Tan-Lucien H. Mohammed, MD, FACRDepartment of RadiologyUniversity of Florida
ESSENTIALS OF RADIOLOGYCHEST: Cystic Lung Disease
Case 1Multifocal cystic lesions21-year old man with cough
Case 1
Case 1Multifocal cystic lesions21-year old man with cough
Imaging Findings:Mural nodules in the tracheaNodules, cavitary nodules, and cystsVariable size, lower lungs, dorsal aspects
Case 1Multifocal cystic lesions21-year old man with cough
Differential Diagnosis:Multifocal cavitary primary lung cancerTracheobronchial papillomatosisVasculitisPneumocystic jiroveci pneumonia (PCP)
30% of all lung cancersCigarette smokersImaging:Central > peripheralAirway involvementCavitation and secondary infection occur
Squamous cell carcinomaLung cancer
Risks: AIDS, Lymphoproliferative disorders, transplantation
Imaging:Bilateral, symmetric GGO or fine reticulationHRCT: may see “crazy paving” patternTends to be perihilarMay be diffuse, mainly upper, or mainly lower
Pneumocystis jiroveci pneumoniaPCP
Pneumocystis jiroveci pneumoniaPCPOther imaging findings:Cystic changes – upper lobes, PneumothoraxFocal consolidation, “mass”Nodules / miliary pattern / reticulationPleural effusionLymphadenopathyNormal CXR: 10%
Pneumocystis jiroveci pneumoniaPCP
Nodules / masses; may be angiocentricCT “halo sign” (surrounding GGO)Cavitation( typically nodules > 2 cm)Wedge-shaped nodules /consolidations May cavitate; thick-walled may evolve to cysticAirway stenosis, endoluminal nodules / masses
VasculitisWegener Granulomatosis
VasculitisWegener Granulomatosis
Teaching Points
Tracheobronchial papillomatosis CTMultifocal pulmonary nodulesThi-walled cavitary noduels or massesEndoluminal soft-tissue nodules or massesPostobstructive atelectasis / consolidationIncreasing mass or consolidation if malignant transformation to Squamous cell carcinoma
Laryngeal Papillomatosis: Demographics and Etiology
Human papilloma virus - HPV types 6 and 110.1% of infants develop LP. Predilection for
first-born infants50% of mothers have genital tract
involvementHPV spread transvaginally at birthInfects oropharyngeal secretions of child
Papillomatosis ImagingMultiple, well-defined nodulesPerihilar, Posterior thoraxGrow to several centimetersCavitate, 2 - 3 mm thick
wallsAir-fluid levels may develop
Papillomatosis ImagingCavities may
represent:PapillomatosisSquamous cell caAbscess
(obstructive pneumonitis)
Papillomatosis Imaging29-year old female
Papillomatosis
Since 3-years of age.
Papillomatosis Squamous cell caRisk for Squamous cell ca15-years after diagnosisRisk factors: Radiation, smoking, other carcinogens
19-year old female
Case 1
Diagnosis:Tracheobronchial papillomatosis
Case 2Multifocal cystic lesions and nodules34-year old woman with cough
Case 2
Case 2Multifocal cystic lesions34-year old woman with cough
Imaging Findings:Irregular centrilobular nodulesSmall cavitary nodulesThick- and thin-walled cystsRelative sparing of lung bases
Differential Diagnosis:SarcoidosisSilicosisPulmonary Langerhans cell histiocytosis (PLCH)Infection (M. tuberculosis, M. avium comples,
histoplasmosis)
Case 2Multifocal cystic lesions34-year old woman with cough
Teaching PointsPulmonary Langerhans cell histiocytosisNodules and cystsNormal intervening pulmonary parenchymaPoorly defined centrilobular (1-15mm) nodulesSolid or cavitating nodules (progression to cysts)Cysts vary in size, shape; thin, thick or irregular cyst wallsRelative sparing of lung bases
Mycobacterium avium complexMAC
Upper lobe cavitary formThin-walled upper lobe cavitiesApical pleural thickeningNodular bronchiectatic formBilateral nodular or reticulonodular opacitiesCentrilobular nodules / tree-in-bud opacitiesBronhiectasis: predominantly RML and Lingula
Mycobacterium avium complex MACUpper lobe cavitary formThin-walled upper lobe cavitiesApical pleural thickening
Mycobacterium avium complex MACNodular bronchiectatic formCentrilobular nodules and tree-in-bud opacitiesBronhiectasis: predominantly RML and Lingula
Chronic histo: upper lobe consolidation/cavitation
Histoplasmosis
DDx:Healed TBSarcoid IV
Staphylococcus aureusLess common:Homogeneous
consolidationNodulesWedge-shaped opacities
(septic emboli)Abscess 15-30%PneumatocelePTXPleural effusion / empyema
Septic emboliIndwelling catheters, IVDUPelvic thrombophlebitisHead and neck infectionsImagingNodular opacities, bilateral, circumscribed or poorly definedCavitation commonWedge-shaped, subpleural consolidationsCT: nodules frequently peripheral, lower zones
Septic emboliIndwelling catheters, IVDUPelvic thrombophlebitisHead and neck infectionsImagingNodular opacities, bilateral, circumscribed or poorly definedCavitation commonWedge-shaped, subpleural consolidationsCT: nodules frequently peripheral, lower zones
ReticulonodularUpper-and-midPredominant
DDx:SarcoidSilicosisTuberculosisPLCH (“EG”)…others
Pulmonary Langerhans Cell Histiocytosis
• Uncommon• > 90% Smokers. • Young adults• Cough, dyspnea, PTX• Peribronchial granulomas• Langerhans cells, eosinophils• Lung destruction
Pulmonary Langerhans Cell HistiocytosisHRCT
• Nodules• Cavitary nodules• Cysts• Upper-zone
predominance• Spares lung bases
Pulmonary Langerhans Cell HistiocytosisHRCT
Spares lung bases
Pulmonary Langerhans Cell Histiocytosis
Distribution constantSpares lung bases
Case 2
Diagnosis:Pulmonary Langerhans cell histiocytosis
Case 3Basilar “cystic” lesions54-year old man with weight loss
Case 3
Imaging findings:Mjultiple nodules, some angiocentricNodules vary in morphology, solid to cysticPredominantly involve lower lung zones
Case 3Basilar “cystic” lesions54-year old man with weight loss
Differential Diagnosis:Pulmonary angiitis and granulomatosisCystic metastasesSeptic emboli
Case 3Basilar “cystic” lesions54-year old man with weight loss
Septic Emboli
Courtesy of Dr. Elizabeth Moore
HoneycombingUIPCystic air spaces 3mm-3cmThick, clearly defined wallsCystic spaces share wallsSeveral contiguous layersPeripheral, subpleuralBasilar predominant“End-stage lung” / Fibrosis
MetastasesCavitation4% of metastases
Primary malignancies:
Squamous cell ca 69%
(Head and neck, cervix)
Adenocarcinoma 31%
(colon, breast)
Sarcomas (bone) - pneumothorax
Case 3
Diagnosis:Metastases(colon cancer)
Case 4Localized multicystic lesion18-year old man with hemoptysis
Case 4
Imaging Findings:Multicystic lesion in left lower loberPosteromedial aspectAdjacent pleural thickeningTwo associated feeding vessels from aorta
Case 4Localized multicystic lesion18-year old man with hemoptysis
Staphylococcus aureusLess common:Homogeneous consolidationNodulesWedge-shaped opacities
(septic emboli)Abscess 15-30%PneumatocelePTXPleural effusion / empyema
Lung abscessSpherical, central necrosisFrequent cavitationAir-fluid levels commonWall thickness <15 mmCT:spherical; central low-attenuation, rim enhancementMost common organisms: Anaerobic bacteria, Staph aureus, Pseudomonas aeruginosa
Active TBIncompletely treated
Localized multicystic lesionInfected BullaeCOPD Chronic debilitating illnessesDiabetes mellitusMalnutritionAlcoholismAdvanced ageCorticosteroid therapy, prolonged
COPD / anaerobic pneumonia
Differential Diagnosis:Lung abscessBronchiectasis with secondary infectionInfected bullaIntralobar sequestration
Case 4Localized multicystic lesion18-year old man with hemoptysis
Staphylococcus aureus3% of CAP15% of nosocomialIVDU, ICU patients
Imaging:Patchy unilateral 60%Bilateral 40%Abscess 15-30% Airspace nodules commonCentrilobular nodules, tree-in-bud
Staphylococcus aureus3% of CAP15% of nosocomialIVDU, ICU patients
Imaging:Patchy unilateral 60%Bilateral 40%Abscess 15-30% Airspace nodules commonCentrilobular nodules, tree-in-bud
Staphylococcus aureus3% of CAP15% of nosocomialIVDU, ICU patients
Imaging:Patchy unilateral 60%Bilateral 40%Abscess 15-30% Airspace nodules commonCentrilobular nodules, tree-in-bud
A college freshman after a recent drinking binge
Case 1
“Passed-out” flat…on his back (supine)
*
Superior segmentRight lower lobe
Aspiration Supine
Air-fluid level - equal length on orthogonal views
Lung Abscess with air-flluid levelRadiography
Air-fluid level - equal length on orthogonal views
Lung Abscess with air-flluid levelRadiography
Lung AbscessRadiographySphericalAir-fluid level
Equal length on orthogonal views
Does not compress lung
PA Lateral
Intralobar sequestrationILSThree faces:Homogeneous / heterogeneous irregular
consolidation / massAir-filled, air-fluid levels, cystsLower lobe, posterior basal segmentSystemic supply: Angiography, CT, MRIPulmonary drainage
Pulmonary SequestrationNo normal communication to tracheobronchial treeSystemic blood supplyIntralobar Sequestration (ILS)
Inside normal visceral pleuraExtralobar Sequestration (ELS)
Outside normal visceral pleuraILS:ELS 4:1
Pulmonary Sequestrations
• Intralobar Extralobar
Intralobar SequestrationClinical FeaturesMales = Females> 50% of patients over 20 years
Rare in infantsInfrequent associated anomalies
Cough, sputum, recurrent pneumoniaAsymptomatic
Intralobar SequestrationILS
Left sided 55-60%Lower lobe 98%
Systemic supplyT-Aorta 73%
Pulmonary Drainage 95%
Case 4
Diagnosis:Intralobar sequestration
Case 5Solitary lung cystAsymptomatic 42-year old man with abnormal CXR
Imaging findings:Solitary thin-walled cystic lesion in lingula
Case 5Solitary lung cystAsymptomatic 42-year old man with abnormal CXR
Differential Diagnosis:PneumatoceleCoccidioidomycosis (chronic)BullaCystic neoplasm
Case 5Solitary lung cystAsymptomatic 42-year old man with abnormal CXR
PneumatocelePost-smoke inhalation
PneumatocelePost-traumatic
PneumatocelePost-traumatic
Fell two stories
EmphysemaBullae
CoccidioidomycosisCoccidioides immitisEndemic: Southwestern USA, northern Mexico
CoccidioidomycosisCoccidioides immitisEndemic: Southwestern USA, northern MexicoImaging:Primary: single/multiple consolidationsChronic: SPN 1-3 cm10-15% cavitate: thick or thin-walled (“grape skin”)Lymphadenopathy (20%)Miliary disease (immunocompromised)
CoccidioidomycosisPrimary: consolidations / Chronic: SPN
1 month later 6 months later
CoccidioidomycosisChronic: SPN 1-3 cm
10-15% cavitate: thick or thin-walled (“grape skin”)
Case 5
Diagnosis:Coccidioidomycosis(chronic)
Case 6Diffuse multifocal cysts38-year old woman with cough
Case 6
Case 6
Imaging Findings:Multiple thin-walled cystsRandomly and diffusely distributed bilaterally
Case 6Diffuse multifocal cysts38-year old woman with cough
Differential Diagnosis:Pulmonary Langerhans cell histiocytosisLymphangioleiomyomatosis (LAM)Pneumocystis jiroveci pneumonia (severe)Emphysema
Case 6Diffuse multifocal cysts38-year old woman with cough
EmphysemaHRCTFocal areas of decreased opacityWith or without visible wallsCentrilobular - invisible walls. Upper lobesPanlobular - uniform destruction of
lobulesParaseptal - subpleural, single layer
EmphysemaCentrilobular
EmphysemaPanlobular
EmphysemaParaseptal
LymphangioleiomyomatosisLAM
Thin-walled cystsDiffuse distributionMild septal thickeningSmall nodules (uncommon)Pleural effusion
LymphangioleiomyomatosisLAM
LymphangioleiomyomatosisLAM
LymphangioleiomyomatosisLAM
Honeycombing EmphysemaLAM
Honeycombing EmphysemaLAM
LCH (EG)
Cystic variant
Case 6
Diagnosis:Lymphangioleiomyomatosis (LAM)
Tan-Lucien H. Mohammed, MD, FCCP
Section of Thoracic Radiology
Imaging Institute
Cleveland Clinic
ESSENTIALS OF RADIOLOGYCHEST: Cystic Lung Disease