2. praktikum 1 patologi thorax

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