VIQ - chest Flashcards
@#e 2) In acute respiratory distress syndrome what is the first change usually seen on the chest radiograph?
a. confluent consolidation
b. pleural effusions
c. increased heart size with globular shape
d. volume loss with atelectasis
e. patchy ill-defined opacities
e. patchy ill-defined opacities
Acute respiratory distress syndrome (ARDS) commences with interstitial edema, progressing to congestion and extensive alveolar, and interstitial edema and hemorrhage. The chest radiograph is often normal for the first 24 hours, before patchy opacities appear in both lungs. These progress to massive airspace consolidation over the following 2448 hours. True volume loss, atelectasis, cardiomegaly and effusions are not seen in ARDS.
@#e2 41- Which of the following CT features indicates post-primary rather than primary pulmonary tuberculosis?
(a) Miliary nodules
(b) Bronchiectasis
(c) Cavitation
(d) Tree-in—bud opacification
(e) Lymphadenopathy
(a) Miliary nodules
The difference between primary and post—primary (reactivated) TB is in the degree Of previous exposure the patient has had to T B. Most features are seen in both to some degree with the exception of miliary nodules.
@#e 12. A 22 year old is diagnosed with tuberculosis. Which of the following features will make a diagnosis of primary tuberculosis more likely?
a. Mediastinal enlargement
b. Septal thickening
c. Upper zone cavitation
d. Miliary nodules
e. Apical consolidation
a. Mediastinal enlargement
Mediastinal enlargement Mediastinal lymph node enlargement is a feature of primary TB. The others are seen with reactivation or fibrocavitary TB. Miliary TB can be seen in any phase with haematogenous dissemination but primary presentation is uncommon.
@# 32. A 35 year old female presents with generalised malaise and cough, occasionally bringing up grape-skin-like material. Blood screen reveals eosinophilia. The patient has a history of travel to several countries worldwide. Which of the following plain film features is unlikely?
a. Homogenous ovoid opacity
b. Cyst with a fluid level
c. Bilateral opacities
d. Calcification.
e. Lower zone location
d. Calcification.
Calcification The case describes hydatid disease. Hydatid cyst of the lungs can present as solid ovoid solitary or occasionally multiple lesions on plain films. When the cyst communicates with a bronchial tree, an air fluid level is demonstrated. Several other signs are described. Whilst bilaterality is less likely (up to 20%), calcification is extremely rare (0.7%).
@#e2 47. A 45-year-old woman had allogenic bone marrow transplant for treatment of leukaemia. Two weeks later she developed cough and shortness of breath. CT demonstrates bilateral ground-glass shadowing, thickened interstitial lines and bilateral pleural effusion. What is the most likely diagnosis?
(a) Bronchiolitis obliterans
(b) Drug toxicity
(c) Pulmonary oedema
(d) Diffuse alveolar haemorrhage
(e) Bronchiolitis obliterans organising pneumonia
- (c) Pulmonary oedema
This is usually secondary to fluid overload and associated renal dysfunction.
Bronchiolitis obliterans and bronchiolitis obliterans organising pneumonia are late complications seen after 3 months.
Drug toxicity and alveolar haemorrhages may present with ground-glass shadowing but do not show pleural effusions or interstitial involvement.
@#e2 73 In the assessment of a thoracic CT, which of the following features is least supportive of a diagnosis of nonspecific interstitial pneumonitis?
(a) Traction bronchiectasis
(b) Volume loss
(c) Ground glass opacifrcation
(d) Thin-walled cysts
(e) Reticular abnormality
(d) Thin-walled cysts
Thin-walled cysts are not a feature of NSIP but should raise the possibility of LIP. The remaining features are typical. Consolidation, honeycombing and nodules are variably reported in the literature as being present or absent.
@#e 1. A 50 year old male presents with a history of occasional haemoptysis and exertional shortness of breath which has been getting progressively worse. Plain chest radiograph demonstrates bibasal reticular shadowing with volume loss. HRCT demonstrates bibasal fibrosis and traction bronchiectasis. Incidental note is made of a patulous oesophagus. Which of the following is the most likely cause?
a. Tuberculosis
b. SLE
c. Rheumatoid arthritis
d. Wegener’s granulomatosis
e. Scleroderma
- e. Scleroderma
Whilst haemoptysis may be a presentation in tuberculosis and Wegener’s and bibasal fibrosis maybe seen in all of the above except tuberculosis (where apical fibrosis is the more likely feature), scleroderma is the only condition resulting in a patulous lower oesophageal sphincter, oesophageal shortening and stricture formation.
@#e 34. A 26 year old female patient with an optic nerve tumour and café-au-lait spots presents with exertional breathlessness. Imaging of the chest is most likely to reveal which of the following?
a. Multiple small lower lobe cysts
b. Emphysema
c. Lower zone fibrosis
d. Thick-walled cavities in the upper zone
e. Asymmetrical upper zone fibrosis
- c. Lower zone fibrosis
The case describes neurofibromatosis I, which is associated with lower zone fibrosis and thin-walled bullae, mainly in the upper zones.
Apart from the pulmonary changes, skeletal abnormalities involving the ribs and spine and mediastinal masses may also be seen
@#e 49. A patient with a known collagen vascular disease has pulmonary fibrosis. HRCT reveals bilateral lower lobe bronchiectasis. Which collagen vascular disease is most likely?
a. Sjogren syndrome
b. Progressive systemic sclerosis
c. SLE
d. Rheumatoid arthritis
e. Dermatomyositis
- a. Sjogren syndrome
Whilst pulmonary fibrosis is a feature of all the above conditions, bronchiectasis is most likely seen in Sjogren syndrome
@# 3. A chest radiograph shows diffuse lung disease with fibrotic changes predominantly affecting the upper lobes. What is the most unlikely diagnosis?
(a) Sarcoidosis
(b) Cystic fibrosis
(c) Allergic bronchopulmonary aspergillosis
(d) Langerhans cell granulomatosis
(e) Scleroderma
- (e) Scleroderma
Other conditions cause predominantly upper zone disease.
@#e2 9. A 48-year-old female non-smoker presents to the Accident & Emergency Department with acute dyspnoea and chest pain. The chest radiograph shows bilateral basal airspace shadowing. Chest CT shows disuse basal consolidation and air-bronchograms within a background of ground-glass opacity. There is septal thickening and bilateral pleural effusions. The most likely diagnosis is?
(a) Desquamative interstitial pneumonitis
(b) Lymphocytic interstitial pneumonitis
(c) Acute interstitial pneumonia
(d) Usual interstitial pneumonitis
(e) Cryptogenic organising pneumonia
- (c) Acute interstitial pneumonia
This clinically presents as adult respiratory distress syndrome and has high mortality. It has a fulminant course leading to respiratory failure and requiring mechanical ventilation with a mortality of > 50%. CT findings are non-specific but include bilateral, diffuse ground-glass opacity with consolidation and air bronchograms. Honeycombing and traction bronchiectasis may be seen in advanced cases after recovery.
@# 5. Which of the following are correct about pulmonary sarcoidosis: (T/F)
(a) Normal CXR excludes the diagnosis.
(b) The large airways are involved in 4-5% of cases.
(c) Subcarinal lymph nodes are characteristically spared.
(d) Fibrosis occurs predominantly in the lower zones.
(e) Pleural effusion is common CXR.
Answers:
(a) Not correct.
(b) Correct
(c) Not correct
(d) Not correct
(e) Not correct
Explanation:
Between 5% to 15% of patients have a normal CXR when first examined.
Pleural effusion is a rare finding (2%).
All mediastinal lymphnodes can be affected in sarcoidosis.
On CT 50% of cases show enlarged subcarinal lymphnodes.
Middle and upper zone fibrosis is characteristic
@# 39. The following finding is more in keeping with chronic eosinophilic pneumonia rather than Churg-Strauss:
A. Centrilobular nodules within areas of ground-glass change
B. Peripheral consolidation with tendency towards lobular distribution
C. Transient opacities, shifting over days
D. Homogenous peripheral airspace consolidation
E. Interlobular septal thickening
D. Homogenous peripheral airspace consolidation
Chronic eosinophilic pneumonia is characterised by the presence of homogenous peripheral airspace consolidation on CT, whereas the peripheral consolidation in Churg-Strauss has a tendency towards lobular distribution and is often associated with centrilobular nodules within the ground glass opacity.
@# 10- A 46-year-old man presents to an A&E department with shortness of breath. The CXR shows a diffuse opacity in the RUL. On a previous film, taken 3 months ago, he had a similar appearance in the LUL which cleared on a CXR taken 10 days later; there was a similar episode a year prior to this with an opacity in the middle lobe, which subsequently cleared. Which of the following conditions is the least likely diagnosis?
(a) Chronic eosinophilic pneumonia
(b) Chug-Strauss syndrome
(c) Extrinsic allergic alveolitis
(d) Good pasture’s syndrome
(e) Loeffler’s syndrome
(a) Chronic eosinophilic pneumonia
Loeffler’s syndrome is also known as transient pulmonary eosinophilia Churg-Strauss syndrome (allergic angiitis granulomatosis) classically presents with fleeting pulmonary opacities.
Causes of pulmonary hemorrhage/vasculitis can also give this appearance (e.g. Wegener’s granulomatosis or Good pasture’s syndrome).
EAA can occur following exposure to the relevant trigger, which subsequently resolves on its removal.
Chronic eosinophilic pneumonia typically has a peripheral distribution (the ‘photographic negative’ of pulmonary edema) and appearances typically remain unchanged for weeks or months.
@#e2 9 A 45 year old man is referred from chest clinic with a cough and intermittent breathlessness. A CT of his thorax demonstrates ill-defined centrilobular nodules and a mosaic attenuation pattern, exacerbated on expiratory phase imaging. What is the most likely diagnosis?
(a) Respiratory bronchilitis-interstitial lung disease
(b) Chronic pulmonary thrombo-embolism
(c) Sarcoidosis
(d) Extrinsic allergic alveolitis
(e) Lymphocytic interstitial pneumonitis
(d) Extrinsic allergic alveolitis
The clinical features are non-specific, but many patients with EAA (also known as hypersensitivity pneumonitis) have exacerbati,on of symptoms on exposure to the antigen, e.g. returning to the workplace.
EAA has acute, sub acute and chronic phases which may progress to widespread pulmonary fibrosis.
The mosaic attenuation with gas trapping described here is a characteristic finding.
@#e 31. A young man presents with progressive productive cough and halitosis. He had severe pneumonia as a child. Plain chest radiograph demonstrates bronchial dilatation and bronchial wall thickening with some volume loss. Which of the following HRCT findings is the most sensitive finding for bronchiectasis?
a. Air trapping
b. Mucous-filled dilated bronchi
c. Bronchial wall thickening
d. Bronchi seen in the subpleural region
e. Lack of bronchial tapering
- e. Lack of bronchial tapering
Whilst all the above can be seen in patients with bronchiectasis, a lack of progressive tapering of the bronchi is the most sensitive (80%).
@#e2 QUESTION 29 You are asked to review the CT scan of an elderly female patient who has evidence of left upper lobe collapse on a CXR. On CT, in which one of the following directions will the left upper lobe have collapsed?
A Anteriorly and laterally
B Anteriorly and medially
C Inferiorly and medially
D Posteriorly and medially
E Superiorly and medially
B Anteriorly and medially
Left upper lobe collapse results in volume loss in an anterior and medial direction, as opposed to superior and medial collapse of the right upper lobe collapse.
@#e2 50 A 40-year-old schoolteacher presented with a non-productive cough, dyspnoea and low-grade pyrexia. She has never smoked. The CXR demonstrated several bilateral areas of patchy consolidation which were confirmed on HRCT and shown to be in a mainly sub-pleural distribution. In addition there is also patchy ground-glass change and small (<5 mm) centrilobular nodules). What is the most likely diagnosis?
a Bronchoalveolar cell carcinoma
b Histoplasmosis
C Sarcoidosis
d Cryptogenic organising pneumonia
e Multifocal streptococcal pneumonia
50 Answer D: Cryptogenic organising pneumonia
These imaging findings are classical of COP. Effusions and adenopathy are also present in up to one third of patients. Bronchoalveolar cell carcinoma is an important differential, but is most commonly solitary and centrilobular nodules are not a feature, and there is a strong smoking association.
@# 40. A 60-year-old recently retired postman presents with chronic cough. The chest radiograph shows soft tissue opacity extending from the right hilum to the lateral chest wall, with loss of the right heart border. There is loss of right lung volume and the right costophrenic angle is seen. Bronchoscopy demonstrates a large endobronchial mass. What is the most likely bronchus involved?
(a) Right upper lobe bronchus
(b) Right middle lobe bronchus
(c) Right lower lobe bronchus
(d) Bronchus intermedius
(e) Right lower lobe apical segment bronchus
- (d) Bronchus intermedius
The chest radiograph findings are suggestive of combined right middle lobe and right lower lobe collapse secondary to tumour obstructing the bronchus intermedius.
@# 13 Which of the following drugs used in treating patients with haematological malignancy is not associated with pulmonary haemorrhage?
(a) Bleomycin
(b) Cytarabine
(c) Amphotericin B
(d) Rituximab
(e) Cyclophosphamide
(a) Bleomycin
Bleomycin may result in one of two conditions: an organising pneumonia with multiple foci of consolidation or tree-in-bud opacification, or diffuse alveolar damage which gives appearances akin to ARDS.
@#e2 32 Plain radiographic signs seen more commonly in patients with acute pulmonary embolism include all but which of the following?
(a) Cardiomegaly
(b) Decreased vascularity
(c) Pulmonary oedema
(d) Pleural opacity
(e) Atelectasis
(c) Pulmonary oedema
Pulmonary oedema is seen in patients with PE rarely (4% vs 13% in patients without PE). Other signs include pleural effusion.
@# 62 A 72 year old woman with a history of recent surgery presents with shortness of breath and pleuritic chest pain. On examination there is a slight swelling of the right leg compared to the left. The D-dimer level is raised. Which imaging investigation should be performed next?
(a) Chest X-ray
(b) CTPA
(c) Pulmonary angiogram
(d) Ultrasound bilateral lower leg veins
(e) V/Q scan
(a) Chest X-ray
The patient is at high risk for a PE. The CXR is less likely to be diagnostic, but may provide a differential diagnosis in some cases (e.g. spontaneous pneumothorax) and forms an important part of the diagnostic flow chart.
A normal CXR means a V/Q scan would be the next appropriate investigation, abnormal CXR requires CTPA.
The right leg swelling may be post-operative rather than due to a DVT, but regardless, it is important to diagnose a PE over a DVT as most clinicians recommend a longer treatment period for the former.
Pulmonary angiography is invasive and is now rarely used in the context of PE diagnosis.
@# QUESTION 6 A 70-year-old man recently underwent a laparoscopic prostatectomy. He now presents to the Emergency Department complaining of shortness of breath, pleuritic chest pain and haemoptysis. D-dimer levels were measured and found to be significantly elevated. A CXR is performed as part of the initial set of investigations. Which one of the following is the most likely CXR finding?
A A normal chest radiograph
B Linear atelectasis
C Localised peripheral oligaemia
D Peripheral airspace opacification
E Pleural effusion
A normal chest radiograph
A normal chest radiograph is the most common finding in the setting of a suspected pulmonary embolus (PE).
@# 75. A 24-year-old woman who is 28 weeks pregnant is admitted with suspected pulmonary embolism. As the on-call radiologist, her obstetrician contacts you seeking advice regarding further management. An admission CXR is normal. What investigation do you advise initially?
A. Venous ultrasound.
B. Low-dose CTPA.
C. Reduced dose lung scintigraphy.
D. MRA.
E. Catheter pulmonary angiography.
- A. Venous ultrasound.
For pregnant patients, venous ultrasound is recommended before imaging tests with ionizing radiation are performed. Up to 29% of pregnant patients with PE will have a positive venous ultrasound, obviating the need for further imaging.
The majority of the PIOPED II investigators currently recommend V/Q scanning over CTPA in the evaluation of PE in pregnant patients. The foetal dose with V/Q is similar to that with CTPA, although the effective dose per breast is much greater with CTPA.
MRI requires further evaluation and gadolinium-based contrast agents have not been proven to be safe in pregnancy.
The role of catheter angiography is probably limited to those patients requiring mechanical thrombectomy.
It should be noted that even a combination of CXR, lung scintigraphy, CTPA, and pulmonary angiography exposes the foetus to approximately 1.5mGy of radiation, which is well below the accepted limit of 50 mGy for the induction of deterministic effects in the foetus. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators.
@#e2 33 A patient with a known malignancy presented with acute shortness of breath. The attending physician requested CT pulmonary angiogram to exclude a pulmonary embolus. A filling defect was seen in the left lower pulmonary artery with a wedge-shaped collapse distal to it. Which primary tumour is most frequently associated with pulmonary embolism?
a Lung carcinoma
b Hepatocellular carcinoma
C Gastric carcinoma
d Ovarian cystadenoma
e Prostate carcinoma
33 Answer C: Gastric carcinoma
Ovarian carcinoma and extra hepatic bile duct carcinomas also demonstrate a high rate of pulmonary emboli.
@# 7. Which of the following has the greatest incidence of metastases to the lung?
A. Choriocarcinoma
B. Hypernephroma
C. Ewing’s sarcoma
D. Rhabdomyosarcoma
E. Testicular seminoma
A. Choriocarcinoma
In order of decreasing frequency, pulmonary metastases arise from choriocarcinoma, hypernephroma/Wilms’ tumor, Ewing’s/rhabdomyosarcoma and testicular tumors.
@# 49. Which of the following is most likely to present as a haemorrhagic rather than a calcified pulmonary metastases?
A. Breast cancer
B. Chondrosarcoma
C. Testicular cancer
D. Choriocarcinoma
E. Mucinous adenocarcinoma of the colon
D. Choriocarcinoma
Choriocarcinoma, renal carcinoma, and melanoma are causes of haemorrhagic pulmonary metastases.
@# 5- A 24-year-old asymptomatic man has a CXR for insurance purposes. The report describes a solitary 2 cm nodule. A subsequent CT is arranged. Which of the following of the features favor a diagnosis of carcinoid over hamartoma?
(a) Avid 18FDG-PET uptake
(b) Calcification
(c) Central location
(d) Hounsfield value of —30
(e) Solitary lesion
(c) Central location
Pulmonary carcinoids represent < 4% of all lung tumors and approximately 15% of all carcinoid tumors within the body. They can be typical (type 1; local tumor; 90%) or atypical (type 2; metastasizes to local LNs, rarely to liver), 80% are centrally located.
They rarely cause carcinoid syndrome, often enhance strongly, 1/3 contain calcification, and they typically have no uptake at PET.
Hamartomas are well circumscribed solitary nodules; 90% are peripheral. They are benign tumors composed of cartilage, connective tissue, muscle, fat, and bone.
Fat attenuation at CT is described as pathognomonic, pompom’ calcification is also diagnostic but is seen in only 20%
@#e2 38- A 40-year-old Woman presents hemoptysis- CXR shows multiple cavitating lesions in both lungs- Needle biopsy confirms the lesions are metastatic. Which of the following is the least likely cause?
(a) Squamous cell carcinoma of the larynx
(b) Adenocarcinoma of the cervix
(c) Transitional cell carcinoma of the bladder
(d) Adenocarcinoma of the colon
(e) Giant cell tumor of the distal femur
(e) Giant cell tumor of the distal femur
The differential diagnosis for cavitating metastases also includes melanoma. Giant cell tumor metastases may calcify.
@# 26 A 64 year old man undergoes nephrectomy for a right renal tumour. A year later he presents with haemoptysis. CT of the chest shows 3 lesions in the right hemithorax measuring 20 x 10 mm, 20 x 12 mm and 10 x 10 mm. Biopsy confirms these are metastases. After a course of chemotherapy, the lesions measure 18 x 8 mm, 17 x 10 mm and 10 x 8
mm. By RECIST criteria the status of the disease is?
(a) Stable disease
(b) Partial response
(c) Good response
(d) Excellent response
(e) No response
(a) Stable disease
Baseline is defined as the sum of the long diameters of the target lesions where up 2 target lesions per organ and 5 overall can be used. Partial response involves a decrease of 30% or more in the sum of the long diameters. Complete response implies the disappearance of all lesions. Disease progression involves an increase in the sum of the long diameters of 20%. Good response, no response and excellent response are not part of the RECIST criteria.
@#e2 17. The staging chest CT of a 40 year old man with a known primary malignancy demonstrates cavitating pulmonary metastases. The least likely type of primary lesion would be:
a. Squamous cell carcinoma
b. Malignant melanoma
c. Renal cell cancer
d. Sarcomas
e. Colonic carcinoma
- c. Renal cell cancer
@#e 38. A 68 year old miner develops an irregular opacity in the upper zone on plain chest radiograph. Which imaging feature would be more in favour of malignancy than progressive massive fibrosis (PMF)?
a. Peripheral enhancement on contrast-enhanced MR
b. Peripheral location on axial images
c. Presence of calcification
d. High signal on T2-weighted images
e. Avid lesion on PET-CT
d. High signal on T2-weighted images
PMF has a peripheral location which moves towards the hilum on follow-up imaging.
Calcification and cavitation may also be seen.
PMF lesions can be FDG-avid on PET-CT.
However, high signal in a mass on T2-weighted images is strongly suspicious for malignancy.
@# 59. A 60 year old man presents with progressive breathlessness. The plain chest radiograph reveals reticular shadowing in the right lower zone, but is otherwise unremarkable. HRCT demonstrates the presence of beaded thickening of the interlobular septae forming a polygonal reticular network in the right lower lobe with central dots within. There is also a small pleural effusion. Which of the following is the most likely cause?
a. Sarcoidosis
b. Bronchogenic carcinoma
c. Heart failure
d. Extrinsic allergic alveolitis
e. Fibrosing alveolitis
- b. Bronchogenic carcinoma
The changes described indicate lymphangitis carcinomatosis.
Whilst similar appearances are seen in sarcoidosis, the changes are usually in the upper lobe and pleural effusion is rare.
In heart failure, the interlobar septal thickening is usually smooth and usually bilateral.
In EAA, pleural effusion is rare and changes are more bronchocentric and bilateral. The polygonal structure is usually distorted in both EAA and cryptogenic fibrosis, where changes are again subpleural.
@#e2 QUESTION 32 A middle-aged man has recently had a CT abdomen performed for chronic lower left abdominal pain. Whilst mild sigmoid diverticular disease was present, it was also noted that there was significant para-aortic lymphadenopathy. Lymphoma was the suspected diagnosis and a chest CT was performed, prior to biopsy. “Which additional CT finding is most likely to suggest a diagnosis of non-Hodgkin’s lymphoma rather than Hodgkin’s disease?
A Isolated pulmonary consolidation
B Paramediastinal interstitial fibrosis
C Peripheral subpleural masses with a pleural effusion
D Peripheral subpleural masses without a pleural effusion
E Pulmonary consolidation with mediastinal lymphadenopathy
A Isolated pulmonary consolidation
At presentation, Hodgkin’s disease most commonly has lung parenchymal disease accompanied by intrathoracic adenopathy,
whereas isolated lung involvement is not uncommon in non-Hodgkin’s lymphoma.
Pleural effusions (unilateral) are common in both types of lymphoma, as are peripheral subpleural masses.
Consolidation with air bronchograms can also be seen in both diseases.
@# 17. A 34-year-old woman presents with a 4-month history of gradually increasing dyspnoea and cough. A CXR and subsequent CT scan show multiple cavitating lung lesions. On the CT scan, some of these lesions are noted to have surrounding ground-glass attenuation. No other abnormality is seen. Which of the following diagnoses are the fi ndings most compatible with?
A. Rheumatoid lung.
B. Lung abscesses.
C. Eosinophilic granuloma.
D. Churg–Strauss syndrome.
E. Melanoma metastases.
- E. Melanoma metastases.
The GGO surrounding a nodule is known as the ‘halo’ sign and represents perilesional haemorrhage. The differential diagnosis given rests on the presence of this feature and cavitation.
Melanoma metastases can both cavitate and produce perilesional haemorrhage.
The halo sign may also be seen in other conditions with perilesional haemorrhage or cellular infiltration and is usually best seen on HRCT. These diagnoses include bronchoalveolar carcinoma, haemorrhagic metastases, Wegener’s granulomatosis, and angio-invasive infections, such as invasive aspergillosis.
Alternative correct answers would be Wegener’s granulomatosis, lymphoma, bronchoalveolar carcinoma, and squamous cell carcinoma as these can produce both cavitating nodules and the halo sign.
Rheumatoid lung, eosinophilic granuloma, and lung abscesses are associated with cavitating nodules but not the halo sign.
Churg–Strauss syndrome is not associated with the halo sign and cavitation is rare.
@# 34. A 68-year-old patient has a CXR carried out due to a recurrent chest infection. The patient is a smoker. The CXR shows a solitary pulmonary nodule. A CT is carried out which demonstrates a 2.8-cm lesion in the right lower lobe as noted on CXR. This lesion is spiculated. There is a second lesion noted in the right lower lobe that is 1.2 cm in size and was not visible on the CXR. There is a 0.8-cm ipsilateral peribronchial lymph node identified. There are no evident metastases. A PET-CT is carried out which shows an SUV max of 8 in both pulmonary lesions. There is no uptake in the lymph node. No metastases are identified. A biopsy confirms non-small cell lung cancer. Based on the available imaging, what is the stage of this lesion?
A. Stage 1A.
B. Stage 1B.
C. Stage 2A.
D. Stage 2B.
E. Stage 3A.
- D. Stage 2B.
The TNM definitions, on which the staging system is based, were recently updated in 2010. In this update, the nodal classifications were not changed, but the T staging was updated, as was M staging. Sub-classifications were added to T1,
with lesions <2 cm being T1a
and lesions between 2 and 3 cm being T1b.
Lesions between 3 and 5 cm are T2a
and between 5 and 7 cm are T2b.
Lesions over 7 cm are T3, as are synchronous lesions within the primary lobe, as in this case.
Multiple lesions within the primary lobe were formerly T4.
In this question, the lymph node is not enlarged by size criteria and is not FDG avid on PET. While this may yet still be involved, on imaging findings alone, this lesion should be classed as N0.
The absence of metastases is obviously M0. Thus this patient is T3 N0 M0, which corresponds to stage 2b.
T2b N1 tumours are also in this stage.
Stage 2a lesions are T2a N1 or T2b N0.
Stage 3a lesions are T3 or less with N2 disease or T3 N1 lesions.
@# (GU) 67. A 48-year-old women presents with shortness of breath and undergoes an HRCT of the chest to assess interstitial changes seen on plain film. She has emigrated from Eastern Europe and knows that she had a gynaecological cancer that was treated there, but is unsure of her treatment. The HRCT reveals unilateral thickened interlobular septa, perilymphatic nodules, and ipsilateral hilar adenopathy. What is the most likely underlying diagnosis?
A. Cervical carcinoma.
B. Ovarian epithelial carcinoma.
C. Endometrial carcinoma.
D. Leiomyosarcoma of the uterus.
E. Vaginal carcinoma.
- A. Cervical carcinoma.
This patient has developed lymphangitis carcinomatosis. In 50% of cases the septal thickening is focal or unilateral and this is useful in distinguishing lymphangitis from other causes of septal thickening, such as pulmonary oedema or sarcoidosis. Hilar adenopathy is present in 50% and pleural effusion in 30–50%. The interlobular septal thickening can be smooth (as in pulmonary oedema and alveolar proteinosis) or nodular (also found in sarcoidosis and silicosis). Lymphangitis carcinomatosis usually occurs secondary to the spread of (adeno-) carcinoma, most commonly bronchogenic, breast, and stomach. The mnemonic Certain Cancers Spread By Plugging The Lymphatics (Cervix Colon Stomach Breast Pancreas Thyroid Larynx) is useful. Lymphangitis carcinomatosis is occasionally associated with cervical carcinoma and certainly more so than with the other options presented.
@# (Ped)46 A 12-year-old girl with known osteosarcoma of the proximal femur presents with acute shortness of breath. What is the most likely finding on CXR?
a Bilateral hilar lymphadenopathy
b Pneumothorax
C Coarsened bronchovascular markings with reticular opacities
d Bilateral lower lobe atelectasis
e Multiple cavitating nodules
46 Answer B: Pneumothorax
The rupture of subpleural metastatic nodules into the pleural space can cause spontaneous pneumothorax. Cavitating metastases classically occur in squamous cell carcinoma. Osteosarcoma lung metastases can calcify.
@# 4 A premature infant, born at 27 weeks, was ventilated for the first 14 days and subsequently on CPAP for a further 21 days. A CXR is performed at three months of age. What is the likely appearance?
a `White out’ of the lungs
b Patchy bilateral ground-glass opacities with air bronchograms
c Hyperinflation with coarse linear densities and focal areas of emphysema
d Reduced lung volumes with bilateral reticulonodular opacities
e Normal volume lungs with no focal abnormality
4 Answer C: Hyperinflation with course linear densities and focal areas of emphysema
The infant described has bronchopulmonary dysplasia, which is caused by oxygen toxicity and barotrauma in infants on assisted ventilation at >21 % oxygen for >28 days. Appearances change with time:
