CHEST CORE 500 Flashcards
1
Q
Solitary Pulmonary Nodule
A
- Granuloma
- Neoplasm (bronchogenic carcinoima, solitary met)
- Hamartoma = Round pneumonia (under 8yo) = AVM
2
Q
Multiple Pulmonary Nodules
A
- Mets
- Granulomas (TB or fungal)
- Septic emboli
= Wegener’s
= Rheumatoid
3
Q
Cavitary Pulmonary Nodule
A
- TB
- Fungal disease
- Sqaumous cell carcinoma
= Pyogenic infection (abscess or septic emboli)
= Wegener’s
= Rheumatoid arthritis
4
Q
Milary Pulmonary Nodule
A
- TB
- Fungal disease
- Mets
= Pneumoconioses
= Healed Varcicella
5
Q
Centrilobular Pulmonary Nodules
A
- Infectious bronchiolitis (MAC, TB) - Hypersensitivity pneumonitits - Endobronchial spread of tumor = RB-ILD = Pneumoconioses
6
Q
Cystic Lung Disease
A
- Emphysema - LAM - LCH/EG = Pneumocystis pneumonia = LIP
7
Q
Lower Lobe Interstitial Disease
A
- Idiopathic pulmonary fibrosis/UIP
- Collagen vascular dz (scleroderma)
- Asbestos-related lung dz
= drug toxicity
8
Q
Upper Lobe Interstitial Disease
A
- TB - Sarcoidosis - Cystic Fibrosis = Pneumoconioses = LCH
9
Q
Hyperlucent Lung
A
- Chest wall abnormality (Polan, mastectomy) - Swyer-James - Acute asthma = Airway obstruction = PE = Pneumothorax
10
Q
Anterior Mediastinal Mass
A
- Lymphoma - Thymic lesion - Thyroid lesion = Germ cell neoplasm (teratoma)
11
Q
Middle Medistinal Mass
A
- Lymphadenopathy - Vascular abnormality (aneurysm) - Congenital cyst / bronchogenic cyst = hiatal hernia
12
Q
Posterior Mediastinal Mass
A
- Neurogenic tumor - Lymphoma - Developmental cyst (neuroenteric cyst) = extramedullary hematopoiesis = mediastinal hematoma
13
Q
Chronic Airspace Disease
A
- Cryptogenic Organizing Pneumonia - Pulmonary Alveolar Proteinosis - Bronchioloalveolar Cell Carcinoma [BAC] = Chronic Eosinophilic Pneumonia = Lipoid Pneumonia
14
Q
Peripheral Airspace Disease
A
- Cryptogenic Organizing Pneumonia - Eosinophilic Pneumonia - Pulmonary Infarction = Pulmonary Contusion = Alveolar Sarcoidosis
15
Q
Ground Glass Opacification
A
- Pulmonary edema - Atypical infection - Pulmonary hemorrhage = ARDS = Alveolar proteinosis = Vasculitis
16
Q
Mediastinal/Hilar lymphadenopathy
A
- Infection - Lymphoma - Sarcoidosis = Mets = Pneumoconioses
17
Q
Calcified Pleural Disease
A
- Asbestos related pleural disease - Fibrothorax (prior infex or hemorrhage) - Iatrogenic (pleurodesis)
18
Q
Bronchiectasis
A
- Postinfectious (bacterial, TB, MAC) - Cystic Fibrosis - ABPA = Obstructive lesion/mass = Ciliary dyskinesia
19
Q
Perilymphatic Pulmonary Nodules
A
- Sarcoidosis - Lymphangitic spread of tumor - Pneumoconioses = Lymphoproliferative disorder
20
Q
Pleural Based Mass
A
- Pleural mets - Empyema - Mesothelioma = Fibrous tumor of the pleura = Fibrothorax
21
Q
Parenchymal Disease in an HIV patient
A
- PCP - TB - Fungal infection = Invasive aspergillosis = Kaposi Sarcoma = Pulmonary lymphoma
22
Q
Abnormal left ventricular contour
A
- True LV aneurysm - False LV aneurysm - Pericardial cyst/ mass = Calcified pericarditis
23
Q
Cardiac mass
A
- Thrombus
- Mets
- Benign Neoplasm (myxoma, rhabdomyoma)
= Malignant neoplasm (sarcoma, lymphoma)
24
Q
Delayed myocardial enhancement
A
- Infarction/scar - Myocarditis - Cardiac mass = Infiltrative disease (amyloid, granulomatous)
25
Cardiac wall fatty deposit
- Lipoma - Lipomatous hypertrophy of the interatrial septum - Arrhythmogenic RV dysplasia
26
Unilateral interstitial lung disease
- Lymphangitic carcinomatosis - lymphoma - sarcoid - pulmonary edema
27
Multiple diffuse calcified nodules
- Histo - Healed varicella - silicosis
28
Honeycombing
- Sarcoid (upper lobe) - EG (upper lobe) - UIP (lower lobe, idiopathic) - Asbestosis (lower lobe) - Pneumoconiosis (upper lobes) - Scleroderma (lower lobe)
29
4 types of Asprergillus
- ABPA (asthmatics) - Noninvasive (normal people, fungus ball) - Semi invasive (mild immunosuppressed) - Invasive (very compromised, ill defined pulm nodules)
30
Crazy Paving
- PAP
- BAC
- lipoid pneumonia
- Drug induced pneumonitis
31
Peripheral ground glass opacification
- COP - sarcoid - BAC - Eosinophilic pneumonia
32
Anterior Mediastinal Mass
1. Thymus (thymoma, carcinoma, thymolipoma) 2. Germ cell neoplasm (teratoma) 3. Lymphoma 4. Throid (goiter, cancer) 5. Vascular abnormality (aneurysm)
33
Multiple cavitary lesions
1. Infection (fungal, bacterial) 2. Wegener's ganulomatosis 3. Septic emboli 4. Cavitary Mets 5. Rheumatoid Nodules 6. Pulmonary lacerations
34
Ground Glass Opacities - Acute
1. Edema 2. Hemorrhage 3. Infection (PCP) 4. Hypersensitivity Pneumonitis 5. Drug Toxcicity/Inhalation
35
Ground Glass Opacities - Chronic
1. BAC 2. NSIP 3. LIP
36
Endotracheal mass
1. Neoplasm (squamous, adenoid cystic, mucoepidermoid)
2. Papillomatosis
3. Tracheopathica Osteoplastica
4. Saroidosis, Amyloidosis, Relapsing Polychondritis
37
Pleural Mass
1. Mesothelioma
2. Pleural Mets
3. Fibrous tumor of pleura
4. Lipoma
5. Empyema/loculated effusion
6. Infection / empyema necessitans
38
Pneumomediastinum causes
1. Esophageal injury/rupture 2. Pulmonary/tracheal trauma 3. Rupture of bleb, asthma, severe coughing 4. Barotrauma 5. Surgery 6. Retropharyngeal infection
39
Basilar Fibrosis
1. UIP / IPF 2. CVD (scleroderma, rheumatoid) 3. Aspiration 4. Asbestosis 5. Durg toxicity (methotrexate, chemo, busulfan)
40
Bilateral hilar adenonopathy
1. Sarcoidosis 2. Lymphoma 3. Mets 4. Small cell lung cancer 5. Infections (TB) 6. Castleman's Dz
41
Small nodules, random distribution
1. Miliary TB / Histo
2. Hematogenous mets (thyroid, renal)
3. Silicosis
4. EG
42
Posterior Mediastial Mass
1. Neruogenic tumor (schwannoma, neurofibroma, paraganglioma, ganglioneuroma)
2. Hematoma
3. Abscess (Pott's dz)
4. Vascular (aortic aneurysm)
5. Extramedullary hematopoesis
43
Bronchiectasis
1. Cystic Fibrosis
2. Kartagener's / Ciliary Dyskinesia
3. Chronic aspiration
4. Chronic infection
5. Inhalation injury
44
Solitary Lung Mass
1. Maligancy (primary and mets) 2. Hamartoma 3. AVM 4. Infection 5. Fluid/effusion 6. Round atelectasis (a/w asbestos exposure)
45
Middle Mediastinal Mass
1. Esophagus (mass, tic, hiatal hernia) 2. Varicies 3. Foregut cyst 4. Lymphadenopathy 5. Pericardial mass/ cyst 6. LV pseudoanerysm 7. Aortic or PA aneurysm
46
Bilateral Patchy Opacities - Acute
1. Edema 2. Hemorrhage / Contusion 3. Infection 4. Drug toxicity 5. Hypersensitivity Pneumontis
47
Bilateral Patchy Opacities - Non-Acute
1. BAC 2. Sarcoidosis 3. COP / BOOP 4. Eosinophilic Pneumonia 5. PAP 6. NSIP
48
Causes of azygous vein enlargement
- Azygous continuation of IVC - Obstruction of vena cava - Tricuspid insufficiency - Rt sided heart failure
49
Causes of unilateral absent perfusion on VQ scan
- Pulmonary embolism - Extrinsic compression of PA (mass, aortic aneurysm [Ehlor-Danlos, Marfan's, syphilis]) - Aortic dissection
50
Upper Lung Chronic Infiltrative Disease
- silicosis - sarcoidosis - Coal worker's pneumoconisosis - ankylosing spondylitis - EG - cystic fibrosis
51
Causes of ascending aortic aneurysms [>4cm]
- Cystic medial necrosis (marfan's, Ehlers-Danlos) - atherosclerosis - syphilis
52
Common extrathoracic sites with endobronchial mets
- kidney - melanoma - thyroid - breast - colon
53
Bilaterally enlarged apical caps
- radiation fibrosis - mediastinal lipomatosis - vascular abnormalites (coarc)
54
Unilateral apical cap
- Bronchogenic carcinoma - lymphoma - extrapleural hematoma - abscess - radiation fibrosis
55
In an HIV + patient, what fungal infection presents with pulmonary nodules, pleural effusion, and lymph node enlargement?
Cryptococcus
56
Disorders that are associated with Hypertrophic Pulmonary Osteoarthropathy
- maligancy - cystic fibrosis - IPF - localized fibrous lesions of the pleura
57
Three types of bronchiectasis (Reid classification)
Cylindrical Varicoid Cystic/Saccular
58
Congenital disorders associated with bronchiectasis
Cystic Fibrosis Williams-Campbell Immotile cilia syndrome Mounier-Kuhn Primary hypogammaglobulinemia
59
Peripheral distribution of consolidation
- Loffler's syndrome
- Chronic eosinophilic pneumonia
- BOOP
- pulmonary infarcts
- vasculitides
60
4 types of emphysema
1. centrilobular 2. paraseptal 3. panlobular 4. paracicatricial
61
Panlobular emphysema with basilar predominance
Alpha-1-antitrypsin
Ritalin lung
IV methylphenidate
62
CT findings of bronchiolitis obliterans
- mosaic perfusion - bronchial dilation - air trapping
63
Conditions associated with bronchilitis obliterans
- bone marrow txplant - viral infections - toxic inhalation - rheumatoid arthritis - lung txplant - IBD
64
5 CT findings of asbestosis
1. curvilinear subpleural lines 2. thickened septal lines 3. subpleural dependent density 4. parenchymal bands 5. honeycombing
65
Define crazy paving
ground glass opacification with smooth septal thickening in a geographic distribution
66
Peripheral pattern of consilidation
- BOOP
- Loffler's syndrome
- chronic eosinophilic pneumonia
- pulmonary infarcts
- vasculitidies
67
CHF in a newborn
- Left to right shunt (Vein of Galen, hemangioendothelioma) - Coarctation - Hypoplastic left heart - narrow proximal Aorta, MV, and LV - Arrhythmia - Cardiomyopathy
68
Head Cheese (air trapping, normal lung, GGO)
- Hypersensitivity pneumonitis
- Sarcoid
- Acute on chronic PE
- GVHD/CVD (BO and OP)
69
Mosaic Attenuation with air traping
Think small airways disease - BO - Asthma
70
Mosaic attenuation with no air trapping
- Chronic PE (pulmonary HTN and enlarged RVH) - Vasculitis - Fibrosing mediastinitis (ST around aorta, RVH, RVE)
71
Neonate with CHD with decreased pulmonary vascularity
- TOF - Ebsteins - Severe pulmonary stenosis - Tricuspid atresia
72
Neonate with CHD and increased pulmonary vascularity
- D-transposition
- Truncus arteriosis
- TAPVR
- VSD
- ASD
- PDA
73
Neonate with CHD and pulmonary venous HTN
- hypoplastic L heart - coarcation - ?TAPVR
74
Noncardiogenic edema
- Neurogenic - ARDS - Near drowning - Re-expansion pulmonary edema - Acute inhalational injury
75
Acyanotic, no shunt vascularity, big heart, +/- edema
- Pericardial effusion - oreo cookie sign - Bicuspid aortic valve, aortic stenosis - Coarctation - figure of 3 sign, rib notching (ddx NF) - Extrathoracic shunt - Vein of galen, hemangioendothelioma - Cardiomyopathy - infiltrating (sarcoid,amyloid,HOCM) - Cardiomyopathy - ischemic/infarction - Kawasaki - coronary artery aneurysms - Cor tritriatrium
76
Types of Atelectasis
Obstructive, Relaxation, Adhesive, Cicatricial
77
Luftsichel sign
Crescent of air on frontal CXR, interface between aorta and hyperexpanded superior segment of LLL
78
Lymphangiomyomatosis findings and association
Diffuse cysts , round in shape, thin walled, diffuse, female childbearing age, assoc with tuberous sclerosis 1%
79
Golden's S sign
RUL atelectasis, usually due to obstructing mass
80
Flat waist sign
LLL atelectasis with downward shift of hilar structures causing flattening of left heart border and cardiac rotation
81
Signs of round atelectasis
1) abnormal adjacent pleura (effusion or pleural thickening/plaque); 2) peripheral, touching pleura; 3) round or elliptical; 4) volume loss in lobe; 5) comet tail sign (pulmonary vessels and bronchi leading to opacity)
82
Ddx of acute consolidation/GGO
Pneumonia (atypical in GGO such as viral or PJP) Pulmonary hemorrhage/edema ARDS
83
Ddx of chronic consolidation/GGO
-Mucinous adenocarcinoma -Organizing pneumonia -Chronic eosinophilic pneumonia **GGO add** Idiopathic pneumonia Hypersensitivity pneumonitis Alveolar proteinosis
84
Ddx of GGO in central distribution
Pulmonary hemorrhage
Pulmonary edema - cardiogenic
PJP
Alveolar proteinosis
85
DDx for peripheral consolidation/GGO
Organizing pneumonia Chronic eosinophilic pneumonia Atypical pneumonia Pulmonary edema - noncardiogenic
86
Interlobular septal thickening types and ddx
Smooth - pulmonary edema/hemorrhage, Alveolar proteinosis, Atypical pneumonia Nodular - Sarcoid, lymphangitic carcinomatosis
87
Ddx for crazy paving
Alveolar proteinosis PJP Organizing pneumonia Mucinous adenocarcinoma Lipoid pneumonia ARDS Pulmonary hemorrhage
88
Ddx of Centrilobular pulmonary nodules
Subpleural sparing --Infectious - endobronchial TB or MAI, bronchopneumonia, atypical PNA --Inflammatory - HSP, RB-ILD, diffuse panbronchiolitis, silicosis, hot tub lung (rxn to atypical mycobacterium like HSP)
89
Ddx of perilymphatic nodules
Sarcoid Pneumoconiosis Lymphangitic carcinomatosis
90
Interstitial lung disease, nodules, acute
Fungal Miliary TB
91
Interstitial lung disease, nodular, chronic
Silicosis Sarcoidosis LCH Lymphangitic carcinomatosis
92
Eggshell calcifications in lungs
Silicosis Sarcoid Treated lymphoma
93
Interstitial,lung disease, reticular, acute
Interstitial edema Atypical pneumonia (viral, PJP)
94
Interstitial lung disease, reticular, chronic
Fibrosis Emphysema Cystic lung dz Bronchiectasis
95
Fibrosis, upper lobe distribution
Sarcoid Chronic HSP Cystic fibrosis Prior TB Ankylosing spondylitis XRT Silicosis
96
Fibrosis, lower lobe distribution
UIP, NSIP Connective tissue disorders with UIP-like findings Chronic aspiration End stage asbestosis
97
Interstitial lung disease, septal lines, chronic
Lymphangitic carcinomatosis
Lymphoma
Kaposi's sarcoma
Amyloid - rare
98
Interstitial lung disease, septal lines, acute (Kerley B lines)
Pulmonary edema Atypical infections
99
Tree in bud nodules
Mycobacterium TB or atypical mycobacterium, bacterial or aspiration pneumonia, airway invasive aspergillus
100
Random nodules
Hematogenous metasteses, septic emboli, pulmonary LCH
101
Miliary nodules
Disseminated TB, fungal or hematogenous mets
102
Cavitary lesion, solitary and multiple
Solitary - primary bronchogenic carcinoma (cavitary adenocarcinoma or squamous cell), TB (upper lobe) Multiple - septic emboli, vasculitis, mets (squamous cell or uterine)
103
Lung cysts , solitary and multiple
Solitary - bulla, bleb, pneumatocoele Multiple - lymphangiomyomatosis, emphysema, pulmonary LCH, diffuse cystic Bronchiectasis, PJP pneumonia, lymphoid interstitial pneumonia
104
Halo sign in pulmonary
Ground glass attenuation surrounding consolidation. Ddx angioinvasive aspegillosis, hemorrhage met, Wegeners granulomatosis, Kaposi's sarcoma, viral infection
105
Tracheal thickening, diffuse, sparing of posterior trachea
Relapsing polychondritis - usu involves ears and nose in middle age female Tracheobrochopathi osteochondroplastica - nodular with calcifications
106
Tracheal thickening, diffuse, circumferential
TB
- smooth long segment Amyloid
- nodular +/- calcifications Wegeners granulomatosis
- subglottic stenosis Sarcoid
- hilar LAD, differing presentations
107
RUL segments?
Apical, posterior, anterior
108
RML segments?
Lateral and medial
109
RLL and LLL segments?
Superior, Lateral, Anterior, Posterior, Medial
110
LUL segments.
Apical posterior. Anterior. Superior lingula. Inferior lingula.
111
**In lower lobes, medial and anterior are anterior, posterior and lateral are posterior
***
112
Minor fissure?
RUL from RML. Fine horizontal line.
113
Azygos lobe?
1%. RUL apical or posterior segments are encased in their own parietal and visceral pleura
114
In which type of atelectasis would you expect to see air bronchograms?
Subsegmental atelectasis. Dont see them in obstructive atelectasis because airways are obstructed of course.
115
Subsegmental atelectasis?
Obstruction of small peripheral bronchi usually due to secretions
116
**Obstructive atelectasis happens more quickly in patients breathing supplemental oxygen because its absorbed from the alveoli quicker than nitrogen. Obstructive atelectasis happens when oxygen from air is absorbed by blood and not replaced.
***
117
**In general obstructive atelectasis is associated with volume loss, but in critically ill ICU patients, there may be rapid transudation of fluid into obstructed alveoli, causing superimposed consolidation
***
118
Relaxation atlectasis?
This is what is seen adjacent to a mass or pleural effusion causing mass effect
119
Adhesive atelectasis?
Lack of surfactant. RDS. ARDS.
120
Cicatrical atelectasis?
Volume loss from architectural distortion of lung parenchyma by fibrosis
121
Acute lobar atelectasis?
Mucus plugging
122
Lobar atelectasis in an outpatient?
Obstructing central tumor must be ruled out
123
What sign in LUL atelectasis?
Luftsichel sign. Crescent of air on the frontal radiograph representing the interface between the aorta and the hyperexpanded superior segment of LLL
124
Sign in RUL collapse?
Reverse S sign of Golden.
125
Juxtraphrenic peak sign?
Peridiaphragmatic triangular opacity caused by diaphragmatic traction from an inferior accessory fissure or an inferior pulmonary ligament
126
What do you see in LLL collapse?
Heart rotates and the L hilum is pulled down.
127
What sign in LLL collapse?
Flat waist sign describes flattening of the L heart border as a result of downward shift of hilar structures
128
**RLL collapse is a mirror image of LLL collapse
***
129
RML atelectasis?
You may only seen loss of R heart border.
130
Round atelectasis?
Focal atelectasis with a round morphology, always associated with an adjacent pleural abnormality
131
Diagnostic criteria for round atelectasis?
All five have to met. Adjacent pleura has to be abnormal. Opacity must be peripheral and in contact with pleura. Must be round or elliptical. Volume loss in affected lobe. Pulmonary vessels and bronchi leading into the opacity must be curved causing comet tail
132
Center of each secondary pulmonary lobule?
Centrilobular artery and central bronchus.
133
Periphery of each pulmonary lobule?
Pulmonary veins and lymphatics
134
Size of SPL?
Between 1-2.5 cm
135
**Only call ground glass on CT
***
136
Histology of consolidation?
Complete filling of the affected alveoli with a liquidlike substance- Blood, pus, water, or cells
137
**Can't see pulmonary vessels through the consolidatoin on unenhnaced CT, but you can with ground glass opacification (GGO)
***
138
Differenential of acute consolidation?
Pneumonia.
Pulmonary Hemorrhage.
ARDS.
Pulmonary edema.
139
Differential of chronic consolidation?
BAC. Organizing pneumonia. Chronic eosinophilic pneumonia.
140
Distribution of chronic eosinophilic pneumonia?
Upper lobes
141
Histology of ground glass opacification?
Incomplete filling of alveoli (blood, pus, water, or cells). Alveolar wall thickneing, or reduced aeration.
142
Differential of acute GGO?
Edema. Pna (Atypical more common). Pulm hemorrhage. ARDS.
143
Chronic GGO differential?
BAC. Organizing pneumonia. Chronic eosinophilic pneumonia. Idiopathic pneumonias. HP (subacute phase). Alveolar proteinosis.
144
Central distribution of GGO?
Edema. Alveolar hemorrhage. Pneumocystis Jiroveci. Alveolar proteinosis.
145
Peripheral consolidation or GGO?
Organizing pna. Chronic eosinophilic (upper lobes). Atypical or viral pna. Edema (noncardiac, cardiac will be central)
146
By far, most common cause of smooth interlobular septal thickening?
Edema
147
Diff for smooth interlobular septal thickening?
Edema. PAP. Pulm hemorrhage. Atypical pna. (Same diff as central GGO)
148
Nodular, irregular, or assymetric septal thickening?
Lymphangitic carcinomatosis. Sarcoidosis.
149
Crazy paving?
Interlobular septal thickening with superimposed GGO
150
Why does PAP cause crazy paving?
Filling of alveoli with proeinaceous material and septal thickening caused by lymphatics taking up the same material
151
Differential for crazy paving? (7)
```
PAP.
Pneumocystic Jiroveci.
Organizing pna.
BAC (mucinous).
Lipoid pneumonia.
ARDS.
Pulm Hemorrhage.
```
152
**Centrilobular nodules never extend to the pleural surface
***
153
Infectious causes of centrilobular nodules?
Endobronchial spread of TB or atypical mycobacteria. Bronchonpneumonia. Atypical pneumonia (esp. mycoplasma)
154
Inflammatory causes of centrilobular nodules?
HSP and RB ILD are most common. Otehrwise Hot tub lung, diffuse panbronchiolitis, and silicosis.
155
Diffuse panbronchiolitis?
Chronic inflammatory disorder characterized by lymphoid hyperplasia of the walls of respiratory bronchioles, usually patients are Asian.
156
What type of hypersensitivity reaction is HSP?
Type III
157
Three locations of perilymphatic nodules?
Subpleural. Peribronchovascular. Septal.
158
Most common cause of perilymphatic nodules?
Sarcoid.
159
Galaxy sign?
Sarcoid. Confluent perilymphatic nodules.
160
Other causes of perilymphatic nodules?
Pneumoconioses and lymphangitic carcinomatosis.
161
Random nodule distribution?
Mets. Septic emboli. Pulmonary LCH.
162
Miliary pattern of nodules?
Diseminated TB. Diseminated fungal infection. Diseminated mets.
163
**Most effusions associated with pneumonia are not empyemas but instead are a sterile effusion caused by increaed capillary permeability
***
164
**Treatment of BPF is very contraversial and individualized
***
165
**Miliary TB can be primary or reactivation TB
***
166
**Normal CT rules out P Jiroveci but it can hide in a normal chest radiograph
***
167
What are the linear branching structures in the tree in bud pattern? The nodules?
Impacted bronchioles, nodules are the impacted terminal bronchioles.
168
Tree in bud are almost always associated with what?
Small airways infection
169
Diff for tree in bud nodules?
Mycobacteria.
Bacterial pna.
Aspiration pna.
Airway invasive aspergillosis
170
Wall thickness for definite benign or malignant cavitary lesions?
Under 4 mm will be benign and over 15 mm will be malignant
171
Solitary cavitary lesion is almost always what?
Cancer or infection
172
Diff for cavitary lesions?
Carcinoma (SCC or adno, usually SCC). TB (Upper lobe cavitation). Septic emboli. Vasculitis (Wegeners). Metastases.
173
Diff for multiple lung cysts?
LAM. Emphysema (upper lobe in a smoker). Pulmonary LCH (cysts and nodules in upper lungs). Diffuse cystic bronchiectasis. Pneumocystis jiroveci. LIP
174
Bulla vs bleb?
Bulla is big, larger than 1 cm, occupies at least 30% of volume of the thorax. Bleb is an air filled structure contiguous with pleura less than 1 cm
175
Diff for lower lobe fibrotic changes?
IPF. End stage asbestosis. NSIP.
176
NSIP usually associated with what?
Collagen vascular disease or drug reaction.
177
Two types of NSIP?
Cellular and fibrotic.
178
Honeycombing in NSIP?
NO
179
Which type of NSIP causes basilar fibrosis?
Fibrotic
180
Upper lobe firbosis differential?
End stage sarcoidosis. Chronic hypersensitivity pneumonitis. End stage silicosis.
181
Types of pneumonia which affect young otherwise healthy patients?
Mycoplasma. Viral. Chlamydia.
182
Who gets legionella?
Elderly smokers. Severe infections
183
Who gets klebsiella?
Alcoholics and aspirators
184
Klebsiella leads to what?
Voluminous inflammatory exudates causing the bulging fissure sign.
185
Most important pathogens in HAP?
MRSA and resistent gram negatives including pseudomonas
186
Pathogens in VAP?
Usually polymicrobial but pseudomonas and acinetobacter are useful
187
What is bronchopneumonia?
Patchy consolidation with poorly defined airspace opacities usually involving several lobes. Usually S Aureus.
188
Interstitial pneumonia?
Inflammatory cells in the interstitial tissues of the alveolar septa. Atypical agents.
189
What causes round pneumonia?
Children. Incomplete pohrs of Kohn. S. Pneumonia.
190
Pulmonary gangrene?
Necrosis or sloughing of a pulmonary segment or lobe, severe manifestation of pulmonary abscess.
191
3 Stages of Empyema?
1- Free flowing exudative effusion- treat with needle aspiration or simple drain. 2- Development of fibrous strands- Large bore chest tube and fibrinolytic therapy. 3- Fluid becomes solid and jelly like- Requires surgery.
192
**Most effusions associated with pneumonia are not empyemas but instead are a sterile effusion caused by increaed capillary permeability
***
193
Most common cause of bronchopleural fistula?
Surgery. More rare causes are lung abscess, empyemia, trauma.
194
Imaging of BPF?
New or increasing gas in a pleural effusion.
195
**Treatment of BPF is very contraversial and individualized
***
196
Empyema necessitans?
Extension of empyema to chest wall, usually due to TB. Can also be caused by Nocardia and Actinomyces
197
Initial exposure to TB can lead to what two clinical outcomes?
Contained disease. Primary TB.
198
Describe contained TB?
90%. Results in calcified granulomas and/or calcified hilar lymph nodes. Normal immune patients will sequester the bacilli with a caseating granuloma.
199
Describe primary TB?
Host cannot contain the organism- Seen in immunocompromised and children
200
What percentage of primary TB have normal radiographs?
15%
201
4 Imaging features of pulmonary primary TB?
Ill defined consolidation.
Pleural effusion.
Lymphadenopathy.
Miliary disease.
202
Most common lobes for primary TB?
Lower lobes and RML.
203
Ghon Focus?
Initial focus of parenchymal infection.
204
Ranke complex?
Ghon focus and lymphadenopathy
205
Which TB gets cavitation?
Rare in primary TB. Common in reactivation TB.
206
Adeonpathy in TB?
Low attenuation centrally and peripheral enhancement.
207
Which TB gets adenopathy?
Primary. Rare in post primary.
208
Where does reactivation TB usually occur?
Upper lobe apical and posterior segments.
209
Reactivation TB in an immunocompetent patient?
Cavitation and lack of adenopathy. Focal upper lobe consolidation and endobronchial spread (Tree in bud) is common.
210
Reactivation TB in an immunocompromised patient?
Low attenuation adenopathy. May mimic immune reconstitution syndrome seen in HIV patients.
211
Tuberculoma?
Well defined rounded opacity in the upper lobes
212
Healed TB?
Apical scarring with upper lobe volume loss and superior hilar retraction.
213
Calcified granulomas signify what?
Containment of initial infection by a delayed hypersensitivity response.
214
**Miliary TB can be primary or reactivation TB
***
215
Classic radiographic findings of Lady Windermere syndrome?
Bronchiectasis and tree in bud nodules in the RML or lingula.
216
Clinical presentation of Lady Windermere syndrome?
Elderly woman with cough, low grade fever and weight loss
217
Organisms in Lady Windermere syndrome?
MAI. M. Kansasii
218
What is hot tub lung?
Hypersensitivity pneumonitis in response to atypical mycobacteria which are often found in hot tubs. Patient is otherwise healthy, no active infection. Imaging is similar to other causes of HP with centrilobular nodules.
219
Rare complication of histoplasmosis?
Fibrosing mediastinitis, infection of lymph nodes leading to pulmonary venous obstruction, bronchial stenosis, and pulmonary artery stenosis.
220
Chronic histoplasmosis can mimic what?
TB- Upper lobe fibrocavitary consolidation
221
Focal airspace opacity in an immunocompromised patient?
Bacterial pna. Consider TB if CD4 count is low.
222
Who gets pneumocystic jiroveci?
CD4 less than 200
223
Classic radiographic findings of P Jiroveci?
Bilateral perihilar airspace opacities with peripheral sparing.
224
Classic CT of P Jiroveci?
Perihilar GGO sometimes with crazy paving.
225
**Normal CT rules out P Jiroveci but it can hide in a normal chest radiograph
***
226
P Jiroveci has a propensity to lead to what?
Upper lobe pneumotoceles which may predispose to pneumothorax or pneumomediastinum.
227
Most common fungal infection in AIDS patients?
Cryptococcus
228
Pulmonary infection with cryptococcus usually coexists with what?
Cryptococcus meningitis
229
CD4 in cryptococcus?
Less than 100
230
Imaging of cryptococcus?
```
Wide range:
GGO,
Focal consolidation,
cavitating nodules,
miliary diseaes, lymphadenopathy,
effusions
```
231
Aspergillus only affects who?
Individuals with abnormal immunity or pre-existing pulmonary disease
232
Types of aspergillus infection?
ABPA, Aspergilloma (Saprophytic), Semi invasive. Airway invasive. Angioinvasive.
233
What is allergic bronchopulmonary aspergillosis and who gets it?
Hypersensitivity reaction to aspergillus in patients with long standing asthma
234
Presentation of ABPA?
Recurrent wheezing, low grade fever, cough, sputum production. Sputum contains fragments of aspergillus hyphae.
235
Key finding on CT of ABPA?
Upper lobe bronchiectasis and mucoid impaction which can be high attenuation or even calcified
236
Combination of mucoid impaction within bronchiectatic airways represents what sign?
Finger in glove
237
What is saprophytic aspergillosis?
An aspergilloma develops in a pre-existing cavity.
238
**Imaging of patient in different positions causes the aspergilloma to move
***
239
Most common causes of a pre-existing cavity?
TB and sarcoid.
240
Most common symptom of aspergilloma?
Hemoptysis
241
Monod sign?
Crescent of air outlines the mycetoma against the wall of the cavity.
242
What is semi-invasive aspergillosis?
Necrotizing granulomatous inflammation (analogous in pathology to reactivation tb) in response to chronic aspergillus infection.
243
Who gets semi-invasive aspergillosis?
Debilated, diabetic, alcoholic, and COPD patients
244
CT of semi-invasive aspergillosis?
Segmental areas of consolidation, often with cavitatoin and pleural thickening, which progress slowly over months or years
245
What is airway invasive aspergillosis?
Infection deep to the airway epithelial cells
246
Who gets airway invasive aspergillosis?
Only the immunocompromised, including neutropenic and AIDS patients
247
Spectrum of clinical disease in airway invasive aspergillosis?
From bronchiolitis to bronchopneumonia
248
CT findings of airway invasive aspergillosis?
Centrilobular and tree in bud nodules. Also bronchopneumonia which is indistinguishable from other causes of bronchopneumonia
249
What is angioinvasive aspergillosis?
Aggressive infection characterized by invasion and occlusion of arterioles and smaller pulmonary arteries by fungal hyphae.
250
Who gets angioinvasive aspergillosis?
Severely immunocompromised patients, including patients on chemotherapy, stem cell or solid organ trasplant recipients, and in AIDS
251
Air cresent sign in angioinvasive aspergillosis?
Represents a crescent of air from retraction of infarcted lung. Good prognostic sign indicating patient is in recovery phase.
252
What do Kerley A lines represent?
Dilated lymphatic channels radiating from hila, clinically insignificant
253
Kerley B lines?
Radiate from periphery- Thickened interlobular septa
254
3 stages of pulmonary edema radiographically?
Vascular redistribution (increased caliber of the upper lobe vessels compared to lower lobe vessels). Interstitial edema. Alveolar edema (Pleural effusions and cardimegaly are usually present)
255
GGO in intrathoracic causes of edema vs non thoracic causes?
Intrathoracic- Patchy. Nonthoracic- Diffuse.
256
When does reexpasion pulmonary edema occur?
Aggressive thoracentesis- reexpansion of lung in a state of collapse for more than 3 days
257
Vascular pedicle?
Transverse width of the upper mediastinum
258
Right border of vascular pedicle?
Interface of the SVC and R mainstem bronchus.
259
L border of the vascular pedicle?
Lateral border of the takeoff of the subclavian from the aorta
260
Normal vascular pedicle width?
Less than 58 mm
261
**Vascular pedicle widths of 63 and 70 have been proposed as cutoffs for increased pulmonary capillary wedge pressure
***
262
**ET Tube can be slightly lower in situations with low pulmonary compliance like ARDS to reduce barotrauma
***
263
Look at pics of azygous malposition of catheter, what risks? What percentage of patients have azygous malposition.
1% of patients. Increased risk of venous perforation and thrombosis
264
Risks of Swan Ganz distal to proximal interlobar pulmonary artery? General risks of Swan Ganz.
Rupture or pseudoanerysm.
Also intracardiac catheter knot and arrythmias are other complications of swan ganz catheters
265
Tobacco is thought to cause what percentage of lung cancers?
80-90%
266
**Asbestos increases lung ca risk by 5 and is synergistic with smoking
***
267
**Pulmonary fibrosis increases lung ca risk by 10
***
268
**Scarring also increases risk
***
269
More likely malignant, solid or gg nodule?
GG nodule
270
What types of calcification are benign?
Central. Laminar. Diffuse.
271
What nodules have popcorn calcification?
Hamartoma
272
Shape of pulmonary nodule and correlation with ca?
Non round is usually benign
273
Clustering of nodules suggests?
Infection
274
Nodule .8-3cm?
18% of malignancy.
275
Nodules over 3 cm?
Very high chance of malignancy
276
Margins which are concerning?
Irregular edge or spiculated margin
277
Doubling in volume corresponds to what increase in diameter?
26%
278
**Decrease in size of a suspicious nodule isn't sufficient to diagnose benignity, can occur with collpase of aerated alveoli or necrosis
***
279
Histology of lung ca with the worst prognosis?
Small cell
280
Most common histological subtype of lung ca?
Adneocarcinoma
281
Adenocarcinoma, central or peripheral?
Peripheral
282
Pathologic marker of adenocarcinoma of the lung?
TTF-1 (Thyroid transcription factor). Positive in adenocarcinoma and negative in pulmonary mets
283
Majority of SCC arise from where?
Main lobar or segmental bronchi. Causes symptoms early due to bronchial obstruction.
284
Lepidic growth?
BAC. Spreading of malignant cells using the alveolar walls as a scaffold
285
Hilic growth?
Most other types of lung cancer. Cancer growth by invasion and destruction of lung parenchyma.
286
BAC on PET?
Negative
287
**New classification of BAC- Going to ignore this
***
288
Better prognosis, nonmucinous or mucinous BAC?
Nonmucinous
289
Imaging of nonmucinous BAC?
Solid or gg nodule with air bronchograms
290
Imaging of mucinous BAC?
Chronic consolidation.
291
CT angiogram sign?
Describes prominent appearance of enhancing pulmonary vessels seen in low attenuation mucin rich consolidation of mucinous BAC
292
Third most common histologic subypte of lung cancer?
Small cell (after adeno and scc)
293
In small cells, neoplastic cells are of what origin?
Neuroendocrine
294
Small cell associated with what?
Smoking
295
Where dose small cell tend to occur?
Central bronchi with invasion through the bronchial wall, typically presenting as a large hilar or perihilar mass.
296
**Small cell is considered disemminated disease, rarely amenable to surgery
***
297
**Large cell is a wastebasket diagnosis for tumors which aren't squamous, adenocarcinoma, or small cell
***
298
Large cell associated with what?
Smoking
299
Where do large cell carcinomas usually occur?
Periphery as a large mass
300
Common presentation of carcnoid?
Endobronchial mass distal to the carina which may cause obstructive atelectasis. Up to 20% of cases present as a pulmonary nodule
301
Describe two subtypes of carcinoid?
Typical- without mets has an excellent prognosis (92% survival over 5 years). Atypical has a worse prognosis and arises in periphery.
302
What is diffuse idiopathic pulmonary neuroendocrine cell hyperplasia?
DIPNECH- Extremely uncommon precursor lesion to typical carcinoid tumor, characterized by mutiple foci of neurondocrine hyperplasia or tumorlets (Carcinoid foci less than 5 mm) and bronchiolitis obliterans
303
50% of cancrs presenting as a solitary pulmonary nodule is what?
Adenocarcinoma, including BAC
304
Hilar mass is a common presentation of which lung cancers?
SCC and Small cell
305
**Tapered bronchus is highly specific for lung cancer
***
306
What is a superior sulcus tumor?
Lung ca occuring in the lung apex
307
What is a pancoast tumor?
Type of superior sulcus tumor with involvement of the sympathetic ganglia causing Horner syndrome
308
Horner syndrome?
Ipsilateral ptosis, miosis, anhidrosis
309
What stage is a superior sulcus tumor?
T3
310
What is lymphangitic carcinomatosis?
Diffuse spread of neoplasm through the pulmonary lymphatics, typically seen in late stage disease. Nodular interlobular septal thickening, usually asymmetric
311
What stage is a malignant effusion?
M1a- meaning it precludes curative resection. Have to do cytologic evaluation to be sure.
312
Surgery is performed for what stages of lung cancer?
Early stages up to IIB and sometimes IIIA. Can do neoadjuvant or adjuvant chemo and radiotherapy also.
313
What makes a tumor IIIb or unresectable?
Contralteral or supraclavicular lymph nodes.
314
**Skipped lung cancer staging. Probably need to review later?
***
315
When can you use pulmonary arterial hypertension instead of pulmonary hypertension?
WHO Class 1 entities
316
Definition of pulmonary arterial hypertension?
Pulmonary arterial systolic pressure greater than 25 at rest or 30 during exercise.
317
When are elevated pulmonary venous pressures present?
When pulmonary capillary wedge pressure is greater than 18
318
Causes of pulmonary hypertension?
Chronic thromboembolic disease, chronic respiratory disease, chronic heart disease, idipathic causes
319
Most common classification of pulmonary hypertension?
Pre-capillary and Post-capillary.
320
Precapillary is what?
Causes clear up to the pulmonary parenchyma.
321
Postcapillary is what?
Problems with pulmonary veins or pulmonary venous pressure.
322
5 classes of pulmonary hypertension according to WHO?
Pulmonary arterial hypertension. Pulmonary venous hypertension. Pulmonary hypertension associated with chronic hypoxemia. Pulmonary hypertension due to thromboembolic disease. Pulmonary hypertension due to miscellaneous disorders.
323
Causes of grade 1 pulmonary hypertension?
Primary (Idiopathic or familial). Congenital L to R shunts. Pulmonary venous or capillary involvement such as pulmonary venoocclusive disease and pulmonary capillary hemangiomatosis
324
Causes of grade 2 pulmonary hypertension?
L sided heart disease.
325
Causes of grade 5 pulmonary hypertension?
Sarcoid, compression of vessels, etc.
326
Pathognominic for pulmonary artery hypertension?
Pulmonary artery calcifications
327
Lungs in pulmonary hypertension?
Mosaic attenuation due to perfusion abnormalities
328
Hilum convergence sign?
Confirms that a hilar mass is in fact a pulmonary artery. There is a convergence of hilar pulmonary artery branches into an enlarged pulmonary artery
329
Hilum overlay sign?
Visualization of hilar vessels thorugh a mass- indicates that a mass is actually present.
330
Where is mass in hilum overlay sign?
Anterior mediastinum, never middle.
331
Imaging of pulmonary arteries in pulmonary hypertension?
Enlarged centrally. Taper distally.
332
Plexiform lesion?
In wall of muscular arteries in pulmonary hypertension- Focal disruption of the elastic lamina by an obstructing plexus of endothelial channels. Relative paucity of prostacyclins and nitric oxide expressed by endothelial cells
333
Pulmonary veno-occlusive disease?
Fibrotic obliteration of the pulmonary veins and venules.
334
Associations of pulmonary veno-occlusive disease?
May be idiopathic but is associated with pregnancy, drugs, and bone marrow transplant
335
Imaging of pulmonary veno-occlusive disease?
Pulmonary arterial enlargement. Pulmonary edema and gg centrilobular nodules are often present
336
Treatment of chronic thromboembolic pulmonary hypertension?
Surgical thromboendartectomy (similar to carotid endarterectomy)
337
Most common cause of fibrosing mediastinitis?
Histoplasmosis and TB
338
Imaging of fibrosing mediastinitis?
Increased mediastinal soft tissue
often with calcified lymph nodes due to prior granulomatous infection
339
Fleishner sign?
Widening of pulmonary arteries due to clot
340
Hamptoms hump?
Peripheral wedge shaped opacity representing pulmonary infarct.
341
Westermark sign?
Regional oligemia in lung distal to pulmonary artery thrombus
342
Type 1 pneumocytes?
Form alveolar wall and participate in gas exchange
343
Type 2 pneumocytes?
Produce surfactant, which prevents atelectasis
344
Mean survival of interstitial pulmonary fibrosis
2-4 years
345
Only interstitial pneumonia with a worse prognosis than pulmonary fibrosis?
AIP
346
Clinical syndrome of UIP?
IPF
347
Other triggers of lung injury that may result in a UIP pattern?
Collagen vascular disease (RA more than scleroderma). Drug injury. Asbestosis.
348
NSIP vs UIP histology
Less fibrotic change in NSIP
349
Treatment difference between NSIP and UIP?
NSIP responds to steroids
350
Most common pulmonary manifestation in patients with collagen vascular disase?
NSIP
351
Important imaging feature of NSIP?
Ground glass opacities, nearly always bilateral
352
Fibrotic NSIP appearance?
Features GGO with fine reticulation and traction bronchiectasis
353
Which NSIP has worse prognosis?
Fibrotic
354
Cellular NSIP appearance?
GGO without much fibrotic changes
355
Which NSIP is more common?
Fibrotic
356
Very specific but uncommon finding in NSIP?
Sparing of immediate subpleural lung
357
What is COP?
Cryptogenic organizing pneumonia- Clinical syndrome of organizing pneumonia without known cause
358
**COP used to be called BOOP
***
359
Treatment and prognosis of COP?
Responds to steroids with a good prognosis, may resolve completely, although recurrences are common
360
Pathologic pattern of OP?
Granulation tissue polyps that fill the distal airway and alveoli
361
CT of OP?
Mixed consolidation and ground glass opacities in a peripheral and peribronchovascular distribution
362
What sign is specific for COP?
Reverse halo or Atoll sign- Central lucency surrounded by a GG halo
363
Central opacity with peripheral GG?
Halo sign- Invasive aspergillus
364
RB-ILD associated with what?
Smoking
365
Pathological finding in RB-ILD?
Pigmented macrophages are found in respiratory bronchioles
366
Key imaging findings of RB-ILD?
Centrilobular nodules and patchy GGO.
367
Distribution of GGO in RB-ILD vs NSIP?
More random in RB-ILD where it is more peripheral in NSIP
368
**RB-ILD and DIP represent a continous spectrum of smoking related lung disease
***
369
Pathology of RB-ILD vs DIP?
In DIP, the brown pigmented macrophages also extend into the alveoli
370
Imaging of DIP?
Diffuse basal predominant patchy or subpleural GGO, more extensive than RB-ILD. A few cysts may also be present although predominant abnormality is GGO
371
LIP is very rare, associated with what?
Sjogrens, HIV
372
Histology of LIP?
DIffuse infiltration of the interstitium by lymphocytes and other immune cells, with resultant distortion of the avleoli.
373
Imaging of LIP?
Diffuse or lower lobe predominant GGO with scattered thin walled perivascular cysts, thought to be due to air trapping from peribronchiolar cellular debris
374
LIP may be complicated by what in advanced disease?
PTX
375
AIP is synonomous with what?
DAD- Diffuse alveolar damage.
376
What is AIP?
Clinical syndrome of ARDS
377
Primary cause of AIP?
Surfactant destruction
378
Two phases of AIP?
Early (Exudative) and chronic (Organizing)
379
Phases of HP?
Acute, subacute, chronic
380
Acute HP?
Inflammatory exudate filling the alveoli, manifests on imaging as groundglass or consolidation. Small, ill defined centrilobular nodules.
381
Subacute HP?
Centrilobular GG nodules. Mosaic attenuation
382
Head cheese sign?
Describes combination of patchy GG and areas of lucency due to mosaic perfusion or air trapping
383
**Abnormalities of HP involve entire axial cross section of lung
***
384
Chronic HP?
Upper lobe predominant pulmonary fibrosis superimposed on findings of subacute and acute HP
385
Honeycombing in HP?
Can be seen in upper lobes but is uncommon.
386
Pneumoconioses vs HP?
Pneumoconiosis is due to inorganic dust inhalation where HP is organic dust inhalation
387
Two most common pneumoconioses?
Silicosis and coal workers pneumoconiosis
388
**Findings of CWP and Silicosis are indistinguishable
***
389
Who gets silicosis?
Miners, from inhalation of silica dust
390
CWP is due to what?
Inhalation of coal dust
391
Most characteristic finding of uncomplicated disease in silicosis and CWP?
Upper lobe predominant centilobular and subpleural nodules
392
Eggshell lymph node calcifications?
Silicosis. Less commonly CWP
393
Complications of silicosis or CWP?
Large conglomerate masses (Progressive massive fibrosis)
394
Both silicosis and CWP have increased risk of?
TB
395
Caplan syndrome?
RA and either CWP (more common) or silicosis- represents necrobiotic rheumatoid nodules superimposed on the smaller centrilobualr and subleural nodules of the pneumoconiosis.
396
End stage asbestosis?
Pulmonary fibrosis with a UIP pathology
397
Upper or lower lobes for asbestosis? Why?
Lower lobes, the asbestos fibers are too large to be removed by the alveolar macrophages and lymphatic system
398
Clue to asbestos exposure?
Pleural thickening and plaques (May or may not be calcified).
399
**Even though pleural plaques are due to asbestos exposure, they are not a component of asbestosis, do not lead to fibrosis, and are usually asymptomatic
***
400
**Eosinophilic lung disease is a spectrum of diseases that feature accumulation of eosinophils in the pulmonary airspaces and interstitium
***
401
Simple pulmonary eosinophilia?
Also called Loeffler syndrome- Transient and migratory areas of focal consolidation, with an elevated eosinophilic count in the peripheral smear
402
**Identical appearance to eosinophilia can be seen with parasites and drugs but simple pulmonary eosinophilia is reserved for idiopathic causes
***
403
Consolidation in chronic eosinophlic pneumonia?
Peripheral with upper lobe predominance- pattern can remain unchanged for months.
404
Treatment of chronic eosinophilic pneumonia?
Steroids- Responds rapidly
405
Churg Strauss?
Systemic small vessel disease associated with asthma and peripheral eosinophilia
406
What is positive in Churg Strauss?
p ANCA
407
Imaging findings of Churg Strauss?
Varied, most common appearance is peripheral consolidation or GG
408
Microscopic polyangiitis is most common cause of what? What is positive?
p ANCA. Most common cuase of pulmonary hemorrhage with renal failure
409
Imaging of microscopic polyangiitis?
Central predominant GG representing hemorrhage
410
Triad of Wegeners?
Sinusitis, lung involvement, and renal insufficiency
411
Lab tests specific for Wegeners?
c ANCA
412
Upper airways in Wegeners?
Nasopharyngeal and eustachian tube obstruction. Involvement of trachea and bronchi is common, leading to airway stenosis
413
Lungs in Wegeners? Superimposed infection?
Multiple cavitary nodules which don't respond to abx. Intra-cavitary fluid level suggests superimposed infection
414
**Drugs can elicit numerous pulmonary responses
***
415
What percentage of patients develop radiographic abnormalities after external radiotherapy?
40%
416
Radiation pneumonitis?
Early stage of radiation injury, can occur within one month of radiotherapy, most severe 3-4 months after treatment. GG centered on radiation port, but can extend out of radiation port
417
Radiation fibrosis?
Late stage of radiation injury. Fibrosis becomes apparent 6-12 months after therapy. Key imaging finding is distribution of fibrosis and traction bronchiectasis within the radiation port, but may extend out of the port
418
Pulmonary sarcoidosis may progress to what in lungs?
Pulmonary fibrosis with honeycombing, slight upper lobe predominance
419
Staging of sarcoid?
Radiographs only- 0 Normal radiograph. 1- Hilar or mediastinal adenopathy only. 2- Adenopathy with lung changes 3- Lung w/o adenopathy. 4- Endstage fibrosis
420
Most common radiographic finding in sarcoid?
Symmetric addenopathy with stippled or egg shell calcification in up to 50%
421
Where is adenopathy in sarcoid?
Right paratracheal, R hilar, L hilar- Completely encircles trachea on lateral- donut sign
422
In addition to lymphadenopathy, most common ct finding in sarcoid?
Upper lobe predominant perilymphatic nodules of variable sizes representing sarcoid granulomas
423
May see superimposed GGO in sarcoid
***
424
Bronchial involvement of sarcoid?
Mosaic perfusion due to air trapping
425
Pulmonary LCH associated with?
Smoking- Nearly 100% association
426
How may pumonary LCH present?
PTX
427
What other associated findings may be seen with pulmonary LCH?
Diabetes insipidus from inflammation of pituitary stalk (hypophysitis), lucent bone lesions, skin involvement.
428
Differential for dz affecting bone and lung?
LCH. Malignancy. TB. Fungal. Sarcoid. Gaucher.
429
Gaucher in lungs?
Rare, but may resemple DIP
430
First detectable abnormality and progression in LCH?
Nodules associated with airways, as they progress they will cavitate and resultant irregular cysts predominate
431
Treatment of pulmonary LCH?
Smoking cessation is critical.
| Responds to steroids.
432
So overall findings in LCH?
Upper lobe predominant cysts and irregular peribronchovascular nodules both sparing the costophrenic sulci
433
PAP vs pulmonary edema?
In PAP, there are no effusions and the heart is normal in size
434
Patients with PAP are susceptible to what?
Superimposed infection, especially with nocardia
435
Treatment of PAP?
Bronchialveolar lavage
436
What percentage of TS patients have LAM?
1%
437
Almost all cases of sporadic LAM are in what patients?
Women of child-bearing age
438
Some cases of LAM respond to what?
Estrogen
439
LAM is associated with what two things?
PTX, Chylous effusion
440
Cysts in LAM vs LCH?
Cysts are round and regular and affect all five lobes where LCH is just upper lobe
441
Two compartments in anterior mediastinum?
Prevascular superiorly and precardiac inferiorly (Precardiac is only a potential space)
442
**Bascially all of the mediastinal structures are in the middle mediastinum including the phrenic, vagus, and recurrent laryngeal nerve
***
443
Anterior border of the posterior mediastinum?
Posterior trachea and posterior pericardium
444
Anterior junction line?
Formed by four laters of pleura at the anterior junction of the R and L lungs. Projections over the superior 2/3 of the sternum.
445
Abnormal convexity or displacement of the anterior junction line?
Anterior mediastinal mass
446
Posterior junction line?
Four layers of pleura, seen projection through the trachea on frontal view, more superior than the anterior junction line.
447
Which extend more superiorly, posterior or anterior lungs?
Posterior
448
Abnormal convexity or displacement of the posterior junction line?
Posterior mediastinal mass
449
Right and Left paratracheal stripes?
Formed by two layers of pleura where the medial aspect of each lung abuts the lateral wall of the trachea and intervening mediastinal fat
450
Thickening of the R paratracheal stripe?
Usually pleural thickening, although a paratracheal or tracheal mass can be the cause
451
Thickening of the L paratracheal stripe?
Same diff as on the R except add mediastinal hematoma in setting of trauma
452
Posterior tracheal stripe?
Only interface seen on lateral view, representing interface of posterior wall of trachea with two pleural layers of the medial right lung
453
Why do we see R and L paraspinal lines?
Mach effect
454
What forms the paraspinal lines?
2 layers of pleura abutting the posterior mediastinum
455
Paraspinal line abnormality?
Posterior mediastinal mass
456
Azygoesophageal recess?
Interface formed by contact of the posteromedial RLL and retrocardiac mediastinum. Extends from the subcarinal region to the diaphragm inferiorly
457
Distortion of the azygoesophageal recess?
Esophageal mass, hiatal hernia, L atrial enlargement and adenopathy
458
What lives in the AP window?
Lymph nodes (most common cause of AP abnormality). L Phrenic nerve. Recurrent laryngeal nerve. L vagus nerve. Ligamentum arteriosum. L bronchial arteries
459
Obliteration of the retrosternal clear space?
Anterior mediastinal mass, RV dilatation, Pulmonary artery enlargement
460
Increase in retrosternal clear space?
Emphysema
461
Aortic nipple?
From the L superior intercostal vein, not usually seen on radiography. It may be dilated in SVC obstruction as a collateral.
462
Easiest way to infer an anterior mediastinal mass on cxr?
Normal posterior junction line because ant junction line isn't always seen
463
Anterior mediastinal mass diff dx?
Thymic epithelial neoplasm. Germ cell tumor. Thyroid lesion if it extends above thoracic inlet. Lymphoma.
464
Most common primary tumor of the anterior mediastinum? Who gets it?
Thymoma. Middle aged to older individuals, 45-60.
465
What percentage of thymoma patients have MG? Other way around.
33%. 10%
466
Thymomas are associated with what other diseases?
```
MG.
Red cell aplasia.
Hypogammaglobulinemia.
Paraneoplastic syndromes.
Malignancies such as lymphoma and thyroid cancer.
```
467
Invasive and non invasive thymoma?
Whether capsule is intact
468
What percentage of thymomas are invasive?
30%. May invade adjacent structures.
469
Thymoma with L hemidiaphragm elevation?
Phrenic nerve invasion
470
Where does invasive thymoma spread?
Drop mets along pleural and pericardial surfaces. Hematogenous mets are very rare.
471
**Thymomas are classfied into A, AB, B1, B2, B3, C, with C being the worst
***
472
Other less common thymic lesions?
Thymic carcinoma. Thymic carcinoid. Thymic cyst. Thymolipoma.
473
Thymic carcinoma characteristics?
Histologically malignant. Aggressive. Hematogenous mets. Poor prognosis.
474
Distinguishing between thymic carcinoma and thymoma on CT?
Metastatic pattern.
475
50% of thymic carcinoids secrete and cause what?
ACTH, causing Cushing syndrome
476
Thymic carcinoid is associated with what?
MEN 1 and 2
477
Imaging of thymic carcinoid?
Indistinguishable from thymoma and thymic carcinoma.
478
If carcinoid is suspected, what imaging?
Preoperative Indium 111 Octreotide.
479
Thymic cyst often caused by what?
Radiation therapy, AIDS, Congenital
480
When thymic cysts are congenital they arise from what?
Remnants of the thymopharyngeal duct
481
Congenital thymic cyst may occur anywhere along the descent of the course of the thymus from neck but usually occur where?
Anterior mediastinum
482
Characteristics of a thymolipoma?
Benign fat containing lesion with interspersed soft tissue. Can become really large and drape over the mediastinum.
483
Malignant germ cell tumor- which gender?
Males
484
What is specific for a teratoma?
Fat fluid level. Not commonly seen.
485
Most common anterior mediastinal germ cell tumor?
Teratoma
486
**Aorta is in posterior mediastinum, posterior mediastinal mass would silhouette the aorta
***
487
What is most common malignant mediastinal germ cell tumor?
Seminoma
488
Cervicothoracic sign?
Obscuration of the superior border of the mass implying mass is in continuity with the soft tissues of the neck
489
Key to diagnosing a thyroid lesion as an anterior mediastinal mass?
Continuity with the superior thyroid obviously
490
**Calcification is rare in untreated lymphoma.
***
491
Lymphoma most commonly in thorax?
Hodgkins
492
Egg shell calcification?
Usually happens in CWP and silicosis. Less commonly in sarcoid, but sarcoid is more common.
493
Low attenuation lymph nodes should raise concern for what?
TB.
Mets
sometimes TB or Lymphoma
494
Avid lymph node enhancement?
Castleman disease. Sarcoid. TB. Vascular mets.
495
What is castleman disease?
Angiofollicular lymph node hyperplasia- cause of highly vascular thoracic lymph node enlargement, uncertain etiology.
496
Who gets localized Castlemen and what is cure?
Children. Surgical resection.
497
Who gets multicentric Castleman disease?
Older patients or AIDS patients.
498
Symptoms of multicentric Castlemans? Treatment?
Systemic illness including fever, anemia, lymphoma. Treat with chemo.
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Key imaging feature of Castemans?
Avidly enhancing lymphadenopathy
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Most common location of pericardial cyst? Appearnce.
R cardiophrenic angle. Cystic lesion abuts pericardium, can change shape.
