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Radiology (Dra.

Bandong)

Pleura, mediastinum…

05 July 2008

Pleura

Anatomy
o a space within the thoracic cavity
o bounded by:
anterior sternum
posterior vertebral bodies A mass is considered to lie in the AMC when it
superior thoracic inlet is situated in the region anterior to the line
inferior diaphragm drawn along the anterior border of the trachea
lateral parietal pleura and posterior border of the heart
o divided into compartments by drawing a
line from the sternal angle to the 4th
thoracic intervertebral disk space
area above superior
compartment
area below inferior compartment
o anterior o Widened o Retrosternal area is
o middle mediatinum filled with mass
o posterior o Loss of cardiac
density
CT SCAN silhouette
o is the imaging modality of choice for o Intact silhouette
diagnosis, staging, and follow up of patients of descending
o offers the advantage of better localization aorta
and characterization of the disease process
o it can demonstrate compression and
involvement of the adjacent structures in
the mediastinum better than plain films.
Anterior Mediastinal Mass
o Thymus
Normal Thymus
Thymoma – Most common
o Lies in a retrosternal location behind the
Thymic cyst
manubrium
Thymolipoma
o Commonly seen anterior to the proximal
Thymic carcinoid
ascending aorta and distal superior vena
Thymic hyperplasia
cava
o Lymphoma
o Size of a normal thyroid is largets between
o Germ cell tumor
12-19 years of age.
Teratoma
Anterior mediastinal compartment Seminoma
Shoriocarcinoma
o Anteriorly by the sternum
o Thyroid
o Posteriorly by the pericardium, aorta, and
Goiter
brachiocephalic vessels
Tumor
Masses situated predominantly in the anterior o Mesenchymal tumors
mediastinal compartment (AMC) Leiomyoma
Liposarcoma
o Hemorrhage

1 of 16
1C ng 3B (jassie, viki, candz..ung iba support
group..hehe)
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

NOTES:
Mediastinal mass: Pulmonary
mass:
o Margins are smooth o LYMPHOMA
Spiculated margins
o Bilateral o
Unilateral
o Loss of cardiac silhouette

Anterior mediastinal mass

Thymoma
Teratoma
Thyroid nodule / goiter
Lymphoma
2 types of lymphoma:
THYMOMA Hodgkin’s (HL)
o Most common neoplasm of the anterior o Bimodal age distribution—25-30 y/o and
mediastinum >70 y/o
o 30-35% are malignant o 67% intrathoracic involvement (anterior/
o Commonly occur in patients >40y/o superior mediastinal and hilar adenopathy)
o Asymptomatic o 15-40% pulmonary involvement by:
o CXR: Direct extension form involved nodes
Found in anterior mediastinum to Pulmonary nodules
the ascending aorta above the Parenchymal consolidation
right ventricular outflow tract and Pleural effusion
main pulmonary artery Sternal erosions
Maybe situated as low in the
mediastinum as the cardiophrenic Non Hodgkin’s (NHL)
angles o 4x more common than HL
o CT(Benign) o 3rd most common childhood malignancy
Well demarcated masses with o More frequently fatal than HL
homogenous density o Middle medisatinum – most frequently
Uniform contrast enhancement involved
Have areas of decrease o Posterior mediastinum and cariophrenic
attenuation angles can be altered
Punctuate or ring like o Appears as a single large conglomerate
calcifications o Other common nodal signs involvement
o CT (Malignant) include
Heterogenous attenuation Lung parenchyma
May obliterate adjacent Pleura
mediastinal fat Pericardium
May detect pleural spread
Germ Cell Tumors

o most are found in the anterior mediastinum


o 20-40 years
o Divided into
seminomatous neoplasms (seminoma)
non seminomas
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

Located anterior to the root of the aorta


Seminomatous neoplasm (Seminoma) and main pulmonary artery
o Most common germ cell tumor Calcification, ossification or even teeth
o most common primary malignant cell may be visible
tumor CT: large cystic mass
o less aggressive Thick, encapsulated wall
o secrete low levels of HCG May enhance
o On CT: May contain curvilinear calcifications
large masses with sharply demarcated
borders
o Homogenous attenuation but may have
hemorrhage and necrosis

Non Seminomatous neoplasm


o More aggressive
o Secrete high levels of fetoprotein and / or
MALIGNANT TERATOMA
HCG
CXR: more lobulated in outline
o Teratoma
Rarely has calcifications and never has
Most common non seminomatous
fat density
tumors
Metastasize to the lungs, bones or
Most common mediastinal germ cell
pleura
tumor
CT: typical mass has irregular border with
Benign: mature teratoma
thick capsule
Enhances with IV contrast
MATURE TERATOMA
Adjacent fat planes are obliterated
CXR: large, well demarcated, rounded masses
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

Extreme local invasion is common Heart and pericardium


*In CT scan, this can be distinguished from Ascending and transverse aorta
thymoma and seminoma. Brachiocephalic vessels
SVC and IVC
Main pulmonary vessels
Trachea and main bronchi
Lymph nodes
Differential diagnosis of middle mediastinal
masses
Lymphadenopathy
Bronchogenic cyst
Vascular abnormalities
Pericardial cyst
Tracheal tumor
Most common: aneurysm

Posterior mediastinum
Boundaries bounded anteriorly by the
posterior margin of
the pericardium and great vessels
and posteriorly by the thoracic
Middle and Posterior Mediastinum vertebral bodies
(MMC / PMC) Normal structures
Descending thoracic aorta
Masses predominantly in the MMC and PMC Esophagus
Thoracic dust
Azygous and hemiazygous
Autonomic nerves
Lymph nodes
Fat
Differential diagnosis
Neurogenic tumors
Paravertebral abnormalities
A lesion can be considered to properly lie in the Vascular abnormalities
MMC or PMC when it is located between a line Esophageal abnormalities
drawn through the anterior aspect of the Lymphadenopathy
trachea and posterior aspect of the heart and Neurenteric cyst
the line drawn through the anterior margins of Bochdalek’s hernia
the vertebral bodies Extramedullary hematopoeisis

NOTES: *It is difficult to delineate middle to posterior


Posterior lesion – 20 to osseous; mediastium.
sarcoma involving the
vertebral column CASE: An 87 year old woman presents with
Middle lesion – esophagus, dysphagia
bronchogenic cyst
Radiographs show a homogenous mass in the
Middle Mediastinum middle / posterior mediastinum extending from
Boundaries by posterior margin of anterior the level of the aortic arch to the diaphragm
division and and displacing the esophagus to the right
anterior margin of posterior (residual contrast is evident in the esophagus
division (malamang!) from a barium swallow)
Normal structures
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

A CT scan just below the level of the carina


reveals a hematogenous soft tissue mass with
a central area of low attenuation (A). Note the
markedly compressed esophagus (B). It is not
possible to discern whether the mass is arising
from the wall of the esophagus or the adjacent
mediastinum. There is an incidental finding of
calcified brachial plates (C)

Contrasted Chest CT demonstrating


heterogenous appearing post mediastinal mass
with punctuate calcifications which appears to
extend into the neural foramina.
Non contrasted chest CT demonstrating
heterogenous appearing post. Mediastinal NEUROGENIC TUMORS
mass with punctuate calcifications which
appears to extend into the neural foramina o Age: occur in young patients in the first 4
(see picture below) decades of life (young???)
o Gender: males and females equally affected
*With contrast, there is enhancement of blood o Round, homogenous with widening of the
vessels and vice versa in non-contrast. neural foramen
o MRI: slightly brighter than muscle
on T1
Very bright on T2 homogenous
enhancement following
gadolinium demonstration

Neuroblastoma
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

CARDIAC IMAGING LECTURE

o Tricuspid valve regulates blood flow allow blood to pass through the ventricles.
between RA and RV During systole, the ventricles contracts
o Pulmonary valve controls blood flow from triggering the atria to contract. The RA empties
right ventricle into the pulmonary artery its contents into RV. The tricuspid valve
which carry blood to the lungs to puck up O2 prevents blood from flowing back into the RA.
o Mitral valve lets O2 rich blood from lungs to
pass from LA to LV NOTES:
o Aortic valve opens the way for O2 rich blood Common Imaging modalities:
to pass from LV to the aorta, the largest a. Ionizing radiation – Radiography, CT,
artery, where it is delivered to the rest of Nuclear Scintigraphy
the body b. Non-ionizing radiation – MRI and 2D Echo

Cardiac Borders: (see


picture above)
Right side – SVC and RA
Left side – aorta, aortic arch,
pulmonary artery, LA, LV

During Diastole, atria and ventricles are


relaxed and the AV valves are open.
DeO2ated blood from the SVC / IVC flows to the
RA. The open ______ atrioventricular valves
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

This sagital MRI shows the mid-section of the


LV, defining the interventricular septum of the
myocardium and the lateral wall. The right
ventricle and its outflow tract are seen as one
continuous structure.

Calcium Score
o Identifies calcification of coronary
arteries
o Screening
o Increased calcification = MI

This coronal MRI shows a somewhat


anterior plane of the heart. The RV and
proximal pulmonary artery is well defined.
Portions of the SVC and RA are also visible.

CARDIO THORACIC RATIO

• The widest diameter of the heart


compared to the widest internal
diameter of the rib cage
• Get the diameter of the heart then
divide it to the diameter of the entire
thoracic area within the confines of the
thorax (ribs not included)
• Normal Cardio-thoracic ratio:
This axial MRI shows the main and right o Adults - < 0.5
pulmonary artery crossing under the aortic
arch (medyo malabo, pxenxa)
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

CARDIAC CONTOURS

o Children – 0.55

o Cardiac contours:
• Ascending aorta
o Enlargement 20 to atherosclerosis
o Enlargement is called: Double
Sometimes, CTR is more than 50% BUT heart is density sign
normal • Left atrium
Extracardiac causes of heart enlargement • Aortic knob
Portable AP films o Normal: not > 0.35 mm
Obesity o If enlarged, there is atherosclerotic
Pregnancy aorta
Ascites o >0.5 cm: aneurysm
Straight back syndrome
• Pulmonary artery
Pectus excavatum
o Congenital disease
CTR is less than 50% BUT heart is abnormal o Dilatation of artery
Obstruction to outflow of the ventricles
Ventricular hypertrophy
Must look at cardiac contours

Here is an
example of a
heart which is
< 50% of the
CTR, in which
the heart is
still abnormal.
This is
recognized
because there
is an
abnormal contour to the heart.
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

DOUBLE DENSITY OF LA ENLARGEMENT

Main Pulmonary Artery


The next bump down is the main pulmonary
artery and is the keystone of this system

Two shadows: the yellow arrow pointing to the


LA and the red arrow to the RA, overlap each
other where the indentation between the
ascending aorta and the right heart border
meet.

Aortic knob
o The first bump on the left side
o Can be measured from the lateral border
of air by the trachea to the edge of the
aortic knob.
o Enlarged by
Increased pressure
Increased flow
Changes in the aortic wall
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

Two major classifications


o Main pulmonary artery projects beyond the
tangent line
Increase pressure
Increase flow

Left atrial enlargement


Concavity where LA will appear on the L side
when enlarged

NOTES:
Small pulmonary artery: TOF, Truncus Which ventricle is enlarged?
arteriosus If heart is enlarged and main pulmonary
Apex of ventricle goes down: Enlargement of artery is big RV is enlarged
left ventricle
Apex of ventricle goes up: Enlargement of
right ventricle

o Main pulmonary artery more than 155mm


away from the tangent line.
Because MPA is small or absent
Because tangent line is being pushed
away from the
MPA
Examples: small pulmonary artery
Truncus arteriosus
Tetralogy of fallot

Five states of the Pulmonary Vasculature:


• Normal (more vessels should be seen
in inferior part of the lungs); with
enlargement of upper lobe, there is
cephalization.
• Pulmonary venous hypertension
• Pulmonary arterial hypertension
• Increased flow
• Decreased flow

What we’re going to evaluate


RADIOLOGY – Pleura and mediastinum by Dra. Bandong

Right descending pulmonary artery


Distribution of flow in the lungs
Upper vs. lower lobes
Central vs. peripheral

Right Descending Pulmonary Artery


o Serves right, middle and lower lobes

Normally should not be more than 17mm in


diameter. (Diameter is measured before the
bifurcation)
*Central Vs. Peripheral distribution of flow:
divide lungs vertically into 3. Outer 2/8: here,
you seldom see vascular markings. If present,
there is congestion.

2. Pulmonary Venous Hypertension


o Has cephalization (more vessels in upper
lobes than lower lobes)
o Increased vascular markings

3. Pulmonary Arterial hypertension


o RDPA > 17 mm
o More central vessels are dilated
o Dilatation of right descending pulmonary
artery
o Main pulmonary artery projects beyond
the tangent line
1. Normal Distribution of flow (U / M/ L
lobes)
o In erect position, blood flow to the
bases is > than flow to the apices
o Size of vessels at the bases is normally
> than the size of vessels at apex
o You cant measure the vessels at the left
because the heart blocks them
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

5. Decreased flow
o Unrecognizable most of the time
o Rapid cutoff on size of peripheral vessels
o Small hila
relative to the size of central vessels
o Fewer than normal blood vessels
o Central vessels appear to large for size
o No vessels in lower lobes (which is
of peripheral vessels which come from
normally present)
them = Pruning

4. Increased flow
o Distribution of flow is maintained as
normal
o Gradual tapering from central to
peripheral
o L lobe bigger than U lobe CONGESTIVE HEART FAILURE

o Causes: coronary artery disease


Hypertension
Cardiomyopathy
Valvular lesion
AS, MS
L to R shunts
o Clinical: left sided heart failure:
Shortness of breath
Paroxysmal nocturnal
dyspnea
Orthopnea
Cough
right sided heat failure:
Edema
Left Atrial Pressure
Correlated with pathologic Findings
Normal 5-10 mm
Hg
Cephalization 10-15 mm
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

Hg
Kerley B lines 15-20 mm
Hg
Pulmonary Interstitial 20-25
edema
Pulmonary Alveolar >25
edema

*Normal pulmonary capillary hydrostatic


pressure: about 7 mmHg
Normal colloid oncotic pressure: 11 mmHg

Kerley A lines – near hilum, longer B lines


Kerley B lines – sign of interstitial edema, Kerley B lines
located in the bases o B = distended interlobular septa
Kerley C lines – does not exist o Location and appearance
Bases
Keeping lungs dry 1-2 cm long
Horizontal in direction
Perpendicular to pleural surface

Pulmonary Interstitial Edema


• Fluid present in minor fissure
• Linear opacities in bases: Kerley B
lines
• X-ray Findings
o Thickening of the interlobular Kerley B lines are short, white lines
septa perpendicular to the pleural surface at the lung
Kerley B lines base
o Peribronchial cuffing
Wall is normally hairline thin
Kerley A and C lines
o Thickening of the fissures o A = connective tissue near bronchoaretrial
Fluid in the subpleural space bundle distends
in continuity with interlobular o Location and appearance
septa Near hilum
• Pleural effusions Run obliquely
Longer than B lines
o C = reticular network of lines
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

**C lines probably don’t exist (huh??) o Fluid collects in the subpleural space
Between visceral pleura and lung
parenchyma
o Normal fissure is thickness of a sharpened
pencil line
o Fluid may collect in any fissure
Major, minor, accessory fissure,
azygous fissures
Minor fissure: thickened fluid
Pleural effusion: there is obliteration
of costophrenic sulcus

Kerley A and C lines form a pattern of


interlocking lines in the lung

PERIBRONCHIAL CUFFING

o Interstitial fluid accumulates around the


bronchi
o Causes thickening of the bronchial wall
o When seen on end, it looks like little
“doughnuts”

PLEURAL EFFUSION

o Laminar effusions collect beneath visceral


pleura
In loose connective tissue between lung
and the pleura
Same location for “pseudotumors”

Peribronchial cuffing results when fluid


thickened bronchial walls become visible
producing doughnut- like densities in the lung
parenchyma Laminar pleural effusion can be difficult to see.
Aerated lung should normally extend to the
Fluid in the fissures inner margin of the ribs. The white band of
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

fluid seen here (white arrow) is a laminar Fluid in the subpleural space in
effusion separating aerated lung from the inner continuity with interlobular septa
rib margin o Pleural effusions
o Cephalization
CEPHALIZATION

o If hydrostatic pressure >10mm Hg fluid


leaks into the interstitium of the lung
o Compresses lower lobe vessels first
Perhaps because of gravity
o Resting upper lobe vessels ‘recruited” to 2. Alveolar
carry more blood o Acinar shadow
o Upper lobe vessels increase in size relative o Outer third of the lung frequently spared
to the lower lobe Bat-wing or butterfly configuration
o Lower lung zones more affected than
upper
o Massive pleural effusion

In pulmonary alveolar edema, fluid presumably


Cephalization means pulmonary venous spills over from the interstitium to the air
hypertension. spaces of the lung producing a fluffy
As long as the person is erect when the chest configuration “bat wing” like pattern of disease
X-ray is
obtained Pulmonary Alveolar edema
Clearing
o Generally clears in 3 days or less
PULMONARY EDEMA o Resolution usually begins peripherally and
moves centrally
Types
o Cardiogenic Differential diagnosis
o Neurogenic
o Increased capillary permeability Cardi Renal ARDS
ac
Congestive heart failure Kerley B lines 30% 30% None
Xray patterns and
1. Interstitial peribronchial
o Thickening of the interlobular septa cuffing
Kerley b lines
o Peribronchial cuffing Distribution of Even Centr Peripher
Wall in normally hairline thin Pulmonary 90% al al in 45%
o Thickening of the fissures Edema 70% Even in
35%
RADIOLOGY – Pleura and mediastinum by Dra. Bandong

Air 20% 20% 70%


bronchograms

Pleural Effusions 40% 30% 10%

CHF in Chronologic Sequence


(e2 po ung last topic, pero hindi n nmin
nkuha..kung meron sa inyong may notes
pshare nlng.

EXCLUSIVE WONCEE TRANS …effort as in…