Chest x ray pathology

1. Basic Chest
Radiology for
the TB Clinician
PRESENTATION MATERIALS

2. 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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3. 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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4. ISTC TB Training Modules 2009
Chest Radiography: Basic Principles
Blackest
air
fat
soft tissue
calcium
bone
X-ray contrast
metal
Whitest
Maximum X-Ray
Transmission
(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
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5. ISTC TB Training Modules 2009
Differential X-Ray Absorption
Why 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

6. ISTC TB Training Modules 2009
Silhouette Sign: RLL Pneumonia
Silhouette Sign: RLL Pneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6

7. ISTC TB Training Modules 2009
Silhouette Sign: RLL Pneumonia
Silhouette Sign: RLL Pneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6

8. 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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9. ISTC TB Training Modules 2009
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8

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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8

13. ISTC TB Training Modules 2009
Inspiratory Effort
Low Lung Volumes Full Inspiration
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 9

14. ISTC TB Training Modules 2009
Overexposure Proper Exposure
Exposure
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 10

15. ISTC TB Training Modules 2009
Overexposure Proper Exposure
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 11

16. ISTC TB Training Modules 2009
Rotated (Oblique)
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 12

17. 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

18. ISTC TB Training Modules 2009
Approach to Reading a CXR
Be Systematic
 Lungs
 Pleural surfaces
 Cardiomediastinal
contours
 Bones and soft
tissues
 Abdomen
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 14

19. ISTC TB Training Modules 2009
Worth a Second Look
 Apices
 Retrocardiac areas (left and right)
 Hilar regions
 Below diaphragm
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20. ISTC TB Training Modules 2009
Apical TB
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 16

21. ISTC TB Training Modules 2009
Image credit: Curry International Tuberculosis Center, University of California, San Francisco
Apical TB (2)
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22. ISTC TB Training Modules 2009
Left Retrocardiac Opacity
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 18

23. ISTC TB Training Modules 2009
Nodule Behind Diaphragm
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 19

24. 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

25. ISTC TB Training Modules 2009
Basic CXR Anatomy
Frontal and Lateral Views
 Heart
 Aorta
 Pulmonary
arteries
 Airways
Image Credit: Lung Health Image Library/Pierre Virot
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26. ISTC TB Training Modules 2009
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 22

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 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

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 Aortic arch
 Right pulmonary
artery
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23

30. ISTC TB Training Modules 2009
 Aortic arch
 Right pulmonary
artery
 Left pulmonary
artery
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23

31. 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

32. ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Patterns of
disease
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33. ISTC TB Training Modules 2009
Chest Radiographic Patterns of Disease
 Consolidation / air-space opacity
 Interstitial opacity
 Nodules and masses
 Lymphadenopathy
 Cysts and cavities
 Pleural abnormalities
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34. ISTC TB Training Modules 2009
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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35. ISTC TB Training Modules 2009
Pneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 27

36. ISTC TB Training Modules 2009
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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37. ISTC TB Training Modules 2009
Interstitial Opacity: Lines
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29

38. ISTC TB Training Modules 2009
Interstitial Opacity: Lines
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29

39. ISTC TB Training Modules 2009
Interstitial Opacity: Lines & Reticulation
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 30

40. ISTC TB Training Modules 2009
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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41. ISTC TB Training Modules 2009
Well-Defined Calcification
Ill-Defined Mass
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 32

42. ISTC TB Training Modules 2009
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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43. ISTC TB Training Modules 2009
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

47. ISTC TB Training Modules 2009
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34

48. ISTC TB Training Modules 2009
 Infrahilar window
(right hilar and/or
subcarinal)
 Left hilar
 Subcarinal
Lymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35

49. ISTC TB Training Modules 2009
 Infrahilar window
(right hilar and/or
subcarinal)
Lymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35

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 Left hilar
Lymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35

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 Subcarinal
Lymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35

52. ISTC TB Training Modules 2009
Right Paratracheal & Bilateral LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 36

53. ISTC TB Training Modules 2009
Right Hilar LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 37

54. ISTC TB Training Modules 2009
Right Hilar LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 38

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Subcarinal LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 39

56. ISTC TB Training Modules 2009
AP Window LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 40

57. ISTC TB Training Modules 2009
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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58. ISTC TB Training Modules 2009
TB or Not TB? Cysts and Cavities
Are there
radiographic
features that
suggest
benign vs.
malignant
diagnoses?
A
“45 year old man
from China with
cough, weight loss”
C
D
B
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 42

59. ISTC TB Training Modules 2009
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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60. ISTC TB Training Modules 2009
Pleural Disease: Basic Patterns
 Effusion
• Angle blunting to
massive
 Thickening
 Mass
 Air
 Calcification
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61. ISTC TB Training Modules 2009
Pleural Effusion
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62. ISTC TB Training Modules 2009
Post-TB Pleural Calcification
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Plombage with Lucite balls
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64. ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Radiographic
Manifestations of
TB
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65. ISTC TB Training Modules 2009
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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66. 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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67. ISTC TB Training Modules 2009
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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68. ISTC TB Training Modules 2009
Can this be TB? Miliary TB
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69. ISTC TB Training Modules 2009
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 Uncommon
Children common
Adults ~30%
Unilateral > bilateral
Effusion May be present May be present
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70. 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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71. 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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72. 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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