Handbook of Imaging in Pulmonary Disease

By Subha Ghosh

This book is a comprehensive and easy-to-read guide to pulmonary imaging. Medical Imaging is one of the cornerstones of modern medicine, and nowhere is this more apparent than pulmonary disease. We have come a long way from the days of chest radiography, though the chest radiograph still remains the single most common imaging test ordered worldwide. Pulmonary disease is now routinely evaluated with ultra-modern computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) scanners, while ultrasonography plays a limited role in critical care and pleural/chest wall diseases. Rapid advancements in the sub-specialty of chest imaging and an exponential increase in the knowledge of pulmonary disease have led to an increasing demand for a comprehensive yet easily digestible handbook of pulmonary imaging, which prepackages knowledge in a form that can be easily understood and readily visualized with high-quality representative images.

This book answers that need by providing the most important, relevant medical knowledge needed to handle pulmonary cases. It is divided into two sections, neoplastic disease and non-neoplastic disease. Chapters detail essential information about each disease, including presentation and the different modalities used to accurately diagnose and/or plan treatment. Major topics that are covered include bronchogenic carcinoma and other lung tumors, COPD, ILD, developmental lung disorders, pulmonary hypertension, and pulmonary infections. Each chapter includes extensive radiographic images to give a complete perspective on how these diseases present. Readers can easily see what the radiology of a particular disease entity looks like, what would be the differential diagnoses for a particular imaging abnormality, and compare the bullet review points associated with an image to their particular case.

This is an ideal guide for general and thoracic radiologists, pulmonary, sleep medicine, and critical care specialists, thoracic surgeons, as well as residents and all clinicians who treat patients with pulmonary disease.

• Language: English
• Publisher: Springer
• Release date: Apr 20, 2021
• ISBN: 9783030681654

Book preview

Part INeoplastic Disease

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

S. GhoshHandbook of Imaging in Pulmonary Diseasehttps://doi.org/10.1007/978-3-030-68165-4_1

1. Adenocarcinoma

Subha Ghosh¹  

(1)

Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA

Subha Ghosh

Email: [e-mail]

Imaging Pearls (Figs. 1.1, 1.2, 1.3, 1.4, 1.5, and 1.6)

Suggested Reading

International Association for the Study of Lung Cancer (IASLC)/the American Thoracic Society (ATS)/the European Respiratory Society (ERS) classification followed despite lack of definitive CT correlation.

Atypical adenomatous hyperplasia (AAH): focal subcentimeter groundglass opacity (GGO) (usually ≤ 5 mm), which remain unchanged over months and considered benign. Premalignant and malignant forms including adenocarcinoma in-situ, minimally invasive adenocarcinoma (MIA) and invasive adenocarcinoma are distinguished based on increasing overall size of the tumor, presence or absence of any associated solid component, and size of the solid (stromal) component.

Adenocarcinoma in situ (AIS): ≤ 3 cm GGO without any invasive component

Minimally invasive adenocarcinoma: ≤ 3 cm predominant GGO lesion with ≤ 5 mm invasive component

Invasive adenocarcinoma:

A.

Lepidic predominant, acinar, solid, papillary, micro-papillary types

B.

Invasive mucinous adenocarcinoma

The lepidic subtype invasive adenocarcinoma (formerly non-mucinous BAC) is characterized by predominant lepidic pattern with >5 mm invasive component, or gross tumor size > 3 cm.

The invasive mucinous adenocarcinoma subtype (formerly mucinous BAC, associated with KRAS mutation) may present as low-density consolidation (air bronchogram sign, CT angiogram sign), multifocal nodules and masses, or rarely as crazy-paving pattern.

Imaging Pearls (Figs. 1.1, 1.2, 1.3, 1.4, 1.5, and 1.6)

Imaging signs depend on histologic growth pattern.

Single nodule or mass, consolidation or GGO, or multi-centric disease (nodules or masses).

Nodules can be solid, part-solid (ground-glass with solid components), or ground-glass attenuation.

Spiculated margins, pleural tags, bubble lucencies or pseudo-cavitations, cheerio sign, air bronchograms and CT angiogram signs, and crazy-paving pattern may be observed.

Percentage of solid component increases with more aggressive adenocarcinoma subtypes, and GGO usually correlates with predominant or purely lepidic pattern of histologic growth. Thus, AIS, minimally invasive adenocarcinoma, and lepidic-predominant adenocarcinoma present either as ground-glass nodules or ground-glass predominant part-solid nodules; remaining invasive subtypes are more likely to present as solid or part-solid nodules, masses, or consolidative opacities.

AIS, MIA and indolent adenocarcinomas may appear PET negative due to low fluorodeoxyglucose F 18 (FDG) avidity.

../images/507979_1_En_1_Chapter/507979_1_En_1_Fig1_HTML.png

Fig. 1.1

Axial CT chest (lung windows). (a) Small GGO in the left upper lobe (LUL) which could represent AAH or AIS (thick arrow). (b) Follow-up CT after 5 years demonstrates a <5 mm solid component, which suggests AIS. (c) Fiducial marker placed prior to surgical resection (thin arrow)

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Fig. 1.2

Axial CT chest (lung windows). (a) Part-solid nodule in the right upper lobe (RUL) with central 5 mm solid component, likely MIA (blue arrow) and adjacent smaller GGO (yellow arrow). (b) Disease progression at 2-year follow-up CT with growth of the dominant nodule and increase in its solid component. Note the other small GGO has resolved (was either inflammatory or AAH)

../images/507979_1_En_1_Chapter/507979_1_En_1_Fig3_HTML.png

Fig. 1.3

Axial CT chest (a) soft-tissue and (b) lung windows demonstrate a solid peripheral right lower lobe (RLL) lung nodule with spiculated margins, conforming to invasive adenocarcinoma non-mucinous type (subtype micro-pappilary on surgical biopsy)

../images/507979_1_En_1_Chapter/507979_1_En_1_Fig4_HTML.png

Fig. 1.4

Axial CT chest (a) soft-tissue and (b) lung windows demonstrate a solid RLL lung nodule with subtle central air lucency, conforming to invasive adenocarcinoma non-mucinous type (subtype pappilary on surgical biopsy)

../images/507979_1_En_1_Chapter/507979_1_En_1_Fig5_HTML.png

Fig. 1.5

Axial CT chest (lung windows). Previous RUL resection with recurrance of lepidic pattern invasive adenocarcinoma in the RML and RLL. Note tiny bubble lucencies in the perihilar region (blue arrow), as well as focal GGO interspersed with smooth interlobular septal thickening (crazy-paving pattern) in the RLL (yellow arrow)

../images/507979_1_En_1_Chapter/507979_1_En_1_Fig6_HTML.png

Fig. 1.6

Invasive mucinous adenocarcinoma presenting as non-resolving RLL consolidation on PA (a) and lateral (b) chest radiograph (CXR) (blue arrows). Axial unenhanced CT chest (C-soft tissue window, D-lung window) show perihilar mass-like consolidation (red arrow) with diffuse distal GGO throughout the RLL (yellow arrow)

Suggested Reading

https://​pubs.​rsna.​org/​doi/​full/​10.​1148/​radiol.​2018180431.

https://​onlinelibrary.​wiley.​com/​doi/​abs/​10.​1111/​1754-9485.​12779.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

S. GhoshHandbook of Imaging in Pulmonary Diseasehttps://doi.org/10.1007/978-3-030-68165-4_2

2. Squamous Cell Carcinoma

Subha Ghosh¹  

(1)

Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA

Subha Ghosh

Email: [e-mail]

Suggested Reading

Endobronchial nodule with segmental, lobar, or total lung collapse (early presentation). The Golden S sign refers to central obstructive right hilar tumor with right upper lobe atelectasis, which may be due to squamous cell carcinoma (SCC) lung.

Peripheral mass with central cavitation (may present later). SCC may cause Pancoast tumor or superior sulcus tumor, which refers to a peripheral mass that is anatomically localized to either of the lung apices and causes chest wall invasion with involvement of the brachial plexus.

Hilar and/or mediastinal lymphadenopathy and malignant pleural effusion are fairly common (Figs. 2.1, 2.2, 2.3, and 2.4).

../images/507979_1_En_2_Chapter/507979_1_En_2_Fig1_HTML.png

Fig. 2.1

Axial unenhanced CT chest. (a) Soft tissue and (b) lung windows demonstrate an endobronchial nodule (SCC lung) within the bronchus intermedius (yellow arrow) with partial atelectasis of the middle lobe (blue arrow)

../images/507979_1_En_2_Chapter/507979_1_En_2_Fig2_HTML.png

Fig. 2.2

Axial unenhanced CT chest (soft tissue windows). (a) Cavitary left lower lobe (LLL) lung mass (SCC lung) with central necrosis (yellow star). (b) Malignant left pleural effusion with nodular pleural thickening (blue star)

../images/507979_1_En_2_Chapter/507979_1_En_2_Fig3_HTML.jpg

Fig. 2.3

CXR shows central right hilar tumor (squamous cell carcinoma lung) resulting in obstruction of the right upper lobe bronchus and right upper lobe atelectasis (Golden S sign). The homogeneous opacity in the right upper hemithorax has a sharp, somewhat S-shaped inferior margin (lateral aspect contributed by the superiorly retracted minor fissure and medial portion by the inferior margin of the mass itself)

../images/507979_1_En_2_Chapter/507979_1_En_2_Fig4_HTML.png

Fig. 2.4

Basaloid-type squamous cell carcinoma. (a) Axial unenhanced CT chest demonstrates a LLL cavitary lung nodule. (b) FDG-PET demonstrates hypermetabolic mural solid component (bright)

Suggested Reading

https://​pubs.​rsna.​org/​doi/​10.​1148/​radiographics.​14.​2.​8190965.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

S. GhoshHandbook of Imaging in Pulmonary Diseasehttps://doi.org/10.1007/978-3-030-68165-4_3

3. Large-Cell Carcinoma

Subha Ghosh¹  

(1)

Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA

Subha Ghosh

Email: [e-mail]

Suggested Reading

Usually peripheral, large, lobulated and/or well marginated, heterogeneously enhancing mass with central necrosis (central necrosis may be absent if size is small).

Rapid growth with metastasis (chest wall, thoracic lymph nodes, distant) at the time of presentation common.

Large-cell neuroendocrine tumor (NET) has almost similar imaging features and speculated to be morphologically between atypical carcinoids and SCLC.

PET-CT may be better than CT in identifying full extent of disease and metastases (Figs. 3.1 and 3.2).

../images/507979_1_En_3_Chapter/507979_1_En_3_Fig1_HTML.png

Fig. 3.1

Axial unenhanced chest CT at the level of the lung apices. (a) Soft tissue and (b) lung window images reveal a large, peripheral, pleural-based mass with heterogenous attenuation (solid and necrotic/cystic components) in the right upper lobe (RUL). The right first and second ribs are partly destroyed

../images/507979_1_En_3_Chapter/507979_1_En_3_Fig2_HTML.png

Fig. 3.2

Axial contrast-enhanced CT chest. Well-circumscribed solid mass in the LLL with peripheral nodular intense contrast enhancement (single arrow). Note adjacent posterior pleural thickening with similar attenuation to mass, suggesting local spread (double arrows)

Suggested Reading

https://​www.​ajronline.​org/​doi/​10.​2214/​ajr.​182.​1.​1820087.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

S. GhoshHandbook of Imaging in Pulmonary Diseasehttps://doi.org/10.1007/978-3-030-68165-4_4

4. Adenosquamous Cell Carcioma

Subha Ghosh¹  

(1)

Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA

Subha Ghosh

Email: [e-mail]

Suggested Reading

Poorer prognosis with early metastasis

Can be peripheral (more common) or central (less common) nodule/mass

May arise in previous scar (radiation fibrosis, pneumoconiosis, interstitial fibrosis, etc.) (Fig. 4.1)

../images/507979_1_En_4_Chapter/507979_1_En_4_Fig1_HTML.png

Fig. 4.1

Adenosquamous carcinoma arising in previously irradiated left lung in a patient with prior contralateral pneumonectomy. (a) Axial contrast-enhanced CT chest (lung window) shows cavitary lung mass in the LLL superior segment at the site of previously irradiated lung (arrow). Note prior right pneumonectomy and Clagett window. (b) CT chest image of PET-CT (middle) shows a spiculated nodule with tiny cavitations (arrow) in the LUL. Fused PET-CT image (right) shows it to be intensely FDG avid due to high metabolic activity

Suggested Reading

https://​www.​ajronline.​org/​doi/​10.​2214/​ajr.​163.​2.​8037019.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

S. GhoshHandbook of Imaging in Pulmonary Diseasehttps://doi.org/10.1007/978-3-030-68165-4_5

5. Small-Cell Carcinoma

Subha Ghosh¹  

(1)

Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA

Subha Ghosh

Email: [e-mail]

Suggested Reading

Usually arises from the main or proximal lobar bronchi and is located centrally in vast majority of patients who present with hilar or mediastinal mass.

Extensive mediastinal and hilar lymphadenopathy is common; degree of lymphadenopathy may obscure underlying primary tumor.

Disseminated disease with multi-system metastasis is fairly common (70% cases present as extensive stage); limited stage disease is less common (limited to one hemi-thorax).

Most common cause of SVC syndrome and paraneoplastic syndromes.

Strong smoking association (Figs. 5.1 and 5.2).

../images/507979_1_En_5_Chapter/507979_1_En_5_Fig1_HTML.png

Fig. 5.1

Contrast-enhanced chest CT: axial (a) and (b) coronal multi-planar reformation demonstrates an infiltrative soft tissue mass involving the right hilum and mediastinum. The primary tumor arises from the right main bronchus and is associated with extensive confluent intrathoracic lymphadenopathy

../images/507979_1_En_5_Chapter/507979_1_En_5_Fig2_HTML.png

Fig. 5.2

Contrast-enhanced CT chest. Axial image through the level of the aortic arch (a) shows post-radiation fibrosis associated with a treated right paramediastinal mass with superior vena cava (SVC) narrowing, retrograde filling of the azygos vein, and numerous chest wall collaterals. 3D volume-rendered images (b, c) show the extent of chest wall venous collateralization

Suggested Reading

https://​pubs.​rsna.​org/​doi/​10.​1148/​rg.​346140178.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

S. GhoshHandbook of Imaging in Pulmonary Diseasehttps://doi.org/10.1007/978-3-030-68165-4_6

6. Large-Cell Neuroendocrine Carcinoma

Subha Ghosh¹  

(1)

Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA

Subha Ghosh

Email: [e-mail]

Suggested Reading

Classified as a subtype of large-cell carcinoma which arises from Kulchitsky cells of the bronchus similar to other neuroendocrine tumors of the lung (sixth decade, smokers).

CT features are nonspecific from other peripheral lung carcinomas such as large-cell carcinomas (see Chap. 3) with aggressive features and generally carries a poor prognosis.

Suggested Reading

https://​www.​ajronline.​org/​doi/​10.​2214/​ajr.​182.​1.​1820087.

https://​www.​jto.​org/​article/​S1556-0864(15)33571-1/​fulltext.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021