Case 13


Section 1

Look at images 1 and 2.

Image 1

Name 3 abnormalities in images 1 and 2.

Answer

 

ilsclnodbvinodperiphbvi

Image 2

fissnodpaunodvesselendilsnod


Section 2

Look at images 1 and 2 below.

1. What is the location of the nodules?

2. Is the distribution diffuse or patchy?

Answers

Image 1

 

 

 

Find an example of thickened interlobular septa surrounding a centrilobular nodule in the left lung.

Find an example of thickened bronchovascular interstitium in the periphery in the left lung.

Find an example of nodular thickening of the central bronchovascular interstitium in the left lung.

 

 

Image 2

Find a nodule at the end of a vessel in the right lung.

Find nodules along a fissure in the right lung.

Find an example of interlobular septal nodules in the left lung.

Find an area with a paucity of nodules compared with other areas.

 

fissnodpaunodvesselendilsnod

Diffuse, bilateral nodules that are distributed along the pleura and fissures, at the ends of vessels, and also in a centrilobular location partially meet the criteria for a random distribution as seen in miliary infection and hematogenous metastases. In contrast, the nodules in these HRCT images are patchy and somewhat asymmetric, which is more typical of lymphangitic tumor, sarcoidosis, and silicosis.

Differential diagnosis of HRCT by abnormality:

a) Smooth thickening of the interstitium is seen with lymphangitic tumor, lymphoma, edema, and Kaposi's sarcoma, but is uncommon in sarcoidosis.

b) Diffuse nodules affecting the pleura, interlobular septa, and bronchovascular and centrilobular regions can be seen with sarcoidosis, lymphangitic tumor, lymphoma, Kaposi's sarcoma, hematogenous infection, and metastases (use the "back" button in the menu bar to return). Hematogenous infection usually gives nodules of uniform size.

c) Smooth interstitial thickening together with diffuse interstitial nodules occur with lymphangitic tumor. Less likely diagnoses are lymphoma, Kaposi's sarcoma, sarcoidosis, and the combination of edema with hematogenous metastases or infection.

Diagnosis: Lymphangitic tumor (primary in urinary bladder)

Diagnostic features of lymphangitic tumor on HRCT

Comment: Lymphangitic tumor is usually bilateral when the primary is outside the lung, as in this case. As seen in a prior case (Case 5), tumor may cause smooth thickening of the lung interstitium. As in this case, lymphangitic tumor may also present as interstitial nodules in bronchovascular, interlobular septal, pleural, and sometimes centrilobular spaces. Because there is no fibrosis, architectural distortion is absent.

The nodules in sarcoidosis can have a similar distribution and anatomic location (Case 1 and Case 6). While bronchovascular interstitial thickening is common in sarcoidosis, interlobular septal thickening is unusual. However, sarcoidosis with extensive nodules and interstitial thickening usually has architectural distortion caused by fibrosis.

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a) Nodules
b) Interlobular septal thickening
c) Bronchovascular interstitial thickening

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1. Location of nodules: Pleural, centrilobular, bronchovascular interstitial, at ends of vessels, interlobular septal.

2. Distribution of nodules: Patchy, some areas have relatively few.

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Nodule at end of vessel

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Thickened interlobular septa surrounding a centrilobular nodule

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Nodular thickening of the central bronchovascular interstitium

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Thickened bronchovascular interstitium in the periphery

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Nodules along interlobar fissure

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Area with paucity of nodules

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Nodules along an interlobular septum

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