Imaging of Solitary and Multiple

Pulmonary nodules

Presenter-Dr. Anshul Varshney(Jr-2)

Moderator-Prof. Ashish Verma

HOD Deptt of Radiodaignosis
IMS, BHU
 INTRODUCTION
Patients presenting with pulmonary nodules are usually asymptomatic,
but they may represent an early disease and importantly early-stage
lung cancer and requiring prompt diagnosis and definitive treatment.
Hence they pose a challenge to both clinicians and patients.

Whether detected serendipitously or during a routine

investigation, a nodule on a chest radiograph
raises several questions:

• Is the nodule benign or malignant?

• Should it be investigated or observed?
• Should it be surgically resected?
 What is SPN?
• Solitary Pulmonary Nodule(SPN) is defined as a
focal opacity , visible on CXR or CT film, which is:
1. relatively well defined
2. round or oval lesion
3. less than 3 cm in size
4. surrounded atleast partially by lung
parenchyma with no associated
lymphadenopathy, atelectesis or pneumonia.
• Lesions larger than 3cm are called mass.
• Also lesions more than 3 cm are termed as T2
in TNM staging of lung cancers.

Spurious SPN:
Pleural lesions, chest wall lesions, nipple shadow,
skin nodules like neurofibroma, artefacts may be
cause of Spurious SPN.
However, oblique views and repeat radiographs
and CT may differentiate these from a true SPN.
Chest radiographs in two patients showing a well-defined spherical lesion less than 3
cm in diameter surrounded by lung and not associated with lymphadenopathy,
atelectasis or pneumonia. The lesions are seen in the right
upper zone in one (A) and in the left lower zone in the other (B) Solitary pulmonary
nodules
 Morphological Characteristics of SPN

1. Size
Size of SPN Likelihood of Malignancy
0.5-1cm 35%
1-2 cm 50%
2-3 cm 85%
>3cm 97%

• Lesions smaller than 0.9 mm are undetectable on plain

radiographs and detected on CT.
• For clinical practice, lesions larger than 3cm are
considered malignant, while less than 1 cm as benign
2.Shape:
Benign Malignant

round/oval irregular

Linear or angular shape is seen in

scar/atelectesis.

3.Location:
• 70 % lung cancers located in RUL.
• Adenocarcinoma are more likely to be centrally
located while squamous cell cancer are peripheral
n location.
3.Edge characteristics-
Round regular margins are seen in benign
lesions while following features are more likely
seen in malignant lesions.
a.Irregularity, Spiculation, lobulation-
b. Corona radiata/corona maligna/Sunburst
appearance
c.Pleural tail/tag-
d.Halo sign
A. Irregular,Lobulated and Spiculated margins:
• Spiculation: It is due to radial extension of malignant cells, along the
interlobular septa, lymphatics, small airways or blood vessels leads
to fibrosis along the track via desmoplastic reaction.
• Exception: Malignancies with sharp, smooth edge are:
metastasis,carcinoid.

Margins of SPN- a)smooth in

benign lesions, b)lobulated and
c)spiculated in malignant
lesions.

B.Corona radiata/maligna:When there is generalized soiculation

around lesion it gives appearance of spokes of a wheel called as corona
radiata/sunburst appearnce. It is very suggestive of malignancy.
C. Pleural tail/tag
• It is a thin linear opacity extending from the edge of lung
nodule to pleural surface.
• However alone it is less suggestive of malignancy as compared
to spiculation as pleural tail can be seen in benign conditions
like tuberculosis and other granulomatous diseases.

CT chest showing an irregular nodule in the right upper lobe with spiculated margins termed
the “sunburst appearance” or corona radiata. The surface of the nodule is lobulated and
notched. Multiple pleural tails are seen extending from the mass to the pleural surface.
D. Halo sign
• It is a ground glass opacity surrounding solid nodule.
• Causes:
1.Invasive aspergillosis
2.Adenocarcinoma
3.Adenocarcinoma in situ
4.Pulmonary hemorrhage
• It represents hemorrhage in invasive aspergillosis and lepidic
spread of tumor in adenocarcinoma.
4. Internal Characteristics:

a. Calcification
b. Fatty infiltration
c. Cavitation
d. Pseudocavitation
e. Air crescent sign
f. Air-fluid level
A. Calcification patterns

These patterns usually are suggestive of benign lesion.

1. Diffuse/homogenous-tuberculoma
2. Target/concentric-calcified tuberculous or fungal granuloma,
histoplasmoma
3. Central/Bulls eye-Hamartoma
4. Popcorn-Hamartoma
Homogeneous calcification

CT scans showing a uniform homogeneous calcification (A) and concentric calcification (B)
in two cases of tuberculomas
Popcorn calcification

Chest radiograph (A) showing a large solitary nodule in the left lung with dense nodular foci
of calcification within s/o characteristic popcorn calcification/central cartilage calcification.
Noncontrast CT scan mediastinal window (B) showing a 3 x 3 cm nodule
containing overlapping, randomly distributed small rings of calcification or the popcorn
calcification and lung parenchymal window settings (C) reveal the nodule to be round in
shape and sharply marginated—Pulmonary hamartoma
In malignant lesions however calcification may be seen which
can be :
• diffuse and amorphous
• psammomatous (colon/ovary metastasis)
• dystrophic (in areas of tumor necrosis)

Indeterminate calcification:
• Eccentric calcification: seen when a beinign lesion gets
engulfed by a malignant lesion.
• Stippled/punctate calcification: seen in both benign and
malignant lesion.
 B. Fatty infiltration
• The presence of fat(-40 HU to -120 HU) is virtually diagnostic of a
hamartoma.
• Other lesions which might show fat include lipoid pneumonia, lipoma and
metastatic liposarcoma.

Noncontrast CT scan showing foci of fat or negative attenuation (–50 to –100 HU) within
the nodule in the left lung consistent with pulmonary hamartoma
C. Cavitation
• Both benign and malignant SPNs can cavitate. A thick
irregular cavity with wall thickness greater than 16 mm
is likely to be malignant.
• About 95% of the nodules with wall thickness less than 5 mm are benign."
About 75% of the cavities with wall thickness 5-15 mm are benign.
• Cavitation usually occurs in squamous cell carcinoma,
large cell carcinoma and adenocarcinoma while small
cell.
D. Pseudocavitation
• Air bronchiologram or bubble like lucencies or pseudocavitation may
simulate cavities and are more commonly seen in malignant nodules
(29%) than in benign nodules(6%).
• Pseudocavitation results from sparing of alveoli and bronchi by tumor
infiltration in malignant lesions.
Cavitary carcinoma. B: Cavitary
squamous cell carcinoma shown at
two levels. The wall of the cavity is
irregular, with several thick
nodular regions (white arrow).
The cavity contains an air-fluid
level (black arrows). This is
uncommon in malignancy and
may represent hemorrhage or
infection.
C: Cavitary adenocarcinoma shown
on HRCT in six
contiguous scans. The nodule
contains an irregular cavity; is
irregular and lobulated in shape,
notched, and spiculated; and is
associated with pleural tails. It also
contains several air
bronchograms.
E. Air Crescent sign-
• It results from a peripheral halo of air between intracvitatory mass and
cavity wall. It is seen in:
1. Aspergilloma/mycetoma(m/c)
2. Blood clot in a cavity
3. Cavitatory carcinoma
4. Comlicated hydatid disease
5. Rasmussen’s aneurysm
6. Mucous plug in bronchiectesis
7. Pulmonary gangrene
F. Air-fluid level-
• It favours benignity of lesion and is seen in:
1.Lung absecess
2.Infected cyst
3.Intracavitatory hemorrhage or superinfection
Chest radiograph (A) showing a small solitary lesion in the left upper lobe with a crescent
of air between the intracavitatory mass and the cavity wall giving rise to the “air cresent”
or air meniscus sign.
CT scan (B) showing the same—Aspergilloma/mycetoma
 Other characteristics of SPN
1. Satellite nodules: The presence of small nodules adjacent to a large nodule
or mass favors a benign lesion such as tuberculosis and sarcoidosis.
• A cluster of small nodules seen within a segment or subsegment of the
lung, 3-15 mm in diameter usually indicates a granulomatous process.
• In sarcoidosis, the term "galaxy-sign“ refers to the presence of multiple
satellite nodules.

Chest radiograph in two cases showing a calcified tuberculoma with multiple small nodules adjacent to
it in the left lung in one case (A) and the right lung in the other (B)—Satellite nodules predicting a
benign disease
Feeding Vessel Sign:
This refers to a small pulmonary artery directly leading to a
nodule. A "feeding vessel sign" is seen in metastasis, septic
emboli, arteriovenous fistula or infarct.

CT scan in a case of septic emboli showing multiple pulmonary arteries directly feeding the
nodules.
2. Positive Bronchus Sign:
When a bronchial carcinoma inflitrates but does not occlude an adjacent
bronchus, a patent brochus is seen entering the nodule.

CT scan of the chest showing a pulmonary lesion abutting and narrowing the right upper
lobe bronchus without completely occluding it—The positive bronchus sign in
bronchogenic carcinoma
Assessment of malignant potential of SPN

• CT attenuation of nodule
• Nodule growth rate
• Nodule enhancement
A. CT attenuation: On the basis of nodule attenuation we can
classify SPN as follows:
1. Solid nodule: commonest but less malignant presentation as
compared to the ground glass and partly solid nodules.
2. GGN(Ground glass nodules):HRCT is required to estabilish
these lesions with 1mm sections as use of thick sections
precludes accurate nodule characterization due to volume
averaging.
3. Partly solid: It includes partly ground glass and partly solid
attenuation. Greater the solid component more likely the
lesion is malignant. However entirely solid nodules are less
malignant than any partly solid nodule.The solid component
represents invasive foci of adenocarcinoma. Hence higher
the attenuation value of partly solid nodule, greater is the
degree of invasion.
Association of Nodule attenuation with
Adenocarcinoma
• AAH(Atypical adenomatous hyperplasia): purely ground glass
in attenuation and usually less than 1cm in size.
• AIS(Adenocarcinoma in situ)(earlier called BAC) lesion with
ground glass attenuation less than 3cm in size
• MIC(Minimally invasive Carcinoma):less than 3 cm in size with
invasive component(solid component) not more than 5mm in
any location.
• Invasive adenocarcinoma: more than 3 cm in size and invasive
component more than 5mm.
B.Nodule growth: It is assessed by measuring volume doubling
time(VDT).

VDT = [t x log 2]/log (Vt/Vo)

Where VO is the initial volume and Vt is the volume at time t.

• The volume doubling time (VDT) for malignant SPNs is rarely less than a month
or more than a year (range 20-400 days)."
• Nodules with a doubling time less than 20 days and more than 400 days are
considered benign.
• Also stability of nodule size over 2 years (730 days) has been considered to
suggest benignity.

Exception: Carcinoids and adenocarcinomas in situ(pure GGO) may remain stable

for more than two years.
C.Nodule enhancement: It is the difference of peak enhancement and
precontrast nodule attenuation.

• Benign lesions show enhancement <15 HU.

• An enhancement of >20 HU is indicative of tumor neovascularity or malignancy.
• The limitation of this technique includes its use in lesions <2 cm as larger lesions
would have areas of necrosis and placement of cursor would be a problem.
• An analysis of combined wash-in and wash out characteristics (studied at 15
minutes delay) gives a more precise evaluation of the nodule enhancement.
For benign nodules:
• Wash in < 25 HU
• Wash in >= 25 HU with a washout >= 31 HU
• Wash in >= 25 HU and a persistent enhancement without a washout.
For malignant nodules:
• Wash in = 25 HU
• Washout = 5-31 HU (not more than 31 HU).
• The arterial supply of a nodule is via the bronchial arteries while the
washout is via the bronchial veins.
• In the case of malignancy, a retarded flow in the intravascular and
interstitial space accounts for contrast retention.
• In the case of benign nodules, this washout takes place through relatively
straight vessels and active lymphatic flow resulting in a significant
washout.
• A persistent enhancement when seen in a benign nodule occurs due to
the presence of fibrosis in the nodule, the fibrotic portion of the nodule
retaining contrast for a long time without washout.

CT scan of a pulmonary
nodule with lobulated
margins showing
contrast enhancement
from 21HU to 71 HU
suggestive of malignant
nodule
 Other imaging modalities for SPN
1.PET/CT: Useful in solid nodules more than 10mm in diameter for
detecting malignancy with 90 percent specificity. A SUV of more than 2.5
is usually is seen in malignancy while a value less than 2.5 is seen in
benign lesions.

2.Dynamic MR imaging: Signal intensity time curves are generated

following intravenous injection of gadolinium and maximum relative
enhancement ratio and shape of enhancement can be calculated from
these.
A ratio >0.15 indicates a malignant SPN, a ratio <0.80 indicates benign
lesion and ratio between 0.8 and 0.15 usually indicates active infection.
These MR indices are useful for differentiating between benign and
malignant SPNs.
CT chest axial and MPR images (A and B) showing an irregularly marginated lesion with
surrounding halo in the left upper lobe.

FDG PET scans (C and D) in the patient showing an increased uptake and accumulation of FDG in
the nodule – Malignant lesion/bronchogenic carcinoma.
3. DWI/MRI:. In a study by Satoh, et al difference between benign and malignant
was based on a DWI scale graded from 1 to 5:
1) nearly no signal intensity as seen in an almost normal lung
2) signal intensity between 1 and 3
3) Signal intensity almost equal to the spinal cord at thoracic spine
4) higher signal than, spinal cord
5) much higher signal than that of the spinal cord.

A score of 3 (a nodule with signal intensity equal to that of the spinal cord) was
considered the threshold for differentiation between benign and malignant
pulmonary nodules in their study.

Lower ADC values for malignant lesions has been reported helping in their
characterization.
4.Dual energy CT :
• Angiogenesis of malignant nodules leads to a stronger
enhancement of malignant tumors on CT.
• Iodine concentration maps can assess the vasculature
and relative vascularity of pulmonary nodule
• Iodine concentration in malignant nodules has been
found to be significantly higher than benign nodules. 
 Causes of SPN
• A solitary pulmonary nodule may be secondary to a wide
differential of causes. However, greater than 95% are formed
by following:
1.malignancies (most likely primary)
2.granulomas (most likely infectious)
3.benign tumors (most likely hamartoma).

A list of various common differentials is as follows:

1.Malignant neoplasm:
- Carcinoma (squamous cell, small cell, adenocarcinoma, bronchioloalveolar carcinoma)
- Lymphoma
- Carcinoid
- Pulmonary metastasis (colon, melanoma, renal cell, breast, osteosarcoma)

2.Benign neoplasm and neoplasm-like condition:

- Hamartoma
- Chondroma
- Fibroma

3.Infective causes:
- Round pneumonia
- Abscess
- Granuloma (fungal, mycobacterial)

4.Noninfectious inflammatory:
- Sarcoidosis
- Rheumatoid arthritis
- Amyloidosis
- Wegener's granulomatosis
5.Airway and inhalational disease:
- Mucoid impaction (mucous plug)
- Bronchial atresia
- Cystic fibrosis
- Conglomerate mass or progressive massive fibrosis (e.g. silicosis)
- Lipoid pneumonia

6.Vascular lesions:
- Pulmonary artery aneurysm
- Hematoma
- Infarct
- Arteriovenous malformation (AVM)

7.Congenital lesions:
- Sequestration
- Bronchogenic cyst
- Bronchial atresia

8.Idiopathic/Miscellaneous:
- Amyloidosis
- Fluid filled bulla
- Round atelectasis
 Differential diagnosis of SPN
1. Malignant neoplasm: -
It includes carcinoma (squamous cell, small cell, adenocarcinoma,
bronchioloalveolar carcinoma),lymphoma, carcinoid, pulmonary metastasis
(colon, melanoma, renal cell, breast, osteosarcoma).
a)Lung cancer:
The most common type presenting as a nodule is adenocarcinoma.
Bronchogenic carcinoma will show irregular, spiculated margins with
absence of calcification.
However, presence of calcification does not completely rule out
malignancy as cancers may develop in a scar or granuloma which shows
pre-existing calcification.
The pre-existing calcification is usually of the stippled or eccentric type and
occupies less than 10% of the nodule.
Mediastinal window (A) showing a 10 mm nodule in the right lower lobe. Eccentric
cavitation is noted within.
HRCT section (B) shows the nodule to be spiculated, irregular and lobulated showing the
characteristic sunburst appearance—Bronchogenic carcinoma
b.Metastasis:
Usually present as multiple nodules, but CA colon, melanoma, RCC may
present with solitary metastasis.
They are sharply marginated though local invasion and surrounding
hemorrhage may lead to the nodules being poorly defined.
Metastatic lesions are predominantly seen in the lung bases because of
greater blood flow.
"Feeding vessel sign" may be seen in these nodules owing to a hematogenous
origin because these nodules are usually seen at the tips of small arteries.

Follow-up CT scan (A) in a postoperative case of right renal cell carcinoma showing a small, smoothly
marginated round solitary lesion in the left lung.(B) The lesion is seen at the tip of a small artery (feeding
vessel sign)—Solitary metastasis in renal cell carcinoma
 C. Carcinoid Tumor :These account for 10-20% of SPNs. These are neuroendocrine
tumors and two forms have been described: typical and atypical.
Typical carcinoids account for 85-90% of these lesions and occur in the main lobar
or segmental bronchi in a central location.
Carcinoids can be intraluminal or extraluminal and are seen as well-defined,
lobulated, round or notched with a smooth edge. Spiculation is rarely seen.
Curvilinear or multiple nodular calcification may be seen. Rarely, dense ossification
may be seen within the lesion. A triad of: well defined, lobulated round lesion ; location
adjacent to bronchial bifurcation ; eccentric calcification Is highly suggestive of carcinoid.

CT sections showing a well-defined rounded lesion in the right lung lying centrally in a perihilar
location/vicinity of bronchial bifurcation with eccentric calcification noted within (A). Lung window shows the
lesion to have a smooth edge with minimal lobulations (B). The right lower lobe bronchus shows the
characteristic widening as it approaches the tumor (C)—Bronchial carcinoid
D.Lymphoma: Both Hodgkin and Non Hodgkin lymphoma involve lung in
about 10-15 % cases and is characterized by single/multiple nodules, masses
or consolidation which may cavitate. It is usually associated with hilar and
mediastinal lymphadenopathy.
2.Benign neoplasms:
• Pulmonary hamartoma: It is a benign
pulmonary mass composed of cartilage, myxomatous connective tissue, fat,
bone, smooth muscle in different amounts.
90% of hamartomas have a peripheral location.
These are seen as well-defined, round or lobulated nodules with a
charactersitic popcorn calcification and fat content.

CT chest mediastinal (A) and lung parenchymal (B) window settings revealing a well-
defined nodular lesion in the right upper lobe. The lesion shows fat attenuation (negative
attenuation) values within. Magnified view of the lesion (C) showing small specks of
calcification in the lesion—Pulmonary hamartoma
3.Infective causes:
• Granuloma
The most common cause of granuloma is tubercular though other causes include
histoplasmosis, cryptococcosis, cocciodioidomycosis. There are seen as solitary
nodule 1-3 cm in diameter with a well defined smooth regular margin and often
showing calcification . The pattern of calcification seen in a granuloma include
amorphous, punctate, fleck like or laminar, often subpleural in location, granulomas
rarely show cavitation. Cavitation when seen should suggest reactivation.

CT scans showing a single well-defined lesion 2 cm in size located subpleurally with no

evidence of cavitation (A). The lesion shows evidence of multiple fibrotic strands around
it (B and C) – Tuberculoma
• Hydatid Cyst
Caused by Echinococcus granulosus, the hydatid cyst is seen as a sharply demarcated
well defined round or oval lesion with a homogeneous soft tissue density on
radiographs . The cysts occur more commonly in mid and lower lobes. An air fluid level,
water lily sign and rising sun sign are seen in cases of rupture of the hydatid cyst.

 A contrast-enhanced computed tomography scan of the chest (mediastinal window) showing a cyst
in the right lower lobe of the lung containing a freely floating endocyst (the “Waterlily sign”). (b) A
contrast-enhanced computed tomography scan of the chest (lung window) showing a cyst in the
right lower lobe of the lung containing a freely floating endocyst (the “water lily sign”)
 • Mycetoma/Fungal Ball
A mycetoma results from saphrophytic invasion of a pre-existing cavity. The
causes of the cavity in the majority of the cases is tubercular. But sarcoidosis,
bronchiectasis, bulla, histoplasmosis. etc. may also result in a cavity in which
the fungal mass develops.
Seen as a intracavitory mass in the upper lobe or superior segment of lower
lobe usually.
"Air crescent sign" (air between the wall of the cavity and the fungal ball) is
usually seen and is a diagnostic imaging findings.
CT shows a sponge like appearance of the mass with irregular air spaces.

CT sections of the chest mediastinal and lung windows (A and B) showing the “air meniscus sign” seen as air
crescent between the mass and the cavity in the right lung—Mycetoma
• Round Pneumonia
Round pneumonias are more commonly seen in children in cases of
Streptococcus infection. Other causative organisms include K.pneumoniae,
S.aureus, M.tuberculosis and fungi.
On imaging round pneumonia appears as a focal round wedge shaped opacity
in a peripheral location typically in the posterior lower lobe.
The underdeveloped pores of Kohn in children accounts for the sharp margins
of the round pneumonia in contrast to the ill-defined margins of pneumonia
seen in adults.

CT scan (A) in a 2-year-old child showing a peripherally located wedge shaped opacity
with air bronchogram within the left lower lobe located posteriorly. The opacity is based
against a focally thickened pleura—Round pneumonia
 • Lung Abscess
The etiology can be pyogenic, anaerobic bacteria or mycobacterial.
Radiographs show an abscess as an ill-defined opacity with surrounding
consolidation. An air fluid level is seen in cases of communication with the
bronchus. Contrast enhancement CT shows the abscess as a hypodense lesion
with thick enhancing walls, shaggy margins and an air fluid level.
 

Chest radiograph (A) showing a focal round lesion in the right lung. A small air loculus is seen within. CT
sections (B and C)showing a low attenuation lesion (i.e. fluid attenuation) lesion with enhancing wall.
Multiple air loculi are seen in the center and in the periphery of the lesion (B). The margins are mildly
irregular with surrounding consolidation (C)—Lung abscess
4. Inflammatory Nodules
• Rheumatoid Nodules
These are an uncommon manifestation of rheumatoid arthritis, may be seen
as solitary or multiple nodules in the lung parenchyma.

5. Airway or Inhalational Disease

Lipoid Pneumonia
Lipoid pneumonia is seen as an ill-defined nodule or mass in posterior lower
lobe. Exogenous variety of lipoid pneumonia results from chronic aspiration
of fat while the endogenous form occurs due to accumulation of lipid rich
cellular debris distal to bronchial obstruction.
 6. Vascular Lesions :
a)Pulmonary Artery Aneurysm
Pulmonary artery aneurysm can present as a lung nodule.
Rasmussen aneurysm is seen in tuberculosis and is a mycotic aneurysm
developing in the infectious cavity.
Contrast-enhanced CT is diagnostic as the aneurysm is seen as a densely
opacified nodular lesion in relation to lobar, segmental or smaller arteries.

Chest radiograph (A) showing a sharply marginated solitary lesion located centrally in a perihilar location in the
right lung (A). CT sections (B and C) showing an enhancing nodule in relation to a right interlobar pulmonary
artery. A crescentic hypodensity is seen in the periphery of the lesion s/o thrombus—Pulmonary artery
aneurysm
b)Pulmonary Vein Varix
A varix can result from a congenital defect of the wall. mitral valvular
diseases or elevated pulmonary venous pressure.
Radiologically, a pulmonary varix is seen as a round or oval density adjacent
to the left atrium.

Usually asymptomatic. a pulmonary varix can enlarge in response to high

atrial pressure with resultant rupture and hemorrhage.

c)Arteriovenous Malformation
It is characterized by an enlarged artery feeding the nodule and a draining
vein.
Seen in the lower lobe, in a subpleural location.
CECT reveals rapid enhancement and washout.
d)Pulmonary Infarction :
• A wedge-shaped opacity in contact with the pleural surface known as
Hampton's hump is seen.
• A halo sign due to adjacent hemorrhage or low attenuating areas due to
necrosis may be seen.
• On contrast administration, feeding vessels may be seen and the
periphery of the infarct may enhance owing to collateral flow.
• Cavitation of a pulmonary infarct occurs with infection of the bland infarct
or with septic emboli.
• Pulmonary infarcts decrease in their size slowly over months what has
been described as the "melting sign”.
Pulmonary infarction

Contrast enhanced CT (A) in a case of DVT showing a filling defect in the right pulmonary
artery s/o thrombus. Lung parenchyma (B) shows a wedge shaped pleural based opacity
with surrounding halo s/o Hampton’s hump in the right lung—Pulmonary
infarction
7.Congenital Lesions
1. Pulmonary Bronchogenic Cyst
A bronchogenic cyst results from abnormal development of the lung bud
located in a perihilar or subcarinal location.
An air fluid level may be seen if the cyst is infected.
On CT, a variable density of the cyst ranging from water to soft tissue may be
seen. The wall of the cyst is usually thin and smooth.
 

CT scan showing a well-circumscribed cystic density lesion adjacent to the trachea on the right side.
The cyst wall is thin and smooth—Bronchogenic cyst
2. Sequestration
A disorganized area of pulmonary parenchyma without normal pulmonary arterial or
bronchial communication is called sequestrated lung.

It is of two types intralobar and extralobar.

1.Intralobar: the more common form, occurs usually in the posterior basal segment of
the left lower lobe adjacent to the diaphragm. The intralobar form has a normal
pulmonary venous drainage and infections are common in this form.
2.Extralobar:associated with congenital anomalies , has its own pleural covering with
systemic venous drainage.

Contrast-enhanced lung CT
scan report intralobar
partial pulmonary
sequestration which arterial
supply arise from a
supradiaphragmatic
aortic diverticulum – axial
view (A–B) and Maximum
Intensity Projection (MIP)
(C–D) view.
8.Miscellaneous:
Round Atelectesis:
• It is a type of chronic atelectasis resembling a mass lesion. It is associated
with asbestosis(m/c), tuberculosis, Dressler syndrome and mesothelioma.
• There is pleural thickening and pleural exudates with the resultant effusion
causing passive atelectasis of the adjacent lung.
• Fibrinous adhesions develop between the pleural surface of the atelectatic
lung and the adjacent parietal pleura.
• On CXR seen as ill defined peripheral opacity based against a thickened
pleura with the edge pointing towards the hilum.
• Distortion, displacement of the blood vessels and bronchi which appear
pulled towards the lesion forms a characteristic imaging appearance called
the "comet tail" or "crow feet" appearance.
ROUND ATELECTESIS

CT sections showing a peripherally located wedge shaped opacity against thickened

pleura (A). There is distortion and displacement of vessels adjacent to the opacity.
The vessels are more numerous than normal in this portion (B) and have a
characteristic curvilinear configuration (C)—Round atelectasis
 MULTIPLE PULMONARY NODULES-
Over 95% of multiple pulmonary nodules (MPNs) on plain chest radiographs are
metastases or tuberculous/fungal granulomas. The larger and more variable the size of
the nodules, the more likely they are to be neoplastic.

Differential diagnosis of MPNs given as follows:

A)Neoplastic
Malignant
Metastatic carcinoma or sarcoma
Lymphoma
Multifocal neoplasms, e.g. Kaposi sarcoma and
bronchioloalveolar carcinoma
B)Benign
Hamartomas, chondromas
Laryngeal papillomatosis Benign metastasizing leiomyoma
C)Inflammatory
1.Infective
Granuloma, e.g. tuberculosis, histoplasmosis,
Cryptococcosis, coccidioidomycosis, nocardiosis
Round pneumonias, particulary fungal and opportunistic infections,lung abscesses,
especially septicemic, septic infarcts
Atypical measles
Hydatid cysts
Paragonimiasis
Rheumatoid arthritis, Caplan syndrome

2.Noninfective
Wegener granulomatosis
Sarcoidosis
Drug-induced

D.Congenital
Arteriovenous malformation

E.Miscellaneous
Progressive massive fibrosis
Hematomas
Amyloidosis
Pulmonary infarct
Mucoid impaction
1. Metastatic Lung Nodules-
• Multiple nodules are most common in metastatic disease and often the
nodules vary in size.
• Benign nodular disease most often results in nodules of similar size.
• Nodules may be small (miliary) and numerous, this appearance is seen
with metastases from very vascular tumors.
• When they are larger and well defined, they are referred to as cannon ball
metastases. For example-multiple pulmonary leiomyomas associated with
smooth muscle tumors of the uterus in women represent pulmonary
metastases from a low grade uterine leiomyosarcoma.
• Cavitation occurs in 5% cases and is seen most commonly in squamous
cell carcinomas, also in adenocarcinoma and some sarcomas.
• Calcification occurs commonly in osteogenic sarcoma, synovial sarcoma,
thyroid carcinomaand mucinous adenocarcinoma.
 Metastatic lung nodules

CT chest in a case of right carcinoma breast (A) showing multiple nodules predominantly in the
lung bases and in a peripheral location (B) associated with a feeding vessel s/o hematogenous
origin (C)—Metastatic nodules
2.Kaposi’s Sarcoma
• It is seen in patients with AIDS.
• Disseminated disease is seen more often and is bronchocentric in
distribution as the lesions spread via the bronchial mucosa.
• These lesions are described as “flame shaped and vary in size from 1 cm
to well over 2 cm in diameter.
• The larger masses may contain air bronchograms and may have a
surrounding rim of ground glass opacity.

3.Sarcoidosis
• Large masses or areas of consolidation measuring 3–4 cm or larger are
seen in 15–25% of patients with active sarcoidosis.
• As they contain air bronchograms they are termed alveolar sarcoid.
• Multiple nodules occur due to the confluence of large number of small
interstitial granulomas.

.
4. Rheumatoid Nodules and Caplan Syndrome
• Rheumatoid nodules (necrobiotic) nodules are an uncommon
manifestation of rheumatoid arthritis.
• They tend to appear and disappear in conjunction with subcutaneous
nodules.
• They range in size from a few millimeters to 5 cm or more and
may be multiple and numerous.
• These nodules predominate in the lung periphery and are typically well
defined.
• They may cavitate, having thick walls that become thin with healing.

• Caplan syndrome is a rare manifestation of rheumatoid arthritis that

occurs in coal miner’s pneumoconiosis or patients with silicosis. It is
characterized by single or multiple lung nodules.
The nodules have an upper lobe predominance.
The nodules appear rapidly and in crops in contrast to the slow
progression of pneumoconiosis
5.Progressive Massive Fibrosis
• PMF presents as masses and is seen in silicosis and coal worker’s
pneumoconiosis
• It represents a conglomeration of small interstitial nodules in combination
with a variable degree of fibrosis.
• Conglomerate masses are usually seen in the upper or middle lung, are
usually oval or lenticular in shape, are distinct from the hila and are
separated from the peripheral pleural surface.
• They are bilateral and symmetrical and have irregular borders.
• Distortion of lung architecture is evident due to fibrosis and volume loss.
• Calcification and cavitation may be seen.
PROGRESSIVE MASSIVE FIBROSIS

Chest radiograph (A) showing small calcific nodules with conglomeration in the upper and
mid-lung bilaterally in a relatively symmetrical manner. The conglomerate opacities are
lenticular in shape.A small pneumothorax is also seen in the right lung.
CT scan (B) showing small calcific centrilobular nodules in both the lungs with
conglomeration of nodules matted together by fibrosis—Progressive massive fibrosis
in a case of silicosis
6.Wegener’s Granulomatosis
• It is a multisystem disease associated with involvement of the upper or lower
respiratory tract and kidney.
• The presence of c-ANCA antibody is characteristic.
• Typically fewer than a dozen nodules are visible.
• In most cases, the nodules are bilateral and widely distributed without
predominance in any lung region .
• Cavitation occurs in about 50% of cases. The cavities usually are thick walled with
an irregular inner margin.
• Air fluid level may be present.
• Calcification of the masses does not occur.

CT scan in a patient with ANCA positive and sinusitis revealing bilateral pleural effusions and multiple
cavitating nodules. Cavitation is seen as a central hypodensity in few nodules and as an air fluid level in
others—Wegener’s granulomatosis
7.Septic Emboli with Infarction
• Septic pulmonary emboli, with or without infarction result in multiple
parenchymal opacities, rarely a septic embolism presents as a solitary lesion.
• In patients with septic embolism peripheral nodules in varying stages of
cavitation are present due to intermittent seeding of lungs by the infected
material.
• The feeding vessel sign is visible in 65% of cases with peripheral and subpleural
location of the nodules.

Chest radiograph in a patient with infective endocarditis showing lung nodules which appear cavitary.
Small pleural effusions are also noted. CT shows the peripheral nature of the nodules, relatively well-
defined margins and evidence of cavitation. The lesions are typically subpleural, peripheral in location
with feeding vessel sign seen—Septic emboli
8. Arteriovenous Malformation
• Multiple AVMs are most common in patients with Osler-Weber-Rendu
syndrome.
• Enlargement of fistulas over a period of months or years is common and
rapid increase in size can occur.

9.Amyloidosis
• Bilateral lung nodules, peripheral or subpleural in location is most typical
finding.
• Nodules range from 0.5 to 5 cm but may be as large as 10 cm.
• Calcification and cavitation may occur.
• Nodules may grow slowly or remain stable over a number of years.
10.Bronchiolitis Obliterans Organizing Pneumonia(BOOP)-

• It shows granulation tissue polyps within bronchioles and alveolar ducts and
patchy areas of inflammation in the surrounding lung (organizing pneumonia).
• Most cases are idiopathic, but BOOP also may be seen in patients with pulmonary
infection, drug reactions, collagen vascular diseases, Wegener’s granulomatosis,
and after inhalation of toxic fumes.
• Most often, BOOP presents with patchy, unilateral or bilateral areas of air–space
consolidation, which may be peripheral or peribronchial.
• Small or large nodules are seen, with or without associated consolidation, in up to
50%.
• Large nodules or masses usually are multiple and may appear very irregular in
shape, mimicking carcinoma.
• A finding termed the “atoll” sign, in which ring-shaped or crescentic opacities are
seen, often with ground glass opacity in the center of the ring (resembling a coral
atoll), strongly suggests the diagnosis.
• Cavitation and calcification do not occur.
BOOP

CT sections showing bilateral areas of air-space consolidation which are peripheral and
peribronchial. Small and large nodules are also seen. Cavitation and calcification are not
seen—Bronchiolitis obliterans organizing pneumonia (BOOP)
MANAGEMENT OF A PULMONARY NODULE

Following the Fleischner Society Guidelines of solid nodules in 2005 and the
subsolid nodules in 2013'' several modifications have taken place leading to the
new guidelines of the Fleischner Society in 2017.

The Fleischner Society guidelines are not for:

I. Patients with known primary cancer
II. Immunocompromised patients who are at risk of infection
III. Those at risk for metastasis
IV. Children and adults younger than 35 years

These are the new guidelines given by the Fleischner Society 2017 for
incidentally detected pulmonary nodules in adult patients <35 years of age.'
Management in these groups should be based on the specific clinical situation
and on a case-by-case basis.
A: Solid nodules
Nodule type Size
  <6 mm (<100 mm3)
Single:
No routine follow-up
Optional CT at 12 months for
high risk cases.
Multiple:
• Low risk No routine follow-up
Optional CT at 12 months for
high risk cases
B: Subsolid nodules
Nodule type Size
  <6 mm (<100 mm3)
Single:
• Ground-glass No routine follow-up
• Part solid No routine follow-up
Multiple CT at 3-6 months. If stable,
consider CT at 2 and 4 years
Comments
6-8 mm (100-250 mm3) >8 mm (>250 mm3)  
CT at 6-12 months, then Consider CT, PET/CT, or tissue Single Nodule <6 mm do not
consider CT at 18-24 months sampling at 3 months require routine follow-up, but
certain patients at high risk with
suspicious nodule morphology,
upper lobe location, or both
may warrant 12-month follow-
up
CT at 3-6 months, then consider CT at 18-24 months Use most suspicious nodule as
guide to management. Follow-
up intervals may vary according
to size and risk.
Comments
a6 mm (>100 mm3)  
In certain suspicious nodules <6
CT at 6-12 months to confirm persistence, then CT every 2 years mm, consider follow-up at 2 and
until 5 years 4 years. If solid component(s) or
CT at 3-6 months to confirm persistence. If unchanged and solid growth develops, consider
component remains 6 mm, annual CT should be performed for 5 resection. In practice, part-solid
years nodules cannot be defined as
  such until a6 mm, and nodules
<6 mm do not usually require
follow-up. Persistent part-solid
nodules with solid components
a6 mm should be considered
highly suspicious
CT at 3-6 months. Subsequent management based on the most Multiple <6 mm pure ground-
suspicious nodule(s) glass nodules are usually benign,
  but consider follow-up in
selected patients at high risk at 2
and 4 years
 Conclusion
• The management of pulmonary nodules involves both clinical
and imaging assessment including risk assessment and
morphology of the nodule.
• Emphasis should be placed on accurate diagnosis using the
least possible resources avoiding surgical intervention where
possible and the judicious use of biopsy procedures.
• Full use of newer techniques should play a part where
available.
 References
1. W. Richard Webb, Charles B. Higgins - Thoracic
Imaging_ Pulmonary and Cardiovascular
Radiology-LWW (2016).