1. พญ. ปาณยา ทุมสท้าน ภาควิชารังสีวิทยา คณะแพทยศาสตร์ มหาวิทยาลัยขอนแก่น
PULMONARY RADIOLOGY
พญ. ปาณยา ทุมสท้าน
ภาควิชารังสีวิทยา คณะแพทยศาสตร์
มหาวิทยาลัยขอนแก่น

2. PULMONARY OPACITY Area that more opaque than the surrounding area
“area that preferentially attenuates the x-ray beam”
Area that more opaque than the surrounding area
CLASSIFIED INTO
Airspace opacities
Atelectasis (collapse)
Nodules and masses
Linear and band like opacities
Cysts and bullae
Nodular and reticulonodular opacities and honeycombing

3. AIRSPACE OPACITIES Acinar shadow Consolidation
Solitary airspace opacity
Multifocal airspace opacity

4. DIFFERENTIAL DIAGNOSIS OF AIRSPACE OPACITES
SOLITARY AIRSPACE OPACITY
Pneumonia
Atelectasis
Infarction
Hemorrhage
Neoplasms
- BAC
- Lymphoma
Radiation fibrosis
Pulmonary contusion, vasculitis, drug reaction, etc.

5. DIFFERENTIAL DIAGNOSIS OF AIRSPACE OPACITES
MULTIFOCAL AIRSPACE OPACITIES
Exudate and transudates
Pneumonia, OP, infarction, connective tissue disease and vasculitis, inhalation of noxious gases or liquids, drug reaction, alveolar proteinosis
Hemorrhage
Pulmonary contusion/hematoma, infarction, vasculitis
Neoplasm
BAC, lymphangitic carcinomatosa, metastases, lymphoma

6. RML PNEUMONIA

7. bronchopneumonia

8. PULMONARY EDEMA

9. RadioGraphics,
Infectious pneumonia in a 35-year-old patient with hypogammaglobulinemia.
November 2009 RadioGraphics, 29,

10. Small focus of pulmonary consolidation caused by pulmonary infarction
David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

11. Widespread, uniform airspace opacities in acute respiratory distress syndrome
David Hansell, Imaging of diseases of the chest, 5th edition, 2010

12. ATELECTASIS Most frequent cause is bronchial obstruction
Bronchial obstruction in adult
Usually the result of a bronchial neoplasm or mucus plug
Occasionally, FB aspiration, broncholiths, extrinsic compression e.g. enlarged LNs, aortic aneurysm
Passive atelectasis
Discoid atelectasis ( Platelike or linear atlectasis)
A form of adhesive atelectasis
Usually abuts the pleura and is perpendicular to pleural surface

13. Golden S sign

14. David Hansell, Imaging of diseases of the chest, 5th edition, 2010

15. Left upper lobe collapse due to bronchial carcinoma
Left upper lobe collapse due to bronchial carcinoma. Note that the carcinoma has caused ‘rat tail’ narrowing of the left upper bronchus.
David Hansell, Imaging of diseases of the chest, 5th edition, 2010

16. Fluid bronchogram at CT
Fluid bronchogram at CT. Fluid-filled bronchi beyond a carcinoma in the atelectatic lower left lobe are clearly visible. 
David Hansell, Imaging of diseases of the chest, 5th edition, 2010

17. ROUND ATELECTASIS
A form of chronic atelectasis that resembles a mass
Main DDx is BCA
“bronchi and vessels curving into the periphery and converging toward a mass and area of pleural thickening (Comet tail sign)”

18. David Hansell, Imaging of diseases of the chest, 5th edition, 2010

19. SOLITARY PULMONARY NODULE/MASS
Pulmonary nodule : lesion up to 3 cm in diameter.
DDx of SPN/mass
Neoplasm
BCA, metastasis, lymphoma, carcinoid tumor, hamartoma, etc
Inflammatory
Infection: TB, fungus, round pneumonia, lung abscess, septic emboli
Non infection: RA, Wegener granulomatosis

20. SOLITARY PULMONARY NODULE/MASS
DDx of SPN/mass
Congenital
Pulmonary AVM, sequestration, lung cyst, bronchial atresia with mucoid impaction
Miscellaneous
Organizing pneumonia, pulmonary infarction, round atelectasis, etc.
Mimics of SPN
External object
Bone island or rib, healing rib fracture
Pleural plaque
Loculated pleural fluid

21. Patient with a known extrathoracic malignant neoplasm
Patients with CA of H&N, bladder, breast, cervix, bile ducts, esophagus, ovary, prostate, or stomach with SPN
“primary lung CA were more likely than metastasis”
Patients with known salivary glands, adrenals, colon, kidney, thyroid, thymus or uterus
“fairly even odds”
Patients with known melanoma, sarcoma, or testicular cancer
“solitary metastasis is more likely than primary lung CA”

22. Features which can be diagnostically helpful
Calcification
Fat density within a nodule
Ground glass opacity
Size
Shape
Cavitation
Air bronchogram and bubblelike lucencies
Enhancment

23. BENIGN CALCIFICATION Concentric calcification Popcorn calcification
Uniform calcification
David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

24. David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

25. Fat in hamartoma
David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

26. Density of the nodule
March 2007 RadioGraphics, 27,

27. Size and shape
David Hansell et al, Imaging of diseases of the chest, 5th edition, 2010

28. Fleischner society recommendations
MacMahon et al. Radiology 237:395, Nov 2005

29. Contrast enhancement
Rate of growth
Adjacent bone destruction

30. Air crescent sign

31. Silva et al. The teaching files chest. 82-83. 2010.

32. Multiple pulmonary nodules
Neoplasm
metastatic CA or sarcoma, lymphoma, BAC
Hamartomas, laryngeal papillomatosis
Inflammatory
Infective
Granulomas (TB, histoplasmosis, nocardiosis)
Lung abscesses, septic emboli,etc.
Noninfective
RA, Wegener granulomatosis
Congenital : AVM
Miscellaneous
Hematomas, pulmonary infarction, mucoid impaction

33. Miliary TB Metastasis thyroid CA SILICOSIS
Silva et al, The teaching files chest , 2010.
SILICOSIS

34. Centrilobular nodules in Subacute hypersensitivity pneumonitis
Silva et al, The teaching files chest, 2010.

35. Tree-in-bud in infective bronchiolitis
Silva et al, The teaching files chest, 46-47,2010.

36. Pulmonary metastasis Miliary TB RANDOM DIST NODULES
Silva et al, The teaching files chest, 48-49, 2010.

37. ABNORMAL LUCENCY LESION
Cyst, cavity, bleb, bulla, emphysema
CYST;
any round circumscribed space that is surrounded by an epithelial or fibrous wall of variable thickness
CAVITY;
a gas-filled space, seen as a lucency or low-attenuation area, within pulmonary consolidation, a mass, or a nodule
usually produced by the expulsion or drainage of a necrotic part of the lesion via the bronchial tree
Cavity is not a synonym for abscess.

38. BLEB;
a small gas-containing space within the visceral pleura or subpleural lung, not > 1 cm in diameter
CT: a thin-walled cystic airspace contiguous with the pleura
BULLA;
An airspace measuring > 1 cm – usually several centimeters – in diameter
sharply demarcated by a thin wall that is no greater than 1 mm in thickness.
usually accompanied by emphysematous changes in the adjacent lung.
Bullous emphysema is bullous destruction of the lung parenchyma
usually on a background of paraseptal or panacinar emphysema

39. EMPHYSEMA;
permanently enlarged airspaces distal to the terminal bronchiole with destruction of alveolar walls
CT; focal areas or regions of low attenuation, usually without visible walls.[

40. cyst

41. Silva et al, The teaching files chest, 2010

42. BULLA

43. BLEB

44. EMPHYSEMA
IMAGE : WIKIPEDIA

45. Paraseptal and centrilobular emphysema
Imagingconsult.com

46. BRONCHIECTASIS

48. HONEYCOMBING

49. CYSTIC BRONCHIECTASIS
HONEYBOMBING

50. LINEAR AND BAND-LIKE OPACITIES
Mucoid impaction
Septal lines
Bronchial wall (peribronchial) thickening

51. MUCOID IMPACTION

52. BRONCHIAL ATRESIA

53. MUCOCELE

54. PERIIBRONCHIAL WALL THICKENING

55. Reticulonodular opacities
Acute
Pulmonary edema, pneumonia (Mycoplasma, viral, opportunistic)
Lower zone
Idiopathic pulmonary fibrosis, RA, scleroderma, drug reaction, HP,
Mid- or upper zone
Pulmonary TB or fungal disease, Pneumoconiosis, HP

56. Nodular and reticulonodular partern
Pulmonary fibrosis

57. thank you all for your attention