pulmonary radiology พญ. ปาณยา ทุมสท้าน...
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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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