275

Pictorial

Essay

High-Resolution
Brendan Adler,1 Simon Padley,1

CT of Bronchioloalveolar
Roberta R. Miller,2 and Nestor L. MUller1

Carcinoma

Bronchioloalveolar

cell

carcinoma

has a wide

spectrum

of

are 43%,

30%,

and 27%,

respectively

[1 ]. Pleural

effusion

pathologic and radiologic appearances. Some of the radiologic features are characteristic enough to suggest the underlying pathologic changes. This article illustrates the various manifestations of bronchioloalveolar cell carcinoma on high-resolution CT (1.5-mm collimation reconstructed with a high-spatial-frequency algorithm). Correlations between the CT and pathologic findings are included.

has been reported to be present in 32% of cases and hilar or mediastinal lymphadenopathy in 1 8% [1]. Solitary nodules are typically located in the periphery of the lungs and have spiculated borders previously described as forming a star pattern [2]. Histopathologic correlation shows

Bronchioloalveolar cell carcinoma typically has one of three radiologic patterns: a solitary nodule, consolidation, and multicentric or diffuse disease. The prevalences of these patterns
Fig. 1.-A, High-resolution CT scan through upper lobe of right lung shows peripheral bronchioloalveolar carolnoma with prominently spiculated herders. Apparent pleural thickening is seen adjacent to mass. B, Pathologic specimen shows a peripheral solitary mass lesion with infiltrative growth pattern and extensive desmoplastic reaction leading to pleural retraction (arrow). Tumor also invades parietal pleura.

that the spiculated appearance may be due to infiltrative tumor growth, localized Iymphangitic spread. or desmoplastic reaction [3] (Fig. 1). This desmoplastic reaction also accounts for the pleural tags that are frequently seen (Fig. 2). A characteristic finding of bronchioloalveolar cell carcinoma is the presence of bubblelike lucencies or pseudocavitation

Fig. through a mass rows). plastic loalveolar (curved

2.-High-resolution CT scan upper lobe of right lung shows with pleural tags (straight arThese are caused by desmoreaction elicited by bronchiocarcinoma. Air bronchogram arrow) is evident.

Received January 13, 1992; accepted after revision February 18, 1992. 1 Department of Radiology, University of British Columbia and Vancouver Department of Pathology, University of British Columbia and Vancouver August 1992 0361 -803X/92/1 592-0275 American

General General Roentgen

Hospital, Hospital, Ray Society

855 W. 12th Ave., Vancouver, B.C., Canada Vancouver, B.C., Canada V5Z 1 Mg.

V5Z

1 Mg.

AJR 159:275-277,

276

ADLER

ET AL.

AJR:159,

August

1992

(Fig. 3), which corresponds to patent small bronchi or aircontaining cystic spaces in papillary tumors [3]. Bubble lucencies are seen more commonly in bronchioloalveolar cell carcinoma (50%) than in acinar adenocarcinomas (31 %) or other lung tumors (1 1 %). Overt cavitation occurs in 7% of cases
[1] (Fig. 4).

Twenty-seven percent of bronchioloalveolar cell carcinomas are multicentric or diffuse. Although CT is superior to radiography in the detection of lung nodules, the sensitivity of CT in showing pathologically proved multicentricity is only 63-68% [5]. Patients in whom more than one lesion is seen
on high-resolution CT scans may have multicentric bronchio-

The combination of growth along the alveolar wall and secretion of mucin may cause features of air-space consolidation with air bronchograms (Figs. 2 and 5). The consolidation may be segmental or may involve an entire lobe. Production of mucin can cause swelling ofthe lobe, leading to bulging
of interlobar fissures. The tumor may extend across the

loalveolar cell carcinoma (Fig. 5) or bronchioloalveolar cell carcinoma associated with a second, apparently unrelated lesion [4] (Fig. 9). Finally, bronchioloalveolar cell carcinoma may have a widespread multinodular pattern (Fig. 10).
REFERENCES
1 . Hill CA. Bronchioloalveolar carcinoma: a review. Radiology 1984; 154: 15-20 2. Kuhlman JE, Fishman EK, Kuhajda FP, et al. Solitary bronchioloalveolar carcinoma: CT criteria. Radiology 1988;1 67 :379-382 3. Zwirewich CV, Vedal 5, Miller AR, MUller NL. Solitary pulmonary nodule: high-resolution CT and radiologic-pathologic correlation. Radiology 1991; 179:469-476 4. Irn J-G, Han MC, Yu EJ, et al. Lobar bronchioloalveolar carcinoma: Angiogram sign on CT scans. Radiology 1990;176:749-753 5. Zwirewich CV, Miller AR, MUller NL. Multicentric adenocarcinorna of the lung: CT-pathologic correlation. Radiology 190176:185-190

fissure into an adjacent lobe (Fig. 6). Mucin is of lower radiographic density than tumor, so it creates areas of lower attenuation when viewed on mediastinal windows. This causes either heterogeneous attenuation in small masses (Fig. 3) or uniform low attenuation in more confluent consolidation (Fig. 7). The low attenuation allows vessels to be clearly seen, particularly after administration of IV contrast material. This finding, recently described as the CT angiogram sign [4] (Fig. 8), is suggestive but not specific for bronchioloalveolar cell carcinoma.

Fig. 3.-High-resolution CT scan through upper lobe of right lung at level of aortic arch (mediastinal windows) shows heterogeneous attenuaton (straight arrows) within region of bronchioloalveolar cell carcinoma. This variable attenuation represents areas of mucus secretion, which have lower attenuation than tumor mass has. Note also bubble lucencies (curved arrows), which have been shown to correspond to patent small bronchi or air-containing cystic spaces in papillary tumors.

Fig. 4.-High-resolution CT scan through upper lobe of right lung shows a lobulated peripheral bronchioloalveolar carcinoma with a broad pleural attachment. Note cavitation within tumor mass, a feature reported to be present in 7% of cases of bronchioloalveolar carcinoma.

Fig. 5.-High-resolution CT scan through left lung at level of bifurcation of main bronchus shows multicentric bronchioloalveolar carcinoma. Segmental malignant consolidation is present in apicoposterior segment of upper lobe, and a nodular opacity is seen within superior segment of lower lobe. Air bronchogram (arrow) is evident within segmental consolidation. Fig. 6.-A, High-resolution CT scan through right lung at level of lower lobes shows Iobar consolidation of lower lobe, with bulging of major f issure, which is thickened (arrow). Tumor extends through fissure (arrowhead) into middle lobe. B, Pathologic specimen shows extensive malignant lobar consolidation and confirms presence of a bulging, thickened fissure (arrow). Tumor involvement of middle lobe is also shown (arrowhead).

AJR:159,

August

1992

CT OF BRONCHIOLOALVEOLAR

CARCINOMA

277

ardt
-

e;

Fig. 7.-A, High-resolution CT scan through both lungs at level of left atrium (mediastinal windows) shows confluent consolidation of low attenuation within lingula and another mass (arrow) in lower lobe of left lung. B, Pathologic specimen of lingula shows extensive malignant consolidation by bronchioloalveolar carcinoma. Tumor has a grossly mucoid appearance. C, Photomicrograph of histologic section from tumor mass shows typical growth of bronchioloalveolar carcinoma along alveolar walls (arrows).

., . ,.,_

Fig. 8.-Contrast-enhanced 10-mm-collimation CT scan through both lungs at level of right pulmonary artery shows consolidation of right upper, left upper, and left lower lobes. Consolidated right upper lobe is of low attenuation, and contrast-enhanced pulmonary vessels are thus readily visualized (arrows) (CT angiogram sign). Note bubble lucencies, air bronchograms, and less well defined angiogram sign in left lung. (Courtesy of J-G. Im, Seoul National University Hospital, Seoul, Korea.)

Fig. 9.-High-resolution CT scan through right lung at level of bronchus intermedius shows segmental con-

fluent bronchioloalveolar carcinoma in middle lobe and a nodular mass (arrow) in lower lobe, proved pathologi-

cally to be acinar adenocarcinoma.

Fig. through

10.-High-resolution CT scan both lungs at level of left upper

lobe bronchus shows widespread

tensive multinodular loalveolar carcinoma.

ex-

foci of bronchio-