tb radiology basic presentation slides
TRANSCRIPT
Basic Chest Radiology for the TB Clinician
Adapted from the ISTC TB Training Modules 2009
PRESENTATION MATERIALS
ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Objectives: At the end of this presentation, participants will be able to:
Analyze the technical quality of chest X-rays (CXRs) using simple parameters
Identify basic normal CXR anatomy on both frontal and lateral views
Recognize radiographic patterns of disease and describe using appropriate terminology
Describe both the typical and atypical patterns of radiographic presentation for pulmonary tuberculosis
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ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician (2)
Overview: Technical aspects of chest
radiography Systematic approach to
reading CXR Basic CXR anatomy Patterns of disease Radiographic manifestations of tuberculosis (TB)
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Chest Radiography: Basic Principles
Blackestairfatsoft tissuecalciumboneX-ray contrastmetal
Whitest
Maximum X-RayTransmission(least dense tissue)
Maximum X-Ray Absorption(densest tissue)
X-ray photon: Absorbed / scattered / transmitted X-ray absorption depends on:
• Beam energy (constant)• Tissue density
X-ray photon: Absorbed / scattered / transmitted X-ray absorption depends on:
• Beam energy (constant)• Tissue density
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Differential X-Ray AbsorptionWhy we see what we see: Structures are visible on a
radiograph because of the juxtaposition of two different densities creating an interface
Silhouette Sign Loss of an expected interface
No boundary can be seen between two structures because they now are similar in density
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 5
ISTC TB Training Modules 2009
Silhouette Sign: RLL PneumoniaSilhouette Sign: RLL PneumoniaSilhouette Sign: RLL Pneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6
ISTC TB Training Modules 2009
Silhouette Sign: RLL PneumoniaSilhouette Sign: RLL PneumoniaSilhouette Sign: RLL Pneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6
ISTC TB Training Modules 2009
Assess CXR Technical Quality
Inspiratory effort• 9-10 posterior ribs
Penetration• thoracic intervertebral disc space just
visible Positioning / rotation• medial clavicle heads equidistant from
spinous process
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ISTC TB Training Modules 2009
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Inspiratory Effort
Low Lung Volumes Full Inspiration
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 9
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Overexposure Proper Exposure
Exposure
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 10
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OverexposureOverexposure Proper ExposureProper Exposure
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 11
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Rotated (Oblique)Rotated (Oblique)Image credit: Curry International Tuberculosis Center, University of California, San Francisco 12
ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
A systematic approach to reading a CXR
Image Credit: Lung Health Image Library/Gary Hampton 13
ISTC TB Training Modules 2009
Approach to Reading a CXRBe Systematic Lungs Pleural surfaces Cardiomediastinal
contours Bones and soft
tissues Abdomen
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 14
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Worth a Second Look
Apices Retrocardiac areas (left and right) Hilar regions Below diaphragm
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Apical TBApical TBImage credit: Curry International Tuberculosis Center, University of California, San Francisco 16
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco
Apical TB (2)Apical TB (2)17
ISTC TB Training Modules 2009
Left Retrocardiac OpacityLeft Retrocardiac Opacity
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 18
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Nodule Behind DiaphragmNodule Behind Diaphragm
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 19
ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Basic CXR Anatomy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 20
ISTC TB Training Modules 2009
Basic CXR Anatomy
Frontal and Lateral Views Heart Aorta Pulmonary
arteries Airways
Image Credit: Lung Health Image Library/Pierre Virot21
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 22
ISTC TB Training Modules 2009
Aortic arch Right pulmonary
artery Left pulmonary
artery Trachea & bronchi
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
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Aortic arch
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
ISTC TB Training Modules 2009
Aortic arch Right pulmonary
artery
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
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Aortic arch Right pulmonary
artery Left pulmonary
artery
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
ISTC TB Training Modules 2009
Aortic arch Right pulmonary
artery Left pulmonary
artery Trachea & bronchi
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
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Basic Radiology for the TB Clinician
Patterns of disease
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Chest Radiographic Patterns of Disease
Consolidation / air-space opacity Interstitial opacity Nodules and masses Lymphadenopathy Cysts and cavities Pleural abnormalities
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Consolidation / Air-Space Opacity
Caused by filling of alveoli with fluid, pus, blood, cells (tumor), etc.
May be diffuse, or isolated to segments or lobes of the lung
May be associated with air bronchograms (air-filled bronchus surrounded by opacified lung)
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PneumoniaPneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 27
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Interstitial Opacity Disease localized to pulmonary interstitium, i.e., the
alveolar septae and connective tissues that support the alveoli
Hallmarks:• Lines and/or reticulation• Small, well-defined nodules
Miliary pattern
DDX: Pulmonary edema, interstitial lung diseases (e.g., idiopathic pulmonary fibrosis), sarcoidosis, infection, tumor (lymphangitic spread), etc.
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Interstitial Opacity: LinesInterstitial Opacity: Lines
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29
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Interstitial Opacity: LinesInterstitial Opacity: Lines
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29
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Interstitial Opacity: Lines & ReticulationInterstitial Opacity: Lines & Reticulation
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 30
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Nodules and Masses Nodule: discrete pulmonary lesion, sharply
defined, nearly circular opacity 0.2 - 3 cm Mass: larger than 3 cm Describe with qualifiers:• Single or multiple• Size• Border characteristics• Presence or absence of calcification• Location
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Well-DefinedWell-Defined CalcificationCalcification
Ill-DefinedIll-Defined MassMass
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 32
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Lymphadenopathy (LAN)
Non-specific terms:• Mediastinal widening• Hilar prominence
Specific patterns:• Particular station enlargement (location)
Important to know what “normal” should look like in order to recognize “abnormal””
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ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
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Infrahilar window (right hilar and/or subcarinal)
Left hilar Subcarinal
LymphadenopathyLymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
ISTC TB Training Modules 2009
Infrahilar window (right hilar and/or subcarinal)
LymphadenopathyLymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
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Left hilar
LymphadenopathyLymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
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Subcarinal
LymphadenopathyLymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
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Right Paratracheal & Bilateral LANRight Paratracheal & Bilateral LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 36
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Right Hilar LANRight Hilar LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 37
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Right Hilar LANRight Hilar LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 38
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Subcarinal LANSubcarinal LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 39
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AP Window LANAP Window LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 40
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Cysts & Cavities
Abnormal pulmonary parenchymal spaces (“holes”), filled with air and/or fluid, with a definable wall (>1 mm)• Cyst: congenital or acquired• Cavity: caused by tissue necrosis, (inflammatory
and/or neoplastic) Characterize:• Wall thickness at thickest portion• Inner lining• Presence / absence of air / fluid level• Number and location
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TB or Not TB? Cysts and Cavities
Are there radiographic features that suggest benign vs. malignant diagnoses?
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“45 year old man from China with cough, weight loss”
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D
B
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 42
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TB or Not TB? Cysts and Cavities (2)
Are there radiographic features that suggest benign vs. malignant diagnoses?
Benign cysts: uniform wall thickness, 1mm, smooth inner lining (e.g., PCP)
Benign cavities: max. wall thickness 4 mm, minimally irregular inner lining (e.g., TB)
Malignant cavities: max. wall thickness 16 mm, irregular inner lining
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Pleural Disease: Basic Patterns
Effusion• Angle blunting to
massive Thickening Mass Air Calcification
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Pleural EffusionPleural Effusion
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Post-TB Pleural Calcification
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Plombage with Lucite balls
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Basic Radiology for the TB Clinician
Radiographic Manifestations of TB
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Can this be TB?““Typical Pattern”:Post-primary TB Distribution• Apical / posterior segments of
upper lobes• Superior segments of lower
lobes• Isolated anterior segment
involvement unusual for M.tb (think M. avium complex)
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ISTC TB Training Modules 2009
“Typical pattern”: Post-Primary TB
Patterns of disease• Air-space consolidation• Cavitation, cavitary nodule• Endobronchial spread• Miliary• Bronchostenosis• Tuberculoma• Pleural effusions
(empyema most likely in post-primary disease)
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Can this be TB?“Atypical pattern”: Primary TB
Distribution : any lobe involved (slight lower lobe predominance)
Air-space consolidation Cavitation is uncommon (<10%) Adenopathy is common
(esp. children and HIV), predilection for right side
Miliary pattern Pleural effusions
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Can this be TB? Miliary TB
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Radiographic Patterns: Pulmonary TB
TB Pattern “Typical” (Post-Primary)
“Atypical”(Primary)
Infiltrate 85% upper
Upper : Lower 60 : 40
Usually upper in children
Cavitation Common Uncommon
Adenopathy UncommonChildren common
Adults ~30%Unilateral > bilateral
Effusion May be present May be present
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ISTC TB Training Modules 2009
CXR Pattern: Early vs. Advanced HIV
Early HIV (CD4>200)
Advanced HIV (CD4<200)
Pattern “Typical” (Post-primary)
“Atypical”(Primary)
Infiltrate Upper lobes Lower lobes, multiple sites, or miliary
Cavitation Common Uncommon
Adenopathy Uncommon Common
Effusion Uncommon More common
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ISTC TB Training Modules 2009
Can this be TB?
“Old / Healed” TB Ca++ granuloma–Ghon lesion Ca++ granuloma and hilar node
calcification–Ranke complex Apical pleural thickening Fibrosis and volume loss
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ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Summary: Remember: Technical quality
can significantly impact your CXR interpretation
Develop a systematic approach (and use it every time!)
Practice identifying normal CXR anatomy
Important to characterize and describe lesions—this can help with your differential diagnosis
Whether typical or atypical TB can always fool you!
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