THE RESPIRATORY SYSTEM AND THE MEDIASTINUM

Radio-imaging - lecture III

ACUTE PNEUMOPATHIES

Inflammatory non-suppurative

Inflammatory suppurative : Primary : abscess, pulmonary gangrene, diffuse pulmonary

suppuration Secondary : complication of

pneumonia, bronchiectasis, pulmonary cysts

ETIOLOGICAL CLASSIFICATION

ETIOLOGICAL CLASSIFICATION OF PNEUMONIA - BACTERIAL - Streptococcus pneumoniae ( Pneumococcus )

- Staphilococcus aureus - Streptococcus pyogenes - Klebsiella pneumoniae ( Friedlander b.) - Other Gram-negative germs: - Pseudomonas aeruginosa ( Pyocyanic b. )

- Escherichia coli - Proteus

- Serratia - Haemophilus influenzae - Legionella pneumophila - Mycobacterium - Bordetella pertussis - Salmonella typhi and paratyphi - Brucella - B. anthracis , etc. -

-VIRAL : - Ifluenza and parainfluenza virus: - Varicella - Measles - Respiratory syncytial virus - Adenovirus - Enterovirus - Herpes virus - Cytomegalic virus - CHLAMIDII : - Chlamidia psittaci - Chlamidia trachomatis - RICKETTSII : - Coxiella burnetti (Q fever) - MYCOPLASMa : - Mycoplasma pneumoniae  - FUNGI : - Actinomyces israelii - Aspergillus fumigatus - Candida albicans - Coccidioidomyces - Histoplasma capsulatum - PROTOZOA: - Pneumocystis carinii - UNINFECTIOUS: - Aspiration pneumonia (Mendelson syndrome) - Toxic gas inhalation pneumonia - Radiation pneumonia - Lipoid pneumonia GHERASIM 2002

EIOLOGIAL CLASSIFICATION

INFLAMMATORY PNEUMONIA (NON-SUPPURATIVE)

Alveolar = pneumonia

Broncho-alveolar = bronchopneumonia

Interstitial = interstitial pneumonia

ALVEOLAR PNEUMONIA - perioada de stare -

1. Lobar or segmental2. Homogeneous opacity3. Variable intensity depending on

extent4. Sharp and linear outline (fissure)5. Blurred outline (the area not outlined

by fissure) 6. Doesn’t change the surrounding

structures7. Doesn’t change the pulmonary volume8. Air bronchogram and alveologram

Dorsal segmentitis, right superior lobe

PA RL

Middle lobe pneumonia, lateral segmentsmall pleural effusion in the right CP angle

Congestion, right inferior lobe

Bilateral air-space filling syndrome

THE EVOLUTION OF PNEUMONIA

Complications : - abcess - pleural effusion

Resorbtion: - homogeneous - unhomogenous : - chess

board -

pseudocavitary

Fowler segment abcess

Pneumonia: evolution

BRONCHOPNEUMONIA1. Broncho-alveolar inflammation2. Multiple round opacities3. Micro or macronodular4. Medium intensity5. Blurred outline6. Unhomogeneous dissemination

(bronchal)

7. The aspect changes rapidly (from one exam to the other)

Bronchopneumonia

Staphylococcal pneumonia (bronchopneumonia)

INTERSTITIAL PNEUMONIA

Etiology: - viral, - bacterial (mixed p.) - mycoplasma - chlamydia - rickettsia, - protozoa

INTERSTITIAL PNEUMONIA1. Accentuated peribronchovascular

interstitium

2. Reticular infrahilar pattern

3. Opaque uni- or bilateral bands in the inferior parts

4. Micro- or macronodular opacities

5. Moderately enlarged pulmonary hila

Viral pneumonia

Varicella (Chickenpox) virus pneumonia

Primary pulmonary abscess

IMAGING TECHNIQUES IN PLEURAL EFFUSIONS

Thoracic x-ray:– orthostatic– lateral decubitus with horizontal

beam

Thoracic ultrasound

CT

ETIOLOGY OF PLEURAL EFFUSIONS

Neoplastic------------------------------ 45% Infectious ------------------------------ 21%

– Tuberculous 10%– Bacterial 9%– Viral 1%– Fungal 1%

Cardiac---------------------------------- 12% Pulmonary infarction------------------ 3% Cirrhosis ------------------------------------ 2% Collagen diseases ------------------------- 1% Other ------------------------------------ 5% Unknown cause --------------------10% !!!

HAUSHEER 1985

RADIOLOGIC CLASSIFICATION OF PLEURAL EFFUSIONS

EFFUSIONS:– FREE in the main pleural cavity-

quantity:• small• medium • large

– LOCULATED • in the main pleural cavity• in the fissures• in the mediastinal pleural space• in the diaphragmatic pleura

Free pleural effusion

Free pleural effusion

ultrasound

left lateral

right lateral

Pleural effusion

Pleural effusion

Loculated effusions

Loculated pleural effsuions

Loculated pleural effusions

“Remember”PneumothoraxPleural calcificationsFibrothorax

Mesothelioma benign

malignant

BRONCHO-PULMONARY TUMORS

Radiologic aspects

BENIGN TUMORS

Benign tumors: - adenoma, - fibroma, - hamartoma, - lipoma, - condroma;Radiology :- Round solitary pulmonary opacity

RADIOLOGIC FEATURES OF BENIGN TUMORS

- regular outline, sharp borders - intensity depends on the size - homogeneous structure - calcifications (hamartoma) - ( intra-tumoral

calcification does not always mean benign, see “scar cancer”)

- no alterations of the surrounding parenchyma - slow growth > 12 months

Bronchal adenoma

Main clinical signs which suggest lung cancer (LC)

1. Local signs: – Cough 45 - 75%– Weight loss 20 – 70%– Dyspnea 40 – 60%– Chest pain 30 – 45%– hemoptysia 25 – 35%– none 2 – 5% !!!

2. Loco-regional signs: – Dysphonia – recurrent laryngeal nerve– Phrenic paralysis – phrenyc nerve– Dysphagia – lymph nodes– SVC syndrome– Pleural or pericardial effusion

3. Paraneoplastic syndromes: endocrine, neurologic, musculoskeletal, hematologic, etc.

Kraut , 2000

THE 4 MAIN HISTOLOGIC TYPES OF LC IN EVERY DAY PRACTICE

Scuamous cell carcinoma ( 40% ) – mostly on main bronchi

Adenocarcinoma ( 20-30% ) - periphery, but also central

Large cell carcinoma( 20% )Small-cell carcinoma ( 10% )“Non – small” cancer

– Scuamous cell carcinoma – adenocarcinoma– Large cell carcinoma

Small-cell carcinoma - non-surgical, responsive to chemo- and radiotherapy

Surgical resection if possible

Travis 1999

RADIOLOGIC TYPES OF LC

Central (hilar) of the large bronchi– exobronchal– endobronchal (stenosis

atelectasis)

Peripheral

Bronchioloalveolar carcinoma

CENTRAL BRONCHAL CANCER (HILAR)

endobronchal

exobronchal

mediastino-pulmonary

Other lesions may coexist

ENDOBRONCHAL CANCER - CONSEQUENCES

Bronchal obstruction: - complete =ATELECTASIS

- incomplete :1. Expiratory valve =

hypertranslucency2. Insufficient inspiration =

hypoventilation +pneumona

Pulmonary tumor - atelectasis

Pulmonary tumor - atelectasis

Pulmonary tumor - pneumonia

Pulmonary tumor – hilar type

OAD

PRIMARY PERIPHERAL PULMONARY TUMORS

Broncho-pulmonary: - non-differentiated carcinoma

- adenocarcinoma - bronchioloalveolar

carcinoma

Other origins: - sarcoma - neuroblastoma - pneumoblastoma - melanoma

Regular/irregular outline

Sharp border

Peripheral cancer – malignant outline

FEATURES OF THE MALIGNANT PULMONARY NODULE

Size > 4 cmMalignant outlineIncrease (doubling of pulmonary tu. volume) :

3-6 monthsAssociated with: - hilar lymph nodes - lysis of ribs - pleural effusions - pulmonary metastases (smaller

than the primary tumor)o Complications: central necrosis/vascular

effusion

Pulmonary tumor – peripheral type

Peripheral LC with enlarged lymph nodes

Peripheral LC with enlarged lymph nodes

Pulmonary tumor - necrosis

Pulmonary tumor - necrosis

CT

LC – lymph nodes/rib lysis/vascular invasion/necrosis

CT

MRI

CT

LC – mediastinal invasion

PANCOAST TOBIAS

Adenocarcinoma

Male, 41, pain of the right shoulder

Pulmonary tumor – brochioloalveolar type

METASTASES OF LCPulmonary metastatic extension

– Metastases– Lymphangitis carcinomatosa

Tumoral extension towards the mediastinum

Tumor extension towards the chest wallLocal and regional extension

– Mediastinal lymph nodes homo- and hetero-lateral– Supraclavicular lymph nodes

Distant extension– brain – adrenals– liver– bone

THE MOST COMMON SOURCES OF PULMONARY METASTASES

1. Breast c.2. Bone c.3. Thyroid c.4. Seminoma, prostate c.5. Uterine c.6. Digestive tract c.7. Renal c.

Metastases – nodular type

Metastases – nodular type

Metastases – thyroid cancer

Milliary carcinomatosis

Lymphangitis carcinomatosa

Solitary pulmonary metastasis

PET SCAN