References
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7.
Cystic & cavitary lung diseases. Mayo clinic proceeding
2003;744752
HRCT , W.Richard webb, UCSF interactive radiology series
Radiology review manual. Wolfgang Dahnert
Diagnostic imaging , Chest , Gurney et al
James reed in chest imaging
Diffuse lung diseases. Prof. Mamdouh Mahfouz
www.Radiologyassistant.nl/images
Holes in the lung

Cyst
- thin walled ( 1-3 mm)
- alone or in groups
•
Cavity
- represents areas of tissue necrosis & clearing within areas of
parenchymal opacification.
- thick walled ( > 3 mm )
- alone or in groups
- suggests a more aggressive pathology
than a cyst.
Holes in the lung

Focal
* cyst

•
•
* cavity
•
•
•
Diffuse
Lymphangioleiomyomatosis
Tuberous sclerosis
L.C.Histeocytosis
Honeycombing disease
Emphysema
Focal holes in the lung

Cyst
* Congenital --- Br. Cyst
- CCAM
* Bleb
* Bulla
* Pneumatocele
* Infection---hydatid
-coccidioidomycosis
-PCP

Cavity
* neoplastic –Br. Ca
- metastasis
- lymphoma
* infection - bacteria
- fungal
- parasites
* immunologic
- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis

In cystic lesions, benign nature is often be
assumed, while cavitary lesions usually suggest
more aggressive pathology.

Woodring et al studied the diagnostic implications
of cavitary wall thickness
1 mm ----------------- all benign
< 4mm --------------- 92% benign
5-15 mm ------------ equally divided
> 15 mm ------------ 95% malignant
Focal cystic lung disease





Congenital
* bronchogenic cyst
* CCAM ( cystic adenomatoid malformation )
Bulla
Bleb
Pneumatocele
Infection
* coccidioidomycosis
* PCP
* hydatid disease

Bronchogenic cyst
* 2/3 in mediastinum
* 1/3 in lung parenchyma,
usually near hilum
* may contain air, fluid or
both

Congenital cystic adenomatoid
malformation ( CCAM )
* air , fluid , or air-fluid containing cysts of
varying sizes
* 3 types are recognized based on cyst size
& number
- type 1---1 or more large cysts(2-10cm)
- type 2---neumerous small cysts
- type 3 – solid with microcysts

Bulla
* intraparenchymal, more
than 1 cm.
* result from coalescence of
emphsematous spaces or
from a Ball-valve type of
air-way obstruction.

Bleb
* usually located in the apex
of lung within the pleura

•
•
•
•
•
Pneumatocele
typically associated with infection,
particularly staph. Pneumonia in
children
characteristically increase in size
over time.
probably due to Ball-valve airtrapping.
resolves eventually.
May reach a large size to fill the
hemi- thorax

Infections
* { coccidioidomycosis }
* { PCP }
* { hydatid disease }
-
Most of the other infections
of the lung tend to cause
cavitary lesion.

Coccidioidomycosis
* endemic in southwestern
United States and Mexico.

Pneumocytis carnii
pneumonia PCP
* in immunocompromised
patients
* upper lobar predilection
* pneumothorax 35%

Hydatid disease
* endemic in sheep-raising areas of Mediterranean
basin
* solitary in 75%, multiple in 25%
* water density
* rare calcify
* complications:
rupture between layers of cyst—meniscus or halo sign
ruptue into bronchus—water lilly sign
rupture into pleura---hydropneumothorax
Focal holes in the lung

Cyst
* Congenital --- Br. Cyst
- CCAM
* Bleb
* Bulla
* Pneumatocele
* Infection---hydatid
-coccidioidomycosis
-PCP

Cavity
* neoplastic –Br. Ca
- metastasis
- lymphoma
* infection - bacteria
- fungal
- parasites
* immunologic
- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis
Focal cavitary lung lesions
* neoplastic -------– - Br. Ca
- metastasis
- lymphoma
* infection ---------- bacteria
- fungal
- parasites
* immunologic
--------- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis

•
•
•
Neoplastic lesions
Bronchogenic carcinoma
Lymphoma
Metastasis

Bronchogenic carcinoma
(squamous cell type)

Squamous cell
carcinoma

Infection
* bacterial
* fungal
* parasites

Immunologic
* Wegener’s granuloma
* Rheumatoid nodules

•
•
•
Septic emboli
Significant febrile illness
Multifocal, peripheral
location
Increase incidence of
cavitation

Bronchiectasis
•
Cystic structures continuous
with broncheal tree.
Signet ring sign
•
Cavity

We have to look at:
* wall thickness
* contents ------- air
------- air-fluid level
------- air with soft tissue mass.
* relation to broncheal tree


Wall thickness : more than 4 mm
Contents
* only air : regularity of the inner margin
- if regular……chronic lung abscess
- if irregular ….cavitating tumor
* air-fluid level:
- if fluid level is straight…acute lung abscess
- if fluid level is wavy ….ruptured hydatid cyst
* contents of the cavity
-if inner wall is smooth with soft tissue
inside….mycetoma
-if inner wall is irregular with soft tissue
mass..necrotic tumor

Cavity containing only air
* regularity of inner margin
- if regular ---ch. Lung abscess
- if irregular---cavitating tumor

Cavity with air-fluid level
- if fluid level is straight------- acute lung abscess
- if fluid level is wavy ---------ruptured hydatid cyst

Cavity with mass inside
- if inner wall is smooth-------- mycetoma
- if inner wall is nodular –
------- necrotic tumor
Abscess vs hydatid
Hydatid vs abscess vs necrotic tumor
Focal holes in the lung

Cyst
* Congenital --- Br. Cyst
- CCAM
* Bleb
* Bulla
* Pneumatocele
* Infection---hydatid
-coccidioidomycosis
-PCP

Cavity
* neoplastic –Br. Ca
- metastasis
- lymphoma
* infection - bacteria
- fungal
- parasites
* immunologic
- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis
Diffuse holes in the lung
•
•
•
•
•
Lymphangioleiomyomatosis
Tuberous sclerosis
L.C.Histiocytosis
Honeycombing disease
Emphysema

Lymphangioleiomyomatosis
(LAM )
•
Proliferation of smooth muscles in lung
interstitium
Hyperinflated lung
Widespread thin wall cysts
No nodules
Diffuse lung involvement
Complicated by pneumothorax (40%)
& chylothothorax (60%)
Only in females
All patients die within 10 years.
•
•
•
•
•
•
•

Tuberous sclerosis
* autosomal dominant
* pulmonary changes seen
almost exclusively only in
females in 3rd-4th decades
* changes similar to LAM
except chylous effusion

L.C.Histeocytosis
•
Histeocytes proliferation
Widespread cyts & nodules
Cysts are irregular in shapes
(bizzare, bilobed, leaf like ),
more numerous in apices, sparing
costo-pherenic angles
Lung volume is preserved
>90% Smokers, middle age , men
Spontaneous pneumothorax in 15%
•
•
•
•
•
•

Honeycombing disease
•
Indicates “end stage “ lung and
can be seen in any process
leading to severe pulmonary
fibrosis
Adjacent small cysts , 1-3 mm,
typically share walls
Predominate in lower lobes,
peripheral & subpleural lung
regions
Typically occur in several
contiguous layers
•
•
•


60% due IPF
Other causes:
- autoimmune disease
like scleroderma & RA
- hypersensitivity
pneumonitis
- drug reactions
- asbestosis

Emphysema
Perminant, abnormal,enlargement of airspaces distal to
the terminal bronchioles, accompanied by destruction of
walls of the involved airspaces
• 3 types:
- centrilobular emphysema
- panlobular emphysema
- paraseptal emphysema
•

Centrilobular emphysema
•
The more commoner
Usually results from cigarette smoking
Mainly involves upper lobes
Multiple, small, lucencies, lack visible walls
centrilobular distributd (grouped near the center of 2ry
pulmonary lobules), surrounding the centrilobular artery
•
•
•
•

Panlolobular ( panacinar)
emphysema
•
Uniform destruction of pulmonary
lobule
diffuse or more severe in lower lung
Pulmonary vessels in affected lung
appear smaller and fewer than normal
No focal lucincies can be seen
•
•
•

Paraseptal emphysema
•
More stricking in subpleural
location, arranged in single layer
Often have visible very thin walls
Can be an isolated phenomenon
Can be associated with
•
•
•
centrilobular emphysema
•
When larger than 1cm , are
termed as bulla

Paraseptal emphysema,
Centrilobular emphysema and
bulla can coexist together while
panlobular emphysema is usually
not associated with paraseptal
emphysema or bulla .
Paraseptal emphysema vs honeycombing
Conclusion
Holes in the lung

Focal
* cyst

•
•
* cavity
•
•
•
Diffuse
Lymphangioleiomyomatosis
Tuberous sclerosis
L.C.Histeocytosis
Honeycombing disease
Emphysema
Focal holes in the lung

Cyst
* Congenital --- Br. Cyst
- CCAM
* Bleb
* Bulla
* Pneumatocele
* Infection---hydatid
-coccidioidomycosis
-PCP

Cavity
* neoplastic –Br. Ca
- metastasis
- lymphoma
* infection - bacteria
- fungal
- parasites
* immunologic
- wegener’s gr.
- Rh. nodules
* septic emboli
* bronchiectasis

In cystic lesions, benign nature is often be assumed,
while cavitary lesions usually suggest more
aggressive pathology.

Other forms of focal pulmonary cysts may be seen in
adults outside these clinical sittings, and are of
obscure origin but are thaught to be related to
smoking.