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EDUCATION EXHIBIT 1369

Mucoid Impactions:
Finger-in-Glove Sign
and Other CT and Ra-
diographic Features1
CME FEATURE
Santiago Martinez, MD • Laura E. Heyneman, MD • H. Page McAdams,
See accompanying
test at http://
MD • Santiago E. Rossi, MD • Carlos S. Restrepo, MD • Andres Eraso, MD
www.rsna.org
/education
/rg_cme.html Mucoid impaction is a relatively common finding at chest radiogra-
phy and computed tomography (CT). Both congenital and acquired
LEARNING abnormalities may cause mucoid impaction of the large airways that
OBJECTIVES
FOR TEST 4
often manifests as tubular opacities known as the finger-in-glove sign.
After reading this
The congenital conditions in which this sign most often appears are
article and taking segmental bronchial atresia and cystic fibrosis. The sign also may be
the test, the reader
will be able to:
observed in many acquired conditions, include inflammatory and
■■Recognize com- infectious diseases (allergic bronchopulmonary aspergillosis, bron-
mon and uncom- cholithiasis, and foreign body aspiration), benign neoplastic processes
mon causes of mu-
coid impaction. (bronchial hamartoma, lipoma, and papillomatosis), and malignancies
■■Describe the (bronchogenic carcinoma, carcinoid tumor, and metastases). To point
most frequent ra- to the correct diagnosis, the radiologist must be familiar with the key
diographic and CT
manifestations of radiographic and CT features that enable differentiation among the
each disorder. various likely causes. CT is more useful than chest radiography for dif-
■■Discuss other an-
cillary findings com-
ferentiating between mucoid impaction and other disease processes,
monly seen in each such as arteriovenous malformation, and for directing further diagnos-
disorder.
tic evaluation. In addition, knowledge of the patient’s medical history,
clinical symptoms and signs, and predisposing factors is important.
TEACHING ©
RSNA, 2008 • radiographics.rsnajnls.org
POINTS
See last page

Abbreviations: ABPA = allergic bronchopulmonary aspergillosis, PA = posteroanterior

RadioGraphics 2008; 28:1369–1382 • Published online 10.1148/rg.285075212 • Content Codes:


1
From the Department of Radiology, Box 3808, Duke University Medical Center, Erwin Rd, Durham NC 27710 (S.M., L.E.H., H.P.M.); Depart-
ment of Radiology, Centro de Diagnóstico Dr. Enrique Rossi, Buenos Aires, Argentina (S.E.R.); Department of Radiology, University of Texas
Health Science Center at San Antonio, San Antonio, Tex (C.S.R.); and Department of Radiology, U.S. Department of Veterans Affairs Medical Cen-
ter, Washington, DC (A.E.). Presented as an education exhibit at the 2006 RSNA Annual Meeting. Received November 12, 2007; revision requested
January 11, 2008; final revision received March 26; accepted April 7. H.P.M. received funding from General Electric Company and owns stock in Bos-
ton Scientific; remaining authors have no financial relationships to disclose. Address correspondence to S.M. (e-mail: santiago.martinez@duke.edu).
©
RSNA, 2008
1370  September-October 2008 RG  ■  Volume 28  •  Number 5

Introduction Table 1
Mucoid impaction is a relatively common finding Causes of Obstructive and Nonobstructive
at chest radiography and computed tomography Mucoid Impactions
(CT) and is associated with a wide variety of dis- Congenital
eases. The disease processes that may cause mu- Segmental bronchial atresia
coid impaction have been variously categorized Cystic fibrosis
as obstructive versus nonobstructive (1) or con- Inflammatory-infectious
genital versus acquired. We have used a hybrid ABPA in asthma or cystic fibrosis*
approach to classification that is based both on Broncholithiasis
the origin (congenital or acquired) and the nature Foreign body aspiration
Neoplastic
(inflammatory, infectious, or neoplastic) of the
Benign
specific disease process (Table 1).   Bronchial hamartoma
The radiographic appearance of mucoid   Lipoma
impaction is variable. In the large airways, the   Papillomatosis
condition is classically manifested by tubular or Malignant
branching opacities that resemble fingers—the   Bronchogenic carcinoma
so-called finger-in-glove sign (Fig 1). However,   Carcinoid tumor
atypical appearances, such as ovoid opacities, also   Metastases
are common. It therefore may be difficult to dif- Note.—Segmental bronchial atresia, cystic fibrosis,
ferentiate mucoid impactions from other causes ABPA, foreign body aspiration, and bronchogenic
of tubular opacities, such as arteriovenous mal- carcinoma are common.
*ABPA = allergic bronchopulmonary aspergillosis.
formations, on the basis of radiographic features.
CT is particularly well suited for differentiating
mucoid impaction from arteriovenous malforma-
tions. In cases of mucoid impaction, CT images (4). The clinical, radiologic, and microbiologic
clearly show characteristic features such as bron- data in these reports suggest that these patients
chiectasis, low-attenuation mucus inspissated in presented with what today would be diagnosed as
the bronchi, and clear connection with the cen- ABPA.
tral airways. Multiplanar reformatted images also
may be of benefit for showing these characteristic Definition of Mucoid Impaction
findings. In the presence of an arteriovenous Mucoid impaction is defined as airway filling by
malformation, on the other hand, CT images mucoid secretions. If the affected airway is large
show a nidus with efferent and afferent vessels. If or dilated (as in bronchiectasis), the secretions Teaching
Point
necessary, iodinated contrast material may be ad- may be depicted on chest radiographs or CT
ministered to aid in the differentiation of unusual images as tubular or branching opacities. These
arteriovenous malformations from mucoid im- opacities, which typically radiate from the hilum
pactions. In addition, the CT appearance may be toward the periphery of the lung, are classically
suggestive of a particular disease process and may described as the finger-in-glove sign (1). When
help direct further diagnostic evaluation. mucus and other secretions are retained in bron-
The term finger in glove (or gloved finger) was chioles and nondilated airways, the radiographic
initially used by Mintzer et al in 1978 to describe appearance typically is normal; any abnormal fea-
a case of ABPA (2). However, the clinical and tures may be subtle and easily overlooked. How-
radiologic findings of mucoid impaction were ever, even in these cases, thin-section chest CT
known for many years before this observation may depict branching and tree-in-bud opacities
was published. In 1951, Shaw described dilated (5–10). The possible causes of the tree-in-bud
bronchi filled with inspissated mucus in five pa- pattern are well described elsewhere (8). The em-
tients who presented with wheezing, cough, and phasis in this article is instead on the differential
a history of allergy (3). In 1957, Greer used the diagnosis of mucoid impactions represented by
descriptive term cluster of grapes to refer to the tubular, branching, and ovoid opacities on ra-
radiographic appearance of mucoid impactions diographic and CT images. The possible causes
in several patients with similar clinical histories of such impaction are outlined, and the clinical,
radiographic, and CT manifestations that provide
evidence of a particular disease process are de-
scribed in detail (Table 2).
RG  ■  Volume 28  •  Number 5 Martinez et al  1371

Figure 1.  Finger-


in-glove sign in a
case of ABPA. Pos-
teroanterior (PA)
radiograph (left) de-
picts a homogeneous
branching opacity
that radiates from the
left hilum, a feature
perhaps more easily
discerned with the
aid of a superimposed
contour line (right).

Table 2
Clues to the Cause of Mucoid Impactions

Occurrence
of Finger-in- Radiographic
Pathologic Entity Glove Sign Clinical Findings Features CT Features
Segmental bron- Common Asymptomatic or Lobular, ovoid, Hyperlucency of surround-
chial atresia recurrent infection round, or branch- ing lung parenchyma
ing opacity from air trapping and
oligemia
Cystic fibrosis Uncommon Chronic or recurrent Diffuse bronchiecta- Diffuse bronchiectasis,
infection sis (“tramlines”), mucoid impactions
hyperinflation
ABPA Common Wheezing, expecto- Classic glove-in- Hyperattenuating mucoid
ration of brown finger sign impaction
mucous plugs
Broncholithiasis Uncommon Cough, hemoptysis, Atelectasis or Mucoid impaction distal to
recurrent infection, obstructive pneu- intrabronchial calcifica-
lithoptysis monia tion
Foreign body Uncommon Cough, dyspnea, Atelectasis or Mucoid impaction distal to
recurrent pneumo- obstructive pneu- intrabronchial calcifica-
nia, hemoptysis monia tion
Lipoma Uncommon Hemoptysis Atelectasis or Obstructive mass with fatty
obstructive pneu- attenuation
monia
Hamartoma Uncommon Recurrent infection Atelectasis or Obstructive mass with
obstructive pneu- coarse calcification, fatty
monia attenuation, or both
Papillomatosis Uncommon Hoarseness, stridor, Cavitary nodules Cavitary nodules
respiratory distress
Carcinoid tumor Uncommon Cough, fever, expec- Hilar or perihilar Endobronchial component,
toration, wheezing, mass, atelectasis enhancement
hemoptysis, chest
pain
Bronchogenic Uncommon Cough, dyspnea, Mass Mass
carcinoma hemoptysis
Metastasis Uncommon Cough, wheezing, Atelectasis Endobronchial nodule
hemoptysis
1372  September-October 2008 RG  ■  Volume 28  •  Number 5

Figure 2.  Segmental bronchial atresia with superinfection by Aspergillus fumigatus in an asymptomatic
45-year-old man. (a) Preoperative PA radiograph depicts a branching opacity (arrows) in the right upper lung
lobe. (b) Axial CT image obtained with a soft-tissue window shows a tubular opacity with attenuation of 21
HU, a finding indicative of a mucoid impaction. (c) Axial CT images obtained at various levels (lung win-
dows) demonstrate a tubular opacity with adjacent regions of variable lucency (*) suggestive of air trapping
and oligemia in the surrounding lung parenchyma. The lesion increased in size over the course of 1 year and
was surgically excised. The diagnosis was obtained at pathologic analysis.

Congenital Conditions average age at diagnosis is 17 years. Most cases


are asymptomatic and detected incidentally at
Segmental Bronchial Atresia chest radiography or CT. In an estimated 20% of
This anomaly results from the interruption of cases, segmental bronchial atresia causes recur-
the origin of a segmental bronchus. The ultimate rent infection, which is manifested radiologically
cause is not fully understood, and the abnormal- as consolidation and, occasionally, as an enlarg-
ity might result from intrauterine ischemia of ing nodule or mass that mimics the growth of
the bronchial wall, abnormal separation of the a neoplasm such as bronchogenic carcinoma.
bronchial bud from the bud remnant, or both. Radiographic and CT features include a peri-
Ultimately, dilatation of the central bronchi distal hilar mass, which may be lobular, ovoid, round,
to the atretic segment, and mucoid accumula- or branching. CT better depicts the associated
tion (also known as a mucocele or bronchocele), features: hyperlucency of the surrounding lung
occur. Segmental bronchial atresia is more com- parenchyma because of air trapping, and oligemia
mon in the apicoposterior segment of the left from hypoperfusion (11,12) (Fig 2).
upper lobe and segmental bronchi of the right
upper lobe. Male predominance is 2:1, and the Bronchiectasis
Bronchiectasis is a common cause of mucoid
impactions observed on chest radiographs and
RG  ■  Volume 28  •  Number 5 Martinez et al  1373

Figure 3.  Bronchiectasis and mucoid impactions in a 28-year-old man with a previous diagnosis of cystic fibro-
sis. (a) PA radiograph shows multiple nodular and branching opacities with upper lobe predominance (arrows).
(b) Axial CT image obtained with a lung window shows central bronchiectasis and distal mucoid impactions in the
right lung (arrows).

CT images. Its etiology includes cystic fibrosis, ings are bronchiolar impaction (centrilobular and
immunodeficiencies, aspiration of foreign ob- tree-in-bud opacities), atelectasis, consolidation,
jects, and ciliary dyskinesia. Bronchial dilatation emphysema, abscess, and bullae (14,15). In a
is represented on chest radiographs by irregular recent study, it was demonstrated that CT has
peripheral opacities in association with the classic advantages over pulmonary function testing and
linear opacities described as tramlines. Although clinical scoring for the detection of pulmonary
CT is superior in depicting small mucous plugs changes over time, particularly when mucous
inside the airways, it is rarely required for confir- plugs, bronchiectasis, and mosaic perfusion are
mation (13). present (16,17).
Cystic fibrosis, a common disease among
Caucasians, results from a defective chlorine ion Acquired Inflammatory
channel that originates in a mutation of chromo- and Infectious Diseases
some 7. This disease causes the production of
thick mucoid secretions that are difficult to clear Allergic Broncho-
from the airways. The secretions accumulate over pulmonary Aspergillosis
time, leading to mucoid plugs and, eventually, su- ABPA is a hypersensitivity reaction to A fumiga-
perimposed infection. The elicited inflammatory tus antigens that are typically seen in patients
response damages the normal structure of the with long-standing asthma or cystic fibrosis.
airways, and bronchiectasis develops. Clinically, While the pathophysiology is complex and not
cystic fibrosis is characterized by mucopurulent fully understood, type I and III hypersensitivity
sputum production, recurrent infection, wheez- reactions as well as cellular immunity seem to
ing, dyspnea, and hemoptysis. Radiographic find- play an important role in the development of the
ings include hyperinflation, mucoid impactions,
and bronchiectasis. Frequent CT findings include
bronchiectasis, peribronchial thickening, mosaic
perfusion, and mucous plugs (Fig 3). Other find-
1374  September-October 2008 RG  ■  Volume 28  •  Number 5

Figure 4.  ABPA in a 40-year-old man with chest pain, cough, and low-grade fever. (a) PA radiograph shows a
nodular opacity (arrow) in the right upper lobe. (b) Axial CT images obtained with lung (right) and soft-tissue (left)
windows depict a hyperattenuating (approximately 75 HU) nodular feature within the bronchus (arrow at right), a
feature that represents a mucoid impaction. The diagnosis was pathologically proved after surgical resection.

Figure 5.  Bronchocentric granu-


lomatosis in a 35-year-old man with
ABPA and a longstanding history of
asthma. (a) PA radiograph shows con-
solidation of the right upper lobe.
(b) Axial CT images obtained with a
soft-tissue window depict opacifica-
tion of the right upper lobe and several
hyperattenuating tubular mucoid im-
pactions (*) in dilated bronchi. The di-
agnosis was based on pathologic analy-
sis of an open lung biopsy specimen.
RG  ■  Volume 28  •  Number 5 Martinez et al  1375

Figure 6.  Broncholith in a 42-year-


old man with acute cough, chest pain,
and hemoptysis. Axial CT images
obtained with lung (a) and soft-tis-
sue (b) windows show a calcification
(arrow) in the right lower lobe. The
intrabronchial location of the calci-
fication is clearly visible in a, which
also shows a distal mucoid impaction
of nondilated bronchus abutting the
pulmonary artery (circles, oval).

disease. Pathologically, ABPA is characterized by may be seen on chest radiographs and CT images
bronchocentric granulomas within both bronchi include atelectasis, consolidation, and air trap-
Teaching and bronchioles, with associated mucoid impac- ping (20,24).
Point tions. Bronchiectasis, mainly in the upper lobes,
is a hallmark of the disease. Fungal hyphae are Broncholithiasis and
frequently seen without evidence of tissue inva- Foreign Body Aspiration
sion. Clinical manifestations include wheezing, Broncholithiasis is usually caused by the extru-
expectoration of brown mucous plugs, pleuritic sion of a calcified peribronchial lymph node into
chest pain, and fever. Early in the course of dis- a bronchial lumen, a condition often seen in
ease, chest radiographs usually show fleeting al- granulomatous infections such as tuberculosis
veolar opacities. In a more chronic disease setting and histoplasmosis. The phenomenon leads to
in which there is bronchial wall damage, inspis- bronchial obstruction, with resultant radiographic
sated secretions within a central region of bron- findings that may include atelectasis, mucoid
chiectasis are manifested as the finger-in-glove impaction, bronchiectasis, and air trapping. The
sign (18,19) (Figs 1, 4). The disease may progress detection of the actual calcification on a chest
to pulmonary fibrosis. CT may help detect early radiograph is uncommon; however, if serial ra-
bronchiectasis and may help more accurately diographs are available, changes in the location of
monitor progression (20). In a study performed a central calcification may be detected. CT, with
in patients with asthma, findings highly sugges- better spatial resolution, may help identify the lo-
tive of ABPA included bronchiectasis affecting cation of a calcification as the bronchus and help
three or more lobes, centrilobular nodules, and distinguish a broncholith from a peribronchial
mucoid impactions (21). In another study, images calcified lymph node. CT images also may show
obtained in approximately 25% of patients with other associated features, such as atelectasis, ob-
mucoid impactions showed high-attenuation mu- structive pneumonia, bronchiectasis, and mucoid
cus secondary to the deposition of calcium salts impaction (Fig 6). Thin-section images (2–3-mm
(22) (Fig 4). High attenuation due to calcium
deposits also has been observed in the setting of
bronchocentric granulomatosis with or without
associated ABPA (23) (Fig 5). Other findings that
1376  September-October 2008 RG  ■  Volume 28  •  Number 5

Figure 7.  Recurrent pneumonia in a 54-year-old man. (a) Axial CT image obtained with
a lung window depicts extensive consolidation of the right lower lobe, with several mucus-
filled dilated peripheral bronchi (*). (b) Axial CT image obtained with a narrow soft-tissue
window shows a calcification in the bronchus intermedius (arrow), a finding discovered at
bronchoscopy to be an aspirated chicken bone.

sections) and multiplanar reformatted images are ate bronchus, and left main bronchus (28). Com-
particularly useful for correctly locating calcifica- plications include bronchiectasis, hemoptysis,
tions while avoiding volume averaging and sec- bronchial stricture, development of inflammatory
tion misregistration artifacts (18,25). polyps, and air trapping with a resultant decrease
Most cases of foreign body aspiration occur in perfusion of the compromised segment, lobe,
in patients younger than 15 years (approxi- or lung (28). The chest radiographic appearance
mately 70% of cases). Most of these patients seek may be normal or may include regions of consoli-
prompt assistance and are seen in the acute care dation, hyperlucency, atelectasis, bronchiectasis,
setting (26). However, in adults, aspirated for- and pleural effusion. Chest CT images often
eign bodies may remain lodged in the airways for show the intrabronchial foreign body and associ-
long periods of time and may produce symptoms ated features such as atelectasis, hyperlucency,
that may be mistaken for asthma, bronchitis, or bronchiectasis, lobar consolidation, mucoid im-
chronic pneumonia. The objects most frequently paction, a tree-in-bud pattern, ipsilateral pleural
aspirated by adults include animal bones, nut- effusion, ipsilateral hilar adenopathy, and a thick-
shells, medications, metallic denture parts, and ened bronchial wall adjacent to the foreign body
needles (27). Factors that contribute to the oc- (27) (Fig 7).
currence of aspiration include disorders of the
central nervous system, dental procedures, and Benign Tumors
alcoholism. Clinical manifestations include
recurrent pneumonia and hemoptysis (27). Al- Lipoma
though foreign bodies may become lodged in any Endobronchial lipoma is a rare benign lesion that
location of the tracheobronchial tree, the most accounts for only approximately 0.1%–0.5% of
common sites are the right lower lobe, intermedi- lung tumors. The lesion tends to occur in middle-
aged men and usually is manifested by cough, he-
moptysis, fever, and dyspnea. The tumor usually
is located in a segmental bronchus (29). Findings
RG  ■  Volume 28  •  Number 5 Martinez et al  1377

The clinical manifestations of an endobronchial


hamartoma comprise cough, dyspnea, respiratory
infection or obstructive pneumonia, and hemop-
tysis. The main radiographic findings are alveolar
opacities, atelectasis, or both (34). Mucoid im-
pactions, although they are infrequent, also have
been described, particularly in association with
obstructive pneumonia (35). On CT images, an
endobronchial hamartoma commonly appears as
an endobronchial mass accompanied by obstruc-
tive pneumonia (34,35). The observation of fat or
coarse calcifications within the mass at CT may
be useful for differentiating an endobronchial
hamartoma from a bronchogenic carcinoma (35).

Papillomatosis
Laryngeal and tracheobronchial-pulmonary
papillomas are benign tumors that result from
infection with a human papilloma virus, often
serotype 6 or 11, that is acquired during delivery
via the birth canal. Clinically, papillomatosis is
accompanied by signs of upper respiratory tract
obstruction, including hoarseness, stridor, and
respiratory distress. The tumors most commonly
Figure 8.  Mucoid impactions in a 41-year-old arise in the larynx but occasionally are seen in
man with a productive cough and dyspnea at the trachea, bronchi, and lungs. Radiographic
presentation and with a history of papillomatosis. findings include solid or cavitary nodules, which
PA radiograph demonstrates branching opacities usually occur in multiples, predominantly in loca-
in the right lower lobe, the so-called finger-in- tions in the lower lobe and posterior part of the
glove sign. The diagnosis, based on pathologic lung (36). Associated findings include atelectasis
analysis after surgical resection, was obstructive
and obstructive pneumonitis (18). Thin-section
papillomas and distal mucoid impactions.
CT of the lungs may be useful for the further
evaluation of the nodules and may depict tree-
at chest radiography include regions of atelecta- in-bud opacities representing tumor growth at
sis, consolidation, or both, and a mass or nodule the level of respiratory bronchioles (37,38). The
(29,30). Occurrences of bronchiectasis with mu- finger-in-glove sign is rarely seen in this condition
coid impaction have been described (30,31). The (Fig 8).
appearance of a homogeneous fatty mass with
no evidence of enhancement is considered diag- Malignancies
nostic; sometimes, however, the mass is not large
enough to be accurately characterized as fatty. At Carcinoid Tumor
magnetic resonance (MR) imaging, the mass may Carcinoid is a low-grade neuroendocrine neo-
have high signal intensity on T1-weighted images plasm that accounts for 1%–2% of primary
and intermediate signal intensity on intermedi- lung tumors. In the vast majority (80%–90%)
ate- and T2-weighted images, an appearance that of cases, the tumor is located in the bronchial
reflects the normal signal characteristics of fat tree, but it occasionally may be found in the lung
(32). parenchyma. Clinically, a bronchial carcinoid
tumor manifests with cough, fever, expectora-
Endobronchial Hamartoma tion, wheezing, hemoptysis, and chest pain (39).
Overall, hamartomas are the most common A central carcinoid tumor may appear on images
benign tumors to manifest as a solitary pulmo-
nary nodule, but they are seldom found (1.4%
of cases) in endobronchial locations (33,34).
1378  September-October 2008 RG  ■  Volume 28  •  Number 5

Figure 9.  Carcinoid tumor in a 77-year-old asymptomatic woman. (a) Preoperative PA radiograph shows a
mass in the right lower lobe (*) and an adjacent small branching opacity (arrows). (b) Axial CT images (lung
windows) show mucus-filled bronchi (arrow) distal to the mass (*). The diagnosis was pathologically proved.

as hilar, perihilar, or endobronchial nodules or bronchiolectasis. Retained secretions are phago-


masses and may occur with associated atelectasis, cytosed by alveolar macrophages that ultimately
air trapping, obstructive pneumonia, and mucoid become foamy. This phenomenon is known as
impaction. CT may help further identify specific endogenous lipoid pneumonia or “golden” pneu-
characteristics, such the presence of eccentric monia because of the macroscopic yellowish
calcifications (39,40), marked enhancement af- discoloration that results from the accumulation
ter the intravenous administration of iodinated of lipid-laden macrophages in the alveolar space.
contrast material, and mediastinal adenopathy. However, despite the name, coexistent infec-
Furthermore, CT is helpful for localizing the in- tion is uncommon (42). Given the frequency
Teaching
tra- and extraluminal components of endobron- of occurrence of bronchogenic carcinoma, the Point
chial nodules (39). The finger-in-glove sign may observation of the finger-in-glove sign on a chest
be seen (41) (Figs 9, 10). radiograph always creates a concern about this
possible diagnosis. On the other hand, since that
Bronchogenic Carcinoma appearance is not common in cases of lung can-
When lung cancer is centrally located (eg, cer, further evaluation with CT generally should
squamous cell carcinoma), it may impair the be considered. The observation of a hilar mass,
normal bronchial clearance, causing inspissated mediastinal adenopathy, or both on the chest
epithelial secretions to become trapped distally. radiograph is suggestive. Direct obstruction of
This eventually results in bronchiectasis and bronchi, as well as distal inspissated hypoattenu-
ating mucus collections, are easily identified at
CT (43) (Fig 11).
RG  ■  Volume 28  •  Number 5 Martinez et al  1379

Figure 10.  Carcinoid tumor


in a 45-year-old man with a
chronic productive cough.
(a) PA radiograph shows a
homogeneous lobulated mass
(arrows) in the left lower lobe.
(b) Axial CT image (soft-tissue
window) shows dilated tortu-
ous mucus-filled bronchi (*).
The diagnosis was proved at
pathologic analysis.

Figure 11.  Squamous cell lung carcinoma in a 57-year-old man with


chest pain and weight loss. (a) PA radiograph depicts branching opacities
(the finger-in-glove sign) in the right upper lobe. (b) Axial CT image ob-
tained with a lung window clearly shows mucus-filled dilated bronchi (ar-
rows) and a mass within the right main bronchus (*). (c) Coronal MIP im-
age obtained with a lung window depicts the typical finger-in-glove appear-
ance of the dilated bronchi (*). The diagnosis was pathologically proved.
1380  September-October 2008 RG  ■  Volume 28  •  Number 5

Figure 12.  Intrabronchial


metastasis in a 53-year-old
woman with cough and chest
pain at presentation and a his-
tory of colon cancer. (a) Axial
CT image (mediastinal win-
dow) shows a slightly enhanc-
ing left upper intrabronchial
mass (arrow). (b) Axial CT
image (lung window) shows
dilated mucus-filled bronchi
in the left upper lobe (arrows)
and adjacent pulmonary artery
(*). The diagnosis, colon cancer
metastasis, was based on histo-
pathologic analysis of a bron-
choscopic biopsy specimen.

Figure 13.  Intrabronchial metastasis in a 61-year-old man with a history of melanoma. (a) PA radiograph shows a
retrocardiac region of atelectasis (arrows). (b) Axial CT image (lung window) depicts an intrabronchial mass (arrow)
in the left lower lobe. (c) Axial CT image (mediastinal window) depicts atelectasis of the posterobasal segment of the
left lower lobe and several mucus-filled bronchi (*). The diagnosis of metastatic melanoma was pathologically proved.

Endobronchial Metastases ever, metastases to the tracheobronchial tree do


Metastases to the trachea and bronchi are un- occur through the hematogenous spread of ma-
common. Endobronchial malignancies usually lignancies of the breast, kidney, colon, rectum,
occur as a result of direct extension (eg, of lung, uterus, and skin. Clinical manifestations include
esophageal, laryngeal, and thyroid cancers) from cough, wheezing, and hemoptysis. The usual
adjacent lymph nodes or primary tumors. How- radiologic findings include a solitary endoluminal
polyp and atelectasis (18,44). Mucoid impactions
distal to the bronchial mass may be identified at
CT (45) (Figs 12, 13).
RG  ■  Volume 28  •  Number 5 Martinez et al  1381

Conclusions 13. van der Bruggen-Bogaarts BA, van der Brug-


gen HM, van Waes PF, Lammers JW. Screening
Mucoid impactions affecting the central airways for bronchiectasis: a comparative study between
frequently appear as branching opacities on chest chest radiography and high-resolution CT. Chest
radiographs—the so-called finger-in-glove sign. 1996;109:608–611.
Sometimes, this abnormality is not evident on 14. Bhalla M, Turcios N, Aponte V, et al. Cystic fibro-
the chest radiograph but is identified at CT. CT sis: scoring system with thin-section CT. Radiology
1991;179:783–788.
may be helpful, moreover, for differentiating mu- 15. Shah RM, Sexauer W, Ostrum BJ, Fiel SB, Fried-
Teaching coid impactions from other causes of branching man AC. High-resolution CT in the acute exacer-
Point opacities (eg, arteriovenous malformations) as bation of cystic fibrosis: evaluation of acute find-
well as for indicating a particular disease process ings, reversibility of those findings, and clinical cor-
relation. AJR Am J Roentgenol 1997;169:375–380.
or processes. The differential diagnosis is broad
16. Helbich TH, Heinz-Peer G, Fleischmann D, et al.
and includes both congenital and acquired ab- Evolution of CT findings in patients with cystic
normalities. In the setting of a central mucoid fibrosis. AJR Am J Roentgenol 1999;173:81–88.
impaction, bronchogenic carcinoma must always 17. Helbich TH, Heinz-Peer G, Eichler I, et al. Cystic
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This article meets the criteria for 1.0 credit hour in category 1 of the AMA Physician’s Recognition Award. To obtain
credit, see accompanying test at http://www.rsna.org/education/rg_cme.html.
RG Volume 28 • Volume 5 • September-October 2008 Martinez et al

Mucoid Impactions: Finger-in-Glove Sign and Other CT and


Radiographic Features

Santiago Martinez et al

RadioGraphics 2008; 28:1369–1382 • Published online 10.1148/rg.285075212 • Content Codes:

Page 1370
Mucoid impaction is defined as airway filling by mucoid secretions. If the affected airway is large or
dilated (as in bronchiectasis), the secretions may be depicted on chest radiographs or CT images as
tubular or branching opacities. These opacities, which typically radiate from the hilum toward the
periphery of the lung, are classically described as the finger-in-glove sign.

Page 1375
Pathologically, ABPA is characterized by bronchocentric granulomas within both bronchi and
bronchioles, with associated mucoid impactions. Bronchiectasis, mainly in the upper lobes, is a
hallmark of the disease.

Page 1378
Given the frequency of occurrence of bronchogenic carcinoma, the observation of the finger-in-glove
sign on a chest radiograph always creates a concern about this possible diagnosis.

Page 1381
CT may be helpful, moreover, for differentiating mucoid impactions from other causes of branching
opacities (eg, arteriovenous malformations) as well as for indicating a particular disease process or
processes.