CHEST RADIOLOGY

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crapeanglr
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14455
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CHEST RADIOLOGY
Updated:
2010-05-05 01:23:38
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chest radiology thoracic imaging
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Chest radiology differentials and pearls for the oral radiology boards
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  1. 4 patterns of interstitial lung disease
    • •Nodular
    • •Reticular
    • •Septal lines
    • •Cystic
  2. DDx: Nodular interstitial lung disease
    • •Acute
    • –atypical infection ( miliary tuberculosis - hematogenous, lower; disseminated fungal)
    • •Chronic
    • –Mets - hematogenous, lower lung
    • –Sarcoid - upper lung
    • –Silicosis / Coal worker’s - upper lung
    • –Eosinophilic granuloma - upper lung
    • –Hypersensitivity: subacute - upper lung
  3. Hematogenous spread mets tends to go where?
    Lower lung distribution
  4. DDx: Calcified "egg shell" lymph nodes on CXR
    Silicosis vs Sarcoidosis vs TB

    If the nodules themselves calcify, think silicosis
  5. DDx: Reticular opacities (irregular lines on CT)
    • •Acute - normal lung volumes
    • –interstitial edema
    • –atypical infection (Pneumocystis-perhilar, viral infection)
    • •Chronic
    • –fibrosis - decreased lung vol
    • –emphysema - inc lung vol
    • –cystic lung disease - inc lung vol
    • –bronchiectasis-normal to inc lung volumes
  6. DDx: Upper lobe fibrosis
    • –sarcoid - adenopathy
    • –chronic hypersensitivity
    • –cystic fibrosis
    • –XRT (head and neck)
    • –prior tuberculosis
    • –ankylosing spondylitis
  7. DDx: Lower lobe fibrosis
    • –UIP, NSIP
    • –(chronic aspiration)
    • -asbestosis
  8. DDx: Progressive massive fibrosis (confluent perihilar masses)
    Silicosis (parallel chest wall) vs sarcoidosis (rounder)
  9. Calcified pleural plaques
    Asbestosis
  10. Esophageal dilation and lower lobe predominant fibrosis
    Scleroderma
  11. DDx; Septal lines
    • •Acute
    • –edema
    • –atypical infection
    • •Chronic
    • –lymphangitic ca
    • –amyloid, sarcoid
    • –Kaposi’s sarcoma
  12. DDx: Cysts/Ring Lucencies
    • •Acute
    • –Pneumocystis pneumonia - upper
    • –(necrotizing pneumonia)
    • •Chronic
    • –honeycombing (sarcoid, EAA/HP-upper) (UIP-lower)
    • –bronchiectasis - (aspiration,Kartagener's-lower) (CF-upper)
    • –eosinophilic granuloma - upper, inc vol
    • –lymphangioleiomyomatosis - diffuse, inc vol
    • –emphysema - (a1 anti-lower)
  13. DDx: Septal lines and nodules
    • •Acute
    • –atypical infection
    • •Chronic
    • –lymphangitic carcinoma
  14. Septal thickening and GGO's on CT
    edema
  15. Reticulation on CXR is known as what on CT?
    Irregular lines (interlobular septal thickening)
  16. Peripheral reticulation/irregular lines
    IPF
  17. Irregular lines/reticulation extending from the hilum to the periphery
    Sarcoidosis
  18. peripheral reticulation and pleural plaques
    asbestosis
  19. air-filled cysts with a central dot
    centrilobular emphysema
  20. DDx: Air-filled cysts in lung with peripheral dot sign
    • •Cystic lung disease
    • -LAM, LCH (EG) (LAM-well rounded, LCH more irregular)
    • -Sjogren syndrome
    • •Infection
    • -PCP
    • •Honeycombing
  21. DDx: Honeycombing on CT
    • •Fibrosis
    • -Idiopathic (UIP)
    • -Asbestos
    • -Collagen vascular disease
    • -Chronic HP
    • -Drug exposure
    • •Sarcoidosis
  22. Solid, perilymphatic nodules
    Sarcoidosis
  23. DDx: Solid, centrilobular nodules
    "BAIL"

    • Bronchiolitis
    • Aspiration
    • Infection -(TB, NTMB)
    • LCH
  24. DDx: Solid, diffuse nodules
    "MeLDS"

    • Metastatic disease
    • Langerhans cell histiocytosis
    • Disseminated infection (miliary)
    • Silicosis, CWP
    • Sarcoidosis
  25. DDx: Ground glass, centrilobular nodules
    "EBB"

    • Extrinsic allergic alveolitis
    • Bronchiolitis
    • -respiratory
    • -infectious
    • Bronchioloalveolar CA
  26. DDx: Ground glass opacities
    "PIE PAD"

    • Pulmonary edema
    • Interstitial pneumonia
    • Extrinsic allergic alveolitis

    • Pneumocystis pneumonia
    • Alveolar proteinosis or hemorrhage
    • Drug toxicity
  27. DDx: Crazy-paving
    "BALD"

    • Bronchioloalveolar carcinoma
    • •Alveolar proteinosis
    • Lipoid pneumonia
    • Drug toxicity
  28. DDx: Consolidation
    "CoNES"

    • Cryptogenic organizing pneumonia
    • Neoplasm- (Bronchioloalveolar carcinoma-Lymphoma/BALT)
    • Eosinophilic pneumonia
    • Sarcoidosis
  29. DDx: Pulmonary nodule
    • Mimics (not pulmonary)
    • Infection–Bacterial (round pneumonia)–Granulomatous
    • Neoplasm–Malignant–Benign
    • Vascular: AVM
    • Infarct
    • Cyst
    • Mucoid impaction
    • Trauma/hematoma
  30. Benign calcification patterns in a pulmonary nodule
    • Lamellated
    • Popcorn
    • Central
    • Diffuse
  31. Malignant calcification patterns in a pulmonary nodule
    • Eccentric
    • Amorphous
    • Stippled - frequently carcinoid
  32. DDx: Multiple diffuse calcified pleural nodules
    • Granulomatousdz(TB, histo)
    • Silicosis (not truly calcified; upper > lower)
    • Healed varicellapneumonia
    • Pulmonary microlithiasis(2-3 mm in size)
    • Metastatic osteosarcoma/ chondrosarcoma
    • If not sure of calcified on CXR:
    • Fungal infection, disseminated
    • Hypersensitivity pneumonitis
    • Thyroid metastases
  33. Fat-attenuation nodule in lung
    Diagnostic of hamartoma
  34. Partly solid ground glass nodule has what percent risk of being malignant
    67% or 2/3
  35. What percent of pure ground glass nodules are going to be benign
    80%
  36. Ground glass nodule greater than 1cm is high risk for
    BAC
  37. Popcorn calcification in a lung lesion?
    Hamartoma
  38. Size discriminator for mass vs nodule
    • Nodule < 3cm
    • Mass < 3 cm

    Larger size has greater likelihood of being malignant
  39. smooth marginated pulmonary nodule has what chance of being malignant?
    30%
  40. DDx: Multiple pulmonary nodules greater than 1cm
    • Neoplasm
    • –Metastases
    • –BAC
    • –Lymphoma
    • –KS
    • Infection
    • –Fungal
    • –Septic emboli
    • –MAC
    • Inflammatory
    • –Wegener’s
    • –Rheumatoid
    • –Sarcoid
  41. DDx: Multiple 5-10mm pulmonary nodules
    • Infection:
    • –Varicella
    • –Fungal
    • Neoplasm
    • –Metastases
    • –BAC
    • Pneumoconiosis
    • Sarcoidosis
  42. DDx: Multiple cavitary pulmonary nodules
    • Infectious - (–Gram negative–Anaerobic–Angioinvasive fungi)
    • Metastases - (SCC, cervical)
    • Wegener’s and rheumatoid
    • Septic Emboli
    • Hematoma/laceration
    • Papillomatosis
    • (EG)
  43. DDx; Focal pleural opacity
    • Fluid loculation
    • Lipoma
    • Solitary fibrous tumor
    • (Solitary metastasis)
  44. DDx: Diffuse pleural opacities
    • Fibrosis
    • Fluid
    • Tumor
    • –Mesothelioma
    • –Metastatic disease
    • Plaque: more multifocal, often bilateral, frequently calcified
  45. DDx: Pleural air fluid level
    • Instrumentation
    • Bronchopleural fistula
    • –Empyema
    • –Trauma
    • –Other causes of spontaneous pneumothorax
  46. DDx: Parenchymal air fluid level
    • Necrotizing infection
    • Malignancy
    • Inflammatory (Wegener’s)
  47. Differential for airspace disease
    • Blood (Acute)
    • Pus (Acute)
    • Fluid (Chronic-PAP, Acute-edema)
    • Cells (Chronic)
  48. DDx: Airspace disease, pulmonary hemmorhage
    • •Diffuse
    • -Vasculitis (WG, MPA)
    • -Goodpasture syndrome
    • -Idiopathic hemorrhage
    • •Focal
    • -Trauma (contusion)
    • -Infarct
  49. Neutropenic fever with area of focal consolidation
    Think angioinvasive aspergillus
  50. CT halo sign
    Invasive aspergillus
  51. CT reverse halo sign
    Cryptogenic organizing pneumonia
  52. CXR Air crescent sign
    Cavitary lesion suggesting invasive aspergillus
  53. Infections that invade the chest wall
    • •Actinomycosis, TB
    • •Blastomycosis
  54. Infections with extensive lymphadenopathy
    • •Primary TB
    • •Fungal pneumonia
    • possibly Histo
  55. DDx: Fluid in the airspaces
    • •Pulmonary edema
    • -Hydrostatic (cardiogenic)
    • -Permeability (non-cardiogenic)
    • •Aspiration
    • •Alveolar proteinosis
  56. DDx: Increased cells in the airspaces
    • •Tumor
    • -•Bronchioloalveolar cell CA
    • -Pulmonary lymphoma
    • •Inflammatory
    • -Eosinophilic pneumonia
    • -Organizing pneumonia
    • -Sarcoidosis
  57. peripheral fleeting opacities
    eosinophilic pneumonia
  58. DDx: Peripheral opacity
    • Pneumonia (bacterial, fungal)
    • Infarct
    • Primary lung neoplasm
    • COP
    • Eosinophilicpneumonia
    • Pleural mass (solitary fibrous tumor; mesolthelioma, metastatic disease)
  59. causes of eosinophilic pneumonia
    • •Idiopathic
    • -Simple (Loffler syndrome)
    • -Chronic eosinophilic pn.
    • •Secondary
    • -Drugs
    • -parasites
    • -ABPA
    • •Churg-Strauss vasculitis
  60. spiculated mass with internal low density
    lipoid pneumonia

    can be caused by aspiration of mineral oil (sometimes used for constipation)
  61. 4 main airway disease processes
    • •Narrowing
    • •Atelectasis
    • •Bronchiectasis
    • •Mucoid impaction
    • and small airways disease
  62. DDx: Narrowing of the airway
    • •Stricture
    • -focal
    • -long-segment
    • •Solitary Mass
    • •Multiple Masses
  63. DDx: Long-segment stricture of the airway
    • •Inflammatory
    • -relapsing polychondritis
    • -Wegener granulomatosis
    • -infection (histo)
    • •Cancer
  64. DDx: Focal, short-segment narrowing of the airway
    • "TIE"
    • Trauma
    • Iatrogenic
    • -ETT/tracheostomy
    • -lung transplant
    • Extrinsic mass
  65. DDx: Airway malignancies
    • -Adenoid cystic carcinoma - younger adults, well marginated good prognosis
    • -SCC - older adults, invasive, poor prognosis
    • -Carcinoid - younger adults, Ca2+, iceberg sign
  66. DDx: Solitary airway mass
    • •Malignancy
    • •Benign (10%)
    • •Inflammatory
    • •Foreign body
  67. DDx: Multiple airway masses
    • •Metastases
    • •Papillomatosis- - can become SCC
    • •Tracheopathia Osteochondroplastica
    • •Amyloidosis
  68. Common airway mets
    • •renal cell
    • •breast
    • •melanoma
  69. Atelectasis in an adult should always alert to the process of
    Malignancy compressing or occluding the airway
  70. DDx: Bronchiectasis
    • Congenital
    • -cystic fibrosis
    • -primary ciliary dyskinesia
    • -immune deficiency
    • --Mounier Kuhn
    • --Williams Campbell
    • --Yellow nail
    • Acquired
    • -infection
    • -toxic fume exposure
    • -central obstruction
    • -recurrent aspiration
    • -traction (pulmonary fibrosis)
  71. Causes of mucoid impaction
    • •Bronchiectasis
    • •Asthma
    • •ABPA
    • •Bronchial atresia
    • •Foreign body
    • •Central tumor
  72. DDx: Anterior mediastinal mass
    • Lymph nodes-lymphoma, mets, inlammatory/infectious (TB)
    • Thyroid-goiter, malignancy
    • Parathyroid-adenoma, carcinoma
    • Thymus-thymoma, carcinoma, thymolipoma, thymic cyst
    • Germ cell tumors-teratoma
    • Hematoma
  73. DDx: Middle mediastinal mass
    • Lymphadenopathy-mets, infection, idiopathic
    • Tracheal abnormalities
    • Aneurysms
    • Foregut malformations
    • Pericardial lesions
  74. DDx: Posterior mediastinal mass
    • Esophageal lesions-duplication cyst, neoplasm, varices, achalasia, hiatal hernia
    • Neurogenic tumors-schwannoma, neurofibroma
    • Vascular-descending thoracic aortic aneurysm/dissection
    • Vertebral/paraspinal-hematoma, parapsinal abscess, metastases, extramedullary hematopoiesis
  75. DDx: Cardiophrenic angle masses
    • Fat pad
    • Pericardial cyst
    • Lymph nodes
    • Diaphragmatic hernia (Foramen of Morgagni)
  76. DDx: Low-density lymph nodes
    • Infection-mycobacterial, fungal
    • Malignancy with central necrosis (SCC, lymphoma)
  77. DDx: Hypervascular lymph nodes
    • Castleman disease
    • Mets-especially RCC, thyroid
  78. DDx: Eggshell calcification in lymph nodes
    silicosis, sarcoid
  79. DDx: Central calcification in lymph nodes
    mycobacterial, fungal infection
  80. DDx: Lucent lobe of the lung with some nodular opacities
    • ABPA
    • Endobronchial neoplasm vs. foreign body
    • Bronchial atresia
  81. DDx: Cavitary apical lesion
    • Reactivation (secondary) TB
    • Fungal infection
    • Cavitary lung ca
    • Sarcoidosis
    • Silicosis
    • Wegener
    • Septic emboli
  82. DDx: Lung hyperlucency
    • Emphysema:
    • Panlobular
    • Centrilobular
    • ParaseptalAir trapping:
    • Foreign body (“ball and valve”)-unilateral
    • SwyerJames-unilateral; not hyperexpanded
    • Bronchiolitis/ small airway disease
  83. DDx: Perilymphatic nodules
    • Sarcoidosis(symmetric; upper lobes)
    • Lymphangiticcarcinomatosis(asymmetric; lower lobes)
    • Silicosis; coalworker’spneumoconiosis
    • Amyloid
    • LIP
  84. Stages of sarcoid
    • •Stage 0-Dx, but no evidence of dz.
    • •Stage 1-Adenopathyonly
    • •Stage 2-Adenopathy+ lung findings
    • •Stage 3-Lung disease only
    • •Stage 4-Fibrosis

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