1. Holes in the lung
Dr. Ahmed Refaey, FRCR

2. References
Cystic & cavitary lung diseases. Mayo clinic proceeding 2003;744752
HRCT , W.Richard webb, UCSF interactive radiology series
Radiology review manual. Wolfgang Dahnert
Diagnostic imaging , Chest , Gurney et al
James reed in chest imaging
Diffuse lung diseases. Prof. Mamdouh Mahfouz

4. Holes in the lung Cyst - thin walled ( 1-3 mm) - alone or in groups
Cavity
- represents areas of tissue necrosis & clearing within areas of parenchymal opacification.
- thick walled ( > 3 mm )
- suggests a more aggressive pathology
than a cyst.

5. Holes in the lung Focal * cyst * cavity Diffuse
Lymphangioleiomyomatosis
Tuberous sclerosis
L.C.Histeocytosis
Honeycombing disease
Emphysema

6. Focal holes in the lung Cyst Cavity * Congenital --- - Br. Cyst - CCAM
* Bleb
* Bulla
* Pneumatocele
* Infection---hydatid
-coccidioidomycosis
-PCP
Cavity
* neoplastic –Br. Ca
- metastasis
- lymphoma
* infection bacteria
- fungal
- parasites
* immunologic
- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis

7. In cystic lesions, benign nature is often be assumed, while cavitary lesions usually suggest more aggressive pathology.

8. Woodring et al studied the diagnostic implications of cavitary wall thickness
1 mm all benign
< 4mm % benign
5-15 mm equally divided
> 15 mm % malignant

9. Focal cystic lung disease
Congenital
* bronchogenic cyst
* CCAM ( cystic adenomatoid malformation )
Bulla
Bleb
Pneumatocele
Infection
* coccidioidomycosis
* PCP
* hydatid disease

10. Bronchogenic cyst * 2/3 in mediastinum
* 1/3 in lung parenchyma, usually near hilum
* may contain air, fluid or both

12. Congenital cystic adenomatoid malformation ( CCAM )
* air , fluid , or air-fluid containing cysts of varying sizes
* 3 types are recognized based on cyst size & number
- type or more large cysts(2-10cm)
- type 2---neumerous small cysts
- type 3 – solid with microcysts

14. Bulla * intraparenchymal, more than 1 cm.
* result from coalescence of emphsematous spaces or from a Ball-valve type of air-way obstruction.

16. Bleb
* usually located in the apex of lung within the pleura

17. Pneumatocele
typically associated with infection, particularly staph. Pneumonia in children
characteristically increase in size over time.
probably due to Ball-valve air-trapping.
resolves eventually.
May reach a large size to fill the hemi- thorax

20. Infections * { coccidioidomycosis } * { PCP } * { hydatid disease }
Most of the other infections
of the lung tend to cause cavitary lesion.

21. Coccidioidomycosis
* endemic in southwestern United States and Mexico.

22. Pneumocytis carnii pneumonia PCP
* in immunocompromised patients
* upper lobar predilection
* pneumothorax 35%

24. Hydatid disease
* endemic in sheep-raising areas of Mediterranean basin
* solitary in 75%, multiple in 25%
* water density
* rare calcify
* complications:
rupture between layers of cyst—meniscus or halo sign
ruptue into bronchus—water lilly sign
rupture into pleura---hydropneumothorax

31. Focal holes in the lung Cyst Cavity * Congenital --- - Br. Cyst - CCAM
* Bleb
* Bulla
* Pneumatocele
* Infection---hydatid
-coccidioidomycosis
-PCP
Cavity
* neoplastic –Br. Ca
- metastasis
- lymphoma
* infection bacteria
- fungal
- parasites
* immunologic
- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis

32. Focal cavitary lung lesions
* neoplastic – - Br. Ca
- metastasis
- lymphoma
* infection bacteria
- fungal
- parasites
* immunologic
wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis

33. Neoplastic lesions
Bronchogenic carcinoma
Lymphoma
Metastasis

34. Bronchogenic carcinoma (squamous cell type)

35. Squamous cell
carcinoma

37. Infection
* bacterial
* fungal
* parasites

40. Immunologic
* Wegener’s granuloma
* Rheumatoid nodules

41. Septic emboli Significant febrile illness
Multifocal, peripheral location
Increase incidence of cavitation

42. Bronchiectasis Cystic structures continuous with broncheal tree.
Signet ring sign

43. Cavity We have to look at: * wall thickness * contents ------- air
air-fluid level
air with soft tissue mass.
* relation to broncheal tree

44. Wall thickness : more than 4 mm
Contents
* only air : regularity of the inner margin
- if regular……chronic lung abscess
- if irregular ….cavitating tumor
* air-fluid level:
- if fluid level is straight…acute lung abscess
- if fluid level is wavy ….ruptured hydatid cyst
* contents of the cavity
-if inner wall is smooth with soft tissue
inside….mycetoma
-if inner wall is irregular with soft tissue
mass..necrotic tumor

45. Cavity containing only air
* regularity of inner margin
- if regular ---ch. Lung abscess
- if irregular---cavitating tumor

46. Cavity with air-fluid level
- if fluid level is straight---
----- acute lung abscess
- if fluid level is wavy -----
-----ruptured hydatid cyst

47. Cavity with mass inside
- if inner wall is smooth---
mycetoma
- if inner wall is nodular –
necrotic tumor

49. Abscess vs hydatid

50. Hydatid vs abscess vs necrotic tumor

53. Focal holes in the lung Cyst Cavity * Congenital --- - Br. Cyst - CCAM
* Bleb
* Bulla
* Pneumatocele
* Infection---hydatid
-coccidioidomycosis
-PCP
Cavity
* neoplastic –Br. Ca
- metastasis
- lymphoma
* infection bacteria
- fungal
- parasites
* immunologic
- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis

54. Diffuse holes in the lung
Lymphangioleiomyomatosis
Tuberous sclerosis
L.C.Histiocytosis
Honeycombing disease
Emphysema

55. Lymphangioleiomyomatosis (LAM )
Proliferation of smooth muscles in lung interstitium
Hyperinflated lung
Widespread thin wall cysts
No nodules
Diffuse lung involvement
Complicated by pneumothorax (40%) & chylothothorax (60%)
Only in females
All patients die within 10 years.

59. Tuberous sclerosis * autosomal dominant
* pulmonary changes seen almost exclusively only in females in 3rd-4th decades
* changes similar to LAM except chylous effusion

60. L.C.Histeocytosis Histeocytes proliferation Widespread cyts & nodules
Cysts are irregular in shapes (bizzare, bilobed, leaf like ),
more numerous in apices, sparing costo-pherenic angles
Lung volume is preserved
>90% Smokers, middle age , men
Spontaneous pneumothorax in 15%

62. Honeycombing disease
Indicates “end stage “ lung and can be seen in any process leading to severe pulmonary fibrosis
Adjacent small cysts , 1-3 mm, typically share walls
Predominate in lower lobes, peripheral & subpleural lung regions
Typically occur in several contiguous layers

63. 60% due IPF
Other causes:
- autoimmune disease
like scleroderma & RA
- hypersensitivity
pneumonitis
- drug reactions
- asbestosis

65. Emphysema
Perminant, abnormal,enlargement of airspaces distal to the terminal bronchioles, accompanied by destruction of walls of the involved airspaces
3 types:
- centrilobular emphysema
- panlobular emphysema
- paraseptal emphysema

66. Centrilobular emphysema
The more commoner
Usually results from cigarette smoking
Mainly involves upper lobes
Multiple, small, lucencies, lack visible walls
centrilobular distributd (grouped near the center of 2ry pulmonary lobules), surrounding the centrilobular artery

69. Panlolobular ( panacinar) emphysema
Uniform destruction of pulmonary lobule
diffuse or more severe in lower lung
Pulmonary vessels in affected lung appear smaller and fewer than normal
No focal lucincies can be seen

70. Paraseptal emphysema
More stricking in subpleural location, arranged in single layer
Often have visible very thin walls
Can be an isolated phenomenon
Can be associated with centrilobular emphysema
When larger than 1cm , are termed as bulla

71. Paraseptal emphysema, Centrilobular emphysema and bulla can coexist together while panlobular emphysema is usually not associated with paraseptal emphysema or bulla .

73. Paraseptal emphysema vs honeycombing

74. Conclusion

75. Holes in the lung Focal * cyst * cavity Diffuse
Lymphangioleiomyomatosis
Tuberous sclerosis
L.C.Histeocytosis
Honeycombing disease
Emphysema

76. Focal holes in the lung Cyst Cavity * Congenital --- - Br. Cyst - CCAM
* Bleb
* Bulla
* Pneumatocele
* Infection---hydatid
-coccidioidomycosis
-PCP
Cavity
* neoplastic –Br. Ca
- metastasis
- lymphoma
* infection bacteria
- fungal
- parasites
* immunologic
- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis

77. In cystic lesions, benign nature is often be assumed, while cavitary lesions usually suggest more aggressive pathology.
Other forms of focal pulmonary cysts may be seen in adults outside these clinical sittings, and are of obscure origin but are thaught to be related to smoking.

78. Thank you