Bronchovascular Nodules- medium sized vessels
Bronchovascular –
Secondary lobule
arteriole
venule
bronchiole
Cavitating
Lymphovascular Nodules
Along Bronchovascular Bundle
Along Fissures
Secondary Lobule
interlobular septa
centrilobular
Fissural Based Nodules
Miliary Nodules
Pleural Based Nodules
Solid Nodules
Single
solid
calcified
ground glass
semisolid
Cluster
Bronchovascular – at the bronchial level
LYMPHATIC DRAINAGE “S” of SARCOIDOSIS In this diagram the arrows show the direction of flow of the lymphatics. Pleural lymphatics (yellow arrows), Fissural lymphatics, green arrows), flow from the interlobular septa (purple arrows) and along the bronchovascular bundles (blue arrows) all flow toward the lymph nodes in the hila and mediastinum (pink arrows). Sarcoidosis is a nodular granulomatous disease which predominated in the upper lobes and has its epicenter in the lymphoid tissue of the lungs. The ?S? drawn on the thoracic cage outlines the lymphatic distribution of the lungs, starting in the pleura involving the lymphatic system in the pleura, interlobular septa, bronchovascular bundles and lymph nodes. The granulomas start out as micronodules and there is a tendency for these to coalesce, sometimes forming large granulomatous masses When the disease affects the interlobular septa, it causes thickening and nodularity in the septa of the secondary lobule. When it involves the lymphatics in the pleura or fissures it causes nodularity and thickening. When it involves the lymphatics around the terminal bronchioles it results in centrilobular micronodules, and when it involves the larger airways it causes thickening and nodularity Lymph nodes in the hila are characteristically large and flesh like (sarcoid = meat) The Pawnbrokers sign (aka Garland sign or the 1,2,3 sign) describes the enlarged right paratracheal node with bilateral hilar adenopathy. Parenchymal nodules and micronodules sometimes coalesce to form a central confluent mass with surrounding micronodules, described as the galaxy sign. Ashley Davidoff MD
MORPHOLOGY OF THE STRUCTURAL CHANGES “S” of SARCOIDOSIS The granulomas start as micronodules in close association with the lymphatics (1) spread in the intralobular septa and centrilobular bronchioles ((2) cluster and conglomerate to form macro nodules (4,5) sometimes manifesting as the galaxy sign (6). As they cluster and conglomerate they can cause conglomerate masses along the pathway (7) most commonly centrally as the lymphatics become confluent in the hila (7) The lymphovascular bundles may be accompanied by nodularity (8) or just by thickening (9). The lymph nodes in the mediastinum become significantly enlarged and fleshy (10). They often calcify (12) sometimes on the calcify on the rim of the node (eggshell calcification (11) Sarcoidosis is a nodular granulomatous disease which predominated in the upper lobes and has its epicenter in the lymphoid tissue of the lungs. The ?S? drawn on the thoracic cage outlines the lymphatic distribution of the lungs, starting in the pleura involving the lymphatic system in the pleura, interlobular septa, bronchovascular bundles and lymph nodes. The granulomas start out as micronodules and there is a tendency for these to coalesce, sometimes forming large granulomatous masses When the disease affects the interlobular septa, it causes thickening and nodularity in the septa of the secondary lobule. When it involves the lymphatics in the pleura or fissures it causes nodularity and thickening. When it involves the lymphatics around the terminal bronchioles it results in centrilobular micronodules, and when it involves the larger airways it causes thickening and nodularity Lymph nodes in the hila are characteristically large and flesh like (sarcoid = meat) The Pawnbrokers sign (aka Garland sign or the 1,2,3 sign) describes the enlarged right paratracheal node with bilateral hilar adenopathy. Parenchymal nodules and micronodules sometimes coalesce to form a central confluent mass with surrounding micronodules, described as the galaxy sign. Ashley Davidoff MD
Pleural Based
CT WITH SUBPLEURAL AND LYMPHOVASCULAR NODULES IN THE LEFT UPPER LOBE Ashley Davidoff MD
CT WITH SUBPLEURAL CHANGES IN THE LUL AND LYMPHOVASCULAR NODULES IN THE RIGHT UPPER LOBE INVOLVING THE SECONDARY LOBULE IN THE FORM OF INTERLOBULAR SEPTA AND CENTRILOBULAR MICRONODULES Ashley Davidoff MD
CT WITH BILATERAL SUBPLEURAL AND LYMPHOVASCULAR NODULES
Ashley Davidoff MD
PLEURAL BASED NODULE (red arrow) and FISSURAL NODULES (green arrow) – SARCOIDOSIS – CHARACTERISTIC NODULES Ashley Davidoff MD
Fissural Based
FISSURAL BASED NODULES Ashley Davidoff MD
SARCOID HEART BLOCK, LUNG DISEASE 70-year-old female with micronodules along the fissures Ashley Davidoff MD TheCommonVein.net
Centrilobular Nodules and Interlobular Septa
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CT WITH SUBPLEURAL AND LYMPHOVASCULAR NODULES IN THE RIGHT UPPER LOBE – INTERLOBULAR SEPTA AND CENTRILOBULAR
Ashley Davidoff MD
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CT OF THE SECONDARY LOBULE WITH LYMPHOVASCULAR NODULES IN INTERLOBULAR SEPTA (blue arrows) AND CENTRILOBULAR REGION (red arrows)
Ashley Davidoff MD
MICRONODULES ALONG THE LYMPHOVASCULAR (blue arrows) AND BRONCHOVASCULAR BUNDLES (red arrow) OF THE SECONDARY LOBULE Ashley Davidoff MD
CT WITH LYMPHOVASCULAR NODULES IN THE LEFT UPPER LOBE – INTERLOBULAR SEPTA SARCOIDOSIS, ACTIVE – ALVEOLAR FORM Ashley Davidoff MD
Bronchovascular – at the medium sized bronchial level
THICKENING OF THE BRONCHOVASCULAR BUNDLES Ashley Davidoff MD
THICKENING OF THE BRONCHOVASCULAR BUNDLES Ashley Davidoff MD
STELLATE OR FLAME SHAPED NODULE, (blue arrow), GROUND GLASS NODULES,(yellow arrows) and BRONCHOVASCULAR MICRONODULES (red arrows)
Ashley Davidoff MD
Micronodules
SARCOIDOSIS with CENTRILOBULAR MICRONODULES, BRONCHOVASCULAR INVOLVEMENT EGG SHELL CALCIFICATION OF THE LYMPH NODES 51-year-old male with Stage 2II Sarcoidosis and egg shell calcification of lymph nodes Ashley Davidoff MD
Larger Nodules
Ground Glass
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40 year old female with a history of sarcoidosis
CT scan shows a 6mm nodule with central calcification in the ligula and ground glass nodules in the middle lobe
Ashley Davidoff
TheCommonVein.net
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SARCOIDOSIS with CENTRILOBULAR MICRONODULES, BRONCHOVASCULAR INVOLVEMENT EGG SHELL CALCIFICATION OF THE LYMPH NODES 51-year-old male with Stage II Sarcoidosis and egg shell calcification of lymph nodes Ashley Davidoff MD
SARCOIDOSIS – CHARACTERISTIC NODULES 51-year-old male with history of sarcoidosis The axial images show a variety of characteristic changes including; Ground glass opacity Stellate or flame shaped nodules Semisolid nodules Ashley Davidoff MD TheCommonVein.net
Conglomerate – Galaxy Sign
CT WITH GALAXY SIGN SARCOIDOSIS, ACTIVE – ALVEOLAR FORM 48-year-old previously well presented with dyspnea and initial CXR showed an infiltrate at the right base, and clinically resolved. He presented a year later with right chest pain and low grade ever and the CXR showed patchy opacities in the LUL and in the RLL A subsequent CT showed LUL nodular opacities and subpleural rim of consolidation in the LUL and more prominently at both lung bases, associated with significant mediastinal adenopathy. Lymphovacscular nodularity was noted in the bronchovascular bundles as well as in the interlobular septa, consistent with sarcoidosis CXR and CT 4 years later showed almost complete resolution of the parenchymal findings and the CT findings except for minimal reticulation and scarring in the subpleural regions Ashley Davidoff MD
CT WITH LYMPHOVASCULAR NODULES SARCOIDOSIS, ACTIVE – ALVEOLAR FORM 48-year-old previously well presented with dyspnea and initial CXR showed an infiltrate at the right base, and clinically resolved. He presented a year later with right chest pain and low grade ever and the CXR showed patchy opacities in the LUL and in the RLL A subsequent CT showed LUL nodular opacities and subpleural rim of consolidation in the LUL and more prominently at both lung bases, associated with significant mediastinal adenopathy. Lymphovacscular nodularity was noted in the bronchovascular bundles as well as in the interlobular septa, consistent with sarcoidosis CXR and CT 4 years later showed almost complete resolution of the parenchymal findings and the CT findings except for minimal reticulation and scarring in the subpleural regions Ashley Davidoff MD
GALAXY SIGN CT WITH SUBPLEURAL NODULES AND MULTIPLE VARIABLY SIZED LEFT APICAL SOLID NODULES Ashley Davidoff MD The CommonVein.net
AIRWAY COMPRESSION (arrow) SARCOIDOSIS, STAGE IV, PTX, ENCASEMENT 50-year-old male presents with history of Stage 4 sarcoidosis acute chest pain and dyspnea The initial CXR shows a left sided pneumothorax, diffuse nodular pattern with confluent perihilar infiltrates and a left pleural effusion A chest tube was placed and a chest CT showed confluent fibrotic masses in the hilar regions totally surrounding the bronchovascular bundles with encasement of the middle lobe artery. In addition, multiple lymphovascular micronodules are demonstrated. The pulmonary artery measures 32.7mm indicating pulmonary hypertension. A CXR during this admission shows re-expansion of the pneumothorax. Left lung volume is reduced. The patient presents 2 years later, again with progressive dyspnea and chest pain and CT PA shows encasement of the airways, right middle lobe pulmonary artery and left lower pulmonary vein by the fibrotic broncho vascular masses, and non-occlusive, subacute pulmonary embolus of the LPA. There are moderate bilateral pleural effusions, calcified lymph nodes, with ongoing pulmonary hypertension with right ventricular enlargement, right atrial enlargement, tricuspid regurgitation and pulmonary hypertension. At this time the patient is intubated. He again presents 1 month after with chest pain and dyspnea. At this time, he has a tracheostomy. The scout frontal view shows persistent encasement of the left upper lobe bronchus and significant reduction on the volume of the left lung with elevated left hemidiaphragm. CT PA has similar findings with a large right pleural effusion and unresolved large non occlusive thrombus in the left pulmonary artery. Ashley Davidoff MD
SARCOIDOSIS, STAGE IV, PTX, ENCASEMENT of RML ARTERY (red arrow) TRICUSPID REGURGITATION 50-year-old male presents with history of Stage 4 sarcoidosis acute chest pain and dyspnea The initial CXR shows a left sided pneumothorax, diffuse nodular pattern with confluent perihilar infiltrates and a left pleural effusion A chest tube was placed and a chest CT showed confluent fibrotic masses in the hilar regions totally surrounding the bronchovascular bundles with encasement of the middle lobe artery. In addition, multiple lymphovascular micronodules are demonstrated. The pulmonary artery measures 32.7mm indicating pulmonary hypertension. A CXR during this admission shows re-expansion of the pneumothorax. Left lung volume is reduced. The patient presents 2 years later, again with progressive dyspnea and chest pain and CT PA shows encasement of the airways, right middle lobe pulmonary artery and left lower pulmonary vein by the fibrotic broncho vascular masses, and non-occlusive, subacute pulmonary embolus of the LPA. There are moderate bilateral pleural effusions, calcified lymph nodes, with ongoing pulmonary hypertension with right ventricular enlargement, right atrial enlargement, tricuspid regurgitation and pulmonary hypertension. At this time the patient is intubated. He again presents 1 month after with chest pain and dyspnea. At this time, he has a tracheostomy. The scout frontal view shows persistent encasement of the left upper lobe bronchus and significant reduction on the volume of the left lung with elevated left hemidiaphragm. CT PA has similar findings with a large right pleural effusion and unresolved large non occlusive thrombus in the left pulmonary artery. Ashley Davidoff MD
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SARCOIDOSIS, STAGE IV, PTX, ENCASEMENT of LEFT LOWER LOBE PA (red arrow)
50-year-old male presents with history of Stage 4 sarcoidosis acute chest pain and dyspnea
The initial CXR shows a left sided pneumothorax, diffuse nodular pattern with confluent perihilar infiltrates and a left pleural effusion
A chest tube was placed and a chest CT showed confluent fibrotic masses in the hilar regions totally surrounding the bronchovascular bundles with encasement of the middle lobe artery. In addition, multiple lymphovascular micronodules are demonstrated. The pulmonary artery measures 32.7mm indicating pulmonary hypertension.
A CXR during this admission shows re-expansion of the pneumothorax. Left lung volume is reduced.
The patient presents 2 years later, again with progressive dyspnea and chest pain and CT PA shows encasement of the airways, right middle lobe pulmonary artery and left lower pulmonary vein by the fibrotic broncho vascular masses, and non-occlusive, subacute pulmonary embolus of the LPA. There are moderate bilateral pleural effusions, calcified lymph nodes, with ongoing pulmonary hypertension with right ventricular enlargement, right atrial enlargement, tricuspid regurgitation and pulmonary hypertension. At this time the patient is intubated.
He again presents 1 month after with chest pain and dyspnea. At this time, he has a tracheostomy. The scout frontal view shows persistent encasement of the left upper lobe bronchus and significant reduction on the volume of the left lung with elevated left hemidiaphragm.
CT PA has similar findings with a large right pleural effusion and unresolved large non occlusive thrombus in the left pulmonary artery.
Ashley Davidoff MD
UPPER LOBE LUNG NODULES (red arrows) AND BRONCHIOLECTASIS (green arrow)-MEDIASTINAL ADENOPATHY (yellow asterisk) (Ref TCV Sarcoidosis and Takotsubo Heart ) Ashley Davidoff MD
Cluster of Solid Nodules
CT WITH SUBPLEURAL NODULES AND MULTIPLE VARIABLY SIZED LEFT APICAL SOLID NODULES Ashley Davidoff MD
Stellate or Flame Shaped
STELLATE OR FLAME SHAPED NODULE Ashley Davidoff MD
STELLATE OR FLAME SHAPED NODULE Ashley Davidoff MD
Calcified
CALCIFIED NODULES NOTE MEDIAL NODULE IS SURROUNDED BY SOFT TISSUE OF THE GRANULOMA (green arrow) Ashley Davidoff MD
Semi Solid
SEMI SOLID NODULE (red arrow) and FISSURAL NODULE (green arrow) Ashley Davidoff MD
Ground Glass
GROUND GLASS OPACITY Ashley Davidoff MD
Galaxy
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org ,
CT WITH GALAXY SIGN Ashley Davidoff MD
GALAXY SIGN Ashley Davidoff MD
GALAXY SIGN CT WITH SUBPLEURAL NODULES AND MULTIPLE VARIABLY SIZED LEFT APICAL SOLID NODULES Ashley Davidoff MD
Calcified
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40 year old female with a history of sarcoidosis
CT scan shows a 6mm nodule with central calcification in the ligula and ground glass nodules in the middle lobe
Ashley Davidoff
TheCommonVein.net
70060c
40 year old female with a history of sarcoidosis CT scan shows a 6mm nodule with central calcification Ashley Davidoff TheCommonVein.net 70060b
Miliary
SARCOIDOSIS vs SILICOSIS Ashley Davidoff MD