Question: what is the diagnosis?

RADIOLOGICAL DIAGNOSIS

Question: what is the diagnosis?

Jorge Kavakama^I; Jaime Ribeiro Barbosa^II; Nestor Müller^III

^IRadiologist, Image Diagnosis, Instituto do Coração-InCor, HCFMUSP, São Paulo, SP

^IIInstituto de Radiologia de Presidente Prudente

^IIIProfessor and Head, Department of Radiology Vancouver General Hospital, Vancouver, BC, Canadá

The aim of this section is to stimulate a practical approach to the diagnosis based on the clinical information and the radiologic findings. We invite all our readers to participate.

You may send your opinion by filling out a form that can be found at the site www.jornaldepneumologia.com.br, or by e-mail ([e-mail]). Do not forget to identify yourself; we will publish the names of the individuals who make the correct diagnosis. The images shown above are the key ones for the diagnosis. Further details can be found at jornaldepneumologia.com.br. THE DIAGNOSIS OF THIS CASE WILL BE PUBLISHED IN THE NEXT ISSUE OF THE JOURNAL.

Diagnosis of previous case

J Pneumol 2003;29(4):246

Bronchioloalveolar carcinoma

Chest Radiograph

The radiograph showed right upper lobe consolidation with an air bronchogram. Poorly defined opacities were present in the right middle and lower lung zones.

High Resolution CT

HRCT demonstrated areas of consolidation with air bronchograms and ground glass opacities with associated septal thickening in the right lung. Poorly defined nodular opacities (airspace nodules) with areas of confluence were present in the left lung.

Comments

Bronchioloalveolar carcinoma (BAC) is a subtype of adenocarcinoma.

It is characterized histologically by lepidic growth along the alveolar septa withou destruction and presence of mucin or tumor cells within the adjacent airspaces.

The most common radiologic presentation of BAC is as a solitary nodule, a pattern seen in approximately 60% of cases. The nodules typically have spiculated margins and often contain bubble-like areas of low attenuation ("bubble lucencies") or air bronchograms. The bubble lucencies reflect the presence of small patent bronchioles or bronchi within the nodule or, occasionally, small cystic structures lined by papillary tumor projections.

The second most common radiographic presentation of BAC is an area of ground-glass opacification or airspace consolidation. Air bronchograms are commonly present. Production of copious amounts of mucin may result in confluent areas of consolidation. Mucin has a lower CT density than tumor. Therefore, BAC's containing large amounts of mucin have relatively low attenuation on CT. Following intravenous administration of contrast the pulmonary vessels can be clearly seen within the low attenuation areas (CT-angiogram sign). It should be noted, however, that this sign is not specific, as it can be observed in various other conditions, including lobar pneumonia, lymphoma, lipoid pneumonia, infarction, and edema.

A third and relatively uncommon radiologic pattern of BAC is as multiple nodules. On CT, these may have well- or poorly-defined margins.

Given the HRCT findings, the differential diagnosis in this case includes mainly alveolar proteinosis, Pneumocystis carinii pneumonia, and primary pulmonary lymphoma.

References:

Fraser RS, Müller NL, Colman N, Paré PD. Diagnosis of diseases of the chest. Fourth edition. WB Saunders Company. Philadelphia, 1999.

Naidich DP, Muller NL, Zerhouni EA, Webb WR, Krinsky GA, Siegelman SS. Compute Tomography and Magnetic Resonance of the Thorax. Third Edition. Lippincott-Raven. Philadelphia, 1999.

Webb RW, Müller NL, Naidich DP. High resolution CT of the lung. Third edition, Philadelphia, Pennsylvania: Lippincott Williams & Wilkins, 2001.

Muller NL, Fraser RS, Lee KS, Johkoh T. Diseases of the lung. Radiologic and pathologic correlations. Lippincott Williams & Wilkins, Philadelphia, 2003.

Tan RT, Kuzo RS. HRCT findings of mucinous bronchioloalveolar carcinoma: a case of pseudopulmonary alveolar proteinosis. AJR 1997;168: 99-100.

Acertadores do caso de julho/agosto de 2003: 34 (50%)

1. Ana Paula Sampaio de Mattos – Hospital São Rafael, Salvador, BA

2. Carlos A.C. Pereira – Unifesp/HSPE-SP, São Paulo, SP

3. Daniela G.N. Miranda – Unifesp, São Paulo, SP

4. Décio Renck – Santa Casa, Pelotas, RS

5. Fabio Haggstram – Hospital São Lucas PUCRS, Porto Alegre, RS

6. Fabricio Piccoli Fortuna – Universidade de Caxias do Sul, Caxias do Sul, RS

7.José Antônio Baddini Martinez – Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP

8. Kátia de Vasconcellos Mathias – Universidade Federal Fluminense, Niterói, RJ

9. Kennedy Kirk – Universidade Estaual do Rio de Janeiro, Rio de Janeiro, RJ

10. Laura de Moraes Gomes – Hospital Copa D'Or, Rio de Janeiro, RJ

11. Leandro Almeida Streher – Hospital de Caridade Astrogildo de Azevedo, Santa Maria, RS

12. Lílian Pinto de Azevedo Oliveira – Fund. Hosp. de Resende, Resende, RJ

13. Lúcia Helena Messias Sales – Universidade Federal do Pará, Belém, PA

14. Luciane Gottardo Nunes – Unicamp, Campinas, SP

15. Luiz Carlos Corrêa da Silva – Pavilhão Pereira Filho, Porto Alegre, RS

16. Marcelo Alcântara – Universidade Federal do Ceará, Fortaleza, CE

17. Marcelo Bicalho de Fuccio – Pneumologista, Unifesp/EPM, São Paulo, SP

18. Marcelo Chalhoub – Escola de Medicina e Saúde Pública, Salvador, BA

19. Marcelo Coelho Machado – Centro Médico Itamaraty, Vitória da Conquista, BA

20. Marcelo Cosentino – Hospital da Policia Militar de Niterói, Niterói, RJ

21. Marco Aurelio Meirelles Pires – Hospital de Aeronáutica de Canoas, Canoas, RS

22. Maria Francisca Siqueira Briglia – Universidade Federal do Amazonas, Manaus, AM

23. Marlon B.M. Molina – HAGF, Ponte Nova, MG

24. Mauro Zamboni – Instituto Nacional de Câncer, Rio de Janeiro, RJ

25. Miguel Aidé – Universidade Federal Fluminense, Rio de Janeiro, RJ

26. Nagib Curi – Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP

27. Olanrewaju Muisi Adedamola Ladipo – Hospital Heliopolis, São Paulo, SP

28. Oreste Pedro Maia Andrade – Hospital Uniclínicas de Chapecó, Chapecó, SC

29. Ricardo Domingos Delduque – Hospital do Servidor Público Municipal, São Paulo, SP

30. Rodrigo Tamer Sertorio – Hospital Regina, Novo Hamburgo

31. Roseane Cardoso Marchiori – Hospital Univ. Santa Maria, Santa Maria, RS

32. Rui Haddad – Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ

33. Simone Castelo Branco Fortaleza – Hospital de Messejana, Fortaleza, CE

34. Tatiana Santos Malheiros Nunes – Hospital São Marcos, Teresina, PI

Publication Dates

• Publication in this collection
  17 June 2004
• Date of issue
  Oct 2003