1horac|c Imag|ng II

8akesh Shah, Mu, lCC

Chlef of 1horaclc 8adlology
ueparLmenLs of 8adlology and Medlclne
norLh Shore unlverslLy PosplLal
AssoclaLe rofessor of 8adlology
PofsLra norLh Shore-Ll! School of Medlclne

D|sc|osure
l have no relauonshlps wlLh any lndusLry
Cb[ecnve
uenluon: SollLary
pulmonary nodule (Sn)
ulerenual ulagnosls
Work-up of nodule:
Solld:
8enlgn
Less Lhan 4 mm
Slze beLween 3 Lo 8 mm
CreaLer Lhan 9 mm
Subsolld
Plgh 8esoluuon C1 ( P8C1 )
AnaLomy
ulsLrlbuuon and pauern
of dlseases
Clossary of Lerms
Lxamples of aLhology
SN
local round or oval area
of lncreased opaclLy
Can be non-solld, parL
solld or solld
Less Lhan 3 cm ln
maxlmum dlameLer
noL assoclaLed wlLh
aLelecLasls, pneumonla
or adenopaLhy
SN: D|erent types of nodu|es
SN
Cen dlscovered lncldenLally
Caused by varleLy of condluons, boLh benlgn and
mallgnanL
lmporLanL Lo ldenufy benlgn versus mallgnanL
nodules
re-LesL probablllLy
Morphology
lmaglng LesLs: Lung nodule enhancemenL, L1 scan
rocedures: 8ronchoscopy, 11n8
Coal: Avold morbldlLy and morLallLy assoclaLed wlLh
LhoracoLomy for benlgn dlseases

SN: DDx |s very |ong
8enlgn:
neumonla
Cranuloma
PamarLoma
AvM
ulmonary arLery
pseudoaneuyrsm
lnLrapulmonary lymph
nodes
lnammaLory
MallgnanL:
Lung cancer
MeLasLasls
Carclnold
Lymphoma
SN: Work-up starts w|th C1 scan
Calclcauon:
8enlgn & MallgnanL pauerns
laL:
Slgnles leslon as benlgn
vascular leslon
lnLrapulmonary lymph node (lLn)
Slze
Morphology
8ound / LobulaLed / SplculaLed: noL very helpful
Solld nodule / ure ground glass / Subsolld nodules
Benign Patterns Malignant Patterns
auerns of Ca|c|hcanon
namartoma
L|po|d pneumon|a
AVM
Intrapu|monary |ymph node ( ILN )
What |s an Intrapu|monary Lymph
Node?
nodule of lymphauc ussue ln Lhe lungs
8enlgn
uevelop ln response Lo anugenlc sumull
Also, someumes referred Lo as perlssural nodule
lnhaled dusL
lnammaLory response
Accumulauon of LymphocyLes and Macrophages
Pyperplasla of lymph nodes
Lymphanc I|ow |n the 1horac|c Cav|ty
Subpleural lnLersuuum
lnLerlobular SepLa
lnLralobular SepLa
CenLrllobular lnLersuuum
erlbronchovascular lnLersuuum
Locanon and Shape of ILN
Locauon:
Subcarlnal
erlpheral, oen subpleural
Shape:
1rlangular or Angular
Llllpucal
Semlclrcular
ILN are assoc|ated w|th ||near opac|nes
Llnear opaclues
represenL:
lnLerlobular
sepLa
ulmonary veln
Lymphauc
channels
Cshlro, ? . lnLrapulmonary lymph nodes: 1hln-secuon C1 feaLures of 19 nodules. ! CompuLer AsslsLed 1omography. (2002) 26 (4), 333-337.
Character|sncs of ILN
Subcarlnal
vasL ma[orlLy are ln Lhe 8ML, Llngula and
lower lobes
Subpleural
vasL ma[orlLy are wlLhln 2 cm of Lhe pleura
Slze
vasL ma[orlLy are less Lhan 1 cm
Shape
1rlangular, Angular, Llllpucal, Semlclrcular
Llnear CpaclLy
AssoclaLed wlLh lnLerlobular sepLa
So||d nodu|e
known hlsLory of mallgnancy
nodules of any slze: MeLasLasls should be consldered
lollow-up/Work-up accordlng Lo relevanL proLocol
for LhaL mallgnancy
lrequenL follow-up may be lndlcaLed
n|story of Co|on CA: 6 mths apart
So||d nodu|e
no known hlsLory of mallgnancy
Work-up ls based on slze of nodule:
Less Lhan 4 mm ln slze
Slze beLween 3 Lo 8 mm
CreaLer Lhan 9 mm
So||d nodu|e: Less than 4 mm |n s|ze
8esulLs from muluple
Lung cancer screenlng
Lrlals
llelschner guldellnes:
no follow-up ln absence
of rlsk facLors
CLherwlse, follow-up ln
one year
8lsk of mallgnancy:
< 3 mm: 0.2
4 Lo 7 mm: 0.9
8 Lo 20 mm: 18
> 20 mm: 30
Midthun DE, Swensen SJ, Jett JR, Hartman TE. Evaluation of nodules detected by screening for lung cancer with
low dose spiral computed tomography. Lung Cancer 2003;41(suppl 2):S40.
So||d nodu|e: Less than 4 mm |n s|ze
8esulLs from muluple
Lung cancer screenlng
Lrlals
llelschner guldellnes:
no follow-up ln absence
of rlsk facLors
CLherwlse, follow-up ln
one year
Many are lLn's
So||d nodu|e: S to 8 mm |n s|ze
Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. Guidelines
for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society Radiology November 2005 237:395-400
I|e|schner Soc|ety Gu|de||nes
Nodu|e S|ze Low-k|sk anent n|gh-k|sk anent
>4-6 mm lollow-up aL 12 mLhs

lf unchanged, no follow-up
lollow-up aL 6-12 mLhs

lf unchanged, follow-up ln
18-24 mLhs
>6-8 mm lollow-up aL 6-12 mLhs

lf unchanged, follow-up ln
18-24 mLhs
lollow-up aL 3-6 mLhs

lf unchanged, follow-up ln
9-12 and 24 mLhs
Should try to perform follow-up scans using low-dose protocol
SN: > 9 mm |n s|ze
neumon|a
neumon|a
So||d nodu|e: Larger than 9 mm
ShorL lnLerval follow-up
lf resolved:
Llkely lnfecuon and no furLher work-up necessary
lf decreased ln slze:
Llkely lnfecuon buL follow-up Lo resoluuon
lf unchanged: 8equlres work-up
lollow-up
8ronchoscopy, 11n8, Surgery
L1 lmaglng
nodule enhancemenL C1 scan
Subso||d nodu|es
ure ground g|ass art so||d
Subso||d nodu|e
ure ground glass nodule (CCn) or arL solld nodule
SollLary or Muluple
May be benlgn
lnfecuon
Assumed Lo be adenocarclnoma ln slLu (AlS),
formerly referred Lo as bronchloloalveolar carclnoma
( 8AC )
arL solld: More llkely Lo be mallgnanL
New c|ass|hcanon of |ung
adenocarc|nomas
remallgnanL:
ALyplcal adenomaLous hyperplasla (AAP)
Adenocarclnoma ln slLu (AlS)
MallgnanL:
MlA
lnvaslve componenL measurlng less Lhan 3 mm
lnvaslve adenocarclnoma:
lnvaslve componenL measures greaLer Lhan 3 mm
So||tary GGN: Less than S mm
uo noL requlre follow-up
examlnauon
uoubllng ume ls 3 Lo 3 years
Many llkely represenL
lncldenLal focl of
adenomaLous hyperplasla
1o esLabllsh Lrue naLure of
CCn:
CbLaln 1 mm Lhln
secuons
Na|d|ch D, 8ank|er AA, MacMahon n, Schaefer-rokop CM, |sto|es| M, Goo IM, Macch|ar|n| , Crapo ID, nero|d CI, Ausnn In, 1rav|s WD.
kecommendanons for the management of subso||d pu|monary nodu|es detected at C1: A statement from the I|e|schner Soc|ety. kad|o|ogy Vo| 266(1):304-317
So||tary GGN: Larger than S mm
lnlual follow-up ln 3
monLhs
lf unresolved:
?early follow-up for
mlnlmum of 3 years
no way Lo know exacL
naLure shorL of resecuon
8lopsy and L1 C1 scan
are noL recommended
Na|d|ch D, 8ank|er AA, MacMahon n, Schaefer-rokop CM, |sto|es| M, Goo IM, Macch|ar|n| , Crapo ID, nero|d CI, Ausnn In, 1rav|s WD.
kecommendanons for the management of subso||d pu|monary nodu|es detected at C1: A statement from the I|e|schner Soc|ety. kad|o|ogy Vo| 266(1):304-317
So||tary Subso||d nodu|e
lnlual follow-up ln 3 monLhs
lf solld componenL <3 mm:
?early follow-up for mlnlmum
3 years
lf solld componenL >3 mm:
8ecommend blopsy or
surglcal resecuon
MosL llkely Lo represenL
lnvaslve adenocarclnoma
Conslder L1 scan for
nodules greaLer Lhan 1 cm
Na|d|ch D, 8ank|er AA, MacMahon n, Schaefer-rokop CM, |sto|es| M, Goo IM, Macch|ar|n| , Crapo ID, nero|d CI, Ausnn In, 1rav|s WD.
kecommendanons for the management of subso||d pu|monary nodu|es detected at C1: A statement from the I|e|schner Soc|ety. kad|o|ogy Vo| 266(1):304-317
Cb[ecnve
uenluon: SollLary pulmonary nodule (Sn)
ulerenual ulagnosls
Work-up of nodule: C1 scan
Solld:
8enlgn
Less Lhan 4 mm
Slze beLween 3 Lo 8 mm
CreaLer Lhan 9 mm
Subsolld


nkC1: Cb[ecnves
8evlew anaLomy
Secondary pulmonary lobule
ulmonary lnLersuuum
lnLerpreLauon
ulsLrlbuuon
auern
Clossary of Lerms
Lxamples of aLhology
nkC1
used Lo evaluaLe dluse pulmonary parenchymal
abnormallLy
rovldes deLalled vlsuallzauon of Lhe lung
parenchyma
re-blopsy work-up
Pelpful ln assesslng dlsease acuvlLy
Secondary u|monary Lobu|e
luncuonal unlL of lung: Cas
exchange occurs
SmallesL unlL of lung LhaL ls vlslble
on P8C1
lrregularly polyhedral ln shape
Lach lobule measures
approxlmaLely 1 - 2.3 cm
AbouL 12 Lo 20 aclnl ln one lobule
Lach aclnl are abouL 0.3 Lo 1 cm
each
Made of cenLral and sepLal
sLrucLures
u|monary Intersnnum
Subpleural
Interlobular
Intralobular
Centrilobular
Peribronchovascular
Norma| nkC1: Lobu|es not v|s|b|e

Norma| nkC1: Lobu|es not v|s|b|e

nkC1: Interpretanon
ulsLrlbuuon
Axlal, mlddle or
perlpheral
upper versus Lower
unllaLeral or
AsymmeLrlc
uluse
auern
Llnear and 8eucular
opaclues
nodules and nodular
opaclues
AlLered auenuauon
L|near and kencu|ar opac|nes
1hlckenlng of Lhe
perlbronchovascular
lnLersuuum
lnLerlobular sepLal
Lhlckenlng
lnLralobular sepLal
Lhlckenlng
Poneycomb cysLs
1racuon bronchlecLasls
arenchymal bands
Subpleural llnes
1h|cken|ng of er|bronchovascu|ar Intersnnum
lncrease ln bronchlal wall Lhlckness and ln Lhe dlameLer of pulmonary
arLerles
1hlckenlng can be smooLh, nodular or lrregular

1h|cken|ng of Inter|obu|ar Septa
Walls of Lhe secondary
pulmonary lobule
become Lhlckened
SepLal llnes exLend Lo
Lhe pleural surface
erpendlcular Lo Lhe
pleura
1hlckenlng can be
smooLh, nodular or
lrregular
Inter|obu|ar Septa| 1h|cken|ng: DDx
SmooLh
ulmonary edema
Lymphangluc spread of cancer
nodular
Sarcoldosls
Lymphangluc spread of cancer
lrregular
ulmonary brosls

ulmonary edema

Lymphangluc
carclnomaLosls

Lymphangluc
carclnomaLosls

ulmonary
alveolar proLelnosls
1h|cken|ng of the Inter and Intra|obu|ar
Septa
noneycomb cysts
Small cysuc spaces llned
by bronchlolar
eplLhellum
usually abouL 1 cm ln
dlameLer
erlpheral / Subpleural
SuggesLs end-sLage lung
dlsease
1racnon bronch|ectas|s
8ronchlal dlllLauon as a
resulL of lung brosls
ulllLauon ls lrregular or
corkscrew ln
appearance
Interpretanon
uescrlpuon of ndlngs uslng approprlaLe
Lermlnology
uemonsLraLes undersLandlng of paLhophyslology and
dlsease processes
ulsLrlbuuon
Anclllary ndlngs
lormulaLe shorL ulerenual ulagnosls
ulagnosls
CPl
Lymphang|nc spread of cancer
II
Asbestos|s
Sc|eroderma
nkC1: Nodu|es and Nodu|ar Cpac|nes
erllymphauc
8andom
CenLrllobular
1ree-ln-bud
er||ymphanc Nodu|es
ulsLrlbuuon:
AL Lhe pleural surface,
lncludlng ssures
ln Lhe lnLerlobular sepLa
ln Lhe
perlbronchovascular
lnLersuuum
ulerenual dlagnosls:
Sarcoldosls
Lymphangluc spread of
carclnoma
Sarco|dos|s
Sarco|dos|s
Sarco|d Ga|axy S|gn
Large nodules arlse
from coalescence of
small granulomas
SlmulaLe Lhe
appearance of galaxy
kandom Nodu|es
8andomly dlsLrlbuLed
relauve Lo sLrucLures of lung
and secondary pulmonary
lobule
Lvenly dlsLrlbuLed
LhroughouL boLh lungs
ulerenual dlagnosls:
Mlllary 18, lungal lnfecuons
PemaLogenous meLasLasls
Nodu|es: kandom D|str|bunon

Nodu|es: kandom D|str|bunon

Metastases



Septic emboli



Miliary pattern
Centr||obu|ar Nodu|es
ln Lhe cenLer of Lhe
secondary pulmonary
lobule
Spares pleural surface
Lvenly spaced and occurs
abouL 3-10 mm from pleural
surface
Cround-glass
1ree-ln-bud
Centr||obu|ar Nodu|es
ln Lhe cenLer of Lhe
secondary pulmonary
lobule
Spares pleural surface
Lvenly spaced and occurs
abouL 3-10 mm from pleural
surface
Cround-glass
1ree-ln-bud
Centr||obu|ar Nodu|es
Differential diagnosis
Bronchiolar
Infection
Inflammatory
bronchiolitis
Bronchiolar-peribronchiolar
Hypersensitivity
pneumonitis
Respiratory bronchiolitis
Arterial / Lymphatic
Rare
nypersens|nv|ty neumon|ns
1ree-|n-bud
8epresenLs dllaLed and
lmpacLed cenLrllobular
bronchlole
AlmosL always lndlcauve of
endobronchlal spread of
lnfecuon
SuggesLs acuLe / acuve
lnfecuon
ulerenual ulagnosls:
Mucus
lnfecuon
8ronchlollus obllLerans
1ree-|n-bud
8epresenLs a dllaLed and
lmpacLed cenLrllobular
bronchlole
AlmosL always lndlcauve of
endobronchlal spread of
lnfecuon
SuggesLs acuLe / acuve
lnfecuon
ulerenual ulagnosls:
Mucus
lnfecuon
8ronchlollus obllLerans
Mucus
keacnvanon 18
nkC1: A|tered Auenuanon
lncreased
Cround glass opaclLy
Consolldauon
uecreased
Lmphysema
CysLs
Mosalc
Small alrways dlsease
vascular dlsease
Increased Auenuanon
Cround Class CpaclLy ( CCC )
Consolldauon
GGO Consolidation
Ground G|ass Cpac|ty
Pazy lncreased auenuauon of lung wlLh preservauon
of bronchlal and vascular marglns
Caused by parual lllng of alr spaces
Long dlerenual dlagnosls
Locauon, dlsLrlbuuon, assoclaLed ndlngs and hlsLory
should help narrow dlerenual dlagnosls
u|monary nemorrhage
A|veo|ar rote|nos|s
Crazy-av|ng auern
8epresenLs a comblnauon of Lhlckenlng of Lhe
lnLerlobular sepLa and ground glass opaclLy
uux:
Alveolar proteinosis
PCP
CHF
Pulmonary hemorrhage
Adenocarcinoma in situ ( formerly referred to as BAC )
Lipoid pneumonia
u|monary edema
Conso||danon
lncreased auenuauon wlLh obscurauon of underlylng
pulmonary vessels
CharacLerlzed by compleLe replacemenL of alveolar alr by
uld, cells and/or ussue
Long dlerenual dlagnosls
Locauon, dlsLrlbuuon, assoclaLed ndlngs and hlsLory
should help narrow dlerenual dlagnosls
Leg|one||a neumon|a
Adenocarc|noma |n s|tu (8AC)
Decreased Auenuanon
Alr-lled cysuc spaces
Lxamples
Poneycomb cysL
Lmphysema
Lung cysLs
CavlLary nodules
8ronchlecLasls
Alr Lrapplng
Lmphysema
Centr||obu|ar an|obu|ar
Centr||obu|ar Lmphysema
Langerhans Ce|| n|snocytos|s k
Lymphang|omyomatos|s
8ronch|ectas|s
Courtesy of Dr. Abbott
Dipth
Varicoid
Cysnc I|bros|s
kartegeners Syndrome
MAC
Mosa|c Auenuanon
AlLernaung areas of
lncreased and decreased
lung auenuauon
Common luall: 8reaLhlng
mouon arufacL
3 maln caLegorles of dlsease
processes:
Small Alrway ulsease
vascular ulsease
arenchymal ulsease

Mosa|c Auenuanon
AlLernaung areas of
lncreased and decreased
lung auenuauon
Common luall: 8reaLhlng
mouon arufacL
3 maln caLegorles of dlsease
processes:
Small Alrway ulsease
vascular ulsease
arenchymal ulsease

Mosa|c Auenuanon
CbLaln palred lnsplraLory-explraLory lmages
Small alrways dlsease:
Lucent regions remain same in size or enlarge
Ancillary findings: Bronchiectasis, Tree-in-bud opacities, Mucoid
impaction
vascular dlsease:
Lucent regions decrease in size
Attenuation of both low and high attenuation lung
increases in similar fashion
Ancillary findings: Enlarged main PA, Eccenteric filling defects in
pulmonary artery, Stenosis and Webs in pulmonary arteries
Inspiratory
Expiratory
Inspiratory
Expiratory
Mosaic pattern is a result of air trapping on expiratory view
Asthma
Inspiration Expiration
Inspiration Expiration
Swyer-Iames Syndrome
u|monary n1N
Chron|c
1hromboembo||c
D|sease
Cb[ecnves
8evlew
1racheobronchlal dlseases
ALelecLasls
C1 pulmonary anglography
Medlasunum
SollLary pulmonary nodule
Plgh 8esoluuon C1 scan
W|thout Mus|c L|fe Wou|d 8e A M|stake
1hank you
Residents
Fellows