POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESION OPACI OPACITY Homo Heterogenous Wellill defined Zone Centralperiph Silhouet eral sign TY Necrotic PATCHY MEDIASTINAL NODULE Central deviasionwided MASS COSTO-PHRENIC ANGEL Freeoblitern CAVITARY OTHERINFILTIRATION Bone soft tissuediaphragm
Solitary Pulmonary Nodule(SPN) Appearance Margin Calcification cavitation Comparison with a Size previous x-ray to >8mm <8mm Assess growth over time. Location Upperhillar zone Lowerbasesup-pleural Associated abnormalitiesLymph node enlargement Rib destruction/erosion
Solitary pulmonary nodule on(CXR or CT) Chest ct Benigncalcification indeterminate or fatNo follow up Risk Risk stratification stratification Age ≤4mmLow 8mm ≥ 4-8 mm ≥4mmHigh risk somking risk History of cancer FDG,PETCT or Biopsy Follow up at 12 mon No follow up Nodule diameter SUV>2,5 or SUV<2,5 or No change in Positive Negative Change Spiculation in size size biopsy biopsy Upper lobe Follow up at Surgery surgery No follow up 12 mon
Fleischner Society pulmonary nodules recommendations.Nodule Low-risk patients High-risk patientssize (mm) ≤ No follow-up needed Follow-up at 12months. If no change, no further imaging needed – > Follow-up at 12 months. Initial follow-up CT at 6–12 months If no change, no further imaging and needed then at 18–24months if no changeLow-risk patients: Minimal or absent history of smoking and other known risk factors asasbestos exposure.High-risk patients: History of smoking or other known risk factors.Adapted from Heber MacMahon et al., Radiology 2005 237:395–400
Fleischner Society pulmonary nodules recommendations.Nodule Low-risk patients High-risk patientssize (mm) – Initial follow-up CT at 6–12 months Initial follow-up CT at 3–6 months and then at 18–24 months And then at 9–12 and 24 months if no change if no change Follow-up CT at around 3, 9and 24 Same as for low-risk months. patients Dynamic contrast-enhanced CT, PET, and/or biopsyLow-risk patients: Minimal or absent history of smoking and other known risk factors asasbestos exposure.High-risk patients: History of smoking or other known risk factors.Adapted from Heber MacMahon et al., Radiology 2005 237:395–400
Case-1• A 40-year-old male smoker presents with a history of chronic cough.• He has had symptoms of an upper respiratory illness for a few months since visiting family in Arizona.• Physical exam is normal.
POSITION •PA CXRQUALITY •Poor Technical Quality •(ROTATION?) •Round density well defined at 5 right posterior rib. •Another round density at left hillum.LESIONMEDIASTINAL •Central trachea,mediastinalANGELS •freeOTHER •No
Case-11. The next step in management should be:• a. Complete pulmonary function tests• b. Fiberoptic bronchoscopy• c. Percutaneous needle biopsy• d. Observation and repeat CXR in 6 to 8 mo
Discussion• Due to the peripheral nature of this lesion, a CT-guided needle biopsy would be the best diagnostic strategy and have a better yield than a bronchoscopy.• Pulmonary function tests would be helpful if surgery is planned, but would not alter the diagnostic steps.• In this case, the CT-guided biopsy revealed coccidioidomycosis.• Most granulomas are smaller than 2 cm, and almost all are less than 3 cm in size.• Besides SPNs, in the early stages of coccidioidomycosis patchy infiltrates may be accompanied by hilar and mediastinal adenopathy and less frequently by pleural effusion.• In cases of persistent disease, infiltrates may enlarge.
Case-2• 34-year-old woman, a recent immigrant from Eastern Europe, is seen with complaints of vague chest discomfort after an upper respiratory tract infection.• She is not a smoker and gives a history of BCG vaccination when she was an infant.• Physical examination is normal.• PPD is 10-mm induration and induced sputum for acid-fast bacilli is negative.
POSITION •PA CXRQUALITY •Poor Technical Quality •(ROTATION?) •Round density well defined at 7 right posterior rib.LESIONMEDIASTINAL •Central trachea,mediastinalANGELS •freeOTHER •No
Case-2• 1. What is the most likely diagnosis?• a. Granuloma• b. Scar carcinoma• c. Coccidioidomycosis• d. Hamartoma• 2. What is the next step in the management of this patient?• a. MRI of the chest• b. Fiberoptic bronchoscopy• c. Comparison of previous chest radiograph, if available, and repeat chest radiograph in 3 mo• d. Treatment with four-drug anti-TB chemotherapy
Discussion• With a history of a positive PPD in a young immigrant and the presence of a calcified peripheral SPN, the likely diagnosis is tuberculous granuloma.• Comparison with a previous x-ray to confirm stability of the lesion would prevent the need for further diagnostic tests.• Since this lesion probably represents latent, old, healed granulomatous focus, treatment with four antituberculosis drugs is not warranted• unless evidence of active disease is seen.
Case-3• A 30-year-old female nonsmoker who recently moved to the U.S. from Mexico presents with dyspnea on exertion.• Her PPD is 8 mm.• On physical examination, her pulse is 110 bpm, blood pressure is 110/70 mm Hg, and she has mild clubbing, cyanosis, and ortho-deoxia.• Otherwise, her physical exam is normal.• Laboratory data: Hb 14 g/dL; Hct 42%; WBCs 11,000/μL; differential normal.• ABGs on room air: pH 7.42; PCO2 38 mm Hg; PO2 70mm Hg.
POSITION •PA CXRQUALITY •Poor Technical Quality •(penetration?) •Multilobulated nodular opacity in the left midlung zone. •No calcifecated.LESION •No cavitation.MEDIASTINAL •Central trachea,mediastinalANGELS •DisappearOTHER •No
Case-3• 1. What is the next step in the management of this patient?• a. Sputum for fungal culture• b. Rib series• c. CT scan with contrast of the chest• d. V/Q scan• 2. Lesions associated with the above disorder include• a. Erythema nodosum• b. Lupus pernio• c. Telangiectasia• d. Oral thrush
Discussion• The clinical picture with ortho-deoxia (oxygen desaturation in an erect position) suggests an arteriovenous malformation (AVM).• Congenital pulmonary AVMs of the lung represent a• direct communication between the pulmonary arteries and the veins, bypassing the capillary bed and resulting in cyanosis due to right-to-left shunt.• Dyspnea and hemoptysis are common clinical presentations.• Fifty percent of AVMs are associated with Osler- Weber-Rendu syndrome (AVMs with mucosal telangiectasias).
Case-4• A 62-year-old woman with a 30-pack-year smoking history is evaluated with a history of chronic shortness of breath.• She has mild left-sided chest discomfort.• She denies fever, chills, and night sweats and has no localizing signs on physical exam.• A CT-guided needle biopsy of the lesion is performed and reveals malignant cells.
POSITION •PA? CXRQUALITY •Poor Technical Quality •(penetration,rotation ?) •Bilateral hazy opacities at lower zone obliterated right cardio-phrenic angel and left hemi-diaphragm.LESION •Round like ill defined opacity at left middle zone peripherally, abutting left chest wall,without calcification,cavitation.MEDIASTINAL •Right deviation trachea,cardiomegalyANGELS •Left costo-phrenic angle obliteratedOTHER •No
Case-4• 1. Based on the CXR finding, the likely diagnosis is:• a. Small cell carcinoma• b. Bronchoalveolar cell carcinoma• c. Adenocarcinoma of the lung• d. Liposarcoma of the chest wall• 2. This malignancy is associated with:• a. Positive sputum cytology• b. A good response to chemotherapy• c. Incidentally detected peripheral carcinomas on CXR• d. Cavitation in the majority of these carcinomas
Discussion• Adenocarcinoma is commonly peripheral and represents about 30% of the total number of lung cancer cases.• Its incidence is rising especially in females.• Adenocarcinoma frequently presents as an incidental finding on x-ray.
Discussion• The other major histological types of lung cancer tend to have central localization and are as follows:• 1. Squamous (epidermoid) carcinoma: – Eighty percent are central; – When peripheral, they have a tendency for cavitation.• 2. Small cell (oat cell) carcinoma: – Believed to originate from neuroendocrine cells of the bronchial mucosa, – these are usually central with mediastinal involvement.• 3. Large cell undifferentiated carcinoma with mixed malignant features.• 4. Bronchoalveolar carcinoma: – A variant of adenocarcinoma, – these arise from type II pneumocytes in the alveoli. – They may simulate pneumonia with focal consolidation – or may present as solitary or multiple nodules.