How to Analyse Difficult Chest CT

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1 How to Analyse Difficult Chest CT

2

3 Complex diseases are:- - Large lesion - Unusual or atypical pattern - Multiple discordant findings Diffuse diseases are:- - Numerous findings in both sides

4 3 basic steps to solve the difficult chest CT 1. Complex or Diffuse Lung Disease? 2. Complex disease Morphological analysis Diffuse Lung Disease Physiology/ Subsegmental Anatomy 3. Synthesis or interpretation and report

5 Morphological analysis Number Size Shape Border Content Contrast enhancement (Bioactive)

6 Morphology and Diagnosis Morphology Number Size Shape Border Content Bioactive Behavior Context Clinical Diagnosis Histology Microbiology Biochemistry Physiology

7 Disease Behavior Non-aggressive Aggressive Congenital/ Postoperative changes Slow growing tumor (benign) Granulomatous infection Number Single Multiple Size Symptom < size Symptom > size Shape Organ of origin Organ of origin Border Fast growing tumor (malignant) Bacterial infection Trauma Content Fat, calcium, fluid, homogeneous Hemorrhage, heterogeneous Bioactive Non-enhancement, rim enhancement Solid enhancement, nodular enhancement

8 Shape Very free growing with destruction more than healing/ or fibrosis At the interface between soft and harder organ Meningioma Loculated pleural effusion Mediastnal mass Free growing with balance of destruction and healing Disease of the unit Infarct Ateclectasis Bronchopneumonia

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10 Case 01/14 A 69 year-old male Hemoptysis for 1 month and progressive dyspnea No weight loss

11 Case 01/15 step 1. Complex or Diffuse Lung Disease? Answer: Complex

12 Step 2 Morphological analysis Number = single Size = large Shape = oval/ hemispheric Border = smooth/ calcified Content = necrotic Enhancement = none

13 Border = Disease activity Border = Destruction-Healing Border = Interface = Interaction = Transition

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15 Step 2 Morphological analysis A single (focally originating) large (long-standing) hemispheric (pleural) non-enhanced (bio-inactive) mass with smooth calcified rim (healed) and an internal air-fluid level (bronchopleural or post-tapping)

16 Step 3 Interpretation: Organized hemothorax

17 Case 02/14 A 59 year-old male Non productive cough for 1 week Underlying disease polycythemia, SMV thrombosis

18 Case 02/15 Step 1. Complex or Diffuse Lung Disease? Answer: Complex

19 Step 2 Morphological analysis Number = multiple Size = small (1-2) Shape = wedge Border = sharp Content = homogeneous Enhancement = marked

20 Disease of the unit Infarct/ ischemia Atelectasis Bronchopneumonia BOOP

21 Step 2 Bilateral multifocal (hematogeneous/bronchial spreading) subpleural homogeneously enhancing (viable) wedge-shaped (unit) consolidation (intrapulmonary) of similar sizes (same age/unit)

22 Step 3 Interpretation: CTEPH with lung ischemia

23 Case 3/14 55 year-old male Pre-operative evaluation for fem-fem bypass Underlying disease: chronic limb ischemia Heavy smoker

24 step 1. Complex or Diffuse Lung Disease? Answer: Complex

25 Step 2 Morphological analysis

26 Step 2 Morphological analysis Number = a few Size = small Shape = cavity, nodule Border = spiculated Content = necrotic Enhancement = none Step 2 Phisiology: Bronchocentric

27 Step 2 A non-enhancing (non-viable) cavity (intrapulmonary, necrotic) in the right upper lobe (tb, silicosis, sarcoidosis) with centrilobular (bronchial spreading) nodules. Step 3 Interpretation: Tuberculosis

28 1)Small opacity 2) Large opacity 3) Cavity 4) Fibrosis

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30 Case 4/14 A 52 year-old male Chronic cough for 1 month and abnormal CXR from check up, no hemoptysis

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33 Case 5/14 55 year-old male Chronic cough 1 month and hemoptysis

34 Case 05/15 Step 1. Complex or Diffuse Lung Disease? Answer: Complex

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36 Step 2 Morphological analysis Number = multiple Size = small and large Shape = round Border = spiculation Content = calcium Enhancement = none

37 Step 2 Morphological analysis Multifocal (air-way or hematogenous spreading) spiculated (desmoplastic, fibrotic) calcified (long-standing) non-enhanced (bioinactive) nodules/ masses (intrapulmonary, free growing) of different sizes (different ages) one of which is cavitating (necrosis)

38 Step 3 Interpretation: Tuberculous complex Multifocal, predominantly upper lobes (tb, silicosis, sarcoidosis), bronchocentric (bronchial spreading), spiculated (desmoplastic, fibrotic) calcified (long-standing) non-enhanced (bio-inactive) nodules/ masses (intrapulmonary) of different sizes (different ages) one of which is cavitating (necrosis)

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40 Tuberculoma Rim enhancement with central necrosis and calcification

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42 Case 6/14 67 year-old male Non productive cough for 1 month and weight loss No dyspnea, no hemoptysis, Heavy smoker

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45 Case 07/14 45 year-old male Chronic cough with hemoptysis for 3 months Previous pulmonary tuberculosis

46 Case 07/15 Step 1 Complex or Diffuse Lung Disease? Answer: Complex

47 Step 2 Morphological analysis Number = multiple Size = large and small Shape = nodule/ cavity Border = nodular Content = necrotic Enhancement = solid

48 Littleton JT, et al. Pulmonary masses: contrast enhancement. Radiology 1990;177:

49 Infection = Uniformly thin rim enhancement

50 Neoplasm = Solid enhancement (more than 1 cm) Malignant neoplasm = Non-uniform

51 Step 2 Morphological analysis Multifocal (spreading), predominantly upper lobes (tb, silicosis, sarcoidosis), nodules and cavity (intrapulmonary) of different sizes (different ages) with non-uniform wall thickness (neoplasm)and solid enhancement (neoplasm)

52 Step 3 Interpretation: Lung cancer

53 Case 08/14 74 year-old male Progressive dyspnea for 2 months Heavy smoker

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55 Case 09/14 61 year-old male Abnormal chest X ray Underlying disease: CA floor of mouth T1N0M0

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57 Case10/14 A 69 year-old male Hemoptysis

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59 Case 11/14 76 year-old male Chronic productive cough for 3 months Old pulmonary tuberculosis

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63 Step 2 Morphological analysis Number = single Size = large Shape = wedge Border = ill-defined Content = necrotic Enhancement = consolidation

64 Step 3 Interpretation: Lung abscess (aspiration) A large wedge-shaped subpleural consolidation (disease of the segment) with multifoci of internal necroses in the basal segment of the left lower lobe (common for aspiration) and smaller bronchocentric (bronchial spreading) consolidations in lingula

65 Case 12/ 14 A 58 year-old male Hemoptysis for 6 months and progressive dyspnea

66 Step 1 Complex or Diffuse Lung Disease? Answer: Complex + Diffuse

67 Step 2 Morphological analysis Number = single Size = large Shape = Cavity Border = ill-defined Content = necrotic Enhancement = solid Step 3 Interpretation: Lung cancer

68 Morphology = poorly-defined nodules Distribution = centrilobular Step 2 Physiology/ Subsegmental anatomy

69 Step 3 Interpretation: Lung cancer with disseminate tuberculosis

70 Case 13/14 A 84 year-old male Productive cough and progressive dyspnea and for 3 weeks

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72 Step 2 Physiology/ Subsegmental anatomy Morphology = poorly-defined nodules Distribution = centrilobular Step 3 Interpretation: Disseminate tuberculosis

73 Case 14/14 25 year-old male Smear negative TB After complete treatment, persistent infiltration

74 Case 14/14 step 1. Complex or Diffuse Lung Disease? Answer: Diffuse

75

76 Step 2 Physiology/ Subsegmental anatomy Morphology = well-defined nodules Distribution = Upper/ perilymphatic

77 Step 2 Physiology/ Subsegmental anatomy Morphology = well-defined nodules Distribution = Upper/ perilymphatic Others = Lymphadenopathy

78 Step 2 Morphology = smooth septal thickening Distribution = lower/ perilymphatic

79 Step 2 Morphology = smooth septal thickening Distribution = lower/ perilymphatic Others = calcified mitral valve

80 Physiology/ Subsegmental anatomy Diffuse, predominantly upper lobes (Tb, silicosis, sarcoidosis), well-defined perilymphatic nodules (Intralymphatic cells, granulomas) with mediastinal lymphadenopathy/ lower lobe smooth septal thickening (lymphatic or venous obstruction) and calcified mitral valve

81 Interpretation: Sarcoidosis + Mitral stenosis Diffuse, predominantly upper lobes (Tb, silicosis, sarcoidosis), well-defined perilymphatic nodules (Intralymphatic cells, granulomas) with mediastinal lymphadenopathy/ lower lobe smooth septal thickening (lymphatic or venous obstruction) and calcified mitral valve

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