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Thoracic And Cardiac Imaging

Effect of 5-Line Signs in the Prediction of Staging, Progression, and Prognosis of Peripheral Lung Carcinoma

Preliminary Observation Report

Yu, Anle MD*; Li, Qun MD, PhD; He, Jinlong MD; Zhan, Yuefu MD§

Author Information
Journal of Computer Assisted Tomography: March/April 2020 - Volume 44 - Issue 2 - p 295-304
doi: 10.1097/RCT.0000000000000941
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Currently, lung carcinoma is the malignant tumor with the highest incidence (11.6% of all cases) and mortality (18.4% of all cancer deaths),1–4 because most patients with lung carcinoma are in intermediate and advanced stages at the time of treatment.5,6 Surgical resection for early lung carcinoma is the most effective therapy,5,7 the overall postoperative 5-year survival rate and 5-year relapse-free survival rate for which may reach 80%.8,9 The wide use of computed tomography (CT) imaging in the clinic has largely increased the detection rate of small lung nodules,10,11 and the lobulation and spiculation are common findings on imaging to differentiate benign or malignant nodules. However, these 2 signs have little effects on the prediction of staging and prognosis of malignant nodules. Pleural tail sign is a finding that has been observed between a nodule and the pleura for a long time. A line of tail sign may be single or multiple, and vary in length and thickness. Earlier researchers often judged whether lung cancers invaded the pleura according to the morphological features and presence of the pleural tail sign.12,13 Studies have shown that this sign is valuable for detection of pleural invasion. After maximal intensity projection (MIP) reconstruction, the pleural tail sign can be shown as a 5-line sign.14 On the basis of previous observations, this article attempts to judge the invasiveness of peripheral lung cancer according to the clarity of the 5-line sign on MIP images and to predict the progression and prognosis of the cancer.


This study was approved by the institutional review boards First Affiliated Hospital of Hainan Medical College and Haikou People's Hospital with a waiver of informed consent.


One hundred fifty-one cases confirmed as peripheral lung carcinoma between December 2007 and December 2014 were collected. Among these cases, 110 were from the First Affiliated Hospital of Hainan Medical University (between December 2007 and December 2014); 41 cases were from Haikou People's Hospital (between February 2012 and December 2014). Inclusion criteria were the following: (1) the lung neoplasm was first discovered with definite pathological diagnosis; (2) there was no history of other tumors in the recent 5 years; (3) cases underwent a plain scan; and (4) the slice thickness of the original scan image was 1 or 1.25 mm, and the image was reconstructed with a standard algorithm. According to the inclusion criteria, 19 cases were excluded. One hundred thirty-two cases were included (93 men and 39 women with average age of 61.37 ± 11.25 years and an age range of 27–82 years). The average size of nodules/lumps was 3.22 ± 1.60 cm (from 0.98 to 8.75 cm). There were 133 nodules (masses) in total (2 nodules existed in left and right lung, respectively, of 1 patient). Among the nodules, 4 were partially solid nodules, and the others were solid nodules (or masses). According to the pathological diagnosis, 93 cases were adenocarcinoma, 16 cases were squamous carcinoma, 5 cases were large cell carcinoma, 2 cases were small cell neuroendocrine carcinoma, 1 case was carcinosarcoma, 1 case was mucoepidermoid carcinoma, and 15 cases were unspecified carcinoma. The pathological information comes from various ways (Table 1).

Methods of Proof of 132 Cases of Lung Cancer


Scanning Parameters

A GE (GE Healthcare, Chicago, Illinois) LightSpeed volume CT scanner with an AW 4.3 workstation was used with the following scanning parameters: 120 kV; 89 to 301 mAs (with tube current modulation active); reconstructive slice thickness, 1.25 mm; interval, 1.25 mm; and slab thickness, 6.25 mm for axial MIP. The parameters for the Philips (Philips Healthcare, Amsterdam, Holland), Brilliance iCT (Cleveland, Ohio), and Siemens (Siemens Healthcare, Erlangen, Germany) Somatom Definition Flash (Munich, Germany) were the following: 120 kV; 180 to 200 mAs (with tube current modulation active on the 16-slice CT unit); rebuilding slice thickness of 1.0 mm; space, 1.0 mm; and slab thickness of 5.0 mm for axial MIP, using a Philips workstation (Brilliance Workspace Portal) for both MIPs rebuilding based on thin section image from either Siemens or Philips.

TNM Staging

The T, N, and M staging in this article is based on the TNM stages of lung cancer from the International Union Against Cancer and the American Joint Committee on Cancer, seventh edition, 2009; pieces of evidence of the imaging and/or pathological data were allowed for staging. When both imaging and pathological data were available, the pathological data were adopted.

T staging was based on the size of the nodule (mass) measured on the imaging.

N staging was based on pieces of evidence of pathology, or image if no pathological data. On the image, a short diameter of the axial lymph node of ≥10 mm was judged to be lymph node enlargement.15

For M staging, distant metastasis was determined by imaging data (metastases of the lung and other organs) and pathological data (positive pleural effusion and metastatic tumors). No metastasis was found in M0. Metastases were classified into M1a and M1b according to the seventh edition of TNM staging of lung cancer in 2009 by the International Union Against Cancer and the American Joint Committee on Cancer.

Diameter Measurements of the Lung Nodules (Masses)

The axial lung window with a slice thickness of ≤5 mm was taken, showing the maximal nodule section. The long diameter was measured on a single CT image that showed the maximal length of a nodule; the wide diameter, defined as the longest perpendicular to the length, was measured on the same CT image. The average of the long and wide diameters was the diameter of the lung nodule (mass).

Grading Method of 5-Line Signs

The single line of the normal interlobar fissure shown on a thin section image can be reconstructed as a 5-line sign on axial MIP.16 The line between the lung nodule and the pleura is called the pleural tail sign on thin image. On the axial MIP, it can also be reconstructed as the 5-line sign or fewer than 5 lines.14 The pleural tail sign can derive from the margin of a nodule as single or multiple lines extending in different directions and be observed in axial, coronary, or sagittal positions, on which the longest line is chosen as a baseline to reconstruct a 5-line sign on axis position in this research (Fig. 1).

Determining the base 5-line sign (main 5-line sign). (A) Thin section of 1.25-mm image. There were 2 tail signs on the edge of a nodule, which were marked as tail sign f (black arrowhead) and tail sign g (black arrow), respectively. The length of line f is longer than that of g on the axial image. (B) The tail sign g is in the axis image (upper right) on the workstation interface, and the red dot (white arrow) is the location point (3-dimensional cursor). The coronal image (upper left and lower right) and sagittal image (lower left) correspond to the axis location point, and each red dot (white arrow) in each image corresponds to the location point of tail sign g in the axis image, respectively. In the coronal position (upper left and lower right), the length of line g is approximately 38.8 mm, which was identified as the base 5-line sign, much larger than that of tail sign f. The minor fissure is segmented (white arrowhead) in the sagittal image (lower left), similar to MIP reconstruction of beaded small vessels; for more details, please see Ref.16. (C) Tail sign g showed a clear 5-line sign (black arrow), and tail sign f showed only 3 lines (black arrowhead) on the 6.25-mm MIP image. The anterior part is a string of beaded small vessels (white fishtail arrow).

Maximal intensity projection reconstruction of all cases was performed by one doctor A. Y. with more than 20 years of experience in chest CT diagnosis. If there was an unclear or no 5-line sign at the edge of the nodule on the axial MIP, rotating the reconstruction tangent lines clockwise or counterclockwise on the sagittal or coronal plane of the workstation interface was tried, to observe whether the 5-line sign would appear or improve the clarity after adjusting the angle,14 and improved sharpness image was retained for grading.

Five-line signs on the margin of the lung nodule (mass) were classified into 5 grades according to their sharpness (Fig. 2), as follows:

(A–E) Grading images of 5-line sign. Lung window (window width, 1000 HU; window level, −700 HU). Axial MIP reconstruction image with a slab thickness of 6.25 mm. (A) Grade 1: 5-line sign disappeared. Adenocarcinoma with lymph node metastases. Only a band shadow between the nodule and the pleura can be observed (arrow). (B) Grade 2: 5-line sign mostly disappeared. Adenocarcinoma. Only 2 lines of nonuniform lengths are on the margin of the nodule (white arrow). (C) Grade 2: adenocarcinoma. Only the distal 5-line sign is clear (black arrow), the proximal 5-line sign is not clear (low density), and 2 to 3 lines (white arrowhead) are dimly visible, and the unclear part is larger than one-half of the length of the whole line. (D) Grade 3: adenocarcinoma. Five-line sign partially disappeared, although the 5-line sign that was the main line could be seen; its length is shorter than the tumor's diameter (black arrow). Five-line signs of normal interlobular fissures (white arrowhead) and lines at the edge of the tumor are thicker and denser than those of normal interlobular fissures. (E) Grade 4: adenocarcinoma without lymph node metastases. Five-line signs were clear/relatively clear; the lines of 5-line shadows are uniform in line thickness and clear in space (arrow).

0: There were no 5-line signs. On the axial, coronal, and sagittal images, the nodule (mass) showed no line shadow between the nodule margin and pleura and no adhesion between the nodule (mass) and pleura.

  • 1: 5-line sign disappeared. A band shadow was connected to the pleura, and/or multiple adhesions between the nodule (mass) and the pleura were observed.
  • 2: Most 5-line sign disappeared. (a) The reconstructed line shadow only showed 2 or 3 lines. (b) The 5 lines were partly fused as high-density shadow, or disappeared (low density); the length of the changed part was more than half of the whole line.
  • 3: The partial 5-line sign disappeared. (a) The number of the main 5 lines was reduced to 4 lines. (b) The merging or disappearing part of the main 5 lines was larger than one-quarter of the line length and less than half of the line length.
  • 4: The 5-line signs were clear or relatively so. Clear: The lines of the 5 lines were uniform in line thickness and clear in space. Relatively clear: The lines of the 5 lines were not so uniform in line thickness and were relatively obscure in space; the unclear part was equal to or shorter than one-quarter of the 5-line length.

When nodules were small in the early stage of tumors, the length of axial 5-line sign was usually greater than or equal to the diameter of nodules. As lung cancer nodules grew and gradually approached the pleura, the pleural tail sign and the axis 5-line sign based on it also became short. When the length of the axis 5-line sign is less than the diameter of the nodule (mass) but longer than one-half of that of the tumor, the grade of the 5-line sign is reduced from grade 4 to grade 3, even it is clarity. If the length of the 5-line sign is less than one-half of the diameter of the tumor, it should be reduced to grade 2.

Statistical Method

The SPSS 16.0 software package was used for statistical analysis. An ordered logistic regression model was used to incorporate tumor size and length of tail sign with the grading of 5-line sign to predict T, N, and TNM staging. Receiver operating characteristic (ROC) curve analysis was used to evaluate the value of 5-line sign grading in predicting the progression and prognosis of lung cancer. It was considered that the diagnostic accuracy was low if the area under the ROC curve was less than 0.7, moderate if it was 0.7 to 0.9, and high if that was more than 0.9. P < 0.05 indicated that the results had statistical significance.


Correlation Between 5-Line Signs and Tumor TNM Staging

Three cases of grade 0 of 5-line sign were not included in the statistics because there were not enough cases. One case had 2 nodules located, respectively, in the left lung (part-solid nodule) with grade 4 of 5-line sign and in the right lung (solid nodule) with grade 2 of 5-line sign. Based on the pathological diagnosis from needle biopsy, the nodule in the left lung was considered a low-grade malignant mucoepidermoid carcinoma, and the nodule in the right lung was a papillary adenocarcinoma, which was high invasion.7 The purpose of this article is to evaluate the effect of 5-line sign on assessing lung carcinoma progression. So only the nodule in the right lung with a lower grade of 5-line sign was selected to enter in the data analysis, as the tumor was enlarged and metastasized after 20 months of follow-up. Meanwhile, the nodule in the left lung had the same size as it was in the initial examination. Thus, 129 nodules are included in Tables 2 and 3.

Multivariate Ordered Logistic Regression Analysis of Influencing Factors on N Stage of Lung Cancer
Multiple Ordered Logistic Regression Analysis of Influencing Factors on Clinical Staging of Lung Cancer

Ordered logistic regression analysis showed that destruction of the 5-line sign was a risk factor for the increase of N stage (“N0 to N1–N3” or “N0–N2 to N3”) and TNM stage (“I A to I B–IV” or “I A–III B to IV”), but it had no effect on T stage and M stage. Tumor enlargement was a risk factor for T, N, and TNM staging, but its size did not affect M staging. The length of pleural tail sign was not a factor influencing T, N, M, and TNM stages of lung cancer (Tables 2, 3).

Small lung nodules (≤3 cm) with 5-line sign 4 or 3 grade showed negative metastasis (Figs. 2E, 3, 4), but those with 5-line sign 2 or 1 grade showed various metastases (Table 4; Figs. 5, 6).

Adenocarcinoma, male, 63 years old. Lung window (window width, 1000 HU; window level, −700 HU). (A) Nodule in the left upper lobe. An axial MIP image thickness of 6.25 mm showed that the 5-line sign at the edge of the nodule was clear and regular (black arrow), and was thicker and denser than those of interlobular fissures (white arrowhead). (B) Five-line sign (arrow) can be seen in multiple images, indicating that the plane (septae) is wide enough. (C) Conventional lung window. Five-millimeter-thick axial image showed that the 5-line sign was a slice of GGO (black arrow), and so did the right and left interlobular fissures (white arrowhead). (D) Lung window 1.25-mm axial folium image showed that the 5-line sign became a pleural tail sign (black arrow), which was also thicker and denser than the lines of both sides of the fissures (white arrowhead). (E) Line (arrow) in the sagittal image (lower left) of the workstation interface is approximately 55.6 mm long and showed segmental appearance, similar to MIP reconstruction of beaded small vessels, and the small red dot (arrow) at the tail sign corresponds to the positioning points (arrows) of the axial image (upper right image) and the coronal image (upper left and lower right). The patient had survived for more than 10 years after resection without metastasis.
Lung cancer, female, 77 years old. Lung window (window width, 1000 HU; window level, −700 HU). (A) A small nodule, 18.1 × 14.5 mm in size, was in the right upper lobe on conventional 5-mm image. A slice increasing attenuation near the nodule (arrow) was similar to GGO with preservation of small vascular margins in it. (B) The 5-line sign, that is, the GGO in panel A, was barely clear on 6.25-mm MIP thickness (arrow); panels A and B were from the same CT examination. (C) The nodule was increased to 28.1 × 12.6 mm in size; doubling time of the tumor was 867 days 3 years later, the characteristics of indolent growth was shown, and cancer cells were found in pleural effusion after 9 years. It is noteworthy that the former GGO became denser and heterogeneous (arrow) on the same conventional 5-mm-thick image. According to our experience, the 5-line sign could not be reconstructed as clearly in this case as that in panel B 3 years before.
Relationship Between Grading of 5-Line Sign and the Invasiveness of 43 Cases of Small Lung Cancer (≤3.0 cm; Cases [%])
Adenocarcinoma, male, 64 years old. Lung window (window width, 1000 HU; window level, −700 HU). Axial MIP thickness of 6.25 mm. A small nodule, 1.5 × 1.8 cm in size, was in the left lower lobe. Five-line sign mostly disappeared (white arrow), and nodal micrometastases in the area of the interlobe region and the hilum were found pathologically. The patient died of metastasis 2 years after surgery.
Adenocarcinoma, female, 39 years old. Lung window (window width, 1000 HU; window level, −700 HU). Axial MIP thickness of 6.25 mm. A small nodule of 16.8 × 17.5 mm in size was in the left upper lobe; 5-line sign disappeared, and only band shadow can be seen (arrow). Pleura invasion was found by pathology from a resected specimen. Tumor pleural metastasis and pleural effusion occurred 4 years after surgery, and the patient died of metastasis.

In lung lumps larger than 3 cm in diameter, 5-line often showed different destructions, and more metastasis were seen (Table 5, Fig. 2A).

Relationship Between 5-Line Sign Grading and Tumor Invasion in 45 Cases of Lung Cancer Resected Surgically (Diameter >3.0 cm; Cases [%])

Correlation of the 5-Line Signs and Lung Carcinoma Progression

Sixty-three patients in 132 cases were followed up by imaging examination for 2 years and 10 months to 6 years (Table 6). Other cases did not get follow-up data for various reasons.

Reasons of No Follow-up Cases in Progressive Analysis From 132 Cases of Lung Cancer

The ROC curve showed that 5-line sign grading and N stage were valuable (medium to high) on predicting progression of lung cancer. The sensitivity and specificity were 0.563 and 0.933 for 5-line sign grading and 0.646 and 0.967 for N stage. We noted that such a trend also existed in small lung nodules (≤3 cm; Fig. 7). That means the lower the sharpness of the 5-line signs, the greater the tumor progression. In this group, 5-line sign and N staging showed a better predictive value than did TNM staging (moderate) and T staging (moderate to low).

Comparison of grading of 5-line sign and TNM staging in the evaluation of tumor progression in patients with lung cancer (not included the patients in stage IV at first visit). Figure 7 can be viewed online in color at

Correlation Between 5-Line Signs and Tumor Prognosis

A statistical analysis was conducted in the 53 cases with follow-up data for the prognosis of lung carcinoma. The remaining 72 cases were not included because they had no survival information (Table 7).

Prognosis Analysis of Cases Admitted in 132 Cases of Lung Cancer

The statistical analyses on prognosis of lung carcinoma were performed for a period of 3 years. According to the ROC curve, the prognostic value of 5-line sign grading for lung cancer was moderately low, with sensitivity and specificity of 0.611 and 0.824, respectively (Fig. 8). N staging and TNM staging were not so valuable (moderately high).

Comparison of grading of 5-line sign and TNM staging in the prognostic prediction to the patients with lung cancer (dead cases for operation were excluded). Figure 8 can be viewed online in color at


The axial MIP reconstruction of normal pleura may form 5-line signs. The number of lines is equal to the ratio of MIP thickness and original slice thickness. This phenomenon may be the same as the beaded manifestations shown by the MIP reconstruction of the small vessels of the lung.14,16 This phenomenon of beaded vessels (Fig. 1C), which was first described as stair-step vessels by Napel et al,17 results when smaller vessels, particularly those with dimensions that approximate the section width, pass obliquely through the scan plane because of partial volume averaging. As a result, artifacts are generated (Fig. 1B).

The pleural tail sign18,19 represented thickened septae histologically.18,20,21 The 5-line sign was formed by MIP reconstruction on the basis of the pleural tail sign at the margin of the tumor. The thickness of pleural tail sign rather than its length is the most important condition for the formation of a 5-line sign. In this study, a small number of nodules with the tail sign on thin section images showed a clear 5-line sign by MIP rebuilding, suggesting that it was a relatively smooth and regular plane,12,14,20 which was difficult to be determined whether it is smooth and regular by conventional multiplanar or thin-section reconstruction. Carefully observed, these lines were thicker and denser than those of normal interlobular fissures (Fig. 2D). We observed that the 5-line sign on MIP showed to be unclear or disappearing in most nodules; we speculated that was for more thickened, rough and irregular tail sign,14,18,20 which reflected tumor's damage and invasion of the septa12,18,20,21 (Figs. 4, 6), whereas disappearance (low density) of the 5-line sign may be due to local edema20 (Fig. 2C).

By reconstruction, the pleura tail sign showed a 5-line sign on 6.25-mm MIP thickness; that is, the pleural tail is seen on 5 contiguous slices of 1.25 mm; in preexploration by the GE CT scanner, 3.75- and 8.75-mm MIPs were used to produce multilines. Three lines by 3.75-mm MIP and 7 lines by 8.75-mm MIP were produced. Relative to 5-line sign from 6.25-mm MIP, 3-line sign was clearer in grading but may cover up some clue, whereas 7-line sign was difficult to analyze for too much lines.

There was no correlation between the length of tail sign and T, N, and TNM staging, suggesting that only the length provided too few information on tumor invasion. Based on the artificial image of pleural tail sign, 5-line sign presented more information for analysis, such as the number of lines, and the clarity and length and width of 5-line sign (Figs. 3A–E). By comprehensive analyzing these phenomena, a prediction of tumor progression can be made.

Multivariate logical regression statistical analysis showed that tumor size positively correlated with T, N, and TNM staging of the tumor in this group. Although 5-line sign had no relation to T staging, it positively correlated with N and TNM staging.

Up to now, tumor size is still regarded as a key factor for evaluating lung cancer staging.22 However, Ohta et al23 considered that tumor size was not a reliable guide for limited surgical intervention for possibility of micro–lymph node metastasis and pleural invasion in a small nodule, especially in small adenocarcinoma (≤2 cm).23–25 The data from this group showed that a small nodule with good 5-line sign (4 or 3 grade) had no any metastasis, but those with bad 5-line sign (2 or 1 grade) were confirmed to have metastasis by various ways, most of that were lymph node metastasis, which implied the significance of 5-line clarity on predicting metastasis in a small malignant lung nodule. A positive correlation also existed between 5-line sign and TNM staging, which indicated a dominant position of N staging in TNM staging.

Multivariable data analysis of the ROC curve showed that the sensitivity and specificity of 5-line sign in predicting tumor progression were 56.3% and 93.3%, respectively. It was also effective in small lung malignant nodule (<3 cm). As a good example, 1 patient in this study had 2 nodules with different grades of 5-line signs in the left (4 grade) and right (2 grade) lungs. Follow-up showed an indolent nodule in the left lung but active growth in the right one, which implied that the lower the sharpness of the 5-line signs, the faster the tumor progression (Fig. 4).

Five-line sign was correlated with prognosis of tumors to some degree (sensitivity, 0.611; specificity, 0.824), but N staging was valuable (sensitivity, 0.778; specificity, 0.941). N staging is considered as the most important factor in lung cancer prognosis.25–27 Five-line sign was useful in predicting lymph node metastasis, so it was indirectly helpful in predicting a patient's prognosis.

From our data, beside tumor size, ground-glass opacity (GGO) component, and other ways,28–30 5-line sign might be another parameter in predicting metastasis, progression, and prognosis of lung carcinoma, particularly in small lung carcinoma (≤3 cm).

The GGO component in a nodule is an important index of prognosis of lung carcinoma,31,32 but it cannot predict the prognosis of solid lung carcinoma. In our group, most small lung carcinomas were solid nodules (41/43), so GGO is useless to these cases. Five-line sign might offset this shortage.

Limitations of the Study

The final survival of a great many cases in this study was not followed up because of various reasons. A 3-year follow-up is not sufficiently long. The samples falling into grades 3 and 4 of 5-line signs are not enough, so the correlation between 5-line signs and lung carcinoma staging, progression, and prognosis has to be proven by using larger samples. Unlike interlobular fissure, the extending direction of pleural tail signs at the margin of the tumor is random, so it is not comprehensive enough to observe the 5-line signs only by rotating the reconstructed tangent line at the coronal or sagittal position on the workstation interface. Forty-seven cases were staged according to tumor biopsy pathology and did not undergo surgery because of the patients' option. Their N staging was performed based on imaging manifestations.


The MIP-rendered 5-line signs at the margin of peripheral lung carcinomas may be a partial volume effect. The sharpness of the 5-line signs might have an effect on the prediction of invasion, progression, and prognosis of lung carcinomas, especially on small (<3 cm) lung carcinoma.


We deeply express our gratitude to Jiangjun Qin and Beihai Wu for advises and suggestions, as well as Baozhong Wu, Miaoqiong Zheng, Anlun Yu, and Zhongxin Hu for contributions to this work.


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lung neoplasm; staging; progression; prognosis; tomography, x-ray computed

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