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LUNG MASSES
The document discusses the evaluation of pulmonary masses and nodules seen on imaging. It defines a mass as greater than 3 cm in diameter and a nodule as 3 cm or less. Location, size, number, characteristics like calcification and cavitation, and doubling times are among the factors used to evaluate lesions. Specific entities like lung cancer often appear as solitary, thick-walled cavitary masses. Cystic lesions may demonstrate water density. Fat density suggests conditions like lipoid pneumonia. Adjacent bone destruction is strongly suggestive of lung cancer.
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LUNG MASSES
- 2. INTRODUCTION •Fleischner Society ofthoracic imaging define thoracic mass as: •Any pulmonary, pleural, or mediastinal lesion seen on chest radiographs as an opacity greater than 3 cm in diameter. •Mass usually implies a solid or partly solid opacity. •Nodule is define ≤ 3 cm in greatest diameter.
- 3. Lung masses •A massis much more likely than a nodule to be malignant = 95% •Imaging ALONE can not differentiate between lung masses. •Calcification in a mass does not exclude malignancy
- 4. Nodule/mass evaluation • Clinicalfindings (Age, risk factor, symptoms, examination, primary tumor) • Previous films • Imaging evaluation Location of the Lesion (lung, pleural, chest wall) Number Size = >3 or <3 Change in Size Calcification Fat Density Water Density Air Bronchogram Cavitation Character of the Nodule-Lung Interface Contrast Enhancement adjacent bone destruction
- 5. Volume doubling times • Faster1 month • Between 1-18 months • Slower than 18 months Faster than1 month suggest infection, infarction, aggressive lymphoma, or a fast growing metastasis Between 1 and 18 months Lung cancers usually take to double in volume Slower than 18 months suggest granuloma, hamartoma, carcinoid, round atelectasis.
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- 9. Location of theLesion (lung, pleural, chest wall) Number Size = >3 or <3 Change in Size Calcification Fat Density Water Density Air Bronchogram Cavitation Character of the Nodule-Lung Interface Contrast Enhancement adjacent bone destruction
- 10. Location of theLesion Number Water Density (CT) Fat Density Air Bronchogram Cavitation Adjacent bone destruction
- 11. REMEMBER THAT: •For everyradiological evaluation points there is/are exception/s, •Clinical data, previous films, correlation is essential to reach the diagnosis.
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- 15. NUMBER OF LESIONS MULTIPLE Metastatic carcinoma Wegener granulomatosis Lungabscesses/ septic emboli
- 17. Wegener Granulomatosis History ofsinus & renal disease Nodules or masses ± cavitation, air-fluid levels rare Subglottic stenosis may be associate
- 18. Septic Emboli Endocarditis, extrathoracicsite of infection, indwelling catheter, or IV drug abuse Often multiple consolidations, rapidly evolve into cavities (24 hours)
- 19. NUMBER OF LESIONS SOLITARY primary pulmonary carcinoma acutelung abscess Hydatid cyst Round pneumonia / atelectasis OTHER LESS COMMON Metastasis Hamartoma Sequestration Arteriovenous malformation
- 20. Lung Cancer Lung cavityin edentulous patient more likely from cancer than abscess Thickest portion of cavity wall > 15 mm suggests tumor Nodular cavity wall Less likely to exhibit surrounding consolidation
- 22. Extralobar Sequestration Supernumerarylung tissue Well-defined pyramidal basilar soft tissue mass o May exhibit intrinsic fluid-filled cysts 90% in left inferior hemithorax o Other locations: Within diaphragm, abdomen, mediastinum Systemic arterial supply Systemic venous drainage
- 23. Water Density onCT •Water density (0 HU) on CT plus a thin or invisible wall is diagnostic of a cystic lesion. Water Density on CT Hydatid cyst Bronchogenic cyst Fluid-filled bulla
- 25. Pulmonary bronchogenic cyst Solitary,well-defined, unilocular, spherical/ovoid Usually lower lobe, rarely upper lobe Medial 1/3 of lung
- 26. Fat Density onCT •Demonstration of the presence of fat (−30 to −120 HU) attenuation values on CT. Fat Density on CT Lipoid pneumonia Metastatic liposarcoma
- 29. Air bronchogram Air bronchogramon CT Bronchoalevoler carcinoma Pulmonary lymphoma Round Pneumonia
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- 33. Cavities and aircrescent sign •Defined radiologically as a gas-containing space within the lung surrounded by a wall whose thickness is greater than 1 mm •Many of the causes of masses may result in cavitation, so the presence or absence of cavitation is of limited diagnostic value. • More important is the morphology of the cavity.
- 34. Cavity morphology • Thicknessof the cavity wall • The character of its inner lining (whether irregular or smooth) • The presence and nature of its contents • The number of lesions Cavities and air crescent sign
- 35. • morphology of thecavity Benign lesions Thin <4 mm smooth inner wall Malignant lesion Thick > 15mm Nodular inner wall 5 to 15 mm Equivocal Cavities and air crescent sign
- 38. • Content ofcavity Non specific Flat, smooth air-fluid level pus, necrotic neoplasm More specific Mobile intracavitry mass fungal mycetomas Fungal ball Aspergiloma collapsed membranes ruptured Echinococcus cyst Cavities and air crescent sign
- 41. •Invasion of adjacentbone by a pulmonary mass is almost pathognomonic of lung cancer. •Actinomycosis and occasionally tuberculosis or fungal disease are the alternative possibilities. Adjacent bone destruction
- 43. 57-year-old woman withcough, hemoptysis and weight loss • PA chest radiographs demonstrate a large right hilar mass with associated upper lobe volume loss. Note the reverse “S” shape produced by the concave outline of the lateral aspect of the minor fissure and the convex outline of the central mass, the so-called reverse “S” sign of Golden. • Contrast-enhanced chest CT (lung and mediastinal windows) reveals a large central mass that produces severe irregular narrowing of the right main bronchus, atelectasis of the right upper lobe, and deformity of the superior vena cava consistent with local invasion Lung Cancer
- 44. PA chest radiographsdemonstrate a well defined spherical pulmonary mass of lobular contours in the left lung Contrast-enhanced chest CT (mediastinal window) at the level of left atrium demonstrates a heterogeneously enhancing mass with irregular central low attenuation, representing necrosis. The mass abuts central bronchi medial and the adjacent pleura laterally 65-year-old man with cough and chest pain Lung Cancer
- 45. Asymptomatic 35-year-old man •PA chest radiograph demonstrates a well-marginated polylobular mass in the right lower lobe. Coned-down contrast-enhanced chest CT (lung and mediastinal windows) demonstrates a polylobular right lower lobe mass with well-defined borders and intrinsic homogeneous fluid attenuation contents. Pulmonary Cystic Hydatid Disease (Echinococcosis)
- 46. 67-year-old man withhemoptysis and prior tuberculosis • PA chest radiograph demonstrates a cavitary left apical mass with an intrinsic soft tissue nodule and an air-fluid level. Air crescent sign • unenhanced chest CT (lung window) demonstrates a left apical thick-walled cavitary lesion with an intrinsic dependent soft-tissue nodule and small cavitary satellite nodules. An adjacent pleural thickening as well as left apical centrilobular and paraseptal emphysema. Aspergillosis; Mycetoma
Editor's Notes
- #13 extrapleural lesions are often associated with rib lesions (fracture or destruction) and lift up the parietal and visceral pleura from the chest wall which is evident as triangular density a the upper and lower margin of the lesion pleural lesions are often lobulated and also demonstrated the pleural lift up sign at their margins pulmonary lesions abutting the pleural surface do not separate the pleural from chest wall and may be well or poorly demarcated an acute angle between a lesion and the chest wall at both its superior and inferior margins is also characteristic of pulmonary mass
- #21 PA chest radiograph of a 60-year-old woman who presented with hemoptysis shows a large right upper lobe pulmonary mass that is highly suspicious for primary lung cancer given its large size. (Right) Axial CECT of the same patient shows the large lobular right upper lobe mass, which involves the lumen of the right upper lobe anterior segmental bronchus. Endoluminal involvement by the neoplasm likely contributed to hemoptysis. Note surrounding centrilobular emphysema.
- #25 ydatid cyst. A, View of the left lung from a chest radiograph shows a smoothly marginated, 6-cm diameter mass. B, CT scan photographed at lung windows shows smooth margins of the cyst in the lingula and normal adjacent parenchyma. C, Contrast-enhanced CT scan shows a cystic lesion containing fl uid with attenuation values similar to water (0 HU).
- #28 image shows NECT of lung (left) and mediastinal (right) window of a patient with lipoid pneumonia manifesting as a spiculated mass with intrinsic fat attenuation
- #31 Bronchioloalveolar carcinoma and CT angiogram sign. A, CT scan shows consolidation in the right lower lobe, a few poorly defined nodular opacities bilaterally, and ground-glass opacities in the lingula. B, Contrast-enhanced CT scan shows that some of the areas of consolidation have lower attenuation than the chest wall muscles, and that opacifi ed vessels are well seen within the consolidation (CT angiogram sign)