Broncholithiasis: Review of the Causes with Radiologic-Pathologic Correlation1
Joon Beom Seo, MD,
Koun-Sik Song, MD,
Jin Seong Lee, MD,
Jin Mo Goo, MD,
Hyae Young Kim, MD,
Jae-Woo Song, MD,
In Sun Lee, MD and
Tae-Hwan Lim, MD
1 From the Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea (J.B.S., K.S.S., J.S.L., I.S.L., T.H.L.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.G.); Institute of Radiation Medicine, SNUMRC, Seoul, Korea (J.M.G.); Department of Radiology, National Cancer Center, Seoul, Korea (H.Y.K.); and Department of Radiology, Seoul Municipal Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea (J.W.S.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received January 31, 2002; revision requested March 19 and received May 1; accepted May 21. Address correspondence to J.B.S. (e-mail: seojb@www.amc.seoul.kr).
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Figure 1a. Broncholithiasis due to extrusion of a calcified lymph node in a 41-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows an irregular calcified nodule in the right lower lung zone (arrow). Also seen are multiple calcified lymph nodes at the right hilum (arrowhead). (b, c) CT scans (mediastinal window, b; lung window, c) show a calcified nodule within a dilated bronchus (arrow). (d) Photograph of the resected specimen shows a yellowish brown calcified nodule within a bronchiectatic cavity (arrow). It proved to be a calcified lymph node at microscopic examination. Another small, calcified lymph node is adjacent to the broncholith (arrowhead). Although broncholithiasis is thought to be related to tuberculosis, no organism was identified with acid-fast staining.
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Figure 1b. Broncholithiasis due to extrusion of a calcified lymph node in a 41-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows an irregular calcified nodule in the right lower lung zone (arrow). Also seen are multiple calcified lymph nodes at the right hilum (arrowhead). (b, c) CT scans (mediastinal window, b; lung window, c) show a calcified nodule within a dilated bronchus (arrow). (d) Photograph of the resected specimen shows a yellowish brown calcified nodule within a bronchiectatic cavity (arrow). It proved to be a calcified lymph node at microscopic examination. Another small, calcified lymph node is adjacent to the broncholith (arrowhead). Although broncholithiasis is thought to be related to tuberculosis, no organism was identified with acid-fast staining.
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Figure 1c. Broncholithiasis due to extrusion of a calcified lymph node in a 41-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows an irregular calcified nodule in the right lower lung zone (arrow). Also seen are multiple calcified lymph nodes at the right hilum (arrowhead). (b, c) CT scans (mediastinal window, b; lung window, c) show a calcified nodule within a dilated bronchus (arrow). (d) Photograph of the resected specimen shows a yellowish brown calcified nodule within a bronchiectatic cavity (arrow). It proved to be a calcified lymph node at microscopic examination. Another small, calcified lymph node is adjacent to the broncholith (arrowhead). Although broncholithiasis is thought to be related to tuberculosis, no organism was identified with acid-fast staining.
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Figure 1d. Broncholithiasis due to extrusion of a calcified lymph node in a 41-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows an irregular calcified nodule in the right lower lung zone (arrow). Also seen are multiple calcified lymph nodes at the right hilum (arrowhead). (b, c) CT scans (mediastinal window, b; lung window, c) show a calcified nodule within a dilated bronchus (arrow). (d) Photograph of the resected specimen shows a yellowish brown calcified nodule within a bronchiectatic cavity (arrow). It proved to be a calcified lymph node at microscopic examination. Another small, calcified lymph node is adjacent to the broncholith (arrowhead). Although broncholithiasis is thought to be related to tuberculosis, no organism was identified with acid-fast staining.
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Figure 2a. Broncholithiasis due to calcification of an aspirated foreign body in a 53-year-old man who presented with cough. (a, b) Posteroanterior (a) and lateral (b) radiographs show combined atelectasis of the right middle and lower lobes. A calcified irregular nodule is in the infrahilar area on the lateral chest radiograph (arrow, b). (c) CT scan shows a calcified nodule in the bronchus intermedius with atelectasis of the right lower lobe (arrow). (d) Bronchoscopic image shows a brownish, hard material in the bronchus intermedius. When removed bronchoscopically, it was found to be vegetable fiber with dystrophic calcification.
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Figure 2b. Broncholithiasis due to calcification of an aspirated foreign body in a 53-year-old man who presented with cough. (a, b) Posteroanterior (a) and lateral (b) radiographs show combined atelectasis of the right middle and lower lobes. A calcified irregular nodule is in the infrahilar area on the lateral chest radiograph (arrow, b). (c) CT scan shows a calcified nodule in the bronchus intermedius with atelectasis of the right lower lobe (arrow). (d) Bronchoscopic image shows a brownish, hard material in the bronchus intermedius. When removed bronchoscopically, it was found to be vegetable fiber with dystrophic calcification.
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Figure 2c. Broncholithiasis due to calcification of an aspirated foreign body in a 53-year-old man who presented with cough. (a, b) Posteroanterior (a) and lateral (b) radiographs show combined atelectasis of the right middle and lower lobes. A calcified irregular nodule is in the infrahilar area on the lateral chest radiograph (arrow, b). (c) CT scan shows a calcified nodule in the bronchus intermedius with atelectasis of the right lower lobe (arrow). (d) Bronchoscopic image shows a brownish, hard material in the bronchus intermedius. When removed bronchoscopically, it was found to be vegetable fiber with dystrophic calcification.
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Figure 2d. Broncholithiasis due to calcification of an aspirated foreign body in a 53-year-old man who presented with cough. (a, b) Posteroanterior (a) and lateral (b) radiographs show combined atelectasis of the right middle and lower lobes. A calcified irregular nodule is in the infrahilar area on the lateral chest radiograph (arrow, b). (c) CT scan shows a calcified nodule in the bronchus intermedius with atelectasis of the right lower lobe (arrow). (d) Bronchoscopic image shows a brownish, hard material in the bronchus intermedius. When removed bronchoscopically, it was found to be vegetable fiber with dystrophic calcification.
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Figure 3. Calcified peribronchial lymph node without intraluminal protrusion that mimicked a broncholith in a 67-year-old woman who presented with fever and blood-tinged sputum. CT scan obtained at the level of the left atrium shows atelectasis of the right middle lobe. Calcified lymph nodes adjacent to the bronchus (arrow) are suggestive of broncholithiasis. At bronchoscopy, the right middle lobar bronchus was narrow and inflamed, without evidence of an intraluminal location of the lymph node. Some authors may regard this case as a broncholithiasis when they use the broader definition of the term, even though the calcified material is not within the bronchus.
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Figure 4. Utility of volumetric data acquisition with helical CT in the diagnosis of broncholithiasis in a 69-year-old woman who presented with hemoptysis. Serial CT scans obtained with a single breath hold, 3-mm collimation, pitch of 1, and a 3-mm reconstruction interval help confirm the endobronchial location of a calcified nodule in the basal bronchus of the right lower lobe (arrows). Enlargement of the left atrium is due to mitral stenosis. Bronchoscopy revealed a calcified nodule within the basal bronchus of the right lower lobe. Because the nodule was fixed to the bronchial wall, bronchoscopic removal was not performed.
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Figure 5a. Utility of thin-section helical CT and multiplanar reformation in the detection of a small broncholith in a 45-year-old woman who presented with cough. (a) CT scan obtained with 8-mm collimation shows a tubular calcified lesion in the right lower lobe (arrow). An area of peripheral air trapping (arrowheads) and suspicious bronchial structure seen at the medial portion of the nodule suggest an endobronchial location of the lesion. (b) CT scan obtained with 2.5-mm collimation and a wide window setting clearly shows the proximal part of the bronchus (arrow) and an impacted endobronchial calcified lesion. (c) Multiplanar reformatted image obtained with volumetric CT data also clearly shows the broncholith (arrow).
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Figure 5b. Utility of thin-section helical CT and multiplanar reformation in the detection of a small broncholith in a 45-year-old woman who presented with cough. (a) CT scan obtained with 8-mm collimation shows a tubular calcified lesion in the right lower lobe (arrow). An area of peripheral air trapping (arrowheads) and suspicious bronchial structure seen at the medial portion of the nodule suggest an endobronchial location of the lesion. (b) CT scan obtained with 2.5-mm collimation and a wide window setting clearly shows the proximal part of the bronchus (arrow) and an impacted endobronchial calcified lesion. (c) Multiplanar reformatted image obtained with volumetric CT data also clearly shows the broncholith (arrow).
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Figure 5c. Utility of thin-section helical CT and multiplanar reformation in the detection of a small broncholith in a 45-year-old woman who presented with cough. (a) CT scan obtained with 8-mm collimation shows a tubular calcified lesion in the right lower lobe (arrow). An area of peripheral air trapping (arrowheads) and suspicious bronchial structure seen at the medial portion of the nodule suggest an endobronchial location of the lesion. (b) CT scan obtained with 2.5-mm collimation and a wide window setting clearly shows the proximal part of the bronchus (arrow) and an impacted endobronchial calcified lesion. (c) Multiplanar reformatted image obtained with volumetric CT data also clearly shows the broncholith (arrow).
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Figure 6a. Broncholithiasis due to extrusion of a calcified lymph node in a 50-year-old man who presented with cough and who had undergone treatment with antituberculous drugs owing to microscopically proved pulmonary tuberculosis 10 years previously. (a) Posteroanterior radiograph shows consolidation in the left perihilar area. A small, radiopaque nodule is seen in the central portion of the lesion (arrowhead). (b) CT scan shows a small, irregular calcified nodule in the superior segmental bronchus of the left lower lobe (arrow) with peripheral consolidation and nodular opacity. Also seen are calcified lymph nodes at the subcarinal nodal station and adjacent to segmental bronchi of the right middle lobe and right lower lobe (arrowheads). Bronchoscopy revealed a broncholith, which was removed.
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Figure 6b. Broncholithiasis due to extrusion of a calcified lymph node in a 50-year-old man who presented with cough and who had undergone treatment with antituberculous drugs owing to microscopically proved pulmonary tuberculosis 10 years previously. (a) Posteroanterior radiograph shows consolidation in the left perihilar area. A small, radiopaque nodule is seen in the central portion of the lesion (arrowhead). (b) CT scan shows a small, irregular calcified nodule in the superior segmental bronchus of the left lower lobe (arrow) with peripheral consolidation and nodular opacity. Also seen are calcified lymph nodes at the subcarinal nodal station and adjacent to segmental bronchi of the right middle lobe and right lower lobe (arrowheads). Bronchoscopy revealed a broncholith, which was removed.
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Figure 7a. Broncholithiasis due to extrusion of a calcified lymph node in a 61-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows consolidation in the right lower lobe. Calcified granulomas in the right apex (boxed area) and calcified right paratracheal lymph nodes due to previous tuberculosis (arrowheads) are also shown. (b) CT scan shows a calcified nodule (arrowhead) in the anterior basal segmental bronchus of the right lower lobe with atelectasis. (c) Bronchoscopic image shows a yellowish hard material with surrounding granulation tissue (arrow), which was removed.
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Figure 7b. Broncholithiasis due to extrusion of a calcified lymph node in a 61-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows consolidation in the right lower lobe. Calcified granulomas in the right apex (boxed area) and calcified right paratracheal lymph nodes due to previous tuberculosis (arrowheads) are also shown. (b) CT scan shows a calcified nodule (arrowhead) in the anterior basal segmental bronchus of the right lower lobe with atelectasis. (c) Bronchoscopic image shows a yellowish hard material with surrounding granulation tissue (arrow), which was removed.
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Figure 7c. Broncholithiasis due to extrusion of a calcified lymph node in a 61-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows consolidation in the right lower lobe. Calcified granulomas in the right apex (boxed area) and calcified right paratracheal lymph nodes due to previous tuberculosis (arrowheads) are also shown. (b) CT scan shows a calcified nodule (arrowhead) in the anterior basal segmental bronchus of the right lower lobe with atelectasis. (c) Bronchoscopic image shows a yellowish hard material with surrounding granulation tissue (arrow), which was removed.
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Figure 8a. Broncholithiasis due to aspirated calcified material in a 48-year-old woman who presented with cough. (a) CT scan shows a tubular calcified lesion at the orifice of the left upper lobar bronchus (arrow). (b) Three-dimensional image obtained with a volume-rendering technique clearly shows the lesion with yellow color (arrow) within the bronchus. (c) Photograph obtained after bronchoscopic removal shows the lesion was an anchovy.
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Figure 8b. Broncholithiasis due to aspirated calcified material in a 48-year-old woman who presented with cough. (a) CT scan shows a tubular calcified lesion at the orifice of the left upper lobar bronchus (arrow). (b) Three-dimensional image obtained with a volume-rendering technique clearly shows the lesion with yellow color (arrow) within the bronchus. (c) Photograph obtained after bronchoscopic removal shows the lesion was an anchovy.
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Figure 8c. Broncholithiasis due to aspirated calcified material in a 48-year-old woman who presented with cough. (a) CT scan shows a tubular calcified lesion at the orifice of the left upper lobar bronchus (arrow). (b) Three-dimensional image obtained with a volume-rendering technique clearly shows the lesion with yellow color (arrow) within the bronchus. (c) Photograph obtained after bronchoscopic removal shows the lesion was an anchovy.
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Figure 9a. Calcified aspergilloma within a dilated bronchus mimicking broncholithiasis in a 31-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows a round mass with nodular calcification in the left lower zone (arrow). (b) CT scan shows the mass within an ectatic bronchus with an air crescent sign (arrow). At pathologic examination, the entire mycelial mass was within the bronchus and without evidence of parenchymal invasion. The high-attenuation area seen at CT was dystrophic calcification of the fungus ball.
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Figure 9b. Calcified aspergilloma within a dilated bronchus mimicking broncholithiasis in a 31-year-old woman who presented with hemoptysis. (a) Posteroanterior radiograph shows a round mass with nodular calcification in the left lower zone (arrow). (b) CT scan shows the mass within an ectatic bronchus with an air crescent sign (arrow). At pathologic examination, the entire mycelial mass was within the bronchus and without evidence of parenchymal invasion. The high-attenuation area seen at CT was dystrophic calcification of the fungus ball.
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Figure 10a. Primary endobronchial actinomycosis with dystrophic calcification mimicking broncholithiasis in a 61-year-old man who presented with left-sided chest pain. (a) CT scan shows a calcified nodule within the bronchus of the lingular division of the left upper lobe (arrow) with peripheral atelectasis. At bronchoscopy, a yellowish, hard material was seen to obstruct the bronchial lumen. Because the lesion was firmly attached to the bronchial wall, removal of it with a bronchoscopic forceps was impossible. (b) Photomicrograph (original magnification, x10; H-E stain) of a section obtained along the axis of the bronchus shows that the mass was partly calcified ( ) and within the bronchus but did not infiltrate into the pulmonary parenchyma. There was no evidence of a coexisting foreign material or a calcified lymph node. (c) Photomicrograph (original magnification, x400; H-E stain) shows sulfur granules surrounded by eosinophilic "clubbing" materials (arrows); this finding is typical for actinomycosis. (Reprinted, with permission, from reference 21.)
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Figure 10b. Primary endobronchial actinomycosis with dystrophic calcification mimicking broncholithiasis in a 61-year-old man who presented with left-sided chest pain. (a) CT scan shows a calcified nodule within the bronchus of the lingular division of the left upper lobe (arrow) with peripheral atelectasis. At bronchoscopy, a yellowish, hard material was seen to obstruct the bronchial lumen. Because the lesion was firmly attached to the bronchial wall, removal of it with a bronchoscopic forceps was impossible. (b) Photomicrograph (original magnification, x10; H-E stain) of a section obtained along the axis of the bronchus shows that the mass was partly calcified () and within the bronchus but did not infiltrate into the pulmonary parenchyma. There was no evidence of a coexisting foreign material or a calcified lymph node. (c) Photomicrograph (original magnification, x400; H-E stain) shows sulfur granules surrounded by eosinophilic "clubbing" materials (arrows); this finding is typical for actinomycosis. (Reprinted, with permission, from reference 21.)
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Figure 10c. Primary endobronchial actinomycosis with dystrophic calcification mimicking broncholithiasis in a 61-year-old man who presented with left-sided chest pain. (a) CT scan shows a calcified nodule within the bronchus of the lingular division of the left upper lobe (arrow) with peripheral atelectasis. At bronchoscopy, a yellowish, hard material was seen to obstruct the bronchial lumen. Because the lesion was firmly attached to the bronchial wall, removal of it with a bronchoscopic forceps was impossible. (b) Photomicrograph (original magnification, x10; H-E stain) of a section obtained along the axis of the bronchus shows that the mass was partly calcified () and within the bronchus but did not infiltrate into the pulmonary parenchyma. There was no evidence of a coexisting foreign material or a calcified lymph node. (c) Photomicrograph (original magnification, x400; H-E stain) shows sulfur granules surrounded by eosinophilic "clubbing" materials (arrows); this finding is typical for actinomycosis. (Reprinted, with permission, from reference 21.)
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Figure 11a. Atypical carcinoid with ossification mimicking broncholithiasis in a 41-year-old man who presented with dyspnea. (a) Magnified view of a posteroanterior radiograph shows a nodular opacity at the right hilum (arrow). (b) CT scan shows a sharply defined, totally ossified mass (arrow) centrally situated in the right lower lobar bronchus; the mass produces abrupt bronchial obstruction. Analysis of the resected specimen revealed atypical carcinoid, the majority of which was ossified.
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Figure 11b. Atypical carcinoid with ossification mimicking broncholithiasis in a 41-year-old man who presented with dyspnea. (a) Magnified view of a posteroanterior radiograph shows a nodular opacity at the right hilum (arrow). (b) CT scan shows a sharply defined, totally ossified mass (arrow) centrally situated in the right lower lobar bronchus; the mass produces abrupt bronchial obstruction. Analysis of the resected specimen revealed atypical carcinoid, the majority of which was ossified.
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Figure 12a. Calcified endobronchial hamartoma mimicking broncholithiasis in a 48-year-old man who presented with cough. Chest radiography (not shown) revealed atelectasis of the right upper lobe. (a) CT scan shows a small, calcified nodule obstructing the right upper lobar bronchus (arrow). (b) Bronchoscopic image shows a yellowish movable mass at the orifice of the right upper lobar bronchus (arrow). Bronchoscopic biopsy revealed chronic inflammation. (c) Photograph of the resected specimen shows a round, reddish endobronchial mass (arrow). The cut surface of the mass was white and firm (not shown). (d) Photomicrograph (original magnification, x100; H-E stain) shows the mass is covered with normal respiratory epithelium. Areas of bone and cartilage tissue () and mature fat tissue are mixed.
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Figure 12b. Calcified endobronchial hamartoma mimicking broncholithiasis in a 48-year-old man who presented with cough. Chest radiography (not shown) revealed atelectasis of the right upper lobe. (a) CT scan shows a small, calcified nodule obstructing the right upper lobar bronchus (arrow). (b) Bronchoscopic image shows a yellowish movable mass at the orifice of the right upper lobar bronchus (arrow). Bronchoscopic biopsy revealed chronic inflammation. (c) Photograph of the resected specimen shows a round, reddish endobronchial mass (arrow). The cut surface of the mass was white and firm (not shown). (d) Photomicrograph (original magnification, x100; H-E stain) shows the mass is covered with normal respiratory epithelium. Areas of bone and cartilage tissue () and mature fat tissue are mixed.
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Figure 12c. Calcified endobronchial hamartoma mimicking broncholithiasis in a 48-year-old man who presented with cough. Chest radiography (not shown) revealed atelectasis of the right upper lobe. (a) CT scan shows a small, calcified nodule obstructing the right upper lobar bronchus (arrow). (b) Bronchoscopic image shows a yellowish movable mass at the orifice of the right upper lobar bronchus (arrow). Bronchoscopic biopsy revealed chronic inflammation. (c) Photograph of the resected specimen shows a round, reddish endobronchial mass (arrow). The cut surface of the mass was white and firm (not shown). (d) Photomicrograph (original magnification, x100; H-E stain) shows the mass is covered with normal respiratory epithelium. Areas of bone and cartilage tissue () and mature fat tissue are mixed.
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Figure 12d. Calcified endobronchial hamartoma mimicking broncholithiasis in a 48-year-old man who presented with cough. Chest radiography (not shown) revealed atelectasis of the right upper lobe. (a) CT scan shows a small, calcified nodule obstructing the right upper lobar bronchus (arrow). (b) Bronchoscopic image shows a yellowish movable mass at the orifice of the right upper lobar bronchus (arrow). Bronchoscopic biopsy revealed chronic inflammation. (c) Photograph of the resected specimen shows a round, reddish endobronchial mass (arrow). The cut surface of the mass was white and firm (not shown). (d) Photomicrograph (original magnification, x100; H-E stain) shows the mass is covered with normal respiratory epithelium. Areas of bone and cartilage tissue () and mature fat tissue are mixed.
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Figure 13a. Bronchial amyloidosis with mural calcification mimicking broncholithiasis in a 53-year-old woman. (a, b) CT scans show localized thickening of the bronchial wall with calcification and partial intraluminal protrusion (arrow, a; arrows, b). (c) Photomicrograph (original magnification, x65; H-E stain) of the transbronchial lung biopsy specimen shows eosinophilic material (arrow) in the perivascular space. (d) Photomicrograph (original magnification, x65; Congo red stain under polarized light) shows apple green birefringent material (arrows). (Fig 13 b-d reprinted, with permission, from reference 28.)
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Figure 13b. Bronchial amyloidosis with mural calcification mimicking broncholithiasis in a 53-year-old woman. (a, b) CT scans show localized thickening of the bronchial wall with calcification and partial intraluminal protrusion (arrow, a; arrows, b). (c) Photomicrograph (original magnification, x65; H-E stain) of the transbronchial lung biopsy specimen shows eosinophilic material (arrow) in the perivascular space. (d) Photomicrograph (original magnification, x65; Congo red stain under polarized light) shows apple green birefringent material (arrows). (Fig 13 b-d reprinted, with permission, from reference 28.)
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Figure 13c. Bronchial amyloidosis with mural calcification mimicking broncholithiasis in a 53-year-old woman. (a, b) CT scans show localized thickening of the bronchial wall with calcification and partial intraluminal protrusion (arrow, a; arrows, b). (c) Photomicrograph (original magnification, x65; H-E stain) of the transbronchial lung biopsy specimen shows eosinophilic material (arrow) in the perivascular space. (d) Photomicrograph (original magnification, x65; Congo red stain under polarized light) shows apple green birefringent material (arrows). (Fig 13 b-d reprinted, with permission, from reference 28.)
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Figure 13d. Bronchial amyloidosis with mural calcification mimicking broncholithiasis in a 53-year-old woman. (a, b) CT scans show localized thickening of the bronchial wall with calcification and partial intraluminal protrusion (arrow, a; arrows, b). (c) Photomicrograph (original magnification, x65; H-E stain) of the transbronchial lung biopsy specimen shows eosinophilic material (arrow) in the perivascular space. (d) Photomicrograph (original magnification, x65; Congo red stain under polarized light) shows apple green birefringent material (arrows). (Fig 13 b-d reprinted, with permission, from reference 28.)
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Figure 14a. Hypertrophied bronchial artery at enhanced CT mimicking broncholithiasis in a 41-year-old woman. (a) Contrast-enhanced CT scan shows a high-attenuation nodular structure (arrow) at the bifurcation of the bronchus intermedius, which mimics broncholithiasis. (b) Thin-section CT scan reveals that the high-attenuation structure in a is not calcified. (Reprinted, with permission, from reference 31.)
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Figure 14b. Hypertrophied bronchial artery at enhanced CT mimicking broncholithiasis in a 41-year-old woman. (a) Contrast-enhanced CT scan shows a high-attenuation nodular structure (arrow) at the bifurcation of the bronchus intermedius, which mimics broncholithiasis. (b) Thin-section CT scan reveals that the high-attenuation structure in a is not calcified. (Reprinted, with permission, from reference 31.)
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Copyright © 2002 by the Radiological Society of North America.
