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6/14/2018
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Chest Radiology
Declare The Past, Diagnose The Present And Foretell The Future - Hippocrates
Disclosures
None
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Objectives• Teach modalities that are commonly
employed in detecting lung / thoracic disease
• Teach a systematic but basic approach to interpret the chest radiograph
• Show examples of some common imaging patterns of chest diseases
Systematic ApproachChest Radiograph
Look at:
Soft tissues and bones
Abdomen
Heart and mediastinum
Pleura
Lungs
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Normal
Systematic Approach
Look for:
Opacity (whiter than normal)
Lucency (blacker than normal)
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Soft Tissues
Radiographs are not great for soft tissues,
but keep an eye out…
Chest wall sarcoma
• Notice the asymmetry
• Notice the large soft tissue opacity on the left (arrow)
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Chest wall sarcoma
Bones
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Normal
Multiple myeloma withrib destruction
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Breast cancer with (blown out ) bone metastasis to the left humerus
Upper Abdomen
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Pneumoperitoneum (from abdominal surgery)
A thin sliver of air below the diaphragm(arrows)
Heart and Mediastinum
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Normal
Cardiomegaly and vascular engorgement
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Mediastinal mass--Lymphoma
Test case
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Lymphangioma
Pleura
• Effusion
• Pneumothorax
• Thickening
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Recurrent left pleural effusion (unknown cause)
R decubitus L decubitus
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Rt Lateral DecubitusUpright
Leave the patient in this position for at least few minutes before shooting the radiograph
Large left pleural effusion (“whiteout”).Note: decubitus views don’t help!
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Lungs
• Vessels
• Hila
• Airway
• Parenchyma
Hila
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Enlarged central pulmonary arteriespulmonary arterial hypertension (PAH)
Normal
Lumpy hilar lymphadenopathy from sarcoidosis
Normal
PAH
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Trachea and Bronchi
Bronchiectasis
Bronchiectasis from cystic fibrosis
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Bronchiectasis
Bronchiectasisfrom cystic fibrosis
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Test Case
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Kartagener’s Syndrome
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Lung Parenchyma
Focal
Diffuse
Nodular
Focal Consolidation
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Right lower lobe (superior segment) pneumonia
Silhouette Sign
• The loss of a normal profilee.g., the right atrial border
• Helps identify lung disease
• Helps locate lung diseasee.g., RML vs RLL pneumonia
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RML vs RLL pneumonia: which is which?
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Test Case
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Normal
Diffuse Lung Disease
Opacity(whiter than
normal)
Ground glass opacity(GGO)—not white enough to obscure vessels
Denser opacity—obscures vessels
Lucency(blacker than
normal)
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Heart failure: cardiomegaly and interstitial edema. Note septal(Kerley B) lines and thick fissure.
Diffuse Lung DiseaseCauses
Edema
Diffuse alveolar damage (ARDS)
Hemorrhage
Pneumonia (often opportunistic)
Aspiration
Fibrosis
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• Air• Fluid• Blood• Pus
Diffuse Lung Disease
Destroyed tissue
(emphysema)
Decreased blood flow
(pulmonary embolism)
Less overlying soft-tissue
(mastectomy)Pneumothorax
Lucent Lung (causes)
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Emphysema
COPD, obstruction, hyperinflation, flat diaphragm
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Test Case
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Alpha 1 antitrypsin deficiency
Nodules
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Lung Nodule or Mass
• Malignancy is the primary concern
• Two findings suggest nodule is benign– Stability for 2 years or more
– Calcification
• Many nodules are indeterminate
Lung cancer (poorly differentiated adenocarcinoma)
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Lung Cancer
CT
PET
Lungs: Localization of Lesion
Know the expected location of lobes and fissures in the lung so that you can tell when they are not normal
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Metastases from unknown primarySome nodules have cavitated.
Multiple small nodules (miliary)
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Miliary Distribution DDx
• TB
• Fungal Infection
• Metastasis
• Sarcoidosis
• Others
Lets put our skill to test!
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TB
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Summary
• Chest radiograph is a great initial tool
• Radiologic features of TB mimic other diseases
• CT often helps in further characterization
• Understanding the spectrum of imaging features of TB aids in making early diagnosis
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