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ISSN: 2165-3259
JAOCR
Official Journal of the American Osteopathic College of Radiology
CHEST IMAGING
Guest Editors: Les Folio, D.O., MPH, FAOCR
Bernard F. Laya, D.O.
Editor-in Chief: William T. O’Brien, Sr., D.O.
April 2014, Vol. 3, Issue 2
JAOCR About the Journal
Aims and Scope
The Journal of the American Osteopathic College of Radiology (JAOCR) is designed to provide practical up-todate reviews of critical topics in radiology for practicing radiologists and radiology trainees. Each quarterly
issue covers a particular radiology subspecialty and is composed of high quality review articles and case
reports that highlight differential diagnoses and important teaching points.
Access to Articles
All articles published in the JAOCR are open access online. Subscriptions to the journal are not required
to view or download articles. Reprints are not available.
Copyrights
Materials published in the JAOCR are protected by copyright. No part of this publication may be
reproduced without written permission from the AOCR.
Guide for Authors
Submissions for the JAOCR are by invitation only. If you were invited to submit an article and have
questions regarding the content or format, please contact the appropriate Guest Editor for that
particular issue. Although contributions are invited, they are subject to peer review and final
acceptance.
Editor-in-Chief
William T. O’Brien, Sr., D.O.
San Antonio, TX
Design Editor
Jessica Roberts
Communications Director, AOCR
Managing Editor
Tammam Beydoun, D.O.
Farmington Hills, MI
Editorial Board
Susann Schetter, D.O.
Daniel J. Abbis, D.O.
Les R. Folio, D.O.
Michael W. Keleher, D.O.
Rocky Saenz, D.O.
Kipp A. Van Camp, D.O.
John Wherthey, D.O.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Page i
Table of Contents
Chest Imaging
Guest Editors: Les Folio, D.O., MPH, FAOCR
Bernard F. Laya, D.O.
Title/Author(s)
Page No.
From the Editor
1
Review Articles
Does This Chest Radiograph Belong to a Survivor of Childhood Cancer?
Radiographic Findings Suggesting Previous Treatment for Childhood Cancer – A Review
Aswin V. Kumar, OMS3, Sue C. Kaste, D.O.
Interpretive Approach and Reporting the Intensive Care Bedside Chest X-Ray
Les Folio, D.O., MPH, FAOCR
2
12
Case Reports
Cavitary Lung Mass in a Febrile Child
Rachel Pevsner Crum, D.O., Ricardo Restrepo, M.D., Nolan Altman, M.D.
21
Pulmonary Vascular Anomaly
David P. Concepcion, M.D., Bernard F. Laya, D.O., Ana Maria Saulog, M.D.
25
Interstitial Lung Disease
Shereef Takla, B.S., Aaron M. Betts, M.D.
28
Posterior Mediastinal Mass
Anagha Joshi, M.D., DMRE, Chintan Trivedi, M.D., DNB, Ashank Bansal, MBBS
32
JAOCR at the Viewbox
Pulmonary Lymphangioleiomyomatosis
Bernard F. Laya, D.O., Regina C. Nava, M.D.
35
Hydatid Cyst of the Lung
Ali Yikilmaz, M.D.
36
Page ii
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
From the Guest Editor
In This Issue
Les Folio, D.O., MPH, FAOCR
Lead Radiologist for CT, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD
When Lt Col (Dr.) O’Brien asked me
to serve as guest editor for the first
chest edition of JAOCR, I quickly
involved our friend and AOCR
colleague, Bernard Laya, DO. With his
expertise in chest imaging and as a
world expert on tuberculosis in
children, combined with Bill O’Brien’s
tireless dedication to make this
Journal a success, I felt as though we
were in great hands to develop a
chest imaging edition worth keeping
on your bookshelf for reference.
"We choose to go the
moon in this decade
and do the other
things, not because
they are easy, but
because they are
hard..."
-President John F. Kennedy
I am confident you will find the
included topics informative, practical
to your practice, and up-to-date. For
example, “The Posterior Mediastinal
Mass” case report by Anagha Joshi,
MD, DMRE, Chintan Trivedi, MD, DNB,
and Ashank Bansal, MBBS, has a
representative biopsy proven mass
with
differentials
and
great
discussion.
Similarly, Dr. Rachel Crum’s
skillful description of a pediatric
cavitary lung mass is supported with
great images and differentials that
allow radiologists to approach this
scenario more confidently.
Aswin V. Kumar, OMS3, and Sue
C. Kaste, DO, provide a thrilling
review of chest x-ray findings that
should make one consider that the
patient might be a childhood cancer
survivor. Knowing these clues will
help radiologists identify the effects
of both the cancer and its therapies.
Nathan David P. Concepcion,
MD, Bernard F. Laya, DO, and Ana
Maria Saulog, MD, orchestrated an
astounding yet concise summary on
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
congenital bronchopulmonary foregut
anomalies while highlighting a
particular case.
Shereef Takla, BS, and Aaron M.
Betts, MD, tackled the challenge of
interstitial lung disease, something
that I thought to be impossible in a
case report. Yet, they met and
exceeded their goal with great
images, differentials, and discussion.
Ali Yikilmaz, MD, presents an
interesting case that although
seemingly uncommon, could show up
at our viewbox at any time. Knowing
the water-lily sign associated with
hydatid cysts will help us make the
diagnosis.
Although I see cases of
lymphangioleiomyomatosis
(LAM)
nearly every day, Bernard Laya, DO,
and Regina C. Nava, MD, put LAM into
the
needed
perspective
with
representative
lung
and
extrapulmonary findings.
I sought Bill and Bernie’s advice
on making my ICU chest x-ray article
useful to the majority of radiologists
in this audience. I included the basics
of line and tube placement,
pulmonary pathology, newer imaging
techniques, and tips on reporting.
Lastly, I would like to recognize
Lt Col William T. O'Brien, Sr., USAF,
MC, for pioneering and bringing the
JAOCR to its current status. Having
served with the Air Force myself for
20 years and the AOCR for nearly the
same amount of time on various
committees, taking on the JAOCR is a
major undertaking and is the epitome
of the quote I selected.
Page 1
Childhood Cancer, Kumar et al.
Does This Chest Radiograph Belong to a Survivor of Childhood Cancer?
Radiographic Findings Suggesting Previous Treatment for Childhood Cancer – A Review
Aswin V. Kumar, OMS3a,b , Sue C. Kaste, D.O.b-d
a
Lincoln Memorial University, Harrogate, TN
Department of Radiological Sciences, Division of Diagnostic Imaging, Memphis TN
c
Oncology, St. Jude Children’s Research Hospital, Memphis TN
d
Department of Radiology, University of Tennessee School of Health Sciences, Memphis, TN
b
Introduction
Advances in the detection, treatment, and
supportive care of pediatric malignancies has allowed
for improved long-term survival among childhood
cancer survivors. At present, the 5-year survival for
those diagnosed with a pediatric malignancy exceeds
80% with a 10-year survival rate of 75%.1 The
increasing number of adult survivors of childhood
malignancies now approaches an estimated 360,000
individuals, allowing for more extensive studies of the
delayed manifestations of adverse effects related to
cancer treatment.1, 2 Medical conditions that persist or
present in 5 or more years following treatment are
referred to as late effects. Studies that investigate the
late effects of pediatric cancer treatment have shown
that 73.4% of survivors will experience a chronic
medical condition, with over 40% experiencing a
serious or life-threatening problem.3
The manifestations of late effects are wide ranging
and involve all organ systems, with differential
presentation largely dependent on both the primary
malignancy and the treatment received. Some of the
most common late effects observed in childhood
cancer survivors are pulmonary and cardiac
complications, with skeletal complications and
secondary malignancies being less common.4 The
increased survivorship and incidence of morbidity
amongst those treated for childhood malignancies
necessitates increased vigilance on the part of the
adult survivors’ health-care providers to both detect
and treat the anticipatory late effects in this
population. The manifestations of tissue injury from
therapy administered during childhood may not
become apparent until the patient enters a phase of
rapid growth, such as adolescence. At such times, the
treatment insult on normal tissues may result in
impaired growth.5 Diagnostic imaging can provide a
robust means through which many late effects can be
detected.
Page 2
The aim of this article is to provide an overview of
selected radiographic manifestations of thoracic
findings that may be associated with previous
treatment for pediatric cancers and their late effects
by providing an image-based approach to identifying
unique radiographic characteristics that may be seen
on chest radiographs obtained for reasons unrelated
to a history of previous childhood cancer. The risk
factors for and prevalence of tumor recurrence and
secondary malignant neoplasms are well-described in
the literature and will not be included in this pictorial
review.
Residual Mediastinal Mass After Treatment For
Lymphoma
The presence of residual abnormality of the
mediastinum or hila after completion of therapy for
lymphoma can induce anxiety in patients, parents, and
healthcare providers. Approximately two-thirds of
patients with Hodgkin lymphoma and one-third of
patients with non-Hodgkin lymphoma have been
reported to have residual mediastinal masses after
completion of therapy,6 which can be apparent on
chest radiographs (Fig. 1). These residual masses more
often occur in patients presenting with bulky
mediastinal disease7 or those with nodular sclerosing
subtype of Hodgkin disease.8 The residual soft tissue
masses are usually composed of benign fibrotic or
inflammatory tissue and may be seen in up to 41% of
chest radiographs and 46% of chest CTs in pediatric
patients treated for Hodgkin disease9; these masses
may calcify (Fig. 2).9 Typically, residual fibrotic masses
continue to regress over time.7,8
Particularly in pediatric patients, thymic rebound,
developing after completion of therapy, may mimic a
residual mass.8 Comparison with prior chest imaging
can resolve whether or not the original mass has
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Childhood Cancer, Kumar et al.
A
B
C
Figure 1. Residual Post-Therapy Mediastinal Mass. 18-year-old man diagnosed with Stage IV B nodular sclerosing Hodgkin disease was
treated with chemotherapy and 2550cGy mantle and 800 cGy whole lung irradiation. Residual mediastinal mass persisted over the
subsequent 8 years from initial imaging at diagnosis through follow-up. Posteroanterior chest radiograph at the time of diagnosis (A) shows
a large anterior mediastinal mass which extends bilaterally from the midline. A follow-up posteroanterior chest radiograph obtained 8
years from diagnosis (B) shows residual superior mediastinal widening that corresponds to the residual masses shown on the corresponding
computed tomography image (C).
A
Figure 2. Calcification of
Residual Mediastinal Mass.
24-year-old survivor of
Stage IIIB nodular sclerosing
Hodgkin disease diagnosed
at 15 years of age. His
disease was refractory to
standard
chemotherapy,
prompting autologous bone
marrow transplantation and
2100
cGy
mediastinal
B
C
radiation. Posteroanterior
(A) and lateral (B) chest radiographs at the time of diagnosis show a bulky anterior mediastinal mass. Follow -up
posteroanterior chest radiograph 6 years later (C) shows significant reduction in the mediastinal mass with development of
dense calcifications.
changed in size and contour. Increase in the residual
mass or new adenopathy warrants further evaluation
for the possibility of recurrent disease (Fig. 3). Such
can be accomplished using MR10, 11 or CT for anatomic
characterization of changes seen on chest
radiographs.6 However, MR and CT have limited ability
to differentiate between active disease and fibrosis or
scarring.9-13 Thus, 18F-FDG PET/PET-CT may be used to
assess for metabolic activity (having largely replaced
67
Gallium imaging) that may indicate disease
relapse.6,13
Pulmonary Complications
The lungs are one of the most radiation- and chemosensitive organs in the body.14 Functional compromise
arising from radiation is compounded by
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
chemotherapy-induced toxicities, all of which may
progress from initial injury to the pulmonary
interstitium to pulmonary fibrosis over time.14
Pulmonary complications after therapy for childhood
cancer include pulmonary fibrosis (Fig. 4), chronic
cough, recurrent pneumonia, requirement for
supplemental oxygen, and pleurisy. Mertens, et al.
reporting on the prevalence of self-reported
pulmonary complications from the Childhood Cancer
Survivor Study, found that chest radiation was
statistically associated with all of these adverse late
effects, as were various chemotherapeutic agents.14
Chemotherapeutic
agents
associated
with
development of pulmonary insufficiency include
busulfan,
carmustine14,15,
cyclophosphamide,
lomustine, and bleomycin.15 At 20 years from
diagnosis of the primary malignancy, a 3.5%
cumulative incidence of pulmonary fibrosis was
Page 3
Childhood Cancer, Kumar et al.
A
B
D
A
E
C
F
Figure 3. Relapse Lymphoma.
9- year-old boy diagnosed with Stage IA
Hodgkin disease right neck achieved
complete remission with chemotherapy.
At routine follow-up 3.5 years later, left
hilar
relapse
was
suspected.
Posteroanterior (A) and lateral (B) chest
radiographs show stable post-therapy
appearance of the thoracic structures.
Follow-up
posteroanterior
chest
radiograph (C) shows slight increased
density left hilum which, on the lateral
view (D), is shown to represent an ovoid
nodule (lines). Axial non-contrast T1 (E)
and T2 (F) weighted MR images of the
chest show right paratracheal (long
arrows), left hilar and subcarinal (short
arrows) adenopathy, consistent with
disease relapse.
Figure 4. Progressive Radiation Fibrosis.
19-year-old woman diagnosed with Stage IIA nodular
sclerosing Hodgkin disease was treated with
chemotherapy and 2550 cGy modified mantle
irradiation. One year after completing therapy, she
developed disease relapse treated with intensive
chemotherapy, autologous stem cell rescue, and
radiation therapy to the lower cervical spine and porta
B
C
hepatis. At diagnosis, the posteroanterior chest
radiograph (A) showed right paratracheal adenopathy and bilateral superior mediastinal widening, which improved with therapy. By 3 years
later, posteroanterior chest radiograph (B) demonstrated straightening of the left mediastinum and early cephalad retraction of the left
hilum. At 11 years, posteroanterior chest radiograph (C) showed progression of cephalad retraction of the left hilum and coarsening of post
-radiation scarring. Imaging findings paralleled the patient’s decreasing pulmonary function, ultimately leading to her demise.
associated with chest radiation14, due to injury to type
II pneumocytes and endothelial cells.5,16 Chronic
pulmonary impairment results from compromise of
alveolar growth and generation of new alveoli.5
Radiographic findings of fibrosis include pleural
thickening, regional or focal pulmonary contraction,
linear scarring, and streaking that may extend beyond
the distribution of radiation portals.5
The likelihood and severity of development of
pulmonary complications is dependent on the dose of
radiation and chemotherapy, younger patient age at
the time of therapy, and smoking.17 Pulmonary
function longitudinally declines after therapy18 and
may compound the decrease in pulmonary function
normally seen with aging.19 Further, chemotherapy,
surgery, and bone marrow transplantation may
compound the effects of radiation therapy.20
Page 4
Cardiomyopathy
An increased risk for cardiovascular disease is seen
in survivors of childhood cancer treated with radiation
therapy or chemotherapy, independently or in
combination, and represents a cause of cardiac
morbidity and mortality.21 Risk factors particularly
identified to increase the likelihood of developing
anthracycline-associated
cardiovascular
toxicity
include age younger than 5 years at the time of
treatment, female sex, cumulative doses of 300 mg/m2
or greater, cardiac irradiation of 3000 cGy or more,
and chemotherapy combined with radiation
therapy.22,23 In addition, Orgel, et al. recently reported
that an elevated body mass index and Hispanic
ethnicity are also independent risk factors for the
development of declining left ventricular shortening
fraction in anthracycline-based therapy for acute
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Childhood Cancer, Kumar et al.
myeloid leukemia.24 Other reported risk factors
include black race and the presence of trisomy 21.25
Breast Hypoplasia
Breast hypoplasia or aplasia is a well-known late
effect following irradiation to the chest during
childhood
(Fig.
6).
Radiation-induced
underdevelopment of the breast has been reported in
a variety of pathologies for which irradiation has been
used, including cutaneous hemangiomas of the
chest29, mediastinal lymphadenopathy30, Wilm
tumor31, 32, and neuroblastoma.32 Radiation effects on
developing human breast tissue is dose dependent30, 33
and may occur with doses of <500 cGy.34 Clinical
changes associated with radiation-induced breast
underdevelopment include the presence of
dyschromasia and telengiectasias on the affected
breast, as well as overall asymmetric breast
development with the irradiated breast being smaller
and irregular in size compared to the non-irradiated
breast.33 Reported histopathological findings of
irradiated hypoplastic breasts include extensive
fibrosis, loss of breast lobules, and significant
shrinkage of the ducts.33 Patients affected by breast
hypoplasia
can
also
experience
significant
psychological distress due to the undesirable cosmetic
effects of asynchronous breast growth.33
The most common cardiac event reported is
congestive heart failure.26 The hallmark of
anthracycline cardiotoxicity is reduced thickness and
mass of the left ventricular wall.27 Though
symptomatic cardiac compromise is infrequent22,23, a
recent study reported a 12.6% incidence of such
events in patients treated with both anthracyclines
and cardiac irradiation, 7.3% incidence with
anthracyclines alone, and 4.0% incidence after cardiac
irradiation with a median patient age of 27 years at
the time of the events26 (Fig. 5). Cardiotoxic effects of
therapy may not manifest until adulthood or during
times of stress, such as pregnancy or physical
exertion.22
A recent investigation of 62 adolescent survivors of
childhood cancer (mean age 14.6 years at the time of
study) who received anthracyclines as part of their
oncotherapy found that gadolinium-enhanced cardiac
MR detected and quantified both left and right
ventricular dysfunction in 61% and 27%, respectively.28
It is important to recognize the association of breast
cancer arising as a result of irradiation that included
A
Figure 5. Anthracycline-Induced Cardiomyopathy.
12-year-old patient diagnosed with nodular
sclerosing Hodgkin disease and received multiagent
chemotherapy
that
included
anthracycline.
Pathologic examination revealed Grade 2 of 3
anthracycline cardiac toxicity. Posteroanterior chest
radiograph obtained about 1 year after completion
of therapy demonstrates cardiomegaly, bilateral
pleural effusions, and pulmonary vascular
congestion indicative of congestive heart failure.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
B
Figure 6. Breast Hypoplasia.
49-year-old woman diagnosed with Wilm tumor at 5 years of age and
received 1200 cGy whole lung irradiation for pulmonary metastases,
as well as 1200cGy abdominal radiation therapy for primary disease
and hepatic metastases. Posteroanterior (A) and lateral (B) chest
radiographs demonstrate hypoplasia of both breasts. The
anteroposterior diameter of the chest is narrow from radiationinduced rib dysplasia.
Page 5
Childhood Cancer, Kumar et al.
A
B
C
Figure 7. Chest Wall Deformity And Scoliosis.
At the age of 6 years, this boy was diagnosed with Ewing sarcoma
family of tumors of the right chest wall. He received multiagent
chemotherapy, surgical resection, and 504 cGy external beam
irradiation. Over the course of 7 years, he developed significant
scoliosis. Axial chest CT image at the time of diagnosis (A) shows
the soft tissue mass with foci of increased attenuation arising
from the right lateral chest wall. Posteroanterior chest
radiograph obtained 2 years after completion of therapy (B)
shows chest wall deformity due to resection of several right
thoracic ribs and pulmonary scarring. Note the absence of a
visible scoliosis. Scoliosis series obtained 7 years after therapy
completion due to the presence of a “thoracic hump” (C)
demonstrates a 52 degree mid-thoracic convex right
rotoscoliosis.
breast tissue.35 After chest irradiation, the
standardized incidence ratio for developing secondary
breast cancer was 24.7 (95%CI 18.3-31.0), as opposed
to 4.8 (95%CI 2.9 - 7.4) for those who received no
chest irradiation.35 Thus, education of these patients
regarding health risks associated with chest irradiation
should be prompted by recognition of this finding
upon verification of prior therapy.
Skeletal Sequelae
Radiation-induced changes of bone have been
recognized for decades, and any bone exposed to the
radiation field can be affected. Therapy inflicted during
the developmental stages of the skeleton can result in
Page 6
hypoplasia of bones exposed to radiation therapy,
demineralization associated with chemotherapy and/
or radiation therapy, growth aberrations related to
radiation therapy, and altered vertebral height when
radiation therapy is compounded by the effects of
chemotherapy.36 Similarly, chemotherapy can directly
affect growing bones.36,37 Growing bone is most
susceptible to the effects of radiation during the two
periods of most rapid growth: during the first 6 years
of life and during puberty.38,39 Radiation injury is most
likely related to injury of chondroblasts with inhibition
of cartilaginous cells and is seen with single doses of
200 to 2000 cGy.5,40 Thus, the adverse impact of
treatment – whether chemotherapy, radiation
therapy, or in combination – on the developing
skeletal structures varies with patient age, as well as
the type, distribution, and intensity of therapy at the
time of treatment.36, 39
Scoliosis
Impaired vertebral growth can occur with doses of
1000 to 2000 cGy41,42 and can lead to short stature38,
altered vertebral body configuration38,42, and
contribute to the development of scoliosis40,43,44 and/
or kyphosis (Figs. 7 and 8).44 Probert and Parker
reported changes in developing vertebral bodies when
exposed to radiation doses of greater than 2000
rads.38 Asymmetric exposure of the vertebral bodies
may contribute to the development of scoliosis.40,43,44
In addition to therapeutic irradiation, chest wall
resection may result in scoliosis. In children, postsurgical scoliosis is progressive and related to the
number of posterior ribs resected.45
Clavicular Growth
Merchant, et al. investigated the effect of
asymmetric exposure of the clavicles to 1500 cGy as
administered with hemi-mini-mantle irradiation for
unilateral Hodgkin disease of the neck or
supraclavicular region. The clavicles which were fully
exposed to radiation therapy grew 0.5 cm less overall
compared to those only partially exposed (p=0.007),
regardless of the patient’s age at the time of therapy
(median age, 13.3 years; range, 5.1 to 18.9 years)
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Childhood Cancer, Kumar et al.
Figure 8. Rib Dysplasia.
49-year-old woman diagnosed
with non-Hodgkin lymphoma at
9 years of age was treated with
mediastinal radiation therapy
and multiagent chemotherapy.
Posteroanterior (A) and lateral
(B)
chest
radiographs
demonstrate linear pulmonary
scarring with mild cephalad
retraction of the hila (arrows)
and a mild levoconvex midthoracic scoliosis (apex of the
A
B
C
curve
indicated
by
the
arrowhead). The striking chest wall deformity with depression of the anterior chest wall (B) resulted from radiation-induced rib dysplasia.
Similarly, note the asymmetric size of the breasts (right smaller than left) and smaller volume of the right hemithorax compared to the left
(A). The lateral view also readily demonstrates demineralization of the thoracic vertebral bodies. Initial posteroanterior ches t radiograph
at the time of diagnosis (C) shows extensive mediastinal, paratracheal, and right hilar adenopathy coupled with a large right pleural effusion.
B
A
Figure 9. Asymmetric Clavicular Growth.
15-year-old boy was diagnosed with Stage IA Hodgkin disease of his right
neck. In addition to multiagent chemotherapy, treatment included right
hemi-mantle irradiation of 1500 cGy. Axial CT image of the neck at the time
of diagnosis (A) shows prominent lymphadenopathy. Posteroanterior chest
radiograph obtained 15 years after completion of treatment (B)
demonstrates asymmetric clavicular growth with the right clavicle
measuring 2 cm shorter than the left.
(Fig. 9). Further, the effect on clavicular growth was
more pronounced in the younger-aged patients (mean
age, 9.9 years) compared to those who were older
(mean age, 16.4 years; p=0.036).46 Thus, as with prior
reports, the effects of radiation therapy on bone are
influenced by patient age, therapeutic dose, and
extent of tissues exposed.40
Radiation-Induced Exostosis
Osteochondromas are the most common benign
tumor of bone to occur following radiation therapy
(Fig. 10).47 They manifest as a late effect of total body
or local irradiation and have also been reported as a
long-term sequela of hematopoietic stem cell
transplantation (HSCT).48,49 The median age of
presentation and latency for osteochondromas
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
following HSCT is 13.3 and 8.9 years, respectively.49, 50
Among the risk factors investigated as contributing to
their development following HSCT, only total body
irradiation and a young age at time of TBI and or HSCT
have been consistently shown to significantly affect
the risk of developing osteochondromas.49,51
The
prevalence
of
osteochondromas
is
approximately 3% in the general population with the
majority presenting as solitary osteochondromas
unless in the setting of hereditary multiple exostosis.52
Among survivors of HSCT, approximately 1% develop
osteochondromas. Unlike the general population, only
a slight majority of long-term survivors of HSCT
develop solitary osteochondromas.49,51 In pediatric
patients who undergo irradiation, damage to the
epiphyseal plate causes a portion of the epiphyseal
cartilage to migrate to the metaphyseal regions
Page 7
Childhood Cancer, Kumar et al.
causing the formation of osteochondromas.
Osteochondromas that occur as a result of
irradiation are radiographically indistinguishable from
those
that
occur
from
other
etiologies.
Osteochondromas most commonly localize to the
metaphysis of long bones, particularly the femur and
proximal tibia, with involvement of flat bones being
less common.49 Clinically, osteochondromas present as
painless slow-growing masses that cause local
distortion of tissue. Depending on their proximity to
neurovascular structures, osteochondromas can
present with paresthesias or loss of peripheral pulse in
the affected limb.52 In addition to the above
presentations, a minority of long-term survivors of
HSCT are diagnosed with osteochondromas
incidentally through the course of routine radiographic
or clinical examination.49
Radiographically,
the
appearance
of
osteochondromas can be described as cartilage
capped protruding osseous lesions that have cortical
and medullary contiguity with the parent bone. The
neck of an osteochondromas can either be wide or
narrow, giving the appearance of either a sessile or
pedunculated lesion, respectively.47 Osteochondromas
can be easily recognized using radiographs. However,
more complex lesions, such as those that involve the
spine or shoulder, can be better resolved with
computed tomography.52 Magnetic resonance imaging
can accurately distinguish osteochondromas from
A
other osseous lesions due to the contrast of high T2
and low T1 signal intensity of the cartilaginous cap.52
Demineralization
Survivors of childhood cancer are at risk for deficits
in bone mineral density which may lead to earlier
onset and more severe osteoporosis and related
fractures.53 Attention to the integrity of bone
mineralization in the thoracic spine of childhood
cancer survivors is important. Occasionally,
compression fractures may be the first indication of
such a deficit in survivors of childhood cancer. Though
the best studied pediatric cancer population has been
children treated for acute lymphoblastic leukemia,
such deficits are associated with a variety of pediatric
malignancies, as well as with bone marrow
transplantation.54,55
Deficits in bone mineralization arise from a
multitude of risk factors and include genetic
predisposition54, lifestyle factors (such as suboptimal
nutrition)53,54, inadequate weight-bearing exercise53,54,
treatment with osteotoxic chemotherapeutic agents
(particularly glucocorticoids but also associated with
ifosfamide
and
methotrexate)37,53,54,56,
37,53,54
endocrinopathies
, and radiation therapy whether
localized to the thoracic spine or gonads53, or cranial
irradiation.37,53
B
Figure 10. Radiation-Induced Exostosis.
A 7-year-old girl returned 4 years after undergoing bone marrow transplantation for chronic myelogenous leukemia because of a newly
found “lump” in her right anterior chest. The preparative regimen for her bone marrow transplantation included total body irradiation.
Posteroanterior chest radiograph (A) was obtained, demonstrating expansion of the right anterior seventh rib (arrow). Axial limited chest
CT (B) was performed through the rib for characterization of the abnormality shown on the chest radiograph and shows the typical
appearance of an exostosis (skin marker).
Page 8
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Childhood Cancer, Kumar et al.
Figure 11. Osteonecrosis.
20-year-old woman diagnosed with Bcell non-Hodgkin lymphoma at 16 years
of age experienced multiple relapses of
the disease. She was treated with
multiagent chemotherapy that included
high
dose
glucocorticoids.
The
posteroanterior
chest
radiograph
showed changes of osteonecrosis of the
left humeral head. Dedicated radiographs of the shoulders confirmed the advanced osteonecrotic changes of both humeral heads with
crescent signs, collapse of the articular surfaces, and intermixed areas of sclerosis and cystic changes.
Osteonecrosis
Acknowledgement
Children undergoing therapy for childhood cancer
are at risk for osteonecrosis when treatment includes
high
dose
glucocorticoids,
bone
marrow
transplantation, and/or local radiation (Fig. 11).57 The
reported prevalence of osteonecrosis in these
survivors varies with the modality used to detect the
toxicity (MR being the most sensitive modality),
whether or not a report was based upon patients
having symptoms, age at the time of diagnosis of the
primary disease, and type of treatment.58,59 In contrast
to the general population, osteonecrosis in survivors
of childhood cancer occurs as a multijoint toxicity in
60% of those in whom it develops. As reported by the
Childhood Cancer Survivor Study, the most frequent
joints involved are the hips (72%), shoulders (24%) and
knees (21%).58
The authors would like to thank Ms. Sandra Gaither
for manuscript preparation.
Disclosure
Supported in part by grant P30 CA-21765 from the
National Institutes of Health, a Center of Excellence
grant from the State of Tennessee, the Le Bonheur
Foundation (Memphis TN), and the American
Lebanese Syrian Associated Charities (ALSAC).
Summary
The rapidly growing population of survivors of
childhood cancer underscores the need for recognizing
potential sequelae of both the primary disease and
associated therapies, to include knowledge of risk
factors for complications. While numerous reports are
available regarding second malignant neoplasms in
this population, only in the more recent past have
investigations and understanding of adverse toxicities
manifesting after completion of therapy been
undertaken. It is with the hope of enhancing care of
survivors of childhood cancer that this review of the
more common chest manifestations has been
developed. Though not meant to be all-inclusive, this
work serves as a starting point to enhance the acumen
of imaging healthcare providers, and thus, improve the
care of these patients.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Page 9
Childhood Cancer, Kumar et al.
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Page 11
Chest X-Ray, Folio
Interpretive Approach and Reporting the Intensive Care Bedside Chest X-Ray
Les Folio, D.O., MPH, FAOCR
Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD
Introduction
Approach to the Bedside Chest X-Ray
The chest x-ray (CXR) remains one of the most
commonly requested imaging studies, yet is one of the
most complex and least understood, particularly the
intensive care unit (ICU) bedside examination. In
addition to deciphering numerous lines, tubes, lung
and pleural findings of the AP (anterior-posterior)
radiograph, critical care providers look to radiologists’
reports to summarize any pertinent changes in
underlying pathological processes. This article will
provide an overview of the bedside chest radiograph
in the ICU setting, as well as a guide to effective
reporting for the radiologist.
The recommended approach to CXR interpretation
is to first identify abnormal findings, including their
location and distribution, and then further define
patterns to help classify and categorize. This
represents the body of the report. Based upon this
information and correlation with any pertinent history,
radiologists generate a differential diagnosis, or
conclusion; that is, the impression section of the
report.
While computed tomography (CT) has added
tremendous value in chest imaging in ICU patients, the
CXR remains the mainstay in ICU imaging. Compared
to CT scans, the CXR can be obtained more readily and
is associated with less radiation; thus, CXRs can be
performed serially for temporal comparison.
Ultrasound is becoming more commonplace and can
often be complementary to CXR, CT, and physiologic
parameters.1
This article presents an overview of common CXR
findings in the ICU setting with example reporting, in
the hope of increasing awareness of accepted report
terminology. It will also touch on traditional views,
new techniques/approaches to bedside chest imaging,
and technological advances that may improve
diagnostic accuracy on CXR and negate the need for CT
in some conditions.2
Topic points include positions of lines and tubes,
abnormal collections of fluid and air, and common
causes of pulmonary opacities. Radiologists should
keep in mind that ICU physicians want to know
findings that may alter management, those which are
potentially life-threatening, as well as pertinent
temporal changes.
Page 12
For example, the report body and impression of a
CXR describing a consolidation in a patient with cough,
fever, and elevated white blood cell count may look
like this:
Findings: A focal patchy opacity is noted in the
right upper lung field with air-bronchograms.
Impression: Consolidation on right, consistent with
pneumonia
It is important to have a systematic approach to CXR
interpretation, especially when reviewing complex
studies, such as the case shown in Fig. 1. One method
uses a mnemonic-based search pattern consisting of
the ABCDEs twice. The acronym includes the following:
Airway (including an endotracheal [ET] tube, when
applicable), Aorta (contours, edges, central lines),
Breathing (lungs and pleura), Bones (quick review
since this often does not significantly change in the
ICU), Circulation (pulmonary vessels), Cardiac
(silhouette), Diaphragm (free air, costophrenic angles),
Deformity (post-operative, positioning considerations),
Soft tissues (chest wall), Shoulders (periphery of
projection). Other search patterns include starting in
the midline and working one’s way outward or vice
versa. The key point is to have a systematic search
pattern which includes all aspects of the CXR and
ensuring that the pattern is followed on each and
every examination. This will help avoid becoming
overwhelmed, especially when there are a multitude
of findings.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Chest X-Ray, Folio
Figure 1. Example of a Potentially Perplexing Case Simplified Through a
Systematic Approach and Routine Reporting.
Starting with the ET tube, the tip is easily seen at the inferior medial clavicles
within 5cm from the carina. Although the NG tube tip is not seen, the sideport
is within the stomach; therefore, there is no need to say the tip is not seen.
Next, describe the chest tubes and the Swan-Ganz catheter with its tip in right
PA. Then move on to the tube effects, such as the subcutaneous emphysema,
surgical clips, and extracardiac lucency. In evaluating the hemithoracies, the
diaphragmatic silhouette is obscured, especially on the left due to a pleural
effusion. Pulmonary opacities within the left hemithorax result from a pleural
effusion with underlying parenchymal consolidation versus atelectasis. The
cardiac silhouette and aortic contour are enlarged and show lucency on the
left representing a pneumomediastinum. Finally, evaluate the extrathoracic
regions of the film, including the upper abdomen, soft tissues, and bony
structures.
Figure 2.
Incorrect Positioning of an
Endotracheal Tube.
A CT scout image (A) shows
an ET tube located within the
left mainstem bronchus.
Portable chest radiograph
following repositioning of the
ET tube (B) demonstrates
correct positioning within the
trachea with residual right
lower lobe atelectasis from
prior malpositioning; the
region of atelectasis resolved
on subsequent films (not
shown).
A
Reports should be predictable and consistent for
critical care providers to quickly understand the
meaning; for example, some radiologists report on
lines and tubes first in the body, keeping that order in
the impression. This allows ICU staff and other
providers to know where to look for specific
information in reports. Standard reporting terminology
and formats for chest CT have been proposed, and the
Radiologic Society of North America (RSNA) has
existing and developing report templates in a variety
of formats.3 The RadLex initiative, implemented by
RSNA, has led to standardized terms and reporting that
may be useful in thoracic imaging.4,5 One group of
researchers developed a structured report for the
chest x-ray with standardized terminology.6 Although
there is no national or international standard, there
seems to be a trend in this direction.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
B
Support Devices: Lines and tubes
The ICU generates many requests for support device
placement on CXR, especially serial examinations in
patients with multiple lines and tubes. The American
College of Radiology (ACR) appropriateness criteria
provides guidelines for imaging in the setting of line
and tube placement.7 The literature supports
obtaining a CXR immediately following placement of
endotracheal, enteric (especially feeding tubes), and
chest tubes; however, it does not support daily CXRs in
the absence of a change in clinical condition or
suspected line or tube migration.8-10
A comprehensive review of lines and tubes is
beyond the scope of this article. However, it is
important to know which types of lines and tubes have
been placed, along with their optimal locations and
potential complications of malpositioning. Figs. 2, 3,
Page 13
Chest X-Ray, Folio
Figure 3. Malpositioning of Central Venous
Catheters.
Portable chest radiograph flowing placement of
a right jugular central line (A) shows an
abnormal cephalad course of the catheter
extending into the neck. Portable chest
radiograph following placement of a left
subclavian central line in a different patient (B)
reveals the catheter coursing into a variant left
superior vena cava.
A
B
examinations when technologists have different
degrees of inclination and thresholds for placing the
“Upright,” “Erect,” or “Semierect” markers on the
cassette. Rotation is often accentuated in bedside
imaging compared to standard PA projections
performed in the Radiology Department, making
changes on serial exams more difficult to assess.
Overlying material, such as the external component of
tubes and lines, also limit visualization and evaluation
of underlying structures.
Figure 4. Positioning of Multiple Central Lines.
Frontal chest radiograph reveals placement of bilateral
peripherally-inserted central venous catheters (PICC lines),
as well as a right internal jugular (IJ) central venous catheter
(CVC). The tip of the right IJ CVC is optimally located within
the distal superior vena cava. The left PICC line tip projects
over the right atrium (arrows).
and 4 demonstrate examples of correct and incorrect
positioning of endotracheal tubes and central venous
catheters. Chest tube positioning is discussed in the
section covering pathology of the pleural space.
Positioning, Technique Ideas and Technical
Advances
The portable CXR is often inconsistent and
sometimes limited due to variable patient positioning
(rotation, tilt, angle of inclination, etc.). For example, it
can be difficult to evaluate pleural effusions on serial
Page 14
New technologies to improve CXR interpretation are
available or in design and include dual energy,
temporal subtraction, tomosynthesis, and decision
support.11 Also available is line and tube visualization
software, which improves conspicuity of various
support devices (Fig. 5).12,13 Some centers are using
portable CT in the ICU, which has been found to be
advantageous due to minimizing the need for patient
transport (especially with many support devices) and
obtaining more rapid assessments with superior
spatial resolution.14
Pleural Fluid, Air, and Loculations
Pleural effusions are common in ICU patients. It is
important to distinguish effusions from other
pathologic processes, as well as to assess for changes
over time on serial examinations. Since fluid is
dependent when not loculated or otherwise bound,
optimal positioning in as upright a position as possible
is paramount. Inconsistent positioning over time often
gives false impressions of changes in severity and has
variable effects on masking of underlying conditions,
such as pneumonia or atelectasis. Technologists will
often indicate patient positioning with use of arrows or
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Chest X-Ray, Folio
Figure 5.
Application of the Line and
Tube Visualization Software.
In
this
patient
who
underwent right forequarter
amputation from a scapular
sarcoma, standard (A) and
post-processed (B) CXR
images were obtained. The
post-processed image (B)
more readily identifies the
malpositioned left PICC line
within
the
right
brachiocephalic vein. There
B
A
are
also
postoperative
features to the lungs bilaterally with resultant volume loss to left lower lung field. Note a prototype inclination marker in the upper left
portion of the image with demonstrates an inclination angle of 60 degrees.
markers stating “Upright;” however, there is poor
agreement or consistency as to when to use such
indications. For example, defining a threshold angle of
60 degrees before an examination is to be considered
“Upright.” The angle of inclination also affects
evaluation for pneumothoraces or free intraabdominal air.
The use of decubitus projections can be extremely
valuable in assessing the mobility and possibly the
drainability of pleural fluid, often negating the need
for CT (Fig. 6). One should keep in mind, however, that
with the many support devices and critical nature of
the patient’s underlying medical condition, decubitus
positioning in the ICU is often difficult and in some
cases not possible. The decubitus view to order is the
A
B
side of the effusion or what technologists often refer
to as “side down, side seen.” This means that a rightsided effusion should be evaluated with a right side
down decubitus projection. This is opposite of the
abdominal decubitus projection when looking for freeair (“side up, side seen”) where a left lateral decubitus
projection detects free air at the liver margin.
Although this appears intuitive, it is important to be
clear with the terminology when recommending,
ordering, performing, or interpreting decubitus
examinations.
Empyemas represent localized infectious collections
within the pleural space and are not uncommon in the
ICU setting. Differentiation from simple pleural
effusions is a common and important question of ICU
C
Figure 6. How the Decubitus Projection Can Determine Mobility of Pleural Effusions. Frontal (A) and lateral (B) chest radiographs
demonstrate a moderate-sized right pleural effusion with suspected peripheral loculations. The right-side down decubitus view (C) verifies
free mobility of the pleural fluid without evidence of loculations, thus negating the need for a CT examination.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Page 15
Chest X-Ray, Folio
Figure 7. Empyemas.
Frontal chest radiograph (A) reveals
peripheral opacities along the lateral
margins of the thoracic cavities, some
of which have irregular borders. The
size and extent of the collections were
resulting in cardiac tamponade.
Coronal reformatted CT image (B)
better depicts the loculated collections
which were subsequently drained but
recurred.
A
B
Figure 8. Lung Abscess.
Frontal (A) and lateral (B) chest
radiographs show a lung cavity with
air-fluid level in the superior
segment of the right lower lobe
(right upper lung field) that has the
same size and configuration on both
the PA and lateral views, confirming
a spherical shape. Biopsy revealed
an aspergilloma in this patient with
Job’s syndrome.
A
B
staff. However, the distinction cannot be made on CXR
alone. Common findings include loculated, non-mobile
collections of pleural fluid (Fig. 7). A relatively specific
finding for empyemas includes air-fluid levels that are
disparate in size/length when comparing the frontal
and lateral projections.15 This supports a non-spherical
shape and is helpful in distinguishing empyemas from
simple effusions or pulmonary abscesses.16
Most parenchymal abscesses or cavities are
spherical in shape, resulting in air-fluid levels of similar
size/length on all projections (Fig. 8). Although there
are findings suggestive of empyemas on CXR,
recommending a CT and potentially image-guided
drainage is often in order.
Visualization of air-fluid levels in the pleural space is
a useful finding in the setting of subtle
pneumothoraces (Fig. 9). A dependent fluid level in the
Page 16
lower lung field often indicates the presence of a
hydropneumothorax. Treatment of pneumothoraces
often depends upon the size and pneumothorax and
clinical status of the patient. Often times, placement of
a chest tube is necessary.
Chest tubes can be malpositioned in a manner
where bedside radiography alone is not adequate for
evaluation.17 In this setting, CT is often necessary to
evaluate for a malpositioned tube, typically when an
abnormal course is identified on CXR or the tube is not
draining properly. Common findings associated with
malpositioning include visualization of the tube within
a pulmonary fissure (Fig. 10) or in a superficial location
with the sideports outside of the chest cavity.
Placement within the pulmonary parenchyma or the
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Chest X-Ray, Folio
Figure 9.
Air-fluid Level in the Pleural Space
Indicative of a Hydropneumothorax.
Frontal chest radiograph (A) demonstrates
an air-fluid level within the inferior right
hemithorax (thick arrows). Magnified view
of the right upper thoracic cavity (B)
reveals a subtle pneumothorax (thin
arrows).
A
A
B
Figure 10.
Malpositioned Chest Tube.
Frontal chest radiograph (A)
shows bilateral chest tubes
with
persistent
pneumothoraces. The chest
tube on the right was not
draining
properly.
Para
coronal/axial (B) and sagittal
reformatted (C) CT images
demonstrate an interfissural
course of the right-sided
chest tube.
A
B
C
Figure 11.
Pneumonia.
Frontal chest radiograph
(A) demonstrates a focal
rounded
consolidation,
likely within the lateral
right middle lobe due to
the lack of obscuration of
the diaphragmatic border.
Coronal reformatted (B)
and axial (C) CT images
confirm the middle lobe location and best depict the central air bronchograms in this patient with fever and X-linked agammaglobulinemia
(XLA), which is the underlying cause of the lower lobe bronchiectasis noted on the CT examination.
chest wall is less common.
Pulmonary/Lung Opacities
Pulmonary opacities are commonly seen in the ICU
setting. Distinguishing between air space disease and
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
atelectasis, especially on hypoinflated portable CXR, is
a common dilemma for radiologists. When air space
opacities are identified, differential conditions include
pneumonia, pulmonary edema, acute respiratory
distress
syndrome
(ARDS),
and
pulmonary
hemorrhage.
Atelectasis often mimics air space disease on CXR,
Page 17
Chest X-Ray, Folio
since it often presents as a focal opacity with or
without air bronchograms. A key distinguishing feature
is volume loss within the affected lobe, which may be
subtle but is a useful discriminator.
The imaging pattern of infectious pneumonia is
dependent upon the causative agent. Bacterial
infections present with lobar air space disease, which
may be localized or multi-focal (Fig. 11).
Parapneumonic effusions or empyemas may be seen.
Atypical infections, such as viral or Mycoplasma, tend
to be interstitial but may occasionally be lobar as well.
Nosocomial infections are more diffuse and aggressive
with a higher prevalence in patients who are
immunosuppressed. Cavitation is common and the
morbidity and mortality is significantly higher than
community-acquired pneumonia.
Left-sided congestive heart failure demonstrates a
predictable sequence of findings on CXR (Fig. 12).
Initially, there is enlargement of the cardiac silhouette
with cephalization of pulmonary blood flow. As the
degree of heart failure progresses, interstitial edema is
noted with prominent interstitial markings along the
periphery of the lung fields (Kerley B lines). Finally,
edema extends into the pulmonary parenchyma and
pleural space, resulting in air space opacities and
pleural effusions.
Acute respiratory distress syndrome (ARDS) often
occurs in the setting of shock or inhalation toxicity and
results in fluid accumulation within the lung
parenchyma. The air space disease may appear similar
to that of pulmonary edema; however, it is not
typically associated with cardiomegaly or pleural
effusions. The air space disease also tends to occur
along the lung periphery.18 Chronically, ARDS may
result in pulmonary fibrosis.
Pulmonary hemorrhage may be focal, especially in
the setting of trauma, or diffuse secondary to an
underlying systemic or autoimmune disease process.
Chest x-rays demonstrate multifocal air space
opacities, which may be ground glass, consolidated,
well-defined, or diffuse (Fig. 13). Cavitation is not
uncommon.19
Reporting/Terminology
Findings in the body of the report should support
the conclusions in the impression. A finding that
includes consolidation, for example, should have an
impression which includes a portion of the well-known
Figure 12.
A
B
C
D
Page 18
Congestive Heart Failure/Pulmonary Edema.
Sequential frontal chest radiographs in a patient
with progressive heart failure (A, B, and C) show an
initial normal examination (A) with subsequent
development of cardiomegaly, cephalization of
pulmonary vasculature, and increased peripheral
interstitial markings – referred to as Kerley B lines
(B). Air space disease and pleural effusions are
common and best depicted on images B and C. The
relative increased lung volumes on image C are the
result of interval intubation; enteric tubes and a
right IJ CVC were also placed in this patient (C) and
are appropriately positioned. A coronal reformatted
image (D) nicely shows the peripheral Kerley lines,
as well air space disease within the right lower lobe.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Chest X-Ray, Folio
Figure 13.
Diffuse Alveolar
Hemorrhage.
Frontal
chest
radiograph in a patient with known
Kaposi Sarcoma involving the lungs
(A)
demonstrates
multifocal
interstitial and air space pulmonary
opacities, as well as a left-sided
pneumothorax. As the patient’s
condition continued to deteriorate,
subsequent imaging (B) shows
extensive,
diffuse
pulmonary
opacification. The support lines
and tubes are appropriately
positioned.
Autopsy
revealed
diffuse alveolar hemorrhage.
Figure 14. Unsuspected Finding on CXR.
A frontal radiograph of the chest and abdomen for line
and tube placement (A) reveals an unusual bowel gas
pattern compatible with pneumotosis intestinalis,
which was confirmed on CT (B). The right-sided PICC
line is in the SVC; the feeding tube tip is not seen,
however, it courses well into the duodenum.
differential diagnosis of water, pus, blood, protein, and
cells based upon the clinical history. If there is a new
finding of a focal opacity and the critical care team is
looking for infection, then pneumonia is most likely. If
the opacity is diffuse, then fluid or blood (DAH) may be
added to the list of differentials.
There are unique considerations in CXR terminology
with regards to 2-dimensional representation of 3dimensional structures. For example, there is
considerable overlap and variability of lung lobes;
hence the use of the term lung “fields,” which is
commonly used and appropriate. Also, if a central line
tip appears low in the superior vena cava (SVC),
positioning and projection could mean that the tip is
actually in right atrium; therefore, the broader phrase
“overlying the cavoatrial junction” may be useful.
ICU staff, like radiologists, are busy and want
concise information at their fingertips. The radiologist
should avoid extraneous information and be
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
consistent and predictable. If the tip of the enteric
tube is not seen but the sideport is visible, state the
location of the sideport; there is no need to state that
the tip is not seen in such cases.
Although residents and fellows are often taught not
to use the term “infiltrate,” it may provide flexibility
for both the radiologist and the ordering provider. For
example, if one commits to “consolidation” or “fluid,”
this may minimize options for the clinician. Keeping
the differential (impression) broader allows providers
to apply the clinical information to their management.
However, there is a fine line between keeping
differentials broad and being noncommittal or
“hedging.”
Having an organized search pattern is essential in
evaluating the entire film. It also helps prevent
“satisfaction of search” where obvious abnormalities
Page 19
Chest X-Ray, Folio
are noted initially and more subtle findings are
overlooked.20 Fig. 14 shows an unsuspected case of
pneumotosis intestinalis picked-up on a CXR for line
and tube placement.
1.
Interaction With Intensive Care Team; The
Report is Just the Beginning; ICU Rounds, Process
3.
2.
4.
Although the radiology report represents the final
product of a particular diagnostic imaging study, it may
also represent the beginning of a diagnostic and
procedural dialogue with ordering providers. A
continuous feedback and understanding of clinicians’
needs provides insight that is otherwise not gained if
radiologists remain in isolation. Breaking the
misguided and stereotypical perceptions of
radiologists keeping to themselves in a dark room will
improve communication chains with ordering
providers and help guide the work-up and care for the
most critically-ill patients.
Summary
The chest x-ray remains one of the most common,
important, and complex examinations in the ICU
setting. Given the multitude of pathologies and
support devices often encountered, it is critical that
radiologists develop and follow a logical search pattern
to help define the underlying abnormalities, evaluate
all aspects of the film, and avoid “satisfaction of
search.” Correlating findings with the patient’s clinical
status will aid in providing a useful list of differentials.
Most importantly, continuous communication with
ordering providers will allow radiologists to help guide
The views expressed in this material are those
of the author, and do not reflect the official
policy or position of the U.S. Government or
NIH.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
the work-up and management of the most critically-ill
patients.
18.
References
Page 20
19.
Silva S, Biendel C, Ruiz J, et al. Usefulness of cardiothoracic
chest ultrasound in the management of acute respiratory
failure in critical care practice. Chest. 2013;144(3):859-65.
Rubinowitz AN, Siegel MD, Tocino I. Thoracic imaging in the
ICU. Crit Care Clin 2007;23(3):539-73.
Radiologic Society of North America (RSNA) radiology
reporting
initiative.
Chest
Radiography.
http://
www.radreport.org/specialty/ch, accessed Sep 2013.
RadLex, Radiology Society of North America (RSNA). Available
at http://www.radlex.com, accessed Aug 2013.
Marwede D, Schulz T, Kahn T. Indexing thoracic CT reports
using a preliminary version of a standardized radiological
lexicon (RadLex). J Digit Imaging 2008;21(4):363-70.
Hasegawa Y, Matsumura Y, Mihara N, et al. Development of a
system that generates structured reports for chest x-ray
radiography. Methods Inf Med 2010;49(4):360-70.
ACR Appropriateness Criteria; http://www.acr.org/~/media/
ACR/Documents/AppCriteria/Diagnostic/
RoutineChestRadiographsInICUPatients.pdf, accessed July
2013.
Hejblum G, Chalumeau-Lemoine L, Ioos V, et al. Comparison
of routine and on-demand prescription of chest radiographs
in mechanically ventilated adults: a multicentre, clusterrandomised, two-period crossover study. Lancet 2009;
374:1687-1693.
Graat ME, Choi G, Wolthuis EK, et al. The clinical value of daily
routine chest radiographs in a mixed medical-surgical
intensive care unit is low. Crit Care 2006; 10(1):R11.
Krivopal M, Shlobin OA, Schwartzstein RM. Utility of daily
routine portable chest radiographs in mechanically ventilated
patients in the medical ICU. Chest 2003; 123(5):1607-1614.
Jaeger S, Karargyris A, Candemir S, et al. Automatic screening
for tuberculosis in chest radiographs: a survey. Quant Imaging
Med Surg 2013;3(2):89-99.
Folio L. Chest Imaging; An algorithmic approach to learning.
New York: Springer, 2012, 136-37.
Foos DH, Yankelevitz DF, Wang X, et al. Improved visualization
of tubes and lines in portable intensive care unit radiographs:
a study comparing a new approach to the standard approach.
Clin Imaging 2011; 35(5):346–352.
Teichgräber UK, Pinkernelle J, Jürgensen JS, et al. Portable
computed tomography performed on the intensive care unit.
Intensive Care Med 2003;29(3):491-5.
Bouros D (ed.). Pleural Disease, 2nd ed. New York: Informa,
2010, 35.
Porcel JM, Light RW. Diagnostic approach to pleural effusion
in adults. Am Fam Physician 2006;73(7):1211-1220.
Lim KE, Tai SC, Chan CY, et al. Diagnosis of malpositioned
chest tubes after emergency tube thoracostomy: is computed
tomography more accurate than chest radiograph? Clin
Imaging 2005;29(6):401-5.
Arsani A, Kaewlai R, Digumarthy S, et al. Urgent findings on
portable chest radiography: what the radiologist should know
– self-assessment module. Am J Roentgenol 2011; 196: WS3746.
Primack SL, Miller RR, Müller NL. Diffuse pulmonary
hemorrhage: clinical, pathologic, and imaging features. Am J
Roentgenol 1995; 164: 295-300.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Case Report, Crum
Cavitary Lung Mass in a Febrile Child
Rachel Pevsner Crum, D.O., Ricardo Restrepo, M.D., Nolan Altman, M.D.
Department of Radiology, Miami Children’s Hospital, Miami, FL
Case Presentation
A 13-year-old boy with asthma, gastroesophageal reflux (GERD), multiple food allergies, and history of 2
uncomplicated right middle lobe pneumonias within the last year presented to the emergency room with persistent
cough and fever (max 102˚F) for 10 days, despite macrolide antibiotic treatment. A chest radiograph was performed in
the emergency, followed by an esophagram/upper GI and CT examinations after admission (Fig).
A
C
B
D
Figure. Chest radiograph on initial presentation (A) shows a large right upper lobe mass-like opacification with an air-fluid level. Also noted
is a dilated esophagus (arrows). Esophagram performed 2 days later (B) shows diffuse, moderate dilatation of the esophagus and typical
findings of achalasia with a “bird’s beak” appearance of distal esophagus (arrow) and persistent air-fluid level in the upright position.
Despite IV antibiotic treatment, the patient did not improve clinically. Increasing size of the abscess on serial radiographs (not shown) was
worrisome. Chest CT for further evaluation (C) shows enlargement of the right upper lobe consolidation with thick, irregular walls and an
internal air-fluid level. The region of consolidation forms acute angles with the chest wall. Ultrasound-guided percutaneous drainage was
performed; procedural chest radiograph following catheter placement and contrast injection (D) reveals confirmation of proper catheter
placement. The infectious collection was successfully drained. Follow-up chest radiograph 8 weeks later showed resolution of the region of
consolidation with a small residual linear opacity (not shown).
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Page 21
Case Report, Crum
Key Clinical Finding
Recurrent pneumonia
Key Imaging Findings
Cavitary mass with internal air-fluid level
Differential Diagnoses
Lung abscess
Empyema
Necrotizing pneumonia
Discussion
Although
uncommon,
complications
from
pneumonia in children do occur, and recent literature
has suggested that they are increasing in prevalence.1
Complications of pneumonia include parapneumonic
effusions, empyemas, lung abscesses, necrotizing
pneumonia (multiple small abscesses), and empyema
neccessitatis.
These complications can lead to
extended hospital admission and increased morbidity.1
Children usually recover completely without significant
sequelae, unlike adults who often have underlying
lung disease or co-morbidities.2 Although surgical
intervention is often required to treat adults with
these same complications due to high associated
mortality (20%), children often need only conservative
medical management.2,3
Ultrasound is invaluable for evaluation of the
pediatric chest, as it involves no ionizing radiation, can
be performed bedside, and allows excellent evaluation
of simple or complex parapneumonic effusions and
abscesses. Ultrasound should be used as first-line
confirmation of a pleural effusion, as well as to guide
treatment and need for percutaneous drainage, as it
can readily distinguish between fluid, consolidations,
and loculations.2 Ultrasound detects thin septae,
fibrin strands, internal debris, and loculations in
complex effusions, which are usually not evident by
CT. CT should be reserved for complicated cases with
worsening
respiratory
function
or
immunocompromised patients.2
For parapneumonic effusions and abscesses which
are expanding or compromising respiratory function,
Page 22
percutaneous drainage should be considered.
Ultrasound guidance is preferred, as it allows for realtime localization of collections or abscesses. Direct
visualization under ultrasound is advantageous for
catheter insertion and manipulation through septae or
thick loculations that can interfere with drainage. In
children, CT should not be used routinely; CT-guided
drainage should be avoided, when possible, due to the
potential risks of ionizing radiation in the pediatric
population.2 Adjunctive tissue plasminogen activator
(tPA) can be administered via a percutaneous catheter
to promote drainage of an abscess by lysing fibrin
strands.4 At our institution, we routinely use tPA for
drainage of loculated effusions and empyemas with
good results, although use of tPA is controversial in
the literature.
One major complication of
percutaneous drainage is the formation of a
bronchopleural fistula; however, these may also occur
directly from the complicated pneumonia alone.
Tissue plasminogen activator is contraindicated if a
bronchopleural fistula is present.
Other major
complications of percutaneous drainage include
pneumothorax and hemorrhage.
Pulmonary Abscess.
Pulmonary abscesses can be classified as primary or
secondary. Primary pulmonary abscesses in a child are
usually a complication of pneumonia or aspiration. 5
Secondary pulmonary abscesses can be caused by
underlying lung disease or pulmonary abnormality,
either congenital or acquired. Secondary abscesses
can also be seen in patients at risk of aspiration, such
as those with neurodevelopmental abnormalities
(seizures, muscular dystrophy) or esophageal
abnormalities (achalasia, tracheoesophageal fistula,
strictures).6 Underlying pulmonary disorders, such as
cystic fibrosis or congenital lung malformation, are
also implicated as causes of recurrent pneumonia and
pulmonary abscesses.6
Radiographs often show a large cavitary mass with
thick walls; air-fluid levels may be seen. CT may not be
necessary on a routine basis, as radiographs may be
sufficient for the diagnosis. Contrast-enhanced CT
may be useful for delineation and extent of disease
but should only be performed for worsening
respiratory symptoms. On CT, pulmonary abscesses
are usually round with thick walls and irregular luminal
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Case Report, Crum
surfaces. Vessels and bronchi terminate abruptly at
the abscess edge, and the walls of the abscess form
acute angles with the chest wall.7 On ultrasound,
abscesses are seen as a thick-walled collections
containing echogenic pus and debris. Internal
septations and bright echogenic foci with dirty
shadowing from intraluminal air may be seen.
Lung abscesses in children often resolve with
medical treatment alone. Usually, at least a 3-week
course of intravenous antibiotics is needed with
coverage for anaerobic organisms, which are most
commonly implicated in pulmonary abscesses. 8,9
However, in some cases, the patient may require
intervention with ultrasound-guided percutaneous
drainage. Abscess drainage is indicated if the patient
has persistent fever, sepsis, or worsening respiratory
symptoms which are not responding to medical
treatment alone.2
Other indications include an
enlarging abscess collection or imminent rupture into
a bronchus. Percutaneous ultrasound-guided drainage
of a recalcitrant pulmonary abscess is safe and
effective, avoids surgery, and helps to shorten the
clinical course of the illness.5
Empyema.
Empyemas form as a complication of pneumonia
and are characterized as complex collections of pus
within the pleural space. Inflammation of the pleura
leads to increased vascular permeability and fibrin
production, resulting in pleural adhesions which can
form a thick rind.3 Blockage of lymphatic drainage
leads to increasing fluid accumulation, further
compressing and compromising the adjacent lung
parenchyma.3 Empyema formation evolves in 3
stages: 1) an exudative phase with inflammation and
simple effusion of low cellular count; 2) a
fibrinopurulent phase in which fibrin covers the pleura
and forms thin septae and loculations; and 3) an
organizing phase with formation of a thick fibrous
capsule which prevents lung re-expansion.3
visceral pleural. Ultrasound is important, as it can
distinguish fluid which is not readily defined on chest
radiographs. Ultrasound of an empyema defines
pleural thickening, loculations (which may have a
honeycombed appearance), fibrous strands, and
septae in the pleural space.
Most empyemas can be treated conservatively with
antibiotics and chest tube drainage.2
At our
institution, adjunctive tPA is used when draining
empyemas. Video-assisted thoracoscopic surgery is
reserved for severe cases which do not respond to
conservative management.
Within the current
literature, there is still no clear consensus on surgical
treatment in children.1-3
Necrotizing Pneumonia.
Necrotizing pneumonia or cavitary necrosis is a
severe complication of pneumonia with destruction of
the lung parenchyma and gangrenous necrotizing
changes; there may be formation of multiple small
abscesses. Necrosis develops as a result of ischemia
caused by inflammation with occlusion of capillary
vessels.6 Although the illness is severe, children
usually recover fully without the need for surgical
intervention or severe sequelae, contrary to what is
typically seen in adults.6
On chest radiographs, necrotizing pneumonia
appears as a large consolidation which may or may not
contain small lucencies or cavities. CT is more
sensitive than radiographs for evaluation of
cavitation.6 Unlike pulmonary abscesses, necrotizing
pneumonia on CT demonstrates loss of the normal
lung
architecture,
decreased
parenchymal
enhancement, and absence of a thick wall. On
ultrasound, consolidated lung will have multiple small
cystic and hypoechoic areas with decreased or only
mild peripheral color flow.
On radiographs, empyemas appear as loculated
effusions with convex borders or consolidated lung.
On CT, empyemas are often lentiform in shape,
compress vessels and bronchi, and form obtuse
margins with the chest wall.7 Uniform thickening of
the visceral and parietal pleura form the “split pleural”
sign previously described in the literature.7 Pleural
enhancement is usually present and greatest along the
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Page 23
Case Report, Crum
Diagnosis
References
Pulmonary abscess secondary to occult aspiration
from underlying esophageal achalasia.
1.
Cohen E, Weinstein M, Fisman DN. Cost-effectiveness of
competing strategies for treatment of pediatric empyema.
Pediatrics 2008; 121:e1250-57.
2.
I M Balfour-Lynn, E Abrahamson, G Cohen, et al. BTS
guidelines for the management of pleural infection in
children. Thorax 2005; 60: i1-21.
In summary, children with recurrent pneumonia
should receive follow-up imaging to document
resolution of the infectious process and exclude an
underlying pathologic process or mass. In our patient,
the underlying cause of recurrent pneumonia - and
ultimately abscess formation - was occult aspiration
due to primary achalasia. Although our patient had
been treated clinically in the past for gastroesophageal
reflux, an upper GI was not preformed until an
observant radiologist recommended the study for a
dilated esophagus noted on chest radiographs.
3.
Calder A, Owens CM. Imaging of parapneumonic pleural
effusions and empyema in children. Pediatr Radiol 2009;
39:527-537.
4.
Grevais DA, Levis DA, Hahn PF, et al. Adjunctive Intrapleurral
Tissue Plasminogen Activator Administered via Chest tubes
Placed with Imaging Guidance: Effectiveness and Risk for
Hemorrhage. Radiology 2008; 246:956-963.
5.
Alsubie H, Fitzgerald DA. Lung Abscess in Children. Journal of
pediatric infectious diseases 2009; 4:27-35.
6.
Donnelly LF, Klosterman LA. Cavitary Necrosis Complicating
Pneumonia in Children: Sequential Findings on Chest
Radiography. AJR 1998; 171:253-256.
Pulmonary abscesses in children are commonly
related to pneumonia or aspiration. Children usually
have an excellent prognosis with conservative medical
management and no significant long-term sequelae.
Percutaneous ultrasound-guided drainage should be
considered if clinical symptoms do not improve, the
abscess enlarges, or there is impending rupture into a
bronchus. First-line ultrasound should be considered
to distinguish between complex and simple
parapneumonic pleural effusions, as it is effective in
delineating loculations and septations.
7.
Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR.
Differentiating lung abscess and empyema: radiography and
computed tomography. Am J Roentgenol 1983;141(1):163167.
8.
Emanuel B, Shulman ST. Lung Abscess in infants & Children.
Clin Pediatr 1995 34:2-6.
9.
Bartlett JG. Anaerobic bacterial infections of the lung and
pleural space. Clin Infect Dis 1993; 16:S248–255.
Summary
Page 24
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Case Report, Concepcion et al.
Pulmonary Vascular Anomaly
Nathan David P. Concepcion, M.D., Bernard F. Laya, D.O., Ana Maria Saulog, M.D.
Institute of Radiology, St. Luke’s Medical Center, Quezon City and Global City, Philippines
Case Presentation
A 32-year-old man presented with a two-year history of chronic cough and episodes of hemoptysis. He had been
previously managed as having pulmonary tuberculosis. A chest CT was performed at another institution, which
revealed a vascular malformation. CT angiography of the pulmonary arteries and aorta (Fig.) was advised and
subsequently performed at our center.
A
LA
C
A
B
Figure. Coronal reformatted images (A and B) show a
large arterial branch emanating from the descending
thoracic aorta (A) supplying the left lower lobe, as well
as a prominent pulmonary vein normally draining into
the left atrium (LA). Axial image in lung window (C)
shows the abnormal vessels with hyperemia in the left
lower lobe. No consolidation, soft tissue mass, or cyst
is noted. 3-D reconstruction seen from the posterior
view (D) shows the large systemic branch from the
descending thoracic aorta (long arrow) and a
hypoplastic pulmonary arterial supply (short arrow) to
the left lower lobe.
D
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Page 25
Case Report, Concepcion et al.
Key Clinical Finding
Chronic cough with hemoptysis
Key Imaging Findings
Pulmonary vascular anomaly
Systemic arterial supply to the left lower lobe with
prominent pulmonary venous drainage
as a plexiform mass of dilated vascular channels or
with dilated, tortuous direct communication between
an anomalous feeding artery and draining vein (nidus).
AVMs may be solitary or multiple. Multiple lesions are
often associated with hereditary hemorrhagic
telangiectasia (HHT), also known as Osler-WeberRendu syndrome.1,5 An AVM is excluded in our patient
because of the presence of a systemic arterial supply
to the left lower lobe and the lack of a definite direct
communication between the pulmonary artery and
vein.
Differential Diagnoses
Pulmonary arteriovenous malformation
Pulmonary varix
Pulmonary sequestration
Pulmonary pseudosequestration
Discussion
Congenital bronchopulmonary foregut anomalies
may involve the lung parenchyma, airways, and/or
vascular arterial supply and venous drainage.1,2 These
are included in a spectrum, which ranges from
abnormal lung parenchyma with normal vasculature to
abnormal vasculature with normal lung parenchyma.
In between are lesions with mixed parenchymal and
vascular abnormalities.3,4,5
Although chest radiographs play a role in the
incidental detection and initial imaging evaluation for
such lung lesions, 5 CT is very useful in confirming the
presence of a lesion, determining its extent, defining
associated abnormalities,1 and as pre-operative
evaluation for surgical cases. 5 3-D and multiplanar
reformations can be particularly helpful in delineating
abnormalities of the bronchi and arterial and venous
vasculature.1
Pulmonary Arteriovenous Malformation.
Pulmonary arteriovenous malformations (AVMs)
usually present with dyspnea, hemoptysis, cyanosis, or
clubbing; they may also be asymptomatic and found
incidentally. These lesions are caused by abnormal
communication between the pulmonary arteries and
veins and occur most frequently in the lower lobes.1,2,5
CT may demonstrate more complex appearances, such
Page 26
Pulmonary Varix.
Pulmonary varix refers to an enlargement of a
segment of a pulmonary vein without an enlarged
feeding artery or nidus. This is typically seen near the
left atrium with contiguity with the pulmonary vein.
Varices may be congenital or acquired. Patients are
usually asymptomatic and generally not treated, but
may also present with hemoptysis; hence, surgery may
be required.5 Although the left inferior pulmonary vein
is prominent in our patient, the presence of a large
systemic arterial supply makes this diagnosis unlikely.
Pulmonary Sequestration.
Pulmonary sequestration is characterized by
dysplastic, nonfunctioning lung parenchyma that does
not communicate with the tracheobronchial tree and
has an anomalous systemic arterial supply,1,2,3,4,5
usually from the thoracic or abdominal aorta; arterial
supply from the celiac, splenic, intercostal, subclavian,
or even coronary arteries is less common.3,4 A
sequestration may appear as a persistent opacity or
mass. It may be associated with congenital pulmonary
airway malformation (CPAM), in which case air may be
present within the lesion. Lesions may also contain air
when infected. The most common location is within
the left lower lobe.1,2,4 Sequestrations can be
intralobar (within visceral pleura and venous drainage
via the inferior pulmonary vein) or extralobar
(separate pleural covering with venous drainage
usually via systemic veins, typically the azygous vein
and less commonly via the portal, left subclavian, or
internal mammary veins).1,2,3,4,5 The imaging findings
in our patient are very similar to a pulmonary
sequestration, except that the involved lung only
shows hyperemia with a normal tracheobronchial tree.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Case Report, Concepcion et al.
Pulmonary Pseudosequestration.
Pseudosequestration is within the sequestration
spectrum and is characterized by lung parenchyma
that is perfused by a systemic artery but maintains a
normal tracheobronchial tree. The pulmonary artery is
often rudimentary or hypoplastic with poor
arborization.6 Although the cause of the systemic
arterial supply is unknown, it is thought that
persistence of an embryonic connection between the
aorta and the pulmonary parenchyma leads to the
anomaly.7
According to Yamanaka and colleagues,8 patients
may range from 0 to 68 years of age and are
predominantly male. Pseudosequestration is often left
-sided and supplied by a branch of the descending
thoracic aorta. The pulmonary veins drain normally
into the left atrium. Most patients are asymptomatic;
when symptomatic, hemoptysis, exertional dyspnea,
and congestive heart failure from left heart overload
are the most common presentations.8 A cardiac
(continuous or systolic) murmur is the most common
clinical manifestation in children.7,8
Based upon the above-mentioned characteristics,
our patient has pulmonary pseudosequestration in the
left lower lobe.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Diagnosis
Pulmonary pseudosequestration
Summary
With the advances in CT having multi-detector
technology, the evaluation and diagnosis of congenital
bronchopulmonary foregut malformations is greatly
enhanced. Thorough and careful assessment of the
airway, lung parenchyma, esophagus, arteries, and
veins should be systematically analyzed in order to
arrive at the correct diagnosis. The treatment plan is
dependent in the proper identification of the
pulmonary and systemic vessels.
In our 32-year-old patient who presented with a two
-year history of chronic cough and hemoptysis, CT
findings in the left lower lobe of a predominantly
systemic arterial supply from the descending thoracic
aorta, a small pulmonary arterial supply, a prominent
left inferior pulmonary vein draining into the left
atrium, and a normal tracheobronchial tree leads to
the diagnosis of pulmonary pseudosequestration.
References
1.
Daltro P, Bradley LF, Donnelly LF, et al. CT of Congenital Lung
Lesions in Pediatric Patients. AJR 2004; 183: 1497-1506.
2.
Daltro P, Werner H, Gasparetto TD, et al. Congenital Chest
Malformations: A Multimodality Approach with Emphasis on
Fetal MR Imaging. RadioGraphics 2010; 30: 385-395.
3.
Biyyam DR, Chapman T, Ferguson MR, et al. Congenital Lung
Abnormalities: Embryologic Features, Prenatal Diagnosis, and
Postnatal Radiologic-Pathologic Correlation. RadioGraphics
2010; 30: 1721-1738.
4.
Newman B. Congenital bronchopulmonary foregut
malformations: concepts and controversies. Pediatr Radiol
2006; 36: 773–791.
5.
Lee EY, Boiselle PM, Cleveland RH. Multidetector CT
Evaluation of Congenital Lung Anomalies. Radiology 2008;
247: 632-648.
6.
Singh AS, Subbain SK, Subramanian KG, et al.
Pseudosequestration of the left lung. Tex Heart Inst J 2007; 34
(2): 195-198.
7.
Do KH, Goo JM, Im JG, et al. Systemic Arterial Supply to the
Lungs in Adults: Spiral CT Findings. RadioGraphics 2001; 21:
387-402.
8.
Yamanaka A, Hirai T, Fujimoto T, et al. Anomalous systemic
arterial supply to normal basal segments of the left lower
lobe. Ann Thorac Surg 1999; 68: 332-338.
Page 27
Case Report, Takla et al.
Interstitial Lung Disease
Shereef Takla, B.S.a, Aaron M. Betts, M.D.b
a
b
Uniformed Services University of the Health Sciences, Bethesda, MD
Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH
Case Presentation
A 76-year-old woman with a history of heart failure presented with 3 days of non-productive cough and increased
dyspnea both at rest and with exertion. The patient had been admitted for community-acquired pneumonia 6 months
earlier and has required supplemental home oxygen since that illness. She denied prior history of smoking or
significant occupational/environmental pulmonary exposures. On clinical examination, she was afebrile with an oxygen
saturation of 93% on room air. Pulmonary auscultation revealed mild respiratory crackles at the lung bases. A high
resolution CT of the chest was performed (Figs. 1-3) .
A
B
C
Figure. Axial high-resolution computed tomography (CT) images through the chest (A and B) show septal thickening with a
subpleural distribution and traction bronchiectasis. Fibrotic changes with honeycombing are noted at the posterior lung bases
(B). Coronal reformatted CT image (C) demonstrates the basilar and subpleural distribution of the findings seen above.
Mosaic ground glass attenuation is also noted .
Page 28
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Case Report, Takla et al.
Key Clinical Findings
Increased dyspnea with non-productive cough
Bibasilar inspiratory crackles
Key Imaging Findings
Interstitial lung disease with a peripheral basilar
distribution
Differential Diagnoses
Usual interstitial pneumonia
Non-specific interstitial pneumonia
Interstitial lung disease associated with connective
tissue disease
Asbestosis
Discussion
Interstitial lung disease (ILD) encompasses a broad
category of pulmonary diseases affecting the
interstitium of the lung. Progressive dyspnea and
cough are common presenting symptoms. The clinical
assessment of patients with suspected ILD includes a
thorough history, physical examination, and
pulmonary function testing. The radiologic evaluation
includes chest radiographs and high-resolution CT.
The information obtained from clinical and imaging
evaluations may often yield a leading diagnosis
without the need for conformational surgical lung
biopsy.
Progressive dyspnea, non-productive cough, and
restrictive pattern on pulmonary function testing raise
clinical suspicion for an interstitial process. The
radiologic findings may confirm the presence of an
interstitial process, and the specific findings and
distribution may further narrow the differential
diagnosis. In the context of high-resolution CT showing
septal thickening with basilar and subpleural
distribution,
honeycombing,
and
traction
bronchiectasis, the primary differential diagnosis
includes usual interstitial pneumonia, interstitial lung
disease associated with connective tissue disease, and
asbestosis. A final diagnosis is often not possible by
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
high-resolution CT alone. However, correlation of the
imaging appearance with patient’s medical history,
occupational/exposure history, and progression over
time can often yield a final diagnosis.
Usual Interstitial Pneumonia/Idiopathic Pulmonary
Fibrosis.
Idiopathic interstitial pneumonias are primarily
classified by histopathologic patterns and criteria.
These patterns correlate with fairly characteristic
findings on high resolution CT imaging of the chest.
Among the idiopathic interstitial pneumonias, usual
interstitial pneumonia (UIP) is the most common
histologic and imaging pattern. Idiopathic pulmonary
fibrosis (IPF) is the prototypical and most common
entity that corresponds to the morphologic pattern of
UIP.
Patients with UIP/IPF are usually 50 years or older at
the time of diagnosis. A history of smoking is
associated with increased risk of IPF. Patients often do
not respond to treatment with corticosteroids,
resulting in a relatively poor prognosis. Patients with
UIP/IPF have a median survival ranging from 2 to 4
years after initial diagnosis.1,2
On chest radiographs, UIP/IPF may appear normal
or demonstrate decreased lung volumes with reticular
markings in an apicobasilar distribution with more
advanced disease. High-resolution CT imaging shows
reticular opacities with a basilar and peripheral
(subpleural) predominance, honeycombing, and
traction bronchiectasis. Ground glass opacities may
also be seen.1,2
Non-Specific Interstitial Pneumonia.
In the context of the morphologic pattern of UIP,
non-specific interstitial pneumonia (NSIP) should be
considered. While the characteristic imaging findings
of NSIP are somewhat different from UIP, there is a
considerable overlap between the two conditions.
NSIP shows a similar pattern of subpleural reticular
opacities with traction bronchiectasis. However, NSIP
tends to lack the apicobasilar gradient and
honeycombing. Ground glass opacities are a more
prominent feature of NSIP compared to UIP. Clinically,
patients with NSIP tend to be slightly younger than
patients with UIP (age 40-50).
Page 29
Case Report, Takla et al.
The most important clinical distinction between UIP
and NSIP is prognosis. The histologic pattern of
cellular NSIP (predominantly inflammatory without
fibrosis) has a survival rate of nearly 100%, and the
histologic pattern of fibrotic NSIP is associated with a 5
-year survival rate of 45-90%. Compared to UIP, NSIP
also shows a favorable response to treatment with
corticosteroids and cytotoxic agents.1-3
Connective Tissue Disease Associated Interstitial Lung
Disease.
fibers are serpentine and amphiboles. As the name
implies, the serpentine fibers are curly and flexibile,
while the amphiboles are straight, needle-shaped
fibers. While both forms may lead to asbestos-related
lung disease, the amphiboles are considered more
toxic. Exposure to asbestos fibers by inhalation can
lead to various manifestations of asbestos-related lung
disease, including pleural effusion, pleural plaques
(with or without calcification), diffuse pleural
thickening, and/or malignant mesothelioma. Patients
with asbestos exposure are also at increased risk of
primary bronchogenic carcinoma.
Connective tissue diseases are a group of
inflammatory autoimmune-mediated processes that
may affect multiple organ systems, including the lung
parenchyma and chest cavity. Rheumatoid arthritis
and progressive systemic sclerosis are two of the more
common connective tissue diseases that may result in
interstitial lung disease with reticular opacities in a
basilar distribution. The interstitial lung disease that
develops with these entities may show a histologic
pattern of UIP or NSIP, with UIP being more common
in rheumatoid arthritis, and NSIP more common in
progressive systemic sclerosis.
Asbestosis is a form of asbestos-related lung disease
that leads to interstitial fibrosis. Asbestosis is clinically
and histologically similar to idiopathic pulmonary
fibrosis. On high-resolution CT imaging, asbestosis will
show subpleural septal thickening and traction
bronchiectasis in a similar distribution as seen with
UIP/IPF; honeycombing is seen in more advanced
cases.6 Concomitant asbestos-related pleural disease
may be seen in 75-83% of patient with asbestosis.
However, in the absence of pleural abnormalities,
asbestosis and idiopathic pulmonary fibrosis cannot be
differentiated by imaging alone.7
The prevalence of interstitial lung disease in
rheumatoid arthritis is variable, ranging from 5 to 40%.
Interstitial lung disease is usually a late complication of
the disease. Other common thoracic manifestations of
rheumatoid arthritis include pleural thickening or
pleural effusion. Rarely, cavitary necrobiotic
rheumatoid nodules may be seen.
Approximately 80% of patients with progressive
systemic sclerosis will develop interstitial lung disease,
and up to 97% of patients with progressive systemic
sclerosis will have esophageal involvement of the
disease, leading to esophageal dysmotility. On
imaging, the esophageal involvement manifests as a
patulous and fluid-filled esophagus. The coexistence of
these common manifestations is highly suggestive of
interstitial lung disease associated with progressive
systemic sclerosis.4,5
Asbestosis.
Asbestos is a non-combustible and durable silicate
mineral that has been commercially developed for
many purposes. The most common commercial
applications include insulation material and brake
pads/linings. The two main classifications of asbestos
Page 30
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Case Report, Takla et al.
Diagnosis
Usual interstitial pneumonia/idiopathic pulmonary
fibrosis
References
1.
Mueller-Mang C, Grosse C, Schmid K, et al. What every
radiologist should know about idiopathic interstitial
pneumonias. Radiographics 2007;27(3):595-615.
2.
Wittram C, Mark EJ, McLoud TC. CT-histologic correlation of
the ATS/ERS 2002 classification of idiopathic interstitial
pneumonias. Radiographics 2003;23(5):1057-1071.
3.
Kligerman SJ, Groshong S, Brown KK, et al. Nonspecific
interstitial pneumonia: radiologic, clinical, and pathologic
considerations. Radiographics 2009;29(1):73-87.
4.
Capobianco J, Grimberg A, Thompson BM, et al. Thoracic
manifestations of collagen vascular diseases. Radiographics
2012;32(1):33-50.
5.
Kim EA, Lee KS, Johkoh T, et al. Interstitial lung diseases
associated with collagen vascular diseases: radiologic and
histopathologic findings. Radiographics 2002;22 Spec No:S151
-165.
6.
Roach HD, Davies GJ, Attanoos R, et al. Asbestos: when the
dust settles an imaging review of asbestos-related disease.
RadioGraphics 2002;22 Spec No:S167-184.
7.
Akira M, Yamamoto S, Inoue Y, et al. High-resolution CT of
asbestosis and idiopathic pulmonary fibrosis. Am J Roentgenol
2003;181(1):163-169.
Summary
High-resolution CT is an important component in
the evaluation of interstitial lung disease. When used
in conjunction with a thorough history, physical
examination, and pulmonary function testing, highresolution CT imaging may eliminate the need for
surgical lung biopsy. Knowledge of subtle differences
in the imaging of various interstitial lung diseases may
help narrow the differential diagnosis. However, there
is significant overlap in the imaging appearance of
various interstitial lung diseases, and a final diagnosis
by imaging alone is not always possible. Rather, the
high-resolution CT findings must often be interpreted
in the context of patients medical, occupation, and
exposure history.
The views expressed in this material are those
of the author, and do not reflect the official
policy or position of the U.S. Government, the
Department of Defense, or the Department of
the Army.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Page 31
Case Report, Joshi et al.
Posterior Mediastinal Mass
Anagha Joshi, M.D., DMRE, Chintan Trivedi, M.D., DNB, Ashank Bansal, MBBS
Lokmanya Tilak Municipal Medical College & Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, India
Case Presentation
A 57-year-old woman presented with epigastric pain and cough for a period of 15 days, as well as a history of
significant weight loss of 12 kgs in past 2 months. The patient had no significant past medical history. A chest x-ray was
performed (Fig. 1), which prompted further work-up, consisting of a contrast-enhanced CT (Fig. 2) MRI (not shown),
and PET-CT (Fig. 3). Frontal chest radiograph done as a part of the routine work up, revealed soft tissue opacity in the
retrocardiac region, with the left heart border seen separate from the lesion. Lateral radiograph confirmed the
posterior location of the mediastinal lesion.
Figure 1. Frontal radiograph (A) reveals a
soft tissue opacity in the retrocardiac region
with the left heart border seen separate
from the lesion (black arrow). Lateral
radiograph (B) confirms a posterior
mediastinal location. The adjacent vertebral
bodies and neural foramina appear normal.
A
B
Figure 2. Post-contrast axial MIP CT image
shows a heterogeneously enhancing mass in
the posterior mediastinum engulfing the
descending thoracic aorta, which shows
multiple contrast-filled outpouchings. The fat
plane with the liver is maintained, and the
adjacent vertebral body does not appear to
be involved. There is displacement of the
esophagus and IVC.
Figure 3. Fused PET-CT image in the axial
plane reveals intense uptake by the
posterior mediastinal mass (SUV 7.3).
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J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Case Report, Joshi et al.
Key Imaging Finding
Posterior mediastinal mass
Differential Diagnoses
Neurogenic Tumors / Peripheral Nerve Sheath
Tumors
characteristic.
Necrosis,
hemorrhage,
and
heterogeneous enhancement are more often seen
with malignant nerve sheath tumors. Sympathetic
ganglion tumors, such as ganglioneuromas, are
typically seen in the first decade of life, and are
vertically oriented along the lateral aspect of
vertebrae, and are less common.2
Foregut Cysts
Foregut Cysts.
Lymphoma
Mediastinal foregut cysts result from embryologic
aberrations with anomalous budding of the primitive
foregut. The spectrum of anomalies includes
bronchogenic cysts, esophageal duplication cysts, and
neuroentric cysts. Bronchogenic cysts are most
commonly located in the carinal region, while
esophageal duplication cysts are most often located
along the esophagus in the lower mediastinum.
Neuroentric cysts communicate with the meninges
and are usually associated with vertebral anomalies.
Foregut cysts usually do not cause symptoms and have
similar imaging features.
Aortic aneurysm
Esophageal neoplasms
Sarcoma
Discussion
The posterior mediastinum is bounded anteriorly by
the pericardium and great vessels, posteriorly by the
prevertebral fascia, and laterally by the pleura.1 Its
contents include the aorta, esophagus, azygous and
hemiazgous vessels, neural structures, and lymph
nodes. By convention, the paravertebral space is also
included in the posterior mediastinum. Posterior
mediastinal masses can arise from any of these
structures.
Morphological
characteristics,
enhancement patterns, and relation to surrounding
organs as studied on imaging help in determining the
organ of origin. Correlation with the clinical profile and
histopathology are essential in arriving at the final
diagnosis. These studies also play an important role in
staging of the disease.
Neurogenic Tumors.
Neurogenic tumors, to include nerve sheath and
sympathetic ganglion tumors, represent the most
common posterior mediastinal masses. Most lesions,
especially if benign, are asymptomatic. Nerve sheath
tumors, such as schwannoma and neurofibroma, are
most often seen in patients around 20-30 years of age.
Frontal and lateral radiographs reveal widening of the
neural foramina with splaying of ribs, which can be
confirmed on CT. These lesions demonstrate
heterogeneous contrast enhancement on CT and
appear hypointense on T1 and hyperintense on T2.
MRI may show intraspinal extension, which is
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Frontal radiographs typically reveal sharply
marginated areas of increased opacity. CT reveals welldefined fluid density lesions, often with a thin
enhancing wall. Occasionally, increased protein
content will result in increased attenuation.1 There is
no infiltration or invasion of adjacent structures and
no solid tissue enhancement within the lesion. On
MRI, foregut cysts appear as well-defined lesions
which are hypointense on T1 and hyperintense on T2
weighted images. MR imaging is useful in determining
the cystic nature of foregut lesions with an atypical
appearance or increased attenuation on CT, since cysts
will typically have T2 bright signal intensity, regardless
of the nature of the cyst contents.
Lymphoma.
Lymphoma presents as a soft tissue mass with
widening of mediastinum, which is often revealed on
conventional radiographs. An anterior or middle
mediastinal location is more common than posterior.
CT demonstrates a lobulated soft tissue density mass
with heterogeneous enhancement; regions of
calcification may be seen post-treatment but are rare
in patients who have not undergone treatment. The
margins often conform to surrounding structures. The
appearance of lymphoma on MRI varies based upon
Page 33
Case Report, Joshi et al.
the type of lymphoma and whether or not the patient
has undergone treatment.3
Diagnosis
Sarcoma
Aortic Aneurysm.
Patients with descending aortic aneurysms are
usually asymptomatic. Frontal radiographs reveal a
posterior mediastinal mass with the aortic shadow not
seen separately from the lesion. Curvilinear
calcification may be seen at the periphery of the
lesion. CT and MRA will show contrast enhancement in
the arterial phase. Partially thrombosed aneurysms
show regions of non-enhancing clot with areas of
hemorrhage.
Esophageal Neoplasms.
Patients with esophageal neoplasms generally
present with dysphagia to solid food and weight loss.
Imaging findings often lag clinical presentation;
therefore, radiographs may be normal initially. When
large, esophageal tumors present as a posterior
mediastinal soft tissue mass. CT shows eccentric or
circumferential esophageal wall thickening with
dilated proximal fluid and debris-filled esophageal
lumen.
Exophytic
components
may
show
heterogeneous enhancement.
Invasion of local
structures is common due to lack of a serosa. 1 MRI
provides little advantage over CT.
Summary
Posterior mediastinal masses are usually
asymptomatic and are best diagnosed by cross
sectional imaging. In this case, imaging findings were
of a mass lesion with heterogeneous and delayed
enhancement with erosion and aneurysm formation of
the descending aorta, thereby favoring a neoplastic
etiology. The tumor did not involve the esophagus or
vertebral bodies, and there was no intraspinal
extension. Sarcoma, therefore, was the most likely
diagnosis despite its rareity. A CT-guided biopsy
revealed that this was a rare case of pleomorphic
undifferentiated sarcoma, formerly referred to as
malignant fibrous histiocytomas,4,5 with secondary
involvement of the aorta. To our knowledge, only 13
cases of pleomorphic sarcoma involving the posterior
mediastinum have been described in literature.6
Hence, if the imaging findings don’t fit in any of the
commonly known posterior mediastinal masses, a
differential of sarcoma should be kept in mind.
References
Sarcoma.
Sarcomas are rare in the mediastinum and present
as posterior mediastinal masses, which may appear illor well-defined on radiographs. Rib erosions may be
seen. CT shows a solid mass lesion, often with
infiltrative margins and heterogeneous enhancement.
MRI will show heterogeneous but predominantly T1
hypointense and T2 hyperintense signal intensity with
foci of hemorrhage and necrosis. Neovascularity may
be present. It is uncommon for sarcomas to invade the
aorta and cause aneurysm formation. No specific
imaging findings are known to differentiate the various
subtypes of sarcomas. Histopathology is essential for
knowing the type of sarcoma. PET imaging helps in
grading and staging of the tumor.
Page 34
1.
Kawashima A, Fishman EK, Kuhlman JE, et al. CT of posterior
mediastinal masses, RadioGraphics 1991;11:1045-1067
2.
Nakazono T, White CS, Yamasaki F, et al. MRI findings of
mediastinal neurogenic tumors. Am J Roentgenol
2011;197:W643-52.
3.
Juanpere S, Cañete N, Ortuño P, et al. A diagnostic approach
to the mediastinal massesA diagnostic approach to the
mediastinal masses Insights Imaging 2013;4(1):29-52.
4.
Fletcher CDM, Unni KK, Mertens F, eds. World Health
Organization Classification of Tumors: Pathology and Genetics
of Tumours of Soft Tissue and Bone. Lyon, France, IARC Press,
2002.
5.
Fletcher CDM. Pleomorphic malignant fibrous histiocytoma:
fact or fiction? A critical reappraisal based on 159 tumors
diagnosed as pleomorphic sarcoma. Am J Surg Pathol 1992;16
(3):213-28.
6.
Hernandez A, Gill, FI, Aventura E, et al. Mediastinal
pleomorphic sarcoma in an immunodeficient patient: case
report and review of the literature. Journal of the Louisiana
State Medical Society 2012; 164(1): 21.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
JAOCR At the Viewbox
JAOCR at the Viewbox
Bernard F. Laya, D.O.a,b, and Regina C. Nava, M.D.b
a
Institute of Radiology, St. Luke’s Medical Center, Quezon City, Philippines
Institute of Radiology, St. Luke’s Medical Center Global City, Taguig, Philippines
b
B
A
C
Pulmonary Lymphangioleiomyomatosis.
This chest radiograph of a 27-year-old woman presenting with severe difficulty of breathing (A) appears grossly
unremarkable. A high resolution chest CT scan was obtained (B), which reveals variably-sized cysts throughout the
lung parenchyma with thickened interlobular septae, compatible with lymphangioleioyomatosis (LAM). Based
upon these findings, an abdominal CT scan was performed (C), revealing a large, heterogeneous right renal mass
with predominantly fatty attenuation. A smaller lesion with similar imaging characteristics is seen in the left
kidney. Brain CT scan (not shown) demonstrated small subependymal calcifications. Overall constellation of
findings is compatible with Tuberous Sclerosis.
Pulmonary LAM is a rare disease affecting mostly women of child-bearing age. It also occurs in some patients
with Tuberous Sclerosis. It is characterized by disorderly proliferation of smooth muscle throughout the lungs,
causing destruction of lung tissue and leading to abnormal cyst formation. Dyspnea and pneumothorax are the
two most common presenting symptoms. LAM is a slowly progressive condition with a poor prognosis. Treatment
is difficult and is primarily supportive.
J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2
Page 35
JAOCR At the Viewbox
JAOCR at the Viewbox
Ali Yikilmaz, M.D.
Istanbul Medeniyet University, Goztepe Research and Training Hospital, Department of Radiology, Istanbul, Turkey
B
A
Hydatid Cyst of the Lung.
A 12-year-old girl presented with cough and fever. PA chest X-ray shows a large air filled cyst in the left lung
base (A). Contrast enhanced axial CT image (B) demonstrates a round cyst with air-fluid level and detachedfloating germinative membranes (asterisk), which are typical for hydatid disease.
Echinococcosis or hydatid disease is a parasitosis caused by infestation with Echinococcus granulosus (dog
tapeworm). Although most children with pulmonary involvement by hydatid disease are asymptomatic, they may
occasionally present with fever, shortness of breath, cough, and/or chest pain, which is usually a sign of cyst
rupture. Diagnosis of hydatid disease depends on the combination of imaging findings and serology tests that use
antigens specific for the organism.
The radiological findings are characterized by single or multiple (~25%), round or oval-shaped, cystic nodules or
masses (1-20 cm in diameter) with well-defined walls, surrounded by normal lung parenchyma. Other findings
include an air-crescent sign when a cyst communicates with a bronchus or the “water-lily sign” when a cyst
membrane floats in residual fluid after the rupture of cyst. The water-lily sign is considered to be highly specific or
pathognomonic, especially in endemic areas.
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J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2