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

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

Micronodules

Larger Nodules

Ground Glass

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