DOI: 10.1148/rg.253045115
Tree-in-Bud Pattern at Thin-Section CT of the Lungs: Radiologic-Pathologic Overview1
Santiago Enrique Rossi, MD,
Tomas Franquet, MD,
Mariano Volpacchio, MD,
Ana Giménez, MD and
Gabriel Aguilar, MD
1 From the Department of Radiology, Centro de Diagnostico Dr Enrique Rossi, Arenales 2777, CP 1425, Buenos Aires, Argentina (S.E.R., M.V., G.A.); and the Department of Radiology, Hospital de Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain (T.F., A.G.). Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA Scientific Assembly. Received May 26, 2004; revision requested August 26 and received November 29; accepted December 6. All authors have no financial relationships to disclose.
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Figure 1. High-resolution CT scan (far left) and drawings of the lung (middle left), a budding tree (middle right), and tree buds (far right) show the tree-in-bud pattern. Note the similarity of the obstructed bronchioles to the objects used in the game of jacks.
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Figure 2. Postprimary active tuberculosis in a 66-year-old woman with a chronic cough. High-resolution CT scans of the right lung show peripheral, poorly defined, small (2–4-mm-diameter) centrilobular nodules and branching linear opacities of similar caliber originating from a single stalk (the tree-in-bud pattern) in the lower lobe (arrow). These findings represent endobronchial spread of tuberculosis.
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Figure 3a. Postprimary active tuberculosis in a 34-year-old man with weight loss and a chronic cough. (a) High-resolution CT scan of the left lung shows a thick-walled cavity and multiple peripheral small nodules and branching linear structures (arrows). Note the thickening of the bronchial walls (arrowhead). (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows impacted caseous material (*) in small peripheral airways (arrow).
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Figure 3b. Postprimary active tuberculosis in a 34-year-old man with weight loss and a chronic cough. (a) High-resolution CT scan of the left lung shows a thick-walled cavity and multiple peripheral small nodules and branching linear structures (arrows). Note the thickening of the bronchial walls (arrowhead). (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows impacted caseous material (*) in small peripheral airways (arrow).
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Figure 4. Infection with M avium-intracellulare complex in a 44-year-old woman with malaise and a chronic cough. High-resolution CT scans of the right lung show multiple peripheral small nodules connected to branching linear opacities and a thick-walled cavity in the superior segment of the lower lobe. Note the thickening of the bronchial walls, bronchial dilatation, and mucus impaction. The diagnosis was confirmed with bronchoalveolar lavage.
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Figure 5a. S aureus bronchiolitis in a 32-year-old man with acquired immunodeficiency syndrome (AIDS). (a) High-resolution CT scan shows small peripheral centrilobular nodules and branching linear opacities, resulting in the tree-in-bud pattern. (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows inflammatory material composed of leukocytes filling the bronchiolar lumen (arrow).
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Figure 5b. S aureus bronchiolitis in a 32-year-old man with acquired immunodeficiency syndrome (AIDS). (a) High-resolution CT scan shows small peripheral centrilobular nodules and branching linear opacities, resulting in the tree-in-bud pattern. (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows inflammatory material composed of leukocytes filling the bronchiolar lumen (arrow).
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Figure 6. H influenzae pneumonia in a 49-year-old woman with breast cancer, fever, and a productive cough. High-resolution CT scan shows diffuse centrilobular nodules and branching linear opacities, resulting in the tree-in-bud pattern.
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Figure 7a. Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantation. (a) High-resolution CT scan (lung window) shows peripheral branching structures (arrow) associated with focal areas of consolidation in the right lower lobe. (b) Corresponding photograph of the autopsy specimen shows multiple yellowish acinar nodules (arrows). (c) Photomicrograph (original magnification, x250; periodic acid–Schiff stain) of a lung biopsy specimen shows complete destruction of the bronchiolar wall (arrowheads) by Aspergillus organisms (arrow).
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Figure 7b. Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantation. (a) High-resolution CT scan (lung window) shows peripheral branching structures (arrow) associated with focal areas of consolidation in the right lower lobe. (b) Corresponding photograph of the autopsy specimen shows multiple yellowish acinar nodules (arrows). (c) Photomicrograph (original magnification, x250; periodic acid–Schiff stain) of a lung biopsy specimen shows complete destruction of the bronchiolar wall (arrowheads) by Aspergillus organisms (arrow).
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Figure 7c. Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantation. (a) High-resolution CT scan (lung window) shows peripheral branching structures (arrow) associated with focal areas of consolidation in the right lower lobe. (b) Corresponding photograph of the autopsy specimen shows multiple yellowish acinar nodules (arrows). (c) Photomicrograph (original magnification, x250; periodic acid–Schiff stain) of a lung biopsy specimen shows complete destruction of the bronchiolar wall (arrowheads) by Aspergillus organisms (arrow).
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Figure 8a. Cytomegalovirus pneumonia in a 51-year-old man with chronic myelogenous leukemia who underwent bone marrow transplantation. (a) Thin-section CT scan of the right lung shows centrilobular ground-glass opacities in addition to nodules and tree-in-bud opacities (arrow). (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows cytomegalic inclusion bodies in the lung tissue (arrows).
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Figure 8b. Cytomegalovirus pneumonia in a 51-year-old man with chronic myelogenous leukemia who underwent bone marrow transplantation. (a) Thin-section CT scan of the right lung shows centrilobular ground-glass opacities in addition to nodules and tree-in-bud opacities (arrow). (b) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows cytomegalic inclusion bodies in the lung tissue (arrows).
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Figure 9. Pneumonia due to respiratory syncytial virus in a 23-year-old man with leukemia. Thin-section CT scan shows peripheral poorly defined centrilobular nodules and tree-in-bud opacities bilaterally. Note the scattered lung nodules surrounded by halos of ground-glass attenuation.
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Figure 10. Cystic fibrosis in a 17-year-old boy with a chronic cough. High-resolution CT scan shows dilated thick-walled bronchi and diffuse tree-in-bud patterns (arrow).
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Figure 11a. Kartagener syndrome in a 39-year-old woman with situs inversus, sinusitis, and bronchiectasis. (a) High-resolution CT scan shows bilateral bronchiectasis (white arrow) and small centrilobular nodules and branching linear opacities in the right lower lobe (black arrow). (b) Follow-up high-resolution CT scan shows bronchial (white arrow) and bronchiolar thickening with mucoid impaction and the tree-in-bud pattern (black arrow). Note the air trapping in the left lower lobe.
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Figure 11b. Kartagener syndrome in a 39-year-old woman with situs inversus, sinusitis, and bronchiectasis. (a) High-resolution CT scan shows bilateral bronchiectasis (white arrow) and small centrilobular nodules and branching linear opacities in the right lower lobe (black arrow). (b) Follow-up high-resolution CT scan shows bronchial (white arrow) and bronchiolar thickening with mucoid impaction and the tree-in-bud pattern (black arrow). Note the air trapping in the left lower lobe.
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Figure 12a. Obliterative bronchiolitis after bone marrow transplantation in a 47-year-old man with myeloma. (a) Expiratory high-resolution CT scan shows diffuse centrilobular nodules connected to branching linear opacities bilaterally. Note the air trapping in the right lower lobe. (b) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) of a specimen from open lung biopsy shows the bronchiolar walls surrounded by concentric chronic inflammatory infiltrates (arrows).
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Figure 12b. Obliterative bronchiolitis after bone marrow transplantation in a 47-year-old man with myeloma. (a) Expiratory high-resolution CT scan shows diffuse centrilobular nodules connected to branching linear opacities bilaterally. Note the air trapping in the right lower lobe. (b) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) of a specimen from open lung biopsy shows the bronchiolar walls surrounded by concentric chronic inflammatory infiltrates (arrows).
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Figure 13. Diffuse panbronchiolitis in a 44-year-old Japanese man. High-resolution CT scan shows diffuse small centrilobular nodules and branching linear opacities (arrow), which resemble the objects used in the game of jacks. Note the bronchiolar dilatation and mucoid impaction (arrowheads).
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Figure 14. Diffuse aspiration bronchiolitis in a 61-year-old woman with achalasia who experienced recurrent aspiration of foreign particles. Thin-section CT scan shows multiple centrilobular areas of increased attenuation with a characteristic tree-in-bud appearance. Esophageal dilatation with an air-fluid level is also seen.
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Figure 15. Inhalation bronchiolitis in a 56-year-old man after accidental exposure to sulfur dioxide. High-resolution CT scan shows bronchiectasis in combination with the tree-in-bud pattern in the right lower lobe.
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Figure 16. Allergic bronchopulmonary aspergillosis in a 36-year-old man with a history of asthma. High-resolution CT scans show peripheral mild bronchiolar dilatation and mucoid impaction in the anterior segment of the left upper lobe (long arrow) and the posterior segment of the right upper lobe, resulting in the tree-in-bud pattern. Note the bronchial wall thickening (short arrow).
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Figure 17. Sjögren syndrome in a 54-year-old woman. Thin-section CT scan shows peripheral tree-in-bud patterns in the right lower lobe. Note the bronchial dilatation, bronchial wall thickening, and consolidation.
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Figure 18. Tumor emboli from breast carcinoma in a 52-year-old woman. High-resolution CT scans show enlarged and beaded subsegmental arteries in the lower lobes. Note the peripheral tree-in-bud opacities.
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Figure 19. Tumor emboli from Ewing sarcoma in a 16-year-old boy. High-resolution CT scan shows enlarged and beaded peripheral arteries in the posterior right lower lobe (arrow), which resemble the tree-in-bud pattern.
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Figure 20a. Pulmonary neoplastic thrombotic microangiopathy caused by gastric adenocarcinoma in a 48-year-old man. (a) High-resolution CT scan shows multiple centrilobular nodules and branching lines with the tree-in-bud appearance (arrows), which is caused by tumor emboli. (b) Photograph of a cut section of the lung from an autopsy specimen shows normal interlobular septa (arrowheads) and pulmonary veins (PV) in the periphery of a secondary pulmonary lobule. Multiple branching opacities can be seen in the central portion of the lobule. (c) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a histopathologic specimen shows complete arteriolar occlusion by fibrocellular proliferation. Clumps of tumor cells are visible in the recanalized organized lesion (arrows). (Reprinted, with permission, from reference 31.)
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Figure 20b. Pulmonary neoplastic thrombotic microangiopathy caused by gastric adenocarcinoma in a 48-year-old man. (a) High-resolution CT scan shows multiple centrilobular nodules and branching lines with the tree-in-bud appearance (arrows), which is caused by tumor emboli. (b) Photograph of a cut section of the lung from an autopsy specimen shows normal interlobular septa (arrowheads) and pulmonary veins (PV) in the periphery of a secondary pulmonary lobule. Multiple branching opacities can be seen in the central portion of the lobule. (c) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a histopathologic specimen shows complete arteriolar occlusion by fibrocellular proliferation. Clumps of tumor cells are visible in the recanalized organized lesion (arrows). (Reprinted, with permission, from reference 31.)
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Figure 20c. Pulmonary neoplastic thrombotic microangiopathy caused by gastric adenocarcinoma in a 48-year-old man. (a) High-resolution CT scan shows multiple centrilobular nodules and branching lines with the tree-in-bud appearance (arrows), which is caused by tumor emboli. (b) Photograph of a cut section of the lung from an autopsy specimen shows normal interlobular septa (arrowheads) and pulmonary veins (PV) in the periphery of a secondary pulmonary lobule. Multiple branching opacities can be seen in the central portion of the lobule. (c) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) of a histopathologic specimen shows complete arteriolar occlusion by fibrocellular proliferation. Clumps of tumor cells are visible in the recanalized organized lesion (arrows). (Reprinted, with permission, from reference 31.)
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Copyright © 2005 by the Radiological Society of North America.
