RADIOLOGY IMAGING OF THE CHEST

1. RADIOLOGY IMAGING OF THE CHEST Part II The respiratory system

2. Interstitial lung disease • The pulmonary interstitium is the network of connective tissue fibres that supports the lung. It includes the alveolar walls, interlobular septa, and the peribronchovascular interstitium • Although the majority of the disorders also involve air spaces, the predominant abnormality – thickening of the interstitium

3. Septal pattern Interstitial pulmonary oedema Lymphatic spread of tumour Reticular pattern Fibrosin alveolitis Sarcoidosis Chronic alergic alveolitis Langerhans cell histiocytosis Lymphangioleiomyomatosis Nodular pattern Silicosis Coal workers` pneumoconiosis Sarcoidosis Tuberculosis Subacute alergic alveolitis Reticulonodular pattern Langerhans cell histiocytosis Sarcoidosis Lymphatic spread of tumour Ground-glass pattern Subacute alergic alveolitis Pneumocystis carini pneumonia Nonspecyfic interstitial pneumonia (NSIP) Idiopathic pulmonary haemorrhage Interstitial lung diseaseBasic radiographic signs and interpretation

4. Septal pattern Thickening of the interlobular septa – Kerley B lines, short (1-2 cm) lines perpendicular to the pleura, continuous with it Reticular pattern The result of summation of smooth or irregular linear opacities, cystic spaces, or both – interlacing line shadows suggesting the mesh Nodular pattern The accumulation of small lesions within the pulmonary inetrstitium well circumscribed, discrete nodules 2mm or less- miliary nodules Reticulonodular pattern Ground-glass pattern A generalized hazy increase in opacity which obscures the underlying vascular markings on chest radiograph Interstitial lung diseaseBasic radiographic signs and interpretation

5. Interstitial lung diseasedifferential diagnosis 1. The predominant pattern of abnormality 2. Its distribution within the lung 3. The presence of associated findings: • hilar or mediastinal lymphadenopathy • cardiomegaly • pleural thickening • effusion

6. Case 1002A 28 year old Afro-Caribbean woman presented with a persistent dry cough and progressive exertional dyspnoea over three months. She was not wheezy and had not noticed any diurnal variation in symptoms. She was otherwise well with no known allergies or hayfever. Clinical examination revealednoabnormalities and her chest sounded normal. • What is the likely clinical diagnosis? • Which investigations would you request?

7. sarcoidosis

8. Sarcoidosis A multisystem granulomatous disorder of unknown aetioloogy characterized by the presence of noncaseating epihelioid cell granulomas in several affected organs (the skin, eyes, peripheral lymph nodes, spleen, cns, parotid glands, bones) A disease of young adults – a peak incidence in the third decade Traditionally staged according to its appearance of the chest radiograph I – lymphadeopathy II – lymphadeopathy with parenchymal opacity III - parenchymal opacity alone

9. Lymphadenopathy Enlargement of bilateral, symmetrical hilar and paratracheal Occasionally asymmetrical – 1-5% In 90% disappears within 6-2 months Lymph nodes can calcify - eggshell fashion (shared only by silicosis) seen on plain films in 5%, on CT scans – 40% Parenchymal changes Rounded or irregular nodules 2-4mm in diameter, which maybe poorly or moderately well defined Patchy airpace consolidation, sometimes contain air bronchograms, with ill defined margins, commonly break up into nodular pattern Sarcoidosis Radiographic features

12. Industrial lung diseases -silicosis Due to the inhalation of silica (SiO2) Radiographic appearance - Multiple, small nodules, predominantly in the middle and upper zones - Enlargement of the hilar lymph nodes- an eggshell patern - Calcification occasionally seen in the mediastinal, cervical and intra-abdominal nodes

13. Micronodular pneumoconiosis Nodular pneumoconiosis

14. Tuberous pneumoconiosis

15. Pneumoconiosis

16. Massive fibrosis in silicosis

17. Industrial lung diseases -asbestosis The silicates: asbestos 90% of malignant mesotheliomas are related to previous exposure to asbestos Pleural changes the pleural plque – well defined, soft tissue sheets originating on the parietal pleural , usually bilateral, in the middle and lower zones and over the diaphragm • When calcified – a „holly leaf” pattern with sharp, often angulated outlines, usually less than 1cm thick • Diffuse pleural thickening • Pleural effusions – uncommon 3% Pulmonary changes - fibrosing alveolitis peripherally at the lung basas

19. Case13 History: A 62 yo gentleman comes to his family practice physician complaining of shortness of breath. The patient normally avoids physicians because he doesn't have insurance and he feels that they are all quacks anyway. However, he has been having more and more difficulty keeping up with his work on the assembly line at an automobile factory and he fears getting fired. The patient has 70 pack-year history of smoking Camel Studs. Otherwise, he is a fairly healthy individual. On physical exam his breath sounds are diminished diffusely. A subsequent chest x-ray is shown on the left. Questions: What is the most likely diagnosis? What part of the history is pertinent to this diagnosis?

21. Emphysema Condition of the lung characterized by permanent , abnormal enlargement of air spaces distal to the terminal bronchiole, accompanied by the destraction of their walls without obvious fibrosis Is thought to result from the distraction of elastic fibres – inbalance between proteases and protease inhibitors, the mechanical stresses of ventilation and caughing

22. Emphysema Radiological findings Overinflation • The height of of the right lung being greater than 29.9cm • Location of the right diaphragm at or below the anterior aspect of the 7-th rib • Flattering of the hemidiaphragm • Enlargement of the retrosternal space • Widening of the sternodiaphragmatic angle • Narrowing of the transverse cardiac diameter

23. Emphysema Radiological findings Alterations in lung vessels • Arterial depletion, whereas vessels of normal calibre are present in unaffected areas • Absence or displacement of vessels caused by bullae • Widened branching angles with loss of side branches and vascular redistribution With the development of cor pulmonale or left heart failure – the radiolographics appearences will alter

24. Emphysema CT, particularly HRCT scans the most accurate mean! (low window values -800 to -1000 HU) specially for surgery treatment Presence of areas of abnormally low attenuation Focal areas of emphysema usually lack distinct walls as opposed to lung cysts Types • Centrilobular • Panlobular • Paraseptal • Irregular

25. Emphysema Bullae • generaly found in patients with centrilobular and/or septal emphysema • Avascular, low-attenuation areas that are larger than 1cm and that can have a thin but perceptible wall Bullous ephysema • Associated with large bullae, mainly in young men • Large, progressive upper lobe bullae, often asymmetrical • Avascular, transradiant areas separated from the lung parenchyma by a thin curvilinear wall • Complications: pneumothorax, infection, haemorrhage

26. Emphysema

27. Emphysema

28. Emphysema

29. Emphysema

30. Emphysema

31. Diseases of the pleura • Pleural effusion • Bronchopleural fistula • Hemothorax • Chylothorax • Pneumothorax • Pleural masses

32. Case7 History: A 54 yo male with a history of Hodgkin's Lymphoma presents to his primary care physician with a one-week history of shortness of breath and pleuritic chest pain. The patient has also noticed a non-productive cough that has progressively worsened over the past two days. Physical exam demonstrates diminished  breath sounds and egophony on the left. The chest x-ray on the left was taken shortly thereafter. Questions: What is the diagnosis? What findings on the x-ray help distinguish this condition from other opacifications?

35. Pleural effusion bil Collapse segment Heart failure

37. Encysted effusion case 6

38. Pleural effusion The most common clinical manifestation of pleural pathology A result of mismatch between the rates of inflow and outflow of fluid in the pleural space

39. Transudates; Result from: a decrease in the colloid osmotic pressure – hypoproteinemia increase in the microvascular hydrostatic osmotic pressure (the systemic venous pressure) Causes: congestive heart failure cirrhosis nephrotic syndrome nephrogenic effusion hypoalbuminemia constrictive pericarditis atelectasis pulmonary embolism Exudates; Result from: alteration in the pleural surface an increase in permeability decrease in the lymph flow Causes: pleural malignancy pleural inflammation Pleural effusion

40. More than 90% of cases caused by Heart failure Cirrhosis Ascites Pleuropulmonary infections Malignancy Pulmonary embolism Diagnostic imaging Chest radiograph CT Ultrasound Pleural effusion

41. Radiographic features Depends on the patient`s position and the mobility of the pleural fluid On the PA radiograph • blunting of the lateral costophrenic angles - 200ml-up to 500ml of fluid • The most sensitive projection – the lateral decubitus chest radiograph – 5ml

42. In the erect patient Initially collects in the subpulmonic region Blunting of the lateral costophrenic angles Elevated hemidiaphram sign - the superior margin of the fluid mimics the contour of the diaphragm – apparent elevation of the hemidiaphragm with flattening of its medial portion Opacity as hazy meniscus higher laterally than medially In the spine patient position Capping of the lung apex with pleural fluid –early sign Increased hazy opacity with preserved vascular markings Blunting of the costophrenic angle Hazy diaphragm silhouette Thickening of the minor fissure Widened paraspinal soft tissues Elevated hemidiaphragm sign Radiographic features

43. Hemothorax Most commonly results from trauma Less common reasons: • Varicella infections • Coagulopathies • Vaascular abnormalities Chest radiogrph: a pleural effusion without any distinguishing factor to suggest blood in the pleeural space Non contrast CT- the characteristic attenuation increase

44. Chylothorax Discruption of the thoracic duct • 50%- neoplastic in origin lymphoma (75%) • 25% traumatic - surgery • 10% miscellaneous • 15% idiopathic Usually cannot be differentiated from other effusions based on chhest radiographs or CT scans

45. Pleural effusion

46. Pleural effusion

47. Pleural effusion

48. Pleural effusion

49. Pleural effusion

50. Pleural effusion