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Chest Film Primer Images and Material courtesy of: David S. Feigin, M.D. Colonel (Ret), USA, MC Professor of Radiology, Uniformed Services University of.

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Presentation on theme: "Chest Film Primer Images and Material courtesy of: David S. Feigin, M.D. Colonel (Ret), USA, MC Professor of Radiology, Uniformed Services University of."— Presentation transcript:

1 Chest Film Primer Images and Material courtesy of: David S. Feigin, M.D. Colonel (Ret), USA, MC Professor of Radiology, Uniformed Services University of the Health Sciences “A Systematic Approach To Abnormal Chest Images: Radiographs And Computed Tomograms” Updates and compilation: Les Folio, DO, MPH Col, USAF, MC, SFS Associate Professor of Radiology, Uniformed Services University of the Health Sciences

2 Main Menu 5 PATTERNS OF PATHOLOGY 1.MassMass 2.ConsolidativeConsolidative 3.InterstitialInterstitial -LinearLinear -NodularNodular 4.VascularVascular 5.AirwayAirway -Wall-ThickenedWall-Thickened -ObstructiveObstructive EXIT NORMAL ANATOMY 1.A-P Chest RadiographA-P Chest Radiograph 2.Lateral Chest RadiographLateral Chest Radiograph THE SEARCH PATTERN 1.A-P Chest RadiographA-P Chest Radiograph 2.Lateral Chest RadiographLateral Chest Radiograph

3 Normal Anatomy- AP  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD  1. Gross Specimen 3.Cardiovascular System A. The Cavals B. The Heart C. The Pulmonary Arteries E. Aorta 2. The Respiratory System A. The Airway B. The Lungs and Diaphragm D. The Pulmonary Veins 3. The Bones, Bowel Gas, Azygous, etc. RUL, next to minor fissure RLL SVC EdgeLeft paratracheal stripe Right AtriumLeft Ventricle LLL LUL RML, next to right heart border

4 Normal Anatomy- Lateral  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD  2. Cardiovascular System 1. Respiratory System A. The Airway B. The Lungs and Diaphragm A. The Vessels B. The Heart 3. The Bones (no link yet) Trachea Left main bronchus RLL, with major fissure RML, with minor fissure RUL Right Pulmonary Artery Left Pulmonary Artery Inferior Vena Cava Left Ventricle Right Ventricle Aorta

5 1. SVC Edge 2. Rt Paratracheal Line 3. Lt Paratracheal Stripe (both red and black lines) (both red and black lines) 4. Aortic Arch 5. Descending Aorta (only left edge seen, and not always) (only left edge seen, and not always) 6. Rt Atrium 7. Azygoesophageal edge 8. Lt Ventricle 9. Main Pulmonary Artery AKA: trunk, middle mogul AKA: trunk, middle mogul MediastinumMid Quiz yourself: Mediastinum Lines, Edges Recommendation: Test yourself before advancing to the answers

6 Left Ventricle (curved line) Lateral IVC (arrows) Right Pulmonary Artery (red) Left Pulmonary Artery (green) Trachea Lt MSB on end

7 Main Menu The 5 PATTERNS OF PATHOLOGY 1.MassMass 2.ConsolidativeConsolidative 3.InterstitialInterstitial -LinearLinear -NodularNodular 4.VascularVascular 5.AirwayAirway -Wall-ThickenedWall-Thickened -ObstructiveObstructive EXIT NORMAL ANATOMY 1.A-P Chest RadiographA-P Chest Radiograph 2.Lateral Chest RadiographLateral Chest Radiograph THE SEARCH PATTERN 1.A-P Chest RadiographA-P Chest Radiograph 2.Lateral Chest RadiographLateral Chest Radiograph

8 Search Pattern- AP  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD PRELIMINARIES Verify patient info, date, L and R markers Verify patient info, date, L and R markers Note technique deficiencies Note technique deficiencies Quick look at both films for obvious abnormalities Quick look at both films for obvious abnormalitiesFRONTAL 1. LUNGS Up and down Side to side Volume and Symmetry 2. PERIPHERY Pneumothorax (air) Effusions (fluid) 3. MEDIASTINUM ContoursEdgesShape 4. TRACHEA AND MAIN BRONCHI 5. HILA Enlargement Abnormal bulges 6. PERIPHERY OF CHEST Neck Chest wall and bones Diaphragms Upper abdomen

9 Search Pattern- Lateral  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD PRELIMINARIES Verify patient info, date, L and R markers Verify patient info, date, L and R markers Note technique deficiencies Note technique deficiencies Quick look at both films for obvious abnormalities Quick look at both films for obvious abnormalitiesLATERAL 1.SIZE AND SHAPE OF LUNGS AND DIAPHRAGMS 2.AIRWAY Neck to Hilum Pulmonary Arteries 3.Back of heart and darkening downward 4.Up anterior mediastinum for darkening 5.Down spine for vertebral bodies and darkening 6.PERIPHERY Abdomen Anterior chest wall Posterior ribs Costophrenic angles

10 Main Menu 5 PATTERNS OF PATHOLOGY 1.MassMass 2.ConsolidativeConsolidative 3.InterstitialInterstitial -LinearLinear -NodularNodular 4.VascularVascular 5.AirwayAirway -Wall-ThickenedWall-Thickened -ObstructiveObstructive EXIT NORMAL ANATOMY 1.A-P Chest RadiographA-P Chest Radiograph 2.Lateral Chest RadiographLateral Chest Radiograph THE SEARCH PATTERN 1.A-P Chest RadiographA-P Chest Radiograph 2.Lateral Chest RadiographLateral Chest Radiograph

11 1. Mass Mechanism - Local destruction of lung parenchyma Mechanism - Local destruction of lung parenchyma Radiological sign - Any localized opacity not completely bordered by fissures or pleura Radiological sign - Any localized opacity not completely bordered by fissures or pleura  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

12 1. Mass Differential Diagnosis Differential Diagnosis Malignancy - Primary or secondary Malignancy - Primary or secondary Granulomatous disease - Infectious or noninfectious, active or inactive Granulomatous disease - Infectious or noninfectious, active or inactive Other inflammation, including pneumonia and abscess, Benign neoplasm, Congenital abnormality Other inflammation, including pneumonia and abscess, Benign neoplasm, Congenital abnormality Crucial appearance characteristics for inactivity Crucial appearance characteristics for inactivity Calcification – central, lamellar Calcification – central, lamellar Evolution – 2-year stability or regression Evolution – 2-year stability or regression  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

13 2. Consolidative (Alveolar) Pattern Mechanism Mechanism Produced in pure form and by ALVEOLAR FILLING Produced in pure form and by ALVEOLAR FILLING May be mimicked by alveolar collapse, as in airway obstruction May be mimicked by alveolar collapse, as in airway obstruction Rarely, confluent interstitial thickening Rarely, confluent interstitial thickening Radiological signs Radiological signs Fluffy, cloud-like, coalescent opacities Fluffy, cloud-like, coalescent opacities Sharp edges when limited by fissures or pleura Sharp edges when limited by fissures or pleura Complete air bronchograms through the clouds Complete air bronchograms through the clouds  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

14 Fluffy and cloud-like appearance Air bronchograms THROUGH clouds  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

15 Air bronchogram Normal lung Consolidated lung, with air in bronchioles  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

16 2. Consolidative (alveolar) Pattern Differential Diagnosis (5 general) Differential Diagnosis (5 general) Hemorrhage - BLOOD - embolism, trauma Hemorrhage - BLOOD - embolism, trauma Exudate - PUS - pneumonia, pneumonitis Exudate - PUS - pneumonia, pneumonitis Transudate - WATER - congestion, ARDS Transudate - WATER - congestion, ARDS Secretions - PROTEIN - Mucous plugging, Alveolar proteinosis Secretions - PROTEIN - Mucous plugging, Alveolar proteinosis Malignancy - CELLS - Alveolar cell carcinoma, Lymphoma Malignancy - CELLS - Alveolar cell carcinoma, Lymphoma  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

17 3. Interstitial Pattern Composition of pulmonary interstitium: Composition of pulmonary interstitium: Alveolar walls, septi Alveolar walls, septi Connective tissue surrounding bronchi and vessels (peribronchial and perivascular spaces) Connective tissue surrounding bronchi and vessels (peribronchial and perivascular spaces) Mechanism Mechanism Thickening of lung interstices Thickening of lung interstices Architectural destruction of interstitium (honeycomb or “end stage” lung) Architectural destruction of interstitium (honeycomb or “end stage” lung)  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

18 3. Interstitial Pattern Radiological Signs: Radiological Signs: Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Destructive form - peripheral, irregular cyst formation Destructive form - peripheral, irregular cyst formation  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

19 3. Interstitial Pattern Radiological Signs: Radiological Signs: Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Destructive form - peripheral, irregular cyst formation Destructive form - peripheral, irregular cyst formation  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

20 Reticular form (Lines in all directions) Kerley B lines (horizontal septal)  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

21 3. Interstitial Pattern – Linear Form Differential Diagnosis: The “LIFE Lines” Differential Diagnosis: The “LIFE Lines” Lymphangitic spread of malignancy Lymphangitic spread of malignancy Inflammation Inflammation Fibrosis Fibrosis Edema Edema  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

22 3. Interstitial Pattern Radiological Signs: Radiological Signs: Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Destructive form - peripheral, irregular cyst formation Destructive form - peripheral, irregular cyst formation  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

23 Multiple small nodules, uniform in shape and distribution  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

24 3. Interstitial Pattern- Nodular Form Differential Diagnosis Differential Diagnosis 1. Granulomas 2. Hematogenous Spread of Malignancy 3. Pneumoconiosus Granulomatous Diseases: Infectious Tuberculosis Atypical mycobacterial diseases - especially MAI Fungal diseases, especially: Histoplasmosis Coccidioidomycosis Blastomycosis (N. A. and S. A.) Cryptococcosis Sporotrichosis Bacterial diseases, especially: Nocardiosis Actinomycosis Non-infectious Sarcoidosis Hypersensitivity Pneumonitis (HP) Vasculitis-granulomatosis diseases Wegener’s Lymphocytic Bronchocentric Allergic (Churg-Strauss) Langerhans Granulomatosis (eosinophilic granuloma, histiocytosis) (LCG) Pneumoconiousus Granulomatous Silicosis Berylliosis “Benign” Coal Worker’s Pneumoconiosis Siderosis Stannosis  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

25 3. Interstitial Pattern Radiological Signs: Radiological Signs: Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Destructive form - peripheral, irregular cyst formation Destructive form - peripheral, irregular cyst formation  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

26 Peripheral cyst formation, ‘Honeycomb’ lung Early findings are non- specific. The peripheral cyst formation (“End-Stage Lung”) is a late finding.  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

27 4. Vascular Patterns Mechanism - increased, or decreased perfusion, altering diameter of pulmonary vessels Mechanism - increased, or decreased perfusion, altering diameter of pulmonary vessels Radiological signs - changes in diameter of specific vessels Radiological signs - changes in diameter of specific vessels  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

28 4. Vascular Patterns Common examples Common examples Congestion - engorged veins, especially upper lungs Congestion - engorged veins, especially upper lungs Congestion Congestion Emphysema - diminished vessels Emphysema - diminished vessels Emphysema Emphysema Shunt vascularity - all vessels enlarged Shunt vascularity - all vessels enlarged Lymphangitic carcinoma - irregular infiltration around vessels may resemble vessel enlargement Lymphangitic carcinoma - irregular infiltration around vessels may resemble vessel enlargement Arterial hypertension - large central arteries with peripheral tapering Arterial hypertension - large central arteries with peripheral tapering Arterial hypertension Arterial hypertension Thromboembolism - locally diminished vessels with possible vessel mass centrally located Thromboembolism - locally diminished vessels with possible vessel mass centrally located Bronchial circulation - irregular vessels in unusual directions Bronchial circulation - irregular vessels in unusual directions  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

29 Congested vasculature Engorged vessels, especially upper lungs  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

30 Emphysematous changes Diminished vasculature  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

31 Enlarged pulmonary trunk (“middle mogul”) Prominent left pulmonary artery  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

32 5. Airway (Bronchial) Patterns Mechanism Mechanism Complete or partial obstruction of airways Complete or partial obstruction of airways Thickening of airway walls Thickening of airway walls Forms Forms Complete airway obstruction - opacity and decreased volume Complete airway obstruction - opacity and decreased volume Partial obstruction - lucency and increased volume Partial obstruction - lucency and increased volume Wall thickening - tram tracks, central cystic spaces or circles Wall thickening - tram tracks, central cystic spaces or circles  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

33 Bronchial wall thickening (circles and “tram tracks”) Flattened diaphragms on lateral  BACKMAIN MENU BACKMAIN MENU FORWARD FORWARD 

34 Differential diagnosis Differential diagnosis Opacities - endobronchial malignancies, granulomas, inflammatory, benign or congenital masses, mucous plugs, foreign bodies Opacities - endobronchial malignancies, granulomas, inflammatory, benign or congenital masses, mucous plugs, foreign bodies Lucencies - COPD, cysts, blebs, pneumatoceles Lucencies - COPD, cysts, blebs, pneumatoceles Thickening - bronchiectasis, chronic bronchitis Thickening - bronchiectasis, chronic bronchitis  BACKMAIN MENU BACKMAIN MENU FORWARD   5. Airway (Bronchial) Patterns

35 Lobar atelectasis (collapse) Lobar atelectasis (collapse) Primary Signs Primary Signs Vessel number assymetry Vessel number assymetry Fissure as edge Fissure as edge Secondary signs Secondary signs Volume loss Volume loss Elevation of diaphragm Elevation of diaphragm Shift of mediastinum and ribs Shift of mediastinum and ribs  BACKMAIN MENU BACKMAIN MENU FORWARD  

36 Right Left Upper Lower Atelectasis Patterns RLL RUL LLL LUL

37 Left lower lung collapse Vessel Asymmetry  BACKMAIN MENU BACKMAIN MENU EXIT  EXIT 


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