Radiolucent Pulmonary Lesions: An Update And Diagnostic

Problems

Poster No.: C-2566

Congress: ECR 2013
Type: Educational Exhibit
Authors: A. B. Veas-Lopez, A. Snchez Gonzlez, M. L. Rodriguez
Rodriguez, R. Rodrguez Mondjar, J. M. Plasencia Martnez, M.
L. Paredes Martnez, I. Bares Fernndez; Murcia/ES
Keywords: Infection, Cysts, Congenital, Computer Applications-Detection,
diagnosis, CT, Lung
DOI: 10.1594/ecr2013/C-2566

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Learning objectives

In This e-poster we are willing to remark the following key points:

Describe the semiology of Radiolucent pulmonary Lesion (RPL) by

Fleischner Society glossary and illustrate MDCT images collected with our
own patients.
Establish a diagnostic algorithm radiolucent lesions.
Troubleshooting semiological that may arise.

Background

Radiolucent pulmonary lesion may be observed clinically by using x-ray or CT scan

as a focus of decreased density of the lung parenchyma. Reviewing the glossary of
society Fleischner found 8 semiological findings referred to as radiolucent lesions. These
findings are: cyst, cavity, pneumatocele, bulla, emphysema, bleb, bronchiectasis and
honeycombing. Fleishner Society description refers to the AP and radiological findings of
these except in the case where only the cavities described based on radiological findings.
It is also difficult to compare some other lesions, since its definition enter multiple factors
described later.

Images for this section:

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Fig. 1: TABLE 1

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Imaging findings OR Procedure details

1. Describe the semiology of radiolucent pulmonary lesions by Fleischner

Society glossary and illustrate MDCT images collected with our own patients.

1. Cyst. Fig. 2 on page 15

2. Cavity. Fig. 3 on page 16

3. Pneumatocele. Fig. 4 on page 17

4. Emphysema. Fig. 5 on page 18

5. Brochiectasis. Fig. 6 on page 19 , Fig. 7 on page 20 y Fig. 8 on page 21

6. Honeycombing. Fig. 9 on page 22 y Fig. 10 on page 23

7. Bleb.

8. Bulla. Fig. 11 on page 24

The more significant data are described as shown in table 1.

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Fig. 1: TABLE 1
References: Jose Maria Morales Meseguer - Murcia/ES

2. Establish a diagnostic algorithm radiolucent lesions.

To establish a diagnostic algorithm to help us quickly and easily to make the differential
diagnosis of radiolucent lesions should respond to three questions:
* Wall is surrounded? The first thing is to discard the emphysema because it is the only
lesion radiolucent without wall, although this is not always true.

Having answered this question we would do two questions:

* How is the wall thickness: thin (less than 4 mm.) Or thick (greater than 4 mm.)?
* What is your distribution?:Focal-multifocal (may be multiple but not affects all lobes)
or diffuse (affecting all lobes).

Depending on the response we get three groups of lesions:

Thin wall lesions (cysts) or thick (cavities) and diffuse distribution.

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Thin walled radiolucent lesions (cysts) and distribution focal / multifocal.
Thick walled radiolucent lesions (cavities) and distribution focal / multifocal.

GROUP 1:

CYSTIC OR CAVITYES. DIFUSSE DISTRIBUTION.

The term refers to diffuse involvement of both lungs and all lobes indicating extensive
involvement is not necessarily uniform.

Fig. 12
References: Jose Maria Morales Meseguer - Murcia/ES

The most representative are lymphangioleiomyomatosis and Langerhans histiocytosis

Fig. 14 on page 27 :

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Fig. 13: TABLE 2
References: Jose Maria Morales Meseguer - Murcia/ES

GROUP 2:

CYSTIC LESIONS. FOCAL OR MULTIFOCAL DISTRIBUTION.

In this group enter the diseases they cause lung cysts but not diffuse distribution: blebs,
bullae, pneumatoceles, infectious cysts and cystic lesions inbred.

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Fig. 15
References: Jose Maria Morales Meseguer - Murcia/ES
Pneumonia Pneumocystis jirovecci (Fig. 19 on page 32)

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Fig. 16
References: Jose Maria Morales Meseguer - Murcia/ES

Cystic adenomatoid malformation (Fig. 20 on page 33 y Fig. 21 on page 34 )

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Fig. 17
References: Jose Maria Morales Meseguer - Murcia/ES

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Fig. 18
References: Jose Maria Morales Meseguer - Murcia/ES

Pulmonary sequestration (Fig. 22 on page 35 )

GROUP 3:

CAVITARY LESIONS. FOCAL OR MULTIFOCAL DISTRIBUTION.

The differential diagnosis of cavitary lesions is broader than that of cystic lesions is
essential to correlate with the clinical evolution and the history of the patient. We can
group them into different types:

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Fig. 23
References: Jose Maria Morales Meseguer - Murcia/ES

What we must do before a solitary cavitary lesion?

The most common cause of a solitary cavitary lesion is bronchogenic carcinoma so

the first thing to do is analyze semiologically the injury to determine its potential for the
case of a primary tumor lesion. Different studies have assessed semiological findings
that allow us to narrow the differential diagnosis. The finding is further repeated wall
thickness which when less than 4 mm. at its thinnest portion oriented toward goodness
and when greater than 16 mm. guides malignancy. However in these articles refers
to the thickness of the wall on chest radiograph need not overlap the TC (Vourti,
references HONDA 3 and 4). Honda et al (assessed with this and other findings TC)
and found no differences in wall thickness (always valued as its thinnest part). If found
in other parameters described in the table that follows.

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Fig. 24
References: Jose Maria Morales Meseguer - Murcia/ES

Here are some examples of single or multiple cavitary lesions frequently:

Neoplastic lesions: Fig. 25 on page 38

Bronchogenic carcinoma Fig. 26 on page 39

Metastatic disease (Fig. 27 on page 40 )

Infectious lesions: Fig. 32 on page 45

Mycobacterial Infection
Fungal infection (Fig. 28 on page 41 y Fig. 29 on page 42 )
Bacterial Infections (Fig. 30 on page 43 y Fig. 31 on page 44)

Vascular lesions: Fig. 33 on page 46

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 Wegener's disease
Pulmonary infarcts
Septic emboli

Miscellaneous: Fig. 34 on page 47

Rheumatoid nodules
Chest Trauma

3. Troubleshooting semiological that may arise.

3.1Thin walled single cyst. What meaning I give?.

Simple cysts emphysema except where bullae may appear, is a very rare and unlike
what happens in other solid organs input should not be branded as worthless simple
cysts usually have meaning and one etiology of greater or lesser importance for each
patient. The first is

The first is to differentiate cyst cavity, whose characteristics have been previously
expressed. Once we make sure we have a solitary cystic lesion we will have to try to
shorten the very broad differential diagnosis of these patients.
It is known that thin-walled cysts solitary or in small numbers can appear in healthy
older individuals in the context of aging and smoking in healthy individuals representing
focal areas of destruction by emphysema centriacinar. Alternatively pneumatoceles
corresponding to persistent. But it may also correspond to other etiologies yy different
diagnosis management, for example in a patient with a history of leiomyosarcoma,
or cancer of head and neck squamous cell may represent a cystic metastasis which
requires biopsy or another set of procedures to confirm the findings. It is therefore
important before labeling them as unimportant findings (simple cysts?) Evaluate other
diagnostic possibilities according to clinical and patient history (history tumor can
metastasize cystic emerging findings of diffuse cystic disease ....).

3.2 Honeycombing associated-emphysem (a new entity?):

The joint appearance in the same patient of idiopathic fibrosis and emphysema was
described over 30 years ago by Auerbach in a review of the lungs in 1824 autopsies.
Later in the 90 Wiggginns et al, introduced the evaluation by CT imaging and since 2005,
Cottin et al, have regained interest in this entity that has received particular attention
in recent years.

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The combination of these two entities is defined as a syndrome resulting from the
combination of different factors, such as smoking, significant dyspnea, spirometry
findings unexpected (minimally altered lung volumes contrasting with severely impaired
monoxide diffusing carbon and arterial hypoxemia, which worsens during exercise),
very often the presence of pulmonary arterial hypertension (50-90%, conditions relevant
to the clinical course and survival of these patients) as well as the characteristic findings
on techniques radiological image, especially by CT.
Although the etiology is unknown, it has been suggested snuff smoke as the main
etiological factor, since the smoking history is constant.
Diagnostic radiology:

*Chest radiography: Pattern interstitial or reticulonodular infiltrates bibasaly distribution

peripheral (subpleural and hiperclridad at the vertices are decreased vascular pattern
at that level.
*CT: The presence of emphysema predominantly in the upper lobes (centrilobular
and paraseptal, the latter has been reported in up to 90% of cases, so some
authors suggest that this is the characteristic feature), which coexists with various
manifestations naumopata radiological characteristic of interstitial (the pattern most
frequently described is the usual interstitial pneumonia, but may also be observed
patterns of nonspecific interstitial pneumonia or desquamative interstitial pneumonia).

The joint appearance of pulmonary fibrosis and emphysema can cause problems in
the interpretation of radiological findings since there is little mention of this syndrome
in the radiology literature.

(Fig. 35 on page 48 )

3.3 Honeycombing mimics:

The term "honeycomb bee" has been defined, based on thin-section CT, clearly by
Fleischer society.
However the valuations of this radiation is very complex entity in daily practice, so we
should keep in mind certain entities with which the differential diagnosis, mainly. (Fig.
36 on page 49 )

Honneycombing is often considered sopecific for pulmonary fibrosis and is an important

criterion in the diagnosis of usual intersticial pneumonia (UIP) and thus " the term should
be used with car because it may directly impact patient care".

Images for this section:

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Fig. 2: Patient, 67 year old woman showing cystic lung metastases with a history of
endometrial cancer stage IV

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Fig. 3: 25 year old male with a history of acute lymphoblastic leukemia with fever of
4 days' duration despite antibiotic treatment. In the image on the left and top shows a
bilateral micronodular pattern and a consolidation in the LSI. In the image on the right and
bottom, made three months later showed a cavity within consolidation by mycobacterium
tuberculosis.

Page 17 of 52
Fig. 4: Pneumatocele within a consolidation infectious.

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Fig. 5: Patient, 54 year old male. Smoker. Emphysema centriacinar (red arrows) with
apical bullae (blue arrows).

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Fig. 6: 55 year old woman with hemoptysis and respiratory infection clinic. Varicose
bronchiectasis in the right upper lobe and the cylindrical in the lingula . Centrilobular
nodules with tree-in-bud pictures. Diagnosis: atypical mycobacterial infection (M.
kansasii).

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Fig. 7: 71 years old man with cystic bronchiectasis.

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Fig. 8: 30 year old man with cystic bronchiectasis in the context of allergic
bronchopulmonary aspergillosis.

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Fig. 9: Honeycombing

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Fig. 10: Honeycombing (red arrows) and tractional bronchiectasis (blue arrows).

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Fig. 11: Bleb/bulla

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Fig. 12

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Fig. 13: TABLE 2

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Fig. 14: 25 year old male with bone involvement (right iliac) by Langerhans histiocytosis

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Fig. 15

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Fig. 16

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Fig. 17

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Fig. 18

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Fig. 19: Coronal CT images demonstrate extensive involvement with glass opacities
bilateral and patchy distribution that tend to consolidate and small cysts. Pneumocystis
Jirovecci.

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Fig. 20: Cystic adenomatoid malformation TYPE I with infectious asociated.
Radyography (Posteroanterior and lateral): Infiltrate in the right upper lobe with the
presence of multiple cysts with air-fluid levels (arrow).

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Fig. 21: Cystic adenomatoid malformation TYPE I with infectious asociated. Axial CT
images demonstrate a confluent area of opacification with muliple air-fluid levels and
multiple faint cysts clustered in the right upper and medium lobes. The affected lobes
are expanded.

Page 35 of 52
Fig. 22: Axial CT images of a patient of 59 years with an intralobar pulmonary
sequestration. Systemic artery (red arrow).

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Fig. 23

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Fig. 24

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Fig. 25

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Fig. 26: Man of 85 years with non small cell lung carcinoma in the left lower lobe

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Fig. 27: Axial images show nodules randomized some cavitation for metastasis of a
squamous cell cancer of the larynx.

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Fig. 28: Micetoma by colonization of residual cavities prior to TBC. Left image is
performed in supine. Lower right image in prone.

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Fig. 29: Glass opacities patchy distribution that is associated with centrilobular
distribution nodules affecting both lungs that tend to consolidation. Consolidations in the
left lower lobe are cavitated. Pneumocystis jiroveci

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Fig. 30: Male 85 years. Fever, chills and dyspnea The radiograph shows anteroposterior
and lateral consolidation cavitated apical segment of the right lower lobe torpid.
Pseudomonas lung abscess.

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Fig. 31: Axial images at lung and mediastinal windows show a cavity in the lower lobe
apical segment passing through the fissure, abscess corresponded to Pseudomonas.

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Fig. 32

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Fig. 33

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Fig. 34

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Fig. 35

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Fig. 36

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Conclusion

1. There are accurate and current definitions of the different lung radiolucent lesions
radiologists should know.

2. Currently not recommended the use of the term given their small bleb clinical.

3. Similarly the term honeycombing be used with caution, given that the diagnosis of UIP
is mainly based on the presence of honeycomb lung

4. Although there are clear definitions of the different lung radiolucent lesions are still
problems and clinical semiological therefore expected that these definitions will be
modified in the future and there are new chemical entities in which the radiologist will
have much to say.

References

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Beddy P, Babar J, Devaraj A. A practical approach to cystic lung disease on HRCT.

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Vourtsi A, Gouliamos A, Moulopoulos L et al. CT appearance of solitary and multiple

cystic and cavitary lung lesions. EurRadiol 2001; 11: 612-622

Pathologic review of cyctic and cavitary lung diseases.

Clin Microbiol Rev.2008 April;21(2): 305-333.

Hansell DM. Thin-section CTof the lungs: The hinterland of normal. Radiology 2010; 256
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Arakawa H, Honma K. Honeycomb lung: history and current concepts. AJR 2011; 196:
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