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Cavitary and Cystic

lesions

高雄長庚醫院 胸腔內科
曾嘉成醫師
Cavity and Cyst
 Cavity: a gas containing space
within the lung surrounded by
a wall whose thickness is
greater than 1 mm.

 Cyst: a gas containing space


with a well-defined thin wall
(< 1 mm) not related to
emphysema.
Lucent lesion
 Bilateral
hyperlucency
 Unilateral
hyperlucency
 Solitary
hyperlucency
 Multiple
hyperlucency
Cavity: Causes (1)
 Inflammation:
– Pyogenic infection.
– TB.
– Fungus infection.
– Parasites.
 Neoplasm:
– Primary lung cancer.
– Metastases.
– Lymphoma
Cavity: Causes (2)
 Vascular:
– Rheumatoid.
– Wegener’s granulomatosis.
– Infarct (thromboemboli or septic
emboli).
 Inhalation:
– Silicosis and coal worker’s
pneumoconiosis.
 Congenital cyst:
– Pulmonary sequestration,
bronchogenic cyst, and congenital
Lung Cavities
Infective, i.e. abscesses
staphylococcus aureus, klebsiella pneumoniae, tuberculosis,
aspiration, others
Neoplastic
carcinoma of the bronchus, metastases, Hodgkin’s disease
Vascular
Infarction
Abnormal lung
cystic bronchiectasis, infected emphysematous bulla,
sequestrated lung, bronchogenic cyst
Granulomas
Wegener’s granulomatosis, rheumatoid nodules,
progressive massive fibrosis
Traumatic
hematoma, traumatic lung cyst
Pseudocyst????
Differential Diagnosis
(1)
 Cavitary wall:
– Thick: favor lung abscess, primary
lung ca, metastasis, Wegener’s
granulomatosis.
– Thin: favor chronic infection
(Coccidiodomycosis, Paragonimiasis).
– Wall thickness: (measure thickest
part)
 < 4 mm favor benign.

 4-15 mm inconclusive.

 > 15 mm favor malignancy.


Differential Diagnosis
(2)
 Character of the Inner Lining(
內緣 ):
– Nodular, irregular: malignancy.

– Shaggy( 毛毛的 ): acute lung


abscess.

– Smooth
Differential Diagnosis
(3)
 Nature of the Cavitary
Content:
– Fluid: in most cases, the
contents are liquid.
– Fungus ball.
– Pulmonary gangrene: irregular
pieces of sloughed necrotic lung
parenchyma float like icebergs
in the cavity fluid.
– Water-lily sign: ruptured
Differential Diagnosis
(4)
 Associated Lesions:
– Surrounding air space
consolidation: acute edema,
hemorrhage, exudate.

– Irregular reticular strands:


chronic fibrotic scar.
 Location
– Upper lobe or lower lobe?
– S3 Vs S2
Differential Diagnosis
(5)
 Multiplicity of Lesions:
– Solitary: typical for lung cancer,
acute lung abscess, post-
traumatic lung cyst.

– Multiple: typical for metastases,


Wegener’s granulomatosis,
Septic emboli.
Pentax Optio S
Cavity: Abscess (1)
 Associated Lesions:
– Surrounding air space consolidation: acute
edema, hemorrhage, exudate.
– Irregular reticular strands: chronic fibrotic
scar

 Virulent pathogen  vasculitis 


thrombosis
 necrosis  cavity
 Necrotizing pneumonia  Abscess
Cavity: Abscess (2)
 Pulmonary infection with cavitary
lesions
narrows the differential diagnosis
– Viral and mycoplasma pneumonia ---
unlikely
– Pneumococcal pneumonia --- rarely
– Most common pathogen
GPC: Staph, β-hemolytic Strep,
GNB: Kleb, Pseudo, E. coli,
Anaerobes
Lung abscess, Klebsiella pneumoniae
Cavity: Abscess (3)
 Aspiration pneumonia frequently
cavitate
– May subclinical aspiration
– Mixed GNB and anaerobes
– Cavity formation in a dependent portion
– Unconscious, poor oral hygiene, alcoholism,

or tumor in mouth, nasopharynx or larynx


Cavity: Abscess (4)
 Pulmonary gangrene:
– Relative uncommon complication
– Very acute ischemic necrosis.A nonviable
lung detached from a viable lung  cavity
– “Ball in hole” --- like fungus ball
– Most common: Klebsiella pneumoniae.
– Pneumococcus, H. influ, S. aureus,
Anaerobes, Mucormycosis, and
Aspergillus.
– Early diagnosis  surgical intervention
Pulmonary gangrene
– Relative uncommon
– Very acute ischemic
necrosis
– “Ball in hole” -- like fungus
ball
– Most common: Kleb.
pneum.
– Pneumo, H. influ, S.
aureus, Anaerobes, Muco.
Aspergillus
Lung abscess vs
Empyema
 Lung abscess : spherical, thick wall,
the air-fluid levels are equal in length
regardless of the radiographic
projection.
 Empyema : pleural disease, lens-
shaped, longer in one view than in
the other

 Lung abscess  bronchopleural


Lung abscess Hydropneumothorax
Lung abscess >>>------------------------>>> empyema
Cavity: Tuberculosis (1)
 好發位置
– Apicoposterior of upper & superior of lower
lobe
 TB in cavitary phase indicates
-- active and at risk of dissemination
– Hematogenous spreading:
diffuse fine nodules, sharply defined
– Bronchogenic spreading:
larger (2-5mm) and ill-defined borders
Cavity: Tuberculosis (2)
 Features unlike TB
– Solitary cavity at ant segment of upper
lobe
– Isolated cavities at lower lobe
 Features suggesting of TB
– Associated reticular pulmonary scars
– Volume loss in the involved lobe
– Pleural thickening and calcification.
– Calcified hilar or mediastinal lymph
Tuberculosis
1.Tuberculosis
2.DM
Cavity: Mycetoma
 Fungus ball in an “existed” hole
– “Hole”: active or inactive TB (most
common), lung abscess, pulmonary
sequestration, cancer, sarcoidosis, etc.
 Generally asymptomatic and indolent
 Hemoptysis: life-threatening
complication
 Air crescent
 Aspergillus fumigatus
Aspergilloma
Aspergilloma in old TB cavity
Aspergilloma in old
coccidiodomycosis
cavity
Fungus
 Cavity formation:
– Cryptococcus
– Aspergillus
– Mucormycosis
– Coccidiodomycosis

 Nocardia
Coccidioidomycosis
Coccidioidomycosis
Hydatid Cyst
 Echinococcus, a parasite
 3 layers of hydatid cyst
– Outer: tough pericyst, produced by host
– Middle: laminated layer, produced by parasite
– Inner: unicellular, germinal layer, produce fluid
and cyst
 Spherical, well-defined, homogenous cyst
growing and asymptomatic until rupture
 Water-lily sign: air entering outer and
middle layer
 cyst fragment floating in the cavity
Cavity: Neoplasm (1)
 Primary lung cancer:
– epidermoid ca.; bronchioloalveolar cell ca.
 Metastatic cancer: (NPC,Eso. Ca,Cx Ca)
– Man: head and neck in origin.
– Woman: Gyn. tract in origin.

 Radiological findings of cavity is not a


reliable signs to D.D. benign or
malignancy
Cavity: Neoplasm (2)
 Features suggesting malignancy
– Not significant amount of fluid
– Eccentric cavitation
– Thick wall
– Lobulated and nodular wall
Lung cancer
Sq Carcinoma
Lung cancer
Sq Carcinoma
Lung cancer
Sq Carcinoma
Lung cancer
Sq Carcinoma
Sq Carcinoma
Stalagmites/stalactites
Lung cancer,
Sq cell carcinoma
Lung cancer,
sq cell carcinoma
Squamous cell ca. of Esophagus
Cervix Ca with meta
Rheumatoid Arthritis
 Pleural effusion
 Nodules
– Necrobiotic nodules
– Cavitate
 Interstitial fibrosis
 Erosion of posterior ribs
 Kaplan syndrome
– Coal worker pneumoconiosis
 Bronchiolitis obliterans
Rheumatoid nodule with central
cavity
Inhalation Diseases
 Pneumoconiosis:
– ischemic necrosis of the
conglomerated mass
 Silicosis:
– May cavitation by itself
– Most likely due to TB superinfection
--- TB must be ruled out in all
patients with silicosis + cavitation
SONY DSC V1
Cystic lesion
 Pneumatocele
 Bullae
 Bleb
 Bronchogenic cyst
 Pulmonary sequestration
Pneumatocele
 A thin wall space, caused by
– Infection: S. aureus in infants & children
Pneumocystis carini in AIDS p’ts
– Hydrocarbon aspiration
– Also occurs following trauma

 Invariably transient
 Mechanism:
– check valve obstruction of the airways
– Subpleural collection of air, dissection occurs
through the interstitium of the lung
Staph. pneumonia with
pneumatocele
Bulla (1)
 A sharp demarcated, air
containing space 1 cm or
more in diameter that
possess a smooth wall 1 mm
or less in thickness.
 Usually occurs with other lung
disease (emphysema or
infection).
 由 infection 引起者,常伴有
Bulla (2)
 Secondary Sign: compression
or displacement of adjacent
structures (lung and
mediastinum).

 Bullae are characteristically


poorly ventilated and
unperfused.
Bullae
1.COPD bullae
2.Fusion rib
3.Calcified TB
Infected bullae
Infected bullae
Tension Bulla
Bleb
 Localized collection of air
located within the pleura.
 Most common occurs over
lung apex, seldom exceeds 1
cm.
 Mechanism: alveolus rupture
>> air dissection through
interstitial tissue into the thin
fibrous layer of visceral
Bronchogenic Cysts (1)
 Mechanism
– Localized portions of the tracheobronchial
tree separated from normal airway during
branching process and do not further
develop
 Usually solitary, thin-walled, and spherical
 Filled with mucoid or serous fluid and do
not communicate with the airways unless
infected.
 Pathology: the wall typically contains
Bronchogenic Cysts (2)
 Mediastinal bronchogenic cyst (65-
90%)
– paratracheal, carinal, hilar, paraesophageal

– The first 2 are more common, more on R’t
side
– Rarely communicates with airways
 Pulmonary bronchogenic cyst
– Sharply circumscribed round nodule
Bronchogenic cyst
Bronchogenic cyst
Pulmonary
Sequestration
 Intralobar and Extralobar sequestration
DD by enclosing pleura and L-L or L-R
shunt
 Intralobar sequestration
– 好犯 post. basal segment of lower lobe, left
side and contiguous with the diaphragm
– recurrent pneumonia
– Less common: cystic mass (with or without
fluid levels) with prominent vessel --- due to
infection
Pulmonary sequestration
Pulmonary sequestration
Casio EX Z3
Multiple Lucent
Lesions-(I)
I. Cavity
A. Infection (bacterial, fungal,
mycobacterial and parasite)
B. Neoplasm
1. Metastasis
2. Bronchioloalveolar cell carcinoma
C. Vascular
1. Wegener’s granulomatosis
2. Rheumatoid disease
3. Infarct (thromboemboli or septic emboli)
Multiple Lucent
Lesions-(II)
I. Cystic bronchiectasis
II. Pneumatocele
III. Bullae
IV. Congenital cystic adenomatoid
malformation (CCAM)
Lung abscess
Multiple aspiration
Multiple bullae
Necrotizing pneumonia,
Klebsiella pneumoniae
Tuberculosis
Lung cancer,
adenocarcinoma
Adenocarcinoma
Septic emboli, cavity
Staphylococcus
aureus
Vascular Lesions
 Wegener’s granulomatosis and
rheumatoid arthritis:
– The 2 most likely collagen vascular
disease to cause cavitation.
 Pulmonary infarction:
– Occur in area of infarction greater
than 4cm in diameter and happen 2
weeks after appearance of the
consolidation.
Wegener’s
granulomatosis (1)
 Adults in their thirties to fifties
 Typical pattern:
--- multiple nodules ranging from 1-10 cm
 Nodules tend to increase in size and
number
 Cavitation:
– 50%
– Thick wall, irregular and shaggy inner
lining
– Less commonly -- thin wall or air-fluid
Wegener’s
granulomatosis (2)
 2nd common CXR pattern
– Multiple non-circumscribed lesions
– Acute air space consolidation or ground-
glass opacities secondary to pulmonary
hemorrhage
--- localized, or bilateral; patchy, or
confluent.
– With or without the presence of nodules
 Other findings
– Airway involvement is also common
Wegener’s
granulomatosis,
Fraser et al,
Synopsis of diseases
of the chest, 2nd ed.
Wegener’s granulomatosis
Sebastian Lange, Radiology of chest diseases, 1990
Congenital cystic adenomatoid malformation,
(CCAM)
Cystic Bronchiectasis
 One of the 4 types( cylindrincal,
varicose, saccular, cystic) of
bronchiectasis
 Not true cavity, but ballooned
dilatation of multiple terminal
bronchi
 Causes:
– Congenital
– Recurrent infection – bacteria, TB,
cystic fibrosis, agammaglobulinemia,
Cystic bronchiectasis
Cystic Bronchiectasis
Histiocytosis X (Langerhan’s cell
histiocytosis)

 Young adult; male=female


 Dry cough, SOB, pneumothorax, or
asymptomatic
 Histiocytes & eosinophils aggregate, no
granuloma
 Upper lobe predominence, sparing lung base
 CXR and CT
nodules  cavitated nodules or cysts 
honeycomb
 Spontaneous pneumothorax
Histiocytosis X
Lymphangioleiomyomat
osis
 Premenopausal women predominence
 Proliferation of smooth muscle-like LAM cells
in small airway, microvasculature and
lymphatics
 Airway obs, cystic change of lung,
pulmonary hemorrhage, pneumothorax,
chylothorax
 Early stage
– CXR: diffuse reticulonodular pattern
– HRCT: air-cysts diffusely distributed in all lung
zones
Lymphangioleiomyomatosis
LAM
LAM
Canon EOS 10D
Colon
Diaphragm rupture
Diaphragm eventratio
Colon herniation
Colon herniation
Plumbage