Thoracic Flashcards
finterface of the right lung and mediastinal reflection of azygous vein?
Azygo-oesophageal recess
Meeting of the parietal and visceral pleural reflection anteromedially?
Anterior junctional line
meeting of the pleural surfaces of the upper lobes behind the oesophagus ?
Posterior junctional line
Above the clavicles
Cervicothoracic sign = if above the clavicles in the posterior mediastinum
Right wall of the trachea agaisnt the right lung?
right paratracheal line
Right lung meeting against posterior mediastinal soft tissue?
right paraspinal stripe
What is luftsichel sign on CXR?
Ongoing aeration of the superior most segment if left lower lobe in upper lobe collapse
DDx for unilateral hyperlucent hemithorax?
-Rotation (lucent side closer to the tube ie away from the plate)
Lung
- Airway obstruction/FB
-PTx
Chest wall =
- Mastectomy
- Ploand syndrome
- Polio
Swyer-james
- unilateral hyperlucent lung on radiography and air-trapping and bronchiectasis on CT
Alpha-1-antitrypsin
- Pan lobular basal emphysema
AIDs with CD4 <200, perihilar GGO, sparing the periphery, pneumatoceles (thin walled) ?
PCP
Can have PTx
Lung infection with CD4 200-400?
Pyogenic - commonest Strep pneumonia
TB
CD4 count less <150
<150
Fungal -
- Cryptococcal - cavity formation, concurrent cerebral
- Histoplasmosis - no CXR apperacnes (50%)
<100
CMV and Kaposi sarcoma
<50
MAC , Lymphoma
Causes of persistent opacities in AIDS patients
Lymphoma
Kaposi - ‘Flame shaped’ perihilar
Tree in bud opacities and and cylindric bronchiectasis of the right middle lobe or lingula?
MAC
Tree in bud - terminal bronchiole filled with radiopaque material
Other causes
TB (Pus)
CF, ABPA (mucus)
Cells - Breast and gastric cancer
Aspiration
CMV (bronchial wall thickening)
Signs of invasive asperigillus ?
Halo sign
=Nodule/mass/consolidation surrounded by ground-glass opacity related to hemorrhage
Air crescent sign
=Crescent-shaped gas collection within nodule, mass, or consolidation
Nodule or mass within preexisting cavity
Aspergilloma
Central upper lobe saccular bronchiectasis with mucoid impaction (finger in glove). Known asthmatic?
ABPA
‘Migratory’ airway consolidation
Central bronchiectasis, peripheral bronchi clasically spared
Cavity formation possible in later stage
Dense mucoid impaction - High-attenuating (>70–100 HU) bronchial contents represent fungal debris
Aggressive fungal infection that invades the mediastinum, pleura and chest wall?
Mucormycosis
Peripheral nodular and wedges shaped densities. Lower lobe predominant. cavity formation
Septic emboli
CAVITY mnemonic?
*Cancer (Squamous)
*Auto-immune (Wegners, Rheumatoid/caplan)
*Vascular - Septic emboli
*Infection - TB, staph, strep
*Truama - pneumatoceles
Y - Young - CPAM, Sequestrations
What bacteria is classic for lemierre syndrome?
Fusobacterium Necrophorum
Peripheral grouns glass/subsolid nodule in the upper lobe. Non-smoker. which type of lung cancer?
Adenocarcinoma
Associated with lung fibrosis
Central mass with cavitation, smoker. which type of lung cancer ?
Squamous
Ectopic PTH
Cushings
Central lung malignancy with central lymphadenopathy. Associated with lambert eaton. which type of lung cancer?
Small cell
Paraneoplastic syndromes
- SIADH
- Lamber eaton = proximal weakness
- Limbic encephalitis
you can use PET for assessing SPN greater than 1cm. If ground glass, what would PET uptake be if malignancy?
Cold
Hot in infection
if solid malignancy then hot (SUV> 2.5)
Benign pleural lesion associated with hypertrophic pulmonary osteoarthropathy?
Pleural fibroma
Malignant lesion would be lung cancer (non -small cell)
Pleural fibroma aka benign mesothelioma
-T1 MR hypointense; T2 MR hyperintense; contrast enhancement on CT avid
About
14%–30% undergo malignant degeneration. Surgical excision is curative.
Round atelectasis can mimic a lung mass. What features differentiate?
Comet tail sign
Adjacent to thickened pleural (assoacited with asbestosis) +/- Ca2+
lung mass with fat density, peripheral and popcorn calcifications?
Hamartoma
Endobronchial lesion, calcification. Histroy of wheeze. Avid enhancement.
Carcinoid
Cold on PET (false negative)
Carcinoid syndrome in chest is uncommon versus abdominal. if present Left sided valves destroyed
Atypical carcinoid are rare and can have no enhancement
Stage 3B lung cancer (N3 or T4) is unresectable, what features?
Unresectable =
-supraclavicular, scalene or contralateral mediastinal or hilar lymphadenopathy
- Tumour in same lung but different lobes (T4)
- Tumour in two different lungs (M1a)
- Malignant pleurant effusion (M1)
Nb - that tumours in the same lobe is (T3)
Early vs later radiation pneumonitis appearances?
Early (1-3 months)
- Homogenous or patchy GGO
Late
- Dense consolidation, traction bronchiectasis and volume loss
Post pneumonectomy, contralateral tracheal shift, reduction on height of fluid on sequential films. what is the complication?
Bronchopleural fistula
Can confirm on Xenon gas nuclear med
Normal appearances -
air fluid level at day4/5, by 14 days 100% fluid filled
ipsilateral tracheal shift
Diaphragm elevation
Young adult, post pneumonectomy, exertional SOB, hyper expansion of lung displaces and rotates the heart anticlockwise. what is complication?
Post-pneumonectomy syndrome
6 months post transplant. Mosaic attenuation, air-trapping, bronchial wall thickening, bronchiectasis ?
Bronchiolitis obliterans
Findings more** Prominet on expiratory phase (air trapping) **
associated bleomycin toxicity, IBD, RA, post BMT
Post-transplant complications in hours, 4-24hrs, 7-10 days, weeks, months, anytime
Hours = hyperacute rejection
4-24 hrs = Reperfusion injury - (perihilar bat opacifications and effusions.)
(second week) = Acute rejection (GGO (basal), septal thickening, pleural effusions
Weeks = drugs - (GGO)
Months - Lymphoid interstitial pneumonitis (GGO + centrilobular nodules + thin-walled cysts)
Anytime - bacterial, PCP, aspergillus
Thoracic duct injury above and below T5/T6 - which side is the pleural effusion?
Above = Left
Below = Right
crosses midline at t5/t6 to drain into junction left SCV and IJV
Lobar condolidation, in bone marrow transplant, cavitation, no lymph node enlargement. what is the infection?
Nocardiosis
Lobar pneumonia in alcoholic/immunocompromised?
Klebsiella
**Strep commonest in non-immunocompromised **
Organism causes bronchopneumonia?
Staph (commonest)
pneumococcus
haemophilus
Viral pneumonia apperances?
like bronchopneumonia affects airways and interstitium
Differentiate from bacterial = Air trapping = hyperinflation on CXR
Round pneumonia?
Young children
Pneumoccous, strep
Spherical area posterior lower lobes
Peripheral soft tissue nodule/mass, abuts pleura, obtuse angle, episodic hypoglycaema?
Fibrous Tumor of the Pleura
Egg shell calcifications nodes ?
Silicosis
Coal workers pneumoconiosis
Sarcoidosis
Treated lymphoma
Mediastinal lymph node calcification
Tuberculosis
Histoplasmosis
Amyloidosis (rare)
Metastases: papillary/medullary thyroid cancer, osteosarcoma, mucinous adenocarcinoma
Feeding vessel sign ?
Mets
Septic emboli
Type of emphysema?
Centrilobular
-smoking, apical segments
Panacinar
- Alpha1-antitrpysin , bases
Paraspetal
- Subpleural, bullous formation, spontaneous PTx
Neonate hyperlucent LUL, mass effect on mediastinum and contralateral mediastinal shift ?
Congenital lobar overinflation
Bronchus unable to remain open in expiration, leading to air trapping
No discrete cyst or feeding vessels
Honeycombing, basilar predominant, traction bronchiectasis, distortion of architecture, smoking association?
UIP
Spare the costophrenic angles
Basilar GGO, subpleural sparing, younger, steroid responsive?
NSIP
Absent honeycombing
Bilateral ground-glass &/or reticular opacities ± traction bronchiectasis/bronchiolectasis
Subpleural sparing ± peribronchovascular fibrosis
associated with
CREST - dilated oesophagus
RA
sjorgens
chemo
HIV
NSIP vs UIP
Features of Desquamative interstitial pneumonia (DIP)?
Smoker
Bilateral, lower zone predominant ground-glass opacities ± subpleural intralobular lines/retiuclations **
Small, round, thin-walled** (2-4 mm in diameter)
Spectrum/similar HRCT to RB-ILD
+ centrilobular nodules
+ upper lobe predominated
Female, 60, Ground-glass opacities, Centrilobular nodules , thin-walled Cysts?
Lymphoid Interstitial Pneumonia - LIP
**DIffuse **
GGO clears with treatment
Associated with Sjogren’s
+ PCP, Hep B, EV
+ AIDs
Female, 30, with diffuse thin-walled lung cysts, spontaneous pneumothorax, effusions. Non-smoker?
Lymphangioleiomyomatosis (LAM)
Diffuse no lobe predominant
Premenopausal.
NORMAL lung volumes
Chylous pleural effusions
increased lung volumes
Associated with tuberous sclerosis - 1/3rd have AMLs
20-30, male, nodules + bizarre-shaped thick pulmonary cysts in cigarette smokers. Increased lung volumes ?
Pulmonary Langerhans cell histiocytosis (PLCH)
Predominant upper lobes
normal lung volumes
Smokers
M:F =
Effusions are rare
Sparing costophrenic angles
Bilateral basilar predominant lentiform cysts, liver and skin lesions?
Birt-hogg-dube
Bilateral basilar predominant lentiform cysts abutting pleura, septa, and pulmonary vessels
Bilateral Renal oncocytomas
+ **chromophobe RCC
Multifocal ground-glass opacities and consolidations. Some with peripheral consolidation around central ground glass nodule?
COP
Reverse halo sign
Associated with
-CF
-Methotrexate
- post-transplant
- connective tissue
Afro-Caribbean, female, 20. Subpleural nodules upper zone. Bilateral hilar and mediastinal lymph nodes?
Sarcoidosis
Bilateral hilar and right paratracheal lymphadenopathy in up to 95% of cases
Garland triad = 1,2,3 sign = lymph nodes both hilum and right paratracheal
Traction bronchiectasis
Perilymphatic nodules
UPPER lobes
Lofgren’s syndrome is an acute form of sarcoidosis characterised by erythema nodosum, bilateral hilar lymphadenopathy and polyarthralgia.
According to BTS guidelines first presentation nodules, features that require no follow up?
Calcification
Perifissural
<5mm
<80mm3
Diffuse or patchy parenchymal opacities (ground-glass &/or consolidation) associated with bilateral septal thickening and pleural effusion. Known Asthma
Acute eosinophilic pneumonia
-Ground-glass opacities (100%)
-crazy-paving pattern
-mosaic attenuation; may mimic pulmonary edema
Reverse pulmonary oedema pattern (peripheral)
acute type I hypersensitivity reaction triggered by variable causes (inhalational exposure, drugs, infections)
Chronic eosinophilic pneumonia (CEP): Peripheral homogeneous consolidations (100%)
Allergic bronchopulmonary aspergillosis (ABPA): Central upper lobe bronchiectasis ± high-attenuation mucous plugs (30%)
Upper lobe predominant - BREASTS?
Berylliosis
Radiation / RB-ILD
Extrinsic allergic alveolitis and Eosionphilic granuluma (LCH)
Ankylosing spondylitis/ ABPA
Sarcoidosis
TB
Silicosis
Nb ++
all pneumoconiosis
Caplans syndrome
Centrilobular emphysema
CF
Lower lobe predominant - BADAS
Bronchiectasis
Asbestosis
DIP/Drugs
Aspiration
Scleroderma (+ RA !!!)
+ Panlobular emphysema (alpha 1)
+ RA (Caplans upper lobes and less common)
+ UIP and NSIP
Centrilobular hyperdense micronodules in recretional drug user?
Talcosis
Where does asbestosis typically spare?
Costophrenic angle
Pleural effusion often first sign but bilateral calcified plaques most common presentation
If mediastinal pleura - ?mesothelioma
If unilateral - ? previous Sx or Empyema
Crocidolite = very fine fibre results in blue asbestosis = very severe pleural disease
Features of Extrinsic allergic alveolitis?
Acute/Nonfibrotic:
Centrilobular ground-glass nodules and air-trapping
Mosiac attenutation
Chronic:
Dyspnoea, clubbing etc
Fibrotic: Upper lobe peribronchovascular fibrosis
Features of alveolar proteinosis ?
Crazy paving sign and ground glass opacities
Features of TB?
Primary
-Hallmark is lymphadenopathy
-Homogenous consooldiation
-compressive atelectasis from compression of adjacent lymph nodes
-pleural effusions (30%)
Post-primary
-Cavitating nodule
-tuberculomas
Mosaic attenuation causes?
Higher attenuation pathological ie Parenchymal disease ie (GGO)
- sarcoidosis, UIP, COP, DIP
- No air trapping.
=Vessels in the whiter areas = dilated
Lower attenuation pathological
**- look for vessels constricted/paucity in lucent areas **
- Poor ventilation =
***Air-trapping
- Exacerbated by expiratory phase
- Bronchitis , bronchiectasis, asthma, emphysema, Hypersensitivity pneumonitis - Mosaic perfusion
- as above but no air trapping
- CTEPH, pulmonary hypertension
Crazy paving causes?
Alveolar proteinosis
ARDS
Goodpastures
COP
Sarcoidosis
lobar collapses on CXR ?
Anterior mediastinal masses
Thymoma
Teratoma
Terrible lymphoma
Thyroid
Germ cell tumours can be fruther subdivded
-Teratoma (usually cystic with fat and calcification)
-seminoma (bulky and lobulated)
-Non-seminomatous Germ Cell Tumour (haemorrhage and necrosis)
Two common trachea malignancy and how to differentiate?
- SCC
- Smoker
- Lower 2/3rd trachea
- ulcerated mass or nodule that projects into tracheal lumen
- infiltration mediastinal structures, Frequent regional metastatic lymphadenopathy - Adenoid cystic carcinoma
- non-smoker
- proximal 1/3rd
- growth along submucosal and perineural structures
Consider Mucoepidermoid carcinoma (MEC) in young patient with endoluminal lesion in segmental airway - lobar or segmental bronchi
Basilar GGO, subpleural sparing, younger, steroid responsive?
NSIP
Absent honeycombing
Bilateral ground-glass &/or reticular opacities ± traction bronchiectasis/bronchiolectasis
Subpleural sparing ± peribronchovascular fibrosis
associated with CREST - dilated oesophagus
RA, sjorgens, chemo
Causes of Lymphangitis carcinomatosis?
Certain Cancers Spread By Plugging The Lymphatics
Cervix
Colon
Stomach
Breast
Pancreas
Thyroid
Larynx (or lung – bronchogenic)
Nb > 50% from breast and most remaining gastric
malignant vs benign pleaural lesion
Nodular pleural thickening, involvement of the mediastinal pleura and circumferential involvement of the pleura all point heavily towards a malignant diagnosis.
stalk strongly suggests a benign lesion
less than 1cm thick, suggests benign pleural plaque
carbey triad vs syndrome
Carneys syndrome - FAST
Carneys triad - PEG (if you have a bad GIST tumour you might need a PEG tube)
Feautres of RB-ILD
Centrilobular nodules
GGO
Upper/mid zones
Smoking
No bronchiectasis or honeycombing
Complication rates posrt lung Bx
PTx = 25%
PTx needing drain = 5-10%
Haemoptysis = 3%
Air embolus = 0.05%
Tumour seeding = 0.05%
Middle mediastinal masses?
Fibrosing mediastinitis
-partly calcifed mass, especially subcarinal and right partatracheal,
- causes vascular compression leading to right heart strain (SVC obsruction)
Tracheal stenosis?
Wegners
Tracheal wall thickening Circumferential (involvement of posterior membranous trachea)
Relapsing polychondritis
Wall thickening ± calcification that spares posterior membranous wall
Tracheobronchomalacia
Weakness of central airway walls
At least 70% tracheal collapse on expiratory CT
saber-sheath trachea
narrowing of its coronal diameter and widening of its sagittal diameter
snokers/COPD
Tracheobronchomegaly
a.k.a. Mounier-Kuhn syndrome
Marked dilatation of trachea and mainstem bronchi
Causes for interlobular septal thikening?
LISA
Lymphangitis carcinomatosis (nodular or smooth) - beaded appearance
Interstitial oedema (smooth)
Sarcoidosis (nodular)
Alveolar proteinosis (smooth)
Occlusion techniques IR?
see picture
bronchiectasis by location
Bronchiectasis with Upper or Mid-Lung Predominance
* Cystic fibrosis
* ABPA
* Sarcoidosis
* TB
Bronchiectasis with Anterior Predominance
* Atypical mycobacterial infection
* ARDS
Bronchiectasis with Lower Lung Predominance
* Pulmonary fibrosis
* Chronic aspiration
* Kartagener’s syndrome
* Common variable immunodeficiency
* α1-Antitrypsin deficiency
Bronchiectasis with Central Predominance
* Mounier–Kuhn syndrome
* Williams–Campbell syndrome
