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Such calcification is secondary to abnormal calcium metabolism without any prior soft tissue damage. The predisposing factors for this condition include chronic renal failure, hypercalcemia such as in primary and secondary hyperparathyroidism, chronic renal failure, sarcoidosis, IV calcium therapy, multiple myeloma and massive osteolysis caused by metastases and increased tissue alkalinity.

The most common imaging features are poorly marginated nodular opacities in the upper zones of the lungs. A frequent associated finding is calcification in the vessels of the chest wall. Many rare non-neoplastic lesions of the lung may mimic lung cancer; these include inflammatory pseudotumor inflammatory myofibroblastic tumor , placental transmogrification of lung, alveolar microlithiasis and metastatic calcification.

Although non-neoplastic, they are nonetheless important to recognize, as their outcome may not necessarily be an innocuous one. The Carney triad is syndrome associated with gastric stromal sarcomas, pulmonary cartilaginous tumors and extra-adrenal paragangliomas. The pulmonary neoplasms in the Carney triad are designated as chondromas and are often misinterpreted clinically and pathologically as metastases from the gastric tumors. The pulmonary neoplasms in the Carney triad are well-differentiated benign cartilaginous tumors that are best designated as chondromas and can be differentiated pathologically from pulmonary cartilaginous PH on the basis of the presence of a thin fibrous pseudocapsule, frequent bone metaplasia, and calcification, and also the absence of entrapped epithelium and fat.

Small calcified lung nodules are often the result of dystrophic calcification in areas of injured lung. Calcified nodules following infections are well defined and often measure mm in diameter. Such nodules often follow healed disseminated histoplasmosis and rarely may follow healed miliary tuberculosis.

Patients with multiple pulmonary nodular calcifications secondary to tuberculosis or histoplasmosis generally have associated calcified hilar or mediastinal lymph nodes. Underlying histopathology findings of typical and atypical CT findings of tuberculosis are caseating granulomas or pneumonia in the active phase and fibrosis and dystrophic calcification in the inactive phase. There is no associated calcification of mediastinal lymph nodes. Miliary diffuse calcific nodules in an adult male with a previous history of Varicella pneumonia.

A chest radiograph shows multiple small calcific nodules in an adult female with a past history of Varicella pneumonia. Hydatid cysts do not normally calcify within the lungs; two calcified hydatid cysts in the superior and posterior mediastinum are seen. Note the calcified hydatid cyst within the left lobe of the liver on the coronal CT reconstruction. Idiopathic pulmonary hemosiderosis causes recurrent episodes of alveolar hemorrhage over several years usually in infants and young adults.

The end result is pulmonary hemosiderosis that causes centrilobular nodular opacities depicted on HRCT. Calcium is often added to the hemosiderin causing increased density of these nodules on imaging. Similar findings of multifocal calcific nodules can occur in patients with secondary hemosiderosis associated with mitral stenosis.

HRCT in patients with silicosis and coal workers' pneumoconiosis show diffuse and randomly distributed small well-defined nodules that are most prominent in the middle and upper lung zones. Stannosis is a condition in which tin oxide is deposited in lung tissue after inhalation. Pleural plaques may mimic PNs on chest radiographs this confusion does not occur with CT [ Figure 33 ]. A chest radiograph shows reticulonodular shadowing with bilateral apical lung fibrosis and high density nodules in coal workers pneumoconiosis.

A chest radiograph shows multiple high density nodules due to a lifetime exposure to hematite and silica. Multiple calcified pleural plaques mimicking PNs on a chest radiographs elegantly depicted on axial CT scan as calcified pleural plaques from previous asbestos exposure.

Two chest radiographs from the same Iron ore worker 10 years apart shows fine high-density nodules left progressing to PMF 10 years later. Pulmonary alveolar microlithiasis is a rare idiopathic lung disorder characterized by the intra-alveolar accumulation of microliths of calcium phosphate. HRCT defines the nodules better as tiny sand-like calcified micronodules distributed bilaterally throughout both lungs.

HRCT showing features of pulmonary alveolar microlithiasis. Note the innumerable calcific nodules bilaterally throughout both lungs giving rise to a sand-like appearance.

Magnesium silicate Talc is often used as a filler in a variety of oral medications. Talcosis is the deposition of Talc within the pulmonary arterioles and capillaries. Eventually, multiple small granulomas composed of multinucleated cells containing birefringent crystals evolve. Talcosis is seen drug addicts who use crushed dissolved tablets for intravenous delivery. With time these nodules can become larger confluent masses. Acrylic cement and sterile barium or tungsten powder opacifier are the elements of a cocktail used to consolidate a collapsed vertebra in a procedure called vertebroplasty.

Pulmonary embolism caused by acrylic cement is a rare complication associated with vertebroplasty. The cement reaches the pulmonary artery via the paravertebral venous plexus.

Conventional radiographs and CT show multiple radio-opaque tubular areas of increased density corresponding to emboli in the segmental and subsegmental levels of the pulmonary arteries. A chest radiograph and coronal reconstruction of CT shows tubular opacities of metallic density due to acrylic cement pulmonary emboli as a complication of vertebroplasty. An axial CT of the same patient as in Figure 34 showing tubular opacities of metallic density due to acrylic cement pulmonary embolism as a complication of vertebroplasty.

Dendriform pulmonary ossification DPO is an uncommon form of diffuse pulmonary ossification that typically affects the pulmonary interstitium in a setting of interstitial fibrosis. DPO is well demonstrated in postmortem examination, and confirmed by microscopy, but rarely diagnosed and virtually never considered clinically. Clinical diagnoses include bronchiectasis and interstitial pneumonitis based on radiographic evidence.

Although such calcification often is invisible on chest radiographs, HRCT performed using the appropriate window settings shows tiny calcific opacities in the periphery of the lung. Diffuse high-attenuation pulmonary abnormalities can result from the deposition of calcium or, less commonly, other high-attenuation material such as talc, amiodarone, iron, mercury and barium sulfate. HRCT is highly sensitive in the detection of areas of abnormally high attenuation in the lung parenchyma, blood vessels and airways.

However, limited information is available on the HRCT findings of diffuse high-attenuation pulmonary abnormalities and the role of CT in the differential diagnosis[ 11 ] [ Figure 37 ].

Section of an HRCT showing amiodarone lung. N ote the high density lung, septal thickening and features of interstitial fibrosis. Disseminated pulmonary ossification can be idiopathic or associated with a variety of pulmonary, cardiac and systemic pathologies. The interstitial dystrophic pulmonary ossification can be focal or diffuse. Dendriform pulmonary ossification is a rare form of diffuse heterotopic bone formation within the lungs.

In chronic pulmonary fibrosis, branching spicules of bone extend through the lung interstitium in a racemose or dendriform manner. High-attenuation consolidation and lung masses may be the result of a variety of drugs, iatrogenic and idiopathic causes.

The tri-iodinated antiarrhythmic drug amiodarone can cause lung toxicity as iodine is deposited in the lungs. The most common CT findings include septal thickening and interstitial fibrosis. Amiodarone pulmonary toxicity can result in high-attenuation focal or multifocal parenchymal opacities due to incorporation of amiodarone into type II pneumocytes. Iodinated oil pulmonary embolism may follow transcatheter oil chemoembolization or after lymphangiography.

It may give an impression of calcification in CXR. However, HRCT findings consist of multifocal patchy areas of ground-glass attenuation and high-attenuation areas of consolidation and collapse.

Thorotrast is a colloidal suspension of thorium dioxide, which was used as an intravascular contrast agent until the s. Thorotrast is retained by the reticuloendothelial system and is found in the liver, spleen, lymph nodes and bone marrow years after it is administered.

Thorium is an alpha emitter and has a half-life of years and is carcinogenic. Lymph nodes within the thorax retain the agent and may cause opacities of metallic density within the thorax. The contrast agent is no longer used[ 71 — 72 ] [ Figure 38 ]. A chest radiograph shows thorotrast deposition in posterior mediastinal lymph nodes seen as tiny metallic nodules. This patient had a carotid angiogram performed in the mid forties for a subarachnoid hemorrhage where thorotrast was used as a contrast agent.

The spleen, which is not clearly depicted here also showed lace-like metallic densities due to thorotrast deposition. A variety of pathological states can result in calcified and high-attenuation PNs.

The imaging evaluation of pulmonary nodules PN is based on clinical history, size and appearance of the nodule and feasibility of obtaining a tissue diagnosis. We have discussed the various patterns of calcification in benign and malignant PN and suggest ways to avoid pitfalls when unusual patterns are encountered as calcification in PN as a criterion to determine benign nature is fallacious and can be misleading.

The differential considerations of calcified and high-attenuation lung lesions including calcified granuloma, PH, carcinoid and lung metastases or a primary bronchogenic carcinoma have been discussed and presented as a pictorial assay emphasizing the various patterns of calcification in PN to aid diagnosis and to discuss the differential diagnosis and the pathogenesis where it is known.

Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Journal List Ann Thorac Med v. Ann Thorac Med. Ali Nawaz Khan , Hamdan H. Al-Jahdali , 1 Carolyn M. Allen , Klaus L. Hamdan H. Carolyn M. Klaus L. Author information Article notes Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: moc. Received Jul 23; Accepted Oct This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC. Abstract The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules PN to aid diagnosis and to discuss the differential diagnosis and the pathogenesis where it is known. Keywords: Benign pulmonary nodules, malignant pulmonary nodules, calcification.

Open in a separate window. Figure 1. Figure 2. Single Large Pulmonary Nodules Pulmonary hamartoma PH is the most common benign lung tumor, composed of tissues that are normally present in the lung, including fat, epithelial tissue, fibrous tissue and cartilage.

Figure 3. Figure 4. Figure 5. Calcified granuloma A variety of infections can elicit a granulomatous tissue response and result in a multitude of intrathoracic dystrophic calcifications. Figure 6. Axial CT scans shows multiple small calcific PNs due to old healed histoplasmosis. Figure 7. Figure Figure 8. Figure 9. Primary lung cancer High CT numbers of solitary nodules do not ensure a benign lesion.

Carcinoid Lung carcinoid tumors are often misdiagnosed as a carcinoma. Intrathoracic sarcomas Primary intrathoracic sarcomas may originate in the lung, mediastinum, pleura and chest wall.

Metastases Lung metastases may be single but more often multiple. Intralobar pulmonary sequestration The radiological diagnosis of intralobar pulmonary sequestration ILPS is based on the identification of a feeding systemic artery on CT. Multiple Large Calcified Nodules or Masses The main diagnostic considerations are PH, calcified pulmonary metastases, primary lung tumors rare , pulmonary chondromas, carcinoid, amyloidosis, calcified hyalinizing granulomas, necrobiotic nodules and progressive massive fibrosis.

Hyalinizing granulomas Pulmonary hyalinizing granulomas PHG are probably related to a chronic immune reaction to endogenous or exogenous antigens or infectious agents such as H.

Progressive massive fibrosis Progressive massive fibrosis PMF is associated with either silicosis or coal miners' pneumoconiosis or presents as an area of mass-like consolidation on chest radiograph and CT often associated with lung parenchymal scarring and adjacent bullae, usually in the upper lobes.

Metastatic pulmonary calcifications Metastatic pulmonary calcification usually occurs in normal pulmonary parenchyma alveolar walls, bronchi and blood vessel walls , the kidney and the stomach. Metastatic calcification in the lungs in a patient with chronic renal failure.

Miscellaneous non-neoplastic lung tumors Many rare non-neoplastic lesions of the lung may mimic lung cancer; these include inflammatory pseudotumor inflammatory myofibroblastic tumor , placental transmogrification of lung, alveolar microlithiasis and metastatic calcification. Carney triad The Carney triad is syndrome associated with gastric stromal sarcomas, pulmonary cartilaginous tumors and extra-adrenal paragangliomas. Diffuse Small Calcified Nodules Infections Small calcified lung nodules are often the result of dystrophic calcification in areas of injured lung.

Hemosiderosis Idiopathic pulmonary hemosiderosis causes recurrent episodes of alveolar hemorrhage over several years usually in infants and young adults. Alveolar microlithiasis Pulmonary alveolar microlithiasis is a rare idiopathic lung disorder characterized by the intra-alveolar accumulation of microliths of calcium phosphate.

Talcosis Magnesium silicate Talc is often used as a filler in a variety of oral medications. Acrylic cement embolism Acrylic cement and sterile barium or tungsten powder opacifier are the elements of a cocktail used to consolidate a collapsed vertebra in a procedure called vertebroplasty.

Dendriform pulmonary ossification Dendriform pulmonary ossification DPO is an uncommon form of diffuse pulmonary ossification that typically affects the pulmonary interstitium in a setting of interstitial fibrosis. We could talk until we're blue in the face about this quiz on words for the color "blue," but we think you should take the quiz and find out if you're a whiz at these colorful terms. Words nearby lobe lobation , lobber , lobby , lobbygow , lobbyist , lobe , lobectomy , lobed , lobe-finned fish , lobelia , lobeliaceous.

Words related to lobe convexity , ear , fold , lap , node , portion , projection , protuberance , section , wattle , excurvation. Coast-to-coast heat dome to deliver sweltering weather next week Matthew Cappucci July 22, Washington Post. The Reign of Greed Jose Rizal. The Jewels of Aptor Samuel R. A rounded projection, especially a rounded, projecting anatomical part, such as the lobe of the ear. A subdivision of a body organ or part bounded by fissures, connective tissue, or other structural boundaries.

One of the larger divisions of the crown of a tooth, formed from a distinct point of calcification. Published by Houghton Mifflin Company.