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Fleischner Society: Glossary of Terms for Thoracic Imaging¹

¹ From the Department of Radiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom (D.M.H.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (A.A.B.); Department of Radiology, University of Chicago Hospital, Chicago, Ill (H.M.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (T.C.M.); Department of Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada (N.L.M.); and Department of Radiology, CHRU de Lille, Hôpital Calmette, Lille, France (J.R.). Received April 21, 2007; revision requested May 29; revision received June 6; accepted August 7; final version accepted September 19. Address correspondence to: D.M.H. (e-mail: d.hansell{at}rbht.nhs.uk).

	ABSTRACT

TOP ABSTRACT INTRODUCTION GLOSSARY References

 
Members of the Fleischner Society compiled a glossary of terms for thoracic imaging that replaces previous glossaries published in 1984 and 1996 for thoracic radiography and computed tomography (CT), respectively. The need to update the previous versions came from the recognition that new words have emerged, others have become obsolete, and the meaning of some terms has changed. Brief descriptions of some diseases are included, and pictorial examples (chest radiographs and CT scans) are provided for the majority of terms.

© RSNA, 2008

	INTRODUCTION

TOP ABSTRACT INTRODUCTION GLOSSARY References

 
The present glossary is the third prepared by members of the Fleischner Society and replaces the glossaries of terms for thoracic radiology (1) and CT (2), respectively. The impetus to combine and update the previous versions came from the recognition that with the recent developments in imaging new words have arrived, others have become obsolete, and the meaning of some terms has changed. The intention of this latest glossary is not to be exhaustive but to concentrate on those terms whose meaning may be problematic. Terms and techniques not used exclusively in thoracic imaging are not included.

Two new features are the inclusion of brief descriptions of the idiopathic interstitial pneumonias (IIPs) and pictorial examples (chest radiographs and computed tomographic [CT] scans) for the majority of terms. The decision to include vignettes of the IIPs (but not other pathologic entities) was based on the perception that, despite the recent scrutiny and reclassification, the IIPs remain a confusing group of diseases. We trust that the illustrations enhance, but do not distract from, the definitions. In this context, the figures should be regarded as of less importance than the text—they are merely examples and should not be taken as representing the full range of possible imaging appearances (which may be found in the references provided in this glossary or in comprehensive textbooks).

We hope that this glossary of terms will be helpful, and it is presented in the spirit of the sentiment of Edward J. Huth that "scientific writing calls for precision as much in naming things and concepts as in presenting data" (3). It is right to repeat the request with which the last Fleischner Society glossary closed: "[U]se of words is inherently controversial and we are pleased to invite readers to offer improvements to our definitions" (2).

	GLOSSARY

TOP ABSTRACT INTRODUCTION GLOSSARY References

 
acinus
Anatomy.—The acinus is a structural unit of the lung distal to a terminal bronchiole and is supplied by first-order respiratory bronchioles; it contains alveolar ducts and alveoli. It is the largest unit in which all airways participate in gas exchange and is approximately 6–10 mm in diameter. One secondary pulmonary lobule contains between three and 25 acini (4).

Radiographs and CT scans.—Individual normal acini are not visible, but acinar arteries can occasionally be identified on thin-section CT scans. Accumulation of pathologic material in acini may be seen as poorly defined nodular opacities on chest radiographs and thin-section CT images. (See also nodules.)

acute interstitial pneumonia, or AIP
Pathology.—The term acute interstitial pneumonia is reserved for diffuse alveolar damage of unknown cause. The acute phase is characterized by edema and hyaline membrane formation. The later phase is characterized by airspace and/or interstitial organization (5). The histologic pattern is indistinguishable from that of acute respiratory distress syndrome.

Radiographs and CT scans.—In the acute phase, patchy bilateral ground-glass opacities are seen (6), often with some sparing of individual lobules, producing a geographic appearance; dense opacification is seen in the dependent lung (Fig 1). In the organizing phase, architectural distortion, traction bronchiectasis, cysts, and reticular opacities are seen (7).

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Transverse CT scan in a patient with acute interstitial pneumonia.

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Transverse CT scan shows air bronchogram as air-filled bronchi (arrows) against background of high-attenuation lung.

View larger version (165K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Magnified chest radiograph shows air crescent (arrows) adjacent to mycetoma.

CT scans.—Air trapping is seen on end-expiration CT scans as parenchymal areas with less than normal increase in attenuation and lack of volume reduction. Comparison between inspiratory and expiratory CT scans can be helpful when air trapping is subtle or diffuse (11,12) (Fig 4). Differentiation from areas of decreased attenuation resulting from hypoperfusion as a consequence of an occlusive vascular disorder (eg, chronic thromboembolism) may be problematic (13), but other findings of airways versus vascular disease are usually present. (See also mosaic attenuation pattern.)

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 4: Transverse CT scans at end inspiration and end expiration show air trapping.

Radiographs and CT scans.—This term is used in conjunction with consolidation, opacity, and nodules to designate the filling of airspaces with the products of disease (14).

aortopulmonary window
Anatomy.—The aortopulmonary window is the mediastinal region bounded anteriorly by the ascending aorta, posteriorly by the descending aorta, cranially by the aortic arch, inferiorly by the left pulmonary artery, medially by the ligamentum arteriosum, and laterally by the pleura and left lung (15,16).

Radiographs and CT scans.—Focal concavity in the left mediastinal border below the aorta and above the left pulmonary artery can be seen on a frontal radiograph (Fig 5). Its appearance may be modified by tortuosity of the aorta. The aortopulmonary window is a common site of lymphadenopathy in a variety of inflammatory and neoplastic diseases.

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 5: Magnified chest radiograph shows aortopulmonary window.

Radiographs and CT scans.—The usual appearance is of homogeneous soft-tissue attenuation capping the extreme lung apex (uni- or bilaterally), with a sharp or irregular lower border (Fig 6). Thickness is variable, ranging up to about 30 mm (17). An apical cap occasionally mimics apical consolidation on transverse CT scans.

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 6: Magnified chest radiograph shows apical cap (arrow).

CT scans.—Lung anatomy has a distorted appearance and is usually associated with pulmonary fibrosis (Fig 7) and accompanied by volume loss.

View larger version (165K): [in this window] [in a new window] [Download PPT slide]   Figure 7: Transverse CT scan shows architectural distortion caused by pulmonary fibrosis.

Radiographs and CT scans.—Reduced volume is seen, accompanied by increased opacity (chest radiograph) or attenuation (CT scan) in the affected part of the lung (Fig 8). Atelectasis is often associated with abnormal displacement of fissures, bronchi, vessels, diaphragm, heart, or mediastinum (22). The distribution can be lobar, segmental, or subsegmental. Atelectasis is often qualified by descriptors such as linear, discoid, or platelike. (See also linear atelectasis, rounded atelectasis.)

View larger version (77K): [in this window] [in a new window] [Download PPT slide]   Figure 8: Transverse CT scan shows atelectasis of right middle lobe as increased attenuation (arrows) adjacent to right border of heart.

Radiographs and CT scans.—On a frontal chest radiograph, the recess is seen as a vertically oriented interface between the right lower lobe and the adjacent mediastinum (the medial limit of the recess). Superiorly, the interface is seen as a smooth arc with convexity to the left. Disappearance or distortion of part of the interface suggests disease (eg, subcarinal lymphadenopathy). On CT scans, the recess (Fig 9) merits attention because small lesions located in the recess will often be invisible on chest radiographs (23).

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 9: Transverse CT scan shows azygoesophageal recess (arrows).

beaded septum sign
CT scans.—This sign consists of irregular and nodular thickening of interlobular septa reminiscent of a row of beads (Fig 10). It is frequently seen in lymphangitic spread of cancer and less often in sarcoidosis (24).

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 10: Transverse CT scan shows beaded septum sign (arrows).

CT scans.—A bleb appears as a thin-walled cystic air space contiguous with the pleura. Because the arbitrary (size) distinction between a bleb and bulla is of little clinical importance, the use of this term by radiologists is discouraged.

bronchiectasis
Pathology.—Bronchiectasis is irreversible localized or diffuse bronchial dilatation, usually resulting from chronic infection, proximal airway obstruction, or congenital bronchial abnormality (26). (See also traction bronchiectasis.)

Radiographs and CT scans.—Morphologic criteria on thin-section CT scans include bronchial dilatation with respect to the accompanying pulmonary artery (signet ring sign), lack of tapering of bronchi, and identification of bronchi within 1 cm of the pleural surface (27) (Fig 11). Bronchiectasis may be classified as cylindric, varicose, or cystic, depending on the appearance of the affected bronchi. It is often accompanied by bronchial wall thickening, mucoid impaction, and small-airways abnormalities (27–29). (See also signet ring sign.)

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 11: Transverse CT scan shows varicose bronchiectasis.

Radiographs and CT scans.—Bronchioles are not identifiable in healthy individuals, because the bronchiolar walls are too thin (4). In inflammatory small-airways disease, however, thickened or plugged bronchioles may be seen as a nodular pattern on a chest radiograph or as a tree-in-bud pattern on CT scans.

bronchiolectasis
Pathology.—Bronchiolectasis is defined as dilatation of bronchioles. It is caused by inflammatory airways disease (potentially reversible) or, more frequently, fibrosis.

CT scans.—When dilated bronchioles are filled with exudate and are thick walled, they are visible as a tree-in-bud pattern or as centrilobular nodules (31,32). In traction bronchiolectasis, the dilated bronchioles are seen as small, cystic, tubular airspaces, associated with CT findings of fibrosis (Fig 12). (See also traction bronchiectasis and traction bronchiolectasis, tree-in-bud pattern.)

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 12: Transverse CT scan shows bronchiolectasis within fibrotic lung (arrow).

CT scans.—This direct sign of bronchiolar inflammation (eg, infectious cause) is most often seen as the tree-in-bud pattern, centrilobular nodules, and bronchiolar wall thickening on CT scans. (See also small-airways disease, tree-in-bud pattern.)

bronchocele
Pathology.—A bronchocele is bronchial dilatation due to retained secretions (mucoid impaction) usually caused by proximal obstruction, either congenital (eg, bronchial atresia) or acquired (eg, obstructing cancer) (34).

Radiographs and CT scans.—A bronchocele is a tubular or branching Y- or V-shaped structure that may resemble a gloved finger (Fig 13). The CT attenuation of the mucus is generally that of soft tissue but may be modified by its composition (eg, high-attenuation material in allergic bronchopulmonary aspergillosis). In the case of bronchial atresia, the surrounding lung may be of decreased attenuation because of reduced ventilation and, thus, perfusion.

View larger version (171K): [in this window] [in a new window] [Download PPT slide]   Figure 13: Coronal CT scan shows bronchocele (arrow).

View larger version (119K): [in this window] [in a new window] [Download PPT slide]   Figure 14: Transverse CT scan shows consolidation with bronchocentric distribution.

Radiographs and CT scans.—The imaging appearance is of a small calcific focus in or immediately adjacent to an airway (Fig 15), most frequently the right middle lobe bronchus. Broncholiths are readily identified on CT scans (38). Distal obstructive changes may include atelectasis, mucoid impaction, and bronchiectasis.

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 15: Transverse CT scan shows a broncholith (arrows).

Radiographs and CT scans.—A bulla appears as a rounded focal lucency or area of decreased attenuation, 1 cm or more in diameter, bounded by a thin wall (Fig 16). Multiple bullae are often present and are associated with other signs of pulmonary emphysema (centrilobular and paraseptal).

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 16: Coronal CT scan shows large bulla in left lower lung zone.

cavity
Radiographs and CT scans.—A cavity is a gas-filled space, seen as a lucency or low-attenuation area, within pulmonary consolidation, a mass, or a nodule (Fig 17). In the case of cavitating consolidation, the original consolidation may resolve and leave only a thin wall. A cavity is usually produced by the expulsion or drainage of a necrotic part of the lesion via the bronchial tree. It sometimes contains a fluid level. Cavity is not a synonym for abscess.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 17: Transverse CT scan shows cavitating mass in right upper lobe.

CT scans.–A small dotlike or linear opacity in the center of a normal secondary pulmonary lobule, most obvious within 1 cm of a pleural surface, represents the intralobular artery (approximately 1 mm in diameter) (41). Centrilobular abnormalities include (a) nodules, (b) a tree-in-bud pattern indicating small-airways disease, (c) increased visibility of centrilobular structures due to thickening or infiltration of the adjacent interstitium, or (d) abnormal areas of low attenuation caused by centrilobular emphysema (4). (See also lobular core structures.)

centrilobular emphysema
Pathology.—Centrilobular emphysema is characterized by destroyed centrilobular alveolar walls and enlargement of respiratory bronchioles and associated alveoli (42,43). This is the commonest form of emphysema in cigarette smokers.

CT scans.—CT findings are centrilobular areas of decreased attenuation, usually without visible walls, of nonuniform distribution and predominantly located in upper lung zones (44) (Fig 18). The term centriacinar emphysema is synonymous. (See also emphysema.)

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 18: Transverse CT scan shows centrilobular emphysema.

consolidation
Pathology.—Consolidation refers to an exudate or other product of disease that replaces alveolar air, rendering the lung solid (as in infective pneumonia).

Radiographs and CT scans.—Consolidation appears as a homogeneous increase in pulmonary parenchymal attenuation that obscures the margins of vessels and airway walls (45) (Fig 19). An air bronchogram may be present. The attenuation characteristics of consolidated lung are only rarely helpful in differential diagnosis (eg, decreased attenuation in lipoid pneumonia [46] and increased in amiodarone toxicity [47]).

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 19: Transverse CT scan shows multifocal consolidation.

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 20: Transverse CT scan shows crazy-paving pattern.

cyst
Pathology.—A cyst is any round circumscribed space that is surrounded by an epithelial or fibrous wall of variable thickness (51).

Radiographs and CT scans.—A cyst appears as a round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung. Cysts have variable wall thickness but are usually thin-walled (<2 mm) and occur without associated pulmonary emphysema (Fig 21). Cysts in the lung usually contain air but occasionally contain fluid or solid material. The term is often used to describe enlarged thin-walled airspaces in patients with lymphangioleiomyomatosis (52) or Langerhans cell histiocytosis (53); thicker-walled honeycomb cysts are seen in patients with end-stage fibrosis (54). (See also bleb, bulla, honeycombing, pneumatocele.)

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 21: Coronal CT scan shows a cyst.

Radiographs and CT scans.—Ground-glass opacity is the dominant abnormality and tends to have a basal and peripheral distribution (Fig 22). Microcystic or honeycomb changes in the area of ground-glass opacity are seen in some cases (55).

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 22: Transverse CT scan in a patient with desquamative interstitial pneumonia.

emphysema
Pathology.—Emphysema is characterized by permanently enlarged airspaces distal to the terminal bronchiole with destruction of alveolar walls (42,43). Absence of "obvious fibrosis" was historically regarded as an additional criterion (42), but the validity of that criterion has been questioned because some interstitial fibrosis may be present in emphysema secondary to cigarette smoking (56,57). Emphysema is usually classified in terms of the part of the acinus predominantly affected: proximal (centriacinar, more commonly termed centrilobular, emphysema), distal (paraseptal emphysema), or whole acinus (panacinar or, less commonly, panlobular emphysema).

CT scans.—The CT appearance of emphysema consists of focal areas or regions of low attenuation, usually without visible walls (58). In the case of panacinar emphysema, decreased attenuation is more diffuse. (See also bullous emphysema, centrilobular emphysema, panacinar emphysema, paraseptal emphysema.)

fissure
Anatomy.—A fissure is the infolding of visceral pleura that separates one lobe or part of a lobe from another; thus, the interlobar fissures are produced by two layers of visceral pleura. Supernumerary fissures usually separate segments rather than lobes. The azygos fissure, unlike the other fissures, is formed by two layers each of visceral and parietal pleura. All fissures (apart from the azygos fissure) may be incomplete.

Radiographs and CT scans.—Fissures appear as linear opacities, normally 1 mm or less in thickness, that correspond in position and extent to the anatomic fissural separation of pulmonary lobes or segments. Qualifiers include minor, major, horizontal, oblique, accessory, anomalous, azygos, and inferior accessory.

folded lung
See rounded atelectasis.

fungus ball
See mycetoma.

gas trapping
See air trapping.

ground-glass nodule
See nodule.

ground-glass opacity
Radiographs and CT scans.—On chest radiographs, ground-glass opacity appears as an area of hazy increased lung opacity, usually extensive, within which margins of pulmonary vessels may be indistinct. On CT scans, it appears as hazy increased opacity of lung, with preservation of bronchial and vascular margins (Fig 23). It is caused by partial filling of airspaces, interstitial thickening (due to fluid, cells, and/or fibrosis), partial collapse of alveoli, increased capillary blood volume, or a combination of these, the common factor being the partial displacement of air (59,60). Ground-glass opacity is less opaque than consolidation, in which bronchovascular margins are obscured. (See also consolidation.)

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 23: Transverse CT scan shows ground-glass opacity.

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 24: Transverse CT scan shows several nodules exhibiting the halo sign (arrows).

Radiographs and CT scans.—A hilum appears as a composite opacity at the root of each lung produced by bronchi, arteries, veins, lymph nodes, nerves, and other tissue. The terms hilum (singular) and hila (plural) are preferred to hilus and hili respectively; the adjectival form is hilar.

honeycombing
Pathology.—Honeycombing represents destroyed and fibrotic lung tissue containing numerous cystic airspaces with thick fibrous walls, representing the late stage of various lung diseases, with complete loss of acinar architecture. The cysts range in size from a few millimeters to several centimeters in diameter, have variable wall thickness, and are lined by metaplastic bronchiolar epithelium (51).

Radiographs and CT scans.—On chest radiographs, honeycombing appears as closely approximated ring shadows, typically 3–10 mm in diameter with walls 1–3 mm in thickness, that resemble a honeycomb; the finding implies end-stage lung disease. On CT scans, the appearance is of clustered cystic air spaces, typically of comparable diameters on the order of 3–10 mm but occasionally as large as 2.5 cm (Fig 25). Honeycombing is usually subpleural and is characterized by well-defined walls (54). It is a CT feature of established pulmonary fibrosis (5). Because honeycombing is often considered specific for pulmonary fibrosis and is an important criterion in the diagnosis of usual interstitial pneumonia (63), the term should be used with care, as it may directly impact patient care.

View larger version (89K): [in this window] [in a new window] [Download PPT slide]   Figure 25: Transverse CT scan shows honeycombing.

Radiographs and CT scans.—The typical imaging findings are reticular opacities and honeycombing, with a predominantly peripheral and basal distribution (Fig 26). Ground-glass opacity, if present, is less extensive than reticular and honeycombing patterns. The typical radiologic findings (65,66) are also encountered in usual interstitial pneumonia secondary to specific causes, such as asbestos-induced pulmonary fibrosis (asbestosis), and the diagnosis is usually one of exclusion. (See also usual interstitial pneumonia.)

View larger version (76K): [in this window] [in a new window] [Download PPT slide]   Figure 26: Coronal CT scan shows reticular opacities and honeycombing in the lower zones, typical of idiopathic pulmonary fibrosis.

Radiographs and CT scans.—A pulmonary infarct is typically triangular or dome-shaped, with the base abutting the pleura and the apex directed toward the hilum (Fig 27). The opacity represents local hemorrhage with or without central tissue necrosis (67,68).

View larger version (91K): [in this window] [in a new window] [Download PPT slide]   Figure 27: Transverse CT scan shows pulmonary infarction.

interlobular septal thickening
Radiographs and CT scans.—This finding is seen on chest radiographs as thin linear opacities at right angles to and in contact with the lateral pleural surfaces near the lung bases (Kerley B lines); it is seen most frequently in lymphangitic spread of cancer or pulmonary edema. Kerley A lines are predominantly situated in the upper lobes, are 2–6 cm long, and can be seen as fine lines radially oriented toward the hila. In recent years, the anatomically descriptive terms septal lines and septal thickening have gained favor over Kerley lines. On CT scans, disease affecting one of the components of the septa (see interlobular septum) may be responsible for thickening and so render septa visible. On thin-section CT scans, septal thickening may be smooth or nodular (70) (Fig 28), which may help refine the differential diagnosis. (See also interlobular septum, beaded septum.)

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 28: Transverse CT scan shows interlobular septal thickening and pleural effusions.

Radiographs and CT scans.—Interlobular septa appear as thin linear opacities between lobules (Fig 29); these septa are to be distinguished from centrilobular structures. They are not usually seen in the healthy lung (normal septa are approximately 0.1 mm thick) but are clearly visible when thickened (eg, by pulmonary edema). (See also interlobular septal thickening, lobule.)

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 29: Transverse CT scan shows interlobular septum (arrow) in a healthy individual.

Radiographs and CT scans.—Interstitial emphysema is rarely recognized radiographically in adults and is infrequently seen on CT scans (Fig 30). It appears as perivascular lucent or low-attenuating halos and small cysts (71,72).

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 30: Transverse CT scan shows interstitial emphysema (arrow).

intralobular lines
CT scans.—Intralobular lines are visible as fine linear opacities in a lobule when the intralobular interstitial tissue is abnormally thickened (Fig 31). When numerous, they may appear as a fine reticular pattern. Intralobular lines may be seen in various conditions, including interstitial fibrosis and alveolar proteinosis (41).

View larger version (175K): [in this window] [in a new window] [Download PPT slide]   Figure 31: Transverse CT scan shows lntralobular lines.

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 32: Chest radiograph shows juxtaphrenic peak of the right hemidiaphragm.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 33: Chest radiograph shows basal linear atelectasis.

lobular core structures
Anatomy.—Lobular core structures are the central structures in secondary pulmonary lobules and consist of a centrilobular artery and bronchiole (40).

CT scans.—The pulmonary artery and its immediate branches are visible in the center of a secondary lobule on thin-section CT scans, particularly if thickened (eg, by pulmonary edema) (Fig 34). These arteries measure approximately 0.5–1.0 mm in diameter. However, the normal bronchiole in the center of the secondary pulmonary lobule cannot be seen on thin-section CT scans because of the thinness of its wall (approximately 0.15 mm) (4,41). (See also centrilobular, lobule.)

View larger version (134K): [in this window] [in a new window] [Download PPT slide]   Figure 34: Transverse CT scan shows lobular core structure (arrow).

CT scans.—On thin-section CT scans, the three basic components of the lobule—the interlobular septa and septal structures, the central lobular region (centrilobular structures), and the lobular parenchyma—can be identified, particularly in disease states. Peripheral lobules are more uniform in appearance and pyramidal in shape than are central lobules (4) (Fig 35). (See also interlobular septa, lobular core structures.)

View larger version (168K): [in this window] [in a new window] [Download PPT slide]   Figure 35: CT scan of resected lung shows lobules.

CT scans.—There is a wide range in the size of normal lymph nodes. Mediastinal and hilar lymph nodes range in size from sub-CT resolution to 12 mm. Somewhat arbitrary thresholds for the upper limit of normal of 1 cm in short-axis diameter for mediastinal nodes (79) and 3 mm for most hilar nodes (80) have been reported, but size criteria do not allow reliable differentiation between healthy and diseased lymph nodes (Fig 36).

View larger version (56K): [in this window] [in a new window] [Download PPT slide]   Figure 36: Transverse CT scan shows lymphadenopathy (enlarged mediastinal lymph nodes).

CT scans.—Ground-glass opacity is the dominant abnormality, and thin-walled perivascular cysts may be present (Fig 37). Lung nodules, a reticular pattern, interlobular septal and bronchovascular thickening, and widespread consolidation may also occur (82,83).

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 37: Transverse CT scan shows ground-glass opacities and perivascular cysts in a patient with lymphoid interstitial pneumonia.

mediastinal compartments
Anatomy.—Nominal anatomic compartments of the mediastinum include the anterior, middle, posterior, and (in some schemes) superior compartments. The anterior compartment is bounded anteriorly by the sternum and posteriorly by the anterior surface of the pericardium, the ascending aorta, and the brachiocephalic vessels. The middle compartment is bounded by the posterior margin of the anterior division and the anterior margin of the posterior division. The posterior compartment is bounded anteriorly by the posterior margins of the pericardium and great vessels and posteriorly by the thoracic vertebral bodies. In the four-compartment model, the superior compartment is defined as the compartment above the plane between the sternal angle to the T4-5 intervertebral disk or, more simply, above the aortic arch (84,85). Exact anatomic boundaries between the compartments do not exist, and there are no barriers (other than the pericardium) to prevent the spread of disease between compartments. Other classifications exist, but the three- and four-compartment models are the most commonly used.

micronodule
CT scans.—A micronodule is a discrete, small, round, focal opacity. A variety of diameters have been used in the past to define a micronodule; for example, a diameter of no greater than 7 mm (86). Use of the term is most often limited to nodules with a diameter of less than 5 mm (87) or less than 3 mm (88). It is recommended that the term be reserved for opacities less than 3 mm in diameter. (See also nodule, miliary pattern.)

miliary pattern
Radiographs and CT scans.—On chest radiographs, the miliary pattern consists of profuse tiny, discrete, rounded pulmonary opacities (3 mm in diameter) that are generally uniform in size and diffusely distributed throughout the lungs (Fig 38). This pattern is a manifestation of hematogenous spread of tuberculosis and metastatic disease. Thin-section CT scans show widespread, randomly distributed micronodules.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 38: Magnified chest radiograph shows miliary pattern.

View larger version (102K): [in this window] [in a new window] [Download PPT slide]   Figure 39: Transverse CT scan shows mosaic attenuation pattern caused by obliterative small-airways disease.

mycetoma
Pathology.—A mycetoma is a discrete mass of intertwined hyphae, usually of an Aspergillus species, matted together by mucus, fibrin, and cellular debris colonizing a cavity, usually from prior fibrocavitary disease (eg, tuberculosis or sarcoidosis).

Radiographs and CT scans.—A mycetoma may move to a dependent location when the patient changes position and may show an air crescent sign (Fig 40). CT scans may show a spongelike pattern and foci of calcification in the mycetoma (93). A synonym is fungus ball. (See also air crescent.)

View larger version (186K): [in this window] [in a new window] [Download PPT slide]   Figure 40: Coronal CT scan shows mycetomas in both lungs.

View larger version (162K): [in this window] [in a new window] [Download PPT slide]   Figure 41: Magnified chest radiograph shows a nodular pattern.

On CT scans, a nodule appears as a rounded or irregular opacity, well or poorly defined, measuring up to 3 cm in diameter (Fig 42). (a) Centrilobular nodules appear separated by several millimeters from the pleural surfaces, fissures, and interlobular septa. They may be of soft-tissue or ground-glass attenuation. Ranging in size from a few millimeters to a centimeter, centrilobular nodules are usually ill-defined (4). (b) A micronodule is less than 3 mm in diameter (see also micronodule). (c) A ground-glass nodule (synonym, nonsolid nodule) manifests as hazy increased attenuation in the lung that does not obliterate the bronchial and vascular margins. (d) A solid nodule has homogenous soft-tissue attenuation. (e) A part-solid nodule (synonym, semisolid nodule) consists of both ground-glass and solid soft-tissue attenuation components. (See also mass.)

View larger version (174K): [in this window] [in a new window] [Download PPT slide]   Figure 42: Transverse CT scan shows irregular nodule in left lower lobe.

CT scans.—NSIP has variable thin-section CT appearances: The most frequent is ground-glass opacities with reticulation, traction bronchiectasis or bronchiolectasis, and little or no honeycombing (Fig 43). The distribution is usually basal and subpleural (95).

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 43: Transverse CT scan shows nonspecific interstitial pneumonia.

Radiographs and CT scans.—Oligemia appears as a regional or widespread decrease in the size and number of identifiable pulmonary vessels (Fig 44), which is indicative of less than normal blood flow. (See also mosaic attenuation pattern, pulmonary blood flow redistribution.)

View larger version (71K): [in this window] [in a new window] [Download PPT slide]   Figure 44: Transverse CT scan shows oligemia (arrows) in left lung.

organizing pneumonia
Pathology.—Organizing pneumonia manifests as a histologic pattern characterized by loose plugs of connective tissue in the airspaces and distal airways. Interstitial inflammation and fibrosis are minimal or absent. Cryptogenic organizing pneumonia, or COP, is a distinctive clinical disorder among the idiopathic interstitial pneumonias (5), but the histologic pattern of organizing pneumonia is encountered in many different situations, including pulmonary infection, hypersensitivity pneumonitis, and collagen vascular diseases.

Radiographs and CT scans.—Airspace consolidation is the cardinal feature of organizing pneumonia on chest radiographs and CT scans. In COP, the distribution is typically subpleural and basal (Fig 45) and sometimes bronchocentric (96). Other manifestations of organizing pneumonia include ground-glass opacity, tree-in-bud pattern, and nodular opacities (37).

View larger version (211K): [in this window] [in a new window] [Download PPT slide]   Figure 45: Transverse CT scan shows cryptogenic organizing pneumonia with subpleural and basal distribution.

CT scans.—Panacinar emphysema manifests as a generalized decrease of the lung parenchyma with a decrease in the caliber of blood vessels in the affected lung (97,98) (Fig 46). Severe panacinar emphysema may coexist and merge with severe centrilobular emphysema. The appearance of featureless decreased attenuation may be indistinguishable from severe constrictive obliterative bronchiolitis (99). The term panlobular emphysema is synonymous. (See also emphysema.)

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 46: Transverse CT scan shows panacinar emphysema.

CT scans.—This emphysema is characterized by subpleural and peribronchovascular regions of low attenuation separated by intact interlobular septa (Fig 47), sometimes associated with bullae. The term distal acinar emphysema is synonymous. (See also emphysema.)

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 47: Transverse CT scan shows paraseptal emphysema.

Radiographs and CT scans.—The portion of the lung exclusive of visible pulmonary vessels and airways.

parenchymal band
Radiographs and CT scans.—A parenchymal band is a linear opacity, usually 1–3 mm thick and up to 5 cm long that usually extends to the visceral pleura (which is often thickened and may be retracted at the site of contact) (Fig 48). It reflects pleuroparenchymal fibrosis and is usually associated with distortion of the lung architecture. Parenchymal bands are most frequently encountered in individuals who have been exposed to asbestos (100,101).

View larger version (88K): [in this window] [in a new window] [Download PPT slide]   Figure 48: Transverse CT scan shows parenchymal bands (arrows).

peribronchovascular interstitium
Anatomy.—The peribronchovascular interstitium is a connective-tissue sheath that encloses the bronchi, pulmonary arteries, and lymphatic vessels. It extends from the hila to the lung periphery.

perilobular distribution
Anatomy.—The perilobular region comprises the structures bordering the periphery of the secondary pulmonary lobule.

CT scans.—This pattern is characterized by distribution along the structures that border the pulmonary lobules (ie, interlobular septa, visceral pleura, and vessels) (102). The term is most frequently used in the context of diseases (eg, perilobular organizing pneumonia) that are distributed mainly around the inner surface of the secondary pulmonary lobule (103) (Fig 49). This may resemble indistinct thickening of the interlobular septa.

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 49: Transverse CT scan shows organizing pneumonia in a perilobular distribution (arrows).

CT scans.—Abnormalities along the pathway of the pulmonary lymphatics—that is, in the perihilar, peribronchovascular, and centrilobular interstitium, as well as in the interlobular septa and subpleural locations—have a perilymphatic distribution (104). A perilymphatic distribution typically seen in sarcoidosis (Fig 50) and lymphangitic spread of cancer.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 50: Transverse CT scan shows sarcoidosis with a perilymphatic distribution.

pleural plaque
Pathology.—A pleural plaque is a fibrohyaline, relatively acellular lesion arising predominantly on the parietal pleural surface, particularly on the diaphragm and underneath ribs (105). Pleural plaques are almost invariably the consequence of previous (at least 15 years earlier) asbestos exposure.

Radiographs and CT scans.—Pleural plaques are well-demarcated areas of pleural thickening, seen as elevated flat or nodular lesions that often contain calcification (Fig 51). Plaques are of variable thickness, range from less than 1 to approximately 5 cm in diameter, and are more easily identified on CT scans than on chest radiographs (106). An en face plaque may simulate a pulmonary nodule on chest radiographs. (See also pseudoplaque.)

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 51: Transverse CT scan shows pleural plaque (arrow) anteriorly in right hemithorax.

Radiographs and CT scans.—A pneumatocele appears as an approximately round, thin-walled airspace in the lung (Fig 52).

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 52: Chest radiograph shows a pneumatocele (arrows).

Radiographs and CT scans.— Pneumomediastinum appears as lucent streaks on chest radiographs, mostly vertically oriented (Fig 53). Some of these streaks may outline vessels and main bronchi. (See also pneumopericardium.)

View larger version (182K): [in this window] [in a new window] [Download PPT slide]   Figure 53: Magnified chest radiograph shows pneumomediastinum.

pneumopericardium
Pathology.—Pneumopericardium is the presence of gas in the pericardial space. It usually has an iatrogenic, often surgical, origin in adults.

Radiographs and CT scans.—Pneumopericardium is usually distinguishable from pneumomediastinum because the lucency (low attenuation) caused by air does not extend outside the pericardial sac (Fig 54). (See also pneumomediastinum.)

View larger version (179K): [in this window] [in a new window] [Download PPT slide]   Figure 54: Chest radiograph shows pneumopericardium.

Radiographs and CT scans.—On chest radiographs, a visceral pleural edge is visible (Fig 55) unless the pneumothorax is very small or the pleural edge is not tangential to the x-ray beam. Tension pneumothorax may be associated with considerable shift of the mediastinum and/or depression of the hemidiaphragm. Some shift can occur without tension because the pleural pressure in the presence of pneumothorax becomes atmospheric, while the pleural pressure in the contralateral hemithorax remains negative.

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 55: Chest radiograph shows pneumothorax.

Radiographs and CT scans.—Progressive massive fibrosis manifests as masslike lesions, usually bilateral and in the upper lobes (Fig 56). Background nodular opacities reflect accompanying pneumoconiosis, with or without emphysematous destruction adjacent to the massive fibrosis (109). Lesions similar to progressive massive fibrosis sometimes occur in other conditions, such as sarcoidosis and talcosis (109,110).

View larger version (174K): [in this window] [in a new window] [Download PPT slide]   Figure 56: Chest radiograph shows bilateral progressive massive fibrosis.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 57: Transverse CT scan shows pseudocavitation in an adenocarcinoma.

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 58: Transverse CT scan shows pseudoplaques (arrows) in a patient with sarcoidosis.

Radiographs and CT scans.—Pulmonary blood flow redistribution is indicated by a decrease in the size and/or number of visible pulmonary vessels in one or more lung regions (Fig 59), with a corresponding increase in number and/or size of pulmonary vessels in other parts of the lung. Upper lobe blood diversion in patients with mitral valve disease is the archetypal example of redistribution (112,113).

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 59: Chest radiograph shows redistribution of blood flow to upper lung zones.

CT scans.—RB-ILD typically manifests as extensive centrilobular micronodules and patchy ground-glass opacity corresponding to macrophage-rich alveolitis (Fig 60), with or without fine fibrosis (115,116). It is often accompanied by bronchial wall thickening and minor centrilobular emphysema. Areas of air trapping reflect a bronchiolitic component.

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 60: Transverse CT scan shows centrilobular micronodules and patchy ground-glass opacity typical of respiratory bronchiolitis–interstitial lung disease.

View larger version (166K): [in this window] [in a new window] [Download PPT slide]   Figure 61: Chest radiograph shows reticular pattern.

View larger version (166K): [in this window] [in a new window] [Download PPT slide]   Figure 62: Chest radiograph shows reticulonodular pattern.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 63: Transverse CT scan shows reversed halo sign (arrow).

View larger version (176K): [in this window] [in a new window] [Download PPT slide]   Figure 64: Magnified chest radiograph shows paratracheal stripe (arrows).

Radiographs and CT scans.—On chest radiographs, rounded atelectasis appears as a mass abutting a pleural surface, usually in the posterior part of a lower lobe. Distorted vessels have a curvilinear disposition as they converge on the mass (the comet tail sign). The degree of lobar retraction depends on the volume of atelectatic lung. It is almost invariably associated with other signs of pleural fibrosis (eg, blunting of costophrenic angle). CT is more sensitive for the detection and display of the characteristic features of rounded atelectasis (122,123) (Fig 65). An additional sign is homogeneous uptake of contrast medium in the atelectatic lung. Synonyms include folded lung syndrome, helical atelectasis, Blesovsky syndrome, pleural pseudotumor, and pleuroma.

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 65: Sagittal CT scan shows rounded atelectasis in left lower lobe.

segment
Anatomy.—A segment is the unit of a lobe ventilated by a segmental bronchus, perfused by a segmental pulmonary artery, and drained by an intersegmental pulmonary vein. There are two to five segments per lobe.

Radiographs and CT scans.—Individual segments cannot be precisely delineated on chest radiographs and CT scans, and their identification is made inferentially on the basis of the position of the supplying segmental bronchus and artery. When occasionally present, intersegmental fissures help to identify segments.

septal line
See interlobular septum.

septal thickening
See interlobular septal thickening.

signet ring sign
CT scans.—This finding is composed of a ring-shaped opacity representing a dilated bronchus in cross section and a smaller adjacent opacity representing its pulmonary artery, with the combination resembling a signet (or pearl) ring (124) (Fig 66). It is the basic CT sign of bronchiectasis (27,125). The signet ring sign can also be seen in diseases characterized by abnormal reduced pulmonary arterial flow (eg, proximal interruption of pulmonary artery [126] or chronic thromboembolism [127]). Occasionally, the tiny vascular opacity abutting a bronchus is a bronchial, rather than a pulmonary, artery.

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 66: Transverse CT scan shows signet ring sign (arrow).

View larger version (186K): [in this window] [in a new window] [Download PPT slide]   Figure 67: Chest radiograph shows silhouette sign, with obscuration of right border of heart (arrows).

CT scans.—Small airways are considered to be those with an internal diameter smaller than or equal to 2 mm and a normal wall thickness of less than 0.5 mm (32). Small-airways disease is manifest on CT scans as one or more of the following patterns: mosaic attenuation, air trapping, centrilobular micronodules, tree-in-bud pattern, or bronchiolectasis.

subpleural curvilinear line
CT scans.—This finding is a thin curvilinear opacity, 1–3 mm in thickness, lying less than 1 cm from and parallel to the pleural surface (Fig 68). It corresponds to atelectasis of normal lung if seen in the dependent posteroinferior portion of lung of a patient in the supine position and is subsequently shown to disappear on CT sections acquired with the patient prone. It may also be encountered in patients with pulmonary edema (132) or fibrosis (other signs are usually present). Though described in the context of asbestosis, this finding is not specific for asbestosis.

View larger version (54K): [in this window] [in a new window] [Download PPT slide]   Figure 68: Transverse CT scan shows a subpleural curvilinear line.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 69: Transverse CT scan shows traction bronchiectasis (arrows) cased by retractile pulmonary fibrosis.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 70: Transverse CT scan shows tree-in-bud pattern (arrows).

Radiographs and CT scans.—Honeycombing with a basal and subpleural distribution (Fig 71) is regarded as pathognomonic (63,65), but not all cases of biopsy-proved UIP have this distinctive CT pattern.

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 71: Transverse CT scan shows basal and subpleural honeycombing, indicative of usual interstitial pneumonia.

	ACKNOWLEDGMENTS

 
The authors thank Peter Armstrong, MD, David A. Lynch, MD, Tom V. Colby, MD, and Tomas Franquet, MD, for their early critical review and members of the Fleischner Society, particularly Eric Milne, MD, and Paul Friedman, MD, for their helpful comments. Hannah Rouse, MD, assisted with the collection of illustrations. Anthony V. Proto, MD, placed arrows on the illustrations.

	FOOTNOTES

 
Authors stated no financial relationship to disclose.

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