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Chest review – Flashcards

William Hopper

7 July 2022

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Abscess

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Risk factors Smoking (70-80%) Immunodeficiency Bronchiectasis Malignancy (lung cancer in 12%) COPD Steroids Aspiration Decreased level of consciousness Seizures Alcohol abuse Swallowing disorders Mechanical ventilation Imaging Thick, irregular wall Thickness > 15 mm suggests neoplasm Spherical Small contact with chest wall Bronchovascular markings extend to margin Air-fluid levels (indicates bronchial communication) Same AP and lateral dimensions

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Acute interstitial pneumonia (AIP)

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Hammon-Rich disease Rapidly progressive organizing form of diffuse alveolar damage with intersitial pulmonary fibrosis Clinical Often history of prior illness suggestive of viral URI Worsening dyspnea, hypoxemia, respiratory failure Deterioratoin over days to weeks Mortality: 50-100% Mean age: 50 years Histology Diffuse alveolar damage Exudative phase: injury to alveolar lining and endothelial cells results in pulmonary edema, inflammation, and hyaline membrane formation Organizing phase: loose fibrosis and type II pneumocyte hyperplasia Survivors may have significant residual parenchymal abnormalities Etiology Always idiopathic Diagnosis of exclusion (rule out infection, toxin, drug exposure) May represent idiopathic form of ARDS Radiograph Resembles ARDS Most patients are intubated Diffuse airspace opacification Spares costophrenic angles CT Early exudative phase Patchy bilateral ground glass opacities Consolidation in dependent zones Focal areas of sparing Late organizing phase Consolidation replaced by ground glass opacities Traction bronchiectasis and architectural distortion: indicates fibrosis with poor prognosis

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Adenocarcinoma

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40% of lung cancer (most common NSCLC) Increased risk with smoking but may not be related to smoking Peripheral origin; alveolar surface epithelium of bronchial mucosal glands May arise in scar tissue: scar carcinoma (rare) Slow growth, early metastases Imaging Peripheral (75%) Solitary mass or nodule More common in upper lobes and on the right Spiculated or lobulated Obstructive pneumonitis (25%) Most have air bronchograms

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Adenoid cystic carcinoma

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Synonym: cylindroma Epidemiology 2nd most common tracheal malignancy (after SCC) 20-35% of tracheal tumors Demographics Average age 40-50 M=F Clinical Cough, wheezing, dyspnea, hemoptysis Pathology Endotracheal, endobronchial mass Sessile, polypoid, or annular growth Proximal to distal spread Surrounds and invades nerves Encases vessels Imaging Mass within trachea or main bronchi 10-15% in lung periphery

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Alpha-1-antitrypsin deficiency

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Pathology Alpha-1-antitrypsin inactivates neutrophil elastase Production controlled by two genes Deficiency leads to lung destruction Smoking accelerates destruction Imaging Panacinar emphysema Bronchiectasis Airway thickening

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Alveolar microlithiasis

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Pathology Diffuse intra-alveolar laminated calcium deposits Autosomal recessive in 50% Clinical Often asymptomatic (70%) despite gross radiographic abnormalities Cough, dyspnea Demographics Age 30-50 (mean 35 years) F > M in familial; M > F in sporadic Natural history and prognosis Slow progression may result in respiratory and cardiac failure Location Bilateral, symmetric Peripheral, basal portions of lower lobes Anterolateral portions of RML, lingula Anterior portion of upper lobes Imaging Ground glass opacities in early disease Micronodular discrete calcifications Polygonal shaped densities from calcificied interlobular septal thickening Calcifications along septa, bronchovascular bundles Small cysts from emphysema Black pleural line: extrapleural fat, subpleural cysts

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Alveolar proteinosis

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Pathology Proteinaceous, lipid-rich surfactant from type II pneumocytes accumulates in alveoli Unknown etiology Associations Silicosis Myeloproliferative disorders Lymphoma Immunodeficiency states Clinical Extensive sputum production (liters/day) May be asymptomatic Demographics Adults 20-50 years M > F (2:1) Complications Nocardiosis Aspergillosis Cryptococcosis Lymphoma Findings Multifocal consolidation (looks worse than clinical symptoms) Central "bat-wing" distribution similar to pulmonary edema Crazy paving on CT: multifocal, panlobular ground glass and airspace opacities with septal thickenig Sharp demarcation between normal and abnormal lung Findings of superimposed opportunistic infection Treatment Whole lung lavage: 25-50L saline (therapy of choice) Aerosollized proteolytic agents Prognosis After lavage, 70% remain symptom-free at 7 years

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Amyloidosis

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Tracheobronchial Focal or diffuse tracheal thickening Mural nodules Submucosal calcifications Strictures Nodular parenchymal Multiple sharply-marginated peripheral nodules Rare cavitation Calcification (20%) Alveolar septal Perilymphatic nodules Subpleural Septal Peribronchovascular Patchy distributuion Resembles sarcoidosis Nodules often calcified Consolidation Interlobular septal thickening, reticulation Honeycombing Pleural Irregular pleural thickening, calcifications Adenopathy Multiple lymph node groups Stippled, diffuse, or eggshell calcifications Cardiac Cardiomegaly

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Ankylosing spondylitis

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Lungs Upper lobe fibrosis with traction bronchiectasis Cystic air spaces, cavities Mycetoma within cysts, cavities Pleura Pleural thickening and effusion Pneumothorax Aorta Aortic regurgitation and aortic dilatation Heart Cardiomyopathy Skeletal Ankylosis Squared vertebral bodies, shiny corners, syndesmophytes Calcification, ossification of paraspinal ligaments

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Apical cap (5)

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Pancoast tumor Lymphoma extending from neck or mediastinum Hematoma Abscess within neck Radiation fibrosis

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Asbestos

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Mineralogy Naturally occurring mineral fibers Flexible and strong Resistant to heat, corrossives, and electricity Fiber types Serpentine Example: chrysotile 95% of commercially used fibers Curly and pliable Fragments easily Dissolves easily (chemically unstable) Less pathogenic Amphiboles Examples: amosite, crocidolite, anthophilite, tremolite, and actinolite 5% of commercially used fibers Strong, broad fiber (often coated) Does not fragment easily Long (> 20 um) Higher carcinogenic potential Epidemiology Risk professions: construction and demolition workers, insulation workers, pipe-fitters, shipbuilders, asbestos miners Urban dwellers Asbestos-body Indicates exposure Long fiber which is larger than macrophages Coated with iron and protein (ferruginous body) Beaded or clubbed appearance Cannot be removed to regional lymph nodes Remains in posterior lower lungs Asbestos in lung found in two forms: uncoated fibers or asbestos bodies

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Asbestos-related malignancy

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Malignant mesothelioma 7000x increased risk 10% lifetime risk Latency > 30 years Bronchogenic carcinoma 5-7x increased risk 50-100x if smoke Laryngeal carcinoma GI malignancies 3x increased risk

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Asbestos-related pleural disease

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Pleural effusion Most common abnormality Early manifestation (first 20 years) Usually sterile, serosanguinous exudate Diagnosis of exclusion: rule out malignant mesothelioma, bronchogenic carcinoma, TB Pleural plaque Latency at least 20 years Hyalinized collagen in submesothelial layer of parietal pleura Uncoated asbestos fibers (asbestos bodies absent) Focal interrupted areas of pleural thickening No functional significance Bilateral, posterolateral parietal pleura and central diaphragm Spares apices and costophrenic angles May calcify extensively Only 15% visible by CXR CT most sensitive and specific Diffuse pleural thickening Less frequent than focal plaques May cause respiratory symptoms Diffuse smooth pleural density Criteria >25% length of chest wall 3 mm thickness 8 cm width 5 cm craniocaudal extent Spares mediastinal pleura (mediastinal involvement suggests mesothelioma) Rounded atelectasis Preceded by pleural effusion Fibrotic tethering of lung to parietal pleura prevents focal reexpansion of lung after resolution of pleural effusion Layers of invaginated pleura bound by fibrous adhesions Surrounding atelectatic and fibrotic lung Volume loss Associated pleural plaques and pleural thickening Broad area of pleural contact Swirling vessels ("comet tail" sign)

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Asbestosis

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Clinical Latency period inversely proportional to exposure level (at least 20 years) Synergistic effect of cigarette smoke Restrictive pulmonary function testing Pathology Associated with asbestos bodies Fibrosis of respiratory bronchioles Progressive involvement of terminal bronchioles, alveolar ducts, and alveolar septa Imaging Lower lobe and posterior predominance Reticulonodular opacities Parenchymal bands Curvilinear subpleural lines Honeycombing Associated pleural disease Need to image prone

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Askin tumor

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Large tumor of chest wall Primitive neuroectodermal tumor (PNET) Demographics Age 20-30 years F > M (1.3 : 1) 9x more common in Caucasians Natural history and prognosis Overall poor survival (38% at 2 years, 14% at 6 years) Metastatic disease (90%) Metastases to lymph nodes, lung, and bone (10%) Extensive necrosis after chemotherapy (pseudo-cystic appearance) Treatment Surgical excision Radiation, chemotherapy

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Aspergilloma

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Pathology Mycetoma, fungus ball Composed of fungus, mucus, inflammatory cells Saprophytic infection Preexisting cavity or bulla TB Enstage sarcoid Emphysema Treatment Surgical resection Intracavitary administration of amphotericin Findings Focal intracavitary mass (3-6 cm), typically in upper lobes Small area of consolidation around cavity Monod sign Air surrounding aspergilloma Mimics crescent sign seen with invasive aspergillosis Adjacent pleural thickening common Fungus ball moves with changing position

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Aspergillosis, allergic bronchopulomonary (ABPA)

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Pathology Complex hypersensitivity reaction (type 1) Almost exclusively in patients with asthma, occasionally cystic fibrosis Initial bronchospasm followed by bronchial wall edema (IgE mediated) Ultimate bronchial wall damage, bronchiectasis, pulmonary fibrosis Clinical Elevated Aspergillus-specific IgE Elevated precipitating IgG against Aspergillus Peripheral eosinophilia Positive skin test Findings Bifurcating opacities (finger in glove) from mucus plugging Hyperdensity from manganese component Lobulated masses Fleeting pulmonary alveolar opacities (common) Central, upper lobe saccular bronchiectasis (hallmark) Bronchial wall thickening Tree-in-bud opacities May progess to pulmonary fibrosis predominating in upper lobe (endstage) Cavitation (10%) Treatment Prednisone

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Aspergillosis, invasive

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Pathology Severely immunocompromised patients (bone marrow transplants, leukemia) Starts with endobronchial fungal proliferation Leads to vascular invasion with thrombosis and infarction (angioinvasive infection) Additional sites of infection (30%) Brain Liver Kidney GI tract Prognosis High mortality (70-90%) Findings Multiple pulmonary nodules (40%) Characteristic halo of ground glass opacity (represents pulmonary hemorrhage) Cavitation within 2 weeks (50%) Air crescent sign indicates recovery phase (increased granulocytic response) Peribronchial opacities Focal areas of consolidation Treatment Amphotericin

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Aspergillosis, semi-invasive

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Mildly immunocompromised Similary pathophysiology as invasive aspergillosis Progresses more chronically over months Risk factors Diabetes Alcoholism Pneumoconioses Malnutrition COPD Connective tissue disease AIDS Findings Upper lobe consolidation progressing to cavitation over months Pleural thickening Nodules Complex internal architecture within cavity Contents of cavity often hyperdense Treatment: amphotericin Mortality 30%

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Atypical adenomatous hyperplasia (AAH)

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Atypical cuboidal epithelium lining alveoli and bronchioles Probable precursor to BAC and adenocarcinoma Patchy ground glass opacity Usually < 5 mm

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Atypical mycobacteria, airways disease

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Clinical Almost exclusively in elderly white women Lady Windermere syndrome No underlying lung disease Chronic, minimally productive cough Imaging Bronchiectasis, distributed mainly in RML and lingula Bilateral multifocal bronchiolitis: centrilobular and tree-in-bud nodules Mosaic attenuation Scarring, volume loss, architectural distortion No cavitation, pleural effusion, extensive adenopathy

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Atypical mycobacteria, fibrocavitary disease

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Clinical Elderly white men Underlying lung disease (COPD, fibrosis) Malaise, fever, weight loss, hemoptysis Chronic, minimally productive cough Imaging Consolidation, masses, nodules Upper lobe predominance Cavitation Feeding bronchus Bronchogenic spread of infection with centrilobular and tree-in-bud nodules Progressive fibrosis and atelectasis of affected areas Bronchiectasis, bronchial wall thickening No lymphadenopathy or pleural effusion

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Atypical mycobacteria, hypersensitivity

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Clinical Hot tub use Aerosolized water in showers Imaging Diffuse centrilobular nodules Ground glass opacities

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Atypical mycobacteria, immunocompromised

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Clinical CD4 < 50 Fever, sweats, weight loss, fatigue, diarrhea, dyspnea Imaging Normal or subtle pulmonary findings Scattered alveolar opacities and centrilobular nodules (most common pattern) Consolidation Miliary disease Lymphadenopathy with low-density necrotic centers Pleural effusions

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Atypical mycobacteria, infection

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Organisms M. avium-intracellulare M. kansasii M. xenopi M. chelonei M. gordoniae M. fortuitum Route of infection Direct infection from soil or water Not acquired by human-human transmission No pattern of primary disease or reactivation Infection is primary and may become chronic Patterns of disease Fibrocavitary disease Airways disease Pneumonia in immunocompromised Hypersensitivity pneumonia

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Berylliosis

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Exposure Used as copper alloy in manufacture of airplane landing gear, electronics, undersea communication cables, and household appliances (air conditioners, fluorescent strip lighting, and electric ranges) Forms of disease Acute toxic chemical pneumonitis Brief exposure of high levels of airborne beryllium Chronic granulomatous disease Cell-mediated hypersensitivity reaction to beryllium bound to tissue proteins Noncaseating granulomas: indistinguishable from sarcoidosis Involves lungs, liver, spleen, lymph nodes, and bone marrow Usually presents 10-20 years after last exposure Clinical: exertional dyspnea and restrictive PFTs Treated with steroids Radiography Diffuse reticulonodular opacities CT Diffuse nodules Occasional conglomerate masses Bronchovascular thickening Fibrosis, traction bronchiectasis in upper lungs Pleural thickening Lymphadenopathy Distinctions between berylliosis and sarcoidosis History of beryllium exposure Positive beryllium transformation test Increased concentration of beryllium in lung or lymph nodes Negative Kveim test

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Blastomycosis

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Consolidation Similar to postprimary TB Upper lobe predominance Usually central, paramediastinal Rounded and ill-defined May be mass-like Air bronchograms Cavitation Nodules Satellite lesions around consolidation May be remote from consolidation Miliary disease Hematogenous dissemination More common than histoplasmosis Associated findings Adenopathy, pleural effusions, calcifications very uncommon Bone lesions (25%) Skin lesions are common

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Bridging bronchus

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Ectopic bronchus arising from left mainstem bronchus Crosses mediastinum to supply RLL

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Bronchial atresia

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Pathology Congenital atresia of segmental bronchus with normal distal architecture Aeration of distal lung through collateral air drift Associated abnormalities Bronchogenic cyst Sequestration CCAM CLE PAPVR Aplastic or hypoplastic lung Pericardial defect Demographics Average age at presentation: 22 years M > F (2:1) Clinical Often asymptomatic Recurrent infections Decreased breath sounds, wheeze over affected segment Imaging Bronchocele Central nodule or mass representing mucoid impaction distal to atretic bronchus Points towards hilum May have air-fluid level Hyperlucent and hypoperfused segment Paucity of vessels Bronchiectasis

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Bronchiectasis, causes

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Congenital Cystic fibrosis Williams-Campbell syndrome Mounier-Kuhn syndrome Kartagener's syndrome Pulmonary sequestration Yellow nail syndrome Infection Childhood infection Chronic granulomatous infection ABPA Measles Pertussis Recurrent aspiration TB MAI Inflammation Sarcoidosis Constrictive bronchiolitis Diffuse panbronchiolitis Bronchial obstruction Neoplasm Enlarged lymph nodes Broncholith Foreign body Bronchial atresia Immune deficiency Radiation Traction Fibrosis Pneumoconiosis

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Bronchiectasis, classification

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Cylindrical Terminal divisions: 20 (normal tracheobronchial tree has 23-24 divisions) Not end-stage Fusiform dilatation Tramlines Signet rings Varicose Terminal divisions: 18 Destroys lung Tortuous dilatation Rare Cystic Terminal divisions: 4 Destroys lung Saccular dilatation String of cysts Air-fluid levels common

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Bronchiectasis, imaging

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Radiography Tramline: horizontal, parallel lines corresponding to thickened, dilated bronchi Bronchial wall thickening (best seen end-on) Indistinctness of central vessels due to peribronchovascular inflammation Atelectasis CT Increased bronchial conspicuity: bronchi seen in outer third of lung Bronchi appear larger than accompanying vessels Bronchial wall thickening Signet ring sign: focally thickened bronchial wall adjacent to pulmonary arterial branch CT has low positive predictive value for mild forms of bronchiectasis: bronchography may be indicated if clinical suspicion is high and CT is negative

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Bronchioloalveolar carcinoma

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Pathology Subtype of adenocarcinoma Slow lepidic growth pattern Alveolar wall intact: spreads through airways No stromal, vascular, or pleural invasion Architecture preserved Types Mucinous Alveolar spaces distended with mucin May present with bronchorrhea Non-mucinous Alveolar fibrosis Alveoli lined by type II cells Patterns Solitary nodule or mass (40%) Focal or diffuse consolidation, ground glass opacity (30%) Air bronchograms Cavitation may be seen Diffuse ill-defined nodules (30%) May be centrilobular due to endobronchial spread May be random mimicking hematogenous metastases

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Bronchogenic cyst

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Abormality of budding and differentiation of primitive foregut Ventral defect containing respiratory epithelium Asymptomatic unless mass effect (usually incidental finding) Location Subcarinal (50%) Paratracheal (20%) Hilar, paracardiac (30%) Imaging Round mass with fluid density and intensity Hyperdensity (40%) may be due to debris, hemorrhage, or infection Imperceptible cyst wall May contain calcification Associated rib anomalies Nonenhancing

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Bronchogenic granulomatosis

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Clinical Dyspnea, cough, fever, malaise, and hemoptysis Peripheral and tissue eosinophilia Pathlogy Mucosal inflammation with histiocytes, eosinophils (asthmatics), and neutrophils (non-asthmatics) Granulomatous destruction of bronchial walls Secondary involvement of adjacent arteries May be associated with fungal infection, TB, RA, and Wegener's granulomatosis Imaging Nodules and consolidation Upper lobe predominance Usually unilateral (75%) Associated findings of ABPA: bronchiectasis, mucoid impaction Treatment and prognosis Asthmatics respond to steroids Some cases remit without treatment Must rule out treatable infection and Wegener's granulomatosis

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Bronchus associated lymphoid tissue (BALT)

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Basis for pulmonary lymphoid disorders Lymphoid collections along bronchioles, interlobular septa, and pleura Absent at birth and in normal adults Common in young children (regresses by age 12) Reappears with antigenic stimulation Cigarette smoke Connective tissue disease AIDS

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Calcifications (6 - broad)`

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Metastases Thyroid carcinoma Mucinous adenocarcinoma Osteogenic tumors Infection Varicella Fungal Tuberculosis Parasitic (schistosomiasis) Pneumoconiosis Silicosis Alveolar microlithiasis Metastatic calcifications (renal failure) Mitral stenosis

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Carcinoid tumor

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Typical carcinoid (80-90%) Low-grade tumor Demographics Age 30-60 F > M Natural history and prognosis Lymph node metastases in 5% 5-year survival 90-95% (without lymph node metastases), 76-88% (with lymph node metastases) Location Main, lobar, or segmental bronchi (85%) 15% peripheral location Tracheal location very rare Imaging Well-defined hilar, perihilar mass May see endobronchial lesion Post-obstructive atelectasis, pneumonia Hyperinflation occasionally seen Calcification in 30% Avid enhancement Atypical carcinoid (10-20%) Intermediate grade tumor Demographics Older (age 40-70) F > M Natural history and prognosis Lymph node metastases in 50-60% 5-year survival 40-70% Liver metastases are very rare (carcinoid syndrome rarely develops) Location Most develop in lung periphery Imaging Well-defined nodule or mass in lung periphery Calcification rare Variable enhancement Associated lymphadenopathy

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Carcinosarcoma

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Pathology Epithelial component SCC Adenocarcinoma Undifferentiated carcinoma Mesenchymal component (usually dominant) Spindle cell Chondrosarcoma Osteosarcoma Rhabdomyosarcoma Demographics Middle-aged, elderly M > F Location Peripheral Large mass (average 6 cm) Frequent necrosis, hemorrhage Central Endobronchial growth resembling mucus plugs May extend into adjacent parenchyma, pleura, chest wall, mediastinum Atelectasis, pneumonia

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Cardiac bronchus

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Distinct airway originating from medial wall of right mainstem bronchus or bronchus intermedius Cephalic to origin of RML bronchus Located in azygo-esophageal recess Cardiac lobulus demarcated from RLL by anomalous fissure Associated with consolidation

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Castleman's disease

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Angiofollicular hyperplasia Benign lymphoproliferative hyperplasia of lymph nodes Etiology Unknown Possible etiologies include chronic inflammation, autoimmune reaction, immunodeficiency, or hamartomatous hyperplasia Histology Hyaline vascular (90%) Plasma cell (10%): more extensive; less enhancing; possible lymphomatous degeneration Demographics Age 20-50 years F > M (F:1) Distribution Localized Multicentric Location Thorax (70%) Neck (10-15%) Abdomen, retroperitoneum, pelvis (10-15%) Imaging Avidly enhancing enlarged mediastinal lymph nodes (especially in hyaline vascular type) Prominent feeding vessels may be seen Nonenhancing areas may reflect necrosis, fibrosis, degeneration Nodal calcification may be presen

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Cavities (4 - broad)

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Infection Pyogenic abscess Septic emboli Fungal infection Tuberculosis Inflammation Sarcoidosis Wegener's granulomatosis Rheumatoid arthritis Tumor Squamous cell carcinoma Lymphoma Sarcoma Transitional cell carcinoma Trauma Hematoma Hydrocarbon aspiration

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Cavities, benign vs. malignant

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Maximal wall thickness Benign: 16 mm Morphology Eccentric cavity: suggests malignancy Shaggy internal margins: suggests malignancy Air-fluid level Uncommon in cancer, TB More common in Wegener's, grossly infected lesions Number and location Solitary nodule more likely bronchogenic carcinoma

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Chondroma

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Benign cartilaginous tumor Parenchymal or endobronchial Young females Carney's triad Gastric epithelioid leiomyosarcoma Functioning extra-adrenal paraganglioma Pulmonary chondroma

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Churg-Strauss syndrome

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Pathology Allergic angiitis and granulomatosis Similar to polyarteritis nodosa Affects skin, kidneys, lung, heart, CNS Perinuclear-ANCA (p-ANCA) positive) Associations Late-onset asthma (100%) Allergic rhinitis and sinusitis (70%) Eosinophilia Demographics Age: 10-40 years (mean age 28 years) M=F Clinical Progressive asthma, sinus pain, myocardial involvement Abdominal pain, diarrhea Myalgias and neuritis Imaging Consolidation: predominantly peripheral (59%) Nodules (12%) Bronchiectasis and bronchial thickening Interlobular septal thickening Pleural effusions Treatment Prognosis relates to early diagnosis and therapy High dose steroids usually effective Cyclophosphamide in resistant cases Therapy stopped after 6-12 months of remission

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Chylothorax

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Tumor (especially lymphoma) Trauma Iatrogenic Penetrating or blunt trauma Idiopathic Lymphangioleiomyomatosis Filariasis

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Coal-worker's pneumoconiosis (CWP), background

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Epidemiology Common in underground miners (9-27%) Disease depends on type of inhaled coal: anthracite (50%) > bituminous > lignite (10%) Simple CWP Clinical Usually asymptomatic Pathology Coal macule: aggregation of dust around dilated respiratory bronchiole Minimal fibrosis Imaging Small nodules in upper lobes (indistinguishable from silicosis) Perilymphatic, centrilobular distribution More symmetric and evenly distributed than sarcoidosis Pseudoplaques: confluent subpleural nodules Centrilobular emphysema Lymphadenopathy with eggshell calcifications Complicated CWP Clinical Respiratory impairment, disability, premature death Pathology Progressive massive fibrosis Imaging Progressive massive fibrosis: masses (> 1 cm) formed by coalescent nodules Upper lobes (apical, posterior) Lenticular shape with lateral margin paralleling chest wall Usually bilateral Migrates centrally with time Emphysematous lung distal to PMF (risk for pneumothorax) Superior hilar retraction

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Coccidiomycosis, acute

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Clinical Incubation period 10-16 days 60% symptomatic Pneumonia symptoms: fever, cough, pleuritic chest pain Valley fever: allergic form with erythema nodosum or multiforme Imaging Consolidation (70%): usually unilateral, hilar, or basal Multifocal nodular or patchy opacities Peribronchiolar thickening Lymphadenopathy (20%): mediastinal lymphadenopathy may herald dissemination Pleural effusion (20%)

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Coccidiomycosis, chronic

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Clinical 5% of patients Persistent symptoms may be present without dissemination May be mildly immunocompromised Imaging Progressive consolidation Biapical fibronodular lesions Cavitation: walls may be thick or thin (grape-skin) Hilar retraction Lymphadenopathy Pneumothorax Empyema

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Coccidiomycosis, disseminated

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Clinical Immunocompromised Non-Caucasian (Filipino, African American, Hispanic) Mortality rate 50% even with early treatment Imaging Miliary or reticulonodular pattern Lymphadenopathy Pericardial effusion Involvement of skin, bone, meninges, GU tract

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Consolidation, acute (12)

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Pneumonia Edema Hemorrhage Aspiration Atelectasis Infarction Neoplasm BAC Lymphoma Sarcoidosis COP Chronic eosinophilic pneumonia Hypersensitivity pneumonitis Lipoid pneumonia

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Consolidation, chronic (10)

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Bronchioloalveolar carcinoma Cryptogenic organizing pneumonia (BOOP) Alveolar proteinosis Lymphoma Pseudolymphoma Lipoid pneumonia Sarcoidosis Eosinophilic pneumonia Hypersensitivity pneumonitis Post-obstructive pneumonia

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Consolidation, peripheral (5)

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Cryptogenic organizing pneumonia (COP) Eosinophilic pneumonia Infarct Septic emboli Contusion

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Constrictive bronchiolitis

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Bronchiolitis obliterans Concentric peribronchiolar fibrosis with narrowing, obliteration of bronchiolar lumen Causes Postinfectious (bacterial, mycoplasmal, or viral) Toxic inhalation Drugs (penicillamine, gold) Post-transplant (lung, bone marrow) Aspiration (gastric acid) Collagen vascular disease Inflammatory bowel disease Idiopathic CXR May be normal Hyperinflation Subtle attenuation of peripheral vascular markings Central airway dilatation HRCT Mosaic attenuation Air trapping Oligemia (reflex vasoconstriction in areas of poor ventilation) Expiratory accentuation of mosaic attenuation Bronchiectasis Centrilobular nodules

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Crazy paving (9)

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Alveolar proteinosis Hemorrhage Edema ARDS CHF Pneumonia PCP Viral Eosinophilic pneumonia Lipoid pneumonia Bronchioloalveolar carcinoma Sarcoidosis NSIP

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CREST syndrome

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Calcinosis Raynaud's Esophageal dysmotility Sclerodactyly Telangiectasia

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Cryptococcosis

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Cryptococcus neoformans Worldwide distribution Ubiquitous in soil, pigeon excreta Inhalation of contaminated dust Population Lymphoma Steroid therapy Diabetes AIDS Findings Pulmonary mass Multiple nodules Segmental or lobar consolidation Cavitation, adenopathy, effusions rare Disseminated form: CNS and other organs

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Cryptogenic organizing pneumonia (COP)

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Previously known as BOOP (bronchiolitis obliterans organizing pneumonia) Always idiopathic Clinical Cough, dyspnea, fever, chills, sweats, myalgias, weight loss Short illness duration < 3 months Elevated ESR, CRP, WBC Bronchoalveolar lavage: increased number and proportion of lymphocytes Most have 2-3 courses of antibiotics Histology Early phase Fibroblastic plugs in alveoli Fibrosis in alveolar walls Late phase Intraluminal branching fibrosis in respiratory bronchioles and alveolar ducts Interstitial fibrosis Demographics Mean age: 55 years Imaging Consolidation (90%) Unilateral or bilateral Peripheral, peribronchial, and basal distribution Ground glass opacities (75%) Centrilobular nodules Bronchial thickening and dilatation Seen in regions of consolidation Reverse halo Central portion clears before rim Relatively specific for COP Treatment and prognosis Most patients recover completely after oral steroids Relapse may occur

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Cystic fibrosis, imaging

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Distribution Upper lobes Superior segments of lower lobes Imaging Bronchiectasis Peribronchial wall thickening Mucus plugging Mosaic attenuation Fibrotic changes Recurrent pneumonia Hilar adenopathy Pulmonary arterial hypertension Complications Early Lobar atelectasis (especially RUL) Pneumonia Late Respiratory insufficiency Hypertrophic pulmonary osteoarthropathy Cor pulmonale and pulmonary arterial hypertension Hemoptysis Aspergillus superinfection

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Cystic fibrosis, pathology

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Pathology Autosomal recessive Abnormality in cystic fibrosis transmembrane conductance regulator protein Regulates passage of ions through membranes of mucus-producing cells Dysfunction of exocrine glands causing thick, tenacious mucus that accumulates and causes bronchitis and pneumonia Reduced mucociliary transport: airway obstruction with massive mucous plulgging Spectrum of disease Pulmonary (100%) Chronic cough Recurrent pulmonary infections: colonization of plugged airways by Staphylococcus and Pseudomonas Progressive respiratory failure Finger clubbing: hypertrophic osteoarthropathy from hypoxemia GI tract Pancreatic insufficiency (85%): steatorrhea, malabsorption Cirrhosis Rectal prolapse Neonates: meconeum ileus, meconium peritonitis, intussusception Sinusitis Hypoplastic frontal sinus Opacification of other sinuses Infertility in males

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Cysts

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Pneumatocele Post-traumatic Post-infectious PCP Staphylococcus Coccidiomycosis Septic emboli Hydrocarbon aspiration Emphysema Bullae (located within lung parenchyma) Blebs (located within layers of visceral pleura) Cystic bronchiectasis Langerhans cell histiocytosis Lymphangioleiomyomatosis and tuberous sclerosis Honeycombing in end-stage interstitial disease Lymphoid interstitial pneumonia Collagen vascular disease (Sjogren's, RA, SLE) Bone marrow transplantation Immunodeficiency (common in pediatric HIV but rare in adult HIV) Hydatid cyst Congenital cysts Intrapulmonary bronchogenic cysts (rib and vertebral anomalies common) Cystic adenomatoid malformation Sequestration Hypersensitivity pneumonitis Papillomatosis

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Desquamative interstitial pneumonia (DIP)

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Smoking-related interstitial lung disease May represent end-stage RB-ILD Demographics Age: 30-54 years Males > females (2:1) Clinical Insidious onset of symptoms Dyspnea Cough Restrictive PFTs with decreased DLCO Pathology Macrophage-laden bronchioles and alveolar spaces Plasma cell and eosinophil interstitial infiltrate Fibrosis Imaging Ground glass opacities Diffuse Symmetric Peripheral and basal predominance Reticulation Interlobular septal thickening Mild honeycombing Cysts Alveolar ducts Bronchioles Emphysematous spaces DDX Hypersensitivity pneumonitis RB, RB-ILD (has centrilobular nodules; upper lobe predominant) PCP Sarcoidosis Prognosis Worse prognosis than RB-ILD 70% survival at 10 years Improves with smoking cessation

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Diaphragmatic paralysis

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Phrenic nerve paralysis Bronchogenic carcinoma CNS injury, stroke Spinal cord injury, myelitis Peripheral nerve injury, inflammation Erb's palsy Muscular disorders Myasthenia gravis Polymyositis, dermatomyositis SLE Muscular dystrophy Idiopathic

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Diffuse panbronchiolitis

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Pathology Peribronchiolar inflammation with lymphocytes and plasma cells Peribronchiolar fibrosis Associated with HLA BW54 Demographics Most common in Japan M > F (2:1) Radiography Diffuse nodules Hyperinflation Cysts and bullae in late disease CT Centrilobular and small airways nodules (tree-in-bud) Mosaic attenuation Cystic bronchiectasis in late disease

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Doubling time

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Time to double volume 1.25x increase in diameter correlates with doubled volume Indicator of malignancy (ask for old films!) Malignant range: 30-450 days Inflammatory lesions more likely short (< 30 days)

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Drug toxicity

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Interstitial opacities Bleomycin Methotrexate Carmustine Cyclophosphamide Gold Consolidation Amiodarone Cytosine arabinoside IL-2 OKT3 Tricyclic antidepressants Salicylates Penicillamine Anticoagulants Nodules Cyclosporine Pleural effusion Procainamide (SLE-like reaction) Hydralazine (SLE-like reaction) Bromocryptine Methysergide Ergotamine tartrate Adenopathy Phenytoin Cyclosporine Methotrexate

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Eggshell nodal calcifications (6)

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Silicosis Coal worker's pneumoconiosis Sarcoidosis Histoplasmosis Tuberculosis Treated lymphoma

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Elevated diaphragm

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Diaphragmatic paralysis Phrenic nerve injury Bronchogenic carcinoma CNS, spinal cord lesions Immobility due to pain Rib fractures Pleuritis Pneumonia PE Mass lesions Subpulmonic effusion Subphrenic collection, abscess Abdominal mass Diaphragmatic hernia Pleural tumor

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Emphysema, centrilobular

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Common Associations Smoking Chronic bronchitis Pathology Areas of emphysema surrounding centrilobular bronchiole and artery Imaging Centrilobular or spotty lucencies Walls usually not visible Upper lobe predominance

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Emphysema, panlobular

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Uncommon Associations Alpha-1-antitrypsin deficiency Smoking IV methylphenidate (Ritalin) abuse Pathology Uniform destruction of secondary lobule Imaging Large lung volumes Low attenuation Small pulmonary vessels Focal lucencies usually absent Diffuse or lower lobe predominance

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Emphysema, paraseptal

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Common Associations Smoking Centrilobular emphysema Pathology Destruction of subpleural lobules Imaging Subpleural lucencies Marginated by interlobular septa Bullae (>1 cm) Pneumothorax Upper lobe predominance

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Empyema

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Pus in pleural space Exudate that contains organism on Gram stain Polymicrobial anaerobe (35%) Mixed aerobe/anaerobe (40%) Three stages Exudative Fibrinopurulent Organizing Other laboratory findings Leukocytosis Low pH Low glucose Causes Postinfection (parapneumonic), 60% Postsurgical, 20% Post-trauma, 20% Findings Pleural fluid Thickened enhancing pleura Lenticular shape Nondependent location Disparate length of air-fluid level on AP and lateral views Split pleura sign Edema, thickening of extrapleural fat Gas in pleural space Thoracentesis Brochpleural fistula Gas-forming organism

question

Empyema necessitans

answer

Spontaneous discharge of emypema through parietal pleura Most commonly into chest wall to form subcutaneous abscess Etiology Tuberculosis (73%) Other infection (bacterial, fungal) Malignancy

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Endobronchial mass

answer

Primary malignant tumors Squamous cell carcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Small cell carcinoma Carcinoid Primary benign tumors Hamartoma Chondroma Papilloma Hemangioma Metastases Renal cell carcinoma Melanoma Colorectal carcinoma Breast carcinoma Thyroid carcinoma Pancreatic carcinoma Tuberculosis Mechanical Mucous plug Foreign body Broncholith Amyloidosis

question

Eosinophilic pneumonia

answer

Pathology Acute: diffuse alveolar damage associated with large number of interstitial and alveolar eosinophils Chronic: filling of alveoli with eosinophilic inflammatory infiltrate Speculated to represent hypersensitivity reaction to unknown antigen Clinical Fever, dyspnea, chest pain Hypoxemia Acute more common in smokers Chronic more common in asthmatics (90% nonsmokers) Demographics Acute: any age, M=F Chronic: peak age 30s, F>M Treatment Rapid response to steroids Acute imaging findings Bilateral lower-lobe predominance Ground glass opacities Occasional localized areas of consolidation or small nodules Band-like opacities paralleling chest wall Interlobular septal thickening and thickening of bronchovascular bundles (crazy paving) Small pleural effusions Chronic imaging findings Bilateral upper-lobe predominance Peripheral consolidation and ground glass opacities Recurrent in same location Pleural effusions rare Band-like opacities paralleling chest wall as consolidation clears from periphery

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Extramedullary hematopoiesis

answer

Paravertebral mass Bone marrow extruded through cortical defects of vertebral bodies Causes Severe anemias (thalassemia) Bone marrow replacement (myelofibrosis, osteopetrosis) Findings Multiple bilateral posterior mediastinal masses Typically T7-T12 Coarse trabeculation, rib expansion Marked enhancement

question

Fibrosing mediastinitis

answer

Etiology Infection Histoplasmosis Tuberculosis Idiopathic Often associated with other autoimmune diseases: retroperitoneal fibrosis, orbital pseudotumor, SLE, RA, Riedel thyroiditis Drugs Methysergide (used for migraine headaches) Hemorrhage Radiation therapy Clinical SVC syndrome Hemoptysis Dyspnea, cough Demographics Adults of any age Most between 21 and 40 Imaging Focal disease Calcified matted nodes Diffuse disease Fibrous tissue replacing mediastinal fat Usually not calcificed Obstruction SVC obstruction with abundant collaterals Airway obstruction, narrowing with postobstructive atelectasis, pneumonitis Pulmonary venous obstruction with pulmonary venous hypertension and interstitial edema Pulmonary artery occlusion Pericarditis

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Fibrothorax

answer

Fibrous obliteration of normal pleural space Etiology Tuberculosis Bacterial empyema Hemothorax Asbestos-related pleural disease Rheumatoid arthritis Imaging Volume loss Smooth, uninterrupted pleural thickening >25% of chest wall >8 cm craniocaudal >3 mm thickness Mediastinal pleura spared May be calcified

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Fibrous tumor of pleura

answer

Pathology Large lobulated mass Pedicle (50%) Cysts, hemorrhage, necrosis with larger tumors No relationship to asbestos exposure or smoking Originate from visceral (80%) or parietal (20%) pleura Classification Benign with pedicle: lowest rate of recurrence Benign with broad-based attachment Malignant with pedicle Malignant with broad-based attachment: highest rate of recurrence Clinical Cough, dyspnea, chest pain Hypertrophic osteoarthropathy (17-30%): more common with tumors > 10 cm Hypoglycemia (5%) Demographics Mean age 50 years F > M Imaging Well-defined, solitary pleural-based mass T1- and T2-hypointense Pedunculated lesions may move Displacement of structures, not invasion Calcification (5% in benign, 20% in malignant) Enhancement homogeneous in tumors < 6 cm; heterogeneous in larger lesions and malignant lesions (necrosis, hemorrhage) No chest wall involvement Pleural effusion (20%, more common with malignant tumors) Treatment and prognosis Surgical excision Recurrence rate as high as 15% (requires long term surveillance) Recurrence higher in malignant tumors with broad-based attachment Malignancy has poor prognosis due to extensive intrathoracic metastatic disease (survival < 2 years)

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Follicular bronchitis

answer

Follicular hyperplasia of bronchus-associated lymphoid tissue (BALT) Pathology Antigenic stimulation of BALT Hyperplastic lymphoid follicles with reactive germinal centers distributed along bronchioles and bronchi Minimal alveolar extension Demographics Mean age 44 years Associations AIDS Collagen vascular disease (RA, Sjogren's) Hypersensitivity Clinical Cough, dyspnea Fever, weight loss Radiography Diffuse reticulonodular opacities CT Centrilobular nodules Ground glass opacities Air-trapping DDX Respiratory bronchiolitis Hypersensitivity pneumonitis Diffuse panbronchiolitis Cystic fibrosis Primary ciliary dyskinesia

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Goodpasture's syndrome

answer

Features Pulmonary hemorrhage Iron deficiency anemia Glomerulonephritis Pathology Binding of circulating antibodies to glomerular and alveolar basement membranes Clinical Hemoptysis Renal failure Imaging Pulmonary hemorrhage Consolidation and ground glass opacities with air bronchograms Characteristic sparing of costophrenic angles Clearing in 1-2 weeks Repeated hemorrhage Leads to hemosiderosis and pulmonary fibrosis Interstitial reticular pattern

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Ground glass opacity (acute x 4, chronic x 6)

answer

Acute Pulmonary edema CHF ARDS AIP Pulmonary hemorrhage Pneumonia Viral Mycoplasma PCP Acute eosinophilic pneumonia Chronic Hypersensitivity pneumonitis Chronic eosinophilic pneumonia Alveolar proteinosis Idiopathic interstitial pneumonia UIP NSIP DIP COP RB, RB-ILD Bronchioloalveolar carcinoma Sarcoidosis

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Halo sign (5 - broad)

answer

Fungal Invasive aspergillosis Candidiasis Nocardia Bacterial Legionella Tuberculosis Viral CMV HSV Inflammatory Wegener's granulomatosis Neoplastic Lung cancer Metastases Angiosarcoma Kaposi's sarcoma

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Hamartoma

answer

Epidemiology Most common benign tumor of lung (77%) 8% of solitary pulmonary nodules 3% of all lung tumors Demographics Age range: 30-70 years F > M (F=M for endobronchial hamartomas) Clinical Asymptomatic (90%) May cause hemoptysis, post-obstructive pneumonitis Pathology Composed of cartilage, connective tissue, muscle, fat, and bone Cleft-like invaginations of entrapped respiratory epithelium Easily shelled-out Location Usually peripheral (90%) No lobar predilection Imaging Sharply defined, lobulated peripheral nodule Calcification Speckled or popcorn (chondroid) 10% of lesions 5 cm Fat attenuation is pathognomonic (54%)

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Hemangioma

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Pathology Lobular, well-marginated unencapsulated mass Infiltrative Classified as capillary, cavernous, or venous Demographics Children and young adults Most common subglottic mass in infant M=F Location Most often anterior and superior mediastinum May involve any region of thorax Imaging Lobular heterogenous mass Phleboliths (30%) Heterogeneous enhancement

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Histoplasmosis, acute

answer

Clinical Flulike syndrome: fever, chills, cough Retrosternal pain from mediastinal LN involvement Erythema nodosum in women Arthralgia Imaging Poorly defined areas of consolidation Multiple nodules (evolve to punctate calcifications) Lymphadenopathy

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Histoplasmosis, chronic

answer

Clinical Usually represents hypersensitivity reaction in patients with emphysema Usually resolves in few weeks Imaging Upper lobe predominance Similar findings to TB Thick-walled bullae filled with fluid Fibrosis, volume loss Cavitation

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Histoplasmosis, complications

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Histoplasmoma Residua of prior area of pneumonitis Solitary nodule (<3 cm) Sharply defined Smaller satellite lesions Central or diffuse calcification (diagnostic of benign lesion if less than 3 cm) May increase in size Hilar calcification common on ipsilateral side Broncholithiasis Calcified regional lymph node with erosion into airway May obstruct bronchus Mediastinal granuloma Result of direct infection of mediastinal lymph nodes Subcarinal or paratracheal mass Enhancing capsule with low attenuation center in acute stage Fibrosing mediastinitis Proliferation of collagen and fibrous tissue within mediastinum Most cases are secondary to histoplasmosis (calcified, focal paratracheal and subcarinal involvement) Idiopathic form less common (noncalcified, diffusely infiltrating, unrelated to histoplasmosis) SVC obstruction Obstruction of pulmonary arteries and veins Central airway narrowing Esophageal narrowing

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Histoplasmosis, disseminated

answer

Clinical 30% infants < 2 years 20% immunocompromised 50% apparently normal Imaging Miliary nodules AIDS-associated disease commonly extrathoracic (50%)

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Hodgkin's disease, classification

answer

Rye classification Lymphocyte predominant 2-10% Excellent prognosis Nodular sclerosis 40-80% Very good prognosis Mixed cellularity 20-40% Good prognosis Lymphocyte depleted 2-15% Poor prognosis Ann Arbor staging Single LN region or extralymphatic site Two or more LN regions on same side of diaphragm; may include localized involvement of extralymphatic site LN regions or extralymphatic sites on both sides of diaphragm Disseminated involvement of one or more extralymphatic organs with or without LN involvement Suffix specifying extralymphatic site Suffix specifying splenic involvement

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Honeycombing (8)

answer

IPF (60%) Collagen vascular disease Scleroderma RA Asbestosis Chronic hypersensitivity pneumonitis Sarcoidosis Silicosis Langerhans cell histiocytosis Drug toxicity Bleomycin Methotrexate Busulfan Vincristine Adriamycin Carmustine

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Hydrocarbon pneumonitis

answer

Aspiration of volatile hydrocarbons such as kerosine, gasoline, or turpentine Demographics "Fire-eater's pneumonia" Fire-eaters, petrochemical workers, painters, hazardous waste workers 40-50% in children < 6 years Findings Consolidation (may be fat density) Well-defined cavitary nodules Pneumatoceles Natural history and prognosis Most have resolution of acute lung injury with supportive care Complications Abscess Effusion Bronchopleural fistula Bacterial superinfection

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Hyperlucent lung (6 - broad)

answer

Technical Grid cutoff, malposition Anode heel effect Rotation Chest wall Mastectomy Poland syndrome (congenital absence of pectoralis muscle Pleura Pneumothorax Lung Hyperexpansion after resection or lobar collapse Airway obstruction Emphysema, bullae Asthma Mucous plug Foreign body Tumor Swyer-James syndrome Congenital lobar emphysema Vascular (oligemia) PE Tumor invasion of pulmonary artery Fibrosing mediastinitis Pulmonary artery hypoplasia or aplasia Scimitar syndrome (hypogenetic lung syndrome)

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Hypersensitivity pneumonitis, imaging

answer

Distribution Middle lung predominance or even distribution throughout upper, mid, and lower lung zones Costophrenic angles spared or less severely involved Radiography Acute CXR abnormal in 10% Fine nodular or reticulonodular pattern Airspace consolidation Subacute CXR abnormal in 90% Poorly defined small nodules Diffuse opacities in middle and lower lungs Chronic Fibrosis with architectural distortion and volume loss CT Acute Small ill-defined centrilobular nodules Bilateral airspace consolidation Subacute Patchy ground glass opacities Ill-defined centrilobular nodules Mosaic attenuation: "head-cheese" sign Cysts Chronic Fibrosis with honeycombing, traction bronchiectasis, and architectural distortion Superimposed subacute findings (centrilobular nodules and ground glass opacities) Pulmonary hypertension

question

Hypersensitivity pneumonitis, pathology

answer

Extrinsic allergic alveolitis Pathology Granulomatous inflammation of bronchioles and alveoli Caused by immunologic response to inhaled organic material Type III (Ag-Ab complex mediated) and type IV (cell-mediated) hypersensitivity reactions Antigens often fungal spores or avian-related Treatment Antigen avoidance and removal from environment Steroids Diseases Farmer's lung: moldy hay (Micropolyspora faeni) Bird fancier's lung: avian excreta (pigeons, parakeets) Humidifier lung: contaminated air conditioners (thermophilic actinomyces) Bagassosis: moldy bagasse dust (Thermoactinomyces sacchari) Malt worker's lung: moldy malt (Aspergillus clavatus) Maple bark stripper's lung: moldy maple bark (Crystostroma corticale) Mushroom worker's lung: spores from mushrooms (thermophilic actinomyces)

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Idiopathic pulmonary fibrosis, background

answer

Progressive inflammation, fibrosis, and destruction of lung (end-stage lung) Synonyms: usual interstitial pneumonia (UIP), cryptogenic fibrosing alveolitis (CFA, British) Demographics Age: 40-70 years Males > females Clinical Insidious onset dyspnea for more than 6 months Restrictive ventilation Rales and clubbing Associations Smoking Dusty environments Gastroesophageal reflux Autoantibodies (ANA, RA) Histology Dense fibroblastic foci Predominantly subpleural collagenous scarring Diagnosis Imaging (PPV 96%) CT always abnormal in patients with IPF Clinical (PPV 87%) Histology Agreement regarding presence or absence of IPF only 85% Agreement in patients without IPF only 48% DDX Asbestosis Collagen vascular disease (e.g. scleroderma, RA) Drug-toxicity (e.g. amiodarone) Chronic hypersensitivity pneumonitis (upper-mid lung zone) Treatment Steroids (useful in 50%) Cytotoxic agents Prognosis Median survival: 2.5-3.5 years 68% mortality at 6 years

question

Idiopathic pulmonary fibrosis, imaging

answer

Radiograph Abnormal in 95% Volume loss Reticulonodular opacities Lower lobe predominance Honeycombing CT Abnormal in 100% Peripheral and lower lobe predominance Irregular interlobular septal thickening Intralobular septal thickening (lace-like or spider web appearance) Subpleural reticulation Stacked cystic spaces (honeycombing) Parenchymal bands Traction bronchiectasis Architectural distortion Ground glass opacities Reflects active potentially-treatable disease May be seen in areas of traction bronchiectasis (more irreversible disease) Irregular fissures Pulmonary hypertension, cardiomegaly

question

Pulmonary Infarct

answer

10-60% of patients with PE Multiple Lower lobe distribution Initially ill-defined; becomes well-defined over days Triangular, subpleural opacities (Hampton's hump) Cavitation Upper lobe infarcts Large infarcts (>4 cm) Superinfected infarcts Shrinks from outside in (melts like an ice cube) Residua: none or linear scar

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Inflammatory pseudotumor

answer

Synonyms Plasma cell granuloma Histiocytoma Fibroxanthoma, xanthoma Myofibroblastic tumor Mast cell granuloma Pathology May begin as organizing pneumonia Usually solitary tumefactive lesion Destroys underlying lung architecture May have aggressive features: vascular invasion, vertebral destruction, recurrence Demographics Wide age range (average 30 years) Most common primary lung mass in children M=F Clinical Most are asymptomatic Many have history of respiratory infection Imaging Well-defined lobulated nodule or mass May manifest as consolidation Endobronchial lesions may occur Variable enhancement, calcification Treatment, prognosis Surgical excision Excellent prognosis 5% recurrence

question

Interstitial lung disease, basilar (mn x 7)

answer

"BAD RASH" Bronchiectasis Asbestosis Drug reaction Rheumatoid arthritis Aspiration Scleroderma Hamann-Rich syndrome (IPF)

question

Interstitial lung disease, patterns

answer

Radiography Small nodules Reticular opacities Interlobular septal thickening Subpleural edema Peribronchiolar opacities Honeycombing CT Stacked cystic spaces, honeycombing Subpleural reticulation Parenchymal bands Ground glass opacities Nodules Interlobular septal thickening DDX Idiopathic interstitial pneumonias Infection TB Viruses Edema Inflammation Sarcoidosis Hypersensitivity pneumonitis Tumor

question

Interstitial lung disease, preserved lung volumes (5)

answer

Lymphangioleiomyomatosis Langerhans cell histiocytosis Sarcoidosis Cystic fibrosis Amyloidosis

question

Kaposi's sarcoma

answer

AIDS-related multicentric neoplasm Propensity to involve skin, lymph nodes, GI tract, and lungs 15-20% of AIDS patients Pulmonary involvement in 20% Demographics Homosexual or bisexual males with AIDS Clinical Dyspnea, cough, hemoptysis Imaging Lymphangitic carcinomatosis Perilymphatic poorly-defined nodules (flame-shaped) (85%) Peribronchovascular interstitial thickening and nodules (80%) Interlobular septal thickening (40%) Progresses to coalescent flame-shaped perihilar consolidation Pleural effusions (40%) Serosanguinous Lymphadenopathy (50%) Marked enhancement

question

Kartagener's syndrome

answer

Immotile cilia syndrome Autosomal recessive Deficiency of dynein arms of cilia causing immotility of respiratory, auditory, sperm cilia Clinical Recurrent sinusitis, ear infections, pneumonia Male infertility Findings Complete thoracic and abdominal situs inversus (50%) Bronchiectasis, bronchial wall thickening Centrilobular and tree-in-bud nodules from bronchiolitis Mosaic attenuation Sinus hypoplasia and mucosal thickening

question

Langerhans cell histiocytosis

answer

Demographics Almost exclusively in smokers Slight male predominance Clinical Cough and dyspnea most common May be asymptomatic Occasional bone lesion Hemoptysis Pathology Nodules within and around airways Cystic spaces represent dilated airways Large histiocytes with eosinophilic cytoplasm Birbeck granules (shaped like tennis rackets) Imaging Upper lobe predominance Nodules which eventually become cystic Numerous irregular, bizarre-shaped cysts Fused and cloverleaf appearances Thick or thin walls Intervening normal lung Pneumothorax (30%) May progress to fibrosis and honeycombing

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Large cell carcinoma

answer

5% of lung cancer Least common NSCLC Poorly differentiated tumor Neuroendocrine features Usually peripheral Large, bulky mass with areas of necrosis (70% > 4 cm at presentation) Fast growth, early metastases

question

Lipoid pneumonia

answer

Etiology Exogenous accumulation of fat in lung Most often secondary to mineral oil: older people who are constipated; may have swallowing dysfunction Infants with feeding difficulties In the past, from oily nose drops Pathophysiology Animal fatty acids produce hemorrhagic bronchopneumonia Mineral oil produces giant cell foreign body reaction Interstitial septal thickening Macrophages, enlarged lymphatics Fibrosing reaction Clinical Usually asymptomatic Best method of diagnosis is direct biopsy Findings Lower lobe predominance (predilection for right) Alveolar consolidation (may be well-circumscribed) May present as peripheral mass or nodule (simulates bronchogenic carcinoma) Fat density may be seen Crazy paving

question

Lobe collapse

answer

Primary signs Opacified lobe Dispaced interlobar fissures Secondary signs Elevated hemidiaphragm Mediastinal shift Hilar displacement Compensatory hyperinflation Crowded vessels Causes Tumor Endobronchial Extrinsic (e.g. bronchogenic carcinoma) Mucus plugging Foreign body Broncholith RML syndrome Compressive atelectasis

question

Lobe collapse, combined RML and RLL

answer

Obstruction of bronchus intermedius Major and minor fissures displaced downward Obscuration of hemidiaphragm

question

Lobe collapse, combined RUL and RML

answer

Bronchi are remote from each other Single endobronchial lesion not sufficient to explain findings May result from extrinsic mass or mucus plugging Findings similar to LUL collapse

question

Lobe collapse, LLL

answer

Left retrocardiac triangular opacity Posterior displacement of left major fissure Inferior displacement of left hilum

question

Lobe collapse, LUL

answer

Hazy density on PA view Obscuration of left heart border Luftsichel Para-aortic crescentic lucency from upward migration of superior segment of LLL Anterior displacement of major fissure on lateral view Juxtaphrenic peak Traction on basal pleura by inferior pulmonary ligament

question

Lobe collapse, RLL

answer

Triangular opacity in right retrocardiac region on PA film with obliteration of diaphragm Posterior displacement of major fissure Gatling gun sign Air bronchograms clustered in RLL seen end-on below right hilus

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Lobe collapse, RML

answer

Obscuration of right heart border Wedge-shaped opacity on lateral view Downward displacement of minor fissure Upward displacement of major fissure RML syndrome Recurrent atelectasis despite patent airway Absent collateral ventilation May have coexistent bronchiectasis May have surrounding lymphadenopathy

question

Lobe collapse, RUL

answer

Wedge-shaped opacity in right upper hemithorax Elevation of minor fissure Anterior displacement of major fissure Reverse S sign of Golden Rightward tracheal shift Elevation of right hilum Luftsichel Hyperexpansion of superior segment of RLL or RML Lucency between mediastinum and RUL opacity on PA view More common in LUL collapse Juxtaphrenic peak More common in LUL collapse Traction on basal pleura by inferior pulmonary ligament

question

Lung biopsy

answer

True positive rate: 90-95% False negatives usually due to poor needle placement, necrotic tissue Contraindications (usually relative) Severe COPD Pulmonary HTN Coagulopathy Contralateral pneumonectomy Suspected echinococcal cysts Technique Fluoroscopic or CT localization of nodule Pass needle over superior border of rib to avoid intercostal vessels Avoid passing through fissures Coaxial needle system: 20-G outer needle, 22-G inner needle Cytopathologist should be present in room to determine if sample is adequate and diagnostic Chest film after procedure to determine presence of PTX Pneumothorax (5-30%) Risk factors COPD, Biopsies at lung apices Deep lesions Transgression of multiple pleural surfaces (fissures) Most do not require chest tube Indications for chest tube (5-10%) PTX > 25% Symptomatic Hemoptysis (up to 20%) Usually benign and self-limited Severe hemoptysis requiring intervention is unusual Tumor seeding extremely uncommon (1:20,000)

question

Lung cancer, staging

answer

Stage 0 TIS - N0 - M0 Stage 1A T1 - N0 - M0 5-year survival 65% Stage 1B T2 - N0 - M0 5-year survival 40% Stage 2A T1 - N1 - M0 5-year survival 35% Stage 2B T2 - N1 - M0 T3 - N0 - M0 5-year survival 25% Stage 3A T3 - N1 - M0 T1-3 - N2 - M0 5-year survival 10% Stage 3B Any T - N3 - M0 T4 - Any N - M0 5-year survival 5% Unresectable Stage 4 Any T - Any N - M1 5-year survival 1%

question

Lung cancer, TNM

answer

Primary tumor (T) TX Malignant cells with no visible tumor T0 No evidence of tumor TIS Carcinoma in situ T1 Mass 3 cm Invasion of visceral pleura Involves major bronchus > 2 cm from carina Lobar atelectasis T3 Any tumor extending into chest wall, diaphragm, mediastinal fat, or pericardium Whole lung atelectasis Involves major bronchus < 2 cm from carina T4 Any tumor invading heart, great vessels, trachea, esophagus, vertebral body, or carina Malignant pleural effusion Satellite nodule in ipsilateral lobe Nodal involvement (N) N0 No involvement N1 Ipsilateral hilar nodes N2 Ipsilateral mediastinal nodes Subcarinal and midline nodes N3 Contralateral mediastinal nodes Any scalene, supraclavicular nodes Distant metastatic involvement (M) M0 None M1 Present

question

Lung contusion

answer

Endothelial damage: extravasation of blood into interstitium and alveoli Occurs mainly in lung adjacent to solid structures: ribs, vertebra, heart, liver Clinical: hemoptysis (50%) Mortality rate: 15-40% Findings Pulmonary opacities due to hemorrhage and edema Air bronchograms commonly seen on CT; not always present if there is associated bronchial obstruction Evolution Appears 6-24 hours after injury Resolves by 7-10 days Nonresolving contusions (after 7-10 days) Post-laceration hematoma Aspiration Hospital-acquired pneumonia Atelectasis ARDS

question

Lung laceration

answer

Disrupted alveoli leading to radial retraction of parenchyma Mechanisms of injury Penetrating trauma (rib fracture) Deceleration, shearing Blunt trauma Complications Infection Bronchopleural fistula (requires prolonged chest tube drainage) Imaging Air-fluid level within complex cystic space Surrounding hemorrhage Spherical and complex if resulting from blunt trauma Conforms to path of penetrating object in penetrating trauma Changing appearance with time Evolution to pneumatocele, scar Hemopneumothorax

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Lymphadenopathy, calcified (5)

answer

Tuberculosis Fungal infection Sarcoidosis Silicosis Treated lymphoma

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Lymphadenopathy, hypervascular (2)

answer

Castleman's disease Vascular metastases Renal cell carcinoma Thyroid carcinoma Small cell lung cancer Melanoma

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Lymphadenopathy, low attenuation (5)

answer

Tuberculosis MAC Fungal infection Necrotic metastases Squamous cell carcinoma Thyroid carcinoma Adenocarcinoma Lymphoma

question

Lymphangioleiomyomatosis (LAM)

answer

Demographics Exclusively in women unless associated with tuberous sclerosis Reproductive years Clinical Spontaneous pneumothorax Chylothorax Hemoptysis Slowly progressive dyspnea Pathology Proliferation of smooth muscle cells along bronchioles, alveolar septa, arteries, veins, and lymphatics Associated with tuberous sclerosis Small air-filled cysts from air trapping throughout lungs Enlarged thoracic duct Enlarged lymph nodes Natural history and prognosis Slowly progressive course Cor pulmonale, respiratory failure 5-year survival: 50-80% Average survival: 10 years Radiographic features Basilar reticulonodular opacities Normal or increased lung volume Chylous pleural effusion (60-75%) Pneumothorax (40%) Honeycombing in late disease CT Numerous thin-walled cysts Bilateral, diffuse throughout lungs Lymphadenopathy Chylous pleural effusion Recurrent PTX Honeycombing in late disease Lymphangiography Obstruction of lymphatic flow at multiple levels Dilated lymphatics Increased number of lymphatics Treatment Oophorectomy Progesterone Lung transplant

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Lymphangioma

answer

Pathology Benign mesenchymal tumor Proliferation of lymphatic vessels without communication with lymphatic tree Lobular, well-marginated unencapsulated mass Infiltrative Classification Simple Capillary-sized lymphatic channels More common in skin Cavernous Dilated lymphatic channels Affects thorax, abdomen, bone Cystic Large lymphatic channels Most common in neck Demographics Children and young adults M > F Location Usually extend from neck into mediastinum (75%) 15% arise exclusively in mediastinum Usually anterior and superior mediastinum Imaging Lobular, circumscribed infiltrative mass Usually cystic with variable sized cysts May appear solid secondary to high density contents (protein and hemorrhage) No enhancement

question

Lymphangitic carcinomatosis

answer

"Certain Cancers Spread Purely By Plugging The Lung Lymphatics" Cervix Colon Stomach Prostate Breast Pancreas Thyroid Lung Laryngeal

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Lymphoid disorders

answer

Hyperplasias of bronchus-associated lymphoid tissue (BALT) Follicular bronchitis (follicular hyperplasia) Pseudolymphoma (nodular hyperplasia) Lymphoid interstitial pneumonia (LIP, diffuse hyperplasia) NHL Low grade B-cell lymphoma Lymphomatoid granulomatosis Immune impairment Post-transplant lymphoproliferative disorder (PTLD) AIDS

question

Lymphoid interstitial pneumonia (LIP)

answer

Pathology Diffuse hyperplasia of bronchus-associated lymphoid tissue (BALT) Infiltration of alveolar septa with T-lymphocytes Peribronchial germinal centers with B-lymphocytes Demographics Age: 40-49 years Females > males Clinical Insidious onset of cough and dyspnea Fever, weight loss, arthralgia BAL: lymphocytes with no clonality Associations Collagen vascular disease (Sjogren's, RA, SLE) Bone marrow transplantation Immunodeficiency (common in pediatric HIV but rare in adult HIV) Radiography Lower lung reticulonodular opacities CT Diffuse ground glass opacities Poorly defined centrilobular nodules Perilymphatic nodules Diffuse cystic airspaces Complete or partial airway obstruction by lymphoid tissue Thickened bronchovascular bundles Adenopathy Treatment: steroids

question

Lymphomatoid granulomatosis

answer

Pathology B-cell lymphoma Associated with EBV Angiocentric infiltration with vascular invasion and destruction Demographics Mean age 48 years M > F (2:1) Clinical Cough, dyspnea (100%) Nodules, ulcers, rash Malaise, weight loss Altered mental status, ataxia, hemiparesis, seizures, neuropathy Renal impairment Imaging Multiple bilateral nodules Predominantly in mid and lower lobes Cavitation (20%) Vessel-associated Larger masses corresponding to infarcts Diffuse reticulonodular opacities Hilar adenopathy (25%) Treatment and prognosis Mortality: 53-90% Long term remissions possible with cyclophosphamide and steroids

question

Malignant mesothelioma

answer

Risk much higher in asbestos workers Latent period: 30-45 years Histologic variants Epithelial (50%) Best prognosis Similar to adenocarcinoma Mesenchymal (20%) Mixed (30%) Clinical Chest pain, dyspnea, fever, weight loss History of occupational exposure to asbestos in 80% Demographics Pead age 60-70 years M > F (4:1) Diagnosis Need to differentiate from metastatic adenocarcinoma Mesothelioma looks like adenocarcinoma on FNA (need core biopsy) Imaging Lobulated pleural thickening Pleural effusion Encasement of lobes and growth along fissures Contraction of hemithorax (expansion with large pleural effusion) Contralateral pleural plaques (20%) May extend along needle or chest tube drainage tracts Mediastinal, chest wall, and diaphragmatic invasion Enhancement Treatment and prognosis Extrapleural pneumonectomy for resectable disease (5-year survival 25%) Prophylactic irradiation of needle tracts Palliative radiation therapy, chemotherapy Dismal prognosis for unresectable disease, median survival 12 months

question

Mediastinal lipomatosis

answer

Exuberant deposition of unencapsulated adipose tissue in mediastinum Etiology Obesity Exogenous steroids Cushing's syndrome Paraneoplastic production of ACTH Multiple symmetric lipomatosis (Madelung disease, Launois-Bensaude disease) Genetic Prader-Willi syndrome Angelman syndrome Familial multiple lipomatosis Associations Lipomatous tissue in other anatomic regions Insulin resistance Hypertension Stigmata of Cushing's syndrome Clinical Usually asymptomatic Obstructive sleep apnea Natural history and prognosis Benign indolent course Regression with correction of underlying disorder Imaging Homogenous fat within mediastinum No mass effect or invasion of adjacent structures No soft tissue components

question

Mediastinal mass, anterior (5 broad)

answer

Thymic mass Thymic cyst Thymoma Thymolipoma Thymic carcinoma Thymic carcinoid Thymic lymphoma Thymic hyperplasia Germ cell tumor Mature teratoma Immature teratoma Seminoma Non-seminomatous germ cell tumor Embryonal carcinoma Yolk sac tumor Choriocarcinoma Mixed germ cell tumor Thyroid goiter Lymphadenopathy Tuberculosis Fungal infection Sarcoidosis Lymphoma Castleman's disease Vascular Hemangioma Lymphangioma

question

Mediastinal mass, anterior (cystic) (6)

answer

Thymic cyst Thymoma Teratoma Bronchogenic cyst Pericardial cyst Lymphangioma

question

Mediastinal mass, any compartment (6)

answer

Hematoma Abscess Lymphadenopathy Mesenchymal tumor Lymphangioma Hemangioma

question

Mediastinal mass, intense enhancement (6)

answer

Thyroid goiter Hemangioma Castleman disease Vascular metastases RCC Thyroid Melanoma Small cell carcinoma Kaposi's Paraganglioma Aneurysm, varices

question

Mediastinal mass, middle (7)

answer

Adenopathy Benign: sarcoid, TB, fungal, berylliosis Malignant: metastases, lymphoma, leukemia Airways, lungs Bronchogenic cysts Tracheal malignancy Bronchogenic tumor Esophageal Hiatal hernia (common) Esophageal duplication cysts Neoplasm Diverticula Megaesophagus: achalasia, hiatal hernia, colonic interposition, Chaga's, scleroderma Varices Thyroid goiter Vascular, aneurysm Aorta, branches Sinus of Valsalva aneurysm Pulmonary artery Aberrant right subclavian artery with associated diverticulum Heart Pericardial cyst Mediastinal soft tissues Hemangioma Lymphangioma Mediastinal lipomatosis Mediastinal hemorrhage Pancreatic pseudocyst Neurinoma from recurrent laryngeal nerve Mesenchymal tumor Abscess

question

Mediastinal mass, posterior

answer

Neurogenic Schwannoma Neurofibroma Neuroblastoma Ganglioneuroblastoma Ganglioneuroma Paraganglioma Lateral meningocele Spinal Neoplasm Hematoma Extramedullary hematopoiesis Pyogenic spondylodiskitis Vascular Aneurysm Azygos continuation of IVC

question

Mediastinal mass, superior (6)

answer

Thyroid mass Lymphadenopathy Lymphoma Lymphangioma Small cell lung cancer Aneurysm, vascular abnormality

question

Metastases, calcified (5)

answer

Osteosarcoma Chondrosarcoma Synovial sarcoma Papillary thyroid carcinoma Mucinous adenocarcinoma (e.g. ovarian)

question

Metastases, cannonball (8)

answer

Colorectal carcinoma Renal cell carcinoma Sarcoma Melanoma Head and neck tumors Testicular tumors Ovarian tumors Breast carcinoma

question

Metastases, endobronchial (6)

answer

Breast Colorectal Thyroid Renal Melanoma Pancreas

question

Metastases, fast-growing (3)

answer

Sarcomas Melanoma Germ cell neoplasms

question

Metastases, micronodular (3)

answer

Papillary thyroid carcinoma Melanoma Choriocarcinoma

question

Metastases, pleural (8)

answer

Thymoma Lymphoma Breast Lung Prostate Thyroid Renal Gastric

question

Metastases, slow-growing

answer

Benign metastasizing leiomyoma Thyroid carcinoma

question

Metastatic calcifications

answer

Secondary to hypercalcemia in patients with abnormal calcium and phosphate metabolism Most common in patients with chronic renal failure and secondary hyperparathyroidism Location Interstitial: alveolar septa, bronchioles, arteries May be associated with fibrosis Predominates in upper lobes (most alkaline region) Imaging Fluffy, poorly-defined nodules and ground glass opacities (3-10 mm diameter) Consolidation Lobular and centrilobular distribution Calcification may not be visible unless lung collapse present Chest wall vascular calcifications Uptake on bone scan

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Microscopic polyangiitis

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Pathology Pulmonary analog of polyarteritis nodosa Most common cause of pulmonary-renal syndrome Affects lungs, kidneys, musculoskeletal, GI, and skin Defect in capillary walls results in capillaritis and hemorrhage May be related to immune complexes Demographics Age: 40s M > F Laboratory Anemia Renal failure Hemosiderin-laden macrophages in BAL fluid p-ANCA positive (Wegener's is c-ANCA positive) Imaging Diffuse pulmonary hemorrhage Multifocal ground glass opacities, consolidation Septal thickening Centrilobular nodules in subacute phase

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Mosaic attenuation

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Small vessel disease Chronic pulmonary embolisms Small airways disease (reactive vasoconstriction) Constrictive bronchiolitis Asthma Hypersensitivity pneumonitis Infection Bronchopneumonia MAC TB Cystic fibrosis

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Mounier-Kuhn syndrome

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Tracheobronchomegaly Pathology Associated with Ehlers-Danlos (adults) and cutis laxis (children) Thin atrophied muscular and elastic tissue in trachea and main bronchi Increased collapsibility during forced expiration and cough Demographics Usually diagnosed age 30-50 years M >> F (19:1) Predisposition in blacks Clinical Recurrent pneumonia Occasional hemoptysis, pneumothorax Size Trachea > 2.5 cm Bronchus > 2.0 cm Imaging Marked dilatation of trachea and central bronchi Corrugated effect due to redundant mucosa prolapsing through tracheal rings Dilated airways on inspiration, collapse on expiration Bronchiectasis Hyperinflation, emphysema Recurrent pneumonia Fibrosis

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Mucoepidermoid carcinoma

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Pathology Submucosal, smooth endobronchial mass High grade tumors may have ragged, invasive appearance Demographics Wide age range M=F Clinical Cough, hemoptysis, fever Pneumonia Location Most in main or lobar bronchi Few in trachea Imaging Solitary endobronchial nodule or mass Distal atelectasis, consolidation

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Necrotizing sarcoid granulomatosis

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Probable vascular manifestation of disseminated or localized sarcoidosis Demographics Age: 20s-60s (mean age 49 years) F > M (2.2:1) Pathology Noncaseating granulomas Vasculitis Pulmonary arteries, pulmonary veins Found in areas away from parenchymal granulomas Widespread coagulative necrosis (distinguishes from other types of sarcoidosis) Clinical Cough, dyspnea, fever, chest pain Weight loss and fatigue Asymptomatic in 15-40% Rare extrapulmonary involvement (13%) Imaging Hilar adenopathy (up to 79%) Subpleural and perivascular nodules (may be cavitary) Parenchymal consolidation Therapy and prognosis May require no therapy Prompt response to steroids

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Neurofibromatosis

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Progressive pulmonary fibrosis Bullae in upper lobes Chest wall and mediastinal neurofibromas Intrathoracic meningoceles Ribbon rib deformities

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Nodule, calcifications

answer

Benign Diffuse Central Popcorn Lamellated Potentially malignant Stippled Eccentric

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Nodule, enhancement

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Protocol Nodule must be relatively spherical in shape and homogeneous without necrosis, calcification, or fat Patient must be able to perform reproducible breath holds Serial CT acquisitions before and at four 1-minute intervals after contrast Criteria Enhancement 15 HU concerning for malignancy, but only moderately specific (Sp 58%)

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Nodule, solitary

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Malignant tumor (50%) Primary cancer (40%) Metastasis (10%) Benign tumor (14%) Hamartoma Chondroma Papilloma Infection TB Fungal Round pneumonia Vascular AVM Varix Inflammatory Sarcoidosis Wegener's granulomatosis RA Inflammatory pseudotumor Congenital Sequestration Lymphadenopathy Fissural pseudotumor

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Nodules, algorithm

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Nodule types SAD: small airways disease CEN: centrilobular PL: perilymphatic RD: random Do nodules abut pleural surface? None: CEN, SAD Few (10%): PL, RD PL, RD nodules Distribution Patchy: PL Diffuse: nondiagnostic Interstitium Thickened: PL Normal: RD SAD, CEN nodules Distribution Patchy: SAD Diffuse: nondiagnostic Bronchiolar impaction Present: SAD Absent: CEN Indeterminate nodules Distribution Patchy: PL or SAD Diffuse: nondiagnostic Interstitium Thickened: PL Bronchiolar impaction Present: SAD Nodule morphology Uniform ground glass: CEN Dense, mixed: CEN or RD

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Nodules, centrilobular (11)

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Features Related to centrilobular bronchiole or artery Centered 5-10 mm from pleura Evenly spaced Diffuse or patchy DDX Bronchiolitis Infectious Constrictive RB, RB-ILD Follicular Bronchopneumonia Endobronchial spread of infection TB MAC Endobronchial spread of tumor BAC Hypersensitivity pneumonitis Cryptogenic organizing pneumonia Pneumoconiosis Silicosis Asbestosis Langerhans cell histiocytosis Edema Vasculitis Talcosis

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Nodules, perilymphatic (6)

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Features Subpleural nodules Peribronchovascular nodules Septal nodules Patchy distribution DDX Sarcoidosis Lymphangitic spread of tumor Silicosis Coal worker's pneumoconiosis Amyloidosis Lymphoid interstitial pneumonia

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Nodules, random (4)

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Features Random distribution relative to lung structures Subpleural nodules Diffuse, uniform distribution DDX Miliary tuberculosis Miliary fungal infection Hematogenous metastases Sarcoidosis (diffuse)

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Nodules, tree-in-bud (8)

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Features Dilatation, impaction of centrilobular airways Clusters, rosettes Centered 5-10 mm from pleura More conspicuous than normal branching vessels Often associated with centrilobular nodules DDX Endobronchial spread of TB, MAC Bronchopneumonia Bronchiectasis, bronchitis Cystic fibrosis Panbronchiolitis Aspiration ABPA BAC

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Nodules, vessel-associated

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Metastatic disease Infection Fungal TB Bacteria Septic emboli Infarcts Langerhans cell histiocytosis Rheumatoid nodules Granulomatosis and granulomatosis Wegener's granulomatosis Churg-Strauss granulomatosis Necrotizing sarcoidosis Bronchocentric granulomatosis Lymphomatoid granulomatosis

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Non-Hodgkin's lymphoma, pathology

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Pathology 60% originate in lymph nodes; 40% in extranodal sites 85% arise from B cells; 15% arise from T cells Demographics All age groups: mean age 50 years Increased incidence in patients with altered immune status Transplant patients AIDS Congenital immunodeficiency Collagen vascular diseases (RA, SLE) Richter syndrome Development of NHL as complication of CLL (may develop while CLL in remission) High-grade B-cell origin Abrupt onset of constitutional symptoms with rapidly progressive lymphadenopathy and clinical deterioration Poor prognosis Resistant to current therapies

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Non-seminomatous germ cell tumor, pathology

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Pathology Large, unencapsulated tumor Hemorrhage, necrosis, ill-defined cysts Types Embryonal carcinoma Yolk sac (endodermal sinus) tumor Choriocarcinoma Mixed germ cell neoplasm Demographics Age 30-40 years Almost exclusively in males Associations Hematologic malignancy Klinefelter syndrome (20%) Clinical Chest pain, dyspnea, cough Imaging Large, irregular anterior mediastinal mass Heterogeneous with central necrosis and hemorrhage Peripheral enhancing soft tissue nodules Local invasion Lymphadenopathy Pleural and pericardial effusions Treatment and prognosis Chemotherapy and surgery Poor prognosis, especially with elevated tumor markers

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Nonspecific interstitial pneumonia (NSIP)

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Group of interstitial lung disorders with more favorable prognosis than IPF Mean age range: 40-50 years Gradual onset with duration of symptoms 6 months to 3 years Cellular, fibrotic, or mixed histologic patterns Clinical Dyspnea Cough Fatigue BAL: increased percentage of lymphocytes Distribution Peribronchovascular Lower lobe predominance Subpleural clearing (distinguishes from IPF) Imaging Ground glass opacities Consolidation Reticulation Traction bronchiectasis Honeycombing infrequent Prognosis Variable but better than IPF May completely recover, stabilize, or relapse

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Pancoast tumor

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Superior sulcus tumor Tumor at lung apex extending into adjacent chest wall Pathology SCC (50%) Adenocarcinoma (25%) Clinical Horner's syndrome (ptosis, miosis, anhidrosis) Pain radiating to arm (invasion of pleura, bone, brachial plexus, or subclavian vessels) Hand muscle atrophy Findings Apical mass Chest wall invasion Involvement of subclavian vessels and brachial plexus Bone involvement: rib, vertebral body

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Papillomatosis, laryngotracheal

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Pathology HPV infection (types 6 and 11 most common) Tropism for keratinizing epithelium Usually self-limited infection 95% cases involve larynx Entire respiratory tract vulnerable Airway dissemination (<1%) Usually apparent in children and young adults Peripartum transmission from infected mother Surgical manipulation of laryngeal papillomas increases risk of dissemination Clinical Wheezing, stridor, dyspnea, hemoptysis Postobstructive pneumonia Demographics Bimodal age distribution Age F in adults Natural history and prognosis Usually self-limited disease in young Slow growth of lung nodules Degeneration to SCC in 2% Imaging Airway papillomas Multiple solid and cavitated nodules May have postobstructive atelectasis, hyperinflation, or pneumonia Rapid growth suspicious for SCC Air-fluid level suspicious for superinfection

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Paraneoplastic syndromes

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Metabolic Cushing's syndrome (ACTH) Inappropriate antidiuresis (SIADH) Carcinoid syndrome (serotonin, other vasoactive substances) Hypercalcemia (PTH, bone mets) Hypoglycemia (insulin-like factor) Musculoskeletal Neuromyopathies Clubbing of fingers (HPO) Periosteal reaction (HPO) Acanthosis nigricans Thrombophlebitis Anemia

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Pleural calcification (5)

answer

Tuberculosis Asbestos-related pleural disease Empyema Hemothorax Talc

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Pleural effusion

answer

Transudate Ultrainfiltrate of plasma Devoid of inflammatory cells Low protein Protein < 3 g/dL Protein (plasma/fluid) < 0.5 Low LDH LDH < 200 IU 3 g/dL Protein (plasma/fluid) > 0.5 High LDH LDH > 200 IU > 70% serum level Common causes Infection Tumor Embolism

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Pleural effusion, causes (7 broad)

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Tumor Bronchogenic carcinoma Pleural metastases Malignant mesothelioma Lymphoma Infection Pneumonia Tuberculosis Empyema Inflammation Collagen vascular disease Esophageal rupture Pancreatitis Subphrenic abscess Meig's syndrome (benign ovarian fibroma) Cardiovascular CHF PE Renal failure Congenital Hydrops (neonate) Metabolic Hypoproteinemia Trauma

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Pleural mass (5 broad)

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Primary tumor Mesothelioma Fibrous tumor of pleura Neurofibroma Lipoma Metastases Thymoma Lymphoma Multiple myeloma Lung Breast Prostate Renal Thyroid Gastric Ovarian Infection Tuberculosis Actinomycosis Asbestos-related pleural disease Plaque Diffuse pleural thickening Trauma Hematoma Splenosis

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Pneumoconiosis, classification

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International Labor Classification (ILO) Small opacities Rounded (nodules) p (<1.5 mm) q (1.5 - 3 mm) r (3-10 mm) Linear (reticular) s (fine) t (medium) u (coarse) Reticulonodular x (fine) y (medium) z (coarse) Location (zone) RU, RM, RL LU, LM, LL Profusion (concentration) 0 (normal) 1 (few nodules) 2 (lung markings still visible) 3 (lung markings obsured) Large opacities Size A (<5 cm) B (half of upper lung zone) C (greater than half of upper lung zone) Other features Pleural thickening, plaques Pleural calcifications Benign pneumoconiosis (asymptomatic or minimal symptoms) Stannosis (tin) Baritosis (barium) Siderosis (iron) Fibrogenic pneumoconiosis (symptomatic) Silicosis Asbestosis Coal worker's pneumoconiosis

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Pneumocystis carinii (jiroveci)

answer

Opportunistic fungal infection Associated with immunodeficiency AIDS patients, especially CD4<200 Long-term corticosteroid therapy Transplant patients Chemotherapy Congenital immunodeficiency Malnutrition Clinical Non-productive cough, fever, dyspnea Hypoxia on room air Elevated LDH (90%) Radiography Perihilar or diffuse hazy opacities Evolution to consolidation Slight upper lobe distribution in patients on aerosolized pentamidine prophylaxis Upper lobe cysts CT Patchy bilateral ground glass opacities Upper lobe, parahilar predominance Progression to consolidation Pneumatocele: upper lobe bizarre-shaped cysts, usually in periphery of lung (AIDS patient) Pneumothorax Bronchopleural fistula Crazy-paving from superimposed interlobular septal thickening No pleural effusions or lymphadenopathy Atypical patterns (5-10%) Unilateral disease Focal lesions Cavitary nodules Treatment Trimethoprim-sulfamethoxazole, pentamidine, adjunctive steroids Prophylaxis with trimethoprim-sulfamethoxazole or dapsone

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Pneumomediastinum (6)

answer

Pulmonary Asthma Barotrauma Childbirth Pneumothorax Airway Tracheobronchial laceration Esophagus Esophageal perforation Boerhaave's syndrome Head and neck Facial fractures Dental or retropharyngeal infection Abdomen Intraperitoneal or retroperitoneal bowel perforation Retroperitoneal surgery Post-surgical

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Pneumonia, aspiration

answer

Predisposing conditions Anesthesia Alcoholism Seizure Esophageal dysmotility Neuromuscular diseases Head and neck surgery Altered mental status Organisms Anaerobes Gram-negative bacteria Staphylococcus Actinomycosis Imaging Bilateral disease common Dependent distribution Posterior segments of upper and lower lobes Superior segments of lower lobes Bronchiectasis in chronic aspiration

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Pneumonia, clinical profiles

answer

Community acquired Pneumococcus Mycoplasma Viruses Staphylococcus Legionella Klebsiella Hospital acquired Staphylococcus Anaerobes Gram-negative organisms Splenectomy Pneumococcus Cystic fibrosis Pseudomonas COPD Haemophilus influenza Branhamella catarrhalis Sickle cell Pneumococcus Aspiration Anaerboic organisms Gram-negative bacteria Staphylococcus Actinomycosis

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Pneumonia, Klebsiella

answer

Friedlander's pneumonia Gram-negative organism Often debilitated patients, alcoholics Imaging Consolidation similar to S. pneumonia Lobar expansion Cavitation in 30-50%, typically multiple Massive necrosis (pulmonary gangrene) Pleural effusion uncommon

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Pneumonia, patterns

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Lobar consolidation Suspicious for postobstructive pneumonia Organisms Pneumococcus Staphylococcus Klebsiella (especially with lobar expansion) Legionella Anaerobic or gram-negative organisms Diffuse interstitial pattern Unusual Organisms Mycoplasma Viral pneumonia Staphylococcus Parapneumonic effusion Early Staphylococcus Pneumococcus Late Anaerobic or gram-negative infections Hilar adenopathy Rare Organisms TB Mycoplasma Fungi EBV Measles Tularemia Plague Anthrax Pertussis Pneumatoceles Late, may persist for months Usually resolve Organisms Staphylococcus Pneumocystis jiroveci Cavitation More common in upper lobes Organisms Staphylococcus Anaerobes, gram-negative bacteria

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Pneumonia, recurrent (6)

answer

Bronchogenic carcinoma Bronchiectasis COPD Alveolar proteinosis Sequestration Esophageal diverticulum

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Pneumonia, resolution

answer

Faster in nonsmokers and outpatients (within 2-3 weeks) Timetable 2 weeks (50% resolution) 4 weeks (66% resolution) 6 weeks (75% resolution) 8 weeks (90% resolution) Delayed with advancing age, involvement of multiple lobes, or complications (abscess, empyema) Recommend follow-up in 6 weeks (unless symptoms worsen) Nonclearance Antibiotic resistance Consider other pathogen (e.g. TB) Recurrent infection Obstruction pneumonitis due to tumor

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Pneumonia, Staphylococcus

answer

Microbiology Gram-positive cocci in clusters Commonly colonizes nasal passages Epidemiology Vast majority are hospital acquired Common cause of death during outbreaks of influenza Increased morbidity and mortality in elderly MRSA increasingly common Imaging Patchy or lobar consolidation Widespread rapid, severe lung destruction Bilateral (>60%) Abscess cavities (25-75%) Pneumatocele formation with abscess healing (50%); may last for years Parapneumonic effusion, empyema (66%)

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Pneumonia, varicella

answer

15% of infected patients have pneumonia 90% older than 20 years Predisposing factors Lymphoma Leukemia Immunodeficiency Pregnancy Clinical Present 2-3 days after appearance of skin eruption Cough, dyspnea, tachypnea, pleuritic chest pain Findings Acute phase: multiple acinar opacities Coalescence of acinar opacities to diffuse patchy airspace disease 1-2 mm calcifications throughout lungs after healing

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Pneumothorax

answer

Iatrogenic Percutaneous biopsy Barotrauma, ventilation Trauma Lung laceration Tracheobronchial rupture Cystic lung disease Bleb, bulla COPD Asthma PCP LAM Langerhans cell histiocytosis Honeycombing Parenchymal necrosis Infectious Abscess Cavitary pneumonia Septic emboli TB Fungal Cavitary neoplasm Radiation Catamenial Pleural endometriosis

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Post-pneumonectomy syndrome

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Pathology Airway obstruction after pulmonary resections Due to extreme shift of mediastinum or rotation of hilar structures Occurs most commonly after right pneumonectomy (or after left pneumonectomy and right arch present) Imaging Air trapping, hyperinflated lung Recurrent pneumonia, bronchiectasis Narrowing of bronchi, trachea Bronchomalacia Marked mediastinal shift Treatment Surgical repositioning of mediastinal structures Reexpansion of postpneumonectomy space (e.g. silicone implant)

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Post-transplant lymphoproliferative disorder (PTLD)

answer

Pathology Driven by EBV infection Diffuse polyclonal expansion with reduced T-cell control Malignant transformation to NHL Imaging Multiple indistinct nodules along bronchovascular bundles May cavitate Ground glass opacities and consolidation Septal thickening Pleural effusion Treatment May respond to antiviral therapy and reduction in immunosuppression Chemotherapy should be avoided

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Progressive massive fibrosis (6)

answer

Silicosis Coal-worker's pneumoconiosis Berylliosis Talcosis Sarcoidosis Tuberculosis

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Pseudolymphoma

answer

Nodular lymphoid hyperplasia Pathology Solitary subpleural mass Lymphoid proliferation of polyclonal B-cells and T-cells Numerous reactive germinal centers Clinical Usually asymptomatic Associations Sjogren's syndrome SLE Transverse myelitis Demographics Middle age Radiography Solitary nodule Focal consolidation CT Subpleural consolidation with indistinct margins Air bronchograms (100%) Usually solitary Adenopathy, effusion suggests lymphoma

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Pulmonary arterial hypertension, etiology (5)

answer

Chronic lung disease COPD Pulmonary fibrosis Anything that causes chronic hypoxia Cardiac disease Left-to-right shunt, Eisenmenger syndrome ASD VSD PDA PAPVR Mitral stenosis LV failure Atrial tumor Chronic pulmonary embolism Schistosomiasis Primary pulmonary hypertension Young women Diagnosis of exclusion

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Pulmonary arterial hypertension, findings

answer

Enlarged central PAs MPA > 30 mm RPA > 20 mm PA:Ao > 1 Rapid tapering of PAs towards periphery Calcification of PAs (chronic) Mosaic pattern of lung attenuation Cardiomegaly RVH Straightening, bowing of interventricular septum towards LV RV predominates at apex Cor pulmonale

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Pulmonary arterial hypertension, pressures

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Normal Psys = 20 mm Hg Pdias = 10 mm Hg Pmean = 14 mm Hg Capillary wedge pressure = 5 mm Hg Definition of pulmonary arterial hypertension Psys > 30 mm Hg Pmean > 18 mm Hg

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Pulmonary arteriovenous malformation (AVM)

answer

Multiple in 35%, bilateral in 8% Most in lower lobes (70%) F > M (2:1) Age: 20s-30s Clinical Dyspnea, cyanosis, clubbing Pansystolic murmur Stroke Cerebral abscess Imaging Lung mass with feeding artery and draining vein Change in size with Valsalva Treatment Coil embolization Etiologies Hereditary hemorrhagic telangiectasia (70%) Osler-Weber-Rendu syndrome 15-20% have pulmonary AVMs Other causes Trauma Infection Hepatopulmonary syndrome (hepatogenic angiodysplasia) Iatrogenic

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Pulmonary artery aneurysm (10)

answer

Pulmonary hypertension Pulmonary valve stenosis Vasculitis Behcet's disease Giant cell arteritis Takayasu's arteritis Hughes-Stovin syndrome Mycotic TB (Rasmussen aneurysm) Endocarditis Septic emboli Necrotizing pneumonia Iatrogenic Pulmonary arterial catheters Congenital Idiopathic Connective tissue disease Marfan Ehlers-Danlos IV drug use Trauma Deceleration Penetration

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Pulmonary artery enlargement (3)

answer

Pulmonary arterial hypertension Pulmonary stenosis Pulmonary artery aneurysm

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Pulmonary artery neoplasms

answer

Primary tumor Angiosarcoma Leiomyosarcoma Rhabdomyosarcoma Fibrosarcoma Osteosarcoma Chondrosarcoma Undifferentiated sarcoma Secondary tumor Lymphoma Bronchogenic carcinoma Breast cancer

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Pulmonary blastoma

answer

Pathology Mixture of epithelial and mesenchymal elements Both components are immature Morphologic mimic of embryonic lung Demographics Biphasic age distribution: 1st and 7th decades M > F Clinical Cough, hemoptysis, dyspnea, chest pain Imaging Large, well-circumscribed peripheral mass May invade pleura Metastases

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Pulmonary complications of transplantation

answer

Early Pulmonary edema Fungal infection CMV pneumonia Pneumocystis jiroveci GVHD Diffuse alveolar hemorrhage Idiopathic pulmonary syndrome Late GVHD Bronchiolitis obliterans Cryptogenic organizing pneumonia VZV Late bacterial infections PTLD NHL

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Pulmonary edema, etiology

answer

Cardiogenic Adults: CHF, MI, mitral regurgitation, ruptured chordae Neonate: hypoplastic left heart, cor triatriatum Renal Renal failure Volume overload Lung injury Septic shock, neurogenic shock Fat embolism Inhalation injury: SO2, O2, Cl2, NO2 Aspiration, drowning

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Pulmonary edema, grading

answer

Grade 1 Vascular redistribution (10-17 mm Hg) Cephalization of vessels Pulmonary veins in 1st intercostal space > 3 mm Grade 2 Interstitial edema (18-25 mm Hg) Peribronchovascular cuffing Perihilar haziness Kerley lines Unsharp central pulmonary vessels (perivascular edema) Pleural effusion Grade 3 Alveolar edema (> 25 mm Hg) Airspace disease: patchy consolidation, air bronchograms

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Pulmonary edema, neurogenic

answer

Upper lobe distribution Enhanced sympathetic activity causes vasoconstriction of basal vessels Redirects blood flow to upper lobes

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Pulmonary embolism, CXR

answer

PIOPED: CXR usually abnormal (84%), but also abnormal in patients without PE (66%) Atelectasis Westermark's sign Localized pulmonary oligemia (rare) Hampton's hump Triangular peripheral cone of infarct Blood in secondary pulmonary lobules Fleishner sign Increased diameter of pulmonary artery (> 16 mm) Seen in acute PE Disappears within few days Cor pulmonale Sudden increase in size of RV, RA Pulmonary edema Pleural effusion (50%)

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Pulmonary gangrene (6)

answer

Pneumococcus Klebsiella Anaerobes Tuberculosis Aspergillus Mucormycosis

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Pulmonary hemorrhage, diffuse (8)

answer

Microscopic polyangiitis Wegener's granulomatosis Churg-Strauss syndrome Collagen vascular disease Goodpasture's syndrome Behcet's syndrome IgA nephropathy Idiopathic pulmonary hemorrhage

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Pulmonary mass (7 broad)

answer

Tumor Bronchogenic carcinoma Lymphoma Metastasis Hamartoma Infection Fungal Parasitic Abscess Congenital CCAM Sequestration Bronchogenic cyst Inflammatory Sarcoidosis Wegener's granulomatosis RA Inflammatory pseudotumor Pneumoconiosis Progressive massive fibrosis Amyloidosis Pleural and chest wall masses

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Pulmonary stenosis, etiology

answer

Valvular (most common) Diaphragm with central hole Bicuspid valve Dysplastic valve with thickened immobile cusps (Noonan syndrome) Carcinoid Rheumatic heart disease Subvalvular Hypoplastic crista supraventricularis in TOF Discrete membrane Double-chambered RV (anomalous muscle bar) RV hypertrophy Tumor Supravalvular Williams syndrome Tetralogy of Fallot Rubella Tumor Carcinoid Thrombus Surgical banding Takayasu's arteritis Behcet's disease

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Pulmonic stenosis, findings

answer

Post-stenotic dilatation of MPA and LPA RPA normal in size Right ventricular hypertrophy Hyperkinetic systolic narrowing of infundibulum Hour-glass appearance of infundibulum beneath pulmonary valve Infundibular stenosis may increase after repair of pulmonary valve stenosis (decreased afterload): fatal RV failure may occur Systolic jet into pulmonary artery Leaflet doming during systole

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Pulmonary varix

answer

Enlarged vein Usually due to mitral stenosis Usually near left atrium

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Pulmonary venoocclusive disease (PVOD)

answer

Occlusion of small pulmonary veins Etiology unknown Pathology: intimal fibrosis Triad Pulmonary arterial hypertension Pulmonary edema Normal wedge pressure Associations Viral infection Environmental toxins Chemotherapy Radiation Oral contraceptives Intracardiac shunts CXR Edema without cephalization Pleural effusion Cardiomegaly CT Secondary pulmonary arterial hypertension Markedly small central pulmonary veins Central and gravity-dependent ground glass opacities Smoothly thickened interlobular septa Normal-sized left atrium Centrilobular nodules Pleural effusion Treatment Lung transplantation

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Relapsing polychondritis

answer

Pathology Collagen vascular disease Inflammation, progressive destruction of cartilage throughout body Location Ear (90%) Joints (80%) Nose (70%) Eye (65%) Respiratory tract (55%) Inner ear (45%) Cardiovascular (25%) Skin (15%) Diagnostic criteria (> 3 needed) Recurrent chondritis of auricles (painful ear) Inflammation of ocular structures (conjunctivitis, scleritis, keratitis Chondritis (painful) of laryngeal, tracheal cartilage Cochlear, vestibular damage Findings Tracheal and bronchial wall thickening, narrowing, and progressive calcification Spares posterior tracheal membrane Focal or diffuse Dynamic airway collapse with expiration Atelectasis, pneumonia in lung distal to stenosis Bronchiectasis from recurrent infection or destruction of cartilage Aortic aneurysm Cardiomegaly from aortic or mitral valve regurgitation

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Respiratory bronchiolitis (RB, RB-ILD)

answer

Definitions Respiratory bronchiolitis (RB) Asymptomatic Respiratory bronchiolitis-interstitial lung disease (RB-ILD) Dyspnea Restrictive or mixed PFTs Smoking-related interstitial lung disease Usually > 30 pack years Good prognosis (reversible with smoking cessation) Pathology Peribronchiolar pigmented macrophages Peribronchiolar fibrosis Upper lobe predominance Imaging Centrilobular nodules Poorly defined 2-3 mm Upper lobe predominance Ground glass opacities Patchy Bronchial wall thickening Air trapping DDX Hypersensitivity pneumonitis Nonspecific interstitial pneumonia (NSIP) Desquamative interstitial pneumonia (DIP) Langerhans cell histiocytosis

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Rheumatoid arthritis

answer

Pleural disease Pleural thickening (20%) Pleural effusion Pneumothorax Pulmonary disease Rheumatoid lung nodules (20%) Caplan's syndrome Fibrosis Ground glass opacities and consolidation Airway disease Constrictive bronchiolitis Follicular bronchitis Bronchogenic granulomatosis Lymphoid disease Lymphoid interstitial pneumonia (LIP) Arterial disease Arteritis Pulmonary hypertension

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Rhinoscleroma

answer

Pathology Chronic granulomatous infection of airways Klebsiella rhinoscleromatis: gram-negative bacteria Primarily affects nasal cavity (95%) and nasopharynx (50%) Paranasal sinuses spared unless ostiomeatal units obstructed Laryngotracheal involvement in 15-40%% Demographics Age: 10-30 years F > M Clinical Nasal obstruction Stridor Epistaxis, rhinorrhea Imaging Irregular subglottic mucosal thickening Diffuse symmetric narrowing Crypt-like spaces nearly diagnostic

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Right middle lobe syndrome

answer

Recurrent or fixed atelectasis or consolidation of right middle lobe (or lingula) Etiology Central obstruction (30%) Lymphadenopathy Bronchostenosis Endobronchial tumor Peripheral obstruction (70%) Lack of collateral ventilation due to complete fissures Ineffective cough Clinical Chronic cough and nonspecific chest pain Demographics Middle-aged F > M Imaging RML collapse with silhouetting of right heart border and wedge-shaped opacity on lateral view Extrinsic compression from lymph nodes, mass, broncholith Endobronchial tumor, foreign body Varying degrees of consolidation and atelectasis Bronchiectasis

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Ritalin abuse

answer

Precocious emphysema in patients who inject ritalin intravenously Resembles alpha-1-antitrypsin deficiency Imaging Large lung volumes Panlobular emphysema May see diffuse micronodular pattern with subsequent development of upper lobe conglomerate masses

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Rounded atelectasis

answer

Features Volume loss Ipsilateral pleural disease Pleural plaques Pleural effusion Broad area of pleural contact Swirling vessels ("comet tail" sign) Associated with asbestos exposure Need follow-up CT to exclude cancer 3 mo, 3 mo, 6 mo, 12 mo for total of 2 years

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Sarcoidosis, imaging

answer

Lymphadenoapathy (80%) Symmetric hilar and paratracheal lymphadenopathy (Garland's triad) Other mediastinal lymph nodes Calcifications common (may be eggshell) Pulmonary involvement (20%) Upper lobe predominance Perilymphatic nodules in subpleural, peribronchovascular, and septal distribution Reticulonodular opacities on CXR Ground-glass opacities Fibrosis with honeycombing, architectural distortion, and traction bronchiectasis (central and upper lobe predominant) Progressive massive fibrosis Cysts, bullae Secondary mycetomas Alveolar sarcoidosis: nodular and mass-like areas of consolidation with air bronchograms Cavitary vessel-associated nodules with necrotizing sarcoid granulomatosis Pleural involvement Pleural effusion (10%) Pneumothorax from ruptured cysts, bullae Airway involvement Bronchiectasis Airway wall thickening and stenoses Atypical findings Asymmetric lymphadenopathy Mediastinal without hilar lymphadenopathy Cavitation Multiple masses Solitary pulmonary nodule

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Sarcoidosis, staging

answer

Silzbach classification (plain film) Stage 0: Initial normal film (10%) Stage 1: Adenopathy (50%) Stage 2: Adenopathy with pulmonary opacities (30%) Stage 3: Pulmonary opacities without hilar adenopathy (10%) Stage 4: Pulmonary fibrosis with or without adenopathy Natural history and prognosis Stage 1 More benign course 75% regress to normal within 3 years 10% remain enlarged 15% progress to stages 2 and 3 Stage 2 and 3 20% develop progressive pulmonary fibrosis Mortality 1-5% Respiratory failure Myocardial involvement Cor pulmonale Hemorrhage (e.g. mycetoma)

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Scleroderma

answer

Type of progressive systemic sclerosis (which also encompasses CREST) After esophagus, lung is 2nd most common site 75% have evidence of lung disease at autopsy 25% have radiographic evidence of lung disease 1% present with pulmonary symptoms Imaging Interstitial fibrosis (most common) Honeycombing (60%) Septal thickening (45%) Basal, posterior, peripheral predominance Ground glass opacities may be present Diffuse pleural thickening (30%) Pulmonary vasculitis and pulmonary hypertension Esophageal dilatation (40-80%)

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Seminoma

answer

Epidemiology 10-20% of mediastinal germ cell tumors Most common malignant mediastinal germ cell tumor Pathology Large unencapsulated tumor Homogeneous soft tissue mass Demographics Age 30-40 years Almost exclusively male Clinical Chest pain, dyspnea, cough Imaging Large, bulky, well-defined anterior mediastinal mass Homogeneous density and enhancement Rare necrosis, cystic change (8%) Calcification rare Treatment and prognosis Radiation therapy Cisplatin-based chemotherapy 5-year survival nearly 100%

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Septal thickening

answer

Smooth Lymphangitic spread of carcinoma or lymphoma Pulmonary edema Alveolar proteinosis Infection Nodular Lymphangitic spread of carcinoma or lymphoma Sarcoidosis Silicosis Coal worker's pneumoconiosis Amyloidosis Lymphoid interstitial pneumonia Irregular Interstitial fibrosis

question

Silicosis, imaging

answer

Well-circumscribed nodules Simple silicosis 1-10 mm Upper-lobe and posterior predominance due to decreased lymphatic drainage Perilymphatic, centrilobular and subpleural distribution More symmetric and evenly distributed than sarcoidosis Calcific nodules Progressive massive fibrosis (PMF) Complicated silicosis Masses (> 1 cm) formed by coalescent nodules Upper lobes (apical, posterior) Lenticular shape with lateral margin paralleling chest wall Usually bilateral Migrates centrally with time Emphysematous lung distal to PMF (risk for pneumothorax) Superior hilar retraction Cavitation due to ischemia or superinfection with TB Pleural lesions Candle-wax or pseudoplaques Nodules concentrated along pleural surfaces within lymphatic loops Lymphadenopathy Calcifications in 10-20% (may be eggshell) Silicoproteinosis Seen with acute silicosis (exposure over few weeks) Central butterfly alveolar pattern with air bronchograms Crazy paving Silicotuberculosis Cavitation of conglomerate masses Apical pleural reaction Caplan syndrome Manifestation of rheumatoid lung disease Rhematoid nodules (necrobiotic nodules) on background of simple silicosis More common with coal worker's pneumoconiosis

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Silicosis, pathology

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Mineralogy Silcon: element Silicon dioxide (SiO2, silica) in quartz, cristobalite, tridy-mite Silicone: synthetic polymer Epidemiology Occupational exposure Mining (gold, tin, copper, mica), quarrying (quartz), sandblasting, stonecutting, engraving, and foundry work M > F Pathology Particles > 5 um removed by upper airways Retained particles 20 years exposure will develop pneumonconiosis May be complicated by lung cancer Treatment Cease exposure; may progress despite removal from exposure (unlike coal worker's pneumoconiosis) Isoniazid (INH) prophylaxis

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Small cell lung cancer, imaging

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CT Bulky mediastinal mass Extensive necrosis, hemorrhage Bronchial encasement, compression, obstruction Post-obstructive pneumonitis, collapse Pulmonary nodules Pleural effusion Vascular encasement, SVC syndrome PET Upstages limited disease to extensive disease in 15%

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Small cell lung cancer, pathology

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Neuroendocrine tumor 20% of primary lung cancer Staging Limited disease (25%) Mediastinum, hila, supraclavicular fossa Feasible port for radiation therapy Median survival 14-16 months 2-year survival 10% Treatment: chemotherapy, radiation therapy Prophylactic cranial irradiation Extensive disease (75%) Extra-thoracic disease Thoracic disease without feasible port (pulmonary metastases, pleural effusion, axillary lymphadenopathy) Median survival 8-11 months 2-year survival 2% Treatment: chemotherapy; palliative radiation therapy Etiology Strong relationship to tobacco use Radiation exposure Exposure to bis-chloromethyl ether Paraneoplastic syndromes Limbic encephalitis Cerebellar degeneration Dermatomyositis, polymyositis Eaton-Lambert syndrome SIADH Cushing syndrome (ectopic ACTH) Hypercalcemic hyperparathyroidism Demographics Age 40s-60s M > F

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Small lung

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Scimitar syndrome Agenesis of pulmonary artery Chronic atelectasis Swyer-James syndrome

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Squamous cell carcinoma

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30% of lung cancer Strongly associated with smoking Arises from proximal segmental bronchi Fast growth, late metastases Most favorable prognosis Paraneoplastic syndrome Hyperparathyroidism from PTH-like substance Findings Cavitating lung mass (30%) Wall thickness > 1 cm suggests malignant cavitary lesion Usually central Atelectasis, lobar collapse Chest wall invasion Pancoast tumor

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Sternal dehiscence

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Complication of median sternotomy (1-2% of cases) Most cases ~ 9 days after surgery Associated with mediastinitis in ~ 50% Predisposing factors COPD Obesity Diabetes Prolonged bypass time during surgery Internal mammary artery grafting Repeat surgery for mediastinal bleeding Prolonged post-operative ventilation Paramedian sternotomy (off-center) Imaging Midsternal stripe sign: midline vertical lucency over sternum > 3 mm usually abnormal Progressive widening of midsternal stripe Displaced (wandering) sternal wires: highly specific for dehiscence (85%) Rotation (50%) or disruption (20%) of sternal wires Wire abnormalities may precede clinical detection of dehiscence by mean of 3 days in 70%

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Swyer-James syndrome

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Unilateral lung hyperlucency Secondary to virally-induced necrotizing and obliterative bronchiolitis Hyperlucent, enlarged lung with static lung volume Attenuation of pulmonary vessels

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Systemic lupus erythematosus (SLE)

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Pleural disease Pleural effusion Pleural thickening Pulmonary disease Acute lupus pneumonitis Fibrosing alveolitis Diaphragmatic disease Elevation Basilar atelectasis

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Talcosis

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Pathology Intravenous injection of oral medications containing magnesium silicate When injected, small talc particles lodge in pulmonary vessels leading to foreign body reaction Agents Ritalin Cocaine Heroin Methadone Acetaminophen Meperidine Diazepam Imaging Numerous small nodules Ground glass opacities from confluent nodules Upper lobe conglomerate masses Possible high attenuation May develop into progressive massive fibrosis

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Teratoma

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Epidemiology 60-75% of mediastinal germ cell neoplasms Demographics Children, young adults (10% immature elements; low potential for malignancy Clinical Often asymptomatic May have symptoms from compression, rupture Imaging Multiloculated cystic mass Internal fat (75%) May have fat-fluid levels Soft tssue elements Calcification Treatment Complete excision is curative 5-year survival 100%

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Thymic carcinoid

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Pathology Aggressive neuroendocrine tumor 20% have metastases on presentation 50% are functionally active Does not produce carcinoid syndrome Associated with Wermer's syndrome (MEN I) in 19-25% Demographics Wide age range (average 43 years) Men > women (3:1) Clinical Most present with symptoms related to mass effect or invasion of mediastinal structures Cushing's syndrome (ectopic ACTH) in 33-40% CT Hypervascular, enhancing solid anterior mediastinal mass Localized or invasive Calcifications and small areas of necrosis may be seen Lymphadenopathy Metastases to lung, pleura, brain Osteoblastic bone metastases Octreotide scan Accumulation is nonspecific (also seen in other thymic tumors and lymphoma) Treatment and prognosis Complete excision may be curative, but local recurrences and metastases develop in 70% Adjuvant radiation and chemotherapy often used Poor prognosis: 5-year survival = 30%

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Thymic carcinoma

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Pathology Aggressive epithelial carcinoma Demographics Wide age range (mean 40s) M > F Clinical Chest pain Weight loss, fatigue Night sweats Imaging Large lobulated, irregular anterior mediastinal mass Heterogeneous enhancement with areas of necrosis Calcification (10-40%) Mediastinal invasion Lymphadenopathy Natural history and prognosis Very poor prognosis Progressive local growth and distant metastatic disease 5-year survival 30%

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Thymic cyst

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Pathology Unilocular or multilocular with septations Likely remnant of fetal thymopharyngeal duct Clinical Usually asymptomatic Rare symptoms from mass effect Imaging Anterior mediastinal mass with single dominant or multiple thin-walled cysts Fluid density, intensity Occasional hemorrhage, calcification No enhancement

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Thymic hyperplasia

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Pathology Lymphoid hyperplasia (autoimmune thymitis) Myasthenia gravis Collagen vascular diseases (SLE, scleroderma, RA) Hyperthyroidism Addison's disease True hyperplasia (rebound thymic hyperplasia) Follows chemotherapy (2 weeks to 14 months), steroids, or severe insult Normal thymus < 20 years: 20 years: 30 years: convex margins abnormal Findings Enlarged thymus without focal mass Fat interspersed in parenchyma No increase in size over time

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Thymic mass

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Thymoma Thymic carcinoma Thymic carcinoid Thymolipoma Thymic hyperplasia Thymic cyst

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Thymolipoma

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Pathology Benign, encapsulated tumor Contains both thymic and adipose tissue Large size (75% > 500g) Demographics Most common in children and young adults Associations Myasthenia gravis: 3% have thymolipomas Aplastic anemia Graves' disease Hypogammaglobulinemia Lipomas in thyroid, pharynx Clinical Little or no symptoms Imaging Anterior, inferior mediastinal mass Fatty and soft tissue elements Usually large, conforms to shape of adjacent structures Positional change in shape Connection to thymus often seen (pedicle)

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Thymoma, imaging

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Oval, lobulated mass within anterior mediastinum Usually asymmetric, projecting to one side Homogeneous when small; heterogeneous when large Calcification (1/3) Capsular thin and linear calcifications Scattered punctate calcifications less common Cystic components, necrosis (1/3) Enhancement No lymphadenopathy Presence of lymphadenopathy excludes thymoma Findings compatible with invasion Indistinctness and obliteration of fat planes Pericardial thickening, encasement of vessels Pleural and transdiaphragmatic metastases

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Thymoma, parathymic syndromes

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Myasthenia gravis (35%) 15% of myastenia patients have thymoma Hypogammaglobulinemia (10%) 5% of hypogammaglobulinemia patients have thymoma Red cell aplasia (5%) 50% of aplastic anemia patients have thymoma

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Thymoma, pathology

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Most common anterior mediastinal tumor in adult Demographics Age > 40 years M=F Pathology Encapsulated and invasive thymoma are histologically identical Diagnosis of invasive thymoma (30%) depends on visualizing gross or microscopic extension beyond capsule "Malignant thymoma" not appropriate terminology Staging Stage I Intact capsule 93% 5-year survivial Stage II Microscopic capsular invasion 80% 5-year survival Stage III Invasion of local structures 70% 5-year survival Stage IV Pleural metastases (IVa) Distant metastases (IVb) 50% 5-year survival Treatment Resection Radiation, chemotherapy

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Tracheal bronchus

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"Pig bronchus" Right upper lobe or segmental right upper lobe bronchus originating from trachea Types Supernumerary: coexists with normal RUL bronchus Displaced: replaces RUL or segmental RUL bronchus No clinical significance Endotracheal intubation may obstruct bronchus

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Tracheal diverticulum

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Mucosal herniation through tracheal wall from increased intraluminal pressure Etiology Congenital Supernumerary lung bud containing all layers of tracheal wall Acquired Chronic increased intraluminal pressure (coughing, emphysema) Larger and wider mouth than congenital diverticula Respiratory epithelium only Imaging Small rounded air-filled cyst Right posterolateral tracheal wall at thoracic inlet Tracheal communication rarely identified on imaging (multiplanar reformations may be useful) Enlarges with expiration, shrinks on inspiration Associated emphysema

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Tracheal enlargement (3)

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Mounier-Kuhn syndrome Tracheomalacia Fibrotic lung disease

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Tracheal narrowing (8)

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Saber-sheath trachea Tracheopathia osteochondroplastica Tracheomalacia Inflammation Relapsing polychondritis Sarcoidosis Wegener's granulomatosis Infection Tuberculosis Fungal infection Rhinoscleroma Post-intubation Post-traumatic Amyloidosis

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Tracheal tumors (5 - broad)

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Primary malignant tumors Squamous cell carcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Carcinoid Primary benign tumors Papilloma Hamartoma Hemangioma Chondroma Lipoma Local invasion Esophageal carcinoma Thyroid carcinoma Lung carcinoma Hematogenous metastases Melanoma Breast carcinoma

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Tracheobronchial tear

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Trachea, left mainstem bronchus Air leak usually confined to mediastinum and subcutaneous tissues Right mainstem bronchus, left distal bronchus Pneumothorax not relieved by chest tube placement

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Tracheobronchomalacia

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Increased compliance and excessive collapsibility of trachea and bronchi Etiology Primary Congenital weakness Secondary COPD Intubation Prior surgery Radiation therapy Long-standing extrinsic compression (e.g. thyroid mass, vascular ring, aneurysm) Chronic inflammation (e.g. relapsing polychondritis) Tracheoesophageal fistula Trauma Recurrent infection Clinical Intractable cough, dyspnea, wheezing, recurrent respiratory infections Congenital: expiratory stridor, cough, difficulty feeding Imaging "Frown sign": crescentic narrowing of tracheal lumen during expiration Trachea may be normal or enlarged during inspiration >50% reduction in airway lumen at expiration is diagnostic May be focal or diffuse

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Tracheopathia osteochondroplastica

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Multiple submucosal osteocartilaginous nodules in tracheobronchial tree Benign, rare condition Most cases discovered incidentally at biopsy Symptoms Dyspnea, hoarseness, expiratory wheeze/stridor (airway obstruction) Hemoptysis (mucosal ulceration) Cough and sputum production Pneumonia (rarely) Demographics Usually > 50 years M > F Findings Calcified nodularity and thickening of tracheobronchial tree Spares posterior membranous wall Narrowed lumen Distal 3/4 of trachea and proximal bronchi most commonly involved

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Tuberculosis, complications (6 - broad)

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End-stage lung disease Hemoptysis Bronchial artery enlargement and erosion in chronic cavities Rasmussen aneurysms of pulmonary arteries Empyema Bronchopleural fistula Empyema necessitans: spontaneous discharge of emypema through parietal pleura, most commonly into chest wall to form subcutaneous abscess Mycetoma Colonization of cavity Pericardial involvement Usually related to adjacent adenopathy Constrictive pericarditis Chest wall involvement Hematogenous or direct spread

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Tuberculosis, post-primary

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Consolidation (50-70%) Apical, posterior segments of upper lobes (85%) Superior segments of lower lobes (14%) Heterogeneous, nodular, linear Focal areas of sparing Cavitation (40-45%) Thin or thick walls Air-fluid levels (20%) Cavitation, necrosis enable spread via airway, bloodstream, pleura Nodules Tuberculoma Endobronchial TB: centrilobular and tree-in-bud nodules Miliary TB: random nodules Airways involvement Bronchiectasis Airway narrowing

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Tuberculosis, primary

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Lymphadenopathy Hallmark of primary TB Children (95%), young adults (43%), elderly (10%) Right paratracheal, hilar Ranke complex Peripheral enhancement, central low-attenuation Atelectasis, overinflation Children Anterior segments of upper lobes Medial segment of middle lobe, lingula Consolidation Mid and lower lung zones Ghon focus Unifocal (75%) > multifocal May be segmental or lobar Homogeneous, patchy, linear, nodular Pleural effusion Adults (38%), children (11%) May be primary manifestation of disease Unilateral pleural effusion in adult is suspicious for TB Smear, culture usually negative Pleural biopsy negative in 50% Low glucose

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Vacuthorax

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Abnormally stiff lung (fibrosis) Lung not able to reexpand to fill pleural space Unlikely to benefit from thoracentesis

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Vanishing lung syndrome

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Idiopathic giant bullous emphysema Often seen in young men Progressive bullae Asymmetric upper lobe involvement Paraseptal and centrilobular emphysema Most are smokers, but occasionally affects nonsmokers

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Wegener's granulomatosis

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Upper respiratory tract Progressive destruction of nasal cartilage and bone Sinusitis Eustachian tube obstruction, otitis media Subglottic stricture Ulcerative tracheobronchitis Tracheal or bronchial stenosis Pulmonary Multiple nodules and masses with cavitation Feeding vessels (88%) Halo sign Subpleural predominance Basilar reticulonodular opacities Airspace consolidation, hemorrhage Pleural effusion (25%) Adenopathy (rare) GU Focal glomerulonephritis Erythrocyte casts and proteniuria Vasculitis Skin (50%) Symmetric papulonecrotic lesions Eye and orbit (30%) Scleritis, conjunctivitis Optic nerve and retro-orbital masses CNS (30%) Mononeuritis multiplex Musculoskeletal Migratory polyarthropathy

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Williams-Campbell syndrome

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Congenital bronchial cartilage deficiency Cystic bronchiectasis Ballooning of central bronchi on inspiration with collapse on expiration Distal air trapping

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Zonal predominance, Upper (8)

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Upper lobes (PB CASSET) Pneumocystis carinii Berylliosis Cystic fibrosis Ankylosing spondylitis Silicosis Sarcoidosis Eosinophilic granuloma (Langerhans cell histiocytosis) Tuberculosis

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Zonal predominance, Lower (6)

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Lower lobes (BADDAS) Bronchiectasis Aspiration Drugs DIP Asbestosis Scleroderma, other collagen vascular diseases

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