Dept.

of Radiology, Szeged University of Sciences

Because of the large number of pathologies

RADIOLOGY OF THE THORAX

Part Two
Lornd L. Frter, M.D.

we have to concentrate to the most outstanding parts

The negative thorax

ANATOMY
parenchyma (alveoli) interstitium (supporting tissues) bronchi vessels (pulmonary and bronchial arteries and venes) lymphatics pleura mediastinum

calculated

projected

PARENCHYMA

TISSUE DEFICIENCY

structure of alveoloacinar system looks grapelike, microscopic view shows a thin section of it

agenesis destruction surgical removement

agenesis

AIR EXCESS

emphysema compensatory destructive bullous cyst left lung of the baby is not developed, left hemithorax is occupied by the rigth lung and heart

compensatory emphysema

centrilobular emphysema

due to pulmonectomy on the left, right lung is overexpanded and emphysematous, calcified left hilar lymph node is distracted to left

CT shows distended alveoloacinar system resulting in cystic degeneration caused by smoking and fine industrial dust

chronic destructive emphysema

AIR DEFICIENCY

atelectasis obstructive compressive contractional reflectory barrel chest, hyperlucent lungs and inverted diaphragm proves high intraalveolar pressure

obstructive atelectasis

discoid or Fleischners atelectasis

intubation deeply into the right main bronchus, left side is obstructed by the tracheal canule

signalizes peritonitis or peritoneal irritation in acute abdomen

TISSUE EXCESS

INFLAMMATIONS

inflammations hypersensitive processes sarcoidosis Hodgkins disease malignancies

primary pneumonia: bacterial or viral pathogens with affinity to the lung secondary pneumonia: non lung specific agents, mainly irritative processes

BACTERIAL PNEUMONIA

Bronchopneumonia

bronchopneumonia lobar pneumonia Staphylococcus pneumonia complications: pleuritis, abscess

frequently occurs inhomogenic, multifocal hilar adenomegalia rapidly changes its form and extension

Lobar pneumonia

Lobar pneumonia

infrequent respects lobar margins almost homogenic intumescent lobes recently incomplet forms are common

sometimes multilobar air bronchogram is characteristic () it changes its form and extension slowly

Staphylococcus pneumonia

abscess

mainly in children rapid tissue destruction abscess, ptx, pyoptx

multilocular pyopneumothorax

following partial drainage crescent shape shadow appears

tuberculosis

primary complexum

homeless, alcoholic, drug addicts or immuncompromised people, immigrants from the East and the South incidence of polyresistent infections is growing often asymptomatic importance of screening in the antibiotic era, its varied forms are radiologically less characteristic indistinct peripheral nodule and hilar lymphadenomegaly connected by inflammated lymphatics (dumbbell form)

caverna

miliary tuberculosis

cavitation:

hematogenous dissemination

watery pus is emptied via bronchi by caughing highly infectious stage

other organs also may be infected

NOTICE
in developed countries the 3rd most frequent death cause is infectious disease again 15% more people dies in pneumonia in the USA now, than 20 years earlier

SECONDARY PNEUMONIA
uremia aspiration irritative gases and vapors (fume, chlorine, sulphuric acid, nitrous and noxious gases etc.) inhalation of lipids (oil, hair spray)

uremia

INTERSTITIUM

interstitial intumescence due to toxic accumulation

connective tissue, vessels, bronchi and lymphatics support the alveoloacinar system

Interstitial shadows

alveolar and interstitial structures

normal alveoli

interstitial fibrosis

are arranged in lines

pneumoconiosis

intraalveolar

interstitial appearance

Interstitial disorders
pneumonitis (interstitial pneumonia) allergic and autoimmune disorders congestion fibrosis pneumoconiosis malignant propagation

connective tissue lines are radiating from the hila to the periphery

viral pneumonia

viral pneumonia

clinical status and radiological manifestation may diverge

rapidly spreading hemorrhagic forms may conclude in lethal exit

hypersensitive vasculitis

interstitial congestion
interlobar fissure parahilar opacity Kerleys lines

severe bilateral perivascular infiltration in systemic lupus erythematosus (SLE), note the linear array of the shadows

pleural fluid

alveolar and interstitial edema

alveolar: butterfly or bats wing pattern interstitial: radiated arrangement

pneumoconiosis: silicosis

reticulonodular infiltrates and fibrosis due to chronic free silica inhalation

siderosis

fibrosis

occupational illness rusty dust inhalation

coagulated fibrine depositions in the interstitial spaces

honeycomb lung

Sarcoidosis (Morbus Boeck)

predominantly interstitial epitheloid granulomatosis hilar, pulmonary and mixed forms exist characteristically symmetrical CT is recommended heals with fibrosis or resolves completely

due to destroyed alveolar surface, gas exchange seriously deteriorates

Sarcoidosis

Hodgkins disease

hilar lymphnodes are symmetrically enlarged, lung parenchyma is also affected

chronic disease with lymphoreticular proliferation mediastinal and cervical lymph node enlargements hilar lymphadenopathy is mainly asymmetrical spreads from one site to the next contiguous site distant manifestation (e. g. in bones) occures diagnosis should be proved by cytopathology

Hodgkins disease

Hodgkins disease

characteristically asymmetrical mediastinal lymphadenomegaly

contiguous proliferation to the mediastinum

Non-Hodgkins lymphoma

Non-Hodgkins disease

neoplasmatic proliferation of lymphoid cells usually disseminates throughout the body thoracic manifestation is characterized by its remarkable asymmetry distant foci are detected by CT, PET or CT-PET diagnosis can be made only by histologic study

plain film shows indistinct, asymmetrical mediastinal lympadenopathy PET reveals cervical lymph nodes of NHL

BRONCHI

Bronchial disorders
cyst polycystic lung bronchiolitis obliterans bronchiectasis bronchostenosis

are tubular structures connecting outside word with alveoloacinar system

polycystic lung

bronchiolitis obliterans

severe honeycombing on the left

mosaic lung most frequently caused by smoking

bronchiectasis

bronchostenosis

extensive saccular dilatation of bronchi bronchography and CT

tumorous obstruction of the left main bronchus

VASCULARISATION

Vascular disorders
congenital malformations hypoperfusion hyperperfusion pulmonary hypertension pulmonary venous congestion pulmonary embolism pulmonary infarction

lungs are perfused paralel by the pulmonary and systemic (bronchial) circulation

agenesia

blood volume

right pulmonary artery is missing, the properly aereated right lung is perfused only by bronchial arteries

normovascularisation hypoperfusion in rightto-left shunt

hyperperfusion in leftto-right shunt

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pulmonary hypertension

pulmonary venous congestion

normotension

normal

abruptly tapered central pulmonary arteries

redistributed perfusion with interstitial imbibition

pulmonary embolism

multiple pulmonary embolism

occlusion of a segmental pulmonary branch (left) and impacted embolus in the right main pulmonary artery

3D MR perfusion MIP

pulmonary infarction
Hamptons hump

TUMORS

multiple hemorrhagic infarction

space occupying disorders

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Main forms of lung tumors

benign: hamartoma semimalignant: bronchial adenoma alveolocellular carcinoma malignant: bronchogenic carcinoma sarcoma

Benign tumors

well differenciated cells, propagation is of the same pace in every direction round or oval form non invasive well defined margins calcification: mainly central, coarse, reminiscent to a popcorn sometimes peripheral and linear (eggshell)

chondroma, hamartoma

Semimalignant tumors

bronchial adenoma: benign on histology, but metastatizes alveolocellular carcinoma: contiguous propagation, malignant on histology, but metastases are rare

well defined peripheral nodules, popcorn calcification

bronchial adenoma

alveolocellular carcinoma

virtual bronchoscopy: bronchial lumen is partly obstructed

due to contiguous alveolar propagation bronchi remain usually intact

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Malignant tumors

bronchogenic carcinoma

imperfectly differenciated cells, growth in different rythm into the adjacent tissues irregular, spiculated form invasive propagation indistinct margins calcification: frequently off-center, pinpoint size metastases are common

coronal, axial and sagittal CT localize right upper lobe cancer

bronchogenic carcinoma

bronchogenic carcinoma

malignant infiltration on plain film and axial CT

spiculated lung cancer in the right upper lobe

bronchogenic carcinoma
recurrent pneumonia: males over 40, smokers repeated infiltrations on the same location

peripheral nodule

cave: incipient bronchogenic carcinoma!

solitary nodules always suggests malignancy

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bronchogenic carcinoma

bronchogenic carcinoma

tumorous propagations demonstrated by 3D CT angiography

CT-PET delivers functional (right) and topographical data

metastases

MEDIASTINUM

numerous, clearly defined, round nodules of different diameter, increasing in size and quantity downwards are characteristic to a prolonged dissemination of a distant malignancy

is the mysterious shadow in the middle of the film

mediastinal structures
heart and great vessels esophagus trachea and main bronchi lymph nodes endocrin organs (thyroid and thymus) loose and fatty connective tissue overshadowing backbone and breastbone

Mediastinal disorders
dislocation mediastinitis mediastinal emphysema haemomediastinum hernia benign tumors and malignancies

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mediastinal shift

mediastinitis

atelectasis on the left

hemothorax on the left

suture insufficiency after esophageal resection

mediastinal emphysema

hemomediastinum

traffic accident, esophagus perforation and rupture of the trachea air bands in the mediastinum

mediastinal hematoma due to arterial suture insufficiency

mediastinal cyst?

intrathoracic stomach

gastric motility sounds from the chest a case for psychiatrists?

patients are always right! stomach was displaced into the right pleural cavity through ruptured diaphragm following an railway accident decades earlier

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Mediastinal tumors
anterior mediastinum: goiter, thymomas middle compartment: lymphoids, metastases posterior mediastinum: neurogenic tumors

intrathoracic goiter

tracheal stenosis caused by benign hyperplasia of the thyroid

thymoma

tumor in the middle mediastinum

well defined, benign tumor in the anterior compartment

invasive malignant tumor infiltration compresses the right main bronchus () and pulmonary artery ()

neurogenic tumor

metastases

arising from peripheral nerves or sympathetic ganglia, tumors of neurogenic origine are found adjacent to the spine (MR)

either in the mediastinum, or extrathoracal, metastases are easily demonstrated by CT-PET

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PLEURA

Disorders of the pleura

pneumothorax pleural fluid collection (transudatum) pleuritis (exudatum) empyema thoracis callous pleural thickening mesothelioma metastases

is a thin, transparent serous membrane enveloping the lungs

pneumothorax

pleural transudatum

air collection in the right pleural cavity: lung collapsed to the hilum, leaving no vascular markings in the right hemithorax

signalizes disease of other organs than pleura, bilateral effusion shows concave margins with dystelectatic adjacent lobes

pleural exudatum

callous calcification

exudative effusions are mainly unilateral, in this case adjacent to a lung abscess

as a late complication of a right hemothorax, coarsely calcified pleural deposits are seen contracting the ipsilateral hemithorax

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mesothelioma

pleural metastases

this malignant pleural thickening frequently induced by azbestos inhalation

large, parietal metastatic masses () of a breast cancer visualized by partially depleted cancerous fluid collection ()

RADIOLOGY OF THE THORAX

difficult but indispensable step to the diagnosis for better result, radiologist should be informed about short history and major data regarding the patient in cases, personal consilium might not be avoided even most sophisticated modalities cant solve the problem by itself and may not replace human intellectual efforts

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