Role of MDCT in Diagnosis of Different Calcified Chest Lesions

Transcription

1 Med. J. Cairo Univ., Vol. 85, No. 3, June: , Role of MDCT in Diagnosis of Different Calcified Chest Lesions YOUSSRIAH Y. SABRI, M.D.*; TAKEYA TAYMOUR, M.D.**; HEBAALLAH A. MOUSSA, M.D.* and REHAM M.A. REFAIE, M.Sc.* The Departments of Diagnostic Radiology* and Pulmonology**, Faculty of Medicine, Cairo University Abstract Introduction: Intrathoracic calcifications occur in a wide variety of disorders. Although they are usually harmless sequel of a remote process, calcifications provide important information for establishing the diagnosis and evaluating the progression of a known disease. MDCT plays an important role diagnosis of different calcified chest lesions. Patients and Methods: This study involved 50 patients; 28 males and 22 females, showing intrathorathic calcification, age ranging from 12 to 88 years. All patients were cases with different chest complaints and all of them underwent assessment of their using 16 channels MDCT; NECT in 20 cases, CECT followed by NECT in 5 and HRCT in 7 patients. Results: The anatomical sites of the calcification were as follows: Lung in 11 cases, lung and mediatinum in 6, pleura in 8, lung and pleura in one and chest wall in 4. Types of calcified lung lesions were cystic lesions in 5 cases, mass lesions in 8 fibrosis in 2 and diffuse in only one case. Conclusion: MDCT is currently the imaging of choice in diagnosis of different calcified chest lesions. Key Words: MDCT Calcified chest lesions. Introduction CALCIFICATION refers to the deposition of calcium salts in tissues, in contrast to ossification, which indicates bone tissue formation (calcification in a collagen matrix), with or without marrow elements. A number of pathologic conditions predispose to soft tissue calcification. Internal organs most commonly affected by ectopic calcification include the stomach, kidneys, lungs, heart, and blood vessels. The lungs seem particularly susceptible to this complication [1]. Pathologic soft tissue calcification can be broadly divided into either; metastatic calcification, in Correspondence to: Dr. Youssriah Y. Sabri, The Department of Diagnostic Radiology, Faculty of Medicine, Cairo University which calcium deposits in normal tissues, or dystrophic calcification, in which calcification is superimposed on previously injured lung [1]. Intrathoracic calcifications provide important information for establishing the diagnosis and evaluating the progression of a known disease. Different sites of intrathoracic calcifications are identified, including: pulmonary, pleural, nodal, cardiac, vascular, airway and chest wall calcifications [2]. The cause of the calcification may be determined by means of the location and pattern of the calcifications within the lung parenchyma and knowledge of the associated clinical features. Calcifications in the thorax are frequently manifestations of previous infectious processes. Less often, they may be due to neoplasms, metabolic disorders, occupational exposure, or previous medical therapy [2]. Large intrathoracic calcifications are usually identified on conventional chest radiographs; detection of smaller calcifications may require use of other imaging modalities, such as dual-energy digital radiography, fluoroscopy, radionuclide scanning, Computed Tomography (CT), and highresolution CT [2]. Patients and Methods This study included fifty CT chest studies; 28 males and 22 females showing intrathorathic calcification. Age ranging between 12 and 88. Cases were referred to The Radiology Department in Kasr Al-Ainy for MDCT of the chest in the period between October 2014 and March 2015 and their clinical presentations were as follow: Dyspnea (33 cases). 1127

2 1128 Role of MDCT in Diagnosis of Different Calcified Chest Lesions Cough (15 cases) Chest pain (12 cases). Malignancy (to access chest metastasis) (6 cases). Chest wall swelling (2 cases). Goiter (to access retrosternal extension) (1 case). Lymphoma post therapy (1 case). All patients were subjected to: - Full clinical examination with history taking. - Pulmonary Function Tests (PFT). - Laboratory tests mostly complete blood picture, the other tests according to case e.g. tuberculin, sputum analysis... etc. - CT was done to all patients using 1 6 channels MDCT; NECT in 20 cases, CECT followed by NECT in 5 and HRCT in 7 patients according to patient initial presentation. 50 cases CT chest studies showing calcification was included in this study and was assessed: - Anatomical site; (lung, pleura, chest wall, mediastinum). - Type of calcified lesion (e.g. mass, cyst, LN, nodule, plaque). - Type of cacification (e.g. punctate, amorphous, egg shell, popcorn). - Pathological confirmation was done to 36 patients; 19 with trans-bronchial biopsy, 3 with CT guided biopsy, one with US-guided biopsy and 13 with surgical biopsy. Results The anatomical sites of the calcification were as follow: Lung in 11 cases, lung and mediatinum in 6, pleura in 8, lung and pleura in one and chest wall in 4. Types of calcified lung lesions; were cystic lesions in 5 cases, mass lesions in 8, fibrosis in 2 and diffuse in only one case. In the eight cases with pleural calcification four showed bilateral calcified pleural plaques pathognomonic of asbestosis and the other four had pleural thickening with decrease volume, post empyema in three cases and post surgery in one case. There were 5 cases of calcified lymph nodes; mediastinal lymphadenopathy in case of thyroid adenocarcinoma showing dense and punctate calcification, mediastinal lymphadenopathy in case of sarcoidosis showing amorphous and punctate calcifications, pericardial lymphnnode showing egg shell calcification in a case of lymphoma post radiotherapy, right para-tracheal tuberculous lymph node showing punctate calcification, right hilar tuberculous lymph nodes showing punctate calcification. 17% Types of calcified mediastinal lesions 18% Lymph nodes calcification 5 cases Mass calcification 5 cases Cyst calcification 1 case 4% Vascular calcification 5 cases Cardiac calcification 4 cases Airway calcification 3 cases Fig. (1): Pie chart showing types of calcified mediastinal lesions. Cardiac calcification 50% Vascular calcification 20% 60% 20% Coronary calcification 2 cases Pericardium calcification 1 case Mitral valve calcification 1 case Aortic atheroscelerotic calcification 3 cases Aortic aneurysm 1 case Calcified muralthrombus in pulmonary arteries in bilharzial cor pulmonale 1 case Fig. (2): Pie chart showing types of cardiac and vascular calcifications.

3 Youssriah Y. Sabri, et al Airway calcification 33% 34% Chest wall calcification 50% 33% Aging process 1 case Broncholith 1 case Warfarin therapy 1 case Metastasis 2 cases Osteomyelitis 1 case Chondrosarcoma 1 case Fig. (3): Pie chart showing types of airway and chest wall calcified lesions. Fig. (4): CT showing diffuse dense calcified micronodules consistent with microlithiasis. Fig. (5): CT showing large mediastinal mass with fat, fluid and calicification in a case of teratoma. Fig. (6): CT showing densely calcified pericardium suggesting constrictive pericarditis. Fig. (7): CT showing bilateral pleural plaques some are calcified and right diaphragmatic pleural calcification consistent with asbestosis. Fig. (8): CT showing densely calcified mediastinal lymh nodes and fibrotic right lung with punctate calcification in a biobsy proved case of amyloidosis.

4 1130 Role of MDCT in Diagnosis of Different Calcified Chest Lesions Discussion Pulmonary calcification may be classified according to either the distribution of calcifications throughout the parenchyma which could be either focal or diffuse or the underlying pathophysiologic mechanism which could be either dystrophic, metastatic or pulmonary alveolar microlithiasis [2]. The aim of this study is to detect the role of MDCT in localization and diagnosis of different calcified chest lesions of different structures and to present a pictorial essay emphasizing the various patterns of calcification in different chest lesions to aid diagnosis and to discuss the differential diagnosis and the pathogenesis where it is known. This study involved 50 patients with different chest complaints who were referred to the radiology department in Kasr Al-Ainy for MDCT of the chest. From this 50 cases 11 cases revealed MDCT signs of pulmonary calcification; 5 cases in the form of calcified cystic lesions, 3 cases in the form of calcified masses, 2 cases in the form of calcified fibrosis and one case in the form of diffuse calcification. In our study the case with calcified chest metastasis from known case of lower limb osteosarcoma the MDCT showed multiple bilateral variable sized heterogeneous cystic lesions with rim and central calcification. Similar to our study Zweibel et al., stated that pattern of calcification in cases of metastatic osteosarcoma is dense eccentric calcifications or multifocal calcifications [3]. Similar to our study, in which MDCT showed dense total granulomatous calcification in a patient known to have tuberculosis, Srivatsaa et al., 2004 stated that diffuse total calcification is a characteristic and pathognomonic feature of tuberculosis [4]. There were 8 cases of pleural calcification in our study 4 of them showed picture pathognomonic of asbestosis related exposure which is bilateral calcified pleural plaques and calcified diaphragmatic pleura. Similarly, Kiviluoto et al., study stated that asbestos related calcification affects parietal pleura and usually are bilateral, radiologically appearing as sharply marginated and prominent along the affected diaphragmatic surface [5]. In our study 6 patients () presented with mediastinal lymph node calcification associated with lung parenchymal calcification, one of them was a patient known to have adenocarcinoma of the colon; his MDCT showed central calcification of pulmonary nodules and calcified mediastinal lymphadenopathy, which is in contrast to, Collins et al., study who stated that although pulmonary metastasis with enlarged mediastinal lymph nodes from a colorectal cancer are common, their calcification is an unusual sign and none of his patients showed calcification [6]. In consistency to our study in which we found that mediastinal lymph node calcification in a patient with Hodgkin lymphoma post irradiation was eggshell calcification, Hooper et al., stated that calcifications of Hodgkin post irradiation was classified as dense, coarse, or popcorn calcification [7]. While Toma et al., study was agreeable with us [8]. In our study the pattern of mediastinal lymph node calcification in cases known to have tuberculosis was punctate calcification, while in in a case of known to have sarcoidosis was amorphous and punctate. According to Miller et al., study, he stated that mediastinal lymph node calcification in case of sarcoidosis is complete dense calcification which is inconsistent to our study [9]. In addition to that, Seo et al., study stated that CT finding which may be strongly suggestive of broncholith is a calcified lymphnode either endobronchial or peribronchial associated with other distal findings suggestive of bronchial obstruction such as atelectasis. In our case, there was a calcified endobronchial node with distal bronchiactasis. Conclusion: Intrathorax calcifications occur because of a wide range of abnormalities and MDCT is currently the imaging of choice in diagnosis of these different calcified chest lesions, being superior in demonstrating the presence and extent of chest abnormalities making its role in diagnosis and evaluation of different calcified chest lesions central. References 1- CHAI J.L. and PATZ E.F.: CT of the lung: Patterns of calcification and other high-attenuation abnormalities. AJR Am. J. Roentgenol., 162 (5): , BROWN K., MUND D.F., ABERLE D.R., BATRA P. and YOUNG D.A.: Intrathoracic calcifications: Radiographic features and differential diagnoses. RadioGraphics, 14: , 2012.

5 Youssriah Y. Sabri, et al ZWEIBEL B.R., AUSTIN J.H.M. and GRIMES M.M.: Bronchial carcinoid tumors: Assessment with CT of location and intratumoral calcification in 31 patients. Radiolog., 179: 483-6, SRIVATSAA S.S., BURGER C.D. and DOUGLAS W.W.: Upper lobe pulmonary parenchymal calcifications in a patient with AIDS and Pneumocystis Carinii pneumonia receiving aerosolized pentamidine. Chest, 101: 266, KIVILUOTO R.: Pleural calcification as a roentgenologic sign of non-occupational endemic anthophyllite-asbestosis. Acta. Radiol, (Suppl.), COLLINS J, STERN E.J.: Chest Radiology. Lippincott Williams & Wilkins, ISBN: , HOPPER K.D., DIEHL L.F., LESAR M., et al.: Hodgkin disease: Clinical utility of CT in initial staging and treatment. Radiology, 169 (1): 17-22, TOMA P., GRANATA C., ROSSI A., et al.: Multimodality imaging of Hodgkin disease Radiographics, 27 (5): , MILLER B.H., ROSADO-DE-CHRISTENSON M.L., MCADAMS H.P., et al.: Thoracic sarcoidosis: Radiologicpathologic correlation. Radiographics, 15 (2): 42137, SEO J.B., SONG K.S., LEE J.S., et al.: Broncholithiasis: Review of the causes with radiologic-pathologic correlation. Radiographics, 22 Spec. No (Suppl 1): S , 2006.