Weizhong ChengDept. Radiology, Zhongshan Hospital

Institute of Medical Imaging, Shanghai

•Basics•Best exam results•Appreciate the role radiology plays•? Instill an interest in radiology

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Histology and EmbryologyAnatomyPathologyInternal MedicineSurgeryGynecologyPediatricsNeurology。。。Everything。。。 U need to know

X-ray CT MR DSA US Nuclear Medicine PET/CT Radionuclide ventilation perfusion imaging

PA （ posteroanterior) & Lateral More information Two views Standardized

Distance Pt needs to be stable

Portable Quick Anywhere One shot No standardization

PA

Portable

•P-A (relation of x-ray beam to patient)

•A-P Supine/Erect

•Lateral

•Lateral Decubitus

•Oblique

•Type•Orientation•Rotation •Inspiration/expiration•Penetration

ABCDE… Airways

Trachea, endotracheal tube, etc Bones

Clavicles, ribs, etc… Cardiac Diaphragm (Right hemidiaphragm slightly

higher (~1.5 cm)

Everything else (tubes), effusions

The big two densities are:

(1) WHITE - Bone

(2) BLACK - Air

The others are:

(3) DARK GREY- Fat

(4) GREY- Soft tissue/water

And if anything Man-made is on the film, it is:

(5) BRIGHT WHITE - Man-made

• Right upper lobe:

• Right middle lobe:

• Right lower lobe:

• Left lower lobe:

• Left upper lobe with Lingula:

• Lingula:

• Left upper lobe - upper division:

Right border: Edge of (r) Atrium

3. Left border: (l) Ventricle + Atrium

4. Posterior border: Reft Ventricle

5. Anterior border: Right Ventricle

IT’S NOT MINE….

Made of:

1. Pulmonary Art.+Veins

2. The Bronchi

Left Hilum higher (max 1-2,5 cm)

Identical: size, shape, density

• Apices• Behind the heart• Costophrenic angle (CPA)• Below the diaphragm• Soft tissues ( breast, surgical emphysema) • Ribs & clavicle •Vertebrae

Darker areas radiolucent Pneumothorax Cysts/bulla Air bronchograms

Lighter areas Opacities Atelectasis “infiltrates”

Blood Pus Water

Nodules or mass

Lobar or not…. Pneumonia Pulmonary Edema

“fluffy,” diffuse, “bat wing” distribution Hemorrhage

Can’t tell by x-ray, need bronch

RML pneumonia Opacities

RLL pneumonia

Opacities

RUL pneumonia

LLL pneumonia

Consolidation on CT

Causes:

1. Adenopathies (neoplasia, infection)

2. Primary Tumor

3. Vascular

4. Sarcoidosis

Mass

Hilar Lymphadenopathy - BL

Multiple Masses Metas

Pleural Effusion

Pulmonary Fibrosis

Heart failure ， Kerley A/B line

（ Interstitial lung hyperplasia edema ）

Heart failure

Pneumothorax

Emphysema

Cavitating lesion

Thin-walled Cavitating lesion Thick-walled Cavitating lesion 3mm

Bronchiectasis

Miliary shadowing

Benign Patterns of Calcification Within a Solitary Pulmonary Nodule

Chest Tube, NG Tube, Pulm. artery cath

Clinical Factors Growth Pattern Size Margin (Border) Characteristics Density Contrast-Enhanced CT Other findings

airspace opacification air bronchogramsdense multifocal segmental

pneumonia

lung abscesslung abscess

cavitation

Lobar/segmental consolidation

Pneumonia finding

infiltrates Miliary shadowing

Tuberculoma

Chronic fibro-cavitary TB

Neoplastic: MalignantBronchogenic carcinomaSolitary metastasisLymphomaCarcinoid tumorNeoplastic: BenignHamartomaBenign connective tissue and neural tumors (e.g., lipoma, fibroma, neurofibroma)InflammatoryGranulomaLung abscessRheumatoid noduleInflammatory pseudotumor (plasma cell granuloma)CongenitalArteriovenous malformationLung cystBronchial atresia with mucoid impactionMiscellaneousPulmonary infarctIntrapulmonary lymph nodeMucoid impactionHematomaAmyloidosisNormal confluence of pulmonary veinsMimics of SPNNipple shadowCutaneous lesion (e.g., wart, mole)Rib fracture or other bone lesion

loculated pleural effusion

Hamartoma

Bronchogenic carcinoma

Bronchogenic carcinoma

Granuloma

chest radiograph shows a small, well-circumscribed, round opacity at the right lung base (arrows).

Lateral view shows that the opacity is within the lung on two views (posterior segment of the right lower lobe) and thus represents a pulmonary nodule (arrow).

Contrast CT in Malignant Solitary Pulmonary Nodule. Thin-collimation (3-mm) CT scans through left upper lobe nodule in a 62-year-old woman with biopsy-proven lung cancer shows a lobulated contour with positive enhancement of 50 H after contrast administration

Malignant SPN

Age at diagnosis: 55-60 years (range 40-80 years); M:F = 1.4:1 asymptomatic (10-50%) usually with peripheral tumors symptoms of central tumors:

cough (75%), wheezing, pneumonia hemoptysis (50%), dysphagia (2%)

symptoms of peripheral tumors: pleuritic/local chest pain, dyspnea, cough Pancoast syndrome, superior vena cava syndrome hoarseness

symptoms of metastatic disease (CNS, bone, liver, adrenal gland) paraneoplastic syndromes:

cachexia of malignancy clubbing + hypertrophic osteoarthropathy nonbacterial thrombotic endocarditis migratory thrombophlebitis ectopic hormone production: hypercalcemia, syndrome of inappropriate

secretion of antidiuretic hormone, Cushing syndrome, gynecomastia, acromegaly

Cigarette smoking (squamous cell carcinoma + small cell carcinoma) 鈥搑 elated to number of cigarettes smoked, depth of inhalation, age at

which smoking began 85% of lung cancer deaths are attributable to cigarette smoking! Passive smoking may account for 25% of lung cancers in nonsmokers!

Radon gas: may be the 2nd leading cause for lung cancer with up to 20,000 deaths per year

Industrial exposure: asbestos, uranium, arsenic, chlormethyl ether Concomitant disease:

chronic pulmonary scar + pulmonary fibrosis Scar carcinoma

45% of all peripheral cancers originate in scars! Incidence: 7% of lung tumors; 1% of autopsies Origin: related to infarcts (>50%), tuberculosis scar (<25%) Histo: adenocarcinoma (72%), squamous cell carcinoma (18%) Location: upper lobes (75%)

Adenocarcinoma (50%) Most common cell type seen in women + nonsmokers Intermediate malignant potential (slow growth, high incidence of early

metastases) almost invariably develops in periphery; frequently found in scars

(tuberculosis, infarction, scleroderma, bronchiectasis) + in close relation to preexisting bullae

solitary peripheral subpleural mass (52%)/alveolar infiltrate/multiple nodules

may invade pleura + grow circumferentially around lung mimicking malignant mesothelioma

upper lobe distribution (69%) air broncho-/bronchiologram on HRCT (65%) calcification in periphery of mass (1%) smooth margin/spiculated margin due to

desmoplastic reaction with retraction of pleura

Adenocarcinoma Presenting as Solitary Pulmonary Nodule. A.Cone-down view of posteroanterior radiograph shows nodule in the right mid-lung (arrow). B.Thin-section CT shows 12-mm nodule with spiculated margins (arrow) in the superior segment of the right lower lobe. Transthoracic needle biopsy revealed adenocarcinoma.

solitary peripheral mass

Squamous cell carcinoma (30-35%) Strongly associated with cigarette smoking

Central location within main/lobar/segmental bronchus (2/3) large central mass & cavitation distal atelectasis & bulging fissure (due to mass) postobstructive pneumonia

All cases of pneumonia in adults should be followed to complete radiologic resolution!

airway obstruction with atelectasis (37%) Solitary peripheral nodule (1/3)

characteristic cavitation (in 7-10%) Squamous cell carcinoma is the most common cell type to

cavitate! invasion of chest wall

Squamous cell carcinoma is the most common cell type to cause Pancoast tumor

Central lung cancer

Squamous Cell Carcinoma. A.Posteroanterior chest film in a 58-year-old male smoker with hemoptysis shows a left hilar mass with left upper lobe atelectasis.B.Enhanced CT scan shows the left hilar mass occluding the left upper lobe bronchus with an endobronchial component (straight arrow). Note the presence of mucus bronchograms within the atelectatic lung (curved arrow)

Squamous Cell Carcinoma

Small cell undifferentiated carcinoma (15%)

Strongly associated with cigarette smoking Rapid growth + high metastatic potential

typically large hilar/perihilar mass often associated with mediastinal widening (from adenopathy)

extensive necrosis + hemorrhage small lung lesion (rare)

Large undifferentiated cell carcinoma (<5%) Strongly associated with smoking large bulky usually peripheral mass >6 cm

(50%) large area of necrosis pleural involvement large bronchus involved in central lesion

(50%)

Large-cell bronchogenic carcinoma small-cell bronchogenic carcinoma

the pattern was shown to be caused by predominantly interstitial diseases in 54% of cases, equal involvement of the interstitium and airspaces in 32%, and predominantly airspace disease in 14%

GGO is an important finding. In certain clinical circumstances, it can suggest a specific diagnosis, indicate a potentially treatable disease, and guide a bronchoscopist or surgeon to an appropriate area for biopsy

Pure GGOPure GGO （（ Ground-glass OpacityGround-glass Opacity ））

Early stage

98,6,17

12*8mm ,Lobular resection,8 yrs alive

Lung cancer:solid nodulesLung cancer:solid nodules