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Flashcards in Chest Deck (135):
1

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

2

Name the different types of pathology with thymus (4)

1. Rebound thymus secondary to stress/chemo
2. Cysts
3. Thymoma (non invasive --> invasive (+/- calcification)
4. thymolipoma- fat and soft tissue

3

What are the associations with thymoma? (3)

1. Myasthenia Gravis
2. Pure red cell aplasia
3. Hypogammaglubinaemia

4

Name the anterior mediastinal masses:

Thymoma
Teratoma
Thyroid
Terrible lymphoma

5

Most common teratoma in anterior mediastinum:

Germ cell tumour

6

What is the appearance of teratoma?

Cystic mass + fat +/- calcification ?teeth

7

What is the most common location for pericardial cyst?

Right anterior cardiophrenic angle.

8

Name the posterior mediastinal masses: (2 and then 7)

a) Neurogenic:
- Schwannoma
- Neurofibroma
- Peripheral nerve sheath tumour
b) BM
- Extra medullary haematopoiesis
- CML
- Myelofibrosis
- Thalasaemia

9

Name the middle mediastinal masses: (4)

1. Lymphadenopathy
2. Bronchogenic cyst
3. Fibrosing mediastinitis
4. Mediastinal lipomatosis- Obesity/cushing/ streroid

10

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

11

Re Pulmonary alveolar proteinosis-PAP
a) What are they at increased risk?
b) Appearances?
c) Treatment?

a) increased risk of Nocardia infection- brain abscess
b) Crazy paving with septal thickening and GG
c) Bronchoalveolar lavage

12

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

13

What are the DDx for crazy paving? (5)

ie septal thickening and GG

1. PAP
2. Oedema
3. Haemorrhage
4. BAC
5. Acute interstitial pneumonia

14

What differentiates a benign from malignant nodule? (3)

Malignant:
1. Spiculated margin
2. Air bronchogram through nodule- usu adenocarcinoma in situ
3. Partially solid lesion with GG component
Benign:
1. Fat
2. Rapid doubling time
3. Slow doubling time

15

Re Squamous cell lung cancer:

1. where is it located?
2. Ectopic ?
3. Example

1. It is centrally located +/- cavitation
2. Ectopic PTH
3. Pancoast tumour

16

What type is a pancoast tumour?

Squamous cell

17

Re Small cell lung cancer:

1. Location
2. Paraneoplastic

1. Central, near main lobarbronchi
2. Paraneoplastic ACTH/SIADH

18

Where is large cell lung cancer usually located?

It is usually peripheral.

19

What is a Lambert Eaton syndrome?

Proximal muscle weakness secondary to ACh near NMJ.

20

Where is the predominance of NSIP?

Lower lobes, posterior and peripheral predominance with sparring of the immediate subpleural spaces.

21

What causes NSIP? (2)

1. Collagen vascular disease
2. Drug reaction

22

What is the histology in UIP?

Heterogenous

23

List the differences between NSIP and UIP:

NSIP:
Homogenous histology.
GG and micronodules.
Most common in scleroderma.


UIP:
Heterogenous histology
Honeycombing and traction bronchiectasis

24

RB-ILD- Smoking related

1. Predominance?
2. When to call it?

1. UL- apical centrilobular GG nodules
2. Resp bronchiolitis and symptoms.

25

DIP- smoking related- end spectrum of RB-ILD

Appearances?

More diffuse GGO with patchy/subpleural distribution mainly in the lower lobes with some small cystic spaces.

26

What is Hughes Stovin syndrome?

This is a PA aneurysm similar or is Behcet.
They get recurrent thrombophlebitis and PAA and rupture.

27

What is a Behcet?

Genital and mouth ulcers.
Turkish descent
Aorta thickening
PAA

28

What is sarcoid staging?

0- Normal
1- Hilar/mediastinal nodes only
2. Nodes + parenchymal disease
3. Parenchymal disease
4. END STAGE- FIBROSIS

29

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.

30

What is sarcoid? Define
Location?
Biochemical?

It is a non caseating granulomas.
Perilymphatic nodules with UL predominance.
Raised ACE and Ca

31

List DDx for reverse halo (ATOL) sign: (5)

1. COP- CLASSIC
2. Fungal pneumonia
3. TB
4. Wegeners
5. Pulmonary infarct

32

List DDx for halo sign (5)

1. Invasive aspergillosis- CLASSIC
2. Other Fungus
3. Haemorrhagic mets including melanoma
4. Wegeners
5. BAC

33

Re hypersensitivity pneumonitis

What is it caused by?
BUZZWORD?

This is caused by inhaled organic antigen.

BUZZWORD: HEAD CHEESE- mix of everything: GG/consolidation/ air trapping

34

Re organising pneumonia

What is a COP?
What are the causes? (4)
Treatment?
What is the main DDx?

When cause is not known: COP: Reverse halo sign

Causes of organising pneumonia:
1. Idiopathic,
2. Collagen vascular disease
3. Drugs (amiodarone)
4. Infection

Treatment: steroid with good prognosis.- No fibrosis.

DDx: Chronic eosinophilic pneumonia

35

Re Chronic eosinophilic pneumonia

What is it?
DDx?
CT?

Peripheral eosinophilia +/- asthma

Looks similar to COP

CT: peripheral GGO/consolidation UL

36

What is a Caplan syndrome?

RA with UL lung nodules which can cavitate
+/- pleural effusion.

37

Re Ankylosing spondylosis:

- Which lobes?

- UL fibrobullous disease

Usually unilateral first --> Bilateral

38

1) What is a shrinking lung syndrome?
2) What condition is associated with shrinking lung?
3) Causes?

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.

39

Re Granulomatous Wegeners:(AKA Granulomatosis with polyangitis)

a) Which organs are affected?
b) Appearance?
c) Markers?

a)
1) Upper tract/ sinuses
2) Lungs
3) Kidneys
b) Nodules with cavitation +/- GG secondary to haemorrhage.
c) cANCA +ve in 90 %

40

Causes of pulmonary hypertension:

PA pressure > 25 mmHg

1. Primary- idiopathic, uncommon
2. Secondary:
- Chronic PE
- Right sided heart strain
- Lung parenchymal disease- Fibrosis and emphysema

41

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.

42

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.

43

Re Fat embolism:

- RF
- Triad/ organs affected
- Timing?

- After long bone fracture or IM rod placement.
- Affects brain (changed mental state), skin (rash) and lung (SOB).
- Timing 1-2 days after #

44

Re Pseudomonas:

Appearance:
Typical patient group:

Patchy opacification with abscess formation

ICU patients on ventilators/ CF and PCD

45

Re Legionella

Appearance:
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.

46

Re Anthrax:

Appearance

Haemorrhagic lymphadenitis, mediastinitis and haemothorax.

Mediastinal widening with pleural effusionin setting of bioterrorism.

47

Re Klebsiella:

Appearance
Typical patient group:
What colour sputum?

BULGING fissure
Pleural effusion with empyema and cavity
Alcoholic and NH resident
Current jelly sputum.

48

What are the 3 main differences between empyema and abscess?

Empyema: Abscess:
- Lentiform - Round
- Split pleural sign - Claw sign-acute angle w pleura
- Treated with chest drain -Not tx with drain risk of fistula

49

Define empyema necessitans:

Extension of empyema into chest wall and soft tissue. It is classically seen with TB or Actinomyces.

50

Types of diaphragmatic hernia: (2)

Back and Left: Bochdalek
Anterior and Right: Morgagni

51

DDx for pleural calcification: (5)

1. Asbestos
2. Old haemothorax
3. Old infection
4. TB
5. Extraskeletal osteosarcoma.

52

Re Mesothelioma:

- What is it associated with?
- Buzzword

Associated with asbestos exposure
*** Pleural Rind***
If direct invasion and extension into fissure, then highly suggestive.

53

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

54

Pleural mets:

1. Adenocarcinoma- most likely:
- Lung
- Breast
- Lymphoma
2. Pleural effusion

55

Lupus

Pleural and pericardial effusion
Fibrosis is uncommon but instead they will get shrinking lung.

56

Scleroderma
Location
GI symtoms

NSIP > UIP
LL
Patulous fluid filled oesophagus

57

Rheumatoid arthritis

Location and appearance

LL
Similar to UIP/COP
Reticulation and honey combing with consolidative opacities: organising pneumonia.
Pleural effusion.

CAPLAN SYNDROME (RA + Nodules)

58

Sjogren
What type of cystic lung disease?

LIP cystic lung disease
Extensive GGO and scattered thin walled cysts.

59

DDx for lung cavity:

Cancer- usu squamous cell
Autoimmune- Wegener's/RA
Vascular- septic emboli
Infection-TB
Trauma- Pneumatocele
Young- congenital- CCAMS. sequestration

60

Re Lemierre syndrome

- Define
- Bacterial agent

Jugular vein thrombosis with septic emboli classically after oropharyngeal infection or recent ENT surgery

Caused by Fusobacterium Necrophorum.

61

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

62

Aspergillus

types:

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.

63

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.

64

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.

65

Subtypes of adenocarcinoma:

1. Atypical adenocarcinoma Hyperplasia- AAH
2. Adenocarcinoma in situ- ACIS
3. Minimally invasive adenocarcinoma-MIA

66

T3 vs T4 vs M1

T3: Two in the same lobe
T4: two in different lobes but same lung
M1: two in different lungs

67

Wagerers or granulomatosis polyangitis

- Circumferential thickening- focal or long segment
- No calcification
- Subglottic involvement

- Sinuses and lungs - nasal perforation and cavity
- cANCA positive 90%

68

TBO

TracheoBronchopathia Osteochondroplasia

- Spares the posterior membrane.
- Cartillaginous and osseous nodules within submucosa of trachea and bronchial wall.

69

Relapsing polychondritis

- Spares the posterior membrane.
- Diffuse thickening of the trachea
- No calcification
- Characterised by recurrent cartilage inflammation and recurrent pneumonia.

70

Post intubation stenosis

Focal subglottic circumferential stenosis with hour glass configuration

71

HSP

- Age group
- Symptoms

Most common in children (4-11yrs)
Systemic disease affecting GI:
- Intussuception: Doughnut sign
- Pain
- Blood
- Diarrhoea
Thumbprinting and massive skin oedema

72

Churg Strauss

- Define
- Appearances
- Marker

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%

73

Microscopic polyangitis

- Which organs are affected
- Marker

Affects kidneys and lungs
Diffuse pulmonary haemorrhage in 1/3 of cases
pANCA positive 80%

74

Behcet

Mouth and genital ulcers in turkish descent
Thickening of aorta and PAA

75

Buergers

BUZZWORD

- 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

76

Name large and medium vessel vasculitis

Large:
- Takayasu- young asian girl
- Giant cell- crutches- SCA, Ax and brachial
- Cogans syndrome: Paeds with ear and eye symphonies and aortitis

Medium:
- PAN- renal micro aneurysm- HepB
- Kawasaki- coronary artery aneurysm

77

Name small vessel vasculitis

ANCA +ve:
- Wegeners- nasal septum erosion and cavity
- Churg Strauss- Transient peripheral lung consolidation
-Micro polyangitis- Diffuse pull haemorrhage

ANCA -ve:
- HSP:Intussception and scrotal oedema
- Behcet: PAA
- Buergers- male smoker

78

Hand angio in exam...

Ulnar artery involved?
- YES: HHS
- NO: Fingers out: Buergers- corkscrew collateral

79

Kaposi in lung vs lymphoma

-NM

Thallium:
- Kaposi and lymphoma: Positive

Gallium:
- Kaposi Negative
- Lymphoma: Positive

80

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

81

Kaposi sarcoma

CD4?
BUZZWORD
NM

- Most common lung tumour in AIDS.
- CD4 < 200
- Tracheobronchial and peripheral lung affected
- Bloody effusion.

BUZZWORD: Flame shaped

Thallium +ve and Gallium -ve

82

Bronchial atresia

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.

83

AVM

- Think of HHT/ Osler weber Rendu
- Usually in lower lobes- more blood flow: R-L shunt : stroke and brain abscess
- Treated when > 3mm

84

Swyer James

- Unilateral lucent lung post viral infections in childhood- post infectious
- Obliterative bronchiolitis
- Size of affected lobe is smaller- Not hyper expanded.

85

Poland

Unilateral absence of pectoral muscles- Unilateral hyper lucent chest
Can have limb issues

86

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

87

Saber sheath trachea

Diffuse corna narrowing of trachea sparring the extra thoracic portion- pathognomonic for COPD.

88

Extra lobar sequestration

- 25%
- Has its own pleural cover
- Systemic venous drainage
- Infancy with resp compromise, associated with:
- CCAM
- Diaph hernia
- Pulmonary hypoplasia
- Heart disease
- Vertebral anomaly

89

Sequestration types:

a) Intralobar- adolscence and adulthood with recurrent pneumonia

b) Exralobar: Infancy with resp compromise

90

Intralobar sequestration

- 75%
- Most common in LLL post segment- uncommon in UL.
- Recurrent infection
- No pleural cover
- Pulmonary venous drainage.

91

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

92

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.

93

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.

94

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

95

What is considered as HIGH probability for PE on VQ scan?

Four moderate segmental defects

96

Bronchial tree blood supply:

Bronchial arteries:

2 left sided from the aorta and the single right side from the right 3rd posterior intercostal artery.

97

Opacity in the Raider triangle is......

aberrant RSCA

98

Pacemaker wire goes through this valve, terminating in .....ventricle

TV and right ventricle

99

Most superior valve is

PV

100

Obtuse margin with the lung, the lesion is in the

mediastinum

101

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.

102

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.

103

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

104

Nodular, irregular, or asymmetric septal thickening DDx (2)

1. Lymphangitis carcinomatosis
2. Sarcoid

105

What is crazy paving?

Septal thickening and GGO

106

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.

107

Lung cysts and AIDS

LIP

108

Lung cysts and GGO and Pneumothorax

PCP

109

Hyper vascular LN

Castlemans
Kaposi

110

Flame shaped perihilar opacity

Capos sarcoma

111

Patient with TB and AIDS started on HAART therapy, now doing worse

Immune reconstitution inflammatory syndrome

112

Ghon lesion

calcified TB granuloma

113

Ranke complex

Calcified TB granuloma AND calcified hilar node.
Healed primary TB

114

Fungal infection in impaired patient. Invading the mediastinum, pleura and chest wall. Reversed halo sign

Mucormycosis

115

Feeding vessel sign ddx

1. Septic emboli
2. Haematogenous mets

116

Pseudocavitation/bubble like licences and fried egg appearances and it is usually cold on PET

MIA- Minimally invasive adenocarcinoma

117

Cannonball metastases (2)

RCC
Choriocarcinoma

118

Causes of Lymphangitis carcinomatosis (4)

Breast
Stomach
Pancreas
Prostate

119

Which side of the heart is affected by chest and GI carcinoid tumours?

Chest : Left sided
GI: Right sided

120

Test to diagnose chest carcinoid

Octreotide

121

AIDS patient with lung nodules, pleural effusion and lymphadenopathy

AIDS-related pulmonary lymphoma (NHL)
CD4 < 100

122

CD4 count in kaposi sarcoma

< 200

123

Most common hepatic neoplasm in AIDS

Kaposi Sarcoma

124

KS vs Lymphoma

KS: Thallium positive, Gallium negative
Lymphoma: Thallium positive, Galium positive

125

Diagnosis?
Macroscopic fat and popcorn calcification

Hamartoma
They can be hot on PET, they are still benign

126

Buzzword: Central dot sign

Centrilobular emphysema , UL

127

This type of emphysema is associated with alpha 1 antitrypsin and ritalin lung

pan lobular
LL

128

Ddx egg shell Ca (4)

1. Silicosis
2. Coal worker
3. Sarcoid
4. Histoplasmosis

129

Perilymphatic nodular pattern ddx

1. Sarcoid
2. LC
3. Silicosis

130

Random nodular pattern ddx

1. Miliary TB
2. Mets
3. Fungal

131

Centrilobular nodular pattern ddx

Infection
Rb-ILD
Hypersensitivity pneumonitis

132

CF vs PCD

CF:
Abnormal mucus, cilia cannot move
Normal sperm, absent vas deferens
UL bronchiectasis

PCD:
Normal mucus. cilia don't move
abnormal sperm , normal vas deferens
LL Bronchiectasis

133

William Campbell Syndrome

congenital cystic bronchiectasis from deficiency of cartilage in 4-6th order bronchi

134

massive dilation of trachea > 3cm

Mounter Kuhn or tracheobronchomegaly

135

PLEURAL CA++ DDX

1. old haemothorax
2. old infection
3. TB
4. Extra-skeletal osteosarcoma