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( ) ?

CXR interpretation

? PA AP density 5 : ()

- density - variation

(aeration) (rotation)

?Posterior rib 10 Anterior rib 6 Midline medial end clavicle spine

(penetration)

Density Metallic

(PA) : Soft tissue, bone Lung - vessels periphery - minor fissure horizontal

Fat Trachea bronchus - Paratracheal stripe - carina variation Diaphragm - - costophrenic angle

Bone

Air Water, Soft tissue

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(PA) : midline structure - thorax - 3 : aorta, pulmonary trunk, left heart - aorta

(PA) : Hilar - Pulmonary artery : : right PA 1.5 - hilar hilar

Pulmonary HT PA

Hilar enlargement in TB

Increase opacity - Alveolar pattern - Interstitial pattern - Mass, nodules - Pleural effusion - Atelectasis (- Bronchial pattern) (- Vascular pattern) Decrease opacity - air emphysema, pneumothorax - soft tissue pulmonary embolism

Alveolar pattern - increased density - confluent - ill-defined margin fluffy - air bronchogram

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Air bronchogram

Patchy

Interstitial pattern - linear : fine coarse : septal line (Kerley lines), honey-comb pattern - nodules : 3 - reticular = network of crossing lines =

Alevolar pattern

- reticulo-nodular

Interstitial opacity

Nodular infiltration

Nodules Acinar Interstitial Acinar - - - interstitial nodules Interstitial - - - ( 2-5 .) Nodules > 1 cm : more malignant Nodules < 5 mm : more benign

Nodules

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Bronchial pattern Peribronchial thickening Loss of normal tapering of bronchi railroad or tram tracks : Bronchiectasis

Tram track

Vascular pattern Increased - left to right shunt - venous congestion (left heart failure) - Pulmonary HT Decreased - right to left shunt - emphysema - pericardial disease - thromboembolism - hypovolemia

Venous congestion

Atelectasis Increased density Clouding of vessels Shift of fissure Elevation of diaphragm Shift of mediastinum Shift of hilum Rib approximation Compensatory hyperinflation

LLL atelectasis

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LUL atelectasis

RLL & RML atelectasis

RUL atelectasis

Golden S = RUL mass with Atelectasis

The Silhouette sign

Structure density ?Air () Soft tissue ()Right heart border RLL, LLL Left ventricle Anterior mediastinum

2 density 2

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Structure density ?Air () Soft tissue ()

RML (medial segment) Right heart borderRLL, LLL

DiaphragmLeft ventricle

LingularAnterior mediastinum

RLL

LLL

Heart

Silhouette lesion Structure RML RLL, LLL Lingular Space anterior mediastinum Descending aorta posterior mediastinum

RML opacity Silhouette

Silhouette = RML lesion = RLL, LLL lesion = lingular lesion Lesion silhouette = anterior middle mediastinal lesion aorta lesion

Lateral segment

Medial segment

Lingular opacity Silhouette

?

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RLL RML

? Anterior mediastinum Middle mediastinum Posterior mediastinum Enlarged left PA Lung mass

Anterior mediastinal mass

The Spine sign lateral view spine

Hilar overlay sign

The Spine sign

( ) 1. 2. 3. 4. ?

5.

6. ? : hidden area : Apex, Hilar, Retrocardiac, Diaphragm

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42 Reassure lordotic view ENT

1. 2. 3. 4. ? CXR Hidden area Apex Hilar Retrocardiac Diaphragm (Miliary)

Hidden area

5. 6. ? : hidden area

Retrocardiac opacity

45 15 pack-yr 3 PE.

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3 ? lateral NSAIDS CT chest EKG Trop-T

( ) 6

NSAIDS 3

50 +/- 2 CA lung Recurrent TB Pneumonia Lung abscess Loculated pleural effusion

Choice CA lung Recurrent TB Pneumonia Lung abscess Loculated pleural effusion

( )........ ...()

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Extra Intra-parenchyma ? alveolar process

Heart failure Pneumonia ?

Kerleys B in volume overload

40 1

(). A. ? B. ?

?

1 2 3 4 5

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paratracheal soft tissue

38 1 . Sputum AFB-neg melioid titer Start HRZE spirometry Sputum C/S for mycobacterium Tuberculin skin test

Diagnosis lymphoma

1

Bronchoscopy Continue HRZE 1 Continue HRZE sputum C/S for TB 2SHRZE/1HRZE/5HRE spirometry, lung volume DLco

DDx diffuse nodular infiltration - Infection - Occupational lung disease - Malignancy - Hypersensitivity TB bronchoscopy with TBBx = Bronchioloalveolar cell CA

Malignancy miliary pattern

Thyroid carcinoma Malignant melanoma Renal cell CA Osteosarcoma Etc.

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40 1 close contact TB, AFB negative

: soft tissue, bone, lung,..

Rx as TB, X-ray 6 Rx as TB, x-ray 1 CT Sputum C/S TB Bronchoscopy

: hemorrhoid TBBx adenocarcinoma = NSCLC stage IV ? Regimen CA lung ?

Cannon-ball Germ cell tumor Osteosarcoma Colorectal CA Testicular CA Breast CA Renal cell CA CA prostate CA nasopharynx

60 : Asymptomatic, check-upRhabdomyosarcoma Renal cell CA

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60 : Asymptomatic, check-up

Asymptomatic, 3

CT chest CXR lateral view CXR lordotic view 1

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RUL infiltration 8

single Lung nodule

40 non-smoking, asymptomatic

Factors influencing the probability of cancer in lung nodule Nodule characterization - size - margin - internal characteristics - density - growth Age Gender Cigarette smoking Spirometry Occupation Endemic granulomatous disease

? PET scan Lobectomy CT-guided FNA Bronchoscopy CXR 3-6

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Likelihood ratios for malignancySize (cm) > 3.0 2.1-3.0 1.1-2.0 < 1.0 Age (y) > 70 50-70 30-39 Growth rate (d) > 465 7-465 15 Irregular speculated edge Indeterminate calcification Current smoker Never smoked

Patterns of Calcification5.23 3.67 0.74 0.52 4.16 1.90 0.24 0.01 3.40 0 2.32 5.54 2.20 2.27 0.19

Nodule (< 3 ) - 40 - - (?) - - 1.5 - Calcification benign CT

Almost 100% benign : - popcorn (hamartoma) - laminated - central nidus - diffuse

Eccentric calcification in cancer

Gurney JW, Radiology 1993, Gould MK, et al. JAMA 2001

Single lung nodule CT chest, non-invasive Ix infection risk : risk 3 6 2 doubling time - : favor benign - : favor malignant : risk

Doubling time = 2

2008

2010

Spiculated nodule Cancer

1 Chronic bronchitis Lung abscess Hiatal hernia Diaphragmatic paralysis RLL atelectasis

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different density density

Hiatal hernia : : GERD : - strangulation : ischemia necrosis (paraesophageal type) - restrict (rare) - GERD

Scenario

CXR in ICU

(Amyotrophic lateral Sclerosis) Byrd ventilator ventilator volume ICU

Intake Output

Effect lung volume

ward 16 . hemodialysis Neuogenic pulmonary edema

7 ribs

10 ribs

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Heart failure vs ARDS heart failure - - vascular redistribution - pleural effusion - septal lines - bat-wing ARDS myocardial dysfunction

Bat-wing

40 lobar pneumonia 1 slightly decreased breath sound & hyperresonance on percussion at left lung, no crepitation, midline trachea CXR

Pneumothorax supine

pneumothorax

1. ARDS 2. pneumothorax 3. pulmonary embolism 4. volume overload 5. worsening of pneumonia

Pneumothorax in ICU Deep sulcus sign Hyperlucent upper quadrant

Radiographic signs of anteromedial pneumothorax (supine)

Suprahilar Sharp delineation of - SVC - Azygos vein - Left subclavian vein - anterior junction line

Infrahilar Sharp outline of - heart border - IVC Deep cardiophrenic sulcus Outline of medial diaphragm under heart silhouette Sharp pericardial fat pad

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DM, nephrotic syndrome, CKD 3 . UTI

Pleural effusion in supine position increased homogeneous density superimposed over (visible) lung fields obliteration of silhouette of the diaphragm meniscus sign accentuation of the right minor fissure

Pulmonary edema volume overload Hospital-acquired pneumonia Pleural effusion .................. ARDS

1

2

3

1

A

2

B

C

3

D

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1 Pancoast tumor

2 COPD

3 Pulmonary TB & TB LN.

( ) ? PA AP density 5 : ()

?

- density - variation

19