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437
What interventions are typically
performed for asymptomatic large
or multifocal HCC without evidence
of vascular invasion or extrahepatic
metastasis (intermediate stage HCC)
(assuming good performance status
and CP score)?
TACE +/− thermal
ablation and TARE
What treatment options are
available for symptomatic HCC with
vascular invasion or extrahepatic
spread (advanced stage HCC)?
Sorafenib and TARE
Acknowledgments I would like to thank Dr. Anuj Malhotra for reviewing
and providing meaningful feedback to early versions of this chapter.
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443© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_34
Evaluating thePatient
Do I need to
evaluate the
patient for a lung
biopsy?
Every lung biopsy patient should have a
formal evaluation by an interventional
radiologist, and close inspection of cross-
sectional imaging, as these patients have a
risk of developing pneumothorax.
Are there
particular
considerations
when consenting a
patient for a lung
procedure?
The most common complication of a lung
biopsy or ablation is a pneumothorax.
Therefore, it is good practice to not only
explain that pneumothoraces are seen in up
to 20% of these procedures but also consent
the patient for a possible chest tube while
consenting them for the main procedure. This
will avoid any delay in placing such a tube
should the patient require one urgently.
Chapter 34
Pulmonary Oncology
JohnSmirniotopoulos andMariaMitry
J. Smirniotopoulos (*)
Interventional Radiology, MedStar Georgetown University
Hospital/MedStar Washington Hospital Center,
Washington, NY, USA
M. Mitry
Department of Radiology, New York Presbyterian Hospital/Weill
Cornell Medicine, New York, NY, USA
(continued)
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444
What is clinically
relevant?
Medical and surgical history with a focus on
cardiopulmonary status, bleeding risk, and
medications
Are there any
adjustments to
medications?
Prior to lung biopsy and ablation,
anticoagulation should be discontinued.
Inpatients currently taking warfarin can
be transitioned to heparin infusion, which
should be stopped 2hours prior to the
procedure for biopsy and 24hours prior to
ablation.
How recent should
a chest CT be for a
procedure?
Cross-sectional imaging of the chest (formal
CT or PET/CT) should be obtained within
4weeks of a procedure.
High Yield
What is the
prevalence of
lung cancer?
Lung cancer is the most common malignancy
in the United States and worldwide, with 2.1
million new cases and 1.8 million related deaths
in 2018.
What is the
average age of
diagnosis?
The majority of patients diagnosed with lung
cancer are older than 65, with an average age of
diagnosis of 70.
What is
the gender
difference?
The age-adjusted death rate for lung cancer
is higher for men (46.7 per 100,000) than for
women (31.9 per 100,000).
What are the
risk factors?
Smoking is the main attributable risk to small-
cell and non-small-cell lung cancers.
How much does
secondhand
smoke affect
the risk of
developing lung
cancer?
Nonsmokers have a 20–30% greater chance of
developing lung cancer if they are exposed to
secondhand smoke at home or work.
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445
Does screening
work?
Early detection, by low-dose CT screening,
can decrease lung cancer mortality by 14–20%
among high-risk populations.
What are the
three types of
lung nodules?
Solid: homogenous, soft-tissue attenuation
nodules
Ground glass: hazy, nonuniform increased
attenuation, does not obscure underlying
vascular or bronchial structures
Part solid: both solid and ground glass
components
What are the
features of
malignant
nodules on
imaging ?
Nodule size: >6–8mm.
Nodule growth rate: assessed by volume
doubling time (VDT). Malignant nodules can
have VDT from 20 to 400days, with VDT
<100days associated with the highest risk of
malignancy.
Location: majority of malignancy is in the upper
lobes.
Other features: spiculated margins, pleural
indentation, vascular convergence, and/or air
bronchograms.
What are the
features of
benign nodules
on imaging?
Perifissural nodules are solid, smooth, and small
(<10mm) and are in contact with the pleural
surface or fissure. Perifissural nodules often
represent benign intrapulmonary lymph nodes.
Calcified nodules are often benign, although the
pattern of calcification should be considered.
Diffuse, central, lamellated, and popcorn
calcifications are generally considered benign,
whereas punctate, eccentric, and amorphous
calcifications are indeterminate.
Intralesional fat suggests pulmonary hamartoma
rather than malignancy.
(continued)
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446
What are the
most common
types of lung
cancer? What
are some
distinguishing
features of each
type?
Squamous cell carcinoma: typically centrally
located, cavitary lesions, and most commonly
associated with humoral hypercalcemia of
malignancy (HHM)
Small-cell carcinoma: typically centrally
located, poorer prognosis, and most commonly
associated with hyponatremia from syndrome
of inappropriate antidiuretic hormone secretion
(SIADH), hypercortisolism from ectopic
Cushing’s syndrome (ECS), and proximal
muscle weakness from Lambert-Eaton
myasthenic syndrome
Adenocarcinoma: typically peripherally located,
often ground glass, or part solid lesion
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How is non-
small-cell
lung cancer
(NSCLC)
staged?
TNM (tumor, nodes, metastasis) staging:
T:
T1: less than 3cm
T2: 3–5cm, involvement of the main bronchus
≥2cm distal to the carina, invasion of visceral
pleura, atelectasis, or obstructive pneumonitis
extending to the hilum
T3: 5–7cm and/or invades the chest wall
(includes superior sulcus tumors), mediastinal
pleura, or parietal pericardium, involves the
main bronchus less than 2cm distal to the
carina, atelectasis or obstructive pneumonitis
involving the whole lung, separate tumor nodule
in the same lobe
T4: greater than 7cm and/or invades the
diaphragm, mediastinum, heart, great vessels,
trachea, carina, recurrent laryngeal nerve,
vertebral body, separate tumor nodule in a
different ipsilateral lobe
N:
N0: No nodal metastases
N1: ipsilateral peribronchial and/or
hilar nodes, direct extension to ipsilateral
intrapulmonary nodes
N2: ipsilateral mediastinal and/or subcarinal
nodes
N3: contralateral mediastinal or hilar nodes
and/or ipsilateral or contralateral scalene or
supraclavicular nodes
M:
M0: No distant metastases
M1: Distant metastases
Staging:
Stage I (A and B): Disease only in the lung,
no nodal or distant metastases (T1 (A) or T2
(B), N0, M0)
Stage II (A and B): T1 N1 M0 (A) or T2 N0
M0, T3 N0 M0 (B)
Stage III (A and B):
A: T3 N1 M0, T1 N2 M0, T2 N2 M0, and T3
N2 M0
B: T4 N0 M0, T4 N1 M0, T4 T2 M0, T1 N3 M0,
T2 N3 M0, T3 N3 M0, and T4 N3 M0
Stage IV: any T or N with M1
(continued)
34 Pulmonary Oncology
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