Imaging of the Lung. István Battyány

Transcription

1 Imaging of the Lung István Battyány

2 Anatomy of airways: (asszimetric dichotomy) trachea Main bronchus Lobar bronchus }lung, lobe 1. segmental bronchus subsegmental bronchus bronchus lobularis bronchiolus terminalis bronchiolus respiratorius ductulus alveolaris sacculus alveolaris alveolus }segment, subsegment 2. }lobulus, acinus 3. } pulm. primer lobulus 4.

3 Base units of the lung: Primary lobule: the last bronchiolus respiratorius and the terminal element. (can not be visualized by X-ray examination) Secundary lobule (Miller): it is build up from primer lobule. The size is 1-2,5 cm. It has poliedrical form and bordered by owner connective tissues (It is can be visualized as Kerley B lines.) Acinus: one bronchiolus terminalis and the distal conductive and respiratorical elements.

4 Examination methods of the lungs I.: non-invasive examinations Chest radiographs: distance from the tube is at least 1.5 m, high energy (KV over 100) X-ray beam. P-A beam direction (frontal view): lateral view: retrosternal space, posterior mediastinum, right ventricle, dorso-basal space. oblique views: (right and left oblique) Frimann-Dahl photograph (lateral decubitus and horizontal direction of the x-ray beam ) fluoroscopy: benefit: for assessing the mobility of the diaphragm, pulsatile movement, paradox movement of the heart wall, Holzkneckt and Jakobson sign. disadvantage: 1,5 R/min radiation dose, bad spatial resolution tomography (laminography): in the predefined planes, 55 degree hilus tomography

5 Computer tomography: early pleural changes, small metastasis, mediastinal tumors, tumor staging, small pleural effusion, ground glass opacities (PCP, AIDS) pulmonary scintigraphy: (pulmonary emboli) perfusion: 99mTc humanalbumin makroaggr. ventillation: Xenon inhalation Ultrasonography: evaluation of the heart disease: echocardiography thoracic interventional procedures, mediastinal US MRI (magnetic resonance imaging): (coronal, sagital, transvers plane), chest wall lesion, neurogen tumors, vertebral tumors, expansive lesions in the mediastinum (large vessels anomalies), congenital heart disease, insufficient CT examination. screening radiographs (made with an optical system): Odelca, Zeiss (7x7, 10x10 cm) benefit: cheap, lower radiation dose than fluoroscopy disadvantage: bad spatial resolution

6 Chest X-ray PA view Lateral view

7 A B/2 Cardiothoracic index A B

8 Normal lung

9 Lymphoid drainage of the lung Lymph drainage of the lung was described by David Trapnell in Lymphography of the superfitial lymph vessels.

10 Lymphoid drainage of the lung Started in the centrilobular region (level of the arterioles, not repsented in the alveolar wall) and started as the pleural plexus continued in the interlobular septa and together with the pulmonary veins directed centrally.

11 Lymphoid drainage of the lung Started at the visceral pleura directed to the hilus following the interlobular septa strongly related to the vessels and ended in the hilar lymphnodes

12 Way of the infections Airways, alveolar system, alveolar macrofages, lymph vessels, hilar and mediastinal lymphnodes.

13 Anatomy

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15 Interstitium Connective tissue, lymphvessels arteriole, venule.

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18 Congenital variations (RS)

19 Tracheal bronchus (pig bronchus) Rare (1-2% in adults) RUL or segment ET tube can cause ostruction!

20 Bronchus cardiacus Rare (0,5% in adults)

21 Aspiration

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36 Which nodule is growing faster? The human eye perceives the arithmetic increase in diameter rather than the change in volume.

37 Nodules Parenchymal nodules Centrilobular ill-defined opacities (hypersensitivity pneumonitis, sarcoidosis and respiratory bronchiolitis) Interstitial nodules along the bronchovascular bundles, interlobular septa and subpleural regions (sarcoidosis, lymphangiosis) larger nodules (1-10 mm) in posterior parts of upper lung zones (silicosis, coal workers pneumoconiosis)

38 Nodular opacities

39 Solitary pulmonary nodule

40 Solitary pulmonary nodule

41 Solitary pulmonary nodule

42 Solitary pulmonary nodule

43 Solitary pulmonary nodule

44 Solitary pulmonary nodule

45 Solitary pulmonary nodule

46 Solitary pulmonary nodule

47 Small pulmonary nodule

48 Small pulmonary nodule

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50 CT Examination conventional, axial CT Spiral CT High Resolution CT (1mm ST) In vitro minimum resolution 300 mikron

51 HRCT findings

52 Increased lung density

53 Increased lung density Ground glass opacity hazy increase in density not obscuring anatomic structures mostly associated with active alveolitis, edema or fine dispersed fibrosis (Hypersensitivity pneumonitis, sarcoidosis, fibrosing alveolitis) Consolidation Increase in lung density masking anatomic structures (inflammatory process, sarcoidosis, pneumoconiosis, tumor)

54 Linear reticular opacities Septal and non-septal densities interlobular septal thickening (edema, infl., fibrosis, lymph spread) non-septal linear densities and irregular reticular patterns (fibrosing disorders fibrosing alveolitis chronic EAA, sarcoidosis, histiocytosis, asbestosis)

55 Linear reticular opacities

56 Decreased lung densities Diffuse - panacinar emphysema, asthma Mosaic-like - airways disease (BO, CTEPH) Focal - centrilobular emphysema Cystic - fibrosing alveolitis, histiocytosis, lympangioleiomyomatosis.

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58 Lung Perfusion BV, MTT BF BF = BV / MTT BF = Blood Flow BV = Blood Volume MTT = Mean Transit Time

59 Perfusion parameters, data analysis Blood Volume (BV) - ml/100g tissue Time to Peak (TTP) - min Peak (P) Wash out (WO) Mean Transit Time (MTT) - min ROI in tha aorta, in the PA and in the focal lesion Intensity-Time Curves and Functional Maps measurement.

60 Perfusion of lung nodules Differential diagnosis of cavities. TBC cavern formation? Abscessus? Necrotic tu.? = the wall irregularly thickened, contrast enhancement, air /gas in the cavity Parameters: blood volume (BV), peak (P), timeto-peak (TTP), washout (WO) TBC : BV, P, WO Abscessus : BV, P, TTP Malignancy : BV, P, WO TTP WO TTP Young Han Leea,Woocheol Kwona,, Myung Soon Kima, Young Ju Kima, Myeong Sub Leea, a Department of Radiology, Yonsei University Wonju College of Medicine, 162 Ilsan-dong, Wonju, Korea EURR-4330; No. of Pages7

61 Tuberculosis

62 Lung abscess

63 Lung tumor

64 Spiral CT - Virtual Bronchoscopy

65 Thank U for Your attention!