Neoplasms, Masses, and Focal Lung Abnormalities

Question 1

What is a congenital pulmonary airway malformation (CPAM) or congenital cystic adenomatoid malformation (CCAM)

Answer 1

a bronchiole derived hamartoma consisting of disorganized lung tissue containing cystic structures

Question 2

What is the lobe predilection for CPAM/CCAM?

Answer 2

Lower lobes, however can occur anywhere

Question 3

What are the arterial and venous sources of CCAM/CPAM?

Answer 3

CPAM/CCAM gets both venous and arterial supply from the pulmonary circulation

Question 4

What is the age of diagnosis for CCAM/CPAM?

Answer 4

70% diagnosed in first week of life

10% in the first year

Very Rarely, adult

Question 5

What is the presentation of Infant versus adult CCAM/CPAM?

Answer 5

Respiratory distress in neonates

Recurrent infection in adults

Question 6

Which types of CCAM/CPAM are the most common?

Answer 6

Type 1 - 65%
Type 2 - 20-25%
Type 3 - 10%
Rare - Type 4 and Type 0

Question 7

What is the characteristics of type 1 CPAM?

Answer 7

> =1 cysts, >2 cm
Initially solid > large air-filled multicystic lesion +/- air fluid levels. Can occupy the entire hemithorax

Question 8

What are the characteristics of type 2 CPAM?

Answer 8

multiple cyst, <2 cm
Initially solid (more often)> large air-filled multicystic lesion +/- air fluid levels

Has renal and cardiac abnormalities with poor prognosis

Question 9

What is the difference between CPAM Type 1 and 2?

Answer 9

Type 2 has <2 cm cysts, compared to >2 cm.

Type 2 has associations with renal/cardiac abnormalities

Type has a poor prognosis

Question 10

What are the characteristics of Type 3 CPAM?

Answer 10

Microscopic (<3-5 mm) cysts, appears as solid mass

Question 11

What distinguishes Type 0 and Type 4 compared to the other types?

Answer 11

Histologic diagnosis.

Type 0 looks like Type 3

Type 4 looks like type 1 and 2

Question 12

What CPAM type is this?

Answer 12

Type 1

Question 13

What type of CPAM is this? CT of neonate

Answer 13

Type II CPAM, white arrow shows opacified vessel in the mass

Question 14

What might a prenatal US of CPAM show?

Answer 14

Polyhydramnios, fetal hydrops, solid/cystic mass in fetal thorax

Question 15

How do you treat CPAM?

Answer 15

Excision of affected lobe

Question 16

What portends a poor prognosis in CPAM?

Answer 16

large size, underdevelopment of uninvolved lung, fetal hydrops or congenital anomalies

Question 17

What is a bronchopulmonary sequestration?

Answer 17

disorganized pulmonary tissue due to abnormal budding of the foregut during development without normal pulmonary arterial or bronchial connection

Question 18

What is the most common type of bronchopulmonary sequestration?

Answer 18

Intralobular sequestration

Question 19

What is the most common location of intralobular sequestrations?

Answer 19

Left lung field, in the posterior aspect

Question 20

What is the arterial blood supply locations for intralobular sequestrations?

Answer 20

Descending thoracic aorta is the most common, followed by upper abdominal aorta or intercostal

Question 21

Systemic or pulmonary: What are the arterial and venous sources of intralobular sequestration?

Answer 21

Systemic Arterial, Pulmonary Venous (but can be azygous or hemiazygous)

Question 22

Does an intralobular sequestration have pleura?

Answer 22

No

Question 23

What would a intralobular sequestration look like on radiographs?

Answer 23

A dense pulmonary mass, usually on the left

Question 24

What would an intralobular sequestration look like on CT?

Answer 24

Parenchymal abnormality cystic or well defined +/- air fluid levels. If enhanced you may see an arterial source.

Question 25

This an angiogram of a dense mass found on CXR. What is the diagnosis?

Answer 25

Pulmonary sequestration, the small black arrows show arterial branches from the descending aorta, and venous drainage into the azygous vein. This was most likely an intralobular sequestration

Question 26

A dense pulmonary mass was found on CXR, CECT of the chest was perform which revealed this abnormality, what is the diagnosis?

Answer 26

Intralobular sequestration. There is a dense mass in the posterior left lung, there is a venous supply from the azygous and arterial supply from the descending thoracic aorta

Question 27

What is the treatment of intralobular sequestration?

Answer 27

Surgical excision, or if asymptomatic, conservative

Question 28

What is the preferred location of extralobular sequestrations?

Answer 28

left lung base

Question 29

What is the arterial supply of extralobular sequestrations?

Answer 29

Systemic arterial, venous from azygous or hemiazygous

Question 30

What is the venous supply of extralobular sequestrations?

Answer 30

Systemic arterial, venous from azygous or hemiazygous

Question 31

What is the difference between Intralobular and extralobular sequestration?

Answer 31

Extralobular sequestration does not contain air, has own pleura, earlier diagnosis in infancy or childhood, and contain not pulmonary or bronchial supply.

Question 32

What are anomalous systemic arteries without sequestration?

Answer 32

Not at all related to pulmonary AVMs, these are persistent embryonic aortic branches that supply a portion of the lung.

Question 33

What are the long term effects of anomalous systemic arteries without sequestration?

Answer 33

Left to left arterial shunt, LV enlargement, and CHF can result

Question 34

A pulmonary arteriogram is performed. What is the abnormality?

Answer 34

Anomalous systemic artery originating from the aorta, withotu sequestration

Question 35

A smoothly marginated mediastinal mass was found on CXR, CT was performed. What is the abnormality?

Answer 35

Bronchogenic cyst, a large round subcarinal mass

Question 36

What are the characteristics of bronchogenic cysts?

Answer 36

circumscribed, thin imperceptible wall, cystic mass in the mediastinum (MC)

Question 37

what locations does bronchogenic cysts prefer?

Answer 37

near carina, mediastinum, 15% in parenchyma

Question 38

What can bronchogenic cysts develop air fluid levels?

Answer 38

If the cyst becomes infected, may produce air fluid levels and mimic an abscess. The other way it can have air is if it has communication with the tracheobronchial tree.

Question 39

What is the frequency of infected bronchogenic cysts?

Answer 39

75%

Question 40

Do bronchogenic cysts enhance on CT?

Answer 40

No

Question 41

What do bronchogenic cysts look like on MRI?

Answer 41

T2 bright (fluid), and T1 bright (if proteinaceous material)

Question 42

What are pericardial cysts?

Answer 42

Defects of embryogenesis of the coelomic cavity that causes formation of fluid filled cysts in the thoracic cavity

Question 43

What is the locational preference of pericardial cysts?

Answer 43

90% contact diaphragm (65% in the right cardiophrenic angle, 25% in the left cardiophrenic angle)

Question 44

Are pericardial cysts symptomatic?

Answer 44

No

Question 45

A round mass was identified on CXR. CT was performed. What is the abnormality?

Answer 45

A fluid attenuating round, sharply marginated cyst bordering the right cardiophrenic angle. This was a pericardial cyst

Question 46

A pulmonary nodule was detected on CXR, pulmonary angiogram was performed. What is the abnormality?

Answer 46

Arteriovenous malformation with feeding artery and enlarged draining vein

Question 47

What is the definition of a pulmonary AVM

Answer 47

a vascular sac with feeding pulmonary artery and draining vein

Question 48

What are the types of pulmonary AVMs?

Answer 48

Simple (1 artery/vein) Complex (>1 feeding artery)

Question 49

What symptoms are associated with pulmonary AVMs?

Answer 49

Right to left shunt, hypoxia Orthodeoxia (hypoxemia in upright position due to more AVMs in lower lobes) Hemoptysis, hemorrhage, paradoxic embolism

Question 50

What is the disease association of pulmonary AVMs?

Answer 50

Hereditary Hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu)

Question 51

What is osler-weber-rendu disease?

Answer 51

Autosomal dominant disease consisting of 3 of the 4 criteria: 1. Spontaneous recurrent epistaxis 2. Multiple mucocutaneous telangiectasias 3. Visceral involvement with AVMs 4. First degree relative with HHT

Question 52

What is the radiographic findings of pulmonary AVMs?

Answer 52

lobulated but sharply defined pulmonary nodule, pref in lower lobes

Question 53

Maximum Intensity Projection CT was performed. What is the abnormality?

Answer 53

Arteriovenous malformation

Question 54

What is the treatment of pulmonary AVMs?

Answer 54

embolotherapy

Question 55

What is the most common organism to cause septic emboli?

Answer 55

Staph A

Question 56

What are the imaging features of septic emboli?

Answer 56

Multiple (rarely solitary) peripheral lesions in various stages of cavitation

Question 57

What are the risk factors or septic emboli?

Answer 57

Heart infection, IVDU, or sepsis

Question 58

Multiple pulmonary nodules/opacitites were identified on CXR. A CT was obtained. What is the abnormality?

Answer 58

Multiple peripheral nodules are noted with a feeding vessel sign. This was septic emboli

Question 59

A CT was obtained from a clinically declining patient with endocarditis

Answer 59

Multiple peripheral pulmonary nodules are noted in various stages of cavitation. This is diffuse septic emboli

Question 60

What is a pulmonary Varix?

Answer 60

A dilation or tortuous appearance of pulmonary vein as it enters the left atrium

Question 61

What are the causes of acquires pulmonary vein varices?

Answer 61

elevated left atrial pressure, e.g. mitral stenosis

Question 62

What are the four types of teratomas?

Answer 62

Mature, Cystic (Dermoid), Immature, Malignant

Question 63

What is the most common type of teratoma?

Answer 63

Mature

Question 64

What components might you see in mature teratomas?

Answer 64

Fluid in 90%, fat in 75%, Calcification in 50%

Question 65

What is diagnostic of teratomas?

Answer 65

Fat fluid level, but only seen in 11% of cases

Question 66

What location is common for pulmonary teratomas?

Answer 66

anterior mediastinum, can see mediastinal widening

Question 67

What are the CT findings of teratomas?

Answer 67

Internal foci of fat in 75%, calcification in 50%, soft tissue enhancement +/-

Question 68

What are the MRI findings of teratoma?

Answer 68

Out of phase drop out of fat signal, fat suppression

Question 69

What is the treatment of teratomas?

Answer 69

Excision

Question 70

A cXR was performed on a patient with shortness of breath. What is the abnormality, what would be the differential?

Answer 70

mediastinal widening, likely anterior. DDx: included teratoma, lymphoma, thymoma

Question 71

A CXR was completed reveal and anterior mediastinal mass. CT was then done showing this abnormality. What is the diagnosis?

Answer 71

Teratoma - large anterior mediastinal mass with fat, soft tissue, calcifications and fluid.

Question 72

What is the definition of a solitary pulmonary nodule?

Answer 72

focal spherical lesion in lung <3 cm in size

Question 73

What classifies an SPN as indeterminate?

Answer 73

nonbenign calcification pattern and not stable for >2 years

Question 74

What is types of benign calcifications in pulmonary nodules?

Answer 74

diffuse, popcorn, central, laminated

Question 75

What are the two most common superior sulcus tumors?

Answer 75

Adenocarcinoma and Squamous cell carcinoma

Question 76

What is pancoast syndrome?

Answer 76

Due to compression of the brachial plexus and cranial nerve 8, produced horners syndrome and pain/paresthesias of the ipsilateral upper extremity.

Question 77

What is the convex margin measurement cutoff to suggest superior sulcus tumors?

Answer 77

>5mm

Question 78

What are signs of chest wall invasion from tumors?

Answer 78

rib destruction or encasement of nerves or bloods vessels

Question 79

What imaging modality should be performed to evaluate neurovascular involvement of superior sulcus tumors?

Answer 79

MRI brachial plexus

Question 80

What are most superior sulcus tumors automatically staged as?

Answer 80

IIb due to extrathoracic invasion on initial imaging.

Question 81

What are the surgical contraindications of superior sulcus tumor resection?

Answer 81

brachial plexus invasion above T1, >50% vertebral body invasion, invasion of esophagus or trachea, distant mets, or N2/N3 nodal mets

Question 82

If you could choose only one MRI sequence for superior sulcus tumors, what would it be?

Answer 82

T1