PGY-2 Curriculum

Specific Lung Nodules/Masses

Features and Interpretation

Charles T. Lau, MD, MBA

Feature-based Approach to Chest Radiology
PGY-2 learning plan

Concepts & Differential Diagnosis Strategy Mechanics

Introduction
Chronic Non-Diffuse Pleural Basic
Consolidation Disorders Lexicon

Nonspecific Interstitial Opacities Anterior Mediastinal How to read

Nodules/Masses Nodular Patterns Disorders Chest CT

Specific Interstitial Opacities Middle Mediastinal How to read

Nodules/Masses Reticular & Septal Patterns Disorders Frontal CXR

Atelectasis
Isolated Posterior Mediastinal How to read
Ground-Glass Opacities Disorders Lateral CXR

Acute Non-Diffuse Hyperlucent Hilar

Consolidation Lung Disorders Disorders

Acute Diffuse Large Airway Chest Wall & Diaphragm

Consolidation Disorders Disorders
Abnormal Lung Opacity
4 causes

Nodule/Mass Atelectasis Consolidation Interstitial

or Fibrosis Opacity
Lung Nodules & Masses

Nodule/Mass
Lung Nodules & Masses

? ⌘

Nodule/Mass Nonspecific Specific

Nodule/Mass Nodule/Mass
Lung Nodules & Masses

Nonspecific
• imaging features not
specific for diagnosis ? ⌘
• require imaging follow-up,
biopsy, culture, etc.
Specific
• imaging features highly
specific for diagnosis
Nonspecific Specific
• example: pulmonary AVM Nodule/Mass Nodule/Mass
Lung Nodules & Masses

Nonspecific
• imaging features not
specific for diagnosis ? ⌘
• require imaging follow-up,
biopsy, culture, etc.
Specific
• imaging features highly
specific for diagnosis
Nonspecific Specific
• example: pulmonary AVM Nodule/Mass Nodule/Mass
Features & Interpretation
Specific Lung Nodules/Masses
Principles

Occasionally a lung nodule/mass will exhibit features that

permit specific diagnosis on CT
• can occur in a couple pathologic entities we’ll need to
remember
• but don’t expect every incidence of these entities will
present specifically on CT → e.g. not every single
hamartoma will present specifically

Nonspecific nodules/masses > specific nodules/masses

Specific Lung Nodules/Masses
Interpretation strategy

Not algorithmic (i.e. unlike our approach to nonspecific lung

nodules/masses)
Pattern recognition / “machine learning” approach
• master list of options
• train, tune, and test with images from lots of cases
Specific Lung Nodules/Masses
9 entities that may sometimes present specifically on CT

Congenital Neoplastic
pulmonary AVM pulmonary hamartoma
infected pulmonary sequestration
infected type 2 CPAM

Infectious Inflammatory non-infectious

noninvasive aspergillosis round atelectasis
invasive aspergillosis lipoid pneumonia
calcified granuloma
Specific Lung Nodules/Masses
9 entities that may sometimes present specifically on CT

Congenital Neoplastic
pulmonary AVM pulmonary hamartoma
infected pulmonary sequestration
infected type 2 CPAM

Infectious Inflammatory non-infectious

noninvasive aspergillosis round atelectasis
invasive aspergillosis lipoid pneumonia
calcified granuloma
Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital
Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

pulmonary artery pulmonary vein

capillary bed
Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

high resistance

high resistance
pulmonary artery pulmonary vein
Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

pulmonary artery pulmonary vein

Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

pulmonary artery pulmonary vein

Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

low resistance

high resistance
pulmonary artery pulmonary vein
Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

low resistance

high resistance
pulmonary artery pulmonary vein
Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

pulmonary artery pulmonary vein

Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

PAVM

pulmonary artery pulmonary vein

Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

PAVM

pulmonary artery pulmonary vein

Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

PAVM

pulmonary artery pulmonary vein

Pulmonary Arteriovenous Malformation (PAVM)
Specific nodule/mass: congenital

Engorged feeding pulmonary artery & draining pulmonary vein

• 80% are “simple” – fed by single segmental artery (multiple
subsegmental arteries included)
• “complex” PAVM – fed by multiple segmental arteries
May appear “solid” or “sub-solid”
Lower lobes > upper lobes
CT > diagnostic angiography
• thin-section non-contrast CT okay
• IV contrast not always required
Pulmonary Arteriovenous Malformations
Infected Pulmonary Sequestration
Specific nodule/mass: congenital
Infected Pulmonary Sequestration
Specific nodule/mass: congenital

Region of primitive, underdeveloped lung parenchyma

Retain systemic (not pulmonary) arterial supply
Two varieties extralobar
25%
• intralobar
• extralobar
intralobar
75%
Infected Pulmonary Sequestration
Specific nodule/mass: congenital

Complex air-filled multicystic structure

• appears lucent if uninfected
• appears mass-like if infected
Usually occur in medial basal lower lobes right lower lobe
33%
left lower lobe
67%
Infected Pulmonary Sequestration
Specific nodule/mass: congenital

Intralobar pulmonary sequestration

• exist inside visceral pleura of existing lobe
• rudimentary communication with airways → infection possible
• feeding systemic artery — but not always visible on CT
• pulmonary (not systemic) venous drainage
• discovered in young adulthood 2° recurrent infection
Infected Pulmonary Sequestration
Specific nodule/mass: congenital

Extralobar pulmonary sequestration

• exist outside visceral pleura of existing lobe, covered in
their own pleura
• no communication with airways → sterile
• focal uniform density triangular mass (think atelectasis)
• feeding systemic artery — but not always visible on CT
• systemic (not pulmonary) venous drainage
• associated with other congenital anomalies
(diaphragmatic hernia, cardiac, skeletal)
• discovered in infancy
Infected Intralobar Sequestration
Infected Intralobar Sequestration
Infected Intralobar Sequestration
Infected Intralobar Sequestration
Infected Intralobar Sequestration
Infected Intralobar Sequestration
c

Extralobar Sequestration
Extralobar Sequestration
Extralobar Sequestration
Infected Type 2 CPAM
Specific nodule/mass: congenital
Congenital Pulmonary Airway Malformation (CPAM)
Specific nodule/mass: congenital

Region of bronchial/bronchiolar overgrowth

with suppression of alveolar development type 4
type 3 10%
5%
Types
• more distal airway → smaller cysts
type 2
• type 1: single/multiple 2-10cm cyst(s) 20%
type 1
• type 2: multiple 0.5-2 cm cysts 65%

• type 3: microscopic cysts → look solid

• type 4: large multilocular cysts
Congenital Pulmonary Airway Malformation (CPAM)
Specific nodule/mass: congenital

Region of bronchial/bronchiolar overgrowth

with suppression of alveolar development type 4
type 3 10%
5%
Types
• more distal airway → smaller cysts
type 2
• type 1: single/multiple 2-10cm cyst(s) 20%
type 1
• type 2: multiple 0.5-2 cm cysts 65%

• type 3: microscopic cysts → look solid

• type 4: large multilocular cysts
Infected Type 2 CPAM
Type 1 CPAM
Type 1 CPAM
Laryngotracheal Papillomatosis
Laryngotracheal Papillomatosis
Bronchogenic Cyst
Specific Lung Nodules/Masses
9 entities that may sometimes present specifically on CT

Congenital Neoplastic
pulmonary AVM pulmonary hamartoma
infected pulmonary sequestration
infected type 2 CPAM

Infectious Inflammatory non-infectious

noninvasive aspergillosis round atelectasis
invasive aspergillosis lipoid pneumonia
calcified granuloma
Pulmonary Hamartoma
Specific nodule/mass: neoplastic
Pulmonary Hamartoma
Specific nodule/mass: neoplastic

Round or oval
Well-circumscribe margins, clean adjacent lung
Specific features sometimes present
• lipid: ≥8 voxels less than -40 HU attenuation
• calcification: popcorn pattern
Lipid-poor hamartomas or without popcorn calcification
present nonspecifically
• imaging follow-up
• excisional biopsy
Pulmonary Hamartoma
Pulmonary Hamartoma
Pulmonary Hamartoma
Pulmonary Hamartoma
Pulmonary Hamartoma
Pulmonary Hamartoma
Specific Lung Nodules/Masses
9 entities that may sometimes present specifically on CT

Congenital Neoplastic
pulmonary AVM pulmonary hamartoma
infected pulmonary sequestration
infected type 2 CPAM

Infectious Inflammatory non-infectious

noninvasive aspergillosis round atelectasis
invasive aspergillosis lipoid pneumonia
calcified granuloma
Specific Lung Nodules/Masses
Infectious

Noninvasive aspergillosis
Invasive aspergillosis
Calcified granuloma
Aspergillosis

Normal Mild Moderate Severe

COPD Organ transplant Leukemia

Diabetes HIV with CD4 Severe neutropenia
between 50-200
Low-dose steroids HIV with CD4
under 200
HIV with CD4
over 200

Non-invasive form Invasive form

Non-invasive Aspergillosis
Specific nodule/mass: infection
Non-invasive Aspergillosis
“Mycetoma” or “Aspergilloma”

Normal immunity
Fungus ball occupies pre-
existing lung cavity from other
disease
• sarcoidosis
• cystic fibrosis
• latent TB
Non-invasive Aspergillosis
“Mycetoma” or “Aspergilloma”

Normal immunity
Fungus ball occupies pre-
existing lung cavity from other
disease
• sarcoidosis
• cystic fibrosis
• latent TB
Non-invasive Aspergillosis
Non-invasive Aspergillosis
Invasive Aspergillosis
Specific nodule/mass: infection
Invasive Aspergillosis

Severe immunosuppression
Invasive
• vascular invasion
• airway invasion
Nodule/mass, sometimes with
ground-glass “halo”
Rapidly progressive
Often fatal
Invasive Aspergillosis
Specific nodule/mass: infection

New moon air-crescent sign

• when present virtually diagnostic
for invasive aspergillosis
Invasive Aspergillosis
Invasive Aspergillosis
Invasive Aspergillosis
Calcified Granuloma
Specific nodule/mass: infection
Calcified Granuloma
Specific nodule/mass: infection

Remote granulomatous infection

• tuberculosis
• non-tubercular mycobacterial infection
• endemic fungal (histo, cocci, crypto)
Solid nodule with
• complete calcification pattern
• central calcification pattern
• concentric calcification pattern
Some granulomas are non-calcified and present
nonspecifically
Calcified Granuloma
Specific Lung Nodules/Masses
9 entities that may sometimes present specifically on CT

Congenital Neoplastic
pulmonary AVM pulmonary hamartoma
infected pulmonary sequestration
infected type 2 CPAM

Infectious Inflammatory non-infectious

invasive aspergillosis round atelectasis
noninvasive aspergillosis lipoid pneumonia
calcified granuloma
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

Visceral pleural fibrosis → focal

atelectasis of peripheral lung
Causes other
15%
• asbestos related pleural disease
• prior trauma or surgery
• histoplasmosis empyema
• tuberculosis empyema asbestos exposure
85%
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

atelectatic
lung

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

atelectatic
lung

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

mass

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

“comet-tail”

visceral pleura
Round Atelectasis
Specific nodule/mass: inflammatory non-infectious

Regional pleural thickening

Dome-like mass abutting pleural thickening
“Comet tail” sign
• vessels seem to converge curvilinearly
on mass
• resemble onion shape
Round Atelectasis
Round Atelectasis
Round Atelectasis
Round Atelectasis
Round Atelectasis
Round Atelectasis
Round Atelectasis
Lipoid Pneumonia
Specific nodule/mass: inflammatory non-infectious
Lipoid Pneumonia
Specific nodule/mass: inflammatory non-infectious

Chronic lipid aspiration → aspiration pneumonia & chronic

inflammation
Mass-like consolidation
Spiculated margins common
Fat attenuation visible if lipid concentration high enough
• if low lipid concentration, will present nonspecifically → biopsy
Lipoid Pneumonia
Lipoid Pneumonia
Specific Lung Nodules/Masses
9 entities that may sometimes present specifically on CT

Congenital Neoplastic
pulmonary AVM pulmonary hamartoma
infected pulmonary sequestration
infected type 2 CPAM

Infectious Inflammatory non-infectious

noninvasive aspergillosis round atelectasis
invasive aspergillosis lipoid pneumonia
calcified granuloma
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Specific Lung Nodules/Masses: Features and Interpretation