07 cavitary & cystic lesions

Cavitary and Cystic lesionsCavitary and Cystic lesions

高雄長庚醫院胸腔內科曾嘉成醫師

Cavity and CystCavity and Cyst

Cavity:Cavity: a gas containing space within the a gas containing space within the lung surrounded by a wall whose thickness lung surrounded by a wall whose thickness is is greater than 1 mmgreater than 1 mm..

Cyst:Cyst: a gas containing space with a well- a gas containing space with a well-defined thin wall defined thin wall (< 1 mm)(< 1 mm) not related to not related to emphysema.emphysema.

Lucent lesionLucent lesion

Bilateral hyperluBilateral hyperlucencycency

Unilateral hyperlUnilateral hyperlucencyucency

Solitary hyperluSolitary hyperlucencycency

Multiple hyperluMultiple hyperlucencycency

Cavity: Causes (1)Cavity: Causes (1)

Inflammation:Inflammation:– Pyogenic infection.Pyogenic infection.– TB.TB.– Fungus infection.Fungus infection.– Parasites.Parasites.

Neoplasm:Neoplasm:– Primary lung cancer.Primary lung cancer.– Metastases.Metastases.– LymphomaLymphoma

Cavity: Causes (2)Cavity: Causes (2)

Vascular:Vascular:– Rheumatoid.Rheumatoid.– Wegener’s granulomatosis.Wegener’s granulomatosis.– Infarct (thromboemboli or septic emboli).Infarct (thromboemboli or septic emboli).

Inhalation:Inhalation:– Silicosis and coal worker’s pneumoconiosis.Silicosis and coal worker’s pneumoconiosis.

Congenital cyst:Congenital cyst:– Pulmonary sequestration, bronchogenic cyst, and congPulmonary sequestration, bronchogenic cyst, and cong

enital cystic adenomatoid malformation.enital cystic adenomatoid malformation.

Infective, i.e. abscesses staphylococcus aureus, klebsiella pneumoniae, tuberculosis, aspiration, others

Neoplastic carcinoma of the bronchus, metastases, Hodgkin’s disease Vascular Infarction

Abnormal lung cystic bronchiectasis, infected emphysematous bulla, sequestrated lung, bronchogenic cyst

Granulomas Wegener’s granulomatosis, rheumatoid nodules, progressive massive fibrosis

Traumatic hematoma, traumatic lung cyst Pseudocyst????

Lung Cavities

Differential Diagnosis (1)Differential Diagnosis (1)

Cavitary wall:Cavitary wall:– Thick:Thick: favor lung abscess, primary lung ca, metastasis, favor lung abscess, primary lung ca, metastasis,

Wegener’s granulomatosis.Wegener’s granulomatosis.– Thin:Thin: favor chronic infection (Coccidiodomycosis, Para favor chronic infection (Coccidiodomycosis, Para

gonimiasis).gonimiasis).– Wall thickness:Wall thickness: (measure thickest part) (measure thickest part)

< 4 mm favor benign.< 4 mm favor benign. 4-15 mm inconclusive.4-15 mm inconclusive. > 15 mm favor malignancy.> 15 mm favor malignancy.


Character of the Inner Lining(Character of the Inner Lining( 內緣內緣 ):):– Nodular, irregular:Nodular, irregular: malignancy. malignancy.

– Shaggy(Shaggy( 毛毛的毛毛的 ):): acute lung abscess. acute lung abscess.

– SmoothSmooth


Nature of the Cavitary Content:Nature of the Cavitary Content:– Fluid:Fluid: in most cases, the contents are liquid. in most cases, the contents are liquid.– Fungus ball.Fungus ball.– Pulmonary gangrene:Pulmonary gangrene: irregular pieces of sloug irregular pieces of sloug

hed necrotic lung parenchyma float like iceberghed necrotic lung parenchyma float like icebergs in the cavity fluid.s in the cavity fluid.

– Water-lily sign:Water-lily sign: ruptured Echinococcus cyst wh ruptured Echinococcus cyst which float on the top of the fluid.ich float on the top of the fluid.


Associated Lesions:Associated Lesions:– Surrounding air space consolidation:Surrounding air space consolidation: acute ede acute ede

ma, hemorrhage, exudate.ma, hemorrhage, exudate.

– Irregular reticular strands:Irregular reticular strands: chronic fibrotic scar. chronic fibrotic scar. LocationLocation

– Upper lobe or lower lobe?Upper lobe or lower lobe?– S3 Vs S2S3 Vs S2


Multiplicity of Lesions:Multiplicity of Lesions:– Solitary:Solitary: typical for lung cancer, acute lung abs typical for lung cancer, acute lung abs

cess, post-traumatic lung cyst.cess, post-traumatic lung cyst.

– Multiple:Multiple: typical for metastases, Wegener’s gra typical for metastases, Wegener’s granulomatosis, Septic emboli.nulomatosis, Septic emboli.

Pentax Optio S

Cavity: Abscess (1)Cavity: Abscess (1)

Associated Lesions:Associated Lesions:– Surrounding air space consolidation: acute edeSurrounding air space consolidation: acute ede

ma, hemorrhage, exudate.ma, hemorrhage, exudate.– Irregular reticular strands: chronic fibrotic scarIrregular reticular strands: chronic fibrotic scar

Virulent pathogen Virulent pathogen vasculitis vasculitis thrombos thrombosisis necrosis necrosis cavity cavity

Necrotizing pneumonia Necrotizing pneumonia Abscess Abscess


Pulmonary infection with cavitary lesionsPulmonary infection with cavitary lesionsnarrows the differential diagnosisnarrows the differential diagnosis– Viral and mycoplasma pneumonia --- unlikely Viral and mycoplasma pneumonia --- unlikely – Pneumococcal pneumonia --- rarelyPneumococcal pneumonia --- rarely– Most common pathogenMost common pathogen

GPCGPC:: Staph Staph, , -hemolytic -hemolytic StrepStrep, , GNB:GNB: KlebKleb, , PseudoPseudo, , E. coliE. coli, , AnaerobesAnaerobes

Lung abscess, Klebsiella pneumoniae


Aspiration pneumonia frequently cavitateAspiration pneumonia frequently cavitate– May subclinical aspirationMay subclinical aspiration– Mixed GNB and anaerobesMixed GNB and anaerobes– Cavity formation in a dependent portionCavity formation in a dependent portion– Unconscious, poor oral hygiene, alcoholism, Unconscious, poor oral hygiene, alcoholism,

or tumor in mouth, nasopharynx or larynxor tumor in mouth, nasopharynx or larynx


Pulmonary gangrene:Pulmonary gangrene:– Relative uncommon complicationRelative uncommon complication– Very acute ischemic necrosis.A nonviable lung Very acute ischemic necrosis.A nonviable lung

detached from a viable lung detached from a viable lung cavity cavity– ““Ball in hole” --- like fungus ballBall in hole” --- like fungus ball– Most common: Most common: Klebsiella pneumoniae.Klebsiella pneumoniae.– PneumococcusPneumococcus, , H. influH. influ, , S. aureusS. aureus, , AnaerobesAnaerobes, ,

MucormycosisMucormycosis, and , and AspergillusAspergillus..– Early diagnosis Early diagnosis surgical intervention surgical intervention

Pulmonary gangrenePulmonary gangrene

– Relative uncommonRelative uncommon– Very acute ischemic necrosisVery acute ischemic necrosis– ““Ball in hole” -- like fungus bBall in hole” -- like fungus b

allall– Most common: Most common: Kleb. pneum.Kleb. pneum.– PneumoPneumo, , H. influH. influ, , S. aureusS. aureus, , AA

naerobesnaerobes, , Muco. AspergillusMuco. Aspergillus– Early diagnosis Early diagnosis

surgical intervention surgical intervention

Lung abscess Lung abscess vsvs Empyema Empyema Lung abscess :Lung abscess : spherical, thick wall, the spherical, thick wall, the

air-fluid levels are equal in length regardair-fluid levels are equal in length regardless of the radiographic projection.less of the radiographic projection.

Empyema :Empyema : pleural disease, lens-shaped, pleural disease, lens-shaped, longer in one view than in the other longer in one view than in the other

Lung abscess Lung abscess bronchopleural fistula bronchopleural fistula hydropneumothorax ( empyema )hydropneumothorax ( empyema )

Lung abscess Lung abscess Hydropneumothorax Hydropneumothorax

Lung abscess >>>------------------------>>> empyema

Cavity: Tuberculosis (1)Cavity: Tuberculosis (1)

好發位置好發位置– Apicoposterior of upper & superior of lower lobeApicoposterior of upper & superior of lower lobe

TB in cavitary phase indicates TB in cavitary phase indicates -- active and at risk of dissemination-- active and at risk of dissemination– Hematogenous spreading: Hematogenous spreading:

diffuse fine nodules, sharply defineddiffuse fine nodules, sharply defined– Bronchogenic spreading: Bronchogenic spreading:

larger (2-5mm) and ill-defined borderslarger (2-5mm) and ill-defined borders

Cavity: Tuberculosis (2)Cavity: Tuberculosis (2)

Features unlike TBFeatures unlike TB– Solitary cavity at ant segment of upper lobeSolitary cavity at ant segment of upper lobe– Isolated cavities at lower lobeIsolated cavities at lower lobe

Features suggesting of TBFeatures suggesting of TB– Associated reticular pulmonary scarsAssociated reticular pulmonary scars– Volume loss in the involved lobeVolume loss in the involved lobe– Pleural thickening and calcification.Pleural thickening and calcification.– Calcified hilar or mediastinal lymph nodesCalcified hilar or mediastinal lymph nodes

Tuberculosis

1.Tuberculosis

2.DM

Cavity: MycetomaCavity: Mycetoma Fungus ball in an “existed” holeFungus ball in an “existed” hole

– ““Hole”: active or inactive TB (most commHole”: active or inactive TB (most common), lung abscess, pulmonary sequestration,on), lung abscess, pulmonary sequestration, cancer, sarcoidosis, etc. cancer, sarcoidosis, etc.

Generally asymptomatic and indolentGenerally asymptomatic and indolent Hemoptysis: life-threatening complicatiHemoptysis: life-threatening complicati

onon Air crescentAir crescent Aspergillus fumigatusAspergillus fumigatus

Aspergilloma

Aspergilloma in old TB cavityAspergilloma in old TB cavity

Aspergilloma in old coccidiodomycosis cavity

FungusFungus

Cavity formation:Cavity formation:– CryptococcusCryptococcus– AspergillusAspergillus– MucormycosisMucormycosis– CoccidiodomycosisCoccidiodomycosis

NocardiaNocardia

Coccidioidomycosis

Hydatid CystHydatid Cyst Echinococcus, a parasiteEchinococcus, a parasite 3 layers of hydatid cyst3 layers of hydatid cyst

– Outer: tough pericyst, produced by host Outer: tough pericyst, produced by host – Middle: laminated layer, produced by parasiteMiddle: laminated layer, produced by parasite– Inner: unicellular, germinal layer, produce fluid and cyst Inner: unicellular, germinal layer, produce fluid and cyst

Spherical, well-defined, homogenous cyst Spherical, well-defined, homogenous cyst growing and asymptomatic until rupturegrowing and asymptomatic until rupture

Water-lily sign:Water-lily sign: air entering outer and middle laye air entering outer and middle layerr cyst fragment floating in the cavity cyst fragment floating in the cavity

Cavity: Neoplasm (1)Cavity: Neoplasm (1)

Primary lung cancer:Primary lung cancer: – epidermoid ca.; bronchioloalveolar cell ca.epidermoid ca.; bronchioloalveolar cell ca.

Metastatic cancer: (NPC,Eso. Ca,Cx Ca)Metastatic cancer: (NPC,Eso. Ca,Cx Ca)– Man: head and neck in origin.Man: head and neck in origin.– Woman: Gyn. tract in origin.Woman: Gyn. tract in origin.

Radiological findings of cavity is not a Radiological findings of cavity is not a reliable signs to D.D. benign or malignancyreliable signs to D.D. benign or malignancy

Cavity: Neoplasm (2)Cavity: Neoplasm (2)

Features suggesting malignancyFeatures suggesting malignancy– Not significant amount of fluidNot significant amount of fluid– Eccentric cavitationEccentric cavitation– Thick wallThick wall– Lobulated and nodular wallLobulated and nodular wall

Lung cancerSq Carcinoma

Sq CarcinomaStalagmites/stalactites

Lung cancer,

Sq cell carcinoma

Lung cancer,

sq cell carcinoma

Squamous cell ca. of EsophagusSquamous cell ca. of Esophagus

Cervix Ca with meta

Rheumatoid ArthritisRheumatoid Arthritis

Pleural effusion Pleural effusion Nodules Nodules

– Necrobiotic nodules Necrobiotic nodules – Cavitate Cavitate

Interstitial fibrosis Interstitial fibrosis Erosion of posterior ribs Erosion of posterior ribs Kaplan syndrome Kaplan syndrome

– Coal worker pneumoconiosis Coal worker pneumoconiosis Bronchiolitis obliterans Bronchiolitis obliterans

Rheumatoid nodule with central Rheumatoid nodule with central cavitycavity

Inhalation DiseasesInhalation Diseases

Pneumoconiosis: Pneumoconiosis: – ischemic necrosis of the conglomerated ischemic necrosis of the conglomerated

massmass Silicosis: Silicosis:

– May cavitation by itselfMay cavitation by itself– Most likely due to TB superinfectionMost likely due to TB superinfection

--- TB must be ruled out in all patients w--- TB must be ruled out in all patients with silicosis + cavitationith silicosis + cavitation

SONY DSC V1

Cystic lesion Cystic lesion

PneumatocelePneumatocele Bullae Bullae BlebBleb Bronchogenic cystBronchogenic cyst Pulmonary sequestration Pulmonary sequestration

PneumatocelePneumatocele A thin wall space, caused byA thin wall space, caused by

– Infection: Infection: S. aureusS. aureus in infants & children in infants & children Pneumocystis cariniPneumocystis carini in AIDS p’ts in AIDS p’ts

– Hydrocarbon aspiration Hydrocarbon aspiration – Also occurs following traumaAlso occurs following trauma

Invariably transientInvariably transient Mechanism: Mechanism:

– check valve obstruction of the airwayscheck valve obstruction of the airways– Subpleural collection of air, dissection occurs throSubpleural collection of air, dissection occurs thro

ugh the interstitium of the lung ugh the interstitium of the lung

Staph. pneumonia with pneumatoceleStaph. pneumonia with pneumatocele

Bulla (1)Bulla (1)

A sharp demarcated, air containing space A sharp demarcated, air containing space 1 1 cm or more in diametercm or more in diameter that possess a smo that possess a smooth wall oth wall 1 mm or less in thickness.1 mm or less in thickness.

Usually occurs with other lung disease (Usually occurs with other lung disease (ememphysema physema oror infection infection).).

由由 infection infection 引起者，常伴有引起者，常伴有 adjacent paradjacent parenchymal scarringenchymal scarring 。。

Bulla (2)Bulla (2)

Secondary Sign: compression or displacemSecondary Sign: compression or displacement of adjacent structures (lung and mediasent of adjacent structures (lung and mediastinum).tinum).

Bullae are characteristically poorly ventilateBullae are characteristically poorly ventilated and unperfused.d and unperfused.

Bullae

1.COPD bullae

2.Fusion rib

3.Calcified TB

Infected bullae

Tension BullaTension Bulla

BlebBleb

Localized collection of air located within the Localized collection of air located within the pleura.pleura.

Most common occurs over lung apex, Most common occurs over lung apex, seldom exceeds 1 cm.seldom exceeds 1 cm.

Mechanism: alveolus rupture >> air Mechanism: alveolus rupture >> air dissection through interstitial tissue into dissection through interstitial tissue into the thin fibrous layer of visceral pleura.the thin fibrous layer of visceral pleura.

Bronchogenic Cysts (1)Bronchogenic Cysts (1) MechanismMechanism

– Localized portions of the tracheobronchial trLocalized portions of the tracheobronchial tree separated from normal airway during branee separated from normal airway during branching process and do not further developching process and do not further develop

Usually solitary, thin-walled, and sphericalUsually solitary, thin-walled, and spherical Filled with mucoid or serous fluid and do not coFilled with mucoid or serous fluid and do not co

mmunicate with the airways unless infected.mmunicate with the airways unless infected. Pathology: the wall typically contains cartilage Pathology: the wall typically contains cartilage

and smooth m. (important for diagnosis)and smooth m. (important for diagnosis)

Bronchogenic Cysts (2)Bronchogenic Cysts (2) Mediastinal bronchogenic cyst (65-90%)Mediastinal bronchogenic cyst (65-90%)

– paratracheal, carinal, hilar, paraesophageal …paratracheal, carinal, hilar, paraesophageal …– The first 2 are more common, more on R’t sideThe first 2 are more common, more on R’t side– Rarely communicates with airwaysRarely communicates with airways

Pulmonary bronchogenic cystPulmonary bronchogenic cyst– Sharply circumscribed round nodule Sharply circumscribed round nodule – In the medial third of the lungs, esp. lower lobesIn the medial third of the lungs, esp. lower lobes– Not communicate with the airways until infectedNot communicate with the airways until infected

Bronchogenic cyst

Pulmonary Pulmonary SequestrationSequestration Intralobar and Extralobar sequestrationIntralobar and Extralobar sequestration

DD by enclosing pleura and L-L or L-R shuntDD by enclosing pleura and L-L or L-R shunt Intralobar sequestrationIntralobar sequestration

– 好犯好犯 post. basal segment of lower lobe, left sidpost. basal segment of lower lobe, left side and contiguous with the diaphragme and contiguous with the diaphragm

– recurrent pneumoniarecurrent pneumonia– Less common: cystic mass (with or without fluiLess common: cystic mass (with or without flui

d levels) with prominent vessel --- due to infectid levels) with prominent vessel --- due to infectionon

Pulmonary sequestration

Casio EX Z3

Multiple Lucent Multiple Lucent Lesions-(I)Lesions-(I)I.I. CavityCavity

A.A. Infection (bacterial, fungal, mycobacterial aInfection (bacterial, fungal, mycobacterial and parasite)nd parasite)

B.B. Neoplasm Neoplasm 1.1. MetastasisMetastasis2.2. Bronchioloalveolar cell carcinomaBronchioloalveolar cell carcinoma

C.C. VascularVascular1.1. Wegener’s granulomatosisWegener’s granulomatosis2.2. Rheumatoid diseaseRheumatoid disease3.3. Infarct (thromboemboli or septic emboli)Infarct (thromboemboli or septic emboli)

Multiple Lucent Multiple Lucent Lesions-(II)Lesions-(II)

II.II. Cystic bronchiectasisCystic bronchiectasisIII.III. PneumatocelePneumatoceleIV.IV. BullaeBullaeV.V. Congenital cystic adenomatoid mCongenital cystic adenomatoid m

alformation (CCAM)alformation (CCAM)

Lung abscessMultiple aspiration

Multiple bullae

Necrotizing pneumonia,

Klebsiella pneumoniae

Tuberculosis

Lung cancer, adenocarcinoma

Adenocarcinoma

Septic emboli, cavity

Staphylococcus aureus

Vascular LesionsVascular Lesions

Wegener’s granulomatosis and rheWegener’s granulomatosis and rheumatoid arthritis:umatoid arthritis: – The 2 most likely collagen vascular diseThe 2 most likely collagen vascular dise

ase to cause cavitation. ase to cause cavitation. Pulmonary infarction:Pulmonary infarction:

– Occur in area of infarction greater than Occur in area of infarction greater than 4cm in diameter and happen 2 weeks af4cm in diameter and happen 2 weeks after appearance of the consolidation.ter appearance of the consolidation.

Wegener’s granulomatosis Wegener’s granulomatosis (1)(1) Adults in their thirties to fiftiesAdults in their thirties to fifties Typical pattern: Typical pattern:

--- multiple nodules ranging from 1-10 cm--- multiple nodules ranging from 1-10 cm Nodules tend to increase in size and numberNodules tend to increase in size and number Cavitation:Cavitation:

– 50%50%– Thick wall, irregular and shaggy inner lininThick wall, irregular and shaggy inner linin

gg– Less commonly -- thin wall or air-fluid levelLess commonly -- thin wall or air-fluid level

Wegener’s granulomatosis Wegener’s granulomatosis (2)(2) 22ndnd common CXR pattern common CXR pattern

– Multiple non-circumscribed lesionsMultiple non-circumscribed lesions– Acute air space consolidation or ground-glass Acute air space consolidation or ground-glass

opacities secondary to pulmonary opacities secondary to pulmonary hemorrhagehemorrhage--- localized, or bilateral; patchy, or confluent.--- localized, or bilateral; patchy, or confluent.

– With or without the presence of nodulesWith or without the presence of nodules Other findingsOther findings

– Airway involvement is also commonAirway involvement is also common– Pleural effusion: 10%; unilateral or bilateralPleural effusion: 10%; unilateral or bilateral

Wegener’s granulomatosis,

Fraser et al,

Synopsis of diseases of the chest, 2nd ed.

Wegener’s granulomatosisWegener’s granulomatosis

Sebastian Lange, Radiology of chest diseases, 1990

Congenital cystic adenomatoid malformation, (CCAM)

Cystic BronchiectasisCystic Bronchiectasis One of the 4 types( cylindrincal, varicose,One of the 4 types( cylindrincal, varicose,

saccular, cystic) of bronchiectasis saccular, cystic) of bronchiectasis Not true cavity, but ballooned dilatation Not true cavity, but ballooned dilatation

of multiple terminal bronchi of multiple terminal bronchi Causes:Causes:

– CongenitalCongenital– Recurrent infection – bacteria, TB, Recurrent infection – bacteria, TB,

cystic fibrosis, agammaglobulinemia, cystic fibrosis, agammaglobulinemia, – ABPAABPA

Cystic bronchiectasis

Cystic Bronchiectasis

Histiocytosis X Histiocytosis X (Langerhan’s cell histio(Langerhan’s cell histiocytosis)cytosis)

Young adult; male=femaleYoung adult; male=female Dry cough, SOB, pneumothorax, or asymptomaticDry cough, SOB, pneumothorax, or asymptomatic Histiocytes & eosinophils aggregate, no granulomaHistiocytes & eosinophils aggregate, no granuloma Upper lobe predominence, sparing lung baseUpper lobe predominence, sparing lung base CXR and CTCXR and CT

nodules nodules cavitated nodules or cysts cavitated nodules or cysts honeycom honeycombb

Spontaneous pneumothoraxSpontaneous pneumothorax Concomitant nodules and cysts in upper and middlConcomitant nodules and cysts in upper and middl

e lung fields sparing lung base is diagnostice lung fields sparing lung base is diagnostic

Histiocytosis X

LymphangioleiomyomatosisLymphangioleiomyomatosis Premenopausal women predominencePremenopausal women predominence Proliferation of smooth muscle-like LAM cells in Proliferation of smooth muscle-like LAM cells in

small airway, microvasculature and lymphaticssmall airway, microvasculature and lymphatics Airway obs, cystic change of lung, pulmonary heAirway obs, cystic change of lung, pulmonary he

morrhage, pneumothorax, chylothoraxmorrhage, pneumothorax, chylothorax Early stage Early stage

– CXR: diffuse reticulonodular patternCXR: diffuse reticulonodular pattern– HRCT: air-cysts diffusely distributed in all lung zonesHRCT: air-cysts diffusely distributed in all lung zones

no nodules, no lobe predominence no nodules, no lobe predominence End stage: honeycombingEnd stage: honeycombing

LymphangioleiomyomatosisLymphangioleiomyomatosis

Canon EOS 10D

ColonDiaphragm ruptureDiaphragm eventration

Colon herniation

Plumbage

07 cavitary & cystic lesions

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