Ch.12 - Recognizing Diseases of the Chest Flashcards
1
Q
The middle mediastinum is home primarily to:
A
Lymphadenopathy from lymphoma and metastatic disease, such as from small cell carcinoma of the lung.
2
Q
The posterior mediastinum is the location of:
A
Neurogenic tumors –> Either from the nerve sheath (mostly benign) or tissues other than the sheath (mostly malignant).
3
Q
Incidental solitary pulmonary nodules (SPNs) less than … in size are rarely malignant.
A
4mm.
4
Q
When clinical or imaging findings suggest malignancy, …% of SPNs in men >50 are malignant.
A
50%.
5
Q
SNPs - Criteria on which an evaluation of benignity can be made include:
A
- Absolute size of the nodule upon discovery.
- Presence of calcification within it.
- The margin of the nodule.
- Change in the size of the nodule over time.
6
Q
Bronchogenic carcinomas present in one of three ways:
A
- Visualizing the tumor itself.
- Recognizing the effects of bronchial obstruction such as pneumonitis and/or atelectasis.
- Recognizing the results of either their direct extension or metastatic spread to the chest or to distant organs.
7
Q
Bronchogenic carcinoma most likely to obstruct + cavitate:
A
SCC.
8
Q
Hematogenous spread –> Common sites of primaries:
A
- Colorectal.
- Breast.
- RCC.
- Head/neck.
- Bladder.
- Uterine.
- Cervical.
- Soft tissue sarcomas.
- Melanoma.
9
Q
In lymphangitic spread of carcinoma, a tumor…:
A
Grows + Obstructs the lymphatics in the lung producing a pattern that is radiologically similar to pulmonary INTERSTITIAL edema.
–> Primaries that metastasize in this fashion –> Breast, lung, pancreatic.
10
Q
Blebs, bullae, cysts, and cavities:
A
All air-containing lesions in the lung that differ in:
- Size.
- Location.
- Wall composition.
11
Q
Anterior mediastinal masses - Thyroid goiter - What to look for:
A
The only anterior mediastinal mass that routinely deviates the trachea.
12
Q
Anterior mediastinal masses - Lymphoma - What to look for:
A
Lobulated, polycyclic mass, frequently asymmetrical, that may occur in any compartment of the mediastinum.
13
Q
Anterior mediastinal masses - Thymoma - What to look for:
A
Well-marginated mass that may be associated with myasthenia gravis.
14
Q
Anterior mediastinal masses - Teratoma - What to look for:
A
Well-marginated mass that may contain fat and calcium on CT scans.
15
Q
Sarcoidosis vs lymphoma - Lymphadenopathy:
A
Sarco –> Bilateral hilar + right paratracheal.
Lymphoma –> More often mediastinal + asymmetrical hilar enlargement.
16
Q
Sarcoidosis vs Lymphoma - Nodes?
A
Sarco –> Bronchopulmonary nodes more PERIPHERAL.
Lymphoma –> Hilar nodes more CENTRAL.
17
Q
Sarcoidosis vs Lymphoma - Pleural effusion?
A
Sarco –> About 5%.
Lymphoma –> About 30%.
18
Q
Sarcoidosis vs Lymphoma - Anterior mediastinal adenopathy:
A
Sarco –> Uncommon.
Lymphoma –> Common.
19
Q
Pancoast tumor:
A
- Soft tissue mass in the apex of the lung.
- MC SCC/Adeno.
- Frequently produces adjacent rib destruction.
- May invade branchial plexus.
- May cause Horner syndrome.
- On the RIGHT side, it may produce SVC obstruction.
20
Q
Some common primary sites of metastatic lung nodules - Men:
A
- Colorectal.
- RCC.
- Head/neck.
- Testicular/bladder.
- Melanoma.
- Sarcoma.
21
Q
Some common primary sites of metastatic lung nodules - Females:
A
- Breast.
- Colorectal.
- RCC.
- Cervical/endometrial.
- Melanoma.
- Sarcoma.
22
Q
DDX 3 cavitating lesions - Thickness of the cavity wall:
A
Bronchogenic carcinoma –> Thick (means >5mm).
TB –> Thin.
Lung abscess –> Thick.
23
Q
DDX 3 cavitating lung lesions - Inner margin of cavity:
A
Bronchogenic carcinoma –> Nodular.
TB –> Smooth.
Lung abscess –> Smooth.
24
Q
Differentiating a mediastinal from a parenchymal lung mass on frontal and lateral CXR (4):
A
- Mediastinal masses originate in the mediastinum (makes sense, right?).
- If a mass is surrounded by lung tissue in BOTH the frontal + lateral projections –> Lies within the lung.
- GENERALLY –> The margin of a mediastinal mass is SHARPER than a mass originating in the lung.
- Mediastinal masses frequently displace, compress, or obstruct other mediastinal structures.
25
DDX for ANTERIOR mediastinal masses?
1. Substernal thyroid masses.
2. Lymphoma.
3. Thymoma.
4. Teratoma.
26
MC anterior mediastinal mass?
Substernal thyroid masses --> Multinodular goiter.
27
On occasion, the isthmus or LOWER pole of either lobe of the thyroid may ...?
Enlarge but project DOWNWARD into the UPPER thorax rather than ANTERIORLY into the neck.
28
```
About ... out of 4 thyroid masses extend ANTERIOR to the trachea.
The remaining (almost ALL right-sided) descend POSTERIOR to the trachea.
```
3/4.
29
Substernal goiters characteristically displace the trachea ...?
Either to the left or right --> ABOVE THE LEVEL of the AORTIC ARCH.
--> A tendency the other anterior mediastinal masses do NOT typically demonstrate.
30
Classically, substernal goiters ...?
Do NOT extend below the top of the aortic arch.
31
Study of choice in confirming the diagnosis of a substernal thyroid?
Radioisotope thyroid scan.
32
On CT, substernal thyroid masses are ...?
Contiguous with the thyroid gland --> Frequently contain calcification + Avidly take up IV contrast but with a mottled, inhomogeneous appearance.
33
What is the MCC of mediastinal mass OVERALL?
Lymphadenopathy - Whether from lymphoma, carcinoma, sarcoidosis or TB.
34
ANTERIOR mediastinal lymphadenopathy is most common in ...?
Hodgkin lymphoma - Especially the nodular sclerosing type.
35
Anterior mediastinal mass - Lymphadenopathy - What to look for?
Lobulated, polycyclic mass, frequently asymmetrical, that may occur in any compartment of the mediastinum.
36
Which mediastinal lymph nodes are considered to be enlarged?
Mediastinal lymph nodes that exceed 1cm measured along their SHORT AXIS on CT scans of the chest are considered to be ENLARGED.
37
Why is it important to find a thymoma in patients with MG?
The importance lies in the favorable PROGNOSIS after thymectomy.
38
On CT, thymomas classically present as?
A smooth or lobulated mass that arises near the junction of the heart and great vessels, which, like a teratoma, may contain calcification.
39
5 other than thymoma lesions that may produce enlargement of the thymus?
1. Thymic cyst.
2. Thymic hyperplasia.
3. Thymic lymphoma.
4. Carcinoma.
5. Lipoma.
40
About ...% of mediastinal teratomas are malignant.
30%.
41
The most common variety of mediastinal teratoma is?
Cystic.
42
On CT, mediastinal teratomas present as?
A well-marginated mass near the origin of the great vessels that characteristically contains fat, cartilage, and possible bone on CT examination.
43
MC mass in MIDDLE mediastinum?
Lymphadenopathy.
44
Malignancies that produce MIDDLE mediastinal lymphadenopathy?
1. HL.
2. Small cell carcinoma of thee lung.
3. Metastasis from breast.
45
Benign causes of MIDDLE mediastinal lymphadenopathy?
1. IM.
| 2. TB --> Usually producing UNILATERAL MEDIASTINAL ADENOPATHY.
46
POSTERIOR mediastinum is the home of ...?
Tumors of neural origin.
47
4 neurogenic tumors seen in posterior mediastinum?
1. Neurofibroma.
2. Schwannoma (neurilemmoma).
3. Ganglioneuroma.
4. Neuroblastoma.
48
MC mass in posterior mediastinum?
Nerve sheath tumors (Schwanommas or neurilemmomas) --> Almost always benign.
49
Neurogenic tumors will produce ...?
A soft tissue mass, usually sharply marginated in the paravertebral gutter.
50
What is the difference between a nodule and a mass?
SIZE:
Nodule.
>3cm --> Mass.
51
It is estimated that as many as ...% of smokers have a nodule discovered by chest CT.
50%.
52
SPN - Benign or malignant - Size?
Nodules 5cm 95% malignant.
53
SPNs that are surgically removed (clinical signs or symptoms and imaging findings suggested malignancy) are ...?
Malignant 50% of the time in men >50.
54
Granulomas?
TB + Histoplasmosis usually produce CALCIFIED nodules
55
Calcification of tuberculomas?
Usually homogeneously calcified.
56
Calcification of histoplasmomas?
May contain a central or "target" calcification or may have a LAMINATED calcification which is diagnostic!
57
Lung hamartomas?
Peripherally located lung tumors of disorganized lung tissue that characteristically contain FAT + CALCIFICATION on CT scan.
--> Popcorn classification.
58
Other UNCOMMON benign lesions that can produce SPNs:
1. Rheumatoid nodule.
2. Fungal diseases - Nocardiosis.
3. AV malformations.
4. Wegener.
59
3 ways in recognizing bronchogenic carcinomas of the lung:
1. There may be recognized by visualization of the tumor itself: i.e. nodule/mass in the lung.
2. Suspected by the effects of bronchial obstruction: i.e. pneumonitis and/or atelectasis.
3. Suspected by recognizing the results of either their direct extension or metastatic spread to the lung or other organs.
60
Bronchogenic carcinomas presenting as a nodule/mass in the lung?
1. Most often ADENOCARCINOMAS.
2. Nodule may have IRREGULAR + SPICULATED margins.
3. If may cavitate --> SCC --> Relatively thick-walled cavity with a nodular + irregular inner margin.
61
Bronchial obstruction is most often caused by?
SCC.
62
Bronchogenic carcinoma presenting with direct extension or metastatic lesions?
1. Rib destruction by direct extension (Pancoast tumor).
2. Hilar adenopathy (usually UNILATERAL).
3. Mediastinal adenopathy.
4. Other nodules in the lung.
5. Pleural effusion.
6. Metastases to bones.
63
5 Important points about pancoast tumor:
1. Manifests as soft tissue mass in the apex of the lung.
2. Most often SCC or adenoCa.
3. Frequently produces adjacent rib destruction.
4. May invade brachial plexus or cause Horner syndrome.
5. On the RIGHT --> SVC syndrome.
64
Lymphangitic spread of carcinoma:
A tumor grows in and obstructs lymphatics in the lung --> A pattern that is radiologically similar to PULMONARY INTERSTITIAL EDEMA from HF including:
1. Kerley B lines.
2. Thickening of fissures.
3. Pleural effusions.
65
Lymphangitic spread of carcinoma - How to differentiate from CHF?
The findings will may be UNILATERAL, or confined to 1 lobe.
66
The MC primary malignancies to produce lymphangitic spread to the lung are those that arise around the THORAX:
1. Breast.
2. Lung.
3. Pancreas.
67
Some common sires of metastatic lung nodules - Males:
1. Colorectal.
2. RCC.
3. Head/Neck tumors.
4. Testicular/Bladder.
5. Melanoma.
6. Sarcomas.
68
Some common primary sites of metastatic lung nodules - Females:
1. Breast.
2. Colorectal.
3. RCC.
4. Cervical/endometrial.
5. Melanoma.
6. Sarcomas.
69
CXR - What may show in PE?
Non specific findings:
1. Subsegmental atelectasis.
2. Small pleural effusions.
3. Elevation of the hemidiaphragm.
70
CXR INFREQUENTLY manifest one of the "classic" findings for PE, which can include:
1. Wedge-shaped peripheral air-space disease = Hampton hump.
2. Focal oligemia = Westermark sign.
3. Prominent central pulmonary artery = knuckle sign.
71
What is ANOTHER benefit of CTPA?
The ability to acquire images of the VEINS of the PELVIS and legs by obtaining slightly delayed images following the pulmonary arterial phase of the study.
72
On CXR the most reliable finding of COPD is?
Hyperinflation - Flattening of the diaphragm, especially on the lateral exposure.
73
Blebs, bullae, cysts, and cavities are all ...?
AIR-containing lesions in the lung of differing SIZE, LOCATION, and WALL COMPRESSION.
74
Blebs are ...?
Very small, blisterlike lesions that form in the visceral pleura, usually at the APEX of the lung.
--> Very thin-walled.
75
Can blebs be seen on CXR:
NO - They are too small to be visible on chest radiographs.
76
Blebs are thought to be associated with?
Spontaneous pneumothoraces.
77
Bullae measure ...?
>1cm.
78
Bullae are usually associated with ...?
Emphysema.
79
Features of bullae?
1. Occur in the lung parenchyma.
2. Very thin-walled ( Seen on CT.
3. They can grow --> Vanishing lung syndrome.
4. Air-fluid level --> Infection or hemorrhage.
80
Cysts are either ... or ... .
Congenital or acquired.
81
Cysts can occur in either the ... or the ... .
Lung parenchyma or the mediastinum.
82
Features of cysts:
1. Thin wall.
| 2. Usually thicker than that of a bulla (
83
Pneumatoceles are ...?
Thin-walled CYSTS that usually develop after a lung infection caused by such organisms as Staphylococcus or Pneumocystis.
84
Cavities - Size?
Variable - From few mm to several cm.
85
Cavities occur?
In the LUNG PARENCHYMA and usually result from a process that produces necrosis of the CENTRAL PORTION of the lesion.
86
Cavities - Wall thickness?
They usually have the thickest wall (3mm - ...cm).
87
Differentiating the 3 cavitating lung lesions:
1. Cancer --> Thick wall + Nodular inner margin.
2. TB --> Thin wall + Smooth inner margin.
3. Lung abscess --> Thick wall + Smooth inner margin.
88
4 Rare causes of bronchiectasis:
1. CF.
2. Kartagener (primary ciliary dyskinesia).
3. ABPA.
4. Swyer-James syndrome = Unilateral hyperlucent lung.
89
Bronchiectasis - What is the hallmark on CT?
The signet-ring sign --> In which the bronchus, frequently with a thickened wall, becomes larger than its associated pulmonary artery.
90
Masses in the ANTERIOR mediastinum include:
1. Substernal thyroid goiters.
2. Lymphoma.
3. Thymoma.
4. Teratoma.
