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Bronchiolitis. Obliterans. Organizing. Pneumonia. Manifesting as Multiple. Large. Nodules or Masses. Masanori Akira 1. Satoru Yamamoto2. Mitsunori Sakatani3.
Bronchiolitis Obliterans Organizing Pneumonia Manifesting as Multiple Large Nodules or Masses OBJECTIVE.

Masanori Akira 1 Satoru Yamamoto2 Mitsunori Sakatani3

The purpose ofthis obliterans organizing

in bronchiolitis

ules or masses. MATERIALS of

AND

I 2 patients

METHODS.

We reviewed

the CT features and clinical features that manifest as multiple large nod-

thin-section

CT scans

and clinical

proven BOOP manifesting as multiple large masses. For all patients follow-up CT scans were available, which we also reviewed. RESULTS. Of 60 lesions found in the 12 patients, 53 (88%) had an irregular (45%)

had

an air

lary findings pleural low-up

with

study was to describe pneumonia (BOOP)

bronchogram,

included

thickening CT scans

into lesions

histologically

with

focal

in four showed pleural

CT.

thickening

BOOP

ryptogenic bronchiolitis (BOOP)

pneumonia condition

should

pathologically

by

presence of polypoid lumen of bronchioles

granulation and alveolar

ciated with a variable air-space infiltration

degree of interstitial with mononuclear

tients

of

with

patchy

BOOP

are

reported:

pulmonary

pneumonia

type.

and cells in pa-

multiple

sites

of

the

pulmonary

in-

large

boli.

We

scans

of BOOP and

Materials

and

the

1996.

1 Department

ripheral

of either

2Department

of Pathology, National Kinki Chuo Hospital for

Chest Disease, Sakai City, Osaka 591, Japan. 3Department of Medicine, National Kinki Chuo Hospital for Chest Disease, Sakai City, Osaka 591, Japan. AJR 1998;170:291-295

0361-803X/98/1702-291 © American

Roentgen

AJR:170, February

Ray Society

1998

small chial

and

may

reticular

type

[3-5].

be seen

that

are

well-defined

or peribronchiolar

7]. Multiple

large

and

have

a peribron-

distribution (>1 cm)

Multitypically

on CT [6,

nodules

or masses

are an uncommon manifestation of BOOP and are only rarely reported [8]. BOOP with multiple large nodules must be differentiated from

other

static

lung

conditions-for tumor,

lymphoma,

example, and

septic

metaem-

large whether

could be seen, features.

and

of 59 consecutive BOOP

between

Twelve

of

the

pattern

paJuly

the

59

of

pa-

multiple

large (>1 cm in diameter) nodules were selected for the study. The study population included 10 men and two women ranging in age from 22 to 80 years pneumonia

subpleural

determine

scans

demonstrated

± SD,

nodules

CT

as multiple

to

CT

September

who

organizing

pie

high-resolution

biopsy-proven

old (mean

Kinki Chuo Hospital for

parensepta.

and Methods

with

1988

the

CT features the clinical

We reviewed

tients

are seen air bron-

with the pleura. of interlobular

masses

characteristic we investigated

lesions contain

manifesting

volvement manifesting as focal consolidation or a solitary nodule or mass, and a diffuse pe-

of Radiology, National

27

Ancil-

of the I 2 patients,

nodular

reviewed

Received May 16,1997;accepted afterrevision July29, 1997. Chest Disease, 1180 Nagasone-cho, Sakai City, Osaka 591, Japan. Address correspondence to M. Akira.

margin,

spicules.

(25%) patients. Folattenuation evolved

the lesions

pleural tags in contact with focal thickening

tients

involvement localized

the

or

or both.

nodules

tissue in the ducts asso-

and foamy macrophages [1, 2]. Three major radiographic patterns

in five (42%)

when

is a

had

bands in three ground-glass multiple

organizing America,

21 (35%)

septa

be considered

idiopathic

obliterans

and

when

relatively broad or are associated

as

in North

characterized

bands

pneumonia.

known

tag,

and parenchymal with surrounding

be considered

BOOP

organizing is

a pleural

of the interlobular

should

In particular,

which

had

(33%) patients, that the lesions

chograms; have irregular margins, chymal bands, or subpleural lines;

C

(38%)

tags or parenchymal

CONCLUSION. on chest

23

records

nodules

lung

open

biopsy was

nective into cytes,

(Pt

was =

samples.

the diagnosis tients

57 ± 12 years).

The

the presence

within

respiratory plasma

histologic

(it

of buds

I 1)

=

criterion

pneumonia

alveoli,

bronchioles. cells.

12 patients, on the basis

I ) or transbronchial

of organizing

tissue

In all

diagnosed

for

in our

of immature

pacon-

with some extension In addition,

macrophages,

and

lymphofibroblasts

were often found within buds of granulation tissue. An acute infective cause of pneumonia was excluded in all cases. Chest radiographs and CT scans of the chest

were

available

for all patients.

In none

291

man with biopsy-proven bronchiolitis obliterans organizing pneumonia.

Fig. 1.-SO-year-old

A, Chest radiograph shows multiple bilateral ill-defined pulmonary nodules and masses. B, High-resolution CT (HRCT) scan shows masses (arrows) in broad contact with pleural surface and major fissure. C, HRCT scan shows focal thickening of interlobular septa (arrows) near nodular lesion (arrowhead).

of the cases

was there a history

exposure,

such

as a cause

of disease.

connective

as to fumes,

of environmental

that could

No patients

be implicated

had evidence

Clinical

data,

ated.

including

findings

during

acute and chronic phases of the illness, tamed from hospital charts. Scanning formed

Medical

of a

tissue disorder.

with

a Quantex

Systems,

Plus

Hino,

the surrounding structures. Follow-up CT was performed in all cases (2 weeks to 18 months after initial CT), and the change in CT findings was also evalu-

scanner

Tokyo.

Japan).

No IV contrast

were obwas per(Yokogawa

CT scans

third

(n

angle

at full inspiration

with

the patient

in

the supine position. All images were reconstructed using a high-resolution algorithm. CT images were analyzed by two observers who were unaware

tamed

consensus

shape,

contour,

pearance

of the BOOP with

special

diagnosis and who attention

to the

atsize.

and location of the lesions; the apof the inside of the nodule; and changes in

=

also experienced I). dyspnea

Duration

(n

=

of symptoms

cough 1), and varied

(n

=

from

cated

3), fever

(n

malaise

I week

=

I).

to2

months, with an average duration of 3 weeks. The numbers of nodules or masses ranged from two to eight per case (mean, five). The size of the lesions ranged from diameter. A total of 60 nodules 12 patients.

The

lesions

were

0.8 to 5 cm in were found in distributed

of the

uni-

and with

bundle,

contact fissure

(ii

=5)

sions (65%),

served ular

on axial

peripheral

19 (32%) the pleural (Figs.

images.

were

lo-

of the lesions were in surface (ii = 14) or the

I B. 2B, and 3B). In 39 leinterface

between

surrounding lung parenA halo of ground-glass

surrounding seen

in

the outer

bronchovascular

a well-defined

was

located

(i.e.,

of the 60 lesions

in 11 lesions margin

were

parenchyma

the lesion and the chyma was observed. attenuation

noted.

parenchyma)

the

in nine

lobe predomi-

57 (95%)

(35%)

along

bilaterally

lower

was

lung lung

and

versus

in distribution

Twenty-one

Patients

patients

Of the 60 lesions,

Pleuritic chest pain (present in six patients) was the most common presenting symptom.

lung

phrenic

nance

Results

in thickness were taken at 10-mm the costo-

No upper

the peripheral

intervals from the

to below

in three

was administered.

the

of sections 2.0 mm

apices

material

laterally

patients.

the

(18%)

mass

(Fig.

in 53 lesions

2B).

was

ob-

An irreg(88%),

and

Fig. 2.-76-year-old man with biopsy-proven bronchiolitis obliterans organizing pneumonia. A, Chest radiograph shows multiple bilateral ill-defined nodules and right pleural thickening. B, High-resolution CT(HRCT) scan shows mass in broad contact with pleural surface and major fissure. Note halo of groundglass attenuation surrounding mass

and air bronchogram

in

mass (arrow). C, HRCT scan targeted to left lung at level of basal segmental bronchi shows mass with long,broad pleuraltag (arrows). 0, HRCT scan at level of right middle-lobe bronchus reveals parenchymal bands (arrow). Note nodule with irregular margin in anterior lung (arrowhead).

E,Follow-up HRCT scan obtained 10 months after A-D shows parenchymal bands at former site of mass in B. E

Akira

et al.

Fig. 3-52-year-old man with proven bronchiolitis obliterans organizing pneumonia.

A, Chest radiograph shows multiple ill-defined pulmonary nodules and thickening of minor fissure. B, High-resolution CT (HRCT) scan shows mass in broad contact with major fissure(arrow).

C, HRCT scan shows nodule with irregular

margin.

Coarse

spicules

and

pleural tag are present Thickening of major fissureisalso seen (arrow). D, Three months later, mass with surrounding ground-glass attenuation changed into nodule with broad

pleural tags.

coarse

spicules

were

seen

in 21

(35%)

lesions

in two

(Fig. 3C). A relativelybroad pleural tag (Fig. 2C) was seen in 23 lesions (38%).

of I 2 patients.

two

(17%)

Forty-two lesions had a relatively inhomogeneous appearance. An air bronchogram was observed in 27 lesions (45%). Small discrete

ing

in four

nodules

or masses

cinity tour

(satellite of the

lesions) main

lesion

in the immediate were

vi-

observed

in

lesions.

A tbcal thickening of the interlobular septa near the nodules or masses (Fig. IC) was observed in five (42%) patients. CT revealed 2D.

294

Irregular.

of the 12 patients. In three parenchymal bands (Fig.

subpleural

bands

were

present

Ancillary

tied on CT included

findings

a small

of 12 patients (33%).

pleural and pleural

evolved

identi-

effusion

in

thicken-

bands

patients

markedly

decreased

completely.

(i.e., were

a migratory noted during

four

patients.

In one

the surrounding

lesions

nature of consolidation) the course of the disease

segmental consolidations to the nodular lesions. with

in attenuation

Wandering

of these

four,

appeared In two cases ground-glass

new

(Fig.

2E).

septa.

pleural

their after

in addition the lesions

showed without

attenuation

2-13

a pleural

tag (Fig.

parenchymal

large

nodules

Parenchymal

ancillary findings. focal thickening

All

sub-

with

had residual

other lines,

completely in

lesions patients

at the site of previous

masses

Radiologic improvement was seen on follow-up CT scans in all patients. Some nodules or disappeared

into

3D). Three

effusion,

bands

or and

including of the

subpleural interlobular

and pleural

thickening,

disappeared. patients

symptoms,

had

corticosteroid complete treatment months).

complete

10 without therapy.

resolution

therapy Ten

of

and

two

patients

clinical resolution over time (mean, 5 months; range, The

remaining

two

patients,

AJR:170, February

1998

CT

who

received

complete one and

corticosteroid

resolution 1 1 months

two showed

disappeared.

nodular

lesions

idation

3 months This

after

patient

not

but also subsegmental

on follow-up

of the lesions

lobular

only

CT scans.

multifocal

[3-5].

consolidation may

show

consolidation.

a migratory

Some

patients

radiographic

subpleural

reticular

et al. [8] reported

that

subpleural

opacities

reticular

sis.

Another

a solitary simulate section

[3, 4].

prognosis. nating, drome

in addi-

of BOOP

nodule leading

Although

cases

peripheral

of BOOP. disease and

manifestation

pulmonary carcinoma,

with showed,

tion to pathologic evidence features such as interstitial

other fibro-

is that

of

or mass that can to biopsy or reBOOP

representing

has

a good

an acute,

fulmi-

and life-threatening variant of the synhave also been reported [9. 10].

In general, the CT findings commonly consist of bilateral idation

involving

mainly

peribronchovascular

in BOOP most areas of consolthe

regions

subpleural

or

[6, 7, 1 1]. How-

ever, in I 2 patients with BOOP described by Bouchardy et al. [8], the most common finding

was

focal

the periphery in five

nodular

or masslike

ofthe

(42%)

opacities

lung that were

of the

12 patients.

in

seen on CT In our

feature

et al. [8] reported of cases

BOOP

sels or small

[14].

that a prominent

the

nodular

was the CT revelation

opacities. Wegener’s [13],

with

septic

bronchi

form

of feeding

yes-

that lead into the nodular

In our study,

and

Kaposi’s

the most

feature

BOOP

described

In our

study,

fined

review

lesions

nodules

features

were

within

AJR:170, February

1998

the presence the

lesions

of an air and

close

WAC, Turnerpneumonitis. Q

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obliterans

and radiological

by Boucha-

of serial

follow-up

findings,

of BOOP

attenuation

CT

the

may begin

with surrounding that thereafter evolve

mul-

as ill-de-

obliterans

ble that steroids

diographic.

of patients

ber

receiving

steroids

a valid

comparison.

not allow

does of our

patients

showed

subsegmental

during

BOOP

reaction

toxicity

has

lar lesions

been [16].

nodules

have

prove

BOOP

from

bleomycin

to appear

cell tumors

of our

patients

had

Although from

reaction

may

but virus

been

infectious biopsies,

viral-

be difficult may

the

special

air bronchograms; contact

large

clinical that

with

Assist

to

be a cause

the

in radiologic

nodules

or masses

conditions.

following

features

diagnosis:

pleura;

findmay

spiculated

relatively visceral

Our

broad and

pneumonia

be

with

ra-

and histologic correlation. Tomogr 1993:17:352-357

J

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be considered

of multiple

in the

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as nodu-

mostly

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resulting

RH, Askin FB. Siegelman

10. Nizami

reaction.

BOOP

gins;

to nod-

disease.

drug.

not

had

ofthe

None

diagnostically

of BOOP

in addition

treated

any

one

patient

metastases were in the differential

cases.

induced

that

reported

adults

were

Only

Bleomycin-related

been

Pulmonary jor consideration

agents

in our series

the course reported

I I 61.

receiving

relapse;

consolidation

ular lesions

but the num-

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AiR

7. Lee KS, Kullnig

Our findings suggest that the nodular form of BOOP is a self-limiting process. It is possihasten

organizing

l4 patients.

ground-glass into nodules

with the irregular margin and pleural tag and, finally, into residual parenchymal bands.

suggest

prominent

1. Davison G, Heard BE, McAllistair Warick M. Cryptogenic organizing

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of our

tinodular

ings

bronchogram

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septa.

basis

helpful

Other

subpleurai

ofthe literature. 5. Haddock JAA. Hansell DM. The radiology and terminology of cryptogenic organizing pneumonia. Br J Radio/ 1992;65:674-680

and

tag.

bands,

of interlobular

showed that some of these findings may represent residual change of mass lesions. On the

appropriate

pleural

lines, respec-

found

[8].

et al.

with

broad

were

with

sarcoma

prominent

bands

12 patients

of cases with BOOP with multiple large nodules was irregular or spiculated lesion margins a relatively

subpleural

rdy

in such

of

The same CT feature is reported in granulomatosis [12], lymphoma emboli,

Subpleural

and young

study,

focal nodular or masslike opacities were seen on CT in I 2 (20%) of 59 patients with BOOP. Bouchardy

and

and two of our patients,

[15].

[3. 4]. Bouchardy

cases

bands

in three

radiohave

the

from

with parenchymal

References

nod-

lesions.

of the

peripheral

inter-

but may be flow

Serial BOOP

or focal thickening

thickening

is unclear

nature of

opacities

seen

ation

form was the the

of focal

septa

increase

near

lively, are findings that have been reported as a feature of pulmonary

with

presentation

cause

in lymphatic

local

Parenchymal finding of BOOP as and CT is bilateral

the

The

surface

transient

seen

the

Discussion

graphs

thickening

of the interlobular exudative

The main radiographic seen on chest radiographs

Pneumonia

to the pleural

on CT of the focal septal

ules or masses.

consol-

Organizing

or a fissure. In cases of the multinodular of BOOP, another interesting feature appearance

the initial

had

Obliterans

proximity

showed

over time (7 months for for the other). One of these

relapse

lesions

therapy,

of Bronchiolitis

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I

295