AJR 2005; 185:S184-S185
© American Roentgen Ray Society
AJR Teaching File: Hemoptysis and Enlarging Right Upper Lobe Mass
Catherine C. Roberts1 and
John R. Muhm1
1 Both authors: Department of Radiology, Mayo Clinic College of Medicine, 13400
E. Shea Blvd., Scottsdale, AZ 85259.
Received February 23, 2005;
accepted after revision March 18, 2005.
Address correspondence to C. C. Roberts
(roberts.catherine{at}mayo.edu).
Clinical History
We profile the case of a 60-year-old woman with hemoptysis and an enlarging
right upper lobe mass. She has a history of histoplasmosis infection.
Radiologic Description
Sequential images from a chest CT (Figs.
1A and
B) show an uncalcified 2.5
x 4 cm lesion in the anterior segment of the right upper lobe. The
lesion enhanced 39 H, measuring 40 H before contrast and reaching a maximum
enhancement of 79 H. A calcified body is present in the anterior segment
bronchus of the right upper lobe. There are several small, calcified, right
hilar nodes.
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Fig. 1A —60-year-old woman with hemoptysis and an enlarging right upper lobe
mass. First of two consecutive CT images through chest showing lobulated
soft-tissue mass with central calcification.
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Fig. 1B —60-year-old woman with hemoptysis and an enlarging right upper lobe
mass. Second of two consecutive CT images better demonstrates the round,
endobronchial calcification and some of the adjacent soft-tissue mass.
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| QUESTION 1
What is the best diagnosis for this case?
- Bronchogenic carcinoma.
- Lymphoma.
- Metastasis.
- Broncholithiasis.
|
18F-FDG PET evaluation (Fig.
1C) shows no increased uptake in the mass along the anterior
segment of the right upper lobe. At a 6-week follow-up CT
(Fig. 1D), there has been a
nearly complete resolution of the mass in the right upper lobe.
| QUESTION 2
Which ONE of the following statements is the best answer?
- Broncholithiasis can be associated with the development of soft-tissue
masses within the lungs.
- Broncholithiasis is associated with calcification of the lymph nodes.
- Broncholithiasis can range from asymptomatic to life-threatening.
- All of the above are correct.
|
| CONTINUING MEDICAL EDUCATION
The AJR Teaching File articles are available for 0.25 CME credit
(both articles must be completed). They are free to ARRS members and may be
purchased by nonmembers for $10.00 each. Detailed information including
objectives, disclosure information, and how to obtain CME credit can be found
at
www.arrs.org
by selecting AJR Integrative Imaging.
|
Diagnosis
Broncholithiasis is the state of having calcifications or ossified bodies
in the bronchi [1]. Most
broncholiths are calcified hilar lymph nodes that erode into bronchi due to
respiratory and/or cardiac motion
[2]. These calcified lymph
nodes commonly are caused by histoplasmosis and tuberculosis. Other causes are
less common, including infectious causes such as coccidioidomycosis and
aspergillosis, and noninfectious causes such as silicosis. Other
calcifications may enter the bronchi via aspiration and fistula formation.
Broncholiths are more common in the right lung. Associated pulmonary findings
include atelectasis, consolidation, bronchiectasis, mucoid impaction, and air
trapping [1,
3].
Broncholithiasis, causing postobstructive pneumonia, would be the best
diagnosis for this case (Option D is correct). The other possible
answers, bronchogenic carcinoma (Option A), lymphoma (Option B),
or metastasis (Option C), are incorrect because they would show
abnormal uptake on the PET scan and would not resolve spontaneously.
Commentary
Other lesions that can be confused with broncholithiasis include calcified
endobronchial infections and tumors
[1]. Luckily, these are rare
and would not typically have associated calcified lymph nodes. However, if the
patient previously had been exposed to an entity causing calcified nodes and
then developed a calcifying endobronchial infection or tumor, the diagnosis
would be more challenging.
Treatment depends on the degree of symptoms. As in the current case,
patients occasionally expectorate the offending broncholith, and any
associated pulmonary findings resolve. Significant hemoptysis, airway
obstruction, or fistula formation may require bronchoscopy or surgery to
remove the stone [2].
Objective
The educational objective of this article is to teach the appearance of
broncholithiasis, which is the state of having calcified or ossified bodies
within the bronchi. This can have myriad associated findings, including
soft-tissue masses, which may mimic malignancy.
Conclusion
Careful attention to the location of any identified calcification within a
mass can aid differentiation.
References
- Seo JB, Song KS, Lee JS, et al. Broncholithiasis: review of the
causes with radiologic–pathologic correlation.
RadioGraphics 2002;22
[spec no.]:S199
-S213
- Craig K, Keeler T, Buckley P. Broncholithiasis: a case report.
J Emerg Med 2002;23
: 359-363[CrossRef][Medline]
- Conces DJ Jr, Tarver RD, Vix VA. Broncholithiasis: CT features in
15 patients. AJR 1991;157
: 249-253[Abstract/Free Full Text]
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Clinical History
Radiologic Description
