CTC Chest Flashcards
How are lateral CXRs taken?
Left lateral position - left side against film.
Left ribs will not be magnified.
Right ribs will be magnified and be more posterior
What is the normal hilum on a lateral CXR?
Put your finger in the “dark hole” - the LUL bronchus.
Front will be the R PA and overtop will be the L PA.
Posterior wall of the bronchus intermedius runs through the black hole and can be thickened by edema.
What is Raider Triangle?
What variant runs through it?
Sits on the aortic arch posterior to the trachea and anterior to the vertebral bodies.
Aberrant right subclavian artery will obliterate this.
How are the heart valves drawn on CXR?
Frontal:
Cross down center: Aortic over X. Pulmonic = upper right. Mitral = lower left. Mitral = lower right.
Lateral: Aortic = upper anterior Pulmonic = upper posterior Tricuspid = lower anterior Mitral = lower posterior
Pulomonic valve is most superior in location.
If you see two metallic heart valves on a CXR, which is bigger?
Mitral and aortic - Mitral is bigger.
Pacer wire going through a valve makes it the tricuspid valve.
How is the R major fissure oriented with the left on the lateral CXR?
Right is anterior to the left.
How many pulmonary segments are there in the R and L lungs?
R = 10 (3 upper, 2 middle, and 5 lower)
L = 8 (4 upper/lingula and 4 lower)
What is in the posterior mediastinum?
Esophagus, thoracic duct, and descending aorta.
Trachea is in middle.
What is the MC pulmonary venous variation?
Separate vein draining the RML
Usually have upper and lower on each side.
What is Proximal Interruption of the PA?
Congential abscence of the R or L PA with the more distal PA vasculature present
Shown with volume loss of one hemi-thorax (CXR or CT), then contrast shot through the heart with only 1 PA.
Volume loss + 1 PA
Seen on the opposite side of the aortic arch - Absent R PA with left arch and absent L PA with right arch
Associated witih PDA
Interrupted L PA is associated with TOF and Truncus
What is interrupted L PA associated with?
TOF and Truncus
What does infection with Anthrax look like?
Hemorrhagic lymphadenitis, mediastinitis, and hemothrax.
Classic look: Mediastinal widening with pleural effusion in the setting of bio-terrorism.
What does Klebsiella pneumonia look like?
Buzzword: Bulging fissure from exuberant inflammation. More likely to have pleural effusions, empyema, and cavity than conventional pneumonia,
Alcoholic and nursing home patient. Currant jelly sputum.
What does H. flu pneumonia look like?
Usually bronchitis, sometimes bilateral lower lobe bronchopneumonia.
COPDers and ppl w/o a spleen
Post Bone Marrow Transplant lung findings
Early Neutropenic (0-30): Pulmonary edema, hemorrhage, drug induced lung injury. Fungal pneumonia (invasive aspergillosis)
Early (30-90): PCP and CMV
Late (>90): Bronchiolitis obliterans, cryptogenic organizing pneumonia
What does post bone marrow transplant GVH pulmonary disease look like?
Acute (20-100 days): Favors extrapulmonary symptoms (skin, liver, GI tract)
Chronic (>100 days): Lymphocytic infiltration of the airways and obliterative bronchiolitis.
Infections in AIDS by CD4
> 200: Bacterial infections, TB
<200: PCP; Atypical mycobacterial
<100: CMV, disseminated fungal, mycobacterial
CT patterns with pulmonary infection with AIDS
Focal airspace opacity: Bacterial infection (Strep pneumonia) is MC. DDx should include TB if CD4 is low. If it’s chronic think lymphoma or Kaposi.
Multi-focal Airspace Opacity: Bacterial or fungal
Ground Glass: PCP (if not a choice, could be CMV if CD4 <100).
AIDS trivia and buzzwords
MC airspace opacity = S pneumonia
CT with ground glass = PCP
“Flame shaped” perihilar opacity = Kaposi Sarcoma
Persistent opacities = Lymphoma
Lung cysts = LIP
Lung cysts + Ground Glass + Pneumothorax = PCP
Hypervascular LN = Castlemans or Kaposi
What are the stages of TB?
Primary - Inhaled and causes necrosis - body forms granuloma (Ghon Focus). Nodal expansion which calcifies (Ranke complex). If node ruptures get endobronchial spread or hematogenous spread. Cavitation is NOT common.
Primary Progressive - Local progression of parenchymal disease with development of cavitation (at the initial site of infection/or hematogenous spread) - uncommon, primary risk is AIDS, immunosuppressed, transplant patients, people on steroids.
Post Primary - Reactivation - 5% - Apical and posterior upper lobe and superior lower lobe (more oxygen, less lymphatics) - progression. Development of a cavity. Can get pseudoaneurysms - Rasmussen.
What is pleural involvement with TB?
Can occur at any time at infection. In primary, can be seen 3-6 months after as a hypersensitivity response. Usually culture negative. Have to biopsy pleura. Don’t see effusions as much with post primary disease, but when you do, the fluid is usually culture positive.
Facts about TB
Primary = no cavity, post primary/primary progressive = cavity
Ghon Lesion = Calcified TB granuloma; sequela of primary TB
Ranke Compes = Calcified TB granuloma + calcified hilar node; healed primary TB.
Bulky hilar and paratracheal LAD = kids
Location for reactivation TB = posterior/apical upper lobes, superior lower lobes.
Miliary spread when? - Hematogenous dissemination (usually in setting of reactivation), but can be in primary progressive as well
Reactive TB pattern (cavitation) seen in HIV patient when CD4 is >200
Primary progressive pattern (Adenopathy, consolidation, miliary spread) in HIV is CD4 <200.
TB does NOT usually cause a lobar pattern in HIV.
What are the patterns of Non-Tuberculous Mycobacteria?
MAC and Mycobacterium Kanasii.
Cavitary (Classic)- Usually MAC - Old white man with COPD (or other chronic lung disease), look like reactivation TB. Upper lobe cavitary lesion with adjacent nodules (suggesting endobronchial spread).
Bronchiectatic (“Non-Classic”) - Lady Windermere Disease - Do not cough and are asymptomatic. Favors old white lady. Tree-in-bud opacities with cylindric bronchiectasis in the RML and lingula
HIV - Low CD4 (<100). GI infection disseminated in the blood. Get a big spleen and liver. Mixed with other pulmonary infections (PCP, etc) given the low CD4 - so lungs can look like anything. Mediasinal LAD is MC.
Hypersensitivity Pneumonitis - Hot tub lung. Aerosolized bugs. Ill-defined, ground glass centrilobular nodules.
What does Aspergillus look like with normal immune, immune depressed, or hyperimmune?
Normal Immune = makes a fungus ball “aspergilloma” in an existing cavity. Show a fungus ball = don’t call it invasive. Cavity from prior trauma or infection.
Immune Suppressed (AIDS or Transplant)- Invasive Aspergillus. Halo sign consolidative nodule/mass with a ground glass halo. Air Crescent Sign - thin crescent of air w/in the consolidative mass. Healing as the necrotic lung separates from the parenchyma. Usually 2-3 weeks after treatment.
Hyper-immune- ABPA. Long-standing asthma
What does Mucomycosis of the lungs look like?
Aggressive fungal infection in impaired patients (AIDS, steroids, Bad diabetes, etc..). Usually in the sinuses, but can get invasion of the mediastinum, pleura, and chest wall.
What is Lemierre Syndrome?
Jugular vein thrombosis with septic emboli - usually seen after oropharyngeal infection or recent ENT surgery.
Fusobacterium Necrophorum
What causes Lemierre Syndrome?
Fusobacterium Necrophorum
Jugular vein thrombosis with septic emboli - usually seen after oropharyngeal infection or recent ENT surgery.
What are the guidelines for lung cancer screening?
Low dose CT for asymptomatic - 55-80 with 30 pack-year history and currently smoke (or have quit w/in the past 15 years)
What are the four “benign” calcification patterns with pulmonary nodules?
Solid/diffuse
Laminated
Central
Popcorn
Qualities of nodules that make you thing benign vs cancer?
Benign:
Presence of fat
Rapid doubling time - less than 1 month
Slow doubling time - longer than 16 months - stable at two years = benign.
Cancer:
Spiculated margins - “Corona Radiata Sign”
Air bronchogram through the nodules (usually adeno in situ)
Partially solid lesions with GG component
What findings of a GG nodule on PET make you think cancer vs infection?
HOT = infection COLD = cancer
Paraneoplastic syndromes with squamous and small cell lung cancers?
Squamous = PTH
Small Cell = SIADH
Lambert Eaton: Paraneoplastic syndrome with small cell - proximal weakness from abnormal release of ACh at the NM junction. Usually comes before cancer diagnosis
What is Lambert Eaton Syndrome?
Paraneoplastic syndrome with small cell - proximal weakness from abnormal release of ACh at the NM junction. Usually comes before cancer diagnosis
What are the precursor lesions of lung cancer?
Atypical Adenomatous Hyperplasia of Lung (AAH): Precursor of adeno
Adenocarcinoma in situ (ACIS): <3 cm. Multiple subtypes - MC is non-mucinous.
Minimally Invasive Adeno (MIA): <3 cm. The distinction is that there is <5mm of stromal invasion (>5 mm will be called lepidic predominant adenocarcinoma).
What stage of lung cancer is unresectable?
3B
Supraclavicular, scalene, or contralateral mediastinal or hilar LAD.
Tumor in the same lung but different lobes from the primary mass.
Malignant pleural effusion
Two lesions in same lobe is T3
Two lesions in different lobes is T4
Two lesions in different lungs is M1a.
MC extrathoracic causes of lymphatic carcinomatosis?
Breast, stomach, pancreas, and prostate.
How is carcinoid classified?
Peripheral pulmonary or bronchial
Typical or atypical - typical grow slower and locally invasive. No association with smoking. Central bronchus, can cause obstructive symptoms. Can cause hemoptysis b/c highly vascular. Octreotide scan can be used to localize.
Can cause carcinoid syndrome with flushing, etc… Valvular regurgitation on left side as opposed to GI which affects the right side.
Atypical are rare, seen in older patients, more likely to be a mass.
What is Adenoid Cystic Carcinoma?
MC bronchial gland tumor. NOT associated with smoking. Usually in the main or lobar bronchus.
More common than carcinoid in the trachea.
Differences between primary, secondary, PTLD, and AIDS related pulmonary lymphoma?
Primary: Rare, usually NHL subtype. Lack of extrathoracic involvement for 3 months. Low grade MALToma.
Secondary: Pulmonary involvement of systemic lymphoma. Much more likely. NHL is much more common, but if you have HL it is more likely to involve the lungs. With HL you get nodes and parenchyma, in NHL you might just get parenchyma.
PTLD- seen after organ or stem cell transplant. Usually w/in a year of transplant (late presentation >1 yr have more aggressive course). B-cell lymphoma with relationship to the EB virus. Nodal or extranodal disease. Well-defined pulmonary nodules/mass, patchy airspace consolidation, halo sign, and interlobular septal thickening.
AIDS-related: 2nd MC lung tumor in AIDS (Kaposi’s is first). Almost exclusively a high grade NHL. Relationship with EBV - CD4 <100. Variable presentation with multiple peripheral nodules ranging from 1-5 cm. Extranodal locations (CNS, bone marrow, lung, liver, and bowel) is common. AIDS patient with lung nodule, pleural effusion, and LAD = lymphoma
Differences between Secondary NHL and HL
Secondary NHL:
80-90% of lyphoma cases
45% have intrathoracic disease at presentation
25% have pulmonary parenchymal disease
Pulmonary involvement frequently occurs in the absence of mediastinal disease.
Secondary HL:
10-20% of lymphoma cases
85% have intrathoracic disease at presentation
40% have pulmonary parenchymal disease
Lung involvement almost always associated with intrathoracic LN involvement.
AIDS patient with lung nodules, pleural effusion, and LAD =
Lymphoma
Things to know about Kaposi Sarcoma?
MC lung tumor in AIDS (requires CD4 <200)
MC hepatic neoplasm in AIDS
Buzzword = Flame shaped opacities - tracheobronchial mucosa and perihilar lung.
Slow growth, and asymptomatic patients (despite terrible looking lungs)
Thallium positive and Gallium negative.
Difference between Kaposi and Lymphoma on Gallium and Thallium
Kaposi: Thallium positive and Gallium Negative
Lymphoma: Thallium positive and Gallium positive
What can pulmonary hamartomas look like on PET?
Can be hot.
What is Swyer-James?
Unilateral lucent lung.
After viral infection in childhood resulting in post infectious obliterative bronchiolitis - from constrictive bronchiolitis. SMALLER lung - not hyperexpanded.
What is Pulmonary Langerhans Cell Histiocytosis (LCH)?
Cystic lung disease - smokers who are young (20s-30s).
Starts out with centrilobular nodules with an upper lobe predominance. Eventually cavitate into cysts which are thin walled to start, then some become more thick walled.
Buzzword = bizarre shaped- which two or more cysts mrege together.
Can spontaneously resolve if you quit smoking.
Spares the costophrenic angles
What diseases spare the costophrenic angles?
LCH
HSP
Differences between LCH and LAM?
LCH:
Cysts and nodules; Smoker; Upper and mid lungs; Thicker cysts (bizarre)
LAM:
Cysts (no nodules); Women, patients with TS; Difuse; Thin round cysts
Differences in cysts with LCH, LAM and Birt Hogg Dube?
LCH: Bizarre shape, thick walled
LAM: Round, thin walled
BHD: Oval, thin wall
What is Birt Hogg Dube?
Cystic lung disease with thin walled “oval” shaped cysts.
Association with renal findings (bilateral oncocytomas and chromophobe RCCs)
Also have skin stuff.
What is Lymphocytic Interstitial Pneumonia (LIP)?
Benign lymphoproliferative disorder with infiltration of the lungs. Association with autoimmune diseases (SLE, RA, and Sjogrens - Sjogrens is MC). Other one to know is HIV in younger patients. Also association with Castlemans. Appearance varies depending on the underlying cause.
Cystic lung disease usually thin walled, “deep w/in the lung parenchyma,” seen predominantly with Sjogrens.
LIP =
Sjogrens and HIV
