Final MB Revision Lecture 45 - Chest Imaging Case Series Jan 2025

- Not meant to be comprehensive

- Not only for exam purposes
- Adopted in final MB format.
- Zoom preferred since need to see through own image rather than
projector

- Lung anatomy
- CXR is a 2-dimensional representation of the lungs.
- CXR: usually either AP or PA – may have some overlap of some lobes.
Hence, will sometimes say ZONE other than LOBE since can be overlap
(see right picture for lateral aspect; apical segment of RLL can be at
RMZ)
 - Hence lesion at a RMZ can be at LOWER or MIDDLE lobe – hence, usu
described as RMZ (but other signs can help)

What do you see in the CXR?

- Opacities (vague), not consolidation/haziness in right lower zone with

LINES and infiltrates in LLZ overlapping with the diaphragm (still see
thing underneath the diaphragm)
 - ?Right pericardiac region? Tramtrack signs?
o Actually, the XR is a bit ROTATED and heart shadow is moved to
the left -> hence exposed to lung
o These are actually vascular markings cannot be too sure what
this opacity means.
o Working diagnosis: LLZ pneumonia. Probably underlying
bronchiectasis.
 Cannot be ILD since usually bilateral and sputum
 Heart shadow probably moved to the left side

Three further tests for immediate management: CBC x neutrophilia, (blood

culture), sputum culture and Gram stain (C/ST of bacteria), ???NPA still
possible

- Advice: justify why you are doing investigations (if asked to in the
question)
- Blood culture if fever is high then can do (but not mentioned here) –
fever, chills, rigors then yes needed
- If more myalgia – need NPA for viral PCR too.

One further investigation you would like for further long-term management:
HRCT thorax.

- Bronchoscopy also possible

- Further imaging studies is usually the norm
So HRCT is done.

- Dilated bronchi/bronchioles?
- Definitely not alveoli dilatation
- LLL is also COLLAPSED.
- Airway ?stenosed previously with ?disease lower airway, fibrosis and
shrunken down for collapse of LLL
- Also see a bit of infiltrates at the lower lobe
- Lower lobe even more dilatation
Abnormalities seen:

- Radioopacity over RMZ. What else?

- Also some opacities/infiltrates in RMZ in general
- Hilar mass? But left side also looking similar. Maybe hilar LN?
o Think ddx of hilar LN
o A bit hard to call it a mass at this stage since too small – just say
right hilar shadow.
- Right hilum and left hilum NOT coming out at the same level; Right
side usu LOWER than the left side
- Right hilum maybe a bit depressed even (but mainly by impression)
- Lateral film: note that anterior aspect is NOT radiolucent: actually it is
the APICAL lower segment that has a mass (around the middle)

- this one, cannot see the vertebrae at all

CT for illustration

- This one no need to know

- Bronchiectasis too obvious so need to know (also ILD)
- Just see that BIG mass surrounding the airway
- Dx is of course a lung tumor
- Blunted L costophrenic angle esp compared to the right
side – so this is a pleural effusion; can always vary the penetration
- Caveat: very dense infiltrate in lungs/collapse of up to a whole lobe
- + some aeration when go up -> probably a consolidation
- Clinical dx: parapneumonic effusion/empyema?
- Management correct? Yes
o But if suspecting some parapneumonic effusion/empyema, what
would you do?
- Pleuritic left chest pain – pleuritis
- Next step of management?
o Get pleural fluid for analysis, C/ST, protein, LDH, even ADA
o What would the chest tapping involve?
 In this situation, this is a small effusion.
o Alternative: decubitus film
 Effusion position can change depending on gravity.
 Can move and change location
o Alternative: USG
 But operator-dependent
 But supposedly very sensitive
 And usu is USG-guided tapping
- Step of tapping?
o Very troublesome!
- Key points:
o Empyema: loculated pus – abtics will NOT work
 Hence, this is probably an empyema and need drainage!
- Left apical opacity

- not very well-formed nodule either, but definitely

round infiltrate; a bit faint
- CT jau very obvious
- Something else to see in the CT?
o Cavitation? Black so reflecting some air (may see fluid level if
more films) within a irregular thick-walled lesion
o Further meaning of cavitation?

o also see some infiltrates next to the lung

 Possibilities? TB, esp when apical involvement, and also
looking like ‘satellite’ lesions
o Ca lung can also cavitate! Which cell type?
 Classically SCC, but can also have AC cavitating and even
Small cell
- On more views, can see fluid level somewhere down there -> abscess
o Fungal/bacterial/tumor/TB
- CXR abnormalities:
o Bilateral infiltrates
o History – looks like influenza/viral illnesses?
o Hyperinflated lung? But portable film, what is the criteria?
 Not a straightforward answer, but even a bit barrel
shaped…
 Heart: disproportionately squeezed
- Probably just COPD exacerbation
- Other patients: heart size should make up more of the chest.
Diaphragm not very flat usually.
- Right side: not very hyperinflated ?obese patient
o Reduced lung markings – but probably due to projected films on
computer screen and have to do with quality.
o Right heart shadow is dilated?
o ?left hilar shadow – by anatomy, just very prominent pulmonary
vessels (since the vasculature also v prominent) so dependent on
clinical context
- Whiteout of right hemithorax, deviated trachea but to the right side…

- just an artifact, actually density is uniformly

homogenous.
- Hypoxemic, next step of management? Give O2, ensure airway is
patent.
o How to make sure airway is patent?
 Observe and hear for stridor
 Professors do not like you say ABC make sure airway is
patent (although some do…)
 Giving O2 is reasonable
 Do NOT put in a needle!
- Obstruction -> collapse
o So need R main bronchus to be blocked
o With this picture, not likely in the upper airway
o Unless FB cannot relieve the obstruction
- Both whiteout hemithorax but trachea is both pushes to the OTHER
SIDE
o Hence left: very big effusion
o Hence right: also big pleural effusion
- Sometimes can have BOTH effusion and collapse.
o Hence, with massive effusion, can have SOME underlying lung
abnormality too!
o Picture may be blurred if both collapse and effusion
- Need to know that the bottom air loculation is a gastric bubble

- this is aortic knuckle with calcified rim

- Opacity at left upper zone!

- not wedged enough since smoother in border.

- Likely still pleural-based
- Scapula is actually coming in (but in this case the ‘opacity’ is not the
scapula)
- When asked of something need to answer but need to have pertinent
features.
- Nowmore left chest pain
- Nowsupine and portable so patient is lying in bed
- Nowwhite out left hemithorax. Why?
o Now actually blunted costophrenic angle (esp if can change
penetration)
o Remember pleural effusion may not always have meniscus
o Lie down – then fluid will have homogenous veil since distribute
over the lung
o + fluid even more dense – so is it still the lesion? + shortness of
breath and chest pain worsening + tenderness when pressing
upon a certain site
 o difficult to look since many things can
cause opacification. But the posterior ribs here have a portion
where you cannot see the post ribs

o The cause: one rib was actually LOST

o The diagnosis: local pleural effusion eroding into the rib

- When we cannot see anything, look for the more occult sites
- Easily missed sites:
o Apex – but normal here
o Around the heart
o Retrocardiac
o Heart shadow – can mask a lot of things

- Actually,

- Now can see the cavity with aeration

 - shadow here!

- Clinical photo?

Finger clubbing? Yes!

Loss of angle + swollen pulp -> points to clubbing

Diagnostic probabilities?

- Wrist pain + clubbing: Ca lung causing the problem – then need XR of

ankle too!
- Hypertrophic osteopathy -> periosteal thickening
-

- Not actually common, related to clubbing, but most patients nowadays

usu have clubbing
- Pulmonary embolism
- Big effusion but not acute; big collapse but site does not correspond
- Esp important in if CXR is clear! Need to consider.
- Hence, the dx investigation is CTPA!
- Difficult to see if small film but can see clearly embolus
- Erythema and swollen upper part of body and neck, and upper chest
and telengiectasiae
- So, this is SVCO

- SVCO compressed to slit like – blockage

- No need to know how to find the SVC on the CT.
- See a bit of fluid in the LLZ – most likely

- !!!!!! Does NOT look normal; Lt PA much more bulky than

normal
- Why is the Lt diaphragm looking like a mass?
- That is elevated LEFT diaphragm!
- + lesion in the left hilum? Affecting the phrenic nerve
- Phrenic nerve will run close to lung hilum – so it may be involved
- Another nerve that may be involved: RLN (again usu by LN)
- Lateral film: anterior lucency much well-seen. Posterior is lost - ?soft
tissue shadow or some effusion (but no obvious effusion so probably
just quite small and soft tissue density)
- CT: abnormality much more obvious at the left lower too
- Can see fluid density thing and soft tissue above - ?tumor or even
involving collapsed lung tissue.
- ?partial collapse and probably tumor/mass element
- Can also see effusion
- 2 major routes that access lung tissue: either from bronchus or from
skin
- Depends on where lesion is
- Bronchoscopy: can get tissue/fluid/biopsy (via BAL)
- EBUS: more famous for its use for LNs in hilar region (too near major
BVs so may need mediastinoscopy but now have this so no need)
- Usu lung tissue: thru airways and lungs
- Most important: know what procedure will help in
- Lavage: NO tissue available, just CELLS
- Details NOT needed but principles

- Likely mutation: EGFR mutation

o Expected to know: epidermal growth factor receptor
o Other mutations: ALK also possible. ROS1 too. Others not a lot of
treatment.
o Found EGFR mutation does NOT mean suitable for TT – need to
give the RIGHT mutation
o Lumen complete obliterated so also need other things (RT)
otherwise just TT/systemic treatment can be reasonable
- Causes of increased SoB:
o Pleural effusion again? (NOT just loss of costophrenic angle; since
opacification is big enough in this case and need to say
 opacification in LLZ and cannot see costophrenic
angle/diaphragm)
o ?loculated effusion in the fissure? Parenchymal infiltrates?
o But why SoB?
 ?LNs in mediastinum push trachea to the right side (since
cannot see the lung collapse on the right side)
 Hazy infiltrates even on the R side + reticular shadows…
 How to be sure? COMPARE with previous XR!
 Lymphangitis carcinomatosis? XR cannot be definitive, but
possible; but then not very close to the tumor; diffuse:
consider lymphangitis.
 TKI and RT: double blow: need to consider side effect –
ILD… (RT: depends on portal of radiotherapy)
 Dx: TKI-induced pneumonitis, ILD
 What can you do?
 Get HRCT thorax.

- Diffuse GGO! (SOME areas are still spared)

- So the dx is TKI induced ILD/pneumonitis.
- Hence, TKI should be SUSPENDED in this patient before you make the
diagnosis (sometimes may need to do lung bx but clinical usually
sufficient)
- Then manage with steroid.
- Also can have PD1 induced pneumonitis (and also other autoimmune
shit)
- Can definitely kill the patient; but usually reversible (occasional
mortality)

- Diffuse reticulonodular opacities

- Mainly peripheral
- Very knitted (some shadows) even give you overall haziness
- Thickened interstitium
- Honeycombing
- No GGO elsewhere.
- The dx is IPF. UIP pattern?
o But radiographic pattern only – implies clinically that this is
pulmonary fibrosis
o So the better dx is IPF. Different origins and different (clinical vs
histology/radiology)
o But this isn’t idiopathic – hence connective tissue associated
pulmonary fibrosis
- Also reticulonodular opacities, this time hilar
- Also haziness
- So this is not PJP (but not have PJP)
- Again GGO
- Differentials: CMV pneumonitis… (COVID can also have ddx)
- PJP: BAL for silver stain or grocott stain (cannot culture)

- Ganciclovir is the first line anyway for CMV

- Then clear up and d/c
- Depending on context: need to consider what GGO is (IPF, PJP…)
- Lung cancer usu NOT enough to cause PJP
- Immunocompetent previously (but may HIV lmao)
- XR: all infiltrates in bilateral lower zones
- Not GGO, just consolidations

- Air bronchograms (should show on CT)

- Consolidation: COP, pneumonia (seldom consolidation), TB?,

malignancy? (possible but RARE and should not put it up), aspiration?
- Actually if only chest XR, then maybe can have pneumonia, non-
infectious pneumonitis, ILD?
- Mx steroids; improved (actually organizing pneumonia)

- Mx is therefore STEROIDS (in some cases of COVID)

- May not always improve
- Lungs may turn fibrotic even after treatment
- This is GGO.

- Pneumothorax (density difference), on the left side

- Lung cysts:
 - nodule can be quite light in color

- Procedure: percutaneous lung bx, bronchoscopy (choice up to

specialists only)
o But in general just rmb these 2
- Why does the lesion become this big? Hemorrhage! (too big to be
explained away by projection)
Expect to see small pneumothorax in post-bronchoscopy film

Hindsight: in the previous pic, looks a bit lucent. Now can see small
pneumothorax
 - Very big chest drain – so had an operation
- Left hemidiaphragm is also a bit elevated - ?left lung removed

- Actually another tumor in left apical -> lung volume

shrinkage
- Also see stitches (probably due to the operation)

- Surgical emphysema (again look outside the chest!)

Conclusion

- Know limitation of interpretation CXR and when other ix will be needed

- Cannot send a patient too ill for a CT scan so CXR is still useful
- Thickened bronchial wall needed to see the dilated bronchi.
- STOP the TKI if suspect s/e from TT
- Do NOT just look at the chest in the CXR!!!!!
- Do NOT miss lung nodules, but can be very vague
- ‘incidental’ CT scans can pick up a lot of things
- Bil blunting of costophrenic angle

- Some round nodules along fissure so loculated fluid

- Also calcification on the left upper/middle zone (?vessels/LNs)
- Haziness of right pedicardium ?congestion in lungs instead?
 - Round, smooth, circular shadow
- May even see pacemaker but this is clearly not one

- the hilum looks VERY strange and pulled WAY up to the apices with some
scarring
- Just very bulky shadows at hilum
- They are actually LNs (so think your ddx)
- Lymphoma, benign cause (sarcoidosis, NOT common)
- MUST know and will be instituted online session and take an exam for
this.
- Look at the NG tube! (news topic!)
Need to properly trace!

- This one placed right into jejunum probably because patient is

aspirating a lot
- Usu not that low! Have to be WELL below diaphragm!

- tracheostomy tube

- O2 connection