Thorax vragen april 2009

Thorax vragen VGT april 2009

20 vragen en 6 beeldvragen

Nicky Peters

Vraag 1

Recidiverende infecties zijn een belangrijke complicatie van intralobaire sequestratie.

a. JUIST b. ONJUIST

Bronchopulmonary sequestration (webb 21-27)

• Congenital malformation; area of disorganized lung without normal arterial or bronchial communication: intra- & extralobar

• Intralobair:– More frequent– Mainly adults and older children– Acute or recurrent infections common complaint, sometimes

hemoptoe, systemic-pulmonary shunt mostly insignificant– Sequester within visceral pleura of one of the lobes– 65% at left lung base, sometimes bilateral– 75% arterial supply form desc. thoracic aorta– Venous drainage mainly pulmonary veins (or azygos)

– Homogeneous well defined mass lesion– Cystic air- & fluidfilled lesion– Hyperlucent & hypovascular area– Combination of above


• Congenital malformation; area of disorganized lung without normal arterial or bronchial communication

• Extralobair:– Less common– Mainly infants– Infection is rare, left to right shunt, associated congenital

abnormalities common– Sequester enclosed in pleural envelope– 90% at left lung base– arterial supply mostly from abdominal aorta– Venous drainage mainly systemic veins (azygos/hemiazygos)

– Sharply marginated mass lesion, no air– Homogeneous buy may contain cystic areas


Intralobar sequestration: Yellow arrow in A and B point to a hyperdense region in left lower lobe of the lung with small cystic lesions containing air within it. Red arrows in C and D show a contrast enhanced vessel arising from the aorta and supplying the area of hyperdensity in the lung.

Vraag 2

Bij een pectus excavatum dient men op een X-thorax beducht te zijn op vervaging van de rechter hartcontour.

a. JUIST b. ONJUIST

Pectus excavatum (funnel chest)

• congenital chest wall deformity: concave sternum depression• Compression of the heart causes characteristic findings on frontal

CXR of an indistinct right heart border, decreased heart density and displacement of the heart to the left

• Ribs appear heart-shaped• usually an isolated anomaly but can be associated with Marfan’s

syndrome, Noonan’s syndrome, fetal alcohol syndrome and homocystinuria.

• Reference: Dahnert W. Radiology Review Manual, 5th edition. Lippincott, Williams and Wilkins 2003 (niet in webb)

Vraag 3

Op een HRCT is het typische aspect van de solitaire vorm van het bronchiolo-alveolaircelcarcinoom (BAC) een onscherp begrensde nodus met ground-glass densiteit.

a. JUIST b. ONJUIST

BAC (webb bac: 70-71halo: 275)

• Subtype of adenocarcinoma

• In lung periphery

• Non-invasive growth pattern (lepidic growth = groeit cellaag voor cellaag) yields unsharp margins and groundglass halo

• 60% solitary nodule

• 40% diffuse patchy consolidation and/or nodules

• Halo sign also in: funghi, bacteria, virus, invasive aspergillosis, P. Carnii, Bronchiolitis obliterans with organizing pneumonia, Wegener, Infarct, metastases, kaposi sarcoma, BAC, adenocarcinoma

BAC (webb bac: 70-71; halo: 275)

Vraag 4

Bij een patiënt met een longtoptumor vraagt de longarts u naar het onderzoek van keuze voor het bepalen van de relatie van de tumor met de grote vaten en de plexus brachialis. U adviseert de longarts een MRI aan te vragen.

Deze beslissing is:

a. JUIST b. ONJUIST

Pancoast tumor (webb 76-77)

• Superior sulcus carcinoma, thoracic inlet carcinoma, apical carcinomas, pancoast only used for symptomatic patients

• 5% of lung tumors, can be all cell types

• Often invasion in brachial plexux, cervicothoracic ganglia, a+v subclavia, vertebral column

• Pancoast syndrome (rare):– Shoulder pain, radicluar pain C8,Th1,Th2, hand muscle atrophy,

horner

• Apical mass (60%), pleural thickening (40%), bone destruction (25%)

• 5-year survival after ok+RT 30%

• Contraindications Tx: invasion of a+v subclavia, plexus, vertebrae, n laryn rec, n phrenicus, mediastinum, distant metastases.

• MRI advantageous over CT for imaging lungtop tumors and local invasion

Pancoast tumor (webb 76-77)

Pancoast tumor with involvement of large vessels

Vraag 5

Bij morbus Hodgkin is het merendeel van de lymfomen inhomogeen op een CT-scan met intraveneus contrast.

a. JUIST b. ONJUIST

Ln in Hodgkin

• 3rd and 8th decade, sternberg-reed cells

• 85% thoracic involvement at diagnosis, almost all have also (superior) mediastinal ln involvement

• CT appearance: well defined, discrete, matted (unclear fatplanes between lns), may have diffuse mediatinal infiltration, most often homogeneous (10-20% of cases area of necrosis), sometimes invasion surrounding structures

Vraag 6

Bij een patiënt met primaire hyperparathyroidie wordt resectie van bijschildklierweefsel in de hals verricht, zonder resultaat. De chirurg vraagt een CT-scan aan.

U dient behalve de hals ook het gehele mediastinum mee te scannen.

a. JUIST b. ONJUIST

Parathyroid adenomas (webb 230)

• 4 glands, location may vary, adenomas mostly in lower 2 glands

• 10% ectopic of which 60% lies in anterior mediastinum (30% in thyroid, 10% post-sup mediast)

• Primary hyperparathyryeoidism from a single adenoma (85%)

• Normal glands not seen on CT• Adnomas 0.3 – 3cm, homogeneous masses• Surgical resection of neck region 90-95%

curative,therefore no pre-op imaging• if not cured, ectopic adenomas. 40-50% of these

patients have mediastinal glands / adenomas

Parathyroid adenomas (webb 230)

35-year-old man with hypertension and hypercalcemia. Chest CT without intravenous contrast shows a 7 mm density in the superior mediastinum adjacent to the aortic arch slightly anterior and to the right of the trachea consistent with an ectopic parathyroid adenoma (arrow).

Vraag 7

Bij primaire, nog onbehandelde, sarcoïdose zijn in meer dan 80% van de gevallen de rechts-paratracheale lymfeklieren vergroot.

a. JUIST b. ONJUIST

Sarcoidosis (webb 439-449)

• 60-90% has ln involvement at some time

• <50% visible lung involvement at some time

• 1, 2, 3 pattern: 1 right paratracheal, 2 right hilar, 3 left hilar (4 aortopulmonary window)

• Frequency of ln enlargement on: X-ray CT– Right paratracheal: 75% 100%– Right hilar: 95% 90%– Left hilar: 95% 90%– Aortopulmonary window: 50% 95%– Subcarinal: 20% 65%


• Stage 0: no visible abnormalities (10%)

• Stage 1: hilar/mediastinal ln NO visible lung disease (50%)

• Stage 2: hilar/mediastinal ln AND visible lung disease (30%)

• Stage 3: diffuse lung disease, NO ln (10%)

• Stage 4: end stage fibrosis


Sarcoidosis stage I: left and right hilar and paratracheal adenopathy (1-2-3 sign)

Vraag 8

Op een CT-thorax ziet u een structuur welke u doet denken aan een bronchogene cyste. U meet de densiteit, deze bedraagt 35 HU.

Deze densiteit maakt bovengenoemde diagnose zeer onwaarschijnlijk.

a. JUIST b. ONJUIST

Bronchogenic cyst (webb 288-289)

• Most common in medial lung and lower lobes

• Uninfected cysts: sharply described, round-oval, thin walls

• Fluid-filled cysts: may have low (0-20 HU) or high (40-80 HU) CT numbers

• Rarely, calcified wall or milk of calcium

• Infection in 75% of cases: growth, margin becomes unsharp due to surrounding lung inflammation

• Post-infection: thin, welldefined wall, air-fluid level

Bronchogenic cyst (webb 288-289)

http://radiographics.rsna.org/content/vol27/issue3/images/large/g07ma08g19b.jpeg

Vraag 9

Het karakteristieke aspect van angioinvasieve aspergillose op een CT-thorax is een onscherpe begrensde consolidatie met een omringende ‘halo’ van ground-glass.

a. JUIST b. ONJUIST

Angioinvasive aspergillosis (webb 389 + 275)

• Halo sign: Halo of ground glass around a central nodule

• Halo: hemorrhage, nodule: septic infarction

• 2 weeks after onset: air crescent sign: nodule with crescentic cavitation

• Halo sign also in: funghi, bacteria, virus, P. Carnii, Bronchiolitis obliterans with organizing pneumonia, Wegener, Infarct, metastases, kaposi sarcoma, BAC, adenocarcinoma

Angioinvasive aspergillosis (webb 389 + 275)

Vraag 10

Op een CT-thorax wordt de centrale ‘dot’ in een pulmonale lobulus gevormd door de pulmonale vene.

a. JUIST b. ONJUIST

Anatomy: secondary pulmonary lobule (webb 313) • 1 – 2.5 cm in size

• Marginated by connective tissue interlobular septa which contain veins & lymphatics

• Central portion (centrilobular region, normally invisible) contains pulmonary artery branch and bronchiolar branch

• Lobule contains around 12 acini of 7-8mm which are invisible

Anatomy: secondary pulmonary lobule (webb 313)

http://www.mdconsult.com/das/article/body/0/jorg=journal&source=&sp=16113840&sid=0/N/528164/f080501.jpg

Vraag 11

Op een HRCT ziet u noduli welke contact maken met de pleura.

Noduli van het perilymphatische type zijn waarschijnlijker dan noduli van het centrilobulaire type.

a. JUIST b. ONJUIST

Nodules (webb 317-322)

• Perilymphatic (along lymphatics)• Subpleural interstitium, pleural surface and fissures• Peribronchovascular interstitium & parahilar• Interlobular septa• Peribronchovascular centrilobular

– In: • sarcoidosis (upper lobes) • lymphangitic tumor spread (lungbase)• silicosis & pneumoconiosis (symmetrical posterior

upper lobes)• rarely amyloidosis and lymphoid interstitial

pneumonitis


• Random• Randomly distributed

relative to secondary lobuleappears diffuse and uniform

• Often also subpleural

– In: • Miliary TBC• Fungal infections• Hematogeneous metastases• Diffuse sarcoidosis


• Centrilobular• Bronchiolar or peribronchiolar in centrilobular location or in

relation to small vessels• Most peripheral nodules 5-10mm from pleura; usually not in

contact with pleura• Evenly spaced• Centrilobular nodules, rosettes or tree-in-bud, patchy or

diffuse

– In: • Endobronchial spread of TBC or other bronchopneumonias

or tumor, e.g. bac• Hypersensitivity pneumonitis• Bronchiolitis obliterans organising pneumonia• Silicosis & pneumoconiosis• Histiocytosis• Vasculitis & pulmonary oedema

Nodule algorithm

Subpleural nodules or along fissure?

Yes: perilymphatic / random NO: centrilobular

Peribronchovascular / septal yes no

tree-in-bud or

Diffuse and uniform

Vraag 12

De aanwezigheid van ‘tree-in-bud’ noduli bevestigt de aanwezigheid van ‘small airways disease’/ infectieuze bronchiolitis.

a. JUIST b. ONJUIST


• Centrilobular tree-in-bud• Separates bronchiolar or peribronchiolar disease from

small vessels disease• Indicates dilatation and impaction of bronchioles• Tree-in-bud 5-10mm from pleura • Often also centrilobular nodules or rosettes

– In: • Infection: TBC, mycobacter avium, bacteria, fungus• Infected airway disease: bronchiectasis, CF• Rarely: astma with mucus plugging, allergic

bronchopulmonary aspergillosis, endobronchial tumor spread

Vraag 13

Bij een Pneumocystis carinii pneumonie (nieuwe naam Pneumocystis jiroveci) ziet men op een HRCT-thorax slechts zelden een ground-glass patroon in de longen.

a. JUIST b. ONJUIST

PCP / Pneumocystis jiroveci (webb 391-393)

• Fungus

• Only in patients with underlying disease (e.g.aids, immunosuppresants, chemo)

• First: bilateral perihilar groundglass opacity (in all aids patients with pcp) or interstital thickening or poor definition of pulmonary vessels

• Later: multifocal airspace consolidation, NO pleural effusion• Sometimes pneumatoceles in upper lobes (AIDS) can lead

to pneumothorax

PCP / Pneumocystis jiroveci (webb 391-393)

Vraag 14

Honeycombing komt bij UIP (usual interstitial pneumonia) en NSIP (nonspecific interstitial pneumonia) ongeveer in gelijke mate voor.

a. JUIST b. ONJUIST

Honeycombing• Reflects extensive lungfibrosis with

alveolar destruction

• Thick-walled, air-filled cysts, 3 – 10 mm, cysts shared wall, at pleural surface

• Favors diagnosis UIP or IPF (60-70%). dd: collagen vascular disease, drug reactions, asbestosis, hypersenstivity pneumonitis, rarely sarcoidosis. May be seen in NSIP.

Honeycombing

Honeycombing in UIP

Vraag 15

Vergrote lymfeklieren in het kader van sarcoïdose vertonen zelden necrose.

a. JUIST b. ONJUIST


• Ln in sarcoidosis often quite large

• Ln calcification 25-50% (hazy, dense, stippled, eggshell)

• Ln rarely appear necrotic, low in attenuation or enhance on CT

Vraag 16

Een van de kenmerken van diffuse pulmonale haemorrhagie (bijvoorbeeld op grond van een vasculitis) is bilateraal pleuravocht.

a. JUIST b. ONJUIST

Diffuse pulmonary hemorrhage (webb 488-490)

• X-ray and CT nonspecific

• In: goodpasture (anti-glomerular basement membrane disease), ideopatic pulmonary hemosiderosis, small vessel vasculitis in e.g. wegener, SLE, drug reactions, anticoagulation, thrombocytopenia

• Patchy or diffuse consolidations or groundglass or centrilobular nodules, abnormalities mostly perihilar, no pleural effusion only in combination with coincident renal failure

Diffuse pulmonary hemorrhage (webb 488-490)

78-year-old woman with Goodpasture syndrome and severe acute pulmonary hemorrhage shows diffuse bilateral ground-glass opacities.

Vraag 17

In tegenstelling tot centrilobulair emfyseem tast panlobulair emfyseem vaak de basale longvelden aan.

a. JUIST b. ONJUIST

Emphysema (webb 553-564) • Centrilobular

– Respiratory bronchioles in central portion lobule. Usually from smoking.

– multiple small (<1cm), round areas of low HU distributed throughout lung but Mainly upper lobes, no visible walls, bullae with visible walls, often paraseptal emphysema and subpleural bullae. If extensive may mamic panlobular EM

• Panlobular– Involves entire lobule. Associated with alfa-1-AT deficiency,

sometimes in smokers, elderly, distal to bronchial obliteration, drug use

– Widespread areas of low HU, generalized and more severe in lower lobes, bullae uncommon, vascular paucity

• Paraseptal– Alveolar ducts and sacs in periphery, areas of destruction

marginated by interlobular septa, young adults, smoking or ideopathic or in elderly with CL emphysema

– Distal part of lobule, subpleural, visible walls, areas >1cm = bulla, can lead to pneumothorax, most severe in apices

Emphysema

Centrilobular: The periphery of the lung is spared (blue arrows). Centrilobular artery (yellow arrows) is seen in the center of the hypodense area.

Panlobular:uniform destruction of lung parenchyma

Paraseptal:localized near fissures and pleura, associated with bullae

http://www.radiologyassistant.nl/images/45b72b08bf82f_emf-centri.jpg

Vraag 18

Bij Langerhanscel histiocytose (histiocytosis X) zijn vooral de basale longvelden aangedaan.

a. JUIST b. ONJUIST

Langerhans cell histiocytosis (webb 565-569)• Unknown etiology, Aka hisitiocytosis X or eosinophilic granulomas

• Recognized in childhood, multiple body systems, 40% lung involvement

• Early stage: peribronchiolar granulomas

• Later stage: fibrosis and lung cysts

• 90% of adults with disease are smokers

• symptoms: cough, dyspnoe, pneumothorax

• X-ray: reticulonodular pattern + cysts, bilateral, mainly middle & upper lung zones, increased lungvolume

• HRCT: cystic airspaces <1cm, various shapes and wall thickness, mainly upper lobes, >50% bullae, often also peribronchial nodules, sometimes mediastinal ln & lytic bone lesions

Langerhans cell histiocytosis (webb 565-569)

(LCH): early stage: granulomatous nodules containing Langerhans histiocytes and eosinophils; later stages, the granulomas are replaced by fibrosis and the formation of cysts.Up to 20% of patients present with pneumothorax and over 90% of patients are smokers. Most cysts appear round, but can also have bizarre shapes (bilobed or clover-leaf shaped). An upper lobe predominance in the size and number of cysts is common.

Vraag 19

Eén van de kenmerken van lymphangioleiomyomatosis (LAM) op een HRCT-thorax is de aanwezigheid van grillig begrensde cysten in de longen.

a. JUIST b. ONJUIST

Lymphangioleiomyomatosis (LAM) webb 569-571

• Rare, proliferation of immature smooth muscle cells in relation to bronchioles and small vessels with peribronchiolar infiltration and destruction and formation of round cysts with diffuse distribution

• Can involve ln, may cause pleural effusion (chylus), may involve veins which van lead to obstruction and hemoptysis (30-40%)

• Women 17-50 years: associated with TSC, dyspnoe, pneumothorax (80%), cough, die within 5-10 years after onset, indication for Ltx

• X-ray: reticulonodular pattern (80%), advanced disease: cystic lesions may mimic honeycombing, lungs diffusely affected, pneumothorax, pleural effusion, 10-25% normal X-ray

• HRCT: numerous, thin-walled rounded cysts 2-5mm, irregular shaped lung cysts are uncommon, parenchyma between cysts normal or thickened septa or groundglass

Lymphangioleiomyomatosis (LAM) webb 569-571

Lam: small cystic lesions surrounded by normal parenchyma. Possible complication: pneumothorax

Vraag 20

Er wordt een CT-thorax verricht bij een patiënt met een pneumonie. Naast een consolidatie in de long ziet u een geloketteerde vochtcollectie in de pleuraholte.

Het ontbreken van luchtbellen in de vochtcollectie pleit tegen een empyeem.

a. JUIST b. ONJUIST

Empyema (webb 595)

• Pus in pleural space

• Mostly in pneumonia, 10% without lung diseasse. Tx: AB + drain, abcess: AB only

• X-ray: lenticular shape, appears larger/better defined in 1 direction, can contain air, dd: peripheral lung abcess

• CT: lenticular shape, non-dependent, sharply demarcated from adjacent lung, split pleura sign, thickened pleura, compression & displacement lungs and vessels

• Lung abcess: round, ill defined, shaggy walls of irregular thickness, destroy lung without displacement of vessels

• Air: thoracosynthesis, bronchopleural fistulas, gasforming organisms less common.

Empyema (webb 595)

Beeldvraag 1

De longarts vraagt een HRCT-thorax aan bij een patiënt met dyspnoe en droge hoest. Bijgevoegd twee coupes van het betreffende onderzoek.

Een extrinsieke allergische alveolitis (EAA, hypersensitivity pneumonitis) staat hoog in de differentiaal diagnose.

a. JUIST b. ONJUIST

Hypersensitivity pneumonitis (webb 450-455)

• Aka allergic intrinsic alvaolitis

• Acute stage: diffuse alvaolar damage, edema, hemorrhage. X-ray/CT: consolidation

• Subacute stage: patchy groundglass, centrilobular nodules, mosaic pattern, airtrapping, lung cysts, may progress to fibrosis

• Chronic stage: fibrosis, irregular reticular opacities, traction bronchiectasis, honeycombing

Beeldvraag 2

X- thorax bij een patiënt met een pneumonie.Het infiltraat bevindt zich in het apicale segment

van de rechteronderkwab.

a. JUIST b. ONJUIST

Lobar anatomy

Beeldvraag 3

X- thorax bij een patiënt met sarcoïdose.Er is sprake van sarcoïdose stadium 3.

a. JUIST b. ONJUIST


• Stage 0: no visible abnormalities (10%)

• Stage 1: hilar/mediastinal ln NO visible lung disease (50%)

• Stage 2: hilar/mediastinal ln AND visible lung disease (30%)

• Stage 3: diffuse lung disease, NO ln (10%)

• Stage 4: end stage fibrosis

Beeldvraag 4

HRCT-coupes van een 50-jarige man. Het beeld is typisch voor een panlobulair emfyseem

in de linkeronderkwab.

a. JUIST b. ONJUIST

Emphysema (webb 553-564) • Centrilobular

– Respiratory bronchioles in central portion lobule. Usually from smoking.

– multiple small (<1cm), round areas of low HU distributed throughout lung but Mainly upper lobes, no visible walls, bullae with visible walls, often paraseptal emphysema and subpleural bullae. If extensive may mamic panlobular EM

• Panlobular– Involves entire lobule. Associated with alfa-1-AT deficiency,

sometimes in smokers, elderly, distal to bronchial obliteration, drug use

– Widespread areas of low HU, generalized and more severe in lower lobes, bullae uncommon, vascular paucity

• Paraseptal– Alveolar ducts and sacs in periphery, areas of destruction

marginated by interlobular septa, young adults, smoking or ideopathic or in elderly with CL emphysema

– Distal part of lobule, subpleural, visible walls, areas >1cm = bulla, can lead to pneumothorax, most severe in apices

Emphysema

Centrilobular: The periphery of the lung is spared (blue arrows). Centrilobular artery (yellow arrows) is seen in the center of the hypodense area.

Panlobular:uniform destruction of lung parenchyma

Paraseptal:localized near fissures and pleura, associated with bullae

http://www.radiologyassistant.nl/images/45b72b08bf82f_emf-centri.jpg

Beeldvraag 5

X-thorax van een kind van 10 dagen oud met dyspnoeklachten.

Bovenaan in de differentiaaldiagnose staat congenitaal lobair emfyseem.

a. JUIST b. ONJUIST

Congenital lobar emphysema (webb 5)

• Overinflation of a lobe

• Most cases present in first month

• Partial or complete bronchial obstruction

• Most common LUL, RML, RUL

• Overinflation and airtrapping, mediastinal shift away from affected lobe (affected lobe can contain fetal fluid)

Beeldvraag 6

CT-thorax van een 60-jarige vrouw. Het beeld is typisch voor een longinfarct.

a. JUIST b. ONJUIST

Rounded atelectasis (can be wedge-shaped), typical comet tail sign, broad area of pleural contact and pleural thickening. Homogeneous contrast-enhancement. Mostly in lower lobes. (prokop 321)

Beeldvraag 6

CT-thorax van een 60-jarige vrouw. Het beeld is typisch voor een longinfarct.

a. JUIST b. ONJUIST

Pulmonary infarction (prokop 328 & 857)

• 10-15% of LE cases

• First groundglass lesion, after that pleural based opacification wedge-shaped sometimes rounded

• May contain air

• Pneumothorax can happen

• Hypopdense centre with rimenhancement

• Accompanying pleural effeusion

• Prone to infection / abcess formation

• Lower lobes commonly affected

Pulmonary infact

http://radiology.rsna.org/content/244/3/875/F3.expansion.html

http://radiology.rsna.org/content/244/3/875/F4.expansion.html

Thorax vragen april 2009

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