Fibrosing mediastinitis 1. Causes? 2. Pathologic mechanism? 3. Imaging appearance?

1. Idiopathic (?IgG4), TB, histoplasmosis, radiation, sarcoid, drugs 2. Causes compression of mediastinal structures 3. Increased mediastinal soft tissue/mass, obliteration of mediastinal fat, calcification within mass or calcified nodes, may be focal lung abnormalities - opacities, septal thickening

Solid pulmonary nodules - at what size do they not need follow up? - when to do a Brock score? - what is a raised Brock score and what to do next? - when can you discharge a solid nodule from follow up?

- 8 mm - >10% - do a PET-CT - if the nodule is stable ( 600 days)

NSIP 1. 2 forms of NSIP? 2. Imaging findings? 3. Most commonly seen in which patients? 4. Steroid responsive?

1. Fibrotic and cellular - cellular has better prognosis 2. Bilateral symmetrical ground glass opacities, less prominent fibrotic changes, immediate subpleural sparing (this is v. specific), homogenous lung involvement in a subpleural pattern, microcysts and micronodules 3. Those with collagen vascular diseases (SLE, scleroderma, RA, polymyositis) 4. Yes - important to make the diagnosis as better prognosis than UIP/IPF

AIP 1. Clinical features? 1. Imaging?

1. Bad prognosis, acute onset, Previously fit and well require ventilation in 1-4 weeks. 2. Bilateral, symmetrical, lower lobe GGO and alveolar consolidation from oedema/haemorrhage, then later fibrotic changes in non-dependent lung Classically spares the costophrenic angles

Chest Flashcards by Claudia Dodds

3 causes of chronic consolidation?

Adenocarcinoma in situ/minimally invasive adenocarcinoma/invasive adenocarcinoma

Organizing pneumonia

Chronic eosinophilic pneumonia

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4 causes of central ground glass opacities?

Pulmonary oedema

Alveolar haemorrhage

Pneumocystis jiroveci pneumonia (PCP) - cancer, HIV, transplant

Alveolar proteinosis

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Fibrosing mediastinitis

Causes?
Pathologic mechanism?
Imaging appearance?

Idiopathic (?IgG4), TB, histoplasmosis, radiation, sarcoid, drugs
Causes compression of mediastinal structures
Increased mediastinal soft tissue/mass, obliteration of mediastinal fat, calcification within mass or calcified nodes, may be focal lung abnormalities - opacities, septal thickening

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8 causes of pulmonary hypertension?

Primary (idiopathic) arterial hypertension
Chronic thromboembolic pulmonary HTN
Pulmonary veno-occlusive disease
Chronic hypoxia - COPD, interstitial fibrosis, sleep apnoea
Pulmonary venous HTN secondary to left-sided heart disease incl. aortic/mitral pathology
Left-to-right sided shunt (ASD, VSD)
Sarcoid
Fibrosing mediastinitis

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A few key points about staging of lung cancer:
- General cut off point for surgical resection?
- stage IV can be resected when?

Tends to be stage IIB/IIIA - when there is contralateral nodal involvement or tumour >7cm
solitary adrenal or brain metastasis

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Solid pulmonary nodules

at what size do they not need follow up?
when to do a Brock score?
what is a raised Brock score and what to do next?
when can you discharge a solid nodule from follow up?

<5 mm
solid nodule >8 mm
> 10% - do a PET-CT
if the nodule is stable (<25% increase on volumetry, VDT >600 days)

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Aspergillus - categories of pulmonary disease?

Allergic bronchopulmonary aspergillosis (asthmatics, CF)
Aspergilloma - in a pre-existing lung cavity (Monod sign)
Subacute invasive pulmonary aspergillosis. Affects the debilitated, diabetic, etoh, COPD. Upper lobe consolidation → cavitation, pleural thickening
Airway-invasive. Severely immunocompromised patients. Centrilobular and tree-in-bud nodularity.
Angio-invasive. Severely immunocompromised. Halo sign (haemorrhagic infarction of surrounding lung), air crescent sign (air from retraction of infarcted lung - a good sign!)

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Lady Windermere syndrome

Right middle lobe or lingula lobe bronchiectasis and tree-in-bud change in an older female, non-smoker, with cough, weight-loss, low-grade fever. Secondary to atypical Mycobacteria (avium intracellulare, kansasii).

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Imaging manifestations of primary TB?

Nothing
Ill-defined consolidation
Adenopathy (peripheral enhancement, central low attenuation)
Pleural effusion
Miliary disease

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Aspergillosis imaging findings?

Fleeting pulmonary opacities
Mucoid impaction - “finger in glove”
Bronchiectasis
Centrilobular nodules

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Causes of lymphangitis carcinomatosis?

Certain Cancers Spread By Plugging The Lymphatics

Cervix
Colon
Stomach
Breast
Pancreas
Thyroid
Lung

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Chest x-ray signs of PE

Westermark sign - regional oligaemia
Hampton’s hump - wedge shaped peripheral opacity
Fleischner sign - enlargement of the pulmonary arteries

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4 causes of UIP pattern?

Trio of signs for UIP?

Idiopathic pulmonary fibrosis
Collagen vascular disease - rheumatoid arthritis, scleroderma
Drug injury
Asbestosis

Subpleural reticulation
Honeycombing with traction bronchiectasis
Apicobasal gradient

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NSIP

2 forms of NSIP?
Imaging findings?
Most commonly seen in which patients?
Steroid responsive?

Fibrotic and cellular - cellular has better prognosis
Bilateral symmetrical ground glass opacities, less prominent fibrotic changes, immediate subpleural sparing (this is v. specific), homogenous lung involvement in a subpleural pattern, microcysts and micronodules
Those with collagen vascular diseases (SLE, scleroderma, RA, polymyositis)
Yes - important to make the diagnosis as better prognosis than UIP/IPF

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COP aka BOOP
1. Associations?
2. Steroid-responsive?
3. Imaging findings?

Idiopathic, post-infectious, rheumatological conditions, CF, post-transplant, medications (bleomycin, nitrofurantoin)
Very - but frequent relapse on cessation
Peripheral patchy lung consolidation/GGO Atoll sign/reverse halo sign
Nodules - small centrilobular mimicking HSP
Larger nodules which cavitate
Or may be a single mass that mimics lung cancer
Perilobular fibrosis “arcade sign”

May be bronchial dilatation within consolidation
May be subpleural sparing

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RB-ILD - respiratory bronchiolitis-interstitial lung disease

Demographics?

Imaging?

Young smokers

Centrilobular nodules and patchy GGO, upper lobes

Continuum with DIP

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DIP - desquamative interstitial pneumonia

Imaging?

Patchy or subpleural GGO - more extensive that RB-ILD, peripheral predominance

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LIP - lymphoid interstitial pneumonia

Causes?
In a child?
Imaging?

Idiopathic, HIV, Sjogren’s, autoimmune, infection (HBV, PCP, EBV), Castleman’s

Think HIV

Diffuse (or lower lobe) GGO
Thin-walled perivascular cysts
Pneumothorax

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AIP

Clinical features?
Imaging?

Bad prognosis, acute onset, Previously fit and well require ventilation in 1-4 weeks.
Bilateral, symmetrical, lower lobe GGO and alveolar consolidation from oedema/haemorrhage, then later fibrotic changes in non-dependent lung
Classically spares the costophrenic angles

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Pleural fibroma
- associations?
- imaging findings?
- management?

Hypoglycaemia, HPOA, not asbestosis

Smooth with contrast enhancement

Surgical resection - 1/3 undergo malignant transformation

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Hypersensitivity pneumonitis (HSP) - organic!

Imaging findings?

Acute - GGO or consolidation
Subacute - ground glass centrilobular nodules, mid to lower zones, mosaicism
Chronic - fibrosis affecting the upper lobes

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Coal worker’s pneumoconiosis
- classification?
- CWP imaging findings?
- PMF imaging findings?

Simple or complicated - complicated has PMF pulmonary massive fibrosis

Multiple small upper and mid zone opacities +/- calcification; enlarged hilar LNs, which are often calcified

Peripheral upper/mid zone mass >1cm, may be bilateral, may become necrotic + cavitate

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Silicosis
- types?
- pathognomonic imaging finding?

Classic silicosis - nodules which may coalesce to form PMF

Silicoproteinosis - very similar to alveolar proteinosis, develops with high exposure over a short time

Egg-shell calcification of hilar lymph nodes

Eosinophilic lung disease

Simple pulmonary eosinophilia (Loffler syndrome)
- causes?
- imaging findings?

Chronic eosinophilic pneumonia
- imaging findings?

Idiopathic, parasitic infections, drug reactions

Migratory and transient areas of focal consolidation

Patchy peripheral consolidation “reverse batwing appearance” with upper lobe predominance - unchanged for months

Pulmonary vasculitis - EGPA - associations? - GPA - classic triad? lung findings? c-anca positive. - microscopic polyangitis - imaging findings?

Asthma, peripheral eosinophilia Sinusitis, lung involvement, renal impairment. Multiple cavitatory nodules. Pulmonary haemorrhage

Sarcoidosis - distribution of pulmonary fibrosis secondary to sarcoid? - most common radiographic findings? most common CT finding?

- mid to upper lobe predominance - symmetric adenopathy. Eggshell calcification of lymph nodes. - perilymphatic nodules

Differential for disease affecting the lungs and bones?

- pulmonary Langerhans cell histiocytosis - malignancy - TB - sarcoid - fungal disease - Gaucher disease

PLCH (pulmonary Langerhans cell histiocytosis) Demographics? Imaging findings? Progression of disease?

Young, **smokers** Upper lobe cysts - thick walled, bizarre shaped Nodules - sparing of the costophrenic sulci Pneumothorax Nodules → cavitatory nodules → cysts

Causes of crazy paving pattern?

Pulmonary oedema ARDS Pulmonary alveolar proteinosis Pulmonary haemorrhage PCP OP + NSIP Mucinous adenocarcinoma Lipoid pneumonia

Lymphangioleiomyomatosis (LAM) - imaging findings? - types? - associations?

Smooth, numerous thin-walled round cysts throughout all five lobes of the lungs Type seen in tuberous sclerosis Idiopathic type - women of child-bearing age Pneumothorax and **chylous pleural effusion**

Causes of paraspinal line abnormality?

Neurogenic tumour Osteophyte Infection/lymphadenopathy Haematoma secondary to traumatic vertebral fracture Aortic aneurysm Extramedullary haematopoiesis Oesophageal varices

Differential for anterior mediastinal mass (prevascular)?

Thymic epithelial neoplasm (thymoma/thymic carcinoma) Thymic cyst Thymolipoma Thymic carcinoid Germ cell tumour - teratoma, seminoma Lymphoma - HL/NHL Adenopathy - pneumoconiosis/sarcoid/TB/Castleman's/metastases Thyroid lesion - goitre/carcinoma/thyroiditis

Causes of vascular metastases?

Renal cell ca Thyroid Lung Melanoma Sarcoma

Differential for anterior mediastinal mass (pre-cardiac)?

Epicardial fat pad Pericardial cyst Morgagni hernia

Causes of bronchiectasis?

Cystic fibrosis ABPA Post infectious TB/atypical mycobacteria Agammaglobulinaemia Immunodeficiency Kartagener Mounier-Kuhn syndrome CAPTAIn Kangaroo has Mounier-Kuhn

Differential for nodular and irregular tracheal wall thickening?

Amyloidosis Adenoid cystic carcinoma Sarcoidosis Tracheal metastases

Airway tumours Most common primary in adults? Most common primary in children? Most common cancers to metastasize to airways?

SCC Endobronchial carcinoid Breast, thyroid, lung, renal cell ca

Benign endobronchial lesions?

Papilloma Chondroma Schwannoma Adenoma Haemangioma Lipoma Leiomyoma Hamartoma

Which cancers metastasize to the pleura?

Lung GI and GU adeno Invasive thymoma

Most common cause of lung metastases in order?

Breast Colon Renal Uterus Head and neck

Most common malignancies to present with synchronous lung metastases?

Lung Bowel Renal cell Pancreas Breast Testis (young men)

Drug causes of lung fibrosis

Amiodarone Chemotherapy - Bleomycin, carmustine, cyclophosphamide, busulfan Methotrexate Antibiotics - nitrofurantoin, sulfasalazine, amphotericin B, isoniazid Biological agents

Carney Triad

Pulmonary chondroma Gastric leiomyosarcoma (GIST) Extra-adrenal paragangliomas

Carney syndrome

Atrial myxoma Facial/buccal pigmentation Sertoli tumour testis Pituitary adenoma

Causes of upper zone fibrosis?

BREASTS Berylliosis Radiation Eosinophilic granuloma (i.e. LCH) and EEA (i.e. HSP) Ankylosing spondylitis Sarcoidosis TB Silicosis/CWP

Causes of lower zone fibrosis?

BADAS Bronchiectasis Asbestosis Drugs and DIP Aspiration pneumonitis Scleroderma and rheumatoid arthritis

Differential for tree-in-bud on HRCT?

Infection - TB - MAI - CMV/RSV - invasive Aspergillus Hereditary - CF - Kartagener's ABPA/asthma Panbronchiolitis Aspiration Tumour invasion

Characteristics of ABPA bronchiectasis?

Upper zone, central, cystic + varicose bronchiectasis High attenuation of mucous plugs Prominent "finger in glove" And then the same as CF: tree-in-bud, bronchial wall thickening, air trapping

Characteristics of CF bronchiectasis?

Upper zone bronchiectasis but can be much more diffuse Air trapping, increased lung volume, mosaicism Nodular opacities + tree-in-bud

Stages of sarcoid on CXR?

0 - normal CXR 1 - lymphadenopathy 2 - lymphadenopathy and parenchymal 3 - parenchymal only 4 - fibrosis

Causes of lower zone bronchiectasis?

Kartagener's PCD Alpha-1 antitrypsin Immunodeficiency Chronic aspiration Pulmonary fibrosis

Causes of upper zone bronchiectasis?

Sarcoid TB CF ABPA

Causes of central bronchiectasis?

CF ABPA Williams Campbell Mounier-Kuhn

Causes of anterior bronchiectasis?

ARDS Atypical mycobacteria

Causes of focal bronchiectasis?

Swyer-James Carcinoma

Asbestos-related lung disease - earliest feature - most common feature - location of pleural plaques - percentage of plaques calcified? - features of fibrosis in asbestosis

Pleural effusion - often haemorrhagic Pleural plaques Mid-lower chest, paravertebral + diaphragmatic, spare the apices/CP angles 15-50% Begins as lower zone proccess. Subpleural dots + linear opacities, curvilinear opacities and PARENCHYMAL BANDS. These are more common in asbestos fibrosis than any other pulmonary fibrosis.

Differential for centrilobular nodules

Non-infective - HSP - RB-ILD - COP - LIP - asbestosis/pneumoconioses - diffuse panbronchiolitis Infective - TB - bronchopneumonia - ABPA - CF

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Chest Flashcards

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