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Open Access 01-12-2023 | Silicosis | Educational Review

Stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities on CT

Authors: Taiki Fukuda, Ryoko Egashira, Midori Ueno, Mikiko Hashisako, Hiromitsu Sumikawa, Junya Tominaga, Daisuke Yamada, Junya Fukuoka, Shigeki Misumi, Hiroya Ojiri, Hiroto Hatabu, Takeshi Johkoh

Published in: Insights into Imaging | Issue 1/2023

Abstract

High-attenuation pulmonary abnormalities are commonly seen on CT. These findings are increasingly encountered with the growing number of CT examinations and the wide availability of thin-slice images. The abnormalities include benign lesions, such as infectious granulomatous diseases and metabolic diseases, and malignant tumors, such as lung cancers and metastatic tumors. Due to the wide spectrum of diseases, the proper diagnosis of high-attenuation abnormalities can be challenging. The assessment of these abnormal findings requires scrutiny, and the treatment is imperative. Our proposed stepwise diagnostic algorithm consists of five steps. Step 1: Establish the presence or absence of metallic artifacts. Step 2: Identify associated nodular or mass-like soft tissue components. Step 3: Establish the presence of solitary or multiple lesions if identified in Step 2. Step 4: Ascertain the predominant distribution in the upper or lower lungs if not identified in Step 2. Step 5: Identify the morphological pattern, such as linear, consolidation, nodular, or micronodular if not identified in Step 4. These five steps to diagnosing high-attenuation abnormalities subdivide the lesions into nine categories. This stepwise radiologic diagnostic approach could help to narrow the differential diagnosis for various pulmonary high-attenuation abnormalities and to achieve a precise diagnosis.

Critical relevance statement Our proposed stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities may help to recognize a variety of those high-attenuation findings, to determine whether the associated diseases require further investigation, and to guide appropriate patient management.

Key points

• To provide a stepwise diagnostic approach to high-attenuation pulmonary abnormalities.

• To familiarize radiologists with the varying cause of high-attenuation pulmonary abnormalities.

• To recognize which high-attenuation abnormalities require scrutiny and prompt treatment.

Graphical Abstract

Available only for authorised users

Sugawara A, Nakashima J, Kunieda E et al (2011) Incidence of seed migration to the chest, abdomen, and pelvis after transperineal interstitial prostate brachytherapy with loose (125)I seeds. Radiat Oncol 6:130PubMedPubMedCentral

Maletzki P, Schwab C, Markart P et al (2018) Late seed migration after prostate brachytherapy with Iod-125 permanent implants. Prostate Int 6:66–70PubMed

Nakano M, Uno H, Gotoh T et al (2006) Migration of prostate brachytherapy seeds to the vertebral venous plexus. Brachytherapy 5:127–130PubMed

Merrell KW, Davis BJ, Goulet CC et al (2019) Reducing seed migration to near zero with stranded-seed implants: comparison of seed migration rates to the chest in 1000 permanent prostate brachytherapy patients undergoing implants with loose or stranded seeds. Brachytherapy 18:306–312PubMed

Voloudaki A, Ergazakis N, Gourtsoyiannis N (2003) Late changes in barium sulfate aspiration: HRCT features. Eur Radiol 13:2226–2229PubMed

Hamid M, Ullah W, Ur Rashid M, Amjad W, Mukhtar M, Hurairah A (2018) An esophagogram or tracheobronchogram? A review of barium sulfate aspiration. J Investig Med High Impact Case Rep 6:2324709618802872PubMedPubMedCentral

Yan GW, Deng JF, Bhetuwal A et al (2017) A case report and literature review of barium sulphate aspiration during upper gastrointestinal examination. Medicine (Baltimore) 96:e8821PubMed

Sehgal IS, Dhooria S, Ram B et al (2015) Foreign body inhalation in the adult population: experience of 25,998 bronchoscopies and systematic review of the literature. Respir Care 60:1438–1448PubMed

Hadad H, de Jesus LK, Poli PP, Garcia-Júnior IR, Souza F, de Oliveira FRG (2021) Aspiration of the dental crown in an elderly patient. Radiol Case Rep 16:2280–2285PubMedPubMedCentral

10.

Mahoney MC, Shipley RT, Corcoran HL, Dickson BA (1990) CT demonstration of calcification in carcinoma of the lung. AJR Am J Roentgenol 154:255–258PubMed

11.

Grewal RG, Austin JH (1994) CT demonstration of calcification in carcinoma of the lung. J Comput Assist Tomogr 18:867–871PubMed

12.

Khan AN, Al-Jahdali HH, Allen CM, Irion KL, Al Ghanem S, Koteyar SS (2010) The calcified lung nodule: what does it mean? Ann Thorac Med 5:67–79PubMedPubMedCentral

13.

Sumi T, Uehara H, Masaoka T et al (2020) Lung adenocarcinoma with tumor resolution and dystrophic calcification after salvage surgery following immune checkpoint inhibitor therapy: a case report. Thorac Cancer 11:3396–3400PubMedPubMedCentral

14.

McLendon RE, Roggli VL, Foster WL Jr, Becsey D (1985) Carcinoma of the lung with osseous stromal metaplasia. Arch Pathol Lab Med 109:1051–1053PubMed

15.

Kim GY, Kim J, Kim TS, Han J (2009) Pulmonary adenocarcinoma with heterotopic ossification. J Korean Med Sci 24:504–510PubMedPubMedCentral

16.

Jeung MY, Gasser B, Gangi A et al (2002) Bronchial carcinoid tumors of the thorax: spectrum of radiologic findings. Radiographics 22:351–365PubMed

17.

Morikawa K, Misumi S, Fukuda T, Ojiri H, Matsudaira H, Sato S (2019) Pulmonary sclerosing pneumocytoma presenting as slow-growing multiple nodules over a long period. Radiol Case Rep 14:602–607PubMedPubMedCentral

18.

Im JG, Kim WH, Han MC et al (1994) Sclerosing hemangiomas of the lung and interlobar fissures: CT findings. J Comput Assist Tomogr 18:34–38PubMed

19.

Katzenstein AL, Gmelich JT, Carrington CB (1980) Sclerosing hemangioma of the lung: a clinicopathologic study of 51 cases. Am J Surg Pathol 4:343–356PubMed

20.

Hu AM, Zhao D, Zheng H, Wang QH, Lyu Y, Li BL (2016) Preoperative diagnosis in 46 cases of pulmonary sclerosing hemangioma. Chin Med J (Engl) 129:1377–1378PubMed

21.

Chung MJ, Lee KS, Han J, Sung YM, Chong S, Kwon OJ (2006) Pulmonary sclerosing hemangioma presenting as solitary pulmonary nodule: dynamic CT findings and histopathologic comparisons. AJR Am J Roentgenol 187:430–437PubMed

22.

Webb WR, Higgins CB (2017) Pulmonary hamartoma. In: Thoracic imaging, 3rd edn. Wolters Kluwer, Philadelphia

23.

Siegelman SS, Khouri NF, Scott WW Jr et al (1986) Pulmonary hamartoma: CT findings. Radiology 160:313–317PubMed

24.

Seo JB, Im JG, Goo JM, Chung MJ, Kim MY (2001) Atypical pulmonary metastases: spectrum of radiologic findings. Radiographics 21:403–417PubMed

25.

Onishi Y, Kusumoto M, Goto Y, Kaku S, Motoi N (2020) Epithelioid hemangioendothelioma of the lung: CT findings and clinical course of 35 cases. Jpn J Clin Oncol 50:1195–1200PubMed

26.

Liu K, Xie P, Peng W, Zhou Z (2014) The computed tomographic findings of pulmonary epithelioid hemangioendothelioma. Radiol Med 119:705–713PubMed

27.

Engleman P, Liebow AA, Gmelich J, Friedman PJ (1977) Pulmonary hyalinizing granuloma. Am Rev Respir Dis 115:997–1008PubMed

28.

Chapman EM, Gown A, Mazziotta R, Churg A (2012) Pulmonary hyalinizing granuloma with associated elevation in serum and tissue IgG4 occurring in a patient with a history of sarcoidosis. Am J Surg Pathol 36:774–778PubMed

29.

Lhote R, Haroche J, Duron L et al (2017) Pulmonary hyalinizing granuloma: a multicenter study of 5 new cases and review of the 135 cases of the literature. Immunol Res 65:375–385PubMed

30.

Yousem SA, Hochholzer L (1987) Pulmonary hyalinizing granuloma. Am J Clin Pathol 87:1–6PubMed

31.

Chabi ML, Goracci A, Roche N, Paugam A, Lupo A, Revel MP (2015) Pulmonary aspergillosis. Diagn Interv Imaging 96:435–442PubMed

32.

Franquet T, Müller NL, Giménez A, Guembe P, de La Torre J, Bagué S (2001) Spectrum of pulmonary aspergillosis: histologic, clinical, and radiologic findings. Radiographics 21:825–837PubMed

33.

Agarwal R, Gupta D, Aggarwal AN, Behera D, Jindal SK (2006) Allergic bronchopulmonary aspergillosis: lessons from 126 patients attending a chest clinic in north India. Chest 130:442–448PubMed

34.

Asano K, Hebisawa A, Ishiguro T et al (2021) New clinical diagnostic criteria for allergic bronchopulmonary aspergillosis/mycosis and its validation. J Allergy Clin Immunol 147:1261-1268.e1265PubMed

35.

Kodaka N, Nakano C, Oshio T et al (2022) Effectiveness of mucus plug removal by bronchoscopy for typical high-attenuation mucus with allergic bronchopulmonary mycosis. Allergol Int 71:150–152PubMed

36.

de Almeida RR, Zanetti G, Pereira ESJL et al (2015) Respiratory tract amyloidosis. State-of-the-art review with a focus on pulmonary involvement. Lung 193:875–883PubMed

37.

Czeyda-Pommersheim F, Hwang M, Chen SS, Strollo D, Fuhrman C, Bhalla S (2015) Amyloidosis: modern cross-sectional imaging. Radiographics 35:1381–1392PubMed

38.

Pickford HA, Swensen SJ, Utz JP (1997) Thoracic cross-sectional imaging of amyloidosis. AJR Am J Roentgenol 168:351–355PubMed

39.

Lee AY, Godwin JD, Pipavath SN (2012) Case 182: pulmonary amyloidosis. Radiology 263:929–932PubMed

40.

Ohdama S, Akagawa S, Matsubara O, Yoshizawa Y (1996) Primary diffuse alveolar septal amyloidosis with multiple cysts and calcification. Eur Respir J 9:1569–1571PubMed

41.

Marchiori E, Souza CA, Barbassa TG, Escuissato DL, Gasparetto EL, Souza AS Jr (2007) Silicoproteinosis: high-resolution CT findings in 13 patients. AJR Am J Roentgenol 189:1402–1406PubMed

42.

Desai SR, Lynch DA, Elicker BM, Devaraj A, Sverzellati N (2021) Silicosis. In: High-resolution CT of the lung, 6th edn. Wolters Kluwer, Philadelphia

43.

Antao VC, Pinheiro GA, Terra-Filho M, Kavakama J, Müller NL (2005) High-resolution CT in silicosis: correlation with radiographic findings and functional impairment. J Comput Assist Tomogr 29:350–356PubMed

44.

Kaltreider HB, Baum GL, Bogaty G, McCoy MD, Tucker M (1969) So-called “metastatic” calcification of the lung. Am J Med 46:188–196PubMed

45.

Conger JD, Hammond WS, Alfrey AC, Contiguglia SR, Stanford RE, Huffer WE (1975) Pulmonary calcification in chronic dialysis patients. Clinical and pathologic studies. Ann Intern Med 83:330–336PubMed

46.

Kuzela DC, Huffer WE, Conger JD, Winter SD, Hammond WS (1977) Soft tissue calcification in chronic dialysis patients. Am J Pathol 86:403–424PubMedPubMedCentral

47.

Chan ED, Morales DV, Welsh CH, McDermott MT, Schwarz MI (2002) Calcium deposition with or without bone formation in the lung. Am J Respir Crit Care Med 165:1654–1669PubMed

48.

Hartman TE, Müller NL, Primack SL et al (1994) Metastatic pulmonary calcification in patients with hypercalcemia: findings on chest radiographs and CT scans. AJR Am J Roentgenol 162:799–802PubMed

49.

Kuhlman JE, Ren H, Hutchins GM, Fishman EK (1989) Fulminant pulmonary calcification complicating renal transplantation: CT demonstration. Radiology 173:459–460PubMed

50.

Belém LC, Zanetti G, Souza AS Jr et al (2014) Metastatic pulmonary calcification: state-of-the-art review focused on imaging findings. Respir Med 108:668–676PubMed

51.

Chung MJ, Lee KS, Franquet T, Müller NL, Han J, Kwon OJ (2005) Metabolic lung disease: imaging and histopathologic findings. Eur J Radiol 54:233–245PubMed

52.

Sumikawa H, Johkoh T, Iwasawa T, Nakanishi K, Tomiyama N (2019) Pleuroparenchymal fibroelastosis-like lesions on chest computed tomography in routine clinical practice. Jpn J Radiol 37:230–236PubMed

53.

Delic JA, Fuhrman CR, Trejo Bittar HE (2016) Pulmonary alveolar microlithiasis: AIRP best cases in radiologic-pathologic correlation. Radiographics 36:1334–1338PubMed

54.

Mariotta S, Ricci A, Papale M et al (2004) Pulmonary alveolar microlithiasis: report on 576 cases published in the literature. Sarcoidosis Vasc Diffuse Lung Dis 21:173–181PubMed

55.

Sumikawa H, Johkoh T, Tomiyama N et al (2005) Pulmonary alveolar microlithiasis: CT and pathologic findings in 10 patients. Monaldi Arch Chest Dis 63:59–64PubMed

56.

Tseung J, Duflou J (2006) Diffuse pulmonary ossification: an uncommon incidental autopsy finding. Pathology 38:45–48PubMed

57.

Egashira R, Jacob J, Kokosi MA et al (2017) Diffuse pulmonary ossification in fibrosing interstitial lung diseases: prevalence and associations. Radiology 284:255–263PubMed

58.

Mathai SK, Schwarz MI, Ellis JH Jr (2013) Extensive diffuse pulmonary ossification after acute respiratory distress syndrome. Am J Respir Crit Care Med 187:890PubMed

59.

Battal B, Kocaoğlu M, Ors F, Vurucu S (2009) Massive pulmonary ossification due to recurrent aspiration pneumonia. Diagn Interv Radiol 15:212–214PubMed

60.

Nishioka Y, Toyoda Y, Egashira R et al (2022) Nationwide retrospective observational study of idiopathic dendriform pulmonary ossification: clinical features with a progressive phenotype. BMJ Open Respir Res 9(1):e001337PubMedPubMedCentral

61.

Kato T, Ishikawa K, Kadoya M, Okamoto K, Kaji M (2012) Spontaneous pneumothorax in a patient with dendriform pulmonary ossification: report of a case. Surg Today 42:903–908PubMed

62.

Gruden JF, Green DB, Legasto AC, Jensen EA, Panse PM (2017) Dendriform pulmonary ossification in the absence of usual interstitial pneumonia: CT features and possible association with recurrent acid aspiration. AJR Am J Roentgenol 209:1209–1215PubMed

63.

Xu H, Yang R, Wang X, Zhu X, Chen H (2014) Symptomatic pulmonary lipiodol embolism after transarterial chemoembolization for hepatic malignant tumor: clinical presentation and chest imaging findings. Chin Med J (Engl) 127:675–679PubMed

64.

Chung JW, Park JH, Im JG, Han JK, Han MC (1993) Pulmonary oil embolism after transcatheter oily chemoembolization of hepatocellular carcinoma. Radiology 187:689–693PubMed

65.

Tajima T, Honda H, Kuroiwa T et al (2002) Pulmonary complications after hepatic artery chemoembolization or infusion via the inferior phrenic artery for primary liver cancer. J Vasc Interv Radiol 13:893–900PubMed

66.

Hatamaru K, Azuma S, Akamatsu T et al (2015) Pulmonary embolism after arterial chemoembolization for hepatocellular carcinoma: an autopsy case report. World J Gastroenterol 21:1344–1348PubMedPubMedCentral

67.

Narayanaswamy S, Kamath S, Williams M (2007) CT appearances of talc pleurodesis. Clin Radiol 62:233–237PubMed

68.

Suwatanapongched T, Nitiwarangkul C (2017) Thin-section CT findings of thoracolithiasis. Jpn J Radiol 35:350–357PubMed

69.

Taybi H, Capitanio MA (1990) Tracheobronchial calcification: an observation in three children after mitral valve replacement and warfarin sodium therapy. Radiology 176:728–730PubMed

70.

Golding LP, Walsh MJ, Sumner TE, Nakagawa TA (2013) Tracheobronchial calcifications in children. Pediatr Radiol 43:937–940PubMed

71.

Eckersley L, Stirling J, Occleshaw C, Wilson N (2014) Two cases of warfarin-induced tracheobronchial calcification after Fontan surgery. Pediatr Cardiol 35:954–958PubMed

72.

Joshi A, Berdon WE, Ruzal-Shapiro C, Barst RJ (2000) CT detection of tracheobronchial calcification in an 18-year-old on maintenance warfarin sodium therapy: cause and effect? AJR Am J Roentgenol 175:921–922PubMed

73.

Webb EM, Elicker BM, Webb WR (2000) Using CT to diagnose nonneoplastic tracheal abnormalities: appearance of the tracheal wall. AJR Am J Roentgenol 174:1315–1321PubMed

74.

Mizukami Y, Takahashi Y, Adachi H (2019) Pulmonary staple-stump granuloma after segmentectomy: two case reports and comparison with cases of stump recurrence. Am J Case Rep 20:1049–1056PubMedPubMedCentral

75.

Siniakowicz RM, Narula D, Suster B, Steinberg JS (2001) Diagnosis of amiodarone pulmonary toxicity with high-resolution computerized tomographic scan. J Cardiovasc Electrophysiol 12:431–436PubMed

76.

Kuhlman JE, Teigen C, Ren H, Hruban RH, Hutchins GM, Fishman EK (1990) Amiodarone pulmonary toxicity: CT findings in symptomatic patients. Radiology 177:121–125PubMed

77.

Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J (2008) Fleischner Society: glossary of terms for thoracic imaging. Radiology 246:697–722PubMed

78.

Kim HY, Song KS, Goo JM, Lee JS, Lee KS, Lim TH (2001) Thoracic sequelae and complications of tuberculosis. Radiographics 21:839–858, discussion 859-860PubMed

79.

Kim JS, Ryu CW, Lee SI, Sung DW, Park CK (1999) High-resolution CT findings of varicella-zoster pneumonia. AJR Am J Roentgenol 172:113–116PubMed

80.

Alshabani K, Ghosh S, Arrossi AV, Mehta AC (2019) Broncholithiasis: a review. Chest 156:445–455PubMed

81.

Asakawa K, Shimada M, Hebisawa A, Tamura A, Miyamoto M (2012) Broncholithiasis. Japanese J Chest Dis 71 supplement:S291–S295. (in Japanese)

82.

Seo JB, Song K-S, Lee JS et al (2002) Broncholithiasis: review of the causes with radiologic-pathologic correlation. Radiographics 22:S199–S213PubMed

83.

Kim TS, Han J, Koh WJ et al (2005) Endobronchial actinomycosis associated with broncholithiasis: CT findings for nine patients. AJR Am J Roentgenol 185:347–353PubMed

84.

Lewis BT, Herr KD, Hamlin SA et al (2021) Imaging manifestations of chest trauma. Radiographics 41:1321–1334PubMed

85.

Kawabata Y, Watanabe A, Yamaguchi S et al (2010) Pleuropulmonary pathology of vascular Ehlers-Danlos syndrome: spontaneous laceration, haematoma and fibrous nodules. Histopathology 56:944–950PubMed

86.

Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE (2004) Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol 183:1097–1102PubMed

87.

Duran C, Sirvanci M, Aydoğan M, Ozturk E, Ozturk C, Akman C (2007) Pulmonary cement embolism: a complication of percutaneous vertebroplasty. Acta Radiol 48:854–859PubMed

88.

Zhou Y, Wang XH, Meng SS et al (2020) Primary pulmonary plasmacytoma accompanied by overlap syndrome: a case report and review of the literature. World J Clin Cases 8:4999–5006PubMedPubMedCentral

89.

Ishida H, Fujino T, Taguchi R et al (2019) Primary pulmonary synovial sarcoma with calcification: a case report. Thorac Cancer 10:2040–2044PubMedPubMedCentral

90.

Marchiori E, Souza AS Jr, Franquet T, Müller NL (2005) Diffuse high-attenuation pulmonary abnormalities: a pattern-oriented diagnostic approach on high-resolution CT. AJR Am J Roentgenol 184:273–282PubMed

Title: Stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities on CT
Authors: Taiki Fukuda
Ryoko Egashira
Midori Ueno
Mikiko Hashisako
Hiromitsu Sumikawa
Junya Tominaga
Daisuke Yamada
Junya Fukuoka
Shigeki Misumi
Hiroya Ojiri
Hiroto Hatabu
Takeshi Johkoh
Publication date: 01-12-2023
Publisher: Springer Vienna
Keyword: Silicosis
Published in: Insights into Imaging / Issue 1/2023
Electronic ISSN: 1869-4101
DOI: https://doi.org/10.1186/s13244-023-01501-x

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Stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities on CT

Abstract

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Abstract

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