Bronchial Carcinoma,Pneumothorax & Pulmonary Edema

BRONCHIAL CARCINOMA.

OVERVIEW

Introduction to bronchial carcinoma

• Types of bronchial carcinoma

Radiographic features/findings

Introduction to Bronchial carcinoma

Also known as bronchogenic carcinoma,refers to the lung cancer originating from the bronchi (the large airways of the lungs).

The most common types of lung cancer can be classified into two main categories histologically as follows:

Bronchial Carcinoma,Pneumothorax & Pulmonary Edema

1: Non–small cell lung cancer(NSCLC): The most common type of lung cancer, accounting for approximately 85% of all lung cancers.

• It's characterized by abnormal cells in the lungs reproducing rapidly and uncontrollably.
• Include 3 types
• Adenocarcinoma
• Squamous cell carcinoma
• Large cell
• 2: Small cell lung carcinoma(SCLC)
• Oat cell carcinoma is a faster-growing cancer that often spreads early.

Histological types

Causes and risk factors

• Smoking( primary causes)
• Exposure to random gas
• Air pollution and harzadous chemicals.
• Genetic predisposition
• Symptoms
• Persistent cough
• Chest pain
• Coughing up blood

Unexplained weight loss

CXR FINDINGS OF BRONCHIAL CARCINOMA.

Irregular mass (tumour): A solitary or multiple lung masses, often with edges. (lung consolidation) Hilar enlargement: Due to the tumour growth near the bronchi.

Lung collapse ( Atelectasis): If the tumour obstructs a bronchus, leading to segmental or lobar collapse.

Golden S sign

Cavitations: 15% of peripheral primary carcinomas cavitate. Most of these are squamous cell carcinomas that may show central necrosis with cavitation.

Pleural effusion: Fluids accumulation in the pleural spaces , often seen in the advanced cases/stages.

• Note: Most cancers ( more than 70%) occurs in the upper lobes.

Many bronchial carcinomas are easy to detect usually as conspicous mass.

BRONCHOGENIC CARCINOMA.

Lung cancer.

Left hilum bronchogenic carcinoma

TUMOR WILL HIDE.

Some of carcinomas are difficult to detect because of their position or because they are overlapped by normal structures.

• To locate a hidden mass you need to inspect four areas very carefully.
• Superimposed on the heart.

Make sure that the density on the heart on both side of the supine is equal.

Bronchial Carcinoma,Pneumothorax & Pulmonary Edema

The lung apices. Some tumor begin as flat lesion and the CXR appearance may be dismissed as simple pleural thickness ,A flat apices carcinoma can mimic a apical pleural cap

Below the horizon of each dome of the diaphragm.

A large part of each lower lobe lies below the horizon of each dome of the diaphragm ,even so if a lung mass is surrounded by air it is usually detectable on frontal CXR.

Bronchial Carcinoma,Pneumothorax & Pulmonary Edema

Around the hila: This does not refer to hilar enlargement. It refers to the lung parenchyma around, behind and in front of a hilum. Overlap by vessels entering or leaving the hilum can cause a nearby lung lesion to be overlooked.

Golden’s S sign

A collapsed right upper lobe with a mass at the hilum results in a reverse S configuration.

The reversed S is made up of an elevated horizontal fissure and a bulky tumour at the hilum.

Golden S sign

Pulmonary metastases

Refer to distant tumour spread from a variety of primary tumours to the lungs via the blood or lymphatics.

Radiographic features

Pulmonary metastases typically appear as multiple, peripheral, rounded nodules scattered throughout both lungs.

Larger nodules and masses may be termed cannonball metastases.

Atypical features include consolidation, cavitation, cystic change, calcification, ossification, haemorrhage, and

secondary pneumothorax(post–primary).

Cannonball

PNEUMOTHORAX

OVERVIEW

Introduction to Pneumothorax.

• Clinical types.

Radiological findings.

Introduction to pneumothorax

Pneumothorax refers to the presence of air in the pleural spaces/ refers to the presence of gas in the pleural space which allows the parietal and visceral pleura to separate and the lung to collapse.

Occurs when the air enter in the pleural spaces( the area between the lung and the chest wall), causing the lungs to collapse partially or completely.

There are several types of the pneumothorax,classified based on their causes and severity:

1. Spontaneous Pneumothorax

Occurs without trauma and is further divided into:

Primary spontaneous pneumothorax : happens in young healthy individuals without underlying lung disease. often due to ruptured lung blebs(sub pleural blebs).

Secondary spontaneous pneumothorax: occurs in people with underlying lung diseases like COPD, asthma or cyst fibrosis.

Caused by the chest injuries such as

Blunt trauma: Ribs fractures puncturing the lung the lung.

Penetrating trauma: stab wound, gunshot injuries or medical procedures like lung biopsies.

• Traumatic pneumothorax

Bronchial Carcinoma,Pneumothorax & Pulmonary Edema

Occurs when the air enter in the pleural spaces but can not escape and increasing pressure in the chest and progressive lungs collapse, this can compress the heart and the major blood vessels cause cardiovascular instability.

• Iatrogenic pneumothorax
• Occurs due to the medical procedures such as;
• Mechanical ventilation ,Excessive pressure causing lung rupture.
• Tension pneumothorax:

PATHOLOGIC

• Simple/ closed pneumothorax:
• The opening in lung is very small and hence ,it heals rapidly.
• There is no continuous communication between the lung and pleural cavity.

This means that pleural pressure is less than atmospheric pressure.

Open / sucking pneumothorax

The rupture site remains open and there is a communication between the pleural cavity and the bronchus forming the broncho-pleural fistula.

Pleural pressure is equal to the atmospheric pressure.

Due to the broncho – pleural fistula, infection in pleural spaces is common and hence lead to Pyo pneumothorax.

open / sucking pneumothorax.

Tension pneumothorax.

The communication between lung and the pleural cavity is small , it allow enter during the respiration and preventing it from escaping during expiration.

Therefore, the pleural pressure is more than atmospheric pressure.

Tension pneumothorax.

CLINICALS FEATURES.

• Closed pneumothorax
• Reduced chest expansion.
• Mediastinal shift to opposite side.
• Decreased vocal resonance.
• Open pneumothorax.
• Apmhoric breath sound.
• Crackpot breath sound.
• Tension pneumothorax.

Displacement of the mediastinum.

SYMPTOMS

• Dyspnoea
• Cyanosis
• Tachycardia
• Tachypnoea
• Increased in respiration rate

Respiration failure

RADIOLOGICAL FINDINGS OF PNEUMOTHORAX

• 1: Visible visceral pleural line.
• A sharp line representing the edge of the collapsed lung.

No makings beyond this line ,indicating air in the pleural space.

Pleural visible line.

2: Shifting of mediastinum on the opposite side of injury.

3: Increase in radiolucency

The affected side appear darker due to the presence of air.

4: Flattened Diaphragm

The diaphragm on the affected side may appear depressed.

5:Razor sharp border of the collapsed lung.

6. Deep sulcus sign

The deep sulcus sign on a supine chest x-ray is a radiographic finding strongly suggestive of a pneumothorax.

It appears as a deep, lucent, sharp, and angular costophrenic angle that extends more inferiorly than usual due to air collecting laterally in the pleural space.

Deep sulcus sign

Note these radiographic features:

• The visible visceral pleural edge is seen as a very thin, sharp white line
• No lung markings are seen peripheral to this line
• The peripheral space is radiolucent compared to the adjacent lung

The lung may completely collapse

The mediastinum should not shift away from the pneumothorax unless a tension pneumothorax is present Erect Chest X-ray:

An upright chest X-ray is generally preferred because it helps to visualize any air that has risen to the upper part of the chest, making the pneumothorax more obvious

PULMONARY EDEMA

OVERVIEWS

Introduction to pulmonary edema

• Etiology and Clinical features
• Types of pulmonary edema

Radiographic features

Pulmonary edema

Pulmonary edema is a broad descriptive term and is usually defined as an abnormal accumulation of fluid in the extravascular compartments of the lung Clinical presentation

• The clinical presentation of pulmonary edema includes:
• Acute breathlessness
• Orthopnea
• Paroxysmal nocturnal dyspnea (PND)
• Foaming at the mouth

Distress

Causes/Etiology

• Broadly causes can be classified as cardiogenic and non-cardiogenic:
• Cardiogenic pulmonary edema
• Left heart failure (Congestive cardiac failure)
• Mitral regurgitation
• Aortic stenosis
• Arrhythmias

Myocardial pathology (Myocarditis ,Cardiomyopathy)

non-cardiogenic pulmonary edema

• Fluid overload

Pulmonary edema with acute asthma

Posto-bstructive pulmonary edema/ postintubation pulmonary edema/negative pressure pulmonary edema Pulmonary edema in pulmonary thromboembolism Pulmonary edema due to air embolism etc

Phases/types of pulmonary edema

Two pathophysiological and radiological phases are recognized in the development of pressure edema (hydrostatic pressure) Pulmonary interstitial edema

• Pulmonary alveolar edema

These phases are virtually identical for left heart failure and fluid overload

Radiographic features

Features useful for broadly assessing pulmonary edema on a plain chest radiograph include:

Increased cardiothoracic ratio /cardiac silhouette size. useful for assessing for an underlying cardiogenic cause or association

Features of pulmonary interstitial oedema:

Peribronchial cuffing (This refers to thickening of the bronchioles (small airways) due to fluid accumulation around the bronchial walls) and Perihilar haze.

Interlobar Septal (Kerley B) lines (These are short, thin white lines(septal line) appearing at the periphery of the lungs extending toward the pleura, indicating thickening of the interlobar septa due to interstitial oedema).

• Thickening of interlobar fissures: These fissures may appear thicker and more prominent.

Perihilar haze:

A hazy appearance around the hilum, indicative of fluid accumulation in the central lung fields.

Septal line

Features of pulmonary alveolar edema:

Patchy opacities classically in a ”batwing” distribution/appearance (which means bilateral, fan-shaped opacities extending outwards from the hilum) May have air bronchograms in severe cases Pleural effusions and fluid in interlobar fissures

Bat wings appear

General radiographic features of pulmonary edema

• Kerley B lines
• Batwing opacities
• Peribronchial cuffing
• Increased vascular markings

May present with air bronchograms

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