References 1. Cystic & cavitary lung diseases. Mayo clinic proceeding 2003;744752 2. HRCT, W.Richard webb, UCSF interactive radiology series 3. Radiology.

References References

1.1. Cystic & cavitary lung diseases.Cystic & cavitary lung diseases. Mayo clinic Mayo clinic proceeding 2003;744752 proceeding 2003;744752

2.2. HRCTHRCT , W.Richard webb, UCSF interactive , W.Richard webb, UCSF interactive radiology seriesradiology series

3.3. Radiology review manualRadiology review manual. Wolfgang Dahnert. Wolfgang Dahnert

4.4. Diagnostic imagingDiagnostic imaging , Chest , Gurney et al , Chest , Gurney et al

5.5. James reed in chest imagingJames reed in chest imaging

6.6. Diffuse lung diseasesDiffuse lung diseases. Prof. Mamdouh . Prof. Mamdouh MahfouzMahfouz

7.7. www.Radiologyassistant.nl/imageswww.Radiologyassistant.nl/images

Holes in the lung Holes in the lung CystCyst - thin walled ( 1-3 mm)- thin walled ( 1-3 mm) - alone or in groups- alone or in groups

• CavityCavity - represents areas of tissue necrosis & clearing - represents areas of tissue necrosis & clearing

within areas of parenchymal opacification.within areas of parenchymal opacification. - thick walled ( > 3 mm )- thick walled ( > 3 mm ) - alone or in groups- alone or in groups - suggests a more aggressive pathology - suggests a more aggressive pathology than a cystthan a cyst..

Holes in the lung Holes in the lung

FocalFocal

* cyst * cyst

* cavity* cavity

DiffuseDiffuse

• LymphangioleiomyoLymphangioleiomyomatosismatosis

• Tuberous sclerosisTuberous sclerosis• L.C.HisteocytosisL.C.Histeocytosis• Honeycombing Honeycombing

diseasedisease• Emphysema Emphysema

Focal holes in the lung Focal holes in the lung CystCyst

* Congenital --- * Congenital --- - Br. Cyst- Br. Cyst - CCAM - CCAM

* Bleb* Bleb * Bulla* Bulla * Pneumatocele* Pneumatocele * Infection---hydatid* Infection---hydatid --

coccidioidomycosiscoccidioidomycosis -PCP-PCP

CavityCavity * neoplastic –Br. Ca* neoplastic –Br. Ca - metastasis- metastasis - lymphoma- lymphoma * infection - bacteria* infection - bacteria - fungal- fungal - parasites- parasites * immunologic* immunologic - wegener’s - wegener’s

gr.gr. - Rh. - Rh.

nodulesnodules * septic emboli* septic emboli * bronchiectasis* bronchiectasis

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

Woodring et al studied the diagnostic Woodring et al studied the diagnostic implications of cavitary wall implications of cavitary wall thicknessthickness

1 mm ----------------- all benign1 mm ----------------- all benign

< 4mm --------------- 92% benign< 4mm --------------- 92% benign

5-15 mm ------------ equally divided 5-15 mm ------------ equally divided

> 15 mm ------------ 95% malignant> 15 mm ------------ 95% malignant

Focal cystic lung diseaseFocal cystic lung disease CongenitalCongenital * bronchogenic cyst* bronchogenic cyst * CCAM ( cystic adenomatoid * CCAM ( cystic adenomatoid

malformation )malformation ) Bulla Bulla Bleb Bleb Pneumatocele Pneumatocele Infection Infection * coccidioidomycosis* coccidioidomycosis * PCP* PCP * hydatid disease* hydatid disease

Bronchogenic cystBronchogenic cyst

* 2/3 in mediastinum* 2/3 in mediastinum

* 1/3 in lung * 1/3 in lung parenchyma, usually parenchyma, usually near hilumnear hilum

* may contain air, * may contain air, fluid or bothfluid or both

Congenital cystic Congenital cystic

adenomatoid malformation adenomatoid malformation ( CCAM )( CCAM )

* air , fluid , or air-fluid containing * air , fluid , or air-fluid containing cysts of varying sizescysts of varying sizes

* 3 types are recognized based on * 3 types are recognized based on cyst size & numbercyst size & number

- type 1---1 or more large cysts(2-- type 1---1 or more large cysts(2-10cm)10cm)

- type 2---neumerous small cysts- type 2---neumerous small cysts

- type 3 – solid with microcysts- type 3 – solid with microcysts

BullaBulla

* intraparenchymal, * intraparenchymal, more than 1 cm.more than 1 cm.

* result from * result from coalescence of coalescence of emphsematous emphsematous spaces or from a spaces or from a Ball-valve type of Ball-valve type of air-way obstruction.air-way obstruction.

Bleb Bleb

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

PneumatocelePneumatocele

• typically associated with typically associated with infection, particularly infection, particularly staph. Pneumonia in staph. Pneumonia in childrenchildren

• characteristically increase characteristically increase in size over time.in size over time.

• probably due to Ball-valve probably due to Ball-valve air-trapping.air-trapping.

• resolves eventually. resolves eventually. • May reach a large size to May reach a large size to

fill the hemi- thoraxfill the hemi- thorax

InfectionsInfections

** { { coccidioidomycosiscoccidioidomycosis }}

* { * { PCPPCP } }

* { * { hydatid diseasehydatid disease } }

- Most of the other Most of the other infectionsinfections

of the lung tend to of the lung tend to cause cavitary lesion.cause cavitary lesion.

CoccidioidomycoCoccidioidomycosis sis

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

Pneumocytis Pneumocytis carnii carnii pneumonia PCPpneumonia PCP

* in * in immunocompromised immunocompromised patientspatients

* upper lobar * upper lobar predilectionpredilection

* pneumothorax 35%* pneumothorax 35%

Hydatid diseaseHydatid disease

* endemic in sheep-raising areas of * endemic in sheep-raising areas of Mediterranean basin Mediterranean basin

* solitary in 75%, multiple in 25%* solitary in 75%, multiple in 25% * water density* water density * rare calcify* rare calcify * complications:* complications: rupture between layers of cyst—rupture between layers of cyst—

meniscus or halo signmeniscus or halo sign ruptue into bronchus—water lilly signruptue into bronchus—water lilly sign rupture into pleura---rupture into pleura---

hydropneumothoraxhydropneumothorax

Focal holes in the lung Focal holes in the lung CystCyst

* Congenital --- * Congenital --- - Br. Cyst- Br. Cyst - CCAM - CCAM

* Bleb* Bleb * Bulla* Bulla * Pneumatocele* Pneumatocele * Infection---hydatid* Infection---hydatid --

coccidioidomycosiscoccidioidomycosis -PCP-PCP

CavityCavity * neoplastic –Br. Ca* neoplastic –Br. Ca - metastasis- metastasis - lymphoma- lymphoma * infection - bacteria* infection - bacteria - fungal- fungal - parasites- parasites * immunologic* immunologic - wegener’s - wegener’s

gr.gr. - Rh. - Rh.

nodulesnodules * septic emboli* septic emboli * bronchiectasis* bronchiectasis

Focal cavitary lung Focal cavitary lung lesionslesions

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

Neoplastic Neoplastic lesionslesions

• Bronchogenic Bronchogenic carcinomacarcinoma

• LymphomaLymphoma• Metastasis Metastasis

Bronchogenic Bronchogenic carcinoma carcinoma (squamous cell (squamous cell type)type)

Squamous cell Squamous cell

carcinomacarcinoma

InfectionInfection * bacterial * bacterial

* fungal* fungal

* parasites* parasites

ImmunologicImmunologic

* Wegener’s * Wegener’s granulomagranuloma

* Rheumatoid * Rheumatoid nodulesnodules

Septic emboliSeptic emboli

• Significant febrile Significant febrile illnessillness

• Multifocal, Multifocal, peripheral locationperipheral location

• Increase incidence Increase incidence of cavitationof cavitation

BronchiectasisBronchiectasis

• Cystic structures Cystic structures continuous with continuous with broncheal tree.broncheal tree.

• Signet ring signSignet ring sign

Cavity Cavity

We have to look at:We have to look at:

* wall thickness* wall thickness

* contents ------- air* contents ------- air

------- air-fluid level------- air-fluid level

------- air with soft ------- air with soft tissue mass.tissue mass.

* relation to broncheal tree* relation to broncheal tree

Wall thickness : more than 4 mmWall thickness : more than 4 mm

ContentsContents * * only aironly air : regularity of the inner margin : regularity of the inner margin - if regular……chronic lung abscess- if regular……chronic lung abscess - if irregular ….cavitating tumor- if irregular ….cavitating tumor * * air-fluid levelair-fluid level: : - if fluid level is straight…acute lung abscess- if fluid level is straight…acute lung abscess - if fluid level is wavy ….ruptured hydatid cyst- if fluid level is wavy ….ruptured hydatid cyst * * contents of the cavitycontents of the cavity -if inner wall is smooth with soft tissue -if inner wall is smooth with soft tissue inside….mycetomainside….mycetoma -if inner wall is irregular with soft tissue -if inner wall is irregular with soft tissue mass..necrotic tumormass..necrotic tumor

Cavity containing Cavity containing

only aironly air

* regularity of inner * regularity of inner marginmargin

- if regular ---ch. Lung - if regular ---ch. Lung abscessabscess

- if irregular---- if irregular---cavitating tumorcavitating tumor

Cavity with air-fluid Cavity with air-fluid levellevel

- if fluid level is - if fluid level is straight---straight---

----- acute lung abscess----- acute lung abscess

- if fluid level is wavy ------ if fluid level is wavy -----

-----ruptured hydatid -----ruptured hydatid cystcyst

Cavity with mass Cavity with mass insideinside

- if inner wall is - if inner wall is smooth---smooth---

------ mycetoma------ mycetoma

- if inner wall is - if inner wall is nodular –nodular –

------- necrotic tumor------- necrotic tumor

Abscess vs hydatidAbscess vs hydatid

Hydatid vs abscess vs Hydatid vs abscess vs necrotic tumornecrotic tumor

Focal holes in the lung Focal holes in the lung CystCyst

* Congenital --- * Congenital --- - Br. Cyst- Br. Cyst - CCAM - CCAM

* Bleb* Bleb * Bulla* Bulla * Pneumatocele* Pneumatocele * Infection---hydatid* Infection---hydatid --

coccidioidomycosiscoccidioidomycosis -PCP-PCP

CavityCavity * neoplastic –Br. Ca* neoplastic –Br. Ca - metastasis- metastasis - lymphoma- lymphoma * infection - bacteria* infection - bacteria - fungal- fungal - parasites- parasites * immunologic* immunologic - wegener’s - wegener’s

gr.gr. - Rh. - Rh.

nodulesnodules * septic emboli* septic emboli * bronchiectasis* bronchiectasis

Diffuse holes in the lungDiffuse holes in the lung

• LymphangioleiomyomatosisLymphangioleiomyomatosis• Tuberous sclerosisTuberous sclerosis• L.C.HistiocytosisL.C.Histiocytosis• Honeycombing diseaseHoneycombing disease• Emphysema Emphysema

LymphangioleiomyomatoLymphangioleiomyomato

sis (LAM )sis (LAM )• Proliferation of smooth Proliferation of smooth

muscles in lung interstitiummuscles in lung interstitium• Hyperinflated lungHyperinflated lung• Widespread thin wall cystsWidespread thin wall cysts• No nodulesNo nodules• Diffuse lung involvementDiffuse lung involvement• Complicated by Complicated by

pneumothorax (40%) & pneumothorax (40%) & chylothothorax (60%)chylothothorax (60%)

• Only in femalesOnly in females• All patients die within 10 All patients die within 10

years.years.

Tuberous sclerosisTuberous sclerosis

* autosomal dominant* autosomal dominant

* pulmonary changes * pulmonary changes seen almost exclusively seen almost exclusively only in females in 3only in females in 3rdrd-4-4thth decadesdecades

* changes similar to LAM * changes similar to LAM except chylous effusionexcept chylous effusion

L.C.HisteocytosisL.C.Histeocytosis

• Histeocytes proliferation Histeocytes proliferation • Widespread cyts & nodulesWidespread cyts & nodules• Cysts are irregular in shapes Cysts are irregular in shapes

(bizzare, bilobed, leaf like ), (bizzare, bilobed, leaf like ), • more numerous in apices, more numerous in apices,

sparing costo-pherenic anglessparing costo-pherenic angles• Lung volume is preservedLung volume is preserved• >90% Smokers, middle age , >90% Smokers, middle age ,

menmen• Spontaneous pneumothorax Spontaneous pneumothorax

in 15%in 15%

Honeycombing Honeycombing

diseasedisease• Indicates “end stage “ Indicates “end stage “

lung and can be seen in lung and can be seen in any process leading to any process leading to severe pulmonary fibrosissevere pulmonary fibrosis

• Adjacent small cysts , 1-3 Adjacent small cysts , 1-3 mm, typically share wallsmm, typically share walls

• Predominate in lower Predominate in lower lobes, peripheral & lobes, peripheral & subpleural lung regionssubpleural lung regions

• Typically occur in several Typically occur in several contiguous layerscontiguous layers

60% due IPF60% due IPF Other causes:Other causes:

- autoimmune - autoimmune diseasedisease

like scleroderma like scleroderma & RA& RA

- hypersensitivity- hypersensitivity

pneumonitispneumonitis

- drug reactions- drug reactions

- asbestosis- asbestosis

Emphysema Emphysema

• Perminant, abnormal,enlargement of Perminant, abnormal,enlargement of airspaces distal to the terminal airspaces distal to the terminal bronchioles, accompanied by destruction bronchioles, accompanied by destruction of walls of the involved airspacesof walls of the involved airspaces

• 3 types:3 types: - centrilobular emphysema- centrilobular emphysema - panlobular emphysema- panlobular emphysema - paraseptal emphysema- paraseptal emphysema

Centrilobular emphysemaCentrilobular emphysema

• The more commonerThe more commoner• Usually results from cigarette smokingUsually results from cigarette smoking• Mainly involves upper lobesMainly involves upper lobes• Multiple, small, lucencies, Multiple, small, lucencies, lack visible wallslack visible walls• centrilobular distributdcentrilobular distributd (grouped near the (grouped near the

center of 2ry pulmonary lobules), center of 2ry pulmonary lobules), surrounding the centrilobular arterysurrounding the centrilobular artery

Panlolobular ( panacinar) Panlolobular ( panacinar) emphysemaemphysema

• Uniform destruction of Uniform destruction of pulmonary lobulepulmonary lobule

• diffuse or more severe in diffuse or more severe in lower lunglower lung

• Pulmonary vessels in affected Pulmonary vessels in affected lung appear smaller and lung appear smaller and fewer than normalfewer than normal

• No focal lucincies can be seenNo focal lucincies can be seen

Paraseptal emphysemaParaseptal emphysema

• More stricking in subpleural More stricking in subpleural location, arranged in single location, arranged in single layerlayer

• Often have visible very thin Often have visible very thin wallswalls

• Can be an isolated Can be an isolated phenomenonphenomenon

• Can be associated with Can be associated with centrilobular emphysemacentrilobular emphysema

• When larger than 1cm , are When larger than 1cm , are termed as termed as bullabulla

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

Paraseptal emphysema vs Paraseptal emphysema vs honeycombinghoneycombing

Conclusion Conclusion

Holes in the lung Holes in the lung

FocalFocal

* cyst * cyst

* cavity* cavity

DiffuseDiffuse

• LymphangioleiomyoLymphangioleiomyomatosismatosis

• Tuberous sclerosisTuberous sclerosis• L.C.HisteocytosisL.C.Histeocytosis• Honeycombing Honeycombing

diseasedisease• Emphysema Emphysema

Focal holes in the lung Focal holes in the lung CystCyst

* Congenital --- * Congenital --- - Br. Cyst- Br. Cyst - CCAM - CCAM

* Bleb* Bleb * Bulla* Bulla * Pneumatocele* Pneumatocele * Infection---hydatid* Infection---hydatid --

coccidioidomycosiscoccidioidomycosis -PCP-PCP

CavityCavity * neoplastic –Br. Ca* neoplastic –Br. Ca - metastasis- metastasis - lymphoma- lymphoma * infection - bacteria* infection - bacteria - fungal- fungal - parasites- parasites * immunologic* immunologic - wegener’s - wegener’s

gr.gr. - Rh. - Rh.

nodulesnodules * septic emboli* septic emboli * bronchiectasis* bronchiectasis

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

Other forms of focal pulmonary cysts Other forms of focal pulmonary cysts may be seen in adults outside these may be seen in adults outside these clinical sittings, and are of obscure origin clinical sittings, and are of obscure origin but are thaught to be related to smoking.but are thaught to be related to smoking.