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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

PatternsRheumatoidSclerodermaPM/DMSjogren
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

  • Interlobular Septa = Kerley B lines
  • Intralobular 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
    1. Chronic liver disease
    2. Increased alveolar-arterial oxygen gradient on room air
    3. 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 SizeLow-Risk PatientHigh-Risk Patient
< 4 mmNo follow-up neededFollow-up CT at 12 mo; if unchanged, no further follow-up
4-6 mmFollow-up CT at 12 mo; if unchanged, no further follow-upInitial follow-up CT at 6-12 mo then at 18-24 mo if no change
6-8 mmInitial follow-up CT at 6-12 mo then at 18-24 mo if no changeInitial follow-up CT at 3-6 mo then at 9-12 and 24 mo if no change
> 8 mmFollow-up CT at around 3, 9, and 24 mo, dynamic contrast enhanced CT, PET, and/or biopsySame 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

chest.txt · Last modified: 2017/07/07 18:30 (external edit)