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182 Cards in this Set

  • Front
  • Back
lobar segmental atelectasis
endobronchial lesions
extrinsic bronchial compression
tumor
lymphadenopathy
mlaignant
benign
rare
bronchial torsion
direct signs of lobar atelectasis
displacement of interlobar fissure
increase in opacity of the involvement segment
indirect signs of lobar atelectasis
displacement of hila
mediastinal displacement
elevation of hemidiaphragm
overinflation of remaining lung
approximation of ribs
RUL collapse
elevation of minor fissure on ap
elevation of minor fissure and proximal major fissure on lateral
shift of trachea to the right
elevation of hilum
thickening of right paratracheal in complete collapse
RML collapse
best seen on lordotic views
rml syndrome recurrent atelectasis despite an open orifice-absent collateral ventilation, bronchus surrounded by enlarged lymph nodes (TB), mave have coexistent bronchiectasis

minor fissure shifts down and major fissure shifts up on AP and lateral
RLL collapse
triangular opacity in retrocardiac region on pa film with obliteration of the diaphragm
posterior displacement of the right margin
posterior displacement of the major fissure on lateral
opacity over the spine
LUL collapse
major fissure shifts up on ap and anteriorly on lateral views

maybe difficult to see hazy density, can be easily confused with loculated pleural effusion on PA film

luftsichel-radiolucency in upper lung zone that results from upward migration of superior segment of left lower lobe
LLL collapse
left retrocardiac opacity on pa film
posterior displacement of left major fissure on lateral film
CT findings of lobar collapse
increased density of collapsed lobe-see primer for pics
types of peripheral atelectasis
relaxation
pleural effusion
pneumothorax
bullous disease
atelectasis associated with fibrosis
granulomatous infections
pneumoconiosis
sarcoid
resorptive atelectasis secondary to obstruction
platelike, discoid atelectasis
depletion of surfacant
ARDS of newborn
radiation injury
rounded atelectasis
due to pleural disease
causes of consolidation
fluid in acini

water (edema)
cardiac pulmonary edema
renal pulmonary edema
lung injury, pulmonary edema

blood
trauma (most common)
bleeding disorder; anticoag
type II antigen-antibody reaction
goodpastures syndrome
henoch schonlein purpura
pulmonary infarct
vasculitis

proteinaceous fluid
alveolar proteinosis

inflammatory exudate in acini

infection
bacteria infection (pus)
nocardia, actinomycosis, TB

noninfectious
allergic hypersensitivity alveolitis
chronic eosinophilic pneumonia
BOOP
pulmonary infiltration with eosinophilia
loefflers sydrome
chronic eosinophilic pneumonia
pneumonitis
ABPA
drugs penicillin
aspiration of lipid material
sarcoid

tumor in acini

bronchoalveolar carcinoma
lymphoma
pulmonary renal syndromes
syndromes characterized by pulmonary hemorrhage and nephritis

goodpastures (anti-gbm +)
wegeners disease (anca +, nodules more common)
SLE
henoch-schonlein purpura
polyarteritis nodosa
penicillamine hypersensitivity
acute respiratory distress syndrome

characterized by respiratory distress, hypoxemia, opaque stiff lungs

diffuse alveolar consolidation--> interstitial fibrosis and scarring
massive pneumonia
trauma
shock
sepsis
pancreatitis
drug overdose
near drowning
aspiration
chronic airspace disease
tumors
bronchoalveolar carcinoma
lymphoma
inflammation
tb, fungus
eosinophilic pneumonia
pneumonitis, boop
alveolar sarcoid
other causes
alveolar proteinosis
pulmonary hemorrhage
lipoid pneumonia, chronic aspiration
approach to pulmonary nodules
primer page 88
solitary nodules

<6 cm, maybe smooth, lobulated, discrete, circumscribed, calcified, cavitated, or have satellite lesions
tumor 45%
primary carcinoma 70%
hamartoma 15%
solitary mets 10%

inflammation 53%
histoplasmosis
tuberculoma
coccidiomycosis

other 2%
vascular 15%
AV fistula
pulmonary varix (dilated pulmonary vein)
infarct, embolism
congenital 30%
sequestration
bronchial cyst

miscellaneous 45%
round pneumonia
loculated effusion in fissure
mucous plug
enlarged subpleural lymph node
silicosis (usually multiple nodules)
multiple nodules

multiplicity often indicates hematogenous dissemination
mets
abscess
pyogenic-stapy>kleb>strept
immunocompromised pt-nocardia, legionella

granulomatous lung diseases
infectious
tb
fungus, aspegillus, histoplasma
noninfectious
sarcoid
rheumatoid nodules
silicosis
wegeners disease
necrotizing granulomatous vasculitis
histiocytosis

unilateral pulmonary embolism
miliary pattern
soft tissue opacities
hematogenous-miliary infection, tb, histo
hematogenous tumor seeding
mets, thyroid, melanoma, breast, choriocarcinoma
eosinophilic granuloma
bronchioalveolar carcinoma
silicosis
sarcoid
high density opacities
calcified lung nodules
larger (>1mm)
tumor
mets from medullary thyroid cancer
mucinous or osteogenic mets
infection
previous varicella pneumonia
histoplasmosis, coccidiomycosis, tb
parasites, schistosomiasis
other
silicosis

very small (0.1-1mm; sandlike)
alveolar microlithiasis
chronic pulmonary venous hypertension
metastatic calcification from severe renal disease
large (>6cm) thoracic mass
pulmonary
tumor
bronchogenic carcinoma
mets (scc from h&n)
abscess
round atelectasis
intrapulmonary sequestration
hyatid disease

extrapulmonary
fibrous tumor of pleura
loculated pleural effusion
torsed pulmonary lobe
chest wall tumors (askin tumor)
AAA
mediastinal masses
cysts
thickness (not always reliable)
<2mm 95% benign
2-15mm 50% malignant
>15mm >95% malignant

morphology (not reliable)
eccentric cavity suggests malignancy
shaggy internal margins suggests malignancy
cysts

parenchyma-lined spaces, filled with air or fluid
pneumatocele (posttraumatic, postinfectious), common
bulla (within lung parenchyma), bleb (located within the 9 histologic layers of the visceral pleura)
cystic bronchiectasis
congenital cysts
intrapulmonary bronchogenic cysts (rib and vertebral body anomalies common)
cystic adenomatoid malformation (multiple lesions)
sequestration
hyatid cyst (onion skin appearance)
cavity

parenchymal necrosis due to inflammation (benign) or tumor (malignant)
abscess
pyogenic, staph>kleb>strept
immunocompromised pt, nocardia, legionella

cavitated tumor
SCC (primary scc>head and neck scc> sarcoma mets)
sarcoma
lymphoma
tcc of bladder
cavitated granulomatous mass (often multiple)
fungus, aspergillus, coccidio (thin wall)
tb
sarcoid, wegeners, rheumatoid nodules
necrotizing granulomatous vasculitis
cavitated postraumatic hematoma
air crescent sign in cavity

most commonly seen with aspegillosis
mucormycosis
actinomycosis
septic emboli
klebsiella pneumoniae
tb
tumors
small cystic disease
true cyst wall
eosinophilic granuloma
lymphangioleiomyomatosis
cystic form of PCP
honeycombing in any end-stage interstitial disease

no cyst wall
emphysema
interstitial lung disease: density types

linear or reticular
thickened interlobular septa, fibrosis
interstitial lung disease: density types

reticulonodular
inflammation in peribronchovascular interstitium
interstitial lung disease: density types

nodular
granulomas
interstitial lung disease: density types

ground glass
usually represents acute interstitial disease (occasionally seen with chronic fibrosis)

hazy density, vessels can be seen
interstitial lung disease: density types

honeycombing
ring shadows 2-10 mm; end stage lung disease
kerley lines (linear densities)
kerley B lines, peripehral in interlobular septa
<2cm long
peripheral and perpendicular to septa

kerley A lines
2-6 cm long
central
no relationship to bronchioarterial bundles

kerley C lines
fine network caused by superimposition of kerley B lines
interstitial lung disease: approach
type of pattern
distribution
lung volumes
evolution
pleural disease
lymph nodes
interstitial lung disease: general approach
due to thickening of interlobular septa (lymphatics, veins, or infiltration by cells), alveolar walls, and interstitium

causes

fluid
water
pulmonary edema
venous obstruction (thrombosis)
proteinaceous material
congenital pulmonary lymphangiectasia (very rare)

inflammation
infectious (interstitial pneumonia)
viral
granulomatous (tb, fungal)
pcp
idiopathic
IPF
sarcoid
collagen vascular disease
rheumatoid arthritis
scleroderma
ankylosing spondylitis
extrinsic agents
pneumoconiosis (asbestos, silicosis, CWP)
drugs

tumor
interstitial tumors
eosinophilic granuloma
lymphangitic tumor spread
desmoplastic reaction to tumor
interstitial lung disease distribution: upper lobes

CASSET P
cystic fibrosis
ankylsosing spondylitis
silicosis
sarcoid
eosinophilic granuloma (spare cp angles)
tb
pneumocystis carinii
interstitial lung disease distribution: lower lobes

BADAS
bronchiectasis
aspiration
drugs, DIP
asbestosis
scleroderma, other collagen vascular disease
interstitial lung disease evolution: acute

HELP
hypersentivity (allergic alveolitis)
edema
lymphoproliferative
pneumonitis, viral
interstitial lung disease evolution: chronic

LIFE
lymphangitis spread
inflammation, infection
fibrosis
edema
interstitial lung disease lung volumes: increased
cystic fibrosis
eosinophilic granuloma (20% pneumothorax)
lymphangioleiomyomatosis (pneumothorax)
interstitial lung disease lung volumes: decreased
idiopathic pulmonary fibrosis
scleroderma
interstitial lung disease pleural disease
pleural plaques
asbestosis
pleural effusion
chf
lymphangitic carcinomatosis
rheumatoid disease
interstitial lung disease lymph nodes
enlarged
malignant adenopathy
tb, fungus
sarcoid
calcified
silicosis
interstitial lung disease hrct pattern: ground glass opacity
allergic hypersentivity
all acute interstitial disease
DIP
active IPF
viral
PCP
BOOP
eosinophilic pneumonia
pulmonary edema
interstitial lung disease hrct pattern: retriculonodular opacities

peribronchovascular thickening (peribronchial cuffing on cxr)

thickening of interlobular septae (kerley lines)
pulmonary edema
viral, mycoplasma pneumonia, and PCP
lymphangitic tumor spread
pulmonary fibrosis
IPF
secondary fibrosis
drugs
radiation
collagen vascular disease
hemosiderosis
asbestosis
interstitial lung disease hrct pattern: nodular opacities

1-2 mm interstitial nodules

often associated with reticular opacities
hematogenous infection
hematogenous mets
sarcoid
pneumoconiosis
silicosis
CWP
histiocytosis (EG, also cysts)
interstitial lung disease hrct pattern: cystic spaces with or without walls
lymphangioleiomyomatosis
cystic PCP
histiocytosis
honecombing
IPF
any end-stage interstitial disease
interstitial lung disease hrct pattern: crazy paving appearance

ground glass with overlying geometric strutures
pulmonary alveolar proteinosis
ARDS
PCP
lipoid pneumonia
halo pattern of ground glass opacity
early invasive aspergillosis in leukemic patient
hemorrhage around a neoplasm
post-biopsy pseudonodule
peripheral ground glass opacity and consolidation
BOOP
infarcts
septic emboli
collagen vascular disease
contusion
DIP
drug toxicity
eosinophilic pneumonia
fibrosis
sarcoidosis
interstitial lung disease hrct pattern: honey combing
UIC (IPF)
scleroderma/RA
asbestosis
chronic hypersensitivity pneumonitis
sarcoidosis
silicosis
EG
drug toxicity, bleomycin
diseases spreading along bronchovascular bundle
sarcoidosis
lymphoma
lymphangitic spread of tumor
TB
kaposi's sarcoma
tree-in-bud
infection
tb
bronchopneumonia
fungal
asian panbronchiolitis
viral pneumonias
bronchial disease
bronchiolitis
congenital disorders
cystic fibrosis
dyskinetic cilia syndrome
other
abpf
lymphangitic carcinomatosis
EG
hyperlucent lung

lobar, segmental, subsegmental, generalized, with or without hyperexpansion
airways
obstruction
emphysema, bullae
asthma, mucous plug, causes of bronchial obstr.
swyer-james syndrome-small in volume, small PA
compensatory hyperexpansion of residual lung after surgical lobectomy or chronic lobar collapse

cysts
congenital
hypogenetic lung syndrome
congenital lobar emphysema

vascular due to oligemia
pe
pulmonary artery stenosis

chest wall abnormalities
mastectomy
polands syndrome

pleural
pneumothorax
small lung

maybe associated with either decreased or increased density
hypogenetic lung syndrome
agenesis of pulmonary artery
chronic atelectasis
bronchiolitis obliterans (Swyer-james syndrome)
endobronchial lesions
tumors 80%
malignancy 70%
scc most common
low grade malignancies
adenoidcystic carcinoma
mucoepidermoid carcinoma
small cell carcinoma
carcinoid
mets 5%, rcc, melanoma, colon, breast, thyroid
other, hamartoma, mucoepidermoid carcinoma, hemangioma

inflammatory disease 20%
tb

other
mucous plug
foreign body
trauma
broncholith
increased tracheal diameter
tracheobronchomegaly (Mounier-kuhn disease)
pulmonary fibrosis
tracheomalacia
decreased tracheal diameter
saber-sheath trachea (most common)
tracheopathia osteochondroplastica
tracheomalacia (decreased on expiration)
relapsing polychondritis
amyloidosis
sarcoidosis
wegeners disease
tb and fungal stenosis
bronchiectasis
postinfectious (most common)
any childhood infection
recurrent aspiration
abpa: central bronchiectasis
chronic granulomatous infection
pertussi

bronchial obstruction
neoplasm
foreign body

congenital
cystic fibrosis
bronchial cartilage deficiency, willaims campbell syndrome
kartageners syndrome
upper lobe bronchiectasis
cystic fibrosis
TB
radiation
abpa, most commonly central, high density mucous plugs highly predictive
mucoid impaction
asthma
cystic fibrosis
abpa
congenital bronchial atresia
pleural based mass

obtuse angles with chest wall
tumor
mesothelioma, multifocal, diffuse
fibrous tumor of pleural, unifocal maybe locally invasive
malignant thymoma, lymphoma
mets, breast, lung, prostate, thyroid, renal
benign mesenchymal tumore (lipoma, leiomyoma)
malignant mesenchymal tumors (fibrosarcoma, MFH, leiomyosarcoma)
extrapleural tumors
rib tumors
children, EG, ABC, ewing's, neuroblastoma
adults, mets>multiple myeloma>paget's, fibrous dysplasia
plexiform neurofibromas in nf (bilateral)

inflammatory
infectious, tb
asbestos
actinomycosis (rib destruction)

loculated fluid
calcified pleural plaques

TAFT
tb, usually diffuse plaques
asbestos related plaques, usually focal
fluid (empyema, hematoma)
talc
elevated hemidiaphragm
phrenic nerve paralysis
tumor
surgery
birth defect, erb's paralysis
immobility due to pain
rib fractures
pleuritis, pneumonia
pe
mass lesions
abdominal masses, subphrenic collection, abcess
diaphragmatic hernia
pleural tumors
subpulmonic effusion
anterior mediastinal masses

4 T's (thymoma, thyroid lesions, t cell lymphoma, teratoma and germ cell tumors)
thymic masses
thymic cyst
thymolipoma
thymoma
cystic
benign
malignant
thymic carcinoma
thymic carcinoid
thymic lymphoma
germ cell tumors (m>f)
seminoma
embryonal cell carcinoma
choriocarcinoma
teratoma
lymphadenopathy due to sarcoid, lymphoma, tb, etc
aneurysm and vascular abnormalities (involve both the anterior and superior mediastinal compartments)
cystic anterior mediastinal mass
thymic cyst (3rd pharyngeal pouch remnant)
cystic thymoma (contains solid components)
teratoma
bronchogenic cysts (usually in middle mediastinum)
pericardial cyst
superior mediastinal mass
descending through thoracic inlet
thyroid masses
adenopathy (1 H&N tumors)
lymphatic cysts, cystic hygroma

ascending through inlet
small cell carcinoma of lung

lymphoma
aneurysm and vascular anomalies
middle mediastinal mass
adenopathy (often bilateral)
benign-sarcoid, tb, funal, chronic beryllium exposure
malignant-mets, lymphoma, leukemia

congenital cysts
bronchogenic cysts (subcarinal, anterior trachea)
percardial cysts
foregut cysts

aneurysm
aorta, aortic branches
pulmonary artery

esophagus
hiatal hernia
neoplasm
diverticula
megaesophagus

other
mediastinal hemorrhage
mediastinal lipomatosis, lipoma
bronchogenic CA
aberrant RSA with diverticulum
varices
neurinoma from recurrent laryngeal nerve
malignancy of trachea
pancreatic pseudocyst
paraganglioma (AP window)
lymphangioma and hemangioma
tracheal tumor
thyroid masses
mediastinal adenopathy
low attenuation lymph nodes
TB and fungal infections in AIDS
necrotic mets
lymphoma
vascularized lymph nodes
castlemans disease
vascular mets-renal, thyroid, small cell, melanoma

calcified lymph nodes
TB
histo, fungus
sarcoidosis
silicosis
radiation therapy
posterior mediastinal mass
neurogenic 90%
peripheral nerves (20-40 years; <2 vert bodies)-schwannoma and neurofibroma 45%

sympathetic ganglia (<20; >2 vertebral bodies)-ganglioneuroma, neuroblastoma, sympathicoblastoma

paraganglionic cells-pheochromocytoma, paranganglioma

lateral meningomyelocele

thoracic spine
neoplasm
hematoma
extramedullary hematopoiesis
disciitis

vascular
aneurysm
azygous continuation (congenital absence of IV with dilated azygous and hemiazygous)

other
foregut cyst
lymph nodes mass (NHL, mets)
esophageal masses and varices
cardiophrenic angle mass
fat pad (most common)
diaphragmatic hernia
morgagni (anterior 90% on right)
bochdalek (posterior, more on the left)

pericardial cyst
cardiophrenic angle nodes (lymphoma usually recurrent s/p radiation)
aneurysm
dilated right atrium
anterior mediastinal mass
primary lung or pleural mass
fatty mediastinal lesions
purely fatty lesions
mediastinal lipomatosis
morgagni hernia (omentum)
bochdalek hernia (omentum)
periesophageal fat herniation

tumor with fatty components
lipoma
liposarcoma
thymolipoma (children and young adults)
germ cell tumors (also contain ca++, cystic and solid region)
high density mediastinal lesions on noncontrast CT
calcified lymph nodes
calcified primary mass
tumor
goiter
aneurysm
hemorrhage
densely enhancing mediastinal mass
vascular
aneurysm
vascular abnormalities
esophageal varices

hypervascular tumors-paraganglioma, mets from thyroid cancer, RCC

goiter
castlemans disease
prominent hila
tumors
central bronchogenic carcinoma
lymphoma

adenopathy
infectious-tb, fungi, histo
inflammatory-sarcoid, silicosis
tumor-commonly oat cell, lymphoma, mets

pulmonary artery enlargement
eggshell calcifications in hilar nodes
silicosis, CWP

treated lymphoma

granulomatous disease such as histoplasomosis rarely contains egg shell calcifications, diffuse are more common

sarcoid (rare and late in disease)
pneumomediastinum
pulmonary
asthma
barotrauma (intubation, diver)
childbirth
pneumothorax

mediastinum
tracheobronchial laceration
esophageal perforation
mediastinal surgery
boerhaaves syndrome

abdomen
intraperitoneal or retroperitoneal bowel perforation
retroperitoneal surgery

head and neck
esophageal rupture
facial fractures
dental and retropharyngeal infection, mediastinitis
asymmetrical interlobular septal thickening
lymphangitic spread of carcinoma
idiopathic interstitial pneumonias
UI
NSIP
OP (organizing pneumonia, BOOP, COP)
DIP
RB-ILD
LIP
AIP
usual interstitial pneumonia
lung volume reduced

reticulation, traction bronchiectasis, and honeycombing

GGO uncommon as isolated findings

basal, posterior, lower lobe predominance

IPF (idiopathic UIP), collagen disease, asbestosis, drug fibrosis, end-stage hypersensitivity pneumonitis
honeycombing
usually due to UIP
IPF
RA, scleroderma, other CVD
drug-related fibrosis
chronic hypersensitivity pneumonitis
asbestosis (uncommon)
end-stage sarcoidosis (uncommon)
fibrotic NSIP
NSIP
less common than UIP

homogenous inflammation or fibrosis, cellular (inflammatory) and fibrotic forms

common pattern in CVD, drug reaction, idiopathic
NSIP imaging findings
GGO alone-cellular NSIP

GGO + reticular opacities-cellular or fibrotic NSIP

traction bronchiectasis

honeycombing = fibrotic nSIP; uncommon, minimal

lower lobe, posterior, peripheral predominance

sparing of subpleural lung
respiratory bronchiolitis and desquamative interstitial pneumonia
related to smoking
RB + symptoms = RB-ILD
DIP similar histology but more extensive
RB-ILD, DIP imaging findings
intraalveolar macrophages, little fibrosis

RB-ILD-GGO localized and often centrilobular

DIP-GGO more diffuse, maybe patchy and subpleural indistribution
consolidation
acute
pneumonia
edema
hemorrhage
diffuse alveolar damage

chronic
organizing pneumonia (OP, BOOP)
chronic eosinophilic pneumonia
bronchioalveolar carcinoma
lipoid pneumonia-fat density or non-fat density, confluent consolidation
sarcoidosis, silicosis
smoldering infectious pneumonia
organizing pneumonia
granulation tissue polyps in bronchioles and patchy organizing pneumonia

assoc with BOOP, COP

idioapthic, infection, drugs, CVD, fumes
organizing pneumonia
patchy airspace consolidation or GGO-90%

large nodules or masses-15%

peripheral and peribronchial distribution

opacities often irregular in shape

fibrosis, uncommon, mild

atol sign or reversed halo sign
chronic eosinophilic pneumonia
idiopathic or associated with a known antigen

peripheral eosinophilia

months of fever, cough, dyspnea, weight loss

identical to BOOP in CT and symptoms

peripheral GGO and consolidation

upperlobe predominance common
ground glass opacity
acute

pulmonary edema
hemorrhage
atypical pneumonia (PCP, viral, etc)
diffuse alveolar damage

chronic

interstitial pneumonia (NSIP, DIP)
hypersensitivity pneumonitis
organizing pneumonia
chronic eosinophilic pneumonia
BAC
lipoid pneumonia (rare)
alveolar proteinosis (rare)
hypersentivity pneumonitis
acute, subacoute, chronic
repeated exposure leads to fever, chills, dry cough, or dyspnea
hypersentivity pneumonitis

imaging findings: subacute stage (typically when imaged)
patchy ground-glass opacity (75-90%)

ill-defined centrilobular nodules of ground glass opacity (50-60%)

mosaic perfusion (patchy lucencies), three types of lucencies (headcheese appearance)

air-trapping on expiratory scans

diffuse or predominant im the mid lung zones

inovles entire cross section of the lung, no subpleural predominance
hypersentivity pneumonitis

imaging findings: chronic
no subpleural predomninance, upper lobes most abnormaly

reticulation and traction bronchiectasis
alveolar proteinosis
crazy paving appearing
perilymphatic nodules
sarcoidosis
lymphangitic spread of tumor
silicosis and CWP (uncommon)
amyloidosis (rare)
LIP (rare)
sarcoid
mediastinal nodes 60-90%

symmetric hilar LAD, absence of hilar lymph nodes suggest diff dxx, isolated masses unusual

50 % lung disease on cxr

cxr staging
1-hilar adenopathy
2-hilar adenopathy + lung dz
3-lung disease only
4-fibrosis

perilymphatic nodules, most subpleural, and peribronchovascular, upper lobe predominance upper lobes masses, satellite nodules, "galaxy sign"

late-upper lobe fibrosis, fibrotic masses, traction bronchiectasis, cysts, eymphysema
silicosis
same as sarcoid

progressive massive fibrosis

distinguish by history
random nodules
miliary TB
miliary fungal infections
hematogenous metastases
sarcoidosis (uncommon)
centrilobular nodules (spares pleural surface as opposed to other types)
bronchiolitis (ie infectious, inflammatory), most common

respiratory bronchiolitis (smoking)

follicular bronchiolitis (cvd, immunosuppression)

endobronchial spread of TB, MAC

bronchopneumonia (any cause)

hypersentivity pneumonitis

endobronchial spread of tumor (BAC)

pneumoconiosis (ie silicosis)

edema, hemorrhage, or vasculitis (uncommon)
tree-in-bud
endobronchial spread of TB or MAC
bronchopneumonia
bronchiectasis, or bronchitis
cystic fibrosis
aspiration (rare)
ABPA, asthma (rare)
BAC (rare)
emphysema
centrilobular-upper lobe predominance, focal lucencies, without walls

panlobular-diffuse, or predominantly lung bases, lung too big, too black, vessels small, cigaretes, alpha 1

paraseptal-beneath pleural surface, involves upperlobes, no fibrosis, can be assoc with centrilobular emphysema
lung cysts
honeycombing

emphysema (bullae)

pneumatoceles associated with pneumonia

hypersensitivity pneumonitis (rare)

histiocytosis (rare)

LAM and TS (rare)

Sjogrens syndrome or CVD with lymphoid pneumonia (rare)

bronchiectasis

misc. causes
juvenile trachealaryngeal papillomatosis
klippel-trenaunay syndrome
neurofibromatosis
histiocytosis
upper lobe predominance
cysts irregular in shape
thick or thin walled
sparing of cp angles
nodules early
smoking related
normal to increased lung volumes
LAM
round cysts
usually thin walled
diffuse, random in distribution
only in women of childbearing age
1% of TS patients, rarely men
80% recurrent pneumothorax
chylothorax
death within 10 years from hypoxia
LIP
round in shape
thin walled
diffuse
limited in number to a few dozen
sonographic evaluation of thyroid nodules
relapsing polychondritis
diffuse tracheal thickening sparing posterior MB

no ca++

tracheomalacia

recurrent pneumonia

tx stent
focal circumferential tracheal thickening
ddx
post intubation stenosis-history

wegeners
focal, or long
concentric thickening
subglottic involvement
no malacia
infection-tb,fungal

sarcoid-tracheal inv. 1-3%

IBD-rare, late
nodular trachea
ddx
tracheobronchopathia osteochondroplastica
rare, idiopathic, benign
no associated malacia
spares posterior mb
ca++

tracheobronchial amyloidosis
nodular irregular or circumferential
focal or long
ca++ or no ca++
papillomatosis

mets
tracheobronchomegaly aka munier kuhn
atrophy of cartilage and connective tissues of airway wall

tracheomegaly >3cm
bronchiectasis

malacia
tracheal neoplasia
90% malignant

primary
scc-most common
adenoid cystic-posterior maybe circum, ecc
mucoepidermoid-airways>>trachea
carcinoid-densley enhances, circumscribed, octr scan+
others-sarcoma, adenoca

secondary
mets
direct invasion
swyer-james syndrome
unilateral bronchiolitas obliterans

due to lower respiratory tract infection in early childhood

unilateral lucency

lung volume usually decreased, but maybe nl or increased

air trapping, bronchiectasis

maybe incidental or associated with recurrent infection
bronchiolitis obliterans
aka constrictive bonchiolitis, not BOOP

fibrosis of peribronchial tissu

ddx-transplant rejection, post viral, CVD, inhalation, drugs

findings-mosaic perfusion, air trapping, dry bronchiectasis
small airways disease (bronchiolitis)
ddx

impaction-tree in bud
infection, panbronchiolitis

inflammation-centrilobular nodules
bronchopneumonia, HP, resp bronchiolitis, follicular bronchiolitis, BOOP

obstruction-mosaic perfusion pattern, air trapping
HP, BO, asthma
panbronchiolitis
diffuse centrilobular nodules

east asians

TIB, nodules

bronchiectasis
mosaic perfusion

areas of ggo and lucent lung

lucent lung sharply distinct

vessels diminutive in areas of lucency compared to ggo

if lucent lung stays lucent and opaque lung gets denser then mosaic perfusion with small airway dz
95% result from airways dz-polygonal areas of lucency


rest from small vessel disease-large lucent areas with decreased vascularity

ddx
asthma
hypersentivity pneumonitis
constrictive bronchilitis (BO)
chronic PE
anterior mediastinal masses simplified differential
thymoma-thymic tumors and masses

teratoma-germ cell tumors

terrible lymphoma-lymphoma and node masses

thyroid-thyroid and parathyroid masses

tons of other stuff-vascular anomlies, foregut cyst, lymphangioma, hemangioma, benign mesenchymal tumors, sarcoma
thymic epithelial tumors
most common primary thymic tumor

15-20% primary mediastinal masses

peak 50-60 yo, rare < 20

myasthenia gravis-50-60%

10-30% of myasthenia have thymoma

types
thymoma (invasive/noninvasive)
thymic carcinoma

spread (local>pleural>extra-thoracic)
germ cell tumors
10% primary mediastinal masses

teratoma, seminoma, nonseminomatous, mixed

most common in anterior mediastinum, 5% posterior

2-4th decades, 80% benign, mostly teratomas

benign tumors-m=f

malignant tumors m>f

benign tumors often asx
anterior mediastinal mass-mature (dermoid cyst)
60-70% GCT

ca++, fat, soft tissue
rupture (pleura, lung, mediastinum)

CT-well defined mature elements (fat, fluid)
anterior mediastinal mass-seminoma
almost entirely men, mean 29yo

20-40% gct

large, smooth, or lobulated, homogenous mass

sensitive to chemo and rad, good px
nonseminomatous GCT
mixed bag, similar appearance and behavior

large heterogenous infiltrative mass
anterior mediastinal masses: lymphoma
hodgkins
85% mediastinal adenopathy
prevascular or paratracheal nodes 98% of thoracic disease
multiple node groups common
low attenuation nodes in 10-20%, ca++ rare

nonhodgkins
40-50% thoracic involvement
inv of one node group more common than HD
inv of posterior nodes more common than HD
inv of anterior med nodes less common than HD

both types infiltrative, not mass like
cardiophrenic angle mass
ddx
thymoma and other anterior mediastinal masses

pericardial cyst

fat pad

morgagni hernia

lymph node masses

lipoma
calcified mediastinal lymph nodes
ddx
dense ca++-old granulomatous dz, sarcoid

egg-shell ca++-silicosis or CWP, sarcoid, TB, treated hodgkins

uncommon-metastatic carcinoma or sarcoma (more irregular), untreated lymphoma, PCP, amyloidosis, scleroderma, castleman's disease
low-attenuation (necrotic) mediastina lymph nodes
ddx
infections (TB and fungus)

mets (lung ca, extrathoracic, ie renal cell)

lymphoma

sarcoidosis (rare)
avidly enhancing mediastinal lymph nodes
ddx
metastases (renal, thyroid, lung ca, melanoma)

TB

rare-castleman's disease, angioimmunoblastic lymphadenopathy, sarcoidosis

differentiate from enhancing masses (substernal thyroid, carcinoid, lymphangioma, hemangioma, paraganglioma)
castleman's disease
hyaline vascular and plasma cell types

localized
80% HV type
children or young adults
enhancing mediastinal mas
benign course, resection curative

multicentric
most PC type
adults 40-50 years
multiple enhancing nodules, splenomegaly
aggressive; associated with anemia, infection, malignancies, LIP, AIDS, neuropathy, POEMS
metastatic mediastinal tumor
mets from extrathoracic primary to mediastinal or hilar nodes uncommon (3%)

head and neck, GU tract, breast, melanoma

location may suggest source
paravertebral nodules-abdomen
superior med nodes-head and neck
internal mammary-breast
paracardiac-breast or abdomen
mediastinal bronchogenic cyst
lined by bronchial epithelium

subcarinal and paratracheal most common

may occur in any mediastinal compartment

rarely contain air, become infected

smoot, round, oval mass

fluid (0 HU) or soft tissue attenuation (20-40)

MRI or CT (pre and post) for problem solving
cystic mediastinal lesions
ddx
esophageal duplication cyst-next to esophagus

neurenteric cyst-paraspinal cyst, assoc with vertebral anomalies

pericardial cyst

mesenchymal tumors (leiomyoma) )-looks cystic due to low density, but really enhances
distinguishing between posterior mediastinal nerve sheath and ganglion cell tumors
nerve sheath
neurofibroma (30yo)

schwannoma (40yo)

rounded. 1-2 vertebral body segments

+/- extension into the neuroforamina

pressure erosion of vertebral body or ribs

CT-70% low attenuation as low as fluid, heterogenous enhancement

ganlion cell
neuroblastoma (<5yo)
ganglioneuroblastoma (10yo)
ganglioneuroma (20yo)

long, sausage shaped, multiple vertebral body segments

CT similar to nerve sheath tumors
causes of pneumothorax
traumatic

iatrogenic ie line placement

alveolar rupture (ARDS, asthma)

bronchopleural fistula (abscess, mets, PCP, lymphangioleiomyomatosis)

spontaneous

catamenial
differentiating lung parenchymal vs pleural/chest wall lesions
parenchymal
spherical
borders well defined
acute angles with periphery

pleural/chest wall
elliptical/elongated
portion of border ill-defined
obtuse angles with periphery
localized fibrous tumor of the pleura
30% malignant

sx's-incidental, chest pain, hypoglycemia, HPO

large pleural mass

CT
solitary pleural mass
necrosis +/- ca++
heterogenous but significant enhancement, particularly on delayed images
large feeding vessels
empyema
infected pleural effusion/pus

staph, pneumococcus, tb

loculated, exudative effusion
thickened enhancing pleura
split pleura sign

air
thoracentesis
bronchopleural fistula
gas forming organisms

treatment
epmyema->drainage
abcess->antibiotics
factors suggesting malignant pleural disease
thickening >1cm

significant mediastinal pleural thickening

circumferential thickening

pleural nodularity

chest wall invasion

ddx
mets
lung ca
breast ca
gi ca
melanoma
mesothelioma
thymoma
asbestos related pleural disease
pleural effusions
earliest feature
often exudative!
pleural thickening and enhancement

pleural plaques
elevated edges
high density +/- Ca++

risk for mesothelioma
round atelectasis
pleural abnormality (ie plaque, effusion)
contact with the pleural abnormality
volume loss
swirled vessels/bronchi (comet tail sign)
must get f/u to exclude cancer
fibrothorax
calcified pleural with lung volume loss

old tb
prior pleural hematoma
prior empyema
mesothelioma
3 types
epithelioid
sarcomatoid
mixed

strong assoc with asbestos exposure

20-40 yr latent period
fat containing nodules of the lung
hamartoma
lipoma
liposarcoma
lipoid pneumonia
teratoma
histoplasmoma (rare)
if given a chest x-ray and abnromality is subtle
look for notched ribs, missing ribs (lytic lesion) or spine abnormality (osteo)

check trachea and airways

look for abnormal air, pneumomediastinum, or in abd

consider also congenital absence of pericardium, hiatal hernia or achalasia, anomalous line
airway masses
ddx
squamous cell carcinoma

adenoid cystic carcinoma

carcinoid

direct invasion, ie esophagus or lung primary

mets, melanoma, breast

benign tumors ie hamartomas, papillomas
name atelectasis
luftsichel-left upper lobe atelectasis

golden s-right upper lobe atelectasis

juxtaphrenic peak-upper lobe atelectasis either side

comet tail-round atelectasis

flat-waist sign-straightening of left heart border in setting of LLL atx
pott's disease
aka tb spondylitis

destruction of disk and adjacent vertebrae by tb < 1% of tb patients

50% no pulmonary lesions

spread via batsons venous plexus

subligamentous spread to adjacent vertebrae
halo sign and neutropenia
angioinvasive aspergillus
bronchiectasis by location
upper lobes
cf
tb
sarcoidosis

middle lobe/lingula
MAC
kartageners

central/perihilar
abpa
williams-campbell

lower lobes
chronic infection/aspiration, ie blue boater
traction bronchiectasis in uip/ipf
pneumocystis pneumonia
fever, dyspnea, hypoxemia, cough

rare pleural effusions

pneumatoceles favoring upper lobes

diffuse ggo on cxr in 85% and normal cxr in 15%

hrct helps exclude disease in setting of nl cxr
ggo centrilobular nodules
ddx
hypersensitivity pneumonitis

respiratory bronchiolitis

atypical infections (acute sx)

follicular bronchiolitis (cvd, immunosuppression, rare)
dense centrilobular nodules
localized, patchy
endobronchial spread of infection (bacteria, mycobacteria)

aspiration

endobronchial spread of tumor (BAC)

diffuse
vascular cause (edema, hemorrhage)
diffuse tracheal wall thickening
sarcoid

amyloid

relapsing polychondritis

wegener's granulomatosis

infection (aspergillus, klebsiella, rhinoscleromatis)

tracheobronchopathia osteochondroplastica

IBD
cystic bronchiectasis lower lungs
ddx
post viral infection (childhood)

primary ciliary dyskinesia

immunodeficiencies ie aggambloulinemia

williams campbell

tracheobronchomegaly
cystic bronchiectasis upper lungs
ddx
symmetric
cystic fibrosis

asymmetric
abpa
tb
endobronchial tumor/stricture
bronchial atresia
lobar collapse
signs
displacement of fissure
elevated diaphragm
displaced PA
mediastinal shift

causes
mucous plug
tumor
aspirated foreign body
extrinsic compression from tumor or LAD
passive collapse and low lung volumes of lower lobes
sequestration
rml, rll collapse
golden s sign
luftsichel sign
lll collapse
crazy paving
ddx
acute
edema
dad/arsp/aip
infections
hemorrhage
hypersensitivity pneumonitis

chronic
BAC
lipoid pneumonia
alveolar proteinosis
mediastinal soft tissue infiltration
ddx
lymphoma
leukemia
mets ie lung ca
acute mediastinitis
fibrosing mediastinitis
erdheim chester
diffuse fibrosing mediastinitis
20%

non-calcified

not assoc with granulomatous infection

associations-autoimmune d/o, retroperitoneal fibrosis
focal fibrosing mediastinitis
80% cases

paratracheal, subcarinal

often ca++

associated with granulomatous infections, ie histoplasmosis
perilymphatic nodules
ddx
common
sarcoid
lymphangitic carcinomatosis

uncommon
silicosis/coal workers pneum
amyloid
lip
progressive massive fibrosis-symmetric bilateral upper lobe masses
ddx
silicosis
CWP
sarcoidosis
fungal disease
talcosis (high density)
multiple cavity nodules
ddx
mets

infections
septic emboli
fungal disease (asp)
mycobacterial disease
nocardia, actino.

vasculitis ie wegeners

lch

rheumatoid nodules

tracheobronchial papillomatosis
cavitary wall thickness
wall thickness
< 5mm benign
5-15mm nonspecific
>15mm malignant
focal lung lucency
ddx
bronchial obstruction
aspirate fb
endobronchial tumor
bronchial strictures
bronchial atresia

sequestration

ccam

asymmetric bullous diseaes
bronchial atresia
scimitar syndrome
papvr
systemic arterial supply
pulmonary hypoplasia
small pulmonary artery
dextroposition of the heart
congenital masses
ccam/cpam
cdh
sequestration
bronchogenic cysts
avm
ccam/cpam
hamartomatous mass

type 1-single or multiple large cysts >2cm diameter

type 2-multiple cysts <2cm diameter

type 3-solid appearing microcystic

maybe assoc with pulmonary hypoplasia or fetal hydrops

in adults typically appear as areas of cystic hyperlucency, with recurrent infxn
congenital diaphragmatic hernia
most common posterolateral (Bockdalek in back), 9/1 on left

solid at birth until swallowed air fills loops

may cause pulmonary hypoplasia
sequestration
developments anomaly resulting in disorganized lung parenchyma

intralobe vs extralobar

both have systemic art supply

favor left lung base
bronchogenic cyst
cystic anomaly of ventral foregut (dorsal forms esophagus)

most common intrathoracic forgut cyst, more common than esoph duplication cyst

usually contain fluid or mucus, with water or high density material

mediastinal 86%, intrapulmonary 14%
pulmonary avm
associated with HHT/OWR

1/3 mult, 1/6 bilat

right to left shunt, 20% cardiac output for 1 cm diam

dyspnea, cyanosis, clubbing, hemoptysis, paradoxical embo

tx with large coils, detach balloons
unresectable nonsmall cell lung ca
stage 3b and up

anything that has either...

t4-tumor invades mediastinal structures, separate tumor nodules in same lobe, tumor with malignant pericardial, pleural effusion

n3-mets to contralateral mediastinum or hila, ipsilateral or contralateral scalene, or supraclavicular lymph nodes

m1-distant mets including separate lobes
lung bx risks
pneuthorax 20%
chest tube req 5-10%
hemoptysis 5%
malignant seeding 0.01%
air embolism 0.1%
death 0.2%
calcified lung masses
ddx
metastatic osteosarcoma
pulmonary microlithiasis
calcified pleural hematoma
metastatic calcification
calcified tuberculoma
airway masses
squamous cell ca (distal)

adenoid cystic ca

carcinoid

direct invasion from esophagus or lung primary

mets ie breast, melanoma

benign tumors ie hamartomas, papillomas
cannonball lung metastases

term for smaller number of large mets typically gi, gu
ddx
colon ca
renal cell ca
testicular/ovarian ca
osteosarc (often ca++)
immunodeficient lung mass
PTLD

pulmonary lymphoma

kaposis sarcoma-flame shaped nodule, irregular, oblong and hazy margins; usually have mucocutaneous dz

bronchogenic ca

mass-like infection
wegeners granulomatosis
systemic small vessel vasculitis assoc with cough, hemoptysis

90% c-anca+

multiple nodules or masses, often with cavitation 50%, less commonly pulm hemorrhage

look for sinus, renal dz