Anomalous pulmonary air spaces. Management radiological

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1 Anomalous pulmonary air spaces. Management radiological Poster No.: C-2608 Congress: ECR 2015 Type: Educational Exhibit Authors: J. C. Quintero Rivera, J. E. Millán Suárez, R. A. Corral Rivadulla, M. F. Hermida Gómez, J. Alain Castillo, J. A. Castillo; Ourense/ES Keywords: Lung, Management, Conventional radiography, CT, Computer Applications-Detection, diagnosis, Cavitation DOI: /ecr2015/C-2608 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 60

2 Learning objectives Describe and illustrate the radiological imaging of the pathologies that cause lung destruction Show data clinical-radiological imaging to help differentiate between malignant and not malignant lesions Page 2 of 60

3 Background The pathogenic mechanisms in the appearance of anomalous air spaces in the lungs ares: - Break the red of lung elastic fibers - Vascular occlusion or ischemic necrosis - Dilation bronchial - Remodeling of the lung architecture - Multifactorial and idiopathic Page 3 of 60

4 Findings and procedure details Semiology Radiological features of cavitated lesion must refer to (among others): size, wall thickness, content, inner lining, number of lesions, location and alteration in the surrounding parenchyma Fig. 1 on page 17 Glossary of terms Fleischner Society periodically reviews the concepts of thoracic radiology, both conventional radiography and CT. The last revision dates from 2008 published in Radiology (Volume 246: Number 3-March 2008) Air crescent Collection of air in a crescentic shape that separates the cavity wall from the inner mass. It is a characteristic finding of colonization by Aspergillus of pre existing cavities or retraction infarcted lung in angioinvasive aspergillosis Fig. 2 on page 17 ). But it also can be found in tuberculosis Fig. 3 on page 18 ), Wegener's granulomatosis, intracavitary hemorrhage and bronchogenic carcinoma. Bleb A bleb is a small gas-containing space within the visceral pleura or in the subpleural lung not longer than 1 cm in diameter. Radiologically appears in contiguous with the pleura. Generally it is not recommended be used by the radiologist. Bronchiectasis Bronchiectasis is a localized or diffuse bronchial dilatation, usually resulting from chronic infection, proximal airway obstruction or congenital bronchial abnormality. Radiologically is characterized by bronchial dilatation with respect to the accompanying pulmonary artery (signet ring sign) and identification of bronchi within 1 cm of the pleural surface. May be classified as cylindric, varicose or cystic depending on the appearance Fig. 4 on page 19 It is often accompanied by bronchial wall thickening, mucoid impaction and small-airways abnormalities. Page 4 of 60

5 Bulla Airspace measuring more than 1 cm in diameter (usually several centimeters), sharply demarcated by a thin wall no greater than 1 mm in thickness. Usually accompanied by emphysematous changes in the adjacent lung Fig. 5 on page 20 Bulla appears as a rounded focal lucency or area of decreased attenuation more than 1 cm in diameter, usually multiple and may be associated with other signs of pulmonary emphysema. Cavity Is a gas-filled space seen as a lucency or low-attenuation area, within pulmonary consolidation, a mass or a nodule. In the case of cavitating consolidation, the original consolidation may resolve and leave only a thin wall. A cavity is usually produced by the expulsion or drainage of necrotic part of the lesion via bronchial tree. It sometimes contains fluid level. Cavity is not a synonym for abscess. Cyst Any round circumscribed space that is surrounded by an epithelial or fibrous wall of variable thickness. Radiologically cyst appears as a round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung. Cyst have a variable wall thickness but are usually thin-walled (<2 mm) and occur without associated pulmonary emphysema Fig. 6 on page 21 Cysts usually contain air but occasionally contain fluid or solid material. The term is often used in patients with lymphangioleiomyomatosis; Langerhans cell histiocytosis and end-stage fibrosis. Pneumatocele Thin-walled, gas-filled space in the lung. Most frequently caused by acute pneumonia, trauma Fig. 7 on page 22 or aspiration of hydrocarbon fluid and is usually transient. The mechanism is a combination of parenchymal necrosis and check-valve airway obstruction. Pneumatocele appears as an approximately round, thin-walled airspace in the lung. Pseudocavity It is an oval or round area of low attenuation in long nodules, masses or areas of consolidation that represent spared parenchyma, normal or ectatic bronchi, or focal emphysema rather then cavitation Fig. 8 on page 23 Usually measure less than 1 cm in Page 5 of 60

6 diameter. They have been described in patients with adenocarcinoma, bronchioloalveolar carcinoma and infectious pneumonia. Pulmonary destruction causes Infectious - Lung abscess - Tuberculosis and atypical mycobacterias - Nocardiosis - Hidatid disease - Necrotizing Pneumonia - Opportunistic infections: Pneumocystis jirovecii Tumor - Primary: squamous cell carcinoma, adenocarcinoma, lymphoma - Metastasis Cystic spaces - Bronchiectasis - Pneumatocele - Pulmonary cyst - Bullae - Cystic Fibrosis Vascular - Non infectious: Wegener, Churg-Strauss, rheumatoid arthritis - Infectious: septic embolism, mycosis, aspergillosis Congenital - Bronchogenic cyst - Cystic adenomatoid malformation Page 6 of 60

7 - Pulmonary sequestration Miscellaneous - Histiocytosis X - Sarcoidosis - Lymphangioleiomyomatosis - Ehlers-Danlos syndrome - Klippel Trenaunay syndrome INFECTIOUS Pulmonary abscess Most of the patients with lung abscesses have one or more predisposing factors: alcoholism, diabetes, poor oral hygiene, laryngeal paralysis, states of unconsciousness (coma and anesthesia) previous history of aspiration and underlying lung pathology. Lung abscess are usually polymicrobial infections caused by both anaerobic and microaerophilic bacteria in oral mucosa. They can appear anywhere in the lung but are more common in lung bases. The cavity walls can be more or less thick and usually airspace around it is affected Fig. 9 on page 24 Typically appears as a cavity with fluid level when it drains to bronchus. Tuberculosis and atypical mycobacteria Cavitation is a characteristic feature of the post-primary pulmonary tuberculosis seen up into 50% of patients Fig. 10 on page 25 Also often seen in tuberculosis reactivation, usually after a period of immunosuppression. Affectation of airspace is observed in apical and posterior segments of upper lobes and apical segments of lower lobes, may develop one or more cavities Fig. 11 on page 26 Other findings associated: tree-in-bud pattern and centrilobular nodules Fig. 12 on page 27 The existence of hilar and mediastinal lymphadenopathy is uncommon in postprimary tuberculosis. Nocardiosis - Actinomycosis Fig. 13 on page 28 Page 7 of 60

8 Hydatid disease Caused by the tapeworm Echinococcus granulosus and Echinococcus multilocularis. Usually appear as multiple nodules with wall thickness between 2-10 mm, frequently in lower lobes and rarely calcify. The content is similar to water density without enhanced after administration of intravenous contrast. In its growth can erode and open to adjacent bronchus. Necrotizing pneumonia Necrotizing pneumonia may cause thick-walled cavitary lesions Fig. 15 on page 30 and exceptionally cystic lesions. These lesions are commonly caused by: Streptococcus pneumonia and Haemophilus Influenzae, although cavitation is rare. Another bacteria potentially causing necrotizing pneumonia is Klebsiella pneumoniae, which have predilection forming cavitary lesions. Among the risk factors: alcoholism, smoking and hospitalization are included. Opportunistic infections: Pneumocystis jirovecii Cysts produced by Pneumocystis jirovecii are more common in AIDS patients than in other patients, representing a chronic infection. It also occurs more frequently in patients taking aerosolized pentamidine. The typical radiographic appearance of P. jirovecii pneumonia is bilateral and progressive, predominantly perihilar, forming cysts in 10% of cases mainly in the upper lobes (subpleural) and size between 1-5 cm, usually multiple and with thin walls. Rupture of cyst with following pneumothorax may occur, in which case mortality is about 20% Coccidioidomycosis Coccidiodes is a ground saprophyte. It may present as an isolated cystic lesion although more typically in the form of necrotizing pneumonia with cavitation especially in chronic forms. When the cavities are thin-walled and associated with apical fibrosis, the radiological findings are indistinguishable from tuberculosis. TUMORS Primary tumors Page 8 of 60

9 Squamous cell carcinoma is the most common histological type of lung cancer that frequently produce cavitation is Fig. 16 on page 31. Notice that presence of cavitation is associated with poor prognosis Fig. 17 on page 32 Other primary tumors that may produce cavitation are lymphoma and Kaposi's sarcoma, especially in HIV-infected patients. Normally the cavity wall is thick although in some cases such as cystic carcinoma may be thin Fig. 18 on page 33 Metastasis Pulmonary cystic metastatic lesions are rare Fig. 19 on page 34 although cystic transformation it is more common after chemotherapy Fig. 20 on page 35 Cystic transformation does not imply a complete tumor response; this is because viable tumor can be found in these lesions when they are resected. CYSTIC SPACES Bronchiectasis Bronchiectasis is a localized or diffuse bronchial dilation characterized by the ring sign (bronchial caliber larger than the accompanying pulmonary artery), fluid levels can appear because fluid retention or infection Fig. 21 on page 36 A number of entities are associated with the occurrence of cystic bronchiectasis: cystic fibrosis, immunoglobulin deficiencies, aspergillosis allergic bronchopulmonary Fig. 22 on page 37 Fig. 23 on page 38 Kartagener syndrome, childhood infections Fig. 24 on page 39 and congenital anomalies of the bronchial wall. Pneumatocele Is often described a history of traumatic lesion with pulmonary laceration Fig. 25 on page 40 or infection (Staphylococcus aureus and Pneumocystis jirovecii). In case of infection usually occurs inflammatory endobronchial obstruction that cause a valve mechanism with hyperinflation of lung distal to obstruction and alveolar septa rupture with pneumatoceles becoming large enough to cause respiratory distress. Radiologically are very similar to the cysts Fig. 26 on page 41 and usually transient. In some cases they may rupture causing pneumothorax. Birt-Hogg-Dobe Syndrome Page 9 of 60

10 Birt-Hogg-Dobe syndrome is a rare hereditary disorder characterized by the presence of facial fibrofolliculomas, kidney malignant tumors (often bilateral and multifocal) and lung thin-walled cystic lesions may present with spontaneous pneumothorax. Cystic lung lesions occur in up to 85% of patients, usually bibasilar and subpleural. Cutaneous manifestations may not necessarily occur. Pathology associated with smoking The presence of isolated cystic lesions in smoking population is very common and probably produced by respiratory bronchiolitis and interstitial lung disease secondary to smoking. Pathology associated with aging Have been described thin-walled lung cysts in elderly patients without smoking. It has involved a retention valvular mechanism by thickening and bronchial obstruction, although it remains unclear. Emphysema Emphysema is characterized by permanent enlargement of air spaces distal to the terminal bronchioles. The cause is not established although it appears due to an imbalance between proteases and antiproteases caused by cigarette smoke, air pollution or bacterial infections. Centrilobular - centriacinar emphysema It is the most common form that affected proximal bronchioles and the center of secondary pulmonary lobule. It is associated with smoking and inhalation of dusts producing enzymatic destruction of lung interstitium. On CT scans appears as not peripheral areas of low attenuation greater than 1 cm surrounded by normal lung Fig. 27 on page 42 for its central location within the secondary pulmonary lobule can be seen in the center of the low attenuation area a dense image representing the centrilobular artery and bronchi. These areas may converge and reach the subpleural region, more common in upper lobes and superior segments of the lower lobes. Paraseptal emphysema Page 10 of 60

11 It is caused by destruction of the lung air spaces in the periphery adjacent to the visceral pleura or interlobular septa. Generally associated with fibrosis and may coexist with other types of emphysema Fig. 28 on page 43 On CT scans: areas of low attenuation or bullae are seen in the lung periphery or grouped in fissural region. It is typically an incidental finding but can cause spontaneous pneumothorax. Bullae can be large causing atelectasis in adjacent lung and producing dyspnea. Panlobular emphysema It is caused by uniform destruction of the secondary pulmonary lobule from the center to the periphery. It is a rare entity associated with a deficit of alpha 1 antitrypsin (autosomal recessive disease) Fig. 29 on page 44 although it has also been described in SwyerJames syndrome Fig. 24 on page 39 and methylphenidate abuse syndrome. The areas of low attenuation are not as evident as in the centrilobular emphysema because there is not much contrast with the healthy lung parenchyma. Diffuse vascular distortion is quite common. Unlike the centrilobular emphysema, panlobular emphysema predominates in the lower lobes. Interstitial emphysema Actually there is not a form of emphysema due to the absence of alveolar wall destruction. There is a permanent enlargement of air space beyond the terminal bronchiole. The CT radiographic appearance is very similar to emphysema and cystic multifocal disease. A detailed analysis of the images shows a peculiar air distribution along the small pulmonary vessels and bronchi giving the appearance of triad: bronchi - pulmonary vessel - air collection. The physiopathological mechanism is the Macklin effect that consists in three phases: alveolar rupture, dissection of air along the bronchovascular sheaths and extension to the mediastinum. So any event having increased pressure within the alveoli may condition the presence of interstitial emphysema, such as: blunt chest trauma, newborn respiratory distress syndrome, Valsalva maneuver (Boerhaave syndrome, seizures), asthma and positive pressure mechanical ventilation Fig. 30 on page 45 Honeycombing Honeycombing is observed in end-stage lung disease associating with different entities such as idiopathic pulmonary fibrosis, fibrosis associated with connective Page 11 of 60

12 tissue disease (SLE, rheumatoid arthritis, scleroderma, polymyositis-dermatomyositis, Sjogren's syndrome and mixed connective tissue disease), asbestosis, sarcoidosis and hypersensitivity pneumonia. It represents destruction of lung parenchyma with complete loss of normal architecture. On CT scans the appearance is of multiple small cysts (3-10 mm), thin-walled (1-3 mm) in subpleural zones, associated findings as traction bronchiectasis, irregular linear opacities and distortion of lung architecture can be found. Bullae Bullous emphysema is characterized by the presence of thin-walled gas collections and no major than 1 cm. Presents a punctate soft tissue density image in the center: "center dot sign". High risk of pneumothorax Frequently seen in upper lobes and subpleural region, normally with asymmetrical distribution. Lymphocytic Interstitial Pneumonia Lymphocytic interstitial pneumonia is a rare disease characterized by interstitial infiltration of lymphocytes compressing the alveolar spaces; hence it can be considered a benign lymphoproliferative disorder. Normally associated with AIDS, SLE, Sjögren's disease, Castleman's syndrome, autoimmune diseases or any other immune system disorder. Primary or idiopathic form is very rare. Commonly affects women between years, children usually associated with AIDS or hypogammaglobulinemia. Clinical manifestations include cough and dyspnea. There is a greater incidence of lymphoma in these patients. Radiologically, 66% of patients have cysts variable in shape and size (1-30 mm), other associated findings are ground-glass pattern, interlobular septa thickening, consolidation areas, nodules, centrilobular cysts and lymphadenopathy. All parenchymal lesions, except cysts, are reversible. Disease improves with corticosteroid treatment. Untreated patients can show pulmonary fibrosis, infections or develop lymphoma (5% of cases). Superinfection is the most common cause of death in these patients. Desquamative interstitial pneumonia Page 12 of 60

13 Desquamative interstitial pneumonia occurs only in ex-smokers with symptoms of cough and dyspnea. Presents accumulation of pigmented macrophage in air spaces. CT findings show diffuse areas of ground-glass pattern with presence of parenchymal cysts. It can evolve to pulmonary fibrosis Fig. 32 on page 47 The process may resolved with corticosteroid treatment and quit smoking. Other Lung cysts can also be found in patients with: Down syndrome, immune reconstitution inflammatory syndrome, amyloidosis, sarcoidosis, Ehlers-Danlos syndrome and hydrocarbon aspiration. VASCULAR Non infectious Wegener's granulomatosis Wegener's granulomatosis findings includes nodules/cavitated mass with thick and irregular walls Fig. 33 on page 48 Other radiographic findings are patchy ground-glass consolidations and multiple nodules variable in size ( cm). Fig. 34 on page 49 Fig. 35 on page 50 Others Other autoimmune diseases as rheumatoid arthritis and systemic lupus erythematosus may associate cavitated nodules. Infectious Septic embolism Poorly defined cavitated lesions with irregular internal walls Fig. 36 on page 51 and typically at different stages of evolution and. Distribution is predominantly peripheral and especially in lower lobes. A feeding blood vessel can be observed, called "feeding sign" Fig. 37 on page 52 not pathognomonic sign of pulmonary embolism, because is seen in other pathologies such as bronchogenic carcinomas Fig. 38 on page 53 Aspergillosis Page 13 of 60

14 Aspergillosis is seen in immunocompromised patients, particularly in hematologic disorders like neutropenia. The characteristic finding: halo sign, is consequence of alveolar hemorrhage around the nodules and the "air-crescent sign" due to nodule cavitation that usually occurs 15 days after the halo sign and it is considered good prognosis reflecting the neutrophil count recovery Fig. 39 on page 54 Rendu Osler - Hereditary hemorrhagic telangiectasia (HHT) The HHT diagnosis is based on the Curaçao criteria, with clinical and anamnesis findings: multiple mucocutaneous telangiectasia characteristic sites (lips, oral cavity, fingers, nose), epistaxis, defined as spontaneous and recurrent episodes of bleeding from the nose, visceral affection as telangiectasias / gastrointestinal AVMs, lung, liver, brain or spine, and family history (first degree relative with HHT). Three criteria indicate definitive diagnosis in adults, and two criteria indicate a possible diagnosis. Internal organs most commonly affected are the lung Fig. 40 on page 55 brain, spinal cord and liver. The pancreatic telangiectasias are easily identifiable as rounded lesions in arterial phase but may not be detectable in portal phase. CONGENITAL Clinical manifestations of congenital abnormalities usually occur in children and young adults. We review the three entities usually manifested by cyst formation. Bronchogenic cyst The bronchogenic cyst is caused by an abnormal budding of the tracheobronchial tree and although is most commonly seen in the posterior mediastinum, up to 1/3 of cases may appear within lung parenchyma, especially in lower lobes.. It appears as a thin wall cyst with content similar to water. Overall not communicate with the tracheobronchial tree exception if infected in which case they can grow and change its density. Complications like pneumothorax, recurrent pneumonia and hemoptysis can be found. Cystic adenomatoid malformation Page 14 of 60

15 Cystic adenomatoid malformation (CAM) is one of the most common lung malformations, most of them intralobar and 2/3 in posterior basal segment of the left lower lobe. Frequently appear as homogeneous masses but we can also find cysts. Patients are usually diagnosed incidentally or in patients with recurrent pneumonias. On CT scans appears as a homogeneous mass or also with presence of well-defined cysts with fluid levels or cavitation. Pulmonary sequestration Pulmonary sequestration is caused by a abnormal stop in the bronchial tree development usually diagnosed in prenatal stage. Clinical manifestations include difficulty breathing. There are three clinical-radiological types depending on the size and number of cysts. CT scans is characterized by the presence of several cysts varying size (2-12 cm) with thin walls, cysts may contain air, liquid or both. They can be found anywhere in the lung, up to 15% of cases are bilateral. Sequestration shows an anomalous systemic arterial supply and venous drainage to pulmonary or systemic circulation. MISCELLANEOUS Histiocytosis X Histiocytosis X affects mainly young adults, most of them smokers. Symptoms like non productive cough, dyspnea and chest pain are seen. Pneumothorax is the initial manifestation of disease in 15% of patients, while 25% are asymptomatic at the time of diagnosis. Interstitial infiltrates appear in small airway leading to the appearance of nodules that may cavitate in which case they can be thin or thick wall. The lesions are frequently seen in upper and middle lung zones (with preservation of costophrenic zone) and are variable in size and number (1-8 cm) Fig. 41 on page 56 In expiratory studies the cysts size is reduced which means communication with the airway. They can cause pulmonary hypertension because intimal fibrosis, vascular hypertrophy or luminal obliteration. Disease can resolve / stabilize with corticosteroids and smoking cessation. In some cases it can progress to pulmonary fibrosis with honeycombing. It has been described association with Hodgkin's disease and lung carcinoma. Page 15 of 60

16 Lymphangioleiomyomatosis (LAM) LAM is a slowly progressive disease caused by abnormal proliferation of atypical muscle cells within the lung. It may occur sporadically or in association with tuberous sclerosis. Appears almost exclusively in reproductive age women and is not smoking related. LAM main symptoms: progressive dyspnea, being pneumothorax the most common symptom in the onset of sporadic forms. 100% of patients have thin-walled cysts varying in size (2-40 mm), distributed diffusely in all lung fields. Its size decreases during expiration because the communication with bronchial tree. Pneumothorax at diagnosis it is present in 50% of cases and it will appear again in 90% of cases. Other radiologic findings are chylous pleural effusion, air trapping (rare), interlobular and intralobular thickening (affecting lymphatic drainage), areas of increased attenuation (hemorrhage or edema), pulmonary hypertension (cell proliferation in pulmonary vein), and lymphadenopathy. The only curative treatment is lung transplantation. Klippel-Trenaunay Page 16 of 60

17 Images for this section: Fig. 1: Radiological features of cavitated lesion: size, wall thickness, content, inner lining, number of lesions, location and alteration in the surrounding parenchyma Page 17 of 60

18 Fig. 2: Air crescent sign. Invasive aspergillosis Page 18 of 60

19 Fig. 3: Pulmonary tuberculosis. Bilateral apical cavities with air crescent sign and small air way dissease: tree-in-bud pattern Page 19 of 60

20 Fig. 4: Cylindric and cystic bronchiectasis Page 20 of 60

21 Fig. 5: Bullaes in patient with sarcoidosis and ankylosing spondylitis Page 21 of 60

22 Fig. 6: Subpleural pulmonary cysts in patient with idiopathic pulmonary fibrosis Page 22 of 60

23 Fig. 7: Post traumatic pneumatoceles Page 23 of 60

24 Fig. 8: Pseudocavity Page 24 of 60

25 Fig. 9: Pulmonary abscess Page 25 of 60

26 Fig. 10: Tuberculous cavity. Chest x ray and MDCT images post TB treatment Page 26 of 60

27 Fig. 11: 23 year old woman contact Mycobacterium tuberculosis (family environment). Pulmonary disease with cavitation Page 27 of 60

28 Fig. 12: Pulmonary tuberculosis with extensive bilateral disease Page 28 of 60

29 Fig. 13: Actinomyces infection. Pulmonary disease with extension to chest wall Page 29 of 60

30 Fig. 14: Severe bilateral pneumonia. Multiple bilateral alveolar infiltrates with relative preservation of subpleural region. Subsequently, patient had multiple cavitations Page 30 of 60

31 Fig. 15: Necrotizing pneumonia in the right upper lobe in patient with emphysematous changes Page 31 of 60

32 Fig. 16: Squamous cell carcinoma. Cavitary lung mass in superior segment of the left lower lobe Page 32 of 60

33 Fig. 17: Squamous cell carcinoma. Cavitated mass in right upper segment of lower lobe, with thick and irregular walls Page 33 of 60

34 Fig. 18: Cystic lung carcinoma in a patient while waiting for surgery developed pneumothorax Page 34 of 60

35 Fig. 19: Bilateral lung cavitary metastasis associated to aspergillus infection (invasive aspergillosis) in male patient with glioblastoma multiforme Page 35 of 60

36 Fig. 20: Breast cancer in a 65 year old woman with pulmonary metastasis during chemotherapy treatment and cystic transformation of lung metastases Page 36 of 60

37 Fig. 21: Cystic bronchiectasis in middle lobe. Chest x ray and MDCT (axial, coronal and sagittal) Page 37 of 60

38 Fig. 22: Allergic bronchopulmonary aspergillosis in a 54 year old woman with asthma Page 38 of 60

39 Fig. 23: Allergic bronchopulmonary aspergillosis. Page 39 of 60

40 Fig. 24: Swyer James Syndrome. LSI hypodensity and volume loss with traction cylindrical bronchiectasis. Hypoplastic left pulmonary artery Page 40 of 60

41 Fig. 25: High-energy trauma. Extensive subcutaneous emphysema, pulmonary contusions and lacerations to the right lower lobe Page 41 of 60

42 Fig. 26: High-energy trauma. Extensive subcutaneous emphysema, pulmonary contusions and lacerations to the right lower lobe Page 42 of 60

43 Fig. 27: Centrilobular-centriacinar emphysema Page 43 of 60

44 Fig. 28: Panlobular emphysema in a patient with alpha-1-antitrypsin deficit. Page 44 of 60

45 Fig. 29: Panlobular emphysema in a patient with alpha-1-antitrypsin deficit. Page 45 of 60

46 Fig. 30: Interstitial air dissecting pleura and progressing to the abdominal cavity (pneumoperitoneum) in a patient with prolonged mechanical ventilation Page 46 of 60

47 Fig. 31: Idiopathic pulmonary fibrosis Page 47 of 60

48 Fig. 32: Desquamative interstitial pneumonia Page 48 of 60

49 Fig. 33: Wegener's granulomatosis Page 49 of 60

50 Fig. 34: 34 year old male with Wegener's granulomatosis. Lung and sinus disease Page 50 of 60

51 Fig. 35: Wegener's granulomatosis. Multiplanar and volumetric reconstructions Page 51 of 60

52 Fig. 36: Septic pulmonary infarct Page 52 of 60

53 Fig. 37: 35 year old male with AIDS. Fever and echocardiogram positive for endocarditis. MDCT: multiple pulmonary septic emboli, some with cavitation and the feeding sign (feeding blood vessel) Page 53 of 60

54 Fig. 38: 75 year old male studied by hemoptysis and weight loss of 15 lbs in 3 months. Lingular tumoral mass with the feeding sign (feeding blood vessel). Page 54 of 60

55 Fig. 39: Invasive aspergillosis in immunocompromised patient (glioblastoma multiforme chemotherapy treatment). Page 55 of 60

56 Fig. 40: Arteriovenous fistula in patient with hereditary hemorrhagic telangiectasia Page 56 of 60

57 Fig. 41: 34 year old male, active smoker for 15 years. Radiological pattern of histiocytosis X Page 57 of 60

58 Conclusion The adequate evaluation of the characteristics of the lesions with conventional radiology and especially in MDCT, together with the clinical evaluation on the patients in vain to allow the mayor of the cases a correct diagnosis. Page 58 of 60

59 Personal information Juan Carlos Quintero Rivera Complexo Hospitalario Universitario de Ourense (CHUO) Radiology Department Chief of department: Manuel Angel Trillo Lista Spain Page 59 of 60

60 References Quigle MJ, and Fraser RS. Pulmonary Pneumatocele: Pathology and pathogenesis: Case report. AJR 150: , June Chateau B., Aravena C., Vuletin F., et al. Complicated Pneumonia with Pneumatocele in a infant: Case-report. Rev Chil Pediatr 2008; 79 (3): Lozano D, López M, Caballero Th. Radiologic findings in twenty cases of pulmonary hydatidosis from Instituto Especializado de Salud del Niño Paediatrica 6(2) Kuhlman J, Reyes B, Hruban R, et al. Abnormal Air-filled Spaces in the lung. Radiographics 1993; 13: Woodring J, Fried A, Chuang V. Solitary Cavities of the Lung: Diagnostic implications of Cavity wall thickness. AJR 135: , Dec Page 60 of 60