Standing PA

Basic Interpretations of CXR (1) ૅ೽YӀТ୷ҁղ᠐໪ޕ!

୯ੀᆕӝᙴଣܫ৔ጕࣽ! !஭҉மᙴৣ! 2017/11/18!

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Standing chest radiograph in lateral (Lat) view --- Rt / Lt Supine AP chest radiograph

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Correlation between frontal radiograph of the chest (A) and the frontal view of MIP image of MRA (B) CXR reading

• Name, chart Number, date • Quality of CXR Film • Age, Gender, characteristics of body built • Position • Reading sequence • Patterns of Lesions • Impression and Management

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Evaluation of size by standing PA CXR • Cardiothoracic index (ratio) = (A1+A2)/B • Normal C-T index:

<5 y/o : < 0.5-0.6 > 5 y/o : < 0.5

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Congenital heart disease

• 1st costal cartilage calcification烉 30~40 y • Tortuous aorta烉50~60 y • Aortic knob calcification烉> 70 y Tetralogy of Fallot Patent ductus arteriosus 11 1212 M/70 F/76

Mitral stenosis Sliding hiatal Æ Enlarged left hernia of atrium stomach

0 M/77, Æ CXR at ER CXR for trauma at ER

Right-sided aorta

Double aortic arch 15 16

F/34, physical A supine AP CXR of a 1 year-old male check-up

Situs inversus totalis

17 A large thymus gland 18 Pathological features/radiological Radiological signs for localizations signs on CXR • Signs for localizations of lesions •• 瀥灙⽝() • Signs related to lung collapse •• 柠傠⽝(Cervicothoracic sign) • Signs related to pleural lesions •• 偢攨央味⽝() • Signs related to malignancy •• 偢攨䵲普⽝(Hilum convergence sign) • Sign for pneumomediastinum •• 澡兄⢾䕭䀞⽝(Extrapleural sign) • Signs for pneumothorax •• 澵⬴ℐ怲䶋⽝(Incomplete border sign) • Other signs 䨢㯋㓗㯋䭉⁷⽝ •• (Air bronchogram sign)

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F/2m, CC: Fever, CXR (2011-09-05) Silhouette sign Æ suspected RUL Æ antibiotics therapy

• Definition: An intra-thoracic opacity, if in anatomic contact with a border of heart or aorta, will obscure that border • Any intra-thoracic lesion anatomically contiguous with a border or a normal

structure will obscure that border 2011-09-09

Prominent thymus gland – ‘Sail sign’ 21 22

F/3 Lobar pneumonia in RML --“Silhouette sign” CC: Fever Cervicothoracic Sign

• Used to determine location of mediastinal lesion in the upper chest • Based on principle that an intrathoracic lesion in direct contact with soft tissues of the neck will not be outlined by air • Uppermost border of the anterior mediastinum ends at level of clavicles

23 24 Cervicothoracic Sign M/50 Dyspnea • Middle and posterior mediastinum extends above the clavicles Superior middle • Mediastinal mass projected superior the and posterior level of clavicles must be located either mediastinal mass within middle or posterior mediastinum • More cephalad the mass extends the most posterior the location

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Hilum overlay sign Hilum convergence sign

• The ability to see the edges of the vessels • A useful chest radiograph sign to help through the mass implies that the mass is distinguish a bulky hilum due to pulmonary not contacting the hilum, and is therefore artery dilatation from a mass/nodal either anterior or posterior to it. enlargement. • In the former, pulmonary vessels can be seen to converge and join a dilated pulmonary artery.

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M/67, LUL small cell CA & mediastinal Extrapleural sign • The appearance of a pulmonary opacity with oblique margins that taper slowly to the chest wall when the lesion is viewed tangentially to the x-ray beam. • The lesion is extrapleural in nature, as opposed to intrapulmonary where an acute angle would be expected as the lesion meets the lung periphery.

29 30 Case 1, M/42, M/61, CXR (2015-05-05) CXR (2015-04-15)

Extrapleural sign

Pathological diagnosis: Paraspinal, right T10-T11, biopsy, suspicious for extramedullary hematopoiesis small cell carcinoma

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M/31. Anterior mediasinal large B-cell lymphoma Incomplete border sign

• Useful to depict an extrapulmonary mass on chest radiograph. • An extrapulmonary mass will often have a inner well defined border and an ill-defined outer margin • 澡兄⢾䕭䀞⎒㚱⛐䨩ℍ偢ℏ䘬悐↮冯偢ℏ䨢㯋䓊 䓇⮵㭼,㓭⎗灘娚䨩ℍ悐↮䘬怲䶋, 侴䕭䀞ỵ㕤䷙ 儰ㆾ㨓儰ㆾ傠⡩ℏ䘬悐↮⇯ ⚈positive silhouette sign䘬䶋㓭,⚈㬌 䚳澵⇘娚悐↮䘬border

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Incomplete border sign

• Common pleural masses: loculated pleural collection, hematoma, pleural Air-bronchogram plaques, fibrous tumour of pleura sign Æ air-space • Extrapleural causes: In adults, skeletal disease of : metastases are the most common Pneumonia malignant chest wall neoplasm while chondrosarcoma is the most common primary malignant tumor.

35 36 Collapse/

• ᶲᶱ奺⽝(upper triangle sign) • ᷣ≽傰䎫塓央⽝(top-of-the-knob sign) • ⸛儘⽝(flat waist sign) • Luftsichel sign

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Flat waist sign Æ LLL collapse with obstructive pneumonia – partial collape of LUL

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Meniscus sign

• Pleural effusion – due to capillary Meniscus sign phenomenon 1. Pleural effusion 2. Mycetoma • Mycetoma – due to air retained inside a cavitary mass

41 42 Signs related to malignancy

• Reverse S sign; Golden's S sign • Tail sign

M/77: Golden’s S sign for lung CA causing collapse of RUL 43 44

Tail sign Thank you for your attention!

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