Radiologic

Pathology
Fifth Edition

VOLUME 1
Chest, Gastrointestinal, and Genitourinary
Radiologic Pathology Correlation

2006
Editors

Angela D. Levy, COL, MC, USA
Chairman and Registrar
Chief, Gastrointestinal Radiology

2007
Ellen M. Chung, LTC, MC, USA
Chief, Pediatric Radiology

Jeffrey R. Galvin, MD
Chief, Chest Radiology

Kelly K. Koeller, MD
Chief, Neuroradiology

Mark D. Murphey, MD
Six Week Course Director
Chief, Musculoskeletal Radiology

Paula J. Woodward, MD Illustrators
Chief, Genitourinary Radiology Aletta A. Frazier, MD
Dianne D. Engelby, MAMS, RDMS
Associate Editor Heike Blum, MFA
Jean-Claude Kurdziel, MD

Department of Radiologic Pathology
Armed Forces Institute of Pathology
Washington DC, USA

American Registry of Pathology
Armed Forces Institute of Pathology
Washington, DC
20306-6000
_____________________________________

© Copyright 2006 by the American Registry of Pathology.

All rights reserved. No part of this publication may be reproduced or transmitted in any form
or by any means: electronic, mechanical, photocopy, recording, or any other information
storage and retrieval system without written permission of the publisher.

Made in the United States of America
_____________________________________

Great care has been taken to guarantee the accuracy of the information contained in this
volume. However, neither the American Registry of Pathology, Armed Forces Institute of
Pathology, nor the editors and contributors can be held responsible for errors or for any
consequences arising from the use of the information contained herein.

The opinions and assertions contained herein are the private views of the authors and are
not to be construed as official nor as representing the views of the Departments of the Army,
Air Force, Navy, or Defense.

987654321

Library of Congress Cataloging-in-publication Data [in process]

ISBN 1-933477-00-8

Preface
The Armed Forces Institute of Pathology’s Radiologic Pathologic Correlation
course presented by the Department of Radiologic Pathology enters its 59th year
of educating radiology residents worldwide. For the fifth year, our staff and visiting
lecturers have contributed their lecture material and images to compile Radiologic
Pathology 2006 – 2007, continuing the tradition of presenting richly illustrated
material that teaches the pathologic basis of disease to improve our understanding
of the imaging appearance of disease. We hope the efforts of our authors and
editors have once again accomplished our goal of bringing the outstanding and
unique Radiologic Pathologic Correlation course to your fingertips.

Acknowledgements

The annual production of the Radiologic Pathologic Correlation course and
syllabus is made possible through the tremendous support, dedication, and
selfless service of countless individuals who work in the AFIP and the various
institutions and organizations throughout the world that believe in the importance
of teaching the principles of disease through radiologic pathologic correlation.

The Department of Radiologic Pathology of the Armed Forces Institute of
Pathology expresses our deepest appreciation and sincerest gratitude to:
- All radiologists and radiology residents who have contributed case material to
the Thompson Radiologic Pathologic Archive at the Armed Forces Institute of
Pathology,
- All pathologists in the AFIP who have donated their time and expertise to
radiologic pathologic correlation,
- All of our outstanding authors, illustrators, and department staff members who
make the course and the syllabus happen effortlessly year after year,
- And, to the extraordinary efforts of our production team, headed by Jean-
Claude Kurdziel, MD, who have tirelessly dedicated the spring and summer of
the last five years to the production of this syllabus.

iii

Faculty – VOLUME 1

Chest Radiology
Marc S. Levine, MD
Jeffrey R. Galvin, MD Professor of Radiology
Chief, Pulmonary and Mediastinal Radiology
Hospital of the University of Pennsylvania
Department of Radiologic Pathology
Advisory Dean
Armed Forces Institute of Pathology
University of Pennsylvania School of Medicine
Washington, DC
Philadelphia, PA
and
and
Professor of Radiology and Pulmonary Medicine
Former Distinguished Scientist
University of Maryland
Department of Radiologic Pathology
Baltimore, MD
Armed Forces Institute of Pathology
Gerald F. Abbott, MD Washington, DC
Director of Chest Radiology
Rhode Island Hospital Deborah Rubens, MD
and Professor and Associate Chair
Assistant Professor of Radiology Department of Imaging Sciences
Brown University School of Medicine University of Rochester Medical Center
Providence, RI Rochester, NY
and
Aletta A. Frazier, MD Distinguished Scientist
Staff Radiologist and Medical Illustrator Department of Radiologic Pathology
Department of Radiologic Pathology Armed Forces Institute of Pathology
Armed Forces Institute of Pathology Washington, DC
Washington, DC
and Francis J. Scholz, MD
Clinical Associate Professor of Radiology Staff Radiologist
University of Maryland School of Medicine Lahey Clinic Medical Center
Baltimore, MD Burlington, MA
and
Leonard M. Glassman, MD Clinical Professor of Radiology
Washington Radiology Associates, PC Tufts University School of Medicine
Washington, DC Boston, MA
and
Clinical Professor Robert K. Zeman, MD
Department of Radiology Chairman and Professor of Radiology
George Washington University Medical Center George Washington University
Washington, DC Washington, DC
Melissa L. Rosado de Christenson, MD, FACR
Clinical Professor of Radiology
Genitourinary Radiology
The Ohio State University Paula J. Woodward, MD
Columbus, OH Acting Chief, Genitourinary Radiology
and Department of Radiologic Pathology
Adjunct Professor of Radiology Armed Forces Institute of Pathology
Uniformed Services University of the Health Sciences Washington, DC
Bethesda, MD and
Adjunct Professor of Radiology
Rosita M. Shah, MD University of Utah School of Medicine
Clinical Associate Professor of Radiology
Salt Lake City UT
Hospital of the University of Pennsylvania
Philadelphia, PA
Peter L. Choyke, MD
Chief Molecular Imaging Program
Gastrointestinal Radiology National Cancer Institute
Angela D. Levy, COL, MC, USA Bethesda, MD
Chairman and Gastrointestinal Radiology Section Chief and
Department of Radiologic Pathology Professor of Radiology and Nuclear Medicine
Armed Forces Institute of Pathology Uniformed University of the Health Sciences
Washington, DC Bethesda, MD
and William D. Craig, MD
Associate Professor of Radiology and Nuclear Medicine Chief, Genitourinary Radiology
Uniformed Services University of the Health Sciences Department of Radiologic Pathology
Bethesda, MD Armed Forces Institute of Pathology
Bruce P. Brown, MD Washington, DC
Associate Professor of Radiology
University of Iowa
Iowa City, IA

iv

David S. Hartman, MD
Professor of Radiology
Department of Radiology
Pennsylvania State University
M. S. Hershey Medical Center
Hershey, PA

Deborah J. Rubens, MD
Professor and Associate Chair
Department of Imaging Sciences
University of Rochester Medical Center
Rochester, NY
and
Distinguished Scientist
Department of Radiologic Pathology
Armed Forces Institute of Pathology
Washington, DC
Brent J. Wagner, MD
Chairman, Department of Radiology
The Reading Hospital and Medical Center
West Reading Radiology Associates
West Reading, PA
Jade J. Wong-You-Cheong, MD
Associate Professor of Diagnostic Radiology
Director of Ultrasound
University of Maryland School of Medicine
Baltimore, MD

v

Table of Contents – VOLUME 1

Chest Radiology
Jeffrey R. Galvin, MD
An Approach to Diffuse Lung Disease, Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
The Idiopathic Interstitial Pneumonias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Airways Disease: The Movement from Anatomic to Physiologic Assessment . . . . . . . . . . . . . . . . . . . . . . . .26
Inhalational Lung Disease (Asbestosis and Silicosis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Pulmonary Lymphoid Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Angiitis and Granulomatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
The Pulmonary Complications of Organ Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
The Diagnosis of Pulmonary Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82
Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93
Fungal Disease in the Thorax: Opportunistic and Primary Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100
Bronchogenic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
Chest Seminar 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
Chest Seminar 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126
Aletta A. Frazier, MD
Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
Pulmonary Metastasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
Melissa L. Rosado de Christenson, MD, FACR
Differential Diagnosis of Mediastinal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148
Chest Seminar: Where is the lesion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168
Chest Seminar: Differential Diagnosis of Mediastinal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
Rosita M. Shah, MD
Pneumonia: Usual and Unusual Organisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178
Gerald F. Abbott, MD
Uncommon Malignant Tumors of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
Benign Tumors of the Lung and Tumor-like Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199
Pleural Disease I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .205
Pleural Disease II and Chest Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213
Leonard M. Glassman, MD (Mammography)
Classic Breast Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .220
Basic Breast Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229
Ductal Carcinoma in Situ (DCIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238
Breast Abnormalities in Young Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .246
The Male Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257

Gastrointestinal Radiology
Angela D. Levy, COL, MC, USA
Benign Hepatic Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .267
Malignant Hepatic Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .275
Hepatic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .284
Imaging of Chronic Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293
Benign Biliary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .303
Biliary Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .313
Pancreatic Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .321
Gastric Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .332
Abdominal Non Hodgkin Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .344
Small Intestinal Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353
Colorectal Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .361
Mesenteric Masses and Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .372
Idiopathic Inflammatory Bowel Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .382
Approach to Inflammatory Diseases of the Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .391
GI Seminar 1: Abdominal Gas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .400
GI Seminar 2: Nonneoplastic Disease of the Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405
GI Seminar 3: Pancreatic Duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .411
GI Seminar 4: Hepatic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .417
GI Seminar 5: Complications of Meckel Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .422

vi

GI Seminar 6: Beyond Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .427
GI Seminar 7: Tumors and Tumor-Like Lesions of the Gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .432
Robert K. Zeman, MD
Cholelithiasis and Cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .438
Marc S. Levine, MD
Inflammatory Diseases of the Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .444
Tumors of the Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .450
Radiology of Peptic Ulcer Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .455
Bruce Brown, MD
Pancreatitis: Imaging Has Made a Difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .460
Gastrointestinal Bleeding In The Age of the Endoscope. What Does a Radiologist Have To Contribute? . .468
Francis J. Scholz, MD
Small Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .475
Acute Mesenteric Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .487
Malabsorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .505
Familial Polyposis and Other Such . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .519
Deborah J. Rubens, MD
The Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .531
Portal Venous Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .542

Genitourinary Radiology
Paula J. Woodward, MD
Imaging of Uterine Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .551
Approach to Renal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .561
Urinary Tract Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .573
Retroperitoneum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .579
Radiologic Evaluation of the Scrotum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .585
First Trimester Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .594
Fetal CNS Malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .602
Fetal Body Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .607
Peter L. Choyke, MD
Cystic Diseases of the Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .614
Imaging of Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .620
William D. Craig, MD
Radiographic Evaluation of Urinary Stone Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .624
Deborah J. Rubens, MD
Testicular Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .630
Brent J. Wagner, MD
Imaging of Ovarian Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .637
Adrenal Imaging in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .645
Imaging of the Urinary Bladder and Urethra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .649
Jade Wong You Cheong, MD
Non-Neoplastic Disorders Of The Ovary And Adnexae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .653
Imaging of Solid Organ Transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .664
David S. Hartman, MD
The Neglected Nephrogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .674
Problem Renal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .681
Paula J. Woodward, MD
GU Seminar 1: MSAFP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .691
GU Seminar 2: Renal Calcifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .693

vii

Chest Radiology

An Approach to Diffuse Lung Disease,
Sarcoidosis
Jeffrey R. Galvin, MD

Describing Diffuse Lung Disease
• The Alveolar vs. Interstitial Problem
• Alveolar or Interstitial ?

An Approach to Diffuse Lung Disease Figure 1-1-2
• Radiograph
➢ Lung volumes
➢ Opacity
➢ Distribution
➢ Ancillary findings
• Computed tomography
➢ Opacity
➢ Distribution

Figure 1-1-1

Radiology and pathology form
a continuum of visualization

Fibrosis results in reduced lung volumes
Lung Volumes
• Reduced [Figure 1-1-2]
➢ Pathology distal to the airway Figure 1-1-3
➢ Fibrosis
➢ IPF, asbestosis, sarcoidosis, chronic
hypersensitivity pneumonitis
• Increased [Figure 1-1-3]
➢ Pathology of the airway
➢ Emphysema, asthma, bronchitis, constrictive
bronchiolitis, LAM

Airways disease results in increased
lung volumes

Chest Radiology 3 An Approach to Diffuse Lung Disease

Distribution: Upper vs Lower [Figure 1-1-4] Figure 1-1-4

Plain Film and CT Opacities
• Nodules
• Reticulation and Lines
• Ground glass
• Consolidation
• Cystic airspaces

Plain Film and CT Opacities
• Nodules
➢ Sarcoid
➢ Silicosis, coal-workers
➢ Hypersensitivity Pneumonitis
➢ Metastasis
• Reticulation and Lines
➢ Fibrosis
✧ IPF-lower, subpleural
✧ Asbestosis-lower, subpleural
✧ Sarcoidosis-peribronchovascular
✧ Chronic hypersensitivity pneumonitis-mid and
upper lung zone
• Ground glass [Shah and Miller AJR 2003]
➢ Non-specific
✧ Airspace, interstitial, combined
– DIP, NSIP, AIP, DAD (32%)
✧ Infection (32%)
✧ Drug toxicity (11%)
✧ Hemorrhage (3%)
✧ Ground glass with reticulation
– Fibrosis Chronic diseases tend to involve the upper lung
• Consolidation
➢ Organizing Pneumonia (BOOP)
➢ Chronic eosinophilic pneumonia
➢ Lymphoma
➢ Bronchoalveolar cell carcinoma
➢ Infection
➢ Hemorrhage
• Cystic airspaces
➢ Mimics reticulation on plain radiographs
➢ Fibrosis and honeycombing
✧ IPF-Lower, subpleural
✧ LAM-Diffuse
✧ LCH-Upper

Radiologic-Pathology Continuum

Anatomy - Secondary Lobule
• As defined by Miller
➢ Polygonal
➢ 1-2.5 cm
➢ Smallest unit demarcated by connective tissue septa
• Most useful diagnostically
➢ Readily identified on:
✧ HRCT
✧ Gross examination
✧ Histologic section
➢ Explains HRCT appearance
✧ Broad range of lung diseases
✧ Especially interstitial disease

An Approach to Diffuse Lung Disease 4 Chest Radiology

Anatomy - Secondary Lobule [Figure 1-1-5]
• Core structures
➢ Axial interstitium
➢ Bronchiole
➢ Pulmonary artery
➢ Lymphatics
• Septal structures
➢ Peripheral interstitium
➢ Pulmonary veins
➢ Lymphatics
• Parenchyma
➢ Alveolar interstitium
➢ Alveoli
➢ Pulmonary capillary bed

Figure 1-1-5

The secondary lobule with lymphatics in the
interloblular septa and along
the bronchovascular bundle

Figure 1-1-6

Septal pattern on HRCT and gross specimen

Chest Radiology 5 An Approach to Diffuse Lung Disease

Abnormal Patterns Figure 1-1-7 Figure 1-1-8
• Bronchovascular
➢ Bronchus
✧ Asthma, CF, bronchitis,
bronchiectasis [Figure 1-1-7]
➢ Lymphatic
✧ CA, lymphoma, sarcoidosis
✧ Edema
• Centrilobular [Figure 1-1-8]
➢ Airway related
• Panlobular [Figure 1-1-9]
➢ Nonspecific
• Septal
➢ Lymphatic
✧ CA, lymphoma, sarcoidosis
[Figure 1-1-10and 1-1-11]
✧ Edema
• Random [Figure 1-1-12] Bronchovascular pattern Centrilobular pattern
➢ Hematogenous spread of tumor
➢ TB
Figure 1-1-9 Figure 1-1-10
Sarcoidosis
• Multisystem granulomatous disorder
• Unknown etiology
• Young and middle aged adults
• Bilateral hilar lymphadenopathy, pulmonary
infiltration, eye and skin lesions
• Clinical and radiologic findings supported
by evidence of noncaseating epithelioid
granulomas
• Exclusion of granulomas of unknown cause
and local sarcoid reactions
ATS Statement on Sarcoidosis 1999

Sarcoidosis: Epidemiology
• Worldwide
➢ both sexes, all races, all ages Panlobular pattern Septal pattern
• Predilection for adults
➢ under 40 years
➢ peak 20-29 years
• U.S. prevalence Figure 1-1-11 Figure 1-1-12
➢ 10 per 100,000 exams
• Highest disease
➢ African-American women

Sarcoidosis: Clinical Features
• Asymptomatic
➢ 15-50%
• Constitutional symptoms
➢ 33%
• Dyspnea, cough, chest pain
➢ 33-50%
• Palpable lymph nodes
➢ 33-75%
• Ocular involvement
➢ 11-83%
• Cutaneous involvement
➢ 20-30% Erythema nodosum, Lupus
pernio Combined septal and Random nodule pattern
bronchovascular pattern

An Approach to Diffuse Lung Disease 6 Chest Radiology

Sarcoidosis: Laboratory Abnormalities Figure 1-1-13
• BAL
➢ ↑ macrophages, ↓ proportions; ↑ CD4 helper
cells
• Angiotensin-Converting Enzyme
➢ Nonspecific Produced by
granuloma/macrophage
➢ ↑ 33-90%
• Hypercalcemia 10%
• Hypercalciuria 30%
➢ Macrophage/granuloma extrarenal sources
of 1-25 Dihydroxyvitamin D
• Anergy
• Hypergammaglobulinemia

Sarcoidosis: Respiratory System
[Figure 1-1-13]
• 100% lung involvement
• Portal of entry
➢ Local lymph nodes
➢ Distant organs
• Disease distribution
➢ Alveolar wall
➢ Secondary lobule,
➢ Axial CT
➢ Radiograph

Non-Caseating Granuloma and Fibrosis
Sarcoidosis pathogenesis
Alveolar Distribution

Sarcoidosis and the Secondary Lobule [Figure 1-1-14]

Figure 1-1-14

Bronchovascular distribution of
granulomas in Sarcoidosis

Chest Radiology 7 An Approach to Diffuse Lung Disease

Figure 1-1-15

Distribution of nodules in sarcoidosis Masses in Sarcoidosis

Ground glass in Sarcoidosis Conglomerate masses and fibrosis in sarcoidosis

Sarcoidosis: Computed Tomography [Figure 1-1-15]
• Nodules
• Masses
• Ground Glass
• Fibrosis
➢ Conglomeration
➢ Distortion
• Emphysema
• Bulla
• Honeycombing

An Approach to Diffuse Lung Disease 8 Chest Radiology

Parenchymal Disease: Radiography Figure 1-1-16
• Bilateral
• Symmetrical
• Nodules
• Reticulonodular
• Masses
• Ground Glass
• Hilar Retraction
• Bulla
• Honeycombing

Sarcoidosis: Adenopathy [Figures 1-1-16 and 1-1-17]
• Node Group CXR CT
• Hilar 84 88
• R. Paratracheal 76 100
• A-P Window 72 92
• Subcarinal 12 64
• Ant. Med. 12 48
• Post. Med. 0 16
Lymph node involvement is a hallmark of sarciodosis
Sarcoidosis:
Staging based on Adenopathy and Parenchyma
Figure 1-1-17
Presentation Resolution

Stage 0 8 –
➢ Normal
Stage 1 51 65
➢ Adenopathy
Stage 2 29 49
➢ Adenopathy &
Parenchyma
Stage 3 12 20
➢ Parenchyma

20% develop fibrosis or Stage 4 disease

Sarcoidosis Stage I

Sarcoidosis Stage II

Sarcoidosis Stage III

Sarcoidosis Stage IV
Bilateral calcified lymph nodes are common
Sarcoidosis Progression

Sarcoidosis and the Parenchyma: Computed Tomography
• Thickened Bronchovascular Bundles
• Nodules
➢ Peribronchovascular
➢ Pleural, subpleural and septal
• Consolidation and Large Nodules
• Ground-Glass Opacities
• Fibrosis

Chest Radiology 9 An Approach to Diffuse Lung Disease

Thickened Bronchovascular Bundles [Figure 1-1-18]
Figure 1-1-18

Peribronchovascular opacities
in sarcoidosis

Peribronchovascular Nodules

Peribronchovascular and Pleural Nodules

Septal Lines

Ground Glass Opacities

Consolidation and Large Nodules

Fibrosis

Bronchovascular Bundle Distortion [Figure 1-1-14]

Conglomerate Mass
Fibrosis and Emphysema

Fibrosis and Honeycombing

Sarcoidosis: Diagnosis
• Typical clinical and radiologic manifestations
• Non-caseating granulomas
• Transbronchial Bx
• Endobronchial Bx

Sarcoidosis: Differential Diagnosis
• Infection
➢ Tuberculosis, Fungal (Histoplasmosis)
• Pneumoconiosis
➢ Silica, Beryllium
• Hypersensitivity Pneumonitis
• Malignancy
➢ Lymphoma

An Approach to Diffuse Lung Disease 10 Chest Radiology

Miliary Tuberculosis

Transbronchial Spread of Tuberculosis

Histoplasmosis

Silicosis

Berylliosis

Extrinsic Allergic Alveolitis

Sarcoidosis: Mortality
• Mortality range 5-10%
• Cor Pulmonale related to fibrosis
• Cardiac Arrhythmia
• Pulmonary Hemorrhage
➢ Aspergilloma

Cor Pulmonale

Sarcoidosis: Cardiac Involvement
• Clinical involvement 5%
➢ Heart block, arrhythmia, mitral regurgitation, CHF (dilated cardiomyopathy)
and sudden death
• Autopsy involvement 20-30%
• Localized wall motion abnormalities
➢ Anterior and apical
➢ MRI, Echocardiograph, Thallium-201
Vignaux AJR 184 Jan 2005

Cardiac Sarcoidosis [Figure 1-1-19]

Figure 1-1-19

Sarcoid infiltration on MRI is represented as focal zones of
increased signal on T2 and early gadolinium images

Dilated Cardiomyopathy

Chest Radiology 11 An Approach to Diffuse Lung Disease

Sarcoidosis: Mycetoma Figure 1-1-20
• Present in 40-50% of cystic lesions
➢ Bullae, cavities or bronchiectasis
• Hemorrhage
• Steroids may convert to invasive process

Mycetoma [Figure 1-1-20]

Sarcoidosis: Therapy
• Cardiac, CNS, eye involvement
• Hypercalcemia
• Corticosteroids
➢ Relief of symptoms; resolution of radiologic abnormalities;
improved function
• Cytotoxic agents
➢ Methotrexate, Azathioprine
• Chlorambucil, cyclophosphamide, antimalarials
• Risk of recurrence

Sarcoidosis: Resolution

Sarcoidosis: Prognosis
• Favorable
➢ Acute onset, erythema nodosum,
➢ > 80% spontaneous remission
➢ Löfgren syndrome
➢ Low stage
• Poor
➢ Chronic course, Lupus pernio
➢ Older age at presentation
➢ Hypercalcemia/nephrocalcinosis
➢ Black race, Extrathoracic involvement
Mycetoma in a cystic space
Sarcoidosis Conclusion caused by sarcoidosis

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General
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An Approach to Diffuse Lung Disease 12 Chest Radiology

14. Mayo JR. Webb WR, Gould R, Stein MG, Bass I, Gamsu G, Goldberg H. High- resolution CT of the lungs: an
optimal approach. Radiology 1987; 163:507-510.
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Radiology 1983; 149(2):353-363.
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Dis 1990; 142(6 Pt 1 ):1440-8.
17. Muller NE, Miller RR. Computed tomography of chronic diffuse infiltrative lung disease. Part lAm Rev Respir Dis
1990; 142(5):1206-15.
18. Muller NE, Coiby TV. Idiopathic interstitial pneumonias: high-resolution CT and histologic findings.
Radiographics 1997; 17(4): 1016-22.
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of the lung: demonstration by high-resolution CT and pathologic correlation. Radiology 1986; 161 :641-645.
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1989; 170:629-635.
22. Muller NI, Miller RR. Computed tomography of chronic diffuse lung disease. American Review of Respiratory
Disease 1990; 142:1206-1215, 1440-1448.
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with clinical, functional, and radiologic findings. Radiology 1987; 162:377-381.
24. Webb WR. High resolution CT of lung parenchyma. Radiologic Clinics of North America 1989; 27(6):1085-1097.
25. Weibel ER. Looking into the lung: what can it tell us? American Journal of Roentgenology 1979; 133:1021-1031.
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27. Weibel ER, Crystal RG. Structural Organization of the Pulmonary Interstitium. In: Crystal RG, West JB, eds. The
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Sarcoidosis
1. Bergin CJ, Bell DY, Coblentz CL, Chiles C, Gamsu C, Maclntyre NR, Coleman RE, Putman CE. Sarcoidosis:
correlation of pulmonary parenchymal pattern at CT with results of pulmonary function tests. Radiology 1989;
171(3):619-24.
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and tuberculosis: a CT study. Clin Radiol 1996; 51(4):263-7.
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AJRAm J Roentgenol 1996; 166(5):1052-4.
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obstruction at thin-section CT. Radiology 1998; 209(3):697-704.
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thoracic sarcoidosis. Radiographics 1989; 9(3):449-66.
6. Miller WT Jr, Shah RM. Isolated diffuse ground-glass opacity in thoracic CT: causes and clinical presentations.
AJR Am J Roentgenol. 2005 Feb;184(2):613-22.
7. Muller NE, Kullnig P, Miller RR. The CT findings of pulmonary sarcoidosis: analysis of 25 patients. AJR Am J
Roentgenol 1989; 152(6):1179-82.
8. Muller NE, Mawson JB, Mathieson JR. Abboud R, Ostrow DN, Champion P Sarcoidosis: correlation of extent of
disease at CT with clinical, functional, and radiographic findings. Radiology 1989; 171 (3):61 3-8.
9. Murdoch J, Muller NE. Pulmonary sarcoidosis: changes on follow-up CT examination. AJR Am J Roentgenol
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findings [published erratum appears in Radiology 1994 Mar;190(3):907]. Radiology 1993; 189(1):105-9.
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Semin Ultrasound CT MR 1995; 16(5):361-70.
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78(1 ):65-71.

Chest Radiology 13 An Approach to Diffuse Lung Disease

The Idiopathic Interstitial Pneumonias
Jeffrey R. Galvin, MD
Figure 1-2-1
The Idiopathic Interstitial Pneumonias
Chronic Diffuse Lung Disease [Figure 1-2-1 and 1-2-2]
• Alveolar involvement
➢ Surrounding airways
➢ Fibrosis and/or cells
✧ Alveolar wall
✧ Alveolar space
• Restrictive physiology
• Decreased lung volumes
• Increased attenuation
• Subacute or chronic
➢ Weeks to months
Figure 1-2-2

The Idiopathic Interstitial Pneumonias
involve the alveolar walls and spaces

The lung volumes are low and
there are areas of increased density

The Idiopathic Interstitial Pneumonias
• Liebow 1975
• Supporting lung structures
➢ Inflammation
➢ Fibrosis
• Not confined to interstitium
• Initiated within the airspace
Liebow, Prog Reps Dis 1975

The Idiopathic Interstitial Pneumonias
Current List-ATS/ERS Consensus Classification
• Idiopathic Pulmonary Fibrosis (IPF)
➢ Usual Interstitial Pneumonia (UIP)
• Respiratory Bronchiolitis-Interstitial Lung Disease (RB-ILD)
• Desquamative Interstitial Pneumonia (DIP)
• Acute Interstitial Pneumonia (AIP)
• Cryptogenic Organizing Pneumonia (COP)
• NonSpecific Interstitial Pneumonia (NSIP)
Travis et al. Am J Respir Crit Care 2002

The Idiopathic Interstitial Pneumonias 14 Chest Radiology

Idiopathic Pulmonary Fibrosis
• Usual Interstitial Pneumonia: histologic pattern
• 5th-7th decade
➢ 66% > 60 years
➢ 7/100,000 women and 10/100,000 men
• Insidious onset of dyspnea
➢ 6 months before diagnosis
➢ Restrictive ventilatory defect
➢ Rales and clubbing
• Associations:
➢ Cigarette smoke
➢ Dusty environments: farming, wood dust, metal dust
➢ GE reflux
Figure 1-2-3
➢ Autoantibodies common (ANA, RA)
• Median survival 2.5-3.5 years

Usual Interstitial Pneumonia: Histology
• Geographic variation
• Temporal variation
➢ Fibroblast foci
➢ Mature fibrous tissue
• Extensive fibrosis
• Inflammation
➢ Minimal
➢ No correlation outcome
Abnormal wound healing
• Prognosis
➢ Fibroblast foci
✧ Presence and extent
Katzenstein, Am J Respir Crit Care Med 1998
Selman, Ann Int Med 2001
King, Am J Respir Crit Care Med 2001

Idiopathic Pulmonary Fibrosis Imaging [Figure 1-2-3]
• Radiograph abnormal-95%
The abnormalities are predominantly
➢ Volume loss
peripheral and lower lung field.
➢ Reticulonodular opacities
There is progressive volume loss
➢ Lower lobe
➢ Honeycombing
• Computed tomography Figure 1-2-4
➢ Peripheral and lower lobe
➢ Reticulation and ground glass
✧ Progress to honeycombing
➢ Ground glass in areas of
traction bronchiectasis
Hartman, Chest 1996

IPF-Progressive Volume Loss

Idiopathic Pulmonary Fibrosis [Figure 1-2-4]

IPF and Emphysema

Typical peripheral reticulation and honeycombing
and traction bronchiectasis in a patient with IPF

Chest Radiology 15 The Idiopathic Interstitial Pneumonias

Utilility of Biopsy for Diagnosis of IPF
• Prospective, multi-center study
➢ 91 patients suspected of IPF
• Clinical diagnosis
➢ Positive predictive value with a confident diagnosis-87%
• Imaging diagnosis
➢ Positive predictive value with a confident diagnosis-96%
➢ CT always abnormal in patients with proven IPF
• Histologic diagnosis
➢ Agreement regarding the presence or absence of IPF-85%
➢ Agreement in patients without IPF-48%
✧ Relevance to NSIP
Figure 1-2-5
• Uncertain diagnosis
• Discordant data
• Disease other than IPF
➢ Hypersensitivity pneumonitis
➢ Collagen-vascular disease
➢ Infection
Hunninghake, Am J Respir Crit Care Med 2001

IPF Rad-Path Discord

Smoking Related ILD
Interstitial Lung Disease [Figure 1-2-5]
• Respiratory bronchiolitis
➢ RB
• Respiratory bronchiolitis-interstitial lung disease
➢ RB-ILD
• Desquamative interstitial lung disease
➢ DIP

Smoking Related ILD
RB
• Clinical
➢ Cigarette smoke or equivalent Smoker’s macrophages
➢ Asymptomatic
• Pathology
➢ Peribronchiolar macrophages
➢ Peribronchiolar fibrosis
• Imaging
➢ Centrilobular nodules
✧ Poorly defined 2-3 mm
✧ Uper lobe predominance
➢ Ground glass opacity
➢ Bronchial wall thickening
➢ Decreased attenuation
➢ Emphysema
➢ Air trapping
➢ Reticulation
Niewoehner, NEJM 1974 ; Remy-Jardin, Radiology 1993

The Idiopathic Interstitial Pneumonias 16 Chest Radiology

Smoking Related ILD [Figure 1-2-6] Figure 1-2-6
RB-ILD
• Clinical
➢ Cigarette smoke or equivalent
➢ Dyspnea
➢ Restrictive or mixed PFT’s
➢ Good prognosis
• Pathology
➢ Peribronchiolar macrophages
➢ Peribronchiolar fibrosis
• Imaging
➢ Centrilobular nodules
✧ Poorly defined 2-3 mm
✧ Uper lobe predominance
➢ Ground glass opacity
➢ Bronchial wall thickening
➢ Decreased attenuation
➢ Emphysema
➢ Air trapping
➢ Reticulation
Meyers, Am Rev Respir Dis 1987
Park, J Comput Assist Tomogr 2002 Small centrilobular nodules with an
upper lobe predominance in RB-ILD
Smoking Related ILD
DIP
• Clinical
➢ Cigarette smoke
➢ 4th and 5th decade
➢ Uncommon
➢ 70% survival-10 years
➢ Steroids
• Pathology
➢ Pigmented macrophages
➢ Interstitial infiltrate
✧ Plasma cells and eosinophils
➢ Fibrosis
• Imaging
➢ Ground glass
✧ Symmetrical
✧ Basal predominance
➢ Reticulation
➢ Cysts
✧ Alveolar ducts
Figure 1-2-7
✧ Bronchioles
✧ Emphysematous spaces
Carrington, NEJM 1978 ; Hartman, Radiology
1993

Desquamative Interstitial
Pneumonia [Figure 1-2-7

Ground glass opacities in DIP

Chest Radiology 17 The Idiopathic Interstitial Pneumonias

Dependent Density Figure 1-2-8

Desquamative Interstitial
Pneumonia

RB and DIP

Smoking Related ILD [Figure 1-2-8]

Acute Interstitial Pneumonia
AIP
• Hammon-Rich disease
• Rapidly progressive
• Days-weeks
• Antecedent flu-like syndrome
• Mean age 50 years
• 50% fatal at least
Vourlekis, Medicine 2000

Acute Interstitial Pneumonia Smoking related interstitial lung disease with upper lobe
Histology indistinct nodules, reticulation and well defined emphysematous
• Exudative phase spaces combined with lowerlobe ground glass
➢ Hyaline membranes Figure 1-2-9
➢ Edema
➢ Inflammation
• Collapse of alveoli
• Organizing phase
➢ Type II hyperplasia
➢ Loose fibrosis
• Diffuse Alveolar Damage
Katzenstein, Am J Pathol 1986 ; Ichikado, AJR 1997

Diffuse Alveolar Damage

Acute Interstitial Pneumonia
Radiography [Figure 1-2-9 and 1-2-10]
• Diffuse
• Airspace opacification Figure 1-2-10
• Costal sparing
• Mechanical ventilation
• Resembles ARDS

AIP involves all 5 lobes

Most patients are intubated with
diffuse opacities

The Idiopathic Interstitial Pneumonias 18 Chest Radiology

Acute Interstitial Pneumonia Figure 1-2-11
Computed Tomography
• Exudative phase
➢ Consolidation
➢ Bilateral
➢ Focal sparing
• Organizing phase
➢ Distortion
➢ Traction bronchiectasis
➢ Ground glass
Johkoh, Radiology 1999;
Ichikado et al. Am J Respr Crit Care Med 2002

Acute Interstitial Pneumonia [Figure 1-2-11]

Cryptogenic Organizing Pneumonia
• Non-specific inflammatory response
• Pattern of repair
• Self-perpetuating
• Cryptogenic
• Secondary
➢ Connective tissues disease, hematologic
malignancy, drugs or organ transplantation
• Focal
➢ Bacteria, legionella, mycoplasma, mycobacterial,
or infarction
Lohr, Arch Int Med 1997
Focal areas of sparing are common in AIP
Cryptogenic Organizing Pneumonia
• Terminology problem
➢ Bronchiolitis obliterans OP (BOOP), bronchiolitis obliterans (BO),
bronchiolitis interstitial pneumonia (BIP)
• Subacute presentation (3 months)
• M=F
• Cough, dyspnea, weight loss, fever
• Restrictive PFT’s Figure 1-2-12
• Steroid responsive
• Relapse common
Epler, NEJM 1985

Cryptogenic Organizing Pneumonia
Histology
• Fibroblastic plugs in alveoli
• Fibrosis in the alveolar space
• May be airway centered
➢ Bronchiolitis

Cryptogenic Organizing Pneumonia [Figure 1-2-12]
Radiography
• Consolidation
➢ Unlateral or bilateral
• Small Nodules
➢ 10-50%
• Lung volumes
➢ normal in 75%

Cryptogenic organizing pneumonia is
characterized by focal areas of
consolidation more common in the
lower lung fields

Chest Radiology 19 The Idiopathic Interstitial Pneumonias

Cryptogenic Organizing Pneumonia Figure 1-2-13
Computed Tomography
• Consolidation 90%
• Ground glass 75%
• Bronchial thickening and dilatation
• Small nodules along bronchvascular
bundles
• Large nodules (15%)
➢ Irregular margins
➢ Air bronchograms
• Reverse halo

Cryptogenic Organizing
Pneumonia [Figure 1-2-13 and 1-2-14]

Figure 1-2-14

Typical findings in COP with peripheral areas of consolidation.
The differential includes chronic eosinophilic pneumonia,
bronchoalveolar cell carcinoma, lymphoma and infection

Diffuse nodules may also be seen in
COP

Nonspecific Interstitial Pneumonia
• Katzenstein
➢ Described in 1994
• Does not fit definition of other IIPs
➢ UIP, RB-ILD, DIP, OP, AIP
• Represents a variety of etiologies
➢ Collagen vascular disease, drug reaction, inhaled antigen
➢ Inadequately sampled UIP or OP
• Median age 45
• Onset gradual with wide range
➢ 6 months to 3 years
• Better prognosis
Katzenstein, Am J Resp Crit Care 1994
Nicholson, Am J Respir Crit Care Med 2001

The Idiopathic Interstitial Pneumonias 20 Chest Radiology

Nonspecific Interstitial Pneumonitis
Histology
• 3 categories
➢ Cellular
➢ Fibrosing
➢ Mixed
• Prognosis=fibrosis
• OP common
• Temporally uniform

Nonspecific Interstitial Pneumonitis
Imaging
• Few reports on chest radiography
• Wide variety of CT patterns
➢ Ground glass, consolidation, reticular and honeycombing
• Traction bronchiectasis=fibrosis
• CT pattern indistinguishable
➢ UIP 32%
➢ Hypersensitivity 20%
➢ OP 14%
➢ Other 12%
Hartman, Radiology 2000

Nonspecific Interstitial Pneumonia

NSIP ATS Consensus Conference
• Pathologists
• Radiologists
• Pulmonalogists
• 300 cases submitted
➢ 11 cases agreed to be NSIP by all pathologists
• Imaging
➢ Lower lobe
➢ Peribronchiolar reticulation and distortion
➢ Subpleural clearing

NSIP Current View

NSIP Fibrosis with IPF Imaging
• Areas of NSIP commonly found in proven cases of UIP
• NSIP and UIP
➢ Different severity of injury?
➢ Different mechanism of injury?
• Prognosis in these cases is driven by the imaging Figure 1-2-15
Katzenstein AA et al, Amer J of Surg Path 2002

Hypersensitivity Pneumonitis

NSIP in Cigarette Smokers

Nonspecific Interstitial Pneumonia

OP-NSIP [Figure 1-2-15]

OP-NSIP is peribronchovascular with UIP is peripheral

Chest Radiology 21 The Idiopathic Interstitial Pneumonias

The Idiopathic Interstitial Pneumonias Figure 1-2-16
Current List
• Idiopathic Pulmonary Fibrosis (IPF)
➢ Usual Interstitial Pneumonia (UIP)
• Respiratory Bronchiolitis-Interstitial Lung Disease
(RB-ILD)
• Desquamative Interstitial Pneumonia (DIP)
• Acute Interstitial Pneumonia (AIP)
• Cryptogenic Organizing Pneumonia (COP)
• NonSpecific Interstitial Pneumonia (NSIP)

Idiopathic Pulmonary Fibrosis
[Figure 1-2-16]

RB/RB-ILD [Figure 1-2-17]

RB-ILD/DIP [Figure 1-2-18]
IPF
Figure 1-2-17
Figure 1-2-18

RB-ILD
DIP

Acute Interstitial Pneumonia [Figure 1-2-19 and 1-2-20]

Figure 1-2-19
Figure 1-2-20

AIP early phase
AIP late phase with organization and fibrosis

The Idiopathic Interstitial Pneumonias 22 Chest Radiology

Organizing Pneumonia [Figure 1-2-21] Figure 1-2-21

NSIP in the Literature

NSIP-IPF

NSIP-Cigarette Smokers [Figure 1-2-22]

Figure 1-2-22

Organizing pneumonia

Patients with smoking related fibrosis may have a
biopsy that demonstrates NSIP

NSIP-Hypersensitivity Pneumonitis

NSIP-Organizing Pneumonia [Figure 1-2-23]

Figure 1-2-23

Patients with organizing pneumonia may have a biopsy
that demonstrates NSIP

Chest Radiology 23 The Idiopathic Interstitial Pneumonias

References General 1. Hyzy R. Am U Respir Crit Care Med 1998. Ryu JH. Douglas WW. Individualization of a clinicopathologic entity in a series of 12 patients. Bjoraker JA. Hunninghake SW. Radiology 1987. Hansell DM. Myers JL. Katzenstein AL. 5. Desquamative interstitial pneumonia. DAD/AIP 1. Popovich U. Am J Respir Crit Care Med 2002. 8. Offord KR. 6. 10(4):256-67. Honda 0. Greene R. The Idiopathic Interstitial Pneumonias 24 Chest Radiology . Interstitial lung disease in progressive systemic sclerosis: high-resolution CT versus radiography. 9. 188(3):817-20. Am U Respir Crit Care Med 1998. Behzad H.Desquamative interstitial pneumonia and respiratory bronchiolitis-associated interstitial lung disease. Taniguchi H. and the European Respiratory Society (ERS) was adopted by the ATS board of directors. 8. Myers UL. 11(4):231-49. June 2001 and by the ERS Executive Committee. Wells AU. Edwin MK. 6. Flint A. Adult respiratory distress syndrome: acute alveolar damage. Nakamura H. Am U Respir Crit Care Med 1998. ultrastructural. New insights from computed tomography [editorial. NSIP 1. 1 68(2):333-8. Cascade PN. Sillery J. Ikezoe U. Donsbeck AV. Wilson JS.127(1):178-84. Toews GB. Am U Respir Crit Care Med 1998. 4. Fiorelli RF. Tscholakoff D. Am J Surg Pathol 1994. 3. Radiology 1999. 158(6): 1804-8. Kazerooni EA. Akira M. Myers JL. AUR Am U Roentgenol 1997. Schwait DA. Pope CE. 2. Prowse CM. Quantification of idiopathic pulmonary fibrosis using computed tomography and histology. Spizarny DL. Katzenstein AL. American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial pneumonias. Takeuchi N. J Thorac Imaging 1996. Schurawitzki H. Analysis of clinical and pathologic findings in three cases. This joint statement of the American Thoracic Society (ATS). comment]. Acute respiratory distress syndrome: CT abnormalities at long-term follow-up. Increased prevalence of gastroesophageal reflux in patients with idiopathic pulmonary fibrosis. Tobin RW. Acute interstitial pneumonia: radiographic and CT findings in nine patients [see comments]. Am U Surg Pathol 1986. 3. Mark EJ. Ikezoe U. Tomiyama N. Vassallo R. Akira M. Gross BH. Goff AM. Chest 1993. 2. Kondoh Y. Decker PA. Raghu G. Kohno N. 157(4 Pt 1):1063-72. Radiology 1993. Mayo Clin Proc 1990. 2. Johkoh T. Ando M. Hamman-Rich syndrome revisited [see comments]. Acute interstitial pneumonia: thin-section CT findings in 36 patients. 176(755- 759). Ichikado K. Kawabata Y. Schork MA. IPF/UIP 1. Herold C. Capizzi SA.23(5):1057-71. Hogg JC. Nakamura H. Definition and classification of interstitial pneumonias in human pathology. 157(1):1 99-203. The ARDS lung. Coxson HO. Am J Respir Crit Care Med 1997. Nagareda T. Idiopathic pulmonary fibrosis: clinical relevance of pathologic classification. 274(3)113-28. 3rd. Loire R. Tazelaar Ho. Whyte RI. Evans TW. McLoud TC. Martinez FJ. 8:1- 33. Wittram C. Radiology 1999. Johkoh T. Hartman TE. 163(1):57-66. 165:277-304 2. 2nd. Muller NL. Whittall KP. Arisawa U. Myers JL. Acute interstitial pneumonia: high-resolution CT findings correlated with pathology. Muller NL. Prognostic significance of histopathologic subsets in idiopathic pulmonary fibrosis. Burghuber OC. Am J Respir Crit Care Med 1998. Cottin V. 7. Sakatani M. Radiology 1990. Graninger W. Desai SR. 65(12):1538-48. June 2001. Mayo JR. Bone RC. Nonspecific interstitial pneumonia/fibrosis. Lynch UP. Hansell DM. Galvin JR. Ando M. A clinicopathologic. Pellegrini CA. 269(1 6):21 34-5. DIP 1. Revel D. Cordier JR Nonspecific interstitial pneumonia. Histologic features and clinical significance. 157(4 Pt 1):1301-15. Jama 1993. 2005 Jan. Schroeder DR. 2. Polzleitner D. Gay SE. Acute exacerbation in idiopathic pulmonary fibrosis. Hartley PC. 155(5):1649-56. 4. Elliott CG. 7. Radiographics. 158(4):1286-93. Katzenstein AL. Gaensler EA. Mazur MT. 5. Colby TV. 210(1):29-35. CT-histologic correlation of the ATS/ERS 2002 classification of idiopathic interstitial pneumonias. 18(2):136-47. CT evaluation of fibrosing alveolitis—applications and insights. Idiopathic pulmonary fibrosis: predicting response to therapy and survival. Prog Resp Res 1975. Olson U. 103(6):1808-12. Kondoh Y. Itoh H. Ryu JH. 211(3):859-63. Acute interstitial pneumonia. and cell kinetic study. Taniguchi H. Chest. N Engl U Med 1966. Ichikado K. Wells AU. Emond MJ. Stiglbauer R. Rubens MB. Liebow AA. Takagi K. 2003 Sep-Oct. Suzuki K. Primack SL. Yokoi T.

Carrington CB. Pare P. Hansell DM. Radiology 1986. 154(5):983-7. Bronchiolitis obliterans. Wollan PC. Muller NL. 8. AJR Am J Roentgenol 1990. Hartman TE. 2. 3rd. Park JS. O’Connell EJ. Miller RR. 162(1 Pt 1):151-6. Arch Intern Med 1997. Cryptogenic organizing pneumonia: CT findings in 43 patients. Myers JL. Bronchiolitis obliterans organizing pneumonia: CT features in 14 patients. Katzenstein AL. Prophet WD. Chest Radiology 25 The Idiopathic Interstitial Pneumonias . Organizing pneumonia. Radiology 1987. Bronchiolitis obliterans organizing pneumonia manifesting as multiple large nodules or masses. Shin MS. 6. 157(12):1323-9. Yamamoto S. Colby TV. Bronchiolitis obliterans and usual interstitial pneumonia. Friedman SE. 312(3):152-8. Epler GR. Features and prognosis of cryptogenic. Shin MS. AJR Am J Roentgenol 1998. 208(3):783-8. Han J. AJR Am J Roentgenol 1994. Swensen SJ. Epler GR. McLoud TC. 11 7(4):81 6-32. Myers JL. 7. Kullnig P. Liebow AA. Corley LS. 11. Lohr RH. Sakatani M. AJR Am J Roentgenol 1986. Hwang JH. Oaensler EA. N Engl J Med 1985. Cuerry-Force ML. Friedman Pd. 162(3):543-6. Bronchiolitis obliterans. Radiographic manifestations of bronchiolitis obliterans with organizing pneumonia vs usual interstitial pneumonia. Bronchiolitis obliterans organizing pneumonia. Roentgenologic¬pathologic correlation. Staples CA. 147(5):899- 906. Colby TV. Wiggs B. The radiology and terminology of cryptogenic organizing pneumonia. Radiology 1998. secondary. 10. 159(1)1-8. Colby TV. 171(6): 1645-50. 4. Swensen SJ. Carrington CB. Am J Roentgenol Radium Ther Nucl Med 1973. Hogg JC. Wright JL. Carlson BA. Hildebolt CF. Mayo Clin Proc 1993. Chung MP. Akira M. and radiologic findings. Edell ES. 68(3):307-8. Gaensler EA. Lee KS. AJR Am J Roentgenol 1998. High-resolution computed tomography for obliterative bronchiolitis. Muller NL. Staples CA. Siegel MJ. Boland BJ. Haddock JA. Katzenstein AL. Lau DM. and focal variants. 9. functional. Nonspecific interstitial pneumonia with fibrosis: high-resolution CT and pathologic findings. McLoud TC. Bronchiolitis obliterans syndrome: thin-section CT diagnosis of obstructive changes in infants and young children after lung transplantation. Gosink RB. Rhee OH. Coppin C. Lee KS. 65(776):674-80. Cohen AH. Silverstein MD. 170(2):291-5. Kwon OJ. A comparative clinicopathologic study. 5. Douglas WW. 12. BOOP/Organizing Pneumonia 1. Kim TS.3. Br J Radiol 1992. Am J Surg Pathol 1986. 10(6):373-81. 3. Muller NL. Chandler PW. Dockrell DH. Differential diagnosis of bronchiolitis obliterans with organizing pneumonia and usual interstitial pneumonia: clinical. 13.

panbronchiolitis. Galvin. MD Assessment of Dyspnea A Common Clinical Problem • 55 million adult smokers • 15 million meet criteria for bronchitis Figure 1-3-1 • 5 million with airway obstruction • 10 million with asthma Gordon Snyder Differential Diagnosis of Airways Obstruction • Common ➢ Emphysema. alpha-1 deficiency. asthma • Uncommon ➢ LAM.Airways Disease: The Movement from Anatomic to Physiologic Assessment Jeffrey R. bronchiectasis. sarcoid. BO. ABPA Diseases with Obstructive Physiology The Changing Role of Imaging • Diagnosis • Functional assessment Why Pulmonary Functions are Insensitive • PFT’s based on wide range of normal ➢ 80-120% predicted • Diseases with opposing physiologic processes • The “silent zone” of the lungs Small airway tethered to The “Silent Zone” of the Lungs the pleural surface by alveolar walls [Figure 1-3-1 and 1-3-2] “Small Airways” • Peter Macklem Figure 1-3-2 ➢ 1970’s • No cartilage ➢ <2mm physiologists ➢ 1mm pathologists • Tethered ➢ fiber skeleton ➢ pleura Weibel Mosaic attenuation on an expiratory CT in patient with constrictive bronchiolitis Airways Disease 26 Chest Radiology . bronchitis.

Diffuse Lung Disease Figure 1-3-3 Figure 1-3-4 Airways [Figure 1-3-3] • Airways involvement • Obstructive physiology • Increased lung volumes • Decreased attenuation Airways Disease Direct Signs [Figure 1-3-4] • Changes ➢ Airway wall ➢ Airway lumen • Opacities ➢ Tubular ➢ Nodular ➢ Branching Airways Disease Indirect Signs • Mosaic density ➢ Air trapping • Subsegmental atelectasis • Ground glass Airways involvement at the level of “Tree-in-bud” in a patient with a Airways Disease the secondary lobule respiratory infection • Emphysema • Emphysema and Fibrosis • Alpha-1 deficiency • Langherhans Cell Histiocytosis • Bronchiectasis • Asthma • Allergic Bronchopulmonary Aspergillosis • Sarcoidosis • Diffuse Panbronchiolitis • Bronchiolitis Obliterans • Lymphangioleiomyomatosis Figure 1-3-5 Emphysema ATS Definition • Permanent enlargement of airspaces distal to the terminal bronchiole. accompanied by destruction of the walls without obvious fibrosis Emphysema Emphysema Classification [Figure 1-3-5] • Proximal Acinar ➢ Centrilobular ➢ Resp bronchiole ➢ Cigarette smoke ➢ Upper lobes • Panacinar ➢ Entire acinus ➢ Alpha-1 deficiency ➢ Lower lobes • Distal Acinar ➢ Paraseptal ➢ Distal acinus Cigarette smoke related ➢ Subpleura emphysema is most severe in the ➢ Pneumothorax upper lobes Chest Radiology 27 Airways Disease .

Am Rev Respir Dis 1990 Early Emphysema Airways Disease 28 Chest Radiology . dyspnea and sputum production • Hemoptysis rare ➢ R/O cancer • Symptomatic air flow obstruction ➢ After age 50. 20-30 years of smoking • Cor pulmonale (late) related to hypoxemia and loss of capillary bed Emphysema and Cor Pulmonale Emphysema Pulmonary Functions • Important to identify patients at risk • Reduction in Fev1 ➢ Most reproducible • RV increases followed by TLC • Volumes and flows Saber trachea ➢ Insensitive to early changes • Diffusing capacity ➢ Sensitive but non-specific Figure 1-3-7 • Small airways tests Emphysema Radiographic Feature • Hyperinflation ➢ Concave diaphragm ➢ Increased A-P diameter ➢ Retrosternal airspace • Arterial deficiency pattern • Bulla ➢ Cystic airspaces > 1cm • Radiography is insensitive ➢ 41% of moderate disease ➢ 66% of severe disease Saber Trachea [Figure 1-3-6] Emphysema and Computed Tomography [Figure 1-3-7] Typical low attenuation lesions of emphysema The Diagnosis of Mild Emphysema Correlation of CT and Pathology Scores • HRCT detects emphysema ➢ Before there is airflow limitation on PFT’s • HRCT excludes emphysema ➢ Patients with moderate to severe airflow limitation Kuwano et al.Emphysema Figure 1-3-6 Clinical Presentation • Cough.

nonsmokers and quitters • Micronodules at TO predisposes to the development of emphysema at T1 • Micronodules and emphysema at TO predicts more rapid decline in lung function Remy-Jardin.Respiratory Bronchiolitis [Figure 1-3-8] Figure 1-3-8 “Smoker’s Bronchiolitis” • Common change ➢ all smokers • Pigmented macrophages ➢ In respiratory bronchioles ➢ Surrounding alveoli • Upper lobe predominance • Usually asymptomatic ➢ May cause symptoms Relationship of RB and Emphysema • Prospective study • 111 subjects ➢ Followed for 5 years ✧ Imaged at inception TO and 5 years T1 ➢ Smokers. Radiology 2001 Emphysema and Fibrosis • 14 patients • Scanning electron microscopy • Thick and thin walls ➢ Both fibrotic Figure 1-3-9 Nagai & Thurlbeck. Radiology 2001 Relationship of RB and Emphysema Respiratory bronchiolitis Remy-Jardin. Am Rev Resp Dis 1985 Emphysema and Fibrosis • Normal lung volumes and • Normal flow rates • Reduced diffusing capacity ➢ Severe • Minimal pulmonary reserve Emphysema and Fibrosis • TLC 119% • VC 126% • RV 109% • FEV1/FVC 88% • D/Va 28% Emphysema and Fibrosis [Figure 1-3-9] Emphysema and fibrosis Idiopathic Pulmonary Fibrosis Langerhans Cell Histiocytosis Clinical Presentation • Almost exclusively cigarette smokers • Slight male preponderance • Cough and dyspnea most common • May be asymptomatic • Occasional bone lesion Chest Radiology 29 Airways Disease .

plasma cells and lymphocytes • Diagnosis requires Langerhans cells ➢ Large histiocytes ➢ Folded nuclei ➢ Eosinophilic cytoplasm • Path DDX ➢ Eos pneumonia. eosinophils.Langerhans Cell Histiocytosis Figure 1-3-10 Histology [Figure 1-3-10] • Nodular ➢ Interstitial lesions ➢ Located near bronchioles • Histiocytes. DIP.0 cm in upper lobes ➢ Early • Cysts replace nodules ➢ Later • Honeycomb lung • Pneumothorax 15% • Adenopathy and effusion are unusual LCH is characterized by low attenuation areas with bizarre shapes Airways Disease 30 Chest Radiology .5-1.UIP Langherhans Cell Histiocytosis [Figures 1-3-11 and 1-3-12] The range of findings in Langerhans Cell Histiocytosis Figure 1-3-11 Figure 1-3-12 Typical nodules in LCH Cystic lesions in LCH Figure 1-3-13 Langherhans Cell Histiocytosis Radiographic Features [Figure 1-3-13] • Varies over time • Upper lobe ➢ Predominance • Nodules ➢ 0.

S-100 protein • Cells in clusters in interstitium • EM ➢ X-bodies ➢ Langerhans cell granules Figure 1-3-14 ➢ Birbeck granules Langerhans Cell Histiocytosis Clinical Course • Clinical resolution ➢ Common • Radiographic abnormalities ➢ Persist • Occasional progression ➢ Fibrosis and honeycombing • May be fatal ➢ Rapid progression Langherhans Cell Histiocytosis Alpha-1 Antitrypsin Deficiency Pathophysiology • 1-2% of emphysema in the US • Alpha-1 antitrypsin inactivates neutrophil elastase • Production controlled by 2 genes • Level of antitrypsin dependent on allele • ZZ homozygotes most severe • Smoking accelerates the destruction Alpha-1 Antitrypsin Deficiency Imaging Features • Radiograph may be normal • Lower lobe predominance • Panacinar emphysema • CT ➢ Upper lobe involvement ➢ Bronchiectasis Alpha-1 antitrypsin deficiency ➢ Airway thickening common • CT more sensitive Alpha-1 Antitrypsin Deficiency [Figure 1-3-14] Figure 1-3-15 Bronchiectasis Pathophysiology • Dilatation of bronchi • Reversible form ➢ Infection ➢ Atelectasis • Congenital ➢ tracheobronchomalacia • Post-inflammatory • Postobstructive • Fibrotic ➢ IPF ➢ Sarcoid Williams-Campbell [Figure 1-3-15] Williams-Campbell Chest Radiology 31 Airways Disease .Langerhans Cell Histiocytosis EM and Immunohistochemistry • Immunoperoxidase staining ➢ CD1a.

pertussis. brain abscess. Measles. amyloidosis Bronchiectasis Radiographic Features Upper lobe smoking related • Prominent markings emphysema • Crowding of Vessels • “Tram Tracks” Figure 1-3-18 • Loss of volume • Cystic spaces Bronchiectasis CT Features • Bronchi in the periphery • “Signet Rings” • “Tram Tracks” • Sensitivity ➢ Collimation RB-ILD Emphysema [Figure 1-3-17] RB/RB-ILD [Figure 1-3-18] Figure 1-3-19 Emphysema and Fibrosis [Figure 1-3-19] Emphysema and fibrosis Airways Disease 32 Chest Radiology . viral • Post-toxic bronchitis ➢ gastric acid aspiration • Immunologic ➢ ABPA Primary Ciliary Dyskinesia Post Obstructive Bronchiectasis [Figure 1-3-16] Post obstructive bronchiectasis in a patient with • Neoplasm mucoepidermoid carcinoma • Foreign body • Broncholith • Lymph node enlargement Figure 1-3-17 Bronchiectasis Clinical Presentation • Cough • Purulent sputum • Hemoptysis (50%) • Dyspnea • Rare ➢ clubbing.Mounier-Kuhn Syndrome Figure 1-3-16 Bronchiectasis Postinflammatory • Primary Ciliary Dyskinesia ➢ Kartagener’s • Immunodeficiency • Postinfectious ➢ TB.

Langherhans Cell Histiocytosis [Figures 1-3-20 to 1-3-22] Alpha-1 Antitrypsin Deficiency [Figure 1-3-23] Figure 1-3-20 Figure 1-3-21 Early LCH nodules Late LCH Cysts and nodules Figure 1-3-22 Figure 1-3-23 End-stage LCH Lower lobe predominance in Alpha-1 antitrypsin Bronchiectasis Diffuse Lung Disease Airways • Airways involvement • Obstructive physiology • Increased lung volumes • Decreased attenuation Asthma ATS Definition • Reversible airway disease • Increased airway responsiveness • Persistent airflow obstruction occurs in chronic asthmatic ➢ Why? • 6% in the American population ➢ Rate has doubled in 20 years ➢ Higher incidence in large cities Asthma Extrinsic • Family history atopy • Early onset <30 years • Seasonal symptoms • Increased IGE • Positive skin tests • Often remits Chest Radiology 33 Airways Disease .

Asthma Figure 1-3-24 Intrinsic • No atopy ➢ Absence of external triggers • Older age group • Increased blood eosinophils • Increased sputum eosinophils • Fixed airway obstruction ➢ Progressive Asthma Pathology • Airway smooth muscle ➢ Hypertrophy • Airway wall ➢ Inflammation ➢ Edema Airway thickening in asthma • Airway plugging ➢ Mucus Figure 1-3-25 ➢ Inflammatory exudate Asthma Radiographic Features [Figure 1-3-24] • Chest roentgenogram ➢ Often normal • Airway thickening ➢ Chronic disease • Rapid attenuation of vessels ➢ hypoxemia • Pneumomediastinum ➢ pneumothorax • Hyperinflation ➢ Adaptive ➢ Later air trapping Silva AJR 183 September 2004 Asthma-Hyperinflation [Figure 1-3-25] Severe hyperinflation in which you Asthma [Figure 1-3-26] can see the slips of the diaphragm CT Features as it inverts • More sensitive than CXR Figure 1-3-26 • Reversible ➢ Consolidation ➢ Atelectasis ➢ Mucoid impaction ➢ Airway Narrowing ➢ Air Trapping • Permanent ➢ Bronchial wall thickening ➢ Bronchiectasis ➢ Emphysema Mucoid impaction in severe asthma Airways Disease 34 Chest Radiology .

Allergic Bronchopulmonary Aspergillosis Figure 1-3-27 Primary Criteria • Asthma • Eosinophilia • Immediate skin test reactivity • Precipitating antibodies (IgG) • Elevated serum (IgE) • Pulmonary infiltrates • Central bronchiectasis Allergic Bronchopulmonary Aspergillosis Presentation & Pathology [Figure 1-3-27] • Atopic individuals ➢ Most common • Cystic fibrosis • Airways filled ➢ Fungus ➢ Inspissated mucous • Presentation with ➢ Cough. Radiology 1998 Figure 1-3-29 Endobronchial Granulomas Small Airway Distortion Reticular Pattern and Fibrosis Central bronchiectasis in ABPA Chest Radiology 35 Airways Disease . fever ➢ Hemoptysis ➢ Worsening asthma • Seen in stable asthmatics ABPA represents a non-invasive • Good response to steroids colonization of the airways Allergic Bronchopulmonary Aspergillosis Imaging [Figures 1-3-28 and 1-3-29] Figure 1-3-28 • Bifurcating opacities ➢ “Gloved-finger” ➢ Mucous filled airways • Central Bronchiectasis • Fleeting infiltrates • Pleural disease ➢ Uncommon Sarcoidosis and the Airways Computed Tomography • Functional evidence of airways obstruction ➢ Obstructive PFT’s are common • Endobronchial biopsies find granulomas • Obstructive physiology correlates with ➢ Decreased attenuation on expiratory scans (small airways) Mucoid impaction in ABPA ➢ Reticular pattern and advanced fibrotic disease (large airways) Hansell et al.

Europe and North America ➢ HLA BW54 ➢ M-F 2:1 • Presentation ➢ Dyspnea ➢ Cough • Obstructive PFT’s • Slowly progressive ➢ 15 yr mean survival • Erythromycin ➢ May not be an antibacterial effect Diffuse Panbronchiolitis Pathology • Discrete nodules • Early infiltration Figure 1-3-30 ➢ Interstitium ➢ Respiratory bronchioles ➢ Alveolar ducts ➢ Foamy histiocyte. China.Diffuse Panbronchiolitis • Japan most common ➢ Rarely: Korea. lymphocyte and plasma cells • Late secondary ectasia ➢ Proximal terminal bronchioles Diffuse Panbronchiolitis Imaging Early • Radiography ➢ Nodules 5mm ➢ Hyperinflation • Computed Tomography ➢ Centrilobular nodules ➢ Branching opacities ➢ Mosaic attenuation Early Diffuse Panbronchiolitis represented by widespread airways nodules Diffuse Panbronchiolitis [Figure 1-3-30] Diffuse Panbronchiolitis Figure 1-3-31 Imaging Late [Figure 1-3-31] • Radiography ➢ Nodules ➢ Cysts and bulla ➢ Hyperinflation • Computed Tomography ➢ Centrilobular nodules ➢ Bronchiolectasis ➢ Bronchiectasis Constrictive Bronchiolitis Introduction • Confusing Terminology ➢ Obliterative Bronchiolitis ➢ Bronchiolitis Obliterans ➢ Bronchiolitis Obliterans Organizing Pneumonia ✧ Different disease ✧ Cryptogenic organizing pneumonia • Small Airways ➢ Fibrosis ➢ Inflammation • Response to Severe airway involvement in ➢ Inflammatory disorders panbronchiolitis ➢ Infectious disorders Airways Disease 36 Chest Radiology .

Constrictive Bronchiolitis Figure 1-3-32 Clinical Presentation • Cough. adenovirus and mycoplasma • Toxic Inhalation ➢ Ammonia. acid and NO • Aspiration: gastric acid • Collagen Vascular: RA • Organ Transplantation • Unknown Constrictive Bronchiolitis Histology [Figure 1-3-32] • Obstruction ➢ Terminal bronchiole Constrictive bronchiolitis ➢ Respiratory bronchioles • Polyps of fibrosis • Cellular infiltration ➢ Lymphs ➢ Plasma cells ➢ Histiocytes Constrictive Bronchiolitis Imaging [Figures 1-3-33 and 1-3-34] • Hyperinflation ➢ Localized ➢ Diffuse • Discrete nodules Figure 1-3-34 ➢ Airway associated • Mosaic pattern • Airway thickening • Bronchiectasis • Air trapping Figure 1-3-33 Central bronchiectasis and mosaic Mosaic attenuation in constrictive bronchiolitis attenuation in constrictive bronchiolitis Chest Radiology 37 Airways Disease . dyspnea and malaise • History ➢ prior infection ➢ exposure • Hypoxemia • Airway obstruction Constrictive Bronchiolitis Classification • Infection ➢ RSV.

veins and lymphatics • Small air filled cysts ➢ Air trapping Lymphangioleiomyomatosis Gross Features [Figures 1-3-37 and 1-3-38] • Cysts ➢ 0. alveolar septa.Swyer-James Syndrome [Figures 1-3-35 and 1-3-36] Figure 1-3-35 Figure 1-3-36 Unilateral hyperlucent lung in a patient with Swyer-James Swyer-James Syndrome Swyer-James Syndrome-Adenovirus Figure 1-3-37 Lymphangioleiomyomatosis Clinical Presentation • Exclusively women • Reproductive years • Progressive dyspnea • Chylous pleural effusions • Hemoptysis • Massive hemorrhage Lymphangioleiomyomatosis Function • Obstructive defect • FEV1 is decreased • TLC and RV increased • DLCO reduced • Hypoxemia • Hypocapnia Lymphangioleiomyomatosis Figure 1-3-38 Histology • Smooth muscle proliferation ➢ Disorderly Typical thin-walled cyst in ➢ Bronchioles. lymphangioleiomyomatosis arteries.2-2cm • Diffuse involvement • Enlarged thoracic duct • Enlarged lymph nodes The upper and lower lobes are equally involved in LAM Airways Disease 38 Chest Radiology .

progesterone Tuberous Sclerosis [Figure 1-3-41] Minimal disease in LAM may be difficult may be Emphysema difficult to separate from emphysema Emphysema and Fibrosis Figure 1-3-41 Langherhans Cell Histiocytosis Alpha-1 Antitrypsin Deficiency Asthma [Figure 1-3-42] Figure 1-3-42 LAM may represent partial expression of tuberous sclerosis Asthma Chest Radiology 39 Airways Disease .Lymphangioleiomyomatosis Figure 1-3-39 Radiographic Features • Reticulonodular opacities ➢ Basilar • Lung volume ➢ Normal ➢ Increased • Pleural effusion ➢ 60-75% • Pneumothorax • Honeycombing late Lymphangioleiomyomatosis Thin-walled cysts and a CT Features [Figure 1-3-39] pneumothorax in patient • Thin-walled cysts with ➢ More sensitive than plain film lymphangioleiomyomatosis • Diffuse • Bilateral involvement • Adenopathy Figure 1-3-40 Lymphangioleiomyomatosis [Figure 1-3-40] Lymphangioleiomyomatosis Therapy and Prognosis • Slowly progressive course ➢ Variable • Progression ➢ Cor pulmonale ➢ Respiratory insufficiency • 50-80% 5 year survival ➢ Average survival 10 years • Hormonal therapy ➢ Oophorectomy.

ABPA [Figure 1-3-43] Figure 1-3-43 Sarcoidosis [Figure 1-3-44] Diffuse Panbronchiolitis [Figure 1-3-45] Constrictive Bronchiolitis [Figure 1-3-46] Swyer-James Syndrome LAM [Figure 1-3-47] Physiologic Measurement An Integral Part of Imaging • Imaging provides physiologic information ➢ not available from pulmonary functions ABPA • Air content and blood flow can be quantified Airways Disease Figure 1-3-44 • Emphysema • Emphysema and Fibrosis • Alpha-1 deficiency • Histiocytosis-X • Bronchiectasis • Asthma • Allergic Bronchopulmonary Aspergillosis • Sarcoidosis • Diffuse Panbronchiolitis • Bronchiolitis Obliterans • Lymphangioleiomyomatosis Sarcoidosis airways involvement Figure 1-3-45 Figure 1-3-46 Diffuse Panbronchiolitis Mosaic attenuation in constrictive bronchiolitis Typical findings in LAM Figure 1-3-47 Airways Disease 40 Chest Radiology .

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Galvin. sedimentation and diffusion Particle Clearance [Figure 1-4-2] Cough. inner liquid sol • 90% of particles removed within 2 hrs • Alveolar transport ➢ Dissolution. Inertial impaction.Inhalational Lung Disease (Asbestosis and Silicosis) Jeffrey R. removed to lymphatics Early Basal Deposition Macrophages remove small particles to regional lymph nodes. engulfed by macrophages. tracheobronchial and alveolar transport • Most important ➢ Deposition less critical • Mucociliary escalator ➢ Outer gel. Inhalational Lung Disease 44 Chest Radiology . dust) recommends itself” Figure 1-4-1 Zenker 1866 Hematite Mining Inorganic Dusts • Silica • Asbestos • Coal • Iron • Beryllium Pneumoconiosis The accumulation of dust in the lungs and the tissue reaction to its presence • Dust macules • Diffuse interstitial fibrosis • Diffuse alveolar damage • Alveolar proteinosis • Giant cell (GIP) • Granulomatous inflammation Types and Sizes of Common Aerosols Particles less that 5 microns can be deposited beyond the conducting Particle Deposition airways in the alveolar spaces. MD Pneumonokoniosis • “It will then be necessary to embrace under a single title all essentially identical forms of disease • …the pneumonokoniosis (from Konis.000-20. sedimentation and diffusion [Figure 1- 4-1] • 10.000 liters/day • Deposition related to particle size • >10 microns deposit in nasopharynx and large airways (100%) Figure 1-4-2 • 1-5 micron particles deposit in lung parenchyma (20%) Airway Velocity Inertial impaction.

pressure in the dependent vessels Therefore lymphatic flow is best in the dependent lung. Therefore most airflow is directed towards the bases Physiologic Gradients-Blood Flow [Figure 1-4-5] Physiologic Gradients-Lymphatic Flow [Figure 1-4-6] Figure 1-4-5 Figure 1-4-6 There is increased blood flow and hydrostatic The lymphatics are driven by hydrostatic pressure.Removal to Lymph Nodes Physiologic Gradients-Airflow FRC [Figure 1-4-3] Physiologic Gradients-Airflow TLC [Figure 1-4-4] Figure 1-4-3 Figure 1-4-4 Alveoli in the bases are smaller than those in the The smaller alveoli in the bases enlarge to a apex. greater degree than those in the apex. Removal to Lymph Nodes [Figure 1-4-7] Figure 1-4-7 This explains the tendency for chronic diseases to be upper lobe Chest Radiology 45 Inhalational Lung Disease .

Tuberculosis Figure 1-4-8 Silicosis Mineralogy • Silicon ➢ Element • Silica (SiO2) ➢ Mineral • Silicone ➢ Synthetic polymer Figure 1-4-9 Adenopathy with peripheral calcification is a hallmark of silicosis Figure 1-4-10 Nodules with an upper lobe predominance is typical Figure 1-4-11 Silicoproteinosis is an acute lower lobe process Silicosis predisposes a patient to having active tuberculosis Inhalational Lung Disease 46 Chest Radiology .

stonecutting. ANA and gamma globulin The silicotic nodule is typical response to inhaled silica Silicosis [Figures 1-4-8 to 1-4-11] Clinical manifestations • Diagnosis ➢ Typical imaging pattern of adenopathy and nodules ➢ Exposure to high concentration of silica ➢ 10-20 years of exposure Figure 1-4-13 • Simple silicosis ➢ Asymptomatic • Symptoms with PMF • Intense exposure ➢ Silicoproteinosis • TB and cancer Simple Silicosis Pathology [Figure 1-4-12] • Progress to mature nodules: 3 zones ➢ Central dense fibrosis ➢ Mid-zone concentric collagen ➢ Peripheral dust laden cells Simple Silicosis Imaging manifestations [Figure 1-4-13] • Adenopathy common • Calcification 10-20% • Calcification 5-10% ➢ Eggshell pattern Simple Silicosis Imaging manifestations • Well-circumscribed nodules ➢ 1-10 mm • Upper lobe and posterior ➢ Lymphatic gradient ➢ CT more sensitive • Pleural lesions ➢ Candle-wax or pseudoplaques Eggshell calcification Chest Radiology 47 Inhalational Lung Disease . engraving and foundry work • Males more commonly affected • Degree of exposure underestimated • Increased risk of neoplasia and scleroderma Silicosis Pathogenesis • 5 million particles/cubic foot-lower threshold • 100 million particles/cubic foot-100% affected • > 5 micron particle removed in nares and upper airways • 80% of particles removed in hours to days • Retained particles consistently .5-.7 microns Silicosis Pathogenesis • Macrophages and polys concentrate • Macrophages generate oxygen-free radicals • Macrophages generate fibrogenic proteins • Immune related tissue damage ➢ Rheumatoid factor.Silicosis Figure 1-4-12 Epidemiology • Occupational exposure predominates ➢ 3 million workers • Mining.

Progressive Massive Fibrosis Figure 1-4-14 Pathology • Conglomeration of nodular lesions • Pathology definition ➢ 2 cm • Radiology definition ➢ 1 cm • Upper lung zones ➢ Posterior Progressive Massive Fibrosis Imaging manifestations [Figure 1-4-14] • Progression after exposure • May fill entire upper lobe ➢ Posterior • Usually bilateral • Carcinoma mimic Progressive massive fibrosis ➢ Solitary ➢ Lower lobe Figure 1-4-15 • Associated emphysema ➢ Not always smoking related ➢ Scar emphysema Silicotic Alveolar Proteinosis Pathology [Figure 1-4-15] • High concentration of particulate silica • Acute onset ➢ Weeks-months • Alveoli filled with PAS+ material • Similar to surfactant • Type II cell hyperplasia Silicosis and Tuberculosis [Figure 1-4-16] Silicosis Computed tomographic technique • Thick sections of value in nodular diseases ➢ Small nodules easier to differentiate from vessels • Thin sections 1-2 mm collimation at 10 mm intervals or 3-5 selected Crazy paving pattern associated images with prior thick section CT with alveolar proteinosis • High spatial frequency algorithm • Supine Figure 1-4-16 • No contrast Silica and Lung Disease • Adenopathy • Nodules • PMF • Silicoproteinosis • Tuberculosis • Cancer Tuberculosis in a patient with silicosis Inhalational Lung Disease 48 Chest Radiology .

3 million tons ➢ 60 years • 9 million people exposed ➢ Primary (mining) ➢ Secondary (industrial) ➢ Nonoccupational (air) Nonoccupational Exposure Asbestos Bodies [Figures 1-4-17 and 1-4-18] • Indicates exposure • Transparent fiber core • Iron and mucopolysaccharide coat • Predominantly amphiboles • Longer fibers are coated Asbestos bodies are Asbestos fibers are much ➢ < 20 microns not coated commonly found larger than macrophages ➢ Uncoated fibers are pathogenic in urban dwellers and therefore cannot be ➢ 7-5000 X’s more uncoated fibers removed to regional lymph • Fibers cannot be removed nodes • Lower posterior disease Asbestos Serpentine: chrysotile Figure 1-4-19 Figure 1-4-20 • 95% of commercial use • Curly and pliable • Textile manufacture • Fragments easily • Chemically unstable ➢ Dissolves easily • Less pathogenic Asbestos Amphiboles: amosite. broad fiber • Do not fragment easily Pleural effusions are the most Rounded atelectasis is usually • Long fibers (>20 microns) common early complication of preceded by a pleural effusion ➢ Not cleared asbestos exposure • More likely coated • Higher carcinogenic potential Figure 1-4-21 Asbestos Related Chest Disease [Figures 1-4-19 to 1-4-21] • Pleural effusions • Pleural plaques • Round atelectsis • Pleural thickening ➢ Diffuse • Mesothelioma • Asbestosis • Lung cancer Asbestosis is a lower lobe subpleural process Chest Radiology 49 Inhalational Lung Disease .Asbestos Figure 1-4-17 Figure 1-4-18 Introduction • Group of naturally occurring mineral fibers ➢ Hydrated fibrous silicate • Flexible and strong • Corrosion. tremolite and actinolite • 5% of commercial use • Straight. thermal and electrical resistance • 500 tons . anthophilite. crocidolite.

Pleural Plaques Figure 1-4-22 Pathology • Common autopsy finding ➢ (50-10%) • Dense bands of collagen ➢ “Basket weave” • Asbestos bodies absent • Uncoated fibers in dissolved lung tissue • Dose response ➢ Between parenchymal asbestos bodies and presence of plaques • Pathogenesis uncertain Pleural Plaques • Postero-lateral parietal pleura • Central diaphragm • Absent ➢ Apices and costophrenic angles • Almost always bilateral The visceral pleural stripe is best seen between the ribs • Sharply demarcated • Millimeters to 10 cm • May calcify extensively • Highly suggestive of asbestos exposure Roberts. JAMA 1982 Visceral pleural plaques Inhalational Lung Disease 50 Chest Radiology . 8 cm wide. AJCP 1971 Figure 1-4-23 Pleural Anatomy [Figure 1-4-22] Pleural Plaques Imaging • Radiography insensitive ➢ (8-40% of autopsy cases) • Companion shadows ➢ Fat and muscle • HRCT ➢ Best sensitivity and specificity Pleural Fat [Figure 1-4-23] Pleural Plaques [Figure 1-4-24] Fat may mimic fibrotic pleural disease Diffuse Pleural Thickening • Smooth pleural density ➢ CXR: > 25% of the length of the chest wall ➢ CT: 3 mm thick. 5 cm craniocaudal • Posteromedial lower lobes • Involves costophrenic angle Figure 1-4-24 • Mediastinal pleural involvement ➢ Rare ➢ Suggests mesothelioma • Visceral and parietal pleura ➢ Adhesions • Sequela of prior effusion? Pleural Effusion Definition • History of exposure to asbestos • Confirmation of effusion ➢ Imaging of thoracentesis • Absence of other disease related to effusion • Absence of malignant tumor for 3 years Epler.

Pleural Effusion Figure 1-4-25 Clinical presentation • Most common abnormality ➢ First 20 yrs • 3% prevalence ➢ Asbestos exposed • Small < 500 ml • Serosanguinous • Persist for weeks to 6 months • 66% asymptomatic • 28% recur Pleural Effusion Differential diagnosis • Lung cancer • Tuberculosis • Benign asbestos effusion • Mesothelioma Round Atelectasis • Described 1928 Loeschke • Usually asymptomatic • Folded lung vs inflammatory reaction • Associated conditions Round atelectasis is associated with ➢ Asbestos exposure. infarct. AJSP 1987 Round Atelectasis Imaging criteria [Figure 1-4-26] • Well-circumscribed • Round or oval opacity • “Comet tail” sign • Pleural thickening • Volume loss Asbestosis Pathologic definition • Interstitial fibrosis ➢ Associated with asbestos bodies • Biopsy ➢ Not the standard of practice Asbestosis • Dose-response relationship • Probable exposure threshold • Latency period inversely proportional to exposure level • Latency is several decades • Cigarette smoke may act synergistically Round atelectasis Chest Radiology 51 Inhalational Lung Disease . CHF. TB and histoplasmosis pleural effusion • Preceded by effusion Round Atelectasis Histology [Figure 1-4-25] • Irregular fibrous thickening of the visceral pleura • Extensive pleural folding beneath the fibrosis • Layers of invaginated pleura bound by fibrous adhesions • Surrounding lung collapsed or fibrotic Figure 1-4-26 Menzies.

alveolar ducts and alveolar septa • Minimum 2 asbestos bodies in area of fibrosis Craighead. 1982 Asbestosis Chest radiography • Lower lobe ➢ Irregular opacities ➢ Nonspecific ➢ Associated pleural disease • Large inter-observer variation ➢ Low perfusion • Normal in 26% of path proven cases Asbestosis and Cigarette Smoking Small irregular opacities • Small opacities are related to ➢ Dust exposure. age. clubbing • Chest radiographic abnormalities ➢ ILO perfusion > 1/0 (s. cigarette smoke. radiographic technique and obesity • Cigarette smoke causes ➢ Interstitial fibrosis ➢ Emphysema ➢ Bronchiolar thickening • Asbestos causes ➢ Interstitial fibrosis • Asbestos workers who smoke ➢ Have more opacities ➢ Related to dust exposure and cigarettes Figure 1-4-27 Asbestosis High-resolution CT • Lower lobe and posterior ➢ Reticulonodular opacities ➢ Parenchymal bands ➢ Curvilinear subpleural line ➢ Interstitial short lines ➢ Honeycombing • High sensitivity • Nonspecific • Specificity increases with # of abnormalities • Prone imaging is key! Parenchymal Bands [Figure 1-4-27] Parenchymal bands in a patient with asbestosis Inhalational Lung Disease 52 Chest Radiology . Arch Pathol Lab Med.Asbestosis ATS criteria 1986 • Reliable history of exposure • Latency of at least 10 years • Restrictive pulmonary functions ➢ DLco and VC <80% • Appropriate physical findings ➢ Inspiratory crackles. t or u) Asbestosis Histology • Early ➢ Fibrosis of respiratory bronchioles • Progression ➢ Terminal bronchioles.

1989 Asbestosis Dependent density • Posterior blood flow ➢ 5X’s greater • Posterior alveoli ➢ Smaller or collapsed ➢ Less steep ventilatory gradient ➢ Closing volumes (10-40% of VC) Asbestosis Computed tomographic technique • 1. Thorax. Radiology. 1988 – Aberle. ARRD. 1991 – Al-Jarad.5-2 mm collimation • 10 mm interval • High spatial frequency algorithm • Prone • Thick section supine: CA screen? Asbestos Related Chest Disease Tuberculosis Silicosis Asbestosis Particle Deposition and Clearance Cough. ARRD.Reticulonodular Opacites Curvilinear Subpleural Line Short Lines Honeycombing Asbestosis vs UIP • Asbestos exposure in the last 30 years is low • Clinical asbestosis requires substantial exposure • Asbestos exposed individuals can have other interstitial lung diseases • Band like opacities merging with the pleura are rare in UIP • Upper zone fibrosis and ground glass are rare in asbestosis Gaensler. AJR. tracheobronchial and alveolar transport Chest Radiology 53 Inhalational Lung Disease . 1992 Asbestosis High-resolution CT • Short lines and parenchymal bands are statistically most significant • Strong association with diffuse pleural disease • Multifocal • HRCT finds asbestosis in exposed individuals with normal radiographs and PFT’s • Obstructive PFT’s correlate with emphysema Aberle. 1988 – Staples.

Galvin. Almost all of these • Langerhans cells bronchi and are demonstrated adhering lymph nodes are subpleural and to the right main pulmonary inferior to the carina Pulmonary Lymphoid Disorders 54 Chest Radiology . MD The Pulmonary Lymphoid System • Lymphatics • Lymph nodes • BALT ➢ Bronchus Associated Lymphoid Tissue Figure 1-5-1 Figure 1-5-2 • Lymphoid aggregates • Lymphocytes • Dendritic cells • Langerhans cells The Pulmonary Lymphoid System [Figures 1-5-1 and 1-5-2] • Lymphatics ➢ Originate in the pleura ➢ Valves ➢ Drain towards hilum ➢ Follow interlobular septa ➢ Accompany blood vessels • Lymph Nodes • BALT • Lymphoid aggregates • Lymphocytes • Dendritic cells • Langerhans cells One set of lymphatics originate in the Lymphatic channels continue along the The Pulmonary Lymphoid visceral pleura as demonstrated by the pulmonary veins to the hilum.Pulmonary Lymphoid Disorders Jeffrey R. A second System lines on the surface of the lung. These set of lymphatics originates near the [Figures 1-5-3 and 1-5-4] lymphatics enter the lung and follow the center of the secondary lobule and • Lymphatics interloblular septa in the periphery of the follows the pulmonary arteries • Lymph Nodes lung ➢ Encapsulated lymph nodes Figure 1-5-3 Figure 1-5-4 ✧ Proximal bronchi ✧ Bifurcations ➢ Reactive lymph nodes ✧ Peripheral and septal ✧ Cigarettes or dust • BALT • Lymphoid aggregates • Lymphocytes • Dendritic cells • Langerhans cells Reactive Lymph Nodes The Pulmonary Lymphoid System • Lymphatics • Lymph nodes • BALT ➢ Bronchus Associated Lymphoid Tissue • Lymphoid aggregates Classic encapsulated intrapulmonary The majority of intrapulmonary lymph • Lymphocytes lymph nodes are found at the nodes are probably not visible • Dendritic cells bifurcations of the first 3-4 orders of radiographically.

It is normally found only in ➢ PTLD. Koss. Sem Diag Pathol 1995 Follicular Hyperplasias of BALT – Hyperplasia of BALT [Figure 1-5-6] • Follicular bronchitis and bronchiolitis Figure 1-5-6 • Pathologic features ➢ Antigenic stimulation of BALT ➢ Lymphoid aggregates ➢ Peribronchial ➢ Reactive follicles ➢ Minimal alveolar extension • Clinical Follicular Hyperplasias of BALT – Hyperplasia of BALT • Pathologic features • Clinical ➢ Young adults (44 yrs. interlobular septa and • Immune impairment pleura. Chest Radiology 55 Pulmonary Lymphoid Disorders .) ➢ Cough and dyspnea ✧ Fever and weight loss ➢ Immune deficiencies ✧ AIDS ✧ Congenital ➢ Collagen vascular diseases ✧ Sjogren’s ✧ Rheumatoid arthritis ➢ Uncertain Etiology Follicular bronchitis is characterized ✧ Hypersensitivity reactions? by hyperplastic lymphoid follicles with reactive germinal centers distributed along bronchioles and to a lesser extent bronchi. AIDS and other young children.BALT – The organizing principle [Figure 1-5-5] Figure 1-5-5 • Lymphoid collections ➢ Bronchial epithelium ➢ Bifurcations • Absent in the normal adult ➢ Absent at birth ➢ Common in young children • Reappears with antigenic stimulation ➢ Cigarette smoke ➢ Connective tissue disease ➢ AIDS • Basis of pulmonary lymphoid disorders Pulmonary Lymphoid Disorders – Derivations of BALT • Hyperplasias of BALT ➢ Follicular hyperplasia ✧ Follicular bronchitis ➢ Diffuse hyperplasia ✧ Lymphoid Interstitial Pneumonia ➢ Nodular Lymphoid Hyperplasia ✧ Pseudolymphoma • Non-Hodgkin’s lymphomas Bronchus associated lymphoid ➢ Low-Grade B Cell lymphomas tissue or BALT is found along the ➢ Lymphomatoid granulomatois bronchiole.

Follicular Hyperplasias of BALT – Hyperplasia of BALT: Imaging Figure 1-5-7 [Figure 1-5-7] • Radiography ➢ Diffuse ➢ Reticulonodular • CT ➢ Nodules 3-12 mm ✧ Centrilobular ✧ Peribronchial ➢ Ground Glass ➢ Air Trapping Follicular Hyperplasia – Differential Diagnosis Almost all patients with follicular • Respiratory Bronchiolitis bronchitis have centrilobular nodes • Hypersensitivity pneumonitis that are less than 3mm. and SLE ➢ Bone marrow transplantation LIP is characterized by diffuse ➢ AIDS rare in adults infiltration of the alveolar septa ✧ Common in children ➢ Dysproteinemia ➢ Restrictive lung functions Pulmonary Lymphoid Disorders 56 Chest Radiology . These • Diffuse panbronchiolitis nodules correlate with the • Cystic Fibrosis peribronchiolar distribution of • Primary ciliary dyskinesia hyperplastic lymphoid follicles shown on the histology section to your left Diffuse Hyperplasias of BALT – Hyperplasia of BALT [Figure 1-5-8] Figure 1-5-8 • Lymphocytic Interstitial Pneumonia • Pathologic Features ➢ Alveolar septal infiltration ✧ Lymphocytes (T-cells) ✧ Diffuse ➢ Lymphoid follicles (B-cells) ✧ Germinal centers ✧ Peribronchial distribution ✧ Spectrum with follicular hyperplasia of BALT (Follicular Bronchitis) • Clinical Diffuse Hyperplasias of BALT – Lymphoid Interstitial Pneumonia LIP.Hyperplasia of BALT • Pathologic features • Clinical ➢ Women>men ➢ 4th-6th decade ➢ Cough and dyspnea ➢ Collagen vascular disease ✧ Sjogrens. RA.

The alveolar wall Cysts 82% 2% thickening is primarily the result of Consolidation 18% 66% lymphoid infiltation Large Nodules 6% 41% Effusions 0% 25% Figure 1-5-10 Nodular Lymphoid Hyperplasia – Hyperplasia of BALT [Figure 1-5-11] • Pseudolymphoma • Pathologic Features ➢ Solitary. The • Pathologic features histology on the left demonstrates • Clinical complete obliteration of the ➢ Rare entity bronchiole by lymphoid infiltration. ➢ Most cases were The accompanying arteriole is lymphomas identified by its typical wall. Previous reports have suggested that Nodular Lymphoid Hyperplasia – Hyperplasia of BALT airway narrowing or obliteration • Pseudolymphoma results in these cystic lesions. ✧ Monoclonal B cell proliferation ➢ Middle age ✧ Asymptomatic ➢ Autoimmune Figure 1-5-11 Diseases 15% ✧ Sjorgren’s Nodular lymphoid hyperplasia or ✧ SLE pseudolymphoma presents as a ✧ Transverse solitary subpleural mass of myelitis lymphoid tissue with numerous ➢ Surgical excision reactive germinal centers curative Chest Radiology 57 Pulmonary Lymphoid Disorders .Diffuse Hyperplasia of BALT – Hyperplasia of BALT: Imaging Figure 1-5-9 [Figures 1-5-9 and 1-5-10] • Radiography ➢ Lower lung zone ➢ Reticulonodular • CT ➢ Ground Glass ➢ Nodules ✧ Centrilobular ✧ Poorly defined ➢ Cystic air spaces ➢ Thickened BVB’s ➢ Adenopathy The lung windows demonstrate diffuse hazy ground glass that LIP vs Lymphoma correlates with diffuse alveolar wall LIP Lymphoma thickening. subpleural mass ➢ Lymphoid proliferation ✧ Interstitial ✧ Perivascular ✧ B and T cells ✧ Polyclonal pattern – Benign ➢ Reactive germinal centers ➢ Difficult to separate from lymphoma Thin walled cysts are often found • Clinical deep within the lung parenchyma.

however. • Immune impairment Low-Grade B-Cell Lymphoma Figure 1-5-13 • Pathologic features ➢ Lymphocytic infiltration ➢ Small lymphocytes ✧ Alveolar wall ✧ Peribronchiolar ✧ Perivascular ➢ Immunologic evidence of malignancy ✧ Monoclonality ✧ B-cell markers CD20 ➢ Germinal Centers Low-Grade B-Cell Lymphoma Air bronchograms are universally • Clinical present and the lymphoid infiltration ➢ Similar presentation to nodular lymphoid hyperplasia gradually diminishes resulting in the ➢ 5th-6th decade classical indistinct margin ➢ Male=Female ➢ Asymptomatic 50% Figure 1-5-14 ➢ 5 year survival 85-95% ➢ Surgical resection ✧ Rare recurrence Low-Grade B-Cell Lymphoma [Figure 1-5-14 • Imaging ➢ Radiography ✧ Solitary nodule/mass – Multiple ✧ Consolidation ✧ Air bronchogram – 50% Grossly low grade B-cell lymphoma ✧ Slow Growth usually presents as a single white tan ➢ CT lesion that can be either well ✧ Consolidation circumscribed or indistinct. The bulk of the lesion • Non-Hodgkin’s lymphomas consists of a mass of lymphoid tissue ➢ Low-Grade B Cell lymphomas with multiple reactive germinal ➢ Lymphomatoid granulomatosis centers. solitary lesion with indistinct • Hyperplasias of BALT margins. be multifocal as shown on the right and has been reported as a primarily endobronchial lesion.Nodular Lymphoid Hyperplasia Figure 1-5-12 Hyperplasia of BALT: Imaging [Figures 1-5-12 and 1-5-13] • Radiography ➢ Solitary Nodule ➢ Focal Consolidation • CT ➢ Air bronchograms ✧ 100% ➢ Indistinct margins ➢ Occasionally multiple ➢ Adenopathy and/or effusion suggests lymphoma Pulmonary Lymphoid Disorders The CT demonstrates the typical sub- Derivations of BALT pleural. This is ✧ Air bronchograms well demonstrated by the gross ✧ Airway narrowing or “stretching” specimen on the left from the AFIP archive. Pulmonary Lymphoid Disorders 58 Chest Radiology . The disease can.

LYG [Figure 1-5-16] Pulmonary Lymphoid Disorders – Derivations of BALT • Hyperplasias of BALT • Non-Hodgkin’s lymphomas • Immune impairment ➢ Posttransplantation Lymphoproliferative Disease (PTLD) ➢ AIDS ➢ Other forms of prolonged immune suppression Chest Radiology 59 Pulmonary Lymphoid Disorders .Primary Tracheal Lymphoma Figure 1-5-15 • Extremely rare • BALT derivative • Extensive at diagnosis • Potentially curable Lymphomatoid Granulomatosis [Figure 1-5-15] • Pathologic features ➢ Majority of cases are B-cell lymphomas ➢ Reactive small T-cells ➢ Malignant B-cells ✧ Majority of infiltrate ➢ Epstein-Barr Virus ➢ Angiocentric infiltration ➢ Necrosis ✧ Peribronchovascular ✧ Peripheral Lymphomatoid Granulomatosis • Clinical ➢ 7-85 years (mean 48 yrs) ➢ Male:Female (2:1) Lymphomatoid Granulomatosis is an ➢ Malaise and weight loss angiocentric B-cell lymphoma which ➢ Lung involvement 100% often demonstrates areas of necrosis. ➢ Cough and dyspnea ➢ Skin 39-53% ✧ Nodules. ulcers and rash Figure 1-5-16 ➢ CNS 37-53% ➢ Renal 32-40% ➢ High mortality rate 53-90% ➢ Most proceed to lymphoma Lymphomatoid Granulomatosis • Imaging ➢ Nodules 80% ✧ Multiple ✧ Bilateral (80%) ➢ Mid and lower lobes ➢ Cavitation 20% ➢ Large masses Chest CT on the left demonstrates a ✧ Correspond to infarcts bronchovascular distribution of ➢ Diffuse reticulonodular opacities nodules that are shown to be areas of ➢ Hilar adenopathy 25% infarction on gross examination.

Genetic mutation may [Figure 1-15-18] eventually result in malignant transformation of one of these clones. reduced T-cell surveillance and PTLD malignant transformation. anti-virals and surgery ➢ Chemotherapy should be avoided ➢ Heart-lung up 20% Lymphoma and Immune Impairment • Imaging ➢ Nodules ✧ May cavitate ✧ Halo ✧ Along bronchovascular bundles ➢ Lymph node ➢ Ground glass ➢ Septa thickening ➢ Consolidation ➢ Effusion Post transplant lymphomas are driven by Epstein- Barr virus. represented in purple. fever and chills for 2 months. The CT reveals multiple multiple indistinct nodules in a characteristic distribution along the bronchovascular bundles Pulmonary Lymphoid Disorders 60 Chest Radiology .Lymphoma and Immune Impairment [Figure 1-5-17] Figure 1-5-17 • Pathologic Features ➢ B-cell non-Hodgkin’s lymphoma ✧ Driven by Epstein-Barr Virus infection ✧ Diffuse polyclonal expansion – Reduced T-cell control ✧ Malignant transformation Lymphoma and Immune Impairment • Clinical ➢ Spectrum of benign to malignant ✧ Infectious mono-like ✧ PTLD polymorphic ✧ PTLD monomorphic ➢ Cyclosporin shortens induction (<1 year) ➢ May respond to reduction in immunosuppression. Bone Marrow Transplant Prolonged Chemotherapy Figure 1-5-18 Pulmonary Lymphoid Disorders Derivations of BALT • Hyperplasias of BALT • Non-Hodgkin lymphomas • Immune impairment ➢ Posttransplantation Lymphoproliferative Disease PTLD ➢ AIDS ➢ Other 58 year old male with alpha 1 antitrypsin deficiency who underwent a double lung transplant 7 years prior to presenting with shortness of breath. cough.

Figure 1-5-23 Low grade B-cell Lymphoma Lymphomatoid Granulomatosis Chest Radiology 61 Pulmonary Lymphoid Disorders .Follicular Hyperplasia [Figure 1-5-19] Figure 1-5-19 Diffuse Hyperplasia of BALT-LIP [Figure 1-5-20] Nodular Lymphoid Hyperplasia [Figure 1-5-21] Low-Grade B-Cell Lymphoma [Figure 1-5-22] LYG [Figure 1-5-23] Figure 1-5-20 Follicular Bronchitis. Figure 1-5-21 Lymphocytic Interstitial Pneumonia (LIP). Figure 1-5-22 Nodular Lymphoid Hyperplasia which was formerly known as Pseudolymphoma.

Thorax. 1995 May. Semin Diagn Pathol.Non-neoplastic pulmonary lymphoid lesions.12(2):158-71. Koss MN.The organizing principle • Lymphoid collections • Basis of pulmonary lymphoid disorders Post Transplant Lymphoproliferative Disorder References General 1. 2001 Dec. Travis WD.Immune Impairment-PTLD [Figure 1-5-24] Figure 1-5-24 BALT . 2. Galvin JR. Pulmonary Lymphoid Disorders 62 Chest Radiology .56(12):964-71. Pulmonary lymphoid disorders.

Angiitis and Granulomatosis Jeffrey R. TB. MD Angiitis and Granulomatosis • First characterized by Averill Liebow 1973 • Unknown etiology • Angiitis ➢ Cellular infiltration of blood vessel • Granulomatosis ➢ Necrosis of lung parenchyma not related to blood vessel occlusion Angiitis and Granulomatosis: Current List • Wegener’s granulomatosis • Churg-Strauss syndrome ➢ Allergic granulomatosis • Necrotizing sarcoid granulomatosis • Bronchocentric granulomatosis • Lymphomatoid granulomatosis Angiitis and Granulomatosis: General Concepts • Etiology remains unknown • Inflammatory vs. lymphoproliferative • Clinical and laboratory findings key to Dx • Adequate tissue samples are important • Must R/O infection: mycobacterial or fungal Pathogenesis of Vasculitis Angiitis and Granulomatosis: Differential Multiple vessel associated nodules [Figure 1-6-1] • Metastatic disease ➢ Squamous • Multifocal infection Figure 1-6-1 ➢ Fungus. bacteria • Septic emboli • Multiple pulmonary infarcts • Langerhans’ cell histiocytosis • Rheumatoid nodules Wegener’s Granulomatosis: Classic Pathology Triad • Vasculitis described 1852 ➢ Von Rokitansky • Wegener described 1936 ➢ Wegener’s • Focal vasculitis of ➢ Arteries and veins • Necrotising granulomas ➢ Upper and lower airways • Necrotising glomerulitis ➢ Focal Vasculitis in the lung fits into the differential of vessel associated nodules Chest Radiology 63 Angiitis and Granulomatosis . Galvin.

Wegener’s Granulomatosis: Gross Pathology Figure 1-6-2 [Figures 1-6-2 and 1-6-3] • Necrotic nodules ➢ With and without cavitation • Parenchymal consolidation • Massive hemorrhage • Airway narrowing Wegener’s Granulomatosis: Demographics • Rare ➢ 3/100.000 in US • 2nd-8th decades of life • Average age-50 years • Male=Female ➢ Slight male predominance (4:3) • May occur in children Wegener’s Granulomatosis: Limited • Involvement of lungs alone • Clinical sparing ➢ Kidneys ➢ Upper respiratory tract • Biopsy positive ➢ When clinically normal Solid and cavitary nodules often • Better prognosis coexist in patients with Wegener’s granulomatosis Wegener’s Granulomatosis: Clinical Presentation • Classic triad Figure 1-6-3 ➢ Sinusitis ➢ Pulmonary symptoms ➢ Renal insufficiency • Variable onset and course • Chronic URI symptoms ➢ May persist for years before pulmonary disease • Overwhelming vasculitis ➢ Diffuse Upper Airway • Chronic nasal obstruction ➢ Chronic discharge • Destruction of cartilaginous nasal septum • “Saddle nose deformity” • Laryngeal involvement ➢ Subglottic stricture • Eustachian tube obstruction • Otitis media • Cochlear nerve vasculitis Pulmonary • Most commonly affected (94%) • Multiple bilateral nodules or masses Airway narrowing is a common • Cavitation common (30-50%) complication • Occasionally solitary mass or nodule ➢ Dx difficult ➢ All patients progress • Less common ➢ Diffuse alveolar hemorrhage • Pleural lesion and effusions are rare Angiitis and Granulomatosis 64 Chest Radiology .

optic nerve and retro-orbital mass • Nervous system (30%) ➢ Mononeuritis multiplex • Joints ➢ Acute arthritis follows activity of disease (+RA latex) Wegener’s Granulomatosis: Airway Involvement [Figures 1-6-4 and 1-6-5] • Endobronchial abnormalities ➢ 59% bronchoscopy • Subglottic stenosis • Tracheobronchitis ➢ Ulcerating • Tracheal or bronchial stenosis Focal airway narrowing is a common • Often multifocal complication in Wegener’s ➢ Variable length of involvement • CT key for evaluation ➢ CXR often normal Wegener’s Granulomatosis: Radiography • Earliest lesions ➢ Bilateral reticulo-nodular opacities Figure 1-6-5 • Multifocal nodules ➢ Bilateral ➢ 5mm-10cm • Sharply marginated • Cavitation 20-50% • Evolution ➢ Thick walls to thin walled cysts with treatment • Airspace consolidation Changing Presentation Necrosis and Hemorrhage [Figure 1-6-6] Figure 1-6-6 Collapse due to airway narrowing in Wegener’s Massive necrosis and hemorrhage in Wegener’s Chest Radiology 65 Angiitis and Granulomatosis .Renal Figure 1-6-4 • Tempo: insidious to explosive • Segmental necrotizing glomerulonephritis • UA: erythrocyte casts and proteinuria • Large vessel vasculitis Wegener’s Granulomatosis: Other Organ Involvement • Skin (50%) ➢ Symmetric papulonecrotic lesion of extremities • Eye and orbit (30%) ➢ Scleritis. conjunctivitis.

Evolution with Treatment [Figures 1-6-7 and 1-6-8] Figure 1-6-7 Figure 1-6-8 Infections are a common complication Nodules in varying stages Figure 1-6-9 Wegener’s Granulomatosis: Computed Tomography [Figure 1-6-9] • Feeding vessels ➢ 88% • Cavitation ➢ Nodules greater than 2cm • Subpleural location ➢ Predominant • CT “halo sign” • Pleural based lesions ➢ Mimic infarcts • Reveals more nodules Diffuse Pulmonary Hemorrhage: Capillaritis [Figure 1-6-10] • Common Figure 1-6-10 ➢ Microscopic polyangiitis ➢ Wegener’s granulomatosis ➢ SLE • Uncommon Nodules with feeding vessels are ➢ Goodpastures common in vasculitis ✧ Anti-GBM ➢ Collagen vascular ➢ Idiopathic pulmonary hemorrhage ➢ Churg Strauss syndrome ➢ Behcet’s syndrome ➢ IgA Nephropathy Pulmonary hemorrhage in capillaritis Angiitis and Granulomatosis 66 Chest Radiology .

GI and cutaneous Figure 1-6-11 Microscopic polyangiitis Wegener’s Granulomatosis: Laboratory • ANCA ➢ Serum Antineutrophil Cytoplasmic Autoantibody • c-ANCA cytoplasmic pattern ➢ Proteinase 3 ➢ 99% specificity and 96% sensitivity in active disease ➢ Positivity drops to 30% in remission • p-ANCA perinuclear pattern ➢ Reacts with myeloperoxidase ➢ positive in collagen vascular diseases Wegener’s Granulomatosis: Treatment and Prognosis • Universally fatal without treatment • Trimethoprim/Sulfa effective in localized disease • Steroids and cyclophosphamide ➢ Remission in 93% • 5 year survival 90-95% • Infectious complications ➢ Relapse and drug toxicity require close monitoring and follow-up imaging • Relapse has different manifestations from presentation Churg-Strauss Syndrome: Allergic Angiitis and Granulomatosis • Described by Churg and Strauss ➢ 1951 • True systemic vasculitis • Associated ➢ Asthma ➢ Allergic rhinitis ➢ Blood eosinophilia • Hypersensitivity response to inhaled antigen? Chest Radiology 67 Angiitis and Granulomatosis . pulmonary. muskuloskeletal.Microscopic Polyangiitis [Figure 1-6-11] • Microscopic polyarteritis nodosa • Most common cause of pulmonary-renal syndrome • 5th decade • Male > Female • Renal.

Churg-Strauss Syndrome: Pathology • Necrotizing vasculitis • Eosinophilic tissue infiltration • “Allergic granulomas” ➢ Extravascular ➢ Eosinophils ➢ Multinucleated giant cells Churg-Strauss Syndrome: Demographics • 2nd-4th decades • 28 years mean age of onset • Male=Female • Excellent response to steroids Churg-Strauss Syndrome: Background • Late onset asthma ➢ 100% • Precedes CSS by weeks to years (30) • Severe rhinitis and sinusitis ➢ 70% Churg-Strauss Syndrome: Prodromal Stage • Infiltration of tissues with eosinophils • Blood eosinophilia • Elevated IgE • + rheumatoid factor • Progressive asthma. and diffuse hemorrhage • Cardiac ➢ Coronary vasculitis and eosinophilic myocarditis (50% of mortality) • GI ➢ Ulcerations. Al. sinus pain. 1998 Churg-Strauss Syndrome: Comparison with Wegener’s • CSS ➢ High incidence of asthma ➢ High incidence of cardiac involvement (47%) ➢ Less severe renal and sinus disease ➢ Associated with P-ANCA Angiitis and Granulomatosis 68 Chest Radiology . myocardial involvement • Loffler’s like fleeting infiltrates • Abdominal pain ➢ Diarrhea and eosinophilic peritonitis • Myalgias and neuritis Churg-Strauss Syndrome: Vasculitic Stage • Increasingly severe and widespread symptoms • Lung ➢ Eosinophilic consolidation. miliary to 2 cm nodules (without cavitation). AJR Feb. perforations and peritonitis Churg-Strauss Syndrome: Computed Tomography • Parenchymal opacification ➢ Predominantly peripheral 59% ➢ Effusions • Nodules ➢ 12% • Bronchial thickening • Dilatation ➢ 12% • Interlobular septal thickening ➢ 6% Worthy et.

fever and dyspnea • Weight loss and fatigue • May be asymptomatic ➢ 15-40% • Rare extrapulmonary involvement ➢ 13% • Aspergillus antigens in some patients Koss et al.2:1 Necrotizing Sarcoid Granulomatosis: Pathology • Non-caseating granulomas ➢ Similar to sarcoidosis • Vasculitis ➢ Pulmonary arteries ➢ Pulmonary veins ➢ Found in areas away from parenchymal granulomas • Coagulative necrosis ➢ Widespread ➢ Main distinction from sarcoidosis Necrotizing Sarcoid Granulomatosis: Clinical Presentation • 100% lung involvement • Cough most common symptom • Chest pain.Churg-Strauss Syndrome: Therapy and Prognosis • Prognosis relates to early diagnosis and therapy • High dose steroids usually effective • Cyclophosphamide in resistant cases • Therapy stopped after 6-12 months of remission Necrotizing Sarcoid Granulomatosis How is this related to sarcoidosis? • A distinct entity? ➢ Katzenstein • Some reported cases are undiagnosed infections • Those with extrapulmonary involvement ➢ Sarcoidosis Necrotizing Sarcoid Granulomatosis: Demographics Figure 1-6-12 • 3rd to 7th decades • Mean age 49 years • Female:male ➢ 2. Human Pathology 1980 Necrotizing Sarcoid Granulomatosis: Imaging [Figure 1-6-12] • Hilar adenopathy ➢ Variable ➢ Up to 79% • Nodules ➢ Cavitation is common ➢ Subpleural ➢ Perivascular • Parenchymal opacities ➢ Same distribution Necrotizing Sarcoid Granulomatosis: Prognosis and Therapy • May require no therapy Typical nodules in NSG • Prompt response to steroids • No reported deaths Chest Radiology 69 Angiitis and Granulomatosis .

histiocytes • Vascular invasion • Vascular destruction • Necrosis ➢ Peribronchovascular ➢ Peripheral Lymphomatoid Granulomatosis: Clinical Presentation • Lung involvement LYG is a large B-cell lymphoma ➢ 100% ➢ Cough and dyspnea • Skin Figure 1-6-14 ➢ 39-53% ➢ Nodules. ulcers and rash • CNS ➢ 37-53% • Renal ➢ 32-40% • Malaise and weight loss ➢ 35% Lymphomatoid Granulomatosis: Imaging [Figure 1-6-14] • Nodules ➢ 80% ➢ Multiple ➢ Bilateral (80%) • Mid and lower lobes • Cavitation ➢ 20% • Large masses ➢ Correspond to infarcts • Diffuse reticulonodular opacities • Hilar adenopathy ➢ 25% Peripheral opacities in LYG Lymphomatoid Granulomatosis: Treatment and Prognosis • Mortality rate ➢ 53-90% • Long term remissions reported ➢ Cyclophosphamide and steroids • All who fail therapy proceed to develop lymphoma ➢ 12-47% Angiitis and Granulomatosis 70 Chest Radiology .Lymphomatoid Granulomatosis: Etiology and Demographics [Figure 1-6-13] Figure 1-6-13 • Majority of cases are B-cell lymphomas • Epstein-Barr Virus • Reactive small T-cells ➢ Majority of infiltrate • Malignant B Cells • Age range ➢ 7-85 years • Mean age of onset ➢ 48 years • Male:Female (2:1) Lymphomatoid Granulomatosis: Pathology • Angiocentric infiltration ➢ Mixed cell population ✧ Atypical lymphocytes. plasma cells.

TB. bacteria • Septic emboli • Multiple pulmonary infarcts • Langerhans’ cell histiocytosis • Rheumatoid nodules Chest Radiology 71 Angiitis and Granulomatosis . blastomyces. aspergillus • Mycobacterial infections • Rheumatoid arthritis • Wegener’s granulomatosis • Idiopathic Bronchocentric Granulomatosis: Pathology • Nonspecific reaction • Early invasion of mucosa ➢ Histiocytes ➢ Eosinophils Mucoid impaction in patients with ✧ Asthmatics BCG ➢ Neutrophils ✧ Non-asthmatics • Secondary involvement of adjacent arteries • Granulomatous destruction ➢ Bronchial walls • Bronchopneumonia ➢ Distal to affected airways Bronchocentric Granulomatosis: Imaging [Figure 1-6-15] Figure 1-6-16 • Most often unilateral ➢ 75% • Multiple or solitary nodules • Parenchymal consolidation ➢ Upper lobe predominance • Associated findings of ABPA ➢ Bronchiectasis ➢ Mucoid impaction BCG and Tuberculosis BCG and Aspergillus [Figure 1-6-16] Bronchocentric Granulomatosis Treatment and Prognosis • Asthmatics respond to steroids ABPA may be clinically unsuspected • Some cases remit without treatment • Must rule out treatable infection and Wegener’s granulomatosis Angiitis and Granulomatosis: Differential Multiple vessel associated nodules • Metastatic disease ➢ Squamous • Multifocal infection ➢ Fungus. malaise and hemoptysis • Peripheral and tissue eosinophilia • No extrapulmonary findings Bronchocentric Granulomatosis Clinical and Demographics – Non-Asthmatics • Average age 50 years • Males=Females • Fungal infections ➢ Histo. fever.Bronchocentric Granulomatosis Figure 1-6-15 Clinical and Demographics – Asthmatics • Average age 22 years • Tissue manifestation of ABPA • Dyspnea. cough.

eds. Radiology 1990. second edition. Diagnosis and treatment of the systemic and cutaneous necrotizing vasculitis syndromes. Am J Respir Crit Care Med 1995. Travis WD. 401-435. Pass HI. 81(1): 243-259. 97:906-912. Allen NB. 58(6): 533-553 3. 13. Kornblut AD. Lüdemann J. Tracheobronchial involvement in Wegener’s granulomatosis. Ann Intern Med 1989. Bressler PB. Laryngoscope 1983. 11. Fauci AS. Am Rev Respir Dis 1973. 4(1): 23-41. Bonavita JA. Fraser RS. Gross WL. Pathology: State of the Art Reviews 1996. Radiol Clin North Am 1991. Katzenstein AA. Surgical pathology of the lung in Wegener’s granulomatosis: review of 87 open lung biopsies from 67 patients. Pulmonary angiitis and granulomatosis. Solitary lung lesions in Wegener’s granulomatosis: Pathologic findings and clinical significance in 25 cases. Formes frustes of Churg-Strauss syndrome. Fleming MV. Wolff SM. Gamsu G. Thoracic manifestations of Wegener granulomatosis: diagnosis and course. Spontaneous pneumothorax: an uncommon manifestation of Wegener granulomatosis. 29(5): 973-982. Chest 1990. New York: Thieme Medical Publishers. Am J Surg Pathol 1987.BCG? Fungal Infection ? Angiitis and Granulomatosis: Conclusion • Wegener’s granulomatosis • Churg-Strauss syndrome ➢ Allergic granulomatosis • Necrotizing sarcoid granulomatosis • Bronchocentric granulomatosis • Lymphomatoid granulomatosis “Until specific causes are found ………we must devise syndromes” • Etiology • Prognosis • Therapy References 1. Med Clin North Am 1997. Chest 1995. 2. Am Rev Respir Dis 1986. Symposium on granulomatous disorders of the head and neck: Wegener’s granulomatosis. 19. 14. Thurlbeck WM. Specks U. McDonald TJ. Liebow AA. Anticytoplasmic autoantibodies: Their immunodiagnostic value in Wegener granulomatosis. Philadelphia: WB Saunders Company. Travis WD. Synopsis of diseases of the chest. Daum TE. 12. 3(1):33-48. Vasculitis in the lung. 174:703-709. Churg A. Travis WD. Wolff SM. Cordier JF. Pathology of pulmonary granulomatous vasculitis. Pare JAP. Specks U. 1954. Brechot JM. 15(3):673-683. 18. Gefter WB. Fauci AS. Churg J. 15. eds. J Thorac Imag 1988. Godman GC. Otol Clin North Am 1982. Am J Surg Pathol 1995. Pathology of the lung. Angiitis and Granulomatosis 72 Chest Radiology . 19(5): 545-552. et al. Churg J. A. Hoffman GS. 151: 522-526. 22. 13:14- 27. Wegener’s granulomatosis: Prospective clinical and therapeutic experience with 85 patients for 21 years. 7. 20. The J. Feigin DS. Staples CA. second edition. 23. Burns Amberson Lecture: pulmonary angiitis and granulomatosis. 21. Leavitt RY. Carpenter HA. Radiol 1980. Conversations on allergy and immunology. Sarcoidosis Vasc and Diffuse Lung Dis 1996. Am J Surg Pathol 1991. Diffuse pulmonary hemorrhage: an uncommon manifestation of Wegener’s granulomatosis. Valeyre D. Epstein DM. Loire R. Fauci AS. Leavitt RY. 135:327-328. Locke WK. Vasculitis of the lung. Fauci AS. 8. Pulmonary Wegener’s granulomatosis: a clinical and imaging study of 77 cases. Colby TV. 5. Cutis 1985. 1995. 11(9): 702-708. 411-419. Katz P. DeRemee RA. Fauci AS. Wegener’s granulomatosis. Guillevin L. 1994. Churg AM. DeRemee RA. Wegener’s granulomatosis: Pathology and review of the literature. Rohrbach MS. Pulmonary vasculitis. 98:76-85. 16. Lynch D. 93: 220-231.M. Miller WT. Haynes BF. 108:1- 18. 108(2):320-323. 6. Arch Pathol. 4. Aberle DR. 9. Cronin SR. Fraser PD. Lie JT. Gohel V. 17. Brallas M.A. Travis WD. Ann Intern Med 1983. 111:28-40. 134:149-166. 15(4): 315-333. Nölle B. 35:27-34. Kornblut AD. 10. DeFries HO.

Maguire R. Carrington CB. Colby TV. Underwood GA. 167:901-904. AJR 1978. Kullnig P. Churg-Strauss pulmonary vasculitis: high-resolution computed tomography scanning and pathologic findings. 34. Davison AM. Manson D. Mark EJ. Fauci AS. and imaging features. Chest 1989. 53. Wadsworth DT. Am J Surg Pathol 1994. Katzenstein AA. Fishman EK. Papiris SA.163:901-904. Can Assoc Radiol J 1992. 45. Jaspan T. Thorax 1982. Friedman PJ. 31. 37. Ebeling SH. 39. Clin Radiol 1979. Amundson DF. Doppman JL. Chest Radiology 73 Angiitis and Granulomatosis . 95(6):1357-1359. 163:273-281. 35. Manoussakis MN. Case records of the Massachusetts General Hospital. 141:233-238. J Can Assoc Radiol 1988. Chest 1994. 41. 43. Cavitary pulmonary cryptococcosis complicating Churg-Strauss vasculitis. Wegener’s granulomatosis presenting as right middle lobe obstruction. Lee SJ. Pleural effusion in Churg-Strauss syndrome. Lymphoproliferative disorders of the lung: histopathology. Lee SH. Weisbrod GL. Radiol 1994. McNeely WF. 335(20):1514-1521. Lockwood CM. 44. clinical manifestations. 47. 103(5):1623-1624. Pleural effusion in Churg-Strauss syndrome. Wegener’s granulomatosis: a radiological review of the pulmonary manifestations at initial presentation and during relapse. Wegener’s granulomatosis in children: chest radiographic manifestations. 93: 529-536. Wegener’s granulomatosis in children. Day DL. and therapeutic considerations. Lymphomatoid granulomatosis. Weisbrod GL. Pulmonary lymphomatoid granulomatosis: evidence for a proliferation of Epstein-Barr virus infected B-lymphocytes with a prominent T-cell component and vasculitis. Kontogiannis D. Farrelly CA. J Comput Assist Tomogr 1990. 3(4):457-558. Cancer 1979. Hartman TE. Drosos AA. Godwin JD. Aitken ML. 30. 52. 51. Peter HH. Carrington CRB. 306(2):68-74. Chest 1993. immunologic. Hum Pathol 1972. Buschman DL. Connolly S. Haynes BF. 99(3):781-784. 49. Imaging of thoracic Wegener’s granulomatosis: the computed tomographic appearance. CT appearance of pulmonary vasculitis in children. AJR 1994. Würtemberger G. 48:377-380. 165(3):743. Dobie JC. Scully RE. Foo SS. McHugh K. 14(6):1004-1006. Underwood GA. Computed tomography of the lung in Wegener’s granulomatosis. Prenovault JMN. 50. Katz P. Frew E. Thorax 1982. Stokes TC. Waldron JA. Constantopoulos SH. 27. 46. pathologic. Chest 1989. Schollmeyer P. Koss MN. Arora NS. Fauci AS. 39:263-266. 18(8): 753-764. 190:513-515. 142:458-461. Laxer RM. et al. Pulmonary nodules and the CT halo sign. 48. Hruban RH. Lymphomatoid granulomatosis: prospective clinical and therapeutic experience over 10 years. 42.105(2):509-513. Eberhard A. Liebow AA. 32. Grotz W. Acute fulminating intrapulmonary haemorrhage in Wegener’s granulomatosis. Jaffe E. Unusual presentation of recurrent Wegener’s granulomatosis. Am Rev Respir Dis 1990. 29. 15(6):948-952. Wolff SM. Katz P. 54. Lymphomatoid granulomatosis: a review of 12 cases. Herman SJ. King TE. 36. Hamilos DL. J Comput Assist Tomogr 1991. Radiol 1982. Primack SL. 43:360-373. Wegener’s granulomatosis: findings from computed tomography of the chest in 10 patients. Kjeldsberg CR. Moutsopoulos HM. Chor PJ. AJR 1996. Walker WC. 40. Maskell GF. Fauci AS. Lee KS. Chamberlain DW. Harrison BDW. Clin Radiol 1982. 37:774- 775 33. Dee PM. Siegel MJ. The spectrum of vasculitis: clinical. Müller NL. Wolff SM. 95 (6):1357-1359. 14(12):1112-1136. Innes DJ. Kingma D. Haynes BF. Lombard C. 38. Sims EH. Husari AW. Flower CDR. Pulmonary lymphoid disorders. 30: 661- 664. Erzurum SC. Hicken R. Herman SJ. Wegener granulomatosis presenting on CT with atypical bronchovasocentric distribution. The radiology of lymphomatoid granulomatosis in the lung. Southern Med J 1992. 89(1):660-676. McCann BG. Costa J. Smith C. Berry GJ. Bragg DG. Murray KA. Liebow AA. 55. Radiographic course of pulmonary manifestations in Wegener’s granulomatosis under immunosuppressive therapy. Clin Radiol 1993. Muller NL. Mundinger A. The pulmonary manifestations of lymphomatoid granulomatosis. Fishback N. Am J Surg Pathol 1990. AJR 1994. Hamilos DL. 143: 613-618. Lymphomatoid granulomatosis: a clinicopathologic study of 152 cases. Erzurum SC. [Letter] AJR 1995. Rees RT. Unusual radiographic features of Wegener’s granulomatosis. Chest 1991. 33:545-551. Chiles C. Guinee D. Carpenter HA. Weir IH. 43(1):31-34. Kuhlman JE. Waldron JA. A clinicopathologic study of 34 cases of diffuse pulmonary hemorrhage with lung biopsy confirmation. Am J Med 1992. 26. Wegener granulomatosis: CT features of parenchymal lung disease. Waldron JA. 25. Semin Diag Pathol 1995. 85(7):700-702. 12(2):158-171. N Engl J Med 1982. Travis WD. Spontaneous pneumothorax in Wegener’s granulomatosis. Ann Intern Med 1978. 28.24. 37:315-316. New Engl J Med 1996. Dugowson CE.

Necrotizing sarcoid granulomatosis: computed tomography and pathologic findings. Necrotizing sarcoid granulomatosis with pleural involvement: clinical and radiographic features. Granulomatous infection mimicking bronchocentric granulomatosis. Klein JJ. Pitchenik AE. 145(4) 230-233. McFadden RG. Lamb D. Clin Chest Med 1988. Radiology 1985. Bronchocentric granulomatosis and allergic bronchopulmonary aspergillosis. Berendsen HH. Koss MN. Thorax 1982. Müller NL. Siewertsz Van Reesema DR.19(6):920-923. 9(4):609-621. Hartman TE. Robinson RG. 154: 289-29 Angiitis and Granulomatosis 74 Chest Radiology . Cincinnati: Audiovisual Radiology of Cincinnati. Ann Med Interne 1994. Bronchocentric granulomatosis. Progressive bronchocentric granulomatosis: case report. J Comput Assist Tomogr 1995. 82(4):481-491. 58. 106:672-676. Chittock DR. Hochholzer L. Epstein DM. Inc. 61. Kambouchner M. Gefter WB. 66. Sulavik SB. 40:396-397. 59. 63. Kapsenberg PD. Granulomatose necrosante sarcoid-like: à propos de 4 observations. Clark RA. Saldana MJ. 40:138-134. Katzenstein AA. Niimi H. Urbaniak SJ. Sadoun D. Warren J. Joseph MG. 37:947-949. Paterson NAM. 62. second edition. Tazi A. South Med J 1989. Am J Surg Pathol 1986. Felson B. et al. Thorax 1985. Granulomatous vasculitides of the lung: a clinicopathologic approach to diagnosis and treatment. Bronchocentric granulomatosis associated with seropositive polyarthritis. 67. 1967: 561-562. Diffuse pulmonary hemorrhage: a review and classification. J Can Assoc Radiol 1989. 64. Reeder MM. Myers JL. Gamuts in radiology. Clee MD. 60. 57. Albelda SM. Hum Pathol 1981.56. 12(7):632-638. Weisbrod CL. 10(5):317-322. Miller WT. Chest 1994. Hofstee N. Pulmonary angiitis and granulomatosis: a review . 65.

MD Introduction • Organ transplant first performed the 1960’s • Solid organ for vital organ failure • Hematopoietic stem cell (HSC) ➢ Standard therapy ✧ Malignant. Galvin. autoimmune and genetic diseases • Not proven in breast cancer Pulmonary Complications in 40-60%: Multifactorial Cause • Underlying disease • Therapy for underlying disease • Graft-vs-host disease • Conditioning regimen ➢ Chemotherapy and radiation Solid Organ Transplant: Typical Schedule [Figure 1-7-1] Figure 1-7-1 Solid organ transplant complications begin predominantly after the first month post-transplant Bone Marrow Transplant: Typical Schedule [Figure 1-7-2] Figure 1-7-2 Complications are usually separated into those that occur before and after there first 100 day Chest Radiology 75 Pulmonary Complications of Organ Transplantation . hematologic.The Pulmonary Complications of Organ Transplantation Jeffrey R.

antibiotics and TPN • Cardiac • Renal dysfunction • Decreased albumin • Often accompanied by fever Pulmonary edema in a bone marrow transplant patient demonstrating interlobular septal thickening and enlarged pulmonary veins Pulmonary Complications of Organ Transplantation 76 Chest Radiology .Early Pulmonary Complications Figure 1-7-3 • Pulmonary edema • Fungal infection • Diffuse alveolar hemorrhage • Bacterial infection • Viral infection ➢ CMV and herpes • Pneumocystis carinii • Acute graft-vs-host disease • Idiopathic pulmonary syndrome ➢ ARDS. From 1999-2002 there was a steady increase in peripheral blood Operative Technique [Figure 1-7-3] stem cell grafts • Donor aspiration ➢ General anesthesia • 150-200 aspirates • Marrow strained • Immunocompetent T-cells ➢ Depleted with monoclonal reagents • Infusion of marrow Figure 1-7-4 ➢ 400-800 ml Immunologic Impact • Profound neutropenia • Prolonged depression ➢ Cellular function ➢ Humoral function • Graft-vs-host ➢ Direct effect ➢ Steroids Pulmonary Edema [Figure 1-7-4] • Common complication • 2nd-3rd week posttransplantation • Rapid onset ➢ Dyspnea and hypoxemia • Reticulo-nodular markings • Fluid overload ➢ Blood products. DAD Late Pulmonary Complications • Chronic graft-vs-host • Obstructive airways disease ➢ Bronchiolitis obliterans • Organizing Pneumonia ➢ BOOP • Restrictive ventilatory defect • Late bacterial infections ➢ Sinopulmonary • Herpes varicella zoster Pretransplant Considerations Traditionally. allogeneic • Residual tumor transplantation used bone marrow • Occult infection grafts.

cough. 1997 Pulmonary Hemorrhage • 21% of BMT patients • 12th day posttransplantation • Neutrophil recovery • Sudden onset: ➢ Dyspnea. 1997 Imaging and Survival: Invasive Aspergillosis Caillot.Fungal Infections Figure 1-7-5 • Up to 45% of BMT patients Fungi normally ➢ 85% mortality invade the lung • Aspergillus is most common via the airway • Occurs in the first 30 days posttransplantation • Symptoms: ➢ Fever. J Clin Oncol. fever and hypoxemia • Rare hemoptysis Typical infarct with a halo of blood in an aspergillus • Mortality 50-80% infection • Radiographic abnormalities before symptoms • Bilateral ground glass opacities ➢ May be localized Figure 1-7-7 Air-crescent sign in a patient with recovering cell counts Chest Radiology 77 Pulmonary Complications of Organ Transplantation . J Clin Oncol. chest pain and hemoptysis • Predisposition ➢ Prolonged granulocytopenia ➢ Broad spectrum antibiotics • Nodules • Early “Halo-Sign” • Late “Air Crescent” Fungal Infections [Figures 1-7-5 to 1-7-7] Invasive Aspergillosis: Diagnosis • BAL (69%) Figure 1-7-6 • Tissue Biopsy (60%) • Antigen (83%) • Computed Tomography (92%) Caillot. dyspnea. cough.

Pulmonary Hemorrhage [Figure 1-7-8] Figure 1-7-8 Cytomegalovirus Pneumonia • 10-40% of BMT patients • 6-12 weeks posttransplantation • Mortality rate of 85% • Reactivation of latent virus in 70% ➢ Remainder infected by “CMV positive” blood products • Anti-viral therapy improves prognosis Cytomegalovirus Pneumonia [Figure 1-7-9] • Bilateral • Ground glass 66% • Nodules 59% • Consolidation 59% ➢ Alone 3% Franquet et al AJR Oct 2003 Aspergillus infection may be a cause of pulmonary Pneumocystis Jiroveci Pneumonia hemorrhage • <10% of BMT patients • Effective prophylaxis ➢ Trimethoprim/sulfa • Rapid progression • Severe dyspnea • Bilateral perihilar • Ground-glass opacities Figure 1-7-9 Noninfectious Pulmonary Complication • Late-onset Noninfectious Pulmonary Complications ➢ LONIPC’s ➢ After the first 3 months ➢ 10-23% of allogeneic grafts • Idiopathic pulmonary syndrome ➢ Diffuse alveolar damage (DAD) • Bronchiolitis obliterans • Organizing pneumonia ➢ BOOP • Associate with GVHD ➢ Sicca syndrome ➢ Acive donor T-cells Sakaida. cough and hypoxemia • Mortality rate of 70% • Diffuse Opacities Pulmonary Complications of Organ Transplantation 78 Chest Radiology . Blood Vol 102 2003 Typical lower lobe nodules of CMV Idiopathic Pulmonary Syndrome • Diffuse lung injury posttransplantation • Histology ➢ Interstitial mononuclear infiltrate ➢ DAD • 12% of allogenic BMT • 40-80 days posttransplantation • Risk factors ➢ GVHD ➢ Radiation • Fever.

biliary cirrhosis and airway obstruction GVHD and IPS In the early phase (exudative) there is diffuse consolidation and ground glass often with peripheral clearing GVHD and Infection Figure 1-7-12 GVHD and IPS Radiation Pneumonitis • Related to dose of TBI • Presents within 90 days • Cough. viruses • Inhalants ➢ Ammonia. Paraquat • Shock/trauma • Sepsis • Radiation • Idiopathic ➢ Hammon-Rich or AIP Patients with IPS present with diffuse opacities involving all 5 lobes Viral Infection Figure 1-7-11 Idiopathic Pulmonary Syndrome [Figure 1-7-12] Graft-vs-Host Disease (GVHD) : Donor T-lymphocytes recognize the recipient’s tissue as foreign • Acute GVHD ➢ 20-100 days posttransplantation ➢ 25-75% of patients ➢ skin. chlorine. BCNU. HS • Drugs ➢ Cytoxan. Bleomycin • Ingestants ➢ Kerosene.Idiopathic Pulmonary Syndrome Figure 1-7-10 [Figures 1-7-10 and 1-7-11] Diffuse Alveolar Damage • Infectious agents ➢ Legionella. fever. and dyspnea • Threshold lowered by chemotherapy Mediastinal Emphysema • Correlates ➢ Idiopathic interstitial pneumonia • Increased likelihood with more radiation • Not a serious complication by itself • May be a harbinger of pneumothorax The late phase of IPS demonstrates traction bronchiectasis consistent with fibrosis Chest Radiology 79 Pulmonary Complications of Organ Transplantation . gut and liver dysfunction ➢ 10% mortality • Chronic GVHD ➢ 1> 100 days posttransplantation ➢ 20-45% of patients ➢ Features of autoimmune diseases ➢ Sjogren’s. scleroderma. mycoplasma.

02% incidence • 7X’s increase ➢ Over the general population • 1 year after transplantation ➢ Median • Hodgkin’s 45% • Leukemia 17% • Solid tumors 38% Lymphoma and Immune Impairment • Pathologic Features ➢ B-cell non-Hodgkin ’s ✧ Driven by Epstein-Barr virus infection ✧ Diffuse polyclonal expansion – Reduced T-cell control ✧ Malignant transformation Bone Marrow Transplant Bronchiolitis Obliterans • 2-13% of BMT’s Bronchiolitis obliterans • Low immunoglobulin level demonstrating mosaic • Chronic GVHD attenuation ➢ Sicca syndrome Figure 1-7-14 • 100 days posttransplantation • Gradual deterioration of PFT’S • Airflow obstruction ➢ Fixed • Reduction in diffusing capacity • Imaging ➢ Mosaic attenuation ➢ Expiratory accentuation ➢ Centrilobular nodules ➢ Patchy consolidation Bronchiolitis Obliterans [Figures 1-7-13 to 1-7-15] Segmental or Lobar Consolidation • Infection Diffuse Opacities • Pulmonary edema Bronchiolitis obliterans demonstrating indistinct • Hemorrhage nodules and branching opacities • Diffuse alveolar damage • Viral pneumonia Figure 1-7-15 • Pneumocystis pneumonia Rapid Progression Over 24 Hours • Bacterial pneumonia • Pulmonary edema • Hemorrhage Progression Over Days • Aspergillus • Pneumocystis • Diffuse alveolar damage • CMV Bronchiolitis obliterans demonstrating bronchiectasis Pulmonary Complications of Organ Transplantation 80 Chest Radiology .Secondary Malignancies Figure 1-7-13 • 0.

Pulmonary complications of solid organ and hematopoietic stem cell transplantation.184(2):629- 37 2. Franquet T. Gimenez A. Muller NL. AJR Am J Roentgenol. Am J Respir Crit Care Med. Ahya VN. Kotloff RM. 2005 Feb.170(1):22-48. Lee KS. Epub 2004 Apr 7 Chest Radiology 81 Pulmonary Complications of Organ Transplantation .High-resolution CT and pathologic findings of noninfectious pulmonary complications after hematopoietic stem cell transplantation.Diffuse Opacities Fluid Overload Organizing Pneumonia BMTP: dyspnea and cough BMTP Lymphangitic Spread BMTP BMTP Aspergillus BMTP: dyspnea and cough BMTP: Edema Bone Marrow Transplant: Typical Schedule References General 1. 2004 Jul 1. Flint JD. Crawford SW.

1991 Embolic Events: Predisposing Causes • Stasis • Trauma • Hypercoagulable states Predisposing Causes • 1° thrombophlebitis 39% • Bed rest 32% • Recent surgery 31% • Venous insufficiency 25% • Recent fracture 15% • Myocardial infarction 12% • Malignancy 8% • CHF 5% • No Predisposition 6% Pulmonary Embolism 82 Chest Radiology . Galvin.The Diagnosis of Pulmonary Embolism Jeffrey R. 1997 Pulmonary Embolus: Epidemiology • 5 million episodes of DVT • 300. cardiac chambers and catheters • A negative venous study ➢ Does not rule out PE • < 50% of PE patients ➢ Positive lower extremity study Kelly.000 new cases The “Clinical Picture” of PE • Predisposing factors • Pathology • Signs and symptoms • Radiography • Arterial blood gases • V/Q scanning • Computed tomography • Arteriography Pulmonary Embolism is a Complication of Deep Venous Thrombosis Hull. Ann Int Med.000 deaths • 100/100. Annals of Internal Med 1983 Sources of Pulmonary Emboli • Majority of clots ➢ Lower extremity veins • Increasing number of clots ➢ Upper extremities. J Clin Path.000 embolic events • 50. MD Pulmonary Embolus • Frequent • Potentially fatal • Largely undiagnosed Baglin.

” patients are symptomatic Morpurgo.PE and Malignancy: 10-15% of unexplained phlebitis • Gastrointestinal • Pulmonary • Genitourinary The History and Physical are Non-Specific Symptoms in Patients with Non-Fatal PE • Chest Pain 88% • Dyspnea 84% • Apprehension 59% • Cough 53% • Hemoptysis 30% • Sweats 27% • Syncope 13% Signs in Patients with Non-Fatal PE • RR> 16 92% • Rales 58% • HR> 100 44% • T> 37. Chest 1995 History and Physical The Role of Clinical Suspicion • Less than 35% of fatal emboli were diagnosed antemortem Symptoms in Patients with Fatal PE • Dyspnea 59% • Syncope 27% • Altered mentation 20% • Apprehension 17% • Chest pain 10% • Sweatiness 9% • Pleuritic Pain 8% • Cough 3% • Hemoptysis 3% • Arrest 8% Chest Radiology 83 Pulmonary Embolism .8°C 43% • Diaphoresis 36% Figure 1-8-1 • Gallop 34% • Phlebitis 32% • Murmur 23% • Cyanosis 19% PE and Underlying Lung Disease The History and Physical are Insensitive We do not know the Prevalence of PE. Many disease. the protean nature of the The clinical diagnosis of PE is unreliable. Diagnostic Algorithm and Clinical Suspicion [Figure 1-8-1] “Among the various causes of an incorrect diagnosis. most important are: the failure to suspect PE and.

1998 Radiographic and CT Findings [Figure 1-8-2] Peripheral opacities may raise suspicion for clinically unsuspected PE Pulmonary Embolism 84 Chest Radiology .Signs in Patients with Fatal PE • RR> 16 66% • HR> 100 54% • Rales 42% • T> 37.8°C 30% • Edema 26% • Hypotension 20% • Cyanosis 12% • Gallop 10% • Diaphoresis 10% • Phlebitis 7% Figure 1-8-2 The Chest X-Ray is Usually Abnormal The Chest X-Ray in Pulmonary Embolism • 84% had abnormal radiographs PE(%) NoPE(%) ➢ Atelectasis/Infiltrate 68 48 ➢ Pleural Effusion 48 31 ➢ Pleural Opacity 35 21 ➢ Elevated Diaphragm 24 19 ➢ Decreased Vascularity 21 12 ➢ Prominent PA 17 28 ➢ Cardiomegaly 12 11 ➢ Westermark’s Sign 7 2 ➢ Pulmonary Edema 4 13 PIOPED Common Radiographic Abnormalities • Infiltrate 54% • Pleural Effusion 51% • Atelectasis 27% • Diaphragm Up 17% • 2 or More 44% • CHF 17% • Focal Oligemia 2% • Normal 7% Chest CT Findings • Atelectasis 100% • Consolidation 57% • Hampton’s hump 50% • Ground glass 57% • Pleural Effusions 87% • Mosaic attenuation Truong. ARRS.

Circulation Res. Chest Vol. 1974 and is more likely to occur in patients Dantzker. 5 with CHF Physiologic Change with Heparinization • Ventilation ➢ Returns more rapidly than perfusion • Perfusion ➢ May return before ventilation Santolicandro.Pathology [Figure 1-8-3] Figure 1-8-3 • Edema • Hemorrhage • Infarction Normal Arterial Oxygenation Does Not Exclude Pulmonary Embolism Arterial Blood Gases • 10-15% will have a PO2 >85mm HG • A low arterial PO2 is non-specific • A respiratory alkalosis is most common The Physiology of Pulmonary Embolism • V/Q abnormalities ➢ Variable • Complete vascular occlusion ➢ Rare • Complete shunt 2° to ➢ Atelectasis ➢ Hemorrhage • Autoregulation ➢ Hypoxic vasoconstriction ➢ Hypocapnic bronchoconstriction Hemorrhage and edema are common Levy. JAP. 1995 V/Q Physiology Ventilation/Perfusion Scanning Clinical Science Probability (%) 80-100 20-79 0-19 All Probabilities • High 96% 88% 56% 87% (103/118) • Intermediate 66% 28% 16% 30% (104/345) • Low 40% 16% 4% 14% (40/296) • Normal 0% 6% 2% 4% (5/128) • Total 68% 30% 9% 28% (252/887) PIOPED The Basis of “Clinical Science Probability” • PE(%) No PE(%) • Dyspnea 73 72 • Pleuritic Pain 66 59 • Cough 37 36 • Leg Swelling 28 22 • Hemoptysis 13 8 • Palpitations 10 18 • Wheezing 9 11 • “Angina” 4 6 PIOPED Chest Radiology 85 Pulmonary Embolism . 91 no. 1974 sequela of PE. Infarct is less common Dantzker. Am J Res Crit Care Med.

” PIOPED.23mm visualizes 90% of segmental arteries Patel. 1978 Pulmonary Embolism 86 Chest Radiology .” Bone. 1990 • A Potentially Lethal Reading ➢ “Pulmonary embolism cannot be diagnosed on clinical grounds. AJR 183. Archives of Internal Medicine. it can only be suspected. Radiology. 2003 Significance of Small Emboli – Standard Angiography • Good outcome ➢ Patients with “negative angio” • 1. lobar and segmental vessels • Misses some subsegmental emboli • Indeterminate 8-10% • Constantly changing ➢ Related to collimation. Radiology.25mm visualizes 75% of subsegmental arteries • 1. JAMA. 1993 The Goal of Imaging – Visualization of the clot The Role of Pulmonary CT Angiography • Initial screening • Detection of unexpected emboli • Detection of other pathology CT Angiography Pulmonary CT Angiography – Sensitivity and Specificity • Accurately identifies emboli ➢ Main. scanner speed and prevalence ➢ Sensitivity 66-93% ➢ Specificity 89-97% Eng. 1995 • “There is a 25%-30% disagreement between expert readers in interpreting INTERMEDIATE and LOW probability V/Q scans.Traditional Approach [Figure 1-8-4] Figure 1-8-4 The Low-Probability Lung Scan • “There is an 8% mortality rate in patients with a “low probability” V/Q scan and limited cardiopulmonary reserve.5% embolize when followed 1 year ➢ 691 patients Novelline. Archives of Internal Medicine. 2004 Pulmonary CT Angiography – Sensitivity and Specificity • 3mm visualizes 40% of subsegmental arteries • 3mm visualizes 75% of segmental arteries • 1.” Hull.

consecutive studies • “The safety of withholding anticoagulants…is uncertain” Pulmonary CT Angiography Negative Predictive Value of a Normal CT n Follow-up NPV Mayo 69 3m 97% Feretti 109 3m 97% Garg 78 6m 99% Loomis 81 6m 100% Goodmann 198 3m 99% Remy-Jardin 71 3m 97% Tillie-Leblond 185 12m 98% Kavanagh 85 9m 99% Pulmonary CT Angiography – Intra and Interobserver Variability • Radiology’s Achilles’ Heel • Related to clot size • Exacerbated by poor exam • Related to reader experience Mayo. Oser. Radiology. 1997.Distribution of Pulmonary Emboli • Multiple locations ➢ > 55% • Marked preference for ➢ Right lung and lower lobes • Subsegmental only ➢ 6-30% PIOPED. 2005 Pulmonary CT Angiography Negative Predictive Value of a Normal CT • No prospective. Radiology.CTA • Small emboli that need treatment ➢ Poor cardiopulmonary reserve ➢ Coexisting acute DVT ➢ Recurrent PE • Small emboli that may not need treatment ➢ Subsegmental clots without evidence of DVT ➢ Indeterminate scan without evidence of DVT ➢ Normal cardiovascular status ➢ Follow-up DVT scan in 1 week Goodman. AJR:184 2005 Chest Radiology 87 Pulmonary Embolism . 1990. Chest. 1995 Significance of Small Emboli . AJR. JAMA. Chartrand-Lefebre. Morpurgo. Radiology 234. 1996. 1999 Pulmonary CT Angiography • Alternate diagnoses ➢ 11-33% • Unexpected emboli ➢ 1-4% Storto.

Alternative Diagnoses [Figure 1-8-5 and 1-8-6] Figure 1-8-5 Figure 1-8-6 Pulmonary infection is a common alternative diagnosis is patients suspected of pulmonary embolus Adenocarcinoma is an important predisposition for hypercoaguability and PE Pitfalls in Helical CT [Figure 1-8-7 and 1-8-8] • Partial volume ➢ Obliquely oriented arteries • Suboptimal contrast enhancement • Breathing artifacts • Lymph nodes Figure 1-8-7 Figure 1-8-8 Breathing artifacts should be Adenopathy can mimic PE assessed before reading a CTA for PE Pulmonary Embolism 88 Chest Radiology .

Radiology. AJR:177 July 2001 Combined Pulmonary CTA and Venography • Increases detection of thromboembolic disease by 20% • Contiguous sections • 1cm collimation Cham.234 2005 Combined Pulmonary CTA and Venography Year N Sensitivity Specificity Loud 00 150 97% 100% Duwe 00 74 89% 94% Garg 00 70 100% 97% Cham 00 116 100% 96% Peterson 01 136 71% 93% A Diagnostic Algorithm for Pulmonary Embolism Pulmonary Embolus and Prognosis The prognosis in PE patients is closely related to the presence and extent of clot in the peripheral veins Chest Pain-Dyspnea Screening Conclusion • The clinical diagnosis of PE is unreliable • The chest radiograph is usually abnormal • V/Q readings restricted to “reliable categories” • Small clots are a problem for all modalities • Outcome studies are key • CT angiography is the modality of choice Chest Radiology 89 Pulmonary Embolism .Technical Improvements • Multi-channel CT • Narrower collimation: 1mm • Subsecond scanning • Contrast timing Figure 1-8-9 ➢ “Smart prep” ➢ Test bolus: peak + 5 sec ➢ 20 seconds normal cardiac output ➢ Caudal-cranial scanning • Workstation viewing ➢ Cine Mode (PACS or Workstation) ➢ Adjust window and levels for each case ➢ Multi-planar reconstruction ➢ Breathing artifact-coronal lung windows 16 Channel CT [Figure 1-8-9] Coronal reconstrution helps separate pulmonary arteries and veins Paddlewheel Reformation Simon.

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Vietnam. states bordering Mexico NMWR.000 ➢ Sub-Saharan Africa: 191/100.2/100. M. the Philippines.000 ➢ 43% decrease from 1992 ➢ 4-6% of population infected ✧ 15 million people • 51% Foreign-born ➢ Mexico. bovis ➢ > 95% of pulmonary mycobacterioses • Slow growth • Person-to-person transmission Chest Radiology 93 Tuberculosis .201 cases ➢ 1. tuberculosis. microti • M.707 deaths • 1985: 22. africnum. tuberculosis and M. immunocompromised. bovis. India and China • U.S. M.000 ✧ HIV co-infection: 60% of children.075 cases ➢ 5. 70% of adults Tuberculosis: History • Ancient disease • 1882: Robert Koch ➢ Isolation of M. elderly • Urban areas. M.304 cases ➢ 19.752 deaths • 1986-1992: 20% increase in reported cases ➢ HIV ➢ Immigration ➢ Congregate settings ➢ Deteriorating TB services ➢ MDR-TB ➢ Decreasing TB research Tuberculosis: United States • 2002: 15. -born ➢ African Americans 25% of all cases ➢ homeless. coastal states.Tuberculosis Jeffrey R. MD Tuberculosis • Leading cause of death from infectious disease • 8-10 million new cases/year • 2-3 million deaths/year • 1/3 of world population infected • > 90% of new cases in developing countries • 80% 15-59 years of age • Highest incidence ➢ Southeast Asia: 247/100. 2003 Vol 52 Mycobacteria • Tuberculosis complex ➢ M. tuberculosis • 1944: streptomycin • 1952: INH Tuberculosis Pre-Antibiotic Era Tuberculosis: United States • 1953: 84.March 21. Galvin.

The actively growing think of TB as an upper bacilli reside in the macrophages in lobe disease. tuberculosis: Pathologic features • Gram positive pleomorphic rod • Acid fast: ➢ Resists decolorization with acid alcohol Figure 1-9-1 • Virulence related to cell wall ➢ No endotoxin or enzymes • Caseous necrosis • Caseating granuloma ➢ Central caseous necrosis ➢ Rim of histiocytes. we inhale the periphery most bacteria into the mid and lower lung zones Figure 1-9-3 Physiologic Gradients-Airflow FRC Tuberculosis: Pathogenesis • Inhaled bacteria ➢ Mid to lower lung zones ➢ Ghon focus • Regional lymph node spread [Figures 1-9-3] ➢ Ranke complex • Lymphatic/hematogenous dissemination • Cell-mediated immunity In primary tuberculosis the ineffective • Delayed hypersensitivity macrophages carry bacteria to ➢ Caseous necrosis regional lymph nodes where they ➢ 2-10 weeks proliferate and disseminate • Healing Tuberculosis 94 Chest Radiology . giant cells Caseous Necrosis [Figure 1-9-1] Tuberculosis: Pathogenesis • Inhaled bacteria [Figure 1-9-2] ➢ Mid to lower lung zones ➢ Ghon focus Figure 1-9-2 The caseating granuloma is the Even though we tend to hallmark of TB.M.

transplantation. nodular • Pleural effusion ➢ Adults 38%.Tuberculosis: Pathogenesis Figure 1-9-4 • Latent TB infection ➢ +PPD ➢ No active signs of infection • Survival of organisms [Figures 1-9-4] ➢ Apical/posterior upper lobe ➢ Superior segment lower lobe ✧ Oxygen gradient ✧ Lymphatic gradient ✧ Bucket handle rib motion • Active TB infection [Figures 1-9-5] ➢ 5% within 2 years ➢ 5-10% lifetime risk ➢ HIV: 50% within 2 years ➢ Pulmonary fibrotic lesions. Vol 210 of reactivation tuberculosis Lymphadenopathy is hallmark of primary TB and is more common in children Chest Radiology 95 Tuberculosis . linear. prolonged immunosuppressive therapy Tuberculosis: Clinical features The lymphatic gradient helps explain • Primary TB the upper lobe distribution of • Postprimary TB reactivation tuberculosis • Disseminated TB Primary Tuberculosis: Clinical features Figure 1-9-5 • Asymptomatic 65% ➢ Nonspecific symptoms when present • Progressive primary complex ➢ Fever. underweight. renal failure. children The lymphatic gradient helps 11% explain the upper lobe distribution Leung. lobar. DM. cough. weight loss Primary Tuberculosis: Radiologic features • Lymphadenopathy [Figure 1-9-6] ➢ Children 95%. hilar ➢ Peripheral enhancement. gastrectomy. multifocal ➢ Homogeneous. hemoptysis. patchy. central low-attenuation • Atelectasis. jejunoileal bypass. silicosis. elderly 10% ➢ Right paratracheal. head and neck cancer. Radiology 1999. overinflation [Figure 1-9-7] ➢ Children ➢ Anterior segements upper lobes ➢ Medial segment middle lobe • Consolidation ➢ Unifocal 75% Figure 1-9-6 ➢ Segmental. young adults 43%.

underweight. prolonged immunosuppressive therapy Postprimary Tuberculosis: Pathogenesis [Figures 1-9-8 and 1-9-9] • Delayed hypersensitivity • Liquifaction • Cavitation ➢ Airway ➢ Vessel ➢ Pleura Figure 1-9-8 The lymph nodes which surround airways may cause narrowing that results in atelectasis Figure 1-9-9 Postprimary TB implies reactivation of dormant bacilli.Postprimary Tuberculosis: Clinical Features • Reactivation Figure 1-9-7 ➢ Fever. jejunoileal bypass. gastrectomy. anorexia. transplantation. chest pain. weight loss. cough. DM. head and neck cancer. malaise. blood stream or pleura Postprimary Tuberculosis: Radiologic features • Consolidation 50-70% • Cavitation 40-45% • Nodules • Airways involvement Tuberculosis 96 Chest Radiology . It is characterized by tissue destruction Cavitation and necrosis enables spread via the airway. hemoptysis • Active TB infection ➢ 5% within 2 years ➢ 5-10% lifetime risk ➢ HIV: 50% within 2 years ➢ Pulmonary fibrotic lesions. anorexia. renal failure. night sweats ➢ Dyspnea. silicosis.

random • Airways involvement ➢ Bronchiectasis. air-fluid levels 20% • Nodules ➢ Tuberculoma ✧ SPN: variable borders. satellite lesions. posterior 85%. airway narrowing Cavitation implies a large number of bacilli speeds Figure 1-9-11 the progression of disease Figure 1-9-12 Endobronchial spread leads to airways nodules Endobronchial spread leads to airways nodules Postprimary Tuberculosis-Cavitation Figure 1-9-13 Thoracoplasty Oleothorax Plumbage [Figure 1-9-14] Postprimary Tuberculosis-Nodules Postprimary Tuberculosis-Airways Endobronchial spread leads to airways nodules Chest Radiology 97 Tuberculosis . Superior segments 14% • Cavitation 40-45% [Figure 1-9-10] ➢ Thin or thick walls. tree-in-bud. bronchitis.Postprimary Tuberculosis: Radiologic features Figure 1-9-10 • Consolidation 50-70% ➢ Heterogeneous. nodular. 100% by CT ➢ Hematogenous spread ✧ Miliary 1-3mm. linear ➢ Apical. upper lobes ➢ Endobronchial spread [Figures 1-9-11 to 1-9-13] ✧ Centrilobular.

empyema necessitatis Hemoptysis-Bronchial Artery Hemoptysis-Mycetoma End-Stage Lung Tuberculosis-Chest Wall Tuberculosis-Pericardial Tuberculosis: HIV/AIDS • CD4>200 ➢ Well formed granulomas ➢ Upper lobe cavities.Postprimary Tuberculosis: Assessment of Activity Figure 1-9-14 • Cannot discern activity from a single film • Inactive disease ➢ radiographic stability ➢ 6mos • Negative cultures • Suggestive of active disease ➢ Cavitation ➢ Consolidation ➢ Ground glass ➢ Centrilobular opacities Lee et al. consolidation and miliary disease • CD4<60 ➢ No hypersensitivity reaction ➢ Organisms spread from GI tract ➢ Miliary Disease Tuberculosis and AIDS Tuberculosis and AIDS-Low CD4 Tuberculosis: Diagnosis • Conventional methods ➢ Acid-fast smear: 1 day ➢ Culture: 1-2 weeks ➢ Identification: 2-3 weeks ➢ Drug susceptibility testing: 3-4 weeks • Radiometric methods • Polymerase chain reaction (PCR) • HPLC Tuberculosis 98 Chest Radiology . consolidation and nodules • CD4<200 ➢ Poorly formed granulomas ➢ Adenopathy. 1996 Tuberculosis: Complications • End-stage disease • Hemoptysis Images demonstrate broncho-esophageal fistula ➢ Bronchial arteries in chronic cavities which was a complication of plumbage ➢ Mycetoma ➢ Rassmussen (pulmonary artery) aneurysm • Chest wall involvement • Pericardial involvement • Empyema ➢ BPF. Chest.

Radiology. 1999 Feb. Leung AN.210(2):307-22 Chest Radiology 99 Tuberculosis .Summary • Primary TB ➢ Consolidation ➢ Ipsilateral lymphadenopathy ➢ Pleural effusion • Postprimary TB ➢ Consolidation ➢ Cavitation ➢ Apical/posterior upper lobe nodules ➢ Tracheobronchial spread Tuberculosis Pre-Antibiotic Era References General 1.Pulmonary tuberculosis: the essentials.

Lawrence river valleys ➢ Reported worldwide but relatively rare outside of the United States ➢ Infection rate up to 95% in endemic areas ➢ Point sources associated with aerosolization ✧ Earth moving. Mississippi and St. MD Fungal Disease in the Thorax: Overview • Opportunistic invaders ➢ Aspergillus species ➢ Candida ➢ Mucormycosis • Primary pathogens ➢ Histoplasma capsulatum ➢ Blastomyces dermatitidis ➢ Coccidioides immitis Opportunistic Invaders • Immunocompromised host ➢ Mucosal disruption ➢ Reduced cellular and/or humoral immunity Figure 1-10-1 • Ubiquitous • Lack dimorphism • Multiple organisms may occur Primary Pathogens • May infect healthy individuals • Dimorphism ➢ Saprophytes in the soil ➢ Spores via germination • Most disease mild or subclinical • Fulminant or chronic disease may occur • Specific geographic regions ➢ Endemic Coccidioidomycosis Blastomycosis The mycelial form of Histoplasmosis is found in soil that has been enriched with bird droppings. Histoplasmosis The fungus then releases conidia or spores Histoplasmosis: Epidemiology and Ecology • Endemic fungal disease ➢ Ohio.Fungal Disease in the Thorax: Opportunistic and Primary Pathogens Jeffrey R. Galvin. bird husbandry and spelunking • Dimorphic fungus • Clinical Histoplasmosis: Epidemiology and Ecology • Endemic fungal disease • Dimorphic fungus ➢ Mycelial form in high nitrogen soil ✧ Guano from birds and bats ➢ Yeast within the infected host • Clinica Histoplasmosis [Figure 1-10-1] Fungal Diseases 100 Chest Radiology .

chills.Histoplasmosis: Pathology [Figure 1-10-2] Figure 1-10-2 • Early sequence of infection The fungal ➢ Mycelia produce micronidia spores are able ➢ Micronidia reach alveolar spaces to reach the ✧ 2-5 microns alveolar level. The ➢ 95-99% of infection in endemic areas yeast within the ➢ Parenchymal opacities in 10-25% alveoli are rapidly ➢ Small inoculum or prior infection (cellular phagacytosed by macrophages immunity) and moderate inoculum • Symptomatic ➢ Acute ✧ Moderate vs large inoculum ➢ Chronic ➢ Disseminated • Late complications ➢ Histoplasmoma ➢ Broncholithiasis ➢ Mediastinal granuloma ➢ Mediastinal fibrosis Figure 1-10-4 Histoplasmosis: Acute Clinical Lymphocyte- • Signs and symptoms mediated ➢ “Flulike”: fever. cough cellular ➢ Retrosternal pain immunity ✧ Mediastinal lymph node involvement develops at 10- ➢ Erythema nodosum in women 14 days ➢ Arthralgia controlling the • Shorter incubation with prior exposure infection through a Histoplasmosis: Acute Radiology necrotizing • Poorly defined areas of consolidation granulomatous ✧ Single or multiple response • Hilar lymph node enlargement • Numerous discrete nodular shadows in heavy exposure ✧ 3-4 mm ✧ Symptoms precede radiographic change ✧ Nodules change to punctate calcifications Chest Radiology 101 Fungal Diseases . bypassing the Histoplasmosis: Pathology [Figure 1-10-3 and 1-10-4] upper airway • Early sequence of infection defenses ➢ Lymphocytes and macrophages replace polys because of ➢ Micronidia transform to conidia or spores their small size ➢ Spores transform into budding yeast which is less ➢ Macrophages phagocytose and kill yeast than 5 microns • Late sequence of infection ➢ Lymphocyte-mediated cellular immunity ➢ Granulomatous inflammation ➢ Necrosis ➢ Fibrosis Histoplasmosis: Pathology • Distinction from tuberculosis ➢ Histoplasmosis relatively benign ➢ Immunity to histoplasmosis short lived Figure 1-10-3 ✧ 20% lose immunity each year From three to 5 ✧ Continuous reinfection days following – Primary and postprimary not appropriate inhalation the spores germinate Histoplasmosis: Clinical and release • Asymptomatic yeast forms.

cavitation and granulomatous consolidation and ipsilateral hilar and mediastinal inflammation enlargement Chronic Histoplasmosis [Figure 1-10-7] Figure 1-10-6 Histoplasmosis Disseminated • Clinical ➢ Rare entity (1/100.000-1/500. The nodules disappear over months leaving behind small calcific densities Fungal Diseases 102 Chest Radiology .000) ➢ Most patients immunocompromised ✧ 30% infants < 2 years ✧ 20% immunocompromised ✧ 50% apparently normal (transient compromise) ➢ Reduced macrophage function ✧ Parasitization of macrophages ✧ Intracellular survival and multiplication ➢ Radiology ✧ Miliary nodules (1-3 mm) ✧ 50% of disease associated with AIDS purely extrathoracic – Normal radiograph – Positive blood or bone marrow biopsy Bilateral soft tissue nodules imply a large innoculum.Acute Histoplasmosis [Figures 1-10-5] Figure 1-10-5 Acute Histoplasmosis – large inoculum Acute Histoplasmosis [Figure 1-10-6] Histoplasmosis: Chronic Pulmonary Histoplasmosis • Emphysema and bullous disease a common predisposition • Upper lobe predominance • Two possible mechanisms ➢ Hypersensitivity reaction in preexisting emphysematous space ✧ Few organisms ✧ Colonization or minimal invasion ✧ Thick walled bulla filled with fluid may clear spontaneously ✧ Progressive loss of volume ➢ Similar to TB Acute histoplasmosis is associated with areas of ✧ Fibrosis.

5-3 cm) ➢ Sharply defined ➢ Smaller satellite lesions ➢ Central or diffuse calcification ✧ Diagnostic of benign lesion if less that 3 cm ➢ May increase in size ✧ Similar reaction to fibrosing mediastinitis • Hilar calcification common on ipsilateral side • Fungal nodules account for 30% of all solitary nodules • 87% are less than 2. They typically demonstrate concentric rings of calcification but may remain uncalcified especially in older individuals Chest Radiology 103 Fungal Diseases .Disseminated Histoplasmosis [Figure 1-10-8] Figure 1-10-7 Histoplasmosis: Late Complications • Histoplasmoma • Broncholithiasis • Mediastinal granuloma • Mediastinal fibrosis Histoplasmosis: Histoplasmoma • Solitary nodule (.5 cm in diameter Histoplasmoma [Figure 1-10-9] Chronic histoplasmosis resembles post-primary TB but usually represents a hypersensitivity reaction in patients Broncholith with emphysema Figure 1-10-8 Histoplasmosis: Mediastinal granuloma • Pathology ➢ Direct infection of hilar and mediastinal lymph nodes • Clinical ➢ Often asypmtomatic with discovery of a mediastinal mass on chest radiograph ➢ SVC or esophageal obstruction less common • Radiology ➢ Middle mediastinal mass ✧ Subcarinal or paratracheal ➢ Enhancing capsule with low attenuation center ➢ Mass may be low signal on T2 weighted MR because of fibrous tissue or calcification Disseminated Histoplasmosis presents with miliary nodules and macrophages filled with organisms Figure 1-10-9 Histoplasmomas are the residua of a prior area of pneumonitis.

infiltrating ✧ Noncalcified ✧ Multiple mediastinal compartments • Clinical ➢ Signs and symptoms of obstruction to mediastinal structures Mediastinal granuloma is the result of direct infection of ✧ Superior vena cava. streams and swamps • Dimorphic fungus Fibrosing mediastinitis due to h. pulmonary veins mediastinal lymph nodes. Acutely the lymph nodes demonstrate low attenuation with an enhancing capsule or arteries.Mediastinal Granuloma [Figure 1-10-10] Figure 1-10-10 Histoplasmosis: Fibrosing Mediastinitis • Pathology ➢ Proliferation of acellular collagen and fibrous tissue within the mediastinum ➢ Most cases in the United States are an immunological response to H. fever. capsulatum usually ➢ Mycelium in natural habitat presents as a mediastinal mass associated with ➢ Releases spores (conidia) into the air calcification ➢ Budding yeast ✧ (8-15 microns) in vivo ✧ Broad based • Clinical Figure 1-10-12 ➢ Less common than Histoplasmosis ➢ High risk of symptomatic disease although most cases are probably asymptomatic ➢ Males more commonly affected (3:1-15:1) ➢ Exposure in heavily wooded areas ➢ Variable course ✧ Symptoms of acute pneumonia – Abrupt onset. capsulatum ✧ Focal form: paratracheal and subcarinal ✧ Calcification ➢ Idiopathic form ✧ Diffuse. chills. bone and genitourinary tract > ARDS ✧ Chronic disease similar to tuberculosis Blastomycosis is usually associated with activity in damp. cough and pleuritic pain – Occasional rapid progression > Hematogenous dissemination: skin. central airway or esophagus Fibrosing Mediastinitis [Figure 1-10-11] Figure 1-10-11 Blastomycosis Blastomycosis: Epidemiology and Ecology • Ecological niche [Figure 1-10-12] ➢ Difficult to establish ➢ Saprophyte in an unidentified resevoir within reach of man and dogs ➢ Survives only in wet soil with a high PH and high organic content ➢ Soil probably contaminated rather than the natural resevoir ➢ Point sources in dead and decaying material near rivers. wooded areas Fungal Diseases 104 Chest Radiology .

ill-defined ➢ Masslike opacities ✧ Central or paramediastinal ✧ Carinoma mimic ✧ Solitary nodules ➢ Air bronchograms (88% CT) ➢ Cavitation • Nodules ➢ Intermediate size ➢ Remote from consolidation ➢ Satellite lesions • Miliary disease Blastomycosis often with an upper lobe areas of mass- ➢ Hematogenous dissemination like consolidation Asymptomatic Mass [Figure 1-10-13] Consolidation Figure 1-10-14 Solitary Pulmonary Nodule Similar to Postprimary TB Disseminated Disease [Figure 1-10-14] Mass and Dissemination Blastomycosis: Treatment • Pulmonary disease may be self-limited even if extensive • Extrapulmonary disease requires treatment • Amphotericin B IV or oral Keotconazole Miliary disease may complicate infection with Blastomycosis Chest Radiology 105 Fungal Diseases . histiocytes and plasma cells ➢ Langhans’ giant cells ➢ Granulomas • Both responses may coexist ➢ Organisms more common in supperative area • Progression ➢ Coalescence of patchy consolidation ➢ Airway perforation ➢ Cavitation • Ulcerative bronchitis is common Blastomycosis: Pathology • Initial response is neutrophilic • Chronic inflammatory response • Both responses may coexist • Progression ➢ Coalescence of patchy consolidation ➢ Airway perforation ➢ Cavitation • Ulcerative bronchitis is common Figure 1-10-13 Blastomycosis: Radiologic Manifestations • Consolidation most common ➢ Upper lobe 2:1 ➢ Rounded.Blastomycosis: Pathology • Initial inflammatory response is neutrophilic ➢ Small collections of cells to hundreds of milliliters of pus • Rapidly followed by chronic inflammatory response ➢ Lymphocyte.

hilar or basal ✧ Segmental or lobar ➢ Multifocal nodular or patchy opacities ➢ Peribronchiolar thickening ➢ Hilar or mediastinal adenopathy (20%) ✧ Mediastinal adenopathy may herald dissemination ➢ Pleural effusion 20% ✧ Small. African American and Hispanic) – Early dissemination more common and carries a poor prognosis – Mortality rate or 50% even with early treatment Coccidioidomycosis: Pathology • Lung the usual portal of entry • Neutrophilic response early ➢ Especially in response to ruptured spherules ➢ Spherules ingested by macrophages • Granulomatous and giant cell reaction follows • Necrosis may occur Coccidioidomycosis: Radiologic Manifestations • Acute Disease ➢ Consolidation most common (75%) ✧ Usually unilateral. African Americans and Hispanics more likely to suffer dissemination ➢ Chronic Disease (5%) ✧ Symptoms persist without dissemination ✧ May be mildly immunocompromised ➢ Dissemination ✧ Rare occurrence – Immunocompromise – Non-Caucasian (Filipino. unilateral • Coccidioidoma Fungal Diseases 106 Chest Radiology . pleuritic chest pain. essentially all in the southwest ✧ No racial.Coccidioidomycosis [Figure 1-10-15] Coccidioidomycosis: Epidemiology and Ecology Figure 1-10-15 • Ecological niche • Dimorphic fungus • Clinical ➢ Acute Disease ✧ 100. cough – Valley Fever: allergic form with erythema nodosum or multiforme ✧ Severity of disease related to immune status Coccidioidomycosis is associated exclusively with the and race desert southwest – Filipinos.000 new cases each year. sex or age predilection in acute disease ✧ Most inhabitants of the endemic area infected in the first year of exposure ✧ Incubation period 10-16 days ✧ 60% are asymptomatic ✧ Symptoms when present include – Fever.

Acute Disease Coccidioidoma [Figure 1-10-16] Coccidioidomycosis: Radiologic Manifestations • Acute Disease • Coccidioidoma Figure 1-10-16 ➢ Area of prior consolidation ➢ Round and well circumscribed ➢ 1. bone. meninges or upper genitourinary tract Thin-walled cavities are suggestive of chronic coccidioidomycosis Chest Radiology 107 Fungal Diseases .5cm average (up to 6cm) ➢ Usually single ➢ Marked enhancement with contrast CT ➢ Caseating chronic granulomatous inflammation • Chronic Disease ➢ Cavitation ✧ Occur in areas of consolidation ✧ May be thin or thick walled ✧ Pneumothorax or empyema may result ➢ Chronic progressive pneumonia Chronic Coccidioidomycosis [Figure 1-10-17] A coccidioidoma is the resdua of an area of infectious Coccidioidomycosis: Radiologic consolidation Manifestations • Chronic Disease ➢ Cavitation ➢ Chronic progressive pneumonia ✧ Indolent course similar to TB Figure 1-10-17 ✧ Biapical fibronodular lesions ✧ Hilar and mediastinal adenopathy ✧ Hilar retraction ✧ Persistently positive sputum ✧ High complement fixing antibody titer ✧ Non-Caucasian • Disseminated Disease ➢ Miliary or reticular nodular pattern ✧ Less well circumscribed that TB ➢ Lymphadenopathy is common ➢ Pericardial effusion ➢ Skin.

Dissemination – Miliary Nodules Histoplasmosis Acute Histoplasmosis [Figure 1-10-18] Histoplasmosis – Solitary Nodule [Figures 1-10-19 and 1-10-20] Histoplasmosis – large inoculum [Figure 1-10-21] Histoplasmosis [Figure 1-10-22] Disseminated Histoplasmosis [Figure 1-10-23] Chronic Histoplasmosis [Figure 1-10-24] Fibrosing Mediastinitis [Figure 1-10-25] Blastomycosis Coccidioidomycosis Figure 1-10-18 Fungal Disease in the Thorax: Overview • Opportunistic invaders ➢ Aspergillus species ➢ Candida ➢ Mucormycosis • Primary pathogens ➢ Histoplasma capsulatum ➢ Blastomyces dermatitidis ➢ Coccidioides immitis ➢ Paracoccidioides brasiliensis Symptomatic patients with acute histoplasmosis may present with solitary or multifocal areas of consolidation and associated adenopathy Figure 1-10-19 Figure 1-10-20 As the infection heals the inflammatory area rounds up and is The nodule may enlarge by adding fibrous tissue to the surrounded by a fibrous capsule. Over a prolonged period periphery calcification may develop in the nodule and regional lymph nodes Fungal Diseases 108 Chest Radiology .

capsulatum Chest Radiology 109 Fungal Diseases . Most focal cases of fibrosing mediastintis in the United States are due to H. Figure 1-10-21 Figure 1-10-22 If the patient inhales a large number of spores then numerous patches of consolidation may round up into well circumscribed nodules Figure 1-10-23 As they heal the patient will be left with numerous calcifications Figure 1-10-24 Patients with reduced immune function may present with hematogenous spread of disease and miliary nodules Figure 1-10-25 Patients with underlying emphysema may develop chronic histoplasmosis which in most cases represents a hypersensitivity reaction to a small number of organisms Fibrosing mediastinitis represents an exuberant fibrous reaction within the mediastinum which may result in damage to mediastinal structures.

Galvin. 1988 Histological Typing of Lung Tumors • Based on light microscopic criteria • Classified by the best differentiated region • Graded by the most poorly differentiated region • Histologic heterogeneity is the “rule” Histological Typing of Lung Tumors • Prognosis: Small cell vs. Semin Oncol. MD A 20th Century Disaster Histological Classification of Tumors • World Health Organization • Lung tumor editions ➢ 1967 ➢ 1981 ➢ 1999 ➢ 2004 • Improve communication • Consistent treatment • Basis for comparative studies • Prognosis Changes in the 1999/2004 WHO • Subclasses of adenomas • Preinvasive lesions • Adenocarcinoma • Definition of BAC • Neuroendocrine tumors • Biphasic and pleomorphic tumors Incidence of Lung Cancer Gazdar. non-small cell • Stage determines prognosis in non small cell • >95% of 1° lung tumors ➢ Adeno ➢ Squamous ➢ Large cell ➢ Small cell ➢ Combination of above Lung Cancer Demographics • Most common cancer in males world-wide • Leading cause of cancer mortality in women and men (United States) • Mortality rates in women began increasing in 1935 and surpassed breast ca in 1987 Age-Adjusted Cancer Death Rates – Males vs Females Cancer 49: 1999 Bonchogenic Carcinoma 110 Chest Radiology .Bronchogenic Carcinoma Jeffrey R.

malaise and fever • Ectopic hormone production ➢ ACTH ➢ ADH ➢ Hypercalcemia ➢ Clubbing and HPO ➢ Thrombotic endocarditis ➢ Non-bacterial • Migratory thrombophlebitis Lung Cancer and Clotting Squamous Cell Carcinoma • Terminology ➢ Squamous ✧ Flattened cells ➢ Epidermoid ✧ Mimics differentiation of the epidermis • Rapid local growth • Distant metastases later • Strong association ➢ Cigarette smoking Squamous Cell Carcinoma • Pancoast Syndrome • Hyperparathyroidism ➢ Parathyroid-like substance • Most common to present as radiographically occult Chest Radiology 111 Bronchogenic Carcinoma .Lung Cancer Etiology – Cigarette smoking • 85-90% of lung cancer deaths • 25% of lung cancer in non-smokers attributed to passive smoke • Risk related to: ➢ Number of cigarettes smoked ➢ Depth of inhalation ➢ Age at which smoking began Clinical Presentation • Central tumors ➢ Cough ➢ Wheezing ➢ Hemoptysis ➢ Pneumonia • Extrapulmonary invasion ➢ Pain ➢ Pancoast Syndrome ➢ SVC Syndrome • Metastases • Paraneoplastic Syndromes • Asymptomatic 10% Paraneoplastic Syndromes • Cachexia.

Preinvasive Lesions: Squamous Dysplasia • Similar to cervical Ca • Squamous metaplasia Figure 1-11-1 • Progression ➢ Dysplastic epithelium • Carcinoma in situ ➢ Full thickness dysplasia • Precursor ➢ Invasive squamous cell Ca Squamous Cell Carcinoma: Microscopic features • Individual cell keratinization ➢ Eosinophilia • Keratin pearls ➢ Well differentiated tumors Figure 1-11-2 • Intercellular bridges Squamous Cell Carcinoma: Gross Features [Figure 1-11-1] • Central lesion ➢ Polypoid. endobronchial. exophytic growth The majority of squamous cell • Central necrosis common cancers are central lesions • Bronchial wall invasion ➢ Common ➢ Positive cytology • Proximal growth ➢ Along bronchial mucosa Squamous Cell Carcinoma: Radiologic Features [Figure 1-11-2] • Hilar or perihilar mass • Bronchial wall thickening ➢ Often focal • Consolidation ➢ Must clear completely Squamous cell cancers are • Atelectasis predominantly central and • Peripheral nodule or mass endobronchial as exemplified by this ➢ 30% tomogram • Cavitation Atelectasis [Figures 1-11-3 to 1-11-5] Figure 1-11-3 Figure 1-11-4 Atelectasis in an adult smoker is lung cancer until proven otherwise Typical central squamous cell carcinoma Bonchogenic Carcinoma 112 Chest Radiology .

JAMA. uniform cells • Scant cytoplasm • Necrosis is common ➢ Often extensive • >10 mitosis per 10 HPF ➢ Average 60-70 • Neuroendocrine morphology • Neuroendocrine markers ➢ 75% • Light microscopy diagnosis WHO. 1992 Small Cell Lung Cancer • Rapid growth • Considered metastatic at presentation • Poorest survival • Strongest association with cigarette smoking Small Cell Lung Cancer Golden’s S sign • Small cell carcinoma ➢ Pure histology • Variant ➢ Combined • Elimination ➢ Oat cell ➢ Intermediate type WHO.Cavitation [Figure 1-11-6] Figure 1-11-5 Pancoast Tumor: Superior Sulcus Tumor • Characteristic pain ➢ 8th cervical ➢ 2nd thoracic trunk • Horner’s Syndrome • Destruction of bone • Hand muscle atrophy Pancoast. 2004 Small Cell Lung Cancer: Microscopic Features • Small. 2004 Figure 1-11-6 Cavitation is most common in squamous cell cancer Chest Radiology 113 Bronchogenic Carcinoma .

Small Cell Lung Cancer: Gross Features Figure 1-11-7 • Large • Central mass (90%) • Bronchial compression • No endobronchial lesion • Proximal growth ➢ Along submucosa • Extensive necrosis • Hemorrhage Small Cell Lung Cancer: Radiologic Features [Figures 1-11-7 and 1-11-8] • Hilar or perihilar mass • Mediastinal adenopathy • Primary tumor ➢ Rarely evident Small cell tends to spread along the • Cavitation peribronchovascular lymphatics without endobronchial ➢ Extremely rare invasion Small Cell Lung Cancer • Cushing Syndrome • SIADH • Eaton Lambert Figure 1-11-8 • Most common cause ➢ SVC Syndrome Small Cell Lung Cancer: Therapy • Response to chemotherapy and radiotherapy • Untreated: median survival 2-4 months • Treated: median survival 9-18 months • Limited stage – 15-25% survive 2 years Large Cell Carcinoma • Rapid growth • Location ➢ Segmental ➢ Subsegmental • Early metastases • Poor prognosis • Strong association with cigarette smoking Small cell most commonly presents as a mediastinal mass Large Cell Carcinoma: Microscopic Features • Large cells • Prominent nucleoli • Poorly differentiated • Diagnosis of exclusion • Neuroendocrine features Large Cell Carcinoma: Gross Features • Large and bulky ➢ Greater that 3 cm • Soft • Large areas of necrosis Bonchogenic Carcinoma 114 Chest Radiology .

the most common lung • Lobulated cancer is predominantly • Borders a peripheral lesion ➢ Ill-defined ➢ Well-defined • Spiculated • Obstructive pneumonitis (25%) Chest Radiology 115 Bronchogenic Carcinoma .10% ➢ Passive smoke ➢ Particulates ➢ Cooking practices Adenocarcinoma: Microscopic Features • Glands • Papillary structures • Mucin ➢ Intracellular ➢ Extracellular • Prominent nucleoli • Moderate cytoplasm • Desmoplastic reaction • “Scar carcinoma” ➢ Rare! Adenocarcinoma: Radiologic Features • Peripheral (75%) • Solitary mass or nodule • Upper lobes 3:2 • Right lung 3:2 Adenocarinoma.Large Cell Carcinoma: Radiologic Features • Usually peripheral • 70% of tumors ➢ > 4 cm at presentation Figure 1-11-9 Large Cell Carcinoma [Figure 1-11-9] Adenocarcinoma: Etiology • Cigarette smoke causatively linked to lung cancer ➢ 1950 ➢ Squamous cell 18X’s Adeno ➢ Squamous cell: central Adenocarcinoma: Etiology [Figure 1-11-10] • Cigarette smoke causatively linked to lung cancer • Adenocarcinoma most common ➢ Peripheral • Filtered low-yield cigarettes ➢ Smaller particles ➢ Reduced nicotine Large cell cancers are commonly necrotic but rarely cavitate ➢ Greater depth of puffs ➢ Increased number of puffs ➢ N-nitrosamines Figure 1-11-10 • Other factors .

Spiculation and Retraction [Figure 1-11-11] Figure 1-11-11 Scar Carcinoma [Figure 1-11-12] Necrosis Air Bronchogram [Figure 1-11-13] Adenocarinomas are commonly spiculated peripheral nodules Figure 1-11-12 In scar carcinomas the scar is usually a reaction to the malignancy Figure 1-11-13 Air bronchograms are commonly seen in adenocarcinomas Bonchogenic Carcinoma 116 Chest Radiology .

Slow Growth Atypical Adenomatous Hyperplasia: Preinvasive lesion [Figures 1-11-14 and 1-11-15] Figure 1-11-14 • Atypical cuboidal epithelium ➢ Lining alveoli ➢ Lining bronchioles • Found in lung cancer resection specimens • Probable precursor ➢ BAC ➢ Invasive adenocarcinoma • Patchy ground glass • 5mm or less Kitamura. 1999 AAH Bronchioloalveolar Carcinoma: Microscopic Features • Lepidic growth pattern • No evidence ➢ Stromal invasion ➢ Vascular invasion ➢ Pleural invasion • Diagnosis cannot be made on a small biopsy • Requires thorough sampling of resected specimen WHO. 1999 The diagnosis of AAH may be difficult and Bronchioloalveolar Carcinoma: Mucinous Type the differentiation form a small BAC may • Alveolar spaces distended with mucin be problematic • Aerogenous spread is common • Multifocal consolidation Figure 1-11-15 Bronchioloalveolar Carcinoma: Non-mucinous Type • Alveoli lined with ➢ Clara cells ➢ Type II cells • Central alveolar fibrosis ➢ Common • Close association ➢ AAH In AAH the architecture of the lung is not disturbed Chest Radiology 117 Bronchogenic Carcinoma . AJCP.

Adenocarcinoma: CT. 2000 Bonchogenic Carcinoma 118 Chest Radiology . Histology and Doubling Time • Type A Figure 1-11-17 • Ground glass • Localized BAC • Doubling time ➢ Mean: 880 days ➢ Range: 662-1486 days Aoki et al. AJR.Adenocarcinoma: CT. Histology and Doubling Time • Type B • Ground glass • Focal increased attenuation • Localized BAC • Doubling time ➢ Mean: 880 days ➢ Range: 662-1486 days Aoki et al.Adenocarcinoma: CT. AJR. Histology and Doubling consolidation Time • Type C • Solid attenuation • Focal ground glass • Spiculation • Pleural tag • Localized BAC ➢ Active fibroblastic proliferation • Doubling time ➢ Range: 42-1346 days Aoki et al.Bronchioloalveolar Carcinoma: Gross Features Figure 1-11-16 [Figure 1-11-16] • Consolidation ➢ Focal ➢ Multifocal • Architecture ➢ Preserved Bronchioloalveolar Carcinoma: Radiologic Features [Figure 1-11-17] • Solitary nodule ➢ Excellent prognosis ➢ Resection • Consolidation ➢ May be multifocal • Ground glass • Multiple nodules • May cavitate? Noguchi. AJR. 2000 BAC . 2000 BAC usually presents as an area of BAC . Cancer 1995 Bronchioloalveolar Carcinoma BAC Recurrence BAC often presents as as area of BAC vs Adenocarcinoma consolidation BAC .

AJR.Adenocarcinoma: CT. Histology and Doubling Time Figure 1-11-18 • Type D • Solid attenuation only • Spiculation • Pleural tag • Poorly differentiated adenocarcinoma • Doubling time ➢ Mean: 252 days ➢ Range: 124-402 days Aoki et al.BAC . 2000 AdenoCa Appearance and Prognosis Aoki et al. 2001 Adenocarcinoma [Figure 1-11-18] One form of adenocarcinoma begins as an invasive BAC process and presents with a solid nodule AAH [Figure 1-11-19] BAC [Figure 1-11-20] Figure 1-11-19 Figure 1-11-20 The precursor lesion to BAC is AAH BAC demonstrates lepidic growth and presents as an area of ground glass and/or consolidation Adenocarcinoma .BAC Prognosis [Figure 1-11-21] Figure 1-11-21 Survival decreases with increasing amount of consolidation and less ground glass opacity Chest Radiology 119 Bronchogenic Carcinoma . AJR.

Patel AM. Travis WD. 68(2):1 83-8. Koss M. 25(1 ):96-1 04. Dalager NA. Peters SG. Yamanda T. Hedelin G. Neuroendocrine carcinomas of the lung. Occupational lung cancer Mayo Clin Proc 1993. Vincent M. Correa P. Chang PY. 7. Thymus and Heart (WHO Classification of Tumours). Charloux A. Mayo Clin Proc 1993. 18. Cancer 1991. Patel AM. 68(4):386-92. Kitamura H. Travis W. Asakura K. Smith I. 14. 4. Davila DG. Stemhagen A. Wynder EL. 26(1 ):14-23. Kameda Y. Pauli G. 46(9):4808-11. 11. 22(8):934-44. 19. Lancet 1998. Ifoundza T. 15. Chang WY.References General 1. Fontham E. Pleura. Hasegawa M. 1999. Whitesell PL. Third ed. Travis WD. Flieder DB. Li F. Third ed. 1999. 8. Implications for the pathogenesis of peripheral lung adenocarcinoma [see comments]. Cherryman G. McDougall JC. Quoix E. Atypical adenomatous hyperplasia of the lung. Williams M. Falk E=R. Karsell PR. Brambilla E. Am J Surg Pathol 1998. 12. Mass screening for lung cancer with mobile spiral computed tomography scanner [see comments]. Sone S. Lung cancer [published erratum appears in Cancer 1995 Jun 15. Risk factors for primary lung cancer among non-smoking women in Taiwan. Ito T. Cancer 1996. Drage CW. 3. Morabia A. Pisani RJ. Semin Roentgenol 1990.75(12):2979]. Pickle LW. Prognostic value of histology in patients with non-small cell lung cancer. Berlin: Springer Verlag. IARC Press. Maruyama Y. Colby T. Muller NL. 2. The relation of passive smoking to lung cancer Cancer Res 1986. Clinical manifestations of lung cancer Mayo Clin Proc 1993. 111(5):610-22. Lee CH. Mayo Clin Proc 1993. increasing among females. Travis LB. Lung Cancer 1997. Shimasato Y. 62(4):684-6. 68(3):278-87. Buffler PA. 351 (9111):1242-5. Cancer 1995. Am J CIin Pathol 1999. Int J Epidemiol 1997. Washington. Lin HJ. Travis W. Pauli G. Ko YC. Int J Epidemiol 1997. 26(1):24-31. Gal AA. Jr. 17. Wang HZ. The etiology of lung cancer. 68(2): 170-82. Rush W. United States lung carcinoma incidence trends: declining for most histologic types among males. et al: Pathology and Genetics of Tumours of the Lung. DC: Armed Forces Institute of Pathology. Devesa SS. Chen MJ. Devesa S. Mayo Clin Proc 1993.. Hardy J. Charloux A. 9. 68(3):273-7. 16. Williams DE. 5. Davila DG. Kubo K. 68(3):288-96. The increasing incidence of lung adenocarcinoma: reality or artefact? A review of the epidemiology of lung adenocarcinoma. Dietemann A. 77(12):2464-70. Paraneoplastic syndromes associated with lung cancer [see comments]. Judson I. Miller RR. 6. Mayo Clin Proc 1993. Histological Typing of Lung and Pleural Tumors. 13. 21. 68(9):2074-8. Kreisman H. Tumors of the Lower Respiratory Tract. 10. International Classification of Tumors. Honda T. Takashima S. Huang CC. Diagnostic tests for lung cancer. Atlas of Tumor Pathology. Hanamura K. 20. Perren T. 17(1):123-34. Peters SG. Fraumeni JF. 2004 (Oxford). Bonchogenic Carcinoma 120 Chest Radiology . Roeslin N. Colby T. Ries L. Survival analysis of 200 pulmonary neuroendocrine tumors with clarification of criteria for atypical carcinoid and its separation from typical carcinoid. Small D. Travis WD. Fleming MV. The value of computed tomographic (CT) scan surveillance in the detection and management of brain metastases in patients with small cell lung cancer Br J Cancer 1990. Lubin J. Ziegler RG. Koss MN. Ouoix E. Hayashi H. Brambilla E. 75(1 Suppl):191-2O2. Travis WD. Bronchogenic carcinoma: immunologic aspects. Cigarette smoking and lung cancer cell types. Yang Z. Mason TJ. Wolkove N.

He now complains of a chronic cough Chest Radiology 121 Chest Seminar 1 . Galvin. MD Case 1: This 57 year old male with a long history of smoking cigarettes.Chest Seminar 1 Jeffrey R.

The original chest radiograph revealed a pneumothorax.Case 2: This 20 year old Caucasian female presented 7 years prior to the current admission with sudden onset of shortness of breath. The patient now presents with increasing shortness of breath. Chest Seminar 1 122 Chest Radiology .

Case 3: This 58 year old Caucasion female presented with a one month history of hemoptysis Chest Radiology 123 Chest Seminar 1 .

Case 4: This 38 year old African American female presented with a history of chronic asthma and increasing cough and shortness of breath Chest Seminar 1 124 Chest Radiology .

She was treated intermittently with antibiotics for 6 months. Chest Radiology 125 Chest Seminar 1 . Open biopsy was obtained because of progressive symptoms.Case 5: This 72 year old Caucasian female presented with cough and occasional fever.

Bilateral lung transplantation was done 19 months later. MD Case 1: 15 year old female was admitted to the ER with an overdose of Nefazodone and other unknown pills. Bronchial lavage was performed and immunosuppressants were started. Activated charcoal was administered after which she developed vomiting and gagging. The patient developed progressive dyspnea and obstructive pulmonary functions over the next 6 months. Galvin. Respiratory distress required intubation. Chest Seminar 2 126 Chest Radiology .Chest Seminar 2 Jeffrey R.

Chest Radiology 127 Chest Seminar 2 . She presented with a right lung mass.Case 2: 59 year old Caucasian female with history of breast cancer 12 years prior to admission and local recurrence treated with radiation 7 years later.

He demonstrated a mild leukocytosis and an increase in serum LDH.Case 3: 46 year old Caucasian male with long standing year history of shortness of breath. He presents with a 3 months of worsening dyspnea. Chest Seminar 2 128 Chest Radiology .

Chest Radiology 129 Chest Seminar 2 . A chest CT was done based on the abnormalities found on the chest radiograph. A bronchoscopy was performed.Case 4: 57 year old Caucasian male with a new history of cough and a new abnormality on chest radiograph.

She presented to the ER complaining of fatigue. Chest Seminar 2 130 Chest Radiology . increasing shortness of breath. and cough productive of blood tinged sputum. chest pain.Case 5: 61 year old female worked as a hospital storage room manager.

Arterial vessels accompany the dichotomously branching airways of the lung Postcapillary Pulmonary Circulation [Figure 1-14-2] Figure 1-14-2 Postcapillary (venous) circulation drains the capillary beds of the alveoli.Pulmonary Hypertension Aletta Ann Frazier. MD Key Points • Radiologic findings distinguish precapillary (arterial) from postcapillary (venous) pulmonary hypertension • Idiopathic and secondary conditions are included in the differential diagnosis • Vascular histopathology and secondary cardiac changes are often reflected in the radiology of pulmonary hypertension Precapillary Pulmonary Circulation [Figure 1-14-1] Figure 1-14-1 Precapillary (arterial) circulation and vascular anatomy. Veins and venules course back to the left atrium within interlobular septa Normal Pulmonary Circulation • Low pressure system with high degree of capacitance (recruitment and distension) • Less than one tenth the resistance to flow in comparison to systemic circulation (low vasomotor tone) • Right ventricle expends minimal energy to perfuse the pulmonary vascular bed Chest Radiology 131 Pulmonary Hypertension .

thickened anterior exceeds 29 mm RV wall. and peripheral oligemia • PA atherosclerosis Figure 1-14-6 Idiopathic Pulmonary Hypertension [Figures 1-14-4 to 1-14-6] Figure 1-14-5 CT criteria for enlarged main PA in precapillary pulmonary hypertension: CT manifestations of cor pulmonale: transverse diameter dilated RA and RV. dilated central hilar • Cor pulmonale vessels. hypoxemia • PH due to thromboembolic dz • Miscellaneous Simonneau G. J Am Coll Cardiol. Pulmonary Hypertension: Precapillary Etiologies • Idiopathic • Secondary ➢ Chronic thromboembolic disease Photomicrograph demonstrates a ➢ Sickle cell disease muscular artery (adjacent to airway) ➢ Eisenmenger physiology narrowed by medial hypertrophy and ➢ Mediastinal fibrosis obstructed by intravascular thrombus ➢ Connective tissue disease Figure 1-14-4 ➢ Chronic hypoxia (COPD. Cor Pulmonale American College of Chest Physicians: “Venice Classification” • PAH • PH with left-sided heart dz • PH with lung dz. chest pain. 2004 Jun 16. et al. syncope • Right heart pressure overload develops late • Imaging reveals pulmonary HTN & clues to etiology • NIH Criteria (cardiac cath): Mean PA pressure > 25 mm Hg at rest (normal 10) Figure 1-14-3 Cor Pulmonale… the best predictor of clinical outcome • PV regurgitation • RV hypertrophy & enlargement • TV regurgitation & RAE • Dilated IVC. hepatic veins Normal Heart vs. and flattened interventricular septum Pulmonary Hypertension 132 Chest Radiology .43 (12 Suppl S):5S-12S.Precapillary (Arterial) Pulmonary Hypertension • Insidious: dyspnea. IPF) Pulmonary Arterial Hypertension: Histology [Figure 1-14-3] • Medial hypertrophy • Intimal proliferation • Thrombosis • Arteritis Precapillary Hypertension: Imaging • Dilated central arteries Radiographic features of pulmonary • Pruning of peripheral vessels hypertension: enlarged main • Mosaic perfusion pulmonary artery.

presents within 2 years • Symptomatic with >60% vascular bed occlusion • 5-year survival rate <35% (without surgery) • V/Q scan . F>M (3:1) • 6% “familial” ➢ Autosomal dominant.o.8 years without treatment [Courtesy of Melissa Rosado de Christenson.high probability (helps to exclude IPH) • CT ➢ Enlarged central PA ➢ Eccentric & linear filling defects +/. MD] Atrial Septal Defect [Figures 1-14-7 to 1-14-9] Figure 1-14-8 Figure 1-14-9 Lung specimen radiograph demonstrates calcified atherosclerotic plaques in the main PA [Courtesy of Melissa Rosado de Christenson. MD] Eisenmenger Physiology • Congenital L-to-R shunt ➢ VSD. ASD. MD Idiopathic Pulmonary Hypertension • Mean age 45. MD] Vascular pruning pattern [Courtesy of Melissa Rosado de Christenson.Cor Pulmonale Figure 1-14-7 • Axial White Blood Cine • Sagittal White Blood Cine Courtesy Laura Heyneman.calcification ➢ Abrupt cut-offs (pruning) ➢ Bronchial arteries (50% of cases) Broad-based intravascular soft tissue ➢ Mosaic perfusion density in the right PA. incomplete penetrance • Associations ➢ HIV infection ➢ Appetite suppressants ➢ Cocaine abuse Longstanding uncorrected ASD with acquired ➢ Chronic liver disease Eisenmenger physiology in 35 y. female • Mean survival 2. PDA ➢ Endocardial Cushion Defect • Shunt reversal (R-to-L) follows sustained elevation in PVR • PAH irreversible & requires lung transplantation Chronic Thromboembolic Disease Figure 1-14-10 [Figures 1-14-10 to 1-14-12] Chronic Thromboembolic Disease • Approx 4% of cases acute PE. suggests CTEPH Chest Radiology 133 Pulmonary Hypertension . combined with ➢ Pleural tags (healed infarcts) multiple bronchial arterial collateral vessels.

75% at six years Chronic thromboembolic disease: Other thromboembolic materials mural-based soft tissue masses and calcium in the lumen of right main PA Intravenous Talcosis • Chronic IV injection of crushed tablets (Methadone. 96-98% specificity for CTEPH ➢ More sensitive than PA angio for proximal disease ➢ Non-invasive modality for pre. amphetamines) • Thrombogenic pharmaceutical binding agent: magnesium silicate Figure 1-14-12 • Granulomas coalesce into birefringent particles Intravenous Talcosis: Imaging • EARLY ➢ Diffuse micronodular opacities • LATE ➢ Fibrosis ➢ High density perihilar masses ➢ Emphysema Postcapillary Pulmonary Circulation Mosaic attenuation reflects geographic variations in blood flow Pulmonary Hypertension: Postcapillary Etiologies • Idiopathic ➢ Pulmonary veno-occlusive disease (PVOD) ➢ Pulmonary capillary hemangiomatosis (PCH) • Secondary ➢ Mitral valve stenosis ➢ Left ventricular failure ➢ Mediastinal fibrosis ➢ Left atrial mass / thrombus ➢ Venous constriction / invasion by tumor Pulmonary Hypertension 134 Chest Radiology .and post-op assessment ➢ Multiplanar & curved multiplanar reconstructions further characterize disease extent • Cardiac MR ➢ Cine imaging ✧ Right heart function ➢ Phase-contrast imaging ✧ low velocities in L & R PA’s ✧ shunt vol from bronchial arteries to pulmonary venous circulation ✧ R-to-L shunt via patent foramen ovale “Recanalized” Chronic Thrombus “Organizing” Chronic Thrombus Pulmonary Thromboendarterectomy • 15-30% CTEPH patients are candidates • Thrombi from main to segmental or subsegmental level • Intima & superficial media removed w/ thrombi • Operative mortality 8-23% • Improved long term survival .Chronic Thromboembolic Disease Figure 1-14-11 • CT Angio ➢ 94-100% sensitivity.

Pulmonary Venous Hypertension Figure 1-14-13 • Acute or chronic onset • Elevated wedge pressures (with exceptions) • PAH . encasement of mediastinal structures Two coronal CT reconstructions show mediastinal fibrosis constricting pulmonary venous drainage at their entrance to left atrium. fibrosis • + Interlobular septa • Subpleural thickening • Ground glass opacities • Pleural effusion PCH/PVOD • Capillary proliferation & dilatation • Venous medial hypertrophy & intimal proliferation • Recanalized thrombus in veins & venules PCH/PVOD • Young adults (M:F is 2:1) • Pediatric in 1/3 of cases • Fatal within 3-5 years • Associations ➢ Chemotherapy ➢ Prior viremia ➢ HIV ➢ ? Toxic exposure PVOD. (Note that precapiillary hypertension is also evident: the main PA is dilated and there is extrinsic compression of the right PA by mediastinal fibrosis) Chest Radiology 135 Pulmonary Hypertension . a rare cause of postcapillary • Current Debate pulmonary hypertension: prominent ➢ Separate entities? interlobular septa and subpleural edema ➢ Contiguous spectrum of injury? ➢ Cause-effect scenario? PCH/PVOD [Figure 1-14-13] Figure 1-4-14 • Difficult to discern from primary PAH clinically • Vasodilators contraindicated: severe pulmonary edema PVOD/PCH • Difficult to discern from primary PAH clinically • Vasodilators contraindicated: severe pulmonary edema • CT clues ➢ Septal lines ➢ GG nodules (+/-) ➢ Normal left atrium Mediastinal Fibrosis [Figure 1-14-14] Mediastinal Fibrosis: Imaging • Mediastinal contours abnormal • Coarse calcium • Soft tissue replaces mediastinal fat • Constriction. thereby creating unilateral postcapillary pulmonary hypertension.secondary • Venous dilatation • Venous “arterialization” • Septal edema.

Mini-symposium: Pulmonary pathology: Evaluation of pulmonary hypertension in biopsies of the lung. 170:955-960. Hemodynamics and pulmonary function. Chest 2004. 33:862-871. Lange RL.Mitral Stenosis Diagnostic Strategy . 75:625-630. Gouverne ML. et al.Recommended Imaging Studies by ACCP • CXR • Echocardiography with Doppler • V/Q (if CTEPH suspected) ➢ PA gram if positive (resectability) ACCP Evidence-based Clinical Practice Guidelines. Ysrael M. Auger WR.126:14S-34S Diagnostic Strategy . early detection. CT findings in pulmonary venoocclusive disease. 2. Steen V. Pulmonary parenchymal abnormalities of vascular origin: high-resolution CT findings. 10. Pulmonary Hypertension 136 Chest Radiology . Quantifying pulmonary perfusion in primary pulmonary hypertension using electron-beam computed tomography. 8. Chronic thromboembolic pulmonary hypertension: CT findings. Padley SP. 8:758-761. J Thorac Imaging 1999. 4. Bull MJ. 9. 7. 12. Burke AP. 126:14S-34S. Rios G. Remy-Jardin M. Small pulmonary nodules: Detection at chest CT and outcome. 6. Gutterman D. Remy J. Botticelli JT. Chest 2004. 9:905-927. AJR Am J Roentgenol 1998. Evans TW.Imaging Studies • From the ACCP: ➢ CXR ➢ Echocardiography with Doppler ➢ V/Q • We also suggest: ➢ Chest CT/CTA ✧ Precapillary vs. Jones AT. Heitzman ER. Maltby JD. Eur Respir J 2004. Radiographics 1994. J Comput Assist Tomogr 1984. Screening. Mayo JR. 166:1371-1377. Krowka MJ. Pulmonary venous and arterial hypertension due to chronic fibrous mediastinitis. Virmani R. Mayo Clin Proc 2000. Radiology 2003. A CT sign of chronic pulmonary arterial hypertension: the ratio of main pulmonary artery to aortic diameter. Circulation 1966. Luna J. King MA. postcapillary origin ✧ Clues to underlying etiology ➢ MRI ✧ Cardiac anatomy/function ✧ Future: hemodynamics of lung perfusion Go With the Flow …. 14:270-278. King MA. Muller NL. 5. Randall PA. 11. 3:14-26. Accuracy of high-resolution CT in identifying chronic pulmonary thromboembolic disease. Radiographics 1989. Mcloud TC. 14:739-746. Pulmonary hypertension: diagnostics and therapeutics. 3. and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Bergin CJ. Schlueter DP. McGoon M. Current Diagnostic Pathology 1996. 23:202-207. 226:489-493. et al. Benjamin MS. Primack SL. Shepard JO. Ng CS. Belezzuoli E. Pulmonary arterial hypertension: a contemporary review. Wells AU. Drucker EA. Hansell DM. AJR Am J Roentgenol 1996. • Pulmonary Arterial Hypertension ➢ Enlarged central and hilar vessels ➢ Pruned peripheral vessels ➢ Mosaic perfusion ➢ Por pulmonale ➢ PA atherosclerosis • Pulmonary Venous Hypertension ➢ Septal lines ➢ Smooth pleural thickening ➢ Ground glass opacities ➢ Pleural effusion References 1. Bergin CJ.

Remy J. Artaud D. Pulmonary hypertension: CT of the chest in pulmonary venoocclusive disease. 38:106- 114. Hartman TE. Radiology 1997. 16. 113:1250-1256. Presberg KW. Semin Roentgenol 2003. Maitre S. 17. Mosaic attenuation pattern on thin- section CT scans of the lung: differentiation among infiltrative lung. 203:355-360. Costello P. Kuzo R. airway. Simonneau G et al. 18. Chest 1998. Muller NL. AJR Am J Roentgenol 1997. 205:465-470. Hartman TE. 14. Remy-Jardin M. Mosaic pattern of lung attenuation on CT scans: frequency among patients with pulmonary artery hypertension of different causes. Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease. Swensen SJ. 19. Humbert M. J Am Coll Cardiol 2004 Jun 16.43 (12 Suppl S): 5S-12S. 169:79-82. Chest Radiology 137 Pulmonary Hypertension . Tan RT.13. Sherrick AD. et al. 15. 183:65-70. Medical College of Wisconsin Lung Transplant Group. and vascular diseases as a cause. Airway changes in chronic pulmonary embolism: CT findings in 33 patients. Siegel R. Swensen SJ. Louvegny S. Radiology 1997. Deschildre F. Haasler GB. Multidetector-row CT imaging of pulmonary embolism. Padley SP. Duhamel A. Hansell DM. Worthy SA. Goodman LR. Schoepf UJ. Clinical classification of pulmonary hypertension. Resten A. AJR Am J Roentgenol 2004.

Testes. others first drain via another filtration organ (bone or liver) • Systemic venous drainage directly to lung ➢ Melanoma ➢ Sarcomas ➢ Choriocarcinoma ➢ Thyroid ➢ Kidney. Cervix Pulmonary Metastases 138 Chest Radiology . Adrenal Gland ➢ Oropharynx • Venous drainage via liver ➢ Colon ➢ Pancreas ➢ Stomach • Venous drainage via bone ➢ Prostate • Dual venous drainage (simultaneous seeding) ➢ Kidney.Pulmonary Metastases Aletta Ann Frazier. Bladder. Ureters ➢ Uterus. MD Key Points • The pathogenesis of pulmonary metastases is complex • The spectrum of radiological manifestations reflects pathways of spread • Many extrathoracic malignancies produce characteristic radiologic patterns of pulmonary metastases Metastatic Disease to the Lung • Most common lung neoplasm • Incidence: 20-55% of patients dying from extrathoracic malignancy • Lung is the ONLY site of metastatic disease in 15-25% of these patients Metastatic Disease to the Lung:Routes of Spread • Pulmonary & bronchial arteries • Pulmonary & pleural lymphatics • Thoracic duct • Airways • Transdiaphragmatic lymphatics What are the most likely primary extrathoracic malignancies? • Breast • Colon • Uterus • Kidney • Prostate • Oropharynx • Stomach • Pancreas Which malignancies are the most highly predisposed? • Choriocarcinoma • Osteosarcoma • Testicular tumors • Melanoma • Ewing’s sarcoma • Thyroid carcinoma • Kaposi’s sarcoma Principle: “Generalizing Sites” • Certain tumors seed the lung directly.

5-1cm • Low specificity (60% in 40-65 y. hemorrhage primary site. ➢ Anus. and establish nodules by expansile growth Chest Radiology 139 Pulmonary Metastases .o. adults) Figure 1-15-2 ➢ intrapulmonary lymph nodes ➢ granulomatous diseases ✧ sarcoidosis ✧ silicosis ➢ amyloidosis ➢ infection Bloodborne tumor cells arrest in distal arterioles of the pulmonary circulation. basilar Hematogenous metastases arise from tumor cells • Variable sizes which penetrate vessels and lymphatics at the • Mixed areas of viability. necrosis. extravasation in distal arterioles • Expansile growth in interstitium and alveoli • Vascularization ➢ Pulmonary arteries ➢ Bronchial circulation ➢ Transpleural collaterals Parenchymal Nodules: Histology • Well-defined • Homogeneous cell population • Adjacent to arteries and arterioles • Alveolar septa compressed or obliterated Nodular Metastases • Rounded. coalescent or multilobulated • Multiple • Peripheral. Rectum • Complex venous (and lymphatic) drainage ➢Breast Pathogenesis of Hematogenous Metastases [Figure 1-15-1] • Tumor cells penetrate draining venules • Enter systemic venous circulation • Filtered by pulmonary arterial circulation Figure 1-15-1 Pathogenesis of Hematogenous Metastases [Figure 1-15-2] • Adherence. extravasate into the interstitium. and are transported to the right heart via the systemic venous circulation Parenchymal Nodules: Multidetector Chest CT • High sensitivity ➢ 95% for nodules >1cm ➢ 91% for nodules .

“cannonball” or miliary • Rarely ➢ cavitary ➢ calcified ➢ solitary ➢ ground glass halo (hemorrhagic) Secondary pulmonary lobule: ✧ angiosarcoma hematogenous metastases may be ✧ choriocarcinoma angiocentric but are random with ✧ post therapy respect to the secondary pulmonary lobular architecture Figure 1-15-4 Figure 1-15-5 Metastatic colon carcinoma in middle aged male: variable-sized nodules are random. occasionally angiocentric in location “Cannonball” Metastases [Figures 1-15-5 and 1-15-6] • Colorectal carcinoma • Renal cell carcinoma • Sarcomas • Melanoma Cannonball metastases (gross lung) in young adult male with soft tissue sarcoma Pulmonary Metastases 140 Chest Radiology . Chest CT • Multiple • Peripheral.161:37-43 Parenchymal Nodules: [Figure 1-15-4] Imaging Features. basilar • Variable in size • “Random” .eccentrically located between BVB & interlobular septa • Occasionally angiocentric • Less commonly .Parenchymal Nodular Metastases: [Figure 1-15-3] HRCT-Pathologic Correlation: Nodules <1cm • Peribronchovascular (12%) • Periseptal (28%) • Intermediate (68%) Figure 1-15-3 • Angiocentric (76%) ➢ Directly-centered on feeding vessel (18%) ➢ Eccentric to feeding vessel (58%) Hirakata et al. peripheral. AJR 1993.

spontaneous ptx • Wall thickness NOT indicative of benignity • DDX ➢ septic emboli ➢ vasculitis ➢ collagen vascular disease Figure 1-15-7 Cannonball metastases in a young adult male with a soft tissue sarcoma (scout.31% ➢ Sarcomas (bone) . axial lung and mediastinal CT images) Figure 1-15-8 Micronodular metastases in middle aged female with thyroid cancer Cavitary metastases in elderly male with oropharyngeal cancer Chest Radiology 141 Pulmonary Metastases . cervix) .69% ➢ Adenocarcinomas (colon. 9% of lung primaries) • Malignancies ➢ Squamous cell neoplasms (head and neck. breast) .Micronodular (Miliary) Metastases [Figure 1-15-7] Figure 1-15-6 • Malignancies ➢ Thyroid CA (papillary) ➢ Choriocarcinoma • Opacities may persist post-treatment (“sterile”) • DDX ➢ Miliary tuberculosis ➢ Viral pneumonia ➢ Sarcoidosis Pulmonary Metastases: Unusual Manifestations • Cavitary. calcified or solitary pulmonary nodules • Lymphangitic carcinomatosis • Tumor thromboembolism • Endobronchial metastases • Pleural-based metastases Cavitation in Metastases [Figure 1-15-8] • Incidence 4% (vs.

217: 257-61 Solitary Metastasis vs. Lung Primary • The incidence is fairly equal in patients with carcinoma of: ➢ Kidney ➢ Colon ➢ Adrenal gland ➢ Uterus ➢ Salivary or parotid gland ➢ Thyroid gland • SPN is more likely solitary metastasis in: ➢ Melanoma ➢ Sarcoma (soft tissue. 2(4):24-37 Solitary Metastasis vs. chondrosarcoma. GI) • Post-chemotherapy or post-radiation • Variable content ➢ Osteoid matrix ➢ Dystrophic calcification ➢ Psammoma body formation Solitary Metastasis • Unusual: 1-28% of all metastatic lesions • 3-10% of all SPNs are solitary metastases • Variable margins ➢ well-defined Calcified metastases in middle-aged ➢ multilobulated female with ovarian cancer ➢ spiculated Solitary Metastasis vs. Lung Primary • A SPN is more likely to be bronchogenic CA than a solitary met if the patient has carcinoma of: ➢ Head and neck ➢ Bladder ➢ Esophagus ➢ Breast ➢ Cervix ➢ Bile Ducts ➢ Ovary ➢ Prostate ➢ Stomach Solitary Metastasis vs. the overall incidence of second primary lung carcinoma is greater than that of solitary metastases” Coppage et al: J Thorac Imaging 1987. Lung Primary • “The likelihood of a primary lung cancer versus a metastasis depends on the histologic characteristics of the extrapulmonary neoplasm and the patient’s smoking history” Quint et al: Radiology 2000. and synovial sarcomas ➢ Papillary/mucinous adenocarcinomas (ovary. thyroid. bone) ➢ Testicular carcinoma Solitary Metastasis Pulmonary Metastases 142 Chest Radiology .Calcification in Metastases [Figure 1-15-9] Figure 1-15-9 • Malignancies ➢ Osteosarcoma. Lung Primary • “In patients with known primary malignancies and single parenchymal nodules.

hilar lymph nodes (25%) • Lymphatics expand with tumorlets and edema • Clusters or cords of tumor in lymphatics of the interlobular septa Secondary pulmonary lobule: and peribronchovascular interstitium lymphangitic carcinomatosis • Edema and desmoplastic reaction accentuate interstitial produces smooth and nodular thickening expansion of bronchovascular bundle • Pleural involvement: 2/3 sheaths and interlobular septa • Nodal involvement: 1/3 Lymphangitic Carcinomatosis: Imaging Features .mediastinal lymphadenopathy (20-40%) • Bilateral or unilateral findings Lymphangitic Carcinomatosis Imaging Features: Chest CT [Figure 1-15-11] • Smooth or nodular thickening of ➢ Bronchovascular bundles ➢ Interlobular septa (Kerley’s lines. polygonal arcades) ➢ Lobar fissures (subpleural edema) • Ground glass opacities Lymphangitic carcinomatosis in a middle aged • Focal or unilateral distribution (50%) female with breast cancer ➢ lung or breast CA • Pleural effusion • Lymphadenopathy (up to 50%) Tumor Embolism • Lodges in distal arterioles (100-200 micron diameter) • 26% cancer pts (at autopsy) • <1% clinically significant • Complications ➢ Cor pulmonale (PAH) ➢ Lung infarction ➢ Lung hemorrhage • Parenchymal or lymphatic mets if extravasation Chest Radiology 143 Pulmonary Metastases .Lymphangitic Carcinomatosis Figure 1-15-10 • Adenocarcinomas in 80%: ➢ Lung ➢ Breast ➢ Stomach ➢ Pancreas ➢ Prostate ➢ Colon • Incidence 6-55% • Symptoms: gradual onset dyspnea. cough • PFT’s: reduced lung compliance & diffusing capacity • Diagnosis: bronchial lavage or TBB Lymphangitic Carcinomatosis [Figure 1-15-10] • Blood-borne tumor cells extravasate and invade lymphatic channels • Tumor also enters lymphatics “retrograde” via mediastinal.Chest radiograph • Normal (50%) • Kerley B lines Figure 1-15-11 • Reticulonodular opacities • Subpleural edema • Pleural effusion (30-50%) • Hilar.

adenoCA) ➢ Breast ➢ ChorioCA ➢ Ovary ➢ Prostate ➢ Liver ➢ Kidney ➢ Lymphoma ➢ Right atrial myxoma Tumor Embolism [Figure 1-15-12] • CXR ➢ typically normal ➢ if widespread: nodules. MD] Endobronchial Metastases • Tumor arrives via bronchial arteries & peribronchial lymphatics Figure 1-15-13 • Rarely.Tumor Embolism Figure 1-15-12 • Malignancies ➢ Stomach ➢ Lung (esp. as well as ➢ if extravasation: nodules. brachytherapy. airspace opacities • CT ➢ “beading” of peripheral pulmonary arteries Tumor thromboembolism may produce ➢ mosaic perfusion beading along peripheral ➢ wedge-shaped peripheral opacities bronchovascular bundles.5 months • Treatment options ➢ Radiation. via airways (BAC) • 2-5% incidence in pts dying from metastases • Malignancies ➢ Kidney ➢ Colon. laser or mechanical resection. Curr Opin Pulm Med 2003.9:301-308 Endobronchial Metastases: Imaging Features [Figure 1-15-13] Figure 1-15-14 • Intraluminal soft tissue mass • Atelectasis or post-obstructive pneumonia • Serpiginous or nodular opacities (distal mucoid impaction) • Hilar mass (if adjacent mediastinal invasion) • DDX: bronchogenic carcinoma Pleural Metastases [Figures 1-15-14 to 1-15-16] • Malignancies ➢ Lung ➢ Breast (50% of patients) ➢ Ovary ➢ Stomach ➢ Lymphoma • Arise from lymphangitic or vascular invasion Large pleural effusion and pleural-based nodule in patient with breast cancer Pulmonary Metastases 144 Chest Radiology . lymphangitic carcinomatosis pulmonary infarction [Image courtesy of Mark Gosselin. Rectum ➢ Breast ➢ Melanoma ➢ Pancreas • Mean interval from diagnosis of primary: 65 months • Mean survival after discovery: 15. photodynamic therapy) Chan et al. Endobronchial metastases with left ➢ Chemotherapy upper lobe collapse (renal cell ➢ Surgery carcinoma) ➢ Interventional bronchoscopy (stenting.

237:395-400 Chest Radiology 145 Pulmonary Metastases .• Typically manifest as exudative pleural effusion Figure 1-15-16 ➢ Pleural nodules less common • Scattered nodules on pleural surface • Visceral & parietal pleura typically both involved • Radiologic DDX ➢ asbestos exposure ➢ splenosis • Rind-like or sheet-like pattern • Radiologic DDX ➢ mesothelioma ➢ post-inflammatory fibrothorax Figure 1-15-15 Pleural rind-like metastases in elderly female with NSCLC Large pleural effusion and pleural-based nodule in patient with breast cancer Do we impact the management of cancer patients with metastatic disease to the lung? Statement from the Fleischner Society: Guidelines for Management of Pulmonary Nodules MacMahon H et al. Radiology 2005.

solitary • Lymphangitic carcinomatosis ➢ Septal lines.26(4):374-377 Parenchymal Nodules Indications for Metastasectomy • To cure. Am J Clin Oncol 2003. renal cell. “A Sarcoid-like Reaction” • Rare but well-documented • Follows resection or treatment ➢ Lymphoma (Hodgkin & Non-Hodgkin) ➢ AML ➢ Lung CA ➢ Testicular CA ➢ Gastric CA ➢ Renal CA • Radiologic manifestations ➢ Mediastinal. but only if ➢ Complete resection possible ➢ No extrathoracic metastases (EXCEPT colon CA with liver mets) ➢ No therapeutic alternative (chemotherapy-insensitive tumors) ➢ Multiple nodules NOT necessarily a contraindication • To prolong 5-year survival ➢ Colorectal cancer: up to 20-50% ➢ Osteogenic & soft tissue sarcomas: up to 40% ➢ Melanoma. female GU: up to 30% ➢ Thyroid. GGO ➢ Pleural effusion ➢ Lymphadenopathy • Tumor thromboembolism ➢ Beading of peripheral arteries ➢ Mosaic perfusion ➢ Pleural-based opacity (infarction) Pulmonary Metastases 146 Chest Radiology . nodular/thickened fissures.impacts treatment strategy & participation in clinical trials Chojniak et al. parathyroid: up to 61% Yoneda et al. random or angiocentric. basilar>apical ➢ Unusual: cavitary. hilar lymphadenopathy ➢ Pulmonary nodules or consolidations ➢ Systemic sarcoidosis absent ➢ Positive on FDG-PET: mimics recurrence • Biopsy required for confirmation • ? Local immunologic response to tumor cells Patterns of Metastatic Disease to the Lung Overview • Parenchymal nodules ➢ Well-circumscribed.6:356-363.Parenchymal Nodules Assessing Therapeutic Response • Tumor doubling time ➢ Definition: 25% increase in tumor diameter separated by time (Tdt) ➢ Nodule growth rates vary widely ✧ according to histologic tumor cell type ✧ within the same patient ➢ Proposed reasons for differences ✧ Not all nodules are tumor (benign or inflammatory) ✧ Smaller mets grow at faster rates than larger mets ✧ Nodules represent different monoclonal cell populations (with variable responses to treatment) • Document changes in several nodules in the same patient for optimal therapeutic assessment . head & neck. Curr Opin Pulm Med 2000. calcified.

180:1- 12. Atypical pulmonary metastases: spectrum of radiologic findings. Radiology 2005. 6(4):356-363. mucoid impaction • Pleural-based metastases ➢ Pleural effusion ➢ Nodules on pleural surface ➢ Variation: rind-like pattern mimics mesothelioma References 1. Moskowitz CS et al. 8. 4. Sarcoid-like hilar and mediastinal lymphadenopathy in a patient with metastatic testicular cancer. Chojniak R.701-5. Radiologic diagnosis of extrathoracic metastases to the lung. Curr Opin Pulm Med 2003. Poste G. Schwartz LH. White CD. Louie S. Radiology 2003. Pugatch RD. 237:395-400. Am J Clin Oncol 2003. 14. Coppage L. Pulmonary metastases doubling time: Assessment by computed tomography. Blood supply of pulmonary metastases. Marglin S. Pulmonary metastases. Westcott J. 12. Hasse J. Chan AL. Fidler I. Libshitz HI.60(7):1545-7. Guidelines for management of small pulmonary nodules detected on CT scans: A statement from the Fleischner Society. Maito H. Completion pneumonectomy for lung metastases. Pugatch RD. Seo JB. J Thorac Imag 1987. 16. Jungraithmayr W. Pathol Res Pract 2004. 13. Metastatic disease to the chest in patients with extrathoracic malignancy. 6. 8(1):29-48. Advances in the management of endobronchial lung malignancies. 283:139-145. 22. Appearance of pulmonary metastases on high-resolution CT scans: comparison with histopathologic findings on autopsy specimens. The pathogenesis of cancer metastasis. 200(10). Haratake J. Radiologic Evaluation in Chest Malignancies. 217:257-261. Chung MJ. 20. 215 Suppl:655-62. Oncology 1998. EJSO 2004. Shaw C. Allen RP. J Thorac Imag 1987. Chest Radiology 147 Pulmonary Metastases . Radiology 2005. ACR Appropriateness Criteria. Murata K. 161:37-43. MacMahon H et al. Gefter WB. Quint L. 11. Solitary pulmonary nodules in patients with extrapulmonary neoplasms. Stoelben E. Yoneda KY. Imaging characteristics of metastatic disease to the chest. 30:1113-1117. Radiology 1992. Parra ER et al. Goo JM. Tomiyama N et al. Iannettoni M. Heffner JE. Dehdashti F. 21:403-417. Pulmonary metastatic nodules: CT-pathologic correlation. Davis S. 15. 18. Snyder BJ. 9. Kozuka T.• Endobronchial nodule ➢ Rounded defect in airway. Chest 1995. Zhao B. J Thorac Imag 1987. 21. Screening for pulmonary metastases. Johkoh T. Zerhouni EA. 107:294S-297S. 5. 10. Park C. Curtis A. 2(4):38-43. Detection of pulmonary metastases with multi-detector row CT scans of 5-mm nominal section thickness: Autopsy lung study. Radiol Clin North Am 1982. North LB. 3. 2(4):15-23. 9:301-308. Hirakata K. David SD. pneumonia. Chest Surg Clin N Am 1998. Castellino R. Albertson TE. Pugatch RD. 20:437-451. Tocino I. 226:231-234. or cut-off of airway lumen ➢ Post-obstructive atelectasis. Pulmonary metastases: Effect of CT section thickness on measurement – initial experience. RadioGraphics 2001. 7. Bode FR. Pulmonary and mediastinal “sarcoidosis” following surgical resection of cancer. CT evaluation for pulmonary metastases in patients with extrathoracic malignancy. Yoneda KY. Im J. Radiologic investigation of thoracic metastases from unknown primary sites. Hamada S. Nakata H. 17. 19. Henschke CI. 2(4):24-37. Kawaguchi N et al. Kim M. Approach to pulmonary metastases. Younes RN. McLoud TC. Am J Roentgenol 1993. 234:934-939. Milne EC. 26(4):374-377. Takahashi M. Mori M. Mortimer J. Yankelevitz D. 23. Sostman HD. Fleishon H. Woodard PK. Milam MG. Radiology 2000. Nature 1980. American College of Radiology. Shelton D. Radiology 1991. 2. Current Opinion in Pulmonary Medicine 2000. Oct 1. 182:331-335. Putman CE. 12(3): 441-444. Cancer 1987. Radiology 2000.

posterior The mediastinum • Radiographic (Fraser. middle.Anterior. Colman. great vessels. middle. FACR Learning Objectives: • To define the mediastinum and describe the mediastinal compartments • To provide a classification for a practical approach to the imaging diagnosis of mediastinal masses • To list clinical and cross-sectional imaging features that allow a focused differential diagnosis • To describe lesions with pathognomonic imaging features • To differentiate neoplastic from non-neoplastic conditions with emphasis on management Mediastinal Compartments [Figure 1-16-1] Figure 1-16-1 • Mediastinum . middle-posterior. MD. Rosado de Christenson. anterior. esophagus. middle.trachea. posterior Includes paravertebral areas • Radiographic (Felson) . heart. lymph nodes. Müller. Paré) .Superior.Superior. anterior. paravertebral Figure 1-16-2 Figure 1-16-3 Anatomic and Surgical Mediastinal Compartments Radiographic Mediastinal Compartments Mediastinal Masses 148 Chest Radiology .space between pleural surfaces and lungs • Bound by sternum and vertebrae • From thoracic inlet to diaphragm • Thymus.Anterior. nerves and other soft tissues • Arbitrary division into compartments .no anatomic boundaries The Mediastinal Compartments [Figures 1-16-2 and 1-16-3] • Anatomic .Differential Diagnosis of Mediastinal Masses Melissa L. posterior Excludes paravertebral areas • Surgical .

Thorac Cardiovasc Surg 1971 Approach to Mediastinal Masses • Clinical ➢ Demographics (age. SVC syndrome. J. gender) / Symptoms • Radiography ➢ Mediastinal compartment / Adjacent structures ➢ Focal mass vs.Mediastinal Masses • Patients are often asymptomatic • 83% of asymptomatic masses are benign • 57% of symptomatic masses are malignant • Approximately 1/3 are malignant • Approximately 1/10 are vascular Mediastinal Masses – Mayo Clinic (N=1. local invasion • Primary neoplasm may not be evident • Non-surgical lesion Malignant Neoplasia . diffuse mediastinal enlargement ➢ Lesion contours / Density • Cross-sectional Imaging ➢ Location / Relationship to normal structures ➢ Morphologic features / Associated findings Mediastinal Masses • Neoplasia ➢ Malignant (secondary / diffuse) ➢ Benign and malignant (primary / focal) • Congenital cysts • Glandular enlargement • Vascular lesions • Herniations / Esophageal abnormalities Figure 1-16-4 • Miscellaneous conditions Malignant Neoplasia – Lung Cancer • Small cell / poorly differentiated lung cancer • Elderly smokers. weight loss • Mediastinal mass.064) • Neurogenic tumor 20% • Thymoma 19% • Cysts 18% • Lymphoma 30% Teratoma Granuloma Mediastinal goiter Wychulis et al.Metastases [Figure 1-16-4] • Known malignancy • Renal cell carcinoma • Testicular carcinoma Metastatic renal cell carcinoma • Head and neck cancer • Breast carcinoma • Melanoma Chest Radiology 149 Mediastinal Masses . lymphadenopathy. males and females • Cough. dyspnea.

paratracheal lymphadenopathy ➢ Nodal coalescence. necrosis • Non-Hodgkin Lymphoma ➢ Lymphoblastic (precursor T-lymphoblastic) -lymphoblasts ➢ Diffuse large B-cell (primary mediastinal [thymic] large B-cell).young adult females Lymphoma: Pathologic Features [Figures 1-16-5 and 1-16-6] • Hodgkin Disease ➢ Nodal cellular infiltrate. infiltrative. cystic change. night sweats. vesicular nuclei. necrosis ➢ Local invasion (including chest wall). fever. paratracheal ➢ Nodal coalescence (homogeneous or heterogeneous) ➢ Ca++. local invasion • Primary mediastinal lymphoma • Non-surgical lesion Lymphoma • Non-Hodgkin lymphoma . hemorrhage. primary thymic involvement. necrosis Lymphoma: Imaging Features [Figures 1-16-7 to 1-16-9] Figure 1-16-7 • Lobulated unilateral/bilateraldiffuse mediastinal enlargement • Hodgkin Disease ➢ Intrathoracic involvement in 85% ➢ Lymphadenopathy. local invasion ➢ Lymphoblastic . prominent nucleoli ➢ Large.Malignant Neoplasia – Lymphoma Figure 1-16-5 • Hodgkin disease / Non-Hodgkin lymphoma • All age groups (young patients). locally invasive mass. Males and females • Palpable lymphadenopathy. prevascular. loss • Non-Hodgkin lymphoma ➢ Systemic disease with constitutional symptoms: lymphadenopathy.75% of all cases • 50-70% of mediastinal lymphoma is Hodgkin disease ➢ 15-21% is non-Hodgkin lymphoma • Hodgkin – 66% intrathoracic at presentation ➢ Non-Hodgkin – 37% intrathoracic at presentation • Treatment: Radiotherapy. nodal coalescence. Hodgkin Disease: Gross Features large cells. collagenous connective tissue (NS). Reed- Sternberg cell ➢ Lymphadenopathy. constitutional symptoms • Lobular / diffuse mediastinal enlargement • Prevascular. paratracheal adenopathy ➢ Isolated involvement of other mediastinal lymph nodes • Local invasion • Primary mediastinal lymphoma Hodgkin Disease: Imaging Features Mediastinal Masses 150 Chest Radiology . hemorrhage. chemotherapy Hodgkin Disease: Microscopic Features Lymphoma: Clinical Features • Hodgkin Disease Figure 1-16-6 ➢ Males = Females (NSHD. supraclavicular ➢ 20-30%.male children / adolescents ➢ Diffuse large-B cell . 1% . 2 X more common in females) ➢ Bimodal distribution: 2nd to 3rd and > 5th decades ➢ Lymphadenopathy: cervical.1 year post-therapy. wt. rare pre-therapy • Non-Hodgkin ➢ Prevascular.

esophagus. circumscribed or locally invasive. dilatation. systemic • Adult females (M:F . vessels • Mediastinal mass.4:1) may be asymptomatic • Middle mediastinal / hilar mass ➢ Solitary mass ➢ Dominant mass with lymphadenopathy ➢ Multiple enlarged lymph nodes ➢ Enhancement. plasma cell variant • Localized vs. excision. Calcification ➢ Other granulomatous infections • Sarcoidosis ➢ Bilateral symmetric hilar lymphadenopathy ➢ Typical lung parenchymal involvement • Castleman disease ➢ Enhancement / calcification (10%) Mediastinal Fibrosis • Granulomatous lymphadenopathy • Young patients with signs and symptoms of obstruction Figure 1-16-10 ➢ Trachea.Figure 1-16-8 Figure 1-16-9 Non-Hodgkin lymphoma – nodal coalescence with low attenuation corresponding to necrosis Hodgkin disease – prevascular and paratracheal lymphadenopathy and left pleural effusion Secondary Neoplasia • Diffuse. calcification (10%) Castleman Disease: Enhancing mediastinal lymphadenopathy Chest Radiology 151 Mediastinal Masses . calcification • Systemic antifungal agents. bilateral mediastinal enlargement • Lymphadenopathy • Local invasion • Metastases • Other imaging features of malignancy Non-Neoplastic Lymphadenopathy • Infection ➢ Fungal: Mediastinal fibrosis. bronchi. bypass graft • 30% mortality Castleman Disease [Figure 1-16-10] • Angiofollicular or giant lymph node hyperplasia • Hyaline vascular type (> 90%) vs.

tumor implants. “benign” behavior • M=F. Invasive • Spherical mass. B1. B3 • Tumor lobules compartmentalized by fibrous septa • Encapsulated vs. cystic change (mural nodules) • Invasive thymoma . 30-50% have MG Thymoma: Pathologic Features [Figures 1-16-11 to 1-16-13] Figure 1-16-12 • Lymphocytes and epithelial cells in varying proportions • WHO 1999 classification (morphology and lymphocyte-to-epithelial cell ratios) • Types A. necrosis. lobular contours.Primary Neoplasia Figure 1-16-11 • Thymus ➢ Thymoma ➢ Thymic malignancy ➢ Thymolipoma ➢ Germ cell neoplasm • Neurogenic neoplasms Thymoma • Epithelial neoplasm. metastases Figure 1-16-13 Thymoma: pathologic features – tumor lobules compartmentalized by fibrous bands Thymoma: Gross Features Mediastinal Masses 152 Chest Radiology . AB.microscopic documentation of capsular invasion. B2. 70% in the 5th and 6th decades • Most patients asymptomatic • 25-30% with symptoms of compression/invasion • Associated parathymic syndromes: ➢ Myasthenia gravis ➢ Pure red cell aplasia ➢ Hypogammaglobulinemia Thymoma and Myasthenia Gravis • Myasthenia gravis (MG) – autoimmune neurological disorder • 85% of patients with MG have follicular thymic hyperplasia • 15% of patients with MG have a thymoma Thymoma: Microscopic Features • Of all patients with thymoma. variable size. local invasion. most common primary thymic neoplasm • Slow growth. typically encapsulated • Hemorrhage.

Thymoma: Imaging Features [Figures 1-16-14 to 1-16-18] Figure 1-16-14 • Anterior mediastinal mass. homogeneous or heterogeneous ➢ Necrosis. calcification (typically curvilinear and peripheral) • No lymphadenopathy • Exclude local invasion of fat. unilateral. variable size • Normal radiographs in 25% (occult thymoma) • Focal. left anterior mediastinal mass Figure 1-16-15 Figure 1-16-16 Occult Thymoma: Well-defined. cardiovascular structures. prevascular mass Thymoma: Well-defined right cardiophrenic angle mass with irregular low attenuation corresponding to necrosis Figure 1-16-18 Figure 1-16-17 Cystic thymoma: Unilateral spherical cystic mass with peripheral curvilinear calcification and mural nodules Invasive thymoma: Direct invasion of left brachiocephalic vein Chest Radiology 153 Mediastinal Masses . lobular. lobular. lobular. lung • Pleural implants (may cause diffuse pleural thickening) Thymoma: Unilateral. cystic (mural nodules). spherical. unilateral.

R/O metastases • WHO Type C thymoma Thymic Carcinoid / Carcinoma: Imaging Features [Figure 1-16-19] • Large anterior mediastinal mass (R/O thymoma) • R/O metastatic lung malignancy (histology) • Lymphadenopathy • Local invasion. soft. wide age range (average. 43 yrs) • 50% functionally active ➢ ACTH – Cushing syndrome (33-40%) • MEN type 1 – (Wermer syndrome) (19-25%) ➢ Hyperparathyroidism (90%). microscopic capsular invasion (55-100%) III Macroscopic invasion of adjacent organs. complete excision ➢ Best prognosis ➢ Occasional local recurrence. atypical carcinoid (necrosis / mitoses / invasion) Figure 1-16-20 • Males > Females. lobular. wide age range (mean: 5th decade) • Several cell types identical to primary lung cancer. pleural or pericardial effusion/implantation. 3:1. lung (47-60%) IVa Pleural / pericardial dissemination (0-11%) IVb Lymphatic / hematogenous dissemination Thymoma: Therapy / Prognosis • Encapsulated. microscopic features: Thymic tissue admixed with mature Thymolipoma adipose tissue • Rare benign thymic neoplasm • M=F. islet cell tumor of pancreas (80%) pituitary adenoma (65%) Thymic Carcinoma • Male > Female. wide age range (average age. pericardium. heart.year survival) I Encapsulated / no microscopic capsular invasion (86-100%) II Microscopic invasion into surrounding fat / mediastinal pleura.Thymoma: Staging (Masaoka) Figure 1-16-19 (10 . 28 yrs) • Asymptomatic patients: 50% ➢ Symptoms with large tumors Thymolipoma: Pathologic Features [Figure 1-16-20] • Encapsulated. distant metastases • Post-operative radiation for invasive thymoma to decrease local Thymic Carcinoid: Mediastinal mass with recurrence adjacent lymphadenopathy in a patient • Chemotherapy for for progression after surgery and unresectable with ACTH production and MEN 1 lesions Thymic Malignancy: Carcinoid / Carcinoma • Rare malignant epithelial neoplasms • Symptomatic patients • Poor prognosis Thymic Carcinoid • Neuroendocrine neoplasm. metastases • Carcinoid ➢ Octreotide imaging for diagnosis for occult (non-specific - metastases and other neoplasms) Thymolipoma. great vessels. yellow • Mature adipose tissue and thymic tissue in variable proportions Mediastinal Masses 154 Chest Radiology .

bone Teratoma. sebaceous. immature [immature Thymolipoma. microscopic features: cystic neoplasm with ectodermal. respiratory tissue.Thymolipoma: Imaging Features [Figure 1-16-21] Figure 1-16-21 • Well-defined anterior / inferior mediastinal mass ➢ Unilateral or bilateral. gelatinous material (lipid) ➢ Focal solid areas: hair. most commonly the mediastinum • Postulated origin in multipotential primitive germ cells “misplaced” during embryogenesis • Cell types: ➢ Teratoma (mature. cartilage. midline locations. mucus glands • Spherical. “malignant” [mixed malignant mass with anatomic connection with the thymus and germ cell neoplasm]) mixture of fat and soft tissue attenuation ➢ Seminoma ➢ Non-seminomatous germ cell neoplasms Figure 1-16-22 Mature Teratoma • 60-75% of mediastinal germ cell neoplasms • Males=Females • Children and young adults (< 40 yrs) • Often asymptomatic • Symptoms of compression or rupture Mature Teratoma: Pathologic Features [Figures 1-16-22 and 1-16-23] • More than one embryonic germ cell layer ➢ Ectoderm – skin. imaging features – anterior mediastinal neuroectoderm]. slow growth • May conform to shape of structures ➢ R/O cardiac enlargement / diaphragmatic elevation ➢ Positional change in shape • Anatomic connection to the thymus (pedicle) • Mixed fat and soft tissue attenuation/signal Germ Cell Neoplasms • Most common in the gonad • Extragonadal germ cell neoplasms. dermal appendages ➢ Mesoderm – bone. lobulated • Multilocular or unilocular cyst ➢ Oily. gross features: multilocular cystic mass Chest Radiology 155 Mediastinal Masses . muscle ➢ Endoderm – GI. encapsulated. teeth. Figure 1-16-23 mesodermal and endodermal components Teratoma.

locally invasive with mass effect • CT: ➢ Homogeneous soft tissue mass ➢ Mimics nodal coalescence ➢ Slight homogeneous contrast-enhancement ➢ Rarely necrosis / cystic change (8%) Figure 1-16-26 Non-Seminomatous Malignant Germ Cell Neoplasms • Yolk sac (endodermal sinus) tumor • Embryonal carcinoma • Choriocarcinoma • Mixed germ cell neoplasm • Males. Germ Cell Neoplasms anterior mediastinal. soft tissue. third to fourth decades • Most patients are symptomatic • Rounded cells with sharp borders. imaging features: Unilateral. lobulated. fat • Extragonadal germ cell neoplasms. necrosis. excision of residual tumor anterior mediastinal locally invasive heterogeneous mass Mediastinal Masses 156 Chest Radiology . Fat 76%. lobular contours. imaging features: Large • Cisplatin-based chemotherapy. well-defined. 90% symptomatic ➢ Klinefelter syndrome (20%). unencapsulated Non-seminomatous malignant germ cell • Hemorrhage. fibrous bands. lymphocytes. clear cytoplasm. “cyst” formation neoplasm. midline locations. “malignant”) ➢ Seminoma ➢ Non-seminomatous germ cell neoplasms Figure 1-16-25 Seminoma • 40% of malignant germ cell neoplasms of a single histology ➢ Caucasian males.11% ➢ ST/FL/FAT/Ca++ 39% ➢ ST/FL/FAT 24% ➢ ST/FL 15% Mature Teratoma: Therapy and Prognosis • Complete excision is curative • Excellent prognosis ➢ Near 100% five-year survival Teratoma. most and calcium commonly the mediastinum • Postulated origin in multipotential primitive germ cells “misplaced” during embryogenenesis • Cell types: ➢ Teratoma (mature. hematologic malignancy • Alpha-fetoprotein (EST.Mature Teratoma: Imaging Features [Figure 1-16-24] Figure 1-16-24 • Unilateral anterior mediastinal mass • Spherical. bulky. granulomas • Homogeneous soft tissue mass • Radiation therapy / Cisplatin-based chemotherapy ➢ 60-80% long-term survival Seminoma: Imaging Features [Figure 1-16-25] Seminoma. Ca++ 53% ➢ Fat fluid level . multilocular cystic • Most common in the gonad mass with intrinsic fluid. well-defined • Multilocular cystic . imaging features: Diffuse • Anterior mediastinal mass (both sides of midline) homogeneous anterior mediastinal mass ➢ Large.85% • Attenuation: ➢ Fluid 89%. immature. plasma cells. EC) ➢ B-human chorionic gonadotropin (choriocarcinoma) ➢ LDH (60%) tumor burden • Large.

well-defined paravertebral mass • Osseous findings (50%): pressure erosion/deformity of ribs or vertebrae. encapsulated ➢ Cellular and less cellular areas (Antoni A / B) • Neurofibroma – second most common mediastinal neurogenic neoplasm ➢ Spherical/fusiform. gross features: [Figures 1-16-29 and 1-16-30] Heterogeneous spherical mass • Spherical. Ca++ in 10% ➢ Growth into spinal canal in 10% • MR Imaging – R/O spinal involvement ➢ T1 – Low-to-intermediate signal ➢ T2 – Foci of high signal Figure 1-16-29 Figure 1-16-30 Schwannoma.Non-Seminomatous GCN: Imaging Features Figure 1-16-27 [Figure 1-16-26] • Large. expanded neuroforamen • Homogeneous/heterogeneous ➢ Heterogeneous enhancement. 3rd and 4th decades • Most (65%) asymptomatic • Symptoms and signs of compression Schwannoma / Neurofibroma: Imaging Features Schwannoma. cystic change. smooth / lobular. unencapsulated • Calcification. lymphadenopathy Neurogenic Neoplasms [Figure 1-16-27] • 20% of primary mediastinal neoplasms ➢ 35% in children • 70–80% benign • Peripheral nerves Neurogenic neoplasms may arise from ➢ Schwannoma peripheral nerves or sympathetic ➢ Neurofibroma ganglia ➢ Malignant peripheral nerve sheath tumor • Sympathetic ganglia Figure 1-16-28 ➢ Ganglioneuroma ➢ Ganglioneuroblastoma ➢ Neuroblastoma Schwannoma / Neurofibroma [Figure 1-16-28] • Schwannoma – Most common mediastinal neurogenic neoplasm ➢ Spherical. well or poorly-defined anterior mediastinal mass ➢ Extends to both sides of midline • Heterogeneous ➢ Large areas of central low attenuation ➢ Frond-like peripheral soft tissue • Loss of tissue planes ➢ Local invasion. imaging features: Intraspinal extension Chest Radiology 157 Mediastinal Masses . hemorrhage • Young adults. imaging features: Unilateral paravertebral spherical mass Schwannoma.

paraplegia. chest wall pain. phrenic nerve • Diffuse enlargement of peripheral nerve • Multiple masses along a nerve Malignant Peripheral Nerve Sheath Tumor • Most frequent in the paravertebral region • Rare among neurogenic neoplasms • Large (> 5 cm) spherical mass ➢ Central low attenuation – necrosis ➢ Calcification ➢ May exhibit local invasion Peripheral Nerve Neoplasms: Therapy and Prognosis • Excision • Schwannoma/Neurofibroma ➢ Excellent prognosis • Malignant peripheral nerve sheath tumor ➢ Solitary – 75% five-year survival ➢ Neurofibromatosis – 30% five-year survival Thoracic Meningocele • Intrathoracic extrusion of meninges and their fluid content • Well-defined spherical paravertebral mass • Enlarged neuroforamen. sympathetic chain.Neurofibromatosis (NF1) • Multiple neoplasms (including ganglioneuroma) • Plexiform neurofibroma • Vagus nerve. Horner syndrome. adolescents. diarrhea. young adults ➢ Asymptomatic patients • De novo. maturation of neuroblastoma • Benign paravertebral neoplasm • Mature ganglion cells. Schwann cells. oblong paravertebral mass • Osseous erosion / displacement • Homogeneous or heterogeneous ➢ Calcification in 25% Ganglioneuroma. pressure erosion. sclerosis Figure 1-16-31 • Homogeneous. gross features: • MR: Homogeneous intermediate signal on T1 / T2 Elongate paravertebral mass ➢ R/O intraspinal extension Ganglioneuroblastoma/Neuroblastoma • Infants and young children • Asymptomatic. nerve fibers • Encapsulated. fluid attenuation / signal Ganglioneuroma [Figure 1-16-31] • Children. hemothorax • Elevation of urine catecholamines ➢ Elevation of urine/serum VMA (screening) • Neuroblastoma – Elongate paravertebral mass ➢ 50% < 2 years ➢ 90% < 5 years ➢ May be congenital Mediastinal Masses 158 Chest Radiology . elongate mass ➢ Gray / yellow with lobular surface Ganglioneuroma: Imaging Features • Well-defined.

unilateral mass ➢ Lymphadenopathy ➢ Local invasion Bronchogenic Cyst [Figure 1-16-33] • Most common congenital cyst of the mediastinum • Abnormal ventral foregut bud • Failure to induce mesenchymal development to lung parenchyma • Mediastinum (85%). excess catecholamines Neuroblastoma. infrequent in children • Young adults • Asymptomatic – incidental finding • Symptomatic – chest pain. obstruction. unilateral mass ➢ No lymphadenopathy Figure1-16-33 ➢ No local invasion • Malignant (invasive) ➢ Focal. mediastinal ➢ Spontaneous maturation to ganglioneuroma Paraganglioma • Middle mediastinum: Aortopulmonary paraganglia ➢ Paravertebral: Aortico sympathetic paraganglia ➢ Heart • Adults (average age 30-40 yrs) ➢ Males > Females. drainage. 2:1 ➢ Asymptomatic. sterile alcohol ablation Chest Radiology 159 Mediastinal Masses . mass effect. Homer-Wright pseudorosettes ➢ Well / poorly differentiated Neuroblastoma: Imaging Features [Figure 1-16-32] • Well-defined large elongate paravertebral mass • Radiographic evidence of Ca++ in 10% • Osseous erosion • R/O intraspinal growth • Local soft tissue invasion Sympathetic Ganglia Tumors • Ganglioneuroma ➢ Excision is curative • Ganglioneuroblastoma ➢ Five-year survival near 90% • Neuroblastoma ➢ Five-year survival – 30% ➢ More favorable course with: age < 2 yrs. pleura and lung Bronchogenic Cyst: Clinical Features • Rare in infants. diaphragm. infection Bronchogenic cyst: Typical subcarinal location • Excision. imaging features: • Well-defined spherical mass Unilateral calcified paravertebral mass in ➢ Homogeneous/heterogeneous a neonate with intraspinal extension • Marked contrast enhancement ➢ 90% uptake of I131 or I123 MIBG Primary Neoplasia • Benign ➢ Focal. pericardium. observation.Ganglioneuroblastoma/Neuroblastoma: Pathologic Features Figure 1-16-32 • Adrenal – most common location ➢ Paravertebral – second most common location • Ganglioneuroblastoma: Neuroblasts and ganglion cells ➢ Well / poorly differentiated • Neuroblastoma: Neuroblasts.

Bronchogenic Cyst : Pathologic Features Figure 1-16-34 [Figures 1-16-34 and 1-16-35] • Respiratory epithelium • Wall: bronchial glands. carina. imaging features: spherical subcarinal mass that may not exhibit water attenuation Mediastinal Masses 160 Chest Radiology . gross features: Thin- walled unilocular cyst Figure 1-16-37 Bronchogenic cyst. fluid attenuation. unilocular • Thin wall • Fluid variable: clear.within esophageal. stem bronchi • CT: ➢ Thin smooth wall (enhancement) ➢ Water (40%) or soft tissue (43%) attenuation ➢ Homogeneous / heterogeneous. air-fluid level Bronchogenic cyst. hemorrhagic. non-enhancing contents • MR: ➢ T1 .variable (slightly hyperintense to muscle) ➢ T2 . turbid. viscous Bronchogenic Cyst: Imaging Features [Figures 1-16-36 and 1-16-37] • Well-defined.Associated spinal anomaly • Pericardial . air.Cardiophrenic angle. fluid. ovoid. microscopic features: respiratory epithelium with Other Congenital Cysts cartilage and smooth muscle in wall • Foregut cysts • Esophageal . asymptomatic patients Figure 1-16-36 Bronchogenic cyst. serous. ectopic gastric mucosa Figure 1-16-35 • Neuroenteric . spherical. imaging features: Subcarinal spherical mass with extension to the right Bronchogenic cyst. imperceptible wall. smooth muscle • Closed foregut connection • Spherical.isointense or hyperintense to CSF • Thin-walled pulmonary cyst. cartilage. middle mediastinal mass • Near trachea.

Congenital • Children / young adults • Association with neoplasia. hyperthyroidism.global increase in the size and weight of the Figure 1-16-39 thymus • Rebound hyperplasia . RA. rarely malignancy or thyroiditis • Fibrous capsule. pathologic features: iodine content. imaging features: ➢ May produce symptoms by mass effect Multilocular cyst • Adenomatous goiter. may not produce thymus enlargement • Myasthenia gravis.following chemotherapy (2 weeks to 14 months). scleroderma. nodules composed of thyroid follicles • Hemorrhage. mediastinal widening • Homogeneous soft tissue • Maximal thickness ➢ Under 20 years – 1. well-defined lobular soft tissue mass Chest Radiology 161 Mediastinal Masses . gross features: multilocular cirrhosis cyst • True hyperplasia . steroids or severe insult • Ant. Thymic cyst. calcification. cystic change Figure 1-16-40 Mediastinal goiter. lupus.3 cm • Follicular thymic hyperplasia – normal or mildly enlarged thymus Mediastinal Goiter [Figure 1-16-40] • 20% of cervical goiters • Asymptomatic females: incidental finding Thymic cyst.Thymic Cyst [Figures 1-16-38 and 1-16-39] Figure 1-16-38 • Uncommon (3% of mediastinal masses) • Acquired vs. spherical • Unilocular • Thin-walled • No mural nodules • No lymphadenopathy • Along foregut-derived structures Thymic Hyperplasia • Lymphoid hyperplasia (lymphofollicular / autoimmune thymitis) - secondary follicles with germinal centers.8 cm ➢ Over 20 years – 1. AIDS Diffuse infiltrative lymphocytosis syndrome (DILS) • Epithelial lining and thymus in cyst wall • Multilocular / unilocular • R/O cystic neoplasm Congenital Cysts • Focal.

punctate.Mediastinal Goiter: Imaging Features Figure 1-16-41 [Figures 1-16-41 and 1-16-42] • Unilateral anterior mediastinal mass (80%) ➢ Other compartments also affected. imaging features: Large calcified unilateral mass with cervicothoracic sign Figure 1-16-43 Mediastinal goiter. high attenuation and calcification Parathyroid Adenoma • Ectopic parathyroid glands: superior pole of thymus (39%).5%) • Primary hyperparathyroidism post surgical parathyroidectomy • MEN I • Imaging ➢ Tc99m / Tl201 subtraction imaging ➢ T123 / Tl201 ➢ Tc99m . coarse. microscopic features: Interconnecting endothelial lined Lymphangioma vascular channels • Benign mesenchymal mediastinal tumor • Proliferation of lymphatic vessels without communication with lymphatic tree • Developmental vs. curvilinear • Cystic change • High attenuation ➢ Intense. mediastinum (2%).2-3. intrathyroid (0. hamartoma • Asymptomatic / symptoms of compression • Mediastinal extension of cystic hygroma (10%). sustained contrast enhancement Figure 1-16-42 Mediastinal goiter. neoplasm vs.Sestamibi (mitochondria) ➢ Single radionuclide/Dual radionuclide • CT/MRI correlation of mediastinal uptake Glandular Enlargement • Anatomically related to normal gland • Continuity with normal gland • Function similar to that of normal gland Lymphangioma. R > L • Well-defined lobular borders • Cervico-thoracic sign ➢ Continuity with cervical thyroid • Calcification . soft palpable mass. cystic mass • Cystic hygroma– large vascular spaces • Cavernous lymphangioma – small vascular spaces Mediastinal Masses 162 Chest Radiology . imaging features: Continuity between cervical and mediastinal portions of the mass. 90% diagnosed in infancy • Mediastinal mass in asymptomatic child / adult Lymphangioma: Pathologic Features [Figures 1-16-43 and 1-16-44] • Intercommunicating spaces of variable size lined by endothelial cells • Soft.

heterogeneous ➢ Solid components. 75% < 35 yrs. imaging features: Multilocular cystic mediastinal mass with channels extension into the axilla Figure 1-16-46 Lymphangioma. phleboliths • Anterior mediastinal mass (also in other compartments) • Spherical. cystic. imaging features: Anterior mediastinal mass with intrinsic • Heterogeneous intense phleboliths and intense heterogeneous enhancement enhancement Chest Radiology 163 Mediastinal Masses . gross features: Multilocular cystic appearance due to enlargement of vascular Lymphangioma.Lymphangioma: Imaging Features [Figures 1-16-45 and 1-16-46] Figure 1-16-44 • Anterosuperior mediastinum. well-defined borders • Circumscribed mass / infiltrative mass • Multilocular. phleboliths Hemangioma. 1/3-1/2 with symptoms of compression ➢ Rendu-Osler-Weber syndrome • Communicating vascular spaces ➢ Endothelial lining. tissue septa Figure 1-16-45 Lymphangioma. Ca++ 28%. • Asymptomatic. other compartments affected • Cervical / axillary / chest wall mass. imaging features: Infiltrative or localized multilocular cystic mediastinal mass Hemangioma [Figure 1-16-47] • Rare vascular mediastinal tumor Figure 1-16-47 ➢ Neoplasm vs. Ca++. mediastinal extension • Spherical. punctate. well-defined. developmental • Young patients. organized thrombi. lobular.

imaging features: • Identification of abdominal contents in hernia sac herniation of abdominal contents through esophageal hiatus Herniation . infiltrative • Lymphatic ➢ Multilocular cystic ➢ Extramediastinal involvement • Blood vessels ➢ Intense.Vascular Lesion . air-fluid Hiatus hernia.Morgagni • Developmental defect in right anteromedial hemidiaphragm • Asymptomatic / Abdominal pain • Right cardiophrenic angle mass • Demonstration of internal fat (omentum). bowel loops or abdominal organs (liver) Herniations • Intrathoracic extension of abdominal contents ➢ Bowel ➢ Omental fat • Esophageal hiatus • Morgagni hernias Miscellaneous – Achalasia • Absent peristalsis and incomplete relaxation of esophageal sphincter • Primary – deficiency of ganglion cells in myenteric plexus • Secondary – (pseudo achalasia) Chagas disease and primary or secondary malignancy at the GE junction • Esophageal dilatation with air-fluid levels ➢ Esophageal displacement to the right. mass effect on mediastinum. heterogeneous / serpiginous enhancement • Aneurysms ➢ Focal vascular enlargement Herniations – Hiatus Hernia [Figure 1-16-48] • Gastric herniation through enlarged esophageal hiatus • Increased intra-abdominal pressure / Increased prevalence with increasing age • Asymptomatic. Left gastric – portosystemic collaterals • Visible on radiography in 10% • Middle-posterior-paravertebral cluster of serpiginous vessels with intense enhancement Figure 1-16-48 Vascular Lesions • Focal vs.EMH • Extramedullary hematopoiesis • Compensatory formation of blood elements outside osseous medulla • Hemolytic anemia • Unilateral or bilateral paravertebral mass.Aneurysm • Abnormal mediastinal contour contiguous with vascular structures • Saccular aneurysms may resemble other primary mediastinal masses • Curvilinear peripheral calcification • Contrast enhancement • Continuity with vascular lumen Vascular Lesion .Varices • Esophageal / paraesophageal • Severe liver disease and portal hypertension. homogeneous. air-filled. may exhibit internal fat attenuation • Adjacent medullary expansion Mediastinal Masses 164 Chest Radiology . pulmonary consolidation (aspiration) Miscellaneous . Reflux / bleeding • Retrocardiac mass.

Müller NL. Dee P. Fraser RS. Colman N. obliteration of tissue planes Mediastinal Masses: Pathognomonic • Lateral thoracic meningocele • Extramedullary hematopoiesis • Aneurysm • Esophageal varices • Teratoma • Lipomatosis • Congenital cyst (BC. PC) • Mediastinal goiter Mediastinal Masses: Cystic • Thymoma (mural nodules) • Congenital cysts (unilocular. Colman N. Philadelphia: Saunders. 2938-2973. 5. posterior mediastinum) • Neurogenic neoplasm (associated osseous erosion) ➢ Meningocele (NF1. Colman N. Hansell DM. eds. 2. Paré PD. pneumothorax • Abscess. homogeneous water attenuation / signal) • Mature teratoma (multilocular cystic mass with internal fat) • Lymphoma (lymphadenopathy) • Lymphangioma (multilocular cysts . 2000.Miscellaneous – Acute Mediastinitis • Surgery. Masses situated predominantly in the paravertebral region. In: Fraser RS. Wilson AG. Müller NL. Fraser RS. London: Mosby. Sharma A. Philadelphia: Saunders. no mass effect) • Lipoma • Thymolipoma (fat / soft tissue connecting to thymus) • Mature teratoma (cystic) • Morgagni hernia (CPA. 6. Masses situated predominantly in the middle-posterior mediastinal compartment. Fraser and Paré's Diagnosis of Diseases of the Chest. middle. Fourth edition. Chest Radiology 165 Mediastinal Masses . Armstrong P. eds.vascular channels) • Esophageal enlargement (achalasia) • Mediastinal goiter (high attenuation. right. continuity with thyroid) Mediastinal Masses: Fat • Lipomatosis (diffuse. Hayman LA. Aquino SL. 25: 489-492. Fraser RS. Third edition. Müller NL. Felson B. eds. Philadelphia: Saunders. Fraser and Paré’s Diagnosis of Diseases of the Chest. continuous with abdominal fat) Mediastinal Masses: Intense Enhancement • Mediastinal goiter (continuity with cervical thyroid) • Hemangioma (phleboliths. 3. surgical. Mediastinal and hilar disorders. chills and chest pain • Focal or diffuse mediastinal widening. Fourth edition. Chest Roentgenology. 789-892. Taber KH. continuity with spinal canal. abnormal mediastinal air. Paré PD. Paré PD. In: Fraser RS. Paré PD. pneumomediastinum. extraluminal ingested contrast. In: Armstrong P. Colman N. Imaging of Diseases of the Chest. Reconciliation of the anatomic. Philadelphia: Saunders. 1999. Paré PD. 1973: 380-420. Duncan G. and radiographic classifications of the mediastinum. instrumentation with esophageal perforation • Ill patients with fever. Paré PD. Müller NL. follows vascular enhancement) • Castleman disease (enhancing lymphadenopathy) • Paraganglioma (catecholamine production) • Aneurysm / Varices References General 1. In: Fraser RS. pleural effusion. Müller NL. eds. Fraser and Paré’s Diagnosis of Diseases of the Chest. 1999. Colman N. Fourth edition. 4. Masses situated predominantly in the anterior compartment. 2974-2983. 1999: 2875-2937. Müller NL. Colman N. J Comput Assist Tomogr 2001.

Colman N. Thymoma: state of the art. Lee KS. Radiology 1998. 12: 645-658. Atlas of Tumor Pathology: Tumors of the Mediastinum. Erguvan B. Blood 1994. et al. Rosado-de-Christenson ML. Helmers RA. New York: Oxford University Press. Mayo Clin Proc 2002. Thoracic carcinoids: Radiologic- pathologic correlation. Tumors of the thymus and related lesions. Jung K-J. Thymolipoma 1. 17: 2280-2289. Müller NL. Teaching Atlas of Chest Imaging. McAdams HP. Malignant thymic epithelial tumors: CT-pathologic correlation. Budavari AI. Müller NL. Kim J. 12. Rossi SE. Stein H. RadioGraphics 2001. ser 3. 2. Colman N. Thymoma 1. Akyar S. Rosado de Christenson ML. Mediastinal mature teratoma: imaging features. Thymic Hyperplasia 1. Galobardes J. New York: Thieme 2006. Herndon JE. Rosado-de-Christenson ML. Burkel WE. Essentials of Human Anatomy. Radiology 1994. Shimosato Y. 3. Tuberculous fibrosing mediastinitis: CT and MRI findings. Mediastinal teratoma: CT differentiation of ruptured and unruptured tumors. Kim TS. Pugatch RD. heart and great vessels. Hara M. Thymic hyperplasia presenting as anterior mediastinal mass in 2 patients with Graves disease. et al. Galvin JR. Second edition. Philadelphia: Saunders. 1994: 370-371.7. et al. 2. Lim T-H. Moran CA. McAdams HP. Wright CD. J Thorac Imag 2001. Tumors of the mediastinum excluding the thymus. In: Rosai J. Vredenburgh JJ. Rosado-de-Christenson ML. Fraser RS. 3. In: Fraser RS. RadioGraphics 2002. Fibrosing mediastinitis. RadioGraphics 1992. International Histological Classification of Tumours. 16: 191-193. Müller NL. Strollo DC. Paré PD. 77: 495-499. Loehrer PJ. Rosado-de-Christenson ML. Abbott GF. 2. 25: 388-393. Lymphoma 1. In: Shimosato Y. 249-273. Moeller KH. 9. 2. Primary mediastinal malignant germ cell neoplasms: imaging features. Tumors of the thymus. AJR 1997. eds. 12: 151-168. Ellis SJ. Harris NL. 84: 1361-1392. Washington. 11. ser 3. AJR 1998. 1997: 33-247. 169: 985-990. Song KS. J Comput Assist Tomogr 2001. Paré PD. Rosai J. 8. Atasoy C. Non-Neoplastic Lymphadenopathy 1. Lymphoproliferative disorders and leukemia. Thymolipoma: analysis of 27 cases. Mediastinal Masses 166 Chest Radiology . 10. 19: 707-736. Abbott GF. Fitoz S. Mukai K. 1269-1330. 621-702. ed. Fraser and Paré’s Diagnosis of Diseases of the Chest. Franks TJ. J Thorac Imag 1999. Sobin LH. Whitaker MD. 2. Kim EA. Rosado-de-Christenson ML. Rosado de Christenson ML. 173: 1341-1344. Sr. J Clin Oncol 1999. Choi S-J. eds. Tomiyama N. Invasive and noninvasive thymoma: distinctive CT features. Fourth edition. 1999. In: Parker MS. Kirejczyk WM. Travis WD. Galvin JR. Rosado-de-Christenson ML. Washington. fasc 21. Strollo DC. AJR 1999. 171: 591-594. Rosado de Christenson ML. Lee JS. Chest Surg Clin N Am 2003. 1997. Shimosato Y. 193: 121-126. Gangi A. 2. 13. A revised European-American classification of lymphoid neoplasms: a proposal from the international lymphoma study group. Thomas CR. AJR 2001: 176: 433-439. Histological Typing of Tumours of the Thymus. Germ Cell Neoplasms 1. RadioGraphics 1999. Imaging of cystic masses of the mediastinum. Templeton PA. DC: American Registry of Pathology and Armed Forces Institute of Pathology. Ninth edition. Jaffe ES. 22: S79- S93. Thymic hyperplasia after high-dose chemotherapy and autologous stem cell transplantation: incidence and significance in patients with breast cancer. Patz EF Jr. McAdams HP. 21:737-757. Mukai K. Fishback NF. Galobardes J. Han J. New York: Springer 1999. fasc 21. Gasser B. Thymoma: Radiologic-Pathologic Correlation. DC: Armed Forces Institute of Pathology. 3. 209: 221-228. Woodburne RT. Abnormalities and Diseases of the Mediastinum. Templeton PA. Castleman disease of the thorax: radiologic features with clinical and histopathologic correlation. Rosado-de-Christenson ML. 14: 152-171. Thymic Malignancy 1. Atlas of Tumor Pathology: Tumors of the Mediastinum. Mukai K. Moran CA. Jeung M-Y.

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MD. Rosado de Christenson.Chest Seminar: Where is the Lesion? Melissa L. relatively asymptomatic woman • Mass with well-defined lobular borders • Lower lobe location • Abutting bronchus Chest Seminar: Where is the Lesion 168 Chest Radiology . FACR Learning Objectives • To review the radiologic features of thoracic radiologic abnormalities based on location • To enumerate the radiologic characteristics that allow lesion localization and the formulation of a focused radiologic differential diagnosis Case 1: 38-year-old woman with cough • Location • Differential diagnosis • Next best study • Diagnosis: Solitary Lung Mass • Lung cancer ➢ Size / frequency ➢ Stage ? • Carcinoid tumor ➢ Borders / bronchus • Solitary metastasis ➢ Lower lobe location / shape • Hamartoma / Infection ➢ Borders Solitary Lung Mass • Young.

calcium. relatively asymptomatic • Well-defined. mural nodule … but fat Chest Radiology 169 Chest Seminar: Where is the Lesion . unilateral mass with peripheral calcification and lobular borders • No lymphadenopathy • Central water attenuation • Low attenuation mural nodule Anterior Mediastinal Mass • Mature teratoma ➢ Fluid / fat / Ca++ • Thymic cyst ➢ Fluid / Ca++ • Lymphoma ➢ Age group … but no lymphadenopathy • Thymoma ➢ Fluid.Case 2: 16-year-old girl with cough • Location • Differential diagnosis • Next best study • Diagnosis: Anterior Mediastinal Mass • Young girl.

fungus • Primary chest wall tumor / Metastasis • Other Chest Seminar: Where is the Lesion 170 Chest Radiology . tuberculosis.Case 3: 58-year-old man with chest pain and hemoptysis • Location • Differential diagnosis • Next best study • Diagnosis: Lung Mass with Cavitation and Chest Wall Involvement • Symptomatic older male • Chest wall invasion (rib destruction) • Upper lobe location • Cavitation Chest Wall Mass / Cavitation • Bronchogenic carcinoma ➢ Chest wall invasion ➢ Stage? • Infection ➢ Actinomycosis.

Abdominal abnormalities? Multifocal Pleural Nodules • Splenosis ➢ Where is the spleen? • Metastases • Malignant pleural mesothelioma • Other Splenosis • Auto-transplantation of splenic tissue typically following splenic rupture • Most common manifestation: Multiple peritoneal nodules • Thoracic splenosis: ➢ Multiple pleural-based nodules ➢ May be missed on radiography ➢ 99mTC-tagged heated RBC scintigraphy ➢ Liver-spleen scan Chest Radiology 171 Chest Seminar: Where is the Lesion . pre-operative radiograph • Location • Differential diagnosis • Next best study • Diagnosis: Multifocal Pleural Nodules • Asymptomatic patient • No known malignancy • Well-defined peripheral pleural-based nodules • Associated findings .Case 4: Asymptomatic 40-year-old male.

Case 5: 34-year-old man with left chest pain for many years • Location • Differential diagnosis • Next best study • Diagnosis: Multifocal Chest Wall and Mediastinal Masses • Chronic lesions with minimal symptoms • Unilateral or bilateral? • Benign pressure erosion • Pulmonary involvement • Other chest wall / mediastinal involvement Multifocal Chest Wall and Mediastinal Masses • Neurofibromatosis ➢ Malignant potential • Vascular lesions • Metastases • Other Chest Seminar: Where is the Lesion 172 Chest Radiology .

MD. Rosado de Christenson.Chest Seminar: Differential Diagnosis of Mediastinal Masses Melissa L. Rim CA++ • Neoplasia ➢ Carcinoma ➢ Lymphoma • Congenital Cyst … but heterogeneous • Vascular lesion ➢ Aneurysm – rim CA++ • Other Chest Radiology 173 Chest Seminar: Differential Diagnosis of Mediastinal Masses . location and morphology in the formulation of a focused differential diagnosis Case 1: Elderly man with chest pain • Location • Characterization • Next study • Biopsy • Differential diagnosis Heterogeneous Middle Mediastinal Mass. FACR Learning Objectives • To review concepts of differential diagnosis of mediastinal masses • To emphasize importance of demographics.

Case 2: Asymptomatic 52-year-old man • Differential diagnosis • Next best study Spherical Paravertebral Mass with Pressure Erosion • Neurogenic Neoplasm ➢ Next study? • Lateral Thoracic Meningocele ➢ History? • Other Chest Seminar: Differential Diagnosis of Mediastinal Masses 174 Chest Radiology .

Mural CA++ • Cystic Thymoma ➢ Mural nodule • Cystic Teratoma ➢ No fat no calcium • Thymic Cyst / Pericardial Cyst ➢ but mural nodule • Cystic Lymphoma ➢ but no lymphadenopathy Unilateral Cystic Anterior Mediastinal Mass.Case 3: 40-year-old woman with difficulty swallowing • Differential diagnosis • Next best study Unilateral Cystic Anterior Mediastinal Mass. Mural CA++ and mural nodule • Symptomatic woman ➢ Symptoms related to function of voluntary musculature • Age over 40 • Pattern of enhancement ➢ Mural nodule Chest Radiology 175 Chest Seminar: Differential Diagnosis of Mediastinal Masses .

No fluid • Morgagni Hernia ➢ Continuity with abdominal fat Chest Seminar: Differential Diagnosis of Mediastinal Masses 176 Chest Radiology .Case 4: 24-year-old man with chronic abdominal discomfort • Differential diagnosis • Diagnosis • Should the lesion be excised? Right Cardiophrenic Angle Mass of Fat and Soft Tissue Attenuation • Thymolipoma ➢ Fat / soft tissue ➢ Does not conform to adjacent structures / thymus? • Lipoma ➢ Fat / soft tissue • Mature Teratoma ➢ But...

Ca++) • Lymphoma: ➢ Age. local invasion. local invasion and soft tissue predominant • Malignant GCN ➢ But…wrong gender Chest Radiology 177 Chest Seminar: Differential Diagnosis of Mediastinal Masses . Ca++. lymphadenopathy ➢ Cystic change.local invasion ➢ But…lymphadenopathy • Teratoma ➢ But…lymphadenopathy. Ca++ ? • Thymoma ➢ Cystic change.Case 5: 29-year-old woman with fatigue and cough • Differential diagnosis • Diagnosis • Should the lesion be excised? ➢ Biopsied? Anterior Mediastinal Mass (Cystic change.

pneumoniae Gram –’s. Shah.pneumoniae Legionella also seen with Actinomycosis Legionella Nocardia Mycoplasma Mycoplasma H.influenzae Typical. pneumoniae LOBAR ➢ Mycoplasma LOBULAR ➢ Influenzae INTERSTITIAL • Nosocomial Pneumonia • Unusual Pulmonary Infections Pulmonary Infection: Classification: Morphology • 3 radiographic and pathologic patterns ➢ Lobar ➢ Lobular (bronchopneumonia) ➢ Interstitial Pulmonary Infection: Classification • Lobar and lobular pneumonias both produce air space filling • Significant differences include: ➢ Site of initial inflammation ➢ Degree of lobular opacification ➢ Radiographic pattern ➢ Etiologic agents Alveolar Filling Pneumonias • Site of initial infection varies ➢ Alveolar level in lobar pneumonia ➢ Bronchiolar level in bronchopneumonia Alveolar Filling Pneumonias • Degree of opacification of secondary lobule is different ➢ Complete in lobar pneumonia ➢ Incomplete in bronchopneumonia Alveolar Filling Pneumonias • Radiographic pattern will vary ➢ Lobar pattern ➢ Bronchopneumonia pattern Alveolar Filling Pneumonias • Etiologic agent may vary Lobar Pneumonia Bronchopneumonia S. MD Classification of Pulmonary Infection • Community-acquired Pneumonia ➢ S.Pneumonia: Usual and Unusual Organisms Rosita M. atypical TB Parasites Pneumonia 178 Chest Radiology . anaerobes K.

pneumophila ➢ Respiratory viruses S. influenzae ➢ L. pneumoniae: Demographics • 25% incidence of bacteremia • 25-40% mortality. pneumoniae most frequent isolate in CAP ➢ 8-76% incidence • Recognized risk factors ➢ alcoholism. congenital and acquired immune deficiencies S.DM ➢ Alcoholism ➢ Thrombocytopenia ➢ Renal dysfunction ➢ Number of lobes Chest 1993. unchanged >30y ➢ Age >65 ➢ CHF. no definitive organism isolated • Most common isolates: ➢ S. viral pneumonia. pneumoniae: Pathology • Aspiration to peripheral air spaces • Alveolus represents site of initial inflammatory lesion • Spread occurs by contignous involvement of adjacent alveoli • 3 pathologic stages S. pneumoniae: Demographics • S.Alveolar Filling Pneumonias • Accurate pattern recognition depends on: ➢ Early imaging ➢ Normal lung structure • Organisms may produce more than one pattern • Basic pattern differentiation may be difficult ➢ Interstitial vs bronchopneumonia Community-acquired Pneumonia: Epidemiology • 2–10 /1000 annual incidence • 22-50% hospitalization rate ➢ Outpatient mortality 1-5% ➢ Inpatient mortality 25% Community-acquired Pneumonia: Etiology • In up to 50%. pneumoniae ➢ M. pneumoniae ➢ H. pneumoniae: Pathology • ACUTE RESPONSE ➢ Increased capillary permeability ➢ Protein rich edema ➢ Contiguous alveolar filling via Pores of Kohn and Canals of Lambert • RED HEPATIZATION ➢ PMN infiltration and intra-alveolar hemorrhage • GRAY HEPATIZATION ➢ Macrophage infiltration and uptake of blood products Chest Radiology 179 Pneumonia . 103:1152-56 S. splenic dysfunction. pneumoniae ➢ K.

pneumoniae S.filamentous rod ➢ Absent cell wall • Acute cellular bronchiolitis ➢ Superficial inflammation involving luminal surface of bronchi. pneumoniae: Radiology • Small pleural effusions up to 60% • Infrequent cavitation ➢ Associated with serotype 3 • Most frequent organism in pulmonary gangrene ➢ Vascular thrombosis from severe necrosis ➢ Intracavitary mass (sloughed lung) M. pneumoniae: Radiology • Spread at alveolar level results in nonsegmental distributions characteristic of Figure 1-19-1 early lobar pneumonia • Round pneumonia ➢ Manifestation of nonsegmental distribution ➢ Most common in pediatric infection with S. pneumoniae: Radiology [Figure 1-19-1] • LOBAR pattern ➢ Homogeneous. pneumoniae: Radiology • LOBAR pattern ➢ Prominent air bronchograms ➢ Preserved volume S. pneumoniae: Demographics • 15-35% of CAP ➢ 50% of CAP during summer months • Peak age 5-25 yo • Self limited ➢ Few fatal cases associated with ARDS ➢ Increased severity in sickle cell anemia • Most frequent etiology in Atypical Pneumonia Syndrome ➢ Atypical radiographic features ➢ Prominent extrapulmonary complaints M. multifocal lobar patterns • 16% lobular pattern • Dominant pattern did not vary with immune status or disease severity Lobar pattern consolidation due to S.S. AJR 2000. pneumoniae: Pathology • Eaton agent-1944 ➢ Gram -. confluent density ➢ Nonsegmental distributions S. bronchioles ➢ Associated interstitial infiltrates Pneumonia 180 Chest Radiology .175:1533 pneumoniae S. pneumoniae: Radiology • 48% of consecutive hospitalized pts demonstrated focal lobar patterns • 33%.

C • Para-influenzae • Respiratory syncytial virus • Adenovirus Figure 1-19-3 • Herpes viruses • SARS Influenzae A: Demographics • 10-20% CAP • 10.hemorrhage HRCT of M.B.000 deaths/ influenzae epidemic • Peak incidence ➢ Pediatric population • Highest mortality-adult and aged ➢ Superinfection ➢ S. pneumoniae: Radiology • CT Findings [Figure 1-19-3] ➢ 86% centrilobular nodules ➢ 82% bronchovascular thickening ➢ 59% consolidation with lobular distribution Reittner. parahilar. lower lobe • Air trapping • Prominent GGO (left) CXR (right) HRCT Influenzae pneumonia mimicking edema Chest Radiology 181 Pneumonia . AJR 2000.M. 174:37 Bronchopneumonia pattern due to Respiratory Viruses M.aureus ➢ S. pneumoniae • Influenzae A. pneumoniae • Ulceration. bacterial infection Influenzae A: Radiology • INTERSTITIAL pattern ➢ Reticular Figure 1-19-4 ➢ Nodular ➢ Peribronchial thickening ➢ Subpleural edema ➢ Hilar haze Influenzae A: Radiology [Figure 1-19-4] • Bilateral. pneumoniae: Radiology [Figure 1-19-2] Figure 1-19-2 • LOBULAR pattern Bronchopneumonia • Heterogeneous.000-40. proliferation and necrosis • St 2 bronchial and alveolar wall edema. patchy consolidation ➢ Minimal exudate into centrilobular alveoli • Segmental distribution ➢ Spread at bronchiolar level • Volume loss • Minimal air bronchograms ➢ Peribronchial thickening M.pneumoniae Influenzae A: Pathology • St 1 infection of epithelial cells.

lung transplantation. airway pediatric viral pneumonia management. latency. pregnancy Varicella Pneumonia • Complication of adult chickenpox Figure 1-19-6 ➢ 5-50% incidence • Prominent acinar opacities ➢ 5-10mm nodules. coalescence ➢ Patchy GGO Kim AJR 1999.230:836. reactivation ➢ Up to 40% mortality • Risk factors Swyer James Syndrome due to ➢ Immune-suppression. rapid spread from Asia • 20-50% require mechanical ventilation • 10% mortality.172:113 • May heal with miliary calcifications Varicella Pneumonia [Figure 1-19-6] • Prominent acinar opacities Severe Acute Respiratory Syndrome • SARS-CoV (corona virus) • Initial cases Nov 2002-June 2003. EBV. Radiology 2004. Macleod’s syndrome ➢ Bronchiolitis obliterans following viral infection in early childhood Respiratory Herpesviruses • HSV-1. AJR 2003. HSV-2. VZV. CMV ➢ Primary infection. cavitation uncommon without bacterial superinfection • Rapid deterioration should suggest superinfection Adenovirus [Figure 1-19-5] • Interstitial pneumonia with prominent necrotizing bronchiolitis Figure 1-19-5 • Potential infection in immune competent and suppressed hosts with high mortality ➢ Pediatric population ➢ Military epidemics ➢ Transplant recipients • Swyer James. multifocal (28%). diffuse (14%) • Ground glass opacity • Reticulation • Bronchiolar dilation • Residual changes in 50% at 4wks Ooi GC. Paul NS.182:493 Severe Community-acquired Pneumonia: Definition • Impending respiratory failure • Hemodynamic instability • Radiographic assessment ➢ Bilateral or multilobar involvemnt ➢ 50% increase in size of opacity within 48hr Pneumonia 182 Chest Radiology . age dependant • Severe DAD Severe Acute Respiratory Syndrome • Predominant consolidation 1-2weeks Acinar nodules in varicella pneumonia ➢ Focal (39%).Influenzae A: Radiology • Pleural effusions.

50% mortality • Males. diarrhea. pneumoniae: Radiology • Lobar pattern ➢ Bulging fissures • Abscess 30-50% • Necrotizing pneumonia at CT ➢ Low density areas with small cavities Moon JCAT 1995. pneumophila: Pathology • Bronchocentric inflammation L. COPD.bacillus ➢ Abundant PMN infiltration of alveoli.Severe Community-acquired Pneumonia: Etiology • S. DM K. aureus • P. pneumophila: Demographics • 15% of CAP ➢ Epidemic and sporadic forms ➢ Legionnaire’s disease= pneumonic form ➢ Peak summer • Aerobic Gram -.Friedlander’s pneumonia ➢ Massive necrosis HRCT in Legionella pneumonia ➢ Common association with gangrene demonstrating bronchocentric nodules and pleural effusion K. pneumophila: Demographics • Acute onset • Prominent extrapulmonary symptoms ➢ Neurologic manifestations. pneumoniae: Pathology • Gram -. aeruginosa in patients with bronchiectasis L.19:176 Chest Radiology 183 Pneumonia . edema ➢ Lobar expansion . pneumoniae: Demographics • Nosocomial or community acquired • 5-10% lobar pneumonias • 25% bacteremic. renal insufficiency • 10% mechanical ventilation • 15% mortality in cases requiring hospitalization L. pneumophila • S.bacillus • Proliferates in warm. pneumophila: Radiology [Figure 1-19-7] • Bronchopneumonia pattern • Pleural effusions in 2/3 • Bilateral and multifocal in 50% • May produce lobar or mass-like consolidation • Cavitation uncommon without immunosupression • Delayed resolution K. pneumoniae • L. humid environments Figure 1-19-7 L. >60yo • Risk factors: alcoholism.

S. IVDA S. aureus Pneumonia 184 Chest Radiology . mechanical ventilation. aureus Figure 1-19-9 Necrotizing bronchopneumonia due to S. aureus: Radiology • Aerogenous infection [Figures 1-19-8 and 1-19-9] ➢ Multifocal Broncho-pneumonia • Hematogenous infection [Figure 1-19-10] ➢ Multifocal.aureus: Demographics Figure 1-19-8 • 30-50% colonization rates in healthy adults ➢ DM ➢ IVDA ➢ HIV ➢ Surgical pts • Methicillin resistance 1944 ➢ Increasing incidence of resistant community-acq infection • Antecedant viral pneumonia • Frequent cause of nosocomial infection • Extremes of age ➢ Nursing home population • Risk factors ➢ Debilitated states. discrete nodular or wedge shaped abnormality with normal intervening lung • Cavitation / abscess (25-75%) • Pneumatoceles (60% ped infection) • Pleural effusions / empyema (50%) CXR and HRCT bronchopneumonia pattern due to S. burns. indwelling catheters.

P.aeruginosa ➢ Mucoid variant ➢ ABX resistance ➢ Elastase production ➢ Bronchiectasis The Practical Points • S. adeno and other respiratory viruses Septic emboli Nosocomial Pneumonia • Rising incidence parallels usage of antibiotics • Gram negative infections ➢ 40-50% increase 1950-60 ➢ 55-65% nosocomial infections ➢ 50% nosocomial pneumonia ➢ 75% ICU pneumonia Nosocomial Pneumonia: Definition • Pneumonia developing >48hr sp admission. consciousness.pneumophilus most commonly associated with broncho-pneumonia pattern and atypical pneumonia syndrome • Viral pneumonias associated with interstitial pattern • Pathologic in immune-competent and suppressed hosts • Prominent bronchiolitis seen with mycoplasma.pneumoniae and K. GI motility ➢ NG / ET Pathophysiology • Abnormal gram negative airway colonization ➢ 25% 24hr ➢ 40% 7d • Gastric alkalinization • Serious illness • Antibiotic TX Johanson Ann Intern Med 1972 Pathophysiology • Repetitive aspiration leads to • Bronchiolitis • Lobular (broncho) pneumonia ➢ Peribronchiolar neutrophilic infiltrate (104 cfu/g) Chest Radiology 185 Pneumonia .pneumoniae. intubation or discharge Diagnosis • Quantitative cultures ➢ Tracheal aspirate 10 5-6 cfu/ml ➢ BAL 10 4 cfu/ml ➢ Protected specimen brush 10 3 cfu/ml ➢ False negative and false positive rates 20-30% Baughman Chest 2000 Pathophysiology • Direct inhalation • Hematogenous spread • Aspiration ➢ 45% incidence in sleep ➢ Altered gag reflex. aeruginosa in Cystic Fibrosis Figure 1-19-10 • Chronic colonization with P. L.pneumoniae most commonly associated with lobar pattern and pulmonary gangrene • M.

aureus • Late >5d ➢ S. >0. MRSA ➢ Population ✧ Highest mortality: medical ICU ✧ 10-20% mortality: trauma ICU ➢ Late onset ✧ MDR Nosocomial Pneumonia and Aspiration [Figure 1-19-11] • Pneumonitis (Mendelson Syndrome) ➢ pH < 2. aureus ➢ P. aeruginosa ➢ Enterobacteriaceae ➢ Acinetobacter spp. ➢ Stenotrophomonas maltophilia Pneumonia 186 Chest Radiology . pneumoniae ➢ S.5.3 ml/kg ➢ Biphasic inflammatory response ✧ 1-2 hr permeability edema ✧ 4-6 hr acute inflammation ➢ 30% mortality ➢ Rapid clearing Nosocomial Pneumonia and Aspiration • Sterile vs • Normal flora (<5d) vs Dependent aspiration pneumonia • Gram – bacilli(>5d) complicated by ARDS • Anaerobes seen in late aspiration • Aspiration accounts for upto 15% of CAP Marik NEJM 2001 Microbiology • Normal flora • Gram – bacilli • S.Nosocomial Pneumonia in the ICU • Ventilator-associated Pneumonia (VAP) • Most common nosocomial infection in ICU ➢ 3-21x greater incidence in intubated patients ✧ > 1 intubation. influenzae ➢ S.aeruginosa. aureus • Anaerobes • Legionella • Respiratory viruses Microbiology • Early <5d ➢ H. >3 days ➢ 10-65% ICU patients acquire VAP ➢ 1/3-3/4 ARDS patients acquire VAP • 20-80% mortality rate Figure 1-19-11 Ventilator-associated Pneumonia • Prognosis depends: ➢ Organism ✧ Highest mortality: P.

Clin Infec Dis 1998. aeruginosa: Radiology • Bronchopneumonia pattern ➢ Discrete nodules may be indicative of vasculitis • Frequent cavitation • Pleural effusions/empyema Nosocomial Viral Pneumonia • Rate of infection assoc with length of hospitalization • Hospital worker as carrier • Frequently unsuspected • High mortality rates ➢ RSV 30-100% ➢ Parainfluenzae 15-30% Nodular or Mass-like Consolidations • Nonsegmental distribution ➢ ‘round’ pneumonia • Granulomatous infection ➢ M. hematogenous dissemination • Increased severity in neutropenia. tuberculosis ➢ Fungi ➢ Actinomycosis ➢ Nocardia A. chest wall and osseous involvement ➢ Up to 50% Chest Radiology 187 Pneumonia .P. aeruginosa: Pathology • Micro-abscesses • Necrotic vasculits ➢ Sm-med pulmonary arteries • Hemorrhage P. israelli A. bacteremia P.26:1255 A. Israelii: Radiology [Figure 1-19-12] • Consolidation ➢ Mass-like ➢ Cavitary • Pleural. Israelii. aeruginosa • Most common ICU isolate • 70% TX failure rate • Distal airway colonization. Demographics • Normal oral flora Figure 1-19-12 • Sites of infection: ➢ Cervicofacial 55% ➢ Abdomen 20% ➢ Pulmonary 25% • Risk factors: poor oral hygiene. aspiration Smego RA. Israelii: Pathology • Multifocal abscesses • Interconnecting sinus tracts • Sulphur granule ➢ Spoke-wheel arrangement of neutrophils surrounding Pneumonia with chest wall filamentous organism involvement due to A.

America. Asteroides: Demographics • Ubiquitous distribution • 50% of patients are immunocompetent • Risk factors: ➢ Neutropenia ✧ Steroids. endemic to S. Australia. patchy infiltrates ➢ Reticulonodular opacities ➢ Bronchopneumonia ➢ Atelectasis Echinococcus granulosus • Cestode (tapeworm). Asteroides: Radiology • Consolidation ➢ Mass-like ➢ Cavitary • Pleural and chest wall involvement 30-50% • Adenopathy 40% Cavitary Pneumonia in AIDS • N. Middle East.asymptomatic • Eosinophilia 25-40% Pneumonia 188 Chest Radiology . Africa and Mediterranean • Definitive host . asteroides Parasitic Infection • Pulmonary involvement due to hypersensitivity or direct invasion ➢ Echinococcosis ➢ Paragonimiasis ➢ Ascariasis Figure 1-19-13 ➢ Strongyloidiasis Parasitic Infection • Radiographic findings may overlap with other infections ➢ Fleeting.portal venous system liver ➢ 45-75% isolated liver involvement ➢ 15-35% pulmonary involvement Intact (right lung) and ruptured (left lung) echinococcal cysts Echinococcus granulosus [Figure 1-19-13] • Pulmonary cysts acquired in childhood • Diagnosis 30-40yo • Intact cyst .TB or fungal infection N.wolf Intermediate host . granulomatous inflammation • Extensive necrosis ➢ May mimic M.N.sheep. alveolar proteinosis N. deer. Asteroides: Radiology • Extrapulmonary disease 50% with 40-90% mortality ➢ CNS 25% ➢ Skin and subcutaneous abscesses N. hemetologic malignancy. cow. late HIV. asteroides Alveolar Proteinosis and N. Asteroides: Pathology • Peribronchial abscesses.dog. moose Echinococcus granulosus • Duodenum .

trachea – small bowel Strongyloides stercoralis • Round worm • Skin – systemic circulation – alveoli – trachea – small bowel Ascariasis Strongyloides: Radiology • Bronchopneumonia • Patchy. Anthracis: Anthrax • Gram+ spore forming rod ➢ Dormant spores are virulent • Infection typical in livestock • Exotoxin production associated with hemorrhagic mediastinitis. 2001 Chest Radiology 189 Pneumonia .Echinococcus granulosus: Pathology • Hydatid cyst consists of 3 layers ➢ Pericyst – host inflammatory cells ➢ Exocyst – acellular laminated membrane ➢ Endocyst – fluid-filled germinal center. homogeneous mass ➢ Spherical when central.air between pericyst and laminated membrane • Ruptured cyst ➢ Water lily sign – rupture of endocyst Paragonimiasis westermani • Trematode (lung fluke) ➢ endemic to Asia ➢ Contaminated freshwater crab • Jejunum – peritoneal cavity – diaphragm – pleura – lung • Chronic granulomatous reaction Paragonimiasis westermani: Radiology • Pulmonary findings dependant on stage of infection ➢ PTX and pleural infection during pleural penetration by juvenile worms ➢ Transient. ovoid when peripheral ➢ Multiple 20-30% ➢ Lower lobes 60% Echinococcus granulosus: Radiology • Impending Rupture ➢ Crescent sign . transient consolidation • Eosinophilic pneumonia B. daughter cysts Echinococcus granulosus: Radiology • Intact cyst ➢ Well demarcated. patchy consolidation and linear tracts during larval migration • Peribronchial cysts associated with mature worm Ascariasis lumbricoides • Roundworm infection • Most common parasitic infection ➢ Endemic worldwide ➢ 25-95% prevalence ➢ Highest incidence in children • Large iingestion associated with pneumonitis • Small bowel – systemic circulation – alveoli . edema and pleuritis Earls Radiology:222:305.

174:1745 ➢ Thin section CT allows earlier diagnosis of pneumonia in immunosuppressed pts (5 days) Heussel CP.Complications of Pneumonia [Figure 1-19-14] Figure 1-19-14 • Pleural Infection • Empyema ➢ Purulent exudate ➢ WBC>25.205:817 The Practical Points • Organisms may produce more than one pattern • Bacterial.pneumoniae ➢ +/. Radiology 1997. AJR 2000.pneumoniae K.pneumoniae • Bronchiectasis ➢ Irreversible dilation ✧ Should not be diagnosed < 4 m of acute infection ➢ Colonization with atypical TB.aureus Figure 1-19-15 ➢ 60% of peds infection Complications of Pneumonia [Figure 1-19-15] • Pulmonary Gangrene ➢ Lung necrosis due to vascular thrombosis • Most common with S. viral and fungal pneumonia have similar CT findings post lung transplantation Collins AJR 2000. aspergillus CXR and CT pulmonary gangrene due to ➢ Advanced course in HIV K.0 ➢ + organisms S.000 ➢ pH<7.mitis Empyema in 51yo male with IVDA hx Complications of Pneumonia Right empyema and LUL septic • Cavitation embolus due to S.175:811 • Consider clinical setting Pneumonia 190 Chest Radiology . aureus ➢ Cavitary pneumonia ➢ Lung abscess ➢ Pneumatocele ➢ Gangrene ➢ DDX bronchopleural fitula Complications of Pneumonia • Pneumatocele ➢ Ball-valve mechanism ➢ Rapid evolution ➢ No lung destruction • Most common with S.169:1347 • Recognition of complications ➢ Decreased enhancement in pneumonia indicates severe necrosis Donnelly LF. AJR 1997.antecedant infection A.fumigatus complicating post-infectious bronchiectasis The Role of Imaging in Pneumonia • Diagnosis of infection ➢ Presence of centrilobular nodules in acute parenchymal disease favors pneumonia Tomiyama N.

Stroh K. Konen E. Provost Y. 2004 Mar-Apr. Radiology. Fischer B. 14. Gold W. Cerva D Jr. Hong HH. Radiology. AJR Am J Roentgenol. High-resolution CT findings of varicella-zoster pneumonia. Review. Clin Infect Dis. Watanakunakorn C. Pneumococcal bacteremia in three community teaching hospitals from 1980 to 1989. Ryu CW. 15. AJR Am J Roentgenol. Pneumonia in children: decreased parenchymal contrast enhancement--CT sign of intense illness and impending cavitary necrosis. AJR Am J Roentgenol. Cugino A. Weisbrod GL. Kozuka T. Clinically documented pleural effusions in medical ICU patients: how useful is routine thoracentesis? Chest. Azoulay E. Roberts HC. 1997 Nov. Mehta S. Johanson WG Jr. Pierce AK.24(2):553-63. Hamada S. Heussel G. Butany J. Schlemmer B. Fartoukh M. Paul NS.References 1. 2. Bersoff-Matcha S. Boylan CE.77(5):701-6. Mehta S. Mildenberger P. AJ. 13. Chevret S. Collins J.121(1):178-84. Severe acute respiratory syndrome: temporal lung changes at thin-section CT in 30 patients. Clayton R. Grossman H. Zhou LJ. Heussel CP. Gupta S.175(3):811-8. Klosterman LA. Im JG. Johkoh T. Roberts H. Smego RA Jr. Le Gall JR. Hong HH. Jarjoura DG. Sanford JP. 2004 Mar. Prognostic significance of the radiographic pattern of disease in patients with severe acute respiratory syndrome. Ooi GC. Weisbrod GL. 1997 Dec. Earls JP. Ognibene. Nicolaou S. Honda O. Mihara N. Actinomycosis. Khong PL. AJR Am J Roentgenol. Tomlinson GA. Inhalational anthrax after bioterrorism exposure: spectrum of imaging findings in two surviving patients. Foglia G. Lee KS. Shah RM. Mycoplasma pneumoniae pneumonia: radiographic and high-resolution CT features in 28 patients. Heyneman L. Pauze D. Nakamura H. Lam B. 7. Chung T. Rosenthal J.175(6):1533-6. Tsang KW. Ann Intern Med. Lee SI. Ho JC. 12. Yiu WC. AJR Am J Roentgenol. Muller NL.222(2):305-12. Greifenstein A.174(1):37-41.19(2):176-81. 4. Ichikado K. Berman E. 9. 2004 Feb. Zelovitsky L. Muller NL. Paul NS. Tomiyama N. Complications of Klebsiella pneumonia: CT evaluation. 2000 Sep. Radiographics. 2002 Feb. Mayer T. The significance of colonization of the respiratory tract. Thelen M. 2002 Jan. 1999 Jan. Acute parenchymal lung disease in immunocompetent patients: diagnostic accuracy of high-resolution CT. Han MC.230(3):836- 44. Muller NL. Park JS. 11. Reittner P. 8. Chest Radiology 191 Pneumonia . 1995 Mar-Apr. Blend D. Galliot R. 1972 Nov. AJR Am J Roentgenol.172(1):113-6.26(6):1255-61. Akira M.103(4):1152-6. Park CK. J Comput Assist Tomogr. 2000 Dec. Donnelly LF. 10. Wolfe PP. 16. Johkoh T. CT findings of pneumonia after lung transplantation. 3. Moon WK.205(3):817-20. Gold WL. 2000 Jun. Thomas GD. Konen E. Early detection of pneumonia in febrile neutropenic patients: use of thin-section CT. 6. quiz 1262-3. 1993 Apr. Fatteh N. Rao A. Paciocco G. Honda O. AJR Am J Roentgenol. Urban B. Sung DW. Radiology. 1998 Jun. Radiologic pattern of disease in patients with severe acute respiratory syndrome: the Toronto experience. Chung T. Angeid-Backman E.174(6):1745-50. Kim JS. Baud F. Pneumococcal pneumonia in patients requiring hospitalization: effects of bacteremia and HIV seropositivity on radiographic appearance. 5. Nosocomial respiratory infections with gram-negative bacilli. O'Donnell J. Murphy C.169(5):1347-53.Chest. Tomiyama N. Kauczor HU. Muller NL. Rao TN. 2000 Jan. Review. Kazerooni EA.182(2):493-8. Yeon KM.

hemoptysis.most common “Uncommon” • Adenoid Cystic Carcinoma ----> Salivary Gland Tumors • Mucoepidermoid Carcinoma----> Salivary Gland Tumors • Carcinosarcoma ----> Mixed Tumors • Pulmonary Blastoma ----> Mixed Tumors “Bronchial Adenoma”: History Lesson • Term formerly referred to: ➢ Bronchial Carcinoid ➢ Adenoid Cystic Carcinoma ➢ Mucoepidermoid Carcinoma • A misnomer • These tumors are not benign Carcinoids • Gastrointestinal tract 90% • Lung • Thymus • Biliary tract • Ovarian teratomas Bronchial Carcinoid • Typical carcinoid ➢ Low-grade malignancy • Atypical carcinoid ➢ Moderate-grade malignancy Typical Carcinoid • 0. stippled nuclear chromatin • Rare mitoses • Ultrastructure: Neurosecretory granules Neuroendocrine Cells and Tumors: Electron microscopy • Cytoplasmic neurosecretory granules • Central or eccentric dense core • Thin lucent halo • May contain biologically active peptides Uncommon Malignant Tumors 192 Chest Radiology .6-2. Median age: 50 years • Symptoms: cough. dyspnea Typical Carcinoid: Microscopy • Uniform cells • Forming nests.Uncommon Malignant Tumors of the Lung Gerald F. Abbott.4% of all pulmonary neoplasms • Low grade malignancy • Good prognosis ➢ 95% five-year survival • Not associated with smoking Typical Carcinoid: Demographics • Males = Females • Wide age range. MD Uncommon Malignant Tumors of the Lung: • Bronchial Carcinoid . ribbons. trabeculae • Stroma highly vascular • May exhibit calcification or osseous metaplasia • Polygonal cells. rosettes. pale cytoplasm.

Neuroendocrine Markers: Immunohistochemistry • Chromogranin • Synaptophysin • Neural cell adhesion molecules (NCAM) Carcinoid: Relationship to Small Cell Carcinoma • Similarities: ➢ Neurosecretory granules ➢ Rosette and trabecula formation • Differences: ➢ Fewer granules in Small Cell Carcinoma ➢ Carcinoid not associated with smoking Tumors with NE Morphology • A spectrum by light micropscopy • Low-grade Typical Carcinoid • Intermediate Atypical Carcinoid • High-grade Small cell lung carcinoma Large cell neuroendocrine carcinoma Neuroendocrine Tumors: World Health Organization criteria (1999) [Figures1-20-1] • Typical carcinoid: <2 mitoses per 10 HPF • Atypical carcinoid: 2-10 mitoses per 10 HPF • Large cell neuroendocrine ca: 11 or more mitoses per 10 HPF (median 70) • Small cell ca: 11 or more mitoses per 10 HPF (median 80) Figure 1-20-1 NE Tumors: Metastases Atypical Carcinoid: Histopathologic criteria • Poor architectural organization • Cellular pleomorphism • Focal necrosis • Increased mitotic activity Arrigoni J Thorac Cardiovasc Surg 1972 Atypical Carcinoid • Morphology between Typical Carcinoid and Small Cell Ca • Tend to be larger. more invasive. peripheral • Age: Decade older than Typical • Symptoms: similar to Typical • Imaging: similar to Typical Chest Radiology 193 Uncommon Malignant Tumors .

early metastases • Osteoblastic bone metastases • Pathology DDx: Small Cell Carcinoma Bronchial Carcinoid: Gross Pathology [Figure 1-20-2] • Usually seen at bronchoscopy • Soft. fleshy. May be pedunculated • Often extend through wall Figure 1-20-2 Growth patterns of bronchial carcinoid tumors. endobronchial mass • Sessile.Atypical Carcinoid • 10% of bronchial carcinoid • Peripheral • Increased mitoses • Aggressive behavior. Partially endobronchial tumors (“iceberg” configuration) most common Bronchial Carcinoid: Central • Bronchiectasis • Mucoid impaction • Obstructive pneumonia Bronchial Carcinoid: Peripheral • Usually asymptomatic • Late presentation • Discovered incidentally Uncommon Malignant Tumors 194 Chest Radiology .

segmental.Bronchial Carcinoid: Radiologic Findings Figure 1-20-3 [Figures 1-20-3 and 1-20-4] • Central tumors in 80% • Lobar. mucoid impaction • Lymphadenopathy Figure 1-20-6 Bronchial carcinoid. Partially endobronchial (‘iceberg”) tumor in left upper lobe Figure 1-20-7 Bronchial carcinoid obstructing left upper lobe bronchus with distal atelectasis. pneumonitis and associated left hilar lymphadenopathy Bronchial carcinoid in a 34-year-old male. bronchiectasis. Contrast enhanced CT (right) shows diffuse contrast enhancement Chest Radiology 195 Uncommon Malignant Tumors . peripheral consolidation. well-defined left perihilar mass Bronchial Carcinoid: CT Features [Figures 1-20-5 to 1-20-7] Figure 1-20-5 • Bronchial relationship in 83% • Partially endobronchial • Completely endobronchial • Abutting a bronchus • Sharply marginated. atelectasis • Pleural effusion Figure 1-20-4 Bronchial carcinoid manifesting as a Small endobronchial carcinoid tumor in distal left mainstem bronchus central. lobulated mass • May enhance or demonstrate Ca++ • Atelectasis. Unenhanced CT (left) demonstrates central tumor and distal. subsegmental bronchi • Consolidation. consolidation.

dyspnea. annular growth • Proximal & distal spread • Extension into mediastinum Adenoid Cystic Carcinoma: Radiology [Figure 1-20-9] Adenoidcystic carcinoma. atelectasis • Low-grade: excellent prognosis • High-grade: better prognosis than Bronchogenic Ca Uncommon Malignant Tumors 196 Chest Radiology . infiltrates bronchi • Few mitoses Adenoid Cystic Carcinoma: Pathologists’ Pitfalls • Misdiagnosis ➢ Adenocaracinoma ➢ Pleomorphic adenoma ➢ Small cell carcinoma • Metastatic salivary gland tumor • Solid pattern on small biopsy Adenoid Cystic Carcinoma: Gross • Endobronchial mass ➢ Trachea and main bronchi • Sessile.15% in lung periphery • CT / MRI: length of involvement. wheezing. pneumonia. hemoptysis.50 • Symptomatic patients: cough.Bronchial Gland Tumors Figure 1-20-8 • Adenoid Cystic Carcinoma • Mucoepidermoid Carcinoma • Equivalent to salivary gland tumors of same name Adenoid Cystic Carcinoma [Figure 1-20-8] • Synonym . polypoid. Wide age range • Cough. fever.Cylindroma • 80% of bronchial gland tumors • 20 to 35% of all tracheal tumors • Second most common tracheal malignancy (after Squamous cell carcinoma) Adenoid Cystic Carcinoma • Guarded prognosis • Common local recurrence Adenoidcystic carcinoma partially occluding the trachea • Occasional metastases to regional nodes and extending into the adjacent soft tissues of the • Rarely extrathoracic spread mediastinum Adenoid Cystic Carcinoma: Demographics • Males = Females • Wide age range . hemoptysis Adenoid Cystic Carcinoma: Microscopy Figure 1-20-9 • Mucin-containing cysts • Varying in caliber • Within larger tumor tubules • Surrounds.Average age: 40 . mediastinal involvement Mucoepidermoid Carcinoma: Demographics and Prognosis • Male=Female. invades nerves • Encases vessels. Coronal (left) and saggital • Central: trachea and main bronchi (right) surface-rendered CT images of the trachea • Intraluminal nodule or mass demonstrate both nodular and circumferential deformity • Constriction of tracheal/bronchial lumen of the air-column in the lower trachea • 10 .

pneumonia • Central lesions • Atelectasis. exophytic. polypoid • High grade may have ragged invasive appearance Mucoepidermoid Carcinoma: Mucoepidermoid carcinoma arising in the right Radiologic Findings [Figures 1-20-11 and 1-20-12] mainstem bronchus at the origin of the right upper lobe • Solitary nodule or mass bronchus • Most in main or lobar bronchi • Few in trachea Figure 1-20-11 • Distal effects: ➢ Atelectasis. and rapid death Carcinosarcoma: Microscopy Mucoepidermoid carcinoma manifesting as a • Epithelial component: solitary pulmonary nodule on chest ➢ Squamous Cell Carcinoma radiography ➢ Adenocarcinoma ➢ Undifferentiated Carcinoma • Mesenchymal component: ➢ Usually dominant Figure 1-20-12 ➢ Spindle cell (common) ➢ Chondrosarcoma ➢ Osteosarcoma ➢ Rhabdomyosarcoma Carcinosarcoma: Gross • Peripheral ➢ Large mass ➢ Average diameter 6 cms.Mucoepidermoid Carcinoma [Figure 1-20-10] Figure 1-20-10 Mucoepidermoid Carcinoma: Microscopy • Low grade: ➢ Mucinous cysts ➢ Solid collections of squamous cells • High grade: ➢ Solid sheets of tumor ➢ Mitoses and necrosis Mucoepidermoid Carcinoma: Gross • Submucosal.0. pneumonia Mixed Tumors: Neoplasms with malignant epithelial and mesenchymal components • Carcinosarcoma • Pulmonary Blastoma Carcinosarcoma • Rare . ➢ Frequent necrosis and hemorrhage • Central ➢ Endobronchial growth ➢ May extend to adjacent parenchyma ➢ Tumor-distended bronchi may resemble mucus plugs Central mucoepidermoid carcinoma manifesting as mild prominence of the suprerior aspect of the right hilum with associated atelectasis of the right upper lobe Chest Radiology 197 Uncommon Malignant Tumors .3% of all lung neoplasms • Middle aged and elderly males • Poor prognosis • Aggressive: local invasion. widespread metastases. smooth surfaced • Endobronchial.

Carcinosarcoma: Imaging [Figure 1-20-13] Figure 1-20-13 • Peripheral ➢ Large ➢ Well-circumscribed mass • Central ➢ Atelectasis. pneumonia ➢ Tumor “mucus plugs” ➢ Upper lobe predominance ➢ Direct extension to pleura. epithelial. dyspnea. chest wall. hemoptysis. chest pain • Poor survival Figure 1-20-14 Pulmonary Blastoma: Microscopy • Mixture: ➢ Epithelial-lined tubules ➢ Primitive stroma • Resembles embryonal lung • Metastases: mesenchymal. or mixed Pulmonary Blastoma: Gross • Large mass • Unencapsulated and soft • Abundant central necrosis and hemorrhage Pulmonary blastoma manifesting as a large. heterogeneous mass in the left Pulmonary Blastoma: Radiology [Figure 1-20-14] lower lobe • Large peripheral mass • Well-circumscribed • May show pleural invasion • May metastasize Endobronchial Tumors: Malignant • Squamous cell ca • Adenocarcinoma • Small cell ca (rare) • Carcinoid • Adenoid cystic ca • Mucoepidermoid ca • Carcinosarcoma • Pulmonary blastoma • Sarcoma (10%) • Endobronchial metastasis • Lymphoid malignancies (NHL>HD) Uncommon Malignant Tumors 198 Chest Radiology . and mediastinum Pulmonary Blastoma • Primary lung tumor • Mix of epithelial and mesenchymal components • Both components blastomatous and immature • Morphologic mimic of embryonal lung • ? a variant of carcinosarcoma Pulmonary Blastoma: Demographics and Carcinosarcoma. Contrast enhanced CT demonstrates Prognosis a peripheral mass with irregular and lobulated borders in • Predominantly males the right upper lobe • Biphasic age distribution: first and seventh decades • Symptoms: cough.

MD Benign Tumors and Tumor-like lesions • Hamartoma • Papilloma / Papillomatosis • Inflammatory pseudotumor • Granuloma “Hamartoma” • Albrecht.Benign Tumors of the Lung and Tumor-like Lesions Gerald F. expectoration. “Local” hamartoma Hamartoma • Acquired lesion • Disorganized growth of tissues normally found in lung • Benign neoplastic proliferation • Probably derived from bronchial wall mesenchymal cell (“benign mesenchymoma”) Hamartoma • Most common benign tumor of lung • 77% of benign lung tumors • 8% of SPNs • 3% of all lung tumors Hamartoma: Evidence of Acquired Lesion • Onset in adult life • Often adults with previously normal CXR • Almost never seen in infants • Histology: passive entrapement of epithelium • Cytogenetics: Chromosome 12: abnormal q13-q15 regions (as in other benign soft-tissue neoplasms) Hamartoma: Demographics • Age range: 30-70 years • Peak incidence: 6th decade • Female: Male = 3:2 (1:1 for endobronchial hamartoma) • Asymptomatic in 90% < 8% obstructive symptoms Hamartoma: Clinical • Most are peripheral and asymptomatic • If symptomatic: hemoptysis • If bronchial obstruction: pneumonitis • Fever. chest pain Hamartoma: Microscopic • Cartilage nests (lobules) in 95% • Surrounded by fibrous tissue • Mature fat cells • Cleft-like invaginations of entrapped respiratory epithelium Chest Radiology 199 Benign Tumors . “Classic”. 1904 • Tumor-like malformation • Tissues normal to location • In excess or disarray (disorganized) • “Adult”. cough. Abbott.

lobulated subpleural Hamartoma. lobulated • Firm lesions.Hamartoma: Gross Figure 1-21-1 • Solitary • 1 – 3 cm (rarely “Giant”) • Rounded. 160:313-317. Unenhanced chest CT demonstrates Carney JA. Usually cartilaginous • May see areas of fat • Easily “shelled-out” Hamartoma: Distribution • Peripheral > Central • 80 – 90 % Peripheral • No lobar predilection Hamartoma: Radiographic • Sharply defined.5 cm diameter • Focal fat in 8 voxels or more • Or fat with calcification Siegelman.5 cm or less • Smooth edge • No fat / Focal fat alone / Fat with areas of calcification Hamartoma. Radiology 1986. Unenhanced chest CT demonstrates a • Most < 3 cm peripheral solitary nodule with focal fat attenuation • Calcification on CXR (10-15% ) • Rarely see fat on CXR Figure 1-21-2 • May enlarge on serial CXRs • Up to 3 to 5 mm per year Hamartoma: Calcification • 10 – 15% speckled or “Popcorn” • “Popcorn” less frequent than once thought • Diagnostic when present ➢ Nodular growths within lesion ➢ Protrude in different directions Hamartoma: Computed Tomography • Distinguishes fat and cartilage • Most are 2. Cancer 1979 speckled calcification in a central endobronchial tumor with associated loss of volume in the left lung Benign Tumors 200 Chest Radiology . Unenhanced chest CT demonstrates a • Cavitation: rare central mass in the left lower lobe with a lobular area of “popcorn” calcification Hamartoma: Computed Tomography [Figures 1-21-1 to 1-21-3] • Thin sections (2mm) • Smoothly contoured nodule • = or < 2. well-circumscribed. no fat “Carney’s Triad” • Gastric smooth muscle tumors • Extra-adrenal paraganglioma • Pulmonary chondroma • Association unclear • Young females < 20 years • May have only 2/3 of the triad Hamartoma. Figure 1-21-3 Hamartoma: Computed Tomography • 36% no fat or calcification • 4% diffuse calcification • 38% areas of fat • 21% calcium and fat • Occasionally: focal calcification.

10 years after laryngeal disease (extension to bronchi. bronchiectasis Juvenile Laryngeal Papillomatosis • Children 18 months to 3 years of age • Majority remain localized. disappear spontaneously • May spread distally and obstruct airways ➢ 5% Spread remains limited to trachea ➢ 1% Develop lung disease .Chondroma • Rare • Benign cartilaginous tissue • Parenchymal or endobronchial • Lack epithelial-lined clefts seen in hamartomas • In young female • Search for Carney’s Triad Hamartoma: Endobronchial • Morphologically identical to parenchymal • Often polypoid.1% of infants develop LP. main or lobar bronchi • Males >40 years of age • Post-obstructive pneumonia.HPV types 6 and 11 • 0. Sessile or thin pedicle • Manifest by airway obstruction • Micro: more fat. lack clefts. cartilage scant or absent Hamartoma: Treatment and Prognosis • Benign • Surgical excision = Cure • Exceptional cases: additional hamartomas Papillomas • Branching or coarsely lobulated tumor • Arise from and project above an epithelial surface • Rare pulmonary tumors • Solitary (rare) or Multiple (papillomatosis) • Proximal or peripheral Solitary Papillomas • Rare • Usually in adults • Papillary exophytic growth • Trachea. bronchioles. alveolar airspaces) Laryngeal Papillomatosis: Demographics and Etiology • Human papilloma virus . Predilection for first-born infants • 50% of their mothers have genital tract involvement • HPV spread transvaginally at birth • Infects oropharyngeal secretions of child Papillomas: Microscopic • Non-keratinizing squamous cells • Fibrovascular core • Form papillomatous projections Papillomatosis: Gross • Cauliflower-like excresences • Protrude into bronchial lumens • May extend into parcenchyma as nodules or cavities Chest Radiology 201 Benign Tumors .

5% mortality if spread to lungs • Worse if malignant degeneration occurs Inflammatory Pseudotumor: Synonyms • Plasma cell granuloma • Histiocytoma • Fibroxanthoma. Xanthoma • Myofibroblastic tumor • Mast cell granuloma Inflammatory Pseudotumor • Uncommon. Chest CT demonstrates nodular and Papillomatosis: Treatment and Prognosis cystic opacities that predominantly involve the dorsal • Multiple recurrences aspects of both lungs • Multiple excisions • Tracheostomy Figure 1-21-5 • 37. well-defined nodules • Perihilar. posterior thorax • Grow to several centimeters • Cavitate.Laryngeal Papillomatosis • Majority remain localized • 5% spread to trachea and distal airways Tracheobronchial Papillomatosis • Many remain limited to trachea • 1% Develop lung disease • Patients with lung disease may develop • Squamous cell carcinoma Tracheobronchial Papillomatosis: Pathogenesis of lower respiratory tract involvement: • Implantation of inhaled fragments from larynx? • Multifocal viral infection? • Trauma-induced by tracheostomy? Figure 1-21-4 • In children. Reactive or neoplastic process? • May begin as organizing pneumonia • May have aggressive features: ➢ Vascular invasion ➢ Vertebral destruction ➢ Recurrence Papillomatosis and squamous cell carcinoma. 2-3 mm thick walls • Air-fluid levels may develop • Cavities may represent: ➢ Papillomatosis ➢ Squamous cell carcinoma ➢ Abscess (obstructive pneumonitis) Papillomatosis. Contrast-enhanced Chest CT demonstrates central squamous cell carcinoma in the left lower lobe with distal pneumonitis Benign Tumors 202 Chest Radiology . 2-3 mm thick walls • Air-fluid levels Papillomatosis: Imaging [Figures 1-21-4 and 1-21-5] • Multiple. papillomas in bronchi and lung associated with multiple papillomas of trachea or larynx Papillomatosis: Imaging • Multiple nodules • Cavities.

heterogeneous mass in • Calcification: variable the left upper lobe • Endobronchial lesions occur Inflammatory Pseudotumor: Therapy and Prognosis • Diagnosed and treated by surgical excision • Excellent prognosis after resection • Recurrence in 5% ➢ Especially if mediastinal or chest wall involvement • DDx: fibrous histiocytoma. and chronic inflammatory cells Inflammatory Pseudotumor: Gross • SPN or Mass • Well-defined. tumefactive lesion • Destroys underlying lung architecture • Reactive or Neoplastic ? Inflammatory Pseudotumor: Demographics • Males = Females • Wide age range: 1 to 77 years. May regress Inflammatory Pseudotumor: CT [Figure 1-21-6] • Solitary nodule or mass • Sharply circumscribed • Lobulated • Heterogeneous or homogeneous Inflammatory pseudotumor. well-defined nodule or mass 70% • Endobronchial lesions occur 10% • May extend into mediastinum 5% • Parenchymal consolidation 6% • Calcification.4 cm mean Inflammatory Pseudotumor • Solitary nodule or mass in 70% • Well-defined • May manifest as consolidation • May mimic neoplasm • Endobronchial lesions occur in 10% Figure 1-21-6 Inflammatory Pseudotumor: Radiographic • Solitary. Contrast-enhanced chest • Enhancement: / calcification variable. heterogeneous • 1-10cm. Lobulated • Lack a capsule • Cut-surface: whorled. 4. cavitation infrequent • May mimic malignant neoplasm • Usually no or slow growth. • A continuum from plasma cell granuloma to fibrohistiocytic • Mixture of collagen. fibroblasts. Firm. Average: 29.5 years • 60% <40 years ➢ Children: peak 6-7 years o ➢ Most common 1 lung mass in children • 74% asymptomatic • Many patients have history of respiratory infection Inflammatory Pseudotumor: Microscopic • Variable.Inflammatory Pseudotumor • WHO 1999: histologic spectrum of fibroblastic and myofibroblastic proliferations • With varying infiltrate of inflammatory cells • Usually solitary. myofibroblasts. sarcomatoid carcinoma Chest Radiology 203 Benign Tumors . nonspecific CT demonstrates an irregular.

smooth • Often calcified when healed Granuloma – Well-defined Pulmonary Nodule Multiple Ill-defined Pulmonary Nodules • TB • Histoplasmosis • Coccidioidomycosis • Cryptococcosis • Aspergillosis Granulomas – Tiny nodules • <5 mm. The coin lesion of the lung. Benign Tumors 204 Chest Radiology . military • Histoplasmosis • Blastomycosis • Cryptococcosis • Coccidioidomycosis Solitary Pulmonary Nodule (n = 955) • Malignant 49% ➢ Primary carcinoma 38% ➢ Metastases 9% ➢ Other 1° malignancy 2% • Benign 51% ➢ Non-neoplastic lesion 37% ➢ Tumor 14% ( Hamartoma 8% ) Toomes H. micronodular. Cancer 1983.Granulomas • Infectious • Sarcoid (necrotizing granuolomatosis) • Hypersensitivity pneumonitis Infectious Granulomas • Mycobacterial 64% • Fungal 30% • Parasitic 6% Granuloma: Infectious • Tuberculoma or Histoplasmoma • Satellite lesions common • Usually small.

Fissures • Visceral pleura • Variable depth into parenchyma • Complete • Incomplete Chest Radiology 205 Pleural Disease I .2 mm • Thin-collimation ➢ 1-2 mm thick line ➢ Intercostal regions ➢ Normal fluid ➢ Endothoracic fascia Pneumothorax in a supine patient manifesting as a ➢ Innermost intercostal m. Abbott.Pleural Disease I Gerald F. MD Pleural Disease I and II: Objectives • Anatomy and physiology • Non-neoplastic and neoplastic pleural disease • Chest wall disease • Radiologic-Pathologic correlation Figure 1-22-1 Pleural Disease I • Normal anatomy ➢ Standard fissures ➢ Accessory fissures • Non-neoplastic pleural disease ➢ Effusions ➢ Fibrosis ➢ Pneumothoraces Standard (solid lines) Pleural Anatomy and accessory (dashed lines) fissures • Parietal Pleura ➢ Covers non-pulmonary surfaces ➢ Systemic supply/drainage ➢ Lymphatics communicate with pleural space Figure 1-22-2 ➢ Pain fibers ➢ 5-15 ml of pleural fluid • Visceral Pleura [Figure 1-22-1] ➢ Covers lung surface ➢ Dual supply/drainage ➢ Vagus nerve/sympathetic trunks ➢ Lymphatics do not communicate with pleural space Pleural Imaging • Radiography / CT ➢ Inconspicuous ➢ Visceral + Parietal = 0. “deep sulcus” and hyperlucency overlying the left hemidiaphragm Pleural Anatomy [Figure 1-22-2] Caudal limit of pleura lower than lung Costal and diaphragmatic pleura contact to form costophrenic recess Pleural Anatomy • Junction Lines • Apposition of layers of pleura ➢ Anterior ➢ Posterior Pleural Anatomy .

Incomplete Major Fissure: CT • More frequent Right • RUL / RLL 70% • RML / RLL 47% • LUL / LLL 40% • Lingula / LLL 46% Major Fissure: Radiography • Major (oblique) fissures • Best seen on lateral CXR • Origin: T4 Left. An endobronchial carcinoid Standard Fissures: Radiography obstructs the origin of the right upper lobe • Minor fissure bronchus ➢ “Lights up” in CHF ➢ Interstitial edema (Subpleural interstitium) Figure 1-22-4 Minor Fissure: CT • Lucent area • Devoid of vasculature • 44% triangular • 8% round / ovoid • Ground glass attenuation Incomplete Minor Fissure: HRCT • Curvilinear line or band • Increased attenuation • C-shaped • Fusion between RUL / RML (60-90%) Accessory Fissures: Radiography [Figure 1-22-4] • 10% CXR / 20% CT (50% of anatomic specimens) ➢ Azygos. Superior. T5 Right • Right fissure more oblique Figure 1-22-3 Major Fissure: CT • 80-90% of standard CT ➢ Lucent band ➢ Line ➢ Dense band Major Fissure: CT Propeller-like morphology [Figure 1-22-3] • Upper thorax ➢ Anterior concave ➢ Lateral-facing • Inferior thorax ➢ Anterior convex Chest CT (lung window) demonstrates right upper ➢ Medial-facing lobe loss-of-volume manifested by displacement of the right major fissure. superior (S) and azygos (az) accessory fissures Pleural Disease I 206 Chest Radiology . Inferior. Left minor Accessory Fissures: Azygos • Abnormal migration of posterior cardinal vein • Four layers of pleural • 1% population Diagram illustrates position of • 2M : 1F inferior (I).

10% • 80% Right-sided • CT: 15% Indirect Signs of Atelectasis: Juxtaphrenic Peak • Common in RUL or LUL atelectasis ➢ Less common in RML • Seen post upper lobectomy • Small triangular opacity • Projects upward from diaphragm • Related to inferior accessory fissure Chest CT demonstrates an azygos fissure forming Accessory Fissures: Superior Accessory the lateral margin of an azygos lobe • Separates superior segment from basilar segments • 6% anatomic specimens • Right > Left Figure 1-22-6 • Horizontal course ➢ Inferior to minor fissure Accessory Fissures: Left Minor Fissure • Separates lingula from remainder of upper lobe • 8-18% anatomic specimens • 1. lymphatics. nodes Figure 1-22-7 Coned-down view of right lung demonstrates an inferior accessory fissure separating the medial basal segment from the remaining basal segments of the right lower lobe Chest CT demonstrates an inferior accessory fissure (arrow). Chest Radiology 207 Pleural Disease I .Accessory Fissures: CT Azygos [Figure 1-22-5] Accessory Fissures: Inferior Accessory [Figures 1-22-6 and 1-22-7] • Separates medial basal segment from remaining basilar segments • Most common Figure 1-22-5 • 30 .5% of chest radiographs • Oblique course • More cephalad Pulmonary Ligament • Formed by Parietal & Visceral pleura • Courses inferiorly & posteriorly • Contains bronchial veins.45% anatomic specimens • CXR: 5 .

Pulmonary Ligament: Imaging [Figure 1-22-8] Figure 1-22-8 • CXR: not visualized • CT: 60%-70% Pleural Effusion Cardiac Decompensation [Figure 1-22-9] • Most common cause • Increased hydrostatic pressure • Bilateral >80% • Unilateral = right-sided • Pseudotumor Figure 1-22-9 Chest CT demonstrates inferior accessory fissure Lateral chest (arrowhead) and right and left pulmonary radiograph ligaments (arrows) demonstrates lenticular opacity of fluid accumulation in the minor fissure (pseudotumor) Figure 1-22-10 Pleural Effusion: Bacterial Pneumonia • Parapneumonic effusions 40% • Exudate • 10% require drainage • Complications Ultrasound demonstrates multiple septations ➢ Loculation within a loculated fluid collection representing ➢ Empyema empyema Pleural Effusion: Empyema [Figure 1-22-10] Figure 1-22-11 • Three phases ➢ Exudative ➢ Fibrinopurulent ➢ Organizing Pleural Effusion: Empyema [Figure 1-22-11] • Lenticular shape • Obtuse margins • Compress lung Contrast • Split pleura sign enhanced chest CT demonstrates Pleural Effusion: smoothly Lung abscess or Empyema ? thickened parietal and Pleural Effusion: Empyema visceral pleura • Lenticular shape enclosing a fluid • Obtuse margins collection of • Compress lung empyema (“split • Split pleura sign pleura sign”) • Disparity in length of air-fluid level Pleural Disease I 208 Chest Radiology .

Pleural Effusion: Lung abscess • Round shape • Does not compress lung • Equal length of air-fluid level Pleural Effusion: Empyema • Treatment ➢ Tube thoracostomy ➢ Fibrinolytics ➢ Decortication Pleural Effusion: Empyema necessitatis • Inadequate treatment • Drainage into chest wall • Tuberculosis 73% • Bacterial / Fungal v Malignancy • Immunocompromised patients Pleural Effusion: Tuberculosis • Exudate ➢ ↑ lymphocyte count ➢ ↓ glucose level • Unilateral • Small to moderate Pleural Effusion: Subpulmonic • Fluid accumulates between lung base and diaphragm • Shifts apex of diaphragm laterally • Usually transudate ➢ Cardiac decompensation ➢ Renal failure ➢ Cirrhosis with ascites Pleural Effusion: Subpulmonic • Imaging ➢ Apparent elevation diaphragm ➢ Ill-defined costophrenic angle ➢ Diaphragmatic spur ➢ Mobile fluid ➢ Displace gastric bubble ➢“Rock of Gibraltar” on lateral Pleural Effusion and Ascites • CT Features ➢ Effusion = outside of hemidiaphragm ➢ Ascites = inside of hemidiaphragm Pleural Effusion: Connective Tissue Disease • Rheumatoid arthritis • Most common thoracic manifestation • Middle aged males • Antedates clinical disease • Exudate / chyliform / low glucose • Imaging ➢ Unilateral ➢ Chronic ➢ Transient / relapse ➢ Fibrothorax / decortication Chest Radiology 209 Pleural Disease I .

Pleural Effusion: Asbestos Exposure • Diagnosis of exclusion • Occupational exposure • No malignancy within 3 yrs • 10 yrs post-exposure • Exudate • 1/3 patients have chest pain • Recurrent 15 .Asbestos Exposure • Associated with diffuse pleural thickening ➢ Involves C-P angle • Implicated in formation of Rounded Atelectasis Round Atelectasis: CXR • Peripheral mass • Abuts thickened pleura • 3. diaphragms • Bronchovascular bundles converge. forming “comet tail” Round Atelectasis: CT • Rounded subpleural mass • Broadly abuts contiguous pleural thickening • Air-bronchogram hilar aspect • Bronchovascular “comet tail” • Loss of volume in same lobe Round Atelectasis: Required CT Findings [Figure 1-22-12] Chest CT (mediastinal and lung windows) demonstrates • Subpleural mass the CT findings of round atelectasis • Thickened pleura • Loss of volume • Comet tail Round Atelectasis: Pathogenesis • Asbestos exposure • Pleural effusion • Atelectasis • Pleural adherence • Effusion subsides • Lung re-expands • Pleural fibrosis • Contraction Pleural Fibrosis • 2nd most common pleural abnormality • Result of many primary diseases of the pleura • Complication of inflammatory disease • Most localized to single area • Less often diffuse ➢ May have functional abnormalities Pleural Fibrosis: Focal • Healed Pleuritis • Bacterial pleuritis/trauma • Imaging ➢ Blunt posteriolateral CP sulci ➢ Rule-out small effusion Pleural Disease I 210 Chest Radiology .5 to 7 cm Figure 1-22-12 • Posterior lower lobe most common ➢ Other lobe.30% • Small (<500 ml) Pleural Effusion .

Chest radiograph demonstrates • Imaging CT pleural thickening and calcification in the right ➢ Extends > 8.0 cm cranio-caudal hemithorax ➢ Pleura > 3 mm thick ➢ Extrapleural fat hypertrophy Figure 1-22-15 ➢ +/.Pleural Fibrosis: Focal [Figure 1-22-13] Figure 1-22-13 • Pleural Plaques • Serpentine (chrysotile) asbestos • Dense hyalinized collagen • Parietal pleural surface • Asbestos exposure • Asymptomatic Pleural Fibrosis: Focal • Pleural Plaques • 50% of exposed individuals • Visible plaques ➢ 15 years non-calcified ➢ 20 years calcified Pleural Fibrosis: Imaging • Bilateral (80%) Chest CT (lung window) demonstrates multiple • Lateral chest wall bilateral pleural plaques • 4th to 8th ribs • Tendinous diaphragm • Spares apices and CPAs Figure 1-22-14 • En face “Holly leaf” Pleural Fibrosis: Diffuse Fibrothorax Figure 1-22-14] • Fibrous obliteration of normal pleural space ➢ Tuberculosis/bacterial empyema ➢ Hemothorax ➢ Asbestos-related pleural effusions ➢ Rheumatoid effusions • Volume loss/restrictive disease Pleural Fibrosis: Diffuse Fibrothorax • Radiographic definition ➢ Smooth/uninterrupted ➢ 25% or more of chest wall ➢ May obliterate c-p suclus ➢ ≤ 2.Pleural calcification ➢ Mediastinal pleura spared Pneumothorax • Air within the pleural space • Spontaneous ➢ Primary ➢ Secondary • Traumatic Pneumothorax: Primary Spontaneous [Figure 1-22-15] • M:F=5:1 • 3rd .0 cm thickness ➢ +/.4th decade • Right-side predominance • 30% ipsilateral recurrence • 10% contralateral recurrence Chest CT demonstrates left pneumothorax • Rupture of apical bleb/bulla and a bleb along the visceral pleural surface of the collapsed lung Chest Radiology 211 Pleural Disease I .calcification Pleural Fibrosis: Diffuse Fibrothorax Pleural fibrosis.

Pneumothorax: Secondary Spontaneous • COPD • Most common concurrent condition • 0.5% per year • 45-65 years of age • Peripheral emphysematous lung • Mortality rate ~3% Pneumothorax: Secondary Spontaneous • Pneumocystis Jiroveci Pneumonia (PCP) • Destruction of alveolar septa → bulla • Subpleural necrosis → cystic degeneration / bulla Pneumothorax: Secondary Spontaneous • Pneumocystis Jiroveci Pneumonia (PCP) • Complicates in 12% • Refractory “air-leaks” • Poor prognosis • Death in 8 weeks (<57%) Pneumothorax: Secondary Spontaneous • Lymphangioleiomyomatosis (LAM) • Women child-bearing age • Proliferation of immature smooth muscle • Bronchiolar obstruction ➢ Cysts → PTX • Recurrence ~40% Pneumothorax: Secondary Spontaneous • Langerhans Cell Histiocytosis • Smokers • Cysts rupture • Recurrent ptx (25%) Pleural Disease I 212 Chest Radiology .

chest pain. dyspnea • HPO 0 . MD Malignant Pleural Effusion • Most common manifestation of metastatic involvement • Exudative effusion • Lung Ca 36% • Breast Ca 25% • Lymphoma 10% • Ovarian 5% • Gastric Ca 2% TNM Staging of Lung Cancer • Malignant Effusion = T4 N0 N1 N2 N3 T1 IA IIA IIIA IIIB T2 IB IIB IIIA IIIB T3 IIB IIIA IIIA IIIB T4 IIIB IIIB IIIB IIIB MI=IV Malignant Pleural Effusion: Diagnosis and Prognosis • Combined pleural cytology and pleural biopsy • Multiple thoracenteses / pleural biopsies • Poor prognosis • Lung Carcinoma .mean survival 7 to 15 months Pleural / Chest Wall Mass • Discrepant margins on orthogonal views • Elliptical shapes • Obtuse angles • Cross boundaries Pleural Neoplasms • Primary • Localized fibrous tumor • Malignant mesothelioma • Secondary • Pleural metastases ➢ Bronchogenic carcinoma ➢ Other carcinomas ➢ Lymphoma ➢ Invasive thymoma Localized Fibrous Tumor • Rare (< 5% of pleural neoplasms) • Not related to asbestos • M=F • Mean age: 50 years • Symptoms in 54% • Cough.Pleural Disease II and Chest Wall Gerald F.mean survival 2 to 3 months • Breast Carcinoma . Abbott.35% • Hypoglycemia 4% Chest Radiology 213 Pleural Disease II .

Chest CT (lung windows) demonstrates a pleural mass that forms obtuse Localized fibrous tumor. cysts Localized Fibrous Tumor: CXR [Figures 1-23-1 to 1-23-3] • Incidental finding • Solitary rounded. lenticular • Heterogeneity: ➢ hemorrhage. PA chest radiograph angles at its interface with the chest demonstrates a large mass that opacifies most of wall the right hemithorax and produces mass effect with contralateral shift of the mediastinum Localized Fibrous Tumor: CT [Figure 1-23-4] Figure 1-23-4 • Well-defined. necrosis. smooth. fibrous hemorrhage. cysts • Contrast enhancement Localized fibrous tumor. encapsulated • Pedicle: good prognosis • Cut-surface: whorled.Localized Fibrous Tumor: Microscopic Figure 1-23-1 • Variable patterns • Disorderly arrangement • Spindle cells and collagen • High mitotic activity suggests malignancy 20% Localized Fibrous Tumor: Gross • 2 . nodular. PA chest radiograph • Pedunculated tumors demonstrates a pleural mass a peripheral ➢ Positional mobility mass in the right lower hemithorax with ➢ Pathognomonic incomplete borders Figure 1-23-2 Figure 1-23-3 Localized fibrous tumor. lobular mass • Mid to inferior thorax • Obtuse or acute angles at interfaces Localized fibrous tumor.40 cm • 80% visceral / 20% parietal • Lobular. Contrast enhanced chest CT demonstrates a large heterogeneous mass in the right lower hemithorax with lobulated contours Pleural Disease II 214 Chest Radiology . lobular • Abutting pleural surface • Elongated. necrosis.

hypoglycemia Malignant Mesothelioma .000 cases / year in USA • 10% of exposed individuals • Shipyards / asbestos plants • Sixth to eighth decades • Male : Female 3-6 : 1 • Amphiboles most tumorigenic • Latency: 30-40 years Malignant Mesothelioma: Clinical • Insidious onset of symptoms • 6-8 months prior to Dx Figure 1-23-5 • Dyspnea. cough.Localized Fibrous Tumor Therapy and Prognosis • Treatment of choice: complete excision • 90% cure rate • Symptoms usually resolve post-op • Recur with tumor recurrence • Recurrence in 10% of patients Malignant Mesothelioma • Most common primary pleural neoplasm • 2. masses • Parietal > Visceral • Bulk in inferior hemithorax • Lung encasement • Fissural growth Malignant mesothelioma. chest pain.Microscopic • Epithelioid 50 % • Sarcomatous 15 % • Biphasic 25 % • Interobserver agreement 50% Malignant Mesothelioma: Gross • Sheets. PA chest • Parenchymal involvement radiograph demonstrates circumferential. dysphagia. vocal cord paralysis. Horner Syndrome. chest wall. HPO. • Ipsilateral ↑ volume 14% nodular pleural thickening in the left hemithorax that extends into the major Kawashima AJR 1990 interlobar fissure. clubbing. • Mediastinal. Calcified pleural plaques are demonstrated bilaterally Chest Radiology 215 Pleural Disease II . weight loss • Rarely: SVC Syndrome.000 to 3. diaphragmatic invasion nodular and contiguous pleural masses throughout the left hemithorax Malignant Mesothelioma: Radiographic [Figure 1-23-5] Figure 1-23-6 • Pleural effusion • Pleural masses • Circumferential • Mediastinal shift • Pleural plaques 25% Malignant Mesothelioma: Radiographic • Malignant mesothelioma cannot be reliably differentiated from pleural metastases Malignant Mesothelioma: CT [Figure 1-23-6] • Pleural thickening 92% • Fissural thickening 86% • Pleural effusion 74% • Ipsilateral ↓ volume 42% • Pleural calcification 20% Chest CT demonstrates circumferential. plaques.

Thymoma • Imaging ➢ Pleural effusion ➢ Pleural masses ➢ Or both Pleural Metastases • Hematogenous / Lymphatic • Direct extension ➢ Lung ca. • Congenital and developmental anomalies circumferential. Chest CT demonstrates adenocarcinoma arising from a right upper lobe Chest Wall bronchus and pleural metastases that are nodular.Malignant Mesothelioma: DX • Video-Assisted-Thoracoscopic-Surgery: Sensitivity 98% ➢ Complication: tumor seeding along entry ports • Open biopsy: when adhesions preclude VATS • Cytology and FNA Bx of limited value Malignant Mesothelioma: MR • Staging • Comparable / superior to CT • Tumor enhancement • Increased signal intensity Malignant Mesothelioma: Treatment and Prognosis • Median survival: 10 months • Best prognosis: ➢ 25-30% 5-year survival ➢ Negative margins ➢ Epithelial cell type ➢ No metastases • Extrapleural pneumonectomy ➢ High mortality / morbidity Pleural Metastases Most common pleural neoplasm • Common ➢ Adenocarcinoma ✧ Lung. breast. breast ca • Drop metastases ➢ Invasive thymoma • May be bilateral Pleural Thickening Malignant Pleural Thickening [Figure 1-23-7] • Circumferential • Nodular • > 1 cm • Mediastinal pleura Leung et al AJR 1990 Pleural metastases. and involve the mediastinal pleura • Inflammatory and infectious diseases • Non-neoplastic conditions • Neoplasia: benign and malignant Pleural Disease II 216 Chest Radiology . ovary. stomach • Less common: Figure 1-23-7 ➢ Lymphoma.

Contrast enhanced chest CT Tuberculosis. aeruginosa • Imaging ➢ Osseous destruction if advanced ➢ CT / MR for better delineation ➢ CT for biopsy and/or drainage Chest Wall:Tuberculosis [Figure 1-23-10] • Uncommon • Hematogenous spread Lateral chest radiograph • Contiguous spread demonstrates pectus carinatum • Abscess / sinus tract 25% • Imaging Figure 1-23-9 ➢ Bone / cartilage destruction ➢ Soft-tissue mass ➢ Calcification ➢ Peripheral enhancement Chest Wall: Inflammatory / Infectious Diseases Chest Wall: Actinomycosis [Figure 1-23-11] • Actinomyces israelii • Anaerobic gram-positive • Lung → Pleura → Chest Wall • Proteolysis → Fistulas • Diagnosis: anaerobic cultures • Imaging: soft-tissue mass draining sinus. P. periostitis Poland syndrome.Chest Wall: Congenital / Developmental Anomalies Figure 1-23-8 [Figures 1-23-8 and 1-23-9] • Pectus deformities • Anomalous ribs • Cleidocranial dysostosis • Poland syndrome Chest Wall: Inflammatory / Infectious Diseases • Hematogenous • Direct extension • Pyogenic infection: S. aureus. Chest CT demonstrates Figure 1-23-11 congenital absence of the right pectoralis muscles Figure 1-23-10 Actinomycosis. Contrast enhanced chest CT demonstrates peripheral consolidation in the left demonstrates an anterior chest wall upper lobe with contiguous soft-tissue density abscess with subtle peripheral extending into the adjacent mediastinum and enhancement and right pleural effusion anterior chest wall and pleural thickening Chest Radiology 217 Pleural Disease II .

Breast. Prostate. • Most: second to fourth decades • Shoulder. chest wall • Soft tissue mass • Frequent recurrence Chest Wall Neoplasms: Soft Tissue Involvement [Figure 1-23-12] • Adults • Malignant: ➢ Fibrosarcoma ➢ Malignant fibrous histiocytoma Chest Wall Neoplasms: Osseous Involvement [Figure 1-23-13] • Rib expansion ➢ Fibrous Dysplasia ➢ Enchondroma • Pressure erosion ➢ Neurogenic (slow growth) • Rib destruction: ➢ Metastatic or Primary ➢ Inflammatory Figure 1-23-13 Chest Wall Neoplasms: Osseous Destruction • Adult ➢ Metastatic disease (Lung. etc. The patient Desmoid (Fibromatosis) received radiation therapy through ports that • Aggressive fibromatosis included the left posterolateral chest wall.Chest Wall: Neoplasms Figure 1-23-12 • Adults • Benign: ➢ Lipoma ➢ Other mesenchymal neoplasms • Malignant: ➢ Fibrosarcoma ➢ Malignant fibrous histiocytoma ➢ Other mesenchymal neoplasms ➢ Lymphoma Chest Wall Neoplasms: Lipoma • Common • Subcutaneous • Intrathoracic • Both • Diagnostic CT number Fibrosarcoma.) ➢ Multiple myeloma ➢ Chondrosarcoma • Child ➢ Ewing sarcoma ➢ Neuroblastoma ➢ Lymphoma ➢ Askin tumor (PPNET) Chest Wall Neoplasms: Myeloma • Males > Females Fibrous dysplasia.7th decades demonstrates an expansile lesion • Axial skeleton with intact cortical margins nvolving • Multiple or solitary a right rib • Imaging: ➢ Osseous destruction ➢ Soft-tissue mass Pleural Disease II 218 Chest Radiology . Chest CT demonstrates post- surgical changes of right mastectomy and a soft- Chest Wall Neoplasms: tissue mass in the left chest wall. Chest CT • 5th .

Chest Wall Neoplasms: Chondrosarcoma • Adults • Painful. rib. adolescents • Female: Male = 3:1 • Unilateral • Rib destruction 2/3 • Pleural effusion • Poor prognosis Chest Radiology 219 Pleural Disease II . palpable mass • Costochondral junction. destructive ➢ Chondroid calcification ➢ Soft-tissue mass PNET “Askin Tumor”: Primitive Neuroectodermal Tumor • Malignant small round cell tumor • Children. sternum • Imaging: ➢ Expansile.

is the sternalis muscle Intramammary Lymph Nodes • Normal finding • 28% of breasts • May enlarge and shrink in size • Circumscribed with hilar notch or fatty hilum • Usually less than 15 mm in size • Not related to the usual lymphatic drainage patterns Figure 1-24-4 • Usually upper outer quadrant Intramammary Lymph Nodes Figures 1-24-4 to 1-24-6] Left: Medial lymph node Right: Typical lymph node with fatty hilum Classic Breast Lesions 220 Chest Radiology .Classic Breast Lesions Leonard M. benign solid mass or a carcinoma Figure 1-24-3 Sharply marginated medial density. MD Figure 1-24-1 Most Lesions are Non-specific [Figure 1-24-1] • Differentials can be given • High likelihood diagnoses can be made • Is this a cyst or a solid mass? Normal Variants • Pectoralis major • Lymph nodes Pectoralis Major [Figure 1-24-2] Figure 1-24-2 CC view showing a rounded density medially. Glassman. Sternalis [Figure 1-24-3] smaller than the pectoralis major. the medial end of the Non specific lobulated mass which could be a pectoralis major muscle cyst.

Figure 1-24-5 Figure 1-24-6 Left: Lymph node with hilar notch Six examples of benign lymph nodes.4% of neonates • Polymastia ➢ 2-3% of women ➢ Axillary breast tissue most common ➢ Inframammary fold and labia next Figure 1-24-8 most common Polythelia [Figures 1-24-7 and 1-24-8] Polymastia [Figures 1-24-9 and 1-24-10] • Can be palpable or visible Benign Abnormalities Accessory nipple seen • Fatty lesions medially • Gynecomastia • Fibrocystic changes • Foreign bodies Fatty Lesions • Hamartoma Accessory nipple in a patient at • Lipoma the inframammary crease • Fat necrosis • Galactocele Figure 1-24-9 All Lesions that Contain Fat are Benign Except • Very rare hamartomas • 1 Phyllodes with liposarcoma Figure 1-24-10 Palpable axillary accessory breast Visible bilateral axillary accessory tissue breast tissue Chest Radiology 221 Classic Breast Lesions . Right: Core biopsy specimen of normal lymph The top three are with traditional real time scanning node and the bottom three with compound scanning Congenital Anomalies Figure 1-24-7 • Polythelia ➢ Accessory nipples ➢ 2.

Hamartoma [Figures 1-24-11 to 1-24-14] • Fibroadenolipoma • Palpable mass or mammographic finding ➢ Can be large and not palpable • Encapsulated normal breast elements Figure 1-24-14 Figure 1-24-11 Figure 1-24-12 Figure 1-24-13 Large hamartoma Small hamartoma Hamartoma showing Hamartoma presenting containing fat. not fatty Right: Water density liposarcoma Figure 1-24-17 Figure 1-24-18 Figure 1-24-19 Fat Necrosis • 50% have history of trauma ➢ Including surgery & XRT • Oil cyst • Partially calcified lesion • Can be spiculated • Can progress from fatty to spiculated Oil Cyst [Figures 1-24-17 to 1-24-19] Oil cyst Oil cyst with scarring Heavily calcified oil and dystrophic cyst calcification Classic Breast Lesions 222 Chest Radiology . glandular mixed echogenicity as an intermediate tissue and fibrous tissue density mass without visible fat Lipoma [Figure 1-24-15] Figure 1-24-15 • Benign tumor • Usually not palpable because it is soft • Liposarcoma usually water density Liposarcoma [Figure 1-24-16] Figure 1-24-16 Lipoma in the axillary region Left: Liposarcoma is water density.

Fat Necrosis . a classic cyst Pneumocystogram of a benign cyst Chest Radiology 223 Classic Breast Lesions .Progression [Figure 1-24-20] Figure 1-24-21 Figure 1-24-20 Left: Oil cyst with scarring Right: Several years later the scarring predominates and the fatty part of the lesion disappears Galactocele [Figure 1-24-21] • Pregnant or breast feeding • Cystic lesion Two galactoceles with layering of • Fat fluid level on horizontal beam film milk • Aspiration usually curative (fat rising and calcium dropping) Fibrocystic Changes [Figures 1-24-22 and 1-24-23] Figure 1-24-22 Figure 1-24-23 • Exaggerated physiologic phenomenon ➢ Cysts ➢ Apocrine metaplasia and hyperplasia ➢ Stromal alterations ➢ Mild epithelial hyperplasia ➢ Mild adenosis Apocrine Metaplasia [Figure 1-24-24] Cyst [Figure 1-24-25] • Cystic lobular involution Specimen showing • Anechoic with sharp back wall Multiple small multiple small cysts with hypoechoic cysts and • Enhanced thru-transmission of sound a characteristic blue color • 10% atypical textural irregularity of (blue domed cysts) fibrocystic change • Diagnosable on ultrasound or aspiration Figure 1-24-24 Figure 1-24-25 Figure 1-24-26 Microcystic nodule of apocrine metaplasia Anechoic mass with sharp borders and enhanced Pneumocystography [Figure 1-24-26] transmission of sound.

Foreign Body Figure 1-24-27 Figure 1-24-28 • Silicone or paraffin ➢ Free injection ➢ Leakage from implants • Surgical drain • Wire fragments Free Silicone (Implant Rupture) [Figure 1-24-27] Free Silicone or Paraffin [Figure 1-24-28] Free Silicone [Figure 1-24-29] Silicone in the tissue from implant rupture Diffuse fibrosis and Figure 1-24-29 calcification from injected silicone or paraffin for augmentation Figure 1-24-30 Figure 1-24-31 Left: Multiple high density globules of injected silicone for augmentation Right: Low power view of “holes” in the tissue from Wire fragment left silicone Penrose drain remaining behind after breast after biopsy biopsy Surgical Drain [Figure 1-24-30] Wire Fragment [Figure 1-24-31] Thickened Skin Pattern Figure 1-24-32 • Edema • Mastitis • Inflammatory carcinoma • Post-radiation change • Obstruction to lymphatic drainage in the axilla or superior mediastinum • Lymphoma Thickened Skin Pattern – Mastitis [Figure 1-24-32] Prominent thickened skin pattern as compared to the normal side Classic Breast Lesions 224 Chest Radiology .

Right: Inflammatory breast cancer • Lucent centered with enlargement. mastectomy and radiation Extensive edema and increased density after Mammographic Findings radiation therapy • Skin thickening • Diffuse increased density • Trabecular thickening Figure 1-24-34 • Adenopathy • Signs of carcinoma ➢ Mass. distortion Inflammatory Carcinoma [Figure 1-24-35] • Axillary nodes • Supraclavicular node Figure 1-24-35 Far advanced inflammatory breast cancer with skin necrosis Left: Enlarged abnormal axillary nodes in inflammatory breast cancer Right: Abnormal supraclavicular node Figure 1-24-36 Inflammatory Carcinoma [Figure 1-24-36] Classically Benign Calcifications • Lobular • Sutural • Fibroadenoma • Skin • Vascular Left: Extremely dense breast in inflammatory • Secretory breast cancer. and extensive skin thickening • Egg shell Chest Radiology 225 Classic Breast Lesions . asymmetry.Thickened Skin Pattern – Radiation Therapy Figure 1-24-33 [Figure 1-24-33] Inflammatory Carcinoma [Figure 1-24-34] • Clinical findings ➢ Heavy firm breast ➢ Red skin ➢ Warm skin ➢ Peau d’orange • Can not differentiate from acute mastitis • Far advanced local disease ➢ Usually poorly differentiated ductal carcinoma • Radiographic findings ➢ Obstruction of dermal lymphatics ✧ Can diagnose with a skin biopsy ➢ Diffuse lymphatic invasion within the breast ➢ Increased density ➢ Trabecular thickening • 50% five year survival ➢ Pre-op chemo. calcification.

Lobular Calcifications [Figure 1-24-37] Figure 1-24-37 • Tightly clustered • Round • Fit together like a jigsaw puzzle Sutural Calcifications [Figure 1-24-38] • Look like sutures • Usually post radiation therapy Figure 1-24-38 Calcified Fibroadenoma • Coarse or “popcorn-like” • Calcification generally peripheral Tight cluster of smooth calcifications. a benign Peripheral Calcification lobular cluster [Figure 1-24-39] Figure 1-24-39 Dystrophic calcification with calcified suture Figure 1-24-40 Surface calcification in a fibroadenoma Calcified Fibroadenoma [Figures 1-24-40 and 1-24-41] Skin Calcifications • Faint peripheral clusters with lucent centers • Tangent view Left: Dense calcification (popcorn like) in a fibroadenoma Dermal Localization [Figure 1-24-42] Right: Sclerotic fibroadenoma with calcification Figure 1-24-41 Figure 1-24-42 Left: Marker over cluster for dermal localization Extremely dense calcification in a Right: Tangential film showing cluster in skin fibroadenoma Classic Breast Lesions 226 Chest Radiology .

Costa-Greco MA. Aust Fam Physician 2005. 9. 170:417-421. Ellis DL. A pathologic definition. 6:549. 4. epidemiology. Radiology 2003. Radiology 1989. 227:183-191. Levine PH. Sonographic features of breast hamartomas. 6.Vascular Calcifications Figure 1-24-43 • Parallel tracks associated with blood vessels • Calcifications are on the outside of the tube • Diabetes ? • Heart Disease ? Vascular / Ductal [Figure 1-24-43] Secretory Calcifications • Large rods ➢ Luminal calcifications ➢ Oriented toward nipple ➢ Relatively smooth surface Left: Calcification in artery ➢ May branch Right: Calcification in duct Loa Loa [Figure 1-24-44 Figure 1-24-44 Figure 1-24-45 • Also called eye worm • Found in rain forest and swamps of West Africa. Cystic lesions of the breast: sonographic-pathologic correlation.5 cm Osteosarcoma • Primary in the breast • 27 to 89 years old • Median 64. 5. 7. Ahern V. 11. Young HA. Ganott MA. Kefford R. AJR Am J Roentgenol 2006. Anderson WF. AJR Am J Roentgenol 1978. Rebner M. 9:85-90. Trends in inflammatory breast carcinoma incidence and survival: the surveillance. Berg WA. Locally advanced and inflammatory breast cancer. 186:888-894. Oberman HA. 10. Dershaw DD. Radiology 1994. Campassi CI. Cancer 1974. Ilkhanipour ZS. 8. and end results program at the National Cancer Institute. Bassett LW. Cove HC. Gold RH. Deutch BM. and MRI features of early complications. Augmentation mammoplasty: normal and abnormal findings with mammography and US. Radiographics 1992. Adler DD. Ung O. sonographic. Inflammatory carcinoma of the breast. Direct injection of paraffin into the breast: mammographic. Mammographic spectrum of traumatic fat necrosis: the fallibility of "pathognomonic" signs of carcinoma. Bosch X. Lancet Oncol 2005. Helvie MA. 97:966-975. Erguvan-Dogan B. 12:281-295. Hance KW.5 years • Highly aggressive tumors Calcified loa loa worm Primary Osteosarcoma [Figure 1-24-45] Mass with dense osteoid National Flower of the Radiologist is the Hedge matrix Some Diagnoses Can be Made • Make them when you can References 1. Adler DD. Devesa SS. Teitelbaum SL. J Natl Cancer Inst 2005. Brennan M. 130:119-122. Helvie MA. 34:1027-1032. 33:1045- 1047. Yang WT. Breast hamartomas: variable mammographic appearance. Inflammatory breast carcinoma: mammographic findings. especially Cameroon • Transmitted by day biting Chrysops flies • Loa loa filarial nematode • Larvae develop over 1 year • Mature worms up to 3-6 cm x 0. Ioffe OB. J Ultrasound Med 1990. Chest Radiology 227 Classic Breast Lesions . Moore MP. Unique features of inflammatory breast carcinoma. 3. Harris KM. 2. 190:831-834. Liberman L. Jeffries DO.

Tubular carcinoma of the breast: mammographic and sonographic features. Radiology 1992. Kushwaha AC. Zuurbier RA. Classic Breast Lesions 228 Chest Radiology . 17. 15. Stacey-Clear A. Vazquez MF. Soo MS. Fat necrosis in the breast: sonographic features. Huynh PT. et al. Svane G. Magnant CM. Stelling CB. 13. Stelling CB. Calcification In Breast Disease Mammographic-Pathologic Correlation. Fornage BD. Harrison EG. Whitman GJ. Am J Roentgenol Radium Ther Nucl Med 1964. AJR Am J Roentgenol 2000. Radiologic appearance of nonpalpable intramammary lymph nodes. 92:29-39. Robinson RE. 18. Dryden MJ. 16. McCarthy KA. 183:207-208. 14. Acta Radiol 1993. Sahin AA. In situ and infiltrating ductal carcinoma arising in a breast hamartoma. Jr. O'Toole M. Radiology 1998. AJR Am J Roentgenol 2000. 19. 175:64-66. Mammographic-pathologic correlation of apocrine metaplasia diagnosed using vacuum-assisted stereotactic core-needle biopsy: our 4-year experience. Hertzberg BS. 206:261- 269. Sheppard DG. Simmons RM. 34:577-580. Levitan LH. AJR Am J Roentgenol 2003. Radiographics 1995. Kornguth PJ. Rosenblatt R.12. 174:253-257. 15:1347-1356. Hogge JP. Hall DA. 180:795-798. Calcified suture material in the breast after radiation therapy. The mammographic spectrum of fat necrosis of the breast. Witten DM. Mester J. Sneige N. Franzen S.

➢ Thickened skin pattern (right) : Diffuse tubular parenchymal pattern ➢ Architectural distortion caused by periductal fibrosis not ductal ➢ Paget’s disease dilatation Rad Path Correlation: What You Need to Remember • The mass edge interface with the surrounding tissue reflects the aggressiveness of the underlying lesion • Benign masses tend to be less aggressive than malignant masses • The shape of the calcification represents a cast of an underling anatomic or pathologic space • Benign processes often cause smooth spaces • Necrosis (benign or malignant) causes irregular spaces Figure 1-25-2 Normal Anatomy • Skin • Nipple and areola • Subcutaneous fat • Premammary fascia Normal Anatomy • Glandular cone ➢ Breast disease occurs here • Retromammary fascia • Retromammary fat (left) Normal ductal distribution from nipple to • Muscle lobules. developing or neodensities ➢ Dilated duct (left) Ductogram showing normal ducts.Basic Breast Imaging Leonard M. MD There are Two Diseases • Cancer and no cancer Figure 1-25-1 Cancer has Two Predominant Signs • Mass and calcification You Have the Opposite Side for Comparison • Anatomy is simple • Physiology is almost irrelevant What You Need to Remember • 90% of cancers present as calcification.20 lobes or segments Figure 1-25-3 Normal Ducts [Figures 1-25-1 and 1-25-2] Terminal Duct Lobular Unit (TDLU) [Figure 1-25-3] • Short segment of terminal duct and a cluster of ductules (acini) • Functional unit of the breast • Ductal and lobular cancers begin here • Explains mixed ductal & lobular features in the same neoplastic lesion (left) Drawing of TDLU (right) Microscopic view of TDLU Chest Radiology 229 Basic Breast Imaging . Glassman. mass or both • 10% present as ➢ Focal asymmetry. • Ribs (right) : Normal duct with single cell epithelial layer and clear lumen Segmental Anatomy • 15 .

Embryology • Milk ridges ➢ Ventral ectodermal thickenings from the axillary to the inguinal region ➢ Usually limited to the pectoral regions by the ninth week of embryonic life Congenital Anomalies • Athelia ➢ Rarest anomaly of the breast ➢ Absence of the nipple • Amastia ➢ Agenesis of breast & nipple ➢ Associated with hypoplasia of the ipsilateral pectoral muscles in 90% ➢ Can be iatrogenic Figure 1-25-4 Congenital Anomalies • Polythelia • Polymastia Pregnancy Changes [Figure 1-25-4] • Increased estrogen & progesterone ➢ Estrogen promotes ductal growth ➢ Progesterone promotes lobular growth and breast secretion • Hyperplasia and hypertrophy • Extremely dense breast pattern • Can still see calcifications on mammography • Can see masses on sonography Mastitis • 3% of primary diagnoses at biopsy • Many different types Very dense parenchyma in a ➢ Infection normal pregnant patient ➢ Systemic ➢ Antigen-antibody reaction Figure 1-25-5 ➢ Idiopathic Mastitis [Figures 1-25-5 and 1-25-6] • Acute mastitis ➢ Usually in lactating women with a cracked nipple ➢ Can go on to abscess • Chronic mastitis Chronic Mastitis • Chronic infection ➢ TB Focal parenchymal ➢ Fungus density from acute • Immunologic bacterial mastitis ➢ Diabetes ➢ Amyloid ➢ Wegener granulomatosis Figure 1-25-6 ➢ Sarcoid ➢ Churg – Strauss • Idiopathic ➢ Necrobiotic xanthogranulomatosis ➢ Granulomatous mastitis Most Common Benign Neoplasms • Fibroadenoma (left) Early abscess with accumulation of pus in ➢ Biphasic tumor small spaces. • Intraductal papilloma (right) Later stage with larger area of pus • Hamartoma Basic Breast Imaging 230 Chest Radiology .

of sound Fibroadenoma Phyllodes Phyllodes Tumor [Figures 1-25-11 and 1-25-12] • Benign epithelial elements and cellular spindle cell stroma Figure 1-25-10 • Can act malignant ➢ Local recurrence ➢ Distant blood born metastases ➢ Lymph node enlargement reactive usually • Well circumscribed lobulated mass • Similar appearance on sonography ➢ May have cystic spaces Figure 1-25-11 (left) Densely calcified fibroadenomas. especially in periphery adherent surrounding tissue • Growth pushes surrounding tissue without invasion • 7-16% of patients have multiple tumors Figure 1-25-9 • Polyclonal cell population ➢ Begins as local fibroadenomatiod change which coalesces into a fibroadenoma Figure 1-25-8 Fibroadenoma [Figures 1-25-8 to 1-25-10] • Fibroadenoma • Carcinoma Carcinoma Arising in a Fibroadenoma • Rare • Most often lobular neoplasia (LCIS) or (left) Fibroadenoma showing pushing DCIS but not invasion of surrounding tissue. Chest Radiology 231 Basic Breast Imaging . • Oval or round circumscribed nodule (right) Fibroadenoma showing surface devoid of • May have coarse calcification. (right) Phyllodes tumor similar to a fibroadenoma except note the small cystic clefts. not enhanced thru transmission pushing.Biphasic Tumors Figure 1-25-7 • Epithelial & stromal elements ➢ Fibroadenoma ❖ Benign epithelial and stromal elements ➢ Phyllodes tumor ❖ Benign epithelial & hyperplastic or sarcomatous stroma ➢ Carcinosarcoma ❖ Both elements malignant Fibroadenoma [Figure 1-25-7] • Begins in TDLU (left) Circumscribed mass (fibroadenoma) showing • Response to unopposed estrogen in young women sharp border since there is no tissue invasion. Fibroadenoma showing • Invasive carcinoma very rare (right) Invasive carcinoma without the sharp borders and ➢ Usually grows in from outside sharp border because of invasion. (right) Irregular calcification and ill defined density from degenerated fibroadenoma (left) Phyllodes tumor as a macrolobulated circumscribed mass similar to a fibroadenoma.

carcinosarcoma Figure 1-25-14 Carcinosarcoma [Figure 1-25-13] Papilloma [Figures 1-25-14 to 1-25-16] • Papillary growth pattern supported by a fibrovascular stalk ➢ Arises centrally ➢ Usually solitary • Papillomatosis ➢ Arises peripherally in the TDLU ➢ Usually multiple Figure 1-25-15 (left) Filling defect in duct from papilloma (right) Specimen of papilloma in a dilated duct. Figure 1-25-12 Figure 1-25-13 (left) Mass with nonvascular cystic clefts in this Phyllodes tumor. (right) Filling defect in a dilated duct from a papilloma (left) Lobulated mass representing a dilated duct. Figure 1-25-16 (left) Unusual presentation of a papilloma as a discrete mass. (right) Dilated duct with papilloma showing prominent blood flow Lobular Neoplasia • No mammographic signs usually • Incidental finding on biopsy • Includes atypical lobular hyperplasia and LCIS Lobular Neoplasia • High incidence of bilaterality and multifocality ➢ Consider it a bilateral disease • High risk marker for the development of invasive carcinoma ➢ Up to 15% in either breast equally within 20 years ➢ Lobular or ductal features • If found on core biopsy 19% upgraded to carcinoma on excision ➢ Usually LN2 or LN3 • Pleomorphic and florid LCIS (subset of LN3) diagnosis carries highest risk Basic Breast Imaging 232 Chest Radiology . Ill defined subareolar (right) Phyllodes tumor showing clefts on low and UOQ mass in this power microscopy.

➢ Pleomorphic type causes necrosis and can present as irregular Figure 1-25-17 calcifications Invasive Ductal Cancer [Figures 1-25-17 to 1-25-25] • NOS (not otherwise specified) ➢ 50 to 75% of invasive cancers • Medullary • Papillary Figure 1-25-18 • Colloid (Mucinous) • Tubular • Metaplastic • Cribriform Diffusely infiltrative invasive • Adenoid cystic ductal carcinoma • Paget's disease • Inflammatory (left) Spiculated mass in this invasive ductal carcinoma (right) Specimen of spiculated invasive ductal carcinoma Figure 1-25-19 Figure 1-25-20 (left) Irregular calcifications in invasive ductal (left) Irregular calcification and spiculation in this carcinoma invasive ductal carcinoma (right) Specimen showing irregular (right) Specimen of this case showing irregular calcifications in irregular ductal lumens in this calcifications in irregular lumens and necrotic invasive ductal carcinoma tissue spaces Figure 1-25-21 Figure 1-25-22 (left) Mass with indistinct borders in invasive ductal MR showing enhancing carcinoma mass in invasive ductal (right) Spiculated mass in this invasive ductal carcinoma carcinoma Chest Radiology 233 Basic Breast Imaging .

Figure 1-25-23 Figure 1-25-24 Irregular shaped mass with lobulations and an acute angle on (left) Invasive ductal carcinoma presenting as a the right side in this invasive thick walled cyst (the “cyst” is central necrosis) ductal carcinoma (right) Dense shadowing by invasive ductal carcinoma Figure 1-25-25 Paget’s Disease [Figures 1-25-26 and 1-25-27] • Red nipple and areola • Scaling eczematoid reaction • 50% have a palpable mass • Must have Paget’s cells in skin • Usually has underlying carcinoma Figure 1-25-26 Many irregular calcifications in this invasive ductal carcinoma Figure 1-25-27 (left) Paget’s disease with red moist nipple (right) Paget’s disease with dry scaly nipple Types of Invasive Ductal Carcinoma With Rounded Expansile Periphery • Medullary • Papillary • Cribriform • Colloid (left) Invasive ductal carcinoma calcifications behind nipple in Paget's disease Types of Invasive Ductal Carcinoma with (right) Specimen confirming calcifications in Improved Prognosis invasive ductal carcinoma. Paget’s cells in skin • Medullary • Papillary • Cribriform Figure 1-25-28 • Colloid • Tubular • Adenoid cystic Medullary Carcinoma [Figure 1-25-28] (left) Medullary carcinoma with slightly more indistinct borders than fibroadenoma (right) Minimal invasion of surrounding tissue (bottom right) by medullary carcinoma Basic Breast Imaging 234 Chest Radiology .

Papillary Carcinoma [Figure 1-25-29] Figure 1-25-29 Tubular Carcinoma [Figures 1-25-30 and 1-25-31] • Typically spiculated • Must have 75 .100% tubular formation • Less than 75% acts like usual invasive carcinoma Figure 1-25-30 Circumscribed macrolobulated mass was a papillary carcinoma Figure 1-25-31 Very spiculated mass is typical tubular carcinoma Adenoid Cystic Carcinoma [Figure 1-25-32] (left) Tubule formation in tubular carcinoma (right) Spiculations in tubular carcinoma Invasive Lobular Cancer • Prognosis similar to invasive ductal cancer Figure 1-25-32 • Most commonly a spiculated mass • Some are more difficult to see as they are diffusely infiltrating ➢ Present as asymmetric density Invasive Lobular Cancer [Figures 1-25-33 to 1-25-35] • Invasive lobular • Invasive ductal Figure 1-25-33 Figure 1-25-34 Typical adenoid cystic carcinoma with lobulations but no spiculation (left) Tumor cells of invasive lobular carcinoma in single file (right) Tumor cells of invasive ductal carcinoma in enlarged thick walled ducts Spiculkated mass is the most common presentation of invasive lobular carcinoma Chest Radiology 235 Basic Breast Imaging .

(right) Specimen of fibrosarcoma (left) Irregular non specific mass in spindle cell Figure 1-25-38 sarcoma. blood vessels. malignant fibrous hystiocytoma. ➢ Angiosarcoma. (right) Specimen of spindle cell sarcoma Angiosarcoma Basic Breast Imaging 236 Chest Radiology . etc.Sarcoma Figure 1-25-35 • 1% of breast malignant tumors • Breast contains fat. fibrous tissue. chondrosarcoma. rhabdomyosarcoma etc. • Metaplasia can occur • Malignant transformation can occur • Often after chest or breast irradiation Fibrosarcoma [Figure 1-25-36] Spindle Cell Sarcoma [Figure 1-25-37] Angiosarcoma [Figure 1-25-38] What You Need to Remember • The mass edge represents the aggressiveness of the underlying abnormality Focal asymmetric density in • The shape of the calcification represents a cast of an underlying space invasive lobular carcinoma often causes misdiagnosis Figure 1-25-36 Figure 1-25-37 (left) Non specific mass in fibrosarcoma.

17. 28. 15. 20. Lo YF. 164:321-326. Radiographics 2005. Mercado CL. de Paredes ES. Blume JD. Papillary carcinoma of the breast: imaging findings. Jr. Moon WK. 13. 186:426-430. Boetes C. 351:427-437. 213:11-14. Wilson JD. Shah YP. Stavros T. 89:2538-2546. Pathology of benign and malignant breast disorders. 103:1898-1905. Radiographics 1999. 4. 2. Prospective evaluation of the value of combined mammographic and sonographic assessment in patients with palpable abnormalities of the breast. AJR Am J Roentgenol 2006. J Ultrasound Med 2003. 19. Digital mammography. Bartella L. Chen MF. Ikeda DM. Huynh PT. Comparison of the performance of screening mammography. van den Bosch MA. Johnson BA. Kornguth PJ. Sahin AA. 7. Fornage BD. Sickles EA. Farr GH. 3. AJR Am J Roentgenol 2000. Goel NB. Shetty MK. Kriege M. J Clin Ultrasound 2000. Phyllodes tumors of the breast. Radiology 2005. 30. et al. 33:1067-1080. Magnetic resonance imaging characteristics of fibrocystic change of the breast. 5. 25. Herfkens RJ. 22:263-268. Alleva DQ. Bassett LW. Han BK. Dennis MA. Choe YH. Ahn SH. Trivedi A. Vidarsson L. 9. Probably benign breast lesions: when should follow-up be recommended and what is the optimal follow- up protocol? Radiology 1999. Dershaw DD. 18. 38:669-691. 21. N Engl J Med 2004. Imaging of breast masses. 23. Nonpalpable mammographically occult invasive breast cancers detected by MRI. Wilken JJ. 19 Spec No:S27-35.. Newhouse JH. Radiology 2002. Chen SC. Ductography: how to and what if? Radiographics 2001. 40:436-441 Chest Radiology 237 Basic Breast Imaging . Su CH. Ultrasound Obstet Gynecol 2004. 196:123-134. Radiology 1995. Soo MS. Radiol Clin North Am 2000. 28:179-186. Schnall MD. Mariano MN. Williford ME.References 1. Papillary lesions of the breast at percutaneous core-needle biopsy. Singer CI. Sewell CW. Stavros AT.825 patient evaluations. Unusual breast lesions: radiologic-pathologic correlation. Pandey S. 20:217-260. Radiographics 1999. Jackson VP. Liberman L. Walsh R. Radiol Clin North Am 1995. Drotman M. Sickles EA. 186:865-870. Metaplastic carcinoma of the breast: mammographic and sonographic findings. Riddick-Young M. discussion S36-37. Radiologic evaluation of uncommon inflammatory and reactive breast disorders. Radiographics 2005. 237:429-436. 22:19-33. 19 Spec No:S11-26. 14. Radiographics 2002. De Las Heras P. Cancer 2000. Liberman L. Rapp CL. 24. Cancer 2005. Zakhour M. Sheppard DG. Breast Dis 1998. Brekelmans CT. and positron emission tomography breast imaging. Liberman L. Ultrasound Q 2004. Hamele-Bena D. Weatherall P. Smetherman DH. Sharman RS. 8. et al. 23:188-193. Morris EA. Parham CA. Park JM. Breast sonography. Radial scar of the breast: radiologic-pathologic correlation in 22 cases. Radiology 2006. Morris EA. 22. Feder JM. Lichy J. Espinosa LA. Analysis of sonographic features for the differentiation of benign and malignant breast tumors of different sizes. Thickman D. Gomez A. sestamibi breast scintigraphy. Cangiarella J. Grimes MM. Clotet M. Radiol Clin North Am 2000. 38:861-869. 33:1123-1130. Sisney GA. Salinas T. Torrubia S. Bluemke DA. Stelling CB. 12. and breast US and evaluation of factors that influence them: an analysis of 27. 6. Cheung YC. The lactating breast: contrast-enhanced MR imaging of normal tissue and cancer. Morris EA. Oken SM. Gong G. Pisano ED. Fibrous lesions of the breast: imaging- pathologic correlation. Daniel BL. Eur Radiol 2003. 238:801-808. Chen MF. Knight TE. Sonography of mammary implants. de Paredes ES. 238:42-53. Kolb TM. AJR 1995. 10:55-66. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Whitman GJ. Screening women at high risk for breast cancer with mammography and magnetic resonance imaging. et al. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. Focal asymmetric densities seen at mammography: US and pathologic correlation. de Paredes ES. 13:88-93. Radiology 2006. Management of probably benign breast lesions. quiz 269-270. Parker SH. Invest Radiol 2005. 27. Hogge JP. Does size matter? Positive predictive value of MRI-detected breast lesions as a function of lesion size. Rapp CL. Lehman CD. Cederbom GJ. Samardar P. Bentley RC. 25:1547-1559. Parker SH. Daniel BL. Blume J. et al. et al. Slawson SH. 174:253-257. Sabate JM. 11. Chao TC. Bassett LW. Dershaw DD. 225:165-175. AJR Am J Roentgenol 2006. 29. 26. 16. Hsueh S. Chen SC. Mason G. Imaging-histologic discordance at percutaneous breast biopsy. physical examination. Hwang TL. Radiol Clin North Am 1995. 10. Tubular carcinoma of the breast: mammographic and sonographic features. Diagnostic architectural and dynamic features at breast MR imaging: multicenter study. 25:411-424. 21:133-150.

Glassman.000 in 1992 Is It Malignant? • 30 to 60% of underdiagnosed DCIS becomes invasive cancer within 25 years • Usually in the same breast and near the biopsy site Ductal Carcinoma in Situ 238 Chest Radiology .000 in 1973 ➢ 15. • Lobular carcinoma in situ (top right) Stretching and thinning if duct lumen by early ➢ High risk DCIS (bottom right) Dilated duct with wall irregularity in DCIS Confined to the Duct [Figure 1-26-1] • No spread to blood or lymph nodes • Less than 1% positive axillary nodes ➢ Probably unrecognized invasion ➢ Most likely in large lesions and palpable lesions The Problems • How big is the problem? • How do we classify the disease? • How do we diagnose it? • What is adequate treatment? How Big is the Problem? • USA data ➢ 50% eligible women get screening annually after 40 ➢ 240.8 per 100.4 per 100. MD Ductal Carcinoma in Situ (DCIS) • Also called intraductal carcinoma ➢ Not invasive ductal carcinoma ➢ DCIS is “benign” ❖ Disease is confined to the breast Figure 1-26-1 ❖ Patients die from metastatic disease secondary to invasive carcinoma Relative Risk of Invasive Carcinoma (Biopsy Findings) • Mild intraductal hyperplasia (IDH) ➢ No increased risk • Moderate or florid IDH ➢ Slight increased risk • Atypical hyperplasia (ductal or lobular) with no family history and/or postmenopausal ➢ Mild to moderate increased risk • Atypical hyperplasia (ductal or lobular) with positive family history and/or premenopausal ➢ High risk • Ductal carcinoma in situ (left) Thickened duct walls with necrosis and comedo ➢ High risk secretion in the lumen.Ductal Carcinoma in Situ (DCIS) Leonard M.000 new breast cancers annually ❖ Includes invasive and intraductal • 1980 5% of new breast cancers were DCIS ➢ Usually a palpable lump or nipple discharge • 2000 20% of new breast cancers ➢ Usually microcalcifications on mammography • Age-adjusted incidence increasing ➢ 2.

8% recurrence with lumpectomy alone (51% invasive) Indicators of Recurrence after Conservative Treatment • Tumor size • Nuclear grade • Necrosis • Margin status • Multifocality • Lymphocytic infiltrate Epidemiology • Same risks as for invasive cancer ➢ Increasing age ➢ Early menarche ➢ Family history ➢ Previous breast biopsy ➢ Nulliparity or late age at first birth Pathologic Classification of DCIS • No uniform agreement on single scheme • Interobserver agreement between schemes is poor Classifications of DCIS • DIN • European Commission Working Group • Lagios • Modified Lagios • Nottingham • UKNBCSP • Van Nuys Architectural Classification of DCIS • Comedo ➢ Needs comedonecrosis and high nuclear grade • Non-comedo ➢ Cribriform ➢ Micropapillary ➢ Papillary ➢ Solid • Special type ➢ Apocrine ➢ Clear cell ➢ Signet ring cell ➢ Small cell ➢ Endocrine ➢ Spindle cell Intraductal Carcinoma (DCIS) • Histology may be able to predict recurrence risk ➢ High grade.Invasive Cancer after DCIS • NASBP B17 (790 women) at 5 years ➢ Women treated with breast conservation ➢ 115 recurrent cancers ❖ 80% same breast ❖ 15. comedo have higher recurrence ➢ Low grade.7% opposite breast ❖ 4. small cell. noncomedo (cribriform. micropapillary) • Poor correlation of calcification type and extent with grade and extent of tumor Chest Radiology 239 Ductal Carcinoma in Situ .3% regional or distant metastases ➢ 12.1% recurrence with lumpectomy + radiation (36% invasive) ➢ 26. large cell.

• Number (right) Small vertically oriented solid mass • Distribution represents DCIS • Shape • Change over time Figure 1-26-5 Size of Particles • < 1 mm ➢ Evaluate malignant potential by smallest particles in the abnormality Number • Cluster is 5 particles or more in 1 cubic cm. Figure 1-26-4 Irregular filling defect in duct represents DCIS MRI with large area of enhancement was DCIS on biopsy Ductal Carcinoma in Situ 240 Chest Radiology .Is DCIS One Disease? Low Grade High Grade • ER +++ + • PR +++ + • HER-2/neu + +++ • p53 + ++ • bcl-2 + – Is DCIS One Disease? Figure 1-26-2 • Associated invasive carcinoma shows marker phenotype like precursor DCIS • Low grade DCIS yields low grade invasive tumors • High grade DCIS yields high grade invasive tumors • Theory: Low grade and high grade DCIS are different from the start Diagnosis of DCIS • Mass • Mammographic calcifications ➢ Can’t distinguish from invasive carcinoma ➢ Associated mass usually invasive disease Mass • Rare today • Usually small Small indistinct mass DCIS Mass Close-up [Figure 1-26-2] represents DCIS DCIS Mass [Figures 1-26-3 to 1-26-5] Figure 1-26-3 Intraductal Carcinoma (DCIS) • Microcalcification usually without mass • Particles < 1 mm • Varying size shape and density • Clustered • May coexist with benign calcifications Calcification • Size (left) Large obscured mass was entirely DCIS.

Distribution [Figure 1-26-6] Figure 1-26-6 • Cluster • Linear ➢ DCIS involves a duct ➢ Linear distribution toward nipple ➢ High grade is continuous involvement ➢ Low grade has skip areas • Segmental ➢ Involvement of an entire ductal system Segmental Intraductal Carcinoma [Figure 1-26-7] (left) Cluster of irregular calcifications was DCIS Shape is Most Important on biopsy • Irregular (right) Broken rod shaped calcification in a linear ➢ Not smooth round or hollow distribution represents DCIS • Heterogeneous or pleomorphic ➢ Not all the same Figure 1-26-7 Pleomorphic [Figure 1-26-8] Calcifications represent the caste of a space • Irregular duct • Necrotic tissue space Intraductal Carcinoma [Figure 1-26-9] Figure 1-26-9 Segmental distribution of granular calcifications was DCIS Left: Small calcifications filling the residual lumen Figure 1-26-8 made irregular by wall thickening of DCIS Right: Duct calcification shape is related to the contour of the duct wall Shapes of DCIS Calcification • Granular • Irregular rods • Casting • Irregular ➢ Branching ➢ Comma shaped ➢ Arrow shaped or pointed Multiple irregular calcifications in biopsy proven DCIS Chest Radiology 241 Ductal Carcinoma in Situ .

5 mm) • Need magnifying glass to evaluate • Too small to see true shape • “Grains of sand” Irregular Rods • Made up of many tiny pieces on magnification • Not solid large rods ➢ Secretory disease • Often branch Rods [Figure 1-26-11] Extremely small calcifications • Regular represent a finding of DCIS • Irregular Casting • Granular calcifications filling the lumen of an irregular duct Figure 1-26-11 • Often branch Irregular [Figure 1-26-12] • Castes of necrotic spaces • Branching • Comma shaped • Arrow shaped or pointed Figure 1-26-12 (left) Smooth rods of secretory disease (right) Broken rods of DCIS Figure 1-26-13 (left) Diffuse microcalcifications of DCIS. (right) Calcification in necrotic wall of duct involved Diffuse amorphous with DCIS calcifications of DCIS Ductal Carcinoma in Situ 242 Chest Radiology . (right) Ultrasound shows calcifications and parenchymal change in DCIS Small irregular clustered calcifications were biopsied yielding DCIS Figure 1-26-14 Intraductal Carcinoma [Figures 1-26-13 to 1-26-15] Figure 1-26-15 (left) Clustered irregular calcifications.Granular [Figure 1-26-10] Figure 1-26-10 • Very small (<0.

annual bilateral for 3 years ❖ No scientific basis Biopsy • Imaging guided biopsy with specimen radiography ➢ Usually stereotactic • Wire guided excision with specimen radiography Pathologic Findings Needed in Any Report • Nuclear grade ➢ Low. intermediate or high • Necrosis ➢ Comedo or punctate • Architectural pattern • Lesion size • Margin assessment • Specimen processing ➢ Report should include ❖ Presence of calcification ❖ Correlation with specimen radiograph and/or mammogram Extent of Calcification Does Not Correspond to the Extent of the Tumor • Best correlation is with comedo type but not good enough ➢ Poor correlation with cribriform and micropapillary • Must use histologic margins to define true extent Treatment • Simple mastectomy without axillary dissection ➢ 25% of patients choose this option ➢ Large lesions in small breasts ➢ Multiple lesions ➢ No radiation ❖ Unavailability ❖ Prior radiation ❖ Collagen vascular disease ➢ Patient preference • Reconstruction Chest Radiology 243 Ductal Carcinoma in Situ .Change Over Time • Benign processes can change • Malignant processes almost always change within 3 years • Short interval follow-up ➢ Probably benign findings ➢ 6 months unilateral.

54 Radiation Therapy • 1.8 to 2.Breast Conservation • Wide local excision without axillary dissection ➢ Sentinel node when large or palpable lesions • Post -excision mammogram with magnification views of biopsy site ➢ May be done 2 or 3 months after excision ➢ Not necessary if specimen radiograph shows complete excision with 10 mm margin • Radiation is standard ➢ Helps in all patients ➢ Benefit may be small in a subset of patients ❖ Small lesions ❖ Low grade histology ❖ Wide clear margins • Local excision alone without radiation ➢ Controversial ➢ Less than 2 .49 ➢ <1 mm 2.3 cm lesion ➢ Margins should be 10 mm or greater ➢ Nuclear grade low or intermediate • Recurrence risk 1% per year What is a Clear Margin? • Relative risk of recurrence after excision and radiation ➢ 10 mm or greater 1.14 ➢ 1 – 9 mm 1.0 Gy fractions Monday through Friday • 45 to 50 Gy total dose • Boost 10 to 20 Gy to surgical bed • No axillary radiation Chemotherapy • No cytotoxic drugs • Tamoxifen 20 mg daily for 5 years ➢ Newer drugs possible with fewer side effects ➢ Decreases invasive recurrences ➢ No change in survival ❖ Survival is over 90% without chemotherapy Treatment of Recurrence • DCIS ➢ Mastectomy if radiation given previously ➢ Mastectomy or wide excision with radiation • Invasive carcinoma ➢ Treat like any invasive cancer ➢ Can not give radiation twice Follow-up • Lifetime • Annual mammography ➢ First exam 6 months after completion of treatment ➢ Every 6 months for the first two years? ➢ Use of magnification views common ❖ Most common in first exam after treatment Summary • DCIS is carcinoma without the ability to spread YET • It is detected on mammography as calcification • Adequate detection and treatment decreases the incidence of invasive cancer and therefore death Ductal Carcinoma in Situ 244 Chest Radiology .

et al. 20:501-508. Park IA. Morris EA. Hunt KK. 50:235-240. 8. Nonpalpable ductal carcinoma in situ versus infiltrating carcinoma of the breast--can they be differentiated by mammography? Can Assoc Radiol J 1991. The Consensus Conference Committee. 3. 16. 9. Cancer 2004. Cancer 2000. et al. High detection rate of breast ductal carcinoma in situ calcifications on mammographically directed high-resolution sonography. 4. 10. Consensus Conference on the classification of ductal carcinoma in situ. Stomper PC. Semin Diagn Pathol 1994. AJR Am J Roentgenol 2003. 9:345-356. Can Assoc Radiol J 1999. discussion 280-281. Lee YJ. Cornfield DB. Cancer 1997.References 1. Hermann G. Hashimoto BE. Cancer Lett 1994. Chew KL. Mirza NQ. Clinically occult ductal carcinoma in situ detected with mammography: analysis of 100 cases with radiologic-pathologic correlation. 86:1-4. 340:1455-1461. Groshen S. et al. 2. Moon WK. Radiology 1989. Hendriks JH. Microcalcifications associated with ductal carcinoma in situ: mammographic-pathologic correlation. Pathology of high-risk breast lesions and ductal carcinoma in situ. Hermann G. Ljung BM. Cancer 2004. Kerlikowske K. Page DL. Consensus Conference on the Treatment of In Situ Ductal Carcinoma of the Breast. Silverstein MJ. Schwartz I. J Ultrasound Med 2001. Palazzo JP. April 22-25. Ernster VL. Schwartz GF. Rabinowitz JG. MRI of occult breast carcinoma in a high-risk population. US of ductal carcinoma in situ. Harris JR. Meyer JE. DeVries S. 2nd. The prognostic significance of multiple morphologic features and biologic markers in ductal carcinoma in situ of the breast: a study of a large cohort of patients treated with surgery alone. 172:235-241. 22:269- 280. Radiol Clin North Am 2004. 100:2317-2327. Radiographics 2002. 13. 14. J Natl Cancer Inst 2000. Waldman FM. 100:942-949. The influence of margin width on local control of ductal carcinoma in situ of the breast. 1999. Pressman PI. Picozzi VJ. Schwartz GF. Physician recommendations regarding tamoxifen and patient utilization of tamoxifen after surgery for ductal carcinoma in situ. 5. Keller RJ. N Engl J Med 1999. Yen TW. Chromosomal alterations in ductal carcinomas in situ and their in situ recurrences. Noh DY. Sewell CW. Im JG. Halton K. Olivotto IA. 181:619-626. Birdwell RL. Liberman L. et al. Mammographic pattern of microcalcifications in the preoperative diagnosis of comedo ductal carcinoma in situ: histopathologic correlation. Connolly JL. Holland R. 11. 11:181-192. Keller RJ. 6. 80:1798-1802. 88:946-954. Chest Radiology 245 Ductal Carcinoma in Situ . Lagios MD. et al. Myung JS. 12. Lagios MD. Ikeda DM. Ballon DJ. 92:313-320. Magn Reson Imaging Clin N Am 2001. 7. Pathology and clinical evolution of ductal carcinoma in situ (DCIS) of the breast. 42:219- 222. Solin LJ. Potential role of magnetic resonance imaging and other modalities in ductal carcinoma in situ detection. Drossman S. 42:821- 830. 15. Moore DH. Tartter P. vii. Daniel BL. Kramer DJ.

3% ➢ Age 20 – 34 ❖ 2% Invasive ❖ 1% DCIS ➢ Age 40 – 49 ❖ 19% High Risk Screening • Multiple first degree family members ➢ Begin mammography 10 years before the earliest affected relative ❖ Interval uncertain but every 1-2 years usual • BRCA 1 and 2 ➢ Begin at 25 ❖ Interval uncertain but annual is common • Ultrasound can be useful • MRI can be useful ➢ More sensitive than mammography in high risk groups Breast Abnormalities in Young Women 246 Chest Radiology . Glassman.Breast Abnormalities in Young Women Leonard M. MD Lesions in Young Women are Rare • Very few patients seen by the average radiologist • Women 21 years of age and younger ➢ Fibroadenoma (up to 95%) ➢ Juvenile hypertrophy ➢ Abscess and mastitis ➢ Phyllodes tumor ➢ Malignancy ❖ Primary ❖ Metastatic ➢ Cysts are rare Lesions in Young Women are Rare • Women over 21 years of age ➢ Fibroadenoma ➢ Abscess and mastitis ➢ Phyllodes tumor ➢ Cysts ❖ More common as age approaches 35 ➢ Malignancy Diagnosis in Young Women • Ultrasound is primary modality ➢ Breasts are dense after puberty ➢ Radiation has a small risk • Mammography is used in select older patients ➢ High risk screening ➢ Masses in patients over 30 ➢ Malignant looking lesions Breast Cancer Incidence in Young Women • % of all breast cancers ➢ Age <20 ❖ 0% ➢ Age <30 ❖ 0.

Ultrasound in Young Women • Good test in dense breasts BUT ➢ Many benign non palpable masses in young women ➢ Very few cancers in young women Breast MRI in Young Women • Diagnosis ➢ Proven cancer ❖ Multifocality ➢ Difficult imaging ❖ Is biopsy needed? • Screening ➢ Strong family history ➢ Gene positive BRCA 1 BRCA 2 Presenting Signs & Symptoms • Mass • Pain • Screening ➢ BRCA 1 ➢ BRCA 2 ➢ Family history Benign Lesions Occurring Multiple Times • Fibroadenoma ➢ Juvenile ➢ Giant • Phyllodes low grade • Granular cell tumor • Lactating adenoma • Hamartoma • Normal breast • Fibrocystic change • Intraductal papilloma • Juvenile papillomatosis • Vascular • Mastitis • Juvenile hypertrophy • Diabetic mastopathy Benign Lesions Occurring Once • PASH • Granulomatous mastitis • Fibromatosis • Adenosis • Intraductal papilloma • Fibroadenomatoid hyperplasia • Fibrosis • Mondor’s disease • Varix • Rosai Dorfman disease (Sinus histiocytosis with lymphadenopathy) 32 Fibroadenoma • Age 0-35 ➢ 3 Age 5-9 ➢ 8 Age 10-14 ➢ 3 Age 15-19 Chest Radiology 247 Breast Abnormalities in Young Women .

It is sharply bordered and homogeneous (lower right) Surgical specimen without adherent surrounding tissue (left) Large solid sharply bordered mass in a 14 year old.Fibroadenoma • Second most common breast lesion ➢ Fibrocystic change is first • Begins in TDLU ➢ Caused by unopposed estrogenic stimulation ➢ Rare in men Figure 1-27-1 ❖ Must have hyperestrogenic state Fibroadenoma • Multiple in 16 – 25% of patients clinically • Found in 25% of breasts examined microscopically • Can undergo myxoid change or hyalinization ➢ Gelatinous nodule ➢ Calcification Fibroadenoma • Originate in lobules (TDLU) • Stages of development ➢ Proliferation of epithelial and stromal elements in (left) Two intermediate density circumscribed multiple lobules fibroadenomas. ➢ Confluence of the hyperplastic lobules (right) Sharply bordered horizontally oriented oval ➢ Formation of fibroadenomatous nodules solid mass representing a fibroadenoma ➢ Nodules coalesce to form FA Fibroadenoma (32) [Figure 1-27-1] Fibroadenoma vs Giant Fibroadenoma vs Juvenile Fibroadenoma • Fibroadenoma • Giant fibroadenoma ➢ Large lesion usually > 10 cm • Juvenile fibroadenoma ➢ Age 20 years or younger ➢ Typically rapid growth and large size ➢ Usually pericanicular type with cellular stroma Giant Fibroadenoma (32) [Figure 1-27-2] Figure 1-27-2 Juvenile Fibroadenoma (14) [Figure 1-27-3] Figure 1-27-3 (left) Large circumscribed intermediate density mass which is a giant fibroadenoma. (upper right) Same lesion on ultrasound. (right) Gross specimen of a juvenile fibroadenoma Breast Abnormalities in Young Women 248 Chest Radiology . a juvenile fibroadenoma.

Phyllodes Tumor • Benign epithelial elements and cellular spindle cell stroma • Can act malignant ➢ Local recurrence Figure 1-27-4 ➢ Distant blood born metastases ➢ Lymph node enlargement reactive usually • Well circumscribed lobulated mass • Similar appearance on sonography to fibroadenoma ➢ May have cystic spaces Phyllodes Tumor • Low grade ➢ Pushing margins ➢ Mild atypia (left) CT scan showing left breast mass with areas ➢ May recur locally of liquefaction necrosis. ➢ Rare metastases (right) Gross specimen of low grade Phyllodes • High grade with areas of necrosis ➢ Invasive margin ➢ Moderate to severe atypia Figure 1-27-5 ➢ Common local recurrence ➢ Hematogenous metastases Phyllodes Tumor • Treatment ➢ Wide local excision 6 Phyllodes Low Grade • Age 25-35 ➢ 3 Age 25-29 ➢ 3 Age 30-35 • Can occur in girls under 10 years old • Usually older than 10 years • Tendency to recur but not metastasize • Pushing margins without invasion (left) Partially obscured large non calcified mass in Phyllodes Low Grade (34) [Figure 1-27-4] the upper breast. (right) Specimen shows mass with only minimal Phyllodes Low Grade (31) [Figure 1-27-5] adherent tissue 6 Granular Cell Tumor • Age 15-35 Figure 1-27-6 ➢ 1 Age 15-19 ➢ 1 Age 20-24 ➢ 2 Age 25-29 ➢ 2 Age 30-35 • Neural cell origin ➢ First described in tongue ➢ 6% in the breast ➢ 1/1000 incidence of invasive ductal carcinoma • Wide age range (17-75 years) ➢ Average age 30’s • Discrete round mass or spiculated mass ➢ Push or invasive margin • Rare metastasis to axillary nodes ➢ One case in literature of lung metastases Granular Cell Tumor (33) [Figure 1-27-6] Circumscribed mass was granular cell tumor on biopsy Chest Radiology 249 Breast Abnormalities in Young Women .

(right) Lactating adenoma presenting as a smooth intermediate density non-calcified mass Hamartoma • Fibroadenolipoma • Palpable mass or mammographic finding ➢ Can be large and not palpable • Encapsulated normal breast elements Hamartoma (34) [Figure 1-27-10] Solid mass with an angular border on the right Juvenile Papillomatosis side which was proven to be a lactating adenoma • Firm discrete mass ➢ Localized cystically dilated ducts with intraductal proliferation • 2/3 less than 20 years old Figure 1-27-10 • Association with family history of breast carcinoma ➢ 10% develop carcinoma within 10 years • Treat with excisional biopsy Juvenile Papillomatosis (14) [Figure 1-27-11] Figure 1-27-11 (left) Hamartoma as a smooth large non- calcified mass with fat in it. (right) Irregular solid markedly hypoechoic mass with microlobulations and spiculation in this granular cell tumor Figure 1-27-9 (left) Lobulated solid mass is a biopsy proven lactating adenoma. (right) Pathologic specimen of juvenile papillomatosis Breast Abnormalities in Young Women 250 Chest Radiology . (right) Lobulated mildly inhomogeneous solid mass corresponding to the hamartoma on the last figure (left) Multicystic mass with many small cystic spaces represents classic juvenile papillomatosis in a 14 year old.Granular Cell Tumor (35) [Figure 1-27-7] Figure 1-27-7 Lactating Adenoma [Figures 1-27-8 and 1-27-9] • Young women • Pregnant or lactating women • Circumscribed lobulated masses Figure 1-27-8 (left) Spiculated granular cell tumor.

Juvenile Hypertrophy [Figure 1-27-12] Figure 1-27-12 • Usually age 11-14 • Usually coincides with first menses • Usually lasts 3-6 months • Unilateral or bilateral palpable mass • Iatrogenic amastia if removed Diabetic Mastopathy • Focal fibrosis in the breast • Diabetes mellitus type 1 since childhood ➢ Poorly controlled ➢ Complications from vasculitis elsewhere • Occurs in young to middle age Diabetic Mastopathy (33) [Figure 1-27-13] Figure 1-27-13 Diabetic Mastopathy (28) [Figure 1-27-14] Figure 1-27-14 Increased tissue behind the nipple in this 12 year old girl was juvenile hypertrophy Very irregular hypoechoic mass with shadowing was also diabetic mastopathy in a 28 year old Dense mass in a 33 year old PASH (Pseudoangiomatous Stromal Type 1 diabetic was diabetic Hyperplasia) mastopathy • Wide age range • Focal lesion usually • Histologically shows slit-like separation of stromal cells • Exaggerated stromal response to hormone stimulation PASH (35) [Figure 1-27-15] Figure 1-27-15 (left) Circumscribed mass in PASH in a 35 year old. (center) Large cystic spaces in PASH (right) Specimen showing large cystic spaces in PASH Chest Radiology 251 Breast Abnormalities in Young Women .

Granulomatous Mastitis [Figure 1-27-16] Figure 1-27-16 • Usually in reproductive age • Often within 3 years of pregnancy • Idiopathic • Specific causes must be excluded ➢ TB or other bacteria ➢ Sarcoid ➢ Fat necrosis ➢ Foreign body Granulomatous Mastitis (26) [Figures 1-27-17 and 1-27-18] Figure 1-27-17 Swelling and redness in granulomatous mastitis Figure 1-27-18 Spiculated mass in granulomatous Irregular hypoechoic mass was mastitis granulomatous mastitis Malignant • No malignant lesion under age 15 in our series • Invasive ductal carcinoma ➢ DCIS Figure 1-27-19 • Sarcoma ➢ Angiosarcoma most common • High grade phyllodes • Lymphoma • Metastasis Ductal Carcinoma • Age 15-35 ➢ 2 age 15-19 ➢ 2 Age 20-24 ➢ 4 Age 25-29 ➢ 18 Age 30-35 • 2 Secretory carcinoma Invasive Ductal Carcinoma [Figure 1-27-19] • Most common carcinoma • Youngest patient 6 years (not in this series) • Signs similar to older patients Clustered amorphous calcifications of invasive ductal carcinoma in a 30 year old Breast Abnormalities in Young Women 252 Chest Radiology .

Invasive Ductal Carcinoma (28) [Figure 1-27-20] Figure 1-27-20 Medullary Carcinoma (24) Figure 1-27-21 [Figure 1-27-21] Medullary Carcinoma (17) [Figure 1-27-22] Figure 1-27-22 Microlobulated mass with spiculations in a 28 year old represents invasive ductal carcinoma Seventeen year old patient with medullary carcinoma Secretory Carcinoma Irregular shaped mass with • Previously called juvenile spiculations in a 24 year old patient carcinoma with medullary carcinoma • Initial report age 3-15 ➢ Oldest patient 87 • Limited aggressiveness in younger patients Figure 1-27-23 Secretory Carcinoma (23) [Figure 1-27-23] DCIS (26) [Figure 1-27-24] • Found on screening mammography in high risk patients • Found as mass rarely or nipple discharge Figure 1-27-24 Slightly irregular mass of secretory carcinoma in a 23 year old Amorphous calcifications of DCIS in a 26 year old Sarcoma • Malignant mesenchymal tumors • 1% of malignant tumors in all ages ➢ Higher % in young women • After radiation therapy 2-15 years • Many histological subtypes Chest Radiology 253 Breast Abnormalities in Young Women .

(right) Angiosarcoma 25] Phyllodes High Grade • Age 20-35 Figure 1-27-26 ➢ 2 Age 20-24 ➢ 1 Age 25-30 ➢ 2 Age 30-35 • Usually older than 10 years • Tendency to recur and metastasize • Invasive margins • Axillary adenopathy usually reactive • Metastases hematogenous Phyllodes High Grade (31) [Figure 1-27-26] Lymphoma • Primary or secondary (left) Lobulated mass representing a high grade • Focal mass or diffuse process phyllodes tumor (right) Lobulated edge of high grade phyllodes Lymphoma (27) [Figure 1-27-27] tumor well seen on ultrasound Metastatic Disease • Neurofibrosarcoma • Medulloblastoma Figure 1-27-27 • In adults (male and female) ➢ Melanoma ➢ Lung ➢ Prostate ➢ Lymphoma Irregular mass of primary lymphoma in a 27 year old Breast Abnormalities in Young Women 254 Chest Radiology .Sarcoma • Age 15-35 ➢ 2 Age 15-19 Figure 1-27-25 ➢ 2 Age 20-24 ➢ 2 Age 25-29 ➢ 4 Age 30-35 • 7 Angiosarcoma • 2 Granulocytic sarcoma • 1 Myosarcoma Angiosarcoma • 14 – 82 years ➢ Mean of 35 • Lobulated mass • Highly aggressive lesion ➢ Axillary metastasis rare ➢ Hematogenous metastasis usual (left) Large mass replacing the entire breast in angiosarcoma Angiosarcoma (34) [Figure 1-27.

Breast masses in African American teenage girls. Farrell EG. Female breast masses during childhood: a 25-year review. Sievert L. 21:664-668. Ciftci AO.al. likely malignant lesions and the older patients in this group • MRI indications are evolving • Cysts are rare especially in the younger age groups • Most solid lesions are benign ➢ Fibroadenoma most common • Juvenile hypertrophy and juvenile papillomatosis are unique to this age group and have specific appearances on imaging • Malignant lesions occur and look like malignant lesions in older women ➢ Invasive ductal carcinoma most common References 1. 172:445-448. Karl SR. Siegel MJ. 3. Radiology 1989. 28:832-835. Diard F. Arboucalot F. Rosai J. Indications for breast imaging in women under age 35 years. Greydanus DE. Hildebolt CF. Murphy JJ. J Ultrasound Med 2001. Wold LE. 11. 36:601-638. Bock K. 20:368-371. Pathologic Breast Conditions in Childhood and Adolescence. Jackson VP. 2. Gow KW.Metastatic Disease (29) [Figure 1-27-28] Figure 1-27-28 • Neurofibrosarcoma Metastatic Disease (35) [Figure 1-27-29] • Medulloblastoma Figure 1-27-29 (left) Well marginated oval solid mass in a metastatic neurofibrosarcoma (right) Specimen shows sharply marginated mass without invasion of surrounding tissue (left) Partially obscured noncalcified mass in metastatic medulloblastoma (right) Well marginated lobulated metastatic medulloblastoma Conclusions • Ultrasound is the primary modality in this age group • Mammography is reserved for screening. 6. 24:1347-1354. Morzaria S. Wait RB. 12. Ambela C. Eur J Pediatr Surg 1998. 20:491-496. Zaino R. Breast disorders in children and adolescents. Juvenile secretory carcinoma of the breast. 9. 21:408-410. J Pediatr Surg 1999. Manivel JC. J Pediatr Surg 2000. Green I. Pediatr Radiol 1998. Pediatr Clin North Am 1989. Breast cancer in a 6-year-old child. Elsheikh A. Tanyel FC. Hicsonmez A. Louvrou N. Parks DS. Dehner LP. Lesions of the breast in children exclusive of typical fibroadenoma and gynecomastia. Song M. J Ultrasound Med 2005. Kronemer KA. 8:67-70. Rhee K. 8. Michalas S. Magee JF. Am J Surg Pathol 1997. Breast involvement by extranodal Rosai-Dorfman disease: report of seven cases. J Pediatr Surg 1985. 7. Breast metastases in adolescent girls: US findings. Buyukpamukcu N. Pathol Annu 1989. 4. et. Harris VJ. A clinicopathologic study of 113 cases. Breast tumors during adolescence. Chateil JF. 35:765-767. Chest Radiology 255 Breast Abnormalities in Young Women . Ballantine TV. Kelly DR. 34:1401- 1404. El-Tamer MB. 24 Pt 2:296-328. Pettinato G. Lazaris D. Dorfman RF. 5. Brun M. Gray scale sonography of breast masses in adolescent girls. Boisserie-Lacroix M. 10. Eur J Gynaecol Oncol 2000. Keramopoulos A. Perel Y. quiz 498. Evaluation by Sonographic Diagnosis.

Rogers DA. 57:243-247. 20:1613-1621. Case report with histologic and therapeutic considerations. Conant EF. 17. Jakate SM. 16. 20. Breast disorders in the pediatric and adolescent patient. 18. Bellah R. Zuckerman JA. Breast malignancy in children. Hughes LE. Spectrum of US findings in pediatric and adolescent patients with palpable breast masses. Diagnostic considerations in breast disorders of children and adolescents. Simmons PS. Juvenile papillomatosis and breast carcinoma. Squire R. Beattie EJ. 29:48-51. Giant breast tumours of adolescence. Rao BN. 14. Simmons PS. Breast disease in young West Indian women: an analysis of 1051 consecutive cases. Orel SG.13. Rosen PP. 55:1345-1352. 19:91-102. Cancer 1985. Williams S. Obstet Gynecol Clin North Am 1992. Raju GC. 13:459-461. Raganoonan C. 19. Postgrad Med J 1985. Radiation-induced sarcoma of the breast in a female adolescent. Fairbairn JK. Breast Abnormalities in Young Women 256 Chest Radiology . Obstet Gynecol Clin North Am 2000. Aust N Z J Surg 1987. Jankey N. 15. Templeman C. Naraynsingh V. Lobe TE. Breast disorders in adolescent females. Bianchi A. Weinstein SP. Hertweck SP. Kinne DW. 27:19-34. 61:977-978. Cancer 1988. 21. J Pediatr Surg 1994. et al. Lesser ML. Curr Opin Obstet Gynecol 2001. 61:2444-2447. Radiographics 2000. Holmes G.

swelling or pain • Presents as nipple discharge • Can be benign or malignant Benign Disease • Gynecomastia • Pseudogynecomastia • Papilloma • Adenoma • Myofibroblastoma ➢ More common in men than women • Granular cell tumor • Fibrocystic change Chest Radiology 257 The Male Breast . MD Figure 1-28-1 Development • Birth to puberty same as female Anatomy [Figure 1-28-1] • Major ducts with little branching • Connective tissue and fat • Almost no lobules Imaging • Less than 1% of breast imaging ➢ Mammography ➢ Ultrasound ➢ MRI ➢ CT Normal Male Mammogram [Figures 1-28-2 to 1-28-5] Normal male with no tissue seen except Figure 1-28-2 Figure 1-28-3 Figure 1-28-4 fat Figure 1-28-5 Normal male with Normal male with Normal male with minimal subareolar small focus of intramammary node tissue subareolar tissue Large amount of subareolar tissue in an asymptomatic Male Breast Disease male • Presents as mass. Glassman.The Male Breast Leonard M.

phyllodes. moderate epithelial proliferation and fibrosis Gynecomastia • 2cm or more of subareolar tissue in non obese male • Common “normal” finding ➢ 55% of men at autopsy ➢ Peak incidence 60 – 69 years ➢ Significant if new or symptomatic • Palpable unilateral or bilateral subareolar mass ➢ Often conical shape • 65% of breast lesions in elderly males ➢ 25% Carcinoma ➢ 10% Other lesions Gynecomastia • Response to hyperestrogenism or estrogen like response • Absolute increase in estrogen HCG or estrogen precursors ➢ Secretion by tumors ✧ Leydig cell tumor ✧ Germ cell tumors ✧ Hepatoma ✧ Adrenal cortical tumors ✧ Pituitary tumors Gynecomastia • Absolute increase in estrogen HCG or estrogen precursors ➢ Estrogen therapy ✧ Prostate carcinoma ✧ Topical estradiol to scalp The Male Breast 258 Chest Radiology . carcinosarcoma ➢ Lesions begin in TDLU (lobules) ✧ Lobular development rare in men Gynecomastia • Potentially reversible enlargement of the male breast • Presents as soft mobile tender subareolar mass • Simultaneous proliferation ducts and stroma without encapsulation ➢ Florid (early) phase ✧ Begins as increased number of ducts and epithelial proliferation with edema and cellular fibroblastic stroma ✧ Reversible phase ➢ Fibrotic (late) stage ✧ Progresses to dilated ducts.Benign Disease • Diabetic mastopathy • Epitheal inclusion cyst • Cystic Lymphangioma • Pleomorphic hyalinizing angioectatic tumor of soft parts • Varix • Leiomyoma • Lipoma Benign Disease • No lactating adenomas ➢ No pregnancy • Rare lobular tumors ➢ No lobules without progesterone ➢ Rare invasive lobular carcinomas reported Benign Disease • Rare biphasic tumors ➢ Fibroadenoma.

➢ Increase in estrogen precursors Figure 1-28-6 ✧ Cirrhosis ✧ Hyperthyroidism Gynecomastia • Relative increase in estrogen ➢ Testicular failure or atrophy ✧ Idiopathic ✧ Cytotoxic chemotherapy ➢ Puberty and senescence ✧ Transient in puberty (1 – 2 years) ➢ Klinefelter’s syndrome (XXY) ➢ Testicular feminization syndrome Gynecomastia • Hyperthyroidism ➢ Reverses when the patient is euthyroid Symptomatic male with prominent • Refeeding after malnutrition or starvation subareolar tissue • Onset of hemodialysis Gynecomastia Figure 1-28-7 Figure 1-28-8 • Drugs (partial list) ➢ Spironolactone ➢ Reserpine ➢ Digitalis ➢ Ergot ➢ Thyroid extract ➢ Dilantin ➢ Thiazide diuretics ➢ Cimetadine ➢ Marijuana Gynecomastia • Mammographic patterns ➢ Nodular glandular (florid phase) ➢ Dendritic (fibrotic phase) Irregular dense Symptomatic male ➢ Diffuse glandular (very high estrogen levels) tissue behind the with diffusely dense nipple pattern Nodular Pattern [Figure 1-28-6] • Fan shaped density radiating from the nipple ➢ May be more prominent in UOQ ➢ Blends into surrounding fat Dendritic Pattern [Figure 1-28-7] Figure 1-28-9 • Subareolar density with prominent extensions into fat ➢ Density smaller than nodular pattern Diffuse Pattern [Figure 1-28-8] • Small heterogeneously dense breast Pseudogynecomastia [Figure 1-28-9] • Usually bilateral • No palpable mass • Excessive fat deposition in breast area ➢ Normal variant ➢ Obesity ➢ Neurifibromatosis Male with enlarged fatty breast Chest Radiology 259 The Male Breast .

Myofibroblastoma [Figures 1-28-10 and 1-28-11] Figure 1-28-10 • Solitary palpable firm mass ➢ Rarely bilateral ➢ No calcifications • Freely moveable • More common in men than women • Mean age late 50’s • Circumscribed lobulated mass without calcification • Treated with local excision Granular Cell Tumor [Figures 1-28-12 and 1-28-13] • Benign tumor of neural origin • 6% in breast • Typical age is 30’s Oval solid mass proven to be • Bimodal appearance myofibroblastoma ➢ Spiculated or circumscribed ✧ Usually circumscribed in males Figure 1-28-13 Figure 1-28-11 Figure 1-28-12 Granular cell tumor with smooth margins Typical appearance Granular cell tumor of a with irregular myofibroblastoma margins Figure 1-28-14 Epidermal Inclusion Cyst [Figure 1-28-14] • Skin lesion • Round well circumscribed dense mass Cystic Lymphangioma Figure 1-28-15 [Figure 1-28-15] Left: Smooth circumscribed superficial mass proven to be an epidermal inclusion cyst. Right: Ultrasound shows epidermal origin of the mass Non specific lobulated mass proven to be a cystic lymphangioma The Male Breast 260 Chest Radiology .

Granulomatous Mastitis Figure 1-28-16 • Idiopathic • Specific causes must be excluded ➢ TB or other bacteria ➢ Sarcoid ➢ Fat necrosis ➢ Foreign body Pleomorphic Hyalinizing Angioectatic Tumor of Soft Parts [Figure 1-28-16] Varix [Figure 1-28-17] Leiomyoma [Figure 1-28-18] • Circumscribed mass Complex mass on MRI with non • No mitotic activity specific appearance proven to be a ➢ >2 mitoses/hpf is leiomyosarcoma pleomorphic hyalinizing angioectatic tumor of soft parts Malignant Disease • Carcinoma Figure 1-28-17 • Metastasis • Lymphoma • Sarcoma Male Breast Cancer • 1690 new cases estimated in 2005 in USA ➢ 460 men will die of disease in 2005 • 1% of all invasive mammary cancers ➢ Less than 0.93 • Unilateral painless subareolar mass ➢ Bilateral in 2% of cases Figure 1-28-18 ➢ Can present as bloody nipple discharge • Most invasive ductal cancer including special types ➢ Invasive lobular cancer very rare ➢ DCIS rare (no screening) ➢ 80% ER positive Male Breast Cancer • Frequently located subareolar ➢ Most common presentation is a painless subareolar mass ➢ Mass usually eccentric to the nipple ➢ Mass round.5% lobular Chest Radiology 261 The Male Breast .8% colloid ➢ 1.6 % papillary ➢ 1.1% of male cancers ➢ Higher incidence in China and Africa ✧ High incidence of hyperestrogenism secondary to parasitic liver disease Male Breast Cancer Large vascular structure with venous • Occurs in 60’s (10 years after women) flow (not shown) ➢ Reported in ages 5 . oval or irregular ➢ Calcifications rare and coarser than in women Male Breast Cancer • Paget’s disease and skin ulceration more common than in women Leiomyoma with • Axillary metastases similar to women at same stage typical appearance • Found at later stage than women as a circumscribed non specific mass Male Breast Cancer • Infiltrating ductal carcinoma including special types ➢ 93.7% invasive ductal (usually NOS) ➢ 2.

XXY ➢ 6% of male breast cancer ➢ 3% lifetime risk Invasive Ductal Carcinoma [Figures 1-28-19 to 1-28-21] Papillary Carcinoma [Figure 1-28-22] Figure 1-28-21 Irregular mass with spiculations is proven invasive ductal carcinoma Figure 1-28-22 Ultrasound of irregular lobulated vascular mass typical of invasive ductal carcinoma Metastasis • Prostate most common in males • Hematogenous spread from primary • Usually in patients with widespread disease ➢ Occasionally solitary • Usually round or oval circumscribed lobulated non-calcified mass Ductal involvement by a papillary carcinoma The Male Breast 262 Chest Radiology .Male Breast Cancer • DCIS Figure 1-28-19 ➢ 10% of cases ➢ Usually papillary type ➢ Comedo type very rare • Liposarcoma • Lymphoblastic lymphoma • Metastasis Carcinoma Risk Factors • Advanced age • Family history • Jewish heritage • Chest wall irradiation • Hyperestrogenism • Hyperthyroidism • Exposure to hepatotoxins Irregular lobulations • Occupational exposure to high heat in a subareolar invasive ductal Carcinoma Risk Factors carcinoma • BRCA 2 in 4 – 16% of cancer patients ➢ 40% in Iceland Figure 1-28-20 • Undescended testes • Orchiectomy and orchitis • Klinefelter’s syndrome ➢ 47.

in this male patient Right: Carcinoma Chest Radiology 263 The Male Breast . fibrotic or diffuse Mass. large or small Figure 1-28-24 Gynecomastia Carcinoma • Nodular Large mass ➢ Fan shaped Lobulated border • Fibrotic Small mass ➢ Subareolar density with Spiculations extensions into fat Gynecomastia / Carcinoma [Figures 1-28-26] Conclusion • Disease presents as mass pain or nipple discharge • Gynecomastia and invasive ductal cancer are the most common lesions in the male breast ➢ There are other rarer benign and malignant lesions Large water density • Gynecomastia and carcinoma can look similar mass in a male ➢ Biopsy is sometimes necessary to separate gynecomastia from carcinoma breast with a • All lesions eccentric to the nipple need biopsy unless they are preexisting lipoma characteristically benign ➢ Contain fat Figure 1-28-25 ➢ Lymph node Figure 1-28-26 CT scan showing water density mass Left: Gynecomastia.Metastasis Small Cell Carcinoma Lung [Figure 1-28-23] Figure 1-28-23 Lymphoma • Primary or secondary • Usually a unilateral mass ➢ Can be diffuse thickening rarely ➢ No calcification or retraction Liposarcoma [Figures 1-28-24 and 1-28-25] • Very rare sarcoma • Slowly enlarging painful mass Gynecomastia Carcinoma • Age 60’s Age 60’s • Soft Soft or hard • Mobile Mobile or fixed Typical rounded • Tender usually Tender or painless masses in • Subareolar Subareolar metastatic disease ➢ Central Eccentric usually • Unilateral or bilateral Unilateral usually • Nodular.

Khamis HJ. Ductal carcinoma in situ of the breast in men: a review. BRCA2 germ-line mutations are frequent in male breast cancer patients without a family history of the disease. Pozzi Mucelli R. Bozkaya H. Franceschi D. Pappo I. Male breast cancer: is the incidence increasing? Ann Surg Oncol 2004. AJR Am J Roentgenol 2005. 6:310-314. Georgian-Smith D. and ultrasonographic features. Perkins G. Braunstein GD. The experiences of men with breast cancer in the United Kingdom. AJR Am J Roentgenol 1993. Liberman L. 11:751-755. Cancer 2004. Curr Ther Endocrinol Metab 1997. et al. Cohen DS. 160:267-270. Giordano SH. Male breast cancer. 4. Hortobagyi GN. 164:853-858. 8. 19:559-568. Comparison of male and female breast cancer incidence trends. 15. 5. 2. Ustun EE. Lancet 2006. Appelbaum AH. 110:574-588.References 1. Evans GF. Mammographic appearances of male breast disease. Gray J. 7. Cornell LD. The Male Breast 264 Chest Radiology . Borg A. 367:595-604. Fentiman IS. A review of the diagnosis and management of male breast cancer. Radiography of gynecomastia and other disorders of the male breast. Ann Epidemiol 2005. Michels LG. Hortobagyi GN. Gynecomastia. Gunhan-Bilgen I. 42:334-341. Livingstone AS. Radiol Med (Torino) 2005. Arndt RD. Zhang QX. Remo A. 185:S205-210. Iredale R. Fourquet A. Button JH. Levy KR. 16. So GJ. Giordano SH. 15:773-780. 101:51-57. AJR Am J Roentgenol 1995. Bassett LW. 6:401-404. Radiology 1977. Cancer Res 1998. mammographic. Memis A. 3. Bonetti F. Hill TD. Borgen PI. Chantra PK. Anthony T. Breast carcinoma in men: a population-based study. 17. 181:96-100. Malago R. Imaging of the male breast. Tyczynski JE. Johannsson O. Male breast disease: clinical. 13. Deutch BM. 10. Olsson H. Wollman JS. France E. Mammography of the male breast. Evans GF. Mammographic findings in men with breast cancer. Haraldsson K. Schumpert TD. Loman N. 9. 6. et al. Oncologist 2005. Glassman HA. Moffat FL. Turnage RH. The diagnostic accuracy of mammography in the evaluation of male breast disease. 14. Shi AA. Williams B. 122:117-122. Gold RH. 12. Jellici E. Eur J Cancer 2006. Brain K. Amirkhan RH. Eur J Radiol 2002. and survival. Radiological reasoning: male breast mass with calcifications. Am J Surg 2001. Halevy A. Hodgson NC. Wasserman I. 11. Radiographics 1999. 58:1367-1371. Berkel HJ. Clin Breast Cancer 2005. 43:246-255. Dershaw DD. Buzdar AU. tumor characteristics. 10:471-479.

Gastrointestinal Radiology .

266 Gastrointestinal Radiology .

Benign Hepatic Neoplasms Angela D. myelolipoma. MC. angiomyolipoma.Objectives • Benign neoplasms ➢ Hemangioma ➢ Focal nodular hyperplasia (FNH) ➢ Hepatocellular adenoma ➢ Bile duct cyst ➢ Biliary cystadenoma/cystadenocarcinoma ➢ Lipomatous tumors • Surgical vs. USA AFIP Classification . COL. biliary cystadenocarcinoma • Mesenchymal origin ➢ Hemangioma. fibrolamellar carcinoma. nodular regenerative hyperplasia ➢ Hepatocellular carcinoma. nonsurgical neoplasms Hemangioma • Most common benign hepatic tumor ➢ Likely a hamartoma rather than true neoplasm • 1% to 7% of the population ➢ Most common in adult women ➢ Least common in pediatric population • More common in women. 5:1 ➢ Estrogen influences ➢ May enlarge during pregnancy • Symptoms ➢ 85% asymptomatic ➢ Pain ➢ Palpable mass ➢ Rupture Hemangioma • Kasabach-Merritt syndrome ➢ Hemolytic anemia and consumptive coagulopathy • Erythropoietin secretion ➢ Erythrocytosis • Associations ➢ Focal nodular hyperplasia ➢ Tuberous sclerosis Hemangioma . focal nodular hyperplasia. hepatoblastoma • Cholangiocellular origin ➢ Bile duct cyst.Pathology • Peripheral feeding vessels • Blood filled spaces • Endothelial lining • Fibrosis from ➢ Slow flowing blood ➢ Thrombosis ➢ Hyalinization ➢ Scar formation Gastrointestinal Radiology 267 Benign Hepatic Neoplasms . biliary cystadenoma.Tumors of the Liver and Intrahepatic Bile Ducts • Hepatocellular origin ➢ Hepatocellular adenoma. mesenchymal hamartoma ➢ Angiosarcoma. epithelioid hemangioendothelioma Benign Hepatic Neoplasms . bile duct adenoma ➢ Cholangiocarcinoma. Levy.

CT and MR • Peripheral globular enhancement in arterial phase • Slow centripetal filling during portal venous/equilibrium • Rapid enhancement pattern ➢ Capillary hemangiomas ➢ "Flash fill" phenomenon Classic appearance of hemangioma on CT.Hemangioma . • MR There is discontinuous. echogenic mass on sonography echogenic border Figure 2-1-2 Hemangioma - Heterogeneous.Pedunculated Hemangioma . hyperechoic • Minimal posterior acoustic enhancement • Atypical features ➢ Hypoechoic center ➢ Echogenic border ➢ Scalloped borders ➢ Heterogeneous hypoechoic Hemangioma . Tagged-RBC nuclear medicine imaging is positive confirming the diagnosis of hemangioma Hemangioma - Heterogeneous with Fibrosis [Figure 2-1-3] Figure 2-1-4 Hemangioma . the tumor is composed of multiple blood filled spaces that provide interfaces to produce an Hemangioma . astrocytoma Multiple hemangiomas shown on MR Benign Hepatic Neoplasms 268 Gastrointestinal Radiology .MR Hemangioma .Edematous Atypical hemangioma on MR due to large size and central scar hyalinization. nodular. Histologically.Hypoechoic Hepatic hemangioma on sonography shows a well-defined mass that Foci is homogenously hyperechoic.Scalloped. 20 to 40 years • 80% asymptomatic • Associations ➢ Hepatic hemangiomas ➢ Intracranial aneurysms ➢ Dysplastic system arteries ➢ Intracranial neoplasms: meningioma.CT [Figure 2-1-2] Hemangioma . hypoechoic Hemangioma .Sonography [Figure 2-1-1] Figure 2-1-1 • Homogeneous. peripheral enhancement and gradual ➢ Homogenous hyperintense contrast filling in the lesion T2 ➢ Progressive hyperintensity Figure 2-1-3 as TE increases ➢ "Light bulb" phenomenon Hemangioma .Multiplicity [Figure 2-1-4] Focal Nodular Hyperplasia • Second most common benign liver neoplasm • 80% to 95% occur in women ➢ Peak age.

CT Figure 2-1-6 • Noncontrast ➢ Iso.or hypo.Sonography [Figure 2-1-5] • Subtle ➢ Similar texture to normal liver ➢ “Stealth lesion” • Scar is hypoechoic • Doppler ➢ Peripheral and central vessels Focal Nodular Hyperplasia .• Pathogenesis ➢ Hyperplastic response to a vascular malformation ➢ Central artery Figure 2-1-5 ➢ Central scar • Gross Pathology ➢ Central scar ➢ Nodular with fibrous septa ➢ No hemorrhage or necrosis ➢ No capsule Focal Nodular Hyperplasia • Histology ➢ Fibrous septa FNH is often isoechoic to normal liver on sonography and may show ➢ Large arteries marked flow on color doppler of power doppler imaging ➢ Normal hepatocytes ➢ Kupffer cells ➢ No portal tracts or central veins Focal Nodular Hyperplasia .MR • T1 isointense ➢ Low signal scar • T2 iso or slightly hyperintense ➢ High signal scar • Gd-DTPA FNH on CT showing late enhancement of the central scar and ➢ Rapid homogeneous peripheral vessels enhancement ➢ May have flash enhancement ➢ Delayed enhancement of the scar ➢ Rim-like enhancement late • T2 with ferumoxide ➢ Lesion decreases signal ➢ Except scar Gastrointestinal Radiology 269 Benign Hepatic Neoplasms .or hypodense ➢ Hypodense scar • Arterial ➢ Rapid enhancement ➢ Hypodense scar • Portal venous ➢ Iso.or hyperdense ➢ Delayed enhancement of scar FNH shows contrast enhancement during the arterial phase and near ➢ Peripheral capsule-like isoattenuation during the portal venous phase vessels FNH [Figures 2-1-6 and 2-1-7] Figure 2-1-7 FNH .Sulfur Colloid • Normal uptake 60% • Defect 30% • Increased uptake 10% FNH .

Atypical Imaging Features Figure 2-1-8 • Multiplicity • Absent scar • Very large scar • Fat • Hemorrhage • Calcification (very rare) Atypical FNH .FNH [Figure 2-1-8] FNH .Flash Enhancement FNH . AJR 2000.Pathologic Features • Histology ➢ Benign hepatocytes ➢ Rich in glycogen ➢ Kupffer cells • Gross ➢ Solitary ➢ Multiple (up to 50%) ➢ Capsule (25%) ➢ Peripheral vessels ➢ Central fat ➢ Necrosis.Absent Scar Atypical FNH . 175:1: 159-63 FNH . hemorrhage Benign Hepatic Neoplasms 270 Gastrointestinal Radiology .Hemorrhage Typical appearance of FNH on MR Hepatocellular Adenoma • Third most common benign liver tumor • Composed of benign hepatocytes • Almost always occur in women ➢ Mean age. et al. type Ia and III ➢ Hurler syndrome Hepatocellular Adenoma . 30 years ➢ History of oral contraceptive use ➢ Declining incidence • Surgical resection ➢ Risk of hemorrhage ➢ Small risk of malignant transformation to HCC • Hepatocyte proliferation ➢ Exogenous estrogens ➢ Ovarian tumors ➢ Anabolic steroids ➢ Antiestrogens ➢ Glycogenosis.Clinical Features • Acute abdominal pain 40% ➢ Hemorrhage within tumor ➢ Intraperitoneal hemorrhage • Palpable mass 35% • Incidental 10% Hepatocellular Adenoma .Ferumoxide-enhanced MR Paley MR. infarcts.

CT and MR • Capsule Figure 2-1-9 • Heterogeneous • Hemorrhage (25% to 50%) ➢ Acute.Out-of-Phase MR Figure 2-1-11 Hepatocellular Adenoma - Fat Suppression Hepatocellular Adenoma - Imaging Difficulties • Nonhemorrhagic • Fibrosis/scar formation • Multiple ➢ Glycogenosis ➢ Hepatocellular adenomatosis Diffuse low attenuation in hepatocellular adenoma due to intracellular glycogen Hepatocellular Adenoma - Multifocality • Multiple estrogen-associated adenomas • Hepatocellular adenomatosis Hepatocellular Adenomatosis [Figure 2-1-12] • Affects men and women • Unrelated to estrogens Figure 2-1-12 • Abnormal LFT's • Biopsy for diagnosis • Treated symptomatically Hepatocellular adenomatosis Gastrointestinal Radiology 271 Benign Hepatic Neoplasms . high density on unenhanced CT ➢ Chronic.Hepatocellular Adenoma . hemosiderin rings on MR • Focal fat • Enhancement ➢ Variable • Intracellular glycogen/fat ➢ Diffuse low attenuation on CT Hemorrhagic hepatocellular adenoma ➢ Loss of signal on out-of- phase MR Hepatocellular Adenoma Acute Hemorrhage Figure 2-1-10 [Figure 2-1-9] Hepatocellular Adenoma Hemosiderin Rings Hepatocellular Adenoma Focal Fat and Capsule [Figure 2-1-10] Hepatocellular Adenoma Hepatocellular adenoma with focal fat and a capsule on CT with the Diffuse Low Attenuation corresponding gross specimen [Figure 2-1-11] Hepatocellular Adenoma .

or excision • Imaging ➢ Unilocular. sclerotherapy. debris when complicated by infection or hemorrhage Bile Duct (Hepatic) Cyst • Complex cyst differential ➢ Echinococcal cyst ➢ Simple cyst with hemorrhage/infection ➢ Post-traumatic cyst ➢ Abscess ➢ Ciliated hepatic foregut cyst ➢ Peliosis ➢ Biliary cystadenoma ➢ Biliary cystadenocarcinoma ➢ Cystic metastasis ➢ Teratoma Biliary Cystadenoma • Benign tumor.55 years ➢ Ovarian stroma histologically • Cystic neoplasms ➢ Unilocular or multilocular ➢ Septations ➢ Mural nodules ➢ Calcification Biliary Cystadenoma .Bile Duct (Hepatic) Cyst • Common • Congenital/developmental origin ➢ Lined by a single layer of columnar cells • Affect all age groups ➢ Majority occur in 4th to 6th decades of life ➢ Rare in children Bile Duct (Hepatic) Cyst • Asymptomatic ➢ Majority of cases ➢ Incidental discovery • Symptomatic ➢ Large size ➢ Secondary hemorrhage or infection ➢ Treated with drainage.Imaging Features • Cystic neoplasms ➢ Unilocular or multilocular ➢ Cyst fluid variable composition • Septations • Mural nodules ➢ May enhance • Calcification ➢ Punctate or linear • May communicate or extend into biliary system Benign Hepatic Neoplasms 272 Gastrointestinal Radiology . simple cyst ➢ Septations. but ➢ May recur after excision ➢ May develop into cystadenocarcinoma • Middle-aged women ➢ 42 .

and blood vessels Angiomyolipoma [Figures 2-1-14 and 2-1-15] Myelolipoma Summary .FNH • CT/MR ➢ Rapid enhancement ➢ Homogenous tumor ➢ Hypodense/intense scar ➢ Delayed scar enhancement ➢ Delayed peripheral enhancement • Sulfur colloid Summary .Hemangioma • Sonography ➢ Homogenous ➢ Hyperechoic • CT/MR ➢ Peripheral nodular enhancement • Tagged-RBC Summary .Benign Hepatic Neoplasms • Nonsurgical lesions ➢ Hemangioma ➢ Focal nodular hyperplasia Biliary cystadenoma • Surgical lesions ➢ Hepatocellular adenoma Figure 2-1-14 ➢ Biliary cystadenoma Summary . and blood vessels ➢ Most cases sporadic ➢ Tuberous sclerosis in 6% • Myelolipoma ➢ Rare ➢ Benign ➢ Composed of myeloid. adipose.HCA • For imaging diagnosis Echogenic angiomyolipomas on ➢ Female patient sonography ➢ Oral contraceptive use ➢ Evidence of hemorrhage • Suggest HCA Figure 2-1-15 ➢ Diffuse low attenuation ➢ Diffuse fat on MR ➢ Appropriate patient • BIOPSY ! Summary .Biliary Cystadenoma • Cystic neoplasm ➢ Septations ➢ Nodules Multiple hepatic angiomyolipomas in a patient with tuberous sclerosis ➢ Calcification who has angiomyolipomas in the right kidney and a history of left • Most common in middle-aged nephrectomy for a hemorrhagic angiomyolipoma women Gastrointestinal Radiology 273 Benign Hepatic Neoplasms . smooth muscle.Biliary Cystadenoma [Figure 2.1-13] Figure 2-1-13 Lipomatous Tumors • Angiomyolipoma ➢ Benign ➢ Composed of adipose.

Madariaga J. Buetow PC. Focal nodular hyperplasia: findings at state-of-the-art MR imaging. Casillas VJ. 171:323-326. Radiology 1995. Discrimination of small hepatic hemangiomas from hypervascular malignant tumors smaller than 3 cm with three-phase helical CT. Armed Forces Institute of Pathology. 3. Imaging of nontraumatic hemorrhagic hepatic lesions. and pathologic analysis. Radiology 1986. 5. 15:313-316. 3. 4. Terkivatan T. Balzano E. AJR Am J Roentgenol 1995. 4. Birnbaum BA. and Tc-99m- labeled red blood cell SPECT images. Nalesnik M. Takahashi M. Radiology 1997. Sironi S. CT. and imaging findings in 15 patients. Focal nodular hyperplasia and hepatocellular adenoma of the liver: differentiation with multiphasic helical CT. Yamashita Y. et al. AJR Am J Roentgenol 2000. Buetow PC. 20:367-378. 148:711-715. Patterns of contrast enhancement of benign and malignant hepatic neoplasms during bolus dynamic and delayed CT. 6. et al. Characterization of focal hepatic lesions with ferumoxides-enhanced T2-weighted MR imaging. Hepatocellular adenoma. Shannon M. Brancatelli G. Federle MP. 2. Biliary cystadenoma: ultrasound. Chew FS. Zebedin D. Quint LE. Solomon C. Nalesnik M. Freeny PC. Pinnar N. Radiology 2000. Cavernous hemangioma of the liver: pathologic correlation with dynamic CT findings. 7. Grazioli L. 203:121-125. Kugler C. Marks WM. Ichikawa T. Federle MP. Focal nodular hyperplasia: CT findings with emphasis on multiphasic helical CT in 78 patients. 24:3-17. Ros PR. Benign Hepatic Neoplasms 274 Gastrointestinal Radiology . Pantongrag-Brown L. and MRI. Buck JL. Hepatocellular Adenoma 1. discussion 18-19. Focal nodular hyperplasia of the liver: radiologic-pathologic correlation. Noz ME. Levi JU. Ruppert-Kohlmayr AJ. AJR Am J Roentgenol 1987. Gastrointest Radiol 1990. Mergo PJ. Federle MP. Schaffler G. 3. CT. 214:861-868. et al. Guzman M. Peterson MS. histopathologic. Radiology 2001. Hussain SM. Ros PR.References Hemangioma 1. Central scars in primary liver tumors: MR features. Rohrmann CA. Radiology 1989. Abbott RM. Mattison GR. Weissleder R. Radiographics 2002. Gascue A. Kim T. 3. Ichikawa T. Radiology 1991. Uggowitzer MM. CT. Goodman ZD. Radiographics 2004. Kawamori Y. Grazioli L. 182:545-548. Hepatocellular adenoma: multiphasic CT and histopathologic findings in 25 patients. Perez JM. and pathologic correlation. Biliary Cystadenoma 1. Benjamin GG. Buck JL. 16:369-388. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Hepatic hemangiomas: diagnosis with fusion of MR. 176:1493-1498. 2. RadioGraphics 1996. 2. 219:61-68. Francis IR. Baron RL. US. Chapnick J. Quinn SF. 219:699-706. Blachar A. Jr. Zondervan PE. Radiology 2000. Hepatic cavernous hemangiomas: simple diagnostic sign with dynamic bolus CT. Rummeny E. Grazioli L. 216:395-402. al-Otaibi L. Torres GM. 165:1426. Ruppert GS. et al. 4. 160:613-618. From the archives of the AFIP. Focal Nodular Hyperplasia 1. Amendola MA. Whitman GJ. MR imaging of hepatic focal nodular hyperplasia: characterization and distinction from primary malignant hepatic tumors. Federle MP. Urata J. Paley MR. Bree RL. Ogata I. Radiographics 2000. Glazer GM. AJR Am J Roentgenol 2001. Biliary cystadenoma and cystadenocarcinoma: clinical-imaging- pathologic correlations with emphasis on the importance of ovarian stroma. 2. 175:159-163. Liver adenomatosis: clinical. Murakata LA. Radiology 2001. Peterson MS. specificity. Levy AD. 181:469-474. 5. Radiology 1992. Palacios E. 196:805-810. Ensminger WD. Thaete L. 22:387-413. Pantongrag-Brown L.

Levy. USA Malignant Hepatic Neoplasms .Etiology • Strong association with chronic liver disease ➢ Cirrhosis ➢ Hepatitis B ➢ Hepatitis C Hepatocellular Carcinoma .Clinical Features • More common in men ➢ 2:1 to 5:1 • Elevated alpha-fetoprotein (AFP) ➢ Elevated in 70%-90% • Paraneoplastic syndromes ➢ Hypoglycemia ➢ Erythrocytosis ➢ Hypercholesterolemia ➢ Rare. COL. aflatoxins ➢ Aggressive • Low incidence areas ➢ Western hemisphere ➢ 70 to 80 years old ➢ Alcoholic cirrhosis. hemochromatosis ➢ Insidious Hepatocellular Carcinoma . hepatitis C.Other Etiologies • Aflatoxin B1 • Metabolic Diseases ➢ Hemochromatosis (25%) ➢ Hereditary tyrosinemia (20%) ➢ Alpha-1-antitrypsin deficiency (15%) • Anabolic steroids Hepatocellular Carcinoma . hypertrophic pulmonary osteoarthropathy Gastrointestinal Radiology 275 Malignant Hepatic Neoplasms .Geographic Variation • High incidence areas ➢ Sub-Saharan Africa.Malignant Hepatic Neoplasms Angela D. hypercalcemia. Asia ➢ 30 to 45 years old ➢ Hepatitis B and C. osteoporosis.Objectives • Malignant neoplasms ➢ Hepatocellular carcinoma (HCC) ➢ Fibrolamellar carcinoma (FLC) ➢ Intrahepatic cholangiocarcinoma ➢ Angiosarcoma ➢ Epithelioid hemangioendothelioma • Approach to the incidentally discovered liver mass Hepatocellular Carcinoma • Neoplasm composed of malignant hepatocytes • Fifth most common cancer worldwide Hepatocellular Carcinoma . gynecomastia. precocious puberty. carcinoid syndrome. MC.

and gross pathology ➢ High velocity arterial flow ➢ Peripheral hypoechoic rim Figure 2-2-3 Hepatocellular Carcinoma Hypoechoic [Figure 2-2-1] Hepatocellular Carcinoma . hypoechoic and uniform ➢ Large lesions.Mosaic Pattern [Figure 2-2-2] Hepatocellular Carcinoma . On CT. The lesion is well defined and • Hemorrhage and necrosis hypoechoic.Peripheral Hypoechoic Rim Hepatocellular Carcinoma .Hepatocellular Carcinoma . CT.Multifocal with Portal Vein Invasion [Figure 2-2-3] Multifocal HCC with portal vein invasion on sonography Malignant Hepatic Neoplasms 276 Gastrointestinal Radiology . the mass is • Multifocal hypervascular in the arterial phase of • Vascular invasion contrast enhancement Hepatocellular Carcinoma .Gross Pathology • Solitary and Encapsulated Sonographic appearance of a small • Macroscopic fat HCC. hypovascular Hepatocellular Carcinoma Gross Pathology • Key features relevant to imaging ➢ Capsule ➢ Necrosis/hemorrhage/fibrosis ➢ Vascular invasion ➢ Macroscopic fat ➢ No calcification when HCC occurs in chronic liver disease Hepatocellular Carcinoma . multinodular pattern • Suggestive features Mosaic appearance of HCC on sonography.Histologic Features • Trabecular growth • Occasional Kupffer cells Figure 2-2-2 • Vascular invasion Hepatocellular Carcinoma - Sonographic Features • Variable and nonspecific ➢ Small lesions. focal and heterogeneous ➢ Diffuse.Pathophysiology Figure 2-2-1 • Key feature relevant to imaging ➢ Angiogenesis • Normal liver blood supply ➢ ~80% portal venous ➢ ~20% hepatic artery • HCC blood supply ➢ ~100% hepatic artery ➢ Rarely.

"mosaic pattern" • Suggestive features ➢ Capsular Hypervascular HCC in cirrhosis enhancement ➢ Central fibrosis Figure 2-2-5 ➢ Fatty change ➢ Vascular invasion ➢ Arterioportal shunting Hepatocellular Carcinoma Small HCC in Cirrhosis [Figure 2-2-4] Hepatocellular Carcinoma HCC with capsule and macroscopic fat Capsule and Macroscopic Fat [Figure 2-2-5] Figure 2-2-6 Hepatocellular Carcinoma .Mosaic Pattern Hepatocellular Carcinoma Mosaic Pattern with Capsular Enhancement [Figure 2-2-6] Hepatocellular Carcinoma Mosaic Pattern Hepatocellular Carcinoma Fibrosis Hepatocellular Carcinoma Multifocal with Portal Vein Invasion Hepatocellular Carcinoma Solitary and Portal Vein Invasion Hepatocellular Carcinoma Hepatic Vein/IVC Invasion [Figure 2-2-7] HCC with IVC HCC with a mosaic pattern and Figure 2-2-7 invasion on MDCT capsular enhancement Gastrointestinal Radiology 277 Malignant Hepatic Neoplasms .CT and MR Features Figure 2-2-4 • Arterial phase ➢ Rapid enhancement in small HCC ➢ Late arterial phase better than early arterial phase • Portal venous phase ➢ Heterogeneous.Hepatocellular Carcinoma .

Noncirrhotic Liver Fibrolamellar Carcinoma [Figure 2-2-8] • Variant of HCC ➢ Bands of fibrous lamellae ➢ Tumor cells have "oncocytic" cytoplasm • Young patients ➢ Mean age. well defined margins • Heterogeneous mass ➢ Arterial phase enhancement • Central scar ➢ Hypodense in all phases of enhancement ➢ Calcification in 40% Figure 2-2-9 Fibrolamellar Carcinoma - MR Features • Lobulated margins • Heterogeneous signal mass ➢ Dark T1 ➢ Bright T2 • Hypointense central scar ➢ Dark T1 ➢ Dark T2 ➢ No enhancement Fibrolamellar carcinoma Fibrolamellar Carcinoma How can I differentiate FLC from FNH? • Tumor heterogeneous in FLC Figure 2-2-10 ➢ Homogeneous in FNH • Scar nonenhancing in FLC ➢ Delayed enhancement in FNH • Scar dark T2 signal in FLC ➢ Scar bright T2 in FNH Fibrolamellar carcinoma Malignant Hepatic Neoplasms 278 Gastrointestinal Radiology .MR Imaging in Cirrhosis Figure 2-2-8 Hepatocellular Carcinoma .Hepatocellular Carcinoma .Gross Pathology Histology and gross pathology of • Central scar fibrolamellar carcinoma ➢ Radiating septa ➢ Calcification • Lobulated contour • Bile staining Fibrolamellar Carcinoma .CT Features[Figures 2-2-9 and 2-2-10] • Lobulated. solitary masses • Heterogeneous • Capsule • Fat (10%) • Calcification (25%) Hepatocellular Carcinoma . 23 years ➢ No cirrhosis ➢ AFP usually normal Fibrolamellar Carcinoma .Noncirrhotic Liver • Large.

Etiologic Associations • Chronic cholestatic disease ➢ Primary sclerosing cholangitis Intrahepatic cholangiocarcinoma ➢ Primary biliary cirrhosis ➢ Caroli disease/congenital hepatic fibrosis • Chronic biliary inflammation ➢ Recurrent pyogenic cholangitis Figure 2-2-12 ➢ Parasitic infection ➢ Hepatolithiasis • Hepatitis B and C • ETOH abuse • Radiation Intrahepatic Cholangiocarcinoma - Pathologic Features [Figure 2-2-11] • Morphology ➢ Solitary ➢ Multifocal Intrahepatic cholangiocarcinoma showing ➢ Diffuse capsular contraction and • Satellite nodules biliary dilatation peripheral to the mass • Marked fibrosis • No capsule • Rare ➢ Hemorrhage and necrosis Figure 2-2-13 ➢ Calcification Intrahepatic Cholangiocarcinoma CT and MR Features • Irregular borders ➢ Infiltrative • Enhancement pattern ➢ Due to fibrosis/hypovascularity ➢ Delayed peripheral to central Intrahepatic cholangiocarcinoma on MR showing central to peripheral • Biliary dilatation peripheral to the enhancement on gadolinium enhanced T1-weighted images. tumor The gross photograph shows • Capsular contraction characteristic fibrosis within the tumor • Vascular invasion Intrahepatic Cholangiocarcinoma [Figures 2-2-12 and 2-2-13] Gastrointestinal Radiology 279 Malignant Hepatic Neoplasms . intrahepatic bile duct carcinoma • Geographic incidence variation ➢ 10 times more common in Japan compared to U.Etiology • Majority of cases ➢ Unknown etiology ➢ Noncirrhotic liver Intrahepatic Cholangiocarcinoma . Intrahepatic Cholangiocarcinoma .S.Intrahepatic Cholangiocarcinoma (ICC) • Adenocarcinoma arising from intrahepatic bile ducts ➢ 10% of bile duct adenocarcinomas Figure 2-2-11 • Synonyms ➢ Peripheral cholangiocarcinoma. cholangiocellular carcinoma.

peripheral to central favors ICC ➢ Rapid filling favors HCC ➢ Marked heterogeneity (mosaic) favors HCC • Tumor margins ➢ Lobulated.Imaging Features • Solitary or multifocal • Evidence of hemorrhage • Enhancement ➢ Peripheral or heterogeneous • Metastatic disease ➢ Spleen and lung Angiosarcoma [Figure 2. lesions coalesce over time ➢ Peripheral enhancement Epithelioid hemangioendothelioma ➢ Central fibrous stroma showing multifocality and capsular ➢ Retracted liver capsule contraction ➢ May calcify Malignant Hepatic Neoplasms 280 Gastrointestinal Radiology . spleen. lung Angiosarcoma . HCC may occur in normal livers • Ultimately ➢ Biopsy is needed for diagnosis How can I differentiate ICC from HCC? • Enhancement ➢ Delayed.How can I differentiate ICC from HCC? • Difficult ➢ HCC has variable morphology ➢ HCC occurs more commonly ➢ HCC associated with cirrhosis and hepatitis ➢ But.2-14] Epithelioid Hemangioendothelioma [Figure 2.2-15] • Rare malignancy of endothelial origin ➢ Contains dense fibrous stroma • Imaging ➢ Multifocal. irregular favors ICC ➢ Capsule favors HCC • Capsular contraction Figure 2-2-14 ➢ More common in ICC • Biliary dilatation peripheral to the tumor ➢ More common in ICC Angiosarcoma • Malignant neoplasm of endothelial cells • Rare ➢ But. most common hepatic Angiosarcoma on CT and MR showing central hemorrhage that is sarcoma fluid attenuation on CT and high signal on T1-and T2-weighted MR • Etiologic associations ➢ Vinyl chloride ➢ Arsenical compounds ➢ Radiation therapy ➢ Anabolic steroids Angiosarcoma • More common in men. 3:1 • Clinical presentation Figure 2-2-15 ➢ Variable ➢ Hemoperitoneum ➢ Metastasis in 60%.

nonsurgical lesion? ➢ Bile duct cyst ➢ Hemangioma ➢ FNH • Are there equivocal features of hemangioma or FNH on CT and/or MR? ➢ Consider scintigraphy • Is there clinical history that will suggest the etiology? ➢ History of primary malignancy ➢ History of chronic liver disease ➢ History or exogenous estrogens • Are there features that suggest HCC? ➢ Capsule ➢ Fat ➢ Vascular invasion ➢ Mosaic pattern • Are there features that suggest hepatocellular adenoma? ➢ Clinical/demographic history ➢ Capsule ➢ Fat ➢ Diffuse low attenuation ➢ Hemorrhage • Are there features that suggest cholangiocarcinoma? ➢ No capsule ➢ Ill-defined margins ➢ Biliary dilatation ➢ Capsular contraction • If the answer is NO to all the above. the possibilities are: ➢ Hemangioma ➢ FNH ➢ Small adenoma ➢ Small HCC ➢ Hypervascular met ➢ AVM ➢ THAD Summary Hepatocellular Carcinoma • Most common primary hepatic malignancy • Strong association with chronic liver disease • Variable imaging features ➢ Rapid enhancement ➢ Capsule ➢ Mosaic pattern ➢ Focal fat ➢ Vascular invasion Summary Fibrolamellar Carcinoma • Variant of HCC • Young patients • Otherwise normal liver • Key features ➢ Lobular tumor ➢ Central scar ➢ Heterogeneous mass Summary Intrahepatic Cholangiocarcinoma • Arise from bile duct epithelium • Uncommon • Key features ➢ Delayed central enhancement Gastrointestinal Radiology 281 Malignant Hepatic Neoplasms . focal area of arterial enhancment on MDCT.Approach to the incidentally discovered liver mass? • Does the mass meet the criteria for a benign. and the finding is a small.

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Levy. 65% right lobe • Hepatic artery • Direct extension • Traumatic-blunt or penetrating trauma • Necrotic tumor Pyogenic Hepatic Abscess • Mortality rate <10% • Effectively treated with percutaneous drainage ➢ 8% failure rate ➢ 8% recurrence rate Pyogenic Hepatic Abscess: Sonography • Variable echogenicity ➢ Anechoic (50%) ➢ Hyperechoic (25%) ➢ Hypoechoic (25%) • Ill-defined margins • Internal character ➢ Irregular wall ➢ Septations ➢ Fluid-fluid levels ➢ Debris ➢ Reverberation artifact if gas is present • Posterior acoustic enhancement Hepatic Infection 284 Gastrointestinal Radiology . MC.Hepatic Infections Angela D. USA Hepatic Infections • Pyogenic Abscess • Amebic Abscess • Echinococcal Infections • Schistosomiasis • Clonorchiasis • Infections in the Immunocompromised host ➢ Candidasis ➢ Pneumocystis Pyogenic Hepatic Abscess • Polymicrobial infections • Variable clinical presentation ➢ Septicemia. pain. COL. fever. indolent symptoms ➢ Tender hepatomegaly Pyogenic Hepatic Abscess: Pathogenesis • Biliary ➢ MOST COMMON ETIOLOGY ➢ Cholangitis. biliary obstruction ➢ Multiple and bilateral • Portal vein ➢ Pylephlebitis ➢ Solitary.

• Helpful CT features ➢ Rim-enhancement ➢ Transition zone ➢ Cluster sign ➢ Gas (<20%) Pyogenic hepatic abscess shows ➢ Air/fluid or debris/fluid level cluster sign and transition zone ❖ Suspect GI communication Pyogenic Hepatic Abscess CT Pyogenic Hepatic Abscess: Cluster Sign Pyogenic Hepatic Abscess: Cluster Sign/ Transition zone [Figure 2-3-1] Pyogenic Hepatic Abscess: Intrahepatic Gas Pyogenic Hepatic Abscess: Imaging Guided Drainage • Unilocular and liquefied • Multilocular or multiple ➢ Multiple catheters • Multiple. RUQ pain • Route of spread ➢ Portal venous (most common) ➢ Lymphatic ➢ Direct extension from colon Amebic Abscess: Sonography • Round or oval shape ➢ Absent wall echoes ➢ Homogenous low level internal echoes • Location ➢ Near or touching the liver capsule Figure 2-3-2 ➢ 85% solitary ➢ 72% right lobe • Enhanced through transmission Amebic Abscess [Figure 2-3-2] Amebic Abscess: CT • Enhancing wall (3-15 mm) ➢ Round ➢ Smooth or irregular ➢ Peripheral zone of edema Amebic abscess • Low attenuation/complex fluid ➢ Septations ➢ Fluid/debris level • Extrahepatic extension Gastrointestinal Radiology 285 Hepatic Infection . small (<1 cm) ➢ Aspiration for diagnosis ➢ Treatment: antibiotics or aspiration + antibiotics Amebic Liver Abscess • Most common extra-intestinal manifestation of amebiasis ➢ 3%-7% of patients with amebic infection ➢ Fever.U.Pyogenic Hepatic Abscess: CT Figure 2-3-1 • Singe best imaging method ➢ Sensitivity 97% ➢ Intravenous contrast essential • Hypoattenuating ➢ 0 to 45 H.

Pyogenic Abscess • Cannot reliably differentiate by imaging • Patients with amebic abscess ➢ More likely to have hepatomegaly and diarrhea ➢ History of recent travel or inhabitant of high prevalence areas ➢ Serologic tests positive in >90% Amebic Abscess: Therapy • Medical therapy • Percutaneous biopsy of abscess wall Worldwide distribution of E. granulosus and E. multilocularis Worldwide distribution of E. granulosus Echinococcus: E. >5 cm abscess ➢ Left lobe ➢ Biliary communication ➢ Pregnancy ➢ Perforation ➢ Poor response to drug therapy Amebic Abscess / Pyogenic Abscess Echinococcus: E. granulosus and E. multilocularis [Figure 2-3-4] Echinococcus E. multilocularis • Nomenclature ➢ Hydatidosis is the infection by the larval tapeworm of the genus Echinococcus • Endemic worldwide ➢ Humans accidental host ➢ Infection usually acquired during childhood E. multilocularis Echinococcus lifecycle Hepatic Infection 286 Gastrointestinal Radiology . multilocularis • Symptoms occur during adulthood ➢ Cyst enlargement ➢ Erosion of cyst into peritoneal or pleural cavity ➢ Development of biliary communication • Serology confirms diagnosis ➢ Positive >80% of cases Echinococcus [Figure 2-3-5] Echinococcus: E.Amebic Abscess Figure 2-3-3 Amebic vs. granulosus [Figure 2-3-3] Figure 2-3-5 E. granulosus ➢ If serology does not confirm diagnosis and clinical suspicion is high • Percutaneous drainage if Figure 2-3-4 ➢ Large.

granulosus ❖ Low MR signal ❖ No enhancement E. granulosus: Figure 2-3-7 Daughter cysts [Figure 2-3-6] E. multilocularis: Imaging Features • Ultrasound ➢ Echogenic ➢ Single or multiple ➢ Ill-defined walls Water lily sign of E. granulosus: Water Lily Sign [Figures 2-3-7 and 2-3-8] E. multilocularis Gastrointestinal Radiology 287 Hepatic Infection . granulosus E. granulosus: Complications and Treatment • Cyst rupture ➢ Anaphylaxis Laminated membranes and water lily sign of E. granulosus: Imaging Features Figure 2-3-6 • Unilocular or multilocular cyst ➢ Calcification in cyst wall ➢ Internal debris (hydatid sand) • Complex cyst ➢ Internal daughter cysts ➢ Undulating membrane (water lily sign) ➢ Fibrous and avascular walls and membranes Daughter cysts of E. granulosus ➢ Biliary tract. granulosus ➢ Partially calcified • CT ➢ Geographic Figure 2-3-9 ➢ Infiltrating lesions ➢ Amorphous calcification E. multilocularis [Figure 2-3-9] E. multilocularis: Pathologic Features • Alveolar hydatid disease • Propagation by external budding • Invade surrounding tissue ➢ Infiltrative mass ➢ No limiting host tissue ➢ Resembles neoplasm E. pericardial cavity • Treatment Figure 2-3-8 ➢ Surgical excision ➢ Laparoscopic excision ➢ Percutaneous drainage + sclerosing scolicidal agents E. peritoneal cavity ➢ Pleural.E.

linear branching Symmers' fibrosis bands Schistosomiasis japonicum Figure 2-3-12 [Figure 2-3-12] Biliary Parasites • Parasites that invade bile ducts ➢ Trematodes ❖ Clonorchis sinensis ❖ Fasciola gigantica. mansoni) ➢ Bladder (S. S. mansoni.Schistosomasis (Bilharziasis) Figure 2-3-10 • Trematode (fluke) ➢ S. hematobium) Schistosomasis: S. japonicum ➢ Hepatic calcification ➢ “Turtle back” configuration • S. mansoni Schistosomasis: S. S. Fasciola hepatica Schistosomiasis japonicum on CT ❖ Opisthorchis viverrini ❖ Opisthorchis felineus ➢ Nematodes ❖ Ascariasis lumbricoides ➢ Cestodes ❖ Taenia saginata Hepatic Infection 288 Gastrointestinal Radiology . japonicum Schistosomasis: S. S. japonicum. rounded foci ➢ Low attenuation. mansoni ➢ Low attenuation. hematobium • Humans are definitive host ➢ Mature in the portal venules • Migrate to deposit eggs ➢ Intestine (S. Japonicum. hematobium Lifecycle of Schistosomiasis Schistosomasis [Figure 2-3-10] Figure 2-3-11 Schistosomasis [Figure 2-3-11] • Granulomatous inflammation • Fibrosis ➢ Symmers' fibrosis ➢ Turtle back liver • Progressive portal vein occlusion • Presinusoidal portal hypertension Schistosomasis: Imaging Features • S.

kidney 69% Hepatosplenic Candidiasis: Pathology • Necrosis with minimal inflammation • Microabscesses with severe inflammation • Collagen formation/fibrosis • Granuloma formation Gastrointestinal Radiology 289 Hepatic Infection . and dilatation due to infestation of Clonorchis sinensis Fasciola Hepatica Hepatic Infections in the Immunocompromised Host • Candidiasis • Pneumocystis Carinii • Herpes Simplex Virus • Liver Abscess ➢ Pyogenic ➢ Multiorganism Disseminated Candidiasis • Synonym: hepatosplenic candidiasis • Pathogenesis ➢ Prolonged neutropenia ➢ Mucosal damage to the GI tract ➢ Local invasion of candida with entry into the hepatosplenic circulation • Clinical manifestations ➢ Neutropenic with fever ➢ Return of neutrophil count • Organ Involvement ➢ Spleen 94%. peripheral intrahepatic strictures. liver 75%.Clonorchis sinensis [Figures 2-3-13 and 2-3-14] Figure 2-3-13 • Peripheral intrahepatic bile ducts ➢ Dilatation of small intrahepatic ducts ➢ Periductal fibrosis • Complications ➢ Cholangitis ➢ Cholangiohepatitis ➢ Liver abscess ➢ Cholangiocarcinoma Figure 2-3-14 Lifecycle of Clonorchis sinensis Cholangiogram shows a filling defect.

high T2 • Fat-suppressed T2 improves detection Hepatic candidiasis on MDCT • Gd-FLASH most sensitive • Splenic gamna-gandy bodies false positive T1 Hepatic Infection 290 Gastrointestinal Radiology .Hepatosplenic Candidiasis: Sonography [Figures 2-3-15] • Type 1 lesion ➢ “wheel-within-a-wheel” • Type 2 lesion ➢ “bull’s-eye” • Type 3 lesion-most common ➢ hypoechoic nodule • Type 4 lesion ➢ hyperechoic nodule Figure 2-3-15 I II III IV Figure 2-3-16 Hepatosplenic Candidiasis: CT Features [Figure 2-3-16] • Concentric rings • Hypodense nodules • Punctate calcification Hepatosplenic Candidiasis: MR Features • Low T1.

multilocularis ➢ Infiltrating mass ➢ Calcification Summary: Immunocompromised Hosts • Candidiasis ➢ Neutropenics ➢ Imaging negative during neutropenia ➢ Imaging positive during WBC rebound • Pneumocystis carinii ➢ Hyperechoic nodules ➢ +/.shadowing ➢ Hypodense on CT with progressive calcification ➢ Renal and lymph node calcification Gastrointestinal Radiology 291 Hepatic Infection . granulosus ➢ Daughter cysts ➢ Water-lily sign Sonogram and CT of disseminated pneumocystis ➢ Rim-like calcification • E.Hepatosplenic Candidiasis: Imaging Management • High index of suspicion • Imaging during neutropenia is often negative ➢ Follow up studies if clinical suspicion high and prophylactic therapy contraindicated • Prophylactic therapy • Biopsy • Lesions change morphology with healing Pneumocystis jiroveci • Previously classified as Pneumocystis carinii • Now considered a fungus • Opportunistic infection ➢ AIDS ➢ Organ transplant recipients Pneumocystis jiroveci (carinii): Imaging Features Figure 2-3-17] • Sonography ➢ Nonshadowing hyperechoic nodules ➢ Shadowing echogenic clumps of calcification • CT scan ➢ Hypodense nodules with progressive calcification ➢ Renal and lymph node calcification Figure 2-3-17 Summary: Pyogenic Abscess • Transition zone • Cluster sign • Percutaneous drainage Summary: Amebic Abscess • Cannot reliably distinguish from pyogenic abscess on imaging • Percutaneous biopsy if necessary • Viable organisms in wall • Drainage if necessary Summary: Echinococcus • E.

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small liver from fibrosis Cirrhosis: Segmental Alterations in Volume • Common feature • Not fully understood ➢ Alteration in blood flow • Atrophy ➢ Segments IV. III Cirrhosis: Imaging • Cannot assess severity • Role of imaging ➢ Assess disease complications ➢ Evaluation of portal hypertension ➢ HCC surveillance Cirrhosis: Sonography • Fibrosis ➢ Increased parenchymal echogenicity ➢ Decreased penetration of the ultrasound beam ➢ Poor visualization of hepatic vasculature ➢ Loss of triphasic hepatic vein doppler ➢ Increased pulsatility of portal vein doppler • Nodules • Volume redistribution • Portal hypertension Gastrointestinal Radiology 293 Imaging of Chronic Liver Disease . hepatomegaly from inflammation ➢ Late. VI.Imaging of Chronic Liver Disease Angela D. II. VIII • Hypertrophy ➢ Segments I. COL. Levy. USA Chronic Liver Disease: Objectives • Cirrhosis • Steatosis and steatohepatitis • Budd-Chiari • Disorders of Iron Deposition ➢ Hemosiderosis ➢ Hemochromatosis Cirrhosis: Definition • Endpoint of chronic liver disease Cirrhosis: Pathology • Hepatocyte injury and loss • Fibrosis • Nodule formation • Architectural reorganization • Nodules ➢ Micronodular (<3mm) ➢ Macronodular (>3mm) ➢ Mixed • Liver volume ➢ Early. MC.

mesenteric changes. altered enhancement. altered enhancement and nodules on CT ➢ Increased mesenteric attenuation Cirrhosis: Volume redistribution and nodules Figure 2-4-2 Cirrhosis: Volume redistribution Cirrhosis: Fibrosis. Adenopathy [Figure 2-4-2] Chronic hepatitis B cirrhosis with nodules. nodules [Figure 2-4-1] Cirrhosis: Mesenteric Changes. Cirrhosis: Nodules and adenopathy • Regenerative nodule ➢ Benign ➢ Proliferation of hepatocytes ➢ Precursor to dysplastic nodule and HCC Figure 2-4-4 • Dysplastic nodule ➢ Premalignant • Hepatocellular carcinoma Cirrhosis: Regenerative Nodule • Benign proliferation of hepatocytes • Hemosiderin deposition ➢ "Siderotic nodule" ➢ Noncontrast scans helpful for detection • CT ➢ Isodense with and without contrast ➢ Hyperdense on noncontrast (siderotic nodule) • MR ➢ Dark T1.Cirrhosis: CT Figure 2-4-1 • Morphologic changes ➢ Volume redistribution ➢ Nodules • Fibrosis ➢ Prominent porta and fissures ➢ Focal confluent fibrosis ➢ Decreased parenchymal enhancement • Mesenteric changes ➢ Lymphadenopathy Cirrhosis with fibrosis. gradient echo ➢ Bright T1 (rare). Dark T2 ➢ Best seen on GRE and T2 images Cirrhosis: Regenerative Nodules on CT [Figures 2-4-3 and 2-4-4] Figure 2-4-3 Cirrhosis with high attenuation regenerating nodules (siderotic Cirrhosis with regenerating nodules nodules) on noncontrast CT on CT Imaging of Chronic Liver Disease 294 Gastrointestinal Radiology . T2.

Cirrhosis: Regenerative Nodules and HCC on MR Figure 2-4-5 Cirrhosis: Regenerative Nodules on MR [Figure 2-4-5] Cirrhosis: Dysplastic Nodule • Premalignant nodule ➢ Nodule with histologic evidence of dysplasia • Very common ➢ Most undetectable on CT and MR ➢ Rarely seen on preoperative imaging • Imaging appearance variable • Detection of malignant transformation depends upon evidence of angiogenesis ➢ Arterial enhancment ➢ Nodule in a nodule ➢ MR bright T1 with central dark signal ➢ MR dark T2 with central high signal Cirrhosis: Dysplastic Nodule on MR Cirrhosis: Hepatocellular Carcinoma [Figure 2-4-6] Cirrhosis with regenerating nodules • Incidence in cirrhosis on T2 MR and gross photography ➢ 20% of hepatitis B and C cirrhosis ➢ 10% of alcoholic cirrhosis • CT and MR equally accurate Figure 2-4-6 ➢ 70%-75% of patients ➢ 35%-40% of lesions • Late arterial phase imaging is key ➢ Maximum contrast volume ➢ 4 to 5 ml/sec injection rate Cirrhosis: HCC Detection • False positives ➢ Transient hepatic attenuation (intensity) difference (THAD/THID) ➢ Focal confluent fibrosis (look for associated atrophy) ➢ Enhancing regenerative nodule ➢ Flash filling hemangioma ➢ Early enhancing pseudolesions (arterioportal shunting) Cirrhosis: Transient Hepatic Attenuation (Intensity) Difference • Causes ➢ Portal vein obstruction ➢ Hepatic venous outflow obstruction ➢ Adjacent benign or malignant mass ➢ Arterioportal shunting ➢ Aberrant venous drainage • Imaging features HCC in cirrhosis ➢ Typical locations ❖ Subcapsular ❖ Adjacent to falciform ligament ➢ No mass effect ➢ Straight margins ➢ Wedge shape Gastrointestinal Radiology 295 Imaging of Chronic Liver Disease .

fatty change.Cirrhosis: Focal Confluent Fibrosis • Massive areas of fibrosis Figure 2-4-7 ➢ Present in up to 30% of cirrhotic livers • Typical location ➢ Anterior segment right lobe ➢ Medial segment left lobe • Imaging ➢ Focal mass ➢ Wedge shape. high signal T2 Cirrhosis: Hemangioma Primary Biliary Cirrhosis Primary biliary cirrhosis • Chronic cholestasis • Unknown etiology ➢ Probably immune mediated • Middle-aged women ➢ Median age 50 ➢ Female to male ratio 9:1 Primary Biliary Cirrhosis: CT [Figure 2-4-7] • Global or segmental atrophy • Nodules • Fibrosis ➢ Lace-like pattern ➢ Segmental ➢ Focal confluent • Portal hypertension ➢ Often present before morphologic changes • At risk for HCC Fatty Liver Diseases • Steatosis ➢ Alcohol-associated ➢ Nonalcoholic fatty liver disease (NAFLD) • Steatohepatitis ➢ Alcoholic steatohepatitis ➢ Nonalcoholic steatohepatitis (NASH) Steatosis • Nomenclature ➢ Fatty infiltration. nonalcoholic fatty liver disease (NAFLD) • Very common • Pathogenesis ➢ Abnormal fatty acid metabolism ➢ Insulin/glucagon imbalance ➢ Shift to lipogenesis Imaging of Chronic Liver Disease 296 Gastrointestinal Radiology . radiating from porta hepatis ➢ Capsular retraction ➢ Low density on noncontrast CT ➢ Isodense with contrast or irregular enhancement ➢ MR: low signal T1.

Steatosis: Etiology Figure 2-4-8 • ETOH • Obesity. diabetes • Malnutrition • Parenteral nutrition • Hepatitis. hepatotoxins. hyperlipidemia. drugs • Malabsorption syndromes • Idiopathic Sonography of diffuse fatty infiltration Steatosis and Steatohepatitis: Clinical Features • Asymptomatic • Mild RUQ pain • Mild hepatomegaly and/or tenderness on exam • Mild transaminase elevation Figure 2-4-9 Steatosis: Sonography • Diffuse ➢ Echogenic parenchyma ➢ Poor visualization hepatic vasculature ➢ Absorption of sound • Focal ➢ Focal fat ➢ Focal sparing Diffuse Steatosis: Sonography [Figure 2-4-8] Focal Steatosis: Sonography Focal Fatty Sparing: Sonography Focal fatty infiltration Steatosis: CT • Normal liver noncontrast CT ➢ 30 to 60 HU ➢ 8 to 10 HU > spleen • Fatty liver noncontrast CT ➢ 10 HU < spleen • Fatty liver contrast CT ➢ 25 HU < spleen Steatosis in Celiac Disease Nonalcoholic Steatohepatitis (NASH): CT NASH with Cirrhosis: CT Focal Steatosis: CT [Figure 2-4-9] • Features of focal fat ➢ No mass effect ➢ Straight line margin ➢ No contour abnormality • Often transient • Common locations ➢ Falciform ligament ➢ Subcapsular ➢ Adjacent to porta hepatis ➢ Adjacent to gallbladder fossa Gastrointestinal Radiology 297 Imaging of Chronic Liver Disease . chemotherapy.

ascites.5T MR [Figure 2-4-11] Steatosis: MR [Figure 2-4-12] Multifocal Steatosis: Pseudometastatic Disease Budd-Chiari Syndrome • Hepatic venous outflow obstruction • Primary ➢ Membranous (web) obstruction of hepatic veins 1. pain Figure 2-4-12 Budd-Chiari Syndrome: Pathophysiology • Sinusoidal dilatation • Increase sinusoidal pressure • Centrolobular hepatocyte necrosis • Centrolobular fibrosis ➢ Lobular collapse ➢ Nodular regeneration Focal fat on in-phase images and out-of-phase images Budd-Chiari Syndrome: Pathology • Acute ➢ Hepatomegaly ➢ Sinusoidal dilatation ➢ Hemorrhagic necrosis • Chronic ➢ Fibrosis ➢ Cirrhosis Imaging of Chronic Liver Disease 298 Gastrointestinal Radiology . neoplasms. 6 months duration ➢ Ascites ➢ Triad of hepatomegaly. infections.5 T MR fat and water proton signal • Secondary intensity ➢ Hypercoaguable states. trauma Budd-Chiari Syndrome: Clinical • Acute fulminant disease ➢ Total obstruction ➢ Rare • Subacute/Chronic ➢ Vague illness. Focal Sparing Focal Sparing [Figure 2-4-10] Focal Steatosis: Transient Steatosis: MR Focal fatty sparing • Conventional spin echo typically insensitive to fat deposition • Chemical shift imaging ➢ Fat and water signal additive in-phase ➢ Fat signal subtracted from water signal out-of-phase Figure 2-4-11 Steatosis: 1.Focal Steatosis: Common Locations Figure 2-4-10 Focal Steatosis vs.

Budd Chiari Syndrome: Imaging Figure 2-4-13 • Vascular changes ➢ Hepatic vein stenosis ➢ Intravascular thrombus ➢ Web-like stenosis or narrowed IVC ➢ Intrahepatic collaterals • Parenchymal changes ➢ Nonvisible hepatic veins ➢ Cirrhosis ➢ Nodular regenerative hyperplasia Hepatic Venous Waveforms [Figure 2-4-13] Budd-Chiari Syndrome: Enhancement Patterns • Noncontrast ➢ Heterogeneous hypodensity ❖ Hepatic parenchymal congestion ➢ Hyperdense thrombi • Contrast enhancement ➢ Patchy enhancement ➢ Normal central hepatic. and caudate lobe Normal hepatic vein (upper image) enhancement and Budd Chiari (lower image) ➢ Late peripheral enhancement Figure 2-4-14 Budd-Chiari Syndrome [Figure 2-4-14] Budd Chiari Syndrome [Figure 2-4-15] Budd Chiari Syndrome: MR [Figure 2-4-16] • Narrowed veins • Intraluminal thrombus Budd Chiari • Collaterals Figure 2-4-15 Figure 2-4-16 Budd-Chiari Budd Chiari Gastrointestinal Radiology 299 Imaging of Chronic Liver Disease . left lobe.

Budd Chiari from IVC Web Budd Chiari and Nodular Regenerative Hyperplasia Disorders of Iron Deposition • Functional Classification ➢ Hemosiderosis ❖ Iron accumulation in the reticuloendothelial system ❖ Iron in the liver with no organ damage ➢ Hemochromatosis ❖ Iron in hepatocytes with eventual fibrosis and cirrhosis ❖ Two types Hereditary hemochromatosis Secondary hemochromatosis ❖ High risk for HCC Hemosiderosis in Sickle Cell Anemia [Figure 2-4-17] Hemochromatosis • Hereditary hemochromatosis ➢ Increased intestinal absorption of iron ➢ Iron predominantly within hepatocytes ➢ Highest incidence of cirrhosis and HCC (14%) • Secondary hemochromatosis ➢ Multiple transfusions ➢ Iron predominantly in the reticuloendothelial system Hereditary Hemochromatosis (HHC): Clinical Features Figure 2-4-17 • Hyperpigmentation • Diabetes mellitus (bronze diabetes) • Hepatomegaly • Chondrocalcinosis/osteoarthritis • Cardiomyopathy Hereditary Hemochromatosis (HHC): Pathology Hemosiderosis Hemochromatosis: Increased CT Attenuation (75-135 HU) Figure 2-4-18 Hereditary Hemochromatosis Increased Hepatic CT Attenuation • Differential Diagnosis ➢ Iron deposition ➢ Glycogen storage disease ➢ Amiodarone ➢ Wilson’s disease Hereditary Hemochromatosis ➢ Chronic arsenic poisoning Hemochromatosis: MR • T2*-gradient echo imaging is most sensitive ➢ Quantitate with liver:muscle ratio • Decrease signal on T2-weighted images ➢ Hereditary = iron in liver and pancreas ➢ Secondary = iron in liver and spleen Hereditary Hemochromatosis [Figure 2-4-18] Imaging of Chronic Liver Disease 300 Gastrointestinal Radiology .

188(1):31-35. 4. Dodd GD. Peterson MS. 8. 154(3):505-507. Confluent hepatic fibrosis in advanced cirrhosis: appearance at CT. Radiology 2003. 21 Spec No:S117-132. et al. Iio M. Radiology 1993. Itai Y. focal abnormalities. Ohtomo Y. 3. 7. 226(2):550-555. Fujita T. Gastrointestinal Radiology 301 Imaging of Chronic Liver Disease . Radiology 2004. 3rd. 3rd. AJR Am J Roentgenol 1999. Regenerating nodules of liver cirrhosis: MR imaging with pathologic correlation. Dodd GD. Spectrum of imaging findings of the liver in end-stage cirrhosis: part I. 3rd. Hussain HK. 6. Marsh W. T2-weighted MR imaging in the assessment of cirrhotic liver. Matsunaga N. AJR Am J Roentgenol 1990. Peterson MS. Nghiem HV. Federle MP. Baron RL. AJR Am J Roentgenol 2003. From the RSNA refresher courses: screening the cirrhotic liver for hepatocellular carcinoma with CT and MR imaging: opportunities and pitfalls. gross morphology and diffuse abnormalities. 173(4):1031-1036. 2. Shimizu K. 3rd. Cirrhosis or chronic hepatitis: evaluation of small (<or=2-cm) early-enhancing hepatic lesions with serial contrast-enhanced dynamic MR imaging. 5.Secondary Hemochromatosis Summary: Cirrhosis • Endpoint of chronic liver disease • Nodules ➢ Regenerative ➢ Dysplastic ➢ HCC • HCC false positives Summary: Fatty Infiltration • Steatosis • Steatohepatitis Summary: Focal Steatosis • No mass effect • Straight line margins • Typical Locations ➢ Subcapsular ➢ Falciform ligament • Chemical shift MR ➢ Signal loss on out-of-phase images Summary: Budd-Chiari Syndrome • Hepatic venous outflow obstruction • Sonography • CT enhancement ➢ Early central ➢ Late peripheral • MR Summary: Disorders of Iron Overload • Hemosiderosis • Hemochromatosis ➢ Hereditary ➢ Secondary References Cirrhosis 1. Koike S. Oliver JH. 173(5):1185-1192. Federle MP. Shimizu A. Oliver JH. 3rd. AJR Am J Roentgenol 1999. 180(4):1007-1014. Shiga J. Ohtomo K. Ohtomo K. Ito K. Brancatelli G. Baron RL. Baron RL. Spectrum of imaging findings of the liver in end-stage cirrhosis: Part II. Radiographics 2001. Syed I. et al. 230(3):637-644. Dodd GD. Baron RL. Baron RL. Helical CT screening for hepatocellular carcinoma in patients with cirrhosis: frequency and causes of false-positive interpretation.

AJR Am J Roentgenol 2002. Spectrum of CT and sonographic appearance of fatty infiltration of the liver. 8. Jacobs JE. et al. 1998 2. Takashima T. Noone TC. Federle MP. CT and MRI findings of multifocal hepatic steatosis mimicking malignancy. et al. Jung G. Lencioni R. Itoh K. Imaging of hepatic steatosis. Radiology 199:13.univ-rennes1. MR imaging of diffuse liver disease. Kroncke TJ. http://www. Maetani Y. 5:347-365. Semelka RC: Abdominal iron deposition: metabolism. Poll LW. et al.radio. Grazioli L. Abdom Imaging 2002. AJR Am J Roentgenol 1987. Rosen MA. Disorders of Iron Deposition 1. Mitchell DG. et al. Shapiro MA. and clinical importance. Semelka RC. Washington.fr/Sources/EN/Hemo. 178:869-875. Yoshikawa J. and MRI. Large regenerative nodules in Budd-Chiari syndrome and other vascular disorders of the liver: CT and MR imaging findings with clinicopathologic correlation. 6. 21:71-80. Semin Liver Dis 2001. Luthen R. Kemper J. 5. 7. Moedder U. MR findings. Hepatic fat and iron. Jain KA. Magn Reson Imaging Clin N Am 1997. 2. 17:162-168. Focal fatty change of the liver adjacent to the falciform ligament: CT and sonographic findings in five surgically confirmed cases. 3. et al. J Magn Reson Imaging 2000. 1996 Imaging of Chronic Liver Disease 302 Gastrointestinal Radiology . 149:491-494. AJR Am J Roentgenol 2002.html.Steatosis/Steatohepatitis 1. Egawa H. Siegelman ES. and chronic disease with magnetic resonance imaging. McGahan JP. Matsui O. AJR Am J Roentgenol 1998. Budd-Chiari syndrome: spectrum of appearances of acute. Benign hepatic nodules in Budd-Chiari syndrome: radiologic-pathologic correlation with emphasis on the central scar. Brunt EM. Kivelitz D. Diagnostic criteria for fatty infiltration of the liver on contrast-enhanced helical CT. 10:1095-1100. 21:3-16. 4. Nonalcoholic steatohepatitis: definition and pathology. Multifocal nodular fatty infiltration of the liver mimicking metastatic disease on CT: imaging findings and diagnosis using MR imaging. Golfieri R. Brancatelli G. 178:877-883. 11:44-50. Birnbaum BA. Siegelman ES. 4. Bonkovsky HL: Disorders of iron overload. In Bloomer JR. Siegelman ES. Siegelman ES. DC: Armed Forces Institute of Pathology. Eur Radiol 2000. 27:708-710. 171:659-664. 2001 3. Jonkmanns C. Gandon Y: Iron. liver. Taupitz M. 5. Budd-Chiari Syndrome 1. Goodman ZD. Semin Liver Dis 2001. Ishak KG (eds): Clinical and pathologoical correlations in liver disease: approaching the next millennium. subacute. Clin Imaging 1993.

ADPCKD ➢ Medullary sponge kidney ➢ Medullary cystic disease Ductal Plate • Embryologic precursor of intrahepatic bile ducts Ductal Plate Malformation • Abnormal development of intrahepatic bile ducts • Lack of ductal plate remodeling ➢ Persistence of embryonic structures (DPM) ➢ Segmental dilatation ➢ Destructive inflammation/fibrosis • Spectrum of diseases ➢ Small interlobular ducts: Congenital hepatic fibrosis (CHF) ➢ Large intrahepatic ducts: Caroli disease ➢ All ducts: Caroli syndrome (CHF and Caroli disease) Gastrointestinal Radiology 303 Benign Biliary Disease . elevated LFTs [Figure 2-5-1] Obstructive Biliary Dilatation • Tubular dilatation • Diffuse dilatation proximal to the obstruction • Abrupt termination at level of obstruction Congenital Disorders • Caroli disease • Choledochal cyst • Polycystic liver disease Saccular and fusiform biliary dilatation in Caroli Disease Caroli disease • Autosomal recessive • Secondary to ductal plate malformation (DPM) • Associated with renal disorders ➢ ARPCKD. Pyogenic Figure 2-5-1 41-year-old male with history of renal stones and diagnosis of medullary sponge kidney presents with abdominal pain. MC. COL. Levy.Benign Biliary Disease Angela D. sepsis. USA Objectives • Congenital Disorders ➢ Caroli disease ➢ Choledochal cyst ➢ Polycystic Liver Disease • Inflammatory Disorders ➢ Primary sclerosing cholangitis ➢ AIDS-related cholangiopathy ➢ Recurrent Pyogenic Cholangitis ➢ Acute Pyogenic Cholangitis Differential Diagnosis • Obstructive biliary dilatation • Caroli disease • Choledochal cyst • Polycystic liver disease • Cholangitis ➢ RPC.

fever.Intrahepatic Duct Embryology: Ductal Plate [Figures 2-5-2 and 2-5-3] Figure 2-5-2 Figure 2-5-3 Single layer of ductal Double layer of Fusion and plate cells ductal plate cells absorption of ductal plate cells Normal ductal plate development of the intrahepatic bile ducts Caroli Disease: Clinical Features • Presentation at any age (mean age 37 years) • Pain. • Cholangiocarcinoma (7%) Ductal plate malformation results in biliary duct ectasia Caroli Disease: Radiologic Features and fibrosis surrounding the • Intrahepatic duct dilatation portal tract ➢ Distribution: segmental (83%) or diffuse (17%) ➢ Shape: saccular (76%) or fusiform (24%) ➢ Central dot sign • Extrahepatic duct dilatation ➢ 53% of cases Figure 2-5-4 ➢ Secondary to cholangitis and stone passage • Cirrhosis Caroli Disease: “Central Dot Sign” [Figure 2-5-4] Caroli disease showing saccular biliary dilatation and the central dot sign Benign Biliary Disease 304 Gastrointestinal Radiology . jaundice ➢ Recurrent cholangitis ➢ Stone formation • Liver failure ➢ Fibrosis Caroli Disease: Complications Normal ductal plate remodeling • Recurrent biliary stones results in intercommunicating • Recurrent cholangitis intrahepatic bile ducts • Hepatic abscess surrounding a normal portal • Fibrosis/cirrhosis tract.

Portal Hypertension Figure 2-5-5 [Figure 2-5-5] Caroli Disease Cholangiography Caroli Disease: Segmental Caroli Disease: Hepatic Abscess Caroli Disease: Intrahepatic Lithiasis Caroli Disease: Intraductal Cholangiocarcinoma Caroli Disease: Cholangiocarcinoma • Enhancing intraductal masses • Focal strictures ➢ Irregular margins ➢ Shoulders ➢ Irregular tapering • Infiltrating masses Caroli disease in two different patients Choledochal Cyst showing diffuse fusiform and saccular • Congenital dilatation of the bile ducts dilatation • Association with anomalous pancreatico-biliary junction (APBJ) Choledochal Cyst: Figure 2-5-6 Clinical Features • Presentation at any age (mean. 17 years) ➢ F>M • Clinical presentation ➢ Pain. palpable mass • Complications ➢ Stones ➢ Cholangitis ➢ Malignancy Normal pancreaticobiliary junction showing union of the ducts in the Choledochal Cyst: sphincter complex. There may be a Etiology [Figures 2-5-6 and 2-5-7] common channel (ampulla) or not • Normal Pancreaticobiliary Junction ➢ Sphincter complex encircles distal CBD and PD Figure 2-5-7 ➢ 80% to 90% have a common channel (4-5 mm • Anomalous Junction (APBJ) ➢ Union of CBD and PD outside of duodenum and sphincter complex ➢ Reflux of pancreatic enzymes into CBD) Choledochal Cyst: Pathologic Features • Extrahepatic duct dilatation • Mural thickening • Normal epithelium Anomalous pancreaticobiliary junction showing union of the common bile duct and pancreatic duct proximal to the duodenal wall and sphincter complex Gastrointestinal Radiology 305 Benign Biliary Disease .Caroli Syndrome Cirrhosis. jaundice. which is located in the duodenal wall.

➢ Isolated to the liver The cholangiogram shows an anomalous ➢ Occurring with ADPCKD pancreaticobiliary junction as well as the extent of • Bile duct cysts duct dilatation ➢ Secondary to von Meyenberg complexes ➢ Von Meyenberg complex is DPM at the lowest level Polycystic Liver Disease . not inherited ➢ Extrahepatic bile duct dilatation with varying degrees Todani classification of choledochal cysts of proximal dilatation ➢ Surgical therapy with biliary reconstruction • Caroli disease Figure 2-5-9 ➢ Congenital.Radiologic Features • Multiple liver cysts ➢ May have internal hemorrhage ➢ Rim-like calcification • Normal bile ducts • Associated feature of ADPCKD ➢ Renal cysts ➢ Pancreatic cysts ➢ Thyroid cysts ➢ Seminal vesicle cysts in males Benign Biliary Disease 306 Gastrointestinal Radiology .Choledochal Cyst: Todani Classification [Figure 2-5-8] Figure 2-5-8 Todani Type I Todani Type II: Diverticulum Todani Type III: Choledochocele Tubulovillous Adenoma Todani Type IV [Figure 2-5-9] Todani Type V: Caroli Disease Is Todani Type V Caroli Disease? • Choledochal cyst ➢ Congenital.extrahepatic dilatation ➢ Liver biopsy shows DPM ➢ Medical therapy (surgery for complications) Malignancy and Choledochal Cyst • Adenocarcinoma most common • Locations ➢ Within the choledochal cyst ➢ Gallbladder ➢ Biliary tract Malignancy and Choledochal Cyst Polycystic Liver Disease Todani Type IV choledochal cyst showing central • Two forms intrahepatic and extrahepatic duct dilatation on CT. inherited ➢ Intrahepatic +/.

Polycystic Liver Disease Figure 2-5-10 Polycystic Liver Disease in ADPCKD [Figure 2-5-10] Polycystic Liver Disease without ADPCKD Polycystic Liver Disease • Bile ducts ➢ Displaced. mural • Diagnosis thickening. but normal ➢ Rare. and inflammatory changes of primary ➢ Liver biopsy sclerosing cholangitis ➢ Cholangiogram Gastrointestinal Radiology 307 Benign Biliary Disease . Pyogenic Caroli Disease Figure 2-5-11 Summary: Congenital Disorders • Exclude obstructive dilatation • Congenital disorders ➢ Caroli disease ❖ Intrahepatic ➢ Choledochal cyst ❖ Extrahepatic ➢ Polycystic liver disease ❖ Noncommunicating Primary sclerosing cholangitis cysts 40-year-old woman with elevated LFT’s [Figure 2-5-11] Figure 2-5-12 Differential Diagnosis • Cholangitis ➢ Primary sclerosing ➢ AIDS-related ➢ Recurrent pyogenic ➢ Acute pyogenic cholangitis • Neoplasm Inflammatory Disorders • Primary sclerosing cholangitis • AIDS-related cholangiopathy • Recurrent pyogenic cholangitis • Acute pyogenic cholangitis Primary Sclerosing Cholangitis [Figure 2-5-12] • Cholestatic liver disease • Unknown etiology • Fibrosing inflammation Illustration showing disease distribution. mucosal irregularity 41-year-old male with history of renal stones and diagnosis of medullary sponge kidney presents with abdominal pain. elevated LFT’s Differential Diagnosis • Obstructive biliary dilatation • Caroli disease • Choledochal cyst • Polycystic liver disease Polycystic liver disease occurring in • Cholangitis ADPCKD ➢ RPC. sepsis.

➢ Cystic duct 30% and hepatoduodenal ligament adenopathy ➢ Pancreatic duct (rare) • Other features ➢ Gallbladder disease (40%) Figure 2-5-14 ➢ Ductal stones (8%) ➢ Adenopathy ➢ Neoplasm PSC: Sonographic Features PSC: CT Features [Figure 2-5-13] PSC: Cholangiography [Figure 2-5-14] • Beading • Pruned-tree • Mural irregularity • Diverticula MRCP PSC: Cholangiocarcinoma • Stricture (90%) ➢ Long strictures (>1cm) ERCP of primary sclerosing cholangitis showing beading and ➢ Completely obstructing strictures pruning of the intrahepatic bile ducts. The extrahepatic bile ➢ Associated mass duct shows mural irregularity with focal stricture formation • Multicentric (10%) • Polypoid mass AIDS Cholangiopathy [Figure 2-5-15] Figure 2-5-15 • Group of disorders ➢ Sclerosing cholangitis ➢ Papillary stenosis ➢ Acalculous cholecystitis • Opportunistic infection ➢ Cryptosporidium ➢ Cytomegalovirus • Declining incidence ➢ HAART therapy AIDS Cholangiopathy • Cholangiographic features ➢ Beading ➢ Pruning ➢ Mural irregularity ➢ Filling defects (granulation tissue) ➢ Papillary stenosis (papillitis) ➢ No EHD stenosis or diverticula Illustration of AIDS cholangiopathy showing disease distribution Benign Biliary Disease 308 Gastrointestinal Radiology .Imaging Figure 2-5-13 • Thickened duct wall ➢ Asymmetric or circumferential ➢ 2 to 5 mm • Hepatic parenchymal changes ➢ Cirrhosis ➢ Periportal fibrosis ➢ Discontinuous duct dilatation ➢ Portal hypertension • Distribution ➢ Intrahepatic 100% CT of primary sclerosing cholangitis showing discontinuous bile ➢ Extrahepatic 70% duct dilatation.PSC . mural thickening of the common hepatic duct.

AIDS Cholangiopathy [Figure 2-5-16] Figure 2-5-16 AIDS Cholangiopathy • Sonographic features ➢ Gallbladder wall thickening ❖ Acalculous cholecystitis ➢ Bile duct wall thickening ➢ Hyperechoic nodule in distal CBD (papillitis) AIDS Cholangiopathy Acalculous cholecystitis [Figure 2-5-17] Recurrent Pyogenic Cholangitis (RPC) [Figure 2-5-18] • Clinical syndrome ➢ Pigmented stones ➢ Recurrent infection • Unknown etiology ➢ Biliary parasites ➢ Malnutrition AIDS cholangiopathy with papillary stenosis ➢ Portal bacteremia • Complications Figure 2-5-17 ➢ Biliary cirrhosis ➢ Cholangiocarcinoma RPC: Imaging [Figure 2-5-19] • Stones. sludge • Duct dilatation • Left lobe predominant • Parenchymal changes ➢ Atrophy ➢ Fatty change Acalculous cholecystitis in AIDS ➢ Altered enhancement ➢ Abscess Figure 2-5-18 RPC Acute Pyogenic Cholangitis [Figure 2-5-20] • Almost always post-obstructive • Polymicrobial • Etiology ➢ Stones ➢ Anastomotic stricture ➢ Papillary stenosis ➢ Carcinoma ➢ Underlying biliary disease Acute Pyogenic Cholangitis • Imaging Features ➢ Duct dilatation ➢ Obstructive lesion ➢ Echogenic bile ➢ Mural irregularity ➢ Hepatic abscess Illustration of recurrent pyogenic cholangitis showing typical disease distribution Gastrointestinal Radiology 309 Benign Biliary Disease .

Rohrmann CA. Pathogenesis of ductal plate abnormalities. Murakata LA. Proesmans WC. Mayo Clinic Proceedings 73:80. et al: Caroli disease: central dot sign in CT. et al: Caroli's disease: radiologic spectrum with pathologic correlation. Desmet VJ. Cercueil JP. Radiology 158:507. Jr. 1986 Benign Biliary Disease 310 Gastrointestinal Radiology . Krause D. Yeon KM. Marchal GJ.Figure 2-5-19 Recurrent pyogenic cholangitis with intrahepatic lithiasis and duct dilatation Figure 2-5-20 Acute Pyogenic Cholangitis with Microabscesses 40-year-old woman with elevated LFT’s Differential Diagnosis • Cholangitis ➢ Primary sclerosing ➢ AIDS-related ➢ Recurrent pyogenic ➢ Acute pyogenic cholangitis • Neoplasm Primary Sclerosing Cholangitis Summary • PSC ➢ Fibrosis • AIDS cholangiopathy ➢ Papillary stenosis Illustration showing typical manifestations of acute ➢ Acalculous cholecystitis pyogenic cholangitis • RPC ➢ Stones ➢ Focal dilatation • Pyogenic cholangitis ➢ Obstruction References Caroli Disease 1. Kim SH. et al: MRI for evaluating congenital bile duct abnormalities. Choi BI. 1998 3. AJR 179:1053. et al: Caroli disease: high-frequency US and pathologic findings. 2002 4. J Comput Assist Tomogr 26:541.. Radiology 174:161. Desmet VJ: Ludwig symposium on biliary disorders--part I. Levy AD. Dranssart M. 1990 2. 2002 5.

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Leong LL. and cholangiography. Teefey SA. et al: Primary sclerosing cholangitis: sonographic findings. Park MS. et al: Recurrent pyogenic cholangitis: comparison between MR cholangiography and direct cholangiography. Chan FL. LaRusso NF. Radiology 158:856. Ferderle MP. et al: Prevalence of primary sclerosing cholangitis in patients with ulcerative colitis. 1987 AIDS Cholangiopathy 1. AJR Am J Roentgenol 145:1061. Clin Radiol 48:307. Radiology 182:139. Da Silva F. 2001 Benign Biliary Disease 312 Gastrointestinal Radiology . et al: AIDS-related cholangitis: radiographic findings in nine patients. Radiology 143:151. Use of ultrasonography. Kim KW. Radiol Clin North Am 25:175. Williams SM. Federle MP. Abdom Imaging 20:109. 2004 4. Gastroenterology 100:1319. Lecomte I. AJR Am J Roentgenol 160:1205. Defalque D. Rohrmann CA. 1988 15. Laing FC. Okuno WT. Menu Y. computed tomography. Bender CE. LaRusso NF. 1985 13. Lumsden AB. Boudghene F. Laing FC. Chen XM. Phoa SS. Cha SW. 1993 3. Forbes A. Baron RL. Teefey SA. Schulte SJ. Radiology 163:313. Wiesner RH. 1995 12. Curr Treat Options Gastroenterol 7:91. et al: Sonographic diagnosis of cholangitis in AIDS patients. et al: Radiological and pathological features of AIDS-related polypoid cholangitis. et al: Nonoperative dilatation of dominant strictures in primary sclerosing cholangitis. et al: Sclerosing cholangitis: CT findings. et al: Sonography in AIDS-related cholangitis: prevalence and cause of an echogenic nodule in the distal end of the common bile duct. 2002 2. Radiology 169:635. 1989 2. Jeyarajah DR: Recurrent Pyogenic Cholangitis. Mitchell DG. et al: Primary sclerosing cholangitis: findings on cholangiography and pancreatography. Harned RK: Hepatobiliary complications of inflammatory bowel disease. Man SW. Semin Liver Dis 22:277. Kim MJ. Radiology 149:39. 1996 6. Whitman GJ. et al: MR imaging findings in recurrent pyogenic cholangitis. 1986 10. 1992 16. Majoie CB. MacCarty RL. AJR Am J Roentgenol 167:484.9. Radiology 170:165. Harcourt-Webster JN. Girard PM. Chew FS: Recurrent pyogenic cholangiohepatitis. 1999 5. 1989 5. 1991 14. 1983 11. Dolmatch BL. et al: Evaluation of recurrent pyogenic cholangitis with CT: analysis of 50 patients. LaRusso NF: Cryptosporidiosis and the pathogenesis of AIDS-cholangiopathy. Gastrointest Radiol 14:143. et al: Recurrent pyogenic cholangitis in Asian immigrants. Yu JS. Jarnerot G. Danielsson A. Radiology 220:677. 1982 3. 1987 Recurrent Pyogenic Cholangitis 1. Cello JP. 1993 4. et al: Patterns of intrahepatic bile duct dilatation at CT: correlation with obstructive disease processes. Collins CD. May GR. Alspaugh JP: Cholangiocarcinoma complicating primary sclerosing cholangitis: cholangiographic appearances. Smits NJ. Olsson R. Baron RL. AJR Am J Roentgenol 173:1545.

NF1 ➢ Infection ❖ Biliary parasites. Levy. ➢ ~2000 to 2500 cases per year • Incidence worldwide ➢ Up to 10 times greater in Asian countries • More common in men ➢ 2:1 Biliary Adenocarcinoma • High risk groups ➢ Autoimmune diseases ❖ PSC.S. COL. MC. ulcerative colitis. USA Objectives • Biliary adenocarcinoma ➢ Intrahepatic cholangiocarcinoma ➢ Intraductal cholangiocarcinoma ➢ Hilar (Klatskin) cholangiocarcinoma ➢ Extrahepatic duct adenocarcinoma • Differential diagnosis ➢ Benign strictures ➢ Other neoplasms Biliary Adenocarcinoma • Incidence in U. FAP. anomalous pancreaticobiliary junction ❖ Abnormal tumor suppressor genes.Biliary Neoplasms Angela D. primary biliary cirrhosis ➢ Congenital anatomic anomalies ❖ Caroli. recurrent pyogenic cholangitis Biliary Adenocarcinoma • Clinical presentation ➢ Jaundice ➢ Pain ➢ Fever if secondary cholangitis Biliary Adenocarcinoma • Moderately to well differentiated • Desmoplastic stroma • Infiltrative margins ➢ NO CAPSULE Biliary Adenocarcinoma • Dismal 5-year survival • < 20% resectable at diagnosis • Curative resection ➢ Tumor free margins ➢ “No touch” technique Biliary Adenocarcinoma • Intrahepatic Cholangiocarcinoma Biliary Adenocarcinoma • Intraductal Cholangiocarcinoma Biliary Adenocarcinoma • Hilar Cholangiocarcinoma Gastrointestinal Radiology 313 Biliary Neoplasms . choledochal cyst.

➢ Parenchymal invasion (segment IV) 30% of cases There is an intrabiliary mass on the • Lobar or segmental atrophy CT and corresponding gross ➢ Secondary to vascular compromise photograph Biliary Neoplasms 314 Gastrointestinal Radiology .Biliary Adenocarcinoma Figure 2-6-1 • Extrahepatic bile duct adenocarcinoma Intrahepatic Cholangiocarcinoma: Pathologic Features • Solitary. large mass • No capsule • Dense fibrous stroma • No necrosis or hemorrhage • Multifocal mass • Satellite lesions • Intrahepatic metastasis Intrahepatic Cholangiocarcinoma [Figure 2-6-1] • Delayed enhancement • Peripheral biliary dilatation • Capsular contraction Intrahepatic Cholangiocarcinoma • Differential diagnosis ➢ Metastasis ➢ HCC ➢ Gallbladder adenocarcinoma ➢ Rare. sarcoma • Identifying key features of ICC ➢ Evidence of fibrous stroma ➢ Contrast enhancement pattern ➢ Capsular contraction Intraductal Cholangiocarcinoma [Figure 2-6-2] Intrahepatic cholangiocarcinoma with • Rare delayed enhancement and capsular • Intrabiliary mass contraction • Biliary diliatation peripheral to the mass Hilar Cholangiocarcinoma: Klatskin Tumor • Tumors arising at or near the confluence of the right and left hepatic ducts • Most common site of biliary adenocarcioma • Aggressive biologic behavior Figure 2-6-2 Hilar Cholangiocarcinoma: Klatskin Tumor • Imaging features • Anatomic location • Pathologic features Hilar Cholangiocarcinoma: “Klatskin Tumor” • Imaging features ➢ Duct dilatation ➢ Ill-defined mass ➢ Lobar atrophy ➢ Vascular invasion Hilar Cholangiocarcinoma: Imaging Features [Figure 2-6-3] • Dilated ducts ➢ Discontinuous ducts • Poorly defined mass ➢ Poor visibility of tumor mass ➢ Minimal tumor enhancement on CT (50% of cases) ➢ More likely to enhance on MR Intraductal cholangiocarcinoma.

Surg Gynecol Obstet 1975. Ill-defined mass adjacent to bile duct stent [Figure 2-6-8] and extending into hepatoduodenal ligament • Tumor at confluence Bismuth-Corlette: Type IIIa and IIIb [Figure 2-6-9] Figure 2-6-5 • Tumor extends to right or left hepatic ducts • Hemiliver resection ➢ Preoperative PV embolism Bismuth-Corlette: Type IIIa Bismuth-Corlette: Type IV [Figures 2-6-10 and 2-6-11] • Tumor in bilateral ducts Hilar cholangiocarcinoma on MRCP and percutaneous transhepatic cholangiography Gastrointestinal Radiology 315 Biliary Neoplasms . Corlette MB.Hilar Cholangiocarcinoma [Figure 2-6-4] Figure 2-6-3 Hilar Cholangiocarcinoma [Figure 2-6-5] • Cholangiographic features of malignant strictures ➢ Evidence of mass effect ➢ Irregular margins ➢ Irregular or abrupt tapering at obstruction • Limitations of MRCP ➢ Spatial resolution ➢ Evaluation of secondary ducts Hilar Cholangiocarcinoma Role of Preoperative Imaging • Determination of resectablility • Surgical planning ➢ Bismuth-Corlette classification1 ➢ Define extent of duct involvement 1Bismuth H. Classic sonographic appearance Hilar Cholangiocarcinoma: Unresectability of hilar cholangiocarcinoma • Bilateral tumor extension showing biliary dilatation and an ➢ Into secondary ducts ill-defined hilar mass ➢ Into hepatic parenchyma ➢ Hepatic artery or portal vein • Occlusion main portal vein Figure 2-6-4 • N2 nodes • Distant mets • Medically unfit patients Bismuth-Corlette: Type I [Figures 2-6-6 and 2-6-7] • Tumor below confluence Bismuth-Corlette: Type II Hilar cholangiocarcinoma. 140: 170-178.

Tumor is cholangiocarcinoma.Figure 2-6-6 Figure 2-6-7 Figure 2-6-8 Bismuth Corlette Type I hilar Bismuth Corlette Type II hilar cholangiocarcinoma. Tumor involves below the confluence of the right the confluence and left hepatic ducts Bismuth Corlette Type I Figure 2-6-10 Figure 2-6-9 Bismuth Colette Type IV hilar cholangiocarcinoma. Tumor involves the right (IIIa) or left (IIIb) hepatic duct Bismuth Corlette Type IV Biliary Neoplasms 316 Gastrointestinal Radiology . Tumor involves bilateral intrahepatic ducts Figure 2-6-11 Bismuth Colette Type IIIa (upper) and IIIb (lower) hilar cholangiocarcinoma.

29:1237. RL. Figure 2-6-13 duct adenocarcinoma Papillary adenocarcinoma of the extrahepatic bile duct Malignant Stricture [Figures 2-6-14 and 2-6-15] EHBD Adenocarcinoma Figure 2-6-14 Figure 2-6-15 Cholangiographic and CT features of a malignant Malignant stricture stricture Gastrointestinal Radiology 317 Biliary Neoplasms .EHBD Adenocarcinoma [Figure 2-6-12] Figure 2-6-12 • Variable morphology ➢ Diffusely infiltrating ➢ Polypoid ➢ Nodular ➢ Constricting (scirrhous) EHBD Adenocarcinoma: Imaging • Biliary obstruction • Tumor ➢ Intraluminal mass ➢ Stenosis ➢ Complete obstruction Papillary Adenocarcinoma [Figure 2-6-13] EHBD Adenocarcinoma vs. Benign Stricture • Malignant ➢ Duct abruptly terminates at stricture • Benign ➢ Duct tapers to stricture Baron. Radiol Clin N Am Morphologic types of extrahepatic 1991.

mean age 34 years • Location: Benign stricture ➢ CBD (50%) ➢ Cystic duct (37%) ➢ CHD (11%) ➢ Gallbladder (4%) Figure 2-6-17 ➢ Intrahepatic ducts (4%) • Infiltrative lesions that produce short annular strictures Figure 2-6-18 Cholangiographic and CT features of a benign stricture Granular cell tumor Biliary Neoplasms 318 Gastrointestinal Radiology .Benign Stricture [Figures 2-6-16 and 2-6-17] Figure 2-6-16 Pancreatitis with Stricture Differential Diagnosis • Post-inflammatory benign strictures ➢ Pancreatitis ➢ Post radiation or chemotherapy • Inflammatory strictures ➢ Primary sclerosing cholangitis ➢ AIDS cholangiopathy ➢ Recurrent pyogenic cholangitis ➢ Biliary parasites • Other neoplasms ➢ Gallbladder adenocarcinoma ➢ Pancreatic adenocarcinoma ➢ Metastasis ➢ Granular cell tumor ➢ Biliary papillomatosis Granular Cell Tumor [Figure 2-6-18] • Benign tumors of Schwann cell origin • 90% of patients are females.

Han JK. 1997 4. AJR Am J Roentgenol 181:819. Hepatogastroenterology 51:43. Tani K. Malignant • Malignant stricture ➢ Abrupt change • Benign stricture ➢ Tapering Klatskin / PSC Summary: Granular Cell Tumor • Benign Neoplasm ➢ Young. women ➢ True mimic for carcinoma References Intrahepatic Cholangiocarcinoma 1. et al: MR imaging of peripheral cholangiocarcinoma. Zhang Y. Radiology 204:539. J Comput Assist Tomogr 15:975. cholangitis • Local recurrence and malignant transformation common Summary • Biliary Adenocarcinomas ➢ Uncommon • Peripheral intrahepatic cholangiocarcinoma ➢ Mass forming tumors ➢ Delayed. J Comput Assist Tomogr 21:59. Choi BI. patchy enhancement ➢ Look for imaging evidence of fibrosis • Intraductal cholangiocarcinoma ➢ Rare ➢ Intraductal masses ➢ Biliary obstruction • Hilar cholangiocarcinoma ➢ Most common subtype ➢ Look for discontinuous biliary dilatation ➢ Determination of resectablility • Extrahepatic duct adenocarcinoma ➢ Must differentiate from a benign stricture Summary: Benign vs. 2003 5. Van Beers BE. et al: Intrahepatic peripheral cholangiocarcinoma: comparison of dynamic CT and dynamic MRI. Semelka RC. Han JK: Imaging of intrahepatic and hilar cholangiocarcinoma. Magn Reson Imaging 16:993. Abdom Imaging 29:548. Washington. Kubota Y. J Comput Assist Tomogr 23:670.Biliary Papillomatosis • Multiple and recurrent adenomas of the biliary tract • Men and women in the 6th and 7th decades • Clinical presentation: biliary obstruction. Flejou JF. Lim JH: Cholangiocarcinoma: morphologic classification according to growth pattern and imaging findings. 2001 3. Abe T. 1991 6. 1997 7. Yamaguchi T. Kim TK. Choi BI. D. Stocker JT: Tumors of the Liver and Intrahepatic Bile Ducts. Vilgrain V. Uchida M. Ishak KG.C. et al: Cholangiocarcinoma: spectrum of appearances on MR images using current techniques.: Armed Forces Institute of Pathology under the auspices of Universities Associated for Research and Education in Pathology For sale by the Armed Forces Institute of Pathology. Yalcin S: Diagnosis and management of cholangiocarcinomas: a comprehensive review. Worawattanakul S. Noone TC. 1998 8. 1999 Gastrointestinal Radiology 319 Biliary Neoplasms . et al: Peripheral cholangiocarcinoma of the liver: two-phase spiral CT findings. et al: Intrahepatic cholangiocarcinoma: MRI and pathologic correlation in 14 patients. 2004 9. Lee JM. Goodman ZD. 2004 2.

Masselli G.: Hilar cholangiocarcinoma: surgical and endoscopic approaches. Hilar cholangiocarcinoma. Bassi F. et al: Imaging of intrahepatic cholangiocarcinoma: 2. Kim TK. Manfredi R. 2003 5. Stroszczynski C. et al: Hilar cholangiocarcinoma: staging with intrabiliary MRI. et al: Differential diagnosis of stenosing lesions at the hepatic hilus. Abdom Imaging 30:314. Maresca G. Koea J. et al: Differentiation of extrahepatic bile duct cholangiocarcinoma from benign stricture: findings at MRCP versus ERCP. Hepatogastroenterology 50:1246. Henson DE. 2004 3. 2004 3. Klimstra DS: Tumors of the gallbladder and extrahepatic bile ducts. 2000 2. 2004 2. Surg Clin North Am 84:525. Washington. Jr. Ishibashi M. 1995 Extrahepatic Bile Duct Adenocarcinoma 1. Bluemke DA. Albores-Saavedra J. 2005 Biliary Neoplasms 320 Gastrointestinal Radiology . Radiology 233:234. 2005 4. World J Surg 28:466. Tomita N. Goodnight JE. Principe A. and ampulla of vater. 2004 4.C.Hilar Cholangiocarcinoma 1. AJR Am J Roentgenol 184:1572. Soyer P. Holden A. Hofmann LV. Uchida M. Ercolani G. Chau K. AJR Am J Roentgenol 183:1071. 2003 6. Bold RJ. Abdom Imaging 28:319. Park MS. et al: Diagnostic dilemmas in biliary strictures mimicking cholangiocarcinoma. et al: Hilar and suprapancreatic cholangiocarcinoma: value of 3D angiography and multiphase fusion images using MDCT. Kim KW. D. Reichle R. et al: MR imaging and MRCP of hilar cholangiocarcinoma. AJR Am J Roentgenol 165:1433.: Armed Forces Institute of Pathology under the auspices of Universities Associated for Research and Education in Pathology For sale by the Armed Forces Institute of Pathology. Arepally A. Georgiades C. Hunerbein M: Malignant biliary obstruction: value of imaging findings.

➢ US: colorectal. liver.S. Levy. USA Classification of Pancreatic Tumors • Tumors of the Exocrine Pancreas ➢ Ductal adenocarcinoma ➢ Acinar cell carcinoma ➢ Solid-pseudopapillary neoplasm ➢ Intraductal papillary mucinous neoplasm ➢ Mucinous cystic neoplasm ➢ Microcystic adenoma ➢ Pancreatoblastoma ➢ Mature cystic teratoma • Tumors of the Endocrine Pancreas ➢ Islet cell tumors (neuroendocrine tumors) ➢ Small cell carcinoma • Non-epithelial tumors ➢ Soft tissue tumors ➢ Lymphoma • Secondary Tumors • Tumor like lesions ➢ Pancreatitis ➢ Lymphoepithelial cyst ➢ Pseudocyst Objectives • Adenocarcinoma ➢ Ductal adenocarcinoma ➢ Mucinous noncystic adenocarcinoma • Intraductal papillary mucinous neoplasm • Cystic neoplasms ➢ Intraductal papillary mucinous neoplasm ➢ Solid and pseudopapillary epithelial neoplasm ➢ Mucinous cystic neoplasm ➢ Microcystic adenoma • Endocrine neoplasms • Metastasis Pancreatic Adenocarcinoma: Epidemiology • 85% to 90% of pancreatic neoplasms • Second most common GI tract malignancy in the U.Pancreatic Neoplasms Angela D. gallbladder ➢ Worldwide: stomach. esophagus. gallbladder Pancreatic Adenocarcinoma: Epidemiology • Death:incidence ratio of .99 ➢ 5-year survival 4%. colorectal. MC. overall ➢ 5-year survival 17%. pancreas. stomach. liver. esophagus. early stage • More common in men than women • 80% of cases occur between 60 to 80 years of age Pancreatic Adenocarcinoma: Risk Factors • Cigarette smoking (2-3 fold relative risk) • Hereditary risk factors ➢ Hereditary nonpolyposis colon cancer (HNPCC) ➢ Familial breast cancer (BRCA2) ➢ Familial adenomatous polyposis ➢ Peutz-Jeghers Gastrointestinal Radiology 321 Pancreatic Neoplasms . COL. pancreas.

Pancreatic Adenocarcinoma: MDCT • Volume rendering • Maximum intensity projection (MIP) • Curved planar reformations ➢ Additional information for local extension ➢ Secondary signs in iso-attenuating carcinomas Pancreatic Adenocarcinoma: CT Features • Pancreatic and CBD duct dilatation ➢ "Double duct sign” ➢ Abrupt tapering of the CBD • Atrophy of the distal gland ➢ Focal soft tissue density in a fatty gland • Alterations in morphology ➢ Spherical enlargement of the pancreatic head ➢ Rounded borders of the uncinate process • Extension to adjacent organs • Vascular encasement Pancreatic Neoplasms 322 Gastrointestinal Radiology .25 mm Fletcher JG. 3 ml/sec ➢ Pancreatic phase. ➢ Peutz-Jeghers ➢ Ataxia telangiectasia ➢ Familial atypical multiple mole-melanoma ➢ Familial pancreatitis Figure 2-7-1 Pancreatic Adenocarcinoma: Clinical Features • Symptoms ➢ Pain most common ➢ Unexplained weight loss ➢ Jaundice in 50% tumors in the head of the pancreas ➢ Diabetes in 25% to 50% • Distribution ➢ 60% head ➢ 20% body ➢ 10% tail ➢ 5% to 10% entire gland Pancreatic Adenocarcinoma: Pathology [Figure 2-7-1] • Microscopy ➢ Moderately to well differentiated Pathology of ductal adenocarcinoma of the pancreas ➢ Desmoplastic stromal reaction • Gross Pathology ➢ Fibrotic ➢ Infiltration and invasion of adjacent structures ➢ Hemorrhage and necrosis uncommon Pancreatic Adenocarcinoma: MDCT • Dual Phase Technique ➢ Rapid bolus. Radiology 2003. Farrell MA. 40 sec after injection ➢ Portal venous phase ➢ Thin reformations with overlap. 1. Wiersema MJ. and hepatic phase imaging with multi-detector row CT. et al. pancreatic. 229(1):81-90. Pancreatic malignancy: value of arterial.

portal vein ➢ Celiac trunk and major branches ➢ +/. SMA Encasement Figure 2-7-5 Resectable? No.isolated focal involvement of PV or SMV ➢ Accuracy of CT 88%-90% ➢ 3D CT angiography • Distant nodal metastasis • Liver metastasis Ductal adenocarcinoma of the pancreas showing atrophy of the distal Resectable? No. SMA Encasement and Liver Mets [Figure 2-7-5] Resectable? YES Nonresectable adenocarcinoma of the pancreas Mucinous Noncystic Adenocarcinoma (Infiltrating Colloid Carcinoma)[Figure 2-7-6] • Rare variant of adenocarcinoma Figure 2-7-6 • Marked extracellular mucin • Signet rings cells • Imaging ➢ Large tumors ➢ Well-defined hypoattenuating mass ➢ May have calcification Mucinous noncystic adenocarcinoma of the pancreas Gastrointestinal Radiology 323 Pancreatic Neoplasms . SMV.Double Duct Sign [Figure 2-7-2] Figure 2-7-2 Spherical Enlargement of the Pancreatic Head Rounded Borders of the Uncinate Process [Figure 2-7-3] Atrophic Changes in the Distal Pancreas [Figure 2-7-4] Double duct sign of ductal adenocarcinoma of the pancreas Pancreatic Adenocarcinoma: MR Figure 2-7-3 • Problem solving ➢ Equivocal CT ➢ Small tumors • T1-weighted images ➢ Low signal tumor on unenhanced images ➢ Subtraction images from in and out of phase images Nonresectability • Invasion of adjacent organs. Ductal adenocarcinoma of the pancreas showing a rounded contour except duodenum to the uncinate process • Tumor diameter > 5 cm • Encasement or occlusion of vessels Figure 2-7-4 ➢ SMA. stomach pancreas and vascular invasion Resectable? No.

focal side branch pattern Pancreatic Neoplasms 324 Gastrointestinal Radiology . focal main duct pattern ➢ Main duct or side branch ➢ Diffuse or focal (cystic appearing) • Pancreatic glandular atrophy • Calcification Figure 2-7-9 • Bulging duodenal papilla IPMN: Diffuse Involvement of Main Pancreatic Duct [Figure 2-7-7] IPMN: Focal Involvement of Main Pancreatic Duct [Figure 2-7-8] IPMN: Focal Involvement of Main Pancreatic Duct • Show communication with duct structures ➢ MRCP ➢ ERCP/EUS • Show intraductal masses IPMN: Focal Involvement of a Side Branch Duct [Figure 2-7-9] Intraductal papillary mucinous neoplasm. diffuse main duct ➢ Microcystic (Oligocystic) adenoma pattern ➢ Pancreatic pseudocyst Intraductal Papillary Mucinous Neoplasm (IPMN) • Intraductal papillary neoplasm ➢ Produces mucin • All have malignant potential ➢ May or may not have an invasive component • Synonyms ➢ Intraductal mucin-hypersecreting neoplasm ➢ Ductectatic type of pancreatic ductal carcinoma ➢ Mucinous ductal ectasia ➢ Mucin-producing tumor (or carcinoma) ➢ Mucin-hypersecreting tumor Figure 2-7-8 Intraductal Papillary Mucinous Neoplasm (IPMN) • Most common in men.Mucinous Noncystic Adenocarcinoma Figure 2-7-7 (Infiltrating Colloid Carcinoma) • Differential diagnosis ➢ Microcystic adenoma ➢ Intraductal papillary mucinous Intraductal papillary mucinous neoplasm neoplasm. 7th decade • Clinical symptoms similar to chronic pancreatitis ➢ Pain ➢ Malabsorption ➢ Diabetes ➢ Prior episodes of pancreatitis IPMN: Histopathology • Neoplastic papillary epithelium • Mucin production • Duct dilatation IPMN: Imaging Features Intraductal papillary mucinous • Duct dilatation neoplasm.

diffuse side branch • ERCP pattern ➢ Definitive imaging technique Solid and Pseudopapillary Tumor (SPT) • Neoplasm of young women ➢ Mean age. pain ➢ Jaundice or duct obstruction is rare SPT: Pathology Features • Pathologic features ➢ Capsule Figure 2-7-11 ➢ Hemorrhage. 24 years • Benign or low-grade malignancy • Good prognosis • Synonyms ➢ Solid-cystic tumor ➢ Papillary cystic tumor ➢ Solid and pseudopapillary epithelial neoplasm Solid and Pseudopapillary Tumor (SPT) • Clinical features ➢ Usually incidentally discovered ➢ Abdominal discomfort.Side Branch IPMN Figure 2-7-10 IPMN: Diffuse Involvement of a Side Branch Duct [Figure 2-7-10] Bulging Papilla [Figure 2-7-11] IPMN: Diagnostic Difficulties • MR/MRCP ➢ Target imaging for ductal communication IPMN: MR/MRCP IPMN: Diagnostic Difficulties • Must differentiate from chronic pancreatitis • Side branch variant may mimic ➢ Pseudocyst ➢ Mucinous cystic neoplasm Intraductal papillary mucinous ➢ Microcystic adenoma neoplasms. necrosis. cystic areas ➢ Solid areas ➢ May calcify • Histopathology ➢ Highly cellular areas ➢ Pseudopapillary areas ➢ Hemorrhage ➢ Sclerosis Bulging papilla in IPMN SPEN: Imaging Features • Circumscribed ➢ Capsule ➢ Early peripheral enhancement • Cystic change ➢ Hemorrhage ➢ Fluid-fluid levels • Calcification • Rare features ➢ Biliary/pancreatic duct dilatation ➢ Adjacent organ invasion Gastrointestinal Radiology 325 Pancreatic Neoplasms .

mean 70 years Figure 2-7-13 Mucinous Cystic Neoplasm (MCN) • Clinical presentation ➢ Variable ➢ Dependent upon tumor size • Jaundice and CBD obstruction are rare • All have malignant potential ➢ Mucinous cystadenoma MCN: Histopathology • Columnar cell lining • May have ovarian-type stroma • Mucin • Hemorrhage MR showing early capsular enhancement in SPT • Calcification MCN: Gross Pathology • Majority in tail of pancreas ➢ 70% to 95% • Large size at diagnosis ➢ Mean diameter. septations. 6 to 10 cm • Multilocular cysts ➢ Septations ➢ Solid mural nodules ➢ Occasional calcifications ➢ Unilocular. septations. mural nodules • Calcifications ➢ Cyst wall.SPT [Figures 2-7-12 and 2-7-13] Figure 2-7-12 SPT: Diagnostic Difficulties • Older patient age • Male patient • May mimic other cystic lesions ➢ Pancreatic pseudocyst ➢ Mucinous cystic neoplasm ➢ Oligocystic adenoma • Supportive CT and MR features for diagnosis ➢ Evidence of capsule ➢ Evidence of blood products Mucinous Cystic Neoplasm (MCN) • Mucin-secreting cystic neoplasm ➢ Mucinous cystadenoma ➢ Mucinous cystadenocarcinoma • Most common in women ➢ 80% occur in women ➢ Mean age 49 years • Less common in men Solid and pseudopapillary tumor ➢ Older age. rare MCN: Imaging • Well-circumscribed cystic mass ➢ Cannot differentiate benign from malignant • Enhancement ➢ Cyst wall. mural nodules • Cyst fluid ➢ Variable CT attenuation/MR signal intensity ➢ Mucin ➢ Hemorrhage ➢ Proteinaceous fluid Pancreatic Neoplasms 326 Gastrointestinal Radiology .

weight loss Figure 2-7-15 ➢ Jaundice is unusual Microcystic Adenoma: Gross Pathology • Small cysts arranged around a central scar ➢ “Honeycomb” or “sponge” appearance ➢ Thin fibrous septae ➢ Central stellate scar ➢ Occasional hemorrhage Microcystic Adenoma: Histopathology • Histology ➢ Small cysts ➢ Cuboidal cells ➢ High glycogen content Microcystic Adenoma: Pathology Microcystic Adenoma: Imaging features [Figures 2-7-15 and 2-7-16] • Sharp. nausea. 66 years • Variable clinical presentation ➢ Incidental ➢ Pain.Mucinous Cystic Neoplasm [Figure 2-7-14] Figure 2-7-14 MCN: Diagnostic Difficulties • Small lesions • Lesions in the head of the pancreas • Lesions without septations and mural nodules • Differential diagnosis ➢ Pseudocyst ➢ Oligocystic adenoma ➢ Solid and pseudopapillary tumor ➢ Rare.calcification Figure 2-7-16 Microcystic adenoma Gastrointestinal Radiology 327 Pancreatic Neoplasms . congenital cysts Microcystic Adenoma • Benign • Synonyms ➢ Serous cystadenoma ➢ Glycogen-rich cystadenoma • Variants ➢ Oligocystic adenoma Microcystic Adenoma Mucinous cystic neoplasm • Most common in women ➢ 70% in women ➢ Mean age. vomiting. circumscribed margins ➢ Lobular margins • Honeycomb appearance Microcystic adenoma ➢ Multiple small cysts • Central scar ➢ +/.

adrenal gland. very large cysts • ? association with von Hippel Lindau syndrome • Synonyms ➢ Macrocystic serous cystadenoma ➢ Serous oligocystic adenoma Oligocystic adenoma Microcystic Adenoma: Diagnostic Difficulties • Oligocystic variant ➢ Differential diagnosis ❖ Mucinous cystic neoplasm ❖ Pseudocyst • Small lesions ➢ Difficult to identify central scar/septations Islet Cell Tumors (Neuroendocrine Tumors) • Tumors of the pancreatic islets • Occur in all age groups • Variable biologic behavior ➢ Benign or malignant Figure 2-7-18 • Clinical evidence of hormone production ➢ 65% to 85% • Clinically silent ➢ 15% to 35% Insulinoma [Figure 2-7-18] • Somatostatin receptor scintigraphy ➢ Positive in only 60-70% of cases Insulinoma Zollinger-Ellison Syndrome . 6 to 20 cm • Nonspecific imaging appearance ➢ Necrosis and cystic degeneration common ➢ 25% calcify ➢ Liver metastases are common Pancreatic Neoplasms 328 Gastrointestinal Radiology .Oligocystic Adenoma [Figure 2-7-17] Figure 2-7-17 • Uncommon variant of microcystic adenoma • Few. thyroid.Pancreatic Gastrinoma • Somatostatin receptor scintigraphy ➢ Sensitivity for primary tumor. 100% Glucagonoma (DM-Dermatitis Syndrome) MEN I Syndrome (Wermer’s Syndrome) • 3P’s ➢ Pituitary ➢ Pancreas ➢ Parathyroid ➢ Other: thymus. 58%-75% ➢ Sensitivity for metastatic disease. GI tract • Autosomal dominant ➢ Long arm chromosome 11 Clinically-Silent Islet Cell Tumors [Figures 2-7-19 and 2-7-20] • Occur at any age • Typically large at time of diagnosis ➢ Range.

calcification Summary: Microcystic Adenoma • Older women • Benign neoplasm ➢ Central scar ➢ Honeycomb pattern of cysts ➢ Lobulated margins Gastrointestinal Radiology 329 Pancreatic Neoplasms .Metastatic Disease Figure 2-7-19 • Mets to pancreas ➢ Lung. breast ➢ Melanoma ➢ Renal cell ➢ Lymphoma-adjacent nodal disease • Mimic primary pancreatic neoplasms ➢ Ductal adenocarcinoma ➢ Islet cell Clinically-silent islet cell tumor • Biliary obstruction in 30% Summary: Adenocarcinoma Figure 2-7-20 • Most common pancreatic neoplasm • MDCT ➢ Dual phase ➢ Thin reformations ➢ Overlapping images • RESECTABLILITY ➢ Vascular encasement ➢ Adjacent organ invasion ➢ Liver mets Summary: IMPN • High index of suspicion • Main duct or side branch • Imaging ➢ Duct dilatation ➢ Intraductal masses ➢ Bulging papilla Renal cell metastatic to the pancreas Summary: Solid Pseudopapillary Tumor • Young women • Imaging features ➢ Capsule ➢ Solid and cystic ➢ Hemorrhage Summary: Mucinous Cystic Neoplasm • Mucinous cystadenoma • Mucinous cystadenocarcinoma • Complex cyst ➢ Middle-aged women ➢ Tail of the pancreas ➢ Septations. nodules.

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anorexia. Gastric Adenocarcinoma: Geographic Variation • High incidence areas ➢ China. stomach. Lyon 2003. MC. Eastern Europe • Low incidence areas ➢ North America and Northern Africa Gastric Adenocarcinoma: Clinical • Peak incidence 50 to 70 years of age • More common in men ➢ 2:1 • Early disease ➢ Asymptomatic • Advanced disease ➢ Epigastric pain. breast. bloating. COL. colorectum. IARC Press. Levy.Gastric Malignancies Angela D. USA Gastric Malignancies • Adenocarcinoma • Lymphoma • Gastrointestinal Stromal Tumors • Carcinoid • Kaposi Sarcoma • Metastases Gastric Adenocarcinoma • Fourth most common cancer worldwide1 ➢ Lung. liver 1Steward BW and Kleihues P (eds). nausea ➢ Early satiety. Japan. vomiting ➢ Upper GI bleeding Figure 2-8-1 Gastric Adenocarcinoma: Etiology [Figure 2-8-1] • Atrophic Gastritis ➢ Helicobacter pylori (80% of cases) ➢ Pernicious Anemia ➢ Partial Gastrectomy • Adenomatous Polyps ➢ Polyposis syndromes • HNPCC-Hereditary Nonpolyposis Colon Cancer Syndromes Normal Gastritis Atrophic Gastritis Intestinal Metaplasia (Lynch Syndromes) Dysplasia Intramucosal Carcinoma Invasive Carcinoma Pathogenesis of gastric adenocarcinoma Gastric Malignancies 332 Gastrointestinal Radiology . South America. World Cancer Report.

irrespective of nodal Mucinous adenocarcinoma produces tumor calcifications metastases Advanced Gastric Carcinoma [Figure 2-8-5] Figure 2-8-5 • Borrmann Classification • Most common gastric cancer in the U.WHO Classification of Gastric Adenocarcinoma Figure 2-8-2 • Signet Ring [Figure 2-8-2] • Papillary [Figure 2-8-3] • Mucinous [Figure 2-8-4] Figure 2-8-3 Signet ring cell adenocarcinoma produces "linitis plastica" Figure 2-8-4 Papillary adenocarcinoma produces intraluminal polypoid masses Early Gastric Carcinoma • Japanese Research Society for Gastric Carcinoma • Carcinoma limited to the mucosa and submucosa.S. • Tumor penetrating the muscularis propria Advanced Gastric Carcinoma • Morphology ➢ Polypoid ➢ Ulcerating ➢ Infiltrating ➢ Scirrhous Gastric Carcinoma: Polypoid [Figure 2-8-6] Figure 2-8-6 Advanced gastric carcinoma (Borrmann) classification Polypoid gastric adenocarcinoma Gastrointestinal Radiology 333 Gastric Malignancies .

Infiltrating gastric adenocarcinoma • Compared to other gastric carcinomas: ➢ Male predominance.distorted folds when the tumor is proximal Carcinoma of the Cardia • One-third of all gastric carcinomas in the U.S. “linitis plastica” ➢ Most common in the antrum ➢ Rarely-nodular. 6:1 Figure 2-8-9 ➢ 40% associated with hiatal hernia ➢ Atrophic gastritis and signet ring cell types are uncommon ➢ Association with smoking and alcohol • Early lesions are difficult to detect • Difficult to differentiate from Barrett’s adenocarcinoma • Pseudoachalasia • Pitfalls on CT: ➢ GE junction pseudomass Scirrhous carcinoma ➢ Hiatal hernias Normal Gastric Cardia Figure 2-8-10 Carcinoma of the Cardia [Figure 2-8-10] Carcinoma of the cardia Gastric Malignancies 334 Gastrointestinal Radiology . Figure 2-8-7 Ulcerated .Bulk of tumor mass has been replaced by ulceration Ulcerated Carcinoma Lesser Curvature Carmen Meniscus Sign [Figure 2-8-7] Ulcerated gastric Gastric Carcinoma: Ulcerated adenocarcinoma showing the Carmen meniscus sign Gastric Carcinoma: Infiltrating [Figure 2-8-8] Scirrhous Carcinoma [Figure 2-8-9] • Infiltrating tumors with desmoplasia ➢ Signet ring cell carcinomas Figure 2-8-8 • Radiologic Features ➢ Irregular narrowing ➢ Decreased gastric capacity ➢ Rigidity.

Extragastric Spread [Figure 2-8-11 and 2-8-12] • Anatomic Pathways ➢ Lesser omentum ➢ Greater omentum ➢ Transverse mesocolon Routes of extragastric spread of ➢ Lesser sac carcinoma ➢ Lower esophagus • CT features ➢ Soft tissue stranding Figure 2-8-12 ➢ Soft tissue nodules Staging .Adjacent Organ Invasion • Contiguous tumor • Loss of fat planes • Focal enlargement of the adjacent organ Direct Extension and Adjacent Organ Invasion Gastric Lymphoma • Increasing incidence • Up to 10% of gastric malignancies • Most common site of extranodal lymphoma • Most common site of GI lymphomas Gastric Lymphoma: Clinical • Low grade ➢ Dyspepsia. vomiting • High grade: ➢ Bleeding. weight loss Mucosa-Associated Lymphoid Tissue (MALT) • Organized lymphoid tissue located in mucosal sites Gastric adenocarcinoma extending into • Native MALT the greater omentum and lesser sac ➢ Intraepithelial lymphocytes ➢ Plasma cells. nausea.Lymphatic Spread Staging . pylori infection) ➢ Accumulates before the development of B cell lymphomas Gastrointestinal Radiology 335 Gastric Malignancies . pain.Staging Figure 2-8-11 • Endoscopic Ultrasound ➢ Depth of tumor invasion ❖ T stage accuracy 85% ➢ Perigastric nodes ❖ Sensitivity 55%-80% • CT ➢ Presence and extent of extragastric spread ➢ Peritoneal ➢ Lymph nodes ➢ Distant metastasis Staging . early satiety. B and T lymphocytes in the lamina propria ➢ Mesenteric lymph nodes ➢ Peyer’s patches • Acquired MALT ➢ Arises as a result of antigenic stimulation (H.Krukenberg Metastasis Staging .

pylori is invariably present ➢ Good clinical prognosis • High grade B cell lymphoma ➢ Probably arises from MALT lymphoma Primary Gastric Lymphoma: Etiology and Pathogenesis Figure 2-8-13] • H. pylori infection H.Primary Gastric Lymphoma Figure 2-8-13 • MALT lymphoma ➢ Arises from acquired MALT Normal mucosa ➢ H. pylori gastritis formation of acquired MALT low-grade MALT lymphoma high-grade B-cell lymphoma Evolution of gastric lymphoma Gastric Malignancies 336 Gastrointestinal Radiology . pylori infection H.

nausea. Moss A. ➢ Early satiety. 1982 CT features differentiating Gastric Adenocarcinoma and Lymphoma1 • Gastric wall thickening in lymphoma (mean 4 cm) is typically more impressive than adenocarcinoma (mean 1.Low Grade Malt Lymphoma [Figure 2-8-14] Figure 2-8-14 • Clinical ➢ Dyspepsia. 1985 Gastrointestinal Radiology 337 Gastric Malignancies .8 cm) • Wall thickening is more homogeneous in lymphoma • Perigastric fat is more likely to be preserved in lymphoma • Regional adenopathy is common in both High grade B cell lymphoma • Adenopathy in lymphoma tends to be bulky and may extend below the level of the renal veins 1Buy J. vomiting ➢ Good prognosis • Imaging ➢ Nodules ➢ Ulcers ➢ Erosions ➢ Thick rugal folds Low Grade Malt Lymphoma: CT Features • Homogeneous mural thickening • Perigastric adenopathy High Grade B Cell Lymphoma • Clinical ➢ Bleeding. pain. Hogstrom H. Endoscopy 17:5-7. weight loss • Imaging ➢ Mural thickening ➢ Adenopathy High Grade B Cell Lymphoma:Typical CT Features [Figure 2-8-15] • Homogeneous mural thickening • Perigastric adenopathy High Grade B Cell Lymphoma:Typical CT Features Low grade MALT lymphoma • Cavitation High Grade B Cell Lymphoma: Atypical CT Features Figure 2-8-15 • Heterogeneous attenuation • Enhancement • Low attenuation necrosis CT features of Gastric Lymphoma • Wall thickening1 ➢ Tends to be greater (mean. 4 cm) than that of adenocarcinoma ➢ Tends to be homogeneous attenuation • Ulceration • Polypoid masses • Regional adenopathy 1Buy J. AJR 138:859-865. AJR 138:859-865. Haglund U. 1982 Fork FT. Moss A.

Hum Pathol 2002.S. ➢ Leiomyomas are the most common benign tumor of the ESOPHAGUS ➢ Leiomyosarcomas of the RETROPERITONEUM GIST • Most common sites ➢ Stomach ➢ Small bowel Gastric Malignancies 338 Gastrointestinal Radiology . Corless C.Gastric Lymphoma Mesenchymal Neoplasm of the Stomach • Gastrointestinal Stromal Tumor • Leiomyoma • Leiomyosarcoma • Schwannoma • Neurofibroma • Ganglioneuroma • Paraganglioma • Granular cell tumor • Lipoma. Berman JJ. et al. liposarcoma • Fibrous lesions • Tumors of blood vessels Gastrointestinal Stromal Tumors (GIST) • Most common mesenchymal neoplasm of the GI tract • Arise from the muscularis propria • Cellular origin ➢ Primitive "stem cell” like cell ➢ Interstitial cell of Cajal (gut pacemaker cell) GIST: Clinical Features • Uncommon tumors • Prevalence in the U. Diagnosis of gastrointestinal stromal tumors: A consensus approach. 33:459-465 GIST: Clinical Features • Median age 50-60 years • 60% occur in the stomach • Benign and malignant • Defined by KIT expression ➢ Initial diagnosis ➢ Therapy (Gleevac) What is KIT? • KIT-tyrosine kinase growth factor • KIT-tyrosine kinase growth factor receptor • CD117 binds to KIT receptors • Normally expressed ➢ Hematopoietic stem cells ➢ Germ cells ➢ Interstitial cell of Cajal (gut pacemaker cell) • KIT-inhibitor therapy ➢ STI-571. ➢ 5000 to 6000 new cases per year1 • Increased incidence ➢ Neurofibromatosis (NF-1) ➢ KIT germline mutations 1Fletcher CD. Imatinib [Gleevac] What Happened to Leiomyomas and Leiomyosarcomas? • Very rare • Except.

exophytic mass. ➢ Anorectum Figure 2-8-16 • Unusual sites ➢ Esophagus ➢ Colon ➢ Mesentery/omentum GIST • Spindle Cell GIST • Epithelioid GIST GIST: CD117 (KIT) Positive GIST [Figure 2-8-16] • Mural Origin ➢ Mural mass ➢ Exophytic mass ➢ Mural and exophytic GIST: Mural Origin [Figure 2-8-17] Figure 2-8-17 Imaging and morphologic patterns of gastrointestinal stromal tumors: intramural polypoid mass. or intramural and exophytic mass Gastrointestinal stromal tumor Gastrointestinal Radiology 339 Gastric Malignancies .

adenocarcinoma Gastric Malignancies 340 Gastrointestinal Radiology .7-19 and 2-7-20] Gastric Carcinoid • Type I: autoimmune chronic atrophic gastritis ➢ Hypergastrinemia ➢ Multiple. de Castro Faria S.GIST: Internal Hemorrhage and Necrosis [Figure 2-8-18] Figure 2-8-18 Gastrointestinal stromal tumor GIST: Cyst Formation GIST: Cavity Formation GIST: Calcification GIST: Metastatic Spread • Direct invasion • Peritoneal • Hematogenous ➢ Liver Management of Metastatic and Recurrent Disease • Kit-inhibitor therapy ➢ Gleevac ➢ Clinical trials of other kit-inhibitors • Imaging features of treated metastasis ➢ Cystic transformation Figure 2-8-19 ➢ Pet important to determine residual functional tumor Imaging of Recurrent Disease Choi H. Charnsangavej C. small ➢ Benign biologic behavior • Type III: sporadic ➢ Single ➢ Aggressive biologic behavior GIST vs. Differential Diagnosis Gastric GIST vs. Adenocarcinoma [Figures 2. small ➢ Benign biologic behavior • Type II: MEN I and Zollinger Ellison syndrome ➢ Hypergastrinemia ➢ Multiple. et al. AJR Am J Roentgenol 2004. 183:1619-1628. CT evaluation of the response of gastrointestinal stromal tumors after imatinib mesylate treatment: a quantitative analysis correlated with FDG PET findings.

Carcinoid: Imaging Features Figure 2-8-20 • Submucosal mass • Central ulceration-”bull’s eye” • Pedunculated polypoid lesions. and small bowel most common GI locations • Radiologic features ➢ Submucosal masses ➢ “Bull’s-eye”appearance ➢ Polypoid masses ➢ Infiltrating variant. duodenum. breast. more extensive adenopathy Summary: GIST • Most common mesenchymal neoplasm • KIT reactivity ➢ Diagnosis ➢ Gleevac therapy • Classic mural masses on barium • May have extensive extragastric growth Bull’s eye lesions from Kaposi Sarcoma. lung • Radiologic features ➢ Ulcerating masses ➢ Polyps GIST vs. lymphoma ➢ Infiltrating ➢ “Linitis Plastica” Figure 2-8-21 Summary: Adenocarcinoma • H. rarely • Large ulcerative masses • Thick. rugal folds if hypergastrinemia is present Carcinoid: “Bull′′s Eye Lesion” Carcinoid: Pedunculated Polyps Kaposi Sarcoma [Figure 2-8-21] • AIDS patients • Cutaneous KS usually • Stomach. Endoscopy shows hemorrhagic masses Gastrointestinal Radiology 341 Gastric Malignancies . pylori • Chronic atrophic gastritis • Primary tumor morphology ➢ Polypoid ➢ Ulcerating ➢ Infiltrating ➢ Schirrous • CT: extragastric spread Summary: Lymphoma • H. rare Metastases • Melanoma. pylori • Low grade MALT to high grade B cell • Compared to adenocarcinoma ➢ Greater wall thickening ➢ Bulky.

Lim HK. et al: Clinical management of gastrointestinal stromal tumors: before and after STI-571. et al: Scirrhous carcinoma of the stomach: radiologic and endoscopic diagnosis. Friedman GD. Talamonti MS. et al: Malignant gastrointestinal stromal tumor: distribution. Megibow AJ. Kochman ML. Kim YH. Radiol Clin North Am 35:331. 2000 Gastric Lymphoma 1. AJR 179:1059. AJR 165:839. Radiol Clin North Am 35:311. Dematteo RP. Balthazar EJ. Bechtold RE. AJR Am J Roentgenol 168:165. Dig Dis 15:346. Ann Surg 218:579. 1996 7. et al: Gastric mucosa-associated lymphoid tissue lymphoma: spectrum of findings at double-contrast gastrointestinal examination with pathologic correlation. AJR 138:859. et al: Helicobacter pylori infection and gastric lymphoma. and pattern of metastatic spread. 2002 4. 2001 2. Morales TG: Adenocarcinoma of the gastric cardia. Radiology 208:239. Gore RM: Gastric cancer. Levine MS. Megibow AJ. Rubesin SE. 1993 6. 1997 3. Chen MY. Radiology 226:527. 1997 8. AJR 178:1117. Wotherspoon AC. Lee SJ. 1998 Gastrointestinal Stromal Tumor (GIST) 1. Choi D. Balthazar EJ. Radiology 175:151. 1995 2. Heinrich MC. Gastroenterol Clin North Am 22:89. Longmire WP. Lim HK. Burkill GJ. Parsonnet J. Rubesin SE. et al: Gastric mucosa-associated lymphoid tissue lymphoma: radiographic findings in six patients. Harris NL. Radiologic diagnosis. Levine MS. Buy JN. 1982 3. 1993 9. Vandersteen DP. 2002 4. Hum Pathol 33:466. 1994 11. Melanoma) • Kaposi’s Sarcoma • Lymphoma • Adenocarcinoma • Ectopic Pancreas References Gastric Carcinoma 1. 2003 2. et al: Low-grade gastric mucosa-associated lymphoid tissue lymphoma: correlation of radiographic and pathologic findings. et al (eds): World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues). Radiology 212:241. 1997 8. Radiol Clin North Am 35:295. et al: CT in patients with scirrhous carcinoma of the GI tract: imaging findings and value for tumor detection and staging. Lyon: IARC Press. Furth EE. Han JK. 2001 5. et al: Computed tomography of gastrointestinal lymphoma. Jaffe ES. 1983 9. Furth EE. Doglioni C. 1999 6. 1997 4. et al: Non-Hodgkin's lymphoma of the gastrointestinal tract: radiographic findings. 2002 Gastric Malignancies 342 Gastrointestinal Radiology . et al: Helicobacter pylori infection and the risk of gastric carcinoma. Savage PD: Cystic changes in hepatic metastases from gastrointestinal stromal tumors (GISTs) treated with Gleevec (imatinib mesylate). de Boni M. Moss AA: Computed tomography of gastric lymphoma. 1997 7. N Engl J Med 325:1127. Marshall BJ: Gastritis and gastric cancer. Sipponen P. Siegel SE. et al: Gastric cancer. imaging features. Kim YH. Miller FH. Lancet 343:1503. N Engl J Med 330:1267. AJR 141:541. et al: Helicobacter pylori and gastric MALT lymphoma. Jr. Hansen S. et al: Gastric cancer. Ghahremani GG. Al-Muderis O. Levine MS. Elmas N. Naidich DP. Parsonnet J. Stein H. Han JK. 2002 3. et al: Antibiotic treatment for low-grade gastric MALT lymphoma. AJR Am J Roentgenol 166:85. Western countries. Fletcher CD: Clinicopathologic correlations in gastrointestinal stromal tumors. Rodriguez L. Levine MS. 1994 10. Hum Pathol 33:455. Kong V. Yoo CC.: A current view of gastric cancer in the US. Levine MS.Summary: Bull’s Eye Lesions • Carcinoid • Metastasis ➢ (Breast. et al: Gastric mucosa-associated lymphoid tissue lymphoma: helical CT findings and pathologic correlation. 1991 10. El-Rifai WM. Radiographics 21:1491. Gastroenterol Clin North Am 29:579. 1990 5. Radiologic staging. Parsonnet J: Helicobacter pylori and gastric cancer. Badran M. Clinical and pathologic features. Pantongrag-Brown L. Gore RM. Lung. An SK.

1982 2. Nishida T. Remotti HE. 2002 6. Virchows Arch 438:1. Hum Pathol 33:478. et al: Carcinoid tumors of the stomach: a clinical and radiographic study. Radiology 201:371. Stephens DH: Gastric carcinoid tumors associated with chronic hypergastrinemia in a patient with Zollinger-Ellison syndrome. 2002 8. Miettinen M. RadioGraphics 21:1557. Bryk D. Kullman E. 2001 9. Megibow A. Binstock AJ. 2003 7. et al: Multidetector CT of high-risk patients with occult gastrointestinal stromal tumors. Stephens DH. Berger MW. clinical. et al: Diagnosis of gastrointestinal stromal tumors: A consensus approach. 1996 3. Kumano S. A prospective analysis of 11 cases. Miettinen M. Sharp RM. and molecular genetic features and differential diagnosis. 2001 4. Sobin LH. et al: From the Archives of the AFIP: Gastrointestinal Stromal Tumors: Radiologic Features with Pathologic Correlation. et al: Evaluation of malignancy and prognosis of gastrointestinal stromal tumors: a review. Berman JJ. Thompson WM. AJR 176:947. Balthazar EJ. Sugiura T. Levy AD. histological. Johnson CD. AJR Am J Roentgenol 139:1123. El-Rifai W. et al: Gastric carcinoid tumors: radiographic features in eight cases. Hum Pathol 33:459. Renvall H. et al: Gastric carcinoid associated with the syndrome of hypergastrinemic atrophic gastritis. RadioGraphics 23:283. AJR Am J Roentgenol 180:185. Horton KM. 2000 Gastrointestinal Radiology 343 Gastric Malignancies .5. 2003 10. Corless C. 1987 5. Am J Surg Pathol 11:435. Clin Imaging 24:200. Ho AC. Keel SB: Best cases from the AFIP: gastrointestinal stromal tumor. Armed Forces Institute of Pathology. Ansel HJ. immunohistochemical. Borch K. Fishman EK: Gastric carcinoid tumors as a consequence of chronic hypergastrinemia: spiral CT findings. 2001 Gastric Carcinoid 1. Fletcher CD. Lasota J: Gastrointestinal stromal tumors--definition.

Levy. MC.Abdominal Non Hodgkin Lymphoma Angela D.3 to 1 • Median age 55 years • Third most common cancer mortality in children under age 15 Non-Hodgkin Lymphoma • Rising incidence ➢ True increase in incidence ➢ Improved identification and understanding ➢ HIV infection ➢ Organ transplants • Immunodeficiency increases risk ➢ Wiskott-Aldrich syndrome ➢ Ataxia telangiectasia ➢ Long-term immunosuppressive therapy Role of Imaging in Newly Diagnosed NHL • Clinical Staging: ➢ Ann Arbor Staging Classification ➢ Tumor bulk has important prognostic significance in intermediate and high grade NHL • Identification of nodal and extranodal sites ➢ Mesenteric adenopathy ➢ GI tract ➢ Liver ➢ Spleen Abdominal Non-Hodgkin Lymphoma 344 Gastrointestinal Radiology . and very aggressive Non-Hodgkin Lymphoma (NHL) • 4% of all cancers ➢ 5th most common cancer ➢ 5th leading cause of cancer death • 4 times more common than Hodgkin lymphoma • Male to female ratio: 1. Hodgkin lymphoma • NHL ➢ Large group of diverse diseases ➢ Indolent. COL. aggressive. T and NK (natural killer) cell. USA Objectives • Definition • Patterns of disease ➢ NHL Adenopathy ➢ Gastrointestinal Lymphoma • Immunodeficiency-related lymphomas ➢ Post-transplantation Lymphoproliferative Disorder (PTLD) ➢ AIDS-related Lymphomas Lymphoid Neoplams • 2001 WHO classification of Hematological Malignancies • Three major categories ➢ B cell.

Is CT scan still necessary for staging in Hodgkin and non-Hodgkin lymphoma patients in the PET/CT era? Ann Oncol 2005.Role of Imaging in Management of NHL Figure 2-9-1 • CT and PET complimentary • CT imaging ➢ Define anatomy ➢ Response to therapy • Limitations of CT ➢ Decrease in node size is not a reliable indicator of response ➢ Cannot differentiate residual tumor vs. Perry C. RCNA 2004. PET/CT in Management of NHL • Initial staging ➢ Equivalent or better to CT alone Figure 2-9-2 • Prognosis ➢ Persistent uptake after chemotherapy predicts treatment failure/early recurrence Kumar R et al. Shasha Y. Utility of fluorodeoxyglucose- PET imaging in the management of patients with Hodgkin’s and non-Hodgkin’s lymphomas. fibrosis vs. necrosis Well-defined mesenteric nodes in NHL Raanani P. et al. There is extensive necrosis and heterogeneous enhancement Gastrointestinal Radiology 345 Abdominal Non-Hodgkin Lymphoma . 42:1083-1100 Sandwich sign of the mesentery in NHL NHL: Abdomimal Adenopathy • Mesentery • Retroperitoneum • CT Patterns ➢ Discrete rounded nodes ➢ Confluent nodes ➢ Ill-defined masses Figure 2-9-3 ➢ Mesenteric caking ➢ Stellate mesentery • CT attenuation at diagnosis ➢ Homogeneous in most cases ➢ Heterogeneous in cases with aggressive histology • CT attenuation during treatment ➢ Heterogeneous from necrosis ➢ Calcification may occur Confluent retroperitoneal nodes in NHL NHL: Discrete Nodes [Figure 2-9-1] NHL: Sandwich Sign [Figure 2-9-2] Figure 2-9-4 NHL: Confluent Nodes [Figure 2-9-3] NHL: Confluent Nodes in AIDS- Associated NHL [Figure 2-9-4] NHL: Mesenteric Caking in AIDS- Associated NHL Confluent nodes in AIDS-associated NHL.

“alpha-heavy chain disease” ➢ Mantle cell lymphoma (multiple lymphomatous polyposis) ➢ Burkitt and Burkitt-type lymphoma ➢ Nodal equivalents (diffuse large B-cell lymphomas. Middle East • B-cell lymphomas ➢ MALT lymphomas ❖ Immunoproliferative small intestinal disease. Northern Africa. etc) Abdominal Non-Hodgkin Lymphoma 346 Gastrointestinal Radiology . discrete nodes • Retrocural nodes atypical in sarcoid Gastrointestinal Lymphoma • Lymphoma that presents with GI disease and no other major site of involvement • Most common extranodal site of NHL ➢ 4. follicular.Differential Diagnosis: Mesenteric Masses • Lymphoma • Metastasis • Carcinoid • Castleman disease • Mesenteric fibromatosis • Gastrointestinal Stromal Tumor (GIST) • Granulomatous disease ➢ Tuberculosis ➢ Histoplasmosis ➢ Sarcoid • Sprue • Whipple disease • Inflammatory Pseudotumor Castleman Disease • Hyperenhancing masses ➢ Homogeneous or heterogeneous • May calcify Mesenteric Fibromatosis (Desmoid Tumor) • Homogeneous attenuation ➢ Soft tissue or low attenuation myxoid stroma • Heterogeneous attenuation ➢ Foci of low attenuation myxoid stroma • May infiltrate adjacent bowel Carcinoid • Primary lesion in bowel • Mesenteric metastasis ➢ Spiculations/tethering of mesentery ➢ May calcifiy Gastrointestinal Stromal Tumor (GIST) • Mesenteric masses of GIST ➢ Primary to small bowel or mesentery ➢ Metastatic disease • Heterogeneous attenuation ➢ Low attenuation hemorrhage/necrosis Sarcoid • Small.4% of all lymphomas ➢ 25% of all extranodal lymphomas • Almost exclusively NHL • Stomach is the most common site in US and Western Europe • Small bowel is the most common site in the Mediterranean.

obstruction. mean age 60 years • Clinical presentation: ➢ Weight loss.• T-cell lymphoma ➢ Enteropathy-type T-cell lymphoma (ETTL) Figure 2-9-5 NHL: Small Intestine • Approximately 25% of all primary small bowel malignancies • Male predominance. pain. bleeding ➢ Intussusception. ulceration. and nodularity Ileal lymphoma extending into small bowel mesentery Gastrointestinal Radiology 347 Abdominal Non-Hodgkin Lymphoma . perforation • Ileum most common location and duodenum least common • Multiple lesions in 10 to 25% of cases NHL Small Bowel: Radiologic Patterns • Mural infiltration ➢ Fold thickening ➢ Circumferential wall thickening ➢ Luminal dilatation • Polypoid nodules ➢ Solitary ➢ Multiple (lymphomatous polyposis) • Cavities • Mesenteric disease NHL Small Intestine: Tumor Morphology [Figure 2-9-5] NHL Small Intestine: Mural Infiltration [Figures 2-9-6 to 2-9-8] Figure 2-9-7 Lymphoma histology shows tumor extension from mucosa to serosa Figure 2-9-6 Ileal lymphoma showing mural infiltration.

0 cm ➢ Solitary polyp ➢ Most common in the ileocecal region Polypoid masses of mantle cell lymphoma Abdominal Non-Hodgkin Lymphoma 348 Gastrointestinal Radiology . not related to EBV ➢ ileocecal region of children • Clinical presentation ➢ Intestinal obstruction ➢ Intussusception Mantle Cell Lymphoma [Figure 2-9-11] Mantle Cell Lymphoma (Multiple Lymphomatous Polyposis) • Histologically resembles the mantle zone of the lymph follicle • Median age 65.5 to 2. related to EBV dilatation ➢ Head and neck disease • Sporadic ➢ Western countries.NHL Small Intestine: Cavitary Mass [Figure 2-9-9] Figure 2-9-8 Figure 2-9-9 Cavitary mass NHL Small Intestine: Adjacent Mesenteric Disease [Figure 2-9-10] Figure 2-9-10 Mesenteric mass engulfing small intestine Burkitt Lymphoma • High grade B-cell lymphoma • More common in males • Endemic Mural infiltration with luminal ➢ African Burkitt. male predominance • Clinical presentation ➢ Abdominal pain and bloody stools Figure 2-9-11 • Imaging ➢ Multiple polyps. 0.

GI tract PTLD [Figures 2.Enteropathy-Type T-cell Lymphoma (ETTL) [Figure 2-9-12] • Associated with celiac disease (Sprue) Figure 2-9-12 ➢ Sixth to seventh decade of life • Most common site jejunum • Gross pathology ➢ Ulcerated plaques ➢ Strictures • Poor prognosis NHL Small Intestine: Differential Diagnosis • Adenocarcinoma Enteropathy type T-cell lymphoma • GIST • Carcinoid • Metastases • Crohn disease Figure 2-9-13 • Tuberculosis • Mesenteric fibromatosis • Causes of fold thickening ➢ Sprue ➢ Hemorrhage ➢ Edema ➢ Ischemia Malignant Melanoma Metastases Gastrointestinal Stromal Tumor Jejunal Adenocarcinoma Tuberculosis / Lymphoma Post-transplantation Lymphoproliferative Disorder (PTLD) • Spectrum of benign and malignant disorders • Variable incidence ➢ 1% renal transplants ➢ 10% combined heart/lung ➢ 10% of patients on cyclosporine and OKT3 • Association with EBV infection • Lung. surgery Figure 2-9-14 AIDS-Related Lymphoma • Second most common neoplasm in HIV infection • AIDS defining illness • Incidence is 4% to 10% in the AIDS population • Three categories ➢ Systemic (nodal and/or extranodal) ➢ Primary CNS Colonic lymphoma in a patient with a renal transplant Gastrointestinal Radiology 349 Abdominal Non-Hodgkin Lymphoma . anti-virals.9-13 and 2-9-14] • Pathologic Features ➢ Driven by Epstein-Barr Virus infection ➢ Diffuse polyclonal expansion Pathogenesis of post-transplantation ➢ Reduced T-cell control lymphoproliferative disorder ➢ Malignant transformation • Clinical ➢ May respond to reducing immunosuppression.

liver Patterns of Adenopathy Patterns of Small Bowel Disease 1-Mural Infiltration 2-Polyps Anorectal lymphoma in AIDS 3-Cavitary Masses 4-Mesenteric Masses AIDS-Related Lymphomas Post Transplantation Lymphoproliferative Disorder (PTLD) Abdominal Non-Hodgkin Lymphoma 350 Gastrointestinal Radiology . luminal dilatation. unusual manifestations • PTLD Figure 2-9-16 ➢ Colon. mesenteric masses • AIDS-related ➢ Aggressive behavior ➢ Unusual sites. polyps. cavitary masses. ➢ Body cavity-based (primary effusion) lymphomas • Major histologic subtypes ➢ Burkitt lymphoma ➢ Burkitt-like lymphoma ➢ Large cell lymphoma ➢ Large cell immunoblastic lymphoma AIDS-Related Lymphoma • 25% have GI tract disease • Higher incidence of mesenteric disease than non-AIDS lymphomas • Aggressive histology and biologic behavior ➢ Atypical radiologic features ➢ Hemorrhage ➢ Necrosis • Unique subtypes ➢ Body cavity-based lymphoma (Kaposi’s sarcoma-associated herpes virus (KSHV)) ➢ Anorectal lymphoma Figure 2-9-15 Primary Peritoneal Lymphoma [Figure 2-9-15] Colonic Lymphoma Anorectal Lymphoma [Figure 2-9-16] Summary Primary peritoneal lymphoma in AIDS • Spectrum of Adenopathy • ➢ GI lymphomas are predominantly NHL ➢ Unique subtypes involve the bowel ➢ Various patterns: infiltrating masses.

Gospodarowicz M. Crump M. Hum Pathol 25:1020. 1994 6. Eur Radiol 10:425.and B-cell types. et al: The World Health Organization classification of neoplasms of the hematopoietic and lymphoid tissues: report of the Clinical Advisory Committee meeting--Airlie House.References Ann Arbor Staging of Gastrointestinal Lymphomas Stage IE: Confined to the wall of the stomach or bowel Stage II1E: Regional lymph nodes contiguous to primary site Stage II2E: Regional lymph nodes not contiguous to primary site Stage III: Lymph nodes on both sides of the diaphragm. Gossios K. Lim HK. Choi D. Lyon: IARC Press. 1997. not otherwise characterized Angioimmunoblastic T-cell lymphoma Anaplastic large-cell lymphoma Lymphoma Classification 1. 2003 2. Jaffe ES. Mod Pathol 12:151. 2001 Imaging of non Hodgkin lymphoma 1. AJR 178:1117. Katsimbri P. Byun JH. 1995 Gastrointestinal Radiology 351 Abdominal Non-Hodgkin Lymphoma . Diebold J. Tsianos E: CT features of gastric lymphoma. Lee SJ. Isaacson PG: Gastrointestinal lymphoma. or both (IIIE&S) Stage IV: Bone marrow or other non-hematolymphoid organ World Health Organization Classification of B-Lymphoid Neoplasms Precursor B-cell Neoplasms Precursor B-lymphoblastic leukemia/lymphoma Mature (peripheral) B-cell Neoplasms B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma B-cell prolymphocytic leukemia Lymphoplasmacytic lymphoma Splenic marginal zone B-cell lymphoma Hairy cell leukemia Plasma cell myeloma/plasmacytoma Extranodal marginal zone B-cell lymphoma of MALT type Nodal marginal zone B-cell lymphoma Follicular lymphoma Mantle-cell lymphoma Diffuse large B-cell lymphoma Burkitt lymphoma World Health Organization Classification of T. 1999 4. Shepherd FA: Lymphoma of the gastrointestinal tract. Semin Oncol 26:324. 2000 5. Ha HK. Isaacson PG: Intestinal lymphoma and enteropathy. Radiology 227:59. et al (eds): World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues). Harris NL. et al: CT Findings in Peripheral T-Cell Lymphoma Involving the Gastrointestinal Tract. Virginia. J Pathol 177:111. Isaacson PG: Gastrointestinal lymphomas of T. et al: Gastric mucosa-associated lymphoid tissue lymphoma: helical CT findings and pathologic correlation. Kim AY. Hematol J 1:53.and NK-Lymphoid Neoplasms Precursor T-cell Neoplasms Precursor T-lymphoblastic lymphoma/leukemia Mature (peripheral) T-cell Neoplasms T-cell prolymphocytic leukemia T-cell granular lymphocytic leukemia Aggressive NK-cell leukemia Adult t-cell lymphoma/leukemia Extranodal NK/T-cell lymphoma Enteropathy-type T-cell lymphoma Hepatosplenic gamma-delta T-cell lymphoma Subcutaneous panniculitis-like T-cell lymphoma Mycosis fungoides/Sezary syndrome Peripheral T-cell lymphoma. November. 1999 7. Jaffe ES. 2000 2. Harris NL. 2002 3. Stein H. spleen (IIIS).

2002 16. Vaswani KK. 1986 4. Davies EA. 1983 6. 2000 2. Meador TL. Albin J. 2003 AIDS-related lymphomas 1. et al: Computed tomography of rectal and perirectal disease in AIDS patients. Eur Radiol 9:693. Rubesin SE. Cheong JJ. Radiographics 23:457. Giancotti F. 1997? 7. Pantongrag-Brown L. 1999 11. thorax. Eftekhari F. AJR Am J Roentgenol 171:1007. et al: Helicobacter pylori and gastric MALT lymphoma. Meiri E. Park MS. Tubman DE. 1983 14. Henry Ford Hosp Med J 38:255. Isaacson PG: Mucosa-associated lymphoid tissue lymphoma. 1984 10. AJR Am J Roentgenol 175:183. Megibow AJ. et al: CT findings in posttransplantation lymphoproliferative disorder of renal transplants.8. Eur Radiol 12:348. Arch Intern Med 146:913. Gottesman L. MacLennan KA. Yu JS. AJR 174:121. 1990 6. Rohatiner AZ. Lewis E. Wu L. 2002 Post-transplantation lymphoproliferative disorder 1. Mulonzia NW. et al: Primary effusion lymphomas in AIDS: CT findings in two cases. et al: Imaging features of posttransplantation lymphoproliferative disorder in pancreas transplant recipients. Maeda KM: Rectal non-Hodgkin's lymphoma: a clinicopathologic study and review. Pickhardt PJ. 2002 15. Frick MP. Levine MS. AJR 141:541. Gill PS. Pickhardt PJ. Sheth S. 2000 5. 2001 5. Ioachimm HL. Hayashi RJ. Guermazi A. Siegel MJ: Posttransplantation lymphoproliferative disorder of the abdomen: CT evaluation in 51 patients. et al: Computed tomography of gastrointestinal lymphoma. Surawicz C: Anorectal pathology in AIDS. 2000 7. Isaacson PG. histopathologic. Pickhardt PJ. Brice P. Kim KW. Rodallec M. Antonescu C. Ferrozzi F. Subbuswamy SG: Multiple lymphomatous polyposis of the gastrointestinal tract. Am J Surg Pathol 21:997. 1998 3. Semin Hematol 36:139. Gastrointest Endosc Clin N Am 8:913. Histopathology 8:641. 1987 2. Kessar P. AIDS Patient Care STDS 16:395. Rappaport DC. Radiology 149:625. et al: Posttransplantation lymphoproliferative disorder in children: clinical. 1999 9. Burkitt's lymphoma. 1996 12. Abdom Imaging 26:200. et al: CT appearances of mucosa-associated lymphoid tissue (MALT) lymphoma. AJR Am J Roentgenol 168:165. Gottlieb CA. et al: EBV-associated anorectal lymphomas in patients with acquired immune deficiency syndrome. Siegel MJ. Meyer PR. Gastrointest Radiol 12:67. AJR 179:1297. Garland MR. Munn S: Imaging HIV/AIDS. Eur Radiol 11:623. Siegel MJ: Abdominal manifestations of posttransplantation lymphoproliferative disorder. Elmas N. Krebs TL. et al: Lymphoproliferative disorders after liver transplantation: imaging features. Radiology 213:73. Burkes RL. Radiology 217:16. et al: Imaging of MALT lymphomas. Hanbidge A. Furth EE. Naidich DP. Balthazar EJ. Hanto DW: Lymphoma after organ transplantation: radiologic manifestations in the central nervous system. 1999 4. Tognini G. Norton A. Horton KM. Brar HS. Vrachliotis TG. 1998 3. and abdomen. 1997 13. Levine MS. et al: Radiographic findings of primary B-cell lymphoma of the stomach: low-grade versus high-grade malignancy in relation to the mucosa-associated lymphoid tissue concept. AJR Am J Roentgenol 166:85. 2001 Abdominal Non-Hodgkin Lymphoma 352 Gastrointestinal Radiology . and imaging features. et al: Rectal lymphoma in homosexual men. et al: Non-Hodgkin's lymphoma of the gastrointestinal tract: radiographic findings. et al: Mesenteric Neoplasms: CT Appearances of Primary and Secondary Tumors and Differential Diagnosis.

NF1. Crohn disease ➢ Association with precursor conditions: FAP. COL. Peutz-Jegher • Trend in distribution of malignant tumors is relative to histology ➢ Adenocarcinoma most common in duodenum ➢ Carcinoid most common in ileum ➢ Lymphoma most common in ileum ➢ GISTs. primary or secondary • Diagnostic approach ➢ Differential diagnosis based upon location.Small Intestinal Neoplasms Angela D. USA Small Intestinal Neoplasms: Introduction • Small bowel neoplasms ➢ Uncommon ➢ Spectrum from hamartoma to benign to malignant ➢ Majority of malignant small bowel tumors are metastatic ➢ Primary small bowel tumors account for 1% to 2% of GI malignancies • Most common benign small bowel tumors ➢ Adenoma ➢ GIST (may be benign or malignant) ➢ Lipoma • Location of benign tumors ➢ Least common in duodenum ➢ Most common in ileum • Primary malignant small bowel tumors ➢ Strong associations with chronic inflammation: sprue. MC. Levy. MEN. morphology. malignant. and associated conditions Small Intestinal Neoplasms: Objectives • Case based approach ➢ Tumors of proximal duodenum ➢ Periampullary tumors ➢ Polypoid jejunal/ileal tumors ➢ Annular tumors of jejunum and ileum ➢ Tumors associated with adjacent disease in the mesentery ➢ Tumors associated with NF1 • Case based approach ➢ Brunner gland lesions ➢ Adenomas ➢ Adenocarcinomas ➢ Carcinoid ➢ GISTs ➢ Metastatic disease 38-year-old man with recent onset of abdominal pain Figure 2-10-1 [Figure 2-10-1] Brunner gland hamartoma Gastrointestinal Radiology 353 Small Intestinal Neoplasms . even distribution throughout small bowel • Clinical features ➢ Many occult and asymtomatic until advanced disease ➢ Symptoms dependent upon location and tumor morphology ➢ Symptoms are similar in benign.

obstruction or bleeding • Treatment ➢ Resection Brunner Gland Hamartoma • Imaging features ➢ Solitary ➢ Sharply circumscribed polyp ➢ Proximal duodenum • Homogenous CT attenuation ➢ Composed of mostly glandular elements • Heterogeneous CT attenuation ➢ Abundant fat.Differential Diagnosis: Proximal Duodenal Polyp • Nonneoplastic ➢ Brunner gland hamartoma ➢ Heterotopia ➢ Prolapsed antral mucosa ➢ Peutz-Jegher hamartoma • Neoplastic ➢ Adenoma ➢ Adenocarcinoma ➢ GIST ➢ Carcinoid ➢ Prolapsed gastric neoplasm Brunner Gland Hamartoma [Figure 2-10-1] • Solitary hamartoma ➢ Brunner glands. smooth muscle. and fatty elements ➢ Heterotopic pancreatic acini and ducts • Synonym: Brunner gland adenoma • Most common in duodenal bulb • Clinical ➢ Peak incidence. muscular. multifocal version of Brunner hamartoma • Clinical associations ➢ Duodenal ulcers Figure 2-10-2 ➢ Gastric hypersecretory states • Treatment ➢ None Brunner Gland Hyperplasia [Figure 2-10-2] • Differential diagnosis ➢ Brunner gland hyperplasia ➢ Lymphoid hyperplasia ➢ Duodenitis ➢ Adenomas in FAP ➢ Hamartomas in Peutz-Jegher ➢ Heterotopia Brunner gland hyperplasia Small Intestinal Neoplasms 354 Gastrointestinal Radiology . 4th to 6th decade ➢ Asymptomatic or rarely. and cystic change Brunner Gland Hyperplasia • Smaller.

Atlas of Tumor Pathology:Tumors of the Intestines. HNPCC Periampullary Adenocarcinoma Periampullary adenocarcinoma • Imaging features ➢ Biliary obstruction ➢ Duodenal mural thickening or polypoid mass ➢ May extend into adjacent pancreas and/ampulla Figure 2-10-5 Adenocarcinoma Duodenum: Ampullary/Periampullary [Figures 2-10-4 and 2-10-5] • May arise from periampullary duodenal mucosa • May arise from ampulla • May be mixed location ➢ Origin not clear Small Bowel Adenocarcinoma • More common in proximal small intestine1 ➢ 55% periampullary/ampullary ➢ 10% duodenum ➢ 25% jejunum ➢ 10% ileum • Association with colonic adenocarcinoma Ampullary adenocarcinoma ➢ APC gene ➢ Mismatch repair gene 1Riddel RH. FAP ➢ Hereditary nonpolyposis colon carcinoma.68-year-old woman with recurrent pancreatitis [Figure 2-10-3] Differential Diagnosis Figure 2-10-3 Periampullary Duodenal Mass • Nonneoplastic ➢ Choledochocele ➢ Duplication cyst ➢ Peutz-Jegher hamartoma • Neoplastic ➢ Adenoma/adenocarcinoma ➢ Carcinoid/NF1 ➢ GIST Periampullary tubulovillous adenoma ➢ Metastatic disease ➢ Adjacent pancreatic or ampullary adenocarcioma Figure 2-10-4 Tubulovillous Adenoma Adenoma • Benign intraepithelial neoplasm composed of dysplastic cells ➢ Tubular. villous. Williams GT. Sobin LH. or tubulovillous histology ➢ May progress to adenocarcinoma • Locations ➢ 80% are periampullary • Increased incidence ➢ Familial adenomatous polyposis. AFIP 2003 Gastrointestinal Radiology 355 Small Intestinal Neoplasms . Petras RE.

bypassed bowel Differential Diagnosis: Small Bowel. HNPCC. Intussuscepting Mass • Benign ➢ Adenoma ➢ Peutz Jegher polyp ➢ Lipoma ➢ Uncommon ❖ Neurofibroma ❖ Schwannoma ❖ Inflammatory fibroid polyp Figure 2-10-6 ❖ Heterotopia • Malignant ➢ Metastasis ➢ Adenocarcinoma ➢ Lymphoma ➢ GIST ➢ Carcinoid Jejunal Adenocarcinoma: Annular Adenocarcinoma of the jejunum with annular morphology [Figure 2-10-6] • CT features ➢ Focal.Small Bowel Adenocarcinoma • Most patients between 50 and 60 years ➢ Mean age. NF1 ➢ Chronic inflammation: sprue. Peutz-Jegher. annular mural thickening ➢ Spiculated or irregular margins ➢ +/. 55 years • Predisposing conditions ➢ Inherited syndromes: FAP. ileostomies. ileal pouches.mesenteric adenopathy Figure 2-10-7 Ileal Adenocarcinoma: Annular and Infiltrating [Figure 2-10-7] Differential Diagnosis: Jejunal or Ileal Stricture • Neoplastic ➢ Adenocarcinoma ➢ Carcinoid Adenocarcinoma of the ileum with annular and infiltrating ➢ Lymphoma morphology ➢ Metastasis • Nonneoplastic ➢ Crohn disease ➢ Celiac disease ➢ NSAID (tend to be web-like) ➢ Ischemia ➢ Tuberculosis ➢ Heterotopia Figure 2-10-8 ➢ Radiation Ileal Adenocarcinoma: Cavitary Mass [Figure 2-10-8] • Unusual presentation for adenocarcinoma • More aggressive histology ➢ Poorly differentiated ➢ Endocrine features mixed with adenocarcinoma Adenocarcinoma of the ileum manifesting as a cavitary mass Small Intestinal Neoplasms 356 Gastrointestinal Radiology . Crohn disease.

proximal transverse colon Figure 2-10-10 ➢ Hindgut. distal transverse colon. ascending colon. ileum. appendix. jejunum. distal duodenum. descending colon.Differential Diagnosis: Jejunal or Ileal Cavitary Mass Figure 2-10-9 • Metastatic disease • Lymphoma ➢ Look for homogenous attenuation tumor • GIST • Adenocarcinoma 50-year-old man with abdominal pain and diarrhea [Figures 2-10-9 and 2-10-10] • CT findings ➢ Fixed segment of ileum ➢ Mural thickening ➢ Adjacent spiculated mesenteric mass Carcinoid Carcinoid • Well-differentiated endocrine neoplasms • All have malignant potential • Classification ➢ Foregut. rectum • Spectrum of clinical/imaging features ➢ Population and type of endocrine cell changes throughout the bowel ➢ Variety of hormones produced ➢ Biologic behavior ranges from benign to malignant Carcinoid Duodenal Carcinoid • Most common in first and second portion ➢ Low-grade malignancies ➢ Gastrin or somatostatin production most common ➢ Periampullary tumors = somatostatin producing and NF1 association • Associations ➢ Zollinger-Ellison syndrome ➢ Multiple endocrine neoplasia (MEN 1) ➢ Neurofibromatosis type 1 (NF1) Figure 2-10-11 Duodenal Carcinoid [Figure 2-10-11] • Imaging features ➢ Solitary or multifocal polyps ➢ Intramural mass Jejunal and Ileal Carcinoid • Aggressive biologic behavior • Serotonin production ➢ Desmoplasia ➢ Kinking of bowel Duodenal carcinoid ➢ Spiculation of mesentery ➢ Ischemia from "elastic vascular sclerosis” ➢ May have carcinoid syndrome with liver mets Gastrointestinal Radiology 357 Small Intestinal Neoplasms . stomach and proximal duodenum ➢ Midgut (60% to 80%).

wheezing. fibrotic mass adjacent to bowel ➢ Sunburst pattern of vessels on angiogram ➢ May calcify Carcinoid Ileum [Figure 2-10-12] Carcinoid Ileum • ”Elastic vascular sclerosis” • Sunburst pattern of mesenteric Ileal carcinoid vessels • Multifocal nodules • Kinking of bowel • Rigid segment of bowel Somatostatin Receptor Scintigraphy: Octreotide Scans (111In-Pentetreotide) [Figure 2-10-13] Carcinoid Syndrome • 10% of patients with carcinoids Figure 2-10-13 • Most common with ileal carcinoids • Hepatic metastasis are usually present ➢ Serotonin and metabolites in systemic circulation • Classic syndrome ➢ Paroxysms of sweating. cyanosis. abdominal colic. right-sided Metastatic carcinoid shown on CT and 111In-pentetreotide heart failure. spiculated folds • Local nodal mesenteric metastasis often most prominent feature ➢ Spiculated. flushing. diarrhea scintigraphy ➢ Symptoms precipitated by ETOH intake.Jejunal and Ileal Carcinoid: Imaging Features • Discrete mass in wall of bowel Figure 2-10-12 ➢ Mural mass ➢ Polypoid mass ➢ Multiple masses. less common • Extensive wall abnormalities ➢ Luminal narrowing ➢ Thick. stress. exercise • Carcinoid heart disease ➢ Right sided valvular dysfunction ➢ Congestive heart failure Carcinoid: Differential Diagnosis • Metastatic disease Figure 2-10-14 • Lymphoma • Granulomatous infection • Sclerosing mesenteritis 77-year-old asymptomatic man [Figure 2-10-14] Gastrointestinal stromal tumor Small Intestinal Neoplasms 358 Gastrointestinal Radiology .

direct extension. leiomyosarcoma • Adenocarcinoma Metastatic Disease • Most common site for metastasis in GI tract • Metastasis are more common than primary malignancies in the small bowel • Widespread metastatic disease usually present • Hematogenous spread ➢ Melanoma ➢ Lung ➢ Breast ➢ Kidney • Intraperitoneal. annular strictures. exophytic [Figure 2-10-16] Gastrointestinal stromal tumor GIST: Small Bowel. cavitary lesions. polypoid and exophytic GIST: Small Bowel. cavitary 52-year-old man with NF-1 complains of abdominal pain Gastrointestinal Neoplasms in NF-1 • Neurofibroma • Carcinoid ➢ Duodenal ➢ Somatostatinoma • Gastrointestinal stromal tumors ➢ Small intestine. mural masses.Differential Diagnosis: Figure 2-10-15 Small Bowel Polypoid Mass • Benign ➢ Adenoma ➢ Peutz Jegher polyp ➢ Inflammatory fibroid polyp ➢ Inflammatory pseudotumor • Malignant ➢ Metastatic disease ➢ Adenocarcinoma ➢ Lymphoma Gastrointestinal stromal tumor ➢ GIST ➢ Carcinoid Gastrointestinal Stromal Tumor (GIST) • Most common mesenchymal neoplasm • Small bowel second most common site • Variable biologic behavior GIST: Small Bowel. polypoid Figure 2-10-16 GIST: Small Bowel. multiple • Ganglioneuroma • Leiomyoma. association with mesenteric nodal masses Gastrointestinal Radiology 359 Small Intestinal Neoplasms . lymphatic spread ➢ Tumors of GI origin ➢ Ovarian and endometrial carcinoma • Imaging patterns ➢ Identical to primary neoplasms ➢ Polyps. mural [Figure 2-10-15] GIST: Small Bowel.

Metastatic Disease: Renal Cell Carcinoma [Figure 2-10-17] Figure 2-10-17 Metastatic Disease: Melanoma [Figure 2-10-18] Summary: Brunner Gland Lesions • Brunner gland hamartoma ➢ Solitary mass ➢ Proximal duodenum • Brunner gland hyperplasia Renal cell carcinoma metastatic to the small bowel ➢ Multiple nodules ➢ Proximal duodenum Summary: Adenoma • Uncommon • Most periampullary • Association Figure 2-10-18 ➢ FAP ➢ HNPCC Summary: Adenocarcinoma • Periampullary location most common • Morphology ➢ Polypoid ➢ Annular ➢ Infiltrating ➢ Cavitary Melanoma metastatic to the small bowel Summary: Carcinoid • Endocrine neoplasms • Midgut most common ➢ Serotonin production ➢ Octreotide scintigraphy • Key imaging features ➢ Mural wall thickening ➢ Fixation of bowel ➢ Mesenteric mass ➢ Mesenteric retraction Summary: GIST • Most common mesenchymal neoplasm ➢ KIT positive • Mural masses ➢ Intraluminal polyp ➢ Exophytic component ➢ Hemorrhage ➢ Cyst formation ➢ Cavitation Summary: Metastatic Disease • Most common malignancy in the small bowel Small Intestinal Neoplasms 360 Gastrointestinal Radiology .

Levy.1 ➢ ~150. USA Colorectal Carcinoma: Objectives • Epidemiology/pathogenesis • Screening • Detection ➢ Preoperative assessment • Staging ➢ Rectal carcinoma Colorectal Carcinoma • Third most frequent cancer in the U. COL. polypoid adenoma. 55:10-30 Colorectal Carcinoma: Risk Factors • Lifetime risk 6% • Incidence increases after age 50 • Familial risk ➢ 2 to 4 fold increase risk with a single first degree relative ➢ 3 to 6 fold increase risk with two first degree relatives • Increased risk ➢ Familial adenomatous polyposis syndrome (FAP) ➢ Hereditary nonpolyposis colon cancer (HNPCC) ➢ Inflammatory bowel disease Colorectal Carcinoma: Pathogenesis • Adenoma-Carcinoma Sequence ➢ Slow evolution to cancer.S. to invasive carcinoma Gastrointestinal Radiology 361 Colorectal Carcinoma . MC. dysplasia. CA Cancer J Clin 2005.000 new cases per year ➢ 11% of cancers in men and women ➢ 10% of cancer deaths 1Jemal A et al. unicryptal adenoma.Colorectal Carcinoma Angela D. average 10 years ➢ Adenoma detection and removal = cure • Exception to adenoma-carcinoma sequence ➢ Carcinomas in inflammatory bowel disease ➢ Hereditary nonpolyposis colon cancer (HNPCC) Adenoma-Carcinoma Sequence [Figures 2-11-1] Colorectal Carcinoma: Role of Radiology • Screening ➢ ACBE Figure 2-11-1 ➢ CT colonography • Detection ➢ Symptomatic patients • Preoperative screening ➢ Primary disease complications ➢ Preoperative staging • Recurrent disease Adenoma to carcinoma sequence progressive from normal mucosa. carcinoma in-situ. high-grade dysplasia.

60% are > 2 cm.5% ➢ Pitfalls ❖ Failure to reach cecum ❖ Blind spots Colorectal Carcinoma: Screening • Virtual colonography ➢ Sensitivity 73% to 93% for >10mm polyps ➢ Prone and supine imaging improves sensitivity ➢ Difficult lesions ❖ Poor bowel preparation ❖ Flat adenomas ❖ Adenomas on folds ❖ Adenomas seen in only one position Colorectal Polyps: Histologic Spectrum • Hyperplastic ➢ Most common ➢ Usually <5 mm. most pedunculated ➢ Villous. villous histology or high-grade dysplasia • Colonoscopy every 5 years. most sessile ➢ Mixed • Juvenile • Peutz-Jeghers • Inflammatory/post-inflammatory Tubular Adenoma Villous Adenoma Colorectal Carcinoma 362 Gastrointestinal Radiology . requiring sedation ➢ Perforation rate . no family history 1Bond JH. descending colon and rectum ➢ NOT neoplastic • Adenoma ➢ Tubular. Am J Gastroenterology 2000. >1cm.Colorectal Carcinoma: American Cancer Society Screening Recommendations • Average risk adults begin screening at age 50 ➢ Annual fecal occult blood (FOBT) or fecal immunochemical test (FIT) ➢ Sigmoidoscopy every 5 years ➢ Annual FOBT or FIT + Sigmoidoscopy every 5 years ➢ Colonoscopy every 10 years ➢ DCBE every 5 years Colorectal Carcinoma: American College of Gastroenterology Polyp guidelines1 • Colonoscopy every 3 years. low risk for metachronous adenomas ➢ 1-2 tubular adenomas. high risk for metachronous adenomas ➢ >2.1% to . 95(11): 3053-3063 Colorectal Carcinoma: Screening • Air contrast barium enema ➢ Accuracy 90% for polyps >1 cm ➢ Pitfalls ❖ Anatomic difficulties (overlapping segments) ❖ Diverticular disease ❖ Perceptive errors • Colonoscopy ➢ Accuracy 90% ➢ Invasive. 75% are <1 cm.

2 cm. carpet-like appearance Gastrointestinal Radiology 363 Colorectal Carcinoma .3% • Three types Sessile adenomatous polyp showing ➢ Flat. 10% are carcinoma ➢ > 2 cm. lobulated ➢ Pedunculated • Histology ➢ Nonbranching finger-like fronds Villous Adenoma: Pathology [Figure 2-11-3] Figure 2-11-3 Villous adenoma of the cecum showing a bubbly.Adenoma Figure 2-11-2 • Size ➢ < 5 mm. carpet-like the Bowler Hat sign ➢ Sessile. benign ➢ 5 mm to 1 cm. 30% to 50% are carcinoma • Synchronous adenomas ➢ 40% to 50% • Recurrence ➢ 20% to 60% recurrence rate ➢ Majority recur within 2 years Adenoma: Barium Features • Filling defect in barium pool • Protrusion into the lumen ➢ “Innies not Outies” ➢ Bowler hat sign ➢ Sessile or pedunculated • Carpet lesions ➢ Sessile lesions ➢ Bubbly or nodular contour ➢ Villous change Bowler Hat Sign [Figure 2-11-2] Virtual Colonography Villous Adenoma • Higher rate of malignancy • Recurrence rate 9. 1% are carcinoma ➢ 1 .

fistula Colorectal Carcinoma: Morphologic Patterns • Polypoid ➢ Intraluminal masses ➢ Bulky. left sided lesions • Symptoms from complications ➢ Obstruction. ischemia.Villous Adenoma: CT Features [Figure 2-11-4] Figure 2-11-4 • Soft tissue mass ➢ Sessile ➢ Eccentric ➢ Stalk ➢ Expands lumen • Irregular luminal margin ➢ Low attenuation luminal margin ➢ High mucin content Villous adenoma of the rectum showing low attenuation along Colonic Adenocarcinoma the luminal margin Colorectal Carcinoma: Distribution [Figure 2-11-5] Colorectal Carcinoma: Clinical Presentation Figure 2-11-5 • Minimal or absent symptoms in up to 12% of patients • Bleeding ➢ Initial complaint in 50% • Weight loss. and sigmoid colon ➢ Encircle the bowel ➢ “Apple core” Distribution of colorectal carcinoma ➢ Diffuse infiltration (linitis plastica) uncommon • Ulcerating ➢ Deeply invade colonic wall ➢ Edge of tumor slightly elevated above normal mucosa • Flat plaques ➢ Carcinomas from flat adenomas ➢ Carcinomas in inflammatory bowel disease Colorectal Carcinoma: Computed Tomography • Primary Tumor ➢ Discrete mass ➢ Mural thickening • Extension beyond the bowel ➢ Irregular outer margin ➢ Soft-tissue stranding in pericolonic fat • Adjacent organ/muscle invasion ➢ Loss of fat planes ➢ Tumor mass in adjacent organ or muscle • Liver metastasis • Lymph node metastasis Colorectal Carcinoma 364 Gastrointestinal Radiology . perforation. malaise • Pain • Change in bowel habits • Right vs. descending. fungating masses in cecum and ascending colon • Infiltrating/annular constricting ➢ Transverse. peritonitis.

1% ➢ Time interval to second lesion discovery ❖ 64% within 5 years ❖ 45% within 3 years ❖ 20% within 1 year Infiltrating adenocarcinoma of the sigmoid colon with • 8% to 20% of patients with colorectal pericolonic extension and pericolonic adenopathy carcinomas have malignancies in other organs Figure 2-11-9 Synchronous Carcinomas [Figure 2-11-10] Rectal adenocarcinoma (T4) showing contiguous soft tissue attenuation into the pelvic side walls consistent with adjacent organ invasion Figure 2-11-10 Synchronous adenocarcinomas of the hepatic flexure and descending colon Gastrointestinal Radiology 365 Colorectal Carcinoma .5% to 12% Figure 2-11-8 ➢ Most are >5 cm away from each other • Metachronous carcinomas ➢ Incidence 0.6% to 9.Polypoid Adenocarcinoma Figure 2-11-6 [Figure 2-11-6] Annular Adenocarcinoma [Figure 2-11-7] Infiltrating Adenocarcinoma [Figure 2-11-8] Pericolonic Extension and Adenopathy Polypoid adenocarcinoma of the cecum showing pericolonic extension Adjacent Organ Invasion: Figure 2-11-7 Contiguous Soft Tissue Attenuation [Figure 2-11-9] Adjacent Organ Invasion Coloduodenal Fistula Multiple Carcinomas • Synchronous carcinomas ➢ Diagnosed within 6 months of each Annular adenocarcinoma of the distal transverse colon other ➢ Incidence 1.

Colonic Adenocarcinoma in Inflammatory Bowel Disease: Figure 2-11-11 [Figure 2-11-11] • Ulcerative colitis ➢ Highest incidence • Crohn disease ➢ Large and small intestinal adenocarcinoma • Features of carcinoma in IBD ➢ Typically do not arise in pre-existing adenomas ➢ Arise in flat mucosa ➢ Carcinomas may be long and flat Adenocarcinoma in Ulcerative Colitis Colorectal Carcinoma: Complications Adenocarcinoma in ulcerative colitis • Bleeding ➢ Occult ➢ Chronic anemia ➢ Massive bleeding. diverticulitis CT of Obstructing Colon Colonic ischemia in an obstructing carcinoma of the Carcinomas descending colon • IV contrast • Identify obstructing lesion Figure 2-11-13 ➢ Infiltration of adjacent fat ➢ Adjacent organ invasion • Evaluate bowel integrity ➢ Obstructive colitis (1% to 7%) ➢ Ischemic changes ➢ Pneumatosis • Stage ➢ Local extension ➢ Lymph node mets ➢ Liver mets Perforated adenocarcinoma of the transverse colon with abscess formation CT of Obstructing Colon Carcinomas Ischemia in Obstructive Cancers [Figure 2-11-12] Carcinoma with Perforation and Abscess [Figure 2-11-13] Colorectal Carcinoma:Role of Preoperative Imaging • Tumors proximal to the rectum are staged surgically ➢ Preoperatively image patients with clinical evidence of advanced disease • Preoperative imaging rectal tumors ➢ EUS and CT ➢ MR Colorectal Carcinoma 366 Gastrointestinal Radiology . unusual Figure 2-11-12 • Obstruction ➢ Occlusion of the colonic lumen ➢ Colocolic intussusception • Perforation ➢ Abscess ➢ Fistula ➢ Differential diagnosis.

Rectal Adenocarcinoma: Management • High T1 or T2 lesion ➢ Lesions 5 to 6 cm above dentate line or at peritoneal reflection ➢ Primary resection and anastomosis (LAR) • Low T1 or T2 lesion ➢ APR (Miles procedure). Beets-Tan RGH. recurrent tumor at resection margin Hustinx R. followed by hyperdensity ➢ Hypodense in the portal venous phase ➢ Isodense in the equilibrium phase • Lymphatic Spread Rectal Adenocarcinoma: Preoperative EUS • Endoscopic Ultrasound (EUS)* ➢ 360 degree probe ➢ Normal 5-layer rectal wall ➢ T stage accuracy 69% to 97% ➢ Nodal accuracy 70% to 80% • EUS limitations ➢ EUS best at early stage tumors ➢ Limited assessment because of location or bulk occurs ➢ May overstage (fibrosis vs. 71% to 91% • Phased array MR ➢ High spatial resolution ➢ Large field of view ➢ Limitations differentiating T2 and T3 lesions Colorectal Carcinoma: Role of PET • No role in screening/diagnosis • Preoperative staging ➢ Highly sensitive for liver mets ➢ Not sensitive for T staging and nodal mets • Detection of recurrent disease ➢ Following liver met resection/treatment ➢ Scar vs. Rectal cancer: review with emphasis on MR imaging. Ott DJ. 232: 335-346 Rectal Adenocarcinoma: Preoperative MR • Endoluminal MR ➢ Equal accuracy for early stage tumors to EUS ➢ T stage accuracy. inflammation) ➢ Intraobserver variability Wolfman NT. Semin Roentgenol 1996. posterior proctotomy • T3 or T4 ➢ Downstage with preoperative neoadjuvant chemoradiation ➢ APR and post operative XRT. Endoscopic Ultrasonography. PET imaging in assessing gastrointestinal tumors. 112 (6) 1123-1139. tumor vs. LAR. Radiology 2004.Colorectal Carcinoma: Preoperative CT • Local tumor extension ➢ Adjacent organ invasion • Liver metastasis ➢ Early rim enhancement. local or transanal excision. RCNA 2004. 31(2): 154-161. Beets GL. adjuvant chemotherapy Gastrointestinal Radiology 367 Colorectal Carcinoma . total mesorectal excision. coloanal anastomosis with J-pouch.

TNM Staging [Figure 2-11-14] Figure 2-11-14 • T-Primary tumor ➢ T1 invades submucosa ➢ T2 invades muscularis propria ➢ T3 through muscularis propria or into nonperitonealized pericolic fat ➢ T4 perforates visceral peritoneum or directly invades adjacent organs or structures • N-Regional nodes • M-Distant metastasis EUS Layer 1: Hyperechoic superficial mucosa EUS Layer 2: Hypoechoic deep mucosa EUS Layer 3: Hyperechoic submucosa EUS Layer 4: Hypoechoic TNM Staging for colorectal carcinoma muscularis propria EUS Layer 5: Hyperechoic perirectal fat [Figure 2-11-15] T1 N0 M0 T2 N0 M0 Figure 2-11-15 T3 N2 M0 [Figure 2-11-16] T3 N10 M0 T3 N8 M1 T4 T4: Extension to pelvic side wall T4: Extension to labia Normal anatomy of the colon wall with endoscopic ultrasound Figure 2-11-16 T3N2M0 rectal adenocarcinoma Colorectal Carcinoma 368 Gastrointestinal Radiology .

Colorectal Carcinoma: Figure 2-11-17 Lymphatic Spread [Figure 2-11-17] • Pericolonic nodes ➢ Paracolic ➢ Epiploic • Mesenteric Nodes ➢ Intermediate nodes • Principal nodes ➢ SMA ➢ IMA Pericolonic Nodes Intermediate Principal Rectal Adenocarcinoma: Lymphatic Drainage [Figures 2-11-18 and 2-11- 19] • Pararectal nodes • Internal iliac nodes ➢ Tumors above dentate line • Inguinal nodes ➢ Tumors below dentate line Distribution of Figure 2-11-18 lymphatic spread for colon carcinoma Distribution of lymphatic spread for rectal carcinoma Figure 2-11-19 Inguinal lymph nodes in a rectal adenocarcinoma that extended below the dental line Gastrointestinal Radiology 369 Colorectal Carcinoma .

60% recur • BE features ➢ Filling defect ➢ Bowler hat ➢ Sessile ➢ Pedunculated Summary: Villous Adenoma • Carpet lesions • Bubbly appearance • Expand lumen • Low attenuation on luminal surface Summary: Primary Tumor • Morphology ➢ Polypoid ➢ Infiltrating/annular ➢ Ulcerating ➢ Flat plaques • Synchronous carcinomas • CT ➢ Local extent ➢ Adjacent organ invasion Summary: Complications • Bleeding ➢ Usually chronic blood loss ➢ Massive GI bleed.Summary: Adenoma • 40% . MR • T3 lesions ➢ Through muscularis propria ➢ Spiculated outer margin on CT ➢ Perirectal adenopathy Colorectal Carcinoma 370 Gastrointestinal Radiology . unusual • Obstruction ➢ CT ➢ Identify lesion and bowel wall integrity • Perforation ➢ Abscess ➢ Fistula ➢ Differential diagnosis inflammatory disorders Summary: Role of Imaging • Preoperative CT ➢ Local tumor extent ➢ Liver metastasis ➢ Lymphatic spread Summary: Rectal Adenocarcinoma • Preoperative staging ➢ EUS and CT.50% synchronous • 20% .

Halligan S. Bartram CI. Pickhardt PJ. 2003 16. 1999 3. N Engl J Med 349:2191. et al: Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. Taylor SA. Gastroenterology 125:311. Fenlon HM. Royster AP. Toledano AY. Semin Ultrasound CT MR 22:432. Goh V. 2003 13. Pickhardt PJ: Three-dimensional endoluminal CT colonography (virtual colonoscopy): comparison of three commercially available systems. pathology and pitfalls. Johnson CD. 2003 9. pitch. Macari M: Virtual colonoscopy: clinical results. AJR Am J Roentgenol 172:1271. Halligan S. Clin Radiol 58:179. Halligan S. Gut 47:126. Wilson LA. Gluecker TM. Gut 44:301. 2001 15. Hwang I. 2003 17. Ahlquist DA: Computed tomography colonography (virtual colonoscopy): a new method for colorectal screening. Fidler JL. Fletcher JG. Clin Radiol 58:723. 2002 2. et al: Computed tomographic colonography and conventional colonoscopy for colon diseases: a prospective. MacCarty RL. et al: Optimizing colonic distention for multi-detector row CT colonography: effect of hyoscine butylbromide and rectal balloon catheter. blinded study. Halligan S. et al: Optimizing bowel preparation for multidetector row CT colonography: effect of Citramag and Picolax. 2003 Gastrointestinal Radiology 371 Colorectal Carcinoma . et al: Characterization of Lesions Missed on Interpretation of CT Colonography Using a 2D Search Method. MacCarty RL. Fletcher JG. Radiology 229:99. colonoscopy. Radiology 227:378. Welch TJ. Harmsen WS. Johnson CD. Glucker T. Radiology 229:109. Belloni G. 2000 11. et al: Colorectal cancer screening with CT colonography. AJR Am J Roentgenol 169:1237. et al: CT colonoscopy of colorectal neoplasms: two-dimensional and three- dimensional virtual-reality techniques with colonoscopic correlation. et al: Computerized tomographic colonography: performance evaluation in a retrospective multicenter setting. and double-contrast barium enema examination: prospective assessment of patient perceptions and preferences. 20 4. et al: Prospective blinded evaluation of computed tomographic colonography for screen detection of colorectal polyps. 1997 14. 2004 5. Fletcher JG. AJR Am J Roentgenol 181:1599. Taylor SA. Johnson CD. Taylor SA. AJR Am J Roentgenol 182:881. Johnson CD. 2003 18. and orientation on polyp detection in a human colectomy specimen. Johnson CD. Abdom Imaging 27:292. Delarive J. Herman BA. Johnson CD. Choi JR. Bartram CI: CT colonography: methods. Gastroenterology 125:688. Am J Gastroenterol 96:394. Harmsen WS. 2003 12. Welch TJ. Pescatore P. Spinzi G. et al: Detection of flat lesions in the colon with CT colonography. 2003 8. Clarke PD. Johnson CD. Goh V. 1999 7. Taylor SA. Martegani A. Gluecker TM.References: Virtual Colonography 1. et al: Optimization of CT colonography technique: prospective trial in 180 patients. et al: CT colonography: potential pitfalls and problem-solving techniques. Radiology 216:704. et al: Multi-detector row CT colonography: effect of collimation. 2001 10. 2003 6. et al: Diagnostic accuracy and interobserver agreement of CT colonography (virtual colonoscopy).

Levy. USA Mesenteric Masses and Cysts: Objectives • Definitions ➢ Review mesenteric anatomy • Case based approach to differential diagnosis ➢ Mesenteric and omental cysts ➢ Mesothelioma ➢ Mesenteric Fibromatosis ➢ Sclerosing mesenteritis Figure 2-12-1 ➢ Inflammatory myofibroblastic pseudotumor ➢ Extrapleural solitary fibrous tumor MesentericAnatomy: Definitions • Mesentery ➢ Double fold of peritoneum ➢ Connects an organ to the abdominal wall • Omentum ➢ Specialized mesentery extending from stomach to an adjacent organ Anatomy Mesentery [Figure 2-12-1] • Transverse mesocolon • Small bowel mesentery • Sigmoid mesentery • Mesoappendix Anatomy: Omentum [Figure 2-12-2] • Greater omentum Normal posterior attachments of the ➢ Gastrocolic ligament mesentery in sagittal and AP planes ➢ Gastrosplenic ligament ➢ Gastrophrenic ligament • Lesser omentum ➢ Gastrohepatic ligament Figure 2-12-2 ➢ Hepatoduodenal ligament Mesenteric and Omental Cyst • Descriptive term • 5 histologic subtypes ➢ Defined by internal lining Mesenteric and Omental Cyst • Lymphangioma ➢ Endothelial lining • Enteric duplication cyst ➢ Enteric lining with muscular wall • Enteric cyst ➢ Enteric lining with a fibrous wall • Mesothelial cyst ➢ Mesothelial lining • Nonpancreatic pseudocyst ➢ No lining Normal anatomy of greater and lesser omentum Mesenteric Masses and Cysts 372 Gastrointestinal Radiology .Mesenteric Masses and Cysts Angela D. COL. MC.

neoplastic • Pseudocyst ➢ Internal hemorrhage. axilla ➢ 5% mesentery ➢ Lymphangiomatosis Abdominal Lymphangioma: Lymphangioma of the greater omentum Pathology • Interconnecting cysts • Endothelial lining • Dilated lymphatic spaces ➢ Proteinaceous fluid ➢ Chyle. low attenuation ➢ Hemorrhage Abdominal Lymphangioma: Imaging Features [Figures 2-12-4 and 2-12-5] • Mesenteric. omental or retroperitoneal location • Complex cyst ➢ Multilocular ➢ Enhancing septations ➢ Internal debris • Closely associated with small bowel • Lack features of free fluid Figure 2-12-5 ➢ Mass effect ➢ Septations ➢ No fluid in dependent spaces peritoneum • Infiltration/insinuation ➢ Within mesentery and bowel • Complications ➢ Small bowel obstruction ➢ Volvulus Mesenteric lymphangioma showing low attenuation ➢ Infection and insinuating growth Gastrointestinal Radiology 373 Mesenteric Masses and Cysts .35-year-old woman with increasing abdominal girth [Figure 2-12-3] Differential Diagnosis: Cystic Mesenteric Mass • Mesenteric cyst Figure 2-12-3 ➢ Lymphangioma ➢ Enteric duplication cyst ➢ Enteric cyst ➢ Mesothelial cyst ➢ Nonpancreatic pseudocyst • Cystic neoplasm ➢ Teratoma ➢ Cystic malignant mesothelioma ➢ Benign multicystic mesothelioma Lymphangioma ➢ Cystic soft tissue primary ➢ Pseudomyxoma peritonei • Complex ascites ➢ Infectious. abscess Lymphangioma Figure 2-12-4 • Benign • Vascular origin • Affect all ages • Many anatomic sites ➢ 95% neck.

71-year-old woman with abdominal pain [Figure 2-12-6] Figure 2-12-6 Differential Diagnosis • Pancreatic cystic neoplasm ➢ Mucinous cystic neoplasm ➢ Oligocystic adenoma • Pancreatic pseudocyst • Mesenteric cyst ➢ Lymphangioma Enteric duplication cyst ➢ Enteric duplication cyst ➢ Enteric cyst ➢ Mesothelial cyst ➢ Pancreatic pseudocyst • Cystic mesenteric neoplasm ➢ Metastatic disease ➢ Cystic mesothelioma Enteric Duplication Cyst Enteric Cyst and Mesothelial Cyst • Enteric cyst ➢ Variant of enteric duplication. abscess • No histologic lining • Imaging ➢ Thick walled ➢ Internal debris 55-year-old man. former shipyard worker. with worsening abdominal pain [Figure 2-12-8] Nonpancreatic pseudocyst Differential Diagnosis • Metastatic disease • Primary neoplasms ➢ Diffuse malignant mesothelioma Figure 2-12-8 ➢ Serous papillary carcinoma ➢ Intra-abdominal desmoplastic round cell tumor ➢ Leiomyomatosis peritonealis disseminata • Diffuse Infection ➢ Tuberculosis ➢ Histoplasmosis Diffuse Malignant Mesothelioma Diffuse malignant mesothelioma • Malignancy of mesothelial origin • Association with asbestos • Variants ➢ Diffuse peritoneal malignant mesothelioma ➢ Cystic malignant mesothelioma Mesenteric Masses and Cysts 374 Gastrointestinal Radiology . does not contain muscular wall • Mesothelial cyst ➢ Rare ➢ Fusion failure of visceral/parietal peritoneum • Nonspecific imaging features • Similar appearance compared to enteric duplication cyst Nonpancreatic Pseudocyst [Figure 2-12-7] Figure 2-12-7 • Old hematoma.

nodular peritoneum ➢ Ascites • Histopathologic variants ➢ Desmoplastic ➢ Lymphohistiocytoid ➢ Small cell ➢ Papillary Diffuse Peritoneal Malignant Mesothelioma • Imaging features ➢ Peritoneal soft tissue nodules ➢ Omental and mesenteric masses. nodules ➢ Ascites ➢ Bowel wall thickening ➢ Fixation of small bowel Diffuse Peritoneal Malignant Mesothelioma: Peritoneal. bladder ➢ May extend into upper abdomen Benign Multicystic Mesothelioma: Differential Diagnosis • Metastasis ➢ Mucinous adenocarcinoma ➢ Serous papillary carcinoma of ovary • Cystic malignant mesothelioma • Primary serous papillary carcinoma of peritoneum • Infection with complex ascites ➢ Tuberculosis Gastrointestinal Radiology 375 Mesenteric Masses and Cysts . masses. caking ➢ Bowel encasement ➢ Thick. 37 years • Clinical symptoms ➢ Chronic pelvic pain Benign Multicystic Mesothelioma • Imaging features ➢ Multicystic pelvic mass Benign multicystic mesothelioma ➢ Enhancing septa ➢ Peritoneal surfaces of uterus. Omental Nodules and Masses Figure 2-12-9 Diffuse Malignant Mesothelioma: Small Bowel Fixation Cystic Malignant Mesothelioma [Figure 2-12-9] Benign Multicystic Mesothelioma [Figure 2-12-10] • Rare Cystic malignant mesothelioma ➢ Arises from pelvic peritoneum • Unrelated to asbestos • Unrelated to malignant mesothelioma • Synonym Figure 2-12-10 ➢ Multilocular peritoneal inclusion cyst • Most common in women ➢ Mean age.Diffuse Malignant Mesothelioma • Gross Pathology ➢ Nodules.

pelvic.31-year-old man complained of abdominal fullness and early satiety. Physical exam revealed a palpable mass [Figure 2-12-11] Figure 2-12-11 Differential Diagnosis: Solid Mesenteric Mass • Malignant ➢ Soft tissue sarcoma ➢ Lymphoma ➢ Gastrointestinal stromal tumor ➢ Metastatic disease • Benign Mesenteric fibromatosis ➢ Mesenteric fibromatosis ➢ Sclerosing mesenteritis ➢ Inflammatory pseudotumor Figure 2-12-12 Mesenteric Fibromatosis: (Intraabdominal Fibromatosis or Abdominal Desmoid) • Classified as a deep fibromatosis ➢ Mesenteric. located in the ➢ Locally aggressive greater omentum ➢ Recurs following excision ➢ Does not metastasize • Mesenteric fibromatosis ➢ No gender predilection ➢ Most cases sporadic ➢ 13% associated with FAP • Abdominal fibromatosis ➢ Most common in young women. retroperitoneal ➢ Abdominal wall ➢ Extraabdominal • Benign proliferative process Mesenteric fibromatosis with low CT attenuation. 20-30 years of age Mesenteric Fibromatosis: Pathologic Features • Gross pathology ➢ Well-defined or infiltrative margins • Histology ➢ “Melting insinuating” and “tentacular growth” ➢ Microscopic tumor infiltration into bowel ➢ Collagenous and/or myxoid stroma Mesenteric Fibromatosis: Imaging Figure 2-12-13 • Homogeneous ➢ Collagenous stroma ➢ Myxoid stroma (low attenuation CT/high signal T2 MR) • Heterogeneous ➢ Bands of myxoid stroma “whorls” Mesenteric Fibromatosis: Homogeneous Attenuation Mesenteric fibromatosis Mesenteric Fibromatosis: Low CT Attenuation Myxoid Stroma [Figure 2-12-12] Mesenteric Fibromatosis : High T2 Signal [Figure 2-12-13] Mesenteric Masses and Cysts 376 Gastrointestinal Radiology .

radiation therapy ➢ Complications and recurrence common • Sporadic cases ➢ Surgery often curative • FAP ➢ Higher recurrence rate ➢ Higher morbidity ➢ Nonsurgical therapy more commonly used Gastrointestinal Radiology 377 Mesenteric Masses and Cysts . and retroperitoneum Mesenteric. chemotherapy. Pelvic. and Retroperitoneal: Fibromatosis in FAP Differential Diagnosis: Solid Mesenteric Mass • Malignant ➢ Soft tissue sarcoma ➢ Lymphoma ➢ Gastrointestinal stromal tumor ➢ Metastatic disease • Benign ➢ Mesenteric fibromatosis ➢ Sclerosing mesenteritis ➢ Inflammatory pseudotumor Metastatic Disease: Metastatic Lung Carcinoma Soft Tissue Sarcoma: Synovial Sarcoma Lymphoma Gastrointestinal Stromal Tumor: Small Bowel Primary Gastrointestinal Stromal Tumor: Primary to the Mesentery Gastrointestinal Stromal Tumor: Retroperitoneal Mesenteric Fibromatosis: Management • Controversial ➢ Wide excision. antiestrogens.Mesenteric Fibromatosis: MR Enhancement Mesenteric Fibromatosis in FAP [Figure 2-12-14] Figure 2-12-14 Mesenteric Fibromatosis • Complications ➢ Small bowel obstruction ➢ Fistula formation ➢ Perforation ➢ GI bleeding Mesenteric Fibromatosis: Infiltrates small bowel wall Mesenteric fibromatosis in a patient with FAP. pelvis. The myxoid stroma creates a “whorled” pattern in this example Mesenteric Fibromatosis in FAP • Almost always post operative ➢ Occurs at operative sites ➢ Usually within 4 years of surgery • Unusual manifestations ➢ Multiplicity ➢ May occur with abdominal wall fibromatosis ➢ Diffuse form may involve mesentery.

Mesenteric Fibromatosis: Postoperative Recurrence Sclerosing Mesenteritis • Rare • Idiopathic. nonneoplastic • Chronic inflammation • Synonyms represent histologic spectrum ➢ Mesenteric panniculitis ➢ Fibrosing mesenteritis ➢ Mesenteric lipodystrophy Sclerosing Mesenteritis: Clinical Features • Twice as common in men • Mean age. 60 years • Symptoms Figure 2-12-15 ➢ Pain ➢ Palpable mass ➢ Bowel complications ➢ Incidental Sclerosing Mesenteritis: Pathologic Features • Pathologic spectrum ➢ Loose myxomatous to dense sclerosis Sclerosing mesenteritis • Histologic features ➢ Sclerosing fibrosis ➢ Fat necrosis ➢ Lipid-laden macrophages ➢ Chronic inflammation ➢ Focal calcification Sclerosing Mesenteritis: Imaging Features [Figure 2-12-15] Figure 2-12-16 • Mesenteric mass ➢ Mixed fat and soft tissue ➢ Radiating fibrosis ➢ Fat-ring sign ➢ Calcifications ➢ Cystic appearance • Small Bowel ➢ Kinking or fixation ➢ Small bowel obstruction Sclerosing mesenteritis with the “fat ring” sign on CT Sclerosing Mesenteritis [Figure 2-12-16] • “Fat-ring Sign” Sclerosing Mesenteritis [Figure 2-12-17] Sclerosing Mesenteritis: Differential Diagnosis Figure 2-12-17 • Carcinoid metastasis ➢ Look for primary ➢ Somatostatin scintigraphy • Metastatic disease • Mesenteric fibromatosis Sclerosing mesenteritis with low CT attenuation from loose myxomatous stroma shown on the accompanying histology image Mesenteric Masses and Cysts 378 Gastrointestinal Radiology .

Sclerosing Mesenteritis: Somatostatin Receptor Scintigraphy Sclerosing Mesenteritis: Management • Biopsy may establish diagnosis • Many cases self-limiting • Asymptomatic or mild symptoms ➢ Observation • Symptomatic ➢ Immunosuppresive therapy ➢ Surgical resection Inflammatory Pseudotumor (Inflammatory Myofibroblastic Tumors) • Chronic inflammation • Unclear pathogenesis ➢ Sequelae occult infection ➢ Minor trauma ➢ Post surgical • Variable nomenclature ➢ Inflammatory myofibroblastic pseudotumor ➢ Plasma cell granuloma ➢ Plasma cell pseudotumor ➢ Inflammatory fibrosarcoma Inflammatory Pseudotumor: Clinical Features • Most common in pediatrics and young adults • May occur in may anatomic locations • Symptoms ➢ Fever ➢ Malaise ➢ Weight loss ➢ Pain Inflammatory Pseudotumor [Figure 2-12-18] Extrapleural Solitary Fibrous Tumor Figure 2-12-18 • Rare neoplasms • Submesothelial origin • Most commonly pleural origin “Solitary Fibrous Tumor of the Peritoneum” • Few case reports • Variable clinical presentation • Natural history unknown Inflammatory myofibroblastic pseudotumor ➢ Pleural lesions may show aggression ➢ Long-term follow up Extrapleural Solitary Fibrous Tumor Summary • Mesenteric cysts • Solid mesenteric masses Summary: Mesenteric Cyst • Lymphangioma • Most common • Imaging ➢ Multilocular ➢ Enhancing septa ➢ Insinuating growth Gastrointestinal Radiology 379 Mesenteric Masses and Cysts .

Summary: Mesenteric Cyst • Enteric duplication cyst • Enteric cyst • Histologic differentiation • Identical imaging Summary: Mesenteric Cyst • Mesothelial cyst • Nonspecific imaging appearance Summary: Mesenteric Cyst • Nonpancreatic pseudocyst • No histologic lining • Old trauma/abscess • Imaging ➢ Thick wall ➢ Internal debris Summary: Mesothelioma • Diffuse malignant mesothelioma ➢ Asbestos ➢ Nodules. masses ➢ Bowel encasement ➢ Bowel fixation • Cystic malignant mesothelioma ➢ Variant of DMM ➢ Cystic masses ➢ Ascites Summary: Benign Multicystic Mesothelioma • Controversial ➢ AKA peritoneal inclusion cyst ➢ Unrelated to DMM ➢ Unrelated to asbestos ➢ Pelvic peritoneum ➢ Multicystic mass Summary: Benign Fibrous Lesions • Mesenteric fibromatosis • Sclerosing mesenteritis • Inflammatory myofibroblastic pseudotumor • Solitary fibrous tumor of peritoneum Summary: Mesenteric Fibromatosis • Benign ➢ Locally aggressive ➢ Association with FAP • Imaging ➢ Homogeneous ➢ Heterogeneous • Myxoid stroma ➢ Low CT attenuation ➢ High T2 signal ➢ “whorled” pattern Summary: Sclerosing Mesenteritis • Idiopathic inflammation • Imaging ➢ Mixed attenuation ➢ Bowel retraction ➢ May calcify • Conservative treatment Mesenteric Masses and Cysts 380 Gastrointestinal Radiology .

AJR Am J Roentgenol 2000. Sobin LH. 174(1):259-260. Torrubia S. Radiology 1987. 142(6):1141-1145. Fat-ring sign in sclerosing mesenteritis. 2001 2. DC: Armed Forces Institute of Pathology. third series. 172(3):625-629. Feinstein R. Ros PR. 182: 1485-1491 3. Emory TS. Fishman EK. Washington. Valls C. 21(4):392-398. Burke AP. Tumors of the soft tissues: atlas of tumor pathology. fascicle 30.164:327-332 Mesenteric Fibromatosis 1. Jr. AJR Am J Roentgenol 1984. Sibley RK.Summary: Inflammatory Pseudotumor • Inflammatory/fibrotic infiltrate • Nonspecific imaging Summary: Extrapleural Solitary Fibrous Tumor • Few case reports References Lymphangioma 1. Am J Surg Pathol 1990. 2. Hendrickson MR. Evans HL. Magid D. Monihan JM. Mehrotra AK. 14(4):335-341. Benign Fibrous Tumors and Tumor-like Lesions of the Mesentery: Radiologic Pathologic Correlation. Sabate JM. AJR 2004. 26: 245. Cantisani V. Helwig EB. Miettinen M. Levy AD. Carr NJ. Monill JM. Sclerosing Mesenteritis 1. RadioGraphics 2006. Perez C. Mesenteric and omental cysts: histologic classification with imaging correlation.. Siegelman SS. Sobin LH. mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol 1997. Kempson RL. Moser RP.264 3. Olmsted WW. AJR Am J Roentgenol 1999. Federspiel BH. Fletcher CDM. Shekitka KM. Franquet T. Sobin LH. Hjermstad BH. A pathologic analysis of 130 tumors with comparison of clinical subgroups. Maideu J. 2. Desmoid tumors in Gardner syndrome: use of computed tomography. Jones B. 3. Hoover HC. Intra-abdominal fibromatosis. Gastrointestinal Radiology 381 Mesenteric Masses and Cysts . Abdominal Lymphangiomas: Imaging Features with Pathologic Correlation. Dachman AH. Rimola J. Levy AD. Sclerosing mesenteritis. Sclerosing mesenteritis: imaging findings in 17 patients. Sobin LH.

USA Idiopathic Inflammatory Bowel Disease: Objectives • Ulcerative colitis (UC) • Crohn disease Idiopathic Inflammatory Bowel Disease: General Features • Etiology unknown ➢ ? Genetic basis ➢ ? Immune related ➢ ? Infectious agent • Incidence of IBD ➢ UC is more common than Crohn IBD: Epidemiologic Comparison • Ulcerative colitis • Crohn disease ➢ 35-100 cases/100.000 ➢ 10-70 cases/100. 2 to 5 times risk ➢ Jewish (8 fold increase) ➢ Jewish. fulminating in 15% ➢ Vomiting ➢ Perianal disease ➢ Alternating attacks and remissions IBD: Comparison of Disease Distribution • Ulcerative colitis • Crohn disease ➢ Colon to anus.000 ➢ Age range. Levy. COL. low grade illness in prandial. MC. colicky most ➢ Abdominal mass ➢ Acute. 50 to 80 years second peak. 12 to 15 times ➢ Family history. 2 to 4 times risk ➢ Family history. 30 to 100 risk times risk IBD: Comparison of Clinical Features • Ulcerative colitis • Crohn disease ➢ Diarrhea ➢ Diarrhea ➢ Obstruction rare ➢ Obstruction common ➢ Rectal bleeding usually ➢ Rectal bleeding. 50-80 years ➢ Urban dwellers ➢ Urban dwellers ➢ Developed countries ➢ Whites ➢ Whites. 15-25 years.Idiopathic Inflammatory Bowel Disease Angela D. less ➢ Abdominal pain. common predefecatory urgency ➢ Abdominal pain. post ➢ Chronic. 15-25 years. second peak. ➢ Age range. skip lesions ➢ Ulcerative proctitis that may ➢ May extend beyond bowel extend proximally Idiopathic Inflammatory Bowel Disease 382 Gastrointestinal Radiology . mouth to anus ➢ Continuous disease or ➢ Asymmetric. rarely TI ➢ Entire GI tract.

granulomas Figure 2-13-1 IBD: Histologic Features • Ulcerative colitis • Crohn disease ➢ Crypt destruction ➢ Aphthous ulcer ➢ Crypt abscess ➢ Lymphoid aggregates ➢ Hemorrhage IBD: Histologic Features • Ulcerative colitis • Crohn disease ➢ Atrophic. serpiginous ulcers ➢ Inflammatory infiltrate ➢ Wide-based ulcers ➢ Pseudopolyps ➢ Cobblestones ➢ Fissures. Crohn disease has marked mural thickening. fistulas. ➢ Ulcers. fissures. distorted ➢ Fissures mucosa ➢ Transmural lymphocytes ➢ Thick muscularis mucosa ➢ Fat within submucosa Gross pathologic specimens show ulcerative colitis with a hemorrhagic ulcerated mucosa and mural thinning. lymphoplasmacytic transmural lymphoid lamina propria infiltrate aggregates.IBD: Pathologic Features • Ulcerative colitis • Crohn disease ➢ Mucosal and submucosal ➢ Transmural inflammation inflammation ➢ Marked mural edema ➢ Minimal mural edema IBD: Gross Pathologic Features [Figure 2-13-1] • Ulcerative colitis • Crohn disease ➢ Fine ulceration ➢ Linear ulcers ➢ Granular mucosa ➢ Cobblestones ➢ Hyperemic ➢ Marked mural thickening IBD: Gross Pathologic Features • Ulcerative colitis • Crohn disease ➢ Shallow ulcers. mucosal cobblestones. abscesses ➢ Strictures ➢ Pseudopolyps IBD: Histologic Features of Active Disease • Ulcerative colitis • Crohn disease ➢ Crypt abscesses. and proliferation of adjacent mesenteric fat Gastrointestinal Radiology 383 Idiopathic Inflammatory Bowel Disease . granularity ➢ Linear ulceration ➢ Loss of haustra ➢ Nodules IBD: Histologic Features • Ulcerative colitis • Crohn disease ➢ Diffuse mucosal ulceration ➢ Aphthous ulcer ➢ Crypt abscesses ➢ Linear.

circumferential disease Ulcerative Colitis: Imaging Features Chronic Changes • Haustra loss • Luminal narrowing • Loss of rectal valves • Widened presacral space • Backwash ileitis • Post-inflammatory pseudopolyps Ulcerative Colitis: Role of CT • Early.Ulcerative Colitis: Imaging Features Figure 2-13-2 Acute Changes [Figure 2-13-2] • Mucosal granularity • Mucosal stippling • Collar button ulcers • Haustral thickening or loss • Inflammatory polyps • Confluent. acute disease Acute ulcerative colitis with fine ➢ Mural thinning mucosal ulceration producing ➢ Pneumatosis granularity and stippling on barium ➢ Perforation evaluation • Subacute and chronic disease Figure 2-13-4 ➢ Mural thickening ➢ Luminal narrowing ➢ Proliferation of Figure 2-13-3 perirectal fat ➢ Assessment/detection of carcinoma Gore RM et al. Ulcerative Colitis: CT Features [Figures 2-13-3 and 2-13-4] • Severe. and an hyperemia on CT increase in the perirectal fat Idiopathic Inflammatory Bowel Disease 384 Gastrointestinal Radiology . contiguous. submucosal mural thickening and pericolonic fat in the rectum. acute disease ➢ Low diagnostic sensitivity ➢ Often normal • Complementary to endoscopy to assess for complications ➢ Toxic megacolon ➢ Pneumatosis ➢ Perforation Gore RM et al. Chronic ulcerative colitis with mural stratification Acute ulcerative colitis with mild (target sign). AJR 1996: 167:3-15. AJR 1996: 167:3-15.

6 to 15 cm ➢ Transverse colon most often involved ➢ Nodular mucosa ➢ Loss of haustra ➢ Intraluminal fluid Toxic Megacolon [Figure 2-13-5] • Ulcerative colitis ➢ Colonic distension ➢ Pseudopolyps Ulcerative Colitis Differential CT Features • CT features suggesting UC over Crohn disease ➢ Mural stratification. hypotension Figure 2-13-5 • Incidence ➢ 5% to 10% of UC ➢ 2% to 4% Crohn disease ➢ May be initial manifestation of IBD • Other causes ➢ Pseudomembranous colitis ➢ Ischemia ➢ Infection • Pathology ➢ Transmural inflammation ➢ Loss of normal tissue cohesion ➢ Thinned wall and areas of denuded mucosa • Imaging ➢ Abdominal radiograph establishes diagnosis ➢ Marked colonic dilatation. smooth in UC and irregular in Crohn Gore RM et al. tachycardia.Ulcerative Colitis • Mural stratification and luminal narrowing in chronic UC ➢ Thickening of muscularis mucosa ➢ Edema and fat in submucosa Ulcerative Colitis: Perirectal Fat Proliferation Toxic Megacolon and IBD • Clinical features ➢ Fever. 8% Crohn ➢ Mural thickness less in UC compared to Crohn ➢ Outer colonic contour. 61% UC vs. AJR 1996: 167:3-15 Crohn Disease Early Imaging Features • Distribution ➢ Asymmetric ➢ Segmental ➢ Skip lesions • Lymphoid hyperplasia Ulcerative colitis with toxic • Ulceration megacolon ➢ Aphthous ulcerations ➢ Linear ulcers ➢ Deep ulcerations (fissuring) • Cobblestoning • Mural thickening • Inflammatory pseudopolyps Gastrointestinal Radiology 385 Idiopathic Inflammatory Bowel Disease .

Crohn Disease: Aphthous Ulcers [Figure 2-13-6] Figure 2-13-6 Crohn Disease: Linear Ulceration and Nodules Crohn Disease • Rose thorn ulcers Crohn Disease: Cobblestoning [Figure 2-13-7] Crohn Disease [Figure 2-13-8] Figure 2-13-7 Crohn disease with aphthous ulcers Figure 2-13-8 Crohn disease with cobblestoning Crohn disease with terminal ileal nodularity and ulceration Idiopathic Inflammatory Bowel Disease 386 Gastrointestinal Radiology .

fibrofatty ➢ Nonenhancing = irreversible fibrosis proliferation of the small bowel • Loss of mural stratification mesentery. nonenhancing = fibrosis or stricture ➢ Enhancing wall = reversible inflammatory disease • Mesenteric changes ➢ Fibrofatty proliferation ➢ Lymphadenopathy ➢ Hypervascularity ➢ Inflammatory stranding ➢ Phelgmon/abscess Crohn Disease Crohn disease with distal ileal • Homogeneous mural thickening inflammation (target sign).Crohn Disease: Acute/Early CT Features Figure 2-13-9 • Mural thickening ➢ 1 to 2 cm • Mural stratification ➢ Mural enhancement ➢ Target or double halo sign Crohn Disease • Mesenteric hyperemia • Target sign ➢ Acute inflammation Crohn Disease • Linear ulceration • Mural thickening • Inflammatory polyps Crohn Disease: Subacute to Chronic CT Features • Mural thickening ➢ Homogeneous. dilated vasa recta ➢ “comb sign” Figure 2-13-10 Crohn disease with prominent and engorged vasa recta (comb sign) Gastrointestinal Radiology 387 Idiopathic Inflammatory Bowel Disease . and mesenteric lymphadenopathy Crohn Disease Crohn Disease [Figure 2-13-9] • Fibrofatty proliferation ➢ “creeping fat” • Mesenteric lymphadenopathy. 3 to 8 mm Crohn Disease [Figure 2-13-10] • Prominent.

Crohn Disease: Chronic Features • Fissures. fistulas. and sinus tracts • Haustral loss • Strictures • Sacculations • Post-inflammatory pseudopolyps Figure 2-13-11 Crohn Disease: Strictures Sacculations and Strictures [Figure 2-13-11] Crohn Disease: Stricture Crohn Disease • Complications ➢ Sinus tracts ➢ Fistula ➢ Abscess ➢ Carcinoma Crohn Disease Intramural Fistula Crohn Disease Fistulae [Figure 2-13-12] Chronic Crohn disease with structuring and sacculations Crohn Disease: Abscess [Figure 2-13-13] • Secondary to deep penetrating ulcers Figure 2-13-12 ➢ Sinus tracts ➢ Fistulas ➢ Perforation • 15% to 20% of patients • Most frequently associated with small bowel or ileocolic disease Crohn Disease: Perirectal Sinus Tract Figure 2-13-13 Crohn disease with a ileal-ileal fistula Crohn disease with a psoas abscess Idiopathic Inflammatory Bowel Disease 388 Gastrointestinal Radiology .

30% to 50% ➢ PSC. Gastrointestinal Radiology 389 Idiopathic Inflammatory Bowel Disease . In: Gore RM. RadioGraphics 1996. 2% to 10% Neoplasia in IBD • Adenocarcinoma ➢ Ulcerative colitis. Laufer I. MR imaging evaluation of the activity of crohn’s disease. Sarrazin J. Wilson SR. Textbook of Gastrointestinal Radiology. 2nd ed. Ulcerative and granulomatous colitis: idiopathic inflammatory bowel disease. Manifestations of crohn disease at US. Berlin. JW. 16: 499-520. highest incidence ➢ Crohn disease. AJR 2001: 177(6) 1325-1332. 20% to 50% ➢ Cholelithiasis. 1% to 4% ➢ Hepatic abscess • Pancreatic ➢ Pancreatitis • Musculoskeletal ➢ Arthritis ➢ Sacroileitis-spondylitis • GU tract ➢ Nephrolithiasis. Levine MS (eds). Additional Imaging Modalities: MR Enterography of Crohn Disease • Evolving technique • Assessment of active disease ➢ Mural thickening > 4mm ➢ Mural enhancement ➢ Increase in mesenteric vascularity Koh DM et al. small and large intestine • Lymphoma ➢ Increased incidence in Crohn disease • Features of carcinoma in IBD ➢ Typically do not arise in pre-existing adenomas ➢ Arise in flat mucosa ➢ Carcinomas may be long and flat ➢ May arise in bypassed segments of bowel Adenocarcinoma in Ulcerative Colitis Adenocarcinoma in Crohn Disease Additional Imaging Modalities: Sonography UC vs. Crohn Disease • Ulcerative colitis • Crohn disease ➢ Hypoechoic wall ➢ Hypoechoic wall ➢ Mural stratification ➢ Loss of mural stratification ➢ Loss of haustra ➢ Loss of haustration ➢ Loss of peristalsis ➢ Diminished compressibility ➢ Absent peristalsis ➢ Increased blood flow Gore RM.Crohn Disease: Extraintestinal Complications • Hepatobiliary ➢ Hepatic steatosis.

Establishing Diagnosis: UC vs. transmural disease with extension into the mesentery Idiopathic Inflammatory Bowel Disease 390 Gastrointestinal Radiology . Crohn • Clinical course • Disease distribution • Endoscopy findings • Biopsy UC vs. perirectal fat may increase in UC • Sinus tracts. mucosal and submucosal disease ➢ Crohn. abscess ➢ Crohn disease Differential Diagnosis of IBD • Infectious colitis • Ischemic colitis • Radiation enteropathy and colitis • Behçet disease • Graft vs. Crohn ➢ Similar demographics ➢ UC. entire GI tract with skip areas ➢ UC. contiguous colonic disease ➢ Crohn. host disease • Diverticular disease Summary • UC vs. fistulas. Crohn Disease: CT Features • Mural thickening ➢ Greatest with Crohn disease • Submucosal fat ➢ More commonly seen in UC • Mesenteric fibrofatty proliferation ➢ Crohn disease ➢ But.

host disease (GVDH) ➢ Radiation Gastrointestinal Radiology 391 Inflammatory Disease of the Colon . USA Objectives • General approach • Differential diagnosis of idiopathic IBD ➢ Pseudomembranous colitis ➢ Neutropenic colitis (typhlitis) ➢ Ischemic colitis ➢ Diverticulitis ➢ Infectious colitis General Approach • Disease location ➢ Small vs. campylobacter. focal vs.Approach to Inflammatory Disease of the Colon Angela D. large bowel ➢ Focal vs. MC. COL. amebiasis ➢ TB ➢ CMV ➢ Amebiasis ➢ Inflammatory bowel ➢ Histoplasmosis disease ➢ Behçet syndrome ➢ Graft vs. Levy. multifocal • Degree of mural thickening ➢ Marked mural thickening favors PMC • Clinical history ➢ Antibiotics (PMC) ➢ Radiation therapy ➢ Neutropenia ➢ Travel history Colitis Differential Diagnosis • Right-sided disease • Diffuse disease ➢ Campylobacter ➢ Ischemia ➢ Yersinia ➢ PMC ➢ Salmonella ➢ E. diffuse ➢ Ascites • Degree and pattern of mural thickening ➢ How much mural thickening? ➢ Mural enhancement? ➢ Fat attenuation in the submucosa? • Associated mesenteric disease ➢ Inflammation ➢ Phelgmon/abscess ➢ Mesenteric fat proliferation • Clinical history Helpful Features for Differential Diagnosis • Location of disease ➢ Small bowel involvement ➢ Diffuse vs. Coli ➢ Typhlitis ➢ Shigella. ➢ Crohn disease salmonella. multifocal vs.

pain. diarrhea. ischemia 65-year-old woman abdominal pain during chemotherapy for leukemia [Figure 2-14-3] Neutropenic Colitis (Typhlitis) • Suggestive features ➢ Clinical history ➢ Right-sided involvement • Clinical features ➢ Children and adults ➢ Neutrophil counts <500 to 1000 cells/mm3 ➢ Fever.41-year-old man who developed diarrhea one month after Figure 2-14-1 hospitalization for pneumonia [Figure 2-14-1] Pseudomembranous Colitis • Features suggesting PMC ➢ Diffuse colonic involvement ➢ Marked low attenuation mural thickening ➢ Accordion sign ➢ Ascites Pseudomembranous Colitis • Onset following antibiotic therapy ➢ Clostridium difficile toxin • Clinical features ➢ Symptoms within days or weeks following antibiotic therapy ➢ Copious watery diarrhea ➢ Abdominal pain ➢ Fever ➢ Leukocytosis Pseudomembranous Colitis • Epithelial necrosis Pseudomembranous colitis • Inflammatory infiltrate • Crypt eruption • Pseudomembranes Figure 2-14-2 Pseudomembranous Colitis: CT Features • Mural thickening ➢ Low attenuation ➢ Accordion sign ➢ Target sign • Intraluminal plaques or nodules • Pericolonic inflammation • Ascites • Complications ➢ Luminal dilatation. infectious. toxic megacolon ➢ Perforation Pseudomembranous Colitis: Thumbprinting = Mural Thickening Pseudomembranous Colitis: Low Attenuation Wall with Accordion Sign Pseudomembranous Colitis: Target Sign [Figure 2-14-2] Pseudomembranous colitis • PMC typically has the greatest amount of mural thickening of the compared to other colitis • Presence of ascites favors acute colitis over IBD ➢ PMC. abdominal distension Inflammatory Disease of the Colon 392 Gastrointestinal Radiology .

Imaging Features • Mucosal ulceration • Mural thickening ➢ Low attenuation ➢ Target sign • Luminal dilatation • Pericolonic inflammation • Ascites • Chronic changes ➢ Fibrosis. especially CMV • Ischemic Injury ➢ Acute. Hemorrhage Ischemic Colitis. fulminant ✧ Transmural necrosis and perforation ➢ Transient.• Pathogenesis Figure 2-14-3 ➢ Cecal stasis ➢ Cytotoxic mucosal injury ➢ Bacterial invasion • CT features ➢ Predominant right-sided disease ➢ Mural thickening.Acute [Figure 2-14-4 and 2-14-5] Figure 2-14-5 Ischemic colitis Ischemic colitis Gastrointestinal Radiology 393 Inflammatory Disease of the Colon . reversible ✧ Confined to mucosa and submucosa ➢ Chronic ✧ Submucosal fibrosis • Locations ➢ Diffuse ➢ SMA and IMA watershed vunerable Neutropenic colitis ✧ Normal communication through Arc of Riolan (marginal artery of Drummond) ✧ Absent in 5% Figure 2-14-4 ✧ Splenic flexure and rectosigmoid Ischemic Colitis • Denuded mucosa • Pseudomembranes. hypertension ➢ Low flow states ➢ Occlusive disease ➢ Complicates infectious colitis. diabetes. stricture Ischemic Colitis. low attenuation ➢ Pericolonic inflammation ➢ Ascites ➢ Pneumatosis 70-year-old man with acute abdominal pain and bloody diarrhea [Figure 2-14-4] Ischemic Colitis • Most common in elderly ➢ Underlying atherosclerosis.

intramural fistula • Mucosal ulceration. infiltrated mesentery ➢ Infiltrated mesentery [Figure 2-14-7] • Mucosal cast. Ischemic enteritis Ischemic Colitis or Enteritis [Figure 2-14-8] • Chronic Chronic ischemic colitis in the Imaging Findings Suggestive of Ischemia watershed region of the colon • Ileus ➢ Dilated bowel ➢ Gasless abdomen ➢ Unchanging bowel • Mural thickening ➢ Stack of coins ➢ Target sign • Mucosal ulceration ➢ Ulceration ➢ Intramural fistulas ➢ Loss of folds • Mucosal breakdown ➢ Intraluminal mucosal cast ➢ Pneumatosis ➢ Mesenteric or portal venous gas ➢ Intraperitoneal air Inflammatory Disease of the Colon 394 Gastrointestinal Radiology .Pathophysiology Figure 2-14-6 • Blood supply reduced by >50% ➢ Arterial occlusive ➢ Venous occlusive ➢ Nonocclusive (low flow states) Ischemic Enteritis • Segmental • Diffuse • Segmental. mesenteric venous gas Figure 2-14-7 Ischemic enteritis due to SMV thrombosis Figure 2-14-8 . ulcerated mucosa • Mural thickening ➢ Stack of coins • Thick wall. engorged mesentery ➢ Target sign [Figure 2-14-6] • Thin wall.Ischemic Enteritis . necrotic. pneumatosis • Pneumatosis.

Hepatic Flexure Diverticular Disease • Most common disease of the colon • Diverticulosis increases with age ➢ 33% to 50% of people over 50 ➢ 50% of people over 80 Acute diverticulitis Diverticular Disease Etiology of Pulsion Diverticula • Pressure gradient ➢ Between lumen and serosa ➢ Compartmentalized by haustra ➢ Highest in sigmoid • Weakness in bowel wall ➢ Intramural vasa recta penetrate wall ➢ Between taenia mesocolica and taenia libera ➢ Between taenia mesocolica and taenia omentalis Diverticular Disease .50-year-old woman with abdominal pain and fever [Figure 2-14-9] Figure 2-14-9 • Diverticulitis .5 to 1.Pathologic Features • False diverticula ➢ Mucosa and submucosa only ➢ 0.0 cm • Myochosis ➢ Thickening of circular muscle ➢ Shortening of taenia ➢ Narrowing of the lumen ➢ Results in corrugated appearance Diverticular Disease: CT Features • Mural thickening • Diverticular outpouchings Diverticular Disease: Complications • Diverticulitis • Hemorrhage • Giant sigmoid diverticulum Diverticulitis • Most common complication ➢ 10% to 20% of patients with diverticulosis • Pathogenesis ➢ Stagnation of fecal material ➢ Inflammatory erosion of the mucosa ➢ Perforation ✧ Intramural abscess ✧ Extramural abscess Diverticular Disease: Complications • Diverticulitis ➢ Luminal obstruction ➢ Infection Gastrointestinal Radiology 395 Inflammatory Disease of the Colon .

Diverticulitis: CT Features Figure 2-14-10 • Diverticula ➢ May have hyperdense fecal material • Inflammatory changes ➢ Pericolonic stranding ➢ Pericolonic phlegmon ➢ Intramural abscess ➢ Pericolonic abscess • Circumferential mural thickening ➢ Usually < 1 cm ➢ Rarely exceeds 2-3 cm • Tethered lumen ➢ Saw-tooth configuration ➢ Due to muscular spasm • Pneumoperitoneum. abscess Diverticulitis: Hyperdense Fecal Material Diverticulitis: Intramural Fistula . Carcinoma • Wall thickening ➢ Mild circumferential thickening in diverticulitis (4 to 5 mm) ➢ Carcinoma usually > 2 cm • Zone of transition ➢ Abrupt change in lumen caliber favors carcinoma ➢ Lobulated soft-tissue favors carcinoma ➢ Tethered (saw-tooth) lumen favors diverticulitis • Inflammatory changes ➢ Favors diverticulitis • Regional adenopathy ➢ Favors carcinoma Inflammatory Disease of the Colon 396 Gastrointestinal Radiology .Pneumatosis [Figure 2-14-10] Diverticulitis: Complications • Hemorrhage 25% • Muscular hypertrophy and obstruction 25% • Pericolic abscess 20% • Free perforation 18% Acute diverticulitis with intramural ➢ Debilitated patients fistula and pneumatosis ➢ Corticosteroid therapy • Vesicocolic fistula 8% • Small bowel obstruction • Pyelophlebitis and liver abscess Diverticulitis: Perforation Diverticulitis: Pericolic Abscess Diverticulitis: Colovesical Fistula Differential Diagnosis • Colon carcinoma • Colitis ➢ Infectious ➢ Ischemic ➢ Crohn disease • Foreign body perforation • Epiploic appendagitis Diverticulitis vs.

Carcinoma Figure 2-14-11 Diverticulitis: CT Pitfalls • Differential diagnosis of colon cancer ➢ Problematic in 10% of cases ➢ If immediate surgery not performed: mucosal evaluation (endoscopy or BE) to exclude cancer Diverticulitis: CT and Surgical Management • Antibiotic therapy ➢ Mild Diverticulitis • CT guided drainage ➢ Focal abscess • Immediate Surgery ➢ Free perforation with peritonitis ➢ Severe hemorrhage • Elective surgical resection ➢ Following successful abscess drainage ➢ Recurrent diverticulitis ➢ Persistent pain ➢ Bleeding Diverticular Hemorrhage • Most common cause of adult rectal bleeding • Site of hemorrhage ➢ Single diverticulum Giant sigmoid diverticulum ➢ Right side of colon in 2/3 of cases • Rupture of the vasa recta Diverticular Hemorrhage • Clinical features ➢ Elderly patients ➢ Sudden onset ➢ Stops spontaneously in 80% ➢ Rebleeding in 25% Cecal Diverticulitis • Congenital or acquired diverticula ➢ Congenital are true diverticula ➢ Acquired are most common • CT features ➢ Pericolonic inflammation ➢ Mural thickening ➢ Demonstration of diverticula ➢ Intramural or pericolonic abscess ➢ Normal appendix Giant Sigmoid Diverticulum [Figure 2-14-11] • Rare • Etiology ➢ Subserosal perforation and inflammation ➢ Air trapping ➢ Ball-valve mechanism • Clinical Features ➢ Chronic pain ➢ Palpable mass Gastrointestinal Radiology 397 Inflammatory Disease of the Colon .Diverticulitis vs.

Giant Sigmoid Diverticulum Figure 2-14-12 • CT features ➢ Mesenteric side of sigmoid colon ➢ Usually 7 cm or greater ➢ Thin wall ➢ Unilocular 30-year-old man with diarrhea and pain following vacation in Mexico [Figure 2-14-12] Campylobacter Colitis ➢ Infectious colitis ✧ Distribution ✧ Clinical Summary • General approach ➢ Location of disease ➢ Degree of mural thickening ➢ Ascites ➢ Mesenteric disease ➢ Clinical history Summary .Ischemic Colitis • Elderly patients ➢ Diffuse ➢ Watershed regions • Acute ➢ Mucosal ulceration ➢ Mural thickening • Chronic ➢ Mural thickening ➢ Stenosis Summary .Neutropenic Colitis/Typhlitis • Chemotherapy ➢ Low neutrophil counts • Bacterial invasion • Predominant right-sided disease ➢ Mural thickening ➢ Pneumatosis ➢ Ascites Summary .Pseudomembranous Colitis • History of antibiotics ➢ Clostridium difficile • Mural thickening • Accordion sign • Pericolonic inflammation Campylobacter colitis • Ascites Summary .Diverticulitis • Focal disease • Diverticula ➢ Air filled ➢ Hyperdense • Adjacent inflammation Inflammatory Disease of the Colon 398 Gastrointestinal Radiology .

salmonella ➢ TB ➢ Amebiasis • Diffuse colitis ➢ PMC ➢ E. yersinia. Carcinoma • Favor Diverticulitis ➢ Lesser mural thickening ➢ Gradual zone of transition ➢ Tethered lumen ➢ Pericolonic inflammation • Favor carcinoma ➢ Greater mural thickening ➢ Lobular mural thickening ➢ Sharp zone of transition ➢ Pericolonic adenopathy Summary • Infectious colitis ➢ Clinical history • Right-sided colitis ➢ Campylobacter.Diverticulitis vs.Summary . salmonella ➢ Amebiasis ➢ CMV Gastrointestinal Radiology 399 Inflammatory Disease of the Colon . Coli ➢ Shigella. campylobacter.

Levy. USA Case 1: 45 year old man with chronic pancreatitis and acute onset of lower abdominal pain. COL. MC. distension. and constipation Cecal volvulus Marked Cecal Dilatation • Differential diagnosis ➢ Cecal volvulus ➢ Cecal bascule ➢ Pseudoobstruction (Ogilvie syndrome) Cecal Volvulus • Volvulus is an axial twist of at least 90 degrees ➢ Abnormal fixation to posterior parietal peritoneum ➢ Freely mobile cecum • Mechanical obstruction • Radiographic features ➢ Cecal dilatation ➢ Beak on contrast enema ➢ Whirl on CT Cecal volvulus Seminar 1: Abdominal Gas 400 Gastrointestinal Radiology .Gastrointestinal Seminar 1: Abdominal Gas Angela D.

Cecal Bascule • Anterior-cephalad fold ➢ May cause obstruction • Volvulus:Bascule = 10:1 Ogilvie Syndrome • Colonic pseudo-obstruction • Marked cecal dilatation Sigmoid Volvulus Transverse Colon Volvulus Cecal bascule Sigmoid volvulus Gastrointestinal Radiology 401 Seminar 1: Abdominal Gas .

fever. and shock Intestinal ischemia with infarction and hepatic portal venous gas Intestinal Ischemia with Infarction and Hepatic Portal Venous Gas Hepatic Portal Venous Gas • Branching radiolucencies extending to within two cm of the hepatic capsule • Must differentiate from pneumobilia • Differential Diagnosis: ➢ Bowel Necrosis (75%) ➢ IBD (10%) ➢ Abscess ➢ Obstruction ➢ Ulcer Pneumobilia Pneumobilia Portal venous gas Intestinal Infarction with Portal Venous Gas Portal venous gas Seminar 1: Abdominal Gas 402 Gastrointestinal Radiology .Case 2: 85 year old woman with abdominal pain.

atelectasis ➢ Left effusion Causes of Esophageal Rupture • Spontaneous ➢ Boerhaave ➢ Mallory-Weiss • Iatrogenic ➢ Endoscopic ➢ Dilation ➢ Tube placement • Other ➢ Caustic Ingestion ➢ Trauma ➢ Inflammatory ➢ Neoplastic Boerhaave syndrome Gastrointestinal Radiology 403 Seminar 1: Abdominal Gas .Case 3: 60 year old man with progressive dyspepsia and acute. vessels • Radiographic features ➢ Mediastinal gas ➢ LLL infiltrate.4 cm tear ➢ Reduced muscle fibers ➢ Entrance of nerves. Hermann Boerhaave • Emetogenic rupture ➢ Distal esophagus or ➢ Gastric cardia • Left posterolateral region ➢ 1. severe upper abdominal pain Pneumoperitoneum Gastric Ulcer Perforation Pneumoperitoneum Signs on the Supine Abdominal Film • Diaphragmatic Slips (Leaping Dolphins) • Central Diaphragm (Cupola) • Morison’s Pouch (Doge’s Cap) • Lesser Sac • Falciform Ligament • Fissure of Ligamentum Teres “Leaping Dolphin” Cupola Sign “Doge’s Cap” Pneumoperitoneum from gastric ulcer perforation Case 4: 67 year old man with severe chest pain after vomiting Boerhaave’s Syndrome • Dr.5 .

Case 5: 50 year old man with upper abdominal pain. and constipation Cecal Herniation through the Foramen of Winslow Foramen of Winslow Foramen Of Winslow Hernia • 8% of internal hernias • Involved bowel ➢ Small intestine 70% ➢ Cecum 25% • Cecal herniation ➢ Persistence of ascending mesocolon ➢ Mobility ➢ Alterations in intraabdominal pressure • Radiographic features Cecal herniation through the foramen of Winslow ➢ Circumscribed gas collection LUQ ➢ Medial and posterior to stomach ➢ Stomach displaced left and anterior ➢ Small bowel obstruction • Differential diagnosis ➢ Gas in lesser sac from abscess or perforation Cecal herniation through the foramen of Winslow Seminar 1: Abdominal Gas 404 Gastrointestinal Radiology . epigastric fullness.

MC. COL.Gastrointestinal Seminar 2: Nonneoplastic Disease of the Stomach Angela D. Levy. The ER physician cannot pass a NG tube into her stomach Gastric Volvulus Mesenteroaxial volvulus • Abnormal rotation of the stomach ➢ Rare ➢ Children and adults ➢ Most are secondary to fixation defect • Associated anomalies ➢ Diaphragmatic defects ➢ Malrotation ➢ Wandering spleen ➢ Asplenia Gastric Volvulus • Classic Clinical presentation ➢ Severe epigastric pain ➢ Violent retching with production of little vomitus ➢ Inability to pass NG tube into stomach • Outcomes ➢ Recurrent ➢ Resolve spontaneously ➢ Resolve with NG placement ➢ Complete obstruction Gastrointestinal Radiology 405 Seminar 2: Nonneoplastic Disease of the Stomach . USA Case 1: 65-year-old woman presents with retching and the production of little vomitus.

• Organoaxial ➢ Rotation about a line extending from cardia to pylorus • Mesenteroaxial ➢ Rotation about a line connecting middle of lesser curvature to middle of greater curvature • Mixed types occur • 30% associated with hiatal hernia Gastric Volvulus .Radiologic Features • Double air-fluid level • Inversion of stomach ➢ Greater curve above lesser curve • Positioning of cardia and pylorus at the same level • Downward pointing pylorus and duodenum Organoaxial Volvulus Mechanism for organoaxial volvulus Mesenteroaxial Volvulus Mechanism for mesenteroaxial volvulus Seminar 2: Nonneoplastic Disease of the Stomach 406 Gastrointestinal Radiology .

Case 2: 22-year-old woman developed epigastric pain when she was dieting in preparation for her wedding Gastric Bezoar • Accumulated ingested material • Trichobezoar ➢ Hair • Phytobezoar ➢ Vegetable matter • Pathophysiology ➢ Altered gastric motility ➢ Altered gastric anatomy Gastric Bezoar ➢ Trichotillomania Gastrointestinal Radiology 407 Seminar 2: Nonneoplastic Disease of the Stomach .

1989 Differential Diagnosis: Thick Gastric Folds • Hypertrophic Gastropathy ➢ Menetrier disease ➢ Zollinger-Ellison syndrome • Gastritis • Neoplasm ➢ Adenocarcinoma ➢ Lymphoma ➢ Metastasis • Miscellaneous ➢ Amyloid ➢ Eosinophilic gastritis ➢ Adjacent inflammation Seminar 2: Nonneoplastic Disease of the Stomach 408 Gastrointestinal Radiology . peak 3rd to 5th decade syndrome • Gastrin-secreting neuroendocrine tumor (gastrinoma) ➢ Pancreas (75%) ➢ Duodenum (15%) ➢ Liver. Gastrointestinal Radiology 14:109- 112. Mirowitz SA. enhancing pancreatic mass • Positive pentetreotide scan Zollinger-Ellison Syndrome: Pancreatic Pancreatic Gastrinoma gastrinoma producing Zollinger-Ellison Syndrome Zollinger Ellison • Affects all ages. Susman N. ovary. lymph nodes ➢ 60% malignant • Clinical Features ➢ One or more benign peptic ulcers ➢ Diarrhea from hypergastrinemia (30%) ➢ Elevated gastrin levels • May occur in MEN I syndrome Zollinger-Ellison Syndrome • Radiologic features ➢ Multiple ulcers ➢ Increased gastric secretions ➢ Thick gastric folds • Preoperative localization of gastrinoma ➢ CT ➢ MR ➢ Somatostatin receptor scintigraphy 47-year-old man with recurrent PUD Ectopic Gastrinoma in Retroperitoneal Lymph Node Thick Gastric Wall? Gastric Air-Fluid Sign* *Hammerman AM.Case 3: 8-year-old girl with recurrent emesis and diarrhea Imaging findings • Thick gastric folds • Thick duodenal wall • Liver metastasis • Large.

glandular atrophy. cysts ➢ Enlarged folds (1-3 cm) resembling cerebral convolutions ➢ H. 50 to 70 years • Symptoms ➢ Epigastric pain ➢ Vomiting ➢ Weight loss ➢ Peripheral edema • Hypoalbuminemia and hypochlorhydria • Diffuse enlargement of gastric folds ➢ Proximal stomach • Mucus hypersecretion • Irreversible Menetrier Disease : Pediatric Form • Associated with CMV infection • Allergic or autoimmune reaction • Symptoms ➢ Periorbital and facial edema ➢ Vomiting ➢ Pain • Self-limited • Spontaneous resolution and reversal of protein loss • Antrum more commonly involved Menetrier Disease : Pathology • Pathology ➢ Foveolar hyperplasia. pylori? Menetrier Disease : Radiology • Thick folds ➢ Nonuniform ➢ Tortuous • Spiculation of greater curvature • Antral sparing • Flocculation of contrast Gastrointestinal Radiology 409 Seminar 2: Nonneoplastic Disease of the Stomach .Case 4: 70-year-old man presents epigastric pain and pedal edema Menetrier Disease Menetrier Disease : Adult Form • Most common in men.

RCNA 1987 Gastric Crohn Disease • Ulcers ➢ Aphthous lesions ➢ One or more large ulcers • Nodules ➢ Focal nodules ➢ Cobblestone mucosa • Abnormal gastric motility • Fibrosis ➢ Tubular antrum (ram’s horn sign or shofar sign) ➢ Obliteration of the pylorus (pseudo-Billroth I sign) Seminar 2: Nonneoplastic Disease of the Stomach 410 Gastrointestinal Radiology . Crohn’s disease of the upper gastrointestinal tract. pylori ➢ Radiation ➢ Caustic ingestion • Neoplasm ➢ Adenocarcinoma ➢ Lymphoma ➢ Mets • Granulomatous disease ➢ Crohn ➢ Sarcoid ➢ Amyloid ➢ TB Gastric Crohn Disease • Histologically present in up to 33% of patients with Crohn disease • 20% of patients with ileo-colic disease have abnormal UGI1 • Antrum and duodenum most often affected 1Levine MS.Case 5: UGI images from two different patients that complained of epigastric pain. Both patients had a history of diarrhea Case 5A: Radiologic Findings Case 5A Case 5B • Narrowed antrum • Multiple filling defects • Nodularity • Ulceration? • Effaced/nodular duodenal bulb Case 5B: Radiologic Findings • Multiple ulcers ➢ Aphthous ulcers • Nodularity Crohn disease Case 5 : Differential Diagnosis • Gastritis ➢ H.

MC.Gastrointestinal Seminar 3: Pancreatic Duct Angela D. Levy. USA Normal Pancreatic Embryology 18 days 22 days Normal Anatomy • Minor Papilla ➢ Accessory PD ➢ Duct of Santorini • Major Papilla ➢ Main PD ➢ Duct of Wirsung 5 weeks 5 weeks Normal pancreatic and biliary duct anatomy Anatomic variants of the pancreatic duct Normal pancreatic duct by ERCP and MRCP Gastrointestinal Radiology 411 Seminar 3: Pancreatic duct . COL.

vomiting. and abdominal distension Annular Pancreas • Bilobed ventral pancreatic bud • Buds migrate in opposite directions • Duodenal obstruction Proposed mechanism for annular pancreas Annular pancreas Seminar 3: Pancreatic duct 412 Gastrointestinal Radiology .Case 1: 25-year-old woman with a long history of nausea.

minor papilla • Incidence ➢ 4 to 11% (autopsy) ➢ 3 to 4% (ERCP) • Most asymptomatic • 12-24% develop idiopathic recurrent pancreatitis Choledocholithiasis in a patient with pancreatic divisum by MRCP Gastrointestinal Radiology 413 Seminar 3: Pancreatic duct .Case 2: 17-year-old female with abdominal pain and elevated LFT’s Pancreatic divisum with focal chronic pancreatitis Pancreatic Divisum and Chronic Pancreatitis Pancreatic Divisum • Incomplete fusion of dorsal and ventral pancreas • Body and tail drain through the duct of Santorini.

Case 3: Two Different Patients with the same Disease Chronic Pancreatitis Chronic Pancreatitis: Ductal Features • Ectasia ➢ Loss of normal tapering • Contour irregularity • Side branches ➢ Clubbing ➢ Stenosis ➢ Opacification of cavities • Stenoses or occlusion ➢ “Chain of lakes” • Intraductal calculi Chronic Pancreatitis Chronic pancreatitis by MRCP Seminar 3: Pancreatic duct 414 Gastrointestinal Radiology .

Case 4: 50-year-old man with abdominal pain Intraductal papillary mucinous neoplasm Intraductal Papillary Mucinous Neoplasm IPMN: Imaging • Duct dilatation ➢ Focal or diffuse ➢ Main duct or side branch • Intraductal masses • Bulging duodenal papilla • Glandular atrophy Main Duct IMPN Side Branch IPMN Bulging Papilla Gastrointestinal Radiology 415 Seminar 3: Pancreatic duct .

Case 5: 45-year-old man with chest pain and elevation of serum amylase Mediastinal pseudocyst from acute pancreatitis Mediastinal Pseudocyst Fluid Collections and Pancreatitis • 50% of patients ➢ Rupture of pancreatic duct ➢ Exudation of fluid from gland surface Seminar 3: Pancreatic duct 416 Gastrointestinal Radiology .

MC. Levy. COL.Gastrointestinal Seminar 4: Hepatic Imaging Angela D. USA Case 1: 50-year-old woman with vague abdominal discomfort Differential Diagnosis: Complex Hepatic Cyst • Nonneoplastic ➢ Echinococcal cyst ➢ Simple cyst with hemorrhage/infection Biliary cystadenoma ➢ Post-traumatic cyst ➢ Abscess ➢ Ciliated hepatic foregut cyst • Neoplastic ➢ Biliary cystadenoma ➢ Biliary cystadenocarcinoma ➢ Cystic metastasis ➢ Peliosis ➢ Teratoma Biliary Cystadenoma Simple Cyst Echinococcus granulosus Pyogenic Hepatic Abscess Gastrointestinal Radiology 417 Seminar 4: Hepatic Imaging .

Case 2: 10-year-old girl with right upper quadrant pain Focal nodular hyperplasia Differential Diagnosis: Hepatic Mass with a Scar • Focal nodular hyperplasia • Fibrolamellar carcinoma • Hepatocellular carcinoma • Hepatocellular adenoma • Hemangioma Hepatic Mass with a Scar Focal Nodular Hyperplasia Fibrolamellar Carcinoma Hepatocellular Carcinoma (HCC) Hepatocellular Adenoma (HCA) with Fibrosis Hemangioma Hemangioma: Tagged RBC Scan Seminar 4: Hepatic Imaging 418 Gastrointestinal Radiology .

Case 3: 54-year-old man with right upper quadrant pain and jaundice Intrahepatic cholangiocarcinoma Differential Diagnosis: Rim-like Enhancement • Hemangioma • Metastatic disease • Hepatocellular carcinoma • Intrahepatic cholangiocarcinoma • Angiosarcoma • Epithelioid hemangioendothelioma Intrahepatic Cholangiocarcinoma Hemangioma Epithelioid Hemangioendothelioma Gastrointestinal Radiology 419 Seminar 4: Hepatic Imaging .

Case 4: 50-year-old male with vague abdominal pain Hepatocellular carcinoma Differential Diagnosis: Liver Mass with Fat • Hepatocellular carcinoma • Angiomyolipoma • Myelolipoma • Hepatocellular adenoma • Metastasis ➢ Liposarcoma • VERY RARE. Teratoma Hepatocellular Carcinoma Hepatocellular Adenoma: Focal Fat and Capsule Hepatocellular Adenoma: Diffuse Hypodensity Angiomyolipoma Myelolipoma Hepatic Teratoma Seminar 4: Hepatic Imaging 420 Gastrointestinal Radiology .

Case 5: 26-year-old woman with RUQ pain and mild elevation of serum AST Fibrolamellar carcinoma Differential Diagnosis: Calcified Liver Mass • Nonneoplastic ➢ Hematoma ➢ Simple cyst ➢ Parasitic infection ➢ Healed infection • Benign neoplasm ➢ Hemangioma ➢ Teratoma • Malignant neoplasm ➢ Fibrolamellar carcinoma ➢ Epithelioid hemangioendothelioma ➢ Hepatoblastoma (kids) Fibrolamellar Carcinoma Colon Adenocarcinoma Metastases Echinococcus multilocularis Gastrointestinal Radiology 421 Seminar 4: Hepatic Imaging .

USA Cases 1-5 • All patients have the same disease • The underlying disease is a congenital anomaly • Each presents with a different manifestation Omphalomesenteric (Vitelline) Duct Anomalies Meckel Diverticulum • Most common anomaly of the GI tract • 2% .3% of the population • M=F • Symptoms more common in males • 60% of patients present before age 10 • Omphalomesenteric duct anomaly ➢ Improper closure and absorption Omphalomesenteric (Vitelline) Duct • Embryonic connection between yolk sac and midgut • 10th week of embryogenesis ➢ Midgut returns to abdomen ➢ Duct is a thin fibrous band connecting midgut to umbilicus ➢ Disintegrate ➢ Absorption Umbilico-ileal fistula Umbilical sinus Umbilical cyst Persistent fibrous cord Meckel diverticula Meckel diverticula Meckel diverticula with a fibrous attachment to the supported by a mesentery umbilicus Seminar 5: Meckel Diverticulum 422 Gastrointestinal Radiology .Gastrointestinal Seminar 5: Complications of Meckel Diverticulum Angela D. MC. Levy. COL.

biliary Meckel Diverticulum: Heterotopic Gastric Mucosa Meckel Diverticulum: Heterotopic Pancreatic Mucosa Gastrointestinal Radiology 423 Seminar 5: Meckel Diverticulum .Omphalomesenteric (Vitelline) Duct Anomalies • Umbilico-ileal fistula • Umbilical sinus • Umbilical cyst • Persistent fibrous cord • Meckel diverticulum ➢ With a fibrous cord ➢ With a portion of mesentery Meckel Diverticulum: Pathology • Antimesenteric side of distal ileum ➢ Within 100 cm of ileocecal valve • True diverticulum ➢ Composed of all layers of the small bowel wall • Heterotopic tissue ➢ 50% of resected diverticula ➢ Gastric most common (23% . colonic.50%) ➢ Pancreas (5% to 16%) ➢ Rare. Brunner glands.

specificity 2% in adults Seminar 5: Meckel Diverticulum 424 Gastrointestinal Radiology .Case 1: 22-year-old man with fever and guaiac positive stools Meckel diverticulitis located in the midline because of persistent attachment to the umbilicus Differential Diagnosis • Inflammatory bowel disease • Urachal remnant • Colonic Diverticulitis • Meckel diverticulitis • Idiopathic ileal diverticula Meckel Diverticulitis Case 2: 22-year-old man with chronic abdominal pain and anemia Hemorrhagic Meckel diverticulum Differential Diagnosis • Neoplasm • Ulcer • Vascular ectasia • Meckel diverticulum Hemorrhagic Meckel Diverticulum Angiographic Features of Meckel Diverticulum • Vitellointestinal artery ➢ Arises from a distal ileal branch of the SMA • Tubular shaped angiographic blush • Intraluminal contrast if brisk bleeding Hemorrhage in Meckel Diverticulum • Most frequent complication • Tc99-pertechnetate ➢ Localizes in ectopic gastric mucosa ➢ Modality of choice in pediatric population ➢ Sensitivity 85%. specificity 95% in kids ➢ Sensitivity 63%.

Case 3: 61-year-old woman with intermittent abdominal pain Inverted Meckel diverticulum Differential Diagnosis • Lipoma • Inverted Meckel diverticula Inverted Meckel Diverticulum Inverted Meckel's Diverticulum with Intussusception Illustration of an inverted Meckel diverticulum Case 4: 57-year-old man with abdominal pain and fever Meckel diverticulitis with perforation and a stone Meckel Diverticulitis with Perforation and a Stone Meckel Diverticulitis with a Stone Meckel Diverticulitis: Etiology • Luminal obstruction ➢ Enterolith ➢ Foreign body ➢ Edema of orifice • Peptic ulceration • Torsion Gastrointestinal Radiology 425 Seminar 5: Meckel Diverticulum .

Meckel Diverticulitis • Differential diagnosis ➢ Appendicitis ➢ Inflammatory bowel disease ➢ Idiopathic ileal diverticula • Helpful CT features ➢ Blind-ending pouch ➢ Mural contrast enhancement ➢ Connection to ileum ➢ Midline location ➢ Associated SBO Case 5: 40-year-old man with pain and vomiting Small bowel obstruction from Meckel diverticulitis Inflamed Meckel with Small Bowel Obstruction Small Bowel Obstruction due to Meckel Diverticula • Second most common complication of Meckel • Etiology ➢ Inversion with intussusception ➢ Diverticulitis ➢ Volvulus from attachment to umbilicus ➢ Congenital mesodiverticular bands ➢ Foreign body impaction ➢ Inclusion of Meckel in a hernia (hernia of Littre) ➢ Neoplasm ➢ Inclusion of Meckel in a true knot Summary: Complications of Meckel Diverticula • Hemorrhage • Obstruction • Diverticulitis • Inversion ➢ Intussusception • Stones • Torsion • Neoplasm Summary: Complications of Meckel Diverticula • High index of suspicion Seminar 5: Meckel Diverticulum 426 Gastrointestinal Radiology .

MC. LTC (P).Gastrointestinal Seminar 6: Beyond Appendicitis Angela D. USA Case 1: 23-year-old man with a 1-day history of left lower quadrant pain and bilious emesis Imaging Features • Reversal of SMA and SMV • Swirling vessels about SMA • Absent colon right side of abdomen • Inflammatory process in LLQ ➢ Inflamed tubular structure ➢ Mesenteric inflammation Differential Diagnosis • Malrotation • Inflammation ➢ Diverticulitis ➢ Meckel diverticulum ➢ Inflammatory bowel disease ➢ Appendicitis Malrotation with Left-sided Appendicitis Malrotation with left-sided appendicitis Various locations of the cecum and appendix within the abdomen Gastrointestinal Radiology 427 Seminar 6: Beyond Appendicitis . Levy.

abdominal swelling • Complications ➢ Bowel obstruction. perforation. intussusception. appendicitis • 20% with a synchronous colonic adenocarcinoma Mucinous Cystadenoma/Cystadenocarcinoma • Radiologic Findings ➢ RLQ mass on plain film ➢ Rim-like calcification ➢ Mass effect medial cecal wall ➢ Nonfilled appendix on BE • Cross-sectional imaging ➢ Fluid-filled. vomiting.Case 2: 47-year-old man complains of fever and right lower quadrant pain Appendiceal mucinous cystadenoma causing appendicitis Appendiceal Mucinous Cystadenoma Causing Appendicitis Appendiceal Neoplasms • Uncommon ➢ <0. nausea. torsion.4% of intestinal tumors • Histologic subtypes ➢ Carcinoid ➢ Mucinous cystadenoma/cystadenocarcinoma ➢ Adencarcinoma ➢ Non-mucin producing adenocarcinoma Appendiceal Carcinoid • Most common location for GI tract carcinoid ➢ 45% of gastrointestinal carcinoids • Most common appendiceal tumor ➢ 50% to 85% of appendiceal tumors • Majority benign clinical course ➢ 70% to 90% discovered incidentally ➢ >95% of appendiceal carcinoids have benign biologic behavior Mucinous Cystadenoma/Cystadenocarcinoma • Mucin producing epithelial neoplasm ➢ M=F ➢ 27 to 77 years of age • Presentation ➢ Right lower quadrant pain. complex mass on CT or US ➢ Mass bulges into cecal lumen ➢ Short T1 and long T2 signal on MR ➢ May be the lead point for intussusception Mucinous Cystadenoma Mucinous cystadenoma of the appendix Seminar 6: Beyond Appendicitis 428 Gastrointestinal Radiology .

224 (3): 775-781 Gastrointestinal Radiology 429 Seminar 6: Beyond Appendicitis .Appendiceal Adenocarcinoma • Non mucin producing • Less common than mucinous tumors • Radiologically resembles colonic adenocarcinoma ➢ Focal soft tissue mass ➢ Soft tissue mural infiltration Neoplastic vs. Primary Neoplasms of the Appendix Manifesting as Acute Appendicitis: CT Findings with Pathologic Correlation. Rohrmann CA. Nonneoplastic Appendicitis Appendiceal Adenocarcinoma • CT findings suggestive of neoplasm ➢ Focal soft tissue mass ➢ Cystic dilatation of the appendix ➢ Nonspecific inflammatory changes may be seen in neoplasms of the appendix ➢ 95% sensitivity for neoplasm if you combine morphologic changes with a diameter > 15 mm1 1Pickhardt PJ. Levy AD. Radiology 2002. Kende AI.

young adults • Self limited • Diagnosis of exclusion Seminar 6: Beyond Appendicitis 430 Gastrointestinal Radiology .Case 3: 65-year-old man with acute RLQ pain Epiploic appendagitis Epiploic Appendagitis • Appendix epiploica ➢ Torsion ➢ Infarction ➢ Ischemia • Clinical course ➢ Self limited ➢ Spontaneous resolution Epiploic Appendagitis: Imaging Features • Pericolonic fatty mass ➢ Peripheral inflammatory change ➢ Central high attenuation from vascular thrombosis ➢ May have mass effect on adjacent bowel Epiploic Appendagitis Case 4: 17-year-old man with RLQ pain and poor appetite Mesenteric adenitis Mesenteric Adenitis • Inflammation of ileocecal nodes ➢ Coexistent inflammation of the TI and cecum may be present • Children.

and small bowel obstruction Cecal Adenocarcinoma Acute Appendicitis: Pathogenesis • Luminal obstruction followed by infection ➢ Stones ➢ Food.Case 5: 64-year-old man with RLQ pain that progressed to involve the entire abdomen. lymphoid hyperplasia ➢ Parasites ➢ Tumors ➢ Endometriosis Cecal Adenocarcinoma • Mural thickening ➢ Eccentric or asymmetric • Intraluminal mass ➢ Often near appendiceal orifice if patient presents with appendicitis • Pericolic lymph nodes • Peritoneal implants. terminal ileum ➢ Fatty mass with concentric or swirling lines Gastrointestinal Radiology 431 Seminar 6: Beyond Appendicitis . mucus. adhesions ➢ Mucosal edema. fever. and vomiting Cecal adenocarcinoma resulting in perforation. distant mets Non Hodgkin Lymphoma Case 6: 42-year-old woman with RLQ pain and peritoneal signs on physical exam Omental Infarction Omental Infarction • Omental torsion ➢ Most commonly site free edge of the right lateral omentum • CT features ➢ Focal inflammation of omental fat ➢ Normal appendix. colon. appendicitis.

LTC (P). USA Case 1: 45-year-old woman with RUQ pain Adenomyomatous hyperplasia Sonographic Findings • Gallbladder wall thickening • Reverberation artifact Differential Diagnosis: Gallbladder Wall Thickening • Infection/inflammation ➢ Acute cholecystitis ➢ Chronic cholecystitis ➢ Xanthogranulomatous cholecystitis • Edema ➢ Cardiac. Levy. MC.Gastrointestinal Seminar 7: Tumors and Tumor-like Lesions of the Gallbladder Angela D. renal failure ➢ Hepatitis • Neoplasm ➢ Primary or secondary • Tumor-like lesions ➢ Adenomyomatous hyperplasia Seminar 7: Tumors and Tumor-like Lesions of the Gallbladder 432 Gastrointestinal Radiology . liver.

Differential Diagnosis: Reverberation (“comet-tail”) Artifact • Gas in gallbladder wall • Adenomyomatous hyperplasia Coronal T2 MR Findings • Gallbladder wall thickening • “String of pearls” Adenomyomatous Hyperplasia • Gallbladder wall thickening • “String of pearls” Adenomyomatous Hyperplasia • Common ➢ 9% cholecystectomy specimens ➢ More common in women than men • Gallstones frequently present • Three variants ➢ Diffuse ➢ Segmental ➢ Localized (fundic adenomyoma) Fundal Adenomyomatous Hyperplasia: "Adenomyoma" Gastrointestinal Radiology 433 Seminar 7: Tumors and Tumor-like Lesions of the Gallbladder .

fever.Case 2: 47-year-old man complains of fever and right lower quadrant pain Xanthogranulomatous cholecystitis CT Findings • Gallstone • Gallbladder wall thickening • Hypodense nodules in gallbladder wall • Ill-defined hepatic margin • Inflammatory change Differential Diagnosis • Cholecystitis ➢ Acute ➢ Chronic ➢ Xanthogranulomatous • Neoplasm Xanthogranulomatous Cholecystitis • Aggressive inflammatory process • Pathophysiology ➢ Intermittent cystic duct obstruction ➢ Bile enters gallbladder wall • Clinical presentation ➢ RUQ pain. tenderness • Surgical treatment ➢ Reported association with gallbladder carcinoma ➢ Difficult to preoperative distinguish from carcinoma ➢ Involvement of adjacent organs Xanthogranulomatous Cholecystitis: Pathology Xanthogranulomatous Cholecystitis: Imaging • Wall thickening • Mural nodules or bands ➢ Hypoechoic on sonography ➢ Low-attenuation on CT • Stones • Pericholecystic fluid • Adjacent invasion • Lymphadenopathy Seminar 7: Tumors and Tumor-like Lesions of the Gallbladder 434 Gastrointestinal Radiology .

squamous cell. gallbladder • More common in women (3:1) ➢ Mean age 72 years Gallbladder Carcinoma: Pathology • Epithelial malignancies (98%) ➢ Adenocarcinoma (90%).Case 3: 75-year-old woman with RUQ pain and weight loss MR Findings • Intraluminal gallbladder mass • Hepatoduodenal ligament mass Differential Diagnosis • Gallbladder carcinoma • Bile duct carcinoma • Metastatic disease Gallbladder Carcinoma • Sixth most common GI tract malignancy ➢ Worldwide: stomach. colorectal. gallbladder ➢ US: colorectal. lymphomas. small cell carcinoma • Other (2%) ➢ Sarcomas. liver. esophagus. pancreas. liver. carcinoid. esophagus. adenosquamous. stomach. metastases Gallbladder adenocarcinoma Gallbladder Carcinoma • Imaging patterns ➢ Intraluminal polypoid mass (15% to 25%) ➢ Focal or diffuse wall thickening (20% to 30%) ➢ Mass replacing the gallbladder (40% to 65%) Adenocarcinoma: Diffuse Wall Thickening Papillary Adenocarcinoma : Polypoid Mass Adenocarcinoma: Mass Replacing the Gallbladder Fossa Gallbladder Adenocarcinoma: Direct Extension to Liver Gallbladder Adenocarcinoma: Direct Extension to Hepatoduodenal Ligament Gastrointestinal Radiology 435 Seminar 7: Tumors and Tumor-like Lesions of the Gallbladder . pancreas.

Case 4: 30-year-old man with RUQ pain Metastatic melanoma Differential Diagnosis: Polypoid Gallbladder Mass • Cholesterol polyp • Gallbladder adenoma • Adenomyomatous hyperplasia • Carcinoma • Metastatic disease Metastatic Melanoma Management of Gallbladder Polyps • Size < 5 mm ➢ Do nothing • Size 5 to 10 mm ➢ Follow • Size >10 mm ➢ Remove • Features suggesting malignancy ➢ Adjacent gallbladder wall thickening ➢ Abnormal gallbladder/liver interface ➢ Abnormal liver parenchyma ➢ Hepatoduodenal ligament adenopathy Seminar 7: Tumors and Tumor-like Lesions of the Gallbladder 436 Gastrointestinal Radiology .

nonshadowing echogenic mass • Adherent to gallbladder wall Cholesterol Polyp • Common ➢ 50% of polypoid lesions in the gallbladder • More common in women ➢ 3:1 Cholesterol Polyp • Lipid laden macrophages • Normal gallbladder epithelium Cholesterol Polyp: Sonography • Most <10 mm • Small lesions ➢ Echogenic nodules • Larger lesions ➢ Hypoechoic ➢ Internal echogenic foci Summary • Look for features to suggest a specific process tumor-like process ➢ Ring-down artifact. pearl necklace sign for adenomyomatous hyperplasia ➢ Focal mural nodules for XGC in the right clinical setting • Look for features to suggest a malignancy ➢ Gallbladder wall thickening in association with a polypoid mass ➢ Abnormal gallbladder/liver interface ➢ Abnormal liver parenchyma ➢ Hepatoduodenal ligament mass or adenopathy Gastrointestinal Radiology 437 Seminar 7: Tumors and Tumor-like Lesions of the Gallbladder .Case 5: 35-year-old woman with RUQ pain Cholesterol polyp Sonographic Findings • Small.

recommend elective laparoscopic cholecystectomy • For acute cholecystitis: ➢ Delayed surgery allows for better vizualization of surgical field ➢ Early surgery means less adhesions US of Cholelithiasis [Figure 2-22-1] Figure 2-22-1 • 3 common appearances ➢ Solitary stone ➢ Gravel ➢ Double-arc (WES) Solitary Gallstone Gravel Double-Arc Sign (WES) How Sensitive is US? • Remember the neck of the gallbladder Solitary stone Gravel Double-arc (WES) Sludge vs Gravel? • Gravel represents small. discrete calculi • Sludge is viscous. Cholelithiasis • For symptomatic stones. 50% chance of colic in 1 year.Cholelithiasis and Cholecystitis Robert K. lithogenic bile Cholelithiasis and Cholecystitis 438 Gastrointestinal Radiology . 1–2% cumulative risk of acute cholecystitis. MD Outline/Objectives • Detection of cholelithiasis • Gravel versus sludge • Acute cholecystitis • Complications of acute cholecystitis ➢ Gangrenous cholecystitis ➢ Emphysematous cholecystitis ➢ Empyema of the gallbladder ➢ Gallbladder perforation ➢ Choledocholithiasis Premise • The radiologist plays a central role in identifying the cause of the patient’s symptoms and… • Detecting complications of cholecystitis (inflammatory and neoplastic) that will dictate the therapeutic approach Cholelithiasis • 30 million American adults harbor stones • Should “silent” stones be treated? • 22% of patients with stones are symptomatic (Sirmione study) • In symptomatic patients. Zeman.

Tumefactive Sludge [Figure 2-22-2] Figure 2-22-2 • Baseline • After walking Is there any role for the OCG? [Figure 2-22-3] • No stones on OCG • See 5mm stone on US Acute Cholecystitis • Uncomplicated vs complicated • Treatment options if complications • (do imaging findings influence operative approach?) • Cholescintigraphy vs US Cholescintigraphy vs. scintigraphy does not identify cause despite high sensitivity. AJR 147:1177. can add EF when confusing symptoms Cholescintigraphy In AC • The only reliable indicator of acute cholecystitis is non-visualization of the gallbladder – remember the lateral • High sensitivity. US may see cause • Scintigraphy great problem solver.1986 Gastrointestinal Radiology 439 Cholelithiasis and Cholecystitis . Tumefactive sludge mimics GB mass-but changes shape with Ultrasound change in patient position • Both equally sensitive and specific • Emergency availability is key Figure 2-22-3 • Ultrasound screens for more non-biliary diseases • If biliary obstruction present. moderate specificity Cholescintigraphy: Positive study for acute cholecystitis Potential Causes of False-Positive Scintigraphy For Acute Cholecystitis Missed stones often “hide” in the • Lack of adequate fasting gallbladder neck • Chronic cholecystitis • Failure to obtain delayed views • Pancreatitis • Hyperalimentation • Biliary obstruction • Prolonged fasting • Intercurrent illness • Alcoholism • Overly conservative pathologic criteria of Acute Cholecystitis • Trauma • Gallbladder Neoplasm Is There Anything That Can Reduce False-Positives? Pharmacologic Enhancement of Cholescintigraphy • Can dramatically reduce false-positives* • Two approaches – CCK versus morphine (in setting of suspected AC) • CCK to “pre-empty” GB • Morphine (.04 mg/kg) given if GB fails to visualize by 30–50 minutes *Kim et al.

Radiology 133:429. 1997 Intramural Sonolucency • Described in 11 patients as first specific sign for acute cholecystitis* • “Consists of a hypo-reflective or sonolucent band. 1987 Acute Cholecystitis-Striate GB Walls [Figure 2-22-5] Acute Cholecystitis-Focal Lucency Lucency in GB Wall is not always Edema • Gallbladder varices in portal hypertension Which one has Varices? Gallbladder Wall Thickening • Failure to fast • Acute cholecystitis • Chronic cholecystitis • Hypoalbuminemia Multiple patients • Hepatitis • Ascites Figure 2-22-6 • Varices • AIDS • Carcinoma • Cholesterolosis • Mononucleosis • Beware of “sliver” of edema in some of these entities Gallbladder Wall Thickening [Figure 2-22-6] • Hepatitis Gallbladder wall thickening has many causes and is not as • Ascites specific as a striate wall Cholelithiasis and Cholecystitis 440 Gastrointestinal Radiology . 1979 **Cohen et al. within the hyper-reflective gallbladder wall” Figure 2-22-5 • Focal lucency or concentric rings (striate) most suggestive of inflammation** *Marchal et al. continuous or interrupted. Radiology 140:449. 1981 **Uggowitzer AJR 168:707.Use of Morphine Reduces False-Positives [Figure 2-22-4] Figure 2-22-4 • 35 minutes (pre-MS) • 55 minutes (post-MS) Sonographic Findings Associated With Acute Cholecystitis • Most useful signs ➢ Cholelithiasis ➢ Intramural sonolucency ➢ Sonographic Murphy Sign* ➢ GB wall hyperemia** 35 minutes (pre-MS) Normal scan after morphine • Secondary signs 55 minutes (post-MS) ➢ Pericholecystic fluid ➢ GB distention ➢ Sludge ➢ Gas in the gallbladder wall or lumen ➢ Pericholecystic abscess *Laing et al. Radiology 164:31.

20–30% are diabetic • Male predominance • 1/3 infected with Clostridia welchii • Perforation 5 times as common as for non-emphysematous cholecystitis • “Dirty” shadowing and echogenic GB wall on sonography is suggestive • Don’t forget plain film – differential diagnosis of RUQ air Figure 2-22-8 Emphysematous Cholecystitis • US-echogenic foci=gas • KUB Emphysematous Cholecystitis [Figure 2-22-8] • US-ring-down • KUB US-ring-down (reverb) KUB Gastrointestinal Radiology 441 Cholelithiasis and Cholecystitis .Hyperemia of Acute Cholecystitis Complications/Severity of Acute Cholecystitis Options for Treatment of Acute Cholecystitis • PCCL • OC • LC • Temporize Role of the Radiologist in Acute Cholecystitis • Identify findings that make temporizing ill-advised or that would potentially result in open cholecystectomy: ➢ Extreme striations ➢ Gangrenous cholecystitis ➢ Emphysematous cholecystitis ➢ Perforation ➢ Biliary obstruction / Mirizzi syndrome ➢ Incidental findings that preclude LC Figure 2-22-7 Incidental Finding • Hemangioma next to GB neck Gangrenous Cholecystitis • Not always Clostridal infection • Implies severe inflammation • Sonography-may see desquamated mucosa/membranes • Scintigraphy-increased pericholecystic activity* due to: ➢ delayed excretion from perihepatitis Two different patients show a band of tracer where the liver ➢ hyperemia with increased tracer abuts the inflamed gallbladder (arrow) delivery *Smith et al. 1985 Gangrenous Cholecystitis-Rim Sign [Figure 2-22-7] • Two different patients Gangrenous Cholecystitis • Sloughed membranes Emphysematous Cholecystitis • Elderly patients. Radiology 156:197.

The duct caliber and dynamics may rapidly change • CT and US are approx. See distention. CT-Nonspecific. inflamed gallbladder • 25% incidence-rises to 80% if untreated after 7 days* • Results in marked GB distention in 38% of patients** • US. non-specific GB Perforation in AC [Figure 2-22-10] GB Perforation Figure 2-22-10 Choledocholithiasis • May occur as primary duct stone (usually pigment). 1948 **Fry et al. CT-pericholecystic collection. gallstone ileus) and AC • In older literature. 1981 Perforation of the Gallbladder • Seen both in the context of chronic cholecystitis (eg. “snow storm” *Goldman et al. 70-80% sensitive for detection of choledocholithiasis • If you suspect CBD stones…options are MRCP. ERCP. intraop cholangiogram When to Perform MRCP • Jaundice Contracted GB • Dilated ducts on US • Delayed egress on IDA • Anatomic finding that suggests process that may result in altered duct anatomy or make laparoscopic cholecystectomy risky • Post-cholecystectomy complications MRCP • T2 wt TSE or FSE. occurs in 3–15% of patients with acute cholecystitis • Patient feels transiently better and then develops peritoneal signs • Cholescintigraphy – extravasated activity – maybe • Sonography.Not all GB Walls with Ring-Down Contain Gas • Diagnosis? Not all GB Walls with Ring-Down Contain Gas • Adenomyomatosis Emphysematous Cholecystitis-CT • Gas confined to GB wall Figure 2-22-9 • Gas in lumen. thin sections or “slab” • Extra sections as needed Cholelithiasis and Cholecystitis 442 Gastrointestinal Radiology . hepatic ducts Gallbladder Empyema [Figure 2-22-9] • Infection in obstructed. secondary to gallstones.. Gastro 11:318. Am J Surg 141:366. or following cholecystectomy • Most small stones will pass spontaneously. bile/debris level.

Cooper C. Illescas FF: Striated intramural gallbladder lucencies on US studies. 1987. Implications for monitoring of gallstone lithotripsy. Smith R. Zeman RK. Radiology 155:767. Kalff V.. Shuman WP. Caride V. Wales LR. 20. 1984.. 19. West MS. AJR 94:480. Federle MP. Burrell MI. Management of acute cholecystitis. scintigraphy. Sugarman LA et al. Desquamated gallbladder mucosa: Unusual sign of cholecystitis. Spectrum of 99m Tc-IDA cholescintigraphic patterns in acute cholecystitis. Predictors of acute cholecystitis. Acute calculous cholecystitis: Sensitivity in detection using technetium-99m iminodiacetic acid cholescintigraphy. AJR 147:171.01) and Fever: Approach • “R/O Acute calculous cholecystitis”. Laing FE. Rudd TG et al. Fox MS et al. 1985. 1990. Gallbladder varices: Imaging findings in patients with portal hypertension. Zeman RK et al. Clemett AR. 27. A test for patency of the cystic duct in acute cholecystitis. Zeman RK. 1981. Burrell MI. Halasz NA. Garra BS. Leopold GR. Siskind B. Capps GW. Becker CD. Counterfeit cholecystitis: A common diagnostic dilemma. Rudd TG et al. Horii SC. Malone DE. Mathieson JR. 2. Radiology 160:33. Gallbladder Imaging: The State-of-the-art. Mirvis SE. Rogers JV. PIDIDA scintigraphy for cholecystitis: False positives in alcoholism and total parenteral nutrition. Froelich JW. Radiology 164:31–35. Zeman RK. Berkowitz D. Am 2:127. 25. 1983. Gastrointestinal Radiology 443 Cholelithiasis and Cholecystitis .. Wong W. 1994. Vainright JR. 5. duPlessis DJ. So CB. Technical Advances and Clinical Applications. Radiology 156:797. Radiology 156:797. et al. A nonspecific finding. The roentgen features of the Mirizzi syndrome. 1985. 1981. J Clin Gastroenterol 9:670–78. Fonseca C. AJR 153:977. 1991. US • “R/O Stones”.RUQ Pain (789. Cahow CE. Cameron JL. Cholescintigraphy in acute and chronic cholecystitis. Gastroent Clin N. Weltman D. 1982. Radiology 142:531. Clin Nucl Med 3:437. Am J Surg 130:189. AJR 136:337. Jeffrey RB. Radiological Clinics of North America 32:933-950. 1975. Burhenne HJ: Accuracy of sonography for determining the number and size of gallbladder stones before and after lithotripsy. 7. Garra BS.? • “R/O a reason to operate”. Callen PW. Greenberg D. 1973. Jeffrey RB et al. Weissmann HS.IDA. Rosen J. 11. 1978. Am J Surg 141:446. 1965. 1991. Zeman RK: Visibility of gallstone fragments at ultrasound and fluoroscopy. Bowie JD. if suspect acute abdomen/GI disease do CT • Remember MRCP References 1. Imaging of acute diseases of the gallbladder and bile ducts. Colletti PM. Gibbs P. Badia J. 1989.US • “R/O Acute acalculous cholecystitis”. Fulcher AS. Eikman EA. 23. Baron RL. Ralls PW. Ultrasonic evaluation of patients with acute right upper quadrant pain.. Radiology 179:179. Radiology 138:167. AJR 156:945. 3. Scheible FW: Sonography of the thickened gallbladder wall. 1999. Alderson PO. 17. 1983. AJR 139:810. Surg Clin North Am 53:1071. Lack EE. 15. 9. Colman M et al. 1987. 1975. Weissmann HS. Cohan RH. Real-time sonography in suspected acute cholecystitis: Prospective evaluation of primary and secondary signs. Assessment of the utility of gallbladder imaging with 99m Tc-IDA. 1991. Garra BS. 8. 6. The diagnosis of acute acalculous cholecystitis: A comparison of sonography. Gangrenous cholecystitis: Diagnosis by ultrasound. Bigler SA: Sonography of the gallbladder. 26. Laing FC. Low sensitivity of sonography and cholescintigraphy in acalculous cholecystitis. RAdiographics 19:25-41.. Radiology 140:449. 21. 14. Rosenthall L et al. 1986. Zeman RK. The role of technetium-99m iminodiacetic acid (IDA) cholescintigraphy in acute acalculous cholecystitis.. Swayne LC. Radiology 146:177. Perforation of the gallbladder: Radiologic-pathologic correlation. Nelson AW. Baker ME. Lapin SA et al. 18. Shuman WP. Jersky J. 24. if suspect biliary do US. Ann Int Med 82:318. Mahony BS. 1981. 28. AJR 138:1. Pericholecystic hepatic activity in cholescintigraphy. 22. and CT. 1982. 10. Gallo LN. Diagnostic utility of cholescintigraphy and ultrasonography in acute cholecystitis. 1981. 4. Shaler WJ. 29. 16. Teefey SA. Cinti D. Radiology 146:191. Semin Nucl Med 12:18. Lowman RM. Freitas JE. 1985. Hawkins M. Davros WJ. Predictive value of an abnormal hepatobiliary scan in patients with severe intercurrent illness.. Radiology 174:343. Significance of striated (layered) thickening of the gallbladder wall.. Turner MA. Horii SC. 12. Lloyd R et al. 1986. 13. 1982.

MD Technique Figure 2-23-1 • Double-contrast: ➢ Upright ➢ Right lateral cardia • Single-contrast: ➢ Separate swallows ➢ Prone esophagus Reflux Esophagitis • Most common inflam condition • Purpose of Ba study not simply to show HH/GER but to R/O morphologic sequelae of GERD Pathogenesis • Frequency of GER ➢ Decreased LES tone ➢ Mult trans LES relaxations • Duration of GER ➢ Abnormal motility ➢ (scleroderma) Pathogenesis • Acidity of refluxate ➢ ZES (increased acid) ➢ Billroth II (bile or panc) • Resistance of mucosa ➢ Age ➢ Debilitation Clinical Findings • Heartburn and regurg Reflux esophagitis with • Epigastric or RUQ pain granular mucosa • Upper GI bleeding • Dysphagia (peptic stx) Figure 2-23-2 Hiatal Hernia and GER • Occur independently • Spont GER at fluoro: ➢ 30–60% in esophagitis ➢ 40–50% in volunteers Reflux Esophagitis: Radiographic Findings [Figures 2-23-1 and 2-23-2] • Abnormal motility • Granularity • Thickened folds • Inflammatory EG polyp • Ulceration Peptic Scarring: Radiographic Findings • Radiating folds • Deformity of wall • Peptic stricture • Sacculations • Transverse folds Reflux esophagitis with ulceration Inflammatory Disease of the Esophagus 444 Gastrointestinal Radiology . Levine.Inflammatory Diseases of the Esophagus Marc S.

W > B • Reflux sx. 1988 Classification of Risk • High: High stx or ulcer or reticular pattern • Mod: Distal stx or reflux esophagitis • Low: None of above Radiologic vs Endoscopic Dx Risk Endo • High 10 9 (90%) • Moderate 73 12 (16%) • Low 117 1 (1%) Barrett esophagus Radiologic Diagnosis with mid esophageal stricture • Less sensitive than endoscopy and reticular pattern • Most false negative exams in mild disease • Vast majority do not have Barrett’s esophagus Gastrointestinal Radiology 445 Inflammatory Disease of the Esophagus . hiatal hernia.Radiologic Dx of Esophagitis Gr 1 Gr 2 Gr 3 • Koehler 13% 90% 100% • Ott 22% 83% 95% • Creteur 53% 93% 100% Schatzki Ring • Variant of peptic stx • Episodic dysphagia (meat) ➢ (Steakhouse syndrome) • Symm ringlike constriction • Vertical height 2–4 mm • Usually sx if < 13 mm diam • Best seen on prone views Barrett’s Esophagus • Prog columnar metaplasia from GER and esophagitis • Prevalence: ➢ 10% with esophagitis ➢ 40% with peptic stx Clinical Findings • Men > Women. or low risk for Barrett’s AJR 150:97–102. mod. reflux esophagitis. dysphagia • 40% asymptomatic • Tx of GER may not cause Barrett’s to regress Histologic Findings • Projections or islands of columnar epith separated by squam epith • Foveolar epith > 3 cm above LES or intestinal metaplasia with goblet cells Figure 2-23-3 Premalignant Condition • Risk of adenocarcinoma • Dysplasia-Ca sequence • Endoscopic surveillance Radiographic Findings [Figure 2-23-3] • Classic: High stx or ulcer or reticular pattern • Common: GER. or peptic stricture Dx of Barrett’s by D/C Tech • 200 pts with reflux sx • Classified at high.

Reflux Symptoms Figure 2-23-4 Candida Esophagitis • Most common type • Immunocompromised (75%) • Local esophageal stasis (25%) ➢ (achalasia. scleroderma) Clinical Findings • Dysphagia/odynophagia • OP Candidiasis (50%) • Marked clinical response to antifungal agents (ketoconazole) Candida esophagitis Radiographic Findings [Figures 2-23-4 and 2-23-5] with plaques • Mucosal Plaques (90%) ➢ Linear Figure 2-23-5 ➢ Etched in white • “Shaggy” esophagus (AIDS) ➢ Plaques and membranes ➢ Superimposed ulcers Herpes Esophagitis • 2nd most common type • Herpes simplex virus type 1 • Immunocompromised • Viral Cx or Bx (intranuclear inclusions in cells adjacent to ulcers) Clinical Findings • Dysphagia/odynophagia • Oropharyngeal herpes • Marked clinical response to antiviral agents (acyclovir) Radiographic Findings [Figure 2-23-6] • Discrete ulcers in upper and midesophagus • Ulcers and plaques (mimics Candida) Herpes Esophagitis in Healthy Pts • Young men (15–30 y/o) • Sexual partners with OP herpes • Flu-like prodrome (3–10 days) • Severe odynophagia • Multiple tiny ulcers • Sx resolve in 3–14 days Candida esophagitis with shaggy esophagus Inflammatory Disease of the Esophagus 446 Gastrointestinal Radiology .

1995 Giant Ulcers in 21 HIV + Pts • All had AIDS (CD4 ct < 200) • Avg time from serodetect 2 yrs • Only 1 pt had palatal ulcers or rash Gastrointestinal Radiology 447 Inflammatory Disease of the Esophagus .CMV Esophagitis • Pts with AIDS Figure 2-23-6 • Odynophagia • Viral Cx or Bx (intranuclear inclusions in cells at ulcer base) • Tx with ganciclovir (endo for confirmation) Radiographic Findings [Figures 2-23-7] • Nodular mucosa • Small ulcers (mimics herpes) • Giant ulcers Figure 2-23-7 Figure 2-23-8 Herpes esophagitis with tiny ulcers CMV esophagitis HIV esophagitis with giant ulcer with giant ulcer HIV Esophagitis • Odynophagia and giant ulcers • Palatal ulcers • Maculopapular rash • Recent seroconversion • Dx of exclusion (No CMV) • Treatment with steroids Radiographic Findings [Figure 2-23-8] • Giant ulcers ➢ (mimics CMV) • Satellite ulcers Giant Ulcers in 21 HIV + Pts Cause No Pts % • HIV 16 76 • CMV 3 14 • Both 2 10 Radiology 194:447–451.

odynophagia. progressive dysphagia (4–8 months) • Adriamycin potentiates XRT (only 500 rad) Radiographic Findings • Acute ➢ Ulceration ➢ Granular mucosa ➢ Decreased distensibility Tetracycline-induced • Chronic esophagitis with three ulcers ➢ Abnormal motility ➢ Strictures Caustic Esophagitis • Strong acids or alkali (liquid lye) • Three phases of injury: Figure 2-23-10 ➢ Acute necrosis ➢ Ulceration and granulation ➢ Cicatrization • Chest pain. tetracycline.Conclusions Figure 2-23-9 • Most giant ulcers in HIV+ Pts caused by HIV not CMV • Impossible to diff by clin or rad criteria • Endoscopy for definitive Dx Drug-Induced Esophagitis [Figure 2-23-9] • Contact esophagitis (doxycycline. shock Radiographic Findings Figure 2-23-11 • Acute ➢ Abnormal motility ➢ Ulceration ➢ Perforation • Chronic ➢ Strictures ➢ (1–3 months) Esophageal Intramural Pseudodiverticulosis • Dilated excretory ducts • Ductal obstruction • Candida. NSAIDs. hematemesis. alcohol • High strictures classic • Peptic stx more common Radiographic Findings [Figures 2-23-10 and 2-23-11] • Flask-shaped outpouchings • “Floating” outside wall • Associated strictures Diffuse esophageal Localized esophageal ➢ (especially peptic stx) intramural intramural pseudodiverticulosis with pseudodiverticulosis with high stricture peptic stricture Inflammatory Disease of the Esophagus 448 Gastrointestinal Radiology . quinidine. KCl. diabetes. alendronate) • Aortic arch or lt main bronchus • Superficial ulcers • Severe odynophagia but rapid clinical improvement after withdrawal of offending agent Radiation Esophagitis • 2–5000 rad: self-limited esophagitis (1 – 2 weeks) • 5000 or more rad: stx.

mid • CMV Giant • HIV Giant Thickened Folds • Esophagitis • Varices • Varicoid Ca High Strictures • Barrett’s esophagus • Mediastinal irradiation • Caustic ingestion • Primary or metastatic tumor Distal Strictures • Peptic stricture • Lower esoph ring • Barrett’s Ca Gastrointestinal Radiology 449 Inflammatory Disease of the Esophagus . mid • Drugs Small.Esophageal Varices Location Cause • Uphill Distal Portal HTN • Downhill Mid SVC obst Diffuse Nodules/Plaques Cause Finding • Reflux Granularity • Candida Plaques • Glycogenic acanthosis Nodules/plaques Localized Nodules/Plaques Cause Finding • Candida Plaques • Sup spr Ca Coalesce nodules • Barrett’s Reticular pattern Ulcers Cause Finding • Reflux Distal • Herpes Small.

exophytic.Tumors of the Esophagus Marc S. 10% PT • Up to 20 cm in diameter • Patterns – submucosal. sessile polyp • Lobulated mass • Bubbly appearance • Diff Dx – early Ca Glycogenic Acanthosis • Accum of cytoplasmic glycogen • White nodules/plaques • Rarely causes esophageal sx • No risk of malignant degeneration Radiographic Findings [Figure 2-24-1] • Round nodules/plaques • 1–5 mm in diameter • Predominantly midesophagus • DDx – Candidiasis Intramural Lesions • Fibrovascular polyp • Leiomyoma • Granular cell tumor • Duplication cyst • Idiopathic varix Leiomyoma: Pathologic Findings • Most common benign tumor Glycogen acanthosis with nodules • Bands of smooth muscle • 60% DT. Levine. circumferential Clinical Findings • Most pts asx • Dysphagia • GI bleed rare • Enucleation Radiographic Findings [Figure 2-24-2] • CXR – soft tissue mass. intraluminal. Ca++ rare Tumors of the Esophagus 450 Gastrointestinal Radiology . 30% MT. MD Mucosal Lesions • Squamous papilloma • Adenoma • Glycogenic acanthosis Squamous Papilloma: Pathologic Findings • Coral-like excrescence • Fibrovascular core • Hyperplastic squamous epithelium Clinical Findings • Usually asymptomatic • Malignant degeneration rare • Multiple papillomas (papillomatosis) Figure 2-24-1 Radiographic Findings • Small.

deafness. • Children/adolescents • Long-standing dysphagia • Familial – autosomal dominant • Alport’s syndrome (nephritis. expansile intraluminal mass ➢ Var size & location ➢ Lobulation common ➢ Prox pedicle rare • DDx Air bubble. choking. achalasia. hemangioma. wheezing • Regurgitation of fleshy mass • Asphyxia/sudden death Radiographic Findings [Figures 2-24-3 to 2-24-5] • CXR ➢ Rt sup med mass ➢ Retrotracheal bowing • Ba Figure 2-24-5 ➢ Smooth. ocular lesions) Esophageal leiomyoma in profile Radiographic Findings • Ba – tapered narrowing of distal esophagus (1° achalasia?) • Length > achalasia • Symmetric fundal defects Figure 2-24-3 • CT – thickened wall (2° achalasia?) Fibrovascular Polyp: Pathologic Findings • Benign intraluminal tumor • Fibrous/adipose/vascular tissue with nl squam epith • Hamartoma/fibroma/lipoma/fibrolipoma/angiolipoma • All classified as FVPs • Malig degen rare Pathologic Findings • Arises in cervical esophagus • Loose submucosal conn tiss • Dragged inf by peristalsis • Occas prolapses into fundus CXR with right superior mediastinal mass • Pedicle in cervical esophagus caused by fibrovascular polyp Clinical Findings Figure 2-24-4 • Dysphagia • Resp sx – inspiratory stridor. duplication cyst Unusual Findings • Annular lesion • Giant intraluminal mass • Gastric involvement • Multiple lesions • Leiomyomatosis Leiomyomatosis • Proliferation of smooth m.• Ba – submucosal mass Figure 2-24-2 • CT – soft tissue mass • DDx – fibroma. malignant tumor Fibrovascular polyp on barium Radiographic Findings study [Figures 2-24-5 and 2-24-6] (same patient as Figure 2-22-3) Path CT Fibrovascular polyp with fat attenuation on CT Gastrointestinal Radiology 451 Tumors of the Esophagus . granular cell tumor.

liver Clinical Findings • Dysphagia and wt loss • Odynophagia (if ulcerated) • Chest pain (poor sign) • Paroxysmal coughing (if TEF) • 5-year survival < 10% Tumors of the Esophagus 452 Gastrointestinal Radiology . celiac) • Hematogenous – lungs. pericard.• Adipose Lipid density [1] Figure 2-24-6 • Mixed Heterogeneous • Fibrous Soft tissue density [1] High-signal intensity on T1MR / High echo on endoscopic U/S Duplication Cyst • Abnl embryo development • Sequest from prim foregut • Ciliated columnar epith • Most pts asymptomatic • Occas bleeding/infection Radiographic Findings Fibrovascular polyp with geographic • CXR: Mediastinal mass areas of fat and soft tissue • Ba: Submucosal mass attenuation on CT • CT: Homogen low atten • MR: High-signal on T2 Malignant Tumors • Squamous cell carcinoma • Adenocarcinoma • Spindle cell carcinoma • Small cell carcinoma • Leiomyosarcoma • Kaposi’s sarcoma • Malignant melanoma • Lymphoma • Metastases Squamous Cell Carcinoma: • Epidemiological Factors • Tobacco and alcohol • Geographic variations (China. neck.5 cm regardless of depth of invasion or lymph node mets Routes of Spread • Direct extension – trachea. bronchi. Iran. diaphragms • Lymphatic spread – nodes in med. aorta. lesser curv. lungs. S Africa) • Low molybdenum in soil (accum of nitrosamines) Predisposing Factors • Achalasia • Lye strictures • Head and neck tumors • Celiac disease • Plummer-Vinson • Tylosis Definitions • Early: mucosa or submucosa without lymph node mets • Superficial: mucosa or submucosa with or without lymph node mets • Small: < 3. upper abdomen (paracardiac. adrenals.

ca-in-situ. high-grade.Early Squamous Cell Carcinoma: Radiographic Findings Figure 2-24-7 [Figure 2-24-7] • Small. invasive) • Comprises 20–50% of esoph Ca’s • Predominantly in distal esophagus • Often invades proximal stomach Figure 2-28-9 • Prevalence 10% in Barrett’s esoph • 30–40X greater risk than gen pop • Dysphagia and weight loss • Same prognosis as squamous Ca • Endoscopic surveillance Figure 2-28-8 Primary ulcerative carcinoma with Varicoid carcinoma with giant meniscoid ulcer surrounded large submucosal defects by rind of tumor in lower esophagus Gastrointestinal Radiology 453 Tumors of the Esophagus . sessile polyp • Plaquelike (central ulcer) • Focal irregularity in wall • Superficial spreading Adv Squamous Cell Carcinoma [Figures 2-24-8 and 2-24-9] • Plain Film ➢ Widened med ➢ Ant tracheal bowing ➢ Thick RT stripe ➢ A/F level in esoph • Barium ➢ Infiltrating ➢ Polypoid ➢ Ulcerative ➢ Varicoid Superficial spreading Squamous Cell Carcinoma: Staging carcinoma with focal nodularity • CT: Sens limited by adenopathy (mets in nl-sized nodes) • MRI: Comparable to CT • US: Depth of invasion & lymph node mets Adenocarcinoma • Arises in Barrett’s mucosa • Dysplasia-Ca sequence (low-grade.

polypoid. plaque.Radiographic Findings [Figures 2-24-10 and 2-24-11] • Early: sessile polyp. stricture • Adv: infiltrating. varicoid (often invades cardia) Figure 2-24-10 Figure 2-24-11 Adenocarcinoma in Barrett esophagus invading gastric cardia Early adenocarcinoma in Barrett’s esophagus with plaque-like lesions Spindle Cell Carcinoma Figure 2-24-12 • Carcinomatous and sarcomatous elements • Spindle cell metaplasia • Dysphagia and weight loss • Same prognosis as squamous Ca Radiographic Findings [Figure 2-24-12] • Ba-polypoid intraluminal mass expanding lumen without obstruction • CT-expansile esophageal mass • DDx-malignant melanoma Spindle cell carcinoma seen as polypoid mass expanding esophagus without causing obstruction Tumors of the Esophagus 454 Gastrointestinal Radiology . ulcerative. sup spreading.

Radiology of Peptic Ulcer Disease Marc S. Levine. MD Hypertrophic Gastritis [Figures 2-25-1 and 2-25-2] • Glandular hyperplasia • Increased acid secretion • Thickened folds • Diff Dx: ➢ Menetrier’s ➢ Lymphoma Figure 2-25-1 Figure 2-25-2 Erosive gastritis with varioloform erosions in antrum Antral gastritis with hypertrophied antral- pyloric fold on lesser curvature of distal antrum Figure 2-25-3 Antral Gastritis [Figure 2-25-1] • Thickened antral folds • Longitudinal or Transverse • Crenulation of lessercurvature • Hypertrophic antral-pyloric fold Causes of Erosive Gastritis [Figure 2-25-3] • PUD • NSAIDs • Alcohol • Stress • Trauma • Crohn’s Acute Aspirin Ingestion (2–8 tabs/day in nl pts) Finding Time Span • Erosions 8–24 hrs • Max damage 1–3 days • Healing 3–7 days Duodenitis • Spastic bulb NSAID-induced erosive gastritis with • Thickened folds linear erosions clustered in gastric • Nodules body near greater curvature • Erosions Gastrointestinal Radiology 455 Peptic Ulcer Disease .

Gastric Ulcers • Shape • Size • Location • Morphology Figure 2-25-4 Figure 2-25-5 Benign posterior wall gastric ulcer Anterior wall gastric ulcer seen as ring shadow on double contrast view Figure 2-25-6 Figure 2-25-7 Ulcer fills with barium on prone compression Giant NSAID greater curvature ulcer Multiple Gastric Ulcers • 2–30% of pts with GUs • Association with aspirin in 80% Figure 2-25-8 • Each ulcer evaluated separately Upper GI vs Endoscopy • More than 95% GUs Dx in North America are benign • 6–16% of benign-app GUs on S/C studies are malignant • Is endo always necessary? Benign Gastric Ulcers [Figures 2-25-4 to 2-25-8-] • En Face ➢ Round or ovoid crater ➢ Smooth mound of edema ➢ Symmetric radiating folds • In Profile NSAID-induced greater curvature ulcer with ➢ Projection outside lumen gastrocolic fistula ➢ Hampton’s line or ulcer mound or collar Peptic Ulcer Disease 456 Gastrointestinal Radiology .

Malignant Gastric Ulcers [Figure 2-25-9] Figure 2-25-9 • En Face ➢ Irregular crater in mass ➢ Loss of areae gastricae ➢ Nodularity. irregularity. 1983 Radiologic Dx of Gastric Ulcers Rad Dx No Pts Endo Final Dx • Benign 68 24 All ben • Equiv 37 33 All ben • Malig 3 3 All malig AJR 164:9–13. or fusion of radiating folds • In Profile ➢ Projection of crater inside lumen within mass ➢ Acute angles of mass Equivocal Ulcers • Irregularity of ulcer shape • Asymmetry of mass effect • Nodularity. clubbing. or clubbing of radiating folds • Enlarged areae gastricae • Location on greater curve Malignant lesser curvature ulcer with clubbed folds abutting ulcer on prone compression Radiologic Dx of Gastric Ulcers Rad Dx No Pts Endo Final Dx • Benign 191 164 All ben • Equiv 69 63 56 ben / 7 malig • Malig 72 68 2 ben / 66 malig AJR 141:331–333. 1987 Gastric Ulcer Investigation Advantages of Upper GI over Endoscopy • Shorter procedure time • Negligible risk • Lower cost Upper GI vs Endoscopy Cost • D/C upper GI $218 • Endoscopy procedure $540 • Pathology $180 • Hospital $102 • Total $822 Cost of Evaluating 1 Million GUs in United States • UGI + endo $1 billion • UGI + sel endo $490 million • Diff in Cost $510 million Gastrointestinal Radiology 457 Peptic Ulcer Disease .

lobulated folds • Enlarged areae gastricae Association with Gastric Carcinoma • Increased risk of gastric Ca • Less than 1% develop Ca • Not enough evidence to treat all pts with H. pylori gastritis with markedly thickened.pylori Polypoid H.Ulcer Healing Figure 2-25-10 • Change in size and shape • Avg pd for healing 8 wks • Ulcer scar in 90% Ulcer Scar • Central pit or depression • Radiating folds • Retraction of adjacent wall Duodenal Ulcers [Figure 2-25-10] • 90% < 1 cm in size • 50% on anterior wall • 85% with deformed bulb • 5% linear Duodenal bulbar ulcer • 15% multiple Giant Duodenal Ulcers • Greater than 2 cm in size Figure 2-25-11 • Higher frequency of complix (bleeding. obst. Pylori Figure 2-25-12 • Gram-negative bacillus • Increases with age (50% of pop > age 60) • Eradicated by antibiotics and antisecretory agents Radiographic Findings [Figure 2-25-12] • Thickened gastric folds (predom antrum and body) • Polypoid gastritis with thickened. lobulated folds in gastric body Peptic Ulcer Disease 458 Gastrointestinal Radiology . perforation) • Fixed configuration at fluoro Postbulbar Duodenal Ulcers [Figure 2-25-11] • 5% of all duodenal ulcers • Medial wall of prox descending duodenum above papilla • Indentation of lateral wall • Notoriously difficult to Dx • Can result in development of ring stricture Investigation of Duodenal Ulcers Post-bulbar duodenal ulcer with ulcer niche in proximal descending duodenum H.

Pylori & Gastric Lymphoma • Stomach devoid of lymphoid tissue • Development of lymph follicles with H.H.Pylori • Endoscopic bx • Urea breath test • Serum Ab test Gastrointestinal Radiology 459 Peptic Ulcer Disease . pylori (MALT) • Low-grade MALT lymphoma (MALTOMA) • Characteristic pathologic features Gastric MALT Lymphoma • Regress with antibiotics in 70-80% • Precursor of high-grade lymphoma Figure 2-25-13 • 50-72% of all gastric lymphomas • More common than prev recognized Radiographic Findings [Figure 2-25-13] • Nodularity of mucosa (rounded 2-7 mm nodules) • Diff Dx: ➢ Focal gastritis ➢ Intest metaplasia ➢ Enlarged areae gastricae Risk of Ulcers Prevalence Gastric ulcer 60-80% Duodenal ulcer 95-100% Gastric MALT lymphoma with confluent nodules in gastric body Detection of H.

hemorrhage • Variable involvement of regional or remote tissues (Atlanta 1992) Chronic Pancreatitis • (Marseilles 1985) • Recurrent or persistent abdominal pain • +/. Focal • Loss of function Acute Pancreatitis: Who Gets It? • Biliary stones (45%) • Alcohol (35%) • Idiopathic (10–15%) • Hypercalcemia • Hypertriglyceridemia • Drugs • Post ercp • Hereditary • Trauma • Infection • Vasculitis • Pancreatic cancer • Pancreas divisum • Sludge? Acute Pancreatitis: Pathophysiology • Alcohol ➢ Alters duct permeability -> protein precipitation in ductules • Gallstones ➢ Common channel of bile and pancreatic ducts -> bile reflux into pancreatic duct Acute Pancreatitis: A Cascade of Events Pancreatitis 460 Gastrointestinal Radiology . MD “Is this heaven?” “No.” Normal Pancreas Acute Pancreatitis • (Marseilles 1985) • Sudden onset abdominal pain • Increased pancreatic enzymes.Pancreatitis: Imaging Has Made a Difference Bruce P. It’s the anterior pararenal space. blood. urine • Pancreatic edema.increased enzymes • Irreversible morphologic change in pancreas ➢ Fibrosis ➢ Acinar destruction ➢ Calcification • Diffuse. Brown. fat and gland necrosis.

pseudocyst. pseudoaneurysm Balthzar 2002 Radiol Clin Acute Pancreatitis: Plain Films • Chest film ➢ Pleural effusion 43% w. colitis -> Thick folds • Mucosa intact • Mass effect from pancreatic fluid • Fundal varices from splenic vein thrombosis Acute Pancreatitis: Ultrasound • Of limited use in Dx • Is pancreatitis associated w gallstones? • Fluid collections? • Vascular complications? • Intervention Gastrointestinal Radiology 461 Pancreatitis .6. cytokines. bowel ischemia. elastase. pancreas.2. IL-1. pulmonary.Acute Pancreatitis: Good and Bad • Interstitial ➢ Edema ➢ Architecture preserved ➢ No hemorrhage • Hemorrhagic ➢ Tissue necrosis. GI. biliary • Late ( months – years ) ➢ Vascular. trypsinogen activated peptide (TAP) • Intermediate ( 2-5 weeks ) ➢ Infection. severity Acute Pancreatitis: Complications • Early ( 2-3 days ) multi-organ failure ➢ Cardiovascular. cholecystitis • Labs ➢ Hyperamylasemia ➢ Elevated lipase. fat ➢ Hemorrhage ➢ Vascular thrombosis & inflammation Acute Pancreatitis: Clinical Dx • Abdominal pain->back • Nausea. renal ➢ Phospholipase A2. duodenitis. more specific for pancreatitis ➢ Degree of enzyme elevation: no correlation w. vomiting • DDx ➢ Perforated ulcer. tumor necrosis factor. severe pancreatitis ➢ ARDS ➢ Pulmonary infarction • Duodenum or colon distention ➢ Sentinal loop = focal dilation ➢ Colon cutoff = gas-filled colon -> abrupt cutoff at splenic flexure Acute Pancreatitis: GI Contrast • No primary role. may screw up CT • Perigastritis.

lesser sac • Not loculated • No capsule • 40% patients w. (30-50%) • 50% resolve spontaneously • > 5 cm less likely to resolve Pseudocyst: Complications [Figure 2-26-2] • Infection • Bile duct or GI obstruction • Perforation -> adjacent organs • Vascular ➢ Venous stenosis. of panc.occlusion ➢ Gastric varices ➢ Pseudoaneurysm ➢ Hemorrhage (top)Large gastric varices produced by splenic vein thrombosis from pancreatic pseudocyst adjacent to splenic hilum. pseudocyst. enzymes • Non-epithelialized wall of fibrous or granulation tissue • 4-6 wks to develop • Arise from acute fluid collect. (bottom) Pseudocyst projecting from the pancreatic tail to the splenic hilum with no visualization of hilar splenic vein Pancreatitis 462 Gastrointestinal Radiology . well-encapsulated pseudocyst adjacent to pancreatic tail Acute Pancreatitis: Terminology Atlanta Symposium 1992 • Confusion of terms • Acute pancreatitis ➢ Mild = minimal organ involvement. uncomplicated recovery w. necrosis. supportive Rx ➢ Severe = organ failure or complications eg. acute pancreatitis • 50% resolve spontaneously • May develop into pseudocyst Acute Pancreatitis: Pseudocyst [Figure 2-26-1] • Loculated collect. abscess Figure 2-26-2 Acute Pancreatitis: Acute Fluid Collections • Extravasated pancreatic fluid • Anterior pararenal space. infected necrosis.Acute Pancreatitis: MRI • Advantages ➢ Gadolinium easy on kidneys Figure 2-26-1 ➢ Able to view biliary tract • Sick Patients ➢ Motion artifacts ➢ Difficult to monitor ➢ Specialized equipment ➢ Intervention difficult Acute Pancreatitis: CT • Best overall modality • Global view • Prognosis & followup • Understand widespread nature of pancreatitis • Routes for intervention Large.

Acute Pancreatitis : Necrosis • Non-enhancing pancreas or peripancreatic tiss. transverse mesocolon • Tail = intraperitoneal -> splenorenal ligament • Posterior to the lesser sac Barium Left Anterior Pararenal Space-o-Gram [Figure 2-26-3] Figure 2-26-3 (top left) Extensive necrosis in the anterior pararenal space on both sides with air anterior to the left kidney mistaken for air in the colon. (right) Barium upper gi contrast study showing erosion of the pancreatic inflammation into the small bowel with barium contrast leaking throughout the entire left anterior pararenal space Acute Pancreatitis: Good and Bad • Interstitial (Good) 80-90% ➢ < 10% organ failure ➢ 1-3% mortality • Hemorrhagic (Bad) 10-20% ➢ Necrosis ➢ 50-60% organ failure ➢ 15-20% mortality Banks. Delayed views showing contrast anterior to the left kidney. – old “phlegmon” • Non-viable tissue • Poor prognosis • Type determines Rx ➢ Sterile-trial of med Rx ➢ Infected-debridement ➢ If infected. Gastro Endoscopy 2002 Gastrointestinal Radiology 463 Pancreatitis . (bottom left). mortality 15-50% • Needle aspiration to Dx Acute Pancreatitis: Abscess • Circumscribed collection of pus • Develops after several weeks • Needle aspiration • Percutaneous drainage Acute Pancreatitis: Location • Central location affords several routes for spreading disease • Anterior pararenal space ➢ Pancreas ➢ Duodenum ➢ Colon • Bare area = reflection of post parietal peritoneum to form the transverse mesocolon • Root of the small bowel mesentery contiguous w. Thought to be in the colon.

value on admit. AST > 250 ➢ At 48 hrs (any 3). ➢ 83 PTS ❖ All A’s discharged w/o complications within 2 wks ❖ A or B -> no abscess ❖ D or E -> 5 of 6 deaths.Acute Pancreatitis: Can we predict trouble? • 75% acute pancreatitis resolve w/o complications • 5–20% mortality • Can′t biopsy • Who is really sick? • Clinical Predictors ➢ Ranson Criteria Sens = 57–85%. WBC > 16K. fluid collections resolved in 54% • Pancreatic necrosis ➢ Poor gland enhancement correlates w. 88% after 48 hrs Clinical Assessment of Pancreatitis Severity • RANSON • Non-Gallstone pancreatitis ➢ Admission (any 3) ❖ > 55yrs old. ❖ Blood sugar >200 ❖ LDH >350 . 6% morbidity ❖ Necrosis = 23% mortality. Spec = 68–85% ➢ APACHE II = 77% pos. ❖ Hct decr >10 ❖ Rise in BUN > 5 ❖ Calcium < 8 ❖ PO2 < 60 ❖ Fluid deficit > 6L ❖ Base deficit > 4 • APACHE II ➢ Vitals signs ➢ PO2 ➢ pH ➢ Electrolytes ➢ Creatinine ➢ HCT. WBC ➢ Glasgow coma score Can Imaging Alone Predict Trouble? Yes • CT grading (Balthazar 1985. Can we refine this further? • Problem: After classifying patients as high-risk. 89% of abscesses Imaging Predicts Trouble. pred.1990) ➢ A = Normal ➢ B = Focal or diffuse enlargement ➢ C = Peripancreatic inflammation ➢ D = Single fluid collection outside gland ➢ E = 2 or more fluid collections or gas in or near panc. degree of necrosis at surgery (Kivisaari GI Radiol 1984) ➢ Gland necrosis correlates with development of complications (Balthazar Radiol 1990) ❖ No necrosis = no mortality. 82% morbidity Pancreatitis 464 Gastrointestinal Radiology .

30-50% = 4. Small amount ➢ Hyperlipidemia of peripancreatic stranding. Severe Pancreatitis: CTSI = 8-9. duct /parenchyma ➢ Focal. ➢ Amylase/Lipase levels +/– abnormal Chronic Pancreatitis: Pathophysiology • Poorly understood ➢ Etoh increases ductal secretion -> ➢ Precipitation of protein plugs -> ➢ Calcification ❖ Chain of lakes / dilated duct ➢ Inflammatory infiltrate + fibrosis Chronic Pancreatitis: Plain Films • Pancreas Ca++ (75-90%) ➢ Most common in Etoh pancreatitis. ➢ Pancreas divisum • Clinical (bottom). Rx • Improving pancreatitis that deteriorates • Severe pancreatitis w. D = 3. No enhancement with contrast ❖ Malabsorption. Mild Pancreatitis: CTSI = 0-1. CTSI 3–10 – follow-up may detect asymptomatic complications Chronic Pancreatitis • Definition (Marseilles 1985) ➢ Recurrent or persistent abdominal pain ➢ May or may not see increase enzymes ➢ Irreversible morphological change in pancreas ❖ Fibrosis ❖ Acinar destruction ❖ Calcification. ➢ Ductal or parenchymal ➢ May be focal ➢ Increase w. 92% complications Acute Pancreatitis: The Power of CT • Suspected pancreatitis – Dx in doubt • Severe pancreatitis suspected of complications • Pancreatitis w/o improvement in 72 hrs of med. Pancreas outlines are obliterated with necrosis. ❖ Diabetes. hereditary pancreatitis. E = 4 • Gland necrosis • < 30% = 2. ➢ Recurrent abdominal pain (95%). cystic fibrosis Gastrointestinal Radiology 465 Pancreatitis . B = 1. diffuse ➢ Progressive loss of exocrine/endocrine function Chronic Pancreatitis • Who Gets It? ➢ Chronic alcohol abuse (60–70%) ➢ Idiopathic (30%) Balthazar Classification of severity of acute ➢ Biliary tract disease pancreatitis ➢ Hereditary (top). C =2. ➢ Pancreatic insufficiency . > 50 = 6 ➢ 0-1 = no mortality or complications ➢ 2 = no mortality. 4% complications ➢ 7-10 = 17% mortality. segmental. progression pancreatic dysfunction ➢ Also w.Acute Pancreatitis: Can we predict trouble? [Figure 2-26-4] • CT Severity Index (Balthazar Radiol: 1990) Figure 2-26-4 • CT anatomic changes ➢ A = 0. initial scan D-E. No fluid collections. ➢ Hyperparathyroid Entire gland enhances.

(right) CT appearance of the same patient showing changes of chronic pancreatitis with parenchymal calcifications and gland atrophy Chronic Pancreatitis: Ultrasound Heterogenous echotexture ➢ Hyperechoic foci = Ca++/ fibrosis. 55-85% • Acute + chronic w. of N. single breath-hold sequences ➢ 85-90% agreement w. Clin. 50-90%: Spec. ➢ Bile &/or pancreatic duct dilation ➢ 40% focal mass DDx = cancer ➢ Complications ❖ Pseudocyst portal / splenic vein thrombosis ➢ Endoscopic ultrasound? ❖ 98% sensitivity / 90% specificity? Chronic Pancreatitis: Endoscopic Ultrasound • Difficult to establish a gold standard esp. ERP for duct caliber ➢ Limited ability to dx early chronic pancreatitis ➢ Functional exam w secretin not conclusive Remer EM Radiol. severe irregularity Pancreatitis 466 Gastrointestinal Radiology . so-called "perigastritis. exacerbation of disease Chronic Pancreatitis: MRI • Parenchymal enhancement ➢ T1 fat-supressed. Am. controls ➢ Sens = 79%. Spec = 75% ➢ Better than morphologic changes alone • MRCP. main duct 2–4 mm ➢ Moderate = small cysts. pre & post Gd dynamic ➢ Decreased signal/Delay in peak vs." There is no primary gastric disease. Spec = ?64% Chronic Pancreatitis: CT • Not as useful as in acute pancreatitis • Gland enlargement (30%) • Mass (30%) ? Cancer • Atrophy (15%) • Sens.Chronic Pancreatitis: Barium [Figure 2-26-5] • Inflammation/scar -> perigastritis • Not primary disease of bowel Figure 2-26-5 (left) Severe distortion of the gastric contours on double-contrast barium study from chronic pancreatitis with inflammatory changes and scar in the perigastric tissues. main duct obstruction.2002 Chronic Pancreatitis: ERCP • Cambridge Classification of chronic pancreatitis ➢ Mild = 3 side branches dilated.ductal anatomy ➢ Highly T2 weighted. irregular duct ➢ Severe = any of above + ❖ Cyst >10mm. intraductal filling defect. calculi. for mild to moderate disease • Few studies with histology ➢ Sens = ?87%.

J. Yekebas E. Staging of Acute Pancreatitis. Complications of Acute Pancreatitis. 1999. In: Yamada T. Topazian M. Volume 2. 8. 2003. Int. 1999. Wiersema MJ. 18: 97-106.40:6. et al. Gastroenterol. Epidemiology. Am 2002. 36: 3. Please aspirate fluid. Chatizicostas C. Clin. Turner MA. 40:6. Owyang C. diagnosis. Textbook of Gastroenterology. of N. but what is the indication for drainage? My staff wants it” • Indication for access to evolving fluid collection or necrosis decided on full evaluation of clinical. Baker ME. Knoefel WT. Isbicki JR. 7. 3. et al. Am 2002. Gastrointestinal Endoscopy 2002. Meyers MA. Radiol. Gorelick GS. 9. • Modality? • Route? ➢ Transgastric? Not for diagnosis only • What is the plan? ➢ Pus -> tube ➢ Indeterminate -> Gram stain +/. 2121-2150. Gastrointestinal Radiology 467 Pancreatitis .25:555-564. Banks PA. Acute Pancreatitis. Hawes RH. 2. Clin of N. Third Edition. Third Edition. natural history. Prospective evaluation of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in patients with chronic abdominal pain of suspected pancreatic origin. 6.tube ➢ Clear fluid -> Gram stain. 1211-1227. New York 2000. Dynamic Radiology of the Abdomen Normal and Pathologic Anatomy. 40:6. 2003. Am 2002: 40:6. Clin.Chronic Pancreatitis: Pancreas Divisum • Dorsal & ventral ducts fail to fuse (5%) • Minor papilla (Santorini) atretic • Most of pancreas drained through atretic minor papilla • Pancreatitis? • Dx = ERCP Pancreatitis Requests We Have Known and Loved Pancreatitis: “Febrile. Volume 2. 5. Balthazar EJ. culture ➢ Solid stuff -> no flow -> saline -> culture. Radiol. Radiol. 253-260. of N. 1363-1376. lab. pathogenesis. Fulcher AS. Roussomoustakaki M. 1229-1242. Lippincott Williams and Wilkins. Lippincott Williams and Wilkins.. J Colorectal Dis. Balthazar EJ. Radiol. MR Cholangiopancreatography.” What then? • You are in charge of thinking ahead. Clin of N. and imaging • Percutaneous drain useless if won′t flow through tube ➢ No tube for necrosis or hematoma ➢ Aspiration to dx infected necrosis • Uninfected collections and small pseudocysts may resolve on their own References 1. 10. Remer EM.Springer. 1199- 1209. 11. Endoscopy 1993. Chronic Pancreatitis: etiology. 56 (6) S226-S230 4. 2002. Fifth Edition. and treatment. In: Yamada T. Imaging of Chronic Pancreatitis. 2151-2177. Clin. Am. and predictors of disease outcome in acute and chronic pancreatitis. Balthazar Computed Tomography Severity Index Is Superior to Ranson Criteria and APACHE II and III Scoring Systems in Predicting Acute Pancreatitis Outcome. BX? Pancreatic Pseudocyst Pancreatic Fluid Collection: “I am happy to help. Chronic Pancreatitis. Textbook of Gastroenterology. Strate T.

J. hypotension. 6 u typed & crossed ➢ ICU Gastrointestinal Bleeding 468 Gastrointestinal Radiology . large-volume upper GI bleed (> 1000 cc) Acute GI Bleeding: Demographics • Upper GI 76% ➢ Duodenal & gastric ulcers >50%. non-steroidal anti-inflammatory • Anticoagulants Peura et al. indicates upper GI bleeding • Melena – Black. 1997 Gastrointestinal Bleeding: Presentation • Hematemesis – Bloody vomitus.J.Gastrointestinal Bleeding In The Age of the Endoscope. Brown. Am.30% of GI bleeders ➢ 5 L (10 Units) = normal volume ➢ Hct poor measure of acute bleeding ➢ 20% blood loss -> 10 mmHg drop BP w. • Lower GI 24% ➢ Diverticular 30-50% • 79% Anemia • 31% Hypovolemia • 59% Transfused • 45% Endoscopic Rx • 7% Surgery • 2% Death Peura et al. Am. pallor. What Does a Radiologist Have To Contribute? Bruce P. tobacco • Aspirin. lower GI bleed.Gastro. 1997 Gastrointestinal Bleeding: How Bad Is It? • Hypovolemia . MD GI Bleeding: Demographics • Older • Male • Use alcohol.Gastro. red. usually indicates upper GI bleeding • Hematochezia – Red blood per rectum. coffee grounds. agitation ➢ Massive GI bleed = > 6 units transfusion needed in 24 hours Acute Gastrointestinal Bleeding: Diagnosis is NOT the first priority • Resuscitation ➢ Two BIG lines 18 gauge ➢ Fluids immediately ➢ Blood when available. tarry stools. standing ➢ 40% blood loss = Shock = resting supine tachycardia.

1ml/min • Two techniques ➢ Tc 99m sulfur colloid ➢ Tc 99m labeled red blood cells • Used to ➢ Delineate obscure sources – small bowel.Gastrointestinal Bleeding: Where Is It? • Upper GI ➢ Proximal to ligament of Treitz. 1981 Lower GI Bleeding: Causes • Diagnosis % of total ➢ Diverticulosis 43 ➢ Vascular Ectasia 20 ➢ Idiopathic 12 ➢ Neoplasia 9 ➢ Colitis ❖ Radiation 6 ❖ Ischemia 2 ❖ Ulcerative colitis 1 ➢ Other 7 Reinus et al GI Clin NA 1990 GI Bleeding: Endoscopy • First line procedure in UGI bleed ➢ 90–95% accurate Dx ➢ Useful for prognosis.Gastro. ➢ Usually melena ➢ NG tube – 16% negative even w.Endosc. intermittent bleeding ➢ Enhance the efficacy of angiography Gastrointestinal Radiology 469 Gastrointestinal Bleeding . treatment • Performed immediately ➢ Alcoholics. UGI bleed • Lower GI ➢ Distal to the ligament of Treitz ➢ Usually hematochezia Upper GI Bleeding: Causes • Diagnosis % of total ➢ Duodenal Ulcer 24 ➢ Gastric Erosions 23 ➢ Gastric Ulcer 21 ➢ Varices 10 ➢ Mallory-Weiss tear 7 ➢ Esophagitis 6 ➢ Neoplasm 3 ➢ Other 11 Silverstein et al. ➢ Large volume loss ➢ Aorto-enteric fistula • Performed more “electively” ➢ Young. no evidence of hypovolemia Nuclear Scintigraphy • Most sensitive non-invasive test • Detects bleeding rates 0.

Angiography • Usually preceded by RBC study • Detects 0. Pylori • Anatomic risk factors ➢ High lesser curve ➢ Posterior-inferior duodenal bulb ➢ Giant gastric (>3 cm) & duodenal (>2 cm) • Endoscopic risk factors Risk of Rebleeding: Endoscopy • Peptic ulcer disease rebleeding ➢ Clean fibrin base 5% ➢ Flat spot 10% ➢ Adherent clot 22% ➢ Visible vessel 43% ➢ Spurting vessel 90% Laine NEJM. duodenal. bleed = non-variceal • Poor prognosis ➢ 30–50% mortality for first bleed ➢ 2/3 die within one year Gastrointestinal Bleeding 470 Gastrointestinal Radiology . ➢ Vascular ectasia on the varices • Rapid bleeding • Emergent endoscopy • 50% of cirrhotics w. punctate bleeding.v • At risk to bleed ➢ Large size ➢ Located near GE Junct. • 1/3 of these bleed • Portal v. 717. pressure >12 mmHg. vascular ectasia • Requires reduction of portal hypertension • Stress Erosions ➢ ICU patients ➢ One or more bleeding erosions ❖ Bleeding may be severe Acute Hemorrhagic Gastritis Esophageal Varices • 50% cirrhotics develop esoph. resolve w. Gastritis • Hemorrhage. H. fibrin base • Causes ➢ Non-steroidals -> antral erosions. erosions • Erosion = superficial break in mucosa w. ulcer ❖ bleeding usually not severe. above Hep. varices. D/C ➢ Alcohol ingestion ❖ Direct toxin? ->erythema Gastritis • Portal hypertension ➢ Diffuse or patchy erythema. punctate bleeding. erythema. UCLA-CURE studies. stomal ulcers = 50% UGI bleeding • Etiology: Non-steroidals.5 ml/min • Upper GI bleeding ➢ When endoscopy inconclusive ➢ Anticipation of transcatheter intervention • Lower GI bleeding ➢ Procedure of choice? Upper GI Bleeding: Peptic Ulcer Disease • Gastric. 1994.

bowel.Esophageal Varices: Rx • Vasopressin ( somatostatin/octreotide ) ➢ 50% effective • Sclerotherapy – 85–95% effective ➢ Probably improves survival. dilated channels w. 75% have o. to ileocec. blue-red discoloration Small Bowel Bleeding: Tough to Dx • 3–5% GI bleeds occur in small bowel (2nd portion duod. thrombosis -> Ca++ ❖ Tendency to bleed ➢ Angiomatosis – large area of hemangioma Gut hemangioma • Cavernous hemangioma ➢ Phleboliths on plain film ➢ UGI = Submucosal mass • CT ➢ Thick wall ➢ Early enhancement – network of vessels & sinuses thickening the wall ➢ Late enhancement – confluent sinus fill-in • Endoscopy ➢ Soft. • 90% resolve spontaneously • Rx ->endo. sm. 40% no retching • Non-penetrating linear tear(s) near GEJ ➢ 25% multiple lesions. submucosal mass or thickened folds. pathol.oversewing Gut Hemangioma • Rare • Described in young and old • Esophagus. ➢ Cavernous – large. few complications • Balloon tamponade ➢ 70–90% effective ➢ 30–50% rebleed after balloon down. valve) • Bleeding is intermittent • Most common causes are vascular • Inaccessible • Anatomy variable Gastrointestinal Radiology 471 Gastrointestinal Bleeding . ➢ 95% technically successful ➢ As effective as sclero Rx ➢ 10–15% complications ➢ 10–25% encephalopathy ➢ 30–50% stenosis at 1 year • Surgical porta-caval shunts ➢ 50–80% mortality for emergency shunt ➢ Elective shunts for endoscopic Rx failures Gastric Varices Without Esophageal Varices Mallory-Weiss Tear • 5–10% GI bleeds • Hx of retching. stomach. ➢ 10–30% severe complications • TIPS (Transjugular Intrahepatic Portosystemic Shunt) ➢ Expandable stent – hepatic to portal v. complications • Band ligation ➢ As effective as sclero Rx. colon • Classification ➢ Capillary – collection of thin-walled vess.

Small Bowel Bleeding: Causes • Vascular lesions ➢ Angiodysplasia. Radiol 144:737. mets • Ulcers ➢ Crohn’s. ➢ Method of choice Gastrointestinal Bleeding 472 Gastrointestinal Radiology .1 ml/min • Two techniques ➢ Tc 99m sulfur colloid ➢ Tc 99m labeled RBC′s • Used to ➢ Delineate obscure sources – small bowel. 1982 [2] Rabe. hemangioma. lymphoma. ZE syndrome • Diverticula • Aortoenteric fistula Small Bowel Bleeding: How Well Does Imaging Do? • Small bowel series vs enteroclysis ➢ 71% lesions missed on small bowel series [1] • Small bowel series for occult bleeding ➢ 5% yield for bleeding site [2] • Enteroclysis ➢ 10 % yield for bleeding site [3] • Enteroscopy ➢ Cumbersome. Meckel’s diverticulum. detection ➢ Loss of tag can produce false +/- • Advantages ➢ Detects intermittent bleeding • Labeled RBC′s ➢ Sensitivity = 85–95%. 140:47. • Continuous dynamic imaging ➢ Large FOV camera over abdomen ➢ 60 images q 15 min ➢ Stored for dynamic playback to detect labeled RBC’s outside normal blood pool Technetium 99m Labeled Red Blood Cells • Disadvantages ➢ Origin of bleed unclear on delayed scans ➢ Vascular organs may interfere w. not generally available [1] Maglinte. Gastro 58. AVM. 1981 [3] Rex. Radiol. intermittent bleeding ➢ Enhance the efficacy of angiography Technetium 99m Labeled RBC′′s • New in vitro process (Ultratag) >95% eff.89. vasculitis • Small bowel tumors ➢ Leiomyoma/sarcoma. adenoma/carcinoma. Specificity = 70–85%. 1997 Small Bowel Bleeding Nuclear Scintigraphy • Most sensitive non-invasive test • Detects bleeding rates of 0.

➢ 2 feet from ileocecal valve • 50% ectopic gastric or pancreatic mucosa • 25–40% symptomatic • Complications ➢ Bleeding – usually in kids <5 yr. Radiol 2004. 3% barium-positive in 52 pts w. diverticulitis [1] Cassarella. • Dacron graft. atheroma. tics bleed • 5% massively • The major cause of lower GI bleed • 75% of tics in left colon • 70% of bleeding tics in right colon [1] • 80% resolve spontaneously • Not asst′s w. occult gi bleed Hara AK. ➢ Intussusception – kids & adults ➢ Volvulus. NEJM 286:450.Meckel’s Diverticulum • Most common congenital GI tract anom. 230: 260-265) Lower GI Bleeding: Causes • Diagnosis % of total ➢ Diverticulosis 43 ➢ Vascular Ectasia 20 ➢ Idiopathic 12 ➢ Neoplasia 9 ➢ Colitis ❖ Radiation 6 ❖ Ischemia 2 ❖ Ulcerative colitis 1 ➢ Other 7 Reinus et al GI Clin NA 1990 Colonic Diverticulosis • Colon Diverticula = herniations of mucosa and submucosa through muscular layers at site of penetration of vasa recta through bowel wall. mycotic aneurysm • “Herald bleed” stops spontaneously followed by exsanguinating bleed • High index of suspicion • Preemptive surgery Pill Endoscopy • Ingestible capsule • 7 hour recording • 2 images per second • Localizing surface antennae • View in “real-time” • Contraindicated w. • Vitelline duct fails to resorb • True diverticulum – ➢ 2% of population ➢ 2 x more common in males ➢ 2 cm long ( 1–10 cm). Colonic Diverticular Bleeding • 35–50% prevalence of diverticula • 15% pts.1972 Gastrointestinal Radiology 473 Gastrointestinal Bleeding . diverticulitis. obstruction • 22% Capsule vs. perforation • Bleeding – ulceration of gastric mucosa Aortoenteric Fistula • Erosion of aorta into 3rd portion of duod.

Approach to the patient with gross gastrointestinal bleeding. Atlas of Gastrointestinal Pathology. Philadelphia. 4. Small bowel: preliminary comparison of capsule endoscopy with barium study and CT Radiology 2004. 19(2): 293-318. 6. 2002. Lanza FL. Williams and Wilkins. Dig. AK et al. Hara AK. 2005. In Textbook of Gastroenterology. 3. Capsule endoscopy: the end of the barium small bowel examination?Abdom Imaging. Gastroenterology Clinics of North America. Dis. Swain CP. Upper and lower gastrointestinal bleeding in the elderly. Jan. Fritscher-Ravens A. coils • Surgery Angiodysplasia • 20–40% acute LGI bleeding • Vascular ectasia ➢ 2/3 in pts >70 yrs old ➢ Aortic valve disease ❖ Von Willebrand factor depletion? • < 5mm vascular tufts • Cecum & right colon • Bleeding ➢ Not massive. heater probe. Jun: 92(6): 924-8. laser – select patients • Angiography ➢ Selective catheterization ❖ Vasopressin 50-90% success ❖ Embolo Rx – Gelfoam. Reinus JF. 5. Gower Medical Publishing. et al eds. et al. Hara. may temporize ➢ Endoscopic electrocoagulation ➢ Embolo Rx ➢ Diffuse disease – estrogen-progesterone ➢ Surgery References 1. Brandt LJ. The American College of Gastroenterology Bleeding Registry: Preliminary Findings. Elta GH. Am J Gastroenterol. Lippincott. 2.Colonic Diverticular Bleeding: RX • Colonoscopic vasoconstrictor injection. 1999. 85% bleed again • Pathogenesis ➢ Increased tension in cecal wall ➢ Repeated. 7. Yamada T. intermittent obstruction of submucosal veins -> dilation & tortuosity ➢ Develop small A-V malformation • Colonoscopy 80–90% sensitive • Angiography ➢ early tangle of vessels ➢ early filling & slow emptying dilated veins • Treatment ➢ Abnormal vessels – poor response to vasoconstrictors.20(2): 127-33. Peura DA. Mitros FA. 1990 Jun. 230: 260-265. 1997. The wireless capsule: new light in the darkness. intermittent ➢ Stop spontaneously. Gastrointestinal Bleeding 474 Gastrointestinal Radiology .

MAB diseases Figure 2-28-2 ➢ Radiation enteritis. not Distended: ➢ Chronic. KUB.Urgent Emergency ! ➢ Classic Appearances ❖ Intermittent “Chronic” SBO ❖ Partial SBO ➢ Motility ❖ Common Ileus ❖ Unusual dysmotilities Acute mechanical SB obstruction SBO showing uniformly distended bowel • Motility ➢ Paralytic Ileus ➢ Scleroderma “Collagen Vasc Disease” ➢ Sprue. intermittent SBO or ➢ DYSMOTILITIES ! Gastrointestinal Radiology 475 Small Bowell Obstruction . to capacity Simple SBO • A tapered distension meandering back toward Treitz. MD Figure 2-28-1 Small Bowel Obstruction • “Impaired passage of contents thru SB. metabolic ➢ Chronic Intestinal Pseudo-obstruction ➢ DYSMOTILITY is a FUNCTIONAL Obstruction ! ➢ Slow passage acts / looks obstructive Chronic vs Acute SBO: Concept to help analyze SB in CT. Scholz. earliest stage ➢ Hypothyroidism. not (XS) Dilated: ➢ Acute.Small Bowel Obstruction Francis J. SB Series • Distention vs Dilatation: 2 variables ➢ Dilatation: SB diameter larger than expected ❖ A few loops or entire SB ❖ May or may not be Distended ➢ Distention: SB uniform appearance of maximum possible diameter ❖ Like a sausage shaped balloon inflated to its capacity ❖ Appears tensely filled. initial SBO • Dilated.” • Partial vs Complete (“High Grade”) • Intermittent vs Continuous • Mechanical vs Paralytic (“Ileus”) SBO • Review ➢ Mechanical ➢ Classic Acute “Complete” SBO ❖ Simple SBO ❖ Closed Loop Obstruction (CLO) . • A single transition point Scleroderma SB shows dilated loops Chronic Intermittent SBO with segments whose diameter are • Dilated but not distended greater than last case of acute SBO. Loops are not uniformly distended Chronic vs Acute SBO [Figures 2-28-1 to 2-28-3] with segments that are partly • Distention vs Dilatation collapsed • Distended.

A history of prior partial colon resection. Pseudoobstruction: POLIP Syndrome. ➢ Atonic ➢ Conceptually like: Scleroderma • Neuropathic forms: ➢ Spastic. infrequent. Intestinal Pseudo-obstruction. obstruction in a patient with chronic Leukoencephalopathy. ➢ Non propulsive peristalsis ➢ Pulsion divertics of SB ➢ Conceptually like: Diffuse Esophageal Spasm Bloating. This suggests acute Simon et al. et al Digestive smooth muscle mitochondrial myopathy in pts with mitochondrial-neuro-gastro-intestinal encephalomyopathy (MNGIE). Gastroenterologie 2005 Aug.• Dilated and Distended: Figure 2-28-3 ➢ Acute. volvulus of colon in a young pt. Segments that do not propel act like mechanical obstruction. • Myopathic forms: ➢ More common ➢ Dilated. 773 .28:349-360 Disease (arrow) Figure 2-28-4 48 Hr films shows barium in proximal SB. Ophthalmoplegia. Dysmotility diseases may produce massive dilatation. SMA syndrome requiring duodeno-jejunostomy.p. Leukoencephalopathy.N 8-9. and require extensive work-up. recurrent SBO Chronic Idiopathic Intestinal Pseudo-obstruction “CIIPO” • No cause (readily) apparent. Diseases affecting nerves and muscles of the bowel are multiple. P-O-L-IP • Rarenth power (73 cases up to 2005) • Familial. Ann recurring obstruction from Crohns Neurol 1990. Polyneuropathy.(double arrow).778 and uniformly distended. or recurrent obstructions without apparent cause should raise suspicion Small Bowell Obstruction 476 Gastrointestinal Radiology . SB appears both dramatically dilated VOL 29 . 3 cases & review of literature. Ophthalmoplegia. Autosomal Recessive Blondon H. Obstruction • Prior Colectomy for constipation with • Ileo-rectal anastomosis • Idiopathic Intestinal Pseudoobstruction [Figure 2-28-4] • Myopathic type MNGIE = POLIP • Mitochondrial Neuro Gastro Intestinal Encephalopathy MNGIE • Polyneuropathy.

moulage. ❖ Strangulating findings both evident on a 24 hr follow ❖ Dead Bowel up film with contrast still in stomach ➢ Etiology and proximal SB. delay • MRI: White matter changes. This “neuropathic intestinal pseudo-obstruction pattern” CT: Acute SBO may be seen in other rare diseases of • Holy Grail = Transition Point disordered mitochondrial activity • Define Lesion: altering peristaltic neuromuscular ❖ Tumor. high signal on T2 • Transition Point: “Single Discordance” • Tapering: Normal @ Treitz to max obstruction • SB Meanders to max allowed by mesentery CT: Acute SBO [Figure 2-28-6] • Early (ER) CT: ➢ Reduce mortality & morbidity ➢ Cost effective • Diagnose SBO Segmental non coordinated SB ➢ Grade Severity contractions of the small bowel may ❖ Simple produce PULSION DIVERTICULA ❖ Closed Loop (T) and marked delay in transit. hernia bowel coordination ➢ No “Lesion” = “Adhesion” ➢ Study: ❖ Colon -? Collapsed SBO Fluid filled: Ileus.Radiology of “POLIP” “MNGIE” [Figure 2-28-5] Figure 2-28-5 • Slow GI Transit • Non-propulsive SB hypermotility ➢ LIKE DES Corkscrew esophagus • SB Tics from segmental spasm • Malabsorption pattern: wet. MAB ❖ Ileocecal Valve Figure 2-28-6 ❖ Duodenal Crossing ❖ Mesenteric Vessels Adhesion • MAJOR CAUSE SBO: • Benign Adhesions ➢ Surgical ➢ Inflammatory -itis ➢ Radiation ➢ Endometriosis ➢ Ischemia • Neoplastic Adhesions ➢ (Carcinoid) Transition point without discernable mass or hernia indicates adhesion Gastrointestinal Radiology 477 Small Bowell Obstruction .

SB “Bezoars” are useful to point to a site of obstruction. Hiatal.Tethered Adhesion [Figure 2-28-7] Figure 2-28-7 Bezoar [Figure 2-28-8] • Rarely sole cause SBO: ➢ THINK: motility dis. et al Oburator H: usefulness of CT in DX. 1995 or entrapment of its Nov. Tiny barely visible in pts with dysmotility disorders hernias may produce significant obstruction Small Bowell Obstruction 478 Gastrointestinal Radiology . scleroderma ➢ Nl person: Fiber binge • More often part of SBO: ➢ Fibrous Food impaction just above minor “lesion”. ❖ Radiation. the bolus reaches the ileocecal valve. etc • By Type ➢ Complete vs Partial (Richter) • By Content ➢ Littre (pre-existing tic). CT SB angulation of a loop is faeces sign: description & clinical suspicious for adhesion significance. Amyand (appendix) • By Severity ➢ Reducible ➢ Non-Reducible or “Incarcerated” ➢ Ischemic or “Strangulated” ➢ Infarcted Figure 2-28-9 Obturator Hernia [Figure 2-28-9] • Elderly F 10 to 1 M • R >> L • Assoc w recent wt loss • Not palpable • SBO in Obturator Pectineal Space • Howship Romberg Sign ➢ Pain medial thigh +/- 50% • Hannington Kiff ➢ Absent thigh adductor reflex Ijiri R. Spigelian. Femoral. They are composed of residual fibrous material that begins fermentation. Clin Radiol. Sciatic.: Surg.1996 Feb.50(11):765-7 mesentery Abdominal Hernias • By Location ➢ External vs Internal Figure 2-28-8 ➢ Inguinal. Wittenberg.119(2):137-40. and other fibrous foods Obturator Hernias are unusual may cause transient symptomatic hernias difficult to detect by obstruction in normal patients when simple physical examination. et al. (adhesion) “SB Feces sign” ➢ POINTS TO OBSTRUCTION Tenting or sharp Mayo-Smith WW. Special maneuvers are Poor peristaltic tone may play a role needed. Carrots. mushrooms.

or non- reducibility. Incarceration often is associated with intermittent obstruction and predisposed to vascular compromise Gastrointestinal Radiology 479 Small Bowell Obstruction . The hernia sac protrudes through a normal weak point where the transversalis muscle fascia changes from posterior to anterior attachment to the rectus sheath. Classic location is either lower quadrant lateral to rectus muscle. may cause inward bowing of the anterior abdominal wall.Spigelian Hernia SBO [Figure 2-28-10] • Note hernia under extern obl muscle Figure 2-28-10 Spigelian Hernias may not be evident on physical examination. Often the hernia stays under the external oblique muscle Figure 2-28-11 Incarcerated & Strangulated Parastomal Hernia [Figure 2-28-11] • SBO upstream ➢ Efferent Limb collapsed ➢ Neck squeezed • CLO ➢ Distended Hernia Loop • Strangulation ➢ Hernia Sac Fluid • Incarceration ➢ Compressed Abd Wall Chronic incarceration.

175(6):1601-7 Value of Combining 2 signs for Dx of Ischemia in SBO Sign Combination Sens% Spec % Mural Thickening + 29. ➢ Volvulus • Obstructed loop fills w fluid. elongates • Base narrows. sites ➢ Adhesion. and stone in distal SB.179(2):383-7 (Chronic) Small Bowell Obstruction 480 Gastrointestinal Radiology .7 94. Herlinger. External ➢ Tumor. Note fistula to duodenum. Radiology. AJR internal mucosa and (right of diamond) adjacent loop which has 2000. Acute high grade SB Series: Value of Tangent unrelieved obstruction causes edema from compression of mucosal venous drainage.Gallstone Ileus [Figure 2-28-12] Figure 2-28-12 Zalcman M. • Distends.7 94. simple SBO may lead to bowel infarction Parastomal Hernias: Tangent with Valsalva Mesenteric Volvulus • Assoc w ➢ Malrotation ❖ Left Colon ❖ Right SB ❖ “Weak” Treitz ➢ Internal Hernia ➢ External Hernia ➢ Post operative • Short / bunched mesentery Closed Loop Obstruction • Lumen occluded at 2 adj.3 Mesen Vasc Congest Mural Thickening + 25 94.2 ? ISCHEMIA Congestion + Ascites Gallstone Ileus with compromised bowel. AJR 2000 Dec.2 Ascites Mesenteric Vasc 41. loop twists • Venous & Art Occlusion . Nolan Rad of CLO: 25 confirmed cases. The lower right arrow points to the longitudinal equivalent of the target sign.Infarct may result or may be chronic intermittent Maglinte. air in hepatic bile duct.Internal. et al Helical CT signs in Dx of intestinal ischemia in SBO. 1991 May. Although above findings are of Value of Tangent…with Valvalsa obstructive edema.2 Mesen Fluid Mural thickening + 29. ➢ Hernia .2 93.175:1601-1607 less mucosal enhancement .2 99.2 Mesen Vasc Congest Mesenteric Fluid + 66.2 Ascites Mesenteric Fluid + 50 94. Top Zalcman et al Helical CT Signs in Dx of right image shows a target sign loop (left of diamond) with white Intestinal Ischemia in SBO.

This increases the weight of the loop and • “BOW TIE” CLO SBO it tends to twist further. does not rule out strangulation fluid will fill the lumen Balthazar et al Closed-loop & strangulating intestinal of the closed loop. • Absence of findings of ischemia or infarction in CLO With early CLO SBO. Additional serum. obstruction: CT signs. mingle with CLO plasma. ➢ Diameter CLO big & uniform Rapid bowel infarction may then occur. Loop SB Obstruction. Radiology. diagnose Closed • Abnormalities in attached mesentery. and decomp loops distal may distending it to the maximum. Then the elevated hydrostatic ➢ Knot angle on slice may obscure pressure forces more fluid into the lumen • Obst loops prox to CLO.CT Closed Loop Obstruction (CLO) [Figure 2-28-13] • Closed Loop “knot” ➢ Clustering of SB loops Figure 2-28-13 ➢ Blocked at two ends ➢ Very distended • Mesentery: ➢ Bunching of engorged vessels • SBO above CLO ➢ Less distended • Ascites Single Discordance of Simple SBO Double Discordance of CLO . It is critical to ➢ Target sign.SBO SB CLO Ischemic & Hemorrhagic [Figure 2-28-14] • Bowel wall changes ➢ Thickening. 1992 Dec Then the fluid heavy loop will spin slightly CLO SBO Problems in Dx around the vessels.and eventually blood may ooze into the • Ascites may mask mes changes wall. • Knot may be elongated This compromises venous outflow engorging • Mesenteric engorgement the wall. This progressive • High Suspicion on all SBOs: twisting begins compromising arterial inflow. ➢ High attenuation I-. This ➢ Criss Crossing: Vessels / SB may all happen before the attending radiologist ➢ Thick walls comes in the next morning ➢ No oral contrast gets in Figure 2-28-14 A non-contrast CT shows high density in the wall of distended loops of SB indicating intramural hemorrhage is occuring Gastrointestinal Radiology 481 Small Bowell Obstruction .

This finding is suggestive of entrapment of mesentery by adhesions or internal hernia Small Bowell Obstruction 482 Gastrointestinal Radiology .186(1):104-9 or large size of knot.CLO SBO in Camouflage [Figure 2-28-15] Figure 2-28-15 CLO SBO Dead Bowel Criss-Crossing Vessels / Bowel [Figure 2-28-16] Bow Tie CLO SBO [Figure 2-28-17] Gastric Bypass [Figure 2-28-18] Gastric Bypass Simple Obstruction Gastric Bypass Closed Loop Obstruction CLO: Stomach to Roux [Figures 2-28-19 and 2-28-20] Sandrasegaran K. Maglinte DD. Radiology Lap slice. by ascites obscuring the mesenteric bunching. Scholz F. et al CT of acute bilio-pancreatic limb obst. AJR 2006 CLO SBO may be obscured by location of the “knot”. et al. by the angle of the “knot” relative to the Scheirey C. by small Jan. and by Roux-Y Gastric Bypass: Conceptualization intertwining of other loops of decompressed distal SB and and Precise Interpretation Radiographics in simply-obstructed proximal SB among the loops of the CLO press Sept 2006 SBO complex Figure 2-28-16 Note that on sequential sections there is an abrupt crisscrossing of bowel and vessels.

this obstruction puts high pressure on the closed gastric stump staple line Gastrointestinal Radiology 483 Small Bowell Obstruction . and shows thin perfusing walls. 1986 Figure 2-28-18 Bilio Pancreatic Alimentary Limb Limb The “Bow Tie” CLO SBO occurs when two or more loops are involved in the closed loop. more distended.Obst post Roux Figure 2-28-17 Paraduodenal Hernia • 50% IH = Paraduodenal • Mortality pre-CT era (20%) • Clinically: ➢ Asymptomatic. Assist. While there is not the risk of a twisting of vessels. ➢ Pain. There will Gastric bypass for morbid obesity offers many be two or more CLOs opportunities for SBO and one unique situation for with each having uniform CLO SBO but differing degrees of distension. CLO2 Figure 2-28-19 involves a more distal longer limb with thicker walls Closed Loop SBO obstruction may occur in Gastric Bypass patients when the bypassed Bilio-Pancreatic Limb obstructs at the Roux Y anastomosis. There will be the simple SBO above the first Common Limb to Cecum closed loop. • Left 3X > R. The Stomach has been stabled shut so a closed loop obstruction is created. CLO 1 in the upper abdomen is shorter in length. Tomo. M > F • SB entrapment = ➢ Congenital anomaly J Comp. ➢ SBO. 10:542.

SMA. V’s into hernia • 4. Note the IMV ( (large pointers) in its normal position behind the SB on the left A Left PDH or Ascending Meso-colic hernia with the Inferior Mesenteric Vein coursing anterior to the entrapped proximal small bowel Small Bowell Obstruction 484 Gastrointestinal Radiology . Note the anterior course of the right colic vessels anterior to the SB (arrows) in a right “PDH”). Normally they pass behind the upper SB. look for the IMV Figure 2-28-22 Right and left meso-colic hernias. Bunched SB possible • If you want to diagnose a Left PDH. Treitz • Normal Cecum • Transverse colon not displaced caudally • CT: Ascending Colon vessels anterior to SB loops Desc Meso-colon H • “Left PDH” • Descending mesocolic H • Ligament of Treitz OK • Cecum OK • Stomach displaced to right • Neck contains IMVein & Left Colic Art. IMV in front of SB • 3. displaced anteriorly by hernia • CT: IMV ant to SB loops Treatment with percutaneous draininage will allow elective surgery if the obstruction does not resolve Desc Meso-colon Hernia [Figure 2-28-22] • 1. Ligament of Treitz OK Figure 2-28-21 • 2. can be defined by the relationship of the right and left colic vessels to the proximal small bowel.Ascending Meso-colic H [Figure 2-28-21] Figure 2-28-20 • “Right PDH” • Ascending Mesocolic H • Absent lig. or “PDHs”.

there will ❖ Common be variation in radiographic ❖ Unusual appearance depending on where the SB is trapped. transverse. External • Dysmotilities • Critical ➢ Diagnose ➢ Stage ➢ Establish etiology descending SBO The Paraduodenal Hernia will • Reviewed remain in our literature and our ➢ Mechanical Board Examinations even ❖ Classic Acute “Complete” SBO though they are not hernias but Simple SBO errors of rotation in which the Closed Loop Obstruction (CLO) SB is trapped behind the Urgent Emergency !!!!!!!! returning meso-colon. Internal. from the Partial SBO ascending. Above one can see ascending.Truth about “PDH”s [Figure 2-28-23] Figure 2-28-23 • PDH: Bad name. and descending retro-meso-colic entrapment Gastrointestinal Radiology 485 Small Bowell Obstruction . • “Retro-mesocolic congenital hernia” ➢ Behind ascending. ➢ Rotation and fixation anomaly ❖ SB does not get out of the way ❖ SB prevents fusion Foramen of Winslow • “Epiploic Foramen” • SB above antrum ascending Cecal Volvulus into lesser sac • SBO ➢ Potential in Cecal Volvulus ➢ SB follows IC Valve Pre op DX: Infarcting Internal Hernia • Assoc w prior bowel surg ( Clips ) • See ➢ Mesenteric: ❖ Bunching ❖ Engorgement transverse ❖ Twisting ➢ Criss-crossed vessels SB Obstruction • Common disease. the transverse. ➢ Space usually obliterated as embryo ➢ Mesocolon fuses to parietal peritoneum. • Mechanical: Acute. or descending mesocolon (and colon).and ➢ Paralytic the descending colon. ❖ Classic Appearances Because there is a wide arc of Intermittent “Chronic” SBO returning colon. transverse. Chronic.

198812(2):123-9. Blondon H. Simon et al. Comp Med Imag Graph. Radiology. Larsen CT of Spigelian H. 12.:Surg. Oburator H: usefulness of CT in DX. Passas V. et al Digestive smooth muscle mitochondrial myopathy in pts with mitochondrial-neuro-gastro- intestinal encephalomyopathy (MNGIE). Ophthalmoplegia. Cho K. et al. AJR 2000. 9. Birbas A. Sandrasegaran K. Karavias D. Ann Neurol 1990. Scholz F. 8- 9:773-778 3. et al Helical CT signs in Dx of intestinal ischemia in SBO. et al.28:349-360 13. Wittenberg. Medwid SW. AJR 2006 Jan.10(3):542-3. Zalcman et al Helical CT Signs in Dx of Intestinal Ischemia in SBO. Small Bowell Obstruction 486 Gastrointestinal Radiology .175(6):1601-7. 1991 May. Zalcman M. J Comput Assist Tomogr.162: 37-41. Luedke. et al CT of acute bilio-pancreatic limb obst. Balthazar E. Radiology Lap Roux-Y Gastric Bypass: Conceptualization and Precise Interpretation Radiographics in press Sept 2006. CT of SBO: Value in Establishing Diagnosis and Determining Degree and Cause. 1995 Nov. Bowel Obstruction: evaluation with CT. Computed tomography of left paraduodenal hernia. Maglinte DD. Radiology.175:1601-1607 14. Nolan. Scheirey C. et al . 6. Ljiri R et al.50(11):765-7. Rad 1991.180:313-318. Grilias D. Frager D. Clin Radiol. 8. 10. Mayo-Smith WW. AJR 2000 Dec. 1992 Dec 2. Pseudoobstruction: POLIP Syndrome. 1986 May-Jun. Polyneuropathy. Scholz. 3 cases & review of literature. 29N.186(1):104-9 11. Rad of CLO: 25 confirmed cases.AJR 1994. et al. Maglinte. Leukoencephalopathy. CT SB faeces sign: description & clinical significance.179(2):383-7 (Chronic) 7.References 1. 119(2): 137-40 5. Herlinger. Gastroenterologie 2005 Aug. 4. Megibow A. 1996 Feb. Balthazar et al Closed-loop & strangulating intestinal obstruction: CT signs.

Symptoms & Prognosis depend on: ➢ Duration ❖ Momentary to Permanent ➢ Degree ❖ 1%-100% ➢ Extent ❖ % of SB Fast Ischemia • Cell. emphasis on CT Acute Mesenteric Ischemia 3 categories ➢ Arterial Occlusive ❖ Without Reperfusion ❖ With Reperfusion ➢ Venous Occlusive ➢ Non-Occlusive Arterial . high metabolism ➢ Edema.Acute Mesenteric Ischemia Francis J.Low Flow Pathophysiology of Ischemia • Initial Damage to Endothelial cells of pre-capillary arteriole and capillaries. Ascites ➢ With healing may see adhesions Ischemia • Rad Findings. Splenic • ESD: never: unless ➢ Surgery ➢ Radiation ➢ Vasculitis The Radiology of Mesenteric Ischemia • 1. Embolus to SMA ➢ Eg. • Blood vessels leak fluid. then cells • Mucosa & submucosa ➢ Most sensitive. Tissue. MD Bowel Ischemia • Small Bowel or “Mesenteric” ischemia ➢ SMA distribution: SB and Right Colon • ”Colonic Ischemia” . Review classifications & pathophysiology • 2.a different disease ➢ Watershed: Sigmoid. & slough • Muscularis propia ➢ Initial spasm ➢ Then atonia ➢ Then perforation / death (healing with stricture) • Serosa ➢ Petechiae. Hypotension: Profound & prolonged Gastrointestinal Radiology 487 Mesenteric Ischemia . Rad Findings: Ischemia & Infarction • 3. Organ & Organism death -24-48 H ➢ Eg. hemorrhage. Clues to Etiology. Scholz.

fleeting. (“non-reperfused”) ➢ SEE: “Thinner” or normal wall. Abd Imaging 2004.Slow or Minimal Ischemia • Cellular & localized tissue death → • Organ dysfunction ➢ Eg Radiation Enteritis ➢ Eg Scleroderma ➢ Eg Arteriosclerotic Abdominal Angina Ischemia • Chronic . 30%-50% sensitive the SB. no / min ascites. ➢ Eg: Venous occlusion. ➢ Eg. CT of SB ischemia. ascites. It is not sensitive in all • No CT perfusion of bowel wall cases. CT Manifestations of Bowel Ischemia.sudden . Chou C. sudden thrombosis. Complete proximal SMA embolus. Because of the length of • 100% specific. Transient hypotension. partial embolism • Dry: Ischemia w no arterial inflow.fast • Often both ➢ Chronic for months then Acute Wet vs Dry Ischemia • Wet: Ischemia w arterial inflow p insult (“reperfusion”) ➢ SEE: Thickest wall.slow • Acute . In this image one ➢ Summation of findings segment is perfusing while ❖ Wall thickening another loop is not ❖ Mesenteric Edema ❖ Ascites Acute Mesenteric Ischemia • WBC • Elevated Lactic Acid • History ➢ Suggestive History: ❖ Pain in excess of Physical Exam ➢ Risk Factors High Risk Patients (Boley. Clark) • Pt > 50 yrs with: • Valvular or Atherosclerotic Ht Dis • Longstanding CHF • Arrythymia • Hypovolemia or hypotension • Dig or diuretic Rx • Recent MI Mesenteric Ischemia 488 Gastrointestinal Radiology . AJR2002. 29:18-22 Figure 2-29-1 Wet vs Dry Ischemia : Personal experience • Two extremes: Prune vs Plum • Wet: Classic ➢ Radiologists overcall on CT ➢ Surgeons undercall at Surgery • Dry: Puzzling SBO ➢ Radiologists undercall . small segments that are • Diagnosis depends on not perfusing may not be ➢ History evident.miss completely ➢ Surgeons baffled by our stupidity (SECRET: Study Mesenteric Vessels I+) Most Specific Single Finding of Acute Mesenteric Absence of wall opacification is Ischemia the most specific sign of wall [Figure 2-29-1] ischemia.178-87 Chou C. bleeding into wall.recurrent .

A loop with a target sign is also noted (curved arrow). Cardiac. US ➢ Stack of Coins . Thoracic Surg Dry Infarct [Figure 2-29-2] • Tendency to: ➢ Thinner Wall ➢ Absent “Target” ➢ No intramural blood ➢ Ascites min /absent ➢ No perfusion • Beware: “Ileus or SBO” in Sick Pt at high risk Dry Infarct. The slightest amount of SB (or colon) air will rise and thin wall of normal bowel.CT. Stack of coin bowel appearance is due to fluid and blood in the valvulae conniventes Gastrointestinal Radiology 489 Mesenteric Ischemia .• Also: AAA w or wo repair Figure 2-29-2 • Also: Any Abd. Dry infarcts may • Intralum mucosal cast be due to a large central SMA embolus or smaller • Mesenteric or portal vein gas embolic or thrombi with lack of adequate • Intraperitoneal air collaterals to allow inflow. Good example of a dry infarct with minimal • Intramural fistulas or absent inflow of arterial blood. This form of ischemia • Stricture and infarction is less common and is hard to • Pseudodiverticulum diagnose unless mesenteric vessel contrast is • Many findings possible in same pt studied carefully Usually there is REPERFUSION or extensive Remember the Law of Burps & Farts inflow via collaterals producing edema or [Figure 2-29-4] hemorrhage into the bowel wall and ascitic fluid • Air rises & thins normal walls (Also note engorged mesentery) Figure 2-29-4 Figure 2-29-3 Image shows normal thin wall effaced by air (arrows) while arrowheads show thick wall not effaced by air. No ascitic • Collar button ulcers fluid. Thin walls • Shaggy gas pattern without target sign or intramural blood.CLO SBO Spectrum: Ischemia to Infarction [Figure 2-29-3] • Gasless abdomen • Ileus • Thick Folds ➢ Target .Films • Loss of Folds in Unchanging Thick-walled Loop Four sequential images (A-D) of a patient with • Focal ulcer infarction WITHOUT REPERFUSION. Dead Bowel . Walls thickened by blood or tumor will not thin out. Understanding this With reperfusion ischemia the wall thickens with fluid concept allows for easy detection of abnormal and blood from leaking capillaries.

A stack of coins appearance can be due to blood or fluid. blood. or bezoar). It is a longitudinal image of cross sectional “target sign”.The Law of Bowel Gas ll [Figure 2-29-5] Figure 2-29-5 • Air in lumen coalesces into one bubble.(unless trapped in pneumatosis. • Note dense blood layering Regular Stack [Figure 2-29-6] • Blood / Edema in Wall • Suggests: ➢ Acute ➢ Recent ➢ Severe • Not specific for ischemia Irregular Stack [Figure 2-29-7] • Blood / Edema in wall • Suggests: Images show non-coalescent air bubble (small ➢ Chronicity arrow) suggesting either pneumatosis or air ➢ Recurrence trapped in viscous blood. There is a low density / ➢ Fibrosis high density fluid-fluid level (large arrow) indicating bleeding into lumen Loss of Folds [Figure 2-29-8] Figure 2-29-7 Figure 2-29-6 An irregular stack of coins suggests re-bleeding and chronicity with fibrosis Figure 2-29-8 A regular stack of coins with relatively uniform appearance of folds is suggestive of recent bleeding into wall. stool. Pts with coagulopathies or with leaking capillaries due to vasculitis will have a similar appearance Loss of folds in an unchanging loop is an ominous sign for infarction. It indicates extreme wall thickening and loss of peristalsis Mesenteric Ischemia 490 Gastrointestinal Radiology .

With even the severest mesenteric ischemia and infarction. The CT of air to enter veins.Thick Wall & Ulcers [Figure 2-29-9] Figure 2-29-9 Ischemic Pneumatosis [Figure 2-29-10] Intramural and Intravenous Air [Figure 2-29- 11] V Air & Lack of Wall Perfusion [Figure 2-29-12] CT Equivalent to stack of coins with arrows pointing to collections of contrast in the wall suggesting loss of mucosal integrity Figure 2-29-11 Figure 2-29-10 Image A: Intramural and intravenous air (arrows). The degree of infarction is difficult to determine and Two spot films(images A & B) from a water soluble may not correlate with amount of air. evidence of a degree of bowel infarction. Once air enters a vein it may scan slice (image C) shows pneumatosis travel long distances. A small contrast ileostomy enema shows multiple focus of wall infarction may allow a large amount ulcerations filling with contrast or with air. the unaffected stomach muscles will continue to peristalse fluid and air into the SB creating SB distension Look carefully for AIR in VESSELS USE lung windows in Ischemic and in SBO cases to look for venous air. When SB obstruction is present air will be under pressure and large Figure 2-29-12 amounts may enter veins through even tiny foci of loss of mucosal integrity. Use narrow windows to find subtle wall density changes indicating either blood or lack of perfusion Gastrointestinal Radiology 491 Mesenteric Ischemia .

It doesn’t stay near its origin Figure 2-29-13 Figure 2-29-14 Loops show EXTREME variations in wall perfusion from absent to HYPERperfusion. a sign of a mucosal cast. air in intra-splenic veins would likely be seen Sloughed Mucosa / Serosa [Figure 2-29-15] Figure 2-29-15 Mucosal Cast [Figure 2-29-16] • Inside Serosa SBO Pearl [Figure 2-29-17] • SBO makes isch / Infarxn look worse • We overestimate Infarction • Edema greater • Air dissects great distances under pressure: ➢ Neck crepitus reported • Pneumatosis not = Infarxn Figure 2-29-16 The mucosa (long arrows) is seen sloughed in lumen outlined by contrast reaching to smooth as yet intact serosa (short arrows) With infarction and diffuse loss of mucosal integrity. (Arrow) Air in enhancement from “shock bowel” in unaffected portal system may distribute anywhere within loops not involved with vasculitis portal circulation by gravity. In prone position. This pt with infarction and perforation from vasculitis. a sloughing of mucosa Mesenteric Ischemia 492 Gastrointestinal Radiology . show shaggy irregular intramural air. A & B. The serosa