chest Flashcards
1
Q
diagnostic modalities - summary
A
- in-situ X-ray: P-A, A-P, lying position, Firmann-Dahl method.
- Fluoroscopy: “motional x-ray” -> movement of the diaphragm/mediastinum (Holczknecht-Jacobson sign), pulsation of the hilum, localisation of casted shades or pathological signs.
It gives functional information. - CT (+ spiral CT, MSCT, HRCT): axial slices, with or without contrast, volume data-sampling, post-processing methods.
- PET-CT: chest deformities, paralytic thorax (tight apex, acute costovertebral angles), emphysematic thorax (apex is wide, horizontal ribs, wide intercostal spaces)
- MR: chest wall, mediastinum,, heart, major arteries.
- radioisotope examination: ventilation, perfusion.
- ultrasound: pleural fluids.
2
Q
terminology for describing x-ray of the lungs
A
- the typical discrepancies of the hilar caliber, dilated - thick hilar vessels, hypoplastic hilar vessels, centroperipheral caliber discrepancy (cpcd), apicobasal caliber discrepancy (abcd), asymmetry of hila
- vascular variances: hyper-, hypo- vascularisation, avascular regions.
- parenchymal (interstitial) linear shades, diffuse web-like image, pinstripe and atelectatic streaks
- patchy opacities: multiplex small patches (diffuse), irregularly and regularly shaped patchy opacities, blur.
- cavernous shades.
- transparential shades: less / more transparent.
3
Q
secondary lobule
A
Anatomical, pathological, physiological unit.
Well visible in case of air trapping or obstruction. Expiration: mosaic pattern - centrilobular GGO, centrilobular emphysema.
4
Q
pleural fluid
A
- large amount of pleural fluid will dislocate the midline.
- we need a Frimann-Dahl snapshot to prove subpulmonal localisation.
- if pleural adhesions are present, the encapsulated fluid & marked fluid gatherings in the small fissures, may imitate pneumonia on a P-A image.
–> hydrothorax, pneumohydrothorax
- pleural irregularities on US are called B lines!
5
Q
atelectasis
A
- deaeration of the lung tissue and consequential patchy opacities in the air-filled surroundings of the lung.
- collapse of the lung tissue.
- DDx: pneumonia.
- Local atelectasis: think of tumor (esp. if repetitive).
- empyema thoracis: compression form of atelectasis
- IRDS: micro- or adhesive atelectasis -> need aerobronchogram!
6
Q
bronchiectasis
A
- types: cystic, cylindric.
- X-ray image: summation of small, ring-like shades.
- HRCT: “signet-ring” sign -> a small artery-branch next to a wide bronchus.
7
Q
pulmonary thromboembolism - modalities
A
- lung scintigraphy -> V/Q scan
- CT angiogaphy
8
Q
pulmonary abscess on x-ray
A
Every infective, inflammatory, malignant disease can develop an abscess!
- x-ray: a cavern with ragged wall, and an air-filled fluid level inside the patchy opacity. Later the wall will become thinner and smoother.
9
Q
causes of closure of a bronchus
A
- foreign body
- bronchial cc
- benign intrabronchial tumor
- mucopurulent plug
- missed intubation
- stricture after an infection
- outer compression by tumor or lymph node
10
Q
pulmonary mycosis on x-ray
A
pneumonia, small shades, multifocal or extensive, homogenous shadow.
- aspergilloma: nestles in the cavern of another lung disease (TB, cancer, abscess) OR grows in a bronchiectasial dilation. the lumen of the cavern deforms to the form of a quarter moon (crescent).
11
Q
lung fibrosis - appearance
A
Irregular, rough/smooth linear-shade network. Covers and deforms the normal structure of the lung. in severe fibrosis, “honeycomb lung” can develop.
12
Q
bronchial carcinoma
A
- Histology: squamous cell carcinoma (-central), adenocarcinoma (-peripheral), anaplastic cc, large cell cc, small cell cc.
- X-ray: the tumor itself and/or symptoms caused by bronchostenosis.
13
Q
bronchial carcinoma
A
- central localisation, in the wall of one of the major bronchi, spreading towards the lumen.
- symptoms: int he beginning -> brnchostenosis, retentive pneumonias, obstructive emphysema, incomplete atelectasis - can be complicated by inflammation. After the extrabronchial breakthrough, unilateral widening of the hilum (the shade becomes homogenous), with irregular outline, spreading towards its environment.
14
Q
pancoast tumor (bronchial carcinoma)
A
- in the apex
- infiltrates the chest wall -> can destroy the posterior arch of the 1st and 2nd ribs & the vertebral bodies.
- symptoms: pain in the shoulder, Horner-triad, paralytic diaphragm of the affected side.
15
Q
post-operative monitoring (what to look for)
A
- localisation of central venous cannula.
- localisation of endotracheal tube -> the end should be 3-4 cm before the bifurcation.
- atelectasis: hypoventillation and/or retention of mucus. –> x-ray: homogenous shade of the deflated segment or lobe.
- aspiration pneumonia (more common in the right side)
- pulmonary edema
- pulmonary embolisation
- pneumonia
- ARDS (lung in shock) –> RTG image: negative in the beginning, moderate interstitial edema, rapid onset of extensive pulmonary edema.
- pleural fluid: check with ultrasound
16
Q
Hodgkin-lymphoma
A
- Has a pulmonary manifestation in 30-40% of cases.
- Asymmetric growth of mediastinal shadow - enlarged lymph nodes in the hilus.
- Can present as patchy opacities with or without cavity, atelectasis, multiplex hilar/subhilar/major disseminated knots, fibrosis, interstitial edema, pleural- , pericardial- fluid, or the combination of these.
- similar signs in case of leukemias: enlargement of mediastinal lymph nodes, interstitial and alveolar shades (linear and patchy).
17
Q
definition of interstitial lung diseases
A
- caused by chronic inflammation of the pulmonary interstitium, resulting in a scarred reconstruction by proliferating connective tissue.
- Mostly the alveoli and interstitium are affected.
- the airways and pulmonary vessels are secondarily affected.
18
Q
clinical signs of interstitial lung diseases
A
- non-productive cough
- stress dyspnoea
- drumstick fingers
- clubbed nails
- basal crackling
- weakness
- weight loss
19
Q
diagnostics of interstitial lung diseases
A
- (ideally) multidisciplinary ILD board: pneumonologists, rheumatologists, radiologists, pathologists
- laboratory: kidney functions, electrolytes, CRP, differential blood counts, antibodies
- lung function (restrictive ventilation fault)
- imaging: x-ray & HRCT
- bronchoscopy with transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL)
- open lung biopsy (VATS)
- biopsy is not necessary in atypical interstitial pneumonia (UIA)
20
Q
typical patterns of an ILD
A
- ground glass opacities (milk glass opacity - increased parenchyma decreasement) -> partially filled and/or collapsed alveoli. Eg) active inflammation.
- consolidation: completely filled and/or collapsed alveoli (accumulation of exudate, transudate, or other tissue in the alveoli).
21
Q
idiopathic pulmonary fibrosis (heterogenous entity)
A
- AIP (acute interstitial pneumonitis)
- UIP (usual interstitial pneumonitis) - 70%
- DIP (desquamative interstitial pneumonia)
- RBILD (respiratory bronchiolitis ILD)
- NSIP (non-specific interstitial pneumonia)
- BOOP = COP (bronchiolitis obliterans organising pneumonia = cryptogenic organising pneumonia)
22
Q
interstitial lung diseases on x-ray
A
- fine-stripping-reticular pattern that is superimposed by a diffuse transparency reduction.
- increased reticulation with basal dominance.
23
Q
HRCT in interstitial lung diseases
A
- central role in detection, diagnosis, and differential diagnosis.
- acute alveolitis: GGO -> the location of optimal bronchoscopic tissue collection.
- chronic: nodules, lines and bands, pleural thickening. Final stage: honeycombing
- pattern of ILD in HRCT:
- linear reticular pattern
- nodular pattern
- structures with density reduction (lesions with “less air”
- structures with density increase (lesions with “more air”)
24
Q
acute interstitial pneumonia (AIP)
A
- acute alveolitis: milk opacity (density increase with still recognisable bronchovascular structures).
- “idiopathic form of ARDS” / ARDS of unclear cause.
- acute and short prognosis.
- HRCT image:
acute -> homogenous GGO (alveolitis), diffuse consolidation.
chronic -> honeycombing, fibrosis
25
Q
non-specific interstitial pneumonia (NSIP)
A
- chronic form: manifests in the 4th decade of life.
- not tobacco-associated.
- usually occurs as a pulmonary involvement in the context of collagenosis
- can be treated with systemic glucocorticosteroids -> more favourable prognosis that UIP
- HRCT image:
- GGO
- peripheral, basal, subpleural, symmetrical fine reticular condensation, traction bronchiolectasis
- NO honeycomb pattern
26
Q
usual interstitial pneumonia (UIP)
A
- simultaneity of inflammation, proliferation and fibrosis
- poor prognosis
- have diaphragm moving disorders -> use ultrasound in M-mode
- complication: shrinking lung
- HRCT:
- very specific -> nearly 100% correct diagnosis
- GGO (signs of active inflammation and fibroblast proliferation)
- honeycomb patterns, bronchiectasis –> signs of fibrosis (not present in NSIP) -> subpleural and basally stressed localisation
- reticular pattern
27
Q
honeycombing “definition”
A
subpleural, multi-rowed, small cystic changes
- usually appears in the lower lobes, at the end-stage of interstitial lung diseases
(the upper pole show signs of activity - GGO, alveolitis)
28
Q
ILD: collagenoses & vasculitides
A
- pulmonary manifestations:
- rheumatoid arthritis (RA)
- SLE
- Sjorgen syndrome
- systemic sclerosis / scleroderma
- dermatopolymyositis
- Wegener granulomatosis
- x-ray: less sensitive. In pronounced cases -> basal-dominant reticulonodular pattern
- HRCT: pathological findings in 30%. Pleural thickening. Late stage - fibrosis.
29
Q
occupational lung diseases
A
- chronic inhalation of inorganic dusts (eg. silicate)
- long-time exposure
- alveolar phagocytosis of inhaled particles and interstitial deposition -> interstitial reticulo-granulome formation, sometimes massive fibrosis
- therapy: stop exposure
- types: diseases of immunological/unclear etiology & pneumoconiosis (inhaled particles)
- x-ray:
- nodular herd often with calcifications
- hilar / mediastinal lymph nodes with calcifications (“laryngeal calcification”)
- HRCT:
- x-ray patterns +
- micronodular lesions
- pulmonary fibrosis
30
Q
organising pneumonia (OP)
A
- occupational -> immunological/unclear etiology
- idiopathic form: cryptogen-organising pneumonia (COP)
- non-infectious inflammation that may occur in collagenous diseases, chronic eosinophilic pneumonia, exogenous allergic alveolitis, infections or even as a medication reaction. - symptoms: chronic subfebrile temperatures, dyspnoea, cough.
- HRCT: band-shaped, subpleural and peribronchial stressed focal consolidations with basal predominance -> migrating consolidations.
- Atoll sign: ring-like consolidation with a central milk glass.
31
Q
exogen allergic alveolitis, EAA (“farmer lung”, hypersensitivity pneumonitis - HP)
A
- occupational -> immunological/unclear etiology.
- immune reaction of the alveoli and bronchioles.
- inhalation of organic dusts (actinomycetes, aspergilli, excrements, flour), chemotherapeutic agents
- x-ray: normal in the acute & subacute stage. Fibrosis in the chronic stage.
- HRCT: acute/subacute stage -> milk glass infiltrates (centrilobular), reticular pattern, bronchial wall thickening
32
Q
silikosis
A
- occupational / pneumoconiosis
- inhalation of mineral dusts (eg. SiO2, coal)
- CT:
- nodules
- hilar and mediastinal lymphadenopathy -> Eggshell calcifications
- complicated pneumoconiosis: fibrosis
33
Q
asbestosis
A
- occupational / pneumoconiosis
- inhalation of asbestos fibres
- manifestation 20-40 years after exposure
- malignisation: pleural mesothelioma, bronchial carcinoma
- 5-10% of all asbestosis cases develop with a latency of 20-30 years
*CT:
- interlobular septal thickening
- honeycomb pattern
pleural plaques
34
Q
mesothelioma
A
- clinical sings: chest pain, dyspnoea, weight loss, fever.
- infiltration of the thorax wall & ribs come before survival is an average of 18-28 months.
- x-ray, CT: elongated or glandular pleural thickening - thickness > 10 mm, pleural calcifications.
35
Q
what is the method of choice for characterisation of interstitial changes?
A
HRCT
36
Q
solitary lung nodules: possible causes
A
tuberculoma bronchial carcinoma metastasis hamartoma abscess aspergilloma adenoma round atelectasis AV shunt bronchogenic cyst sequestration echinococcal cyst infarction
37
Q
multiple lung nodules: possible causes
A
- miliary: TB, sarcoidosis, histiocytosis, silicosis, metastases
- medium (sub-miliary): bronchogenic TB, metastases, peripheral Kaposi sarcoma
- large: metastases, Wegener’s disease, lymphoma
38
Q
differential diagnosis of nodules
A
tumor
inflammation
connective tissue disorders & vasculitis
pneumoconioses
vascular diseases
hypersensitivity & idiopathic diseases
- centrilobular nodules: bronchial disease, pulmonary edema, vasculitis
- perilymphatic nodules: sarcoidosis, silicosis, lymphangiosis, cc
- random: miliary TB, miliary fungal infection, miliary viral infection, metastases
39
Q
perilymphatic nodules: DDx
A
- silicosis:
- upper lobe
- pseudo-plaques
- calcified hilar lymph nodes
- sarcoidosis:
- upper lobe
- symmetric lymphadenopathy (BHL)
- peribronchovascuar nodules
- lymphangitis:
- irregular nodular thickening of the interlobular septa
- pleural effusion
40
Q
random distribution of lung nodules : DDx
A
- inflammatory:
- TB
- virus: CMV, flu, chickenpox
- fungi: blastomycosis, histoplasmosis
- metastases:
- thyroid cancer
- adenocarcinoma
41
Q
solitary pulmonary nodules (< 3 cm)
A
round or oval
surrounded by the lung parenchyma
benign Vs malignant - depends on:
- density
- growth rate
- wind, shape
- cavitation
- air
- calcification
- size
42
Q
density: the three types of lung nodules (<3 cm)
A
- solid nodule
- parsolid (semisolid) nodule
- clear ground glass (GG) (nonsolid) nodule
43
Q
growth rate of solitary nodule
A
- volume doubling time (VDT): volume doubling over time = 26% diameter increase
- solid nodules:
- VDT: 20-400 days: most likely malignant
- VDT: <20 or > 400 days: likely benign
- there is no growth in 2 years: the most reliable sign of benign behaviour
- subsolid nodules can grow very slowly
44
Q
wind, shape of solitary nodule
A
- sharp, spherical: 20-30% malignant
- lobulated, spiculated, irregular: 33-100% malignant
45
Q
cavitation of solitary nodules
A
- especially in squamous cell carcinoma
- any size
- often eccentric
- often thick, irregular wall ( =/> 5mm)
- air and/or liquefaction
- often air-fluid level
46
Q
air in the solitary nodule
A
- air bronchogram
- cyst-like hypodensities (“soap bubbles”)
- most commonly: adenocarcinoma
47
Q
calcification in the solitary nodule
A
- benign patterns: diffuse, central, popcorn, laminated
- malignant pattern: stippled, eccentric
48
Q
node detection
A
- CAD = computer aided diagnosis: better for hilar than peripheral nodes
- RAD = diagnosis by a radiologists: better for subpleural than central nodules
49
Q
primary tumors
A
- benign: hamartoma, chondroma, lipoma -> rare
- semimalignant: adenoma, hamartoma, carcinoid
- malignant bronchial carcinoma
- BAC (bronchoalveolar carcinoma)
50
Q
semimalignant tumors
A
- adenoma, hamartoma, carcinoid
- x-ray: round or lobulated node with well demarcated boundary, calcifications
- CT: small hilar lymphadenopathy, possible metastases
51
Q
malignant bronchial carcinoma
A
- central: in hilar area, unclear hilar extension
- peripheral: in the lung parenchyma or along the thoracic wall
- pancoast tumor: in the lung apex. Grows transpleurally though the chest wall, infiltrating the cervical sympathetic ganglia
52
Q
bronchoalveolar carcinoma (BAC)
A
- spreads into the alveoli
- manifested by multinodular, infiltrative condensations in the peripheral pulmonary parenchyma
- can also appear int he from of round condensations
- 1-9% of all lung tumors
- subtype of NSCLC (adenocarcinoma)
- 50% asymptomatic
- terminal bronchioles + alveoli are affected
- slow, non-invasive growth -> the blood and lymph vessels surrounding the lung parenchyma are not affected -> lepidic growth
- pre-invasive malignant lesions (in situ carcinoma) -> invasive adenocarcinoma
- non-smoker, women, Asia
53
Q
carcinoid
A
- central lesion
- well circumscribed, round or oval
- 2-5 cm
- homogenous contrast enhancement
- calcification (eccentric)
54
Q
metastases
A
- hematogenous spread: breast, prostate, kidney, thyroid, cervical, testicular, bone, melanoma, gastrointestinal and pancreatic tumors
- lymphatic spread: breast, bronchial carcinoma
- lymphangitis carcinomatosa
55
Q
staging of lung cancer
A
- DDD (detection, delineation, differentiation)
- nodules: > 8-10 mm –> DO STAGING
- TNM staging:
- T: CT, MRI assessment of some cases (resectability)
- N: PET-CT
- M: PET-CT or MRI
56
Q
screening for lung cancer
A
CT
- low dose CT
- volumetry
- disadvantages:
- overdiagnoses
- false positive cases –> reduced by categorisation of nodules & volumetry for accurate assessment of growth
- resection through benign disease
- advantages:
- fear-induced anxiety –> smoking cessation
