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249
Broncholithiasis: Patients
Dewey
J. Conces, Jr.1 Robert D. Tarver Vernon A. Vix
CT Features in 15
Broncholithiasis is a disorder characterized by peribronchial calcific nodal disease that either erodes into an adjacent bronchus or distorts the bronchi The key radiologic finding is a calcified endobronchial or penbronchial lymph node. To determine the CT findings of broncholithiasis, we retrospectively reviewed the chest radiographs and CT scans of 15 patients with proved broncholithiasis. Ten patients had endobronchial nodes as proved by bronchoscopy, surgery, or lithoptysis. Broncholiths were identified on bronchoscopy in only five cases. Five patients had penbronchial nodes with associated bronchial distortion. Collimation of the CT scans varied; 1.0-cm-, 0.6-cm-, and 0.5-cmthick sections were obtained. Three patients had both 1.0-cm- and 0.5-cm-thick sections. The calcified lymph node was identified on CT in all 15 patients. CT correctly localized six of 10 endobronchial nodes and four of five penbronchial nodes. Findings due to bronchial obstruction also were seen on CT; atelectasis (n = 11), infiltration (n = 4), bronchiectasis (n = 4), and air trapping (n = 1). An associated soft-tissue mass was not seen in any case. Difficulty in determining the relationship between lymph node and bronchus is due to volume averaging, which can be decreased by scanning thinner sections. CT can suggest the diagnosis of broncholithiasis and is useful when bronchoscopy does not show a broncholith. AJR
157:249-253,
August
Broncholithiasis
1991
is an uncommon
medical
problem
that
often
is a diagnostic
challenge. Broncholithiasis traditionally is defined as a condition in which calcified material is present within the bronchus or in an adjacent communicating cavity [1 ]. More recently, the definition has been expanded to include those cases in which peribronchial calcific nodal disease distorts the tracheobronchial tree without erosion of the calcified lymph node into the bronchus [2]. Plain film radiography and tomography have been used to examine patients with suspected broncholithiasis [3, 4]. More recently, cases have been reported in which CT has been used [5-9]. With all radiologic studies, the goal is to identify a calcified lymph node located within or next to an involved bronchus. The purpose
of this study
broncholithiasis peribronchial Received January 25, 1991 : accepted vision March 27, 1991.
after
re-
Presented at the annual meeting of the American Roentgen Ray Society, Boston, MA, May 1991. 1A11 authors: Department of Radiology, Indiana University Medical Center (X-64), 926 W. Michigan St., Indianapolis, IN 46202-5253. Address reprint requests to D. J. Conces, Jr. 0361-803X/91/1572-0249 © American Roentgen
Ray Society
Materials
was to determine
and to assess the usefulness
the CT findings
of CT in identifying
in 1 5 patients
with
endobronchial
or
broncholiths. and
Methods
We retrospectively evaluated the chest radiographs and chest CT scans of 15 patients the diagnosis of broncholithiasis. The examinations were performed between 1982 and 1 991 and include all known patients with broncholithiasis who underwent chest CT. Of the 1 5 patients, eight were men and seven were women. The age range was 24-76 years (mean, 48.5 years). All patients lived in a region where histoplasmosis is endemic. The patients were divided into two groups on the basis of the location of the broncholith. The calcified lymph node was endobronchial in 1 0 patients [1 ].The endobronchial location of with
the lymph
node
was
confirmed
during
surgery
in four
patients,
bronchoscopy
in three
patients,
CONCES
250
surgery
and bronchoscopy
in two
patients,
and
of a calcified lymph node in one patient. lymph
node
was
cholithiasis
peribronchial.
was
calcified
made
lymph
nodes
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ease (bronchial copy,
and
Three
no
other
bron-
to explain
dis-
on bronchoschanges [2].
the of
the
lymph
1), and
patients
=
wheezing
had
examined
(n
had
All chest
a cough
(n
13).
=
of pneumonia.
Two
of these
Other
were
obtained
with
(Du Pont,
Wilmington,
DE). CT was
chest
performed
at
with
several
CT scanners: Technicare 1440 or 2030 (GE Medical Systems, Milwaukee, WI), Picker 1 200SX (Picker International, Highland Heights, OH), GE 9800 (GE Medical Systems, Milwaukee, WI), or 31 0 (Philips
Medical
Systems
The scans consisted of contiguous tients, 0.5-cm-thick sections in four patients,
two tients.
and both
Scanning
patients
time
received
North
America,
1 .0-cm-thick patients,
0.6-cm-thick
1 .0- and 0.5-cm-thick
2 sec (4.6
was
a rapid
sec
IV infusion
Shelton,
sections sections
with
the
CT).
in six
pa-
sections
in
in three
Philips
pa-
310).
Nine
1 50 ml of 60%
of either
diatri-
zoate meglumine or 200 ml of 43% iothalamate meglumine. Some patients received a 75-mI bolus of contrast material at the beginning of the infusion. None of the patients underwent oblique tomography. The
chest
radiographs
and
CT scans
authors.
The scans were analyzed
calcified
lymph nodes,
tissue
masses.
The
of broncholithiasis, not
atelectasis, the
were the
reviewed
were
by two
presence
infiltrates,
radiologists but
for
and
aware
bronchoscopic
of the and
of
and soft-
clinical
surgical
of the
location
bronchiectasis,
diagnosis
findings
were
Findings
on the chest lymph
1A). Atelectasis tasis
was
infiltrate
node
radiographs
near
were
a bronchus
was identified
abnormal
was
seen
in nine patients
segmental
in six
cases
and
lobar
was present
in two
cases. Calcified
in all patients. in 1 1 patients
A (Fig.
(Fig. 1A). The atelecin three.
granulomas
Parenchymal in the
lung
were seen in four patients. Bronchoscopy bronchoscopy
was
performed
in all cases.
One
in 1 4 patients. patient
had
CT was lithoptysis
done and
node
the
in only was
of
five
found
blood
cases.
In the and
precluded patients
lymph
node
was
of the to
be
One patient node.
Five
had
nine
was
surgical
found
in three.
an endobronchial
remaining blood
evaluation underwent
radiograph
showed
expectorated
that most
2). In the 14 patients examined, nine broncholith, a broncholith was den-
(Fig.
in seven
chest
of Iithoptysis,
cases,
found
bronchial
in three.
involved
bronchus.
resection
of the
endobronchial
had partial
patients
were
distor-
In two
cases,
involved
lung.
in six
cases
bronchoscopic
and
removal
observed.
before did
Abnormalities
Calcified 1 0 patients
were
identified
on CT scans
lymph nodes were identified in whom
the lymph
in all patients.
in all 15 patients.
nodes
ultimately
were
In the proved
to be endobronchial, six of the lymph nodes appeared to be endobronchial (Fig. 3) and four appeared to be penbronchial on CT. Of the five patients whose lymph nodes were penbronchial, one node appeared to be located within a bronchus (Fig. 4) and the remaining
four appeared
to be peribronchial.
In two patients with endobronchial lymph nodes, the bronchus appeared to be occluded by material (Fig. 1 B) that had the same density as soft tissue. The involved bronchi in these patients were found during bronchoscopy to be occluded by blood clot or edematous mucosa. CT scans showed atelectasis in six patients with endobronchial lymph nodes (Fig. 1 B) and in all five patients with peribronchial nodes (Fig. 4). Parenchymal infiltrate was seen in four patients with endobronchial nodes (Fig. 5). In three patients, the infiltrates were patchy, and in one patient, the
involved lung was densely consolidated. Bronchiectasis was present distal to endobronchial lymph nodes in four patients
available.
calcified
lymph
years
1991
Results
unit
different
Philips
A follow-up
several
August
were
of 6 ft (1 .83 m) and set at 1 40 kVp. The film-screen consisted of Cronex 1 OL film and Quanta Fast Detail
combination
tion
peribronchial
for pneumonia.
a dedicated
calcified
Nine
signs
patients
that failed to clear after therapy
radiographs
a distance
tified
node
hemoptysis (n = 6), chest pain (n = 3), 3), fever (n = 2), lithoptysis (n = 2), halitosis (n = 1). One patient was asymptomatic. Four
episodes
for infiltrates
was
after
of whom had an endobronchial
of peribronchial
location
bronchoscopy.
patient,
of the
peribronchial
or stenosis)
disease
peribronchial
symptom
included
production
screen
evidence
of
this
The
common
symptoms
=
the
a diagnosis
AJR:157,
undergo
the calcified
demonstrable
compression,
pulmonary
had
most
sputum (n
group,
had
on radiographs,
expectoration
surgically.
The and
patients
distortion,
patients
confirmed
In this
if the
by the
In five patients,
ET AL.
not
(Figs.
1 B and 3B). This was characterized
of the bronchi,
which
in three
cases
by tubular
dilatation
was associated
with
atelectasis of the involved lung. Air trapping in the involved lung was seen in one patient with an endobronchial node. Using CT, we determined that broncholithiasis involved the right lung in 13 patients and the left lung in two patients. The
distribution
in the right lung was the anterior
segment
upper
Fig. 1.-66-year-old asymptomatic woman with an endobronchial broncholith. A, Posteroanterior chest radiograph shows atelectasis in right middle lobe and calcified lymph nodes near nght-middle-lobar bronchus. B, CT scan through level of right-middlelobar bronchus shows calcified lymph node(arrow) in expected location of rlght-middle-lobar bronchus and atelectasis and bronchiectasis distal to lymph node. Soft tissue within bronchus proximal to node represents blood clot and edematous mucosa seen during bronchoscopy. Lymph node was found during surgery to be endobronchial.
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AJR:157,
August
CT OF BRONCHOLITHIASIS
1991
251
Fig. 2.-33-year-old woman with a chronic cough and Iithoptysis. A, Posteroanterior chest radiograph shows a large calcified lymph node in hilum of right lung. B, CT scan obtained at same time as A shows a large calcified lymph node in right hilum that appears to be next to, but not within, (arrow). C, Chest radiograph obtained after 2 years of lithoptysis (2 years after A) shows marked reduction in calcifications in right hilum
Fig. 3.-.-30-year-oid woman with bronchiectasis due to chronic bronchial obstruction by an endobronchial broncholith. A, CT scan at level of origin of right-middlelobar bronchus shows proximal bronchus abuts an endobronchial broncholith (arrow). B, CT scan at level immediately below A shows bronchus abutting distal side of bronchollth (arrow). Bronchiectasis Is present in lateral segment.
A Fig. 4.-61-year-old man with a peribronchial broncholith that was incorrectly localized by CT
as endobronchial.
CT at level of anterior segment
of right upper lobe shows calcified lymph node (arrow), apparently occluding bronchus, and associated distal atelectasis. During surgery, node
was found to be peribronchial,
and bronchial
obstruction was due to postinflammatory chial distortion and stenosis.
Fig. 5.-Si-year-old
woman
bron-
who had persistfor pneumonia. CT scan shows endobronchial broncholith within anterior segment of right-upperlobar bronchus and infiltrate within segment.
ent inflftrate in right upper lobe after therapy
B
bronchus of lung.
intermedius
CONCES
252
ET AL.
AJR:157,
August
1991
Downloaded from www.ajronline.org by 173.85.21.185 on 10/28/15 from IP address 173.85.21.185. Copyright ARRS. For personal use only; all rights reserved
Fig. 6.-24-year-old man with hemoptysis. A, CT scan (1.0-cm section) through superior segment of right lower lobe shows calcification (arrow) that does not appear to involve a bronchus. B, CT scan of thinner section (0.5 cm) clearly shows broncholith (arrow) is in a subsegmental bronchus.
A
lobar
B
bronchus
cases,
in five cases,
bronchus
intermedius
middle
lobar
bronchus
in two cases,
segment lower lobar bronchus in three cases. the upper lobar bronchus and the lower lobar
involved
in three
and the superior In the left lung, bronchus were
in one case each.
In three patients, both 1 .0- and 0.5-cm-thick sections were obtained. In two patients, both section thicknesses provided essentially equivalent information. In the other patient, the 0.5-cm-thick images provided much better definition of the relationship between the broncholith and the bronchus (Fig.
6). In this case, involvement of a subsegmental bronchus was depicted clearly on the thinner section but was not seen on the thicker
sections.
persistent infiltrates after therapy for pneumonia. Bronchiectasis, which was found in four patients, indicates that the bronchial obstruction may be chronic in some patients, resuIting in repeated episodes of postobstructive infection. Of interest is that the bronchiectasis seen on CT was not identified on the plain radiographs. Air trapping is an unusual finding that reflects the obstructive nature of this disease. No soft-tissue mass was associated with any of the broncholiths. This is in contrast to fibrosing mediastinitis, which
as with broncholithiasis
difference
process may distort the bronchus. The CT findings were representative of this pathologic process. In all cases, CT showed a calcified lymph node. This lymph node was identified as endobronchial
in only six of 1 0 cases
in which
it was
located within the bronchus. In one case with a peribronchial node, CT showed that the node was endobronchial. These discrepancies are the result of volume averaging of the lymph ncc, bronchus, and surrounding tissues. In two cases of endobronchial lymph nodes. the bronchus appeared to be occluded by soft tissue, which e ented edematous mucosa or blood. The difficulty CT haU i determining the exact of the lymph
node is not of great
practical
significance
because the key radiologic finding, a calcified lymph node in or adjacent to the involved bronchus, was shown in all cases. Atelectasis, the most common parenchymal finding, is the of bronchial occlusion bronchial distortion.
by a broncholith Infiltrates were
or postinflampresent in four
cases, appearing as either a patchy infiltrate or an area of consolidation. The infiltrates also are due to the occlusive effect of the broncholiths, which may result in postobstructive infection.
the much more localized
Two
of the
patients
were
examined
because
of
with infection
by
disease
that cc-
of a broncholith.
We did not specifically
Most broncholiths arise from peribronchial lymph nodes that calcify after an inflammatory process. They may erode into an adjacent bronchus, and the associated inflammatory
product matory
reflects
curs in the development
Discussion
location
usually is associated
Histoplasma capsulatum and may produce bronchial obstruction. In fibrosing mediastinitis, a soft-tissue mass is the main finding and usually is associated with calcification [10]. This
address
the relative
usefulness
of
thick vs thin sections. However, in one of the three cases in which both 1 .0- and 0.5-cm-thick sections were used, the thinner sections provided superior definition of the broncholith in relation to the bronchus. This is because less volume
averaging
occurred
with the thinner section.
It seems reason-
able that in cases in which broncholithiasis is suspected cm-thick or thinner sections should be obtained through
0.5the
area of interest. This would minimize the effect of volume averaging and allow better localization of the calcified lymph node. Although contrast material was administered in nine of the CT scans, it is not necessary for the evaluation of broncholithiasis. Fiber-optic bronchoscopy is a relatively insensitive technique for the detection of broncholiths. In our series, only five (56%) of nine endobronchial broncholiths were identified with bronchoscopy. This is slightly better than other series, in which broncholiths were identified in 28-44% of patients examined [3, 1 1 , 1 2]. The failure of bronchoscopy to identify some broncholiths is due either to the node being penibronchial or to bronchial distortion obscuring an endobronchial node. It is in these patients that CT is of value. The usefulness
of CT for identifying
the hidden
broncholith
provides
infor-
mation that is essential if broncholithiasis is to be diagnosed. An important role of bronchoscopy is to exclude an endo-
AJR:157,
August
CT OF BRONCHOLITHIASIS
1991
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bronchial neoplasm, which in rare cases may be calcified and simulate a broncholith [13]. The results of this study suggest that CT can provide useful information in the examination of patients with suspected broncholithiasis. A diagnosis of broncholithiasis is suggested strongly by the following CT findings: (1) a calcified lymph node that is either endobronchial or peribronchial; (2) the
presence of changes due to bronchial obstruction: atelectasis, infiltrates, bronchiectasis, or air trapping; and (3) the absence of an associated soft-tissue mass. Bronchoscopy should be done then to exclude the presence of an endobronchial neoplasm and to look for either a broncholith or evidence of penibronchial disease (bronchial compression, stenosis, or distortion). If no other pulmonary disease is present to explain the findings, we think that the results of CT and bronchoscopy will be sufficient for a diagnosis of broncholithiasis.
REFERENCES 1. Schmidt HW, Claggett OT, McDonald diovasc Surg 1950:19:226-245 2. Arrigoni MG, Bematz PE, Donoghue
JR. Broncholithiasis.
J Thorac
Car-
FE. Broncholithiasis.
J Thorac Car-
diovasc Surg 1971:62:231-237 3. Vix VA. Radiographic manifestations 4. 5. 6. 7.
8.
9. 10.
253
of
broncholithiasis.
Radiology
1978:128:295-299 Freedman E, Billings JH. Active bronchopulmonary lithiasis. Radiology 1949:53:203-214 Kowal LE, Goodman LR, Zarro VJ, Haskin ME. CT diagnosis of broncholithiasis. J Comput Assist Tomogr 1983:7:321-323 Morris JF, Antonovic R, Galey WT, Khanijo V. Lithoptysis in a marathon runner. Chest 1989:96:655-656 Hirshfield LS, Graver LM, lsenberg HD. Broncholithiasis due to Histoplasma capsulatum subsequently infected by actinomycetes. Chest 1989:96: 218-219 Shin MS, Ho KJ. Broncholithiasis: its detection by computed tomography in patients with recurrent hemoptysis of unknown etiology. J Comput Tomogr 1983:7:189-193 Adler 0, Peleg H. Computed tomography in the diagnosis of broncholithiasis. Eur J Radiol 1987:7:211-212 Weinstein JB, Aronberg DJ, Sagel SS. CT offibrosing mediastinitis: findings
and their utility. AJR 1983;141 :247-251 1 1 . Dixon GF, Donnerberg AL, Schonfeld SA, Whitcomb ME. Advances in the diagnosis and treatment of broncholithiasis. Am Rev Respir Dis 1984:129:1028-1030 12. Trastek VF. Pairolero PC, Ceithami EL, Piehler JM, Payne WS, Bematz PE. Surgical management of bronchohthiasis. J Thorac Cardiovasc Surg 1985:90:842-848 13. Shin MS, Berland LL, Myers JL, Clary G, Zorn GL. CT demonstration of an ossifying bronchial carcinoid simulating broncholithiasis. AJR 1989:153:51-52
249
Broncholithiasis: Patients
Dewey
J. Conces, Jr.1 Robert D. Tarver Vernon A. Vix
CT Features in 15
Broncholithiasis is a disorder characterized by peribronchial calcific nodal disease that either erodes into an adjacent bronchus or distorts the bronchi The key radiologic finding is a calcified endobronchial or penbronchial lymph node. To determine the CT findings of broncholithiasis, we retrospectively reviewed the chest radiographs and CT scans of 15 patients with proved broncholithiasis. Ten patients had endobronchial nodes as proved by bronchoscopy, surgery, or lithoptysis. Broncholiths were identified on bronchoscopy in only five cases. Five patients had penbronchial nodes with associated bronchial distortion. Collimation of the CT scans varied; 1.0-cm-, 0.6-cm-, and 0.5-cmthick sections were obtained. Three patients had both 1.0-cm- and 0.5-cm-thick sections. The calcified lymph node was identified on CT in all 15 patients. CT correctly localized six of 10 endobronchial nodes and four of five penbronchial nodes. Findings due to bronchial obstruction also were seen on CT; atelectasis (n = 11), infiltration (n = 4), bronchiectasis (n = 4), and air trapping (n = 1). An associated soft-tissue mass was not seen in any case. Difficulty in determining the relationship between lymph node and bronchus is due to volume averaging, which can be decreased by scanning thinner sections. CT can suggest the diagnosis of broncholithiasis and is useful when bronchoscopy does not show a broncholith. AJR
157:249-253,
August
Broncholithiasis
1991
is an uncommon
medical
problem
that
often
is a diagnostic
challenge. Broncholithiasis traditionally is defined as a condition in which calcified material is present within the bronchus or in an adjacent communicating cavity [1 ]. More recently, the definition has been expanded to include those cases in which peribronchial calcific nodal disease distorts the tracheobronchial tree without erosion of the calcified lymph node into the bronchus [2]. Plain film radiography and tomography have been used to examine patients with suspected broncholithiasis [3, 4]. More recently, cases have been reported in which CT has been used [5-9]. With all radiologic studies, the goal is to identify a calcified lymph node located within or next to an involved bronchus. The purpose
of this study
broncholithiasis peribronchial Received January 25, 1991 : accepted vision March 27, 1991.
after
re-
Presented at the annual meeting of the American Roentgen Ray Society, Boston, MA, May 1991. 1A11 authors: Department of Radiology, Indiana University Medical Center (X-64), 926 W. Michigan St., Indianapolis, IN 46202-5253. Address reprint requests to D. J. Conces, Jr. 0361-803X/91/1572-0249 © American Roentgen
Ray Society
Materials
was to determine
and to assess the usefulness
the CT findings
of CT in identifying
in 1 5 patients
with
endobronchial
or
broncholiths. and
Methods
We retrospectively evaluated the chest radiographs and chest CT scans of 15 patients the diagnosis of broncholithiasis. The examinations were performed between 1982 and 1 991 and include all known patients with broncholithiasis who underwent chest CT. Of the 1 5 patients, eight were men and seven were women. The age range was 24-76 years (mean, 48.5 years). All patients lived in a region where histoplasmosis is endemic. The patients were divided into two groups on the basis of the location of the broncholith. The calcified lymph node was endobronchial in 1 0 patients [1 ].The endobronchial location of with
the lymph
node
was
confirmed
during
surgery
in four
patients,
bronchoscopy
in three
patients,
CONCES
250
surgery
and bronchoscopy
in two
patients,
and
of a calcified lymph node in one patient. lymph
node
was
cholithiasis
peribronchial.
was
calcified
made
lymph
nodes
Downloaded from www.ajronline.org by 173.85.21.185 on 10/28/15 from IP address 173.85.21.185. Copyright ARRS. For personal use only; all rights reserved
ease (bronchial copy,
and
Three
no
other
bron-
to explain
dis-
on bronchoschanges [2].
the of
the
lymph
1), and
patients
=
wheezing
had
examined
(n
had
All chest
a cough
(n
13).
=
of pneumonia.
Two
of these
Other
were
obtained
with
(Du Pont,
Wilmington,
DE). CT was
chest
performed
at
with
several
CT scanners: Technicare 1440 or 2030 (GE Medical Systems, Milwaukee, WI), Picker 1 200SX (Picker International, Highland Heights, OH), GE 9800 (GE Medical Systems, Milwaukee, WI), or 31 0 (Philips
Medical
Systems
The scans consisted of contiguous tients, 0.5-cm-thick sections in four patients,
two tients.
and both
Scanning
patients
time
received
North
America,
1 .0-cm-thick patients,
0.6-cm-thick
1 .0- and 0.5-cm-thick
2 sec (4.6
was
a rapid
sec
IV infusion
Shelton,
sections sections
with
the
CT).
in six
pa-
sections
in
in three
Philips
pa-
310).
Nine
1 50 ml of 60%
of either
diatri-
zoate meglumine or 200 ml of 43% iothalamate meglumine. Some patients received a 75-mI bolus of contrast material at the beginning of the infusion. None of the patients underwent oblique tomography. The
chest
radiographs
and
CT scans
authors.
The scans were analyzed
calcified
lymph nodes,
tissue
masses.
The
of broncholithiasis, not
atelectasis, the
were the
reviewed
were
by two
presence
infiltrates,
radiologists but
for
and
aware
bronchoscopic
of the and
of
and soft-
clinical
surgical
of the
location
bronchiectasis,
diagnosis
findings
were
Findings
on the chest lymph
1A). Atelectasis tasis
was
infiltrate
node
radiographs
near
were
a bronchus
was identified
abnormal
was
seen
in nine patients
segmental
in six
cases
and
lobar
was present
in two
cases. Calcified
in all patients. in 1 1 patients
A (Fig.
(Fig. 1A). The atelecin three.
granulomas
Parenchymal in the
lung
were seen in four patients. Bronchoscopy bronchoscopy
was
performed
in all cases.
One
in 1 4 patients. patient
had
CT was lithoptysis
done and
node
the
in only was
of
five
found
blood
cases.
In the and
precluded patients
lymph
node
was
of the to
be
One patient node.
Five
had
nine
was
surgical
found
in three.
an endobronchial
remaining blood
evaluation underwent
radiograph
showed
expectorated
that most
2). In the 14 patients examined, nine broncholith, a broncholith was den-
(Fig.
in seven
chest
of Iithoptysis,
cases,
found
bronchial
in three.
involved
bronchus.
resection
of the
endobronchial
had partial
patients
were
distor-
In two
cases,
involved
lung.
in six
cases
bronchoscopic
and
removal
observed.
before did
Abnormalities
Calcified 1 0 patients
were
identified
on CT scans
lymph nodes were identified in whom
the lymph
in all patients.
in all 15 patients.
nodes
ultimately
were
In the proved
to be endobronchial, six of the lymph nodes appeared to be endobronchial (Fig. 3) and four appeared to be penbronchial on CT. Of the five patients whose lymph nodes were penbronchial, one node appeared to be located within a bronchus (Fig. 4) and the remaining
four appeared
to be peribronchial.
In two patients with endobronchial lymph nodes, the bronchus appeared to be occluded by material (Fig. 1 B) that had the same density as soft tissue. The involved bronchi in these patients were found during bronchoscopy to be occluded by blood clot or edematous mucosa. CT scans showed atelectasis in six patients with endobronchial lymph nodes (Fig. 1 B) and in all five patients with peribronchial nodes (Fig. 4). Parenchymal infiltrate was seen in four patients with endobronchial nodes (Fig. 5). In three patients, the infiltrates were patchy, and in one patient, the
involved lung was densely consolidated. Bronchiectasis was present distal to endobronchial lymph nodes in four patients
available.
calcified
lymph
years
1991
Results
unit
different
Philips
A follow-up
several
August
were
of 6 ft (1 .83 m) and set at 1 40 kVp. The film-screen consisted of Cronex 1 OL film and Quanta Fast Detail
combination
tion
peribronchial
for pneumonia.
a dedicated
calcified
Nine
signs
patients
that failed to clear after therapy
radiographs
a distance
tified
node
hemoptysis (n = 6), chest pain (n = 3), 3), fever (n = 2), lithoptysis (n = 2), halitosis (n = 1). One patient was asymptomatic. Four
episodes
for infiltrates
was
after
of whom had an endobronchial
of peribronchial
location
bronchoscopy.
patient,
of the
peribronchial
or stenosis)
disease
peribronchial
symptom
included
production
screen
evidence
of
this
The
common
symptoms
=
the
a diagnosis
AJR:157,
undergo
the calcified
demonstrable
compression,
pulmonary
had
most
sputum (n
group,
had
on radiographs,
expectoration
surgically.
The and
patients
distortion,
patients
confirmed
In this
if the
by the
In five patients,
ET AL.
not
(Figs.
1 B and 3B). This was characterized
of the bronchi,
which
in three
cases
by tubular
dilatation
was associated
with
atelectasis of the involved lung. Air trapping in the involved lung was seen in one patient with an endobronchial node. Using CT, we determined that broncholithiasis involved the right lung in 13 patients and the left lung in two patients. The
distribution
in the right lung was the anterior
segment
upper
Fig. 1.-66-year-old asymptomatic woman with an endobronchial broncholith. A, Posteroanterior chest radiograph shows atelectasis in right middle lobe and calcified lymph nodes near nght-middle-lobar bronchus. B, CT scan through level of right-middlelobar bronchus shows calcified lymph node(arrow) in expected location of rlght-middle-lobar bronchus and atelectasis and bronchiectasis distal to lymph node. Soft tissue within bronchus proximal to node represents blood clot and edematous mucosa seen during bronchoscopy. Lymph node was found during surgery to be endobronchial.
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AJR:157,
August
CT OF BRONCHOLITHIASIS
1991
251
Fig. 2.-33-year-old woman with a chronic cough and Iithoptysis. A, Posteroanterior chest radiograph shows a large calcified lymph node in hilum of right lung. B, CT scan obtained at same time as A shows a large calcified lymph node in right hilum that appears to be next to, but not within, (arrow). C, Chest radiograph obtained after 2 years of lithoptysis (2 years after A) shows marked reduction in calcifications in right hilum
Fig. 3.-.-30-year-oid woman with bronchiectasis due to chronic bronchial obstruction by an endobronchial broncholith. A, CT scan at level of origin of right-middlelobar bronchus shows proximal bronchus abuts an endobronchial broncholith (arrow). B, CT scan at level immediately below A shows bronchus abutting distal side of bronchollth (arrow). Bronchiectasis Is present in lateral segment.
A Fig. 4.-61-year-old man with a peribronchial broncholith that was incorrectly localized by CT
as endobronchial.
CT at level of anterior segment
of right upper lobe shows calcified lymph node (arrow), apparently occluding bronchus, and associated distal atelectasis. During surgery, node
was found to be peribronchial,
and bronchial
obstruction was due to postinflammatory chial distortion and stenosis.
Fig. 5.-Si-year-old
woman
bron-
who had persistfor pneumonia. CT scan shows endobronchial broncholith within anterior segment of right-upperlobar bronchus and infiltrate within segment.
ent inflftrate in right upper lobe after therapy
B
bronchus of lung.
intermedius
CONCES
252
ET AL.
AJR:157,
August
1991
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Fig. 6.-24-year-old man with hemoptysis. A, CT scan (1.0-cm section) through superior segment of right lower lobe shows calcification (arrow) that does not appear to involve a bronchus. B, CT scan of thinner section (0.5 cm) clearly shows broncholith (arrow) is in a subsegmental bronchus.
A
lobar
B
bronchus
cases,
in five cases,
bronchus
intermedius
middle
lobar
bronchus
in two cases,
segment lower lobar bronchus in three cases. the upper lobar bronchus and the lower lobar
involved
in three
and the superior In the left lung, bronchus were
in one case each.
In three patients, both 1 .0- and 0.5-cm-thick sections were obtained. In two patients, both section thicknesses provided essentially equivalent information. In the other patient, the 0.5-cm-thick images provided much better definition of the relationship between the broncholith and the bronchus (Fig.
6). In this case, involvement of a subsegmental bronchus was depicted clearly on the thinner section but was not seen on the thicker
sections.
persistent infiltrates after therapy for pneumonia. Bronchiectasis, which was found in four patients, indicates that the bronchial obstruction may be chronic in some patients, resuIting in repeated episodes of postobstructive infection. Of interest is that the bronchiectasis seen on CT was not identified on the plain radiographs. Air trapping is an unusual finding that reflects the obstructive nature of this disease. No soft-tissue mass was associated with any of the broncholiths. This is in contrast to fibrosing mediastinitis, which
as with broncholithiasis
difference
process may distort the bronchus. The CT findings were representative of this pathologic process. In all cases, CT showed a calcified lymph node. This lymph node was identified as endobronchial
in only six of 1 0 cases
in which
it was
located within the bronchus. In one case with a peribronchial node, CT showed that the node was endobronchial. These discrepancies are the result of volume averaging of the lymph ncc, bronchus, and surrounding tissues. In two cases of endobronchial lymph nodes. the bronchus appeared to be occluded by soft tissue, which e ented edematous mucosa or blood. The difficulty CT haU i determining the exact of the lymph
node is not of great
practical
significance
because the key radiologic finding, a calcified lymph node in or adjacent to the involved bronchus, was shown in all cases. Atelectasis, the most common parenchymal finding, is the of bronchial occlusion bronchial distortion.
by a broncholith Infiltrates were
or postinflampresent in four
cases, appearing as either a patchy infiltrate or an area of consolidation. The infiltrates also are due to the occlusive effect of the broncholiths, which may result in postobstructive infection.
the much more localized
Two
of the
patients
were
examined
because
of
with infection
by
disease
that cc-
of a broncholith.
We did not specifically
Most broncholiths arise from peribronchial lymph nodes that calcify after an inflammatory process. They may erode into an adjacent bronchus, and the associated inflammatory
product matory
reflects
curs in the development
Discussion
location
usually is associated
Histoplasma capsulatum and may produce bronchial obstruction. In fibrosing mediastinitis, a soft-tissue mass is the main finding and usually is associated with calcification [10]. This
address
the relative
usefulness
of
thick vs thin sections. However, in one of the three cases in which both 1 .0- and 0.5-cm-thick sections were used, the thinner sections provided superior definition of the broncholith in relation to the bronchus. This is because less volume
averaging
occurred
with the thinner section.
It seems reason-
able that in cases in which broncholithiasis is suspected cm-thick or thinner sections should be obtained through
0.5the
area of interest. This would minimize the effect of volume averaging and allow better localization of the calcified lymph node. Although contrast material was administered in nine of the CT scans, it is not necessary for the evaluation of broncholithiasis. Fiber-optic bronchoscopy is a relatively insensitive technique for the detection of broncholiths. In our series, only five (56%) of nine endobronchial broncholiths were identified with bronchoscopy. This is slightly better than other series, in which broncholiths were identified in 28-44% of patients examined [3, 1 1 , 1 2]. The failure of bronchoscopy to identify some broncholiths is due either to the node being penibronchial or to bronchial distortion obscuring an endobronchial node. It is in these patients that CT is of value. The usefulness
of CT for identifying
the hidden
broncholith
provides
infor-
mation that is essential if broncholithiasis is to be diagnosed. An important role of bronchoscopy is to exclude an endo-
AJR:157,
August
CT OF BRONCHOLITHIASIS
1991
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bronchial neoplasm, which in rare cases may be calcified and simulate a broncholith [13]. The results of this study suggest that CT can provide useful information in the examination of patients with suspected broncholithiasis. A diagnosis of broncholithiasis is suggested strongly by the following CT findings: (1) a calcified lymph node that is either endobronchial or peribronchial; (2) the
presence of changes due to bronchial obstruction: atelectasis, infiltrates, bronchiectasis, or air trapping; and (3) the absence of an associated soft-tissue mass. Bronchoscopy should be done then to exclude the presence of an endobronchial neoplasm and to look for either a broncholith or evidence of penibronchial disease (bronchial compression, stenosis, or distortion). If no other pulmonary disease is present to explain the findings, we think that the results of CT and bronchoscopy will be sufficient for a diagnosis of broncholithiasis.
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JR. Broncholithiasis.
J Thorac
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FE. Broncholithiasis.
J Thorac Car-
diovasc Surg 1971:62:231-237 3. Vix VA. Radiographic manifestations 4. 5. 6. 7.
8.
9. 10.
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1978:128:295-299 Freedman E, Billings JH. Active bronchopulmonary lithiasis. Radiology 1949:53:203-214 Kowal LE, Goodman LR, Zarro VJ, Haskin ME. CT diagnosis of broncholithiasis. J Comput Assist Tomogr 1983:7:321-323 Morris JF, Antonovic R, Galey WT, Khanijo V. Lithoptysis in a marathon runner. Chest 1989:96:655-656 Hirshfield LS, Graver LM, lsenberg HD. Broncholithiasis due to Histoplasma capsulatum subsequently infected by actinomycetes. Chest 1989:96: 218-219 Shin MS, Ho KJ. Broncholithiasis: its detection by computed tomography in patients with recurrent hemoptysis of unknown etiology. J Comput Tomogr 1983:7:189-193 Adler 0, Peleg H. Computed tomography in the diagnosis of broncholithiasis. Eur J Radiol 1987:7:211-212 Weinstein JB, Aronberg DJ, Sagel SS. CT offibrosing mediastinitis: findings
and their utility. AJR 1983;141 :247-251 1 1 . Dixon GF, Donnerberg AL, Schonfeld SA, Whitcomb ME. Advances in the diagnosis and treatment of broncholithiasis. Am Rev Respir Dis 1984:129:1028-1030 12. Trastek VF. Pairolero PC, Ceithami EL, Piehler JM, Payne WS, Bematz PE. Surgical management of bronchohthiasis. J Thorac Cardiovasc Surg 1985:90:842-848 13. Shin MS, Berland LL, Myers JL, Clary G, Zorn GL. CT demonstration of an ossifying bronchial carcinoid simulating broncholithiasis. AJR 1989:153:51-52
