Approach to Peribronchovascular Disease on CT

Abstract

Diseases that are predominantly peribronchovascular in distribution on computed tomography by definition involve the bronchi, adjacent vasculature, and associated lymphatics involving the central or axial lung interstitium. An understanding of diseases that can present with focal peribronchovascular findings is useful for establishing diagnoses and guiding patient management. This review will cover clinical and imaging features that may assist in differentiating amongst the various causes of primarily peribronchovascular disease.

Figure 1

64-year-old man after cardiac and renal transplantation who is chronically immunosuppressed, presented with dyspnea and weight loss. Soft tissue peribronchial nodular left lower lobe opacity (arrow) and right lower lobe ill-defined predominantly ground-glass opacity with mild consolidation. Bronchoalveolar lavage showed T-cell lymphoma, while transbronchial subcarinal lymph node biopsy showed B-cell and T-cell lymphoma in subcarinal node.

Figure 2

Primary pulmonary lymphoma. (A) 46-year-old man. Incidental soft tissue peribronchial focal opacity on pulmonary vein CT performed for atrial fibrillation ablation planning. Air bronchograms are present within the lesion. Biopsy revealed extranodal marginal zone B-cell MALT lymphoma. (B) 90-year-old woman with confirmed extranodal marginal zone B-cell MALT lymphoma. CT image demonstrates a soft tissue nodule centered around the bronchovascular bundle (arrows) seen entering the lesion.

Figure 3

Lymphomatoid granulomatosis. Patchy ground- glass opacities and consolidation are seen in the right lung. Additionally, soft tissue nodules, some of which have ill-defined borders are present (arrows) and are clustered.

Figure 4

Lung adenocarcinoma. A soft-tissue spiculated mass containing air bronchograms is detected incidentally in an HIV-positive woman with renal failure. On coronal (A) and axial (B) CT images, the mass is centered around bronchovascular bundles, and the center of the finding is within the inner two-thirds of the lung.

Figure 5

Organizing pneumonia. (A) A woman with gastrointestinal stromal tumor has a history of yttrium-90 (Y-90) therapy for liver metastasis and known shunting of Y-90 to the lungs. The predominantly peripheral consolidation spares the subpleural region and is associated with bronchovascular structures, such as in the right middle lobe and lingula. Organizing pneumonia, confirmed by wedge resections, is attributed to radiation pneumonitis. (B) CT image of a 44-year-old woman with muscle-biopsy proven dermatomyositis and pathologically confirmed bronchiolocentric organizing pneumonia. The lower lobe predominant ground glass nodules are associated with bronchovascular regions.

Figure 6

Bronchopneumonia in two different patients. Focal areas of consolidation (A) and nodular ground glass and soft tissue opacities (B) surround the bronchovascular regions. A right pleural effusion (A) is present.

Figure 7

Human metapneumovirus pneumonia. 86-year-old man presented with wheezing and fever and was diagnosed by molecular testing. Patchy ground-glass opacities in the right lower lobe are centered around the bronchovascular bundles, and mild clustered nodules are present. Bilateral mild ground-glass opacities are present.

Figure 8

Vasculitis. Pulmonary hemorrhage related to P-ANCA vasculitis (A, B) in a 65-year-old woman with hemoptysis. (A) Ill-defined ground glass areas (white arrows) centered along bronchovascular bundles and soft-tissue patchy focal areas (black arrow) are present. (B) Soft-tissue patchy areas are also seen on follow-up CT in upper lobes. (C) 33-year-old woman with SLE vasculitis with soft tissue central mass-like consolidation, with central ground-glass (reversed-halo) appearance, and subsolid nodules (arrows) that improve with increasing immunosuppression. (D) IgG-4 related vasculitis diagnosed by wedge resection in a 70-year-old immunocompromised man with weight loss and dyspnea on exertion.

Figure 9

Chronic eosinophilic pneumonia. Man with history of eosinophilia with history of recurrent cough, wheezing. Eosinophilic pneumonia with organizing pneumonia was diagnosed on wedge resection.

Figure 10

Sarcoid. 35-year-old male with left back pain and fever had a CT demonstrating peribronchovascular soft-tissue mass-like opacities. The patient had confirmed sarcoid on wedge resection. The CT imaging appearance represents the “alveolar” form of sarcoid, which are related to confluent interstitial granulomas. Peripheral nodularity in the right upper lobe can be an indicator of an interstitial process that becomes coalescent.

Figure 11

Kaposi's sarcoma that was related to AIDS. Patient with skin lesions and (A) peribronchovascular soft tissue opacities in the lower lobes with a nodular opacity (arrow) in the left lower lobe are seen. Interlobular septal thickening present particularly in the lingula and right middle lobe. (B) Soft tissue image shows confluent hilar soft tissue representing adenopathy and bilateral pleural effusions.

Figure 12

Approach to peribronchovascular CT opacities.