Radiology, CMU Juntima Euathrongchit, MD. Department of Radiology Faculty of Medicine, CMU June 17, 2014. [email protected]Saranair Vorapitirangsi Welcome to Radiology world 2014 Radiology, CMU Objective • Introduction to Investigation Methods for Chest • Limitation vs Precaution on chest film Radiology, CMU Radiology, CMU Radiology, CMU Anterior junctional line oblique course crossing the upper two-thirds of the sternum from the upper right to lower left and does not extend above the manubriosternal joint Posterior junctional line thin, vertical line projecting through the trachea that extends to the pleural dome above the clavicles to the level of the aortic arch Azygoesophageal al recess straight stripe running from the azygos arch to the level of the right hemidiaphram Radiology, CMU On Chest Films Apical lordotic PA upright Lateral AP supine PA upright Lateral
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Radiology, CMU
Juntima Euathrongchit, MD.Department of RadiologyFaculty of Medicine, CMU
Anterior junctional lineoblique course crossing the upper two-thirds of the sternum from the upper right to lower left and does not extend above the manubriosternaljoint
Posterior junctional linethin, vertical line projecting through
the trachea that extends to the pleural dome above the clavicles to the level of the aortic arch
Azygoesophagealal recess straight stripe running from the azygos
arch to the level of the right hemidiaphram
Radiology, CMU
On Chest Films
Apical lordotic
PA upright Lateral AP supinePA upright Lateral
Radiology, CMU
Dual Energy Subtraction
• Find out calcification.• Find bone, rib lesion.
Standard soft tissue bone
Radiology, CMU
Digital tomosynthesis
Radiology, CMU
Special Imaging Tools
VQ scanUltrasoundAngiography
MRA MRI
Radiology, CMU
MRIAdvantage: No Iodine contrastDisadvantage: Time consuming, Expensive, not good for lung detection
New CT technique: Perfusion• An iodine map from dual-energy CT can showed
the distribution of pulmonary perfusion• Photoelectric effect of Iodine
*R Kaewlai http://radiologyinthai.blogspot.com/2010/12/dual-energy-ct-2.html M Riedel, An introduction to dual energy CTKang et al RadioGraphics 2010; 30:685–698
Radiology, CMU
New CT technique: Ventilation
Air trapping
Chae et al Radiology: Volume 248: Number 2—August 2008 Radiology, CMU
PET – CT (FDG – glucose)
http://www.ajronline.org/content/194/1/W91.full
Radiology, CMU
CT CHEST
Radiology, CMU
MDCT
• CT scans– Incremental
– Spiral single
– MDCT
Volume images
images
Radiology, CMU
MDCT
• 4-slice to 16-slice 64-slice multidetector CT
• Progressively No of detectors
scan acquisition times. • In clinical use now, 64-slice CT systems
– gantry rotation times = 0.33 sec. – a spatial resolution = 0.4 mm.
Radiology, CMU
Indication of CT chest• ACR: American College of Radiology• SCBT-MR: Society of Computed Body
Tomography and Magnetic Resonance• SPR: Society for Pediatric Radiology
PRACTICE GUIDELINE FOR THE PERFORMANCE OF THORACIC COMPUTED TOMOGRAPHY (CT)
Radiology, CMU
Indications1. Evaluation of abnormalities discovered on chest images [1].2. Evaluation of clinically suspected cardiothoracic pathology.3. Staging and follow-up of lung cancer and other primary thoracic malignancies, and
detection and evaluation of metastatic disease [2-5].4. Evaluation of cardiothoracic manifestations of known extrathoracic diseases [6-9].5. Evaluation of known or suspected thoracic cardiovascular abnormalities (congenital or
acquired), including aortic stenosis, aortic aneurysms, and dissection [10-12].6. Evaluation of suspected acute or chronic pulmonary emboli [13-22].7. Evaluation of suspected pulmonary arterial hypertension [23].8. Evaluation of known or suspected congenital cardiothoracic anomalies [24,25].9. Evaluation and follow-up of pulmonary parenchymal and airway disease [26-33].10. Evaluation of blunt and penetrating trauma [34,35].11. Evaluation of postoperative patients and surgical complications [36,37].12. Performance of CT-guided interventional procedures [38-41].13. Evaluation of the chest wall [42-44].14. Evaluation of pleural disease [45,46].15. Treatment planning for radiation therapy [47,48].16. Evaluation of medical complications in the intensive care unit or other settings [49,50].
Radiology, CMU
HRCT:- Indication vs contraindication
Indications 1. Evaluation of diffuse pulmonary
disease discovered on chest radiographs, conventional CT of the chest or other CT examinations that include portions of the chest, including selection of the appropriate site for biopsy of diffuse lung disease.
2. Evaluation of the lungs in patients with clinically suspected pulmonary disorders with normal or equivocal chest radiographs.
3. Evaluation of suspected small and/or large airway disease.
4. Quantification of the extent of diffuse lung disease for evaluating effectiveness of treatment.
Additional techniques• Repeat film with changed position• Dual energy subtraction• Digital tomosynthesis• CT scan
Radiology, CMU
Chest wall abnormality - C
• Pectus excavatum– depression of the sternum– Incidence - 0.13 – 0.4% of general population (Fraser et al. 1999)– PA chest: left-sided heart deviation & rotation a mitral
configuration. Parasternal opacity liked RML infiltration or mediastinal mass
Radiology, CMU
Blind areas – D
As complexity of thoracic organs overlying each other in the same plane on each view, they could obscure the lung pathology , these areas called blind areas.
Radiology, CMU
Blind areas
• On PA view – Central airway– Apical lung– Mediastinum– Hila– Retrocardiac field– Inferior lung base– Thoracic cage– Upper abdomen
Cover range – Inlet upper abdomenRepeat nodules at delayed phase
Frist study: Plain nodule + Post contrast scan thorax + delayed 30 sec, 1, 2, 3, 4 min
Reconstruction -* CMUSlice thickness: 5 mm, at leastInterval 5 mm no skip Axial imagesSoft tissue W 1 set - 5 mm slice thickness Lung W 1 set – 5 mmSoft tissue W 1 set – 1 mm slice thickness and intervalCoronal vs sagittal – up to PACS systemReconstruction nodule, 1 – 2 mm thickness for each series
Low dose CT scan• Hypothesis: Generic factor and/or indirect receiving carcinogen or second
smoker could be cause of lung cancer• Cost – effectiveness analysis
Parameter Hs) SLST (care dose)Somatom definition CT
Voltage (kVp) 120 – 140 120
Tube current time product (mAs) 40 – 80 25
Slice thickness (mm) 1.0 – 3.2 1.0 – 5.0
Reconstruction interval (mm) 1 – 2.5 0.8 – 1.0
Number of studies 26,722 60
RiskFamily Hx (closed relative)
20 – 65 YrsNo other cancer
Radiology, CMU
Compare, normal dose vs low dose
Low dose - noise
Radiology, CMU
Tumor growth
Radiology, CMU
Hemoptysis – bronchial a. systemic a.In over 90% of cases of hemoptysis requiring intervention with arterial embolization or surgery,the bronchial arteries are responsible for the bleeding
Radiology, CMU
Protocol
Radiology, CMUR ddR dRadRaddR dRRRaR i li li llolioliiio
to the left system: jugular, subclavian, back venules, and hemiazygos v.
A
B
SVC obstruction
AJR:178, May 2002
Radiology, CMU
Rt brachiocephalic venous obstruction with collateral vessels
Radiology, CMULayering in SVC, reflux CM into the azygos v, hemiazygos v. AJR:178, May 2002 Radiology, CMU
Opacification of right ventricle, right atrium, right hepatic veins, and vena cava. Note regurgitation of contrast agent into coronary sinus (arrowhead)