1. Liu lin xiang, Radiology school,
Respiratory disease
Liu lin xiang, Radiology school,

2. Bronchiectasis Chronic irreversible dilatation of bronchi
Major cause of morbidity in less developed countries
Causes:
Postinfectious
Mechanical obstruction
Congenital
Granulomas and fibrosis

3. Bronchiectasis: Clinical features
Large volumes of purulent sputum
Finger clubbing
Frequent infective exacerbation
Recurrent hemoptysis
Mild bronchiectasis: few physical signs

4. Bronchiectasis
Cylindrical varicose cystic

5. Radiological findings
Margins of pulmonary vessels indistinct
Tramlines, ill-defined ring opacities
Filled with pus and mucus lead to tubular and ovoid opacities
Cystic: multiple thin-walled ring opacities and contain fluid levels
Coarse honeycombing pattern
Patchy peribronchial consolidation and focal areas of subsegmental collapse in diffuse disease
Affected lobe overinflated or relatively collapsed

6. Bronchiectasis Plain radiograph 10% may be normal
margins of pulmonary vessels indistinct
coarse honeycomb

7. Bronchiectasis Plain film margins of pulmonary vessels indistinct
coarse honeycomb

8. Bronchiectasis CT Dilatation of bronchi w\o bronchial wall thickening
Bronchial dilatation in isolate cystic spaces grouped along a fissure or mediastinal pleura
Volume loss of lung associated crowding of mildly dilated airways and displaced fissure
Accumulation of secretions easily recognizable as lobulated glove-finger, V or Y densities
Bronchiolitis may present in the same areas

9. Bronchiectasis CT
Cylindrical: smooth dilatation of the affected bronchi, not taper normally towards the periphery, but no actual loss of bronchi
Varicose: irregularity and beading of the affected bronchi. destruction and loss of the bronchial lumen peripherally
Saccular: increasing dilatation of bronchi towards the periphery, with ballooning, and a loss of bronchial subdivisions

10. Bronchiectasis CT Define the extent, severity and location
Thick-walled dilated bronchi, with a diameter greater than their accompanying pulmonary artery
In cross-section, ring-shaped, "signet ring"
In long axis, bronchi look like tramlines
Associated: air-fluid levels in dilated bronchi, cystic spaces, and occasional ectatic beaded bronchi
Bronchi visible in peripheral half of lung
Focal volume loss, hyperlucency or oligaemia

14. Bronchiectasis CT

15. Bronchiectasis

16. Bronchiectasis　CT MPR

17. Lobar pneumonia
Result of alveolar wall injury with severe hemorrhagic edema induced by inhaled infectious organisms that reach the subpleural zone of the lung
Rapid multiplication of organisms and invasion of the infected edematous fluid by polynuclear leukocytes
Spreads rapidly through the pores of Kohn leading to a consolidation of an entire lobe or segment
The most common causes are streptococcus pneumonia, klebsiella pneumonial infection, legionella infection and mycoplasma pneumonia infection

18. Radiological findings
Air space consolidation involving an entire lobe containing air bronchograms
Because of antibiotics, the pneumonia is limited to one or more segments within a lobe
Sometimes, voluminous edema may result in expansion of the lobe recognized radiographically by bulging of the fissures
Necrosis and cavitation represent the potential complication of lobar pneumonia

19. Lobar pneumonia
Consolidation in entire lobe with air bronchograms

20. Lobar pneumonia
Consolidation in apical segment of superior lobe

21. Lobar pneumonia

22. Lung abscess
Certain virulent bacteria create focal areas of necrosis or lung abscess
Abscess may not be recognized on chest films because of surrounding lung consolidation or no communication with a conducting airway and thus no cavitation is appreciated
Abscess formation is most likely with anerobic and Gram-negative bacteria
Lung abscess may occur because of inflammatory necrosis of otherwise normal lung or occasionally secondary to vascular involvement leading to ischemic necrosis and death of lung

23. Lung abscess
Radiographically, a lung abscess may be difficult to appreciate secondary to surrounding lung consolidation
but will be recognized when air enters the abscess cavity creating either a large single abscess or multiple smaller microabscesses
With the larger abscess cavities the inner walls are thick and irregular

24. Lung abscess
Resolution of an abscess is recognized when abscess cavity decreases in size or amount of fluid within an abscess fluctuates
This is not related to healing necessarily but instead to ease of communication between abscess cavity and a conducting airway
Fluid levels will rise in cavity if exit is blocked and will fall if opening remains patent

25. Lung abscess
Thick-walled cavity
Fluid level

26. Lung abscess
Thick-walled cavity and fluid level

27. Lung abscess

28. abscess

29. Lung abscess

30. Pulmonary tuberculosis
Infection by Mycobacterium tuberculosis bacillus by respiratory inhalation, with the organism multiplying in the alveolar walls
Primary tuberculosis represents the development of a positive reaction to tubercle bacilli following the first exposure
Often subclinical, but in infants or those with impaired defence due to poor nutrition or underlying illness, may be present clinically

31. Pulmonary tuberculosis
As the immune system develops a positive reaction to the bacillus, the multiplication of the organism is halted
Localized inflammatory response in the lung parenchyma and the draining lymph nodes
Central necrosis within this area, later heals by fibrosis and calcification

32. Pulmonary tuberculosis
If response is delayed, organisms may spread from draining lymph nodes into regional nodes and, via thoracic duct into circulation to pass by hematogenous spread throughout the body. This can also give rise to tuberculous meningitis and miliary tuberculosis
Bronchogenic spread of tuberculosis occurs following poor containment of the original infection, with pulmonary consolidation
Spread can occur as infected material expectorated and enters other non-affected bronchi

33. Primary tuberculosis
Reaction to the tubercle bacillus following first exposure to the organism, typically by inhalation
presence of primary tuberculosis in childhood varies from subclinical to overwhelming and life-threatening
In healthy child, should be a self-limiting condition, lasting at most a few weeks. If there are clinical symptoms there is fever, loss of appetite, general malaise and, possibly, a skin rash
Inspired bacilli lodge on the alveolar walls and multiply. A localized, mainly histiocytic, inflammatory reaction is set up
Draining lymph nodes may enlarge as part of this sensitivity reaction

34. Primary tuberculosis
Usually, the immune response is sufficient to contain the initial infection, which heals as a small granuloma. The granuloma may show associated lymph node calcification. There may be central necrosis within this area, which later heals by fibrosis and calcification, which may take 6 months or more to appear
In infants, this process may not be adequate and pulmonary consolidation may occur as part of the primary infection. Bronchogenic spread may then cause widespread pulmonary infection, while hematogenous spread may cause a miliary pattern of pulmonary infection. Once it is in the circulation, the child is at risk from hepatic and meningeal infection. This bacteremia is also the source of miliary tuberculosis

35. Primary tuberculosis
Radiography of the chest in primary tuberculosis varies from a small subpleural exudative reaction, w\o unilateral hilar lymphadenopathy, to more extensive disease such as multifocal pneumonic change or a diffuse interstitial nodularity
Enlarged lymph nodes cause distal atelectasis
Pleural effusion is not an unusual feature
Lung changes take months or years to clear, and any calcified lesions persist indefinitely

36. Primary tuberculosis
In children without tuberculous consolidation, the radiographic changes represent the development of the immune reaction to the infection
Main reason for regular radiography is to allow early diagnosis of miliary tuberculosis, which may be visible before there is any clinical suspicion
As this is a manifestation of hematogenous spread, meningitis is also a very likely complication
Radiographic changes in uncomplicated primary tuberculosis are not visible until after the immune response has developed, so skin testing is a more sensitive method of diagnosis

37. Primary pulmonary tuberculosis
Exudative
Draining lymph nodes
hilar lymphadenopathy

38. Primary pulmonary tuberculosis

39. Primary pulmonary tuberculosis
hilar lymphadenopathy

40. Miliary tuberculosis
Clinical presentation is variable, with infants being relatively asymptomatic
Seen some time following a bacteraemia
Usually occurs during the incubation period, when the tubercle bacilli are deposited throughout the lungs
Patients are generally very ill with respiratory failure, fever and malaise at the time of diagnosis

41. Miliary tuberculosis
Chest film demonstrates multiple, small nodular opacities throughout both lungs that are too numerous to count
Untreated disease results in steady enlargement of these nodules until death of the patient ensues
Lymphadenopathy and pleural fluid or other evidence of primary tuberculosis may not be present on chest film
Diagnosis may require transbronchial biopsy to identify acid-fast bacilli
When treated the miliary pattern gradually disappears leaving a normal chest film within several weeks to months

42. Miliary tuberculosis
multiple, small nodular opacities throughout both lungs that are too numerous to count

43. Acute military pulmonary tuberculosis
multiple, small nodular opacities throughout both lungs that are too numerous to count

44. Subacute hematogenous disseminated pulmonary tuberculosis

45. Hematogenous disseminated pulmonary tuberculosis

46. Lung cancer Also called bronchogenic carcinoma
The most common fatal malignant neoplasm in men and it has now surpassed breast cancer as the leading cause of cancer death in women
The risk of lung cancer occurrence is related to the number of cigarettes smoked, the number of smoking years, the age at which smoking began, and the depth of inhalation
The risk decreases with cessation of smoking but never completely disappears

47. Lung cancer
Most patients with lung cancer present with clinical symptoms, and only a minority are asymptomatic
Patients with central tumors obstructing a major bronchus may present with cough, wheezing, hemoptysis and lung infection
Local intrathoracic spread result in left laryngeal nerve paralysis, pleural or chest wall pain, symptoms related to SVC obstruction or Pancoasts neoplasm
Sometimes symptoms resulting from distant metastases may reveal the lung cancer

48. Lung cancer
A large variety of paraneoplastic syndromes may also be associated with lung cancer
Include skeletal abnormalities such as clubbing, hypertrophic pulmonary osteoarthropathy and osteomalacia or endocrine and metabolic disorders such as Cushing's syndrome from adenocorticotrophic hormone production, hyponatraemia associated with inappropriate antidiuretic hormone syndrome production, and insulin-like activity

49. Histological type
The common types include adenocarcinoma, squamous cell carcinoma, small cell carcinoma and large cell undifferentiated carcinoma
Multidifferentiated carcinomas may also occur (adenosquamous carcinoma)
Giant cell carcinoma is a subset of large-cell undifferentiated carcinoma
Bronchioalveolar cell carcinomatosis is a subset of adenocarcinoma

50. Squamous cell carcinoma
A frequent type representing about one third of all lung cancers, associating with smoking
Pathologically, often arise in squamous metaplasia commonly seen in the bronchial mucosa of cigarette smokers
Centrally located involving the proximal bronchi and growth is mainly endobronchial
Extension through the bronchial walls and along the bronchial mucosa

51. Squamous cell carcinoma
Central necrosis is a frequent feature
Involvement of regional lymph nodes is common, occurring by direct extension or by means of lymphatic metastases
Grow rapidly, but distant metastases occur relatively late
Associated with the best prognosis

52. Squamous cell carcinoma
May associated with hypercalcaemia due to ectopic parathormone production
Most common cause of Pancoast neoplasm
Radiological features vary with location of tumor
Central and endobronchial produce a hilar or perihilar mass. Atelectasis or obstructive pneomonitis present distal to bronchial obstruction
When small, bronchial wall abnormalities can be missed on standard radiography but are well depicted on CT

53. Squamous cell carcinoma
When the tumor is more peripheral (one third of cases) it manifests characteristically as a thick-walled cavitary mass with or without an airfluid level
Such a lesion may be indistinguishable radiographically from primary lung
A solitary pulmonary nodule or mass is also a possible radiological manifestation

54. Lung cancer Macro-pathology
Central type: main bronchus, lober bronchiel and segmental bronchiel
Peripheral type: from segmental bronchiel to terminal bronchiole
Alveolar type: bronchioalveole

55. Central type Direct signs Indirect signs hilar or perihilar mass
Nerrow or obstruction of bronchiel
Indirect signs
Atelectasis
Obstructive pneomonitis

56. Central type

57. Central type

58. Central type

59. Central type

60. Central type

61. Central type--CT findings
Bronchial wall thick
Endobronchial nodules
Extrabronchial mass
Bronchial Obstruction
Atelectasis
Obstructive pneomonitis
Hilar and mediastinal metastasis
Remote metastasis

62. Central type

63. Central type--CT

64. Central tumor F62 Tumor in left upper lobe and atelectasis
Tumor occluding the left upper lobe bronchus and surrounding the pulmonary artery

65. Squamous cell carcinoma

66. Peripheral type Asymptomatic Nodule and mass Solitary pulmonary nodule
Spiculated appearance
Air bronchograms within a nodule
Cavitation with thick wall
Pleural indentation

67. Peripheral type

68. Peripheral type

69. Pancoast’s neoplasm
Henry Khunrath Pancoast, , American radiologist
Also called superior sulcus neoplasm
Occurs at extreme apex of lung in superior sulcus
Typically invades chest wall and into neck
Posterior extension may result in an involvement of roots of the brachial plexus with spread to spinal canal and vertebral bodies
Anterior extension leads to involvement of the subclavian artery with invasion of trunks, division and cords of brachial plexus within interscalenic space and medial invasion of sympathetic stellate ganglion

70. Pancoast’s neoplasm Is most often a pulmonary squamous cell carcinoma
Clinical manifestations are thoracic pain, Horner's syndrome, destruction of bone, atrophy of hand muscles and brachial plexopathy
Radiographs, an apical mass or an asymmetrical pleural thickening with irregularities sometimes associated with rib destruction
Enhanced CT and thin collimation and MRI are the preferred modalities for evaluating
if local tumor is not extensive and if there is no evidence of mediastinal or distant metastases, can be treated successfully with preoperative radiation therapy, followed by lobectomy and chest wall resection

71. Pancoast’s neoplasm An asymmetrical pleural thickening
Associated with rib destruction

72. Pancoast tumor

73. Peripheral type—CT Nodule or mass
irregular or spiculated margin with distortion of adjacent vessels
Pseudocavitation (small, focal, low-attenuation regions within or surrounding the periphery of a nodule)
Cavitation have thick, irregular walls
Hilar metastasis
Mediastinal metastasis
Remote metastasis

74. Peripheral carcinoma

75. Peripheral carcinoma

76. Peripheral carcinoma
ground-glass opacity

77. Peripheral carcinoma

78. Peripheral carcinoma

79. Peripheral carcinoma--lobulation

80. Hilar metastases

81. Peripheral carcinoma-cavity

82. Bronchioalveolar cell carcinoma
is a subtype of adenocarcinoma of the lung accounting for less than 5% of all lung cancers
Pathologically, it consists of a peripheral neoplasm in which the malignant cells use the surrounding alveolar walls as a scaffold
The cells produce mucus in such large amounts that expectoration of mucoid sputum may become a major presenting symptom

83. Bronchioloalveolar cell carcinoma
May present three distinct radiological patterns
The most common is a SPN, peripheral in location with ill-defined and hazy contours
On CT, the nodule frequently contains an air bronchogram and/or small bubble-like lucencies suggestive of pseudocavitation
Less characteristically, the nodule may appear homogeneously dense with irregular or spiculated contours, often associated with pleural retraction

84. Bronchioloalveolar cell carcinoma
The second pattern consists of lobar consolidation mimicking pneumonia, sometimes associated with nodules in the same lobe, other lobes or the contralateral lung. This reflects the presumed dissemination of the tumor through the tracheobronchial tree. The finding of a so-called angiogram sign may be seen on CT

85. Bronchioloalveolar cell carcinoma
The third pattern occurs in only a small minority of patients. It consists of multiple nodules scattered throughout both lungs, measuring 3-10 mm in diameter, having very irregular margins, and only rarely appearing cavitated
Prognosis of bronchioloalveolar carcinoma when resected as a SPN is relatively good, whereas the prognosis of the large and disseminated lesions is very poor

86. Alveolar cancinoma multiple nodules scattered throughout both lungs
measuring 3-10 mm in diameter
having very irregular margins

87. Alveolar cancinoma SPN
peripheral in location with ill-defined and hazy contours

88. Alveolar cancinoma

89. Bronchioloalveolar cell carcinoma

90. Bronchioloalveolar carcinoma, 53M
Initial (1mm) CT
a nodular of ground-glass attenuation
Follow-up CT (5mm) 48 months later
increased nodule size

91. Metastasitic tumor

92. Lung metastases from colon cancer