1000 - Wednesday - Thoracic Imaging I - Shah PDF

Thoracic Imaging I
Rakesh Shah, MD, FCCP

Chief of Thoracic Radiology
Departments of Radiology and Medicine
North Shore University Hospital
Associate Professor of Radiology
Hofstra North Shore-‐LIJ School of Medicine
© 2014 American College of Chest Physicians

Disclosure
I have no relaFonships with any industry

Objectives
•  Review
•  Tracheobronchial diseases
•  Atelectasis
•  Solitary pulmonary nodule
•  MediasFnum
•  High ResoluFon CT scan

Objec&ves: Tracheobronchial diseases
•  Review anatomy of the trachea
•  Review diseases associated with
•  Tracheal narrowing
•  Malignancy
•  Inflammatory condiFons
•  Tracheal dilitaFon

Anatomy of Normal Trachea

Tracheal Stenosis
•  Malignancy •  Inflammatory disorders
•  Squamous cell carcinoma •  Saber sheath
•  Tracheobronchomalacia
•  Adenoid cysFc carcinoma •  Post-‐intubaFon
•  Mucoepidermoid carcinoma •  Tracheobronchopathia
•  Benign lesions OsteochondroplasFca
•  Relapsing PolychondriFs
•  Papilloma, Hamartoma
•  Amyloidosis
•  Metastasis •  Wegener’s Granulomatosis
•  InfecFon
•  Rhinoscleroma
•  Tuberculosis
•  Fungal

Clinical Presentation
•  OPen misdiagnosed with refractory asthma

•  Wheezing
•  Dyspnea on exerFon
•  Cough
•  Hoarseness
•  Hemoptysis

Tracheal Tumors
•  Squamous cell and Adenoid cysFc carcinoma account for 85%
of all tracheal tumors
•  Imaging: Polypoid, sessile or circumferenFal thickening
•  Metastasis: Direct or hematogenous spread
Squamous cell carcinoma: Adenoid cysFc carcinoma:

Associated with history of Not related to smoking
smoking or alcohol abuse Originates in the submucosal
Aggressive tumors bronchial glands of trachea or
Poor prognosis main bronchi

Tracheobronchomalacia
•  Common underrecognized cause of dyspnea and cough
•  Excessive expiratory collapse of the trachea and bronchi
•  greater than 50% decrease in cross-‐secFonal area of the airways
•  Frown-‐like configuraFon of trachea
•  Causes
•  Prior trauma, intubaFon, infecFon
•  Relapsing polychondriFs
•  Diagnosis
•  Paired Inspiratory-‐Dynamic expiratory imaging
•  Bronchoscopy

Post intubation stricture
•  Stenosis of the trachea
•  ComplicaFon
•  Endotracheal intubaFon
•  Tracheostomy
•  Trauma
•  Mechanism
•  High pressure of cuff causes
mucosal necrosis which leads
to fibrosis and granulaFon
Fssue formaFon

Tracheobronchopathia Osteochondroplas&ca
•  Rare, benign condiFon that involves the trachea and major
bronchi
•  Characterized by mulFple submucosal osteocarFlagenous
nodules
•  EFology is unknown
•  Imaging:
•  3-‐8 mm submucosal osteocartlaginous nodules
•  Tracheal scalloping and nodular irregularity
•  Irregular narrowing of trachea
•  Spares the posterior wall of trachea

Relapsing Polychondritis
•  Rare systemic disease of unknown eFology
•  Recurrent episodes of carFlage inflammaFon
•  Mainly affects ear, nose, joints and the laryngeal and tracheal carFlage
•  Major airways are involved in 50% of cases
•  Recurrent pneumonia is the most common cause of death
•  Imaging:
•  Thickening of ant. & lat. tracheal walls
•  with or without calcificaFon
•  Spares posterior membrane
•  Dynamic imaging may demonstrate airway collapse

Amyloidosis
•  DeposiFon of abnormal proteinaceous material in extracellular
Fssue
•  Idiopathic, however, someFmes associated with various
inflammatory, hereditary or neoplasFc pathogenesis
•  Imaging:
•  Submucosal tracheobronchial deposits
•  Concenteric, smooth or nodular thickening of the tracheal wall
•  Posterior wall of trachea is involved
•  Single or mulFple pulmonary nodules
•  Diffuse intersFFal deposits

Wegener’s Granulomatosis
•  Unknown eFology
•  NecroFzing granulomatous vasculiFs of upper and lower
respiratory tract
•  More common in middle aged men
•  Imaging:
•  CircumferenFal mucosal thickening, ulceraFon & narrowing of trachea
•  Posterior wall of trachea is involved

You are shown axial CT images of a 50 year old
man. What is the most likely diagnosis?
A. Squamous cell carcinoma
B. Tracheomalacia
C. Amyloidosis
D. Post-intubation stricture

SUMMARY -‐ PROMINENT CT FINDINGS
There are various tracheal inflammatory disorders
Differential diagnosis should be approached from recognition of characteristic

radiographic manifestations and an understanding of the tracheal wall components
Circumferen&al Calcifica&on Ulcera&on Sparing of posterior wall Loca&on
thickening
Rhinoscleroma Amyloidosis TB Relapsing Focal Diffuse

PolychondriFs
Tuberculosis Tracheobronchopathia Wegener’s Tracheomalacia Post-‐ All

osteochondroplasFca intubaFon others
stricture
Wegener’s Tracheobronchopathia
osteochondroplasFca
Amyloidosis

Tracheobronchomegaly (Mounier-‐Kuhn Syndrome)
•  EFology:
•  Congenital
•  Defect in the elasFc Fssues of the trachea and large airways
•  Acquired
•  From chronic inflammatory disorders of the airways
•  From diseases that cause severe upper lobe fibrosis resulFng in wall
retracFon and tracheomegaly (Sarcoidosis)
•  Imaging:
•  Tracheal and bronchial dilation
•  Corrugated / sacculated / scalloped appearance to the trachea
due to atrophic mucosa prolapsing between the tracheal rings
•  Diverticula

Objectives
•  Review
•  Atelectasis
•  MediasFnum

Pulmonary Atelectasis
•  Defined: Decrease in volume of lung
•  Types:
•  ResorpFon
•  RelaxaFon or Passive
•  Adhesive
•  CicatrizaFon

Resorption Atelectasis
•  Defined:
•  Results from absorpFon of gas
from the alveoli when
communicaFon between alveoli
and trachea is obstructed
•  EFologies:
•  Mucus plug
•  Misplaced Endotracheal tube
•  Foreign body
•  Tumor

Mucus Plug

Passive Atelectasis
•  Caused by extrinsic
pressure on the lung
•  EFology:
•  Large pleural effusion
•  Pneumothorax
•  Mass

Lobar Atelectasis
•  Direct signs
•  Displacement of interlobar fissures
•  Crowding of bronchovascular markings
•  Indirect signs
•  Increased opacity
•  MediasFnal shiP
•  Compensatory hyperinflaFon
•  DiaphragmaFc elevaFon

Right upper lobe atelectasis
Courtesy of Dr. Abbott

LeR upper lobe atelectasis

RLL atelectasis LLL atelectasis

Right middle lobe atelectasis

Round Atelectasis: Pathogenesis

Rounded Atelectasis: Diagnosis
•  Round peripheral opacity
•  Associated with pleural abnormality
•  Pleural effusion or pleural thickening
•  Curving of bronchi and vessels into the lesion
•  Comet-‐tail sign
•  Volume loss of affected lobe

You are shown axial CT images of a 40 year old
man. What is the next most appropriate step?
A. Follow-up CT scan in 3 months
B. Nothing to do
C. Perform biopsy
D. Obtain PET scan

Objectives
•  Review
•  Atelectasis
•  Solitary pulmonary nodule ( SPN )
•  MediasFnum

Objec&ve
•  DefiniFon
•  DifferenFal Diagnosis
•  Work-‐up of Nodule: CT scan
•  Solid:
•  Benign
•  Less than 4 mm
•  Size between 5 to 8 mm
•  Greater than 9 mm
•  Subsolid


•  Focal round or oval area of
increased opacity
•  Can be non-‐solid, part
solid or solid
•  Less than 3 cm in maximum
diameter
•  Not associated with
atelectasis, pneumonia or
adenopathy


SPN: Different types of nodules

SPN
•  OPen discovered incidentally

•  Caused by variety of condiFons, both benign and malignant
•  Important to idenFfy benign versus malignant nodules
•  Pre-‐test probability
•  Morphology
•  Imaging tests: Lung nodule enhancement, PET scan
•  Procedures: Bronchoscopy, TTNB
•  Goal: Avoid morbidity and mortality associated with
thoracotomy for benign diseases

SPN: DDx is very long
Benign: Malignant:
•  Pneumonia •  Lung cancer
•  Granuloma •  Metastasis
•  Hamartoma •  Carcinoid
•  AVM •  Lymphoma
•  Pulmonary artery
pseudoaneuyrsm
•  Intrapulmonary lymph nodes
•  Inflammatory

SPN: Work-‐up starts with CT scan
•  CalcificaFon:
•  Benign & Malignant paderns
•  Fat:
•  Signifies lesion as benign
•  Vascular lesion
•  Intrapulmonary lymph node (IPLN)
•  Size
•  Morphology
•  Round / Lobulated / Spiculated: Not very helpful
•  Solid nodule / Pure ground glass / Subsolid nodules

PaUerns of Calcifica&on
Benign Patterns Malignant Patterns

Hamartoma

Lipoid pneumonia

AVM

Intrapulmonary lymph node ( IPLN )

What is an Intrapulmonary Lymph Node?
Nodule of lymphaFc Fssue in the lungs
Benign
Develop in response to anFgenic sFmuli
Inhaled dust
Inflammatory response
AccumulaFon of Lymphocytes and Macrophages
Hyperplasia of lymph nodes
Lympha&c Flow in the Thoracic Cavity
Subpleural IntersFFum
Interlobular Septa
Intralobular Septa
Centrilobular IntersFFum
Peribronchovascular IntersFFum

Loca&on and Shape of IPLN
•  LocaFon:
•  Subcarinal
•  Peripheral, oPen subpleural
•  Shape:
•  Triangular or Angular
•  EllipFcal
•  Semicircular

IPLN are associated with linear opaci&es
•  Linear opaciFes
represent:
•  Interlobular
septa
•  Pulmonary vein
•  LymphaFc
channels
Oshiro, Y et al. Intrapulmonary lymph nodes: Thin-‐secFon CT features of 19 nodules. J Computer Assisted Tomography. (2002) 26 (4); 553-‐557.
Characteris&cs of IPLN
Vast majority are in the RML, Lingula and
Subcarinal lower lobes
Subpleural Vast majority are within 2 cm of the pleura
Size Vast majority are less than 1 cm
Shape Triangular, Angular, EllipFcal, Semicircular
Linear Opacity Associated with Interlobular septa

Solid nodule
•  Known history of malignancy

•  Nodules of any size: Metastasis should be considered
•  Follow-‐up/Work-‐up according to relevant protocol for that
malignancy
•  Frequent follow-‐up may be indicated

History of Colon CA: 6 mths apart

Solid nodule
•  No known history of malignancy

•  Work-‐up is based on size of nodule:
•  Less than 4 mm in size

Solid nodule: Less than 4 mm in size
•  Learned from mulFple •  Risk of malignancy:
Lung cancer screening •  < 3 mm: 0.2%
trials
•  4 to 7 mm: 0.9%
•  Fleischner guidelines: •  8 to 20 mm: 18%
•  No follow-‐up in absence •  > 20 mm: 50%
of risk factors

•  Otherwise, follow-‐up in
one year
Midthun DE, Swensen SJ, Jett JR, Hartman TE. Evaluation of nodules detected by screening for lung cancer with
low dose spiral computed tomography. Lung Cancer 2003;41(suppl 2):S40. © 2014 American College of Chest Physicians
Solid nodule: Less than 4 mm in size
•  Learnt from mulFple Lung
cancer screening trials
•  Fleischner guidelines:
•  No follow-‐up in absence
of risk factors
•  Otherwise, follow-‐up in
one year
•  Many are IPLN’s

Fleischner Society Guidelines
Solid nodule: 5 to 8 mm in size
Nodule Size Low-‐Risk Pa&ent High-‐Risk Pa&ent
>4-‐6 mm Follow-‐up at 12 mths Follow-‐up at 6-‐12 mths

If unchanged, no follow-‐up If unchanged, follow-‐up in
18-‐24 mths
>6-‐8 mm Follow-‐up at 6-‐12 mths Follow-‐up at 3-‐6 mths

If unchanged, follow-‐up in If unchanged, follow-‐up in
18-‐24 mths 9-‐12 and 24 mths
Should try to perform follow-up scans using low-dose protocol

Heber MacMahon, John H. M. Austin, Gordon Gamsu, Christian J. Herold, James R. Jett, David P. Naidich, Edward F. Patz, Jr, and Stephen J. Swensen. Guidelines
for Management of Small Pulmonary Nodules Detected on CT Scans: A Statement from the Fleischner Society Radiology November 2005 237:395-400
SPN: > 9 mm in size

Pneumonia

Pneumonia

Solid nodule: Larger than 9 mm
•  Short interval follow-‐up

•  If resolved:
•  Likely infecFon and no further work-‐up necessary
•  If decreased in size:
•  Likely infecFon but follow-‐up to resoluFon
•  If unchanged: Requires work-‐up
•  Follow-‐up
•  Bronchoscopy, TTNB, Surgery
•  PET Imaging
•  Nodule enhancement CT scan
Subsolid nodules
Pure ground glass Part solid

Subsolid nodule
•  Pure ground glass nodule (GGN) or Part solid nodule

•  Solitary or MulFple
•  May be benign
•  InfecFon
•  Assumed to be adenocarcinoma in situ (AIS), formerly
referred to as bronchioloalveolar carcinoma ( BAC )
•  Part solid: More likely to be malignant

New classifica&on of lung adenocarcinomas
•  Premalignant:
•  Atypical adenomatous hyperplasia (AAH)
•  Adenocarcinoma in situ (AIS)
•  Malignant:
•  MIA
•  Invasive component measuring less than 5 mm
•  Invasive adenocarcinoma:
•  Invasive component measures greater than 5 mm

Solitary GGN: Less than 5 mm
•  Do not require follow-up
examination
•  Doubling time is 3 to 5
years
•  Many likely represent
incidental foci of
adenomatous hyperplasia
•  To establish true nature of
GGN:
•  Obtain 1 mm thin sections
Naidich DP, Bankier AA, MacMahon H, Schaefer-‐Prokop CM, Pistolesi M, Goo JM, Macchiarini P, Crapo JD, Herold CJ, AusFn JH, Travis WD.
RecommendaFons for the management of subsolid pulmonary nodules detected at CT: A statement from the Fleischner Society. Radiology Vol 266(1):304-‐317
Solitary GGN: Larger than 5 mm
•  IniFal follow-‐up in 3
months
•  If unresolved:
•  Yearly follow-‐up for
minimum of 3 years
•  No way to know exact
nature short of resecFon
•  Biopsy and PET CT scan are
not recommended

Solitary Subsolid nodule
•  Initial follow-up in 3 months
•  If solid component <5 mm:
•  Yearly follow-up for
minimum 3 years
•  If solid component >5 mm:
•  Recommend biopsy or
surgical resection
•  Most likely to represent
invasive adenocarcinoma
•  Consider PET scan for
nodules greater than 1 cm
Objec&ve
•  DefiniFon: Solitary pulmonary nodule (SPN)
•  DifferenFal Diagnosis
•  Work-‐up of Nodule: CT scan
•  Solid:
•  Benign
•  Less than 4 mm
•  Subsolid


Objectives
•  Review
•  Atelectasis
•  MediasFnum

Without Music Life Would Be A Mistake
Residents
Fellows
Thank you

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Thoracic Imaging I

Rakesh Shah, MD, FCCP

© 2014 American College of Chest Physicians

I have no relaFonships with any industry

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

• OPen misdiagnosed with refractory asthma

© 2014 American College of Chest Physicians

Squamous cell carcinoma: Adenoid cysFc carcinoma:

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

Differential diagnosis should be approached from recognition of characteristic

Rhinoscleroma Amyloidosis TB Relapsing Focal Diﬀuse

Tuberculosis Tracheobronchopathia Wegener’s Tracheomalacia Post-­‐ All

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

Courtesy of Dr. Abbott

Courtesy of Dr. Abbott

Courtesy of Dr. Abbott

© 2014 American College of Chest Physicians

Courtesy of Dr. Abbott

Courtesy of Dr. Abbott

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

• OPen discovered incidentally

© 2014 American College of Chest Physicians

Benign Patterns Malignant Patterns

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

Subpleural Vast majority are within 2 cm of the pleura

Size Vast majority are less than 1 cm

Shape Triangular, Angular, EllipFcal, Semicircular

Linear Opacity Associated with Interlobular septa

© 2014 American College of Chest Physicians

• Known history of malignancy

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

• No known history of malignancy

© 2014 American College of Chest Physicians

•  OPen misdiagnosed with refractory asthma

Tuberculosis Tracheobronchopathia Wegener’s Tracheomalacia Post-‐ All

•  OPen discovered incidentally

•  Known history of malignancy

•  No known history of malignancy

Nodule Size Low-‐Risk Pa&ent High-‐Risk Pa&ent

•  Short interval follow-‐up

•  Pure ground glass nodule (GGN) or Part solid nodule