Transcript Malformations bronchopulmonaires chez l’enfant

A. AROUS, A. MAALEJ, H. ABID, F. AKID, W. TURKI, S. HADDAR,
KH. BEN MAHFOUDH, J. MNIF
CHU HABIB BOURGUIBA – SFAX - TUNISIA
ARAB CONGRESS OF RADIOLOGY 2012
CHEST IMAGING : CH 1
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A lung nodule is defined as a “spot” on the lung that is between
0.5 and 3 cm in diameter.
If an abnormality is seen on an x-ray of the lungs that is larger
than 3 cm, it is considered a “mass” instead of a nodule.
The availability and increasing number of chest CT scans in
patients with pulmonary complaint cause frequent incidental
findings of multiple pulmonary nodules.
The etiology of multiple pulmonary nodules can usually be
determined with a thorough history and physical examination.
However, further testing is sometimes required for diagnosis,
which may include additional imaging and/or a biopsy.
The objective of our study is to illustrate the contribution of the
Computed Tomography (CT) in the etiologic diagnosis of the
multiple pulmonary nodules.
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Retrospective study concerning 68 patients.
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Age varies between 4 years and 77 years.
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A thoracic CT was realized within the framework of a staging
evaluation or control of a cancer (in 40 cases), or in front of a
respiratory symptomatology with multiple pulmonary nodules in
the chest radiography (in 28 cases).
The diagnosis was confirmed in all cases by the biology or by
histological study .
Etiologies
Number of cases
Lung metastases
46
lymphoma lung nodules
6
tuberculosis
4
pulmonary aspergillosis
3
nodules rheumatoid
3
pulmonary staphylococcia
2
sarcoidosis
1
candidiasis
1
a Wegener's granulomatosis
1
non-specific interstitial pneumonia
1
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The diagnosis was confirmed in all cases by the biology or by histological
study .
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These etiologies can be classified into three major
categories:
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Malignant tumor disease: This includes lung cancer,
lymphomas, and cancer that has spread to the lungs from other
parts of the body, among others.
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Infectious disease: This includes bacterial infections such
as
tuberculosis,
fungal
infections
such
as
histoplasmosis and coccidiomycosis, and parasitic infections .
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Inflammatory disease: Conditions such as rheumatoid
arthritis, sarcoidosis, and Wegener’s granulomatosis can cause
lung nodules.
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With regard to malignancy, multiple pulmonary nodules occur
primarily as a manifestation of metastatic disease, which can
come either from an adenocarcinoma of the lung or from a distant
primary.
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Although it is not always recognized during life, 30 to 40% of
cancer patients have pulmonary metastases at autopsy.
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Cancer, particularly metastatic cancer, is a source of multiple
pulmonary nodules, according to a 2007 article in the medical
journal "Chest."
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Multiple pulmonary nodules evoke metastatic cancer. and the rate
of malignancy in nodules >20 mm is 81%.
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The nodules are variable in size and location, with a proclivity for
the better perfused lung bases.
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The lesions are usually round with sharply demarcated borders,
although metastases with a tendency towards hemorrhage, such
as choriocarcinoma, can also have indistinct, fuzzy borders.
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Cavitation of metastatic lesions occurs in less than 5 percent of
cases.
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Non-Hodgkin's lymphoma can also cause multiple pulmonary
nodules; these are more common in the lower lobes.
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Intrapulmonary lymphoma nodules usually originate from the
bronchial-associated lymphoid tissue (BALT). Cavitation occurs in
less than 4 percent of cases.
In our study, concerning malignant etiologies, we
have found:
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The central localization of the nodules predominate in 78% of
patients having a malignant etiology.
Lower lung distribution of nodules predominate in 86% of
cases.
Solid nodules were found in all cases, while subsolid nodules
were found in 4% of cases.
Speculated and irregular contours were found in 36 % of cases.
Lobulated contours were found in 7% of cases.
Angiocentric nodules were found in 13% of cases.
Excavated nodules were found in 13% of cases.
Calcification were found in 5% of cases.
Patient follow-up for osteosarcoma
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multiple pulmonary nodules scattered
throughout both lungs:
spiculated margin
Cavitation
Calcification
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Biopsy= Osteosarcoma lung metastases
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A women was diagnosed with an uterine carcinosarcomam since 2 years,
consulting for chest pain.
multiple well defined lung parenchymal nodules predominate in the middle
and lower lung zones
Excavated nodules in pulmonary apex
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Pulmonary metastasis of an uterine carcinosarcoma
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An old man presents a dry cough with qn impaired general conditions
Multiple pulmonary nodules with lower lung distribution
 Lobulated contours
 Angiocentric nodule
Biopsy: Large B cell lymphoma
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Prolonged fever with cervical lymphadenopathy and dyspnea
A chest x-ray demonstrated a widened mediastinum
The chest CT scan demonstrated multiple pulmonary nodulesm one of
them is excavated and present spiculated contours
Multiple mediastinal lymphadenopathy with pleural effusion
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Biopsie: Hodgkin's lymphoma
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According to a 2005 journal article in "Radiology," various
infections can cause pulmonary nodules. Several types of fungal
infections appear as pulmonary nodules on x-ray. These include:
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Multiple abscesses: bacteremic patients may develop multiple
lung abscesses, which are more common in dependent areas of
the lungs. Recurrent aspiration can yield multiple abscesses as
well. Typically the lesions are between 0.5 and 3 cm in diameter,
round, and well-defined. Formation of thick-walled cavities is
common once the central necrotic debris has been expectorated
through a bronchiolar communication.
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Septic emboli: septic thrombophlebitis may generate septic
emboli which produce multiple round or wedge-shaped nodules
with a predilection for peripheral areas of the lower lobes.
Cavitation is common, usually producing thin-walled lesions.
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Fungi: multiple pulmonary nodules can arise from a number of
fungal infections, like histoplasmosis, coccidioidomycosis, or
invasive Aspergillosis in immunocompromised hosts. In these cases,
the lesions tend to range from 0.5 to 3 cm in diameter without a
clear predilection for a specific area of the lungs. Patients with
invasive Aspergillosis commonly display a surrounding halo of
ground glass attenuation due to local hemorrhage (the halo sign),
followed by cavitation and "crescent-sign" formation.
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Tuberculomas of the lung: are round or oval lesions situated
commonly in an upper lobe, the right more often than the left.
Typically they are sharply circumscribed and has a diameter
ranging from 0.5 to 4 cm or more. Lobulation may be present in 25%
of cases, and satellite lesions may be identified in up to 80% of
cases.
In our study, concerning infectious etiologies, we
have found:
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The central localization of the nodules predominate in 80% of
cases.
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Uper lung distribution of nodules predominate in 80% of cases.
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halo sign were found in 2 cases of invasive aspergillosis.
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Subsolid nodules were found in 20% of cases.
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Excavated nodules were found in 30% of cases.
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Calcification were found in one case of tuberculosis.
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Patient have received chemotherapy, present a persistent fever with
neutropenia
Chest CT scan revealed multiple nodules and demonstrate in the right
upper lobe an excavated nodule surrounded by ground-glass
attenuation (halo sign)
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Positive Aspergillus serology
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A young man. fever, weight loss, night sweats, and cough with
expectoration
Subsolid nodules, it has indistinct margins
excavated nodule in the left upper lobe
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Mycobacterium tuberculosis were found in a sputum sample
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Prolonged fever, and cough
Multiple pulmonary nodules, some of them are calcified
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Pulmonary tuberculosis confirmed with biological tests
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Multiple pulmonary nodules may result from a number of
noninfectious inflammatory conditions:
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Wegener's Granulomatosis: is the most common, it is a disorder
causing inflammation of the blood vessels that affects the kidneys,
lungs, and upper airway. It causes inflammatory tissues, called
granulomas, to grow in and around the blood vessels. It can
produce multiple round, sharply or poorly demarcated lesions
varying in size from 0.5 to 10 cm. Areas of consolidation may be
associated with nodules, and cavitation occurs in slightly less than
one-half of patients, generally producing a thick wall with an
irregular inner lining
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Rheumatoid arthritis: it causes rheumatoid nodules in different
areas of the body including the lungs. Pulmonary nodules can
appear before, with, or after the onset of RA. They are more
commonly multiple than single, vary from a few millimeters to
several centimeters in diameter, and tend to involve both lungs
these nodules usually occur at the periphery of the lung, just
beneath the pleura, and occasionally can cause bronchopleural
fistula, pneumothorax, and abscess formation or cavitation leading
to hemoptysis.
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Sarcoidosis: Lung involvement in sarcoidosis has a strong
predilection for the upper lung. sarcoid granulomas in the lung are
typically distributed along the lymphatic vessels. The pattern of
distribution, upper lung predominance, and coexistence of
mediastinal lymphadenopathy strongly indicate the presence of
sarcoidosis. Nodules have well defined but irrigular contours.
In our study, concerning noninfectious inflammatory
conditions, we have found:
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The peripheral localization of the nodules were found in all cases.
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Uper lung distribution of nodules predominate in sarcoidosis.
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Solid nodules with well defined contours were found in all cases.
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Excavated nodules were found in 40% of cases.
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Calcification were found in 2 case of rheumatoid nodules .
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a woman followed for cutaneous sarcoidosis and has a dry cough with
dyspnea.
multiple lung nodules some of which haves irregular contours with
subpleural distribution
Bronchial distortion
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Pulmonary sarcoidosis was confirmed by biopsy of a lymphadenopathy
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Pulmonary nodules in patients with
Rhumatoide Arthritis
 Perilyphatic distribution of nodules
 Some of them are excavated
Thickened interlobular septum
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Rheumatoid lung nodules
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Male patient presented with history of cough with since two months.
multiple pulmonary excavated nodules predominate in the right upper lobe
withe a perepheral distribution
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The c-ANCA is positive: Wegener's granulomatosis
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The multiple nodules must be analyzed according to semiological
criteria concerning the aspect of margins and the distribution by
taking into account the evolutionary context. The chest CT remains
essential in the etiologic orientation and possibly in the histological
confirmation.
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A basilar predominance is typically noted in hematogenous
metastases due to preferential blood flow to the lung bases.
Nodules may also be either cavitary or surrounded by a "halo" of
ground-glass attenuation, which is typical of hemorrhagic
metastases such as those due to choriocarcinoma.
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If nodules are clustered in a predominantly subpleural/axial
distribution, they are deemed to be perilymphatic in distribution.
The main disease to be considered is sarcoidosis.
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Less commonly, diffuse nodules may be identified in patients with
septic emboli, invasive fungal infections, and pulmonary
vasculitides. These entities frequently result in cavitary nodules,
some with a distinct "halo" of ground-glass attenuation, and have
even been described in patients with organizing pneumonia.
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Mandel J, Stark P. Differential diagnosis and evaluation of Multiple
Pulmonary Nodules, topic. In UpToDate, Waltham, MA, 2007
Lillington GA, Caskey CI. Evaluation and management of solitary and
multiple pulmonary nodules. Clinics in chest medicine. 1993 Mar;
14(1):111-9.
Borie, R., Debray, M.-P., Jondeau, G., Crestani, B. Multiple pulmonary
nodules: and if it was not a cancer. Thorax doi:10.1136/thx.2010.134726
Bass, A., Schneider R., Sanders A.; et al. Pulmonary Nodules in an
Infliximab-Treated Rheumatoid Arthritis Patient. Hospital for Special
Surgery Journal (2007) 3:119-125
McWilliams A,Mayo J. Computed tomography-detected noncalcified
pulmonary nodules: a review of evidence for significance and
management. Proc Am Thorac Soc2008;5:900–4.
Abramson S, Gilkeson RC. Multiple pulmonary nodules in an
asymptomatic patient. Chest 1999;116(1):245-7.