CHEST CHEST RADIOLOGY RADIOLOGY Louis Allan P. Serrano, MD, Louis Allan P. Serrano, MD, FPCR FPCR
CHEST CHEST RADIOLOGYRADIOLOGY
Louis Allan P. Serrano, MD, FPCRLouis Allan P. Serrano, MD, FPCR
““You only see what you know.”You only see what you know.”
- Lawrence R. Goodman, MD - Lawrence R. Goodman, MD Felson’s Principles of Chest RoentgenologyFelson’s Principles of Chest Roentgenology
Normal Chest, AdultNormal Chest, Adult(AP and Lateral views)(AP and Lateral views)
Normal Chest (PA view)Normal Chest (PA view)
Normal Chest (Lateral View)Normal Chest (Lateral View)
Normal Chest, PediatricNormal Chest, Pediatric(AP and Lateral views)(AP and Lateral views)
Normal Thymus Gland, PediatricNormal Thymus Gland, Pediatric
““sail sign”sail sign”
Normal Thymus Gland, PediatricNormal Thymus Gland, Pediatric
““wavy margin or wavy sail wavy margin or wavy sail sign”sign”
Right Lung (PA View)Right Lung (PA View)
Right Lung (Lateral View)Right Lung (Lateral View)
Left Lung (AP View)Left Lung (AP View)
Left Lung (AP View)Left Lung (AP View)
Companion ShadowsCompanion Shadows
Minor FissureMinor Fissure
Rhomboid FossaRhomboid Fossa
Nipple ShadowsNipple Shadows
Calcified Costal CartilagesCalcified Costal Cartilages
Apicolordotic ViewApicolordotic View
Right Lateral Decubitus ViewRight Lateral Decubitus View
Right Lateral Decubitus ViewRight Lateral Decubitus View
Bony ThoraxBony Thorax
Poor InspirationPoor Inspiration
Chest AP, Supine
DISEASES DISEASES OF THE OF THE LUNG LUNG
PARENCHYMPARENCHYMAA
P N E U M O N I P N E U M O N I A A
PNEUMOCOCCAL PNEUMOCOCCAL PNEUMONIAPNEUMONIA
Caused by Caused by Streptococcus Streptococcus PneumoniaePneumoniae, serotype 8, serotype 8
Produces lobar pneumonia - lower Produces lobar pneumonia - lower lobes and posterior segments of lobes and posterior segments of upper lobes are most often involvedupper lobes are most often involved
Consolidation seen as homogenous Consolidation seen as homogenous density on x-ray, begins peripherally density on x-ray, begins peripherally and spreads centripetally, may cross and spreads centripetally, may cross segmental boundariessegmental boundaries
Pneumococcal Pneumococcal PneumoniaPneumonia
Lobar PneumoniaLobar Pneumonia
KLEBSIELLA PNEUMONIAKLEBSIELLA PNEUMONIA
““Friedlander’s Pneumonia”Friedlander’s Pneumonia”caused by caused by Klebsiella pneumoniaeKlebsiella pneumoniaecommon in elderly and debilitated common in elderly and debilitated
patientspatientsconfluent densities seen in one or both confluent densities seen in one or both
upper lobesupper lobesmay have cavitationsmay have cavitations increase lung volume producing bulging increase lung volume producing bulging
fissurefissure
Klebsiella PneumoniaKlebsiella Pneumonia
Klebsiella PneumoniaKlebsiella Pneumonia
““bulging fissure sign”bulging fissure sign”
STAPHYLOCOCCAL STAPHYLOCOCCAL PNEUMONIAPNEUMONIA
Caused by Caused by Staphylococcus aureusStaphylococcus aureus may be primary in the lungs or secondary to a may be primary in the lungs or secondary to a
primary Staph. infection elsewhere in the bodyprimary Staph. infection elsewhere in the body debilitated adults and infants in 1st year of lifedebilitated adults and infants in 1st year of life seen as dense areas that may be segmental or seen as dense areas that may be segmental or
diffuse on x-raydiffuse on x-ray Pleural effusion, empyema, pneumothorax, Pleural effusion, empyema, pneumothorax,
pneumatocoeles, abscess formation may occurpneumatocoeles, abscess formation may occur
Pneumatocoele - thin walled cystic Pneumatocoele - thin walled cystic lucency showing rapid change in sizelucency showing rapid change in size
caused by check-valve type of caused by check-valve type of obstructionobstruction
STAPHYLOCOCCAL STAPHYLOCOCCAL PNEUMONIAPNEUMONIA
STAPHYLOCOCCAL STAPHYLOCOCCAL PNEUMONIAPNEUMONIA
PneumatocelePneumatocele
PneumatocoelePneumatocoele
Day 1
Day 2
Day 3
Day 4
LUNG ABSCESSLUNG ABSCESS Occurs when suppurative lung infections Occurs when suppurative lung infections
break down to form a cavitybreak down to form a cavity majority are bronchogenic in originmajority are bronchogenic in origin most often due to anaerobic organismsmost often due to anaerobic organisms On x-ray: On x-ray:
- initially seen as consolidation and - initially seen as consolidation and eventually forming a cavitation (thick eventually forming a cavitation (thick walled) with bronchial communicationwalled) with bronchial communication
- may have air-fluid level within the cavity- may have air-fluid level within the cavity
Lung AbscessLung Abscess
Lung AbscessLung Abscess
Lung AbscessLung Abscess
Lung AbscessLung Abscess
SILHOUETTE SIGNSILHOUETTE SIGN
Felson’s “Silhouette sign” Felson’s “Silhouette sign”
- an intrathoracic lesion - an intrathoracic lesion touching a border of the touching a border of the heart, aorta or diaphragm will heart, aorta or diaphragm will obliterate that border on the obliterate that border on the roentgenogramroentgenogram
Right Middle Lobe Right Middle Lobe PneumoniaPneumonia
(Silhouette sign) (Silhouette sign)
TUBERCULOSISTUBERCULOSIS upper lobes is the most common siteupper lobes is the most common site
- apical and posterior segment- apical and posterior segment
- sometimes in the superior segment of - sometimes in the superior segment of the lower lobethe lower lobe
may exhibit cavitation in cases of necrosismay exhibit cavitation in cases of necrosis dissemination of three types:dissemination of three types:
1. Bronchogenic1. Bronchogenic
2. Hematogenous - miliary TB, 2. Hematogenous - miliary TB, extrapulmonary lesions throughout the bodyextrapulmonary lesions throughout the body
3. Lymphangitic - common in Primary 3. Lymphangitic - common in Primary PTBPTB
TUBERCULOSISTUBERCULOSIS Healing of PTB:Healing of PTB:
- complete resolution, decrease in - complete resolution, decrease in thickness and size of cavitation, fibrosis, thickness and size of cavitation, fibrosis, calcification calcification
PRIMARY TUBERCULOSISPRIMARY TUBERCULOSIS
- seen as primary complex on x-ray:- seen as primary complex on x-ray:
* Ghon’s tubercle* Ghon’s tubercle
* Hilar adenopathy* Hilar adenopathy
* Lymphangitis* Lymphangitis
PRIMARY PRIMARY TUBERCULOSISTUBERCULOSIS
TUBERCULOSISTUBERCULOSIS
TUBERCULOSISTUBERCULOSIS
Tuberculosis, healingTuberculosis, healing
TUBERCULOMASTUBERCULOMAS
MILIARY TUBERCULOSISMILIARY TUBERCULOSIS
C O N G E N I T A C O N G E N I T A L L
D I S O R D E R SD I S O R D E R S
TRACHEOMALACIATRACHEOMALACIA Is a rare expiratory problemIs a rare expiratory problem it is due to the presence of extremely it is due to the presence of extremely
frail and underdeveloped tracheal frail and underdeveloped tracheal cartilage, hence adequate support is cartilage, hence adequate support is lacking and exaggerated expiratory lacking and exaggerated expiratory collapse of the entire trachea occurscollapse of the entire trachea occurs
TRACHEOMALACIATRACHEOMALACIA
CONGENITAL LOBAR CONGENITAL LOBAR EMPHYSEMAEMPHYSEMA
Male predominance 3:1Male predominance 3:1 left upper and right middle lobes are left upper and right middle lobes are
most often involvedmost often involved lower lobes are rarely affectedlower lobes are rarely affected On X-ray:On X-ray:
- marked radiolucency in the region - marked radiolucency in the region of the involved lobeof the involved lobe
- volume is markedly increased, - volume is markedly increased, resulting in depression of the resulting in depression of the hemidiaphragm in the involved side and hemidiaphragm in the involved side and displacement of the mediastinum away displacement of the mediastinum away from it.from it.
CONGENITAL LOBAR CONGENITAL LOBAR EMPHYSEMAEMPHYSEMA
CONGENITAL LOBAR CONGENITAL LOBAR EMPHYSEMAEMPHYSEMA
CONGENITAL LOBAR CONGENITAL LOBAR EMPHYSEMAEMPHYSEMA
CONGENITAL CYSTIC CONGENITAL CYSTIC ADENOMATOID ADENOMATOID
MALFORMATION (CCAM)MALFORMATION (CCAM)
Rare form of congenital cystic Rare form of congenital cystic disease of the lung in which neonatal disease of the lung in which neonatal respiratory distress is often presentrespiratory distress is often present
polyhydramnios and associated fetal polyhydramnios and associated fetal anomalies are commonanomalies are common
CONGENITAL CYSTIC CONGENITAL CYSTIC ADENOMATOID MALFORMATION ADENOMATOID MALFORMATION
(CCAM)(CCAM) On X-ray:On X-ray:- quite variable, depending on the - quite variable, depending on the
size of the lesion and whether it contains size of the lesion and whether it contains fluid or air.fluid or air.
- may present as a pulmonary mass - may present as a pulmonary mass that displaces the mediastinum and often that displaces the mediastinum and often herniates into the opposite hemithoraxherniates into the opposite hemithorax
- the multiple cysts result in a course, - the multiple cysts result in a course, honey-combed appearance; air-fluid levels honey-combed appearance; air-fluid levels may be observedmay be observed
- the cysts may be filled with fluid, - the cysts may be filled with fluid, presenting an x-ray picture of a large solid presenting an x-ray picture of a large solid massmass
CONGENITAL CYSTIC ADENOMATOUS CONGENITAL CYSTIC ADENOMATOUS MALFORMATIONMALFORMATION
CONGENITAL CYSTIC ADENOMATOUS CONGENITAL CYSTIC ADENOMATOUS MALFORMATIONMALFORMATION
CONGENITAL CYSTIC ADENOMATOUS CONGENITAL CYSTIC ADENOMATOUS MALFORMATIONMALFORMATION
DIAPHRAGMATIC HERNIADIAPHRAGMATIC HERNIA
BOCHDALEK HERNIABOCHDALEK HERNIA
- posterolateral in position- posterolateral in position
- common on the left side (2:1)- common on the left side (2:1)
- loops of bowel herniates causing - loops of bowel herniates causing respiratory distress and unilateral respiratory distress and unilateral hypoplasiahypoplasia
Diaphragmatic Hernia Diaphragmatic Hernia (Bochdalek)(Bochdalek)
Diaphragmatic Hernia Diaphragmatic Hernia (Bochdalek)(Bochdalek)
Diaphragmatic Hernia Diaphragmatic Hernia (Bochdalek)(Bochdalek)
MORGAGNI HERNIAMORGAGNI HERNIA
occurs mainly on the right through occurs mainly on the right through the retrosternal Morgagni’s foramen the retrosternal Morgagni’s foramen (Larrey’s space)(Larrey’s space)
small and contains omentumsmall and contains omentumoften seen as a basal mass shadow often seen as a basal mass shadow
usually in the cardiohepatic regionusually in the cardiohepatic region
MORGAGNI HERNIAMORGAGNI HERNIA
U P P E R A I R W A U P P E R A I R W A Y Y
D I S E A S ED I S E A S E
CROUPCROUP
Common inflammatory Common inflammatory conditions of the larynx and conditions of the larynx and upper trachea in childhoodupper trachea in childhood
usually caused by a virus and usually caused by a virus and usually occurs in children from usually occurs in children from 6 months to 3 years of age6 months to 3 years of age
CROUPCROUP On X-ray:On X-ray:
- typical lateral view finding are those - typical lateral view finding are those of pronounced hypopharyngeal of pronounced hypopharyngeal overdistention, indistinctness and overdistention, indistinctness and thickening of the vocal cords, thickening of the vocal cords, prominence of the laryngeal ventricle prominence of the laryngeal ventricle and subglottic tracheal narrowingand subglottic tracheal narrowing
- on frontal view - slit-like narrowing of - on frontal view - slit-like narrowing of the glottis is seen termed as the the glottis is seen termed as the “steeple” or “funnel” sign“steeple” or “funnel” sign
CROUP (“Steeple” or “Funnel” CROUP (“Steeple” or “Funnel” Sign)Sign)
CROUP (“Steeple” or “Funnel” CROUP (“Steeple” or “Funnel” Sign)Sign)
EPIGLOTTITISEPIGLOTTITIS also a common inflammatory condition of also a common inflammatory condition of
the larynx and upper trachea in childhoodthe larynx and upper trachea in childhood due to due to Haemophilus influenzaeHaemophilus influenzae On X-ray:On X-ray:
- thickening of both epiglottis and - thickening of both epiglottis and aryepiglottic foldsaryepiglottic folds
- there is also swelling of the arytenoids, - there is also swelling of the arytenoids, uvula, the prevertebral and uvula, the prevertebral and retropharyngeal soft tissuesretropharyngeal soft tissues
EPIGLOTTITISEPIGLOTTITIS
“thumb sign”
L O W E R A I R W A L O W E R A I R W A Y Y
D I S E A S ESD I S E A S ES
BRONCHOPNEUMONIABRONCHOPNEUMONIAlobular pneumonialobular pneumoniaoriginates in the airways and originates in the airways and
spread to peribronchial alveolispread to peribronchial alveolioften presents at the extremes of often presents at the extremes of
lifelifehas variety of x-ray patterns has variety of x-ray patterns
caused by a number of organismscaused by a number of organisms
BRONCHOPNEUMONIABRONCHOPNEUMONIA
AIR - BRONCHOGRAM SIGN
BRONCHIECTASISBRONCHIECTASISpersistent dilatation of the persistent dilatation of the
bronchibronchican be cylindrical, varicose or can be cylindrical, varicose or
saccularsaccularX-ray:X-ray:
- patchy pneumonic densities - patchy pneumonic densities which parallel linear or circular which parallel linear or circular ring like shadowsring like shadows
BRONCHIECTASISBRONCHIECTASIS
BRONCHIECTASISBRONCHIECTASIS
BRONCHIECTASISBRONCHIECTASIS
BRONCHIECTASISBRONCHIECTASIS
BRONCHIOLITISBRONCHIOLITISAcute disease usually observed Acute disease usually observed
in infants in the first 2 years of in infants in the first 2 years of life, peak incidence is around 6 life, peak incidence is around 6 months wherein there is months wherein there is widespread involvement of widespread involvement of small bronchi & bronchiolessmall bronchi & bronchioles
BRONCHIOLITISBRONCHIOLITIS On X-ray:On X-ray:
- overaeration of the lungs is the rule, - overaeration of the lungs is the rule, flat diaphragmsflat diaphragms
- lung appears clearer than normal and - lung appears clearer than normal and there is very little change in expirationthere is very little change in expiration
- some demonstrates with parahilar - some demonstrates with parahilar and peribronchial infiltrates with and peribronchial infiltrates with scattered areas of atelectasisscattered areas of atelectasis
- others, probably over 50% - others, probably over 50% demonstrate completely clear lungsdemonstrate completely clear lungs
BRONCHIOLITISBRONCHIOLITIS
ASTHMAASTHMAMay have no x-ray findings early in the May have no x-ray findings early in the
course of the diseasecourse of the diseaseX-ray fidnings:X-ray fidnings:
- increase lucency of the lungs - increase lucency of the lungs because of acute overdistention because of acute overdistention - focal areas of atelectasis- focal areas of atelectasis - interstitial markings thickened in the - interstitial markings thickened in the parahilar and central pulmonary zoneparahilar and central pulmonary zone - depression of the diaphragm- depression of the diaphragm - pneumomediastinum and - pneumomediastinum and pneumothorax may occur in acute pneumothorax may occur in acute attackattack
ASTHMAASTHMA
PULMONARY PULMONARY EMPHYSEMAEMPHYSEMA
An anatomic alteration of the lung An anatomic alteration of the lung characterized by an abnormal characterized by an abnormal permanent enlargement of the air permanent enlargement of the air spaces distal to the terminal non-spaces distal to the terminal non-respiratory bronchiole, respiratory bronchiole, accompanied by destructive accompanied by destructive changes of the alveolar walls and changes of the alveolar walls and without obvious fibrosiswithout obvious fibrosis
PULMONARY PULMONARY EMPHYSEMAEMPHYSEMA
Types:Types:
1. Centrilobular (centriacinar) - 1. Centrilobular (centriacinar) - destruction of parenchyma predominates destruction of parenchyma predominates in central portion of secondary lobulein central portion of secondary lobule
- most frequently associated with - most frequently associated with cigarette smokingcigarette smoking
2. Panlobular (panacinar) - more diffuse; 2. Panlobular (panacinar) - more diffuse; associated with α-1 antitrypsin associated with α-1 antitrypsin deficiencydeficiency
PULMONARY PULMONARY EMPHYSEMAEMPHYSEMA
BULLOUS EMPHYSEMABULLOUS EMPHYSEMA
COR PULMONALECOR PULMONALETerm used to indicate right ventricular Term used to indicate right ventricular
hypertrophy that may lead to right hypertrophy that may lead to right sided heart failure, produced by any sided heart failure, produced by any disease abnormality (exclusive of disease abnormality (exclusive of primary cardiac disease)primary cardiac disease)
Usually leads to pulmonary Usually leads to pulmonary hypertensionhypertension
Pulmonary emphysemaPulmonary emphysema – most – most common cause. common cause.
Other causes of cor pulmonale:Other causes of cor pulmonale:
- congenital and acquired - congenital and acquired alterations in the thorax alterations in the thorax (kyphoscoliosis and thoracoplasty)(kyphoscoliosis and thoracoplasty)
- COPD, PTB, pneumoconioses, - COPD, PTB, pneumoconioses, recurrent pulmonary embolirecurrent pulmonary emboli
COR PULMONALECOR PULMONALE
Roentgen findings:Roentgen findings:
- enlarged pulmonary infundibulum & - enlarged pulmonary infundibulum & pulmonary arteries with increase in pulmonary arteries with increase in size of hilar arteries bilaterallysize of hilar arteries bilaterally
- when RVH is marked, there may be - when RVH is marked, there may be convexity of the lower right convexity of the lower right anterior cardiac silhouette and the anterior cardiac silhouette and the apex may be elevated and rounded.apex may be elevated and rounded.
- pulmonary emphysema is often - pulmonary emphysema is often present present
COR PULMONALECOR PULMONALE
COR PULMONALECOR PULMONALE
N E O P L A S T N E O P L A S T I C I C
D I S E A S E S D I S E A S E S
BENIGN TUMORSBENIGN TUMORS HAMARTOMAHAMARTOMA
most common benign lung tumormost common benign lung tumor may contain cartilage, muscle, fibrous may contain cartilage, muscle, fibrous
connective tissue, fat and epithelial connective tissue, fat and epithelial elementselements
usually peripheral in type and is found usually peripheral in type and is found near a pleural surfacenear a pleural surface
peak incidence in the 6th decade of peak incidence in the 6th decade of lifelife
On X-ray:On X-ray:
- well circumscribed, - well circumscribed, pulmonary parenchymal nodule pulmonary parenchymal nodule < 4 cm in diameter< 4 cm in diameter
- (+) calcification in 25-30% - (+) calcification in 25-30% of cases, “of cases, “popcorn calcification”popcorn calcification”
HAMARTOMAHAMARTOMA
HAMARTOMAHAMARTOMA
““popcorn calcification”popcorn calcification”
MALIGNANT TUMORSMALIGNANT TUMORS BRONCHOGENIC CARCINOMABRONCHOGENIC CARCINOMA
Classification:Classification:1. EPIDERMOID OR SQUAMOUS CELL CA1. EPIDERMOID OR SQUAMOUS CELL CA
> in males with ratio of 2 or 3:1> in males with ratio of 2 or 3:1 accounts for almost 1/3 of all bronchogenic tumorsaccounts for almost 1/3 of all bronchogenic tumors tends to occur in relatively older age grouptends to occur in relatively older age group often arises in or immediately adjacent to lobar often arises in or immediately adjacent to lobar
and segmental bronchi but is occasionally and segmental bronchi but is occasionally peripheralperipheral
when a primary tumor is noted to invade the when a primary tumor is noted to invade the thoracic wall, it is more likely to be epidermoidthoracic wall, it is more likely to be epidermoid
invasion with veins with hematogenous metastases invasion with veins with hematogenous metastases occur lateoccur late
2. ADENOCARCINOMA2. ADENOCARCINOMA
most common of the most common of the bronchogenic tumor found in bronchogenic tumor found in femalesfemales
tends to be more peripheraltends to be more peripheral
MALIGNANT TUMORSMALIGNANT TUMORS
ADENOCARCINOMAADENOCARCINOMA
3. SMALL CELL CA3. SMALL CELL CA often occurs centrally with hilar often occurs centrally with hilar
enlargement and massive mediastinal enlargement and massive mediastinal lymph node metastaseslymph node metastases
does not undergo necrosis to form does not undergo necrosis to form cavitationcavitation
MALIGNANT TUMORSMALIGNANT TUMORS
Small cell CA. Contrast-enhanced CT scan of the Small cell CA. Contrast-enhanced CT scan of the chest shows a large left lung and a hilar mass, chest shows a large left lung and a hilar mass, with invasion of the left pulmonary artery.with invasion of the left pulmonary artery.
4.4. LARGE CELL CALARGE CELL CA
Bulky large tumors that occurs Bulky large tumors that occurs peripherallyperipherally
Pleural involvement with effusion Pleural involvement with effusion is common is common
MALIGNANT TUMORSMALIGNANT TUMORS
LARGE CELL LUNG CA
5. 5. BRONCHOALVEOLAR CABRONCHOALVEOLAR CAa form of adenocarcinomaa form of adenocarcinomatwo (2) forms:two (2) forms:
1. Tumor-like or nodular form1. Tumor-like or nodular form
2. diffuse type - resembles 2. diffuse type - resembles pneumonic consolidation pneumonic consolidation roentgenographicallyroentgenographically
MALIGNANT TUMORSMALIGNANT TUMORS
BRONCHOALVEOLAR CABRONCHOALVEOLAR CA
PLAIN RADIOLOGIC FINDINGS IN PLAIN RADIOLOGIC FINDINGS IN LUNG CANCER BY CELL TYPELUNG CANCER BY CELL TYPE
FINDINGSFINDINGSSquamoSquamo
usus
Cell CACell CA
AdenoCAAdenoCA Small Small CellCell
CACA
Large Large CellCell
CACA
Solitary Solitary nodule or nodule or massmass
30%30% 75%75% 15%15% 65%65%
AtelectasisAtelectasis 40%40% 10%10% 20%20% 15%15%
ConsolidatiConsolidationon
20%20% 15%15% 20%20% 25%25%
Hilar Hilar enlargemenenlargementt
40%40% 20%20% 80%80% 30%30%
FINDINGSFINDINGSSquamoSquamo
usus
Cell CACell CA
AdenoAdeno
CACASmall Small CellCell
CACA
Large Large CellCell
CACA
MediastinalMediastinal
MassMass<5%<5% <5%<5% 15%15% 10%10%
Pleural Pleural effusioneffusion
5%5% 5%5% 5%5% 5%5%
No No abnormalitiabnormalitieses
5%5% <5%<5% 0%0% 0%0%
Multiple Multiple abnormalitiabnormalitieses
35%35% 30%30% 65%65% 45%45%
PLAIN RADIOLOGIC FINDINGS IN PLAIN RADIOLOGIC FINDINGS IN LUNG CANCER BY CELL TYPELUNG CANCER BY CELL TYPE
SOLITARY PULMONARY SOLITARY PULMONARY NODULENODULE
Approximately Approximately 1/31/3 of lung of lung cancers present cancers present radiographically as a SPN radiographically as a SPN (<3cm)(<3cm) or a lung mass or a lung mass (>3cm)(>3cm)
This CT scan shows a single lesion (pulmonary nodule) in the right lung
FINDINGS WHICH DISTINGUISH FINDINGS WHICH DISTINGUISH BENIGN AND MALIGNANT SPNBENIGN AND MALIGNANT SPN
BENIGNBENIGN MALIGNANTMALIGNANT
PATIENT AGEPATIENT AGE** <35<35 >50>50
Size Size <2 cm<2 cm >2 cm>2 cm
ShapeShape round, ellipticalround, elliptical irregularirregular
ContourContour smoothsmooth spiculatedspiculated
EdgeEdge well definedwell defined poorly definedpoorly defined
BENIGNBENIGN MALIGNANTMALIGNANT
CALCIFICATIONCALCIFICATION** Dense, central, Dense, central, concentricconcentric
None or other None or other patternspatterns
Doubling TimeDoubling Time <1 month or > <1 month or > 16 months16 months
>1 month and>1 month and
< 16 months< 16 months
GROWTHGROWTH** No growth in 2 No growth in 2 yrs.yrs.
GrowthGrowth
Satellite lesionsSatellite lesions NoNo YesYes
CavitationCavitation No No Yes Yes
* Findings of most value in diagnosing benign SPN
USES OF CT IN PATIENTS WITH A USES OF CT IN PATIENTS WITH A SPN ON PLAIN RADIOGRAPHSSPN ON PLAIN RADIOGRAPHS
1. confirm that a nodule is present1. confirm that a nodule is present2. define its morphology2. define its morphology3. detect calcification3. detect calcification4. detect fat4. detect fat5. help in planning a needle biopsy or 5. help in planning a needle biopsy or
bronchoscopybronchoscopy6. staging purposes6. staging purposes
PULMONARY METASTASESPULMONARY METASTASES
Hematogenous pulmonary metastases are Hematogenous pulmonary metastases are usually multiple and consists of smoothly usually multiple and consists of smoothly rounded nodules scattered throughout rounded nodules scattered throughout both lungs. They may be uniform or vary both lungs. They may be uniform or vary considerably in size.considerably in size.
All of the sarcomas and malignant All of the sarcomas and malignant melanoma frequently metastasize to the melanoma frequently metastasize to the lungs. Carcinomas of the breast, kidney, lungs. Carcinomas of the breast, kidney, ovary, testis, colon and thyroid also ovary, testis, colon and thyroid also metastasize to the lungs.metastasize to the lungs.
PULMONARY METASTASES
D I S E A S E S O F D I S E A S E S O F
T H E T H E
M E D I A S T I N U MM E D I A S T I N U M
PNEUMOMEDIASTINUMPNEUMOMEDIASTINUMFree air in the mediastinumFree air in the mediastinum in infants, thymus gland is outlined by in infants, thymus gland is outlined by
air in the mediastinum frequently it still air in the mediastinum frequently it still looks like the thymus gland except that looks like the thymus gland except that the lobes are elevated and the term the lobes are elevated and the term “angel wings“angel wings”” or or ““spinnaker sail”spinnaker sail” sign sign have been suggested have been suggested
other configurations include air other configurations include air surrounding the heart and air outlining surrounding the heart and air outlining the inferior aspect of the heart, referred the inferior aspect of the heart, referred to as the continuous diaphragm signto as the continuous diaphragm sign
PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM
“spinnaker sail sign”
PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM
MEDIASTINUMMEDIASTINUM
space lying between the right and space lying between the right and left pleurae in and near the median left pleurae in and near the median sagittal plane of the chest.sagittal plane of the chest.
extends from the posterior aspect of extends from the posterior aspect of the sternum to the anterior surface the sternum to the anterior surface of the thoracic vertebrae.of the thoracic vertebrae.
Four Major SubdivisionsFour Major Subdivisions
SUPERIORSUPERIOR – lies between the manubrium – lies between the manubrium sterni and upper four thoracic vertebraesterni and upper four thoracic vertebrae
ANTERIORANTERIOR – bounded above by the – bounded above by the thoracic inlet, laterally by the pleura, thoracic inlet, laterally by the pleura, anteriorly by the sternum, posteriorly by anteriorly by the sternum, posteriorly by the pericardium and great vessels.the pericardium and great vessels.
MIDDLEMIDDLE – the – the “vascular space”,“vascular space”, contains contains the heart and pericardium, ascending the heart and pericardium, ascending and transverse arch of the aorta.and transverse arch of the aorta.
POSTERIORPOSTERIOR - the - the “postvascular space”,“postvascular space”, lies behind the heart and pericardium lies behind the heart and pericardium and extends from the level of the and extends from the level of the thoracic inlet to T12. thoracic inlet to T12.
SUBDIVISIONS OF THE MEDIASTINUM
MEDIASTINAL MASSESMEDIASTINAL MASSES
ANTERIORANTERIOR MIDDLEMIDDLE POSTERIORPOSTERIORThyroid massThyroid mass Pericardial Pericardial
cystscystsEsophageal Esophageal cystscysts
Lipoma, Lipoma, FibromaFibroma
Tracheal Tracheal tumorstumors
Gastroenteric Gastroenteric cystscysts
HemangiomaHemangioma Thyroid massesThyroid masses Thoracic spine Thoracic spine tumorstumors
LymphangiomaLymphangioma Aortic Aortic aneurysmaneurysm
Foramen of Foramen of Morgagni Morgagni herniahernia
AmyloidosisAmyloidosis
MEDIASTINAL MASSESMEDIASTINAL MASSES
ANTERIORANTERIOR MIDDLEMIDDLE POSTERIORPOSTERIOR
Thymic cyst & Thymic cyst & tumorstumors
Hodgkin’s and Hodgkin’s and Non –Hodgkins Non –Hodgkins lymphomalymphoma
Neurogenic Neurogenic tumorstumors
Dermoid cystsDermoid cysts Lymph node Lymph node MetastasisMetastasis
MeningoceleMeningocele
TeratomaTeratoma SarcoidosisSarcoidosis Neurenteric Neurenteric cystscysts
ChoriocarcinomChoriocarcinomaa
Infectious Infectious MononucleosisMononucleosis
Esophageal Esophageal tumorstumors
SeminomaSeminoma Bronchogenic Bronchogenic cystscysts
Esophageal Esophageal diverticuladiverticula
ANTERIOR MEDIASTINAL ANTERIOR MEDIASTINAL MASSMASS
THYMOMA
ANTERIOR MEDIASTINAL MASSANTERIOR MEDIASTINAL MASS
MIDDLE MEDIASTINAL MIDDLE MEDIASTINAL MASSMASS
AORTIC ARCH ANEURYSM
POSTERIOR MEDIASTINAL MASSPOSTERIOR MEDIASTINAL MASS
Aneurysm of Descending Aorta"Mass" density
Extrapleural Posterior Mediastinal Mass
DI S E A S E S O F T H DI S E A S E S O F T H E E
P L E U R AP L E U R A
PLEURAL EFFUSIONPLEURAL EFFUSIONPleural space is lined by a smooth Pleural space is lined by a smooth
serous membrane that is lubricated by serous membrane that is lubricated by a small amount (5-15 cc) of serous fluida small amount (5-15 cc) of serous fluid
earliest x-ray sign is obliteration of the earliest x-ray sign is obliteration of the costophrenic sulcus on upright chest costophrenic sulcus on upright chest filmfilm
““meniscus sign”meniscus sign” lateral decubitus view - shifting of fluid lateral decubitus view - shifting of fluid
in the dependent portionin the dependent portion
PLEURAL EFFUSIONPLEURAL EFFUSION
PLEURAL EFFUSIONPLEURAL EFFUSION
PLEURAL EFFUSIONPLEURAL EFFUSION
PNEUMOTHORAXPNEUMOTHORAXPresence of air in the pleural cavityPresence of air in the pleural cavityOn X-ray:On X-ray: - area of hyperlucency devoid of - area of hyperlucency devoid of
lung markingslung markings - tension pneumothorax: associated - tension pneumothorax: associated
with shifting of mediastinal with shifting of mediastinal structures to the contralateral sidestructures to the contralateral side
PNEUMOTHORAXPNEUMOTHORAX
PNEUMOTHORAXPNEUMOTHORAX
Benign TumorsBenign Tumors
Pleural based tumors include lipoma, Pleural based tumors include lipoma, fibroma, myxoma, hemangioma, fibroma, myxoma, hemangioma, chondroma, neurofibromachondroma, neurofibroma
Lipoma - most commonLipoma - most common
TUMORS OF THE PLEURA
PRIMARY MALIGNANT PRIMARY MALIGNANT TUMORSTUMORS
DIFFUSE MALIGNANT DIFFUSE MALIGNANT MESOTHELIOMAMESOTHELIOMA- usually unilateral but may spread to- usually unilateral but may spread to
pericardiumpericardium- arise in the pleura, usually in the interlobar - arise in the pleura, usually in the interlobar fissuresfissures- etiology: asbestos exposure,- etiology: asbestos exposure,
irradiation, exposure to zeolite ( nonirradiation, exposure to zeolite ( non asbestos mineral fiber)asbestos mineral fiber)
- XRAY: scalloped appearing mass involving - XRAY: scalloped appearing mass involving the pleurathe pleura
MESOTHELIOMA
MESOTHELIOMA
MISCELLANEOUS MISCELLANEOUS PULMONARY PULMONARY CONDITIONSCONDITIONS
ATELECTASISATELECTASIS
Loss of lung volume (collapse)Loss of lung volume (collapse)A sign of disease rather than disease A sign of disease rather than disease
in itselfin itselfDirect radiographic signs: Direct radiographic signs:
increase density of the involved increase density of the involved segmentsegment
displacement of the interlobar fissure displacement of the interlobar fissure towards the involved segmenttowards the involved segment
crowding and displacement of vesselscrowding and displacement of vessels
ATELECTASISATELECTASIS
Indirect Radiographic findings:Indirect Radiographic findings: - elevation of the hemidiaphragm- elevation of the hemidiaphragm
- mediastinal displacement- mediastinal displacement
- compensatory overinflation- compensatory overinflation
- displacement of the hila- displacement of the hila
- changes in the chest wall- changes in the chest wall
- absence of air bronchogram- absence of air bronchogram
ATELECTASISATELECTASIS
Types:Types:1. Resorption Atelectasis - 1. Resorption Atelectasis - occurs when communication between occurs when communication between
trachea and alveoli are obstructedtrachea and alveoli are obstructedobstruction may be in a major bronchus obstruction may be in a major bronchus
or in multiple small bronchi or bronchiolesor in multiple small bronchi or bronchioles
2. Passive Atelectasis -2. Passive Atelectasis -- accompanies a space occupying - accompanies a space occupying
process (e.g. pneumothorax , process (e.g. pneumothorax , hydrothorax)hydrothorax)
ATELECTASISATELECTASIS Types:Types: 3. Compression atelectasis3. Compression atelectasis
- designates a localized form of - designates a localized form of parenchymal collapse contiguous to a parenchymal collapse contiguous to a space occupying process (e.g. space occupying process (e.g. pulmonary mass, bulla)pulmonary mass, bulla)
4. Adhesive atelectasis4. Adhesive atelectasis - microatelectasis or non-- microatelectasis or non-
obstructive (e.g. RDS)obstructive (e.g. RDS) 5. Cicatrization atelectasis 5. Cicatrization atelectasis
- loss of volume resulting from - loss of volume resulting from pulmonary fibrosispulmonary fibrosis
ATELECTASISATELECTASIS
ATELECTASISATELECTASIS Right upper lobe collapseRight upper lobe collapse
RIGHT MIDDLE LOBE RIGHT MIDDLE LOBE COLLAPSECOLLAPSE
LEFT LOWER LOBE COLLAPSELEFT LOWER LOBE COLLAPSE
PULMONARY PULMONARY THROMBOEMBOLISMTHROMBOEMBOLISM
Most common source: thrombi in the Most common source: thrombi in the deep veins of the thigh, pelvis, calfdeep veins of the thigh, pelvis, calf
X-ray findings:X-ray findings:1) elevation of the hemidiaphragm on 1) elevation of the hemidiaphragm on
the involved sidethe involved side2) small pleural effusion2) small pleural effusion3) hyperluscent area 23) hyperluscent area 2°° to oligemia to oligemia
distal to the obstructing embolus distal to the obstructing embolus (Westermark’s Sign)(Westermark’s Sign)
4) increase in size of the central 4) increase in size of the central pulmonary arteriespulmonary arteries
5) atelectasis5) atelectasis
Figure 2. Westermark's Sign Frontal chest radiograph shows
enlargement of the left hilum accompanied by left lung
hyperlucency, indicating oligemia (Westermark's sign).
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.
ADULT RESPIRATORY ADULT RESPIRATORY DISTRESS SYNDROME DISTRESS SYNDROME
(ARDS)(ARDS)used widely to describe a syndrome used widely to describe a syndrome
resulting from a number in which there is resulting from a number in which there is
pulmonary injury leading to severe pulmonary injury leading to severe
permeabilitypermeability
(non-cardiogenic) pulmonary edema(non-cardiogenic) pulmonary edema
ADULT RESPIRATORY DISTRESS SYNDROME
RADIOGRAPHIC FEATURES OF RADIOGRAPHIC FEATURES OF PULMONARY EDEMAPULMONARY EDEMA
CARDIACCARDIAC RENALRENAL INJURYINJURY
Heart sizeHeart size Enlarged Enlarged Enlarged Enlarged not enlarged not enlarged
Vascular Vascular pediclepedicle
Normal or Normal or engagedengaged
Enlarged Enlarged normal or normal or reduced reduced
Pulm. blood Pulm. blood flow flow distributiondistribution
inverted inverted Balanced Balanced normal or normal or reducedreduced
Pulm. Blood Pulm. Blood volumevolume
Normal or Normal or increasedincreased
Increased Increased normal normal
Septal linesSeptal lines Not commonNot common not common not common Absent Absent
RADIOGRAPHIC FEATURES OF RADIOGRAPHIC FEATURES OF PULMONARY EDEMAPULMONARY EDEMA
CARDIACCARDIAC RENALRENAL INJURYINJURY
PeribronchiPeribronchial cuffsal cuffs
Very Very commoncommon
Very Very commoncommon
Not absentNot absent
Air Air BronchograBronchogramm
Not commonNot common Not commonNot common Very Very commoncommon
Lung Lung edema, edema, regional regional distributiondistribution
Even Even Central Central PeripheralPeripheral
Pleural Pleural effusionseffusions
Very Very commoncommon
Very Very commoncommon
Not commonNot common
SURFACTANT DEFICIENCY SURFACTANT DEFICIENCY DISEASEDISEASE
due to decrease in surfactantdue to decrease in surfactant usually seen in premature infantsusually seen in premature infants Four (4) stages - X-ray findings:Four (4) stages - X-ray findings:
Stage I: air bronchogram Stage I: air bronchogram pattern>normalpattern>normal
Stage II: “ground glass” appearanceStage II: “ground glass” appearance
Stage III: confluent opacification/dense Stage III: confluent opacification/dense
reticular patternreticular pattern
Stage IV: white lungStage IV: white lung
SURFACTANT DEFICIENCY SURFACTANT DEFICIENCY DISEASEDISEASE
SURFACTANT DEFICIENCY SURFACTANT DEFICIENCY DISEASEDISEASE
SURFACTANT DEFICIENCY SURFACTANT DEFICIENCY DISEASEDISEASE
THE ENDTHE ENDHave a nice day!