Thoracic Flashcards
Unilateral Hypertransradiancy
-Rotation (lucent side closer to the tube ie away from the plate)
- Airway obstruction/FB
-PTx
Chest wall =
- Mastectomy
- Poland syndrome
- Polio
Swyer-james
- unilateral hyperlucent lung on radiography and air-trapping +/- bronchiectasis on CT. underdeveloped pulonary vasculatiry
- Unilateral or focal postinfectious Constrictive bronchiolitis
-emphysema
Congenital Lobar Emphysema
- Neonates (hyperexpansion
Mass effect on adjacent uninvolved lung &/or mediastinum
Left upper lobe > middle lobe > right upper lobe
MAC
Tree in bud - terminal bronchiole filled with radiopaque material
cylindric bronchiectasis
clasically right middle lobe or lingula (aka lady windermere syndrome)
Other causes/areas of lung
TB (Pus)
CF, ABPA (mucus)
Cells - Breast and gastric cancer
Aspiration
CMV (bronchial wall thickening)
Angioinvasive aspergillosis
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
heralds improvement in the condition.
Aspergilloma
Nodule or mass within preexisting cavity
Lies dependent/ Intracavitary movement
Monod sign - gas that surrounds a mycetoma/aspergilloma in a pre-existing pulmonary cavity
ABPA
‘Migratory’ airway consolidation
**Central (saccular) and upper lobe predomiannt bronchiectasis
(peripheral bronchi clasically spared)
**Dense mucoid impaction/finger in gloove - High-attenuating (>70–100 HU) bronchial contents represent fungal debris
Asthma
Cavity formation possible in later stage
Mucormycosis
Difficult to discern radiologically and clinically from aspergillosis
Can have halo sign but more specific reverse halo sign
unlike COP, peripheral capsule in the reversed halo sign tends to be thicker
Septic emboli
Peripheral wedges shaped densities +/- cavity
Lower lobe predominant
CAVITY mnemonic?
*Cancer (Squamous)
*Auto-immune (Wegners, Rheumatoid/caplan)
*Vascular - multiple pulmonary infarcts
*Infection - septic emboli - TB, staph, strep
*Truama - pneumatoceles
Y - Young - CPAM, Sequestrations
Round atelectasis
Comet tail sign
Adjacent to thickened pleural (assoacited with asbestosis) +/- Ca2+
can mimic a lung mass
Carcinoid
Endobronchial lesion, calcification (1/3).
Avid enhancement.
commonest lung primary in children and young adults
Atypical carcinoid are rare and can have no/heterogenous enhancement
iodine-123-octreotide scanning detect primary and metasatic disease for typical
atypical - FDG
Bronchopleural fistula
Post pneumonectomy
contralateral tracheal shift
Reduction on height of fluid on sequential films.
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
Round pneumonia
Young children
Pneumoccous, strep
Spherical area posterior lower lobes
With antibiotic and resolution of symptoms it doesnt need followed up
Fibrous Tumor of the Pleura (pleural fibroma)
Peripheral soft tissue nodule/mass, abuts pleura, obtuse angle
Often beningn
Less likely to malignant transform to sarcoma
Fibrous = low on T1 and T2
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
Centrilobular
-smoking, apical/upper lobes segments
Panacinar
- Alpha1-antitrpysin , lower lobes/bases
Paraspetal
- Subpleural, bullous formation, spontaneous PTx
Congenital lobar overinflation
Neonate
hyperlucent LUL,-
mass effect on mediastinum and contralateral mediastinal shift
Bronchus unable to remain open in expiration, leading to air trapping
No discrete cyst or feeding vessels
UIP
CXR
Reticular or reticulonodular opacities
Subpleural/peripheral; mid and lower lung zones
Macrocystic Honeycombing (strongest predictor)
Basilar predominant
Traction bronchiectasis
Subpleural reticulations
smoking association
Causes
- connective tissue disease such as RA
- asbestosis
- Drugs (amidorane, nitrofurantoin, methotrexate)
- IPF (diagnosis of exclusion)
NSIP
lower lung zone predominant
CXR
bilateral, reticular opacities
CT
Absent (less) / microcystic honeycombing
Bilateral ground-glass &/or reticular opacities
Traction bronchiectasis/bronchiolectasis
Relative Subpleural sparing
peribronchovascular fibrosis
Most hunt for assocation/cause on CT
?dilated oesophagus - scleroderma
? joint disease - RA
?portcath/PICC - chemotherapy
sjorgens
HIV
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
Lymphoid Interstitial Pneumonia - LIP
Basilar predominace
Thin walled cysts
GGO
Centilobualr micronodules
GGO clears with treatment
Associated with Sjogren’s
+ PCP, Hep B, EV
+ AIDs
Lymphangioleiomyomatosis (LAM)
Diffuse no lobe predominant Thin walled cysts
Spontaneous PTX
Premenopausal women
NORMAL lung volumes
Chylous pleural effusions
increased lung volumes
Associated with tuberous sclerosis - 1/3rd have AMLs
Pulmonary Langerhans cell histiocytosis (PLCH)
Predominant upper lobes
bizarre-shaped thick pulmonary cysts
Smokers
Early stages of disease, 1-10mm nodules in mid/upper zone predominant
M:F =
Effusions are rare
Sparing costophrenic angles
Birt-hogg-dube
Bilateral basilar predominant lentiform cysts abutting pleura, septa, and pulmonary vessels
Liver and skin lesions
Bilateral Renal oncocytomas
+ **chromophobe RCC
COP
Reverse halo sign
Associated with
-CF
-Methotrexate
- post-transplant
- connective tissue
Sarcoidosis
-Bilateral hilar and right paratracheal lymphadenopathy (95% of cases)
-Perilymphatic nodules
-Mid and upper zones is classic
- End stage = fibrosis and traction bronchiectasis
Side notes
Garland triad = 1,2,3 sign = lymph nodes both hilum and right paratracheal
Lofgren’s syndrome is an acute form of sarcoidosis characterised by erythema nodosum, bilateral hilar lymphadenopathy and polyarthralgia.
stage 1: bilateral hilar lymphadenopathy
stage 2: bihilar lymphadenopathy and reticulonodular infiltrates of parts or the entire lung
stage 3: bilateral pulmonary infiltrates without signs of hilar lymphadenopathy
stage 4: fibrotic degeneration of the lung (possibly with upward hilar traction, cystic and/or bullous destruction of the lung)
Acute eosinophilic pneumonia
-Ground-glass opacities (100%)
-crazy-paving pattern (septal thickening)
-mosaic attenuation; may mimic pulmonary edema
Asthma
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
EAA/hypersensitivity pneumontits
Acute/Nonfibrotic:
Centrilobular ground-glass nodules and air-trapping
Mosiac attenutation
Chronic:
Dyspnoea, clubbing etc
Fibrotic: Upper lobe peribronchovascular fibrosis
Crazy paving sign and ground glass opacities
DDx
Pulmonoary oedema (?cardiomegaly, pleural effusion)
ARDS (?anteriorposterior gradient)
Alveolar haemmorhage
PCP (?cysts)
Adenocarcinoma
Primary
-Hallmark is lymphadenopathy
-Homogenous consooldiation
-compressive atelectasis from compression of adjacent lymph nodes
-pleural effusions (30%)
Tree-in-bud opacities are the most common sign of active tuberculosis on CT.
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
Anterior mediastinal mass
mediastinal mass that makes obtuse angles with the mediastinal contour. The hilar vessels can be seen through the mass - (hilum overlay sign) and means this is not in the middle mediastinum. The paravertebral line can also be seen, placing this mass in the anterior mediastinum.
Thymoma
Teratoma/GCT
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)
- 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
RB-ILD
Centrilobular nodules
GGO
mosiac attenutation
SImilar to EAA
Upper/mid zones
**Smoking **
No bronchiectasis or honeycombing
Middle mediastinal masses?
DDX
Lymphadenopathy
Foregut duplication cyst
Haitus hernia
Tracheal stenosis?
Wegners
Tracheal wall thickening Circumferential (involvement of posterior membranous trachea)
Relapsing polychondritis
Wall thickening ± calcification that spares posterior membranous wall
Autoimmune disease - polyarthiris, uveitis, vestibulitis
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
DDx Causes for interlobular septal thikening?
LISA
Lymphangitis carcinomatosis (nodular or smooth) - beaded appearance
Interstitial oedema (smooth)
Sarcoidosis (nodular)
Alveolar proteinosis (smooth)
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 - Tracheal dilatation
Williams–Campbell syndrome
-subsegemental bronchiectasis, central normal
Solitary pulmonary nodule
**Granuloma **
- benign patterns of calcification (central, diffuse, popcorn, or laminated).
- Calcified hilar and lymph nodes
Neoplasm
- primary lung cancer and metastatic disease
may present as a solitary pulmonary nodule or mass (>3 cm)
- Irregular borders or suspicious calcifications (speckled, eccentric)
- Adenocarcinoma - Solid, Part or GG. Peripheral
- Squamous, proclivity to cavitate
- Small cell, typically perhilar and lymphadenopathy
Hamartoma
- Comonest benigin aetiology. classic < 4cm , well defined and focal macroscopic fat and popcorn calcifcation
Other Differerntials
- Round pneumonia - paeds, < 8
- AVM - 90% associated with HHT, look for feeding vessels
Multiple pulmonary nodules
Metastatic
- randomly distributed with a lower lobe predominance, various sizes
Tuberculosis or fungal granulomatous disease
Septic emboli
- Well defiend and peripheral. ‘Vessel Feeding’ sign, not specific
Ohers
- Granulomatosis with polyangitis (GPA) - May cavitate, thick walls with air fluid levels.
- Rheumatoid - dissapear after treatment.
Cavitary pulmonary nodule/mass
- TB
- Typically reactivation phase. Multiple cavitations reflecting the increased inflammation and necrosis
- Predominantly in the upper lobes (lymphatic clearance lower in lower lobes.) - Squamous cell carcinoma (Primary or metastatic)
- typically located centrally with involvement of hilar or medistinal lymph nodes. - Pyogenic infection (pulmonary abscess, septic emboli)
Fungal disease - Histoplasmosis
