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Advanced Imaging 1

Dr. Warshel's Advanced Imaging #1

What are a type 1 and a type 2 error? Type 1: very sensitive, high false positive; Type 2: very specific, low false negative
What are the 5 radiographic densities? Say it quickly now: air-fat-water-bone-metal
What is VINDICATES as a DDx for radiographic exam? Vascular, Infxn/inflam, Neoplasia, Degenerative, Ingested/iatrogenic, Congenital, Autoimmune, Trauma, Endocrine/metabolic, Syche
What are absolute contraindications for MRI? Heart pacemaker, metallic foreign body in the eye, cochlear implants, ferromagnetic surgical clips
What is CT the gold standard of imaging for? Chest, Abdomen, Acute head trauma; more sensitive for acute blood products
When is abdominal plain film the first line to Dx? Abdominal pain, Abdominal trauma, Abdominal distension, Nausea/vomiting, diarrhea, constipation
What conditions are possible to visualize on an abdominal plain film? Perforated viscus, intestinal obstruction, abdominal or gallstone ileus, organomegaly, AAA, abdominal calcifications
What imaging modality is best for abdomen cases after plain film? CT!
What are the 3 types of abdominal calcifications? Normal physiologic, Dystrophic (diseased tissues), Metastatic (not anaplasia, calcification of normal tissue)
What causes dystrophic calcifications? Myositis ossificans,, scleroderma, SLE, dermatomyositis
What are the terms used when describing calcifications? CMCC: Conduit wall, Cystic, Mass-like, Concretion
Describe a conduit wall calcification. Confined only to tubular walls; seen as parallel, linear opacities; non-homogenous calcification; commonly in arterial walls
Where is the most common site for calcification of the abdominal aorta to be seen? Below the renal arteries that may extend into both common iliac aa.
A AAA represents a ___________ calcification. CYSTIC
What causes AAA and who is affected? Atherosclerosis, collagen diseases; 60-80 y/o, males 4:1
What are S/S of AAA? Asymptomatic; pain in the low back, buttocks, or down the back of the leg; abdominal mass; abdominal pain
What is the second most frequent site for abdominal arterial calcification? Iliac arteries, possible to undergo aneurysmal changes
What is calcification of vas deferens associated with? Diabetes, usually bilateral and symmetric forming a V shape and parallels the pubic rami
Describe mass-like abdominal calcifications. Diverse presentation, characterized by irregularly calcified borders and complex internal architecture, may occur anywhere in the abdomen, classically looks like cumulous cloud
DDX for solid mass calcification? Calcified mesenteric lymph nodes, Leiomyoma, Dermoid cyst (teratoma), Injection granuloma
What are the most common causes of calcified mesenteric lymph nodes? Granulomatous diseases: TB and histoplasmosis, more commonly TB
What is the term used for calcified mesenteric lymph nodes? Mulberry calcification
Who gets leiomyomas and what are they? Women, common in uterus; benign tumor containing smooth muscle with classic cloud appearance
Describe a dermoid cyst (teratoma). Benign tumor that contains tissue fromall 3 dermal layers; may become extremely large; may contain teeth, hair and fat; pre-malignant only 1% go on to degrade into squamous cell CA
Describe cyst wall calcification. Calcium deposition w/in the all of an abnormal fluid-filled structure; calcification shows up as a smooth curvilinear rim; adjacent organs or vessels may be displaced or distorted
DDX cystic wall calcification Hydatid cyst; porcelain gallbladder; hemorrhagic cysts; hematoma (post-traumatic); arterial aneurysms (begin w/ conduit wall calcification that becomes cystic when aneurysmal.
What is 2/3 of all splenic cysts? Echinococcus, hydatid cyst disease
What makes up an echinococcal cyst and where does it form? Tape worm scolex; liver, spleen, lung and brain
What is a calcified gallbladder called and what can it develop into? Porcelain gallbladder; 10-20% develop gallbladder CA, very aggressive w/ poor Px
Describe a concretion. Stone or calculus; represents a calcified mass that forms in a tubular or hollow structure; forms in a similar fashion as a pearl (layered)
What is the radiographic appearance of a concretion? Sharp; clearly defined outer margins; almost always continuous
What is the most common abdominal concretion we’ll see? phlebolith
What concretion is found in the appendix and what is it associated with? Appendicolith; associated w/ current or future appendiceal perforation; appendocolith + abdominal pain = 90% probability of acute appendicitis
What percentage of gallstones calcify? 20%
What do multiple gallstones look like on a radiograph? A “bag of diamonds” appearance
What does the Mercedes Benz sign mean? Gallstones; gas formation in stone
What are pancreatic calculi associated with? chronic pancreatitis secondary to alcoholism; caused by long-standing ductal obstruction and inflammation; visualized as multiple, dense, tiny, discrete opacities that cross the midline at L1-2
Where are prostatic calculi seen on film? Seen as multiple concretions of various sizes clustered behind the pubic symphysis
What causes urinary stones and where in the US are they common? Most caused by chronic low-level dehydration (renal stasis) or infxn; more common in SE and SW US
What do urinary stones contain and what % can be seen on plain film? Mineral deposit embedded in an inoraganic matrix; 90% of upper tract calculi contain enough calcium to be visualized on plain film (concretion pattern)
What are the most common urinary stones? Calcium phosphate, calcium oxalate and magnesium ammonium phosphate
What is a staghorn calculus made up of? Usually struvite; may cause hydronephrosis that leads to renal failure
What percentage of kidney stones calcify? 80%
How to DDX urinary stones from phlebolith? Most phleboliths are ovoid w/ a central lucency and are located below the ischial spines; most calculi are slightly irregular, uniformly dens and are located above the ischial spines
What are the 3 most common locations for a kidney stone to lodge? 1. Ureto-pelvic junction 2. Region of sacral ala where iliac vessels bifurcate 3. Uretero-vesicular junction
Would you order a contrast study if looking for stones? No! Contrast looks like bone
Where do stones cause a unilateral hydronephrosis, bilateral? Ureter = unilateral; bladder or urethra = bilateral
What causes bladder stones? Obstruction and infection or by a migrant renal stone
Describe a double contrast study. Single contrast performed then pt swallows “poppers” that forms gas distending the bowel lumen; best for visualizing the mucosal pattern
What are the 5 pathologic alterations seen in the bowel? Polypoid lesions, mucosal masses, ulceration, diverticula, extrinsic compression
How do polypoid lesions appear? Small, rounded, fillinf defects in the lumen; may be broad-based (sessile) or on a stalk (pedunculated)
How do mucosal masses appear? Begin as small polyps then an abrupt change of the mucosa from normal to tumor; Further growth produces encasement as the tumor grows completely around the lumen = apple-core appearance
How does ulceration appear? A collection of barium found outside the lumen; frequently surrounded by an edematous ulcer collar or mound
What is Hampton’s line? A smooth collar of inflamed mucosa present b/w the lumen and the crater that is occasionally found
How do diverticula appear? Benign out-pouching of the wall of the GI tract may be xmall (colon) or large (esophagus)
How does extrinsic compression appear? Appears as a smooth indentation of the bowel wall w/ gradually tapering margins
How does Zenker’s Diverticulum appear on film? May see an air-fluid level in front of the cervical spine in the retropharyngeal space
What are S/S of peptic/duodenal ulcer Dz? Nagging pain, bloating, vomiting
How are ulcers indentified radiographically? A small out-pouching of the barium column w/ a rim of edema around the ulcer
If a rim of edema is seen around the edge of an ulcer, what is it called? Hampton’s line indicates a benign ulcer
How does a perforation appear on an xray? Extends through mucosa into free abdominal space or into an adjacent organ; Free air on xray underneath the diaphragm = subdiaphragmatic air big indicator for perforation
What is the most common type of hiatal hernia, who gets it and what are S/S? Sliding hiatal hernia; older individuals; heartburn and gastroesophageal reflux
How does a hiatal hernia appear on radiograph? Air/fluid level through the heart shadow on the frontal view above the left hemidiaphragm; On lateral view, air/fluid level is behind the heart
What is the rule of 3’s that a normal small bowel should have? No more than 3 air/fluid levels; No more than 3 cm of bowel distention; The distance b/w the folds should not exceed 3mm
When is bowel obstruction visible on plain film? Adynamic ileus, bowel becomes exhausted and stops all peristalsis, air collects in dilated loops -> bowel distention
What are plain film findings of obstruction? Dilated small-bowel loops; air-fluid levels are seen on upright films proximal to the obstruction; abdomen distal to the obstruction is usually gasless (filled w/ fluid)
How are inguinal hernias recognized? By the presence of an enlarged scrotum that contains multiple loops of air-filled bowel
What is seen radiographically in early Crohn’s disease? Nodular enlargement of lymphoid follicles = cobblestone appearance; Ulcerations; SKIP LESIONS: discontinuous involvement w/ intervening normal areas
What do skip lesion create in Crohn’s disease? Pseudodiverticula
What is seen radiographically in the stenotic phase of Crohn’s disease? String sign: marked narrowing of ridged loops from strictures, stenotic bowel may cause obstruction, usually surgically removed
Which bowel disease is right-sided? Left-sided? Crohn’s is a right-sided bowel disease b/c prefers ileocecal valve; Ulcerative colitis is a left-sided bowel disease b/c prefers the rectum
What is the related cause to colonic diverticulosis? Low fiber diet
Where are diverticula most numerous? Sigmoid colon but can be found throughout the colon
What does granularity of the mucosa relate to in UC? Edema and granulation tissue
What happens with ulceration in UC on film? Ill-defined collections of barium; May have a “collar button” appearance (hallmark sign of UC)
How does end stage UC look on film? Lead pipe appearance; seen in chronic UC, fibrosis leads to diffuse narrowing of the bowel lumen w/ a loss in any mucosal pattern (lose haustra)
What are complications of UC? Toxic megacolon (Dx by plain film, high risk perforation); Stricture formation; Malignancy (increased risk of CA)
What 4 categories are used to DDX Crohn’s and UC? Colonic involvement; Involvement of the rectum; Continuity of lesions; Fistula formation
DDX Crohn’s vs UC using colonic involvement. Crohn’s is predominantly right sided (ileocecal junction); UC is either left sided or universal (rectum)
DDX Crohn’s vs UC by involvement of the rectum. Hallmark of UC
DDX Crohn’s vs UC by continuity of lesions. Crohn’s has skip lesions (cobblestone); UC has continuous involvement
DDX Crohn’s vs UC by fistula formation. Much more common in Crohn’s Dz
What is the most commonly performed radiographic exam worldwide? Chest Radiology
What is CXR an important screening tool for? Pulmonary diseases, mediastinal diseases, disorders of the bony thorax
PA chest is taken at what distance, what inspiration and what kVp? 72, detailed chest cassette w/ shallow slope on H&D; 2nd deep inspiration; high kVp
What are the 4 criteria for a CXR to be diagnostic? Full inspiration, see rib 10 posteriorly; Exposure, see T6 IVD; Top margin, see lung apices; Bottom/lateral margin, lateral costophrenic angles (MC mistake)
Lateral chest is taken with what side close to film and why? Left side closes to film to decrease heart magnification
What criteria determine a quality lateral CXR? Top, bottom, front and back need to be seen
Why would an apical lordotic be taken? See lung apex free of clavicular superimposition; to evaluate for apical lung tumors and apical TB scarring
What film is used to evaluate for pneumothroax? Expiratory film, good to evaluate trapped air in the lungs since gets larger in expiration
What view is most sensitive for pleural effusion? Lateral decubitus; also used to assess for fluid levels in cavitated lesions
What are indications for CT of the chest? Staging of primary pulmonary neoplasm; DDX of pulmonary mets from primary tumor; characterize solitary pulmonary nodules; characterize of focal and diffuse lung disease; evaluate the chest wall
What does radionuclide scanning of the chest document? Using a ventilation perfusion imaging scan to document regional blood supply and regional ventilation; assesses mucociliary clearance
What is the indication for bronchography? Bronchiectasis but not used often anymore as an imaging modality
What does MRI do better than CT of the chest? Advantages over CT in imaging heart, great vessels and chest wall; offers no clinically relevant additional information in the thorax compared to CT
How is fine needle biopsy done? Used under guidance of CT for diagnosis of pulmonary lesions after all other appropriate imaging has been performed; 25% get pneumothorax w/in 1 week
What is a rhomboid fossa? Irregular undersurface of the clavicle at the attachment of the costoclavicular ligament – normal variant
Describe how the horizontal fissure is seen in CXR. Seen in both PA and Lateral views in the right lung; in the lateral view it is located just above he spine; separates the RUL from the RML
Describe how the major (oblique) fissures are seen in CXR. Lateral projection only; from T3-T4 to the hemidiaphragm; right major fissure: separates the RLL from both the RUL and RML; Left major fissure: separates LUL from LLL
Where is the apical radiographic zone on CXR? Above the clavicles
Where should the tracheal air shadow be found? Should cover the spinous processes, normal slight right deviation by arch of the aorta
What is the carina? Bifurcation of trachea into main stem bronchi (T5-6); should not exceded 90 degrees
What are the 2 types of pleura in the lungs? Viseral: reflects into lungs to form lobs and Parietal: lines thoracic cage, mediastinum and diaphragm
What is an apical pleural cap? Thickening of the pleura in the apex of the lung; seen as water density; parallels normal contour and won’t displace lung tissue could be congenital or from an old infxn
What are the 3 pleural reflections we should be able to identify? Paratracheal stripe: soft tissue stripe just by trachea; Paraspinal: thin layersoft tissue on either side of spine; Para-aortic: aorta
What is the azygos lobe and fissure? Lobe created by downward invagination of the azygos vein through the apical portion of the right upper lobe; congenital; formed by 4 pleural layers, 2 parietal and 2 visceral
What radiographic findings can be seen with pectus excavatum? Chest wall concavity; shift of heart shadow to the left (none on right); consolidation of compressed lung
Why is the left hemidiaphragm lower than the right? The heart pushes down on the left and the liver pushes the right up
What type of density is the liver seen as under the hemidiaphragm? Water density
What view is best to measure distance b/w gastric air bubble and what is the max measurement? Lateral view; should not be greater than 1cm, if it is, suspect subpulmonic effusion
Is air under the right hemidiaphragm normal? What could it indicate? No, ALWAYS abnormal; Indicates pneumoperitoneum: ruptured hollow viscus, recent abdominal surgery
Why are the lateral costophrenic angles always a pertinent negative? That is where fluid goes; lateral view for posterior angle is the most sensitive for pleural effusion
Which lateral cardiophrenic angle is blurry and why? Left is blurry because of the epicardiac fat pad
What is eventration? Congenital anomaly w/ failure of muscular development of part or all of one or both hemidiaphragms; partial more common; seen as elevation of a part or the whole of a hemidiaphragm
What is the DDX of eventration of a whole hemidiaphragm? Unilateral phrenic nerve palsy, hepatomegaly, pneumothorax
What is tenting? The hemidiaphragm comes to a point; sign of previous inflammation or scar tissue formation; pleura retracts upward to form tenting
What is the hilum of the lung composed of? primary and secondary divisions of bronchi, upper lobe arteries and veins, lymph nodes (most important!)
Which hilum is higher and what if it isn’t? left is higher than the right 95% of the time; if right is higher, ALWAYS abnormal b/c something is causing hilar shift
Where are the lymph nodes in the chest, where do they drain? Parahilar, paratracheal, subcarinal; drain into tracheobronchial lymph nodes
What is right paratracheal fullness? When a lymph node enlarges on the right and looks like a water density
What is the sarcoidosis 1-2-3 sign? Full hila with right paratracheal fullness
What makes up interstitial markings? Blood and lymph vessels, bronchiole structures, connective tissue; bronchovascular bundle – arteries follow path of the bronchi, veins do not
What is the distribution of vascular markings in the chest by width? Medial to lateral distribution; large vessels in medial portion; medium vessels in middle zone; small vesels in lateral zone; no significant vessels w/in 1cm of outer chest wall
If blood vessels are visible in the lateral cm of the outer chest wall what could be causing it? Out to edge too much blood flow or tissue is interstitial fibrosis
What is the distribution of vascular markings in the chest by length? Inferior to superior; more vessels in base than apex d/t gravity; if other way called cephalization
What portion of the heart is not normally seen on a PA chest? Right ventricle seen in a lateral view though
Describe the cardiothoracic ratio. Greatest right to left diameter of the heart shadow should not exceed half the diameter of the thoracic cage “CA sign”
Describe sagittal dimensions of the thoracic cage and normal measurement in males and females. Distance b/w T8 and the sternum; should be >13cm in males and 11cm in females; if below this measurement may indicate straight back syndrome
Describe the anterior mediastinum. Sternum to a line drawn from the anterior aspect of the trachea down through he posterior heart
Describe the middle mediastinum. Posterior aspect of the anterior mediastinum to the 1cm back from the anterior aspect of the vertebral column
Describe the posterior mediastinum. From posterior aspect of the middle mediastinum to the posterior chest wall
What is located in the anterior mediastinum? Lymph nodes, thymus, pericardium, heart, ascending aorta; MC anterior mediastinal mass is thyroid enlargement (MC mediastinal mass is lymphadenopathy)
What is located in the middle mediastinum? Lymph nodes, aortic arch and descending aorta, brachiocephalic vessels, trachea/carina/hila, esophagus; MC middle mediastinal mass is lymphadenopathy
What is located in the posterior mediastinum? Lymph nodes, spine, neural tissues, fat; MC posterior mediastinal mass is neural tumors
What are the 4 radiographic densities found in the chest and where are they found? 1. Air: lung 2. Fat: muscular fat stripes 3. Water: muscles 4. Bone: ribs, spine, clavicle
How are anatomic structures recognized on xray and what is an interface? By their density differences; the exact point where the densities differ called an interface; the greater the difference in density b/w 2 adjoining structures, the sharper the interface
What is silhouette sign and what does it help you do? The loss of the normal radiographic silhouette; enables you to locate where a disease process is occurring by the obliteration of normal interfaces
What is the silhouetted interface of the RUL? Upper mediastinal shadow
What is the silhouetted interface of the RML, medial segment? Right atrium
What is the silhouetted interface of the LUL? Aortic knob
What is the silhouetted interface of the LUL, lingular segment? Left heart border
What is the silhouetted interface of the L/R LL, basilar segments? Hemidiaphragm since both sit on diaphragm
What portion of the lung has a silhouette interface of the upper mediastinal shadow? RUL
What portion of the lung has a silhouette interface of the right atrium? RML, medial segment
What portion of the lung has a silhouette interface of the aortic knob? LUL
What portion of the lung has a silhouette interface of the left heart border? LUL, lingular segment
What portion of the lung has a silhouette interface of the hemidiaphragms? L/R LL, basilar segments
What is an air bronchogram sign? Visualization of air in the intrapulmonary bronchi on a chest radiograph
What is the use of an air bronchogram sign, is it always useful? When present it denotes the presence of a pulmonary lesion; only useful when present
What are the conditions that must exist for an air bronchogram to be present? Bronchi must be present and have air in them; the surrounding lung tissue must be of water density
What is an extrapleural sign? A mass OUTSIDE the lung pressing into the pleura that shows a convexity toward the lung (cat under rug appearance), tapering margins, sharp inner edge and indistinct outer edge, and rib destruction
What can give an extrapleural sign? Rib fracture, fibrous dysplasia, mediastinal masses
Describe a cavitation. Cavitation of a process arising from necrosis in the center the necrotic mat’l drains out through a bronchi leaving a space; cavitation almost always indicates a significant lesion; may have an air-fluid level
What is the most common neoplasm to cavitate? Squamous cell carcinoma, a primary lung tumor
What can cause a cavitation? neoplasm, infection, trauma but CA big for this
What does meniscus sign represent? Obliteration of the costophrenic anble
What causes meniscus sign? Fluid w/in the pleural space (pleural effusion); collects in most gravity dependent portions; posterior costophrenic is lowest portion then R/L costophrenic angles
How do you DDX meniscus sign from a scar? Fluid can shift if a lateral decubitus view performed, scars don’t move
What is atelectasis? A collapse or loss of lung volume or a segment or segments of a lung = collapse of lung tissue; opposite of consolidation
What are direct radiographic findings of atelectasis? Displacement of fissures, no air bronchogram sign, increased density (collapsed lung loses air density and becomes water dense), crowding of vessels in affected area
What are indirect radiographic findings of atelectasis? Changes that occur in the chest d/t collapse: ipsi hemidiaphragm may elevate (exception of tension pneumothorax), mediastinum is displaced toward collapse, increase or decrease in rib interspaces
What are the MC causes of atelectasis? Tumor: squamous cell CA, adenoCA; Inflammation: TB (scarring); Mucus plug: morphine, bronchitis (COPD), asthma
What causes unilateral elevation of the diaphragm? Neuromuscular: phrenic n. palsy (CA invasion), eventration; Pulmonary: LL collapse (atelectasis), LL consolidation, tenting from pulmonary fibrosis; Subphrenic: subphrenic abscess/mass (LV), distended ST/LI
What causes pleural effusions? Cardiac failure, infxn, malignancy, collagen vascular diseases, trauma, pancreatitis, cirrhosis
What is DDx of obliteration of retrosternal clear space (anterior mediastinum)? 3T’s and an H: Thyroid (MC), Thymus, Teratoma and Hodgkins
What is the most common cause of mediastinal masses? Lymphadenopathy, primarily in the anterior and middle compartments
What is DDx of middle mediastinal mass? Lymphadenopathy (MC), Bronchogenic cyst, Aneurysms, Hiatal Hernia
What is DDx of posterior mediastinal mass? Neurogenic tumors (MC), spine lesions
What is pneumothorax? Results from air leakage into the pleural space
Where does the air come from in pneumothorax? Usually lung itself; bronchopleural fistulas MC (blebs in tall, skinny people); swab wounds may produce pleurocutaneous fistulas
What usually causes a pneumothorax? Blunt trauma; Mediastinal shift TOWARD the pneumothorax
What occurs in a pneumothorax? Sudden increase in the intra-alveolar pressure, alveoli burst, visceral pleura rupture, negative pressure in the pleural space sucks in the air and the lung collapses
How do you tell the difference b/w a spontaneous and a tension pneumothorax? Spontaneous: mediastinal shift toward and diaphragm rises toward pneumothorax; Tension: Shifts away and diaphragm depressed on that side, pressure out > pressure in
What is a spontaneous pneumothorax? A small pneumothorax that occurs spontaneously can be d/t rupture of a bleb into the pleural space or a coughing episode; may be asymptomatic but if the volume of the collapsed lung is > 25% of the hemithorax Sx likely
What are the symptoms of a spontaneous pneumothorax? Hypoxemia, Dyspnea, May be severe enough to mimic an MI, pain referred to scapula
What sign is seen with a pneumothorax? Visceral pleural line, where the lung doesn’t extend to the chest wall and a line is visible
What are the radiographic findings of a pneumothorax? Lung is collapsed and homogenously dense, diaphragm may be flattened or inverted, widening of intercostal spaces (useless)
Describe tension pneumothorax. Increase in pressure outside of lung, mediastinal shift away from side of pneumo, emergency situation since can lead to intracranial HTN; Heart way right, JVD big finding for tension pneumo
What are the 3 types of diseases in the lung? Mass, consolidation, interstitial
Define mass pattern of lung disease. Any localized density not completely bordered by fissures/pleura can be well or poorly defined; does not obey fissures
Describe a mass found in lung. Soft tissue density, may push structures out of way, may silhouette a border, no airbronchogram, smooth or irregular borders, may be solitary or multiple, may cavitate
DDX for mass pattern disease in lung? IING: Infection, Inflammation, Neoplasia, Granuloma
What can cause an inflammatory mass pattern in the lung? RA, Wegener’s granulomatosis
What neoplasms can cause a mass pattern in the lung? Bronchogenic CA, Mets, Lymphoma, Primary benign neoplasms
What usually occurs with granulomas in mass pattern diseases of the lung? Calcification, usually benign; no calcification is malignant until proven otherwise
What are primary malignant neoplasms in the lung? Squamous cell CA, Adenocarcinoma, Small cell (oat cell) CA, Large cell CA
What is a primary benign neoplasm that can be found in the lung? Hamartoma: most common benign tumor, tumor-like malformation of cartilage, connective tissue, fat and muscle, popcorn calcification
Multiple masses in the lungs are d/t and what are the types? Mets: multifocal is MC presentation with 2 types: Carcinomatous: breast, prostate, renal cell, etc.; Sarcomatous: Cannon ball mets from osteosarcoma
What should you as a doctor do if you see a mass? Consult w/ your radiologist, request old films, order a CT, order blood work
Describe consolidation pattern in CXR. Air in lungs replaced 1:1 w/ fluid, negligible collapse of affected lobe, this area changes density from air to water
What does consolidation do that mass doesn’t? OBEYS FISSURES! Should be able to tell what lobe affected
What does consolidation pattern have that other patterns do not? Air bronchogram
What is the DDX for consolidation pattern in lung? Blood, Pus, Water, Cells, Protein
What is included in DDX for consolidation pattern in the blood category? Noxious inhalants, anticoagulants
What is included in DDX for consolidation pattern in the pus category? Pneumonia (most), TB
What is included in DDX for consolidation pattern in the water category? Edema
What is included in DDX for consolidation pattern in the cells category? Carcinoma, Lymphoma
What is included in DDX for consolidation pattern in the protein category? Alveolar proteinosis
Describe an interstitial pattern in lung disease. An increase in the density, thickness and/or number of the interstitial markings
What are interstitial markings? Surrounding (support) tissues
What don’t interstitial lines do? Do not branch or taper, consistently the same diameter (BVs have different diameters depending on location)
What are the 3 types of interstitial patterns? Reticular interstitial, Nodular, Reticulo-nodular
What is the DDX list of an interstitial pattern of lung disease? LIFE lines: L=Lymphatic spread (CA), I=Infection/Inflammation, F=Fibrosis, E=Edema (CHF)/Emphysema
What is the role of CXR with pneumonia? Confirm suspicion of pneumonia, R/O predisposing causes like tumors, follow course of pneumonia (retake CXR 10-14 days after antibiotics Rx)
What are the radiographic patterns of pneumonia based on? Morphologic appearance; type and amount of inflammatory exudate in air spaces and interstitial infiltration determine classification criteria
What is the most common pattern of pneumonia? Alveolar pattern w/ MC cause as strep. pneumoniae that is transmitted through inhalation to lower lung field and when reaches alveoli multiplies
How does the alveolar pattern of pneumonia appear on film? Does not cross fissures, acinar shadow, rosette pattern, air bronchogram
Describe bronchopneumonia. MC cause is Staph. Aureus; typically nosocomial, affects very young or very old
What is the pathway of bronchopneumonia? Begins in walls of terminal bronchus via air passages &/or bloodstream, causes inflammation that spreads to alveoli, spreads through pores of Khon, causes multifocal, patchy appearance
How does bronchopneumonia appear on film? Multiple, ill defined, confluent, nodular opacities; consolidation pattern; usually in base of lungs; air bronchogram not typical
Describe interstitial pneumonia. Infiltration of the wall of the bronchus and interlobular septa (not airspace), can be viral or bacterial (mycoplasma pneumonia), AKA walking or atypical pneumonia
How does interstitial pneumonia appear on film? Liner and reticular opacities found in the central portion of the lung (near hilum) often bilateral; dynamic radiographic picture; no pleural fluid
What are possible outcomes of pneumonia? Streaky scarring, more extensive w/ cavitation; Can have dilatation of bronchi w/ cluster of grapes appearance
What are the 4 granulomatous diseases? 1. TB (MC) 2. Histoplasmosis 3. Coccidiomycosis 4. Sarcoidosis
Describe a granuloma. Small, round soft tissue density; represents an inactive, walled off disease process that is a small focus usually <1cm in diameter; most calcify punctate or target calcification
What are the fungal brothers? Histoplasmosis, coccidiomycosis, blastomycosis; caused by pathogenic fungi in an otherwise healthy person
What is the most common fungal infection in the US? Histoplasmosis in MS and OH river valleys, usually benign course
What does histoplasmosis compare to in its phases of development? TB, MC form is primary; body walls off infection and forms a granuloma most calcify; granulomas in lymph nodes calcify in a mulberry pattern
What occurs in post-primary histoplasmosis? Reactivation of the bug, may be in an immunocompromised patient; Lung destroyed in short period of time
Where is coccidiomycosis endemic? SW US AKA San Joaquin Valley fever usually asymptomatic has a similar course to histoplasmosis w/ primary and post-primary stages
Where is blastomycosis endemic? SE US and South America looks identical to other endemic fungals
What are the phases of TB? Primary, Post-primary, Organ manifestation
What occurs in the primary phase of TB? Alveolar pattern evolves into a TB specific inflammatory focus in ~10 days = Ghon focus
What is a Ghon focus? Central, caseous necrosis surrounded by granulation tissue composed of lymphocytes, epitheloid cells, and giant cells is radiographically well circumscribed, small peripheral nodule w/ ill-defined borders (Ghon tubercle)
What is the Ranke complex? The presence of a Ghon tubercle in the periphery and calcification w/in the lymph nodes of the hila
Describe post-primary TB radiographic findings. Initially see opacity in apical region; does not have a random distribution: prefers upper lungs on the right, Boyden #1 and #3; If a lesion is seen in #2 most likely bronchogenic CA or histoplasmosis
What view shows apical density in post-primary TB best? Apical lordotic view
If apical density in post-primary TB cavitates what is DDX? Staph, Klebsiella, Pseudomonas; don’t see lymphadenopathy in post-primary
If there is hematogenous dissemination of TB what occurs? Spread to every organ (organ stage), Kidney: calcific debris in KI, Bone, Cecum; Miliary TB can also occur: numberous small nodules 1-3mm in diameter throughout entire lung, rapidly fatal
Define Emphysema. A chronic, irreversible, progressive dilation of the air spaces distal to the terminal bronchioles, w/ alveolar wall destruction
What type of emphysema can be differentiated w/ radiography? Bullous emphysema
What is the pathological progression in emphysema? Irreversible over inflation and airspace confluence that creates a useless dead space w/ little or no gas exchange
Describe the lung involvement in emphysema. Spotty involvement of lung, normal tissue interspersed b/w emphysematous tissue there is increased pulmonary vascular resistance and pulmonary HTN -> RVH
Describe the alveoli and what they form in Bullous Emphysema. Dilated and confluent d/t dissolution of alveolar and lobular septa; Form air containing cysts larger than 1cm called a bulla. If Bulla larger than 1/3 of one lung called giant bulla
What would be found on physical examination in a person w/ emphysema? Barrel chest, prominent supraclavicular soft tissues, shallow breathing, hyper-resonance w/ percussion, blood gas analysis shows arterial hypoxemia and hypercapnia
What are radiographic findings in emphysema and what are they d/t? D/t increased total lung capacity w/ subsequent deformity; Found in thoracic wall, heart, diaphragm, attenuation and disorganization of pulmonary vascular pattern (cephalization)
Define oligemia. Decrease in the number of vessels per unit area
Describe barrel chest. Sagittal diameter is increased, posterior parts of ribs are vertical, intercostal spaces are widened, the retrosternal space is also widened >3.5cm
Describe flattened diaphragm in emphysema. Domes of diaphragm are flat and low at level of 11-12 posterior ribs, costophrenic sulcus almost 90 degrees giving pseudoblunting, respiratory diaphragmatic excursion is reduced
What happens to the heart in emphysema? Small, vertical heart d/t flattened diaphragm it assumes a vertical orientation (not as much heart enlargement as RVH)
What happens to the central pulmonary arteries in emphysema? Dilated d/t increased pulmonary vascular resistance and subsequent pulmonary HTN and enlarged hila (width > 12cm)
What are hanging vessels? Lower lobe arteries appear to hang or stretch down in emphysema
What is seen radiographically w/ bullous emphysema? Found in lung apices, bulla push vessels out of way so see areas of crowding by bulla
What percent of lung tumors are benign? 2% Hamartoma (MC benign lung tumor, popcorn calcification) and Adenoma What are the malignant lung tumors?
What are s/s of benign and malignant tumors, how are they found, what can they cause? Both benign and malignant may or may not have symptoms, may be found incidentally, R/O artifact possibility; malignant tumors can cause weight loss and hemoptysis (directly to CXR)
What is doubling time? When a mass is found in a CXR get previous CXR and compare sizes and if it hasn’t changed in shape or size it is benign. If size has doubled can calculate the time it took to double.
What is the next imaging modality after plain films with lung masses? CT! Assess morphology of mass, lymph node changes and calcification
Describe bronchogenic carcinoma. Tumor of bronchial epithelium w/ local expansile growth and infiltration of nearby tissues spreads via lymph and blood; MC lethal CA in M and W; M>F, older age; smokers at risk; CXR detects 3x more cases than sputum
What are clinical symptoms of bronchogenic CA? Appear late in course of disease: hemoptysis, weight loss, recurrent pneumonia; invasion of extrapulmonary structures: SVC obstruction, dysphagia, hoarseness, Horner’s syndrome
What are the classifications of bronchogenic carcinoma? Based upon cell types, undifferentiated more aggressive; squamous cell, adenocarcinoma, small cell (oat cell), large cell, bronchoalveolar (subtype)
Describe the demographics of squamous cell CA of the lung. 30% of cases, 2-3:1 males; strongly associated w/ cigarette smoking; peak incidence 60 y/o; most arise around hilar area (mediastinal/perihilar) causing atelectasis and postobstructive pneumonia
How does squamous cell CA of the lung spread, what does it cause, and what else does it like to do? Direct extension; most common tumor to invade thoracic wall, MC cause of pancoast tumor; MC to undergo necrosis forming a cavity; MC to cause hypercalcemia as paraneoplastic syndrome
Describe adenocarcinoma of the lung. 50% of all bronchogenic tumors; F>M; not associated w/ smoking; appears as peripheral mass w/ lobulated or irregular margins; arises w/in glands of lungs; arises w/in scars in the lung AKA scar CA
Describe small cell CA or the lung. 15% of lung tumors; occurs centrally; spreads to lymph nodes in mediastinum giving a mass; very aggressive, worst Px by Dx mets all over; belongs to neuroendocrine CA
What lung tumor is MC to cause Cushing’s syndrome? Small cell CA of the lung; may secrete chemically active substances
Describe large cell CA of the lung. 5% of lung tumors; tend to be large, bulky tumors in periphery of lung; undifferentiated = very aggressive and spread early; pleural involvement w/ effusions common
Describe bronchoalveolar cell CA. Subtype of adenocarcinoma; 2-6% of lung tumors; Consolidation pattern that is indistinguishable from pneumonia – patchy consolidation looks like cells; typically have late Sx; check f/u films for resolution of pneumonia
What are the 3 main presentations of bronchogenic carcinoma on CXR? Central form; Peripheral form; Diffuse, infiltrating, pneumonic form
Describe central presentation of lung cancer. MC, 75-80% of cases; originates at orifice of segmental and subsegmental bronchi; grow partly into bronchial lumen and partly along lymphatics in bronchial wall, nodal involvement in mediastinum
Describe peripheral presentation of lung cancer. 15-30% of cases; originates from mucosa of smaller bronchi; initially forms solitary pulmonary nodule and grows slower than central tumors
What do peripherally presenting tumors of the lung cause and what are their borders and shapes? mediastinal enlargement, hilar enlargement; any mass over 4cm is CA until proven otherwise; shape varies but most are lobulated; borders ill-defined some get corona radiate w/ interstitial markings out from mass
Describe an apical mass of the lung. Grows in the superior sulcus, may be hard to see (apical lordotic view if suspicious); MC’ly squamous cell CA to cause pancoast; rib destruction and Horner’s syndrome may be present.
Created by: kabrown
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