Objective. On Chest Films. Welcome to Radiology world Introduction to Investigation Methods for Chest Limitation vs Precaution on chest film

Transcription

1 Welcome to Radiology world 2014 Objective Juntima Euathrongchit, MD. Department of Radiology Faculty of Medicine, CMU June 17, Introduction to Investigation Methods for Chest Limitation vs Precaution on chest film Saranair Vorapitirangsi Posterior junctional line thin, vertical line projecting through the trachea that extends to the pleural dome above the clavicles to the level of the aortic arch On Chest Films Anterior junctional line oblique course crossing the upper two-thirds of the sternum from the upper right to lower left and does not extend above the manubriosternal joint Azygoesophagealal recess straight stripe running from the azygos arch to the level of the right hemidiaphram PA upright Lateral AP supine Apical Radiology, lordoticcmu

2 Dual Energy Subtraction Digital tomosynthesis Find out calcification. Find bone, rib lesion. Standard soft tissue bone Special Imaging Tools MRI Advantage: No Iodine contrast Disadvantage: Time consuming, Expensive, not good for lung detection Angiography Ultrasound VQ scan MRA MRI MRI: Oxygen-Enhanced MR Ventilation CT scans - CT chest HRCT

3 Special CT scans New CT technique: Perfusion An iodine map from dual-energy CT can showed the distribution of pulmonary perfusion Photoelectric effect of Iodine CT pulmonary angiogram MIP Av IP 3DVR Virtual bronchoscopy MnIP Radiology, ogy CMU Kang et al RadioGraphics 2010; 30: M Riedel, An introduction to dual energy CT *R Kaewlai New CT technique: Ventilation PET CT (FDG glucose) Air trapping Chae et al Radiology: Volume 248: Number 2 August MDCT CT scans Incremental images Spiral single CT CHEST Volume images MDCT

4 MDCT 4-slice to 16-slice 64-slice multidetector CT Progressively No of detectors scan acquisition times. In clinical use now, 64-slice CT systems gantry rotation times = 0.33 sec. a spatial resolution = 0.4 mm. Indication of CT chest ACR: American College of Radiology SCBT-MR: Society of Computed Body Tomography and Magnetic Resonance SPR: Society for Pediatric Radiology PRACTICE GUIDELINE FOR THE PERFORMANCE OF THORACIC COMPUTED TOMOGRAPHY (CT) Indications 1. Evaluation of abnormalities discovered on chest images [1]. 2. Evaluation of clinically suspected cardiothoracic pathology. 3. Staging and follow-up of lung cancer and other primary thoracic malignancies, and detection and evaluation of metastatic disease [2-5]. 4. Evaluation of cardiothoracic manifestations of known extrathoracic diseases [6-9]. 5. Evaluation of known or suspected thoracic cardiovascular abnormalities (congenital or acquired), including aortic stenosis, aortic aneurysms, and dissection [10-12]. 6. Evaluation of suspected acute or chronic pulmonary emboli [13-22]. 7. Evaluation of suspected pulmonary arterial hypertension [23]. 8. Evaluation of known or suspected congenital cardiothoracic anomalies [24,25]. 9. Evaluation and follow-up of pulmonary parenchymal and airway disease [26-33]. 10. Evaluation of blunt and penetrating trauma [34,35]. 11. Evaluation of postoperative patients and surgical complications [36,37]. 12. Performance of CT-guided interventional procedures [38-41]. 13. Evaluation of the chest wall [42-44]. 14. Evaluation of pleural disease [45,46]. 15. Treatment planning for radiation therapy [47,48]. 16. Evaluation of medical complications in the intensive care unit or other settings [49,50]. HRCT:- Indication vs contraindication Indications 1. Evaluation of diffuse pulmonary disease discovered on chest radiographs, conventional CT of the chest or other CT examinations that include portions of the chest, including selection of the appropriate site for biopsy of diffuse lung disease. 2. Evaluation of the lungs in patients with clinically suspected pulmonary disorders with normal or equivocal chest radiographs. 3. Evaluation of suspected small and/or large airway disease. 4. Quantification of the extent of diffuse lung disease for evaluating effectiveness of treatment. Contraindications 1. There are no absolute contraindications to HRCT of the lungs. 2. Precaution in Pregnancy Unable hold breathing RUL: apical, anterior, posterior Lobe Chest lobe, segment RML: lateral, medial RLL: superior, anterior~,posterior or~, lateral~, medial basal LUL: apicoposterior, anterior,lingula (superior&inferior) LLL: superior, anteromedial~, posterior~, lateral basal

5 Radiology Anatomy: CT chest CT images: Mediastinum window CT anatomy Chest Xray, PA upright Normal, after mastectomy Abnormality on film Increased density, Opacity Infiltration Mass Pleural effusion Atelectasis Interesting case 17 year-old man Chronic cough and dyspnea on exertion for 3 months, Clear sputum, no pus, no hemoptysis, no fever Physical examination:- T36.7 C, PR 100/min, RR 18/min, BP 110/60 mmhg, O2 sat 98% (Room air) Chest: Decrease chest wall movement Lt.,no accessory muscle use Lung: BS decrease entire Lt. lung, Dullness on percussion, Decrease tactile fremitus and Vocal resonance, no egophony, no adventitious sound (wheezing, Rhonchi)

6 Chest PA upright Chest PA upright, what is this lesion? A. Large pleural effusion B. Total left lung atelectasis C. Combined effusion and atelectasis D. Huge lung mass E. Huge mediastinal mass Chest PA & Left lateral Chest PA upright, what is this lesion? A. Large pleural effusion B. Total left lung atelectasis C. Combined effusion and atelectasis D. Huge lung mass E. Huge mediastinal mass Answer Unilateral hemithorax opacity Differential Diagnosis Positioning: rotation or scoliosis Large pleural effusion, pleural thickening, mesothelioma Lung: consolidation, mass, collapse, fibrosis, agenesis Pneumonectomy, thoracoplasty Chest wall: mass (breast, chest wall musculatures) Extrathoracic: external structures

7 Total lung opacity Total opacity Massive pleural effusion Lt. lateral decubitus film A B C Massive pleural effusion Atelectasis + pleural effusion Atelectasis Which one is a lung pathologic lesion? Which one is a lung pathologic lesion? A B Which one is a lung pathologic lesion? Which one is a lung pathologic lesion? C D

8 Which one is a lung pathologic lesion? Adequate quality image - A Remove object A C B D Radiology, ogy, CMU Adequate quality image Removable vs non removable object Mimiced nodule - B Chest wall lesion Bone island Additional techniques Chest wall abnormality - C Repeat film with changed position Dual energy subtraction Digital tomosynthesis CT scan Pectus excavatum depression of the sternum Incidence % of general population (Fraser et al. 1999) PA chest: left-sided heart deviation & rotation a mitral configuration. Parasternal opacity liked RML infiltration or mediastinal mass

9 Blind areas D Blind areas As complexity of thoracic organs overlying each other in the same plane on each view, they could obscure the lung pathology, these areas called blind areas. On PA view Central airway Apical lung Mediastinum Hila Retrocardiac field Inferior lung base Thoracic cage Upper abdomen Tracheal lesion Sub- diaphragmatic lesion Min IP 3DVR Steak artifact from Dense CM, CTA - PE Right sided venous approach CT

10 Conventional routine CT CTA systemic circulation Cover range thoracic inlet to whole lung Scan type Helical KV, ma, rotation time Machine, Respiratory inspiration Image reconstruction: 5 mm thickness, axial mediastinum and lung / coronal IV contrast + delayed 40 sec (arterial phase liver) Hemoptysis, Aortic disease CTA pulmonary circulation HRCT HRCT Radiology, ogy CMU

11 Plain arterial liver portovenous lung image CT Chest for SPN protocol - CMU Frist study: Plain nodule + Post contrast scan thorax + delayed 30 sec, 1, 2, 3, 4 min Cover range Inlet upper abdomen Repeat nodules at delayed phase Reconstruction -* CMU Slice thickness: 5 mm, at least Interval 5 mm no skip Axial images Soft tissue W 1 set - 5 mm slice thickness Lung W 1 set 5 mm Soft tissue W 1 set 1 mm slice thickness and interval Coronal vs sagittal up to PACS system Reconstruction nodule, 1 2 mm thickness for each series CT for solitary pulmonary nodule Total Iodine contrast 420 mgi / kg, 2 ml/sec injection rate Plain 1-2 mm slice thickness 30 sec D Low dose CT The National lung screening trial (NLST) LDCT screening could reduce lung cancer mortality to 20% when compared with chest X-ray screening 1 min 2 min 3 min 4 min Risk groups Risk criteria High risk yr-old, and yrs yrs) High risk yr-old, and yrs of smoking, and One other risk factor (except for second-hand smoke) Moderate risk yr-old, and yrs of smoking or second-hand smoke, and No other risk factors Low risk < 50 yr-old, and/or < 20 pack yrs smoking Screening Recommendation Get baseline LDCT Get baseline LDCT No screening at this time No screening at this time Low dose CT scan Hypothesis: Generic factor and/or indirect receiving carcinogen or second smoker could be cause of lung cancer Cost effectiveness analysis Parameter Hs) SLST (care dose) Somatom definition CT Voltage (kvp) Tube current time product (mas) Slice thickness (mm) Reconstruction interval (mm) Number of studies 26, Risk Family Hx (closed relative) Yrs No other cancer

12 Compare, normal dose vs low dose Tumor growth Low dose - noise Hemoptysis bronchial a. systemic a. In over 90% of cases of hemoptysis requiring intervention with arterial embolization or surgery, the bronchial arteries are responsible for the bleeding Protocol Bronchiectasis, HRCT Bronchial a enlargement

13 Airway Airway Tracheal Stenosis Bronchial Stenosis Tracheal-Esophageal Fistula Suspected Tracheal or Bronchial Injury or Fracture Tracheomalacia Tracheobronchomalacia Mounier-Kuhn Syndrome Protocol CT bronchi - CTISUS Tracheomalacia: Full inspired vs expired D VR Reconstruction

14 Tracheal bronchus Abnormal chest wall Radiology, ogy CMU Pectus excavatum Early filled aorta CTA PE ASD Cardiac arrest During exam not uncommon Awareness Risk factors Unstable patient : previous shock, poor station Multiple trauma To much monitors Drug allergy * Normal not cardiac arrest Motion normal artifact

15 Normal respiration can control Except cardiac gating At cardiac arrest CT features characterized by a in the dependent parts of the right side of the body, including the venous system and the right lobe of the liver. - -yr man, cardiac ac arrest polytrauma Marked enhanced azygos v., pooling CM in dependent part of IVC, hepatic v., right renal v.; no CM in Lt heart, aorta, kidney Ref: Indian J Radiol Imaging, May yr man, accident. Dense contrast opacified azygos v, SVC, great cardiac v, hemiazygos v, right lumbar v, back venues, Rt atrium, Rt hepatic v, Rt kidney, splenic v, SMV, No CM in aorta, left heart. Ref: Indian J Radiol Imaging, May Near arrest hypotension. Contrast layering in IVC, in cardiogenic shock. Great cardiac v Note bilateral pleural effusions and pericardial effusion without tamponade.

16 Cardiac tamponade Gross pericardial effusion with pressure effect to the heart. Mod. bilateral pleural effusions. Contrast layering in abdomen:- IVC & Rt renal vein 30 year-old male with disseminated Tb, hypotension and worsening of breathlessness. Pt developed cardiogenic shock within a few hours and died. Radiology, ogy CMU What happen? A Injection: - right side Regurgitation of CM to the left system: jugular, subclavian, back venules, and hemiazygos v. B SVC obstruction AJR:178, May 2002 Rt brachiocephalic venous obstruction with collateral vessels AJR:178, May 2002 Layering in SVC, reflux CM into the azygos v, hemiazygos v. AJR:178, May 2002 Opacification of right ventricle, right atrium, right hepatic veins, and vena cava. Note regurgitation of contrast agent into coronary sinus (arrowhead)