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Cantin et al.
Bronchiectasis
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Residents Section
Pattern of the Month
Residents
inRadiology
Luce Cantin1
Alexander A. Bankier
Ronald L. Eisenberg
Cantin L, Bankier AA, Eisenberg RL
Bronchiectasis
Bronchiectasis is a relatively frequent condition in the United States, with an estimated
prevalence of 4.2 per 100,000 persons 1834 years old and 272 per 100,000 persons 75 years
or older. It is defined as an irreversible localized or diffuse dilatation, usually resulting from
chronic infection, proximal airway obstruction, or congenital bronchial abnormality. On
chest radiographs, bronchiectasis manifests as tram tracks, parallel line opacities, ring opacities, and tubular structures. However, chest radiographs lack sensitivity for detecting mild or
even moderate disease. CT is substantially more sensitive than chest radiography for showing
bronchiectasis, which is characterized by lack of bronchial tapering, bronchi visible in the
peripheral 1 cm of the lungs, and an increased bronchoarterial ratio producing the so-called
signet-ring sign. According to appearance and severity, bronchiectasis can be classified as
cylindric, varicose, or cystic (Fig. 1). The wide differential diagnosis of bronchiectasis can be
substantially narrowed by considering both the anatomic location and the distribution of this
pathology (Fig 2).
WEB
This is a Web exclusive article.
AJR 2009; 193:W158W171
0361803X/09/1933W158
American Roentgen Ray Society
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Bronchiectasis
Detection of bronchiectasis
Focal bronchiectasis
Upper lung
predominance
Cystic fibrosis
Sarcoidosis
Postradiation fibrosis
Diffuse bronchiectasis
Peripheral
predominance
Lower lung
predominance
Idiopathic
Postinfectious
Repeated aspiration
Fibrotic lung disease
Posttransplant rejection
Hypogammaglobulinemia
Central
predominance
Fig. 2Flowchart shows algorithm for evaluation of bronchiectasis. MAI = Mycobacterium avium-intracellulare.
Focal Bronchiectasis
Any cause of airway obstruction can lead to focal bronchiectasis (Fig. 3). In contrast to
diffuse bronchiectasis, focal bronchiectasis requires diagnostic bronchoscopy in almost all
patients.
Bronchial Atresia
The most common cause of congenital focal bronchiectasis is bronchial atresia, characterized by obliteration of a bronchus with distal bronchiectasis, mucoid impaction, and air trapping that is most commonly seen in the left upper lobe (Fig. 4). In this rare lesion, the bronchial tree peripheral to the point of obliteration is patent and the lung parenchyma is overinflated because of collateral air drift.
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Cantin et al.
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Fig. 3Focal
bronchiectasis
(idiopathic) in left lower
lobe (arrow).
Extrinsic Compression
Extrinsic compression is an acquired cause of focal bronchiectasis, most commonly caused
by lymphadenopathy, usually from previous granulomatous exposure. Less frequent causes
include sarcoidosis, hilar mass, and metastatic lymphadenopathy.
Endoluminal Obstruction by Tumor
Most carcinoid tumors are primarily endobronchial lesions, occurring in the central, main,
or segmental bronchi (Fig. 5). Some small tumors are located entirely within the lumen. How-
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Bronchiectasis
Fig. 5Carcinoid. This predominantly endobronchial tumor, arising before bifurcation of left upper and lower
lobe bronchi, causes distal bronchiectasis.
A and B, Transverse images of tumor (arrow, A) and distal bronchiectasis (arrows, B).
C and D, Coronal oblique image (C) and volume-rendering reformation (D) in similar orientation as A and B show
central carcinoid tumor (arrows) and distal bronchiectasis (arrowheads, C).
ever, some display a dominant extraluminal component with only a small part of the tumor
lying within the airway (iceberg lesion). A variety of other benign and malignant neoplasms
can also result in obstruction leading to focal bronchiectasis.
Foreign Body
Aspirated foreign material can result in focal bronchiectasis. Persistence of a noncalcified
foreign body, such as a vegetable fiber, within a bronchus for a prolonged period of time can
serve as a nidus for calcium deposition.
Broncholithiasis
Calcified or ossified material within the bronchial lumen can cause focal bronchiectasis.
By far the most common cause of broncholithiasis is erosion by and extrusion of a calcified
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Cantin et al.
Fig. 6Broncholithiasis.
AC, Calcified left upper lobe endobronchial
broncholithiasis (arrow) from previous tuberculosis
exposure is seen on transverse image (A), minimumintensity-projection reformation in coronal oblique
plane (B), and volume-rendering reformation (C)
in similar orientation. In C, arrow points to distal
bronchiectasis.
C
adjacent lymph node, usually associated with a long-standing focus of necrotizing granulomatous lymphadenitis, especially after tuberculosis (Fig. 6). Nevertheless, the frequency of
broncholithiasis complicating granulomatous infection is quite low. The most common sites
are the proximal right middle lobe bronchus and the origin of the anterior segmental bronchus
of the upper lobes because of airway anatomy and lymph node distribution.
Airway Stenosis
Airway stenosis causing focal bronchiectasis (Fig. 7) can result from a broad spectrum of
entities including infection, intubation stricture, healing of a tracheostomy stoma, tracheobronchopathia osteochondroplastica, amyloidosis, relapsing polychondritis, sarcoidosis, and
fibrosing mediastinitis.
Diffuse Bronchiectasis: Upper Predominance
Cystic Fibrosis
The most common cause of congenital upper-lung-predominant bronchiectasis is cystic
fibrosis, commonly associated with enlarged lung volumes and interstitial alterations (Fig. 8).
An autosomal recessive genetic disorder causing ineffective clearance of secretions, cystic
fibrosis presents with recurrent pneumonias, sinusitis, pancreatic insufficiency, and infertility.
Milder forms of cystic fibrosis, however, can remain unrecognized until adulthood (Fig. 9).
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Bronchiectasis
C
Fig. 7Congenital stenosis of left mainstem bronchus.
A and B, Transverse images show stenosis (arrow, A), distal bronchiectasis, and mucoid impaction (arrows, B).
C, Coronal reformation image shows bronchial stenosis (arrow).
Sarcoidosis
Parenchymal involvement by sarcoidosis can lead to upper and mid lung fibrosis and traction bronchiectasis, typically associated with multiple nodules in a perilymphatic distribution
(Fig. 10). Mediastinal and bilateral symmetric lymphadenopathy is common, although it can
regress as the interstitial disease worsens.
Postradiation Fibrosis
Another important cause of upper-lung-predominant bronchiectasis is postradiation fibrosis, in which traction bronchiectasis is usually limited to the radiation port (Fig. 11). A straight
interface between the irradiated field and normal lung is often seen. This does not respect
anatomic borders, such as fissures and lobes. Postradiation fibrosis may also be bilateral after
mediastinal radiation for lymphoma.
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Cantin et al.
A
Fig. 8Cystic fibrosis.
A and B, Transverse (A) and coronal (B) images show
upper lobe predominance of cystic bronchiectasis
(arrows) and volume loss, enlarged lung volumes, and
diffuse heterogeneous attenuation.
Fig. 9Adult cystic fibrosis. In this milder case, there is upper lobe predominance of cylindric bronchiectasis
(white arrows) and bronchiolitis (black arrows).
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Bronchiectasis
B
Fig. 10Sarcoidosis.
A and B, Transverse images show fibrosis and traction bronchiectasis (arrows, B) that predominantly involve
upper lobes.
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Cantin et al.
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Bronchiectasis
Fig. 13Scleroderma. There is patulous esophagus (white arrow), recurrent aspiration with subsequent
bibasilar bronchiectasis, and chronic ground-glass opacities. Black arrow points to bronchus visible in
peripheral 1 cm of lung.
Fig. 14Usual interstitial pneumonia. Bibasilar and subpleural reticulation and traction bronchiectasis are
seen in areas of fibrosis (arrows).
bibasilar distribution with geographic heterogeneity (Fig. 14). Although often idiopathic, UIP
occurs in asbestosis, drug toxicity, and collagenvascular disease. Nonspecific interstitial
pneumonia has almost the same differential diagnosis but typically occurs in younger patients
and carries a better prognosis. Ground-glass opacity is more frequent than in UIP and honeycombing usually remains minimal.
Rare Causes
Bronchiolitis obliterans from posttransplantation rejection is a rare cause of bronchiectasis
associated with patchy mosaic perfusion, air trapping, and bronchiolar obstruction (Fig. 15).
Hypogammaglobulinemia can also be a cause of lower-lung-predominant bronchiectasis,
most often caused by recurrent infections.
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Cantin et al.
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Bronchiectasis
B
AJR:193, September 2009
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Cantin et al.
B
Fig. 19Mounier-Kuhns syndrome.
A, Enlarged trachea (arrow).
B, Enlarged mainstem bronchi (black arrows) and distal bronchiectasis (white arrows).
Fig. 20Williams-Campbell syndrome. There is mostly varicose and cystic central bronchiectasis (arrows).
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Bronchiectasis
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