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Pulmonary Metastasis

Multiple Lesions

Multiple discrete lung lesions occur due to widely disseminated hematogenous metastasis.
The pattern can vary from
o diffuse micronodular shadows resembling miliary disease
o to multiple large well defined masses cannon balls.
Occasionally, cavitation or calcification can be noted.
Symptoms
o Due to the interstitial location, these lesions are often asymptomatic.
o Cough and hemoptysis are the usual symptoms.
Needle aspiration or trans-bronchial biopsy would be the procedure of choice for confirmation of the nature of
the lesion.
Treatment
o Chemotherapy is the choice when the tumor is responsive.
o Occasional surgical resection of multiple lesions were attempted with some reported success.
o In refractory hemoptysis, selective occlusion of bronchial arteries by teflon is a consideration.

Cannon balls

52 Y/O, W/M with Ca of the colon with cannon ball mets.

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Neoplasms with rich vascular supply draining directly into the systemic venous system often present in this
fashion.

Miliary Pattern: This presentation is seen in patients with

thyroid carcinoma
renal cell carcinoma
sarcoma of the bone
trophoblastic disease.

Cavitating lesions:

Cavitating mets in a patient with squamous cell cancer of larynx.

Cavitation is identified in 4% of metastatic deposits and, as with primary bronchial carcinoma, is more likely in
squamous cell lesions.
Colon, anus, cervix, breast and larynx account for 69% of such occurrences.
Generally, small thin walled metastases usually indicate a primary site in the head or neck, where as most
large, thick walled secondaries arise from the gastrointestinal tract.

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Avascular necrosis of the lesion secondary to vascular occlusion, is the presumed mechanism for cavitation.

Calcification

Calcification or ossification is rarely visible in metastasis to the thorax.


o Calcification of metastasis from ovarian, thyroid, breast and mucin producing gastro-intestinal
neoplasms.
o Calcification in lymphomatous nodes has most often occurred following therapy.
o Lung metastasis may also calcify following therapy.
o Almost all calcified or ossified lung metastasis occurring prior to therapy are due to osteosarcoma or
chondrosarcoma.
o Isolated cases of such metastasis have also been reported with synovial sarcoma and giant cell tumor
of the bone.

Solitary Pulmonary nodule

Pulmonary metastases clinically present as a Solitary Pulmonary nodule.


Similar to other Solitary Pulmonary nodular lesions, these are detected by routine chest x-rays.
Of the Solitary Pulmonary nodular lesions, solitary metastases accounts for less than 3% of cases.
Colon, chest, sarcoma, melanoma and genitourinary malignancies account for 79% of such instances.
Solitary metastatic lesion can precede, follow or appear concomitantly with the malignancy.

Diagnostic strategy

When it appears concomitantly or following definitive therapy of the primary, thin needle aspiration of the
lesion is probably the best procedure to establish the nature of the lesion.
CT scans are superior to whole lung tomograms in evaluating the presence of other occult metastatic lesions.
When the solitary pulmonary metastasis precedes clinical recognition of the primary, standard management of
the Solitary Pulmonary nodular lesion should follow.
o This clinical presentation accounts for less than 1% and routine search for primary is not
recommended.

Treatment

Surgical resection of single metastasis should be considered


o when the primary tumor is resectable.
o No other organ metastasis is evident
o and no effective alternate therapy is available
Surgical resection of solitary lung lesions occurring a few years following curative resection of primary have a
better prognosis than the lesions that manifest concomitantly with the primary tumor.

Solitary pulmonary nodule

Definitions

History of Value

Common Diagnoses

Radiological Features

CT-Index

Demonstration of Calcification

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Stability of Size

Benign Lesions

Pseudo Coin Lesion

Confirmation of Diagnosis

Need for Bronchoscopy

Need for Pre-op Diagnosis

Management

Common Diagnosis

A wide variety of congenital, inflammatory, neoplastic, traumatic, collagen vascular and idiopathic diseases are known
to cause coin lesions. Granulomas, bronchogenic carcinomas, benign tumors and solitary pulmonary metastasis account
for 94% of coin lesions. There is a large list of uncommon causes for coin lesions.

Etiology No of Cases Percentage


Granuloma 924 54%
Bronchogenic CA 479 28%
Hamartoma 113 7%
Metastasis 60 4%
Bronchogenic CA 34 2%

Radiological Features

Most cases are detectable by chest x-ray. Radiologic features are by far the most important in helping decide on the
etiology of solitary pulmonary nodule. Systematic attention to the following features of the lesion enable the Radiologist
to suggest a possible lesion.

Location
Size
Margin
Doubling time
Calcification

Demonstartion of calcium and the stability of lesion over two year period are the most reliable findings to distinguish a
benign from malignant lesion.

CT Index

There is controversy regarding the value of CT index. The absolute CT density number is no longer used to distinguish
benign from malignant lesions. The coin lesion being evaluated is compared to a phantom coin lesion which is just dense
enough to be safely called a granuloma or hamartoma. CT numbers are quite variable.

There is no one CT number that identifies a nodule as benign. The CT machine measures the attenuation of the x-ray
beam after it passes through a small volume of tissue. This CT number reflects the density of the tissue. CT numbers
vary from machine to machine and from day to day. CT numbers of a lesion are also altered by the surrounding anatomy.
For example, the same nodule would have three different density readings if it were in the middle of the lung, next to the
heart and next to a vertebra.

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This marked variability is compensated for by doing a CT study of a chest phantom duplicating the location of the
patient's nodule. The patient's nodule is then closely compared to the phantom nodule. The phantom nodule has a known
density. Determination of the density of the patient's nodule is relative to the phantom nodule. Absolute CT numbers do
not enter into the determination.

Demonstration of Calcification

Since the demonstration of calcification is such a valuable finding, let us review the radiological methods available for
identifying calcium in a coin lesion. If the plain chest x-ray shows definite calcium, no further tests are necessary. If the
plain x-ray does not show calcium, one of the three radiological procedures can be ordered.

CT Scan

At present, computed tomography (CT) is the best radiological procedure for demonstrating calcium in a coin lesion.

1. CT is much more sensitive to differences in density. CT can electronically determine the density of a coin lesion
in units less than 1 cubic mm. Because of the greater sensitivity of CT in determining density, calcifications can
be identified with CT before they can be identified by other radiographic methods.
2. CT provides thin axial (cross section) views of the chest so that the coin lesion is demonstrated free of
overlapping anatomical structures.

In many patients, the lesion is considered to be probably calcified. Fluoroscopy with spot films or tomography in these
patients will usually demonstrate the calcification so that it can be definitely identified. These procedures are much less
expensive than CT. If a lesion has no sign of calcification on radiographs, initial examination by CT is identified.

There is controversy regarding the utility of CT for coin lesions. I like to routinely obtain a CT of the chest for non-
calcified coin lesions for the following reasons:

Best to identify additional occult lung lesions


Best for localization of coin lesions
Best for identifying the size of intra-thoracic nodes
Best for identifying calcifications

Stability of Size

The second most valuable radiologic criteria helpful to distinguish benign from malignant coin lesion is the stability of
size over two years. Comparison with old x-rays is the only way to establish stability of size of a coin lesion over two
years. Remind the patient about past hospitalizations, surgeries, emergency room visits, insurance and employment
physicals, etc., to obtain past chest x-rays for comparison. Many times, this one piece of information often saves a lot of
anxiety and unnecessary work-up and surgery.

Following a patient every three months with chest x-ray and carefully monitoring the size for a period of two years is
permissible in selected cases.

Benign Lesions

There are some benign lesions that can be recognized by specific radiologic criteria.

Granuloma

Hamrtoma

AV fistula

Pulmonary Vein Varix

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Sequestration

Round Atelectasis

Mycetoma

Hydatid Disease

Tuberculoma (Most likely)

Many years of follow up of the solitary pulmonary nodule, Note central calcification in the nodule. In general a growing
lesion should be considered as a malignant lesion. Tuberculomas can grow. Scar cancer is another consideration. Central
location of calcium is against that possibilty. In modern time, PET scan would have been of value.

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46 year old male scheduled for Gall bladder surgery for stones. History of 40 pack years of smoking

Findings:

Size - Less than 3 cms


Number - Single
Margin - Sharp
Shape - Round
Has been stable in size for 4 years

Diagnosis

Benign Tumor Hamrtoma

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AV Fistula

Note the feeding vessel (arrow) to the "Pulmonary nodule"


A second lesion is located retrocardiac (arrowhead).
Marked cardiomegaly.
Patient with Osler rendu weber syndrome ( Hereditary hemorrhagic telengiectasis)

Pulmonary Vein Varix

A pulmonary vein varix is rare. They are either congenital or due to acquired pulmonary venus hypertension. The
location adjacent to the heart, where the pulmonary vein enters the heart in a patient with pulmonary venous
hypertension, should suggest the diagnosis which is confirmed by angiography or CT with intravenous contrast material.
Most patients have mitral insufficiency.

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Sequestration

Pulmonary sequestrations are congential malformations of lung tissue which almost always occur in the lower lobes.
They sometimes appear as a solitary nodule in chest radiographs. They almost always contact the diaphragm. They can
be cystic or contain air/fluid levels following infection. The diagnosis is made by demonostrating an anamolous feeding
vessel from the aorta.

Round Atelectasis

Round atelectasis is a form of lung collapse in which the atelectatic lung appears as a solitary pulmonary nodule. This
type of atelectasis is due to pleural disease, usually asbestos exposure. The nodule is always adjacent to a thickened
surface. Pleural thickening compresses the lung which rolls up into a ball and drags pulmonary vessels with it. These
vessels are seen on the radiograph as a curved tail extending from the round atelectasis toward the hilus. The trail of
thickened pleura, a pleural based nodule, and a tail extending toward the hilus are characteristic of round atelectasis.

Mycetoma

A mycetoma is a mass of fungal mycelia located in a pre-existing pulmonary cavity. The mycetoma is a saprophyte and
can cause local affects, usually hemoptysis. However, it does not cause systemic effects. The mycetoma is seen on
radiographs as a rounded mass within a cavity. The mass changes position when the patient changes position because it
is free in the cavity. Most are due to an aspergillus organism.

Hydatid Disease

Hydatid disease is a parasitic infection due to echinococcus granulosis. The parasite is filtered out in the small vessels in
the lung where it grows. The parasite has a tough outer layer and a delicate inner layer which produces more organisms.
In addition, the host lung produces a reactive layer of tissue around the parasitic cyst. When the cyst eventually
communicates with a bronchus, air enters it and produces characteristic radiographic signs. The delicate inner layer may
collapse and float on cyst fluid (the floating lilly sign). A pathognomonic sign is produced by air outlining both sides of
the thick and delicate parasitic cyst walls (double wall sign) producing an appearance similar to the McDonald's double
arcus logo.

Radiological patterns of Pneumonia

Lobar Pneumonia

Bronchopneumonia

Necrotizing Pneumonia

Segmental Pneumonia

Round Pneumonia

Diffuse Alveolar Pneumonia

Diffuse Interstitial Pneumonia

Radiation port

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Lobar Pneumonia :Most common causes for lobar pneumonia are:

1. Pneumococcus
2. Mycoplasma
3. Gram negative organisms
4. Legionella

Bronchopneumonia

Most common causes for bronchopneumonia are:

1. Streptococcus
2. Viral
3. Staph

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Necrotizing Pneumonia

Most common causes for Necrotizing pneumonia are:

Staphylococcal
Anaerobic infection
Gram negative organisms

Segmental Pneumonia

Most common causes for segmental pneumonia are:

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1. Post obstructive
2. Aspiration

A patient with aspiration lung abscess

Round Pneumonia

Most common causes for round pneumonia are:

1. Fungal
2. Tuberculous

The CXR on right is from a patient with Aspergillus Pneumonia developed while on steroids.

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Diffuse Alveolar Pneumonia

Most common causes for diffuse alveolar pneumonia are:

1. Pneumocystis
2. Cytomegalovirus

Patient with Pneumocystis Carinii pneumonia

Diffuse Interstitial Pneumonia

Most common causes for diffuse interstitial pneumonia are:

1. Viral
2. Chickenpox

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Radiation Port Pneumonia

There is air space disease on either side of mediastinum not corresponding to any segmntal or lobar anatomy. It has a
vertical delineation outside. This appearance is characteristic to radiation port pneumonia.

Diffuse alveolar disease

Radiological signs

Butterfly distribution / Medullary distribution


Lobar or segmental distribution
Air bronchogram
Alveologram
Confluent shadows
Soft fluffy edges
Acinar nodules
Rapid changes
No significant loss of lung volume
Ground glass appearance on HRCT

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Useful Clinical Classification

Acute
Chronic

Acute diffuse alveolar disease

Water
o Pulmonary edema Cardiogenic
o Neurogenic pulmonary edema
Blood
o SLE
o Goodpasteures syndrome
o Idiopathic pulmonary hemosiderosis
o Wegners granulomatosis
Inflammatory
o Cytomegalo virus pneumonia
o Pneumocystis carinii pneumonia
o Influenza
o Chicken pox pneumonia
o Fat embolism
o Amniotic fluid embolism
o Adult respiratory distress syndrome
CT

Chronic alveolar disease

Alveolar proteinosis
Alveolar cell carcinoma
Mineral oil pneumonia
Alveolar form of Sarcoidosis
Alveolar form of Lymphoma
Alveolar form of Tuberculosis
Alveolar metastases from Cancer Pancreas
Desquamative interstitial pneumonia

General

Cannot tell whether there is co-existent interstitial disease.


Alveolar and interstitial pattern can be evident in different portions of lung and is of diagnostic significance
Evolution of Changes in x-ray helpful in the diagnosis.
None of the x-ray findings are specific
History and the clinical setting under which the problem is encountered is of great help in diagnosis
Presence of co-existing findings helpful e.g. Lympadenopathy etc
Options for a diagnostic procedure is based on the working diagnosis: Sputum evaluation, HRCT, Broncho-
alveolar lavage, Brushings, TBB, Open lung biopsy, VAT lung biopsy, CBC, ID workup, auto-immune
workup, Cardiac workup
Distribution
o Cortical
Eosinophilic pneumonia
BOOP
o Lower lobes / Mineral oil aspiration

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Butterfly distribution

Air bronchogram

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Confluent shadows

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Acinar nodules

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Pulmonary edema

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Lympadenopathy
What is the significance of increased markings in outer third of lung fields?

There is paucity of vascular markings in outer third of lung fields


In left to right shunts (ASD, VSD, PDA) and in high output states, there is increased pulmonary flow, the
vascular markings in the outer third will be prominent.
In interstitial disease, lymphangitic malignant spread and in CHF with increased lymphatic flow the markings in
outer third will be prominent.

List conditions, where vascular markings are prominent in upper lung fields

Mitral stenosis
Congestive heart failure
Alpha one antitrypsin deficiency
High output states

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How is altered relationship between left and right hilum helpful in diagnostic interpretation?

It gives clues to loss of lobar lung volumes


o Left hilum will be pulled up with LUL atelectasis
o Left hilum will be pulled down with LLL atelectasis
o Right hilum will be pulled up with RUL atelectasis
o Right hilum will be pulled down with RLL atelectasis
o Hilar position does not change with RML atelectasis because of small volume of RML
Displaced by mass

Halo Sign

In a cavity with fungus ball there is a crescentic lucent space along the upper portion of a density giving the appearance
of a halo. This phenomenon is seen with two clinical presentations of pulmonary aspergillosis, fungous ball and
necrotizing subacute pneumonia during recovery phase from leukopenic episodes.

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