Chest Radiology Interpretation: Findings of Tuberculosis Get out your laptops, smart phones or other devices pollev.com/chestradiology Case #1 1
Plombage Pneumonia Cancer 2
Reading the TB CXR Be systematic! Start centrally and work outwards Normal or abnormal If abnormal, consider technique as cause Describe the finding(s) Consider the significance of the finding(s) Mediastinum Hila Lungs Pleura Bones Mediastinum 3
Normal Abnormal Lymphoma Normal Abnormal Metastatic disease (unknown primary) 4
AO PA Normal Abnormal Lung Cancer Heart <55% thoracic diameter Technique important Larger in: AP film Poor inspiration Rotation Children True enlargement Chamber enlargement Pericardial effusion Mass Artifactual cardiomegaly 5
End stage rheumatic heart disease Pericarditis 6
Hila Normal Sarcoidosis Abnormal 7
Normal Abnormal Pulmonary Hypertension Lungs Pleura & Diaphragms 8
Pleura & Diaphragms 9
10
Lung Pleura Lung Pleura Lung Pleura 11
Lung Pleura TB Empyema Don t forget about the bones 12
Case #1 Case #2 13
Inspiration: ( 10 posterior ribs) 1st rib 3rd rib 2nd rib 14
1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Poor inspiration Good inspiration 15
Rotation Rotation 16
Intervertebral Disks Penetration Over-penetrated 17
Case #3 Categories of lung opacities 1. Nodule(s) or mass(es) 2. Alveolar, airspace, consolidation 3. Interstitial (diffuse lines or nodules) 4. Airways (circular or tubular) 18
Nodule 3cm, Mass > 3 cm 3.4 cm 2.7 cm Consolidation Confluent opacity Fluffy around the periphery Air bronchograms ARDS 19
Interstitial disease Normal Nodular Reticular Miliary TB Idiopathic pulmonary fibrosis 20
Airways disease Circular Tubular 21
Tuberculosis Case 3 Questions Could this be TB? (the answer is always Is TB the most likely yes!) diagnosis? If so, what form of TB does the radiology suggest? Is active disease likely or unlikely? What are possible alternative diseases to produce the radiographic pattern? 22
Key points TB patterns overlap with each other TB patterns overlap with other diseases If there is an abnormality, it could be due to TB You must know the classic TB patterns But, if it doesn t fit into a typical TB pattern, it is unlikely to be TB It s all about likelihood! Clinical-radiographic correlation Case #3 Reactivaton TB- radiology Location Apical/posterior segments upper lobes Superior segment lower lobes Isolated anterior disease very unusual Presence of cavities Pleural disease Volume loss/scarring early in disease Diff dx: fungal, bacterial infections 23
Chest Radiology Interpretation: Findings of Tuberculosis (Part 2) Is this likely TB? 24
Lobar anatomy LUL LLL Left Lung Lobar anatomy RUL RML RLL Right Lung Lobar anatomy RUL RML RLL Right Lung 25
RUL Pneumonia Lobar anatomy RUL RML RLL Right Lung Lobar anatomy RUL RML RLL Right Lung 26
Silhouette sign A B A B Silhouette sign A B AB 27
Lobar anatomy RUL RML RLL Right Lung Diaphragm RLL pneumonia RLL Obscured Diaphragm Clear Heart Border? Which lobe is involved 28
Lobar anatomy RUL RML RLL Right Lung RML pneumonia RML Clear Diaphragm Obscured Heart Border? pneumonia 29
? pneumonia Superior Anterior Posterior Inferior Lateral View of the Chest Heart 30
Lateral View of the Chest Spine Lateral View of the Chest Diaphragm Lateral View of the Chest Diaphragm 31
Normal LLL Pneumonia Normal Pleural effusion Normal Nodule 32
Normal Pott s disease Case #4 33
Abnormal Normal Prior reactivation tuberculosis Upper lobe scarring Volume loss Retraction of hila superiorly Band-like (linear) opacities Architectural distortion Asymmetric > symmetric Bronchiectasis Cystic changes Diff dx: fungal, sarcoid, pneumoconioses Prior TB 34
Warning signs Consolidation outside areas of fibrosis Consolidation with cavitation Lower lobe abnormalities Non-calcified nodules (ill-defined) Change from prior CXR Reactivation TB 35
Case #5 Solitary nodule/mass- the top 5 Granuloma Hamartoma Solitary metastasis Bronchogenic carcinoma Lots of others 36
So you see a nodule on CXR 1. Look for old films 2. Is diffuse calcification present? 3. Get a CT scan When to get a CT scan? Questionable CXR findings Further characterization of CXR findings Concern for cancer 37
Role of CT scan for nodules 1. Attempt to prove they are definitively benign Benign pattern of calcification (diffuse, central, ring-like, popcorn) Fat 2 years of stability Features of benign nodules include: Benign patterns of calcification Presence of fat Long term stability Diffuse Central Hamartoma Initial CT Ring-like Popcorn 24 month follow-up Hamartoma. 38
Irregular calcification: adenocarcinoma Role of CT scan for nodules 1. Attempt to prove they are definitively benign Benign pattern of calcification (diffuse, central, ring-like, popcorn) Fat 2 years of stability 2. Determine likelihood of nodule being benign or malignant Low likelihood -> CT follow-up High likelihood -> immediate action (e.g. biopsy) Suspicious features of nodules include: Large size Spiculated borders Growth Initial CT The size threshold above which malignancy is likely demonstrates geographic variability, depending upon the prevalence of endemic granulomatous infection. Follow-up 39
Size and likelihood of cancer 81% 0% 1% 15% Swensen. Radiology 2005; 235: 259 Follow-up recommendations Nodule size Low-risk patient High-risk patients 4 mm No follow-up 12 months >4-6 mm 12 months 6-12 months 18-24 months 6-8 mm 6-12 months 18-24 months >8 mm 3 months 9 months 24 months 3-6 months 9-12 months 24 months 3 months 9 months 24 months Fleischner Guidelines. Radiology 2005; 237: 395. Old tuberculosis 40
Bronchogenic carcinoma Case #6 Ghon focus Case #6 41
Ranke complex Case #6 Case #7 42
Primary tuberculosis Difficult radiologic diagnosis Mimics other diseases Findings Nonspecific consolidation Nodule Lymphadenopathy Cavitation unusual LAD more common than with 2 TB (particularly kids + HIV) Primary tuberculosis Primary tuberculosis 43
Case #8 Miliary pattern CXR Miliary tuberculosis Fungal infection (histo, cocci, blasto) Metastases Sarcoidosis 44
Miliary tuberculosis Miliary TB Sarcoidosis 45
Metastases Case #10 Pleural + pericardial disease Primary or secondary May be only manifestation in 1 TB Empyema more common in secondary Adults >> kids 46
Suspected pleural effusion Case #11 47
Case #11 Lymphoma Leukemia Germ cell tumor Bacterial mediastinitis Fungal infection Tuberculosis 48
Lymphadenopathy with TB Kids >> adults Primary >> secondary Asymmetric (right > left) Most common locations Hilar Right paratracheal Necrosis very common TB lymphadenitis Case #12 49
thymus heart <65% thoracic diameter Conclusions Be systematic when reading CXR Typical TB patterns Mimics of TB Get a CT scan when appropriate 50