Sarcoidosis – Nodules and Micronodules

  • Bronchovascular Nodules- medium sized vessels
  • Bronchovascular –
    • Secondary lobule
      • arteriole
      • venule
      • bronchiole
  • Cavitating
  • Lymphovascular Nodules
    • Along Bronchovascular Bundle
    • Along Fissures
    • Secondary Lobule
      • interlobular septa
      • centrilobular
    • Fissural Based Nodules
  • Miliary Nodules
  • Pleural Based Nodules
  • Solid Nodules
    • Single
      • solid
      • calcified
      • ground glass
      • semisolid
    • Cluster
      • galaxy

Bronchovascular – at the bronchial  level

LYMPHATIC DRAINAGE
“S” of SARCOIDOSIS
In this diagram the arrows show the direction of flow of the lymphatics. Pleural lymphatics (yellow arrows), Fissural lymphatics, green arrows), flow from the interlobular septa (purple arrows) and along the bronchovascular bundles (blue arrows) all flow toward the lymph nodes in the hila and mediastinum (pink arrows).
Sarcoidosis is a nodular granulomatous disease which predominated in the upper lobes and has its epicenter in the lymphoid tissue of the lungs.
The “S” drawn on the thoracic cage outlines the lymphatic distribution of the lungs, starting in the pleura involving the lymphatic system in the pleura, interlobular septa, bronchovascular bundles and lymph nodes.
The granulomas start out as micronodules and there is a tendency for these to coalesce, sometimes forming large granulomatous masses
When the disease affects the interlobular septa, it causes thickening and nodularity in the septa of the secondary lobule.
When it involves the lymphatics in the pleura or fissures it causes nodularity and thickening.
When it involves the lymphatics around the terminal bronchioles it results in centrilobular micronodules, and when it involves the larger airways it causes thickening and nodularity
Lymph nodes in the hila are characteristically large and flesh like (sarcoid = meat) The Pawnbrokers sign (aka Garland sign or the 1,2,3 sign) describes the enlarged right paratracheal node with bilateral hilar adenopathy.
Parenchymal nodules and micronodules sometimes coalesce to form a central confluent mass with surrounding micronodules, described as the galaxy sign.
Ashley Davidoff MD
MORPHOLOGY OF THE STRUCTURAL CHANGES
“S” of SARCOIDOSIS
The granulomas start as micronodules in close association with the lymphatics (1) spread in the intralobular septa and centrilobular bronchioles ((2) cluster and conglomerate to form macro nodules (4,5) sometimes manifesting as the galaxy sign (6). As they cluster and conglomerate they can cause conglomerate masses along the pathway (7) most commonly centrally as the lymphatics become confluent in the hila (7)
The lymphovascular bundles may be accompanied by nodularity (8) or just by thickening (9).
The lymph nodes in the mediastinum become significantly enlarged and fleshy (10). They often calcify (12) sometimes on the calcify on the rim of the node (eggshell calcification (11)
Sarcoidosis is a nodular granulomatous disease which predominated in the upper lobes and has its epicenter in the lymphoid tissue of the lungs.
The “S” drawn on the thoracic cage outlines the lymphatic distribution of the lungs, starting in the pleura involving the lymphatic system in the pleura, interlobular septa, bronchovascular bundles and lymph nodes.
The granulomas start out as micronodules and there is a tendency for these to coalesce, sometimes forming large granulomatous masses
When the disease affects the interlobular septa, it causes thickening and nodularity in the septa of the secondary lobule.
When it involves the lymphatics in the pleura or fissures it causes nodularity and thickening.
When it involves the lymphatics around the terminal bronchioles it results in centrilobular micronodules, and when it involves the larger airways it causes thickening and nodularity
Lymph nodes in the hila are characteristically large and flesh like (sarcoid = meat) The Pawnbrokers sign (aka Garland sign or the 1,2,3 sign) describes the enlarged right paratracheal node with bilateral hilar adenopathy.
Parenchymal nodules and micronodules sometimes coalesce to form a central confluent mass with surrounding micronodules, described as the galaxy sign.
Ashley Davidoff MD

 

Pleural Based

CT WITH SUBPLEURAL AND LYMPHOVASCULAR NODULES IN THE LEFT UPPER LOBE
Ashley Davidoff MD
CT WITH SUBPLEURAL CHANGES IN THE LUL AND LYMPHOVASCULAR NODULES IN THE RIGHT UPPER LOBE INVOLVING THE SECONDARY LOBULE IN THE FORM OF  INTERLOBULAR SEPTA AND CENTRILOBULAR MICRONODULES
Ashley Davidoff MD
CT WITH BILATERAL SUBPLEURAL AND LYMPHOVASCULAR NODULES

Ashley Davidoff MD

PLEURAL BASED NODULE (red arrow) and FISSURAL NODULES  (green arrow) –
SARCOIDOSIS – CHARACTERISTIC NODULES
Ashley Davidoff MD

Fissural Based

FISSURAL BASED NODULES
Ashley Davidoff MD
SARCOID HEART BLOCK, LUNG DISEASE
70-year-old female with micronodules along the fissures
Ashley Davidoff MD
TheCommonVein.net

Centrilobular Nodules and Interlobular Septa

CT WITH SUBPLEURAL AND LYMPHOVASCULAR NODULES IN THE RIGHT UPPER LOBE – INTERLOBULAR SEPTA AND CENTRILOBULAR
Ashley Davidoff MD
CT OF THE SECONDARY LOBULE WITH LYMPHOVASCULAR NODULES IN INTERLOBULAR SEPTA (blue arrows)  AND CENTRILOBULAR REGION (red arrows)
Ashley Davidoff MD
MICRONODULES ALONG THE LYMPHOVASCULAR (blue arrows) AND BRONCHOVASCULAR BUNDLES (red arrow) OF THE SECONDARY LOBULE
Ashley Davidoff MD
CT WITH LYMPHOVASCULAR NODULES IN THE LEFT UPPER LOBE – INTERLOBULAR SEPTA
SARCOIDOSIS, ACTIVE – ALVEOLAR FORM
Ashley Davidoff MD

Bronchovascular – at the medium sized bronchial level

THICKENING OF THE BRONCHOVASCULAR BUNDLES 
Ashley Davidoff MD
THICKENING OF THE BRONCHOVASCULAR BUNDLES 
Ashley Davidoff MD
STELLATE OR FLAME SHAPED NODULE, (blue arrow), GROUND GLASS NODULES,(yellow arrows) and BRONCHOVASCULAR MICRONODULES (red arrows)

Ashley Davidoff MD

 

Micronodules

SARCOIDOSIS with CENTRILOBULAR MICRONODULES, BRONCHOVASCULAR INVOLVEMENT EGG SHELL CALCIFICATION OF THE LYMPH NODES
51-year-old male with Stage 2II Sarcoidosis and egg shell calcification of lymph nodes
Ashley Davidoff MD

Larger Nodules

Ground Glass

40 year old female with a history of sarcoidosis
CT scan shows a 6mm nodule with central calcification in the ligula and ground glass nodules in the middle lobe
Ashley Davidoff
TheCommonVein.net
70060c
SARCOIDOSIS with CENTRILOBULAR MICRONODULES, BRONCHOVASCULAR INVOLVEMENT EGG SHELL CALCIFICATION OF THE LYMPH NODES
51-year-old male with Stage II Sarcoidosis and egg shell calcification of lymph nodes
Ashley Davidoff MD
SARCOIDOSIS – CHARACTERISTIC NODULES
51-year-old male with history of sarcoidosis
The axial images show a variety of characteristic changes including;
Ground glass opacity
Stellate or flame shaped nodules
Semisolid nodules
Ashley Davidoff MD
TheCommonVein.net
  • Solid
    • Single Stellate
      SARCOIDOSIS with STELLATE NODULES
      42 year old female with known history of sarcoidosis characterised by confluent granulomas, with spiculated nodules, retractile fibrosis and moderate adenopathy
      Ashley Davidoff MD
      81 F with sarcoidosis
      Irregular spiculated solid nodule
      Ashley Davidoff
      TheCommonVein.net
      81 F with sarcoidosis
      Mixed solid and ground blass nodule
      Ashley Davidoff
      TheCommonVein.net
      81 F with sarcoidosis
      Irregular solid bilobed nodule
      Ashley Davidoff
      TheCommonVein.net
      CT – 3 MAJOR REGIONS OF NODULAR CHANGE ON THE LATERAL cxr
      SARCOIDOSIS – CHARACTERISTIC NODULES
      51-year-old male with history of sarcoidosis
      The frontal CXR shows subtle nodular changes in the right upper peripheral lung field (red circles) and the lateral examination shows 3 regions of nodular changes (red arrowheads)
      The CT examination scout film confirms 3 major regions of nodular change in the posterior and superior segment of the RUL along the confluence of the right major and minor fissure and in the posterior segment of the left upper lobe peripherally.
      The axial images show a variety of characteristic changes including;
      Ground glass opacity
      Stellate or flame shaped nodules
      Semisolid nodules
      Fissural based nodules
      Subpleural nodules
      Micronodules along the
      lymphovascular and
      bronchovascular bundles of the secondary lobule
      Calcified nodule some of which are surrounded by soft tissue of the granuloma
      There are small calcified nodes in the mediastinum, but no significant pathological adenopathy
      No obvious cardiac nor splenic involvement is noted
      Ashley Davidoff MD

      SARCOIDOSIS – CHARACTERISTIC NODULES
      51-year-old male with history of sarcoidosis
      Ashley Davidoff MD
      TheCommonVein.net

Conglomerate – Galaxy Sign

CT WITH GALAXY SIGN
SARCOIDOSIS, ACTIVE – ALVEOLAR FORM
48-year-old previously well presented with dyspnea and initial CXR showed an infiltrate at the right base, and clinically resolved. He presented a year later with right chest pain and low grade ever and the CXR showed patchy opacities in the LUL and in the RLL
A subsequent CT showed LUL nodular opacities and subpleural rim of consolidation in the LUL and more prominently at both lung bases, associated with significant mediastinal adenopathy. Lymphovacscular nodularity was noted in the bronchovascular bundles as well as in the interlobular septa, consistent with sarcoidosis
CXR and CT 4 years later showed almost complete resolution of the parenchymal findings and the CT findings except for minimal reticulation and scarring in the subpleural regions
Ashley Davidoff MD
CT WITH LYMPHOVASCULAR NODULES
SARCOIDOSIS, ACTIVE – ALVEOLAR FORM
48-year-old previously well presented with dyspnea and initial CXR showed an infiltrate at the right base, and clinically resolved. He presented a year later with right chest pain and low grade ever and the CXR showed patchy opacities in the LUL and in the RLL
A subsequent CT showed LUL nodular opacities and subpleural rim of consolidation in the LUL and more prominently at both lung bases, associated with significant mediastinal adenopathy. Lymphovacscular nodularity was noted in the bronchovascular bundles as well as in the interlobular septa, consistent with sarcoidosis
CXR and CT 4 years later showed almost complete resolution of the parenchymal findings and the CT findings except for minimal reticulation and scarring in the subpleural regions
Ashley Davidoff MD
GALAXY SIGN
CT WITH SUBPLEURAL NODULES AND MULTIPLE VARIABLY SIZED LEFT APICAL SOLID NODULES
Ashley Davidoff MD The CommonVein.net
AIRWAY COMPRESSION (arrow)
SARCOIDOSIS, STAGE IV, PTX, ENCASEMENT
50-year-old male presents with history of Stage 4 sarcoidosis acute chest pain and dyspnea
The initial CXR shows a left sided pneumothorax, diffuse nodular pattern with confluent perihilar infiltrates and a left pleural effusion
A chest tube was placed and a chest CT showed confluent fibrotic masses in the hilar regions totally surrounding the bronchovascular bundles with encasement of the middle lobe artery. In addition, multiple lymphovascular micronodules are demonstrated. The pulmonary artery measures 32.7mm indicating pulmonary hypertension.
A CXR during this admission shows re-expansion of the pneumothorax. Left lung volume is reduced.
The patient presents 2 years later, again with progressive dyspnea and chest pain and CT PA shows encasement of the airways, right middle lobe pulmonary artery and left lower pulmonary vein by the fibrotic broncho vascular masses, and non-occlusive, subacute pulmonary embolus of the LPA. There are moderate bilateral pleural effusions, calcified lymph nodes, with ongoing pulmonary hypertension with right ventricular enlargement, right atrial enlargement, tricuspid regurgitation and pulmonary hypertension. At this time the patient is intubated.
He again presents 1 month after with chest pain and dyspnea. At this time, he has a tracheostomy. The scout frontal view shows persistent encasement of the left upper lobe bronchus and significant reduction on the volume of the left lung with elevated left hemidiaphragm.
CT PA has similar findings with a large right pleural effusion and unresolved large non occlusive thrombus in the left pulmonary artery.
Ashley Davidoff MD
SARCOIDOSIS, STAGE IV, PTX, ENCASEMENT of RML ARTERY (red arrow) TRICUSPID REGURGITATION
50-year-old male presents with history of Stage 4 sarcoidosis acute chest pain and dyspnea
The initial CXR shows a left sided pneumothorax, diffuse nodular pattern with confluent perihilar infiltrates and a left pleural effusion
A chest tube was placed and a chest CT showed confluent fibrotic masses in the hilar regions totally surrounding the bronchovascular bundles with encasement of the middle lobe artery. In addition, multiple lymphovascular micronodules are demonstrated. The pulmonary artery measures 32.7mm indicating pulmonary hypertension.
A CXR during this admission shows re-expansion of the pneumothorax. Left lung volume is reduced.
The patient presents 2 years later, again with progressive dyspnea and chest pain and CT PA shows encasement of the airways, right middle lobe pulmonary artery and left lower pulmonary vein by the fibrotic broncho vascular masses, and non-occlusive, subacute pulmonary embolus of the LPA. There are moderate bilateral pleural effusions, calcified lymph nodes, with ongoing pulmonary hypertension with right ventricular enlargement, right atrial enlargement, tricuspid regurgitation and pulmonary hypertension. At this time the patient is intubated.
He again presents 1 month after with chest pain and dyspnea. At this time, he has a tracheostomy. The scout frontal view shows persistent encasement of the left upper lobe bronchus and significant reduction on the volume of the left lung with elevated left hemidiaphragm.
CT PA has similar findings with a large right pleural effusion and unresolved large non occlusive thrombus in the left pulmonary artery.
Ashley Davidoff MD
SARCOIDOSIS, STAGE IV, PTX, ENCASEMENT of LEFT LOWER LOBE PA (red arrow)
50-year-old male presents with history of Stage 4 sarcoidosis acute chest pain and dyspnea
The initial CXR shows a left sided pneumothorax, diffuse nodular pattern with confluent perihilar infiltrates and a left pleural effusion
A chest tube was placed and a chest CT showed confluent fibrotic masses in the hilar regions totally surrounding the bronchovascular bundles with encasement of the middle lobe artery. In addition, multiple lymphovascular micronodules are demonstrated. The pulmonary artery measures 32.7mm indicating pulmonary hypertension.
A CXR during this admission shows re-expansion of the pneumothorax. Left lung volume is reduced.
The patient presents 2 years later, again with progressive dyspnea and chest pain and CT PA shows encasement of the airways, right middle lobe pulmonary artery and left lower pulmonary vein by the fibrotic broncho vascular masses, and non-occlusive, subacute pulmonary embolus of the LPA. There are moderate bilateral pleural effusions, calcified lymph nodes, with ongoing pulmonary hypertension with right ventricular enlargement, right atrial enlargement, tricuspid regurgitation and pulmonary hypertension. At this time the patient is intubated.
He again presents 1 month after with chest pain and dyspnea. At this time, he has a tracheostomy. The scout frontal view shows persistent encasement of the left upper lobe bronchus and significant reduction on the volume of the left lung with elevated left hemidiaphragm.
CT PA has similar findings with a large right pleural effusion and unresolved large non occlusive thrombus in the left pulmonary artery.
Ashley Davidoff MD

 

    • UPPER LOBE LUNG NODULES (red arrows) AND BRONCHIOLECTASIS (green arrow)-MEDIASTINAL ADENOPATHY (yellow asterisk) (Ref TCV Sarcoidosis and Takotsubo Heart)
      Ashley Davidoff MD
    • Cluster of Solid Nodules

    • CT WITH SUBPLEURAL NODULES AND MULTIPLE VARIABLY SIZED LEFT APICAL SOLID NODULES
      Ashley Davidoff MD
    • Stellate or Flame Shaped
    • STELLATE OR FLAME SHAPED NODULE
      Ashley Davidoff MD

      STELLATE OR FLAME SHAPED NODULE
      Ashley Davidoff MD
Calcified
CALCIFIED NODULES NOTE MEDIAL NODULE IS SURROUNDED BY SOFT TISSUE OF THE GRANULOMA (green arrow)
Ashley Davidoff MD
Semi Solid
SEMI SOLID NODULE (red arrow) and FISSURAL NODULE (green arrow)
Ashley Davidoff MD
Ground Glass
GROUND GLASS OPACITY
Ashley Davidoff MD
Galaxy
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, 

CT WITH GALAXY SIGN
Ashley Davidoff MD
GALAXY SIGN
Ashley Davidoff MD
GALAXY SIGN
CT WITH SUBPLEURAL NODULES AND MULTIPLE VARIABLY SIZED LEFT APICAL SOLID NODULES
Ashley Davidoff MD

Calcified

40 year old female with a history of sarcoidosis
CT scan shows a 6mm nodule with central calcification in the ligula and ground glass nodules in the middle lobe
Ashley Davidoff
TheCommonVein.net
70060c
40 year old female with a history of sarcoidosis
CT scan shows a 6mm nodule with central calcification
Ashley Davidoff
TheCommonVein.net
70060b

Miliary

SARCOIDOSIS vs SILICOSIS
Ashley Davidoff MD