I II III Radiology of Chest Diseases Sebastian Lange, MD Professor and Chairman Department of Radiology Knappschaftshospital Recklinghausen Germany Geraldine Walsh, MRCP, FRCR, FRANZCR Consultant Radiologist Department of Radiology Royal Berkshire Hospital Reading United Kingdom With a contribution by Michael Montag Third edition, fully revised and updated 1118 illustrations 35 tables Thieme Stuttgart · New York IV LibraryofCongressCataloging-in-PublicationData Importantnote:Medicineisanever-changingscienceundergoing isavailablefromthepublisher. continualdevelopment.Researchandclinicalexperiencearecon- tinuallyexpandingourknowledge,inparticularourknowledgeof propertreatmentanddrugtherapy.Insofarasthisbookmentions Thisbookisafullyrevisedandexpandedauthorizedtranslationof anydosageorapplication,readersmayrestassuredthattheauthors, the3rdGermaneditionpublishedandcopyrighted2005byGeorg editors,andpublishershavemadeeveryefforttoensurethatsuch Thieme Verlag, Stuttgart, Germany. Title of the German edition: referencesareinaccordancewiththestateofknowledgeatthetime RadiologischeDiagnostikderThoraxerkrankungen. ofproductionofthebook. Nevertheless, this does not involve, imply, or express any guaranteeorresponsibilityonthepartofthepublishersinrespectto 1stEnglishedition1990 anydosageinstructionsandformsofapplicationsstatedinthebook. 1stSpanishedition1990 Everyuserisrequestedtoexaminecarefullythemanufacturers’leaf- 1stItalianedition1991 letsaccompanyingeachdrugandtocheck,ifnecessaryinconsulta- 1stFrenchedition1991 tionwithaphysicianorspecialist,whetherthedosageschedules 1stJapaneseedition1993 mentionedthereinorthecontraindicationsstatedbythemanufac- 1stChineseedition1994 turersdifferfromthestatementsmadeinthepresentbook.Suchex- 2ndEnglishedition1998 aminationisparticularlyimportantwithdrugsthatareeitherrarely 2ndChineseedition2000 used or have been newly released on the market. Every dosage 1stBrazilianedition(Portuguese)2002 scheduleoreveryformofapplicationusedisentirelyattheuser’s own risk and responsibility. The authors and publishers request everyusertoreporttothepublishersanydiscrepanciesorinaccura- ciesnoticed.Iferrorsinthisworkarefoundafterpublication,errata Translator:TerryTelger,FortWorth,Texas,USA willbepostedatwww.thieme.comontheproductdescriptionpage. ©2007GeorgThiemeVerlag, Someoftheproductnames,patents,andregistereddesignsreferred Rüdigerstrasse14,70469Stuttgart,Germany tointhisbookareinfactregisteredtrademarksorproprietarynames http://www.thieme.de eventhoughspecificreferencetothisfactisnotalwaysmadeinthe ThiemeNewYork,333SeventhAvenue, text.Therefore,theappearanceofanamewithoutdesignationas NewYork,NY10001,USA proprietaryisnottobeconstruedasarepresentationbythepub- http://www.thieme.com lisherthatitisinthepublicdomain. Thisbook,includingallpartsthereof,islegallyprotectedbycopy- TypesettingbyprimustypeHurlerGmbH,Notzingen right.Anyuse,exploitation,orcommercializationoutsidethenar- PrintedinGermanybyGrammlich,Pliezhausen rowlimitssetbycopyrightlegislation,withoutthepublisher’scon- sent,isillegalandliabletoprosecution.Thisappliesinparticularto ISBN-10:3-13-740703-6(GTV) photostat reproduction, copying, mimeographing, preparation of ISBN-13:978-3-13-740703-4(GTV) microfilms,andelectronicdataprocessingandstorage. ISBN-10:1-58890-447-4(TNY) ISBN-13:978-1-58890-447-8(TNY) 123456 V To Maritta, Constantin, Caroline, Christian, and Clemens Sebastian Lange To Colin Geraldine Walsh VI VII Preface Almostadecadehaspassedsincethepublicationofthe Inthistext,wehavetriedtoconveyhowtheseexcit- second edition of Radiology of Chest Diseases in 1997. ingadvancesintechnologyfitintotheclinicalsettingof This period has seen tremendous advances in imaging cardiothoracicimagingevaluation. technology. We also recognize the ever-increasing availability Single-slicehelicalCThasgivenwaytomulti-detec- anduseofCTasan“early”second-lineimagingtoolin torrowCT(MDCT),andwithincreasingnumbersofde- assessment of the patient with suspected pulmonary tectorswemovetowardtheconceptof“isotropic”spa- diseaseandhaveplacedagreateremphasisontherole tialresolution.Thishasbeencombinedwithdecreased of high-resolution/thin-section CT in evaluation of scantimesandimprovedtemporalresolution.Therapid parenchymallungdisease. evolutionofCTtechnologyhasledtomarkedimprove- A new chapter on interventional procedures in the ments in the quality of thoracic CT studies and has al- thorax describes a spectrum of procedures from the lowedustocontemplateandperformwithsomesuccess standardimage-guidedbiopsyanddrainagethroughto cardiacevaluationandCTcoronaryangiography. the more specialized interventions of pulmonary AVM Positron emission tomography (PET)/PET-CT has andpulmonaryfalseaneurysmembolization. beenincorporatedintoeverydayclinicalpracticeinthe Onceagain,wehopethatthistextconveysthefasci- pastdecadeandtodayplaysasignificantroleinimaging nating diversity of cardiothoracic radiology and that it evaluationofthoracicdisease,particularlyinoncologic willproveausefulguidetothepractitionerintheevery- stagingandassessment. dayclinicalsetting. Advancesinmagneticresonanceimaging(MRI)today allowimprovedcardiacevaluationandparticularlymy- SebastianLange,MD ocardialfirst-passperfusionandviabilityassessment. GeraldineWalsh,MRCP,FRCR,FRANZCR VIII IX Table of Contents 1 Examination Technique and Normal Findings 1 RadiographicExamination....................... 2 VascularSystem ............................. 20 FrontalChestRadiograph..................... 2 TheMediastinum ............................ 24 LateralChestRadiograph ..................... 3 ConventionalTomography ...................... 25 ObliqueViews ............................... 3 ComputedTomography ......................... 28 ApicalLordoticView ......................... 4 RadionuclideImaging ........................... 38 Fluoroscopy ................................. 4 LungScintigraphy............................ 38 Scatter-ReductionGrids ...................... 4 MyocardialPerfusionScintigraphy ............ 39 TheNormalChestRadiograph ................... 5 PositronEmissionTomography(PET) StructuresoftheChestWall .................. 5 andPET-CT .................................. 41 Diaphragm .................................. 9 Ultrasound ..................................... 42 Pleura ....................................... 9 PulmonaryAngiography ........................ 42 LungParenchyma ............................ 16 Bronchography ................................. 45 TracheobronchialSystem ..................... 18 MagneticResonanceImaging.................... 47 2 Malformations 50 BronchopulmonarySequestrations............... 50 CongenitalBronchialAtresia..................... 60 HypogeneticLungSyndrome VascularMalformations ......................... 61 (ScimitarSyndrome) ............................ 53 PulmonaryArteriovenousMalformations BronchogenicCysts ............................. 54 (AVM)....................................... 61 CongenitalCysticAdenomatoidMalformationof PartialAnomalousPulmonaryVenousDrainage theLung(CCAM) ............................... 56 (PAPVD) ..................................... 61 PulmonaryAgenesis,Aplasia,andHypoplasia .... 57 HypoplasiaandAtresiaofthePulmonary CongenitalLobarEmphysema ................... 59 Artery ....................................... 62 3 Infection and Inflammatory Disorders 64 Pneumonia ..................................... 64 Echinococciasis .............................. 89 LungAbscessandSepticPulmonaryEmboli ...... 69 Paragonimiasis .............................. 90 PulmonaryTuberculosis ......................... 72 Ascariasis.................................... 90 FungalDiseasesoftheLung ..................... 80 StrongyloidiasisandAnkylostomiasis ......... 91 Candidiasis .................................. 80 Sarcoidosis ..................................... 91 Aspergillosis ................................. 81 IdiopathicInterstitialPneumonias ............ 95 Histoplasmosis .............................. 84 AcquiredImmunodeficiencySyndrome........... 97 Coccidioidomycosis .......................... 84 Infections ................................... 97 Actinomycosis ............................... 85 IntrathoracicMalignancy ..................... 98 Nocardiosis .................................. 85 LymphoproliferativeDisorders................ 99 Cryptococcosis(Torulosis) .................... 86 AutoimmuneDisorders/ConnectiveTissue ParasiticInfections.............................. 86 Diseases........................................ 100 Amebiasis ................................... 86 SystemicLupusErythematosus ............... 100 Toxoplasmosis ............................... 87 RheumatoidArthritis......................... 100 PneumocystisJiroveciPneumonia ProgressiveSystemicSclerosis(PSS) .......... 101 (PreviouslyKnownasPneumocystisCarinii SjögrenSyndrome ........................... 102 Pneumonia—PCP) ............................ 87 Dermatomyositis ............................ 102 Schistosomiasis .............................. 88 AnkylosingSpondylitis(AS) .................. 102