6/14/2018

1

Chest Radiology

Declare The Past, Diagnose The Present And Foretell The Future - Hippocrates

Disclosures

None

6/14/2018

2

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

6/14/2018

3

Normal

Systematic Approach

Look for:

Opacity (whiter than normal)

Lucency (blacker than normal)

6/14/2018

4

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)

6/14/2018

5

Chest wall sarcoma

Bones

6/14/2018

6

Normal

Multiple myeloma withrib destruction

6/14/2018

7

6/14/2018

8

Breast cancer with (blown out ) bone metastasis to the left humerus

Upper Abdomen

6/14/2018

9

Pneumoperitoneum (from abdominal surgery)

A thin sliver of air below the diaphragm(arrows)

Heart and Mediastinum

6/14/2018

10

Normal

Cardiomegaly and vascular engorgement

6/14/2018

11

Mediastinal mass--Lymphoma

Test case

6/14/2018

12

6/14/2018

13

Lymphangioma

Pleura

• Effusion

• Pneumothorax

• Thickening

6/14/2018

14

Recurrent left pleural effusion (unknown cause)

R decubitus L decubitus

6/14/2018

15

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!

6/14/2018

16

Lungs

• Vessels

• Hila

• Airway

• Parenchyma

Hila

6/14/2018

17

Enlarged central pulmonary arteriespulmonary arterial hypertension (PAH)

Normal

Lumpy hilar lymphadenopathy from sarcoidosis

Normal

PAH

6/14/2018

18

Trachea and Bronchi

Bronchiectasis

Bronchiectasis from cystic fibrosis

6/14/2018

19

Bronchiectasis

Bronchiectasisfrom cystic fibrosis

6/14/2018

20

Test Case

6/14/2018

21

Kartagener’s Syndrome

6/14/2018

22

Lung Parenchyma

Focal

Diffuse

Nodular

Focal Consolidation

6/14/2018

23

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

6/14/2018

24

RML vs RLL pneumonia: which is which?

6/14/2018

25

Test Case

6/14/2018

26

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)

6/14/2018

27

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

6/14/2018

28

• Air• Fluid• Blood• Pus

Diffuse Lung Disease

Destroyed tissue

(emphysema)

Decreased blood flow

(pulmonary embolism)

Less overlying soft-tissue

(mastectomy)Pneumothorax

Lucent Lung (causes)

6/14/2018

29

Emphysema

COPD, obstruction, hyperinflation, flat diaphragm

6/14/2018

30

Test Case

6/14/2018

31

Alpha 1 antitrypsin deficiency

Nodules

6/14/2018

32

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)

6/14/2018

33

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

6/14/2018

34

Metastases from unknown primarySome nodules have cavitated.

Multiple small nodules (miliary)

6/14/2018

35

Miliary Distribution DDx

• TB

• Fungal Infection

• Metastasis

• Sarcoidosis

• Others

Lets put our skill to test!

6/14/2018

36

6/14/2018

37

6/14/2018

38

TB

6/14/2018

39

6/14/2018

40

6/14/2018

41

6/14/2018

42

6/14/2018

43

6/14/2018

44

6/14/2018

45

6/14/2018

46

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

6/14/2018

47