Radiology Athlas - Thorax

RADIOLOGY ATLAS THORAX ANATOMY

*

CLINICAL CASES

Vasco Sabino Silva

* João Carlos Costa

RADIOLOGY ATLAS

THORAX ANATOMY

*

CLINICAL CASES

Coordination Vasco Junior Sabino da Silva, MD, MSC Radiologist Executive Board Member Clínica Girassol Director of Diagnostic and Therapeutics Hospital Militar Principal / Instituto Superior Luanda - Angola

João Carlos Costa, MD Radiologist Head of the Department of Radiology Hospital Particular de Viana do Castelo – Portugal Department of Radiology Clínica Girassol Luanda - Angola CDIL Centro de Diagnóstico por Imagem de Luanda Board Member

7

Vasco Sabino Silva, MD Radiologist

João Carlos Costa, MD Radiologist

Original title: Atlas de Radiologia Tórax This publication may only be reproduced, distributed, transmitted or altered, in any form, with the express consent of its authors, except in cases permitted by law.

Reproduction of any part of this publication, either by means of photocopy, scan or transcription, requires prior permission.

© February de 2015 Printed by: Tipografia Nova

ISBN: 978-989-20-5445-2

8

PROLOGUE

It was late in the afternoon on a wednesday in October.

I was finishing my work in the reports room of Clínica Girassol’s Department of Radiology, when I received an internal call - “Dr Gito, come up here; Dr Vasco wants to talk to you”.

Nothing unusual so far...

But I had no idea how different that conversation with my Friend and Boss Vasco Silva would be.

“I am going to issue you a challenge - create a Radiology Atlas, including all its areas. Use all the means you need, as long as it presents maximum quality”.

I am an emotional person, so I got a little embarrassed; not because of the challenge itself, but due to of the trust placed on me!

It was one of the best moments of my life!

I would be able to do what I had always wished for! Create an Atlas about my passion - Radiology.

It would serve as a launching pad for developing the residency programme that we were introducing in the Department of Radiology.

It was with great enthusiasm that I told my Department colleagues, and the enthusiasm spread.

We decided to publish eight volumes, each regarding a bug system.

The first would be based on the THORAX. Thus, our intent to fullfil the requirements of the One who made the Order comes into existence.

Luanda, February 2015 João Carlos Costa

9

FOREWORD

Following the aim that has always guided us in Clínica Girassol - the search for Excellence - we now develop this Radiology Atlas.

This is our modest, but honest, contribution for what will almost certainly be one of the greatest works of this kind published in Portuguese, covering all areas of Medical Imaging.

Its execution is justified by the experience acquired throughout the years, particularly in the last four years, when there was significant improvement on the range of equipment in the Department of Radiology. Also, a great investment was made in the qualification of technicians working in this Department, whose cross-disciplinary knowledge and decisive character within an Institution as Clínica Girassol made us decide to prioritize them.

This is an extensive work, where great rigour and quality were demanded.

For now, the first volume is published - THORAX; seven others will follow regarding the remaining areas.

This work also reflects the organisation and teamwork present not only in the Department of Radiology, but in the whole Clínica Girassol, evidenced by the rapid and enthusiastic collaboration of the other Departments.

Considering the important teaching and training aspects assumed as one of the main purposes of this work, its configuration was chosen intentionally to motivate not only Doctors in the area of Imaging, but mostly Doctors from other Specialities, Residents, and Medical students.

The association of images with clinical issues demonstrates what the current Radiology should be like.

I hope the reader enjoys reading or consulting this Atlas.

Luanda, February 2015 António Pedro Filipe Júnior President of the Executive Council Clínica Girassol

11

ACKNOWLEDGEMENTS

Acknowledgements, as usual, are directed to all who collaborated in the accomplishment of a certain work.

However, there are well-deserved special acknowledgements.

To Dr Conceição Pernadas and Dr Henrique Rodrigues, I thank for their commitment, and mostly for guiding Dr Elza da Cunha Gondjo and Dr Conceição Esteves Júlio. To these latter, I appreciate the magnificent work in describing the anatomical images and selecting many of the cases.

To the Technicians from the Department of Radiology of Clínica Girassol and from the Department of Radiology of the Viana do Castelo Private Hospital I acknowledge their help in obtaining images with great quality.

I would also like to thank the IT technician Hélder Juvenal for his availability to fullfil my whims, and help with the layout. Without him, it would have been impossible to accomplish this work.

My special thank you to the Department of Radiology of the University Hospital of Coimbra, in particular to its Director, Prof. Filipe Caseiro Alves, for providing some case reports that enhanced this Atlas.

To every collaborating Doctors, I appreciate all the help.

My gratefulness to all.

Luanda, February 2015 João Carlos Costa

13

AUTORES João Carlos Costa, MD

Constança de Palma Gomes, MD

Radiologist Head of Department of Radiology Hospital Particular de Viana do Castelo Portugal Department of Radiology Clínica Girassol Luanda – Angola CDIL - Centro de Diagnóstico por Imagem de Luanda

Radiologist Head of the Department of Radiology Clínica Girassol Luanda - Angola

Henrique Rodrigues, MD Radiologist Hospital Particular de Viana do Castelo Portugal Clínica Girassol Luanda - Angola

Conceição Pernadas, MD Radiologist Clínica Girassol Luanda - Angola

João Oliveira, MD Radiologist Hospital Particular de Viana do Castelo Portugal Clínica Girassol Luanda - Angola

Teresa Joana Costa, MD Radiology Resident Department of Radiology Hôpital Erasme Université Libre de Bruxelles Belgium

Dinis Teixeira, MD Radiologist Hospital Particular de Viana do Castelo Portugal Clínica Girassol Luanda - Angola

Pedro Marques, MD Radiologist Hospital Particular de Viana do Castelo Portugal Clínica Girassol Luanda - Angola

Ana Frias Vilaça, MD Radiologist Hospital Particular de Viana do Castelo Portugal

Elza da Cunha, MD Radiology Resident Clínica Girassol Luanda - Angola

Conceição Júlio, MD Radiology Resident Clínica Girassol Luanda - Angola

Frederico Cavalheiro, MD Radiologist Hospital Particular de Viana do Castelo Portugal Clínica Girassol Luanda - Angola

15

LIST OF CLINICAL CASES Achalasia 53 _____________________________________________________ Miliary tuberculosis 54 _____________________________________________________ Cavitary tuberculosis 55 _____________________________________________________ Necrotising pneumonia 56 _____________________________________________________ PT complicated with aspergilloma 57 _____________________________________________________ Diaphragmatic paralysis 58 _____________________________________________________ Achalasia 59 _____________________________________________________ Acute pulmonary oedema 60 _____________________________________________________ Pyopericardium 61 _____________________________________________________ Mediastinitis 62 _____________________________________________________ Tuberculous pericarditis 63 _____________________________________________________ Idiopathic pulmonary fibrosis 64 _____________________________________________________ Panacinar and paraseptal emphysema 65 _____________________________________________________ Bronchioloalveolar carcinoma 66 _____________________________________________________ Cylindrical bronchiectasis 67 _____________________________________________________ Centrilobular emphysema 68 _____________________________________________________ Histiocytosis X 69 _____________________________________________________ Extramedullary haematopoiesis 70 _____________________________________________________ Epidermoid carcinoma 71 _____________________________________________________ Bacterial lobar pneumonia 72 _____________________________________________________ Septic pulmonary emboli 73 _____________________________________________________ Extrinsic allergic alveolitis 74 _____________________________________________________ Atelectasis of the left upper lobe 75 _____________________________________________________ Atelectasis of the middle lobe 76 _____________________________________________________ Traction bronchiectasis 77 _____________________________________________________ Bronchioloalveolar carcinoma 78 _____________________________________________________ Epidermoid carcinoma 79 _____________________________________________________ Ranke complex 80 _____________________________________________________ Cryptogenic organising pneumonia (COP) 81 _____________________________________________________

21

LIST OF CLINICAL CASES Elastofibroma dorsi 82 _____________________________________________________ Progressive systemic sclerosis 83 _____________________________________________________ Congestive heart failure 84 _____________________________________________________ Lymphangioleiomyomatosis 85 _____________________________________________________ Lymphoma of the anterior mediastinum 86 _____________________________________________________ Lipoma of the thoracic wall 87 _____________________________________________________ Pulmonary arteriovenous malformation 88 ____________________________________________________ Alveolar microlithiasis 89 _____________________________________________________ Aorto-oesophageal fistula 90 _____________________________________________________ Organising pneumonia secondary to amiodarone 91 _____________________________________________________ Right coronary artery stenosis 92 _____________________________________________________ Hypertensive pneumothorax 93 _____________________________________________________ Hepatic, splenic, and pulmonary (stage II) sarcoidosis 94 _____________________________________________________ Cavitary tuberculosis 95 _____________________________________________________ Fibrous tumour of the pleura 96 _____________________________________________________ Tracheobronchomegaly (Mounier-Kuhn syndrome) 97 _____________________________________________________ Mediastinal abscess 98 _____________________________________________________ Noncompacted myocardium 99 _____________________________________________________ Aberrant right subclavian artery 100 _____________________________________________________ Calcified pachypleuritis 101 _____________________________________________________ Bronchioloalveolar carcinoma 102 _____________________________________________________ Pneumothorax in tuberculosis 103 _____________________________________________________ Normal thymus for the patient’s age 104 _____________________________________________________ Pulmonary tuberculosis - alveolar form 105 _____________________________________________________ Community-acquired pneumonia 106 _____________________________________________________ Metastasis of breast adenocarcinoma 107 _____________________________________________________ Right aortic arch 108 _____________________________________________________ Silhouette sign 109 _____________________________________________________ Dextrocardia with situs inversus 110 _____________________________________________________

23

LIST OF CLINICAL CASES Intralobar sequestration 111 _____________________________________________________ Thymic carcinoma 112 _____________________________________________________ Circumflex coronary artery aneurysm 113 _____________________________________________________ Rounded atelectasis 114 _____________________________________________________ Aneurysm of the ascending aorta 115 _____________________________________________________ Epidermoid carcinoma 116 _____________________________________________________ Bochdalek hernia 117 _____________________________________________________ Cystic and varicose bronchiectasis 118 _____________________________________________________ Fibrolipid plaque in the left coronary artery 119 _____________________________________________________ Coarctation of the thoracic aorta 120 _____________________________________________________ Oesophageal hiatus hernia 121 _____________________________________________________ Pulmonary sarcoidosis 122 _____________________________________________________ Lung adenocarcinoma 123 _____________________________________________________ Constrictive pericarditis 124 _____________________________________________________ Centrilobular emphysema 125 _____________________________________________________ Round pneumonia 126 _____________________________________________________ Lobar pneumonia 127 _____________________________________________________ Pleural metastasis of melanoma 128 _____________________________________________________ Infection by Mycobacterium avium complex (MAC) 129 _____________________________________________________ Pectus escavactum 130 _____________________________________________________ Left atrial myxoma 131 _____________________________________________________ Aortic dissection, type B 132 _____________________________________________________ Aspergilloma, semi-invasive aspergillosis 133 _____________________________________________________ Lesions secondary to prostate tumour 134 _____________________________________________________ Tracheobronchial papillomatosis 135 _____________________________________________________ Hypertrophic cardiomyopathy 136 _____________________________________________________ Primary tuberculosis 137 _____________________________________________________ Ganglioneuroblastoma 138 _____________________________________________________ Middle-lobe pneumonia 139 _____________________________________________________

25

LIST OF CLINICAL CASES Pulmonary silicosis 140 _____________________________________________________ Pulmonary thromboembolism (PTE) 141 _____________________________________________________ Form of massive fibrosis in silicosis 142 _____________________________________________________ Post-primary tuberculosis 143 _____________________________________________________ Aspergilloma 144 _____________________________________________________ Post-primary / progressive tuberculosis 145 _____________________________________________________ Scar after transmural infarction 146 _____________________________________________________ Segmental pneumonia 147 _____________________________________________________ Left coronary artery stenosis 148 _____________________________________________________ Apical infarction with thrombus 149 _____________________________________________________ Calcified adenopathy 150 _____________________________________________________ Hamartoma 151 _____________________________________________________ Anomalous origin of the coronary artery 152 _____________________________________________________ Cryptogenic organising pneumonia (COP) 153 _____________________________________________________ Teratoma 154 _____________________________________________________ Iatrogenic lesion 155 _____________________________________________________ Pulmonary tuberculosis 156 _____________________________________________________ Infected cyst 157 _____________________________________________________ Idiopathic pulmonary fibrosis 158 _____________________________________________________ Fibrosarcoma of the pleura 159 _____________________________________________________ Cystic bronchiectasis 160 _____________________________________________________ Myocardial amyloidosis 161 _____________________________________________________ Metastasis of adrenal carcinoma 162 _____________________________________________________ Acute pulmonary thromboembolism (PTE) 163 _____________________________________________________ Hamartoma 164 _____________________________________________________ Amiodarone pulmonary toxicity 165 _____________________________________________________ Lung metastasis of melanoma 166 _____________________________________________________ Circumflex coronary artery fistula 167 _____________________________________________________

27

2

Clinical presentation: 43-year-old female patient, HIV+, presenting with fever of insidious onset and severe cough, asthenia, and anorexia.

Imaging findings: Diffuse well-defined micronodules are seen randomly distributed in the peripheral subpleural, peribronchovascular and centrilobular interstitium.

Differential diagnosis: Miliary metastasis (thyroid carcinoma, kidney carcinoma, osteosarcoma, melanoma), miliary infection (tuberculosis, fungi), sarcoidosis, silicosis.

Diagnosis: Miliary tuberculosis.

Discussion: When miliary pattern is found in an immunocompromised patient, tuberculosis is the first hypothesis. Miliary tuberculosis consists in massive haematogenous dissemination of microorganisms from a pulmonary nidus. It may occur associated with progressive-primary tuberculosis in an immunocompromised patient, or with post-primary infection in an immunosuppression context.

54

7

Clinical presentation: 53-year-old male patient, presenting with retrosternal discomfort, is referred to a coronary CT angiography with suspicion of coronary disease.

Imaging findings: A dual-source multi-slice (256 slices) coronary CT angiography, performed with prospective acquisition in Flash mode (Siemens Somatom Flash), revealed normal coronary arteries. Images from axial acquisition showed significant dilation of the thoracic oesophagus with intraluminal content, which is consistent with achalasia. The effective radiation dose was 0.7 mSv. Diagnosis: Achalasia, normal coronary arteries.

Discussion: Achalasia explains this patient’s symptoms. See case 1.

59

13

Clinical presentation: Patient presenting with dyspnea.

Imaging findings: The thoracic CT reveals significant changes in lung architecture caused by multiple areas of lower pulmonary density, without wall or interstitium, which do not spare the secondary lobules. Peripheral vascular attenuation is also seen, as well as small subpleural bubbles, which appear separated by lines perpendicular to the pleura that represent the interlobular septa.

Differential diagnosis: Panacinar emphysema, centrilobular emphysema, paraseptal emphysema, Langerhans histiocytosis, lymphangioleiomyomatosis.

Diagnosis: Panacinar and paraseptal emphysema.

Discussion: The normal pulmonary parenchyma density levels range between -850 and -900 Hounsfield units. Density levels inferior to -910 Hounsfield units reduce the differential diagnosis to three major options: emphysema, cystic lung disease, and bronchial obstruction.

The absence of a wall surrounding lower-density areas differentiates emphysema from cystic lung diseases, which have a more-or-less thick wall that may be associated with other parenchymal abnormalities, such as nodules. Panacinar emphysema is differentiated from the centrilobular one by involvement of the secondary lobule and by more-significant changes in the parenchymal architecture, resulting in peripheral vascular attenuation. There is also greater impact on the lower lobes and higher probability of pulmonary hypertension findings.

65

18

Clinical presentation: Patient presenting with anaemia.

Imaging findings: In the thoracic CT, well-defined paravertebral masses, with no fat associated, are seen in the posterior mediastinum, adjacent to the ribs. The posterior aspect of the ribs is expanded, with irregular trabeculation and some cortical discontinuity. Images also show expansion of the iliac bones and sacrum, structural abnormalities in the bone marrow, cortical thickening, and a presacral soft-tissue mass.

Differential diagnosis: Extramedullary haematopoiesis, glycogen disease, lymphoproliferative disease.

Diagnosis: Extramedullary haematopoiesis.

Discussion: Extramedullary haematopoiesis is associated with diseases like spherocytosis, thalassaemia, and drepanocytosis. Bone marrow expansion occurs as a response to haemolyse, and causes structural bone changes, visceromegalies, and soft-tissue masses, which represent the haematopoietic tissue. Symmetrical masses in the posterior mediastinum, sometimes with fat foci, strongly indicate this entity, mainly in the presence of known anaemia. These soft-tissue masses may appear anywhere in the reticuloendothelial system, occasionally mimicking adenopathy. The bone changes result from medullary expansion, but are not specific. They are polyostotic, affect mostly the axial skeleton (which is rich in red marrow), and show a mixed pattern with areas of sclerosis, bone lysis, and cortical continuity.

70

19

Clinical presentation: Asymptomatic 57-year-old male patient, smoker, presenting with a nodule in the left lung upper lobe, which was detected in a chest radiograph.

Imaging findings: A nodule of about 1 cm diameter, with spiculated contour, and without calcifications or fat, is seen in the left upper lobe. Magnetic Resonance Imaging (MRI) showed significant diffusion restriction.

Differential diagnosis: Malignant nodule.

Diagnosis: Epidermoid carcinoma, revealed by biopsy.

Discussion: Epidermoid carcinoma (or squamous cells carcinoma) occurs more frequently in men, and rarely in non-smokers. Lowdose CT is the best method to detect and characterize nodules in asymptomatic patients, as it permits to correctly establish their dimensions, the existence/absence of calcifications and fat, and the lung-nodule interface. Nodules similar to the ones of the present case strongly suggest malignancy. Diffusion MRI is a current method with great potential for characterising these nodules, since the ones with diffusion restriction are suspect of malignancy.

71

33

Clinical presentation: Female patient presenting with chronic cough.

Imaging findings: The chest radiograph shows interstitial enhancement. The thoracic CT reveals several thin-walled cysts with regular outlines, widespread in the lung, without associated nodules or pleural effusion.

Differential diagnosis: Lymphangioleiomyomatosis, Langerhans cells histiocytosis, emphysema, neurofibromatosis, tuberous sclerosis.

Diagnosis: Lymphangioleiomyomatosis.

Discussion: Lymphangioleiomyomatosis only affects women of childbearing age. It results from the proliferation of muscular tissue in the lymphatics, and is typically associated with thin-walled cysts with regular outlines that do not spare the lung bases. These findings allow its differentiation from histiocytosis. The absence of changes in the central nervous system or nerve sheath tumours differentiates this condition from tuberous sclerosis and neurofibromatosis. Its differentiation from emphysema is based on images analysis, since the latter typically shows hyperlucent areas without walls, which are not cysts, but instead the result of destruction and simplification of the pulmonary parenchymal architecture.

85

40

Clinical presentation: Asymptomatic 64-year-old male patient undergoes a routine treadmill test, which was positive.

Imaging findings: A dual-energy coronary CT angiography was performed using the multi-slice (256 slices) equipment Siemens Somatom Flash in flash mode, with an effective radiation dose of 0.9 mSv. It revealed a short marked stenosis (greater than 70%) in the proximal third of the right coronary artery. This lesion was confirmed by cardiac catheterisation.

Diagnosis: Short, mixed, highly-stenotic plaque in the proximal third of the right coronary artery.

Discussion: In 80% of the cases, myocardial infarction is the first symptom of the atherosclerotic disease. The coronary CT angiography performed with a 256-slices equipment is a quick diagnostic method with high accuracy for the coronary pathology, especially in cases without large calcium plaques. A stent was introduced via cardiac catheterisation, with complete normalisation of the calibre of this coronary artery.

92

47

Clinical presentation: 45-year-old male patient presenting with episodes of arrhythmia and syncope.

Imaging findings: Four-chamber, left ventricular outflow tract, and short axis views were acquired with MRI, as well as late gadolinium-enhanced MRI acquisition of four-chamber view. A trabecular pattern was seen in the apical and lateral aspects of the left ventricle, with a thin compacted layer in the epicardial aspect of the myocardium. No late enhancement was detected.

Diagnosis: Noncompacted myocardium.

Discussion: Left ventricular noncompaction (or spongy myocardium) is a rare congenital cardiomyopathy that may be diagnosed in any age. It typically involves a thin layer of compacted myocardium in the epicardial aspect, and an extensive noncompacted layer in the endocardium, with evident trabecular pattern and deep recesses that communicate with the left ventricular cavity, but not with the coronary circulation. This condition is caused by cessation of compaction during embryonic development.

Clinically, it is manifested by ventricular arrhythmias, which may be fatal, chronic heart failure, and systemic embolic events. These findings occur frequently in patients with advanced disease, but are uncommon in early stages.

99

55

Clinical presentation: 42-year-old female patient who underwent surgery for breast carcinoma three years earlier.

Imaging findings: Several infracentimetric nodules are seen spread in the parenchyma of both lungs. A CT fluoroscopy-guided biopsy was performed.

Differential diagnosis: Metastasis.

Diagnosis: Metastasis of breast adenocarcinoma, confirmed by biopsy.

Discussion: Breast carcinoma often produces lung metastases. The patient may be completely asymptomatic, as in this case, and lesions are only detected by imaging examinations. In an adequate clinical context, the radiologist should indicate this suspicion. Since lesions do not display any specific feature, a biopsy is required.

107