Flashcards in Chest Deck (135):
When is pancoast's tumour unresectable? (4)
1. Brachial plexus involvement above T1 (C8 or higher).
2. Diaphragm paralysis (C3,4 and 5): phrenic nerve compression from lung cancer. Test: sniff test.
3. > 50% vertebral body involvement.
4. Distal nodes/mets
Name the different types of pathology with thymus (4)
1. Rebound thymus secondary to stress/chemo
3. Thymoma (non invasive --> invasive (+/- calcification)
4. thymolipoma- fat and soft tissue
What are the associations with thymoma? (3)
1. Myasthenia Gravis
2. Pure red cell aplasia
Name the anterior mediastinal masses:
Most common teratoma in anterior mediastinum:
Germ cell tumour
What is the appearance of teratoma?
Cystic mass + fat +/- calcification ?teeth
What is the most common location for pericardial cyst?
Right anterior cardiophrenic angle.
Name the posterior mediastinal masses: (2 and then 7)
- Peripheral nerve sheath tumour
- Extra medullary haematopoiesis
Name the middle mediastinal masses: (4)
2. Bronchogenic cyst
3. Fibrosing mediastinitis
4. Mediastinal lipomatosis- Obesity/cushing/ streroid
What are the causes of lipoid pneumonia?
a) Exogenous- aspiration of oil
b) Endogenous- more common- secondary to post obstructive processes
ie Fat density in consolidation
Re Pulmonary alveolar proteinosis-PAP
a) What are they at increased risk?
a) increased risk of Nocardia infection- brain abscess
b) Crazy paving with septal thickening and GG
c) Bronchoalveolar lavage
What are the three stages of congestive cardiac failure?
1. Redistribution: cardiomegaly, UL vessel diversion
2. Interstitial oedema: Kerley lines, peribronchial cuffing
3. Alveolar oedema: airspace fluffy opacity
What are the DDx for crazy paving? (5)
ie septal thickening and GG
5. Acute interstitial pneumonia
What differentiates a benign from malignant nodule? (3)
1. Spiculated margin
2. Air bronchogram through nodule- usu adenocarcinoma in situ
3. Partially solid lesion with GG component
2. Rapid doubling time
3. Slow doubling time
Re Squamous cell lung cancer:
1. where is it located?
2. Ectopic ?
1. It is centrally located +/- cavitation
2. Ectopic PTH
3. Pancoast tumour
What type is a pancoast tumour?
Re Small cell lung cancer:
1. Central, near main lobarbronchi
2. Paraneoplastic ACTH/SIADH
Where is large cell lung cancer usually located?
It is usually peripheral.
What is a Lambert Eaton syndrome?
Proximal muscle weakness secondary to ACh near NMJ.
Where is the predominance of NSIP?
Lower lobes, posterior and peripheral predominance with sparring of the immediate subpleural spaces.
What causes NSIP? (2)
1. Collagen vascular disease
2. Drug reaction
What is the histology in UIP?
List the differences between NSIP and UIP:
GG and micronodules.
Most common in scleroderma.
Honeycombing and traction bronchiectasis
RB-ILD- Smoking related
2. When to call it?
1. UL- apical centrilobular GG nodules
2. Resp bronchiolitis and symptoms.
DIP- smoking related- end spectrum of RB-ILD
More diffuse GGO with patchy/subpleural distribution mainly in the lower lobes with some small cystic spaces.
What is Hughes Stovin syndrome?
This is a PA aneurysm similar or is Behcet.
They get recurrent thrombophlebitis and PAA and rupture.
What is a Behcet?
Genital and mouth ulcers.
What is sarcoid staging?
1- Hilar/mediastinal nodes only
2. Nodes + parenchymal disease
3. Parenchymal disease
4. END STAGE- FIBROSIS
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.
What is sarcoid? Define
It is a non caseating granulomas.
Perilymphatic nodules with UL predominance.
Raised ACE and Ca
List DDx for reverse halo (ATOL) sign: (5)
1. COP- CLASSIC
2. Fungal pneumonia
5. Pulmonary infarct
List DDx for halo sign (5)
1. Invasive aspergillosis- CLASSIC
2. Other Fungus
3. Haemorrhagic mets including melanoma
Re hypersensitivity pneumonitis
What is it caused by?
This is caused by inhaled organic antigen.
BUZZWORD: HEAD CHEESE- mix of everything: GG/consolidation/ air trapping
Re organising pneumonia
What is a COP?
What are the causes? (4)
What is the main DDx?
When cause is not known: COP: Reverse halo sign
Causes of organising pneumonia:
2. Collagen vascular disease
3. Drugs (amiodarone)
Treatment: steroid with good prognosis.- No fibrosis.
DDx: Chronic eosinophilic pneumonia
Re Chronic eosinophilic pneumonia
What is it?
Peripheral eosinophilia +/- asthma
Looks similar to COP
CT: peripheral GGO/consolidation UL
What is a Caplan syndrome?
RA with UL lung nodules which can cavitate
+/- pleural effusion.
Re Ankylosing spondylosis:
- Which lobes?
- UL fibrobullous disease
Usually unilateral first --> Bilateral
1) What is a shrinking lung syndrome?
2) What condition is associated with shrinking lung?
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.
Re Granulomatous Wegeners:(AKA Granulomatosis with polyangitis)
a) Which organs are affected?
1) Upper tract/ sinuses
b) Nodules with cavitation +/- GG secondary to haemorrhage.
c) cANCA +ve in 90 %
Causes of pulmonary hypertension:
PA pressure > 25 mmHg
1. Primary- idiopathic, uncommon
- Chronic PE
- Right sided heart strain
- Lung parenchymal disease- Fibrosis and emphysema
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.
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.
Re Fat embolism:
- Triad/ organs affected
- After long bone fracture or IM rod placement.
- Affects brain (changed mental state), skin (rash) and lung (SOB).
- Timing 1-2 days after #
Typical patient group:
Patchy opacification with abscess formation
ICU patients on ventilators/ CF and PCD
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.
Haemorrhagic lymphadenitis, mediastinitis and haemothorax.
Mediastinal widening with pleural effusionin setting of bioterrorism.
Typical patient group:
What colour sputum?
Pleural effusion with empyema and cavity
Alcoholic and NH resident
Current jelly sputum.
What are the 3 main differences between empyema and abscess?
- Lentiform - Round
- Split pleural sign - Claw sign-acute angle w pleura
- Treated with chest drain -Not tx with drain risk of fistula
Define empyema necessitans:
Extension of empyema into chest wall and soft tissue. It is classically seen with TB or Actinomyces.
Types of diaphragmatic hernia: (2)
Back and Left: Bochdalek
Anterior and Right: Morgagni
DDx for pleural calcification: (5)
2. Old haemothorax
3. Old infection
5. Extraskeletal osteosarcoma.
- What is it associated with?
Associated with asbestos exposure
*** Pleural Rind***
If direct invasion and extension into fissure, then highly suggestive.
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 hypoglycaemia, hypertrophic osteoarthropathy
1. Adenocarcinoma- most likely:
2. Pleural effusion
Pleural and pericardial effusion
Fibrosis is uncommon but instead they will get shrinking lung.
NSIP > UIP
Patulous fluid filled oesophagus
Location and appearance
Similar to UIP/COP
Reticulation and honey combing with consolidative opacities: organising pneumonia.
CAPLAN SYNDROME (RA + Nodules)
What type of cystic lung disease?
LIP cystic lung disease
Extensive GGO and scattered thin walled cysts.
DDx for lung cavity:
Cancer- usu squamous cell
Vascular- septic emboli
Young- congenital- CCAMS. sequestration
Re Lemierre syndrome
- Bacterial agent
Jugular vein thrombosis with septic emboli classically after oropharyngeal infection or recent ENT surgery
Caused by Fusobacterium Necrophorum.
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
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.
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.
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.
Subtypes of adenocarcinoma:
1. Atypical adenocarcinoma Hyperplasia- AAH
2. Adenocarcinoma in situ- ACIS
3. Minimally invasive adenocarcinoma-MIA
T3 vs T4 vs M1
T3: Two in the same lobe
T4: two in different lobes but same lung
M1: two in different lungs
Wagerers or granulomatosis polyangitis
- Circumferential thickening- focal or long segment
- No calcification
- Subglottic involvement
- Sinuses and lungs - nasal perforation and cavity
- cANCA positive 90%
- Spares the posterior membrane.
- Cartillaginous and osseous nodules within submucosa of trachea and bronchial wall.
- Spares the posterior membrane.
- Diffuse thickening of the trachea
- No calcification
- Characterised by recurrent cartilage inflammation and recurrent pneumonia.
Post intubation stenosis
Focal subglottic circumferential stenosis with hour glass configuration
- Age group
Most common in children (4-11yrs)
Systemic disease affecting GI:
- Intussuception: Doughnut sign
Thumbprinting and massive skin oedema
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%
- Which organs are affected
Affects kidneys and lungs
Diffuse pulmonary haemorrhage in 1/3 of cases
pANCA positive 80%
Mouth and genital ulcers in turkish descent
Thickening of aorta and PAA
- Strong association with smoking
- Small and medium vessels in arms and legs - more common in legs
- Extensive arterial occlusive disease and development of corkscrew collateral vessels.
BUZZWORD: AUTO AMPUTATION
Name large and medium vessel vasculitis
- Takayasu- young asian girl
- Giant cell- crutches- SCA, Ax and brachial
- Cogans syndrome: Paeds with ear and eye symphonies and aortitis
- PAN- renal micro aneurysm- HepB
- Kawasaki- coronary artery aneurysm
Name small vessel vasculitis
- Wegeners- nasal septum erosion and cavity
- Churg Strauss- Transient peripheral lung consolidation
-Micro polyangitis- Diffuse pull haemorrhage
- HSP:Intussception and scrotal oedema
- Behcet: PAA
- Buergers- male smoker
Hand angio in exam...
Ulnar artery involved?
- YES: HHS
- NO: Fingers out: Buergers- corkscrew collateral
Kaposi in lung vs lymphoma
- Kaposi and lymphoma: Positive
- Kaposi Negative
- Lymphoma: Positive
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
- Most common lung tumour in AIDS.
- CD4 < 200
- Tracheobronchial and peripheral lung affected
- Bloody effusion.
BUZZWORD: Flame shaped
Thallium +ve and Gallium -ve
Most likely involves apical posterior segment of LUL. Blind ending bronchus filled with mucus: finger in glove. with distal lung hyper inflated from collateral drift and air trapping.
- Think of HHT/ Osler weber Rendu
- Usually in lower lobes- more blood flow: R-L shunt : stroke and brain abscess
- Treated when > 3mm
- Unilateral lucent lung post viral infections in childhood- post infectious
- Obliterative bronchiolitis
- Size of affected lobe is smaller- Not hyper expanded.
Unilateral absence of pectoral muscles- Unilateral hyper lucent chest
Can have limb issues
Vanishing lung syndrome
Idiopathic cause for giant bollous emphysema
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
Saber sheath trachea
Diffuse corna narrowing of trachea sparring the extra thoracic portion- pathognomonic for COPD.
Extra lobar sequestration
- Has its own pleural cover
- Systemic venous drainage
- Infancy with resp compromise, associated with:
- Diaph hernia
- Pulmonary hypoplasia
- Heart disease
- Vertebral anomaly
a) Intralobar- adolscence and adulthood with recurrent pneumonia
b) Exralobar: Infancy with resp compromise
- Most common in LLL post segment- uncommon in UL.
- Recurrent infection
- No pleural cover
- Pulmonary venous drainage.
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
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.
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.
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
What is considered as HIGH probability for PE on VQ scan?
Four moderate segmental defects
Bronchial tree blood supply:
2 left sided from the aorta and the single right side from the right 3rd posterior intercostal artery.
Opacity in the Raider triangle is......
Pacemaker wire goes through this valve, terminating in .....ventricle
TV and right ventricle
Most superior valve is
Obtuse margin with the lung, the lesion is in the
The differential diagnosis for ground glass in a central distribution (4)
1. Pulmonary edema.
2. Alveolar hemorrhage.
3. Pneumocys s jiroveci pneumonia.
4. Alveolar proteinosis.
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.
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.
3. Pulmonary hemorrhage.
4. Atypical pneumonia, especially PCP
Nodular, irregular, or asymmetric septal thickening DDx (2)
1. Lymphangitis carcinomatosis
What is crazy paving?
Septal thickening and GGO
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.
Lung cysts and AIDS
Lung cysts and GGO and Pneumothorax
Hyper vascular LN
Flame shaped perihilar opacity
Patient with TB and AIDS started on HAART therapy, now doing worse
Immune reconstitution inflammatory syndrome
calcified TB granuloma
Calcified TB granuloma AND calcified hilar node.
Healed primary TB
Fungal infection in impaired patient. Invading the mediastinum, pleura and chest wall. Reversed halo sign
Feeding vessel sign ddx
1. Septic emboli
2. Haematogenous mets
Pseudocavitation/bubble like licences and fried egg appearances and it is usually cold on PET
MIA- Minimally invasive adenocarcinoma
Cannonball metastases (2)
Causes of Lymphangitis carcinomatosis (4)
Which side of the heart is affected by chest and GI carcinoid tumours?
Chest : Left sided
GI: Right sided
Test to diagnose chest carcinoid
AIDS patient with lung nodules, pleural effusion and lymphadenopathy
AIDS-related pulmonary lymphoma (NHL)
CD4 < 100
CD4 count in kaposi sarcoma
Most common hepatic neoplasm in AIDS
KS vs Lymphoma
KS: Thallium positive, Gallium negative
Lymphoma: Thallium positive, Galium positive
Macroscopic fat and popcorn calcification
They can be hot on PET, they are still benign
Buzzword: Central dot sign
Centrilobular emphysema , UL
This type of emphysema is associated with alpha 1 antitrypsin and ritalin lung
Ddx egg shell Ca (4)
2. Coal worker
Perilymphatic nodular pattern ddx
Random nodular pattern ddx
1. Miliary TB
Centrilobular nodular pattern ddx
CF vs PCD
Abnormal mucus, cilia cannot move
Normal sperm, absent vas deferens
Normal mucus. cilia don't move
abnormal sperm , normal vas deferens
William Campbell Syndrome
congenital cystic bronchiectasis from deficiency of cartilage in 4-6th order bronchi
massive dilation of trachea > 3cm
Mounter Kuhn or tracheobronchomegaly