Chest imaging (Case-based teaching) 胸腔病例教學 謝叔強 財團法人恩主公醫院主治醫師萬芳醫院放射科兼任主治醫師.

Transcription

1 Chest imaging (Case-based teaching) 胸腔病例教學 謝叔強 財團法人恩主公醫院主治醫師萬芳醫院放射科兼任主治醫師

2 Check List(1) 1. Check patient data, position, technical quality and normal anatomy. 2. Review systematically o o Initial survey Review skeletal structures of shoulder girdles and chest wall

3 Check List(1) o o Review mediastinum: overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic retrosternal clear space Review hila: normal relationships size

4 Check List(2) o Review lungs and pleura: compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

5 Check List(2) o Soft tissue including breast, companion shadow. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. Review soft tissues and spine of neck. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc.

6 Normal anatomic land mark

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8

9 1.Right paratracheal stripe 2.SVC 3.AP window 4.Carina

10 Rt paratracheal LAP

11 AP window lesion

12 Find lesion Normal Normal variant Artifact

13 Normal variant Fork rib Azygus Fissure (lobe)

14 Artifact Hair Skin fold

15 Lesion description Shape, size, location

16 Lobar anatomy ,2: Upper lobe 3,4: Lower lobe 5: Middle lobe 6: Lingula lobe

17 Lung or mediastinum?

18 Lung or chest wall?

19 Pattern of disease

20 Lung Alveolar pattern Interstitial pattern Nodules/mass

21 Alveolar Pattern Filling of the alveoli Rapid appearance and resolution Early coalescence Fluffy outline Lobar or segmental consolidation Batwing, Butterfly Air bronchogram Air alveologram

22 Alveolar process (air-space consolidation) Water (edema) Blood (pulmonary hemorrhage) Proteinaceous fluid (alveolar proteinosis) Inflammatory exudate (pneumonia) Tumor in acini (bronchoalveolar carcinoma, lymphoma)

23 Alveolar Pattern

24 Alveolar Pattern

25 Interstitial pattern Reticular Nodular Reticulonodular Linear Honeycomb Ground glass (HRCT)

26 Reticular nodular pattern

27 Interstitial pattern Idiopathic pulmonary fibrosis with honeycombing cysts

28 Lucent lung

29 Pulmonary emphysema

30 Bulla

31 Pneumothorax

32 Pneumomediastinum and subcutaneous emphysema

33 Nodules/mass

34 Single pulmonary nodule

35 Evaluation of a lung mass Predisposing factors smoking, occupation Growth pattern Stable for 2 years = Benign. Diameter > 3 cm almost always malignant. Margins Spiculated mass malignant Smooth margins malignant or benign. Calcifications Coarse usually benign. Fine might be malignant. Fat benign.

36 Lung mass

37 Multiple pulmonary nodules

38 Miliary pattern Hematogenous,miliary infection: TB, histoplasmosis Hematogenous tumor seeding: Metastases: thyroid, melanoma, breast, choriocarcinoma Eosinophilic granuloma Bronchioalveolar cancer Silicosis Sarcoid (rare)

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40 Cavity

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42 Differential Diagnosis (for the cavity): Neoplasm with necrosis/cavitation Bacterial abscess with necrotizing pneumonia Pulmonary infarct Indolent granulomatous infection (e.g., tuberculosis) Wegener's granulomatosis

43 Collapse

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47 Signs Silhouette sign Airbronchogram Golden s S sign Cervicothoracic Sign Hilum overlay sign Hilum convergence sign Incomplete border sign

48 Silhouette sign By Felson : An intrathoracic lesion touching a border of the heart or aorta will obliterate that border in the roentgenogram; an intrathoracic lesion not anatomical contiguous with a border of the heart or aorta will not obliterate the border Right heart border Medial segment RML Left heart border Lingula Diaphragm Basal segments lower lobe Ascending aorta Anterior segment RUL Aortic knob Apicoposterior segment LUL

49 LINGULA RML

50 Lesion must be situated with lung parenchyma Parenchyma must be completely or almost completely airless as a result of consolidation or atelectasis or both. The lumen of the bronchi leading to the affected parenchyma must be patent. Airbronchogram

51 Golden s S sign

52 Cervicothoracic Sign Felson: "If a thoracic lesion is in antomic contact with the soft tissues of the neck, its contguous border will be lost." The cephalic border of the anterior mediastinum ends at the level of the clavicles, whereas that of the posterior mediastinum extends much higer. Hence, a lesion clearly visible above the clavicles on the frontal view must lie posteriorly and be enitrely wtihin the thorax.

53 Anterior Posterior

54 Hilum overlay sign

55 Hilum convergence sign

56 Incomplete border sign

57 Calcification

58

59 Mitral valve calcification

60 Calcified granulomas and calcified L/Ns

61 Mediastinum Overall size and shape Trachea- position Margins SVC- Ascending aorta Right atrium Left subclavian artery- Aortic arch Main pulmonary artery Left antrium Left ventricle Lines and stripes Retrosternal clear space

62 Margins

63 4 1cm

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65

66 Chest wall/pleura

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68

69 Incomplete border sign

70 ICU lines

71 Iatrogenic trauma NG tubes: -coiling -endobronchial placement -pneumothorax Chest tubes: - subcutaneous - intraparenchymal - intrafissural Central lines: - neck - coronary sinus - pneumothorax

72 Misplaced NG tube

73 Misplaced ET tube

74 Misplaced NG tube

75 Easy miss lesion

76 Lung cancer (Pancost tumor)

77 Lung cancer

78 Lung cancer (Pancost tumor)

79 Pneumonia

80 Others

81 Pneumoperitoneum

82 Liver abscess

83 Summary 1. Check patient data, position, technical quality and normal anatomy. 2. Review systematically. 3. Review lungs and pleura. 4. Soft tissue including breast, companion shadow.