CHEST CORE 2 Flashcards
**Aorta is in posterior mediastinum, posterior mediastinal mass would silhouette the aorta
What is most common malignant mediastinal germ cell tumor?
Seminoma
Cervicothoracic sign?
Obscuration of the superior border of the mass implying mass is in continuity with the soft tissues of the neck
Key to diagnosing a thyroid lesion as an anterior mediastinal mass?
Continuity with the superior thyroid obviously
**Calcification is rare in untreated lymphoma.
Lymphoma most commonly in thorax?
Hodgkins
Egg shell calcification?
CWP and Silicosis = usually
Sarcoid = Less apt to calcify… but sarcoid is a more common dz
Low attenuation lymph nodes should raise concern for what?
TB.
Can also be seen in:
Fungal
Mets
Lymphoma sometimes
Avid lymph node enhancement?
Castleman disease.
Sarcoid.
TB.
Vascular mets.
What is castleman disease?
Angiofollicular lymph node hyperplasia
uncertain etiology
- cause of highly vascular thoracic lymph node enlargement
Who gets localized Castlemen and what is cure?
Children. Surgical resection.
Who gets multicentric Castleman disease?
Older patients or AIDS patients.
Symptoms of multicentric Castlemans? Treatment?
Systemic illness including fever, anemia, lymphoma. Treat with chemo.
Key imaging feature of Castlemans?
Avidly enhancing lymphadenopathy
Most common location of pericardial cyst? Appearnce.
R cardiophrenic angle. Cystic lesion abuts pericardium, can change shape.
Anterior mediastinal mass containing bowel gas?
Morgagni hernia
Foregut duplication cysts? What and where?
Middle or posterior mediastinum.
Bronchogenic cysts.
Esophageal duplication cysts.
Neurenteric cysts.
Most adult neurenteric cysts are what?
Peripheral nerve sheath tumors.
Most children neurenteric cysts are what?
Sympathetic ganglion origin.
3 types of ganglion tumors in children?
Ganglioneuroma.
Neuroblastoma.
Ganglioneuroblastoma.
Peripheral nerve sheath tumors in adults?
Schwannoma.
Neurofibroma.
Malignant peripheral nerve sheath tumor
Imaging of extramedullary hematopoiesis?
Bilateral lobulated paraspinal masses inferior to T6
Lateral meningocele is what?
Lateral herniation of spinal meninges through an iv foramen or a defect in the vertebral body
Lateral meningocele is associated with what?
NF
Esophageal neoplasm on plain film?
Abnormal convexity of the azygoesophageal recess, mediastinal widening, or a retrotracheal mass
Differential for non neoplastic diffuse tracheal disease?
Sparing the posterior trachea?
Circumferential?
Sparing the posterior trachea:
ROT=
Relapsing polychondritis
Osteochondroplastica
Tracheobronchopathia
Circumferential:
SWAT= Sarcoid Wegener Amyloid TB
Etiology of relapsing polychondritis?
Unknown
What is relapsing polychondritis?
Recurrent inflammation of cartilaginous structures including the
Nose, ear
larynx, trachea, and bronchi. (Airway involvement in 50%)
Joints
Most common sites of airway involvement in relapsing polychondritis?
Larynx and subglottic trachea
Who gets relapsing polychondritis?
Middle aged women
Cross sectional imaging of relapsing polychondritis?
Sparing of the posterior membranous trachea with smooth tracheal thickening
Why is posterior spared in relapsing polychondritis?
No cartilage
What other finding in relapsing polychondritis?
Increased attenuation of the airway wall, ranging from subtle to frank calcification
Tracheobronchopathia Osteochdronplastica?
Benign condition of multiple submucosal calcified osteocartilaginous nodules along the tracheal walls
Appearance of tracheobronchopathia osteochondroplastica?
Sparing of posterior membranous trachea
**Endobronchial spread of tb occurs in a prominent minority of patients with pulmonary tb, most commonly distal trachea and proximal bronchi.
Imaging of TB of airways?
Nonspecific- usually relatively long segment of concentric narrowing.
Amyoloidosis in airways causes what?
Irregular narrowing of airways due to submucosal amyloid deposition, which may be calcified
Wegener with the airways?
Subglottic tracheal stenosis with circumferential mucosal thickening
Large airways involved in what percentage of Wegener patients?
20%
Sarcoid in trachea?
Rare. Advanced disease.
Smooth stenosis to a nodular or mass like appearance
What percent risk of tracheal stenosis after intubation? Tracheostomy?
1%. 30% if long standing.
Uncommon causes of tracheal stenosis?
Behcet. Chron
Etiologies of bronchiectasis?
Bronchial wall injury.
Bronchial lumen obstruction.
Traction from adjacent fibrosis.
Mounier Kuhn is what?
Connective tissue disorder causing tracheobronchomegaly leading to recurrent pneumonia
Common causes of bronchiectasis?
CAPTAIn Kangaroo has Mounier-Kuhn.
Cystic Fibrosis ABPA Post Infectious TB Agammaglobulinemia Immunodeficiency
Kartagener
Mounier Kuhn
Cystic fibrosis vs post infectious bronchiectasis?
CF is upper lobes. Post infectious is lower lboes.
Types of bronchiectasis?
Most and least severe?
Cylindrical (least severe).
Varicose.
Cystic (most severe)
**Cystic may have multiple cysts that don’t connect to the airways
Most common cause of bronchioLITHiasis?
Erosion of an adjacent calcified granulomatous lymph node
Enzyme causing emphysema?
Elastase which is increased in smokers.
What neutralizes elastase?
Alpha-1-antitrypsin
What type of emphysema is alpha 1 antitrypsin deficient
Panacinar
Primary tumors of trachea and central bronchi in adults and children?
Adults malignant, children benign
Most common primary central airway tumors in adults?
By far SCC (1st) and adenoid cystic carcinoma
Typical CT appearance of tracheal SCC?
Polypoid intraluminal mass.
Contours can be irregular smooth or lobulated.
Tumor can invade esophogus causing fistula.
What age group for ACC vs SCC?
ACC usually patients in their forties, a decade or two younger than SCC
ACC and smoking?
No association
ACC on PET?
Intense uptake
What type of spread for ACC?
Perineural and submucosal
Typical CT of ACC?
Submucosal mass that infiltrates the tracheal wall and surrounding mediastinal fat. May also present as circumferential tracheal or bronchial thickening causing airway stenosis
Most common bronchial tumor in children?
Carcinoid. Much less common in adults.
Carcinoid almost always occurs where?
Distal to carina
CT of carcinoid?
Endoluminal bronchial mass with homogenous enhancement
Differential of enhancing endobronchial mass?
Carcinoid.
Mucoepidermoid carcinoma.
Hemangioma.
Glomus tumor.
Describe mucoepidermoid carcinoma?
Rare tumor originating from tiny salivary glands lining the tracheobronchial tree.
Affects younger patients than ACC.
Indistinguishable on imaging from carcinoid.
Tracheal lymphoma is rare, but associated with what?
MALT
Four most common airway mets?
BReThy Lung.
Breast
Renal
Thyroid
Lung
**Direct airway invasion by tumor is more common than mets to airway
What to do with airway papillomas?
Follow closely as they may transform
Single papilloma has what cause?
Irritation
Multiple papillomas are from what?
HPV, may be acquired at birth.
Papillomas in lungs?
Very very rarely they can spread to the lungs and form multiple cavitary nodules.
Other benign endobronchial lesions?
Schwannoma. Adenoma. Hamartoma. Hemangioma. Lipoma. Leiomyoma.
Latency from exposure to asbestos to mesothelioma?
Greater than 20 years.
Most common subtype of mesothelioma? Less common?
Most common is epithelial. Less common are sarcomatoid and mixed.
CT of mesothelioma?
Nodular concentric pleural thickening, often with an associated pleural effusion.
Role of surgery in mesothelioma?
Goal is to resect all visible tumor.
Surgery in locally invasive disease?
Extrapleural pneumonectomy
Surgery in less advanced mesothelioma?
Pleurectomy and decortication. Spares lung and fissures.
**A certain subset of patients have shown positive results with heated chemotherapy, radiation, and surgery
Mets to pleura?
Lung. GI. GU. Invasive thymoma
What percentage of fibrous tumor of pleura is malignant?
20-30%
FTP may be associated with what?
Hypoglycemia or hypertrophic pulmonary osteoarthropathy.
What is a classic appearance of FTP?
Pleural based mass that changes position?
FTP on PET?
Low uptake
Lights criteria?
Distinguishes transudate and exudate. Pleural fluid protein to serum protein greater than 0.5 Ratio of pleural LDH to serum LDH greater than 0.6. Pleuar fluid LDH greater than 2/3 the upper level of normal for serum. All of those are for exudate.
**Presence of exudate implies increased permeability of pleural capillaries which can be due to underlying disease
Cause of chylothorax?
Pleural effusions consisting of lymph from neoplastic obstruction of thoracic duct or LAM
Drainage of thoracic duct?
L brachiocephalic or subclavian vein.
anterior junction line
formed by the apposition of the visceral and parietal pleura of the anteromedial aspects of the lungs with a small amount of intervening mediastinal fat. Begins at the clavicles. If this line is displaced, pathology is in the anterior mediastinum.
posterior junction line
formed by the apposition of the visceral and parietal pleura of the posteromedial portion of the lungs posterior to the esophagus and anterior to the third through the fifth thoracic vertebra
most common benign pulmonary neoplasm
pulmonary hamartoma - will contain fat. these are the lesions with popcorn calcifications.
lung segments
upper lobe- apical, posterior, anterior; right middle lobe- lateral, medial; left lingular segments- superior, inferior; lower lobe- apical, anterior basal, lateral basal, posterior basal, subapical
posterior mediastinal tumors
neurogenic origin - peripheral nerve tumors (schwannomas, neurofibromas - will be more rounded), sympathetic chain (ganglioneuroma, neuroblastoma - more linear and vertically oriented) and paraganglia (pheo).
split pleura sign
Thickened visceral and parietal pleural layers are split apart and surround an empyema. for empyema - look for lenticular shape with obtuse margins.
difference between invasive thymoma and thymic carcinoma
carcinoma hematogenous, invasive thymoma is local.
NSIP
subpleural and basilar predominant without honeycombing and with ground glass opacities. +traction bronchiectasis. associated pattern with systemic scleroderma.
UIP pattern associations
IPF, asbestosis, connective tissue disorders and drug toxicity.
parenchymal consolidation (pna) with mediastinal and hilar LAD
think TB.
Ghon complex
TB granulomas (Ghon focus) w/ lobar and perihilar lymph node involvement. Reflects primary infxn or exposure.
ranke complex
Combination of calcified lung nodule and calcified lymph nodes. Associated with TB.
pulmonary venous wedge pressure for kerley lines to appear
17 mm Hg.
Etiology for ascending thoracic aortic aneurysm
cystic medial necrosis and syphilis.
Etiology for descending thoracic aortic aneurysm
mycotic (infectious), traumatic, atherosclerotic.
feature of peripheral consolidation on ct that will push you to think pulmonary infarction?
central hypoattenuation inside of a wedge shaped opacity.
AIDS lymphoma
Agressive lymphomas of b cell origin, non-hodgkins
Differentiate kaposi and lymphoma in AIDS patients
gallium - avid uptake by lymphoma, poor uptake by kaposi
thoracic inlet mass in a child (most common)
lymphangioma
causes of chronic airspace consolidation
lipoid pneumonia, BAC, alveolar proteinosis, lymphoma, alveolar sarcoid
crazy paving
PAP, Hemorrhage, Edema (DAD), CEP, COP, lipoid pneumonia, PCP,NSIP. “The CHAPEL PEN has stained-glass, looks like crazy paving” lipid laden macrophages and hypertrophy of type II pneumocytes causes septal wall thickening.
Kartegener’s syndrome
Problems with cilia bc of microtubular dynein. Recurrent sinusitis, bronchiectasis, immobile sperm (infertility). POSSIBLY related to situs inversus.
tumors resulting in central lobar obstruction
lung cancer, carcinoid, mucoepidermoid carcinoma, hamartoma, endobronchial mets
staging for centrally obstructing lung lesion
T2 as long as it doesn’t invovle the entire lung. if entire lung involved, T3.
Most common endobronchial subtype of lung ca
squamous. in contrast to small cell, which is most often submucosal and peribornchial. small cell often is a large central mass that may narrow the bonrchial lumen by extrensic compression. adenoas are usually peripheral in location.
lymphangioleiomyomatosis
Extensive nodular infiltration of the lungs and lymphatics with SM-like cells, dyspnea, pneumothorax, chylous pleural effusions and hemoptysis, interstitial pattern with mid-upper lung predominance on CXR with multiple cystic lesions and preserved lung volumes. Differential consideration include LCH (EG) which would be cysts of varying sizes and bizarre shapes.
Unilateral absence of persuion on VQ scan
mediastinal and hilar masses, ascending aortic aneurysm/dissection, PA hypoplasia/agenesis, PA sarcoma, pneumonectomy. Thromboembolic disease is a minor cause.
round atelectasis
form of contraction atelectasis;
visceral pleura locally fibroses, associated w/ infolding of pleura that extends into lung;
maybe asbestos; looks like a mass on radiology.
Comet tail sign.
cystic medial necrosis
loss of elastic and muscle fibers in the aortic media, with accumulation of mucopolysaccharide, sometimes in cystlike spaces between the fibers, A disease of unknown cause, which may be inherited (Marfan’s, Ehler-Danlos, etc) and predisposes to dissecting aneurysms.
Central pulmonary mass that obstructs the right upper lobe bronchus and has calcium.
carcinoid. will show intense contrast enhancement.
boorhave
Pt w/ mediastinal widening and substernal emphysema. CXR notable for L sided pleural effusion and decreased breath sounds. Pleural fluid is tapped and shows increased amylase and decreased pH. Dx? occurs at the left diaphragmatic crus
kaposi’s sarcoma
not gallium avid. HHV8.
endobronchial mets
breast, colon, melanoma, kidney, thyroid
varicella pneumonia
adolescent with fever, cough, dyspnea, malaise, pruritic vesicular rash and cxr showing pneumonia - will be diffuse with poorly defined smll lung noduels,some coaslescing to form areas of consolidation. post-primarly is multiple small calcified nodules.
differentce on ct between parasepptal and centriobular emphesema
paraspetal will have thin walls. centrilobular will have no discernable wall. Paraseptal usually more peripheral in location. centrilobular more common in smokers.
Bug in AIDS fungal meningitis?
cryptococcus. may also spreak to the skin and bone and lungs in diffuse fugemia.
SVC syndrome
due to lung cancer compressing and obstructing the SVC –> swelling/plethora of the head and neck and distension of venous collaterals. Usually Bronchogenic carcinoma - small cell. oother causes - fibrosing mediastinitis and indwelling catheters
Hypertrophic OsteoArthropathy (HOA, HPOA)
Cause?
from CANCER in regions supplied by the VAGUS or GlossoPharyngeal Nerves.
May also be caused by Fibrosis or Cystic Fibrosis.
Will be symptomatic with pain.
most common endobronchial lesions
lung ca, carcinoid, hamartoma, mucoepidermoid, lymphoma, lipoma, mets.
Castleman’s disease
dissem’d: usu plasma cell; localized: usu hyaline-vascular. 3 patterns: 1)solitary mass, 2)dominant infiltrative mass w. assoc LAN, 3)diffuse LAN in a single mediastinal compartment. Enhancing on con-CT. Hyaline vascular more common. plasma cell more likely to be symptomatic.
hypervascular mets to the mediastinum
renal cell, carcinoid, melanoma, thyroid.
relapsing polychondritis
Systemic autoimmune disorder. Affects cartilage of earlobes, nose, larynx, tracheobronchial tree, joints, and large elastic arteries. Diffuse smooth wall thickening of the wall of trachea and central bronchi with luminal narrowing.
postinfectious obliterative bronchiolitis
swyer james syndrome. hyperlucency with reduced pulmonary vascularity. caused by viral illness early in childhood that prevents normal development of hte aftected lung.
arises from the medial wall of the bronchus intermedius
cardiac bronchus. is directed caudally toward the mediastinum.
diverticulum of kommerell
Enlargement of the proximal portion of an aberrant proximal right subclavian artery at its site of origin from the descending aorta. The left-sided enlargment infrequently causes airway or oesophageal compression. dysphagia lusoria.
pulmonary sequestration
intralobar is the most common type. usually gets blood supply from the descending thoracic aorta nd drains to the inferior pulomnary vein. most often on the left posterior basal segment. no normal connection with the bronchial tree.
extralobar sequestration
contained within its own little envelope of pleura.
acute interstitial pneumonia
Diffuse ground-glass opacity and consolidation with air bronchograms. Linear opacities, honeycombing, and traction bronchiectasis are uncommon. aka idiopathic ARDS, Diffuse alveolar damage.
cryptogenic organizing pneumonia
Idiopathic form of organizing pneumonia. Most common finding: Patchy consolidation or ground-glass opacity with subpleural or peribronchial distribution. Scattered nodular opacities may be present. DDX includes: Loffler’s syndrome, chronic eosinophilic pneumonia, pulmonary infarcts, vasculidities.
ddx peribronchovascular nodules
Sarcoid
Lymphangitic carcinomatosis
Lymphoma
Kaposi’s sarcoma
bronchiolitis
An acute, infectious, inflammatory disease of the upper and lower respiratory tracts that results in obstruction of the small airways. results in tree-in-bud opacities, often in HIV. Will be bacterial. Will have mucus plugging in the small airways.
lung infections post RENAL Transplant
in the FIRST month, still normal immune system - more susceptible to the usual suspects post surgery such as gram negatives from aspiration.
Months 2-8, immunosuppression really sets in and patient’s T-cell immunity wiped out
- viral and fungal infections run rampant in the absence of preventative drugs.
CMV is the biggie.
PJP happens, but only if not taking their prophylaxis.
pulmonary venoocclusive disease
rare. intimal fibrosis of the intrapulmonary veins and venules. will have pulmonary artery hypertension with a normal venous wedge pressure. will have ground glass opacities with septal thickening and mediastinal lymphadenopathy.
multiple tracheal lesions
tracheal papillomatosis (papillomavirus) and amyloid. papillomatosis will have synchronous lesions in the bronchi. amyloid differentiation on MRI will show low signal on T1 and T2.
causes of tracheal stenosis
trauma, infection, sarcoid, Wegener’s, relapsing polychondritis, amyloidosis, tracheobronchopathia, osteochondroplastica and COPD.
acute infectious bronchiolitis
TB, RSV, adenovirus, mycoplasma
if mosaic attenuation, how to differentiate small airway disease from pulmonary vascular disease?
Expiratory imaging - will show air trapping in small airway disease and not with pulmonary vascular disease. Infiltrating lung disease is also in the differential, but that will show ground glass opacities. Low attenuating areas are abnormal in pulm vascular disease and small airway disease. In diffuse infiltrating disease, the low attenuating areas are the normal lung (high attenuation is the ground glass areas).
cystic adenomatoid malformation
Congenitallung lesion containing dysplastic adenomatous tissue with communicating cysts of variable sizes. Vary from solid lesion to multiple tiny cysts to large, thin-walled cysts. May mimic congenital lobar emphysema. Cysts can enlarge leading to respiratory distress. Usually are unilateral and can affect any portion of the lung.
congenital lung lesions with cyst or cyst-like regions
Congenital lobar emphysema, Cystic adenomatoid malformation, intralobar sequestration and bronchogenic cyst.
bronchogenic cyst
this cystic lung mass has no communication with the bronchi or bronchial tree, and is usually in the mediastinum or the lung itself. On ultrasound you will see a well circumscribed anechoic mass. posterior mediastinal mass, near the carina.
ground glass opacities and cysts
LIP and PJP. LIP associated with sjogren’s syndrome, pernicious anemia, chronic active hepatitis, myasthenia gravis and viral infection.
pneumocystis jiroveci pneumonia
perihilar GG opacities may progress to consolidation.
as opposed to LIP - extensive GG opacities with thin walled cysts.
Desquamative interstitial pneumonia
hazy GG opacities in the lower lungs. small cystic spaces are common. May be confused with NSIP, RB-ILD (along the same spectrum) and hypersensitivity pneumonitis.
significant of right aortic arch with mirror imaging vs right arch with aberrant subclavian?
Mirror imaging often associated with congenital heart anomalies, where as aberrant subclavian (left) is often incidental.
asthmatic with finger in glove, upper lobe predominant.
allergic bronchopulmonary aspergillosis (ABPA) - accumulation of thick material (mucus) in the dilated bronchi.
most common chest manifestation of nocardiosis
homogeneous consolidation. May have multiple nodules/masses. May eventually cavitate.
RB-ILD vs DIP
RB-ILD - ill defined ground glass, upper lobe predominant. DIP - cystic, lower lobe predominant with subpleural sparing?
Eosinophilic PNA on CXR
Peripheral and peripheral predominance. Chronic course.
Pulmonary HTN on CXR
Enlarged bilateral pulmonary arteries, central pruning, pulmonary artery calcifications. Sx dyspnea.
CT appearance of Radiation Pneumonitis
Early and late manifestations.
Acute pneumonitis:
- 1-3 months.
- Homogeneous or patchy GGO, lucency’s and volume loss.
The changes evolve over the next 6-12 months and usually become stable within 2 years.
Chronic Radiation changes:
Dense Consolidation, traction Bronchiectasis and volume loss.
Kartagener’s Syndrome.
Bronchiectasis, situs inversus and sinusitis due to primary ciliary dyskinesis.
Sarcoidosis on CXR
Symmetric patchy opacities, volume loss of upper lobes and calcified mediastinal and hilar nodes is a fairly classic appearance of Sarcoidosis
Necrotic mediastinal lymph nodes
Most likely tuberculosis.
Castelman Disease
A nonclonal lymphoproliferative disorder and one of the more common causes of nonneoplastic lymphadenopathy. The lymph nodes brightly enhance with contrast. Should be in the Ddx for lymph adenopathy NOS.
Wegener’s Granulomatosis on CT
90% demonstrate lung nodules and masses.
Hypersensitivity Pneumonitis on CT
Most common finding is a normal HRCT. Chronic shows reticular opacities in the middle and lower lung zones.
IPF
Idiopathic pulmonary fibrosis: 50 and 70 yo. Progressive fibrosis with median survival of 2-3 years fromdx. CT peripheral and basilar predominant reticular opacities. Confidence increased with honeycomb cysts in the peripheral and basilar distribution.
NSIP
Non-specific interstitial pneumonia, the predominant CT feature includes ground glass opacities
Atoll Sign
AKA reverse halo sign and is seen in Cryptogenic organizing pneumonia. Central ground glass surrounded by denser consolidation of crescentic or ring shape of at least 2 mm in thickness.
Eaton Lambert Syndrome chest association
It is characterized by proximal weakness, a result of an abnormality in the release of acetylcholine at the neuromuscular junction. About 50% of the cases have an associated small cell cancer.
Pulmonary AVM
Represent right to left shunt and can present with paradoxical embolisms.
Single artery to single vein and are most common in the lower lobes.
Shrinking Lung syndrome
Seen with SLE but is of unknown etiology. Progressive volume loss bilateral lungs.
Bronchogenic cysts
Most common in the subcarinal region.
Swyer-James Syndrome
Postinfectious obliterative bronchiolitis, results in underdevelopment of 1 lung or region of a lung, and appears as hyperlucency due to expansion of remaining alveoli.
What is teh classic appearance of RUL collapse?
Right volume loss with Tenting of the right HD, Oblique anterior superior opacity on lateral CXR. S sign of Golden is the elevation of the right minor fissure with central obstructing mass.
What is the relationship between Right Ao arch and congenital heart disease?
A R Ao arch with mirror image branching has a very high association (> 95%) with cyanotic congenital heart disease, especially TOF, truncus arteriosus, and D-TGA. IF instead of MIB, there is an aberrant L SCA, then only 10% assoc with TOF.
What is the classic finding with left upper lobe collapse?
The Luftsichel sign: a crescent of air outlining the Aortic knob with increased hazy opacification of the whole left lung zone, but with pulmonary markings still visible.
What are the classic findings of RLL collapse on frontal CXR?
Right vascular hilum is depressed. Silhouette signs of the right heart border and right medial hemidiaphragm. Shift of the trachea to the right.
What are the size criteria for pulmonary nodule vs mass?
Pulmonary lesions that measure < 3 cm are designated as nodules. Pulmonary lesions that measure ≥ 3 cm are designated as masses.
What are the classic findings of LLL collapse on frontal CXR?
Inferior displacement of the left fissure with a retrocardiac opacity and medial silhouetting of the diaphragm.
What are the classic findings of RML collapse on CXR?
on Frontal there might be obscuration of the right heart border and inferior displacement of the hilum and pleura, but the clencher is the triangular opacity overlapping the cardiac shadow characteristic fo RML collapse.
What is the ddx of the CT halo sign?
Central ground-glass opacity surrounded by rim of consolidation: Angioinvasive aspergillus Mets Kaposi Wegner BAC/Adenocarcinoma in situ (AIS) atypical infx.
What is the ddx of the reverse CT halo sign?
COP Fungal infection (aspergillus, paracocci, mucor)
Bacterial infx Wegner Infarct TB sarcoid tumor
What is the tx for Cryptogenic Organizing Pneumonia (COP)?
Corticosteroids are the mainstay of treatment for COP.
What is a radiographic sign for identifying pericardial effusion?
The fat pad sign is defined as soft tissue density measuring greater than 2 mm separating the subepicardial and mediastinal fat, best seen on the lateral radiograph.
What are the CT findings differentiating atelectasis from consolidation?
Atelectasis is enhancing opacified lung (RLL) Consolidation is non-enhancing (LLL)
What is the typical appearance of a Bochdalek hernia?
Posterior diaphragmatic hernia, usually fat, 80% left sided but can be bilateral. Not an eventration which is usually anterior, or a Morgagni hernia (anterior and retrosternal).
What is the typical appearance of a Morgagni hernia?
Anterolateral/retrosternal diaphragmatic defect with hernia sac containing omental fat and bowel. 90% are located on right side. Congenital defect secondary to maldevelopment of septum transversum, rarely traumatic.
Type of vasculitis
Solid and cavitated parenchymal nodules with circumferential mural thickening involving the trachea and main bronchi.
Thoracic disease may occur in the absence of sinus and renal disease.
An elevated level of serum antineutrophil cytoplasmic antibodies (ANCAs) (particularly antiproteinase-3 antibodies)
Type of emphysema
Panacinar empysema - Basilar regions of hypoattenuation associated with marked vascular attenuation reflect confluent regions of panacinar emphysema. - associated with alpha-1 antitrypsin deficiency.
What are the multiorgan findings of Tuberous Sclerosis?
Brain: subcortical tubers, SEGA, Subependymal hamartoma (calcs) Lungs: Lymphangioleiomyomatosis Abd: Renal angiomyeolipomas, Hepatic AMLs GI: polyps
What is the conus artery?
The conus artery is typically the first branch of the right coronary artery but may originate directly from the right coronary sinus/Ao.
What are the typical imaging findings of interstitial pulmonary fibrosis? Aka? Prognosis?
Fibrosis in a peripheral and bibasilar pattern causing “honeycombing,” traction bronchiectasis, and architectural distortion. Bx will show usual interstitial PNA. Limited ground glass. UIP has a poor prognosis but is more common.
What are the typical findings of non-specific interstitial pneumonitis? Prognosis?
Bilateral symmetrical ground-glass opacities, sometimes crazy paving pattern, fine reticular/lacy pattern with subpleural sparing. No significant honeycombing. NSIP has a much better prognosis than UIP but is less common.
What are the five dx criteria for this?
1) A pleural abnormality (pleural thickening/plaque/effusion) 2) Broad-based consolidation adjacent to the pleural abnormality 3) Volume loss 4) Swirling of bronchovasculature into mass-like consolidation, or the “comet-tail” sign 5) Acute angles with the pleura
What is a broncholith?
Calcified or ossified material within bronchial lumen, usually due to erosion from adjacent lymph nodes! Look for post obstruction atelectasis/infection.
What is the ddx for (peri)lymphatic distribution of reticular nodules?
Peribronchovascular and along the fissures. Ddx: Sarcoidosis Silicosis, Coal Worker’s Pneumoconiosis Lymphangitic Carcinomatosis
What is the ddx for random/miliary pattern of reticular nodules?
Random distribution of nodules in 2ndary pulmonary lobule Ddx: Mycobacterial Mets Viral infxn Disseminated fungal infxn Granulomatous (Sarcoid/silicosis/talcosis)
What causes diffuse thin calcifications within the wall of the left atrium?
Rheumatic heart disease.
What is the typical cause of mosaic attenuation pattern?
Hypersensitivity pneumonitis (HP).
Look for centrilobular nodules.
Assoc with exposure to antigens/irritants.
What is Boerhaave syndrome and how is it different from a Mallory-Weiss tear?
Boerhaave syndrome refers to spontaneous transmural rupture of the esophagus after forceful emesis, you’ll see a lot of gas in soft tissues, and fluid in the pleural space. A mallory-weiss tear is a partial thickness tear after forcefull emesis usually with massive bleeding into the stomach common in cirrhotics with esophageal varices.
Emphysema in Marfan and Ehlers-danlos
Paraseptal emphysema - Classically paraseptal bullae, usually seen with centrilobular emphysema and assoc with smoking;
What are the differentiating findings for the smoking related interstitial lung diseases?
Respiratory Bronchiolitis-ILD: Upper lung zone centrilobular nodules and ground glass. Desquamative interstitial pneumonia: Bibasilar peripheral distribution of innumerable small cysts with ground glass.
What is the difference between synchronous cancers and metachronous cancers?
Synchronous lung cancers are 2 or more separate lung cancers detected simultaneously without systemic metastases. Metachronous lung cancers are 2 or more separate lung cancers separated by time without systemic metastases.
What is the ddx for CT angiogram sign for chest CT?
Lymphoma Metastasis, Gastrointestinal Carcinoma Adenocarcinoma in situ (AIS/BAC) Edema, Cardiogenic Pneumonia, Post-Obstructive
What stage?
stage 4 sarcoidosis - large, generally symmetric, upper lobe opacities, with air bronchograms - adjacent parenchymal nodule - regional lymph node calcifications.
What are the types of NSCLC?
Non-small cell lung cancer (NSCLC) include bronchogenic carcinoma (CA), adenocarcinoma (adenoCA), squamous cell carcinoma (SCCA), large cell carcinoma (LCCA), bronchoalveolar carcinoma (BAC). If you see the pulmonary mass, then it is more likely NSCLC. If there is cavitation, it is more likely NSCLC.
What is the most likely cause of diffuse tree-in-bud appearance on CT?
Infectious bronchiolitis (endobronchial spread of infection) and it is usually viral or atypical bacterial.
What is the pathognomonic finding for persistent left IVC?
A persistent vessel draining inferiorly across the left hilar region into the coronary sinus, pathognomonic of a persistent left superior vena cava.
What is the preferred tx empyema?
Chest tube for drainage, dx of organism, and instillation of Fibrinolytics.
IV Abx also administered.
Infection
Ggo Cavity Tree in bud
Nosocomial
Gram neg
Centrilobular nodules- non infection
Hp Pnuemoconiosis Rb Vasculitis
Tb in immunocomp
Cavitary nodules Masses ie chest wall
Lobar pna
Klebsiella Strep Pneumococcus
Viral
Influenza- Rsv Parainfluenza Various appearance Symmetric
ntbm
Non tb mycoplasma Lady windamere
Cavitary in lungs
Staph Tb Klebsiella Coccidiomycosis Aspergillus
Aspergillus
Aspergilloma- air cresent, asthma, immunosupp Invasive- halo, immunocomp
Pcp, pneumocystis
Ggo, pneumatoceles
Dont miss- be safe
Influenza: any bl Septic emboli-tb: cavitary Tree in bed: tb- miliary
solid pulmonary nodule
SPN malignant until excluded- larger is more suspicious, air bronchogram and enhancement (>25 HU). Ddx: Tb or round pan or granuloma or hamartoma. 50% adeno, then 25% squamous
pneumatoceles
not cavitary, thin walled, gas filled, check-valve mechanism, may resolve in weeks- aw w acute pna
DDx for nodules w skin rash
DDx for nodules w skin rash Varicella Pna, CMV, Influenze, Measles hemorrhagic pulmonary mets
Asbestos relate pleural plaques- b/l, diaphragm, firbtotic, post hemorrhage,
Ddx: post infection (TB) or posthemorrhagic (Both UL). rib fractures mimic
HIV + w BL axillary LN
Kaposi Sarcoma
(shown fish vert and calcified spleen)
acute chest syndrome: symptom plus new chest opacity
severe neutropenia- ho recent BM tx etc
Invasive Aspergillosis: air cresent sign and halo sign (don’t confuse w monad sign of aspergilloma- non gravity dependent side)
Lofgren syndrome
sarcoid, erythema nodosum, arthralgias and intrathoracic LN
Heerfort Syndrome
sarcoid, parotid/ocular involvement, facial palsy, fever
cardiac mets
waaay mc than primary (angiosarc) if higher than simple pericardial effusion
calcified micronodules
mets (ie papillary thyoir ca- I-131 will be pu) sarcoid, granuloma, HSP, silicosis, etc
hematopoeisis - extramedullary
abnormal vert (H shaped) and no spleen
woman w weakness and chest mass
thymoma
Lofgren Syndrome
intrathoracic LN, erythema nodusum,
Wegners *
c-anca, gg/air space, nodules, cavitary, w hemoptysis
Churge Strauss
P anca, rarely cavitate
chronic peripheral consolidation that wont respond to abx
COP, BAC
Scleroderma
(not NSIP) - dilated edophagus and cystic/fibrotic lung bases
RB - ILD
vs HSP (non-smokers vs younger heavy smoking males), DIP, NSIP
large coalescent thick walled
predominantly lower lobe cysts
10 yo
papillomatosis (hpv 6 and 10) vs LHC and wegners
P-LCH shaped cysts
irregularily shaped, upper lobes - ddx: LAM (thin walled), papillomatosis
LIP
lymphoproliferative- HIV (aids defining in kids), sjogrens, castlemans cysts and nodules ddx- LCH,
direct sign of atelectasis
opacity and displacement of fissures
mc cause of bl chest adenopathy
sarcoid
appearance of pulmonary laceration on radiograph
ovoid lucency (post-traumatic pneumocele) with surrounding contusion - air fluid level in cyst if it fills w blood
vol to detect effusion on cxr
200 AP, 75 lat, 5 lat decub
exudative effusion caused by
neoplasm and infection transudate- CHF, low protein, cirrhosis, nephrotic
pattern of malig calcification in lung nodule
eccentric or stippled
CF
AR mild form diagnosed in adults
sign seen w aspergilloma
Monads sign- crescent of air- fungus ball w CF, TB, sarcoid
3 classifications of neurogenic tumro
peripheral nerves: schwannoma and NF sympathetic chain: NB, GNB, GN paraganglioma/pheo
osseous findings of NF
widened NF, rib erosions/notching, post scalloping of vert body
NAV above or below rib
below
thymic carcinoma vs invasive thymoma
TCa: hematogenous mets IT: local spread along pleura esp
mc ant med mass in adults
thymic- thymoma
forms of silicosis
acute chronic - simple: multi small nodules, may calcify, eggshell ln - complicated: large confluent nodules to progressive massive fibrosis
Obliteration of the Raider’s triangle (retrotracheal) is due to what?
Aberrant Right Subclavian Artery
Flat waist sign is associated with what CXR abnormality?
LLL collapse
On Lateral CXR, which chamber doesn’t contribute to heart border?
Right atrium doesn’t form a border (RV is anterior, LA/LV are posterior border)
On Frontal CXR, which chamber doesn’t contribute to heart border?
Right ventricle doesn’t form a border (RA is the right, LA appendage/LV are left border)
Is the right or left hilum usually higher on CXR?
The left hilum is located higher than the right in 97% of normal frontal chest radiographs due to the heart being there! (right hilum never higher than left on normal CXR)
How do you tell difference btw PA & AP CXR?
PA will NOT have scapulae over the lungs!
How many layers of pleura in the azygos fissure?
4 (2 parietal and 2 visceral)
What kind of bugs cause pneumonia in COPDer?
H Flu & Legionella (“Legion of Flu”)
Different CD4 counts put you at risk for?
CD4 > 200 = Bacterial / TB (e.g. strep pneumo) CD4 < 200 = PCP (ground glass!), or atypical mycobacteria CD4 < 100 = CMV, Fungal, Mycobacterial
Imaging appearance of PCP pneumonia? Nuclear med findings?
GGO in perihilar regions with sparing of lung periphery (“Ggo see your PCP”) ** Gallium positive Thallium negative cysts (weird bc thallium is positive for both lymphoma and Kaposi sarcoma) = cysts don’t have mitochondria
When do you see hypervascular LNs?
Castleman’s or Kaposi’s
What is a Ghon Lesion vs Ranke Complex?
- Ghon lesion = calcified TB granuloma
- Ranke complex = calcified TB granuloma + Calcified HILAR lymph node
Calcified HILAR lymph node = healed primary TB
What is Lady Windermere?
Asymptomatic, tree-in bud opacities and bronchiectasis in RML and lingula; Bronchiectactic mycobacterial infection
Imaging appearance of Hypersensitivity Pneumonitis?
“Head Cheese” - bit of everything! * Peribronchiloar distribution - ill-defined ground glass centrilobular nodules - Subacute = patchy GGO, ill defined centrilobular GGNs, mosaic perfusion, air trapping - Chronic = “UIP + Air trapping” / MOSAIC LUNG = bronchiectasis and air trapping (mix of everything = GG, consolidation, air trapping, and some normal lung)
Cavetating Lesion in Lung?
“CAVITY”
Cancer (squamous cell)
AutoImmune (Wegener’s, RA/Caplan - “Pneumocaplanosis”)
Vascular = Septic emboli
Infection = TB
Trauma = pneumatoceles
Young = Congenital CCAM/Sequestration
Imaging appearance of Atypical Adenomatous Hyperplasia of the lung (AAH) –> Adenocarcinoma in situ (AIS) –> Minimally Invasive Adenocarcioma (MIA)
- Ground glass, COLD on PET, Fried Egg, Pseudocavitation
What makes a lung cancer 3B (unresectable)?
Supraclavicular/scalene or contralateral mediastinal/hilar LAD; Same lung Different lobe tumor; ;primary in each lung, malig pleural eff
What do you suspect if pneumonectomy cavity progressively fills with air instead of (expected) fluid?
Bronchopleural fistula
Which is associated with intrathoracic lymphadenopathy? Hodgkins or NHL?
Hodgkins. (NHL = “Non Lymphadenopathy in the chest)
PTLD Imaging findings?
- Well defined pulmonary nodules/mass - patchy airspace consolidation, halo sign, interlobular septal thickening * usually within 1 year of transplant
Kaposi’s vs Lymphoma vs Toxoplasma nuclear findings?
- Kaposi’s Sarcoma = Thallium Positive, Gallium NEGATIVE (“Kaposi is a Flamer and gets no GALs”) - Lymphoma = Thallium Positive, Gallium POSITIVE - Toxoplasma = Thallium NEGATIVE (“Toxo is short, not Thall”)
Extra lobar sequestration findings?
“ExtraLobar = ExtraTerrible” = it affects newborns (causing resp compromise) with associated congenital anomalies - Luckily though, it HAS It’s OWN EXTRA PLEURAL COVER and Systemic venous drainage, so it RARELY GETS Infected
If you see a SYSTEMIC ARTERIAL FEEDER from aorta to the “CCAM”, then what it is?
SEQUESTRATION!
Which 2 entities spare the costophrenic angle?
LCH (classically)
Hypersensitivity pneumonitis
Pulmonary LCH findings?
Bizarre shaped-thick walled cysts and centrilobular nodules in upper lobe that SPARE THE COSTOPHRENIC ANGLE - Young and middle aged adult smokers - Upper lobe predominant nodules, Cysts, and cavitary nodules - Primary tx: STOP SMOKING! See RP 24a 4/19
LAM findings?
Women of childbearing age (due to ESTROGEN); Thin walled ROUND cysts; think with TUBEROUS SCLEROSIS and CHYLOTHORAX - Associated renal AMLs!! - Elvated serum VEGF!
Birt-Hogg-Dube?
Oval cysts with thin walls and renal findings (OncOcytOmas and Chromophobe RCC) - “a lot of O’s”
Lymphoid interstitial pneumonia associations?
Sjogren’s (adult) and HIV (kid) - thin walled cysts deep within lung parenchyma
Silicosis Findings?
Multiple nodular opacities in UPPER LOBES, Perilymphatic nodules (“SSL” - sarcoid, silicosis, lymphangitic spread), EGG SHELL Calcs hilar nodes - Progressive massive fibrosis (T2 dark!) is formation of large masses in upper lobes with radiating strands - if see cavitation, raise suspicion for TB (increased risk)
Coal Workers?
- multiple nodular opacities with calcifications showing a central nodular dot - PERILYMPHATIC
Silo Fillers?
PULMONARY EDEMA PATTERN! 2/2 nitrogen dioxide
UIP Imaging Findings?
Worse in lower lobes, TRACTION bronchiectasis and HONEYCOMBING;
heterogeneous histology;
seen first in posterior costophrenic angle
NSIP findings?
- GROUND GLASS IS KEY W/O HONEYCOMBING (cellular) + reticulation and traction bronchiectasis (fibrotic); HOMOgeneous histology; * Spares immedate subpleural lung; lower lobe/posterior/peripehral predominance
RB-ILD & Desquamative ILD?
RB = Apical centrilobular GGNs; respiratory bronchiolitis with symptoms DIP = Diffuse GGO & HYperattenuation with patchy or subpleural distribution; small cystic spaces
Sarcoidosis findings?
Upper lobe predominant, Perilymphatic nodules (“SSL”); later on can see upper lobe fibrosis and traction bronchiectasis - lambda sign = 1-2-3 sign (1-2-3 sign (b/l hilar LAD and R paratracheal LAD)) on Gallium scan CT galaxy sign = upper lobe masses (conglomerate of nodules) w/ satellite nodules
Post-lung tx findings?
- Hyperacute Rejection (< 24 hours) = massive homgeneous infiltration 2. Acute rejection (1 day to 1 week) = GGOs and intralobular septal thickening (must have ground glass) 3. CMV (2-4 months) = Ground glass, tree-in-bud 4. Chronic Rejection/Bronchiolitis Obliterans (> 4-6months) = bronchiectasis, bronchial wall thickening, air trapping, interlobular septal thickening - Air trapping on expiration at 6 months or more
Protein alveolar proteinosis?
Seen in SMOKERS, risk for NOCARDIA, can progress to pulmonary fibrosis; patients often ASYMPTOMATIC!
Crazy paving seen in?
PAP, edema, hemorrhage, BAC, Acute interstitial PNA, alveolar sarcoidosis, PCP pneumonia
COP findings? What looks exactly like COP?
Patchy air space consolidation or GGO in a Peripheral or peribronchial distribution; no fibrosis (history of “being treated for PNA for some time”) - ATOLL sign (reverse halo) = consolidation around a ground glass CENTER - Chronic Eosinophilic pneumonia looks EXACTLY THE SAME (always in diff dx = COP + CEP) = h/o ASTHMA
Which 2 disease spare posterior tracheal membrane?
Relapsing polychondritis (DIFFUSE tracheal thickening/ears/nose/joints affected)
TBO (cartilaginous and Osseous NODULES) - TBO does NOT require treatment
Which 2 diseases do NOT spare posterior tracheal membrane?
Amyloidosis (with calcifications) and Wegener’s (NO CALCS)
Adenoid cystic of the trachea?
Extensive irregular mural infiltrative thickening
Mounier Kuhn?
Tracheobronchomegaly (trachea dilated > 3 cm)
Williams Campbell Syndrome?
Congenital cystic bronchiectasis 2/2 deficiency of cartilage in 4th - 6th order bronchi (“Trachea looks like part of a Campbell’s Soup Can”)
Collagen vascular disease lung findings?
SLE RA Scleroderma Sjogren's Ankylosing Spondylitis
SLE = pleural and pericardial effusions; Shrinking Lung
RA = looks like UIP and COP in lower lobes (e.g. honeycombing, opacities)
or possibly air trapping and constrictive bronchiolitis + Cavitating necrobiotic lung nodules
Scleroderma = Looks like NSIP; look for dilated fluid filled esophagus! (duh - Crest syndrome)
Sjogrens = looks like LIP (GROUND GLASS with scattered thin walled cysts)
Ank Spond = Upper lobe fibrobullous disease
Empyema air-fluid on PA & CXR will have the same or different dimensions?
DIFFERENT
When is a superior sulcus tumor not resectable?
Brachial plexus involvement above T1; diaphragm paralysis (C3-5 involvement), > 50% vertebral body; invasion of esophagus / trachea, distal nodes/mets (N2, N3, M1)
Thymoma imaging? Carcinoma?
Thymoma = smooth soft tissue mass with possible necrosis or cystic change * Cystic mass with mural nodules * T1 low to intermediate; T2 high (esp in the intracystic change) * peripheral curvilinear calcification along the capsule 5th to 6th decade in life - Thymic carcinoma = look for LAD and local invasion; calcification makes it more worrisome
Hughes Stovin Syndrome?
Pulmonary artery aneurysm like in Bechets with recurrent thrombophlebitis - “Extremity is Hot (thrombophlebitis) like in a Hot Stove”
Pulmonary veno occlusive disease?
Pulmonary arterial hypertension affecting post-capillary pulmonary vasculature = Normal Wedge pressure! - Occlusion of pulmonary veins by fibrous tissue in a patchy distribution
Extra pleural hematoma?
injury to chest wall with PARIETAL PLEURAL REMAINING INTACT - *** DISPLACED EXTRAPLEURAL FAT and persistent fluid collection after pleural drain placement
Bechet’s?
Turkish descent, mouth and genital ulcers, 2nd most common cause of pulmonary artery anuerysm/pseudoanuerysm after Iatrogenic swan ganz
Pericardial vs bronchogenic cysts?
- pericardial - contiguous with pericardium - bronchogenic - usually subcarinal or paratracheal
Findings of Staph pneumonia?
The 3 most common patterns of Staphylococcal pneumonia are bronchopneumonia, septic emboli and septic infarcts (as in this case), and acute respiratory distress syndrome.
Findings of round atelectasis?
- Pleural abnormality/thickening, plaque or eff
- broad based attachment/mass like consolidation
- comet tail sign = swirling of bronchovasculature
- acute angles with the pleura
- seen in asbestos exposure (e.g. Shipyard worker), particularly if there’s also pleural thicekning
What can mosaic attenuation mean on Chest CT? How to tell the difference?
Air trapping or small vessel disease Do CT in EXPIRATION to see if it persists and is due to air trapping. Otherwise, it’s likely small vessel disease (esp. in a patient with prior PE)
What is LAM’s histology? Complications?
LAM is due to interstitial proliferation of abnormal smooth muscle resulting in dilated pulmonary lymphatics.
- It can actually also present as b/l reticulonodular densities with hyperinflation on CXR
- Recurrent pneumothorax and chylothorax are complications
- Women of CHILD-BEARING age (almost exclusively!)
Findings of acute eosinpholic pneumonia?
Think of it like pulmonary edema B/l Lower lobe GGOs w/wo interlobular septal thickening and small effusions (similar to edema) CENTRAL not peripheral in distribution (also like edema)
Differential diagnosis for peripheral Ground glass and solid consolidation in the lung?
Churg Strauss, COP, and CEP
What constitutes M1a disease in lung cancer?
Tumor in contralateral lung, pleural nodules, malignant pleural or pericardial effusions M1b = distant mets (osseous, adrenal, brain)
Which groups are susceptible to different forms of Aspergillosis infection?
Aspergilloma = Prior lung disease (TB, sarcoid, CF) ABPA = asthmatics Semi-Invasive aspergillosis = mildly compromised immune systems (Alcoholics & Diabetics) - nodules or consolidation near prior scarring Angio-invasive = Severely neutropenic (post BMT, AML patients) - CT halo, Air crescent, and peripheral wedge-like consolidations * Air crescent sign indicates that the neutropenia has resolved and patient is mounting a response against the infxn by “walling it off”
Findings of SVC syndrome?
Enlarged azygos and aortic nipple with mediastinal widening + collaterals
Viral pneumonia imaging findings?
Miliary calcified nodules, centrilobular nodules, and diffuse interstitial thickening See RP 5a 4/19
How does Farmer’s lung present?
Diffuse pulmonary edema within hours of toxic fume inhalation
Chronic MAI infection on CT?
Scattered peripheral bronchiectasis and clusters of airway-centric nodules - if Old man and COPD, then thick-walled CAVITIES with or w/o adjacent consolidation
What is neurogenic pulmonary edema?
Increased ICP results in pulmonary capillary stress failure –> pulmonary edema that’s rapidly onsetting (even few minutes to hours difference in CXR) - Looks like any other pulmonary edema
How does fibrosing mediastinitis look on CT?
Heterogeneous mediastinal mass with occluding or narrowing vessels or airways
(due to immune response to Histo)
History is often PROGRESSIVE dyspnea and facial swelling
What causes pleural mets?
Adenocarcinoma and invasive thymoma “drop mets!”
Most common primary tracheal neoplasm?
Squamous cell! (then adenoid cystic)
“CT angiogram sign”?
Lung mass exhibits intrinsic-contrast enhanced pulmonary arteries = usually diffuse invasive adenocarcinoma or lymphoma (no vascular or bronchial obliteration)
How does coccidioidomycosis look on CT/CXR?
Focal necrotizing pneumonia as a thin-walled cystic lesion
- history of travel to California w/ fever and cough
Histo = Mississippi and Ohio River valleys
Blasto = states east of Mississippi River
Paracoccidioidomycosis = Rural Latin America
What is PCP infection in terms of gallium and thallium?
Gallium HOT and thallium cold (“Toxo is also thallium cold in the brain = toxo is short, not Thall”)
PCP pneumonia where are the GGOs on CT?
CENTRAL and PERIHILAR (patchy or geographic) GGOs
possibly cysts with GGOs in the UPPER lungs
What are the contraindications to pulmonary angiography and if you have to do it, what precautions?
- PAH with right heart failure (Pulm artery pressure > 70 mm Hg AND RV End diastolic pressure > 20 mm Hg) 2. LBBB Use a low osmolar contrast agent injected directly into the right or left main pulmonary artery, instead of into the Main PA!
What is the T-staging of solitary bronchogenic carcinoma based on size?
T1a < 2 cm and distal to lobar bronchus T1b 2-3 cm and distal to lobar bronchus T2a 3-5 cm and > 2 cm from carina T2b 5-7 cm and > 2 cm from carina T3 > 7 cm and < 2 cm from carina
What is the best modality to image thymoma?
Contrast-Enhanced Chest CT (to see any local invasion + vasculature) (if can’t get contrast, non-con CT with MRI)
Tumor markers in non seminomatous GCT?
Embryonal & Yolk Sac = high AFP and LDH Choriocarcinoma = high B HCG and LDH (Seminoma can cause high B HCG and LDH too, but not high AFP and it’s seminomatous, duh)
What are the malignant non-seminomatous Germ Cell Tumors?
“DEET”
Dysgerminoma
Embryonal cancer
Endodermal sinus tumor (= Yolk Sac tumor!),
Teratoma (immature or malignant)
- Note Granulosa thecal cell tumor is a sex-cord stromal tumor, NOT a GCT
What is the N-staging for lung cancer?
N0 = no local regional LN mets N1 = ipsilateral peribronchial or hilar Nodes N2 = ipsilateral mediastinal or subcarinal nodes N3 = ipsilateral /contralateral scalene or SUPRACLAVICULAR nodes or contralateral mediastinal/hilar nodes *only N0, N1, and N2 benefit from SURGERY
Difference in imaging findings between Rheumatoid lung disease vs Caplan syndrome?
Caplan is upper lobe predominant fibrosis * Both have cavitary lung nodules with associated pleural effusions
Thymic carcinoma is in which age range? Imaging findings?
Adults males mean age 40 yo Can mimic squamous cell lung Ca and unlike thymoma, shows up with LAD
What is the imaging follow up for a stage 1 resected thymoma?
Annual Chest CT x 5 years, alternating CT with CXR til year 11, then annual CXR - If grade 3 or 4a thymoma, or carcinoma, then CT q6 mo x 3 years then less frequently if scan remains clean
Thoracic meningocele is due to what syndrome?
NF-1 Extrusion of meninges containing CSF into the posterior mediastinum through the neural foramen
The GOLD parameters for COPD staging rely on which lung capacity?
FEV1 & FEV1/FVC < 70%
Tracheal laryngeal papillomatosis increases risk of what type of cancer?
Squamous cell Ca (HPV exposure)
Thymic carcinoid tumor occurs in whom?
Males & MEN type 1 (MEN and MEN) - most common neuroendocrine tumor of thymus and 50% are functionally active - * usually Cushing’s from ACTH
Solitary fibrous tumor of the pleura presents how? Clinically with what abnormality?
Hypoglycemia or pulmonary hypertrophic osteoarthropathy! Benign slow growing tumor NOT associated with calcifications, effusion, or rib destruction (usually go to surgery though as they get large before discovery)
Features of rheumatoid lung disease?
Looks like UIP (lower lobe predominant), necrobiotic lung nodules that can cavitate, EXUDATIVE pleural effusion, and bronchiolitis obliterans (Caplan’s syndrome is similar but is upper lobe predominant b/c pneumoconiosis)
What does the superior accessory fissure separate?
RLL into the superior and basal segments (exclusive to right side) Inferior accessory fissure: Medial basal segment from rest of the lower lobe (R > L)
What does the inferior accessory fissure separate?
Medial basal segment from rest of the lower lobe (R > L) Superior accessory fissure: RLL into the superior and basal segments (exclusive to right side)
What does the left minor fissure separate?
LUL from lingula
Most common imaging appearances of amiodarone toxicity in the lungs?
Peripheral areas of airspace consolidation (hyper dense) > pulmonary interstitial fibrosis - heart and liver may be hyper dense - Stop amiodarone and give steroids! (most cases resolve)
Causes of CT halo sign?
Angioinvasive aspergillus Primary lung malignancy (adeno & squamous) Hemorrhagic mets (Kaposi) Inflammatory (Wegener’s, Endometriosis, eosinophilic pneumonia) Septic Emboli Mycobacterial infection Other fungal infections
What do you think of if someone develops bilateral arm weakness, slurred speech, and double vision with multiple pleural lesions? What other paraneoplastic symptoms may be associated?
Invasive thymoma causing myasthenia graves! - Thymoma also causes Pure Red Cell Aplasia and Hypogammaglobulinemia
How to distinguish Congenital Lobar Emphysema from Congenital Bronchial Atresia?
Congenital Bronchial Atresia triad:
1) Mucous impaction,
2) Distal hyperinflation (air trapping)
3) Hypoperfusion from reflex vasoconstriction, most commonly apicoposterior segment of LUL
VQ shows:
- Decreased perfusion
- Air trapping (Delayed wash-in and prolonged wash-out of the ventilation tracer)
Congenital Lobar Emphysema: NO mucous impaction
Which LNs are difficult to access by mediastinoscopy?
Pre-vascular station, AP nodes, and posterior subcarinal nodes!
Which entity most closely mimics acute hypersensitivity pneumonitis on imaging?
Desquamative interstitial pneumonitis * Both have b/l symmetric GGOs in a lower lobe predominant distribution (but DIP more likely in SMOKER and Acute hypersensitivity in a non-smoker)
How to distinguish sarcoidosis from lymphangitic carcinomatosis?
Architectural distortion and / or Fibrosis in sarcoid * Both have perilymphatic distribution of disease, with irregular septal thickening, sub pleural nodularity, thickened bronchovascular interstititum and hilar LAD * Lymphangitic carcinomatosis rarely causes destruction of overall lung architecture!
Thyroglossal duct cyst on US?
Cystic structure with low-level internal echoes and posterior thru transmission in the upper midline neck (midline, at or above hyoid; can occur from base of tongue to thyroid)
Origin of bronchus for the superior segment of the RLL occurs at the same level as?
As the origin of the RML bronchus
Therapy for invasive thymoma involving the pericardium?
If it involves the pericardium, must do neoadjuvant chemo then surgery then post-op radiation
Which type pneumocytes can replicate?
Only Type II can replicate - Type II = surfactant producing - Type 1 = lining of the alveoli (susceptible to injury) * Multifocal microndular pneumocyte hyperplasia (MMPH) in TS presents as < 1 cm scattered pulmonary nodules due to hamartomatous proliferation of Type II pneumocytes!
How does tracheobronchial papillomatosis present?
Soft tissue nodules in trachea (including posterior trachea) with cavitary and solid pulm nodules in a posterior distribution (dependent portion of lung) - 2/2 permpartum transmission of HPV
Imaging findings of Lymphocytic interstitial pneumonia (LIP)?
Mediastinal LAD, b/l patchy GGO and scattered thin-walled lung cysts in a LOWER LOBE distribution - think Sjogren’s and AIDS in KIDS :-(
What are the Wedge pressure (pulmonary venous) pressures for different pulmonary edemas?
13-18 mm Hg = Vascular redistribution 19-25 mm Hg = Interstitial edema > 25 mm Hg = Alveolar edema “13, 18, 25”
In which disease do you see progressive massive fibrosis?
Silicosis and Coal Worker’s and Sarcoid (Large fibrotic mass-like conglomeration in UPPER lobes with radiating strands of fibrosis) (Multiple pulmonary nodules that have coalesced into irregularly shaped masses + LOW lung volumes)
Hodgkin’s Lymphoma (nodular sclerosing type) is more common in females or males?
Which LNs usually involved?
FEMALES = nodular sclerosing type
- Supraclavicular, cervical, and mediastinal nodal groups most often involved
- Bimodal age distribution (2-3rd decades then 5th decade)
- Reed Sternberg Cells (owl eyes)
Most common causes of fungal pneumonia in AIDS patients?
- PCP 2. Cryptococcus! (Interstitial opacities and/or focal nodular or widespread alveolar consolidation)
Does thymoma often cross midline? What to think of when you see anterior mediastinal mass in young woman (20s)?
Does NOT often cross midline (usually one lobe of the thymus) In a female, think of LYMPHOMA first if large anterior mediastinal mass. Females RARELY get malignant neoplasm of germ cell origin
How to distinguish thymoma from thymic hyperplasia on MRI?
Thymic hyperplasia has microscopic fat/intravoxel fat so it will DROP on out of phase imaging. Thymoma will NOT do that Both are usually T2 bright
What is the specific treatment for tension PNX?
Needle decompression with a 5 cm needle in the 2nd intercostal space at the mid clavicular line
What is the difference between FRC and vital capacity in lung volumes?
Functional residual capacity: Volume left in the lungs after normal expiration Vital capacity: Volume of air expelled from max inspiration to max expiration
Pulmonary abscess requires which imaging follow up?
Pa/Lateral CXR until resolution - Air inside is from communication with bronchial tree * Do not drain, as it may cause bronchopleural fistula
What % of myasthenia gravis patients have thymoma?
15%! (85% have have follicular thymic hyperplasia) Conversely, 30-50% of patients with thymoma have myasthenia gravis
Which thymic pathology is associated with MEN I?
Thymic CARCINOID!
Which one affects the bronchi and which affects the trachea? (adenoid cystic vs mucoepidermoid) How else to tell apart?
Adenoid Cystic = Thoracic Trachea “Trachea is closer to your “adenoids” - Surgery + Radiation * Tends to EXTEND into Mediastinum Mucoepidermoid = Bronchi “more mucous at the bronchi!” - Does NOT tend to extend into mediastinum - if low grade, then cured after local excision
Most common primary tracheal malignancy?
Squamous cell Ca
What is the surgical treatment for pulmonary sling?
Surgical reanastomosis of the aberrant left PA to the main PA ANTERIOR to the trachea
If there’s new hemorrhagic mediastinitis in a previously normal individual, what do you think of?
Inhalational anthrax! Flu-like illness for 4 days followed by deadly “second stage” with exotoxin causing hemorrhagic mediastinitis, hemorrhagic pleural effusion, and shock/death
Name the mediastinal abnormality: bulky homogeneous soft tissue mass?
Mediastinal seminoma (not often with cystic space or hemorrhage/necrosis)
Name the mediastinal abnormality: Large heterogeneous soft tissue mass with necrosis?
Non-seminomatous GCT
Name the mediastinal abnormality: Cystic lesion with mural nodularity?
Thymoma
Name the mediastinal abnormality: Complex multiloculated cystic mass with fluid/fat/calcification?
Mature teratoma
Findings of RUL collapse?
Most specifically: Right juxtaphrenic peak - Also right hilar & minor fissure elevation; density in medial aspect of upper right hemithorax,
Which of the following does not produce acute GGOs? Pulmonary edema, pulmonary hemorrhage, atypical pneumonia, Proteinosis, or Diffuse alveolar damage
Proteinosis is a CHRONIC process
Which lung malignancies can present as GGOs in the lungs?
Usually more indolent processes
Atypical Adenomatous Hyperplasia (AAH)
Adenocarcinoma in situ
Mucinous adenocarcinoma
Metastatic Mucinous GI tumors
Most common site of the left bronchial arteries and right bronchial arteries?
LEFT (2) from Descending Aorta
RIGHT (usually only 1) from thoracic aorta (common trunk or directly from) 3rd posterior intercostal artery…OR from the superior bronchial artery on the LEFT
How to avoid post lung bx pneumothorax?
Place biopsy side down after procedure Use Co-axial technique Do NOT cross the fissures Discourage talking or deep breathing afterwards * Note must place chest tube if enlarging or symptomatic PNX
If you have imaging findings classic for mature cystic teratoma in the anterior mediastinum (e.g. fat containing), what is next step?
Go straight to surgical excision (the treatment); No need for further imaging or biopsy
What is Hermansky Pudlak Syndrome?
Prominent honeycombing, interlobular septal thickening, diffuse GGO AND ALBINO & Platelet dysfunction! “Herman the Honeycombed Albino”
What is elastofibroma dorsi due to? In what age group?
Older people age 70-80 yo Due to friction between scapula and chest wall (no surgery needed; no bony erosion/destruction)
What increases your risk of post-biopsy pneumothorax?
COPD Long needle tract > 4 cm Small lesion Needle LESS PERPENDICULAR to the pleura
What are imaging findings of Rheumatoid arthritis in the chest?
Lower lobe interstitial fibrosis / honeycombing / traction bronchiectasis (e.g. “UIP”) + pleural effusion or thickening + single or multiple peripheral cavitating nodules (“necrobiotic nodules”)
Does mesothelioma often calcify?
No!! The calcified pleural plaques of asbestos are NOT associated with mesothelioma Therefore the differential for thick pleural nodularity is mesothelioma or invasive thymoma. - It’s Invasive thymoma if there’s a focus of calcification in the mediastinum
Is malignant thymoma more or less likely to calcify compared with benign?
Malignant thymoma = MORE likely to calcify!
How to distinguish mucoepidermoid tumor from carcinoid?
Difficult by imaging Carcinoid tends to enhance more avidly and be more distal, but not reliable * Mucoepidermoid does NOT have a propensity to invade mediastinum (unlike ADENOID CYSTIC)
In reverse Golden S sign (RUL collapse), which fissure is the elevated one that gets indented upon?
Right MINOR fissure
What is the most common lymphoma overall and most common intra-thoracic lymphoma?
Overall = NHL Intrathoracic = Hodgkin’s!
Causes of exudative vs transudative pleural effusions?
Transudative (protein content 1.5-2.5 g/dL) = Cirrhosis, Nephrotic syndrome, CHF, hypothyroid Exudative (protein content > 2.5 g/dL) - Malignancy, UREMIA, MEIG’s, TB, PNA, SLE, Scleroderma, Wegener’s, and pancreatitis
Most common anterior mediastinal mass in a patient > 30 yo?
Thymoma!
How to conceptualize T3 vs T4 disease of bronchogenic carcinoma that’s invading an adjacent structure?
If it’s invading a “Vital” structure, call it T4 ex) T3 = chest wall, mediastinal pleura, diaphragm, pericardium T4 = mediastinal fat, heart, trachea, carina, esophagus, great vessels, recurrent laryngeal nerve, vertebral body
Which is LEAST associated with smoking? (RB-ILD, Desquamative ILD, Bronchiolitis obliterans, or LCH)?
Bronchiolitis Obliterans! (this is NOT assoc with smoking; it’s a constrictive bronchiolitis in post lung transplant GVHD, drug reactions (penicillamine), and rheumatoid arthritis!) The other 3 definitely are assoc with smoking!
How to distinguish the superior right intercostal vein from the azygos vein?
Superior right intercostal vein is ABOVE the aortic arch (drains 2nd-4th interspaces) and drains into the azygos arch itself.
The azygos vein is BELOW the aortic arch and arches over the Right mainstem bronchus as the azygos “arch” into the SVC
Findings of Acute eosinophilic PNA on chest CT?
How to distinguish from Chronic eosinophilic PNA?
CT = b/l Ground glass with interlobular septal thickening
Acute eosinophilic PNA = positive Eosinophils in bronchoavleolar Lavage but NOT in the peripheral blood smear
Acute eosinophilic PNA = tends NOT to recur after steroids; acute onset of symptoms or severe hypoxemia
What can cause diffuse alveolar hemorrhage 2/2 pulmonary capillaritis?
Wegener’s & Microscopic polyangiitis - Also consider SLE, Goodpasture, cocaine
How does a persistent Left SVC drain?
Inferiorly across the left hilar region into the coronary sinus, which drains to the right atrium
Bronchiolitis obliterans imaging findings and associations?
CT: sharply defined, areas of decreased lung attenuation associated with vessels of decreased calibre, possibly mosaic Causes: GVHD, drugs (penicillamine), and Rheumatoid Arthritis!!
After Bone Marrow Transplant, what are common causes of chest CT abnormalities?
< 3 weeks = Invasive Aspergillosis (solitary or multiple nodules with halo)
< 100 days = CMV (multiple small nodules) & PCP
> 100 days = PTLD, COP
