Download - Tb Radiology Basic Presentation Slides
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Basic Chest Radiology for the TB Clinician
Adapted from the ISTC TB Training Modules 2009
PRESENTATION MATERIALS
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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
Blackestairfatsoft tissuecalciumboneX-ray contrastmetal
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
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 AbsorptionWhy 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
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ISTC TB Training Modules 2009
Silhouette Sign: RLL PneumoniaSilhouette Sign: RLL PneumoniaSilhouette Sign: RLL Pneumonia
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ISTC TB Training Modules 2009
Silhouette Sign: RLL PneumoniaSilhouette Sign: RLL PneumoniaSilhouette Sign: RLL Pneumonia
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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
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ISTC TB Training Modules 2009
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ISTC TB Training Modules 2009
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ISTC TB Training Modules 2009
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ISTC TB Training Modules 2009
Inspiratory Effort
Low Lung Volumes Full Inspiration
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ISTC TB Training Modules 2009
Overexposure Proper Exposure
Exposure
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ISTC TB Training Modules 2009
OverexposureOverexposure Proper ExposureProper Exposure
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ISTC TB Training Modules 2009
Rotated (Oblique)Rotated (Oblique)Image credit: Curry International Tuberculosis Center, University of California, San Francisco 12
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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
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ISTC TB Training Modules 2009
Approach to Reading a CXRBe Systematic Lungs Pleural surfaces Cardiomediastinal
contours Bones and soft
tissues Abdomen
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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 TBApical TBImage credit: Curry International Tuberculosis Center, University of California, San Francisco 16
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ISTC TB Training Modules 2009Image credit: Curry International Tuberculosis Center, University of California, San Francisco
Apical TB (2)Apical TB (2)17
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ISTC TB Training Modules 2009
Left Retrocardiac OpacityLeft Retrocardiac Opacity
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ISTC TB Training Modules 2009
Nodule Behind DiaphragmNodule Behind Diaphragm
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ISTC TB Training Modules 2009
Basic Radiology for the TB Clinician
Basic CXR Anatomy
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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
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ISTC TB Training Modules 2009
Aortic arch Right pulmonary
artery Left pulmonary
artery Trachea & bronchi
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ISTC TB Training Modules 2009
Aortic arch
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ISTC TB Training Modules 2009
Aortic arch Right pulmonary
artery
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ISTC TB Training Modules 2009
Aortic arch Right pulmonary
artery Left pulmonary
artery
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ISTC TB Training Modules 2009
Aortic arch Right pulmonary
artery Left pulmonary
artery Trachea & bronchi
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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
PneumoniaPneumonia
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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: LinesInterstitial Opacity: Lines
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ISTC TB Training Modules 2009
Interstitial Opacity: LinesInterstitial Opacity: Lines
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ISTC TB Training Modules 2009
Interstitial Opacity: Lines & ReticulationInterstitial Opacity: Lines & Reticulation
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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-DefinedWell-Defined CalcificationCalcification
Ill-DefinedIll-Defined MassMass
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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 2009
Infrahilar window (right hilar and/or subcarinal)
Left hilar Subcarinal
LymphadenopathyLymphadenopathy
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ISTC TB Training Modules 2009
Infrahilar window (right hilar and/or subcarinal)
LymphadenopathyLymphadenopathy
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ISTC TB Training Modules 2009
Left hilar
LymphadenopathyLymphadenopathy
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ISTC TB Training Modules 2009
Subcarinal
LymphadenopathyLymphadenopathy
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ISTC TB Training Modules 2009
Right Paratracheal & Bilateral LANRight Paratracheal & Bilateral LAN
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ISTC TB Training Modules 2009
Right Hilar LANRight Hilar LAN
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ISTC TB Training Modules 2009
Right Hilar LANRight Hilar LAN
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ISTC TB Training Modules 2009
**
Subcarinal LANSubcarinal LAN
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ISTC TB Training Modules 2009
AP Window LANAP Window LAN
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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
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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 EffusionPleural 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 lobes Lower 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 normal CXR 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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