(BQ) Part 1 book Chest radiology has contents: Anatomy of Anatom, chest wall, pleura, infections and diffuse lesions, diseases of the airway, idiopathic interstitial pulmonary fibrosis, kartagener syndrom,.... and other contents.
Jaypee Gold Standard Mini Atlas Series® CHEST RADIOLOGY Jaypee Gold Standard Mini Atlas Series® CHEST RADIOLOGY Editor Hariqbal Singh MD DMRD Professor and Head Department of Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • London • Philadelphia • Panama ® Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +507-301-0496 Fax: 507-301-0499 Email: cservice@jphmedical.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers Ltd The Bourse 111, South Independence Mall East Suite 835, Philadelphia, PA 19106, USA Phone: + 267-519-9789 Email: joe.rusko@jaypeebrothers.com Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: jaypee.nepal@gmail.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2013, Jaypee Brothers Medical Publishers All rights reserved No part of this book and Photo CD-ROM may be reproduced in any form or by any means without the prior permission of the publisher Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only While every effort is made to ensure accuracy of information, the publisher and the editor specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the editors Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device Jaypee Gold Standard Mini Atlas Series®: Chest Radiology First Edition: 2013 ISBN : 978-93-5090-463-3 Printed at Dedicated to My son Hamitesh Singh on joining Indian Armed Forces Buoyancy Low knowledge, bestows high confidence Less one knows, more sure he is as One fails to know what he does not know —Hariqbal Singh Contributors Abhijit Pawar DNB (Radiology) Parvez Sheik MBBS DMRE Aditi Dongre MD (Radiology) Roshan Lodha DMRD Amol Nade DMRE Santosh Konde MD (Radiology) Assistant Professor Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Assistant Professor Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Consultant Radiology Nidam Imaging Centre Pune, Maharashtra, India Amol Sasane MD (Radiology) Lecturer Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Hariqbal Singh MD DMRD Professor and Head Department of Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Consultant Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Consultant Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Assistant Professor Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Shishir Zargad DMRE Consultant Radiology Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Sikandar Sheikh MD (Radiology) DMR Consultant (Radiology and PET-CT) Apollo Health City Hyderabad, Andhra Pradesh India viii Chest Radiology Sushil Kachewar MD (Radiology) Associate Professor Rural Medical College Loni, Maharashtra India Varsha Rangankar MD (Radiology) Associate Professor Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Vikash Ojha MD (Radiology) Consultant Radiology Department of Radio-Diagnosis Apollo Jehangir Hospital Pune, Maharashtra, India Preface Chest X-ray is the most commonly requisitioned film in any medical establishment and continues to be the most informative film due to availability of tissue contrast provided by air in the lungs; consequently, the approach to understanding chest X-ray is important In routine, reporting practice often the technical quality is below perfect, such films have also been included in this collection to expose the reader to actual life situation Contrast studies, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography in many cases complement the plain film to provide perfect diagnosis This book is steal a look into chest imaging in an easy and understandable manner This assemblage of images will be useful to all residents entering the domain of any medical specialization and to any general practitioner or specialist in the field of medicine Hariqbal Singh Tumors Fig 7.3 CECT shows a well-defined fat pad anteriorly in right cardiophrenic angle pericardial in position Solitary Pulmonary Nodule Solitary pulmonary nodule (SPN) or coin lesion is a round or oval lesion in the lung smaller than cm in diameter (Figs 7.4 A to D) If it is more than cm in diameter, it is called a mass It appears as a distinct discrete white area in the lung on chest radiograph The smaller the nodule the more likely it is benign It can be an incidental finding and most commonly represents a benign tumor such as a granuloma or hamartoma, but in around 20 percent of cases, it is a malignant especially in smokers and individuals above 40 years Solitary pulmonary nodules with smooth well-defined margin are likely to be benign and SPN with irregular (Fig 7.5) speculated margin are likely to be malignant Calcification in the nodule suggests the lesion as benign, however, eccentric calcification suggests malignancy If the lesion is more than cm in diameter, it is likely to be malignant in 90 percent of cases 85 86 Chest Radiology B C A D Figs 7.4A to D X-ray and CT scan chest shows a solitary pulmonary nodule Fig 7.5 CT chest shows a hete rogeneously enhancing solitary pulmonary nodule in left lung which was proved to be a carcinoma Tumors To evaluate, SPN one must compare with older X-rays, if available This is important because doubling time of most malignant SPNs is to months, and any nodule that grows more slowly or quickly is likely benign CT scan is usually considered an essential follow-up to the chest X-ray Carcinoma Lung Lung tumors are classified as: Primary a Benign: Pulmonary hamartoma b Malignant: Carcinoma of bronchus, alveolar cell carcinoma, lymphoma and carcinoid Metastases Most common fatal malignancy in the adult males is carcinoma of the bronchus Carcinoma bronchus is of four types—squamous cell carcinoma, adenocarcinoma, small cell carcinoma and large cell carcinoma On X-ray chest, it presents as central or peripherally situated mass (Figs 7.6 and 7.7) Features suggesting malignancy are nodular mass with irregular, spiculated margins; cavitating mass lesion with thick irregular or nodular walls It may be associated with hilar enlargement or segmental or lobar collapse of the lung Central bronchogenic carcinoma causes collapse of distal lobe resulting in the traditional Golden S sign; however, a more appropriate would be inverted pyramid sign (Figs 7.8A to D) CT is indicated for the staging of carcinoma lung and detecting metastasis 87 88 Chest Radiology A B Figs 7.6A and B X-ray chest PA (A) and lateral (B) views show a mass lesion in right upper lobe (arrow) in a 70-year-old male, likely bronchogenic carcinoma Lung is the most common site for metastatic disease Most common primaries are breast, gastrointestinal tract, kidney, testes, head and neck, and bones On imaging, it shows various patterns like multiple parenchymal nodules, and lymphangitis carcino matosis or pleural effusion Pancoast Tumor Carcinoma of the apex of the lung is termed as Pancoast’s tumor or superior sulcus tumor that involves the brachial plexus and sympathetic ganglion of the lower neck and upper mediastinum (Figs 7.9A and B) Lung malignancy or metastatic diseases are the most common causes of pancoast tumors, other causes are lymphoma, mesothelioma, and multiple mye loma Pancoast Tumors A B C D Figs 7.7A to D CT of the same case confirms the diagnosis Figures (A and B) show ill-defined rounded opacity abutting the chest wall with radiating strand seen in right upper lobe (A) with minimal necrosis within seen in mediastinal window (C) Mediastinal window shows aortopulmonary lymph node (arrow) (D) A small round hypodense metastasis is seen in the right lobe of liver syndrome is a clinical triad of: (a) Horner’s syndrome (ptosis, miosis, anhidrosis, and enophthalmos, (b) ipsil ateral arm pain and (c) wasting of the hand muscles Pulmonary Metastasis When multiple lung metastases are present, they can be recognized in the topogram Depending upon the age and vascularization of the metastases, they appear as spherical nodules of varying 89 90 Chest Radiology A B C D Figs 7.8A to D (A) Scout image of chest shows right upper lobe collapse consolidation (B) Post-contrast CT shows right upper lobe mass causing collapse consolidation of distal lobe (C and D) Coronal and sagittal reconstructed images demonstrate the inverted pyramid sign as seen in Figures A and B Tumors A B Figs 7.9A and B (A) X-ray chest shows a mass lesion occupying left apex with trachea pushed to the right (B) Penetrated view chest in addition to mass in the left apex shows destruction of 1st and 2nd ribs on the left sizes The more irregular the contours of the lesions (stellate or speculated), the more likely they are to be malignant If, however, they are solitary and have central calcification (like a popcorn), or peripheral calcification, the lesions are most likely to be a benign hamartoma or granuloma Pulmonary metastases are not visible in conventional X-rays unless they are larger than mm in diameter Peripheral metastases are also not visible on X-ray chest In CT images, however, they can be detected at about mm in diameter If metastases are located in the periphery, it is easy to differentiate them from blood vessels cut in cross-section Small metastases located close to the hilum are much more difficult to distinguish from vessels 91 92 Chest Radiology Lung windows should always be used for examining lung parenchyma In the case of multiple small metastases close to the pleura can be overlooked if lung windows are not used These examples demonstrate the importance of viewing each image on bone and soft-tissue windows and in different window width and window center Case A 64 years old male, operated case of carcinoma larynx reported with pain on right side of chest X-ray chest showed small rounded opacities in both upper zones and left lower zone CT neck revealed radical neck dissection on the right side of neck secondary to surgery for carcinoma larynx CT chest confirmed presences of well-defined nodules in both upper zones and a small rounded nodule noted in left lower zone—the metastatic lesions (Figs 7.10A to E) Case A case of unknown primary carcinoma with pleural and pulmonary metastases (Figs 7.11A to D) Case A 12 years male presented with pain in abdomen and fever for 20 days Diagnosed as hepatoblastoma with pulmonary meta stases (Figs 7.12A to C) Hepatoblastoma is the most common primary liver tumor in children, accounting for 79 percent of pediatric liver malignancies in children younger than 15 years Tumors B A C E D Figs 7.10A to E (A) CT neck shows radical dissection on the right side of neck secondary to surgery for carcinoma larynx (B) CT chest confirmed presences of well-defined nodules in both upper zones (C) A metastatic mass is seen in right mid zone (D) A small-rounded nodule noted in left lower zone (E) A small enhancing metaststic lesion is seen in the periphery of the right lobe of liver-metastatic lesions Case An elderly female presented with postmenopausal bleed was subjected to CT abdomen and pelvis Diagnosed as endometrial carcinoma with myometrial invasion Left renal and pulmonary metastases with metastatic para-aortic adenopathy was seen (Figs 7.13A to D) 93 94 Chest Radiology A B C D Figs 7.11A to D (A) Scout image shows left pleural thickening with effusion (B and C) CT images show irregular and thick left pleura with effusion (D) Lung window image shows multiple hyperdense lung metastases, few of which have speculated margins Case A six years old male child presented with gradually increasing lump abdomen Diagnosed as Wilms’ tumor (nephroblastoma) with hepatic and pulmonary metastases CT showed a large well defined enhancing mass lesion × 10 cm with few areas of necrosis, involving the right kidney, sparing its upper pole Medially, the lesion displaced the pancreas and great vessels to left side with Tumors B A C Figs 7.12A to C (A) X-ray chest is flooded with multiple rounded opacities involving all zones of both lungs, they can also be appreciated through the cardia; (B) CECT abdomen shows large enhancing lobulated mass lesion involving right lobe and extending to left lobe (C) CECT chest shows both lung fields flooded with rounded hyperdense lesions with varying size and degree of contrast enhancement compression of IVC (Figs 7.14A to D) Cranially, the lesion abuts the inferior surface of liver and inferiorly extends up to iliac crest Wilms’ tumor primarily affects children Also known as nephroblastoma, it is the most common malignant tumor of the kidneys in children The peak incidence of Wilms’ tumor is to years of age and is rare after years of age Most Wilms’ tumors can be cured 95 96 Chest Radiology A B C D Figs 7.13A to D (A and C) CT shows enlarged uterus and cystic structure in left adnexa, CECT shows heterogeneous enhancement of uterus No distinction is seen between myometrium and endometrium Tubular fluid collection seen in the left adnexa, (B) HRCT thorax shows metastatic lesions in both lungs (D) Contrast CT shows a mass in left kidney, left para-aortic nodes are enlarged (arrow) Tumors B A E C D Figs 7.14A to D (A) X-ray chest appears normal; (B) CECT shows large well-defined enhancing mass lesion × 10 cm with few areas of necrosis, involving the right kidney, sparing its upper pole (inset E) Medially, the lesion is seen to displace the pancreas and great vessels to left side with compression of IVC Cranially, the lesion is seen to abut the inferior surface of liver The lesion extended inferiorly to iliac crest (C) Photograph of the six years old male child who presented with gradually increasing lump abdomen (D) CECT chest, at the level of carina shows on right side two peripheral and one paraspinal pulmonary metastatic lesions 97 98 Chest Radiology MRI in Tumors of the Lung CT is an established technique in the staging of lung carcinoma, with MRI currently used in a problem-solving role Both CT and MRI are equally good at assessing tumor size MRI is more accurate, than CT in evaluating mediastinal tumors, vascular tumor invasion and apical (superior sulcus) tumors Superior sulcus tumors can be visualized better by MRI (Fig 7.15) because of improved anatomical display on coronal and sagittal plane images and help radiation treatment planning Fig 7.15 A case of Pancoast tumor on MRI shows a large hetero geneous lesion in the apex of right lung involving the ribs, brachial plexus and adjacent soft tissues Brachial plexus is normal on left side (arrow) Tumors On MRI, peripheral pulmonary vessels and lobar fissures are not visualized, hence it may be difficult to access the position of a lung mass with respect to a lobe or segment The normal pleural space cannot be resolved by MRI but adjacent fat is well shown Early chest wall invasion by tumor is better demonstrated on MRI Rib destruction is not well shown on MRI However, the extension of tumor into the marrow space is better recognized on MRI MRI is helpful in differentiating pleural from parenchymal disease and has the potential to elucidate complex effusions, it is complementary to CT in the evaluation of pleural abnormalities Vascular invasion by tumor is more clearly demonstrated by MRI than by CT while CT is more sensitive in the detection of pleural effusions 99 ... 12 9 Thymoma 13 1 Teratoma 13 1 10 Esophagus Amol Sasane Achalasia Cardia 13 3 Carcinoma Esophagus 13 5 13 3 xv xvi Chest Radiology 11 Pediatric Chest Santosh Konde 13 8 Holt-Oram Syndrome 13 8... assessing aortopul monary window (Figs 1. 11 and 1. 12), the tracheal bifurcation (Figs 1. 10 to 1. 16), the hilar and perihilar tissues (Figs 1. 12 to 1. 14), carefully looking for lymph nodes The... 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