Cavitatory LUNG Disease ULTIMATE.pptx

A beautiful presentation about all CAVITARY LUNG DISEASE by Dr. Nithin n Shenoy

1. CAVITARY LUNG DISEASE Dr. Nithin n Shenoy 2nd year junior resident SMS jaipur medical college

2. WHAT IS A CAVITY? A Cavity , as defined by the flieschner society , is a gas filled space , seen as a lucency or low attenuation area, within a nodule , mass or area of parenchymal consolidation. It has a clearly defined wall that is greater than 4mm thickness

3. PATHOPHYSIOLOGY OF CAVITY Suppurative Necrosis (e.g., pyogenic lung abscess), Caseous Necrosis (e.g., tuberculosis), Ischemic Necrosis (e.g., pulmonary infarction), Cystic Dilatation Of Lung Structures (e.g., ball valve obstruction and Pneumocystis pneumonia)

4. Displacement Of Lung Tissue by Cystic Structures (e.g. Echinococcus) Malignant processes may cavitate because of treatment-related necrosis, internal cyst formation, or internal desquamation of tumor cells with subsequent liquefaction

5. CHEST IMAGING TO DETECT CAVITIES Plain chest radiography and computed tomography are the radiographic modalities most often used to image the chest. Ultrasound is a suboptimal modality for imaging the lung parenchyma because of poor sound transmission through the mostly air-filled lungs .

6. Magnetic resonance imaging of the lung has been limited by motion artifact and relatively low spatial resolution so this modality is not generally used to examine the lungs. Computed tomography is clearly more sensitive than plain chest radiography for the detection of pulmonary pathology, particularly in immunocompromised hosts

7. ARE WE DEALING WITH TRUE CAVITIES? True cavities must be differentiated from its mimics such as cystic disease, emphysema , infected bullae and cystic bronchiectasis.

8. CAVITY BULLA BLEB CYST PNEUMATOCELE DEFINITION Thick/Thin walled abnormal gas filled spaces in lung, fluid level may be present Focal Regions of Emphysema Small Sub pleural thin walled air containing spaces adjacent to visceral pleura Round thin walled low attenuation spaces . May contain air/fluid Intra pulmonary gas filled cystic spaces SIZE Usually thick walled (>2mm) No discernible wall(<1mm) >1-2 cm in diameter up to 75%of lung Walls <1mm thick <1-2 cm in diameter Thin Walled (1-3mm) 2-10 cm in diameter Thin Walled <1mm SITE Within Pulmonary Parenchyma Arises from 2 nd Pulmonary Lobule Within Visceral Pleura Lung Parenchyma or Mediastinum Lining Connective Tissue Septa Elastic lamina of the pleura Epithelium No Epithelial Wall

9. Radiological Characteristics of Cavitary Lesion Wall Thickness Characteristics of Inner Contour Internal Content Number And Location Other Findings

10. Classification Based on Wall Thickness THICK WALLED >4mm Lung Abscess Necrotizing Squamous Cell Carcinoma Granulomatosis with Polyangitis Blastomycosis Rheumatoid Arthritis THIN WALLED <4mm Coccidiomycosis Metastatic Carcinomas M.Kansasii infection Open Negative Tuberculosis Infected Bullae MORE THAN 15mm wall thickness is HIGHLY suggestive of Malignancy

11. Characteristics Of the Inner Contour Nodular or Irregular – Usually in case of neoplasms Poorly Defined/ Shaggy- Corresponds with Abscess Smooth –Cavitary lesions of other Etiology

12. Number And Location Few Locations guide to the possible Etiology of the Cavitatory lesion eg : upper lobes are typical for tuberculosis. Solitary Cavitatory lesion is frequently found in pulmonary abscess , neoplasm or post traumatic lung cyst etc. Multiple cavitatory lesions suggest infection, Granulomatosis, Septic emboli or metastatic disease, Tuberculosis.

13. Valuation of the Clinical Context and the time of the disease Process Clinical Scenario Duration And Evolution Acute or Sub acute Chronic Lesions

14. ALGORITHM TO APPROACH CAVITARY LUNG DISEASE

15. Differential Diagnosis Of Cavitary Lung Disease Neoplastic Pathology- Primary Bronchogenic Carcinoma, Lymphoma , Mets Infections- Bacterial , Mycobacterial, Fungal, Parasitic Pulmonary Infarcts Septic Emboli Autoimmune- GPA , Rheumatoid Arthritis Traumatic Congenital

16. NONINFECTIOUS DISEASES ASSOCIATED WITH LUNG CAVITIES Malignancies Rheumatologic Diseases Pulmonary Embolism Granulomatosis with Polyangitis Pulmonary Infarct

17. NEOPLASMS Isolated Cavitatory Lung Lesion Lesion of Variable Size Irregular or Speculated Margins Thick Walls ( >15mm) Associated with mass and other findings

18. Squamous cell carcinoma of the lung. Axial and coronal CT images demonstrate a thick-walled cavitary mass in the left upper lobe. The internal walls of the cavity are irregular (yellow arrows). Axial CT image in a 66 year old man demonstrating thick walled cavitary mass with irregular internal wall in the superior segment of the left lower lobe. Pathology confirmed primary squamous cell carcinoma of the lung.

19. METASTATIC CAVITIES

20. HRCT image in 73 year old man with history of pyoderma grangrenosum , and pathology proven granulomatosis and polyangitis , demonstrating multiple bilateral cavitary masses and nodules; the larger, more anterior lesion in the right upper lobe has a dependent air-fluid level 45 year old woman, former smoker with 30 year history of rheumatoid arthritis and incidental pulmonary nodule. Axial CT demonstrates irregular, lobulated and speculated cavitary nodule in the left upper lobe. Surgical biopsy confirmed rheumatoid nodule

21. Systemic Necrotizing Vasculitis affects upper and lower Tract manifests as Multiple and bilateral nodules or mass which may cavitate by itself or by necrosis secondary to arterial occlusion

22. INFECTIONS ASSOCIATED WITH LUNG CAVITIES Common Bacterial Infections Necrotizing pneumonias 1. Streptococcus pneumoniae or Haemophilus influenzae 2. Klebsiella pneumoniae 3. Staphylococcus aureus Lung Abscesses Prevotella , Fusobacterium , and streptococci (particularly the Streptococcus milleri group) Septic pulmonary emboli

23. Necrotizing pneumonia. Axial CT images of right lung with lung and soft tissue windows. There is a large area of consolidation with surrounding ground glass opacity and septal thickening in the right lower lobe. Areas of lucency within the consolidation are consistent with cavitation Septic emboli. Axial and coronal images with lung windows demonstrate multiple nodules in different stages of cavitation in both lungs. There is ground glass opacity surrounding the cavity in the left apex. A “feeding vessel sign” is seen adjacent to that cavity as well (arrow).

24. Mycobacterial Infections And Cavity Mycobacterium tuberculosis Nontuberculous mycobacteria 1. Mycobacterium avium complex 2. Mycobacterium kansasii 3. Mycobacterium malmoense 4. Mycobacterium xenopi Rapidly growing mycobacteria 1. Mycobacterium abscessus 2. M. fortuitum and M. chelonae

25. PYOGENIC CAVITY Illness- Short Duration Acute Onset High Grade Fever Purulent, Foul smelling Expectoration Clubbing present Thick walled Cavity Irregular Inner Lining Air Fluid Level Common Surrounding Parenchyma Normal TUBERCULAR CAVITY Long Duration history Insidious Onset Low Grade Fever Non Purulent expectoration usually Absent usually Thin Walled Regular Lining Uncommon Patchy Nodular Infiltrate

26. Fungal Infections Associated Cavitatory Lung Disease Aspergillosis Zygomycosis Histoplasmosis Blastomycosis Coccidioidomycosis Paracoccidioidomycosis Cryptococcosis Penicillium . Penicillium marneffei Pneumocystis jiroveci

27. Aspergilloma . Axial image from CT demonstrates solid masses in dependent positions within biapical cavities, consistent with “fungus balls.” Histoplasmosis . Axial HRCT image demonstrates a thick-walled, cavitary nodule with eccentric calcification in the right upper lobe .

28. PARASITES AND CAVITY

29. CONCLUSION Diagnosing the cause of cavitatory lung disease is a challenge given the broad differential and varying presentations. Significant advances have been made in chest imaging with CT, especially increasing awareness of the wide variety of associated findings identified in association with lung cavities.

30. While imaging findings such as the “halo sign”, “reversed halo sign”, peripheral nodules in varying stages of cavitation, or an irregular internal wall constitute an important component, radiographic findings alone are usually insufficient for definitive diagnosis. As a consequence clinical context provides critical clues and must be combined with the imaging findings to narrow the differential . Lung abscess can leads to complications like Massive hemoptysis , BRAIN ABSCESS leads to stroke/CVA, sepsis, AMYLOIDOSIS ( very rare)

31. THANK YOU