Radiografie Del Torace

Radiografia normale del polmone PA

Noduli polmonari Observation of discrete abnormal densities within the lung fields are described as nodules. When the density is similar to that of the ribs, they can be presumed to be calcified. Confirmation of the presence of calcium can be obtained quantitatively from computed tomography which may, with its greater quantitative soft tissue sensitivity, reveal other inapparent parenchymal density

Noduli polmonari maligni

This 28 year old male with a history of non-seminomatous testicular carcinoma was being followed by routine chest X-rays. The x-ray in this example shows very little evidence of abnormality but the computed tomography scan done simultaneously show multiple nodules and demonstrate the increased sensitivity of that cross-sectional technique for small tissue density nodules in the lungs. Some of the greater visibility of these nodules on CT are due to that technique's greater range of intensity differentiation of soft-tissue densities, but some of the result is also due to the cross-sectional imaging plane it produces which avoids confusing overlapping structures.

K del polmone, lobomedio dx This PA radiograph demonstrates a large wedge-shaped density in the right middle lobe. Also note a coin lesion at the right costophrenic angle. The right middle lobe large density on biopsy was determined to be a metastasis from cervical carcinoma. Note that the sharp upper boundary of the right middle lobe triangular mass is the right middle lobe fissure. In addition, there is enlargement of the right hilar structures due to metastases within the hilar lymph nodes.

Embolia polmonare

The Westermark is an eponym indicating the abrupt cutoff of pulmonary vascularity distal to a large central pulmonary embolus. The presumed mechanism behind the image arises from the nearly complete obstruction of bloodflow to the pulmonary artery distal to the embolic clot. Presumably the lack of flow to these more distal vessels results in their radiographic transparency and an appearance of an abrupt truncation as is shown in this exemplary case.

Emphysema The findings of emphysema include hyperinflation of the lungs, low diaphragm positions, and relative radiotransparency of the pulmonary parenchyma. When bullae form, curved parenchymal lines at their borders may be present. The emphysema may be asymmetric but is commonly noted particularly in the upper lung fields. Hypodense lungs Findings are relatively transparent lungs (denser, or darker, than normal on the X-ray image because it is more transparent to X-ray photons, more of which are then available to expose the image and make it darker in that region) arises from the absence of parenchymal tissue. This may be caused either by a pneumothorax or destruction of parenchyma by emphysema and bullae. With pneumothorax, a sharp line dividing the lung parenchyma separating the air in the thorax can be visualized particularly on expiration films. With bullous emphysema there may be increased crowding of the remaining vasculature and pulmonary parenchyma as it is crowded into a smaller fraction of the thoracic space.

Adenopatia ilare

Enlargement of one or both hila must distinguish between lymphadenopathy vs. vascular enlargement. With few exceptions, vascular enlargement produces a branching pattern at its borders and generally is bilateral, whereas lymphadenopathy is more spherical or elipsoidal. Bilateral lymphadenopathy occurs with a variety of immunological disorders as well as sarcoid, but unilateral adenopathy results from either unilateral pulmonary infection or, more ominously, malignant tumors.

Questa lastra è la n° 2 di questo stesso documento, usata sopra come rppresentazione di noduli calcifici.

Adenopatia ilare da sarcoidosi

Hilar adenopathy (due to sarcoid). Hilar adenopathy must be distinguished from enlargement of the hilar vasculature (such as by pulmonary hypertension). Hilar lymph nodes appear more nodular and "lumpy" than hilar vessels which usually retain their branching pattern when enlarged. Bilateral hilar adenopathy implies diseases that are generalized and include sarcoid and lymphoma.

Pulmonary edema (in congestive heart failure) Normal blood flow in the pulmonary capillaries are subject to a variety of influences. The mean hydrostatic intravascular pressure in the pulmonary artery is approximately 14 mmHg. The transmural vascular pressure is the intravascular pressure minus the intrapleural pressure in the larger vessels. Pressure in the pulmonary circulation is significantly influenced by gravity. In erect subjects, the driving pressure in the upper lung, where alveolar pressure is greater than pulmonary venous pressure, is the difference between arterial and alveolar pressures. In the lower lung, the driving pressure is the difference between arterial and venous pressures. Intravascular pressure in the capillaries is presumed to be 5-10 mmHg and the colloidal osmotic pressure, which is 25-30 mmHg, serves to keep the alveoli dry. This sixty year-old male presented with shortness of breath and orthopnea. The x-ray shows cardiomegaly and marked prominence of the pulmonary vascularity. In addition, there is increased density in the small vasculature and alveolar spaces of the lung peripherally. Small, linear septal densities identified as Kerley B lines are a hallmark of the seepage of fluid into the interstitium due to elevated pulmonary venous pressure, which in turn is due to elevated left ventricular end-diastolic pressure from a failing left ventricle. The cardiomegaly could be presumed to be primarily due to enlargement of the left ventricle and left atrium due to contractile failure, although the enlarged cardiac silhouette could also arise from some degree of pericardial fluid, which can be ruled out by echocardiogram. Echocardiography would easily permit examination of systolic left ventricular contractile function and relative chamber sizes. The pulmonary pattern arises from the backup of pressure in the pulmonary venous space and transudate into the interstitial space when then oncotic pressure is exceeded. Kerley lines: Kerley A lines are straight, long lines in lung parenchyma mostly midway between hilum and pleura. Presence of these lines depend on the accumulation of abnormal amounts of edema or other tissue within the perilymphatic connective tissue but are not due to distention of the lymphatics themselves. They are reversible in pulmonary edema, but irreversible when caused by pneumoconiosis or lymphangitic carcinoma. KerleyB lines are short, straight lines in the periphery of the lung lying approximately perpendicular to the pleural surface. B lines are caused by increased fluid or tissue in the interlobular septa, primarily the perilymphatic interstitial tissue. When the edema is transient, the lines may appear or disappear episodically, but chronic changes may produce fibrosis or irreversible lines such as in sarcoidosis, lymphangitic carcincomatosis, or lymphoma. Kerley C lines consist of a fine network of interlacing, linear lines occasionally seen in interstitial pulmonary edema and are caused by the superimposition of many Kerley B lines.

Kerley lines Patients with congestive heart failure commonly will have increased density of the interstitial markings of the lung fields. Very specific patterns have been described as Kerley "B" or "A" lines. The "B" lines are most commonly cited and when identified imply the presence of interstitial edema in the pulmonary septa. The Kerley "B" lines are short, horizontal lines perpendicular to the lateral aspects of the lung. They are commonly accompanied by other signs of interstitial edema such as bronchial cuffing and a blurring of the margins of the pulmonary vasculature at the hila. Kerley A lines are straight, long lines in lung parenchyma mostly midway between hilum and pleura. Presence of these lines depend on the accumulation of abnormal amounts of edema or other tissue within the perilymphatic connective tissue but are not due to distention of the lymphatics themselves. They are reversible in pulmonary edema, but irreversible when caused by pneumoconiosis or lymphangitic carcinoma. KerleyB lines are short, straight lines in the periphery of the lung lying approximately perpendicular to the pleural surface. B lines are caused by increased fluid or tissue in the interlobular septa, primarily the perilymphatic interstitial tissue. When the edema is transient, the lines may appear or disappear episodically, but chronic changes may produce fibrosis or irreversible lines such as in sarcoidosis, lymphangitic carcincomatosis, or lymphoma. Kerley C lines consist of a fine network of interlacing, linear lines occasionally seen in interstitial pulmonary edema and are caused by the superimposition of many Kerley B lines.

Broncogramma aereo

Air bronchograms occur when there is pulmonary infiltration or edema in the tissues immediately adjacent to the bronchi. Darker tubular densities can be seen when the inflammatory process involves the alveoli but has not filled the bronchi with fluid, and therefore distinguishes this disease from cases of atelectasis or pulmonary edema.

Broncogamma aereo 2 Air bronchograms are most often associated with infectious processes that fill the alveoli but leave

the small and medium bronchioles intact and air-filled. These small tubular radiating densities are usually more visible proximally.

Cavitazione

Cavitation in the pulmonary parenchyma is more common with infectious diseases such as tuberculosis or fungal etiologies but can also arise from tumors.

In this case the cause was a primary lung cancer.

zoom cavitazione

Pneumotorace Note the marked difference in X-ray transparency (density) between the left and right thoracic cavities.

The complete radio-translucency (manifest as greater film density or darker lung field on the image) of the thorax with absence of vascular markings is characteristic of a pneumothorax.

Atelettasia del lobo dx superiore

Atelectasis Right Upper Lobe Right upper lobe atelectasis usually produces a wedge-like density adjacent to the right side of the upper spine and mediastinum on the frontal film. The trachea may be somewhat drawn to that side. Lung vasculature and markings of the right

middle and right lower lobes stretch to fill the hemi-thorax resulting in an angulation of the right middle lobe fissure which pivots at the hilum where it is attached. Atelectasis implies collapse of the lung parenchyma with resorption of its air content and an increase in its radiodensity resulting in a portion of the lung that appears more opaque (white). Collapse of a significant amount of lung on one side of the hemithorax may lead to a mediastinal shift toward the side of the collapse. Since bronchi serve individual lobes there are specific appearances that accompany individual lobar atelectasis.

Atelettasia lobo medio dx

Atelectasis-Right Middle Lobe Atelectasis is the loss of lung volume and therefore a direct sign is the displacement of interlobular fissures. Generally this is accompanied by increased density and possibly elevation of the hemidiaphragm, mediastinal displacement, or compensatory over-inflation. If there has been resorption of air within the atelectatic segment, there is generally an absence of air

bronchograms. The pattern of the specific lobar or segmental collapse produces relatively specific findings on the chest film, often requiring both PA and lateral films for clear and specific definition. PA (posterior-anterior) radiograph of this female patient (note breast shadows bilaterally) showed obscuration of the lower right cardiac border merging with opacification of the lung field underlying the right breast. Because the right middle lobe is immediately adjacent to the cardiac silhouette in that position collapse or opacification of the right middle lobe will merge densities between the lung and the heart and thus, the normal sharp boundary between heart and lung is lost. The lateral radiograph shows the triangular wedge of density that is characteristic of right middle lobe infiltrate. Note that the triangle has its apex superiorly and posteriorly. With atelectasis, the angle of that wedge will decrease and the right upper and lower lobes will overinflate slightly to compensate for loss of the right middle lobe volume.

Atelettasia lobo superiore sinistro

Atelectasis Atelectasis is the loss of lung volume and therefore a direct sign is the displacement of interlobular fissures. Generally this is accompanied by increased density and possibly elevation of the hemidiaphragm, mediastinal displacement, or compensatory over-inflation. If there has been resorption of air within the atelectatic segment, there is generally an absence of air bronchograms. The pattern of the specific lobar or segmental collapse produces relatively specific findings on the chest film, often requiring both PA and lateral films for clear and specific definition. The radiograph shows marked increased density in the left hemithorax which obscures the left heart border. Note that the opacification extends from the upper portion of the thorax to nearly the diaphragm and that the diaphragm is elevated on the left. Loss of the cardiac boundary indicates that the heart and the infiltrated collapsed left upper lobe (including the lingula) are immediately adjacent and therefore no distinct left boundary of the heart is defined. The lateral radiograph shows the opacification anteriorly and superiorly that is characteristic of left upper lobe atelectasis.

Atelettasia lobo inferiore sinistro Atelectasis left lower lobe Left lower lobe atelectasis usually produces a wedge-like density behind the heart and adjacent to the spine on the frontal film. Note that the lateral heart border is still intact and distinct. The left diaphragm may become slightly elevated and may not be seen medially along the portion that is immediately adjacent to the collapsed lobe. Lung vasculature and lingular markings stretch to fill the hemi-thorax and the upper lobe becomes overexpanded. Atelectasis implies collapse of the lung parenchyma with resorption of its air content with an increase in its radiodensity resulting in a portion of the lung that appears more opaque (white). This can occur in a sub-segmental way ("plate-like" atelectasis at the lung bases due to poor inspiration after surgery) or may involve a whole lobe or a whole lung. Collapse of a significant amount of lung on one side of the hemithorax may lead to a mediastinal shift toward the side of the collapse. Since bronchi serve individual lobes there are specific appearances that accompany specific lobar atelectasis.

Enfisema This image was obtained from a fifty-eight year-old female with long history of smoking and shortness of breath. Note the extensive translucency (darker portions of the image) occupying both upper lung fields and extending lower on the left with general crowding of the markings of the lung toward both bases. There are irregular strands and probable bullae formation.

Patologia interstizio Interstitial lung disease The findings of interstitial disease include not only the localized increased density (whiter because more X-ray photons are absorbed by tissue and fewer reach the film to expose and darken it) but also radiating linear findings consistent with air bronchograms indicating that the process has filled the distal alveoli while retaining the capacity for aeration.

IDROPNEUMOTORACE

Si nota che nel polmone di sn non c’è più disegno vascolare: questo è dovuto al fatto che c’è aria nel cavo pleurico che lo ha fatto collassate: infatti si vede iperdiafania. In più si vede che il seno costofrenico sn è obliterato da raccolta liquida: da versamento pleurico: Quindi significa che in questo polmone c’era un primitivo versamento pleurico che è stato drenato, ma il drenaggio ha causato uno pneumotorace. Così nel cavo pleurico si hanno sia aria che liquido da versamento pleurico.

ATELETTASIA

ATELETTASIA

ATELETTASIA

IMMAGINI RX TORACE SIA PA SIA LL, IN CUI SI VEDE UNA MASSA MEDIASTINICA NEL MEDIASTINO ANTERIORE CHE DISLOCA LA TRACHEA, SENZA RESTRINGERLA.

Case Presentation Pg 4 of 5 (GoTo: Pg 1 || Pg 2 || Prev(3) || Next(5))

Radiographic Findings: Chest x ray: Superior mediastinal mass displacing trachea. Barium upper GI series: Extrinsic mass displacing esophagus toward the right. This produces a smooth indentation along the left lateral wall of the esophagus. No mucosal abnormality is identified in this region. The lumen of the esophagus is narrowed to approximately 30% of its intrinsic diameter. (During original workup before CT, goiter was strongly considered here!). CT: Middle mediastinal cystic mass, nonenhancing, measuring water density

Bronchogenic cyst Purely cystic mediastinal masses are usually congenital. Foregut Cyst: Results from aberrant development of primitive foregut. Characterization requires histology since location overlaps. Usually spherical, unilocular. Smooth thin walls. Bronchogenic Cyst: Arises from ventral foregut, which forms tracheobronchial tree. Lined by respiratory epithelium. • • • • •

85% arise in mediastinum, close to airway; 15% arise in lung parenchyma. May occur anywhere in thorax. Spherical, nonenhancing lesions of variable attenuation. Cyst wall enhancement and calcification may occur. Mean age of presentation: 36 years. May be asymptomatic, but can result in bleeding, infection, or mass effect. 2/3 patients eventually develop symptoms, usually aerodigestive obstruction, therefore resection is recommended in all patients.

Enterogenous Cyst : arise from dorsal foregut, which gives rise to esophagus. Contains alimentary epithelium, and may contain gastric mucosa or pancreatic tissue. • • •

Mean age of presentation: 1 year. CT appearance nearly identical to bronchogenic cysts, but rarely calcifies. Presents with aerodigestive compression or hemorrhage/rupture if there is pancreatic or digestive tissue.

Neurenteric Cysts: Forms during early embryogenesis when foregut and notochord are in close proximity. Adhesion between the two may pinch off foregut tissue, forming an enteric cyst with intraspinal extension. Contains both alimentary and neural tissue. • • •

90% occur in posterior mediastinum, superior to carina. Most are connected to spinal canal, but minority may not be. Associated with vertebral anomalies.

Pericardial Cysts: • • •

Abuts the heart, anterior chest wall, and diaphragm. Usually contains clear fluid, mural calcification is rare. Usually asymptomatic lesions can be followed clinically.