Please refer to section “Cavity” in Chap. 12.

In patients with diffuse lung diseases, multiple cavities are seen in patients with Langerhans cell histiocytosis, fungal infection, and sarcoidosis. Cavitary nodules are also seen in patients with rheumatoid lung disease (Fig. 23.1), antineutrophil cytoplasmic antibody (ANCA)-associated granulomatous vasculitis (former Wegener’s granulomatosis), septic embolism, and metastatic tumors (squamous cell carcinoma of head and neck and the uterine cervix) (Fig. 23.2).

In Langerhans cell histiocytosis, the cavitating nodules are associated with noncavitating nodules and are distributed mainly in the upper and middle lung zones, sparing the lower lung zones [1]. Cavitary nodules in patients with (ANCA)-associated granulomatous vasculitis have no predilection for any lung zones [2]. Rheumatoid lung nodules, metastatic tumors, fungal infection, and septic embolism nodules tend to predominate in the lung periphery [3–5].

Cigarette smoking is highly related to pulmonary Langerhans cell histiocytosis, and the cavitating nodules in the disease are reversible with corticosteroid or cytotoxic drug therapy [6]. Immunocompromised patients and patients with underlying lung disease are at increased risk of fungal infection. Rheumatoid lung nodules are typically seen in patients with subcutaneous nodules and tend to wax and wane in proportion to the activity of the arthritis [3]. Septic embolism occurs most commonly in intravenous drug users and in immunocompromised patients with central venous lines. The site of the primary neoplasm with cavitation is most frequently in the head and neck in men and the uterine cervix in women [7]. Cavitation also may occur in metastatic adenocarcinomas, particularly in lesions originating from the large bowel, and in metastatic sarcoma, particularly osteogenic.

The rheumatoid lung nodules have a necrotic center of finely granular eosinophilic debris surrounded by a capsule of chronic inflammatory granulation tissue. The boundary between dead and viable tissue is marked by a characteristic palisade of radially oriented macrophages (Fig. 23.1). The inflammatory cells include a small number of giant cells as well as plentiful lymphocytes and plasma cells [8].

Most patients with rheumatoid lung nodules are asymptomatic. Occasionally, cavitation may lead to hemoptysis [9]. Due to their typical subpleural distribution, complications, including pneumothorax, empyema, pleural effusions, and bronchopleural fistula, may occur.

Rheumatoid nodules have a maximum diameter of 0.5–5.0 cm and are usually located in peripheral zones of the upper and middle lung regions [10] (Fig. 23.1). Pulmonary nodules may increase in size or resolve spontaneously. Cavitation of nodules is common and is rarely associated with rupturing into the pleural space, producing bronchopleural fistula, pneumothorax, pleural effusion, or empyema [11]. Calcification of rheumatoid pulmonary nodules is not a frequent finding but may be seen in some patients with Caplan syndrome.

Rheumatoid pulmonary nodule is pathologically identical to subcutaneous rheumatoid nodule. They contain three histologically distinct zones: central fibrinoid necrosis, surrounding palisading epithelioid cells, and an outer zone of lymphocytes, plasma cells, and fibroblasts [12]. The necrotic central zone becomes cavitary or cystic, likely with the resolution of necrosis and subsequent inflation resulting from airflow in the lumen. Therefore, patients exhibit rheumatoid pulmonary nodules in various stages from new nodules with central necrosis to older nodules with cavitary or cystic changes.

Rheumatoid lung nodules may remain stable, regress spontaneously, or enlarge. Depending on the clinical circumstances, serial radiographic follow-up or surgical resection may be required.

Cavitation in pulmonary metastases is thought to be uncommon. The primary sites were the large intestine, opposite lung, cervix, stomach, esophagus, pancreas, larynx, and mesenchymal tumors. It seems that the principal cause of necrosis and subsequent cavitation in metastatic tumors of the lung is interference with their blood supply by vascular involvement [13].

Significant number of patients with cavitary lung metastasis is asymptomatic. Hemoptysis can occur. Nonspecific symptoms including cough, vague chest discomfort, and dyspnea can result from a very large tumor burden. Constitutional symptoms such as weight loss, anorexia, and generalized weakness may be accompanied.

CT finding of cavitary metastasis consists of multiple nodules with or without cavitation (Fig. 23.2). The size of nodules range from a few millimeters to several centimeters in diameter, and nodules are usually of varying size. They tend to be most numerous in the outer third of lungs, particularly the subpleural regions of the lower zones, and have a random distribution within the secondary pulmonary lobules [14, 15]. Most nodules are round and have smooth margins. They may be lobulated, however, and have irregular margins. The wall of cavitary metastatic nodule is generally thick and irregular, although thin-walled cavities can be found with metastases from sarcomas and adenocarcinomas [7].

Please note section “Cavity” in Chap.​ 12 and section “Pulmonary Metastasis” in Chap.​ 19.

Prognosis of the patients with cavitary lung metastasis is poor since the primary tumor is not highly responsive to anticancer chemotherapy.

A cyst is a round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung. Cysts have variable wall thickness but are usually thin walled (<2 mm). The cysts usually contain air but occasionally contain fluid or solid material [16] (Fig. 23.3).

Many diffuse lung diseases may manifest cysts as the primary abnormality [17, 18]. Lymphangioleiomyomatosis (LAM) (Fig. 23.3) and Langerhans cell histiocytosis (LCH) are the most common to present with diffuse lung cysts. Other interstitial lung diseases that may cause multiple cysts include lymphocytic interstitial pneumonia (LIP) (Fig. 23.4), desquamative interstitial pneumonia (DIP), subacute hypersensitivity pneumonitis, and amyloidosis. Cystic pulmonary metastasis (angiosarcoma) (Figs. 23.5 and 23.6) and Birt–Hogg–Dube syndrome also cause multiple pulmonary cysts. Honeycombing cysts in various interstitial lung diseases (usual interstitial pneumonia, nonspecific interstitial pneumonia, asbestosis, chronic hypersensitivity pneumonitis, advanced fibrotic sarcoidosis) also appear as multiple pulmonary cysts (please note section “Cyst” in Chap.​ 12and section “Honeycombing with Subpleural or Basal Predominance” in Chap.​ 17).

Please note section “Cyst” in Chap.​ 12 and section “Honeycombing with Subpleural or Basal Predominance” in Chap.​ 17.

Please note section “Cyst” in Chap.​ 12

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