Neoplasms, Masses, and Focal Lung Abnormalities Flashcards
Contains: Lung Cancer, Metastatic Tumors, Lymphoma, Mediastinal Masses, Congenital and Vascular anomalies of the lung, Pulmonary Nodules/Cavities/Cysts
What is a congenital pulmonary airway malformation (CPAM) or congenital cystic adenomatoid malformation (CCAM)
a bronchiole derived hamartoma consisting of disorganized lung tissue containing cystic structures
What is the lobe predilection for CPAM/CCAM?
Lower lobes, however can occur anywhere
What are the arterial and venous sources of CCAM/CPAM?
CPAM/CCAM gets both venous and arterial supply from the pulmonary circulation
What is the age of diagnosis for CCAM/CPAM?
70% diagnosed in first week of life
10% in the first year
Very Rarely, adult
What is the presentation of Infant versus adult CCAM/CPAM?
Respiratory distress in neonates
Recurrent infection in adults
Which types of CCAM/CPAM are the most common?
Type 1 - 65%
Type 2 - 20-25%
Type 3 - 10%
Rare - Type 4 and Type 0
What is the characteristics of type 1 CPAM?
> =1 cysts, >2 cm
Initially solid > large air-filled multicystic lesion +/- air fluid levels. Can occupy the entire hemithorax
What are the characteristics of type 2 CPAM?
multiple cyst, <2 cm
Initially solid (more often)> large air-filled multicystic lesion +/- air fluid levels
Has renal and cardiac abnormalities with poor prognosis
What is the difference between CPAM Type 1 and 2?
Type 2 has <2 cm cysts, compared to >2 cm.
Type 2 has associations with renal/cardiac abnormalities
Type has a poor prognosis
What are the characteristics of Type 3 CPAM?
Microscopic (<3-5 mm) cysts, appears as solid mass
What distinguishes Type 0 and Type 4 compared to the other types?
Histologic diagnosis.
Type 0 looks like Type 3
Type 4 looks like type 1 and 2
What CPAM type is this?
Type 1
What type of CPAM is this? CT of neonate
Type II CPAM, white arrow shows opacified vessel in the mass
What might a prenatal US of CPAM show?
Polyhydramnios, fetal hydrops, solid/cystic mass in fetal thorax
How do you treat CPAM?
Excision of affected lobe
What portends a poor prognosis in CPAM?
large size, underdevelopment of uninvolved lung, fetal hydrops or congenital anomalies
What is a bronchopulmonary sequestration?
disorganized pulmonary tissue due to abnormal budding of the foregut during development without normal pulmonary arterial or bronchial connection
What is the most common type of bronchopulmonary sequestration?
Intralobular sequestration
What is the most common location of intralobular sequestrations?
Left lung field, in the posterior aspect
What is the arterial blood supply locations for intralobular sequestrations?
Descending thoracic aorta is the most common, followed by upper abdominal aorta or intercostal
Systemic or pulmonary: What are the arterial and venous sources of intralobular sequestration?
Systemic Arterial, Pulmonary Venous (but can be azygous or hemiazygous)
Does an intralobular sequestration have pleura?
No
What would a intralobular sequestration look like on radiographs?
A dense pulmonary mass, usually on the left
What would an intralobular sequestration look like on CT?
Parenchymal abnormality cystic or well defined +/- air fluid levels. If enhanced you may see an arterial source.
This an angiogram of a dense mass found on CXR. What is the diagnosis?
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
A dense pulmonary mass was found on CXR, CECT of the chest was perform which revealed this abnormality, what is the diagnosis?
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
What is the treatment of intralobular sequestration?
Surgical excision, or if asymptomatic, conservative
What is the preferred location of extralobular sequestrations?
left lung base
What is the arterial supply of extralobular sequestrations?
Systemic arterial, venous from azygous or hemiazygous
What is the venous supply of extralobular sequestrations?
Systemic arterial, venous from azygous or hemiazygous
What is the difference between Intralobular and extralobular sequestration?
Extralobular sequestration does not contain air, has own pleura, earlier diagnosis in infancy or childhood, and contain not pulmonary or bronchial supply.
What are anomalous systemic arteries without sequestration?
Not at all related to pulmonary AVMs, these are persistent embryonic aortic branches that supply a portion of the lung.
What are the long term effects of anomalous systemic arteries without sequestration?
Left to left arterial shunt, LV enlargement, and CHF can result
A pulmonary arteriogram is performed. What is the abnormality?
Anomalous systemic artery originating from the aorta, withotu sequestration
A smoothly marginated mediastinal mass was found on CXR, CT was performed. What is the abnormality?
Bronchogenic cyst, a large round subcarinal mass
What are the characteristics of bronchogenic cysts?
circumscribed, thin imperceptible wall, cystic mass in the mediastinum (MC)
what locations does bronchogenic cysts prefer?
near carina, mediastinum, 15% in parenchyma
What can bronchogenic cysts develop air fluid levels?
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.
What is the frequency of infected bronchogenic cysts?
75%
Do bronchogenic cysts enhance on CT?
No
What do bronchogenic cysts look like on MRI?
T2 bright (fluid), and T1 bright (if proteinaceous material)
What are pericardial cysts?
Defects of embryogenesis of the coelomic cavity that causes formation of fluid filled cysts in the thoracic cavity
What is the locational preference of pericardial cysts?
90% contact diaphragm (65% in the right cardiophrenic angle, 25% in the left cardiophrenic angle)
Are pericardial cysts symptomatic?
No
A round mass was identified on CXR. CT was performed. What is the abnormality?
A fluid attenuating round, sharply marginated cyst bordering the right cardiophrenic angle. This was a pericardial cyst
A pulmonary nodule was detected on CXR, pulmonary angiogram was performed. What is the abnormality?
Arteriovenous malformation with feeding artery and enlarged draining vein
What is the definition of a pulmonary AVM
a vascular sac with feeding pulmonary artery and draining vein
What are the types of pulmonary AVMs?
Simple (1 artery/vein)
Complex (>1 feeding artery)
What symptoms are associated with pulmonary AVMs?
Right to left shunt, hypoxia
Orthodeoxia (hypoxemia in upright position due to more AVMs in lower lobes)
Hemoptysis, hemorrhage, paradoxic embolism
What is the disease association of pulmonary AVMs?
Hereditary Hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu)
What is osler-weber-rendu disease?
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
What is the radiographic findings of pulmonary AVMs?
lobulated but sharply defined pulmonary nodule, pref in lower lobes
Maximum Intensity Projection CT was performed. What is the abnormality?
Arteriovenous malformation
What is the treatment of pulmonary AVMs?
embolotherapy
What is the most common organism to cause septic emboli?
Staph A
What are the imaging features of septic emboli?
Multiple (rarely solitary) peripheral lesions in various stages of cavitation
What are the risk factors or septic emboli?
Heart infection, IVDU, or sepsis
Multiple pulmonary nodules/opacitites were identified on CXR. A CT was obtained. What is the abnormality?
Multiple peripheral nodules are noted with a feeding vessel sign. This was septic emboli
A CT was obtained from a clinically declining patient with endocarditis
Multiple peripheral pulmonary nodules are noted in various stages of cavitation. This is diffuse septic emboli
What is a pulmonary Varix?
A dilation or tortuous appearance of pulmonary vein as it enters the left atrium
What are the causes of acquires pulmonary vein varices?
elevated left atrial pressure, e.g. mitral stenosis
What are the four types of teratomas?
Mature, Cystic (Dermoid), Immature, Malignant
What is the most common type of teratoma?
Mature
What components might you see in mature teratomas?
Fluid in 90%, fat in 75%, Calcification in 50%
What is diagnostic of teratomas?
Fat fluid level, but only seen in 11% of cases
What location is common for pulmonary teratomas?
anterior mediastinum, can see mediastinal widening
What are the CT findings of teratomas?
Internal foci of fat in 75%, calcification in 50%, soft tissue enhancement +/-
What are the MRI findings of teratoma?
Out of phase drop out of fat signal, fat suppression
What is the treatment of teratomas?
Excision
A cXR was performed on a patient with shortness of breath. What is the abnormality, what would be the differential?
mediastinal widening, likely anterior. DDx: included teratoma, lymphoma, thymoma
A CXR was completed reveal and anterior mediastinal mass. CT was then done showing this abnormality. What is the diagnosis?
Teratoma - large anterior mediastinal mass with fat, soft tissue, calcifications and fluid.
What is the definition of a solitary pulmonary nodule?
focal spherical lesion in lung <3 cm in size
What classifies an SPN as indeterminate?
nonbenign calcification pattern and not stable for >2 years
What is types of benign calcifications in pulmonary nodules?
diffuse, popcorn, central, laminated
What are the two most common superior sulcus tumors?
Adenocarcinoma and Squamous cell carcinoma
What is pancoast syndrome?
Due to compression of the brachial plexus and cranial nerve 8, produced horners syndrome and pain/paresthesias of the ipsilateral upper extremity.
What is the convex margin measurement cutoff to suggest superior sulcus tumors?
> 5mm
What are signs of chest wall invasion from tumors?
rib destruction or encasement of nerves or bloods vessels
What imaging modality should be performed to evaluate neurovascular involvement of superior sulcus tumors?
MRI brachial plexus
What are most superior sulcus tumors automatically staged as?
IIb due to extrathoracic invasion on initial imaging.
What are the surgical contraindications of superior sulcus tumor resection?
brachial plexus invasion above T1, >50% vertebral body invasion, invasion of esophagus or trachea, distant mets, or N2/N3 nodal mets
If you could choose only one MRI sequence for superior sulcus tumors, what would it be?
T1
