2. praktikum 1 patologi thorax
TRANSCRIPT
Radiopathology of Respiratory tract
Dr Wawan Kustiawan
SpRad,M.Kes,DFM.
ContentI. Disorder of
A. DiaphragmB. PleuraC. Thoracic wall
II. Lung parenchym disorderA. Radiopaque disorder
1. Diffuse2.Patchy3. Noduler4. Linear
B. Radioluscent disorder1. Local2. Diffuse
Diaphragm abnormality
1. Abnormality in function- Fixation / immobility
* Phrenicus nerve paralysis* Pleuritis* Subdiaphragm abcess
- Relative immobility – COPD- Paradoxal movement
- Inspiratory Phrenicus nerve paralyse- Expiratory
2. Abnormality in position
- Bilateral elevation
- Ascites
- Obesity
- Pregnancy
- Unilateral elevation
- Gastric or colonic distention
- Decrease in size of hemithorax
- Liver or splenic enlargement
- Bilateral low position of diaphragm
- COPD
- Asthenic type
- Bilateral Pneumothorax
- Unilateral low position of diapraghm- Unilateral check – valve – obstruction of
bronchus
3. Abnormality in shape
Scalloping / tenting
- Normal variation
- Diaphragm tumor
- Pleural tumor
- Subdiaphragm tumor
- Subpulmonary tumor
4. Abnormality in integrity
a. Congenital
- Diaphragm muscle abnormality eventration
- Diaphragmatic hernia
b. Diaphragmatic rupture
- Trauma
5. Abnormality in density- Calcification of
diaphragm- Free air in diaphragmatic
muscle interstitial emphysema of thoracic wall
6. Abnormality in number (Accessory diaphragm)
- Rare Second leaf of right diaphragm separating right inferior lobe
Rö- Left diaphragm elevation- Depression / thickening of major fissure- Retrosternal : triangular shape opaque
shadow- Sometimes accompanied by pulmonary
hypoplasia
THE PLEURA
1. Abnormality of shape, position, size Widening of pleural cavity
- Pneumothorax
- Hydrothorax
- Chylothorax
- Emphyema
- Neoplasm
2. Abnormality in densitya. Increased density (opaque)
- Neoplasm / pleural tumor- Calcification / fibrosis- Hydrothorax
b. Diminished density ( lucent)- Pneumothorax
Mesotelioma
Pneumothorax
- Air in pleural cage
- Ro : - Radiolucent pocket of free air
located between the parietal pleura and visceral pleura
- No bronchovascular marking
With Pleural effusion hydropneumothorax
Pneumothorax
Etiologies-Traumatic- Spontaneus- Theurapeutic
Expiratory stand :for small pneumothorax
Hydrothorax : pleural effusion-Ro
- Increased opacity shadow (air bronchogram (-)
- Concave upper border
- Localized effusion hard to differentiate with pulmonary processes (Vanishing tumor)
Pleural tumorBenign – Lipoma- Fibroma- AngiomaMalignant- Mesothelioma- Sarcoma
Mesothelioma : from the endothelial pleura layer
Pleural tumorBenign – Lipoma- Fibroma - AngiomaMalignant- Mesothelioma- Sarcoma
Mesothelioma : from mesothelial layer
Pleural tumor
2 type – Noduler : > often
Diffuse effusion
Metastase :
From bronchogenic Ca
From Mammae
From Lymphosarcoma
Pleural fibrosis & Pleural adhesion
Fibrosis : pleural thickening
Adhesion : betweenLung –parietalis pleura
Lung –diaphragmatica pleuraLung – mediastinalis pleura
THORACIC WALL DISORDER
1. Thoracic wall shape & size disorder
a. Hemithorax widening
• Massive pleural effusion
• Unilateral lung tumor
• Tension pneumothorax
• Check valve emphysema
• Hernia diaphragmatica that pushed the mediastinum
b. Shrinking of hemithoraxWhole lung atelectasisPleural / lung fibrosisN. phrenicus paralysisLung hipogenesis / hipoplasia c. Thoracic cage asimetricOne side of hemithorax is shrinking while the
other side is enlargingAtelectasis + compensatoir emphysema
d. Congenital disorder
• Achondroplasia : Short costae, thick, flat
• Thanata phoric dwarfism
• Cleidocranial dysostosis
• Osteogenesis imperfecta
• Multiple fracture
• Barrel chest
• Cont..
d. Congenital disorder
• Pectus excavatus : sternal depression
• Pectus carinatus
• Hour glass chest : Multiple fracture from costae & chest muscle paralysis Hiperparathyroid
1. Thoracic wall density disordera. Deminishing density
• Generalized osteophorosis / osteolysis• Osteogenesis imperfecta• Hyperparathyroid• Hypovitaminosis C & D• Achondroplasia / Thanatoporic
b. Increasing density (Sclerosis)
• Prostatic Ca metastase
II. Lung parenchymal disorderA. Radio opaque disorder
1. Diffuse homogen2. Patchy3. Noduler4. Linear
B. Radio lucent disorder
1. Generalized2. Local
Diffuse homogenous radioopaque Disorder
a. Pulmonary atelectasis b. Pneumoniac. Epituberculosad. Lung infarct e. Lung squester.
f. Pleura effusion.g. Tumor
Atelectasis
Et/
Corpus alienum
Neoplasm
Mucus plug
Bronchial stricture / spasm
Atelectasis
Ro : Primary Sign
Fissural shiftHypoaeration radio opaqueCrowded of bronchovascular
marking
Secondary sign
• Compensatory effect to pulmonary collaps
•Diaphragm elevation
•Mediastinal shift
•Hilar transposition
•Compensatory emphysema
Atelectasis classification
Generalized atelectasis
• Radioopaque shadow covering the whole left/right lung
• Tracheal / Mediastinal pulling
• Compensatory emphysema
• Herniation
Lobar atelectasis
Superior lobeHilus pulled upward
Trachea pulled
Wedging with apex in hilus
Medial lobeTraction of the heart , hazy border
Triangular shaped shadow beside the heart
Inferior lobeInferior lobe twisted pulled downward,
medially backward
Traction of the major fisure
Lobulus atelectasisFleischner line ( Diag < moveable) post op
Neonatal atelectasisHMD
Segmental atelectasis
PneumoniaLung parenchymal inflamation that
radiologicaly shows a consolidation process affecting segmen / lobus in lung
ClassificationMorphologi : Lobar, lobulerEtiology : virus, bacterial
Radiology appearance : (generally)• Increasing density / inhomogen opaque
shadow affecting one/ few segmen / lobus
• No volume decrease / still visible air bronchogram
• Sometimes accompanied by hilar node enlargement
• Recovery : Reticular shadow
Viral pneumoniaRo
Reticulo noduler appearance in both lung field
Patchy
Generalised consolidation process
Bacterial pneumoniaPneumococ pneumonia
Usually lobar consolidation – basal
Pleural effusion – rare
Staphylococ pneumoniaUsually affecting children / baby / elderlySuperinfection with influenzaOften with pleural effusion + cavitation
Friedlander pneumoniaUsually on elderlyUsually lobar consolidation mostly right and
topAccompanied by cavitationClinical appearance severe
Varicella Zoster pneumonia
EpituberculosaNon specific reaction from lung tissue around
primary tuberculosa lesion
Pulmonary TBCTBC on paediatricTBC on adult
Infection byOralInhalation
Pulmonary infarctionEtiologyTumorPneumothoraxAtelectasisVein obstructionDisturbance of pulmonal drainageChronic cardiovascular disease
RoPoligonal homogenous opaque
shadow, triangular or round shaped depending on the obstruction zone
Usually in intersection between 2 pleura in lung base
Cont..
Ro (cont..)
If emboli without infarction, the affected area ussualy appear more lucent because of the ischaemic area perifer to the emboli
Enlarged heart Sometimes accompanied by Pulmonary
hipertension Radiological appearanced ussually
disappear in 4-7 days
Nodular opaque radiological disorder
Classification
1. Big nodule : > 2-3 cma. Solitary
Lung abcessPrimary lung carcinomaPulmonary adenomatosis – alveoler
cell ca
Solitary large metastaseHamartomaA-V aneurismPulmonary sequestration = Accessories
lobe
b. MultipleMultiple pulmonary metastasis tumorPneumoconiosis
2. Small nodule 0,5-2 cm
3. Granuler nodule < 0,5 cm
Big nodule disorder :
Solitary
1. Lung abscessRo:Round cavity, distinct border with wall
consist of granulation tissueUsually around pleura and could
rupture in into the pleura causing fistelSometimes with air-fluid level
DD1. Caverne TBC
• Irregular cavity, distinct border with TBC lesion around them
• Mostly in apex 2. Cavity in malignancy
• Thick wall, irregular border
3. Pulmonary cyst
Thin walled sometimes multiple
Sometimes Accompanied by emphysema
4. Mycotic processes cavitation
Thin walled with fungus ball inside
Positional change fungus ball changed
Often with fistula
Pulmonary Carcinomaa. Bronchogenic Ca
OftenMale > FemaleRight > oftenAge : 50 – 60Related : Smoking, Radioactive
material, TBC
a. Bronchogenic Ca
Classified into :a. Central typeb. Perifer nodulerc. Pneumonic typed. Miliar type
b. Pancoast tumor In apex sulcus posterior medius Posterior costae 1- 3 destruction with vertebral
erosion Cervicalis symphatis paralysis Horner
syndrome
3. Alveolar Ca = Pulmonary adenomatosis Female = Male 40 years
Ro: Small nodule on both lung field with large
masses in pulmonary base No visible node enlargement but shows nodal
consolidation in perihiler Pleura ussualy not affected Heart normal