GC Proceedings

Dated:15/5/18
X RAY presenter : Dr.Thejus.B
Malathi 38 year old female

Chest X Ray PA view

Exposure Adequate
Inspiratory Film
No Rotation
Trachea Central
Soft Tissues are normal
Bilateral Costophrenic angles are normal
Bilateral Cardiophrenic angles are normal
Right heart Border obscured , left heart border is seen
Gastric fundal shadow present
No mediastinal widening seen
Bilaterally diaphragm appears normal
Crowding of ribs seen bilaterally
Multiple Cystic air spaces visible in the right Mid zone and lower zones and left mid
and lower zones

Diagnosis: Bilateral cystic bronchiectasis

Discussion:
1.Which Disease presents with productive cough, clubbing and cluster of thin walled
cystic spaces on chest X ray?

Cystic bronchiectasis

2. What are the chronic complications of Bronchiectasis?

Progressive respiratory failure

Cor Pulmonale
Secondary Amyloidosis
Metastatic Abscesses
Recurrent pneumonia
Massive Hemoptysis

Reference: www.emedicine.medscape.com
Chest X Ray PA view

Inspiratory Film
Exposure Adequate
No Rotation
Trachea is not seen
Soft Tissues are normal , Bony rib cage appears normal
Bilateral Costophrenic angles are normal
Bilateral Cardiophrenic angles are normal
Right heart border seen , left heart border is seen
Gastric fundal shadow present
Lung Parenchyma appers normal
Widening of the upper mediastinum present due to an anterior mediastinal mass
There is a presence of an anterior mediastinal mass with smooth lobulated lateral
margins

Diagnosis : Anterior mediastinal mass thymoma

Discussion:

1. Where is the superior mediastinum?

Superior mediastinum is a wedge-shaped compartment of the mediastinum that lies

above an imaginary line that runs from the sternal angle or angle of Louis to the
inferior endplate of T4 vertebra(thoracic plane)

2. How is the inferior mediastinum divided?

It is divided into Anterior , middle and posterior mediastinum

Anterior Mediastinum:​The anterior mediastinum is the portion of
the ​mediastinum​ anterior to the ​pericardium​ and below the ​thoracic plane​.
Middle Mediastinum​: ​The middle mediastinum is bounded anteriorly by the
pericardium, posteriorly by the posterior tracheal wall, superiorly by the thoracic inlet,
and inferiorly by the diaphragm
Posterior Mediastinum: The posterior mediastinum is bounded anteriorly by the
posterior trachea and pericardium, anteroinferiorly by the diaphragm, posteriorly by
the vertebral column, and superiorly by the thoracic inlet

3. What are the contents of the anterior and middle mediastinum?

Anterior Mediastinum: Its contents include the thymus, lymph nodes, adipose tissue,
and internal mammary vessels

Middle Mediastinum: Its contents include the heart and pericardium; the ascending
and transverse aorta; the superior vena cava (SVC) and inferior vena cava (IVC); the
brachiocephalic vessels; the pulmonary vessels; the trachea and main bronchi; lymph
nodes; and the phrenic, vagus, and left recurrent laryngeal nerve
4. What are the features of a retrosternal Goitre on chest x ray?

Chest x-ray may show a superior mediastinal radiopacity causing the deviation of
trachea to opposite site. The superior margin of the radio-opacity/mass is untraceable

5. What is Cervicothoracic sign?

The cervicothoracic sign, a variation of the ​silhouette sign​, helps to localize a mass in
the superior mediastinum on frontal chest radiographs as either anterior or posterior.
As the anterior mediastinum ends at the level of the ​clavicles​, the upper border of an
anterior mediastinal lesion cannot be visualised extending above the clavicles. Any
lesions with a discernible upper border above that level must be located posteriorly in
the chest, i.e. apical segments of upper lobes, pleura, or posterior mediastinum

6.What are the causes of Anterior Mediastinal mass?

Thymus:
➢ Thymoma
➢ Thymic cyst
➢ Thymic hyperplasia
➢ Thymic carcinoma

➢ Lymphoma

Germ cell tumor:

➢ Teratoma/dermoid cyst
➢ Seminoma

Non-seminoma:
➢ Yolk sac tumor
➢ Embryonal carcinoma
➢ Choriocarcinoma

Intrathoracic thyroid:
➢ Substernal goiter
➢ Ectopic thyroid tissue
7. If a patient presents with proximal muscle weakness that worsens at the end of
the day with above chest x ray what would be the diagnosis?

Thymoma , up to one-half of patients with thymoma have symptoms consistent with

myasthenia gravis.

8. How do you define cyst , cavity and bulla?

➢ Pulmonary cyst is defined as a round parenchymal lucency or low-attenuating area

with a well-defined interface with normal lung which may be round ,irregular or
variabe in size and is thin walled (<2mm thick )

➢ A bulla is defined as an air space in the lung measuring more than one centimeter
in diameter and maybe rounded, focal and is thin-walled (<1 mm thick)

The term giant bulla is used for bullae that occupy at least 30 percent of a hemithorax

➢ Pulmonary cavities are defined as a gas-filled space, seen as a lucency or

low-attenuation area, within pulmonary consolidation, a mass, or a nodule and it is
thick walled (>4 mm)

Reference : ​www.uptodate.com

Hansell DM, Bankier AA, Macmahon H et-al. Fleischner Society: glossary of terms
for thoracic imaging. Radiology. 2008;246 (3): 697-722

9. What are the differential diagnosis for cystic shadows on chest x ray?

Cystic Bronchiectasis
Staphylococcal pneumonia
Primary and metastatic tumors (eg, lung adenocarcinoma, metastatic gastrointestinal
and genitourinary adenocarcinoma, lymphoma, mesenchymal cystic hamartoma,
metastatic sarcomas)
Hypersensitivity pneumonitis
Fungal Infections (eg, coccidioidomycosis, Pneumocystic jirovecii)
Smoking-related interstitial lung disease (desquamative interstitial
pneumonia, pulmonary Langerhans cell histiocytosis, respiratory bronchiolitis
interstitial lung disease)
Lymphoid interstitial pneumonia​(eg, associated with Sjögren syndrome,
immunodeficiency)
Lymphangioleiomyomatosis (sporadic or related to tuberous sclerosis complex)
Birt-Hogg-Dubé syndrome
Amyloidosis

References:
www.radiopaedia.com

www.uptodate.com

Whitten CR, Khan S, Munneke GJ, Grubnic S. A Diagnostic Approach to Mediastinal

Abnormalities. RadioGraphics 2007;27(3):657–71