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Slide 1-

Basic Chest Radiology for the TB Clinician Adapted from the ISTC TB Training Modules 2009 PRESENTATION MATERIALS
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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 2
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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) 3
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Chest Radiography: Basic Principles Blackest air fat soft tissue calcium bone X-ray contrast metal Whitest Maximum X-Ray Transmission (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 4
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Differential X-Ray Absorption Why 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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Silhouette Sign: RLL Pneumonia Silhouette Sign: RLL Pneumonia Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6
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Silhouette Sign: RLL Pneumonia Silhouette Sign: RLL Pneumonia Image credit: Curry International Tuberculosis Center, University of California, San Francisco 6
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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 7
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
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10 1 2 3 4 5 6 7 8 9 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
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10 1 2 3 4 5 6 7 8 9 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
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10 1 2 3 4 5 6 7 8 9 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
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Inspiratory Effort Low Lung Volumes Full Inspiration Image credit: Curry International Tuberculosis Center, University of California, San Francisco 9
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Overexposure Proper Exposure Exposure Image credit: Curry International Tuberculosis Center, University of California, San Francisco 10
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Overexposure Proper Exposure Image credit: Curry International Tuberculosis Center, University of California, San Francisco 11
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Rotated (Oblique) Image credit: Curry International Tuberculosis Center, University of California, San Francisco 12
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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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Approach to Reading a CXR Be Systematic Lungs Pleural surfaces Cardiomediastinal contours Bones and soft tissues Abdomen Image credit: Curry International Tuberculosis Center, University of California, San Francisco 14
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Worth a Second Look Apices Retrocardiac areas (left and right) Hilar regions Below diaphragm 15
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Apical TB Image credit: Curry International Tuberculosis Center, University of California, San Francisco 16
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco Apical TB (2) 17
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Left Retrocardiac Opacity Image credit: Curry International Tuberculosis Center, University of California, San Francisco 18
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Nodule Behind Diaphragm Image credit: Curry International Tuberculosis Center, University of California, San Francisco 19
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Basic Radiology for the TB Clinician Basic CXR Anatomy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 20
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Basic CXR Anatomy Frontal and Lateral Views Heart Aorta Pulmonary arteries Airways Image Credit: Lung Health Image Library/Pierre Virot 21
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 22
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Aortic arch Right pulmonary artery Left pulmonary artery Trachea & bronchi Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
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Aortic arch Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
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Aortic arch Right pulmonary artery Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
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Aortic arch Right pulmonary artery Left pulmonary artery Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
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Aortic arch Right pulmonary artery Left pulmonary artery Trachea & bronchi Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
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Basic Radiology for the TB Clinician Patterns of disease 24
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Chest Radiographic Patterns of Disease Consolidation / air-space opacity Interstitial opacity Nodules and masses Lymphadenopathy Cysts and cavities Pleural abnormalities 25
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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) 26
Slide 35-

Pneumonia Image credit: Curry International Tuberculosis Center, University of California, San Francisco 27
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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. 28
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Interstitial Opacity: Lines Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29
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Interstitial Opacity: Lines Image credit: Curry International Tuberculosis Center, University of California, San Francisco 29
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Interstitial Opacity: Lines & Reticulation Image credit: Curry International Tuberculosis Center, University of California, San Francisco 30
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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 31
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Well-Defined Calcification Ill-Defined Mass Image credit: Curry International Tuberculosis Center, University of California, San Francisco 32
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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” 33
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 34
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Infrahilar window (right hilar and/or subcarinal) Left hilar Subcarinal Lymphadenopathy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
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Infrahilar window (right hilar and/or subcarinal) Lymphadenopathy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
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Left hilar Lymphadenopathy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
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Subcarinal Lymphadenopathy Image credit: Curry International Tuberculosis Center, University of California, San Francisco 35
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Right Paratracheal & Bilateral LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 36
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Right Hilar LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 37
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Right Hilar LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 38
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* Subcarinal LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 39
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AP Window LAN Image credit: Curry International Tuberculosis Center, University of California, San Francisco 40
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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 41
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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 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 42
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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 43
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Pleural Disease: Basic Patterns Effusion Angle blunting to massive Thickening Mass Air Calcification 44
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Pleural Effusion 45
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Post-TB Pleural Calcification 46
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Plombage with Lucite balls 47
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Basic Radiology for the TB Clinician Radiographic Manifestations of TB 48
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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) 49
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“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) 50
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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 51
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Can this be TB? Miliary TB 52
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Radiographic Patterns: Pulmonary TB 53
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CXR Pattern: Early vs. Advanced HIV 54
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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 55
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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! 56