1
Q
When is pancoast’s tumour unresectable? (4)
What type of lung cancer?
A
- Brachial plexus involvement above T1 (C8 or higher).
- Diaphragm paralysis (C3,4 and 5): phrenic nerve compression from lung cancer. Test: sniff test.
- > 50% vertebral body involvement.
- Distal nodes/mets
Non small cell lung cancer (Squamous cell)
2
Q
Name the different types of pathology with thymus (4)
A
- Rebound thymus secondary to stress/chemo
- Cysts
- Thymoma (non invasive –> invasive (+/- calcification)
- Thymolipoma- fat and soft tissue
3
Q
What are the associations with thymoma? (3)
A
- Myasthenia Gravis
- Pure red cell aplasia
- Hypogammaglubinaemia
4
Q
Name the anterior mediastinal masses: (4)
A
- Thymoma
- Teratoma
- Thyroid
- Terrible lymphoma
5
Q
Most common teratoma in anterior mediastinum:
A
Germ cell tumour
6
Q
What is the appearance of teratoma?
A
Cystic mass + fat +/- calcification ?teeth
7
Q
What is the most common location for pericardial cyst?
A
Right anterior cardiophrenic angle.
8
Q
Name the posterior mediastinal masses: (2 and then 7)
A
a) Neurogenic: -
- Schwannoma -
- Neurofibroma -
- Peripheral nerve sheath tumour
b) BM -
- Extra medullary haematopoiesis -
- CML -
- Myelofibrosis -
- Thalasaemia
9
Q
Name the middle mediastinal masses: (4)
A
- Lymphadenopathy
- Bronchogenic cyst
- Fibrosing mediastinitis
- Mediastinal lipomatosis- Obesity/cushing/ streroid
10
Q
What are the causes of lipoid pneumonia?
A
a) Exogenous- aspiration of oil
b) Endogenous- more common- secondary to post obstructive processes ie Fat density in consolidation
11
Q
Re Pulmonary alveolar proteinosis-PAP
a) What are they at increased risk?
b) Appearances?
c) Treatment?
A
a) increased risk of Nocardia infection- brain abscess
b) Crazy paving with septal thickening and GGO
c) Bronchoalveolar lavage
12
Q
What are the three stages of congestive cardiac failure?
A
- Redistribution: cardiomegaly, UL vessel diversion
- Interstitial oedema: Kerley lines, peribronchial cuffing
- Alveolar oedema: airspace fluffy opacity
13
Q
What are the DDx for crazy paving? (5) ie septal thickening and GG
A
- PAP
- Oedema
- Haemorrhage
- BAC
- Acute interstitial pneumonia
14
Q
What differentiates a benign from malignant nodule? (3)
A
Malignant:
- Spiculated margin
- Air bronchogram through nodule- usu adenocarcinoma in situ
- Partially solid lesion with GG component
Benign:
- Fat
- Rapid doubling time
- Slow doubling time
15
Q
Re Squamous cell lung cancer:
- where is it located?
- Ectopic ?
- Example
A
- It is centrally located +/- cavitation
- Ectopic PTH
- Pancoast tumour (NSCLC)
16
Q
What type is a pancoast tumour?
A
Squamous cell
17
Q
Re Small cell lung cancer:
- Location
- Paraneoplastic
A
- Central, near main lobarbronchi
- Paraneoplastic ACTH/SIADH
18
Q
Where is large cell lung cancer usually located?
A
It is usually peripheral.
19
Q
What is a Lambert Eaton syndrome?
A
Proximal muscle weakness secondary to ACh near NMJ.
20
Q
Where is the predominance of NSIP?
A
Lower lobes, posterior and peripheral predominance with sparring of the immediate subpleural spaces.
immediate subpleural sparing - a relatively specific sign
21
Q
What causes NSIP? (3)
it is important to carefully scrutinise the images, looking for findings such as joint or bony changes, oesophageal dilatation, pleural and pericardial effusion, etc. as it has been mentioned earlier NSIP pattern is also associated with many other conditions.
A
- Collagen vascular disease
- Drug reaction
- Hypersensitivity pneumonitis
22
Q
What is the histology in UIP?
A
Heterogenous
23
Q
List the differences between NSIP and UIP:
A
NSIP:
- Homogenous histology.
- GG and micronodules.
- Most common in scleroderma.
UIP:
- Heterogenous histology
- Honeycombing and traction bronchiectasis
24
Q
RB-ILD- Smoking related
- Predominance?
- When to call it?
A
- UL- apical centrilobular GG nodules
- Resp bronchiolitis and symptoms.
25
DIP- smoking related- end spectrum of RB-ILD Appearances?
More diffuse GGO with patchy/subpleural distribution mainly in the lower lobes with some small cystic spaces.
26
What is Hughes Stovin syndrome?
This is a PA aneurysm similar or is Behcet. They get recurrent thrombophlebitis and PAA and rupture.
27
What is a Behcet?
Genital and mouth ulcers. Turkish descent Aorta thickening PAA
28
What is sarcoid staging?
0- Normal
1- Hilar/mediastinal nodes only
2. Nodes + parenchymal disease
3. Parenchymal disease
4. END STAGE- FIBROSIS
29
Name the signs associated with sarcoid: (3)
a) 1,2,3 : biliateral hilar and right paratracheal nodes
b) Lambda sign: Same as 123 but in Gallium scan
c) CT Galaxy sign- UL masses with satellite nodules.
30
What is sarcoid?
Define Location?
Biochemical?
It is a non caseating granulomas.
Perilymphatic nodules with UL predominance.
Raised ACE and Ca
31
List DDx for reverse halo (ATOL) sign: (5)
1. COP- CLASSIC
2. Fungal pneumonia
3. TB
4. Wegeners
5. Pulmonary infarct
32
List DDx for halo sign (5)
1. Invasive aspergillosis- CLASSIC
2. Other Fungus
3. Haemorrhagic mets including melanoma
4. Wegeners
5. BAC
33
Re hypersensitivity pneumonitis
What is it caused by? BUZZWORD?
This is caused by inhaled organic antigen. (farmers lung, bird, mushroom, paint and etc)
BUZZWORD: _HEAD CHEESE_- mix of everything:
GG/consolidation/ air trapping
34
Re organising pneumonia
What is a COP?
What are the causes? (4)
Treatment?
What is the main DDx?
When cause is not known: COP: Reverse halo sign
Causes of organising pneumonia:
1. Idiopathic,
2. Collagen vascular disease
3. Drugs (amiodarone)
4. Infection
Treatment: steroid with good prognosis.- No fibrosis.
DDx: Chronic eosinophilic pneumonia
35
Re Chronic eosinophilic pneumonia
What is it?
DDx?
CT?
Peripheral eosinophilia +/- asthma Looks similar to COP
CT: peripheral GGO/consolidation UL
36
What is a Caplan syndrome?
RA with UL lung nodules which can cavitate +/- pleural effusion.
37
Re Ankylosing spondylosis: - Which lobes?
- UL fibrobullous disease Usually unilateral first --\> Bilateral
38
1) What is a shrinking lung syndrome?
2) What condition is associated with shrinking lung?
3) Causes?
1) Loss of volume in both lungs with lupus.
2) Shrinking lung for SLE
3) Diaphragm dysfunction/ pleuritic chest pain- present with pleuritis +/- pleural effusion.
39
**Re Granulomatous Wegeners:(AKA Granulomatosis with polyangitis)**
## Footnote
a) Which organs are affected?
b) Appearance?
c) Markers?
a)
1. Upper tract/ sinuses
2. Lungs
3. Kidneys
b) Nodules with cavitation +/- GG secondary to haemorrhage.
c) cANCA +ve in 90 %
40
Causes of pulmonary hypertension:
## Footnote
**ie; PA pressure \> 25 mmHg**
1. Primary- idiopathic, uncommon
2. Secondary: -
* Chronic PE -
* Right sided heart strain -
* Lung parenchymal disease-
* Fibrosis and emphysema
41
Define pulmonary veno-occlusive disease
PA HTN with normal wedge pressure.
The normal wedge pressure differentiates it from post cap causes such as: - LA myxoma - MS- mitral stenosis - PV stenosis.
42
What is an extra pleural haematoma?
If there is damage to the parietal pleural: Haemothorax If parietal pleura is intact : Extrapleural haematoma Persistent fluid collection after drain. There could be displacement of the extrapleural fat.
43
Re Fat embolism: - RF - Triad/ organs affected - Timing?
- After long bone fracture or IM rod placement. -
1. Affects brain (changed mental state),
2. skin (rash) and
3. lung (SOB). -
Timing 1-2 days after #
44
Re Pseudomonas:
Appearance:
Typical patient group:
Patchy opacification with abscess formation
ICU patients on ventilators/ CF and PCD
45
Re Legionella Appearance:
Typical patient group:
Peripheral and subpleural airspace opacity.
Cavities in immunocompromised patients.
COPD and crappy air conditions X rays tend to lag behind resolution of symptoms.
46
Re Anthrax: Appearance
Haemorrhagic lymphadenitis, mediastinitis and haemothorax. Mediastinal widening with pleural effusionin setting of bioterrorism.
47
Re Klebsiella:
Appearance
Typical patient group:
What colour sputum?
BULGING fissure Pleural effusion with empyema and cavity
Alcoholic and NH resident
Current jelly sputum.
48
What are the 3 main differences between empyema and abscess?
Empyema: Abscess: -
Lentiform - Round -
Split pleural sign - Claw sign-acute angle w pleura -
Treated with chest drain -Not tx with drain risk of fistula
49
Define empyema necessitans:
Extension of empyema into chest wall and soft tissue. It is classically seen with TB or Actinomyces.
50
Types of diaphragmatic hernia: (2)
Back and Left: Bochdalek
Anterior and Right: Morgagni
51
DDx for pleural calcification: (5)
1. Asbestos
2. Old haemothorax
3. Old infection
4. TB
5. Extraskeletal osteosarcoma.
52
Re Mesothelioma: -
What is it associated with? - Buzzword
Associated with asbestos exposure
\*\*\* Pleural Rind\*\*\*
If direct invasion and extension into fissure, then highly suggestive.
53
Re Fibrous tumour of pleura
What is it?
What is it associated with?
This is a solitary tumour arising from visceral pleura
It is not associated with smoking/asbestos
It is associated with
1. hypoglycaemia,
2. hypertrophic osteoarthropathy
54
Pleural mets:
1. Adenocarcinoma- most likely: - Lung - Breast -
2. Lymphoma
3. Pleural effusion
55
Lupus
Pleural and pericardial effusion
Fibrosis is uncommon but instead they will get shrinking lung.
56
Scleroderma
Location
GI symtoms
NSIP \> UIP
LL
Patulous fluid filled oesophagus
57
Rheumatoid arthritis
Location and appearance
LL
Similar to UIP/COP
Reticulation and honey combing with consolidative opacities: organising pneumonia. Pleural effusion.
CAPLAN SYNDROME (RA + Nodules)
58
Sjogren What type of cystic lung disease?
LIP cystic lung disease
Extensive GGO and scattered thin walled cysts.
59
DDx for lung cavity: 6
1. Cancer- usu squamous cell
2. Autoimmune- Wegener's/RA
3. Vascular- septic emboli
4. Infection-TB
5. Trauma- Pneumatocele
6. Young- congenital- CCAMS. sequestration
60
Re Lemierre syndrome -
Define -
Bacterial agent
Jugular vein thrombosis with septic emboli classically after oropharyngeal infection or recent ENT surgery
Caused by Fusobacterium Necrophorum.
61
Non TB mycobacteria
1. Cavitary: old white male smoker-
2. Bronchiectatic - lady windermere: RML and lingula bronchiectasis
3. HIV, CD4 \<100,
4. Hypersensitivity pneumonitis- hot tub lung
62
Aspergillus types:
1. Fungal ball: aspergilloma in existing cavity-NOT invasive
2. Immunocompromised- Invasive asp. - Halo sign- INVASIVE - Air crescent- healing
3. Hyperimmune- asthma/ ABPA/CF UL central saccular bronchiectasis with mucoid impaction-finger in glove.
63
What would count as stage 3B cancer? (3)
3B is non resectable.
3B = T4 or N3 : NOT RESECTABLE
1. Supraclavicular, scalene or contralateral med/hilar adenopathy
2. Same lung but different lobes.
3. Malignant pleural effusion.
64
Bronchopleural fistula went wrong...
In fistula the space is filled with air as opposed to fluid.
Diagnosis by Xe NM scan: Xe detected in pneumonectomy space.
65
Subtypes of adenocarcinoma:
1. Atypical adenocarcinoma Hyperplasia- AAH
2. Adenocarcinoma in situ- ACIS
3. Minimally invasive adenocarcinoma-MIA
66
T3 vs T4 vs M1
T3: Two in the same lobe
T4: two in different lobes but same lung
M1: two in different lungs
67
Wagerers or granulomatosis polyangitis
Circumferential thickening- focal or long segment -
No calcification -
Subglottic involvement - Sinuses and lungs - nasal perforation and cavity -
cANCA positive 90%
68
TBO TracheoBronchopathia Osteochondroplasia
- **_Spares the posterior membrane._** - Cartillaginous and osseous nodules within submucosa of trachea and bronchial wall.
Classically affects the lower 2/3 of trachea.
69
Relapsing polychondritis
- Spares the posterior membrane.
- Diffuse thickening of the trachea -
No calcification -
Characterised by recurrent cartilage inflammation and recurrent pneumonia.
70
Post intubation stenosis
Focal subglottic circumferential stenosis with hour glass configuration
71
HSP - Age group - Symptoms
Most common in children (4-11yrs)
Systemic disease affecting GI: -
* Intussuception: Doughnut sign -
* Pain - Blood - Diarrhoea Thumbprinting and
* Massive skin oedema
72
Churg Strauss -
Define -
Appearances -
Marker
D: Necrotising pulmonary vasculitis (part of eosinophilic lung consolidation spectrum). Eosinophilia and asthma
Peripheral lung consolidation and GGO- transient
Cavitation is rare-
Ddx: Wagerers
pANCA +ve 75%
73
Microscopic polyangitis -
Which organs are affected -
Marker
Affects kidneys and lungs
Diffuse pulmonary haemorrhage in 1/3 of cases
pANCA positive 80%
74
Behcet
Mouth and genital ulcers in turkish descent
Thickening of aorta and PAA
75
Buergers
Strongly associated with...
What size vessels are affected?
BUZZWORD
- Strong association with **smoking** -
Small and medium vessels in arms \< legs -
Extensive arterial occlusive disease and development of **_corkscrew collateral vessels._**
BUZZWORD: AUTO AMPUTATION
76
Name large and medium vessel vasculitis
* Large: -
* Takayasu- young asian girl -
* Giant cell- crutches- SCA, Ax and brachial -
* Cogans syndrome: Paeds with ear and eye symphonies and aortitis
* Medium: -
* PAN- renal micro aneurysm-
* HepB -
* Kawasaki- coronary artery aneurysm
77
Name small vessel vasculitis
* ANCA +ve: -
* Wegeners- nasal septum erosion and cavity -
* Churg Strauss- Transient peripheral lung consolidation -Micro polyangitis- Diffuse pull haemorrhage
* ANCA -ve: -
* HSP:Intussception and scrotal oedema -
* Behcet: PAA -
* Buergers- male smoker
78
Hand angio in exam...
* Ulnar artery involved? -
* YES: HHS -
* NO: Fingers out: Buergers- corkscrew collateral
79
Kaposi in lung vs lymphoma -NM
* Thallium: - Kaposi and lymphoma: Positive
* Gallium: -
* Kaposi Negative -
* Lymphoma: Positive
80
Lymphoma in lung (4)
1. Primary : NHL and maltoma No extra thoracic disease for 3/12
2. Secondary: NHL and HL
3. PTLD- BMT or organ Tx, B cell lymphoma, associated with EBV
4. AIDS related lymphoma, secondary most common cancer in AIDS - NHL associated with EBV- CD4\< 100 - Affecting: CNS/ Lung/ Bone/ Liver/ Bowel
81
Kaposi sarcoma
CD4?
BUZZWORD
NM
* Most common lung tumour in AIDS.
* CD4 \< 200 -
* Tracheobronchial and peripheral lung affected -
* Bloody effusion.
* BUZZWORD: Flame shaped
* **Thallium +ve and Gallium -ve**
82
Bronchial atresia
Which segment is most likely affected?
Buzzword appearance?
* Most likely involves apical posterior segment of LUL.
* Blind ending bronchus filled with mucus: finger in glove.
* Distal lung hyper inflated from collateral drift and air trapping.
83
AVM
Name 2 conditions
location? What type of shunt?
when treated?
* Think of HHT/ Osler weber Rendu
* Usually in lower lobes- more blood flow: R-L shunt : stroke and brain abscess
* Treated when \> 3mm
84
Swyer James
* Unilateral lucent lung post viral infections in childhood- post infectious - Obliterative bronchiolitis
* Size of affected lobe is smaller
* Not hyper expanded.
85
Poland
Unilateral absence of **pectoral muscles-** Unilateral hyper lucent chest
Can have limb issues
86
Vanishing lung syndrome/ Giant bollous emphysema
* Location?
* 20% have ..........
* Resulting from avascular necrosis of lung parenchyma and hyperinflation UL,
* young male
* Bollous disease occupying 1/3 of hemithorax
* 20% have alpha 1 antitrypsin deficiency
87
Saber sheath trachea
Side-to-side narrowing of the intrathoracic trachea. It is longer (anterior-posterior) than it is wide (side-to-side).
Diffuse coronal narrowing of trachea sparring the extra thoracic portion
- pathognomonic for COPD.
The sagittal:coronal diameter is over 2:1 and the extra-thoracic portion of the trachea is not narrowed. The supporting tracheal cartilage is usually thickened and densely calcified
88
Extra lobar sequestration
* 25% -
* Has its own pleural cover -
* Systemic venous drainage -
* Infancy with resp compromise, associated with: -
* CCAM -
* Diaph hernia -
* Pulmonary hypoplasia -
* Heart disease -
* Vertebral anomaly
89
Sequestration types:
1. Intralobar- adolscence and adulthood with recurrent pneumonia
2. Exralobar: Infancy with resp compromise
90
Intralobar sequestration
* 75% -
* Most common in LLL post segment-
* uncommon in UL. -
* Recurrent infection -
* No pleural cover -
* Pulmonary venous drainage.
91
Signs of PE on CXR (4)
1. Westermak sign- regional oligaemia
2. Fleishner sign: enlarged pulm artery
3. Hamptons hump: peripheral wedge shaped opacity
4. Pleural effusion
92
Acute vs chronic PE (3)
Acute vs chronic:
1. Central vs peripheral
2. Venous dilatation vs shrunken vein collateral
3. Perivenous soft tissue oedema vs calc within thrombi and venous wall.
93
What is considered as low probability for PE on VQ scan? (2)
1. Triple matched defect in MIDDLE and UPPER lung.
2. Stripe sign: Perfusion defect with rim of surrounding normal perfused lung.
94
What is considered as INTERMEDIATE probability for PE on VQ scan?
1. Triple matched defect in the LOWER zones
2. Single moderate matched VQ with normal CXR
95
What is considered as HIGH probability for PE on VQ scan?
Four moderate segmental defects
96
Bronchial tree blood supply:
Bronchial arteries:
* 2 left sided from the aorta and
* the single right side from the right 3rd posterior intercostal artery.
97
Opacity in the Raider triangle is......
aberrant RSCA
98
Pacemaker wire goes through this valve, terminating in .....ventricle
TV and right ventricle
A biventricular pacemaker with its three wires in appropriate positions:
1. right ventricle
2. right atrium
3. coronary sinus pacing the left ventricle
99
Most superior valve is
PV
100
Obtuse margin with the lung, the lesion is in the
mediastinum
101
The differential diagnosis for ground glass in a central distribution (4)
1. Pulmonary edema.
2. Alveolar hemorrhage.
3. Pneumocys s jiroveci pneumonia- PCP
4. Alveolar proteinosis.
102
The differential diagnosis for peripheral consolidation or ground glass (4)
1. Organizing pneumonia.
2. Chronic eosinophilic pneumonia, typically with an UL predominance.
3. Atypical or viral pneumonia.
4. Pulmonary edema.
103
the differential diagnosis for smooth interlobular septal thickening is identical to the differential for central ground glass: (4)
1. Pulmonary oedema - by far the most common cause of smooth interlobular septal thickening .
2. Pulmonary alveolar proteinosis- PAP
3. Pulmonary hemorrhage.
4. Atypical pneumonia, especially PCP
104
Nodular, irregular, or asymmetric septal thickening DDx (2)
1. Lymphangitis carcinomatosis
2. Sarcoid
105
What is crazy paving?
Septal thickening and GGO
106
Ddx for crazy paving: (7)
1. Alveolar proteinosis.
2. Pneumocys s jiroveci pneumonia.
3. Organizing pneumonia.
4. bronchioloalveolar carcinoma, mucinous subtype.
5. Lipoid pneumonia,
6. Acute respiratory distress syndrome.
7. Pulmonary hemorrhage.
107
Lung cysts and AIDS
LIP
108
Lung cysts and GGO and Pneumothorax
PCP
109
Hyper vascular LN
Castlemans Kaposi
110
Flame shaped perihilar opacity
Kaposi sarcoma
Th201: usually positive in both lymphoma and Kaposi sarcoma
Ga67: usually negative in Kaposi sarcoma but positive in lymphoma and infection
111
Patient with TB and AIDS started on HAART therapy, now doing worse
Immune reconstitution inflammatory syndrome
112
Ghon lesion
calcified TB granuloma
113
Ranke complex
Calcified TB granuloma AND calcified hilar node. Healed primary TB
114
Fungal infection in impaired patient. Invading the mediastinum, pleura and chest wall. Reversed halo sign
Mucormycosis
115
Feeding vessel sign ddx
1. Septic emboli
2. Haematogenous mets
116
Pseudocavitation/bubble like licences and fried egg appearances and it is usually **_cold_** on PET
MIA- Minimally invasive adenocarcinoma
117
Cannonball metastases (2)
1. RCC
2. Choriocarcinoma
118
Causes of Lymphangitis carcinomatosis (4)
1. Breast
2. Stomach
3. Pancreas
4. Prostate
119
Which side of the heart is affected by chest and GI carcinoid tumours?
* Chest : Left sided
* GI: Right sided
120
Test to diagnose chest carcinoid
Octreotide
121
AIDS patient with lung nodules, pleural effusion and lymphadenopathy
AIDS-related pulmonary lymphoma (NHL) CD4 \< 100
122
CD4 count in kaposi sarcoma
\< 200
123
Most common hepatic neoplasm in AIDS
Kaposi Sarcoma
124
KS vs Lymphoma
KS: Thallium positive, Gallium negative
Lymphoma: Thallium positive, Galium positive
125
Diagnosis? Macroscopic fat and popcorn calcification
Hamartoma
They can be hot on PET, they are still benign
126
Buzzword: Central dot sign
Centrilobular emphysema , UL
127
This type of emphysema is associated with alpha 1 antitrypsin and ritalin lung
pan lobular LL - ie The entire lung appears darker with attenuation of bronchovascular markings. The lung volumes are increased and distinct spaces of low attenuation may not be seen.
128
Ddx egg shell Ca (4)
1. Sarcoid
2. Silicosis
3. Coal worker
4. Histoplasmosis
129
Perilymphatic nodular pattern ddx
1. 1. Sarcoid
2. . Silicosis
3. LC
130
Random nodular pattern ddx
1. Miliary TB
2. Mets
3. Fungal
131
Centrilobular nodular pattern ddx
1. Infection
2. Rb-ILD
3. Hypersensitivity pneumonitis
132
CF vs PCD
CF:
1. Abnormal mucus, cilia cannot move
2. Normal sperm, absent vas deferens
3. UL bronchiectasis
PCD:
1. Normal mucus. cilia don't move
2. abnormal sperm , normal vas deferens
3. LL Bronchiectasis
133
William Campbell Syndrome
congenital cystic bronchiectasis from deficiency of cartilage in 4-6th order bronchi
134
massive dilation of trachea \> 3cm
Mounter Kuhn or tracheobronchomegaly
135
PLEURAL CA++ DDX
1. old haemothorax
2. old infection
3. TB
4. Extra-skeletal osteosarcoma
136
Function of Intra-aortic balloon pump
1. decreases LV afterload through a vacuum effect, decreasing myocardial oxygen requirements, and
2. increases myocardial perfusion (during diastole)
137
Location of IABP
* in the proximal descending aorta, just below the origin of the left subclavian artery/ LSCA
* This ideally results in the balloon terminating just above the splanchnic vessels
138
Tracheobronchial injury is most common at what location and what does it cause?
* usu within 2cm of carina.
* It causes pneumomediastinum rather than pneumothorax.
chest FRCR
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