CHEST
DIFFERENTIALS
Multiple Pleural Opacities (Each >2 cm)
subpleural_parenchymal_lung_opacities
Pleural Effusion With Large
Cardiac Silhouette
Small Pleural Effusion With
Subsegmental Atelectasis
Pleural Effusion With Lobar Opacities
Pleural Effusion With Hilar
Enlargement
Right_cardiophrenic_angle_mass
multifocal_illdefined_opacities
diffuse_fine_nodular_pattern_afebrile_pt
diffuse_fine_nodular_pattern_febrile_pt
diffuse_fine_reticular_opacities
fine_reticular_pattern_with_effusion
fine_reticular_pattern_with_hilar_LAD
Classification_primary_ling_carcinoma
multiple_nodules_sharp_borders
illdefined_opacities_with_holes
pulmonary_lucent_lesions_related_to_aids
CHART 2-l.
I. Nipples, supernumerary nipples
II. Artifact
III. Skin lesions (e.g., moles,
neurofibromas, extra thoracic musculature)
IV. Mesenchymal tumors (muscle tumors,
fibromas, lipomas, desmoid tumor)
V. Neural tumors (schwannoma,
neurofibroma, neuroblastoma)
VI. Hodgkin's and non-Hodgkin's lymphoma
VII.
Vascular tumors (hemangioma, hemangiopericytoma)
VIII.
Bone tumor (metastasis, multiple myeloma, Ewing's sarcoma, fibrous dysplasia,
chondrosarcoma, osteosarcoma [rare]. fibrosarcoma, solitary plasmacytoma)
IX. Hematoma
X. Rib fractures
XI. Infection (actinomycosis, aspergillosis, nocardiosis, blastomycosis,
tuberculosis,
osteomyelitis
[rare])
XII.
Thoracopulmonary small cell ("Askin") tumor
XIII.
Invasion by contiguous mass (lung cancer)
CHART
3-1.
I. Loculated pleural
effusion
II. Metastasis
III. Mesothelioma, (benign or malignant)
IV. Lipoma
V. Organized empyema
VI. Hematoma
VII.
Mesothelial cyst VIII, Neural tumor (schwannoma and
neurofibroma)
IX. Localized fibrous tumor of the pleura
CHART 3-2.
Multiple
Pleural Opacities (Each >2 cm)
I. Loculated pleural effusion
II.
Metastases (particularly from
adenocarcinomas)
III.
Malignant thymoma (rare)
IV.
Mesothelioma (malignant)
V.
Pleural plaques (asbestos-related)
VI.
Splenosis
CHART 3-3.
Subpleural parenchymal Lung Opacities
I. Infarct
II. Granuloma (tuberculosis, fungus)
III. Inflammatory pseudotumor
IV. Metastasis
V. Rheumatoid nodule
VI. Primary carcinoma of the lung
including
Pancoast's
tumor
VII.
Lymphoma
VIII.
Round atelectasis
I. Congestive heart failure
II.
Thromboembolic disease
III.
Infection
A.
Bacteria (Klebsiella pneumoniae. Staphylococcus aureus, Streptococcus
pyogenes, Nocardia aster
oides/
Streptococcus pneumoniae [Diplococcus], anaerobic
and other necrotizing bacterial
infections)
B.
Tuberculosis
C.
Viral (uncommon)
D.
Mycoplasma (uncommon)
E.
Fungus (blastomycosis, actinomycosis, coccidioidomycosis, histoplasmosis,
cryptococcosis
[effusion secondary to fungal infection is
rare], malaria)
F.
Parasites (Entamoeba histolytica: Echinococcus, Paragonimus, malaria)
G.
Infectious mononucleosis
IV.
Neoplasms
A.
Metastases
1.
Bronchogenic
2.
Distant (e.g., breast, gastrointestinal, pancreatic)
B.
Multiple myeloma
C.
Mesothelioma
D.
Chest wall: primary bone (Ewing's sarcoma, chondrosarcoma, osteosarcoma,
fibrosarcoma) E. Lymphoma635
F.
Waldenstrom's macroglobulinemia
V. Collagen-vascular disease (autoimmune)
A.
Systemic lupus erythematosus
B.
Rheumatoid arthritis
C.
Wegener's granulomatosis
D.
Systemic sclerosis
VI. Trauma
A.
Chest wall trauma
B.
Rupture of the esophagus
C.
Rupture of the thoracic duct
D.
Laceration of great vessels (e.g., aorta, vena cava, pulmonary veins)
VII. Abdominal diseases
A.
Pancreatitis
B.
Pancreatic neoplasms
C.
Pancreatic pseudocyst
D.
Pancreatic abscess
E.
Subphrenic abscess
F.
Abdominal or retroperitoneal surgery (e.g. renal surgery, splenectomy)
G.
Urinary tract obstruction with extension of retroperitoneal urine
H.
Ovarian tumors (e.g., Meigs' syndrome)
I.
Cirrhosis of the liver
J.
Peritoneal dialysis
K.
Renal disease
1. Renal failure
2. Acute glomerulonephritis
3. Nephrotic syndrome
L.
Whipple's disease
VIII. Diffuse pulmonary diseases
A.
Lymphangiomyomatosis
B.
Asbestosis (rare)
C.
Usual interstitial pneumonitis (rare)
D.
Sarcoidosis (reported to be 4% of cases)
IX. Drug reactions
A.
Nitrofurantoin
B.
Methysergide
C.
Busulfan
D.
Procainamide
E.
Hydralazine
F.
INH (isoniazid)
G.
Dilantin
H.
Propylthiouracil
I.
Procarbazine
X. Other
A.
Postmyocardial infarction syndrome (Dressler's) and postpericardiotomy syndrome
B.
Coagulation defect
C.
Radiation therapy (very rare)
D.
Idiopathic
E.
Pleural fistulas (bronchial, gastric, esophageal, subarachnoid)
F.
Empyema from retropharyngeal and neck abscess
G.
Empyema in postpneumonectomy space
CHART 4-2.
Pleural Effusion With Large Cardiac Silhouette
I. Congestive heart failure
II.
Pulmonary embolism with right-sided heart
enlargement
III.
Myocarditis or pericarditis with pleuritis
A.
Viral infection
B.
Tuberculosis
C.
Rheumatic fever
IV.
Tumor: metastasis, mesothelioma
V. Collagen vascular disease
A.
Systemic lupus erythematosus (pleural
and
pericardial effusion)
B.
Rheumatoid arthritis
VI.
Postpericardiotomy syndrome
CHART
4-3.
Small Pleural Effusion With Subsegmental Atelectasis
I.
Postoperative (thoracotomy, splenectomy, renal surgery)
II. Pulmonary embolism
III. Abdominal mass
IV. Ascites
V. Rib fractures
CHART 4-4.
Pleural Effusion With Lobar Opacities
I. Pneumonia with empyema
II.
Pulmonary embolism
III. Neoplasm
A.
Bronchogenic carcinoma (common)
B.
Lymphoma
IV.
Tuberculosis
CHART 4-5.
Pleural Effusion With Hilar Enlargement
I.
Pulmonary embolism
II.
Tumor (bronchogenic carcinoma, lymphoma,metastasis)
III.
Tuberculosis
IV.
Pungal infections (rare)
V. Sarcoidosis
I. Infection
A.
Empyema (chronic)
B.
Tuberculosis
C.
Aspergillosis (saprophytic form, fungus ball)
II. Neoplasm
A.
Metastases
B.
Diffuse mesothelioma
C.
Pancoast's tumor
D.
leukemia
III.
Collagen-vascular (rheumatoid arthritis) IV. Trauma (healed hemothorax)
V. Inhalational diseases
A.
Asbestosis
B.
Talcosis
VI. Other
C. Splenosis
D. Mimics (extrathoracic musculature)
CHAPTER 5
CHART 5-2. Pleural Calcification
I. Trauma (healed hemothorax)
II. Infection
A.
Chroic empyema
B.
Tuberculosis
III. Inhalation
A.
Asbestos-related plaques
B. Silicosis
I. Subpulmonic pleural
effusion
II.
Abdominal disease
A. Subphrenic abscess
B. Distended stomach
C. Interposition of the colon
D. Liver mass (tumor, abscess, echinococcal cyst)
III. Altered pulmonary volume
A.
Atelectasis
B.
Postoperative lobectomy and pneumonectomy
C.
Hypoplastic lung
IV. Phrenic nerve paralysis
A.
Primary lung tumor
B.
Malignant mediastinal tumor
C.
Iatrogenic
V. Diaphragmatic hernia (foramina of Morgagni.
Bochdalek)
VI.
Eventration of the diaphragm
VII. Traumatic rupture of the diaphragm
VIII. Diaphragmatic tumor (lipoma, fibroma,
mesothelioma, metastasis, lymphoma)
CHART 7-l.
I. Decreased lung volume
A.
Atelectasis
B.
Hypoplastic lung
C.
Postoperative (lobectomy, pneumonectomy)
II. Increased lung volume
A.
Foreign body obstructing large bronchus (common in children)
B.
Bronchiolitis obliterans (Swyer-James syndrome) (rare)
C.
Bullous emphysema
D.
Congenital lobar emphysema (only in infants)
E.
Interstitial emphysema
F.
Bronchogenic cyst (usually in infants)
G.
Cystic adenomatoid malformation (only in infants)
H.
Large masses (pulmonary, mediastinal)
III. Pleural space abnormalities
A.
Large unilateral pleural
effusion
B.
Tension pneumothorax
C.
Large diaphragmatic
hernias (usually either congenital or posttraumatic)
D.
Large masses
IV. Other
A.
Partial absence of the pericardium (shift of heart)
CHART 8-1.
I. Radiographic technique
A.
Magnification (AP supine film, low-volume inspiration)
B.
Lordotic position
II. Vascular structures (nontraumatic)
A.
Tortuous atherosclerotic dilatation of aorta
B.
Aneurysm
C.
Aortic dissection
D.
Coarctation of aorta
E.
Congenital left superior vena cava (SVC) with absent right SVC
III.
Trauma
A. Hematoma
1.
Transection of aorta
2.
Venous and arterial tears
3.
Sternal fractures
4.
Vertebral fractures (thoracic and lower cervical spine)
5.
Postoperative
6.
Malposition of vascular catheters (also the cause of hydromediastinum)
IV. Neoplasms
A.
Lymphoma
B.
Primary bronchogenic carcinoma (small cell tumors)
C.
Metastases
V.
Inflammation
A. Mediastinitis
1.
Perforated esophagus (Boerhaave's syndrome, carcinomas)
2.
Tracheobronchial rupture (traumatic)
3.
Iatrogenic" (postoperative, endoscopic)
4.
Pneumonias
5.
Thberculosis
6.
Coccidioidomycosis
7.
Histoplasmosis
8.
Actinomycosis
9.
Fibrosing or sclerosing mediastinitis
B.
Granulomatous adenopathy
1.
Mycobacterium avium-intracellu/are (in patients with acquired immune
deficiency syn
drome [AIDs]m
2.
Thberculosis
3.
Coccidioidomycosis
C. Extension of extrathoracic infections
1.
Pharyngeal abscess
2.
Abdominal abscess
3.
Pancreatitis or pancreatic pseudocyst
VI. Lipomatosis
A.
Cushing's syndrome
B.
Corticosteroid therapy
C.
Obesity
D.
Normal variant
VII. Other
A.
Chylomediastinum (thoracic duct obstruction or iatrogenic laceration)
B.
Mediastinal edema (allergic)
C.
Penetrating trauma (stab wound)
D.
Achalasia
CHART
9-l.
I. Thymic lesions
A.
Thymoma (benign and malignant)
B.
Thymic cyst
C.
Thymolipoma
D.
Lymphoma
E.
Thymic hyperplasia
F.
Thymic carcinoid tumor
II. Teratoid lesions
A.
Dermoid cyst
B.
Teratoma (benign and malignant)
C.
Embryonal cell carcinoma
D.
Choriocarcinoma
E.
Seminoma
III. Thyroid
A.
Goiter
B.
Adenoma
C.
Carcinoma
IV. Lymph nodes
A.
Lymphoma (both Hodgkin's and non-Hodgkin's)
B.
Metastases
C.
Benign lymph node hyperplasia
D.
Angioblastic lymphoid adenopathy
E.
Sarcoidosis and granulomatous infections (rare)
V. Cardiovascular
A.
Epicardial fat pad
B.
Aneurysm of ascending aorta
C.
Aneurysm of sinus of Valsalva
D.
Dilated superior vena cava
E.
Pericardial cyst
F.
Cardiac tumors
G.
Traumatic false aneurysm of common carotid artery
VI. Cysts
A.
Cystic hygroma (lymphangioma)
B.
Bronchogenic cysts
C.
Extralobar sequestration
D.
(See thymic and teratoid lesions, above)
VII. Other
CHART 9-2.
Inlet Lesion from the Neck into the Superior
Mediastinum
I.
Thyroid masses
II. Cystic hygroma
III. Lymphoma
IV. Metastases
CHART
9-3.
Right
Cardiophrenic Angle Mass
I. Epicardial fat pad
II.
Pericardial cyst (mesothelial cyst)
III.
Aneurysm
IV.
Dilated right atrium
V.
Diaphragmatic lesion
VI.
Other anterior mediastinal masses (Chart 9-1)
VII.
Primary lung mass
VIII.
Hernia of the foramen of Morgagni
CHART 10-1.
I. Neoplastic adenopathy
A.
Metastasis, including lesions derived from lung primaries
B.
Lymphoma (Hodgkin's)
C.
Leukemia
D.
Angioimmunoblastic lymphadenopathy
E.
Kaposi's sarcoma (in AIDS patients)
II. Inflammatory adenopathy
A.
Tuberculosis
B.
Histoplasmosis
C.
Blastomycosis (rare)
D.
Coccidioidomycosis
E.
Sarcoidosis
F.
Viral pneumonia (particularly measles and cat scratch fever)
G.
AIDS
H.
Infectious mononucleosis
I.
Pertussis pneumonial
J.
Amyloidosis
K.
Plague
L.
Tularemia
M.
Drug reaction
N.
Giant lymph node hyperplasia (Castleman's disease)
O.
Connective tissue disease (mixed, rheumatoid, and lupus)
P.
Bacterial lung abscess
Q.
Mycobacterium avium-intracellulare (in AIDS patients)
III. Inhalational disease adenopathy
A.
Silicosis
B.
Coal-worker's pneumoconiosis
C.
Berylliosis
IV. Duplication cysts
V. Primary tumors
A.
Carcinoma of the trachea
B.
Bronchogenic carcinoma
C.
Esophageal tumor
1.
Benign (leiomyoma)
2.
Malignant (carcinoma, leiomyosarcoma)
D.
Mesothelioma
E.
Granular cell myoblastoma of trachea (rare)'"
VI. Vascular lesions
VII. Other
A.
Hiatal hernia
B.
Esophageal diverticulum
C.
Dilated esophagus (achalasia)
D.
Thyroid and parathyroid masses that extend into the mediastinum
E.
Cystic hygroma (lymphangioma)
I. Large pulmonary arteries (pulmonary arterial
hypertension)
A.
Left-sided heart failure, mitral stenosis, and left atrial myxoma
B.
Emphysema (see Chapter 22)
C.
Chronic interstitial lung disease (see Chapter 19)
D.
Pulmonary embolism (acute and chronic)
E.
Portal hypertension
F.
Metastatic tumor emboli
G.
Idiopathic pulmonary hypertension (plexogenic pulmonary arteriopathy)
H.
Cardiac shunts
l. Ventricular septal defect
2. Atrial septal defect
3. Patent ductus arteriosus
4. Truncus arteriosus
5. Transposition of great vessels
A. Neoplasm
1.
Bronchogenic carcinoma
2.
Metastasis
3.
Lymphoma
B. Inflammation
I.
Tuberculosis
2.
Fungal infection (histoplasmosis, coccidioidomycosis, blastomycosis)
(rare in cryptococcosis)
3.
Viral infections (atypical measles)
4.
Infectious mononucleosis (rare)
5.
AIDS
6.
Drug reactions (phenytoin [Dilantin])
7.
Sarcoidosis (infrequent)
8.
Bacterial lung abscess
A. Neoplasm
l.
Lymphoma
2.
Leukemia (chronic lymphocytic leukemia)
3.
Metastasis
4.
Primary bronchogenic carcinoma (usually asymmetric)
B. Inflammation
I.
Sarcoidosis
2.
Occupational diseases: silicosis
C. Collagen-vascular diseases
1.
Lupus (rare)
2.
Polyarteritis nodosa
3.
Mixed
IV.
Duplication cysts (bronchogenic cysts)
CHART
12-1.
1.
Neoplasms
A. Neural tumors
B.
Metastases
C.
Lymphomas
D.
Mesenchymal tumors (fibroma, lipoma, muscle tumors, leiomyoma)
E.
Hemangiomas
F.
Thyroid tumors
G.
Vertebral tumors (osteoblastoma and giant cell tumor)
II. Inflammation
A.
Paraspinous abscess (tuberculosis and staphylococcus)
B.
Mediastinitis
C.
Lymphoid hyperplasia
D.
Sarcoidosis
III.
Vascular lesions
A.
Aneurysm of the descending aorta
IV. Trauma
A.
Traumatic aneurysm
B.
Hematoma
C.
Loculated hemothorax
D.
Traumatic pseudomeningocele
V. Developmental lesions
A.
Enteric cysts
B.
Neurenteric cysts
C.
Bronchogenic cysts
D.
Extralobar sequestration
VI. Abdominal diseases
A.
Bochdalek's hernia (thoracic kidney)
B.
Pancreatic pseudocyst or abscess
C.
Retroperitoneal masses (teratomas, sarcomas, and metastases)
VII. Other
A.
Loculated pleural effusion (empyema)
B.
Lateral meningocele
C.
Lipoma and lipomatosis
D.
Extramedullary hematopoiesis
E.
.Pseudomass of the newborns
I.
Large airway obstruction
A. Tumor
1. Bronchogenic carcinoma
2. Bronchial carcinoid
3. Metastasis
4. Lymphoma
5. Less frequent (lipoma, granular cell myoblastoma)
B. Inflammatory
1. Tuberculosis (endobronchial granuloma, broncholith
bronchial stenosis)
2. Sarcoidosis, endobronchial granuloma (rare)
C. Other
1. Large
left atrium
2. Foreign body (including malpositioned endotracheal
tube)
3. Amyloidosis
4. Wegener's granulomatosis
5. Bronchial transection
II.
Small airway obstruction: predisposing factors
A. Mucus plugs
1. Severe chest or abdominal pain (particularly in the
postoperative patient)
2. Respiratory depressant drugs (e.g., morphine)
3. Asthma
4.Cystic fibrosis
B. Inflammatory
1. Bronchopneumonia
2. Bronchitis
3. Bronchiectasis
III.
Compressive atelectasis
A. Peripheral tumor
B. Extensive interstitial disease (e.g., sarcoidosis,
lymphoma)
C. Air trapping in adjacent lung (e.g., bullous
emphysema, lobar emphysema, interstitial emphysema, bronchial obstruction by
foreign body)
IV.
Passive atelectasis pleural space-occupying processes
A. Pneumothorax
B. Hydrothorax, hemothorax
C. Diaphragmatic hernia
D. Pleural masses (e.g., metastases, mesothelioma)
V.
Adhesive atelectasis
A. Respiratory distress syndrome of the newborn
B. Pulmonary embolism
C. Intravenous injection of hydrocarbon
VI.
Cicatrization atelectasis
A. Tuberculosis
B. Histoplasmosis
C. Silicosis
D. Scleroderma
E. Idiopathic pulmonary fibrosis (usual interstitial
pneumonia, desquamative interstitial
pneumonia)
F. Radiation pneumonitis (late phase)
CHART 14-1.
I. Lobar pneumonia
II. Lobular pneumonia (bronchopneumonia)
A.
Pseudomonas
B.
Klebsiella pneumoniae
C.
Bacillus proteus
D.
Escherichia coli
E.
Anerobes (Bacteroides and clqstridia)
F.
Legionella pneumophila
G.
Staphylococcus aureus
H.
Nocardiosis and actinomycosis
I.
Streptococcus pneumoniae
J.
Serratia
III. Acute interstitial pneumonia
A.
Viruses
B.
Mycoplasma
IV. Aspiration pneumonia
V. Tuberculosis and atypical mycobacteria
VI.
Pulmonary embolism
A. Hemorrhage and edema
B. Infarction
VII. Neoplasms
A.
Obstructive pneumonia (carcinoma of bronchus)
B.
Bronchioloalveolar cell carcinoma
C.
Lymphoma
VIIl. Atelectasis (Chapter 13)
IX.
Mitral regurgitation with pulmonary edema localized to the right upper lobe
X.
Lung torsion
I. Streptococcus
pneumoniae
II. Klebsiella pneumoniae
III. Pseudomonas
IV. Staphylococcus'?"S
V. Tuberculosis"o
VI.
Carcinoma with obstructive pneumonia
(drowned
lung)
CHART 15-1.
I. Edema
A.
Cardiac failure
B.
Noncardiac (see Chart 15-2)
II. Exudate (pneumonias)
A.
Bacteria
B.
Viruses
C.
Mycoplasmal
D.
Fungi
E.
Pneumocystis carinii pneumonia
F.
Parasites (Strongyloidiasis)
G.
Aspiration
H.
Rickettsiae (Rocky Mountain spotted fever)
1.
Tuberculosis
III. Hemorrhage
A.
Anticoagulation therapy
B.
Bleeding diathesis (e.g., leukemia)
C.
Disseminated intravascular coagulation (18- to 72-hour delay)
D.
Blunt trauma (usually not diffuse)
E.
Vasculitis
F.
Idiopathic pulmonary hemosiderosis
G.
Infectious mononucleosis
IV. Tumor
A.
Bronchioloalveolar-cell carcinoma
B.
Lymphoma and rare lymphocytic disorders including:
1.
Lymphocytic interstitial pneumonits
2.
Angioblastic lymphadenopathy
3.
Mycosis fungoides
4.
Waldenstrom's macroglobulinemia
V. Other
A.
Pulmonary alveolar proteinosis
B.
Adult respiratory distress syndrome or oxygen toxicity
C.
Sarcoidosis (very unusual)
D.
Desquamative interstitial pneumonitis
E.
Mineral oil aspiration (exogenous cholesterol pneumonia)
F.
Eosinophilic lung disease
G.
Chemical pneumonitis from intravenous hydrocarbon
H.
Respiratory distress syndrome of the newborn
CHART 15-2.
I.
Chronic renal failure
II.
Toxic inhalations
III.
Anaphylaxis (penicillin, transfusion, radiologic contrast medium)
IV.
Narcotics (morphine, heroin)
V.
Drug reaction, (e.g., nitrofurantoin, interleukin-2, adrenergic drug)
VI. Acute airway obstruction (e.g.,
foreign body)
VII. Near-drowning
VIII. High altitude
IX. Fluid overload
X. Cerebral (trauma, stroke, tumor)
XI. Hypoproteinemia
XII. Pulmonary embolism
XIII. Adult respiratory distress syndrome
(early stages)
XIV. Pancreatitis
XV. Amniotic fluid embolism
XVI. Fat embolism
XVII.
Reexpansion following treatment of pneumothorax
XVIII.
Organophosphate insecticide ingestion
CHART
16-l.
Multifocal
Ill-defined Opacities
I. Inflammatory
A.
Bronchopneumonial (Staphylococcus,
Streptococcus, Pseudomonas, Legionella, Klebsiella,
Escherichia coli, other gram-negative bacteria, Nocardia)
B. Fungal pneumonia (histoplasmosis,
blastomycosis, candidiases, actinomycosis
coccidioidomycosis, aspergillosis,51,608
cryptococcosis252,315,521 mucormycosis, sporotrichosis
E.
Eosinophilic granuloma (Langerhans cell histiocytosis)
F.
Bronchiolitis obliterans with organizing pneumonia (BOOP)
G.
Eosinophilic pneumonitis (idiopathic and secondary to parasites)
H.
Viral and mycoplasma pneumonias
I. Rocky Mountain spotted fever
J.
Pneumocystis carinii pneumonia
K.
Paragonimiasis
L.
Q fever
M.
Atypical mycobacteria in AIDS patients
II. Vascular
A.
Thromboemboli
B.
Septic emboli
C.
Vasculitis (Wegener's granulomatosis and variants, including lymphomatoid
granulomatosis
D.
Infectious vasculitis (mucormycosis, aspergillosis, Rocky Mountain spotted
fever)
E.
Goodpasture's syndrome
F.
Scleroderma
III. Neoplastic
A.
Bronchioloalveolar cell carcinoma
B.
Lymphoma (Hodgkin's and non-Hodgkin's)
C.
Metastasis (vascular tumors, malignant hemangiomas, choriocarcinoma)
D.
Kaposi's sarcoma in AIDS patients
E.
Waldenstrbm's macroglobulinemia
F.
Angioblastic lymphadenopathy
G.
Mycosis fungoides
H.
Amyloid tumors
I.
Post-transplant lymphoproliferative disorder
IV. Idiopathic
A.
Lymphocytic interstitial pneumonial
B.
Desquamative interstitial pneumonia
C.
Usual interstitial pneumonia1
V. Inhalational
A.
Allergic alveolitis
B.
Silicosis
VI. Other
A.
Drug reactions
B.
Radiation reactions
C.
Metastatic pulmonary calcification (secondary to hypercalcemia)
CHART 17-1.
I. Inhalational diseases (dust)
A.
Silicosis and coal-worker's pneumoconiosis
B.
Berylliosis
C.
Siderosis
D.
Allergic alveolitis (farmer's lung)
II. Eosinophilic granuloma (Langerhans' cell
histiocytosis)
III.
Sarcoidosis
IV.
Tuberculosis
V. Fungus
infections
A.
Histoplasmosis
B.
Blastomycosis
C.
Coccidioidomycosis
D.
Aspergillosis (rare)
E.
Cryptococcosis (rare)
VI. Bacterial infections
A.
Nocardiosism
B.
Bronchopneumonias (unusual)
VII.
Viral pneumonia (e.g., varicella)
VIII. Metastatic tumor
A.
Thyroid carcinoma
B.
Melanoma
C.
Other adenocarcinomas (e.g., pancreas)
IX. Other
A.
Bronchiolitis obliterans
B.
Alveolar microlithiasis rare)
C.
Gaucher's disease
D.
Wegener's granulomatosis (rare)
CHART 17-2.
Diffuse Fine Nodular Pattern: Afebrile Patient
I.
Inhalational disease
II. Eosinophilic granuloma (Langerhans' cell
histiocytosis)
III. Sarcoidosis
IV. Fungal infection (late stage)
V. Metastasis
VI.
Miliary tuberculosis (rare)
CHART 17-3.
Diffuse Fine Nodular Pattern: Febrile Patient
I.
Tuberculosis
II. Fungal infection III. Nocardiosis IV. Viral
pneumonia
CHART 18-1.
Diffuse Fine Reticular Opacities
1.
Acute
A. Edema
1.
Congestive heart failure
2.
Uremia
3.
Fluid overload
B. Infection
1.
Viral pneumonia
2.
Mycoplasma pneumonia
3.
Infectious mononucleosis
4.
Malaria (Plasmodium falciparum)
5.
Pneumocystis carinii pneumonia
II.
Chronic
A. Chronic edema
1.
Atherosclerotic heart disease
2.
Mitral stenosis
3.
Left atrial tumor (myxoma)
4.
Pulmonary vena-occlusive disease
5.
Sclerosing mediastinitis
B. Granulomatous disease
1.
Sarcoidosis
2.
Eosinophilic granuloma (Langerhans' cell histiocytosis)
C. Collagen vascular disease
1.
Rheumatoid lung
2.
Scleroderma lung
D. Lymphangitic spread of tumor
E. Lymphocytic disorders
1.
Lymphoma and leukemia
2.
Waldenstrom's macroglobulinemia
3.
Lymphocytic interstitial pneumonia
F. Lymphatic obstruction
1.
Mediastinal mass (lymphoma)
2.
Lymphangiectasia (pediatric patient
G. Inhalational disease
1.
Asbestosis and talcosis
2.
Silicosis
3.
Hard metals
H. Drug reactions (see Chart 19-1 )
I. Idiopathic
1.
Usual interstitial pneumonia (Hamman-Rich, fibrosing alveolitis, chronic
fibrosing interstitial pneumonia, muscular cirrhosis)
2.
Desquamative interstitial pneumonia
3.
Tuberous sclerosis
4.
Lymphangiomyomatosis
5.
Idiopathic pulmonary hemosiderosis
6.
Amyloidosis
7.
Interstitial calcification (chronic renal failure
8.
Alveolar proteinosis (late complication)
9.
Gaucher's disease
CHART 18-2.
Fine Reticular Pattern and Pleural Effusion
I. Acute
A. Edema
B.
Infection (viral or
mycoplasma pneumonia)
C.
Malaria (rare)
II. Chronic
A.
Congestive heart failure
B.
Rheumatoid disease
C.
Lymphangitic spread of tumor
D.
Lymphoma and leukemia
E.
Lymphangiectasis
F.
Lymphangiomyomatosis
CHART 18-3.
Fine Reticular Pattern and Hilar Adenopathy
I.
Viral pneumonia (rare combination)
II. Sarcoidosis
III. Lymphoma and leukemia
IV. Primary carcinoma (particularly small cell
carcinoma)
V. Metastases (lymphatic
dilation or lymphangitic spread)
VI.
Silicosis
CHART
18-4.
Differential Diagnosis for the Histologic Changes of
Usual Interstitial Pneumonia
I. Idiopathic
II.
Viral
III.
Radiation-induced
IV.
Drug-related (e.g.. bleomycin. amiodarone)
V.
Collagen vascular diseases
A.
Scleroderma
B.
Rheumatoid arthritis
C.
Lupus erythematosus
D.
Erythema nodosum
E.
Dermatomyositis
VI.
Pneumoconioses
A.
Asbestosis and talcosis
VII.
Noxious gases
CHART 19-1.
Coarse Reticular Opacities (Honeycomb Lung)
1. Collagen vascular diseases
A.
Rheumatoid lung
B.
Scleroderma
C.
Dermatomyositis
D.
Ankylosing spondylitis (upper lobe)
II.
Inhalation
A. Pneumoconiosis
1.
Silicosis
2.
Asbestosis
3.
Berylliosis
B. Chemical inhalation (late)
1.
Silo-filler's disease
2.
Sulfur dioxide
3.
Other noxious gases
C.
Allergic alveolitis (e.g., farmer's lung)
D.
Oxygen toxicity
E.
Chronic aspiration (e.g., lipid pneumonia) (usually localized)
III. Inflammation
A.
Sarcoidosis
B.
Eosinophilic granuloma
IV. Drug reaction
A.
Nitrofurantoin
B.
Methotrexate
C.
Hexamethonium
D.
Busulfan
E.
Cyclophosphamide (Cytoxan)
F.
Bleomycin
G.
Amiodarone
V. Idiopathic
E. Neurofibromatosis (very rare)
CHART 20-1.
Most Likely Causes of Solitary Nodule
I. Mimicking opacities
A.
Artifacts (e.g., button, snap)
B.
Nipple shadow
C.Skin
and subcutaneous lesions (e.g.. mole. Neurofibroma, lipoma)
D.
Pleural lesions (loculated effusion or pleural mass)
II. Infections
A.
Histoplasmosis
B.
Tuberculosis
C.
Coccidioidomycosis
D.
Organizing pneumonia
III.
Neoplasms
A.
Malignant
1.
Primary lung tumor (Chart 20-2)
2.
Metastasis
B.
Benign (less common)
I.
Hamartoma
2.
Arteriovenous malformation
IV.
Vascular
A.Infarct
CHART 20-2.
Solitary Pulmonary Nodule
or Mass
I. Neoplastic
A.
Malignant
1. Primary carcinoma of the lung (see Chart 20-2)
2. Metastasis (e.g., kidney, colon, ovary, testis,
Wilms' tumor, sarcoma)
3. Lymphoma
4. Primary sarcoma of lung
5. Plasmacytoma (primary or secondary)
B.
Benign
1. Hamartoma
2. Chondroma
3. Arteriovenous malformation
4. Lipoma (usually pleural lesion)
5. Amyloidosis
6. Leiomyoma
7. Hemangioma
8. Intrapulmonary lymph node
9. Endometrioma
10. Fibroma
11. Neural tumor (schwannoma and neurofibroma)
12. Paraganglioma (chemodectoma)
13. Inflammatory pseudotumor (fibroxanthoma,
histiocytoma, plasma cell granuloma,
sclerosing hemangioma)
II. Inflammatory
A.
Granuloma
1. Tuberculosis
2. Histoplasmosis
3. Coccidioidomycosis
4. Cryptococcosis (torulosis)
5. Nocardiosis
6. Talc
7. Dirofilaria immitis (dog heartworm)
8. Gumma
9. Atypical measles infection
10. Sarcoidosis
11. Q fever-°7
B.
Abscess
C.
Hydatid cyst (fluid-filled)
D.
Bronchiectatic cyst (fluid-filled)
E.
Fungus ball
F.
Organizing pneumonia (atypical measles pneumonia, cytomegalic inclusion virus)
G.
Inflammatory pseudotumor
H.
Bronchocele and mucoid impaction
1.
Intrapulmonary lymph node
III. Vascular
A.
Infarct (organizing)
B.
Pulmonary vein varix or anomaly
C.
Rheumatoid nodule
D.
Wegener's granulomatosis
E.
Arteriovenous malformation
F.
Pulmonary artery aneurysm (Behcet disease)
IV. Developmental
A.
Bronchogenic cyst (fluid-filled)
B.
Pulmonary sequestration
V. Inhalation
A.
Silicosis (conglomerate mass)
B.
Mucoid impaction (allergic aspergillosis)
C.
Paraffinoma (lipoid granuloma)
D.
Aspirated foreign body
VI. Other
A.
Hematoma
B.
Extramedullary hematopoiesis
C.
Emphysematous bulla (fluid-filled)
D.
Thrombolytic therapy
E.
Mimicking opacities
1.
Fluid in interlobar fissure
2.
Mediastinal mass
3.
Pleural mass (mesothelioma)
4.
Chest wall opacities (nipple, rib lesion, skin tumor)
5.
Artifacts
F.
Post-transplant lymphoproliferative disorder
CHART 20-3.
Solitary Pulmonary Nodule in Childhood*
I.
Neoplasms
A. Malignant
B. Benign
1.
Arteriovenous malformation
2.
Hamartoma
3.
Hemangioma
II. Inflammatory
A.
Granuloma
B.
Organizing pneumonia (especially atypical measles pneumonia)
III. Developmental
A.
Bronchopulmonary sequestration
B.
Bronchogenic cyst
CHART 20-4.
Classification
of Primary Carcinoma of the Lung*
I. Squamous cell carcinoma (30%-40%)
A.
Well differentiated
B.
Moderately differentiated
C.
Poorly differentiated
II. Adenocarcinoma (25%-30%)
A.
Well differentiated
B.
Moderately differentiated
C.
Poorly differentiated
III.
Bronchioloalveolar cell carcinoma (subtype of adenocarcinoma)
IV.
Large cell undifferentiated carcinoma (10-15 %)
V.
Small cell undifferentiated carcinoma (20%)
VI.
Typical carcinoid (low grade malignant tumor 5% metastasize to lymph nodes)
VII.
Atypical carcinoid tumor (malignant tumor with prognosis similar to other
non-small cell
tumors)
Vill.
Adenoid cystic carcinoma (uncommon malignant tumor)
IX.
Mucoepidermoid carcinoma (uncommon malignant tumor)
X.
Multicomponent tumors (adenosquamous or small cell adenocarcinoma)
CHART 20-5.
TNM Definitions of
Primary Tumor*
TX
Tumor
proven by the presence of malignant cells in bronchopulmonary secretions I;JUt
not visualized radiographically, or any tumor that cannot be assessed, as in a
retreatment staging. Carcinoma in situ.
A
tumor that is 3 cm or less in greatest dimension, surrounded by lung or
visceral pleura, and without evidence of invasion proximal to a lobar bronchus
at bronchoscopy.
A
tumor more than 3 cm in greatest dimension, or a tumor of any size that either
invades the visceral pleura or has associated atelectasis or obstructive
pneumonitis extending to the hilar region. At bronchoscopy, the proximal extent
of demonstrable tumor must be within a lobar bronchus or at least 2 cm distal
to the carina. Any associated atelectasis or obstructive pneumonitis must
involve less than an entire lung.
A
tumor of any size with direct extension into the chest wall (including superior
sulcus tumors), diaphragm, or the mediastinal pleura or pericardium without
involving the heart, great vessels, trachea, esophagus, or vertebral body, or a
tumor in the main bronchus within 2 cm of the carina without involving the
carina.
A
tumor of any size with invasion of the mediastinum or involving heart, great
vessels, trachea or carina, esophagus, vertebral body, or presence of
malignant pleural effusion.
TIS Tl
T2
T3
T4
'Modified from Mountain CF: A new international
staging system for lung cancer, Chest 1986; 89 (4 5uppl): 2255-2335.
CHART 20-6.
TNM Definitions: Nodal
Involvement*
NO Nl
No
demonstrable metastasis to regional lymph nodes.
Metastasis
to lymph nodes in the peribronchial or the ipsilateral hilar region, or both,
including direct extension.
Metastasis
to ipsilateral mediastinal lymph nodes and subcarinallymph nodes.
Metastasis
to contralateral mediastinal lymph nodes, contralateral hilar lymph nodes, or
ipsilateral or contralateral scalene or supraclavicular lymph nodes.
N2 N3
*Reprinted from Mountain CF: A new international
staging system for lung cancer, Chest 1986; 89 (4 Suppl): 225S-233S.
CHART 20-7.
TNM Definitions:
Distant Metastasis*
MO Ml
No
(known) distant metastasis.
Distant
metastasis present-specify site(s).
*Reprinted from Mountain CF: A new international
staging system for lung cancer, Chest 1986; 89 (4 Suppl): 2255-233S.
CHART 20-8. |
|
|
|
Stage Grouping of TNM
Subsets* |
|
||
Occult Carcinoma |
TX |
NO |
MO |
Stage 0 |
TIS |
NO |
MO |
Stage I |
Tl |
NO |
MO |
|
T2 |
NO |
MO |
Stage II |
Tl |
Nl |
MO |
|
T2 |
Nl |
MO |
Stage Ida |
T3 |
NO |
MO |
|
T3 |
Nl |
MO |
|
Tl-3 |
N2 |
MO |
Stage 11Th |
AnyT |
N3 |
MO |
|
T4 |
AnyN |
MO |
Stage IV |
AnyT |
AnyN |
Ml |
*Reprinted from Mountain CF: A new international
staging system for lung cancer, Chest 1986; 89 (4 Suppl): 225S-233S.
CHART
21-l.
Multiple
Nodules and Masses With Sharp Borders
I. Neoplastic
A. Malignant
1.
Metastases (kidney, gastrointestinal tract, uterus, ovary, testes; melanoma,
sarcoma)
2.
Lymphoma
3.
Post-transplant lymphoproliferative disorder
B. Benign
1.
Hamartoma
2.
Arteriovenous malformation or hemangioma
3.
Amyloidosis
4.
Pseudolymphoma
II. Inflammatory
A. Fungal
1.
Histoplasmosis
2.
Coccidioidomycosis
3.
Cryptococcosis
4. Invasive aspergillosis
B. Nocardiosis
C. Tuberculosis (typical and atypical)
D. Parasites
1.
Hydatid cysts
2. Paragonimiasis
E. Septic emboli
F. Atypical measles
G. Inflammatory pseudotumors (fibrous histiocytoma,
plasma cell granuloma, hyalinizing
pulmonary nodules)
H. Q fever
III. Vascular
A.
Rheumatoid nodules and Caplan's syndrome
B.
Wegener's granulomatosis and Wegener's variants
C.Organizing
infarcts
IV. Post-traumatic (organizing hematoma)
V. Chronic renal failure (calcified nodules)
I. Bilateral
A.
Mastectomy
B,
Absent pectoralis muscles
C.
Faulty radiologic technique including rotation of patient
D.
Extrapulmonary air collections (e.g., pneumothorax, mediastinal emphysema,
subcuta
neous emphysema)
E.
Pulmonary embolism (acute or chronic)
F.
Emphysema (particularly bullous emphysema)
G.
Atrophy of trapezius muscle (after radical neck dissection)
H
Bronchial obstruction
1. Neoplastic
a. Bronchogenic carcinoma
b. Metastatic (rare, but most common primary sites are
breast, thyroid, pancreas, colon,
melanoma)
2. Granulomatous masses including broncholith
3. Bronchial mucocele
4.
Foreign body (common in children)
I.
Hilar mass (e.g., adenopathy, bronchogenic cyst)
J.
Bronchiolitis obliterans (Swyer-James, or Macleod, syndrome)
K.Compensatory
overaeration
L.
Congenital lobar emphysema
M.
Cardiomegaly (left lower lobe)
CHART 23-l. Solitary Lucent Defect
I. Cavity
A. Inflammation
1.
Abscess, acute or chronic
a.
Pyogenic infection (staphylococcal and gram-negative pneumonia)
b.
Aspiration pneumonia'! (common source of anaerobes)
2. Fungal infection
a. Histoplasmosis
b. Coccidioidomycosis
c. Blastomycosis
d. Cryptococcosis
e. Mucormycosis
3.
Mycobacterial infection
a. Tuberculosis (typical and atypical)
b. Nocardiosis
B. Neoplasms
1.
Primary lung tumor
2.
Metastases (usually multiple)
a. Squamous cell (nasopharynx, esophagus, cervix)
b. Adenocarcinoma (lung, breast, gastrointestinal
tract)
c. Osteosarcoma (rare)
d. Melanoma
C. Vascular (commonly multiple)
1.
Rheumatoid
2.
Wegener's granulomatosis
3.
Infarct (thromboemboli or septic emboli)
D. Inhalation
1.
Silicosis and coal-worker's pneumoconiosis (most commonly owing to complicating
tuberculosis)
II. Pneumatocele (infectious and traumatic)
III. Congenital cyst (bronchogenic cyst and
intrapulmonary sequestration
IV. Bronchiectatic cyst. Bullous emphysema
CHART 24-1.
Multiple Lucent Lesions
I.
Cavities
A.
Infection
1. Bacterial pneumonias (Staphyloccus,
Klebsiella, other gram-negative organisms, anaer
obes,
and Nocardia)
2. Fungal
a. Histoplasmosis
b. Blastomycosis
c. Coccidioidomycosis
d. Cryptococcosis
e. Mucormycosis
f. Sporotrichosis
g. Aspergillosis
3.
Tuberculosis
4.
Parasites (echinococcal disease)
B. Neoplasms
1.
Metastases
2.
Lymphoma (rare)
3.
Bronchioloalveolar cell carcinoma
C. Vascular
1.
Rheumatoid disease
2.
Wegener's granulomatosis
3.
Infarcts
4.
Septic emboli
II. Cystic bronchiectasis (recurrent pneumonias,
tuberculosis, cystic fibrosis, agammaglobulinemia,
allergic aspergillosis)
III. Pneumatoceles
IV. Bullous emphysema
V. Honeycomb lung (see Chapter 19)
VI. Cystic adenomatoid malformation (newborn)
VII. Herniation of small bowel (congenital or traumatic)
CHART 24-2.
Cavitating Nodules
I. Neoplasms
A. Primary lung
1.
Squamous cell carcinoma
2.
Adenocarcinoma
3.
Bronchioloalveolar cell carcinoma
B. Metastasis
1.
Squamous cell (e.g., head and neck, cervix, esophagus)
2.
Adenocarcinoma
3.
Melanoma
4.
Sarcoma (e.g., osteosarcoma)
5.
Lymphoma
II. Infections
A.
Septic emboli (Staphylococcus aureus)
B,
Nocardiosis
C.
Cryptococcosis
D.
Coccidioidomycosis
E.
Aspergillosis
III. Vascular and collagen vascular diseases
A.
Pulmonary embolism with infarction
B.
Vasculitis (e.g., Wegener's granulomatosis, Wegener's variants)
C.
Rheumatoid nodules and Caplan's syndrome
CHART 24-3.
Ill-defined Opacities With Holes
I.
Infections
A. Necrotizing pneumonias
1. Staphylococcus aureus
2. B-Hemolytic streptococcus
3. Klebsiella pneumoniae
4. Escherichia coli
5. Proteus, Aerobacter
6. Pseudomonas
7. Anaerobes
B. Aspiration pneumonia (usually mixed gram-negative
organisms)
C. Septic emboli
D. Fungus
1. Histoplasmosis
2. Blastomycosis
3. Coccidioidomycosis
4. Cryptococcosis
E. Tuberculosis
II.
Neoplasms
A. Primary carcinomas
B. Bronchioloalveolar cell carcinoma
C. Lymphoma
III.
Vascular and collagen vascular diseases
A. Emboli with infarction
B. Wegener's granulomatosis
IV.
Trauma
A.
Contusion with pneumatoceles
CHART 24-4.
Pulmonary Lucent Lesions Related to AIDS
1.
PCP-related lung cysts
2.
Premature bullous
emphysema (periphery of upper lobe)
3.
Pneumatoceles
4.
Necrotizing pneumonias
5.
Pyogenic bacteria and Pneumocystis
6.
Tuberculosis
7.
Atypical mycobacterial
infection
8.
Fungal infections (fewer
than 5% of AIDS patients.3.)
a.
Cryptococcosis
b. Coccidioidomycosis
c.
Nocardiosis (not a true fungus)
d. Histoplasmosis
9.
Mixed infections (common)