1. Chest Cases 51-75

2. 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

3. Case 51

5. 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)

6. 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

7. Case 52

9. 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)

10. 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

11. 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

12. Case 53

14. 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

15. 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

16. Case 54

17. 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

18. Case 55

19. 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)

20. Case 56

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

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

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

25. Case directory
Pericardial cyst

26. Case 57

28. 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

29. 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

30. Bronchogenic cyst

31. Case directory
Bronchogenic cyst

32. Case 58

33. 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

34. 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

35. Case 59

37. 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

38. 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

39. 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

40. Case 60

43. 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

44. 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

45. Case 61

47. 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

48. Case 62

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

51. 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

52. Case 63

53. 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

54. Case 64

56. 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

57. Case directory

58. Case 65

59. 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)

60. Aspergilloma (mycetoma)

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

62. Case 66

63. 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)

64. 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

65. Case 67

66. 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

67. 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

68. 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

69. Case 68

70. 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

71. Case 69

72. 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

73. Case 70

74. 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

75. Case 71

77. 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

78. 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

79. Case 72

80. Case 73

81. Case 74

82. Case 75