1. Surgical Pathology & X-rays
for Medical Students
Chest Surgery
2008

2. 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

3. Normal
Chest
X ray
Index

4. AA
SVC PA
PA
RA
LV
CoPhS
Index

5. Pneumothorax
5 © Vascular 2007
Index

6. Lt. side pneumothorax
6 © Vascular 2008
Index

7. 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
7 © Vascular 2007
Rt. thorax with absence of vascular markings Index

8. Note:
Note
Lt. tension pneumothorax •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 NormalVascular 2007
©

9. Lt. Tension
pneumothorax
Index

10. 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

11. Rt. side tension
pneumothorax
in an infant
Index

12. Tension Pneumothorax
12 © Vascular 2007
Index

13. 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
13 © Vascular 2007
Index

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

15. Pleural Effusion
15 © Vascular 2007
Index

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

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

18. Lt. pleural effusion
18 © Vascular 2007
Index

19. 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

20. Massive Lt. pleural effusion
20 © Vascular 2007
Index

21. 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

22. 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

23. Hydro-
pneumothorax
23 © Vascular 2007
Index

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

25. Lt. Massive hydro-pneumothorax
25 © Vascular 2007
Index

26. Lung Collapse
26 © Vascular 2007
Index

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

28. Complete Lt. Lung Collapse
o40-year-old woman
with tuberculous
bronchial stricture
oChest radiograph
shows complete
collapse of left lung and
deviation (arrows) of
trachea to left lung
28 © Vascular 2007
Index

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

30. Compare
Rt. lung Lt. lung
30
effusion Index
collapse

31. Compare
Lt. tension Lt. lung
pnemothorax collapse
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Index

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

33. Massive
Pneumonia
33 © Vascular 2007
Index

34. Lt. lung
pneumonia
The hemithorax is
opaque and there is
no shift of the heart
or trachea
Index

35. 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

36. Lt. lung collapse Rt. lung effusion
Causes of
an
Opacified
Hemithorax
Lt. lung pneumonia
The arrow
Lt. neumonectomy
shows
mediastinal
shift
No
Index

37. Which is this?
Atelectasis
Pneumonia
Effusion
Index

38. Bronchogenic
Carcinoma
38 © Vascular 2007
Index

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

40. 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 © Vascular 2007
Index

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

42. Lung
Carcinoma
42 © Vascular 2007
Index

43. Lung Carcinoma
oA large, well-
defined mass in
the right upper
lobe
oExtensive
emphysematous
change
43 © Vascular 2007
Index

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

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

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

47. Lung Abscess
47 © Vascular 2008
Index

48. Fibro-caseous
Pulmonary TB
48 © Vascular 2007
Index

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

50. Pulmonary
Metastasis
50 © Vascular 2007
Index

51. Multiple
Pulmonary
secondaries
Index

52. Renal adenocarcinoma with multiple pulmonary metastasis
52 © Vascular 2007
Index

53. Lung metastasis
from CA colon
53 © Vascular 2007
Index

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

55. Aortic Arch
Aneurysm
55 © Vascular 2007
Index

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

57. Pulmonary Thoracic
T.B. aortic
aneurysm
Index