Computed Tomography Virtual Bronchoscopy: Normal Variants, Pitfalls, and Spectrum of Common and Rare Pathology  K.M. Das, MD, FSCCT, Hani Lababidi, MD, FCCP, FACP, Sadeq Al Dandan, MBBS, Shanker Raja, MD, Hussam Sakkijha, MD, FCCP, FACP, Mohammad Al Zoum, MD, Khalid AlDosari, MD, Sven G. Larsson, MD, DMSc  Canadian Association of Radiologists Journal  Volume 66, Issue 1, Pages 58-70 (February 2015) DOI: 10.1016/j.carj.2013.10.002 Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 1 Tracheal bronchus in a 34-year-old man with history of fever. (A) A 3-dimensional volume rendered computed tomographic image, showing right-sided tracheal bronchus arising from the trachea above the carina (arrow). (B) A craniocaudally oriented virtual bronchoscopy endoluminal view, showing an anomalous opening of the tracheal bronchus (arrow) just above the origin of the right main bronchus (arrowhead). Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 2 Tracheal diverticulumin a 56-year-oldmanwith laryngeal carcinoma. (A) A 3-dimensional volume rendering computed tomographic (CT) image, showing a well-defined diverticulum arising from the right side of the trachea (arrow), with a narrow neck. (B) Minimum intensity projection CT coronal oblique image of the trachea, showing the diverticulum communicating with the trachea through a narrow neck (arrow). Combined (C, D) computer-generated axial CT image with corresponding craniocaudally oriented virtual bronchoscopy (VB) endoluminal view, showing the location of the narrow communication between the diverticulum and the trachea in the (C) 2-dimensional CT image as a linear communication (arrowhead) and (D) as a dimple in the inner surface of the VB image of the trachea (arrowhead). Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 3 Bronchiectasis in a 15-year-old boy with a history of cough and repeated chest infection. (A) Sagittal oblique computed tomographic section, showing dilated bronchus with well-defined cystic cavity formation (arrow). (B) Craniocaudally oriented virtual bronchoscopy endoluminal view, showing a dilated bronchus (arrowhead) with a large cystic cavity (arrow) adjacent to the lumen of the bronchus wall. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 4 Invasive mucormycosis in a 18-year-old man with a history of acute myeloid leukaemia with a history of high-grade fever and neutropenia. A mucor species was isolated from sputum. (A) Axial contrast-enhanced computed tomographic image (section thickness, 2 mm), showing cavitary focus of consolidation with dependent intracavitary mass partially invading the dependent wall (arrow). (B) Craniocaudally oriented virtual bronchoscopy endocavitary view, showing a well-defined mass settled to the bottom of the cavity (arrow). Lobectomy showed extensive tissue necrosis, and (C) high-power photomicrograph from the fungus ball removed by lobectomy showed extensive tissue necrosis and broad nonseptate hyphae branching at right angles and positive for Grocott's methenamine silver stain and periodic acid–Schiff stains confirming the diagnosis of mucormycosis. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 5 Tracheal narrowing due to prolonged intubation after polytrauma in a 21-year-old man after a road traffic accident. (A) Sagittal computed tomographic image (section thickness, 2.5 mm), showing an indwelling endotracheal tube with thickening of the subglottic tracheal wall oedema (arrow). (B) Craniocaudally oriented virtual bronchoscopy endoluminal view, taken after 3 months, showing high-grade narrowing of a cervical portion of the trachea (arrow). Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 6 Foreign-body-related bronchoesophageal fistula in a 10-year-old girl with a history of repeated chest infection and fever. (A) Coronal computed tomographic (CT) reconstruction (section thickness, 3 mm), showing a linear defect attached to the wall of the left main bronchus (arrow) that extends to partially cover the right bronchus. Tracheal bronchus noted (white arrow). (B) Craniocaudally oriented virtual bronchoscopy (VB) endoluminal view, showing a shelf-like structure entirely overlapping the left bronchus and partially covering the right bronchus (arrow). (C) Caudocranially oriented VB endoluminal view through the right bronchus, showing a linear foreign body crossing the right bronchial lumen (arrow) with an unusual opening posteromedially (arrowhead) not seen on the fiberoptic bronchoscopy and a right main bronchus (notched arrow). (D) Curved multiplanar reconstruction CT reconstruction, showing the fistula communication between the right bronchus and the esophagus (arrow). Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 7 Tracheobronchial tuberculosis that presented as intraluminal bronchial lesions in a 55-year-old woman with a history of repeated cough and shortness of breath. (A) Coronal computed tomographic (CT) reconstruction (section thickness, 2.5 mm) in the mediastinal window, showing subcarinal enlarged lymph nodes (black arrow) continuing with intrabronchial mass (white arrow) and causing narrowing of the lumen. (B) Craniocaudally oriented virtual bronchoscopy endoluminal view, showing that more than two-thirds of the lumen of the right bronchus intermedius was invaded by a well-defined mass (arrow). (C) Corresponding bronchoscopy image, showing a multilobular mass arising from the medial wall of the right lower lobe bronchus, which caused high-grade narrowing of the lumen (arrow). A transbronchial biopsy specimen of the mass revealed caseous necrotic material with multiple granuloma. A repeated CT after 8 months of antituberculosis treatment, showing the size of the subcarinal node reduced, with calcification and the intrabronchial mass almost disappeared (not shown). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 8 A laryngeal mass in a 66-year-old man with a history of shortness of breath and hemoptysis. (A) Craniocaudally oriented virtual bronchoscopy (VB) endoluminal view, showing a tumour arising from the left vocal cord filling in the anterior commissure (arrow), with bulging of the false vocal cord. (B) Caudocranially oriented VB endoluminal view, showing the subglottic extension of the tumour (arrow). A biopsy revealed squamous-cell carcinoma. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 9 Mediastinal and hilar lymphadenopathy in a 60-year-old man undergoing staging investigation for non–small cell lung cancer. (A) Axial contrast-enhanced computed tomography (section thickness, 2.5 mm), showing an ill-defined mass completely occluding the lingular segment with positive bronchus sign (arrowhead) and enlarged lymph nodes at the carina (arrow). (B) Craniocaudally oriented virtual bronchoscopy endoluminal view, showing complete occlusion of the lingular segment (arrow). (C) Corresponding bronchoscopy, showing the complete occlusion of the lingular segment by the mass (arrow). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 10 Squamous-cell carcinoma of the trachea in a 61-year-old man with a history of progressive breathing difficulty. (A) Craniocaudally oriented virtual bronchoscopy (VB) endoluminal view, showing an eccentric mass (arrow) that caused high-grade narrowing of the tracheal lumen. (B) Corresponding bronchoscopic image, showing mass arising from the wall of the trachea (arrow), which caused high-grade narrowing of the lumen. (C) Contrast-enhanced axial computed tomography done 8 months after stent placement, showing near total occlusion of the right bronchus (arrow), with upper lobe collapse. (D) Craniocaudally oriented VB endoluminal view, showing totally occluded right main bronchus by the tumour mass (arrow). (E) Corresponding bronchoscopic image, showing recurrence of the tumour (arrowhead) through the stent strut and gross narrowing of the right main bronchus (arrow). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 11 Tracheobronchial involvement in a diffuse large B-cell lymphoma in a 79-year-old man presenting with shortness of breath and weakness. (A) Craniocaudally oriented virtual bronchoscopy endoluminal view, showing multiple irregular nodular submucosal lesions (arrows) arising from the tracheobronchial wall and the carina. (B) A corresponding bronchoscopic image, showing similar multiple submucosal nodular lesions (arrows) arising from the carina and tracheal wall with erythema. (C) High-power photomicrograph (H&E stain, original magnification ×40), showing diffuse infiltration by large atypical lymphoid cells (arrow) that are positive for CD45 and CD20 immunostains, which indicates diffuse large B-cell lymphoma. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 12 Primary subglottic T-cell lymphoma in a 18-year-old man with a history of throat pain and dysphagia. (A) Caudocranially oriented virtual bronchoscopy endoluminal view, showing asymmetry of the subglottic lumen with a mass (arrow) arising from the posterior wall. (B) High-power photomicrograph (H&E stain, original magnification ×40), showing infiltration by atypical lymphoid cells that have a T-cell lineage by immunohistochemistry (positive for CD7, CD3, and CD2) suggestive of T-cell lymphoma. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 13 Tracheobronchial Kaposi sarcoma in a 61-year-old patient who was not positive for human immunodeficiency virus and with a history of painful swallowing. (A) Craniocaudally oriented virtual bronchoscopy (VB) endoluminal view, showing a polypoid soft-tissue mass (arrow) attached to the soft palate at the base of the uvula. (B) Caudocranially oriented VB endoluminal view, showing the tracheal lumen compromised by multiple irregular nodular lesions (arrow) distributed unevenly. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 14 Tracheobronchopathia osteochondroplastica that involves the tracheobronchial tree in a 71-year-old man with a history of repeated chest infection. (A) Craniocaudally oriented virtual bronchoscopy endoluminal view, showing marked irregular submucosal nodules (arrows) distorting the lumen of the trachea sparing the posterior wall. (B) Bronchoscopy, showing multiple submucosal nodules (arrows) of irregular pattern arising from the wall of the trachea, sparing the posterior wall; a tracheal biopsy was suggestive of tracheobronchopathia osteochondroplastica. (C) High-power photomicrograph (H&E stain, original magnification ×20), showing lamellar-type bone (arrow) with fat-filled marrow embedded within the submucosa, constellation of features consistent with tracheobronchopathia osteochondroplastica. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 15 Tracheobronchopathia osteochondroplastica involving the tracheobronchial tree in a 71-year-old man with a history of repeated chest infection. (A) Coronal computed tomographic reconstruction (section thickness, 8-mm Minip image), showing irregular thickening of tracheal wall and left main bronchus (arrowheads) with near total occlusion of left lower lobe bronchus (arrow). (B) Craniocaudally oriented virtual bronchoscopy endoluminal view, showing marked irregular orifice of the left lower lobe bronchus, with marked narrowing (arrow). (C) Corresponding bronchoscopy image, showing narrowed lower lobe bronchus with white discharge (arrow). A biopsy specimen was suggestive of tracheobronchopathia osteochondroplastica. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 16 Cricoid involvement by disseminated multiple myeloma in a 56-year-old man with a history of stridor and difficulty in breathing. (A) Axial computed tomographic image, showing expansion of the cricoid cartilage with central low attenuation (arrow) at the level of the undersurface of the true vocal cord. (B) Craniocaudally oriented virtual bronchoscopy endoluminal view, showing expansion of cricoid lamina bulging into the pyriform sinus and displacing the arytenoids forward and closing of the glottic airway (arrow). A bone marrow biopsy specimen, showing increased infiltration by plasmacytoid cells, that is CD138 positive, which confirmed the diagnosis of multiple myeloma. Canadian Association of Radiologists Journal 2015 66, 58-70DOI: (10.1016/j.carj.2013.10.002) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions