Radiology Notes

My notes during radiology residency, fellowship, and beyond…

Archive for the ‘chest’ Category

Abscess vs Empyema, Chest

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  • Abscess: Thick, irregular wall; round shape, narrow contact with chest wall
  • Empyema: Thin, uniform wall; lenticular shape, broad contact with chest wall, split pleura sign

Written by lmwong

April 9, 2008 at 4:12 pm

Posted in abscess, chest, empyema

Types of Atelectasis

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  • Obstructive = bronchogenic carcinoma
  • Passive = pleural effusion, pneumothorax
  • Compressive = bulla
  • Cicatricial = post-primary TB, radiation fibrosis
  • Adhesive = respiratory distress syndrome of the newborn

Written by lmwong

April 9, 2008 at 4:08 pm

Diffuse Confluent Airspace Opacities Differential

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  • pulmonary edema
  • pneumonia
  • hemorrhage
  • neoplasm
  • alveolar proteinosis

Written by lmwong

April 9, 2008 at 4:06 pm

Posted in chest, differential

Pulmonary Hypertension

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  • Enlarged hilar and perihilar pulmonary arteries
  • main pulmonary artery > 28.6mm transverse dimension
  • RV enlargement

causes

  • pulmonary venous hypertension
  • left to right shunts
  • connective tissue disorders
  • chronis pulmonary embolisms
  • left heart dysfunction

Written by lmwong

April 8, 2008 at 4:12 am

Posted in chest, pulmonary

Bronchopneumonia

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  • Most common form
  • Staph
  • in the hospitalized and debilitated
  • Begins centrally in and around lobular bronchi, extends peripherally along bronchus
  • Multifocal consolidation = patchwork quilt; eventually coalesce.
  • Exudates fill airways = no air bronchograms
  • 25-75% form abscess
  • Empyema and parapneumonic effusion common

Written by lmwong

April 8, 2008 at 3:51 am

Posted in chest, pneumonia, pulmonary

Lobar Pneumonia

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  • Pneumococcal >> Klebsiella >> mycoplasma >> legionella
  • Inflammation begins in distal airspaces and spreads via pore of Kohn and canals of Lambert
  • Nonsegmental consolidation, eventually causing lobar consolidation
  • Predominantly lower lobes and posterior segment upper lobes
  • Spares airways = air bronchograms
  • Volume loss is common

Written by lmwong

April 8, 2008 at 3:35 am

Posted in chest, pneumonia

Lymphangitic Carcinomatosis

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“Certain Caners Spread By Plugging The LLymphatics”

  1. Cervix
  2. Colon
  3. Stomach
  4. Breast
  5. Pancreas
  6. Thyroid
  7. Lung
  8. Larynx
  • Invasion of lymphatic channels by tumor
  • Retrograde lymphatic flow with dilation of lymphatic channels, interstitial deposits and fibrosis
  • fine reticulonodular opacities and thickened septal lines, bronchial cuffing
  • Associated subpleural edema or pleural effusion
  • Extrathoracic tumors usually bilateral
  • bronchogenic carcinoma usually unilateral

Written by lmwong

April 8, 2008 at 3:32 am

Metastatic Lung Disease

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Primary tumors that cause lung mets:

  • breast
  • colon
  • kidney
  • uterus
  • prostate
  • head & neck

Patterns

  • Cannonball pattern = colon cancer, sarcoma, RCC, melanoma
  • Miliary pattern = ovarian or thyroid, RCC, melanoma
  • Lymphangitic spread = breast cancer, stomach cancer, pancreatic cancer, prostate cancer, and lung cancers, particularly small cell cancer and adenocarcinoma.
  • Cavitary = uterine cervix, colon, head and neck, squamous cell carcinoma

Spread

  • Direct
  • Hematogenous = pulmonary nodules, lymphangitic carcinomatosis

Written by lmwong

April 8, 2008 at 3:29 am

Bronchogenic Carcinomas

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Leading cause of malignant mortality in US

Adenocarcinoma:

  • MC, 35%
  • peripheral nodules, peripheral mass >> central mass
  • Arise from bronchiolar or alveolar epithelium
  • Irregular or spiculated appearance,
  • Invade adjacent lung, causes fibrosis
  • Produces mucin
  • Subtype = bronchioalveolar cell carcinoma (BAC)
  • can have GG appearance; Simulated PNA

Squamous Cell:

  • 25%
  • hilar mass and atelectasis.
  • Arises from lobar or segmental bronchus = central
  • Invades bronchiole lumen = obstruction, symptoms
  • Central necrosis and cavitation

Small Cell:

  • 25%
  • Central main or lobar bronchi
  • Associated with hilar mass and mediastinal mass (LAD)
  • Most malignant type
  • Present with lymph node spread

Large Cell

  • 15%
  • Large peripheral mass.

General Radiographic Findings

  • irregular edges
  • solitary nodule
  • Hilar mass
  • >3cm
  • doubles in 1-18 months
  • Atelectasis, obstructive pneumonitis
  • Lobar or lung collapse
  • S-sign of Golden

See Lung CA staging

Written by lmwong

April 8, 2008 at 3:19 am

Solitary Pulmonary Nodule Workup

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  • Nipple? Use nipple markers…it’s cheap and fast.
  • 3cm = mass
  • 95% fall into 1 of 3: malignant neoplasm, infectious granulomas, benign hamartoma
  • Always: Look at AP/LA views; Look for old studies
  • What to think about:
  1. Clinical ( 35yo)
  2. Growth pattern (doubling time)
  3. Size (not reliable)
  4. Margins
  5. density

Most likely B9 if:

  • Calcium (extremely rare eccentric scar carcinomas and carcinoid tumors) or fat present (hamartoma)
  • well circumscribed

Volume Doubling time (increased diameter by 25%):

  • 1-24 months = bronchogenic carcinoma
  • >24 months = granuloma, hamartoma, bronchial carcinoid, salivary gland adenoid cystic carcinoma, thyroid carcinoma met, round atelectasis, adenocarcinoma, carcinoid tumors

Margins
Smooth, well circumscribed

  • Most likely benign = granuloma, hamartoma
  • Rare malignant causes = carcinoid tumor, adenocarcinoma, solitary met

- Other (notched, lobulated, spiculated)

  • Strongly suggestive of malignancy, but not diagnositic
  • B9 causes = lipod pneumonia, organizing pneumonia, TB, progressive fibrosis from silicosis
  • Differentiate round atelectasis (on CT):
    • Comet tail of bronchi and vessels swirling around density
    • Crow’s feet branching from consolidation to lung parenchyma
    • Associated with pleural effusion or pleural disease (ie asbestos)
    • Lung bases predominate

Density ( most important factor)

  • Calcification pattern:
    • B9 = central, complete, concentric/laminated, peripheral, or popcorn
    • Bronchogenic Carcinoma = eccentric internal calcification (engulfment)
  • Fat = harmartoma

Contrast Enhancement

  • Virtually all malignant lesions enhance 15HU
  • Lack of significant enhancement = B9

PET

  • FDG-PET has high sensitivity and specificity for lesions >10mm (97% and 78%), for being malignant

Fleischner Society Guidelines: Radiology 2005 Nov; 237:395-400.

Low risk patients

  • < or = 4 mm: No follow-up needed.
  • >4 – 6: Follow-up at 12 months. If no change, no further imaging needed.
  • >6 – 8: Initial follow-up CT at 6 -12 months and then at 18 – 24 months if no change.
  • >8: Follow-up CTs at around 3, 9, and 24 months. Dynamic contrast enhanced CT, PET, and/or biopsy.

High risk patients

  • < or = 4 mm: Follow-up at 12 months. If no change, no further imaging needed.
  • >4-6: Initial follow-up CT at 6 -12 months and then at 18 – 24 months if no change.
  • >6-8: Initial follow-up CT at 3 – 6 months and then at 9 -12 and 24 months if no change.
  • >8: Follow-up CTs at around 3, 9, and 24 months. Dynamic contrast enhanced CT, PET, and/or biopsy.

Management Algorithm

Differential Diagnosis

Written by lmwong

April 8, 2008 at 2:51 am

Posted in chest, nodule, pulmonary

Chest CT Dictation

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Indication: [x]

Technique: A chest CT was performed utilizing contiguous axial images from the thoracic inlet to the level of the adrenal glands [with/without] the use of intravenous contrast.

Comparison: [x]

Findings: No thoracic lymphadenopathy is present. No pleural or pericardial effusion is seen. The heart is normal in size.

The lungs are clear. The trachea and central airways are patent.

Impression: Normal chest CT.

Written by lmwong

April 7, 2008 at 4:34 am

Posted in chest, ct, sample dictation

Chest CT for PE Dictation

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Indication: [x]

Technique: A CT of the chest, pelvis and lower extremities was performed following the administration of intravenous contrast as per routine pulmonary embolus protocol.

Comparison: [x]

Findings: No evidence of a pulmonary embolus or deep venous thrombosis is seen.
No thoracic lymphadenopathy is identified. No pleural or pericardial effusion is identified. The heart is normal in size.

The trachea and central airways appear patent. The lungs are clear.

Impression: No evidence of central pulmonary embolus or deep venous thrombosis.

Written by lmwong

April 7, 2008 at 4:34 am

Chest Portable Dictation

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Indication: [x]
Technique: Portable AP view of the chest.
Comparison: [x]
Findings: The lungs are clear. The cardiomediastinal silhouette is stable. No pleural effusion is seen.
Impression: [x]

Written by lmwong

April 7, 2008 at 4:33 am

Chest PA & LA Dictation

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Indication: [x]
Technique: PA and lateral views of the chest.
Comparison: [x]
Findings: The lungs are clear. The cardiomediastinal silhouette is within normal limits. No pleural effusion is identified.
Impression: Normal chest film.

Written by lmwong

April 7, 2008 at 4:31 am

Diffuse Lung White Out

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  • Post pneumonectomy
  • PNA
  • Hemorrhage
  • Asymmteric Edema

Written by lmwong

April 5, 2008 at 7:11 pm

Saber Sheath Trachea

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  • Chronic bronchitis or COPD
  • tracheomalacia
  • saber sheath deformity
  • amyloidosis
  • relapsing polychondritis
  • tracheobronchopathia osteochondroplastica
  • complete cartilage rings

Written by lmwong

April 5, 2008 at 7:10 pm

Rheumatoid Findings in the Chest

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  • basilar predominance
  • fine reticular GG opacities, progress to mod
  • coarse reticular or reticulonodular pattern
  • lung nodules (cavities)
  • pleural effusions
  • pulmonary artery HTN
  • MSK: distal erosion of clavicle, high riding humeral head, GH space narrowing, superior rib notching

see Rheumatoid arthritis

Written by lmwong

April 5, 2008 at 7:09 pm

SLE findings

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  • acute lupus pneumonitis: like ARDS, airspace disease
  • fibrosis
  • elevated hemidiaphragm
  • low volumes
  • bibasilar linear atelectasis
  • pulmonary artery HTN
  • pulmonary embolism
  • superior rib notching, erosion

Written by lmwong

April 5, 2008 at 7:08 pm

Posted in chest, differential, lupus, sle

Scleroderma findings

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  • fibrosis, degeneration and atrophy of smooth muscle
  • bronchiectesis
  • coarse reticular or reticulonodular pattern
  • subpleural regions of lower lobes- pulmonary artery HTN
  • mediastinal lymph node egg-shell calcifications
  • dilated air filled esophagus; decreased peristalsis
  • masses = cancer

CREST

  • Calcifications
  • Raynauds phenomenon
  • Esophageal dysmotility
  • Sclerodactyly
  • Telangiectasia

Written by lmwong

April 5, 2008 at 7:06 pm

Multiple Pulmonary Nodules

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  • Mets
  • **Infection (Histoplasmosis) **
  • Lymphoma (non-Hodgkins, + gallium scan)
  • Bronchogenic Carcinoma
  • Kapsoi’s sarcoma (+HIV)
  • Granulomatous Disease
  • Sarcoidosis
  • Wegener’s Granulomatosis
  • RA
  • Amyloid
  • Septic emboli

lung

Written by lmwong

April 5, 2008 at 7:05 pm

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