Quiz 2 Flashcards
Do solitary masses have a silhouette sign??
Silhouette sign is unlikely
Do solitary masses exhibit air bronchogram??
Air bronchogram unlikely
Is atelectasis possible with solitary masses?
Atelectasis possible
What is the DDX list for solitary masses? (8)
Bronchogenic carcinoma Hematogenous metastasis Hamartoma Tuberculoma, other granuloma Lung abscess Hydatid cyst Hematoma Bronchopulmonary sequestration
What % of patients under 30 have a possibility of a malignant solitary mass?
<1%
What % of patients 30-45 have a possibility of a malignant solitary mass?
15%
What % of patients older than 45 have a possibility of a malignant solitary mass?
50%
What are some benign types of calcifications? (4)
Diffuse
Central
Popcorn
Concentric
What are some questionable types of calcifications? (2)
Stippled and Eccentric
What are different types of bronchogenic carcinoma? (4)
Adenocarcinoma
Squamous cell carcinoma
Small (a.k.a. oat cell) carcinoma
Large cell carcinoma
What is the most frequently diagnosed maligancy and what age is it most commonly diagnosed?
Bronchogenic carcinoma and 55-60 y.o.
What % of lung cancer deaths associated with smoking are caused by bronchogenic carcinoma?
80-85% of lung cancer deaths associated with smoking
What are some bronchogenic carcinoma signs and symptoms (7)
Cough Wheezing Dyspnea Hemoptysis Chest pain Weight loss Asymptomatic
What are some complications of bronchogenic carcinoma?
Phrenic nerve palsy - Hemidiaphragm paralysis Superior vena caval syndrome -Swelling of neck, face -Dizziness -Vision change -Syncope -Stupor Recurrent laryngeal nerve palsy -Hoarseness
What is the treatment of bronchogenic carcinoma?
Surgery
Chemotherapy
Radiation therapy
Combination
What is the prognosis of bronchogenic carcinoma?
Dependent on
- Stage at presentation
- General health
- Age
- Histological type of tumor
- Growth rate
- Therapy
What are some radiographic findings of bronchogenic carcinoma?
Solitary mass - Mediastinal - Apical - Lung field Atelectasis possible Hilar enlargement possible Cavitation possible Pleural effusion possible
What do pancoast tumors present as? (3)
Squamous cell or adenocarcinoma Mass in apex - Look for rib or vertebra destruction Clinical presentation -Horner’s syndrome -Arm / shoulder pain -Asymptomatic
Where are possible primary sites that cause mets?
Breast, kidney, ovary, testis, colon, thyroid, sarcoma, malignant melanoma
What is the appearance of mets? (5)
Multiple masses (95%)(5% solitary) Often smooth, rounded Uniform or variable size Pleural effusion possible Pleural mass possible
What is the most common benign tumor?
Hamartoma
What does a hamartoma contain?
Normal tissue elements, unorganized
What is the peak incidence age of hamartomas?
Peak incidence 50-60 y.o.
Are hamartoma’s usually found centrally or peripherally?
Peripherally
Are syymptoms common with hamartomas?
Symptoms rare
What are the radiographic findings of a hamartoma? (3)
Solitary mass
Usually < 4cm
Popcorn calcification possible
What are the 3 granuloma infections?
Tuberculosis
Histoplasmosis
Coccidiodomycosis
What does TB look like?
Diffuse, localized or mass (single or multiple)
What is histoplasmosis caused by?
- Mold spore inhalation; endemic to central and eastern USA, eastern Canada, Mexico, Central and South America, Africa, SE Asia
- Asymptomatic or mild to severe URTI
What is coccidiodomycosis caused by?
- Mold spore inhalation; endemic in arid soil of SW USA, Mexico, Central and South America
- Variable infectious presentation
What do lung abscesses present like?
Single or multiple masses
- > 2cm
- Usually air-fluid level
What are some predisposing factors of a lung abscess?
Predisposing factors
- Aspiration
- Alcoholism, neurological disease
- Intubation
- Bronchiectasis, bronchial obstruction
What are hydatid cysts caused by?
Echinococcus (dog tapeworm); humans are intermediate host
Where do hydatid cysts affect in the body?
May involve liver, lung, spleen, kidney, bone, CNS
Where are hydatid cysts most prevalent?
Most prevalent Greece, Argentina, New Zealand
What serious complication can come from a ruptured hydatid cyst?
anaphylactic shock
What are the ddx for multiple masses?
Pulmonary metastasis Lymphoma Granulomatous infection - TB, histoplasmosis, coccidioidomycosis Rheumatoid nodules Wegener’s granulomatosis
Where does Hodgkin’s lymphoma originate?
90% originate in lymph nodes; 10% in extranodal lymphoid tissue of lung, GI, skin
What peak ages does Hodgkin’s lymphoma affect?
Peak ages 30 and 70 years
Where does Hodgkin’s lymphoma typically present?
- 95% superior mediastinal node involved
- 15% lung masses; 15% pleural effusions
Where does non-Hodgkin’s lymphoma originate?
60% originate in lymph nodes; 40% in extranodal lymphoid tissue
How does Hodgkin’s lymphoma typically present?
- Mediastinal and hilar adenopathy
- Lung involvement possible without adenopathy
What can cause an icrease in incidence of non-hodgkin’s lymphoma?
Increased incidence with immune suppression
What causes Wegener’s Granulomatosis?
- Systemic; autoimmune; relatively rare
- Perivascular inflammation leads to granuloma formation
How does Wegener’s Granulomatosis usually present?
Multiple nodules; cavitation common
how often does wegener’s granulomatosis present with pleural effusion?
1/4
Is adenopathy common with wegener’s granulomatosis?
No it is rare
What lung base change occurs with wegener’s granulomatosis?
Interstitial changes in lung bases
Ho does interstitial disease usually present?
- Thickened interlobular septa, alveolar walls; interstitial lymph, veins, cells
- Usually a diffuse pattern of involvement
- Often combined with consolidation
What are the 5 ways that interstitial patterns can present?
- Ground Glass
- Linear (reticular) - fibrosis
- Nodular (granulomas)
- Reticulonodular (inflmmation)
- Honeycombing (end stage lung disease
What are ddx for interstitial?
Pulmonary edema Infection - Viral, TB, fungal, PCP Idiopathic - IPF, sarcoidosis Collagen vascular diseases - RA, scleroderma, AS Extrinsic agents - Pneumoconiosis, drugs Tumors - Lymphangitic metastasis, eosinophilic granuloma
What are disease that decrease radiographic density? (5)
Pneumothorax
Emphysema
Cystic disease
- Congenital
- Infectious
- Post-traumatic
Air trapping
- Obstruction (Foreign body)
Asthma (mucous plugs + constriction)
Inspiration vs. expiration films may help
Compensatory hyperexpansion
Congenital
What are some radiographic findings of decreased radiographic density?
Hyperlucency
- Lobar, segmental, subsegmental, general
- With or without hyperexpansion
Decreases lung markings
What are some pneumothorax radiographic findings?
Visceral pleura visible No lung markings peripheral to pleura Possible signs of atelectasis -Passive / compressive Upright expiration PA more sensitive Lateral decubitus may be helpful
What are the different types of pneumothorax?
Spontaneous and traumatic
What population does primary spontaneous pneumothorax occurs in?
Tall, thin females
What are some causes of secondary spontaneous pneumothorax?
Underlying lung disease
Bullae, blebs
Air trapping
What is a traumatic pneumothorax caused by?
Trauma
Iatrogenic
What does a tension pneumothorax do?
Valve effect with progressive accumulation of air Shift of mediastinum Leads to vascular compromise Medical emergency - Chest tube
What is the most common physical finding of primary spontaneous pneumothorax?
Tachycardia is most common physical finding
Hypotension, cyanosis and tachycardia may suggest tension pneumothorax
What happens during the lung exam of a large pneumothorax?
- Decreased or absent breath sounds on affected side,
- Decreased chest wall motion,
- Hyperresonance to percussion,
- Decreased fremitus
What are the risk factors for recurrence for a primary spontaneous pneumothorax? (5)
Pre-existing lung disease Tall stature Female gender (?) Smoking Younger age
When do most recurrences of pneumothorax occur?
Most recurrences occur within 6 months to two years after initial pneumothorax
What are some pneumothorax symptoms? (6)
1) Chest pain
2) Dyspnea
3) Onset during rest
4) Diminished breath sounds
5) Decreased tactile fremitus
6) Hyperresonance on percussion
- Larger
What are some pneumothorax treatments? (3)
1) Chest tube
- All symptomatic cases
- Any >15% loss
- Tension = emergency
2) Monitor
- Asymptomatic and <15% may resolve
3) Recurrence
- UP to 50%
- Increased with altitude extremes
- Smoking increases
What is emphysema? (3)
1) Enlarged air spaces with destruction of alveolar walls
- Usually due to COPD, usually chronic bronchitis
2) Correlate with functional tests
3) Moderate to severe changes seen on CXR; mild seen on HRCT
What are some radiographic changes with emphysema? (5)
1) Flattened, depressed hemidiaphragms
2) Hyperlucency
3) Increased retrosternal clear space
4) Increased AP chest diameter
5) Decreased peripheral vascular markings
What are some pleural abnormalities? (3)
1) Pleural effusion
- Transudate, exudate, blood, pus, lymph
2) Pleural masses
- Loculated effusion
- Neoplasm
- Extrapleural sign
3) Calcifications
How much fluid fluid is normally in the pleural space?
Normally 2-10 cc of fluid in pleural space;
How much fluid is produced by parietal pleura each hour?
As much as 100 cc fluid produced by parietal pleura each hour;
How does a fluid drain from the pleural space?
Fluid drains to visceral pleura via lymphatics;
Where does fluid accumulate in the pleural space?
> 75 cc accumulates posterior costophrenic blunts
How much fluid needs to accumulate for the costophrenic angle to become blunted?
200-300 cc accumulates lateral CP become blunted
What is a meniscus sign?
1) Blunting of the costophrenic angles due to pleural fluid accumulation (also subpulmonic fluid)
2) Need to determine the underlying cause of the fluid accumulation
What are some Pleural Effusion ddx? (9)
1) CHF
2) Pneumonia
3) Neoplasm
4) Infection (empyema)
5) Trauma
6) Embolism
7) Connective tissue disease
8) TB
9) Abdominal disease
- Pancreatitis, cirrhosis
What are some pleural effusion symptoms? (7)
- Dyspnea
- Pleuritic chest pain
- Dry cough
- Tactile fremitus increased
- Dullness to percussion
- Decreased breath sounds
- Small effusions usually asymptomatic
What are some ways to manage pleural effusion? (2)
1)Thoracentesis
- Reduces symptoms
- Provides tissue for lab evaluation (Culture & sensitivity,
Histology, Chemistry)
2) Treatment of underlying disease
What are some causes of pleural masses? (3)
1) Loculated effusion
2) Neoplasm
- Primary: mesothelioma (malignant), fibroma (benign)
- Secondary: breast, bronchus most common
3) Extrapleural sign
- Rib lesion
What are some causes of pleural calcifications? (3)
1) Asbestos-related pleural disease
- Other inhalation diseases
(Talcosis, Silicosis)
2) Old empyema
- More localized; history
3) Old hemothorax
- More localized; history
What are the asbestos related disease findings? (4)
1) Pleural plaques
2) Diffuse pleural thickening
3) Pleural effusions
4) Interstitial pulmonary fibrosis
What is the most common change in with asbestos related disease?
Pleural plaques
What is the radiographic finding for pleural plaques?
1) 15% visible on CXR
2) May calcify (pathognomonic of asbestos exposure); takes up to 20 years
What are the pathoanatomical findings with diffuse pleural thickening?
1) May cause respiratory symptoms
2) Thickened fissures; round atelectasis
How does interstitial pulmonary fibrosis due to asbestosis appear?
- Reticular, linear
- Initially subpleural
- Begins at base, moves to apex
- Honeycombing late stages
- No adenopathy
What does types of cancer does asbestos increase the risk for?
1) 7000x increased incidence of mesothelioma
- 10% lifetime risk
- Usually >30 years after exposure
2) 7x increased risk of bronchogenic CA
- Exponential increase with smoking
3) 3x increased risk of GI neoplasm
What is the DDX for unilateral hilar enlargement ?
Bronchogenic carcinoma
What are the DDX for bilateral hilar enlargement? (3)
1) Lymphoma
2) Infection (granulomatous)
3) Sarcoidosis
What are the DDX for unilateral hemidiaphragm elevation? (5)
1) Atelectasis
2) Phrenic nerve palsy
3) Splinting
4) Eventration
5) Subphrenic inflammation
What are the DDX for bilateral hemidiaphragm elevation? (5)
1) Poor inspiration
2) Obesity
3) Pregnancy
4) Ascites
5) Hepato-splenomegaly
In a normal lateral radiograph of the thorax, what are the borders of the anterior portion of the mediastinum?
Sternum to anterior cardiac silhouette = anterior (retrosternal) clear space
- Sternum to posterior heart border
In a normal lateral radiograph of the thorax, what are the borders of the middle portion of the mediastinum?
Anterior to posterior cardiac silhouette
- Posterior heart border to 1 cm posterior to the anterior vertebral bodies
In a normal lateral radiograph of the thorax, what are the borders of the posterior portion of the mediastinum?
Posterior cardiac silhouette to posterior border of lung field
- From line 1 cm posterior to anterior vertebral bodies to posterior chest wall
What are the contents of the anterior mediastinum? (2)
1) Thymus gland
2) Lymph nodes
What are the pathologies in the anterior mediastinum? (4)
1) Retrosternal goiter
2) Hodgkin’s lymphoma
3) Thymic mass
4) Thymoma
-Germ cell tumor
(4 T’s (Thyroid goiter, Thymic mass, Thymoma, Terrible Hodgkin’s Lymphoma)
Are thyroid goiter’s more common or thyroid neoplasms?
Much more common than thyroid neoplasm
What portion of the mediastinum is continuous with the thyroid gland?
Superior mediastinum; continuous with thyroid gland
What is the most common finding of a CXR that happens with thyroid goiters?
Tracheal displacement most common finding on CXR
How do you diagnose a thyroid goiter?
Dx: nuclear medicine scan; CT with contrast strongly suggestive
What is the most common anterior mediastinal mass in adults?
Thymoma
What specific conditions are common with those that have a thymoma? (2)
1) 35% have myasthenia gravis; 15% of MG patients have thymoma;
2) 50% with aplastic anemia have thymoma
What % of thymoma are benign?
75%
What population do thymolipoma occur?
children, young adults
What conditions can result in benign thymic hyperplasia? (4)
1) MG
2) thyrotoxicosis
3) collagen vascular disease, 4) rebound thymic hyperplasia (chemotherapy, Addison’s, acromegaly)
What are germ cell tumors?
Primitive rest cells; variable malignant potential
Which is the most common type of germ cell tumor?
Teratoma (70% of germ cell tumors); 20% malignant = teratocarcinoma
What are the contents of the middle mediastinum? (7)
1) Pericardium
2) Heart
3) Great and pulmonary vessels
4) Phrenic nerve
5) Upper vagus nerves
6) Trachea, primary bronchi
7) Lymph nodes
What are the pathologies of the middle mediastinum? (4)
1) Lymphadenopathy
2) Bronchogenic carcinoma
3) Aneurysm
4) Bronchogenic cyst
Are thoracic aneurysms often symptomatic?
Most asymptomatic
What are some clinical symptoms of thoracic aneurysm?
Clinical symptoms = very large, expanding, or contained rupture
What are some causes of thoracic aneurysm?
1) Atherosclerosis
2) Connective tissue disease (Marfan’s, etc)
3) Syphilis
4) Posttraumatic
5) Mycotic
6) Aortitis
What are the contents of the posterior mediastinum? (7)
1) Descending thoracic aorta
2) Esophagus
3) Thoracic duct
4) Azygous, hemiazygous veins
5) Sympathetic ganglia
6) Lower vagus nerves
7) Lymph nodes
What are the pathologies of the posterior mediastinum? (6)
1) Hiatal hernia
2) Neurogenic tumors
3) Paravertebral masses
4) Meningocele
5) Esophageal masses
6) Aneurysm
What hiatal hernia is more common?
Sliding (95%), Paraesophageal (5%)
What is a sliding hernia and what can it cause??
- GE junction above hemidiaphragm
- Reflux if large
- May reduce when upright
- Esophagitis (25%); duodenal ulcer (20%)
What is a paraesophageal hernia and what can it cause??
- GE junction below hemidiaphragm
- Fundus above diaphragm
- More complications
What is the choice imaging for following up an abnormal plain film in the chest?
- Follow-up for abnormal plain film = CT
- Masses
- Mediastinal abnormalities
- Unexplained pleural effusion or atelectasis
- Recurrent consolidation, atelectasis, effusion
- Negative plain film; high clinical suspicion
