chest X ray 2

Bronchiectasis:
Bronchiectasis is the irreversible dilatation of a bronchus, and it is usually the results of severe, recurrent or chronic infections. Bronchiectasis may be localized, multifocal, or generalized depending on its aetiology. It is commonly basal or basally predominant but in some conditions it may be confined to the upper zones (e.g. tuberculosis) or be predominantly in the upper zones (e.g. cystic fibrosis).It may be cylindrical(tubular), varicoid(the walls are irregular) or saccular(or cystic).

The chest radiograph is usually abnormal in moderate or severe bronchiectasis, but is commonly normal in mild disease. Airway walls become visible because they are thickened. Side-on they produce single thin lines or parallel-line opacities that are more widely separated than would be expected with normal diameter airways. End-on dilated airways produce ring and curvilinear opacities with relatively thin walls that may contain air-fluid levels. When filled with secretions airways parallel to the film generate simple or branched band opacities (5–10 mm diameter) that point towards the hilum and may have expanded distal ends. Seen end-on, such dilated fluid filled airways produce rounded or oval nodular opacities. In generalized forms of bronchiectasis lung volume is often increased but with focal disease there is commonly volume loss.


Emphysema:
Defined in morphological terms as an increase beyond normal of airspaces distal to the terminal bronchiole, due either to dilatation or destruction of their walls.

Radiologically: The diaphragm is usually at the level of the 6th or 7th anterior rib at the end of a deep inspiration. Normal individuals may contract their diaphragm below this level and a low position alone is not therefore sufficient evidence for over-inflation, the most reliable sign for which is associated flattening of the diaphragmatic dome. Films exposed at the end of inspiration and expiration respectively will reveal limited diaphragmatic excursion (well under the normal lower limit of 3 cm). The low, flat diaphragm results in an apparently small heart and a decreased cardiothoracic ratio. Enlargement of the retrosternal translucent zone on the lateral radiograph (measured from the back of the sternum to the anterior aspect of the lower ascending aorta) provides additional evidence of over-inflation, but should be 4 cm or greater to be considered abnormal.
In emphysema, in addition to overinflation of the lungs, the pulmonary vessels are abnormal. In widespread generalized emphysema, the midfield and peripheral vessels are attenuated in both size and number. The normal smooth gradation in size of vessels from the hilum outwards is lost, with the hilar vessels being larger than normal and tapering abruptly. With the development of cor pulmonale, or left heart failure, the radiographic appearances will alter and may become less obviously abnormal. The heart may then appear to be normal in size, or sometimes enlarged, the diaphragm becomes less flat and the pulmonary vessels less attenuated.

Bullae: These are recognized by their transradiancy, their hairline walls and a distortion of adjacent pulmonary vessels. Bullae vary greatly in size and are occasionally large enough to occupy the whole hemithorax. They can be identified in about one-third of patients with other radiographic evidence of emphysema and they are sometimes seen independently of emphysema.

Bronchial carcinoma:
Types:
1-Squamous cell carcinoma (central, cavitates more often than other types).
2-Adenocarcinoma (peripheral).
3-small cell carcinoma (central and often associated with extensive hilar and mediastinal lymphadenopathy).
4-large cell tumors (undifferentiated type).
Radiological features: There are no radiological features that can reliably differentiate between a benign and malignant pulmonary nodule or mass. However, malignant tumors are usually larger than benign lesions at the time of presentation. Peripheral lung cancers tend to have poorly defined, lobulated or umbilicated margins, or may appear speculated. Satellite opacities around the main lesion are more frequently seen with benign masses, but may be associated with carcinoms.Diffuse or central calcification in the peripheral pulmonary mass is very suggestive of benign lesion, but occasionally calcified granuloma will have been engulfed by malignant tumors. Doubling time of Ca bronchus between (1-18) months. Any mass or nodule that has not changed in appearance over 2 year is almost certainly benign.Cavitation is seen in about (10-15) % of peripheral lung cancers on plain CXR (thick walled with an irregular, nodular inner margins, but some may appear as thin walled cavities).
Secondary signs of malignancy: hilar and mediastinal LAP, atelectasis, obstructive pneumonia, pleural effusion, interstial patterns (lymphatic tumor spread) and metastasis (ipsi-, contralateral lungs…..).