Archived case 221 · April 24-May 1, 2017
Primary Adenocarcinoma, bilateral
65 y/o male, nonsmoker with dry cough and dyspnea for several months
The question posed to readers
Describe the findings.
Images
Imaging findings
Axial and coronal CT images of the chest reveal mixed groundglass and reticular opacities in a relatively symmetric pattern bilaterally. The associated septal thickening is smooth and widespread. This is a good example of “crazy paving.” There is a predilection for the mid and lower lung zones. There does not appear to be a significant amount of fibrotic change, e.g. bronchiectasis, architectural distortion. Answer Diagnosis: Primary Adenocarcinoma, bilateral
Diagnosis
Primary Adenocarcinoma, bilateral
Discussion:
Crazy paving refers to the combination of groundglass and reticular opacities in the lung parenchyma on CT. The linear component of this pattern can be caused by a thickening of the interlobular septa, the intralobular septa/interstitium, or a linear deposition of material within the airspaces at the borders of the acini. It is a nonspecific pattern that can be seen in numerous conditions.
Differential Diagnosis (Partial):
• Alveolar Proteinosis
• Pulmonary Edema
• Pulmonary Hemorrhage
• Lipoid PNA
• Organizing PNA
• Pneumocystis PNA
• Adenocarcinoma
Discussion, cont.
In this case, it is imperative to ensure the resolution of such widespread abnormalities with short-term follow up imaging. Further assessment with bronchoscopy is also indicated in this case.
References and suggested reading
Lee SM, Goo JM, Park CM et-al. A new classification of adenocarcinoma: what the radiologists need to know. Diagn Interv Radiol. 2012;18 (6): 519-26.
Lee CH. The crazy-paving sign. Radiology. 2007;243 (3): 905-6.
Original case written by its authors at Virginia Commonwealth University and published at this address as part of a weekly teaching collection. Reproduced here as an archive.