Morgagni hernia

A congenital defect in the anteromedial aspect of the diaphragm. At approximately 5% of all diaphragmatic
hernias, Morgagni hernias are much less common than Bochdalek hernias which account for a further 90%. It is
usually just omental fat which is found within the hernia but abdominal viscera can also herniated. (Conversely a
Bochdalek hernia usually contains viscera but can contain just fat). Morgagni hernias tend to be small and
asymptomatic, hence they usually present as incidental findings. The closest differential diagnosis to a
Morgagni hernia would be a cardiac fat pad. Given coronal or sagittal CT slices it should be easy to see the
omental vessels coursing upwards from the abdomen through the diaphragmatic defect. There will be vessels
supplying a cardiac fat pad but these are likely to be far smaller. Granted, the description provided in the
question is deliberately vague.

Bochdalek hernia
A congenital defect in the posterior aspect of the diaphragm which usually (80%) occurs on the left and
accounts for around 90% of all diaphragmatic hernias. They tend to be Big, at the Back (ie posterior), present as
a Baby, contain Bowel, and can be quite Bad since they are associated with pulmonary hypoplasia due to mass
effect. The exact content of the hernia will depend on the laterality. In real life radiology when they occur on the
right they may be as an occult finding of a right lower zone mass silhouetted against the diaphragm. Despite the
classical appearance on a CXR, a CT is usually performed for confirmation.

Pulmonary sequestration
There are two types of pulmonary sequestration and two features which unite them. A segment of lung firstly,
which derives its arterial blood supply from the systemic circulation and secondly, has no communication with
the bronchial tree is termed pulmonary sequestration. It is a congenital abnormality and usually affects the left
lower lobe with a smaller percentage affecting the right lower lobe.
o Intralobar sequestration – This is more common (75%) but less severe. The affected segment does not have its
own pleura and drains, like normal, via the pulmonary veins. Presents as recurrent pneumonias and is seen on a
CXR as cysts with fluid levels. Some are associated with other congenital abnormalities but a larger proportion
develop in isolation.
o Extralobar sequestration – This is less common (25%) and more severe with around half of patients suffering
from other additional congenital anomalies. Venous drainage is via the systemic circulation and patients present
in childhood either with respiratory distress due to shunting of blood or with symptoms attributed to the
associated congenital anomalies (e.g. diaphragmatic hernia). The segment has its own pleura and therefore
collateral air drift via the pores of Kohn cannot occur. The lack of aeration helps differentiate it from intralobar
sequestration. Seen on a CXR as an opacity adjacent to the heart, abutting the diaphragm.

Thymoma
As a differential diagnosis of a thoracic low attenuation lesion, thymomas can be included. They are usually
anterosuperior in location however, although may, if sufficiently large, extend as far down as the diaphragm.
Although they can be surrounded by fat any low attenuation seen within the mass is actually due to necrosis
and fibrosis rather than fat within the mass. They can also contain calcification in amorphous or curvilinear
formations. Features of invasion which would point towards a malignant thymoma as opposed to a benign one
would include an irregular outline, spread along the pleura and invasion of the mediastinal fat.

Cardiac fat pad

There is fat around the heart in everyone but in some individuals, and in those of a higher BMI, this can be more
prominent. The right side usually has more prominent fat pads than the left but both can be seen on CXRs if
sufficiently prominent.

A 41-year-old lady presents with palpitations. She undergoes an echocardiogram and a subsequent CT
angiogram which demonstrates a 2cm coronary artery aneurysm arising from the right coronary artery.

Coronary fistula
This occurs when a connection between a coronary artery and cardiac chamber or great vessels. It can result in
large coronary artery aneurysms.
 Inter-arterial left main coronary artery
This variant is the most significant and likely to cause symptoms. It is often repaired even if not symptomatic,
but always repaired if symptomatic as there is an associated with a significant risk of sudden cardiac death.

Anomalous right coronary artery arising from the left coronary cusp
This variant is rarely symptomatic and is usually only repaired if symptomatic.

Myocardial bridging of the left anterior descending artery

This describes a short portion of the left anterior descending artery which dives within the myocardium. It can
occasionally be symptomatic.

Anomalous left coronary artery arising from the pulmonary artery

This variant can result in symptoms due to reversal of flow in the left coronary artery when pulmonary artery
pressure decreases. This is also known as ‘steal’ syndrome.

Anatomical considerations of pleural aspiration:

A 66-year-old woman presents with worsening breathlessness. She has decreased movement of the chest on
the left side. She also has dullness to percussion and diminished breath sounds over the left lower lobe. She is
referred for a chest X-ray which shows a large pleural effusion. A percutaneous needle aspiration is
recommended.

A pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid filled space that is situated
between the parietal and visceral pleura. The pleural cavity usually contains between 5-10 ml of this lubricating
fluid. This fluid lubricates the surfaces of the pleurae, allowing them to slide over each other. It also produces a
surface tension that pulls the two membranes together and ensures that as the thorax expands, the lungs do
also and fill with air. Excess fluid in the pleural cavity impairs breathing by limiting expansion of the lungs.
Percutaneous pleural aspiration is generally carried out for two main indications:

1. For investigation of pleural effusion

2. For symptomatic relief of breathlessness caused by pleural effusion

The British Thoracic Society (BTS) guidelines suggest that pleural aspiration should be reserved for the
investigation of unilateral exudative pleural effusions. It should not be carried out if unilateral or bilateral
transudative effusion is suspected, unless there are atypical features or failure of response to therapy. It can
also be used for the urgent decompression of the pleural space for the relief of respiratory distress caused by
pleural effusion.

The procedure is usually carried out with the patient sat upright with a pillow nused to support their arms and
head. The patient should not lean forwards too much as it increases the risk of injury to the liver and spleen.

The conventional site for aspiration is posteriorly in the mid-scapular line (approximately 10 cm lateral to the
spine), one or two spaces below the upper level of the fluid. The needle should be inserted just above the upper
border of the chosen rib to avoid the intercostal nerves and vessels that run immediately below the ri

Lung cancer management:

A 64-year-old man undergoes a CXR for investigation of a persistent cough. This shows a mass lesion in the
right lung and a subsequent CT scan stages the mass at T2 N2 M0 with ipsilateral hilar and paratracheal lymph
nodes. A CT guided biopsy reveals this to be a non-small cell lung cancer.

In an ideal world every trainee radiologist would have all the intricacies of staging for all tumour types
committed to memory. A qualified subspecialist radiologist could reasonably be expected to be extreFibrotic
lung disease:
A 65-year-old lady is diagnosed with a fibrotic lung condition on HRCT. There is subpleural honeycombing,
particularly dominant at both lung bases, becoming less prominent superiorly.
Which of the following is the most likely diagnosis?

Answer Option Question Statistics

IPF 82%

NSIP 10%

RBILD 2%

Sarcoidosis 3%

LIP 3%

Explanation:
There is much overlap between NSIP and IPF but gross trends can be seen which help point towards either
diagnosis. Although honeycombing is the go-to feature for IPF, a microcystic version is found with NSIP.

IPF
Macrocystic honeycombing
Apicobasilar gradient
Traction bronchiectasis
Smoking association
Architectural distortion
Slightly older
No response with steroids
NSIP
↔ GGO
↔ Peripheral
↔ No nodules
No smoking
↔
association
↔ Less distortion
↔ Slightly younger
↔ Responds to steroids

IPF (Idiopathic pulmonary fibrosis) can only be diagnosed in the absence of a precipitating condition such as
asbestosis, rheumatoid arthritis, or drug toxicity. Where such exists, the condition is termed UIP (Usual
interstitial pneumonia). CFA (Crytpogenic fibrosing alveolitis) is a historic term for the same thing.

There is much overlap in the features of the various different fibrotic lung diseases.

Therefore, look for specific features which are most strongly associated with the different conditions. The table
below (despite appearances) simplifies the overall situation significantly and is inadequate for real life radiology
but does provide a framework on which to build further understanding of these conditions.

The features in bold are the most prominent in each of the conditions.

Diagnosis Feature

IPF = UIP = CFA Macrocystic honeycombing, apicobasilar gradient

 NSIP Peripheral, associated with CREST/Sjogrens/RA, chemotherapy

COP = BOOP Patchy. Associated with connective tissue diseases, CF, methotrexate, post-transplant

RBILD Smoking, young patients, no bronchiectasis or honeycombing

DIP Smoking, GGO, difficult to tell apart from RBILD

AIP ‘Outpatient ARDS’, spares costophrenic angles

LIP Diffuse pattern, associated with Sjogrens, autoimmune conditions, Hep B, EBV, PCP

A more detailed description of each condition is listed here with those associated with smoking listed first.
There are demographic traits to most of these conditions however for the sake of simplicity these have not been
included here.

Smoking Misc. and

Diagnosis Dominant features Location
association? associations

IPF Lower Prognosis is poor,

Macrocystic
= UIP zones ‘apicobasilar Yes poorer than many
subpleural honeycombing
= CFA gradient’ cancers.

Young patients with an

extensive smoking
Centrilobular nodules + GGO. history
RBILD No bronchiectasis or Upper and mid zones Yes +++
honeycombing
Hard to tell apart from
DIP

Hard to tell apart from

DIP GGO Peripheral Yes
RBILD

Associated with:
Ground glass opacification • Collagen vasculitides
(GGO) (CREST, -myositis,
NSIP Peripheral No sjogrens, RA)
Microcystic honeycombing
• Drugs - chemotherapy
• HIV

Preceded by flu-like
illness
Patchy appearance
GGO Peripheral, Associated with:
COP peribronchial.
Consolidation No • Connective tissue
= BOOP disease
Basal
Reverse halo appearance • Cystic fibrosis
• Drugs - methotrexate
• Post-transplant

Bilateral, symmetrical, ‘Outpatient

AIP GGO initially. No ARDS’. Previously fit
lower lobes.
and well patients
 = Hammam Subsequently traction Spares costophrenic require ventilation in
Rich bronchiectasis and angles 1-4 weeks.
syndrome honeycombing in non- Poor prognosis.
= idiopathic dependant lung
ARDS

Associated with:
• Sjogrens
GGO and centrilobular • AIDS
LIP Diffuse No
nodules • Autoimmune conditions
• Infections (PCP, Hep
B, EBV)

y familiar with the staging for cancers within their remit but for the majority of trainees it is simply not practical to
memorise each and every staging scheme. As an overall strategy, the most important stages to understand are
those which change the management for patients. The patient in this scenario is stage IIIa and thus potentially
curable with an aggressive management plan. At Stage IIIb the management changes significantly because
stage IIIb and stage IV patients are unresectable. Other facts relating to lung cancer (TNM staging) that are
useful to know are those regarding satellite nodules:

o Same lobe = T3
o Different lobe = T4
o Contralateral lung = M1
Post-operative radiotherapy should be offered to the following patient groups:

• Patients with N2 level nodes

• Patients with positive resection margins
• These patients should be WHO performance status 0 or 1 and should also have ‘satisfactory’ pre-operative lung
function tests
Post-operative chemotherapy should be offered to:

• T1-3
• N1-2
• (Stage II/III)
For lung cancer some of the important staging features are as follows:

T1 tumours are <3cm N1 = ipsilateral hilar nodes

T2 tumours are >3cm but >2cm from the carina N2 = ipsilateral mediastinal or subcarinal nodes

N3 = contralateral hilar, mediastinal or

T3 tumours are any size with extension to: supraclavicular nodes

• Chest wall
• Pleura or pericardium
• <2cm of the carina
• Satellite nodules within the same lobe
M1 = bilateral lesions, malignant pleural effusion,
distant metastases

T4 tumours affect diaphragm, mediastinal organs,

carina, vertebral body

T1 and T2 both have further subdivisions.

Unresectable tumours are T4, N3 or M1.

Beyond TNM staging patients with similar prognostic outcomes are given further stages. Simple observation of
these groupings reveals the following:

• Stage I patients MUST be N0

• Stage III patients MUST have a sum ≥ 3 (ie T2N2M0, or T1N2M0). [NB some patients with Stage II will also have
a sum of 3 (for example T2N1M0) however ALL stage III patients have a sum ≥ 3.]
• Stage IIIb patients are unresectable → stage IIIb is denoted either by N3 status or T4N2.
The management of the less common small cell lung cancer is slightly different; the tumours are usually much
more aggressive, with earlier metastasis and poorer long term survival statistics. The primary lesion may not be
seen separately to the resultant associated nodal mas.

A 40-year-old man attends A+E with abdominal pain and is diagnosed with pancreatitis. He deteriorates rapidly,
is intubated and ventilated and is admitted to the Intensive Care Unit. There his respiratory failure worsens
although the capillary wedge pressure is normal. He undergoes a CT scan on day 2 of admission which is
reported as showing Acute Respiratory Distress Syndrome.

Bilateral symmetrical posterior dense consolidation and ground glass opacification

Explanation:
ARDS is a severe life threatening entity that accelerates rapidly. Patients develop rapidly progressive dyspnoea,
tachypnoea and hypoxia. As the alveoli fill with fluid and debris an arteriovenous (right-to-left) shunt develops
since although the lungs may be well perfused, the under-aeration of the alveoli prevents gas exchange. Despite
oxygenation therefore, the hypoxia becomes refractory to oxygen therapy as oxygenation can only improve a
situation where the patient is ventilating adequately.
Causes of ARDS (Mnemonic - DICTIONARIES)
• DIC
• I nfection
• Caught drowning
• Trauma
• I nhalants (smoke, NO )
2

• Oxygen toxicity
• Narcotics / drugs
• Aspiration
• Radiation
• I ncludes pancreatitis
• Emboli (fat, fluid)
• Shock (septic, cardiogenic, anaphylactic, haemorrhagic)

The chest x-ray may be normal initially but descends into patchy opacification and which becomes confluent
and extensive within hours, involving most if not all of both hemithoraces. On a CT scan there is usually
extensive ground glass opacification and dependant consolidation. The presence of non-dependant
consolidation should raise the possibility of superadded infection at any stage of the course of the disease.

Image 1: Patchy opacification

Image sourced from Wikipedia(link is external)
Courtesy of Samir CC BY-SA 3.0(link is external)

Image 2: Confluent opacification

Image sourced from Wikipedia(link is external)
Courtesy of Altaf Gauhar Haji, Shekhar Sharma, DK Vijaykumar and Jerry Paul CC BY-SA 2.0(link is external)

The changes within a lung can be charted according to a timeline:

Time Lung pathology Radiological findings

First 12 During this time there may be no radiological

Microemboli of fibrin and platelets
hours findings

Air space opacities

12-24
Interstitial oedema
hours Dependant consolidation

Air space opacities

24-48 Interstitial and alveolar oedema,
hours microatelectasis Dependant consolidation

Hyaline membrane formation, hyperplasia of

5-7 days Reticular opacities and decreasing consolidation
type 2 pneumocytes

Collagen deposition and fibrosis, often with Non dependant consolidation (suggesting
7-14 days infection)
superadded infection
 Subpleural reticulation and honeycombing
(sequelae of developing fibrosis)

If patients do survive they are initially often left with fibrotic changes in the lungs but many patients actually
experience surprisingly few long-term sequelae. The lungs gradually remodel and resolve the fibrotic changes
that take place in the intermediate term.
The wedge capillary pressure is measured via a Swan-Ganz catheter inserted peripherally and fed through the
right side of the heart to reach a branch of the (usually left) pulmonary artery. A small balloon can be inflated to
temporarily occlude this artery and a tiny transducer at the tip of the catheter measures the pressure as the
balloon deflates (the mechanism is similar to blood pressure recording via an upper arm cuff).

Wedge capillary pressure is a surrogate measure for left atrial pressures which rise with left ventricular failure or
problems with the aortic and mitral valves. If the capillary wedge pressure is elevated then a cardiac cause
should be strongly suspected. Non-cardiogenic causes of ARDS should not elevate the capillary wedge
pressure.

An 85-year-old man is found to have lymphangitis carcinomatosis.

What is the most likely description of the nodules that have been seen as part of this condition?

Explanation:
Lung nodules seen on CT take one of three different patterns:

1. Perilymphatic nodules
Peribronchiolar, perivascular, subpleural and close to the fissures

Lymphangitis carcinomatosis, sarcoidosis, pneumoconioses

2. Centrilobular nodules
Found in the centre of the secondary pulmonary lobule, with subpleural sparing

Infections, hypersensitivity pneumonitis, vasculitis

3. Random
Miliary disease, metastatic disease, langerhans cell histiocytosis
Subpleural nodules are associated with the secondary pulmonary lobule and nodules here represent a
perilymphatic distribution such as would be expected with lymphangitis carcinomatosis. They can also be seen
in usual interstitial pneumonia (UIP) or idiopathic pulmonary fibrosis (IPF).
Fissural nodules are usually isolated and feature heavily in the lung MDT with follow up CT scans arranged
according to the British Thoracic Society guidelines. Fissural thickening is associated with lymphangitis
carcinomatosis, this can be smooth or nodular thickening but the nodularity is as part of the overall thickening
rather than as discrete nodules.
Perihilar is a term usually used to refer to either cardiogenic or non-cardiogenic in origin. A perihilar distribution
of airspace shadowing is also a classical description for Pneumocystis Carinii Pneumonia (PCP).
Peribronchial is a term usually coupled with cuffing and refers to opacification surrounding the larger airways
which may be resultant from either oedema or bronchial inflammation (e.g asthma).
Intrapleural is not a classic descriptor for pulmonary pathology. Disease affecting the periphery of the chest are
classified as either extrapleural or pleural meaning they either don’t or do affect the pleura.
Lymphangitis carcinomatosis is easy to recognize on a scan but can be described in a number of different ways
on paper. It occurs when tumour cells, spread via the lymphatics, accumulate in the connective tissues of the
lung, in particular the interlobular septa. The classical description is as a smooth thick reticular polygonal
network.
A mnemonic for the likely cancers is: Certain Cancers Spread By Plugging The Lymphatics (this is not an
exclusive list). Of these Breast accounts for just over half of cases and gastric cancer accounts for most of the
remainder.
• Cervix
• Colon
• Stomach
• Breast
• Pancreas
• Thyroid
• Larynx (or lung – bronchogenic)

Openings in the diaphragm:

Which of the following structures passes through the diaphragm at the vertebral level of T10? Select ONE
answer only.

Explanation:
The diaphragm has three main openings:
• The caval opening: passes through the central tendon
• The oesophageal hiatus: situated in the posterior part of the diaphragm, to the left of the central tendon through
the muscular sling of the right crus
• The aortic hiatus: situated in the posterior part of the diaphragm, between the left and right crus

The main openings in the diaphragm and their contents are shown in the table below:

Opening Vertebral level Contents

Inferior vena cava
Caval opening T8
Branches of right phrenic nerve
Oesophagus
Anterior vagal trunk
Oesophageal hiatus T10
Posterior vagal trunk
Oesophageal branches of left gastric vessels
Aorta
Aortic hiatus T12 Azygous veins
Thoracic duct
 Score 1 of 1
A persistent cough:
A 50-year-old man undergoes a CXR for a persistent cough. There is asymmetrical bilateral hilar
lymphadenopathy.

Explanation:
Lymphangioleiomyomatosis (LAM) is associated with mediastinal lymph node enlargement but is not a usual
differential diagnosis for bilateral hilar lymph node enlargement. The main differential diagnoses would be:

• Malignancy

o Lymphoma (Hodgkin > non-Hodgkin)

o Carcinoma
• Infection

o Tuberculosis
o Histoplasmosis
o Mycoplasma
• Silicosis
• Sarcoidosis
Lymphangioleiomyomatosis (LAM)
LAM can go misdiagnosed for many years as emphysema. It occurs exclusively in non-smoking women of
childbearing age, unlike this patient, and quite often a history of spontaneous pneumothorax is given.
Radiologically there are numerous small cystic spaces surrounded by normal lung. A chylous pleural effusion
(negative Hounsfield units) is reasonably specific. The main differential diagnosis would be histiocytosis which
tends to be associated with smoking, classically spares the costophrenic angles and gives small nodules but
both can present with spontaneous pneumothorax and give small cysts. The lung volumes in LAM will remain
normal whereas they can be increased in Histiocytosis (surprisingly for a fibrotic lung disease).
 Score 1 of 1
Pulmonary hamartoma:
A 7mm peripherally lesion suspected to be a pulmonary hamartoma is being reviewed in the lung MDT.

Explanation:
Fat within a thoracic mass is diagnostic of a hamartoma but is only seen in approximately half of cases. In
contradistinction to carcinoid tumours, hamartomas tend to be peripherally located whereas carcinoid tumours
are often more central. Exceptions to both are reasonably frequent however. Calcification, especially popcorn
calcification, is also very classical for hamartomas if present. Cavitation is not a feature often associated with
them, but it can be found occasionally. Hamartomas are very similar to the chondromas which form part of the
Carney triad (pulmonary chondromas, gastric leiomyosarcomas and extra-adrenal paragangliomas). NB this is
different from Carney syndrome (atrial myxoma, facial/buccal pigmentation, sertoli tumours of the testis and
multiple other findings).

Carney Triad Carney syndrome

1. Pulmonary chondromas • Atrial myxoma
2. Gastric leiomyosarcoma (GIST) • Facial/buccal pigmentation
3. Extra-adrenal paraganglioma • Sertoli tumour of the testis
• Pituitary adenoma

Score 0 of 1
EVAR:
Which of the following features if noted on a CT abdominal angiogram is most likely to render an abdominal
aortic aneurysm unsuitable for endovascular repair?

Select one answer only.

Answer Option Question Statist

Neck angle >150deg 20

20mm infrarenal neck 4

Common iliac artery diameter of 5mm 62

Iliac artery angle >90deg 11

Common iliac artery length of 20mm 3

Explanation:

For the most part it will be the vascular surgeons or interventional radiologists themselves who decide on a
case-by-case basis whether they themselves are prepared to attempt endovascular repair of a given aneurysm.
Broadly speaking however, there are a number of criteria which the surgeon or interventionalist would be wise
to abide by:

• Distance to the renal arteries – 10mm used to be the absolute minimum landing zone distance required but
many of the grafts would required a minimum of 15mm. If the landing zone is less than 10mm a fenestrated
graft must be used to preserve the patency of the renal arteries.
• Angle of the neck – this is measured one of two ways in the literature. Consequently there are two different
values for an acceptable angle. A purely straight aneurysm would have a neck angle of either 180 or 0 in each
o o

of the different measuring systems. Thus the acceptable neck cut-off values are 120 or 60 in each case.
o o

• Angle of the common iliac artery – fortunately this is easier to remember. Iliac arteries at 90 or worse are
o

significantly harder to stent. Further consideration is usually given to the overall tortuosity of the iliac arteries but
this relates to endovascular access as opposed to stent deployment.
• Common iliac artery (CIA) length – Ideally the CIA should be longer than 20mm to accommodate the stents
used. Shorter lengths may require landing in the external iliac artery with deliberate occlusion of the internal iliac
artery and reliance on pelvic collaterals.
• Common iliac artery diameter – Stents are difficult to place where the diameter of the CIA is less than 7mm.

A 28-year-old man undergoes an HRCT after complaints of chronic cough and phlegm production. He is known
to be a user of recreational drugs.

Centrilobular hypodense micronodules

Explanation:
Please note that the question asks which finding is NOT likely to be found.

Talcosis causes hypERdense nodules, not hypOdense nodules.

There are a number of ways in which recreational drug use can affect the patient and be seen radiologically.

• Talcosis - embolisation of particulate matter injected intravenously gives rise to centrilobular micronodules
which may be high density.
• Septic emboli - secondary to non-sterile intravenous injection and endocardial vegetations. Cavitating lung
nodules associated with clinical manifestations of infection.
• Apical bullae/pneumothorax - associated with inhalational drugs, cannabis, cocaine, ecstasy, amphetamines
• Pulmonary oedema - Perihilar airspace opacification with or without pleural effusions. Associated with cocaine,
heroin, methamphetamine use.
• Consolidation - straightforward lower respiratory tract infection secondary to atypical lifestyle, concurrent
immunosuppression, or aspiration during periods of reduced consciousness.
• Nasal septum destruction - associated with snorting cocaine, due to vasoconstriction and necrosis.
• Skin abscesses and pseudoaneurysm - formation at injection sites

64-year-old man with known rheumatoid arthritis develops respiratory symptoms. He undergoes an HRCT.
In which region would you most expect there to be radiological changes?

Answer Option Question Statistics

Upper zones 14%

Centrally 1%

No zonal predilection 3%

Peripherally 7%

Lower zones 75%

Explanation:

Involvement of either the upper or lower zones is typical for a number of different pathologies. Many of the
upper lobe pathologies related to inhalational processes and conversely many of the lower lobe pathologies can
 be explained by their basis in the increased blood flow. There are a number of different mnemonics for either
area, some better than others.

For example, a mnemonic for involvement of the upper zones is BREASTS:

B = Beryllosis

R = Radiation

E = Eosinophilic granuloma (Langerhans cell histiocytosis) and Extrinsic Allergic Alveolitis

A = Ankylosing spondylitis

S = Sarcoidosis
T = Tuberculosis

S = Silicosis

Involvement of the lower zones can be remembered with the mnemonic BADAS:

B = Bronchiectasis

A = Aspiration pneumonia

D = Drugs and Desquamative interstitial pneumonia

A = Asbestosis
S = Scleroderma (and Rheumatoid arthritis)

You are assisting with a lung biopsy for a suspected malignancy.

Explanation:

Questions on post-procedure complications are relatively easy to write.

For lung biopsy there are a few key statistics that are important to know.

Approximate statistics
Pneumothorax of any size 25%

Pneumothorax needing chest drain insertion 5-10%

Haemoptysis 3%

Air embolus 0.05%

Tumour seeding 0.05%

Contraindications to CT guided lung biopsy are:

• Severe COPD
• Pulmonary hypertension
• Coagulopathy

o PLT <50
o INR <1.4
• Contralateral pneumonectomy
• (echinococcal cysts)

Various details regarding technique can also be asked:

• Make the incision ‘just above the rib below’ to avoid the main neurovascular bundle
• Avoid crossing fissures where possible.
• A coaxial needle is best – an FNA should only be used if there is a cryopathologist on-site for immediate
evaluation but since the complication rate between FNA and coaxial biopsies is largely the same this is of little
consequence.
• Oxygen saturations must be monitored throughout.
• The CT images should be taken under breath-holding
• Most cases can be done as day cases unless complications arise or are predicted.

Back pain and intravenous drug use:

A 56-year-old man who has a history of intravenous drug use presents with severe back pain. He undergoes a
CT scan which shows aortic pathology adjacent to a left psoas abscess.

A mycotic aneurysm occurs when the integrity of the wall of the aorta is compromised by bacterial infection,
usually spread from a source elsewhere within the body either haematogenously or by local spread. These
aneurysms tend to be more saccular or multilobulated in morphology, reflecting the focal mural compromise.
Adjacent soft tissue stranding is present and adjacent gas locules are almost pathognomonic, albeit rare.
An aortic aneurysm is simply a dilatation of the aorta. The vast majority of these will be degenerate, caused by
longstanding atherosclerosis and hypertension. Connective tissue diseases such as Marfan syndrome or Ehlers-
Danlos can predispose to aortic aneurysms at an earlier age. Fusiform aneurysmal dilatation is typical of a
degenerate aneurysm.
Pseudoaneurysm formation occurs when there is rupture through one or more of the layers of an artery but
there is containment of the rupture either by the adventitial layer or surrounding soft tissues. They are commonly
either traumatic or iatrogenic in aetiology. Mycotic aneurysms can become pseudoaenurysmal.

A 68-year-old man undergoing chemotherapy for leukaemia has a CT scan. This shows nodular region with a
crescent of air in the left upper lobe which was not there three weeks previously.

Explanation:

How the fungus aspergillus affects a patient depends on their underlying immune status.

• Severely immunocompromised patients → Invasive aspergillosis

• Mildly immunocompromised patients → semi-invasive aspergillosis
• Normal patients → non-invasive aspergillosis (such as colonization of a pre-existing cyst or cavity)
• Hypersensitive patients (Cystic fibrosis or asthmatics) → Allergic bronchopulmonary aspergillosis (ABPA)

Invasive aspergillosis
Invasive aspergillosis is one of the ways in which the fungus aspergillus can affect the lungs. It occurs only in
patients with a severely compromised immune system such as those with AIDs, on high dose steroids or (like
the patient in the question) neutropenic. There is endobronchial fungal growth with vascular invasion leading to
microthrombois and microinfarction. This is seen initially as a characteristic halo sign which over the ensuing
two weeks undergoes necrosis and cavitation developing as it does so, an air crescent sign. Although this is a
different process to the creation of a Monod sign (air crescent at the superior aspect of an aspergilloma) they
can seem similar.

ABPA
ABPA causes a ‘migratory pneumonitis’, typically affecting the upper lobes. Parenchymal changes are fleeting;
appearing in one area of the lung one week and a different area the next. The ‘finger in glove’ sign can often be
seen, where mucus plugging of a bronchus allows the distal airway to fill with secretions giving rise to a ‘V’ or Y’
shaped shadow on a CXR or CT. This is known as a finger in glove sign owing to its appearance. Central
bronchiectasis is a prominent feature and is can be given in an exam question setting as ‘ring shadows’ on a
CXR. The peripheral bronchi are classically spared. Cavity formation is seen in the later stages of the disease
although aspergillomas are not typical (these occur in patients with a normal immune system). The typical
patient in an exam question setting will be young, with a history of either asthma or cystic fibrosis or ‘chronic
lung disease’, symptoms of malaise, headache and intermittent chest pains, and an eosinophilia on their full
blood count.
 Score 1 of 1
Thoracic dissection:
You are on duty and called by a cardiothoracic surgeon to discuss a 45-year-old man with Marfan syndrome,
and known anaphylaxis to iodine, who presented with intense chest pain. His oxygen saturation is 95% on room
air, heart rate is 86 beats per minute and blood pressure is 154/98mmHg. The surgeon suspects he may have
an aortic dissection.

What should you advise next before the patient is taken to theatre?

Answer Option Question Statistics

CT thoracic angiogram 3%

Nothing 8%

CXR 13%

MR angiogram 54%

CT whole aorta angiogram 22%

Explanation:
This patient is haemodynamically stable. In the absence of a confirmed diagnosis, a CT angiogram should be
performed. Depending on local availability, MR angiography can be a useful adjunct to CT for patients who are
allergic to iodinated contrast although clearly the patient must be sufficiently stable to undergo an MRI scan.
In a haemodynamically stable patient for whom the diagnosis was in doubt the correct study to perform would
be a cardiac-gated CT aortogram:

• Unenhanced CT thorax - This phase is important in the diagnosis of an intramural haematoma which can be
difficult to pinpoint on subsequent phases.
• Arterial phase CT Thorax and Abdomen - It is important to know whether a dissection extends into the
abdominal aorta or iliac arteries as well as whether there is any compromise of the mesenteric or renal arteries.
• (Portal venous phase CT Thorax and Abdomen - This phase is not always performed but is most useful if
previous repairs have been undertaken and a leak is suspected)

Although not universally available, cardiac-gating of CT scans for acute aortic syndrome is optimal to reduce the
rate of false positives which are a well-documented pit-fall to non-gated studies.

Depending on local availability, MR angiography can be a useful adjunct to CT for patients who are allergic to
iodinated contrast although clearly the patient must be sufficiently stable to undergo an MRI scan.

Score 0 of 1
PR bleeding:
A 76-year-old man presents with fresh blood PR. He requires a transfusion of 4 units due to the volume of blood
lost and investigations are underway to establish the source of the bleeding. He undergoes a catheter
angiogram.

Which vessel should be targeted first in the search for the source of the bleeding?
 Answer Option Question Statistics

Coeliac axis 2%

IMA 78%

Gastroduodenal artery 4%

Marginal artery of Drummond 6%

SMA 10%

Explanation:
Fresh PR bleeding is most likely to be colonic. When performing a mesenteric angiogram it is wise to begin with
the IMA since once contrast begins to be excreted renally, the filling of the bladder may obscure more inferiorly
placed bowel loops.

The gastroduodenal artery arises from the common hepatic artery, a main branch of the celiac axis. The
Marginal artery of Drummond completes an anastomotic loop connecting the SMA, via the middle colic artery,
and the IMA.

CT chest changes:
A 37-year-old woman with progressive dyspnoea and cough over the last 20 months is being investigated. She
has never smoked and has a history of recurrent pneumathoraces. Her CT chest shows a coarse reticulonodular
interstitial pattern with multiple cysts in both lungs.

What is the most likely diagnosis?

Answer Option Question Statistics

Neurofibromatosis 1%

Idiopathic pulmonary fibrosis 2%

Langerhans Cell Histiocytosis 11%

Alpha 1 antitrypsin disorder 4%

Lymphangioleiomyomatosis 82%

Explanation:
Lymphangioleiomyomatosis (LAM)
This is the classic description of LAM. LAM can go misdiagnosed for many years as emphysema. It occurs
exclusively in non-smoking women of childbearing age, and quite often a history of spontaneous pneumothorax
is given. Radiologically there are numerous small cystic spaces surrounded by normal lung. A chylous pleural
effusion (negative Hounsfield units) is reasonably specific. The main differential diagnosis would be histiocytosis
which tends to be associated with smoking, classically spares the costophrenic angles and gives small nodules
but both can present with spontaneous pneumothorax and give small cysts. The lung volumes in LAM will
remain normal whereas they can be increased in Histiocytosis (surprisingly for a fibrotic lung disease).
 Histiocytosis (also known as Langerhans cell histiocytosis - LCH)
There are three separate forms of this disease:
1. Eosinophilic granuloma (70%) – a limited version confined to the skeleton in children or young adults. Clinically
presents as fever, raised WCC and ESR with painful bony lesions. In the skull these have a typical ‘beveled
edge’ or ‘hole within a hole’ appearance or can be seen as a ‘button sequestrum’. In the spine it is one of the
main causes of vertebra plana.
2. Hand-Schüller-Christian Disease (20%) – classically a triad of destructive bony lesions, diabetes insipidus and
exophthalmos. In a quarter of these patients the lungs are involved with cyst formation and spontaneous
pneumothoraces possible. Nodule formation, fibrosis and honeycombing is also seen.
3. Letterer-Siwe Disease (10%) – a fulminant multi-organ variant affecting very young infants

There is a strong association with smoking for patients who develop pulmonary features of LCH. Heavy
smoking causes an accumulation of Langerhans cells and hence, as with other inspiration-related lung
diseases, there is a predilection for the upper zones. The Langerhans cells can collect with other cells and
become small granulomas seen as small lung nodules. Despite being a type of fibrotic lung disease the lung
volumes can be increased. Small lung cysts form and there is a risk of spontaneous pneumothorax. There is
usually sparing of the costophrenic angles which can be a key finding.

Idiopathic pulmonary fibrosis (IPF)

IPF (Idiopathic pulmonary fibrosis) can only be diagnosed in the absence of a precipitating condition such as
asbestosis, rheumatoid arthritis, or drug toxicity. Where such exists, the condition is termed UIP (Usual
interstitial pneumonia). CFA (Crytpogenic fibrosing alveolitis) is a historic term for the same thing. IPF is not a
true differential diagnosis for cysts since the low attenuation areas seen on CT are not true cysts (no epithelial
lining is present). The macrocystic honeycombing seen is merely the consequence of the fibrotic process
underlying the condition. Another clue to the diagnosis of IPF lies in the distribution; there is an apicobasilar
gradient with honeycombing and traction bronchiectasis affecting the lung bases and fading away superiorly.

Neurofibromatosis
Technically neurofibromatosis (type I) is included in the differential diagnosis for lung cysts (particularly when
apical) however the rest of the information provided is insufficient to make this the most likely answer here.

Score 1 of 1
Tree-in-bud:
An HRCT performed on an outpatient shows a classic tree-in-bud pattern peripherally in the middle lobe.

Which of the following is the likely diagnosis?

Answer Option Question Statistics

Aspergillosis 10%

Diffuse panbronchiolitis 6%

MAC 68%

CMV infection 8%

Cystic fibrosis 9%
 Explanation:
A tree-in-bud pattern occurs when the lumen of the terminal bronchiole is filled with radiopaque material.
Historically the appearance was associated most strongly with tuberculosis however it is more recently
recognized as a feature common to many different pathologies. The nature of the material depends on the
underlying pathology. For instance:

• Pus – mycobacterial infection

• Mucus – cystic fibrosis
• Cells – breast cancer, stomach cancer (infiltration of the centrilobular artery with tumour cells)
• Aspirated substances
• Inflammatory infiltrate – autoimmune conditions
• Bronchial wall thickening - CMV

Here we are given the term tree-in-bud but this can also be indicated with a visual description of this entity such
as ‘small centrilobular nodules connected by branching opacities’ or words to that effect.
MAC – mycobacterium avium complex
This is an atypical mycobacterial infection is often seen in the form of Lady Windermere syndrome. Classically
there is bronchiectasis and tree-in-bud in the right middle lobe which is affected in isolation from the rest of the
lung and the patient is usually an otherwise perfectly healthy Caucasian elderly woman. Lady Windermere is the
central character in a play by Oscar Wilde. The play was written in an era where it would have been considered
impolite and unpleasant to cough. The term applies to a form of MAC infection thought to result from voluntary
suppression of the kind of cough which would usually be expected with the airway irritation brought on a
pathogen. Where MAC occurs in not otherwise healthy individuals there is an association with any disease
causing bronchiectasis.

Cystic fibrosis
Lung changes in cystic fibrosis affect all lobes of the lung.
The problems caused by this autosomal recessive condition have their origins in a two separate processes.
Firstly exocrine gland dysfunction causes the usual mucus secretions of the lungs to be far more viscous than
normal and thus harder to clear. Secondly ciliary dyskinesia means that this thick mucus is poorly cleared. The
combination of both processes results in stasis of mucus in the lumen of the broncho-alveolar tree (giving rise
to the tree-in-bud appearance) and this then becomes a breeding ground for various infections, with
subsequent bronchiectasis.

Diffuse panbronchiolitis
This is an idiopathic condition where there is progressive inflammation of the small airways in, as the name
implies, a diffuse pattern. The classic patient demographic is a middle-aged non-smoker of Asian heritage.

Aspergillosis
Of the different varieties of pulmonary aspergillosis it is allergic bronchopulmonary aspergillosis (ABPA) which is
most associated with the tree-in-bud appearance. This occurs due to hypersensitivity towards aspergillus
spp and is seen in asthmatics or, less commonly, patients with cystic fibrosis. Hypersensitivity reactions give
rise to bronchial wall oedema and the broncho-alveolar lumen becomes filled with fluid. Superimposed mucous
impaction is also a feature. Owing to the inhalational element of pathogen exposure there is a predisposition for
the upper lobes.

CMV infection
An opportunistic infection, CMV is seen in immunocompromised patients, most commonly those with AIDs. As
a cause of the tree-in-bud appearance it is unusual because the luminal opacification is derived from bronchial
wall thickening as opposed to an exogenous substance. Changes are usually widespread; there is no particular
predilection for the middle lobe.
Sagittal reformatted CT image showing "tree in bud" appearance of impacted distal small airways in primary
ciliary dyskinesia.

Uterine artery embolisation:

You are reviewing an MRI scan of a 45-year-old woman who recently underwent a successful uterine artery
embolisation for management of menorrhagia.

Which of the following is a complication of this procedure? Select ONE answer only.

Answer Option Question Statistics

Ovarian dysfunction 88%

Asherman syndrome 7%
 Meig syndrome 2%

Endometrioma 3%

Dermoid formation 0%

Explanation:
Asherman syndrome
Historically this condition was the result of infection with tuberculosis but nowadays it is more often the
consequence of iatrogenic endometrial damage. The formation of intrauterine synechiae leads to subfertility and
these fibrous bands can be seen on HSG as filling defects and surface irregularity. Asherman syndrome should
not occur following uterine artery embolisation.

In the world of interventional radiology, uterine fibroid embolisation is gaining momentum. The uterine artery
arises from the internal iliac artery whereas the ovarian artery arises directly from the aorta and has a corkscrew
appearance on angiography. Anastomoses between the two arteries or the two sides exist in approximately
20% of patients. Patients should be counselled for the risk of ovarian dysfunction subsequent to the procedure
and patients over the age of 45 are at particular risk. Pedunculated fibroids are said to be poor candidates for
embolisation owing to their propensity to detach however the literature is slightly contradictory on this topic.
Following a successful embolisation the fibroid should undergo infarction and involution. On an MRI scan there
will be high T1 signal with low T2 signal and no enhancement of the infarcted tissue post-contrast.

Complications include:

• Infections (Endometritis, PID and TOA)

• DVT / PE - due to compression of pelvic veins by enlarged uterus (therefore a complication of the underlying
pathology as opposed to the procedure itself)
• Ovarian dysfunction - increased risk >45years due to greater propensity for uterine-ovarian artery anastomoses.
Careful examination of pre-procedure MR angiography images helps reduce this risk
• Fibroid passage
• Haemorrhage
• Uterine necrosis - look for lack of endometrial enhancement

Asherman syndrome
Historically this condition was the result of infection with tuberculosis but nowadays it is more often the
consequence of iatrogenic endometrial damage. The formation of intrauterine synechiae leads to subfertility and
these fibrous bands can be seen on HSG as filling defects and surface irregularity. Asherman syndrome should
not occur following uterine artery embolisation.

Meig syndrome
This is a triad of an ovarian fibroma (usually, other ovarian tumours do cause it too), ascites and pleural
effusions. A right sided pleural effusion is more common than the left. The underlying mechanism is unclear.
Two possible explanations are that either the tumour irritates the peritoneum leading to a build-up of
inflammatory fluid, or that histamine release alongside other chemicals and hormones causes vasodilation and
fluid exudation that way.

Score 0 of 1
Silicosis:
A 53-year-old man with chronic dyspnoea has a CT scan which shows biapical volume loss with reticulonodular
changes in both upper lobes. There are tiny opacities with a density greater than that of soft tissue and eggshell
calcification of mediastinal lymph nodes.

Which of the following would make a diagnosis of silicosis less likely?

 Answer Option Question Statisti

Pleural thickening 65

Intralobular reticulations 12

Dense nodules 9%

Eggshell calcification of lymph nodes 7%

Upper lobe predominance 6%

Explanation:
Silicosis
Inhalation of silica leads to fibrosis. It is an occupational hazard associated with working in mines, quarries or
with glass and ceramics. Chronic silicosis occurs following exposure over 10-20 years. Small nodules
measuring a few millimeters in diameter form with an upper zone distribution (involvement of the upper zones is
classical for inhalational diseases). Around 10% of these nodules calcify and this can be seen on imaging as
multiple small foci of calcification in the upper zones. Lymph node enlargement is also a feature with eggshell
calcification often quoted as a dominant feature of silicosis despite only being present in around 5% of patients.
Intralobular septal thickening is often seen but pleural involvement is not a feature of silicosis.

Fibrosis by location:
You are reviewing a chest x-ray which shows upper zone fibrosis.

Which of these is the LEAST likely cause?

Answer Option Question Statistics

Asbestosis 75%

Silicosis 3%

Ankylosing spondylitis 7%

Progressive massive fibrosis 9%

Extrinsic allergic alveolitis 7%

Explanation:

Involvement of either the upper or lower zones is typical for a number of different pathologies. Many of the
upper lobe pathologies related to inhalational processes and conversely many of the lower lobe pathologies can
be explained by their basis in the increased blood flow. There are a number of different mnemonics for either
area, some better than others.

For example, a mnemonic for involvement of the upper zones is BREASTS:

B = Beryllosis
 R = Radiation

E = Eosinophilic granuloma (Langerhans cell histiocytosis) and Extrinsic Allergic Alveolitis

A = Ankylosing spondylitis
S = Sarcoidosis

T = Tuberculosis

S = Silicosis

Involvement of the lower zones can be remembered with the mnemonic BADAS:
B = Bronchiectasis

A = Aspiration pneumonia
D = Drugs and Desquamative interstitial pneumonia

A = Asbestosis

S = Scleroderma (and Rheumatoid arthritis)

Progressive massive fibrosis

Finding a large mass within the lungs on CT would make any radiologist suspicious that it could be a
malignancy. Sometimes in the context of pneumoconioses (especially coal worker’s pneumoconiosis or
silicosis) the masses can be from progressive massive fibrosis. Like the pneumoconioses these mass like
changes usually predominate in the upper zones. Curiously the masses can demonstrate air bronchograms and
yet more curiously they can, over time, be seen to migrate towards the hila.

Lymphangitis carcinomatosis is easy to recognize on a scan but can be described in a number of different ways
on paper. It occurs when tumour cells, spread via the lymphatics, accumulate in the connective tissues of the
lung, in particular the interlobular septa. The classical description is as a smooth thick reticular polygonal
network.

A mnemonic for the likely cancers is: Certain Cancers Spread By Plugging The Lymphatics (this is not an
exclusive list). Of these Breast accounts for just over half of cases and gastric cancer accounts for most of the
remainder.
• Cervix
• Colon
• Stomach
• Breast
• Pancreas
• Thyroid
• Larynx (or lung – bronchogenic)

Score 1 of 1
Cavitating lung lesions:
A 78-year-old woman undergoes an outpatient pacemaker insertion for cardiac arrhythmia. Following an
uneventful operation she is re-admitted 10 days later with severe shortness of breath. She undergoes a CT scan
which shows cavitating lung nodules and a wedged shaped liver lesion.

What is the most likely diagnosis?

Answer Option Question Statistics

Septic emboli 89%

 Metastatic lung cancer 1%

Under anticoagulation 9%

Metastatic HCC 1%

Primary tuberculosis 0%

Explanation:
The history of a recent cardiological intervention together with the liver pathology suggest this to be the most
likely diagnosis. If a lesion has a ‘wedge’ shape, this strongly suggests a vascular origin such as an embolus or
infarction. Although none has been given here, a suggestion of systemic sepsis would further solidify the
diagnosis.

The differential diagnosis for cavitating lesions is unusually memorable (CAVITY):

C = Cancer (Squamous cell carcinoma – either bronchogenic or metastatic, or adenocarcinoma)

A = Autoimmune granulomas (Wegener granulomatosis and Rheumatoid arthritis granulomas)

V = Vascular (septic emboli)

I = Infection (abscess, TB or cavitating pneumonias [strep, staph, aspergillus, legionella, klebsiella])

T = Trauma – pneumatocoeles
Y = Youth (ie congenital – CPAM, sequestration, bronchogenic cyst) These all form cysts, not true cavities as
such.

Under anticoagulation leading to embolus formation could occur but would not classically affect the liver.
Metastatic HCC – HCC usually metastasizes late in the disease. They can present either as solitary lesions,
multiple lesions or as an infiltrative area but none of these would usually be described as wedge-shaped.
Metastatic lung cancer – a lung nodule is technically smaller than 3cm in diameter (this would be T1 in the TNM
classification of non-small cell lung cancers) and bronchogenic SCCs tend to be larger than this when they do
metastasize. Liver metastases would not usually be conform to the description of ‘wedge-shaped’.
Primary tuberculosis does not usually cavitate but by contrast cavitation can be seen in anything upto two fifths
of post-primary tuberculosis cases.

Score 1 of 1
CXR findings:
You are reviewing a CXR with a left upper lobe collapse on it.

Which is the most likely finding in-keeping with this diagnosis?

Answer Option Question Sta

The hilum overlay sign

Obscuration of the left heart border

Veil like opacity in the upper and middle zones

 Obscured descending aorta

Loss of visualisation of the horizontal fissure

Explanation:

The silhouette (pronounced as: sil-o-wet) sign has a leading role in the interpretation of chest xrays. It occurs
when two structures are adjacent to one another and it is therefore not possible to see where one begins and
the other ends on a CXR. In order to see all the way around any structure it must have a difference in density
between it and any structure touching it; this is called ‘contrast’. The silhouette sign is useful because it can be
used to define the anatomical location of pathology.

• The left lower lobe is adjacent to the descending thoracic aorta

• The lingula is adjacent to the left heart border
• The left upper lobe is adjacent to the aortic knuckle

Lobar collapse
Lobe Silhouette sign CXR finding
Veil-like opacification over upper and middle
Left upper lobe Aortic knuckle zones, Luftsichel sign

Lingula Left heart border

Retrocardiac triangular opacity, double cardiac
Left lower lobe Descending aorta
contour
Right upper zone opacity with elevation of the
Right upper lobe Right paratracheal stripe horizontal fissure

Right middle Blurred right heart border with loss of visualization

Right heart border
lobe of the horizontal fissure
Right heart border and right
Right lower lobe medial hemidiaphragm Inferomedial opacity

The hilum overlay sign

This sign makes use of the silhouette sign to determine whether a central mass on a CXR arises from the hilum
as opposed to either the anterior or posterior mediastinum. If the hilar vessels can be visualized through or
against the mass then there must be lung separating the mass from the hilum; hence it must be in either the
posterior or anterior mediastinum. If the vessels cannot be seen then the mass must be in contact with the
hilum.

Hyperlucent lung:
What is the most common cause of an incidental hyperlucent left lung on a PA chest radiograph of a 30-year-
old woman?

Select one answer only.

Answer Option Question Statistics

Rotation to the left 56%

 Poland syndrome 6%

Rotation to the right 31%

Swyer-James syndrome 6%

Alpha-1-antitrypsin 1%

Explanation:
Film rotation
Unfortunately it is more likely that technical features will cause unilateral hyperlucency than any of the
pathological conditions which may feature in the differential diagnosis. Rotation of the patient to the left on a PA
film will bring the left hemithorax away from the plate. The chest anatomy is such that in doing so the xray beam
travels through less lung tissue in terms of depth than either the contralateral side in the same rotated patient or
the left lung in an unrotated patient. The beam travelling through less lung tissue is therefore less attenuated
and the lung appears hyperlucent on the resultant film

Poland syndrome
Poland syndrome is a rare cause of a hyperlucent hemithorax on a CXR. There is hypoplasia or even aplasia of
the chest wall musculature plus/minus breast. Abnormalities of the fingers on the same side such as syndactyly
(fusion) or brachydactyly (shortening) can also occur and the ipsilateral ribs may also be abnormal.

Swyer-James syndrome
In this condition, normal development of the infant lung is impeded by bronchiolitis (viral or mycoplasma) at an
early age, with superadded acute airspace destruction. Consequently the affected lobe is small and lucent on
the CXR due to air trapping. It is a differential diagnosis for a unilateral lucent hemithorax, along with a
pneumothorax, very large pulmonary emboli and causes of decreased chest wall musculature such as Poland
syndrome or, historically, polio. In an an exam situation Swyer-James syndrome is usually given as a teenage or
young adult patient with a history of recurrent LRTIs. Air trapping, and bronchiectasis can also be described.

Alpha 1 antitrypsin deficiency

Alpha-1 antitrypsin is a glycoprotein which is made in the liver and secreted. One of its functions in the lungs is
to oppose the action of proteolytic enzymes the likes of which are secreted by white blood cells in order to
counter sub-clinical bacterial infections. Since A1AT is deficient in these patients the unopposed action of the
enzymes goes beyond the intended destruction of pathogenic bacteria and causes damage to the lung tissue.
Patients are usually diagnosed in early adulthood when their symptoms develop. On CT there is panacinar
emphysema, particularly affecting the bases. Bronchiectasis is also often seen. Cirrhosis is another feature of
this disease and should be looked for on imaging.

Eggshell calcification:
Which of the following is NOT a cause of eggshell calcification of thoracic lymph nodes?

Select one answer only.

Answer Option Question Statistics

Tuberculosis 12%

Asbestosis 64%
 Talcosis 13%

Coal workers pneumoconiosis 6%

Sarcoidosis 5%

Explanation:
Eggshell calcification
When the outer rim of a lymph node becomes calcified it is seen on CT as eggshell calcification. There is a
relatively specific differential diagnosis for diseases which can manifest in this way.

• Fibrosing mediastinitis
• Amyloidosis
• Pneumoconioses - silicosis and coal workers only. Not seen in most others.
• Sarcoidosis
• Scleroderma
• Treated lymphoma (ie post radiotherapy)
• TB
• Histoplasmosis

Aortic dissection:
A 47-year-old man experiences sudden onset chest pain and is being investigated for a myocardial infarction.
On examination, the A+E doctor notices he is unusually tall with pectus excavatum deformity and long fingers.
An early diastolic murmur is heard on auscultation. He undergoes a CT scan and is found to have an aortic
dissection.

From where is the dissection most likely to have originated?

Answer Option Question Stati

Just proximal to the brachiocephalic artery 3

At the site of the ligamentum arteriosus 1

Just distal to the right subclavian artery 4

Aortic root 7

At the level of the diaphragm 0

Explanation:

The patient has Marfan syndrome which is an autosomal dominant connective tissue disease. Among other
common features associated with this condition, the patient in this scenario is tall, with arachnodactyly and
pectus excavatum. An early diastolic murmur suggests regurgitation, usually of the aortic valve but less
commonly the pulmonary valve. Aortic regurgitation is another feature common to Marfan syndrome but
although this may be present it would not necessarily explain his sudden chest pain. Patients with Marfan
syndrome are at increased risk of developing aortic dissection compared to the general population.

Dissections are classified according to their involvement of the aortic root and their distal extent. There are two
different classification systems. The Stanford classification is more useful clinically since the primary decision
post-diagnosis is whether the dissection will be managed surgically or medically. Those involving the proximal
aorta and arch are managed surgically. If the arch is not involved, the patient can be managed medically. Thus
Stanford A dissections involve the aorta proximal to the origin of the left subclavian artery with or without
concurrent distal involvement. Stanford B dissections do not involve the proximal aorta.
Most dissections originate just distal to the aortic valve and extend proximally, ie Stanford type A.

Traumatic aortic rupture is most likely to occur at the site of the ligamentum arteriosus, just distal to the origin of
the left subclavian artery. This is termed the aortic isthmus. The proximal aorta is fixed by the ligamentum
arteriosus but distal to this point the aorta is more freely mobile.
Coarctation of the aorta is associated with a late systolic or continuous systolic murmur.

Mitral stenosis gives a mid-diastolic murmur.

Rheumatic heart disease can affect any of the heart valves, although most commonly affects the mitral valve
causing mitral stenosis.

Pectus Excavatum:
Image sourced from Wikipedia(link is external)
Courtesy of Bakalli et al. CC BY-SA 3.0(link is external)
Classification:

Image sourced from Wikipedia