Approach to lung opacities This is hard! You will not be an expert - - PDF document

▶

Nov 20, 2023 44 likes •427 views

10/12/2018 Algorithmic Approach to Lung Opacities Brett M. Elicker, MD University of California, San Francisco Approach to lung opacities This is hard! You will not be an expert today Approach Practice Think like a

SLIDE 1

10/12/2018 1

Algorithmic Approach to Lung Opacities

Brett M. Elicker, MD University of California, San Francisco

Approach to lung opacities

This is hard!
You will not be an expert today
Approach
Practice
Think like a pathologist

SLIDE 2

10/12/2018 2

Categories of lung opacities

1. Consolidation
2. Interstitial (diffuse lines or nodules)
3. Airways
4. One or a few nodules

SLIDE 3

10/12/2018 3

Alveolar

Interstitial

SLIDE 4

10/12/2018 4

Airways

Not applicable

SLIDE 5

10/12/2018 5

Consolidation

Confluent opacity
Fluffy around periphery
Air bronchograms
Lack of volume loss

Confluent opacity, no volume loss

SLIDE 6

10/12/2018 6

Air bronchograms

SLIDE 7

10/12/2018 7

Well-defined: interstitial Ill-defined: alveolar

Consolidation

Acute vs. chronic symptoms
Distribution
Acuity of changes
Differential diagnosis in acute setting

– Focal: pneumonia/aspiration, hemorrhage – Diffuse: edema, acute lung injury, pneumonia, hemorrhage

SLIDE 8

10/12/2018 8

2 month f/u

SLIDE 9

10/12/2018 9

Invasive mucinous adenocarinoma 4 month f/u Chronic alveolar disease

Tumor

– Invasive mucinous adenocarinoma (aka multifocal bronchoalveolar CA) – Lymphoma (recurrent or 1° pulmonary)

Inflammatory

– Organizing pneumonia – Chronic eosinophilic pneumonia – Sarcoidosis

Other

– Lipoid pneumonia – Alveolar proteinosis

SLIDE 10

10/12/2018 10

Comparison

SLIDE 11

10/12/2018 11

Signs of atelectasis: volume loss

Fissure displacement Elevated diaphragm Deviation of mediastinal structures

Rapid change

SLIDE 12

10/12/2018 12

? atelectasis or an alveolar process

Atelectasis (types)

Obstructive/resorptive (obstruction of bronchus)
Passive (compression of lungs)
Cicatricial (related to scarring)
Adhesive (surfactant deficiency)

SLIDE 13

10/12/2018 13

Lung cancer (Golden S sign)

SLIDE 14

10/12/2018 14

Lower lobe atelectasis Combined RML/RLL atelectasis

SLIDE 15

10/12/2018 15

Left upper lobe collapse

1. Veil-like density
2. Volume loss

– Elevated diaphragm – Elevated left PA

Luftsichel sign

SLIDE 16

10/12/2018 16

Nodules Lines

Interstitial opacities

SLIDE 17

10/12/2018 17

Nodules: diff dx

Hematogenous spread

– Miliary tuberculosis – Miliary fungal infection (e.g. cocci) – Metastases

Lymphatic spread

– Sarcoidosis – Lymphangitic spread of tumor – Pneumoconioses (e.g. silica)

Histoplasmosis

SLIDE 18

10/12/2018 18

Miliary tuberculosis Interstitial: lines

SLIDE 19

10/12/2018 19

Causes of interstitial lines

Edema
Malignancy
Fibrotic lung diseases (this

is a long list)

Kerley-b lines may be present These lines are typically thick, wavy and irregular

Linear opacities

SLIDE 20

10/12/2018 20

Pulmonary edema (kerley-b lines)

SLIDE 21

10/12/2018 21

Reticular opacities (distribution)

Lower lobe predominant

– Idiopathic pulmonary fibrosis – Connective tissue disease – Drugs – Asbestosis – Hypersensitivity pneumonitis

Upper lobe predominant

– Sarcoidosis – Prior TB/fungus – Pneumoconioses

SLIDE 22

10/12/2018 22

Idiopathic pulmonary fibrosis Hypersensitivity pneumonitis

SLIDE 23

10/12/2018 23

Tuberculosis

SLIDE 24

10/12/2018 24

Airways disease

Circular
Tubular

SLIDE 25

10/12/2018 25

Differential diagnosis of airways disease

Mild:

– Asthma – Viral infection – Chronic bronchitis – Etc.

Severe:

– Bronchiolitis obliterans – Immunodeficiency – Ciliary dyskinesia – Cystic fibrosis – ABPA – Tuberculosis – Cartilage diseases

SLIDE 26

10/12/2018 26

Cystic fibrosis

Which compartment of lung is affected?

SLIDE 27

10/12/2018 27

Solitary pulmonary nodule: differential diagnosis

Granuloma
Hamartoma
Primary bronchogenic carcinoma
Metastasis
Lots of others

SLIDE 28

10/12/2018 28

Which one is malignant? Nodules: benign vs. malignant

Benign Malignant Small size Large size Smooth border Spiculated border Diffuse calcification No or irregular calcification Stability over time Growth over time

SLIDE 29

10/12/2018 29

Nodule: size Nodule: calcification

SLIDE 30

10/12/2018 30

Nodule borders So you see a nodule on CXR…

1. Is it actually a nodule?

SLIDE 31

10/12/2018 31

? nodule Shallow obliques

SLIDE 32

10/12/2018 32

? nodule Apical lordotic

SLIDE 33

10/12/2018 33

So you see a nodule on CXR…

1. Is it actually a nodule?
2. Look for prior films?
3. Is diffuse calcification present?

Dual energy subtraction x-ray

SLIDE 34

10/12/2018 34

So you see a nodule on CXR…

1. Is it actually a nodule?
2. Look for prior films?
3. Is diffuse calcification present?
4. Get a CT scan or a follow-up CXR

Category Subcategory CXR features Common causes Alveolar

Confluent opacities
Air bronchograms
Fluffy edges
Edema
Acute lung injury
Infection

Interstitial Nodules

Small, well‐defined nodules
Opacities not confluent
Normal lung between nodules
Tuberculosis
Fungal infection
Metastases
Sarcoidosis

Lines (kerley‐b)

Thin, fine, delicate lines
Lines at periphery of lung

(kerley‐b)

Pulmonary edema
Cancer

Lines (reticular)

Thick, wavy, irregular lines
Fibrotic lung

disease Airways

Circular or tubular
Thin or thick walled
Numerous causes

Not in a single compartment

One or a few nodules (≤3 cm) or

masses (>3 cm)

Lung cancer
Metastasis
Granuloma
Hamartoma

SLIDE 35

10/12/2018 35

Algorithmic Approach to Lung Opacities

On to the cases…

SLIDE 36

10/12/2018 36

SLIDE 37

10/12/2018 37

SLIDE 38

10/12/2018 38