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Basic Chest Radiology for the TB Clinician
Adapted from the ISTC TB Training Modules 2009
PRESENTATION MATERIALS
ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Objectives: At the end of this presentation, participants will be able to:
Analyze the technical quality of chest X-rays (CXRs) using simple parameters
Identify basic normal CXR anatomy on both frontal and lateral views
Recognize radiographic patterns of disease and describe using appropriate terminology
Describe both the typical and atypical patterns of radiographic presentation for pulmonary tuberculosis
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ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician (2)
Overview:
Technical aspects of chest radiography
Systematic approach to reading CXR
Basic CXR anatomy
Patterns of disease
Radiographic manifestations of tuberculosis (TB)
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ISTC TB Training Modules 2009
Chest Radiography: Basic Principles
Blackest
air
fat
soft tissue
calcium
bone
X-ray contrast
metal
Whitest
Maximum X-RayTransmission(least dense tissue)
Maximum X-Ray Absorption(densest tissue)
X-ray photon: Absorbed / scattered / transmitted X-ray absorption depends on:
• Beam energy (constant)• Tissue density
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ISTC TB Training Modules 2009
Differential X-Ray Absorption
Why we see what we see:
Structures are visible on a radiograph because of the juxtaposition of two different densities creating an interface
Silhouette Sign
Loss of an expected interface
No boundary can be seen between two structures because they now are similar in density
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 5
ISTC TB Training Modules 2009
Silhouette Sign: RLL PneumoniaSilhouette Sign: RLL Pneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6
ISTC TB Training Modules 2009
Silhouette Sign: RLL PneumoniaSilhouette Sign: RLL Pneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6
ISTC TB Training Modules 2009
Assess CXR Technical Quality
Inspiratory effort
• 9-10 posterior ribs
Penetration
• thoracic intervertebral disc space just visible
Positioning / rotation
• medial clavicle heads equidistant from spinous process
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ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
ISTC TB Training Modules 2009
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
ISTC TB Training Modules 2009
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
ISTC TB Training Modules 2009
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
ISTC TB Training Modules 2009
Inspiratory Effort
Low Lung Volumes Full Inspiration
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 9
ISTC TB Training Modules 2009
Overexposure Proper Exposure
Exposure
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 10
ISTC TB Training Modules 2009
Overexposure Proper Exposure
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 11
ISTC TB Training Modules 2009
Rotated (Oblique)Image credit: Curry International Tuberculosis Center, University of California, San Francisco 12
ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
A systematic approach to reading a CXR
Image Credit: Lung Health Image Library/Gary Hampton 13
ISTC TB Training Modules 2009
Approach to Reading a CXR
Be Systematic
Lungs
Pleural surfaces
Cardiomediastinal contours
Bones and soft tissues
Abdomen
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 14
ISTC TB Training Modules 2009
Worth a Second Look
Apices
Retrocardiac areas (left and right)
Hilar regions
Below diaphragm
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ISTC TB Training Modules 2009
Apical TBImage credit: Curry International Tuberculosis Center, University of California, San Francisco 16
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco
Apical TB (2)17
ISTC TB Training Modules 2009
Left Retrocardiac Opacity
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 18
ISTC TB Training Modules 2009
Nodule Behind Diaphragm
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 19
ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Basic CXR Anatomy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 20
ISTC TB Training Modules 2009
Basic CXR Anatomy
Frontal and Lateral Views
Heart
Aorta
Pulmonary arteries
Airways
Image Credit: Lung Health Image Library/Pierre Virot21
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 22
ISTC TB Training Modules 2009
Aortic arch
Right pulmonary artery
Left pulmonary artery
Trachea & bronchi
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
ISTC TB Training Modules 2009
Aortic arch
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
ISTC TB Training Modules 2009
Aortic arch
Right pulmonary artery
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
ISTC TB Training Modules 2009
Aortic arch
Right pulmonary artery
Left pulmonary artery
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
ISTC TB Training Modules 2009
Aortic arch
Right pulmonary artery
Left pulmonary artery
Trachea & bronchi
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Patterns of disease
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ISTC TB Training Modules 2009
Chest Radiographic Patterns of Disease
Consolidation / air-space opacity
Interstitial opacity
Nodules and masses
Lymphadenopathy
Cysts and cavities
Pleural abnormalities
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ISTC TB Training Modules 2009
Consolidation / Air-Space Opacity
Caused by filling of alveoli with fluid, pus, blood, cells (tumor), etc.
May be diffuse, or isolated to segments or lobes of the lung
May be associated with air bronchograms (air-filled bronchus surrounded by opacified lung)
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ISTC TB Training Modules 2009
Pneumonia
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 27
ISTC TB Training Modules 2009
Interstitial Opacity
Disease localized to pulmonary interstitium, i.e., the alveolar septae and connective tissues that support the alveoli
Hallmarks:• Lines and/or reticulation• Small, well-defined nodules
Miliary pattern
DDX: Pulmonary edema, interstitial lung diseases (e.g., idiopathic pulmonary fibrosis), sarcoidosis, infection, tumor (lymphangitic spread), etc.
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ISTC TB Training Modules 2009
Interstitial Opacity: Lines
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29
ISTC TB Training Modules 2009
Interstitial Opacity: Lines
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29
ISTC TB Training Modules 2009
Interstitial Opacity: Lines & Reticulation
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 30
ISTC TB Training Modules 2009
Nodules and Masses
Nodule: discrete pulmonary lesion, sharply defined, nearly circular opacity 0.2 - 3 cm
Mass: larger than 3 cm
Describe with qualifiers:
• Single or multiple
• Size
• Border characteristics
• Presence or absence of calcification
• Location
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ISTC TB Training Modules 2009
Well-Defined Calcification
Ill-Defined Mass
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 32
ISTC TB Training Modules 2009
Lymphadenopathy (LAN)
Non-specific terms:
• Mediastinal widening
• Hilar prominence
Specific patterns:
• Particular station enlargement (location)
Important to know what “normal” should look like in order to recognize “abnormal”
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ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
ISTC TB Training Modules 2009
Infrahilar window (right hilar and/or subcarinal)
Left hilar
Subcarinal
Lymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
ISTC TB Training Modules 2009
Infrahilar window (right hilar and/or subcarinal)
Lymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
ISTC TB Training Modules 2009
Left hilar
Lymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
ISTC TB Training Modules 2009
Subcarinal
Lymphadenopathy
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
ISTC TB Training Modules 2009
Right Paratracheal & Bilateral LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 36
ISTC TB Training Modules 2009
Right Hilar LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 37
ISTC TB Training Modules 2009
Right Hilar LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 38
ISTC TB Training Modules 2009
*
Subcarinal LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 39
ISTC TB Training Modules 2009
AP Window LAN
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 40
ISTC TB Training Modules 2009
Cysts & Cavities
Abnormal pulmonary parenchymal spaces (“holes”), filled with air and/or fluid, with a definable wall (>1 mm)
• Cyst: congenital or acquired
• Cavity: caused by tissue necrosis, (inflammatory and/or neoplastic)
Characterize:
• Wall thickness at thickest portion
• Inner lining
• Presence / absence of air / fluid level
• Number and location
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ISTC TB Training Modules 2009
TB or Not TB? Cysts and Cavities
Are there radiographic features that suggest benign vs. malignant diagnoses?
A
“45 year old man from China with cough, weight loss”
C
D
B
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 42
ISTC TB Training Modules 2009
TB or Not TB? Cysts and Cavities (2)
Are there radiographic features that suggest benign vs. malignant diagnoses?
Benign cysts: uniform wall thickness, 1mm, smooth inner lining (e.g., PCP)
Benign cavities: max. wall thickness 4 mm, minimally irregular inner lining (e.g., TB)
Malignant cavities: max. wall thickness 16 mm, irregular inner lining
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ISTC TB Training Modules 2009
Pleural Disease: Basic Patterns
Effusion
• Angle blunting to massive
Thickening
Mass
Air
Calcification
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ISTC TB Training Modules 2009
Pleural Effusion
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ISTC TB Training Modules 2009
Post-TB Pleural Calcification
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ISTC TB Training Modules 2009
Plombage with Lucite balls
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ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Radiographic Manifestations of TB
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ISTC TB Training Modules 2009
Can this be TB?
“Typical Pattern”:Post-primary TB
Distribution• Apical / posterior segments of
upper lobes
• Superior segments of lower lobes
• Isolated anterior segment involvement unusual for M.tb(think M. avium complex)
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ISTC TB Training Modules 2009
“Typical pattern”: Post-Primary TB
Patterns of disease
• Air-space consolidation
• Cavitation, cavitary nodule
• Endobronchial spread
• Miliary
• Bronchostenosis
• Tuberculoma
• Pleural effusions (empyema most likely in post-primary disease)
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ISTC TB Training Modules 2009
Can this be TB?
“Atypical pattern”: Primary TB
Distribution : any lobe involved (slight lower lobe predominance)
Air-space consolidation
Cavitation is uncommon (<10%)
Adenopathy is common (esp. children and HIV), predilection for right side
Miliary pattern
Pleural effusions
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ISTC TB Training Modules 2009
Can this be TB? Miliary TB
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ISTC TB Training Modules 2009
Radiographic Patterns: Pulmonary TB
TB Pattern“Typical”
(Post-Primary)“Atypical”(Primary)
Infiltrate 85% upper
Upper : Lower 60 : 40
Usually upper in children
Cavitation Common Uncommon
Adenopathy UncommonChildren common
Adults ~30%Unilateral > bilateral
Effusion May be present May be present
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ISTC TB Training Modules 2009
CXR Pattern: Early vs. Advanced HIV
Early HIV (CD4>200)
Advanced HIV (CD4<200)
Pattern“Typical”
(Post-primary)“Atypical”(Primary)
Infiltrate Upper lobesLower lobes, multiple
sites, or miliary
Cavitation Common Uncommon
Adenopathy Uncommon Common
Effusion Uncommon More common
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ISTC TB Training Modules 2009
Can this be TB?
“Old / Healed” TB Ca++ granuloma–Ghon lesion
Ca++ granuloma and hilar node calcification–Ranke complex
Apical pleural thickening
Fibrosis and volume loss
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ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Summary: Remember: Technical quality
can significantly impact your CXR interpretation
Develop a systematic approach (and use it every time!)
Practice identifying normalCXR anatomy
Important to characterize and describe lesions—this can help with your differential diagnosis
Whether typical or atypical
TB can always fool you!
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