Radio - Chest 2008 Las

CHEST RADIOLOGY Louis Allan P. Serrano, MD, FPCR

“You only see what you know.” - Lawrence R. Goodman, MD Felson’s Principles of Chest Roentgenology

Normal Chest, Adult (AP and Lateral views)

Normal Chest (PA view)

Normal Chest (Lateral View)

Normal Chest, Pediatric (AP and Lateral views)

Normal Thymus Gland, Pediatric

“sail sign”

Normal Thymus Gland, Pediatric

“wavy margin or wavy sail sign”

Right Lung (PA View)

Right Lung (Lateral View)

Left Lung (AP View)

Left Lung (AP View)

Companion Shadows

Minor Fissure

Rhomboid Fossa

Nipple Shadows

Calcified Costal Cartilages

Apicolordotic View

Right Lateral Decubitus View

Right Lateral Decubitus View

Bony Thorax

Poor Inspiration

Chest AP, Supine

DISEASES OF THE LUNG PARENCHYM A

PNEUMONI A

PNEUMOCOCCAL PNEUMONIA  Caused

by Streptococcus Pneumoniae, serotype 8  Produces lobar pneumonia - lower lobes and posterior segments of upper lobes are most often involved  Consolidation seen as homogenous density on x-ray, begins peripherally and spreads centripetally, may cross segmental boundaries

Pneumococcal Pneumonia

Lobar Pneumonia

KLEBSIELLA PNEUMONIA  “Friedlander’s

Pneumonia”  caused by Klebsiella pneumoniae  common in elderly and debilitated patients  confluent densities seen in one or both upper lobes  may have cavitations  increase lung volume producing bulging fissure

Klebsiella Pneumonia

Klebsiella Pneumonia

“bulging fissure sign”

STAPHYLOCOCCAL PNEUMONIA  Caused

by Staphylococcus aureus  may be primary in the lungs or secondary to a primary Staph. infection elsewhere in the body  debilitated adults and infants in 1st year of life  seen as dense areas that may be segmental or diffuse on x-ray  Pleural effusion, empyema, pneumothorax, pneumatocoeles, abscess formation may occur

STAPHYLOCOCCAL PNEUMONIA  Pneumatocoele

- thin walled cystic lucency showing rapid change in size  caused by check-valve type of obstruction

STAPHYLOCOCCAL PNEUMONIA

Pneumatocele

Pneumatocoele

Day 1

Day 3

Day 2

Day 4

LUNG ABSCESS  Occurs

when suppurative lung infections break down to form a cavity  majority are bronchogenic in origin  most often due to anaerobic organisms  On x-ray: - initially seen as consolidation and eventually forming a cavitation (thick walled) with bronchial communication - may have air-fluid level within the cavity

Lung Abscess

Lung Abscess

Lung Abscess

Lung Abscess

SILHOUETTE SIGN Felson’s

“Silhouette sign” - an intrathoracic lesion touching a border of the heart, aorta or diaphragm will obliterate that border on the roentgenogram

Right Middle Lobe Pneumonia (Silhouette sign)

TUBERCULOSIS  upper

lobes is the most common site - apical and posterior segment - sometimes in the superior segment of the lower lobe  may exhibit cavitation in cases of necrosis  dissemination of three types: 1. Bronchogenic 2. Hematogenous - miliary TB, extrapulmonary lesions throughout the body 3. Lymphangitic - common in Primary

TUBERCULOSIS  Healing

of PTB: - complete resolution, decrease in thickness and size of cavitation, fibrosis, calcification

 PRIMARY

TUBERCULOSIS - seen as primary complex on x-ray: * Ghon’s tubercle * Hilar adenopathy * Lymphangitis

PRIMARY TUBERCULOSIS

TUBERCULOSIS

TUBERCULOSIS

Tuberculosis, healing

TUBERCULOMAS

MILIARY TUBERCULOSIS

CONGENITA L DISORDERS

TRACHEOMALACIA  Is

a rare expiratory problem  it is due to the presence of extremely frail and underdeveloped tracheal cartilage, hence adequate support is lacking and exaggerated expiratory collapse of the entire trachea occurs

TRACHEOMALACIA

 Male

CONGENITAL LOBAR EMPHYSEMA

predominance 3:1  left upper and right middle lobes are most often involved  lower lobes are rarely affected  On X-ray: - marked radiolucency in the region of the involved lobe - volume is markedly increased, resulting in depression of the hemidiaphragm in the involved side and displacement of the mediastinum away from it.

CONGENITAL LOBAR EMPHYSEMA

CONGENITAL LOBAR EMPHYSEMA

CONGENITAL LOBAR EMPHYSEMA

CONGENITAL CYSTIC ADENOMATOID MALFORMATION (CCAM)  Rare

form of congenital cystic disease of the lung in which neonatal respiratory distress is often present  polyhydramnios and associated fetal anomalies are common

CONGENITAL CYSTIC ADENOMATOID MALFORMATION (CCAM)  On X-ray: - quite variable, depending on the size of the lesion and whether it contains fluid or air. - may present as a pulmonary mass that displaces the mediastinum and often herniates into the opposite hemithorax - the multiple cysts result in a course, honey-combed appearance; air-fluid levels may be observed - the cysts may be filled with fluid, presenting an x-ray picture of a large

CONGENITAL CYSTIC ADENOMATOUS MALFORMATION

CONGENITAL CYSTIC ADENOMATOUS MALFORMATION

CONGENITAL CYSTIC ADENOMATOUS MALFORMATION

DIAPHRAGMATIC HERNIA  BOCHDALEK

HERNIA

- posterolateral in position - common on the left side (2:1) - loops of bowel herniates causing respiratory distress and unilateral hypoplasia

Diaphragmatic Hernia (Bochdalek)

Diaphragmatic Hernia (Bochdalek)

Diaphragmatic Hernia (Bochdalek)

MORGAGNI HERNIA  occurs

mainly on the right through the retrosternal Morgagni’s foramen (Larrey’s space)  small and contains omentum  often seen as a basal mass shadow usually in the cardiohepatic region

MORGAGNI HERNIA

UPPER

AIRWA

Y DISEASE

CROUP Common

inflammatory conditions of the larynx and upper trachea in childhood usually caused by a virus and usually occurs in children from 6 months to 3 years of age

CROUP  On

X-ray: - typical lateral view finding are those of pronounced hypopharyngeal overdistention, indistinctness and thickening of the vocal cords, prominence of the laryngeal ventricle and subglottic tracheal narrowing - on frontal view - slit-like narrowing of the glottis is seen termed as the “steeple” or “funnel” sign

CROUP (“Steeple” or “Funnel” Sign)

CROUP (“Steeple” or “Funnel” Sign)

EPIGLOTTITIS  also

a common inflammatory condition of the larynx and upper trachea in childhood  due to Haemophilus influenzae  On X-ray: - thickening of both epiglottis and aryepiglottic folds - there is also swelling of the arytenoids, uvula, the prevertebral and retropharyngeal soft tissues

EPIGLOTTITIS

“thumb sign”

LOWER

AIRWA

Y D I S E A S ES

BRONCHOPNEUMONIA lobular

pneumonia originates in the airways and spread to peribronchial alveoli often presents at the extremes of life has variety of x-ray patterns caused by a number of organisms

BRONCHOPNEUMONIA

AIR - BRONCHOGRAM SIGN

BRONCHIECTASIS persistent

dilatation of the

bronchi can be cylindrical, varicose or saccular X-ray: - patchy pneumonic densities which parallel linear or circular ring like shadows

BRONCHIECTASIS

BRONCHIECTASIS

BRONCHIECTASIS

BRONCHIECTASIS

BRONCHIOLITIS Acute

disease usually observed in infants in the first 2 years of life, peak incidence is around 6 months wherein there is widespread involvement of small bronchi & bronchioles

BRONCHIOLITIS  On

X-ray: - overaeration of the lungs is the rule, flat diaphragms - lung appears clearer than normal and there is very little change in expiration - some demonstrates with parahilar and peribronchial infiltrates with scattered areas of atelectasis - others, probably over 50% demonstrate completely clear lungs

BRONCHIOLITIS

ASTHMA  May

have no x-ray findings early in the course of the disease  X-ray fidnings: - increase lucency of the lungs because of acute overdistention - focal areas of atelectasis - interstitial markings thickened in the parahilar and central pulmonary zone - depression of the diaphragm - pneumomediastinum and

ASTHMA

PULMONARY EMPHYSEMA  An

anatomic alteration of the lung characterized by an abnormal permanent enlargement of the air spaces distal to the terminal nonrespiratory bronchiole, accompanied by destructive changes of the alveolar walls and without obvious fibrosis

PULMONARY EMPHYSEMA  Types:

1. Centrilobular (centriacinar) destruction of parenchyma predominates in central portion of secondary lobule - most frequently associated with cigarette smoking 2. Panlobular (panacinar) - more diffuse; associated with α-1 antitrypsin deficiency

PULMONARY EMPHYSEMA

BULLOUS EMPHYSEMA

COR PULMONALE  Term

used to indicate right ventricular hypertrophy that may lead to right sided heart failure, produced by any disease abnormality (exclusive of primary cardiac disease)  Usually leads to pulmonary hypertension  Pulmonary emphysema – most common cause.

COR PULMONALE Other

causes of cor pulmonale: - congenital and acquired alterations in the thorax (kyphoscoliosis and thoracoplasty) - COPD, PTB, pneumoconioses, recurrent pulmonary emboli

COR PULMONALE Roentgen findings: - enlarged pulmonary infundibulum & pulmonary arteries with increase in size of hilar arteries bilaterally - when RVH is marked, there may be  convexity of the lower right anterior cardiac silhouette and the apex may be elevated and rounded. - pulmonary emphysema is often present

COR PULMONALE

NEOPLASTIC DISEASES

BENIGN TUMORS HAMARTOMA most common benign lung tumor  may contain cartilage, muscle, fibrous connective tissue, fat and epithelial elements  usually peripheral in type and is found near a pleural surface  peak incidence in the 6th decade of life 

HAMARTOMA On X-ray: - well circumscribed, pulmonary parenchymal nodule < 4 cm in diameter - (+) calcification in 25-30% of cases, “popcorn calcification”



HAMARTOMA

“popcorn calcification”

MALIGNANT TUMORS  BRONCHOGENIC

CARCINOMA

Classification: 1. EPIDERMOID OR SQUAMOUS CELL CA >

in males with ratio of 2 or 3:1  accounts for almost 1/3 of all bronchogenic tumors  tends to occur in relatively older age group  often arises in or immediately adjacent to lobar and segmental bronchi but is occasionally peripheral  when a primary tumor is noted to invade the thoracic wall, it is more likely to be epidermoid

MALIGNANT TUMORS 2. ADENOCARCINOMA most

common of the bronchogenic tumor found in females tends to be more peripheral

ADENOCARCINOMA

MALIGNANT TUMORS 3. SMALL CELL CA  often occurs centrally with

hilar enlargement and massive mediastinal lymph node metastases does not undergo necrosis to form cavitation

Small cell CA. Contrast-enhanced CT scan of the chest shows a large left lung and a hilar mass, with invasion of the left pulmonary artery.

MALIGNANT TUMORS 1.

LARGE CELL CA Bulky large tumors that occurs peripherally  Pleural involvement with effusion is common 

LARGE CELL LUNG CA

MALIGNANT TUMORS 5. BRONCHOALVEOLAR CA a

form of adenocarcinoma two (2) forms: 1. Tumor-like or nodular form 2. diffuse type - resembles pneumonic consolidation roentgenographically

BRONCHOALVEOLAR CA

PLAIN RADIOLOGIC FINDINGS IN LUNG CANCER BY CELL TYPE FINDINGS Solitary nodule or mass Atelectasis

Squamo AdenoCA us Cell CA 30% 75%

Small Cell CA 15%

Large Cell CA 65%

40%

10%

20%

15%

Consolidati on

20%

15%

20%

25%

Hilar enlargemen t

40%

20%

80%

30%

PLAIN RADIOLOGIC FINDINGS IN LUNG CANCER BY CELL TYPE Squamo us Cell CA <5%

Adeno CA

Pleural effusion No abnormaliti es Multiple abnormaliti es

FINDINGS Mediastinal Mass

<5%

Small Cell CA 15%

Large Cell CA 10%

5%

5%

5%

5%

5%

<5%

0%

0%

35%

30%

65%

45%

SOLITARY PULMONARY NODULE Approximately 1/3

of lung

cancers present radiographically as a SPN (<3cm) or a lung mass (>3cm)

This CT scan shows a single lesion (pulmonary nodule) in the right lung

FINDINGS WHICH DISTINGUISH BENIGN AND MALIGNANT SPN

PATIENT AGE* Size Shape Contour Edge

BENIGN

MALIGNANT

<35

>50

<2 cm

>2 cm

round, elliptical

irregular

smooth

spiculated

well defined

poorly defined

BENIGN

MALIGNANT

CALCIFICATION*

Dense, central, concentric

None or other patterns

Doubling Time

<1 month or > 16 months

>1 month and < 16 months

GROWTH*

No growth in 2 yrs.

Growth

Satellite lesions

No

Yes

Cavitation

No

Yes

* Findings of most value in diagnosing benign SPN

USES OF CT IN PATIENTS WITH A SPN ON PLAIN RADIOGRAPHS 1. confirm that a nodule is present 2. define its morphology 3. detect calcification 4. detect fat 5. help in planning a needle biopsy or bronchoscopy 6. staging purposes

PULMONARY METASTASES  Hematogenous

pulmonary metastases are usually multiple and consists of smoothly rounded nodules scattered throughout both lungs. They may be uniform or vary considerably in size.  All of the sarcomas and malignant melanoma frequently metastasize to the lungs. Carcinomas of the breast, kidney, ovary, testis, colon and thyroid also metastasize to the lungs.

PULMONARY METASTASES

DISEASES OF THE MEDIASTINUM

PNEUMOMEDIASTINUM  Free

air in the mediastinum  in infants, thymus gland is outlined by air in the mediastinum frequently it still looks like the thymus gland except that the lobes are elevated and the term “angel wings” or “spinnaker sail” sign have been suggested  other configurations include air surrounding the heart and air outlining the inferior aspect of the

PNEUMOMEDIASTINUM

“spinnake r sail sign”

PNEUMOMEDIASTINUM

MEDIASTINUM  space

lying between the right and left pleurae in and near the median sagittal plane of the chest.  extends from the posterior aspect of the sternum to the anterior surface of the thoracic vertebrae.

Four M ajor Subdivisions SUPERIOR – lies between the manubrium sterni and upper four thoracic vertebrae ANTERIOR – bounded above by the thoracic inlet, laterally by the pleura, anteriorly by the sternum, posteriorly by the pericardium and great vessels. MIDDLE – the “vascular space”, contains the heart and pericardium, ascending and transverse arch of the aorta. POSTERIOR - the “postvascular space”, lies behind the heart and pericardium and extends from the level of the thoracic inlet to T12.

SUBDIVISIONS OF THE MEDIASTINUM

MEDIASTINAL MASSES ANTERIOR

MIDDLE

POSTERIOR

Thyroid mass

Pericardial cysts

Esophageal cysts

Lipoma, Fibroma

Tracheal tumors

Gastroenteric cysts

Hemangioma

Thyroid masses

Thoracic spine tumors

Lymphangioma

Aortic aneurysm

Foramen of Morgagni hernia

Amyloidosis

MEDIASTINAL MASSES ANTERIOR Thymic cyst & tumors Dermoid cysts Teratoma Choriocarcinoma Seminoma

MIDDLE

POSTERIOR

Hodgkin’s and Non –Hodgkins lymphoma Lymph node Metastasis Sarcoidosis

Neurogenic tumors

Infectious Mononucleosis Bronchogenic cysts

Esophageal tumors Esophageal diverticula

Meningocele Neurenteric cysts

ANTERIOR MEDIASTINAL MASS

THYMOMA

ANTERIOR MEDIASTINAL MASS

MIDDLE MEDIASTINAL MASS

AORTIC ARCH ANEURYSM

POSTERIOR MEDIASTINAL MASS

Aneurysm of Descending Aorta "Mass" density Extrapleural Posterior Mediastinal Mass

DI S E A S E S O F T H E PLEURA

PLEURAL EFFUSION  Pleural

space is lined by a smooth serous membrane that is lubricated by a small amount (5-15 cc) of serous fluid  earliest x-ray sign is obliteration of the costophrenic sulcus on upright chest film  “meniscus sign”  lateral decubitus view - shifting of fluid in the dependent portion

PLEURAL EFFUSION

PLEURAL EFFUSION

PLEURAL EFFUSION

PNEUMOTHORAX  Presence  On

of air in the pleural cavity

X-ray:  - area of hyperlucency devoid of lung markings  - tension pneumothorax: associated with shifting of mediastinal structures to the contralateral side

PNEUMOTHORAX

PNEUMOTHORAX

TUMORS OF THE PLEURA Benign Tumors Pleural

based tumors include lipoma, fibroma, myxoma, hemangioma, chondroma, neurofibroma

Lipoma

- most common



PRIMARY MALIGNANT TUMORS

DIFFUSE MALIGNANT MESOTHELIOMA

- usually unilateral but may spread to pericardium - arise in the pleura, usually in the interlobar fissures - etiology: asbestos exposure, irradiation, exposure to zeolite ( non asbestos mineral fiber) - XRAY: scalloped appearing mass involving the pleura

MESOTHELIOMA

MESOTHELIOMA

MISCELLANEOUS PULMONARY CONDITIONS

ATELECTASIS  Loss

of lung volume (collapse)  A sign of disease rather than disease in itself  Direct radiographic signs: increase

density of the involved

segment displacement of the interlobar fissure towards the involved segment crowding and displacement of vessels

ATELECTASIS Indirect

Radiographic findings:

- elevation of the hemidiaphragm - mediastinal displacement - compensatory overinflation - displacement of the hila - changes in the chest wall - absence of air bronchogram

ATELECTASIS  Types:

1. Resorption Atelectasis occurs

when communication between trachea and alveoli are obstructed obstruction may be in a major bronchus or in multiple small bronchi or bronchioles

2. Passive Atelectasis -

accompanies a space occupying process (e.g. pneumothorax , hydrothorax)

ATELECTASIS  Types:

3. Compression atelectasis - designates a localized form of parenchymal collapse contiguous to a space occupying process (e.g. pulmonary mass, bulla) 4. Adhesive atelectasis - microatelectasis or non-obstructive (e.g. RDS) 5. Cicatrization atelectasis - loss of volume resulting from pulmonary fibrosis

ATELECTASIS

ATELECTASIS  Right

upper lobe collapse

RIGHT MIDDLE LOBE COLLAPSE

LEFT LOWER LOBE COLLAPSE

PULMONARY THROMBOEMBOLISM  Most

common source: thrombi in the deep veins of the thigh, pelvis, calf  X-ray findings: 1) elevation of the hemidiaphragm on the involved side 2) small pleural effusion 3) hyperluscent area 2° to oligemia distal to the obstructing embolus (Westermark’s Sign) 4) increase in size of the central pulmonary arteries 5) atelectasis

Figure 1. Oligemia Frontal chest radiograph in a patient with acute onset hypoxemia following surgery shows diffuse, decreased attenuation throughout the right lung, consistent with oligemia secondary to acute pulmonary embolism.

Figure 2. Westermark's Sign Frontal chest radiograph shows enlargement of the left hilum accompanied by left lung hyperlucency, indicating oligemia (Westermark's sign).

ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)  used

widely to describe a syndrome resulting from a number in which there is pulmonary injury leading to severe permeability

 (non-cardiogenic)

pulmonary edema

ADULT RESPIRATORY DISTRESS SYNDROME

RADIOGRAPHIC FEATURES OF PULMONARY EDEMA CARDIAC

RENAL

INJURY

Heart size

Enlarged

Enlarged

not enlarged

Vascular pedicle

Normal or engaged

Enlarged

normal or reduced

Pulm. blood flow distribution

inverted

Balanced

normal or reduced

Normal or increased

Increased

normal

Pulm. Blood volume Septal lines

Not common not common

Absent

RADIOGRAPHIC FEATURES OF PULMONARY EDEMA Peribronchi al cuffs Air Bronchogra m Lung edema, regional distribution Pleural effusions

CARDIAC

RENAL

INJURY

Very common

Very common

Not absent

Not common Not common

Very common

Even

Central

Peripheral

Very common

Very common

Not common

SURFACTANT DEFICIENCY DISEASE  due

to decrease in surfactant  usually seen in premature infants  Four (4) stages - X-ray findings: Stage I: air bronchogram pattern>normal Stage II: “ground glass” appearance Stage III: confluent opacification/dense reticular pattern Stage IV: white lung

SURFACTANT DEFICIENCY DISEASE

SURFACTANT DEFICIENCY DISEASE

SURFACTANT DEFICIENCY DISEASE

THE END Have a nice day!