肺實質化病變與肺塌陷

胸腔內科周百謙醫師 Dr. Pai-chien Chou MD PhD Department of Thoracic Taipei Medical University Hospital Chest X-ray

• P-A view • Lateral view

• Oblique view • Lordotic view • Expiratory film • Decubitus view • Overpenetrated grid film The Elements of a chest x-ray (CXR)

• The Broncho-vascular markings in the • The borders of the • The contours of the and pleural space • The ribs and spine Segmental anatomy Segmental Anatomy Cardiomediastinal outlines on Chest X-ray Density of image

◆ Gas ◆ Water ◆ Fat ◆ Metal and bone ◆ Thinking of pathogenesis Basic thinking of a lesion on Chest X-ray

◆ Size ◆ Location () – Anterior, posterior – Which lobe is involved ◆ Intrapulmonary (Air bronchogram sign) ◆ Extrapulmonary (Incomplete border sign) Infiltrate in the • Fluid accumulates in lung, predominate in the alveolar (airspace) compartment or the interstitial compartment.

interstitial compartment

Lymphatic compartment Alveolar unit Vascular unit Air space opacification

The opacification is caused by fluid or solid material within the airways that causes a difference in the relative attenuation of the lung: • transudate, e.g. secondary to heart failure • pus, e.g. bacterial • blood, e.g. pulmonary hemorrhage • cells, e.g. bronchoalveolar carcinoma • protein, e.g. alveolar proteinosis • fat, e.g. lipoid pneumonia • gastric contents, e.g. aspiration pneumonia • water, e.g. drowning When considering the likely causes of airspace opacification, it is useful to determine chronicity (by reviewing previous radiographs) and considering laterality. Major Respiratory Diagnoses with Common Chest Radiographic Patterns Diffuse interstitial disease Idiopathic pulmonary fibrosis Pulmonary fibrosis with systemic rheumatic disease Drug-induced lung disease Pneumoconiosis Hypersensitivity pneumonitis Infection (Pneumocystis, viral pneumonia) Eosinophilic granuloma Diffuse alveolar disease Cardiogenic pulmonary edema Acute respiratory distress syndrome Diffuse alveolar hemorrhage Infection (Pneumocystis, viral or bacterial pneumonia) Sarcoidosis Interstitial Lung Disease

interstitial compartment

Lymphatic compartment Alveolar unit Vascular unit Silhouette Sign The disappearance of a normal lung border (ie. mediastinum or diaphragm)

(-)

(+) (+)

(-) (+) the portion of the mediastinum associated with each of the lobes Silhouette Sign

◆ Two lesions of the same density contact, then loss of the border of one lesion ◆ A border of the heart, aorta or diaphragm is obliterated

Loss of the border of ascending aorta Dx: in anterior segment of RUL The following structures are obliterated what lung segment or lobe is involved

◆ Left heart border Lingula

◆ Right heart border RML

◆ Upper part of left heart Anterior segment of LUL border

◆ Ascending aorta Anterior segment of RUL

◆ Upper part of right Anterior segment of RUL heart border Apical posterior segment of ◆ Aortic knob the LUL Silhouette Sign: Anatomy

◆ Neck (SCM muscle and clavicle)  Neck LAP or neck mass

◆ Chest wall: Incomplete border sign as breast, nipple, or chest wall tumors

◆ Diaphragm: Loss of margin  extension of lesions in lung, pleural, or abdomen

◆ Pleural: Incomplete border sign Applications of Silhouette Signs

◆ Cervicothoracic sign ◆ Thoracoabdominal sign ◆ ◆ Hilum convergency sign ◆ Incomplete border sign ◆ Air bronchogram or air alveologram signs Air bronchogram sign

◆ Visualization of air in the intrapulmonary bronchi on chest X-ray

◆ Pulmonary lesion

◆ Pneumonia, pulmonary edema, pulmonary infarcts, certain chronic lung lesions Consolidation Causes of consolidation (Segmental or lobar opacities)

Common Rare Infection Allergic lung disease Pneumonia Connective tissue disease Tuberculosis, atypical mycobacteria Drug reactions Infarction Hemorrhage Cardiogenic pulmonary edema Lymphoma Noncardiogenic pulmonary edema Radiation Adult respiratory distress syndrome Amyloid Neurogenic edema Eosinophilic lung disease Drug-induced edema Sarcoid Neoplasm Alveolar proteinosis Lobar Consolidation

Lobar Expansion

Chest , 7th Edition Patterns and Differential Diagnoses Pneumonia (CAP)

• Air-bronchogram in Right upper lobe • No volume reduction • Border of ascending aorta obliterated • Clinics: Pneumonia, RUL (CAP) • Streptococcus pneumonia Right Middle Lobe Pneumonia Right Lower Lobe Pneumonia Left Upper Lobe Pneumonia Pulmonary tuberculosis

• Inferior surface of RUL consolidation is sharply defined • Cavity change • Slight volume reduction of RUL • AFB +++ • Dx: Pulmonary TB Lung cancer with obstructive pneumonitis

• LUL opacity with cavitary change • Thick wall with irregular contour and air-fluid level (favor mass with cavitation) • Left volume reduction with LLL compensatory hyperaeration Necrotizing pneumonia

• Multiple cavities, some containing air-fluid level with B6 of RLL Pathology Round pneumonia

• Well-defined, round- opacity in RLL • Fading out peripherally • Clinics: Round pneumonia caused by pneumococcal infection Round pneumonia

➢ Round are roundish and while they are well-circumscribed parenchymal opacities, they tend to have irregular margins. They most commonly occur in superior segments of lower lobes and in the majority of cases (98%), they are solitary. ➢ Air-bronchograms are often present. They are only seen in 17% of cases when they occur in adults. Pulmonary infarction

• Right lower lung wedge shape pleural based consolidation • Clinics: Pulmonary infarction : A dome- shaped, pleural-based opacification in the lung most commonly due to and lung infarction The melting ice cube sign Pulmonary Embolism with Infarction LLL Pulmonary Embolism with Infarction Actinomycosis

• Right hilar area opacity without definite margin • Clear right pulmonary trunk shadow (negative Silhouette sign) • No prominent volume reduction • Imp: right B6 pneumonia • Clinics: Actinomycosis Pulmonary nocardiosis

Major radiographic patterns ➢ lobar or multilobar consolidation ➢ probably the predominant feature ➢ focal areas of decreased attenuation may reflect abscess formation ➢ cavitation in 30% ➢ solitary lung masses and/or nodules ➢ reticulonodular infiltrates ➢ mediastinal or hilar is not a feature of nocardiosis endobronchial spread or disseminated pulmonary nocardiosis Pulmonary alveolar proteinosis

• Large perihilar and lower lobe opacities with normal cardiac silhouette sign • Ground-grass opacification and thickened interlobular structures and interlobular septa Non-cardiogenic pulmonary edema

• Bilateral dependent lungs consolidation • Air-bronchogram (fluffy margin with confluence) • Normal heart size and hilums • Imp: Noncardiogenic pulmonary edema (Heroin induced) Diffuse bilateral air space opacities due to Smoke inhalation Lung cancer with lung to lung

• Right upper lung field consolidation without volume reduction • Mass effect on upper mediastinum with trachea contralateral deviation • Left lower nodules with retrocardial opacity (loss medial part of diaphragm) • Kerley’B lines • Clinics: Squamous cell carcinoma & Collapse Types of Atelectasis

• Obstructive atelectasis • Compressive atelectasis • Passive atelectasis • Adhesive atelectasis • Cicatrization atelectasis Etiologies related to Atelectasis

Chest Radiology, 7th Edition Patterns and Differential Diagnoses Signs of Atelectasis or collapse

Direct sign Indirect sign

◆ Displacement of interlobar ◆ Displacement of hilum fissures ◆ Elevation of diaphragm ◆ Shift of mediastinum, heart and ◆ Increased radiopacity (loss of trachea aeration) ◆ Compensatory hyperinflation ◆ Narrowing of intercostal space ◆ Vascular and bronchial (crowding of the ribs) Crowding ◆ Herniation of contralateral lung ◆ Absence of air bronchogram Signs Associated with Collapse

• Reverse “S” sign (“S” line of Golden) : RUL collapse • Upper triangle sign (lower lobe collapse) • Top-on-the knob sign (LLL collapse) • Flat waist sign (LLL collapse) • Juxtaphrenic peak sign (upper lobe collapse) • Luftsichel sign (LUL collapse) • Comet-tail sign (round atelectasis) Flat Waist Sign Superior Triangle Sign Triangular Density to the right of the mediastinum seen in right lower lobe collapse due to displacement of anterior junctional structures. Luftsichel sign The luftsichel sign is seen in some cases of left upper lobe collapse and refers to the frontal chest radiographic appearance due to hyperinflation of the superior segment of the left lower lobe interposing itself between the mediastinum and the collapsed left upper lobe.

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 30421 Luftsichel sign

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 30421 Right upper lobe collapse

◆ Direct signs – Right upper reversed Golden “S” sign – upward minor fissure shift ◆ Indirect signs – Elevated right hilum and diaphragm – Narrowing inter costal spaces ◆ Dx: Lung cancer with RUL collapse (SCLC)

◆ Ps: Right folk rib (↗) Right upper and middle lobe atelectasis Right upper lobe lobectomy

Indirect sign ◆ Upper mediastinum right deviation ◆ Juxtaphrenic peak sign ◆ Elevated right diaphragm ◆ Right hilar elevation ◆ Right shift of pleural junction line ◆ Enlarged SVC contour

◆ Imp: RUL lobectomy ◆ Clinics: Lung cancer (SqCC) Right lower lobe collapse

◆ Direct sign – Right lower triangular opacity connecting to hilar; minor fissure not seen ◆ Indirect sign – Elevated right diaphragm; Right upper triangle sign

◆ Imp: RLL collapse

Clinics : Lung cancer Right middle lobe collapse

◆ Direct sign – Right opacity with blurred heart border – Crowding of right medial lower lung marking ◆ Indirect sign – Elevated right medial part of diaphragm

◆ Imp: RML collapse ◆ Clinics: RML syndrome (endobrochial TB) Bilobar collapse

◆ Direct sign – RUL and RLL opacity – Minor fissure shift – Golden reverse “S” sign ◆ Indirect signs ↗ – Elevated right diaphragm – Hyperinflation of contralateral lung ↖ ◆ Imp: Bilobar collapse (RUL and RLL) ◆ Clinics: Lung cancer (adenocarcinoma) Bilobar collapse

◆ Indirect signs – Elevated right diaphragm ↙ – Right shift of pleural junctional line with right herniation of left lung – Compensated hyperinflation of left lung – Trachea right shift ◆ Imp: Right bilobar lobectomy (RML & RLL) ◆ Clinics: Adenocarcinoma Bilobar collapse

◆ Direct sign – Right lower triangular opacity – Loss of right heart border – Downward minor fissure ◆ Indirect signs – Elevated right diaphragm – Heart right deviation – Left lung compensatory hyperinflation ◆ Imp: Bilobar collapse (RML and RLL) Left upper lobe collapse

◆ Direct sign – Increased density of LUL ◆ Indirect Signs – Elevated left hilum and diaphragm – Mediastinal left shift – Juxtaphrenic peak sign – Luftsichel sign (para-aorta hyperlucency due to LLL upward compensatory replacement for LUL collapse) ◆ Imp: LUL total collapse LUL collapse

• Direct sign: = Left upper lung opacity = Blurred aortic arch • Indirect sign: = Elevated left diaphragm = Mediastinum left shift = Left hilum elevation • Imp: LUL total collapse • Clinics: Lung cancer (SCC) • Ps: Hilum enlargement ? Left upper lobe lobectomy

◆ Indirect signs – Decreased left lung volume with elevated diaphragm and hilum ← – Left shift of mediastinum – Narrowing left intercostal space – Posterior pleural junction line left shift with herniated right upper lung – Decreased left lung marking ◆ Imp: LUL lobectomy ◆ Clinics: LUL (B3) lung cancer post lobectomy Left lower lobe collapse

◆ Direct signs – Left retrocardial triangular opacity with mass like opacity – Loss of left medial part of diaphragm and descending aorta ◆ Indirect sign – Elevated left diaphragm

◆ Imp: LLL lung cancer with collapse Left lower lobe collapse

◆ Lateral view – Loss of normal retrocardial hyperlucency – Loss of descending aorta contour – Loss of posterior part of left diaphragm (↗)with complete right one ↗ Left lower lobe Lobectomy

◆ Left volume reduction with diaphragm elevation ◆ Decreased left lung marking ◆ Narrowing left intercostal space with left scoliosis ◆ Blunt left lateral costophrenic angle ◆ Clinics: LLL lobectomy (LLL lung cancer adenocarcinoma post operation) With Great Thanks to Dr. 王圳華，Dr. 林鴻銓，Dr. 唐家駿