2022 Pulmo Residents Exam Flashcards

Question

Which is NOT listed as an indication for MR of the thorax? (Brant 4th ed., p. 327)

Answer 1

ANS: Evaluation of middle mediastinal masses Indicated: -Staging of lung cancer patients who can't receive iodinated contrast -Evaluation of aortic disease -Evaluation of mediastinal, vascular, and chest wall invasion of lung cancer

Answer 2

Highest mediastinal

Answer 3

ANS: Descending aorta Part of middle mediastinum: - Brachiocephalic vein - Phrenic nerve - Vagus nerve

Answer 4

ANS: As the two lungs approximate anteromedially, they are separated by two layers of pleura and intervening mediastinal adipose tissue, forming the anterior junction line. The aortopulmonary window consists of the space between the aortic arch and the left pulmonary artery. The normal maximal width of the right paratracheal stripe is 4 mm. The azygoesophageal recess is formed by the contact of the right lower lobe with the esophagus and ascending portion of the azygos vein.

Answer 5

Ans: Left paratracheal 1-2-3 pattern: Right paratracheal Right hilar Left hilar

Answer 6

Superior vena cava obstruction ## Footnote The most common cause of this rare condition is granulomatous infection, usually secondary to Histoplasma capsulatum. The hallmarks of chronic fibrosing mediastinitis are chronic inflammatory changes and mediastinal fibrosis.

Answer 7

Highly proteinaceous cyst content is common. ## Footnote Bronchogenic cysts are foregut duplication cysts and result from abnormal development of the lung bud. They are lined by pseudostratified ciliated columnar epithelium, typical of bronchi. The cyst wall may also contain smooth muscle, mucous glands, or cartilage.

Answer 8

It reflects a defect in the embryogenesis of the coelomic cavity. ## Footnote Pericardial cyst reflects a defect in the embryogenesis of the coelomic cavity. The wall of a pericardial cyst is composed of connective tissue and a single layer of mesothelial cells. Most patients are asymptomatic. On plain radiographs, pericardial cysts are smooth and sharply marginated (Fig. 7.56A). Approximately 90% of pericardial cysts contact the diaphragm, with 65% occurring in the right cardiophrenic angle and 25% in the left cardiophrenic angle. In this location, they sometimes are seen to extend into the major fissure, having a lenticular shape on lateral chest films. Ten percent of pericardial cysts do not touch the diaphragm and are seen at higher levels, contiguous with the proximal aorta or pulmonary arteries.

Answer 9

- Convexity of the lower aspect of the azygoesophageal recess - Increased amount of fat surrounding the distal esophagus - Dehiscence of the diaphragmatic crura ## Footnote Hiatal hernia represents a protrusion of a portion of the stomach through the esophageal hiatus. The esophageal hiatus is an elliptical opening just to the left of the midline, corresponding superiorly to the level of the 10th thoracic vertebral body. It is margined on each side by the diaphragmatic crura. Variation in the normal appearance of the crura is common. In patients with hiatal hernia, chest radiographs show characteristic findings of convexity of the lower aspect of the azygoesophageal interface, sometimes with a similar convexity of the preaortic recess in a retrocardiac location. Air or air and fluid may be seen in association with this convexity. On the lateral view, a retrocardiac opacity may be seen but is usually less conspicuous. In a patient with sliding hiatal hernia, the most common CT abnormality identified is dehiscence of the diaphragmatic crura, visible as widening of the esophageal hiatus on cross- section, with projection of a portion of the stomach into the mediastinum. The width of the esophageal hiatus, defined as the distance between the medial margins of the crura, has a maximum normal value of 15 mm. Sliding hiatal hernias are frequently associated with an increase in the amount of fat surrounding the distal esophagus, secondary to herniation of omentum.

Answer 10

Plexiform neurofibroma ## Footnote Plexiform neurofibroma represents an extensive fusiform or infiltrating mass along the course of the sympathetic chains or mediastinal or intercostal nerves (see Figs. 7.68 and 7.70). It is considered pathognomonic of von Recklinghausen’s disease. As with localized nerve sheath tumors, plexiform neurofibromas often appear low in attenuation compared to muscle, with CT numbers ranging from 15 to 20 HU on unenhanced scans. They are often multiple and lobulated, have ill-defined margins, and tend to surround mediastinal vessels with loss of normally visible fat planes. They can closely mimic the appearance of extensive mediastinal lymph node enlargement. Calcification and contrast enhancement can be seen.

Answer 11

ANS: Often multiple, bilateral, and cephalad to the 6th thoracic vertebra ## Footnote - May be of homogeneous soft tissue attenuation or may show areas of fat attenuation - Paravertebral masses in patients with severe anemia caused by inadequate production or excessive destruction of blood cells - Well marginated - Extramedullary hematopoiesis can result in paravertebral masses in patients with severe anemia caused by inadequate production or excessive destruction of blood cells. It can be seen in the presence of thalassemia, hereditary spherocytosis, and sickle cell anemia. These masses are of unknown origin but may arise from herniations of vertebral or rib marrow through small cortical defects or may arise from lymph nodes or elements of the reticuloendothelial system. Lobulated paravertebral masses, usually multiple and bilateral and caudad to the sixth thoracic vertebra, are typically seen (Fig. 7.75). They appear well marginated. On CT, the paravertebral masses are of homogeneous soft tissue attenuation (30 to 65 HU) or may show areas of fat attenuation (−50 HU), which may increase in extent after treatment.

Answer 12

Ans: mitral valve stenosis Causes of volume overload: ventricular septal rupture renal failure overhydration

Answer 13

fat embolism ## Footnote The embolization of marrow fat to the lung is a common complication occurring 24 to 72 hours after the fracture of a long bone such as the femur. Within the lung, the fat is hydrolyzed to its component fatty acids, causing increased pulmonary capillary permeability and hemorrhagic pulmonary edema. Radiographically and on CT, confluent ground-glass and airspace opacities are seen (Fig. 12.6). The diagnosis is made by recognizing findings of systemic fat embolism (petechial rash, CNS depression) and pulmonary changes in the appropriate time period following trauma. Most patients have a mild course with minimal respiratory compromise, whereas a minority will develop progressive respiratory failure leading to death.

Answer 14

Wegener's granulomatosis ## Footnote - Granulomatosis with polyangiitis (GPA), formerly referred to as Wegener granulomatosis, is a systemic autoimmune disorder characterized pathologically by a necrotizing granulomatous vasculitis involving the upper and lower respiratory tracts and kidneys. The characteristic lesions in the lungs are discrete nodules or masses of granulomatous inflammation with central necrosis and cavitation. The lesions involve pulmonary vessels, accounting for the high incidence of central necrosis and for the occasional presentation with pulmonary hemorrhage. Mucosal and submucosal lesions may be present in the tracheobronchial tree and are seen almost exclusively in women. - Most patients with GPA are middle-aged, with a slight male predominance. The respiratory tract is affected in 100% of patients, with symptoms usually dominated by sinus and nasal mucosal involvement. Pulmonary involvement may be asymptomatic or manifested by cough, dyspnea, or chest pain. Presentation with pulmonary hemorrhage and hemoptysis may mimic other pulmonary–renal syndromes such as Goodpasture syndrome and idiopathic pulmonary hemorrhage. Renal involvement usually follows involvement of the respiratory tract and is seen in almost 90% of patients.

Answer 15

Ans: does not exhibit air bronchograms ## Footnote With some causes of consolidation, air bronchograms may not be visible. This usually occurs because of central bronchial obstruction (e.g., by cancer or mucus) or filling of bronchi in association with the underlying pathologic process. For example, pulmonary infarction often results in consolidation without air bronchograms because of blood filling the bronchi. In patients with bronchopneumonia, bronchi may be filled with mucus or pus.

Answer 16

contrast venography

Answer 17

Ans: central in location - concentric with contrast in vessel center - has small linear defects or "webs" - adherent to vessel wall ## Footnote CTPA is an excellent study for the evaluation of patients with suspected chronic PE, and several CT findings are specifically suggestive of chronic thromboembolic disease. Histopathologically, chronic pulmonary emboli usually are organizing thromboemboli and typically are adherent to the vessel wall. Therefore, chronic emboli are eccentric in location and usually appear as a smooth or sometimes nodular thickening of the vessel wall on CT studies (Fig. 27.15). When an artery is seen in cross section, the chronic emboli may appear to involve one wall of the vessel, may be horseshoe shaped, or may occasionally appear concentric, with contrast in the vessel center, an appearance that likely reflects recanalization 2184 of a previously occluded vessel. Chronic emboli occasionally may calcify, and the main pulmonary arteries may be dilated because of associated pulmonary hypertension. Additionally, small linear filling defects, or “webs” (Fig. 27.16), are indicative of chronic PE.

Answer 18

AOTA are true: - Defined as resting mean pulmonary arterial pressure (mPAP) ≥ 30 mm HG with exercise - Defined as resting mean pulmonary arterial pressure (mPAP) ≥ 25 mm HG at rest - Its characteristic findings is dilation of the central pulmonary arteries with rapid tapering of the pulmonary vessels as they course peripherally

Answer 19

Goodpasture syndrome

Answer 20

ANS: it results from hypoxic vasoconstriction with a decrease in resistance in the pulmonary arterial vasculature - it occurs when there is intimal thickening with a reduction in pulmonary vascular cross sectional area - pulmonary vascular remodeling is implicated in its pathogenesis ## Footnote The histopathological changes associated with pulmonary hypertension associated with COPD include pulmonary vascular remodeling, including intimal thicken- ing with a reduction in pulmonary vascular aoss sectional area. V/Q mismatching is the primary mechanism of hypox- emia in COPD, and regional alveolar hypoxia physiologically results in hypoxic vasoconstriction and increased resistance in the pulmonary arterial vasculature.

Answer 21

As many of 25% of patients with a solid malignancy may have microemboli in the pulmonary circulation

Answer 22

Ans: Pulmonary infarction is a common sequela ## Footnote - X-rays show small nodules, representing parasitic granulomas - Cardiopulmonary schistosomiasis most often is the result of Schistosoma mansoni - Patients present with right heart failure, dyspnea, and cough. -Chest radiography in patients with parasitic embolization shows ndings consistent with pulmonary hypertension. Small nodules, representing parasitic granulomas, may be evident. Pulmonary infarction rarely is seen with parasitic embolization.

Answer 23

respiratory motion ## Footnote pulmonary veins lymph nodes impacted bronchi partial volume averaging of pulmonary arteries pulmo arterial catheters pulmo artery sarcoma

Answer 24

invasive pulmonary aspergillosis ## Footnote Size. Although size does not reliably discriminate benign from malignant SPNs, the larger the lesion, the greater the likelihood of malignancy. Masses exceeding 4 cm in diameter are usually malignant. However, the converse does not hold true; many pulmonary malignancies are less than 2 cm in diameter at the time of diagnosis, particularly if detected by screening chest CT. Nodules <6 mm in diameter have a less than 1% likelihood of malignancy even in high-risk patients, and, therefore, most radiologists will not recommend evaluation of such lesions unless there is a very high clinical likelihood of malignancy. Margin (Border, Edge) Characteristics. The appearance of the margin (i.e., border or edge) of an SPN is a helpful sign in determining the nature of the lesion. The edge characteristics are best evaluated on thin-section CT, as this technique is considerably more accurate than plain radiographs. The margins of an SPN may be sharp or ill defined. A round, smooth nodule is most likely a granuloma or hamartoma, although a rare primary pulmonary malignancy such as a carcinoid tumor, adenocarcinoma, or a solitary metastasis may have a perfectly smooth margin. A notched or lobulated margin may be seen in hamartomas but malignant lesions including carcinoid tumors and some lung cancers will have a lobulated border. Pathologic examination has shown that the lobulated edge of a malignant nodule represents mounds of tumor extending into the adjacent lung. A spiculated margin is highly suspicious for malignancy (Fig. 13.1). The term corona radiata has been used to describe this appearance, in which linear densities radiate from the edge of a nodule into the adjacent lung. Pathologically, these linear radiations represent reoriented connective tissue (interlobular) septa drawn into the tumor by the cicatrizing (scarring) nature of many malignant lung tumors (Fig. 13.1C). Tumor extension from the nodule or fibrosis and edema of these connective tissue septa may thicken these linear densities. However, it has been shown that spiculation is not specific for malignancy, as benign processes that produce cicatrization can have an identical appearance. Benign lesions that have a spiculated border include lipoid pneumonia, organizing pneumonia, tuberculomas, and the mass lesions of progressive massive fibrosis in complicated silicosis. A peripherally situated pulmonary nodule may contact the costal pleura or interlobar fissure via a linear opacity known as a “pleural tail” (Fig. 13.2), which reflects pleural retraction associated with fibrosis related to the lesion and is not specific for malignancy. As with the corona radiata, the recognition of this line, while suggestive of malignancy (particularly adenocarcinoma), is not specific and may be seen in peripheral granulomas. An SPN with an ill-defined margin may be benign or malignant, with benign nodules usually reflecting a resolving inflammatory process. The presence of small “satellite” nodules around the periphery of a dominant nodule is strongly suggestive of benign disease, particularly granulomatous infection. The identification of feeding and draining vessels emanating from the hilar aspect of an SPN is pathognomonic of a pulmonary arteriovenous malformation (AVM) (Fig. 13.3). A posttraumatic pulmonary artery pseudoaneurysm will show marked contrast enhancement and contiguity with the feeding artery on CT. The presence of a halo of ground-glass opacity encircling an SPN in an immunocompromised, neutropenic patient should suggest the diagnosis of invasive fungal infection. Finally, a nodule or mass adjacent to an area of pleural thickening with a “comet tail” of bronchi and vessels entering the hilar aspect of the mass and associated lobar volume loss is characteristic of rounded atelectasis. Density. The density of an SPN is probably the single most important factor in characterizing the lesion as benign or indeterminate. In general, lesions that are calcified are benign. There are five patterns of calcification that when present in a solid nodule that is smooth or lobulated reliably indicates benignity. These patterns can be identified on conventional radiography but thin-section CT is often necessary to detect and characterize the calcification. Complete, central, or peripheral rim-like calcification within an SPN is specific for a healed granuloma from tuberculosis or histoplasmosis. Concentric or laminated calcification indicates a granuloma and allows confident exclusion of neoplasm. Popcorn calcification within a nodule is diagnostic of a pulmonary hamartoma in which the cartilaginous component has calcified.

Answer 25

The presence of a pleural effusion in patients with bronchogenic carcinoma is associated with a poor prognosis because it is synonymous with malignant pleural involvement. | it is not synonymous with malignant pleural involvement ## Footnote The “CT angiogram” sign refers to the finding of enhanced PAs traversing consolidated regions which are produced by filling of the airspaces with mucoid material produced by malignant cells. The presence of air bronchograms or bubbly lucencies within a nodule or mass or mixed solid/ground-glass attenuation is highly suggestive of an adenocarcinoma, particularly BAC

Answer 26

N3 ## Footnote adapted from 8th ed.

Answer 27

25% (26% in 5th ed)

Answer 28

Pleural thickening Rib destruction

Answer 29

Localized invasion of the mediastinal pleura or pericardium

Answer 30

CT at 6-12 months, then at 18-24 months

Answer 31

Squamous cell

Answer 32

Small cell ## Footnote Small cell carcinoma, a type of neuroendocrine tumor of the lung, accounts for 13% of bronchogenic carcinomas and arises centrally within the main or lobar bronchi. These tumors are the most malignant neoplasms arising from bronchial neuroendocrine (Kulchitsky) cells and are alternatively referred to as Kulchitsky cell cancers or KCC-3. Typical carcinoid tumors (KCC-1) represent the least malignant type, with atypical carcinoid tumors (KCC-2) intermediate in aggressiveness. Small cell carcinomas exhibit a small endobronchial component invading the bronchial wall and peribronchial tissues early in the course of disease. This produces a hilar or mediastinal mass with extrinsic bronchial compression and obstruction. Invasion of the submucosal and peribronchial lymphatics leads to local lymph node enlargement (Fig. 13.12D) and hematogenous dissemination, which are almost invariable at the time of presentation. Microscopically, these malignant cells are tightly clustered with nuclei molded together because of the scant amount of cytoplasm. This lesion is distinguished from carcinoid tumor histologically by the presence of mitoses. Electron microscopy and immunocytochemistry demonstrate the presence of intracytoplasmic neurosecretory granules.

Answer 33

Small cell

Answer 34

Adenocarcinoma

Answer 35

Renal cell carcinoma ## Footnote Calcified pulmonary mets: Mucinous adenocarcinoma Thyroid carcinoma Osteogenic sarcoma Calcification of metastases occurs most commonly with osteogenic sarcoma, chondrosarcoma, synovial sarcoma, thyroid carcinoma, and mucinous adenocarcinoma (Fig. 5.5). Calcification may be dense, particularly with osteogenic sarcoma, mimicking a granuloma. Calcification may persist following successful chemotherapy despite resolution of the tumor.

Answer 36

Cavity with wall measuring more than 15mm ## Footnote SPN measuring 2.5cm, and which contains fat Mass within a cavity that moves with gravity Air-fluid level in a cavitary SPN

Answer 37

ANS: It occurs when pulmonary arterial pressures are leveled because of left-sided myocardial failure. Below are true: - The most common cause in children is acute glomerulonephritis. - It can occur in hypoplastic left heart syndrome. - A noncardiogenic cause is increased intracranial pressure.

Answer 38

Ans: chronic asthma ## Footnote tuberous sclerosis connective tissue disease primary interstitial pneumonitis

Answer 39

left lower lobe ## Footnote right upper lobe left upper lobe middle lob

Answer 40

Ans: Classically, infants present with lungs that are granular in pattern and large in volume. | small lungs, finely granular, w. air bronchograms ## Footnote It occasionally occurs in full-term infants of diabetic moms. Pneumothorax and pneumomediastinum are common complications of positive pressure ventilation.

Answer 41

persistent fetal circulation

Answer 42

distal airspaces ## Footnote air bronchograms are common spreads via pores of Kohn and canals of Lambert significant volume loss is unusual

Answer 43

ans: Air bronchograms are commonly seen | bcoz inflammatory exudate fills the airways, air bg are rarely seen ## Footnote Empyema is a common sequela Typically produces a bronchopneumonia Pneumatocele is common in children Staphylococcus aureus pneumonia is most common in hospitalized and debilitated patients. It may also develop following hematogenous spread to the lung in patients with endocarditis or indwelling catheters and in intravenous drug users. Community-acquired infection may complicate influenza or other viral pneumonias. S aureus typically produces a bronchopneumonia and appears radiographically as patchy opacities (Fig. 16.3). In severe cases, the opacities may become confluent to produce lobar opacification. Because the inflammatory exudate fills the airways, air bronchograms are rarely seen. In adults, the process is often bilateral and may be complicated by abscess formation in 25% to 75% of patients. In patients who develop pulmonary infection from hematogenous seeding, one sees multiple bilateral poorly defined nodular opacities that even- tually become more sharply defined and cavitate. Parapneu- monic effusion and empyema are common. Pneumatocele formation is common in children and may lead to pneumotho- rax. Pneumatoceles may be distinguished from abscesses by their thin walls, rapid change in size, and tendency to develop during the late phase of infection.Air bronchograms are commonly seen

Answer 44

lobar pneumonia | cavitation, bronchopneumonia patten tree-in-bud or centrilobular ## Footnote Chest radiographs show a pattern typical of bronchopneumonia, including segmental, often multifocal, patchy consolidation that favors the lower lobes. Pleural effusions may occur, as may empyema. Cavita- tion may also be seen (see Fig. 12-9). 'free-in-bud or cen- trilobular nodules may be seen on HRCT (see Fig. 10-28C in Chapter 10). The pattern of P. aeruginosa infection is insufficiently specific to distinguish it from other causes of bronchopneumonia.

Answer 45

Ranke complex

Answer 46

Miliary pattern ## Footnote Air-space consolidation of an entire lobe No radiologic abnormalities Right lung is more commonly affected than the left

Answer 47

bilateral perihilar ground-glass opacity

Answer 48

Tracheobronchomalacia

Answer 49

Penetrating tracheal injuries usually involve the distal trachea | usually involve the cervical trachea ## Footnote Exhibits the "fallen lung" sign Diagnosis is suggested by presence of pneumothorax that fails to respond to chest tube drainage. Horizontal laceration parallel to the tracheobronchial cartilage is the most common form of injury.

Answer 50

Secondary pulmonary lobule

Answer 51

Nonspecific interstitial pneumonia

Answer 52

Usual interstitial pneumonia/Idiopathic pulmonary fibrosis

Answer 53

Wegener Granulomatosis

Answer 54

Pulmonary alveolar proteinosis

Answer 55

characterized by marked decrease in sagittal diameter of the intrathoracic trachea associated with an increase in its coronal diameter | dec coronal, inc sagittal ## Footnote The ff are true: during forced expiration, CT demonstrates further inward bowing of the tracheal walls the main bronchi are of normal size almost always associated with COPD

Answer 56

Tracheobronchopathia osteochondroplastica

Answer 57

ANS: high concentration of chloride on sweat test bronchiectasis sinusitis situs inversus

Answer 58

CHEST WALL LIPOMA

Answer 59

LUFTSICHEL SIGN

Answer 60

ATOLL SIGN REVERSE HALO SIGN

Answer 61

TUBEROUS SCLEROSIS LYMPHANGIOLEIOMYOMATOSIS RENAL ANGIOMYOLIPOMA

Answer 62

CENTRILOBULAR EMPHYSEMA

Answer 63

MOUNIER-KUHN SYNDROME TRACHEOBRONCHOMEGALY

Answer 64

KLEBSIELLA

Answer 65

CONGENITAL DIAPHRAGMATIC HERNIA MORGAGNI HERNIA

Answer 66

BRONCHOPULMONARY DYSPLASIA

Answer 67

PANLOBULAR EMPHYSEMA

Answer 68

PULMONARY ARTERIAL HYPERTENSION

Answer 69

KERLEY LINES

Answer 70

HALO SIGN ## Footnote Represents hemorrhage angioinvasive aspergilosis lung adenoCA

Answer 71

CT ANGIOGRAM SIGN ## Footnote represents vessel traversing airless consolidated lung; seen also in lung adenoCA, mets)

Answer 72

Feeding vessel sign ## Footnote represents vessel leading to mass (e.g. septic emboli, pulmo infarct)

Answer 73

Achalasia ## Footnote esophageal stricture?

Answer 74

Mature teratoma

Answer 75

7 (subcarinal)