Surgical Pathology Xrays for Medical Students Chest Surgery

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 2 • Aortic Arch Aneurysm © Vascular 2007

Normal Chest X ray Index

AA SVC PA PA RA LV Co. Ph. S Index

Pneumothorax 5 Index © Vascular 2007

Lt. side pneumothorax 6 © Vascular 2008 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 © Vascular 2007 7 Rt. thorax with absence of vascular markings Index

Lt. tension pneumothorax Note: Note • 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 8 Index © Vascular 2007 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 12 Index © Vascular 2007

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 simple procedure can save the patient’s life © Vascular 2007 13 Index

Severe Rt. tension pneumothorax 14 Mechanism: The air enters to the pleural space and cannot escape The intrapleural pressure increases and the lung becomes collapsed with secondary shift of the mediastinal contents to the opposite side. Index © Vascular 2007 After treatment

Pleural Effusion 15 Index © Vascular 2007

Rt. pleural effusion o. Flat opacified line at the right hemidiaphragm with obliteration of the costo-phrenic angle o. The right middle lobe fissure is more sharply visible which tends to occur when (there is fluid in that fissure) 16 Index © Vascular 2007

Lt. pleural effusion o. The left base is showing a curved density in place of the normally convex diaphragm. o. That curvature is characteristic of a pleural effusion 17 Index © Vascular 2007

Lt. pleural effusion 18 Index © Vascular 2007

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 20 Index © Vascular 2007

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

Hydropneumothorax 23 Index © Vascular 2007

Rt. hydropneumothorax Hydropneumothorax in three different views: The PA, lateral, and right decubetus reveal a horizontal air and fluid level. PA Lateral Rt. decubetus 24 Index © Vascular 2007

Lt. Massive hydro-pneumothorax 25 © Vascular 2007 Index

Lung Collapse 26 Index © Vascular 2007

Index Normal For comparison Massive pleural effusion Left Plural Tap was NEGATIVE Complete Lt. Lung Collapse

Complete Lt. Lung Collapse o 40 -year-old woman with tuberculous bronchial stricture o. Chest radiograph shows complete collapse of left lung and deviation (arrows) of trachea to left lung 28 Index © Vascular 2007

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

Compare 30 Rt. lung effusion Index Lt. lung collapse

Compare Lt. tension pnemothorax 31 Lt. lung collapse Index © Vascular 2007

Compare Rt. pleural effusion 32 Lt. lung collapse Index © Vascular 2007

Massive Pneumonia 33 Index © Vascular 2007

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 The arrow shows mediastinal shift Lt. lung pneumonia No Index Lt. neumonectomy

Which is this? Atelectasis Pneumonia Effusion Index

Bronchogenic Carcinoma 38 Index © Vascular 2007

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 39 Index Can you relate his symptoms to the pathology seen? © Vascular 2007

§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. 40 Index © Vascular 2007

72 -year-old man with bronchogenic carcinoma : Bone scintigraphy study shows multiple sites of increased uptake in left tibia, fibula and foot (metastasis) 41 Index © Vascular 2007

Lung Carcinoma 42 Index © Vascular 2007

Lung Carcinoma o. A large, welldefined mass in the right upper lobe o. Extensive emphysematous change 43 Index © Vascular 2007

Squamous cell carcinoma A portion of the tumor demonstrates central cavitation, probably because the tumor outgrew its blood supply 44 Index © Vascular 2007

Cavitary Lung Lesion o. The air-fluid level indicates communication with the airway - hence sputum is likely to be helpful in diagnosis. o. The appearance of the lesion could be a carcinoma or an abscess. o Sputum cytology was squamous cell bronchogenic carcinoma. o. Cavitation is a typical morphologic feature of this form of lung cancer. 45 Index © Vascular 2007

Cavitary Lung Lesions Bronchogenic carcinoma 46 Cavitating staphylococcal pneumonia Note left lower lobe consolidation with large cavity and air-fluid level Index Fibro-caseous cavitary TB © Vascular 2007

Lung Abscess 47 Index © Vascular 2008

Fibro-caseous Pulmonary TB 48 Index © Vascular 2007

Fibro-caseous TB of both superior lobes with cavitations on the Rt. side 49 Index © Vascular 2007

Pulmonary Metastasis 50 Index © Vascular 2007

Multiple Pulmonary secondaries Index

Renal adenocarcinoma with multiple pulmonary metastasis 52 Index © Vascular 2007

Lung metastasis from CA colon 53 Index © Vascular 2007

Can you identify the pulmonary metastasis? 54 Index © Vascular 2007

Aortic Arch Aneurysm 55 Index © Vascular 2007

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

Thoracic aortic aneurysm Pulmonary T. B. Index