Facolta di Medicina e Chirurgia, Universita degli Studi di Torino, Italia.

Instituto de Medicina Tropical, Instituto Prncipe Leopoldo, Ambres, Blgica.

Universidad Catlica del Sagrado Corazn , Roma Italia. Hospital Agostino Gemelli, Roma, Italia. Centre Hospitalier Universitaire Vaudois, Lausanne, Suiza. Gerontologa Pontificia Universidad Catlica de Chile. Diploma AIH. Academia Internacional Homotoxicologa, Alemania. Clnica de Asma y Alergia Reparto Serrano #12 Email: jhsdoctor@hotmail.com Tel. 2278 1169, 2270 3359, 8882 5513. Radiologia de Torax. Enfermedades Cavitarias.
Chest X-Ray Arcot J. Chandrasekhar, MD, FRCP, FACP, FCCP

his module is meant for advanced learner. Radiological criteria Hole in lung with a wall, lumen and contents. Focus of increased density whose central portion has been replaced by air. Following characteristics help in differential diagnosis. Number Multiple bilateral cavities would raise suspicion for either bronchogenous or hematogenous process. Hematogenous lesions usually have sharp margins because they are located in the interstitium. Bronchogenous cavities , the margins are shaggy.
Bronchogenous o o o Aspiration lung abscess Coccidiomycosis, Tuberculosis Bronchiectasis

Hematogenous

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Septic emboli Metastatic lesions Vasculitis (Wegners)

Single cavity
Primary lung cancer Post traumatic lung cyst Many other diseases

Size
A large cavity encompassing the entire lobe or lung should raise suspicion for gangrene of lung.

Location
Classical locations for aspiration lung abscess are superior segment of lower lobes and axillary sub segments of anterior and posterior segments of upper lobes. Tuberculous cavities are common in superior segments of upper and lower lobes. When a cavity in anterior segment is encountered, a strong suspicion for lung cancer should be raised. TB and aspiration lung abscess are rare in anterior segments. Cancer lung can occur in any segment.

Wall Thickness
Thick walls are seen in o o o o Lung abscess Necrotizing squamous cell lung cancer Wegners granulomatosis Blastomycosis

Thin walled cavities Extremely thin walled cavities are seen in o o o o o o Coccidiomycosis Metastatic cavitating squamous cell carcinoma from Cervix M. Kansasii infection Congenital or acquired bullae Posttraumatic cysts Open negative TB.

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Lining of wall The lining of wall is irregular and nodular in cancer lung or shaggy in lung abscess . The appearance is akin to stalactites and stalagmites. Contents
Most common cause for air fluid level is lung abscess. Air fluid levels can rarely be seen in malignancy and in tuberculous cavities from rupture of Rasmussen's aneurysm. A fungous ball should make you consider Aspergillosis. Blood clot and fibrin ball will have the same appearance. Floating Water Lily: I have never seen this. The collapsed membrane of a ruptured echynococcal cyst, floats giving this appearance

Associated Features
Ipsilateral lymph nodes or lytic lesions of bone is seen with malignancy. Adjacent thickening of pleura should raise suspicion for fungous ball.

Evolution of lesion Many times review of old films to assess the evolution of the radiological appearance of the lesion extremely helpful. Examples
Infected bullae Aspergilloma Sub acute necrotizing aspergillosis Bleeding from Rasmussen's aneurysm in a tuberculous cavity

Etiology Cavity can be encountered in practically most lung diseases. Common diseases and their characteristics
Primary Lung Cancer o o o Thick wall Shaggy lumen Eccentric cavitation

Necrotizing Pneumonia Lung abscess o Gravity dependant segments

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Thick wall Air-fluid levels

Tuberculosis o o o Superior segments Infiltrate around Bilateral

Fungal infections o Aspergillus Fungous ball Sub acute invasive aspergillosis

Metastatic disease o o Thin walled (Squamous cell) Thick wall (Adenoca)

Not all of the cavities you see in CXR are due to lung disease. Be aware of cavities in other locations projecting in CXR.
Empyema Mediastinum o o o o Abscess Esophagus Colon Hernia

Chest wall Biliary ectasia Colon interposition

Comprehension of the above principles.

Rationale for multiple bilateral cavities. Why does reactivation Tb occurs in superior segments? Why does aspiration lung abscess occur in the superior segment of lower lobes? What is the criteria for thick and thin wall ?

Programas Educativos; Clnica de Asma y Alergia. Dr. Juan Herrera Salazar . Tel 22781169, 2270 3359, 88825513, 89465022. ( English spoken, Francs, Italiano, Ingls) 20/08/2011

What is the pathogenesis of stalactites and stalagmites? What is crescentic sign? How do you differentiate between aspergilloma and sub acute necrotizing aspergillosis? Does the location of cavity in a density have diagnostic significance? What is open negative Tb? In metastatic disease, when do you get thin walled cavities and when do you get thick walled cavities? How do you distinguish loculated empyema from lung abscess?

Comprehension of the above principles.

Rationale for multiple bilateral cavities. Bronchi and pulmonary artery characteristically branch many times in lungs. Obviously if there is bronchogenous or hematogenous process, you can encounter bilateral multiple lung lesions. Diseases of vessels, like vasculitis also can result in multiple bilateral lung lesions (Eg Wegners granulomatosis). Bronchogenous and inflammatory vascular processes have indistinct margins. Non-inflammatory interstitial vascular lesions like metastasis, the margins are sharp. Why does reactivation Tb occurs in superior segments? This is gravity dependant phenomenon. In upright position there is less blood flow to apices of lungs. Since Tb organism is aerobic it thrives better, where there is more alveolar oxygen. In Bats tuberculosis characteristically occurs in basal segments. I have seen basal segment Tb in diabeteics, reason not clear. Why does aspiration lung abscess occur in the superior segment of lower lobes? 85% of aspiration lung abscesses occur in superior segment of lower lobes and axillary sub-segment of upper lobes. This is again a gravity dependant phenomenon. Location of aspiration depends on the position of patient at the time of aspiration. You also need to have an understanding of three dimentional view of bronchial anatomy. If the patient is supine on back, the first dependant entry is into the superior segment of lower lobe. If the patient is in right lateral decubitus position, it is the axillary sub-segments of RUL. If you are in supine positionwith face down, aspiration into lungs does not occur. Hence it is very unusual to encounter aspiration lung abscesees in anterior segemnets. What is the criteria for thick and thin wall ?

Programas Educativos; Clnica de Asma y Alergia. Dr. Juan Herrera Salazar . Tel 22781169, 2270 3359, 88825513, 89465022. ( English spoken, Francs, Italiano, Ingls) 20/08/2011

This arbitrary. Thin wall is when it resembles a cavity drawn with a pencil. I suppose we can arbitrarily set up some rules. Thin: < 1mm Thick: > 5 mm

What is the pathogenesis of stalactites and stalagmites? In necrotizing pneumonia and primary lung cancer you start off with a mass lesion. In cancer, when it outstrips its blood supply, necrosisoccurs and the contents eventually get evacuated through bronchi. You can visualize a cavity with irregular lumen, variable wall thicknessand possible fluid or necrotic tissue level as content. What is crescentic sign?

How do you differentiate between aspergilloma and sub acute necrotizing aspergillosis?

Does the location of cavity in a density have diagnostic significance?

What is open negative Tb?

In metastatic disease when do you get thin walled cavities and when do you get thick walled cavities?

Self evaluation Are you ready to see whether you have learned the subject. Remember not all the rules apply in each case. I am going to show you images. Come up with your differential and then check to see what it turned out to be. You are OK as long as you had it in your differential.
Programas Educativos; Clnica de Asma y Alergia. Dr. Juan Herrera Salazar . Tel 22781169, 2270 3359, 88825513, 89465022. ( English spoken, Francs, Italiano, Ingls) 20/08/2011

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