Chest RadiologyChest RadiologyInteractive Teaching SessionInteractive Teaching Session

Nevzat KARABULUT, M.D.

Pamukkale University Hospital

nkarabulut@yahoo.com

Case 1Case 1

• 76-year-old female

• Bronkorhea

• Loss of apetite, weight loss (10 kg in 5 months)

76-year-old female76-year-old female

Which dx is the most unlikely?a) Diffuse pneumoniab) Pulmonary alveolar

proteinosisc) Cryptogenic organizing

pneumoniad) Tumore) Hypersensitivity

pneumonitis

76-year-old female76-year-old female

Which of the following signs are present on CT?Which of the following signs are present on CT?

a) CT Angiogram

b) Crazy paving

c) Halo sign

d) 1+2

e) 1+2+3

Which of the following signs are present on CT?Which of the following signs are present on CT?

1. CT Angiogram

2. Crazy paving

3. Halo sign

4. 1+2

5. 1+2+3

What is your final diagnosis?a) Diffuse pneumoniab) Pulmonary alveolar proteinosisc) Cryptogenic organizing pneumonia

d) Bronchioloalveolar cell carcinoma

e) Diffuse alveolar damage

Mucinous Bronchioloalveolar Mucinous Bronchioloalveolar cell carcinomacell carcinoma

Bronchioloalveolar cell carcinomaBronchioloalveolar cell carcinoma

• Subgroup of adenocarcinoma • 5% of all bronchogenic carcinomas • Mucinous (20-30%) and Clara cell or

type II pneumocyte • Can be seen as

– Single or multiple nodules– single or multiple consolidation (more

common in mucinous tumors)

Consolidative BACConsolidative BAC

• CT findings that suggest BAC rather than pneumonia – non-resolving peripheral

consolidative pneumonia with associated nodules

– stretching, squeezing and widening of the branching angle of bronchus within consolidation

– Bulging of the interlobar fissure

– multiple cysts or bubble like radiolucencies

Jung JI. Br J Radiol 2001; 74:490-494

CTCT angiogramangiogram signsign

• Presence of >3 cm pulmonary vessel within a consolidation

• Initially described for lobar form of BAC– 92% specificity

• Pneumonia• Pulmonary edema• Obstructive pneumonitis • Lymphoma• Mets from GI carcinomas

Crazy paving patternCrazy paving pattern

• Interlobular septal thickening superimposed on ground glass opacity

• Initially described for PAP

• Bronchiloloalveolar cell carcinoma

• Exogeneous lipoid pneumonitis

• Infections

Alveolar proteinosis

Pneumocystis jiroveci pneumonitis

CASE 2CASE 2

• 49-year-old male

• Chest pain and cough

• CABG operation 5 years ago

49-year-old male

What is the most likely diagnosis?

a) Foreign body

b) Lung cancer

c) Hamartoma

d) Solitary fibrous tumor

GossypibomaGossypiboma

• Hx of surgery

• Low-density inhomogeneous mass with hyperdense capsule

• Whirling hyperdense lines

Topal U. Intrathoracic gossypiboma. AJR 2001 177:1485-1486.

IInnccompletomplete border sign e border sign

• Partial obscuration of border of extrapulmonary lesions where it is not surrounded by air

• Analogy with Sillhoutte sign

• Extrapleural fat

• Solitary fibrous tumor of pleura

• Rib lesions

64 y-male, RLLobectomy 3 months ago64 y-male, RLLobectomy 3 months ago

50 y-female, CABG

CASE 3CASE 3

45-year-old asymptomatic female with abnormal CXR

A) Central mass @ RLL

B) Atelectasis of RLL

C) Vascular abnormality

D) RML disease

E) Kartagener syndrome

a) AVM

b) Atelectasis of RLL

c) Abnormal pulmonary venous return

d) Swyer James Syndrome

e) Kartagener’s syndrome

Scimitar signScimitar sign

Scimitar signScimitar signHHyypogenetipogenetic Lungc Lung s syyndromndromee

• Small Right hemithorax

• Retrocardiac or paracardiac tubular density

• Abnormal vein:– IVC– PV, HV, Right atrium

• 25% associated with CHD– ASD, VSD, PDA

The recognition of signs and The recognition of signs and patterns on CXR and CT is helpful patterns on CXR and CT is helpful for accurate diagnosisfor accurate diagnosis

Case 4: Case 4: 25-year-old man, smoking (+)25-year-old man, smoking (+) Cough, bloody sputum, mild dispnea Cough, bloody sputum, mild dispnea

What is your presumptive diagnosis?What is your presumptive diagnosis?

a) Mass

b) Interstitial thickening

c) Cystic lung disease

d) 3+1

e) 4+1

a) Fungus ball in tuberculosis cavity

b) Fungus ball in Lymphangioleiomyomatosis

c) Fungus ball in Langerhans cell histiocytosis

d) Cystic and solid metastases

e) Invasive aspergillosis in cystic lung disease

What is your final diagnosis?

Fungus ball in Fungus ball in Langerhans cell Langerhans cell histiocytosishistiocytosis

Aspergilloma (mycetoma)Aspergilloma (mycetoma)

• Colonization of a preexisting lung cavity by

saprophytic fungi (Aspergillus spp)• Preexisting lung cavity

• TB• Sarcoidosis• Bronchiectasis

• Fungus ball: fungus, cellular debris, fibrin, and inflammatory cells

• Thick and vascular wall: hemoptysis

LCH LAMLCH LAM

Case 5: Case 5: 59-year-old female with dry mouth59-year-old female with dry mouth

59-year-old female with dry mouth59-year-old female with dry mouth

a) Lymphangioleiomyomatosis

b) Langerhans cell histiocytosis

c) Lymphoid interstitial pneumonia

d) Centrilobular emphysema

e) Birt Hogg Dubé syndrome

What is your diagnosis?

LIP (Sjögren syndrome)

25% of cases

Thank you for your attention and participation

nkarabulut@yahoo.com