Quiz 2 Flashcards
(116 cards)
1
Q
Do solitary masses have a silhouette sign??
A
Silhouette sign is unlikely
2
Q
Do solitary masses exhibit air bronchogram??
A
Air bronchogram unlikely
3
Q
Is atelectasis possible with solitary masses?
A
Atelectasis possible
4
Q
What is the DDX list for solitary masses? (8)
A
Bronchogenic carcinoma Hematogenous metastasis Hamartoma Tuberculoma, other granuloma Lung abscess Hydatid cyst Hematoma Bronchopulmonary sequestration
5
Q
What % of patients under 30 have a possibility of a malignant solitary mass?
A
<1%
6
Q
What % of patients 30-45 have a possibility of a malignant solitary mass?
A
15%
7
Q
What % of patients older than 45 have a possibility of a malignant solitary mass?
A
50%
8
Q
What are some benign types of calcifications? (4)
A
Diffuse
Central
Popcorn
Concentric
9
Q
What are some questionable types of calcifications? (2)
A
Stippled and Eccentric
10
Q
What are different types of bronchogenic carcinoma? (4)
A
Adenocarcinoma
Squamous cell carcinoma
Small (a.k.a. oat cell) carcinoma
Large cell carcinoma
11
Q
What is the most frequently diagnosed maligancy and what age is it most commonly diagnosed?
A
Bronchogenic carcinoma and 55-60 y.o.
12
Q
What % of lung cancer deaths associated with smoking are caused by bronchogenic carcinoma?
A
80-85% of lung cancer deaths associated with smoking
13
Q
What are some bronchogenic carcinoma signs and symptoms (7)
A
Cough Wheezing Dyspnea Hemoptysis Chest pain Weight loss Asymptomatic
14
Q
What are some complications of bronchogenic carcinoma?
A
Phrenic nerve palsy - Hemidiaphragm paralysis Superior vena caval syndrome -Swelling of neck, face -Dizziness -Vision change -Syncope -Stupor Recurrent laryngeal nerve palsy -Hoarseness
15
Q
What is the treatment of bronchogenic carcinoma?
A
Surgery
Chemotherapy
Radiation therapy
Combination
16
Q
What is the prognosis of bronchogenic carcinoma?
A
Dependent on
- Stage at presentation
- General health
- Age
- Histological type of tumor
- Growth rate
- Therapy
17
Q
What are some radiographic findings of bronchogenic carcinoma?
A
Solitary mass - Mediastinal - Apical - Lung field Atelectasis possible Hilar enlargement possible Cavitation possible Pleural effusion possible
18
Q
What do pancoast tumors present as? (3)
A
Squamous cell or adenocarcinoma Mass in apex - Look for rib or vertebra destruction Clinical presentation -Horner’s syndrome -Arm / shoulder pain -Asymptomatic
19
Q
Where are possible primary sites that cause mets?
A
Breast, kidney, ovary, testis, colon, thyroid, sarcoma, malignant melanoma
20
Q
What is the appearance of mets? (5)
A
Multiple masses (95%)(5% solitary) Often smooth, rounded Uniform or variable size Pleural effusion possible Pleural mass possible
21
Q
What is the most common benign tumor?
A
Hamartoma
22
Q
What does a hamartoma contain?
A
Normal tissue elements, unorganized
23
Q
What is the peak incidence age of hamartomas?
A
Peak incidence 50-60 y.o.
24
Q
Are hamartoma’s usually found centrally or peripherally?
A
Peripherally
25
Are syymptoms common with hamartomas?
Symptoms rare
26
What are the radiographic findings of a hamartoma? (3)
Solitary mass
Usually < 4cm
Popcorn calcification possible
27
What are the 3 granuloma infections?
Tuberculosis
Histoplasmosis
Coccidiodomycosis
28
What does TB look like?
Diffuse, localized or mass (single or multiple)
29
What is histoplasmosis caused by?
- Mold spore inhalation; endemic to central and eastern USA, eastern Canada, Mexico, Central and South America, Africa, SE Asia
- Asymptomatic or mild to severe URTI
30
What is coccidiodomycosis caused by?
- Mold spore inhalation; endemic in arid soil of SW USA, Mexico, Central and South America
- Variable infectious presentation
31
What do lung abscesses present like?
Single or multiple masses
- > 2cm
- Usually air-fluid level
32
What are some predisposing factors of a lung abscess?
Predisposing factors
- Aspiration
- Alcoholism, neurological disease
- Intubation
- Bronchiectasis, bronchial obstruction
33
What are hydatid cysts caused by?
Echinococcus (dog tapeworm); humans are intermediate host
34
Where do hydatid cysts affect in the body?
May involve liver, lung, spleen, kidney, bone, CNS
35
Where are hydatid cysts most prevalent?
Most prevalent Greece, Argentina, New Zealand
36
What serious complication can come from a ruptured hydatid cyst?
anaphylactic shock
37
What are the ddx for multiple masses?
```
Pulmonary metastasis
Lymphoma
Granulomatous infection
- TB, histoplasmosis, coccidioidomycosis
Rheumatoid nodules
Wegener’s granulomatosis
```
38
Where does Hodgkin's lymphoma originate?
90% originate in lymph nodes; 10% in extranodal lymphoid tissue of lung, GI, skin
39
What peak ages does Hodgkin's lymphoma affect?
Peak ages 30 and 70 years
40
Where does Hodgkin's lymphoma typically present?
- 95% superior mediastinal node involved
| - 15% lung masses; 15% pleural effusions
41
Where does non-Hodgkin's lymphoma originate?
60% originate in lymph nodes; 40% in extranodal lymphoid tissue
42
How does Hodgkin's lymphoma typically present?
- Mediastinal and hilar adenopathy
| - Lung involvement possible without adenopathy
43
What can cause an icrease in incidence of non-hodgkin's lymphoma?
Increased incidence with immune suppression
44
What causes Wegener's Granulomatosis?
- Systemic; autoimmune; relatively rare
| - Perivascular inflammation leads to granuloma formation
45
How does Wegener's Granulomatosis usually present?
Multiple nodules; cavitation common
46
how often does wegener's granulomatosis present with pleural effusion?
1/4
47
Is adenopathy common with wegener's granulomatosis?
No it is rare
48
What lung base change occurs with wegener's granulomatosis?
Interstitial changes in lung bases
49
Ho does interstitial disease usually present?
- Thickened interlobular septa, alveolar walls; interstitial lymph, veins, cells
- Usually a diffuse pattern of involvement
- Often combined with consolidation
50
What are the 5 ways that interstitial patterns can present?
- Ground Glass
- Linear (reticular) - fibrosis
- Nodular (granulomas)
- Reticulonodular (inflmmation)
- Honeycombing (end stage lung disease
51
What are ddx for interstitial?
```
Pulmonary edema
Infection
- Viral, TB, fungal, PCP
Idiopathic
- IPF, sarcoidosis
Collagen vascular diseases
- RA, scleroderma, AS
Extrinsic agents
- Pneumoconiosis, drugs
Tumors
- Lymphangitic metastasis, eosinophilic granuloma
```
52
What are disease that decrease radiographic density? (5)
Pneumothorax
Emphysema
Cystic disease
- Congenital
- Infectious
- Post-traumatic
Air trapping
- Obstruction (Foreign body)
Asthma (mucous plugs + constriction)
Inspiration vs. expiration films may help
Compensatory hyperexpansion
Congenital
53
What are some radiographic findings of decreased radiographic density?
Hyperlucency
- Lobar, segmental, subsegmental, general
- With or without hyperexpansion
Decreases lung markings
54
What are some pneumothorax radiographic findings?
```
Visceral pleura visible
No lung markings peripheral to pleura
Possible signs of atelectasis
-Passive / compressive
Upright expiration PA more sensitive
Lateral decubitus may be helpful
```
55
What are the different types of pneumothorax?
Spontaneous and traumatic
56
What population does primary spontaneous pneumothorax occurs in?
Tall, thin females
57
What are some causes of secondary spontaneous pneumothorax?
Underlying lung disease
Bullae, blebs
Air trapping
58
What is a traumatic pneumothorax caused by?
Trauma
| Iatrogenic
59
What does a tension pneumothorax do?
```
Valve effect with progressive accumulation of air
Shift of mediastinum
Leads to vascular compromise
Medical emergency
- Chest tube
```
60
What is the most common physical finding of primary spontaneous pneumothorax?
Tachycardia is most common physical finding
Hypotension, cyanosis and tachycardia may suggest tension pneumothorax
61
What happens during the lung exam of a large pneumothorax?
- Decreased or absent breath sounds on affected side,
- Decreased chest wall motion,
- Hyperresonance to percussion,
- Decreased fremitus
62
What are the risk factors for recurrence for a primary spontaneous pneumothorax? (5)
```
Pre-existing lung disease
Tall stature
Female gender (?)
Smoking
Younger age
```
63
When do most recurrences of pneumothorax occur?
Most recurrences occur within 6 months to two years after initial pneumothorax
64
What are some pneumothorax symptoms? (6)
1) Chest pain
2) Dyspnea
3) Onset during rest
4) Diminished breath sounds
5) Decreased tactile fremitus
6) Hyperresonance on percussion
- Larger
65
What are some pneumothorax treatments? (3)
1) Chest tube
- All symptomatic cases
- Any >15% loss
- Tension = emergency
2) Monitor
- Asymptomatic and <15% may resolve
3) Recurrence
- UP to 50%
- Increased with altitude extremes
- Smoking increases
66
What is emphysema? (3)
1) Enlarged air spaces with destruction of alveolar walls
- Usually due to COPD, usually chronic bronchitis
2) Correlate with functional tests
3) Moderate to severe changes seen on CXR; mild seen on HRCT
67
What are some radiographic changes with emphysema? (5)
1) Flattened, depressed hemidiaphragms
2) Hyperlucency
3) Increased retrosternal clear space
4) Increased AP chest diameter
5) Decreased peripheral vascular markings
68
What are some pleural abnormalities? (3)
1) Pleural effusion
- Transudate, exudate, blood, pus, lymph
2) Pleural masses
- Loculated effusion
- Neoplasm
- Extrapleural sign
3) Calcifications
69
How much fluid fluid is normally in the pleural space?
Normally 2-10 cc of fluid in pleural space;
70
How much fluid is produced by parietal pleura each hour?
As much as 100 cc fluid produced by parietal pleura each hour;
71
How does a fluid drain from the pleural space?
Fluid drains to visceral pleura via lymphatics;
72
Where does fluid accumulate in the pleural space?
> 75 cc accumulates posterior costophrenic blunts
73
How much fluid needs to accumulate for the costophrenic angle to become blunted?
200-300 cc accumulates lateral CP become blunted
74
What is a meniscus sign?
1) Blunting of the costophrenic angles due to pleural fluid accumulation (also subpulmonic fluid)
2) Need to determine the underlying cause of the fluid accumulation
75
What are some Pleural Effusion ddx? (9)
1) CHF
2) Pneumonia
3) Neoplasm
4) Infection (empyema)
5) Trauma
6) Embolism
7) Connective tissue disease
8) TB
9) Abdominal disease
- Pancreatitis, cirrhosis
76
What are some pleural effusion symptoms? (7)
- Dyspnea
- Pleuritic chest pain
- Dry cough
- Tactile fremitus increased
- Dullness to percussion
- Decreased breath sounds
- Small effusions usually asymptomatic
77
What are some ways to manage pleural effusion? (2)
1)Thoracentesis
- Reduces symptoms
- Provides tissue for lab evaluation (Culture & sensitivity,
Histology, Chemistry)
2) Treatment of underlying disease
78
What are some causes of pleural masses? (3)
1) Loculated effusion
2) Neoplasm
- Primary: mesothelioma (malignant), fibroma (benign)
- Secondary: breast, bronchus most common
3) Extrapleural sign
- Rib lesion
79
What are some causes of pleural calcifications? (3)
1) Asbestos-related pleural disease
- Other inhalation diseases
(Talcosis, Silicosis)
2) Old empyema
- More localized; history
3) Old hemothorax
- More localized; history
80
What are the asbestos related disease findings? (4)
1) Pleural plaques
2) Diffuse pleural thickening
3) Pleural effusions
4) Interstitial pulmonary fibrosis
81
What is the most common change in with asbestos related disease?
Pleural plaques
82
What is the radiographic finding for pleural plaques?
1) 15% visible on CXR
| 2) May calcify (pathognomonic of asbestos exposure); takes up to 20 years
83
What are the pathoanatomical findings with diffuse pleural thickening?
1) May cause respiratory symptoms
| 2) Thickened fissures; round atelectasis
84
How does interstitial pulmonary fibrosis due to asbestosis appear?
- Reticular, linear
- Initially subpleural
- Begins at base, moves to apex
- Honeycombing late stages
- No adenopathy
85
What does types of cancer does asbestos increase the risk for?
1) 7000x increased incidence of mesothelioma
- 10% lifetime risk
- Usually >30 years after exposure
2) 7x increased risk of bronchogenic CA
- Exponential increase with smoking
3) 3x increased risk of GI neoplasm
86
What is the DDX for unilateral hilar enlargement ?
Bronchogenic carcinoma
87
What are the DDX for bilateral hilar enlargement? (3)
1) Lymphoma
2) Infection (granulomatous)
3) Sarcoidosis
88
What are the DDX for unilateral hemidiaphragm elevation? (5)
1) Atelectasis
2) Phrenic nerve palsy
3) Splinting
4) Eventration
5) Subphrenic inflammation
89
What are the DDX for bilateral hemidiaphragm elevation? (5)
1) Poor inspiration
2) Obesity
3) Pregnancy
4) Ascites
5) Hepato-splenomegaly
90
In a normal lateral radiograph of the thorax, what are the borders of the anterior portion of the mediastinum?
Sternum to anterior cardiac silhouette = anterior (retrosternal) clear space
- Sternum to posterior heart border
91
In a normal lateral radiograph of the thorax, what are the borders of the middle portion of the mediastinum?
Anterior to posterior cardiac silhouette
| - Posterior heart border to 1 cm posterior to the anterior vertebral bodies
92
In a normal lateral radiograph of the thorax, what are the borders of the posterior portion of the mediastinum?
Posterior cardiac silhouette to posterior border of lung field
- From line 1 cm posterior to anterior vertebral bodies to posterior chest wall
93
What are the contents of the anterior mediastinum? (2)
1) Thymus gland
| 2) Lymph nodes
94
What are the pathologies in the anterior mediastinum? (4)
1) Retrosternal goiter
2) Hodgkin’s lymphoma
3) Thymic mass
4) Thymoma
-Germ cell tumor
(4 T's (Thyroid goiter, Thymic mass, Thymoma, Terrible Hodgkin's Lymphoma)
95
Are thyroid goiter's more common or thyroid neoplasms?
Much more common than thyroid neoplasm
96
What portion of the mediastinum is continuous with the thyroid gland?
Superior mediastinum; continuous with thyroid gland
97
What is the most common finding of a CXR that happens with thyroid goiters?
Tracheal displacement most common finding on CXR
98
How do you diagnose a thyroid goiter?
Dx: nuclear medicine scan; CT with contrast strongly suggestive
99
What is the most common anterior mediastinal mass in adults?
Thymoma
100
What specific conditions are common with those that have a thymoma? (2)
1) 35% have myasthenia gravis; 15% of MG patients have thymoma;
2) 50% with aplastic anemia have thymoma
101
What % of thymoma are benign?
75%
102
What population do thymolipoma occur?
children, young adults
103
What conditions can result in benign thymic hyperplasia? (4)
1) MG
2) thyrotoxicosis
3) collagen vascular disease, 4) rebound thymic hyperplasia (chemotherapy, Addison’s, acromegaly)
104
What are germ cell tumors?
Primitive rest cells; variable malignant potential
105
Which is the most common type of germ cell tumor?
Teratoma (70% of germ cell tumors); 20% malignant = teratocarcinoma
106
What are the contents of the middle mediastinum? (7)
1) Pericardium
2) Heart
3) Great and pulmonary vessels
4) Phrenic nerve
5) Upper vagus nerves
6) Trachea, primary bronchi
7) Lymph nodes
107
What are the pathologies of the middle mediastinum? (4)
1) Lymphadenopathy
2) Bronchogenic carcinoma
3) Aneurysm
4) Bronchogenic cyst
108
Are thoracic aneurysms often symptomatic?
Most asymptomatic
109
What are some clinical symptoms of thoracic aneurysm?
Clinical symptoms = very large, expanding, or contained rupture
110
What are some causes of thoracic aneurysm?
1) Atherosclerosis
2) Connective tissue disease (Marfan's, etc)
3) Syphilis
4) Posttraumatic
5) Mycotic
6) Aortitis
111
What are the contents of the posterior mediastinum? (7)
1) Descending thoracic aorta
2) Esophagus
3) Thoracic duct
4) Azygous, hemiazygous veins
5) Sympathetic ganglia
6) Lower vagus nerves
7) Lymph nodes
112
What are the pathologies of the posterior mediastinum? (6)
1) Hiatal hernia
2) Neurogenic tumors
3) Paravertebral masses
4) Meningocele
5) Esophageal masses
6) Aneurysm
113
What hiatal hernia is more common?
Sliding (95%), Paraesophageal (5%)
114
What is a sliding hernia and what can it cause??
- GE junction above hemidiaphragm
- Reflux if large
- May reduce when upright
- Esophagitis (25%); duodenal ulcer (20%)
115
What is a paraesophageal hernia and what can it cause??
- GE junction below hemidiaphragm
- Fundus above diaphragm
- More complications
116
What is the choice imaging for following up an abnormal plain film in the chest?
- Follow-up for abnormal plain film = CT
- Masses
- Mediastinal abnormalities
- Unexplained pleural effusion or atelectasis
- Recurrent consolidation, atelectasis, effusion
- Negative plain film; high clinical suspicion
