RADIOLOGY - IMAGING OF

THE THORAX
 THE CHEST
 
METHODS OF EXAMINATION
Radiography
Standard examination : PA + lateral projection; tube-film distance –
1,5m to minimize divergent distorsion and magnification; full
inspiration.
Apical lordotic view – is used to see disease in the pulmonary
apices, which may be obscured by the clavicle and first rib; AP direction
with the patient leaning backward on the cassette holder.
Lateral decubitus – indicated to outline fluid levels in cavities or in
pleural space; x-ray beam directed in a horizontal plane and the patient
lying on either right or left side.
Prone chest film – useful in patients in whom the lung bases are
obscured by fluid.
Supine radiographs – intensive care units.
Computed radiography – employs photostimulable phosphor plates;
the latent image stored on the imaging plate is read out by a laser beam.
 Fluoroscopy – to study the dynamics of the cardiovascular
system, diafragmatic motion , air trapping. Disadvantage: high
radiation dose.
Bronchography – the study of the bronchial tree by
means of the introduction of opaque material into the desired
bronchi. Replaced by CT. Direct methods such as fiberoptic
bronchoscopy, brush biopsy, percutaneous biopsy permit a
tissue or bacteriologic diagnosis.
Tomography – it is possible to examine a single layer of
tissue and to blur the tissues above and below the level by
motion ( the tube and the film move in opposite direction).The
method was largely replaced by CT.
 Computed tomography – indications in the lung:
- Evaluation and staging of primary pulmonary neoplasms
- Detection of metastasis from non-pulmonary primary tumors.
- Characterization of solitary pulmonary nodules as benign or
malignant
- Characterization of focal and diffuse lung disease for
diagnosis.
Indications for the mediastinum:
- Causes of mediastinal widening
- Staging of tumors that spread to the mediastinum
- Characterization of mediastinal masses – cysts, solid,
vascular, fat.
Other indications:
Pleura plaques, masses, loculated fluid, occult calcification,
chest wall masses.
High-resolution CT – evaluation of interstitial lung disease,
bronchiectasis, emphysema, cystic lung disease.
 Ultrasonography – fluid can be localized and
differentiated from solid pleural masses; mediastinal cysts in
contact with the chest wall and several conditions near the
diafragm.
Magnetic resonance imaging – indications:
Assesment of aortic vascular disease, subacute and chronic
dissection, vascular anomalies.
Cardiac evaluation of selected congenital and acquired
heart conditions and pericardial diseases.
Evaluation of brachial plexopathy.
Evaluation of the diafragm and peridiafragmatic processes.
Evaluation of intracardiac and paracardiac masses.
Assesment of chest-wall lesions.
Evaluation of breast implants and breast masses.
Determination of the extent posterior mediastinal masses,
especially those with intraspinal extension.
 Pulmonary and bronchial angiography – arterial or
venous anomalies; thromboembolic disease.

Percutaneous transthoracic needle biopsy.

Scintigraphy.
  

Chest X-ray – how to analyze ?

- Bony thorax – ribs, clavicles, scapulae, thoracic vertebrae

- Soft tissues
- Mediastinum
- Lungs – anatomy (lobar and segmental), hilum, vessels,
bronchi, apices
- Pleura
- Diafragm

Roentgen observations must be correlated with all of

the available clinical information !!!
 CHEST INFECTIONS

Acute pulmonary infections

1. Lobar (alveolar, air-space) pneumonia – the organism

reaches the periphery of the lung via the airways.Alveolar
transudation is followed by migration of leucocytes into the
alveolar fluid.
2. Bronchopneumonia (lobular pneumonia) – often observed
in staphyloccocal infection of the lung. The disease
originates in the airways and spreads to peribronchial
alveoli.
3. Acute interstitial pneumonia – usually caused by a virus or
a mycoplasma.
4. Mixed pneumonia – is a combination of lobar,
Pneumococcal pneumonia
- Caused by S.pneumoniae.
- The onset is sudden, roentgen findings can be observed
within 6 to 12 hours after onset of symptoms.
- Rx: opacity, triangular, the tip towards the hilum, the base
towards the periphery of the lung. All of the elements in the
diseased lobe except the larger bronchi may be affected – “air
bronchogram”.
- Resolution is fairly rapid if there are not complications – the
opacity becomes more irregular and patchy, the intensity
decreases.
- Complications – delayed resolution or nonresolution,
empyema, lung abscess, pleural effusion.
Bronchopneumonia – is an acute pulmonary infection,
bacterial in origin.
- It is most commonly found in the very young or very
old
- The inflammatory disease does not cross septal
boundaries, therefore the pattern of disease is
discontinous or patchy.
- Rx: nodular opacities, of varying size, poorly defined
with the center more opaque compared to the periphary.
- It is particularly difficult to define and diagnose when
it occurs as a complication in cardiac failure.
Staphyloccocal pneumonia – caused by S.aureus may be
primary in the lungs or secondary to a primary staphyloccocal
infection elsewhere in the body.
- Usually occurs in debilitated adults or in the first year
of life.
- Consolidation rapidly spreads to involve a whole lobe
and bronchi are obscured by exudate so the air
brohogram is rarely seen.
- Abscess formation may occur and coalescense of
small abscesses is frequent.
- Pleural effusion, empyema and pneumothorax are
often noted.
- Pneumatocele – a check-valve obstruction develops
between the lumen of a small bronchus and the adjacent
interstitium.
- The disease is usually bilateral
Acute interstitial pneumonia
Mycoplasmal Pneumonia
Mycoplasma pneumoniae is responsible for a significant
percentage of primary atypical pneumonia in children and
young adults.
- Roentgen findings:
- Peribronchial or interstitial type – streaky
densities extending outward from the hilum
following the vascular markings.
- Bronchopneumonic type.
- Segmental or lobar types
- Diffuse type
Mycoplasma vs.bacterial pneumonia: lack of pleural
involvement, delay in radiological appearance, the tendency to
clear in one area and to spread in another, bilaterality.
Acute
Acuteinterstitial
interstitialpneumonia
pneumonia::influenza
influenza
Acute interstitial pneumonia
Acute
Acuteinterstitial
interstitial
pneumonia
pneumonia
COMPLICATIONS
COMPLICATIONS

BRONHOPNEUMONIA

SEGMENTAL
PNEUMONIA
Lung abscess
- When an acute suppurative pulmonary infectious process
breaks down to form a cavity it is termed lung abscess.
- Primary / secondary.
- Rx: consolidation that produces an opacity confined to one
pulmonary segment,round, irregular borders. When
bronchial communication is established the fluid contents of
the cavity are replaced by air – hydro-aeric image with
orizontal fluid level.
- Very useful CT – to define the inner and outer walls and
for complications (rupture into a bronchus or into the
pleural space).
- Differential diagnosis: early stage – pneumonia; cavity –
tbc, cancer, hydatid cyst, fungal infection
 TUBERCULOSIS
 
- Transmitted by inhalation of infected droplets of
Mycobacterium tuberculosis
- Target population: patients of low economic scale,
alcoholics, elderly, AIDS

Primary infection: Rancke complex :

1.Ghon focus – pulmonary consolidation (1-7cm),

irregular borders, non-homogeneous, low intensity,
lower lobe  upper lobes
2.Lymphadenopathy – hilar and paratracheal, 95%
3.Lymphangitis linear opacity
Evolution:

- Healing
- Fibrosis
- Calcification
- Cavitation

Complications:

- Miliary TB
- TB pneumonia
- TB bronchopneumonia
- Pleural effusion
 Secondary infection: active disease in adults most
commonly represents reactivation of a primary focus.
Distribution:
- Typically limited to apical and posterior segments of
upper lobes
- Rarely in anterior segments of upper lobes

Radiographic features:

•Exudative TB – patchy or confluent airspace disease,

adenopathy is uncommon.
•Fibrocalcific TB – sharply circumscribed linear densities
radiating to hilum
•Cavitation - 40%
Complications:
 
1. Miliary TB
2. Bronchogenic spread to lung
3. Tuberculoma
4. Bronchial stenosis
5. Bronchiectasis
6. Pneumothorax
7. Pleural effusion – often loculated
 AIDS
Known routes of HIV transmission:
- Blood and blood products
- Sexual activity
- In utero transmission
- During delivery

Clinical:
- Lymphadenopathy
- Opportunistic infections
- Tumors: lymphoma, Kaposi sarcoma
- Other manifestations: lymphocytic interstitial
pneumonia, spontaneous pneumothorax, septic emboli
 Spectrum of chest manifestations:

Nodules – Kaposi sarcoma (usually associated with skin

lesions), septic infarcts, fungal (Cryptoccocus, Aspergillus)
Large opacity: consolidation, mass – hemorrhage, NHL,
Pneumonia
Linear or interstitial opacities – PCP, atypical
mycobacteria, Kaposi sarcoma
Lymphadenopathy – Mycobacterial infections, Kaposi
sarcoma, lymphoma
Pleural effusion – Kaposi sarcoma, fungal infection,
pyogenic empyema