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Surgical Pathology & X-rays

for Medical Students


Chest Surgery
2008
Index •Normal Chest X-ray
•Pneumothorax
•Pleural Effusion
•Hydro-pnemothorax
•Complete Lung Collapse
•Opacified Hemithorax
•Bronchogenic Carcinoma
•Cavitary Lung Lesions
•Lung Abscess
•Fibro-caseous TB
•Pulmonary Metastasis
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Normal
Chest
X ray

Index
AA

SVC PA
PA

RA
LV

CoPhS
Index
Pneumothorax

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Index
Lt. side pneumothorax

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Index
Rt. side pneumothorax

Normal for comparison

•Marked difference in X-ray transparency (density) between the left and right thoracic cavities.
•Complete radio-translucency (manifest as greater film density or darker lung field on the image) of the
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Rt. thorax with absence of vascular markings Index
Note:
Lt. tension pneumothorax •The marked density
difference between the left
and right thoracic cavities.
•The complete translucency
on the left with absence of
vascular markings
•Shifting of the mediastinum

•What appears as a left


hilar mass is in fact the
collapsed left lung retracted
into a small central density

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Index Normal
Lt. Tension
pneumothorax

Index
Lt. side tension
pneumothorax
Basis of Diagnosis:

•Hyperresonance of
affected hemithorax
•Decreased or
absence of breath
sounds
•Tracheal deviation to
the other side of
pneumothorax
•Respiratory distress
•Hypotension
•Tachypnea
•Hypoxia
•Distended neck
veins (unless the
patient is hypovolemic)

Index
Rt. side tension
pneumothorax
in an infant

Index
Tension Pneumothorax

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Index
Emergency treatment of tension pneumothorax

Needle decompression (thoracostomy) with large-bore needle in the


second intercostal space in the midclavicular line to convert the tension
pneumothorax into a simple pneumothorax, then prepare for intercostal
tube insertion
This
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simple procedure can save the patient’s life © Vascular 2007
Index
Severe Rt. tension Mechanism:
The air enters to the pleural
pneumothorax space and cannot escape
The intrapleural pressure
increases and the lung becomes
collapsed with secondary shift of
the mediastinal contents to the
opposite side.

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Index After treatment
Pleural Effusion

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Index
Rt. pleural effusion
oFlat opacified line
at the right
hemidiaphragm
with obliteration of
the costo-phrenic
angle

oThe right middle


lobe fissure is
more sharply
visible which tends
to occur when
(there is fluid in
that fissure)
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Index
Lt. pleural effusion
oThe left base is
showing a
curved density in
place of the
normally convex
diaphragm.

oThat curvature
is characteristic
of a pleural
effusion

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Index
Lt. pleural effusion

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Index
Lt. massive
pleural effusion

Normal

Massive effusions usually


have an accompanying
mediastinal shift to the
contralateral side
If a massive effusion does not shift the
mediastinum, suspect malignant effusion
where the mediastinum is fixed.

Index
Massive Lt. pleural effusion

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Index
Massive Right Pleural Effusion

The right
hemithorax is
opaque
There is a shift of
the heart and
trachea away from
the side of
opacification

Index
Rt. lung
effusion
If an effusion (whatever
the fluid is) fills the entire
hemithorax
It acts like a mass
Pushing the heart and
trachea away from the
side of opacification

Index
Hydro-
pneumothorax

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Index
Rt. hydro-
pneumothorax

Hydropneumothorax
in three different
views:
PA Lateral
The PA, lateral, and
right decubetus
reveal a horizontal
air and fluid level.

Rt. decubetus
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Index
Lt. Massive hydro-pneumothorax

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Index
Lung Collapse

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Index
Index

Normal

For comparison

Massive pleural effusion


Left Plural Tap was
NEGATIVE

Complete Lt. Lung Collapse


Complete Lt. Lung Collapse
o40-year-old woman
with tuberculous
bronchial stricture

oChest radiograph
shows complete
collapse of left lung and
deviation (arrows) of
trachea to left lung

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Index
Lt. Lung
Collapse
There is a shift of
heart and
hemidiaphragm
toward side of
opacification
(toward side of volume loss)

Normal Index
Compare

Rt. lung Lt. lung


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effusion Index
collapse
Compare

Lt. tension Lt. lung


pnemothorax collapse

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Index
Compare

Rt. pleural effusion Lt. lung collapse

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Index
Massive
Pneumonia

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Index
Lt. lung
pneumonia
The hemithorax is
opaque and there is
no shift of the heart
or trachea

Index
Pneumonia of the
Left upper lobe

The left hemithorax is


opaque

There is no shift of
the heart or trachea

The opacified
hemithorax contains
air bronchograms

Index
Lt. lung collapse Rt. lung effusion

Causes of
an
Opacified
Hemithorax

Lt. lung pneumonia


The arrow
Lt. neumonectomy
shows
mediastinal
shift

No

Index
Which is this?

Atelectasis

Pneumonia

Effusion

Index
Bronchogenic
Carcinoma

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Index
Bronchogenic
Carcinoma
Fungating, hard solid white
mass arising from the
bronchial lining invading into
the left bronchus and
surrounding tissues.
This is the lung of a 74-year-old man
who first presents with cough, chest
pain, wheezing, hemoptysis and
progressive dyspnea

Can you relate his symptoms


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to the pathology seen?
© Vascular 2007
Index
Cough: infection distal to
airway blocked by tumor.
Hemoptysis: ulceration
of tumor in bronchus.
Dyspnoea: local
extension of tumor.
Chest pain: involvement
of pleura and chest wall.
Wheeze: narrowing of
airway.

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Index
72-year-old man with bronchogenic carcinoma : Bone scintigraphy study shows multiple sites of
increased uptake in left tibia, fibula and foot (metastasis)

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Index
Lung
Carcinoma

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Index
Lung Carcinoma

oA large, well-
defined mass in
the right upper
lobe

oExtensive
emphysematous
change

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Index
Squamous cell carcinoma
A portion of the tumor
demonstrates central
cavitation, probably because the
tumor outgrew its blood supply

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Index
Cavitary Lung Lesion
oThe air-fluid level
indicates
communication with
the airway - hence
sputum is likely to be
helpful in diagnosis.
oThe appearance of
the lesion could be a
carcinoma or an
abscess.
o Sputum cytology was
squamous cell
bronchogenic
carcinoma.
oCavitation is a typical
morphologic feature of
this form of lung cancer.

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Index
Cavitary Lung Lesions

Bronchogenic Cavitating staphylococcal Fibro-caseous


carcinoma pneumonia Note left lower lobe cavitary TB
consolidation with large cavity and
air-fluid level

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Index
Lung Abscess

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Index
Fibro-caseous
Pulmonary TB

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Index
Fibro-caseous TB of both superior
lobes with cavitations on the Rt. side

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Index
Pulmonary
Metastasis

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Index
Multiple
Pulmonary
secondaries

Index
Renal adenocarcinoma with multiple pulmonary metastasis
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Index
Lung metastasis
from CA colon

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Index
Can you identify the pulmonary metastasis?

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Index
Aortic Arch
Aneurysm

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Index
The mediastinal shadow is dominated by the dilation of the aorta.
Better definition of the aortic anatomy is achieved with the CT scan Index
Pulmonary Thoracic
T.B. aortic
aneurysm

Index