ecr2010_c-0850

of 28

Gammut of the lung cavity: Clinical and radiologic-pathologic correlation

Poster No.: C-0850Congress: ECR 2010Type: Educational ExhibitTopic: ChestAuthors: R. dos Santos, . Marques, N. Costa, H. Marques, O. Fernandes,

M. Passos Faria, Z. Seabra, L. Figueiredo; Lisbon/PTKeywords: cyst, cavity, lung cavitiesDOI: 10.1594/ecr2010/C-0850

Any information contained in this pdf file is automatically generated from digital materialsubmitted to EPOS by third parties in the form of scientific presentations. Referencesto any names, marks, products, or services of third parties or hypertext links to third-party sites or information are provided solely as a convenience to you and do not inany way constitute or imply ECR's endorsement, sponsorship or recommendation of thethird party, information, product or service. ECR is not responsible for the content ofthese pages and does not make any representations regarding the content or accuracyof material in this file.As per copyright regulations, any unauthorised use of the material or parts thereof aswell as commercial reproduction or multiple distribution by any traditional or electronicallybased reproduction/publication method ist strictly prohibited.You agree to defend, indemnify, and hold ECR harmless from and against any and allclaims, damages, costs, and expenses, including attorneys' fees, arising from or relatedto your use of these pages.Please note: Links to movies, ppt slideshows and any other multimedia files are notavailable in the pdf version of presentations.www.myESR.org

of 28

Learning objectives

To present a pictorial review of the wide spectrum of pathologies that maytypically or occasionally present as a lung cavity. To describe the imagingcharacteristics that help distinguishing these lesions, along with a clinicaland pathological correlation.

Background

Cavitated lung lesions are frequently encountered in clinical practice.Although some lesions are benign and uncomplicated, others may bemalignant.

Computed Tomography provides excellent characterization of these lesionsand when combined with the clinical setting, can help narrow the differentialdiagnosis or even provide a specific diagnosis, thus optimizing treatmentand obviating unnecessary interventions.

Imaging findings OR Procedure details

In 2008, members of the Fleischner Society compiled a glossary of terms for thoracicimaging, some of which are presented below1.

of 28

Fig.: Glossary of Terms - BlebReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Glossary of Terms - BullaeReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Glossary of Terms - CystReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Glossary of Terms - CavityReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Glossary of Terms - Air CrescentReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Glossary of Terms - PneumatoceleReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Glossary of Terms - BronchiectasisReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

Cysts and cavities are commonly encountered lesions in the lung. The differentialdiagnosis is broad because many different processes can originate these abnormalities2.Besides the patient's history, the clinical and analytical data, along with the imagingsemiology contribute to the narrow the differential diagnosis.

Different pathophysiologies have been proposed to the development of cystic airspaces, including vascular occlusion or ischaemic necrosis (pulmonary infarction),bronchial dilatation, destruction of the elastic fibre network of the lung, remodelling withretractile interstitial fibrosis, partial bronchiolar obstruction resulting in a ''ball valve''effect, suppurative necrosis (e.g., pyogenic lung abscess), caseous necrosis (e.g.,tuberculosis), or a combination of the above factors 3,4.

of 28

This wide spectrum of pathologies can be grouped in a simple mnemonic - "CAVITY",which stands for: Cysts/Cancer, Auto-immune, Vascular, Infectious, Traumatic andYoung/congenital 5.

Fig.: "CAVITY" - a helpful mnemonicReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Bleb, Bullae, Centrilobular and Paraseptal EmphysemaReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

BULLOUS EMPHYSEMA1

Gas-containing areas (1 to several cm), without a wall. Increased risk for pneumothorax.

Subpleural and upper lobe predominance, assymmetrical.

Central dot sign.

LYMPHANGIOMYOMATOSIS2,3

Round, thin-walled cysts in a diffuse distribution, uniformly scattered, between 2 mmand 2 cm, with no sparing of any particular areas in the lung.

Increased risk for pneumothorax. Chylous effusion.

of 28

Almost exclusive of female patients; Associated to Tuberous Sclerosis.

LANGERHANS CELLS HYSTIOCYTOSIS2,3

Irregular cysts qith thin or thick wall, mostly smaller than 10mm.

Centrilobular nodules (may cavitate) Upper lobe predominance; does not affect the costo-phrenic angles.

Progression for honeycombing.

Affects men and women equally.

Middle-age smokers.

Fig.: Cystic Bronchiectasis, in Cystic FibrosisReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

CYSTIC BRONCHIECTASIS2

Group of thin-walled cysts. Signet ring sign.

Air-fluid levels (mucous retention / infection) Childhood: Cystic Fibrosis. Adulthood: Allergic broncho-pulmonary aspergillosis. Otherrarer causes (Kartagener syndrome)

PULMONARY FIBROSIS 2

Several layers of irregular cysts (3 a 10 mm). Well defined, irregular wall, 1-3 mm.

Subpleural and peripheral, lower lobe predominance.

The wall is shared between adjacent cysts.

LUNG CANCER4

The hystologic type of lung cancer that most commonly courses with acavitation is the epidermoid carcinoma.

The presence of A cavitation in a lung tumor has been associated with aworse prognosis.

Other primary tumors in the lung, such as lymphoma and Kaposi's sarcoma,may also present with cavitary lesions, particularly among persons infectedwith human immunodeficiency virus.

of 28

Fig.: Epidermoid CarcinomaReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Lung AdenocarcinomaReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Cavitated metastasesReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

CAVITATED METASTASES3

Metastatic squamous cell carcinoma accounts for two-thirds of cases ofcvitated metastases.

of 28

Fig.: Wegenner's GranulomatosisReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

WEGENNER'S GRANULOMATOSIS3

Thick and irregular walled cavitated nodules.

Patchy Ground glass consolidations and multiple nodules (a few mm to 10 cm). Other auto-immune disorders which course with cavitated nodules include RheumatoidArthritis (necrobiotic nodules) and Systemic Lupus Erythemathosus.

of 28

Fig.: Septic EmboliReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

EMBOLI4

Poorly defined cavities, several stages.

Irregular inner wall.

Peripheral, lower lobe predominance. A feeding vessel may be seen.

of 28

Fig.: Angioinvasive Pulmonary AspergillosisReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

ANGIOINVASIVE PULMONARY ASPERGILLOSIS3

Deeply immunocompromised patients, usually in the setting of hematological disorders.

Febrile neutropenia.

Halo sign: (alveolar perinodular hemorrhage) Air crescent sign: cavitation (15 days after the halo sign - neutrophil count recovery).

of 28

Fig.: Pulmonary Tuberculosis - cavity and endobronchic disseminationReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

PULMONARY TUBERCULOSIS3

Cavitation is the hallmark of post-primary pulmonary tuberculosis and isseen in up to 50% of patients. There is reactivation of a previous tuberculousinfection, usually following a period of immunodepression.

Segmental consolidation is seen in the apical and posterior segments of theupper lobes and also in the apical segments of the lower lobes. Single ormultiple cavities can develop.

"Tree in bud" opacities and centrilobular nodules can also be present,representing airway dissemination of the disease. Hilar and mediastinaladenopathy in post-primary tuberculosis is uncommon.

of 28

Fig.: Pulmonary abscess in a childReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

of 28

Fig.: Pulmonary abscess in a diabetic patient.References: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

LUNG ABSCESS4

Most patients have one or more predisposing risk factors, includingalcoholism, diabetes, poor dentition, a prior history of aspiration andunderlying lung damage from other processes.

The predominant organisms responsible for lung abscess in both adults andchildren are anaerobic and microaerophilic components of the oral flora, andlung abscesses are frequently polymicrobial.

of 28

Fig.: Necrotizing pneumonia in a 72 year-old ventilated patient, who died 16 dayslater.References: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

NECROTIZING PNEUMONIA2,4

Tend to cause cavitary lesions (thick walled) rather than cysts. Because S. pneumoniae and H. influ- enzae are such common causes of

pneumonia, these pathogens may cause a significant fraction of cavitarypneumonias, even though cavitation is relatively rare with these pathogens.

Klebsiella pneumoniae is a common cause of severe, necrotizingpneumonia. Alcoholism and smoking have been considered important riskfactors for community-acquired Klebsiella pneumonia, and hospitalizationhas recently been also regarded as a risk factor.

of 28

Fig.: Post-traumatic pneumatocelesReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

PNEUMATOCELES2

Irregular, thin walled airspaces.

Central and upper lobe predominance.

Usually in a post-traumatic pulmonary laceration context, or infection (Staphylococcosaureus and Pneumocystis jirovecii). Usually transient.

Very similar to cysts.

of 28

Fig.: Congenital cystic adenomatoid malformationReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

CYSTIC ADENOMATOID MALFORMATION2

Cystic or solid lung masses restricted to part of one lung. Can present with respiratory distress or compromise during infancy or with

recurrent pneumonias in later years. Typically, chest radiography reveals multiple air-filled thin-walled cysts of

varying sizes.

of 28

Fig.: Hiatus herniaReferences: R. dos Santos; Radiology, Hospital de Santo Antnio dos Capuchos;CHLC, Lisbon, PORTUGAL

Diaphragmatic hernias include esophageal hiatus hernias, Bochdalek(usually posterior, left paravertebral ) and Morgagni (usually anterior, rightparavertebral) hernias.

Conclusion

This presentation will help the readers to provide clinicians with the relevantdifferential diagnoses when confronted with a cavitated lesion of the lung.

of 28

Personal Information

Rosana dos Santos; Radiology Resident

[email protected]

Lisbon

Portugal

References

1. Hansell D, Bankier A, MacMahon H, McLoud T, Mu #ller N, Remy J. Fleischner Society:Glossary of Terms for Thoracic Imaging. Radiology.2008; 246 (3):697-722.

2. Ryu J, Swensen S. Cystic and Cavitary Lung Diseases: Focal and Diffuse.

Mayo Clin Proc. 2003;78:744-752

3. Granta LA, Babara J, Griffinb N. Cysts, cavities, and honeycombing in multisystemdisorders: differential diagnosis and findings on thin-section CT.

Clinical Radiology (2009) 64, 439e448.

4. Gadkowski L, Stout J. Cavitary Pulmonary Disease. CLINICAL MICROBIOLOGYREVIEWS, Apr. 2008, p. 305-333

5. Gaillard F., in Radiopedia.org. May2008

ecr2010_c-0850

Documents

dos santos radiology

glossary of terms

santo antnio dos capuchoschlc

lung cavity

lung cavitiesdoi

pdf file

clinical practice

clinical setting