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(BQ) Part 1 book Thoracic imaging - Pulmonary and cardiovascular radiology has contents: The normal mediastinum, the pulmonary hila, lung cancer and bronchopulmonary neoplasms, metastatic tumor, lymphoma and lymphoproliferative disease,... and other contents.
THORACIC IMAGING Pulmonary and Cardiovascular Radiology Third Edition THORACIC IMAGING Pulmonary and Cardiovascular Radiology Third Edition W Richard Webb, MD Professor Emeritus of Radiology and Biomedical Imaging Department of Radiology and Biomedical Imaging Emeritus Member, Haile Debas Academy of Medical Educators University of California, San Francisco San Francisco, California Charles B Higgins, MD Distinguished Professor Emeritus of Radiology and Biomedical Imaging Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco, California Acquisitions Editor: Ryan Shaw Product Development Editor: Lauren Pecarich Marketing Manager: Dan Dressler Production Project Manager: Priscilla Crater Design Coordinator: Terry Mallon Manufacturing Coordinator: Beth Welsh Prepress Vendor: SPi Global Third edition Copyright © 2017 Wolters Kluwer Copyright © 2011 Lippincott Williams & Wilkins, a Wolters Kluwer business All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services) 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Names: Webb, W Richard (Wayne Richard), 1945- author | Higgins, Charles B., author Title: Thoracic imaging : pulmonary and cardiovascular radiology / W Richard Webb, Charles B Higgins Description: Third edition | Philadelphia : Wolters Kluwer, [2017] | Includes bibliographical references and index Identifiers: LCCN 2016033166 | ISBN 9781496321046 (hardback) Subjects: | MESH: Lung Diseases—diagnosis | Cardiovascular Diseases—diagnosis | Radiography, Thoracic—methods | Diagnostic Imaging—methods Classification: LCC RC78.7.D53 | NLM WF 975 | DDC 616.07/54—dc23 LC record available at https://lccn.loc.gov/2016033166 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient The publisher does not provide medical advice or guidance and this work is merely a reference tool Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work LWW.com To Hideyo Minagi, my first teacher as a Resident, who taught me my most important lessons —to recognize what is real and what is not—and to understand that not everything unusual or abnormal is important After that, it’s all gravy and J, an exceptional big sister, who has helped me grow up in many ways —W Richard Webb To the many fellows who have contributed to our progress in developing new cardiovascular imaging techniques —Charles B Higgins Contributors Brett Elicker, MD Associate Professor of Clinical Radiology Chief, Cardiac and Pulmonary Imaging Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco, California Michael B Gotway, MD Consultant and Professor of Radiology Mayo Clinic Phoenix, Arizona Clinical Associate Professor Departments of Radiology and Biomedical Imaging and Pulmonary and Critical Care Medicine University of California, San Francisco San Francisco, California Clinical Professor University of Arizona College of Medicine, Phoenix Phoenix, Arizona Adjunct Professor Department of Biomedical Informatics at Arizona State University Tempe, Arizona Charles B Higgins, MD Distinguished Professor Emeritus of Radiology and Biomedical Imaging Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco, California Michael D Hope, MD Associate Professor of Radiology Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco, California Clinton E Jokerst, MD Consultant and Professor of Diagnostic Radiology Mayo Clinic Phoenix, Arizona Kimberly Kallianos, MD Fellow, Cardiac and Pulmonary Imaging Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco, California Stefano Muzzarelli, MD Privat Docent, Division of Cardiology Cardiocentro Ticino University of Zurich Lugano, Switzerland Privat Docent, Division of Cardiology University of Lausanne Lausanne, Switzerland Karen Ordovas, MD, MAS Associated Professor of Radiology and Medicine Director of Cardiac Imaging Cardiac and Pulmonary imaging Department of Radiology and Biomedical imaging University of California, San Francisco San Francisco, California W Richard Webb, MD Professor Emeritus of Radiology and Biomedical Imaging Department of Radiology and Biomedical Imaging Emeritus Member, Haile Debas Academy of Medical Educators University of California, San Francisco San Francisco, California Preface Our goal in writing Thoracic Imaging: Pulmonary and Cardiovascular Radiology has been to provide a single volume, with a comprehensive but easy-to-digest review of both pulmonary and thoracic cardiovascular imaging and to review the use and interpretation of both chest radiographs and computerized imaging techniques, such as spiral computed tomography, high-resolution CT (HRCT), CT angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) It is intended to provide the fundamentals of thoracic imaging for Medical Students and Residents and Fellows in Radiology, Pulmonology, Cardiology, and Cardiovascular Surgery We have tried to be thorough without being exhaustive Rather than referencing specific studies and their results, which are now easily accessed via the Internet, we have summarized what we consider to be the most important and most pertinent information and have provided numerous tables to make key facts easily available to the reader More than 2,500 illustrations demonstrate important imaging findings and the typical appearances of the various disease entities one might expect to encounter in clinical practice This, the third edition of our book, provides extensive updates of a number of important topics, including, but not limited to, the World Health Organization (WHO) classification of thoracic neoplasms, lymphoma classification, lung cancer screening, classification and diagnosis of diffuse lung diseases, pulmonary hypertension, pulmonary vasculitis, the idiopathic interstitial pneumonias, and the diagnosis of various cardiovascular diseases Furthermore, an additional chapter regarding cardiac arrhythmias has been added, reflecting imaging advances in this field Current references of value in further reading have been added wherever appropriate In this edition, we have grouped chapters in sections, related to key findings or fundamental clinical problems or diagnoses, in the hope that this may guide the reader to an organized understanding of disease and diagnosis In the years since the prior edition, there has been considerable progress in understanding pulmonary and cardiovascular diseases, and many entities we discuss in our sections and chapters are newly defined or have been redefined, reclassified, or have had their diagnosis clarified New tables and illustrations have been provided to summarize and illustrate these additions and changes W Richard Webb, MD Charles B Higgins, MD San Francisco, California Contents Contributors Preface SECTION ONE The Basics Lobar Anatomy, Air-space Consolidation, the Silhouette Sign, and Atelectasis W Richard Webb The Normal Mediastinum W Richard Webb The Pulmonary Hila W Richard Webb SECTION TWO Neoplasms, Masses, and Focal Lung Abnormalities Lung Cancer and Bronchopulmonary Neoplasms W Richard Webb Metastatic Tumor W Richard Webb Lymphoma and Lymphoproliferative Disease W Richard Webb The Mediastinum: Mediastinal Masses W Richard Webb Congenital Lung Abnormalities and Pulmonary Vascular Malformations W Richard Webb Solitary and Multiple Nodules, Masses, Cavities, and Cysts W Richard Webb SECTION THREE Diffuse and Multifocal Lung Diseases 10 Plain Film and Computed Tomographic Assessment of Diffuse Lung Disease W Richard Webb 11 Pulmonary Edema, the Acute Respiratory Distress Syndrome, and Radiology in the Intensive Care Unit W Richard Webb 12 Pulmonary Infections Michael B Gotway 13 The Idiopathic Interstitial Pneumonias W Richard Webb 14 Collagen Vascular Diseases W Richard Webb 15 Sarcoidosis W Richard Webb 10 1744 FIG 21.6 Tracheobronchial amyloidosis A: CT shows extensive bronchial calcifications (large arrows) Hilar lymph node calcification (small arrow) also is present B: Airway calcification due to amyloid deposition also is visible more peripherally PULMONARY ALVEOLAR MICROLITHIASIS Pulmonary alveolar microlithiasis is characterized by the presence of numerous minute calculi (so-called microliths or calcispheres) within alveoli (Table 21.3) It is very rare but has a characteristic radiographic appearance TABLE 21.3 Pulmonary Alveolar Microlithiasis 1745 Histologically, the calcispheres are located largely within the alveolar lumen, although they probably are formed within the alveolar walls They consist of concentric layers of calcium phosphate In the early stages of disease, the alveolar walls appear normal, although fibrosis may occur late in the disease process Emphysema also may be seen, particularly in the apices and subpleural regions Microlithiasis may be seen at any age, but most cases occur in patients from 20 to 50 years of age Two forms have been recognized: sporadic and familial, predominantly affecting siblings Microlithiasis occurs because of a gene mutation, resulting in an abnormal protein, which is normally responsible for sodium-dependent phosphate transport in the lungs The abnormal protein prevents transport of phosphorus ions from the alveolar spaces into type II pneumocytes, which leads in turn to the development of calcospherites within alveoli Autosomal recessive inheritance of the abnormal gene may occur Abnormalities of calcium metabolism are absent Patients typically are asymptomatic at diagnosis, despite spectacular radiographic abnormalities There is a tendency for the abnormalities to progress slowly over a period of several years, although findings may remain stable Dyspnea may develop with progression of the disease, with other symptoms including hemoptysis and finger clubbing Although lung fibrosis and cor pulmonale may develop, the prognosis generally is good There is no treatment Radiographs show characteristic findings Despite their small size, the individual calcispheres may be visible as discrete, dense dots, less than mm in diameter (Fig 21.7) A basal predominance is typical (see Fig 21.7) When limited in number, the calcispheres 1746 predominate in a subpleural location and in relation to vessels, bronchi, and interlobular septa When myriad, they become confluent and appear very dense, obscuring the hemidiaphragm, heart, and mediastinal contours If the lungs are sufficiently dense, the heart may appear relatively lucent, a very unusual finding Another typical finding on chest radiographs, although it is not always seen, is the so-called black pleural line, a stripe of relative lucency at the pleural surface (see Fig 21.7) Although this feature was thought to be due to sparing of the pleura by the calcispheres, it reflects small subpleural areas of emphysema FIG 21.7 Alveolar microlithiasis Detail view of the left lower lobe in a patient with diffuse lung opacity Individual dense calcispheres are visible The subpleural lung appears relatively lucent (arrows) This is the so-called black pleural line HRCT shows a posterior and lower lobe predominance of the calcifications with a high concentration in the subpleural parenchyma and in association with bronchi and vessels (Figs 21.8 and 21.9) A perilobular and centrilobular distribution of the calcifications may be seen or calcifications may be associated with interlobular septa Intraparenchymal emphysema may be seen Subpleural paraseptal emphysema (i.e., the black pleural line) is common (see Fig 21.9) In children or patients with early disease, ground-glass opacity or reticulation may be the predominant finding; calcifications may be difficult to detect 1747 FIG 21.8 HRCT in alveolar microlithiasis Extensive lung calcification is present with a subpleural and perivascular predominance 1748 FIG 21.9 HRCT in alveolar microlithiasis Lung calcification is confluent in some regions and nodular in others Small areas of emphysema (arrows) in the peripheral lung account for the black pleural line Calcification of small interstitial nodules seen on HRCT has a limited differential diagnosis Multifocal lung calcification, often associated with lung nodules, also has been reported in association with amyloidosis, infectious granulomatous diseases such as tuberculosis, sarcoidosis, silicosis, and coal worker’s pneumoconiosis, talcosis, and metastatic calcification METASTATIC CALCIFICATION The term metastatic calcification refers to the deposition of calcium in soft tissues due to abnormal calcium and phosphate metabolism (Table 21.4) It is associated with hypercalcemia and is most common in patients with chronic renal failure and secondary hyperparathyroidism and in those undergoing chronic hemodialysis TABLE 21.4 Metastatic Calcification Metastatic calcification commonly affects the lung; it typically is interstitial, involving the alveolar septa, bronchioles, and pulmonary arteries, and can be associated with secondary lung fibrosis Patients may be asymptomatic or may have dyspnea With appropriate treatment of the underlying abnormality, metastatic calcification may resolve 1749 Abnormalities typically predominate in the lung apices because they are more alkaline than the lung bases, increasing the likelihood of calcium salt precipitation in this region A higher ratio of ventilation to perfusion in the apices results in a decrease in the partial pressure of CO2 and a corresponding increase in pH Plain radiographs are relatively insensitive in detecting metastatic calcification In some patients, ill-defined nodules or patchy areas of increased opacity may be seen (Figs 21.10 and 21.11A) Nodules visible on chest films usually appear to be about to cm in diameter They may or may not appear to be of calcium density With progressive disease, these opacities become confluent, mimicking pneumonia An apical predominance of opacities is typical but not invariable (see Fig 21.11A) 1750 FIG 21.10 Metastatic calcification in a patient with renal disease and secondary 1751 hyperparathyroidism Dense nodular opacities (arrows) are visible in the right lung 1752 FIG 21.11 Metastatic calcification in renal failure A: Chest radiograph shows ill-defined nodular opacities (arrows) with an apical predominance B, C:CT with a lung window setting shows nodular opacities in the peripheral upper lobes These opacities appear lobular or centrilobular in distribution D: Soft tissue window scan shows evidence of calcification CT can show areas of ground-glass opacity, consolidation, or calcification in the absence of plain film abnormalities Numerous fluffy and poorly defined nodules, measuring to 10 mm in diameter, are typical, but opacities can appear focal, centrilobular, lobular, patchy, or diffuse (Figs 21.11 to 21.13) Even with HRCT, these opacities may not appear calcified An 1753 apical predominance is common Calcification of vessels in the chest wall may also be seen 1754 1755 FIG 21.12 Metastatic calcification in renal failure A, B: HRCTs with a lung window setting show nodular opacities in the upper lobes These opacities appear centrilobular in distribution They were not obviously calcified on soft tissue windows C: CT at the lung base shows dense subpleural calcification and calcification of consolidated lung (arrows) D: Radionuclide bone (99mTc-diphosphonate) scintigraphy shows extensive isotope uptake within both lungs 1756 FIG 21.13 Metastatic calcification in renal failure HRCT shows centrilobular and lobular ground-glass opacities without obvious calcification A dialysis catheter is in place Radionuclide bone (99mTc-diphosphonate) scintigraphy (see Fig 21.12D) is highly sensitive for the detection of metastatic calcification and may show lung uptake when chest films are normal It may serve to confirm the diagnosis when CT shows typical apical opacities without obvious calcification SELECTED READING De Almeida RR, Zanetti G, Pereira E, Silva J, et al Respiratory tract amyloidosis State-of-the-art review with a focus on pulmonary involvement Lung 2015; 193:875–883 Aylwin ACB, Gishen P, Copley SJ Imaging appearance of thoracic amyloidosis J Thorac Imaging 2005; 20:41–46 Ayuso MC, Gilabert R, Bombi JA, Salvador A CT appearance of localized pulmonary amyloidosis J Comput Assist Tomogr 1987; 11:197–199 Castellana G, Lamorgese V Pulmonary alveolar microlithiasis World cases and review of the literature Respiration 2003; 70:549–555 Colombat M, Stern M, Groussard O, Droz D, et al Pulmonary cystic disorder related to light chain deposition disease Am J Respir Crit Care Med 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Pulmonary alveolar microlithiasis: an overview of clinical and pathological features together with possible therapies Respir Med 2003; 97:1081–1085 Pickford HA, Swensen SJ, Utz JP Thoracic cross-sectional imaging of amyloidosis AJR Am J Roentgenol 1997; 168:351–355 Seaman DM, Meyer CA, Gilman MD, McCormack FX Diffuse cystic lung disease at highresolution CT Am J Roentgenol 2011; 196:1305–1311 Siddiqui NA, Fuhrman CR Best cases from the AFIP: Pulmonary alveolar microlithiasis Radiographics 2011; 31:585–590 Utz JP, Swensen SJ, Gertz MA Pulmonary amyloidosis The Mayo Clinic experience from 1980 to 1993 Ann Intern Med 1996; 124:407–413 1758 .. .THORACIC IMAGING Pulmonary and Cardiovascular Radiology Third Edition THORACIC IMAGING Pulmonary and Cardiovascular Radiology Third Edition W Richard Webb, MD Professor Emeritus of Radiology. .. writing Thoracic Imaging: Pulmonary and Cardiovascular Radiology has been to provide a single volume, with a comprehensive but easy-to-digest review of both pulmonary and thoracic cardiovascular imaging. .. MD Consultant and Professor of Diagnostic Radiology Mayo Clinic Phoenix, Arizona Kimberly Kallianos, MD Fellow, Cardiac and Pulmonary Imaging Department of Radiology and Biomedical Imaging University