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Text book of radiology and imaging. 7th edition by D. Sutton. ☆It is poignant to note that this 7th edition is the last “true Sutton” due to the recent PDF (31 KB). This Website Provides Over Free Medical Books and more for all Students and Doctors This Website the best choice for medical students during and after. Sutton - Radiology for Students - Download as PDF File .pdf) or read online.

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Radiology and imaging for medical students. David Sutton. 4th edition. × mm. Pp. + vii. Illustrated. Edinburgh: Churchill Livingstone. £ Sorry, this document isn't available for viewing at this time. In the meantime, you can download the document by clicking the 'Download' button above. Download File David Sutton Textbook Radiology volume pdf. Download File David_Sutton_Textbook_of_Radiology volume You have requested.

The mass was causing distortion of the renal parenchyma, collecting system, and sinus fat Figure 3. The differential diagnosis includes renal cysts, renal metastatic disease, lymphoma, oncocytoma, adenoma, renal abscess, inflammatory pseudotumor, angiomyolipoma, and renal sarcoma. It usually affects people between 40 and 60 years of age.

The male-to-female ratio is and the etiology is unknown. The tumor involves the soft tissues of the renal sinus. Secondary deposits to the bones, liver and opposite kidney are commonly seen. CT scan is the preferred imaging modality for patients suspected of having renal neoplasia. Percutaneous catheterisation and embolisalion is also used for treatment of internal haemorrhage and for the treatment of angiomas and arteriovenous fistulae.

Percutaneous catheterisation with balloon catheters can be used to occlude arteries temporarily, either to stop haemorrhage or to obtain a bloodless field at operation. Percutaneous cathererisation is also used for the delivery of chemotherapeutic drugs to tumours, or for the delivery of vasospastic drugs in patients with internal haemorrhage. It is also used for thrombolysis by delivering 'thrornbolytic drugs directly to the clot.

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Percutaneous rransfurninal dilatation of arterial stenoses is now being practised for the treatrnerrr of localised stenoses in the femoral and iliac arteries..

The method has been extended to m. Needle biopsy under imaging control is widely practised both for lung tumours and abdominal rriasses of all kinds.. Transhepatic catheterisation of the bile ducts both for drainage in obstructive jaundice and for dilatation of stenosing strictures or insertion of prostheses.

Needle puncture and drainage. This list will no doubt be further extended in the future and is discussed in detail in Chapter The stuclent should develop as a routine a systematic approach to the examination of any X-ray filrn.

The technique is described in detail in Chapter 2 see p. A new method of forming images from X-rays was developed and introduced into clinical use by a British physicist Godfrey Hounsfield in Hounsfield was awarded the Nobel Prize for medicine jointly with Professor A.

Cormack in The principle of CT scanning is that conventional X-ray films provide only a small proportion ofthe data theoretically available when X-rays are passed through frurnan tissues. By using multi-directional scanning of the object; multiple data are collected concerning all tissues in the path of the X-ray beams.. The detector response is directly related to the n;-;nber of phoThns impinging on it and so to tissue density since more X-ray photons are absorbed by denser tissues.

The scintillations produced can be quantified and recorded digitaJly. The iiifOFiilatiOn is fed into a computer which produces different readings as the X-ray beam traverses round the patient. The computer is required to deal with a vast number of digital readings. These can be presented as a numerical read-out representing the X-ray absorption in each tiny segment of tissue traversed. The infonnation can also be presented in analogue form as a.

The first machine had only two detectors and housed a sharply collimated beam of X-rays. The more modern machines use a fan beam and multiple detectors Fig. The early machines were used for head scanning only but these were superseded by 'body scanners' which can examine all parts of the body including the head.

The original machines took 4 Y:! The analogue mages are presented on a cathode ray tube immediately after each section. The picture is usually in grey scale in which the more radiopaque tissue, e. The range can be varied by changing the gate or window width W at will so that the tissues can be evaluated within a wide or narrow range of density. The central point or level L of the window can also be varied. The tube rotates around the patient. The detectors remain sta tionary. The full scale on the left extends over units.

The expanded scale on the right extends over ioo units and includes all body tissues. Head scans are usually done routinely at a window level L of and a window W covering Radionuclides and radioisotopes are radioactive varieties but the terms in practice are interchangeable with nuclides and isotopes.

Most of thern are made artificially and disintegrate spontaneously, emitting radiation which includes gamma radiation.

This is an electro-magnetic wave radiation of high penetrating power. The energy is measured in electron-Volts eV. The half-life of a radioisotope is the time taken for its activity to fall by one half, e. Almost every organ of the body can be investigated by means of radioisotope scanning.. It is important, however, that the radiation dose to the patient should be kept to the minimum by using low doses of substances with short half-lives. In the individual organ, lesions such as tumours may take up selectively rriore of the isotope resulting in so-called 'hot' areas on the scan, as in the brain.

Alternatively, they may fail to take up the isotope resulting in 'cold' areas, as in the liver. The uptake can be recorded as an 'image' by scanning machines. Basically, a scanning machlne consists ofa detector, This is usually a large crystal of sodium iodide containing thallium iodide as activator. Gamrna rays ernirted by the isotope and striking the detector are converted directly into light quanta or photons..

These are led off into a photomultiplier. This converts the light quanta into a small voltage pulse and the number of pulses is directly related to the original radioactivity. The gamma camera. The gamrna carrrera is more flexible than the earlier linear, scanner. It has a large stationary crystal which records activity over the whole of its field at the same time. The size of the field is limited by the size of the crystal but the whole field can be shown as an image on a cathode-ray tube and the image can then be photographed with a camera.

Since the activity recorded by the scanners is converted into electrical pulses, these can be recorded in digital form, This digital infonnation can be fed into a computer and manipulated to provide physiological infonnation about what is happening in the particular organ data processing.

Ultrasonic diagnosis employs sound waves whose frequency is far higher than can be registered by the human ear. These ultrasonic waves are produced frorn a transducer and travel through human tissues at a velocity of some metres per second.

When the wave reaches an object or surface with a different texture, or acoustic nature, a wave is reflected back. These echoes are received by the apparatus and changed into electric current. This can be amplified and shown on a cathode-ray tube.. Transducers are substances that have the property of being able to convert one forrn of energy into another.

Ultrasound transducers are made of materials that are mechanically deforrrred when an electric voltage is applied to them.. This is the direct 'piezo-electric' pressure electric effect, Conversely if mechanical stress is applied. The substance most widely used in medical ultrasonics is lead zirconate titanate Fig.

It enables linear rneasurernerits to be made between internal structures and was once widely used for rneasurernerrt of displacement of the midline structures of the brain. With this method echoes are shown, not as deflections of varying amplitude, but as dots of varying brightness.

As the transducer moves over the skin the series of linear dots are frozen as bright lines which form a two-dimensional image representing a linear section of the organ underexarnination. Grey-scale is a further refinement enabling the B-scan to be sealed in varying shades of grey to give a more realistic picture. It this technique a linear scan is held whilst a tirneposition graph of any motion builds up.

Moving points are seen to oscillate fonning wavy lines whilst stationary parts are represented as straight lines. In this way a time-position graph of moving parts is built up. The method proved most valuable in cardiac work,. The transducer hatched coated with conducting material is in a resting phase.

A voltage - is applied to the transducer surface. Real time two dimensional scanning is a further advance on the B-scan in which an automatic scanning mechanism is used to jrro-.

B shows 2DE sector scan covering section in long axis of me hean. The M-mode echocardiogram shows the characteristic features of this condition: The special probes used are complex linear, phased or sector scanners. Moving pans such as heart valves can be seen in motion, and the method is widely used in cardiology two-dimensional echocardiography or 2DE Figs 1. The velocity of blood flow towards or away from an ultrasound probe can be derived from the reflected ultrasound wave using the well known Doppler principle.

The effect has found widespread use in fetal monitoring, cardiology and vascular studies. Duplex scanners combine both pulse echo ultrasound and Doppler shift facilities.. Both modes can be simultaneously recorded.

Continuous wave Doppler uses two transducer crystals mounted side by side, one transmitting and the other receiving ultrasound waves. The method is best for measuring high velocity flow and for recording peak velocities.

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Pulsed Doppler uses a single transducer to emit short bursts of ultrasound which are received back by the same transducer and. The 2DE shows marked fibrosis and tethering of the mitral em Ieaflects due to chordal and commissural fusion.

This method permits precise focussing on small sample volumes but is less accurate than continuous wave Doppler for peak and high velocity flow.

Colour flow mapping is based on pulsed Doppler but allows assessrnenr across the whole field of a two dimensional image. The results can be coded in colour pennitting imrrrediate visual recognition of flow towards or away from the transducer.. Magnetic resonance irnaging MRI represents the most exerting advance in imaging since medical radiology began in It has also been labelled nuclear magnetic resonance NMR and is based on the fact that some nuclei - those with un aired electrons Hydrogen nuclei protons are particcl"arly suitable since t1iey are normally present in vast numbers in the body tissues.

Water for instance has per mL The use of a strong external magnetic field will force a proportion of these nuclei to align in a new magnetic axis from their previous random orientation Fig. The fields used in clinical practice range from 0. In addition to the large and costly magnet required for MRI the machine also uses pulses of radio waves.. These are essential to excite and detect the magnetise.

A pulse of radiowaves of the. They return to this irrnnediately after the pulse ceases. At the same time they release the energy absorbed as a radiosignal of the same frequency. This is detected by the coils used for excitation Fig. Since the signal returned is proportional to the concentration of protons it forms the basis for a digital record of the proton content of the tissues under examination.

Using a similar technique to that established in CT this is converted by computer into an analogue image presented on a cathode ray tube in varying shades of black and white. In summary. The different pulse sequences give different weighting in the recovered signal to various parameters which affect the resulting image, Inversion recovery T I weighted sequences show better anatomical detail and better separation of solid and cystic structures.

Spin echo T 2 weighted sequences are more sensitive to detecting local pathology. Whilst MRI can produce axial images resembling those of CT it also has the great advantage that images can also be readily produced in any other plane including the sagittal and coronal, features of particular value in the study of the spine and brain.

Other advantages compared with CT are the absence of ionising radiation or any other apparent biological hazard, and the high intrinsic contrast. The new method also holds out the promise of tissue characterisation and can be used for blood flow imaging.

B Rerum of proton to its former axis with release of energy as radiofrequency pulse which can be registered by receiving coil and quantified. Disadvantages of MRI are the high cost of the sophisticated machinery and inability to image bone and calcium.

It is also unsuitable for patients with cardiac pacemakers which can be adversely affected by the magnetic fields as can metallic clips or im. In hospital practice rriarry patients have a routine chest X-rayon admission.

This is done not only to exclude serious chest disease, but also to provide evidence of the preoperative condition of the chest in patients about to undergo surgery. Postoperative chest corrrplications include basal collapse, lung infections, and p'ulrnonary embolus.

In the assessment of such postoperative cornplications it is important to have a preoperative filrn for comparison. Chest X-ray also shows the size and shape of the heart and provides base line evidence of the cardiac status. Simple radiography of the chest is also carried out as a routine in all patients with suspected chest disease.. The study of chest X-rays requires an irrtirnare knowledge of the normal anatorny of the lungs including the bronchi and their lobar and segmental arrangements Fig.

Lesions must be anatomically localised and this will often require a lateral projection as well as a simple posteroanterior film. In studying the simple X-ray the radiologist will note not only the lung fields but also the heart and mediastinum,. Nomenclature approved by the Thoracic Society. Reproduced by permission of the Editors of Thorax.

The student inspecting a chest film should try to examine 11 in a systematic manner. Though a radiologist may give an opinion, after what appears to the student only a cursory inspection, this is based on years of experience, and the examination of many thousands of films.

The radiologist will have noted the normality or abnormality of all the following features:. The student should train himself to follow a routine which examines each of the above features in turn. A similar systematic approach should be applied to the other features listed above, since significant abnormalities may be seen in any of them.

Thus an irregular bony defect in a rib with an adjacent soft tissue swelling may represent the first evidence of metastasis. An elevated diaphragm on one side with a small basal effusion rnay be evidence of a subphrenic abscess. A small bulge of the upper mediastinum may represent a turnour or an aneurysm. These few examples serve to illustrate the importance of the simple chest film in identifying disease not only of the lung parenchyma but also of many other systems.

In the early days of radiology chest screening was regarded as an essential pan of the examination of the chest.

Chest screening, however, involves an increased dose of irradiation to the patient compared with a simple chest X-ray. In practice it is now only carried out for the elucidation of specific problems. This is used for the clearer demonstration of doubtful opacities in the lung field Fig. This procedure is now little used and mainly for the demonstration of bronchiectasis Fig. It is also sornetirnes used for the. There is bronchiectasis involving the left lower lobe and part of the lingula.

Bronchography is performed in the X-ray department by the radiologist. There are several techniques available.

The contrast rriecliurn, propyliodine Dioriosil , can be injected over the back of the tongue, or through the nares, or directly through the cricothyroid membrane. In all cases the trachea is first rendered anaesthetic by means of local anaesthesia. Once the contrast medium has been injected the patient is tilted into the various positions necessary for filling the appropriate lobes of the lung with contrast Fig. Pulmonary angiography is performed by passing a catheter from a peripheral vein through the right atrium and right ventricle into the main pulmonary artery and then if necessary into the right or left pulmonary artery.

The main use of the method is to confirm. Pulmonary angiography is also occasionally used for the elucidation of opacities in the lung fields; e.

Most of these cases, however, can be diagnosed by simple X-ray or tomography Fig. Radioisotope scanning of the lungs is widely practised to confirm or refute a clinical diagnosis or suspicion of pulmonary embolus.


If the findings are riorrnal the more invasive pulmonary angiography can be dispensed with, and if they are abnormal and typical treatment may be instituted. Lung scans can be performed following intravenous injection of technetium 99Tcm labelled macroaggregates or microspheres. This is known as the perfusion or P scan. It can also be performed by inhalation of radioactive xenon Xe or krypton This is known as the ventilation or Q scan.

If the perfusion scan is normal no further action is required, but if it shows perfusion defects suggestive of embolism then a ventilation scan can be done. Typically in pulrnoriary embolus the lung remains aerated and the ventilation scan remains normal, giving rise. This mismatch is virtually diagnostic of pulrnonary emboli Fig.

With most chest diseases radiology mirrors the gross pathology of the disease. Tuberculosis, though no longer the ubiquitous and sinister threat of past decades, is still a problem that must be borne in mind, particularly with irnrnigrants from underdeveloped countries and in the immunosuppressed patient.

The primary form of tuberculous infection, which used to be seen almost exclusively in children, is now also being seen in older patients. The characteristic X-ray picture of a primary tuberculous. There are several large defects in the right lung and a smaller defect in the left lung. B Same patient after ventilation scan with 87Kr"'. There are no ventilation defects.

These mismatched perfusion and ventilation scans are characteristic of pulmonary embolus. This appears on the X-ray as a diffuse opacity representing a patch of consolidation in the lung field with increased striations extending towards the hilum where the enlarged glands show as rounded opacities. Pleural effusion is also a cornmon manifestation of primary tuberculous infection. The adult type of pulmonary tuberculosis secondary or reactivated tuberculous infection manifests in a different way.

There is again an area of pneumonitis in the lung but this is not accompanied by glandular enlargement. The infection has a predilection for the posterior segment of the upper lobe. On the postero-anterior film it appears as an area of shadowing near the lung apex often mottled in character.

Cavitation may occur, and as the disease progresses fibrosis will follow.

The appearance in the majority of cases is characteristic both in the acute and chronic fibroid stages Fig. Although the fulminating and serious forms of the disease are now rare in Britain they are by no means extinguished. Bronchogenic spread may occur from a tuberculous cavity, and on the X-ray this will appear as mottled srriall opacities in the newly invaded area.

Miliary tuberculosis, being haernarogenous, appears as fine pinpoint mottling spread uniform. With chronic fibroid tuberculosis in the upper lobes cavitation is quite cornrnori, but owing to the dense fibrous tissue tornography may be required for its demonstration. With the widespread and early use of antibiotics for chest infections lobar prieurnorria is less commonly seen than previously.

In its classical form. As resolution occurs the dense opacity becomes irregular. A postero-anterior film; B lateral film. With incomplete resolution fibrosis may occur and bronchiectasis may later supervene.

Legionnaires" disease occurs in sporadic or epidemic outbreaks due to Legionella pneumophila contaminating water coolers or air conditioning units. The chest X-ray shows a peripheral rapidly spreading consolidation. Broncho-pneumonia is still conunonly seen in hospital practice, particularly in elderly patients. The X-ray usually shows mottled shadowing, mainly in the lower lobes. Local areas of pneumonitis are often seen in association with upper respiratory tract infection.

These appear on the X-ray as an opacity localised to one segment of a lobe and resolving fairly rapidly. The imrrrunoauppressed patient and the patient with AIDS is parricularly prone to lung infections, often with unusual pathogens.

Certain organisms, notably Pneumocystis carinii and cytomegalovirus rarely if ever cause disease in the absence of immunosuppression. Although radiology is vital to the diagnosis of most chest conditions and in some cases will demonstrate lesions which cannot be shown by any other rnethod, e. Thus a patient may have severe chronic bronchitis with gross physical signs on auscultation and severe clinical drsab'ility, yet X-rays may show little or nothing.

This is because the bronchial walls are not normally visible on X-rays, and inflammation of the bronchial mucosa cannot be seen except by its secondary effects. In severe cases there is usually some degree of emphysema. The latter is diagnosed at X-ray by the barrel-shaped deformity of the chest and by the flattened diaphragm.. The lung fields may appear translucent and the hllar shadows prominent. In some cases of chronic bronchitis thickening of the bronchial walls due to peribronchial infection may occur and this may be seen on the X-ray.

In severe cases of chronic bronchitis bronchography often shows characteristically enlarged mucous glands in the walls of the larger bronchi. Bronchiectasis rnay be suspected in the patient with recurrent infection, usually in the basal areas of the lung, or with the characteristic clinical picture of repeated infection and purulent foul-smelling sputum. In chronic cases there is usually increased shadowing in the affected area of the lung, sometimes with thickened bronchi visible on plain X-ray, or cystic shadows in the affected area.

Bronchography was usually indicated to delineate the tOtal extent of the disease since surgical removal of localised chronic bronchiectasis is the treatment of choice. Often bronchography will show that the disease is m. Thin section CT now offers a noninvasive alternative to bronchography.

Lung abscess. The possibility of bronchial blockage by an inhaled foreign body should not be overlooked. The inhaled peanut is a notorious cause of bronchial occlusion with secondary infection in children.

Most lung abscesses usually develop a fluid level visible on plain X-ray Fig. Dry pleurisy is another condition in which clinical symptoms may be severe yet the radiological findings lllay be negative.. Pleural rumours are rare, but attention has been drawn to the frequency of malignant pleural tumours mesothelioma in asbestos workers.

Linear pleural or diaphragmatic calcification is a frequent: Pleural effusions manifest radiologically as basal peripheral opacities which first fill in the costophreriic angle Fig. A large effusion may rnask the whole of a lung field and even a moderate-sized effusion may obscure underlying lung disease. Pleural effusions were often a manifestation of prim. They are now less often seen accompanying pneumonia or as post-pneumonic complications. In the middle-aged or elderly person the possibility thata pleural effusion may be malignant must always be considered.

As is well. Apart from the inflammatory effusions and those associated with malignant disease, pleural effusions may also be seen as complications of heart failure, hepatic failure or the nephrotic syndrome. Spontaneous pneumothorax Fig. In some cases rupture of an emphysematous bulla is inferred. In others there may be a subpleural tuberculous focus. In most cases, however, the etiology is never established.

A small pneurnothorax is usually better shown by obtaining a film taken in expiration as well as the routine inspiration film. Tension pneumothorax isa particularly dangerous condition when air continues to enter the pneumothorax but cannot escape owing to the pleural tear being valvular. It should be suspected if there is displacement of the mediastinum and overdistension of the affected side of the chest and requires emergency treatment.

In this group of conditions foreign substances are inhaled and stored in the lungs.. They are of considerable industrial importance and occur in many different occupations, including mining and industries using abrasives and refractories. SOIDe of the inhaled foreign materials are capable of producing extensive fibrosis and a severe effect on lung function. Silicosis is due to the inhalation of small particles of silicon dioxide.. In the advanced stages of the disease there is widespread nodulation and fibrosis throughout the lung fields and tuberculosis was a cornrnori complication.

With modern industrial precautions the severe cases are now less comrnorrly seen but it is important for the radiologist to recognise the early changes of pneumoconiosis. These may consist merely of a slight exaggeration of the normal lung markings. As the disease advances this increases to small nodules, a few millrmetres in diameter, scattered throughout the lung fields Fig. Enlargement of the mediastinal lymphatic glands is a frequent and early manifestation and may be the sole radiological lesion.

The glands involved are bronchopulmonary and appear as bilateral symmetrical hilar and peri-hilar masses Fig. The lesions slowly resolve over a period varying from six months to two years.. Miliary lung mottling is also an early manifestation of sarcoidosis and mayor may not aCCOITIpany the hilar glandular enlargem.

It usuaUy disappears in a few months but may be followed by chronic pulmonary fibrosis.. Large nodular lung lesions are unusual but are sometimes seen as a manifestation of pulmonary sarcoidosis, and these can persist for years.

Female aged 33 years. Routine radiology discovery. Considered clinically [0 be sarcoidosis. Tomography demonstrates enlargement of the brcmcb o-p'ulrnorrary hilar and tracheobronchial glands of both sides.

The right b ilar region shows the lobulation characteristic of enlarged lyrrrph glands. Complete resolution within a year. Hodgkin's disease is the most frequent type of lymphoma to affect the mediastinum.. The paratracheal glands are the ones m. The non-Hodgkin's lymphomas can give rise to similar changes and leukaemia can also present similar radiological appearances. Hodgkin's disease and the other lymphomas usually show a marked initial response 1: This is in contrast to glands involved by bronchial carcinoma which sometimes have to be considered in differential diagnosis.

Other masses which enter into the radiological differential diagnosis on a PA chest film include the following:. A lateral chest film is of course essential to localise and help in elucidating the mass seen on the PA film. In difficult cases CT Fig.. MRI has the added attraction of distinguishing aneurysms and other vascular structures without injection of contrast Fig..

Benign tumours of the lung are rare compared with malignant tumours. They include bronchial adenoma and hamartomas. The latter can sometimes be diagnosed on X-ray by the presence of irregular calcification within the tumour. Thymoma confirmed at surgery.

Note how the heart and great vessels are readily cliffererrtiated by low signal due to blood flow from the glandular rrrasaes due to Hodgkin's disease.

Radiology plays an essential part in the early diagnosis and students should be aware of the protean radiological manifestations of the conclition. The radiological appearances in bronchial carcinoma can be discussed under three main headings:. L The primary rurnour may be shown as a nodular opacity in the lung fields Fig.

Ina patient over 40 the possibility that any rounded lesion in the lung periphery may be a primary carciriorna must always be borne in mind. Nowadays the condition must even be considered in patients in their thirties or younger. In many of these cases it is quite impossible to exclude malignancy and needle biopsy must be undertaken.

Solitary pulmona. Primary, secondary, lymphoma, plasmacytoma Hamartoma, adenoma, arteriovenous malformation Tuberculosis, histoplasmosis, paraffinoma, fungi, parasites. The priInary lesion may also be seen as an opacity at or near the hilum of the lung Fig. It is often difficult to be certain whether such an opacity represents the actual primary or a glandular metastasis.

Fortunately, most of the hilar lesions are within reach of the bronchoscope and rapid confinnation of the diagnosis can usually be obtained. A bronchial carcinoma will often occlude the bronchus in which it arises and this will lead to secondary collapse of the affected segrnerit or lobe of the lung.

Infection may then occur in the collapsed or partially collapsed area.

X-rays may derncmstrare these secondary effects without showing the original lesion. For this reason an unexplained area of collapse or consolidation in the lung fields in a man of carcinoma age must always be regarded with suspicion. An area of infection distal to a partially blocked bronchus may give rise to a difficult problem of differential diagnosis.

As already noted, a hilar mass may represent not the primary tumour but glandular metastases. Peripheral lesions or metastases involving the pleura may result in pleural effusion. Characteristically the malignant effusion may be blood-stained and will recur rapidly after tapping. The pathologist may demonstrate malignant cells in the fluid. A hilar carcinoma or glandular metastases may involve the phrenic nerve.

This will manifest itself by elevation of the diaphragm on the affected side, and on screening the affected dome will be seen to move paradoxically. With an apical or Pancoast tumour there is often direct invasion of ribs, with bony destruction apparent on X-rays Fig.

Bony metastases may occur elsewhere in the body and will manifest thernselves as destructive areas on X-ray or by pathological fractures. Note the high diaphragm due [0 phrenic paralysis.

Textbook of Radiology and Imaging - 2 vol set IND reprint

Once the diagnosis of carcinoma of the lung has been made or confirmed, radiology is also useful in assessing operability. Evidence of metastases usually precludes operation. By demonstrating large glands encroaching on the oesophagus a barium swallow may save a useless thoracotomy. If involvernerit of the superior vena cava is suspected this should be conformed by superior vena cavography or CT and again a useless thoracotomy may be prevented.

The lungs are a cornrnon site for the development of metastases. Haematogenous tumour emboli are carried to the heart and then become lodged in the capillaries of the pulmonary circulation. Thus X-ray of the lungs is necessary in most forms of malignant disease.

Secondary deposits in the lungs usually appear as rounded opacities which can be multiple and widespread Fig. Large so-called 'cannon-ball' secondary deposits IT13Y be seen with certain types of. Secondary deposits can also present a variety of different appearances, ranging from miliary mottling throughout the lung fields to extensive perihilar spread lymphangitis carcinornatosa. Peripheral tumours in the lung which are normally beyond the reach of bronchoscopic investigation are now biopsied percutaneously by the radiologist using a fine needle.

Under image intensifier control the tip of the needle is advanced to the lesion and a biopsy obtained by suction as the needle is passed into the lesion.

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Occasional complications of the procedure are prieuruothorax and haernaternesis but these usually require no treatrnerit and are preferable to the alternative of thoracotomy.

Ultrasound is helpful in assessing pleural and subphrenic disease and is invaluable in cardiac lesions see Ch. It has however no significant part to play in the diagnosis of pulmonary lesions. The main use of CT in the chest is in assessing mediastinal disease and in staging of lung cancer and other malignant lesions. It is also more sensitive than simple X-ray in identifying small pulmonary metastases and in detecting pulmonary fibrosis and bronchiectasis. MRI of the chest has proved most valuable in the assessment and characterisation of mediastinal masses Fig.

Its ability to show sections in the sagittal and coronal as well as the axial plane and its ability to show vascular structures without contrast injections give it an advantage over CT. It is also useful in the diagnosis of hilar and mediastinal lymphadenopathy and in the staging of malignant tumours.

A simple X-ray of the chest is mandatory as the first imaging investigation in cases of heart disease, because it yields vital information concerning the size of the heart, enlargement of individual chambers and condition of the lung fields. All these features are important in the assessment of the nature of the specific heart disease and its severity.

An initial chest X-ray also forms a base line against which future progress or deterioration can be measured. The rnaxirrrum transverse diameter TD of the heart is compared with the maximum transverse diameter of the thorax Fig. Shape of heart. The cardiac contour has characteristic appearances in specific conditions depending on the chambers mainly enlarged.

Left ventricular enlargement is seen in hypertension, aortic valve disease and other conditions where the main burden is on the left ventricle..

It manifests by enlargement of the apical region of the heart in both the PA and lateral projections Figs 3. The transverse thoracic diameter is measured in a variety of ways. Here it is measured as the maximum internal diarnete r of the thorax. The apell:. Left auricular enlargement is seen characteristically in mitral valve disease, when it enlarges backwards and to the right, appearing as an added density superitnposed on the central part of the heart shadow in the P A view.

It projects backwards and slightly upwards in the lateral view, presenting a marked impression on the barium filled oesophagus Figs 3. Right ventricular enlargement may also be seen in mitral disease because of the increased pulmonary resistance secondary to the pulmonary congestion. It is also seen in many congenital cardiac lesions associated with pulmonary stenosis or left to right shunts, and in pulmonary conditions with chronic airways obstruction.

The enlarged right ventricle is best seen in the lateral view where it fills in the normal retrosternal space, but is also identifiable when gross in the PA view where it straightens the left border and elevates the apex of the heart Fig. In mitral disease the combination of left auricular and right ventricular enlargement leads to the cottage loaf' appearance Fig.

The appearance of the lung fields is of great importance in cardiac assessment since alterations in pulmonary haemodynamics are a feature of many forms of heart disease. Three types of change can be identified:. Left ventricular failure or mitral disease are typical causes. The characteristic features are diversion of blood from the lower to the upper zones of the lung in the erect PA film. Normally the upper zone vessels appear smaller than those in the lower zone, but with pulm.

As pressure rises pulmonary oedema develops involving the interstitial or alveolar spaces or both. The article also draws attention to the need of appropriately training the involved personnel, and also to the personal difficulties in using new technologies. Such difficulties tend to be reduced to a minimum with routine use and continuous training in digital reports.

With the trend towards increasing the use of electronic methods, the work done by the transcriptionists at the radiological centers tends to fade away over time, as with speech to text capability with the radiologist being able to see on a screen the text he is dictating in real time, typing errors will no longer exist, and formatting will be solely dependent upon the radiologist.

It is important, however, that the costs of such systems be reduced in order to encourage their use in our community. There are already several alternative manners to adopt the use of electronically dictated reports, as mentioned in the article in the present issue, that can be replicated at any type of Radiology center, optimizing workflows. Currently, the use of electronically dictated reports is perfectly feasible at a relatively low cost, still keeping the transcriptionist in the workflow.

The direct speech to text systems can still be greatly improved, although there are excellent systems in use, with a good performance in the daily practice. This observation must be taken carefully, as both reliability and time required to prepare the reports are largely dependent on the system, local conditions and especially on user training.

With greater user experience and time using the system, errors decrease in an exponential manner. Thus the importance of reading the article published in the present issue, which is also a stimulus to all private or public institutions providing Radiology training in Brazil to adopt such technological tool at their Radiology centers, providing users with quality training, with the final objective of overall improvement of Radiology in our country.

Expediting the turnaround of radiology reports in a teaching hospital setting. Sutton J. Speech-to-text: the next revelation for recording data.

Radiol Manage. Wheeler S, Cassimus GC.There are several techniques available. Ultrasound provides a cheap non-invasive and radiation free rnethod of screening elderly patients with suspected abdominal aneurysms Fig. Alternatively, it can be investigated by percutaneous transfernoral catheterisation using the Seldinger techrrique, The thoracic aorta is examined by transfernoral catheterisation and passage ofa catheter into the aortic arch arch aortography , Where the femoral or iliac arteries are too diseased for this to he possible transaxillary catheterisation can be used.

The 2DE shows marked fibrosis and tethering of the mitral em Ieaflects due to chordal and commissural fusion. The procedure will demonstrate a non opaque calculus. Miniature radiography. The normal development of bone requires both vitamin C and vitamin D.

Evidence of metastases usually precludes operation.

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