Chest Cases 51-75

Case directory 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

Case 51

Silicosis (with progressive massive fibrosis) Case findings: CXR: progressive massive fibrosis, masses surrounded by emphysematous lung CT: Bilateral masses of fibrosis Small nodules are present in the superior segment of the left lower lobe, and irregular emphysematous spaces lateral to the left fibrotic mass Nodular calcification is seen in the right hilum (arrow)

Silicosis (with progressive massive fibrosis) Case directory Silicosis (with progressive massive fibrosis) Early findings: small (1-2 mm) nodules are seen predominantly in the posterior portions of the upper and middle lung Nodes with eggshell-type calcifications Progressive massive fibrosis Complication of coal worker's pneumoconiosis (CWP) Occurs only after long-term exposure to coal dust Coal dust alone can cause PMF, but the role of silica in the production of PMF remains uncertain PMF starts as bilateral masses near the periphery of the lung, but these masses can be completely or predominantly unilateral

Case 52

Histoplasmosis with broncholithiasis Case findings: CXR: Scattered nodules with focal calcification in the right hilar area Fullness of the hila on the lateral view CT: Scattered calcified nodules bilaterally with slight hypodensity in the right middle lobe Soft tissue mass with dense central calcification located in the middle mediastinum (calcified nodes)

Histoplasmosis with broncholithiasis Caused by Histoplasma capsulatum Acute phase: Single or multiple areas of consolidation Associated hilar or mediastinal adenopathy Resolves without treatment within weeks to months Epidemic form: Multiple discrete nodules throughout both lungs Hilar adenopathy, which become calcified when they heal Histoplasmoma (solitary granuloma): Well-defined necrotic focus of infection surrounded by an inflammatory reaction, MC in lower lobes

Histoplasmosis with broncholithiasis Case directory Histoplasmosis with broncholithiasis Complications from calcified lymph nodes Fibrosing mediastinitis: from large calcified lymph nodes and surrounding fibrotic reaction that constrict and encase mediastinal structures Broncholithiasis: calcified nodes erode into a bronchus DDX broncholithiasis: Histoplasmosis, tuberculosis Actinomycosis Coccidiodomycosis, cryptococcosis Silicosis

Case 53

Solitary fibrous tumors of the pleura (SFTP) Case findings: CXR: complete opacification of the right hemithorax with shift of the mediastinum to the left CT: large, heterogeneous mass occupying the right hemithorax without significant enhancement Coronal T2: large, well-encapsulated, heterogeneous (suggests necrosis) low-signal mass in the right hemithorax with surrounding pleural effusion MC low T1 and T2: indicative of fibrosis High T2: represent areas of necrosis or hemorrhage

Solitary fibrous tumors of the pleura (SFTP) Case directory Solitary fibrous tumors of the pleura (SFTP) Other names: benign or localized mesothelioma, benign fibrous mesothelioma, subpleural fibroma Slow growing, not histologically related to mesothelioma Most (> 80%) SFTP are benign, but still excised because of their growth Rare, < 5% of all tumors involving the pleura Well-demarcated, solitary, enhancing masses that form obtuse angles with the chest wall or mediastinum MC in middle and lower chest Calcifications (~5%) and pleural effusions (~8-17%) are uncommon

Case 54

Tracheobronchopathia osteochondroplastica (TPO) Case directory Tracheobronchopathia osteochondroplastica (TPO) Case findings: Irregular narrowing of the airway with calcification of the lateral walls Idiopathic benign disease of the trachea and major bronchi characterized by multiple submucosal osteocartilaginous nodules Posterior membranous trachea spared DDX: tracheobronchial amyloidosis

Case 55

Tracheobronchial amyloidosis Case directory Tracheobronchial amyloidosis Case findings: Nodular and irregular narrowing of the tracheal lumen Affects posterior membranous wall Multiple concentric or eccentric strictures and mural nodulation Calcific deposits are frequently present DDX: Tracheobronchopathia osteochondroplastica (does not affect posterior membranous tracheal wall)

Case 56

Pericardial cyst Case findings: CXR: sharply defined area of increased opacity in the right cardiophrenic angle (arrow) CT: thin walled water attenuation cyst (arrow)

Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma

Cystic mediastinal masses Tumors with cystic degeneration: Thymomas Hodgkin’s disease Germ cell tumors Mediastinal carcinomas Metastases to lymph nodes Nerve root tumors

Case directory Pericardial cyst

Case 57

Bronchogenic cyst Case findings: CXR: CT: Round mass (arrow) that displaces the right primary bronchus superiorly RML pneumonia and pleural effusion CT: Cyst with uniform fluid attenuation and an imperceptible wall

Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration

Bronchogenic cyst

Case directory Bronchogenic cyst

Case 58

Lateral thoracic meningocele Case findings: CT: low-attenuation mass protruding from the enlarged left intervertebral foramen Intrathoracic meningocele is an anomalous herniation of the leptomeninges through an intervertebral foramen or a defect in the vertebral body Associated with neurofibromatosis Features: Sharply defined round, smooth, or lobulated paraspinal masses Enlargement of intervertebral foramina and associated vertebral and rib anomalies or scoliosis

Cystic mediastinal masses Case directory Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration

Case 59

Thymic cyst Case findings: CT: thin-walled water-attenuation cyst (arrow) Sagittal T1: low SI cyst (arrow) in a thymic location Uncommon and represent 1% of all mediastinal masses May be unilocular or multilocular

Thymic cyst Congenital thymic cysts: Acquired thymic cysts: Rare and derive from a patent thymopharyngeal duct Acquired thymic cysts: Occur in patients after radiation therapy for Hodgkin’s disease Association with thymic tumor Status post thoracotomy

Cystic mediastinal masses Case directory Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration

Case 60

Mature cystic teratoma Case findings: CXR: large, well-defined mediastinal mass (arrow) CT: heterogeneous anterior mediastinal mass with areas of fat (long arrow), calcification (short arrow), fluid attenuation, and thin soft-tissue septa MRI T1 and T2: mass with a high SI area of fat (arrow), low SI calcification, and a high SI multilocular cyst

Cystic mediastinal masses Case directory Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration

Case 61

Lymphangioma Case findings: Case directory Lymphangioma Case findings: CXR: large mediastinal mass CT: low-attenuation mass (arrow) that extends to all mediastinal compartments Coronal T2: high SI cystic mass with multiple septa (arrows) MC discovered during the first 2 years of life MC in neck and axilla (10% extend into mediastinum) Types of lymphangioma: Simple (capillary) Cavernous Cystic (hygroma), MC type

Case 62

Poland syndrome Case findings: CXR: hyperlucent left hemithorax CT: aplasia of pectoralis muscle Partial or total absence of greater pectoralis muscle Ipsilateral syndactyly

Poland syndrome DDX unilateral hyperlucent hemithorax: Case directory Poland syndrome DDX unilateral hyperlucent hemithorax: Swyer-James-MacLeod's syndrome Pneumothorax Poland syndrome Bullous emphysema Endobronchial foreign body Congenital lobar emphysema Pulmonary artery hypoplasia/occlusion (no air trapping evident on expiratory images) Compensatory hyperinflation

Case 63

Empyema necessitans Case findings: Case directory Empyema necessitans Case findings: CXR: destruction and fracture of ribs CT: well-defined fluid-filled mass with rim enhancement Spontaneous discharge of an empyema that has burrowed through the parietal pleura to form a subcutaneous abscess Etiology: Tuberculosis Actinomycosis

Case 64

Left upper lobe collapse LUL collapses forwards Presents no sharp margins on the frontal film, unlike that due to the horizontal fissure on the right Casts a veil like opacity over the left hemithorax, normally more dense towards the apex

Case directory

Case 65

Aspergilloma (mycetoma) Case findings: Thin-walled cavity in the left upper zone Homogeneous mass in cavity Air crescent sign: Rim of air in the periphery of a rounded area of consolidation or pulmonary nodule or mass DDX: Aspergilloma Rupture of hydatid cyst Necrotizing pneumonia (invasive pulmonary aspergillosis, pulmonary gangrene)

Aspergilloma (mycetoma)

Aspergilloma (mycetoma) Case directory Aspergilloma (mycetoma) Manifestations of aspergillus: Allergic bronchopulmonary aspergillosis (ABPA) Mycetoma (aspergilloma) Semi-invasive aspergillosis Invasive aspergillosis

Case 66

Hydatid disease Case findings: Parasitic infection: Air crescent sign: Ruptured hydatid cyst in the left lower lobe in the airways and giving rise to the water lily sign (arrows) Parasitic infection: Echinococcus granulosus Echinococcus multilocularis (alveolaris) Air crescent sign: Rim of air in the periphery of a rounded area of consolidation or pulmonary nodule or mass DDX: Rupture of hydatid cyst Aspergilloma Necrotizing pneumonia (invasive pulmonary aspergillosis, pulmonary gangrene)

Hydatid disease Meniscus or air crescent sign: Water lily sign: Case directory Hydatid disease Meniscus or air crescent sign: Communication develops between the cyst and the bronchial tree Air enters between fibrotic lung forming the pericyst and the exocyst, producing appearance of a crescent of air at the periphery of the cyst Water lily sign: Cyst ruptures resulting in an air-fluid level Floating ruptured membrane floats in the residual fluid

Case 67

Bronchopleural fistula Case findings: Left image shows an air-fluid level normal for the 5th POD Right image taken two weeks later shows a drop in the height of the fluid level highly suggestive of a bronchopleural fistula Connection between the bronchial tree and the pleural space Presence of air in the pleural cavity with an air-fluid level

Bronchopleural fistula May occur following: Classically after a lung abscess Pulmonary resection Acute bacterial pneumonia Granulomatous infection (tuberculosis or fungal infection) Failure of this ipsilateral shift almost always indicates an abnormality in the postpneumonectomy space, including: Bronchopleural fistula Empyema Hemorrhage Chylothorax

Post-pneumonectomy syndrome Case directory Post-pneumonectomy syndrome MC right side, MC in children and adolescents Displacement of trachea and mediastinum towards the side of the pneumonectomy with displacement and herniation of the lung Produces clockwise rotation of heart and great vessels Trachea and left main bronchus are compressed between aorta and pulmonary artery Leads to dyspnea and recurrent left-sided pneumonia

Case 68

Pneumothorax Case findings: Case directory Pneumothorax Case findings: Lucency at left costophrenic angle Deep sulcus sign: presence of a pneumothorax on a supine radiograph of the chest Etiology: Spontaneous pneumothorax: MC rupture of subpleural blebs Catamenial pneumothorax LCH Lymphangioleiomyomatosis (LAM) Emphysema

Case 69

Plombage therapy Early treatment of TB Case directory Plombage therapy Early treatment of TB Collapsing lung by introducing air into the pleural space Extrapleural insertion of a “plombe” to collapse the lung Fat, oleothorax (oil in pleural cavity) Solid paraffin wax Lucite spheres Plastic ping pong balls (1940s) Sponges of inert plastic material Thoracoplasty: anther procedure to collapse lung Several upper ribs were removed Chest cage was pushed toward the mediastinum, collapsing the upper lobe

Case 70

Thymoma Case findings: Arises from thymic epithelium Case directory Thymoma Case findings: Lobulated mass located in prevascular space Mass is of soft tissue attenuation and contains irregular calcifications Arises from thymic epithelium MC cause of a thymic mass Cystic changes are common 30% aggressive  invasion through fibrous capsule May have multiple discrete pleural masses (drop metastases) Extent of tumor in pleura may be so great as to mimic a mesothelioma Associated with myasthenia gravis: 85% of patients with MG have thymoma 15% of patients with MG have thymoma 50% of patients with thymoma have MG

Case 71

Fibrosing mediastinitis Diagnosis: post-tuberculous chronic mediastinitis Case findings: Right hilar mass containing a large calcification Mass obstructs lumen of RUL bronchus by extrinsic compression  induce atelectasis Stenosis of SVC with abnormal opacification of azygos vein (collateral venous circulation) Absence of opacification of anterior trunk of RPA (compressed by mass) Bibrachial venography: stenosis of distal part of SVC Chronic inflammation of the mediastinum which may progress to diffuse fibrosis Histoplasmosis: May be cause of fibrosing mediastinitis Can lead to obstruction of pulmonary vessels, bronchi or constrictive pericarditis

Fibrosing mediastinitis Case directory Fibrosing mediastinitis Etiologies: Granulomatosis processes MC Histoplasmosis TB, sarcoidosis, Coccidioidomycosis Association with other sites of fibrosis Retroperitoneal fibrosis, Riedel's thyroiditis Orbital pseudotumour Association with immunological disorders SLE, RA, Raynaud's phenomenon Drug-induced Methysergide

Case 72

Case 73

Case 74

Case 75