of tracheobronchial origin
  • Gray-white or tan polypoid lesions
  • Size ranges from 1–4 cm
  • Infiltrative margins
  • Invades other cell layers
  • Heterogeneous cellularity
  • Cribriform pattern
  • Perineural invasion
  • Well circumscribed
  • Nodule
Epithelial-myoepithelial carcinoma
  • Age ranges from 33 to 71 years
  • No association with smoking
  • Endobronchial
  • Solid to gelatinous in texture
  • White to gray in colour
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Preinvasive lesions[28] Squamous carcinoma in situ
  • Most commonly seen in fifth or sixth decades
  • Mostly seen in women
  • Basal cells of squamous epithelium
  • Focal or multi-focal plaque-like greyish lesions
  • Nonspecific erythema
  • Even nodular or polypoid lesions
  • Micropapillomatosis
  • Cauliflower like
  • Mosaic pattern
Atypical adenomatous hyperplasia
  • Multiple grey to yellow foci
  • 1mm to 10mm in size
  • Typically not visualized on radiographs
  • Small non-solid nodules
  • Ground-glass opacity
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia
  • Endobronchial
  • Early lesions are:
    • Small, gray-white nodules
    • Resembling ‘miliary bodies’
  • Larger carcinoid tumors are:
    • Firm
    • Homogeneous
    • Well-defined
    • Grey or yellow-white masses
  • Mosaic pattern of air trapping
  • Sometimes with nodules
  • Thickened bronchial and bronchiolar walls
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Mesenchymal tumors[29] Epithelioid haemangioendothelioma / Angiosarcoma
  • Caucasian
  • 80% are women
  • Endothelial cells
  • 0.3-2.0 cm circumscribed mass
  • Gray-white or gray-tan firm tissue
  • Yellow flecks
  • Central calcifications
  • Cut surface has a cartilaginous consistency
Pleuropulmonary blastoma
  • Most common in children
  • Median age of diagnosis is 2 years
  • Purely cystic
  • Thin-walled
  • Rarely solid
  • Firm to gelatinous
  • Upto 15 cm
  • Unilateral
  • Localized airfilled cysts
  • Septal thickening or an intracystic mass
Chondroma
  • Young women
  • Capsulated lobules
  • Hypocellular
  • Features of malignancy are absent
  • N/A
  • Multiple
  • Well circumscribed lesions
  • “Pop-corn” calcifications
Congenital peribronchial myofibroblastic tumor
  • Along the bronchi
  • 5-10 cm
  • Well-circumscribed
  • Non-encapsulated
  • Smooth or multinodular surface
  • The cut surface has a tann-grey to yellow-tan fleshy appearance
  • Hemorrhage
  • Necrosis
  • Well circumscribed
  • Opaque hemithorax
  • Heterogeneous mass
  • Rare
Diffuse pulmonary lymphangiomatosis
  • Children
  • Young adults of both sexes
  • Prominence of the bronchovascular bundles along
  • Anastomosing endothelial-lined cells along lymphatic routes
  • Increased interstitial markings
  • Skin
  • Bone
Inflammatory myofibroblastic tumor
  • Localized to bronchi
  • Solitary
  • Round rubbery masses
  • Yellowish-gray discoloration
  • Average size of 3.0 cm
  • Non-encapculated
  • Calcifications
  • No local invasion
  • Solitary mass
  • Regular borders
  • Spiculated appearance
  • Accompanied by
  • Rare
Pulmonary artery sarcoma
  • Mucoid or gelatinous clots filling vascular lumens
  • The cut surface may show
    • Firm fibrotic areas
    • Bony/gritty or chondromyxoid foci
    • Hemorrhage and necrosis are common in high-grade tumors
  • Spindle cells in
    • A myxoid background
    • Collagenized stroma
    • Recanalized thrombi
Pulmonary vein sarcoma
  • Most common in women
  • Mean age of diagnosis is 49
  • Fleshy-tan tumor
  • Can occlude the lumen of the involved vessel
  • 3.0- 20.0 cm
  • Invasion of wall of the vein
  • N/A

References

  1. ↑ {{Small cell lung cancer [Internet]. BMJ Publishing Group Limited 2015 [updated 2014 Oct 29]. Available from: http://bestpractice.bmj.com/best-practice/monograph/1081/diagnosis/differential.html}}
  2. ↑ Bhatt M, Kant S, Bhaskar R (2012). "Pulmonary tuberculosis as differential diagnosis of non-small cell lung cancer". South Asian J Cancer. 1 (1): 36–42. doi:10.4103/2278-330X.96507. PMC 3876596. PMID 24455507.
  3. ↑ Kamiya K, Yoshizu A, Misumi Y, Hida N, Okamoto H, Yoshida S (2011). "[Lung abscess which needed to be distinguished from lung cancer; report of a case]". Kyobu Geka. 64 (13): 1204–7. PMID 22242302.
  4. ↑ Matsuoka T, Uematsu H, Iwakiri S, Itoi K (2013). "[Chronic eosinophilic pneumonia presenting as a solitary nodule, suspicious of lung cancer;report of a case]". Kyobu Geka. 66 (10): 941–3. PMID 24008649.
  5. ↑ Beeson, Michael S. "Superior Vena Cava Syndrome". Retrieved 2008-03-24.
  6. ↑ Radiation Oncology/Palliation/SVC Syndrome. WikiBooks https://en.wikibooks.org/wiki/Radiation_Oncology/Palliation/SVC_Syndrome Accessed on January 13, 2016
  7. ↑ Bruzzi JF, Komaki R, Walsh GL, Truong MT, Gladish GW, Munden RF, Erasmus JJ (2008). "Imaging of non-small cell lung cancer of the superior sulcus: part 1: anatomy, clinical manifestations, and management". Radiographics. 28 (2): 551–60, quiz 620. doi:10.1148/rg.282075709. PMID 18349457.
  8. ↑ Foroulis CN, Zarogoulidis P, Darwiche K, Katsikogiannis N, Machairiotis N, Karapantzos I, Tsakiridis K, Huang H, Zarogoulidis K (September 2013). "Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment". J Thorac Dis. 5 Suppl 4: S342–58. doi:10.3978/j.issn.2072-1439.2013.04.08. PMC 3791502. PMID 24102007.
  9. ↑ Marulli G, Battistella L, Mammana M, Calabrese F, Rea F (June 2016). "Superior sulcus tumors (Pancoast tumors)". Ann Transl Med. 4 (12): 239. doi:10.21037/atm.2016.06.16. PMC 4930518. PMID 27429965.
  10. ↑ Thoracic outlet syndrome Mount Sinai Hospital, New York
  11. ↑ Stepansky F, Hecht EM, Rivera R, Hirsh LE, Taouli B, Kaur M, Lee VS. Dynamic MR angiography of upper extremity vascular disease: pictorial review. Radiographics. 2008 Jan-Feb;28(1):e28. Epub 2007 Oct 29. PMID 17967936
  12. ↑ Superior Vena Cava Syndrome.Dr Amir Rezaee and Radswiki et al. Radiopedia http://radiopaedia.org/articles/superior-vena-cava-obstruction Accessed on January 13, 2016
  13. ↑ Erasmus JJ, Connolly JE, McAdams HP, Roggli VL (2000). "Solitary pulmonary nodules: Part I. Morphologic evaluation for differentiation of benign and malignant lesions". Radiographics. 20 (1): 43–58. doi:10.1148/radiographics.20.1.g00ja0343. PMID 10682770.
  14. ↑ Gümüştaş S, Inan N, Akansel G, Ciftçi E, Demirci A, Ozkara SK (June 2012). "Differentiation of malignant and benign lung lesions with diffusion-weighted MR imaging". Radiol Oncol. 46 (2): 106–13. doi:10.2478/v10019-012-0021-3. PMC 3472932. PMID 23077446.
  15. ↑ Maxwell RJ, Gibbons JR, O'Hara MD (January 1985). "Solitary squamous papilloma of the bronchus". Thorax. 40 (1): 68–71. PMC 459982. PMID 3969658.
  16. ↑ Shiota Y, Matsumoto H, Sasaki N, Taniyama K, Hashimoto S, Sueishi K (1998). "Solitary bronchioloalveolar adenoma of the lung". Respiration. 65 (6): 483–5. doi:10.1159/000029319. PMID 9817965.
  17. ↑ Kanchustambham V, Saladi S, Patolia S, Mahmoud Assaf S, Stoeckel D (March 2017). "A Rare Case of a Benign Primary Pleomorphic Adenoma of the Lung". Cureus. 9 (3): e1069. doi:10.7759/cureus.1069. PMC 5375953. PMID 28409070.
  18. ↑ Kelley LC, Puette M, Langheinrich KA, King B (November 1994). "Bovine pulmonary blastomas: histomorphologic description and immunohistochemistry". Vet. Pathol. 31 (6): 658–62. doi:10.1177/030098589403100605. PMID 7863581.
  19. ↑ Roth E, Smidt D (January 1970). "[Studies on early ejaculate collection using electroejaculation in German improved land-swines and Goettinger miniature pigs]". Berl. Munch. Tierarztl. Wochenschr. (in German). 83 (1): 7–11. PMID 5528918.
  20. ↑ Jackman DM, Johnson BE (2005). "Small-cell lung cancer". Lancet. 366 (9494): 1385–96. doi:10.1016/S0140-6736(05)67569-1. PMID 16226617.
  21. ↑ Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson. "Chapter 13, box on morphology of adenocarcinoma". Robbins Basic Pathology (8th ed.). Philadelphia: Saunders. ISBN 1-4160-2973-7.
  22. ↑ Soda M, Choi YL, Enomoto M, Takada S, Yamashita Y, Ishikawa S; et al. (2007). "Identification of the transforming EML4-ALK fusion gene in non-small-cell lung cancer". Nature. 448 (7153): 561–6. doi:10.1038/nature05945. PMID 17625570.
  23. ↑ Adenocarcinoma of the lung. Librepathology 2015. http://librepathology.org/wiki/index.php/File:Adenocarcinoma_%283950819000%29.jpg
  24. ↑ Rossi G, Mengoli MC, Cavazza A, Nicoli D, Barbareschi M, Cantaloni C, Papotti M, Tironi A, Graziano P, Paci M, Stefani A, Migaldi M, Sartori G, Pelosi G (January 2014). "Large cell carcinoma of the lung: clinically oriented classification integrating immunohistochemistry and molecular biology". Virchows Arch. 464 (1): 61–8. doi:10.1007/s00428-013-1501-6. PMID 24221342.
  25. ↑ Huang SY, Shen SJ, Li XY (October 2013). "Pulmonary sarcomatoid carcinoma: a clinicopathologic study and prognostic analysis of 51 cases". World J Surg Oncol. 11: 252. doi:10.1186/1477-7819-11-252. PMC 3850921. PMID 24088577.
  26. ↑ Dahabreh J, Stathopoulos GP, Koutantos J, Rigatos S (March 2009). "Lung carcinoid tumor biology: treatment and survival". Oncol. Rep. 21 (3): 757–60. PMID 19212636.
  27. ↑ Elnayal A, Moran CA, Fox PS, Mawlawi O, Swisher SG, Marom EM (July 2013). "Primary salivary gland-type lung cancer: imaging and clinical predictors of outcome". AJR Am J Roentgenol. 201 (1): W57–63. doi:10.2214/AJR.12.9579. PMC 3767141. PMID 23789697.
  28. ↑ Greenberg AK, Yee H, Rom WN (2002). "Preneoplastic lesions of the lung". Respir. Res. 3: 20. PMC 107849. PMID 11980589.
  29. ↑ Koenigkam-Santos M, Sommer G, Puderbach M, Safi S, Schnabel PA, Kauczor HU, Heussel CP (April 2014). "Primary intrathoracic malignant mesenchymal tumours: computed tomography features of a rare group of chest neoplasms". Insights Imaging. 5 (2): 237–44. doi:10.1007/s13244-013-0306-0. PMC 3999366. PMID 24407922.

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