Pictorial Essay pissn 1738-2637 / eissn 2288-2928 J Korean Soc Radiol 2018;79(3):139-151 https://doi.org/10.3348/jksr.2018.79.3.139 Pulmonary Comorbidities of Lung Emphysema Hye Rim Park, MD, Young Tong Kim, MD*, Sung Shick Jou, MD, Chan Ho Park, MD Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea Pulmonary emphysema is defined as the abnormal permanent enlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of the alveolar wall and without obvious fibrosis. Pulmonary emphysema could result in various complications or comorbidities, many of which are interrelated. Pulmonary emphysema can result in a number of interrelated complications and comorbidities. When pulmonary emphysema is accompanied by comorbidities, it may exhibit different and unique radiologic findings, depending on the underlying lung condition. The purpose of this article was to review radiologic findings that have been reported in patients with underlying emphysema, as well as localized pulmonary comorbidities including infection, fibrosis, primary lung cancer, hemorrhage, and other rare conditions. Index terms Computed Tomography, X-Ray Emphysema Lung Cancer Received April 2, 2018 Revised April 27, 2018 Accepted May 8, 2018 *Corresponding author: Young Tong Kim, MD Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea. Tel. 82-41-570-3515 Fax. 82-41-570-3516 E-mail: ytokim@schmc.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 폐기종은말단세기관지이하부위의폐포벽의파괴로인하여폐포강의영구적확장을유발하는질환으로만성폐쇄성폐질환의한부류이다. 만성폐쇄성폐질환은미국에서성인사망원인의 4번째를차지하며, 2020 년에는 3번째사망원인이될것으로예측한다. 만성폐쇄성폐질환의사망원인은만성폐쇄성폐질환자체보다폐를포함한여러장기에합병증내지동시이환질환 (comorbidity) 에의해유발된다 (1, 2). 동시이환질환은서로독립적인질환들이동시에같이있을때를일컬었지만, 최근에는그개념이확장되어두질환사이에서로원인관계가있거나상호연결이있는질환들이같이있는상황을포함한다. 폐기종은폐감염, 폐암, 기흉, 폐동맥고혈압, 폐성심, 술통가슴 (barrel chest) 과같은흉곽변형, saber sheath trachea 와같이흉곽내에다양한합병증내지동시이환질환을동반할수있다. 이러한폐기종에서폐에국한된동시이환질환은감염, 섬유화, 원발성암, 출혈, 그외폐기종이동반되거나폐기종에동반될수있는드문소견등으로크게나뉠수있다. 폐기종에동시 이환질환이동반되면기존폐의변화에따라다양하고독특한영상소견을보일수있다. 폐기종에관한이전논문들은폐기종의유형이나정도의평가에관한논문들이대부분이다 (3, 4). 또한폐기종의동시이환질환은만성폐쇄성폐질환의합병증에포함해서기술되거나 (5), 폐기종의독특한폐동시이환질환은증례로보고된것들이대부분이다. 폐기종에의한폐에만국한된동시이환질환을모아서기술한논문은거의없는것으로알고있다. 이논문은폐기종에동반된폐의동시이환질환을열거하고, 동시이환질환에따른영상소견들을기술하고자하였다. 폐감염만성폐쇄성폐질환은폐렴을잘동반하며, 폐렴이만성폐쇄성폐질환의급성악화의원인이되기도한다. 폐렴환자의약 20% 가만성폐쇄성폐질환환자이며, 약 10% 는폐렴으로인해만성폐쇄성폐질환으로새로진단을받는다고한다. 폐기종은면역저하와 chronic microbial colonization 에의해폐렴의빈도가증가하며, 치료제인스테로이드제흡입도폐렴의빈도를증가 Copyrights 2018 The Korean Society of Radiology 139
폐기종의 동시이환 폐질환들 시킨다(6). 폐기종이 있는 부위는 적은 capillary bed, pore of 또한 폐렴으로 인한 폐기종의 벽비후와 주변의 폐경화로 인해 Kohn의 결손, 세기관지의 변형을 보이기 때문에, 진행된 폐기 거친 간질성 음영으로 보일 수 있다(Fig. 2)(7-9). 폐기종이 심 종에 폐렴이 동반되면 비전형적인 폐렴의 영상소견을 보일 수 한 경우, 폐렴부위에 저음영의 낭성 병변을 보여서 괴사성 폐렴 있다(Fig. 1). 폐기종이 있는 부위에 폐감염이 생기면 비교적 정 혹은 다발성의 낭성 병변으로 오인할 수 있다(Fig. 3)(8). 드물 상적인 폐포강에는 삼출액이 차고, 비정상적으로 늘어난 폐포 게, 폐기종 환자에서 폐렴이 생기면 흉부사진과 CT에서 폐경 강에는 삼출액이 드물게 차게 되어, 경화내부에 다발성 저음영 화와 폐경화가 없는 부위 사이에 경계가 분명한 공기액체층을 을 보이는 스위스 치즈 혹은 벌집모양을 보일 수 있다(Fig. 2). 보일 수 있다(Figs. 4, 5). 이러한 공기액체층은 환자가 자세를 A B Fig. 1. Pneumonia with underlying emphysema in an 80-year-old man. A. Chest radiograph shows a long rectangular structure (arrowheads) in the right lower lung. B. Coronal CT images show a long rectangular mass-like lesion (arrowheads) in the right lower lobe. This was confirmed as chronic nonspecific pneumonitis by percutaneous transthoracic needle biopsy. Also note emphysema in both lungs. Pneumonia that develops in an emphysematous lung may manifest as an unusual finding. A B Fig. 2. Pneumonia with underlying emphysema in a 79-year-old man. A. Chest radiograph shows irregular consolidation in the right upper lobe and irregular reticular or reticulo-nodular opacities in both lower lungs. B. CT shows ill-defined consolidation with multiple small, low-attenuation (Swiss cheese-like appearance) lesions in the right lung and left lower lobe. The reticular or reticulo-nodular opacities in both lower lungs on chest radiograph correspond to pneumonic consolidation with underlying emphysema on CT. Pneumonia that develops in an emphysematous lung may mimic interstitial lung disease. 140 대한영상의학회지 2018;79(3):139-151 jksronline.org
박혜림외 엎드리면새로운체위의존부위인배쪽으로공기액체층이이동하는것을볼수있다 (Fig. 5). 이러한현상은심한폐기종환자에서는폐포막이심하게파괴되어폐포강이서로연결이되면서, 삼출액이자유롭게이동하여공기액체층으로보이는것으로생각된다. 하지만폐기종이심하지않는환자에서는 pore of Kohn 과같은측부순환들이특히잘발달되어삼출액이폐포강사이를잘이동함으로써공기액체층을형성했을가능성도생각해볼수있다. 기종성낭종내의공기액체층은감염시비교적흔하게볼수있으며 (Figs. 6, 7) 울혈성심부전이나 (Fig. 8) 폐암에서보일수있다. Chandra 등 (10) 은액체를포함한기종성낭종을가진 52 명의환자들의증상이다양하여, 2/3는발열, 기침, 가래, 흉 통과같은증상이있었고 1/3은무증상이었다고보고하였다. 그리고가래배양에서약 26% 에서양성이었다고하였다. 비교적흔하게볼수있는폐기종내의공기액체층과감별이필요한데, 폐기종내공기액체층은 CT에서기종성낭종이보이지않고, 폐경화가있는체위의존부위에공기액체층을보이기때문에 CT에서는쉽게감별이된다 (11). 기종성낭종의크기는일반적으로시간이지남에따라커진다. 기종성낭종이커지는기전은기도의부분폐색으로기종이있는폐로 one way valve 가형성되면서기종성낭종이커진다고하였다. 하지만 Morgan 등 (12) 이기종성낭종내의압력을측정하였는데낭종의압력이흉막강압력을따라움직이며높지않기때문에인접한폐의무기폐에의해기종성낭종의크기가커지는것으로설명하였다. Fig. 3. Pneumonia with underlying severe emphysema in an 84-year-old man. Axial and reformatted coronal CT images show multiple irregular cystic lesions containing fluid (asterisks) in the left lower lobe and severe emphysema in the right lung. Pulmonary infection that develops in severe emphysematous lung may mimic cystic lung disease. Fig. 4. Pneumonia with underlying emphysema in a 75-year-old man. Axial and sagittal images show horizontal fluid levels (arrowheads) between the consolidative lesion and the preserved lung in the right upper and lower lobes. jksronline.org 대한영상의학회지 2018;79(3):139-151 141
Fig. 5. Pneumonia with underlying emphysema in a 63-year-old man. Supine axial image shows fluid levels (arrowheads) in the dependent portion of both lower lobes. On prone axial image obtained the same day, fluid levels have disappeared. Fig. 6. The sequential change in bulla by infection in a 64-year-old man. Initial CT image shows a bulla (arrow) at the right azygoesophageal recess. Follow-up CT image obtained 6 months later shows a mediastinal thin walled cystic lesion with air-fluid level (open arrow). A bulla is smaller and anteriorly displaced (arrow). On follow-up CT image obtained 18 months later, the mediastinal thin-walled cystic lesion has disappeared, although the bulla has persisted (arrow). Fig. 7. Air fluid level in an infected bulla in the left lower lobe in a 63-year-old man. Chest posteroanterior and lateral views show air-fluid levels (arrowheads) in the dependent portion of both lower lobes. 142 대한영상의학회지 2018;79(3):139-151 jksronline.org
박혜림외 추적검사를시행한 30 명중 4명에서기종성낭종이줄어들었으며이중 2명은기종성낭종이보이지않았다고하였다 (12, 13). 기종성낭종이사라지거나크기가줄어드는현상을자동폐낭포절제술 (autobullectomy) 이라하며, 자동폐낭포절제술의기 전은확실하지않다. 기종성낭종이없어진일부환자들에서기종성낭종이없어지기전에기종성낭종내에공기액체층을보였다고하여염증에의해유발되었을것으로보고있고자동폐낭포절제술을염증에의해이루어진다고염증성자동폐낭포 Fig. 8. Air fluid level in a bulla in a 90-year-old woman with pulmonary edema. Coronal CT image shows interlobular septal thickening in the right lung (arrows), suggesting pulmonary edema; also note cardiomegaly. Sagittal CT image shows air-fluid level in the bulla (arrowhead) in the left lower lobe; also note left pleural effusion (asterisk). Fig. 9. Autobullectomy of a bulla by infection in a 61-year-old man. Initial coronal image shows a large bulla (asterisk) in the right lower lobe. On follow-up CT images, the bulla became smaller with an irregular thick wall. If initial CT image is unavailable, this needs to be differentiated from other cavitary disease such as tuberculosis. jksronline.org 대한영상의학회지 2018;79(3):139-151 143
절제술이라고도한다 (Fig. 9). 염증으로인해서폐기종이된폐포벽의섬유화와폐기종으로가는기관지의폐쇄로설명한다. 기종성낭종이기관지와의연결이끊어지고, 내부의공기가흡수되면서기종성낭종의크기가감소한다고설명한다. 염증외에도종양 (Fig. 10), 점막마개 (mucous plug), 혈병 (blood clot) 등이기관지의폐쇄를유발하여자동폐낭포절제술을유발할수있다고한다 (14, 15). 크기가큰낭종의자동폐낭포절제술이환자의폐기능을향상시킬수있다고한다 (16). 정상적으로도기종성낭종은호흡의정도에따라크기의변화를보일수있는데, Worthy 등 (17) 은기종성낭종의 7예중 6예에서흡기시의 HRCT 에서낭종의크기변화를보였다고한다 (Fig. 11). 공동은대부분이결핵과같은염증성질환에의해형성되지만악성혹은비염증성질환에의해만들어질수있다. 기종성낭종에염증이동반되어낭종의벽이비후되면공동을형성할 수있는결핵과같은질환들과감별이필요하기도하다. 아스페르길루스종은 80% 정도는결핵에서발생하고, 그외기관지확장증, 기종성낭종, 폐공기소낭 (pneumatocele), 기관지낭포 (bronchogenic cyst) 에서도발생할수있다 (Fig. 12)(18). 폐기종에동반된섬유화폐기종은말단세기관지이하부위의폐포벽의파괴로인하여폐포강의영구적확장을유발하는질환으로육안적으로분명한섬유화를동반하지않는다고정의하였다. 하지만폐기종환자에서콜라겐이증가되어있으며섬유화가약하기때문에 CT에서보이지않을뿐병리학자들은분명한섬유화를자주본다고한다. Katzenstein 등 (19) 의보고에의하면폐엽절제술로얻은표본의 23 예중 15 예에서폐기종이있었고이중 13 예는폐기종에섬유화를동반하고있었다. 이와같이최근들어 * * A B Fig. 10. Autobullectomy by lung cancer in a 51-year-old man. A. Initial CT images shows lung cancer (asterisk) and multiple air fluid levels in bullae (arrowheads) in the right upper lobe. B. On CT images after 4 months, lung cancer (asterisk) is enlarged and the previously noted air-fluid level in the bulla of the right upper lobe has disappeared. Fig. 11. Changes in bullae by degree of respiration in an 87-year-old man. Bullae (arrows) in both lower lobes have markedly decreased in expiration view. 144 대한영상의학회지 2018;79(3):139-151 jksronline.org
박혜림외 같은환자에서폐기종과섬유화가같이있는예들이많이보고되면서이런현상이폐기종에서섬유화를동반하는것인지, 아니면여러질환이같은폐에공존하는것인지대한의견이분분하다 (20, 21). 복합폐섬유화와폐기종 (combined pulmonary fibrosis and emphysema; 이하 CPFE) 은폐기종에섬유화가같이공존하는대표적인질환이다. 또다른질환으로최근병리학자들사이에이슈화가 (6-9, 22) 되고있는흡연관련섬유화 (smoking related interstitial fibrosis) 가있다 (19, 23, 24). 복합폐섬유화와폐기종폐기종과폐섬유화는비흡연자에비해흡연자에서현저하게많다 (25). 흡연을하면폐에호중구가많아지면서엘라스틴분해활동 (elastolytic activity) 이증가하여폐기종을형성하고폐포성간질의섬유화를초래하는것으로설명한다. 1990 년대에들어오면서 CT에서상엽에폐기종, 하엽에는간질성폐질환이같이있는환자에대한보고들이있어오다가, 2005 년에 Cottin 과 Cordier(24) 가복합폐섬유화와폐기종이라는질환명을처음으로사용하였다. 이때결합조직질환을가진환자들은제외시켰고, 또한약물에의한간질성폐질환, 진폐증, 과민성폐 렴, 유육종등과같은간질성폐질환들도제외시켰다. 모두가현재흡연자혹은흡연유경험자들이었으며, 한명을제외한모든환자들이남자였다. CT 소견은상엽에는소엽중심성 (centrilobular) 폐기종이 97%, 중격주위 (paraseptal) 기종이 94%, 기종성낭종이반수에보였다고한다 (Fig. 13). 하엽의간질성폐렴은전형적인특발성폐섬유증이 51%, 특발성폐섬유증혹은섬유화비특이성간질성폐렴이 34% 에서보였다고한다. 조직학적으로확진된 8예는상엽에소엽중심성폐기종이있었고, 5 예는특발성폐섬유증이었고, 박리성간질성폐렴, 기질화폐렴, 분류되지않는간질성폐렴이각각 1예씩이었다. 섬유화와폐기종의기전은명확하지않으나흡연과흡연에의한 TNF-α의과발현이주요역할을하는것으로보고있다. 그래서복합폐섬유화와폐기종을흡연에의해유발되는간질성폐질환의한부류로보기도한다. 최근에는복합폐섬유화와폐기종을유발하는질환에결합조직질환을포함시키고있다. 흡연관련섬유화 Katzenstein 등 (19) 은 23명에서폐암으로엽절제술을시행한후얻은흡연자의폐표본에서폐포격막이두꺼운콜라겐 Fig. 12. Multiple aspergillomas in a bulla in a 59-year-old man. Serial axial images show multiple aspergillomas (arrows) with air crescent signs in the right lung and the left upper lobe. Fig. 13. Combined pulmonary fibrosis and emphysema in a 71-year-old man. Axial image of upper lungs shows emphysema, and axial CT image of lower lungs shows honeycombing appearance suggesting usual interstitial pneumonia. jksronline.org 대한영상의학회지 2018;79(3):139-151 145
bundle 로현저하게두꺼워져있는섬유화소견이보이는데기존에알려진간질성섬유화에는해당되지않아서흡연과관련된간질성섬유화라는병명을처음사용하였다. 흡연과관련된간질성섬유화는흉막하부위와소엽성기종이있는부위에현저하게보이지만그렇지않은부위에도보인다고하였다. 또한대부분에서폐기종과호흡세기관지염을동반하였다. 흡연과관련된간질성섬유화는흡연자에서흔한소견으로증상이없거나경미하다. Katzenstein(26) 은흡연과관련된간질성섬유화가새로운질환은아니며이전에보고된섬유화를동반한호 흡세기관지염-간질성폐렴과섬유화를동반한폐포강의확장 (airspace enlargement with fibrosis) 과도유사한소견을보인다고하였다. 그래서이들질환들이아마도같은질환일것이라고보고하였다. Kawabata 등 (27) 도폐암으로엽절제술을시행한후얻은폐표본에서흡연의정도와섬유화를동반한폐포강의확장의정도가비례하였다고한다. 그래서섬유화를동반한폐포강의확장은흡연과관련된폐변화로보고있다. 섬유화를동반한폐포강은 CT에서다발성의얇은낭종들로보이며흉막하에위치하지만흉막과닿아있지않으며낭종벽의두께 Fig. 14. Lung cancer developing in a bulla in a 79-year-old man. CT images show an irregular-shaped nodule (arrows) in a bulla in the right lower lobe. This nodule was confirmed as moderately differentiated squamous cell carcinoma by percutaneous transthoracic needle biopsy. Fig. 15. Lung cancer developing in a bulla in a 79-year-old man. CT images show irregular wall thickening (arrowheads) in a bulla in the right upper lobe. This wall thickening was confirmed as poorly differentiated squamous cell carcinoma by percutaneous transthoracic needle biopsy. 146 대한영상의학회지 2018;79(3):139-151 jksronline.org
박혜림외 A B Fig. 16. Spontaneous pulmonary hematoma and hemorrhage in a 54-year-old man. A. Initial CT image shows small bullae (arrow) in the right upper lobe. B. Follow-up CT images show a high-attenuation hematoma (arrow) in the bullae. Pulmonary hemorrhage (arrowheads) is also noted in the adjacent lung. A B Fig. 17. Spontaneous pulmonary hematoma and hemorrhage in a 46-year-old man. A. Initial CT images show high-attenuation consolidation and diffuse ground glass opacities with Swiss cheese-like appearance in the left upper lobe. B. On sequential CT images, high-attenuation consolidation in the left upper lobe has decreased. jksronline.org 대한영상의학회지 2018;79(3):139-151 147
가벌집모양보다얇다고한다 (28). 원발성폐암만성폐쇄성폐질환에서폐암의빈도가증가하며만성폐쇄성폐질환의사망원인의약 7~10% 가폐암과관련되어있다. 기종성낭종과폐암과의연관성을보고한논문들이많으며폐암으로수술을시행한환자중 2.5~4.4% 는기종성낭종에서폐암이발생하였다고한다 (29, 30). Stoloff 등 (31) 은폐암의빈도가기종성낭종이있는환자에서의 6.1%, 낭종이없는환자는 0.19% 로기종성낭종이있는환자에서폐암의빈도가 32 배높다고하였다. 낭성폐포강 (cystic airspace) 과관련된폐암은초기검진에서는 2% 에서, 연간검진에서는 12% 에서발견되어연간검진에서의폐암발생빈도가휠씬높았다. 조직학적슬라이드를얻은 15 예에서 7예는기종성낭종, 5예는내벽세포 (lining cell) 가없는섬유화벽 (fibrous wall), 3예는흉막소기포 (pleural bleb) 로진단되었다 (32). 조직학적으로확진된증례를보면폐기종이있는부위의편평상피화생 (squamous metaplasia) 에서암이생기거나, 기종성낭종의벽에있던반흔에서암이발생하였다고한다 (33). 기종성낭종내에발암물질이갇혀서암을유 발하거나기종성낭종이폐의환기와청결 (clearance) 을저해해서폐암의빈도를증가시킨다고한다. 이는흡연과폐암의연관성을설명할때흡연이폐의청결을저해해서발암물질을축적시키는현상과도연관이있다. 또한흡연은폐포격막을파괴함으로써폐기종과기종성낭종을만든다. 기종성낭종에서기원한암은선암과편평세포암이가장많으며이는기종성낭종이없는폐암환자들과차이가없다 (30, 34). 하지만 Goldstein 등 (29) 은 14예중미분화암 (anaplastic carcinoma) 이 12예로가장많았다고보고하였다. 영상소견으로는기종성낭종에암이생기면낭종내부혹은주변폐실질에결절성음영, 낭종벽비후를보일수있고, 또한낭종크기의변화, 액체저류, 기흉, 폐출혈과같은이차적인소견을보일수있다 (34). 낭종내에암이발생하면진균종과감별이필요한데조영증강이되면폐암으로진단할수있다 (Fig. 14). 기종성낭종주변의원발성폐암은동그랗게자라지않고폐기종과정상폐를따라가면서자라기때문에두꺼운밴드모양을보일수있고 (Fig. 15) 이러한경우염증성병변과감별이필요하다 (34). Farooqi 등 (32) 은초기 CT에서진단된폐암은낭종의벽두께가평균 4 mm이며, 연간검진에서진단된폐암은낭종벽이 1 Fig. 18. Combined emphysema with mediastinal dermoid cyst in a 21-year-old woman. CT images show a mediastinal dermoid cyst (arrowheads) containing fat and calcification in the left anterior mediastinum and focal emphysema (arrows) in the adjacent left upper lobe. 148 대한영상의학회지 2018;79(3):139-151 jksronline.org
박혜림외 mm에서 8 mm로두꺼워졌다고한다. 기종성낭종을추적관찰하다가, 기종성낭종의내부혹은주변의결절성음영혹은벽비후가보이거나두꺼워지면암발생의가능성을염두에두어야한다. 폐출혈폐출혈은대부분이외상후에발생하거나혹은항응고요법 (anticoagulation) 후에발생한다. 하지만드물게이런병력이없는만성폐쇄성폐질환환자에서자발적폐출혈이생긴다고한다 (35, 36). 기종성낭종의자발적출혈은낭종내의혈관벽괴사를원인으로보는데, 이러한혈관벽괴사는폐감염과연관이있을것으로보고있다. 폐출혈에의한영상소견은다른원인에의한폐출혈과유사하게보일수있다. 폐출혈에의한혈종은 CT에서기종성낭종내부에고음영의종괴로보이거나기종성낭종주변에경계가분명하고조영증강이되지않는낭성종괴로보인다. 폐출혈은경화와간유리음영으로보여스위스치즈모양으로보일수있다. 혈종은고립성폐결절들과감별이필요한데, 객혈을주소로하는환자에서기존에폐기종이나기종성낭종이있고, 기종성낭종의내부혹은주변에고음영의종괴가보이면출혈에의한혈종으로진단할수있다 (35)(Figs. 16, 17). 증례수가적어서치료방침이정해져있지않으며, 증례에따라수술적치료를시행하기도하고내과적치료를시행하기도하여, 환자의상태를고려하여결정해야할것으로생각된다. 드물게출혈을일으키는원발성폐암의가능성도생각할수있다 (37). 그외폐기종이동반되거나폐기종에동반될수있는드문소견종격동의기형종이폐로파열되면서드물게폐에국소적폐기종을만들수있다. 폐기종의기전은프로테아제와안티프로테아제의불균형으로설명하는데기형종내부의췌장조직에서분비되는프로테아제에의해국소적폐기종을형성한것으로보고하고있다. 또한기형종에의해폐가파열되면서반복된폐렴과동반감염도폐기종을유발하는원인으로보고있다 (Fig. 18). 결론 폐기종은다양한합병증을가져올수있으며, 폐기종환자에서폐에다양한동시이환질환들을보일수있다. 폐기종을가진환자에서동시이환질환이발생한다면폐의변화에따라다양한영상의학적소견을보일수있고이러한영상의학적소견을이해하는것은폐기종환자에서발생한동시이환질환들의진단과치료에도움을줄것으로생각한다. References 1. Chatila WM, Thomashow BM, Minai OA, Criner GJ, Make BJ. Comorbidities in chronic obstructive pulmonary disease. Proc Am Thorac Soc 2008;5:549-555 2. Cavaillès A, Brinchault-Rabin G, Dixmier A, Goupil F, Gut- Gobert C, Marchand-Adam S, et al. Comorbidities of COPD. Eur Respir Rev 2013;22:454-475 3. Cleverley JR, Müller NL. Advances in radiologic assessment of chronic obstructive pulmonary disease. Clin Chest Med 2000;21:653-663 4. Friedman PJ. Imaging studies in emphysema. Proc Am Thorac Soc 2008;5:494-500 5. Takasugi JE, Godwin JD. Radiology of chronic obstructive pulmonary disease. Radiol Clin North Am 1998;36:29-55 6. Sethi S. Infection as a comorbidity of COPD. Eur Respir J 2010;35:1209-1215 7. Juhl KS, Bendstrup E, Rasmussen F, Hilberg O. Emphysema mimicking interstitial lung disease: two case reports. Respir Med Case Rep 2015;15:24-26 8. Nambu A, Ozawa K, Kobayashi N, Tago M. Imaging of community-acquired pneumonia: roles of imaging examinations, imaging diagnosis of specific pathogens and discrimination from noninfectious diseases. World J Radiol 2014; 6:779-793 9. Ziskind MM, Schwarz MI, George RB, Weill H, Shames JM, Herbert SJ, et al. Incomplete consolidation in pneumococcal lobar pneumonia complicating pulmonary emphysema. Ann Intern Med 1970;72:835-839 10. Chandra D, Rose SR, Carter RB, Musher DM, Hamill RJ. Fluid-containing emphysematous bullae: a spectrum of illness. Eur Respir J 2008;32:303-306 11. Kim YT, Han KS, Kim YI. [Parenchymal air-fluid level in emphysematous lung: a report of two cases]. J Korean Radiol Soc 1999;40:713-715 12. Morgan MD, Edwards CW, Morris J, Matthews HR. Origin and behaviour of emphysematous bullae. Thorax 1989;44:533-538 13. Boushy SF, Kohen R, Billig DM, Heiman MJ. Bullous emphysema: clinical, roentgenologic and physiologic study of 49 patients. Dis Chest 1968;54:327-334 14. Bradshaw DA, Murray KM, Amundson DE. Spontaneous re- jksronline.org 대한영상의학회지 2018;79(3):139-151 149
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박혜림외 박혜림 김영통 * 조성식 박찬호폐기종은말단세기관지이하부위의폐포벽의파괴로인하여폐포강의영구적확장을유발하는질환으로만성폐쇄성폐질환의한부류이다. 폐기종은폐와전신의여러질환들을유발하기도하고상호연관되어있어다양한동시이환질환을동반할수있다. 폐기종에동시이환질환이생기면기존폐의변화에따라다양하고독특한영상소견을보일수있다. 저자들은폐기종에서폐에국한된동시이환질환을감염, 섬유화, 원발성암, 출혈, 그외폐기종이동반되거나폐기종에동반될수있는드문소견등으로나누어기술하고영상소견에대해알아보았다. 순천향대학교천안병원영상의학과 jksronline.org 대한영상의학회지 2018;79(3):139-151 151