radio - chest 2008 las

CHEST CHEST RADIOLOGYRADIOLOGY

Louis Allan P. Serrano, MD, FPCRLouis Allan P. Serrano, MD, FPCR

““You only see what you know.”You only see what you know.”

- Lawrence R. Goodman, MD - Lawrence R. Goodman, MD Felson’s Principles of Chest RoentgenologyFelson’s Principles of Chest Roentgenology

Normal Chest, AdultNormal Chest, Adult(AP and Lateral views)(AP and Lateral views)

Normal Chest (PA view)Normal Chest (PA view)

Normal Chest (Lateral View)Normal Chest (Lateral View)

Normal Chest, PediatricNormal Chest, Pediatric(AP and Lateral views)(AP and Lateral views)

Normal Thymus Gland, PediatricNormal Thymus Gland, Pediatric

““sail sign”sail sign”

Normal Thymus Gland, PediatricNormal Thymus Gland, Pediatric

““wavy margin or wavy sail wavy margin or wavy sail sign”sign”

Right Lung (PA View)Right Lung (PA View)

Right Lung (Lateral View)Right Lung (Lateral View)

Left Lung (AP View)Left Lung (AP View)

Companion ShadowsCompanion Shadows

Minor FissureMinor Fissure

Rhomboid FossaRhomboid Fossa

Nipple ShadowsNipple Shadows

Calcified Costal CartilagesCalcified Costal Cartilages

Apicolordotic ViewApicolordotic View

Right Lateral Decubitus ViewRight Lateral Decubitus View

Bony ThoraxBony Thorax

Poor InspirationPoor Inspiration

Chest AP, Supine

DISEASES DISEASES OF THE OF THE LUNG LUNG

PARENCHYMPARENCHYMAA

P N E U M O N I P N E U M O N I A A

PNEUMOCOCCAL PNEUMOCOCCAL PNEUMONIAPNEUMONIA

Caused by Caused by Streptococcus Streptococcus PneumoniaePneumoniae, serotype 8, serotype 8

Produces lobar pneumonia - lower Produces lobar pneumonia - lower lobes and posterior segments of lobes and posterior segments of upper lobes are most often involvedupper lobes are most often involved

Consolidation seen as homogenous Consolidation seen as homogenous density on x-ray, begins peripherally density on x-ray, begins peripherally and spreads centripetally, may cross and spreads centripetally, may cross segmental boundariessegmental boundaries

Pneumococcal Pneumococcal PneumoniaPneumonia

Lobar PneumoniaLobar Pneumonia

KLEBSIELLA PNEUMONIAKLEBSIELLA PNEUMONIA

““Friedlander’s Pneumonia”Friedlander’s Pneumonia”caused by caused by Klebsiella pneumoniaeKlebsiella pneumoniaecommon in elderly and debilitated common in elderly and debilitated

patientspatientsconfluent densities seen in one or both confluent densities seen in one or both

upper lobesupper lobesmay have cavitationsmay have cavitations increase lung volume producing bulging increase lung volume producing bulging

fissurefissure

Klebsiella PneumoniaKlebsiella Pneumonia

““bulging fissure sign”bulging fissure sign”

STAPHYLOCOCCAL STAPHYLOCOCCAL PNEUMONIAPNEUMONIA

Caused by Caused by Staphylococcus aureusStaphylococcus aureus may be primary in the lungs or secondary to a may be primary in the lungs or secondary to a

primary Staph. infection elsewhere in the bodyprimary Staph. infection elsewhere in the body debilitated adults and infants in 1st year of lifedebilitated adults and infants in 1st year of life seen as dense areas that may be segmental or seen as dense areas that may be segmental or

diffuse on x-raydiffuse on x-ray Pleural effusion, empyema, pneumothorax, Pleural effusion, empyema, pneumothorax,

pneumatocoeles, abscess formation may occurpneumatocoeles, abscess formation may occur

Pneumatocoele - thin walled cystic Pneumatocoele - thin walled cystic lucency showing rapid change in sizelucency showing rapid change in size

caused by check-valve type of caused by check-valve type of obstructionobstruction

STAPHYLOCOCCAL STAPHYLOCOCCAL PNEUMONIAPNEUMONIA

PneumatocelePneumatocele

PneumatocoelePneumatocoele

LUNG ABSCESSLUNG ABSCESS Occurs when suppurative lung infections Occurs when suppurative lung infections

break down to form a cavitybreak down to form a cavity majority are bronchogenic in originmajority are bronchogenic in origin most often due to anaerobic organismsmost often due to anaerobic organisms On x-ray: On x-ray:

- initially seen as consolidation and - initially seen as consolidation and eventually forming a cavitation (thick eventually forming a cavitation (thick walled) with bronchial communicationwalled) with bronchial communication

- may have air-fluid level within the cavity- may have air-fluid level within the cavity

Lung AbscessLung Abscess

SILHOUETTE SIGNSILHOUETTE SIGN

Felson’s “Silhouette sign” Felson’s “Silhouette sign”

- an intrathoracic lesion - an intrathoracic lesion touching a border of the touching a border of the heart, aorta or diaphragm will heart, aorta or diaphragm will obliterate that border on the obliterate that border on the roentgenogramroentgenogram

Right Middle Lobe Right Middle Lobe PneumoniaPneumonia

(Silhouette sign) (Silhouette sign)

TUBERCULOSISTUBERCULOSIS upper lobes is the most common siteupper lobes is the most common site

- apical and posterior segment- apical and posterior segment

- sometimes in the superior segment of - sometimes in the superior segment of the lower lobethe lower lobe

may exhibit cavitation in cases of necrosismay exhibit cavitation in cases of necrosis dissemination of three types:dissemination of three types:

1. Bronchogenic1. Bronchogenic

2. Hematogenous - miliary TB, 2. Hematogenous - miliary TB, extrapulmonary lesions throughout the bodyextrapulmonary lesions throughout the body

3. Lymphangitic - common in Primary 3. Lymphangitic - common in Primary PTBPTB

TUBERCULOSISTUBERCULOSIS Healing of PTB:Healing of PTB:

- complete resolution, decrease in - complete resolution, decrease in thickness and size of cavitation, fibrosis, thickness and size of cavitation, fibrosis, calcification calcification

PRIMARY TUBERCULOSISPRIMARY TUBERCULOSIS

- seen as primary complex on x-ray:- seen as primary complex on x-ray:

* Ghon’s tubercle* Ghon’s tubercle

* Hilar adenopathy* Hilar adenopathy

* Lymphangitis* Lymphangitis

PRIMARY PRIMARY TUBERCULOSISTUBERCULOSIS

TUBERCULOSISTUBERCULOSIS

Tuberculosis, healingTuberculosis, healing

TUBERCULOMASTUBERCULOMAS

MILIARY TUBERCULOSISMILIARY TUBERCULOSIS

C O N G E N I T A C O N G E N I T A L L

D I S O R D E R SD I S O R D E R S

TRACHEOMALACIATRACHEOMALACIA Is a rare expiratory problemIs a rare expiratory problem it is due to the presence of extremely it is due to the presence of extremely

frail and underdeveloped tracheal frail and underdeveloped tracheal cartilage, hence adequate support is cartilage, hence adequate support is lacking and exaggerated expiratory lacking and exaggerated expiratory collapse of the entire trachea occurscollapse of the entire trachea occurs

TRACHEOMALACIATRACHEOMALACIA

CONGENITAL LOBAR CONGENITAL LOBAR EMPHYSEMAEMPHYSEMA

Male predominance 3:1Male predominance 3:1 left upper and right middle lobes are left upper and right middle lobes are

most often involvedmost often involved lower lobes are rarely affectedlower lobes are rarely affected On X-ray:On X-ray:

- marked radiolucency in the region - marked radiolucency in the region of the involved lobeof the involved lobe

- volume is markedly increased, - volume is markedly increased, resulting in depression of the resulting in depression of the hemidiaphragm in the involved side and hemidiaphragm in the involved side and displacement of the mediastinum away displacement of the mediastinum away from it.from it.

CONGENITAL LOBAR CONGENITAL LOBAR EMPHYSEMAEMPHYSEMA

CONGENITAL CYSTIC CONGENITAL CYSTIC ADENOMATOID ADENOMATOID

MALFORMATION (CCAM)MALFORMATION (CCAM)

Rare form of congenital cystic Rare form of congenital cystic disease of the lung in which neonatal disease of the lung in which neonatal respiratory distress is often presentrespiratory distress is often present

polyhydramnios and associated fetal polyhydramnios and associated fetal anomalies are commonanomalies are common

CONGENITAL CYSTIC CONGENITAL CYSTIC ADENOMATOID MALFORMATION ADENOMATOID MALFORMATION

(CCAM)(CCAM) On X-ray:On X-ray:- quite variable, depending on the - quite variable, depending on the

size of the lesion and whether it contains size of the lesion and whether it contains fluid or air.fluid or air.

- may present as a pulmonary mass - may present as a pulmonary mass that displaces the mediastinum and often that displaces the mediastinum and often herniates into the opposite hemithoraxherniates into the opposite hemithorax

- the multiple cysts result in a course, - the multiple cysts result in a course, honey-combed appearance; air-fluid levels honey-combed appearance; air-fluid levels may be observedmay be observed

- the cysts may be filled with fluid, - the cysts may be filled with fluid, presenting an x-ray picture of a large solid presenting an x-ray picture of a large solid massmass

CONGENITAL CYSTIC ADENOMATOUS CONGENITAL CYSTIC ADENOMATOUS MALFORMATIONMALFORMATION

DIAPHRAGMATIC HERNIADIAPHRAGMATIC HERNIA

BOCHDALEK HERNIABOCHDALEK HERNIA

- posterolateral in position- posterolateral in position

- common on the left side (2:1)- common on the left side (2:1)

- loops of bowel herniates causing - loops of bowel herniates causing respiratory distress and unilateral respiratory distress and unilateral hypoplasiahypoplasia

Diaphragmatic Hernia Diaphragmatic Hernia (Bochdalek)(Bochdalek)

MORGAGNI HERNIAMORGAGNI HERNIA

occurs mainly on the right through occurs mainly on the right through the retrosternal Morgagni’s foramen the retrosternal Morgagni’s foramen (Larrey’s space)(Larrey’s space)

small and contains omentumsmall and contains omentumoften seen as a basal mass shadow often seen as a basal mass shadow

usually in the cardiohepatic regionusually in the cardiohepatic region

MORGAGNI HERNIAMORGAGNI HERNIA

U P P E R A I R W A U P P E R A I R W A Y Y

D I S E A S ED I S E A S E

CROUPCROUP

Common inflammatory Common inflammatory conditions of the larynx and conditions of the larynx and upper trachea in childhoodupper trachea in childhood

usually caused by a virus and usually caused by a virus and usually occurs in children from usually occurs in children from 6 months to 3 years of age6 months to 3 years of age

CROUPCROUP On X-ray:On X-ray:

- typical lateral view finding are those - typical lateral view finding are those of pronounced hypopharyngeal of pronounced hypopharyngeal overdistention, indistinctness and overdistention, indistinctness and thickening of the vocal cords, thickening of the vocal cords, prominence of the laryngeal ventricle prominence of the laryngeal ventricle and subglottic tracheal narrowingand subglottic tracheal narrowing

- on frontal view - slit-like narrowing of - on frontal view - slit-like narrowing of the glottis is seen termed as the the glottis is seen termed as the “steeple” or “funnel” sign“steeple” or “funnel” sign

CROUP (“Steeple” or “Funnel” CROUP (“Steeple” or “Funnel” Sign)Sign)

EPIGLOTTITISEPIGLOTTITIS also a common inflammatory condition of also a common inflammatory condition of

the larynx and upper trachea in childhoodthe larynx and upper trachea in childhood due to due to Haemophilus influenzaeHaemophilus influenzae On X-ray:On X-ray:

- thickening of both epiglottis and - thickening of both epiglottis and aryepiglottic foldsaryepiglottic folds

- there is also swelling of the arytenoids, - there is also swelling of the arytenoids, uvula, the prevertebral and uvula, the prevertebral and retropharyngeal soft tissuesretropharyngeal soft tissues

EPIGLOTTITISEPIGLOTTITIS

“thumb sign”

L O W E R A I R W A L O W E R A I R W A Y Y

D I S E A S ESD I S E A S ES

BRONCHOPNEUMONIABRONCHOPNEUMONIAlobular pneumonialobular pneumoniaoriginates in the airways and originates in the airways and

spread to peribronchial alveolispread to peribronchial alveolioften presents at the extremes of often presents at the extremes of

lifelifehas variety of x-ray patterns has variety of x-ray patterns

caused by a number of organismscaused by a number of organisms

BRONCHOPNEUMONIABRONCHOPNEUMONIA

AIR - BRONCHOGRAM SIGN

BRONCHIECTASISBRONCHIECTASISpersistent dilatation of the persistent dilatation of the

bronchibronchican be cylindrical, varicose or can be cylindrical, varicose or

saccularsaccularX-ray:X-ray:

- patchy pneumonic densities - patchy pneumonic densities which parallel linear or circular which parallel linear or circular ring like shadowsring like shadows

BRONCHIECTASISBRONCHIECTASIS

BRONCHIOLITISBRONCHIOLITISAcute disease usually observed Acute disease usually observed

in infants in the first 2 years of in infants in the first 2 years of life, peak incidence is around 6 life, peak incidence is around 6 months wherein there is months wherein there is widespread involvement of widespread involvement of small bronchi & bronchiolessmall bronchi & bronchioles

BRONCHIOLITISBRONCHIOLITIS On X-ray:On X-ray:

- overaeration of the lungs is the rule, - overaeration of the lungs is the rule, flat diaphragmsflat diaphragms

- lung appears clearer than normal and - lung appears clearer than normal and there is very little change in expirationthere is very little change in expiration

- some demonstrates with parahilar - some demonstrates with parahilar and peribronchial infiltrates with and peribronchial infiltrates with scattered areas of atelectasisscattered areas of atelectasis

- others, probably over 50% - others, probably over 50% demonstrate completely clear lungsdemonstrate completely clear lungs

BRONCHIOLITISBRONCHIOLITIS

ASTHMAASTHMAMay have no x-ray findings early in the May have no x-ray findings early in the

course of the diseasecourse of the diseaseX-ray fidnings:X-ray fidnings:

- increase lucency of the lungs - increase lucency of the lungs because of acute overdistention because of acute overdistention - focal areas of atelectasis- focal areas of atelectasis - interstitial markings thickened in the - interstitial markings thickened in the parahilar and central pulmonary zoneparahilar and central pulmonary zone - depression of the diaphragm- depression of the diaphragm - pneumomediastinum and - pneumomediastinum and pneumothorax may occur in acute pneumothorax may occur in acute attackattack

ASTHMAASTHMA

PULMONARY PULMONARY EMPHYSEMAEMPHYSEMA

An anatomic alteration of the lung An anatomic alteration of the lung characterized by an abnormal characterized by an abnormal permanent enlargement of the air permanent enlargement of the air spaces distal to the terminal non-spaces distal to the terminal non-respiratory bronchiole, respiratory bronchiole, accompanied by destructive accompanied by destructive changes of the alveolar walls and changes of the alveolar walls and without obvious fibrosiswithout obvious fibrosis

Types:Types:

1. Centrilobular (centriacinar) - 1. Centrilobular (centriacinar) - destruction of parenchyma predominates destruction of parenchyma predominates in central portion of secondary lobulein central portion of secondary lobule

- most frequently associated with - most frequently associated with cigarette smokingcigarette smoking

2. Panlobular (panacinar) - more diffuse; 2. Panlobular (panacinar) - more diffuse; associated with α-1 antitrypsin associated with α-1 antitrypsin deficiencydeficiency

BULLOUS EMPHYSEMABULLOUS EMPHYSEMA

COR PULMONALECOR PULMONALETerm used to indicate right ventricular Term used to indicate right ventricular

hypertrophy that may lead to right hypertrophy that may lead to right sided heart failure, produced by any sided heart failure, produced by any disease abnormality (exclusive of disease abnormality (exclusive of primary cardiac disease)primary cardiac disease)

Usually leads to pulmonary Usually leads to pulmonary hypertensionhypertension

Pulmonary emphysemaPulmonary emphysema – most – most common cause. common cause.

Other causes of cor pulmonale:Other causes of cor pulmonale:

- congenital and acquired - congenital and acquired alterations in the thorax alterations in the thorax (kyphoscoliosis and thoracoplasty)(kyphoscoliosis and thoracoplasty)

- COPD, PTB, pneumoconioses, - COPD, PTB, pneumoconioses, recurrent pulmonary embolirecurrent pulmonary emboli

COR PULMONALECOR PULMONALE

Roentgen findings:Roentgen findings:

- enlarged pulmonary infundibulum & - enlarged pulmonary infundibulum & pulmonary arteries with increase in pulmonary arteries with increase in size of hilar arteries bilaterallysize of hilar arteries bilaterally

- when RVH is marked, there may be - when RVH is marked, there may be convexity of the lower right convexity of the lower right anterior cardiac silhouette and the anterior cardiac silhouette and the apex may be elevated and rounded.apex may be elevated and rounded.

- pulmonary emphysema is often - pulmonary emphysema is often present present

COR PULMONALECOR PULMONALE

N E O P L A S T N E O P L A S T I C I C

D I S E A S E S D I S E A S E S

BENIGN TUMORSBENIGN TUMORS HAMARTOMAHAMARTOMA

most common benign lung tumormost common benign lung tumor may contain cartilage, muscle, fibrous may contain cartilage, muscle, fibrous

connective tissue, fat and epithelial connective tissue, fat and epithelial elementselements

usually peripheral in type and is found usually peripheral in type and is found near a pleural surfacenear a pleural surface

peak incidence in the 6th decade of peak incidence in the 6th decade of lifelife

On X-ray:On X-ray:

- well circumscribed, - well circumscribed, pulmonary parenchymal nodule pulmonary parenchymal nodule < 4 cm in diameter< 4 cm in diameter

- (+) calcification in 25-30% - (+) calcification in 25-30% of cases, “of cases, “popcorn calcification”popcorn calcification”

HAMARTOMAHAMARTOMA

““popcorn calcification”popcorn calcification”

MALIGNANT TUMORSMALIGNANT TUMORS BRONCHOGENIC CARCINOMABRONCHOGENIC CARCINOMA

Classification:Classification:1. EPIDERMOID OR SQUAMOUS CELL CA1. EPIDERMOID OR SQUAMOUS CELL CA

> in males with ratio of 2 or 3:1> in males with ratio of 2 or 3:1 accounts for almost 1/3 of all bronchogenic tumorsaccounts for almost 1/3 of all bronchogenic tumors tends to occur in relatively older age grouptends to occur in relatively older age group often arises in or immediately adjacent to lobar often arises in or immediately adjacent to lobar

and segmental bronchi but is occasionally and segmental bronchi but is occasionally peripheralperipheral

when a primary tumor is noted to invade the when a primary tumor is noted to invade the thoracic wall, it is more likely to be epidermoidthoracic wall, it is more likely to be epidermoid

invasion with veins with hematogenous metastases invasion with veins with hematogenous metastases occur lateoccur late

2. ADENOCARCINOMA2. ADENOCARCINOMA

most common of the most common of the bronchogenic tumor found in bronchogenic tumor found in femalesfemales

tends to be more peripheraltends to be more peripheral

MALIGNANT TUMORSMALIGNANT TUMORS

ADENOCARCINOMAADENOCARCINOMA

3. SMALL CELL CA3. SMALL CELL CA often occurs centrally with hilar often occurs centrally with hilar

enlargement and massive mediastinal enlargement and massive mediastinal lymph node metastaseslymph node metastases

does not undergo necrosis to form does not undergo necrosis to form cavitationcavitation

Small cell CA. Contrast-enhanced CT scan of the Small cell CA. Contrast-enhanced CT scan of the chest shows a large left lung and a hilar mass, chest shows a large left lung and a hilar mass, with invasion of the left pulmonary artery.with invasion of the left pulmonary artery.

4.4. LARGE CELL CALARGE CELL CA

Bulky large tumors that occurs Bulky large tumors that occurs peripherallyperipherally

Pleural involvement with effusion Pleural involvement with effusion is common is common

LARGE CELL LUNG CA

5. 5. BRONCHOALVEOLAR CABRONCHOALVEOLAR CAa form of adenocarcinomaa form of adenocarcinomatwo (2) forms:two (2) forms:

1. Tumor-like or nodular form1. Tumor-like or nodular form

2. diffuse type - resembles 2. diffuse type - resembles pneumonic consolidation pneumonic consolidation roentgenographicallyroentgenographically

BRONCHOALVEOLAR CABRONCHOALVEOLAR CA

PLAIN RADIOLOGIC FINDINGS IN PLAIN RADIOLOGIC FINDINGS IN LUNG CANCER BY CELL TYPELUNG CANCER BY CELL TYPE

FINDINGSFINDINGSSquamoSquamo

Cell CACell CA

AdenoCAAdenoCA Small Small CellCell

Large Large CellCell

Solitary Solitary nodule or nodule or massmass

30%30% 75%75% 15%15% 65%65%

AtelectasisAtelectasis 40%40% 10%10% 20%20% 15%15%

ConsolidatiConsolidationon

20%20% 15%15% 20%20% 25%25%

Hilar Hilar enlargemenenlargementt

40%40% 20%20% 80%80% 30%30%

FINDINGSFINDINGSSquamoSquamo

Cell CACell CA

AdenoAdeno

CACASmall Small CellCell

Large Large CellCell

MediastinalMediastinal

MassMass<5%<5% <5%<5% 15%15% 10%10%

Pleural Pleural effusioneffusion

5%5% 5%5% 5%5% 5%5%

No No abnormalitiabnormalitieses

5%5% <5%<5% 0%0% 0%0%

Multiple Multiple abnormalitiabnormalitieses

35%35% 30%30% 65%65% 45%45%

PLAIN RADIOLOGIC FINDINGS IN PLAIN RADIOLOGIC FINDINGS IN LUNG CANCER BY CELL TYPELUNG CANCER BY CELL TYPE

SOLITARY PULMONARY SOLITARY PULMONARY NODULENODULE

Approximately Approximately 1/31/3 of lung of lung cancers present cancers present radiographically as a SPN radiographically as a SPN (<3cm)(<3cm) or a lung mass or a lung mass (>3cm)(>3cm)

This CT scan shows a single lesion (pulmonary nodule) in the right lung

FINDINGS WHICH DISTINGUISH FINDINGS WHICH DISTINGUISH BENIGN AND MALIGNANT SPNBENIGN AND MALIGNANT SPN

BENIGNBENIGN MALIGNANTMALIGNANT

PATIENT AGEPATIENT AGE** <35<35 >50>50

Size Size <2 cm<2 cm >2 cm>2 cm

ShapeShape round, ellipticalround, elliptical irregularirregular

ContourContour smoothsmooth spiculatedspiculated

EdgeEdge well definedwell defined poorly definedpoorly defined

BENIGNBENIGN MALIGNANTMALIGNANT

CALCIFICATIONCALCIFICATION** Dense, central, Dense, central, concentricconcentric

None or other None or other patternspatterns

Doubling TimeDoubling Time <1 month or > <1 month or > 16 months16 months

>1 month and>1 month and

< 16 months< 16 months

GROWTHGROWTH** No growth in 2 No growth in 2 yrs.yrs.

GrowthGrowth

Satellite lesionsSatellite lesions NoNo YesYes

CavitationCavitation No No Yes Yes

* Findings of most value in diagnosing benign SPN

USES OF CT IN PATIENTS WITH A USES OF CT IN PATIENTS WITH A SPN ON PLAIN RADIOGRAPHSSPN ON PLAIN RADIOGRAPHS

1. confirm that a nodule is present1. confirm that a nodule is present2. define its morphology2. define its morphology3. detect calcification3. detect calcification4. detect fat4. detect fat5. help in planning a needle biopsy or 5. help in planning a needle biopsy or

bronchoscopybronchoscopy6. staging purposes6. staging purposes

PULMONARY METASTASESPULMONARY METASTASES

Hematogenous pulmonary metastases are Hematogenous pulmonary metastases are usually multiple and consists of smoothly usually multiple and consists of smoothly rounded nodules scattered throughout rounded nodules scattered throughout both lungs. They may be uniform or vary both lungs. They may be uniform or vary considerably in size.considerably in size.

All of the sarcomas and malignant All of the sarcomas and malignant melanoma frequently metastasize to the melanoma frequently metastasize to the lungs. Carcinomas of the breast, kidney, lungs. Carcinomas of the breast, kidney, ovary, testis, colon and thyroid also ovary, testis, colon and thyroid also metastasize to the lungs.metastasize to the lungs.

PULMONARY METASTASES

D I S E A S E S O F D I S E A S E S O F

T H E T H E

M E D I A S T I N U MM E D I A S T I N U M

PNEUMOMEDIASTINUMPNEUMOMEDIASTINUMFree air in the mediastinumFree air in the mediastinum in infants, thymus gland is outlined by in infants, thymus gland is outlined by

air in the mediastinum frequently it still air in the mediastinum frequently it still looks like the thymus gland except that looks like the thymus gland except that the lobes are elevated and the term the lobes are elevated and the term “angel wings“angel wings”” or or ““spinnaker sail”spinnaker sail” sign sign have been suggested have been suggested

other configurations include air other configurations include air surrounding the heart and air outlining surrounding the heart and air outlining the inferior aspect of the heart, referred the inferior aspect of the heart, referred to as the continuous diaphragm signto as the continuous diaphragm sign

PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM

“spinnaker sail sign”

PNEUMOMEDIASTINUMPNEUMOMEDIASTINUM

MEDIASTINUMMEDIASTINUM

space lying between the right and space lying between the right and left pleurae in and near the median left pleurae in and near the median sagittal plane of the chest.sagittal plane of the chest.

extends from the posterior aspect of extends from the posterior aspect of the sternum to the anterior surface the sternum to the anterior surface of the thoracic vertebrae.of the thoracic vertebrae.

Four Major SubdivisionsFour Major Subdivisions

SUPERIORSUPERIOR – lies between the manubrium – lies between the manubrium sterni and upper four thoracic vertebraesterni and upper four thoracic vertebrae

ANTERIORANTERIOR – bounded above by the – bounded above by the thoracic inlet, laterally by the pleura, thoracic inlet, laterally by the pleura, anteriorly by the sternum, posteriorly by anteriorly by the sternum, posteriorly by the pericardium and great vessels.the pericardium and great vessels.

MIDDLEMIDDLE – the – the “vascular space”,“vascular space”, contains contains the heart and pericardium, ascending the heart and pericardium, ascending and transverse arch of the aorta.and transverse arch of the aorta.

POSTERIORPOSTERIOR - the - the “postvascular space”,“postvascular space”, lies behind the heart and pericardium lies behind the heart and pericardium and extends from the level of the and extends from the level of the thoracic inlet to T12. thoracic inlet to T12.

SUBDIVISIONS OF THE MEDIASTINUM

MEDIASTINAL MASSESMEDIASTINAL MASSES

ANTERIORANTERIOR MIDDLEMIDDLE POSTERIORPOSTERIORThyroid massThyroid mass Pericardial Pericardial

cystscystsEsophageal Esophageal cystscysts

Lipoma, Lipoma, FibromaFibroma

Tracheal Tracheal tumorstumors

Gastroenteric Gastroenteric cystscysts

HemangiomaHemangioma Thyroid massesThyroid masses Thoracic spine Thoracic spine tumorstumors

LymphangiomaLymphangioma Aortic Aortic aneurysmaneurysm

Foramen of Foramen of Morgagni Morgagni herniahernia

AmyloidosisAmyloidosis

MEDIASTINAL MASSESMEDIASTINAL MASSES

ANTERIORANTERIOR MIDDLEMIDDLE POSTERIORPOSTERIOR

Thymic cyst & Thymic cyst & tumorstumors

Hodgkin’s and Hodgkin’s and Non –Hodgkins Non –Hodgkins lymphomalymphoma

Neurogenic Neurogenic tumorstumors

Dermoid cystsDermoid cysts Lymph node Lymph node MetastasisMetastasis

MeningoceleMeningocele

TeratomaTeratoma SarcoidosisSarcoidosis Neurenteric Neurenteric cystscysts

ChoriocarcinomChoriocarcinomaa

Infectious Infectious MononucleosisMononucleosis

Esophageal Esophageal tumorstumors

SeminomaSeminoma Bronchogenic Bronchogenic cystscysts

Esophageal Esophageal diverticuladiverticula

ANTERIOR MEDIASTINAL ANTERIOR MEDIASTINAL MASSMASS

THYMOMA

ANTERIOR MEDIASTINAL MASSANTERIOR MEDIASTINAL MASS

MIDDLE MEDIASTINAL MIDDLE MEDIASTINAL MASSMASS

AORTIC ARCH ANEURYSM

POSTERIOR MEDIASTINAL MASSPOSTERIOR MEDIASTINAL MASS

Aneurysm of Descending Aorta"Mass" density

Extrapleural Posterior Mediastinal Mass

DI S E A S E S O F T H DI S E A S E S O F T H E E

P L E U R AP L E U R A

PLEURAL EFFUSIONPLEURAL EFFUSIONPleural space is lined by a smooth Pleural space is lined by a smooth

serous membrane that is lubricated by serous membrane that is lubricated by a small amount (5-15 cc) of serous fluida small amount (5-15 cc) of serous fluid

earliest x-ray sign is obliteration of the earliest x-ray sign is obliteration of the costophrenic sulcus on upright chest costophrenic sulcus on upright chest filmfilm

““meniscus sign”meniscus sign” lateral decubitus view - shifting of fluid lateral decubitus view - shifting of fluid

in the dependent portionin the dependent portion

PLEURAL EFFUSIONPLEURAL EFFUSION

PNEUMOTHORAXPNEUMOTHORAXPresence of air in the pleural cavityPresence of air in the pleural cavityOn X-ray:On X-ray: - area of hyperlucency devoid of - area of hyperlucency devoid of

lung markingslung markings - tension pneumothorax: associated - tension pneumothorax: associated

with shifting of mediastinal with shifting of mediastinal structures to the contralateral sidestructures to the contralateral side

PNEUMOTHORAXPNEUMOTHORAX

Benign TumorsBenign Tumors

Pleural based tumors include lipoma, Pleural based tumors include lipoma, fibroma, myxoma, hemangioma, fibroma, myxoma, hemangioma, chondroma, neurofibromachondroma, neurofibroma

Lipoma - most commonLipoma - most common

TUMORS OF THE PLEURA

PRIMARY MALIGNANT PRIMARY MALIGNANT TUMORSTUMORS

DIFFUSE MALIGNANT DIFFUSE MALIGNANT MESOTHELIOMAMESOTHELIOMA- usually unilateral but may spread to- usually unilateral but may spread to

pericardiumpericardium- arise in the pleura, usually in the interlobar - arise in the pleura, usually in the interlobar fissuresfissures- etiology: asbestos exposure,- etiology: asbestos exposure,

irradiation, exposure to zeolite ( nonirradiation, exposure to zeolite ( non asbestos mineral fiber)asbestos mineral fiber)

- XRAY: scalloped appearing mass involving - XRAY: scalloped appearing mass involving the pleurathe pleura

MESOTHELIOMA

MISCELLANEOUS MISCELLANEOUS PULMONARY PULMONARY CONDITIONSCONDITIONS

ATELECTASISATELECTASIS

Loss of lung volume (collapse)Loss of lung volume (collapse)A sign of disease rather than disease A sign of disease rather than disease

in itselfin itselfDirect radiographic signs: Direct radiographic signs:

increase density of the involved increase density of the involved segmentsegment

displacement of the interlobar fissure displacement of the interlobar fissure towards the involved segmenttowards the involved segment

crowding and displacement of vesselscrowding and displacement of vessels

Indirect Radiographic findings:Indirect Radiographic findings: - elevation of the hemidiaphragm- elevation of the hemidiaphragm

- mediastinal displacement- mediastinal displacement

- compensatory overinflation- compensatory overinflation

- displacement of the hila- displacement of the hila

- changes in the chest wall- changes in the chest wall

- absence of air bronchogram- absence of air bronchogram

Types:Types:1. Resorption Atelectasis - 1. Resorption Atelectasis - occurs when communication between occurs when communication between

trachea and alveoli are obstructedtrachea and alveoli are obstructedobstruction may be in a major bronchus obstruction may be in a major bronchus

or in multiple small bronchi or bronchiolesor in multiple small bronchi or bronchioles

2. Passive Atelectasis -2. Passive Atelectasis -- accompanies a space occupying - accompanies a space occupying

process (e.g. pneumothorax , process (e.g. pneumothorax , hydrothorax)hydrothorax)

ATELECTASISATELECTASIS Types:Types: 3. Compression atelectasis3. Compression atelectasis

- designates a localized form of - designates a localized form of parenchymal collapse contiguous to a parenchymal collapse contiguous to a space occupying process (e.g. space occupying process (e.g. pulmonary mass, bulla)pulmonary mass, bulla)

4. Adhesive atelectasis4. Adhesive atelectasis - microatelectasis or non-- microatelectasis or non-

obstructive (e.g. RDS)obstructive (e.g. RDS) 5. Cicatrization atelectasis 5. Cicatrization atelectasis

- loss of volume resulting from - loss of volume resulting from pulmonary fibrosispulmonary fibrosis

ATELECTASISATELECTASIS Right upper lobe collapseRight upper lobe collapse

RIGHT MIDDLE LOBE RIGHT MIDDLE LOBE COLLAPSECOLLAPSE

LEFT LOWER LOBE COLLAPSELEFT LOWER LOBE COLLAPSE

PULMONARY PULMONARY THROMBOEMBOLISMTHROMBOEMBOLISM

Most common source: thrombi in the Most common source: thrombi in the deep veins of the thigh, pelvis, calfdeep veins of the thigh, pelvis, calf

X-ray findings:X-ray findings:1) elevation of the hemidiaphragm on 1) elevation of the hemidiaphragm on

the involved sidethe involved side2) small pleural effusion2) small pleural effusion3) hyperluscent area 23) hyperluscent area 2°° to oligemia to oligemia

distal to the obstructing embolus distal to the obstructing embolus (Westermark’s Sign)(Westermark’s Sign)

4) increase in size of the central 4) increase in size of the central pulmonary arteriespulmonary arteries

5) atelectasis5) atelectasis

Figure 2. Westermark's Sign Frontal chest radiograph shows

enlargement of the left hilum accompanied by left lung

hyperlucency, indicating oligemia (Westermark's sign).

Figure 1. Oligemia Frontal chest radiograph in a patient

with acute onset hypoxemia following surgery shows diffuse,

decreased attenuation throughout the right lung, consistent with oligemia

secondary to acute pulmonary embolism.

ADULT RESPIRATORY ADULT RESPIRATORY DISTRESS SYNDROME DISTRESS SYNDROME

(ARDS)(ARDS)used widely to describe a syndrome used widely to describe a syndrome

resulting from a number in which there is resulting from a number in which there is

pulmonary injury leading to severe pulmonary injury leading to severe

permeabilitypermeability

(non-cardiogenic) pulmonary edema(non-cardiogenic) pulmonary edema

ADULT RESPIRATORY DISTRESS SYNDROME

RADIOGRAPHIC FEATURES OF RADIOGRAPHIC FEATURES OF PULMONARY EDEMAPULMONARY EDEMA

CARDIACCARDIAC RENALRENAL INJURYINJURY

Heart sizeHeart size Enlarged Enlarged Enlarged Enlarged not enlarged not enlarged

Vascular Vascular pediclepedicle

Normal or Normal or engagedengaged

Enlarged Enlarged normal or normal or reduced reduced

Pulm. blood Pulm. blood flow flow distributiondistribution

inverted inverted Balanced Balanced normal or normal or reducedreduced

Pulm. Blood Pulm. Blood volumevolume

Normal or Normal or increasedincreased

Increased Increased normal normal

Septal linesSeptal lines Not commonNot common not common not common Absent Absent

RADIOGRAPHIC FEATURES OF RADIOGRAPHIC FEATURES OF PULMONARY EDEMAPULMONARY EDEMA

CARDIACCARDIAC RENALRENAL INJURYINJURY

PeribronchiPeribronchial cuffsal cuffs

Very Very commoncommon

Not absentNot absent

Air Air BronchograBronchogramm

Not commonNot common Not commonNot common Very Very commoncommon

Lung Lung edema, edema, regional regional distributiondistribution

Even Even Central Central PeripheralPeripheral

Pleural Pleural effusionseffusions

Very Very commoncommon

Not commonNot common

SURFACTANT DEFICIENCY SURFACTANT DEFICIENCY DISEASEDISEASE

due to decrease in surfactantdue to decrease in surfactant usually seen in premature infantsusually seen in premature infants Four (4) stages - X-ray findings:Four (4) stages - X-ray findings:

Stage I: air bronchogram Stage I: air bronchogram pattern>normalpattern>normal

Stage II: “ground glass” appearanceStage II: “ground glass” appearance

Stage III: confluent opacification/dense Stage III: confluent opacification/dense

reticular patternreticular pattern

Stage IV: white lungStage IV: white lung

SURFACTANT DEFICIENCY SURFACTANT DEFICIENCY DISEASEDISEASE

THE ENDTHE ENDHave a nice day!

radio - chest 2008 las

lung volume

lung parenchym

lobar pneumonia lower

suppurative lung infections

calcification tuberculosis

pediatric ap

abscess formation

primary complex

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