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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
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Neoplasms with rich vascular supply draining directly into the systemic venous system often present in this
fashion.
thyroid carcinoma
renal cell carcinoma
sarcoma of the bone
trophoblastic disease.
Cavitating lesions:
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
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
Definitions
History of Value
Common Diagnoses
Radiological Features
CT-Index
Demonstration of Calcification
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Stability of Size
Benign Lesions
Confirmation of 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.
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:
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
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Sequestration
Round Atelectasis
Mycetoma
Hydatid Disease
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:
Diagnosis
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AV Fistula
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.
Lobar Pneumonia
Bronchopneumonia
Necrotizing Pneumonia
Segmental Pneumonia
Round 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
1. Streptococcus
2. Viral
3. Staph
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Necrotizing Pneumonia
Staphylococcal
Anaerobic infection
Gram negative organisms
Segmental Pneumonia
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1. Post obstructive
2. Aspiration
Round Pneumonia
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
1. Pneumocystis
2. Cytomegalovirus
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.
Radiological signs
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Useful Clinical Classification
Acute
Chronic
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
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
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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?
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?
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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