Chest Film Primer Images and Material courtesy of: David S. Feigin, M.D. Colonel (Ret), USA, MC...

Chest Film PrimerChest Film Primer Images and Material Images and Material

courtesy of:courtesy of:David S. Feigin, M.D. David S. Feigin, M.D. Colonel (Ret), USA, MCColonel (Ret), USA, MCProfessor of Radiology, Professor of Radiology,

Uniformed Services University of the Health SciencesUniformed Services University of the Health Sciences““A Systematic Approach To Abnormal Chest A Systematic Approach To Abnormal Chest

Images:Images:Radiographs And Computed Tomograms”Radiographs And Computed Tomograms”

Updates and compilation:Updates and compilation:Les Folio, DO, MPHLes Folio, DO, MPHCol, USAF, MC, SFSCol, USAF, MC, SFS

Associate Professor of Radiology, Associate Professor of Radiology, Uniformed Services University of the Health SciencesUniformed Services University of the Health Sciences

Main MenuMain Menu5 PATTERNS OF

PATHOLOGY

1. Mass

2. Consolidative

3. Interstitial- Linear- Nodular

4. Vascular

5. Airway- Wall-Thickened- Obstructive

EXIT

NORMAL ANATOMY

1. A-P Chest Radiograph

2. Lateral Chest Radiograph

THE SEARCH PATTERN



Normal Anatomy- APNormal Anatomy- AP BACK MAIN MENU FORWARD

1. Gross Specimen

3. Cardiovascular System

A. The CavalsB. The HeartC. The Pulmonary ArteriesE. Aorta

2. The Respiratory System

A. The Airway B. The Lungs and Diaphragm

D. The Pulmonary Veins

3. The Bones, Bowel Gas, Azygous, etc.

RUL, next to minor fissure

RLL

SVC Edge Left paratracheal

stripe

Right Atrium

Left Ventricle

LLL

LUL

RML, next to right heart

border

Normal Anatomy- LateralNormal Anatomy- Lateral BACK MAIN MENU FORWARD

2. Cardiovascular System

1. Respiratory System

A. The AirwayB. The Lungs and Diaphragm

A. The VesselsB. The Heart

3. The Bones (no link yet)

Trachea

Left main bronchus

RLL, with major fissure

RML, with minor fissure

RUL

Right Pulmonary

Artery

Left Pulmonary

Artery

Inferior Vena Cava

Left Ventricle

Right Ventricle

Aorta

1.1. SVC EdgeSVC Edge2.2. Rt Paratracheal LineRt Paratracheal Line3.3. Lt Paratracheal StripeLt Paratracheal Stripe

(both red and black lines)(both red and black lines)

4.4. Aortic ArchAortic Arch5.5. Descending AortaDescending Aorta

(only left edge seen, and not (only left edge seen, and not always)always)

6.6. Rt AtriumRt Atrium7.7. Azygoesophageal edgeAzygoesophageal edge8.8. Lt VentricleLt Ventricle9.9. Main Pulmonary ArteryMain Pulmonary Artery

AKA: trunk, middle mogulAKA: trunk, middle mogul

Mediastinum Mid

Quiz yourself: Mediastinum Lines, Edges

1

2

3

4

56

78

9

Recommendation: Test yourself before advancing to the answers

Left VentricleLeft Ventricle

(curved line)(curved line)

Lateral

IVC (arrows)

Right Pulmonary Artery Right Pulmonary Artery (red) (red)

Left Pulmonary Artery (green)

TracheaTrachea

Lt MSB on endLt MSB on end

Main MenuMain MenuThe 5 PATTERNS OF

PATHOLOGY

1. Mass

2. Consolidative


4. Vascular


EXIT

NORMAL ANATOMY



THE SEARCH PATTERN



Search Pattern- APSearch Pattern- AP BACK MAIN MENU FORWARD

PRELIMINARIESPRELIMINARIES Verify patient info, date, L and R markersVerify patient info, date, L and R markers Note technique deficienciesNote technique deficiencies Quick look at both films for obvious Quick look at both films for obvious

abnormalitiesabnormalities

FRONTALFRONTAL1. LUNGS1. LUNGS

Up and downUp and downSide to sideSide to sideVolume and SymmetryVolume and Symmetry

2. PERIPHERY2. PERIPHERYPneumothorax (air)Pneumothorax (air)Effusions (fluid)Effusions (fluid)

3. MEDIASTINUM3. MEDIASTINUMContoursContoursEdgesEdgesShapeShape

4. TRACHEA AND MAIN BRONCHI4. TRACHEA AND MAIN BRONCHI5. HILA5. HILA

EnlargementEnlargementAbnormal bulgesAbnormal bulges

6. PERIPHERY OF CHEST6. PERIPHERY OF CHESTNeckNeckChest wall and bonesChest wall and bonesDiaphragmsDiaphragmsUpper abdomenUpper abdomen

Search Pattern- LateralSearch Pattern- Lateral BACK MAIN MENU FORWARD

PRELIMINARIESPRELIMINARIES Verify patient info, date, L and R Verify patient info, date, L and R

markersmarkers Note technique deficienciesNote technique deficiencies Quick look at both films for Quick look at both films for

obvious abnormalitiesobvious abnormalities

LATERALLATERAL1.1. SIZE AND SHAPE OF SIZE AND SHAPE OF

LUNGS AND DIAPHRAGMSLUNGS AND DIAPHRAGMS2.2. AIRWAYAIRWAY

Neck to HilumNeck to HilumPulmonary ArteriesPulmonary Arteries

3.3. Back of heart and darkening Back of heart and darkening downwarddownward

4.4. Up anterior mediastinum for Up anterior mediastinum for darkeningdarkening

5.5. Down spine for vertebral Down spine for vertebral bodies and darkeningbodies and darkening

6.6. PERIPHERYPERIPHERYAbdomenAbdomenAnterior chest wallAnterior chest wallPosterior ribsPosterior ribsCostophrenic anglesCostophrenic angles

Main MenuMain Menu5 PATTERNS OF

PATHOLOGY

1. Mass

2. Consolidative


4. Vascular


EXIT

NORMAL ANATOMY



THE SEARCH PATTERN



1. Mass1. Mass MechanismMechanism - Local - Local

destruction of lung destruction of lung parenchymaparenchyma

Radiological signRadiological sign - - Any localized Any localized opacity not opacity not completely bordered completely bordered by by fissures or pleurafissures or pleura

BACK MAIN MENU FORWARD

1. Mass1. Mass Differential DiagnosisDifferential Diagnosis

MalignancyMalignancy - Primary or secondary - Primary or secondary Granulomatous diseaseGranulomatous disease - Infectious or - Infectious or

noninfectious, active or inactive noninfectious, active or inactive Other Other inflammation, including pneumonia and inflammation, including pneumonia and

abscess, Benign neoplasm, Congenital abnormalityabscess, Benign neoplasm, Congenital abnormality

Crucial appearance characteristics for Crucial appearance characteristics for inactivityinactivity Calcification – central, lamellarCalcification – central, lamellar Evolution – 2-year stability or regressionEvolution – 2-year stability or regression


2. Consolidative (Alveolar) 2. Consolidative (Alveolar) PatternPattern

MechanismMechanism Produced in pure form and by Produced in pure form and by ALVEOLAR ALVEOLAR

FILLINGFILLING May be mimicked by alveolar collapse, as in airway May be mimicked by alveolar collapse, as in airway

obstructionobstruction Rarely, confluent interstitial thickeningRarely, confluent interstitial thickening

Radiological signsRadiological signs Fluffy, cloud-like, coalescent opacitiesFluffy, cloud-like, coalescent opacities Sharp edges when limited by fissures or pleuraSharp edges when limited by fissures or pleura Complete air bronchograms through the cloudsComplete air bronchograms through the clouds


Fluffy and cloud-like appearance

Air bronchograms THROUGH clouds


Air bronchogram

Normal lung

Consolidated lung, with air in bronchioles


2. Consolidative (alveolar) 2. Consolidative (alveolar) PatternPattern

Differential Diagnosis (5 general)Differential Diagnosis (5 general) HemorrhageHemorrhage - - BLOODBLOOD - embolism, trauma - embolism, trauma ExudateExudate - - PUSPUS - pneumonia, pneumonitis - pneumonia, pneumonitis TransudateTransudate - - WATERWATER - congestion, ARDS - congestion, ARDS SecretionsSecretions - - PROTEINPROTEIN - Mucous plugging, - Mucous plugging,

Alveolar proteinosisAlveolar proteinosis MalignancyMalignancy - - CELLSCELLS - Alveolar cell - Alveolar cell

carcinoma, Lymphomacarcinoma, Lymphoma


3. Interstitial Pattern3. Interstitial Pattern

Composition of pulmonary interstitium:Composition of pulmonary interstitium: Alveolar walls, septiAlveolar walls, septi Connective tissue surrounding bronchi Connective tissue surrounding bronchi

and vessels (peribronchial and and vessels (peribronchial and perivascular spaces) perivascular spaces)

MechanismMechanism Thickening of lung intersticesThickening of lung interstices Architectural destruction of interstitium Architectural destruction of interstitium

(honeycomb or “end stage” lung)(honeycomb or “end stage” lung)



Radiological Signs:Radiological Signs: Linear formLinear form - reticulations (lines in all - reticulations (lines in all

directions), septal lines (Kerley lines)directions), septal lines (Kerley lines) Nodular formNodular form - small, sharp, - small, sharp,

numerous, evenly distributed, uniform numerous, evenly distributed, uniform (especially uniform in shape) nodules(especially uniform in shape) nodules

Destructive formDestructive form - peripheral, - peripheral, irregular cyst formationirregular cyst formation


Reticular form (Lines in all directions)

Kerley B lines (horizontal septal)


3. Interstitial Pattern – 3. Interstitial Pattern – Linear FormLinear Form

Differential Diagnosis: The “LIFE Differential Diagnosis: The “LIFE Lines”Lines” Lymphangitic spread of malignancyLymphangitic spread of malignancy InflammationInflammation FibrosisFibrosis EdemaEdema


Multiple small nodules, uniform in shape and distribution


3. Interstitial Pattern- 3. Interstitial Pattern- Nodular FormNodular Form

Differential DiagnosisDifferential Diagnosis1. Granulomas

2. Hematogenous Spread of Malignancy3. Pneumoconiosus

Granulomatous Diseases:Infectious

TuberculosisAtypical mycobacterial diseases -

especially MAIFungal diseases, especially:

HistoplasmosisCoccidioidomycosisBlastomycosis (N. A. and S.

A.)CryptococcosisSporotrichosis

Bacterial diseases, especially:NocardiosisActinomycosis

Non-infectiousSarcoidosisHypersensitivity Pneumonitis (HP)Vasculitis-granulomatosis diseases

Wegener’sLymphocyticBronchocentric

Allergic (Churg-Strauss)Langerhans Granulomatosis

(eosinophilic granuloma, histiocytosis)

(LCG)

PneumoconioususGranulomatous

SilicosisBerylliosis

“Benign”Coal Worker’s PneumoconiosisSiderosisStannosis


Peripheral cyst formation, ‘Honeycomb’ lung

Early findings are non-specific. The

peripheral cyst formation (“End-Stage Lung”) is a

late finding.


4. Vascular Patterns4. Vascular Patterns

MechanismMechanism - increased, or - increased, or decreaseddecreasedperfusion, altering diameter of perfusion, altering diameter of pulmonarypulmonaryvesselsvessels

Radiological signs Radiological signs - changes in - changes in diameterdiameterof specific vesselsof specific vessels


4. Vascular Patterns4. Vascular Patterns

Common examplesCommon examples CongestionCongestion - engorged veins, especially upper lungs- engorged veins, especially upper lungs EmphysemaEmphysema - diminished vessels - diminished vessels Shunt vascularityShunt vascularity - all vessels enlarged - all vessels enlarged Lymphangitic carcinomaLymphangitic carcinoma - irregular infiltration - irregular infiltration

around vessels may resemble vessel enlargementaround vessels may resemble vessel enlargement Arterial hypertensionArterial hypertension - large central arteries with - large central arteries with

peripheral taperingperipheral tapering ThromboembolismThromboembolism - locally diminished vessels with - locally diminished vessels with

possible vessel mass centrally locatedpossible vessel mass centrally located Bronchial circulationBronchial circulation - irregular vessels in unusual - irregular vessels in unusual

directionsdirections


Congested vasculature

Engorged vessels, especially upper lungs


Emphysematous changes

Diminished vasculature


Enlarged pulmonary trunk (“middle mogul”)

Prominent left pulmonary artery


5. Airway (Bronchial) 5. Airway (Bronchial) PatternsPatterns

MechanismMechanism Complete or partial obstruction of airwaysComplete or partial obstruction of airways Thickening of airway wallsThickening of airway walls

FormsForms Complete airway obstructionComplete airway obstruction - opacity and - opacity and

decreased volumedecreased volume Partial obstructionPartial obstruction - lucency and increased - lucency and increased

volumevolume Wall thickeningWall thickening - tram tracks, central cystic - tram tracks, central cystic

spaces or circlesspaces or circles


Bronchial wall thickening (circles and “tram tracks”)

Flattened diaphragms on lateral


Differential diagnosisDifferential diagnosis OpacitiesOpacities - endobronchial malignancies, - endobronchial malignancies,

granulomas, inflammatory, benign or granulomas, inflammatory, benign or congenital masses, mucous plugs, foreign congenital masses, mucous plugs, foreign bodiesbodies

LucenciesLucencies - COPD, cysts, blebs, - COPD, cysts, blebs, pneumatocelespneumatoceles

ThickeningThickening - bronchiectasis, chronic - bronchiectasis, chronic bronchitisbronchitis

BACK MAIN MENU FORWARD 5. Airway (Bronchial) 5. Airway (Bronchial)

PatternsPatterns

5. Airway (Bronchial) 5. Airway (Bronchial) PatternsPatterns

Lobar atelectasis (collapse)Lobar atelectasis (collapse) Primary SignsPrimary Signs

Vessel number assymetryVessel number assymetry Fissure as edgeFissure as edge

Secondary signsSecondary signs Volume lossVolume loss Elevation of diaphragmElevation of diaphragm Shift of mediastinum and ribsShift of mediastinum and ribs


Right Left

Upper

Lower

Atelectasis Atelectasis PatternsPatterns

RLL

RUL

LLL

LUL

Left lower lung collapse

Vessel Asymmetry

BACK MAIN MENU EXIT

Chest Film Primer Images and Material courtesy of: David S. Feigin, M.D. Colonel (Ret), USA, MC...

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Transcript of Chest Film Primer Images and Material courtesy of: David S. Feigin, M.D. Colonel (Ret), USA, MC...