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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of serial
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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
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be
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ra-
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BA. Idiopathic
as nodu-
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resulting
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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-
CT
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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
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bronchogram
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basis
helpful
Other
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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
correlation.
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I
295