Cavitary lesions of lung

Maj Manu Chopra

Cyst
Air filled lesion Smooth and uniform wall > 1mm Epithelial lining +/ Infected cyst > surrounding lung inflammation > thick wall
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Cavity
Air containing space Wall thickness > 1mm A lesion that has cavitated (regardless of wall thickness) 10% cancers cavitate (80% are Sq cell ca)
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Abscess
Lesion with no communication with bronchial tree so is radiologically opaque

How to define a cavity

a. b. c. d. Thickness of wall Smoothness / irregularity of inner lining Presence & character of contents number

Cavity wall
Thick Acute lung abscess Primary carcinoma Metastic carcinoma Wegeners granulomatosis Thin Chronic lung infection Thicker cavities are more often malignant
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Character of inner lining

Nodular carcinoma Shaggy acute lung abscess Smooth most of lung conditions

Nature of contents
Liquid - majority Fungus ball freely mobile Echinococcus cyst water lily sign Pulmonary gangrene sloughed, necrotic iceberg

Number of lesions
Solitary Primary carcinoma Ac lung abscess Post traumatic lung cyst Multiple Metastatic neoplasm Wegeners granulomatosis Septic emboli
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Cavity
Malignant lesions - Thick, nodular wall Benign lesions - Thin, smooth wall Wall thickness>15mm -85% malignant 5-15mm -75% benign <5mm -95% benign <1mm -malignancy rare
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Cavity
Air fluid level- benign disease Focal thickening of cyst or cavity wall or fluid within cyst- s/o malignancy

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Air crescent sign

Air outlining or capping the superior aspect of the mass or nodule within the cavity resulting in a crescent shaped collection of air Gravitational shift of the mass strongly suggests mycetoma and excludes carcinoma

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Supine

Prone
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Air crescent sign

Aspergilloma Angioinvasive aspergillosis with septic infarction Ca arising in a cyst Cavitary ca Clot in a cyst or cavity Echinococcus Mucous plug in cystic bronchiectasis Papillomatosis Pulm gangrene

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Cavitary lesions- common

1. 2. 3. 4. 5. Abscess of lung Bronchogenic carcinoma Bulla Cystic bronchiectasis Fungus disease

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Cavitary lesions- common

6. Honeycomb lung 7. Metastasis 8. Pneumatocele 9. Pneumocystis carinii pneumonia 10. Tuberculosis

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1.1. Abscess
Localized infection >tissue destruction & necrosis Communication with tracheobroncheal tree >cavitation & air fluid level Inner wall -smooth/shaggy & irregular Wall thickness -5 to 15 mm
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1.1. Abscess
Cause -Anaerobic inf, S aureus, P aeruginosa Often result of aspiration Infarction, cavitary neoplasm/ conglomerate mass

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1.1. Abscess
Anaerobic abscessLow gd fever, cough, sputum Duration- several weeks Other causesAcute Resemble pneumonia

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1.1. Abscess
CT-Densely enhancing wall- variable in thickness/ irregular in contour -Internal wall- shaggy -Contents- low attenuation -Air fluid level may be seen
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Pneumococcal pneumonia

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air-fluid level

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fever and foul-smelling sputum

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Thin-walled cavity, surrounding consolidation

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Predisposing Factors for a Lung Abscess

DEPRESSED GAG REFLEX UPPER AIRWAY INFECTION ESOPHAGOGASTRIC DISEASE WITH ASPIRATION PULMONARY DISEASE
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6.Predisposing Factors for a Lung Abscess

DEPRESSED GAG REFLEX 1. Alcoholism 2. Anesthesia; postoperative state 3. Cerebral disease (eg, stroke; neoplasm) 4. Debilitation 5. Drug abuse 6. Epilepsy; other convulsive disorders 7. Intubation (eg, indwelling nasogastric tube)
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6.Predisposing Factors for a Lung Abscess

UPPER AIRWAY INFECTION 1. Gingivitis 2. Tonsillitis

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6.Predisposing Factors for a Lung Abscess

ESOPHAGOGASTRIC DISEASE WITH ASPIRATION 1. Achalasia 2. Chalasia (gastroesophageal regurgitation) 3. Other esophageal disease (eg, scleroderma) 4. Peptic disease 5. Tracheoesophageal fistula
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6.Predisposing Factors for a Lung Abscess

PULMONARY DISEASE 1. Actinomycosis; nocardiosis 2. Bronchiectasis 3. Bronchogenic carcinoma 4. Cystic fibrosis (mucoviscidosis) 5. Foreign body (eg, peanut in bronchus)

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1.2.Carcinoma
Diam >2cm - 60% Upper lobes- 2/3rd Margin- ill defined, irregular, or spiculated Shape- irregular/lobulated Air bronchograms or bubbly lucencies (pseudocavitation)
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1.2.Carcinoma
Cavitation with a thick(>15 mm) & nodular wall Satellite nodules absent Calcification absent Enhancement >15 HU Doubling time 30 to 200 days

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Sq cell Ca of bronchus

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Sq cell ca of bronchus

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1.3.Bulla
Thin-walled <1 mm air-filled space Contained within the lung 1 cm in size when distended Walls may be formed by pleura, septa, or compressed lung tissue Unilocular / multilocular Poorly ventilated Decrease in size during ventilation o o o o o

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What a bulla isn t

o o o o Pneumatocoele Cavity Cyst Bleb
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Bulla
o Enlarge progressively over a period of months to years Most are associated with emphysema May become infected or lead to pneumothorax

o o

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Imaging findings
o o Seen more in upper lobes Thin-walled, sharply demarcated areas containing no visible blood vessels Only portion of wall is usually seen

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Imaging findings
o Tend to trap air May become larger on expiration

o Bullae may become so large as to render the remaining normal lung almost invisible, pancaked atop the hemidiaphragm = vanishing lung syndrome
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Infected Bulla
o o Differentiation from lung abscess Bulla contains less fluid Much thinner wall No surrounding pneumonitis Patients less sick Clearing may take weeks to months
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1.4.Cystic bronchiectasis
Multiple air filled cystic lesions Thick/thin walled Clustered Lobar patchy or diffuse Air fluid levels ( inf/retained secretions) Air fluid levels at or about same height in all the affected cysts with less fluid in the upper lobe cysts (water flows downhill)
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Bronchiectasis

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1.4.Cystic bronchiectasis
CT1. Increased bronchoarterial diameter >1 (signet ring sign) 2. Lack of tapering- airway diam unchanched for 2 cm distal to a branching point 3. Contour abnormality- cluster of grapes 4. Visibility of airways in peripheral 1cm of lung

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Bronchiectasis

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1.5.Semi invasive Aspergillosis

In patients with low grade form of immunocompromise (COPD, low dose cortico steroid, TB, DM, Collagen vascular disease) Tissue invasion and infarction over months Mimics appearance of active TB Irregular upper lobe consolidation and pleural thickening, slow progression to cavitation

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Semi-invasive Aspergillosis

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1.5.Aspergilloma
Hyphae form a ball/mycetoma, lying free in the cavity CXR- density surrounded by air within a cavity, best shown by CT (mobile intracavitary mass)-Air crescent sign Usually in upper lobes adjacent to pleura which almost always is thickened
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1.6.Honeycomb lung
Reflects extensive lung fibrosis with alveolar destruction HRCT- thick walled air filled cysts, measuring 3mm to 1cm in diameter. Cysts share wall and occur in several layers at the pleural surface Associated findigs- reticular opacities, traction bronchiectasis
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1.6.Honeycomb lung
Usual interstitial pneumonia Idiopathic pulm fibrosis Collagen vascular dis Drug related fibrosis, Asbestosis, Sarcoidosis (end stage) Non specific interstitial pneumonia Radiation ARDS (end stage)
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Honeycombing- idiopathic fibrosis

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1.7.Metastasis
80%- Breast, skeleton and urogenital system The commonest primary tumours producing solitary pulmonary metastases- colon , kidney and breast, testicular tumours , bone Sarcomas and malignant melanoma

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1.7.Metastasis
Cavitation more common in sq carcinomas and sarcomas Cavitation of a subpleural metastasis is a recognised cause of spontaneous pneumothorax

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Metastases, carcinoma of cervix

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1.8.Pneumatoceles
Thin walled air filled space within lung occurs in assosciation with infection Haematogenous- septicaemia by S aureus, a common complication of i/v drug abuse Cavitation evident on later examination Due to check valve mechanism Causes staph. aureus, pneumocystis carinii, trauma
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staph abscess, i/v drug abuser, thin-walled cavities, effusion

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staph tricuspid endocarditis, pneu-matoceles

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Staph bronchopneumonia, pneumatocele

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1.8.Pneumatocele
1. Hemorrhage in lung with interstitial emphysema 2. Hydrocarbon aspiration 3. Hyperimmunoglobulinemia E syndrome 4. Pneumonia 5. Pulmonary infarct 6. Respirator therapy 7. Trauma (contusion/laceration/hematoma lung) 8. Tuberculosis
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1.9.Pneumocystis carinii
Cavities, usually thin walled, occasionally up to several mm in thickness, may develop Appearances may return entirely to normal, some residual scarring and cyst formation is common

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1.10.Tuberculosis
Post primary tuberculosis Start in the subapical parts of the upper lobes or in the apical segment of the lower lobes as small areas of exudative inflammation. These extend, coalesce, caseate and cavitate
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1.10.Tuberculosis
Consolidation patchy and nodular and may be bilateral Progressive infection indicated by extension and coalescence of the areas of consolidation, and development of cavities

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1.10.Tuberculosis
A large cavity with smaller satellite cavities, often bilateral but more advanced on one side Cavity walls are lined by tuberculous granulation tissue and traversed by fibrotic remnants of bronchi and vessels
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1.10.Tuberculosis
Cavities- single/ multiple, large/ small and thin/ thick walled Fluid levels are sometimes visible Chronic cavities- colonised by Aspergilus and other fungi, and mycetomas may develop
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Tuberculosis, complete destruction of the right lung

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Tuberculosis, bronchopneumonic spread to the opposite lung

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Aspergilloma , previous TB

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thick-walled, LLL cavity with an air-fluid level

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treated TB, persistent hemoptysis, crescent sign

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2.Cavitary lesions- uncommon

1. Amyloidosis 2. Behet syndrome 3. Cyst (eg, bronchial) 4. Cystic adenomatoid malformation 5. Cystic fibrosis (mucoviscidosis)

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2.1.Amyloidosis
A group of conditions characterised by extracellular deposition of fibrillary protien Multiple nodular angular opacities up to several centimetres in size and grow slowlycan cavitate or calcify Calcification- fine stippling
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2.1.Amyloidosis
Alternatively diffuse reticulonodular shadowing or honeycombing due to diffuse deposition of amyloid within alveolar walls, lobular septa and pulmonary arterioles

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2.4.CCAM
Hamartomatous proliferation of terminal bronchioles at the expense of alveolar development Lesions composed of both cystic and solid tissue

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2.4.CCAM
Cysts are lined by respiratory epithelium and usually communicate with the tracheobronchial tree with a slight predilection for the upper lobes Air-fluid levels may be seen with or without superadded infection

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2.4.CCAM
Type I- One or more cysts >2cm with adjacent smaller cysts- large multicystic lesion, sometimes with air fluid levels Type 2- More heterogeneous and smaller cysts< 2cm. Air filled multicystic mass, or solid mass, or area of consolidation Type 3- <3-5 mm cysts. A solid mass with mass effect and a ground-glass appearance on CT
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CCAM - type 1, multiple cystic lesions, in RLL, air-fluid levels

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Thick-walled cysts in RLL

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2.5.Cystic fibrosis
Increased viscosity of the bronchial secretionsbronchial obstruction- air trapping/ predisposes to bronchiectasis CXR- signs of air trapping with flattening of the diaphragm, bowing of the sternum and increased dorsal kyphosis, and signs of bronchiectasis
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Cystic fibrosis, bronchiectasis

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2.Cavitary lesions- uncommon

6. 7. 8. 9. 10. Diaphragmatic hernia Langerhans cell histiocytosis Hydatid cyst Hydropneumothorax Inflammatory pseudotumors

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2.7.Langerhens cell histiocytosis

Earliest- ill-defined transient patchy consolidation Fine reticulonodular pattern throughout both lungs, predominantly in the mid and upper zones Confirmation with lung biopsy HRCT a mixture of discrete nodules and cystic spaces As fibrosis progresses, a coarser linear pattern appears, with development of ring shadows, honeycombing and bullae
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2.8.Hydatid disease
Echinococcal cyst Three layers: (1) Pericyst/ adventitia formed of compressed host tissue (2) Ectocyst friable middle layer (3) Endocyst inner germinal layer from producing scolices
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2.8.Hydatid disease
Daughter cysts- formed if viability threatened, but in the lung the cyst is unilocular Approx 20% of pulm cysts bilateral 10% associated with hepatic cysts Uncomplicated pulm hydatid cysts- wellcircumscribed, round or oval, homogeneous masses, up to 10 cm in diam
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2.8.Hydatid disease
Calcification rare Cysts may rupture into the pleura or bronchi Rupture into a bronchus- air-fluid level Ectocyst may separate from the adventitia so that a double walled cyst may be seen
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Walls of the cavity have partly collapsed, fluid level

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Water-lily sign

Cudad LLL consolidation

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2.Cavitary lesions- uncommon

11. Lymphomas 12. Melioidosis 13. Papillomatosis of lung 14. Parasitic disease (paragonimiasis) 15. Plombage, lucite 16. Polyarteritis nodosa; lupus erythematosus 17. Pulmonary infarct
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2.12.Melioidosis
Pseudomonas pseudomallei May manifest years after the patient has left an endemic area Two pulmonary forms: (1) septicaemicdisseminated infection with necrotising lesions (2) chronic apical pneumoniabreaks down to form a thin-walled cavity
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Patchy infiltrates Rt lung with cavitation

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2.14.Paragonimiasis
Infected shellfish (Southeast
Asia, esp Phillippines)

Commonest reactions in the lung- formation of multiple 1-2 cm-diam cysts and bronchopneumonic shadows which may resemble tuberculosis Dead flukes may calcify
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2.15.Ping pong ball plombage

2.15.Wax plombage

2.Cavitary lesions- uncommon

18. Pulmonary sequestration (intralobar) -SM -SM 19. Rheumatoid nodule 20. Sarcoidosis (cystic) -M 21. Septic embolus -SM 22. Traumatic lung cyst (hematoma; laceration) -SM 23. Wegener granulomatosis -SM
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2.19.Rheumatoid pulmonary nodules

Necrotic nodules are usually associated with subcutaneous nodules, and are similar histologically Well-defined, round opacities up to 7 cm in diameter and may be single or multiple and may cavitate

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2.19.Rheumatoid pulmonary nodules

Caplan's syndrome- rheumatoid nodules against a background of pneumoconiosis The two diseases modify each other and numerous round opacities up to 5 cm in diameter, resembling metastases, may appear The solid fibrotic lesions eventually become hyalinised and may calcify
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Rheumatoid disease, cavitating necrotic nodules

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2.23.Wegener s granulomatosis
A necrotising vasculitis, involves the upper respiratory tract, the lungs and the kidneys A limited variant, confined to the thorax Symptoms referable to the upper air passages almost always present

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2.23.Wegener s granulomatosis
Cough, haemoptysis and pleurisy accompanied by constitutional symptoms of malaise, weakness and fever Rheumatoid and antinuclear factors are commonly found in the blood Inflammatory necrosis in the walls of small arteries and veins leading to occlusion of lumen
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2.23.Wegener s granulomatosis
Granulation tissue represents a reparative process- undergoes necrosis Necrotic granulation tissue forms rubbery pulmonary masses, which may be single or multiple up to several centimetres in diam, fairly well defined and often cavitate: they may resolve spontaneously, while new masses appear
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2.23.Wegener s granulomatosis
Cavitating lesions may have thick or thin walls, depending on how much of the necrotic material is expectorated Multiple cavities can closely mimic tuberculosis

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Wegener's granulomatosis pulmonary masses

Wegener's Granulomatosis, cavitating masses

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2.6. Diaphragmatic hernia

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2.9.Hydropneumothorax
A pneumothorax containing a horizontal fluid level which separates opaque fluid below from Iucent air above

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Loculated pyo-pneumothorax

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Empyema

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Abscess
Shape Angles with pleural surface Wall Pulm vessel/ bronchi Round/ oval Acute Irregular, thick entering wall/ center

Empyema
Oval/ lenticular/ crescentic Obtuse Smooth, regular displaced
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