1、Diagnostic Radiology of Respiratory SystemLEARNING OBJECTIVES Master degree (*): X-ray and CT appearance of pneumonia, pulmonary tuberculosis and lung cancerCommon imaging methodsa. Chest plain filming b. Computed tomography (CT) CTPlain filmDifference between X-ray plain filming and CTChest plain f
2、ilmimgRightLeft Normal chest CTCommon abnormal imaging patterns and lesionsa.Atelectasisb.Consolidationc.Noduled.Masse.Calcificationf.Cavityg.Interstitial lesionh.Pleural effusioni.Pneumothoraxj.Pleural thickening and calcificationDiagnosis of Common Disease (I) Inflammatory lesions:-Bronchiectasis-
3、Pneumonia & abscess-TuberculosisBronchiectasis BronchiectasisClinical features Production of large volumes of purulent sputum Recurrent haemoptysis Frequent infective exacerbation BronchiectasisTypes of bronchiectasis（*）：）：(a) Cylindrical bronchiectasis(b) Varicose bronchiectasis(c) Cystic bronchiec
4、tasisBronchiectasisBronchiectasisCystic bronchiectasisCylindrical dilationdense infiltration of the both lungBronchiectasisshows dilated bronchi and bronchioles, forming a “cluster of grapes” Signet ring signnormalarterybronchus“cluster of grapes” Pneumonia-infective consolidation of the lungClassif
5、ication by anatomy (*) l Lobar pneumonial Lobular pneumonial Interstitial pneumoniaLobar pneumonia Causes pneumococcus（usually）Clinical manifestation Commonest in young and adults sudden onset high fever(39) shaking chill cough with rusty color sputum Lobar pneumonia Divided into 4 stages (*) :(1)Co
6、ngestive stage (in 24h after onset )(2)Red consolidation stage(3)Gray consolidation stage(4)Resolution stage (2 weeks)X-ray findings (*) The typical radiological pattern Air-space consolidation involving an entire lobe Air bronchogram signhomogeneous air-space consolidation involving the entire righ
7、t lower lobeLobar pneumonia Air bronchogram signCauses Staphylococcus aureus Gram-negativeorganisms such as Pseudomonas aeruginosaClinical manifestations History of acute bronchitis Commonly seen in children and eldly people， or the patients with predisposing factor . Fever Productive cough, Infecte
8、d (yellow or green) sputum. Corse crepitations Dullness to percussion Bronchial breathingPathological changes Lobular consolidation Edema and thickening of walls of the smaller bronchioles.X-ray findings (*) A scattered appearance of heterogeneous or homogeneous opacities incomplete resolution ：fibr
9、osisill-defined，scattered appearance，heterogeneous shadowsmultifocal areas of consolidationInterstitial pneumonia-Involvement of the interstitial tissue of lungs-Occurs around the bronchial tree, blood vessels , the alveolar septa, and interlobular setpa.X-ray findings (*) Linear, reticular, or hone
10、ycombing shadows in both lung fields.Interstitial pneumoniastreak-like and reticular, net-like shadows Interstitial pneumoniaHoneycombing pattern. traction bronchiectasis sub-pleuralcystsPulmonary abscess- Focal areas of necrosis caused by various suppurative inflammation, then develops lung abscess
11、Pathways Aspirated Haematogenous InfectiveClinical manifestations Fever, shaking chill, foul smelling sputum.Acute stage Exudative and consolidative shadow.Subacute stage Abscess cavity with fluid level; The wall thick and irregular.Chronic stage Thick and well-defined wall;.l al bl cPulmonary absce
12、ssPulmonary abscess *air-fluid levelPulmonary tuberculosis (*) Causes:Mycobacterium tuberculosis affects predominantly the lungs, lumph nodes and gut.Classic Symptoms：Fever，night sweets and coughSome features of the disease vary with the patients sensitivity to tuberculin.Pulmonary tuberculosis Clas
13、sification (*) Type I Primary pulmonary TBType II Hemo-disseminated pulmonary TBType III Post-primary pulmonary TBType IV Tuberculous pleuritisType V Other Primary pulmonary TB (Type I)-infection with M.tuberculosis in nonsensitive patients（in children and young people）those who have not previously
14、been infected.Pathology(*) Primary focus Lymphangitis LymphadenitisPrimary complex (*) Definition - the combination of the primary pulmonary tuberculous focus，lymphangitis and intrathoracic lymphadenitisX-ray Findings (*) Consolidation/exudation in the lung （ pulmonary tuberculous focus ） Ipsilatera
15、l enlargement of hilar/mediastinal lymph nodes（ lymphadenitis ） Streaky shadows leading from the exudation to the hilar（ lymphangitis ） “Dumbbell-like” signA: a man with fever, hemoptysis, and weight loss ,shows bilateral patchy airspace opacities, with areas of cavitation in the upper lobes (arrows
16、). B: 9 months later shows changes of healing in upper lobes consisting of linear opacities (straight arrow) and thin-walled cavities (curved arrows).Primary tuberculosis AB CT shows the enlargement of hilar with amounts of enlarged ，necrotic and low-density lymph nodesIntrathoracic lymph node TBHem
17、o-disseminated pulmonary TB (Type II)Two types： Acute miliary TB Subacute or chronic disseminated TB X-ray Findings(*) a lot of fine，pin-point mottling opacities，with same size， same density and diffused distributionHemo-disseminated pulmonary TB (Type II)Acute miliary TB shows diffuse small nodules
18、 in the right lung, and cavitary disease on the leftresult of hematogenous spreadPost-primary pulmonary TB(Type III)most common type， chiefly in adultsX-ray findings Caseous lesion encapsulated by connective tissue. Round, solitary nodules; Commonly in the apical regions; Associated “satellite” lesi
19、onPost-primary pulmonary TB(Type III)cavity and “satellite” lesionType I Primary pulmonary TBType II Hemo-disseminated pulmonary TBType III Post-primary pulmonary TBType IV Tuberculous pleuritisType V Other Diagnosis of Common Disease (II) Tumor like lesions:-Primary lung cancer : Primary Bronchogen
20、ic carcinoma)-Secondary lung cancer :Metastatic pulmonary tumors)Primary Bronchogenic carcinoma *Histology (*) Squamous cell carcinoma（commonest） Adenocarcinoma Small cell carcinoma Large cell anaplastic carcinomaBronchogenic carcinoma*Classification by position (*) Central bronchogenic carcinoma Pe
21、ripheral bronchogenic carcinoma Diffuse bronchogenic carcinomaCentral bronchogenic carcinoma- originated from main bronchi，lobar bronchi or segmental bronchi and located in the area of hilumX-ray Findings (*) Direct sign：hilar massIndirect signs： Obstructive emphysema Obstructive pneumonitis Obstruc
22、tive atelectasis enlargement of hilar/ mediastinal lymph nodesChest radiographs of a 46y woman with symptoms of pneumonia show a mass in the left upper lobe. CT shows a 7.8-cm mass arising from the left upper lobe bronchus (arrow) Central tumorA: PA chest radiograph of a 48y man shows an irregular m
23、ass in the right upper lobe abutting the mediastinum.CT shows the mass extending into the mediastinum. The center of the mass is of low attenuation, secondary to tumor necrosis. CT with lung windowing shows the spiculated mass Central tumor Reverse S Sign（Gloden S sign）Right upper lobe bronchus is o
24、bstructed by an endo-bronchial mass, causing collapse of the right upper lobe, the minor fissure is elevated.: Shape of a reverse S。 Central tumorcollapse of the right lungPeripheral bronchogenic carcinoma-located in the peripheral lung fieldX-ray Findings (*) Direct sign： Mass or nodule-like lesion
25、s Homogeneous density hazy or lobulated, notched，spiculated margin mass with eccentric and irregular cavityIndirect signs：enlargement of hilar/mediastinal lymph nodes PA chest radiograph of a 72-y man with a 53 year history of smoking shows a mass in the right upper lobe. CT shows a spiculated mass.
26、 Peripheral bronchogenic carcinoma spiculated massCT scan shows a lobulated, spiculated nodule in the right upper lobe (arrow).Peripheral bronchogenic carcinoma Lobulated lesionMetastatic pulmonary tumors（secondary） Sources： The breast, colon, kidney, uterus, prostate, head and neck. Choriocarcinoma
27、,osteosarcoma,Ewings sarcoma, testicular tumours,melanoma and thyroid carcinoma. X-ray findings multiple nodules predominantly distributed in the periphery of the lungs. Usually well-defined outlines Lymphangeitis - beading changes Metastatic pulmonary tumorsnumerous bilateral well-defined nodules o
28、f varying sizesTesticular carcinoma multiple well defined and various size nodules in both lungs come from hepatic carcinoma brief summaryDiseasesX ray featuresBronchiectasisSignet ring sign, cluster of grapesPneumoniaAir bronchogram signPulmonary abscessCavity with fluid levelPrimary complex TB“Dum
29、bbell-like” signAcute miliary TB a lot of fine，pin-point mottling opacities，with same size and same densityCentral bronchogenic carcinoma causing collapse of the right upper lobeReverse S SignMetastatic pulmonary tumorsnumerous bilateral well-defined nodules of varying sizeshttp:/www.radiologyassistant.nl/
