====== Nick's Chest Mnemonics ====== ===== Upper Lobe Interstitial Disease (RadioCASSET) ===== * XRT * Cystic Fibrosis * Ankylosing Spondylitis * Silicosis * Sarcoid * EG * Tuberculosis - post 1°, not miliary (miliary is lower lobe) ===== Lower Lobe Interstitial Disease (BADAS RIDL) ===== * Bronchiectasis * Aspiration * Drugs (Ritalin, Bleomycin)/Dermatomyositis * Asbestosis * Scleroderma * Rheumatoid * IPF * DIP * Lymphangitic Carcinomatosis ===== Upper Lobe Predominant Fibrosis ===== * Sarcoidosis * Upper lung perilymphatic nodules * Interlobular * Peribronchial * Coalescent masses secondary to fibrosis * Silicosis/Coal Worker's Pneumoconiosis * Upper lung nodules * Subpleural * Centrilobular * Progressive massive fibrosis (PMF) * Paracicatricial emphysema * Idiopathic pleuroparenchymal fibroelastosis * Extensive subpleural and pleural fibrosis * Familial pulmonary fibrosis * Upper lung or diffuse zonal distribution * Hypersensitivity pneumonitis * Ground glass * Air trapping * Exposure history ===== Lower Lobe Predominant Fibrosis ===== * Aspiration (mimic) * Ground-glass or consolidation * Often dependent * May be peribronchovascular * Transient bronchial dilation * Usual interstitial pneumonitis/Idiopathic pulmonary fibrosis * Subpleural and basilar predominant * Reticular opacities * Bronchiolectasis * Honeycombing * Diffuse pulmonary hemorrhage * Ground-glass consolidation * Spares lung periphery * May progress to fibrosis if recurrent * Nonspecific interstitial pneumonitis * Ground-glass and reticulation * Basilar * Peripheral sparing highly suggestive * Usually secondary * Collagen vascular disease * Drugs * Chronic hypersensitivity pneumonitis * Organizing pneumonia (not cryptogenic) * Consolidation * Transient bronchial dilation * Reverse halo sign * Perilobular pattern * Usually secondary * Collagen vascular disease (Myopathies and RA) * Aspiration * Radiation * Drugs * Lung or stem cell transplant ===== Collagen Vascular Disease Patterns in Interstiital Lung Disease ===== ^Patterns^Rheumatoid^Scleroderma^PM/DM^Sjogren^ |UIP|++|++|+|+| |NSIP|+|++++|++|+| |Organizing Pneumonia|++|+|++|-| |Obliterative Bronchiolitis|++|-|-|-| |Bronchiectasis|++|-|-|++| |LIP|-|-|-|+++| * Obliterative Bronchiolitis * Air trapping * Mosaic attenuation * Bronchial wall thickening and dilation * Lymphocytic Interstitial Pneumonitis * Peribronchovascular cysts * Pericystic dots ===== Cysts (LEP LIP) ===== * LAM - uniform cysts * EG (Call it Langerhans Cell Histiocytosis, the chest guys like that) - bizarre cysts w/ small nodules * PCP * LIP * IPF (honeycombing) * Papillomatosis ===== Bronchiectasis (CIT KAM) ===== * Cystic Fibrosis * Immunodeficiency * The most common congenital conditions involve B-lymphocyte functions—specifically, hypogammaglobulinemia. An aggressive form of bronchiectasis has been described in patients with acquired immunodeficiency syndrome (AIDS). * Traction * Associated with pulmonary fibrosis * Kartagener's * ABPA * Mournier-Kuhn/Williams-Campbell (both are lower lobe; Mournier-Kuhn has tracheal widening, Williams-Campbell does not) * Others * Infection: Typical organisms include Klebsiella species, Staphylococcus aureus, Mycobacterium tuberculosis, Mycoplasma pneumoniae, nontuberculous mycobacteria, Mycobacterium avium-intracellulare complex, measles, pertussis, influenza, respiratory syncytial virus, herpes simplex virus, and certain types of adenovirus. * Bronchial obstruction: Obstruction occurs as a result of endobronchial tumors, broncholithiasis, bronchial stenosis resulting from infections, encroachment of hilar lymph nodes, and foreign body aspiration. * Young syndrome * Alpha-1 Antitrypsin deficiency * Lung and bone marrow transplants * Rheumatoid arthritis and Sjögren syndrome * Bronchopulmonary sequestration * Swyer-James syndrome (unilateral hyperlucent lung) * Yellow nail syndrome ===== Patchy Peripheral Airspace Disease (RRECH DB) ===== * Resolving Edema * Resolving Multifocal PNA * Eosinophilic Pneumonia/Loffler's * COP (has peripheral clear zone) * Hypersensitivity Pneumonitis * Drug Toxicity * Bronchioloalveolar CA ===== Cavitary Lesions (CAVITY) ===== * Carcinoma (SCC, colon, TCC, sarcoma, melanoma, cervical) * Autoimmune (Rheumatoid, Wegeners) * Vascular * Infection (abscess, fungal, TB, echinococcus) * Trauma * Young (congenital) ===== Crazy Paving (PEPPAH) ===== * Pulmonary Alveolar Proteinosis * Edema * PCP * Pneumonia * ARDS * Hemorrhage ===== Miliary Pattern (FAT SPAM) ===== * Fungal * Amyloid * TB * Sarcoid * Pneumoconiosis * Alveolar Microlithiasis * Mets (ThRAB - thyroid, renal cell, any adenoCA, breast) ===== Pleural Mets (GIBT) ===== * GI Adenocarcinomas * Breast * Thymoma ====== Other Differentials ====== ===== Chronic Patchy Consolidation ===== * BAC * Lymphoma * Eosinophilic Pneumonia * COP * Sarcoid * Infarct * Metastatic Pulmonary Calcification * TB * Lipoid Pneumonia * Pulmonary Alveolar Proteinosis ===== Tree-In-Bud ===== * Endobronchial Spread of Infection (esp TB) * Bronchiolitis * Viral/Fungal Infection * ABPA * Aspiration * Atypical Mycobacteria * Mycoplasma ===== Reverse Batwing ===== * Loffler's * Parasitic Infection ===== Air Crescent Sign ===== * Aspergilloma * Echinococcus ===== Honeycombing ===== * IPF * Collagen Vascular Disease * Asbestosis * Drugs ===== Unilateral Pulmonary Edema ===== * Reexpansion Edema * Gravity * Mass Obstructing Pulmonary Veins * Large Contralateral PE ===== Solitary Pulmonary Metastasis ===== * Colon * Sarcomas * Renal Cell * Testicular * Breast * Melanoma ===== Cannonball Lesions ===== * Mets * Renal Cell * Lymphoma * Sarcoid ===== Mets Causing Bilateral Hilar Adenopathy ===== * Renal Cell * Melanoma * Breast * GU Tumors ===== Centrilobular Nodules ===== * Hypersensitivity Pneumonitis * RB-ILD * TB/Atypical Infection * LIP * Sarcoid ===== Peribronchovascular Nodules ===== * Sarcoid * Lymphangitic Carcinomatosis * Lymphoma * Kaposi's Sarcoma * Plus Tree-In-Bud DDx ===== Endobronchial Masses ===== * Carcinoid * Adenoid Cystic CA * Mucoepidermoid CA * Papilloma * Fibrous tumors * Leiomyomas * Neurofibromas * SCC (trachea) ===== Endobronchial Mets ===== * Breast * Renal * Melanoma ===== Causes of Diffuse Pulmonary Hemorrhage ===== * Immune-mediated * antiglomerular basement membrane antibody disease (Goodpasture syndrome) * systemic lupus erythematosus (SLE) * Wegener granulomatosis * immune complex disease * polyarteritis nodosa * rheumatoid arthritis * Henoch-Schonlein purpura * Non-immune * idiopathic pulmonary hemorrhage (IPH) * coagulopathies * drugs (penicillamine) ===== Causes of Hypertrophic Pulmonary Osteoarthropathy ===== * Pulmonary Neoplasm (Benign or Malignant) * Chronic Infection (CF, TB) * R -> L Shunt * Congenital Heart Disease ===== Cardiac Mets ===== * Lung * Breast * Melanoma * Lymphoma ===== Lymphangitic Mets ===== * Lung * Breast * Gastric * Pancreatic * Esophageal ===== Causes of Pulmonary Edema ===== ==== Cardiogenic ==== * LV failure * mitral valve dz * pulmonary venous occlusion * pericardial dz * beta blockers ==== Non-cardiogenic ==== * Renal Failure * Fat Emboli * Neurogenic * Sepsis * Volume Overload * Hypoproteinemia * Increased Capillary Permeability * Aspiration * Near-drowning * Anaphylaxis ===== Diffuse Tracheal Narrowing ===== * COPD (saber sheath trachea) * radiation Δ * Tracheobronchopathia Osteochondroplastica * Relapsing Polychondritis * Tracheomalacia ===== Chronic Consolidation ===== * COP * Eosinophilic PNA * Lymphoma * Bronchioloalveolar CA ===== Halo Sign ===== * Hemorrhagic Mets * Kaposi's * Renal Cell * Choriocarcinoma * Invasive Aspergillus ===== Chest Wall Mass ===== * Benign * Lipoma * Fibrous Tumor of Pleura * Desmoid * Hemangioma * Pleural Plaque (i.e. asbestos related pleural disease) * Trauma with hematoma * Malignant * Mets * Chondrosarcoma * Liposarcoma * Leiomyosarcoma * MFH/Fibrosarcoma * Neurogenic Tumors * Infectious * Staph * TB * Actinomycosis * Nocardia ===== Vascular Rings ===== * Pulmonary Sling -> L pulm art travels behind trachea * Right Arch w/ Aberrant L Subclavian ====== Approach to Mosaic Lung Attenuation ====== Perform expiratory CT -> Is there air trapping? * Yes -> Small Airway Disease (CHABB) * Cystic Fibrosis * Hypersensitivity Pneumonitis * Asthma * Bronchiolitis * Bronchiolitis Obliterans/Obliterative Bronchiolitis * No -> Compare Vessel Disease * Equal -> Ground Glass Abnormal * Hemorrhage * PCP * NSIP/DIP * Hypersensitivity Pneumonitis * Edema * ARDS * Bronchioloalveolar CA * Pulmonary Alveolar Proteinosis * Ground Glass Vessels Large/Dark Vessels Small -> Dark Areas Abnormal * Chronic PE * Pulmonary HTN ====== Situs ====== * Solitus = normal * Inversus = everything inverted; asymptomatic * Ambiguous = L cardiac apex, R stomach ===== Polysplenia ===== * Multiple spleens * Bilateral L-sidedness * No IVC; azygous continuation ===== Asplenia ===== * No spleen * Bilateral R-sidedness * Bilateral liver ====== Facts ====== * Int__er__lobular Septa = Kerley B lines * Int__ra__lobular Septa = reticular lines * Shaggy Heart Sign = Interstitial Lung Disease * Semisolid Lesion suggests Bronchioloalveolar CA * Aortic Nipple = L Superior Intercostal Vein * Azygous Line Placement = High Risk of Rupture * Luftsickle Sign = LUL Collapse * lucent crescent representing SS LLL * Abnormal Rotation of Heart -> Think Congenital Absence of Pericardium * Don't forget the relationship b/w osteosarcoma mets and PTX ===== Types of Bronchiectasis ===== * Cylindrical -> bronchi are minimally dilated and straight and regular * CXR will show tram tracking or ring shadows in the distribution of bronchi * Varicose -> string of pearls, with alternating dilation and narrowing * Cystic -> a cluster of cysts ± air fluid levels ===== False Negative Tumors on PET ===== * BAC * mucinous tumors * GI mets ====== Diseases ====== ===== Legionella Pneumonia ===== * begins w/ large, focal, ill-defined opacity * progresses to bilateral lung involvement w/i first few days * pleural effusion may be present (30-60%) * cavitation and lymphadenopathy are rare ===== Hypersensitivity Pneumonitis ===== * acute -> lower lobe consolidation * subacute -> upper lobe nodules * chronic -> upper lobe interstitial fibrosis ===== Causes of Emphysema ===== * Smoking * Chronic Fibrosis * XRT ===== Metastatic Pulmonary Calcification ===== * Associated with ESRD * Looks like edema on CXR * MDP bone scan shows extensive uptake ===== Mediastinal Fibrosis ===== * also known as chronic fibrosis, fibrosing mediastinitis, chronic mediastinal fibrosis, or cryptogenic mediastinal fibrosis * histoplasmosis is the most common cause * can cause SVC obstruction ===== Churg-Strauss ===== * Eosinophilia * Severe Asthma * Systemic Vasculitis ===== Hepatopulmonary Syndrome ===== * Triad of - Chronic liver disease - Increased alveolar-arterial oxygen gradient on room air - Intrapulmonary arteriovenous shunting ===== Carney's Triad ===== * pulmonary chondroma * gastric leiomyosarcoma * extra-adrenal paraganglioma ===== Cowden's Disease ===== * pulmonary and GI hamartomas * multiple mucocutaneous lesions ====== Lung Cancer Staging ====== __Tumor__ * T1 <3 cm, limited to lung * T2 >3 cm, >2 cm distal to carina * T3 any size, direct extension into chest wall, superior sulcus, diaphragm, pleura, pericardium, or within 2 cm of carina * T4 mediastinal (heart, great vessels, esophagus), carinal, brachial plexus, vertebral body invasion or malignant pleural effusion -> **unresectable** __Nodes__ * N0 no LN involvement * N1 ipsilateral hilar nodes * N2 ipsilateral mediastinal or subcarinal nodes * N3 contralateral hilar or mediastinal nodes; supraclavicular nodes -> **unresectable** __Mets__ * M0 none * M1 distant mets -> **unresectable** __Important Stages__ * Tumor unresectable if T4, N3, or M1 * Stage 3b * N3, M0, any T * T4, M0, any N * Stage 4 * M1, any T, any N ====== Recommended Followup for Pulmonary Nodules ====== Fleischner Society Criteria ^Nodule Size^Low-Risk Patient^High-Risk Patient^ |< 4 mm|No follow-up needed|Follow-up CT at 12 mo; if unchanged, no further follow-up| |4-6 mm|Follow-up CT at 12 mo; if unchanged, no further follow-up|Initial follow-up CT at 6-12 mo then at 18-24 mo if no change| |6-8 mm|Initial follow-up CT at 6-12 mo then at 18-24 mo if no change|Initial follow-up CT at 3-6 mo then at 9-12 and 24 mo if no change| |> 8 mm|Follow-up CT at around 3, 9, and 24 mo, dynamic contrast enhanced CT, PET, and/or biopsy|Same as for low-risk patient| ====== Features of Solitary Pulmonary Nodules suspicious for malignancy ====== * Microlobulated or spiculated margins * Bubbly or cystic lucencies; air bronchograms * Mixed ground glass/solid attenuation; subsolid (mixed attenuation) * Airway component * Relatively rapid growth * Recommend biopsy or resection in pts with moderate to high risk of lung CA or solitary metastasis