대한흉부영상의학회 Weekly Chest Cases

Case No : 1384 Date 2024-05-01

Courtesy of Bok dong Yeo, Jongmin Park, Jaekwang Lim / Kyungpook National University Hospital
Age/Sex 75 / M
Chief ComplaintRheumatic arthritis, multiple lung nodules on chest radiograph and CT.

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 9

Diagnosis With Brief Discussion

Diagnosis: Necrobiotic (rheumatoid) nodule
Radiologic Findings: Fig 1. Chest PA shows a few nodular consolidation in both lung zone. Both CP angles were clear.
Fig 2-6. CT scans reveals multiple low density solid nodules(average HU 40-50) with partial calcification. Enhancement was not evident.
Fig 7-9. After 8 months, size and number of lung nodules slightly increased. Still, there was no evident enhancement of nodules.
Brief Review: Rheumatoid nodules are highly specific for RA and occur in 20% of patients, with a predilection in men and patients who smoke cigarettes. Lung nodules are associated with subcutaneous nodules in 80% of cases. The two are histologically identical, demonstrating central fibrinoid necrosis surrounded by palisading epithelioid histiocytes and peripheral chronic inflammatory cells.
Rheumatoid lung nodules at CT are round or lobulated, several millimeters to several centimeters in size, and often peripheral with mid upper lung predominance. They are commonly multiple but may manifest as a single nodule. Calcification can be found. Nodules may increase in size and number, remain stable for years, or resolve spontaneously. Patients are typically asymptomatic but may develop symptoms if nodules cavitate or erode into the pleural space.
Rheumatoid patients with rheumatoid lung nodules are more likely to manifest subcutaneous rheumatoid nodules and seropositivity and tend to be younger than those with malignancy but a history of smoking is common in both groups. When compared to malignancies in the lung, rheumatoid lung nodules appear to have distinctive imaging features including multiplicity, smooth border, satellite nodules, cavitation, and peripheral location with occasionally associated subpleural rind of confluent soft tissue. Rheumatoid lung nodules manifest low to moderate FDG avidity and are not associated with FDG-avid draining lymph nodes.
References: 1. Groner, L. K., Green, D. B., Weisman, S. V., Legasto, A. C., Toy, D., Gruden, J. F., & Escalon, J. G. (2021). Thoracic manifestations of rheumatoid arthritis. Radiographics, 41(1), 32-55.
2. Koslow, M., Young, J.R., Yi, E.S. et al. Rheumatoid pulmonary nodules: clinical and imaging features compared with malignancy. Eur Radiol 29, 1684–1692 (2019).
Keywords

No. of Applicants : 78

▶ Correct Answer : 29/78, 37.2%

- Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
- ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
- Shiga University of Medical Science , Japan AKITOSHI INOUE
- McGill University Health Center , Canada ALEXANDRE SEMIONOV
- Oita university , Japan AYUMI KAMEI
- NIMS, HYDERABAD , India BHASKAR K
- , Korea (South) JIN YOUNG LEE
- , China FANG YING GEN
- Seoul Medical Center , Korea (South) HYUK GI HONG
- , Korea (South) KANGHWI LEE
- Uniyersity of Yamanashi , Japan TAKAAKI HASHIMOTO
- , Japan KENTARO KOTANI
- Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
- Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
- Shiga General Hospital , Japan YUSAKU MORIBATA
- Korea University Guro Hospital , Korea (South) LEE DAKYONG
- Kyoto university , Japan HIROKAZU SAWAMURA
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- Other , Korea (South) JY LEE
- TB centre kasaragod. , India rikhy krishnan
- Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
- Hyogo Prefectural Kobe Children , Japan SHUHEI NORIMOTO
- Pusan National University Yangsan Hospital , Korea (South) JI HWAN KIM
- Inje University Pusan Paik Hospital , Korea (South) GEOJEONG SEO
- , Japan YUMI MAEHARA
- Toyota Kosei Hospital , Japan YUKI HAYASHI
- The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
- Juntendo University , Japan YUTAKA IKENOUCHI
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Correct Answer as Differential Diagnosis : 38/78, 48.7%

- , Japan SUZUNE TSUKAMOTO
- medical scanning , Japan HIROAKI ARAKAWA
- Kyoto University , Japan AKIHIKO SAKATA
- Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
- , Korea (South) DONG-HO BANG
- Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Other , Korea (South) SEONGSU KANG
- Secomedic Hospital , Japan FUMINORI MIYOSHI
- Oita University, Faculty of Medicine , Japan FUMITO OKADA
- Osaka University , Japan AKINORI HATA
- Mie University , Japan HIKARI FUKUI
- University of Yamanashi , Japan HIROYUKI MORISAKA
- Other , Korea (South) HYEJOO PARK
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- , Japan YOSHIKI ISHII
- University of Yamanashi , Japan HIROAKI WATANABE
- Gifu University Hospital , Japan Yo Kaneko
- Nankai medical center , Japan NORITAKA KAMEI
- Kyoto University Hospital , Japan YASUHISA KURATA
- MAGNUM DIAGNOSTICS - Goa INDIA , India PARESH K DESAI
- , Japan SHUNJIRO NOGUCHI
- Ome Medical Center , Japan MIKIYA FUJII
- Mie university , Japan MIYUKO FUJITA
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
- Osaka metropolitan university Hospital , Japan TATSUSHI OURA
- Mie university , Japan SHIKO OKABE
- GHICL , France MANUEL TOLEDANO
- Manipal hospital Hebbal, Bengaluru , India PRAVIN KUMAR M
- Paras hospital, Panchkula , India SHALEEN RANA
- Kyoto University , Japan SHO KOYASU
- Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
- Fukuoka university , Japan KEISUKE SATO
- Kantou Rousai Hospital , Japan KAORU SUMIDA
- Matsunami General Hospital , Japan TARO TAKEDA
- University of Yamanashi , Japan TIHAN WUMU
- University of Yamanashi , Japan KOJIRO ONOHARA

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1384 Date 2024-05-01

Discussion

No. of Applicants : 78