CT Applications in Chest Pathology

Objectives are as follows,

List the types of CT

List the indications of chest CT

Understand the applications of chest CT

Identify the radiological signs of common chest diseases on CT

Basics of CT

Two dimensional representation of a three dimensional slice

Internal structure of the organ can be reconstructed from multiple slices

Image display settings can be varied by adjusting WW & WL

Lung window

Mediastinal window (soft tissue window)

Bone window

Types of CT Scans are,

Conventional CT

High resolution CT

Conventional CT Vs HRCT

Conventional- 3 to 10 mm thick slices are obtained contiguously, imaging

100% of the lung

HRCT- 1-1.5mm thin slices of lung are obtained at non-contiguous intervals,

usually 1 to 2 cm apart, throughout the whole lung. . Only 5 to 10% of the
lung is sampled

Indications of Chest CT

Evaluation of an abnormality identified on conventional radiographs - Solitary

pulmonary nodule/ lung tumour/mediastinal mass

Diagnosing & Staging of Lung Cancer

Detection of occult pulmonary metastases

Detection of mediastinal nodes /masses

Distinction of empyema from peripheral lung abscess

Detection and evaluation of aortic disease

Pulmonary embolism

Haemoptysis

Applications of CT
1. Detection of Lung Tumours
2. Diagnosis
3. Anatomic extent of disease -Intra and/or extra thoracic disease extent , TNM
descriptors
4. Decision of therapeutic strategy -Surgery -vs- Chemotherapy -vs- Palliative
Care Resectability / Irresectability
5. Image guided biopsies

Lung tumours

Benign tumours

- Harmatoma, Adenoma, AV Malformation

Malignant tumours- Primary (Bronchial Ca, Alveolar cell Ca), Secondary

Benign tumours- Harmatoma

8% of all solitary pulmonary nodules are harmatomas

It is the most common benign lung tumour

They are mostly asymptomatic

Harmatoma

Round, smooth mass - increase in size slowly

Calcification in 15% - pathognomonic if popcorn type

Fat in 50%

Cavitation - extremely rare

2/3 are peripheral

Rarely multiple

Bronchial Adenoma

Uncommon- Possess some of the properties of malignant growth

Two histological types

1. Carcinoid tumour (relatively common)
2. Cylindroma/adenoid cystic Ca (rare)

Malignant tumours Bronchial carcinoma

Most common malignant tumour

Arises from bronchial epithelium

Pathological types
Squamous (30-35%)
Adenocarcinoma (30-35%)
Large Cell Undifferentiated (15-20%)
Small Cell (20-25%): systemic disease

Application of CT in Lung Carcinoma

1. Assess the primary tumour

2. Assess the secondary effect /complications
3. Assess the nodal/ other metastasis
CT appearances in primary malignant tumour
1. Dense irregular hilar opacity
2. Dense peripheral opacity
3. Dense irregularly cavitating lesion
4. Hilar opacity with collapse of a segment /whole lung
Malignant tumour-Secondary effects
1. Pleural effusion
2. Mediastinal widening
3. Osteolytic lesions of the rib
4. Diaphragmatic paralysis
Detection of Lung Cancer Plain Radiography vs. CT

Contrast resolution of CT is superior to plain chest radiography

Significantly more nodules detected on CT

The Stages of Lung Cancer

Stage I

No nodal metastases and surgically removable

Stage II
Adds hilar lymph node involvement (IIA) or resectable chest
wall/mediastinal
involvement (IIB)

Stage III

Stage III B Extensive but irresectable by conventional criteria but still

confined to chest, therefore
consider radical radiotherapy

Stage IV Distant metastases

A Extensive but resectable disease

The Staging of Lung Cancer: International Staging System

PRIMARY TUMOUR (T)

T1 Diameter 3cms, surrounded by lung /visceral pleura. No involvement of

lobar bronchi

T2>3cm diameter; involves main bronchus but 2cm distal to carina; invades
visceral pleura; associated with atelectasis or obstructive pneumonitis extending to
hila but not involving entire lung

T3Tumour of any size but with invasion of: chest wall,diaphragm, mediastinal pleura,
parietal pleura, parietal pericardium, or tumour in main bronchus <2cm from carina
but not involving carina; or atelectasis / obstructive pneumonitis of entire lung

T4Tumour of any size but with invasion of: heart, great vessels, trachea,
oesophagus, vertebral
body, carina; tumour with malignant pleural / pericardial
effusion; or with satellite tumour nodule(s) in ipsilateral primary-tumour lobe

The CT Staging of Lung Cancer: T1 versus T2 lesions

T
1
The CT Staging of Lung Cancer: T1 / T2 lesions

T2

The CT Staging of Lung Cancer: T3 / T4 lesions

T3

Superior sulcus tumours

The CT Staging of Lung Cancer: Nodal Staging

NO

None

N1

Ipsilateral hilar

N2

Ipsilateral mediastinal (incl subcarinal)

N3

Contralateral mediastinal / hilar or supraclavicular

Detection of Lung Cancer- BIOPSY

Central Obstructing lesion - bronchoscopy

Peripheral tumour - percutaneous biopsy under CT guidance Cytology, Histology

Cavitating Carcinoma

Metastases in Lung Cancer

Liver

33-39%

Adrenals

20-33%

Brain

16-26%

Bone

15-21%

Key point
CT remains the mainstay in the non-invasive staging of lung cancer;

Mediastinal masses

ANTERIOR MEDIASTINUM
THYMOMA
TERATOMA
INTRATHORACIC THYROID ENLARGEMENT
LYMPHOMA (3 Ts and an L)

OTHER

- LYMPHANGIOMA
ANEURYSM OF ASCENDING AORTA

Middle mediastinium Masses

Merge with hilae and cardiac borders

Lymphadenopathy

Bronchogenic cyst

Aortic aneurysm

Most middle mediastinal masses are due to enlarged nodes.

Posterior mediastinal masses

Neurogenic tumour

Extramedullary haemopoeisis

Reticulosis, myeloma

Paravertebral abscess

Enlarged paravertebral lymph nodes

Haematoma following injury to the spine

Aortic aneurysm

Hiatus hernia

Dilated oesophagus in achalasia

Thymoma CT

Retrosternal goiter

Commonest pleural masses

Mesothelioma: It is a diffuse or localised pleural mass. Large pleural effusions are

common. May have associated pleural plaques

Pleural metastases - often obscured by the accompanying effusion

Malignant mesothelioma

Lung Abscess

Aortic aneurysm

Pulmonary embolism

Indications of Chest HRCT

Detection of lung disease in patient with pulmonary signs and symptoms or

abnormal pulm function test but normal or equivocal CXR

Emphysema, Extrinisic allergic alveolitis, small airway disease,

immunocompromised patient

Evaluation of diffusely abnormal CXR

Cystic fibrosis, Sarcoidosis, interstitial lung disease Histocytosis X, ARDS

HRCT Normal lung

Basic HRCT Patterns

Lines

Nodules

Consolidation

Ground-glass Opacity

Cysts

Linear abnormalities
a) thickened interlobular septa
b) bronchovascular interstitial thickening
c) reticular change
e.g Fibrosing alveolitis Lymphangitic tumours

Fibrosing alveolitis

Lymphangitic tumour

Nodules

A nodule is a rounded density that does not correspond to a vessel.

The anatomic distribution of nodules--centrilobular, random, or interstitial--helps

to identify potential causes

e.g- bronchopneumonia gives nodules in a centrilobular distribution

Nodules Infective

Ground glass opacity

A hazy opacity that does not obscure the associated pulmonary vessels. This
appearance results from parenchymal abnormalities that are below the spatial
resolution of HRCT.

E.g. alveolar wall inflammation or thickening, with partial air-space filling, or with
some combination of the two.

Ground glass- Influenza pneumonia

Cysts

Rounded structure that is filled with air and usually has a thin wall.

The cyst contents are as dark as air surrounding the patient

[Link] bronchiectasis
Chronic interstitial fibrosis (subpleural honeycombing)
Langerhans cell Histiocytosis
Lymphangioleiomyomatosis

Cystic Bronchiectasis

Consolidation