3. POSITION
PA AP
QUALITY
ROTATION PENETRATION INSPIRATION
LESION
OPACI
OPACITY
Homo
Heterogenous Wellill defined Zone
Centralperiph Silhouet
eral sign
TY Necrotic
PATCHY
MEDIASTINAL
NODULE Central deviasionwided
MASS COSTO-PHRENIC ANGEL
Freeoblitern
CAVITARY
OTHER
INFILTIRATION Bone soft tissuediaphragm
6. Solitary Pulmonary Nodule(SPN)
Appearance
Margin Calcification cavitation
Comparison with a
Size
previous x-ray to >8mm
<8mm
Assess growth over
time. Location
Upperhillar zone Lowerbasesup-pleural
Associated abnormalities
Lymph node enlargement Rib destruction/erosion
7. Solitary pulmonary nodule on(CXR or CT)
Chest ct
Benign
calcification indeterminate
or fat
No follow up Risk
Risk stratification
stratification
Age
≤4mmLow
8mm ≥ 4-8 mm ≥4mmHigh risk
somking risk
History of
cancer
FDG,PETCT or Biopsy Follow up at 12 mon No follow up
Nodule
diameter
SUV>2,5 or SUV<2,5 or
No change in
Positive Negative Change
Spiculation in size
size
biopsy biopsy
Upper lobe
Follow up at
Surgery surgery No follow up
12 mon
8. Fleischner Society pulmonary nodules
recommendations.
Nodule Low-risk patients High-risk patients
size (mm)
≤ No follow-up needed Follow-up at 12months.
If no change, no further imaging
needed
– > Follow-up at 12 months. Initial follow-up CT at 6–12 months
If no change, no further imaging and
needed then at 18–24months
if no change
Low-risk patients: Minimal or absent history of smoking and other known risk factors as
asbestos exposure.
High-risk patients: History of smoking or other known risk factors.
Adapted from Heber MacMahon et al., Radiology 2005 237:395–400
9. Fleischner Society pulmonary nodules
recommendations.
Nodule Low-risk patients High-risk patients
size (mm)
– Initial follow-up CT at 6–12 months Initial follow-up CT at 3–6 months
and then at 18–24 months And then at 9–12 and 24 months
if no change if no change
Follow-up CT at around 3, 9and 24 Same as for low-risk
months. patients
Dynamic contrast-enhanced CT, PET,
and/or biopsy
Low-risk patients: Minimal or absent history of smoking and other known risk factors as
asbestos exposure.
High-risk patients: History of smoking or other known risk factors.
Adapted from Heber MacMahon et al., Radiology 2005 237:395–400
10. Case-1
• A 40-year-old male smoker presents with a
history of chronic cough.
• He has had symptoms of an upper respiratory
illness for a few months since visiting family in
Arizona.
• Physical exam is normal.
12. POSITION •PA CXR
QUALITY •Poor Technical Quality
•(ROTATION?)
•Round density well defined at 5 right
posterior rib.
•Another round density at left hillum.
LESION
MEDIASTINAL •Central trachea,mediastinal
ANGELS •free
OTHER •No
13. Case-1
1. The next step in management should be:
• a. Complete pulmonary function tests
• b. Fiberoptic bronchoscopy
• c. Percutaneous needle biopsy
• d. Observation and repeat CXR in 6 to 8 mo
14. Discussion
• Due to the peripheral nature of this lesion, a CT-guided
needle biopsy would be the best diagnostic strategy and
have a better yield than a bronchoscopy.
• Pulmonary function tests would be helpful if surgery is
planned, but would not alter the diagnostic steps.
• In this case, the CT-guided biopsy revealed
coccidioidomycosis.
• Most granulomas are smaller than 2 cm, and almost all are
less than 3 cm in size.
• Besides SPNs, in the early stages of coccidioidomycosis
patchy infiltrates may be accompanied by hilar and
mediastinal adenopathy and less frequently by pleural
effusion.
• In cases of persistent disease, infiltrates may enlarge.
15. Case-2
• 34-year-old woman, a recent immigrant from
Eastern Europe, is seen with complaints of
vague chest discomfort after an upper
respiratory tract infection.
• She is not a smoker and gives a history of BCG
vaccination when she was an infant.
• Physical examination is normal.
• PPD is 10-mm induration and induced sputum
for acid-fast bacilli is negative.
17. POSITION •PA CXR
QUALITY •Poor Technical Quality
•(ROTATION?)
•Round density well defined at 7 right
posterior rib.
LESION
MEDIASTINAL •Central trachea,mediastinal
ANGELS •free
OTHER •No
18. Case-2
• 1. What is the most likely diagnosis?
• a. Granuloma
• b. Scar carcinoma
• c. Coccidioidomycosis
• d. Hamartoma
• 2. What is the next step in the management of
this patient?
• a. MRI of the chest
• b. Fiberoptic bronchoscopy
• c. Comparison of previous chest radiograph, if
available, and repeat chest radiograph in 3 mo
• d. Treatment with four-drug anti-TB chemotherapy
19. Discussion
• With a history of a positive PPD in a young
immigrant and the presence of a calcified
peripheral SPN, the likely diagnosis is tuberculous
granuloma.
• Comparison with a previous x-ray to confirm
stability of the lesion would prevent the need for
further diagnostic tests.
• Since this lesion probably represents
latent, old, healed granulomatous
focus, treatment with four antituberculosis drugs
is not warranted
• unless evidence of active disease is seen.
20. Case-3
• A 30-year-old female nonsmoker who recently
moved to the U.S. from Mexico presents with
dyspnea on exertion.
• Her PPD is 8 mm.
• On physical examination, her pulse is 110
bpm, blood pressure is 110/70 mm Hg, and she
has mild clubbing, cyanosis, and ortho-deoxia.
• Otherwise, her physical exam is normal.
• Laboratory data: Hb 14 g/dL; Hct 42%; WBCs
11,000/μL; differential normal.
• ABGs on room air: pH 7.42; PCO2 38 mm Hg;
PO2 70mm Hg.
22. POSITION •PA CXR
QUALITY •Poor Technical Quality
•(penetration?)
•Multilobulated nodular opacity in the
left midlung zone.
•No calcifecated.
LESION •No cavitation.
MEDIASTINAL •Central trachea,mediastinal
ANGELS •Disappear
OTHER •No
23. Case-3
• 1. What is the next step in the management of this
patient?
• a. Sputum for fungal culture
• b. Rib series
• c. CT scan with contrast of the chest
• d. V/Q scan
• 2. Lesions associated with the above disorder
include
• a. Erythema nodosum
• b. Lupus pernio
• c. Telangiectasia
• d. Oral thrush
24. Discussion
• The clinical picture with ortho-deoxia
(oxygen desaturation in an erect position) suggests an
arteriovenous malformation (AVM).
• Congenital pulmonary AVMs of the lung represent a
• direct communication between the pulmonary arteries
and the veins, bypassing the capillary bed and
resulting in cyanosis due to right-to-left shunt.
• Dyspnea and hemoptysis are common clinical
presentations.
• Fifty percent of AVMs are associated with Osler-
Weber-Rendu syndrome (AVMs with mucosal
telangiectasias).
25.
26.
27. Case-4
• A 62-year-old woman with a 30-pack-year
smoking history is evaluated with a history of
chronic shortness of breath.
• She has mild left-sided chest discomfort.
• She denies fever, chills, and night sweats and
has no localizing signs on physical exam.
• A CT-guided needle biopsy of the lesion is
performed and reveals malignant cells.
29. POSITION •PA? CXR
QUALITY •Poor Technical Quality
•(penetration,rotation ?)
•Bilateral hazy opacities at lower zone
obliterated right cardio-phrenic angel
and left hemi-diaphragm.
LESION •Round like ill defined opacity at left
middle zone peripherally, abutting left
chest wall,without
calcification,cavitation.
MEDIASTINAL •Right deviation trachea,cardiomegaly
ANGELS •Left costo-phrenic angle obliterated
OTHER •No
30. Case-4
• 1. Based on the CXR finding, the likely
diagnosis is:
• a. Small cell carcinoma
• b. Bronchoalveolar cell carcinoma
• c. Adenocarcinoma of the lung
• d. Liposarcoma of the chest wall
• 2. This malignancy is associated with:
• a. Positive sputum cytology
• b. A good response to chemotherapy
• c. Incidentally detected peripheral carcinomas on CXR
• d. Cavitation in the majority of these carcinomas
31. Discussion
• Adenocarcinoma is commonly peripheral and
represents about 30% of the total number of
lung cancer cases.
• Its incidence is rising especially in females.
• Adenocarcinoma frequently presents as an
incidental finding on x-ray.
32. Discussion
• The other major histological types of lung cancer tend to have central
localization and are as follows:
• 1. Squamous (epidermoid) carcinoma:
– Eighty percent are central;
– When peripheral, they have a tendency for cavitation.
• 2. Small cell (oat cell) carcinoma:
– Believed to originate from neuroendocrine cells of the
bronchial mucosa,
– these are usually central with mediastinal involvement.
• 3. Large cell undifferentiated carcinoma with mixed malignant features.
• 4. Bronchoalveolar carcinoma:
– A variant of adenocarcinoma,
– these arise from type II pneumocytes in the alveoli.
– They may simulate pneumonia with focal consolidation
– or may present as solitary or multiple nodules.
