PULMONARY RADIOLOGY พญ. ปาณยา ทุมสท้าน...

PULMONARY RADIOLOGY

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PULMONARY OPACITY “area that preferentially attenuates the x-ray beam”

Area that more opaque than the surrounding area

CLASSIFIED INTO Airspace opacities Atelectasis (collapse) Nodules and masses Linear and band like opacities Cysts and bullae Nodular and reticulonodular opacities and

honeycombing

AIRSPACE OPACITIES Acinar shadow Consolidation Solitary airspace opacity Multifocal airspace opacity

DIFFERENTIAL DIAGNOSIS OF AIRSPACE OPACITES

Pneumonia Atelectasis Infarction Hemorrhage Neoplasms

- BAC - Lymphoma

Radiation fibrosis Pulmonary contusion, vasculitis, drug

reaction, etc.

SOLITARY AIRSPACE OPACITY

DIFFERENTIAL DIAGNOSIS OF AIRSPACE OPACITES

Exudate and transudates Pneumonia, OP, infarction, connective tissue

disease and vasculitis, inhalation of noxious gases or liquids, drug reaction, alveolar proteinosis

Hemorrhage Pulmonary contusion/hematoma, infarction,

vasculitis Neoplasm

BAC, lymphangitic carcinomatosa, metastases, lymphoma

MULTIFOCAL AIRSPACE OPACITIES

RML PNEUMONIA

bronchopneumonia

PULMONARY EDEMA

Infectious pneumonia in a 35-year-old patient with hypogammaglobulinemia.

RadioGraphics,

November 2009 RadioGraphics, 29, 1909-1920.

Small focus of pulmonary consolidation caused by pulmonary infarction

David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

Widespread, uniform airspace opacities in acute respiratory distress syndrome

David Hansell, Imaging of diseases of the chest, 5th edition, 2010

ATELECTASIS Most frequent cause is bronchial obstruction Bronchial obstruction in adult

Usually the result of a bronchial neoplasm or mucus plug

Occasionally, FB aspiration, broncholiths, extrinsic compression e.g. enlarged LNs, aortic aneurysm

Passive atelectasis Discoid atelectasis ( Platelike or linear

atlectasis) A form of adhesive atelectasis

Usually abuts the pleura and is perpendicular to pleural surface

Golden S sign

David Hansell, Imaging of diseases of the chest, 5th edition, 2010

Left upper lobe collapse due to bronchial carcinoma. Note that the carcinoma has caused ‘rat tail’ narrowing of the left upper bronchus.

David Hansell, Imaging of diseases of the chest, 5th edition, 2010

Fluid bronchogram at CT. Fluid-filled bronchi beyond a

carcinoma in the atelectatic lower left lobe are clearly visible.  David Hansell, Imaging of diseases of the chest, 5th edition, 2010

ROUND ATELECTASIS A form of chronic atelectasis that resembles

a mass

Main DDx is BCA

“bronchi and vessels curving into the periphery and converging toward a mass and area of pleural thickening (Comet tail sign)”

David Hansell, Imaging of diseases of the chest, 5th edition, 2010

SOLITARY PULMONARY NODULE/MASS Pulmonary nodule : lesion up to 3 cm in

diameter. DDx of SPN/mass1. Neoplasm

BCA, metastasis, lymphoma, carcinoid tumor, hamartoma, etc

2. Inflammatory1. Infection: TB, fungus, round pneumonia, lung

abscess, septic emboli2. Non infection: RA, Wegener granulomatosis

SOLITARY PULMONARY NODULE/MASS DDx of SPN/mass

3. Congenital Pulmonary AVM, sequestration, lung cyst, bronchial

atresia with mucoid impaction

4. Miscellaneous Organizing pneumonia, pulmonary infarction, round

atelectasis, etc.

5. Mimics of SPN External object Bone island or rib, healing rib fracture Pleural plaque Loculated pleural fluid

PATIENT WITH A KNOWN EXTRATHORACIC MALIGNANT NEOPLASM

Patients with CA of H&N, bladder, breast, cervix, bile ducts, esophagus, ovary, prostate, or stomach with SPN “primary lung CA were more likely than

metastasis” Patients with known salivary glands,

adrenals, colon, kidney, thyroid, thymus or uterus “fairly even odds”

Patients with known melanoma, sarcoma, or testicular cancer “solitary metastasis is more likely than

primary lung CA”

Features which can be diagnostically helpful Calcification Fat density within a nodule Ground glass opacity Size Shape Cavitation Air bronchogram and bubblelike lucencies Enhancment

Concentric calcification BENIGN CALCIFICATION

Popcorn calcification

Uniform calcification

David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

Fat in hamartoma

David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

DENSITY OF THE NODULE

March 2007 RadioGraphics, 27, 391-408.

SIZE AND SHAPE

David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

FLEISCHNER SOCIETY RECOMMENDATIONS

MacMahon et al. Radiology 237:395, Nov 2005

Contrast enhancement Rate of growth Adjacent bone destruction

Air crescent sign

Silva et al. The teaching files chest. 82-83. 2010.

MULTIPLE PULMONARY NODULES Neoplasm

metastatic CA or sarcoma, lymphoma, BAC Hamartomas, laryngeal papillomatosis

Inflammatory Infective

Granulomas (TB, histoplasmosis, nocardiosis) Lung abscesses, septic emboli,etc.

Noninfective RA, Wegener granulomatosis

Congenital : AVMMiscellaneous

Hematomas, pulmonary infarction, mucoid impaction

Metastasis thyroid CA

Miliary TB

SILICOSIS

Silva et al, The teaching files chest. 40-41, 2010.

Centrilobular nodules in Subacute hypersensitivity pneumonitis Silva et al, The teaching files chest,

2010.

Tree-in-bud in infective bronchiolitis

Silva et al, The teaching files chest, 46-47,2010.

RANDOM DIST NODULES

Pulmonary metastasis

Miliary TB

Silva et al, The teaching files chest, 48-49, 2010.

ABNORMAL LUCENCY LESION Cyst, cavity, bleb, bulla, emphysema CYST;

any round circumscribed space that is surrounded by an epithelial or fibrous wall of variable thickness

CAVITY; a gas-filled space, seen as a lucency or low-

attenuation area, within pulmonary consolidation, a mass, or a nodule

usually produced by the expulsion or drainage of a necrotic part of the lesion via the bronchial tree

Cavity is not a synonym for abscess.

BLEB; a small gas-containing space within the visceral

pleura or subpleural lung, not > 1 cm in diameter

CT: a thin-walled cystic airspace contiguous with the pleura

BULLA; An airspace measuring > 1 cm – usually several

centimeters – in diameter sharply demarcated by a thin wall that is no

greater than 1 mm in thickness. usually accompanied by emphysematous changes in the

adjacent lung. Bullous emphysema is bullous destruction of the

lung parenchyma usually on a background of paraseptal or panacinar

emphysema

EMPHYSEMA; permanently enlarged airspaces distal to the

terminal bronchiole with destruction of alveolar walls

CT; focal areas or regions of low attenuation, usually without visible walls.[

cyst

Silva et al, The teaching files chest, 2010

BULLA

BLEB

IMAGE : WIKIPEDIA

EMPHYSEMA

Paraseptal and centrilobular emphysema

Imagingconsult.com

BRONCHIECTASIS

HONEYCOMBING

CYSTIC BRONCHIECTASIS HONEYBOMBING

LINEAR AND BAND-LIKE OPACITIES

Mucoid impaction Septal lines Bronchial wall (peribronchial) thickening

MUCOID IMPACTION

BRONCHIAL ATRESIA

MUCOCELE

PERIIBRONCHIAL WALL THICKENING

RETICULONODULAR OPACITIES

Acute Pulmonary edema, pneumonia (Mycoplasma,

viral, opportunistic) Lower zone

Idiopathic pulmonary fibrosis, RA, scleroderma, drug reaction, HP,

Mid- or upper zone Pulmonary TB or fungal disease,

Pneumoconiosis, HP

NODULAR AND RETICULONODULAR PARTERN

Pulmonary fibrosis

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