Holes in the lung Dr. Ahmed Refaey, FRCR

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 www.Radiologyassistant.nl/images

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.

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

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

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

Woodring et al studied the diagnostic implications of cavitary wall thickness 1 mm ----------------- all benign < 4mm --------------- 92% benign 5-15 mm ------------ equally divided > 15 mm ------------ 95% malignant

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

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

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 1---1 or more large cysts(2-10cm) - type 2---neumerous small cysts - type 3 – solid with microcysts

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

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

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

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

Coccidioidomycosis * endemic in southwestern United States and Mexico.

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

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

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

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

Neoplastic lesions Bronchogenic carcinoma Lymphoma Metastasis

Bronchogenic carcinoma (squamous cell type)

Squamous cell carcinoma

Infection * bacterial * fungal * parasites

Immunologic * Wegener’s granuloma * Rheumatoid nodules

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

Bronchiectasis Cystic structures continuous with broncheal tree. Signet ring sign

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

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

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

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

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

Abscess vs hydatid

Hydatid vs abscess vs necrotic tumor

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

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

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.

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

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%

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

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

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

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

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

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

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

Paraseptal emphysema vs honeycombing

Conclusion

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

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

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.

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