How read chest xr 7
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The chest x-ray shows bilateral hazy opacities and a peripherally located ill-defined opacity, suggesting adenocarcinoma as the likely diagnosis given its common peripheral presentation as an incidental finding; a CT-guided biopsy revealed malignant cells consistent with adenocarcinoma, which is often an incidentally detected peripheral carcinoma on chest x-ray in smokers.
How read chest xr 7
- 1. HOW READ CHEST XR -7 ANAS SAHLE ,MD
- 2. Brief review
- 3. POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESION OPACI OPACITY Homo Heterogenous Wellill defined Zone Centralperiph Silhouet eral sign TY Necrotic PATCHY MEDIASTINAL NODULE Central deviasionwided MASS COSTO-PHRENIC ANGEL Freeoblitern CAVITARY OTHER INFILTIRATION Bone soft tissuediaphragm
- 4. Consolidation Infection causes Non-infection causes Broncho- WEGNER Cardiac Pneumonia Lymphoma alveolar COP Sarcoid disease failure carcinoma
- 5. Solitary Pulmonary Nodule(SPN) • Is • Single. • Discrete. • intrapulmonary density. • < 3cm in diameter. • completely surrounded by aerated lung. • DDX: • Bronchogenic ca. • Solitary metastasis. • Granuloma (infectioninflamation). • Benign lung tumor(hamartoma). • Round pneumonia. • Round atelectasis. • AVM.
- 6. Solitary Pulmonary Nodule(SPN) Appearance Margin Calcification cavitation Comparison with a Size previous x-ray to >8mm <8mm Assess growth over time. Location Upperhillar zone Lowerbasesup-pleural Associated abnormalities Lymph node enlargement Rib destruction/erosion
- 7. Solitary pulmonary nodule on(CXR or CT) Chest ct Benign calcification indeterminate or fat No follow up Risk Risk stratification stratification Age ≤4mmLow 8mm ≥ 4-8 mm ≥4mmHigh risk somking risk History of cancer FDG,PETCT or Biopsy Follow up at 12 mon No follow up Nodule diameter SUV>2,5 or SUV<2,5 or No change in Positive Negative Change Spiculation in size size biopsy biopsy Upper lobe Follow up at Surgery surgery No follow up 12 mon
- 8. Fleischner Society pulmonary nodules recommendations. Nodule Low-risk patients High-risk patients size (mm) ≤ No follow-up needed Follow-up at 12months. If no change, no further imaging needed – > Follow-up at 12 months. Initial follow-up CT at 6–12 months If no change, no further imaging and needed then at 18–24months if no change Low-risk patients: Minimal or absent history of smoking and other known risk factors as asbestos exposure. High-risk patients: History of smoking or other known risk factors. Adapted from Heber MacMahon et al., Radiology 2005 237:395–400
- 9. Fleischner Society pulmonary nodules recommendations. Nodule Low-risk patients High-risk patients size (mm) – Initial follow-up CT at 6–12 months Initial follow-up CT at 3–6 months and then at 18–24 months And then at 9–12 and 24 months if no change if no change Follow-up CT at around 3, 9and 24 Same as for low-risk months. patients Dynamic contrast-enhanced CT, PET, and/or biopsy Low-risk patients: Minimal or absent history of smoking and other known risk factors as asbestos exposure. High-risk patients: History of smoking or other known risk factors. Adapted from Heber MacMahon et al., Radiology 2005 237:395–400
- 10. Case-1 • A 40-year-old male smoker presents with a history of chronic cough. • He has had symptoms of an upper respiratory illness for a few months since visiting family in Arizona. • Physical exam is normal.
- 11. Case-1
- 12. POSITION •PA CXR QUALITY •Poor Technical Quality •(ROTATION?) •Round density well defined at 5 right posterior rib. •Another round density at left hillum. LESION MEDIASTINAL •Central trachea,mediastinal ANGELS •free OTHER •No
- 13. Case-1 1. The next step in management should be: • a. Complete pulmonary function tests • b. Fiberoptic bronchoscopy • c. Percutaneous needle biopsy • d. Observation and repeat CXR in 6 to 8 mo
- 14. Discussion • Due to the peripheral nature of this lesion, a CT-guided needle biopsy would be the best diagnostic strategy and have a better yield than a bronchoscopy. • Pulmonary function tests would be helpful if surgery is planned, but would not alter the diagnostic steps. • In this case, the CT-guided biopsy revealed coccidioidomycosis. • Most granulomas are smaller than 2 cm, and almost all are less than 3 cm in size. • Besides SPNs, in the early stages of coccidioidomycosis patchy infiltrates may be accompanied by hilar and mediastinal adenopathy and less frequently by pleural effusion. • In cases of persistent disease, infiltrates may enlarge.
- 15. Case-2 • 34-year-old woman, a recent immigrant from Eastern Europe, is seen with complaints of vague chest discomfort after an upper respiratory tract infection. • She is not a smoker and gives a history of BCG vaccination when she was an infant. • Physical examination is normal. • PPD is 10-mm induration and induced sputum for acid-fast bacilli is negative.
- 16. Case-2
- 17. POSITION •PA CXR QUALITY •Poor Technical Quality •(ROTATION?) •Round density well defined at 7 right posterior rib. LESION MEDIASTINAL •Central trachea,mediastinal ANGELS •free OTHER •No
- 18. Case-2 • 1. What is the most likely diagnosis? • a. Granuloma • b. Scar carcinoma • c. Coccidioidomycosis • d. Hamartoma • 2. What is the next step in the management of this patient? • a. MRI of the chest • b. Fiberoptic bronchoscopy • c. Comparison of previous chest radiograph, if available, and repeat chest radiograph in 3 mo • d. Treatment with four-drug anti-TB chemotherapy
- 19. Discussion • With a history of a positive PPD in a young immigrant and the presence of a calcified peripheral SPN, the likely diagnosis is tuberculous granuloma. • Comparison with a previous x-ray to confirm stability of the lesion would prevent the need for further diagnostic tests. • Since this lesion probably represents latent, old, healed granulomatous focus, treatment with four antituberculosis drugs is not warranted • unless evidence of active disease is seen.
- 20. Case-3 • A 30-year-old female nonsmoker who recently moved to the U.S. from Mexico presents with dyspnea on exertion. • Her PPD is 8 mm. • On physical examination, her pulse is 110 bpm, blood pressure is 110/70 mm Hg, and she has mild clubbing, cyanosis, and ortho-deoxia. • Otherwise, her physical exam is normal. • Laboratory data: Hb 14 g/dL; Hct 42%; WBCs 11,000/μL; differential normal. • ABGs on room air: pH 7.42; PCO2 38 mm Hg; PO2 70mm Hg.
- 21. Case-3
- 22. POSITION •PA CXR QUALITY •Poor Technical Quality •(penetration?) •Multilobulated nodular opacity in the left midlung zone. •No calcifecated. LESION •No cavitation. MEDIASTINAL •Central trachea,mediastinal ANGELS •Disappear OTHER •No
- 23. Case-3 • 1. What is the next step in the management of this patient? • a. Sputum for fungal culture • b. Rib series • c. CT scan with contrast of the chest • d. V/Q scan • 2. Lesions associated with the above disorder include • a. Erythema nodosum • b. Lupus pernio • c. Telangiectasia • d. Oral thrush
- 24. Discussion • The clinical picture with ortho-deoxia (oxygen desaturation in an erect position) suggests an arteriovenous malformation (AVM). • Congenital pulmonary AVMs of the lung represent a • direct communication between the pulmonary arteries and the veins, bypassing the capillary bed and resulting in cyanosis due to right-to-left shunt. • Dyspnea and hemoptysis are common clinical presentations. • Fifty percent of AVMs are associated with Osler- Weber-Rendu syndrome (AVMs with mucosal telangiectasias).
- 27. Case-4 • A 62-year-old woman with a 30-pack-year smoking history is evaluated with a history of chronic shortness of breath. • She has mild left-sided chest discomfort. • She denies fever, chills, and night sweats and has no localizing signs on physical exam. • A CT-guided needle biopsy of the lesion is performed and reveals malignant cells.
- 28. Case-4
- 29. POSITION •PA? CXR QUALITY •Poor Technical Quality •(penetration,rotation ?) •Bilateral hazy opacities at lower zone obliterated right cardio-phrenic angel and left hemi-diaphragm. LESION •Round like ill defined opacity at left middle zone peripherally, abutting left chest wall,without calcification,cavitation. MEDIASTINAL •Right deviation trachea,cardiomegaly ANGELS •Left costo-phrenic angle obliterated OTHER •No
- 30. Case-4 • 1. Based on the CXR finding, the likely diagnosis is: • a. Small cell carcinoma • b. Bronchoalveolar cell carcinoma • c. Adenocarcinoma of the lung • d. Liposarcoma of the chest wall • 2. This malignancy is associated with: • a. Positive sputum cytology • b. A good response to chemotherapy • c. Incidentally detected peripheral carcinomas on CXR • d. Cavitation in the majority of these carcinomas
- 31. Discussion • Adenocarcinoma is commonly peripheral and represents about 30% of the total number of lung cancer cases. • Its incidence is rising especially in females. • Adenocarcinoma frequently presents as an incidental finding on x-ray.
- 32. Discussion • The other major histological types of lung cancer tend to have central localization and are as follows: • 1. Squamous (epidermoid) carcinoma: – Eighty percent are central; – When peripheral, they have a tendency for cavitation. • 2. Small cell (oat cell) carcinoma: – Believed to originate from neuroendocrine cells of the bronchial mucosa, – these are usually central with mediastinal involvement. • 3. Large cell undifferentiated carcinoma with mixed malignant features. • 4. Bronchoalveolar carcinoma: – A variant of adenocarcinoma, – these arise from type II pneumocytes in the alveoli. – They may simulate pneumonia with focal consolidation – or may present as solitary or multiple nodules.