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431 Cards in this Set

  • Front
  • Back
What are causes of lobar pneumonia?
Bacteria

Fungus
What does lobar pneumonia affect?
Primarily alveoli
Why are there air bronchograms?
Because bronchi are not primarily affected, as alveoli are.
Why is there no volume loss?
Because airways remain patent
What are causes of bronchopneumonia?
Bacteria


Mycoplasma
What does it primarily affect?
Bronchi, with involvement of adjacent alveoli
What does this result in?
Involvement of bronchi results in some volume loss


Involvement of bronchi also results in a patchy alveolar pattern, with air alveolograms, as some bronchi will be affected, and some will just by luck be spared. As person coughs, will spread to other lobes and even other lung.
What are infectious causes of pulmonary nodules?
1) Fungal


2) Bacterial


3) Septic emboli
What is appearance of infectious nodules?
Variable size

Indistinct margins
What may nodules do?
Cavitate
What causes pneumatocele formation?
Air leak into the pulmonary interstitium
What organism is famous for pneumatoceles?
Staph
What organisms are famous for cavitary abscesses?
Anaerobes (i.e. klebsiella)


Fungal


Tb
What are appearances of diffuse lung opacities?
Reticulonodular


Nodular (miliary)
What causes reticulonodular pattern?
Peribronchovascular inflammation
What are causes of this?
Viral pneumonia


Mycoplasma
What is another pathogen that causes diffuse lung opacities?
PCP
What is PCP pattern of involvement?
Primarily interstitial, with alveolar involvement later on.
What is the extreme of the interstitial involvement?
Upper lobe cystic changes, with resultant pneumothorax.
What percent get PTX?
10%
What else is result of involvement of interstitium?
They can also get bronchpleural fistulae
What is the pattern of alveolar involvement in PCP?
Scattered involvement
What does this result in on imaging?
Ground glass on HRCT. Also see cysts due to interstitial involvement.
What is distribution on CXR?
Diffuse or perihilar.
What is initial CXR appearance of PCP?
Bilateral symmetric interstial pattern
What is later pattern?
Add in different degrees of alveolar consolidation
What can an organized effusion or empyema do?
Erode into chest wall or lung
When should pneumonia resolve by?
4 weeks
In what patients can you give up to 8 weeks?
Diabetics and older patients
What is differential for nonclearance?
Abx resistance or wrong pathogen


Recurrent infection


Underlying neoplasm
What patients get pseudomonas pneeumonia?
Ventilated patients


Immunocompromised
What are presentations?
There are 3:

1) Extensive bilateral consolidation, lower lobe predominant


2) Abscess formation


3) Nodular disease (rare)
What is another bacteria with lower lobe predilection?
Legionnaires
What is the most common atypical pneumonia?
Mycoplasma
What is appearance?
Diffuse reticular pattern, with lower lobe predominance
In what percent is there alveolar consolidation?
50%
What is the first stage of primary Tb?
1-7 cm focus of lung consolidation
Where does it occur?
Anywhere. Lower lobe is more common (60%) than upper lobe (40%) probably just because there is more lung and bloodflow in lower lobes
What is the next stage in primary Tb?
The consolidation undergoes caseous necrosis.
What occurs next?
Lesion calcifies
What also always occurs in primary Tb?
Lympadenopathy
Where is lymphadenopathy?
Hilar and paratracheal
What percent of primary Tb gets pleural effusion?
10%
What are potential complications of primary Tb?
Hematogenous spread from the area of consolidation, resulting in miliary Tb, which can go all over the body.


Cavitation of the area of consilidation, with erosion into bronchus, and transbronchial spread to rest of lungs.
What is commonly the only finding in primary Tb?
Adenopathy. The Ghon focus is not visible always.
What is this called in kids?
Epituberculosis
What populations get complicated primary Tb?
Children


Immunosuppressed
What causes secondary Tb infection?
Reactivation
Where does reactivation occur?
Apical and posterior segments of upper lobes


Superior segment of lower lobe
What occurs in anterior segment upper lobe?
Histo commonly does. Tb does not.
What is appearance of Tb?
Airspace disease, patchy or confluent.


May see linear densities radiating to hilum
What is common in secondary Tb?
Cavitation
In what percent?
40
What is rare in secondary Tb that is common in primary Tb?
Adenopathy
What other space can secondary Tb involve?
Pleural.
What occurs?
Pleuritis, with empyema formation, and subsequent bronchopleural fistula and/or pneumothorax.
What is empyema that invades chest wall called?
Empyema necessatatis
What is Tb vascular invasion with aneurysm formation called?
Rasmussen aneurysm
What other way can Tb spread?
Hematogenously
What occurs?
Miliary Tb, which can seed other end organs
What is most common complication of parenchymal disease?
Lung fibrosis, which can be severe with cicatricial changes
What are other complications of parenchymal Tb involvement?
Bronchial invasion


Rasmussen aneurysm


Spread to GI tract via swallowed secretions
what is acute complication of bronchial invasion?
Transbronchial spread to other parts of lung(s)
What are late complications of bronchial involvement?
Bronchiectasis


Bronchial stenosis


(opposite seeming lesions, but both caused by inflammatory process)
Differentiate primary and secondary Tb by location.
Primary more often lung bases


Secondary in upper lobes and superior seg LLs
Differentiate primary and secondary Tb by appearance
Primary is focal


Secondary is Patchy
Where is effusion more common, Primary or secondary Tb?
Primary
What is different about mycobacteria avium intracellulare infection versus Tb?
No primary/secondary crap. All infection is primary.
What patient populations get MAI?
AIDS


Elderly people with COPD


Elderly women in good health
What may MAI be indistinguishable from on imaging?
Tb
What features suggest MAI over TB?
Bronchiectasis and Bronchial wall thickening
What percent of patients with TB vs. MAI have bronchiectasis?
30% in TB; almost 100% in MAI.

Similar values for bronchial wall thickening
What findings suggest TB over MAI?
1) Calcified granuloma (rare in MAI)


2) Septal thickening (common in MAI)
What types of patients get nocardia pneumonia?
Immunocompromised in some way
What patients are most susceptible
1) Lymphoma patients


2) Steroid therapy patients, especially those who underwent transplant.


3) Pulmonary alveolar proteinosis.
What is appearance of Nocardia?
Focal consolidaton is most comon
What are other appearances?
Irregular nodules


Cavitation
What are causes of actinomyces pneumonia?
Aspiration (lives in sputum of people with poor dentition)


Direct penetration into thorax
What is appearance?
Focal consolidation. Less commonly cavitating mass
What feature is highly suspicious for actinomyces?
Pleural thickening with invasion of chest wall
What is not present?
Lymphadenopathy
What organism class causes pulmonary abscess?
Anaerobic bacteria
What are the varieties of pulmonary infection caused by anaerobes?
1) Abscess


2) Necrotizing pneumonia


3) Empyema
What defines abscess?
Cavity(ies) greater than 2 cm, usually with fluid level
What defines necrotizing pneumonia?
Similar pathology as abscess, but a more diffuse process, with cavities under 2 cm.
What predisposes to anaerobic infection?
Aspiration


Intubation


Bronchial disease
What defines bronchial disease
Functional bronchial obstruction
What are examples of this?
Actual bronchial occlusion, i.e. from mass lesion


Bronchiectasis, resulting in functional bronchial obstruction
What are manifestations of viral pneumonia?
1) Acute interstitial pneumonia


2) Lobular inflammatory reaction


3) Hemorrhagic pulmonary edema
What is appearance of acute interstitial edema?
Thickening of peribronchovascular tissues


Thickening of interlobular septae
What is the distribution of acute interstitial pneumonia?
Diffuse or patchy
What is appearance of lobular inflammatory reaction?
5 mm nodules forming within secondary pulmonary lobules
What virus causes a special variety of this appearance?
Varicella
What is special about varicells's nodular appearance?
Late calcification of nodules
What is appearance of hemorrhagic pulmonary edema?
Mimics lobar pneumonia
What is uncommon in viral pneumonia?
Effusion
What is a potential sequela of viral pneumonia?
Chronic interstial fibrosis
What is this called?
Bronchiolitis obliterans
What percent of patients who get varicella develop pneumonia?
15%
What is true of almost all of these patients?
Over age 20, so normal little kiddies with chicken pox are unlikely to get pneumonia. This also is a reason why they say chicken pox is so much worse in adults than children.
What is the progression of findings in varicella pneumonia? First stage:
Formation of numerous 5mm acinar nodules
What is next stage?
Coalescence of acinar nodules into diffuse but patchy airspace disease
What is next stage?
Healing, resulting in 1-2 mm calcifications throughout lungs.
In whom does CMV pneumonia occur?
Neonates


Immunosuppressed
What is appearance?
Interstial pattern, with small nodules
What other feature is sometimes present in CMV?
Adenopathy
What are the two broad categories of pulmonary fungal infection?
Endemic human mycoses


Opportunistic mycoses
What are endemic mycoses?
The infections limited to certain geographic regions
What are these?
Histoplasmosis


Coccidiomycosis


Blastomycosis
Where are opportunistic mycoses located?
Everywhrere
In what population do they occur primarily?
Immunocompromised
What are the opportunistic mycoses?
Aspergillosis


Candidiasis


Cryptococcosis


Mucormycosis
What opportunistic mycoses can also occur in immunocompetent hosts?
Aspergillosis


Cryptococcosis
What are the phases in fungal pulmonary infection?
1) Acute phase


2) Reparative phase


3) Chronic phase
What additional phase can occur in immunocompromised patients only?
Disseminated disease
What is appearance of acute phase?
1) Segmental or nonsegmental confluent opacity


OR


2) Patchy opacities
What can this appearance look like in immunocompromised person?
Miliary pattern
What is this due to?
Hematogenous dissemination
What is the appearance in the reparative phase?
Nodular lesions
What is a classic appearance of these nodules?
May cavitate
When they cavitate, what is the radiographic appearance?
Crescent sign
What is appearance of chronic phase?
Calcified lymph node or lung focus
What are the symptoms of histoplasmosis?
Usually none
What is appearance early in histo infection?
Parenchymal consolidation with adenopathy
What happens when histo heals?
Adenopathy heavily calcifies
What is appearance of histo when it goes into chronic infection mode?
Histoplasmoma
What is appearance of histoplasmoma?
Solitary, sharply demarcated nodule
Where is histoplasmoma usually?
Lower lobes
What is another manifestation of chronic histo?
Fibrocavitary disease of upper lobes
What is this appearance the same as?
Post-primary TB
What is another appearance of chronic histo?
Cavitary nodules
What is appearance of disseminated histo?
Miliary lung nodules
What else is seen as a sequela of disseminated histo?
Calcifications in liver and spleen
What is sometimes a sequela of pulmonary histoplasmosis?
Mediastinal histoplasmosis
What are the two entities that can occur due to mediastinal histo?
1) Mediastinal granuloma


2) Mediastinal fibrosis
What is mediastinal granuloma?
Nothing. Just calcified mediastinal lymph nodes. But heavy mediastinal calcification is different than TB, however.
What is mediastinal fibrosis?
Diffuse infiltration of mediastinum with multiple densely calcified nodes and fibrotic change.
What are effects?
Constrictive pericarditis


SVC syndrome


Pulmonary artery occlusion


Airway compression
What are symptoms of coccidiomycosis lung infection?
Usually asymptomatic
What is appearance in the acute phase?
"Fleeting" consolidation
What part of lungs involved?
Lower lobes
What is another manifestation sometimes seen?
Adenopathy (20%)
What is appearance of coccy in the reparative phase?
Doesn't really have one, goes into chronic phase in some patients.
What percent of patients go into chronic coccy infection?
5%
What is the appearance of chronic coccy?
Nodules
What is characteristic of the nodules?
Not much
What percent cavitate?
15%
When nodule cavitates, what suggests coccy?
Thin wall
What percent of cavitating nodules have thin wall?
50%
What does the other 50% that have thick wall suggest?
Nonspecific
What can patients who progress to the chronic form of coccy present with?
PTX, if their nodules cavitate and a bronchopleural connection is created
What percent of coccy nodules calcify?
Rare
What is characteristic of the disseminated form of coccy?
Nothing. Miliary nodules
What is appearance of blastomycosis?
Nonspecific.

Air space disease, more common than nodular disease (15% cavitate, like chronic coccy), more common than miliary disease
What is one manifestation of blasto that is somewhat suggestive?
Paramediastinal infiltrate with an air bronchogram
When there is nodular disease, what is commonly associated with it?
Satellite lesions around the nodule
What is very uncommon in blasto?
Calcification


Adenopathy


Pleural effusion
What is involved in 25% of cases of blasto?
Bone
How many varieties of aspergillosis are there?
4
What is each variety paired with?
A specific immune status
What are the immune statuses?
Hypersensitive


Normal


Mild immunosuppression


Severe immunosuppression
What is the variety of aspergillosis associated with hypersensitive immune response?
Allergic bronchopulmonary aspergillosis
What is the variety of aspergillosis assd with normal immune response?
Aspergilloma
What other variety can occur in normal host?
Semiinvasive form, if person is exposed to a large load of inhaled aspergillus.
What is variety associated with mild immunosuppression?
Semiinvasive
What is variety associated with severe immunosuppression?
Invasive
What is ABPA?
Type I hypersensitivity reaction to aspergillus
What patients does it occur in?
Asthmatics
What proportion are asthmatics?
Almost all affected by ABPA are asthmatics
What other group is sometimes affected?
Cystic fibrosis
What occurs initially?
Bronchospasm and bronchial wall edema, just like their asthma causes
What occurs in late stage ABPA?
Bronchial wall damage
What does this result in?
Bronchiectasis


Pulmonary fibrosis
What is treatment for ABPA?
Oral steroids
What is the most common radiographic finding?
Fleeting pulmonary opacities
What is the HALLMARK radiographic feature?
Central, upper lobe, saccular bronchiectasis with associated mucus plugging
What is this classic appearance called on CXR?
finger in glove
What is seen on CT?
Central upper lobe saccular bronchiectasis with mucus plugging and associated bronchial wall thickening
What occurs if ABPA is not appropriately treated?
Goes on to pulmonary fibrosis
Where does the fibrosis occur?
Mainly upper lobes, the same part involved with bronchiectasis
What is another feature sometimes associated with ABPA?
Cavitation in 10% of cases
What is required for aspergilloma to occur?
Preexisting lung cavity or bulla
What lesions typically cause such cavities?
TB


End stage sarcoid
What about bullae?
Emphysema
Where do most fungus balls occur?
Upper lobes
What is treatment for fungus ball?
Surgical resection of fungus ball and intracavitary amphotericin
What is appearance?
Intracavitary mass.
What may be seen specific to aspergilloma?
Lucent ring surrounding the ball
What can this be confused with?
Air-crescent sign of invasive aspergillosis.
How do you differentiate the two?
1) Clinical history (i.e. patient immunocompromised? Very sick?)


2) Air crescent doesn't go all the way around like air around a fungus ball does
What is seen around aspergilloma cavity?
Small rind of consolidation
What else is seen?
Adjacent pleural thickening
What is HALLMARK of aspergilloma?
Fungus ball moves with positional changes
What is progression of invasive aspergillosis?
Starts with endobronchial fungal proliferation.
What does this lead to?
Vascular invasion with thrombosis and infarction of lung
What is this type of infection called?
Angioinvasive
When invasion of vessels occurs, what happens?
Hematogenous spread
To where?
Brain


Liver


Kidney


GI tract
What is characteristic initial radiographic feature of invasive aspergillosis?
Multiple pulmonary nodules
On CT, what is the characteristic associated feature of the nodules that is seen?
Halo of ground glass
What does this represent?
Pulmonary hemorrhage
What is the characteristic change in the lesion that occurs?
Cavitation
When do the lesions cavitate by?
2 weeks
What is the characteristic finding in invasive aspergillosis that signifies reparative phase?
Air crescent sign
Is the sign specific to aspergillosis?
No
What is the DDx for air crescent sign?
TB


Septic emboli


Tumor


Actino


Mucor
What are the nonspecific findings also seen in invasive aspergillosis?
Focal consolidations


Peribronchial opacity
What is prognosis of invasive aspergillosis
Very poor. 70% to 90% mortality
What is treatment?
Amphotericin, systemic and intracavitary
Who is at risk for semi-invasive aspergillosis?
Diabetics, alchoholics, COPDers, malnourished, pneumoconiotics.
What is difference between this and regular invasive form?
Progresses more slowly (doesn't cavitate until 6 months, versus 2 weeks!)


Lower mortality (30%)
What is imaging appearance?
Same as invasive, just slower progression
Where is cryptococcus primarily endemic?
Not endemic to one region. Found everywhere.
Who gets infected with crypto?
AIDS


Lymphoma patients


Diabetics


Steroid therapy
What are the 3 most common appearances of crypto lung disease?
Pulmonary mass


Multiple nodules


Lobar or segmental consolidation
What does not occur in crypto?
Cavitation


Adenopathy


Effusion
What patients get candidal pneumonia?
Lymphoma/leukemia patients


Bone marrow transplant patients
What are plain film findings?
Nonspecific opacities, usually lower lobe.
What is appearance of mucormycosis?
Similar to invasive aspergillosis, because also angioinvasive
What are characteristics of AIDS?
1) Lymphadenopathy (Think of CT of axilla with Gordon)


2) Opportunistic infections


3) Tumors
What are the infections associated with AIDS: Most common?
PCP
What percent of AIDS related opportunistic infection does PCP represent?
70
What CD4 count is needed to get PCP?
<200
What percent of AIDS related infx is mycobacterial infx (TB, MAI)?
20%
What CD4 count is needed for MAI?
<50
What percent of AIDS related infx are bacterial pneumonia?
10%
What are other AIDS defining infections?
Fungal infx (5%)


Nocardia (5%)
What tumors do AIDS patients get?
Kaposi Sarcoma


Lymphoma
What can not exclude PCP?
A normal CXR
What does CMV infection do to AIDS patients?
Nothing much, just high titers
When is CT indicated in AIDS patient?
1) Symptomatic patient with normal CXR


2) Confusing CXR


3) Work up of focal opacities, adenopathy, or nodules
What is top 3 DDx for lung nodules in AIDS patient?
Septic infarcts/necrotizing pneumonia


Kaposi Sarcoma


Fungal disease
What defines septic infarcts?
Rapid increase in size
What fungal diseases present with nodular pattern in AIDS?
Aspergillosis


Crypto
What is top 3 DDx of large opacity in AIDS?
1) Pneumonia (incl TB)


2) Non-Hodgkins pneumonia


3) Hemorrhage
What is top 3 DDx of linear interstitial opacities in AIDS?
1) PCP


2) Atypical mycobacteria


3) Kaposi
Top 3 for lymphadenopathy in AIDS?
AIDS itself can probaby do it.


1) Mycobacterial


2) Kaposi


3) Lymphoma
Top 3 for pleural effusion?
1) Kaposi


2) Mycobacterial or fungal


3) Pyogenic empyema
What percent of PCP has normal CXR?
10
What is appearance of PCP on HRCT?
Ground glass opacity with cystic changes
What does MAI usually cause?
Extrathoracic disease
What is most salient difference in appearance of TB in AIDS versus immunocompetent?
Prominent mediastinal adenopathy
What is DDx for mediastinal lymphadenopathy in AIDS?
Mycobacterial (TB, MAI)

KS

Lymphoma
How do you differentiate infection from tumor in AIDS patients on CT?
MAI and TB have low attenuation centers, and only exhibit rim enhancement.


Adenopathy in lymphoma enhances uniformly, unless treated.


KS enhances uniformly.
What is another finding more common in AIDS related TB?
Pleural effusion
What is appearance o/w?
Same as regular, with upper lobe consolidations and cavitations.
What percent of AIDS patients get fungal infection?
Less than 5%, so quite uncommon
What is the most common systemic fungal infection in AIDS?
Cryptococcus
What organ system does cryptococcosis usually involve in AIDS patients?
CNS
What percent of crypto patients have CNS involvement?
90%!
What are the other two systemic fungal infections in AIDS?
Histo


Coccidiomycosis
What are the most common tumors in AIDS?
Kaposi (most common)


Lymphoma (more uncommon)
What percent of AIDS patients get lymphoma?
About 5%
What always precedes pulmonary Kaposi sarcoma?
Cutaneous (and visceral) involvement
What is most common pulmonary appearance in KS?
Nodules
How big are the KS nodules?
1-3 cm
How many nodules are seen?
Usually multiple, but can be single
What is another appearance of KS?
Coarse linear opacities emanating from hilum
What percent of KS has pleural effusion?
40%
What is another parenchymal finding seen in KS?
Lymphangitic spread of tumor
What are auxilliary findings often seen in KS?
Pleural effusion



Adenopathy
What is appearance of AIDS related lymphoma in lungs?
Solitary or multiple pulmonary masses
What is an associated finding seen in 25% of cases?
Air bronchogram
What is not much seen in pulmonary lymphoma?
Lymphadenopathy
Why?
AIDS related lymphoma is an extranodal disease
What are organ systems involved typically by AIDS related lymphoma?
CNS


GI tract


Liver


Bone marrow
What is a common auxilliary finding in AIDS related lymphoma?
Pleural effusion
What interstitial lung disease is common in pediatric AIDS patients?
Lymphoid interstitial pneumonia
What is appearance of lymphoid interstitial pneumonia?
Diffuse reticulonodular pattern
When a neoplasm is seen in the throax, what basic categorization is made?
Primary location
What are the choices?
Lung


Mediastinum


Pleura


Airway


Chest wall
What are the broad categories of lung tumors?
Malignant


Low grade malignancies


Benign
Which is more uncommon: Benign or malignant lung tumors?
Benign
What is the only really important benign tumor?
Hamartoma
Where are they located?
Peripherally in lung
What is the general appearance?
Well circumscribed
What features are diagnostic of hamartoma on CXR?
Popcorn calcification
What percent of hamartomas have popcorn calcs?
Only 20%
So how is the diagnosis made?
When solitary pulmonary nodule found on CXR or regular CT, you must do thin section CT for characterization.
How is diagnosis of hamartoma made on thin section CT?
Fat attenuation in the lesion is diagnostic. Of course, you must be sure you are not volume averaging soft tissue with adjacent lung.
What are the low grade malignant lung neoplasms?
Carcinoid and tumors that resemble salivary tissue
What is the most common one?
Carcinoid. 90% of low grade malignancies.
What are the names of the ones that resemble salivary tissue?
Adenoid cystic carcinoma


Mucoepidermoid
What did adenoid cystic used to be called?
Cylindroma
What is the most common appearance for carcinoid in the thorax?
Segmental or lobar collapse, or a patient with recurrent episodes of atelectasis. They could develop asthmatic symptoms because of carcinoid syndrome, but this is not so common.
What needs to be seen when you encounter a patient with atelectasis?
Endobronchial evaluation.
What is most common appearance of the carcinoid tumor?
Endobronchial lesion
What is a less common appearance of carcinoid?
Pulmonary nodule.
What are the broad categories of malignant lung tumors?
Bronchogenic carcinoma


Metastatic disease


Lymphoma


Sarcomas (rare)
What are contraindications to percutaneous lung mass biopsy?
Severe COPD


Pulmonary HTN


Coagulopathy


Contralateral pneumonectomy


Suspected echinococcal cyst
Where is the needle passed?
Over top of rib
Where is needle not passed?
Through fissures
What percent get PTX?
25%
What percent of those require a chest tube?
about 25%
What are criteria for chest tube?
Symptomatic PTX


OR


PTX greater than 25%


(So just remember 25%--25% get PTX, 25% of those need chest tube, and max allowed ptx without chest tube is 25%)
What are the varieties of malignant tumors called bronchogenic tumors?
Adenocarcinoma (40%)


SCCA (30%


Small cell CA (15%)


Large cell CA (1%)
What percent of heavy smokers develop lung CA?
10%
What are other risk factors for lung CA?
1) Radiation exposure (radon, uranium miners)


2) Asbestos exposure (remember, it greatly increases risk for bronchogenic CA, which is more likely than mesothelioma to occur)


3) Genetic
What are signs of bronchogenic CA?
Spiculated mass


Cavitating mass (esp SCCA)


Unilateral hilar enlargement


Mediastinal widening
What are secondary signs that should alert you to possibility of malignancy?
Atelectasis


Pneumonia that does not clear


Pleural effusion


Interstitial marking pattern suggestive of lymphangitic spread
When you see a lung cavity, you should include CA in your differential, except when?
When wall is paper thin.
What type of lung cavity is almost definitely CA?
Wall thicker than 1.5 cm
Does air bronchogram seen in a mass exclude neoplasm?
NO. Adenocarcinomas COMMONLY have air bronchograms on CT, and the bronchioloalveolar variety of adenocarcinoma has air bronchgrams on CXR!!!!!
What is a special type of atelectasis that is always due to tumor?
RUL collapse with reverse S sign of Golden. The medial aspect of the collapsed segment is bulkier and presses down on minor fissure. This is due to the mass expanding this area.
What percent of lung CA has a paraneoplastic syndrome?
2%
What are the paraneoplastic syndromes?
Carcinoid syndrome


Cushings's (ACTH prod by SCCA)


SIADH (ADH produced by Small cell)


Hypercalcemia (can be produced by mets, which is expected, but also by parathyroid hormone made by SCCA)


Hypoglycemia (tumor produces insulin like factor).


Migratory thrombophlebitis
Does radiation to lung cause changes?
Yes
When are they seen?
Acute phase--3 weeks


Fibrosis--6mo to 1 year
What are typical symptoms of acute phase?
Asymptomatic usually.


Can have cough/fever.
What is appearance?
Acute: Diffuse opacities in port distribution


Chronic: Lung scarring
What is T staging of lung CA:

T1?
limited to lung and less than 3 cm
T2?
Limited to lung and greater than 3 cm
T3?
Any size tumor with direct extension to any pleural surface (except fissures?). Deep to the pleura, it can involve chest wall, diaphragm, superior sulcus, or pericardium.


OR


Any size tumor within 2 cm of the carina
T4?
Invasion of carina, vertebral bodies, mediastinal organs (i.e. esophagus)

OR

Malignant pleural effusion
What does this mean?
If you have a cancer patient with a pleural effusion, must tap effusion before decision to resect is made.
Why?
Malignant effusion will seed pleura. Then when patient is post-op and in a weakened state, they will deteriorate very quickly.
What is N staging for bronchogenic tumor:

N1?
Ipsilateral HILAR nodes
N2?
Ipsilateral MEDISTINAL or SUBCARINAL nodes
N3?
Nodes CONTRALATERAL to primary


OR


Any SUPRACLAVICULAR node
When are tumors unresectable?
T4


N3


M1
Where are the important anterior mediastinal lymph nodes?
Internal mammary


Prevascular


Cardiophrenic
Why are tumors that involve the carina unresectable when ones that involve a central main bronchus are not?
Because you cant remove both lungs
Where do lung tumors metastasize to most commonly?
Liver


Adrenal


Brain


Also bone and kidney
What are the appearances of bronchioloalveolar carcinoma?
Small peripheral nodule


Multiple nodules


Chronic air space disease
What is most common appearance?
Single nodule
What is not seen in BAC?
Adenopathy
What are appearances of SCCA?
Cavitating mass


Peripheral nodule


Central obstructing lesion causing lobar collapse


Chest wall invasion
What are most common appearances?
Cavitating mass and peripheral nodule
What is presentation of small cell CA usually?
Massive bilateral adenopathy, with or without lobar collapse
What else is typically present?
Brain mets
How does large cell usually present?
Large peripheral mass
What are the ways mets get to the lung, most common to least common.
1) Hematogenous


2) Spread via lymph nodes from elsewhere to posterior mediastinal and paraesophageal nodes, and eventually into lung parenchyma. (Lymphangitic spread)


3) Direct extension
What tumors tend to have lymphangitic spread to the lung?
Breast CA


Stomach


Pancreas


Laryngeal


Cervical
Where are most lung mets, peripheral or central?
90% peripheral
What are margins of mets usually?
Sharp
When they are fuzzy, what does it mean?
Peritumoral hemorrhage
What mets cavitate?
Just like primary of lung, SCCA from head/neck do too.
What lung mets calcify? Broad categories---
Bone tumor mets


Mucinous tumors


Mets post chemotherapy
What bone tumors show calcified mets to lung?
Osteosarcoma


Chondrosarcoma
What are the mucinous tumors that calcify when metastasizing to lung?
Ovarian


Thyroid


Pancreas


Colon


Stomach
What causes cannonball mets?
Head and neck tumors


Breast CA


Colon CA


Renal CA


Testicular/ovarian


Soft tissue tumors
What is sterile metastasis?
A met under treatment with no viable tumor. Made of necrotic and/or fibrous tissue
What is other name for idiopathic pulmonary fibrosis?
UIP (usual interstitial pneumonia)
What is appearance in IPF?
Nonspecific, with changes also occurring in other diseases such as collagen vascular, drug reactions, and pneumoconioses.
What is appearance?
Primarily lower lung zones


Peripheral subpleural involvement
What is early appearance of IPF on HRCT?
early--ground glass


later--reticular pattern, primarily lower lobes


endstage--honeycombing
What else is seen in IPF?
Cardiomegaly due to pulm HTN from loss of so much functional lung
What is appearance of stage 1 sarcoid?
Symmetric hilar adenopathy



Right paratracheal adenopathy
What percent of sarcoid patients have calcified lymph nodes?
5%
What is typical appearance?
Eggshell
What is pulmonary appearance in stage 2?
Reticulonodular pattern or acinar pattern which can coalesce and consolidate
What is stage 4 sarcoid?
Pulmonary fibrosis
What is appearance of stage 4?
Cicitricial changes of upper lobes, like post TB
What can complicate lung disease in sarcoid?
PTX due to blebs


Aspergillus fungus ball
What percent of sarcoid has pleural effusion?
10%
What are CT features of sarcoid?--most common
Nodules along lymphatic distribution
What percent of carcoid with lung dz has this appearance?
90%
What are other appearances?
Linear pattern


Ground glass


subpleural thickening
What are two other CT findings in sarcoid that will almost alway be present?
Adenopathy


Bronchial wall abnormalities
What are the lympoproliferative disorders of the chest?
Accumulation of lymphocytes and plasma cells in the pulm interstitium or mediastinal/hilar nodes.
What are the lymphoproliferative disorders that affect the nodes?
Castleman's dz


Mononucleosis


Angioimmunoblastic lymphadenopathy
What is angioimmunoblastic lymphadenopathy?
Drug hypersensitivity reaction
What are the parenchymal disorders?
Plasma cell granuloma


Pseudolymphoma


Lymphoid interstitial pneumonia
How can you identify left lower lobe atelectasis?
1) Obliteration of the outline of descending aorta


2) Obliteration of medial aspect of left hemidiaphragm
If a mass is seen at the level of the aortic knob, but the knob is still well seen, where do you know it is NOT?
Superior segment of left lower lobe
How do you identify lingular consolidation?
Loss of left cardiac border
When is collapse of the right middle lobe not seen so well on AP view?
When the collapse is of the medial segment of RML.
Where is it seen clearly?
Lateral view.
What is a sign of right middle lobe collapse that is subtle on PA view?
Loss of clarity of right heart border
What are the most common reasons for air bronchogram?
Pneumonia


Pulmonary edema
What are the other causes of air bronchogram?
ARDS/HMD


Nonobstructive atelectasis


Fibrotic scarring


Severe interstitial disease


Certain neoplasms
What are the neoplasms known to cause air bronchograms?
Bronchioloalveolar


Lymphoma
What is CT angiogram sign? (Armstrong, 73)
Branching enhancing vessels coursing through lower density pulmonary consolidation. Looks like liver.
What is DDx for CT angiogram sign?
Pneumonia


Bronchioloalveolar carcinoma


Lymphoma
What are the different types of pulmonary opacities?
1) Airspace filling


2) Atelectasis


3) Mass


4) Line or band shadows


5) Ring shadows (cysts and bullae)


6) Diffuse nodular, reticulonodular and honeycomb shadows
What are appearances of airspace filling?
1) Consolidation


2) Acinar shadows and air alveolograms


3) Ground glass opacity
What is DDx for solitary (solitary meaning just one, but can still be large) airspace filling leisons?
1) Pneumonia


2) Atelectasis


3) Infarct or hemorrhage due to PE.


4) Contusion


5) Neoplasm (if it causes post-obstructive pneumonia or atelectasis)


6) Radiation pneumonitis or fibrosis (conforms precisely to port)


7) Collagen vascular disease (rare to cause solitary airspace lesion)
What varieties of pneumonia cause solitary air space shadow?
All kinds: Bacterial (incl TB), viral, fungal and parasitic.
In adult pneumonia what does associated hilar mass suggest?
Underlying neoplasm causing postobstructive pneumonia
In pediatric pneumonia what does associated hilar mass suggest?
Primary TB
When you see a relatively small airspace opacity, about the size of a segment, and it has a base on the pleura, what does this suggest?
Infarct
When do pulmonary contusions form?
Within hours of injury
When do they clear?
Within a few days
What is a common complicating feature of contusion?
Pneumatocele formation
What if there is chest trauma and within the area of airspace disease there is a mass?
It is a hematoma.
What makes this situation different than regular contusion?
Takes much longer to get better. Can cavitate and get infected.
What a patient with known collagen vascular disease has solitary airspace shadow, what is DDx?
Most likely pneumonia, or sometimes infarct.


Unlikely but possible to be due to underlying disease itself.
What neoplasms can cause focal air space disease?
Bronchioloalveolar



Lymphoma
What suggests one of these diagnoses?
The patient is not presenting with typical pneumonia symptoms, and the "pneumonia" doesn't get better radiographically.
What is the broad differential for multifocal airspace filling lesions?
1) Pulmonary exudates and transudates



2) Hemorrhage



3) Neoplasm



4) Miscellaneous
What falls into the exudate/transudate category?
Pneumonia (including aspiration pneumonia)


Pulmonary edema (both transudative and exudative types)


Toxic inhalation (including hydrocarbon ingestion)


Near drowning


Allergic and drug reactions


Collagen vascular disease


Eosinophilic pneumonia


Alveolar proteinosis


Amyloidosis
What is the exudative variety of pulm edema?
ARDS, due to increased membrane permeability
What are the hemorrhagic causes of multifocal airspace filling lesions
Contusion


PE


Goodpasture's


(Wegener's?)


Anticoagulant therapy
What are neoplastic causes of this appearance?
Lymphangitic spread of metastatic disease



Bronchioloalveolar



Lymphoma
What are miscellaneous causes of this appearance?
Sarcoid



Silicosis



Alveolar microlithiasis
What is the next pattern of airspace filling disease?
Widespread airspace disease
What familiar pattern is present in a type of this?
Bat wing pattern
What are common causes of widespread airspace disease?
Pulmonary edema (both trans and exud)



Pneumonia



Toxic inhalation



Hemorrhage



Alveolar proteinosis
What conditions occasionally cause this pattern?
Drug/allergic reactions



Collagen vasc disease/vasculitis



Lymphangitic spread



Lymphoma



Bronchioloalv CA
What is "bat wing" pattern actually?
Just bilateral perihilar shadowing
What is DDx for sperical conolidative process?
Pneumonia



Neoplasm
What pneumonias are most likely to cause round appearance?
Bacteria, TB, and fungi
What is the DDx of bat wing appearance?
1) Pulm edema



2) Lymphangitic spread of mets



3) Pneumonia



4) Toxic inhalation



5) Aspiration



6) Multifocal pulm hemorrhage
What if bat wing appearance does not go away for few weeks?
Alveolar proteinosis


Neoplasm (lymphangitic spread or BAC or lymphoma)
What is DDx for bat wing appearance with Kerley B lines?
1) Pulm edema



2) Lymphangitic spread



3) Alveolar proteinosis
Patient with sx of pulm edema but normal CXR. What is not the cause?
Not cardiogenic, unless acute heart failure in previously normal person (i.e. papillary muscle rupture, severe acute MI).
Widespread pulm consolidation and patient with hemoptysis. Likely cause?
Pulmonary hemorrhage
What appearance is almost diagnostic of pneumonia
Opacity of more than 1/2 a lobe without volume loss
What is DDx of this?
Bronchioloalveolar CA.
How does bronchioloalveolar CA create its appearance?
Spreading through alveolar spaces without occluding central bronchi
Lobar consolidation with lobar expansion?
Strep pneumo, klebsiella, pseudomonas or staph



Obstructive pneumonia due to CA
What is this appearance called when caused by obstructing neoplasm?
"Drowned lung"
What is DDx of lucencies within consolidated lung?
1) partial resolution



2) Necrosis with cavitation



3) Pneumatocele
Nonsegmental airspace shadows that are clearly peripheral?
Chronic eosinophilic pneumonia
Causes of airspace opacity that resolves, then a new one appearing in same area or different location?
Pulmonary edema



Eosinophilic pneumonia, acute or chronic



Asthma
What type of asthmatic is this most typical of?
Patient with ABPA
What is the classic appearance of ARDS?
Uniform opacity of both lungs without pleural effusion.
What else is often seen in the lungs of these patients?
air bronchograms
What other findings increase the likelihood of ARDS?
PTX


Pneumomediastinum
Back to Weissleder
Back
What lung findings are seen in Castlemans?
None
What is the appearance of plasma cell granuloma?
Solitary pulmonary mass, 1-12 cm.
What is true of its epidemiology?
Most common tumor-like abnormality in kids under 15
What is its growth pattern?
No growth to very slow growth
How often does it calcify?
rare
How do you differentiate lymphoproliferative disorder from lymphoma?
Lympoproliferative disorders will involve either the nodes or the parenchyma, but not both. Lymphoma will affect both the parenchyma and the nodes.
What is the pathology in lymphangioleiomyomatosis?
As the name implies, there is proliferation of smooth muscle cells along the lymphatics.
What is LAM often associated with?
Tuberous sclerosis
What is most important finding?
Lung hyperinflation
What is the most striking finding?
Lung is full of thin walled cystic spaces
What are the collagen vascular diseases that affect the lung?
Rheumatoid


Lupus


Systemic sclerosis


Ankylosing spondylitis