radiological presentation of chest diseases gamal agmy

Gamal Rabie Agmy, MD, FCCP

Professor of Chest Diseases, Assiut University

ERS National Delegate of Egypt

L:Lung

T:Trachea

AK:Aortic knob

A:Ascending aorta

H:Heart

V: Vertebra

P: Pulmonary

artery

S:Spleen

Missing Right Breast

"Hyperlucent" right base secondary

to missing breast.

Silicone Breast Implantation

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Cervical Rib

Pleural Effusion / Lytic Lesions in Clavicle and Scapula

Cervical rib

Kyphoscoliosis

Rib Fracture / Hematoma

Extra Pleural Sign

Cancer Lung

Density in periphery

Sharp inner margin

Indistinct outer margin Angle of contact with chest wall

Expanding destructive rib lesion

Paratracheal widening

This is an example of an RUL lesion

Neurofibromatosis

Sprengel's Deformity

High set scapula

Vertebral anomaly

Rib anomaly

Subcutaneous Emphysema

Air outlining pectoral muscles

Air along chest wall

Pneumomediastinum

Lateral Chest

There is valuable information that can be obtained by a chest

lateral view. A few of them are listed below:

Sternum

Vertebral column Retrosternal space

Localization of lung lesions

Lobes of lungs

Oblique fissures

Pulmonary artery Heart

Mediastinal masses

Diaphragm

Volume measurements SPN

Radiologic TLC

Tracheoesophageal stripe

Tuberculosis of Spine

Loss of intervertebral space

Vertebral collapse

Cold abscess is not present in this case. PA view is not diagnostic.

Mediastinal Lymph Nodes

Extrapleural

Polycyclic margin

Anterior mediastinum

RML Atelectasis

Vague density in right lower lung field, almost normal

RML atelectasis in lateral view, not evident in PA view

Atelectasis Left Upper

Hazy density over left

upper lung field

Loss of left heart silhouette

Tracheal shift to left

A: Forward movement of oblique

fissure

C: Atelectatic LUL

B: Herniated right lung

Localization

When a lesion is not contiguous to a

silhouette, it is not possible to localize it

without a lateral view. This is a case of a

solitary pulmonary nodule with popcorn calcification: Hamartoma.

Air Bronchogram

• In a normal chest x-ray, the tracheobronchial tree is not

visible beyond the 4th order. As the bronchial tree

branches, the cartilaginous rings become thinner, and

eventually disappear in respiratory bronchioles. The

lumen of the bronchus contains air and the surrounding

alveoli contain air. Thus, there is no contrast to visualize

the bronchi.

• The air column in the bronchi beyond the 4th order

becomes recognizable if the surrounding alveoli is filled,

providing a contrast or if the bronchi get thickened

• The term air bronchogram is used for the former state

and signifies alveolar disease.

Silhouette Sign

Adjacent Lobe/Segment Silhouette

RLL/Basal segments Right diaphragm

RML/Medial segment Right heart margin

RUL/Anterior segment Ascending aorta

LUL/Posterior segment Aortic knob

Lingula/Inferior segment Left heart margin

LLL/Superior and basal segments Descending aorta

LLL/Basal segments Left diaphragm

Cardiac margins are clearly seen because there is contrast between the fluid

density of the heart and the adjacent air filled alveoli. Both being of fluid density,

you cannot visualize the partition of the right and left ventricle because there is no

contrast between them. If the adjacent lung is devoid of air, the clarity of the

silhouette will be lost. The silhouette sign is extremely useful in localizing lung lesions.

Atelectasis Right Lung Homogenous density right hemithorax

Mediastinal shift to right

Right heart and diaphragmatic silhouette are not identifiable

Atelectasis Left Lung

Homogenous density left hemithorax Mediastinal shift to left

Left hemithorax smaller

Diaphragm and heart silhouette are not identifiable

•Homogenous density lef t hemithorax •Mediastinal shif t to the lef t

•Lef t hemithorax smaller •Diaphragmatic and heart silhouette are not identif iable

Lateral Movement of oblique and transverse fissures

Atelectasis Right Upper Lobe

Homogenous density right upper lung

Loss of silhouette of ascending aorta

upper lung field

Lateral A: Forward movement of

oblique fissure

C: Atelectatic LUL

Consolidation Right

Upper Lobe /

Density in right upper lung

field Lobar density

Loss of ascending aorta

silhouette

No shift of mediastinum

Transverse fissure not significantly shifted

Air bronchogram

Consolidation Left Lower Lobe

Density in left lower lung field

Left heart silhouette intact

Loss of diaphragmatic silhouette

No shift of mediastinum Pneumatocele

One diaphragm only visible

Lobar density

Oblique fissure not significantly

shifted

Left Upper Lobe Consolidation

Density in the left upper lung field

Loss of silhouette of left heart margin

Density in the projection of LUL in lateral view

Air bronchogram in PA view No significant loss of lung volume

Vague density right lower lung field

Indistinct right cardiac silhouette

Intact diaphragmatic silhouette

Density corresponding to RML

No loss of lung volume

RML pneumonia

S Curve of Golden

When there is a mass

adjacent to a fissure, the

fissure takes the shape

of an "S". The proximal convexity is due to a mass,

and the distal concavity is

due to atelectasis. Note the

shape of the transverse

fissure. This example represents a

RUL mass with atelectasis

Tracheal Shift

Trachea is index of upper mediastinal position. The pleural pressures on either

side determine the position of the mediastinum. The mediastinum will shift towards the side with relatively higher negative pressure compared to the opposite side. Tracheal deviation can occur under the following conditions:

• Deviated towards diseased side – Atelectasis

– Agenesis of lung

– Pneumonectomy

– Pleural fibrosis

• Deviated away from diseased side – Pneumothorax

– Pleural effusion

– Large mass

• Mediastinal masses

• Tracheal masses

• Kyphoscoliosis

Atelectasis Right Lung

• Homogenous density

right hemithorax

• Mediastinal shift to right

• Right hemithorax smaller

• Right heart and

diaphragmatic silhouette

are not identifiable

Pleural Effusion Massive

• Unilateral homogenous

density

• Mediastinal shift to right

• Left diaphragmatic and

left heart silhouettes lost

• Left hemithorax larger

Pneumonectomy

• Opacity left

hemithorax

• Tracheal shift to left

• Cardiac and left

diaphragmatic

silhouettes missing

• Crowding of ribs

Air Bronchogram

• In a normal chest x-ray, the tracheobronchial tree is not

visible beyond the 4th order. As the bronchial tree

branches, the cartilaginous rings become thinner, and

eventually disappear in respiratory bronchioles. The

lumen of the bronchus contains air and the surrounding

alveoli contain air. Thus, there is no contrast to visualize

the bronchi.

• The air column in the bronchi beyond the 4th order

becomes recognizable if the surrounding alveoli is filled,

providing a contrast or if the bronchi get thickened

• The term air bronchogram is used for the former state

and signifies alveolar disease.

Bowing Sign

• In LUL atelectasis or

following resection, as in

this case, the oblique

fissure bows forwards

(lateral view). Bowing

sign refers to this feature.

The arrow points to the

forward movement of the

left oblique fissure.

Doubling Time

• Time to double in volume (not diameter)

• Useful in determining the etiology of solitary

pulmonary nodule

• Utility

– Less than 30 days: Inflammatory process

– Greater than 450 days: Benign tumor

– Malignancy falls in between

Eccentric Location of Cavity in a

• Thick wall and irregular lumen can be

seen in both malignancy and

inflammatory lesions.

• However eccentric location of cavity is

diagnostic of malignancy.

• This is an example of squamous cell carcinoma lung.

• LUL mass

• Thick walled cavity

• Eccentric location of cavity

• Fluid level

• This is diagnostic of malignancy.

Cortical Distribution

• Mirror image of pulmonary edema

• Alveolar disease of outer portion of lung

• Encountered in:

– Eosinophilic pneumonia

– Bronchiolitis obliterans with pneumonia

Medullary Distribution

• It is also called "butterfly pattern"

• Note the sparing of lung periphery both in

the CT, PA and lateral views

• This is one of the radiologic signs

indicative of diffuse alveolar disease

• This is an example of alveolar proteinosis.

Note the sparing of lung periphery both in the CT, and PA view

This is one of the radiologic signs indicative of diffuse alveolar disease

This is an example of alveolar proteinosis.

Diffuse Alveolar Disease

Radiological Signs

• Butterfly distribution / Medullary distribution

• Lobar or segmental distribution

• Air bronchogram

• Alveologram

• Confluent shadows

• Soft fluffy edges

• Acinar nodules

• Rapid changes

• No significant loss of lung volume

• Ground glass appearance on HRCT

Distribution

• Cortical

– Eosinophilic pneumonia

– BOOP

• Lower lobes / Mineral oil aspiration

• Medullary

Acute Diffuse Alveolar Disease

• Water

– Pulmonary edema, Cardiogenic, Neurogenic pulmonary edema • Blood

– SLE

– Goodpasture's syndrome

– Idiopathic pulmonary hemosiderosis

– Wegener's granulomatosis • Inflammatory

– Cytomegalovirus pneumonia

– Pneumocystis carinii pneumonia

– Influenza

– Chicken pox pneumonia • Fat embolism

• Amniotic fluid embolism

• Adult respiratory distress syndrome

Acinar Nodules

Interstitial Acinar

Same size

Sharp edges

smaller

Varying in size

Indistinct edges

Larger than interstitial nodules

Acinar nodules are difficult to distinguish from interstitial

nodules. Some distinguishing characteristics are as follows:

Cut Off Sign

• When you see an abrupt ending of visualized

bronchus, it is called a "cut off sign". It indicates

an intrabronchial lesion. This is useful to identify

the etiology of atelectasis . Be careful as the

tracheobronchial tree is three dimensional and

the finding need to be confirmed with tomogram.

In the modern era, a CT scan will take care of

Air Fluid Level

Causes • Cavities

• Pleural space: Hydropneumothorax

• Bowel: Hiatal hernia

• Esophagus: Obstruction

• Mediastinum: Abscess

• Chest wall

• Normal stomach

• Dilated biliary tract

• Sub diaphragmatic abscess

Wedge Shaped Density The wedge's base is pleural

and the apex is towards the

hilum, giving a triangular

shape. You can encounter

either of the following:

Vascular wedges :

Infarct

Invasive aspergillosis

Bronchial wedges :

Consolidation

Atelectasis

Polycyclic Margin The wavy shape of

the mediastinal mass

margin indicates that

it is made up of

multiple masses,

usually lymph nodes.

This is a case of

lymphoma.

Open Bronchus Sign / Alveolar Atelectasis

The right lung is atelectatic. You can see air bronchogram, which indicates

that the airways are patent .This case is an example of adhesive alveolar

atelectasis.

Pulmonary Artery Overlay

This is the same concept as

a silhouette sign. If you can

recognize the interlobar pulmonary artery, it means

that the mass seen is either

in front of or behind it.

This is an example of a

dissecting aneurysm.

S Curve of Golden

When there is a mass

adjacent to a fissure, the

fissure takes the shape

of an "S". The proximal convexity is due to a mass,

and the distal concavity is

due to atelectasis. Note the

shape of the transverse

fissure. This example represents a

RUL mass with atelectasis

Tracheoesophageal Stripe

The posterior wall of the trachea (T)

and the anterior wall of the esophagus

(E) are in close contact and form the

tracheoesophageal stripe in the lateral view (arrow).

It is considered abnormal when it is

wider than __ mm.

Common causes for thickening of

tracheoesophageal stripe are:

Esophageal disease

Nodal enlargement

AV Fistula

Osler-Weber-Rendu

Syndrome

"Pulmonary nodule"

Multiple lesions Feeding vessel

Cardiomegaly

Patient presented with

severe congestive heart failure and severe iron

deficiency anemia. Had

multiple telangiectasia of

tongue, lips and

conjunctivae.

Pneumonectomy

Diffuse haziness

Smaller right hemithorax

Mediastinal shift to right Surgical clips

The definition of atelectasis is loss of air in the alveoli;

alveoli devoid of air (not replaced).

A diagnosis of atelectasis requires the following:

1-A density, representing lung devoid of air

2-Signs indicating loss of lung volume

Atelectasis

1-Absorption Atelectasis When airways are obstructed there is no further

ventilation to the lungs and beyond. In the early

stages, blood flow continues and gradually the

oxygen and nitrogen get absorbed, resulting in

atelectasis.

Types of Atelectasis:

2-Relaxation Atelectasis The lung is held close to the chest wall because of the

negative pressure in the pleural space. Once the

negative pressure is lost the lung tends to recoil due

to elastic properties and becomes atelectatic. This

occurs in patients with pneumothorax and pleural

effusion. In this instance, the loss of negative

pressure in the pleura permits the lung to relax, due

to elastic recoil. There is common misconception that

atelectasis is due to compression.

3-Adhesive Atelectasis :

Surfactant reduces surface tension and keeps the

alveoli open. In conditions where there is loss of

surfactant, the alveoli collapse and become

atelectatic. In ARDS this occurs diffusely to both

lungs. In pulmonary embolism due to loss of blood

flow and lack of CO2, the integrity of surfactant

gets impaired.

4-Cicatricial Atelectasis

– Alveoli gets trapped in scar and

becomes atelectatic in fibrotic

disorders

5-Round Atelectasis An instance where the lung gets trapped by

pleural disease and is devoid of air.

Classically encountered in asbestosis.

Generalized 1-Shift of mediastinum: The trachea and heart gets shifted

towards the atelectatic lung.

2-Elevation of diaphragm: The diaphragm moves up and

the normal relationship between left and right side gets

altered.

3-Drooping of shoulder.

4-Crowding of ribs: The interspace between the ribs is

narrower compared to the opposite side.

Signs of Loss of Lung Volume:

Movement of Fissures You need a lateral view to appreciate the movement of

oblique fissures. Forward movement of oblique fissure in

LUL atelectasis. Backward movement in lower lobe

atelectasis.

Movement of transverse fissure can be recognized in the

PA film.

Movement of Hilum The right hilum is normally slightly lower than the left.

This relationship will change with lobar atelectasis.

Compensatory Hyperinflation

Compensatory hyperinflation as evidenced by increased

radiolucency and splaying of vessels can be seen with the

normal lobe or opposite lung.

Alterations in Proportion of Left and

Right Lung

The right lung is approximately 55% and left lung 45%. In

atelectasis this apportionment will change and can be a

clue to recognition of atelectasis. .

Hemithorax Asymmetry In normals, the right and left hemithorax are equal in size.

The size of the hemithorax will be asymmetrical and

smaller on the side of atelectasis

Signs of Loss of Lung Volume: Generalized

Shift of mediastinum: The trachea and heart gets shifted towards the atelectatic lung.

Elevation of diaphragm: The diaphragm moves up and the normal relationship between left

and right side gets altered.

Drooping of shoulder.

Crowding of ribs: The interspace between the ribs is narrower compared to the opposite side.

Movement of Fissures

You need a lateral view to appreciate the movement of oblique fissures. Forward movement of

oblique fissure in LUL atelectasis. Backward movement in lower lobe atelectasis.

Movement of transverse fissure can be recognized in the PA film.

Movement of Hilum

The right hilum is normally slightly lower than the left. This relationship will change with lobar

atelectasis.

Compensatory Hyperinflation

Compensatory hyperinflation as evidenced by increased radiolucency and splaying of vessels

can be seen with the normal lobe or opposite lung.

Alterations in Proportion of Left and Right Lung

The right lung is approximately 55% and left lung 45%. In atelectasis this apportionment will

change and can be a clue to recognition of atelectasis.

Hemithorax Asymmetry

In normals, the right and left hemithorax are equal in size. The size of the hemithorax will be

asymmetrical and smaller on the side of atelectasis

Atelectasis Right Lung Homogenous density right hemithorax

Right heart and diaphragmatic silhouette are not identifiable

Homogenous density left hemithorax Mediastinal shift to left

Left hemithorax smaller

Diaphragm and heart silhouette are not identifiable

•Homogenous density lef t hemithorax •Mediastinal shif t to the lef t

•Lef t hemithorax smaller •Diaphragmatic and heart silhouette are not identif iable

Left Lower Lobe Atelectasis • Inhomogeneous cardiac density

• Left hilum pulled down

• Non-visualization of left diaphragm

• Triangular retrocardiac atelectatic LLL

Atelectasis Left Lower Lobe Double density over heart

Inhomogenous cardiac density

Triangular retrocardiac density

Left hilum pulled down

Other findings include:

Pneumomediastinum

Atelectasis Left

Upper Lobe

Mediastinal shift to left

Density left upper lung field Loss of aortic knob and left hilar

silhouettes

Herniation of right lung

Atelectatic left upper lobe

Forward movement of left

oblique fissure "Bowing sign"

upper lung field

Lateral A: Forward movement of

oblique fissure

C: Atelectatic LUL

Homogenous density right upper lung

Homogenous density right upper lung field

RML Atelectasis

Vague density in right lower lung field, almost normal

RML atelectasis in lateral view, not evident in PA view

Vague density in right lower lung field (almost a normal film).

Dramatic RML atelectasis in lateral view, not evident in PA view. Movement of

transverse fissure.

Other findings include: Azygous lobe

Atelectasis Right Lower Lobe Density in right lower lung field Indistinct right diaphragm

Right heart silhouette retained

Transverse fissure moved down

Right hilum moved down

Adhesive Atelectasis

Alveoli are kept open by the integrity of surfactant. When there is loss

of surfactant, alveoli collapse. ARDS is an example of diffuse alveolar

atelectasis.

Plate-like atelectasis is an example of focal loss of surfactant.

Relaxation Atelectasis

The lung is held in apposition to the chest wall because of negative pressure

in the pleura. When the negative pressure is lost, as in pneumothorax or

pleural effusion, the lung relaxes to its atelectatic position. The atelectasis is

a secondary event. The pleural problem is primary and dictates other radiological findings.

Round Atelectasis

Mass like density

Pleural based

Base of lungs

Blunting of costophrenic angle Pleural thickening

Pulmonary vasculature curving

into the density

Esophageal surgical clips

Round Atelectasis

Mass like density

Pleural based

Base of lungs

Blunting of costophrenic angle, pleural thickening Pulmonary vasculature curving into the density

RML Lateral Segment Atelectasis

Sub-segmental Atelectasis

Atelectasis

Segmental

Anterior sub-segment of RUL

"Bronchial wedge"

Hilar Displacement

Bronchiectasis

Left lung atelectasis due to mucus plugging

Mucus plugs suctioned with bronchoscopy

Bronchogram done after bronchoscopy

Saccular bronchiectasis in bronchogram below

Bronchogram

Bronchograms are rarely done nowadays. The need for it

disappeared with the invention of the fiberoptic

bronchoscopy and high resolution CT scan. View these images to get a greater understanding of a three

dimensional view of a bronchial tree..

Bronchogram

Bronchograms are rarely done nowadays. The need for it disappeared with the

invention of the fiberoptic bronchoscopy and high resolution CT scan.

Calcification

Focal lung lesion: Ghon's complex

Miliary lung calcification:

Histoplasmosis

Tuberculosis

Alveolar microlithiasis

Chicken pox pneumonia

Solitary pulmonary nodule :

Central / Granuloma

Lamellar / Histoplasmosis

Pop corn / Hamartoma

Eccentric / Scar Cancer

Calcification

Nodes:

Homogenous / TB

Clumpy / Histoplasmosis

Egg shell / Silicosis, Sarcoidosis

Tracheal cartilage : Aging

Tumor:

Mediastinal mass / Teratoma

Healed lymphoma / Metstasis

Calcification

Vascular:

Aortic calcification

Pulmonary artery calcification

Pulmonary hypertension

Pleural:

Visceral / Hemothorax, TB, Empyema

Parietal / Asbestosis

Subcutaneous calcification:

Cysticercus

Broncholith

Subsegmental atelectasis

Calcified node

Broncholith obstructing bronchus

Silicosis Egg shell calcification of lymph nodes

Other findings include:

Diaphragmatic pleural calcification

Multiple cavities with fluid levels

Histoplasmosis

Calcified nodes

Clumpy calcification Calcified nodules in lungs

Hamartoma

Popcorn calcification

Pleural Calcification

Visceral pleural

calcification

Parietal pleura appears

black because it is sandwiched between

bony densities

Pleural Calcification Visceral pleura

Old TB

Visceral pleural calcification

Open drainage with air fluid levels in pleural space

Subcutaneous calcification

Cavitary Lung Lesions

Number:

Multiple bilateral cavities would raise

suspicion for either bronchiogenous or

hematogenous process. You should consider:

Aspiration lung abscess

Septic emboli

Metastatic lesions

Vasculitis (Wegener's)

Coccidioidomycosis, tuberculosis

Location:

• Classical locations for aspiration lung abscess are superior segment of the lower lobes posterior segments of upper lobes.

• Tuberculous cavities are common in superior segments of upper and lower lobes or posterior segments of upper lobes.

• When a cavity in anterior segment is encountered, a strong suspicion for lung cancer should be raised. TB and aspiration lung abscess are rare in anterior segments. Cancer lung can occur in any segment.

Wall Thickness:

• Thick walls are seen in:

– Lung abscess

– Necrotizing squamous cell lung cancer

– Wegener's granulomatosis

– Blastomycosis

Wall Thickness:

• Thin walled cavities are seen in:

• Coccidioidomycosis

• Metastatic cavitating squamous cell carcinoma from the cervix

• M. Kansasii infection

• Congenital or acquired bullae

• Post-traumatic cysts

• Open negative TB

Contents:

• The most common cause for air fluid level is lung abscess. Air fluid levels can rarely be seen in malignancy and in tuberculous cavities from rupture of Rasmussen's aneurysm.

• A fungous ball should make you consider aspergillosis. A blood clot and fibrin ball will have the same appearance.

• Floating Water Lily: The collapsed membrane of a ruptured echinococcal cyst, floats giving this appearance.

Lining of Wall:

The wall lining is irregular and nodular in

lung cancer or shaggy in lung abscess

Evolution of Lesion:

Many times review of old films to assess the

evolution of the radiological appearance of

the lesion extremely helpful. Examples

• Infected bullae

• Aspergilloma

• Sub acute necrotizing aspergillosis

• Bleeding from Rasmussen's aneurysm in a

tuberculous cavity

Associated Features:

Ipsilateral lymph nodes or lytic

lesions of the bone is seen

with malignancy

Bulla<1mm wall

>1cm size

Pneumatocele<1mm wall

staph. infection

Honey combing<1cm size

multiple equal

Cyst1-3mm wall

1-10 cm size

Cavity>3mm wall

Any size

Cavitary lesions of lung

Definition

•Thin-walled–less than 1 mm

•Air-filled space

•In the lung> 1 cm in size and up to 75% of lung

•Walls may be formed by pleura, septa,

or compressed lung tissue.

•Results from destruction, dilatation and

confluence of airspaces distal to terminal

bronchioles.

•Bullous disease may be primary or associated

with emphysema or interstitial lung disease.

• Primary bullous lung disease may be familial

and has been associated with Marfan's, Ehler's

Danlos, IV drug users, HIV infection, and

vanishing lung syndrome.

•Bullae may occasionally become very large

and compromise respiratory function. Thus

has been referred as vanishing lung syndrome,

and may be seen in young men.

Upper lobe Bulla

Lower lobe Bulla

A: Xray shows bilateral bulla.

B: CT shows bilateral bulla.

C: CT after bullectomy.

Pneumatocele is a benign air containing cyst of lung, with

thin wall < 1mm as bulla but with different mechanism

Infection with staph aureus is the commonest cause ( less

common causes are, trauma, barotrauma) lead to necrosis

and liquefaction followed by air leak and subpleural

dissection forming a thin walled cyst.

•Honeycombing is defined as multiple cysts < 1cm in diameter,with

well defined walls, in a background of fibrosis, tend to form

clusters and is considered as end stage lung .

•It is formed by extensive interstitial fibrosis of lung with residual

cystic areas.

A cyst is a ring

shadow > 1 cm in

diameter and up to

10 cm with wall

thickness from 1-3

Thin walled cysts of LAM

A cavity is > 1cm

in diameter, and its

wall thickness is

more than 3 mm.

•A central portion necrosis and communicate to bronchus.

•The draining bronchus is visible (arrow). CT (2 mm slice thickness)

shows discrete air bronchograms in the consolidated area.

Mechanism

1. Site

A cavity in apicoposterior segment of left upper lobe

2.Number

Multiple cavities:

1. Aspiration.

3. Fungal.

4. Metastatic.

5. Septic emboli.

6.Wegners granulomatosis

Multiple cysts of metastasis

from squamous cell

carcinoma.

Multiple thick wall cavities from

adenocarcinoma of right lung

Irregular , nodular inner lining of thick wall abscess

Malignant cavity.

3. Thickness and

irregularity

4. eccentric

Malignant

5. Relation to lymph

node enlargement

6. Contents

•Arrow head Crescent sign.

•Black arrows Fibrotic bands surrounding cavity

(Fibrocavitary TB).

Primary Lung Cancer

• Thick wall

• Shaggy lumen

• Eccentric cavitation

Squamous Cell Carcinoma Lung

LUL mass

Thick walled cavity

Eccentric location of cavity

Fungous Ball Long standing cavity

Containing round density (A)

Mobile density Adjacent pleural reaction (B) - characteristic of aspergilloma

Cavitating Metastasis

Multiple Thin Walled Cavities

Cancer Cervix

Lung Cancer / Squamous Cell

Mass density

Anterior segment of LUL

Thick wall cavitation

Squamous Cell Carcinoma

Anterior segment of LUL

Thick wall

Fluid level

Full hilum

Squamous Cell Carcinoma Lung

Thick wall

Irregular lumen

left hilar LN

Etiology:

Cavity can be encountered in practically most lung

diseases.

Common diseases and their characteristics include:

Primary Lung Cancer Thick wall

Shaggy lumen

Eccentric cavitation

Necrotizing Pneumonia

Lung abscess Gravity dependant segments

Thick wall

Air-fluid levels

Tuberculosis

Superior segments Infiltrate around

Bilateral

Fungal infections

Aspergillus

Fungous ball Sub acute invasive aspergillosis

Metastatic disease

Thin walled (Squamous cell)

Thick wall (Adenoma)

Diffuse Alveolar Pneumonia

The most common causes for diffuse alveolar pneumonia are:

Pneumocystis

Cytomegalovirus

Consolidation Right

Upper Lobe /

Density in right upper lung

field Lobar density

Loss of ascending aorta

silhouette

No shift of mediastinum

Air bronchogram

Necrotizing Pneumonia / Lung Abscess / Aspiration

Superior segment RLL dense pneumonia

Progression / Cavity

Radiation Pneumonia

Post Mediastinal Radiation

Air space disease (air bronchogram)

Over radiation port (vertical and paramediastinal) Bilateral

Progression to fibrosis

Round Pneumonia

Round density

Shorter doubling time

Air bronchogram

The most common causes for round pneumonia are: Fungal

Tuberculosis

Consolidation / Lingula

Diaphragmatic silhouette intact

No shift of mediastinum Blunting of costophrenic angle

Lateral

Lobar density

Oblique fissure not

significantly shifted

Air bronchogram

Consolidation Left Lower Lobe

Left heart silhouette intact

Loss of diaphragmatic silhouette

No shift of mediastinum Pneumatocele

One diaphragm only visible

Lobar density

Oblique fissure not significantly

shifted

Left Upper Lobe Consolidation

Density in the left upper lung field

Loss of silhouette of left heart margin

Density in the projection of LUL in lateral view

Air bronchogram in PA view No significant loss of lung volume

Vague density right lower lung field

Indistinct right cardiac silhouette

Intact diaphragmatic silhouette

Density corresponding to RML

No loss of lung volume

RML pneumonia

Consolidation Right Upper Lobe /

Air Bronchogram

Density in right upper lung field

Lobar density

Loss of ascending aorta silhouette No shift of mediastinum

Air bronchogram

Pneumoperitoneum

Air under diaphragm

Elevated Diaphragm"

Note pneumoperitoneum

Supradiaphragmatic mass

Can be mistaken for elevated diaphragm

Pellets

Alveolar Cell Carcinoma - Progression

Old film on left

Solitary pulmonary nodule resected

Onset of diaphragmatic paralysis

Progression to multicentric acinar nodules

Hyperlucent Lung

Factors

Vasculature: Decrease

Air: Excess Tissue : Decrease

Bilateral diffuse

Emphysema

Asthma

Unilateral Swyer James syndrome

Agenesis of pulmonary artery

Absent breast or pectoral muscle

Partial airway obstruction

Compensatory hyperinflation Localized

Bullae

Westermark's sign : Pulmonary embolus

Agenesis of Left Pulmonary Artery

Missing vascular markings in left lung

Left hilum not seen

Entire cardiac output to right lung

Missing Right Breast

"Hyperlucent" right base secondary to missing breast.

Unilateral Hyperlucent Lung

Left Upper Lobe Resection

Left lung hyper lucent

Left hilum pulled up

No abnormal density

Pneumomediastinum

Alveolar Proteinosis

Bilateral diffuse alveolar disease

Butterfly pattern

Medullary distribution

Air bronchograms

Adult Respiratory Distress Syndrome

Non-cardiogenic pulmonary edema

Distinguishing characteristics:

Normal size heart

No pleural effusion

Foreign Body Aspiration

Chest Tubes

Achalasia of

esophagus

• Inhomogeneous

cardiac density:

Right half more

dense than left

• Density crossing

midline (right black

arrow)

• Right sided inlet to

outlet shadow

• Right para spinal line

(left black arrow)

• Barium swallow

below: Dilated

esophagus

Aortic Aneurysms

• Location – Ascending / Anterior mediastinum

– Arch / Middle mediastinum

– Descending / Posterior mediastinum

• Characteristics – Mediastinal "mass" density

– Extrapleural

– Calcification of wall

• Dissecting – Inward displacement of calcified intima

– Wavy margin – Inlet to outlet shadow

– Left pleural effusion

Dissecting Aneurysm

Mediastinal widening

Inlet to outlet shadow

on left side

Retrocardiac: Intact silhouette of left heart

margin

Pulmonary artery

overlay sign: Density

behind left lower lobe Wavy margin

Pulmonary Metastsis

Colon in front of liver

Lymph Nodes

Thrombotic Pulmonary Embolism

Embolism Nonthrombotic Pulmonary

of PE Diagnostic Algorithm

1. Patients with normal chest radiographic findings

are evaluated with a perfusion scan and, if

necessary, an aerosol ventilation scan. Patients

with normal or very low probability scintigraphic

findings are presumed not to have pulmonary

emboli .

2-Patients with a high-probability scan usually

undergo anticoagulation therapy. All other patients

should be evaluated with helical CT pulmonary

angiography, conventional pulmonary

angiography, or lower-extremity US, depending on

the clinical situation

of PE Diagnostic Algorithm 3-Patients with abnormal chest radiographic findings, are

unlikely to have definitive scintigraphic findings. These

patients undergo helical CT pulmonary angiography as well

as axial CT of the inferior vena cava and the iliac, femoral,

and popliteal veins. If the findings at helical CT pulmonary

angiography are equivocal or technically inadequate (5%–

10% of cases) or clinical suspicion remains high despite

negative findings, additional imaging is required.

4-Patients who have symptoms of deep venous thrombosis

but not of pulmonary embolism initially undergo US, which

is a less expensive alternative. If the findings are negative,

imaging is usually discontinued; if they are positive, the

patient is evaluated for pulmonary embolism at the

discretion of the referring physician.

Developmental Anomalies

Pulmonary A-V Malformations

Pulmonary Edema

Pulmonary Artery Aneurysms

Pulmonary –Systemic Communications

Pulmonary –Systemic ommunications

Abnormal Systemic Arteries

Pulmonary Hypertension

Pulmonary Hemorrhage

Pneumomediastinum

Potential Sources of Mediastinal Air

Intrathoracic Trachea and major bronchi

Esophagus

Pleural space

Extrathoracic Head and neck

Intraperitoneum and retroperitoneum

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Mediastinal Cysts

The CT features of benign

mediastinal cyst are

(a) a smooth, oval or tubular mass with a well-

defined thin wall that usually enhances after

intravascular administration of contrast

material,

(b) homogeneous attenuation, usually in the

range of water attenuation (0–20 HU),

(c) no enhancement of cyst contents, and

(d) no infiltration of adjacent mediastinal

structures.

Cysts that contain serous fluid typically have

long T1 and T2 relaxation values, which

produce low signal intensity on T1-weighted

MR images and high signal intensity on T2-

weighted images.

Because cysts containing nonserous

fluid can have high attenuation at CT,

they may be mistaken for solid

lesions. MR imaging can be useful in

showing the cystic nature of these

masses because these cysts continue

to have characteristically high signal

intensity when imaged with T2-

weighted sequences regardless of the

nature of the cyst contents

Radionuclide imaging can be helpful in

detecting functioning thyroid tissue

(iodine-123 or I-131) or parathyroid

tissue (technetium-99m sestamibi) in

the mediastinal cystic mass . gallium-

67 scintigraphy may show increased

radiotracer uptake in the cystic

malignancy owing to necrosis such as

lymphoma or metastatic carcinoma.

Ultrasonography (US) can be useful in

evaluating a mass adjacent to the

pleural surface or cardiophrenic angle.

At US, the benign cysts typically

appear as anechoic thin-walled

masses with increased through

transmission

Bronchogenic Cysts

Duplication Cyst

Pericardial Cyst

Meningocele

Thymic Cysts

Cystic Teratoma

Lymphangioma

Cystlike Lesions

•Mediastinal Pancreatic Pseudocyst

Mediastinal Abscess

radiological presentation of chest diseases gamal agmy

adjacent lung

left heart margindensity

left ventricle

lower lung fieldindistinct

herniated right lungc

upperlobehazy density

upper lobehomogenous

fluid density

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