How to Analyse Difficult Chest CT

How to Analyse Difficult Chest CT

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

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

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

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

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

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

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

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

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

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

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)

Step 3 Interpretation: Organized hemothorax

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

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

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

Disease of the unit Infarct/ ischemia Atelectasis Bronchopneumonia BOOP

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

Step 3 Interpretation: CTEPH with lung ischemia

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

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

Step 2 Morphological analysis

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

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

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

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

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

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

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

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)

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)

Tuberculoma Rim enhancement with central necrosis and calcification

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

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

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

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

Littleton JT, et al. Pulmonary masses: contrast enhancement. Radiology 1990;177:861-871

Infection = Uniformly thin rim enhancement

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

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)

Step 3 Interpretation: Lung cancer

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

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

Case10/14 A 69 year-old male Hemoptysis

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

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

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

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

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

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

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

Step 3 Interpretation: Lung cancer with disseminate tuberculosis

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

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

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

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

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

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

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

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

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

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