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IMAGING MODALITIES FOR LUNG DISEASES

Aimee Esther Vicedo-Reyes, MD Radiology Resident


January 21, 2014 BaTWO-BaTWO

INTRODUCTION
Every year, more than 300 million x-rays, CT scans, MRIs and other medical imaging exams are performed in the United States Seven out of 10 people undergo some type of radiologic procedure

Figure 1. AP view (left); PA view (right) Table 2. Comparison of features seen in PA and AP views of chest x-ray Criteria PA AP Mongolian Present Absent; vertebral bodies hat sign are rectangular Ribs Angulated Straighter Clavicle V-shaped More horizontal Scapula Winging No winging Heart Heart not Heart and other magnification magnified structures more magnified

CHEST X-RAY
Oldest radiographic technique Most commonly performed procedure (~25% of radiographic examinations) Cost effective Important in diagnosis of pulmonary, mediastinal and bony thorax diseases Makes images of the heart, lungs, airways, blood vessels, and bones of the spine and the chest

PROJECTION It indicates the direction in which the x-ray beam traverses the patient on its way to the film There are several projections of chest radiography: Table 1. Comparison of PA and AP views of chest x-ray Criteria PA view AP view Indications Routine For ill patients that cant stand erect Tube-film ~72 in. (6 ft.) ~40 in. (3.33 ft) distance Direction of X-ray beam from X-ray beam from beam behind, plate in the front to front of the posterior, plate patient behind the patient Patient Upright Supine position

Figure 2. Mongolian hat sign in PA view (left); AP view (right)

Figure 3. V-shaped clavicle in PA view (left); More horizontal clavicle in AP view (right)

Figure 4. Winging of scapula in PA view (left); No winging of scapula in AP view (right) Figure 5. Lateral view (left); Oblique view (right)

LATERAL POSITION
INDICATIONS Assess mediastinal structures: heart, sternum, retrocardiac space, retrosternal space and the lungs Confirmation of findings in PA or AP views We use this to determine if the lesion is anteriorly or posteriorly located Used to evaluate blunting of posterior gutter (posterior costophrenic sulcus) in pleural effusion IMAGE CRITERIA Ribs posterior to the vertebrae should be superimposed Costophrenic (CP) angles and lung apices included Hilar region should be at the center Circular structures on this view may represent blood vessels

APICOLORDOTIC (AL) POSITION


Lung apices viewed better Leaning backward in exaggerated lordosis The anterior and posterior segments of the same ribs are superimposed

Figure 6. AL position (left); AL view (right)

LATERAL DECUBITUS POSTION


Patient lying on his side for 10-15 minutes Can detect the following: o Pleural effusions: mobile vs. loculated o Small pneumothorax

OBLIQUE POSITION
INDICATIONS Assess tracheal bifurcation Study heart, hilum and ribs Tracheal lumen should be normally about 1.5cm in diameter If it is wider then one should suspect a pathology

Figure 7. A patient in position for a right lateral decubitus position (left); Example of a decubitus film in this case showing mobile pleural effusion(right)

When we suspect that the problem is effusion, the patient should lie on the ipsilateral side For pneumothorax, we ask them to lie on the contralateral side so that the air will rise to the non-dependent portion of the lungs

FLUOROSCOPY
Not normally used It is more used when we assess the activity of the structures involved like the diaphragm and the heart Only indicated for patients with acute obstructive overinflation secondary to aspiration of foreign body Uses a higher radiation exposure When used, necessary to use smallest aperture so that the radiation exposure is limited Limit total fluoroscopic time to reduce radiation exposure (<5 mins.) because any longer would increase the risk for patients, esp. younger ones, for sterility

CONTRAINDICATIONS Respiratory insufficiency Allergy (for the contrast material) Recent hemoptysis When the hemoptysis occurs 7-14 days before the procedure, it is no longer a contraindication Active infections COMPLICATIONS Anesthetic reactions Allergic reactions to iodized oil

Figure 9. Use of fluoroscopy while performing bronchoscopy

ULTRASONOGRAPHY
Real-time scanning Non-invasive No radiation exposure Can detect, localize and differentiate fluid from solid pleural masses Disadvantage: It cannot evaluate wellaerated lungs because air cannot be traversed by sound waves Quantify amount of pleural fluid

Figure 8. A modern fluoroscope (left); A fluoroscopy burn from long exposure (right)

BRONCHOGRAPHY / BRONCHOSCOPY
Study of the bronchial tree by means of introduction of opaque material into the desired bronchus or bronchi, usually under fluroscopic guidance Rarely used because it has already been replaced by fiberoptic bronchoscopy which has biopsy capabilities

INDICATIONS Bronchiectasis Lumen of the bronchus should be larger than its accompanying vascular supply Suspected bronchogenic tumor Anomalies of the bronchial tree

Figure 10. Chest ultrasound using a probe (left); Example of ultrasound result (right)

COMPUTED TOMOGRAPHY
Uses series of x-rays to produce detailed images of the inside of the body Offers a spatial resolution in the submillimeter range (1 5mm) Best method in evaluating very small lesions within the lungs Main tool for the diagnosis and staging of lung cancer

Characterization of mediastinal masses for diagnosis Localization of mediastinal masses whether it is in the anterior mediastinum, midmediastinum or posterior mediastinum

USES IN PLEURAL IMAGING Localization and evaluation of extent of plaques, masses, loculated fluid and occult calcification USES IN CHEST WALL IMAGING Study of masses involving soft tissue, bone, spinal canal and adjacent lung ADDITIONAL USES Evaluation of chest involvement in trauma

HIGH RESOLUTION CHEST TOMOGRAPHY (HRCT) Based on thin (1 5 mm) sections Method of choice for assessing lung tissue Analyzing diffuse lung diseases such as pulmonary fibrosis, emphysema or diseases affecting the airways Help locate the abnormality and suggest the most suitable location for a histological biopsy In CT scan, we usually do CT-guided biopsy if the lesion is adherent to the pleura. We do not do biopsy if the lesions are centrally-located due to the risk for pneumothorax MULTIDETECTOR CHEST TOMOGRAPHY (MDCT) Most high-end CT machines Uses multiple detectors Allows for production of cross sections through the chest in any direction (axial, sagittal or coronal) Produces three-dimensional (3D) images compared to HRCT USES IN LUNG IMAGING Evaluation and staging of primary pulmonary neoplasm Detection of pulmonary metastases from nonpulmonary primary tumors Characterization of solitary pulmonary nodules Characterization of focal and diffuse lung diseases Useful in guidance for needle biopsy Helpful in the study of cavitary masses, peripheral lung tumors and pulmonary collapse USES IN MEDIASTINAL IMAGING Study the causes of mediastinal widening whether tumor/neoplasms or aortic dissections/aneurysms Staging of tumors that spread to the mediastinum

Figure 11. Example of chest CT results

MAGNETIC RESONANCE IMAGING (MRI)


Latest technique for lung examination Uses subtle resonant signal that can be obtained from hydrogen nuclei (protons) of H2O or organic substances when they are exposed to a strong magnetic field and excited by precise radio frequency pulses Provides more functional information and excellent morphological imaging capacities

ADVANTAGES No radiation hazard or other known biological risk Images may be acquired without use of mechanical motion devices and views in multiple planes can be acquired directly IV contrast agents are not necessary to identify intrathoracic vascular structures or to show the presence of vascular flow

Greater ability than CT or plain films to differentiate types of tissue based on signal characteristics Magnetic resonance angiography is capable of demonstrating some vascular anatomy in a display format comparable to that of conventional angiography, but non-invasively

DISADVANTAGES Motion artifacts cause degradation of the images Imaging of lung parenchyma is poor due to low proton density of the lung tissue and the many air-tissue interfaces that cause loss of signal Patients with o cardiac pacemakers o ferromagnetic intracranial aneurysm clips o metal fragments in the eye or near the spinal cord o cochlear implants, and o neurostimulators cannot be examined Claustrophobia Longer time required for most MRI examinations Higher cost APPLICATIONS Assessment of o aortic vascular disease, o subacute and chronic dissection, o vascular anomalies, and o venous obstruction of mediastinal and subclavian vessels o chest-wall lesions and infections Cardiac evaluation of selected congenital and acquired heart conditions and pericardial diseases Evaluation of o brachial plexopathy including determination of the extent of pancoast tumors, o the diaphragm and peridiaphragmatic processes o intracardiac and paracardiac masses including staging of tumors that may potentially involve the heart, pericardium, or pulmonary arteries and veins, o breast implants for rupture and breast masses, and

congenital and developmental anomalies of the pediatric chest such as vascular rings, coarctation of the aorta, lympangiomas, and sequestrations Determination of the extent of posterior mediastinal masses, especially those with intraspinal extension Detection of ectopic parathyroid adenomas in the mediastinum

Figure 12. Examples of chest MRI results

POSITRON EMISSION TOMOGRAPHY


Uses radioactive tracers and photon detectors Based on injection of radioactive-labelled biomolecules (tracers), which are then followed and detected (enhancement) 18F-fluorodeoxyglucose (FDG) o Most widely used tracer

ADVANTAGES Improved diagnostic accuracy for staging Allows detection of lesions not initially seen on CT or PET More precise lesion localization Better delineation of surrounding structures Better characterization of lesions as benign or malignant DISADVANTAGES Small lesions (<5 mm) are difficult to detect FDG not only enhances malignant tumors; can also enhance non-malignant areas that are metabolically active (inflammation, brown fatty tissue) Slow-growing tumors (adenocarcinoma, carcinoid tumors) show little or no FDG uptake

Figure 13. Examples of PET Scan Results. Areas pointed out by the arrows are sites of metabolic activity

PULMONARY ANGIOGRAPHY
Outline the pulmonary arterial system Used to study patients with suspected pulmonary arterial or venous anomalies or diseases Study of thromboembolic disease of the lungs by means of pulmonary arteriography Needed when the diagnosis remains in doubt after roentgen and scintiscan studies When patient is not responding to treatment for presumed pulmonary embolism

Figure 14. An example of pulmonary angiography showing several PAVMs (Pulmonary ArterioVenous Malformations) in a patient

BRONCHIAL ARTERIOGRAPHY
Requires selective catheterization of bronchial arteries LIMITED use in pulmonary disease Still plays a therapeutic role in the treatment of selected cases of life-threatening hemoptysis that may be mitigated with bronchial arterial embolization Not available in our locality

TECHNIQUE Injection of contrast material into the superior vena cava with the use of digital subtraction angiography (DSA) Injection of contrast material into the right atrium using DSA Direct injection of contrast medium through a catheter placed in a main pulmonary artery Selective injection of contrast material into a pulmonary artery branch using DSA or balloonocclusion cineangiography or serial filming ADVANTAGES A very small amount of iodinated contrast material is necessary DISADVANTAGES Artifacts produced by motion Limited field of view

PERCUTANEOUS TRANSTHORACIC NEEDLE BIOPSY


Used extensively to obtain material for histologic and bacteriologic study

INDICATIONS Peripheral lung masses beyond the reach of fiberoptic bronchoscopy Focal or general pulmonary infections in immunocompromised hosts ADVANTAGES High diagnostic yield Low incidence of complications MAJOR COMPLICATIONS Pneumothorax Hemorrhage

CONTRAINDICATIONS Patients with bleeding diathesis or thrombocytopenia A suspected vascular lesion Recent severe hemoptysis Severe dyspnea at rest Those who cannot cooperate

LUNGS
Right hilum is lower than the left Right HHR is approximately 1/2 : 1/2 Left HHR is approximately 1/3 : 2/3 * Hilar Height Ratio (HHR) value that expresses the normal position of a hilus in its hemithorax. Pulmonary volume changes, infrapulmonary and subphrenic processes may produce an abnormal hilar height ratio. Detection of pathologic states that do not alter the relative hilar heights is made possible by the recognition of this abnormal ratio. It is calculated by dividing the distance from the hilus to the lung apex by the distance from the hilus to the diaphragm.

CHEST ANATOMY REVIEW

Figure 16. Shows the comparison of the Right HHR and Left HHR BRONCHOVASCULAR RATIO Diameter of bronchus and artery that accompanies it should be 1:1 If artery is larger than the bronchus: congestion or edema If bronchus is larger than the artery: Bronchiectasis

RIGHT LUNG
3 lobes and 2 fissures o Minor fissure Horizontal, at 4th rib Separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes o Major fissure From T3 spinous process to 6th costal cartilage anteriorly Oriented obliquely

Figure 15. Normal Radiographic Anatomy of the Chest

Separates the right lower lobe from the upper and middle lobes

Figure 19. Highlights the locations of the RML

RIGHT LOWER LOBE


Figure 17. Shows the different locations of the fissures on CXR results Largest of all three lobes Separated from the others by the major fissure Posteriorly: extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm

RIGHT UPPER LOBE


Occupies the upper 1/3 of the right lung Anteriorly: extends inferiorly as far as the 4th right anterior rib Posteriorly: adjacent to the first three to five ribs

Figure 20. Shows the RLL on CXR film

LEFT LUNG
Figure 18. Shows the location of the RUL on CXR films 2 lobes and 1 fissure o Major fissure Divides left upper and lower lobe No defined left minor fissure There are only two lobes on the left o Left upper lobe o Left lower lobe

RIGHT MIDDLE LOBE


Smallest lobe Triangular in shape, being narrowest near the hilum

Middle lobe 4. Lateral 5. Medial Lower lobe 6. Superior 7. Medial basal 8. Anterior basal 9. Lateral basal 10. Posterior basal

SEGMENTS OF THE LEFT LUNG


Upper lobe 1. Apical posterior 2. Anterior 3. Apical posterior 4. Superior lingular 5. Inferior lingular Lower lobe 6. Apical 7. Anteromedial Basal 8. Anteromedial Basal 9. Lateral Basal 10. Posterior Basal

Figure 21. Shows the areas occupied by the LUL and LLL on CXR film Two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe

BRONCHOPULMONARY SEGMENTS
Each pyramid shaped segment is: o Enveloped by a connective tissue sheath o Supplied by a single segmental bronchus and a single pulmonary arterial branch o Orient so that its apex projects towards the hilum of the lung The importance has increased now that segmental resection and sub-segmental pulmonary resection are common procedures

Figure 22. Shows the areas of the different segments of the lungs on CXR

SEGMENTS OF THE RIGHT LUNG:


Upper lobe 1. Apical 2. Anterior 3. Posterior

TRACHEA
Midline, within the boundaries of the vertebral body Location: C6-T5 Bifurcates at the level of T5

Subcarinal angle must be <90o A slight tracheal deviation to the right at the level of the aortic arch can be normal radiographic finding

HEART
Right border: o Superior vena cava o Right atrium o Inferior vena cava Left border: o Aortic arch o Left pulmonary artery o Left atrial appendage o Let ventricle

Figure 23. Highlights the location of the trachea on CXR

HILUM
The wedge shaped area on the central portion of each lung where the bronchi, pulmonary arteries, veins and nerves leave the lung Figure 25. Highlights the border of the heart on CXR Check for the Aorta o Note if the aortic notch is prominent and atherosclerotic Cardiac size is assessed as cardiothoracic ratio (CTR) CTR is the transverse cardiac diameter divided by the transverse chest diameter Cardiothoracic ratio Neonates: <0.6 Infants: <0.56 to 0.6 Children: <0.56 Adults: PA: 0.5 AP: 0.55

Figure 24. Highlights the location of the Hilums on CXR Both hilar should be concave Both hilar should be of similar density Left hilar point is usually higher than the right

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Figure 27. Felsons division Figure 26. Show how to calculate for the CTR. Obtain line A by measuring from the middle up to the most lateral border on the right side. Line B is by measuring from the middle up to most lateral border on the left side. Add A and B, then divide it by C which can be obtain by measuring the length of the chest wall as shown above. ANTERIOR/ PREVASCULAR Loose areolar tissue Lymph nodes Lymphatic vessels MIDDLE/ VASCULAR Heart and pericardium Ascending and transverse aorta SVC Other main vessels (ie. pulmonary artery) Main veins Trachea POSTERIOR/POST-VASCULAR/NEURAL Thoracic portion of descending aorta Esophagus Thoracic duct Azygos and hemizygos veins Sympathetic nerve COSTOPHRENIC SULCI Check if it is sharp/blunted Blunted may denote presence of pleural effusion

MEDIASTINUM The space between the two pleural sacs which


contains all the structures in the thorax except the lungs and the pleura Note for obliteration of spaces Note for opacities

MEDIASTINAL WIDTH Upright: 8 cm Supine: 10 cm FELSONS DIVISION

Anterior: Everything from the sternum to the posterior aspect of the heart and great vessels Middle: The compartment posterior to the heart and great vessels, to a line drawn 1 cm posterior to the anterior edge of the thoracic vertebrae Posterior: The space behind the posterior limit of middle mediastinum

HEMI-DIAPHRAGMS
Right hemi-diaphragm is higher than the left Lies at 5th ICS on moderately deep inspiration The curvature of both hemi-diaphragms should be assessed to identify diaphragmatic flattening

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-look for osteolytic/osteoblastic and other lesions -look for fractures OTHER MASSES: BREAST MASS -look for opacities and lucencies in other areas

Figure 28. Outlines the hemi-diaphragms *HEMIDIAPHRAGMS Convex cephalad Right hemi-diaphragm is higher than the left because of the liver The cardiac apex on the left pushes the diaphragm downwards During moderately deep inspiration, the dome of the diaphragm on the right lies in the region of the 5th anterior intercostal space while the left is slightly lower (usually by intercostal space) Figure 30. Interpret the findings REPORTING OF RESULT: Normal There are no lung infiltrates. Trachea is at midline. The heart is not enlarged. The costophrenic sulci are intact. The hemi-diaphragms are smooth. The rest of the findings are unremarkable. IMPRESSION: Essentially negative cardiopulmonary findings

COMMON PATHOLOGIES ENCOUNTERED

Figure 29. Hemi-diaphragm OTHER STRUCTURES Portions of liver, spleen, gastric fundus are routinely visualized on most x-rays Enlargement of liver cause right diaphragmatic elevation & lateral compression of stomach SOFT TISSUES -look for swelling BONE

Figure 31. Pneumonia

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Pleural effusion

Figure 32. Pleural effusion Figure 34. Pulmonary tuberculosis

Figure 35. Pneumothorax

Figure 33. Chest x-ray of patient with pulmonary tuberculosis showing cavitation (arrowheads)

Figure 36. Pulmonary Mass

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POST QUIZ
1. What chest x-ray projection shows a more magnified heart? ANSWER: AP view 2. What position is used to evaluate lesions in the lung apices? ANSWER: Apicolordotic view 3. What position checks for mobility of fluid and presence of small pneumothorax? ANSWER: Lateral decubitus view 4. What position is used to evaluate retrosternal and retrocardiac spaces? ANSWER: Lateral view 5. What projection shows a more horizontal position of the clavicle? ANSWER: AP view

References: Lecturers slides, audio Prepared by:

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The difference between a successful person and others is not lack of knowledge but rather lack of will. -Vince Lombardi

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