Diagnostic Imaging of Focal Lung Lesions

1. Chest
Focal Lung Lesions

2. Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

5. Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

6. Focal Lung Lesions
-Comment on :
1-Size
2-Growth
3-Calcification
4-Margin
5-Central Lucencies
6-Other Signs

7. 1-Size : Nodule versus mass
-Rounded well-defined opacity < 3 cm
-If > 3 cm = mass
2-Growth : Doubling time
< 1 month = inflammatory
> 15 months = benign
1-15 months = further evaluation

8. **N.B. : Follow up recommendations for noncalcified nodules in
patients older than 35 years without a history of malignancy , a high
risk patient is defined as a patient with a history of smoking or other
risk factors for lung cancer
1-Nodule <or= 4 mm :
-Low risk : No follow up
-High risk : at least one follow up at 12 months , if unchanged , no
further follow up
2-Nodule > 4 mm and <or= 6 mm :
-Low risk : at least one follow up at 12 months , if unchanged , no
further follow up
-High risk : at least 2 follow up at 6-12 months and 18-24 months if no
change
3-Nodules > 6 mm and <= 8 mm :
-Low risk : at least 2 follow up at 6-12 months and 18-24 months if no
change
-High risk : at least 3 follow up at 3-6 month , 9-12 and 24 months if no
change
4-Nodule > 8 mm :
-Regardless of risk , either PET , biopsy , or at least 3 follow ups at 3 ,
9 & 24 months

9. 3-Calcification :
-Calcification is more in benign lesions
-Mets >>> no calcium
4-Margin :
-Smooth = benign lesions
-Speculated (ill-defined) = malignant lesions
-N.B. : Smooth well-defined margins , if no
calcifications , suspicious of metastases

10. 5-Central Lucencies :
-Fat = pulmonary hamartoma
Slowly growing benign lesion , in middle age
, 50 % contains fat & 30 % contains
calcium

11. 6-Other Signs :
a) Pleural tail = malignancy
b) Satellite nodules surrounding a dominant
nodule = granulomatous
c) Feeding & draining vessels entering the
hilar aspect of a nodule = AVM
d) Halo sign (ground glass veiling around
the nodule) = lesion with angioinvasive
character , aspergillosis

12. -Focal Lung Lesions are :
a) Nodules
b) Masses
c) Cavities
d) Patches

13. a) Nodules : (D.D. of solitary lung nodule)
1-Hamartoma
2-Tuberculoma
3-Carcinoid
4-Bronchogenic Carcinoma
5-Metastases
6-Fungus
7-AVM
8-Haematoma
9-Septic Emboli

14. 1-Hamartoma :
-Single may calcify
-Smooth edge
-< 3 cm

19. 2-Tuberculoma :
-The same as hamartoma
-Differential Diagnosis from Hamartoma :
a) Site :
-Tuberculoma is more in the apex of the upper
lobe and apex of the lower lobe
-Hamartoma can occur at any site
b) Multiplicity :
-More in hamartoma

20. There is a well defined round lesion in left midzone, the lesion shows
flecks of calcific foci, the two small white arrows point to the well
defined borders with no evidence of malignancy

22. Calcified granuloma

23. 3-Carcinoid :
a) Centrally located carcinoid, 80% :
-Endobronchial mass
-Segmental or lobar collapse (most common
finding)
-There is often marked homogeneous contrast
enhancement due to high vascularity
b) Peripherally located carcinoid, 20% :
-Pulmonary nodule range around 10-30mm
-May enhance with contrast

26. CXR shows complete collapse of the left lower , CT shows a
hyperattenuating nodule (126 HU) within the left main bronchus

29. 4-Bronchogenic Carcinoma :
-Speculated margins
5-Metastases :
-Subpleural , 80 %
-N.B. : Mets + pneumothorax in a child =
osteogenic sarcoma

30. Speculated margin, bronchogenic carcinoma

32. Metastases

33. Osteosarcoma metastases

34. 6-Fungus :
-Focal intracavitary mass (3-6 cm)
-Upper lobes
-Air surrounds the aspergilloma >> Monod
sign
-Small area of consolidation around the
cavity
-Adjacent pleural thickening

39. 7-AVM :
-Lower lobes
-Sharply defined lobulated / rounded mass
lesion + feeding artery & draining vein
-Cord like bands from the lesion to hilum

41. NECT

43. 8-Hematoma :
-Peripheral smooth and well-defined , 2-6
cm
-Slow resolution over several weeks
9-Septic Emboli :
-Septic emboli usually present as multiple ill-
defined nodules
-In about 50% cavitation is seen

44. Septic emboli

45. Multiple Pulmonary Nodules :
1-Metastases (Most common ever)
2-Septic emboli
3-Wegner’s granulomatosis
4-Rheumatoid Nodules
5-Abscesses , commonly with staph , cavitation is
common , no calcification
6-Sarcoidosis
7-Caplan’s Syndrome
8-AVM , multiple in 33 %

46. b) Masses : Solid or Cystic
1-Solid :
-Carcinoma or Metastases
-Comment on :
*Lymph nodes
*Chest wall invasion (rib destruction)
*Mediastinal invasion
*Pleural effusion
*Diaphragm
*Upper abdomen (Liver , suprarenal)

49. -N.B. :
*Multiple spiculated masses >> lymphoma
or metastases
*Mets of bronchogenic >> brain &
suprarenal
*Big mass in a child = neuroblastoma

50. 2-Cystic : Hydatid cyst
-Water density
-Multiple cysts in the wall of a large cyst
-Rupture in a bronchus = fluid level (wavy) ,
water lily sign
-Meniscus sign = rupture between the layers
of the cyst
-Rupture in a pleura = hydropneumothorax

52. Air meniscus in the superior aspect of the lesion as a result of the enlarging
cyst communicating with an adjacent bronchiole

53. Water Lilly

54. c) Cavities :
-Wall thickness >> thin or thick
-Content >> air , air-fluid & soft tissue
-Causes : ABC
1-Lung Abscess
2-Bulla
3-Cyst (Pneumatocele & cystic bronchiectasis)
4-Lung carcinoma, more in the upper lobes, squamous cell
carcinoma
5-Metastases
6-Wegner’s granulomatosis
7-Rheumatoid Nodules
8-Progressive massive fibrosis
9-Sarcoidosis
10-Traumatic (hematoma , traumatic lung cyst)

55. 1-Lung Abscess :
-Cavitary lesion >>
*Air fluid level : acute
*Air + thick wall : chronic
-Air + thin wall = Abscess & Ruptured Hydatid
Differential Diagnosis :
Abscess : straight air fluid level
Hydatid : wavy level (water Lilly)

57. Non-Contrast Contrast

58. 2-Bulla :
-Air filled cavity + lung shows
emphysematous changes
-Peripheral
-Its wall has no relation to chest wall
-May be secondary infected
-If ruptured >>> pneumothorax

62. 3-Cyst : Pneumatocele :
-Centered (caused by prior lung trauma or
infection)
-Air filled cavity , thin walled +/- air fluid level
(secondary infected)
**N.B. : Intracavitary Lesions >>
-Cavity inside it a ball :
1-Fungal ball
2-Tumor (non-uniform wall with lymphadenopathy)
3-Hydatid Cyst
4-Blood Clot

63. **N.B.
D.D. of solitary cavitary lesion :(cancer or infection)
1-Primary bronchogenic carcinoma (both squamous cell &
adenocarcinoma can cavitate , squamous cell cavitates
more frequently , small cell carcinoma is never known to
cavitate)
2-T.B. (classically produces an upper lobe cavitation)
D.D. of multiple cavitary lesions (typically vascular or
spread through the vascular system)
1-Septic emboli
2-Vasculitis (including Wegner granulomatosis which is
specially prone to cavitate)
3-Metastases (squamous cell carcinoma and uterine
carcinosarcoma are known to cavitate)

64. Post infectious pneumatocele, the initial chest x-ray shows
consolidation in the right lung, follow up chest done, when the
patient was asymptomatic, shows multiple thin walled lucencies in
the right lung

65. (a) Initial CXR shows a dense right upper lobe consolidation, (b) CXR a
week later shows a round cyst with thin walls in the right upper lobe

66. Cavitating Lung Tumor

67. Metastases

68. Wegner’s granulomatosis

69. d) Patches :
-Patches + Air bronchograms =
Pneumonia or Infarction
1-Pneumonia :
-Pneumococcal , one patch + air bronchogram
-Bronchopneumonia (staph) , more than one patch
-Pneumonia >> sharp cut >> fissure :
Child : Foreign body
Adult : Carcinoma

73. 2-Pulmonary Infarction :
-Right basal , pleural + hemoptysis
-Patch + air bronchogram :
*Peripheral (wedge-shaped)
*Pleural based patch
*Pleural effusion
*Filling defect in the pulmonary artery
*+/- Marginal enhancement
*Check pulmonary artery for a thrombus
*Need clinical picture to confirm

74. PE causing pulmonary infarction

75. Pulmonary embolism causing lung infarction