Transcript Radiology of Respiratory System

RADIOLOGY OF
RESPIRATORY SYSTEM
Weizhong Cheng
Dept. Radiology, Zhongshan Hospital
Institute of Medical Imaging, Shanghai
AIMS
•Basics
•Best
exam results
•Appreciate the role radiology plays
•? Instill an interest in radiology
BEFORE CLASS:
Textbook
 Reference book
 Literature
 Internet
 Apps
 Teacher & classmate

Histology and Embryology
Anatomy
Pathology
Internal Medicine
Surgery
Gynecology
Pediatrics
Neurology
。。。
Everything。。。U need to know
METHODS
X-ray
 CT
 MR
 DSA
 US
 Nuclear Medicine

PET/CT
Radionuclide ventilation perfusion imaging
X-RAY TECHNIQUES
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PA （posteroanterior) &
Lateral
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More information
Two views
Standardized
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Distance
Pt needs to be stable
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Portable
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Quick
Anywhere
One shot
No standardization
Portable
PA
TECHNIQUES - PROJECTION
•P-A
(relation of x-ray beam to patient)
TECHNIQUES - PROJECTION (CONTINUED)
•A-P
Supine/Erect
TECHNIQUES - PROJECTION (CONTINUED)
•Lateral
TECHNIQUES - PROJECTION (CONTINUED)
•Lateral
•Oblique
Decubitus
TECHNICAL DETAILS
•Type
•Orientation
•Rotation
•Inspiration/expiration
•Penetration
ROTATION
ROTATION
(CONTINUED)
PENETRATION
INSPIRATION/EXPIRATION
THINGS TO SEE
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ABCDE…
Airways
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Bones
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Trachea, endotracheal tube, etc
Clavicles, ribs, etc…
Cardiac
Diaphragm (Right hemidiaphragm slightly higher (~1.5
cm)
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Everything else (tubes), effusions
DENSITIES
The big two densities are:
(1) WHITE - Bone
(2) BLACK - Air
The others are:
(3) DARK GREY- Fat
(4) GREY- Soft tissue/water
And if anything Man-made is on the film, it is:
(5) BRIGHT WHITE - Man-made
ANATOMY
ANATOMY
BRONCHOPULMONARY ANATOMY
CROSS-SECTIONAL ANATOMY OF LUNG SEGMENTS （CT）
LOBES
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Right upper lobe:
LOBES (CONTINUED)
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Right middle lobe:
LOBES (CONTINUED)
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Right lower lobe:
LOBES (CONTINUED)
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Left lower lobe:
LOBES (CONTINUED)
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Left upper lobe with Lingula:
LOBES (CONTINUED)
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Lingula:
LOBES (CONTINUED)
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Left upper lobe - upper division:
HEART
Right border: Edge of (r) Atrium
3. Left border: (l) Ventricle + Atrium
4. Posterior border: Reft Ventricle
5. Anterior border: Right Ventricle
HEART (CONTINUED 。。。。)
HEART
IT’S NOT MINE….
HILUM
Made of:
1. Pulmonary Art.+Veins
2. The Bronchi
Left Hilum higher (max 1-2,5 cm)
Identical: size, shape, density
HILUM
RIBS
REVIEW AREAS:
Apices
• Behind the heart
• Costophrenic angle (CPA)
• Below the diaphragm
• Soft tissues ( breast, surgical emphysema)
• Ribs & clavicle
•Vertebrae
•
ABNORMALS
LUNG FINDINGS
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Darker areas
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radiolucent
Pneumothorax
Cysts/bulla
Air bronchograms
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Lighter areas
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Opacities
Atelectasis
“infiltrates”
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Blood
Pus
Water
Nodules or mass
OPACITIES
Lobar or not….
 Pneumonia
 Pulmonary Edema
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 “fluffy,”
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diffuse, “bat wing” distribution
Hemorrhage
 Can’t
tell by x-ray, need bronch
RML pneumonia
Opacities
Opacities
RLL pneumonia
RUL pneumonia
LLL pneumonia
Consolidation on CT
THE ENLARGED HILA
Causes:
1. Adenopathies (neoplasia, infection)
2. Primary Tumor
3. Vascular
4. Sarcoidosis
Mass
Hilar Lymphadenopathy - BL
Multiple Masses
Metas
Pleural Effusion
Pulmonary Fibrosis
Heart failure， Kerley A/B line
（Interstitial lung hyperplasia edema）
Heart failure
Pneumothorax
Emphysema
Cavitating lesion
Thin-walled Cavitating lesion
3mm
Thick-walled Cavitating lesion
Bronchiectasis
Miliary shadowing
CALCIFICATION
Benign Patterns of Calcification Within a Solitary Pulmonary Nodule
Chest Tube, NG Tube,
Pulm. artery cath
CT INDICATIONS
KEY
Clinical Factors
 Growth Pattern
 Size
 Margin (Border) Characteristics
 Density
 Contrast-Enhanced CT
 Other findings
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PULMONARY INFECTION
dense multifocal segmental
airspace opacification
pneumonia
air bronchograms
lung abscess
Pneumonia finding
Lobar/segmental consolidation
cavitation
TUBERCULOSIS
infiltrates
Miliary shadowing
Tuberculoma
Chronic fibro-cavitary TB
CAUSES OF SOLITARY PULMONARY NODULES （SPN）
Neoplastic: Malignant
Bronchogenic carcinoma
Solitary metastasis
Lymphoma
Carcinoid tumor
Neoplastic: Benign
Hamartoma
Benign connective tissue and neural tumors (e.g., lipoma, fibroma, neurofibroma)
Inflammatory
Granuloma
Lung abscess
Rheumatoid nodule
Inflammatory pseudotumor (plasma cell granuloma)
Congenital
Arteriovenous malformation
Lung cyst
Bronchial atresia with mucoid impaction
Miscellaneous
Pulmonary infarct
Intrapulmonary lymph node
Mucoid impaction
Hematoma
Amyloidosis
Normal confluence of pulmonary veins
Mimics of SPN
Nipple shadow
Cutaneous lesion (e.g., wart, mole)
Rib fracture or other bone lesion
loculated pleural effusion
NEOPLASTIC: BENIGN
Hamartoma
Bronchogenic carcinoma
NEOPLASTIC:
MALIGNANT
NEOPLASTIC: MALIGNANT
Bronchogenic carcinoma
INFLAMMATORY
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Granuloma
chest radiograph shows a small, wellcircumscribed, round opacity at the right
lung base (arrows).
Lateral view shows that the opacity is within the
lung on two views (posterior segment of the right
lower lobe) and thus represents a pulmonary
nodule (arrow).
Malignant SPN
Contrast CT in Malignant Solitary
Pulmonary Nodule. Thin-collimation (3mm) CT scans through left upper lobe
nodule in a 62-year-old woman with
biopsy-proven lung cancer shows a
lobulated
contour
with
positive
enhancement of 50 H after contrast
administration
BRONCHOGENIC CARCINOMA（CLINICAL）
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Age at diagnosis: 55-60 years (range 40-80 years); M:F = 1.4:1
asymptomatic (10-50%) usually with peripheral tumors
symptoms of central tumors:
 cough (75%), wheezing, pneumonia
 hemoptysis (50%), dysphagia (2%)
symptoms of peripheral tumors:
 pleuritic/local chest pain, dyspnea, cough
 Pancoast syndrome, superior vena cava syndrome
 hoarseness
symptoms of metastatic disease (CNS, bone, liver, adrenal gland)
paraneoplastic syndromes:
 cachexia of malignancy
 clubbing + hypertrophic osteoarthropathy
 nonbacterial thrombotic endocarditis
 migratory thrombophlebitis
 ectopic hormone production: hypercalcemia, syndrome of inappropriate secretion of
antidiuretic hormone, Cushing syndrome, gynecomastia, acromegaly
RISK FACTORS
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Cigarette smoking (squamous cell carcinoma + small cell carcinoma)
 鈥搑elated to number of cigarettes smoked, depth of inhalation, age at which smoking
began
 85% of lung cancer deaths are attributable to cigarette smoking!
 Passive smoking may account for 25% of lung cancers in nonsmokers!
Radon gas: may be the 2nd leading cause for lung cancer with up to 20,000 deaths per year
Industrial exposure: asbestos, uranium, arsenic, chlormethyl ether
Concomitant disease:
 chronic pulmonary scar + pulmonary fibrosis
 Scar carcinoma
 45% of all peripheral cancers originate in scars!
Incidence: 7% of lung tumors; 1% of autopsies
Origin: related to infarcts (>50%), tuberculosis scar (<25%)
Histo: adenocarcinoma (72%),
squamous cell carcinoma (18%)
Location: upper lobes (75%)
TYPES:
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Adenocarcinoma (50%)
Most common cell type seen in women + nonsmokers
Intermediate malignant potential (slow growth, high incidence of early metastases)
almost invariably develops in periphery; frequently found in scars (tuberculosis,
infarction, scleroderma, bronchiectasis) + in close relation to preexisting bullae
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solitary peripheral subpleural mass (52%)/alveolar
infiltrate/multiple nodules
may invade pleura + grow circumferentially around lung
mimicking malignant mesothelioma
upper lobe distribution (69%)
air broncho-/bronchiologram on HRCT (65%)
calcification in periphery of mass (1%)
smooth margin/spiculated margin due to desmoplastic
reaction with retraction of pleura
solitary peripheral mass
Adenocarcinoma Presenting as Solitary Pulmonary Nodule.
A.Cone-down view of posteroanterior radiograph shows nodule in the right mid-lung (arrow).
B.Thin-section CT shows 12-mm nodule with spiculated margins (arrow) in the superior segment of the right
lower lobe. Transthoracic needle biopsy revealed adenocarcinoma.
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Squamous cell carcinoma (30-35%)
Strongly associated with cigarette smoking
 Central location within main/lobar/segmental bronchus (2/3)
 large central mass & cavitation
 distal atelectasis & bulging fissure (due to mass)
 postobstructive pneumonia
 All cases of pneumonia in adults should be followed to complete
radiologic resolution!
 airway obstruction with atelectasis (37%)
 Solitary peripheral nodule (1/3)
 characteristic cavitation (in 7-10%)
 Squamous cell carcinoma is the most common cell type to cavitate!
 invasion of chest wall
 Squamous cell carcinoma is the most common cell type to cause
Pancoast tumor
Central lung cancer
Squamous Cell Carcinoma.
A.Posteroanterior chest film in a 58-year-old male smoker with hemoptysis
shows a left hilar mass with left upper lobe atelectasis.
B.Enhanced CT scan shows the left hilar mass occluding the left upper lobe
bronchus with an endobronchial component (straight arrow). Note the presence
of mucus bronchograms within the atelectatic lung (curved arrow)
Squamous Cell Carcinoma
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Small cell undifferentiated carcinoma (15%)
Strongly associated with cigarette smoking
Rapid growth + high metastatic potential
 typically
large hilar/perihilar mass often associated
with mediastinal widening (from adenopathy)
 extensive necrosis + hemorrhage
 small lung lesion (rare)
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Large undifferentiated cell carcinoma (<5%)
 Strongly
associated with smoking
 large bulky usually peripheral mass >6 cm (50%)
 large area of necrosis
 pleural involvement
 large bronchus involved in central lesion (50%)
Large-cell bronchogenic carcinoma
small-cell bronchogenic carcinoma
GROUND-GLASS OPACITY
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the pattern was shown to be caused by predominantly interstitial diseases
in 54% of cases, equal involvement of the interstitium and airspaces in
32%, and predominantly airspace disease in 14%
GGO is an important finding. In certain clinical circumstances, it can
suggest a specific diagnosis, indicate a potentially treatable disease, and
guide a bronchoscopist or surgeon to an appropriate area for biopsy
Pure GGO（ Ground-glass Opacity）
Early stage
98,6,17
Lung cancer:solid nodules
12*8mm ,Lobular resection,8 yrs alive
SELF TEST？
MR INDICATIONS
NEVER STOP LOOKING, CARRY ON
WITH YOUR SYSTEMATIC APPROACH!!