CHEST RADIOLOGY:

Primary function of the airways:

To conduct air to the alveolar surface, where gas
transfer takes place between inspired air and blood of the
alveolar capillaries
Lungs are subdivided into 3 zones:
! CO"D#CTI"G $O"E
- composed of airways whose walls do not
contain alveoli
- walls are thick enough that gas cannot
diffuse into the adjacent lung parenchyma
- it includes the trachea, bronchi and
membranous (nonalveolated! bronchioles
%! TRA"SITIO"AL $O"E
- carries out both conductive and respiratory
functions
- it consists of the respiratory bronchioles
and alveolar ducts
- alveolar ducts conduct air to the most
peripheral portion of the lung"
- #lveoli that arise from the walls of these
airways also serve in gas e$change
&! RESPIRATORY $O"E
- consists of the alveoli
whose primary function is the
e$change of gases between air and
blood
The res'iratory (one to)ether with the transitiona*
(one constitutes the L#"G PARE"CHY+A
The cornerstone of radiologic diagnosis is the %&'(T
)#*+,-)#.&
The most satisfactory basic or routine radiographic views
for evaluation of the chest are:
/" posteroanterior and
0" left lateral projections
The o'tima* chest ra,io)ra'h is o-taine,
in the posteroanterior (.#! view
at a targettofilm distance of 10 inches
with the patient in the upright position
at ma$imum inspiration
#*'23#T' .'4'T)#T+,4 56 )#*+#T+,4
Thoracic spine shld be barely seen thru the heart
bronchovascular structures can usually be seen
thru the heart
spine appears to be darker caudally" This is due to
more air in lung in the lower lobes and less chest
wall"
(ternum shld be seen edge on
.osteriorly there should be two sets of ribs
1
"on.stan,ar, chest ra,io)ra'hy
LORDOTIC PRO/ECTIO":
+t is advocated in 3 situations:
/" for improving visibility of the lung apices, superior
mediastinum and thoracic inlet
0" for locating a lesion by paralla$
3" for identifying the minor fissure in these suspected
cases of atelectasis of the right middle lobe
LATERAL DEC#0IT#S
it is particularly helpful for the identification of small pleural
effusions
it is also useful to demonstrate a change in position of an air
fluid level in a cavity
to ascertain whether a structure that forms part of a cavity
represents a freely mowing intracavitary loose body(fungus
ball!
O0LI1#E PRO/ECTIO"
useful in locating a disease process ( pleural
pla7ue!
(.'%+#L )#*+,-)#.&+% T'%&4+23'(:
/" +nspiratory'$piratory radiography
- main indication is the investigation of air
trapping either general or local
i" -eneral air trapping 8 e$emplified
by asthma or emphysema
ii" Local air trapping 8 there is bronchial
obstruction, or lobar emphysema
- 0
nd
indication 8 when pneumothora$ is
suspected and the visceral pleural line is
not visible
0" 9alsalva and :uller maneuvers
may aid in determining thevsacukar or solid
nature of intrathoracic mass
3" 5edside radiography
+n patients who are too ill to stand,
anteroposterior (#.! upright or supine projections
offer an alternative
%,:.3T'* T,:,-)#.&6
:ost common indication for the used of %T scan
/" 'valuation of suspected mediastinal abnormalities
identified on standard chest radiograph
0" (earch for occult thymic lesions
3" determination of the presence and e$tent of
neoplastic
;" search for diffuse or central calcification in a
pulmonary nodule
:iscellaneous indications:
/" assisting in the percutaneous biopsy of a lesion
such as mediastinal, pleural or pulmonary masses
0" localization of loculated collections of fluid within
the pleural space
3" assessment of the size and configuration of the
thoracic aorta
:ain indication for the use of &)%T
/" diagnosis of bronchiectasis
2
0" detection of parenchymal lung disease
:#-4'T+% )'(,4#4%' +:#-+4-:
- plays an important role in the evaluation of
the abnormalities of the great vessels,
mediastinum, hila and chest wall"
3LT)#(,4,-)#.&6
- assessment of pleural effusion and
distinction of effusions from solid pleural
lesions
- assessment of the diaphragm
- guide to needle biopsy and catheter
placement
#4#T,:6: .lease review the chest anatomy
ATELECTASIS
state of incomplete e$pansion of a lung or any portion of
it
loss of lung volume (collapse!
CA#SES O2 COLLAPSE
+ntrinsic mass :
primary or metastatic neoplasms or eroding
lymph nodes
+ntrinsic stenosis :
T5, inflammatory processes, fracture of a
bronchus
'$trinsic pressure :
enlarged lymph nodes, mediastinal tumor,
aortic aneurysm, cardiac enlargement
5ronchial plugging :
<5 or mucus accumulation
DIRECT SIG"S O2 COLLAPSE
*isplaced septa most reliable sign
Loss of aeration
9ascular = bronchial signs crowding
I"DIRECT SIG"S O2 COLLAPSE
'levation of a leaf of diaphragm
(hift of the mediastinal structures toward the side
of the affected lobe
+psilateral decrease in size of the thoracic cage
%ompensatory hyperaeration of the uninvolved
lobes
&ilar displacement most important indirect sign
of collapse
L34- &')4+#T+,4
:ore common in left side collapse
3 main locations:
/" anterior to the ascending aorta > most common
0" lower thora$ behind the heart
3" under the arch of aorta
TYPES
! Resor'tion 3 o-structi4e ate*ectasis
3
occurs when communication between the trachea and
alveoli is obstructed
may be intrinsic, caused by a tumor, foreign body,
inflammatory disease, heavy secretions
e$trinsic pressure on bronchi caused by tumor or
enlarged nodes or bronchial constriction secondary to
inflammatory disease
%! Passi4e ate*ectasis
intrapleural abnormalities
caused by space occupying process that can compress
the lung
pneumothora$, pleural fluid, diaphragmatic elevation,
herniation of the abdominal viscera into the thora$, large
intrathoracic tumors
&! Com'ressi4e ate*ectasis
. intrapulmonary abnormalities
is a secondary effect of compression of normal lung by
a primary, spaceoccupying abnormality
bullous emphysema, lobar emphysema
5! A,hesi4e ate*ectasis
. occurs when the luminal surfaces of the alveolar walls
stick together
hyaline membrane disease, pulmonary embolism, acute
radiation pneumonitis, uremia
6! Cicatri(ation ate*ectasis
is primarily the result of fibrosis and scar tissue
formation in the interalveolar and interstitial space
classic cause of cicatrizing atelectasis T5
histoplasmosis
P"E#+O"IA:
%lassification:
/" Lobar pneumonia
0" Lobular pneumonia
3" +nterstitial pneumonia
%omplication of .neumonia:
/" %avitation
organisms
(taph aureus
(treptococci
-r(! bacilli
#naerobes
types
a" Lung abscess
> single well defined mass often with air fluid
levels"
b" 4ecrotizing pneumonia
small lucencies or cavities
c" .ulmonary gangrene
sloughed lung
0" .neumatoceles
subpleural collections of air which result from
alveolar rupture
thin walled
seen in children
organisms
(taph aureus
4
3" &ilar and mediastinal adenopathy
T5 and fungi
;" .leural effusion and empyema
?" ,ther complications
#)*(
5ronchiectasis
)ecurrent pneumonitis
Summary of c*inica* c*ues to the etio*o)y of
'neumonia
! Pre4ious*y we** community ac7uire,
?@1@A (trep pneumoniae
:ycoplasma pneumoniae
virus or legionella pneumophila
%! Hos'ita* ac7uire,
gr(! .seudomonas aeruginosa
Blebsiella pneumoniae
'scherichia coli
'nterobacter species
&! A*coho*ism
:ost common .neumococcus
<re7uent -ram (!, anaerobes, (" aureus
5! Dia-etes me**itus
gram (!, (" aureus
6! A*tere, consciousness an, coma
gram(!, anaerobes
8! Postinf*uen(a
(taphyloccus aureus
9! Chronic -ronchitis with e:acer-ation
&aemophilus influenzae
Summary of ra,io)ra'hic c*ues to the etio*o)y of
'neumonia
! ;Roun,< 'neumonia
(treptococcus pneumoniae
%! Com'*ete *o-ar conso*i,ation
(treptococcus pneumoniae, Blebsiella
pneumoniae
,ther gram (! bacilli
&! Lo-ar en*ar)ement
Blebsiella pneumoniae, (taphylococcus aureus
&aemophilus influenzae
5! 0i*atera* 'neumonia =-roncho'neumonia>?
.neumococcus >still common
(taphylococcus aureus
6! Interstitia* 'neumonia
9irus, :ycoplasma pneumoniae
8! Se'tic em-o*i
(" aureus
9! Em'yema or -roncho'*eura* fistu*a
(" aureus,
-r(!bacilli, anaerobes
@! Ca4itation
(" aureus, gr(! bacilli, anaerobic bacteria
(treptococcus
A! 'u*monary )an)rene
Blebsiella pneumoniae, 'scherichia coli
&aemophilus influenzae, :" tuberculosis
B! 'neumatoce*es
(" aureus, gr(! bacilli, &" influenzae, :"
tuberculosis,
measles
! *ym'ha,eno'athy
5
:" tuberculosis, fungi, virus, :ycoplasma
pneumoniae
P"E#+O"IAS CA#SED 0Y GRA+ =C> 0ACTERIA
! Stre'tococcus 'neumoniae
:ost common community ac7uired pneumonia
:ore common in adults
)adiograhic features
Lower lobes
%onsolidation
Lobar or sublobar
)ound pneumonia in children
%! Sta'hy*ococcus aureus
:ore common in infants and children
)adiograhic features in children
%onsolidation
Lower lobes
.neumatoceles
)adiograhic features in adults
5ilateral
%avitation
'mpyema
&! Stre'tococcus 'yo)enes
)adiograhic features
%onsolidation
(egmental
Lower lobes
'ffusion
P"E#+O"IAS CA#SED 0Y GRA+ =.> AERO0IC
ORGA"IS+S
! D*e-sie**a 'neumoniae
:iddle age, elderly patients
%hronic lung disease and alcoholic patients
)adiologic features
Lobar consolidation
5ulging fissures
%avitation
.ulmonary gangrene
%! Escherichia co*i
*irect e$tension from -+ C -3 tract
(econdary to bacteremia
)adiologic features
4ecrosis, multiple cavities
Lower lobes
&! Pseu,omonas aeur)inosa
&ospitalized, debilitated patients
Tracheostomy tubes and suction devices
)adiologic features
Lower lobes, consolidation
)apid spread to both lungs
:ultiple irregular nodules
%avitation
5! Haemo'hi*us inf*uen(ae
6
%,.*
5ronchopneumonia
)adiographic features
&omogeneous segmental
Lower lobes
T35')%3L,(+(
3sually deposited in the middle and lower lobes
.rimary T5
remains clinically silent
*evelopment of delayed hypersensitivity
occurs / 3 weeks after inoculation
..* is positive
5y 3weeks
.)+:#)6 T5
-hon focus
+nitial focus of parenchymal disease
)anke comple$
%ombination of -hon focus and affected lymph
nodes
)adiologic manifestations
.arenchymal involvement
airspace consolidation
)t upper lobe > most common (adult!
)ight middle lobe > least common
Lymph node involvement
&ilar and mediastinal >right paratracheal region
(children!
#irway involvement
Lobar and right sided atelectasis (children!
#nterior segment of the upper lobes (adult!
.leural involvement
.leural effusion is more common in adult
(low resolution may occur in 3D months
POST PRI+ARY T0
.ulmonary involvement increases
,ften cavitation occus
5ronchogenic spread
.leural involvement and C or empyema
Eith bronchopleural fistula
Tendency to localized in the apical and posterior
segment of the upper lobes
<ocal areas of consolidation
%avities occurs
#pical and posterior segments of upper
lobes
(uperior segments of the lower lobes
Tuberculoma
3pper lobe, right more often than the left
*+((':+4#T'* T5
/" 5),4%&,-'4+%
,ccurs when e$udate from a cavity or small area of
caseation drains into a bronchus
#spirated into previously unaffected areas,
,n the same side
,n the opposite side
7
0" &':#T,-'4',3(
Leads to
miliary T5
'$trapulmonary lesions thru out the body
#cute massive hematogeneous
(pread causes miliary T5
%hronic spread in smaller amount
)esults in the chronic e$trapulmonary foci
3" L6:.&#T+%
%ommon in primary T5
)esponsible for involvement with subse7uent
enlargement of hilar and mediastinal node ( children!
+n adults, hilar and mediastinal nodes
.rimary infection
)eactivation
Pu*monary neo'*asms
I! 0eni)n tumors
! Hamartomas
%haracteristics
#c7uired
Tissues normal to organ
*isorganized growth
?AFA solitary pulmonary nodules
%linical
3@1@ years
#symptomatic
.athology
%artillage
<at
<ibrous tissue
)adiologic features
(olitary welldefined pulmonary nodules
%#
GG
/@ A to /?A
%T fat and calcium (0?A!
II! +a*i)nant tumors
! A,enocarcinoma
:ost common of the bronchogenic tumors
:ost common type found in women
nonsmokers
C*inica* features
,ccasionally asymptomatic
Patho*o)ic features
(low growing
:etastasize early
#ssociation with fibrosis
.eripheral, subpleural
Ra,io)ra'hic features
.eripheral with lobulated or irregular margins
(olitary nodule or mass
(piculated border
.leural retraction or tethering
&ilar or perihilar mass
.arenchymal mass with hilar or mediastinal
lymphadenopathy
8
%! 0ronchio*oa*4eo*ar carcinoma
(ubtype of adenocarcinoma
C*inica* features
(evere bronchorrhea
Ra,io)ra'hic features
(olitary nodule
:ost common
&azy, illdefined
HgroundglassI on %T
#ir bronchogram
%onsolidation
:ultiple nodules
&! S7uamous.Ce** Carcinoma
0nd most common
.redominantly in men
.eak incidence at the age of J@ yrs
(trong association with cigarette smoking
:ost common cause of .ancoast tumor
:ost common type of lung %# to cause
hypercalcemia
C*inica* 2eatures
5est prognosis
,ne third of all lung cancers
'ctopic parathormone production
Patho*o)ic features
%entral, endobronchial
Local mestastases to lymph nodes
%entral necrosis

Ra,io*o)ic features
Two thirds central
'ndobronchial lesion best seen on %T
#telectasis of lung or lobe
.ostobstructive pneumonitis
,ne third peripheral
Thickwalled, cavitary mass
(olidary nodule
Su'erior Su*cus Carcinoma
=Pancoast tumor>
C*inica* features
.ain
&ornerKs syndrome
5one destruction
#trophy of hand muscles
Patho*o)ic features
:ost common s7uamous cell
+nvasion
%hest wall
5ase of neck
5rachial ple$us
9ertebral bodies and spinal canal
9
(ympathetic ganglion
(ubclavian artery
Ra,io*o)ic features
#pical mass or asymmetric thickening
5one destruction
:)+
:ultiplanar imaging
Local e$tension
5! Sma** Ce** Carcinoma
:ost common lung %# to cause superior vena cava
obstruction
:ost common lung %# to cause %ushingKs
syndrome and secretion of inappropriate antidiuretic
hormone ((+#*&!
C*inica* features
:ost aggressive
(trongest association with smoking
.oorest survival
/?A to 0@A of cancers
Treated with chemotherapy
Patho*o)ic features
Large central mass
Tumor necrosis
Ra,io)ra'hic features
#rises in association with pro$imal airways
Lobar and main bronchi
%entrally located tumor
&ilar or perihilar mass
:assive adenopathy, often bilateral
Lobar collapse
)areperipheral nodule
6! Lar)e.Ce** #n,ifferentiate, Carcinoma
Characteristics
0A?A of lung cancers
(trong association with cigarette smoking
)apid growth
'arly metastases
.oor prognosis
Patho*o)ic features
.eripheral
Large, L ; cm
Ra,io*o)ic features
Large bulky peripheral mass
4ecrosis
.leural involvement with effusion
:ore aggressive and spread early
.eripheral
L ; cm
Paraneo'*astic syn,romes associate, with
-roncho)enic carcinoma
&ypercalcemia
'ctopic adrenocorticotropic hormone production
(yndrome of inappropriate secretion of antidiuretic
hormone
'atonLambert syndrome (peripheral neuropathy with
myasthenialike symptoms!
#canthosis nigricans
&ypertrophic osteoarthropathy
10
OTHER +ALIG"A"T T#+OR
! Carcinoi, Tumors
Characteristics
#rise from neuroendocrine cells
Type /, typical carcinoid
Type 0, atypical carcinoid
Lowgrade malignancy in type /
-ood prognosis
C*inica* features
:edium age ?@
:ales and females e7ually affected
%ough, hemotysis
)arely %ushingKs syndrome
Patho*o)ic features
(mall cells
4euroscretory granules
#typical carcinoids
.eripheral
/@A of cases
:etastasize in ;@A to ?@A of cases
Ra,io)ra'hic features
%entral
F@A of cases
Lobar, segmental, subsegmental bronchi
,bstructive pneumonia and atelectasis
.eripheral
0@A of cases
(low growth if typical
Large and faster growth if atypical
%alcification seen on %T
%! Ho,)EinFs ,isease
C*inica* features
5imodal agedistribution
6oung adults
'lderly men
:ass in neck or groin
(ystemic symptoms > M5K classification
(urvival of 1?A stage / and ++ radiotherapy alone
Ra,io)ra'hic features
%T for staging
F?A thoracic involvement
:ultiple lymphnode groups
#nterior mediastinum most common
Lung involvement
.rimarylung hdogkinKs rare
4odules,masses
.erihilar
%avitation
#ir bronchograms
<ollowup
)ecurrence adjacent to radiation portal
.ericardial nodes
11
:)+
*ifferentiates residual from recurrent tumor from fibrosis
T0 weighed
<ibrosis > low (+
Tumor > bright (+
'ggshell calcification in nodes
&! "on.Ho,)EinFs *ym'homa
C*inica* features
Low grade
,lder patients
-eneralized lymphadenopathy
#symptomatic
+ntermediate and high grade
6ounger patients
Treatment with aggressive chemotherapy
+mmunocompromised hosts
#+*(
Transplant recipients
N?@A intrathoracic involvement
Ra,io*o)ic features
(imilar to &odgkinKs disease
%hestwall involvement
:ore common
*irect e$tension or primary site
.leura
*irect e$tension
Localized pla7uelike seeding
.leural effusionslymphatic obstruction
Lung parenchyma
.rimary e$tranodal site
:ass with air bronchogram
:ultiple masses or consolidation
<ollow up
Localized recurrence
Eithin 0 years
)adiation pneumonitis and fibrosis
J to F weeks posttreatment
%onforms to portal
%onsolidation with air bronchograms
<ibrosis
Loss of volume
Linear opacities
Traction bronchiectasis
5! +etastatic ,isease G hemato)enous spread
%T
&igh sensitivity, low specificity, false positives
owing to intraparenchymal lymph nodes,
granulomas
5oth lungs, lower lobes
.eriphery
)ound, well marginated
9ariable doubling times
%a
GG
.rimary bone and cartilage tumors
:ucinous adenocarcimonas
%avitation
:etastatic s7uamous cell
(olitary pulmonary nodule
N/@A of cases
12
+f s7uamous cell, likely a lung primary
6! +etastatic ,isease. *ym'han)itic s'rea,
Characteristics
:ay result from hematogenous spread
.rimary sites
Lung
5reast
3pperabdominal malignancy
:ore commonly bilateral
Ra,io)ra'hic features
%hest radiograph
)eticulonadar pattern
Berley 5 lines
.leural effusion (J@A!
#denopathy (0?A!
&igh resolution %T
4odular thickening of bronchovascular bundles
.olygonal arcades
5eaded septal thickening
8! +etastatic Disease G en,o-ronchia* metastases
Site of 'rimary ma*i)nancy
Bidney
:elanoma
Thyriod
5reast
%olon
Ra,io)ra'hic features
#telectasis
&ilar :ass
9! +etastatic ,isease G intrathoracic a,eno'athy
Sites of 'rimary ma*i)nancy
-enitourinary
&ead and neck
5reast
(kin (melanoma!
Ra,io)ra'hic features
#denopathy
O parenchymal metastases
Location of IC# tu-es:
! Ti' of the en,otrachea* tu-e
tip should be about ; cm the tracheal carina
%! Ti' of the naso)astric tu-e
tip and sideport of the 4-T should be positioned
distal to the esophagogastric junction and pro$imal to the
gastric pylorus
&! I,ea* 'osition of the chest tu-e
chest tube placed to evacuate a pneumothora$ should
ideally be placed with its tip in the nondependent part of
the pleural space
13
chest tube placed to evacuate a pleural fluid should be
positioned in a dependent portion of the pleural space
5! 0est 'osition of the centra* 4enous catheter
used primarily to administer fluid and medication
to provide vascular access for hemodialysis
if pressure measurements are going to be obtained
tip of the catheter must be pro$imal to the venous valves
a well positioned central venous catheter projects over
the silhouette of the superior vena cava, in zone
demarcated superiorly by the anterior /
st
rib and clavicle
and inferiorly by the top of the right atrium
6! Ti' of the Swan.Gan( catheter
used to monitor pulmonary capillary wedge pressure
to measure cardiac output in patients suspected of
having left ventricular dysfunction
tip should be positioned within the right or left main
pulmonary arteries or in one of their large lobar branches
8! Intraaortic -a**on 'um'
cardiac assist device positioned in the descending
thoracic aorta via a femoral arterial approach
a balloon on the catheter inflates during diastole,
improving myocardial perfusion by increasing blood flow
through the coronary arteriesP the balloon deflates during
systole"
tip of +#5. should be seen at the junction of the aortic
arch and descending thoracic aorta, just distal to the
origin of the left subclavian artery

Chronic O-structi4e Pu*monary Disease
! Em'hysema
Patho*o)y
%entrilobular (central lobule!
.anlobular (entire lobular!
.araseptial (distal lobule, subpeural!
.aracicatricial (around scars!
C*inica* features
%igarette smoking
*yspnea
%hronic airflow obstruction (Q <'9/, R TL%, R )9, Q *L%,!
Ra,io*o)ic features
,verinflation
Low, flat diaphragm
+ncreased retrosternal clear space
Em'hysema as Seen on HRCT
Centri*o-u*ar
:ultiple small areas of low attenuation
4o walls
14
3pper lobes
Pan*o-u*ar
<ewer and smaller vessels
Lower lobes
Parase'ta*
(ubpleural and along fissures
Thin walls
(ingle row
Paracicatricia*
3sually focal
#ssociated with scars
%! Chronic 0ronchitis
%linical and pathologic features
%linical definition
.athologymucousgland hyperplasia
Ra,io)ra'hic features
4ormal
Thickened bronchial walls
'ndon ring shadows
Tram lines (in profile!
,verinflation
&! Asthma
%linical pathologic features
)eversible bronchospasm
Two thirds atopic
#ctive inflammation of the airways
Ra,io)ra'hic features
3ncomplicated
4ormal in majority
(igns of hyperinflation
5ronchialwall thickening
&)%T 5roncialwall thickening and mild dilation of
bronchi
Com'*icate,
.neumonia
Lobar or segmental atelectasis
#llergic bronchopulmonary aspergillosis (#5.#!
:ucoid impaction
.neumomediastinum
.neumothora$
0RO"CHIECTASIS
%auses of 5ronchiectasis
Infection
9iral ()(9, adenovirus, mycoplasma!
Tuberculosis
%hronic or recurrent bacterial infections
)ecurrent aspiration pneumonia
Deficiency in host ,efense
#gammaglobulinemia
-ranulomatous disease of childhood
A-norma*ities of carti*a)inous structure
Eilliams%ampbell syndrome
A-norma* mucus 'ro,uction
%ystic fibrosis
15
A-norma* ci*iary c*earance
*yskinetic cilia syndrome
BartegenerKs syndrome
0ronchia* o-struction
A**er)ic -roncho'u*monary as'er)i**osis =A0PA>
"o:iou: fume inha*ation
Pu*monary fi-rosis
Traction bronchiectasis
)adiation fibrosis
(arcoidosis
+diopathic pulmonary fibrosis
C*assification of -roncheictasis
! Cy*in,rica*
5ronchi are minimally dilated, have straight
regular outlines and end s7uarely and abruptly
#verage number of bronchial divisions is /J
microscopically (/10@ bronchial divisions
normally!
%! Haricose
*ilation of bronchus with sites of relative
construction, bulbous appearance
#verage number of bronchial divisions: F
&! Cystic or saccu*ar
5allooned appearance, airCfluid levels
#verage number of bronchial divisions: ;
Ra,io)ra'hic features of -ronchiectasis
Thickwalled bronchus larger in diameter than
accompanying pulmonary artery
*ilated and thick walled bronchi in the periphery of the
lung
Cy*in,rica* -roncheictasis
(mooth dilation of bronchus with lack of tapering
HTramlinesI when seen on plane of scan
H(ignet ringI when seen in cross section
Haricose -ronchiectasis
5ulbous appearance of bronchus
:ay mimic cylindrical broncheictasis in cross
section
Cystic -roncheictasis
(tring or cluster of cysts with discernable walls
#irCfluid levels within cysts
HRCT
Air tra''in)
refers to the abnormal retention of gas within the lung
following e$piration"
,n &)%T, the lung parencyhma remains lucent on
e$piration, while normal lung areas show increased
attenuation" +nspiration scans can be completely
normal in air trapping"
#ir trapping therefore cannot be diagnosed on
inspiration scansP lung inhomogeneity during
inspiration scans can be interpreted as mosaic
perfusion"
Traction -ronchiectasis
16
refers to bronchial dilation that occurs in patients with
lung fibrosis or distorted lung architecture"
Traction on the bronchial walls due to fibrous tissue
reults in irregular bronchial dilation (bronchiectasis!"
3sually segmental and subsegmental bronchi are
involved, but small periperhal bronchi or bronchioles
may also be affected"
%ommonly associated with honeycombing
Centri*o-u*ar no,u*es
4odules as small as /0 mm in diameter can be
detected by &)%T"
4odules can be classified according to their
appearance such as welldefined (likely interstitial! or
illdefined (likely airspace! or classified according to
their distribution in relation to other lung structures (i"e"
perilymphatic, random, or centrilobular!"
Ran,om*y ,istri-ute, no,u*es
)andom nodules are usually welldefined and appear
diffuse, but uniform in distribution"
Peri*ym'hatic no,u*es
.erilymphatic nodules are usually welldefined and
occur in relation to the lymphatics" They often affect the
pleural surfaces and the peribronchovascular,
interlobular septa, and centrilobular interstitial
components!
P*eura* effusions
Transudative pleural effusions are formed when normal
hydrostatic and oncotic pressures are disrupted"
'$udative pleural effusions occur when pleural
membranes or vasculature are damaged or disrupted
therefore leading to increased capillary permeability or
decreased lymphatic drainage"
Groun,.)*ass o'acity
is a nonspecific term that refers to the presence of
increased hazy opacity within the lungs that is not
associated with obscured underlying vessels (obscured
underlying vessels is known as consolidation!"
+t can reflect minimal thickening of the septal or
alveolar interstitium, thickening of alveolar walls, or the
presense of cells or fluid filling the alveolar spaces"
+n an acute setting, it can represent active disease
such as pulmonary edema, pneumonia, or diffuse
alveolar damage"
Honeycom-in)
suggests e$tensive lung fibrosis with alveolar
destruction and can result in a cystic appearance on
gross pathology"
can be diagnosed via &)%T by the presence of thich
walled, airfilled cysts, usually between the size of 3mm
to /cm in diameter"
Lym'ha,eno'athy
'nlargement of hilar or mediastinal lymph nodes can
be symmetric or asymmetric"
17
+t can represent hematogenous metastasis, a primary
carcinoma, or other pathology"
+osaic 'erfusion 3 attenuation
refers to areas of decreased attenuation which results
from regional differences in lung perfusion secondary
to airway disease or pulmonary vascular disease"
*istribution is often patch, hence the designation
Smosaic"S
,ften with mosaic perfusion, the pulmonary arteries will
be reduced in size in the lucent lung fields thus
allowing mosaic perfusion to be distinguished from
groundglass opacity
Inter*o-u*ar se'ta* thicEenin)
is commonly seen in patients with interstitial lung
disease"
,n &)%T, numerous clearly visible septal lines usually
indicates the presence of some interstitial abnormality"
(eptal thickening can be defined as being either
smooth, nodular or irregular and each likely represents
a different pathologic process"
Tree.in.-u,
appearance represents dilated and fluidfilled (i"e" pus,
mucus, or inflammatory e$udate! centrilobular
bronchioles"
#bnormal StreeinbudS bronchioles can be
distinguished from normal centrilobular bronchioles by
their more irregular appearance, lack of tapering or
knobbyCbulbous appearance at the tip of their
branches"
The StreeinbudS distribution is often patch throughout
the lung"
Patterns of O'acities in Infi*trati4e Lun) Disease
"o,u*ar or reticu*ar no,u*ar 'attern =Sma** Roun,e,
O'acities>
(ilicosis
%oal workerKs pneumoconiosis
&ypersensitivity pneumonitis
&istiocystosis T
Lymphangitic carcinomatosis
(arciodosis
.ulmonary alveolar microlithiasis
Linear Pattern =Sma** Irre)u*arI Reticu*ar O'acities>
+diopathic pulmonary fibrosis (3+.! (+.<!
%hronic interstitial pneumonias (*+., L+., 5+.!
(arciodosis
)adiotion fibrosis
<ibrosis associated with collagen vascular disease
#sbestosis
*rug reactions
18
Lymphangitic carcinomatosis
Cystic Pattern
+.< (honeycombing!
Lymphangioleiomyomatosis
&istiocytosis T
Groun,.G*ass Attenuation
&ypersensitivity pneumonitis
*+., +.<
#lveolar proteinosis
Parenchyma* conso*i,ation =air.s'ace or a*4eo*ar
,isease>
5ronchiolitis obliterans organizing pneumonia
%hronic eosinophilic pneumonia
5ronchioloalveolar carcinoma
Lymphoma
#lveolar proteinosis
9asculitis
.ulmonary hemorrhage
Se'ta* Lines
Lymphangitic carcinomatosis
%&< > interstitial edema
$ona* Preference
#''er $ones
(ilicosis
%oal workerKs pneumoconiosis
(arcoidosis
#nkylosing spondylitis
&istiocytosis T
Lower $ones
%hronic interstitial pneumonias
+.<
#sbestosis
<ibrosis due to collagen vascular disease
Centra*
.ulmonary edema
.ulmonary alveolar proteinosis
(ome lymphangitic tumors (BaposiKs!
Peri'hera*
%hronic interstitial pneumonias, +.<
5ronchiolitis obliteransorganizing pneumonia
%hronic eosinophilic pneumonia
P*eura* Disease
.neumothora$
&istiocytosis T
'ndstage honeycombing
P*eura* Effusion
Lymphangioleiomyomatosis
%ollagen vascular disease
Lymphangitic carcinomatosis
.ulmonary edema
P*eura* ThicEenin)
19
#sbestosis (pla7ues or diffuse!
%ollagen vascular disease
Lun) Ho*umes Re,uce,
+diopathic pulmonary fibrosis
%hronic interstitial pneumonias
#sbestosis
%ollagen vascular disease
"orma*
(arcoidosis
&istiocytosis
Increase,
lymphangioleoiomyomatosis
Hi)h.reso*ution CT.Linear O'acities
Thickening of bronchovascular bundles (a$ial!
+nterlobular septal thickening (septal lines!
+ntralobular interstitial thickening
&oneycombing
(ubpleural lines
%entrilobular abnormalities
:'*+#(T+43::
! Anterior +e,iastinum
0oun,aries
anteriorly by the sternum
posteriorly by the anterior margins of the pericardium,
aorta, and brachiocephalic vessels
"orma* structures
Thymus gland
Lymph nodes
<at
+nternal mammary vessel
Differentia* ,ia)nosis of anterior me,iastina* masses
Thymoma
Lymphoma
-erm cell neoplasms
Thyroid abnormalities
%! +i,,*e +e,iastinum
0oun,aries
5y posterior margin of anterior division and anterior
margin of posterior division
"orma* structures
&eart and pericardium
#scending and transverse aorta
5rachiocephalic vessels
(9% and +9%
:ain pulmonary vessel
Trachea and main bronchi
Lymph nodes
<at
Differentia* ,ia)nosis of mi,,*e me,iastina* masses
Lymphanedopathy
5ronchogenic cyst
9ascular abnormalities
.ericardial cyst
20
Tracheal tumor
&! Posterior +e,iastinum
0oun,aries
5ounded anteriorly by the posterior margins of the
pericardium and great vessels and posteriorly by the
thoracic vertebral bodies
"orma* structures
*escending thoracic aorta
'sophagus
Thoracic duct
#zygousChemiazygous
#utonomic nerves
Lymph nodes
<at
Differentia* ,ia)nosis of 'osterior me,iastina*
masses
4eurogenic tumors
.aravertebral abnormalities
9ascular abnormalities
'sophageal abnormalities
Lymphadenopathy
4eurenteric cyst
5ochdalek hernia
'$tramedullary hematopoeisis
Thymoma
Demo)ra'hics
A)e
3sually ;@J@P unusal in patients less than 3@
Gen,er
:ale and females e7ually
#ssociations
:yasthenia gravis, hypogammaglobulinemia, red cell
aplasia
Descri'ti4e features
Thymoma =nonin4asi4e>
Eelldefined, round, soft tissue, density mass,
usually located anterior to the junction of the heart and
great vessels
%urvilinear calcification in 0@A
In4asi4e thymoma
#dditional findings of invasion of adjacent
mediastinal structures, chest wall invasion, or contiguous
spread along pleural surfaces (usually unilaterally!
Ho,)EinFs *ym'homa
Demo)ra'hics
A)e
5imodal distribution, with initial peak in young adults
and second peak after age ?@
Gen,er
21
:ale predominance, especially among youngest patients
Descri'ti4e features
9ariable appearance, ranging from a single
spherical soft tissue mass to a large lobulated mass
:argins may be welldefined or irregular
The mass may be homogenous or heterogenous
soft tissue attenuation
%alcification is rare in untreated cases
Germ.ce** neo'*asms
Demo)ra'hics
A)e
6oung patients, usually third decade
Gen,er
:alignant germ cell neoplasms >male predominance
Descri'ti4e features
0eni)n GC" =TeratomaI Dermoi, Cyst>
&eterogenous, predominantly cystic mass with
solid components
Eelldefined margins
%alcification common
.resence of fat is suggestiveP identification of a
tooth, while rare, is diagnostic
+a*i)nant GC"=seminomaI choriocarcinomaI
Em-ryona* ce** carcinomaI Yo*E sac tumor>
&eterogenous solid mass
+rregular margins
%alcification uncommon
Thyroi, +asses
Demo)ra'hics
A)e > usually L3@ years of age
Gen,er female predominance
Descri'ti4e features
CJR features
Eelldefined mass that e$tends from above the
thoracic inlet
*isplacement andCor compression of the trachea
<oci of calcification may occasionally be visible
CT features
%ontinuity with the cervical thyroid gland
<oci of high attenuation on noncontrast images
+ntense enhancement following intravenous
contrast administration
%ystic areas and foci of calcification are common
0roncho)enic Cyst
Demo)ra'hics
#ge > often seen on younger patients but may be
detected at any age
-ender > males and females e7ually
Descri'ti4e features
(ubcarinal or right paratracheal location
Eelldefined homogenous mass with
imperceptible walls
<luid or softtissue attenuation on %T
9ariable appearance on :)+, depending on cyst
contents low signal on T/ and bright on T0 or
22
bright signal or T/ and bright on T0 (if cyst
contains mucin, protein or hemorrhage
"euro)enic tumors
Demo)ra'hics
#ge usually occur in younger patients first ; decades of
life
-ender males and females e7ually affected
Descri'ti4e features
"er4e sheath tumors
)ound, homogenous, paraspinal mass
:ay be associated with widening of the neural
foramen
:)+: slightly brighter than muscle on T/ and very
bright on T0 homoegenous enhancement following
gadolinium administration
Sym'athetic chain tumors
<usiforms, homogenous parspinal mass
:ay be associated with vertebral body erosion
:) characteristics similar to those of nerve sheath
tumor
.L'3)#
)adiologic featuers of pneumothora$
(tandard radiographs
9isceral pleural line separated from chest wall by gas
space devoid of vessels
#pe$ when upright
Lung opa7ue only with complete collapse
Tension
:ediastinal shift
*epression of hemidiaphragm
(upine
:edial recessju$tacardiac
*eep sulcus sign
(ubpulmonic
)etrocardiac lucent triangle medially
#ncillary views
'$piratory
*ecubitus
.itfalls
(kinfolds
%lothing
Tubing artifacts
5ullae
%T
23
:ore sensitive in detection of small pneunothoraces
:ore accurate in determining size
:alignant :esothelioma
%linical features
)are > 0@@@ to 3@@@ cases per year
F@A history of asbestos e$posure
3@ to ;@ year latency
J
th
to F
th
decades of life
:en more than women > ;:/
(ymptoms
%hest pain
*yspneaP weight loss
.athologic features
Types
'pithelial (?@A!
(arcomatous
:i$ed
-ross fetures
'ncasement of lung
-rowth of tumor into lung, chest wall, mediastinum,
diaphragm
)adiologic features
(tandard radiographs
*iffuse pleural thickening
4odular
'ncases lung
.leural effusion
.leural mass
*ecrease in size of hemithora$, shift of mediastinum to
affected side
.la7ues
%T
(taging
'$tent
%hest wall, mediastinal diaphragmatic invasion
:)
+mproved staging
.leural metastases
,rigins
Lung
5reast
,vary
(tomach
Lymphoma
:anifestation
:aligant effusion
*iffuse thickening
<ocal seeding
BENIGN VS MALIGNANT NODULE
Benign M!ignn"
S#$e %&'n( i))eg'!)
Si*e + 3 ,- . 3 ,-
S$i,'!"i&n /0en" $)e0en"
M)gin0 1e!! (e2ine( i!! (e2ine(
24
3!,i2i,"i&n $)e0en" /0en"
34i""i&n /0en" $)e0en"
D&'/!ing "i-e + 1 -& &) . 2 5)0 . 1 -& &) + 2 5)0
MEDIASTINAL VS PULMONARY MASS
MEDIASTINAL MASS PULMONARY MASS
E$i,en"e) in "#e -e(i0"in'- E$i,en"e) in !'ng
O/"'0e ng!e 16 "#e !'ng A,'"e ng!e 16 "#e !'ng
7-8 i) /)&n,#&g)- 798 i) /)&,#&g)-
S-&&"# n( 0#)$ -)gin0 I))eg'!) -)gin0
M&4e-en" 16 01!!&1ing M&4e-en" 16 )e0$i)"i&n
Bi!"e)! 'ni!"e)!
)adiologic signs
/" air bronchogramUindicates a parenchymal process,
including nonobstructive atelectasis, as distinguished
from pleural or mediastinal processes
0! deep sulcus sign on a supine radiographUindicates
pneumothora$
3" -olden ( sign indicates lobar collapse caused by a
central mass, suggesting an obstructing bronchogenic
carcinoma in an adult
;" &amptonKs humpUpleuralbased, wedgeshaped
opacity indicating a pulmonary infarct
?" silhouette signUloss of the contour of the heart, aorta
or diaphragm allowing localization of a parenchymal
process (eg, a process involving the medial segment of
the right middle lobe obscures the right heart border, a
lingular process obscures the left heart border, a basilar
segmental lower lobe process obscures the diaphragm!
25