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PULMONARY RADIOLOGY
พญ. ปาณยา ทุมสท้าน
ภาควิชาร ังสีวท
ิ ยา คณะแพทยศาสตร ์
มหาวิทยาลัยขอนแก่น
PULMONARY OPACITY

“area that preferentially attenuates the x-ray beam”
Area that more opaque than the surrounding
area
 CLASSIFIED INTO







Airspace opacities
Atelectasis (collapse)
Nodules and masses
Linear and band like opacities
Cysts and bullae
Nodular and reticulonodular opacities and
honeycombing
AIRSPACE OPACITIES
Acinar shadow
 Consolidation
 Solitary airspace opacity
 Multifocal airspace opacity

DIFFERENTIAL DIAGNOSIS OF AIRSPACE OPACITES
SOLITARY AIRSPACE OPACITY
Pneumonia
Atelectasis
Infarction
Hemorrhage
Neoplasms
- BAC
- Lymphoma
Radiation fibrosis
Pulmonary contusion, vasculitis, drug reaction, etc.
DIFFERENTIAL DIAGNOSIS OF AIRSPACE OPACITES
MULTIFOCAL AIRSPACE OPACITIES

Exudate and transudates


Hemorrhage


Pneumonia, OP, infarction, connective tissue disease
and vasculitis, inhalation of noxious gases or liquids,
drug reaction, alveolar proteinosis
Pulmonary contusion/hematoma, infarction, vasculitis
Neoplasm

BAC, lymphangitic carcinomatosa, metastases,
lymphoma
RML PNEUMONIA
bronchopneumonia
PULMONARY EDEMA
RadioGraphics,
Infectious pneumonia in a 35-year-old patient with hypogammaglobulinemia.
November 2009 RadioGraphics, 29, 1909-1920.
Small focus of pulmonary consolidation caused by pulmonary infarction
David Hansell et al, Imaging of diseases of the chest, 5th edition,
2010
Widespread, uniform airspace opacities in acute respiratory distress syndrome
David Hansell, Imaging of diseases of the chest, 5th edition, 2010
ATELECTASIS
Most frequent cause is bronchial obstruction
 Bronchial obstruction in adult

Usually the result of a bronchial neoplasm or mucus plug
 Occasionally, FB aspiration, broncholiths, extrinsic compression
e.g. enlarged LNs, aortic aneurysm

Passive atelectasis
 Discoid atelectasis ( Platelike or linear atlectasis)


A form of adhesive atelectasis

Usually abuts the pleura and is perpendicular to pleural surface
Golden S sign
David Hansell, Imaging of diseases of the chest, 5th edition, 2010
Left upper lobe collapse due to bronchial carcinoma. Note that the
carcinoma has caused ‘rat tail’ narrowing of the left upper bronchus.
David Hansell, Imaging of diseases of the chest, 5th edition, 2010
Fluid bronchogram at CT. Fluid-filled bronchi beyond a carcinoma in the
atelectatic lower left lobe are clearly visible.
David Hansell, Imaging of diseases of the chest, 5th
edition, 2010
ROUND ATELECTASIS

A form of chronic atelectasis that resembles a mass

Main DDx is BCA
 “bronchi
and vessels curving into the
periphery and converging toward a mass
and area of pleural thickening (Comet tail
sign)”
David Hansell, Imaging of diseases of the chest, 5th edition, 2010
SOLITARY PULMONARY NODULE/MASS
Pulmonary nodule : lesion up to 3 cm in diameter.
 DDx of SPN/mass
1. Neoplasm


2.
BCA, metastasis, lymphoma, carcinoid tumor,
hamartoma, etc
Inflammatory
1.
2.
Infection: TB, fungus, round pneumonia, lung abscess,
septic emboli
Non infection: RA, Wegener granulomatosis
SOLITARY PULMONARY NODULE/MASS

DDx of SPN/mass
Congenital
3.

Pulmonary AVM, sequestration, lung cyst, bronchial atresia
with mucoid impaction
Miscellaneous
4.

Organizing pneumonia, pulmonary infarction, round
atelectasis, etc.
Mimics of SPN
5.



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External object
Bone island or rib, healing rib fracture
Pleural plaque
Loculated pleural fluid
PATIENT WITH A KNOWN EXTRATHORACIC MALIGNANT
NEOPLASM

Patients with CA of H&N, bladder, breast, cervix, bile
ducts, esophagus, ovary, prostate, or stomach with
SPN

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Patients with known salivary glands, adrenals, colon,
kidney, thyroid, thymus or uterus


“primary lung CA were more likely than metastasis”
“fairly even odds”
Patients with known melanoma, sarcoma, or
testicular cancer

“solitary metastasis is more likely than primary lung
CA”

Features which can be diagnostically helpful
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Calcification
Fat density within a nodule
Ground glass opacity
Size
Shape
Cavitation
Air bronchogram and bubblelike lucencies
Enhancment
BENIGN CALCIFICATION
Concentric calcification
Popcorn calcification
Uniform calcification
David Hansell et al, Imaging of diseases of the
chest, 5th edition, 2010
David Hansell et al, Imaging of diseases of the
chest, 5th edition, 2010
Fat in
hamartoma
David Hansell et al, Imaging of diseases of the chest, 5th
edition, 2010
DENSITY OF THE NODULE
March 2007 RadioGraphics, 27, 391-408.
SIZE AND SHAPE
David Hansell et al, Imaging of diseases of the
chest, 5th edition, 2010
FLEISCHNER SOCIETY RECOMMENDATIONS
MacMahon et al. Radiology 237:395, Nov 2005
Contrast enhancement
 Rate of growth
 Adjacent bone destruction

Air crescent sign
Silva et al. The teaching files chest. 82-83. 2010.
MULTIPLE PULMONARY NODULES
Neoplasm
metastatic CA or sarcoma, lymphoma, BAC
 Hamartomas, laryngeal papillomatosis

Inflammatory

Infective
Granulomas (TB, histoplasmosis, nocardiosis)
 Lung abscesses, septic emboli,etc.


Noninfective

RA, Wegener granulomatosis
Congenital : AVM
Miscellaneous

Hematomas, pulmonary infarction, mucoid impaction
Metastasis thyroid CA
Miliary TB
Silva et al, The teaching
files chest. 40-41, 2010.
SILICOSIS
Centrilobular nodules in Subacute hypersensitivity pneumonitis
Silva et al, The teaching files chest, 2010.
Tree-in-bud in infective bronchiolitis
Silva et al, The teaching files chest, 46-47,2010.
RANDOM DIST NODULES
Pulmonary metastasis
Miliary TB
Silva et al, The teaching files chest, 48-49, 2010.
ABNORMAL LUCENCY LESION
Cyst, cavity, bleb, bulla, emphysema
 CYST;



any round circumscribed space that is surrounded by an
epithelial or fibrous wall of variable thickness
CAVITY;
a gas-filled space, seen as a lucency or low-attenuation
area, within pulmonary consolidation, a mass, or a nodule
 usually produced by the expulsion or drainage of a
necrotic part of the lesion via the bronchial tree
 Cavity is not a synonym for abscess.


BLEB;
a small gas-containing space within the visceral pleura or
subpleural lung, not > 1 cm in diameter
 CT: a thin-walled cystic airspace contiguous with the
pleura


BULLA;
An airspace measuring > 1 cm – usually several
centimeters – in diameter
 sharply demarcated by a thin wall that is no greater than
1 mm in thickness.


usually accompanied by emphysematous changes in the adjacent
lung.

Bullous emphysema is bullous destruction of the lung
parenchyma

usually on a background of paraseptal or panacinar emphysema

EMPHYSEMA;
permanently enlarged airspaces distal to the terminal
bronchiole with destruction of alveolar walls
 CT; focal areas or regions of low attenuation, usually
without visible walls.[

cyst
Silva et al, The
teaching files chest,
2010
BULLA
BLEB
EMPHYSEMA
IMAGE : WIKIPEDIA
Paraseptal and centrilobular emphysema
Imagingconsult.com
BRONCHIECTASIS
HONEYCOMBING
CYSTIC BRONCHIECTASIS
HONEYBOMBING
LINEAR AND BAND-LIKE OPACITIES
Mucoid impaction
 Septal lines
 Bronchial wall (peribronchial) thickening

MUCOID IMPACTION
BRONCHIAL ATRESIA
MUCOCELE
PERIIBRONCHIAL WALL THICKENING
RETICULONODULAR OPACITIES

Acute
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Lower zone

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Pulmonary edema, pneumonia (Mycoplasma, viral,
opportunistic)
Idiopathic pulmonary fibrosis, RA, scleroderma, drug
reaction, HP,
Mid- or upper zone

Pulmonary TB or fungal disease, Pneumoconiosis, HP
NODULAR AND RETICULONODULAR PARTERN
Pulmonary
fibrosis
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