interpretation of chest radiographs - rutgers universityglobaltb.njms.rutgers.edu/courses/tri-state...

9/14/2018

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Interpretation of Chest Radiographs

Sarah Tapyrik, MD

Sept 26, 2018

Slides curtesy of Alfred Lardizabal, MD

Executive DirectorGlobal Tuberculosis Institute

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Basic Radiology for the TB Clinician

Overview:

• Technical aspects of chest radiography

• Systematic approach to reading CXR

• Basic CXR anatomy

• Patterns of disease

• Radiographic manifestations of tuberculosis (TB)

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Chest Radiography: Basic Principles

Blackest

air

fat

soft tissue

calcium

bone

X‐ray contrast

metal

Whitest

Maximum X‐RayTransmission(least dense tissue)

Maximum X‐Ray Absorption(densest tissue)

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X‐ray photon: Absorbed / scattered / transmitted X‐ray absorption depends on:

• Beam energy (constant)• Tissue density

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Differential X‐Ray Absorption

Why we see what we see:

• Structures are visible on a radiograph because of the juxtaposition of two different densities Creating an interface

• Silhouette Sign

Loss of an expected interface

No boundary can be seen between two structures because they now are similar in density

Image credit: Curry International Tuberculosis Center, UCSF 4

Silhouette Sign: RLL Pneumonia


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Silhouette Sign: RLL Pneumonia


Assess CXR Technical Quality

• Inspiratory effort

‒ 9‐10 posterior ribs

• Penetration

‒ Thoracic intervertebral disc space just visible

• Positioning / rotation

‒ Medial clavicle heads equidistant from spinous process

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Inspiratory Effort

Low Lung Volumes Full Inspiration


Overexposure Proper Exposure

Exposure


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OverexposureOverexposure Proper ExposureProper Exposure


Rotated (Oblique)Rotated (Oblique)Image credit: Curry International Tuberculosis Center, UCSF 15

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A Systematic Approach to Reading a CXR

16Image Credit: Lung Health Image Library/Gary Hampton

Approach to Reading a CXR

Be Systematic

• Lungs

• Pleural surfaces

• Cardiomediastinal contours

• Bones and soft tissues

• Abdomen


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Interpretation: A-B-C-D-E

A=Air

B=Bones

C=Cardiovascular

D=Diaphragm

E=Everything else

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Worth a Second Look

• Apices

• Retrocardiac areas (left and right)

• Hilar regions

• Below diaphragm

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Apical TBApical TBImage credit: Curry International Tuberculosis Center, UCSF 20

Image credit: Curry International Tuberculosis Center, UCSF

Apical TB (2)Apical TB (2)21

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Left Retrocardiac OpacityLeft Retrocardiac Opacity


Nodule Behind DiaphragmNodule Behind Diaphragm


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Basic CXR Anatomy


Basic CXR Anatomy

Frontal and Lateral Views

• Heart

• Aorta

• Pulmonary arteries

• Airways

Image Credit: Lung Health Image Library/Pierre Virot25

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• Aortic arch

• Right pulmonary artery

• Left pulmonary artery

• Trachea & bronchi


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• Aortic arch


• Aortic arch



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• Aortic arch




• Aortic arch



• Trachea & bronchi


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Patterns of Disease

34Image Credit: Lung Health Image Library/Gary Hampton

Chest Radiographic Patterns of Disease• Consolidation / air‐space opacity

• Interstitial opacity

• Nodules and masses

• Lymphadenopathy

• Cysts and cavities

• Pleural abnormalities

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Consolidation / Air‐Space Opacity

• Caused by filling of alveoli with fluid, pus, blood, cells (tumor), etc.

• May be diffuse, or isolated to segments or lobes of the lung

• May be associated with air bronchograms (air‐filled bronchus surrounded by opacified lung)

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PneumoniaPneumonia


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Interstitial Opacity

• Disease localized to pulmonary interstitium, i.e., the alveolar septae and connective tissues that support the alveoli

• Hallmarks:

‒ Lines and/or reticulation

‒ Small, well‐defined nodules

Miliary pattern

• DDX: Pulmonary edema, interstitial lung diseases (e.g., idiopathic pulmonary fibrosis), sarcoidosis, infection, tumor (lymphangitic spread), etc.

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Interstitial Opacity: LinesInterstitial Opacity: Lines

39Image credit: Curry International Tuberculosis Center, UCSF

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Interstitial Opacity: LinesInterstitial Opacity: Lines


Interstitial Opacity: Lines & ReticulationInterstitial Opacity: Lines & Reticulation


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Nodules and Masses

• Nodule: Discrete pulmonary lesion, sharply defined, nearly circular opacity 0.2 ‐ 3 cm

• Mass: Larger than 3 cm

• Describe with qualifiers:

‒ Single or multiple

‒ Size

‒ Border characteristics

‒ Presence or absence of calcification

‒ Location

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Well‐DefinedWell‐Defined CalcificationCalcification

Ill‐DefinedIll‐Defined MassMass


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Lymphadenopathy (LAN)

• Non‐specific terms:‒ Mediastinal widening

‒ Hilar prominence

• Specific patterns:‒ Particular station enlargement (location)

Important to know what “normal” should look like in order to recognize “abnormal”

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• Infrahilar window (right hilar and/or subcarinal)

• Left hilar

• Subcarinal

LymphadenopathyLymphadenopathy


• Infrahilar window (right hilar and/or subcarinal)



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• Left hilar



• Subcarinal



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Right Paratracheal & Bilateral LANRight Paratracheal & Bilateral LAN


Right Hilar LANRight Hilar LAN


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Right Hilar LANRight Hilar LAN


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Subcarinal LANSubcarinal LAN


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AP Window LANAP Window LAN


Cysts & Cavities

• Abnormal pulmonary parenchymal spaces (“holes”), filled with air and/or fluid, with a definable wall (>1 mm)

‒ Cyst: Congenital or acquired

‒ Cavity: Caused by tissue necrosis, (inflammatory and/or neoplastic)

• Characterize:

‒ Wall thickness at thickest portion

‒ Inner lining

‒ Presence / absence of air / fluid level

‒ Number and location

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TB or Not TB? Cysts and Cavities

Are there radiographic features that suggest benign vs. malignant diagnoses?

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“45 year old man from China with cough, weight loss”

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D

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TB or Not TB? Cysts and Cavities (2)

Are there radiographic features that suggest benign vs. malignant diagnoses?

Benign cysts: Uniform wall thickness, 1mm, smooth inner lining (e.g., PCP)

Benign cavities: Max. wall thickness 4 mm, minimally irregular inner lining (e.g., TB)

Malignant cavities: Max. wall thickness 16 mm, irregular inner lining

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Pleural Disease: Basic Patterns

• Effusion

‒ Angle blunting to massive

• Thickening

• Mass

• Air

• Calcification

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Pleural EffusionPleural Effusion

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Post‐TB Pleural Calcification

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Plombage with Lucite balls

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Radiographic Manifestations of TB

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Can this be TB?“Typical Pattern”:

Post‐Primary TB

• Distribution

‒ Apical / posterior segments of upper lobes

‒ Superior segments of lower lobes

‒ Isolated anterior segment involvement unusual for M.tb (think M. aviumcomplex)

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“Typical Pattern”: Post‐Primary TB

Patterns of disease• Air‐space consolidation

• Cavitation, cavitary nodule

• Endobronchial spread

• Miliary

• Bronchostenosis

• Tuberculoma

• Pleural effusions (empyema most likely in post‐primary disease)

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Can this be TB?

“Atypical Pattern”: Primary TB

• Distribution: Any lobe involved (slight lower lobe predominance)

• Air‐space consolidation

• Cavitation is uncommon (<10%)

• Adenopathy is common (esp. children and HIV), predilection for right side

• Miliary pattern

• Pleural effusions

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Can this be TB? Miliary TB

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Radiographic Patterns: Pulmonary TB

TB Pattern“Typical”

(Post‐Primary)“Atypical”(Primary)

Infiltrate 85% upper

Upper: Lower 60: 40

Usually upper in children

Cavitation Common Uncommon

Adenopathy UncommonChildren common

Adults ~30%Unilateral > bilateral

Effusion May be present May be present

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CXR Pattern: Early vs. Advanced HIV

Early HIV (CD4>200)

Advanced HIV (CD4<200)

Pattern“Typical”

(Post‐Primary)“Atypical”(Primary)

Infiltrate Upper lobesLower lobes, multiple

sites, or miliary

Cavitation Common Uncommon

Adenopathy Uncommon Common

Effusion Uncommon More common

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Can this be TB?“Old / Healed” TB

• Ca++ granuloma–Ghon lesion

• Ca++ granuloma and hilar node calcification–Ranke complex

• Apical pleural thickening

• Fibrosis and volume loss


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Summary:

• Remember: Technical quality can significantly impact your CXR interpretation

• Develop a systematic approach (and use it every time!)

• Practice identifying normalCXR anatomy

• Important to characterize and describe lesions—this can help with your differential diagnosis

• Whether typical or atypical

TB can always fool you!

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Questions?

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interpretation of chest radiographs - rutgers universityglobaltb.njms.rutgers.edu/courses/tri-state...

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