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