High-Yield Imaging: Chest: Expert Consult - Online and Print (HIGH YIELD in Radiology)

687 Pages·2009·98.055 MB·English

by  Nestor L. Muller MD PhD

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HIGH-YIELD IMAGING: CHEST  ISBN: 978-1-4160-6161-8
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The  aim  of  High-Yield Imaging:  Chest  is  to  provide  it is well recognized that the chest radiograph has impor-
an overview of the main aspects of chest imaging in a  tant limitations. High-resolution CT and multidetector 
succinct  and  user-friendly  bulleted  format  and  with  spiral CT have become the imaging modalities of choice 
 state-of-the art illustrations. It includes a review of the  in many chest diseases, and one or the other technique is 
various radiographic and high-resolution CT patterns of  performed almost routinely in the evaluation of patients 
disease and their differential diagnosis and a summary of  with suspected interstitial lung disease, bronchiectasis, 
the main pulmonary, mediastinal, pleural, and chest wall  pulmonary embolism, abnormalities of the aorta, and 
diseases.  The text provides the essential information  pulmonary or mediastinal tumors. MR imaging has an 
that the radiologist needs to know, including  definition  important role in the assessment of cardiovascular, me-
of the various abnormalities, radiologic manifestations,  diastinal, and chest wall abnormalities. PET imaging and 
clinical utility of the various imaging  modalities, char- integrated PET-CT have replaced CT as the imaging mo-
acteristic  clinical  presentation,   pathologic   features,  dalities of choice for the staging of pulmonary carcinoma 
main  diagnostic pearls, and differential diagnosis, as  and lymphoma. The main role of ultrasound in chest im-
well as the key information that the referring physi- aging is as a guide for aspiration and drainage of pleural 
cian needs to know about the condition and its imaging  fluid collections and for biopsy of pleura-based tumors.
 manifestations. The text is based on the 2-volume book   This book is aimed at radiologists, respiratory physi-
Imaging of the Chest, published in 2008 by Elsevier, with  cians, and radiology and pulmonary medicine residents 
the text updated in 2009. The figures include the most  and fellows, as well as internists and family practitioners 
representative illustrations from that textbook plus new  taking care of patients with chest disease. We hope that 
updated images.  it will be of value in improving the understanding of the 
The chest radiograph continues to be the most com- various chest diseases and thus be helpful in improving 
mon imaging modality used in diagnostic imaging. The  patient care.
combination of high-quality chest radiographs and a 
good clinical history allows the radiologist and the respi-
ratory physician to diagnose or to markedly narrow the  Nestor L. Müller
differential diagnosis of many chest diseases. However,  C. Isabela S. Silva
vii
To Alison and Phillip Müller
and to Nicinha Silva
Acknowledgments
The text of High-Yield Imaging: Chest is based on the  neither that book nor this one would have been possible. 
2-volume book Imaging of the Chest, published in 2008,  Our special thanks to the outstanding contributions by 
with the text updated in 2009, and the  figures include  Drs. David Hansell, Kyung Soo Lee, Martine Remy-Jardin, 
the most representative illustrations from that textbook  Jacques Remy, and Kiminori Fujimoto. We wish also to  
plus new updated images.  We wish to  acknowledge all  thank Drs. Philippe Grenier, Catherine Beigelman-Aubry, 
of our colleagues throughout the world listed below who  Jim Barrie, Gustavo Meirelles, Claudia M. Figueiredo, 
contributed to Imaging of the Chest and without whom  and Marcos Manzini for the  images they kindly provided.
Contributors
Masanori Akira Deepa Gopalan Rebecca M. Lindell
Galit Aviram Marc V. Gosselin  Jaume Llauger
Anoop P. Ayyappan Ahuva Grubstein Reginald F. Munden
Alexander A. Bankier David M. Hansell Clara G. Ooi
Phillip M. Boiselle Thomas E. Hartman Steven L. Primack
John F. Bruzzi Christian J. Herold Maureen Quigley
M. Kara Bucci Joshua R. Hill Jacques Remy
Susan J. Copley Peder E. Horner Martine Remy-Jardin
Sujal R. Desai Kazuya Ichikado Nicholas J. Screaton
Jeremy J. Erasmus Harumi Itoh, Jean M. Seely
Anthony Febles Takeshi Johkoh Nicholas J. Statkus
Joel E. Fishman Jeffrey S. Klein Maryellen R.M. Sun
Thomas O. Flukinger Karen S. Lee Nicola Sverzellati 
Tomás Franquet Kyung Soo Lee William D. Travis
Kiminori Fujimoto Ann Leung Charles S. White
Nestor L. Müller
C. Isabela S. Silva
ix
CONSOLIDATION
Part 1
Focal Consolidation: Acute Causes
DEFINITION: Focal consolidation is replacement of gas within airspaces by fluid, protein, cells,
or other material at a single pulmonary focus.
IMAGING
DIAGNOSTIC PEARLS
Radiography
n N onsegmental consolidation is associated with air
Findings bronchograms and normal or increased lung volume.
n F airly homogeneous opacity that is associated with n S egmental consolidation is typically associated
obscuration of the pulmonary vessels and little or no
with atelectasis and lack of air bronchograms.
volume loss.
n P arenchymal consolidation may result in poorly
n A djacent soft tissue structures are obscured: silhouette defined 5- to 10-mm nodular opacities known as
sign.
airspace nodules.
n M argins are poorly defined except where the consoli-
dation abuts the pleura.
n A ir-containing bronchi (air bronchograms) are fre- Utility
quently visible within areas of consolidation. n S uperior to radiography in demonstrating presence of
n N onsegmental (lobar) pneumonia may be associated focal consolidation or ground-glass opacity and the
with increased volume and bulging of the interlobar presence of underlying lung disease.
fissure.
n S egmental consolidation may be seen in pneumonia, CLINICAL PRESENTATION
distal to bronchial obstruction, and in association with
acute pulmonary embolism. n F ever and cough are present in patients with pneumonia.
n S pherical (round) areas of consolidation may occur in n A cute shortness of breath may occur in patients with
pneumonia or occasionally in pulmonary hemorrhage. pulmonary embolism.
n L ung contusion results in focal consolidation that n S ome patients may be asymptomatic or present with
crosses normal anatomic boundaries. nonspecific symptoms.
n F ocal right upper lobe pulmonary edema typically
occurs secondary to papillary muscle dysfunction after DIFFERENTIAL DIAGNOSIS
acute myocardial infarction.
Utility n B acterial, viral, or fungal pneumonia
n S ilhouette sign is most useful in differentiation of mid- n A spiration pneumonia
dle lobe and lingular disease from lower lobe disease n A cute pulmonary embolism
and may also provide precise anatomic information in n P ulmonary hemorrhage
other sites.
n R adiography is usually the first and often the only PATHOLOGY
imaging modality used in the assessment of focal con-
solidation. n R eplacement of gas within the airspaces by fluid,
blood, or other material.
CT
Findings INCIDENCE/PREVALENCE
n C onsolidation: homogeneous increase in pulmonary AND EPIDEMIOLOGY
parenchymal attenuation that obscures the margins of
vessels and airway walls. n C ommon causes of acute focal consolidation include
n G round-glass opacities indicating incomplete filling of pneumonia (bacterial, viral, fungal), hemorrhage, and
alveoli adjacent to airspace consolidation. pulmonary edema.
WHAT THE REFERRING PHYSICIAN NEEDS TO KNOW
n A ssessment of silhouette sign is only reliable on radiographs performed using proper technique.
n H emorrhage should be considered particularly in patients with hemoptysis and those with blunt
chest trauma.
n F ocal opacities are more commonly seen on high-resolution CT than on radiography.
2
CONSOLIDATION Focal Consolidation: Acute Causes 3
Figure 2. Bulging fissure sign. Anteroposterior chest radiograph
Figure 1. Parenchymal consolidation and silhouette sign. shows dense right upper lobe consolidation with increase in
Posteroanterior chest radiograph shows consolidation in the volume of the right upper lobe and inferior bulging of the minor
right lower lung zone. Note obscuration of the right-sided heart fissure (arrows). The patient was a 64-year-old man with
border (silhouette sign) consistent with consolidation in the right Streptococcus. pneumoniae pneumonia.
middle lobe. The dome of the right hemidiaphragm is clearly
seen consistent with sparing of the basal segments of the lower
lobes. The patient was a 37-year-old man with right middle lobe
pneumonia.
Figure 4. Right upper lobe pulmonary edema due to acute
mitral regurgitation. Anteroposterior chest radiograph shows
prominence and ill-definition of the pulmonary vascular
markings and septal lines consistent with interstitial pulmonary
edema. Also noted is extensive right upper lobe consolidation.
Figure 3. Round pneumonia. Posteroanterior chest radiograph Although the upper lobe consolidation is most suggestive of
shows round mass-like area of consolidation (arrow) in the right a pneumonia, it was proved to be due to airspace pulmonary
middle lobe. The patient was a 41-year-old man who presented edema secondary to acute mitral regurgitation after myocardial
with fever and cough. Incidental note is made of azygos fissure. infarction. The patient was an 83-year-old woman.
n S egmental consolidation with or without volume loss Suggested Readings
typically results from endobronchial obstruction or
Gluecker T, Capasso P, Schnyder P, et al: Clinical and radiologic fea-
pulmonary infarction. tures of pulmonary edema. RadioGraphics 19:1507-1531, 1999.
n S egmental distribution seen after aspiration and with Grenon H, Bilodeau S: Pulmonary edema of the right upper lobe
pneumonia caused by Staphylococcus aureus, Strepto- associated with acute mitral regurgitation. Can Assoc Radiol J
45:97-100, 1994.
coccus pyogenes, or a variety of gram-negative bacteria.
Wagner AL, Szabunio M, Hazlett KS, Wagner SG: Radiologic mani-
n R ound pneumonia occurs much more frequently in festations of round pneumonia in adults. AJR Am J Roentgenol
children than in adults. 170:723-726, 1998.
n A lthough round pneumonia in adults may result from bac-
terial infection, most commonly no organism is identified.
n F ocal right upper lobe pulmonary edema is seen most typi-
cally with myocardial infarction resulting in papillary mus-
cle dysfunction or rupture and acute mitral regurgitation.
Focal Consolidation: Chronic Causes
DEFINITION: Focal consolidation is replacement of gas within airspaces by fluid, protein, cells,
or other material at a single pulmonary focus.
IMAGING DIAGNOSTIC PEARLS
Radiography
n F ocal consolidation progressing slowly over several
Findings months is suggestive of bronchioloalveolar carci-
n F airly homogeneous opacity associated with obscura- noma or lymphoma.
tion of the pulmonary vessels and adjacent soft tissue n P ulmonary lymphoma may result in single or
structures is known as a silhouette sign. multiple mass-like areas of consolidation.
n A ir-containing bronchi (air bronchograms) are fre- n P resence of fat attenuation in focal consolidation
quently visible within areas of consolidation. is characteristic of lipoid pneumonia.
n C onsolidation in pulmonary carcinoma and lymphoma
may be round or have irregular margins.
n C hronic segmental or lobar consolidation with or with-
out associated volume loss suggests bronchial obstruc-
tion by tumor or foreign body. Utility
n C hronic focal nonsegmental consolidation often with n S uperior to radiography in the differential diagnosis.
irregular and poorly defined margins may be seen in n S uperior to radiography in demonstrating presence of
lipoid pneumonia. bronchial obstruction.
Utility n F requently allows diagnosis of lipoid pneumonia by
n S ilhouette sign is most useful in differentiation of mid- demonstrating areas of fat density.
dle lobe and lingular disease from lower lobe disease
and it may also provide precise anatomic information
CLINICAL PRESENTATION
in other sites.
n C hest radiograph is useful in demonstrating the pres- n F ocal ground-glass opacity or consolidation is fre-
ence of focal consolidation and in monitoring changes quently an incidental finding in asymptomatic patients.
over time. n S ymptoms when present are nonspecific, usually con-
sisting mainly of cough and, occasionally, shortness of
CT breath and hemoptysis.
Findings
n C onsolidation is a homogeneous increase in pulmo- DIFFERENTIAL DIAGNOSIS
nary parenchymal attenuation that obscures the mar-
gins of vessels and airway walls. n O rganizing pneumonia
n G round-glass opacity is a homogeneous increase in n L ipoid pneumonia
attenuation that does not obscure underlying vessels. n P ulmonary Hodgkin lymphoma
n A small, round, focal ground-glass opacity is a common n P ulmonary non-Hodgkin lymphoma
manifestation of bronchioloalveolar cell carcinoma. n B ronchioloalveolar cell carcinoma
n T he presence of a solid component in association with n A denocarcinoma
the focal ground-glass opacity is suggestive of adeno-
carcinoma.
n C hronic focal area of consolidation with air broncho- PATHOLOGY
grams may represent a carcinoma or primary pulmo-
nary lymphoma (maltoma). n R eplacement of gas within the airspaces by fluid, pro-
n F ocal consolidation with localized areas of fat density tein, cells, or other material
(−30 to −120 Hounsfield units) is virtually diagnostic n B ronchial obstruction with distal obstructive pneumo-
of extrinsic lipoid pneumonia. nitis and atelectasis in endobronchial lesions
WHAT THE REFERRING PHYSICIAN NEEDS TO KNOW
n P ulmonary carcinoma should be suspected in patients with ground-glass opacities or consolidation that
is progressive over several months.
n C hronic segmental consolidation with or without atelectasis should suggest the presence of an
endobronchial lesion with distal obstruction.
n C T commonly allows the diagnosis of lipoid pneumonia by demonstrating the presence of fat within the
consolidation.
4
CONSOLIDATION Focal Consolidation: Chronic Causes 5
Figure 1. Primary pulmonary lymphoma. Posteroanterior Figure 2. Lipoid pneumonia. Posteroanterior chest radiograph
chest radiograph shows focal consolidation in the right lower shows focal consolidation in the right upper lobe. The patient
lung zone (arrow). Note focal obliteration of the right-sided was a 55-year-old man with lipoid pneumonia confirmed by fine-
heart border (silhouette sign) at the level of the consolidation. needle biopsy and clinical history.
The patient was a 53-year-old man with primary lymphocytic
lymphoma of the lung (maltoma).
Figure 4. Lipoid pneumonia. High-resolution CT image demon-
Figure 3. Primary pulmonary lymphoma. CT image shows focal con - strates small foci of fat attenuation (arrows) within the parenchymal
solidation (arrow) in the right middle lobe. The patient was a 53-year- consolidation. The patient was a 55-year-old man with lipoid
old man with primary lymphocytic lymphoma of the lung (maltoma). pneumonia confirmed by fine-needle biopsy and clinical history.
INCIDENCE/PREVALENCE Suggested Readings
AND EPIDEMIOLOGY King LJ, Padley SP, Wotherspoon AC, et al: Pulmonary MALT lympho-
ma: Imaging findings in 24 cases. Eur Radiol 10:1932-1938, 2000.
n S egmental consolidation with or without volume loss Lee KS, Kim Y, Han J, et al: Bronchioloalveolar carcinoma: Clinical,
typically results from endobronchial obstruction or histopathologic, and radiologic findings. RadioGraphics 17:1345-
pulmonary infarction. 1357, 1997.
Lee KS, Müller NL, Hale V, et al: Lipoid pneumonia: CT findings.
n C hronic lobar consolidation and atelectasis are usually
J Comput Assist Tomogr 19:48-51, 1995.
due to an endobronchial tumor. Raz DJ, Kim JY, Jablons DM: Diagnosis and treatment of bronchio-
n L ipoid pneumonia results from aspiration of mineral, loalveolar carcinoma. Curr Opin Pulm Med 13:290-296, 2007.
vegetable, or animal oil. Travis WD, Garg K, Franklin WA, et al: Bronchioloalveolar carcinoma
and lung adenocarcinoma: The clinical importance and research
n I n approximately 80% of patients with lipoid pneumonia,
relevance of the 2004 World Health Organization pathologic crite-
focal areas of fat attenuation can be seen on CT.
ria. J Thorac Oncol 1(9 Suppl):S13-S19, 2006.
Multifocal Consolidation: Acute Causes
DEFINITION: Multifocal consolidation is replacement of gas within airspaces by fluid, protein, cells,
or other material in two or more areas of the lungs.
IMAGING
DIAGNOSTIC PEARLS
Radiography
n B ronchopneumonia is characterized by multifocal
Findings lobular areas of consolidation, centrilobular
n M ultifocal areas of consolidation presenting acutely are nodules, and tree-in-bud pattern.
commonly ill defined but may become rapidly confluent.
n P ulmonary edema and diffuse pulmonary
n A ir bronchogram may be associated. hemorrhage tend to be bilateral and symmetric
n B ronchopneumonia (bacterial, fungal, or viral) typi- and to have a central predominance.
cally results in patchy unilateral or bilateral asymmet-
ric consolidation that may have lobular, subsegmental,
or segmental distribution.
n P oorly defined fluffy 5- to 10-mm nodules (airspace n F ever is usually present in bronchopneumonia.
nodules) may be evident on the radiograph. n H emoptysis occurs in patients with diffuse pulmonary
n D iffuse pulmonary hemorrhage (e.g., Goodpasture hemorrhage.
syndrome, microscopic polyangiitis, Wegener granu-
lomatosis) most commonly results in symmetric, bilat-
eral, poorly defined areas of consolidation.
DIFFERENTIAL DIAGNOSIS
n H ydrostatic pulmonary edema tends to involve mainly
the central lung regions and is commonly associated n A spiration pneumonia
with septal (Kerley B) lines. n B ronchopneumonia
Utility n H emorrhage
n U sually the first imaging modality performed in the
evaluation of patients with suspected acute airspace
disease.
PATHOLOGY
n H elpful in detecting the presence of consolidation and
in monitoring disease progression. n R eplacement of gas within the airspaces by fluid, pro-
tein, cells, or other material.
CT n I nflammatory exudate in bronchopneumonia.
Findings n D iffuse pulmonary hemorrhage in patients with vascu-
n B ronchopneumonia is characterized by multifocal lobular litis (e.g., Goodpasture syndrome, microscopic polyan-
or confluent areas of consolidation, centrilobular nodules, giitis, Wegener granulomatosis).
and branching linear opacities (“tree-in-bud” pattern).
n G round-glass opacities denote incomplete filling of
alveoli adjacent to airspace consolidation. INCIDENCE/PREVALENCE
n D iffuse pulmonary hemorrhage most commonly results AND EPIDEMIOLOGY
in symmetric bilateral ground-glass opacities or poorly
defined areas of consolidation that often have a lobular n C auses of acute multifocal consolidation are broncho-
distribution. pneumonia (bacterial, viral, fungal), hemorrhage, and
Utility pulmonary edema.
n S uperior to chest radiography in demonstrating pres-
ence and extent of disease, presence of underlying Suggested Readings
lung disease, and presence of complications.
Gluecker T, Capasso P, Schnyder P, et al: Clinical and radiologic fea-
tures of pulmonary edema. RadioGraphics 19:1507-1531, 1999.
Herold CJ, Sailer JG: Community-acquired and nosocomial pneumo-
nia. Eur Radiol 14(Suppl 3):E2-20, 2004 Mar.
CLINICAL PRESENTATION
Hiorns MP, Screaton NJ, Muller NL: Acute lung disease in the immu-
nocompromised host. Radiol Clin North Am 39:1137-1151, 2001:vi.
n A cute multifocal consolidation usually results in cough Kjeldsberg KM, Oh K, Murray KA, Cannon G: Radiographic approach to
and shortness of breath. multifocal consolidation. Semin Ultrasound CT MR 23:288-301, 2002.
WHAT THE REFERRING PHYSICIAN NEEDS TO KNOW
n H emorrhage should be considered particularly in patients with hemoptysis and in patients with blunt chest
trauma.
n N odular opacities are more commonly seen on high-resolution CT than on radiography.
6